Dear Editor,
We welcome the BMJ Appeal [1] to support independent food banks; as Watson & Lloyd point out [2], it has the potential to have significant and immediate benefits for food insecurity and children’s health. Perhaps more important for longer term change, is the powerful voice of doctors and nurses in advocating for the ability for all citizens to be able to access a healthy diet for physical and mental health and wellbeing.
The immediate and direct effects of the national coronavirus pandemic response strategies on food security and nutrition are well documented in Baraniuk’s exposition [3]. Food banks report an enormous uplift in demand for emergency food aid (Trussell Trust: 47% increase in first six months of the crisis compared to the same period in 2019[4]; IFAN: 110% rise February to November 2020 compared to 2019 [5]).
However, the end of the Brexit transition period on 31 December 2020 now adds to this already uncertain landscape, with the prospect of reduced levels of employment, general downward pressure on wages and perturbations in food supply[6]. In speaking of this disruption, Lang et al [7] state the “The jury is out as to whether these are mere ‘teething problems’ or permanent features of the new normal”.
In an initial expert elicitation in 2019 [8], we asked the question ‘what will be the “new normal” in terms of food prices after Brexit and what are the implications for health?’ When the deadline for the completio...
Dear Editor,
We welcome the BMJ Appeal [1] to support independent food banks; as Watson & Lloyd point out [2], it has the potential to have significant and immediate benefits for food insecurity and children’s health. Perhaps more important for longer term change, is the powerful voice of doctors and nurses in advocating for the ability for all citizens to be able to access a healthy diet for physical and mental health and wellbeing.
The immediate and direct effects of the national coronavirus pandemic response strategies on food security and nutrition are well documented in Baraniuk’s exposition [3]. Food banks report an enormous uplift in demand for emergency food aid (Trussell Trust: 47% increase in first six months of the crisis compared to the same period in 2019[4]; IFAN: 110% rise February to November 2020 compared to 2019 [5]).
However, the end of the Brexit transition period on 31 December 2020 now adds to this already uncertain landscape, with the prospect of reduced levels of employment, general downward pressure on wages and perturbations in food supply[6]. In speaking of this disruption, Lang et al [7] state the “The jury is out as to whether these are mere ‘teething problems’ or permanent features of the new normal”.
In an initial expert elicitation in 2019 [8], we asked the question ‘what will be the “new normal” in terms of food prices after Brexit and what are the implications for health?’ When the deadline for the completion of UK’s exit from the EU was extended to December 2020, we ran a fresh analysis to estimate prices in April 2022, i.e. 15 months after Brexit date to allow for any initial disruption to subside [9]. In this second elicitation, we considered three different trade deal scenarios: A: full WTO terms; B: a moderately disruptive trade agreement (better than WTO); C: a minimally disruptive trade agreement. We elicited prices for 10 categories of foods used for CPI under these scenarios. We calculated the weekly cost of a healthy diet of basic foodstuffs for a family of four and for a single pensioner, and how these would vary under the three scenarios. Later, in July 2020, as a follow-up we asked the same food industry experts to indicate how likely each scenario would be the actual outcome (or close to it) in January 2021.
Now the UK-EU trade deal has been published, it remains unclear - and debatable - which of these scenarios can be considered closest to the actual trade deal that was negotiated. As a consequence, we went back to our experts in January 2021 and asked them to reconsider the probabilities they had ascribed to the three scenarios in the light of their understanding of the agreement. Pooling their revised judgements suggests the following relative weights:
July 2020: A:24%; B 41%; C34%
January 2021 A:70%; B16%; C13%
In short, in July 2020 our expert panel regarded Scenario A (full WTO terms) as the least likely analogue for what the final agreement would entail for food supplies, but in January 2021, the most likely.
Adjusting our food price projections to these January 2021 scenario weights results in a likely weekly food bill increase, by April 2022, a family of four of +£17.83, from a baseline cost £95.41 (see [9]) to £113.24, i.e. a rise of more than £927 per annum. There is, of course, uncertainty on this estimate and our analysis also provides the one-in-20 lower plausible and higher plausible price change; these extremes are much less likely than the median price increase, but cannot be said to be far-fetched. For this ‘family of four’ weekly food basket, the lower plausible price increase is +£7.08, giving a weekly bill of £102.49 (an increase of more than £368 per annum). The higher plausible weekly increase is +£30.86 per week, giving a weekly bill of £126.27 (an increase of £1604 or more per annum).
Similar analysis for a single pensioner gives a likely weekly food bill increase of +£6.36 per week from £35.92 (see [9]) to £42.28, an increase of more than £330 per annum. The lower plausible increase is +£2.41 per week (more than £125 per annum) and the higher plausible increase is +£11.22 per week (more than £583 per annum).
These potential price rises represent significant incursions into household budgets and a likely driver towards lower nutrient diets with consequent health consequent implications for heath and wellbeing and demand on health and social care services. With a fixed income, pensioners are particularly vulnerable to large rises in the costs of essentials. The effects of Brexit on fruit and vegetable prices are particularly severe (see [9]), raising the spectre that the fall in fruit and vegetable consumption during lockdown, especially among poorer households, would persist long term. Food bank growth is possible only because of slack in the food system – which may not endure.
As the details of the Brexit agreement - parts incomplete, parts untested and parts unconstrued - and its effects emerge, this analysis would be amenable to revising and updating. If the economic effects of coronavirus lockdown or the impacts of Brexit on employment are more than transitory, then we are likely to see the double pressure of falling incomes and rising prices leading to increases in financial exclusion and child poverty with consequent impacts on diet-related ill health.
References
1. Feinmann, J., How doctors can help end food insecurity. BMJ, 2021. 372: p. n53.
2. Watson, M.C. and J. Lloyd, Rapid Response: Food poverty should not be allowed to continue: government action is needed. BMJ, 2021. 372.
3. Baraniuk, C., Fears grow of nutritional crisis in lockdown UK. BMJ, 2020. 370: p. m3193.
4. The Trussell Trust. 2,600 food parcels provided for children every day in first six months of the pandemic. 2020 [cited 2021 09/02/2021]; Available from: https://www.trusselltrust.org/2020/11/12/2600-food-parcels-provided-for-...
5. IFAN. Independent food banks and increased need for emergency food parcels since the outbreak of COVID-19. 2020; Available from: https://www.foodaidnetwork.org.uk/ifan-data-since-covid-19
6. Ranta, R. and H. Mulrooney, Pandemics, food (in)security, and leaving the EU: What does the Covid-19 pandemic tell us about food insecurity and Brexit. Social Sciences & Humanities Open, 2021. 3(1).
7. Lang, T., E. Millstone, and T. Marsden, An Open Letter on the Food Emergency to the Prime Minister and Government. 2021.
8. Barons, M.J. and W. Aspinall, Anticipated impacts of Brexit scenarios on UK food prices and implications for policies on poverty and health: a structured expert judgement approach. BMJ Open, 2020. 10(3): p. e032376.
9. Barons, M.J. and W. Aspinall, Anticipated impacts of Brexit scenarios on UK food prices and implications for policies on poverty and health: a structured expert judgement update. 2020: arXiv.
The workshops [8,9] were funded by the Warwick Global Research Priority for Food. The study is part of work undertaken for EPSRC grant number EP/K007580/1.
The views expressed here are ours alone and do not necessarily reflect the views of our employers.
Kenkre et al. designed a multicenter investigation in order to prospectively evaluating preoperative parameters that can predict a stable diabetes remission in obese patients with type 2 diabetes (T2DM) undergoing bariatric/metabolic surgery (1). Candidate predictors , ave been detected from previous retrospective studies and their predicting efficacy will be tested in a large and disseminated cohort of operated patients. Multivariate logistic regression model will be then used to assess the value in terms of prediction of diabetes remission of these preoperative parameters. In severely obese patients with T2DM biliopancreatic diversion (BPD) causes a steadily long term serum glucose level normalization in the majority of the cases. In patients with a preoperative T2DM duration of approximately one year, the diabetes remission was observed in nearly all cases, while in those with a T2DM duration of more than five years the remission rate was lower than 75% (2). This suggest a major role of T2DM duration as a predictor of insulin secretion reserve. In severely obese operated subjects, most likely for a still adequate beta-cell reserve (3), a rapid recovery of insulin secretion after BPD subjects develops (4), thus determining a stable improvement in metabolic pattern. A long T2DM duration entails a severe reduction of functioning pancreatic B cells and a reduced beta bell mass , insulin secretion and a lower postoperative T2DM remission rate. At a lower obesity degree, a p...
Kenkre et al. designed a multicenter investigation in order to prospectively evaluating preoperative parameters that can predict a stable diabetes remission in obese patients with type 2 diabetes (T2DM) undergoing bariatric/metabolic surgery (1). Candidate predictors , ave been detected from previous retrospective studies and their predicting efficacy will be tested in a large and disseminated cohort of operated patients. Multivariate logistic regression model will be then used to assess the value in terms of prediction of diabetes remission of these preoperative parameters. In severely obese patients with T2DM biliopancreatic diversion (BPD) causes a steadily long term serum glucose level normalization in the majority of the cases. In patients with a preoperative T2DM duration of approximately one year, the diabetes remission was observed in nearly all cases, while in those with a T2DM duration of more than five years the remission rate was lower than 75% (2). This suggest a major role of T2DM duration as a predictor of insulin secretion reserve. In severely obese operated subjects, most likely for a still adequate beta-cell reserve (3), a rapid recovery of insulin secretion after BPD subjects develops (4), thus determining a stable improvement in metabolic pattern. A long T2DM duration entails a severe reduction of functioning pancreatic B cells and a reduced beta bell mass , insulin secretion and a lower postoperative T2DM remission rate. At a lower obesity degree, a progressively lower insulin production and beta cell mass is present and restoration of insulin secretion is lacking (5). By consequence, the postoperative metabolic improvement is essentially sustained by the reduction insulin resistance due to the surgically-obtained weight loss. Since as a rule the extent of weight loss is strictly correlated to the initial body weight, and in most moderate/mild obese subjects a defective beta cell mass can be hypothesized, at low BMI level the T2DM duration loses its predicting efficacy, and the postoperative T2DM remission becomes strictly related only to the initial BMI (5). In our opinion these facts and considerations have to be taken into account when the prediction role of preoperative parameters on the T2DM remission after metabolic/bariatric surgery is investigated, and the hypothesis that any parameter might have not the same predicting efficacy in different cohorts of diabetic patients cannot be ruled out.
REFERENCES
1) Kenkre JS, Ahmed AR, Purkayastha S, Malallah K, Bloom S, Blakemore AI,
Prevost AT, Tan T. Who will benefit from bariatric surgery for diabetes? A
protocol for an observational cohort study. BMJ Open. 2021 Feb 10;11(2):e042355.
doi: 10.1136/bmjopen-2020-042355. PMID: 33568372.
2) Camerini GB, Papadia FS, Carlini F, Catalano M, Adami GF, Scopinaro N. The
long-term impact of biliopancreatic diversion on glycemic control in the
severely obese with type 2 diabetes mellitus in relation to preoperative
duration of diabetes. Surg Obes Relat Dis. 2016 Feb;12(2):345-9. doi:
10.1016/j.soard.2015.05.012. Epub 2015 May 28. PMID: 26381876.
3) Inaishi J, Saisho Y Beta-Cell Mass in Obesity and Type 2 Diabetes, and Its Relation to Pancreas Fat: A Mini-Review. Nutrients. 2020 Dec 16;12(12):3846. doi: 10.3390/nu12123846.
4) Briatore L, Salani B, Andraghetti G, Maggi D, Adami GF, Scopinaro N, Cordera
R. Beta-cell function improvement after biliopancreatic diversion in subjects
with type 2 diabetes and morbid obesity. Obesity (Silver Spring). 2010
May;18(5):932-6. doi: 10.1038/oby.2010.28. Epub 2010 Feb 25. PMID: 20186136.
5) Scopinaro N, Adami GF, Papadia FS, Camerini G, Carlini F, Briatore L,
D'Alessandro G, Parodi C, Weiss A, Andraghetti G, Catalano M, Cordera R. The
effects of biliopancreatic diversion on type 2 diabetes mellitus in patients
with mild obesity (BMI 30-35 kg/m2) and simple overweight (BMI 25-30 kg/m2): a
prospective controlled study. Obes Surg. 2011 Jul;21(7):880-8. doi:
10.1007/s11695-011-0407-0. PMID: 21541815.
6) Scopinaro N, Adami GF, Bruzzi P, Cordera R. Prediction of Diabetes Remission
at Long Term Following Biliopancreatic Diversion. Obes Surg. 2017
Jul;27(7):1705-1708. doi: 10.1007/s11695-017-2555-3. PMID: 28101844.PMID: 33339276
*Kenkre et al. designed a multicenter investigation in order to prospectively evaluating preoperative parameters that can predict a stable diabetes remission in obese patients with type 2 diabetes (T2DM) undergoing bariatric/metabolic surgery (1). Candidate predictors , ave been detected from previous retrospective studies and their predicting efficacy will be tested in a large and disseminated cohort of operated patients. Multivariate logistic regression model will be then used to assess the value in terms of prediction of diabetes remission of these preoperative parameters. In severely obese patients with T2DM biliopancreatic diversion (BPD) causes a steadily long term serum glucose level normalization in the majority of the cases. In patients with a preoperative T2DM duration of approximately one year, the diabetes remission was observed in nearly all cases, while in those with a T2DM duration of more than five years the remission rate was lower than 75% (2). This suggest a major role of T2DM duration as a predictor of insulin secretion reserve. In severely obese operated subjects, most likely for a still adequate beta-cell reserve (3), a rapid recovery of insulin secretion after BPD subjects develops (4), thus determining a stable improvement in metabolic pattern. A long T2DM duration entails a severe reduction of functioning pancreatic B cells and a reduced beta bell mass , insulin secretion and a lower postoperative T2DM remission rate. At a lower obesity degree, a progressively lower insulin production and beta cell mass is present and restoration of insulin secretion is lacking (5). By consequence, the postoperative metabolic improvement is essentially sustained by the reduction insulin resistance due to the surgically-obtained weight loss. Since as a rule the extent of weight loss is strictly correlated to the initial body weight, and in most moderate/mild obese subjects a defective beta cell mass can be hypothesized, at low BMI level the T2DM duration loses its predicting efficacy, and the postoperative T2DM remission becomes strictly related only to the initial BMI (5). In our opinion these facts and considerations have to be taken into account when the prediction role of preoperative parameters on the T2DM remission after metabolic/bariatric surgery is investigated, and the hypothesis that any parameter might have not the same predicting efficacy in different cohorts of diabetic patients cannot be ruled out.
REFERENCES
1) Kenkre JS, Ahmed AR, Purkayastha S, Malallah K, Bloom S, Blakemore AI,
Prevost AT, Tan T. Who will benefit from bariatric surgery for diabetes? A
protocol for an observational cohort study. BMJ Open. 2021 Feb 10;11(2):e042355.
doi: 10.1136/bmjopen-2020-042355. PMID: 33568372.
2) Camerini GB, Papadia FS, Carlini F, Catalano M, Adami GF, Scopinaro N. The
long-term impact of biliopancreatic diversion on glycemic control in the
severely obese with type 2 diabetes mellitus in relation to preoperative
duration of diabetes. Surg Obes Relat Dis. 2016 Feb;12(2):345-9. doi:
10.1016/j.soard.2015.05.012. Epub 2015 May 28. PMID: 26381876.
3) Inaishi J, Saisho Y Beta-Cell Mass in Obesity and Type 2 Diabetes, and Its Relation to Pancreas Fat: A Mini-Review. Nutrients. 2020 Dec 16;12(12):3846. doi: 10.3390/nu12123846.
4) Briatore L, Salani B, Andraghetti G, Maggi D, Adami GF, Scopinaro N, Cordera
R. Beta-cell function improvement after biliopancreatic diversion in subjects
with type 2 diabetes and morbid obesity. Obesity (Silver Spring). 2010
May;18(5):932-6. doi: 10.1038/oby.2010.28. Epub 2010 Feb 25. PMID: 20186136.
5) Scopinaro N, Adami GF, Papadia FS, Camerini G, Carlini F, Briatore L,
D'Alessandro G, Parodi C, Weiss A, Andraghetti G, Catalano M, Cordera R. The
effects of biliopancreatic diversion on type 2 diabetes mellitus in patients
with mild obesity (BMI 30-35 kg/m2) and simple overweight (BMI 25-30 kg/m2): a
prospective controlled study. Obes Surg. 2011 Jul;21(7):880-8. doi:
10.1007/s11695-011-0407-0. PMID: 21541815.
6) Scopinaro N, Adami GF, Bruzzi P, Cordera R. Prediction of Diabetes Remission
at Long Term Following Biliopancreatic Diversion. Obes Surg. 2017
Jul;27(7):1705-1708. doi: 10.1007/s11695-017-2555-3. PMID: 28101844.PMID: 33339276
Kenkre et al. designed a multicenter investigation in order to prospectively evaluating preoperative parameters that can predict a stable diabetes remission in obese patients with type 2 diabetes (T2DM) undergoing bariatric/metabolic surgery (1). Candidate predictors , ave been detected from previous retrospective studies and their predicting efficacy will be tested in a large and disseminated cohort of operated patients. Multivariate logistic regression model will be then used to assess the value in terms of prediction of diabetes remission of these preoperative parameters. In severely obese patients with T2DM biliopancreatic diversion (BPD) causes a steadily long term serum glucose level normalization in the majority of the cases. In patients with a preoperative T2DM duration of approximately one year, the diabetes remission was observed in nearly all cases, while in those with a T2DM duration of more than five years the remission rate was lower than 75% (2). This suggest a major role of T2DM duration as a predictor of insulin secretion reserve. In severely obese operated subjects, most likely for a still adequate beta-cell reserve (3), a rapid recovery of insulin secretion after BPD subjects develops (4), thus determining a stable improvement in metabolic pattern. A long T2DM duration entails a severe reduction of functioning pancreatic B cells and a reduced beta bell mass , insulin secretion and a lower postoperative T2DM remission rate. At a lower obesity degree, a p...
Kenkre et al. designed a multicenter investigation in order to prospectively evaluating preoperative parameters that can predict a stable diabetes remission in obese patients with type 2 diabetes (T2DM) undergoing bariatric/metabolic surgery (1). Candidate predictors , ave been detected from previous retrospective studies and their predicting efficacy will be tested in a large and disseminated cohort of operated patients. Multivariate logistic regression model will be then used to assess the value in terms of prediction of diabetes remission of these preoperative parameters. In severely obese patients with T2DM biliopancreatic diversion (BPD) causes a steadily long term serum glucose level normalization in the majority of the cases. In patients with a preoperative T2DM duration of approximately one year, the diabetes remission was observed in nearly all cases, while in those with a T2DM duration of more than five years the remission rate was lower than 75% (2). This suggest a major role of T2DM duration as a predictor of insulin secretion reserve. In severely obese operated subjects, most likely for a still adequate beta-cell reserve (3), a rapid recovery of insulin secretion after BPD subjects develops (4), thus determining a stable improvement in metabolic pattern. A long T2DM duration entails a severe reduction of functioning pancreatic B cells and a reduced beta bell mass , insulin secretion and a lower postoperative T2DM remission rate. At a lower obesity degree, a progressively lower insulin production and beta cell mass is present and restoration of insulin secretion is lacking (5). By consequence, the postoperative metabolic improvement is essentially sustained by the reduction insulin resistance due to the surgically-obtained weight loss. Since as a rule the extent of weight loss is strictly correlated to the initial body weight, and in most moderate/mild obese subjects a defective beta cell mass can be hypothesized, at low BMI level the T2DM duration loses its predicting efficacy, and the postoperative T2DM remission becomes strictly related only to the initial BMI (5). In our opinion these facts and considerations have to be taken into account when the prediction role of preoperative parameters on the T2DM remission after metabolic/bariatric surgery is investigated, and the hypothesis that any parameter might have not the same predicting efficacy in different cohorts of diabetic patients cannot be ruled out.
REFERENCES
1) Kenkre JS, Ahmed AR, Purkayastha S, Malallah K, Bloom S, Blakemore AI,
Prevost AT, Tan T. Who will benefit from bariatric surgery for diabetes? A
protocol for an observational cohort study. BMJ Open. 2021 Feb 10;11(2):e042355.
doi: 10.1136/bmjopen-2020-042355. PMID: 33568372.
2) Camerini GB, Papadia FS, Carlini F, Catalano M, Adami GF, Scopinaro N. The
long-term impact of biliopancreatic diversion on glycemic control in the
severely obese with type 2 diabetes mellitus in relation to preoperative
duration of diabetes. Surg Obes Relat Dis. 2016 Feb;12(2):345-9. doi:
10.1016/j.soard.2015.05.012. Epub 2015 May 28. PMID: 26381876.
3) Inaishi J, Saisho Y Beta-Cell Mass in Obesity and Type 2 Diabetes, and Its Relation to Pancreas Fat: A Mini-Review. Nutrients. 2020 Dec 16;12(12):3846. doi: 10.3390/nu12123846.
4) Briatore L, Salani B, Andraghetti G, Maggi D, Adami GF, Scopinaro N, Cordera
R. Beta-cell function improvement after biliopancreatic diversion in subjects
with type 2 diabetes and morbid obesity. Obesity (Silver Spring). 2010
May;18(5):932-6. doi: 10.1038/oby.2010.28. Epub 2010 Feb 25. PMID: 20186136.
5) Scopinaro N, Adami GF, Papadia FS, Camerini G, Carlini F, Briatore L,
D'Alessandro G, Parodi C, Weiss A, Andraghetti G, Catalano M, Cordera R. The
effects of biliopancreatic diversion on type 2 diabetes mellitus in patients
with mild obesity (BMI 30-35 kg/m2) and simple overweight (BMI 25-30 kg/m2): a
prospective controlled study. Obes Surg. 2011 Jul;21(7):880-8. doi:
10.1007/s11695-011-0407-0. PMID: 21541815.
6) Scopinaro N, Adami GF, Bruzzi P, Cordera R. Prediction of Diabetes Remission
at Long Term Following Biliopancreatic Diversion. Obes Surg. 2017
Jul;27(7):1705-1708. doi: 10.1007/s11695-017-2555-3. PMID: 28101844.PMID: 33339276
*Kenkre et al. designed a multicenter investigation in order to prospectively evaluating preoperative parameters that can predict a stable diabetes remission in obese patients with type 2 diabetes (T2DM) undergoing bariatric/metabolic surgery (1). Candidate predictors , ave been detected from previous retrospective studies and their predicting efficacy will be tested in a large and disseminated cohort of operated patients. Multivariate logistic regression model will be then used to assess the value in terms of prediction of diabetes remission of these preoperative parameters. In severely obese patients with T2DM biliopancreatic diversion (BPD) causes a steadily long term serum glucose level normalization in the majority of the cases. In patients with a preoperative T2DM duration of approximately one year, the diabetes remission was observed in nearly all cases, while in those with a T2DM duration of more than five years the remission rate was lower than 75% (2). This suggest a major role of T2DM duration as a predictor of insulin secretion reserve. In severely obese operated subjects, most likely for a still adequate beta-cell reserve (3), a rapid recovery of insulin secretion after BPD subjects develops (4), thus determining a stable improvement in metabolic pattern. A long T2DM duration entails a severe reduction of functioning pancreatic B cells and a reduced beta bell mass , insulin secretion and a lower postoperative T2DM remission rate. At a lower obesity degree, a progressively lower insulin production and beta cell mass is present and restoration of insulin secretion is lacking (5). By consequence, the postoperative metabolic improvement is essentially sustained by the reduction insulin resistance due to the surgically-obtained weight loss. Since as a rule the extent of weight loss is strictly correlated to the initial body weight, and in most moderate/mild obese subjects a defective beta cell mass can be hypothesized, at low BMI level the T2DM duration loses its predicting efficacy, and the postoperative T2DM remission becomes strictly related only to the initial BMI (5). In our opinion these facts and considerations have to be taken into account when the prediction role of preoperative parameters on the T2DM remission after metabolic/bariatric surgery is investigated, and the hypothesis that any parameter might have not the same predicting efficacy in different cohorts of diabetic patients cannot be ruled out.
REFERENCES
1) Kenkre JS, Ahmed AR, Purkayastha S, Malallah K, Bloom S, Blakemore AI,
Prevost AT, Tan T. Who will benefit from bariatric surgery for diabetes? A
protocol for an observational cohort study. BMJ Open. 2021 Feb 10;11(2):e042355.
doi: 10.1136/bmjopen-2020-042355. PMID: 33568372.
2) Camerini GB, Papadia FS, Carlini F, Catalano M, Adami GF, Scopinaro N. The
long-term impact of biliopancreatic diversion on glycemic control in the
severely obese with type 2 diabetes mellitus in relation to preoperative
duration of diabetes. Surg Obes Relat Dis. 2016 Feb;12(2):345-9. doi:
10.1016/j.soard.2015.05.012. Epub 2015 May 28. PMID: 26381876.
3) Inaishi J, Saisho Y Beta-Cell Mass in Obesity and Type 2 Diabetes, and Its Relation to Pancreas Fat: A Mini-Review. Nutrients. 2020 Dec 16;12(12):3846. doi: 10.3390/nu12123846.
4) Briatore L, Salani B, Andraghetti G, Maggi D, Adami GF, Scopinaro N, Cordera
R. Beta-cell function improvement after biliopancreatic diversion in subjects
with type 2 diabetes and morbid obesity. Obesity (Silver Spring). 2010
May;18(5):932-6. doi: 10.1038/oby.2010.28. Epub 2010 Feb 25. PMID: 20186136.
5) Scopinaro N, Adami GF, Papadia FS, Camerini G, Carlini F, Briatore L,
D'Alessandro G, Parodi C, Weiss A, Andraghetti G, Catalano M, Cordera R. The
effects of biliopancreatic diversion on type 2 diabetes mellitus in patients
with mild obesity (BMI 30-35 kg/m2) and simple overweight (BMI 25-30 kg/m2): a
prospective controlled study. Obes Surg. 2011 Jul;21(7):880-8. doi:
10.1007/s11695-011-0407-0. PMID: 21541815.
6) Scopinaro N, Adami GF, Bruzzi P, Cordera R. Prediction of Diabetes Remission
at Long Term Following Biliopancreatic Diversion. Obes Surg. 2017
Jul;27(7):1705-1708. doi: 10.1007/s11695-017-2555-3. PMID: 28101844.PMID: 33339276
Dear Editor,
Regarding ‘A sword of Damocles’: patient and caregiver beliefs, attitudes and perspectives on presymptomatic testing for autosomal dominant polycystic kidney disease: a focus group study” by Logeman et al, we think it may be interesting to focus on some themes. What raised our attention, is the striking difference of patients attitude we experience everyday at our center, San Raffaele Hospital ADPKD outpatient clinic. With these few words, we really wish to emphasize the need for a joint approach on ADPKD patient management.
For many patients, futility in uncertainty and anticipating in impact on quality of life are good reasons to prefer keeping on being unaware and surely the most common we have experienced. The other motivations reported in the article can be differently mentioned according to the healthcare system, ethical-social habits and political and economic regulation of the country of origin.
We do firmly believe in the importance of early diagnosis and management, through lab tests, blood pressure control and imaging. Moreover, genetic testing is increasingly important, especially in asymptomatic subjects at risk or in patients with not clear phenotypes due to ADPKD heterogeneity or differential diagnosis. Precocity is fundamental in order to avoid future evitable complications. Too often the attitude “wait and see” is perpetuated even by nephrologists and this is no longer acceptable, also because sometimes it amplifies the fear...
Dear Editor,
Regarding ‘A sword of Damocles’: patient and caregiver beliefs, attitudes and perspectives on presymptomatic testing for autosomal dominant polycystic kidney disease: a focus group study” by Logeman et al, we think it may be interesting to focus on some themes. What raised our attention, is the striking difference of patients attitude we experience everyday at our center, San Raffaele Hospital ADPKD outpatient clinic. With these few words, we really wish to emphasize the need for a joint approach on ADPKD patient management.
For many patients, futility in uncertainty and anticipating in impact on quality of life are good reasons to prefer keeping on being unaware and surely the most common we have experienced. The other motivations reported in the article can be differently mentioned according to the healthcare system, ethical-social habits and political and economic regulation of the country of origin.
We do firmly believe in the importance of early diagnosis and management, through lab tests, blood pressure control and imaging. Moreover, genetic testing is increasingly important, especially in asymptomatic subjects at risk or in patients with not clear phenotypes due to ADPKD heterogeneity or differential diagnosis. Precocity is fundamental in order to avoid future evitable complications. Too often the attitude “wait and see” is perpetuated even by nephrologists and this is no longer acceptable, also because sometimes it amplifies the fear of the patients. That’s why a psychological path must be offered to ADPKD patients who must be followed step by step. This need must be spelt out in very strong terms.
Our institution gained a lot of traction during the last 15 years, with 250 patients coming from all over the country and 5 new diagnosis per month. The average Nephrology center expertise regarding this disease improved during the time, especially while dealing with uncertain phenotypes, asymptomatic patients and family members, building on a multidisciplinary integrated approach. In the past ten years, a reallysignificant increase of genetic diagnosis has been observed in our Institution with a transition from a genetic to a genomic approach realized. Genetic testing was performed even in 2020 despite of the outpatient clinic closure due to pandemic situation. This is a great achievement as it shows the change of attitude and beliefs even towards a relatively uncommon test. And all this, because of the work of many specialists in team (nephrologists, geneticists and psychologists). On the other hand, as mentioned above, patients also show some sort of ambiguous attitude regarding the matter. Some of them are extremely interested in an early and accurate diagnosis, sporting a fighting spirit against the disease, while others prefer to keep themselves in the dark, surrendering to the idea that there is nothing that can be done about it. Our institute has always pushed patients to get tested, whether for those with non-canonical phenotypes or in order to set a customized treatment depending on the severity of the pathogenic variants. Italy had set a disability care aid for ADPKD patients, therefore all expenses are covered by the SSN, our national healthcare system. Even without this coverage, the overall price for a MRI is about 40 USD and genetic testing lands at about 47 USD. Customizing the treatment means setting the urgency for a stricter follow up, ruling out certain complications especially in the most severe cases or choosing candidates for tolvaptan therapy if appropriate or clinical trials. Our center also provides psychological counseling, specifically targeted at and tailored for ADPKD patients and this led to a better understanding of their own situation, especially for the most sensitive ones or the less educated.
Therefore, psychological and emotional support is crucial and more than often underestimated. ADPKD patients need a 360° approach, beyond the pure nephrological aspect. The key is setting a multidisciplinary approach and this helped us increase the number of patients and the number of genetic tests as a direct consequence, the overall knowledge about the disease and greater adhesion to experimental protocols.
Last but not least, this approach also helps to set a path for those women willing to become mothers, with prenatal counseling, erasing the idea of being unable to deliver a newborn safely. The importance of facing this disease through a complete and multidisciplinary approach cannot be stressed enough, avoiding the risk of hyperspecialization without considering the patient as a whole, but understanding the patient as someone more than the sum of his parts.
We were delighted to learn from enthusiastic responses to our article (1) that other researchers are also finding that the analysis of routine NHS datasets can shed light on the high volume and variety of care that people seek out-of-hours in their last year of life.
Miller focussed on Primary Care Out-of-hours and Emergency Department data of people dying specifically of cancer. She included prescribing data, and her detailed textual analyses allowed a nuanced understanding of the presenting complaints and diagnoses to be gained. (2) She also quantified the very substantial role that unscheduled care plays in meeting the acute palliative care needs of people in the last year of life.
Chu in her study, like us, concluded that unscheduled care databases should incorporate more domains relevant to palliative care, and increase the capability of linking with Electronic Palliative Care Co-ordination Systems (EPaCCS). (3) This would help to understand the benefits of these systems and describe their use by health care professionals. We found in Scotland that GPOOH is the only unscheduled care database that captures such information.
Diernberger recently analysed the patterns and NHS costs of out-patient and in-patient hospital care in the last year of life in Scotland, noting as we had done that people dying of cancer had the highest number of admissions. (4) The mean cost of planned and unplanned admissions was £10,000 per patient in the last year of...
We were delighted to learn from enthusiastic responses to our article (1) that other researchers are also finding that the analysis of routine NHS datasets can shed light on the high volume and variety of care that people seek out-of-hours in their last year of life.
Miller focussed on Primary Care Out-of-hours and Emergency Department data of people dying specifically of cancer. She included prescribing data, and her detailed textual analyses allowed a nuanced understanding of the presenting complaints and diagnoses to be gained. (2) She also quantified the very substantial role that unscheduled care plays in meeting the acute palliative care needs of people in the last year of life.
Chu in her study, like us, concluded that unscheduled care databases should incorporate more domains relevant to palliative care, and increase the capability of linking with Electronic Palliative Care Co-ordination Systems (EPaCCS). (3) This would help to understand the benefits of these systems and describe their use by health care professionals. We found in Scotland that GPOOH is the only unscheduled care database that captures such information.
Diernberger recently analysed the patterns and NHS costs of out-patient and in-patient hospital care in the last year of life in Scotland, noting as we had done that people dying of cancer had the highest number of admissions. (4) The mean cost of planned and unplanned admissions was £10,000 per patient in the last year of life, with a sharp rise in the last 3 months of life. The average cost for older people was less.
Our study, integrating data from NHS24, PCOOH, ambulance service, Emergency Departments and emergency admissions identified typical unscheduled care pathways for people dying from cancer, organ failure and dementia, allowing us to understand the interactions and how a lack of services in the community increases hospital referrals.
These recent articles all show the utility of big data studies to understand service usage patterns and frequencies which raise questions about whether these mesh with the needs of patients in their last year of life. Further studies, including social care and specialist palliative care datasets, would create an even broader understanding from a systems perspective, especially if integrated with qualitative patient and carer experiences. Analysing the change in usage of these demand-led services during the COVID pandemic would yield lessons for future planning.
1 Mason B, Kerssens JJ, Stoddart A, et al Unscheduled and out-of-hours care for people in their last year of life: a retrospective cohort analysis of national datasets BMJ Open 2020;10:e041888. doi: 10.1136/bmjopen-2020-041888
2 Mills SEE, Buchanan D, Guthrie B, Donnan P, Smith BH. Factors affecting use of unscheduled care for people with advanced cancer: a retrospective cohort study in Scotland. British Journal of General Practice. 2019;69:e860–8. doi:10.3399/bjgp19X706637
3. Chu CS. Using routine databases to evaluate Electronic Palliative Care Co-ordination Systems (EPaCCS). BMJ Evidence-Based Medicine Published Online First: 29 January 2021. doi: 10.1136/bmjebm-2019-111332
4.Diernberger K, Luta X, Bowden J, et al Healthcare use and costs in the last year of life: a national population data linkage study. BMJ Supportive & Palliative Care Published Online First: 12 February 2021. doi: 10.1136/bmjspcare-2020-002708
We thank Schmieding and colleagues for commenting on our study. As noted, we took great effort to compare different symptom checkers fairly.
Vignettes studies have advantages, but as discussed at length in the manuscript, vignette studies also have some inherent limitations. For this reason, as described, we are carrying out real patient studies to further investigate results.
We support the efforts of Schmieding and colleagues to work towards transparency and a standardization of methods in the field of technology-supported clinical decision support: the literature is advancing in this direction. We agree the study of (Semigran et al., 2015) is important, but it evaluated a relatively small number of vignettes and used a small number of researcher vignettes enterers, likely not highly reflective of real world symptom assessment app use.
There was discussion of the limitations of our study in the manuscript which we do not further elaborate here, except with respect to two of the points made by Schmieding and colleagues.
Firstly, regarding open access to the repertoire of case vignettes, in our study, although not open access, researchers can request access to the vignettes as described in the Data Sharing Agreement and this is similar to the approach described for other recently reported studies (Richens et al., 2020). Although there are some advantages in releasing all the vignettes, as done by (Semigran et al., 2015) there is a degree to whi...
We thank Schmieding and colleagues for commenting on our study. As noted, we took great effort to compare different symptom checkers fairly.
Vignettes studies have advantages, but as discussed at length in the manuscript, vignette studies also have some inherent limitations. For this reason, as described, we are carrying out real patient studies to further investigate results.
We support the efforts of Schmieding and colleagues to work towards transparency and a standardization of methods in the field of technology-supported clinical decision support: the literature is advancing in this direction. We agree the study of (Semigran et al., 2015) is important, but it evaluated a relatively small number of vignettes and used a small number of researcher vignettes enterers, likely not highly reflective of real world symptom assessment app use.
There was discussion of the limitations of our study in the manuscript which we do not further elaborate here, except with respect to two of the points made by Schmieding and colleagues.
Firstly, regarding open access to the repertoire of case vignettes, in our study, although not open access, researchers can request access to the vignettes as described in the Data Sharing Agreement and this is similar to the approach described for other recently reported studies (Richens et al., 2020). Although there are some advantages in releasing all the vignettes, as done by (Semigran et al., 2015) there is a degree to which this transparency is highly misleading. As soon as any vignettes are made available through open access, some app developers will (entirely legitimately) use these as cases for the optimization of their reasoning engine. This renders the vignettes of no use and misleading for any future studies, as they have unknown objectivity, and overestimate the performance of the (unknown) optimized apps, and only accurately assess the (unknown) non-optimized apps. We have had several requests for access to the vignettes through the procedure described in the Data Sharing Agreement in the paper, and when our the data governance board formally considers these requests, we will discuss whether we will release a random sample of the vignettes to all researchers, holding the remainder back as an objective testing set, thereby providing transparency whilst maintaining a means to ensure objectivity.
Secondly, with respect to transparent reporting of the performance results, for instance, using confusion tables with absolute numbers and percentages of the correct and the observed triage recommendations - the absolute numbers and percentages of the correct and the observed triage recommendations can be derived by readers from the confusion matrices provided in Figure 6, by simply dividing by the weighing applied, which is clearly defined in the paper methods.
References
1. Richens, J.G., Lee, C.M., Johri, S., 2020. Improving the accuracy of medical diagnosis with causal machine learning. Nature Communications 11, 3923. https://doi.org/10.1038/s41467-020-17419-7
2. Semigran, H.L., Linder, J.A., Gidengil, C., Mehrotra, A., 2015. Evaluation of symptom checkers for self diagnosis and triage: audit study. BMJ 351. https://doi.org/10.1136/bmj.h3480
Yours faithfully
Dr. Stephen Gilbert (corresponding author, response discussed with other authors)
Clinical Evaluation Director
Ada Health GmbH
Karl-Liebknecht-Str. 1
10178 Berlin, DE
Conflict of Interest:
Employee of Ada Health GmbH.
This study demonstrates the utility of routinely collected databases in palliative and end of life care research. Obtaining large sample sizes covering a whole population of interest is a significant advantage of using routine databases. I found the unscheduled care patterns of different disease groups (cancer, organ failure, frailty/progressive neurological condition, etc.) particularly interesting.
As explored in a recent article, routine databases should work to incorporate more domains relevant to palliative care, and increase the capability of linking with Electronic Palliative Care Co-ordination Systems (EPaCCS) [1]. This will help further our understanding the potential benefits of these systems and their use by health care professionals.
References:
1. Chu CS. Using routine databases to evaluate Electronic Palliative Care Co-ordination Systems (EPaCCS). BMJ Evidence-Based Medicine Published Online First: 29 January 2021. doi: 10.1136/bmjebm-2019-111332
We would like to thank the reader for taking interest in our work. We used 2018 international arrival data, as these were the latest published figures at the time of the study. Based on yearly trends in international arrivals before 2018, we have no reason to believe that these figures and more importantly, the between-country differences, would differ from early 2020 figures. We therefore assumed that the 2020 figures recorded prior to the awareness of the spread of SARS-CoV-2 would have been the same as previous years, despite subsequent decreases in international flights occurring after January 2020 as observed by Dr Cairns.
We used 2018 international data as a proxy for countries’ global connections and have therefore found that countries which were better connected globally had significantly higher increases in COVID-19 related mortality during the first wave of the pandemic. A plausible mechanistic link for our findings may therefore be that the virus would have spread significantly out of China before February 2020, after which community transmission would have become predominant in each individual country. Therefore, our findings support the hypothesis that very early travel restrictions should be considered to control the spread of SARS-CoV-2 during future waves of the current and future pandemics. This is of particular importance currently, especially as the world is facing the emergence and international spread of new SARS-CoV-2 strains.
We would like to thank the reader for taking interest in our work. We used 2018 international arrival data, as these were the latest published figures at the time of the study. Based on yearly trends in international arrivals before 2018, we have no reason to believe that these figures and more importantly, the between-country differences, would differ from early 2020 figures. We therefore assumed that the 2020 figures recorded prior to the awareness of the spread of SARS-CoV-2 would have been the same as previous years, despite subsequent decreases in international flights occurring after January 2020 as observed by Dr Cairns.
We used 2018 international data as a proxy for countries’ global connections and have therefore found that countries which were better connected globally had significantly higher increases in COVID-19 related mortality during the first wave of the pandemic. A plausible mechanistic link for our findings may therefore be that the virus would have spread significantly out of China before February 2020, after which community transmission would have become predominant in each individual country. Therefore, our findings support the hypothesis that very early travel restrictions should be considered to control the spread of SARS-CoV-2 during future waves of the current and future pandemics. This is of particular importance currently, especially as the world is facing the emergence and international spread of new SARS-CoV-2 strains.
The authors state that least 21 of the 106 analytes exhibited time dependent increases in biological variation. Such increases can be due to at least two different factors: 1) seasonal variation if more than 2 or 3 months elapse between sequential tests in a subject living in a non-equatorial region and 2) diurnal variation with sequential intra-subject measurements occurring within a day in analytes that exhibit large diurnal variation. In fact, many of the authors of the Labtracer+ validation recently published a remarkable paper documenting large intra-day, intra-subject variation in components of the complete blood count (Reference). What are the 21 analytes that exhibit increased biological variation and would the authors provide the literature citations documenting these variations?
Hilderink JM, Klinkenberg LJ, Aakre KM, de Wit NC, Henskens YM, van der Linden N, Bekers O, Rennenberg RJ, Koopmans RP, Meex SJ. Within-day biological variation and hour-to-hour reference change values for hematological parameters. Clinical Chemistry and Laboratory Medicine (CCLM). 2017 Jun 27;55(7):1013-24.
The study by ADA undertook great effort to compare different symptom checkers competitively. Some of the study’s limitations are unavoidable, such as the authors’ conflict of interest or the limits of vignette-based assessments in general. Other limitations, however, could be avoided in the future. To advance the field of technology-supported clinical decision support, we reason that more transparency and a standardization of methods are needed in at least four areas: (1) open access to the repertoire of case vignettes used to benchmark symptom checker performance; (2) reporting of the performance variation of those who entered the vignettes into the symptom checkers and defining clear guidelines on how to handle the ambiguities that occur when data from vignettes are entered in symptom checkers ; (3) transparent reporting of the performance results, for instance, using confusion tables with absolute numbers and percentages of the correct and the observed triage recommendations; and (4) full reporting of results showing each app’s assessment of each case vignette to make the analyses reproducible, and allow for secondary analysis of the data, as was commendably done by Semigran et al. (2015).
In the following we elaborate these arguments in detail. Ultimately, we think that increasing transparency and standardization of assessment methods will not only advance the field, but also help to address the current discrepancy between industry-funded stud...
The study by ADA undertook great effort to compare different symptom checkers competitively. Some of the study’s limitations are unavoidable, such as the authors’ conflict of interest or the limits of vignette-based assessments in general. Other limitations, however, could be avoided in the future. To advance the field of technology-supported clinical decision support, we reason that more transparency and a standardization of methods are needed in at least four areas: (1) open access to the repertoire of case vignettes used to benchmark symptom checker performance; (2) reporting of the performance variation of those who entered the vignettes into the symptom checkers and defining clear guidelines on how to handle the ambiguities that occur when data from vignettes are entered in symptom checkers ; (3) transparent reporting of the performance results, for instance, using confusion tables with absolute numbers and percentages of the correct and the observed triage recommendations; and (4) full reporting of results showing each app’s assessment of each case vignette to make the analyses reproducible, and allow for secondary analysis of the data, as was commendably done by Semigran et al. (2015).
In the following we elaborate these arguments in detail. Ultimately, we think that increasing transparency and standardization of assessment methods will not only advance the field, but also help to address the current discrepancy between industry-funded studies, which tend to make a strong case for how well symptom checkers may perform, and independent studies, which often draw less optimistic conclusions from their data.
Detailed analyses
The study by Gilbert and colleagues evaluates the diagnostic and triage accuracy, safety of triage advice and scope of diagnoses of eight commonly used symptom checker apps. Most similar studies conducted thus far assess either the performance of a single symptom checker, symptom checker performance in a narrow clinical domain, or symptom checkers’ performance on an aggregate level to draw conclusion about the “population” of current symptom checkers. Hence, we acknowledge the authors’ efforts to competitively test and compare the performance of existing symptom checkers apps on a broad set of case vignettes.
Ada’s study design is highly elaborated and probably required higher financial and time investments than most academic research group could afford to conduct such a study: as the authors correctly pointed out in their manuscript, their study includes more case vignettes than prior academic studies, and involved more (wo)men power than comparable studies, as evidenced by the number of authors and contributors involved.
As the authors themselves point out, their inherent conflict of interest limits the interpretability of their study’s results. Hence, we consider the study’s contribution in advancing the methods of assessing technology-supported clinical decision support of greater importance than its results. We would like to review the methods of the present study and point out some avenues toward improving the design of future similar studies and thereby contribute to a framework of best practices for researchers, app developers and regulators for evaluating symptom checker apps in particular, and clinical decision support systems in general.
1) GPs entered the vignettes – but how reliably?
The case vignettes were entered by eight General Practitioners (GPs), but no measures are described to ensure that they entered the vignettes in a manner comparable to each other and/or reproducibly. Without an assessment of the interrater reliability or other measure of rater agreement, the differences in symptom checker’s accuracies observed in the present Ada study might just as well be differences in the eight GPs’ ability to unbiasedly enter clinical vignettes into symptom checkers.
The authors write that “it is known that lay-people are less reliable at entering clinical vignettes than healthcare providers” (see section Strengths and limitations of this study, p. 11). To support this claim, Gilbert et al. refer to the study from Jungmann et al. (2019). The evidence the Jungmann et al. (2019) study provides for this conclusion, however, is scarce and, in our view, does not support the implicit assumption that GPs can be considered the gold standard for entering vignettes without further proof.
Specifically, the Jungmann et al. (2019) study is based on only six participants (two psychotherapists, two psychology students, and two laypersons), case vignettes from the psychiatric domain only, and only considers one app (namely Ada). Although the two psychotherapists had a greater interrater reliability at entering the vignettes than the other groups, they were not perfect either with Cohen’s kappa values of .78 for adult cases, .53 for pediatric cases (this compares to Cohen’s kappa values of .60 and .29 of the laypeople entering the respective cases). In contrast, Semigran et al. (2015), report a Cohen’s kappa of .90 for two non-clinically trained persons entering a random sample of 25 vignette evaluations.
Taken together, the Jungmann et al. (2019) and Semigran et al. (2015) study stress the importance of determining the interrater reliability of the test users entering the vignettes (whether they are healthcare provider or not), rather than relying on the assumption that GPs are the gold standard at entering vignettes.
Although studies based on case vignettes do not provide high ecological validity, they can help to estimate the maximum triage and diagnostic accuracy of a symptom checker under the ideal condition of a user who minimizes variation during data entry. To avoid limitations due to unreliable or untransparent data entry, future studies could (1) let all vignettes be entered by the same person, (2) develop clear guidelines on how to enter vignettes and how to handle ambiguities, (3) determine interrater reliability of those users entering vignettes and/or (4) app developers themselves could specify how information is best entered into their app (an approach followed by Berner et al. 1994). However, the latter approach might not work with all types of symptom checkers.
2) "Fair" case vignettes? - Hard to tell.
Unfortunately, we as readers cannot get a clear picture of the vignettes and the methods how they were created because the authors do not provide open access to the case vignettes. The authors describe that they made significant efforts to generate a pool of representative and suitable case vignettes but leave room for interpretation as to how exactly this was done: For instance, they state that vignettes “were created to be fair cases representing real-world situations.” (p. 2). Similarly, the authors call it a strength that “moderately complex and challenging presentations” (p. 10) were included. They do not elaborate, however, what constitutes a fair vignette in their definition, why unfair vignettes should be excluded, which vignettes are deemed complex or challenging, which ones are not, and why. Further elaboration on how case complexity was operationalized would have been of great benefit for other researcher or app developers planning to replicate or to conduct a similar study.
To advance the general understanding of this study and symptom checkers in general, we suggest that authors should specify whether labels such as fairness and complexity are based on an objective criterion (e.g., number of symptoms, incidence of diagnosis or symptom), on the judgment of the authors who created the vignettes, the GPs who set the gold standard, or the GPs who entered the vignettes. Also, we suggest that the authors of studies on symptom checkers should provide open access to the vignettes used in their studies. Without more transparency, it will remain difficult to judge the validity of research findings, and it will be impossible to replicate this study and other studies independently to advance our understanding of what symptom checkers can and cannot do, which is a goal the authors themselves call for in their paper.
3) Transparent presentation of results
The authors introduce a penalty score to rate minor triage errors differently than major triage errors. That is, they consider a recommendation to seek emergency care for a vignette a greater error if home care rather than a non-urgent primary care consultation is the appropriate response. This approach is valuable. It is not valuable, however, if the presentation of penalty scores replaces a more transparent presentation of the results, for instance, in a confusion table with absolute numbers and percentages of the correct and the observed triage recommendations. Although confusion tables may be simple contingency tables, they can help readers identify patterns in the data on their own and assess the validity of the conclusions drawn by the authors more easily than with the “weighted” and “normalized” penalty score tables and aggregate inferential statistical analyses as provided by the authors. Additionally, we suggest that future studies should provide a transparent presentation of their results similar to Semigran et al. (2015), showing how each symptom checker responded to each case vignette.
Dear Editor,
We welcome the BMJ Appeal [1] to support independent food banks; as Watson & Lloyd point out [2], it has the potential to have significant and immediate benefits for food insecurity and children’s health. Perhaps more important for longer term change, is the powerful voice of doctors and nurses in advocating for the ability for all citizens to be able to access a healthy diet for physical and mental health and wellbeing.
The immediate and direct effects of the national coronavirus pandemic response strategies on food security and nutrition are well documented in Baraniuk’s exposition [3]. Food banks report an enormous uplift in demand for emergency food aid (Trussell Trust: 47% increase in first six months of the crisis compared to the same period in 2019[4]; IFAN: 110% rise February to November 2020 compared to 2019 [5]).
However, the end of the Brexit transition period on 31 December 2020 now adds to this already uncertain landscape, with the prospect of reduced levels of employment, general downward pressure on wages and perturbations in food supply[6]. In speaking of this disruption, Lang et al [7] state the “The jury is out as to whether these are mere ‘teething problems’ or permanent features of the new normal”.
In an initial expert elicitation in 2019 [8], we asked the question ‘what will be the “new normal” in terms of food prices after Brexit and what are the implications for health?’ When the deadline for the completio...
Show MoreKenkre et al. designed a multicenter investigation in order to prospectively evaluating preoperative parameters that can predict a stable diabetes remission in obese patients with type 2 diabetes (T2DM) undergoing bariatric/metabolic surgery (1). Candidate predictors , ave been detected from previous retrospective studies and their predicting efficacy will be tested in a large and disseminated cohort of operated patients. Multivariate logistic regression model will be then used to assess the value in terms of prediction of diabetes remission of these preoperative parameters. In severely obese patients with T2DM biliopancreatic diversion (BPD) causes a steadily long term serum glucose level normalization in the majority of the cases. In patients with a preoperative T2DM duration of approximately one year, the diabetes remission was observed in nearly all cases, while in those with a T2DM duration of more than five years the remission rate was lower than 75% (2). This suggest a major role of T2DM duration as a predictor of insulin secretion reserve. In severely obese operated subjects, most likely for a still adequate beta-cell reserve (3), a rapid recovery of insulin secretion after BPD subjects develops (4), thus determining a stable improvement in metabolic pattern. A long T2DM duration entails a severe reduction of functioning pancreatic B cells and a reduced beta bell mass , insulin secretion and a lower postoperative T2DM remission rate. At a lower obesity degree, a p...
Show MoreKenkre et al. designed a multicenter investigation in order to prospectively evaluating preoperative parameters that can predict a stable diabetes remission in obese patients with type 2 diabetes (T2DM) undergoing bariatric/metabolic surgery (1). Candidate predictors , ave been detected from previous retrospective studies and their predicting efficacy will be tested in a large and disseminated cohort of operated patients. Multivariate logistic regression model will be then used to assess the value in terms of prediction of diabetes remission of these preoperative parameters. In severely obese patients with T2DM biliopancreatic diversion (BPD) causes a steadily long term serum glucose level normalization in the majority of the cases. In patients with a preoperative T2DM duration of approximately one year, the diabetes remission was observed in nearly all cases, while in those with a T2DM duration of more than five years the remission rate was lower than 75% (2). This suggest a major role of T2DM duration as a predictor of insulin secretion reserve. In severely obese operated subjects, most likely for a still adequate beta-cell reserve (3), a rapid recovery of insulin secretion after BPD subjects develops (4), thus determining a stable improvement in metabolic pattern. A long T2DM duration entails a severe reduction of functioning pancreatic B cells and a reduced beta bell mass , insulin secretion and a lower postoperative T2DM remission rate. At a lower obesity degree, a p...
Show MoreDear Editor,
Show MoreRegarding ‘A sword of Damocles’: patient and caregiver beliefs, attitudes and perspectives on presymptomatic testing for autosomal dominant polycystic kidney disease: a focus group study” by Logeman et al, we think it may be interesting to focus on some themes. What raised our attention, is the striking difference of patients attitude we experience everyday at our center, San Raffaele Hospital ADPKD outpatient clinic. With these few words, we really wish to emphasize the need for a joint approach on ADPKD patient management.
For many patients, futility in uncertainty and anticipating in impact on quality of life are good reasons to prefer keeping on being unaware and surely the most common we have experienced. The other motivations reported in the article can be differently mentioned according to the healthcare system, ethical-social habits and political and economic regulation of the country of origin.
We do firmly believe in the importance of early diagnosis and management, through lab tests, blood pressure control and imaging. Moreover, genetic testing is increasingly important, especially in asymptomatic subjects at risk or in patients with not clear phenotypes due to ADPKD heterogeneity or differential diagnosis. Precocity is fundamental in order to avoid future evitable complications. Too often the attitude “wait and see” is perpetuated even by nephrologists and this is no longer acceptable, also because sometimes it amplifies the fear...
We were delighted to learn from enthusiastic responses to our article (1) that other researchers are also finding that the analysis of routine NHS datasets can shed light on the high volume and variety of care that people seek out-of-hours in their last year of life.
Miller focussed on Primary Care Out-of-hours and Emergency Department data of people dying specifically of cancer. She included prescribing data, and her detailed textual analyses allowed a nuanced understanding of the presenting complaints and diagnoses to be gained. (2) She also quantified the very substantial role that unscheduled care plays in meeting the acute palliative care needs of people in the last year of life.
Chu in her study, like us, concluded that unscheduled care databases should incorporate more domains relevant to palliative care, and increase the capability of linking with Electronic Palliative Care Co-ordination Systems (EPaCCS). (3) This would help to understand the benefits of these systems and describe their use by health care professionals. We found in Scotland that GPOOH is the only unscheduled care database that captures such information.
Diernberger recently analysed the patterns and NHS costs of out-patient and in-patient hospital care in the last year of life in Scotland, noting as we had done that people dying of cancer had the highest number of admissions. (4) The mean cost of planned and unplanned admissions was £10,000 per patient in the last year of...
Show MoreWe thank Schmieding and colleagues for commenting on our study. As noted, we took great effort to compare different symptom checkers fairly.
Vignettes studies have advantages, but as discussed at length in the manuscript, vignette studies also have some inherent limitations. For this reason, as described, we are carrying out real patient studies to further investigate results.
We support the efforts of Schmieding and colleagues to work towards transparency and a standardization of methods in the field of technology-supported clinical decision support: the literature is advancing in this direction. We agree the study of (Semigran et al., 2015) is important, but it evaluated a relatively small number of vignettes and used a small number of researcher vignettes enterers, likely not highly reflective of real world symptom assessment app use.
There was discussion of the limitations of our study in the manuscript which we do not further elaborate here, except with respect to two of the points made by Schmieding and colleagues.
Firstly, regarding open access to the repertoire of case vignettes, in our study, although not open access, researchers can request access to the vignettes as described in the Data Sharing Agreement and this is similar to the approach described for other recently reported studies (Richens et al., 2020). Although there are some advantages in releasing all the vignettes, as done by (Semigran et al., 2015) there is a degree to whi...
Show MoreThis study demonstrates the utility of routinely collected databases in palliative and end of life care research. Obtaining large sample sizes covering a whole population of interest is a significant advantage of using routine databases. I found the unscheduled care patterns of different disease groups (cancer, organ failure, frailty/progressive neurological condition, etc.) particularly interesting.
As explored in a recent article, routine databases should work to incorporate more domains relevant to palliative care, and increase the capability of linking with Electronic Palliative Care Co-ordination Systems (EPaCCS) [1]. This will help further our understanding the potential benefits of these systems and their use by health care professionals.
References:
1. Chu CS. Using routine databases to evaluate Electronic Palliative Care Co-ordination Systems (EPaCCS). BMJ Evidence-Based Medicine Published Online First: 29 January 2021. doi: 10.1136/bmjebm-2019-111332
We would like to thank the reader for taking interest in our work. We used 2018 international arrival data, as these were the latest published figures at the time of the study. Based on yearly trends in international arrivals before 2018, we have no reason to believe that these figures and more importantly, the between-country differences, would differ from early 2020 figures. We therefore assumed that the 2020 figures recorded prior to the awareness of the spread of SARS-CoV-2 would have been the same as previous years, despite subsequent decreases in international flights occurring after January 2020 as observed by Dr Cairns.
We used 2018 international data as a proxy for countries’ global connections and have therefore found that countries which were better connected globally had significantly higher increases in COVID-19 related mortality during the first wave of the pandemic. A plausible mechanistic link for our findings may therefore be that the virus would have spread significantly out of China before February 2020, after which community transmission would have become predominant in each individual country. Therefore, our findings support the hypothesis that very early travel restrictions should be considered to control the spread of SARS-CoV-2 during future waves of the current and future pandemics. This is of particular importance currently, especially as the world is facing the emergence and international spread of new SARS-CoV-2 strains.
Yours Si...
Show MoreThe authors state that least 21 of the 106 analytes exhibited time dependent increases in biological variation. Such increases can be due to at least two different factors: 1) seasonal variation if more than 2 or 3 months elapse between sequential tests in a subject living in a non-equatorial region and 2) diurnal variation with sequential intra-subject measurements occurring within a day in analytes that exhibit large diurnal variation. In fact, many of the authors of the Labtracer+ validation recently published a remarkable paper documenting large intra-day, intra-subject variation in components of the complete blood count (Reference). What are the 21 analytes that exhibit increased biological variation and would the authors provide the literature citations documenting these variations?
Hilderink JM, Klinkenberg LJ, Aakre KM, de Wit NC, Henskens YM, van der Linden N, Bekers O, Rennenberg RJ, Koopmans RP, Meex SJ. Within-day biological variation and hour-to-hour reference change values for hematological parameters. Clinical Chemistry and Laboratory Medicine (CCLM). 2017 Jun 27;55(7):1013-24.
Summary
The study by ADA undertook great effort to compare different symptom checkers competitively. Some of the study’s limitations are unavoidable, such as the authors’ conflict of interest or the limits of vignette-based assessments in general. Other limitations, however, could be avoided in the future. To advance the field of technology-supported clinical decision support, we reason that more transparency and a standardization of methods are needed in at least four areas: (1) open access to the repertoire of case vignettes used to benchmark symptom checker performance; (2) reporting of the performance variation of those who entered the vignettes into the symptom checkers and defining clear guidelines on how to handle the ambiguities that occur when data from vignettes are entered in symptom checkers ; (3) transparent reporting of the performance results, for instance, using confusion tables with absolute numbers and percentages of the correct and the observed triage recommendations; and (4) full reporting of results showing each app’s assessment of each case vignette to make the analyses reproducible, and allow for secondary analysis of the data, as was commendably done by Semigran et al. (2015).
In the following we elaborate these arguments in detail. Ultimately, we think that increasing transparency and standardization of assessment methods will not only advance the field, but also help to address the current discrepancy between industry-funded stud...
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