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Recent eLetters

Displaying 1-10 letters out of 434 published

  1. Corrections to Mansikkamaki et al

    Page 3, the right column, figures 1 and 2 are incorrect, and should be figures 2 and 3.

    Page 6, figure 3, there are two incorrect headings on the left: the upper "Physical functioning" should be "Social functioning" and the lower "General health".

    Page 8, reference number 7 is incorrect, it should be: Mansikkamaki K, Raitanen J, Nygard C-H, Heinonen R, Mikkola T, Tomas E, Luoto R. Sleep quality and aerobic training among menopausal women - A randomized controlled trial. Maturitas, 2012;72(4):339-45.

    Conflict of Interest:

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  2. Hospital mortality and admissions show small area spatial irregularities

    This is a useful study which reaches the conclusion that there was no difference between the two groups.

    It would seem that the authors were not aware that both deaths and medical admissions show very small area spatiotemporal variation.

    Over the time period of their study deaths (all cause mortality) in both North Yorkshire and York show evidence for two step like changes which could alter the conclusions of the study.

    It has now been confirmed in three locations that this is made up from very small area spatiotemporal effects against both deaths and medical admissions, i.e. the exact location as to where individuals live makes a difference in time and can therefore lead to confounding effects in seemingly 'matched' populations.

    The following references give more detail and the in press articles should be available in a few weeks.

    References

    Jones R, Beauchant S (2015) Spread of a new type of infectious condition across Berkshire in England between June 2011 and March 2013: Effect on medical emergency admissions. British Journal of Medicine and Medical Research 6(1): 126-148. Doi: 10.9734/BJMMR/2015/14223

    Jones R (2015) A time series of infectious-like events in Australia between 2000 and 2013 leading to extended periods of increased deaths (all -cause mortality) with possible links to increased hospital medical admissions. International Journal of Epidemiologic Research 2(2): 53-67.

    Jones R (2015) Small area spread and step-like changes in emergency medical admissions in response to an apparently new type of infectious event. FGNAMB 1(2): 42-54. doi: 10.15761/FGNAMB.1000110

    Jones R (2016) Is cytomegalovirus involved in recurring periods of higher than expected death and medical admissions, occurring as clustered outbreaks in the northern and southern hemispheres? British Journal of Medicine and Medical Research 11(2): 1-31. doi: 10.9734/BJMMR/2016/20062

    Jones R (2015) Simulated rectangular wave infectious-like events replicate the diversity of time-profiles observed in real-world running 12 month totals of admissions or deaths. FGNAMB 1(3): in press

    Jones R (2015) A 'fatal' flaw in hospital mortality models: How spatiotemporal variation in all-cause mortality invalidates hidden assumptions in the models. FGNAMB 1(3): in press

    Jones R (2015) Infectious-like spread of an agent leading to increased medical hospital admission in the North East Essex area of the East of England. FGNAMB 1(3): in press

    Jones R (2015) Influenza-like-illness, deaths and health care costs. Brit J Healthc Manage 21(12): 587-589.

    Jones R (2016) The real reason for the huge NHS overspend? Brit J Healthc Manage 22(1): 40-42.

    Jones R (2016) A fatal flaw in national mortality-based disease surveillance. Brit J Healthc Manage 22(3): in press

    Jones R (2016) Deaths in English Lower Super Output Areas (LSOA) show patterns of very large shifts indicative of a novel recurring infectious event. SMU Medical Journal (submitted)

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  3. Health Checks

    Robson at al's recent article describes a large project with great ambitions. It provides a classical example of how political intentions can waste a vast amount of resource whilst avoiding feasible methods of assessment of effectiveness. This is reinforced by the accompanying press release, which claimed the saving of 2500 lives.

    The "evaluation" of the first 4 years gives no assessment of the value (or benefit) of Health Checks. It merely describes the coverage, not an evaluation. The numbers included are large. It was introduced in a phased manner. Suitable design could have enabled the impact on both mortality and morbidity to be measured as well as making an economic assessment. There is no reference in the paper of the effect on mortality or morbidity.This is a great pity as the opportunity to evaluate adequately an imaginative national programme has been missed.

    It is furthermore unfortunate that the study relies on routine general practice data collected by an electronic database. Although supposedly validated, there is no evidence of any check on the variability of recording by different practitioners or the validity of the Read codes used. Most scientific studies make at least some attempt to assess the reliability of data by random checks rather than relying on "validity" stated by the dataset owners. The authors also neglect the variability of diagnoses and symptoms recorded by GPs and assume that what has been recorded in the dataset by the 655 general practices will be the same. There was no evidence of verification or details of training given to participating practitioners.

    The authors make no comments on some strange anomalies, and classify new diagnoses in those undergoing a Health Check as an "outcome" (table 4). For example, although more individuals were classified as having type 2 diabetes in the Health Check group more individuals who had no Health Check had abnormal blood glucose levels. This demonstrates a problem, highlighted 50 years ago (1), that applying a disease label (i.e. diabetes or hypertension) in a condition where the risk factor is a continuous variable (blood sugar or BP) is particularly liable to observer variability.

    It appears the programme sponsors and their researchers assume that by " doing something" intended to be good, good will be done, whatever it costs or whatever harm is caused; they do not seem to appreciate that a Health Check differs from a patient initiated medical consultation (2), and that randomised controlled trials of health checks are consistently negative (3,4). They appear to have ignored Public Health England's own consultation about research priorities where "The most consistent (feedback) was the need to demonstrate the effectiveness of NHS Health Check in improving health outcomes,and to demonstrate their cost effectiveness". It is slightly surprising at this time of austerity that a programme costing ~165 m annually continues to receive support without proper evaluation and that research to assess its value has been so limited.

    References

    1. Pickering G, High Blood Pressure. Harcourt Brace/Churchill Livingstone, 2nd edition. 1968

    2. Cochrane AL ,Holland WW. Validation of screening procedures. British Medical Bulletin, 1971;27: 3-8

    3. Krogsboll LT, JorgensenKJ, Gronhoj Larsen C, Gotzsche PC, General Health Checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ, 2012;345:e7191

    4. Jorgensen T, Jacobsen RK, Toft U, Aadahl M, Glumer C, Pisinger C. Effect of screening and lifestyle counselling on incidence of ischaemic heart disease in general population: Inter99 randomised trial. BMJ, 2014;348

    5. NHS Health Check programme: priorities for research consultation feedback 24.02.2015 https://www.gov.uk/government/consultations/nhs-health -check-programme-priorities-for-research. (last accessed 20th January 2016)

    Conflict of Interest:

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  4. Virtual online consultations: advantages and limitations (VOCAL) study. Time to act.

    With perhaps too many different and conflicting systems in healthcare, it is deeply encouraging to read such a comprehensive and sophisticated proposal by Greenhalgh et al to examine how it might be possible to utilise technology to offer skype consultations to vulnerable individuals and potentially isolated communities within the UK. Innovation within healthcare is essential to consider and potentially create long term sustainable solutions for addressing and meeting a variety of health needs. Collaborative partnerships between clinicians and academics offer a unique way of examining complex scenarios with direct clinical translation opportunities.

    Our work as specialist clinicians within the NHS, often requires us to actively seek resources where-ever we can and to build networks with diverse partners, who are also focused on understanding how we can deliver what is needed at a specific time-point for an individual within the means that we have. Within an NHS under increasing financial pressure, identifying and building resources must be a priority.

    We recognise that consultation by skype could potentially offer wider access to healthcare across many parts of the world, though are also conscious that there are many factors, which present challenge to the implementation of such an idea, even within the UK. For example, a lack of access and permission to use skype within NHS hospital organisations; information governance related issues and patient/user demographics relating to whether an individual service user themselves has access to skype, and is able to use it. Ethical considerations are also relevant and have been identified as of specific concern within teleneurology [1]. We see the diversity of the populations studied as being a key strength of this research and this would be directly relevant to our planned research into using skype for consultations between different countries, e.g. UK and Bangladesh.

    Reference

    1. Teleneurology: ethics of devolving responsibilities from clinicians to families and/or carers. (MacKenzie, R and Sakel, M) 2011. British Journal of Neuroscience Nursing. Vol. 7. Issue 2. P. 490- 493.

    Conflict of Interest:

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  5. Access to Emergency Care: Spotlight on a Social Determinants of Health Intersectionalty Lens

    Spatial or geographic contexts are central in determining access to emergency health care, regardless of global region or nation. As Amram, Schuurman, Pike, Friger, and Yancher (2015) attest, outcomes are significantly improved when Canadian individuals and families have access to a trauma center within one hour of serious injury--the "golden hour". However, spatial access, when viewed in isolation of the social determinants of health (SDH), provides a limited lens for practitioners and policy-makers in their quest for increasing access to emergency care.

    Geography remains a persistent barrier in equitable access to care in Canada, particularly for rural people who do not live within an hour of a trauma center. In terms of rural, remote, fly-in, and northern health care, there is a lack of diagnostic services, significantly decreased access to emergency and acute care services, lack of non-acute health services, and under-servicing of special needs groups, such as seniors and people with disabilities (Kulig & Williams, 2011). For Canada's rural and remote Aboriginal peoples, low population density, lack of transportation infrastructure, ability to speak only Aboriginal languages, long wait times, inadequate human resources, and northern climate conditions also act as significant barriers to health care access (National Collaborating Center for Aboriginal Health, 2011).

    These barriers are related to the social determinants of health (SDH) and the isms (e.g. ageism, heterosexism, sexism, racism) as SDH. Analyses of emergency care access will be greatly enhanced with integration of the SDH. Furthermore, the invisibility of SDH-related barriers may indeed reinforce the commonly held view that they are not central in determining emergency access to timely, competent, and compassionate emergency room care. Although there are a growing number of clinicians who are cognizant of SDH-related access to care statistics, clinicians and policy-makers are still grappling with how to bring the SDH into research, practice, and institutional policy discussions, especially the isms as SDH.

    Access to care, including emergency care, involves complex pathways of discrimination. For example, in the point-of-care context, the personal experience of racially discriminatory practices, such as clinician stereotyping and expressing prejudice in the health care setting, can reduce patients' use of health care services and have a negative impact on patient adherence and satisfaction (Mody, Gupta, Bikdeli, et al., 2010). These practices may be overt or covert and they can happen whether or not clinicians are aware of their discriminatory actions or inactions.

    Despite best efforts to provide effective and efficient care, there is clear evidence that analyzing access to care requires a broader lens that is explicitly informed by the fields of social sciences and the humanities. It has been shown that members of racialized groups continue to experience inequities in effective acute cardiac care therapies such as cardiac catheterization, percutaneous coronary interventions, and surgical revascularization (Brewer & Cooper, 2014). Among American patients presenting with acute myocardial infarction (MI), Black people are less likely to be admitted to medical facilities with revascularization capabilities and high-quality acute MI outcomes (Mody, Gupta, Bikdeli, et al.). Studies in the Unites States (US) have also found evidence of racism in areas such as clinician adherence to prescribing guidelines, therapy intensification, and use of invasive cardiac procedures, even after controlling for clinical and socioeconomic factors (Mody, Gupta, Bikdeli, et al.).

    When acute care barriers related to racism are considered in the context of sexism and access to care, evidence shows that women of color are under threat of double jeopardy when it comes to timely care--sexism intersects with racism to deepen disadvantages in access to care (McGibbon, Waldron, & Jackson, 2013). Breast cancer patients have reported experiencing different forms of medical discrimination related to class, race, and language (Quach, Nuru-Jeter, Morris, et al., 2012). In a systematic review of MEDLINE articles between 2000 and 2010, O'Keefe, Meltzer, and Bethea (2015) compared lung, breast, prostate, and colorectal cancer mortality rates and mortality trends for Blacks and Whites in the US.

    Across all four cancers, survival rates were consistently lower for Black people than for White people. Authors stated that although there are complex factors involved in cancer causation and outcomes, contributing factors included differential access to care, more advanced disease at diagnosis, differences in treatment recommendations, and higher rates of surgery refusal. Authors concluded..."it is important to examine why racially patterned cancer survival disparities persist. An increasing body of evidence points to underlying societal inequities as a significant player in cancer outcomes disparities" (O'Keefe, Meltzer, & Bethea, 2015, p. 10). Breast cancer findings were particularly troubling-- the gap in breast cancer mortality between Black and White women is increasing, and between 2000 and 2010, the breast cancer mortality disparity ratio increased from 30.3 to 41.8%. In Canada, there is, as yet, relatively little documentation of evidence about inequities in breast cancer detection and treatment, although there are some important targeted efforts (Yavari, Barroetavena, Hislop, et al., 2010).

    Sexism has also been found to be a significant barrier in access to acute and emergency care. A Canadian retrospective study of almost one half million critical care patients' charts found that after adjustment for admission diagnoses and comorbidities, women were less likely than men to receive care in an intensive care unit (ICU) setting, and the difference was most pronounced when women were older than fifty years of age (Fowler, Sabur, Li et al., 2007). After adjusting for illness severity, older women were also less likely to receive mechanical ventilation or pulmonary artery catheterization. The authors concluded that among patients 50 years or older, women appear less likely than men to be admitted to an ICU and to receive selected life-supporting treatments, and they are more likely than men to die after critical illness (Fowler, Sabur, Li et al.).

    This evidence raises the spectres of ageism and sexism in women's access to acute care. Ageism has also been found to intersect with heterosexism and racism to deepen discrimination at point-of-care: "Older lesbians often experience triple discrimination because of their status as women, older adults, and lesbians, while ethnic minority LGBT older adults face a quadruple whammy" (Clay, 2014, p. 46). Sustainable and effective emergency care improvements will be most achievable when these intersections of the SDH are analyzed and integrated in clinical practice and research protocols, as well as policy-making. The concept of intersectionality, and intersections of the SDH, must become a central aspect of access to care discussions and debates.

    As the above evidence attests, access can be utterly dependent on synergies among SDH-related barriers. Private transportation, money for public transportation, or even money to pay for ambulance transport, are powerful a priori barriers to even arriving at the emergency room for timely treatment. "The oppressions of sexism, racism, heterosexism, and ageism, to name a few, can and do happen together to produce a complex synergy of material and social disadvantage. Here, synergy implies working together, fusion, coalescence, and symbiosis--the parts interacting to form a complex whole that cannot be disentangled into any single phenomenon" (McGibbon & McPherson, 2011, p. 61). These synergies point to the urgent need to assess and disentangle "structural" barriers in access to emergency care. Here, structural refers to the political, economic, and social structure of society and of the culture that informs them (Navarro, 2007).

    A SDH intersectionality lens helps us frame access to emergency care in a way that integrates the structural barriers in access to care, such as rural and remote geography, ageism, sexism, and racism, to name a few. Even if patients and families arrive at the emergency department within the "golden hour", there is increasing evidence that the SDH can and do determine health outcomes, regardless of timely arrival for emergency treatment.

    References:

    Ard, K.l. & Makadon, H.J. (2012). Improving the health care of lesbian, gay, bisexual and transgender (LGBT) people: Understanding and eliminating health disparities. Boston: The National LGBT Health Education Center.

    Amram O., Schuurman N., Pike I., Friger, M. & Yanchar, N.L. (2015). Assessing access to paediatric trauma centres in Canada, and the impact of the golden hour on length of stay at the hospital: an observational study. BMJ Open, 6:e010274.doi:10.1136/bmjopen-2015-01027

    Brewer, L.C. & Cooper, L.A. (2014). Race, discrimination, and cardiovascular disease. American Medical Association Journal of Ethics, 16(6), 455-60.

    Clay, R.A. (2014). Double-whammy discrimination: Health care providers' biases and Misunderstandings are keeping some older LGBT patients from getting the care they need. Monitor on Psychology, 45(10), 46-9.

    Fowler, R.A., Sabur, N.S., Li, P., Jurrlink, D.N., Pinto, R., Hladunew, M.A, Adhikari, N. et al.(2007). Sex- and age-based differences in the delivery and outcomes of critical care. Canadian Medical Association Journal, 177(12), 1513-9.

    Institute of Medicine (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: The National Academies Press.

    Kulig, J.C. & Williams, A.M. (2011). Health in rural Canada. Vancouver: University of Columbia Press.

    McGibbon, Waldron, & Jackson, 2013). The social determinants of cardiovascular disease: Time for a focus on racism. Diversity and Equity in Health and Care, 10: 139-42.

    McGibbon, E. McPherson, C. (2011). Applying intersectionality theory and complexity theory to address the social determinants of women's health. Women's Health and Urban Life: An International Journal, (10)1, 59 -86. University of Toronto Press.

    Mody, P., Gupta, A., Bikdeli, B., Lampropulos, J.F., & Dharmarajan, K. (2012). Most important articles on cardiovascular disease among racial and ethnic minorities. Circulation: Cardiovascular Quality and Outcomes, 5(4), e33-41.

    National Collaborating Center for Aboriginal Health (NCCAH, 2011). Access to health services as a social determinant of First Nations, Inuit and Metis Health. Prince George: NCCAH.

    Navarro, V. (2007). What is national health policy?International Journal of Health Services, 37(1).1-14.

    O'Keefe, E.B., Meltzer, J.T., & Bethea, B.N. (2015). Health disparities and cancer: Racial disparities in cancer mortality in the United States, 2000-2010. Frontiers in Public Health, 3(51), 1-15.

    Quach, T., Nuru-Jeter, A., Morris, P., Allen, L., Shea, S., & Winters, J.K. (2012). Experiences and perceptions of medical discrimination among a multiethnic sample of breast cancer patients in the greater San Francisco Bay Area, California. American Journal of Public health, 102(5), 1027-34.

    Yavari, P., Barroetavena, M.C., Hislop, T.G., & Bajdik, C.D. (2010). Breast cancer treatment and ethnicity in British Columbia, Canada. BioMedCentral Cancer, 10, 154.

    Conflict of Interest:

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  6. Bare below the elbows

    Thank you for your fantastic review. As you note [1]: finally, it is important to remember that sartorial style is but skin-deep and not a surrogate for medical knowledge or competence. Even the best-dressed physicians are likely to fare poorly in the eyes of their patients if medical expertise is perceived absent.

    We asked this question directly [2] and from our research it is our opinion that rather than getting hung up on the type of doctors attire we should be concentrating more on ensuring that our doctors are clean and well educated. Fortunately as we noted: "The doctors' appearance is of importance to patients and their relatives, but they view many other attributes as more important than how we choose to dress. While not specifically addressing the role of doctors clothing in the transmission of infection, our results do support the preference of patients for 'bare below the elbows' workplace attire". This stance supports the view of infection control and good medical practice.

    We look forward to seeing your results of PROMS with regards doctors dress.

    References

    1. Petrilli CM, Mack M, Petrilli JJ, et al. Understanding the role of physician attire on patient perceptions: a systematic review of the literature-- targeting attire to improve likelihood of rapport (TAILOR) investigators. BMJ Open, 2015;5:e006578. doi:10.1136/bmjopen-2014- 006578

    2. The importance of the orthopaedic doctors' appearance: A cross- regional questionnaire based study Aitken, Stuart A. et al. The Surgeon , Volume 12 , Issue 1 , 40 - 46 DOI: http://dx.doi.org/10.1016/j.surge.2013.07.002

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  7. Author Affiliation

    Please note that the author's correct affiliation is: Imperial College London.

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  8. People's attitudes to physical activity - an old statement

    I read with interest the excellent article by Dr. Jouni Lahti et al. in the January 2016 issue of the BMJ Open [1]. Here I had to think of the old statement of the English medical writer Francis Fuller (1670 - 1706), who wrote more than 310 years ago on people's attitudes to physical activity [2]: "As for the exercise of the body, which is the subject of this ensuing discourse, if people would not think so superficially of it, if they would but abstract the benefit got by it, from the means by which it is got, they would set a great value upon it, if some of the advantages accruing from exercise, were to be procured by any one medicine, nothing in the world would be in more esteem, than that medicine would be; but as those advantages are to be obtained another way, and by taking some pains, mens heads are turn'd to overlook and flight 'em. The habitual increasing of the natural heat of the body, as I took notice above, is not to be despised; but if we consider that it is done without charging nature with any subsequent load, it ought to be more valuable, for I may by some generous medicine, or a glass of wine, raise nature to a great pitch for a time, but then when these Ingredients come to be digested and resolved into their principles, nature may be more oppressed with the remains of the medicine, than she was at first relieved by it: Therefore if any drug could cause such an effect, as the motion of the body does, in this respect, it would be of singular use in some tender cafes upon this very account; but then add to this the great strength, which the muscular and nervous parts acquire by exercises, if that could be adequately obtain'd likewise by the same internal means, what a value, what an extravagant esteem, would mankind have for that remedy, which could produce such wonderful effects? But since those benefits are to be procured another way, how difficult is it to bring people to conceive it? To build up such a belief in the minds of men, is to raise a structure, the foundations of which can be laid with no less difficulty, than the removing of the rubbish of a vulgar error." At that time, as now applies: physical activity is and remains organismic necessity!

    References:

    1. Lahti J, Sabia S, Singh-Manoux A, et al. Leisure time physical activity and subsequent physical and mental health functioning among midlife Finnish, British and Japanese employees: a follow-up study in three occupational cohorts. BMJ Open, 2016;6(1):e009788.

    2. Fuller F. Medicina gymnastica: or a treatise concerning the power of exercise with respect to the animal oeconomy; and the great necessity of it in the cure of several distempers. London: Printed [by John Matthews] for Robert Knaplock; 1705.

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  9. National evaluation of NHS Health Check published previously

    Dear M Soljak and C Millett,

    You are quite correct and your paper (1) was indeed published before ours - the error occurred because we submitted our paper in May 2015 with some delay before publication this year in January 2016. I apologise for not altering the text in the light of your publication in June 2015.

    References

    1) Chang KC-M, Soljak M, Lee JT, Woringer M, Johnston D, Khunti K, Majeed A, Millett C. Coverage of a national cardiovascular risk assessment and management programme (NHS Health Check): Retrospective database study. Preventive Medicine, 2015;78:1-8.

    Conflict of Interest:

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  10. Efficacy of the intravitreal anti-vascular endothelial growth factor (VEGF) agent ranibizumab on driving

    Diabetic macular edema (DME) is a common complication of diabetic retinopathy (1). Vision loss in patients with diabetes is often associated with diabetic macular edema, DME. Even though DME is a chronic condition, appropriate use of available effective treatment modalities of therapy can be used to prevent moderate and severe vision loss from DME (1).

    "Despite the current wider spectrum of treatments for Diabetic Macular Edema (DME), only a small proportion of patients recover good vision (20/40)"(2). Authors of this systematic review on current treatment modalities of therapy suggested that the most of DME patients would not achieve the 20/40 visual acuity required for driving. Therefore the authors proposed more effective treatments or combinations of treatments in order to achieve the 20/40 visual acuity (2).

    The Diabetic Retinopathy Clinical Research Network (DRCR.net) has recently published a study that shows the efficacy of the intravitreal anti-vascular endothelial growth factor (VEGF) agent ranibizumab on driving (3). The study result suggests that 12 months after initiating ranibizumab for vision impairment from center-involved DME, patients not driving at initiation of treatment are more likely to report driving. The study also reported that for patients treated with ranibizumab, their visual acuity improved to have driving-eligible visual acuity of 20/40 or better in the better-seeing eye than those treated with sham or laser (3). Authors also suggest that additional work needs to be done, in order to determine whether driving skills or driving safety are maintained or improved (3).

    Meanwhile, a recent Cochrane systematic review also found high quality evidence that antiangiogenic drugs provide a benefit for DME patients compared to currently available other therapeutic options such as grid laser photocoagulation (4).

    References:

    1. Apte RS. What Is Chronic or Persistent Diabetic Macular Edema and How Should It Be Treated?. JAMA Ophthalmol. Published online January 07, 2016. doi:10.1001/jamaophthalmol.2015.5469.

    2. Ford JA, Lois N, Royle P, Clar C, Shyangdan D, Waugh N. Current treatments in diabetic macular oedema: systematic review and meta- analysis. BMJ Open, 2013 Mar 1;3(3). pii: e002269. doi: 10.1136/bmjopen- 2012-002269.

    3. Bressler NM, Varma R, Mitchell P, et al. Effect of Ranibizumab on the Decision to Drive and Vision Function Relevant to Driving in Patients With Diabetic Macular Edema: Report From RESTORE, RIDE, and RISE Trials. JAMA Ophthalmol. Published online November 19, 2015. doi:10.1001/jamaophthalmol.2015.4636.

    4. Virgili G, Parravano M, Menchini F, Evans JR. Anti-vascular endothelial growth factor for diabetic macular oedema.Cochrane Database Syst Rev, 2014 Oct 24;10:CD007419. doi: 10.1002/14651858.CD007419

    Conflict of Interest:

    None declared

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