- Email: [email protected]
Wounded by words
Correspondence
Wounded by words As the mother of a child with cystic fibrosis, I was shocked but not surprised when the doctor from the fetal medicine unit rang to say that the 12-week-old fetus I was carrying was also affected. A week later I had a termination. Although the clinical treatment I received was irreproachable, I was astonished by the degree to which small errors of tact on the part of staff transformed a difficult experience into one which was deeply psychologically painful. When we arrived on the ward on the Monday morning, the anaesthetist was the first to pop around the edge of the curtain. “You don’t look very happy!” she said, reprovingly. I said that we would much rather termination hadn’t been necessary. “Well it’s a lot less painful than having a baby!” she cracked, and disappeared. We met again at the point of injection. “Where are your notes?” she asked me, as I proffered my arm. I really didn’t know. “We shouldn’t really be doing this without your notes.” Sorry, I said, reduced by her irritation to a state of uncontentious passivity. My next visitor was a nurse, who asked me to help her fill out a form. We did that. “What about contraception?” she asked. “No”, I said, “we’ll sort that out thanks.” Her voice rose. “Why don’t you want contraception?” she demanded. I felt like the whole ward fell silent. An unregenerate in bed ten! I was 16 again, not 39 and trying to get pregnant. She was right, we didn’t want another pregnancy straight away, and were considering preimplantation diagnosis. But we knew about condoms by now. I put her alarm down to the fact that all the other nine women whose dreary procession I watched in shadow-form through the curtain, as they left the ward and returned on trolleys, were terminating unwanted pregnancies. I know it must have been equally painful and upsetting for some of them. But a note somewhere to the effect that mine was a relatively late termination in a much wanted pregnancy might have made people tread a little bit more warily. It might even have given pause for thought to the ward sister, who, within 2 metres of me, held a long and gushing www.thelancet.com Vol 364 August 28, 2004
conversation about a friend who had given birth to a beautiful healthy baby boy the previous afternoon. Routine as an enema the operation may be for those who witness it ten times a day, but you don’t have to be Albert Schweitzer to have a sense of reverence for life and the pain involved in letting that life go. Especially when expressing that reverence requires nothing more than occasionally keeping your mouth shut.
Helen Stevenson [email protected] 8 Burghley Road, Kentish Town, London NW5 1UE, UK
Observational versus randomised trial evidence Debbie Lawlor and colleagues (May 22, p 1724)1 compare findings from observational studies and randomised trials, using the EPIC-Norfolk prospective study on plasma ascorbic acid and mortality2 as an example. In this article, we stressed that our results indicated that plasma vitamin C was probably a marker of particular foods, and it was not supplements that were protective. We made this point first in the results section, and several times subsequently in the discussion. There is no contradiction between our findings and our interpretation, and the result of the later randomised trial3 cited by Lawlor and colleagues, showing no effect of vitamin C supplements on cardiovascular mortality. Confounding is an issue in all observational studies and we discussed the subject extensively. There might be disagreement with our interpretation that “our findings suggest that an increase in dietary intake of foods rich in ascorbic acid might have benefits for cardiovascular disease and all-cause mortality in men and women and add to the large amount of evidence that lends support to the health benefits of fruit and vegetable intake”. However, alternative explanations for the observed association, such as other confounders, also
need to be biologically and quantitatively plausible. Nevertheless, based on the misinterpretation of our findings, Lawlor and colleagues suggest that our findings must be the result of confounding. They present data (their table 1) for women from their study, indicating that plasma vitamin C concentrations in adult life are associated with both early life exposures and exposures in adult life, findings we have also reported previously.4 However, the issue is whether these associations could induce substantial confounding to explain our findings. Lawlor and co-workers would have to show that there were pronounced differences in risk associated with the degree of difference in socioeconomic indicators they describe. As an example, they provide data on adult height, adult leg length, and the adult leg-to-trunk ratio as biomarkers of childhood environment. In their data, there is a 1·3 cm difference in height between individuals in the top quarter and those in the bottom quarter of the plasma vitamin C distribution. As in our cohort, the SD of height among women is about 6 cm. In our data, height is only weakly (negatively) associated with cardiovascular mortality (relative risk 0·8 between the bottom and top fifth of the distribution). The largest confounding risk ratio (RR) that these anthropometric measures could induce for cardiovascular mortality lies between 0·95 and 1·0. Similar quantitative considerations apply to the other variables shown. In their data on indicators of childhood socioeconomic status, 91·6% of the lowest vitamin C quartile and 82·1% of the highest quartile were manual social class in childhood. Even if non-manual social class in childhood were 100% protective against later cardiovascular mortality, the confounding risk ratio between the highest and lowest quartiles would be 0·90 (RR 82·1/91·6). For realistic values for the protective effect of early life non-manual social class, the confounding RR would be about 0·95. Our results displayed a relative risk for cardiovascular mortality, comparing the highest quintile of plasma vitamin C with the lowest, of 0·29 in men and
Wounded by words: see Viewpoint page 812
e-mail submissions to [email protected]
753
Wounded by words As the mother of a child with cystic fibrosis, I was shocked but not surprised when the doctor from the fetal medicine unit rang to say that the 12-week-old fetus I was carrying was also affected. A week later I had a termination. Although the clinical treatment I received was irreproachable, I was astonished by the degree to which small errors of tact on the part of staff transformed a difficult experience into one which was deeply psychologically painful. When we arrived on the ward on the Monday morning, the anaesthetist was the first to pop around the edge of the curtain. “You don’t look very happy!” she said, reprovingly. I said that we would much rather termination hadn’t been necessary. “Well it’s a lot less painful than having a baby!” she cracked, and disappeared. We met again at the point of injection. “Where are your notes?” she asked me, as I proffered my arm. I really didn’t know. “We shouldn’t really be doing this without your notes.” Sorry, I said, reduced by her irritation to a state of uncontentious passivity. My next visitor was a nurse, who asked me to help her fill out a form. We did that. “What about contraception?” she asked. “No”, I said, “we’ll sort that out thanks.” Her voice rose. “Why don’t you want contraception?” she demanded. I felt like the whole ward fell silent. An unregenerate in bed ten! I was 16 again, not 39 and trying to get pregnant. She was right, we didn’t want another pregnancy straight away, and were considering preimplantation diagnosis. But we knew about condoms by now. I put her alarm down to the fact that all the other nine women whose dreary procession I watched in shadow-form through the curtain, as they left the ward and returned on trolleys, were terminating unwanted pregnancies. I know it must have been equally painful and upsetting for some of them. But a note somewhere to the effect that mine was a relatively late termination in a much wanted pregnancy might have made people tread a little bit more warily. It might even have given pause for thought to the ward sister, who, within 2 metres of me, held a long and gushing www.thelancet.com Vol 364 August 28, 2004
conversation about a friend who had given birth to a beautiful healthy baby boy the previous afternoon. Routine as an enema the operation may be for those who witness it ten times a day, but you don’t have to be Albert Schweitzer to have a sense of reverence for life and the pain involved in letting that life go. Especially when expressing that reverence requires nothing more than occasionally keeping your mouth shut.
Helen Stevenson [email protected] 8 Burghley Road, Kentish Town, London NW5 1UE, UK
Observational versus randomised trial evidence Debbie Lawlor and colleagues (May 22, p 1724)1 compare findings from observational studies and randomised trials, using the EPIC-Norfolk prospective study on plasma ascorbic acid and mortality2 as an example. In this article, we stressed that our results indicated that plasma vitamin C was probably a marker of particular foods, and it was not supplements that were protective. We made this point first in the results section, and several times subsequently in the discussion. There is no contradiction between our findings and our interpretation, and the result of the later randomised trial3 cited by Lawlor and colleagues, showing no effect of vitamin C supplements on cardiovascular mortality. Confounding is an issue in all observational studies and we discussed the subject extensively. There might be disagreement with our interpretation that “our findings suggest that an increase in dietary intake of foods rich in ascorbic acid might have benefits for cardiovascular disease and all-cause mortality in men and women and add to the large amount of evidence that lends support to the health benefits of fruit and vegetable intake”. However, alternative explanations for the observed association, such as other confounders, also
need to be biologically and quantitatively plausible. Nevertheless, based on the misinterpretation of our findings, Lawlor and colleagues suggest that our findings must be the result of confounding. They present data (their table 1) for women from their study, indicating that plasma vitamin C concentrations in adult life are associated with both early life exposures and exposures in adult life, findings we have also reported previously.4 However, the issue is whether these associations could induce substantial confounding to explain our findings. Lawlor and co-workers would have to show that there were pronounced differences in risk associated with the degree of difference in socioeconomic indicators they describe. As an example, they provide data on adult height, adult leg length, and the adult leg-to-trunk ratio as biomarkers of childhood environment. In their data, there is a 1·3 cm difference in height between individuals in the top quarter and those in the bottom quarter of the plasma vitamin C distribution. As in our cohort, the SD of height among women is about 6 cm. In our data, height is only weakly (negatively) associated with cardiovascular mortality (relative risk 0·8 between the bottom and top fifth of the distribution). The largest confounding risk ratio (RR) that these anthropometric measures could induce for cardiovascular mortality lies between 0·95 and 1·0. Similar quantitative considerations apply to the other variables shown. In their data on indicators of childhood socioeconomic status, 91·6% of the lowest vitamin C quartile and 82·1% of the highest quartile were manual social class in childhood. Even if non-manual social class in childhood were 100% protective against later cardiovascular mortality, the confounding risk ratio between the highest and lowest quartiles would be 0·90 (RR 82·1/91·6). For realistic values for the protective effect of early life non-manual social class, the confounding RR would be about 0·95. Our results displayed a relative risk for cardiovascular mortality, comparing the highest quintile of plasma vitamin C with the lowest, of 0·29 in men and
Wounded by words: see Viewpoint page 812
e-mail submissions to [email protected]
753