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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: Addiction to exercise Heather A Hausenblas, Katherine Schreiber, James M Smoliga. 357:doi 10.1136/bmj.j1745

Well done to the BMJ for publishing this very interesting article on a subject that is rarely discussed. I would certainly like to see more research done in this area. However, the subject is not new, I remember addiction to exercise and being able to detect it being part of my athletics coaching courses during the 1980s. I have heard very little since so it is good to see it being discussed here.

I am, and have been, an enthusiastic runner for about 40 years, generally running 6 days a week. Am I addicted to running? I don’t think so but when I completed the Exercise Addiction Inventory screening tool I scored 23 out of 30, which is borderline between ‘potentially symptomatic’ and ‘at risk for exercise addiction who should be referred to a specialist’. I’m sure this will be a concern to many amateur runners like myself who will fall into this category.

While I agree with most of the points made in the article I disagree that high volume exercisers (as opposed to exercise addicts) do not suffer from emotional, social or occupational disruptions. In fact, it is difficult to train at high volume without those sorts of disruptions. The key point is being able to control these disruptions and not let them get out of hand. Quite often this needs a third party, usually a member of the family or a coach, to spot any disruptions and this should be addressed as part of the consultation.

This shows good progress in the subject of exercise addiction and should be developed further. I would suggest involving athletes and coaches in the next stage and perhaps a refinement of the screening tools to improve assessment.

Competing interests: No competing interests

30 April 2017
Brian Jones
Engineering Manager
1, Donnington Drive, Chandler's Ford, Eastleigh. Hampshire
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Re: Severe postpartum headache Jeremy Chee, Thian Phey Lau. 357:doi 10.1136/bmj.j1856

Additional important differential diagnoses in a patient with neurological signs who presents with a severe postpartum headache include pituitary apoplexy and subarachnoid haemorrhage. It is thus important to additionally measure pituitary function tests including a cortisol, and look carefully at the pituitary fossa and consider haemorrhage on imaging. Steroid replacement may be needed at the time and in patients who have neurological signs, sometimes urgent neurosurgical review is required

Competing interests: No competing interests

30 April 2017
Nigel Mendoza
Consultant Neurosurgeon
Professor K Meeran Consultant endocrinologist ; Dr Niamh Martin consultant endocrinologist
Imperial NHS Healthcare trust
Charing Cross Hospital Fulham palace road London w6 8rf
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Re: Humanising healthcare Robin Youngson, Mitzi Blennerhassett. 355:doi 10.1136/bmj.i6262

Impact of behavioral science curriculum in medical education
Background:
Humanization of health care is defined as a state of well-being, involving affection, dedication, respect for the other, that is, to consider the person as a complete and complex being (1). We applauded this insightful editorial and sincerely appreciated author’s call for building a more compassionate society (2). When we are sick, injured, or facing an existential life crisis, our greatest human need is loving kindness and compassion in response to our vulnerability and suffering (2).
Most commonly young generation medical graduates find it difficult to initiate respectful and compassionate dialogues with their patients while working in a crowded out-patient department. Many of them fail to maintain professional conduct in a stressful working environment. Some of them often feel sick due to burn out state of their mind after long hours of emergency ward duties.
It is most unfortunate that many of them did not get an opportunity to learn about behavioral science as a part of their curriculum during their medical school training program. They were never been exposed to the local community for a supervised health screening program with a mission to develop doctor-patient relationship and professional communication skills in real life scenario. Psychological state of our patients vary widely. Many of our patients expect kind and friendly approach before explaining their personal health problems.
In recent years behavioral science has created its own space in medical curriculum which is now taking care of building foundation of compassionate behavioral changes among new generation of medical professionals. Patient-centered care has been a focus of health care management for many years, with emphasis ranging from the policy and health system levels to individual care at the bedside.(3) We suggest that work environments that support caring and compassion, for patients as well as for care providers, best provide a foundation upon which high quality patient-centered care can flourish (2). One of the challenges that makes humanizing health care difficult is the lack of financial resources for improving the physical and material structure of the services (3). It is necessary to understand the patient as unique and irreplaceable, who deserves to be treated with dignity (4, 5).
In recent years, the outreach program of All American Institute of Medical Sciences, Jamaica is gaining popularity and our medical students are getting early exposure to local population and their cultural background, which may help them to understand the human need of loving kindness and compassion in response to their vulnerability and sufferings.
Concluding remark:
The routine class room teaching of doctor-patient-relationship and case history taking course work, remain incomplete till we expose our young medical students to interact in a real life scenario. Medical professionals need a supervised environment to develop compassionate relationship with unknown patients in a limited time period. A supervised and well-designed training course work on behavioral science may help to build up confidence and self-respect among young generation medical students. All patients want to be looked after by a good doctor. This is because they know instinctively that a doctor's decisions and advice about diagnosis and treatment can affect the outcome and possible consequences of illness and may make the difference between life and death (6)
Nothing tests our communication skills so much as breaking bad news. Such conversations can be extremely emotional for both doctor and patient. The right words said in the right way make a huge difference (7). Compassionate behavioral skills of medical practitioners often help to reduce anxiety and worries of patients and accompanying relatives.
We understand that behavioral science curricula may even include content that favors the students' humane education, however, curricula hinder such content being effectively appropriated by the students in a significant manner, which includes the possibility of the content being transformed in routine care actions. More integrative models, and especially those that permit students to gradually approximate content to professional practice, connecting it to theoretical references, may have a greater potential for improving critical-reflective learning committed to reality (1).

References:
1. Rev. esc. enferm. USP vol.46 no.1 São Paulo Feb. 2012 http://dx.doi.org/10.1590/S0080-62342012000100029
CRITICAL REVIEW: The humanization of care in the education of health professionals in undergraduate courses*
2. Editorials: Christmas 2016; Humanizing healthcare: BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6262 (Published 13 December 2016) Cite this as: BMJ 2016;355:i6262.
3. Re-humanizing Health Care: Facilitating “Caring” for Patient-centered Care
Cheryl Rathert, Timothy J. Vogus, and Laura McClelland
The Oxford Handbook of Health Care Management
Edited by Ewan Ferlie, Kathleen Montgomery, and Anne Reff Pedersen
http://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780198705109.001.0...
4. Rev Saude Publica. 2013 Dec; 47(6): 1186–1200. doi: 10.1590/S0034-8910.2013047004581: PMCID: PMC4206092 : Humanization policy in primary health care: a systematic review: Carlise Rigon Dalla NoraI and José Roque JungesII
5. Humanizing Health Care: Creating Cultures of Compassion With Nonviolent Communication (Nonviolent Communication Guides) Paperback – October 15, 2010: by Melanie Sears RN (Author)https://www.amazon.com/Humanizing-Health-Care-Compassion-Communication/d...
6. Education And Debate: GMC and the future of revalidation: Patients, professionalism, and revalidation: BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7502.1265 (Published 26 May 2005); Cite this as: BMJ 2005;330:1265
7. Breaking bad news: BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7500.1131 (Published 12 May 2005) Cite this as: BMJ 2005;330: 1131.

Competing interests: 1. The author is teaching Behavioral Science in different USMLE based medical schools since 2006. 2. The outreach community health screening program was organized under All American Institute of Medical Sciences in Jamaica on 17th March 2017.

30 April 2017
Tanu Pramanik
Associate Professor
All American Institute of Medical Sciences
66 High Street, Black River, St Elizabeth, Jamaica.
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Re: Low LDL cholesterol, PCSK9 and HMGCR genetic variation, and risk of Alzheimer’s disease and Parkinson’s disease: Mendelian randomisation study Marianne Benn, Børge G Nordestgaard, Ruth Frikke-Schmidt, Anne Tybjærg-Hansen. 357:doi 10.1136/bmj.j1648

This is an important reassurance in support of lowering LDL levels, especially when there is a climate of anti-statin and pro-saturated fat tide in the press and public.

However the conclusion in the abridged print version suffers from a confusion due to the wording - is it Low Density Lipoprotein or Lower Low Density Lipoprotein that is the subject of reassurance? Would the authors please read the shorter version in the printed BMJ to see if they agree with the conclusions?

I paraphrase the text from the Abridged version in this weeks printed BMJ.

Study answers "Genetic evidence suggested that low density lipoprotein cholesterol levels may lead to a low risk of Alzheimer’s dementia."

What this study adds "The findings suggest that low density lipoprotein cholesterol has no harmful causal effect on risk of Alzheimer’s dementia, vascular dementia, any dementia, and Parkinson’s disease."

The full paper's conclusions are different though: "low LDL cholesterol levels may have a causal effect in reducing the risk of Alzheimer’s disease."

Competing interests: No competing interests

29 April 2017
Vadivelu Saravanan
Consultation Rheumatologist
Queen Elizabeth Hospital
Gateshead, NE9 6SX
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Re: Most drugs paid for by £1.27bn Cancer Drugs Fund had no “meaningful benefit” Deborah Cohen. 357:doi 10.1136/bmj.j2097

Such poor cancer drug efficacy/survival benefit results should not come as a surprise, since it is well established that most old [1] or novel [2] chemotherapeutic agents prolong patients' survival for only 3 months.
References
[1] http://www.bmj.com/content/355/bmj.i5792
[2] http://www.bmj.com/content/356/bmj.j30

Competing interests: No competing interests

29 April 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Private Clinic
Kalamaria, Thessaloniki, Greece
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Re: India launches strategy to curb antimicrobial resistance Sumi S Dutta. 357:doi 10.1136/bmj.j2049

The article by Dutta S was read with interest (1). India was the worlds largest consumer of antibiotics in 2010 (2). Antibiotic resistance to various antibiotics ampicillin, naladixic acid, co-trimoxazole, aminoglycosydes, third generation cephalosporins, carbapenems and fluoroquinolones are on rise in India (2). Some of the contributing factors responsible for antibiotic resistance include increasing incomes, ready access to antibiotics over the counter without prescription. Increasing use of antibiotics for promoting growth and preventing disease in poultry industry is one of the major factors contributing to antibiotic resistance (3). The farmers use one tenth to one hundredth of the therapeutic dose resulting in obvious antibiotic resistance (3). This irrational use results not only in antibiotic resistance in poultry birds, but also both in people who handle them and consume their meat. Antibiotic pollutants in waste water treatment plants serving antibiotic manufacturing facilities are also implicated in transfer of resistance genes into human microbiota (2).

Stricter formulation and implementation of laws are necessary to curb the growing antibiotic resistance problems in India. Antibiotics should be made available to consumers only when they bring to the pharmacy the prescriptions with dose, duration and frequency, signed and sealed with date by registered medical practitioners. Medical practitioners should strictly adhere to the best practices of antibiotic prescription. Antibiotics should be prescribed only when absolutely necessary i.e., in conditions where it is clearly indicated. Whenever possible, microbial culture and antibiotic sensitivity tests should be carried out. Continuing medical education programs highlighting the antibiotic resistance problem and how to curb them should be made mandatory for every medical practitioners for at least once in two years. This will refresh the knowledge of medical practitioners and empower them on using the antibiotics judiciously. Patients exhibit tendency not to complete the full course of the prescribed antibiotics, especially when they feel better after the initial intake. Also, patients tend to self reuse the old prescriptions made by their doctors and even recommend it to their close relatives without medical supervision. This can be effectively discouraged by mentioning in every prescription paper about the exact date of prescription and also the words- "To be taken for the full course as prescribed by the doctor. Prescription not to be reused after its original indication has been fulfilled. Prescription not to be transferred." These simple measures would also educate the patients about the best use of antibiotics and could certainly lead to decreased antibiotic resistance.

Antibiotic use as growth promoters in livestock should be phased out. Stricter regulating laws should be implemented to direct the antibiotic manufacturing plants to take care of not releasing antibiotic pollutants into environment. These measures would also contribute to limit the growing antimicrobial resistance in India.

References

1. Dutta SS. India launches strategy to curb antimicrobial resistance. BMJ. 2017;357:j2049.
2. Laxminarayan R, Chaudhury RR. Antibiotic Resistance in India: Drivers and Opportunities for Action. PLoS Med. 2016 Mar 2;13(3):e1001974.
3. Pulla P.Doctors’ leaders in India call for ban on prophylactic antibiotics in poultry. BMJ 2014;349:g5052 .

Competing interests: No competing interests

29 April 2017
Vagish Kumar L Shanbhag
Reader
Department of Oral Medicine and Radiology, Yenepoya Dental College and Hospital, Yenepoya Research Centre, Yenepoya University.
University Road, Deralakatte, Mangalore-575018
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Re: A woman with intermittent heartburn Hao Chen. 357:doi 10.1136/bmj.j1936

Nice images, However if the patient presented with retrosternal heartburn, why do a chest radiograph? Often such hernias are detected as a coincidental finding on radiographs for other indications, but as we should be reducing the exposure of patients to radiation to a minimum, there does not seem any indication for doing the investigation. It would be wrong to suggest a chest X-ray is a useful or appropriate investigation for heartburn.
The discussion suggests that high-resolution manometry (HRM) is indicated in cases with gastro-oeosophageal reflux: this also seems incorrect. Although HRM can accurately define both the lower oesophageal sphincter and oesophageal dysmotility and is particularly useful in cases of dysphagia or recurrent heartburn with a normal endoscopy. In cases such as this with a large hiatal hernia, when associated with symptoms, oesophageal manometry really adds little to the management, which usually requires either acid suppression or consideration of surgical repair where safe and appropriate when dysphagic symptoms are mechanical due to the abnormal anatomy.

Competing interests: No competing interests

29 April 2017
Ian L. P. Beales
Consultant Gastroenterologist
Norfolk and Norwich University Hospital
Norwich
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Re: Three quarters of physician aided deaths in Oregon are in patients with cancer Jacqui Wise. 357:doi 10.1136/bmj.j1765

This article confirms the acceptability of a choice over assisted death for me. Two concepts rise for me:
1. many people with supported assistance to take their own lives when terminally ill do not do so - the existence of a 'plan B' is in itself reassuring and facilitates an option of an easier death, thus often prolonging meaningful life.
2. the existential suffering of loss of autonomy, dignity and pleasure in life are - for many of us - more of a threat than pain - which, as palliative care physicians keep telling us, can be dealt with.
It is surely no coincidence that many people who 'come out' about a planned trip to Dignitas, or like Noel Conway take their cases to the High Court, have motor neurone disease - a terminal illness with a notoriously unpleasant death with the added torture of full mental capacity to the end.
I am heartily sick of others trotting out the arguments about 'playing God' (what is IVF if not doing that - as well as most medicine for that matter?) and the 'slippery slope' (many of us who are middle aged and healthy are clear that if assisted dying were legal and we fitted our own criteria in the future we would avail ourselves of it - we are talking about advance directives and LPAs here, not bumping off disabled and elderly willy nilly)
The debate on assisted dying must be honest and the BMA and politicians MUST seek the opinions of its members - AND the people they care for / represent. We and parliament are well out of step with Joe Public. The person who is mentally competent to decide if their life is worth living should be able to do so - we are talking about having a choice and nothing more. Currently that choice is only open to people with money who are still well enough to travel to Switzerland. How ironic is that?

Competing interests: member of Health Care Professionals for Assisted Dying have heard many patients and their families express a desire for the option of assisted dying

29 April 2017
Alison Payne
GP
Willenhall Primary Care Centre
Coventry
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Re: Is there any place for counterterrorism in the NHS? Anne Gulland. 357:doi 10.1136/bmj.j1998

Politicians would also like us to look out for tax evasion and money laundering.

Competing interests: No competing interests

29 April 2017
Anand Beri
Consultant psychiatrist
St Margarets hospital Epping
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Re: Evolution of biological agents: how established drugs can become less safe Nicole Casadevall, Oliver Flossmann, David Hunt. 357:doi 10.1136/bmj.j1707

I commend David Hunt and colleagues for a well written article describing the unique Pharmacovigilance considerations with evolving biologics. It is vital that physicians are aware of this phenomenon and that due diligence is taken to report adverse events appropriately. Such pharmacovigilance considerations may be similarly applicable to biosimilar products. Hunt et al. describe several strategies for monitoring of adverse events, which of course are valid, however we must not forget that an educated and empowered patient is fundamental to the success of drug safety monitoring. I would encourage all prescribers of these medicines to take a moment in your next consultation to explain the pharmacovigilance considerations with evolving biologics - not only is this essential for accurate drug safety monitoring but the patient has a right to know.

Competing interests: Employed as a Medical Advisor for Bayer Plc

29 April 2017
Simon Rowland
ST3 in Pharmaceutical Medicine
7a St Hilda's Road, Barnes
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