490 e-Letters

published between 2015 and 2018

  • Further insights into Acute Kidney Injury

    Dear Editor,

    We have read with great interest the article “What insights do patients and caregivers have on acute kidney injury and post-hospitalisation care? A single-center qualitative study from Toronto, Canada” by Silver et al.

    The article sheds light on the fact that most of its participants prioritised chronic conditions that ‘progress over time’ over AKI. These co-morbidities often include heart failure, hypertension and Type 2 diabetes mellitus, which are treated with non-steroidal anti-inflammatory drugs, diuretics and metformin respectively( 1). There is considerable data that these drugs are nephrotoxic and should therefore, be deprescribed or temporarily with-held or dose-adjusted in patients with AKI.

    However, from unpublished research at our hospital, there is often reluctance to stop these drugs, suggesting that this misconception may be shared by physicians as well. As this is a common clinical problem with considerable morbidity, Think Kidneys Campaign (NHS collaboration of various trusts) have developed a checklist for medication optimization in patients with AKI (2), but its use is sparse at least from our experience.

    Studies have shown that in-hospital mortality due to AKI far exceeds that due to these long-standing, chronic conditions. In a large nation-based study, in-hospital mortality of AKI was found to be 12.32% (3), with an increase in number of absolute deaths from 2001 to 2011. This is in contrast to the 3% in-...

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  • To the editor

    To the editor:
    We read with interest the protocol for the validation of the Cow’s Milk-related Symptom Score (CoMiSS) against open food challenge by Vandenplas et al.(1) They have proposed this symptom score as a resource for primary healthcare providers, aiming to increase awareness of cow’s milk allergy (CMA)-related symptoms to facilitate an earlier diagnosis. The score was developed to increase awareness of mainly non-IgE mediated CMA, a disorder of increasing interest in recent literature publications.(2,3) However, dysmotility, dysmotility-related symptoms, blood in stool and failure to thrive (weight ≤2.5 Z-scores, drift from growth curve of >2 percentiles over 6 months or weight-for-length -2 Z-scores)(4) are excluded from the score. These are considered key features in non-IgE mediated allergy.(5) In contrast, severe respiratory symptoms and urticaria are included in the score. In our opinion, using the CoMiSS for diagnosing CMA will therefore hamper diagnosing non-IgE mediated CMA. The authors stress that the design of this study might not enable a reliable distinguishment between IgE-mediated CMA, non-IgE mediated CMA and non-allergic cow’s milk-related symptoms. In addition, in our experience we believe that healthcare professionals might even get confused in the differential diagnosis regarding non-allergic cow’s milk-related symptoms. For example pyloric stenosis, gastroesophageal reflux disease, hemorrhagic disease of the newborn or infective gastro...

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  • Excess sugar consumption, obesity and cancer

    The difference in levels of sugar in very similar foods that this study has revealed is shocking, but it does show that if one manufacturer can reduce sugar levels in their products, then it is possible for other manufacturers to do the same. We now need the government to take stronger action and make it compulsory for food manufacturers and retailers to reduce sugar levels in their products. Eating too much sugar leads to overweight and obesity, which our latest cancer prevention report shows is a cause of 12 different types of cancer. Healthy lifestyle patterns depend not only on individual choices but also on governments creating an environment that encourages people to eat healthily and do more exercise. WCRF calls on the government to prioritise cancer prevention through the development and implementation of effective policies to address the rising burden of obesity and cancer in the UK.

  • Response to ‘Baby-led weaning and iron - looking good but not clear-cut’

    Gill Rapley makes some useful points about our recent paper (Daniels, L., Taylor, R.W., Williams, S.M., Gibson, R.S., Fleming, E.A., Wheeler, B.J., Taylor, B.J., Haszard, J.J. and Heath, A-L.M. (2018) Impact of a modified version of baby-led weaning on iron intake and status: a randomised controlled trial, BMJ Open, 8: e019036).

    In particular, she points out that:
    (a) While our Baby-Led Introduction to Solids (BLISS) intervention group was given specific advice on increasing iron intake, the Control group received only standard care.
    (b) It is not clear whether the infants in the BLISS group would have had equivalent iron status to that of the Controls even without the additional advice.
    (c) Infants following a traditional approach to infant feeding may also need advice to improve their iron intake, particularly now that complementary feeding should ideally be delayed to 6 months of age.

    There are many interesting questions that can be asked about baby-led approaches to complementary feeding, and their impact on infant nutrient status. Each of these questions would need a different study design. In our case, we were interested in answering the pragmatic question – Is it possible to follow a baby-led approach to infant feeding instead of traditional feeding without negatively impacting on iron status? This required that we have an intervention group (our BLISS group) and a group representing the status quo, i.e. what is happening in the commu...

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  • Young adult cataracts - a 10 year study

    In the UK I have observed that the number of cataract operations is undulating in parallel with changes in the number of deaths. The number of deaths is showing highly unusual on/off switching which may arise from a hidden infectious outbreak. This on/off switching can be revealed by applying a rolling 12-month total to your data. Are you able to apply such a rolling total to your data to see if there are any hidden patterns in the trends? A list of publications regarding on/of switching in deaths and medical conditions can be found at http://www.hcaf.biz/2010/Publications_Full.pdf I hope that this will prove to be helpful. Kind Regards

  • Seasonal variation in mortality subsequent to acute MI

    Dear Sirs, Can I suggest that you apply a rolling 12-month average to the mortality rate and a rolling 12-month total to the raw deaths as a means of detecting possible step-like changes (on/off switching) in the mortality trends. I have recently identified that international deaths are subject to on/off switching which may indicate the hidden presence of infectious outbreaks of an unknown pathogen (possibly cytomegalovirus ????). I have published a number of studies on this topic which can be located in the relevant sections at http://www.hcaf.biz/2010/Publications_Full.pdf I hope this will stimulate further analysis of this fascinating data.

  • Last year of life

    Dear Authors, Are you able to use your data to compare attendances/admissions/costs in the last year of life versus previous years. For some years I have been arguing that nearness-to-death is the key missing variable in healthcare demand planning, which currently, and misleadingly, mainly uses population demography. You can view my publications in this area at http://www.hcaf.biz/2010/Publications_Full.pdf - look in the sections dealing with hospital beds and the links between death and admissions. Hope this helps.

  • Editor's Note

    Since publication, BMJ Open has received queries relating to the ethical approval statement in the article along with the reference number provided. We have asked the University of Bristol to investigate the accuracy of the statement and to confirm that the correct approval processes were followed. We are also in contact with the Health Research Authority, who are investigating the project.

    Once we have clarification of the ethical approval process, we will post an update.

  • Antivirals for ILI

    This is a useful study. The participants may not be aware that viruses like cytomegalovirus (CMV) interfere with both influenza vaccination and the immune response to influenza infection especially in the elderly. There is also some evidence that influenza may be interacting with outbreaks of an unknown agent (perhaps CMV?). See relevant references in the sections dealing with deaths and medical admissions and roles for CMV in human health at http://www.hcaf.biz/2010/Publications_Full.pdf

    I hope this is helpful to the study.

  • Women’s prepregnancy lipid levels and number of children: a Norwegian prospective population-based cohort study

    Dear authors,
    Recently, the work “Women’s prepregnancy lipid levels and number of children: a Norwegian prospective population-based cohort study” [1] was published in BMJ Open, it aims to study prepregnancy serum lipid levels and the association with the number of children. First, as part of the BMJ Open audiences, we thank for the work was presented to us. But, we think there are some problems on the tables of this study. When we firstly learn scientific knowledge, and the professor will tell us some rules on table and figure in scientific paper, and one of the most important is that table and figure should be “stand-alone” [2], that is, all important information should be presented, including table, figure, title, legend and footnotes etc. We found, although the “BMI” was given measurement unit as “kilogram/ (height in meters)2” in the text, but we did not find it in all of tables. In order to regulate writing rules, we raised the question.

    Conflicts of interest
    We declare that we have no conflicts of interest.
    1. Pirnat A, DeRoo LA, Skjaerven R, et al. Women's prepregnancy lipid levels and number of children: a Norwegian prospective population-based cohort study. BMJ open 2018;8(6): e021188.
    2. Cargill M, O'Connor P. Writing Scientific Research Articles: Strategy and Steps [M] Writing Scientific Research Articles. Wiley John + Sons, 2013:1018.