979 e-Letters

  • Concerns regarding the inference that EDS is not rare

    Dear Sir or Madam

    Re. Diagnosed prevalence of Ehlers-Danlos syndrome and hypermobility spectrum disorder in Wales, UK: a national electronic cohort study and case-control comparison.
    Demmler J C, Atkinson M D, Reinhold E, Choy E, Lyons R A, Brophy S T
    BMJ Open 2019;9:e031365

    We write concerning the paper by Demmler et al., published in BMJ Open. We wish to raise the following concerns:

    1. With regard to combining the Joint Hypermobility Syndrome (JHS) and Ehlers-Danlos syndromes (EDS) populations for analysis.

    If one combines data from a cohort that is found to be ‘common’ (in this case ‘diagnosed JHS’) with one that is found to be ‘rare’ (in this case ‘diagnosed EDS’), the new combined cohort (i.e. diagnosed JHS/EDS) will be common. To then consider the rare cohort common is a fallacy.

    Also, although individuals in a population with a previous diagnosis of JHS (i.e. prior to the 2017 international classification (1,2)) might have Hypermobile EDS (hEDS) by the current classification, it is not known how JHS segregates into Hypermobility Spectrum Disorder (HSD) and hEDS. A JHS population would need to be reassessed to confirm this, or modelling assumptions of the data would need to be applied.
    In addition, it is not known what proportion of the EDS cohort have hEDS versus the rare Mendelian types of EDS. As such, there is no way of knowing whether or by what proportion the two cohorts represent the same or similar or dif...

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  • Supplements will not be effective if people have undiagnosed Coeliac Disease or Dermatitis Herpetiformis

    I believe that bipolar/mental disorders could be related to coeliac disease. Any study in relation to diet / supplements etc could be affected by this as undiagnosed coeliacs who are continuing to eat gluten do not digest foods properly and become deficient in minerals and vitamins as they CANNOT ABSORB them. I do feel that more research and studies need to be done with this in mind. Doctors should be testing more people. In Australia the AVERAGE time it takes for a coeliac to be diagnosed is 9 YEARS. A blood test is not reliable as often it comes back a false negative. Meanwhile they get diagnosed with bipolar and other illnesses caused by mineral and vitamin deficiencies. I have a father in law who was diagnosed bipolar BEFORE being diagnosed gluten intolerant (he has Dermatitis Herpetiformis which is related to coeliac disease). I don’t believe he is bipolar. My husband also was misdiagnosed with bipolar instead of coeliac disease. Brain cells recover after going on a gluten free diet!
    All people diagnosed with bipolar should be tested for Coeliac Disease (or Dermatitis Herpetiformis if they have any kind of rash). And any study for treating bipolar disease with nutritional supplements should be done after the test and/or on people who have excluded gluten from their diet.

  • Inhaler devices and global warming: Flawed arguments

    Mark L Levy,1,9 Darragh Murnane2, Peter J Barnes,3,9 Mark Sanders,4 Louise Fleming,5 Jane Scullion,6,9 Chris Corrigan,7,9 Omar S Usmani8,9

    1. Locum general practitioner, Clinical Lead NRAD (2011-2014)
    2. King’s College London Faculty of Life Sciences & Medicine, School of Immunology & Microbial Sciences ; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire
    3. National Heart & Lung Institute, Imperial College, London
    4. Clement Clarke international Ltd (CCI) and founder of online museum of inhaler devices, www.inhalatorium.com.
    5. Imperial College, London and the Royal Brompton and Harefield, NHS Foundation Trust
    6. University Hospitals of Leicester
    7. King’s College London Faculty of Life Sciences & Medicine, School of Immunology & Microbial Sciences
    8. Imperial College London & Royal Brompton Hospital
    9. Aerosol Drug ManagementImprovement Team (ADMIT), www.inhalers4u.org

    In an attempt to address issues related to global warming contributed to by the use of pressurised, metered-dose inhalers (pMDIs), Wilkinson et al (1) have succeeded in generating a great deal of negative, potentially harmful media interest for patients who currently rely on these devices. They analysed the potential impact of switching therapy from pMDIs to dry powder inhalers (DPIs) in terms of both c...

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  • Comments to the response “Regarding “Early childhood vaccination and subsequent mortality or morbidity: are observational studies hampered by residual confounding? A Danish register-based cohort study”” by Lise Gehrt et al

    We appreciate the response to our study.
    The response assumes that a restriction in the population under study also limited the bias in two previous studies (1;2). In the two previous studies only individuals, who had two diphtheria–tetanus–pertussis–polio–H. influenzae type b-vaccines at 11 months of age were included.
    Therefore, we found it relevant to apply the same restriction to our study population and present the corresponding estimates adjusted for the confounders included in our study (3) (Table 1 - https://bmjopen.bmj.com/pages/wp-content/uploads/sites/7/2019/11/table-1...).
    In Table 1 it can be seen that the restriction of the analysis to include only individuals with two diphtheria–tetanus–pertussis–polio–H. influenzae type b-vaccines at 11 months of age had little impact on the estimates. Importantly, the associations showing a reduced risk of hospitalisation for accidents among children with two or three diphtheria–tetanus–pertussis–polio–H. influenzae type b-vaccines and the measles-mumps-rubella vaccine were essentially unchanged when we restricted the analysis to include individuals with two diphtheria–tetanus–pertussis–polio–H. influenzae type b-vaccines at 11 months of age only.

    Reference List

    (1) Sorup S, Benn CS, Poulsen A, Krause TG, Aaby P, Ravn H. Live vaccine against measles, mumps, and rubella and the risk of hospita...

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  • Note from the Editors

    The editors acknowledge the readers' comments about this article. We have asked the authors to respond and we will amend the article if necessary.

  • Editorial in The BMJ

    The BMJ have published an editorial, written by Jeremy Taylor, linked to the results of this research paper. https://doi.org/10.1136/bmj.l6324

  • Search strategy for this scoping review too limited and missed some JLA Priority Setting Partnerships

    I read this paper with interest - I think there is a lot to be gained from studying the James Lind Alliance approach and the diversity of methods that have been applied by James Lind partnerships. I do think however that your search strategy (and approach to searching) was unnecessarily narrow and wonder why you didn't start with the James Lind PSP website (http://www.jla.nihr.ac.uk/priority-setting-partnerships/) which lists all the JLA PSPs undertaken and would have been the best place to start. Had you done this (and/or used Google) you would have identified more JLA PSPs, including ours on pressure ulcers (reported here http://www.jla.nihr.ac.uk/priority-setting-partnerships/pressure-ulcers/ and also [1, 2]. I bring this to your attention merely because we considered extensively some of the issues your raise regarding facilitating broad participation and we have also discussed other methodological aspects.

    [1] Cullum N, Buckley H, Dumville J, Hall J, Lamb K, Madden M, Morley R, O'Meara S, Goncalves PS, Soares M, Stubbs N. Wounds research for patient benefit: a 5 year programme of research. NIHR Journals Library; 2016
    [2] Madden M, Morley R. Exploring the challenge of health research priority setting in partnership: reflections on the methodology used by the James Lind Alliance Pressure Ulce...

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  • Rapid action is needed

    As corresponding author of the only paper out of 68 that "appeared to have undertaken a reassessment, which led to a correction" I have some sympathy for the authors of the other 67 papers. We decided that it was important that the problem due to the inclusion of subsequently retracted papers needed to be brought to the attention of readers, which we assumed would be relatively rapid. After agreement with my co-authors I emailed to the journal some text to highlight the problem and for readers to ignore the principle findings and rely on a secondary analysis which had excluded the suspect trials. The first email was sent on 18th August 2017. After receiving no response or acknowledgement a second email was sent on 13th November 2018, with a third on the 30th January 2018. A response was received on the 18th February 2018 and a correction published June 2018. Therefore it took the best part of a year to flag up an uncontested correction, which was a simple thing to do. It would be of interest to see if any of the authors of the remaining 67 papers had tried or are still trying to have a correction issues.
    David Torgersoni

  • Adverse mortality trends in Scotland

    As readers will be aware, in the early years of the adverse mortality trends it was postulated that this may be due to UK government austerity. Using data at local authority level in England, Wales and Scotland this hypothesis has been questioned [1], and looks to have been a case of (inadvertent) correlation and not causation. This paper [1] also makes reference to the contribution from a series of influenza epidemics which coincidentally occurred in the austerity years.

    It has also been pointed out that the use of calendar year data has been acting to conceal complex spatiotemporal patterns affecting deaths which resemble outbreaks of an infectious agent (influenza excluded as the causative agent) [2,3]. For this very reason the Office for National Statistics has begun publishing quarterly mortality data for England [4].

    Since age standardized mortality is a single measure of mortality (with inherent assumptions), it is suggested that wider measures including single year of age patterns may need to be investigated.

    As pointed out by the Scottish study, further research is indeed required.

    1. Jones R. Austerity in the UK and poor health: Were deaths directly affected. British Journal of Healthcare Management 2019; 25(11): in press

    2. Jones R. The calendar year fallacy: the danger of reliance on calendar year data in end-of-life capacity and financial planning. International Journal Health Planning Management 2019; doi: 10.1002/hpm.2838...

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  • Please Review and Revise to Include the Acupuncture Results

    To the editors of the BMJ:

    Allina Health is a Minnesota based not-for-profit healthcare system caring for patients across our 90+ clinics, 12 hospitals, 15 pharmacies, specialty care centers and specialty medical services. This includes our Penny George Institute for Health and Healing, which brings together physical therapy, chiropractic care and acupuncture alongside our traditional healthcare system to provide whole-person-care. As one of the largest healthcare systems in the United States, we are deeply committed to making a positive difference in the opioid crisis by including access to all effective modalities of care.

    We found your recently published paper (by Kazis et al [BMJ Open 2019;9e028633] regarding their retrospective study of the association between initial health provider for low back pain with subsequent opioid use) to be a very valuable study with the potential to further shape healthcare’s response to the opioid epidemic. Unfortunately, some of the pertinent concluding evidence has been left out of the abstract - specifically acupuncture effectiveness. We are reaching out to request that you address this in order to maximize the acceptance of all effective treatments in responding to our opioid crisis.

    In the body of the study, data on three types of conservative therapists as well as various types of physicians are included. It showed that there was a decrease in both early and long-term opioid use among patients with either physi...

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