We have read the proposed vaccine study with interest and wish to make the following comments;
It is worth noting that the study population is specifically focused on students and their trainers. Depending on the setting these will not have had direct involvement in the management, logistics and overall governance of vaccine administration let alone managing daily vaccine queries from staff and the public. Therefore , there is a limitation as to how their views reflect current feelings, attitudes, practices and gaps in knowledge. However, as the main aim is to look towards future vaccines and building healthcare knowledge and engagement then studying this population makes it relevant and identifies gaps that will need to be addressed in future. This then should assist in placing healthcare workers in a better position in order to enable them to improve vaccine uptake . A key question might be what are the things that will make them confident in a vaccine and furthermore to be prepared to take it .
Furthermore, this population may also be more familiar with multiple social media platforms that the public and " vaccine sceptics “ have used. They are , therefore an ideal group to interface with the public as their communication platform is relevant and likely to reach beyond the noticeboards and publications that current interventions or communications have utilized.
We read with interest paper of Barber C., et al. recently published in your journal about the strategies for developing and implementing a rheumatoid arthritis (RA) healthcare quality framework considering the perspectives from arthritis stakeholders; and rightly, stakeholders advocated for the use of existing healthcare frameworks over frameworks developed in the business world and adapted for healthcare. The authors identified 9 guiding principles for framework development and 13 potential topics for measuring the effectiveness, safety, healthcare efficiency, costs, and quality of care, which in turn should be further developed and established by the interested focus groups of stakeholders. Subsequently, some barriers are raised that may eventually delay the successful implementation of a RA healthcare quality framework. Participants highlighted strategies that were important to ensure effective quality framework implementation and at a system level, financial and political will of decision makers were highlighted as major facilitators.1 The latter is true, but also no less important is the fact that doctors, mainly specialists, "change their chip" and begin to work under the rules that it presupposes within a framework of quality in healthcare, which implies making decisions within a framework of check list type; for example, be adherent to a clinical practice guideline for the diagnosis, follow-up, and treatment of a specific pathology. Finally, clinical mode...
We read with interest paper of Barber C., et al. recently published in your journal about the strategies for developing and implementing a rheumatoid arthritis (RA) healthcare quality framework considering the perspectives from arthritis stakeholders; and rightly, stakeholders advocated for the use of existing healthcare frameworks over frameworks developed in the business world and adapted for healthcare. The authors identified 9 guiding principles for framework development and 13 potential topics for measuring the effectiveness, safety, healthcare efficiency, costs, and quality of care, which in turn should be further developed and established by the interested focus groups of stakeholders. Subsequently, some barriers are raised that may eventually delay the successful implementation of a RA healthcare quality framework. Participants highlighted strategies that were important to ensure effective quality framework implementation and at a system level, financial and political will of decision makers were highlighted as major facilitators.1 The latter is true, but also no less important is the fact that doctors, mainly specialists, "change their chip" and begin to work under the rules that it presupposes within a framework of quality in healthcare, which implies making decisions within a framework of check list type; for example, be adherent to a clinical practice guideline for the diagnosis, follow-up, and treatment of a specific pathology. Finally, clinical models of care and health policies conducive to outcome measurement were highlighted as drivers of successful measurement initiatives; regarding this topic, we consider that the models of Centers of Excellence (CoE) in RA and other chronic non-communicable diseases, based on comprehensive multidisciplinary models of healthcare, are the best option to have a framework of clinical cost-effectiveness and quality in healthcare.2,3
In recent years, PANLAR (The Panamerican League of Associations for Rheumatology), has found that there are inequalities and inequities in the care of rheumatoid arthritis in Latin America, with problems associated with the lack of specialists, fragmentation of health care, lack of access to medicines, etc.4,5 Therefore, a significant effort has been made to find ways to overcome these challenges; thus arises in 2015 the REAL-PANLAR Project for the Implementation and Accreditation of Centers of Excellence in Rheumatoid Arthritis Throughout Latin America a consensus position from REAL-PANLAR Special Group which aims to standardize and improve RA care in Latin America with minimum quality requirements in healthcare; this project seeks the creation of a CoE network for RA care within a defined framework of indicators (of structure, process and results).6 To date, an accreditation process for the CoEs has even been implemented, which has led to several institutions on the continent being accredited with excellence in RA care.7,8
An especially important contribution to the subject has also been brought by the ICHOM initiative which pretends unlock the potential of value-based healthcare by defining global Standard Sets of Outcome Measures that matter most to patients and to create better value for all stakeholders; as they say, work on own outcomes data can help physicians evaluate how they are doing compared to their peers worldwide and provide an opportunity to learn from each other to improve the care they provide.9,10
Finally, we believe that there may be a collaborative work between the different initiatives that exist on the matter in discussion, but under the premise that there must be minimum standards of care for RA, which we believe cannot be so high in the beginning, because otherwise in many less developed parts of the world, there could be enormous difficulties in its implementation. We think that the REAL-PANLAR initiative meets those requirements and is adaptable to diverse environments around the world.
REFERENCES:
1 Barber C, Lacaille D, Hall M et Al. Strategies for developing and implementing a rheumatoid arthritis healthcare quality framework: a thematic analysis of perspectives from arthritis stakeholders. BMJ Open 2021;11:e043759. doi:10.1136/bmjopen-2020-043759.
2. Santos-Moreno P., Castañeda O, Garro B, et Al. From the model of integral attention to the creation of centers of excellence in rheumatoid arthritis. Clin Rheumatol 2015 Mar;34 Suppl 1(Suppl 1):S71-7. doi: 10.1007/s10067-015-3017-8.
3 Porter M. E., Teisberg E. Redefining Health Care: Creating Value-Based Competition On Results. Harvard Business School Press, 2006.
4 Pineda C, Caballero-Uribe CV. Challenges and opportunities for diagnosis and treatment of rheumatoid arthritis in Latin America. Clin Rheumatol 2015 Mar;34 Suppl 1(Suppl 1):S5-7. doi: 10.1007/s10067-015-3019-6.
5 Caballero-Uribe CV. The history of PANLAR throughout its evolution. J Clin Rheumatol 2019 Jan;25(1):1-3. doi: 10.1097/RHU.0000000000000798.
6 Santos-Moreno P, Galarza-Maldonado C, Caballero-Uribe CV, et Al. REAL-PANLAR Project for the Implementation and Accreditation of Centers of Excellence in Rheumatoid Arthritis Throughout Latin America: A Consensus Position Paper From REAL-PANLAR Group on Improvement of Rheumatoid Arthritis Care in Latin America Establishing Centers of Excellence. J Clin Rheumatol 2015 Jun;21(4):175-80. doi: 10.1097/RHU.0000000000000247.
7 Santos-Moreno P, Caballero-Uribe CV, Cardiel MH, et Al. A Consensus Position Paper From REAL-PANLAR Group About the Methodological Approach for the Accreditation Process of Centers of Excellence in Rheumatoid Arthritis in Latin America.. J Clin Rheumatol 2019 Jan;25(1):54-58. doi: 10.1097/RHU.0000000000000773.
8 Santos-Moreno P, Caballero-Uribe CV, Massardo ML,et Al. Systematic and progressive implementation of the centers of excellence for rheumatoid arthritis: a methodological proposal. Clin Rheumatol 2017 Dec;36(12): 2855-2858. doi: 10.1007/s10067-017-3790-7.
9 ICHOM - Institute For Strategy And Competitiveness – Harvard University. https://www.isc.hbs.edu › ISC.
10 Kelley TA. International Consortium for Health Outcomes Measurement (ICHOM). Trials 2015; 16(Suppl 3): O4. doi: 10.1186/1745-6215-16-S3-O4.
Schoep et al. evaluated age-dependent productivity loss caused by menstruation-related symptoms, which were measured in absenteeism (time away from work or school) and presenteeism (productivity loss while present at work or school), in women aged 15-45 years (1). Odds ratio (95% CI) of women under 21 years with menstruation-related symptoms for absenteeism was 3.3 (3.1 to 3.6). In addition, menstruation-related symptoms caused a great deal of lost productivity, and presenteeism contributed to lost productivity larger than absenteeism. I present an interventional study regarding productivity loss and menstruation-related symptoms.
Song and Kanaoka conducted a randomized controlled trial to investigate the effectiveness of the application for menstrual management in female workers, aged 20-45 years (2). The incidences of depression and dysmenorrhea were significantly lower than those of the non-intervention group in the third month. Although labor productivity and absenteeism varied, and there was no significant change in presenteeism, the aggregate of medical expenses, productivity loss, and application fee for the intervention group presented lower costs with 1,170 USD per individual. They concluded that the application was cost-effective and might reduce the incidence of dysmenorrhea and depression. They reported that presenteeism did not improve by this application. As the incidences of depression and dysmenorrhea were quite low in their population, there is a ne...
Schoep et al. evaluated age-dependent productivity loss caused by menstruation-related symptoms, which were measured in absenteeism (time away from work or school) and presenteeism (productivity loss while present at work or school), in women aged 15-45 years (1). Odds ratio (95% CI) of women under 21 years with menstruation-related symptoms for absenteeism was 3.3 (3.1 to 3.6). In addition, menstruation-related symptoms caused a great deal of lost productivity, and presenteeism contributed to lost productivity larger than absenteeism. I present an interventional study regarding productivity loss and menstruation-related symptoms.
Song and Kanaoka conducted a randomized controlled trial to investigate the effectiveness of the application for menstrual management in female workers, aged 20-45 years (2). The incidences of depression and dysmenorrhea were significantly lower than those of the non-intervention group in the third month. Although labor productivity and absenteeism varied, and there was no significant change in presenteeism, the aggregate of medical expenses, productivity loss, and application fee for the intervention group presented lower costs with 1,170 USD per individual. They concluded that the application was cost-effective and might reduce the incidence of dysmenorrhea and depression. They reported that presenteeism did not improve by this application. As the incidences of depression and dysmenorrhea were quite low in their population, there is a need of applying the application to female workers with higher risk of depression and dysmenorrhea. In addition, presenteeism is not determined solely by menstruation-related symptoms. Furthermore, they did not handle women under 20 years old. In any case, a randomized controlled trial is effective to verify the effect of menstruation-related symptoms on productivity loss.
References
1. Schoep ME, Adang EMM, Maas JWM, et al. Productivity loss due to menstruation-related symptoms: a nationwide cross-sectional survey among 32,748 women. BMJ Open 2019;9(6):e026186.
2. Song M, Kanaoka H. Effectiveness of mobile application for menstrual management of working women in Japan: randomized controlled trial and medical economic evaluation. J Med Econ 2018;21(11):1131-1138.
I would like to point to potential problems with the statistical models of Rydahl et al:
For stillbirths, they fit a Poisson model log(rate) = a + b*year + c*dummy(2011) (dummy(2011) is 0 before and 1 after the change in guideline) [personal communication], a model that obviously allow for no change in the slope before and after 2011. This is problematic because the actual data indicate that the stillbirth rate decreases up to 2011 and increases after 2011 (acknowledged by Rydahl et al (p. 6) and suggested by a recent paper based on similar data [1]). Because the model is underfitted, the findings may be unreliable (false negative).
A basic simulation illustrates the problem: the underlying hypothesis is that the stillbirth rate reflects the induction rate (i.e. the number of ongoing pregnancies) and that stillbirths consequently reflects the Figure 2A changes over time. If the risk of stillbirth is proportional to the number of ongoing pregnancies, one simple simulated data could be per year n=16, 16, 14, 13, 12, 12, 11, 11, 11, 10, 11, 8, 5, 6, 6, 7, 8 from 2000 to 2016. The model applied by Rydahl et al would be unable to detect the build-in change in this simulated data. In fact, as expected, only some models would be able to detect the change: for example, in a quasi-Poisson model with interaction, the before-after dummy is statistically significant (p=0.045). Interestingly, if this model is applied to the published data, the dummy(2011) is statistically...
I would like to point to potential problems with the statistical models of Rydahl et al:
For stillbirths, they fit a Poisson model log(rate) = a + b*year + c*dummy(2011) (dummy(2011) is 0 before and 1 after the change in guideline) [personal communication], a model that obviously allow for no change in the slope before and after 2011. This is problematic because the actual data indicate that the stillbirth rate decreases up to 2011 and increases after 2011 (acknowledged by Rydahl et al (p. 6) and suggested by a recent paper based on similar data [1]). Because the model is underfitted, the findings may be unreliable (false negative).
A basic simulation illustrates the problem: the underlying hypothesis is that the stillbirth rate reflects the induction rate (i.e. the number of ongoing pregnancies) and that stillbirths consequently reflects the Figure 2A changes over time. If the risk of stillbirth is proportional to the number of ongoing pregnancies, one simple simulated data could be per year n=16, 16, 14, 13, 12, 12, 11, 11, 11, 10, 11, 8, 5, 6, 6, 7, 8 from 2000 to 2016. The model applied by Rydahl et al would be unable to detect the build-in change in this simulated data. In fact, as expected, only some models would be able to detect the change: for example, in a quasi-Poisson model with interaction, the before-after dummy is statistically significant (p=0.045). Interestingly, if this model is applied to the published data, the dummy(2011) is statistically significant (with the important limitation that it is based on imputed data for the 3 years correctly reported as <5 in Rydahl et al).
For ruptures, they fit a ITS model to the risk of ruptures over time. It is not clear to me whether the 2011 change in slope is significant in their ITS model, I hope the authors can clarify this. When I fit a simple ITS model with interaction between time and intervention, there is no effect of the 2011 change. Importantly, when one fits the same model as Rydahl et al apply to the stillbirth data, there is no effect of the 2011 change. This calls for attention given the overall conclusion of Rydahl et al contrasting stillbirths and ruptures.
Rydahl et al further reports a statistically significant increase between 2010 and 2012 from 2.6‰ to 4.2‰ (p<0.02), which seems to be a simple comparison? There is, however, a larger increase between 2006 and 2008 from 1.0‰ to 2.9‰ (p<0.01). Interestingly, if one applies even the simple Poisson model used by Rydahl et al on a potential change in 2007, there is a statistically significant change (p=0.016). There is, to my knowledge, no relevant national changes that may explain this 2007 result. Rather, the results more likely reflect random or systematic variations in coding over time (Thisted et al found that of 95 women that had a uterine rupture code in the Danish registries, 48 had no rupture [2]).
The problematic statistical models should cause concern for the authors and the journal because the published findings may be unreliable. I hope the authors will take suitable action to address the above concerns and questions.
Disclaimer: The last author and I are employed at the same department, and I participate in a working group under the National Board of Health with the first author. They have been informed several times about my concerns by e-mails and at meetings. Because the discussions have led to no common ground, I feel compelled to comment in public.
1. Lidegaard, O., et al., Are the Danish stillbirth rates still record low? A nationwide ecological study. BMJ Open, 2020. 10(12): p. e040716.
2. Thisted, D.L., L.H. Mortensen, and L. Krebs, Uterine rupture without previous caesarean delivery: a population-based cohort study. Eur J Obstet Gynecol Reprod Biol, 2015. 195: p. 151-5.
Blauth et al. conducted one-year follow-up study with participation of international multicentre (1). The authors determined the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures by setting usual care centres (UCC) as a control. A total of 281 patients, aged ≥70 with operatively treated proximal femur fractures, were analyzed. Odds ratio (OR) (95% confidence interval [CI]) of patients in GFC against UCC for an MAE was 4.56 (2.23 to 9.34). In addition, OR (95% CI) of patients in GFC against UCC for pneumonia and delirium were 3.40 (1.08 to 10.70) and 5.76 (1.64 to 20.23), respectively. The authors explained the increased OR as higher ability of detecting MAEs in GFC than that in UCC, and considered as positive effect of geriatric comanagement. I have comments about their study.
Blauth et al. cited 4 randomized controlled trials in the past, and most recent article was reported by Prestmo et al (2). They compared the effectiveness of treatment for hip fracture between GFC and UCC. Patients, aged ≥70, were able to walk 10 m before their fracture. Mean Short Physical Performance Battery scores at 4 months were significantly higher in GFC patients than that in UCC patients, and they recognized the advantage of GFC for the treatment of older patients with hip fractures.
Regarding delirium as a MAE in patients after hip-fracture repair, Marcantonio et al. reported that relative risk...
Blauth et al. conducted one-year follow-up study with participation of international multicentre (1). The authors determined the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures by setting usual care centres (UCC) as a control. A total of 281 patients, aged ≥70 with operatively treated proximal femur fractures, were analyzed. Odds ratio (OR) (95% confidence interval [CI]) of patients in GFC against UCC for an MAE was 4.56 (2.23 to 9.34). In addition, OR (95% CI) of patients in GFC against UCC for pneumonia and delirium were 3.40 (1.08 to 10.70) and 5.76 (1.64 to 20.23), respectively. The authors explained the increased OR as higher ability of detecting MAEs in GFC than that in UCC, and considered as positive effect of geriatric comanagement. I have comments about their study.
Blauth et al. cited 4 randomized controlled trials in the past, and most recent article was reported by Prestmo et al (2). They compared the effectiveness of treatment for hip fracture between GFC and UCC. Patients, aged ≥70, were able to walk 10 m before their fracture. Mean Short Physical Performance Battery scores at 4 months were significantly higher in GFC patients than that in UCC patients, and they recognized the advantage of GFC for the treatment of older patients with hip fractures.
Regarding delirium as a MAE in patients after hip-fracture repair, Marcantonio et al. reported that relative risk (95% CI) of patients with consultation against patients with usual care for delirium and severe delirium were 0.64 (0.37-0.98) and 0.40 (0.18-0.89), respectively (3). Blauth et al. described that interdisciplinary treatment including regular geriatric consultation and daily physiotherapy were prepared for GFC patients. I think that other reasons of increased risk of MAEs in GFC patients should be considered.
References
1. Blauth M, Joeris A, Rometsch E, et al. Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study. BMJ Open 2021;11(5):e039960.
2. Prestmo A, Hagen G, Sletvold O, et al. Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial. Lancet 2015;385(9978):1623-33.
3. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001;49(5):51622.
We read with interest your protocol to develop a core outcome set (COS) for congenital pulmonary airway malformations and applaud your intention to develop a COS for this population of children. We wish to highlight one area about which we have significant concerns, which is your decision to specifically exclude parents' and patients' views from your Delphi process.
There are strong arguments for involving patients' and parents' views in COS development. Only by specifically including them can researchers be certain that outcomes of particular importance to patients and parents have at least an opportunity of being represented in the COS. The specific exclusion of these important stakeholders risks not only excluding outcomes that are most important to this vital stakeholder group but also risks sending completely the wrong message to patients and parents. By deliberately excluding this group the researchers risk sending the message to patients and parents that their views simply don’t matter.
To ensure that important considerations such as this are not overlooked during COS development, the COS-STAD set of standards has been developed. A specific recommendation is that ‘COS developers should involve those who have experienced or who are affected by the condition (e.g., patients, family members, and carers)’. The authors of this protocol claim to have developed it in accordance with the COS-STAD guidance yet do not appear to incorporated...
We read with interest your protocol to develop a core outcome set (COS) for congenital pulmonary airway malformations and applaud your intention to develop a COS for this population of children. We wish to highlight one area about which we have significant concerns, which is your decision to specifically exclude parents' and patients' views from your Delphi process.
There are strong arguments for involving patients' and parents' views in COS development. Only by specifically including them can researchers be certain that outcomes of particular importance to patients and parents have at least an opportunity of being represented in the COS. The specific exclusion of these important stakeholders risks not only excluding outcomes that are most important to this vital stakeholder group but also risks sending completely the wrong message to patients and parents. By deliberately excluding this group the researchers risk sending the message to patients and parents that their views simply don’t matter.
To ensure that important considerations such as this are not overlooked during COS development, the COS-STAD set of standards has been developed. A specific recommendation is that ‘COS developers should involve those who have experienced or who are affected by the condition (e.g., patients, family members, and carers)’. The authors of this protocol claim to have developed it in accordance with the COS-STAD guidance yet do not appear to incorporated this particular recommendation within their plans. We note their justification that patients and parents were not included since ‘the final COS is intended specifically intended for patients with asymptomatic CPAM’ yet we wish to register our disagreement with this justification. Arguably patients who are currently asymptomatic are those affected most greatly by outcomes and therefore have the most to offer.
Consequently we urge these researchers to take stock and pause before proceeding with their Delphi process and specifically to amend their proposed protocol to facilitate the inclusion of patients and parents. Failure to do so risks their positive endeavour being futile and misinterpreted.
Haapanen et al. investigated the association between retirement characteristics and frailty of older businessmen (1). The adjusted OR of men who retired at ages of 58-69 years compared with men who retired before 55 years old for frailty significantly decreased. In addition, the adjusted ORs (95% CIs) of men who retired due to disability for pre-frailty and frailty were 1.53 (1.01-2.32) and 3.52 (1.97-6.29), respectively. Exiting working life early and continuing work until age of 70 years and older were both significantly associated with increased risk of frailty. They presented U-shaped relationship and there was a difference in the magnitude of OR between pre-frailty and frailty in men who retired due to disability. I present information about their study with special reference to employment status and outcomes.
Kalousova et al. examined the association between psychosocial working conditions and frailty in later life (2). Low reward, high effort, effort to reward ratio, and effort to control ratio were all significant predictors of increasing frailty. In addition, Non-retired workers with low-reward jobs experienced the largest increases in frailty at follow-up. They considered that retirement might protect frailty in older workers with low reward jobs. Applying job-stress model to frailty in older workers is also important for keeping quality of life in later life.
Palmer et al. examined the association between frailty and employment difficulties in work...
Haapanen et al. investigated the association between retirement characteristics and frailty of older businessmen (1). The adjusted OR of men who retired at ages of 58-69 years compared with men who retired before 55 years old for frailty significantly decreased. In addition, the adjusted ORs (95% CIs) of men who retired due to disability for pre-frailty and frailty were 1.53 (1.01-2.32) and 3.52 (1.97-6.29), respectively. Exiting working life early and continuing work until age of 70 years and older were both significantly associated with increased risk of frailty. They presented U-shaped relationship and there was a difference in the magnitude of OR between pre-frailty and frailty in men who retired due to disability. I present information about their study with special reference to employment status and outcomes.
Kalousova et al. examined the association between psychosocial working conditions and frailty in later life (2). Low reward, high effort, effort to reward ratio, and effort to control ratio were all significant predictors of increasing frailty. In addition, Non-retired workers with low-reward jobs experienced the largest increases in frailty at follow-up. They considered that retirement might protect frailty in older workers with low reward jobs. Applying job-stress model to frailty in older workers is also important for keeping quality of life in later life.
Palmer et al. examined the association between frailty and employment difficulties in workers with age of 50-65-year olds (3). Frailty was observed even in mid-life and was strongly associated with adverse employment outcomes, such as health-related job loss, prolonged sickness absence and difficulty in coping with work's demands. In addition, the associations were stronger in manual workers than in managers. I suspect that cause of frailty in mid-life workers might closely related to subsequent employment outcomes. Especially in manual workers, frailty was strongly related to subsequent employment difficulties. Social supporting system should be constructed to protect economic crisis in individual (family) life.
References
1. Haapanen MJ, von Bonsdorff MB, Perttilä NM, et al. Retirement age and type as predictors of frailty: a retrospective cohort study of older businessmen. BMJ Open 2020;10(12):e037722.
2. Kalousova L, Mendes de Leon C. Increase in frailty of older workers and retirees predicted by negative psychosocial working conditions on the job. Soc Sci Med 2015;124:275-283.
3. Palmer KT, D'Angelo S, Harris EC, et al. Frailty, prefrailty and employment outcomes in Health and Employment After Fifty (HEAF) Study. Occup Environ Med 2017;74(7):476-482.
The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) congratulates the British Association of Cardiovascular Prevention and Rehabilitation (BACPR), a foundational member, in providing an informative report on the effects of COVID-19 on the delivery of cardiac rehabilitation (CR). ICCPR is looking forward to providing further peer-reviewed data soon to add to these important findings.
Indeed, ICCPR’s soon-to-be published international survey of CR programs corroborates findings from BACPR’s study; we collated responses from over 1,000 programs in 70 countries (or 63% of those known to have CR in the world) and similarly found half of programs had been closed. Based on estimates of the number of CR programs available from our global audit (https://globalcardiacrehab.com/Global-CR-Program-Survey) and those temporarily shuttered, this would translate to 4400 programs being closed globally last Spring.
Results from our survey also showed drastic increases in use of videoconferencing, but this work by BACPR provides much more information for the CR community on the use of technology for various components of CR.
We also reported on the major impacts of the pandemic on staff from an occupational and psychosocial perspective. The pre-print of this work is available here: https://www.medrxiv...
The International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) congratulates the British Association of Cardiovascular Prevention and Rehabilitation (BACPR), a foundational member, in providing an informative report on the effects of COVID-19 on the delivery of cardiac rehabilitation (CR). ICCPR is looking forward to providing further peer-reviewed data soon to add to these important findings.
Indeed, ICCPR’s soon-to-be published international survey of CR programs corroborates findings from BACPR’s study; we collated responses from over 1,000 programs in 70 countries (or 63% of those known to have CR in the world) and similarly found half of programs had been closed. Based on estimates of the number of CR programs available from our global audit (https://globalcardiacrehab.com/Global-CR-Program-Survey) and those temporarily shuttered, this would translate to 4400 programs being closed globally last Spring.
Results from our survey also showed drastic increases in use of videoconferencing, but this work by BACPR provides much more information for the CR community on the use of technology for various components of CR.
We also reported on the major impacts of the pandemic on staff from an occupational and psychosocial perspective. The pre-print of this work is available here: https://www.medrxiv.org/content/10.1101/2020.11.11.20230045v1) and is currently in press in Global Heart.
Given how the pandemic has evolved and the variation in vaccination penetration globally, it would be informative to get a more current assessment of the impact of COVID-19 on CR delivery. In the meantime, ICCPR works to support the CR community by collating the latest COVID-19 resources and research on our website (see: https://globalcardiacrehab.com/COVID-19). We are encouraged by the continually accumulating evidence on the efficacy of remote CR pre and peri-pandemic.
We remain dedicated to augmenting CR capacity and access, considering also that many COVID-19 survivors with cardiorespiratory sequelae (i.e., so-called “long-COVID” and “COVID long-haulers”) may also be in need of our services. We conclude with a call to the CR community for research on the effects of CR in this population, and for dialogue on ways we might accommodate these patients where warranted by evidence.
I would like to provide some insight regarding our article "Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial" that you included in your review.
All participants were randomly allocated to any of three groups and were unaware until the end of the five treatment sessions being notified following the last assessment at the follow up. The person providing the treatments techniques was not the one collecting the data and a separate person did the statistical analysis, thus blinding the therapist.
This was part of a larger study that included gait analysis before and after treatment.
Thank you for this important and interesting article! Often non-medics think it's straightforward for medics, when if you actually talk to doctors on the pathway you find it is not that easy. I just wanted to comment that the NMAHP issues also apply to other non-medical healthcare professionals, including psychologists, pharmacists, biomedical scientists and clinical scientists and engineers.
These professions include significant postgraduate research training as part of clinical training, but this does not seem to have made clinical-academic careers more accessible to these groups. For example, I had to resign from my NHS position as a medical physicist to do a PhD in medical physics that was directly relevant to my role and career development. So I don't think better provision of research training in NMAHP degrees is the answer (although it won't be a negative thing).
I think the only thing that will help is for the clinical-academic pathway to become more normal, which will happen as people who have struggled with these issues over the past decade obtain senior positions and are able to help their more junior peers. These senior staff with a clinical academic background will hopefully recognise the value of research trained clinical staff and put a lot of effort in to breaking down the barriers.
We have read the proposed vaccine study with interest and wish to make the following comments;
It is worth noting that the study population is specifically focused on students and their trainers. Depending on the setting these will not have had direct involvement in the management, logistics and overall governance of vaccine administration let alone managing daily vaccine queries from staff and the public. Therefore , there is a limitation as to how their views reflect current feelings, attitudes, practices and gaps in knowledge. However, as the main aim is to look towards future vaccines and building healthcare knowledge and engagement then studying this population makes it relevant and identifies gaps that will need to be addressed in future. This then should assist in placing healthcare workers in a better position in order to enable them to improve vaccine uptake . A key question might be what are the things that will make them confident in a vaccine and furthermore to be prepared to take it .
Furthermore, this population may also be more familiar with multiple social media platforms that the public and " vaccine sceptics “ have used. They are , therefore an ideal group to interface with the public as their communication platform is relevant and likely to reach beyond the noticeboards and publications that current interventions or communications have utilized.
We read with interest paper of Barber C., et al. recently published in your journal about the strategies for developing and implementing a rheumatoid arthritis (RA) healthcare quality framework considering the perspectives from arthritis stakeholders; and rightly, stakeholders advocated for the use of existing healthcare frameworks over frameworks developed in the business world and adapted for healthcare. The authors identified 9 guiding principles for framework development and 13 potential topics for measuring the effectiveness, safety, healthcare efficiency, costs, and quality of care, which in turn should be further developed and established by the interested focus groups of stakeholders. Subsequently, some barriers are raised that may eventually delay the successful implementation of a RA healthcare quality framework. Participants highlighted strategies that were important to ensure effective quality framework implementation and at a system level, financial and political will of decision makers were highlighted as major facilitators.1 The latter is true, but also no less important is the fact that doctors, mainly specialists, "change their chip" and begin to work under the rules that it presupposes within a framework of quality in healthcare, which implies making decisions within a framework of check list type; for example, be adherent to a clinical practice guideline for the diagnosis, follow-up, and treatment of a specific pathology. Finally, clinical mode...
Show MoreSchoep et al. evaluated age-dependent productivity loss caused by menstruation-related symptoms, which were measured in absenteeism (time away from work or school) and presenteeism (productivity loss while present at work or school), in women aged 15-45 years (1). Odds ratio (95% CI) of women under 21 years with menstruation-related symptoms for absenteeism was 3.3 (3.1 to 3.6). In addition, menstruation-related symptoms caused a great deal of lost productivity, and presenteeism contributed to lost productivity larger than absenteeism. I present an interventional study regarding productivity loss and menstruation-related symptoms.
Song and Kanaoka conducted a randomized controlled trial to investigate the effectiveness of the application for menstrual management in female workers, aged 20-45 years (2). The incidences of depression and dysmenorrhea were significantly lower than those of the non-intervention group in the third month. Although labor productivity and absenteeism varied, and there was no significant change in presenteeism, the aggregate of medical expenses, productivity loss, and application fee for the intervention group presented lower costs with 1,170 USD per individual. They concluded that the application was cost-effective and might reduce the incidence of dysmenorrhea and depression. They reported that presenteeism did not improve by this application. As the incidences of depression and dysmenorrhea were quite low in their population, there is a ne...
Show MoreI would like to point to potential problems with the statistical models of Rydahl et al:
For stillbirths, they fit a Poisson model log(rate) = a + b*year + c*dummy(2011) (dummy(2011) is 0 before and 1 after the change in guideline) [personal communication], a model that obviously allow for no change in the slope before and after 2011. This is problematic because the actual data indicate that the stillbirth rate decreases up to 2011 and increases after 2011 (acknowledged by Rydahl et al (p. 6) and suggested by a recent paper based on similar data [1]). Because the model is underfitted, the findings may be unreliable (false negative).
Show MoreA basic simulation illustrates the problem: the underlying hypothesis is that the stillbirth rate reflects the induction rate (i.e. the number of ongoing pregnancies) and that stillbirths consequently reflects the Figure 2A changes over time. If the risk of stillbirth is proportional to the number of ongoing pregnancies, one simple simulated data could be per year n=16, 16, 14, 13, 12, 12, 11, 11, 11, 10, 11, 8, 5, 6, 6, 7, 8 from 2000 to 2016. The model applied by Rydahl et al would be unable to detect the build-in change in this simulated data. In fact, as expected, only some models would be able to detect the change: for example, in a quasi-Poisson model with interaction, the before-after dummy is statistically significant (p=0.045). Interestingly, if this model is applied to the published data, the dummy(2011) is statistically...
Blauth et al. conducted one-year follow-up study with participation of international multicentre (1). The authors determined the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures by setting usual care centres (UCC) as a control. A total of 281 patients, aged ≥70 with operatively treated proximal femur fractures, were analyzed. Odds ratio (OR) (95% confidence interval [CI]) of patients in GFC against UCC for an MAE was 4.56 (2.23 to 9.34). In addition, OR (95% CI) of patients in GFC against UCC for pneumonia and delirium were 3.40 (1.08 to 10.70) and 5.76 (1.64 to 20.23), respectively. The authors explained the increased OR as higher ability of detecting MAEs in GFC than that in UCC, and considered as positive effect of geriatric comanagement. I have comments about their study.
Blauth et al. cited 4 randomized controlled trials in the past, and most recent article was reported by Prestmo et al (2). They compared the effectiveness of treatment for hip fracture between GFC and UCC. Patients, aged ≥70, were able to walk 10 m before their fracture. Mean Short Physical Performance Battery scores at 4 months were significantly higher in GFC patients than that in UCC patients, and they recognized the advantage of GFC for the treatment of older patients with hip fractures.
Regarding delirium as a MAE in patients after hip-fracture repair, Marcantonio et al. reported that relative risk...
Show MoreWe read with interest your protocol to develop a core outcome set (COS) for congenital pulmonary airway malformations and applaud your intention to develop a COS for this population of children. We wish to highlight one area about which we have significant concerns, which is your decision to specifically exclude parents' and patients' views from your Delphi process.
There are strong arguments for involving patients' and parents' views in COS development. Only by specifically including them can researchers be certain that outcomes of particular importance to patients and parents have at least an opportunity of being represented in the COS. The specific exclusion of these important stakeholders risks not only excluding outcomes that are most important to this vital stakeholder group but also risks sending completely the wrong message to patients and parents. By deliberately excluding this group the researchers risk sending the message to patients and parents that their views simply don’t matter.
To ensure that important considerations such as this are not overlooked during COS development, the COS-STAD set of standards has been developed. A specific recommendation is that ‘COS developers should involve those who have experienced or who are affected by the condition (e.g., patients, family members, and carers)’. The authors of this protocol claim to have developed it in accordance with the COS-STAD guidance yet do not appear to incorporated...
Show MoreHaapanen et al. investigated the association between retirement characteristics and frailty of older businessmen (1). The adjusted OR of men who retired at ages of 58-69 years compared with men who retired before 55 years old for frailty significantly decreased. In addition, the adjusted ORs (95% CIs) of men who retired due to disability for pre-frailty and frailty were 1.53 (1.01-2.32) and 3.52 (1.97-6.29), respectively. Exiting working life early and continuing work until age of 70 years and older were both significantly associated with increased risk of frailty. They presented U-shaped relationship and there was a difference in the magnitude of OR between pre-frailty and frailty in men who retired due to disability. I present information about their study with special reference to employment status and outcomes.
Kalousova et al. examined the association between psychosocial working conditions and frailty in later life (2). Low reward, high effort, effort to reward ratio, and effort to control ratio were all significant predictors of increasing frailty. In addition, Non-retired workers with low-reward jobs experienced the largest increases in frailty at follow-up. They considered that retirement might protect frailty in older workers with low reward jobs. Applying job-stress model to frailty in older workers is also important for keeping quality of life in later life.
Palmer et al. examined the association between frailty and employment difficulties in work...
Show MoreThe International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) congratulates the British Association of Cardiovascular Prevention and Rehabilitation (BACPR), a foundational member, in providing an informative report on the effects of COVID-19 on the delivery of cardiac rehabilitation (CR). ICCPR is looking forward to providing further peer-reviewed data soon to add to these important findings.
Indeed, ICCPR’s soon-to-be published international survey of CR programs corroborates findings from BACPR’s study; we collated responses from over 1,000 programs in 70 countries (or 63% of those known to have CR in the world) and similarly found half of programs had been closed. Based on estimates of the number of CR programs available from our global audit (https://globalcardiacrehab.com/Global-CR-Program-Survey) and those temporarily shuttered, this would translate to 4400 programs being closed globally last Spring.
Results from our survey also showed drastic increases in use of videoconferencing, but this work by BACPR provides much more information for the CR community on the use of technology for various components of CR.
We also reported on the major impacts of the pandemic on staff from an occupational and psychosocial perspective. The pre-print of this work is available here: https://www.medrxiv...
Show MoreDear authors,
I would like to provide some insight regarding our article "Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial" that you included in your review.
All participants were randomly allocated to any of three groups and were unaware until the end of the five treatment sessions being notified following the last assessment at the follow up. The person providing the treatments techniques was not the one collecting the data and a separate person did the statistical analysis, thus blinding the therapist.
This was part of a larger study that included gait analysis before and after treatment.
Kind regards,
G. Krekoukias
Thank you for this important and interesting article! Often non-medics think it's straightforward for medics, when if you actually talk to doctors on the pathway you find it is not that easy. I just wanted to comment that the NMAHP issues also apply to other non-medical healthcare professionals, including psychologists, pharmacists, biomedical scientists and clinical scientists and engineers.
These professions include significant postgraduate research training as part of clinical training, but this does not seem to have made clinical-academic careers more accessible to these groups. For example, I had to resign from my NHS position as a medical physicist to do a PhD in medical physics that was directly relevant to my role and career development. So I don't think better provision of research training in NMAHP degrees is the answer (although it won't be a negative thing).
I think the only thing that will help is for the clinical-academic pathway to become more normal, which will happen as people who have struggled with these issues over the past decade obtain senior positions and are able to help their more junior peers. These senior staff with a clinical academic background will hopefully recognise the value of research trained clinical staff and put a lot of effort in to breaking down the barriers.
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