While it is a clinical insight subject to multiple variables, I have consistently been able to clear up statin myalgias an have the patient remain on the statin by having the patient take enough of an absorbable magnesium (usually a chelated magneium) to achieve a blood level of magnesium of 2.2 mg/dL or only slightly higher plus have loose stools. After the myalgias have cleared with this treatment, the magnesium dose can be reduced so the stools are no longer loose but the blood levels remains 2.1-2.4 ng/dL
A medical student perspective on history-taking for a child presenting with a limp: doing it for the first time
Ravi Patel & Matthew Knights
A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.
Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachm...
A medical student perspective on history-taking for a child presenting with a limp: doing it for the first time
Ravi Patel & Matthew Knights
A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.
Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachment being 5 weeks in all 23 UK medical schools.[4] With such short exposure to a large subject may encourage superficial learning which medical education is specifically trying to avoid. It is estimated that 30% of all GP consultations in the UK are Musculoskeletal, of which a quarter who visit their GP are <18 years old. [5,6,7] This is fundamentally important as 50% of all medical graduates in the UK will be training to become GPs.[8] We believe from our clinical experience in numerous primary care and secondary care sites that observation of clinicians alone may be an ineffective method in acquiring the key skills to conduct a concise consultation.
When asked to take our first history for a child presenting with a limp in new patient clinic, we found difficulty phrasing sensitive questions about non-accidental injury, asking about childhood obesity as well as establishing a clear contralateral history from family members. This uncertainty sometimes led us to neglect certain parts of the history entirely. One case, when observing a FY2 led to a partial delay in diagnosis of an acute on chronic slipped capital femoral epiphysis (SCFE). As the plain anteroposterior radiographs of the pelvis were unremarkable as the slip was subtle and the child was not overweight, nor was there any endocrinal abnormalities such as hypothyroidism and growth hormone deficiency from the patient history. When reflecting, we feel additional techniques should be implemented in other aspects of clinical education alongside history taking under supervision in order to prevent pit-falls in core principles as a clinician. For example, practicing with simulated patients has given us a greater degree of confidence when handling difficult discussions, having an index of suspicion for abuse cases and identifying good clinical practice when communicating with children and parents. The removal of the fear factor in a safe environment prior to seeing patients additionally helped. When examining the literature further, it shows simulated patients are as effective learning resource in the orthopaedic training of undergraduate medical students as real patients. [9] Driving changes by Royal College of surgeons Ireland to implement more SP training as part of the undergraduate syllabus.
From Student Feedback across 5 hospital sites across the Yorkshire and Humber region, our medical school is now adopting a multi-modal approach. In which simulated orthopaedic patients has now been adopted as part of the curriculum, alongside sexual health and ABCDE masterclass SP teaching sessions. We hope our efforts provide the foundations for a more competent and confident medical students in identifying issue in relation to with a child presenting with a limp.
References
[1] Perry D C, Bruce C. Evaluating the child who presents with an acute limp BMJ 2010; 341: c4250 doi:10.1136/bmj.c4250
[2] 1. Al-Nammari SS, Pengas I, Asopa V, Jawad A, Rafferty M, et al. (2015) The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom. J Bone Joint Surg Am 97: e36.
[3] 2. Pinney SJ, Regan WD (2001) Educating medical students about musculoskeletal problems. Are community needs reflected in the curricula of Canadian medical schools? J Bone Joint Surg Am 83: 1317-1320.
[4] J.R. Williams. A review of undergraduate teaching in orthopaedic surgery in the United Kingdom. Orthopaedic Proceedings Vol. 85-B, No. SUPP_I. British Orthopaedic Association/Japanese Orthopaedic Association Combined Congress. 21 Feb 2018
[5] de Inocencio J. Musculoskeletal pain in primary paediatric care: analysis of 1000 consecutive general paediatric clinic visits. Paediatrics. 1998 Dec;102(6):E63. doi: 10.1542/peds.102.6.e63. PMID: 9832591
[6] De Inocencio J. Epidemiology of musculoskeletal pain in primary care. Arch Dis Child. 2004;89(5):431-434. doi:10.1136/adc.2003.028860
[7] Hassan Raja, Shehzaad A Khan, Abdul Waheed. The limping child — when to worry and when to refer: a GP’s guide. British Journal of General Practice 2020; 70 (698): 467. DOI: 10.3399/bjgp20X712565
[8] Deakin N. Where will the GPs of the future come from? BMJ 2013; 346 :f2558 doi:10.1136/bmj.f2558
[9] Gardiner S, Coffey F, O’Byrne J, et al. 0209 Simulated Patients Versus Real Patients As Learning Resources In The Clinical Skill Training Of Medical Students – A Randomised Crossover Trial Of Their Effectiveness. BMJ Simulation and Technology Enhanced Learning 2014;1:A23.
We appreciate the interest that Dr. Pedersen has shown in our paper, but he has apparently misunderstood some aspects of our analysis. In the analysis of the stillbirth data, we first described the dependence of log (rate) on calendar year by a straight line. Next, we allowed the slope to change from 2011 onwards (a so-called linear spline with a knot at 2011). This did not improve the fit significantly. This is the analysis reported in our paper. Besides we also tried to see if a change in intercept from 2011 onwards would lead to a significantly better fit. This was not the case. This latter model is the one that Dr. Pedersen considers, but this was not the one presented in our paper.
We are also concerned about Dr. Pedersen’s suggestion that we have been unresponsive to his questions. We can document at least 11 email correspondences and two face to face meetings with Dr. Pedersen to accommodate Dr. Pedersen’s wish for more information and discussion of our analyses. These mails and meetings have also included the Lead Professor of Dr. Pedersen’s department and a Professor in Biostatistics from Aarhus University. The Professor in Biostatistics has confirmed to all included in the meetings and in the additional emails that our analysis as well as our conclusions in the paper were valid.
Eva Rydahl, Eugene Declercq, Mette Juhl, Rikke Damkjær Maimburg
De Rubeis et al. conducted a systematic review to evaluate the effect of disasters, including pandemics, on cardiometabolic outcomes (1). Clinical outcomes were checked ≥1 month following the disaster. The effects of exposure to disaster during pregnancy/childhood and during adulthood were included, and increased cardiovascular disease incidence or mortality, diabetes and obesity were observed in each study. Although the biological mechanisms of the association might be complex, long-term effects of disasters on cardiometabolic health should be explored to elucidate prevention strategies against forthcoming disasters (2-4).
References
1. e Rubeis V, Lee J, Anwer MS, et al. Impact of disasters, including pandemics, on cardiometabolic outcomes across the life-course: a systematic review. BMJ Open. 2021;11(5):e047152.
2. Chua MWJ. Managing patients with obesity in the post COVID-19 world: Time to sharpen the saw. Obes Res Clin Pract. 2021;15:85-88.
3. Narita K, Hoshide S, Tsoi K, et al. Disaster hypertension and cardiovascular events in disaster and COVID-19 pandemic. J Clin Hypertens (Greenwich). 2021 ;23(3):575-583.
4. Burg MM, Soufer R. Post-traumatic Stress Disorder and Cardiovascular Disease. Curr Cardiol Rep. 2016;18(10):94
Dear Dr. Walid Al-Wali et al,
Thank you for interest in our work, particularly for your comments on the published protocol titled: Estimating the vaccine confidence levels among healthcare students and staff of a tertiary institution in South Africa.
As you rightly observed, and as stated in the article, the study population is healthcare students and staff of a tertiary institution in South Africa. In this particular setting (a medical campus) a significant number of medical students in their senior years as well as staff have direct dealings with, and exposure to patients in the adjacent teaching hospital as part of their studies and routine duties. These, therefore, were considered as part of the frontline healthcare workers that were prioritized for the receipt of the COVID 19 vaccines, the roll-out of which at the time of the design of our study, was imminent. One of the main aims of our study was to investigate the intention to receive a COVID 19 vaccine when one becomes available. This cogent reason makes the population described above ideal for our study.
Moreover, the selected study population is relevant to gaining some insight on the probable vaccine sentiments of future healthcare workers, identifying any issues of concern and planning how to mitigate them, and gauging how well they might likely advocate for vaccine acceptance. The representability of the current population views (though they are part of the larger population and possibly part...
Dear Dr. Walid Al-Wali et al,
Thank you for interest in our work, particularly for your comments on the published protocol titled: Estimating the vaccine confidence levels among healthcare students and staff of a tertiary institution in South Africa.
As you rightly observed, and as stated in the article, the study population is healthcare students and staff of a tertiary institution in South Africa. In this particular setting (a medical campus) a significant number of medical students in their senior years as well as staff have direct dealings with, and exposure to patients in the adjacent teaching hospital as part of their studies and routine duties. These, therefore, were considered as part of the frontline healthcare workers that were prioritized for the receipt of the COVID 19 vaccines, the roll-out of which at the time of the design of our study, was imminent. One of the main aims of our study was to investigate the intention to receive a COVID 19 vaccine when one becomes available. This cogent reason makes the population described above ideal for our study.
Moreover, the selected study population is relevant to gaining some insight on the probable vaccine sentiments of future healthcare workers, identifying any issues of concern and planning how to mitigate them, and gauging how well they might likely advocate for vaccine acceptance. The representability of the current population views (though they are part of the larger population and possibly participate in the ongoing conversations about vaccines and vaccination, especially COVID 19 vaccines and vaccination) by these future health care workers and their trainers was not the intention nor part of the expected outcome of this current study.
We do concede that there is a limit to the extent to which their views will reflect current feelings, attitudes, practices and gaps in knowledge when compared to that of the general public. However, we do not consider this to be a major issue, as the merits of the study far outweighs this limitation. Nonetheless, this limitation will be duly acknowledged in the full report of the study.
Admittedly, exploring what are the things that will make health care students and staff confident in a vaccine, be prepared to take it, recommend and administer it to the public is a worthwhile question to ask, but, that again, is outside the scope of this present study.
Finally, we also agree that the study population due to its peculiarity is an ideal group to interface with the public as their communication platform is relevant and may be far reaching than the ‘traditional’ means of communication.
Thank you once again for your interest in our work, and for constructively engaging with us.
Do be on the lookout for the detailed report of the study that is now in progress. We look forward to future interactions with you.
Thank you all, God bless you all
I would like to congratulate Hannah Dahlen and colleagues on their recent publication in BMJ Open (1), particularly with respect to their follow-up of longer-term outcomes for infants born following induction of labour between 37 and 41 completed weeks gestational age compared with women who had a spontaneous onset of labour.
Dahlen et al found that adverse maternal outcomes including caesarean section, instrumental birth, epidural use (potentially indicating a more painful and/or longer labour), episiotomy and post-partum haemorrhage were more common among women with an induced labour compared with women who went into spontaneous labour.
They list absence of an intention-to-treat analysis as a weakness in the study design, but go on to say, “the data sources have a good track record of accuracy, so we do not believe these errors are likely to be large, or that they would have significantly influenced the direction of effect of the outcomes.”
However, even if the data were perfectly accurate, the lack of intention-to-treat analysis causes a selection bias to an extent which makes it impossible to assess the impact of non-medically indicated induction of labour on maternal, neonatal, and child outcomes.
In a randomised trial of planned induction of labour at a given gestational age, an intention-to-treat analysis will include all randomised women, including those who went on to have a later medically indicated induction of labour. Similarly, in an o...
I would like to congratulate Hannah Dahlen and colleagues on their recent publication in BMJ Open (1), particularly with respect to their follow-up of longer-term outcomes for infants born following induction of labour between 37 and 41 completed weeks gestational age compared with women who had a spontaneous onset of labour.
Dahlen et al found that adverse maternal outcomes including caesarean section, instrumental birth, epidural use (potentially indicating a more painful and/or longer labour), episiotomy and post-partum haemorrhage were more common among women with an induced labour compared with women who went into spontaneous labour.
They list absence of an intention-to-treat analysis as a weakness in the study design, but go on to say, “the data sources have a good track record of accuracy, so we do not believe these errors are likely to be large, or that they would have significantly influenced the direction of effect of the outcomes.”
However, even if the data were perfectly accurate, the lack of intention-to-treat analysis causes a selection bias to an extent which makes it impossible to assess the impact of non-medically indicated induction of labour on maternal, neonatal, and child outcomes.
In a randomised trial of planned induction of labour at a given gestational age, an intention-to-treat analysis will include all randomised women, including those who went on to have a later medically indicated induction of labour. Similarly, in an observational study an intention-to-treat analysis will include women who go on to have a later induction of labour.
The study group (women who had an apparent non-medically indicated induction of labour) included women who would have had a medically indicated induction at a later gestational age. The control group (women who went into spontaneous labour) purposefully excluded this higher-risk group of women. Thus, we are not comparing like with like and medically indicated induction of labour is artificially made to appear to be associated with adverse outcomes.
This bias is well-recognised and is specific to studies about induction of labour.(2) It explains why observational studies which include only women in spontaneous labour in the comparison group show that induction of labour is associated with caesarean section,(2) whereas randomized controlled trials and observational studies such as the study published by Stock et al in BMJ(3) show the opposite.
Additionally, other biases may affect these observational studies, such as incorrect identification of truly non-medically indicated inductions of labour, and adjustment for confounders that may be on the causal pathway between induction of labour and adverse outcomes.
Thus, in my opinion, while Dahlen et al describe important population-based trends such as increasing rates of apparent non-medical indications of labour, the findings of their comparative analysis must be treated with caution. Specifically, the findings cannot be used to infer that non-medical induction of labour causes any of the adverse outcomes described.
1. Dahlen HG, Thornton C, Downe S, et al. Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study. BMJ Open. 2021;11(6):e047040.
2. Caughey AB, Sundaram V, Kaimal AJ, et al. Systematic review: elective induction of labor versus expectant management of pregnancy. Ann Intern Med. 2009;151(4):252-263, W253-263.
3. Stock SJ, Ferguson E, Duffy A, Ford I, Chalmers J, Norman JE. Outcomes of elective induction of labour compared with expectant management: population based study. BMJ. 2012;344:e2838.
The BACPR would like to thank the ICCPR for their recent letter highlighting the work undertaken by both organisations. We are reassured to learn that the results of the ICCPR survey are similar to our own [1]. Both studies, conducted to support cardiovascular prevention and rehabilitation programmes, found that half of all cardiac rehabilitation services were cancelled during the first wave of COVID-19 (~March to June 2020). This is concerning because the closure of so many cardiac rehabilitation programmes is likely to have had a significant negative effect on patient outcomes, cause avoidable hospital admissions, and undermine government efforts to reduce the pressure on acute hospital and healthcare services, during the COVID-19 pandemic. We agree with the ICCPR that further work is needed to investigate whether cardiac rehabilitation services have been restored. The BACPR remain committed to undertaking research that guides decision making and would be happy to explore opportunities with the ICCPR to combine existing research datasets and conduct future collaborative projects.
We believe that it is essential that government, governing bodies, and local policy makers, support cardiac rehabilitation teams to resume the delivery of effective services. Whilst restrictions on face-to-face human contact remain in place, services should be supported to adopt and refine remotely delivered models of cardiac rehabilitation. As we demonstrate in our survey [1], significan...
The BACPR would like to thank the ICCPR for their recent letter highlighting the work undertaken by both organisations. We are reassured to learn that the results of the ICCPR survey are similar to our own [1]. Both studies, conducted to support cardiovascular prevention and rehabilitation programmes, found that half of all cardiac rehabilitation services were cancelled during the first wave of COVID-19 (~March to June 2020). This is concerning because the closure of so many cardiac rehabilitation programmes is likely to have had a significant negative effect on patient outcomes, cause avoidable hospital admissions, and undermine government efforts to reduce the pressure on acute hospital and healthcare services, during the COVID-19 pandemic. We agree with the ICCPR that further work is needed to investigate whether cardiac rehabilitation services have been restored. The BACPR remain committed to undertaking research that guides decision making and would be happy to explore opportunities with the ICCPR to combine existing research datasets and conduct future collaborative projects.
We believe that it is essential that government, governing bodies, and local policy makers, support cardiac rehabilitation teams to resume the delivery of effective services. Whilst restrictions on face-to-face human contact remain in place, services should be supported to adopt and refine remotely delivered models of cardiac rehabilitation. As we demonstrate in our survey [1], significant progress has been made in this regard and the BACPR are hopeful that the COVID-19 pandemic will catalyse a change in the way cardiac rehabilitation is delivered around the world, in the longer-term. Improving access to high quality home-based cardiac rehabilitation could enable more people to participate in this vital part of their cardiac recovery. As discussed in our survey [1], a concerted effort should be made to eliminate the barriers relating to remotely delivered cardiac rehabilitation. The BACPR will be working hard to ensure that this vital message is not lost as countries around the world eventually begin to recover from the effects of COVID-19.
1. O'Doherty, A., F., et al., How has technology been used to deliver cardiac rehabilitation during the COVID-19 pandemic? An international cross-sectional survey of healthcare professionals conducted by the BACPR. BMJ Open, 2021. 11:e046051.
Atmore et al (2021) have reported findings from a general practice patient records review in New Zealand.1 Main research question was to compare harms between rural and urban locations. Sampling design was a stratified sampling design with unequal probabilities of selection from strata.2 Authors reported “weights developed from the SHARP study data were applied to enable generalisability of results to the NZ population”. Analyses include Chisquare test, Fishers exact test, independent sample t-test, Mann-Whitney test, Wald test, Poisson regression, and ordinal logistic regression. Some of these procedures cannot accommodate any type of weights, some can accommodate frequency weights but not sampling weights. So, with these procedures authors either may not have used sampling weights or may have incorrectly used them as frequency weights. Closer look at the presented results shows most, if not all, percentages reported are simply the simple percentages observed in data, ignoring sampling weights. In stratified sampling designs, researchers can observe any desired strata-specific percentage by altering the strata-specific sampling fraction of participants, therefore not using sampling weights or incorrectly using them to compare outcomes between strata almost always invalidate results. Further, authors have interpreted main effects from the regression models ignoring interaction effects. For these reasons, the results presented in the Atmore et al paper are unreliable, and t...
Atmore et al (2021) have reported findings from a general practice patient records review in New Zealand.1 Main research question was to compare harms between rural and urban locations. Sampling design was a stratified sampling design with unequal probabilities of selection from strata.2 Authors reported “weights developed from the SHARP study data were applied to enable generalisability of results to the NZ population”. Analyses include Chisquare test, Fishers exact test, independent sample t-test, Mann-Whitney test, Wald test, Poisson regression, and ordinal logistic regression. Some of these procedures cannot accommodate any type of weights, some can accommodate frequency weights but not sampling weights. So, with these procedures authors either may not have used sampling weights or may have incorrectly used them as frequency weights. Closer look at the presented results shows most, if not all, percentages reported are simply the simple percentages observed in data, ignoring sampling weights. In stratified sampling designs, researchers can observe any desired strata-specific percentage by altering the strata-specific sampling fraction of participants, therefore not using sampling weights or incorrectly using them to compare outcomes between strata almost always invalidate results. Further, authors have interpreted main effects from the regression models ignoring interaction effects. For these reasons, the results presented in the Atmore et al paper are unreliable, and therefore the conclusions arrived from those results are not trustworthy.
References:
(1) Atmore C, Dovey S, Gauld R, et al. Do people living in rural and urban locations experience differences in harm when admitted to hospital? A cross-sectional New Zealand general practice records review study. BMJ Open 2021;11:e046207. doi:10.1136/bmjopen-2020-046207
(2) Dovey SM, Leitch S, Wallis KA, et al. Epidemiology of patient harms in New Zealand: protocol of a general practice records review study. JMIR Res Protoc 2017;6:e10.
Since the publication of the article, it has come to the authors’ attention that the flowchart (Figure 1) can be misleading. According to the flow chart, 1 738 358 pregnancies ending as an abortion were excluded due to missing gestational age or gestational age >140 days. This seems to be a large proportion of missing data, which could question the validity of the coding of abortions in the patient registry. It was, however, not at missing data problem but was due to technical reasons. In the raw data, a unique abortion could be recorded more than once. Removing duplicates is therefore a regular part of the data cleaning process when working with these data. In our data, 1 733 799 abortions were removed because they were duplicates, which would have been the correct designation in the flow chart rather than missing gestational age. Of notice, the final number of pregnancies included in the analyses was correct.
Anne Staub Rasmussen
Christian Fynbo Christiansen,
Niels Uldbjerg,
Mette Nørgaard
Thank you for your research regarding this retrospective population linked data in NSW.
We wish to make a number of comments regarding the methods and conclusions reached.
Firstly, the premise of retrospectively comparing birth outcomes for induction versus spontaneous labour at a particular gestation is an erroneous one. It is not possible to elect to go into spontaneous labour. The only option available to women is elect to have an induction at a certain gestation, or to continue with the pregnancy, i.e. expectant management. Expectant management may include the pregnancy going post-dates, requiring an IOL at a later gestation, or the development of complications that are known to increase beyond 40 weeks including preeclampsia, placental insufficiency, stillbirth and macrosomia.
It is for this simple reason that prospective RCT data that compares IOL at 39-40 weeks versus expectant management demonstrate a clear reduction in the rate of caesarean section, third and fourth degree perineal tears, and a reduction in perinatal adverse outcomes.
It is not possible with your data to make any comment regarding the outcomes of IOL for no medical reason versus expectant management. Given, in reality, this is the only choice that women are able to make, we do not believe that your conclusion, that women may have an increased rate of caesarean section and adverse outcomes if they elect for an IOL, is supported at all...
Thank you for your research regarding this retrospective population linked data in NSW.
We wish to make a number of comments regarding the methods and conclusions reached.
Firstly, the premise of retrospectively comparing birth outcomes for induction versus spontaneous labour at a particular gestation is an erroneous one. It is not possible to elect to go into spontaneous labour. The only option available to women is elect to have an induction at a certain gestation, or to continue with the pregnancy, i.e. expectant management. Expectant management may include the pregnancy going post-dates, requiring an IOL at a later gestation, or the development of complications that are known to increase beyond 40 weeks including preeclampsia, placental insufficiency, stillbirth and macrosomia.
It is for this simple reason that prospective RCT data that compares IOL at 39-40 weeks versus expectant management demonstrate a clear reduction in the rate of caesarean section, third and fourth degree perineal tears, and a reduction in perinatal adverse outcomes.
It is not possible with your data to make any comment regarding the outcomes of IOL for no medical reason versus expectant management. Given, in reality, this is the only choice that women are able to make, we do not believe that your conclusion, that women may have an increased rate of caesarean section and adverse outcomes if they elect for an IOL, is supported at all by your data.
As you note, RCT meta-analyses evidence shows the opposite to occur. Whilst exact calculations are not possible from your data, it would appear that IOL at 39-40 weeks compared to expectant management (which may result in either spontaneous labour at a later gestation or IOL at a later gestation with higher risk of adverse outcomes) likely result in similar findings in your study to those demonstrated in the RCTs.
Secondly, we question the study population. As you note, the records were not able to be verified for accuracy, and it is noted that such records are often incomplete. We believe it is likely that a significant proportion of those included as ‘no medical indication for IOL’ did in fact have a medical indication.
In our knowledge of private and public obstetrics in Australia over the timeframe studied (which is prior to the ARRIVE trial and prior to the publication of the meta analyses showing benefit and safety of IOL for low risk women), we would be very surprised if 1 in every 6 inductions were being performed for no medical reason. Even in 2021, with evidence of both safety and benefit, IOL is not offered without a medical reason, and as such it is exceedingly rare for an induction to be performed in our busy maternity centre for no medical indication.
The finding that women who were induced differed significantly on all maternal and child characteristics is further reason to doubt the accuracy of the study population. The two groups (IOL versus spontaneous labour) that you have compared were two clearly disparate groups that differed statistically significantly on all characteristics.
Thirdly, we would like to draw particular attention to the exclusion of all women who suffered a stillbirth from your data. Reducing the tragedy of stillbirth is a national health priority. RCT evidence consistently demonstrates a significant reduction in stillbirth for IOL compared to expectant management. You state that ‘our data accords with other whole population, longer term observational studies, such as that reported recently from Denmark’. We disagree. Crucially, the Denmark trial, which was a well designed prospective trial comparing IOL at 41 weeks compared to IOL at 42 weeks, was stopped early due to a significantly higher rate of perinatal mortality in the expectant group. Five stillbirths occured in the expectant group compared to none in the induction group. We believe the inability to assess stillbirth risk, and the omission of stillbirth from your data, further limits the interpretation and validity of any findings. This is particularly the case given reduction of post-term stillbirth is one of the primary reasons women may choose to request an induction of labour.
Lastly, despite the RCT evidence of safety and the clear reduction in caesarean rate, we wish to make it clear that we are not advocating for IOL of all low risk women between 39 and 40 weeks.
We wholeheartedly support the many women who have a low risk pregnancy and place high value on having a birth experience that is free from medical intervention. We strongly support this woman and her choice. Another woman, given the same information, may elect to request an IOL at 39-40 weeks to reduce their risk of caesarean section, third and fourth degree tears, and post-term stillbirth. Equally, we support this woman and her choice.
We believe that our role as pregnancy care providers is to provide clear and current evidence of the risks and benefits of IOL and to support women in their birth choices. We believe that this retrospective study, that does not have the ability to compare IOL with expectant management, and excludes stillbirth as an outcome, does not alter the high level evidence from the multiple prospective RCT findings on this important topic in pregnancy care.
While it is a clinical insight subject to multiple variables, I have consistently been able to clear up statin myalgias an have the patient remain on the statin by having the patient take enough of an absorbable magnesium (usually a chelated magneium) to achieve a blood level of magnesium of 2.2 mg/dL or only slightly higher plus have loose stools. After the myalgias have cleared with this treatment, the magnesium dose can be reduced so the stools are no longer loose but the blood levels remains 2.1-2.4 ng/dL
A medical student perspective on history-taking for a child presenting with a limp: doing it for the first time
Ravi Patel & Matthew Knights
A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.
Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachm...
Show MoreWe appreciate the interest that Dr. Pedersen has shown in our paper, but he has apparently misunderstood some aspects of our analysis. In the analysis of the stillbirth data, we first described the dependence of log (rate) on calendar year by a straight line. Next, we allowed the slope to change from 2011 onwards (a so-called linear spline with a knot at 2011). This did not improve the fit significantly. This is the analysis reported in our paper. Besides we also tried to see if a change in intercept from 2011 onwards would lead to a significantly better fit. This was not the case. This latter model is the one that Dr. Pedersen considers, but this was not the one presented in our paper.
We are also concerned about Dr. Pedersen’s suggestion that we have been unresponsive to his questions. We can document at least 11 email correspondences and two face to face meetings with Dr. Pedersen to accommodate Dr. Pedersen’s wish for more information and discussion of our analyses. These mails and meetings have also included the Lead Professor of Dr. Pedersen’s department and a Professor in Biostatistics from Aarhus University. The Professor in Biostatistics has confirmed to all included in the meetings and in the additional emails that our analysis as well as our conclusions in the paper were valid.
Eva Rydahl, Eugene Declercq, Mette Juhl, Rikke Damkjær Maimburg
De Rubeis et al. conducted a systematic review to evaluate the effect of disasters, including pandemics, on cardiometabolic outcomes (1). Clinical outcomes were checked ≥1 month following the disaster. The effects of exposure to disaster during pregnancy/childhood and during adulthood were included, and increased cardiovascular disease incidence or mortality, diabetes and obesity were observed in each study. Although the biological mechanisms of the association might be complex, long-term effects of disasters on cardiometabolic health should be explored to elucidate prevention strategies against forthcoming disasters (2-4).
References
1. e Rubeis V, Lee J, Anwer MS, et al. Impact of disasters, including pandemics, on cardiometabolic outcomes across the life-course: a systematic review. BMJ Open. 2021;11(5):e047152.
2. Chua MWJ. Managing patients with obesity in the post COVID-19 world: Time to sharpen the saw. Obes Res Clin Pract. 2021;15:85-88.
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Dear Dr. Walid Al-Wali et al,
Show MoreThank you for interest in our work, particularly for your comments on the published protocol titled: Estimating the vaccine confidence levels among healthcare students and staff of a tertiary institution in South Africa.
As you rightly observed, and as stated in the article, the study population is healthcare students and staff of a tertiary institution in South Africa. In this particular setting (a medical campus) a significant number of medical students in their senior years as well as staff have direct dealings with, and exposure to patients in the adjacent teaching hospital as part of their studies and routine duties. These, therefore, were considered as part of the frontline healthcare workers that were prioritized for the receipt of the COVID 19 vaccines, the roll-out of which at the time of the design of our study, was imminent. One of the main aims of our study was to investigate the intention to receive a COVID 19 vaccine when one becomes available. This cogent reason makes the population described above ideal for our study.
Moreover, the selected study population is relevant to gaining some insight on the probable vaccine sentiments of future healthcare workers, identifying any issues of concern and planning how to mitigate them, and gauging how well they might likely advocate for vaccine acceptance. The representability of the current population views (though they are part of the larger population and possibly part...
I would like to congratulate Hannah Dahlen and colleagues on their recent publication in BMJ Open (1), particularly with respect to their follow-up of longer-term outcomes for infants born following induction of labour between 37 and 41 completed weeks gestational age compared with women who had a spontaneous onset of labour.
Show MoreDahlen et al found that adverse maternal outcomes including caesarean section, instrumental birth, epidural use (potentially indicating a more painful and/or longer labour), episiotomy and post-partum haemorrhage were more common among women with an induced labour compared with women who went into spontaneous labour.
They list absence of an intention-to-treat analysis as a weakness in the study design, but go on to say, “the data sources have a good track record of accuracy, so we do not believe these errors are likely to be large, or that they would have significantly influenced the direction of effect of the outcomes.”
However, even if the data were perfectly accurate, the lack of intention-to-treat analysis causes a selection bias to an extent which makes it impossible to assess the impact of non-medically indicated induction of labour on maternal, neonatal, and child outcomes.
In a randomised trial of planned induction of labour at a given gestational age, an intention-to-treat analysis will include all randomised women, including those who went on to have a later medically indicated induction of labour. Similarly, in an o...
The BACPR would like to thank the ICCPR for their recent letter highlighting the work undertaken by both organisations. We are reassured to learn that the results of the ICCPR survey are similar to our own [1]. Both studies, conducted to support cardiovascular prevention and rehabilitation programmes, found that half of all cardiac rehabilitation services were cancelled during the first wave of COVID-19 (~March to June 2020). This is concerning because the closure of so many cardiac rehabilitation programmes is likely to have had a significant negative effect on patient outcomes, cause avoidable hospital admissions, and undermine government efforts to reduce the pressure on acute hospital and healthcare services, during the COVID-19 pandemic. We agree with the ICCPR that further work is needed to investigate whether cardiac rehabilitation services have been restored. The BACPR remain committed to undertaking research that guides decision making and would be happy to explore opportunities with the ICCPR to combine existing research datasets and conduct future collaborative projects.
We believe that it is essential that government, governing bodies, and local policy makers, support cardiac rehabilitation teams to resume the delivery of effective services. Whilst restrictions on face-to-face human contact remain in place, services should be supported to adopt and refine remotely delivered models of cardiac rehabilitation. As we demonstrate in our survey [1], significan...
Show MoreAtmore et al (2021) have reported findings from a general practice patient records review in New Zealand.1 Main research question was to compare harms between rural and urban locations. Sampling design was a stratified sampling design with unequal probabilities of selection from strata.2 Authors reported “weights developed from the SHARP study data were applied to enable generalisability of results to the NZ population”. Analyses include Chisquare test, Fishers exact test, independent sample t-test, Mann-Whitney test, Wald test, Poisson regression, and ordinal logistic regression. Some of these procedures cannot accommodate any type of weights, some can accommodate frequency weights but not sampling weights. So, with these procedures authors either may not have used sampling weights or may have incorrectly used them as frequency weights. Closer look at the presented results shows most, if not all, percentages reported are simply the simple percentages observed in data, ignoring sampling weights. In stratified sampling designs, researchers can observe any desired strata-specific percentage by altering the strata-specific sampling fraction of participants, therefore not using sampling weights or incorrectly using them to compare outcomes between strata almost always invalidate results. Further, authors have interpreted main effects from the regression models ignoring interaction effects. For these reasons, the results presented in the Atmore et al paper are unreliable, and t...
Show MoreSince the publication of the article, it has come to the authors’ attention that the flowchart (Figure 1) can be misleading. According to the flow chart, 1 738 358 pregnancies ending as an abortion were excluded due to missing gestational age or gestational age >140 days. This seems to be a large proportion of missing data, which could question the validity of the coding of abortions in the patient registry. It was, however, not at missing data problem but was due to technical reasons. In the raw data, a unique abortion could be recorded more than once. Removing duplicates is therefore a regular part of the data cleaning process when working with these data. In our data, 1 733 799 abortions were removed because they were duplicates, which would have been the correct designation in the flow chart rather than missing gestational age. Of notice, the final number of pregnancies included in the analyses was correct.
Anne Staub Rasmussen
Christian Fynbo Christiansen,
Niels Uldbjerg,
Mette Nørgaard
Dear Professor Dahlen et al
Thank you for your research regarding this retrospective population linked data in NSW.
We wish to make a number of comments regarding the methods and conclusions reached.
Firstly, the premise of retrospectively comparing birth outcomes for induction versus spontaneous labour at a particular gestation is an erroneous one. It is not possible to elect to go into spontaneous labour. The only option available to women is elect to have an induction at a certain gestation, or to continue with the pregnancy, i.e. expectant management. Expectant management may include the pregnancy going post-dates, requiring an IOL at a later gestation, or the development of complications that are known to increase beyond 40 weeks including preeclampsia, placental insufficiency, stillbirth and macrosomia.
It is for this simple reason that prospective RCT data that compares IOL at 39-40 weeks versus expectant management demonstrate a clear reduction in the rate of caesarean section, third and fourth degree perineal tears, and a reduction in perinatal adverse outcomes.
It is not possible with your data to make any comment regarding the outcomes of IOL for no medical reason versus expectant management. Given, in reality, this is the only choice that women are able to make, we do not believe that your conclusion, that women may have an increased rate of caesarean section and adverse outcomes if they elect for an IOL, is supported at all...
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