647 e-Letters

published between 2017 and 2020

  • Response to the Comments to the article by Savelieva E. et al “Psychological factors and indoor environmental quality in respiratory symptom reports of pupils: a cross-sectional study in Finnish schools”

    Poor indoor air quality in schools is a major problem in Finland that has increasingly been assessed using questionnaires to parents and pupils on symptoms and indoor air complaints. The fact that other factors beside indoor air quality may influence symptom reporting has, however, been largely neglected in the ongoing discussions also in Finland. Previous research has clearly established that symptoms which accompany indoor air problems are associated with both physical characteristics of the building environment and various psychosocial factors (1–3). The majority of the studies, however, were conducted among adults in office settings (4–6), and very little research was done among pupils in school setting. Our study (7) was conducted to fill this gap and examine whether, in addition to indoor environmental quality (IEQ) in schools, different psychosocial factors and other pupils’ individual and allergic characteristics are associated with symptom reporting.

    The main message of our study is the following: where high levels of symptoms are reported, both psychosocial factors and physical characteristics of indoor environment should be fully considered in the decision-making process of the indoor air quality in school buildings. Our paper (7), as well as our previous research (8,9), clearly demonstrates that our current findings cannot be used as a justification for ignoring physical environment in indoor air research. Below we provide our responses to the specific...

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  • Stillbirth rates in Denmark

    Trend analysis is always fraught with potential confounding. The authors may be unaware that the trends in life expectancy over the same period were also showing unexpected trends, see references in [1]. Even excess winter mortality has been undergoing unexpected fluctuations [1]. Total deaths have also been showing peculiar trends and 2015 in particular showed a very odd increase around the world [2,3]. I have recently suggested that it is the combined and interactive effects of multiple infectious outbreaks .including competition between pathogens which lie behind these unusual trends [4]. This can be inferred but is difficult to establish since most pregnant women are not screened for the presence of multiple pathogens, including seemingly trivial periods of unwellness, but it does suggest an interesting study.

    1. Jones R. Excess winter mortality (EWM) and stalling international improvements in life expectancy and mortality rates. Brit J Healthc Manage 2020; 26(12); https://doi.org/10.12968/bjhc.2020.0020

    2. Jones R. Austerity in the UK and poor health: were deaths directly affected? Brit J Healthc Manage 2019; 25(11): 337-347.

    3. Jones R. Role of social group and gender in outbreaks of a novel agent leading to increased deaths, with insights into higher international deaths in 2015. FGNAMB 2017; 3(1): 1-7. doi: 10.15761/FGNAMB.1000146

    4. Jones R. Multidisciplinary insights into health ca...

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  • Frequency of unscheduled care use in the last year of life.

    This study provides an excellent comprehensive overview of unscheduled care use across a wide variety of conditions. The frequency of unscheduled care use by people in their last year of life identified in this study (94.5%) is consistent with our findings examining unscheduled care use in the last year of life by people who go on to die from cancer (1). The rates of unscheduled care use identified in this paper and in our own work are substantially greater than those reported in previous research in this field (2). Previous studies have often focused on A&E-only, rather than taking into account unscheduled care services as a whole, including GP Out-of-Hours services, and have been largely attendance-based rather than cohort-based, making population use estimates less reliable.

    The trends emerging from these papers suggests that the magnitude of unscheduled care use in the last year of life is significantly greater than has been previously believed to be the case. This analysis strengthens the case for improved recognition of the substantial role that unscheduled care, particularly GPOOH, plays in meeting community care needs for people with palliative and end of life care needs, and improving resourcing, training and staffing available to in unscheduled care, in order to deliver high-quality palliative and end of life care through all unscheduled care services.

    1. Mills SEE, Buchanan D, Guthrie B, Donnan P, Smith BH. Factors affe...

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  • Management of abnormal uterine bleeding: comment on Henry et al. 2020.


    To the editors, BMJ Open

    We are interested in the recent paper from New Zealand (NZ), describing the experiences of 15 patients with abnormal uterine bleeding, by Claire Henry and others [1]. We agree that abnormal uterine bleeding deserves more attention and have documented the rapid recent increase in endometrial cancer (EC) in NZ Pacifica women [2,3]. However, some of these authors’ statements are not supported by the data they cite. They state “Studies which report on EC prevalence in NZ often link the cause of advanced stage diagnosis to ‘late presentation’...”. For this, they cite one of our studies [2] and another NZ study [4]. However, neither of these papers mentions late presentation, and in another paper which Henry et al. cite [3], we report that Māori and Pacific women did not present with higher grade or stage EC compared to other NZ women. However, both Māori and Pacific women experienced a worse disease-specific survival, which was statistically significant in Pacific women.

    More importantly, Henry et al. continue with reference to these studies “… placing women at fault for not having sought more timely medical intervention. We aimed to reframe these deficit narratives....”. We strongly object to these inaccurate claims and the implication that our papers are ‘deficit narratives’ is unacceptable. Nowhere in our papers do we “place women at fault”. We feel strongly that clinicians should be supportive and more alert to sympt...

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  • Second-generation antipsychotics and chronic kidney disease: a risk assessment

    Højlund et al. conducted a 1:4 matching case-control study to examine the association between use of second-generation antipsychotics (SGA) and the risk of chronic kidney disease (CKD) (1). They defined CKD as an estimated glomerular filtration rate below 60 mL/min/1.73 m2 for 3 months or more. The adjusted odds ratios (ORs) (95% confidence intervals [CIs]) of ever and current SGA users for the risk of CKD were 1.24(1.12 to 1.37) and 1.26 (1.12 to 1.42), although there was no dose-response relationship. In addition, the adjusted ORs (95% CIs) of short-term and long-term SGA users for the risk of CKD were 1.22 (1.01 to 1.48) and 1.45 (1.19 to 1.76), respectively. Furthermore, clozapine presented the highest risk of CKD, and aripiprazole presented no significant risk of CKD. I have a comment about their study with special reference for the psychiatric diseases.

    Wang et al. conducted a risk assessment of CKD between patients with schizophrenia using first and second-generation antipsychotics (2). They defined CKD as a kidney damage as albumin-to-creatinine ratio >30 mg/g or glomerular filtration rate below 60 mL/min/1.73 m2 for 3 months or more. The risks for CKD were significantly higher in patients with SGA, although the risk did not increase as the patients used SGA for longer period. As the information in the risk of CKD in patients with SGA is limited, further studies are recommended by specifying the psychiatric diseases and CKD-related comorbidities.


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  • Evaluation of psychological stress of medical students

    Abbie Lane et al. (1), reported a high level of distress among medical students.
    However, in the report 15 students of 161 (9%) expressed a high level of objective stress and the major cause of stress was the exams.
    We do not know when the questionnaire was offered to students in relation to the date of their exams. Indeed, before the exams it is normal that a majority of students are stressed and this situation is not specific to medical students. The authors omitted that some stress was necessary and could have positive impact to be competitive. Acute stress was not differentiated from chronic psychological stress which could impact cognitive functions by decreasing the arterial cerebral blood flow related to the persistent increase of high level of plasmatic cortisol (2; 3).
    The authors reported that medical students were highly stressed, they thought that it was due to medical studies. Perhaps yes, perhaps no. Maybe this situation is comparable to that of other students of other disciplines or to other young people who are not students. The absence of control group in this study leaves the question unanswered.
    In addition, the small number of participants (161), makes the results difficult to analyse. Furthermore, only 15 students had a high level of objective stress. What significance could be attributed to this small subgroup, whereas the authors conclude that medical students had a high level of stress like senior doctors. This conclusion cou...

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  • Falls and nearness to death

    Excellent study on a contemporary topic. If you are able, can I suggest you extend the study to a retrospective analysis of falls and nearness to death. I suspect that falls are one of a composite of indicators which can be used to estimate which persons are in the last year of life.

  • letter to the editor

    Jaleel Saunders, Nursing Student University of The Bahamas
    Other Contributors:
    Terry J Campbell, Lecturer

    Dear Editor,
    I am a fourth-year nursing student at the University of The Bahamas. I would like to share my views on “Childhood peer status and circulatory disease in adulthood, a prospective cohort study in Stockholm, Sweden.” Circulatory diseases have become somewhat of an epidemic within Bahamian society and your article enlightened me on how childhood peer status may increase the likelihood of circulatory diseases in adulthood. This study can provide some important knowledge to understanding why circulatory diseases like diabetes and hypertension are so prominent within The Bahamas.
    This research on childhood experience should not be overlooked as it is quintessential to the development of an adult. Studies imply that childhood socioeconomic circumstances have a strong influence on stomach cancer and are likely to contribute, along with adult circumstances, to lung cancer through cumulative exposure to smoking (Vohra et al., 2015, p. 630). However, as socioeconomics are easily measurable, peer status amongst children is a multifaceted circumstance that one question cannot simply answer. The question used in this research to assess peer status “Whom do you best like working with at school?” can have skewed responses. The answer may have been based on a student wanting to have the best outcome in terms...

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  • Falls among elderly subjects: a risk assessment

    Sasidharan et al. conducted a prospective study to examine the risk factors for falls among community-dwelling elderly subjects in India (1). The incidence rate of falls was 31 per 100 person-years. Adjusted odds ratios (ORs) (95% confidence intervals [CIs]) of female sex, movement disorders, arthritis, dependence in basic activities of daily living, not using antihypertensive medications, living alone during daytime, and a history of falls in the previous year for a fall in the following year were 1.48 (1.05 to 2.10), 2.26 (1.00 to 5.05), 1.48 (1.05 to 2.09), 3.49 (2.00 to 6.09), 1.53 (1.10 to 2.13), 3.27 (1.59 to 6.71), and 2.25 (1.60 to 3.15), respectively. I have some concerns about their study.

    First, Tripathy et al. reported epidemiological findings of falls among older adults in India (2). The prevalence rate of fall episodes was 67 per 100 person-years. Adjusted OR (95% CI) of female sex, taking four or more medicines, and having poor body balance were 1.6 (1.0 to 2.8), 2.1 (1.2 to 3.5), 1.9 (1.0 to 3.4), respectively. Female sex was also a risk factor for fall in this study, and sex difference for predicting fall in the elderly should be specified by further studies.

    Second, Susilowati et al. assessed the prevalence and related factors for falls in the past year in a sample of community-dwelling and institutionalized older Indonesians (3). The prevalence of falls in the past year was 29%, and women and institutionalized older adults had higher preval...

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  • Response to "Depression and anxiety in ovarian cancer: a systematic review and meta-analysis of prevalence rates"

    We read with interest the systematic review and meta-analysis by Watts et al. published in BMJ Open [1] which reported on the prevalence of depression and anxiety in women with ovarian cancer at three time-points: pre-treatment, on-treatment and post-treatment. We agree this is an important topic but, after reviewing the article, would like to raise some concerns. We have reproduced the key components of Table 1 from that paper with additional comments to note some potential inaccuracies. Our main concerns are as follows:
    First, it appears that the same women have been counted twice in some analyses. The most concerning instance of this relates to the Australian Ovarian Cancer Study, which is by far the largest study with 794 cases with data on depression and anxiety. Women in this study have been double counted (Price 2009 [2] and Price 2010 [3]) in the pre-treatment analysis, then also counted (Price 2009) in the on-treatment analysis, when in practice 79% of women in this study were post-treatment so these data (one or other of the reports) should have been included in the post-treatment analyses only (but they are not). Watts et al. also include two papers (Liavaag 2007 [4] and Liavaag 2009 [5]) from a single study at the Norwegian Radium Hospital and count these women in two separate analyses. Furthermore, they include four papers from a group with study sites in Iowa, Miami and Texas (Lutgendorf 2008 [6], Lutgendorf 2008 [7], Lutgendorf 2009 [8] and Clevenger 2...

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