1238 e-Letters

  • Enabling healthcare staff to improve vaccine uptake

    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.

  • Dr. Pedro Santos-Moreno

    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...

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  • RE: Productivity loss due to menstruation-related symptoms

    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...

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  • Issues with the statistical models, Rydahl et al, BMJ Open, 2019

    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...

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  • RE: Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits?

    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...

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  • Exclusion of parents' and patients' views risks futility and sends the wrong message

    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...

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  • RE: Retirement age and type as predictors of frailty: a retrospective cohort study of older businessmen

    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...

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  • Evidence from the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) Corroborates Rate of Cardiac Rehabilitation Program Closure Due to COVID-19

    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...

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  • Blinding and bias

    Dear 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

  • Similar issues for Healthcare Scientists

    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.