We appreciate the letter submitted by Dr. Mark Whelan and colleagues regarding our recently published article and very much appreciate their important suggestions. Whelan et al. pointed out that the authors have confused the standard deviation (SD) with the standard error (SE) regarding the Nelson’s trial1. After checking all the original data of included trials, admittedly, we confused the SE value with the SD value in the Nelson’s trial1. The corrected effect size is -0.92 [95% confidence interval (CI) -1.64 to -0.20] in the Nelson’s trial1. Meanwhile, the pooled effect should be corrected as -0.34 [95%CI -0.72 to 0.03] and the conclusion should be that the treatment is not effective in alleviating knee OA pain. All calculations were performed using the Review Manager 5.2. The random-effects models were built using weighted averages of the differences in means of outcomes, using the inverse variance as weights, for weighted mean differences (WMD) of outcomes reported on the same scale2.
Secondly, Whelan et al. raised a question worth thinking about that authors should alert the reader to how atypical some very large effect sizes are3-5. We are also grateful to Dr. Whelan and colleagues for this suggestion. The extreme values indicated non-random variation in effect sizes, such that a minority of interventions might have a significantly larger effects beyond the 95% CI around the standard mean difference of meta-analysis6. Especially for cer...
We appreciate the letter submitted by Dr. Mark Whelan and colleagues regarding our recently published article and very much appreciate their important suggestions. Whelan et al. pointed out that the authors have confused the standard deviation (SD) with the standard error (SE) regarding the Nelson’s trial1. After checking all the original data of included trials, admittedly, we confused the SE value with the SD value in the Nelson’s trial1. The corrected effect size is -0.92 [95% confidence interval (CI) -1.64 to -0.20] in the Nelson’s trial1. Meanwhile, the pooled effect should be corrected as -0.34 [95%CI -0.72 to 0.03] and the conclusion should be that the treatment is not effective in alleviating knee OA pain. All calculations were performed using the Review Manager 5.2. The random-effects models were built using weighted averages of the differences in means of outcomes, using the inverse variance as weights, for weighted mean differences (WMD) of outcomes reported on the same scale2.
Secondly, Whelan et al. raised a question worth thinking about that authors should alert the reader to how atypical some very large effect sizes are3-5. We are also grateful to Dr. Whelan and colleagues for this suggestion. The extreme values indicated non-random variation in effect sizes, such that a minority of interventions might have a significantly larger effects beyond the 95% CI around the standard mean difference of meta-analysis6. Especially for cervical and hand joints, the extreme values could bias the results of these two subgroups due to very few studies having been involved. More trials thus are needed to evaluate the efficacy after pulsed electromagnetic field (PEMF) therapy.
Lastly, Dr. Whelan and colleagues would like to see a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) rating in this meta-analysis. We agree that GRADE rating is a useful tool to help assess the credibility of studies, and we would like to present the GRADE rating in future studies.
References
1. Nelson FR, Zvirbulis R, Pilla AA. Non-invasive electromagnetic field therapy produces rapid and substantial pain reduction in early knee osteoarthritis: a randomized double-blind pilot study. Rheumatol Int 2013;33:2169-73.
2. Negm A, Lorbergs A, Macintyre NJ. Efficacy of low frequency pulsed subsensory threshold electrical stimulation vs placebo on pain and physical function in people with knee osteoarthritis: systematic review with meta-analysis. Osteoarthritis Cartilage 2013;21:1281-9.
3. Bagnato GL, Miceli G, Marino N, et al. Pulsed electromagnetic fields in knee osteoarthritis: a double blind, placebo-controlled, randomized clinical trial. Rheumatology 2016;55:755-62.
4. Kanat E, Alp A, Yurtkuran M. Magnetotherapy in hand osteoarthritis: A pilot trial. Complement Ther Med 2013;21:603-8.
5. Sutbeyaz ST, Sezer N, Koseoglu BF. The effect of pulsed electromagnetic fields in the treatment of cervical osteoarthritis: a randomized, double-blind, sham-controlled trial. Rheumatol Int 2006;26:320-4.
6. Kwan JL, Lo L, Ferguson J, et al. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ 2020;370:m3216.
Correspondence to: Dongxing Xie, MD, PhD, Department of Orthopaedics, Xiangya Hospital, Central South University, #87 Xiangya Road, Changsha, Hunan, China, 410008. E-mail: xdx1024@csu.edu.cn.
We read the article by Muche AA et al1on the predictors of postpartum glucose intolerance in women with history of GDM. The study is interesting despite the limited sample size, as the risk score developed would be useful for Ethiopia and other low-resource settings. The inclusion of the antenatal depression, dietary diversity, and level of physical activity adds value to the study. However, the study findings could have been strengthened further if the following details were provided. Firstly, what were the characteristics of the women who did not attend the post-partum OGTT? There is evidence that women with higher cardiovascular risk factors tend not to attend for the OGTT2. Secondly, what was the impact of breastfeeding? Breastfeeding has a positive impact on post-partum weight loss, which could potentially improve glucose intolerance and elevated lipid levels3.In addition, it may also have other positive benefits through other mechanisms4. Exclusive breastfeeding in Ethiopia at 59.3% is lower than international recommendations with wide variations across the regions.5Specifically, in Gondor town (place of study - Muche AA et al) the rate was reported to be 34.8% 6. This might also play a vital role in such a high glucose intolerance observed and will enable healthcare professionals to encourage women to breastfeed for their own metabolic benefit (in addition to their children, which is the primary reason for breastfeeding).Finally, did the authors have any data on ges...
We read the article by Muche AA et al1on the predictors of postpartum glucose intolerance in women with history of GDM. The study is interesting despite the limited sample size, as the risk score developed would be useful for Ethiopia and other low-resource settings. The inclusion of the antenatal depression, dietary diversity, and level of physical activity adds value to the study. However, the study findings could have been strengthened further if the following details were provided. Firstly, what were the characteristics of the women who did not attend the post-partum OGTT? There is evidence that women with higher cardiovascular risk factors tend not to attend for the OGTT2. Secondly, what was the impact of breastfeeding? Breastfeeding has a positive impact on post-partum weight loss, which could potentially improve glucose intolerance and elevated lipid levels3.In addition, it may also have other positive benefits through other mechanisms4. Exclusive breastfeeding in Ethiopia at 59.3% is lower than international recommendations with wide variations across the regions.5Specifically, in Gondor town (place of study - Muche AA et al) the rate was reported to be 34.8% 6. This might also play a vital role in such a high glucose intolerance observed and will enable healthcare professionals to encourage women to breastfeed for their own metabolic benefit (in addition to their children, which is the primary reason for breastfeeding).Finally, did the authors have any data on gestational weight gain during pregnancy or the treatment modality for managing GDM (diet vs insulin for example)? Insulin treatment is known to be an independent predictor of postpartum glucose intolerance and would be a simple measure to use in the prediction model.
1. Muche AA, Olayemi OO, Gete YK. Predictors of postpartum glucose intolerance in women with gestational diabetes mellitus: a prospective cohort study in Ethiopia based on the updated
diagnostic criteria. BMJ Open 2020;10: e036882.
2. Saravanan P. Diabetes in Pregnancy Working Group; Maternal Medicine Clinical Study Group; Royal College of Obstetricians and Gynaecologists, UK. Gestational diabetes: opportunities for improving maternal and child health. Lancet Diabetes Endocrinol. 2020;8(9):793-800.
3. Shub, A., Miranda, M., Georgiou, H.M. et al. The effect of breastfeeding on postpartum glucose tolerance and lipid profiles in women with gestational diabetes mellitus. Int Breastfeed J 2019; 14, 46.
4. Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, Bahl R, Martines J. Breastfeeding, and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):96-113.
5. Alebel A, Tesma, C, Temesgen, B, Ferede, A, &Kibret, GD. Exclusive breastfeeding practice in Ethiopia and its association with antenatal care and institutional delivery: a systematic review and meta-analysis. Int Breastfeed J 2018, 13,31.
6. Chekol DA, Biks GA, Gelaw YA, Melsew YA. Exclusive breastfeeding andmothers’ employment status in Gondar town, Northwest Ethiopia: acomparative cross-sectional study. Int Breastfeed J. 2017; 12:27.
We support the use of DSTs in the routine care of nursing home residents as adult care in nursing homes may vary from culture to culture, but the necessary standards should be on an equal plain. Quality in the care given at nursing homes is of global concern, due to the worlds aging populations. This article by N. Carey et al seek to assess views and experiences of workers in nursing homes in England and Sweden, on infection detection. The researchers were rather thorough in raising awareness to the rise in cost on a global scale, with Sweden’s healthcare system ejecting >SEK 36 trillion a year for people aged >65yrs (Havasi M. , 2020) . These exuberant cost in healthcare are according to the researchers, the direct effects of unplanned hospital admissions of nursing home residents. Therefore, decision support tools are a necessary way to reduce on these pheromones and improve on consistency and timely treatment. Nursing home staff are given the autonomy to recognize and communicate signs of deterioration, which reduces on unplanned hospital admissions. This paper seamlessly highlights the use of Decision Support Tools like “Stop and Watch” and “Early detection of Infection Scale,” both of which can be used to assess patients, catch acute condition, prioritize care, and acting promptly (Ouslander JG, 2014) (Tingström P, 2015).
References
Havasi M. . (2020). Costs of Healhcare for people aged over 65 in Sweden, Statistician Department of Finance and Gov...
We support the use of DSTs in the routine care of nursing home residents as adult care in nursing homes may vary from culture to culture, but the necessary standards should be on an equal plain. Quality in the care given at nursing homes is of global concern, due to the worlds aging populations. This article by N. Carey et al seek to assess views and experiences of workers in nursing homes in England and Sweden, on infection detection. The researchers were rather thorough in raising awareness to the rise in cost on a global scale, with Sweden’s healthcare system ejecting >SEK 36 trillion a year for people aged >65yrs (Havasi M. , 2020) . These exuberant cost in healthcare are according to the researchers, the direct effects of unplanned hospital admissions of nursing home residents. Therefore, decision support tools are a necessary way to reduce on these pheromones and improve on consistency and timely treatment. Nursing home staff are given the autonomy to recognize and communicate signs of deterioration, which reduces on unplanned hospital admissions. This paper seamlessly highlights the use of Decision Support Tools like “Stop and Watch” and “Early detection of Infection Scale,” both of which can be used to assess patients, catch acute condition, prioritize care, and acting promptly (Ouslander JG, 2014) (Tingström P, 2015).
References
Havasi M. . (2020). Costs of Healhcare for people aged over 65 in Sweden, Statistician Department of Finance and Governance SKR.
Ouslander JG, B. A. (2014). The interventions to reduce acute care transfers (interact) quality improvement program: an overview for medical directors and primary care clinicians in long term care. J Am Med Dir Assoc, 15:162–70.
Tingström P, M. A. (2015). Nursing assistants: "he seems to be ill" - a reason for nurses to take action: validation of the Early Detection Scale of Infection (EDIS). BMC Geriatr, 15:122.
We thank Torsy and colleagues to publish their comments on our upcoming prospective study aimed to assess the diagnostic accuracy of a combined method (auscultation and pH measurement) and ultrasonography versus an X-ray method to confirm the correct placement of the nasogastric tube (NGT), on 7 October 2020. Based on a decision analytical modelling approach proposed by Ni et al.(2017), Torsy and colleagues argue that the pH test with 5 is the safest cut-off for the verification of nasogastric feeding tube placement. However, Ni and colleagues concluded that is important to understand the local clinical environment so that appropriate choice of pH cut-offs can be made to maximize safety and to minimize the use of chest X-rays. In addition, in a recent review of 14 international guidelines to distinguish between gastric and pulmonary placement of NGT, Metheny and colleagues (2019) found considerable disagreement about the ‘best’ pH cut-point to distinguish between gastric and respiratory aspirates and that geographical location has a strong influence on recommendations for use of the pH method. In Brazil there is no national safety guideline recommending a pH cut-point. Thus, we will reconsider the set pH cut-off value to 5 to differentiate between gastric and oesophageal NGT placement in our study.
In their comments, Torsy and colleagues affirm that the NEX (Nose-Earlobe-Xiphoid appendix) method to calculate the NGT insertion length is not the mos...
We thank Torsy and colleagues to publish their comments on our upcoming prospective study aimed to assess the diagnostic accuracy of a combined method (auscultation and pH measurement) and ultrasonography versus an X-ray method to confirm the correct placement of the nasogastric tube (NGT), on 7 October 2020. Based on a decision analytical modelling approach proposed by Ni et al.(2017), Torsy and colleagues argue that the pH test with 5 is the safest cut-off for the verification of nasogastric feeding tube placement. However, Ni and colleagues concluded that is important to understand the local clinical environment so that appropriate choice of pH cut-offs can be made to maximize safety and to minimize the use of chest X-rays. In addition, in a recent review of 14 international guidelines to distinguish between gastric and pulmonary placement of NGT, Metheny and colleagues (2019) found considerable disagreement about the ‘best’ pH cut-point to distinguish between gastric and respiratory aspirates and that geographical location has a strong influence on recommendations for use of the pH method. In Brazil there is no national safety guideline recommending a pH cut-point. Thus, we will reconsider the set pH cut-off value to 5 to differentiate between gastric and oesophageal NGT placement in our study.
In their comments, Torsy and colleagues affirm that the NEX (Nose-Earlobe-Xiphoid appendix) method to calculate the NGT insertion length is not the most safe method. Although we agree with them, in our study, the insertion of the NGT will be performed by the hospital's nurses in order to reflect the context of its use. Therefore, the NEX measure will be adopted because it is an institutional protocol. We believe that our results will contribute to future discussion in Brazil about safest NGT insertion length and to the review of guidelines to distinguish between gastric and pulmonary placement of NGT at national level.
References
Metheny, N. A., Krieger, M. M., Healey, F., & Meert, K. L. (2019). A review of guidelines to distinguish between gastric and pulmonary placement of nasogastric tubes. Heart Lung, 48(3), 226-235. doi:10.1016/j.hrtlng.2019.01.003
Ni, M. Z., Huddy, J. R., Priest, O. H., Olsen, S., Phillips, L. D., Bossuyt, P. M. M., & Hanna, G. B. (2017). Selecting pH cut-offs for the safe verification of nasogastric feeding tube placement: a decision analytical modelling approach. BMJ Open, 7(11), e018128. doi:10.1136/bmjopen-2017-018128
We thank Rigobello and colleagues to publish their protocol of an upcoming prospective study to assess the diagnostic accuracy of a combined method (auscultation and pH measurement) and ultrasonography versus an X-ray method to confirm a correct placement of the gastric tube (Rigobello et al., 2020). The authors emphasize the importance of verifying a correct tube placement to reduce adverse events and patient safety risks. We confirm the need for such study. However, the pH cut-off value to differentiate between gastric and oesophageal NG tube placement and the NEX method to calculate the NG tube insertion length are to be discussed.
Applying a 5.5 pH cut-off to confirm the correct placement of the nasogastric (NG) tube in the stomach is debatable. Based on a decision analytical modelling approach, Ni et al. (2017) concluded a pH of ≤ 5 as an adequate cut- off value to indicate correct positioning of the NG tube tip in the stomach and therefore a non-pulmonary placement. Ni et al. (2017) concluded that the pH test with a 5.5 pH cut-off point has low sensitivity (81.0%) in detecting oesophageal placements (Ni et al., 2017). Therefore, a 5.0 pH cut-off has been adopted by several guidelines (American Society for Parenteral and Enteral Nutrition [ASPEN], 2017; American Association of Critical-Care Nurses [AACN], 2016) to confirm a non-pulmonary NG tube placement (Boullata et al., 2017; Metheny, 2016).
We thank Rigobello and colleagues to publish their protocol of an upcoming prospective study to assess the diagnostic accuracy of a combined method (auscultation and pH measurement) and ultrasonography versus an X-ray method to confirm a correct placement of the gastric tube (Rigobello et al., 2020). The authors emphasize the importance of verifying a correct tube placement to reduce adverse events and patient safety risks. We confirm the need for such study. However, the pH cut-off value to differentiate between gastric and oesophageal NG tube placement and the NEX method to calculate the NG tube insertion length are to be discussed.
Applying a 5.5 pH cut-off to confirm the correct placement of the nasogastric (NG) tube in the stomach is debatable. Based on a decision analytical modelling approach, Ni et al. (2017) concluded a pH of ≤ 5 as an adequate cut- off value to indicate correct positioning of the NG tube tip in the stomach and therefore a non-pulmonary placement. Ni et al. (2017) concluded that the pH test with a 5.5 pH cut-off point has low sensitivity (81.0%) in detecting oesophageal placements (Ni et al., 2017). Therefore, a 5.0 pH cut-off has been adopted by several guidelines (American Society for Parenteral and Enteral Nutrition [ASPEN], 2017; American Association of Critical-Care Nurses [AACN], 2016) to confirm a non-pulmonary NG tube placement (Boullata et al., 2017; Metheny, 2016).
Rigobello et al. (2020) describe that the NG tube insertion length will be decided using the NEX method, measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid. Although being a commonly used method, evidence indicates that this is not the most safe method (Taylor, 2020). In a randomised trial by Torsy et al. (2018), using the NEX method, 20.2% of all NG tube tips were located in the oesophageal danger zone (Torsy et al., 2018), increasing the risk of regurgitation and pulmonary aspiration. In another study by Torsy et al. (2020), they concluded that the corrected nose-earlobe-xiphoid distance formula was a safer option to determine the NG tube insertion length (Torsy et al., 2020). All nasogastric feeding tubes in this study, whose length was determined by this alternative method, were correctly positioned in the stomach.
Considering these concerns, we suggest to reconsider the set pH cut-off value to differentiate between gastric and oesophageal NG tube placement and to consider an alternative for the NEX method to calculate the NG tube insertion length.
Sincerely,
Tim Torsy, Mats Eriksson, Sofie Verhaeghe and Dimitri Beeckman tim.torsy@odisee.be
References
1. Boullata, J. I., Carrera, A. L., Harvey, L., Escuro, A. A., Hudson, L., Mays, A., McGinnis, C., Wessel, J. J., Bajpai, S., Beebe, M. L., Kinn, T. J., Klang, M. G., Lord, L., Martin, K., Pompeii-Wolfe, C., Sullivan, J., Wood, A., Malone, A., & Guenter, P. (2017). ASPEN Safe Practices for Enteral Nutrition Therapy. Journal of Parenteral and Enteral Nutrition, 41(1), 15–103. https://doi.org/10.1177/0148607116673053
2. Metheny, N. (2016). Initial and ongoing verification of feeding tube placement in adults. Critical Care Nurse, 36(2), e8–e13. https://doi.org/10.4037/ccn2016141
3. Ni, M. Z., Huddy, J. R., Priest, O. H., Olsen, S., Phillips, L. D., Bossuyt, P. M. M., & Hanna, G. B. (2017). Selecting pH cut-offs for the safe verification of nasogastric feeding tube placement: A decision analytical modelling approach. BMJ Open, 7(11), e018128. https://doi.org/10.1136/bmjopen-2017-018128
4. Rigobello, M. C. G., Elias Junior, J., Bonacim, C. A. G., Silveira, R. C. de C. P., Bonardi, F. C., Nunes, R. S., Pereira, R. A., & Gimenes, F. R. E. (2020). Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study. BMJ Open, 10(9), e036033. https://doi.org/10.1136/bmjopen-2019-036033
5. Taylor, S. J. (2020). Methods of Estimating Nasogastric Tube Length: All, Including “NEX,” Are Unsafe. Nutrition in Clinical Practice, 35(5), 864–870. https://doi.org/10.1002/ncp.10497
6. Torsy, T., Saman, R., Boeykens, K., Duysburgh, I., Eriksson, M., Verhaeghe, S., & Beeckman, D. (2020). Accuracy of the corrected nose-earlobe-xiphoid distance formula for determining nasogastric feeding tube insertion length in intensive care unit patients: A prospective observational study. International Journal of Nursing Studies, 110. https://doi.org/10.1016/j.ijnurstu.2020.103614
7. Torsy, T., Saman, R., Boeykens, K., Duysburgh, I., Van Damme, N., & Beeckman, D. (2018). Comparison of Two Methods for Estimating the Tip Position of a Nasogastric Feeding Tube: A Randomized Controlled Trial. Nutrition in Clinical Practice, 33(6), 843–850. https://doi.org/10.1002/ncp.10112
To the editor:
In a recently published article Walbaum et al. reported revisited estimates of the prevalence of chronic kidney disease (CKD) among Chilean adults and examine their association with sociodemographic characteristics, health behaviors and comorbidities (1). This study was an analysis of two periods, using nationally representative Chilean Health Surveys (CHS) performed in 2010 (CHS-2010) and 2017 (CHS-2017), respectively. They showed that the prevalence of reduced kidney function has not increased significantly between both periods; 2.5% (1.9% to 3.2%) and 3.2% (2.6% to 4.0%) respectively. However, the authors highlight that 15.4% of adults aged 40+ years in 2017 had CKD (stages 1–5). The distribution by CKD stage in this population was: 9.6% had increased albuminuria but mildly decreased, normal or high eGFR (CKD stages 1 and 2) and that 5.8% had CKD stages 3a – 5.
These findings are concordant to those reported by Zuniga et al. in 2011 on the prevalence of CKD in the adult population served in primary health centers (PHCs) in Chile (2). In that study, 27,894 clinical records of adults aged 55 ± 18 years (66% females), consulting in outpatient clinics and in whom serum creatinine was measured to calculate the estimated glomerular filtration rate (eGFR / MDRD-4), with or without assessment of urine albumin levels (albumin to creatinine ratio, ACR), were reviewed. The global prevalence of CKD was 12.1% (3,371 patients), significantly higher in women...
To the editor:
In a recently published article Walbaum et al. reported revisited estimates of the prevalence of chronic kidney disease (CKD) among Chilean adults and examine their association with sociodemographic characteristics, health behaviors and comorbidities (1). This study was an analysis of two periods, using nationally representative Chilean Health Surveys (CHS) performed in 2010 (CHS-2010) and 2017 (CHS-2017), respectively. They showed that the prevalence of reduced kidney function has not increased significantly between both periods; 2.5% (1.9% to 3.2%) and 3.2% (2.6% to 4.0%) respectively. However, the authors highlight that 15.4% of adults aged 40+ years in 2017 had CKD (stages 1–5). The distribution by CKD stage in this population was: 9.6% had increased albuminuria but mildly decreased, normal or high eGFR (CKD stages 1 and 2) and that 5.8% had CKD stages 3a – 5.
These findings are concordant to those reported by Zuniga et al. in 2011 on the prevalence of CKD in the adult population served in primary health centers (PHCs) in Chile (2). In that study, 27,894 clinical records of adults aged 55 ± 18 years (66% females), consulting in outpatient clinics and in whom serum creatinine was measured to calculate the estimated glomerular filtration rate (eGFR / MDRD-4), with or without assessment of urine albumin levels (albumin to creatinine ratio, ACR), were reviewed. The global prevalence of CKD was 12.1% (3,371 patients), significantly higher in women than in men, 14.5% vs 7.4% respectively (p <0.05). Likewise, there was a significant negative correlation between age and eGFR (Pearson r = - 0.54) p <0.05.
In 5495 adults aged 40+ years, both eGFR and albuminuria were evaluated. The prevalence of CKD stages 1–5 was 34.6%, tripling what was reported in ENS 2016–2017 and the distribution was 20.5% and 14.1%, CKD stages 1-2 and 3a-5 respectively.
The differences in prevalence between the two studies could be explained because PHCs control high cardiovascular risk patients (that is, with diabetes or hypertension among others). A further analysis of the CHS ought to estimate the prevalence in high risk patients such as those who are under control in PHCs and we may find out that the prevalence in this group of patients is even higher.
The high prevalence of adults 40 years and over with CKD stages 1 and 2 in the adult Chilean population alerted by Walbaum et al., confirms what was reported in PHCs, and supports the urgent need to implement prevention strategies in PHCs and its timely reference to a nephrologist for specialized evaluations and treatment.
Unfortunately, the growing proportion of CKD patients referred from PHC (2-4) and the lack of nephrologists (5) constitute a complex health challenge, especially critical in developing nations.
In this context, Chilean healthcare public system has progressively implemented telenephrology programs since 2012. Telenephrology is very likely to be responsible for a decrease in the demand for nephrologist's consultations at hospital level, a transference of resolution capacities to the primary care, and a decrease in the waiting times for specialist in-person evaluation. We have recently reported the impact of telenephrology in Chile (6), an experience that can be valued and used by other health systems facing similar high demand for CKD care around the world (6-7).
References
1. Walbaum M, Scholes S, Pizzo E, et alChronic kidney disease in adults aged 18 years and older in Chile: findings from the cross-sectional
Chilean National Health Surveys 2009–2010 and 2016–2017. BMJ Open 2020;10:e037720. doi: 10.1136/bmjopen-2020-037720
2. Zuniga C, Muller H, Flores M. Prevalence of chronic kidney disease in subjects consulting in urban primary care clinics. Rev Med Chil.
2011;139(9):1176-84.
3. B Bikbov, CA Purcell, AS Levey, et al. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the
Global Burden of Disease Study 2017. Lancet; 2020; 395:709-733.
4. De Francisco AL, De la Cruz JJ, Cases A, De la Figuera M, Egocheaga MI, Gorriz JI, et al. Prevalence of kidney insufficiency in primary care
population in Spain: EROCAP study. Nefrologia. 2007;27(3):300-12.
5. Osman MA, Alrukhaimi M, Ashuntantang GE, Bellorin-Font E, Benghanem Gharbi M, Braam B, et al. Global nephrology workforce: gaps and
opportunities toward a sustainable kidney care system. Kidney Int Suppl 2018;8:52–63.
6. Zuniga C, Riquelme C, Muller H, Vergara G, Astorga C, Espinoza M. Using Telenephrology to Improve Acces to Nephrologist and Global Kidney
Management of CKD Primary Care Patients. Kidney Int Rep (2020) 5, 920–923.
7. Osman MA, Okel J, Okpechi IG, Jindal K, Bello AK. Potential applications of telenephrology to enhance global kidney care. BMJ global health.
2017;2(2): e000292.
We would like to thank Professor Kawada for their comments on our paper.
In our retrospective cohort study, we report gender-stratified prevalence rates (Figure 3B, Figure S7) and gender-stratified odds ratios (Figure 5) for all 18 comorbidities. We discussed these results in the paper as we found that the presence of T2D was associated with significantly higher risk for comorbidities in women and similar estimates were obtained when regression models were also adjusted for deprivation.
Our team co-authored the Nowakowska et al. paper and hence we recognise the methodological differences between both studies. Nevertheless, we also reported that depression prevalence was nearly double in women than in men (16.7% vs. 9% – Figure 3). We agree on the need for care for both physical and mental comorbidities in people with T2DM, as we noted in our discussion on the need for future studies to investigate the reasons for the observed gender differences, which may inform future gender-specific multimorbidity prevention and management strategies.
We fully agree that stress management is essential for people with T2DM, as we mention in the ‘Clinical implications’ section on the clinical need for mental health interventions, especially for young patients with T2DM.
Zghebi et al. conducted a prospective study to investigate physical and mental health comorbidities in patients with type 2 diabetes (T2D) (1). By conditional logistic regression models, odds ratio (95% CI) of T2D diagnosis for myocardial infarction, heart failure, and depression were 2.13 (1.85 to 2.46), 2.12 (1.84 to 2.43), and 1.75 (1.62 to 1.89), respectively. The authors also clarified that the risk of osteoarthritis, hypothyroidism, anxiety, schizophrenia and respiratory conditions were also selected as highly prevalent comorbidities in patients with T2D. I have some concerns about their study with special reference to causal association and sex difference.
Williams et al. conducted a 5-year follow-up study to examine the effects of stress on abnormal glucose metabolism (2). The primary outcome was the development of abnormal glucose metabolism such as impaired fasting glucose, impaired glucose tolerance, and T2D, and perceived stress predicted incident abnormal glucose metabolism in women but not men. Based on the sex difference on the association, stratified analysis by sex might be needed to investigate the risk of comorbidities in patients with T2D. In addition, stress management seems important to prevent comorbidities in patients with T2D. Although the mechanism of the association would be complicated, comprehensive management is indispensable for keeping quality of life in patients with T2D.
Regarding sex difference, Nowakowska et al. evaluated c...
Zghebi et al. conducted a prospective study to investigate physical and mental health comorbidities in patients with type 2 diabetes (T2D) (1). By conditional logistic regression models, odds ratio (95% CI) of T2D diagnosis for myocardial infarction, heart failure, and depression were 2.13 (1.85 to 2.46), 2.12 (1.84 to 2.43), and 1.75 (1.62 to 1.89), respectively. The authors also clarified that the risk of osteoarthritis, hypothyroidism, anxiety, schizophrenia and respiratory conditions were also selected as highly prevalent comorbidities in patients with T2D. I have some concerns about their study with special reference to causal association and sex difference.
Williams et al. conducted a 5-year follow-up study to examine the effects of stress on abnormal glucose metabolism (2). The primary outcome was the development of abnormal glucose metabolism such as impaired fasting glucose, impaired glucose tolerance, and T2D, and perceived stress predicted incident abnormal glucose metabolism in women but not men. Based on the sex difference on the association, stratified analysis by sex might be needed to investigate the risk of comorbidities in patients with T2D. In addition, stress management seems important to prevent comorbidities in patients with T2D. Although the mechanism of the association would be complicated, comprehensive management is indispensable for keeping quality of life in patients with T2D.
Regarding sex difference, Nowakowska et al. evaluated comorbidity patterns in patients with T2D (3). Depression was predicted to affect 33% of females and 15% of males diagnosed with T2D, and the percentage in females was more than 2-fold higher than that in males. As comorbidities are common and mental health is a growing concern in patients with T2D, there is a need for cares of physical and mental comorbidities in this population, especially in females.
References
1. Zghebi SS, Steinke DT, Rutter MK, Ashcroft DM. Eleven-year multimorbidity burden among 637 255 people with and without type 2 diabetes: a population-based study using primary care and linked hospitalisation data. BMJ Open. 2020 Jul 1;10(7):e033866.
2. Williams ED, Magliano DJ, Tapp RJ, Oldenburg BF, Shaw JE. Psychosocial stress predicts abnormal glucose metabolism: the Australian Diabetes, Obesity and Lifestyle (AusDiab) study. Ann Behav Med. 2013 Aug;46(1):62-72.
3. Nowakowska M, Zghebi SS, Ashcroft DM, Buchan I, Chew-Graham C, Holt T, Mallen C, Van Marwijk H, Peek N, Perera-Salazar R, Reeves D, Rutter MK, Weng SF, Qureshi N, Mamas MA, Kontopantelis E. The comorbidity burden of type 2 diabetes mellitus: patterns, clusters and predictions from a large English primary care cohort. BMC Med. 2019 Jul 25;17(1):145.
We read with interest the article by Astorp et al. which details the responses from questionnaires given to medical students in Denmark about what would motivate them to join the healthcare workforce in the event of a pandemic [1]. As final-year medical students in the UK (one who joined the NHS workforce as a student volunteer [OT] and one who did not [ET]), we felt that the points highlighted by Astorp et al. did not fully explore the factors affecting students’ decision to join the workforce, based on our own experiences.
The authors correctly identify their primary focus on the ‘positive’ motivational points as a limitation to their study. It is our opinion that the ‘negative’ points (i.e., what may demotivate students) are perhaps more pertinent. For example, the article mentions that personal safety was a significant concern yet fails to explore the students’ fears for the safety of their friends and family. This was a significant concern for us both and a key consideration in making the decision to volunteer or not. Fears of infecting elderly family members and other vulnerable people were also raised in a similar questionnaire given to medical students in India [2].
Astorp et al. also mention that in their results that “encouragement from their university was essential” to some students. We agree that encouragement from university, or at least explicit permission, is an important factor to consider. The UK Medical School Council...
We read with interest the article by Astorp et al. which details the responses from questionnaires given to medical students in Denmark about what would motivate them to join the healthcare workforce in the event of a pandemic [1]. As final-year medical students in the UK (one who joined the NHS workforce as a student volunteer [OT] and one who did not [ET]), we felt that the points highlighted by Astorp et al. did not fully explore the factors affecting students’ decision to join the workforce, based on our own experiences.
The authors correctly identify their primary focus on the ‘positive’ motivational points as a limitation to their study. It is our opinion that the ‘negative’ points (i.e., what may demotivate students) are perhaps more pertinent. For example, the article mentions that personal safety was a significant concern yet fails to explore the students’ fears for the safety of their friends and family. This was a significant concern for us both and a key consideration in making the decision to volunteer or not. Fears of infecting elderly family members and other vulnerable people were also raised in a similar questionnaire given to medical students in India [2].
Astorp et al. also mention that in their results that “encouragement from their university was essential” to some students. We agree that encouragement from university, or at least explicit permission, is an important factor to consider. The UK Medical School Council released advice to medical students who wished to volunteer [3], which stated that volunteering must not take priority over learning. In our case this consisted of a full-time online timetable of lectures and webinars, which we believe in the absence of direct encouragement from our university may have been enough to deter some students.
Astorp et al. mention that they did not investigate what was “impeding to students”, which they say could have helped to further “guide clinicians and administrators”. However, we think trying to establish what was most important to the medical students without considering these demotivating factors makes it difficult to draw useful conclusions. Given the uncertainty of the current COVID-19 situation, we suggest an emphasis should be placed on communication between healthcare providers and universities such that if medical students are called upon to assist the workforce, they feel safe and supported whilst doing so.
References:
[1] Astorp MS, Sørensen GVB, Rasmussen S, et al. Support for mobilising medical students to join the COVID-19 pandemic emergency healthcare workforce: a cross-sectional questionnaire survey. BMJ Open. 2020;10(9)
[2] Agarwal V, Gupta L, Davalbhakta S, et al. Prevalent fears and inadequate understanding of COVID-19 among medical undergraduates in India: results of a web-based survey. J R Coll Physicians Edinb. 2020;50(3):343-350.
[3] Medical Schools Council, 2020. Statement of expectation: Medical Student volunteers in the NHS. [Online] Available at: https://www.medschools.ac.uk/media/2622/statement-of-expectation-medical... [Accessed September 2020].
We read with great interest your recent article which explores the many barriers involved in passing licensing examinations to practise in another country.
In the UK, the NHS workforce relies on, and is massively enriched by, migration. As a student here, I am interested to hear your thoughts about how the introduction of a new licensing requirement, the UKMLA, will influence physician migration and integration into the UK workforce.
From early 2024, international medical graduates who would have sat the PLAB test will start to sit the MLA instead, as will all medical students in the UK. The GMC states that 'the MLA will give patients and employers greater confidence in doctors new to working in the UK, wherever they were educated or trained' [1].
This approach is new in that it aims to provide a common approach, no matter where one has obtained their medical degree. There are arguably two possible directions in which this will go. The first possibility is that the UKMLA will indeed streamline entry in to practice in the UK, by making the requirements more consistent. Asking international graduates to sit broadly the same examination as doctors who train in the UK may also mean that there are more resources available to prepare for the examination. In the USA for example, the requirements for board licensing are largely the same for doctors who obtained their degree in America and for internati...
We read with great interest your recent article which explores the many barriers involved in passing licensing examinations to practise in another country.
In the UK, the NHS workforce relies on, and is massively enriched by, migration. As a student here, I am interested to hear your thoughts about how the introduction of a new licensing requirement, the UKMLA, will influence physician migration and integration into the UK workforce.
From early 2024, international medical graduates who would have sat the PLAB test will start to sit the MLA instead, as will all medical students in the UK. The GMC states that 'the MLA will give patients and employers greater confidence in doctors new to working in the UK, wherever they were educated or trained' [1].
This approach is new in that it aims to provide a common approach, no matter where one has obtained their medical degree. There are arguably two possible directions in which this will go. The first possibility is that the UKMLA will indeed streamline entry in to practice in the UK, by making the requirements more consistent. Asking international graduates to sit broadly the same examination as doctors who train in the UK may also mean that there are more resources available to prepare for the examination. In the USA for example, the requirements for board licensing are largely the same for doctors who obtained their degree in America and for international graduates. At face value, it does seem more fair that graduates should sit the same assessments, irrespective of where they trained.
There are some concerns regarding the introduction of the UKMLA: one could argue that far from being a leveler, different medical institutions and countries may be able to variably allocate resources towards preparing students for it, which may lead to worsening disparities. Furthermore, looking at the information from the GMC, it seems that international graduates will not quite be sitting the same assessment as UK graduates: there will possibly be variation in both content and threshold setting. Furthermore, in your article it is clear that even when the same licensing exam is used for international graduates as their peers educated within the country, the pass rate of migrant physicians is much lower. Some of the main factors seem to be age-related, a lack of time to familiarise oneself with the exam type and the language used. A key contributor to difficulties with licensing exams suggested in the article is time passed after participants' original medication. Given that the UKMLA aims to assess UK graduates whilst still at medical school, this may create disparity between UK graduates and international graduates who would presumably sit the exam later, when they would have sat the PLAB test.
To the Editor:
We appreciate the letter submitted by Dr. Mark Whelan and colleagues regarding our recently published article and very much appreciate their important suggestions. Whelan et al. pointed out that the authors have confused the standard deviation (SD) with the standard error (SE) regarding the Nelson’s trial1. After checking all the original data of included trials, admittedly, we confused the SE value with the SD value in the Nelson’s trial1. The corrected effect size is -0.92 [95% confidence interval (CI) -1.64 to -0.20] in the Nelson’s trial1. Meanwhile, the pooled effect should be corrected as -0.34 [95%CI -0.72 to 0.03] and the conclusion should be that the treatment is not effective in alleviating knee OA pain. All calculations were performed using the Review Manager 5.2. The random-effects models were built using weighted averages of the differences in means of outcomes, using the inverse variance as weights, for weighted mean differences (WMD) of outcomes reported on the same scale2.
Secondly, Whelan et al. raised a question worth thinking about that authors should alert the reader to how atypical some very large effect sizes are3-5. We are also grateful to Dr. Whelan and colleagues for this suggestion. The extreme values indicated non-random variation in effect sizes, such that a minority of interventions might have a significantly larger effects beyond the 95% CI around the standard mean difference of meta-analysis6. Especially for cer...
Show MoreWe read the article by Muche AA et al1on the predictors of postpartum glucose intolerance in women with history of GDM. The study is interesting despite the limited sample size, as the risk score developed would be useful for Ethiopia and other low-resource settings. The inclusion of the antenatal depression, dietary diversity, and level of physical activity adds value to the study. However, the study findings could have been strengthened further if the following details were provided. Firstly, what were the characteristics of the women who did not attend the post-partum OGTT? There is evidence that women with higher cardiovascular risk factors tend not to attend for the OGTT2. Secondly, what was the impact of breastfeeding? Breastfeeding has a positive impact on post-partum weight loss, which could potentially improve glucose intolerance and elevated lipid levels3.In addition, it may also have other positive benefits through other mechanisms4. Exclusive breastfeeding in Ethiopia at 59.3% is lower than international recommendations with wide variations across the regions.5Specifically, in Gondor town (place of study - Muche AA et al) the rate was reported to be 34.8% 6. This might also play a vital role in such a high glucose intolerance observed and will enable healthcare professionals to encourage women to breastfeed for their own metabolic benefit (in addition to their children, which is the primary reason for breastfeeding).Finally, did the authors have any data on ges...
Show MoreWe support the use of DSTs in the routine care of nursing home residents as adult care in nursing homes may vary from culture to culture, but the necessary standards should be on an equal plain. Quality in the care given at nursing homes is of global concern, due to the worlds aging populations. This article by N. Carey et al seek to assess views and experiences of workers in nursing homes in England and Sweden, on infection detection. The researchers were rather thorough in raising awareness to the rise in cost on a global scale, with Sweden’s healthcare system ejecting >SEK 36 trillion a year for people aged >65yrs (Havasi M. , 2020) . These exuberant cost in healthcare are according to the researchers, the direct effects of unplanned hospital admissions of nursing home residents. Therefore, decision support tools are a necessary way to reduce on these pheromones and improve on consistency and timely treatment. Nursing home staff are given the autonomy to recognize and communicate signs of deterioration, which reduces on unplanned hospital admissions. This paper seamlessly highlights the use of Decision Support Tools like “Stop and Watch” and “Early detection of Infection Scale,” both of which can be used to assess patients, catch acute condition, prioritize care, and acting promptly (Ouslander JG, 2014) (Tingström P, 2015).
References
Havasi M. . (2020). Costs of Healhcare for people aged over 65 in Sweden, Statistician Department of Finance and Gov...
Show MoreDear editors
We thank Torsy and colleagues to publish their comments on our upcoming prospective study aimed to assess the diagnostic accuracy of a combined method (auscultation and pH measurement) and ultrasonography versus an X-ray method to confirm the correct placement of the nasogastric tube (NGT), on 7 October 2020. Based on a decision analytical modelling approach proposed by Ni et al.(2017), Torsy and colleagues argue that the pH test with 5 is the safest cut-off for the verification of nasogastric feeding tube placement. However, Ni and colleagues concluded that is important to understand the local clinical environment so that appropriate choice of pH cut-offs can be made to maximize safety and to minimize the use of chest X-rays. In addition, in a recent review of 14 international guidelines to distinguish between gastric and pulmonary placement of NGT, Metheny and colleagues (2019) found considerable disagreement about the ‘best’ pH cut-point to distinguish between gastric and respiratory aspirates and that geographical location has a strong influence on recommendations for use of the pH method. In Brazil there is no national safety guideline recommending a pH cut-point. Thus, we will reconsider the set pH cut-off value to 5 to differentiate between gastric and oesophageal NGT placement in our study.
Show MoreIn their comments, Torsy and colleagues affirm that the NEX (Nose-Earlobe-Xiphoid appendix) method to calculate the NGT insertion length is not the mos...
Dear editors
We thank Rigobello and colleagues to publish their protocol of an upcoming prospective study to assess the diagnostic accuracy of a combined method (auscultation and pH measurement) and ultrasonography versus an X-ray method to confirm a correct placement of the gastric tube (Rigobello et al., 2020). The authors emphasize the importance of verifying a correct tube placement to reduce adverse events and patient safety risks. We confirm the need for such study. However, the pH cut-off value to differentiate between gastric and oesophageal NG tube placement and the NEX method to calculate the NG tube insertion length are to be discussed.
Applying a 5.5 pH cut-off to confirm the correct placement of the nasogastric (NG) tube in the stomach is debatable. Based on a decision analytical modelling approach, Ni et al. (2017) concluded a pH of ≤ 5 as an adequate cut- off value to indicate correct positioning of the NG tube tip in the stomach and therefore a non-pulmonary placement. Ni et al. (2017) concluded that the pH test with a 5.5 pH cut-off point has low sensitivity (81.0%) in detecting oesophageal placements (Ni et al., 2017). Therefore, a 5.0 pH cut-off has been adopted by several guidelines (American Society for Parenteral and Enteral Nutrition [ASPEN], 2017; American Association of Critical-Care Nurses [AACN], 2016) to confirm a non-pulmonary NG tube placement (Boullata et al., 2017; Metheny, 2016).
Rigobello et al. (2020) describe that th...
Show MoreTo the editor:
Show MoreIn a recently published article Walbaum et al. reported revisited estimates of the prevalence of chronic kidney disease (CKD) among Chilean adults and examine their association with sociodemographic characteristics, health behaviors and comorbidities (1). This study was an analysis of two periods, using nationally representative Chilean Health Surveys (CHS) performed in 2010 (CHS-2010) and 2017 (CHS-2017), respectively. They showed that the prevalence of reduced kidney function has not increased significantly between both periods; 2.5% (1.9% to 3.2%) and 3.2% (2.6% to 4.0%) respectively. However, the authors highlight that 15.4% of adults aged 40+ years in 2017 had CKD (stages 1–5). The distribution by CKD stage in this population was: 9.6% had increased albuminuria but mildly decreased, normal or high eGFR (CKD stages 1 and 2) and that 5.8% had CKD stages 3a – 5.
These findings are concordant to those reported by Zuniga et al. in 2011 on the prevalence of CKD in the adult population served in primary health centers (PHCs) in Chile (2). In that study, 27,894 clinical records of adults aged 55 ± 18 years (66% females), consulting in outpatient clinics and in whom serum creatinine was measured to calculate the estimated glomerular filtration rate (eGFR / MDRD-4), with or without assessment of urine albumin levels (albumin to creatinine ratio, ACR), were reviewed. The global prevalence of CKD was 12.1% (3,371 patients), significantly higher in women...
We would like to thank Professor Kawada for their comments on our paper.
In our retrospective cohort study, we report gender-stratified prevalence rates (Figure 3B, Figure S7) and gender-stratified odds ratios (Figure 5) for all 18 comorbidities. We discussed these results in the paper as we found that the presence of T2D was associated with significantly higher risk for comorbidities in women and similar estimates were obtained when regression models were also adjusted for deprivation.
Our team co-authored the Nowakowska et al. paper and hence we recognise the methodological differences between both studies. Nevertheless, we also reported that depression prevalence was nearly double in women than in men (16.7% vs. 9% – Figure 3). We agree on the need for care for both physical and mental comorbidities in people with T2DM, as we noted in our discussion on the need for future studies to investigate the reasons for the observed gender differences, which may inform future gender-specific multimorbidity prevention and management strategies.
We fully agree that stress management is essential for people with T2DM, as we mention in the ‘Clinical implications’ section on the clinical need for mental health interventions, especially for young patients with T2DM.
SS Zghebi, DT Steinke, MK Rutter, DM Ashcroft.
Zghebi et al. conducted a prospective study to investigate physical and mental health comorbidities in patients with type 2 diabetes (T2D) (1). By conditional logistic regression models, odds ratio (95% CI) of T2D diagnosis for myocardial infarction, heart failure, and depression were 2.13 (1.85 to 2.46), 2.12 (1.84 to 2.43), and 1.75 (1.62 to 1.89), respectively. The authors also clarified that the risk of osteoarthritis, hypothyroidism, anxiety, schizophrenia and respiratory conditions were also selected as highly prevalent comorbidities in patients with T2D. I have some concerns about their study with special reference to causal association and sex difference.
Williams et al. conducted a 5-year follow-up study to examine the effects of stress on abnormal glucose metabolism (2). The primary outcome was the development of abnormal glucose metabolism such as impaired fasting glucose, impaired glucose tolerance, and T2D, and perceived stress predicted incident abnormal glucose metabolism in women but not men. Based on the sex difference on the association, stratified analysis by sex might be needed to investigate the risk of comorbidities in patients with T2D. In addition, stress management seems important to prevent comorbidities in patients with T2D. Although the mechanism of the association would be complicated, comprehensive management is indispensable for keeping quality of life in patients with T2D.
Regarding sex difference, Nowakowska et al. evaluated c...
Show MoreDear Editor,
We read with interest the article by Astorp et al. which details the responses from questionnaires given to medical students in Denmark about what would motivate them to join the healthcare workforce in the event of a pandemic [1]. As final-year medical students in the UK (one who joined the NHS workforce as a student volunteer [OT] and one who did not [ET]), we felt that the points highlighted by Astorp et al. did not fully explore the factors affecting students’ decision to join the workforce, based on our own experiences.
The authors correctly identify their primary focus on the ‘positive’ motivational points as a limitation to their study. It is our opinion that the ‘negative’ points (i.e., what may demotivate students) are perhaps more pertinent. For example, the article mentions that personal safety was a significant concern yet fails to explore the students’ fears for the safety of their friends and family. This was a significant concern for us both and a key consideration in making the decision to volunteer or not. Fears of infecting elderly family members and other vulnerable people were also raised in a similar questionnaire given to medical students in India [2].
Astorp et al. also mention that in their results that “encouragement from their university was essential” to some students. We agree that encouragement from university, or at least explicit permission, is an important factor to consider. The UK Medical School Council...
Show MoreDear Authors,
Show MoreWe read with great interest your recent article which explores the many barriers involved in passing licensing examinations to practise in another country.
In the UK, the NHS workforce relies on, and is massively enriched by, migration. As a student here, I am interested to hear your thoughts about how the introduction of a new licensing requirement, the UKMLA, will influence physician migration and integration into the UK workforce.
From early 2024, international medical graduates who would have sat the PLAB test will start to sit the MLA instead, as will all medical students in the UK. The GMC states that 'the MLA will give patients and employers greater confidence in doctors new to working in the UK, wherever they were educated or trained' [1].
This approach is new in that it aims to provide a common approach, no matter where one has obtained their medical degree. There are arguably two possible directions in which this will go. The first possibility is that the UKMLA will indeed streamline entry in to practice in the UK, by making the requirements more consistent. Asking international graduates to sit broadly the same examination as doctors who train in the UK may also mean that there are more resources available to prepare for the examination. In the USA for example, the requirements for board licensing are largely the same for doctors who obtained their degree in America and for internati...
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