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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Anaemia, prenatal iron use, and risk of adverse pregnancy outcomes: systematic review and meta-analysis Majid Ezzati, Wafaie W Fawzi, et al. 346:doi 10.1136/bmj.f3443

Editor,
in their systematic review Haider and colleagues report that the included randomised trials were 48 and, according to the main text, the respective references go from 31 to 78. When one go through the studies in the meta-analysis (Figure 2, for example) there appears two references [Falahi 2011; Ouladsahebmadarek 2011] that are not present in list of references in the main text. It is important that the authors indicate which of the 48 references in the main paper are wrongly placed and should be replaced by Falahi 2011 and Ouladsahebmadarek 2011.

Sincerely

Iosief Abraha MD

Competing interests: No competing interests

12 October 2017
Iosief Abraha
Consultant
Servizio Immunostrasfusionale, Azienda Ospedaliera di Perugia,
Piazza Menghini, 1, 06129 Perugia, Italy
Re: David Oliver: How much information should patients’ families expect on acute wards? David Oliver. 359:doi 10.1136/bmj.j4295

Professor Oliver seems to have neglected - perhaps because of brevity, or because of an implication of 'on acute wards', but I'm not sure - a rather obvious point about this: unless for some reason the patient is not capable of telling the visitor 'what is happening', the visitor should start by asking the patient.

I have written about this, in the context of a case when very clearly 'communication with the family was awful':

https://www.dignityincare.org.uk/Discuss-and-debate/Dignity-Champions-fo...

As I wrote in my piece:

Putting this simply, if a patient has reached a stage when the patient cannot communicate with either clinicians or with relatives, it is perfectly legitimate (and, there is some legal backing for the idea that family/friends are expected to be questioning professionals in this situation, as part of a 'checks and balances' system) for the family to ask nurses and doctors 'What is going on - what is being done to my dad ?': and the clinicians should be answering those questions, and properly engaging with family and friends.

The simple rule of thumb, probably, is that if a wife could be asked by her husband 'What have they been doing today, then ?', then the husband should be asking the wife: but if the wife has lapsed into a coma, or for other reasons could not answer herself, then it is perfectly reasonable for the husband to put the question to the doctors and nurses, and to expect answers.

Mike Stone mhsatstokelib@yahoo.co.uk @MikeStone2_EoL

Competing interests: No competing interests

12 October 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
Re: Seven days in medicine: 27 September to 3 October . 359:doi 10.1136/bmj.j4563

This article raises an important point about health equity in the UK. Though it highlights a number of factors contributing to poorer screening rates in women with disabilities, I would like to draw attention to one: the increasing lack of breast radiologists, which is only perceived to grow in the coming years. Radiology remains a competitive specialty at recruitment level, so how can we build capacity to increase training numbers? If we are committed to providing effective screening programmes, surely we need to invest in training more radiologists, just as much as overcoming barriers to healthcare?

Competing interests: No competing interests

12 October 2017
Dilan D Joshi
Academic FY2
Northampton General Hospital, UK
Re: Spending on junk food advertising is nearly 30 times what government spends on promoting healthy eating Adrian O’Dowd. 359:doi 10.1136/bmj.j4677

Junk food is a mixed blessing. It provides us with tasty, convenient, low-cost calories; but it also provides us with addictive, unhealthy ingredients like trans fats, monosodium glutamate, sugar, and excess salt and oil. Moreover, it teaches us to be dependent on restaurants and not to cook at home, where we can control the freshness and ingredients of our food. The best way to cure ourselves of junk food addiction is to exchange junk food for real food, by practicing safe home cooking and stocking our kitchen with fresh produce, basic equipment, and interesting cookbooks. Home cooking is “health ensurance.”

Competing interests: No competing interests

11 October 2017
Hugh Mann
Physician
Retired
New York, NY, USA
Re: Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study Allan S Detsky, Raj Satkunasivam, et al. 359:doi 10.1136/bmj.j4366

I would like to preface with the statement that I do not, in any way, want to undermine the results of this study or the important societal dialogue that is sure to follow. Thank you to the authors for your interesting analysis on an interesting topic, with very thought-provoking results. I believe that their ultimate conclusion may very well still be valid and certainly warrants further exploration.

I am, however, very curious about their analysis with respect to year of surgery. This seems the be the most significant potential confounder that was unfortunately not included in their matching process.

The authors reports that there was no significant difference between the two groups in year of surgery, presumably on the basis of a standardized difference of 0.05. This seems like an inappropriate use of this statistical test resulting in an inaccurate conclusion. Simply reviewing Table 5 visually (or better yet, graphing the distribution of the two groups by year) makes it readily apparent that the variables are not normally distributed (as assumed in the standardized difference calculation), but rather inversely linearly related. The male surgeons are disproportionately represented in the early years and the female surgeons in the later years.

The authors also report that the year of surgery was not associated with the primary outcome, referring to Supplementary Table 5. While the second column would support this assertion, there are glaring discrepancies in columns 3-6. The absence of difference in the composite outcome masks very compelling decreases in death and length of stay and increasing complication rate with increasing year of surgery. While the claim that year of surgery was not statistically associated with the primary outcome may still hold true, I would suggest that matching by year of surgery is absolutely necessary (at least on an approximate basis) as there is good evidence that procedures in 2007 and 2015 are not readily comparable.

Competing interests: No competing interests

11 October 2017
Michael S Jansz
Resident
UBC
Vancouver, BC
Re: AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both Candyce Hamel, Julian Moran, David Moher, Peter Tugwell, et al. 358:doi 10.1136/bmj.j4008

We have read and used AMSTAR 2 with great interest [1]. This instrument has made a major revision based on the original AMSTAR and will be used to assess systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. However, when we use the AMSTAR 2 instrument to assess the quality of systematic reviews including both randomised and non-randomised studies, debates on some items have been highlighted.

Item 2 (a protocol prior to conduct), it’s extremely important to develop a protocol of systematic review in advance. AMSTAR 2 answers this item as “Yes”, “Partial Yes”, and “No”. However, only a small minority of published non-Cochrane reviews reported a protocol [2]. When a protocol of systematic review doesn’t exist, “Not applicable” or “No protocol available” should be considered.

Item 4 (Literature search strategy), AMSTAR 2 has considered all key contents except for the reliability of the literature search. Methodological studies and guidelines have highlighted the importance of searchers, involving a local healthcare librarian or information specialist could effectively avoid errors during the conduct of the search [3-5]. Therefore, it’s important to determine the reliability of search by identifying whether systematic reviewers involve an information specialist or whether the search strategies were peer-reviewed.

Item 7 (provide a list of excluded studies and justify the exclusions), this item should contain two parts, one is a list of excluded studies, and another is the reasons for exclusion. Our experience tell us most published non-Cochrane reviews don’t provide the list of excluded studies, but give a reason of exclusion and (or) a c. When systematic reviews just report the reason of exclusion and (or) a PRISMA flow graph, should evidence users answer this item as “Partial Yes” or “No”?

Item 11 (appropriate methods for statistical combination), AMSTAR 2 indicates that authors should report pooled estimates separately for the different study types. In fact, some systematic reviews including both randomised and non-randomised studies combine the estimates from two study types. And there are some methodological studies to support the combination of evidence from randomised and non-randomised studies [6,7]. However, it’s more important to justify the combination methods for different study types.

Item 15 (investigation of publication bias), quantitative synthesis is performed, authors should investigate the likelihood and magnitude of publication bias. “Yes” are answered when performing graphical or statistical tests for publication bias. However, the Cochrane Handbook doesn’t recommend performing graphical or statistical tests for publication bias when the number of included studies is less than 10. In this situation, how do we assess this item?

The original AMSTAR has been a popular instrument for critically assessing systematic reviews of randomised studies. We believe that the current updated version will be more popular and more operable for researchers to assess the quality of systematic reviews and for evidence users to identify high quality systematic reviews.

Competing interests: No competing interests

References
1. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017,358:j4008. doi: 10.1136/bmj.j4008.
2. Moher D, Tetzlaff J, Tricco AC, Sampson M, Altman DG. Epidemiology and reporting characteristics of systematic reviews. PLoS Med 2007, 4, e78.
3. Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
4. Li L, Tian J, Tian H, et al. Network meta-analyses could be improved by searching more sources and by involving a librarian. J Clin Epidemiol. 2014, 67:1001-7. doi: 10.1016/j.jclinepi.2014.04.003.
5. Sampson M, McGowan J, Cogo E, Grimshaw J, Moher D, Lefebvre C. An evidence-based practice guideline for the peer review of electronic search strategies. J Clin Epidemiol 2009;62: 944e52. doi: 10.1016/j.jclinepi.2008.10.012.
6. Verde PE, Ohmann C. Combining randomized and non-randomized evidence in clinical research: a review of methods and applications. Res Synth Methods 2015;6(1):45-62. doi: 10.1002/jrsm.1122.
7. Schunemann H, Morgan R, Cuello C, Santesso N, Guyatt G, Verbeek J. Using GRADE to integrate randomised and non-randomised studies in systematic reviews. Abstracts of the Global Evidence Summit, Cape Town, South Africa. Cochrane Database of Systematic Reviews 2017, Issue 9 (Suppl 2). dx.doi.org/10.1002/14651858.CD201702.

Competing interests: No competing interests

11 October 2017
Long Ge
PhD candidate
Jin-hui Tian associate professor, Ke-hu Yang professor
The First Clinical Medical College of Lanzhou University; Evidence-Based Medicine Center of Lanzhou University
No. 199, Donggang West Road, Chengguan District, Lanzhou City, China
Re: Childhood adversity and risk of suicide: cohort study of 548 721 adolescents and young adults in Sweden Charlotte Björkenstam, Kyriaki Kosidou, Emma Björkenstam. 357:doi 10.1136/bmj.j1334

Recent evidence reveals that administered antidepressants actually increase suicide risks by 2-5 times. [2][3][4][5][6][9]
A recent meta-analysis, level I evidence, clearly demonstrated that SSRIs double the risk of suicide and violence in adults. [4]
Furthermore, antidepressants increase all cause mortality by 33%! [10][11]
All pharmaceutical Companies must be obbliged to incude these warnings in every antidepressant preparation sold.
Another meta-analysis published in the British Journal of Psychiatry has found that even patients with the most severe depression can expect to get as much benefit from cognitive behavioural therapy (CBT) as those with less severe symptoms. [7]
Even Behavioural Activation effectively decreases depressive symptoms. [8]
References
[1] http://www.bmj.com/content/355/bmj.i6761
[2] http://journals.sagepub.com/doi/pdf/10.1177/0141076816666805
[3] http://www.bmj.com/content/348/bmj.g3510
[4] http://www.bmj.com/content/352/bmj.i65
[5] http://nordic.cochrane.org/sites/nordic.cochrane.org/files/public/upload...
[6] http://www.bmj.com/content/355/bmj.i6103
[7] http://bjp.rcpsych.org/content/210/3/190.long
[8] http://www.bmj.com/content/356/bmj.j914
[9] http://www.bmj.com/content/358/bmj.j3697/rr-4
[10] http://dailynews.mcmaster.ca/article/antidepressants-associated-with-sig...
[11] https://www.ncbi.nlm.nih.gov/pubmed/28903117

Competing interests: No competing interests

11 October 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Hellas
Re: Simon Wessely: “Every time we have a mental health awareness week my spirits sink” Sophie Arie. 358:doi 10.1136/bmj.j4305

How refreshing to see an article that addresses some of the issues that face mental health.
--- overmedicalisation of normal Human distress
----separation of psychiatry care from physical care when mortality gap in psychiatry patients is 20 Years, with other population is attributed to physical Health disease.
--- issues around recruitment that arise from Above.

The over emphasis on the fleeting distress and acopia which neglects the severe mental illness: brain disorders which lead to poor outcomes and where consultants should be putting in their expertise.

As a liaison psychiatrist integrated into an acute trust, reintegration helps addresses many of these.
---medical students and foundation doctors see psychiatrists and understand the specialty better.
---patients get integrated care.
---stigma is addressed and education about identifying mental disorders which are often missed whilst medicalising normal distress is addressed.

The lack of physical health training in mental health nursing is also a huge contributor.

Competing interests: No competing interests

11 October 2017
Anne Abe
Psychiatrist
Southampton
Re: Indications for anticoagulant and antiplatelet combined therapy Christopher N Floyd, Albert Ferro. 359:doi 10.1136/bmj.j3782

Thank you for identifying this typological error. We have discussed with the editorial team and a correction notice will be issued.

Competing interests: No competing interests

11 October 2017
Christopher N Floyd
Clinical Lecturer in Clinical Pharmacology and Therapeutics
A Ferro
King's College London
Department of clinical pharmacology, cardiovascular division, British Heart Foundation Centre of Research Excellence, King’s College London, London, UK
Re: Indications for anticoagulant and antiplatelet combined therapy Christopher N Floyd, Albert Ferro. 359:doi 10.1136/bmj.j3782

We thank Ray and Saraf for their comments. We did not define valvular heart disease within the article and instead used the definitions as referenced. In the context of the article and its focus on atrial fibrillation, the term ‘valvular heart disease’ referred to moderate or severe mitral stenosis or prosthetic heart valves as per European Society of Cardiology guidelines. The term ‘native valvular heart disease’ was used to further distinguish between mitral stenosis and prosthetic valves.

Saraf also raised a question around the dose of direct oral anticoagulant when used in combination therapy. Our recommendation that patients should be prescribed ‘the lower licensed dose of a DOAC when combined with an antiplatelet’ is supported by the recent European Society of Cardiology focused update on dual antiplatelet therapy in coronary artery disease. This states that in patients treated with a direct oral anticoagulant the ‘lowest effective tested dose for stroke prevention’ should be considered [1].

1. Valgimigli M, et al. Eur Heart J 2017; 0, 1–48

Competing interests: No competing interests

11 October 2017
Christopher N Floyd
Clinical Lecturer in Clinical Pharmacology and Therapeutics
A Ferro
King's College London
Department of clinical pharmacology, cardiovascular division, British Heart Foundation Centre of Research Excellence, King’s College London, London, UK

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