1099 e-Letters

  • Epidemiology of lower limb extremity amputations – Do we already have the answer to why there is significant variation in the reporting of incidence, prevalence and number?

    Dear Editor,

    It is interesting to read that Meffen A, et al. (2020) will study the incidence, prevalence and number of major-lower limb amputations in the UK, amongst their objectives. They plan to investigate the reasons for significant variation in the reporting of epidemiology of major lower extremity amputation (LEA). Prevalence of LEA has been evaluated, on numerous occasions in many epidemiological studies (1-14).

    There has been a recent study that has followed similar methods and objectives to Meffen A, et al. (2020), to determine the methodological differences that create the variation of prevalence of LEAs (1). There are also studies that have used robust methodology to report on incidence, prevalence and number of LEAs, which include age standardised, gender, ethnic minority, and regional specific data analysis (6, 13, 14).

    The same systematic searches of peer reviewed journals using PRISMA guidelines, have already been carried out from a comprehensive range of databases: PubMed, Cumulative index to Nursing and Allied Health Literature (CINAHL), ExperptaMedica Database (EMBASE), Medical Literature Analysis and Retrieval Online (MEDLINE), Cochrane database, NHS Digital, Diabetes UK and Healthcare Quality Improvement Partnership (HQIP), of all LEA studies performed in England, over a 30 year period (1988- 2018) (1).

    The variation in prevalence of major LEAs, reported by Davies M, Burdett L, Bowling F, et al. (2019) range from 0.7...

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  • One pharmacist’s perspective on “ Changes over a decade in psychotropic prescribing for people with intellectual disabilities: prospective cohort study”.

    Inequalities and inequities in health and healthcare for people with intellectual disabilities have been of longstanding concern. Medication use is the major therapeutic intervention in this vulnerable population. The use of medication cannot be separated from the environment –physical and social – in which the person with intellectual disabilities lives and is supported.

    There is no ‘one size fits all’ regarding psychotropic medication use in this population group. Those providing direct care are the most important person in the life of an individual with intellectual disabilities and may have a direct influence on medication prescribed or de-prescribed, for problem behaviours etc.

    The social environment, the physical environment and societal preconditions, and their interconnectivity with one another and with individuals in the setting, play an important role in healthy settings for people with intellectual disabilities[1] . Physical, mental, psychological and spiritual well being may all be influenced by the environment. A recent study highlights a health-promoting social network of people with ID as a prerequisite for change [1].

    Pharmacists, as medication experts, in all healthcare environments can make positive contributions to the pharmaceutical care of patients with intellectual disabilities, in collaboration with other healthcare professionals, carers and patients themselves [2,3]. The expertise of specialist and other pharmacists i...

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  • Shift work and burnout in police officers: a risk assessment

    Dear Dr. Kawada,

    Thanks for your comment on our article, Shift work and burnout in police officers: a risk assessment. We appreciate that the risk of burnout may be multi-factorial and the relative contribution of each factor may vary by occupation. We did not examine work-related stress and conflict but appreciate that such factors may contribute to burnout risk in police officers. We maintain, however, our findings that sleepiness, inadequate sleep, irregular schedules, mandatory overtime, long shifts and night shifts are factors associated with elevated burnout risk in this population. We also controlled for age in our analyses and found that age was significant in the adjusted models examining shift work, sleep and their association with Depersonalisation and Personal Accomplishment. We agree that more research into the factors contributing to burnout and programs to mitigate it in safety-sensitive shift working occupations is necessary.

    Scott A Peterson, Alexander P Wolkow, Steven W Lockley, Conor S O'Brien, Salim Qadri, Jason P Sullivan, Charles A Czeisler, Shantha M W Rajaratnam and Laura K Barger

  • Shift work and burnout in police officers: a risk assessment

    Peterson et al. examined associations between shift work and burnout in 3140 police officers with special reference to sleep duration and sleepiness. The Maslach Burnout Inventory, shift schedules (irregular, rotating, fixed), shift characteristics (night, duration, frequency, work hours), sleep duration and sleepiness were used for the analysis. Adjusted odds ratios (ORs) (95% confidence intervals [CIs]) of long shifts and mandatory overtime for emotional exhaustion were 1.91 (1.35 to 2.72) and 1.37 (1.14 to 1.65), respectively. Adjusted OR (95% CI) of night shifts for depersonalisation was 1.32 (1.05 to 1.66). In addition, Adjusted ORs (95% Cis) of irregular schedules for emotional exhaustion and depersonalisation were 1.91 (1.44 to 2.54) and 1.39 (1.02 to 1.89), respectively. Furthermore, adjusted ORs (95% Cis) of sleeping <6 hours and excessive sleepiness for motional exhaustion were 1.60 (1.33 to 1.93) and 1.81 (1.50 to 2.18), respectively. I have a comment about their study.

    Ogundipe et al. determined factors burnout among 204 medical doctors undergoing residency training. General Health Questionnaire (GHQ-12) and Maslach Burnout Inventory (MBI) were used for the analysis. Adjusted OR (95% CI) of call duty as being not stressful for emotional exhaustion was 0.52 (0.29, 0.97). In contrast, adjusted OR (95% CI) of emotional distress, based on GHQ score of ≥3, for emotional exhaustion was 6.97 (3.28, 14.81). In addition, adjusted OR (95% CI) of absence of doc...

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  • Nearness to death and sarcopenia

    Hopefully this will become an invaluable study. Can I alert the authors to the role of nearness to death (the nearness to death effect) in both cognitive and functional decline especially in the last year of life.

  • Multimobidity or Comorbidity?

    In the references you cite, the definition of multimorbidity is showed as the co-existence of two or more chronic conditions, where one is not necessarily more central than the others. But you have defined multi-morbidity comorbidity as the presence of two or more chronic health conditions in an individual. Does your definition indicate comorbidity?

  • Comment on: “Incidence and risk factors of retinopathy of prematurity in Korle-Bu Teaching Hospital: a baseline prospective study.”

    To the editor:
    In response to the article titled “Incidence and risk factors of retinopathy of prematurity in Korle-Bu Teaching Hospital: a baseline prospective study.” published in your esteemed journal, I would like to raise a few points regarding this study. This is a well thought of and written paper which demonstrated that birth weight less than 1.5 kg, confirmed neonatal sepsis, nasogastric tube feeding and poor pupil dilation were independently associated with increased incidence of ROP. ROP screening should be a part of the routine service for premature infants in Ghana. (1)

    Retinopathy of prematurity (ROP) has a prevalence of 6 to 18% as one of the main causes of vision loss in childhood worldwide (2). Early diagnosis is of fundamental importance to avoid sequelae associated with this disease. However, we have a lack of trained professionals for the proper screening and monitoring of this disease. In addition, studies have shown that there may be a discrepancy in the diagnosis of this pathology among the specialists themselves. (3)
    Due to this difficulty in monitoring, new technologies can be developed to assist in early diagnosis and monitoring, avoiding this important cause of childhood blindness. There are devices such as Retcam that can assist in telemedicine monitoring. This device has a high cost that can be compensated with the development of technologies that allow the registration of newborn images with smartphones, facilitating documen...

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  • Response to comment on “Cost-effectiveness of total knee replacement in addition to non-surgical treatment”

    We thank Drs Müller and Shukri(1) for their interest in our recent publication in BMJ Open entitled “Cost-effectiveness of total knee replacement in addition to non-surgical treatment: a 2-year outcome from a randomised trial in secondary care in Denmark”(2).

    We agree with the authors, that clarity and transparency are crucial when reporting research in order to interpret findings. Below we have responded to each of the two comments given by the authors.

    First, while Table 2 and 3 of our publication reflects the actual, observed cost and health utilities, the incremental cost and health utilities presented in table 4 is estimated based on the regression analyses2. As such you cannot go directly from the numbers in Table 2 and 3 to the results in Table 4 without the parameters used for the regression. In order to ensure full transparency, please see the parameters used for the primary regression analyses in the new Table 1 below.

    Table 1: https://blogs.bmj.com/bmjopen/files/2020/08/eLetter-Table-1-full-3.jpg

    Second, during follow-up, three persons died in TKR plus non-surgical treatment group, while one person in the non-surgical treatment only group died. We decided to exclude the four persons who died from the primary analyses as we had no reason to believe that either of the treatments would be associated with an increased risk of dying and as including deaths...

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  • Population density and SARS-CoV-2

    It is of interest to note that risk of infection is associated with population density in this study. My research indicates that weighted population density is associated with higher SARS-CoV-2 deaths in US states, in UK local authorities and sub-local authority geographies [1,2]. This is an entirely logical association.


    1. Jones R. Would the United States have had too few beds for universal emergency care in the event of a more widespread Covid-19 epidemic? IJERPH 2020; 17: 5210. https://doi.org/doi:10.3390/ijerph17145210

    2. Jones R. How many extra deaths have really occurred in the UK due to the Covid-19 outbreak? XIII. Population density and risk of Covid-19 death. DOI: 10.13140/RG.2.2.23027.35365

  • RE: Blood pressure and cognitive function across the eighth decade: a prospective study of the Lothian Birth Cohort of 1936

    Altschul et al. conducted a prospective study to investigate the association between blood pressure (BP) and cognitive functions across the eighth decade (1). Women with higher early-life cognitive function had lower BP during the eighth decade. In addition, prescribed antihypertensive medication was closely associated with lower BP, but antihypertensive medication had no effect on better cognitive function. Regarding no relationship between BP and cognitive decline, I have some concerns.

    First, Ou et al. conducted a meta-analysis regarding the association between BP and cognitive impairment/dementia in prospective studies (2). The significant relationship of BP with cognitive impairment/dementia was observed in different BP variables, which were classified into midlife and late-life periods. In addition, prescribed antihypertensive medications exhibited a 21% reduction in dementia risk, which was different from data by Altschul et al. I suspect that long-term follow-up might change the relationship between BP and cognitive functions. Long survivors’ effect on BP and cognitive functions should be specified by further study.

    Second, visit-to-visit variability in blood pressure was a significant predictor of subsequent cognitive decline in old subjects (3,4). But the association between BP variability and cognitive impairment was not mediated by BP lowering medication (5). As BP variables such as high systolic BP, low diastolic BP, excessive BP variability, and...

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