Dear Editor:
We peruse with interest the interesting study by Meng Lee et al (1).
We would like to share the followings:
1.One of the strengths of any retrospective data analysis is the
acceptance/compliance with therapy in the real-life situation ( whatever
the compliance rate may be).The exclusion of 1632 patients ( 42% of the
total) because of medication possession ratio <80% has limited the
external vali...
Dear Editor:
We peruse with interest the interesting study by Meng Lee et al (1).
We would like to share the followings:
1.One of the strengths of any retrospective data analysis is the
acceptance/compliance with therapy in the real-life situation ( whatever
the compliance rate may be).The exclusion of 1632 patients ( 42% of the
total) because of medication possession ratio <80% has limited the
external validity of the study.
2.Excluding 355 patients (9% of the total) further because of Atrial
fibrillation, valvular heart diseases or coagulopathy may not be justified
( if they were put either on aspirin or clopidogrel ,they should have been
included).
3.During the follow-up period, statin and diuretics were used more
frequently ( statistically significant) in the clopidogrel group. It is
well known that statin and diuretics reduce ischemic strokes (2,3).Thus
tilting the balance in favor of clopidogrel.
4.Much less patients were put on clopidogrel (384 patients) versus
aspirin (1500 patients),even the best statistical model may not be able to
completely nullify the bias as the disparity is substantial.
As the above mentioned limitations are influential, the results of
the study may be biased and should be interpreted with caution.
References
1.Meng Lee, Yi-Ling Wu, Jeffrey L Saver, Hsuei-Chen Lee, Jiann-Der
Lee,Ku-Chou Chang, Chih-Ying Wu, Tsong-Hai Lee, Hui-Hsuan Wang, Neal M
Rao, and Bruce Ovbiagele.Is clopidogrel better than aspirin following
breakthrough strokes while on aspirin? A retrospective cohort study. BMJ
Open 2014 4:e006672; doi:10.1136/bmjopen-2014-006672
2.Pierre Amarenco, Julien Labreuche.Lipid management in prevention of
stroke:review and updated meta-analysis od statin for stroke
prevention.The Lancet Neurology. 2009;8(5):453-463.doi:1016/s1474-4422(09)
70058-4
3.PROGRESS Collaborative group. Randomised trial of a perindopril-
based blood pressure-lowering regimen among 6105 individuals with previous
stroke or transient ischemic attack.The Lancet. 2001;358:9287,1033-1041.
doi:10.1016/s014-6736(01)06178-5
I wish to address the eLetter responding to our recently published
article in BMJ Open (Joshi SR, et al. Results from a dietary survey in an
Indian T2DM population: a STARCH study. BMJ Open. 2014 Oct
31;4(10):e005138.) Firstly, thank you to Prof.Vishnupriya R Paturi for
taking the time to read our article and providing feedback. We believe
that the impact and relative importance that the type or sou...
I wish to address the eLetter responding to our recently published
article in BMJ Open (Joshi SR, et al. Results from a dietary survey in an
Indian T2DM population: a STARCH study. BMJ Open. 2014 Oct
31;4(10):e005138.) Firstly, thank you to Prof.Vishnupriya R Paturi for
taking the time to read our article and providing feedback. We believe
that the impact and relative importance that the type or source of
carbohydrate has on postprandial glucose level has continued to be an area
of debate. However, many studies highlights that the dietary carbohydrate
determines the postprandial blood glucose response. Garg A & Parillo M
reported that dietary carbohydrate increases blood glucose concentrations,
particularly in the postprandial period. Therefore, in diabetic patients,
particularly those treated with insulin or who have more severe forms of
type 2 diabetes, a carbohydrate-rich diet can have detrimental effects on
glycemic control, which plays a major role in the development of coronary
artery disease and other macrovascular and microvascular complications
(1,2). In parallel with the plasma glucose rise, plasma insulin and
triacylglycerol concentrations also tend to increase with a high-
carbohydrate diet, along with other cardiovascular disease risk
factors(3). Although, it is known that not all carbohydrate-rich foods are
equally hyperglycemic: differences in the postprandial blood glucose
response to various carbohydrate-containing foods have been shown in both
healthy subjects and diabetic patients, even when consumed in portion
sizes containing identical amounts of carbohydrate. It was observed that
carbohydrate-rich foods represent a heterogeneous category and, therefore,
may have a variable effect on energy and substrate metabolism in humans.
(4-6).
The American Diabetes Association reviewed the available scientific data
regarding the effect of the type or source of carbohydrate on the
prevention and management of diabetes and suggested the following
statements: [7]
* The component of the diet that has the greatest influence on blood
glucose is carbohydrate. However, other macronutrients in the diet, i.e.,
fat and protein, can influence the postprandial blood glucose level.
* Regulation of blood glucose to achieve near-normal levels is a primary
goal in the management of diabetes, and, thus, dietary techniques that
limit hyperglycemia following a meal are likely important in limiting the
complications of diabetes.
* Low-carbohydrate diets are not recommended in the management of
diabetes. Although dietary carbohydrate is the major contributor to
postprandial glucose concentration, it is an important source of energy,
water-soluble vitamins and minerals, and fiber.
* Both the amount (grams) of carbohydrate as well as the type of
carbohydrate in a food influence blood glucose level.
* The maintenance of a healthy body weight is strongly recommended as a
means of preventing this disease, because much of the risk of developing
type 2 diabetes is attributable to obesity,
Also most experts agree that the total carbohydrate intake from a
meal or snack is a relatively reliable predictor of postprandial blood
glucose. Thus in addition to advice fat proportions in diets, monitoring
total grams of carbohydrate, whether by use of exchanges or carbohydrate
counting, remains a key strategy in achieving glycemic control.In our
study, we suggested the need to investigate further the benefit of various
therapeutic interventions in high carbohydrate-consuming Indian type-2
diabetes mellitus participants in a prospective randomised controlled
study.
References:
1.Garg A, Bonanome A, Grundy SM, et al. Comparison of a high carbohydrate
diet with a high-monounsaturated-fat diet in patients with noninsulin-
dependent diabetes mellitus. N Engl J Med 1988;319:829 -34.
2.Parillo M, Giacco R, Ciardullo AV, et al. Does a high carbohydrate diet
have different effects in NIDDM patients treated with diet alone or
hypoglycemic drugs? Diabetes Care 1996;19:498 -500.
3.Rivellese A, Giacco R, Genovese S, et al. Effects of changing amount of
carbohydrate in diet on plasma lipoproteins and apolipoproteins in type II
diabetic patients. Diabetes Care 1990;13:446-8.
4.Coulston AM, Hoolenbeck CB. Swislocki AML, et al. Deleterious metabolic
effects of high carbohydrate, sucrose containing diets in patients with
NIDDM. Am J Med 1987;82:213-20.
5.O'Dea K, Nestel R, Autonoff L. Physical factors influencing postprandial
glucose and insulin responses to starch. Am J Clin Nutr 1980;33:760-5.
6.Liljeberg H, Granfeldt Y, Bjorck I. Metabolic responses to starch in
bread containing intact kernels versus milled flour. Eur J Clin Nutr
1992;46:561-5.
7.Nancy F. Sheard, et al. Dietary Carbohydrate (Amount and Type) in the
Prevention and Management of Diabetes. Diabetes Care 2004; 27(9):2266-
2271
CAM includes both complementary and alternative practices.
Alternative practices, by definition, either have not been proven to work,
or have been proven not to work. Complementary practices have always been
mainstream and many are evidence-based. There is no sound scientific or
medical justification for analysing the two together. Alternative
practitioners may prefer them to be considered together, as this may
provide...
CAM includes both complementary and alternative practices.
Alternative practices, by definition, either have not been proven to work,
or have been proven not to work. Complementary practices have always been
mainstream and many are evidence-based. There is no sound scientific or
medical justification for analysing the two together. Alternative
practitioners may prefer them to be considered together, as this may
provide a halo effect of legitimacy from being considered alongside
obviously valid concepts such as diet and exercise, but in analysing the
cost-effectiveness of these interventions it seems to me rather important
to unpick the two.
For example, any judgment of the validity of medical training in
nutrition cannot possibly shed light on the validity of training in a
refuted dogma such as homeopathy or reiki.
It is plausible that autohypnosis may be able to materially benefit
patients with anxiety disorders. It is wholly implausible that homeopathy
would deliver any objectively provable benefit at all. To consider the two
jointly, is to needlessly muddy the waters.
The authors reference the US National Center for Complementary and
Alternative Medicine (NCCAM), a body set up at the instigation of a pro-
CAM legislator to investigate and produce evidence around CAM
interventions.
Dr. David Gorski has been looking closely at NCCAM for some years,
along with several colleagues. They have noted that NCCAM has spent in
excess of one billion dollars since its inception in 1993. To date, they
have failed to validate a single alternative intervention. They have
produced supportive evidence for massage therapy (which is scarcely
controversial), but not for any of the alternative therapies tested - many
of which are by now considered refuted though still doggedly promoted by
believers.
I would suggest the authors do their best in future to unpick the
effects of legitimate and medically plausible complementary therapies,
from those of alternative therapies. This will reduce the risk of their
research being abused by advocates as support for therapies which, of
themselves, have little or no provable validity.
In the light of surveys showing that large numbers of doctors
knowingly prescribe placebos, it would also be valuable to understand how
many of the doctors using CAM therapies consider them to be valid
interventions and administer them on that basis.
"Let food be thy medicine and medicine be thy food." Hippocrates
We read with interest the study by T.Sekhri,R.S.Kanwar et al(1).The
authors needs to be congratulated for such a meticulous and unique study
involving subjects from all over India.The study is first of its kind in
India and an eye-opener. However,the following issues we shall like to
share:
1.As it was a non-interventional and free-of-cos...
"Let food be thy medicine and medicine be thy food." Hippocrates
We read with interest the study by T.Sekhri,R.S.Kanwar et al(1).The
authors needs to be congratulated for such a meticulous and unique study
involving subjects from all over India.The study is first of its kind in
India and an eye-opener. However,the following issues we shall like to
share:
1.As it was a non-interventional and free-of-cost to the
participating subjects study.Why only 14,500 subjects( 55%) gave the
informed consent out of approximately 26,000.It may be worth mentioning
some important reasons of this rather less acceptance for the study.This
low level of participation compromises the external validity of the study.
2.The subjects with known coronary artery disease (CAD) were
excluded.It would have been interesting to know how many subjects with
newly discovered CAD were detected,including silent old MI pattern in ECG.
3.As mentioned in the introduction of the study(1),over 60% of CAD in
native Indians remain unexplained by conventional risk factors,why only
conventional risk factors were considered in the study.
4.Gainfully,in the protocol,disease history is included,it would have
been relevant to know about the other diseases and if any correlation with
the risk factors could have been made. Like patients with
depression/psychiatric morbidity (common diseases these-days)and
obstructive sleep apnea have much worse risk factor profile and are
increasing recognized as novel risk factors per se. Interestingly in
women( obstetric history was ascertained),any correlation with adverse
obstetric history and risk factor profile was observed?.The data is
rapidly accumulating between adverse obstetric history and development of
cardiovascular disease in future(2).
5.In the present study interestingly only 27% of hypertensives were
aware about their condition ( 73% were newly discovered).A rather lower
percentage particularly for civilian government employee,having free
access to the medical services.
6.78.6% of the subjects had two or more risk factors is a disturbing
fact.In Prabhakaran's study(3) in 2005 amongst industrial workers of north
India 47% subjects had atleast two risk factors.Is it a temporal trend or
the difference is due to the location of the subjects in the study,needs
to be explained.
The study emphasized the disturbing trend in the health status in
India and serious thoughts and actions are needed to contain this unabated
epidemic.What will be the peak of the epidemic is anybody's guess.
However, we have the following suggestions to offer:
1.When the epidemic reaches this gigantic proportion,secondary and
tertiary prevention have very limited impact at a community level.
2.The primordial and primary prevention assume huge importance. As
they are much more cost-effective and result yielding.
3.For Primordial prevention and primary prevention ,in a nutshell the
message is : to eat and try to assume the level of physical activity and
lifestyle ( may not be possible for everyone) similar to what our
grandparents used to have.
4.To counteract the adverse health consequences of modern life .We
advocate three levels of prevention: health education, health education
and health education of the entire world ( in particular developing
world), with emphasis upon educating health policy - makers.
References
1.T Sekhri, R S Kanwar, R Wilfred, P Chugh, M Chhillar, R Aggarwal, Y
K Sharma, J Sethi, J Sundriyal, K Bhadra, S Singh, N Rautela, Tek Chand, M
Singh, and S K Singh.Prevalence of risk factors for coronary artery
disease in an urban Indian population. BMJ Open 2014 4:e005346;
doi:10.1136/bmjopen-2014-005346
2.Bellamy L,Casas JP,Hingorani AD,Williams DJ.Pre-eclampsia and risk
of cardiovascular disease and cancer in later life:Systematic review and
meta-analysis.BMJ.2007;335:974
3.Prabhakaran D, Shah P, Chaturvedi V, et al. Cardiovascular risk
factor prevalence among men in a large industry of northern India. Natl
Med J India 2005;18:59-65.
Landis et al. describe a temporal association between wartime
conflict, internal displacement, and Nodding syndrome (NS)(1). They raise
infectious, nutritional and neuropsychiatric elements as possible causal
factors. The authors, however, do not mention a key factor that may have
played a major role during the NS epidemic in northern Uganda: a lack of
ivermectin treatment in onchocerciasis endemic areas.
Landis et al. describe a temporal association between wartime
conflict, internal displacement, and Nodding syndrome (NS)(1). They raise
infectious, nutritional and neuropsychiatric elements as possible causal
factors. The authors, however, do not mention a key factor that may have
played a major role during the NS epidemic in northern Uganda: a lack of
ivermectin treatment in onchocerciasis endemic areas.
Mass-distribution of ivermectin is routinely used to interrupt
onchocerciasis transmission in endemic foci, and an association between NS
and onchocerciasis has repeatedly been reported (2). NS only occurs in
onchocerciasis hyperendemic areas, and other forms of epilepsy are also
thought to be highly prevalent in many of these regions(3).
During the civil war in northern Uganda (1986-2006/2008), there was
no access to ivermectin in districts affected by NS, and it was only after
the war that ivermectin treatment programmes were established. Ivermectin
has been distributed annually in NS-affected districts since 2008, and
biannually since 2012 (2). This has coincided with a dramatic drop in the
number of new NS cases, and no new cases were officially reported in 2013
(4). The ivermectin distribution programme in northern Uganda was
supplemented by control measures targeting blackflies (Simuliidae), the
vectors of onchocerciasis, in late-2012. The Achwa and Pager rivers were
initially treated with larvicides applied from boats and light aircraft,
and larval breeding sites are now being treated with the organophosphate,
temephos, at predefined points along the rivers (2). We believe that this
integrated approach, targeting both the vectors of onchocerciasis and the
parasite in the human population, has contributed to the reduction of NS
cases in northern Uganda.
The link between NS and onchocerciasis appears to be further
reinforced by a recent study which suggests that an antibody-mediated
autoimmune response to leiomodin-1 may be involved in the etiology of NS.
Johnson et al. have demonstrated that antibodies against leiomodin-1 are
more likely to be present in NS cases than in controls (5). These
antibodies are also present in the cerebrospinal fluid of certain patients
with NS, are neurotoxic in vitro, and cross-react with Onchocerca volvulus
-specific proteins.
We do not believe that NS can be explained by events only related to
war. In the Mahenge NS-focus in Tanzania, there is no recent history of
conflict or household internment. Hypotheses regarding NS etiology should
be based on information from all affected regions.
Further research is needed to explore whether NS is caused by an auto
-immune reaction in response to Onchocerca volvulus infection; whether the
species or strain of Onchocerca is unique in NS-affected areas, or whether
NS is caused by a currently unidentified agent transmitted by blackflies
(6).
R. Colebunders, K. Coudere, N. Van der Moeren, A Hendy
Reference List
(1) Landis JL, Palmer VS, Spencer PS. Nodding syndrome in Kitgum
District, Uganda: association with conflict and internal displacement. BMJ
Open 2014;4(11):e006195.
(2) Colebunders R, Post R, O'Neill S, Haesaert G, Opar B, Lakwo T et
al. Nodding syndrome since 2012: recent progress, challenges and
recommendations for future research. Trop Med Int Health 2014 October 28.
(3) Pion SD, Kaiser C, Boutros-Toni F, Cournil A, Taylor MM,
Meredith SE et al. Epilepsy in onchocerciasis endemic areas: systematic
review and meta-analysis of population-based surveys. PLoS Negl Trop Dis
2009;3(6):e461.
(4) Ministry of Health, Uganda. Weekly epidemiological bulletin. 2014.
(5) Johnson T, Tyagi R, Lee PR, Leea M-h, Johnson KR, Kowalak J,
Medynets M, Hategan A, Nutman TB, Sejvar J, Makumbi I, Aceng JR, Dowell
SF, Nath A. Detection of auto-antibodies to leiomodin-1 in patients with
nodding syndrome. j.jneuroim , 103. 2014.
(6) Colebunders R, Hendy A, Nanyunja M, Wamala JF, van OM. Nodding
syndrome-a new hypothesis and new direction for research. Int J Infect Dis
2014 August 23;27C:74-7.
Thanks to statistician Ole Olsen who again expresses his concern
about the validity of the data in the National Birth Registry, and the
inconsistent reporting of these data on the official on-line sites. This
time Ole Olsen, however, goes one step further. Now he demands the editors
of BMJ open to ensure "documentation of the validity of all variables for
all years in the study period".
Thanks to statistician Ole Olsen who again expresses his concern
about the validity of the data in the National Birth Registry, and the
inconsistent reporting of these data on the official on-line sites. This
time Ole Olsen, however, goes one step further. Now he demands the editors
of BMJ open to ensure "documentation of the validity of all variables for
all years in the study period".
To validate all recorded birth related diagnosis and procedural codes
over a time span of 13 years, during which more 829,000 women have
delivered, would require providing the clinical notes of a representative
sample of these deliveries to see first, if all the relevant codes were
recorded appropriately, and secondly, if any non-relevant codes had been
recorded. Fortunately such validation studies have been made,
demonstrating a general high validity of the recorded obstetrical
diagnosis and procedural codes in the National Health Registry, which
feeds the Danish Birth Registry (1).
The main variables used for our study were calendar years, the
gestational age of delivering women, and the codes assessing stillbirth.
As reported, the gestational age was recorded in 99.4 % of all deliveries,
and has been found to have a high validity (1). The same applies to the
codes for stillbirths, which is generally considered as a "hard" end
point. We have previously indicated how we assessed stillbirths (2).
So the remaining question is whether other circumstances than the
earlier induction practice could explain the encouraging substantial
decline in stillbirths - not whether such a decrease actually occurred.
Considering the dramatic increase in risk of stillbirth with increasing
gestational age, it is not surprising that moving deliveries from high-
risk post-term weeks to earlier weeks with substantial lower risk of
intrauterine death would decrease the overall stillbirth rate from 37
gestational weeks. This is possibly not a very welcome message for people
like Ole Olsen, who for many years has argued for home deliveries, but it
does not make the scientific evidence less valid. Ole Olsen indicates
specifically, that the recording of induction of labour may have had a
lower validity than ideal. However this variable was used only for
descriptive purposes in our study, to demonstrate the increasing
proportion of inductions of deliveries from 12.4% to 25.2% during the
study period. If some of the codes used to assess labour induction have
been prone to variation between departments, which is not unlikely, these
circumstance would not change anything in our analysis or in our
conclusion.
As Ole Olsen also demonstrates, there have been several attempts to
ensure the validity and standardisation of obstetrical coding in Denmark.
This has been done through national guidelines elaborated by the Danish
Society of Obstetrics and Gynaecology (DSOG)(3), and by annual meetings
where these registration rules are discussed and posted solid. These
attempts are expected generally to have improved the registration practice
in Denmark by time.
The experiences Ole Olsen and his midwife collaborators Rydahl and
Clausen have had by getting access to data in the Danish Birth Registry,
and the inconsistencies in the official online statistics are - again -
not our responsibility and should be addressed to the relevant bodies.
About data sharing, one of the strengths about Danish registry
research is that these registry data are available for all scientists,
including Ole Olsen, who want to investigate any obstetrical question.
Based on the high validity of the diagnosis codes used in our study,
we are still confident with our analyses, and with the conclusions drawn.
1) Langhoff-Roos J, Rasmussen S. [Validation of the National Health
Registry concerning obstetrical research and quality assurance][In
Danish]. National Health Board 2003. Page 1-193.
2) Lidegaard O. Reply to Rydahl and Clausen. BMJ open 2014, October
13, 2014.
3) https://dsog.squarespace.com/obstetrik/. Accessed December 4,
2014.
I wish to address the eLetter responding to our recently published
article in BMJ Open (Abouzeid M, Versace VL, Janus ED, et al. A population
-based observational study of diabetes during pregnancy in Victoria,
Australia, 1999-2008). Firstly, thank you to Wigdan Farah for taking the
time to read our article and providing positive feedback. Specifically
they suggest that we add the variable 'socio-eco...
I wish to address the eLetter responding to our recently published
article in BMJ Open (Abouzeid M, Versace VL, Janus ED, et al. A population
-based observational study of diabetes during pregnancy in Victoria,
Australia, 1999-2008). Firstly, thank you to Wigdan Farah for taking the
time to read our article and providing positive feedback. Specifically
they suggest that we add the variable 'socio-economic status' (SES) to our
analysis. They cite the paper by Nomura Y, Marks DJ, Grossman B, et al.
(2012) in Archives of Pediatrics & Adolescent Medicine as an example
of the influence of SES on health outcomes. We are pleased to advise that
we have just had an article accepted by PLoS One entitled 'Socio-cultural
disparities in GDM burden differ by maternal age at first delivery'
(accepted December 2nd, 2014, Abouzeid M, Versace V, Janus E, et al.). We
encourage Wigdan Farah to access this article once it appears online in
the near future.
Kind regards
Abouzeid M, Versace VL, Janus ED, M-A Davey M-A, Philpot B, Oats J,
and Dunbar JA
Articles cited
1. Abouzeid M, Versace VL, Janus ED, et al. A population-based
observational study of diabetes during pregnancy in Victoria, Australia,
1999-2008. BMJ Open. 2014;4(11):e005394.
2. Nomura Y, Marks DJ, Grossman B, et al. Exposure to gestational
diabetes mellitus and low socioeconomic status: effects on neurocognitive
development and risk of attention-deficit/hyperactivity disorder in
offspring. Arch Pediatr Adolesc Med. Apr 2012;166(4):337-343.
3. Abouzeid M, Versace VL, Janus ED, et al. Socio-cultural
disparities in GDM burden differ by maternal age at first
delivery.(Accepted December 2nd, 2014). PLoS One.
Dr Ian Brown rightly highlights the potential dangers of an
atmosphere of stigma around weight, and suggests that rejection of the
term 'obese' may be protective of body self-esteem (1). This is an
important point, as the term 'obese' is clearly perceived as stigmatising
by many, and perceived stigma has been associated with poorer weight
outcomes as well as psychological distress (2). However, our perspective
is that...
Dr Ian Brown rightly highlights the potential dangers of an
atmosphere of stigma around weight, and suggests that rejection of the
term 'obese' may be protective of body self-esteem (1). This is an
important point, as the term 'obese' is clearly perceived as stigmatising
by many, and perceived stigma has been associated with poorer weight
outcomes as well as psychological distress (2). However, our perspective
is that the specific terminology used to discuss body weight may be less
important than there being a common language shared between health
professionals, the research community, media and the public. At present,
clinically descriptive approaches to weight classification are severely
out of kilter with the way in which the public perceives body weight,
which must impede individuals' ability to access information and make
informed decisions about their own health and lifestyle.
Meanwhile, a valuable asset in tackling weight stigma could be a far
greater public understanding that there is no level playing field when it
comes to body weight. It is well recognised in the research community that
there are strong genetically-mediated predispositions that mean that some
individuals are more susceptible to weight gain, and make the challenge of
weight management in an obesogenic environment far greater for them. This
fact does not seem widely understood by the public or discussed in the
media (3, 4), and greater awareness of this could contribute to less
judgemental (and self-blaming) attitudes towards difficulties with weight
control (5).
Ultimately the best solution to the problem of high levels of
population obesity lies in reversing the trajectory of the food
environment, but progress toward this is minimal at present. In the
meantime, the lack of effective channels of communication about weight
must be a formidable obstacle to fostering the knowledge and skills
required to manage the difficulties of living in an obesogenic society.
1. Brown, I. Is self-identification as 'obese' really a public health
solution? BMJ Open. 2014 Letter (Response to Johnson F, et al. BMJ Open
2014; 4(11):e005561. doi: 10.1136/bmjopen-2014-005561)
2. Jackson SE, Beeken RJ, Wardle J. Perceived weight discrimination and
changes in weight, waist circumference, and weight status. Obesity (Silver
Spring). 2014 Dec;22(12):2485-8.
3. Beeken RJ, Wardle J. Public beliefs about the causes of obesity and
attitudes towards policy initiatives in Great Britain. Public Health Nutr.
2013 Dec;16(12):2132-7.
4. Sikorski C, Luppa M, Kaiser M, Glaesmer H, Schomerus G, K?nig HH,
Riedel-Heller SG. The stigma of obesity in the general public and its
implications for public health - a systematic review. BMC Public Health.
2011 Aug 23;11:661. doi: 10.1186/1471-2458-11-661.
5. Meisel SF, Wardle J. 'Battling my biology': psychological effects of
genetic testing for risk of weight gain. J Genet Couns. 2014 Apr;23(2):179
-86.
I am still concerned about the validity of the data used in the paper
"Reduction in stillbirths at term after new birth induction paradigm:
results of a national intervention" (1). The paper covers the time period
2000-2012. Lack of validity of the used registry data was documented in
2003 (2) and serious concern about the validity of the data in the
registries still exist.
I am still concerned about the validity of the data used in the paper
"Reduction in stillbirths at term after new birth induction paradigm:
results of a national intervention" (1). The paper covers the time period
2000-2012. Lack of validity of the used registry data was documented in
2003 (2) and serious concern about the validity of the data in the
registries still exist.
For the year 2001 the validity of the data in the registers was
thoroughly investigated for all Danish births during one specific week by
comparing register data with data extracted from patient records by two
senior obstetricians (2). In a 192 page report in Danish the authors
conclude that "you cannot use the registered interventions to calculate
the rates of induction of birth [my translation]" (2) and they note that
"the use of the codes in the register is different from one hospital to
the other" (2). The work in the report had been initiated because "Since
the medical birth registration [...] was transferred to electronic
reporting to the National Patient Register (LPR), there has been
uncertainty about the quality of the reported data and a growing need for
a current validation and a prospective quality improvement of registration
practice" (2). Particularly "the lack of feedback from the Board of Health
gave uncertainty about the validity of the data reported among health
professionals, who entered data, and clinical researchers who used the
data" (2). I would appreciate if the authors of the paper (1) could
explain how they have overcome this problem for the early years of their
study period.
For the more recent years in the study period I have previously
documented several large inconsistencies in annual stillbirth rates
between the paper published in this journal (1) and the official published
national statistics (comment published 10th September 2014) and Rydahl and
Clausen have brought attention to unexplained and dramatic retrospective
changes in the online electronic register that supplied data to the paper
(7th October). In a joint newspaper commentary leading Danish
obstetricians and midwives state "access to the data has been difficult,
costly and time consuming" (3), and they add that "[u]nfortunately, we are
no longer able to use the data to navigate in everyday clinical practice.
Data not used regularly lose their immediate value - proper registration
requires motivation and ongoing feedback" (3). The latter concern is
identical to the concern issued ten years earlier (2). I would appreciate
if the authors of the paper (1) could explain in sufficiently transparent
detail how they have overcome the inconsistencies, variability and
motivational problems for the middle and late years of their observation
period and ensured validity of their data.
Editors are responsible for everything published in their journals
and should ensure the quality of the material they publish (4). I thus ask
the editors of BMJ Open to ensure transparent documentation of the
validity of all variables for all years in the study period. I also
propose that the authors publish and share data and documentation with
other researchers on the web as it is encouraged by The BMJ (5).
1. Hedegaard M, Lidegaard O, Skovlund CW, M?rch LS, Hedegaard M.
Reduction in stillbirths at term after new birth induction paradigm:
results of a national intervention. BMJ Open. 2014 Aug 14;4(8)
2. Sundhedsstyrelsen, Center for Evaluering og Medicinsk
Teknologivurdering. Validering af Landspatientregistret (LPR) med henblik
p? obstetrisk forskning og kvalitetssikring - et
kvalitetsudviklingsprojekt [Validation of the National Patient Register
(LPR) in relation to obstetric research and quality - a quality
development project]. Sundhedsstyrelsen, Copenhagen 2003.
3. Krebs L, Langhof-Roos J, Petersen KR, Bondo L. Sundhedsstyrelsen
gemmer vigtig viden om f?dsler [National Board of Health hides important
information on births]. Politiken, 14. okt. 2013 [at
http://politiken.dk/debat/debatindlaeg/ECE2102941/sundhedsstyrelsen-gemmer
-vigtig-viden-om-foedsler/; accessed 25. Nov 2014].
4. Kleinert S & Wager E (2011) Responsible research publication:
international standards for editors. A position statement developed at the
2nd World Conference on Research Integrity, Singapore, July 22-24, 2010.
Chapter 51 in: Mayer T & Steneck N (eds) Promoting Research Integrity
in a Global Environment. Imperial College Press / World Scientific
Publishing, Singapore (pp 317-28). (ISBN 978-981-4340-97-7)
5. The BMJ. Data sharing [at http://www.bmj.com/about-bmj/resources-
authors/article-types/research; accessed 25. Nov 2014].
I am writing to support the author in their outcomes and to add one
point to their article "A population-based observational study of diabetes
during pregnancy in Victoria, Australia 'from the British Medical Journal
on November 14th, 2014 1
It is an interesting article specially with the significant side
effect of diabetes during pregnancy and I suggest the author to add the
socioeconomic...
I am writing to support the author in their outcomes and to add one
point to their article "A population-based observational study of diabetes
during pregnancy in Victoria, Australia 'from the British Medical Journal
on November 14th, 2014 1
It is an interesting article specially with the significant side
effect of diabetes during pregnancy and I suggest the author to add the
socioeconomic status as one of the study variable, depending on the
Exposure to Gestational Diabetes Mellitus and Low Socioeconomic Status
Effects on Neurocognitive Development and Risk of Attention-Deficit
Hyperactivity Disorder in Offspring study 2,which showed that maternal
gestational diabetes and low socioeconomic status were associated with an
approximately 2-fold increased risk for ADHD at age 6 years, impaired
neurobehavioral functioning, including lower IQ, poorer language, and
impoverished behavioral and emotional functioning.
Sincerely,
Wigdan Farah
Research Trainee
Preventive Medicine Department
Mayo Clinic
Rochester, MN
References:
1. Abouzeid M, Versace VL, Janus ED, et al. A population-based
observational study of diabetes during pregnancy in Victoria, Australia,
1999-2008. BMJ Open. 2014;4(11):e005394.
2. Nomura Y, Marks DJ, Grossman B, et al. Exposure to gestational
diabetes mellitus and low socioeconomic status: effects on neurocognitive
development and risk of attention-deficit/hyperactivity disorder in
offspring. Arch Pediatr Adolesc Med. Apr 2012;166(4):337-343.
Dear Editor: We peruse with interest the interesting study by Meng Lee et al (1). We would like to share the followings:
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CAM includes both complementary and alternative practices. Alternative practices, by definition, either have not been proven to work, or have been proven not to work. Complementary practices have always been mainstream and many are evidence-based. There is no sound scientific or medical justification for analysing the two together. Alternative practitioners may prefer them to be considered together, as this may provide...
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Dear Editor
I wish to address the eLetter responding to our recently published article in BMJ Open (Abouzeid M, Versace VL, Janus ED, et al. A population -based observational study of diabetes during pregnancy in Victoria, Australia, 1999-2008). Firstly, thank you to Wigdan Farah for taking the time to read our article and providing positive feedback. Specifically they suggest that we add the variable 'socio-eco...
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I am still concerned about the validity of the data used in the paper "Reduction in stillbirths at term after new birth induction paradigm: results of a national intervention" (1). The paper covers the time period 2000-2012. Lack of validity of the used registry data was documented in 2003 (2) and serious concern about the validity of the data in the registries still exist.
For the year 2001 the validity of the...
Dear Editor,
I am writing to support the author in their outcomes and to add one point to their article "A population-based observational study of diabetes during pregnancy in Victoria, Australia 'from the British Medical Journal on November 14th, 2014 1
It is an interesting article specially with the significant side effect of diabetes during pregnancy and I suggest the author to add the socioeconomic...
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