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Recent rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, 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.

All rapid responses

Displaying 1-10 out of 95142 published

Re: The pressures of pregnancy. Trish Groves. 348:doi:10.1136/bmj.g2789

Pregnancy and child rearing and family development are a crucial ingredient in all human societies. Best case scenario is that females have their families when they are young and have the health and energy levels to maintain a vibrant lifestyle which motherhood requires. The pregnancy outcomes from younger women are much better than for older women, both for mother and baby. The article on hypertension and older pregnancy in this edition of the BMJ highlights this.

The other relevant article in this edition is the plummeting birth rate in teenagers in UK and USA. The obvious reason is because the teenagers are taking contraceptives. The downstream effects of contraception is that pregnancy gets pushed into the third and fourth decades. This results in smaller families. The long term effect of this is an upside-down demography where you have more older people than younger people. Older people use more fossil fuel for heating, transport, complex medical needs etc and so if the fossil fuel global warming theory is correct the more elderly you have the warmer it gets.

The northern hemisphere is top heavy with older people and these depend more and more on a dwindling cohort of young workers. To prop up this situation millions of workers from other countries (who have enough young people) have to come and service the economy or else the situation would collapse. This is a real evidence base for what contraception at a population level does to a country over a generation or two. It thins out the workforce, reduces family size, which in turn reduces social connectedness and support for the elderly with all the financial implications this has, and makes fossil fuel consumption worse by having to put elderly into high carbon using hospitals, nursing homes and intensive nursing units.

The other impact of contraception is that it is directly responsible for the increase of invasive breast cancer in young women. The number of women between the ages of 25 and 39 who got breast cancer with secondary spread in USA between the years 1976 and 2009 almost doubled.1 This is also a real evidence base. Overpopulation itself is a myth and the impact that the human population has on climate change is also unfounded and possibly grossly overstated. Contraception is the wolf in sheep's clothing since it skews a population toward a dependent elderly demographic.

1.Johnson RH,Chien FL, et al. JAMA: Feb 27th; 2013.

Competing interests: I have published a book on breast cancer and contraception called "The Screech Owls of Breast Cancer". Available online.!

Eugene G Breen, Physician/psychiatrist

Mater Misericordiae University Hospital, 62/63 Eccles St., Dublin 7. Ireland.

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17 April 2014

Re: Early management of head injury: summary of updated NICE guidance. Sarah Hodgkinson, Vicki Pollit, Carlos Sharpin, Fiona Lecky. 348:doi:10.1136/bmj.g104

We note the comments from Fryer et al(1) as regards vomiting in relation to CT scanning and observation practices in paediatric head injury.

The GDG considered the CHALICE,(2) CATCH,(3) and PECARN(4) clinical decision rules as potential strategies to guide imaging decisions in paediatric head injury. All three include vomiting as a clinical finding which increases the risk of traumatic brain injury (TBI), and the GDG therefore felt strongly that vomiting should remain in the current NICE guidance (CG176). An in depth review of existing evidence indicated that isolated vomiting in paediatric head injury represents a lower risk of TBI than some other clinical features. The current NICE guidance reflects this, suggesting active observation for children with three or more discreet episodes of isolated vomiting, though patients with persisting vomiting and/or other clinical features should undergo CT scanning.

Subsequent to the publication of the current NICE guidance (CG176) the Pediatric Emergency Care Applied Research Network (PECARN) published further evidence on the association of traumatic brain injuries with vomiting in children with blunt head trauma. This study represents a sub-analysis of 42,114 patients.(5) Of 298 patients who had a CT scan and any vomiting as an isolated finding, 5 (1.7%) had radiologic features of TBI. This increased when vomiting occurred in association with other clinical findings, with CT findings of TBI in 211 of 3284 (6.4%). This demonstrates that though the risk is low, TBI does occur with isolated vomiting. These children may therefore undergo a period of observation prior to imaging decisions, and a CT scan should be performed in the presence of persisting symptoms and/or other clinical features.

The GDG considered the role and duration of observation, and reached consensus that observation should be performed for a minimum of four hours from the time of injury. This is unlikely to result in a substantial increase in admission rates as this relates to the time of injury, not time of Emergency Department presentation. Rather only those children who require ongoing observation and/or a CT scan will require admission. However we urge common sense be employed when considering the necessary period of observation for an individual patient, recognising that some will require observation beyond this time point due to time elapsed between injury and Emergency Department attendance.

References
1. Fryer J, Abrahamson E. Remove isolated vomiting as an automatic indication for computed tomography in children with head injury. BMJ. 2014 Mar 10;348(mar10 15):g2032–g2032.
2. Dunning J, Daly JP, Lomas J-P, Lecky F, Batchelor J, Mackway-Jones K, et al. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006 Nov;91(11):885–91.
3. Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Joubert G, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ Can Med Assoc J. 2010 Mar 9;182(4):341–8.
4. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160–70.
5. Dayan PS, Holmes JF, Atabaki S, Hoyle Jr. J, Tunik MG, Lichenstein R, et al. Association of Traumatic Brain Injuries With Vomiting in Children With Blunt Head Trauma. Ann Emerg Med [Internet]. [cited 2014 Mar 25]; Available from: http://www.sciencedirect.com/science/article/pii/S0196064414000213
6. Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet. 2012 Aug;380(9840):499–505.
7. Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, et al. Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ. 2013 May 21;346(may21 1):f2360–f2360.

Competing interests: None declared

Fiona Lecky, Clinical Professor / Honorary Consultant in Emergency Medicine

Mark Lyttle, Carlos Chapin, Susan Latchem, Vicki Pollit, Sarah Hodgkinson on behalf of the GDG

EMRiS, Health Services Research, School of Health and Related Research, University of Sheffield / Salford Royal Hospitals NHS Trust, Regent's Court, Regent Street, Sheffield S1 4DA

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Re: The “Saatchi bill” will allow responsible innovation in treatment. Michael D Rawlins. 348:doi:10.1136/bmj.g2771

It is important to distinguish the legal principles from the consequences of professional misinterpretation of them. Elizabeth Butler-Schloss was clear in the case cited that all that the law needed was evidence "that there is a responsible body of relevant professional opinion which supports this innovative treatment." In law, the Bill may raise the barriers to innovation by imposing significantly greater procedural requirements than the current legal test. However, if clinicians perceive there to be a problem, then there is one (although not one of legal doctrine).

Competing interests: Also Chair, Health Research Authority but writing in a personal capacity here.

Jonathan Montgomery, Professor of Health Care Law

University College London, Bentham House, Endsligh Gardens, London WC1 0EG

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Re: The impact of antibiotics on growth in children in low and middle income countries: systematic review and meta-analysis of randomised controlled trials. Ethan K Gough, Erica E M Moodie, Andrew J Prendergast, Sarasa M A Johnson, Jean H Humphrey, et al. 348:doi:10.1136/bmj.g2267

The study by Gough et al (1) provides an interesting finding on the possible role of antibiotic use in promoting growth of children. The study examined eight trials related to treatment of malnutrition, infections such as diarrhea, Giardiasis, HIV infection (prophylaxis) from different low and middle income settings. While interpreting the results we would like to highlight some factors which might lead to possible bias in the study results.

The heterogeneity of the studies by geographical regions and ethnicity brings forth the possibility of bias, which is related to differences in the growth pattern in children in different ethnic groups. The genetic basis of growth, based on ethnicity, needs to be factored into the analysis. The selected trials have also included different disease categories which may influence the growth pattern on treatment. As an example, four trials related to malnutrition treatment have also focused on treating malnutrition with dietary regimens in addition to treating infection. The dietary intervention itself might have contributed to possible better growth pick up as compared to other studies with infections.

According to the authors, the study has excluded four other studies which have reported no growth benefits from antibiotics. These studies should have been considered for inclusion in the systematic review, meta-analysis and their exclusion could lead to possible selection bias.

The relationship between infections and malnutrition is well known. Treating infections in malnourished children can lead to improvement in dietary intake and hence the resultant normal growth. But the problem lies in identifying sub-clinical infections, the concerns of antibiotic resistance in case of prophylactic treatment, choosing the dose and duration for antibiotic prescription. In such situations, is it worth giving antibiotic to children irrespective of their nutritional status and the state of infectivity due to microbial agents? The finding of the study does not lead to any guidance on this issue. However, as a routine clinical practice, the need for giving antibiotics to those who require cannot be overruled and its utility is well established.

We need to gather more evidence on the role of antibiotic use in promoting growth in children. Prospective studies in children with comparisons between antibiotic use and non-usage in similar geographical, ethnic groups, with similar socio-economic factors might be able to give a better understanding on the issue.

Reference

1. Gough EK, Moodie EEM, Prendergast AJ, Johnson SMA,, Jean H Humphrey JH et al. The impact of antibiotics on growth in children in low and middle income countries: systematic review and meta-analysis of randomised controlled trials. BMJ 2014;348:g2267

Authors

Mongjam Meghachandra Singh
Professor, Department of Community Medicine
Maulana Azad Medical College, New Delhi

Reeta Devi
Assistant Professor
School of Health Sciences,
Indira Gandhi National Open University, New Delhi

Vibhor Wadhwa
Ex-intern, Maulana Azad Medical College, New Delhi

Competing interests: None declared

Mongjam Meghachandra Singh, Professor

Reeta Devi, Vibhor Wadhwa

Maulana Azad Medical College, New Delhi; co-author- Indira Gandhi National Open University, New Delhi, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India. Co-author : School of Health Sciences, IGNOU, New Delhi (India)

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Re: Gestational diabetes: new criteria may triple the prevalence but effect on outcomes is unclear. Tim Cundy, Evan Ackermann, Edmond A Ryan. 348:doi:10.1136/bmj.g1567

The excellent article on Gestational Diabetes over diagnosis comes to the heart of what defines a medical condition. The association of risk factors with adverse outcomes is one method of defining disease. The example of the changes in diagnostic criteria and treatment of hypertension over the last six decades is a clear illustration of the considerations needed in determining the parameters into which a condition falls. In the 1940s, hypertension was defined at a BP ≥ 200/110mmHg in association with a cerebrovascular event or renal failure (1). Despite the knowledge that lesser degrees of systolic and diastolic blood pressures were associated with poor outcomes, the definition of hypertension was not modified until the 1960s when pharmacological advances allowed treatments to be better tolerated. Hypertension can now in effect be defined as a level of blood pressure at which the benefits of treatment outweigh the risks. The actual values of blood pressure continue to change as new evidence demonstrates safety and efficacy for a particular group.

The term Gestational Diabetes Mellitus (GDM) was first introduced to describe women with poor obstetric outcomes who had high glucose levels in subsequent pregnancies. Initial diagnostic criteria were based on values that best predicted later development of maternal T2DM (2). GDM can be viewed as an early phase of T2DM, the metabolic stress of pregnancy demonstrating a predisposition to glucose intolerance. The main fetal complication, macrosomia, encompasses a spectrum from normality to hyperglycaemia and is predicted by factors other than hyperglycaemia such as ethnicity, weight and dyslipidaemia. Importantly, maternal obesity predicts macrosomia, a common complication of untreated GDM, with numerically more macrosomic babies being born to obese mothers compared to those with GDM. Additionally maternal dyslipidaemia is a predictive factor and in some specific groups is a stronger one than glucose.

The Hyperglycaemia Adverse Pregnancy Outcomes study (HAPO) clearly demonstrates the linear relationship between glycaemia and fetal birth weight; however, there exists no evidence on treating glucose levels to the diagnostic criteria now formulated by the IADPSG and WHO in response to the study results (3). The two landmark trials demonstrating an improvement in outcomes in women with impaired glucose tolerance levels both defined GDM with a 2-post 75g load level of ≤7.8mmol/L (4, 5). Furthermore the HAPO data places a greater emphasis on fasting hyperglycaemia in direct contrast to studies demonstrating the importance of postprandial hyperglycaemia in predicting adverse fetal outcomes (6, 7).

Management policy is best guided by evidence-based medicine, the clear demonstration that a condition, within well-defined parameters, is safely and effectively managed by a certain strategy. Until such data exist we should define gestational diabetes, in terms of the data on glycaemia, with a 2-hour glucose of 7.8mmol/L. Should future evidence demonstrate that defining GDM with a combination of weight and glycaemia benefits from a particular management, then this should alter guidance.

References

1. M M. Historical Perspectives on the Management of Hypertension. The Journal of Clinical Hypertension. 2006;8(8):15-20.
2. O'Sullivan JB. Establishing criteria for gestational diabetes. Diabetes Care. 1980; 3(3):437-9.
3. HAPO Study Cooperative Research Group. Hyperglycaemia and Adverse Pregnancy Outcomes. The New England Journal of Medicine. 2008;358(19):1991-2002.
4. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes. The New England Journal of Medicine. 2005;352(24):2477-86.
5. Landon MS, CY.; Thom, E.; Carpenter, MW.; Ramin, SM.; Casey, B.; Wapner RJ.; Varner, MW.; Rouse, DJ.; Thorp, JM.; Sciscione, A.; Catalano, P.; Harper, M.; Saade, G.; Lain, KY.; Sorokin, Y.; Peaceman, AM.; Tolosa, JE.; Anderson, GB. A Multicenter, Randomized Trial of Treatment for Mild Gestational Diabetes. The New England Journal of Medicine. 2009;361(14):1339-48.
6. De Veciana M, Major C, MA. M, Asrat T, Toohey J, Lien J, et al. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy. The New England Journal of Medicine. 1995;333(19):1237-41.
7. Jovanovic-Peterson L, Peterson C, Reed G, Metzger B, Mills J, Knopp R, et al. Maternal postprandial glucose levels and infant birth weight: The Diabetes in Early Pregnancy Study. American Journal of Obstetrics and Gynecology. 1991;164(1):103-11.

Competing interests: None declared

Rochan Agha-Jaffar, Diabetes Clinical Research Fellow

Stephen Robinson

Imperial College NHS Trust, Department of Metabolic Medicine, St Mary's Hospital, Praed Street, London W2 1NY

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Re: Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis. Kate Bramham, Bethany Parnell, Catherine Nelson-Piercy, Paul T Seed, Lucilla Poston, et al. 348:doi:10.1136/bmj.g2301

The research article concludes that women with chronic hypertension in US studies have an approximately threefold increased risk of delivery before 37 weeks’ gestation, birth weight <2500 g, and neonatal intensive care admission and a fourfold increased risk of perinatal death compared with the US general pregnancy population1. This systematic review and meta-analysis also shows that women with chronic hypertension have a high pooled incidence of superimposed pre-eclampsia and all other pregnancy complications1

Compared with the US general pregnancy population, the incidence of superimposed pre-eclampsia on average across study populations was nearly eightfold higher compared with pre-eclampsia1.

But my concern is that preterm delivery, caesarean sections, low birth weights, neonatal intensive care admissions and perinatal deaths are all complications of pre-ecclampsia alone. And as said above, that in chronic hypertension there is a high incidence of superimposed pre-eclampsia. So we may infer that the lion's share of complications due to chronic hypertension may be due to superimposed pre-eclampsia. In that case, patients with chronic hypertension with super-imposed pre-eclampsia need more attention in the antenatal period. This factor has to be studied in isolation as the meta-analysis has not answered this.

Competing interests: None declared

Neeru Gupta, Scientist E

Indian Council of Medical Research, Ansari Nagar, New Delhi-110029

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Re: Expert views: what the next Indian government should do for health and healthcare. Jeetha D’Silva. 348:doi:10.1136/bmj.g2479

It is very sad to note that many of the speakers are from private care. One of them commenting on poor farmers happens to be a pioneer of health innovation and tourism. Unfortunately today to treat a simple upper respiratory infection one needs to spend more than one thousand rupees for medicine alone. The goverment should think about bringing health along the lines of the NHS. Privatisation and competition is eating into research and leading to bad care. I hope that the government revives primary care.

Competing interests: None declared

Mohan Devegowda, GP

SOLO, 613 2nd main first stage indirnagar bangalore 560038

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Re: Persistent health disparities in the US signal need for new thinking. Keith Epstein. 345:doi:10.1136/bmj.e6204

This corrects and updates my February 2013 comment [1] on an article by Epstein regarding the need for new thinking about health disparities in the US.[2] In the comment, I criticized US health and healthcare disparities research for its failure to recognize patterns by which standard measures of differences between outcome rates tend to be systematically affected by the prevalence of an outcome. The patterns include those whereby as the prevalence of an outcomes changes (a) relative (percentage) differences in favorable outcomes and relative differences in the corresponding adverse outcomes tend to change in opposite directions and (b) absolute (percentage point) differences tend to change in the same direction as the smaller relative difference. And I stated that in the yearly National Healthcare Disparities Report (NHDR) the US Agency for Healthcare Research and Quality (AHRQ) measured health and healthcare disparities in terms of whichever of the two relative differences is larger and therefore tended to reach opposite conclusions about directions of changes in disparities from those reached by AHRQ-funded researchers relying on absolute differences.

The statement that AHRQ relied on the larger of the two relative differences in the NHDR was based on statements in NHDRs from 2005 until 2009 that a disparity would be deemed important where “the relative difference is at least 10% different from the reference group when framed positively as a favorable outcome or negatively as an adverse outcome.” [3 (at 28 n.9)]. But I have since recognized that that approach was limited to determinations of the importance of a disparity. For the purpose of determining whether disparities have increased or decreased, it has been AHRQ’s intention to measure all disparities in terms of relative differences in adverse outcomes, in accord with the approach of the US National Center for Health Statistics (NCHS). AHRQ has not, however, invariably implemented that approach. As shown in Table 5 of reference 4(a), among cases that the 2012 NHDR highlights as the fastest decreasing disparities in healthcare outcomes are situations where the relative difference in the adverse outcome in fact increased (though the relative difference in the favorable outcome and the absolute difference decreased). The failure of the agency to correctly implement its intended measurement approach is less serious an issue, however, than its failure yet to understand that the measures it employs or intends to employ tend to be systematically affected by changes in the prevalence of the outcome examined, and, hence, why those measures cannot effectively indicate whether the strength of the forces causing outcome rates of disadvantaged and advantaged groups to differ has increased or decreased over time.

The earlier comment did not discuss the US Centers for Disease Control and Prevention (CDC), which had issued its own extensive 2011 Health Disparities and Inequalities Report.[5] Last December the agency issued a similarly extensive 2013 Health Disparities and Inequalities Report.[7] Like the earlier document and other disparities research of CDC, the 2013 report shows no awareness that the measures on which it relies may be affected by the prevalence of an outcome, or even that NCHS (an arm of CDC) has specifically found that determinations of directions of changes in disparities will commonly turn on whether one examines relative differences in favorable outcomes or relative differences in adverse outcomes. See pages 26 to 32 of reference 4(a) regarding the disarray of health and healthcare disparities research among the most prominent US governmental and nongovernmental institutions involved in such research (or guidance on such research) and the failure of those institutions yet to provide sound research, or sound guidance on research, regarding whether health and healthcare disparities should be deemed to have increased or decreased over time. That failure will continue until those institutions recognize and responsibly address the implications of the fact that standard measures tend to change simply because the prevalence of an outcome changes.

As reflected in a more recent comment [7] on a Marmot and Goldblatt’s editorial emphasizing the importance of monitoring health inequalities, such monitoring is no sounder in the UK than in the US.

References

1. Scanlan JP. The need for new thinking about how to measure disparities. BMJ 4 Feb 2013. http://www.BMJ.com/content/345/BMJ.e6204/rr/628910

2. Epstein K. Persistent health disparities in the US signal for new thinking. BMJ 2012;345:e6204 doi: 10.1136/BMJ.e620). http://www.bmj.com/content/345/bmj.e6204

3. Agency for Healthcare Research and Quality, 2009 National Healthcare Disparities Report. http://www.ahrq.gov/research/findings/nhqrdr/nhdr09/index.html

4. Measuring Health and Healthcare Disparities. Proceedings of the Federal Committee on Statistical Methodology 2013 Research Conference (March, 2014)
(a) Presentation: http://jpscanlan.com/images/2013_FCSM_Presentation_pdf_.pdf
(b) Paper: http://jpscanlan.com/images/2013_Fed_Comm_on_Stat_Meth_paper.pdf

5. Centers for Disease Control and Prevention. 2011. CDC Health Disparities and Inequalities Report – United States, 2011: http://www.cdc.gov/mmwr/pdf/other/su6001.pdf

6. Centers for Disease Control and Prevention. 2013. CDC Health Disparities and Inequalities Report – United States, 2013. http://www.cdc.gov/minorityhealth/CHDIReport.html#CHDIR

7. Scanlan JP. The monitoring of health inequalities has never been sound. BMJ 9 Nov 2012). http://www.bmj.com/content/347/bmj.f6576/rr/671152

8. Marmot M, Goldblatt P. Importance of monitoring health inequalities. BMJ 2013;347:f6576. http://www.bmj.com/content/347/bmj.f6576

Competing interests: None declared

James P. Scanlan, Attorney

James P. Scanlan, Attorney at Law, Washington, DC USA

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Re: Improving the selection of medical students. David Powis. 340:doi:10.1136/bmj.c708

Dear Editors,

Half of the 600,000 students in Greek public universities are inactive, and only 10% of those enrolled will ever manage to graduate. [1]

These "eternal students", long tolerated by the managements of tertiary institutions, will get permanently erased from the student registers in a few months. [2][3]

Maximum graduation deadlines are established for those remaining.

This unique and embarrassing phenomenon allowed Greek Universities to boast hundreds of thousands of additional registered students, claiming more State and European research and education funds.

Thousands of “eternal students” were living in free University dorms for decades! [4]

References

[1] http://www.grreporter.info/en/greek_phenomenon_eternal_student/3649
[2] http://greece.greekreporter.com/2014/03/05/greek-eternal-students-facing...
[3] http://www.ekathimerini.com/4dcgi/_w_articles_wsite3_1_07/03/2014_537977
[4] http://greece.greekreporter.com/2012/12/23/student-booted-from-room-afte...

Competing interests: None declared

Stavros Saripanidis, Consultant in Obstetrics and Gynaecology

Private Surgery, Thessaloniki, Greece

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17 April 2014

Re: US internists call for public health approach to gun violence in US. Michael McCarthy. 348:doi:10.1136/bmj.g2796

We are torn between verbiage and violence. Our intelligence tells us to resolve disputes patiently and peacefully. But our anger tells us to end disputes fast and forcefully. How can we resolve this dichotomy? We must own up to our tendency to impatience, anger, and violence, and learn to express this tendency verbally, safely, and humanely, because violence is ruinous, but patience is luminous and numinous. 


Competing interests: None declared

Hugh Mann, Physician

Retired, Eagle Rock, MO, USA

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