This is indeed an important finding on several levels, yet it remains
difficult in
translating this into clinical practice. I have found myself even more
ambivalent about suggesting SMBG to patients reasonably well-controlled on oral anti-diabetes medications.
In an effort to translate these findings, I propose the following
practical
suggestions.
1. For patients struggling to comply with health care...
This is indeed an important finding on several levels, yet it remains
difficult in
translating this into clinical practice. I have found myself even more
ambivalent about suggesting SMBG to patients reasonably well-controlled on oral anti-diabetes medications.
In an effort to translate these findings, I propose the following
practical
suggestions.
1. For patients struggling to comply with health care
recommendations, we
now know that SMBG does not need to be as high a priority in our
counseling.
2. For patients struggling to afford all the components necessary to
actually
perform SMBG (e.g., glucometer, strips, lancets), this now becomes an area
of
potential cost savings. Freeing up their limited discretionary income
might
allow them to afford a nutrition consultation, important medications or
other
expensive interventions with better evidentiary support.
3. For patients fully complying with SMBG, this might be a time to
allow them
to check their BG less frequently (e.g., Tuesday and Friday, fasting and
post-prandial, and prn for signs and symptoms of hypoglycemia and/or
hyperglycemia) instead of at their current rate.
Finally, since there is potential to have a critical study in the
future overturn
these recommendations, I am choosing to use caution both in how I explain
this study and in discontinuing anyone from SMBG.
Re: editorial BMJ 5th April 2008 Volume 336 pages 729-30: Improving uptake of MMR vaccine - Recognising and targeting between population groups are the
priorities
Dear Editor,
In the editorial on improving uptake of MMR vaccine, no mention was made
of the parents who decline MMR vaccination on ethical grounds.
The rubella vaccine component of MMR is derived from an aborted human
fetal cell line. The Takah...
Re: editorial BMJ 5th April 2008 Volume 336 pages 729-30: Improving uptake of MMR vaccine - Recognising and targeting between population groups are the
priorities
Dear Editor,
In the editorial on improving uptake of MMR vaccine, no mention was made
of the parents who decline MMR vaccination on ethical grounds.
The rubella vaccine component of MMR is derived from an aborted human
fetal cell line. The Takahasi rubella vaccine is a safe and effective
alternative. It is extremely difficult to access the Takahasi rubella
vaccine, grown on animal cell lines, due to import licence
restrictions. (Measles and mumps vaccines are not grown on aborted human
fetal cell lines. For those who can afford them, it is still possible to
have separate immunisations against measles and mumps.)
To achieve the goal of 95% immunisation several strategies should be
employed which also recognise diversity in the population. In 1994,Kenneth
Calman, then Health Minister, promised the Joint Faith Committee that an
ethical vaccine would be made available. However,as noted previously,
access to an ethical rubella vaccine has been made even more difficult.
Only coercive strategies to improve
completion of immunisation were mentioned in the article and the term
'..require legislative action..' (Ref 12) was used.
Are we now facing compulsory vaccination?
Ref 12 SalmonDA, TeretSP, MacIntyreCR, SalisburyD, BurgessMA,
Halsey NA. Compulsory vaccination and conscientious or philosophical exemptions:past present and future. Lancet 2006;367:436-42.
We agree with doctors Evans and Hadler that our clinical decision
rule[1] should be validated in another setting and that it should be shown
to cause more good than harm before it could be widely used. Our study was
a first step in the process of developing a predictive tool for the
occupational outcome of back pain. In a next phase of development, not
only should the rule be validated in a new group of...
We agree with doctors Evans and Hadler that our clinical decision
rule[1] should be validated in another setting and that it should be shown
to cause more good than harm before it could be widely used. Our study was
a first step in the process of developing a predictive tool for the
occupational outcome of back pain. In a next phase of development, not
only should the rule be validated in a new group of subjects, but it
should also be compared with the judgment of clinicians; a decision tool
that is no better than the clinician’s own judgment is of no interest. If
the tool adds significantly to the clinician’s judgment, then the impacts
of its systematic use could be further studied.[2]
Evans and Hadler are also right to be cautious about the performance
of the rule. However, it includes a subset of predictors selected among
more than 100 variables, several of which measured at baseline, 6 weeks
and 12 weeks. We are confident to have identified the best predictors. As
we have recognized ourselves in the paper, the rule is however far from
perfect. But in its appreciation, it is also very important to understand
the limitations of the methods that are currently available to quantify
the performance of our model: for example, because classical measures of
concurrent validity ask for dichotomous outcomes, we had to regroup the
outcome categories and this tended to dilute the performance of the rule.
The alternative approach of comparing each group with the “Success” group
would have resulted in much better indices of predictive validity, but
they would however have been artificial, since the physician always works
from the complete pool of patients. Again, the real test will come from
comparisons with the clinicians’ judgment.
We do not believe that “return to work in good health” is an
“unstable psychosocial construct”. It was clearly defined and is certainly
clinically important. In many instances, this is the kind of outcomes on
which the primary care physician is asked to give a prognosis. It is,
obviously, not easy to predict. Should we then abandon our efforts because
the task is too difficult?
The interpretation Evans and Hadler seem to give to our results, as
to the association of the patient’s “own premonition” with their future
status, is clearly flawed. In a predictive statistical approach as the one
we have used, there is no intent to identify causal associations and there
is no adjustment for confounders.[3] All that can be said about this
association is that this variable is one of the most useful to predict the
outcome. Why not use it then? Others have also found patients’ recovery
expectations to be strongly linked with different health outcomes.[4-7]
Finally, interpreting Figure 2 of the paper to say that the outcome
at 12 weeks had a predictive accuracy of >90% is, unfortunately, too
simple: at 12 weeks, only 52% of subjects were in the “Success” category.
Forty-eight percent were in the other categories, and there was a
difference of 7.3% in “Failures” between 12 weeks and 2 years. Given that
the largest part (>80%) of the costs of back pain comes from a small
minority (<10%) of patients, this is not trivial.
References
1. Dionne CE, Bourbonnais R, Frémont P, Rossignol M, Stock SR,
Larocque I. A clinical return-to-work rule for patients with back pain.
Cmaj 2005;172(12):1559-1567.
2. Laupacis A, Sekar N, Stiell IG. Clinical prediction rules. A
review and suggested modifications of methodological standards. Jama
1997;277(6):488-494.
4. Cole DC, Mondloch MV, Hogg-Johnson S. Listening to injured
workers: how recovery expectations predict outcomes--a prospective study.
Cmaj 2002;166(6):749-754.
5. Kalauokalani D, Cherkin DC, Sherman KJ, Koepsell TD, Deyo RA.
Lessons from a trial of acupuncture and massage for low back pain: patient
expectations and treatment effects. Spine 2001;26(13):1418-1424.
6. Kiyak HA, Vitaliano PP, Crinean J. Patients' expectations as
predictors of orthognathic surgery outcomes. Health Psychol 1988;7(3):251-
268.
7. Mondloch MV, Cole DC, Frank JW. Does how you do depend on how you
think you'll do? A systematic review of the evidence for a relation
between patients' recovery expectations and health outcomes. Cmaj
2001;165(2):174-179.
Looking at the effectiveness of actions for well-child care makes us
forget that paediatricians are specialists and not primary care givers in
our health care system.
Specialists are the best professionals to deal with pathology and complex
problematic health situations for children. I think that well child should
be followed by a family doctor, having time to do prevention by education
and screening....
Looking at the effectiveness of actions for well-child care makes us
forget that paediatricians are specialists and not primary care givers in
our health care system.
Specialists are the best professionals to deal with pathology and complex
problematic health situations for children. I think that well child should
be followed by a family doctor, having time to do prevention by education
and screening. The complementarity of the level of care would add to the
effectiveness of care.
We can use the same analogy in maternity care, using GP and midwives for
primary care (the normal), and using obstetricians/gynecologist for
pathology and high risk situations.
The recommended interventions should be supported by evidence but the
organisation of care itself should be supported by evidence too.
This is indeed an important finding on several levels, yet it remains difficult in translating this into clinical practice. I have found myself even more ambivalent about suggesting SMBG to patients reasonably well-controlled on oral anti-diabetes medications.
In an effort to translate these findings, I propose the following practical suggestions.
1. For patients struggling to comply with health care...
Re: editorial BMJ 5th April 2008 Volume 336 pages 729-30: Improving uptake of MMR vaccine - Recognising and targeting between population groups are the priorities
Dear Editor,
In the editorial on improving uptake of MMR vaccine, no mention was made of the parents who decline MMR vaccination on ethical grounds. The rubella vaccine component of MMR is derived from an aborted human fetal cell line. The Takah...
Dear Editor,
We agree with doctors Evans and Hadler that our clinical decision rule[1] should be validated in another setting and that it should be shown to cause more good than harm before it could be widely used. Our study was a first step in the process of developing a predictive tool for the occupational outcome of back pain. In a next phase of development, not only should the rule be validated in a new group of...
Dear Editor,
Looking at the effectiveness of actions for well-child care makes us forget that paediatricians are specialists and not primary care givers in our health care system. Specialists are the best professionals to deal with pathology and complex problematic health situations for children. I think that well child should be followed by a family doctor, having time to do prevention by education and screening....