We read with great interest your recent article which explores the many barriers involved in passing licensing examinations to practise in another country.
In the UK, the NHS workforce relies on, and is massively enriched by, migration. As a student here, I am interested to hear your thoughts about how the introduction of a new licensing requirement, the UKMLA, will influence physician migration and integration into the UK workforce.
From early 2024, international medical graduates who would have sat the PLAB test will start to sit the MLA instead, as will all medical students in the UK. The GMC states that 'the MLA will give patients and employers greater confidence in doctors new to working in the UK, wherever they were educated or trained' [1].
This approach is new in that it aims to provide a common approach, no matter where one has obtained their medical degree. There are arguably two possible directions in which this will go. The first possibility is that the UKMLA will indeed streamline entry in to practice in the UK, by making the requirements more consistent. Asking international graduates to sit broadly the same examination as doctors who train in the UK may also mean that there are more resources available to prepare for the examination. In the USA for example, the requirements for board licensing are largely the same for doctors who obtained their degree in America and for internati...
We read with great interest your recent article which explores the many barriers involved in passing licensing examinations to practise in another country.
In the UK, the NHS workforce relies on, and is massively enriched by, migration. As a student here, I am interested to hear your thoughts about how the introduction of a new licensing requirement, the UKMLA, will influence physician migration and integration into the UK workforce.
From early 2024, international medical graduates who would have sat the PLAB test will start to sit the MLA instead, as will all medical students in the UK. The GMC states that 'the MLA will give patients and employers greater confidence in doctors new to working in the UK, wherever they were educated or trained' [1].
This approach is new in that it aims to provide a common approach, no matter where one has obtained their medical degree. There are arguably two possible directions in which this will go. The first possibility is that the UKMLA will indeed streamline entry in to practice in the UK, by making the requirements more consistent. Asking international graduates to sit broadly the same examination as doctors who train in the UK may also mean that there are more resources available to prepare for the examination. In the USA for example, the requirements for board licensing are largely the same for doctors who obtained their degree in America and for international graduates. At face value, it does seem more fair that graduates should sit the same assessments, irrespective of where they trained.
There are some concerns regarding the introduction of the UKMLA: one could argue that far from being a leveler, different medical institutions and countries may be able to variably allocate resources towards preparing students for it, which may lead to worsening disparities. Furthermore, looking at the information from the GMC, it seems that international graduates will not quite be sitting the same assessment as UK graduates: there will possibly be variation in both content and threshold setting. Furthermore, in your article it is clear that even when the same licensing exam is used for international graduates as their peers educated within the country, the pass rate of migrant physicians is much lower. Some of the main factors seem to be age-related, a lack of time to familiarise oneself with the exam type and the language used. A key contributor to difficulties with licensing exams suggested in the article is time passed after participants' original medication. Given that the UKMLA aims to assess UK graduates whilst still at medical school, this may create disparity between UK graduates and international graduates who would presumably sit the exam later, when they would have sat the PLAB test.
Lorente et al. identified significant heterogeneity in the tools, procedures, and definitions used by systematic reviewers to evaluate instrument measurement properties and highlighted key omissions in the reported methodological information in nearly 250 published systematic reviews on quality of life instruments.1 As we encounter with other health outcome measurement instruments used in child health and mental health research, poor compliance with methodological or reporting guidance in published reports impedes appraisal of the quality of the instruments’ measurement properties.2-6 This impairs knowledge users’ (such as policy-makers, other researchers, patients, healthcare providers) comprehensive appraisal of the sufficiency of the instruments that are used in studies or that are recommended to be used, as related to their key measurement properties and to issues of feasibility, burden, and fairness.
The authors raised important points concerning the current shortcomings of systematic reviews conducted to assess measurement properties of instruments. Lorente et al. concluded that improved adherence to methodological and reporting guidelines for the conduct and dissemination of systematic reviews on measurement properties of instruments is urgently needed. They recommended the COSMIN (Consensus-based Standards for the selection of health Measurement Instruments) checklist as the optimal framework to be used to conduct high-quality systemat...
Lorente et al. identified significant heterogeneity in the tools, procedures, and definitions used by systematic reviewers to evaluate instrument measurement properties and highlighted key omissions in the reported methodological information in nearly 250 published systematic reviews on quality of life instruments.1 As we encounter with other health outcome measurement instruments used in child health and mental health research, poor compliance with methodological or reporting guidance in published reports impedes appraisal of the quality of the instruments’ measurement properties.2-6 This impairs knowledge users’ (such as policy-makers, other researchers, patients, healthcare providers) comprehensive appraisal of the sufficiency of the instruments that are used in studies or that are recommended to be used, as related to their key measurement properties and to issues of feasibility, burden, and fairness.
The authors raised important points concerning the current shortcomings of systematic reviews conducted to assess measurement properties of instruments. Lorente et al. concluded that improved adherence to methodological and reporting guidelines for the conduct and dissemination of systematic reviews on measurement properties of instruments is urgently needed. They recommended the COSMIN (Consensus-based Standards for the selection of health Measurement Instruments) checklist as the optimal framework to be used to conduct high-quality systematic reviews on measurement properties of health instruments for an evaluative purpose. Indeed, COSMIN hosts on online database of such systematic reviews (https://www.cosmin.nl/tools/database-systematic-reviews). Yet, empirical analysis of studies in the COSMIN database shows that there still are important gaps in the quality of the reporting of these reviews.5 6
We propose that guidance for reporting knowledge synthesis studies on measurement properties of outcome measurement instruments in health research be developed and implemented. To this aim, expansion of the widely used and recently updated reporting checklist, PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses7 8; cited >36 000 times9) checklist with the key methodological details relevant to reviews of measurement instruments, e.g., as specified by COSMIN methodology,10 could facilitate ease of use and uptake. If developed using modern scientific methods11 and subsequently implemented in ways that make the task of reporting studies of outcome measurement instruments easier, not more cumbersome, by providing a checklist of reporting items with a clear “user manual,” this new reporting guideline would have the potential to reduce a vast ongoing source of research waste in health measurement.
References
1. Lorente S, Viladrich C, Vives J, et al. Tools to assess the measurement properties of quality of life instruments: a meta-review. BMJ Open 2020;10:e036038.
2. Monsour A, Mew EJ, Patel S, et al. Primary outcome reporting in adolescent depression clinical trials needs standardization. BMC Med Res Methodol 2020;20:129.
3. Ding S, Mew EJ, Chee ATA, et al. Neurodevelopmental outcome descriptions in cohorts of extremely preterm children. Arch Dis Child Fetal Neonatal Ed 2020;0:F1-F10.
4. Stallwood E, Monsour A, Rodrigues C, et al. Systematic review: The measurement properties of the Children’s Depression Rating Scale-Revised (CDRS-R) for adolescents with major depressive disorder. J Am Acad Child Adolesc Psychiatry 2020, in-principle acceptance.
5. Terwee CB, Prinsen CA, Ricci Garotti MG, et al. The quality of systematic reviews of health-related outcome measurement instruments. Qual Life Res 2016;25:767-79.
6. Mokkink LB, Terwee CB, Stratford PW, et al. Evaluation of the methodological quality of systematic reviews of health status measurement instruments. Qual Life Res 2009;18:313-33.
7. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097.
8. Page M, McKenzie J, Bossuyt P, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. 2020. doi:10.31222/osf.io/v7gm2.
9. Caulley L, Cheng W, Catalá-López F, et al. Citation impact was highly variable for reporting guidelines of health research: a citation analysis. J Clin Epidemiol 2020;127:96-104.
10. Prinsen CA, Mokkink LB, Bouter LM, et al. COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual Life Res 2018;27:1147-57.
11. Moher D, Schulz KF, Simera I, et al. Guidance for developers of health research reporting guidelines. PLoS Med 2010;7:e1000217.
There are no case reports anywhere in the world of patients receiving cannabis under medical supervision coming to any significant harm. There is no doubt that cannabis is safe as a medicine. Those opposed to it, usually with vested financial interests, are trying to undermine use of CBPMs with spurious claims of harms caused by smoking cannabis in its most potent form as a recreational drug.
The senior clinicians responsible for drafting the guidelines, from the Royal Colleges and other professional bodies, are the same people who have failed to provide up-to-date medical education on the endocannabinoid system, through which cannabis exterts its therapeutic effects. These same people are also responsible for running and supervising the clinical trials that pharmaceutical companies use to prove the safety and efficacy of their new products. For this they receive very substantial fees and long-running sponsorship for their institutions. The conflict of interest is obvious, yet is being entirely overlooked.
I fully support Prof Nutt's analysis but suggest that senior clinicians responsible for drafting guidelines do not wish to consider other forms of evidence as they are not in their financial self-interest.
In summary there is no evdience of any harm in the medically supervised use of CBPMs and substantial evidence of great benefit. Failing to prescribe in such circumstances is unethical, irresponsible and may actually be 'doing harm...
There are no case reports anywhere in the world of patients receiving cannabis under medical supervision coming to any significant harm. There is no doubt that cannabis is safe as a medicine. Those opposed to it, usually with vested financial interests, are trying to undermine use of CBPMs with spurious claims of harms caused by smoking cannabis in its most potent form as a recreational drug.
The senior clinicians responsible for drafting the guidelines, from the Royal Colleges and other professional bodies, are the same people who have failed to provide up-to-date medical education on the endocannabinoid system, through which cannabis exterts its therapeutic effects. These same people are also responsible for running and supervising the clinical trials that pharmaceutical companies use to prove the safety and efficacy of their new products. For this they receive very substantial fees and long-running sponsorship for their institutions. The conflict of interest is obvious, yet is being entirely overlooked.
I fully support Prof Nutt's analysis but suggest that senior clinicians responsible for drafting guidelines do not wish to consider other forms of evidence as they are not in their financial self-interest.
In summary there is no evdience of any harm in the medically supervised use of CBPMs and substantial evidence of great benefit. Failing to prescribe in such circumstances is unethical, irresponsible and may actually be 'doing harm' to patients.
I found the results of this study very relatable and thought-provoking. Following and posting on social media is a major past time for many teenagers and young adults. The study found that those who spent the most time on their electronic devices, (five hours or more) also had much later bedtimes. Therefore, it is not surprising that the study links the amount of time spent on social media with poor sleeping patterns. The researchers pointed out as well that the use of social media is a reflection of our current culture and links it to negative effects and behaviors on today’s youth. It was found that very high social media users were more likely to have nightmares, feelings of depression, and anxiety. The researchers make suggestions for parents on how to manage the time that their children spend on media outlets, such as Facebook, Instagram, Snapchat, and Twitter. I thought the research was well balanced as it included a large number of participants aged 13-15 years from the U.K. I think this type of research is important to help parents evaluate how the use of social media is affecting their children’s lives. Adequate sleep is obviously necessary to be healthy, both physically and mentally. The study also links later sleep onset in students to poor academic performance and emotional fluctuations. The emphasis is placed on helping heavy social media users balance their online interactions appropriately. The research inspires parents to become more involved in monitoring...
I found the results of this study very relatable and thought-provoking. Following and posting on social media is a major past time for many teenagers and young adults. The study found that those who spent the most time on their electronic devices, (five hours or more) also had much later bedtimes. Therefore, it is not surprising that the study links the amount of time spent on social media with poor sleeping patterns. The researchers pointed out as well that the use of social media is a reflection of our current culture and links it to negative effects and behaviors on today’s youth. It was found that very high social media users were more likely to have nightmares, feelings of depression, and anxiety. The researchers make suggestions for parents on how to manage the time that their children spend on media outlets, such as Facebook, Instagram, Snapchat, and Twitter. I thought the research was well balanced as it included a large number of participants aged 13-15 years from the U.K. I think this type of research is important to help parents evaluate how the use of social media is affecting their children’s lives. Adequate sleep is obviously necessary to be healthy, both physically and mentally. The study also links later sleep onset in students to poor academic performance and emotional fluctuations. The emphasis is placed on helping heavy social media users balance their online interactions appropriately. The research inspires parents to become more involved in monitoring their children’s use and to come up with strategies to reduce the time they spend on media to improve their overall health, mental and physical.
It is interesting to read that Meffen A, et al. (2020) will study the incidence, prevalence and number of major-lower limb amputations in the UK, amongst their objectives. They plan to investigate the reasons for significant variation in the reporting of epidemiology of major lower extremity amputation (LEA). Prevalence of LEA has been evaluated, on numerous occasions in many epidemiological studies (1-14).
There has been a recent study that has followed similar methods and objectives to Meffen A, et al. (2020), to determine the methodological differences that create the variation of prevalence of LEAs (1). There are also studies that have used robust methodology to report on incidence, prevalence and number of LEAs, which include age standardised, gender, ethnic minority, and regional specific data analysis (6, 13, 14).
The same systematic searches of peer reviewed journals using PRISMA guidelines, have already been carried out from a comprehensive range of databases: PubMed, Cumulative index to Nursing and Allied Health Literature (CINAHL), ExperptaMedica Database (EMBASE), Medical Literature Analysis and Retrieval Online (MEDLINE), Cochrane database, NHS Digital, Diabetes UK and Healthcare Quality Improvement Partnership (HQIP), of all LEA studies performed in England, over a 30 year period (1988- 2018) (1).
The variation in prevalence of major LEAs, reported by Davies M, Burdett L, Bowling F, et al. (2019) range from 0.7...
It is interesting to read that Meffen A, et al. (2020) will study the incidence, prevalence and number of major-lower limb amputations in the UK, amongst their objectives. They plan to investigate the reasons for significant variation in the reporting of epidemiology of major lower extremity amputation (LEA). Prevalence of LEA has been evaluated, on numerous occasions in many epidemiological studies (1-14).
There has been a recent study that has followed similar methods and objectives to Meffen A, et al. (2020), to determine the methodological differences that create the variation of prevalence of LEAs (1). There are also studies that have used robust methodology to report on incidence, prevalence and number of LEAs, which include age standardised, gender, ethnic minority, and regional specific data analysis (6, 13, 14).
The same systematic searches of peer reviewed journals using PRISMA guidelines, have already been carried out from a comprehensive range of databases: PubMed, Cumulative index to Nursing and Allied Health Literature (CINAHL), ExperptaMedica Database (EMBASE), Medical Literature Analysis and Retrieval Online (MEDLINE), Cochrane database, NHS Digital, Diabetes UK and Healthcare Quality Improvement Partnership (HQIP), of all LEA studies performed in England, over a 30 year period (1988- 2018) (1).
The variation in prevalence of major LEAs, reported by Davies M, Burdett L, Bowling F, et al. (2019) range from 0.7 to 332.4 per 100,000 in the diabetic population and 3.0 to 76.1 per 100,000 in the general population (1). A reliable conclusion has been reached as to why there is significant variation in the studies. There is absence in the application of standardised epidemiological principles when calculating and reporting on (LEA rates (1). Methodology used in most studies does not facilitate comparison across populations and time. The inconsistent nature of reporting LEAs make drawing conclusions on temporal and population change difficult, which is evidenced comprehensively in Table 1 and Table 2 of Davies M, Burdett L, Bowling F, et al. (2019) study.
Ahmad et al, (6, 13, 14) have successfully published regional and subgroup differences relating to LEA prevalence, using robust methodology, which Meffen A, et al. (2020) plan to study. They reported that above to below knee amputation ratio (a potential marker of poor care) is higher in Northern regions of England (North 1.3:1, Midlands 1.2:1, South 0.9:1) and that amputation rates are three times higher in men compared with women. They have also reported that LEAs are 70% higher in black than white populations, and half of amputations are in people that do not have diabetes.
Collecting and analysing NHS data for LEA patients that do not have diabetes, but have peripheral arterial disease, is difficult due to lack of specific coding. This is despite this patient group making up at least forty percent of all LEAs (14). Hopefully, studies such as Meffen A, et al. (2020) will initiate the urgently needed implementation of national NHS coding for non-diabetic amputations (other than caused by cancer and trauma) as a result of their investigation of healthcare data sources, by evidencing such limitations in their findings.
Meffen A, et al. confirms that in England there are fewer major LEAs than minor, however minor amputations will be excluded from their study. Minor LEAs have significant variation in rates, which relate to similar issues as major LEAs. It is important that accurate data exists for both minor and major LEAs, to allow public health professionals to implement preventative strategies, and plan their services on a local, regional and national level.
Future studies will need to describe and present basic numerator and denominator population characteristics e.g. number, age and gender, and use standardised definitions and coding for the type of LEA, to achieve accurate data reporting. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines ought to considered to become requisite for authors conducting and publishing observational studies, in order to publish standardised high-quality presentation of epidemiology studies (15).
It is without doubt that public health specialists, vascular surgeons, diabetologists, podiatric surgeons, podiatrists, and all other lower limb specialists will find future studies that deliver accurate number and prevalence rates of LEAs, extremely valuable. Standardised methodology when carrying such studies in this subject is long- awaited.
Competing interests: No competing interests
References
1. Davies M, Burdett L, Bowling F, et al. The epidemiology of major lower-limb amputation in England: a systematic review highlighting methodological differences of reported trials. Diabetic Foot Ankle 2019;22:53–61
2. Kvitkina T, Narres M, Claessen H, Droste S, Morbach S, Kuss O, Icks A. Incidence of lower extremity amputation in the diabetic compared to the non-diabetic population: a systematic review protocolmoxey. Systematic Reviews. 2015; 4(74):1-5. Available from: doi: https://doi.org/10.1186/s13643-015-0064-9.
3. Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, Holt PJ. Lower extremity amputations — a review of global variability in incidence. Diabetic Medicine. 2011;28(10):144-1153. Available from: doi: 10.1111/j.1464-5491.2011.03279.x
4. Narres M, Kvitkina T, Claessen H, Droste S, Schuster B, Morbach S, ... Icks A. Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: A systematic review. PLoS One. 2017;12(8):e018208. Available from: doi: 10.1371/journal.pone.0182081.
5. Margolis DJ, Jeffcoate W. Epidemiology of Foot Ulceration and Amputation: Can Global Variation be Explained?. Medical Clinics of North America. 2013;97(5):791-805. Available from: doi: https://doi.org/10.1016/j.mcna.2013.03.008.
6. Ahmad N, Thomas GN, Gill P, Torella F. The prevalence of major lower limb amputation in the diabetic and non-diabetic population of England 2003–2013. Diabetes & Vascular Disease Research. 2016;13(5):348-353. Available from: doi: 10.1177/1479164116651390.
7. Canavan RJ, Kelly WF, Unwin NC, Connolly VM. Diabetes- and Nondiabetes-Related Lower Extremity Amputation Incidence Before and After the Introduction of Better Organized Diabetes Foot Care. Diabetes Care. 2008;31(3):459-463. Available from: doi: 10.2337/dc07-1159.
8. Rayman G, Krishnan S, Baker NR, Wareham AM, Rayman A. Are we underestimating diabetes-related lower-extremity amputation rates? Results and benefits of the first prospective study. Diabetes Care. 2004;27(8):1892-1896. Available from: doi: https://doi.org/10.2337/diacare.27.8.1892.
9. Vamos EP, Bottle A, Edmonds ME, Valabhji J, Majeed A, Millett C. Changes in the Incidence of Lower Extremity Amputations in Individuals With and Without Diabetes in England Between 2004 and 2008. Diabetes Care. 2010;33(12):2592-2597. Available from: doi: 10.2337/dc10-0989.
10. Vamos EP, Bottle A, Majeed A, Millett C. Trends in lower extremity amputations in people with and without diabetes in England, 1996-2005. Diabetes Research and Clinical Practice. 2010;87(2):275-282. Available from: doi: 10.1016/j.diabres.2009.11.016.
11. Holman N, Young RJ, Jeffcoate WJ. Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia 2012;55:1919–25. 10
12. Moxey PW, Hofman D, Hinchliffe RJ, et al. Epidemiological study of lower limb amputation in England between 2003 and 2008. Br J Surg 2010;97:1348–53
13. Ahmad N, GN Thomas, Gill P, Torella F. Endovascular revascularisation is associated with a lower risk of above knee amputation than surgical or combined modalities. Analysis of English hospital admissions over a six year period. Int J Angiol 2016;35:498-503 39
14. Ahmad N, Chan C, Thomas GN, Gill P. Ethnic differences in lower limb revascularisation and amputation rates. Implications for the aetiopathology of atherosclerosis 2014; 233:503-507
15. Cuschieri S. (2019). The STROBE guidelines. Saudi journal of anaesthesia, 13(Suppl 1), S31–S34. https://doi.org/10.4103/sja.SJA_543_18
Inequalities and inequities in health and healthcare for people with intellectual disabilities have been of longstanding concern. Medication use is the major therapeutic intervention in this vulnerable population. The use of medication cannot be separated from the environment –physical and social – in which the person with intellectual disabilities lives and is supported.
There is no ‘one size fits all’ regarding psychotropic medication use in this population group. Those providing direct care are the most important person in the life of an individual with intellectual disabilities and may have a direct influence on medication prescribed or de-prescribed, for problem behaviours etc.
The social environment, the physical environment and societal preconditions, and their interconnectivity with one another and with individuals in the setting, play an important role in healthy settings for people with intellectual disabilities[1] . Physical, mental, psychological and spiritual well being may all be influenced by the environment. A recent study highlights a health-promoting social network of people with ID as a prerequisite for change [1].
Pharmacists, as medication experts, in all healthcare environments can make positive contributions to the pharmaceutical care of patients with intellectual disabilities, in collaboration with other healthcare professionals, carers and patients themselves [2,3]. The expertise of specialist and other pharmacists i...
Inequalities and inequities in health and healthcare for people with intellectual disabilities have been of longstanding concern. Medication use is the major therapeutic intervention in this vulnerable population. The use of medication cannot be separated from the environment –physical and social – in which the person with intellectual disabilities lives and is supported.
There is no ‘one size fits all’ regarding psychotropic medication use in this population group. Those providing direct care are the most important person in the life of an individual with intellectual disabilities and may have a direct influence on medication prescribed or de-prescribed, for problem behaviours etc.
The social environment, the physical environment and societal preconditions, and their interconnectivity with one another and with individuals in the setting, play an important role in healthy settings for people with intellectual disabilities[1] . Physical, mental, psychological and spiritual well being may all be influenced by the environment. A recent study highlights a health-promoting social network of people with ID as a prerequisite for change [1].
Pharmacists, as medication experts, in all healthcare environments can make positive contributions to the pharmaceutical care of patients with intellectual disabilities, in collaboration with other healthcare professionals, carers and patients themselves [2,3]. The expertise of specialist and other pharmacists is often an untapped resource for the optimisation of medication use in this population group.
Research has shown that many people with intellectual disabilities who can make decisions about their daily life aren’t given clear information about their medication[4]. Healthcare professionals such as pharmacists and doctors will have to spend longer explaining their medication, use different resources, and explain 'things' ( prescribing and de-prescribing) in simpler language.
Strategies to reduce inequalities and inequities will require use of data to educate decision makers, including doctors and pharmacists, attention to and awareness of social determinants, and a life course model with emphasis on leveraging inclusion in mainstream services where possible.
Understanding the various elements in ‘the system’ that results in psychotropic medication being prescribed for each person with intellectual disability is vital. To optimise medication use we will require an understanding of the complex interactions and relationships that occur in the lives of people with intellectual disabilities.
General information [5]:
All health-care professionals need to have an understanding of the nature of complexity in health care, as it is important for preventing adverse events. Health care is complex due to:
• the diversity of tasks involved in the delivery of patient care
• the dependency of health-care providers on one another
• the diversity of patients, clinicians and other staff
• the huge number of relationships between patients, carers, health-care providers, support
staff, administrators, family and community members
• the vulnerability of patients
• variations in the physical layout of clinical environments
• variability or lack of regulations
• implementation of new technology
• the diversity of care pathways and organizations involved
• increased specialization of health-care professionals—while specialization allows a wider
range of patient treatments and services, it also provides more opportunity for things to go
wrong and errors to occur.
References:
1.Kristel Vlot-van Anrooij, J Naaldenberg, T I M Hilgenkamp, L Vaandrager, K van der Velden, G L Leusink, Towards healthy settings for people with intellectual disabilities, Health Promotion International, Volume 35, Issue 4, August 2020, Pages 661–670, https://doi.org/10.1093/heapro/daz054
2. Flood B. Safety of people with intellectual disabilities in hospital. What can the hospital pharmacist do to improve quality of care. Pharmacy (Basel)2017;5:44. doi:10.3390/pharmacy5030044 pmid:28970456CrossRefPubMedGoogle Scholar
3. O’Dwyer M, Meštrović A, Henman M. Pharmacists’ medicines-related interventions for people with intellectual disabilities: a narrative review. Int J Clin Pharm2015;37:566-78. . doi:10.1007/s11096-015-0113-4 pmid:25903938
4.Smith MVA, Adams D, Carr C, Mengoni SE . Do people with intellectual disabilities understand their prescription medication? A scoping review. J Appl Res Intellect Disabil2019;32:1375-88. . doi:10.1111/jar.12643 pmid:31338972CrossRefPubMedGoogle Scholar
5. https://www.who.int/patientsafety/education/curriculum/course3_handout.pdf
Thanks for your comment on our article, Shift work and burnout in police officers: a risk assessment. We appreciate that the risk of burnout may be multi-factorial and the relative contribution of each factor may vary by occupation. We did not examine work-related stress and conflict but appreciate that such factors may contribute to burnout risk in police officers. We maintain, however, our findings that sleepiness, inadequate sleep, irregular schedules, mandatory overtime, long shifts and night shifts are factors associated with elevated burnout risk in this population. We also controlled for age in our analyses and found that age was significant in the adjusted models examining shift work, sleep and their association with Depersonalisation and Personal Accomplishment. We agree that more research into the factors contributing to burnout and programs to mitigate it in safety-sensitive shift working occupations is necessary.
Sincerely,
Scott A Peterson, Alexander P Wolkow, Steven W Lockley, Conor S O'Brien, Salim Qadri, Jason P Sullivan, Charles A Czeisler, Shantha M W Rajaratnam and Laura K Barger
Peterson et al. examined associations between shift work and burnout in 3140 police officers with special reference to sleep duration and sleepiness. The Maslach Burnout Inventory, shift schedules (irregular, rotating, fixed), shift characteristics (night, duration, frequency, work hours), sleep duration and sleepiness were used for the analysis. Adjusted odds ratios (ORs) (95% confidence intervals [CIs]) of long shifts and mandatory overtime for emotional exhaustion were 1.91 (1.35 to 2.72) and 1.37 (1.14 to 1.65), respectively. Adjusted OR (95% CI) of night shifts for depersonalisation was 1.32 (1.05 to 1.66). In addition, Adjusted ORs (95% Cis) of irregular schedules for emotional exhaustion and depersonalisation were 1.91 (1.44 to 2.54) and 1.39 (1.02 to 1.89), respectively. Furthermore, adjusted ORs (95% Cis) of sleeping <6 hours and excessive sleepiness for motional exhaustion were 1.60 (1.33 to 1.93) and 1.81 (1.50 to 2.18), respectively. I have a comment about their study.
Ogundipe et al. determined factors burnout among 204 medical doctors undergoing residency training. General Health Questionnaire (GHQ-12) and Maslach Burnout Inventory (MBI) were used for the analysis. Adjusted OR (95% CI) of call duty as being not stressful for emotional exhaustion was 0.52 (0.29, 0.97). In contrast, adjusted OR (95% CI) of emotional distress, based on GHQ score of ≥3, for emotional exhaustion was 6.97 (3.28, 14.81). In addition, adjusted OR (95% CI) of absence of doc...
Peterson et al. examined associations between shift work and burnout in 3140 police officers with special reference to sleep duration and sleepiness. The Maslach Burnout Inventory, shift schedules (irregular, rotating, fixed), shift characteristics (night, duration, frequency, work hours), sleep duration and sleepiness were used for the analysis. Adjusted odds ratios (ORs) (95% confidence intervals [CIs]) of long shifts and mandatory overtime for emotional exhaustion were 1.91 (1.35 to 2.72) and 1.37 (1.14 to 1.65), respectively. Adjusted OR (95% CI) of night shifts for depersonalisation was 1.32 (1.05 to 1.66). In addition, Adjusted ORs (95% Cis) of irregular schedules for emotional exhaustion and depersonalisation were 1.91 (1.44 to 2.54) and 1.39 (1.02 to 1.89), respectively. Furthermore, adjusted ORs (95% Cis) of sleeping <6 hours and excessive sleepiness for motional exhaustion were 1.60 (1.33 to 1.93) and 1.81 (1.50 to 2.18), respectively. I have a comment about their study.
Ogundipe et al. determined factors burnout among 204 medical doctors undergoing residency training. General Health Questionnaire (GHQ-12) and Maslach Burnout Inventory (MBI) were used for the analysis. Adjusted OR (95% CI) of call duty as being not stressful for emotional exhaustion was 0.52 (0.29, 0.97). In contrast, adjusted OR (95% CI) of emotional distress, based on GHQ score of ≥3, for emotional exhaustion was 6.97 (3.28, 14.81). In addition, adjusted OR (95% CI) of absence of doctor-to-doctor conflict for depersonalization was 0.36 (0.17, 0.76). They also clarified that aging and adequate support for the management prevented burnout with reducing personal accomplishment. I suppose that risk of burnout might not be regulated by shift of job and sleep. To prevent burnout in police officers, stress-lowering strategies should be prepared and applied comprehensively.
References
1. Peterson SA, Wolkow AP, Lockley SW, et al. Associations between shift work characteristics, shift work schedules, sleep and burnout in North American police officers: a cross-sectional study. BMJ Open. 2019;9(11):e030302. Published 2019 Dec 1. doi:10.1136/bmjopen-2019-030302
2. Ogundipe OA, Olagunju AT, Lasebikan VO, Coker AO. Burnout among doctors in residency training in a tertiary hospital. Asian J Psychiatr. 2014;10:27-32. doi:10.1016/j.ajp.2014.02.010
Hopefully this will become an invaluable study. Can I alert the authors to the role of nearness to death (the nearness to death effect) in both cognitive and functional decline especially in the last year of life.
In the references you cite, the definition of multimorbidity is showed as the co-existence of two or more chronic conditions, where one is not necessarily more central than the others. But you have defined multi-morbidity comorbidity as the presence of two or more chronic health conditions in an individual. Does your definition indicate comorbidity?
Dear Authors,
Show MoreWe read with great interest your recent article which explores the many barriers involved in passing licensing examinations to practise in another country.
In the UK, the NHS workforce relies on, and is massively enriched by, migration. As a student here, I am interested to hear your thoughts about how the introduction of a new licensing requirement, the UKMLA, will influence physician migration and integration into the UK workforce.
From early 2024, international medical graduates who would have sat the PLAB test will start to sit the MLA instead, as will all medical students in the UK. The GMC states that 'the MLA will give patients and employers greater confidence in doctors new to working in the UK, wherever they were educated or trained' [1].
This approach is new in that it aims to provide a common approach, no matter where one has obtained their medical degree. There are arguably two possible directions in which this will go. The first possibility is that the UKMLA will indeed streamline entry in to practice in the UK, by making the requirements more consistent. Asking international graduates to sit broadly the same examination as doctors who train in the UK may also mean that there are more resources available to prepare for the examination. In the USA for example, the requirements for board licensing are largely the same for doctors who obtained their degree in America and for internati...
To the editor:
Lorente et al. identified significant heterogeneity in the tools, procedures, and definitions used by systematic reviewers to evaluate instrument measurement properties and highlighted key omissions in the reported methodological information in nearly 250 published systematic reviews on quality of life instruments.1 As we encounter with other health outcome measurement instruments used in child health and mental health research, poor compliance with methodological or reporting guidance in published reports impedes appraisal of the quality of the instruments’ measurement properties.2-6 This impairs knowledge users’ (such as policy-makers, other researchers, patients, healthcare providers) comprehensive appraisal of the sufficiency of the instruments that are used in studies or that are recommended to be used, as related to their key measurement properties and to issues of feasibility, burden, and fairness.
The authors raised important points concerning the current shortcomings of systematic reviews conducted to assess measurement properties of instruments. Lorente et al. concluded that improved adherence to methodological and reporting guidelines for the conduct and dissemination of systematic reviews on measurement properties of instruments is urgently needed. They recommended the COSMIN (Consensus-based Standards for the selection of health Measurement Instruments) checklist as the optimal framework to be used to conduct high-quality systemat...
Show MoreThere are no case reports anywhere in the world of patients receiving cannabis under medical supervision coming to any significant harm. There is no doubt that cannabis is safe as a medicine. Those opposed to it, usually with vested financial interests, are trying to undermine use of CBPMs with spurious claims of harms caused by smoking cannabis in its most potent form as a recreational drug.
The senior clinicians responsible for drafting the guidelines, from the Royal Colleges and other professional bodies, are the same people who have failed to provide up-to-date medical education on the endocannabinoid system, through which cannabis exterts its therapeutic effects. These same people are also responsible for running and supervising the clinical trials that pharmaceutical companies use to prove the safety and efficacy of their new products. For this they receive very substantial fees and long-running sponsorship for their institutions. The conflict of interest is obvious, yet is being entirely overlooked.
I fully support Prof Nutt's analysis but suggest that senior clinicians responsible for drafting guidelines do not wish to consider other forms of evidence as they are not in their financial self-interest.
In summary there is no evdience of any harm in the medically supervised use of CBPMs and substantial evidence of great benefit. Failing to prescribe in such circumstances is unethical, irresponsible and may actually be 'doing harm...
Show MoreI found the results of this study very relatable and thought-provoking. Following and posting on social media is a major past time for many teenagers and young adults. The study found that those who spent the most time on their electronic devices, (five hours or more) also had much later bedtimes. Therefore, it is not surprising that the study links the amount of time spent on social media with poor sleeping patterns. The researchers pointed out as well that the use of social media is a reflection of our current culture and links it to negative effects and behaviors on today’s youth. It was found that very high social media users were more likely to have nightmares, feelings of depression, and anxiety. The researchers make suggestions for parents on how to manage the time that their children spend on media outlets, such as Facebook, Instagram, Snapchat, and Twitter. I thought the research was well balanced as it included a large number of participants aged 13-15 years from the U.K. I think this type of research is important to help parents evaluate how the use of social media is affecting their children’s lives. Adequate sleep is obviously necessary to be healthy, both physically and mentally. The study also links later sleep onset in students to poor academic performance and emotional fluctuations. The emphasis is placed on helping heavy social media users balance their online interactions appropriately. The research inspires parents to become more involved in monitoring...
Show MoreDear Editor,
It is interesting to read that Meffen A, et al. (2020) will study the incidence, prevalence and number of major-lower limb amputations in the UK, amongst their objectives. They plan to investigate the reasons for significant variation in the reporting of epidemiology of major lower extremity amputation (LEA). Prevalence of LEA has been evaluated, on numerous occasions in many epidemiological studies (1-14).
There has been a recent study that has followed similar methods and objectives to Meffen A, et al. (2020), to determine the methodological differences that create the variation of prevalence of LEAs (1). There are also studies that have used robust methodology to report on incidence, prevalence and number of LEAs, which include age standardised, gender, ethnic minority, and regional specific data analysis (6, 13, 14).
The same systematic searches of peer reviewed journals using PRISMA guidelines, have already been carried out from a comprehensive range of databases: PubMed, Cumulative index to Nursing and Allied Health Literature (CINAHL), ExperptaMedica Database (EMBASE), Medical Literature Analysis and Retrieval Online (MEDLINE), Cochrane database, NHS Digital, Diabetes UK and Healthcare Quality Improvement Partnership (HQIP), of all LEA studies performed in England, over a 30 year period (1988- 2018) (1).
The variation in prevalence of major LEAs, reported by Davies M, Burdett L, Bowling F, et al. (2019) range from 0.7...
Show MoreInequalities and inequities in health and healthcare for people with intellectual disabilities have been of longstanding concern. Medication use is the major therapeutic intervention in this vulnerable population. The use of medication cannot be separated from the environment –physical and social – in which the person with intellectual disabilities lives and is supported.
There is no ‘one size fits all’ regarding psychotropic medication use in this population group. Those providing direct care are the most important person in the life of an individual with intellectual disabilities and may have a direct influence on medication prescribed or de-prescribed, for problem behaviours etc.
The social environment, the physical environment and societal preconditions, and their interconnectivity with one another and with individuals in the setting, play an important role in healthy settings for people with intellectual disabilities[1] . Physical, mental, psychological and spiritual well being may all be influenced by the environment. A recent study highlights a health-promoting social network of people with ID as a prerequisite for change [1].
Pharmacists, as medication experts, in all healthcare environments can make positive contributions to the pharmaceutical care of patients with intellectual disabilities, in collaboration with other healthcare professionals, carers and patients themselves [2,3]. The expertise of specialist and other pharmacists i...
Show MoreDear Dr. Kawada,
Thanks for your comment on our article, Shift work and burnout in police officers: a risk assessment. We appreciate that the risk of burnout may be multi-factorial and the relative contribution of each factor may vary by occupation. We did not examine work-related stress and conflict but appreciate that such factors may contribute to burnout risk in police officers. We maintain, however, our findings that sleepiness, inadequate sleep, irregular schedules, mandatory overtime, long shifts and night shifts are factors associated with elevated burnout risk in this population. We also controlled for age in our analyses and found that age was significant in the adjusted models examining shift work, sleep and their association with Depersonalisation and Personal Accomplishment. We agree that more research into the factors contributing to burnout and programs to mitigate it in safety-sensitive shift working occupations is necessary.
Sincerely,
Scott A Peterson, Alexander P Wolkow, Steven W Lockley, Conor S O'Brien, Salim Qadri, Jason P Sullivan, Charles A Czeisler, Shantha M W Rajaratnam and Laura K Barger
Peterson et al. examined associations between shift work and burnout in 3140 police officers with special reference to sleep duration and sleepiness. The Maslach Burnout Inventory, shift schedules (irregular, rotating, fixed), shift characteristics (night, duration, frequency, work hours), sleep duration and sleepiness were used for the analysis. Adjusted odds ratios (ORs) (95% confidence intervals [CIs]) of long shifts and mandatory overtime for emotional exhaustion were 1.91 (1.35 to 2.72) and 1.37 (1.14 to 1.65), respectively. Adjusted OR (95% CI) of night shifts for depersonalisation was 1.32 (1.05 to 1.66). In addition, Adjusted ORs (95% Cis) of irregular schedules for emotional exhaustion and depersonalisation were 1.91 (1.44 to 2.54) and 1.39 (1.02 to 1.89), respectively. Furthermore, adjusted ORs (95% Cis) of sleeping <6 hours and excessive sleepiness for motional exhaustion were 1.60 (1.33 to 1.93) and 1.81 (1.50 to 2.18), respectively. I have a comment about their study.
Ogundipe et al. determined factors burnout among 204 medical doctors undergoing residency training. General Health Questionnaire (GHQ-12) and Maslach Burnout Inventory (MBI) were used for the analysis. Adjusted OR (95% CI) of call duty as being not stressful for emotional exhaustion was 0.52 (0.29, 0.97). In contrast, adjusted OR (95% CI) of emotional distress, based on GHQ score of ≥3, for emotional exhaustion was 6.97 (3.28, 14.81). In addition, adjusted OR (95% CI) of absence of doc...
Show MoreHopefully this will become an invaluable study. Can I alert the authors to the role of nearness to death (the nearness to death effect) in both cognitive and functional decline especially in the last year of life.
In the references you cite, the definition of multimorbidity is showed as the co-existence of two or more chronic conditions, where one is not necessarily more central than the others. But you have defined multi-morbidity comorbidity as the presence of two or more chronic health conditions in an individual. Does your definition indicate comorbidity?
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