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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: Restoring balance to “best interests” disputes in children Dominic Wilkinson. 358:doi 10.1136/bmj.j3666

A number of authors have captured the ethics, emotions and medicine evoked in the Charlie Gard case(1,2,3,4). However much of the narrative centres on the dilemma where parents disagree with doctors on the matter of best interests. However this case really turns on how parents and patients respond when doctors disagree as to what constitutes the best course of action. The parents' stance was predicated almost exclusively on the offer from the American professor of neurology that he may be able to improve their son's quality of life(3,4). Similarly hospitals both in Europe and the USA offered to care for the child, Charlie; further reinforcing the notion that this course of action was not medically futile(3,4). Had the professor advised the family that his techniques were only experimental and the chances of any clinical improvement were from zero to negligible, it is inconceivable that the parents would have pursued a course of action to keep their son alive, with no prospect of amelioration of his condition.

There can be the popular perception that science consists only of incontrovertible truths, when there is disagreement, both sides of the argument must be viable alternatives, rather than one being necessarily inapposite, inferior or incorrect. However doctors disagree on a host of matters; most recently the appropriateness of near global statin therapy for men and women over 60 and 75 respectively or, for example, the need for mandatory immunisation(5,6). There is even no unanimity on traditional medical dogma such as the utility of bisphosphonates(7). Patients will invariably affiliate themselves to one side of a medical argument, and pursue that. If the debate is public, as in this case, eminent political and religious figures will equally align themselves to one side and eschew the other. To suggest that public opinion is only a manifestation of ochlocracy is in some ways a misrepresentation. The debate is only nubile in the public arena as two rival medical prepositions are presented. As a profession we must learn how best to engage with patients where there exists disagreement between doctors and lack of consensus within the profession. The age of paternalism, where patients are excluded from the debate, and effectively told "be quiet sweetie, mummy and daddy are talking"; is dead. The seminal case of Montgomery v Lanakshare Healthcare Board 2015 was the fatal injection for this attitude(8). However intriguingly where there is a dispute in medical opinion, as a profession, is there a tendancy to revert to a Bolamesque paradigm, where the patient has to comply with what the main or most influential body of the profession believes is best?

In 2014 the British Medical Journal published an instructive piece on an analogous case entitled "Lessons from the Ashya King case"(9). In this case, which also attracted significant global interest, doctors in the UK and Europe disagreed on the use of proton beam therapy. Ashya's parents took him from hospital, with a view of submitting him for such treatment in Europe, however this was without notifying his healthcare team. They were ultimately arrested and incarcerated. The general consensus what that this response was disproportionate and the parents were released(9). The child eventually underwent photon therapy. Again the BMJ piece centred entirely on disputes between families and their care teams. However, as in the case of Charlie, this disagreement only had force because there was no consensus amongst clinicians. It would appear that there are still lessons to be learnt from the Ashya King case; not least of all how to involve patients in the decision-making process when doctors disagree. Even further we must introgress some medical method into the legal profession such that it gains a greater appreciation of how to integrate conflicting medical evidence into the deliberative process. As a profession, if we fail to find a formula to address these polemics the courts will increasingly be the arbiter of medical disputes, which has, in the past, resulted in some verdicts which seem somewhat antithetical to our profession(10).

1. Wilkinson D Restoring balance to “best interests” disputes in children BMJ 2017; 358
2. Hurley R. How a fight for Charlie Gard became a fight against the state BMJ 2017; 358
3. Truog RD.The United Kingdom Sets Limits on Experimental Treatments: The Case of Charlie Gard. JAMA. 2017 Jul 20. doi: 10.1001/jama.2017.10410
4. Sokol D. Charlie Gard case: an ethicist in the courtroom. BMJ. 2017 Jul 19;358:j3451
5. https://www.doctors.net.uk/News/Article.aspx?newsid=26753
6. Moberly T.UK doctors re-examine case for mandatory vaccination.Wise J.Teenage boys shouldn't be given HPV vaccine, says joint committee. BMJ. 2017 Jul 20;358:j3523 BMJ. 2017 Jul 18;358:j3414.
7. Järvinen TL, Michaëlsson K, Jokihaara J, Collins GS, Perry TL, Mintzes B, Musini V, Erviti J, Gorricho J, Wright JM, Sievänen H.Overdiagnosis of bone fragility in the quest to prevent hip fracture. BMJ. 2015; 350:h2088.
8. Chan SW, Tulloch E, Cooper ES, Smith A, Wojcik W, Norman JE. Montgomery and informed consent: where are we now? BMJ. 2017 May 12;35
9. O'Brien A, Sokol DK. Lessons from the Ashya King case. BMJ. 2014 Sep 10;349:g5563
10. Dyer C. Courts can decide that vaccine has caused harm despite lack of evidence. BMJ. 2017 Jun 26;357:j308

Competing interests: No competing interests

13 August 2017
Chika E Uzoigwe
Doctor
Jagdeva Mehet
Harcourt House
Sheffield
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Re: Trainee GP who was warned over falsifying timesheets to get new sanction after GMC appeal Clare Dyer. 358:doi 10.1136/bmj.j3864

The BMJ declares, the GMC won!

I can’ t quite workout if the BMJ are being triumphalistic, high fiving in the office clutching their organic, ethically sourced Venti Soy Quadruple Shot Latte with No Foam or if they are lamenting the success of the mighty over the weak.

Maybe there is no answer and their moral compass now acts as a desk fan.

Please don’ t misunderstand me I would not wish to condone Nwachuku’s Misdemeanour anymore than I would:

1. Colleagues who make a financial claim for ‘extra-clinical’ work during their contractual hours
2. Those who misrepresent the criticism they receive from the Appeal court or the Coroner.
3. Those doctors who pervert the course of Justice.
4. Those who defraud the public purse by manipulating waiting lists
5. The colleagues who still enjoy a platinum merit award long after they stopped doing anything meritorious.

Greed and corruption are corrosive and repulsive. They provoke indignation which would make most of us respond to the call of Victor Hugo’s student revolutionaries to “man the barricades!”

But, on the theme of French Romantics, would we really side with the Police Inspector, Javert, in his misguided and self-destructive pursuit of justice or even the GMC in this case?

Aside from the fact the success of the GMC undermines the independence of the Medical Practitioners Tribunal Service. The crime and charge in this case is surely the profligate misuse of our GMC subscriptions.

For any normal human being going to the High Court usually involves risking large sums or even your home. It is not something any of us would do lightly or over a trivial matter but not so with the GMC who take no personal risk and spend our funds.

Like Cicero, I ask Cui bono? "For whose benefit?" 1

This is a disturbing trend when one notes recently a three day hearing was conducted for a doctor already serving a 15 year prison sentence.

It is well understood that there are few winners if natural justice prevails. The exception, of course, are those who enjoy the gravy train, which is becoming ever richer and distasteful!

1. "Cicero: Pro Sex. Roscio Amerino". thelatinlibrary.com.

Competing interests: No competing interests

13 August 2017
Michael Bowen
Consultant Gynaecologist
Oxford
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Re: “Going the extra mile” endangers doctors, patients, and NHS Tom Moberly. 358:doi 10.1136/bmj.j3547

The system of healthcare in the province of Nova Scotia, Canada, is in crisis ,as evidenced by patients frontline medical & healthcare providers. Family doctors like myself have expressed our observations that , it has felt like a crisis to us for the last ten years. We were ten years younger then and believed it was our duty and obligation to take more on in the name of patient centered care and advocacy.
Our system of care has not valued the unseen, relationship building and continuity of care that inherently is our domain. The unsexy tenets of long term care, the cold realities of incurable, relapsing conditions, and the stark underpinnings of end of life decisions are our 'bread and butter'. Our work is dogged, with no fanfare and is never-ending. We willingly turned into hamsters and ran faster, harder, to prove our shoulders were wide enough to carry the burdens heaped upon us.
Many of us are not only burning out, but are tasting the bitter disappointment of now being cast aside by administrators, politicians, lawyers, accountants and bureaucrats who believery they know what primary care reformation is all about. None of them have earned the right or meritocracy to achieve this. They have little knowledge and even less competency for this work. It appears that our silence and steadfast patient centered sacrifices, done with compassion to uphold what it is to be a doctor has been seen to cost nothing, is replaceable and has no value.
As I feel my hope run out, like sand in an hour glass, despair fills that space, and the futility of it all steals whatever is left.

Competing interests: No competing interests

12 August 2017
Ajantha Jayabarathan
Family Physician
Coral Shared-Care Health Center
Unit #4, 2751 Gladstone street
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Re: Why I’ve changed my views on assisted dying David Nicholl. 358:doi 10.1136/bmj.j3566

Dr. David Nicholl's views on assisted dying and his change of opinion about euthanasia is as relevant as that of most of his opposing colleagues (1). It is significant that palliative care doctors, who treat terminally ill patients, are against euthanasia (2)
Why do we need a law of euthanasia? Fabienne Vanheuverbeke committed suicide with the help of a doctor (1) but she could have done so without his help and without having to involve the medical profession.
To introduce assisted suicide, it would be better to contract trained executioners, without involving doctors. Our profession is not meant to kill but to help die. We doctors value human life with functional limitations, and we do know that loss of functional autonomy does not lead to loss of dignity (3).

References
(1). David Nicholl. Why I’ve changed my views on assisted dying? BMJ 2017;358:j3566
(2). Bridge D. Palliative care, euthanasia and physician assisted suicide. MJA Insights 2017: 10 / 20 March 2017. Accesed in https://www.doctorportal.com.au/mjainsight/2017/10/palliative-care-eutha...
(3). Krahn GL. Reflections on the debate on disability and aid in dying. Disabil Health J. 2010 Jan;3(1):51-5.

Competing interests: No competing interests

12 August 2017
Monedero Pablo
Intensive care anaesthetist
Clínica Universidad de Navarra
Pio XII, 36. 31008 Pamplona (SPAIN)
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Re: Incretin based treatments and mortality in patients with type 2 diabetes: systematic review and meta-analysis Jason W Busse, Per Olav Vandvik, Sheyu Li, Gordon H Guyatt, et al. 357:doi 10.1136/bmj.j2499

Rajkumar Rajendram [1-3]
Ahmed Al Ibrahim [1]

1. Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
2. Medication Use and Process Evaluation Subcommittee of the Medication Safety Program, Central Region, Ministry of National Guard Health Affairs, Saudi Arabia
3. Department of Nutrition and Dietetics, School of Biomedical and Life Sciences, King’s College London, UK

Mortality from diabetes is primarily due to cardiovascular disease.[1] However, before the United States Food and Drug Administration industry required data on cardiovascular outcomes (CVO) to license new hypoglycaemic agents in 2008; few studies had examined the relationship between glucose lowering drugs and cardiovascular (CV) risk. This paradigm shift encouraged the use of hypoglycaemic agents with mortality benefits.

It was therefore extremely disappointing that the meta-analysis of 189 studies of incretin-based treatment on all cause mortality in patients with type 2 diabetes reported by Liu et al.[2] found that there was no difference between incretin drugs and control. Indeed, Glucagon-like peptide-1 analogs and dipeptidyl peptidase-4 (DPP-4) inhibitors have joined a long list of hypoglycaemic agents that do not improve cardiovascular outcomes or reduce mortality. This failure to identify hypoglycaemic medications that improve patient-relevant outcomes demands yet another paradigm shift in the management of type 2 diabetes.

Rather than attempting to control hyperglycaemia it may be more appropriate to prevent the development of hyperglycaemia. This may be achieved by regulation of carbohydrate intake. Cohort studies have suggested that whilst a carnivorous low-carbohydrate diet is associated with higher all-cause mortality; a vegetarian low-carbohydrate diet improves cardiovascular disease and reduces mortality.[3]

Although further research is required to confirm these data; such lifestyle modifications are extremely difficult to achieve and maintain.[4] Regardless, reducing morbidity and mortality from diabetes mellitus is critical to public health so a novel approach to the management is urgently required to improve outcomes.

REFERENCES

1. Khan SS, Butler J, Gheorghiade M. Management of comorbid diabetes mellitus and worsening heart failure. JAMA2014;311:2379-80.
2. Liu J, Li L, Deng K, Xu C, Busse JW, Vandvik PO, Li S, Guyatt GH, Sun X. Incretin based treatments and mortality in patients with type 2 diabetes: systematic review and meta-analysis. BMJ. 2017;357:j2499.
3. Fung TT, van Dam RM, Hankinson SE, Stampfer M, Willett WC, Hu FB. Low-carbohydrate diets and all-cause and cause-specific mortality: two cohort studies. Ann Intern Med. 2010;153:289-98.
4. Norris SL, Engelgau MM, Venkat Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 2001;24:561--87.

Competing interests: No competing interests

12 August 2017
Rajkumar Rajendram
Consultant in Internal Medicine; Chairman of Medication Use and Process Evaluation Subcommittee of the Medication Safety Program
Ahmed Al Ibrahim
Department of Medicine
King Abdulaziz Medical City, Riyadh, Ministry of National Guard Health Affairs, Saudi Arabia
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56
Re: Doctors are told to use hepatitis B vaccine sparingly because of global shortage Zosia Kmietowicz. 358:doi 10.1136/bmj.j3801

Risk of Aquiring Diseases will increase in Vaccines Shortage period.

Own manufacture of vaccines like hepatitis B Vaccines in all countries are lmportant. We shouldn't relay upon one or a few companies for the production of vaccines and life saving drugs to face the short supply at any time and anywhere in the world.

Competing interests: No competing interests

12 August 2017
M.A. Aleem
Neurologist
A.M.Hakkim
ABC Hospital
Annamalainagar Trichy 620018 Tamilnadu India
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68
Re: More patients are surviving heart failure, audit finds Zosia Kmietowicz. 358:doi 10.1136/bmj.j3860

Beware "echo" cardiac failure. I cannot remember seeing a report saying "normal heart".

Competing interests: No competing interests

12 August 2017
simon d price
Sessional GP
1A Jesmond Road
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58
Re: Plan for army-style conscription of doctors is reconsidered Abi Rimmer. 358:doi 10.1136/bmj.j3839

Can I ask this simple question?
Will UK graduates qualifying as Vets and Dentists, the majority of who will go into private practice, though possibly not abroad, receive the same attention and "conscription" as that being considered for our Uk Medical Graduates? And why stop there? What about Accountants or Lawyers?
Dil Sen

Competing interests: No competing interests

11 August 2017
Dil Sen
Clin Senior lecturer &Hon.Consultant in Occupational Medicine
Univ of Manchester
Centre for Occupational & Environmental Health, Univ of manchester
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67
Re: A new drug strategy for the UK Adam R Winstock, Niamh Eastwood, Alex Stevens. 358:doi 10.1136/bmj.j3643

We agree with Winstock A, Eastwood N and Stevens A about there being no real prospect of reducing harm, by the Government recently published 2017 Drug Strategy . We express great concern at the lack of focus on harm reduction - an evidence-based response that protects people and ultimately saves lives - at a time when drug-related deaths are the highest on record.
• Heroin and morphine deaths rose by 109 percent in the England and Wales between 2012 and 2016 , when the evidence is overwhelming that harm reduction initiatives can reduce them. Initiatives such as opioid substitution treatment (OST) and needle and syringe programmes are only mentioned fleetingly within the Strategy, and others such as drug consumption rooms and heroin assisted therapy (HAT) are completely absent.
• It is appalling that the Government acknowledges in the strategy that the rise in drug-related deaths is ‘dramatic and tragic’, but proposes no concrete action plan to reduce them. For example, the strategy comments on the importance of naloxone to prevent overdose deaths but proposes no national systematic approach to naloxone provision, nor any new funding for this vital intervention. It is shocking that whilst drug-related deaths have outstripped both road traffic fatalities and deaths from blood borne viruses , there is no coordinated response from central government.
• This erosion of services continues against a backdrop of funding for all drug services being continuously reduced. Public health spending has reduced by more than 5% since 2013 , and according to analysis a further £22 million in cuts are to made for drug treatment by the end of 2017/18 . Without funding drug services will not be able to function effectively.
• The Government has dismissed decriminalisation of drug possession offences as being simplistic. Yet the World Health Organisation and a multitude of United Nations agencies have called for the end of criminal sanctions for possession and use of drugs in recognition that criminalisation creates barriers to those needing treatment and increases health harms.
People who use drugs are often vulnerable and marginalised. This new Drug Strategy simply does not begin to support them and reduce drug-related deaths. We call on the Government to implement the recommendations of the Advisory Council on the Misuse of Drugs to tackle opiate related deaths, these include: optimal OST prescribing; easier access to naloxone; a national HAT programme; and that drug consumption rooms are implemented where there is need . The Government must also ensure a minimum level of care by requiring local authorities to provide drug treatment and harm reduction services by law.

A new drug strategy for the UK BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3643 (Published 03 August 2017)
Cite this as: BMJ 2017;358:j3643

HM Government ‘2017 Drug Strategy- July2017’. Accessed 10th August 2017. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...

Office for National Statistics (ONS), 2017. Accessed 10th August 2017. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri...

Department for Transport, ‘Annual Road Fatalities’. Accessed 10th August 2017. Available at: https://www.gov.uk/government/publications/annual-road-fatalities

Public Health England ‘HIV in the UK’, 2017. Accessed 10th August 2017. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...

Public Health England ‘HIV in the UK’, 2017. Accessed 10th August 2017. Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...

The King’s Fund, ‘Big cuts planned to public health budgets’. Accessed 10th August 2017. Available at: https://www.kingsfund.org.uk/press/press-releases/big-cuts-planned-publi...

The King’s Fund, ‘Chickens coming home to roost: local government public health budgets for 2017/18’. Accessed 10th August 2017. Available at: https://www.kingsfund.org.uk/blog/2017/07/local-government-public-health...

Advisory Council on the Misuse of Drugs (ACMD), ‘Reducing Opioid-Related Deaths in the UK’ (December 2016). Accessed 10th August 2017. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...

Competing interests: No competing interests

11 August 2017
Chris H Ford
Clinical Directo IDHDP
Professor David Nutt, Drug Science Niamh Eastwood, Release Deborah Gold, National AIDS Trust John Jolly, Blenheim CDP Fionnuala Murphy, Harm Reduction International Kate Halliday, SMMGP Jamie Bridge, International Drug Policy Consortium
13 Victoria Mews London NW6 6SY
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73
Re: Considering syphilis and HIV in differential diagnoses Meredith A Elangasinghe. 358:doi 10.1136/bmj.j3633

I read with interest Dr. Elangasinghe's letter promoting more widespread syphilis and HIV testing. NICE guidance changed in 2016 to include the recommendation that all patients admitted to hospital in an area of high HIV prevalence who are having blood tests for any reason should also be offered a HIV test (1). Although this practice has been adapted in many general hospitals, it appears not to have yet become common place in mental health.

Recent snapshot audits conducted by two of the authors (KD and GS) in two inpatient units in high prevalence areas in the South of England (Reading and Milton Keynes) confirm this, with no patients being tested within one week of admission to the unit at either site, and poor documentation of risk-factors for blood-borne virus infection. The epidemiology of HIV infection amongst mental health patients is complex, with rates differing depending on diagnosis and co-morbid substance use (2), but large observational studies consistently demonstrate an increased rate of HIV infection amongst mental health patients (3). The converse is also true: people infected with HIV have higher rates of mental illness than the general population (4). This implies that we should be no less pro-active in encouraging testing in this population than in the general hospital.

We conducted qualitative research during the course of this audit to identify barriers to HIV testing. Most notable was the finding that doctors were reluctant to offer testing because of concerns about capacity, consent and the requirement for pre-test counselling in our patient population. Specific concerns included: 1. The belief that written consent is required for a HIV test. This is not the case - verbal consent is sufficient (5). 2. The belief that extensive pre-test counselling is required. It is not - the crucial information that must be shared is (i) the benefits of being tested and (ii) how and when the patient will receive the results (5). 3. Some doctors were concerned about the assessment of capacity to consent to HIV testing. Capacity to consent to a HIV test is assessed in the same way as capacity to make any decision (5). At the Milton Keynes site, we aimed to correct these misconceptions and introduce opt-out HIV testing for all acute psychiatric admissions. Following the introduction of simple education measures (teaching junior doctors in a 15 minute session about opt-out testing including appropriate counselling, and the production of a FAQ document directed at doctors) the proportion of new admissions tested for HIV increased to 87.5%. This work demonstrates that improved HIV testing rates in an inpatient psychiatric setting are acceptable to doctors and patients and achievable with simple quality-improvement measures. We believe that basic physical health interventions like this are a key part of achieving “parity of esteem” for physical and mental health.

REFERENCES 1. https://www.nice.org.uk/guidance/ng60, “HIV testing: increasing uptake among people who may have undiagnosed HIV”, published Dec. 2016, accessed 24/07/2017. 2. “Understanding Associations Between Serious Mental Illness and HIV Among Patients in the VA Health System”, Himelhoch et al. Psychiatric Services, 2007. 3. “Review of the evidence: prevalence of medical conditions in the United States population with serious mental illness”, Janssen et al., General hospital psychiatry, 2015. 4. “Psychiatric Disorders and Drug Use Among Human Immunodeficiency Virus– Infected Adults in the United States”, Bing et al., Archives of General Psychiatry, 2001. 5. “UK National Guidelines for HIV Testing 2008”, British HIV Association, 2008. Accessed 24/07/2017

Competing interests: No competing interests

11 August 2017
Killian Donovan
FY2 Doctor
Gavinda Sangha, David Marchevsky, Clare Woodward
The Campbell Centre, Milton Keynes, MK6 5NG
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