Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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A new and honest Weltanschauung to prevent further disasters in Medicine.
- Sergio Stagnaro (18 February 2005)
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PILLS THRILL BUT COULD KILL
- BM Hegde (19 February 2005)
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Re: PILLS THRILL BUT COULD KILL
- Dr. Herbert H. Nehrlich (20 February 2005)
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Remember Paracelcus and keep the big picture in mind
- Enrique J. Sánchez-Delgado, M.D., Prof. Dr. med. (20 February 2005)
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Slanted Language
- Donald F. Klein (21 February 2005)
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Re: Slanted Language
- John S Belstead (23 February 2005)
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Re: Re: Slanted Language
- Jonathan T. Leo (24 February 2005)
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Re: Re: PILLS THRILL BUT COULD KILL
- Peter Morrell (25 February 2005)
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Objection, Your Honour !
- Dr. Herbert H. Nehrlich (25 February 2005)
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Thrills, spills and happy pills
- Mark Struthers (25 February 2005)
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Decline of BMJ...more
- Peter Morrell (2 March 2005)
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Re: Decline of BMJ...more
- Jay Ilangaratne (5 March 2005)
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Re: Re: Decline of BMJ...more
- Dr John Rumbold (7 March 2005)
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Re: Decline of BMJ...more
- Samantha Line (8 March 2005)
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Re: Re: Decline of BMJ...more
- Graeme Johnston (11 March 2005)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genova) Italy
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Sir. After COX2-inhibitors (i.e., the link between rofecoxib and cardiovascular toxicity), here are serotonin reuptake inhibitors: in October the US Food and Drug Administration directed manufacturers to include a "black box" label warning about all antidepressants and risk of suicidal thoughts and suicide attempts in children (1); the novel goes on, of course. Importantly, in my view, depression in children is considered by a lot of authors a condition that some psychiatrists argue should not be treated with drugs! At this point, doctors need certainly more information on both drugs benefit data and drug harms. However, in my opinion, around the world general practitioners can play a paramount role in post-marketing drug regulation, with a beneficial effect in helping their patient. In addition, we have to discuss in a serious way, without delay, the real importance of Primary Prevention on very large scale without expense of all common and dangerous human diseases, including cancer, today realizable clinically (2-4). Unfortunately, in doing that doctors must know firmly all new advancements of physical semeiotics, realized over last 5 decades (See www.semeioticabiofisica.it) and overlooked – for reasons to be elucidated – by all Health World Authorities, with the only exception of Competent Authorities Health Europe (“Planning for the EU public Health Portal” all’URL:http://www.google.it/search? q=cache:U5A- DtWmRDsJ:europa.eu.int/comm/health/ph_information/documents/ ev_20030710_co01_en.pdf+single+patient+based+medicine+and+st agnaro&hl=it&ie=UTF -8 Pg 36). 1) Abbasi K. Pills, thrills, and bellyaches. BMJ 2005;330 (19 February), doi:10.1136/bmj.330.7488.0-h 2) Stagnaro Sergio, Stagnaro-Neri Marina. Introduzione alla Semeiotica Biofisica. Il Terreno oncologico”. Travel Factory SRL., Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm 2) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico- Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Ediz. Travel Factory, Roma, 2004. 3) Stagnaro S., Stagnaro-Neri M., La Melatonina nella Terapia del Terreno Oncologico e del “Reale Rischio” Oncologico. Ediz. Travel Factory, Roma, 2004. 4) Stagnaro S., Stagnaro-Neri M., Single Patient Based Medicine.La Medicina Basata sul Singolo Paziente: Nuove Indicazioni della Melatonina. Travel Factory SRL., Roma, Competing interests: None declared |
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BM Hegde, Retd. Vice Chancellor Mangalore 575004, India
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Dear Editor, Bellyaches alone would have been tolerable but pills sending people to meet their maker should alert the establishment to contemplate deeply. All our drug studies have major flaws. Firstly, a chemical molecule is discovered in the laboratory and then this is checked for its potency, toxicity, and other dynamic features using an animal model. The animal data is then extrapolated to man and preliminary studies are done on volunteers. If all these are uneventful, the final phase of drug development, the controlled study is mounted. In addition, all the controlled studies are done for not longer than five years before the drug is let lose on the gullible public,usually one single drug at a time tested under ideal settings, while in real life situations a single drug is rarely ever, if ever, given. The ideal situation obtaining in controlled studies is rarely seen in patient care setting. Occasionally, the last step is even given a go by before letting patients have the drug with disastrous consequences as had happened in the case of Milrinone. Many of the unforeseen side effects occur only after five years when the drug has been given to millions of people. Similar is the fate of surgical interventions and many other medical interventions. Swan-Ganz catheter, that used to be routinely used in the intensive care set up, was found to have resulted in at least 100,000 deaths in the American hospitals in one year! Sexed-up Studies: Research funds drying up from independent sources more and more studies are done with industry sponsorship. Most of them have strings attached, the new breed of CROs in the third world is another cause for anxiety. Positive reports having better chance of publication, the sponsors, many times, indulge in data dredging in addition. Occasionally, companies get doctors to create diseases to sell drugs. It is a multibillion dollar business anyway and market forces influence research in this area very significantly. Academic medicine seems to be on sale these days with doctors and researchers being offered lavish gifts by the companies. Even the textbooks are written with drug company money! Final blow comes from researchers trying to confuse the doctors with complicated statistical methods when the data are not convenient to their mentors. One only has to read the editorial in the Lancet on the influence of drug company money in medical education in the US as also the one in the New England Journal same year 2000 entitled “Is Academic Medicine for Sale?” John Cleland systematically deciphers the long term effects of small dose aspirin in healthy people in the British Medical Journal in 2002, to show how the good effects sold to the public are the result of sexing up the real data. The present scenario: SSRIs and Cox2 inhibitiors are not the only culprits in making man miserable. Let us survey the other common diseases and their drugs. Type 2 diabetes has been a history of failures, while the drugs lower the glucose levels complications set in, sometimes more vigourously in the tightly controlled sugar status. In a paper entitled-Treatment and Mistreatment of Type 2 diabetes- Prof. Leif Groop stated that no treatment thus far has been able to change the inevitable course of this disease; diabetes is far more heterogeneous than thus far thought of, therefore treatment should be custom built for the individual patient, a sagely advised followed for “time out of mind” in Indian Ayurveda. Unfortunately, in the reductionist science that we follow the individual patient does not exist. Only bits and pieces exist. Rheumatoid arthritis drugs, present controversy notwithstanding, lower the pain, yet mortality and morbidity remain frightening. Pincus discusses this and says "RA trials paint a rosy short term picture, while patients’ status deteriorates over the long term." Anderson et. al have shown that while anti-hypertensive drugs lower blood pressures, yet survival and mortality rates worsen compared to non-hypertensives. Recent IOM report in America showed that modern medicine is the third cause of death in that country and adverse drug reactions the fourth cause. Most conventional medical treatments are not helping the majority of people taking them most of the time! Many Americans are seriously harmed by modern medicine while more than 200,000 die annually because of modern medical interventions, drugs and all. Aaron Wildavsky in 1977 said: “Most of the bad things that happen to people are at present beyond the reach of medicine.” In the same book Lewis Thomas questioned concerning the major issues like cancer, heart attack, hypertension, stroke, diabetes, arthritis and peptic ulcer, the following: “For many of these illnesses, do we possess a decisively effective technology for cure or prevention, directed at a central agent or mechanism, comparable to the treatment, say, of pneumococcal lobar pneumonia with penicillin?” His answer was that “It does not look like the record of a completed job, or even of a job more than half begun, when you run through the list,” In essence a reflection of failure. The story seems to be veering round to Heinemann’s thinking that drugs in large doses seem to cause diseases that they are supposed to control. Recent reports about one of the beta-blockers in the long run causing higher strokes in hypertensives, and pain killers causing heart failures comes close to this thinking. Incidentally, the name pain killer is very apt; while it removes the pain it could kill the patient. The Future: The moral of the story is that we seem to have built our modern medical buildings on quick sand using the bricks of reductionism and linear mathematics both of which do not have any relevance to human dynamic system. Our controlled studies are seriously flawed, to say the least. No one wants drug companies to close shop; on the contrary, the powerful drug companies could listen to sane advice and try and mend their ways and be more transparent for the common good of mankind. Medical science should learn from quantum physics and try and take the right road to success. Change is a part of life and change is science. Blind faith in our methods is close to being unscientific. yours ever, bmhegde Competing interests: None declared |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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One day, I will shake the hand of Professor Monappa Hegde. He is one reason that I am telling all my patients, friends, relatives, neighbours and a few bums in the streets, to look at the BMJ. Look and learn. Perhaps without being aware of it, the BMJ, through its open access and general attitude toward making information available, is doing a tremendously important service, a genuine public service. The facts revealed here, bits and pieces from everywhere in the thing called Healthcare, are opening eyes, ears, minds and will eventually lead to a better "deal for all". The facts that Big Pharma and its allies would so dearly like to keep under wraps, like useless and dangerous drugs, like useless and dangerous procedures and other interventions, are being placed on the community tables, in open air markets and for all to see. No other source of information today can say the same. People are entitled to know and they are able to find out now. If we had more Monappas in this world we could be even happier. And, no he is not a relative. Competing interests: None declared |
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Enrique J. Sánchez-Delgado, M.D., Prof. Dr. med., Director for Medical Education Hospital Metropolitano Vivian Pellas, Managua, Nicaragua
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The recent developments related to COX-2 anti-inflammatory drugs and SSRI antidepressants, should make us clear that facts,not fear, balance and long lasting experience should lead our decisions when treating, counseling and educating our patients. Both, the FDA in USA and the EMEA in Europe, accepted that the risk of treatments with Cox-2 can be acceptable if you consider not only life expectancy but also the quality of life, and choose the proper type of patients that would become more help than harm. I have been advising my patients, pharmaceutical representatives, and my colleagues in the same line of reasoning and evidence, since the discussion about Cox-2 and SSRI began. In the case of SSRI, it was reasonable, from the beginning of the problem, to compare with the known risk of older antidepressant, the TCA. It was very well known that in the early periods of treatment there should be a vigilance to prevent suicides attempting. That was especially truth with young patients. The same precautions are necessary with SSRI, despite their relative less toxicity; which could make many doctors to feel too confident with the new drugs. The mathematical instruments of evidence based medicine, like RR, AR, RRR, ARR, RRI, ARI, RBI, ABI, NNT and NNH are wonderful and very useful for our daily work, but the same is true for long time validated concepts like that of Paracelcus that: "alle Dinge sind Gift, und Nichts ist ohne Gift, allein die Dosis macht, dass ein Ding kein Gift ist". That means, every treatment has beneficial and adverse effects and toxicity, and the appropriate indication, doses and potency, determines that the benefits outweighs the risks. Also, of similar importance, long term experience and intuition, continued medical education, the dedication to listen and treat the patients with real personal and humane interest, and keeping in mind the broad picture of not only to cure, whenever possible, but also to alleviate, to help to improve the quality of life, to counsel, to support, to encourage, to inform and educate our patients, all these are core elements of a quality medicine, not only in the industrialized, rich technological countries, but anywhere in the world. Competing interests: None declared |
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Donald F. Klein, Professor Psychiatry Columbia University 1051 Riverside Drive NEW YORK NEW YORK USA 10032
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Kamran Abbasi asks, ." How many people who turned to "happy pills" would not have done so if they had been fully aware of the potential harms? " To refer to anti-depressants as "happy pills" appears to be an attempt to forge an association with drugs of abuse . It should be noted there is zero market for anti-depressants on the street. They do not make non-patients happy. They do treat a serious disease. One expects more from the BMJ editorial staff. Competing interests: Have studied Anti-depressants for 50 years with academic ,industrial and federal funding. |
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John S Belstead, Retired A&E consultant Ashford, TW15 3ER
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Since retirement from the hurley burley of Emergency Medicine I have been helping with substance misusers in a prison. I hate to disappoint Professor Klein but 'trips' (amitryptiline) trade well in prison - but then I suppose other illicit substances are less available. Competing interests: None declared |
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Jonathan T. Leo, Writer Parrish FL 34219
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Maybe there is so little "street trade" because it is so easy to go to a physician, answer a series of questions, get a diagnosis, and walk out with a prescription. And on top of that, insurance will pay for it. Speaking of slanted lanquage, there is little proof that depression is a "disease" in the typical sense. When I ask psychiatrists and researchers to provide evidence for a biological basis of disease they usually provide a citation to a textbook or review articles. Maybe Dr. Klein could provide a short list of research papers that he thinks are the best evidence supporting the biological theory (or theories) of mental illness. Competing interests: None declared |
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University, UK
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When Richard Smith said: "everybody I speak to says that the journal is better," [1] there are those who would not be surprised to find just how wrong he is...he could not have been MORE wrong. There are those who regard "the restrictions on access to the BMJ are a major problem. I appreciate the business arguments for your decision but I feel very strongly that they are regressive and in the long run counterproductive." [2] And, touchingly, there are still those who love BMJ very deeply: "Perhaps without being aware of it, the BMJ, through its open access and general attitude toward making information available, is doing a tremendously important service, a genuine public service." [3] Open access? Not since January… Now over to the facts! In the past 2 months I have been collecting data on the rapid responses and watching its massive decline compared to the October/November figures. It is only a whopping 70% drop!! Therefore, it is quite absurd to say "everybody I speak to says that the journal is better." [1] It is in fact the voice of an ostrich. The journal is worse, far worse than many readers imagine. Not only has the number and average of rapid responses tumbled massively since last year, but the amount of what I call 'BMJ activity'* has also collapsed by roughly the same amount from 230-240 per month for the past 5 years to only 80 or so for December and January—a drop of about two thirds. At 82 items, January 2005 is 63.5% down on the 2000-2003 average. This massive decline started in 2003 but has continued through 2004 and most especially since July 2004, since which time it has run downhill. Throughout January and February 2005 the average rapid response per article has been running at between 1 and 1.5 compared with figures like 3.9 to 4.5 in October, November and December. The average of current "rapid response per article" as a percentage of November averages is running at between 22 and 39% for the whole of January and February, and is persistently in the 28-29% bracket for this entire 8 week period. That is some drop. I would suggest that these are quite shocking figures, and that the BMJ ought to ponder long and hard on the likely reasons behind them. By stopping unpaid open access to articles, a policy announced in October, unilaterally and without any warning or consultation, people have simply stopped visiting the site or have stopped responding to articles they cannot read anyway. I cannot think of any other reason that would cause this massive collapse of readership and usefulness of the journal. If BMJ wishes to publish the entire tracking details, I can send it in, not that it makes very joyful reading. Sources [1] Richard Smith, Great news for the BMJ and the BMJ Publishing Group, 11 Feb 2005 [2] Harry Rutter, Please reconsider, 24 February 2005 [3] Dr. Herbert H. Nehrlich, Re: PILLS THRILL BUT COULD KILL, 19 Feb 2005 * BMJ activity is the total number of all publications listed by the search engine for any month you enter. For example, if you type in July 2000 you get 252; if you type in July 2004 you get 187, and so on. It includes both articles and rapid responses. Tracking of this figure for each month for the last five years reveals a recent and massive decline since about last July. Competing interests: None declared |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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Yes Peter, he could have been more wrong. While I do not agree with some of the policies that have been implemented by the BMJ as of late, I must say that even a cursory look at ALL other medical publications will show you that the baby has not been thrown out with the bathwater. I remember clearly how you (and others) attacked Richard Smith when he was editor. Now you attack him for saying that things are better since he has left. I do not (and I have said so repeatedly) like the most ridiculous censorship on the e-mail addresses of the individual writers, I am not in favour of paying for something that I previously could get for free and, last but most certainly least, I am quite sick and tired of finding the same names, re-hashing the same old stuff, akin to whipping a very dead and tired (in that order) horse, again and again. Overall, however, what are the glaring faults of the "new" BMJ? Is the number of posts indicative of some kind of "acceptance", of quality or relevance among rivals? I have felt no undue restrictions since Richard Smith left, and I still count the BMJ as my favourite journal. After all, my wife isn't all she once was anymore, either. Competing interests: None declared |
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Mark Struthers, GP Bedfordshire, UK. mark.struthers@which.net
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Peter Morrell should not forget that October through December last, the BMJ indulged very heavily in peacekeeping operations in the Middle East - at the instigation of London psychiatrist Dr Derek Summerfield and with Leeds GP Dr Simon Fellerman to add some balance to the debate. This bizarre activity will most certainly have skewed the figures on rational responding. I have personally long been keen to keep my end up and reinforce the BMJ rapid response tally. However, during the prolonged Israel/Palestine intifada, my responses were deemed to be ‘fouling up the website like rank weeds’. Ever since, I have found postings an increasingly uphill struggle. These two events must surely account for the massive decline in BMJ activity since the beginning of this year. I can’t see that charging for access is a good idea either. Competing interests: None declared |
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Peter Morrell, Hon Research Associate, History of Medicine Staffordshire University, UK
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Decline of BMJ Mark Struthers claims my figures contain a distortion due to his postings about the Middle East: and that this "will most certainly have skewed the figures on rational responding," [1] and that this "must surely account for the massive decline in BMJ activity since the beginning of this year. I can’t see that charging for access is a good idea either." [1] I agree that using the search engine figures provide an only crude figure of BMJ activity. But it must show 'something'...a something that has stayed steady in 1999-2003 and has then declined since last July. I think many ups and downs in the year can have distorted the figures, but these would tend to cancel each other out over time. The data may contain many distortions and do not also forget the impact of the censorship issue…more rapid responses must have been received since September that were not posted due to them being defamatory or offensive in some way. This policy must have contributed something to the observed ‘decline.’ It is hard to quantify this aspect. Herbert Nehrlich claims I "(and others) attacked Richard Smith when he was editor. Now you attack him for saying that things are better since he has left.” [2] That is not strictly true. I did not ‘attack’ him…how could I? I would not even know who he was if he rode past me on his bicycle, let alone attack him. What I did was to criticise him when he published a disgraceful obituary to David Horrobin and then compounded his error by refusing to retract or amend it, and refusing to apologise for the upset he had caused to the Horrobin family. Then he continued to pay the same person to write further BMJ obituaries. I was not alone in thinking that such a gross error of judgement was and is unforgivable. Nor do the criticisms I have recently made are said because he has gone, because he is a living being called ‘Richard Smith’ or because he was once BMJ editor. They are made simply and solely because the comment he made seemed woefully inappropriate, if not downright inaccurate. And here below are the figures to support my point. Here is a summary of the search engine figures:
What this data shows is that compared to the years 2000-2002, then 2003 and 2004 are below par and the gap seems to be widening. Here is a second table showing further data from the search engine info:
What this data shows is that overall ‘BMJ activity’ has been declining since June 2004 to the tune of first 10-20% [June to August] of the 1999-2003 averages, then to 20-30% [Sept and Oct] and more recently by 50-84% [November to Feb]. Here is the corresponding data for recent rapid responses:
This table shows that the number of rapid responses per article, in each of the months shown, has declined from 4.55 in November to around 1.4 this month. This in turn represents about 30% of the November amount and hence a 69% reduction in the BMJ rapid responses since that date. The additional fact that for January 2005 the percentage reduction in rapid responses [62.68%] matches almost exactly the percentage reduction shown by the search engine data [63.44%] illustrates that something real is being measured by these figures and that something is in steep decline. I have provisionally suggested that the cause of this reduction is the unilaterally introduced removal of email addresses from the site [since October] and the ‘pay to view’ decision for articles from January onwards. The data certainly supports such a view. The biggest drop has been since December and hence it seems safe to conclude that it is the ‘pay to view’ policy that is the bigger of those two possible causes. Whether it is the whole truth of the matter is, however, for others to judge. Several people have called for the email addresses to be put back on the site and some also for the ‘pay to view’ policy to be reconsidered or rescinded. If BMJ wishes to recover its steep collapse in popularity then it might well be advised to seriously consider reviewing these recently introduced changes to the site, which appear to be losing the journal the support of the worldwide web-browsing public. Sources [1] Mark Struthers, Thrills, spills and happy pills 25 February 2005 [2] Dr. Herbert H. Nehrlich, Objection, Your Honour ! 25 February 2005 Competing interests: None declared |
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Jay Ilangaratne, Founder Medical-Journals.com
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I admire Peter Morrell's analytical skills. I hope the BMJ will take his constructive remarks in the right spirit.The BMJ's declining popularity might also be because disaffected BMA-members are less inclined to visit a journal owned by the same organisation.As for 'attacking'(in writing), it was the former editor, Dr Smith, who was in the forefront rather than Peter Morrell.For an example, many will remember Dr Smith's intemperate oubursts in his response titled "Bores on the web" which were apparently aimed at a few including myself, which landed him in court at great expense and trouble to his then employer,the BMA. Competing interests: See Text |
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Dr John Rumbold, n/a West Midlands
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I have just read Dr Smith's ideas for restricting "bores on the web" and I think many BMJ readers will agree with most of the ideas. Many of the rapid responses posted are of no interest to 99% of BMJ subscribers, being posted by lay campaigners on one or two topics repeating the same sentiments again and again. Competing interests: I don't know much about rocks |
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Samantha Line, Research student in psychopharmacology The University of Oxford, OX1 3BN
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Peter Morrell discussed the apparent decline in rapid responses over the past few years and I would like to add to his theories with the reasons that I stopped responding (and am back… for now). First and foremost was that after making even the most innocuous posts I would receive a number of derogatory emails from people with opposing views (at best rude, at worst hate-mail). Of course I don’t mind debate, because that’s why we’re here after all, but I didn’t enjoy that sinking feeling that would come when I opened up my email every morning. Thus I’ve really welcomed the move to no longer post email addresses – if you would like to respond to a comment I don’t see why you can’t do it on the site. The second reason for my personal decline in responding was that I don’t have any desire to be in a slanging match, and I’m not terribly keen on watching one either. Debate is good, interesting and enjoyable. But personal insults, sarcasm and general rudeness is childish and uninviting. I’m probably naïve, but I would have thought that a bunch of intelligent adults could behave as such, without resorting to squabbling, petty insults and in-fighting. (I apologise in advance to all the people I’ve offended, but this is something I’ve been feeling for a long time) Competing interests: None declared |
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Graeme Johnston, Student MK7 6AA
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Like Samantha
Line, I dreaded the hate mail that I'd receive after submitting rapid responses. The hate mail hasn't stopped since e-mail addresses were removed from our postings (I suppose the hate mailers have us in their address books), but it has slowed down. Competing interests: None declared |
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