988 e-Letters

  • Infant mortality in England

    The rise in infant mortality is concerning. As this paper points out around one-third of the extra deaths may be due to 'austerity'.

    On a very pragmatic level it would be useful to see an analysis of the cause of death for these infants.

    In this respect there have been a number of influenza epidemics in the UK in recent years , mainly involving influenza A(H3N2) [1]. Influenza is known to disproportionately affect the poorest parts of society [2], partly due to lower vaccination rates [3].

    From a policy viewpoint, it is important to separate cause and effect, and for this reason the effects of influenza need to be disentangled and the cause(s) of death identified in order to correctly target any intervention(s).


    1. Public Health England. National Influenza report. 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploa... (accessed 5 October 2019)

    2. Okland H, Mamelund S-E. Race and 1918 influenza pandemic in the United States: A review of the literature. Int J Environ Res Public Health 2019; 16: 2487. doi: 10.3390/ijerph16142487

    3. Vukovic V, Lillini R, Lupi S, et al. Identifying people at risk for influenza with low vaccine uptake based on deprivation status: a systematic review. Eur J Public Health 2018; cky264,...

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  • Did industry unduly influence Ofcom’s decision on restricting TV advertising of unhealthy kids’ foods?: A response

    Dear Editor,

    We were interested to read the response to our recently published paper from the Principal Economist of OfCom during the time of the consultation, which is also available on the Institute of Economic Affairs website - https://iea.org.uk/does-ofcom-prioritise-commercial-interests-over-publi.... The additional context Mr. Gibson provides is welcome. On close reading we find that our original paper agrees with many of the points that Mr Gibson raises. We describe these, and provide more explanation on a number of other points below.

    Mr Gibson points out that OfCom used much more than just the stakeholder responses analysed in our article to come to a decision on their final policy on TV food advertising to children. We recognise this in Figure 1 and in the discussion section of our paper where we describe the other ways in which interested parties could influence OfCom. A number of OfCom reports, in which much of the evidence noted by Mr Gibson was published, are also cited in our paper.

    Mr Gibson appears concerned with our claim that the only independent evaluation of the regulations on TV food advertising to children found no change in the proportion of HFSS adverts seen by children between before and after implementation. As far as we are aware, the paper we cite (Adams et al, 2012) remains the only independent, peer-reviewed evaluatio...

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  • Author's response to Dr. Hurley

    We thank Dr. Hurley for his interest in the manuscript and, hereby, respond to his 3 questions.
    1) We consider the in-hospital mortality of the patients included in both studies that were included in this individual patient-data cost-effectiveness meta-analysis to be representative for that patient population (i.e. ICU patients with an expected length of stay >48h) in Dutch ICUs. Due to the cluster design of both trials almost all eligible patients were enrolled in the De Smet study and all eligible patients were automatically included in the Oostdijk study.
    2) As mentioned in the Introduction, SDD is recommended by our national guidelines and is thus the standard of care in Dutch ICUs. The domain of our CEA was – as noted throughout the paper – ICU settings with low levels of AMR. The study that Dr. Hurley refers to (ref 20; Wittekamp et al. JAMA 2018) did not meet that domain, and was, therefore, not included.
    3) Current direct medical costs of SDD surveillance cultures were included in our bottom-up calculations (Table 3). Hypotheses on potential future scenarios due to potential increased antibiotic resistance were not explored. So far there is no scientific evidence that the long-term use of SDD or SOD leads to increased resistance to colistin or tobramycin in the setting of the included studies (Wittekamp et al. Critical Care 2015; Houben et al. JAC 2014; Buitinck et al. Crit Care 2019). Furthermore, the proportion of surveillance costs in total...

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  • Did industry unduly influence Ofcom’s decision on restricting TV advertising of unhealthy kids’ foods?

    In December 2003 the Secretary of State for Health asked Ofcom to look into the regulation of television advertising of High Fat, Salt and Sugar (HFSS) food to children in order to address concerns about the rising levels of childhood obesity. How did Ofcom decide on an appropriate set of advertising regulations to address those concerns?
    According to the authors of a paper in the BMJ Open , Ofcom consulted on the issue, considered the arguments advanced by the different stakeholder groups (advertising companies, food manufacturers, food retailers and broadcasters on one side, lobbying for more relaxed regulations, and civil society groups, politicians and public health stakeholders on the other, arguing for stricter rules to protect children), decided which arguments they liked and determined their final recommendations accordingly. They argue that because Ofcom moved towards the industry arguments between their original proposals and final recommendations on more issues than they moved towards the public health direction, that they favoured commercial interests over protecting children’s health. They even suggest that Ofcom might have been Machiavellian enough to cynically set some of their initial proposals in such a way that that they could concede ground to public health stakeholders on those issues and distract from more contentious issues.
    In fact, the truth is somewhat different. Ofcom when moving forward with a complicated public policy question such...

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  • Re:The prevalence and influencing factors of physical activity and sedentary behaviour in the rural population in China: the Henan Rural Cohort Study. BMJ Open. 2019;9(9):e029590.

    Dear editor
    The recent study published by Runqi et al (1) on the prevalence and influencing factors of physical activity and sedentary behavior in the rural population in China: the Henan Rural Cohort Study found that lack of physical activity and sedentary in rural China contribute to increasing the incidence of disease, especially among the elderly and those who drink alcohol. (1) I commend the authors for their study but also wish to point out the importance of socioecological determinants of physical activity, particularly climate change.

    A study in the United States found that cold and hot weather, strong winds, and days of rain all forces people to spend more time indoors, all of which can reduce physical activities. (2, 3) A study in New York showed that people’s cycling time and distance decreased with increasing temperature at temperatures above 26 to 28 degrees Celsius. (4) Climate change significantly affects physical activity in older people. (5) In addition, climate change has increased the incidence of heat-related diseases, infectious diseases, food security, and mental health problems among people in rural areas and disadvantaged social-economic groups. (6) Climate change is leading to more frequent, persistent and intense extreme weather, age, obesity, diabetes, and cardiovascular diseases are risk factors for fever-related disease. (7) Therefore, these high-risk populations may reduce physical activity and increase sedentary during summer....

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  • Comparison of amblyopia in schoolchildren in Ireland and Northern Ireland

    Dear Editor

    We note the letter from Mr Declan McClements on September 9th 2019 and thank him for his interest in our work. As Mr McClements notes, the paper illustrates the significantly better outcomes achieved by children in Northern Ireland and the comprehensive school vision screening coverage that exists across the whole of Northern Ireland is acknowledged as a component of this success in our conclusions.

    Mr McClements is concerned regarding “the omission in this article of any reference to Orthoptics or Orthoptists.” We recognise the work in Northern Ireland and Ireland carried out by orthoptists, school nurses, optometrists and ophthalmologists; reference to orthoptists is made in Table 1 of the paper.

    The purpose of the study was to report and compare the prevalence and cause of persistent amblyopia in broadly similar population cohorts but different healthcare systems. Orthoptists, public health nurses, optometrists and ophthalmologists are comparable in Northern Ireland and Ireland with regard to training, qualifications and the functions they undertake, including their role in school-entry vision screening. The differences between the two jurisdictions, which were relevant to the disparity in outcomes on which we were reporting, relate to the less comprehensive nature of school-entry vision screening in Ireland and the differences in accessing treatment that exist between the two countries.

    Yours sincerely,

    Dr Siofra Harrin...

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  • Three questions

    The findings here by Denise van Hout et al that in Dutch ICUs, SDD has a very high probability of cost-effectiveness as compared to SOD is of great interest. However, do their findings support the implementation of SDD in settings with low levels of antimicrobial resistance? There are three specific questions.
    Firstly, is the hospital mortality of the SDD and SOD groups comparable to expected? In this regard, the untreated group from the original de Smet et al study [ref 13] had an in-hospital mortality that was not significantly different to either the SDD or SOD groups in an unadjusted analysis. Of note, Denise van Hout et al concede the play of chance as the best explanation for the difference in the findings of two included studies even with the two studies as large as they were.
    Second, why has the standard care group from the original de Smet et al study [ref 13] not been included in their analysis? As they note, SDD is not yet widely implemented in the Netherlands due to concerns in relation to prolonged selective antibiotic pressure. So, with this in mind, what is standard care in this context? Moreover, a large multi-center comparison to standard care [ref 20] has been excluded after failing to meet the study inclusion criteria. This [ref 20] study failed to demonstrate a mortality difference between these groups in a crude or an adjusted analysis.
    Thirdly, as the authors note, surveillance of respiratory and rectal carriage with Gram-negative ba...

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  • some thoughts about your plans.

    Dear Ferozkhan,
    I read about your interesting plans to study the prevalence of common mental health disorders in adults who are high or costly users of healthcare services in BMJ Open.
    Please allow me to share with you some thoughts about your plans produced by our own research.
    - We studied the prevalence of (physical, mental and social) problems in the Netherlands (as defined by the GP on the Problem list; ICPC) in (persisting) frequent attenders 1 and whether we could predict, with these GP data, which frequent attender would persist in this behaviour.2
    - We found that high users and costly users are two different groups. Frequent users of primary care3 have higher average/median costs (also and especially in sec care), but high costs are mostly generated in sec care.4
    - We also found that costs are more substantial in persisting frequent users. Perhaps you can consider to differentiate between temporarily and persisting frequent users.
    - Costs are very high in a few outliers. Do you exclude these patients from your research?? Median costs? Average costs?
    - We also found that anxiety, and especially panic disorder, is associated with persistence of frequent attendance in primary care.5
    Much success with your plans!

    Kind regards,
    Frans Smits, GP PhD

    1 Smits FT, Brouwer HJ, Ter Riet G, Van Weert HCP. Epidemiology of frequent attenders: A 3-year historic cohort study comparing attendance, morbidity and pr...

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  • Query regarding Orthoptics Omission

    Dear BMJ Open,

    I wish to raise a concern in relation to an article in the BMJ Open Volume 9 Issue 8 titled 'Comparison of amblyopia in schoolchildren in Ireland and Northern Ireland: a population-based observational cross-sectional analysis of a treatable childhood visual deficit' written by Siofra Harrington(1), Karen Breslin(2), Veronica O'Dwyer(3) and Kathryn Saunders(4).

    On behalf of Orthoptists within Northern Ireland we feel we should bring to your attention the omission in this article of any reference to Orthoptics or Orthoptists, and the excellent long established Orthoptic Led Vision Screening Service that exists across the whole of Northern Ireland for the detection of amblyopia as a preventable and treatable condition as recommended by Hall and Elliman in "Health for all children".

    In mainstream schools across Northern Ireland all consented children at four to five years of age are tested by their school nurse with the Keeler LogMAR crowded visual acuity test. Children tested that achieve a score of less than 0.2 LogMAR are referred into Orthoptic Services and the Multi-Disciplinary Eye Team (including Optometry and Ophthalmology) for assessment, diagnosis and treatment of many eye conditions including amblyopia. This is part of the school nurse training provided by Orthoptists described in their training manual relating to the vision screening pathway developed by the Public Health Agency and relevant stakeholders....

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  • Current T2DM guidelines are unsuccessful - my clinical way of fighting T2DM, based on Diabetic Constitution-Dependent, Inherited Real Risk

    The irrefutable fact that about half of the diabetics in the world have not yet received diagnosis shows that all guidelines for T2DM have inexorably failed. As long as physicians around the world ignore the five diabetic stages, and are not be able to bedside recognize the Diabetic Constitution-Dependent, Inherited Real Risk using a stethoscope and remove it with Reconstructing Mitochondrial Quantum Therapy, T2DM will continue to be a growing pandemic (1-5).

    1) Stagnaro S., West PJ., Hu FB., Manson JE., Willett WC. Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. [Medline]
    2) Sergio Stagnaro and Simone Caramel (2013). Inherited Real Risk of Type 2 Diabetes Mellitus: bedside diagnosis, pathophysiology and primary prevention. Frontiers in Endocrinology. Front. Endocrinol., 26 February 2013 | https://doi.org/10.3389/fendo.2013.00017
    3) Sergio Stagnaro. Siniscalchi's Sign. Bedside Recognizing, in one Second, Diabetic Constitution, its Inherited Real Risk, and Type 2 Diabetes Mellitus. 24 December, 2010, http://www.sci-vox.com, http://www.sci-vox.com/stories/story/2010-12-25siniscalchi%27signi.bedsi... www.sciphu.com;...

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