BioMed Central - Latest comments

A response to readers comments and questions

Karleen Gribble — 2012-01-29T02:58:18Z

After the publication of our paper ¿Emergency preparedness for those who care for infants in developed country contexts¿ the authors received questions, helpful comments and suggestions for possible modification of emergency kits for babies. We would like to respond.

Several health professionals and mothers questioned whether there was a place for a chemical sterilisation process in emergencies. Chemical sterilisation could be used in an emergency situation however, there would be little benefit to doing so. Thorough washing using hot water of feeding and preparation implements is required before sterilisation. Furthermore the water used for chemical sterilisation needs to be renewed every 24 hours. Thus, avoiding sterilisation by boiling by using chemical sterilisation would only save a small amount of water and fuel.

Some have questioned the volume of water required for hand washing, suggesting that much less water is required. The authors allowed 500 mL for each hand washing. This figure was chosen after discussion with Water, Sanitation and Hygiene (WASH) specialists in the humanitarian sector. It should be recognised that in an emergency situation, contamination of surfaces with waste is common and hands can become very soiled. Five hundred millilitres to thoroughly clean dirty hands is a conservative estimate based on field experience. However, the authors recognise that there is no research to indicate how much water is needed to thoroughly clean hands and that such research would be welcome.

Reducing the volume of water required to be stored in the ready-to-use infant formula kit is possible if disposable knifes can be used to open the containers of ready-to-use infant formula. This would reduce the amount of water required to be stored to 56L. Disposable knifes might be either high quality plastic knives that are intended to be disposable or metal knifes that are intended to be reusable but are disposed of after a single use. Care needs to be taken to ensure that the knives are sharp enough and strong enough to open the containers.

The authors have been made aware that in some locations it is possible to purchase ready-to-use infant formula in disposable bottles and with disposable teats. This option may be more cost effective and take less space to store than purchasing ready-to-use infant formula and bottles and teats separately. However, use of this product still requires the opening of the bottle before assemblage with the teat. Therefore water to clean hands and a preparation area are still required. This option does not materially change the requirements for the ready-to-use infant formula kit.

Some mothers expressed confusion about the amount of ready-to-use infant formula that needs to be stored, stating that they believed that the volume suggested was excessive. It should be understood that the amount of ready-to-use formula stored needs to be based both on the anticipated volume of milk that the infant would be expected to consume and the number of feeds per day that the infant is expected to need. This is because once a package of formula is opened it must be fed immediately to the infant and any leftover formula discarded; left over infant formula cannot be saved to be fed to the infant later. Thus, if an infant requires frequent small feeds (most likely in a very young infant), the amount of formula that needs to be stored may be much greater than the volume that the infant will actually consume because of the number of feeds required each day.

One mother suggested to the authors that it would be possible to reconstitute powdered infant formula with stored water in disposable bottles, negating the need for heating water for cleaning and sterilisation. This would require storage of the same number of bottles and teats as for the ready-to-use infant formula kit but also make it more feasible to use powdered infant formula in an emergency situation. This option has some risks. In particular, reconstitution of powdered infant formula with cool water does not deactivate any bacteria present in the infant formula. Whilst intrinsic contamination of powdered infant formula is common [1], infection causing illness as a result, is rare. However, it should be noted that medical resources required to treat infections may not be readily available during emergencies.

It should also be noted that the risk of infection differs depending on characteristics of the infant with newborns, premature or low birth weight infants and infants otherwise immunocompromised over represented amongst those infected [2]. Mothers with healthy older infants may decide that the risk posed by intrinsic contamination of powdered infant formula is acceptable and that they are willing to reconstitute infant formula with water at ambient temperature.

The other factor to consider is the quality of water for reconstitution. Ordinary bottled water is not sterile and can contain levels of microbes greater than that in tap water [3]. Tap water itself can be contaminated with disease causing organisms [4-6]. Long-term storage of water can allow bacterial proliferation [7]. Guidelines for the safe storage of water for emergency use are available and include practices such as rinsing storage containers with bleach prior to use, limiting storage to six months and chlorination of water [8, 9]. In some locations it is possible to purchase sterile water for reconstitution of infant formula.

Given that the option of reconstituting powdered infant formula in disposable bottles involves practices that are more likely to result in the infant formula containing higher levels of bacterial contamination than is usually the case, it is even more important that the formula be fed immediately to the infant and the unused portion discarded immediately.

If considering using powdered infant formula with disposable bottles in an emergency kit, caregivers should ensure that the volumetric measurements on the feeding bottle are accurate. Clinical experience has shown that volumetric measurements on feeding bottles can be inaccurate and if the bottle is used to measure water for reconstitution, errors resulting in over or under-dilution of the infant formula can occur

Thus, while reconstitution of powdered infant formula in disposable bottles is certainly feasible, the risks associated with it require careful consideration. It is unlikely that this option would be recommended by health authorities because of these risks. If individual caregivers decide that this option is one that they wish to use, ensuring that they understand how to minimise the risks is important. The risks of this option are decreased if the infant is older, has no history of low birth weight, prematurity or immunocompromise, if sterile water is used for reconstituting the powdered infant formula and if the formula is fed immediately to the infant.

Some concerns were raised about the cost of the emergency kits for formula fed infants. The figures provided were based on the cost of purchasing the products at one of Australia¿s major supermarkets. The cost is likely to vary widely depending upon location and the ability of the individual to source the cheapest possible products. It should be recognised however, that in the event of an approaching emergency (such as a cyclone or hurricane) that caregivers will have limited options for sourcing the items in the kits and costs may be much greater than those provided in the paper.

The authors would welcome further comment and questions from health professionals and parents.

Karleen D Gribble
Nina J Berry

1. Forsythe SJ: Enterobacter sakazakii and other bacteria in powdered infant milk formula. Maternal and Child Nutrition 2005, 1:44-50.
2. WHO, FAO: Enterobacter sakazakii and other microorganisms in powdered infant formula. Geneva: WHO; 2004.
3. Lalumandier JA, Ayers LW: Fluoride and bacterial content of bottled water vs tap water. Archives of Family Medicine 2000, 9:246-250.
4. Almeida A, Moreira MJ, Soares S, Delgado ML, Figueiredo J, Silva E, Castro A, Cosa JM: Presence of Cryptosporidium spp. and Giardia duodenalis in drinking water samples in the north of Portugal. Korean Journal of Parasitology 2010, 48:43-48.
5. Rudi K, Tannaes T, Vatn M: Temporal and spatial diversity of the tap water microbiota in a Norwegian hospital. Applied and Environmental Microbiology 2009, 75:7855-7857.
6. Xi C, Zhang Y, Marrs CF, Ye W, Simon C, Foxman B, Nriagu J: Prevalence of antibiotic resistance in drinking water treatment and distribution systems. Applied and Environmental Microbiology 2009, 75:5714-5718.
7. Morais PV, Da Costa MS: Alterations in the major heterotrophic bacterial populations from a still bottled mineral water. Journal of Applied Bacteriology 1990, 69:750-757.
8. Food and Water Concerns [http://www.bt.cdc.gov/disasters/earthquakes/food.asp]
9. Water [http://www.fema.gov/plan/prepare/water.shtm]

concerns about study method

Katja Taxis — 2012-01-26T16:40:52Z

Szczepura et al have written an interesting and certainly important study on medication administration errors for older people in long-term residential care. My primary concern about this study is the term ¿disguised observation method¿ they use in the method section to describe their data collection. To support their data collection method, they specifically refer to a study by van den Bemt et al. (2009).
Within medication administration error research ¿disguised observation¿ is the observation of actual administration using independent observers as has been used in the study by van den Bemt et al. (2009) and in many other studies (e.g. Taxis et al. 2003). Observers are present and accompany staff during medication rounds recording all details of drug preparation and administration. Several methodological studies have confirmed this to be a valid and reliable method to establish the frequency of medication administration errors. It is therefore considered the ¿gold standard¿ method in this field (Allan Flynn et al. 2002; Dean and Barber 2001)
However, closely examining the method of data collection described by Szczepura shows that data on medication administrations were extracted from the central data base linked to the barcode medication administration system. This would suggest that an independent observer has not been present during medication rounds. Some types of error may not be possible to identify from electronic records, e.g. crushing of tablets with modified release, an error known to be relevant in long-term residential care.
The authors should clarify this point as well as discussing the possible limitations of not using observation of actual practice for their data.

Katja Taxis
Professor of Pharmacotherapy and Clinical Pharmacy
Department of Pharmacy
Section of Pharmacotherapy and Pharmaceutical Care
University of Groningen, The Netherlands

Reference List
Allan Flynn E, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled nursing facilities. Am J Health-Syst Pharm 2002; 59:436-446.

Dean B, Barber N. Validity and reliability of observational methods for studying medication administration errors. Am J Health-Syst Pharm 2001; 58:54-59.

van den Bemt PM, Idzinga JC, Robertz H, Kormelink DG, Pels N: Medication
administration errors in nursing homes using an automated medication
dispensing system. J Am Med Inform Assoc 2009, 16(4):486-492.

Taxis K, Barber N. Ethnographic study of incidence and severity of intravenous drug errors. BMJ 2003; 326:684-687.

Correction to recruitment data.

Janet de Moor — 2012-01-26T11:08:48Z

The manuscript contains a typographical error on page 2, under Eligibility Criteria and Sample Recruitment. There were 773 survivors who were alive and eligible for PFH-2, not 733 as reported in the paper.

About the use of GADS as outcome measure

Enric Aragonès — 2012-01-25T10:50:55Z

The Goldberg¿s Anxiety and Depression Scales (GADS) are heteroapplied questionnaires that were derived by latent trait analysis from a standardized psychiatric research interview. They were designed and calibrated to aid general practitioners and other non-psychiatrists in the better recognition of anxiety and depression [1].
These scales were translated and validated as screening tool in Spanish primary care patients by Monton et al. [2] Afterward, these scales were recommended as a screening test by the Program of Preventive Activities and Health Promotion (PAPPS) of the Spanish Society of Family and Community Medicine (semFYC) and they became widely known among Spanish GPs [3].
However, in this research protocol the GADS anxiety sub-scale is proposed to use not as a tool for detection, but as a primary outcome measure by means of monitoring changes in anxiety severity.
As far as we know, this questionnaire is not designed for this purpose and there are no studies examining its operability as an instrument to monitor the symptomatic progression of anxiety or depression symptoms. We have reviewed some systematic reviews of therapeutic interventions for anxiety disorders [4,5,6] and we have seen that there are no clinical trials using the GADS as an outcome measurement.
We advocate using a well validated test to measure the clinical outcomes with reliability. Otherwise, this methodological error may cause difficulties to properly interpret the results of the evaluation, and also difficulties to pass the filters of editors and peer-reviewers when the authors want to publish their report.

1. Goldberg D, Bridges K, Duncan-Jones P, Grayson D. Detecting anxiety and depressionin general medical settings. Br Med J 1988; 297:897-9.
2. Montón C, Pérez-Echevarría MJ, Campos R, et al. Escalas de ansiedad y depresión de Goldberg: una guía de entrevista eficaz para la detección del malestar psíquico. Aten Primaria 1993; 12: 345-9.
3. Tizón García JL, Buitrago Ramírez F, Ciurana Misol R, Chocrón Bentata L, Fernández Alonso C, García Campayo J, Montón Franco C, Redondo Granado MJ. Prevención de los trastornos de salud mental desde la atención primaria. Aten Primaria 2003;32(Supl 2):77-101.
4. Hunot V, Churchill R, Silva de Lima M, Teixeira V. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev. 2007;(1):CD001848.
5. Kapczinski F, Lima MS, Souza JS, Schmitt R. Antidepressants for generalized anxiety disorder. Cochrane Database Syst Rev. 2003;(2):CD003592.
6. Depping A, Komossa K, Kissling W, Leucht S. Second-generation antipsychotics for anxiety disorders. Cochrane Database Syst Rev. 2010;(12):CD008120.

in support of KT training

David Phipps — 2012-01-25T10:16:56Z

Having recently presented at a knowledge brokers forum in the UK there is international interest in capacity building for knowledge brokering, more than we usually do through individual peer sessions and one off workshops. As valuable as these are for supporting and sustaining knowledge brokering there is a need for accredited knowledge brokering training. 30 years into technology transfer that industry has established a series of accredited training courses for tech transfer. We need the same degree of rigour in training for knowledge brokering. The KTPC session described in the previous comment by Melanie Barwick has been accredited by Univ. Toronto. We need more KTPC across Canada

Typographical error in Table 1

James Hane — 2012-01-24T11:55:22Z

In the fourth line of Table 1 (beginning "CpT"), the 3rd and 4th columns ("ApA ApG") should instead read ("ApG ApA").

Comment on Belda-Lois et al.

william rymer — 2012-01-23T10:28:36Z

This review focuses on assessing the impact of a wide range of rehabilitation therapies promoting gait recovery after hemispheric stroke. The review emphasizes the role of reorganizing the central nervous system in promoting gait recovery, by contrasting this approach with classical therapies targeting peripheral neuromuscular interventions. The review is detailed, broad and comprehensive.

The authors affirm the position taken recently by an number of United States Agencies including the Veterans Administration, the Department of Defense (1) and the American Heart Association (2), that gait retraining with either body weight supported treadmill training techniques, or with robotic devices has not been shown to be demonstrably superior to traditional therapy methods.

It is interesting to speculate as to why so many therapies appear to be promising in preliminary studies, yet fail to reach satisfactory outcomes in larger multicenter clinical trials. There are several possibilities:

1. Difficulties in standardizing therapy in Multicenter trials
In many recent clinical trials, studies were performed in multiple sites, and relied on multiple therapists for patient selection and care delivery. It is rather hard to be certain that in such multicenter trials, different sites adopt consistent study entry criteria and that they administer therapy in a consistent manner.

2. Outcome Assessments
Our outcome assessments for gait retraining are relatively imprecise. Most investigators rely on a 10-meter walk, which is a measure of speed, and a 6 min. walk, which is a measure of endurance. There is rarely an opportunity for assessment of gait kinematics or even gait asymmetry.

3. Timing of therapy
Many researchers believe that there may be a window of opportunity arising relatively early after a stroke, conceivably beginning within a few days of the acute lesion. This time frame is not usually regarded as either safe or appropriate for energetic early gait retraining, but this interval may be our best chance to modify cortical structure and function.

For all these reasons, we may be missing promising therapeutic responses, and treating potentially rational therapies as ineffectual.

Finally, the authors of this review assert that combination therapies appear to be the most effective. While this claim may well be correct, a rational experimental analysis of combination therapies is very difficult because of the need to use many different dose combinations in order to precisely chracterize combinatorial effects.

For the future, this reviewer would prefer to see a more rigorous experimental analysis of individual therapies before launching into studies requiring that multiple therapies be delivered.

Key References:

1. Management of Stroke Rehabilitation Working Group. Management of stroke rehabilitation. VA/DOD Clinical Practice Guideline. VA/DOD Evidence Based Practice. Version 2.0, 2010. Washington, DC: Veterans Health Administration, Department of Defense; 2010. Available at: http://www.healthquality.va.gov/stroke/stroke_full_221.pdf.

2. Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient : A Scientific Statement From the American Heart Association Elaine L. Miller, Laura Murray, Lorie Richards, Richard D. Zorowitz, Tamilyn Bakas, Patricia Clark and Sandra A. Billinger Stroke 2010, 41:2402-2448: originally published online September 2, 2010

Correction of Figure 4B

Maria Jose Lopez-Barragan — 2012-01-23T09:42:07Z

The ID numbers of the genes and isoforms shown in Figure 4B are MAL7P1.157, MAL7P1.157a and MAL7P1.157b, instead of MAL7P1.175, MAL7P1.175a and MAL7P1.175b, respectively.

Errata for Mushtaq et al. BMC Public Health 2011, 11:724 (II)

Muhammad Umair Mushtaq — 2012-01-20T11:32:03Z

Please note corrections to the following errors. Page references are to the final PDF version.

1. Page 3, Results, second paragraph, lines 7-8:

¿overweight and obesity prevalence was 33% (95% CI 31.1-35.3) and 24% (95% CI 22.4-26.2)¿ should read ¿overweight and obesity prevalence was 8.3% (95% CI 7.1-9.6) and 4.7% (95% CI 3.8-5.7)¿.

2. Page 4, Table 2:

The correct values of mean BMI (SD) in column 3 are:
Severely Obese 25.7 (2.9), Obese 23.4 (2.8), Overweight 21.2 (2.9)

The correct values of overweight and obesity according to the IOTF cut-offs in column 6 are:
Obese 4.7 (3.8-5.7), Overweight 8.3 (7.1-9.6).

3. Page 6, second paragraph, lines 1-8:

¿Prevalence of overweight by the IOTF cut-offs was twice the prevalence by the WHO 2007 reference (33% versus 17%) and prevalence of obesity by the IOTF cutoffs was three times higher than that calculated by the WHO 2007 reference (24% versus 7.5%). Using IOTF cut-offs for overweight and obesity in Pakistani schoolaged children would result in higher estimates than the WHO 2007 reference.¿ should read ¿Prevalence of overweight by the IOTF cut-offs was half the prevalence by the WHO 2007 reference (8% versus 17%) and prevalence of obesity by the IOTF cutoffs was two-third of that calculated by the WHO 2007 reference (5% versus 7.5%). Using IOTF cut-offs for overweight and obesity in Pakistani schoolaged children would result in lower estimates than the WHO 2007 reference.¿

M.U. Mushtaq, et al.

Correction of typographical error in statistical methods

Karen Heichman — 2012-01-19T14:55:46Z

Following publication of this article, we noticed a significant typographical error in the statistical section that needs to be corrected. Please note that specificity of the test was determined according to the following formula:

Specificity = 1 - false-positives/total controls

The same results are obtained if the following formula is used:

Specificity = true negatives/total controls