This paper from Villalbi and colleagues use a before-after design
without control group to analyse deaths due to Acute Myocardial Infarction
(AMI) in Spain from 2004-2007 and concludes "the extension of smoke-free
regulations in Spain [came into force in January 2006] was associated with
a reduction in AMI mortality, especially among the elderly". While we are
clearly in favour of this law, their imm...
This paper from Villalbi and colleagues use a before-after design
without control group to analyse deaths due to Acute Myocardial Infarction
(AMI) in Spain from 2004-2007 and concludes "the extension of smoke-free
regulations in Spain [came into force in January 2006] was associated with
a reduction in AMI mortality, especially among the elderly". While we are
clearly in favour of this law, their immediate impact on the population
coronary health is doubtful, and this paper does not help to raise doubts.
First, coronary deaths have been declining in Spain, as in other
developed countries, during the last years. Raw rates for men have changed
from 109/100,000 in 2001 to 89 in 2008 (77 to 69 for women). The most
important relative change for men was between 2004 and 2003 (before the
law implementation). Authors argument that the 2003 heat wave distort the
mortality patterns, but previous years maintain a similar pattern than
2003(1). AMI mortality rates in Spain (age-adjusted to European standard
population) for 100,000 men were: 2001: 89.5; 2002: 87.5; 2003: 87.9;
2004: 81.2; 2005: 80.0; 2006: 74,6; 2007: 72.7; 2008: 67.8; similar
figures for women were: 39.0; 38.8; 38.5; 36.2; 35.3; 31.9; 31.0; 29.2).
Second, the law did not have an additional effect in the prevalence
of cigarettes consumption. According to the Spanish National Survey on
Drug Use (EDADES, biannual periodicity) the prevalence began to decline
years before the smoke-free regulation(2). For adult men: 2001: 51.5%,
2003: 53.0 2005: 47.2%, 2007: 46.0% (for adult women in the same years:
40.5%, 42.6, 37.5%, 37.6%).
Third, while the main effect of the Spanish 2006 law was the smoking
ban in workplaces, the paper reports a higher mortality reduction in
elderly (retired people who no longer work).
Fourth, in the paper the decline of mortality rates were steeply
falling in the first 12 months after the implementation of the law. In
contrast, other study that has evaluated the impact of anti-smoke laws in
coronary mortality rates reported a modest non significant effect in the
short term(3) (1.6% CI95%: -4.0%;7.0%), but larger effects after the first
12 months (18.6% CI95%=13.6%;23.3%).
In the 70s and 80s in Spain the number of storks decreased
dramatically, and contemporary, the birth rate fell among the lowest in
the world. Policies on these birds were able to recover their number in
the 90's. In this period the Spanish birth rate increased again. The
association of uncontrolled temporal trends -specially with a very short
trend as in this study- should not be interpreted as causal (unless we are
willing to accept that babies come from Paris).
Therefore, in the absence of other evidences we should be cautious
about establishing causal relationships between the decrease in coronary
deaths and one specific policy. As much as we favour that policy,
scientific causality has other rules.
References:
1.Instituto de Salud Carlos III. Ministerio de Ciencia e Innovacion.
Mortalidad Espana y comunidades autonomas. Available:
http://www.isciii.es/htdocs/centros/epidemiologia/anexos/ww9201_cau.htm
2. Ministerio de Sanidad, Politica Social e Igualdad. Encuesta
Domiciliaria Sobre Alcohol y Drogas en Espana (EDADES). Available:
http://www.pnsd.msc.es/Categoria2/observa/estudios/home.htm
3.Dove MS, Dockery DW, Mittleman MA, Schwartz J, Sullivan EM, Keithly
L, et al. The impact of Massachusetts' smoke-free workplace laws on acute
myocardial infarction deaths. Am J Public Health. 2010;100:2206-12.
I feel that this study leaves me with a sense of being on safari to
catch a glimpse of the 'Big Five' - as a health professional from South
Africa I recognize that it is only but interesting to note the first world
trends in pre-eclampsia, but it does not provide any sustainable short or
long term treatment modalities, where it is so urgently required.
Hypertension during pregnancy has been attributed to one of t...
I feel that this study leaves me with a sense of being on safari to
catch a glimpse of the 'Big Five' - as a health professional from South
Africa I recognize that it is only but interesting to note the first world
trends in pre-eclampsia, but it does not provide any sustainable short or
long term treatment modalities, where it is so urgently required.
Hypertension during pregnancy has been attributed to one of the top
five causes of maternal deaths in South Africa (Blaauw and Penn-Kekana,
2010). The South African Health Review, 2010, admits that despite an
increase in antenatal care coverage and skilled birth attendance, maternal
mortality is still on the rise (Blaauw and Penn-Kekana, 2010). While other
interventions like low dose asprin and multi-vitamin supplementation do
play a role, in this study elective delivery before the due date was one
of the primary causes attributed to the trend in the decrease of pre-
eclampsia. I am not convinced that elective caesarean sections is the
ideal, as this method of delivery may contribute to other causes of
morbidity and mortality, not to mention increased costs of surgical
delivery, especially in the African setting.
The abovementioned article makes some valuable contributions to the
understanding of international trends in pre-eclampsia. However, once
again it raises the issue of what we interpret as 'international'. My
concern about these trends being acknowledged as international is that the
study takes place across borders but it does not necessarily apply to the
global context.
The study lacks inclusion of developing nations, and thus does not
take in consideration the countries urgently seeking solutions, in their
urgency to reach Millenium Development Goals and reduce maternal mortality
(MDGs 4 and 5). I would urge that cognizance be taken of the location of
the countries used in the study.
References:
Blaauw, D & Penn-Kekana, M. 2010. In: Fonn, S., Padarath, A.
South African Health Review. Durban: Health Systems Trust. Available
online: http://www.hst.org.za/publications/876
The above article focused on the prevalence of factors associated with increased risk of pregnancy hypertension and pre-eclampsia period: an international comparative study. The countries involved were Australia, Canada, Denmark, Norway, Scotland, Sweden and USA.
The key message from this study is that pregnancy hypertension and pre-eclampsia remain global health concerns in both developed and developing countries. This type of s...
The above article focused on the prevalence of factors associated with increased risk of pregnancy hypertension and pre-eclampsia period: an international comparative study. The countries involved were Australia, Canada, Denmark, Norway, Scotland, Sweden and USA.
The key message from this study is that pregnancy hypertension and pre-eclampsia remain global health concerns in both developed and developing countries. This type of study is important because it informs policy makers that there are unique and complex factors that may reduce the rates of pregnancy hypertension and pre-eclampsia. The knowledge learned from the study on these factors (risk of pregnancy hypertension and progression of pre-eclampsia) will assist policy makers to use interventions such as different International Classification of Diseases coding versions to identify and describe such factors. As a South African Primary health care nurse I am concerned about the translation of the study into community/primary health care practice. In the remote areas where the majority of Primary health care services are provided, nurses may not be familiar with the International Classification of Diseases (ICD) coding version, and may not even have access to ICD. I really like this study and it makes me to think on how primary health care nurses in South Africa practice without knowledge of the ICD version on the interpretation of the prevalence of pregnancy hypertension and pre-eclampsia. I therefore recommend that policy makers in South Africa should train their primary health care nurses on the use of ICD and should make sure that accessibility of such intervention is ensured.
I found this article that highlights junior doctors' lack of
awareness with regard to the procedures in case of a major incident,
interesting. It covers an important aspect of emergency planning and
preparedness, which stimulated my thinking. As a health professional
educator, the article's findings drew to my attention the need to
strengthen the integration of such procedures into the pre-service...
I found this article that highlights junior doctors' lack of
awareness with regard to the procedures in case of a major incident,
interesting. It covers an important aspect of emergency planning and
preparedness, which stimulated my thinking. As a health professional
educator, the article's findings drew to my attention the need to
strengthen the integration of such procedures into the pre-service
curriculum. Education institutions that train health professionals have
the responsibility of preparing new graduates with the necessary
competencies so that they can practice effectively. The mastery of such
competencies allows smooth running of hospitals especially in case of
major incidents that require professionals to know how to respond quickly.
A teaching intervention was implemented to raise the awareness of
major incidents and related procedures. The advantages of in-service
training such as this have been documented in the literature and this
intervention was noted to be highly effective when assessed immediately
after the intervention. However, many in-service training interventions
result in positive changes but such changes tend to be short-lived. It has
been documented that benefits of in-service training on various aspects of
care do not last long with regard to changing practice (Gammon, Morgan-
Samuel & Gould, 2008, Opiyo & English, 2010). As health
professional educators, we need to recognize that in-service training can
only act as a supplement to comprehensive pre-service training.
A final issue to consider is to establish the level of awareness in
other professions that have a role in managing a major incident. In case
of such an incident, all health professionals, such as nurses,
pharmacists, laboratory technicians, need to be well prepared to be able
to act effectively and efficiently. Establishing this ensures timely
intervention to prepare all health professionals in case of a major
incident.
Gammon J, Morgan-Samuel H & Gould D (2008) A review of the
evidence for suboptimal compliance of healthcare practitioners to
standard/universal infection control precautions. Journal of Clinical
Nursing 17, 157-167
Opiyo N, English M. (2010) In-service training for health
professionals to improve care of the seriously ill newborn or child in low
and middle-income countries (Review). Cochrane Database of Systematic
Reviews, Issue 4. Art. No.: CD007071. DOI: 10.1002/14651858.CD007071.pub2
Data files that support this article are available at the Dryad
repository:
BMJ open Access MHRA Field Safety Notices 2006_2010
MHRA Field safety notices_FDA 19_5_11
When using this data, please cite the original article and the Dryad
data package. The data package should be cited as follows:
Heneghan C, Thompson M, Billingsley M, Cohen D (2011) Data from:
Medical-device recalls in the UK and the device-regulation process:
retrospective review of safety notices and alerts. Dryad Digital
Repository. doi:10.5061/dryad.585t4
I read with great interest the article "Doctors accessing mental-
health services: an exploratory study" by Josephine Stanton and Patte
Randal and the response posted by Andrew K Ntanda and I would agree that
this group of doctors should consider accessing individual psychotherapy.
My training region also offers support to doctors with Mental Health and
other problems I would like to direct any reade...
I read with great interest the article "Doctors accessing mental-
health services: an exploratory study" by Josephine Stanton and Patte
Randal and the response posted by Andrew K Ntanda and I would agree that
this group of doctors should consider accessing individual psychotherapy.
My training region also offers support to doctors with Mental Health and
other problems I would like to direct any readers to their deanery website
to find out about availability of any similar services in their region.
From a very personal perspective I suffered from moderate post natal
depression following a c-section which coincided with the
completion of my CCST. I accessed the relevant service and found it most
helpful. However I also sought help and advice from my consultant
supervisor, a decision I now deeply regret. Since disclosing my
difficulties I have been unable to gain any consultant post. While this
may seem to the reader to be a case of sour grapes or perhaps slightly
over-sensitive on my part it has been difficult to shake the feeling that,
perhaps, by disclosing my difficulties I have made myself unemployable.
For this reason I would very much like to see further studies that
consider the longitudenal impact on doctors who access help for their
mental health difficulties and further to this their subsequent career
trajectories. Such a study may help allay the fears described by
participants in Stanton and Randal's paper and enable them to adopt
appropriate health seeking behaviours. Moreover I hope such studies will
enable the profession to be more self reflective and cease out-grouping
those of our peers with conditions that traditionally attract stigma.
Yours faithfully
Anon
Conflict of Interest:
None declared
The author of this e-letter has identified herself to the journal but requested to remain anonymous.
The fact that a high percentage of patients with locked-in syndrome
(LIS) shows an unexpected well-being does not surprise us, but we are very
interested in this. The first part of the work carried out by Bruno and
colleagues provides a basis for researchers to formulate new working
hypotheses in patients who have a lesion that is so localised and yet
leads to such a complex mosaic of consequences on a functional level. I...
The fact that a high percentage of patients with locked-in syndrome
(LIS) shows an unexpected well-being does not surprise us, but we are very
interested in this. The first part of the work carried out by Bruno and
colleagues provides a basis for researchers to formulate new working
hypotheses in patients who have a lesion that is so localised and yet
leads to such a complex mosaic of consequences on a functional level. In
the conclusions authors raise some additional ethical questions about this
challenging group of patients. We have identified a series of 'syndromes
within the syndrome' in patients with LIS due to ventral pontine damage
(pathological laughter and crying, motor imagery impairment and a
selective impairment in the recognition of facial expressions).1-3 At the
same time we found, albeit in a much smaller group of subjects, values
almost comparable to those of the general population in self-reported
Quality of Life.4 This is neurology; this is science and science must stop
here.
Prof. Savulescu attacks the work of Bruno et al., saying that this is the
classic research approach of those opposing euthanasia. In other words the
'ethical' conclusions would invalidate empirical data on the grounds that
these tendentially favour a certain ethical or political vision of the
world (and therefore are prejudiced). In our opinion, an alternative
approach, based not on scientific findings but rather on moral and/or
political motivations, would be prejudiced too. We find ourselves asking
"Who is invading whom?" Is politics invading science, or is science
invading politics? This would be a rhetorical question had we not arrived
at this point of convergence. Either Prof. Savulescu denies that the data
presented by Bruno et al. have scientific value on the basis that they go
against common sense (and asks Bruno and colleagues to 'abjure') or he
claims that the data are false. Yet in our opinion there is a third way to
proceed: separating science from politics and ethics. A disconnection that
must be clean and definitive.
1. Pistoia F, Conson M, Trojano L, Grossi D, Ponari M, Colonnese C,
Pistoia ML, Carducci F, Sara' M. Impaired conscious recognition of
negative facial expressions in patients with locked-in syndrome. J
Neurosci 2010;30:7838-7844.
2. Conson M, Sacco S, Sara' M, Pistoia F, Grossi D, Trojano L.
Selective motor imagery defect in patients with locked-in syndrome.
Neuropsychologia 2008;46:2622-2628.
3. Sacco S, Sara' M, Pistoia F, Conson M, Albertini G, Carolei A.
Management of pathologic laughter and crying in patients with locked-in
syndrome: a report of 4 cases. Arch Phys Med Rehabil 2008;89:775-778.
4. Pistoia F, Conson M, Sara' M. Opsoclonus-myoclonus syndrome in
patients with locked-in syndrome: a therapeutic porthole with gabapentin.
Mayo Clin Proc 2010;85:527-531.
I read with interest the authors' qualitative study assessing
potential barriers of doctors assessing mental health facilities.
In particular it was striking that 6/8 of the participants interviewed
worked in psychiatry, and as the author alluded to in the beginning, were
most likely to either treat themselves or trust their own council.
I think a way forward for this particular group of patients is for them to
consider in...
I read with interest the authors' qualitative study assessing
potential barriers of doctors assessing mental health facilities.
In particular it was striking that 6/8 of the participants interviewed
worked in psychiatry, and as the author alluded to in the beginning, were
most likely to either treat themselves or trust their own council.
I think a way forward for this particular group of patients is for them to
consider individual psychotherapy, and in our particular region, there
exits House concern within the department of psychotherapy, which deals
specifically with doctors who do have mental, behavioural or emotional
problems.
The service is confidential, and is unique in a sense that
it is a novel way of accessing some help. It is run by a consultant
psychotherapist(and practicing psychiatrist)who can then signpost the
doctors to other services, if they consent for this to happen.
As the other points out, a lot more qualitative work about the attitudes and
heath seeking behaviour of doctors needs to be done, and this study is a
step in the right direction.
This sort of research demonstrating remarkable adaptation is often
used by anti-euthanasia lobbyists to argue that assisted suicide and
euthanasia should not be offered to such people because they come to value
their life. They find meaning. However, that conclusion is not warranted.
Some do want to die and should be allowed to die. The lesson that should
be learnt is the one authors draw: you should wait to see how you a...
This sort of research demonstrating remarkable adaptation is often
used by anti-euthanasia lobbyists to argue that assisted suicide and
euthanasia should not be offered to such people because they come to value
their life. They find meaning. However, that conclusion is not warranted.
Some do want to die and should be allowed to die. The lesson that should
be learnt is the one authors draw: you should wait to see how you adapt.
But, if after waiting a suitable time, you want to die, you should be
allowed or helped to die. The authors adopt a similar moderate view. " In
our view, shortening-of-life requests by LIS patients are valid only when
the patients have been given a chance to attain a steady state of SWB."
But this is too paternalistic. If a competent person does not want to
wait, and has been advised of this kind of research and the possibility of
adaptation, but still wants to die, he should be allowed to die. It is
hard paternalism to keep people alive when they competently and informedly
want to die.
This kind of research is also used to call into question the validity
of living wills or advance directives. However it provides no grounds for
questioning the validity of living wills. It provides reasons to make sure
people are aware of the phenomenon of adaptation before completing a
living will. Imagine that I know I will be happy some years after having
developed locked-in syndrome. Can I now validly ask doctors to allow me to
die at the time I have a massive stroke that will leave me locked-in? Yes.
I can refuse any medical treatment, even if I am having a perfectly good
life. Jehovah's Witnesses do this when they refuse life-saving blood
transfusion.
What makes each person's own living hell is a matter for that person.
It is subjective. And we can adapt to hell. That is important for all of
us to know. But it does not change the rights of individuals to make what
they will of their lives, including choosing the conditions under which
and the time to end them.
Conflict of Interest:
Stephen Laureys is a collaborator with our Oxford Centre for Neuroethics which I direct
I just wanted to add a few other dimensions to the topic on the
happiness of persons who are living with a disability in which they have a
limited ability to communicate: resources.
I work with participants at a cerebral palsy center. The persons I
find to be more content are those who are given access to equipment that
allows them to communicate with others and equipment in which their
mobili...
I just wanted to add a few other dimensions to the topic on the
happiness of persons who are living with a disability in which they have a
limited ability to communicate: resources.
I work with participants at a cerebral palsy center. The persons I
find to be more content are those who are given access to equipment that
allows them to communicate with others and equipment in which their
mobility is less restricted.
The people who use our program either have the luxury of private
insurance in which they can have excellent augmentative communication
devices, have state insurance that allows lower-end devices that take over
two years to replace or fix when they break down, or no insurance and
either use crappy equipment we have left over or none at all.
The same is true for the types of mobility equipment that
participants have. Those with resources have better autonomy due to their
wheelchairs' capabilities. Unfortunately for some, the use of any type of
wheelchair only happens at our center.
Our computer lab is stocked with mid-range devices and substandard
computers for this day in age. We do our best, but continued budget cuts
have left this area wanting as well. There are a few participants whose
augmentative devices access the internet, thus serving as their own
computer as well, but this is rare.
I just thought I'd tell you that the study should include the subject
of resources that allow people with severe disability to still be included
in society would surely make a difference in how content their lives are.
It is a terrible shock to most who become disabled later in life to
see how little value society puts on their inclusion when it comes down to
it! I know because I have had two children born with disability, one in
the state that your article is written about. Also, I majored in
Disability Studies at UC Berkeley after raising my children. I now am a
special educator working with adults who are living with a variety of
disabilities.
Dear Editor,
This paper from Villalbi and colleagues use a before-after design without control group to analyse deaths due to Acute Myocardial Infarction (AMI) in Spain from 2004-2007 and concludes "the extension of smoke-free regulations in Spain [came into force in January 2006] was associated with a reduction in AMI mortality, especially among the elderly". While we are clearly in favour of this law, their imm...
I feel that this study leaves me with a sense of being on safari to catch a glimpse of the 'Big Five' - as a health professional from South Africa I recognize that it is only but interesting to note the first world trends in pre-eclampsia, but it does not provide any sustainable short or long term treatment modalities, where it is so urgently required.
Hypertension during pregnancy has been attributed to one of t...
Dear Editor,
I found this article that highlights junior doctors' lack of awareness with regard to the procedures in case of a major incident, interesting. It covers an important aspect of emergency planning and preparedness, which stimulated my thinking. As a health professional educator, the article's findings drew to my attention the need to strengthen the integration of such procedures into the pre-service...
Data files that support this article are available at the Dryad repository:
BMJ open Access MHRA Field Safety Notices 2006_2010 MHRA Field safety notices_FDA 19_5_11
When using this data, please cite the original article and the Dryad data package. The data package should be cited as follows:
Heneghan C, Thompson M, Billingsley M, Cohen D (2011) Data from: Medical-device recalls in the UK an...
Dear Editor
I read with great interest the article "Doctors accessing mental- health services: an exploratory study" by Josephine Stanton and Patte Randal and the response posted by Andrew K Ntanda and I would agree that this group of doctors should consider accessing individual psychotherapy. My training region also offers support to doctors with Mental Health and other problems I would like to direct any reade...
The fact that a high percentage of patients with locked-in syndrome (LIS) shows an unexpected well-being does not surprise us, but we are very interested in this. The first part of the work carried out by Bruno and colleagues provides a basis for researchers to formulate new working hypotheses in patients who have a lesion that is so localised and yet leads to such a complex mosaic of consequences on a functional level. I...
I read with interest the authors' qualitative study assessing potential barriers of doctors assessing mental health facilities. In particular it was striking that 6/8 of the participants interviewed worked in psychiatry, and as the author alluded to in the beginning, were most likely to either treat themselves or trust their own council. I think a way forward for this particular group of patients is for them to consider in...
This sort of research demonstrating remarkable adaptation is often used by anti-euthanasia lobbyists to argue that assisted suicide and euthanasia should not be offered to such people because they come to value their life. They find meaning. However, that conclusion is not warranted. Some do want to die and should be allowed to die. The lesson that should be learnt is the one authors draw: you should wait to see how you a...
Hello,
I just wanted to add a few other dimensions to the topic on the happiness of persons who are living with a disability in which they have a limited ability to communicate: resources.
I work with participants at a cerebral palsy center. The persons I find to be more content are those who are given access to equipment that allows them to communicate with others and equipment in which their mobili...
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