rss

Recent eLetters

Displaying 11-20 letters out of 433 published

  1. National evaluation of NHS Health Check published previously

    In the Strengths and Limitations section of their paper Robson et al state that (their paper) "is the first national study describing implementation of the new National Health Service (NHS) Health Check programme 2009-2012". This is incorrect, we published a similar paper in Preventive Medicine in June 2015.[1]

    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. Link: http://www.sciencedirect.com/science/article/pii/S0091743515001838.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  2. Erratum

    In table 2 the correct number in column MDC is 2.7 for BBS and 0.08 for 6 meters walking test. In column MDC% the correct number is 7.1 for BBS.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  3. A commentary on 'Euthanasia for psychiatric patients: ethical and legal concerns about the Belgian practice' from Claes et al.

    In their warning call to Belgium and other countries in the world to (re)consider euthanasia legalisation, Claes et al. highlight some arguments that were also described in our descriptive study, including the key conditions 'untreatable and unbearable suffering' as subjects of controversy. However, we would like to react to some of the other statements in their commentary.

    Firstly, Claes et al. wrote "that 35% and probably 50% of the euthanasia cases have been approved by one single psychiatrist", referring to psychiatrist Thienpont L. The Belgian Law on Euthanasia (2002) clearly states that in case of the non-terminally ill, it is a specific legal requirement of due care that - besides the treating physician - two 'additional' physicians, a psychiatrist or specialist in the disorder amidst them, have to be involved in careful evaluation of all legal requirements, including patient's mental capacity and the suffering experience in the context of patient's (psycho)pathology, before any advice regarding a euthanasia request can be given to patients' treating physician. In all cases in our study, these legal requirements were met.

    Secondly, Claes et al. focussed on the 38 euthanasia requests that were withdrawn: we want to clarify that these patients did not withdraw their request but were referred by the first author for additional diagnostic test and/or treatment, hence their request can be considered as pending, not withdrawn. Hence, at the moment of the final analysis of our study, these euthanasia procedures were still in process as patients accepted being referred to further testing- or treatment options and were giving these new perspectives a fair chance for success. Therefore, a final decision to grant their euthanasia requests could not be reached.

    Thirdly, concerning the key factor 'untreatable suffering', Claes et al. state - and rightly so - that mental disorders could be seen as a 'transient state'. We could not agree more on this. They rightly warn psychiatrist for having 'a narrow technical view on psychiatry' and 'denying patients' recovering abilities', when 'denying the fact that psychiatrists do not primarily treat diseases, but persons', by referring to scientific evidence showing that diseases tend to resolve over time, and specifically referring to borderline patients in remission 10 years after their diagnose. While these results are extremely hopeful, this doesn't mean that every patient can reach the state of being in remission. As could be read in the result section from our paper it concerned patients being treatment resistant, due to a comorbid psychiatric disorder. For example, it is noteworthy that almost every patient (90%) was diagnosed with more than one disorder at intake, which makes the effort to remission success a very complex one. Only when no alternative options are left and only if all legal requirements are complied, we face the boundaries of medical treatment. As stated in the introduction section of our paper, a patient can be considered to be in a medically futile situation, or treatment resistant, if the suffering is unbearable and untreatable and there is no prospect of any improvement. According to the Law, both physician and patient have to come to the conclusion that there is no reasonable alternative left to relieve the patient's suffering. In practice (and also stated in the introduction section of our paper), the guidelines from the Dutch Psychiatric Association (NVvP) are then followed to qualify untreatable suffering (e.g. any therapeutic option for a particular condition must meet the following three requirements: (i) a real prospect of improvement, (ii) the possibility to administer adequate treatment within a reasonable period of time, and (iii) a reasonable balance between the expected treatment results and the burden of treatment consequences for the patient, must be reached). Therefore, untreatable suffering is not vague in its essence.

    Fourthly, in response to the vagueness of the key factor 'unbearable suffering', we have stated in the introduction section of our paper that the unbearability of suffering cannot easily be defined, as it is a subjective term by its nature and qualitative research in the context of death wishes is paid cursory attention to (Dees et al, 2010). Delbeke (2013) described that the evaluation whether suffering is continuous and unbearable, is up to the patient. The physician has no solid psychophysical or psychological instruments to measure the irrefutable degree of physical or mental suffering, but has to come to a level of mutual and empathic understanding with the patient about the extend of his or her intolerable, unendurable suffering. However, the consulted physician can have patient's consent in having access to patient's medical file that contains information about patients' suffering history. Moreover, it belongs to the expertise of the advising specialist (psychiatrist) involved to judge patient's mental competency and whether there are any opportunities left to alleviate that type, extend or intensity of patients' suffering (Naudts et al., 2006). Psychiatrists are expected and supposed to have the knowledge and skills to decide whether and to estimate the extent to which the mental disorder is curable or not and whether or not there's a prospect of improvement. However, the dependence of the actual state of medicine and treatment options does include a subjective element.

    The aim of our paper was to open the discussion about the realised practice of euthanasia because of psychiatric illness within the Belgian legal framework. We take note of the considerations of Claes et al. and fully acknowledge that more research needs to be done in order to improve the quality of healthcare for this patient group. Therefore, we are already working on qualitative and quantitative research in order to gain more insight in this topic and to offer human and legal protection of patients, friends and relatives involved.

    References

    Delbeke E. Legal aspects of care at the end of life. Antwerp: Intersentia; 2012 (in Dutch).

    Dees, M, Vernooij-Dassen, M, Dekkers, W, & van Weel, C. (2010). Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: an integrative review. Psycho-Oncology, 19(4), 339-352.

    Federal Control and Evaluation Committee on Euthanasia. Fourth report to the Parliament (2008-2009). Brussels: Federal Control and Evaluation Committee on Euthanasia; 2010. Available from: http://www.ieb- eib.org/nl/pdf/rapport-euthanasie-2010-belgique-nl.pdf (in Dutch).

    Federal Control and Evaluation Committee on Euthanasia. Fifth report to the Parliament (2010-2011). Brussels: Federal Control and Evaluation Committee on Euthanasia; 2012. Available from: http://www.senate.be/www/webdriver-MItabObj=pdf&MIcolObj=pdf&MInamObj=pdfid&MItypeObj=application/pdf&MIvalObj=83889004 (in Dutch and French).

    Ministry of Justice. Law on euthanasia of May 28, 2002. Belgian Official Gazette: Brussels, 2002. Available from: http://www.npzl.be/files/107a_B3_Wet_euthanasie.pdf (in Dutch and French).

    Naudts, K, Ducatelle, C, Kovacs, J, Laurens, K, Van den Eynde, F, Van Heeringen, C. (2006). Euthanasia: the role of the psychiatrist. The British Journal of Psychiatry, 188(5), 405-409.

    Tholen AJ, Berghmans RLP, Huisman J, Scherders MJ. Guideline dealing with the request for assisted suicide by patients with a psychiatric disorder. Utrecht: Dutch Psychiatric Association. De Tijdsstroom; 2009. Available from: http://steungroeppsychiaters.nl/wp-content/uploads/Richtlijn-hulp- bij-zelfdoding_NVvP-2009.pdf (in Dutch)

    Conflict of Interest:

    Authors of the original article 'Euthanasia Requests, Procedures and Outcomes for 100 Belgian Patients Suffering from Psychiatric Disorders: A Retrospective, Descriptive Study'

    Read all letters published for this article

    Submit response
  4. Renaming CRPS type 1 in Post Immobilisation Syndrome (Reaction on the findings by Barnhoorn et al.)

    I would like to compliment Barnhoorn and colleagues with their recent results on CPRS type 1 and the resulting publication (1). The paper demonstrates that the effect of PEPT is at least comparable to conventional therapy and has no side effects in patients with acute CRPS type 1. However, with my background in this subject, there are a few remarks to make about the study and a few more about CRPS type 1 in general. Similar remarks I have made before in a reaction to Bass in April 2014 (2). The new study shows no significant differences between populations treated with either the intervention (PEPT) or conventional therapy. One of the main reasons may be the natural course of CRPS type 1. The patients studied did have CPRS type 1 only for 7 months and it is therefore possible that many of them improved irrespective of the therapy. The functional treatment, now called PEPT, has been used in the Netherlands since 2004. We introduced it after visiting a local therapist in Macedonia in the company of six patients suffering from chronic CRPS type 1. Since then, many colleagues have come to take a look at our rehabilitation department in Hoogeveen (NL) and have copied the therapy. We have published articles and gave lectures about the approach and the first promising results. In particular, in 2009 we published a case-series of 106 patients with chronic CRPS type 1 in Clinical Rehabilitation (3). In this case-series the therapy was effective in patients with chronic CRPS type 1 (mean duration 55 months), most of whom had had 3 or more therapies. This case-series was followed by a study concerning the safety of the treatment (4) and a follow-up study of the first study (5). So the approach is well known and used by many therapists in the country. In this context the therapists and patients in the Barnhoorn study appear to represent a biased population: how sure can we be that patients in the conventional therapy group were not subject to some form of functional treatment or have acted in daily life more active when they were not in the clinic? And how blind can an assessor be in such a context? Can an assessor be blind when neither the patient nor the therapist are blinded? In the Netherlands there was and still is a debate going on whether the functional treatment has a scientific basis. A useless debate, in my opinion, especially if there is no effective alternative therapy. It is the proper scientific approach to debate the diagnosis and ineffective therapies. The criteria to diagnose CRPS type 1 change regularly, so it is not even clear what we are looking at. Maybe every research-group defines its own kingdom by changing the borders every now and then (6). If solid research shows time after time no or small differences between the intervention and control group, we must reconsider the hypothesis and not continue with research directed at the periphery of the body, starting from end organ damage. We must use our common sense instead of believing the scientific method resolves every problem in the end. Clinical science is more than trying to prove hypothesis by RCT's. If we don't use our common sense, we keep digging a hole without finding oil. We are neglecting other perspectives and sources of evidence when we don't leave our pit and thereby become dogmatic. CRPS type 1 is the description of a cluster of symptoms. Typically, physicians will give aetiologic and therapeutic connotations to a wide range of symptoms and thereby creating a chronic pain syndrome by the nocebo effect. The constant adaptation of the diagnostic criteria and the different names of the syndrome that emerged over the last decades, show the uncertainty of the diagnosis. Moreover, the criterion that all other diseases must be excluded before diagnosing CRPS type 1, makes it a questionable diagnosis. Harden (7) stated that criteria are meant to improve communication between researchers and that they have no etiopathological meaning. But by grouping symptoms, clinicians and patients and even researchers can add other meanings (connotations) to a cluster of symptoms with a particular name. Causal mechanisms and matching therapies can then be suggested. If doctor and patient start to behave according to the hypothesis/connotations an iatrogenic circle develops. Ochoa already said: "there is much iatrogenesis in the realm of misdiagnosed chronic neuropathic pain". A comparable mechanism was suggested for fibromyalgia by Wolfe (8). Bell, quoted by Ochoa and Verdugo, said: "The newfound experts developed therapeutic empires with a vigorous entrepreneurial spirit that was undeterred by the ineffectiveness of the treatment methods" I propose to define the symptoms as a normal reaction to immobilisation (9) with a broad range in manifestations. Chronicity develops in a group of patients depending on the nature of the trauma, the duration of the immobilisation, the genetic make-up and the reaction of the physician and therapist. If we change the name into 'post immobilisation syndrome' (PIS), we can start to prevent chronicity by stimulating normal use after immobilisation. Of course we will have to exclude peripheral causes first (10,11).

    References

    1. Barmhoorn KJ, van de Meent H, van Dongen RTM, et al. Pain exposure physical therapy (PEPT) compared to conventional therapy in complex regional pain syndrome type 1: a randomised controlled trial. BMJ Open, 2015;5:e008283.

    2. Bass C. Complex regional syndrome medicalises limb pain. BMJ, 2014;348:g2631

    3. Ek JW, van Gijn JC, Samwel H, van Egmond J, Klomp FP, van Dongen RT. Pain exposure physical therapy may be a safe and effective treatment for longstanding complex regional pain syndrome type 1: a case series. Clin Rehabil, 2009;23:1059-66.

    4. Van de Meent H, Oerlemans M, Bruggeman A, Klomp F, van Dongen R, Oostendorp R, Fr?lke JP. Safety of "pain exposure" physical therapy in patients with complex regional pain syndrome type 1. Pain, 2011: 152,1431-8.

    5. Van Egmond J, Koen C, Ek JW, van Dongen R, Klomp F, Samwel H. Draaijer E. Follow up study of the first series treated PEPT CRPS type 1 patients shows further improvement. Presented as poster and published on F1000research.

    6. Ochoa J, Verdugo R. Mechanisms of neuropathic pain: nerve, brain, and psyche: perhaps the dorsal horn but not the sympathetic system. Clinical Autonomic Research, 2001;11:335-9

    7. Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR. Proposed New Diagnostic Criteria for Complex Regional Pain Syndrome. Pain Medicine, 2007;4:326-31.

    8.Wolfe F. Fibromyalgia wars. J Reumatology 2009;36:671-8.

    9. Terkelsen AJ, Bach FB, Jensen TS. Experimental Forearm Immobilization in Humans Induces Cold and Mechanical Hyperalgesia. Anesthesiology, 2008;109:297-307.

    10. Frolke JP, van Rumund A, de Waardt D, van Dongen RT, Klomp FP, Verbeek AL, van de Meent H. Complex regional pain syndrome type 1? In 77% of people had a different diagnosis. Ned Tijdschr Geneeskd, 2009;153:550-3

    11. Del Pinal F. Editorial. I have a dream ... reflex sympathetic dystrophy (RSD or Complex Regional Pain Syndrome - CRPS I) does not exist. J Hand Surg Eur Vol, 2013;38:595-7

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  5. Correction of the first affiliation

    We would like to confirm that the name of the first affiliation: Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China should be: Department of Biostatistics, Key Laboratory of Public Health Safety, School of Public Health, Fudan University, Ministry of Education, Shanghai, China.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  6. More data and works are needed on shared decision-making in Malaysia

    This is very interesting research on primary care in Malaysia. The strength and limitations were rightly mentioned. However, the researchers should consider reporting on the roles of preference and actual roles in decision-making according to the different disease profiles such as those with acute diseases versus those with chronic diseases. This was somehow left out in the Table 2. These reasons for seeing doctors were probably verified from the patients' case notes?

    With regards to the CPS, it would also be enlightening to know the responses to each of the items. Responses to item 1 and 5 to this questionnaire do make ones seem like they are held by someone who has very strong opinions about their own health and treatment, which might invite very few responses. This then leaves items 2 to 4 to be more socially acceptable and desirable. This leads to my third query with regards to the post-consultation actual shared decision roles. Whose perception, the patients or the doctors, is more reliable and accurate about the actual roles played by patients in shared decision-making? This again is probably hugely influenced by the nature of the diseases the patients have, or the process of consultation and whether shared decision-making was really needed. Absent of the need for or lack of a clear process of shared decision-making in the clinical consultation would cause the actual roles played as perceived by the patients and the doctors to be mere imaginations. This might explain the wide gap of different perceptions between that of the patients and the doctors on the post-consultation roles in shared decision-making.

    It was surprising to learn that the total household income influenced the preference of roles in shared decision-making. Does having more money empowers our patients more than their internal and personal abilities (such as cognitive, emotional skills and spiritual/value systems) when making decisions about treatment and health choices? This does seem to go in line with the current direction of engaging patients with health incentives and behavioural economics research [1].

    Reference

    [1] Volpp KG, Asch DA, Galvin R, Loewenstein G. Redesigning employee health incentives-lessons from behavioral economics. N Engl J Med. 2011 Aug 4;365(5):388-90. doi: 10.1056/NEJMp1105966.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  7. Extreme obesity may predict better functional outcomes among stroke patients: concerns regarding body composition and weight management

    In a recent paper published in BMJ Open, Jang et al. reported that extreme obesity [body mass index (BMI) >= 30] is an independent predictive factor for good functional outcomes in stroke survivors 6 months after onset [1]. These results are consistent with previous studies [2-5] and are important in the stroke rehabilitation setting because weight management of obese patients has been a critical issue for improving physical function and preventing future cerebrovascular diseases. However, we have some concerns regarding the study.

    First, the authors did not include age in the multiple regression analysis. Although the study participants were stratified into two groups based on age (>= 65 years and < 65 years), previous reports have shown a significant correlation between age per year and functional outcomes [2-5]. The results of the current study [1] also showed that the mean age tended to decrease among BMI stratification groups, such as 79.1, 75.7, 74.3, 73.6, and 72.6 years in the underweight, normal, overweight, obese, and extremely obese groups, respectively, in participants >= 65 years of age. Thus, the authors should have included age as a continuous variable in the multiple regression analysis.

    Second, the pre-stroke physical and cognitive function was not described. Stroke patients have often experienced functional difficulties before stroke onset due to various conditions, such as dementia, particularly in older patients. These problems usually limit the patients' functional recovery. Some articles have suggested that pre-stroke functional conditions are independent risk factors for functional outcomes or mortality [2-4]. Therefore, the pre-stroke activities of daily living or the residential situation status, such as living at home or in an institution, should be investigated.

    Third, the length of the hospital stay, implementation of rehabilitation, and destination at discharge were not shown in this paper. This study used the functional independence measure (FIM) at discharge as a confounder for the 6-month FIM; however, the length of hospital stay also affects FIM at discharge [6]. In addition, rehabilitation implementation and discharge destination correlate with functional recovery. We consider that describing the length of hospital stay, implementation of rehabilitation, and destination at discharge would be helpful in interpreting the results.

    Fourth, the National Institutes of Health Stroke Scale (NIHSS) scores were measured at 7 days after stroke onset. However, the initial NIHSS score is a stronger independent predictor for functional outcomes than BMI [7]. From this perspective, the NIHSS scores at admission could be a more effective factor for functional recovery than those at 7 days after stroke onset.

    Finally, whether extremely obese stroke patients should lose weight or not is still unclear. We recognize that extremely obese stroke patients have often been encouraged to lose weight because extreme obesity, particularly excessive fat deposition, has been associated with metabolic disorders and functional disabilities. Moreover, the existence of an obesity paradox among stroke survivors remains controversial [7-9]. To maximize functionality in stroke patients, we believe that optimal rehabilitation nutrition as a combination of rehabilitation and nutrition care management [10] should emphasize on body composition rather than BMI in the rehabilitation setting. Further studies investigating the proportion or distribution of body mass and weight changes after stroke are required.

    We believe that these concerns should be addressed to confirm the reported findings from this study.

    References

    [1] Jang SY, Shin Y-I, Kim DY, et al. Effect of obesity on functional outcomes at 6 months post-stroke among elderly Koreans: a prospective multicentre study. BMJ Open. 2015;5(12):e008712. doi:10.1136/bmjopen-2015- 008712.

    [2] Doehner W, Schenkel J, Anker SD, Springer J, Audebert H. Overweight and obesity are associated with improved survival, functional outcome, and stroke recurrence after acute stroke or transient ischaemic attack: Observations from the TEMPiS trial. Eur Heart J. 2013;34(4):268- 277.

    [3] Zhao L, Du W, Zhao X, et al. Favorable functional recovery in overweight ischemic stroke survivors: Findings from the China National Stroke Registry. J Stroke Cerebrovasc Dis. 2014;23(3):e201-e206.

    [4] Nishioka S, Wakabayashi H, Yoshida T, Mori N, Watanabe R, Nishioka E. Obese Japanese Patients with Stroke Have Higher Functional Recovery in Convalescent Rehabilitation Wards: A Retrospective Cohort Study. J Stroke Cerebrovasc Dis. 2015. doi:10.1016/j.jstrokecerebrovasdis.2015.08.029.

    [5] Andersen KK, Olsen TS. Body mass index and stroke: Overweight and obesity less often associated with stroke recurrence. J Stroke Cerebrovasc Dis. 2013;22(8):e576-e581.

    [6] Miyai I, Sonoda S, Nagai S, et al. Results of new policies for inpatient rehabilitation coverage in Japan. Neurorehabil Neural Repair. 2011;25(6):540-547.

    [7] Kim Y, Kim CK, Jung S, Yoon B-W, Lee S-H. Obesity-stroke paradox and initial neurological severity. J Neurol Neurosurg Psychiatry. 2014;308664. doi:10.1136/jnnp-2014-308664.

    [8] Dehlendorff C, Andersen KK, Olsen TS. Body Mass Index and Death by Stroke: No Obesity Paradox. JAMA Neurol. 2014;71(8):1-7.

    [9] Razinia T, Saver JL, Liebeskind DS, Ali LK, Buck B, Ovbiagele B. Body mass index and hospital discharge outcomes after ischemic stroke. Arch Neurol. 2007;64(3):388-391.

    [10] Wakabayashi H, Sakuma K. Rehabilitation nutrition for sarcopenia with disability: a combination of both rehabilitation and nutrition care management. J Cachexia Sarcopenia Muscle. 2014;5(4):269-77.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  8. Intact aldehyde dehydrogenase 2 activity is required for beneficial effects of moderate alcohol intake

    Beneficial effect of moderate alcohol intake on a variety of health issues should be limited to people with normal acetaldehyde-metabolizing capacity from intact aldehyde dehydrogenase 2 (ALDH2), which is true of the majority of western people like the subjects in Berntsen's study [1]. However, Asians, particularly East Asians (Korean, Chinese, and Japanese) include significant numbers of the population with inactive ALDH2, approximately 30 to 40% of the whole population, which is encoded by the genotype - either homozygous (ALDH2*2/*2) or heterozygous (ALDH2*1/*2) - of the mutant ALDH2 allele (ALDH2*2), leading to loss of ALDH2 activity [2,3]. This point mutation in ALDH2 is the most frequent variant in humans and is present in 8% of the world's population, or approximately 560 million people, who show a distinctive physiological response to drinking even a small amount of alcohol. This phenomenon includes facial flushing, nausea, palpitation, headache, pruritus, and a hangover the next morning. [3,4] Thus, such bad experiences with alcohol produced a lot of non- drinkers in East Asia, which is predominantly caused by immediate and prolonged acetaldehyde exposure with an inherited deficiency of ALDH2 enzyme. Moreover, this genetic polymorphism has been indicated to be closely associated with digestive tract cancer, neurodegenerative disease, metabolic syndrome, and atherosclerotic vascular disease [5], which potentially gives some new insights into the mechanism of health protective effects of moderate alcohol intake, and future research directions.

    References

    1. Berntsen S, Kragstrup J, Siersma V, Waldemar G, Waldorff FB. Alcohol consumption and mortality in patients with mild Alzheimer's disease: a prospective cohort study. BMJ Open 2015;5(12):e007851.

    2. Eng MY, Luczak SE, Wall TL. ALDH2, ADH1B, and ADH1C genotypes in Asians: A literature review. Alcohol Res Health 2007;30:22-27.

    3. Yokoyama A, Omori T, Yokoyama T. Alcohol and aldehyde dehydrogenase polymorphisms and a new strategy for prevention and screening for cancer in the upper aerodigestive tract in East Asians. Keio J Med 2010;59:115- 130.

    4. Gross ER, Zambelli VO, Small BA, et al. A personalized medicine approach for Asian Americans with the aldehyde dehydrogenase 2*2 variant. Annu Rev Pharmacol Toxicol 2015;55:107-27.

    5. Chen CH, Ferreira JC, Gross ER, Mochly-Rosen D. Targeting aldehyde dehydrogenase 2: new therapeutic opportunities. Physiol Rev 2014;94:1-34.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  9. Questions about Comorbidities

    There was never any intention to match the wound patients with their matched controls on the basis of their comorbidities, since differences in comorbidities between the groups is an outcome we wanted to measure. The patients' records did not describe the severity of their comorbidities in all cases. Furthermore, it would have been difficult to disentangle resource use for the comorbidities from that associated with wound care in all instances. It would also have proved very challenging to identify which resources were used to manage individual comorbidities as many patients in both groups had two or more comorbidities. Hence, we employed the two methods described in the article to separate the cost of comorbidities from that of wound care. We recognise this is methodologically limited and we state in the article that the possibility of resource use associated with managing a comorbidity being conflated with that of wound management cannot be excluded. Previous experience working with the THIN database indicated that the population size of 1,000 patients per group would be sufficient to address the study's objectives.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  10. Cardiovascular mortality 1990 to 2006

    I note with interest that your population cohort covers a 16 year time period.

    In this respect may I direct you to some research I have been conducting on a time-series of infectious like outbreaks affecting both medical admissions and all-cause mortality (1-17).

    I have recently demonstrated these events across the whole of Europe (10) and Australia (14), they are condition specific (1,3-9,11,13), and show infectious-like small area spread (5,8,14,15).

    Preliminary evidence suggests that cardiovascular conditions are also affected (1,11,17).

    Can I suggest that your long time series presents an ideal opportunity to determine if these events are as wide-spread and wide- reaching, as seems to be indicated.

    References

    1. Jones R. Could cytomegalovirus be causing widespread outbreaks of chronic poor health? Hypotheses in Clinical Medicine, 2013, pp 37-79, Eds M. Shoja, et al. New York: Nova Science Publishers Inc. Available from: http://www.hcaf.biz/2013/CMV_Read.pdf

    2. Jones R. Widespread outbreaks of a subtle condition leading to hospitalization and death. Epidemiology: Open access, 2013, 4(3): 137.

    3. Jones R. Increased deaths in 2012: which conditions? BJHCM, 2014, 20(1): 45-47.

    4. Jones R, Goldeck D. Unexpected and unexplained increase in death due to neurological disorders in 2012 in England and Wales:Is cytomegalovirus implicated? Medical Hypotheses, 2014, 83(1): 25-31.

    5. Jones R. Infectious-like Spread of an Agent Leading to Increased Medical Admissions and Deaths in Wigan (England), during 2011 and 2012. British Journal of Medicine and Medical Research, 2014, 4(28): 4723 -4741.

    6. Jones R. A Study of an Unexplained and Large Increase in Respiratory Deaths in England and Wales: Is the Pattern of Diagnoses Consistent with the Potential Involvement of Cytomegalovirus? British Journal of Medicine and Medical Research, 2014, 4(33): 5179-5192.

    7. Jones R. An unexpected increase in adult appendicitis in England (2000/01 to 2012/13): Could cytomegalovirus (CMV) be a risk factor? British Journal of Medicine and Medical Research, 2015, 5(5): 579-603.

    8. Jones R, Beauchant S. 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, 2015, 6(1): 126-148.

    9. Jones R. Unexpected and Disruptive Changes in Admissions Associated with an Infectious-like Event Experienced at a Hospital in Berkshire, England around May of 2012. British Journal of Medicine and Medical Research, 2015, 6(1): 56-76.

    10. Jones R. Recurring Outbreaks of an Infection Apparently Targeting Immune Function, and Consequent Unprecedented Growth in Medical Admission and Costs in the United Kingdom: A Review. British Journal of Medicine and Medical Research, 2015, 6(8): 735-770.

    11. Jones R. A new type of infectious outbreak? SMU Medical Journal, 2015, 2(1): 19-25.

    12. Jones R. Are emergency admissions contagious? BJHCM, 2015, 21(5): 227-235.

    13. Jones R. Unexpected Increase in Deaths from Alzheimer's, Dementia and Other Neurological Disorders in England and Wales during 2012 and 2013. Journal of Neuroinfectious Diseases, 2015, 6:172.

    14. Jones R. 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, 2015, 2(2): 53-67.

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

    16. Jones R. 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, 2015, 11(2): 1-31.

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

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response

Don't forget to sign up for content alerts to receive selected information relevant to your specialty interests and be the first to know when the latest research is published.