1013 e-Letters

  • Women and Health

    Dear Editor ,

    This article mainly focuses on knowledge about health related states and events for women in South Asian region i.e in Pakistan and India . Mostly women presenting in public hospitals for their antenatal checkup belongs to poor socioeconomic status and cannot afford a good living to maintain a healthy lifestyle . So, despite of having adequate knowledge about good health they can not afford one . So, i think hospitals should compile data of such women and share with concerned authorities who can provide them in this regard.
    Psychological support should be freely available for pregnant women during their antenatal visit by experts .

  • PTSD risk factors in obstetrics & gynaecology

    Farren et al (1) state that they, ”were surprised by the prevalence of PTSD symptoms in our study”, and that, ”Future research should be aimed at assessing the risk factors for PTSD”.
    My research of 1993, into Post Traumatic Stress Disorder in women who have undergone Obstetric and/or Gynaecological Procedures (2), which was widely reported in the press, obstetric and midwifery literature, including the N.I.C.E Guidelines, identified several risk factors for the development of PTSD in the women affected.
    The key areas in the procedures seem to be those concerning the level of control which the woman has, the attitude of the doctor, the degree to which the patient’s views are heeded, and whether or not consent was perceived to have been given for the procedure. The gender of the examiner did not seem to be relevant.
    The women were asked in the questionnaire to describe their experiences, some of which were quite explicit and reminiscent of assault: “dehumanising and painful”; “degrading and distressing….no account was taken of my feelings”; “my opinions were dismissed as irrelevant although it was my body which was being invaded”; “I came away hurting and feeling violated”; “very brutal internal was excruciating”; “you begin to feel like a thing”; “I cried and shouted but was held down and told to stop making a noise”; “humiliation…as if it happened yesterday”; “I felt assaulted and then abandoned”; “I felt abused…like a piece of meat on a slab”; “the mo...

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  • Dyslipidemia is an unlikely cause of atherosclerosis

    The study by Popa et al. (1) is potentially of value in identifying adverse influences on cardiovascular health. Their study, however, suggests that dyslipidemia causes cardiovascular disease (CVD). We feel compelled to show that the broader literature is not consistent with this perspective and that their finding of an association between dyslipidemia and CVD is influenced by a methodological flaw in their design.

    First, there is no evidence that dyslipidemia causes atherosclerosis. Already in 1936 Lande ́ and Sperry found that when corrected for age, healthy people with low total cholesterol (TC) were just as atherosclerotic as healthy people with high TC (2) and their finding has been verified and replicated later by many research groups (2). A strong contradiction has also been documented by sixteen angiographic trials where the authors had calculated exposure-response, which was present in only two of them (2). Furthermore, a study of the coronary arteries of 304 asymptomatic women by Hecht and Superco showed that the role of high LDL-cholesterol (LDL-C) is questionable as well. By using electron beam tomography, they found that neither the calcium percentile or the calcium score were associated with LDL-C (3). Also contradictory is, that In five studies of people with familial hypercholesterolemia there were no association between degree of atherosclerosis and LDL-C (4).

    Second, numerous observations and experiments have shown that dyslipidemia does no...

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  • Response

    Dear Editor,
    Excellent research topic with a catchy title. This research paper helps in identifying the role of TW’s in the spread of HIV. In Pakistan HIV/AIDS is now an established epidemic. This life threatening condition is still considered a stigma and the fear of disclosure restricts the patients from getting timely treatment. Although the number TW’s in Pakistan is not much but there role in spreading HIV should not be overlooked. The researchers have done justice in identifying the root causes and the idea of giving incentives to participants definitely needs appraisal.

  • Response to the comments of the COMPACT-2 researchers

    Dear Compact-2 researchers,
    Thank you very much for your comments, which we have read with great interest as they certainly contribute to the opening of an interesting debate. Below there are some points which go to clarify some issues highlighted in your letter:

    1 – We are confused by the reasons you decided to stop your trial. In your comment you have indicated that this was due to futility reasons. However, in the conclusion of the report which was uploaded to your web page, we read the following phrase: “The interim analysis requested by the EDSMC shows higher mortality for the CPFA group compared to the controls, particularly in the first days of treatment.” Furthermore, on April 27th, 2018 Medtronic issued an Urgent Field Safety Notice for the intervention product: “In a clinical study, higher early mortality (within 72 hours of randomization) was observed in septic shock patients receiving CPFA Coupled Plasma Filtration Adsorption therapy compared to patients receiving standard care. Septic shock patients often have clinical characteristics (hemodynamic instability, coagulation disorders) that increase the risk of extracorporeal treatment. Based on the preliminary data from this study, CPFA should not be used in patients with septic shock.” Finally, in the Annual Update in Intensive Care and Medicine 2019 (Chapter 29), we can read the following information about the COMPACT-2 trial. “The trial was prematurely terminated because of higher early mortality...

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  • Claims of cycle helmet benefit: Selection bias has a stronger claim as explanatory factor.

    In their recent paper Dodds et al. analysed cycling-related injuries recorded in the NHS England Trauma Audit and Research Network (TARN) Database for the period from 14 March 2012 to 30 September 2017(Dodds et al., 2019). They claim their methods show an association between cycle helmet use and reductions in, crude 30-day mortality, severe traumatic brain injury (TBI), intensive care unit requirement and neurosurgical intervention. Cycle helmets are light structures, generally weighing 250g to 600g, and are typically composed of a thin shell of stiff plastic outside a thicker shell of expanded polystyrene foam. The standard approval tests simulate simple falls, with no other vehicles involved (ROSPA, 2018). They are not rated for high-energy impacts involving moving motor vehicles. Eighty four per cent of fatality and serious cyclist accidents reported to the police involve motor vehicles (ROSPA, 2017). Cycle helmets are shaped to "cup" the top of the skull rather than enclose the head, which means they need a system of well-adjusted straps to stay attached in the event of a crash. When worn by non-enthusiast cyclists they are often poorly adjusted or the wrong size (Parkinson and Hike, 2003; Thai et al., 2015). When claims are made of "significant correlation between use of cycle helmets and reduction in adjusted mortality and morbidity associated with TBI and facial injury" (Dodds et al., 2019), then some observers will be immediately sceptical an...

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  • Modifications to Prevent-ED map-task

    This is a response to the PREVENT-ED protocol from its authors. The original paper is a protocol for a spoken dialogue study, for which data collection has been taking place since all ethical approvals were granted in August 2018. It proposes the use of a cooperative navigation task created specifically for dementia context, in order to elicit spontaneous dialogues in search for linguistic markers of cognitive decline.

    Alongside data collection, we have gathered participants’ feedback about the experimental procedure. As a result, we have made some changes to the main element of task: the map. We hereby would like to make the research community aware of these changes, should anyone wish to make use of our protocol.

    Our modifications aim mainly at enhanced readability, comprehensibility, and generalisability; hence making the task more inclusive for vulnerable populations. Changes were also partially motivated by the request from another research group to use this task with an elderly population living with Alzheimer’s Disease at different stages (see https://arxiv.org/pdf/1909.06644.pdf), rather than with healthy participants, for which the original protocol was designed.

    Therefore, taking into account the participants’ feedback so far, as well as the need for the protocol to be inclusive to a more vulnerable population, the changes we have made to the map are as follows:

    - Clearer drawings. T...

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  • The PAUSE score study

    May I recommend that you also run a rolling 12-month total of deaths at each site in the study. This is based on the observation that in-hospital deaths are showing curious hidden patterns [1] as are international deaths [2]. These patterns have the potential to slightly modify inter-site comparison. This may have no material impact on your study, however, it is worth checking.

    I hope this helps.


    1. Jones R. Unexpected trends in hospital standardized mortality indicate a novel cause. European Journal of Internal Medicine. 2018; 52: e9-e11.

    2. Jones R. Unexplained periods of higher deaths contribute to marginal changes in health care demand and health insurance costs: International perspectives. International J Health Planning Management 2019;1-12 https://doi.org/10.1002/hpm.2917

  • Comments to the response “Response to comment 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, Peter Aaby, Chris

    Andreas Jensen (0000-0003-4302-2982), Per Kragh Andersen (0000-0003-0490-0885), Lone Graff Stensballe (0000-0003-1569-153X)

    Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, DK-2100 Copenhagen Ø, Denmark. Andreas Jensen, MSc in Statistics
    Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital. Lone Graff Stensballe, professor
    Section of Biostatistics, Department of Public Health, University of Copenhagen. Per Kragh Andersen, professor

    We appreciate the response to our study.
    First, considering the latest response, we further restricted our study population to children who reached 16 months of age before 1 January 2007, where PCV was introduced, and received 3 DTP vaccines before that age i.e. omitting the 2DTP+MMR-group. Here we present the corresponding estimates (Table 2 - https://blogs.bmj.com/bmjopen/files/2020/01/table-2.png).

    Second, the interpretation and properties of a ratio between a hazard ratio for one outcome and a hazard ratio for another outcome is not obvious.

    Finally, we note that Table 1 of our original response has been revised (please find it here: https://blogs.bmj.com/bmjopen/files/2020/01/table-1.png) . The first version of Table 1 presented the estimates from the crude analy...

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  • Schistosomiasis-Associated Neoplasia

    As highlighted in the interesting article by Dr Humphrey D. Mazigo and coworkers1, Schistosoma mansoni-induced intestinal schistosomiasis and Human Immunodeficiency Virus (HIV) are frequently detected in association with each other in geographical areas where the two infections are highly endemic. Noteworthy, several patients affected by the urogenital form of schistosomiasis, caused by S. haematobium, will also develop schistosomiasis-associated bladder neoplasia2. This was already apparent 40 years ago in S. haematobium-infected individuals of a rural population from Egypt, 2/3 of whom had nitrites in their urines2, while also showing a positive correlation between nitrite occurrence, on one side, and urinary infection by nitrate reductase-rich Escherichia coli, on the other. Under these circumstances, the production within the bladder of carcinogenic nitrosamines, following chemical interaction between urinary nitrite and amines, was deemed as a highly plausible event2.
    Could a similar pathogenetic mechanism also drive the neoplastic transformation of the genital apparatus in S. haematobium-infected, Human Papillomavirus-negative patients? And, what about its contributory role, if any, in the development of intestinal neoplasia in S. mansoni-infected individuals?
    In this respect, while a significant E. coli predominance has been reported also within the microbiota inhabiting the human cervix4, it should be additionally emphasized that the reduced immune resp...

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