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Recent eLetters

Displaying 11-20 letters out of 524 published

  1. The Possible Association of the Incidence of ESRD in the Patient with Diabetic Nephropathy with Salt Intake in the World

    Increasing number of the patients with endstage renal disease (ESRD) is nowadays a serious problem in each country, including many Western countries and Asian countries. Diabetic nephropathy (DMN) is the major cause of the incidence of ESRD in worldwide. In Japan, DMN has been the leading cause of dialysis since 1998 despite many innovative achievements in the pharmacological treatment for diabetes mellitus. Excessive salt intake causes hypertension and increases the risk for cerebro-cardio- vascular disease as well as ESRD [1]. However, the association of salt intake and the incidence of ESRD in the patients with DMN remains unknown. It is reported that many Asian countries, such as Singapore, Malaysia, Republic of Korea, Hong Kong, Taiwan, Philippines and Japan, head the list of the percentage of incident patients of ESRD due to diabetes [2]. Meanwhile, many Western countries, such as United States, Iceland, Canada, Finland, Portugal, Croatia, Czech Republic, Austria, Greece, Denmark, Bosnia/Herzegovina, United Kingdom, Sweden, Spain, Scotland, France, Serbia, Belgium, Netherlands, Norway and Romania, run after Asian countries. A report of global national sodium intakes shows that these East Asian countries consume more salt than these Western countries [3]. We simply analyzed the relationship between percent incidence of DMN in ESRD and salt intake(Figure, not shown). It clearly demonstrated a significant relationship between them (r = 0.483, P = 0.009). The average percent incidence of DMN in ESRD in East Asian countries was significantly higher than that in Western countries (47.5 % vs 27 %, p < 0.001) as well as salt intake (11.8 g/day vs 9.5 g/day, p < 0.001), suggesting the link between progression of DMN and salt intake in East Asian countries, while the protection of DMN by low salt consumptions in Western countries. A multiple linear regression analysis adjusted by salt intake demonstrated that the average percent incidence of DMN in ESRD in East Asian countries was still significantly higher than that in Western countries (p < 0.001). The result indicated that DMN patients in East Asian countries are genetically salt-sensitive compared with Western countries. A few reports supported the idea that there is a certain difference of salt sensitivity between East Asian and Western countries [4]. Further studies are required to confirm the association of the incidence of ESRD in the patients with DMN and salt intake.

    References

    1. Mozaffarian D, Fahimi S, Singh GM, et al. Global sodium consumption and death from cardiovascular causes. N Engl J Med 2014;371:624-34.

    2. U S Renal Data System. USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013.

    3. Powles J, Fahimi S, Micha R, et al, Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide. BMJ Open, 2013, 3:e003733.

    4.Mente A, O'Donnell MJ, Rangarajan S, et al. Association of urinary sodium and potassium excretion with blood pressure. N Engl J Med 2014;371:601-611

    Conflict of Interest:

    None declared

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  2. Blood transfusion: a double-edged sword

    Dear Editor,

    I read with interest the article. Though blood transfusion is life- saving in patients with massive bleed, its routine use like transfusion in post-operative patients with Hb <10 gm% is definitely counter- productive.The transfusion of even as little as 1 unit of RBCs has been associated with decrease 10-year survival after CABG.(1,2)

    References:

    1. Koch CG,Duncan AI, Mihalijevic T, et al.Transfusion in coronary artery bypass grafting is associated long-term survival. Ann Thorac Surg.2006;81:1650-1657.

    2.Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation. 2007;116:2544-2552.

    Conflict of Interest:

    None declared

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  3. Effectiveness of the Assessment of Burden of COPD (ABC) tool on health-related quality of life in patients with COPD: Twitter Discussions from the University of Toronto Respirology and Sleep Journal Club (@respandsleepjc)

    Preyanka Abhyankar, Anju Anand, Matthew B. Stanbrook

    We welcomed the study by Slok and colleagues examining the effect of a tool for assessing the burden of COPD on quality of life as the article of discussion for our Twitter-based asynchronous monthly respirology and sleep journal club. This non-blinded cluster randomized control trial included both primary and hospitalist care and found that the Assessment of Burden of COPD (ABC) tool produced improvements on two separate quality of life measures (SGRQ, PACIC) but not on a third measure (the CAT) (1).

    The most important issue identified in our online discussions was the potential that the main results could be an artefact of regression to the mean. The intervention and control groups differed at baseline, both with regard to baseline disease severity as reflected by FEV1 and FEV1/FVC ratio, as well as in the baseline values of the quality of life outcome measures. Post-intervention, the two groups became progressively more similar over time, as illustrated in Table 2. Thus, rather than a true effect of the intervention, the study results could simply reflect natural variation around a common mean level of disease- specific quality of life with the intervention group, showing the greatest response only because they happened to diverge furthest from this level at baseline (2,3). It was unclear if the groups were unbalanced due to cluster randomization itself or due to the real-world nature of the study not lending itself well to randomization, which was further exacerbated by the small sample size (4,5).

    Another important issue highlighted in our discussions was that this study was unblinded or and lacked a sham group. Compounded with the subjective nature of the outcome measure, this may have introduced reporting bias (6). The study's inability to capture more objective lung function and exacerbation outcomes as planned is thereby even more problematic, and as a result our group felt that it is difficult for the study to yield a meaningful evaluation of the ABC tool (7).

    A final issue raised was that the study was performed under real- world conditions, which can be an asset, however the liberal inclusion criteria (e.g. including any obstructive lung pathology with FEV1/FVC < ,0.7, not requiring a smoking history, etc.) raised concern around misclassification of patients (8,9).

    We do agree with Slok et al. that developing and validating patient care interventions like the ABC tool is an important step towards enhancing patient involvement in the management of their chronic illness and we commend the efforts of the authors to do so via a randomized trial. However, we feel further studies are still needed to assess the effectiveness of this tool before it becomes clear what value it may hold for clinical practice (10, 11).

    REFERENCES 1. Slok, A. H., Chavannes, N. H., van der Molen, T., Rutten-van M?lken, M. P., Kerstjens, H. A., Salom?, P. L., ... & van Schayck, O. C. (2014). Development of the Assessment of Burden of COPD tool: an integrated tool to measure the burden of COPD. NPJ primary care respiratory medicine, 24, 14021. 2. Stanbrook, M. [drstanbrook]. (2016, Jul 21). @respandsleepjc Take a look at table of continuous SGRQ scores. Clear evidence of regression to the mean. This is all an artefact. #rsjc [Tweet]. Retrieved from https://twitter.com/drstanbrook/status/756268723980292096 3. Stanbrook, M. [drstanbrook]. (2016, Jul 22). @respandsleepjc Still a problem. Intervention got better while control got WORSE = RTTM. #rsjc https://t.co/JG77Qub5Az [Tweet]. Retrieved from https://twitter.com/drstanbrook/status/756278596495368193 4. Vagaon, A. [AndreiV_Resp]. (2016, Jul 21). @respandsleepjc Perhaps an effect of the real world not randomizing in a good way; ?smaller sample more prone; but throws things off #rsjc [Tweet]. Retrieved from https://twitter.com/andreiv_resp/status/756271906786074625 5. Christiansen, D. [dcwpg]. (2016, Jul 21). Unusual to see groups so unequal at baseline. Is it a result of the clustered randomization and having too few study docs? #rsjc [Tweet]. Retrieved from https://twitter.com/dcwpg/status/756270239516467201 6. Stanbrook, M. [drstanbrook]. (2016, Jul 21). @respandsleepjc Not good enough. This is an unblinded trial with a subjective outcome measure. Setup for bias. #rsjc https://t.co/Wph3qMC7F2 [Tweet]. Retrieved from https://twitter.com/drstanbrook/status/756266741462728704 7. Zaheen, A. [drazaheen]. (2016, Jul 22). @respandsleepjc But difficult to comment on the value of ABC in the absence of objective data! #rsjc [Tweet]. Retrieved from https://twitter.com/drazaheen/status/756278274444005378 8. Christiansen, D. [dcwpg]. (2016, Jul 21). Great to see an RCT done under real-world conditions. Struck by the very liberal inclusion criteria (didn't even require a smoking Hx) #rsjc [Tweet]. Retrieved from https://twitter.com/dcwpg/status/756265754329092096 9. Vagaon, A. [AndreiV_Resp]. (2016, Jul 21). @thelungdr Not sure why absolute ratio 0.7, rather than LLNs. Ptnt can be misclasified. Esp. as impact was 49 v 33 people @ 18 months #rsjc [Tweet]. Retrieved from https://twitter.com/andreiv_resp/status/756268872781664256 10. Anand, A. [respandsleepjc]. (2016, Jul 22). Summary- interesting study - grp not bal to start, blinding (lack of) & RTTM problematic-- need more studies to assess this tool #rsjc [Tweet]. Retrieved from https://twitter.com/respandsleepjc/status/756285601477980160 11. Zaheen, A. [drazaheen]. (2016, Jul 22). @respandsleepjc Part of the important trend towards patient involvement in the management of chronic illness #rsjc [Tweet]. Retrieved from https://twitter.com/drazaheen/status/756277959481143296

    Conflict of Interest:

    None declared

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  4. Response to Levett et al

    We read with much interest the recent article by Levett et al on the use of alternative therapies in labour and delivery to manage pain.[1] This is certainly a hot topic of research and we were pleased to see groups working to provide an evidence base for maternity care practises. To aid implementation and wider use we thought some aspects require closer scrutiny.

    It seems to us that the study was designed to assess both pain control and unnecessary medical intervention. Epidural use as analgesia was used as a surrogate measure for failing pain management during labour. Whilst the use of surrogate endpoints can be highly problematic,[2] the authors justify its use in this case due to its role in initiating the 'cascade of interventions'. They describe that as epidural rates increase, so do the rates of instrumental births and other associated unnecessary medical interventions.

    Whilst reviews cited by the authors have shown instrumental deliveries may increase, the same high-quality evidence shows epidural blocks neither increase the overall caesarean rate nor adverse neonatal outcomes.[3] Not all epidurals are created equal; some blocks have higher rates of side effects and adverse events.[3] As such it is important to distinguish between high-dose epidurals, low-dose epidurals and combined spinal-epidurals, for example.

    Levett et al assume that epidural blocks are used when other pain management strategies fail. We question whether this is a true reflection of how epidurals are used in practice. Epidurals can be placed early in labour, which allows for the use of blocks with fewer side effects however delivery suite personnel and other factors occasionally delay administration.[4, 5] As such the rate of epidural block may more accurately represent women's antenatal attitudes to pain relief during labour rather than the pain they experience.[6] Previous studies have assessed attitudes towards analgesia and the birthing process as a baseline characteristic between groups.[6]

    As the authors mention, designing robust studies of such interventions is challenging. Delivery suite personnel were aware of the study's existence but they were not informed of group allocations of participants. In our experience not many women or their partners are trained to administer alternative therapies in the manner described. Whether by simple observation of techniques or by the usual rapport a midwife forms with patients, it is plausible that group allocation may have become apparent to delivery floor practitioners. Simple methods such as asking involved personnel to guess which group a participant was allocated to could assess such risk in future studies.

    Whilst we take the authors' advice to interpret secondary outcomes with caution, the labour agency scale (LAS) outcomes were incongruent; despite extra education women in the study group felt they had significantly less control or 'agency' over their birthing process. Levett et al conclude their course 'increased personal control for women', which contradicts their description of the LAS measure they used and its results. The origin of this disparity remains unclear through the discussion, which refers to a more 'positive attitude towards birth in the antenatal period'. Did the authors assess antenatal birthing attitudes?

    Some other outcome measures, such as 'other pharmacological pain relief' were either incompletely defined or only partially reported. It is unclear why only pethidine and nitrous use were reported. Other medications have more favourable side effect profiles in the peripartum population, are commonly utilised and are recorded in the datasets utilised by the authors of this study.[7, 8] Whilst there was no difference in pethidine or nitrous use between the groups, it is not reasonable to draw any conclusions about pain management or control without data on women's intra-partum pain levels and their use of other medications.

    Despite approximately three times the epidural rate in the control group there was no significant difference in the instrumental delivery rate. Epidural analgesia increases instrumental delivery rate by approximately 1.4 times.[3] Given the differences in epidural rate between groups, the magnitude of this effect would be expected to be detectable with this sample. This might reflect underlying differences in the groups or that practises in the studied hospitals vary from the norm. Alternatively perhaps these large studies that are dominated by US data may not reflect Australian practice. One of the best UK trails to date showed where epidurals are utilised less routinely there is no increase in caesareans or instrumental delivery.[9]

    High-quality studies have concluded relaxation and education classes for low-risk women can reduce the caesarean rate which may in part explain the observed effects in this study.[10] Overall we welcome this new contribution to the field; it raises interesting points for further study. We would caution against over interpretation of the results, particularly in mainstream media where broad statements might overreach the scientific conclusions that can be drawn from any one piece of research.[11] We look forward to perusing the results of future iterations of this group's work on a larger scale.

    In the meantime, the rights of women to weigh up the potential benefits of epidural analgesia[3] against a possible increase in instrumental deliveries continues to be an important focus of antenatal discussion. As one review eloquently concluded, current evidence suggests "in the absence of a medical contraindication, maternal request is a sufficient medical indication for [epidural] pain relief during labor."[4]

    References:

    1. Levett, K.M., et al., Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour. BMJ Open, 2016. 6(7): p. e010691.
    2. Fleming, T.R. and D.L. DeMets, Surrogate End Points in Clinical Trials: Are We Being Misled?Annals of Internal Medicine, 1996.125(7): p. 605-613.
    3. Anim-Somuah, M., R.M. Smyth, and L. Jones, Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev, 2011(12): p. CD000331.
    4. Sng, B.L., et al., Early versus late initiation of epidural analgesia for labour. Cochrane Database Syst Rev, 2014(10): p. CD007238.
    5. Hess, P.E., et al., Predictors of Breakthrough Pain During Labor Epidural Analgesia.AnesthAnalg, 2001. 93: p. 5.
    6. Goldberg, A.B., A. Cohen, and E. Lieberman, Nulliparas' Preferences for Epidural Analgesia: Their Effects on Actual Use in Labor.Birth, 1999.26(3): p. 139-143.
    7. Jones, L., et al., Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev, 2012(3): p. CD009234.
    8. Wellfare, A.I.o.H.a., Meteor - National Dataset Standards.
    9. Loughnan, B.A., et al., Randomized controlled comparison of epidural bupivacaine versus pethidine for analgesia in labour.British Journal of Anaesthesia, 2000.84(6): p. 715-719.
    10. Khunpradit, S., et al., Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev, 2011(6): p. CD005528.
    11. Reporter: McCullagh, C., et al., Fewer medical problems with natural pain relief in childbirth, in ABC Radio National, L. Raine, Editor. 2016, ABC Radio National: Australia.

    Conflict of Interest:

    None declared

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  5. Commentary on: Does attractiveness influence condom use intentions in heterosexual men? An experimental study.

    Evan S. Herrmann1, Patrick S. Johnson2, and Matthew W. Johnson3

    1Division on Substance Abuse, New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons

    2Department of Psychology, California State University, Chico

    3Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine.

    In an article recently published in BMJ Open, Eleftheriou et al (2016) describe the results of an experimental study that examined the influence of partner attractiveness on condom use intentions. Heterosexual men completed a task where they rated the attractiveness of 20 photographs of women, estimated the likelihood each woman had a sexually transmitted infection (STI), and indicated their willingness to have sex with each woman with or without a condom. Higher ratings of attractiveness and lower ratings of STI risk were associated with lower condom use intentions. Participant sociodemographic and sexual history characteristics associated with STI acquisition were also associated with lower condom use intentions. Increasing our understanding of factors that affect choices about condom use has the potential to greatly improve public health, and we commend the authors on their contribution. Here we draw attention to a body of published work using a measures that have shown similar effects of attractiveness and STI risk, but also reveal another important dimension modulating condom use decisions: delay to condom availability.

    Johnson and Bruner (2012) developed the Sexual Delay Discounting Task (SDDT) to examine how sexual desirability, perceived STI risk, and delayed condom availability influence decisions about condom use. On the most commonly used version of this task, individuals view pictures of 30 men and 30 women and select pictures of the individuals whom they would consider having sex based on appearance alone. From these photographs, participants select the individual they most wanted to have sex with, least wanted to have sex with, they think is least likely to have an STI, and most likely to have an STI. Then, they rate their likelihood of using an immediately available condom when having sex with each individual, using a Visual Analog Scale ranging from 0 to 100. Next, they rate their likelihood having immediate unprotected sex vs. waiting for a specified delay to have condom-protected sex with each individual. Seven delays are examined, allowing for quantification of how delayed condom availability influences choices about condom use with partners who have different perceived levels of desirability and STI risk.

    We are aware of 12 studies using the SDDT that are currently published, in press, or under peer review. Across a variety of populations, including cocaine users (Johnson et al., 2015, 2016, Koffarnus et al., in press) men who have sex with men (Herrmann et al., 2015), opioid-dependent women (Herrmann et al., 2014), non-drug-using controls (e.g., Herrmann et al., 2015, Johnson et al., 2015), and emerging adults (Collado et al., in press; Dariotis and Johnson, 2015; Wongsomboon and Robles, 2016), participants reliably indicated they would be less likely to use immediately available condoms with those whom they most (vs. least) want to have sex and those they thought were least likely (vs. most likely) to have a STI. Individuals who reported higher rates of real-world risky sexual behavior and/or sociodemographic characteristics associated with STI risk also reported lower likelihood of using immediately available condoms on the SDDT. Condom use likelihood decreased as a function of delay to condom availability in an orderly manner well-fit by hyperbolic discounting functions that also describe the effects of delay on choices for other commodities (e.g., food or money). The SDDT has demonstrated test-retest reliability (Johnson and Bruner, 2013), and participants at higher risk for STI infection (e.g., individuals who report drug use or unprotected sex with multiple partners) showed larger decreases in condom use likelihood as a function of delay. One study (Herrmann et al., 2015) demonstrated that steeper discounting on the SDDT was associated with increased likelihood of having unprotected sex in the past six months specifically because a condom was not immediately available, suggesting the task has external validity. Lastly, the SDDT is sensitive to acute drug effects; alcohol and cocaine intoxication increased the deleterious effects of delay on condom use likelihood (Johnson et al., 2016, Johnson et al., under review), while the antipsychotic buspirone increased immediate condom use likelihood (Bolin et al., 2016).

    We commend Eleftheriou et al (2016) on their contribution to the literature, and note that the consistencies between their results and our own provide further evidence supporting the validity of behavioral tasks to study condom use decisions. Finally, as Eleftheriou et al (2016) stated, we hope that the knowledge gained from these studies can inform the development of new evidence-based interventions to reduce STI transmission.

    References

    Bolin, B. L., Lile, J. A., Marks, K. R., Beckmann, J. S., Rush, C. R., & Stoops, W. W. (2016). Buspirone reduces sexual risk-taking intent but not cocaine self-administration. Experimental and Clinical Psychopharmacology, 24, 162.

    Collado A., Johnson, P. S., Loya, J. M., Johnson, M. W., & Yi, R. (in press). Discounting of Condom-Protected Sex as a Measure of High-Risk for Sexually Transmitted Infection among College Students. Archives of Sexual Behavior.

    Dariotis, J. K., & Johnson, M. W. (2015). Sexual discounting among high-risk youth ages 18-24: Implications for sexual and substance use risk behaviors. Experimental and Clinical Psychopharmacology, 23, 49.

    Eleftheriou, A., Bullock, S., Graham, C. A., Stone, N., Ingham, R. (2016). Does attractiveness influence condom use intentions in heterosexual men? An experimental study. Sexual Health Research.

    Herrmann, E. S., Hand, D. J., Johnson, M. W., Badger, G. J., & Heil, S. H. (2014). Examining delay discounting of condom-protected sex among opioid-dependent women and non-drug-using control women. Drug and Alcohol Dependence, 144, 53-60.

    Herrmann, E. S., Johnson, P. S., & Johnson, M. W. (2015). Examining delay discounting of condom-protected sex among men who have sex with men using crowdsourcing technology. AIDS and Behavior, 19, 1655-1665.

    Johnson, M. W., & Bruner, N. R. (2012). The Sexual Discounting Task: HIV risk behavior and the discounting of delayed sexual rewards in cocaine dependence. Drug and Alcohol Dependence, 123, 15-21.

    Johnson, M. W., & Bruner, N. R. (2013). Test-retest reliability and gender differences in the sexual discounting task among cocaine- dependent individuals. Experimental and Clinical Psychopharmacology, 21, 277.

    Johnson, M. W., Herrmann, E. S., Johnson, P. S., Sweeney, M. M., & LeComte, R. S. (under review). Cracking the code of cocaine and HIV sexual risk behavior: Cocaine administration dose-dependently increases sexual desire and decreases condom use likelihood via delay and probability discounting.

    Johnson, M. W., Johnson, P. S., Herrmann, E. S., & Sweeney, M. M. (2015). Delay and probability discounting of sexual and monetary outcomes in individuals with cocaine use disorders and matched controls. PloS one, 10, e0128641.

    Johnson, P. S., Sweeney, M. M., Herrmann, E. S., & Johnson, M. W. (2016). Alcohol increases delay and probability discounting of condom- protected Sex: A novel vector for alcohol-related HIV transmission. Alcoholism: Clinical and Experimental Research, 40, 1339-1350.

    Koffarnus, M. N., Johnson, M. W., Thompson-Lake, D. G. Y., Wesley, M. J., Lohrenz, T., Montague, R., & Bickel, W. K. (in press). Cocaine- dependent adults and recreational cocaine users are more likely than controls to choose immediate unsafe sex over delayed safer sex. Experimental and Clinical Psychopharmacology.

    Wongsomboon, V., & Robles, E. (2016). Devaluation of safe sex by delay or uncertainty: A within-subjects study of mechanisms underlying sexual risk behavior. Archives of Sexual Behavior, 1-14.

    Conflict of Interest:

    None declared

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  6. Why to focus on men only? Hypertension is almost equally prevalent and equally pernicious for both genders.

    Dear Editor,

    I read with interest the article. However, it is hard to justify their conclusion as "Focusing on men, an intervention could be designed for lifestyle modification to curb the prevalence of hypertension".

    Firstly, it was not a study to study the role of risk factors for hypertension and prehypertension, secondly, why to focus on men only? As not much difference in the prevalence of non-normotension (for prehypertension 39% in men and 25% in women for hypertension 12.5% in men and 11.3% in women). Moreover, authors clearly mentioned in the paper " We hypothesised that observed sex differences in hypertension may be in part due to differences in risk factors, such as BMI, smoking, and physical activity. However, taking these factors into account had virtually no effect on the sex differences in hypertension. This suggests that the sex differences among young adults may be partly due to biological sex differences, but more research is needed to investigate other behavioural factors that may explain this early disparity".

    Yes, as reported earlier, the risk of the complications of arterial hypertension is greater in men than in women 1. Interestingly,in elderly groups; this difference between sexes is reduced, particularly the risk of cardiovascular complications, which is strikingly increased in women after menopause 2,3. In conclusion, my message is: prevention of hypertension is equally important for both genders.

    Reference:

    1. Messerli FH, Garavaglia GE, Schmieder RE, Sundgaard-Riise K, Nunez BD, Amodeo C. Disparate cardiovascular findings in men and women with essential hypertension. Ann Intern Med 1987; 107: 158-61.

    2. Nachtigall LE. Cardiovascular disease and hypertension in older women. Obstet Gynecol Clin North Am 1987; 14: 89-105.

    3. Rosenthal T, Oparil S. Hypertension in women. J Hum Hypertens 2000; 14: 691-704.

    Conflict of Interest:

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  7. Early Intervention to Prevent ARF and Prolonged Mechanical Ventilation

    To the Editor:

    Regarding the study of early intervention of patients at risk for acute respiratory failure and prolonged mechanical ventilation, I agree that a checklist, such as the PROOFCheck, aimed at the prevention of organ failure would be beneficial in lowering rates of mortality.

    The authors' report that often times the acuity and severity of patients' conditions often are not recognized in a timely manner. Rather than recognize and intervene with the signs and symptoms of ARF and acute organ failure on the general medical floors, health care works sometimes don't catch a patient spiraling downward until they are already moved to an intensive care unit. To my attest from working as a respiratory therapist, I have seen this countless times. As I am not sure of the stipulations of the six hospitals where this study is being conducted, I have witnessed many times that general floors are understaffed. The nursing to patient ratio is often times too low and therefore they cannot provide adequate care. In one of the facilities I was employed at, a general floor nurse could have as many as seven patients. Another problem I've seen is that while many of the critical care nurses are experienced nurses, a lot of the general floor nurses are new graduate nurses and therefore are still trying to learn as they go so may not have the knowledge or experience to spot a critical patient on the general floor and intervene or call the rapid response team in time before a patient gets worse.

    I commend the authors of this study for attempting to research whether or not an EMR-based alert system would be sufficient in preventing and recognizing ARF and acute organ failure. Both the APPROVE score and PROOFCheck, as well as a notification feature provided a patient may meet certain criteria for going into ARF all seem like they would be excellent tools for early detection and prevention.

    I thank you for your time and enjoyed reading the article, and I look forward to following up with the outcome of this study.

    Sincerely,

    Alexandria Erickson BAS Cardiopulmonary Science Student Physician Assistant - Nova Southeastern Fort Myers Fort Myers, FL ae633@nova.edu

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  8. To improve patients' uptake of diabetic retinopathy screening programme

    We read this article with great interest. We similarly aimed to explore barriers to patient engagement with diabetic retinopathy screening as part of a medical student service evaluation project. We explored reasons for non-attendance using a GP practice population that serves a large Asian community in Blackburn. We found that from June 2014 to June 2015, 81.2% (n=307) of the patients invited for screening attended and 18.8% (n=71) did not attend. We managed to conduct telephone interviews with 43 non-attenders to establish their understanding of screening and reasons for non-engagement. 33 (76.7%) patients who were interviewed cited other commitments, 3 (7%) did not recall receiving any invite letters, 3 (7%) were housebound, and the remaining 4 patients (9.3%) voiced a general lack of interest in attending medical appointments. Surprisingly, 23 (53.4%) patients were unaware of the need of attending screening appointments when visually asymptomatic and 8 (18.6%) stated that they did not believe that diabetes could damage eyes. As a result of these findings, we have now designed a patient information leaflet outlining the importance and rationale behind the diabetic retinopathy screening programme. This has now been adopted by the local CCG allowing GPs in the locality to provide these at the point of diagnosis and at routine diabetic review appointments to help promote uptake for the future. We plan to re-audit uptake rates following this intervention.

    Conflict of Interest:

    None declared

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  9. Minor corrections in the conclusion section.

    My name is Damaris Kinyoki, I recently published with BMJ Open. Please note that the conclusion section of the article should be corrected to read as follows:

    Conclusion This study has demonstrated that wasting, stunting and underweight in children 6-59 months in Somalia share common risk factors with evidence of correlation in space (17,47). The emergency response funding is by nature short term. The spatial patterns and trends of wasting and stunting and information on seasonal variation, the age and gender of the child can be used to support effective interventions. Although emergency nutrition response in Somalia focuses on wasting, our evidence suggests implementation of a more joined-up program may be most effective. This will require political will, appropriate financing, policies and programmatic links between partners on the main indicators of malnutrition.

    Kind regards, Damaris

    Conflict of Interest:

    None declared

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  10. Some major error in the article

    A pooled SMD of 1.20 (95% CI 0.89 to 1.51; T2=0.27; I2=99%; p<0.00001) was observed (figure 3), equivalent to a prevalence of ?50% asymptomatic coronary stenosis of 32% (95% CI 19% to 47%).

    This paragraph mismatch the figure 3 in all numbers. Please correct it if possible.

    Conflict of Interest:

    None declared

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