785 e-Letters

  • Response to the reader's eLetter

    We thank the reader for identifying these errors and a correction to the article will be published shortly.

  • Letter to the Editor “Association between exposure to the Chinese famine during infancy and the risk of self-reported chronic lung diseases in adulthood a cross-sectional study”

    We recently read with great interest an article entitled “Association between exposure to the Chinese famine during infancy and the risk of self-reported chronic lung diseases in adulthood a cross-sectional study, ” by Zhenghe Wang(2017) in BMJ Open 7(5), e015476.The authors examine the association between early-life exposure to the Chinese famine and the risk of chronic lung diseases in adulthood. This study makes a worthy contribution to the area. However, some issues should be taken into account.

    In the paper, there are some mistakes in the figure 1 which named “Flowchart on the sample selecting methods at each step”, Combine the context, the number of non-exposed(855)、fetal-exposed(830)、infant-exposed(568)、preschool-exposed(630) groups are wrong in the second line from the bottom. We would like to bring to your attention the errors in methods reported in the aforementioned article.

  • Fabry disease requires a multidisciplinary approach

    We are delighted to read the misleadingly entitled letter by Karapanagiotidis and Grigoriadis, as it gives us the opportunity to present additional convincing evidence gathered after publication in favor of the pathogenicity of the D313Y GLA mutation. It might also be noted that Karapanagiotidis and Grigoriadis refer to only two of the reported cases, disregarding the strong supporting evidence provided by the study of the other cases. Obviously, their objections come from the fact that they were restricted to the neurological approach to Patient 4 (thus their mention in the Acknowledgements of our paper), underestimating her nephrological profile, which is not even mentioned in their letter. Taking into account that, one year after the last stroke, the patient presented with microalbuminuria that was duplicated after 3 months, as was mentioned in our paper, we proceeded to renal biopsy. On electron microscopy, typical signs of Fabry disease were detected, i.e. podocyte injury, significant cytoplasmic vacuolization of podocytes with a mild presence of sphingolipids and myelin bodies in podocytes and tubular cells. According to the current diagnostic criteria, these findings confirm the definite diagnosis of Fabry disease in patients with “genetic variants of uncertain significance and non-specific FD signs” (Biegstraaten et al, Orphanet J Rare Dis 2015). Additionally, in a recent ophthalmological assessment, this patient presented with signs of "cornea verticillata...

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  • Authors’ response to ICCPR, BACPR and CACPR

    We are delighted that our paper on exercise-based CR has generated a lively debate(1). We are also pleased that correspondents all agree that our findings are robust(2-4). No correspondents have identified any important RCTs we have overlooked that might have changed our conclusions, and none have challenged the veracity of our findings. The majority of concerns were already addressed in the discussion of our original review, and are clarified below.

    Correspondents have identified three main areas for discussion-

    1. Mortality as the main metric of effectiveness-

    Reduction in all-cause mortality has been the focus of the majority of research in this area. Nineteen of the 22 studies in our review reported on this outcome. It was also the primary outcome in all three previous Cochrane reviews(5-7). This focus on all-cause mortality, or cardiovascular mortality, as the justification for offering exercise-based CR is also reflected in current guidance, and must therefore continue to be of some importance. We provide here some examples-

    • NICE Myocardial Infarction secondary prevention; ‘All patients (regardless of their age) should be given advice about and offered a cardiac rehabilitation programme with an exercise component.’ The evidence statements underpinning this recommendation include; ‘Cardiac rehabilitation in patients after MI reduces all-cause and cardiovascular mortality rates provided it includes an exercise component’(8).

    • Bri...

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  • Response to Price et al: Randomised trial of coconut oil, olive oil or butter on blood lipids and other cardiovascular risk factors in healthy men and women

    Dear Editors,
    Thank you for the comments from Jessica Price and colleagues. In response to the three points they raised:

    For pragmatic and scientific reasons this study did not have a control group as defined by a study group in whom no additional lipid was added/replaced in the diet. Interpretation of a comparison with such a control group would have been challenging in a free-living intervention that did not control the participants’ total energy intake which would have been substantially lower in the control group (by approximately 450 kcal/day based on 9 kcal per gram of fat in the intervention arms). However, we did include a highly relevant comparison group in the trial, taking extra virgin olive oil, as from the existing literature extra virgin olive oil is reported either to have no effect or to lower LDL-cholesterol, so we could also compare coconut oil with olive oil. The pre-specified primary outcome was a comparison of the effect of different fats/oils on changes in LDL-cholesterol. As can be seen in the results, coconut oil was not different from olive oil in terms of the changes in LDL-cholesterol. In addition, we also presented the absolute change in LDL-cholesterol concentrations following the interventions and the groups on coconut oil or olive oil showed no increase in LDL-cholesterol from baseline, if anything a non significant small decrease.

    As we state in the report, participants were free to consume the oil any w...

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  • Further information request

    I am one member of a group of medical students, currently studying at the University of Birmingham Medical School in the United Kingdom, who seek to seek to evaluate the mounting body of evidence to suggest that capsular contracture development is decreased with the use of textured over smooth implants. We have a special interest in the evaluation of breast implants in the use of breast augmentation and reconstruction, and are currently constructing a review entitled 'A comparison of textured breast implants versus smooth implants in breast reconstruction and augmentation surgery in preventing capsular contracture.' We came across your protocol in our literature searches and were extremely intrigued. We believe your findings could influence our perspectives and allow us to further develop our evaluations.
    My fellow researchers wish to enquire as to whether you have any preliminary findings or interesting new outlooks that you could share with us?
    We look forward to hearing from you.

    Yours faithfully,
    Phoebe Pottinger

  • Figure clarification and data correction from the authors

    Readers of our article have indicated that the description of Figure 1 was insufficient to help them understand what it represents. Below, we further describe the figure, correct two minor errors, and provide a summary table.

    Figure 1 description:
    Figure 1 was designed to show two overarching pieces of information. First, the line plots allow the reader to see how the filtering process progresses for individual studies. Each line represents a single study going from one phase to the next. Each phase is centered on the midpoint of the range, giving it a Buchner funnel-like shape. The purpose of this representation, as opposed to having the x-axis anchored to 0 for instance, is that it better highlights the rank changes across phases. Just because a study has a large number of papers at one phase does not mean that it will have the largest number included at a subsequent phase, and this difference can sometimes be pronounced (as evidenced by steeply crossing lines).The second piece of information was summary statistics represented in boxplots overlaid at each phase, which are more self-explanatory.

    Figure 1 data processing:
    For the lineplots, four studies were excluded because their values were greater than 2.5 standard deviations above the mean for the ‘Total N Found’ variable. Had these four studies been plotted, all other lines would have been compressed to the left of the figure because of how far these four values would have extended the axis...

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  • D313Y variant: Evidence in favour or against its pathogenicity in Fabry Disease?

    Dear Editor,

    We read with interest the article by Koulousios et al. The authors report five patients with a presumed “definite” diagnosis of Fabry Disease (FD) out of a group of 17 Greek individuals with the D313Y variant of the a-galactosidase A (GLA) gene. The authors claim that they provide “strong evidence that the D313Y mutation could be pathogenic”. Beyond the obvious contradiction of being certain about an uncertainty, the study contradicts to overwhelming evidence from the literature, mainly due to a mechanistic interpretation of incomplete patient data without (in the majority of cases) the appropriate counseling and expertise by the medical specialties responsible for the management of the patients’ principal clinical manifestations. In particular, the authors claim that the “vast majority of patients with the D313Y mutation presented with neurologic symptoms and signs”. Nevertheless, none of the authors is a neurologist and it is obvious that a neurological perspective is missing from the manuscript.
    For the past two years, we have been following in our department Patient 4 (table 1) and her mother (Patient 5). Patient 5 had a history of slowly progressing spastic tetraparesis over at least 20 years, initially diagnosed in another institution as primary progressive multiple sclerosis. After all relevant investigations, our diagnosis was that of an undetermined moderate leukoencephalopathy. Plasma Gb3 levels were 4.7 nmol/mL (reference: 0.8-4.52). I...

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  • A possible explanation may be exposure to hydrocarbons

    As suggested by Kim et al. the association between decreased lung function and chronic kidney disease (CKD) implies that there must exist a common pathogenic mechanism. A likely one is exposure to organic solvents or other types of hydrocarbons because such exposure may cause both lung disease2-6 and CKD.7-10
    1. Kim SK, Bae JC, Baek J et al. Is decreased lung function associated with chronic kidney disease? A retrospective cohort study in Korea BMJ Open 2018.
    2. Angerer P, Marstaller H, Bahemann-Hoffmeister A et al. Alterations in lung function due to mixtures of organic solvents used in floor laying. Int Arch Occup Environ Health 1991;63:43-50.
    3. Harving H, Dahl R, Mølhave L. Lung function and bronchial reactivity in asthmatics during exposure to volatile organic compounds. Am Rev Respir Dis 1991;143:751-4.
    4. Spanier AJ, Fiorino EK, Trasande L. Bisphenol A exposure is associated with decreased lung function. J Pediatr 2014;164:1403-8.
    5. Padula AM, Balmes JR, Eisen EA et al. Ambient polycyclic aromatic hydrocarbons and pulmonary functionin children. J Expo Sci Environ Epidemiol 2015;25:295-302.
    6. Wang S, Bai Y, Deng Q et al. Polycyclic aromatic hydrocarbons exposure and lung function decline among coke-oven workers: A four-year follow-up study. Environ Res 2016;150:14-22.
    7. Ravnskov U, Lundström S, Nordén A. Hydrocarbon exposure and glomerulonephritis: evidence from patients' occupations. Lancet 1983;2(8361):1214-6....

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  • Note from Production

    The correct number of shifts measured was 62 (not 61), and 13 evening shifts (not 12). The measured hours in evening shifts were 7:15 h:m (not 7:25).