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...
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 to 332.4 per 100,000 in the diabetic population and 3.0 to 76.1 per 100,000 in the general population (1). A reliable conclusion has been reached as to why there is significant variation in the studies. There is absence in the application of standardised epidemiological principles when calculating and reporting on (LEA rates (1). Methodology used in most studies does not facilitate comparison across populations and time. The inconsistent nature of reporting LEAs make drawing conclusions on temporal and population change difficult, which is evidenced comprehensively in Table 1 and Table 2 of Davies M, Burdett L, Bowling F, et al. (2019) study.
Ahmad et al, (6, 13, 14) have successfully published regional and subgroup differences relating to LEA prevalence, using robust methodology, which Meffen A, et al. (2020) plan to study. They reported that above to below knee amputation ratio (a potential marker of poor care) is higher in Northern regions of England (North 1.3:1, Midlands 1.2:1, South 0.9:1) and that amputation rates are three times higher in men compared with women. They have also reported that LEAs are 70% higher in black than white populations, and half of amputations are in people that do not have diabetes.
Collecting and analysing NHS data for LEA patients that do not have diabetes, but have peripheral arterial disease, is difficult due to lack of specific coding. This is despite this patient group making up at least forty percent of all LEAs (14). Hopefully, studies such as Meffen A, et al. (2020) will initiate the urgently needed implementation of national NHS coding for non-diabetic amputations (other than caused by cancer and trauma) as a result of their investigation of healthcare data sources, by evidencing such limitations in their findings.
Meffen A, et al. confirms that in England there are fewer major LEAs than minor, however minor amputations will be excluded from their study. Minor LEAs have significant variation in rates, which relate to similar issues as major LEAs. It is important that accurate data exists for both minor and major LEAs, to allow public health professionals to implement preventative strategies, and plan their services on a local, regional and national level.
Future studies will need to describe and present basic numerator and denominator population characteristics e.g. number, age and gender, and use standardised definitions and coding for the type of LEA, to achieve accurate data reporting. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines ought to considered to become requisite for authors conducting and publishing observational studies, in order to publish standardised high-quality presentation of epidemiology studies (15).
It is without doubt that public health specialists, vascular surgeons, diabetologists, podiatric surgeons, podiatrists, and all other lower limb specialists will find future studies that deliver accurate number and prevalence rates of LEAs, extremely valuable. Standardised methodology when carrying such studies in this subject is long- awaited.
Competing interests: No competing interests
References
1. Davies M, Burdett L, Bowling F, et al. The epidemiology of major lower-limb amputation in England: a systematic review highlighting methodological differences of reported trials. Diabetic Foot Ankle 2019;22:53–61
2. Kvitkina T, Narres M, Claessen H, Droste S, Morbach S, Kuss O, Icks A. Incidence of lower extremity amputation in the diabetic compared to the non-diabetic population: a systematic review protocolmoxey. Systematic Reviews. 2015; 4(74):1-5. Available from: doi: https://doi.org/10.1186/s13643-015-0064-9.
3. Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, Holt PJ. Lower extremity amputations — a review of global variability in incidence. Diabetic Medicine. 2011;28(10):144-1153. Available from: doi: 10.1111/j.1464-5491.2011.03279.x
4. Narres M, Kvitkina T, Claessen H, Droste S, Schuster B, Morbach S, ... Icks A. Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: A systematic review. PLoS One. 2017;12(8):e018208. Available from: doi: 10.1371/journal.pone.0182081.
5. Margolis DJ, Jeffcoate W. Epidemiology of Foot Ulceration and Amputation: Can Global Variation be Explained?. Medical Clinics of North America. 2013;97(5):791-805. Available from: doi: https://doi.org/10.1016/j.mcna.2013.03.008.
6. Ahmad N, Thomas GN, Gill P, Torella F. The prevalence of major lower limb amputation in the diabetic and non-diabetic population of England 2003–2013. Diabetes & Vascular Disease Research. 2016;13(5):348-353. Available from: doi: 10.1177/1479164116651390.
7. Canavan RJ, Kelly WF, Unwin NC, Connolly VM. Diabetes- and Nondiabetes-Related Lower Extremity Amputation Incidence Before and After the Introduction of Better Organized Diabetes Foot Care. Diabetes Care. 2008;31(3):459-463. Available from: doi: 10.2337/dc07-1159.
8. Rayman G, Krishnan S, Baker NR, Wareham AM, Rayman A. Are we underestimating diabetes-related lower-extremity amputation rates? Results and benefits of the first prospective study. Diabetes Care. 2004;27(8):1892-1896. Available from: doi: https://doi.org/10.2337/diacare.27.8.1892.
9. Vamos EP, Bottle A, Edmonds ME, Valabhji J, Majeed A, Millett C. Changes in the Incidence of Lower Extremity Amputations in Individuals With and Without Diabetes in England Between 2004 and 2008. Diabetes Care. 2010;33(12):2592-2597. Available from: doi: 10.2337/dc10-0989.
10. Vamos EP, Bottle A, Majeed A, Millett C. Trends in lower extremity amputations in people with and without diabetes in England, 1996-2005. Diabetes Research and Clinical Practice. 2010;87(2):275-282. Available from: doi: 10.1016/j.diabres.2009.11.016.
11. Holman N, Young RJ, Jeffcoate WJ. Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia 2012;55:1919–25. 10
12. Moxey PW, Hofman D, Hinchliffe RJ, et al. Epidemiological study of lower limb amputation in England between 2003 and 2008. Br J Surg 2010;97:1348–53
13. Ahmad N, GN Thomas, Gill P, Torella F. Endovascular revascularisation is associated with a lower risk of above knee amputation than surgical or combined modalities. Analysis of English hospital admissions over a six year period. Int J Angiol 2016;35:498-503 39
14. Ahmad N, Chan C, Thomas GN, Gill P. Ethnic differences in lower limb revascularisation and amputation rates. Implications for the aetiopathology of atherosclerosis 2014; 233:503-507
15. Cuschieri S. (2019). The STROBE guidelines. Saudi journal of anaesthesia, 13(Suppl 1), S31–S34. https://doi.org/10.4103/sja.SJA_543_18
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...
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 is often an untapped resource for the optimisation of medication use in this population group.
Research has shown that many people with intellectual disabilities who can make decisions about their daily life aren’t given clear information about their medication[4]. Healthcare professionals such as pharmacists and doctors will have to spend longer explaining their medication, use different resources, and explain 'things' ( prescribing and de-prescribing) in simpler language.
Strategies to reduce inequalities and inequities will require use of data to educate decision makers, including doctors and pharmacists, attention to and awareness of social determinants, and a life course model with emphasis on leveraging inclusion in mainstream services where possible.
Understanding the various elements in ‘the system’ that results in psychotropic medication being prescribed for each person with intellectual disability is vital. To optimise medication use we will require an understanding of the complex interactions and relationships that occur in the lives of people with intellectual disabilities.
General information [5]:
All health-care professionals need to have an understanding of the nature of complexity in health care, as it is important for preventing adverse events. Health care is complex due to:
• the diversity of tasks involved in the delivery of patient care
• the dependency of health-care providers on one another
• the diversity of patients, clinicians and other staff
• the huge number of relationships between patients, carers, health-care providers, support
staff, administrators, family and community members
• the vulnerability of patients
• variations in the physical layout of clinical environments
• variability or lack of regulations
• implementation of new technology
• the diversity of care pathways and organizations involved
• increased specialization of health-care professionals—while specialization allows a wider
range of patient treatments and services, it also provides more opportunity for things to go
wrong and errors to occur.
References:
1.Kristel Vlot-van Anrooij, J Naaldenberg, T I M Hilgenkamp, L Vaandrager, K van der Velden, G L Leusink, Towards healthy settings for people with intellectual disabilities, Health Promotion International, Volume 35, Issue 4, August 2020, Pages 661–670, https://doi.org/10.1093/heapro/daz054
2. Flood B. Safety of people with intellectual disabilities in hospital. What can the hospital pharmacist do to improve quality of care. Pharmacy (Basel)2017;5:44. doi:10.3390/pharmacy5030044 pmid:28970456CrossRefPubMedGoogle Scholar
3. O’Dwyer M, Meštrović A, Henman M. Pharmacists’ medicines-related interventions for people with intellectual disabilities: a narrative review. Int J Clin Pharm2015;37:566-78. . doi:10.1007/s11096-015-0113-4 pmid:25903938
4.Smith MVA, Adams D, Carr C, Mengoni SE . Do people with intellectual disabilities understand their prescription medication? A scoping review. J Appl Res Intellect Disabil2019;32:1375-88. . doi:10.1111/jar.12643 pmid:31338972CrossRefPubMedGoogle Scholar
5. https://www.who.int/patientsafety/education/curriculum/course3_handout.pdf
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.
Sincerely,
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
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...
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 doctor-to-doctor conflict for depersonalization was 0.36 (0.17, 0.76). They also clarified that aging and adequate support for the management prevented burnout with reducing personal accomplishment. I suppose that risk of burnout might not be regulated by shift of job and sleep. To prevent burnout in police officers, stress-lowering strategies should be prepared and applied comprehensively.
References
1. Peterson SA, Wolkow AP, Lockley SW, et al. Associations between shift work characteristics, shift work schedules, sleep and burnout in North American police officers: a cross-sectional study. BMJ Open. 2019;9(11):e030302. Published 2019 Dec 1. doi:10.1136/bmjopen-2019-030302
2. Ogundipe OA, Olagunju AT, Lasebikan VO, Coker AO. Burnout among doctors in residency training in a tertiary hospital. Asian J Psychiatr. 2014;10:27-32. doi:10.1016/j.ajp.2014.02.010
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.
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?
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...
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 documentation and monitoring by telemedicine (4)
In addition to telemedicine, the development of artificial intelligence algorithms can assist in the diagnosis and monitoring of ROP. Brown et al. developed and validated a fully automated deep learning system with a database of 5,511 retinography images obtained with RetCam (for the diagnosis of three disease levels (positive, pre-positive and normal) with an area under the ROC Curve of 0, 98 for the positive diagnosis of the disease with a reference standard defined by specialists.The algorithm reached 93% sensitivity and specificity of 94% for the diagnosis of disease plus and 100% sensitivity and specificity of 94% for the diagnosis pre-more or worse disease (5). Xiao et al. developed a training program with neural networks to quantify the area of neovascularization in patients with retinopathy of prematurity. (6)
The development of automated artificial intelligence systems can, therefore, help in telemedicine projects that help in tracking ROP performed by health professionals in a neonatal intensive care unit, reducing the request for eye exams. These methods can be indicated in countries with a lack of qualified professionals for adequate screening and monitoring, reducing the costs to the health system that these visually impaired children can cause, in addition to reducing one of the main causes of childhood blindness.
Compliance with ethical standards
Conflict of interest: The authors declare that they have no conflict of interest.
REFERENCES
1. Braimah IZ, Enweronu-Laryea C, Sackey AH, et al. Incidence and risk factors of retinopathy of prematurity in Korle-Bu Teaching Hospital: a baseline prospective study. BMJ Open. 2020;10(8):e035341. Published 2020 Aug 5. doi:10.1136/bmjopen-2019-035341
2. Fleck BW, Dangata Y. Causes of visual handicap in the Royal Blind School, Edinburgh, 1991-2. Br J Ophthalmol. 1994;78:421.
3. Chiang MF, Jiang L, Gelman R, Du YE, Flynn JT. Interexpert Agreement of Plus Disease Diagnosis in Retinopathy of Prematurity. Arch Ophthalmol. 2007;125:875-880.
4. Shanmugam MP, Mishra DK, Madhukumar R, Ramanjulu R, Reddy SY, Rodrigues G. Fundus imaging with a mobile phone: a review of techniques. Indian J Ophthalmol. 2014;62(9):960-962. doi:10.4103/0301-4738.143949
5. Brown JM, Campbell JP, Beers A, Chang K, Ostmo S, Chan RVP, Dy J, Erdogmus D, Ioannidis S, Kalpathy-Cramer J, Chiang MF, Imaging and Informatics in Retinopathy of Prematurity (i-ROP) Research Consortium. Automated Diagnosis of Plus Disease in Retinopathy of Prematurity Using Deep Convolutional Neural Networks. JAMA Ophthalmol. 2018;136:803- 810.
6. Xiao S, Bucher F, Wu Y, Rokem A, Lee CS, Marra KV, Fallon R, Diaz-Aguilar S,Aguilar E, Friedlander M, Lee AY. Fully automated, deep learning segmentationof oxygen-induced retinopathy images. JCI Insight. 2017 Dec 21;2(24). pii:97585. doi: 10.1172/jci.insight.97585.
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.
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...
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.
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 would have a major effect on the health utilities (death=0). Given the rather small sample size of the study, the uneven distribution of deaths between groups would carry the risk of creating spurious findings if the dead people had been included. However, to support transparency, we presented both the analyses including and excluding death, which would allow the reader to make their own interpretation.
Either way, both the analyses including and excluding the people who had died during follow-up led to the same conclusion, i.e. that TKR plus non-surgical treatment was not cost-effective as compared to non-surgical treatment alone in the 2-year time horizon. We believe that long-term analyses of our data will provide further clarity when it comes to the long-term clinical effectiveness and cost-effectiveness of TKR as treatment of moderate to severe knee osteoarthritis.
References
1. Müller D, Shukri A. Comment to ‚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‘ (Skou et al. BMJ Open. 2020 Jan 15;10(1):e033495)
2. Skou, ST; Roos, EM; Laursen, M; Arendt-Nielsen, L; Rasmussen, S; Simonsen, O; Ibsen, R; Larsen, AT; Kjellberg, J. Cost-effectiveness of total knee replacement in addition to non-surgical treatment: 2-year outcome from a randomized trial in secondary care in Denmark. BMJ Open 2020;10:e033495.
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.
References
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
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...
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 orthostatic hypotension would interact with each other for increased dementia risk in later life (1), comprehensive analyses are needed to understand the effect of BP variables on subsequent cognitive decline.
Finally, Rajan et al. reported a U-shaped relationship between BP and Alzheimer disease (AD) (6), which was in agreement with data by Ou et al (2). These study present that non-linear relationships between BP and subsequent cognitive impairment/dementia might be existed.
References
1. Altschul D, Starr J, Deary I. Blood pressure and cognitive function across the eighth decade: a prospective study of the Lothian Birth Cohort of 1936. BMJ Open. 2020;10(7):e033990. doi:10.1136/bmjopen-2019-033990
2. Ou YN, Tan CC, Shen XN, et al. Blood pressure and risks of cognitive impairment and dementia: A systematic review and meta-analysis of 209 prospective studies. Hypertension. 2020;76:217-225. doi: 10.1161/HYPERTENSIONAHA.120.14993
3. Sabayan B, Wijsman LW, Foster-Dingley JC, et al. Association of visit-to-visit variability in blood pressure with cognitive function in old age: prospective cohort study. BMJ. 2013;347:f4600. doi: 10.1136/bmj.f4600
4. Qin B, Viera AJ, Muntner P. Visit-to-visit variability in blood pressure is related to late-life cognitive decline. Hypertension. 2016;68:106-113. doi: 10.1161/HYPERTENSIONAHA.116.07494
5. Wijsman LW, de Craen AJ, Muller M. Blood pressure lowering medication, visit-to-visit blood pressure variability, and cognitive function in old age. Am J Hypertens. 2016;29:311-318. doi: 10.1093/ajh/hpv101
6. Rajan KB, Barnes LL, Wilson RS, Weuve J, McAninch EA, Evans DA. Blood pressure and risk of incident Alzheimer's disease dementia by antihypertensive medications and APOE ε4 allele. Ann Neurol. 2018;83(5):935-944. doi:10.1002/ana.25228
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...
Show MoreInequalities 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...
Show MoreDear 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.
Sincerely,
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
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...
Show MoreHopefully 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.
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?
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)
Show MoreDue 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...
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...
Show MoreIt 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.
References
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
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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