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We are writing to you in response to Mahar et al.’s (2019) recent publication in your journal (“Suicide in Canadian veterans living in Ontario: a retrospective cohort study linking routinely collected data”).
The authors found a lower risk of suicide in Canadian Armed Forces (CAF) Veterans (former members) using Ontario Health Insurance Plan coverage, in contrast to the findings of higher CAF Veteran suicide risk in the Canadian Forces Cancer and Mortality Study (CF CAMS) and the Veteran Suicide Mortality Study (VSMS), which use nation-wide Vital Statistics and cancer registry data collected by Statistics Canada. We strongly feel that there is synergistic value in having different studies by different investigator groups using different data sources, but it is essential to understand the limitations in these different approaches and their findings.
Mahar et al. state that their study was the “...first study of suicide risk in Canadian veterans...” However, CF CAMS, which looked at suicide risk in Canadian Veterans, was published eight years prior to the Mahar et al. study (Statistics Canada, 2011). This was followed by the Veteran Suicide Mortality Study (VSMS) Technical report was published in 2017 (Simkus et al., 2017), its accompanying peer-reviewed publication (VanTil et al., 2018), and the 2018 VSMS Technical report (Simkus et al., 2018).
We have questions about the authors’ choice of covariates for the adjusted an...
We are writing to you in response to Mahar et al.’s (2019) recent publication in your journal (“Suicide in Canadian veterans living in Ontario: a retrospective cohort study linking routinely collected data”).
The authors found a lower risk of suicide in Canadian Armed Forces (CAF) Veterans (former members) using Ontario Health Insurance Plan coverage, in contrast to the findings of higher CAF Veteran suicide risk in the Canadian Forces Cancer and Mortality Study (CF CAMS) and the Veteran Suicide Mortality Study (VSMS), which use nation-wide Vital Statistics and cancer registry data collected by Statistics Canada. We strongly feel that there is synergistic value in having different studies by different investigator groups using different data sources, but it is essential to understand the limitations in these different approaches and their findings.
Mahar et al. state that their study was the “...first study of suicide risk in Canadian veterans...” However, CF CAMS, which looked at suicide risk in Canadian Veterans, was published eight years prior to the Mahar et al. study (Statistics Canada, 2011). This was followed by the Veteran Suicide Mortality Study (VSMS) Technical report was published in 2017 (Simkus et al., 2017), its accompanying peer-reviewed publication (VanTil et al., 2018), and the 2018 VSMS Technical report (Simkus et al., 2018).
We have questions about the authors’ choice of covariates for the adjusted analysis. Specifically, the authors did not adjust for mental illnesses because they asserted that mental illnesses are on the causal pathway to suicide. However, most with mental illness do not die by suicide (Nordentoft et al., 2013). A diagnosis of depression is common in those who die by suicide but remains a poor predictor of a suicidal act (Franklin et al., 2017). Furthermore, the authors’ use of socioeconomic factors and physical health problems as covariates implies that they felt that those factors are not on the suicide causal pathway. This is counter to the epidemiological, clinical and theoretical evidence indicating that such factors are on causal pathways to suicide (Gunnell and Lewis, 2005). The authors wrote that they chose as covariates “established risk factors”, but Franklin et al. (2017) demonstrated that epidemiologists have tended to look at a narrow list of risk indicators over the past 50 years. Just because researchers keep using the same risk indicators does not mean that those indicators are “established” as significant.
We think that Mahar et al.’s statements of discordance between their findings and the CFCAMS findings are overstated, particularly given the lack of statistical significance to support their assertions. The breadth of the confidence intervals in their adjusted models suggest that their findings may actually be aligned with the findings published in studies with census-level coverage of the Veteran population (namely the CF CAMS study [Statistics Canada, 2011] and the VSMS publications [Simkus et al, 2017; Simkus et al, 2018; Van Til et al, 2018]) that found the risk of suicide to be significantly elevated in those with a history of military service. However, a notable exception was the youngest male age group, where the OHIP study reports much lower rates than VSMS. Unfortunately, the authors did not discuss the effect of the OHIP “under-representation of those who released before age 25” on their subsequent comparisons of Veteran and civilian suicides. Future examination of Veterans in the OHIP data should be more cautious in extrapolating conclusions to all Veterans, particularly for conditions that are more common in younger Veterans.
Disagreements notwithstanding, we agree wholeheartedly with the authors’ statement that “...this work raises a need to conduct further high-quality research on the topic of suicide in the military, including veteran populations”, as recommended in the Canadian Armed Forces – Veterans Affairs Canada Joint Suicide Prevention Strategy (CAF and VAC, 2017).
References
Canadian Armed Forces, Veterans Affairs Canada. Joint Suicide Prevention Strategy. Ottawa, ON: Canadian Armed Forces and Veterans Affairs Canada. 2017.
Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EM, Huang X, Musacchio KM, Jaroszewski AC, Chang BP, Nock MK. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychological Bulletin. 2017;143(2):187.
Gunnell D, Lewis G. Studying suicide from the life course perspective: implications for prevention. British Journal of Psychiatry. 2005;187:206-8.
Mahar AL, Aiken AB, Whitehead M, Tien H, Cramm H, Fear NT, Kurdyak P. Suicide in Canadian veterans living in Ontario: A retrospective cohort study linking routinely collected data. BMJ Open. 2019;9:e027343.
Nordentoft M, Wahlbeck K, Hällgren J, Westman J, Ösby U, Alinaghizadeh H, Gissler M, Laursen TM. Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden. PloSOne. 2013;8(1):e55176.
Simkus K, VanTil LD, Pedlar D. 2017 Veteran Suicide Mortality Study (1976 to 2012). Charlottetown, PEI (Canada): Veterans Affairs Canada, 2017.
Statistics Canada. Canadian Forces Cancer and Mortality Study: Causes of death. Catalogue no. 82-584-X. Ottawa (Canada): Minister for Industry, 2011.
VanTil L, Simkus K, Rolland-Harris E, Pedlar DJ. Veteran suicide mortality in Canada from 1976 to 2012. Journal of Military, Veteran, and Family Health. 2018;4(2):110-6.
We thank Belinda WC Ommering et al. for their insightful and original research regarding how medical students motivation translates into research involvement. Whilst the article focusses on motivation of medical students wanting to be involved in research and the resultant degree of participation, we believe it is important to remark on the extrinsic barriers that medical students may face in obtaining research experience despite being highly motivated and the effect this can have on their motivation to participate in research. We are sharing our thoughts on this article from the point of view of two final year medical students involved in undergraduate research. Our response includes results from a short live survey carried out at a student research conference we held locally.
Previous studies indicate that students encounter personal and organisational barriers to research such as inadequate skill or training, limited access to information and unsupportive or unmotivated supervisors1 2. Students reported that a lack of proper training in understanding and writing papers, and difficulty finding an encouraging supervisor were two of the main barriers to conducting research as an undergraduate3. These students seemed to be motivated more by extrinsic factors, as 66.7% reported that the main reason they published their research was to improve their curriculum vitae3.
During the student research conference we held, students were provided with a live questionnair...
We thank Belinda WC Ommering et al. for their insightful and original research regarding how medical students motivation translates into research involvement. Whilst the article focusses on motivation of medical students wanting to be involved in research and the resultant degree of participation, we believe it is important to remark on the extrinsic barriers that medical students may face in obtaining research experience despite being highly motivated and the effect this can have on their motivation to participate in research. We are sharing our thoughts on this article from the point of view of two final year medical students involved in undergraduate research. Our response includes results from a short live survey carried out at a student research conference we held locally.
Previous studies indicate that students encounter personal and organisational barriers to research such as inadequate skill or training, limited access to information and unsupportive or unmotivated supervisors1 2. Students reported that a lack of proper training in understanding and writing papers, and difficulty finding an encouraging supervisor were two of the main barriers to conducting research as an undergraduate3. These students seemed to be motivated more by extrinsic factors, as 66.7% reported that the main reason they published their research was to improve their curriculum vitae3.
During the student research conference we held, students were provided with a live questionnaire through Socrative software on their attitudes, motivations and perceived barriers to research. 19 participants responded to the white space question ‘What have been the most significant barriers to gaining research experience?’. Responses were grouped into recurring themes and represented in Table 1.
Table 1: What have been the most significant barriers to gaining research experience? Reasons provided by medical students.
Barriers to research as reported by students Number of students
Lack of supervisor support 9
Lack of institutional support 4
Time factors 3
Lack of research opportunity 3
From the results of our survey we determined that there were several key extrinsic factors that limit students participation in research. Particularly, lack of supervisor support was identified as a key challenge to students, which we particularly identify with as students at a centre where a lower volume of research is conducted. The identified barriers are consistent with current literature that aims to address these challenges4. Some studies have shown that medical schools providing extrinsic resources to enable research participation fosters greater research productivity5 6and medical student research programmes that equip students for academic careers can motivate them to pursue academia in the future7. Further work could involve determining whether students with more intrinsic motivation towards research are better able to overcome these barriers compared to students motivated by extrinsic factors.
1. Dadipoor S, Ramezankhani A, Aghamolaei T, Safari-moradabadi A. Barriers to research activities as perceived by medical university students : A cross-sectional study. 2019:8-14.
2. Vallabhajosyula S, Shetty RS, Nair S. Knowledge , Attitude and Practice towards Medical Research among Students of a Medical College in Southern India Knowledge , Attitude and Practice towards Medical Research among Students of a Medical College in Southern India. 2014;(January). doi:10.5958/2231-6728.2014.00893.2
3. Marwan Y, Al-Halabi B, Hasan M, Alkhadhari S. Extracurricular research activities among senior medical students in Kuwait: experiences, attitudes, and barriers. Adv Med Educ Pract. 2014:95. doi:10.2147/AMEP.S61413
4. Zemlo TR, Garrison HH, Partridge NC, Ley TJ. The Physician-Scientist : Career Issues and Challenges at the Year 2000. 2000.
5. Dorrance KA, Denton GD, Proemba J, et al. An internal medicine interest group research program can improve scholarly productivity of medical students and foster mentoring relationships with internists. Teach Learn Med. 2008;20(2):163-167. doi:10.1080/10401330801991857
6. Schexnayder S, Starring H, Fury M, Mora A, Leonardi C, Dasa V. The formation of a medical student research committee and its impact on involvement in departmental research. Med Educ Online. 2018;23(1):1424449. doi:10.1080/10872981.2018.1424449
7. Hunskaar S, Breivik J, Siebke M, Tømmers K, Figenschau K, Hansen JB. Evaluation of the medical student research programme in Norwegian medical schools. A survey of students and supervisors. BMC Med Educ. 2009;9(1). doi:10.1186/1472-6920-9-43
The recently published article by Chan et al. questions the value of AAA screening. [1] We question the validity of the arguments and the data they use to support it, which we believe are either irrelevant or support the case for screening. Furthermore, the Chan et al. paper completely neglects the important equity gains that AAA screening can produce in the New Zealand (NZ) population.
Chan and his co-authors’ critique of AAA screening is based on 3 arguments: (i) patients with AAA are too sick with other comorbidities to benefit from screening and die of these other illnesses; (ii) most patients with AAA would be diagnosed by the health system anyway without a screening programme; and (iii) the size of the population that can benefit from screening is too small for it to be cost effective. Let us look more closely at each of these.
Co-morbidities in patients with AAA
The authors emphasise the point that co-morbidities in AAA patients might limit the benefit they attain from screening. They calculate that 77% of those dying of AAA had some other comorbidity. However, to imply that these were fulminant conditions and that preventing AAA death in this group would have been futile because they are moribund is highly misleading. The collection of co-morbidities includes: atrial fibrillation (a condition very prevalent in any elderly population), cardiovascular disease (CVD), also highly prevalent especially for Māori (which could range in severity f...
The recently published article by Chan et al. questions the value of AAA screening. [1] We question the validity of the arguments and the data they use to support it, which we believe are either irrelevant or support the case for screening. Furthermore, the Chan et al. paper completely neglects the important equity gains that AAA screening can produce in the New Zealand (NZ) population.
Chan and his co-authors’ critique of AAA screening is based on 3 arguments: (i) patients with AAA are too sick with other comorbidities to benefit from screening and die of these other illnesses; (ii) most patients with AAA would be diagnosed by the health system anyway without a screening programme; and (iii) the size of the population that can benefit from screening is too small for it to be cost effective. Let us look more closely at each of these.
Co-morbidities in patients with AAA
The authors emphasise the point that co-morbidities in AAA patients might limit the benefit they attain from screening. They calculate that 77% of those dying of AAA had some other comorbidity. However, to imply that these were fulminant conditions and that preventing AAA death in this group would have been futile because they are moribund is highly misleading. The collection of co-morbidities includes: atrial fibrillation (a condition very prevalent in any elderly population), cardiovascular disease (CVD), also highly prevalent especially for Māori (which could range in severity from stable angina or transient ischaemic attacks to severe stroke), diabetes (which in fact has a negative association with AAA [2]), bronchiectasis (which is acquired in childhood by many in NZ) and previous hip fracture (also a common event in the elderly and one which would not normally on its own be considered a contraindication to life-saving intervention).
Even for the 25.6% with “evidence of malignant cancer” the majority (24.5% of the 25.6%) were non-metastatic cancers and the group excludes two of the most lethal tumour sites (lung, upper gastrointestinal). The malignant cancer group would have included (among others): successfully treated malignant melanoma; chronic haematological malignancies that can remain in remission for many years; and non-metastatic prostate cancer, which is rarely lethal. Note that the five-year net survival in England at ages 55-74 for Stage 1-3 cancers of the anus, colon and rectum, urinary tract including kidney and bladder, liver, and thyroid, plus Hodgkin lymphoma, myeloma, and malignant melanoma (weighted by incidence) is 78%. [3]
Although the authors do not provide a general population comparison of the prevalence of the conditions listed in Table 2, they use the M3 co-morbidity index to argue that the AAA deaths had higher co-morbidities than the general population. The authors fail to countenance the possibility that this could be attributable to reverse causality: in a country without population screening, those with high co-morbidities are far more likely to have their AAA diagnosed than those with AAA and low co-morbidities. It would clearly be difficult for AAA not to be diagnosed in someone with stage 3 renal disease whose abdomen will almost certainly have been imaged by CT or ultrasound as part of the diagnostic work-up. And why compare morbidities in patients who have died from AAA rather than with patients who have been diagnosed with AAA but not died from it? Clearly patients who are dead are likely to have much higher rates of co-morbidity than age-matched peers who are still alive, no matter what the patient died of. Why not compare the co-morbidity index in patients diagnosed with colorectal cancer as a similar screening programme?
Other arguments in relation to co-morbidities in fact support the case for screening. Stating that “out of a group of people with AAA… there were eight times more deaths from other cardiovascular causes than AAA rupture” only serves to underline the high efficacy of modern treatment of AAA disease. They go on to say, “For people with known AAA, the absolute risk of AAA rupture resulting in death is actually low”. That is exactly why screening is effective in preventing those deaths.
The issue of co-morbidities becomes even less relevant if good systems exist to exclude patients with limited life expectancy or poor quality of life from participating in screening. We have piloted a screening programme based in primary care in Auckland, NZ that has ample scope to do just that. [4]
Capacity of the health system to diagnose AAA without a screening programme
A crucial element to Chan et al.’s case against AAA screening is that 31.3% of patients had been diagnosed prior to the acute event resulting in death. This implies that the vast majority – 68.7% – had not been diagnosed before their death and highlights how poor the existing health system is at identifying this treatable disease. Without doubt, a high proportion of deaths in the large undiagnosed majority (of this group) could have been prevented by diagnosis in a screening programme, not to mention all of those who died of AAA without the death being recorded as AAA (see below). And even so, this figure was calculated only in those patients with AAA as their primary cause of death, which is biased to those who had a known history of AAA.
In a country with no population screening many, perhaps even the majority of, AAA deaths will never be recorded as such because the underlying cause of death documented in sudden fatalities frequently relies on a person’s medical history. Sudden deaths in older people, particularly those with a history of CVD, are most often classified as ischaemic heart disease or stroke, and the autopsy rate in NZ, like many other Western countries, is now very low (approximately 13% of all deaths in 2010, but likely to be much lower in older age groups). [5] So just as those with AAA cited as the cause of death are more likely to have previously been diagnosed with AAA and more likely to have had prior aortic surgery, there is likely to be a significant degree of under-reporting of AAA deaths in people without a prior diagnosis of AAA in NZ, since death is more likely to be attributed to AAA in those who have a pre-existing diagnosis of AAA.
Even this low proportion of 31% with a prior AAA diagnosis exaggerates the extent that this might undermine the case for screening. Chan et al. fail to disaggregate the proportion of these cases that would have been diagnosed prior to screening, in which case they would be excluded as ineligible. Our screening pilots have now produced more accurate data on the prevalence of undiagnosed AAA in the NZ population. In just one large rural practice in the north of Auckland we identified 34 previously undiagnosed AAA screening 480 men and women using a risk-based algorithm (set at a threshold of 2%). Three of these undiagnosed aneurysms were large and at significant risk of imminent rupture.
The authors are remarkably sanguine about the likelihood that AAA will be diagnosed (and followed up) as an incidental finding in abdominal CT and ultrasound imaging. It has been our experience that when AAA is not the reason for abdominal imaging, the size of the abdominal aorta is often not examined and/or reported. Others are reported but not followed up by referral to either the patient’s general practitioner or the vascular service. Khashram et al’s NZ study of aneurysms detected through CT colonography noted that 65 of 223 (29.1%) were not reported and only 84 (37.6%) were in surveillance. [6] Similarly, Claridge et al, performed a retrospective audit of all abdominal CT scans in those over 50 years of age in the Otago Southland region of NZ in 2013-14. [7] Of the 187 AAA were identified, 35% were not documented on the original radiology report, including 48% of small (30-39mm) aneurysms. Having a prior diagnosis is manifestly no guarantee of adequate surveillance and treatment. Conversely, formal screening programmes provide the structure and quality control systems to ensure that diagnosed patients receive appropriate follow-up.
The lack of structured surveillance of patients diagnosed with AAA as an incidental finding may help to explain the fact that, according to Chan et al., 89.1% of those who died from AAA had not undergone surgical repair Given this high proportion it is surprising that the authors chose to focus on the small proportion who died with a previously repaired AAA, rather than the huge proportion who, for whatever reason, did not benefit from this highly effective procedure.
Size of benefit and cost-effectiveness
The third theme of Chan et al.’s paper is that AAA does not have a large population health benefit. They claim that “One of the primary objectives for screening for AAA is to reduce all-cause mortality at a population level”. In fact, the aim of screening for AAA is to produce a net benefit in those who are screened (at an acceptable cost), and in NZ at least, to reduce health inequities. AAA is a deadly but relatively uncommon disease that has high prevalence among groups with extensive exposure to tobacco smoke – as is the case for the indigenous Māori population in NZ, as we have ascertained in our recent AAA prevalence research. While there is legitimate debate about whether screening programmes should be required to demonstrate an impact on all-cause mortality [8], there is no doubt that existing programmes, which the authors have not gone on record to criticise, fail to meet their requirement in this regard. For example, evidence is lacking for an all-cause mortality benefit in screening colorectal cancer, a disease with a far higher incidence and mortality than AAA, and one where population screening programmes now exist in many countries, including NZ. The Cochrane Collaboration report on colorectal cancer screening found that “combining the four trials did not show any significant difference between the screening and control groups”. [9] Similarly breast screening may not even reduce breast cancer mortality. [10]
Contrast this with the finding from the most recently published meta-analysis of AAA screening “Invitation to AAA screening in ≥64-year-old men significantly reduced both all-cause and AAA-related mortalities.” [11] In fact, Chan et al. argue that instead of screening for AAA we should be “designing interventions to more directly improve systematic CVD risk management in primary care”. Their inconsistency is ironic given a recently published overview of system reviews of using cardiovascular risk scoring in routine risk assessment in primary prevention of CVD which noted that “none of the included [systematic reviews] reported changes in all-cause mortality” and it concluded that there is “a possible lack of effectiveness of [total risk assessment] in reducing CVD events and mortality, as well as a clinically insignificant influence on individual risk factor levels.” [12]
Space does not permit us to respond point by point to each of the authors’ comments on the cost-effectiveness of AAA screening. We note that of the numerous published studies of AAA screening cost-effectiveness, most of which have reported favourable ratios, a recent one examined it from a NZ perspective and concluded that “a UK-style AAA screening programme would be cost-effective in New Zealand.” [13] Crucially, their cost-effectiveness analysis did not assume that all participants with screen-detected AAA would receive what Chan et al call “the full benefit”; it accounted for not only co-morbidity and opportunistic detection, but also treatment failure, lower life expectancy in AAA cases, non-attendance at screening, complication costs and even unrelated healthcare costs. Rather than simply speculating about the negative impact that certain factors may have had, whilst ignoring the positive effect that others might have had (e.g. the life expectancy gain of almost 3 years in 65-year old men between 1999 and 2017 when the MASS trial ended recruitment), [14] it would have been more useful if Chan et al. had published their own cost-effectiveness estimates.
Other methodological flaws and inaccuracies
Chan et al. incorrectly suggest that there was evidence of rapidly falling prevalence of AAA prior to commencement of screening in the UK. There was evidence of falling rates of mortality and hospital admission, but not of prevalence. The authors have excluded the proportion of patients with an acute AAA presentation that died within 2 days of the admission which further reduces the number of AAA-related deaths in this analysis.
Equity impact?
There is not a single mention of equity in the paper by Chan et al. and none of the published cost-effectiveness studies of AAA screening assign any value to the reductions in health inequities that AAA screening might produce. AAA, like lung cancer, places a disproportionate burden on specific ethnic groups and is also patterned by deprivation and gender. While AAA prevalence rates in 65 year old men in the UK range from 1.0-1.3%, in NZ Māori men it was 3.6% in our own study. [4] The Chan et al paper completely ignores the impact that differential access to primary care, diagnostics and surgery [15-17] contributes to the well-documented inequity in AAA outcomes for Maori compared to non-Māori. [18]
NZ has yet to take the steps required for elimination of unfair, avoidable and remedial health inequalities between its Indigenous and non-Indigenous populations. Such poorly thought through studies illustrate how deeply entrenched and unexamined bias against Māori creates and continues to maintain health inequities in New Zealand.
References
1. Chan WC, Papaconstantinou D, Winnard D, et al. Retrospective review of abdominal aortic aneurysm deaths in New Zealand: what proportion of deaths is potentially preventable by a screening programme in the contemporary setting? BMJ Open 2019; 9: e027291. DOI: 10.1136/bmjopen-2018-027291.
2. Raffort J, Lareyre F, Clément M, et al. Diabetes and aortic aneurysm: current state of the art. Cardiovasc Res 2018; 114: 1702-1713. DOI: 10.1093/cvr/cvy174.
4. Sandiford P, Grey C, Salvetto M, et al. The population prevalence of abdominal aortic aneurysm in New Zealand Māori. J Vasc Surg 2019; In press.
5. New Zealand Law Commission. Final words: death and cremation certification in New Zealand. (Issues paper 23). 2011. Wellington: New Zealand Law Commission.
6. Khashram M, Jones GT and Roake JA. Prevalence of abdominal aortic aneurysm (AAA) in a population undergoing computed tomography colonography in Canterbury, New Zealand. Eur J Vasc Endovasc Surg 2015; 50: 199-205. 2015/06/15. DOI: 10.1016/j.ejvs.2015.04.023.
7. Claridge R, Arnold S, Morrison N, et al. Measuring abdominal aortic diameters in routine abdominal computed tomography scans and implications for abdominal aortic aneurysm screening. J Vasc Surg 2017; 65: 1637-1642. 2017/02/22. DOI: 10.1016/j.jvs.2016.11.044.
8. Editorial. Screening Matters. 2007, p. 1-2.
9. Hewitson P, Glasziou P, Irwig L, et al. Screening for colorectal cancer using the faecal occult blood test, Hemoccult. The Cochrane database of systematic reviews 2007: Cd001216. 2007/01/27. DOI: 10.1002/14651858.CD001216.pub2.
10. Møller MH, Lousdal ML, Kristiansen IS, et al. Effect of organized mammography screening on breast cancer mortality: A population-based cohort study in Norway. Int J Cancer 2019; 144: 697-706. DOI: 10.1002/ijc.31832.
11. Takagi H, Ando T and Umemoto T. Abdominal Aortic Aneurysm Screening Reduces All-Cause Mortality: Make Screening Great Again. Angiology 2018; 69: 205-211. 2017/02/15. DOI: 10.1177/0003319717693107.
12. Studziński K, Tomasik T, Krzysztoń J, et al. Effect of using cardiovascular risk scoring in routine risk assessment in primary prevention of cardiovascular disease: an overview of systematic reviews. BMC Cardiovascular Disorders 2019; 19: 11. DOI: 10.1186/s12872-018-0990-2.
13. Nair N, Kvizhinadze G, Jones GT, et al. Health gains, costs and cost-effectiveness of a population-based screening programme for abdominal aortic aneurysms. BJS 2019; 106: 1043-1054. DOI: 10.1002/bjs.11169.
15. Crengle S, Lay-Yee R, Davis P, et al. A Comparison of Māori and Non-Māori Patient Visits to Doctors: The National Primary Medical Care Survey (NatMedCa): 2001/02. Report 6. . Wellington: Ministry of Health, 2005.
16. Rahiri J-L, Alexander Z, Harwood M, et al. Systematic review of disparities in surgical care for Māori in New Zealand. ANZ journal of surgery 2018; 88: 683-689. DOI: 10.1111/ans.14310.
17. Jansen P, Bacal K and Buetow S. A comparison of Māori and non-Māori experiences of general practice. NZ Med J 2011; 124: 24-30.
18. Sandiford P, Mosquera D and Bramley D. Ethnic inequalities in incidence, survival and mortality from abdominal aortic aneurysm in New Zealand. J Epidemiol Community Health 2012; 66: 1097-1103. 2012/07/07. DOI: 10.1136/jech-2011-200754.
One aspect of gout which is too often overlooked in guidelines and in practice is that most gout flares are initiated during sleep. The sleep connection has been known at least since Dr. Thomas Sydenham, himself a gout sufferer, wrote about it in 1683. A recent study [1] confirms Dr. Sydenham's observation. It is a very important clue to the pathogenesis of gout whether symptomatic or not.
Many gout flares are a direct result of sleep apnea, and overcoming the sleep apnea can cure the gout. Four epidemiologic studies have been reported that show gout to be significantly more prevalent in people diagnosed with sleep apnea than it is in people never diagnosed with sleep apnea [2,3,4,5]. Here are the physiological reasons for those results. The chronic intermittent hypoxemia of sleep apnea has three effects which can lead to an overnight gout flare in short order. Effect #1 is intermittent cellular catabolism in which adenosine triphosphate degradation is accelerated, leading to nucleotide turnover which culminates irreversibly in the intermittent cellular generation of excess uric acid fed into the blood [6,7], faster than any food would cause. Effect #2 is concurrent intermittent hypercapnia and acidosis [8], so the blood can hold less uric acid in solution. Effect #3 is a long term deterioration of the kidneys' glomerular filtration rate [9] so that removal of uric acid from the blood is slowed. Thus, with sleep apnea there are repeated abrupt increases i...
One aspect of gout which is too often overlooked in guidelines and in practice is that most gout flares are initiated during sleep. The sleep connection has been known at least since Dr. Thomas Sydenham, himself a gout sufferer, wrote about it in 1683. A recent study [1] confirms Dr. Sydenham's observation. It is a very important clue to the pathogenesis of gout whether symptomatic or not.
Many gout flares are a direct result of sleep apnea, and overcoming the sleep apnea can cure the gout. Four epidemiologic studies have been reported that show gout to be significantly more prevalent in people diagnosed with sleep apnea than it is in people never diagnosed with sleep apnea [2,3,4,5]. Here are the physiological reasons for those results. The chronic intermittent hypoxemia of sleep apnea has three effects which can lead to an overnight gout flare in short order. Effect #1 is intermittent cellular catabolism in which adenosine triphosphate degradation is accelerated, leading to nucleotide turnover which culminates irreversibly in the intermittent cellular generation of excess uric acid fed into the blood [6,7], faster than any food would cause. Effect #2 is concurrent intermittent hypercapnia and acidosis [8], so the blood can hold less uric acid in solution. Effect #3 is a long term deterioration of the kidneys' glomerular filtration rate [9] so that removal of uric acid from the blood is slowed. Thus, with sleep apnea there are repeated abrupt increases in the influx of uric acid in the blood along with abruptly reduced storage capacity, plus slowed efflux -- perfect storm conditions for monosodium urate precipitation. Furthermore, after awakening and normal breathing is restored, the first two effects dissipate so that a blood test taken during waking hours misses their peaks. And if monosodium urate has precipitated recently, then the measurement of serum uric acid is greatly undervalued.
A clinical study conducted by rheumatologists reported that in a cohort of 54 gout patients, 89% of them were diagnosed by polysomnography with sleep apnea [10]. Gout has been reported to have so many of the same comorbidities already known to be consequences of long-term untreated sleep apnea (eg., cardiovascular diseases, diabetes, kidney disease, hypertension) [11,12]. A recent study has found that increasing the dosage of allopurinol had no benefit for reducing the risk of major cardiovascular events or all-cause mortality in gout patients [13], and another study found that febuxostat increased the risk [14]. One of the first steps for treating gout should be diagnostic testing for sleep apnea, followed by treatment of the sleep apnea where indicated. I know from my own experience and the experiences of others that overcoming sleep apnea can prevent additional inflammatory gout flares immediately and completely. Effects #1 and #2 don't occur, and Effect #3 may reverse within three months of effective treatment for sleep apnea [15,16]. More importantly, gout is usually an early warning of sleep apnea, which when heeded can lead to the prompt treatment of sleep apnea, thereby greatly reducing the risk for later development of sleep apnea’s life-threatening consequences [17]. Overcoming the sleep apnea can save lives as well as save joints.
References
1. Choi HK, Niu J, Neogi T, et al. Nocturnal risk of gout attacks. Arthritis Rheumatol. 2015 Feb; 67(2):555-62.
2. Roddy E, Muller S, Hayward R, Mallen CD. The association of gout with sleep disorders: a cross-sectional study in primary care. BMC Musculoskelet Disord. 2013 Apr; 14:119.
3. Zhang Y, Peloquin CE, Dubreuil M, et al. Sleep apnea and the risk of incident gout: a population-based, body mass index-matched cohort study. Arthritis Rheumatol. 2015 Dec; 67(12):3298-302.
4. Singh JA, Cleveland JD. Gout and the risk of incident obstructive sleep apnea in adults 65 years or older: an observational study. J Clin Sleep Med. 2018 Sep. 14(9):1521-1527.
5. Blagojevic-Bucknall M, Mallen C, Muller S, et al. The risk of gout among patients with sleep apnea: a matched cohort study. Arthritis Rheumatol. 2019 Jan. 71(1):154-160.
6. Hasday JD, Grum CM. Nocturnal increase of urinary uric acid:creatinine ratio. A biochemical correlate of sleep-associated hypoxemia. Am Rev Respir Dis. 1987 Mar; 135(3):534-8.
7. Grum CM. Cells in crisis. Cellular bioenergetics and inadequate oxygenation in the intensive care unit. Chest. 1992 Aug; 102(2):329-30.
8. Firestein GS, Budd RC, Gabriel SE, et al. Kelley’s Textbook of Rheumatology 9th edition. Elsevier Saunders, Piladelphia, 2013.
9. Ahmed SB, Ronksley PE, Hemmelgarn BR, et al. Nocturnal hypoxia and loss of kidney function. PLoS One. 2011 Apr; 6(4):e19029.
10. Cantalejo Moreira M, Veiga Cabello RM, Garcia Diaz V, et al. Gout, hyperuricaemia, sleep apnoea-hypopnoea syndrome and vascular risk. Rheumatology (Oxford) 2013; 52:1619-22.
11. Huang CF, Liu JC, Huang HC, et al. Longitudinal transition trajectory of gouty arthritis and its comorbidities: a population-based study. Rheumatol Int. 2017 Feb; 37(2):313-22.
12. Chiang CL, Chen YT, Wang KL, et al. Comorbidities and risk of mortality in patients with sleep apnea. Ann Med. 2017 Aug; 49(5): 377-83.
13. Coburn BW, Michaud K, Bergman DA, Mikuls TR. Allopurinol dose escalation and mortality among patients with gout:a national propensity-matched cohort study. Arthritis Rheumatol. 2018 Aug; 70(8): 1298-1307.
14. White WB, Saag KG, Becker MA, et al. Cardiovascular safety of febuxostat or allopurinol in patients with gout. N Engl J Med. 2018 Mar; 378(13):1200-1210.
15. Kinebuchi S, Kazama JJ, Satoh M, et al. Short-term use of continuous positive airway pressure ameliorates glomerular hyperfiltration in patients with obstructive sleep apneoa syndrome. Clin Sci (Lond). 2002 Sep; 107(3):317-22.
16. Koga S, Ikeda S, Yasunaga T, et al. Effects of nasal continuous positive airway pressure on the glomerular filtration rate in patients with obstructive sleep apnea syndrome. Intern Med. 2013 Mar; 52(3):345-9.
17. Huang QR, Qin Z, Zhang S, Chow CM. Clinical patterns of obstructive sleep apnea and its comorbid conditions: a data mining approach. J Clin Sleep Med. 2008 Dec; 4(6):543-550.
T2DM can be divided into Five Stages (1-2). The altered metabolism of uric acid, often associated with DM, may be diagnosed from birth, starting with its Uricemic Constitution-dependent, Inherited Real Risk (3, 4). As all other inherited real risks, such a predisposition to hyperuricemia and gout is removed by Reconstructing Mitochondrial Quantum Therapy (5).
References.
1) Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica. Il Terreno Oncologico. Travel Factory, Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm
2) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico-Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Travel Factory, Roma, 2004. http://www.travelfactory.it/libro_costituzionisemeiotiche.htm
3) Stagnaro S., West PJ., Hu FB., Manson JE., Willett WC. Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. [Medline]
4) Stagnaro Sergio. Epidemiological evidence for the non-random clustering of the components of the metabolic syndrome: multicentre study of the Mediterranean Group for the Study of Diabetes. Eur J Clin Nutr. 2007 Feb 7; [Epub ahead of print] [Medline]
5) Caramel S., Marchionni M., Stagnaro S. Morinda citrifolia Plays a Central Role in the Pr...
T2DM can be divided into Five Stages (1-2). The altered metabolism of uric acid, often associated with DM, may be diagnosed from birth, starting with its Uricemic Constitution-dependent, Inherited Real Risk (3, 4). As all other inherited real risks, such a predisposition to hyperuricemia and gout is removed by Reconstructing Mitochondrial Quantum Therapy (5).
References.
1) Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica. Il Terreno Oncologico. Travel Factory, Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm
2) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico-Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Travel Factory, Roma, 2004. http://www.travelfactory.it/libro_costituzionisemeiotiche.htm
3) Stagnaro S., West PJ., Hu FB., Manson JE., Willett WC. Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. [Medline]
4) Stagnaro Sergio. Epidemiological evidence for the non-random clustering of the components of the metabolic syndrome: multicentre study of the Mediterranean Group for the Study of Diabetes. Eur J Clin Nutr. 2007 Feb 7; [Epub ahead of print] [Medline]
5) Caramel S., Marchionni M., Stagnaro S. Morinda citrifolia Plays a Central Role in the Primary Prevention of Mitochondrial-dependent Degenerative Disorders. Asian Pac J Cancer Prev. 2015;16(4):1675. http://www.ncbi.nlm.nih.gov/pubmed/25743850 [Medline]
Thank you for the reactions to our article. We absolutely agree with the comments made.
This study was never meant to give the idea that standardized patients (SP) wearing an obesity simulation suit (OSS) could replace the contact with real patients suffering from obesity.
Simulation is a gold-standard method in medical education to prepare students for clinical work (1). It offers the opportunity to practice in a safe and standardized environment with structured feedback. Our students are used to encounter SP with various conditions as a teaching tool. It is important to acknowledge the purpose of this session: It is meant to be a basic step and is not about “true life experience” involving real patients. For example, medical faculties all over the world train their students on how to break bad news with SP (2). Here, it is also well accepted that this offers a good training opportunity despite the SP not having a serious condition themselves.
Our first intention was to make a simulated scenario more realistic to support the concept of “suspended disbelief” (3). The other opportunity it offered was to sensitize towards the issue of patients with obesity and start a first reflection process on otherwise unnoticed prejudices. Many students appreciated the fact that due to the “before/after effect” (SP with OSS in simulation vs. SP of normal weight giving feedback) made them reflect even more on differences a...
Thank you for the reactions to our article. We absolutely agree with the comments made.
This study was never meant to give the idea that standardized patients (SP) wearing an obesity simulation suit (OSS) could replace the contact with real patients suffering from obesity.
Simulation is a gold-standard method in medical education to prepare students for clinical work (1). It offers the opportunity to practice in a safe and standardized environment with structured feedback. Our students are used to encounter SP with various conditions as a teaching tool. It is important to acknowledge the purpose of this session: It is meant to be a basic step and is not about “true life experience” involving real patients. For example, medical faculties all over the world train their students on how to break bad news with SP (2). Here, it is also well accepted that this offers a good training opportunity despite the SP not having a serious condition themselves.
Our first intention was to make a simulated scenario more realistic to support the concept of “suspended disbelief” (3). The other opportunity it offered was to sensitize towards the issue of patients with obesity and start a first reflection process on otherwise unnoticed prejudices. Many students appreciated the fact that due to the “before/after effect” (SP with OSS in simulation vs. SP of normal weight giving feedback) made them reflect even more on differences and possible problems. This class is supposed to be a first step in training medical students on the issues of patients with obesity. Later on in our curriculum, they are of course in contact with patients with obesity and do get proper “first hand experience” as well as more theoretical background.
1. Barry Issenberg S, Mcgaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. 2005;27(1):10-28.
2. Rosenbaum ME, Ferguson KJ, Lobas JGJAM. Teaching medical students and residents skills for delivering bad news: a review of strategies. 2004;79(2):107-17.
3. Dieckmann P, Gaba D, Rall MJSiH. Deepening the theoretical foundations of patient simulation as social practice. 2007;2(3):183-93.
Herrmann-Werner et al (2019) brought to our attention an increasingly relevant topic. The study proposed that the obesity simulation suit (OSS) could be used to address the issue of stigmatisation of obesity(1). We are medical students at Imperial College London. As part of our course, we have regularly attended clinical communication sessions in the form of simulated role play.
We believe that whilst using a simulated patient in an OSS may be useful, it is a superficial way of addressing the deep-rooted societal problem of how obesity is viewed and may even reinforce the stigma. The use of simulated patients should be adapted to reduce prejudice towards obese patients, especially with reference to their physical and psychological comorbidities.
The study argues that using healthy weight actors in the OSS was of benefit because using obese actors ‘entails the potential danger of issues becoming too personal for the patient’(1). However, we believe that using actors with a healthy BMI may reinforce to students that obese patients are embarrassed or ashamed to have a conversation about their weight. At Imperial College, we simulate consultations with real patients to better understand their conditions. Rees et al also prefer the use of real patients, arguing that it provides medical students with a more realistic experience(2). Therefore, we recommend that students talk to obese patients who are willing to partake and understand the sensitiv...
Herrmann-Werner et al (2019) brought to our attention an increasingly relevant topic. The study proposed that the obesity simulation suit (OSS) could be used to address the issue of stigmatisation of obesity(1). We are medical students at Imperial College London. As part of our course, we have regularly attended clinical communication sessions in the form of simulated role play.
We believe that whilst using a simulated patient in an OSS may be useful, it is a superficial way of addressing the deep-rooted societal problem of how obesity is viewed and may even reinforce the stigma. The use of simulated patients should be adapted to reduce prejudice towards obese patients, especially with reference to their physical and psychological comorbidities.
The study argues that using healthy weight actors in the OSS was of benefit because using obese actors ‘entails the potential danger of issues becoming too personal for the patient’(1). However, we believe that using actors with a healthy BMI may reinforce to students that obese patients are embarrassed or ashamed to have a conversation about their weight. At Imperial College, we simulate consultations with real patients to better understand their conditions. Rees et al also prefer the use of real patients, arguing that it provides medical students with a more realistic experience(2). Therefore, we recommend that students talk to obese patients who are willing to partake and understand the sensitive nature of the session.
Furthermore, actors with a healthy BMI may not have experienced the same physical and psychosocial problems endured by many obese people. This limits the usefulness of the session, especially the ways in which obese people feel stigmatised. Speaking to real patients during our time at Imperial College has furthered our understanding of the physical and psychosocial impact of disease. In addition, teaching sessions exploring how body image is portrayed in social media, the fashion industry and other areas of society may help medical students recognise and understand their own attitudes towards obese patients.
Allowing students to talk to obese patients with related health conditions would be more beneficial than using actors with an OSS. Furthermore, the physical and psychosocial aspects of disease should be explored alongside formal teaching about disease pathology, to help reduce the stigma surrounding obesity.
1 Herrmann-Werner A, Loda T, Wiesner LM, Erschens RS, Junne F, Zipfel S. Is an obesity simulation suit in an undergraduate medical communication class a valuable teaching tool? A cross-sectional proof of concept study. BMJ open. 2019 Jul 1;9(8):e029738.
2 Rees C, Sheard C, McPherson A. Medical students’ views and experiences of methods of teaching and learning communication skills. Patient Education and Counseling. 2004 July;54(1): 119-121
Kapoor et al. highlight one aspect of gender discrimination, gender injustice and gender prejudice in Indian society using data acquired from their hospital information system at AIIMS New Delhi.1 Under a title of introduction the authors write, ”There have been a handful of small sample studies on gender bias in access to healthcare in select patient groups or for specific medical conditions….” Then under a title of Discussion, they cite several studies, some conducted at their Institute in the department of Cardiology, some in Pediatrics and some conducted abroad. Here we want to state that we too conducted a manual small study in Emergency Department of our hospital. We assessed demographic profile of alleged self -harm patients presenting to our referral tertiary care public hospital. In our study -among other variables- when we estimated sex ratio among male and female patients, it was 62:38(2). And that’s eerily close to 63:37 in this study. So there is a difference of just 1 percentage point. When 38 women per hundred patients present in our hospital in Lucknow with a history of alleged self- harm , 37 present to AIIMS New Delhi on an average in OPDs.
Similarly at reference number 8, there is a study to estimate gender- bias in (availing) cardiovascular healthcare at a tertiary care center of north India. In the study Chhabra et al. assess that the ratio of girls to boys to avail cardiac interventions for their congenital and rheumatic heart disease is 38:62...
Kapoor et al. highlight one aspect of gender discrimination, gender injustice and gender prejudice in Indian society using data acquired from their hospital information system at AIIMS New Delhi.1 Under a title of introduction the authors write, ”There have been a handful of small sample studies on gender bias in access to healthcare in select patient groups or for specific medical conditions….” Then under a title of Discussion, they cite several studies, some conducted at their Institute in the department of Cardiology, some in Pediatrics and some conducted abroad. Here we want to state that we too conducted a manual small study in Emergency Department of our hospital. We assessed demographic profile of alleged self -harm patients presenting to our referral tertiary care public hospital. In our study -among other variables- when we estimated sex ratio among male and female patients, it was 62:38(2). And that’s eerily close to 63:37 in this study. So there is a difference of just 1 percentage point. When 38 women per hundred patients present in our hospital in Lucknow with a history of alleged self- harm , 37 present to AIIMS New Delhi on an average in OPDs.
Similarly at reference number 8, there is a study to estimate gender- bias in (availing) cardiovascular healthcare at a tertiary care center of north India. In the study Chhabra et al. assess that the ratio of girls to boys to avail cardiac interventions for their congenital and rheumatic heart disease is 38:62 (same as in ours). So findings of the authors reveal an all pervasive ingrained truth of our patriarchal society- marginalising women, uncaring for even when they struggle for their survival while fighting to maintain their bodily integrity, and losing their battle many a times.
Early this year Government of India issued a Report on the Ranks of States and Union Territories, entitled “Healthy States Progressive India”(3). On page number 44 of this report, there is an indicator 1.1.5 - Sex Ratio at Birth (SRB). Y Axis of this diagram measures number of girls born per thousand boys born. On having a glance on this diagram it’s apparent that UP, Bihar and Haryana treat girl children badly (in fact Haryana fairs the worst). Therefore what is “normal’ in this study, including normal baseline ratio; is actually picked up from discriminatory population. What is normalised in our society is injustice meted out,
oppressing the body and minds of potential female workforce.
As in Discussion the authors write, “This discrimination of(against) women is not fully captured in the overall sex ratio or excess mortality of women relative to men, we want to draw attention towards reference number 1 of the Research Article. There Amartya Sen writes ,” But after conception, biology seems on the whole to favour women. Considerable research has shown that if men and women receive similar nutritional and medical attention and general health care, women tend to live noticeably longer than men. Women seem to be, on the whole, more resistant to disease and in general hardier than men, an advantage they enjoy not only after they are forty years old but also at the beginning of life, especially during the months immediately following birth, and even in the womb. When given the same care as males, females tend to have better survival rates than males.” So as women are less likely to fall ill due to their better biological design, our hospital based indicators of disease -monitoring of incoming patient population are likely to have their own limitations.
And in 1992, Prof. Amartya Sen wrote in the same journal, “Considerable direct evidence exists of neglect of female children in terms of health care ,admission to hospitals, and even feeding.” Under a title ,”Missing Women”(4). Therefore both the author and our team demonstrate a very small aspect of gender -discrimination ,and that’s reflected in admission to (and attendance at) hospitals. As usually research questions explore a very limited prespecified objective, other facets of differential treatment should be taken into account, which are likely to have a bearing on women’s health.
18 Years ago Prof. Amartya Sen wrote an essay- The Gendered Body. In the essay he writes in part 3, “Indeed there is some direct information about comparative medical neglect of girls vis -a vis boys in South Asia. When I studied, with Jocelyn Kynch, admissions data from two large public hospitals in Bombay (Mumbai), it was very striking to find clear evidence that the admitted girls were typically more ill than boys, suggesting the inference that a girl has to be more stricken before she is taken to the hospital. Undernourishment may well result from greater morbidity, which can adversely affect both the absorption of nutrients and the performance of bodily functions.”(5) This area needs further exploration in our times.
Moreover while visualising the world, sometimes our lens of scrutiny should move inwards too. While we discuss and debate gender- bias in the population at large, it’s time to have a fair opinion for ourselves too: the academia. While it’s a routine experience that female patients are short -changed, same is also true for healthcare providers. Female workforce in the position of authority makes only a minor proportion in several regions(6-8). Government of India recognises the fact and plans to make suitable amendments in rules(9). In this paper our government states,”Sex ratio is also a major area of concern for our country.” And on course correction ,”India is expected to gain from its ‘demographic dividend’ in the coming years and women are an integral part of this development process if India wants to tap its full potential. It is only through empowering the women in all forms that women will transcend beyond the constraints they presently face. It is essential to focus on these aspects if India wants to achieve its vision of ‘A society in which women attain their full potential and are able to participate as equal partners in all spheres of life and influence the process of social change (Draft National Policy for Women 2016)”.
What is intriguing is that out of 6 authors of this research article, only one is female although it looks specifically into female subjugation and mistreatment to women. We believe that in near future when more women are around, hitherto unexplored areas will be investigated to give us a new vision. With the beginning of harmonious representation of all the sections of our society in our investigative team, new avenues of research will be created and together we will make a world where injustice of any sort will be rapidly identified and timely course correction be made. And to begin with, in that utopian world, women will not die soon!
References-
(1) Kapoor M, Agrawal D, Ravi S, et al. Missing female patients: an observational analysis of sex ratio among outpatients in a referral tertiary care public hospital in India. BMJ Open 2019;9:e026850. doi: 10.1136/bmjopen-2018-026850
(2) Agrawal M, Tiwary NK, Nigam N, et al. Assessment of demographic profile of patients admitted with a diagnosis of alleged self-harm at a teaching hospital in Hindi heartland. J. Evid. Based Med. Healthc. 2019; 6 (17), 1288-1291. DOI: 10.18410/jebmh/2019/267 ,available at https://jebmh.com/latest_articles/98391
(6) The Editors of the Lancet group. The Lancet group’s commitments to gender equity and diversity. Lancet 2019 Aug 10; 394: 452-453 ,doi https://doi.org/10.1016/S0140-6736(19)31797-0
We read with interest the paper by Van de Velde et al delineating the concept of self-management in chronic conditions.1 We agree that there is a lack of consensus on the meaning of self-management, ambiguity regarding the concept, and an urgent need for uniformity with regard to terminology. One major area of ambiguity is the relationship between self-management and self-care. These terms are often thought of as synonyms, used interchangeably, or considered as integrated concepts (e.g. self-care as an overarching or umbrella term, with self-management as onecomponent of self-care).2 This is why, until 2018, major search engines combined the terms. When one searched for “self-management”, literature on “self-care” was provided as well. Since Van de Velde and co-workers aimed to delineate the concept of self-management and develop a definition for its use in healthcare, we expected a more thorough review of related concepts in their concept analysis. Thus, we were surprised to find that several important publications on self-care were excluded.
We believe that the concept analysis by van de Velde et al would have been stronger if they also had included publications related to self-care. In 2012, after many years studying self-care in heart failure, we developed the Middle-Range Theory of Self-Care of Chronic Illness,3 which was updated this year.4 In this theory we defined self-care as the process of “maintaining health through health promoting practices and managi...
We read with interest the paper by Van de Velde et al delineating the concept of self-management in chronic conditions.1 We agree that there is a lack of consensus on the meaning of self-management, ambiguity regarding the concept, and an urgent need for uniformity with regard to terminology. One major area of ambiguity is the relationship between self-management and self-care. These terms are often thought of as synonyms, used interchangeably, or considered as integrated concepts (e.g. self-care as an overarching or umbrella term, with self-management as onecomponent of self-care).2 This is why, until 2018, major search engines combined the terms. When one searched for “self-management”, literature on “self-care” was provided as well. Since Van de Velde and co-workers aimed to delineate the concept of self-management and develop a definition for its use in healthcare, we expected a more thorough review of related concepts in their concept analysis. Thus, we were surprised to find that several important publications on self-care were excluded.
We believe that the concept analysis by van de Velde et al would have been stronger if they also had included publications related to self-care. In 2012, after many years studying self-care in heart failure, we developed the Middle-Range Theory of Self-Care of Chronic Illness,3 which was updated this year.4 In this theory we defined self-care as the process of “maintaining health through health promoting practices and managing illnesses” (p. 195),3 a definition quite similar to the definition provided for self-management. Since publication, investigators around the globe have used our theory to study how individuals maintain their health, monitor and manage their illnesses. But even before the official publication of the Middle-Range Theory of Self-Care of Chronic Illness, there was a wealth of publications studying self-care that might have been included in the present concept analysis.
We agree with the authors that self-management, or self-care, is important for the sustainability of our healthcare systems into the future. Discussions aimed at reaching consensus on shared terminology can only benefit society and the development of the science. So, we thank you for your efforts to examine “self-management” and hope that you will do the same for “self-care”. Such an effort to compare and contrast the two common terms would be a major contribution to our shared goal of consensus.
1. Van de Velde D, De Zutter F, Satink T, et al. Delineating the concept of self-management in chronic conditions: a concept analysis. BMJ Open. 2019;9(7):e027775.
2. Godfrey CM, Harrison MB, Lysaght R, Lamb M, Graham ID, Oakley P. Care of self - care by other - care of other: the meaning of self-care from research, practice, policy and industry perspectives. Int J Evid Based Healthc. 2011;9(1):3-24.
3. Riegel B, Jaarsma T, Stromberg A. A middle-range theory of self-care of chronic illness. ANS Adv Nurs Sci. 2012;35(3):194-204.
4. Riegel B, Jaarsma T, Lee CS, Stromberg A. Integrating Symptoms Into the Middle-Range Theory of Self-Care of Chronic Illness. ANS Adv Nurs Sci. 2019;42(3):206-215.
Thank you for your recent BMJ Open article,1 which has correctly noted that it is critical for journal editors’ potential conflicts of interest to be publicly disclosed. A limitation of the study is that only the digital version of the journals were considered. Obstetrics & Gynecology has included a conflict of interest statement for the Editor-in-Chief and Deputy or Associate Editors on the masthead of the print journal since the July 2008 issue. The article by Dal-Ré has prompted us to review our digital presence, and the website has since been updated to reflect our long-standing presentation of the editors’ potential conflicts of interest. I thank the authors for highlighting the importance of disclosing potential conflicts of interest but express concern that their work is biased toward the digital presence only.
Reference
1. Dal-Ré R, Caplan AL, Marusic A. Editors’ and authors’ individual conflicts of interest disclosure and journal transparency. A cross-sectional study of high-impact medical specialty journals. BMJ Open 2019;9:e029796. doi: 10.1136/bmjopen-2019-029796.
Dear Editor-in-Chief,
We are writing to you in response to Mahar et al.’s (2019) recent publication in your journal (“Suicide in Canadian veterans living in Ontario: a retrospective cohort study linking routinely collected data”).
The authors found a lower risk of suicide in Canadian Armed Forces (CAF) Veterans (former members) using Ontario Health Insurance Plan coverage, in contrast to the findings of higher CAF Veteran suicide risk in the Canadian Forces Cancer and Mortality Study (CF CAMS) and the Veteran Suicide Mortality Study (VSMS), which use nation-wide Vital Statistics and cancer registry data collected by Statistics Canada. We strongly feel that there is synergistic value in having different studies by different investigator groups using different data sources, but it is essential to understand the limitations in these different approaches and their findings.
Mahar et al. state that their study was the “...first study of suicide risk in Canadian veterans...” However, CF CAMS, which looked at suicide risk in Canadian Veterans, was published eight years prior to the Mahar et al. study (Statistics Canada, 2011). This was followed by the Veteran Suicide Mortality Study (VSMS) Technical report was published in 2017 (Simkus et al., 2017), its accompanying peer-reviewed publication (VanTil et al., 2018), and the 2018 VSMS Technical report (Simkus et al., 2018).
We have questions about the authors’ choice of covariates for the adjusted an...
Show MoreWe thank Belinda WC Ommering et al. for their insightful and original research regarding how medical students motivation translates into research involvement. Whilst the article focusses on motivation of medical students wanting to be involved in research and the resultant degree of participation, we believe it is important to remark on the extrinsic barriers that medical students may face in obtaining research experience despite being highly motivated and the effect this can have on their motivation to participate in research. We are sharing our thoughts on this article from the point of view of two final year medical students involved in undergraduate research. Our response includes results from a short live survey carried out at a student research conference we held locally.
Previous studies indicate that students encounter personal and organisational barriers to research such as inadequate skill or training, limited access to information and unsupportive or unmotivated supervisors1 2. Students reported that a lack of proper training in understanding and writing papers, and difficulty finding an encouraging supervisor were two of the main barriers to conducting research as an undergraduate3. These students seemed to be motivated more by extrinsic factors, as 66.7% reported that the main reason they published their research was to improve their curriculum vitae3.
During the student research conference we held, students were provided with a live questionnair...
Show MoreThe recently published article by Chan et al. questions the value of AAA screening. [1] We question the validity of the arguments and the data they use to support it, which we believe are either irrelevant or support the case for screening. Furthermore, the Chan et al. paper completely neglects the important equity gains that AAA screening can produce in the New Zealand (NZ) population.
Chan and his co-authors’ critique of AAA screening is based on 3 arguments: (i) patients with AAA are too sick with other comorbidities to benefit from screening and die of these other illnesses; (ii) most patients with AAA would be diagnosed by the health system anyway without a screening programme; and (iii) the size of the population that can benefit from screening is too small for it to be cost effective. Let us look more closely at each of these.
Co-morbidities in patients with AAA
The authors emphasise the point that co-morbidities in AAA patients might limit the benefit they attain from screening. They calculate that 77% of those dying of AAA had some other comorbidity. However, to imply that these were fulminant conditions and that preventing AAA death in this group would have been futile because they are moribund is highly misleading. The collection of co-morbidities includes: atrial fibrillation (a condition very prevalent in any elderly population), cardiovascular disease (CVD), also highly prevalent especially for Māori (which could range in severity f...
Show MoreOne aspect of gout which is too often overlooked in guidelines and in practice is that most gout flares are initiated during sleep. The sleep connection has been known at least since Dr. Thomas Sydenham, himself a gout sufferer, wrote about it in 1683. A recent study [1] confirms Dr. Sydenham's observation. It is a very important clue to the pathogenesis of gout whether symptomatic or not.
Many gout flares are a direct result of sleep apnea, and overcoming the sleep apnea can cure the gout. Four epidemiologic studies have been reported that show gout to be significantly more prevalent in people diagnosed with sleep apnea than it is in people never diagnosed with sleep apnea [2,3,4,5]. Here are the physiological reasons for those results. The chronic intermittent hypoxemia of sleep apnea has three effects which can lead to an overnight gout flare in short order. Effect #1 is intermittent cellular catabolism in which adenosine triphosphate degradation is accelerated, leading to nucleotide turnover which culminates irreversibly in the intermittent cellular generation of excess uric acid fed into the blood [6,7], faster than any food would cause. Effect #2 is concurrent intermittent hypercapnia and acidosis [8], so the blood can hold less uric acid in solution. Effect #3 is a long term deterioration of the kidneys' glomerular filtration rate [9] so that removal of uric acid from the blood is slowed. Thus, with sleep apnea there are repeated abrupt increases i...
Show MoreT2DM can be divided into Five Stages (1-2). The altered metabolism of uric acid, often associated with DM, may be diagnosed from birth, starting with its Uricemic Constitution-dependent, Inherited Real Risk (3, 4). As all other inherited real risks, such a predisposition to hyperuricemia and gout is removed by Reconstructing Mitochondrial Quantum Therapy (5).
References.
Show More1) Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica. Il Terreno Oncologico. Travel Factory, Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm
2) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico-Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Travel Factory, Roma, 2004. http://www.travelfactory.it/libro_costituzionisemeiotiche.htm
3) Stagnaro S., West PJ., Hu FB., Manson JE., Willett WC. Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. [Medline]
4) Stagnaro Sergio. Epidemiological evidence for the non-random clustering of the components of the metabolic syndrome: multicentre study of the Mediterranean Group for the Study of Diabetes. Eur J Clin Nutr. 2007 Feb 7; [Epub ahead of print] [Medline]
5) Caramel S., Marchionni M., Stagnaro S. Morinda citrifolia Plays a Central Role in the Pr...
Dear Sir,
Dear contributors,
Thank you for the reactions to our article. We absolutely agree with the comments made.
This study was never meant to give the idea that standardized patients (SP) wearing an obesity simulation suit (OSS) could replace the contact with real patients suffering from obesity.
Simulation is a gold-standard method in medical education to prepare students for clinical work (1). It offers the opportunity to practice in a safe and standardized environment with structured feedback. Our students are used to encounter SP with various conditions as a teaching tool. It is important to acknowledge the purpose of this session: It is meant to be a basic step and is not about “true life experience” involving real patients. For example, medical faculties all over the world train their students on how to break bad news with SP (2). Here, it is also well accepted that this offers a good training opportunity despite the SP not having a serious condition themselves.
Our first intention was to make a simulated scenario more realistic to support the concept of “suspended disbelief” (3). The other opportunity it offered was to sensitize towards the issue of patients with obesity and start a first reflection process on otherwise unnoticed prejudices. Many students appreciated the fact that due to the “before/after effect” (SP with OSS in simulation vs. SP of normal weight giving feedback) made them reflect even more on differences a...
Show MoreDear Editor,
Herrmann-Werner et al (2019) brought to our attention an increasingly relevant topic. The study proposed that the obesity simulation suit (OSS) could be used to address the issue of stigmatisation of obesity(1). We are medical students at Imperial College London. As part of our course, we have regularly attended clinical communication sessions in the form of simulated role play.
We believe that whilst using a simulated patient in an OSS may be useful, it is a superficial way of addressing the deep-rooted societal problem of how obesity is viewed and may even reinforce the stigma. The use of simulated patients should be adapted to reduce prejudice towards obese patients, especially with reference to their physical and psychological comorbidities.
The study argues that using healthy weight actors in the OSS was of benefit because using obese actors ‘entails the potential danger of issues becoming too personal for the patient’(1). However, we believe that using actors with a healthy BMI may reinforce to students that obese patients are embarrassed or ashamed to have a conversation about their weight. At Imperial College, we simulate consultations with real patients to better understand their conditions. Rees et al also prefer the use of real patients, arguing that it provides medical students with a more realistic experience(2). Therefore, we recommend that students talk to obese patients who are willing to partake and understand the sensitiv...
Show MoreKapoor et al. highlight one aspect of gender discrimination, gender injustice and gender prejudice in Indian society using data acquired from their hospital information system at AIIMS New Delhi.1 Under a title of introduction the authors write, ”There have been a handful of small sample studies on gender bias in access to healthcare in select patient groups or for specific medical conditions….” Then under a title of Discussion, they cite several studies, some conducted at their Institute in the department of Cardiology, some in Pediatrics and some conducted abroad. Here we want to state that we too conducted a manual small study in Emergency Department of our hospital. We assessed demographic profile of alleged self -harm patients presenting to our referral tertiary care public hospital. In our study -among other variables- when we estimated sex ratio among male and female patients, it was 62:38(2). And that’s eerily close to 63:37 in this study. So there is a difference of just 1 percentage point. When 38 women per hundred patients present in our hospital in Lucknow with a history of alleged self- harm , 37 present to AIIMS New Delhi on an average in OPDs.
Similarly at reference number 8, there is a study to estimate gender- bias in (availing) cardiovascular healthcare at a tertiary care center of north India. In the study Chhabra et al. assess that the ratio of girls to boys to avail cardiac interventions for their congenital and rheumatic heart disease is 38:62...
Show MoreWe read with interest the paper by Van de Velde et al delineating the concept of self-management in chronic conditions.1 We agree that there is a lack of consensus on the meaning of self-management, ambiguity regarding the concept, and an urgent need for uniformity with regard to terminology. One major area of ambiguity is the relationship between self-management and self-care. These terms are often thought of as synonyms, used interchangeably, or considered as integrated concepts (e.g. self-care as an overarching or umbrella term, with self-management as onecomponent of self-care).2 This is why, until 2018, major search engines combined the terms. When one searched for “self-management”, literature on “self-care” was provided as well. Since Van de Velde and co-workers aimed to delineate the concept of self-management and develop a definition for its use in healthcare, we expected a more thorough review of related concepts in their concept analysis. Thus, we were surprised to find that several important publications on self-care were excluded.
We believe that the concept analysis by van de Velde et al would have been stronger if they also had included publications related to self-care. In 2012, after many years studying self-care in heart failure, we developed the Middle-Range Theory of Self-Care of Chronic Illness,3 which was updated this year.4 In this theory we defined self-care as the process of “maintaining health through health promoting practices and managi...
Show MoreThank you for your recent BMJ Open article,1 which has correctly noted that it is critical for journal editors’ potential conflicts of interest to be publicly disclosed. A limitation of the study is that only the digital version of the journals were considered. Obstetrics & Gynecology has included a conflict of interest statement for the Editor-in-Chief and Deputy or Associate Editors on the masthead of the print journal since the July 2008 issue. The article by Dal-Ré has prompted us to review our digital presence, and the website has since been updated to reflect our long-standing presentation of the editors’ potential conflicts of interest. I thank the authors for highlighting the importance of disclosing potential conflicts of interest but express concern that their work is biased toward the digital presence only.
Reference
1. Dal-Ré R, Caplan AL, Marusic A. Editors’ and authors’ individual conflicts of interest disclosure and journal transparency. A cross-sectional study of high-impact medical specialty journals. BMJ Open 2019;9:e029796. doi: 10.1136/bmjopen-2019-029796.
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