853 e-Letters

  • Editor's Note

    This is a note to indicate that BMJ Open is still looking into the disagreement between Albert Donnay and the authors of the paper.

    We will post further updates on the article in due course.

  • Response to letter from Alasdair Philips

    We recently reported on brain tumour incidence time trends in 20 to 59 year old Australians, from 1982 to 2013, and analysed these in terms of mobile phone usage patterns and diagnostic improvements over that interval1. This was designed to determine whether claims that mobile phone use causes brain tumours, are consistent with the pattern of brain tumour incidence in Australia, and in particular to compare such incidence patterns with the results of the multinational Interphone case control study2. In summary, we reported that: 1/ Overall brain tumour incidence rates did not change over time; 2/ Increased glioblastoma incidence was seen during intervals that coincided with improvements in diagnostic technologies (CT, MRI); 3/ Decreased incidence of ‘unspecified’ tumours was seen during the same intervals; and 4/ No evidence of increased tumour incidence (including glioblastoma) related to mobile phone use was found (based on incidence rates seen during the period of substantial mobile phone use and on modelling using a range of hypothetical relative risks and latency periods).

    Philips submitted a Letter to the Editor3 of BMJ Open, where he purports to show that there are ‘significant flaws and unjustifiable conclusions’ in the above paper. Although he may firmly hold this view, his letter does not provide any evidence of this, and we strongly disagree with his statement. We have addressed the substance of his letter below to hopefully obviate potential misunderstan...

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  • Research Assistant - Error correction.

    Page 8/9; Acknowledgements.
    The spelling of research assistant Rohan Navani was misspelt as Rohan Navari.

  • Use of telephone first approach in general practice

    We have read with interest the article by Ball et al (2018) recently published in BMJ Open and note that they refer to our letter (Pereira Gray and Wilkie, 2017) which listed disadvantages of this system from the point of view of patients and where we reported the opposition of the National Association of Patient Participation (N.A.P.P.) to this system.

    We agree with the authors that ‘telephone first’ system is a “fundamental” change in the provision of general practice.
    The authors refer in detail to the independent review of this system Newbould et al (2017), which was published on the BMJ in 2017 and in which three of the authors were the same. We are puzzled by the way they summarise it.

    Authors’ statements in 2018 can be contrasted with the published results in Newbould et al 2017. For example, Ball et al write “No evidence of reduced secondary care costs.” Whereas Newbould et al wrote “we found a significant increase of cost of admissions… leading to an estimated overall increase in secondary care costs of £11,766 per 10,000 patients (i.e. over £1 per patient registered in the general practices).

    Secondly, Ball et al write “Little overall improvement in patient satisfaction as expressed in patient surveys” when Newbould et al reported:
    1.GP communication composite-Significant fall (P<0.001)
    2. Would you recommend your surgery?- Significant fall (P<0.001) 3.Seeing preferred GP- Significant fall (P<0.035)

    Why h...

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  • Social predictors of A&E attendance

    This is a useful study. May I suggest that the Output Area Classification (OAC) offers similar insights based on social groupings. Several studies have explored the use of the OAC relating to A&E attendance and Critical Care admission [1-3]. I suspect that your data is amenable to further helpful analysis using the OAC.

    1. Beeknoo N, Jones R. Factors influencing A&E attendance, admissions and waiting times at two London hospitals. British Journal of Medicine and Medical Research 2016; 17(10): 1-29. doi : 10.9734/BJMMR/2016/28783

    2. Beeknoo N, Jones R. Using Social Groups to Locate Areas with High Emergency Department Attendance, Subsequent Inpatient Admission and Need for Critical Care. British Journal of Medicine and Medical Research 2016; 18(6): 1-23. doi: 10.9734/BJMMR/2016/29208

    3. Beeknoo N, Jones R. Using social groups to locate areas of high utilization of critical care. BBritish Journal of Healthcare Management 2016; 22(11): 551-560.

  • Do not assume homogeneity of experience

    I worked on emergency ambulances in London from 1974 to 1978. I attended several bomb calls during the IRA campaign and it was terrifying to sit in a fibreglass ambulance knowing that there was a real risk of being right next to a car bomb that might be detonated with the intention of harming the emergency services. I was 19 at the time. Looking back, with my current knowledge, I can see that the experience was quite harmful for me. In addition to the existential threat there was also the fear of failing to perform and letting people down and being seen to be a coward. This also took its toll.

    Other things also took a toll and they were not so obvious. Dealing with sick elderly patients was incredibly depressing. I came to fear growing old, because the only old people that I was meeting were ill and depressed and really not enjoying life. I saw so many old people living sad lives in grinding poverty.

    Again, with maturity, this seems totally absurd, but as a 19 year old with no experience of healthy older people (my grandparents were all dead) ambulance work made me very sad. I was surrounded by other ambulance workers who I think tended to be able to cope by having sociopathic tendencies. A very toxic milieu!

    My point here is that when I compared notes with ambulance workers with similar seniority in more rural settings and away from the IRA bombs, their experiences were entirely different. They attended the occasional serious RTC, but mos...

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  • Significant flaws and unjustifiable conclusions

    Karipidis et al report that in Australia, glioblastoma (GBM) incidence increased significantly only during the period 1993-2002. They conclude that this was due to diagnostic improvements and that there has been no increase in any brain tumour histological type or glioma location that can be attributed to mobile phones.

    I am lead author of an ecological study published early in 2018 that examined detailed underlying incidence trends for 81,835 biologically malignant (ICD10 C70) brain tumours, recorded in England over the period 1995-2015 [1]. Karipidis et al cite our study and note that we reported that the overall incidence of GBM more than doubled over that time period (from 2.4 to 5.0 per 100,000 person years, age-standardised to the European Standard Population ESP2013, with annual case numbers rising from 983 to 2531). Zada et al (2012) [2] and Ho et al (2014) [3] have reported similar trends.

    Although we briefly discussed five possible causal factors that might have contributed to the rise in incidence, we stated that our article reported incidence data trends and did not provide additional evidence for the role of any particular risk factor. We showed that most of the rise in incidence was in people over 55 years of age. We discussed the possible mix of promotion of lower grade tumours and de-novo tumours. We also discussed the effect of better imaging and more accurate diagnosis and concluded that although it did have an effect, especially for topogra...

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  • Biased Study and Misrepresentation of Actual Rates of Plagiarism in African Medical Journals

    We write to express our concern about the prevalence estimate of plagiarism in African medical journals in the study reported by Rohwer et al.(1) The authors’ finding that 63% of African medical journal articles are plagiarized to some degree is a gross overestimate.

    The study definitions of “some,” “moderate,” and “extensive” plagiarism are unvalidated and, as the authors admit in the fourth paragraph of their Discussion section, lack inter-rater reliability and precision. Articles were classified as having “some” plagiarism if there were as few as 1-2 sentences that included identical words or sentences in another article by different authors even if the sentences were properly referenced. Numerous publishing organizations, including the Council of Science Editors,(2) the World Association of Medical Editors,(3) and the US Office of Research Integrity,(4) reserve the use of plagiarism for instances when another’s words are used without proper credit or attribution. The authors developed their definition based on suggestions from the Committee on Publication Ethics (COPE), yet even COPE’s Flowchart for managing suspected plagiarism in a submitted manuscript defines plagiarism as “unattributed use of large portions of text and/or data.”(5)

    In fairness to the African journals implicated in the study, we request the authors go back to their data, identify all instances in which identical wording with formal source citations were defined as plagiarism, recalcu...

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  • Decline in neonatal mortality in Northern Ghana: Non-specific effects of BCG vaccination or Improvements in health systems?

    Decline in neonatal mortality in Northern Ghana: Non-specific effects of BCG vaccination or Improvements in health systems?

    In an ecological study carried out in Northern Ghana, Welaga et al., assessed changes in neonatal mortality rates (NMR) and BCG vaccination age from 2002 to 2012. The authors found that among home deliveries, median BCG vaccination age declined from 46 days in 1996 to 4 days in 2012. Within the same period , NMR decreased from 46 to 12 per 1000 live births (1). The authors concluded their study by suggesting that the significant decline in mortality observed may be due to the beneficial non-specific effects of early BCG vaccination. The authors should be commended for studying whether BCG vaccination may have non-specific effects. However, several issues need to be raised when interpreting these results.
    1) Adjustment for other vaccine effects
    The authors did not expand on the potential role that improvements on the Expanded Programme on Immunization (EPI) in Ghana may have played in reducing neonatal mortality. Diarrhea and Pneumonia are the main causes of neonatal mortality. Although still sub-optimal, Rotac and PCV3 immunization coverage estimates for Ghana in 2012 were significantly better than in 1996 or 2002 (2). A similar trend was observed for almost all the vaccines in the EPI schedule. For example, UNICEF immunization coverage estimates for Ghana indicate that DTP3 vaccine coverage increased from 71 % in 1996 to 92 %...

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  • In-hospital dementia deaths

    Dear Sirs,

    My research has detected curious patterns of on/off switching in international deaths. Basically, deaths run at a baseline level and then suddenly switch-on to a new and higher level for around 12 to 18 months after which they switch-off and revert back to the baseline. They stay at baseline until the next switch-on event. Deaths in person's with Alzheimer's and other dementias seem highly sensitive to the switch-on events. This curious behaviour is most readily revealed using a rolling (running or moving) 12-month total or average.

    In England, in-hospital deaths show the same on/off-switching.

    Should you have access to monthly data it may be useful if you could apply such a rolling 12-month analysis of the data.

    You can access a list of publications relating to this research at http://www.hcaf.biz/2010/Publications_Full.pdf

    I have proposed that this behaviour may reflect some new type or kind of disease outbreak, however, this is open to further research.

    I hope this response is helpful.