1013 e-Letters

  • Vulnerability assessment

    In England I have used the output area classification with success for over 10 years to identify social groups with higher rates of admission. I have found deprivation to be a very crude measure. Alas much of this is not published. but several studies regarding admission to the CCU. Also a couple of studies looking at outbreaks of a mystery disease. See below.

    Hope this helps.

    Beeknoo N, Jones R. Using Social Groups to Locate Areas with High Emergency Department Attendance, Subsequent Inpatient Admission and Need for Critical Care. British Journal of Medicine and Medical Research 2016; 18(6): 1-23. doi: 10.9734/BJMMR/2016/29208

    Beeknoo N, Jones R. Using social groups to locate areas of high utilization of critical care. Brit J Healthcare Manage 2016; 22(11): 551-560.

    Jones R. Year-to-year variation in deaths in English Output Areas (OA), and the interaction between a presumed infectious agent and influenza in 2015. SMU Medical Journal 2017; 4(2): 37-69.

    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. Fractal Geometry and Nonlinear Analysis in Medicine and Biology 2017; 3(1): 1-7. doi: 10.15761/FGNAMB.1000146

    Jones R. Differ...

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  • Inconclusive evidence on self-assessed health in Spain during the Great Recession

    Saez, Vidiella-Martin, and López Casasnovas1 investigate the impact of the Great Recession on self-assessed health in Spain analyzing data from four waves—2005, 2008, 2011 and 2014—of a Survey of Household Finances by the Bank of Spain. The surveys included repeated observations of self-assessed health and other variables measured in the same individuals.
    The statistical model of Saez et al. is a mixed logistic regression in which the log of the odds of poor health (log [P / (1 - P)], where P is the probability of declaring poor health) is computed as a linear combination of a random effect for the year of the survey, random effects for individuals and families, and a large set of control variables at both family level (gross wealth, total debt, family income, savings rate, family size, number of family members who work, and type of family residence—owned or rented) and individual level (sex, age—stratified in six groups—, educational level, occupation, and marital status). Saez et al. computed the model with and without adjustment for the control variables and both for the whole sample and for 12 subsamples stratified by sex and age. The observations were weighted, to compensate for the fact that the original survey oversampled the wealthiest households, and the sample was trimmed to eliminate outliers.
    Saez et al. found a downward change in self-perceived health during the third wave of the survey, i.e., that of 2011, which coincides with the most severe per...

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  • Response to Letter by Pollock et al on “Appropriateness of initial dose of non-vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation in the UK”

    We thank Dr Pollock and colleagues for their interest in our recent study, which suggested that among patients with non-valvular atrial fibrillation in the UK, inappropriate underdosing was more than twice as common among patients starting on apixaban than those starting on dabigatran or rivaroxaban.

    In our analyses, we assumed that patients with missing data on renal function were likely to have unimpaired renal function. Pollock et al expressed their concern regarding the possibility of significant bias resulting from misclassification of renal function among these patients, which could have resulted in the percentage of patients inappropriately prescribed a reduced dose NOAC being overestimated. Among our study population of 30,467 patients, 3856 (12.7%) had missing data on renal function (eGFR values).

    Pollock and colleagues also queried the absence of bodyweight data in our results. We acknowledge that it may have been useful for the reader to see these data, although we presented data on BMI in Table 1 of our article as a proxy measure. Nevertheless, we can confirm that in our dataset very few patients had missing data on bodyweight (2.6% of patients starting on apixaban, 3.0% of those starting on dabigatran and 2.3% of those starting on rivaroxaban). Among patients with a recorded bodyweight, the mean bodyweight was 81.4 kg for patients starting on apixaban, 82.6 kg for those starting on dabigatran, and 82.0 kg for those starting on rivaroxaban. While...

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  • Vitamin test: on patient or doctor's request?

    Thank you for this critical note about vitamin D and B12 testing. The aim of our study was to explore the barriers and facilitators for reducing the number of unnecessary ordered vitamin D and B12 laboratory tests. We found that GPs experienced difficulty to request laborotory tests only for evidenced based indications; often vitamin testing was performed to satisfy patients' requests. We acknowledge the presence of certain medical indications to test vitamin D or B12 bloodlevels and we also performed a training for participating GPs of our study on vitamin D and B12 deficiency and people at risk of such deficiency. The purpose of our study was not to reduce the number of vitamin D and B12 tests to zero, but to explore the barriers and facilitators related to vitamin D and B12 testing in order to improve properly indicated vitamin testing in general practice.

  • Concerns regarding the inference that EDS is not rare

    Dear Sir or Madam

    Re. Diagnosed prevalence of Ehlers-Danlos syndrome and hypermobility spectrum disorder in Wales, UK: a national electronic cohort study and case-control comparison.
    Demmler J C, Atkinson M D, Reinhold E, Choy E, Lyons R A, Brophy S T
    BMJ Open 2019;9:e031365

    We write concerning the paper by Demmler et al., published in BMJ Open. We wish to raise the following concerns:

    1. With regard to combining the Joint Hypermobility Syndrome (JHS) and Ehlers-Danlos syndromes (EDS) populations for analysis.

    If one combines data from a cohort that is found to be ‘common’ (in this case ‘diagnosed JHS’) with one that is found to be ‘rare’ (in this case ‘diagnosed EDS’), the new combined cohort (i.e. diagnosed JHS/EDS) will be common. To then consider the rare cohort common is a fallacy.

    Also, although individuals in a population with a previous diagnosis of JHS (i.e. prior to the 2017 international classification (1,2)) might have Hypermobile EDS (hEDS) by the current classification, it is not known how JHS segregates into Hypermobility Spectrum Disorder (HSD) and hEDS. A JHS population would need to be reassessed to confirm this, or modelling assumptions of the data would need to be applied.
    In addition, it is not known what proportion of the EDS cohort have hEDS versus the rare Mendelian types of EDS. As such, there is no way of knowing whether or by what proportion the two cohorts represent the same or similar or dif...

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  • Supplements will not be effective if people have undiagnosed Coeliac Disease or Dermatitis Herpetiformis

    I believe that bipolar/mental disorders could be related to coeliac disease. Any study in relation to diet / supplements etc could be affected by this as undiagnosed coeliacs who are continuing to eat gluten do not digest foods properly and become deficient in minerals and vitamins as they CANNOT ABSORB them. I do feel that more research and studies need to be done with this in mind. Doctors should be testing more people. In Australia the AVERAGE time it takes for a coeliac to be diagnosed is 9 YEARS. A blood test is not reliable as often it comes back a false negative. Meanwhile they get diagnosed with bipolar and other illnesses caused by mineral and vitamin deficiencies. I have a father in law who was diagnosed bipolar BEFORE being diagnosed gluten intolerant (he has Dermatitis Herpetiformis which is related to coeliac disease). I don’t believe he is bipolar. My husband also was misdiagnosed with bipolar instead of coeliac disease. Brain cells recover after going on a gluten free diet!
    All people diagnosed with bipolar should be tested for Coeliac Disease (or Dermatitis Herpetiformis if they have any kind of rash). And any study for treating bipolar disease with nutritional supplements should be done after the test and/or on people who have excluded gluten from their diet.

  • Inhaler devices and global warming: Flawed arguments

    Mark L Levy,1,9 Darragh Murnane2, Peter J Barnes,3,9 Mark Sanders,4 Louise Fleming,5 Jane Scullion,6,9 Chris Corrigan,7,9 Omar S Usmani8,9

    1. Locum general practitioner, Clinical Lead NRAD (2011-2014)
    2. King’s College London Faculty of Life Sciences & Medicine, School of Immunology & Microbial Sciences ; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire
    3. National Heart & Lung Institute, Imperial College, London
    4. Clement Clarke international Ltd (CCI) and founder of online museum of inhaler devices, www.inhalatorium.com.
    5. Imperial College, London and the Royal Brompton and Harefield, NHS Foundation Trust
    6. University Hospitals of Leicester
    7. King’s College London Faculty of Life Sciences & Medicine, School of Immunology & Microbial Sciences
    8. Imperial College London & Royal Brompton Hospital
    9. Aerosol Drug ManagementImprovement Team (ADMIT), www.inhalers4u.org

    In an attempt to address issues related to global warming contributed to by the use of pressurised, metered-dose inhalers (pMDIs), Wilkinson et al (1) have succeeded in generating a great deal of negative, potentially harmful media interest for patients who currently rely on these devices. They analysed the potential impact of switching therapy from pMDIs to dry powder inhalers (DPIs) in terms of both c...

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  • Comments to the response “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 et al

    We appreciate the response to our study.
    The response assumes that a restriction in the population under study also limited the bias in two previous studies (1;2). In the two previous studies only individuals, who had two diphtheria–tetanus–pertussis–polio–H. influenzae type b-vaccines at 11 months of age were included.
    Therefore, we found it relevant to apply the same restriction to our study population and present the corresponding estimates adjusted for the confounders included in our study (3) (Table 1 - https://blogs.bmj.com/bmjopen/files/2019/11/Jenson-et-al-table.jpg).
    In Table 1 it can be seen that the restriction of the analysis to include only individuals with two diphtheria–tetanus–pertussis–polio–H. influenzae type b-vaccines at 11 months of age had little impact on the estimates. Importantly, the associations showing a reduced risk of hospitalisation for accidents among children with two or three diphtheria–tetanus–pertussis–polio–H. influenzae type b-vaccines and the measles-mumps-rubella vaccine were essentially unchanged when we restricted the analysis to include individuals with two diphtheria–tetanus–pertussis–polio–H. influenzae type b-vaccines at 11 months of age only.

    Reference List

    (1) Sorup S, Benn CS, Poulsen A, Krause TG, Aaby P, Ravn H. Live vaccine against measles, mumps, and rubella and the risk of hospital admissions for no...

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  • Note from the Editors

    The editors acknowledge the readers' comments about this article. We have asked the authors to respond and we will amend the article if necessary.

  • Editorial in The BMJ

    The BMJ have published an editorial, written by Jeremy Taylor, linked to the results of this research paper. https://doi.org/10.1136/bmj.l6324