Sir,
In their recent study from Oxfordshire, Wyllie and colleagues questioned
the role that intensive infection control measures have played in
controlling the epidemic of MRSA in hospitals in their region. [1] The
authors suggest that effects of introducing intensive interventions for
MRSA may have been limited, given that stabilization and subsequent
declines in rates of MRSA occurred prior to such measures, and were...
Sir,
In their recent study from Oxfordshire, Wyllie and colleagues questioned
the role that intensive infection control measures have played in
controlling the epidemic of MRSA in hospitals in their region. [1] The
authors suggest that effects of introducing intensive interventions for
MRSA may have been limited, given that stabilization and subsequent
declines in rates of MRSA occurred prior to such measures, and were strain
-specific. They defined stages in the dynamics of the epidemic using an
approach based on quarterly count data, with visual assessment of fitted
cubic splines and join point modelling to find significant inflections in
secular trend. However, without further clarification, the methodological
assumption appeared to be that successive observations in the time-series
were independent. We believe this assumption together with a failure to
offer alternative methods of analysis raise important questions about the
authors' conclusions.
A growing number of studies in recent years have applied and
developed Time Series Analysis (TSA) techniques to study the evolution of
antimicrobial resistance, and dynamic relationships to use of antibiotics
or infection control measures, at an ecological level. [2-9] The common
underlying assumption that rates of resistance or infectious disease in a
population measured over time reveal autocorrelation (i.e. relation with
levels in previous time periods) has both construct validity and empirical
support. Autoregression is explained by both inertia and transmissibility
of resistance in a given environment: intuitively we expect observed
resistance to reflect that in prior months given that factors affecting
resistance (e.g. levels of hand-hygiene, antibiotic use) are not typically
subject to abrupt change; and risks of nosocomial acquisition are
proportional to colonisation pressures and horizontal transfer of
resistance within the patient and general population. Moreover, when time-
series of rates of infectious disease or resistance, are analyzed it is
common to detect autocorrelation.
TSA integrates a family of techniques, such as the (seasonal)
Autoregressive Integrated Moving Average ((S)ARIMA) formulation, able to
control for prior temporal behaviour, including secular trend,
seasonality, inertia and stochastic variations. Other models can be
applied to the identification of unexpected or unplanned change-points.
[10-11] Methods assuming the independence of serial data, including
linear, Poisson or negative binomial regression, fail to account for this
behaviour can lead to erroneous conclusions about the significance, or
even direction, of changes in trends. [10-12] This problem is compounded
in the study by Wyllie et al. by use of quarterly data with fitting of
cubic splines for intermediate values. The dynamics of resistance also
imply short-term variations. These rapid changes make up a seemingly
chaotic evolution that evolves around an underlying process of stochastic
nature, more or less stable in the medium term. Most literature
investigating trends in MRSA take month as the time unit and a general
principle in the study of time series is that greater aggregation of data
involves a loss of information.[ 2-9] This is of particular relevance to
the change-point analysis. Confidence-intervals extending over several
months reflect large uncertainties in the timing of declines and
relationship to specific interventions which can act over varying time-
scales.
Wyllie et al. further note that given potential spontaneous declines
in epidemic MRSA '...it was difficult to estimate how much, if any, of the
observed decline in MRSA isolations is attributable to recent infection-
control measures' and elsewhere call for randomized, rather than time-
series, designs to solve this problem.[13]. There are several reasons to
question an assumed 'hierarchy of evidence' in answering this question.
Resistance is an ecological phenomenon dependent upon population level
determinants. Any randomised trial would necessarily require multi-centre
involvement, and even then contamination between intervention and control
areas would be problematic: the global spread of specific resistant
pathogens invalidates assumptions of closed populations even at
international scales; and, as the second phase of the Safer Patients
Initiative (SPI2) demonstrates, impacts of specific interventions may be
difficult to define in the context of a 'rising tide' of quality
improvement, as exemplified by national hand-hygiene campaigns.[14] Other
issues include, prolonged time-scales required to capture delayed effects
from changes in care, standardisation of interventions and risks of
selection bias.[15] TSA can facilitate robust research alongside
implementation of national infection control strategies. Transfer models
and intervention analysis allow effects of planned interventions or
dynamic explanatory factors - which may also exhibit autocorrelation (e.g.
strain distribution)- to be determined, while accounting for secular trend
and temporal behaviour in the dependent time-series. [10-11] Moreover non-
linear, threshold and delayed effects can be modelled providing
information on the sustainability and required intensity of
intervention.[16]
We strongly support Wyllie et al's calls for more robust evidence in
this field. However, given the importance of their conclusions in terms of
future MRSA control policy and research, consideration should be given to
methodological issues mentioned in this reply.
References:
1 Wyllie DH, Walker AS, Miller R, et al. Decline of meticillin-
resistant Staphylococcus aureus in Oxfordshire hospitals is strain-
specific and preceded infection-control intensification. BMJ Open
2011;1:e000160.
2 Lopez-Lozano JM, Monnet DL, Yague A et al. Modelling and
forecasting antimicrobial resistance and its dynamic relationship to
antimicrobial use: a time series analysis. Int J Antimicrob Agents 2000;
14: 21-31.
3 Monnet DL, MacKenzie FM, Lopez-Lozano JM et al. Antimicrobial drug
use and methicillin-resistant Staphylococcus aureus, Aberdeen, 1996-2000.
Emerg Infect Dis 2004; 10: 1432-1441.
4 Muller A, Lopez-Lozano JM, Bertrand X et al. Relationship between
ceftriaxone use and resistance to third-generation cephalosporins among
clinical strains of Enterobacter cloacae. J Antimicrob Chemother 2004; 54:
173-177.
5 Mahamat A, Lavigne JP, Fabbro-Peray P et al. Evolution of
fluoroquinolone resistance among Escherichia coli urinary tract isolates
from a French university hospital: application of the dynamic regression
model. Clin Microbiol Infect 2005; 11: 301-306.
6 Monnet DL, Lopez-Lozano JM, Campillos P et al. Making sense of
antimicrobial use and resistance surveillance data: application of ARIMA
and transfer function models. Clin Microbiol Infect 2001; 7 (suppl): 29-
36.
7 Aldeyab M, Harbarth S, Vernaz N, Kearney M, Scott M, Darwish
Elhajji F, Aldiab M, McElnay J. The impact of antibiotic use on the
incidence and resistance pattern of ESBL-producing bacteria in primary and
secondary healthcare settings. Br J Clin Pharmacol. 2011; doi:
10.1111/j.1365-2125.2011.04161.x. [Epub ahead of print]
8 Church EC, Mauldin PD, Bosso JA. HYPERLINK
"http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/21460495" Antibiotic resistance in
Pseudomonas aeruginosa related to quinolone formulary changes: an
interrupted time series analysis.
Infect Control Hosp Epidemiol. 20111 Apr;32(4):400-2
9 Vernaz N, Huttner B, Muscionico D, Salomon JL, Bonnabry P, L?pez-
Lozano JM, Beyaert A, Schrenzel J, Harbarth S. HYPERLINK
"http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/21393172" Modelling the impact of
antibiotic use on antibiotic-resistant Escherichia coli using population-
based data from a large hospital and its surrounding community. J
Antimicrob Chemother. 20111 Apr; 66(4):928-35. Epub 2011 Jan 19
10 Pakratz A. Forecasting with Dynamic regression Models. New York
(NY): Wiley; 1991.
11 Liu L-M, Hudak GB: Forecasting and time series analysis using the
SCA statistical system. Chicago (IL): Scientific Computing Associates;
1994.
12 Erdelji? V, Franceti? I, Bo?njak Z, Budimir A, Kaleni? S, Bielen
L, Makar-Au?perger K, Liki? R. HYPERLINK
"http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/21277747" Distributed lags time
series analysis versus linear correlation analysis (Pearson's r) in
identifying the relationship between antipseudomonal antibiotic
consumption and the susceptibility of Pseudomonas aeruginosa isolates in a
single Intensive Care Unit of a tertiary hospital. Int J Antimicrob
Agents. 2011 May; 37(5):467-71. Epub 2011 Jan 31
13. Wyllie D, Paul J, Crook D. Waves of trouble: MRSA strain dynamics
and assessment of the impact of infection control. J Antimicrob Chemother
2011;66:2685-2688
14 Benning A, Dixon-Woods M, Nwulu U, et al. Multiple component
patient safety intervention in English hospitals: controlled evaluation of
second phase. BMJ 2011;342:d199\
15 Puffer S, Torgerson D, Watson J. Evidence for risk of bias in
cluster randomised trials: review of recent trials published in three
general medical journals. BMJ. 2003 Oct 4;327(7418):785-9.
16 Lon-Mu Liu. Time Series An?lisis and Forecasting. Snd Edition.
Chicago (IL). Scientific Computer Associates. 2009
The authors conclude "Unhealthy substance use is a risk factor for not receiving all appropriate preventive health services".
To my mind, a risk factor is something which is causally associated with something - it increases the risk. It is not the same as a marker for an increased risk.
Surely the authors meant: "Unhealthy substance use is associated with not receiving all appropriate preventive health services"...
The authors conclude "Unhealthy substance use is a risk factor for not receiving all appropriate preventive health services".
To my mind, a risk factor is something which is causally associated with something - it increases the risk. It is not the same as a marker for an increased risk.
Surely the authors meant: "Unhealthy substance use is associated with not receiving all appropriate preventive health services".
Whilst acknowledging the previous comment's valid concerns over what
constitutes an international survey, I wanted to correct the assumption
that all elective deliveries must be Caesarean sections. Most elective
deliveries prior to term are likely to be inductions of labour as per the
HYPITAT study. This may still not be relevant for the South African
setting but it is very different concept than suggested in the respons...
Whilst acknowledging the previous comment's valid concerns over what
constitutes an international survey, I wanted to correct the assumption
that all elective deliveries must be Caesarean sections. Most elective
deliveries prior to term are likely to be inductions of labour as per the
HYPITAT study. This may still not be relevant for the South African
setting but it is very different concept than suggested in the response.
Reference
Koopmans CM, Bijlenga D, Groen H, Vijgen SM, Aarnoudse JG, Bekedam
DJ, van den Berg PP, de Boer K, Burggraaff JM, Bloemenkamp KW, Drogtrop
AP, Franx A, de Groot CJ, Huisjes AJ, Kwee A, van Loon AJ, Lub A,
Papatsonis DN, van der Post JA, Roumen FJ, Scheepers HC, Willekes C, Mol
BW, van Pampus MG; HYPITAT study group. Induction of labour versus
expectant monitoring for gestational hypertension or mild pre-eclampsia
after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised
controlled trial. Lancet. 2009 Sep 19;374(9694):979-88. Epub 2009 Aug 3.
Christiaan Monden, lecturer (1), Jeroen Smits, associate professor
(2)
1. University of Oxford, 2. Radboud University Nijmegen
Vaupel, Zhang and Van Raalte (VZ&V) have made an interesting
contribution to the study of variation in length of life (or life
disparity as they call it) on the basis of life table data [1]. A
fascinating aspect of this literature is that the inequality measures that
are...
Christiaan Monden, lecturer (1), Jeroen Smits, associate professor
(2)
1. University of Oxford, 2. Radboud University Nijmegen
Vaupel, Zhang and Van Raalte (VZ&V) have made an interesting
contribution to the study of variation in length of life (or life
disparity as they call it) on the basis of life table data [1]. A
fascinating aspect of this literature is that the inequality measures that
are used - such as the Gini coefficient, Standard Deviation, Coefficient
of Variation, Interquartile Range, and also the e+ used by VZ&V - are
highly correlated, not only amongst themselves, but also with life
expectancy[2-4]. In fact, the correlation between life expectancy (LE) and
life inequality (LI) is so high (often over -0.9[4]), that one might
expect an increase in life expectancy to be almost always associated with
lower inequality.
VZ&V also observe this in their data: the country with the highest
e(0) in a given year often had the lowest inequality (e+) in that
particular year. From this finding, VZ&V seem to conclude that countries
that are leaders in life expectancy are also the most equal ones. However,
they base this conclusion on a comparison of differences between countries
within a specific year, which in our vision is not the most informative
approach in this context.
This can be seen in Figure 1 -- an adapted version of a figure
presented in our 2009 paper[4] --, in which e(0) is plotted against LI
(measured by the GINI coefficient) for 4,690 life tables. The data are for
males in 194 countries and include besides all the life tables used by
VZ&V many additional life tables we collected from other sources[5]. The
figures are for all ages (instead of 15+ as in our 2009 paper) to make
them better comparable with VZ&V. We show outcomes of tables with an e(0)
of over 40, because that range includes all life expectancy leaders of
VZ&V.
Figure 1 can be viewed here - http://dx.doi.org.ezproxy.u-pec.fr/10.6084/m9.figshare.95456
Figure 1 contains three kinds of points. The light-colored background
points show the association between LI and LE for all 4,690 country-year
combinations. The black and green points reveal the positions of the life
expectancy leaders from VZ&Vs paper (Table S4 of VZ&V; 169 leaders for
each year from 1840-2008). The black points represent the 59 leaders who
were true record breakers; they reached an e(0) level that had not been
observed before (e.g. Sweden in 1898). The green points represent follow-
up leaders; they were VZ&Vs best performers in a particular year, but at a
level of e(0) that had already been reached in the past (e.g. Norway 1899-
1901).
Figure 1 makes clear that the countries that reached a certain e(0)
first are not the most equal countries at that level of e(0). On the
contrary, in almost all years the life expectancy leaders are found in the
middle or upper part of the inequality distribution. In other words,
compared to countries that reached a certain level of life expectancy
later, the life expectancy leaders seem to perform only average (or worse)
in terms of inequality.
One might observe that at a high level of life expectancy (say an
e(0) of over 75) in Figure 1, the life expectancy leaders have relatively
low inequality. Note however that the picture at those levels is not yet
complete, as the mass of other countries has not yet arrived. Based on
what we see at the lower e(0) levels in Figure 1, it seems likely that
when the lagging countries reach e(0) of over 75, many of them will do so
at a lower level of inequality compared to VZ&Vs leaders.
Reducing premature mortality generally leads to higher life
expectancy and lower inequality in life spans. However, Figure 1 makes
clear that reaching a high life expectancy earlier than other countries
does not result in the lowest possible inequality at that life expectancy
level. An interesting question that thus remains is why many countries
that reach a certain level of life expectancy later can do so with lower
inequality.
References
1. Vaupel JW, Zhang Z, Van Raalte A. Life expectancy and disparity:
an international comparison of life table data. BMJ Open 2011;1:e000128
doi:10.1136/bmjopen-2011-000128.
2. Wilmoth JR, Horiuchi S. Rectangularization revisited: variability
of age at death within human populations. Demography 1999;36:475-95.
3. Shkolnikov V, Andreev E, Begun AZ. Gini coefficient as a life
table function. Computation from discrete data, decomposition of
differences and empirical examples. Demogr Res 2003;8:305-58.
4. Smits J, Monden C. Length of life inequality around the globe. Soc
SciMed 2009;68:1114-1123.
5. The data used for Table 1 are available at www.lengthoflife.org.
This paper from Villalbi and colleagues use a before-after design
without control group to analyse deaths due to Acute Myocardial Infarction
(AMI) in Spain from 2004-2007 and concludes "the extension of smoke-free
regulations in Spain [came into force in January 2006] was associated with
a reduction in AMI mortality, especially among the elderly". While we are
clearly in favour of this law, their imm...
This paper from Villalbi and colleagues use a before-after design
without control group to analyse deaths due to Acute Myocardial Infarction
(AMI) in Spain from 2004-2007 and concludes "the extension of smoke-free
regulations in Spain [came into force in January 2006] was associated with
a reduction in AMI mortality, especially among the elderly". While we are
clearly in favour of this law, their immediate impact on the population
coronary health is doubtful, and this paper does not help to raise doubts.
First, coronary deaths have been declining in Spain, as in other
developed countries, during the last years. Raw rates for men have changed
from 109/100,000 in 2001 to 89 in 2008 (77 to 69 for women). The most
important relative change for men was between 2004 and 2003 (before the
law implementation). Authors argument that the 2003 heat wave distort the
mortality patterns, but previous years maintain a similar pattern than
2003(1). AMI mortality rates in Spain (age-adjusted to European standard
population) for 100,000 men were: 2001: 89.5; 2002: 87.5; 2003: 87.9;
2004: 81.2; 2005: 80.0; 2006: 74,6; 2007: 72.7; 2008: 67.8; similar
figures for women were: 39.0; 38.8; 38.5; 36.2; 35.3; 31.9; 31.0; 29.2).
Second, the law did not have an additional effect in the prevalence
of cigarettes consumption. According to the Spanish National Survey on
Drug Use (EDADES, biannual periodicity) the prevalence began to decline
years before the smoke-free regulation(2). For adult men: 2001: 51.5%,
2003: 53.0 2005: 47.2%, 2007: 46.0% (for adult women in the same years:
40.5%, 42.6, 37.5%, 37.6%).
Third, while the main effect of the Spanish 2006 law was the smoking
ban in workplaces, the paper reports a higher mortality reduction in
elderly (retired people who no longer work).
Fourth, in the paper the decline of mortality rates were steeply
falling in the first 12 months after the implementation of the law. In
contrast, other study that has evaluated the impact of anti-smoke laws in
coronary mortality rates reported a modest non significant effect in the
short term(3) (1.6% CI95%: -4.0%;7.0%), but larger effects after the first
12 months (18.6% CI95%=13.6%;23.3%).
In the 70s and 80s in Spain the number of storks decreased
dramatically, and contemporary, the birth rate fell among the lowest in
the world. Policies on these birds were able to recover their number in
the 90's. In this period the Spanish birth rate increased again. The
association of uncontrolled temporal trends -specially with a very short
trend as in this study- should not be interpreted as causal (unless we are
willing to accept that babies come from Paris).
Therefore, in the absence of other evidences we should be cautious
about establishing causal relationships between the decrease in coronary
deaths and one specific policy. As much as we favour that policy,
scientific causality has other rules.
References:
1.Instituto de Salud Carlos III. Ministerio de Ciencia e Innovacion.
Mortalidad Espana y comunidades autonomas. Available:
http://www.isciii.es/htdocs/centros/epidemiologia/anexos/ww9201_cau.htm
2. Ministerio de Sanidad, Politica Social e Igualdad. Encuesta
Domiciliaria Sobre Alcohol y Drogas en Espana (EDADES). Available:
http://www.pnsd.msc.es/Categoria2/observa/estudios/home.htm
3.Dove MS, Dockery DW, Mittleman MA, Schwartz J, Sullivan EM, Keithly
L, et al. The impact of Massachusetts' smoke-free workplace laws on acute
myocardial infarction deaths. Am J Public Health. 2010;100:2206-12.
The above article focused on the prevalence of factors associated with increased risk of pregnancy hypertension and pre-eclampsia period: an international comparative study. The countries involved were Australia, Canada, Denmark, Norway, Scotland, Sweden and USA.
The key message from this study is that pregnancy hypertension and pre-eclampsia remain global health concerns in both developed and developing countries. This type of s...
The above article focused on the prevalence of factors associated with increased risk of pregnancy hypertension and pre-eclampsia period: an international comparative study. The countries involved were Australia, Canada, Denmark, Norway, Scotland, Sweden and USA.
The key message from this study is that pregnancy hypertension and pre-eclampsia remain global health concerns in both developed and developing countries. This type of study is important because it informs policy makers that there are unique and complex factors that may reduce the rates of pregnancy hypertension and pre-eclampsia. The knowledge learned from the study on these factors (risk of pregnancy hypertension and progression of pre-eclampsia) will assist policy makers to use interventions such as different International Classification of Diseases coding versions to identify and describe such factors. As a South African Primary health care nurse I am concerned about the translation of the study into community/primary health care practice. In the remote areas where the majority of Primary health care services are provided, nurses may not be familiar with the International Classification of Diseases (ICD) coding version, and may not even have access to ICD. I really like this study and it makes me to think on how primary health care nurses in South Africa practice without knowledge of the ICD version on the interpretation of the prevalence of pregnancy hypertension and pre-eclampsia. I therefore recommend that policy makers in South Africa should train their primary health care nurses on the use of ICD and should make sure that accessibility of such intervention is ensured.
I found this article that highlights junior doctors' lack of
awareness with regard to the procedures in case of a major incident,
interesting. It covers an important aspect of emergency planning and
preparedness, which stimulated my thinking. As a health professional
educator, the article's findings drew to my attention the need to
strengthen the integration of such procedures into the pre-service...
I found this article that highlights junior doctors' lack of
awareness with regard to the procedures in case of a major incident,
interesting. It covers an important aspect of emergency planning and
preparedness, which stimulated my thinking. As a health professional
educator, the article's findings drew to my attention the need to
strengthen the integration of such procedures into the pre-service
curriculum. Education institutions that train health professionals have
the responsibility of preparing new graduates with the necessary
competencies so that they can practice effectively. The mastery of such
competencies allows smooth running of hospitals especially in case of
major incidents that require professionals to know how to respond quickly.
A teaching intervention was implemented to raise the awareness of
major incidents and related procedures. The advantages of in-service
training such as this have been documented in the literature and this
intervention was noted to be highly effective when assessed immediately
after the intervention. However, many in-service training interventions
result in positive changes but such changes tend to be short-lived. It has
been documented that benefits of in-service training on various aspects of
care do not last long with regard to changing practice (Gammon, Morgan-
Samuel & Gould, 2008, Opiyo & English, 2010). As health
professional educators, we need to recognize that in-service training can
only act as a supplement to comprehensive pre-service training.
A final issue to consider is to establish the level of awareness in
other professions that have a role in managing a major incident. In case
of such an incident, all health professionals, such as nurses,
pharmacists, laboratory technicians, need to be well prepared to be able
to act effectively and efficiently. Establishing this ensures timely
intervention to prepare all health professionals in case of a major
incident.
Gammon J, Morgan-Samuel H & Gould D (2008) A review of the
evidence for suboptimal compliance of healthcare practitioners to
standard/universal infection control precautions. Journal of Clinical
Nursing 17, 157-167
Opiyo N, English M. (2010) In-service training for health
professionals to improve care of the seriously ill newborn or child in low
and middle-income countries (Review). Cochrane Database of Systematic
Reviews, Issue 4. Art. No.: CD007071. DOI: 10.1002/14651858.CD007071.pub2
The fact that a high percentage of patients with locked-in syndrome
(LIS) shows an unexpected well-being does not surprise us, but we are very
interested in this. The first part of the work carried out by Bruno and
colleagues provides a basis for researchers to formulate new working
hypotheses in patients who have a lesion that is so localised and yet
leads to such a complex mosaic of consequences on a functional level. I...
The fact that a high percentage of patients with locked-in syndrome
(LIS) shows an unexpected well-being does not surprise us, but we are very
interested in this. The first part of the work carried out by Bruno and
colleagues provides a basis for researchers to formulate new working
hypotheses in patients who have a lesion that is so localised and yet
leads to such a complex mosaic of consequences on a functional level. In
the conclusions authors raise some additional ethical questions about this
challenging group of patients. We have identified a series of 'syndromes
within the syndrome' in patients with LIS due to ventral pontine damage
(pathological laughter and crying, motor imagery impairment and a
selective impairment in the recognition of facial expressions).1-3 At the
same time we found, albeit in a much smaller group of subjects, values
almost comparable to those of the general population in self-reported
Quality of Life.4 This is neurology; this is science and science must stop
here.
Prof. Savulescu attacks the work of Bruno et al., saying that this is the
classic research approach of those opposing euthanasia. In other words the
'ethical' conclusions would invalidate empirical data on the grounds that
these tendentially favour a certain ethical or political vision of the
world (and therefore are prejudiced). In our opinion, an alternative
approach, based not on scientific findings but rather on moral and/or
political motivations, would be prejudiced too. We find ourselves asking
"Who is invading whom?" Is politics invading science, or is science
invading politics? This would be a rhetorical question had we not arrived
at this point of convergence. Either Prof. Savulescu denies that the data
presented by Bruno et al. have scientific value on the basis that they go
against common sense (and asks Bruno and colleagues to 'abjure') or he
claims that the data are false. Yet in our opinion there is a third way to
proceed: separating science from politics and ethics. A disconnection that
must be clean and definitive.
1. Pistoia F, Conson M, Trojano L, Grossi D, Ponari M, Colonnese C,
Pistoia ML, Carducci F, Sara' M. Impaired conscious recognition of
negative facial expressions in patients with locked-in syndrome. J
Neurosci 2010;30:7838-7844.
2. Conson M, Sacco S, Sara' M, Pistoia F, Grossi D, Trojano L.
Selective motor imagery defect in patients with locked-in syndrome.
Neuropsychologia 2008;46:2622-2628.
3. Sacco S, Sara' M, Pistoia F, Conson M, Albertini G, Carolei A.
Management of pathologic laughter and crying in patients with locked-in
syndrome: a report of 4 cases. Arch Phys Med Rehabil 2008;89:775-778.
4. Pistoia F, Conson M, Sara' M. Opsoclonus-myoclonus syndrome in
patients with locked-in syndrome: a therapeutic porthole with gabapentin.
Mayo Clin Proc 2010;85:527-531.
I read with great interest the article "Doctors accessing mental-
health services: an exploratory study" by Josephine Stanton and Patte
Randal and the response posted by Andrew K Ntanda and I would agree that
this group of doctors should consider accessing individual psychotherapy.
My training region also offers support to doctors with Mental Health and
other problems I would like to direct any reade...
I read with great interest the article "Doctors accessing mental-
health services: an exploratory study" by Josephine Stanton and Patte
Randal and the response posted by Andrew K Ntanda and I would agree that
this group of doctors should consider accessing individual psychotherapy.
My training region also offers support to doctors with Mental Health and
other problems I would like to direct any readers to their deanery website
to find out about availability of any similar services in their region.
From a very personal perspective I suffered from moderate post natal
depression following a c-section which coincided with the
completion of my CCST. I accessed the relevant service and found it most
helpful. However I also sought help and advice from my consultant
supervisor, a decision I now deeply regret. Since disclosing my
difficulties I have been unable to gain any consultant post. While this
may seem to the reader to be a case of sour grapes or perhaps slightly
over-sensitive on my part it has been difficult to shake the feeling that,
perhaps, by disclosing my difficulties I have made myself unemployable.
For this reason I would very much like to see further studies that
consider the longitudenal impact on doctors who access help for their
mental health difficulties and further to this their subsequent career
trajectories. Such a study may help allay the fears described by
participants in Stanton and Randal's paper and enable them to adopt
appropriate health seeking behaviours. Moreover I hope such studies will
enable the profession to be more self reflective and cease out-grouping
those of our peers with conditions that traditionally attract stigma.
Yours faithfully
Anon
Conflict of Interest:
None declared
The author of this e-letter has identified herself to the journal but requested to remain anonymous.
This sort of research demonstrating remarkable adaptation is often
used by anti-euthanasia lobbyists to argue that assisted suicide and
euthanasia should not be offered to such people because they come to value
their life. They find meaning. However, that conclusion is not warranted.
Some do want to die and should be allowed to die. The lesson that should
be learnt is the one authors draw: you should wait to see how you a...
This sort of research demonstrating remarkable adaptation is often
used by anti-euthanasia lobbyists to argue that assisted suicide and
euthanasia should not be offered to such people because they come to value
their life. They find meaning. However, that conclusion is not warranted.
Some do want to die and should be allowed to die. The lesson that should
be learnt is the one authors draw: you should wait to see how you adapt.
But, if after waiting a suitable time, you want to die, you should be
allowed or helped to die. The authors adopt a similar moderate view. " In
our view, shortening-of-life requests by LIS patients are valid only when
the patients have been given a chance to attain a steady state of SWB."
But this is too paternalistic. If a competent person does not want to
wait, and has been advised of this kind of research and the possibility of
adaptation, but still wants to die, he should be allowed to die. It is
hard paternalism to keep people alive when they competently and informedly
want to die.
This kind of research is also used to call into question the validity
of living wills or advance directives. However it provides no grounds for
questioning the validity of living wills. It provides reasons to make sure
people are aware of the phenomenon of adaptation before completing a
living will. Imagine that I know I will be happy some years after having
developed locked-in syndrome. Can I now validly ask doctors to allow me to
die at the time I have a massive stroke that will leave me locked-in? Yes.
I can refuse any medical treatment, even if I am having a perfectly good
life. Jehovah's Witnesses do this when they refuse life-saving blood
transfusion.
What makes each person's own living hell is a matter for that person.
It is subjective. And we can adapt to hell. That is important for all of
us to know. But it does not change the rights of individuals to make what
they will of their lives, including choosing the conditions under which
and the time to end them.
Conflict of Interest:
Stephen Laureys is a collaborator with our Oxford Centre for Neuroethics which I direct
Sir, In their recent study from Oxfordshire, Wyllie and colleagues questioned the role that intensive infection control measures have played in controlling the epidemic of MRSA in hospitals in their region. [1] The authors suggest that effects of introducing intensive interventions for MRSA may have been limited, given that stabilization and subsequent declines in rates of MRSA occurred prior to such measures, and were...
Whilst acknowledging the previous comment's valid concerns over what constitutes an international survey, I wanted to correct the assumption that all elective deliveries must be Caesarean sections. Most elective deliveries prior to term are likely to be inductions of labour as per the HYPITAT study. This may still not be relevant for the South African setting but it is very different concept than suggested in the respons...
Christiaan Monden, lecturer (1), Jeroen Smits, associate professor (2)
1. University of Oxford, 2. Radboud University Nijmegen
Vaupel, Zhang and Van Raalte (VZ&V) have made an interesting contribution to the study of variation in length of life (or life disparity as they call it) on the basis of life table data [1]. A fascinating aspect of this literature is that the inequality measures that are...
Dear Editor,
This paper from Villalbi and colleagues use a before-after design without control group to analyse deaths due to Acute Myocardial Infarction (AMI) in Spain from 2004-2007 and concludes "the extension of smoke-free regulations in Spain [came into force in January 2006] was associated with a reduction in AMI mortality, especially among the elderly". While we are clearly in favour of this law, their imm...
Dear Editor,
I found this article that highlights junior doctors' lack of awareness with regard to the procedures in case of a major incident, interesting. It covers an important aspect of emergency planning and preparedness, which stimulated my thinking. As a health professional educator, the article's findings drew to my attention the need to strengthen the integration of such procedures into the pre-service...
The fact that a high percentage of patients with locked-in syndrome (LIS) shows an unexpected well-being does not surprise us, but we are very interested in this. The first part of the work carried out by Bruno and colleagues provides a basis for researchers to formulate new working hypotheses in patients who have a lesion that is so localised and yet leads to such a complex mosaic of consequences on a functional level. I...
Dear Editor
I read with great interest the article "Doctors accessing mental- health services: an exploratory study" by Josephine Stanton and Patte Randal and the response posted by Andrew K Ntanda and I would agree that this group of doctors should consider accessing individual psychotherapy. My training region also offers support to doctors with Mental Health and other problems I would like to direct any reade...
This sort of research demonstrating remarkable adaptation is often used by anti-euthanasia lobbyists to argue that assisted suicide and euthanasia should not be offered to such people because they come to value their life. They find meaning. However, that conclusion is not warranted. Some do want to die and should be allowed to die. The lesson that should be learnt is the one authors draw: you should wait to see how you a...
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