Answer to Comment by prof Alain Braillon

Thank you for commenting on our paper "Stroke incidence and association with risk factors in women: a 32-year follow- up of the Prospective Population Study of Women in Gothenburg". We appreciate your proposals for extension of the paper, and in this reply, we have clarified the study design and added the inquired information.

1. We used continuous variables in the analysis of baseline data except for categorical data as the ordinal data for leisure time physical inactivity, self-perceived mental stress, education where a dichotomization was used in accord with given references and data in Methods and Supporting file with references. Smoking was assessed in three categories as described. Blood pressure, blood lipids were assessed and analyzed as continuous variables. The measures were repeated as described in the original papers with references given in the "supporting file". In addition to the baseline blood pressure values analyzed as continuous variables we also used baseline diagnosis of hypertension yes/ no according to present criteria at that time. The criteria are given in Methods. To add facts in the ongoing clinical discussion about low grade hypertension we studied three levels of hypertension 1-3 at baseline in accordance to modern guidelines. We further made a model-predicted risk plot for systolic and diastolic blood pressures. Risk factors as atrial fibrillation, myocardial infarction and diabetes during follow-up were analyzed through survival curves based on Cox regression analysis. We do not agree that the title is misleading; Studying associations between baseline risk factor levels in cohort studies (e.g. Framingham, Nurse's Health Study) is an accepted epidemiological method. However, as we have the advantage of access to 4 follow-up examinations in the Prospective Population Study of Women in Gothenburg (PPSWG) during the 32 year observation period (performed 1974,1980, 1992 and 2000), we could regard it as a limitation that we have not taken full advantage of the possibility to take into account also individual changes in risk factor levels during the 32 years. However, this was not within in the aim of this study which focused on associations between baseline risk factors and stroke during follow-up.

2. You are quite right that hazard ratio is a relative measure and gives no information about how soon stroke will occur. We have calculated median time to stroke for the women with systolic blood pressure <140 and >= 140, respectively, during the 32 years (n=105 and n=81), which was 27 (95% CI 24.17 - 26.44) and 24 (95% CI 20.50- 24.14) years (significant difference); and with diastolic blood pressure <90 and >= 90 (n=111 and n=75), which was 26 (95% CI 23.84-26.12) and 24 (95% CI 20.65-24.47) years(non-significant difference). '

3. We have calculated population attributable fraction (PAF) for hypertension as follows:

PAF% =100 x (NO-NE)/NT where NE= numbers expected in the exposed group if the (age standardized) risk is the same as in the control group; NO= numbers observed in the exposed group; NT= total number of cases. PAF% for SBP >140=10.91% PAF% for DBP >90=15.89%

Thank you once again for showing interest in our paper! Ann Blomstrand, Christian Blomstrand, Nashmil Ariai, Cecilia Bjorkelund

Conflict of Interest:

None declared

Dear BMJ Open,

We kindly request that the following amendments be made to the authors' affiliations in the Protocol:

PROTOCOL FOR DEVELOPING THE EVIDENCE BASE FOR A NATIONAL SALT REDUCTION PROGRAM FOR INDIA

Claire Johnson 1,2 Sailesh Mohan 3, Devarsetty Praveen 2,4, Mark Woodward 1,2, Pallab K Maulik 2,4, Roopa Shivashankar 3,6 , Ritvik Amarchand 7,Jacqui Webster 1, Elizabeth Dunford 1, Thout Sudhir Raj 4, Graham MacGregor 8, Feng He 8, K. Srinath Reddy 3, Anand Krishnan 7, Dorairaj Prabhakaran 3,6, Bruce Neal 1,9,10

1 George Institute for Global Health, Australia,

2 The University of Sydney

3 Public Health Foundation of India, New Delhi, India

4 George Institute for Global Health, India

5 George Institute for Global Health, Oxford University

6 Centre for Chronic Disease Control, India

7 All India Institute of Medical Sciences, New Delhi, India

8 Wolfson Institute of Preventative Medicine

9 Royal Prince Alfred Hospital

10 Imperial College London

Conflict of Interest:

None declared

Dear Editor

We read with interest Mr Ali's response (Supervised Learning Events: is rebranding enough?) to our article (1) and we agree with the sentiments expressed in his letter.

In terms of the issue of training raised by Mr Ali, although we did have a question on our discussion guide that asked trainees and trainers about their 'needs for SLE development in order to improve educational practice', we did not always specifically ask each participant 'what training have you had for SLEs?'. However, some participants did talk about this in response to our fourth research question (what are participants' suggestions for how SLEs should be developed?).

While some trainers talked about receiving information from their Deaneries but perhaps not fully engaging with it, others talked about finding out about SLEs through courses attended, sometimes about WPBAs/SLEs or the tools used within them, but also through their attendance at courses meant to be about something else. Therefore, SLE training for trainers, who discussed this issue, seemed to be variable, serendipitous and lacking coordination.

While some trainees mentioned receiving informal training about WPBAs/SLEs, formal training about SLEs was not particularly mentioned by our sample. Therefore, many of our study participants had not received training on SLEs.

One of the key recommendations from our study is that we need to improve trainee and trainers' understandings of SLEs (1). Ultimately, we agree with Mr Ali that we cannot begin to improve trainee and trainer perceptions about SLEs and educational practices around them without trainees and trainers having a better understanding of what they are and how best to do them.

References 1. Rees CE, Cleland JA, Dennis A, Kelly N, Mattick K, Monrouxe LV. Supervised learning events in the Foundation Programme: a UK-wide narrative interview study. BMJ Open. 2014 16;4(10).

Conflict of Interest:

None declared

Surgery should not be performed unless a medical condition has developed. This is a fundamental concept in surgery [1, 2]. Unless a disease or medical condition is present the risk of surgery cannot be balanced against a risk of disease. If no disease is present no risk can be accepted [1]. This would make male circumcision in infants unacceptable, especially given the risk of death due to blood loss [3,4].

Hidden motivations for circumcision can result from the trauma associated with the amputation of an area of the genitals [5]. People who have been circumcised, had people close to them circumcised or performed circumcision could encourage others to embrace circumcision, without fully considering the dangers, in order to deal with the trauma. This may occur consciously or subconsciously.

Research into amputation would require consenting adults who would be fully informed about what will be amputated and the associated dangers. An alternative to this would be people having tissue removed to help solve a medical problem that has developed. The person's health after the procedure can then be monitored and studied. For many occurrences of male circumcision it appears the surgery has been carried out on children and now attempts are being made to explain why it was done. An example of this is the argument about circumcision to prevent sexually transmitted diseases (STDs) and the human immunodeficiency virus (HIV). A person who is circumcised can still contract HIV.

Circumcision cannot be compared to vaccination as unlike vaccination it deprives the child of healthy tissue.

Care must be taken to watch out for any bias in research (conscious or subconscious). This is relatively easy to notice in male circumcision research. For example the basic surgical concept (mentioned above) will often not be addressed or mentioned. Alternative arguments will not be addressed or discussed. There are three examples of this for male circumcision. Firstly, alternative factors, such as personal hygiene and exposure to carcinogens will not be discussed or considered. Secondly, lack of education amongst adults and medics means they often retract the foreskin with force causing damage to the gland, foreskin and opening the urethra further increasing the risk of infection especially during bathing. This concept of lack of education is often ignored and forgotten when a bias exists. Thirdly, less extreme methods (such as education and testing before sexual intercourse for HIV prevention and less invasive surgery for foreskin tightness [6]) will be ignored.

REFERENCES 1. J M Hutson, Circumcision: a surgeon's perspective, J Med Ethics, 2004;30:238.

2. American Academy of Pediatrics, Committee on Fetus and Newborn. Standards and recommendations for hospital care of newborn infants. [5th ed]. Evanston, IL: American Academy of Pediatrics, 1979

3. Baker RL. Newborn male circumcision: needless and dangerous. Sexual Medicine Today. 1979;3(11):35-36.

4. Bollinger, Dan. Lost Boys: An Estimate of U.S. Circumcision- Related Infant Deaths. Thymos: Journal of Boyhood Studies. 2010;4(1):78- 90.

5. R Goldman, Circumcision: The Hidden Trauma, Boston, Vanguard Publishing, 1997

6. P. M. Cuckow, G Rix, and P. D.E. Mouriquand Preputial Plasty: A Good Alternative to Circumcision Journal of Pediatric Surgery, Vol 29 (4): (April), 1994: pp 561-563

Conflict of Interest:

None declared