Increasing number of the patients with endstage renal disease (ESRD)
is nowadays a serious problem in each country, including many Western
countries and Asian countries. Diabetic nephropathy (DMN) is the major
cause of the incidence of ESRD in worldwide. In Japan, DMN has been the
leading cause of dialysis since 1998 despite many innovative achievements
in the pharmacological treatment for diabetes mellitus. Excessive...
Increasing number of the patients with endstage renal disease (ESRD)
is nowadays a serious problem in each country, including many Western
countries and Asian countries. Diabetic nephropathy (DMN) is the major
cause of the incidence of ESRD in worldwide. In Japan, DMN has been the
leading cause of dialysis since 1998 despite many innovative achievements
in the pharmacological treatment for diabetes mellitus. Excessive salt
intake causes hypertension and increases the risk for cerebro-cardio-
vascular disease as well as ESRD [1]. However, the association of salt
intake and the incidence of ESRD in the patients with DMN remains unknown.
It is reported that many Asian countries, such as Singapore, Malaysia,
Republic of Korea, Hong Kong, Taiwan, Philippines and Japan, head the list
of the percentage of incident patients of ESRD due to diabetes [2].
Meanwhile, many Western countries, such as United States, Iceland, Canada,
Finland, Portugal, Croatia, Czech Republic, Austria, Greece, Denmark,
Bosnia/Herzegovina, United Kingdom, Sweden, Spain, Scotland, France,
Serbia, Belgium, Netherlands, Norway and Romania, run after Asian
countries. A report of global national sodium intakes shows that these
East Asian countries consume more salt than these Western countries [3].
We simply analyzed the relationship between percent incidence of DMN in
ESRD and salt intake(Figure, not shown). It clearly demonstrated a
significant relationship between them (r = 0.483, P = 0.009). The average
percent incidence of DMN in ESRD in East Asian countries was significantly
higher than that in Western countries (47.5 % vs 27 %, p < 0.001) as
well as salt intake (11.8 g/day vs 9.5 g/day, p < 0.001), suggesting
the link between progression of DMN and salt intake in East Asian
countries, while the protection of DMN by low salt consumptions in Western
countries. A multiple linear regression analysis adjusted by salt intake
demonstrated that the average percent incidence of DMN in ESRD in East
Asian countries was still significantly higher than that in Western
countries (p < 0.001). The result indicated that DMN patients in East
Asian countries are genetically salt-sensitive compared with Western
countries. A few reports supported the idea that there is a certain
difference of salt sensitivity between East Asian and Western countries
[4]. Further studies are required to confirm the association of the
incidence of ESRD in the patients with DMN and salt intake.
References
1. Mozaffarian D, Fahimi S, Singh GM, et al. Global sodium
consumption and death from cardiovascular causes. N Engl J Med
2014;371:624-34.
2. U S Renal Data System. USRDS 2013 Annual Data Report: Atlas of
Chronic Kidney Disease and End-Stage Renal Disease in the United States.
Bethesda, MD: National Institutes of Health, National Institute of
Diabetes and Digestive and Kidney Diseases; 2013.
3. Powles J, Fahimi S, Micha R, et al, Global, regional and national
sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary
sodium excretion and dietary surveys worldwide. BMJ Open, 2013, 3:e003733.
4.Mente A, O'Donnell MJ, Rangarajan S, et al. Association of urinary
sodium and potassium excretion with blood pressure. N Engl J Med
2014;371:601-611
Evan S. Herrmann1, Patrick S. Johnson2, and Matthew W. Johnson3
1Division on Substance Abuse, New York State Psychiatric Institute,
Columbia University College of Physicians and Surgeons
2Department of Psychology, California State University, Chico
3Behavioral Pharmacology Research Unit, Department of Psychiatry and
Behavioral Sciences, Johns Hopkins University School of Medicine.
In an article recently published in BMJ Open, Eleftheriou et al
(2016) describe the results of an experimental study that examined the
influence of partner attractiveness on condom use intentions. Heterosexual
men completed a task where they rated the attractiveness of 20 photographs
of women, estimated the likelihood each woman had a sexually transmitted
infection (STI), and indicated their willingness to have sex with each
woman with or without a condom. Higher ratings of attractiveness and lower
ratings of STI risk were associated with lower condom use intentions.
Participant sociodemographic and sexual history characteristics associated
with STI acquisition were also associated with lower condom use
intentions. Increasing our understanding of factors that affect choices
about condom use has the potential to greatly improve public health, and
we commend the authors on their contribution. Here we draw attention to a
body of published work using a measures that have shown similar effects of
attractiveness and STI risk, but also reveal another important dimension
modulating condom use decisions: delay to condom availability.
Johnson and Bruner (2012) developed the Sexual Delay Discounting Task
(SDDT) to examine how sexual desirability, perceived STI risk, and delayed
condom availability influence decisions about condom use. On the most
commonly used version of this task, individuals view pictures of 30 men
and 30 women and select pictures of the individuals whom they would
consider having sex based on appearance alone. From these photographs,
participants select the individual they most wanted to have sex with,
least wanted to have sex with, they think is least likely to have an STI,
and most likely to have an STI. Then, they rate their likelihood of using
an immediately available condom when having sex with each individual,
using a Visual Analog Scale ranging from 0 to 100. Next, they rate their
likelihood having immediate unprotected sex vs. waiting for a specified
delay to have condom-protected sex with each individual. Seven delays are
examined, allowing for quantification of how delayed condom availability
influences choices about condom use with partners who have different
perceived levels of desirability and STI risk.
We are aware of 12 studies using the SDDT that are currently
published, in press, or under peer review. Across a variety of
populations, including cocaine users (Johnson et al., 2015, 2016,
Koffarnus et al., in press) men who have sex with men (Herrmann et al.,
2015), opioid-dependent women (Herrmann et al., 2014), non-drug-using
controls (e.g., Herrmann et al., 2015, Johnson et al., 2015), and emerging
adults (Collado et al., in press; Dariotis and Johnson, 2015; Wongsomboon
and Robles, 2016), participants reliably indicated they would be less
likely to use immediately available condoms with those whom they most (vs.
least) want to have sex and those they thought were least likely (vs. most
likely) to have a STI. Individuals who reported higher rates of real-world
risky sexual behavior and/or sociodemographic characteristics associated
with STI risk also reported lower likelihood of using immediately
available condoms on the SDDT. Condom use likelihood decreased as a
function of delay to condom availability in an orderly manner well-fit by
hyperbolic discounting functions that also describe the effects of delay
on choices for other commodities (e.g., food or money). The SDDT has
demonstrated test-retest reliability (Johnson and Bruner, 2013), and
participants at higher risk for STI infection (e.g., individuals who
report drug use or unprotected sex with multiple partners) showed larger
decreases in condom use likelihood as a function of delay. One study
(Herrmann et al., 2015) demonstrated that steeper discounting on the SDDT
was associated with increased likelihood of having unprotected sex in the
past six months specifically because a condom was not immediately
available, suggesting the task has external validity. Lastly, the SDDT is
sensitive to acute drug effects; alcohol and cocaine intoxication
increased the deleterious effects of delay on condom use likelihood
(Johnson et al., 2016, Johnson et al., under review), while the
antipsychotic buspirone increased immediate condom use likelihood (Bolin
et al., 2016).
We commend Eleftheriou et al (2016) on their contribution to the
literature, and note that the consistencies between their results and our
own provide further evidence supporting the validity of behavioral tasks
to study condom use decisions. Finally, as Eleftheriou et al (2016)
stated, we hope that the knowledge gained from these studies can inform
the development of new evidence-based interventions to reduce STI
transmission.
References
Bolin, B. L., Lile, J. A., Marks, K. R., Beckmann, J. S., Rush, C.
R., & Stoops, W. W. (2016). Buspirone reduces sexual risk-taking
intent but not cocaine self-administration. Experimental and Clinical
Psychopharmacology, 24, 162.
Collado A., Johnson, P. S., Loya, J. M., Johnson, M. W., & Yi, R.
(in press). Discounting of Condom-Protected Sex as a Measure of High-Risk
for Sexually Transmitted Infection among College Students. Archives of
Sexual Behavior.
Dariotis, J. K., & Johnson, M. W. (2015). Sexual discounting
among high-risk youth ages 18-24: Implications for sexual and substance
use risk behaviors. Experimental and Clinical Psychopharmacology, 23, 49.
Eleftheriou, A., Bullock, S., Graham, C. A., Stone, N., Ingham, R.
(2016). Does attractiveness influence condom use intentions in
heterosexual men? An experimental study. Sexual Health Research.
Herrmann, E. S., Hand, D. J., Johnson, M. W., Badger, G. J., &
Heil, S. H. (2014). Examining delay discounting of condom-protected sex
among opioid-dependent women and non-drug-using control women. Drug and
Alcohol Dependence, 144, 53-60.
Herrmann, E. S., Johnson, P. S., & Johnson, M. W. (2015).
Examining delay discounting of condom-protected sex among men who have sex
with men using crowdsourcing technology. AIDS and Behavior, 19, 1655-1665.
Johnson, M. W., & Bruner, N. R. (2012). The Sexual Discounting
Task: HIV risk behavior and the discounting of delayed sexual rewards in
cocaine dependence. Drug and Alcohol Dependence, 123, 15-21.
Johnson, M. W., & Bruner, N. R. (2013). Test-retest reliability
and gender differences in the sexual discounting task among cocaine-
dependent individuals. Experimental and Clinical Psychopharmacology, 21,
277.
Johnson, M. W., Herrmann, E. S., Johnson, P. S., Sweeney, M. M.,
& LeComte, R. S. (under review). Cracking the code of cocaine and HIV
sexual risk behavior: Cocaine administration dose-dependently increases
sexual desire and decreases condom use likelihood via delay and
probability discounting.
Johnson, M. W., Johnson, P. S., Herrmann, E. S., & Sweeney, M. M.
(2015). Delay and probability discounting of sexual and monetary outcomes
in individuals with cocaine use disorders and matched controls. PloS one,
10, e0128641.
Johnson, P. S., Sweeney, M. M., Herrmann, E. S., & Johnson, M. W.
(2016). Alcohol increases delay and probability discounting of condom-
protected Sex: A novel vector for alcohol-related HIV transmission.
Alcoholism: Clinical and Experimental Research, 40, 1339-1350.
Koffarnus, M. N., Johnson, M. W., Thompson-Lake, D. G. Y., Wesley, M.
J., Lohrenz, T., Montague, R., & Bickel, W. K. (in press). Cocaine-
dependent adults and recreational cocaine users are more likely than
controls to choose immediate unsafe sex over delayed safer sex.
Experimental and Clinical Psychopharmacology.
Wongsomboon, V., & Robles, E. (2016). Devaluation of safe sex by
delay or uncertainty: A within-subjects study of mechanisms underlying
sexual risk behavior. Archives of Sexual Behavior, 1-14.
We read with much interest the recent article by Levett et al on the use of alternative
therapies in labour and delivery to manage pain.[1]
This is certainly a hot topic of research and we were pleased to see groups working...
We read with much interest the recent article by Levett et al on the use of alternative
therapies in labour and delivery to manage pain.[1]
This is certainly a hot topic of research and we were pleased to see groups working
to provide an evidence base for maternity care practises. To aid implementation
and wider use we thought some aspects require closer scrutiny.
It seems to us that the study was designed to assess both pain
control and unnecessary medical intervention. Epidural use as analgesia was
used as a surrogate measure for failing pain management during labour. Whilst
the use of surrogate endpoints can be highly problematic,[2]
the authors justify its use in this case due to its role in initiating the
'cascade of interventions'. They describe that as epidural rates increase, so
do the rates of instrumental births and other associated unnecessary medical
interventions.
Whilst reviews cited by the authors have shown instrumental
deliveries may increase, the same high-quality evidence shows epidural blocks
neither increase the overall caesarean rate nor adverse neonatal outcomes.[3] Not all epidurals are created equal; some blocks have
higher rates of side effects and adverse events.[3] As such it is important to
distinguish between high-dose epidurals, low-dose epidurals and combined
spinal-epidurals, for example.
Levett et al assume that epidural blocks are
used when other pain management strategies fail. We question whether this is a
true reflection of how epidurals are used in practice. Epidurals can be placed
early in labour, which allows for the use of blocks with fewer side effects
however delivery suite personnel and other factors occasionally delay
administration.[4, 5] As such the rate of epidural
block may more accurately represent women's antenatal attitudes to pain relief
during labour rather than the pain they experience.[6] Previous studies have
assessed attitudes towards analgesia and the birthing process as a baseline
characteristic between groups.[6]
As the authors mention, designing robust studies of such
interventions is challenging. Delivery suite personnel were aware of the
study's existence but they were not informed of group allocations of participants.
In our experience not many women or their partners are trained to administer
alternative therapies in the manner described. Whether by simple observation of
techniques or by the usual rapport a midwife forms with patients, it is
plausible that group allocation may have become apparent to delivery floor
practitioners. Simple methods such as asking involved personnel to guess which
group a participant was allocated to could assess such risk in future studies.
Whilst we take the authors' advice to interpret secondary
outcomes with caution, the labour agency scale (LAS) outcomes were incongruent;
despite extra education women in the study group felt they had significantly less
control or 'agency' over their birthing process. Levett
et al conclude their course 'increased personal control for women', which
contradicts their description of the LAS measure they used and its results. The
origin of this disparity remains unclear through the discussion, which refers
to a more 'positive attitude towards birth in the antenatal period'. Did the
authors assess antenatal birthing attitudes?
Some other outcome measures, such as 'other pharmacological
pain relief' were either incompletely defined or only partially reported. It is
unclear why only pethidine and nitrous use were reported. Other medications
have more favourable side effect profiles in the peripartum
population, are commonly utilised and are recorded in the datasets utilised by
the authors of this study.[7, 8] Whilst there was no
difference in pethidine or nitrous use between the groups, it is not reasonable
to draw any conclusions about pain management or control without data on
women's intra-partum pain levels and their use of other medications.
Despite approximately three times the epidural rate in the
control group there was no significant difference in the instrumental delivery
rate. Epidural analgesia increases instrumental delivery rate by approximately
1.4 times.[3] Given the differences in epidural rate
between groups, the magnitude of this effect would be expected to be detectable
with this sample. This might reflect underlying differences in the groups or
that practises in the studied hospitals vary from the norm. Alternatively
perhaps these large studies that are dominated by US data may not reflect
Australian practice. One of the best UK trails to date showed where epidurals
are utilised less routinely there is no increase in caesareans or instrumental
delivery.[9]
High-quality studies have concluded relaxation and education
classes for low-risk women can reduce the caesarean rate which may in part
explain the observed effects in this study.[10]
Overall we welcome this new contribution to the field; it raises interesting
points for further study. We would caution against over interpretation of the
results, particularly in mainstream media where broad statements might
overreach the scientific conclusions that can be drawn from any one piece of
research.[11] We look forward to perusing the results
of future iterations of this group's work on a larger scale.
In the meantime, the
rights of women to weigh up the potential benefits of epidural analgesia[3] against a possible increase in instrumental deliveries
continues to be an important focus of antenatal discussion. As one review
eloquently concluded, current evidence suggests "in the
absence of a medical contraindication, maternal request is a sufficient medical
indication for [epidural] pain relief during labor."[4]
References:
1. Levett, K.M., et al., Complementary
therapies for labour and birth study: a randomised controlled trial of antenatal integrative
medicine for pain management in labour. BMJ Open,
2016. 6(7): p. e010691.
2. Fleming, T.R. and D.L. DeMets, Surrogate End
Points in Clinical Trials: Are We Being Misled?Annals of
Internal Medicine, 1996.125(7): p. 605-613.
3. Anim-Somuah, M., R.M. Smyth, and L. Jones, Epidural
versus non-epidural or no analgesia in labour.
Cochrane Database Syst Rev, 2011(12): p. CD000331. 4. Sng, B.L., et al., Early
versus late initiation of epidural analgesia for labour.
Cochrane Database Syst Rev, 2014(10): p. CD007238.
5. Hess, P.E., et al., Predictors of Breakthrough Pain During Labor Epidural
Analgesia.AnesthAnalg,
2001. 93: p. 5.
6. Goldberg, A.B., A. Cohen, and E. Lieberman, Nulliparas'
Preferences for Epidural Analgesia: Their Effects on Actual Use in Labor.Birth, 1999.26(3): p. 139-143.
7. Jones, L., et al., Pain management for women in labour:
an overview of systematic reviews. Cochrane Database Syst
Rev, 2012(3): p. CD009234.
8. Wellfare, A.I.o.H.a., Meteor
- National Dataset Standards.
9. Loughnan, B.A., et al., Randomized controlled
comparison of epidural bupivacaine versus pethidine
for analgesia in labour.British
Journal of Anaesthesia, 2000.84(6): p.
715-719.
10. Khunpradit, S., et al., Non-clinical interventions
for reducing unnecessary caesarean section. Cochrane Database Syst Rev, 2011(6): p. CD005528.
11. Reporter: McCullagh, C., et al., Fewer medical
problems with natural pain relief in childbirth, in ABC Radio National,
L. Raine, Editor. 2016, ABC Radio National:
Australia.
Preyanka Abhyankar, Anju Anand, Matthew B. Stanbrook
We welcomed the study by Slok and colleagues examining the effect of
a tool for assessing the burden of COPD on quality of life as the article
of discussion for our Twitter-based asynchronous monthly respirology and
sleep journal club. This non-blinded cluster randomized control trial
included both primary and hospitalist care and found that the Assessment
of...
Preyanka Abhyankar, Anju Anand, Matthew B. Stanbrook
We welcomed the study by Slok and colleagues examining the effect of
a tool for assessing the burden of COPD on quality of life as the article
of discussion for our Twitter-based asynchronous monthly respirology and
sleep journal club. This non-blinded cluster randomized control trial
included both primary and hospitalist care and found that the Assessment
of Burden of COPD (ABC) tool produced improvements on two separate quality
of life measures (SGRQ, PACIC) but not on a third measure (the CAT) (1).
The most important issue identified in our online discussions was the
potential that the main results could be an artefact of regression to the
mean. The intervention and control groups differed at baseline, both with
regard to baseline disease severity as reflected by FEV1 and FEV1/FVC
ratio, as well as in the baseline values of the quality of life outcome
measures. Post-intervention, the two groups became progressively more
similar over time, as illustrated in Table 2. Thus, rather than a true
effect of the intervention, the study results could simply reflect natural
variation around a common mean level of disease- specific quality of life
with the intervention group, showing the greatest response only because
they happened to diverge furthest from this level at baseline (2,3). It
was unclear if the groups were unbalanced due to cluster randomization
itself or due to the real-world nature of the study not lending itself
well to randomization, which was further exacerbated by the small sample
size (4,5).
Another important issue highlighted in our discussions was that this
study was unblinded or and lacked a sham group. Compounded with the
subjective nature of the outcome measure, this may have introduced
reporting bias (6). The study's inability to capture more objective lung
function and exacerbation outcomes as planned is thereby even more
problematic, and as a result our group felt that it is difficult for the
study to yield a meaningful evaluation of the ABC tool (7).
A final issue raised was that the study was performed under real-
world conditions, which can be an asset, however the liberal inclusion
criteria (e.g. including any obstructive lung pathology with FEV1/FVC <
,0.7, not requiring a smoking history, etc.) raised concern around
misclassification of patients (8,9).
We do agree with Slok et al. that developing and validating patient
care interventions like the ABC tool is an important step towards
enhancing patient involvement in the management of their chronic illness
and we commend the efforts of the authors to do so via a randomized trial.
However, we feel further studies are still needed to assess the
effectiveness of this tool before it becomes clear what value it may hold
for clinical practice (10, 11).
REFERENCES
1. Slok, A. H., Chavannes, N. H., van der Molen, T., Rutten-van M?lken, M.
P., Kerstjens, H. A., Salom?, P. L., ... & van Schayck, O. C. (2014).
Development of the Assessment of Burden of COPD tool: an integrated tool
to measure the burden of COPD. NPJ primary care respiratory medicine, 24,
14021.
2. Stanbrook, M. [drstanbrook]. (2016, Jul 21). @respandsleepjc Take a
look at table of continuous SGRQ scores. Clear evidence of regression to
the mean. This is all an artefact. #rsjc [Tweet]. Retrieved from
https://twitter.com/drstanbrook/status/756268723980292096
3. Stanbrook, M. [drstanbrook]. (2016, Jul 22). @respandsleepjc Still a
problem. Intervention got better while control got WORSE = RTTM. #rsjc
https://t.co/JG77Qub5Az [Tweet]. Retrieved from
https://twitter.com/drstanbrook/status/756278596495368193
4. Vagaon, A. [AndreiV_Resp]. (2016, Jul 21). @respandsleepjc Perhaps an
effect of the real world not randomizing in a good way; ?smaller sample
more prone; but throws things off #rsjc [Tweet]. Retrieved from
https://twitter.com/andreiv_resp/status/756271906786074625
5. Christiansen, D. [dcwpg]. (2016, Jul 21). Unusual to see groups so
unequal at baseline. Is it a result of the clustered randomization and
having too few study docs? #rsjc [Tweet]. Retrieved from
https://twitter.com/dcwpg/status/756270239516467201
6. Stanbrook, M. [drstanbrook]. (2016, Jul 21). @respandsleepjc Not good
enough. This is an unblinded trial with a subjective outcome measure.
Setup for bias. #rsjc https://t.co/Wph3qMC7F2 [Tweet]. Retrieved from
https://twitter.com/drstanbrook/status/756266741462728704
7. Zaheen, A. [drazaheen]. (2016, Jul 22). @respandsleepjc But difficult
to comment on the value of ABC in the absence of objective data! #rsjc
[Tweet]. Retrieved from
https://twitter.com/drazaheen/status/756278274444005378
8. Christiansen, D. [dcwpg]. (2016, Jul 21). Great to see an RCT done
under real-world conditions. Struck by the very liberal inclusion criteria
(didn't even require a smoking Hx) #rsjc [Tweet]. Retrieved from
https://twitter.com/dcwpg/status/756265754329092096
9. Vagaon, A. [AndreiV_Resp]. (2016, Jul 21). @thelungdr Not sure why
absolute ratio 0.7, rather than LLNs. Ptnt can be misclasified. Esp. as
impact was 49 v 33 people @ 18 months #rsjc [Tweet]. Retrieved from
https://twitter.com/andreiv_resp/status/756268872781664256
10. Anand, A. [respandsleepjc]. (2016, Jul 22). Summary- interesting study
- grp not bal to start, blinding (lack of) & RTTM problematic-- need
more studies to assess this tool #rsjc [Tweet]. Retrieved from
https://twitter.com/respandsleepjc/status/756285601477980160
11. Zaheen, A. [drazaheen]. (2016, Jul 22). @respandsleepjc Part of the
important trend towards patient involvement in the management of chronic
illness #rsjc [Tweet]. Retrieved from
https://twitter.com/drazaheen/status/756277959481143296
Comparison of drug requirement among study participants
Using the WHO guidelines for CVD risk assessment and management, (2)
estimates of proportions
should be:
Comparison of drug requirement among study participants
Using the WHO guidelines for CVD risk assessment and management,
estimates of proportions
Issue 3: Page 5, Table 4 footnote
*Without cholesterol versus single risk factor, threshold greater than or equal to 30%: x(squared)
=6.32, p<0.012
(dagger)Without cholesterol, threshold greater than or equal to 30% versus without cholesterol,
threshold greater than or equal to 20%: x(squared) =10.06, p<0.002.
(double dagger)Without cholesterol versus single risk factor, threshold greater than or equal to 20%: x(squared)
=0.45, p<0.500.
(section sign)With cholesterol versus single risk factor, threshold greater than or equal to 30%: x(squared)
=123.9, p<0.001.
(paragraph sign)With cholesterol, threshold greater than or equal to 30% versus with cholesterol, threshold
greater than or equal to 20%: x(squared) =8.77, p<0.003.
**With cholesterol versus single risk factor, threshold greater than or equal to 20%: x(squared) =74.5,
p<0.001.
should be:
*Without cholesterol versus single risk factor, threshold greater than or equal to 30%: x(squared)
=6.32, p=0.012
(dagger)Without cholesterol, threshold greater than or equal to 30% versus without cholesterol,
threshold greater than or equal to 20%: x(squared) =10.06, p=0.002
(double dagger)Without cholesterol versus single risk factor, threshold greater than or equal to 20%: x(squared)
=0.45, p=0.500
(section sign)With cholesterol versus single risk factor, threshold greater than or equal to 30%: x(squared)
=123.9, p<0.001
(paragraph sign)With cholesterol, threshold greater than or equal to 30% versus with cholesterol, threshold
greater than or equal to 20%: x(squared) =8.77, p=0.003
**With cholesterol versus single risk factor, threshold greater than or equal to 20%: x(squared) =74.5,
p<0.001.
A pooled SMD of 1.20 (95% CI 0.89 to 1.51; T2=0.27; I2=99%;
p<0.00001) was observed (figure 3), equivalent to a prevalence of ?50%
asymptomatic coronary stenosis of 32% (95% CI 19% to 47%).
This paragraph mismatch the figure 3 in all numbers.
Please correct it if possible.
My name is Damaris Kinyoki, I recently published with BMJ Open. Please note that the conclusion section of the article should be corrected to read as follows:
Conclusion
This study has demonstrated that wasting, stunting and underweight in
children 6-59 months in Somalia share common risk factors with evidence of
correlation in space (17,47). The emergency response funding is by nature
short term. The spatial pat...
My name is Damaris Kinyoki, I recently published with BMJ Open. Please note that the conclusion section of the article should be corrected to read as follows:
Conclusion
This study has demonstrated that wasting, stunting and underweight in
children 6-59 months in Somalia share common risk factors with evidence of
correlation in space (17,47). The emergency response funding is by nature
short term. The spatial patterns and trends of wasting and stunting and
information on seasonal variation, the age and gender of the child can be
used to support effective interventions. Although emergency nutrition
response in Somalia focuses on wasting, our evidence suggests
implementation of a more joined-up program may be most effective. This
will require political will, appropriate financing, policies and
programmatic links between partners on the main indicators of
malnutrition.
We read this article with great interest. We similarly aimed to
explore barriers to patient engagement with diabetic retinopathy screening
as part of a medical student service evaluation project. We explored
reasons for non-attendance using a GP practice population that serves a
large Asian community in Blackburn. We found that from June 2014 to June
2015, 81.2% (n=307) of the patients invited for screening attended and...
We read this article with great interest. We similarly aimed to
explore barriers to patient engagement with diabetic retinopathy screening
as part of a medical student service evaluation project. We explored
reasons for non-attendance using a GP practice population that serves a
large Asian community in Blackburn. We found that from June 2014 to June
2015, 81.2% (n=307) of the patients invited for screening attended and
18.8% (n=71) did not attend. We managed to conduct telephone interviews
with 43 non-attenders to establish their understanding of screening and
reasons for non-engagement. 33 (76.7%) patients who were interviewed cited
other commitments, 3 (7%) did not recall receiving any invite letters, 3
(7%) were housebound, and the remaining 4 patients (9.3%) voiced a general
lack of interest in attending medical appointments. Surprisingly, 23
(53.4%) patients were unaware of the need of attending screening
appointments when visually asymptomatic and 8 (18.6%) stated that they did
not believe that diabetes could damage eyes. As a result of these
findings, we have now designed a patient information leaflet outlining the
importance and rationale behind the diabetic retinopathy screening
programme. This has now been adopted by the local CCG allowing GPs in the
locality to provide these at the point of diagnosis and at routine
diabetic review appointments to help promote uptake for the future. We
plan to re-audit uptake rates following this intervention.
Regarding the study of early intervention of patients at risk for
acute respiratory failure and prolonged mechanical ventilation, I agree
that a checklist, such as the PROOFCheck, aimed at the prevention of organ
failure would be beneficial in lowering rates of mortality.
The authors' report that often times the acuity and severity of
patients' conditions often are not recognized in a ti...
Regarding the study of early intervention of patients at risk for
acute respiratory failure and prolonged mechanical ventilation, I agree
that a checklist, such as the PROOFCheck, aimed at the prevention of organ
failure would be beneficial in lowering rates of mortality.
The authors' report that often times the acuity and severity of
patients' conditions often are not recognized in a timely manner. Rather
than recognize and intervene with the signs and symptoms of ARF and acute
organ failure on the general medical floors, health care works sometimes
don't catch a patient spiraling downward until they are already moved to
an intensive care unit. To my attest from working as a respiratory
therapist, I have seen this countless times. As I am not sure of the
stipulations of the six hospitals where this study is being conducted, I
have witnessed many times that general floors are understaffed. The
nursing to patient ratio is often times too low and therefore they cannot
provide adequate care. In one of the facilities I was employed at, a
general floor nurse could have as many as seven patients. Another problem
I've seen is that while many of the critical care nurses are experienced
nurses, a lot of the general floor nurses are new graduate nurses and
therefore are still trying to learn as they go so may not have the
knowledge or experience to spot a critical patient on the general floor
and intervene or call the rapid response team in time before a patient
gets worse.
I commend the authors of this study for attempting to research
whether or not an EMR-based alert system would be sufficient in preventing
and recognizing ARF and acute organ failure. Both the APPROVE score and
PROOFCheck, as well as a notification feature provided a patient may meet
certain criteria for going into ARF all seem like they would be excellent
tools for early detection and prevention.
I thank you for your time and enjoyed reading the article, and I look
forward to following up with the outcome of this study.
Sincerely,
Alexandria Erickson
BAS Cardiopulmonary Science
Student Physician Assistant - Nova Southeastern Fort Myers
Fort Myers, FL
ae633@nova.edu
Thank you for the comments and support for our work.
Firstly you raise the issue of access to the survey and response
rate. The RCOG is aware that IT systems within NHS organisations can
sometimes prohibit access to our surveys and we are unable to resolve this
at the college as it is often related to NHS firewalls. In terms of
response rate the RCOG reports that its usual response rate to a national
survey is a...
Thank you for the comments and support for our work.
Firstly you raise the issue of access to the survey and response
rate. The RCOG is aware that IT systems within NHS organisations can
sometimes prohibit access to our surveys and we are unable to resolve this
at the college as it is often related to NHS firewalls. In terms of
response rate the RCOG reports that its usual response rate to a national
survey is around 30% and thus our response rate of 28% was consistent with
that figure. Yet it is unfortunate that a small number of consultants,
such as you, could not participate.
We would agree with your observations regarding bullies as victims
and indeed other work we have undertaken and hope to publish would
corroborate this. We would also agree that interventions targeted at
promoting self-awareness and helping to break this cycle are key, although
with the caveat that since few such interventions publish any effective
evaluation of what worked, for whom and why, it is difficult to be
certain.
Increasing number of the patients with endstage renal disease (ESRD) is nowadays a serious problem in each country, including many Western countries and Asian countries. Diabetic nephropathy (DMN) is the major cause of the incidence of ESRD in worldwide. In Japan, DMN has been the leading cause of dialysis since 1998 despite many innovative achievements in the pharmacological treatment for diabetes mellitus. Excessive...
Evan S. Herrmann1, Patrick S. Johnson2, and Matthew W. Johnson3
1Division on Substance Abuse, New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons
2Department of Psychology, California State University, Chico
3Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine.
In...
We read with much interest the recent article by Levett et al on the use of alternative therapies in labour and delivery to manage pain.[1] This is certainly a hot topic of research and we were pleased to see groups working...
Preyanka Abhyankar, Anju Anand, Matthew B. Stanbrook
We welcomed the study by Slok and colleagues examining the effect of a tool for assessing the burden of COPD on quality of life as the article of discussion for our Twitter-based asynchronous monthly respirology and sleep journal club. This non-blinded cluster randomized control trial included both primary and hospitalist care and found that the Assessment of...
There are some corrections to be made to this article.
Issue 1: Page 4, Table 2 footnote
*x(squared) =0.35 p=0.557. (dagger)x(squared) =0.88 p=0.348. (double dagger)x(squared) =0.70 p=0.403. (section sign)x(squared) =2.90 p<0.088
should be:
*x(squared) =0.35 p=0.557 (dagger)x(squared) =0.88 p=0.348 (double dagger)x(squared) =0.70 p=0.403 (section sign)x(squared) =2.90 p=0.088
...A pooled SMD of 1.20 (95% CI 0.89 to 1.51; T2=0.27; I2=99%; p<0.00001) was observed (figure 3), equivalent to a prevalence of ?50% asymptomatic coronary stenosis of 32% (95% CI 19% to 47%).
This paragraph mismatch the figure 3 in all numbers. Please correct it if possible.
Conflict of Interest:
None declared
My name is Damaris Kinyoki, I recently published with BMJ Open. Please note that the conclusion section of the article should be corrected to read as follows:
Conclusion This study has demonstrated that wasting, stunting and underweight in children 6-59 months in Somalia share common risk factors with evidence of correlation in space (17,47). The emergency response funding is by nature short term. The spatial pat...
We read this article with great interest. We similarly aimed to explore barriers to patient engagement with diabetic retinopathy screening as part of a medical student service evaluation project. We explored reasons for non-attendance using a GP practice population that serves a large Asian community in Blackburn. We found that from June 2014 to June 2015, 81.2% (n=307) of the patients invited for screening attended and...
To the Editor:
Regarding the study of early intervention of patients at risk for acute respiratory failure and prolonged mechanical ventilation, I agree that a checklist, such as the PROOFCheck, aimed at the prevention of organ failure would be beneficial in lowering rates of mortality.
The authors' report that often times the acuity and severity of patients' conditions often are not recognized in a ti...
Thank you for the comments and support for our work.
Firstly you raise the issue of access to the survey and response rate. The RCOG is aware that IT systems within NHS organisations can sometimes prohibit access to our surveys and we are unable to resolve this at the college as it is often related to NHS firewalls. In terms of response rate the RCOG reports that its usual response rate to a national survey is a...
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