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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: Prehabilitation: preparing patients for surgery Venetia Wynter-Blyth, Krishna Moorthy. 358:doi 10.1136/bmj.j3702

Dear Editor,

Thanks for this wonderful piece. When patients come for their final input before going in for surgery, a GP always does the good work of explaining the procedure and giving (most of the time false because you are not doing the surgery!) confidence. Probably we need to start doing prehabilitation. I particularly do for knee replacement surgeries, cardiac invasive procedures, etc, which has immensely helped patients. As most GPs are doing this already (worldwide), you have given an acceptance for this service. Thank you for recognizing an important issue in health care.

Competing interests: No competing interests

11 August 2017
Mohan Devegowda
GP
Mohans Clinic
Bengaluru 560038
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74
Re: Diagnosis and early management of inflammatory arthritis Joanna Ledingham, Neil Snowden, Zoe Ide. 358:doi 10.1136/bmj.j3248

We are grateful for the responses to our review, which raise a number of important issues. We would like to offer a brief clarification and explanation of some of the points raised.

The review was commissioned to support non-specialist clinicians, in particular general practitioners, in the diagnosis and early management of inflammatory arthritis. This is a vast topic and the article was restricted in length and therefore in the detail that could be included. All 3 authors, along with editors from the BMJ, were involved in selecting the aspects covered.

Timely referral is a key message In the UK primary care has a “gatekeeper” function in onward referral to specialist rheumatology services. The National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis in England and Wales showed that the median time from first presentation in primary care to referral to rheumatology is 34 days, and more than 25% of people with arthritis wait more than 3 months. This is too long, and we would argue that earlier recognition of even the more stereotypical clinical features outlined in our review has considerable potential to reduce delays in referral. We avoided any specific definition of persistence as we felt that severity and progression of symptoms should be the main drivers for referral.

We recognise and tried to highlight the varied ways in which inflammatory arthritis can present (including with non-musculoskeletal symptoms such as fatigue and with little obvious joint swelling). Our patient authors history was included to reflect a non-stereotypical presentation that we hope highlights the challenge of diagnosing inflammatory arthritis in primary care, where symptoms of musculoskeletal pain and fatigue account for around 25% of patient visits, and where access to diagnostic tests may be limited (most UK general practices do not have rapid access to musculoskeletal ultrasound or anti-CCP antibodies).
Because of the focus on early diagnosis and treatment issues relevant to primary care, we only had the opportunity to touch briefly upon important aspects of chronic disease management such as psychological support, signposting to patient organisations and the vital role of the multi-disciplinary team but were keen to highlight these crucial aspects of support at an early stage. We did not discuss the role of biologics as, in the UK, early use is not supported by NICE. However, we agree that these are central to the management of many people with inflammatory arthritis. We also fully support active involvement of patients in dealing with their arthritis, making full use of shared decision making and supported self-management.

We also acknowledge the challenges of living with a diagnosis of inflammatory arthritis, that help is required for patients to help them manage all aspects of their disease, that achieving ‘remission’ with treatment and tolerating DMARDS is difficult for many patients. Nevertheless, outcomes from inflammatory arthritis have improved considerably in recent years, and while there is still a long way to go before we can talk about “cure”, the outcomes are likely to be better if people are seen promptly and given the chance of early, intensive treatment; the rationale for this article. Latest National Audit data show that just under 40% of people are seen in rheumatology within 3 weeks of referral - we would also like to see this improve (a detailed breakdown of local waiting times can be found in the National Audit reports)

In response to specific questions with regard to treatment:

1) Evidence about stopping DMARDs during infection is limited, and there is probably no need to stop during minor infections, such as URTIs and uncomplicated UTIs. It does, however, seem a sensible precaution to stop immunosuppressive DMARDs in people who are systemically unwell.

2) Both the US CDC https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm and the Public Health England Green Book https://www.gov.uk/government/publications/shingles-herpes-zoster-the-gr... consider that the live shingles vaccine can be given safely in most people taking rheumatological DMARDs. In the UK, we would only consider the vaccine in the limited age group defined by the Green Book. The Green Book advice has changed slightly in recent years, and factors such as steroid exposure need to be considered, so our advice about discussion is to ensure that the most up to date advice is followed.

References in main article

Competing interests: No competing interests

11 August 2017
Zoe Ide
Patient
Neil Snowden, Joanna Ledingham
National Rheumatoid Arthritis Society
Maidenhead, UK
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Re: Margaret McCartney: Alarm overload makes a difficult job harder Margaret McCartney. 358:doi 10.1136/bmj.j3593

Not everyone with deranged physiological parameters is septic, or ‘triggers sepsis' in the sloppy shorthand we all end up using.

On the way to the Emergency Department, ambulance crews make life-changing diagnoses based on nothing more than the observation of a few basic measurements, and forward these gems of wisdom so we can be ready with suitable treatment (there’s a pneumonic - BUFALO - because we are all stupid).

There are causes of illness though, other than infective agents. Toxins, for example. There’s no antibiotic for poisoning, yet. There are however other treatments that can be life saving, brain preserving, but which won’t get a look in on a patient who’s been diagnosed as ‘septic.’

When you’ve got a new hammer, everything looks like a nail.

Focused, relevant history, and brief examination precede testing and measuring. It’s always been like that for a reason.

Competing interests: No competing interests

11 August 2017
Ed Walker
Senior A&E doc
Halifax, West Yorks
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Re: Global climate is warming rapidly, US draft report warns Michael McCarthy. 358:doi 10.1136/bmj.j3824


The climatologists and epidemiologists at the Henny Penny Institute of Pseudo-Science and Scare-Care have inadvertently performed a public service. Climate-gate, flu-gate, ebola-gate, and zika-gate have immunized the public against media-spread alarmism, opportunism, euphemisms, and pseudo-schisms.

Competing interests: No competing interests

11 August 2017
Hugh Mann
Physician
Retired
New York, NY, USA
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Re: UK doctors re-examine case for mandatory vaccination Tom Moberly. 358:doi 10.1136/bmj.j3414

Wendy E Stephen raises some interesting issues [1]. Whether it was ever the intention of the Department of Works and Pensions (as it now is) to honour the terms of the 1979 Act, it should be pointed out that at the time - and for a further nine years - it was incorporated with the Department of Health as the Department of Health and Social Security. And even this year they were trying to deny payments on the basis of a frivolous reading of the Act. Obviously there are two issues here: one is averting cost - and I understand that the DWP has to go cap in hand to the Treasury for every individual payment - and the other is protecting the reputation of the programme by making as few payments as possible.

There is simply no basis for trusting governments about vaccines. This is not a good position - particularly considering the vastly expanded schedule of the last 38 years - from which to impose compulsion. The shoddiness of this history - and the lack of transparency - speak for themselves. Let us have some daylight even before anyone begins considering making changes.

[1] Wendy E Stephen, Rapid Responses for Moberly, 'UK doctors re-examine case for mandatory vaccination', http://www.bmj.com/content/358/bmj.j3414/rapid-responses

Competing interests: No competing interests

10 August 2017
John Stone
UK Editor
AgeofAutism.com
London N22
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Re: Yoga is reasonable alternative to physical therapy for lower back pain, say researchers Jacqui Wise. 357:doi 10.1136/bmj.j2964

“The purpose of achieving equanimity through yoga is to diminish suffering” The Yoga Sutras of Patanjali, Aphorism 2, Chapter 2

Chronic back pain is increasingly becoming common especially in younger people and hence an important public health concern. The causes appear to be multi-factorial and observed to be related increasingly to work-related demands, lifestyle, posture, diet, etc. all contributing to chronic physical and psychological stress.

In a country like India which is witnessing rapid urbanization creating a highly competitive, fast-paced and demanding external environment, the youth seem to find themselves helplessly being driven to make maladaptive and irrational choices. This is only maintaining and perpetuating chronic stress related health conditions of which chronic musculo-skeletal pain disorders are increasing. This is an unfortunate trend. With particular reference to chronic pain, there are certain factors that are a pain in the neck uniquely to today’s urban youngster of India and I am sure in several other countries too.

The young Indian lives an artful life having to dodge and dive from commuting to work to managing life on shaky infrastructures full of dangerous defects put to reckless public usage by the many, disorganized mass movements in cities with even more disorganized planning and management and callous unconcern by the high and mighty. As someone wisely said in this rat race, even if you win you are still a rat! Articles like this seem to reassure us there is indeed some light at the end of the rat hole!

It is indeed heartening to read positive original research on yoga in high impact journals like the Annals of Internal Medicine and the BMJ. I am indeed grateful for this. This does have an impact on the modern youth of India who increasingly look to the West for trustworthy health information.

Yoga as a holistic preventive and curative health system is increasingly being reaffirmed and revalidated through several good scientific studies especially coming out of prestigious academic centers in the West. Several of these studies however seem to focus more on the physical aspect of yoga – the asanas or postural exercises and pranayama or breathing techniques. Some recent studies do highlight dhyana or meditation techniques.

Whereas the classical yoga of Patanjali (circa 1500 bce) has eight parts: yama or ethical observances, niyama or hygienic disciplines, asana or adaptability training, pranayama or breath regulation training, pratyahara or sensory-perceptual regulation training, dharana or focused attention training, dhyana or meditation training and samadhi or balanced mind-body state of equanimity. The classical yoga originating from the culture and civilization of the Indian sub-continent several thousand years ago developed as a holistic empowering system of wise living leading to freedom from suffering. The system was practiced widely by all strata of society. But for various reasons the practice became less prevalent over the ages.

All this appears to be changing with a revival of the classical yoga albeit through the physical aspect. With the support of the modern evidence-based medical research showing increasing interest and validating many of the ancient Eastern wisdom practices there seems to be a change in the mind-set from material reductionism to an open and integrative holism. This renaissance is a welcome trend and promises to be a great preventive and public health revolution in the making if the essence of the ancient classical yoga practice is understood and wisely adopted by the many. A heartfelt thank you indeed.

“Know well what leads you forward and what holds you back, and choose the path that leads to wisdom” – the Buddha

References

Büssing, A., Michalsen, A., Khalsa, S. B. S., Telles, S., & Sherman, K. J. (2012). Effects of yoga on mental and physical health: a short summary of reviews. Evidence-Based Complementary and Alternative Medicine, 2012.

Lipton, L. (2008). Using yoga to treat disease: An evidence‐based review. Journal of the American Academy of Physician Assistants, 21(2), 34-41.

Whicher, I. (1998). Yoga and freedom: a reconsideration of Patañjali's classical yoga. Philosophy East and West, 272-322.

Competing interests: No competing interests

10 August 2017
Anand Ramanujapuram
Neuropsychiatrist
Independent Practitioner
Malleswaram, Bengaluru, India
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Re: Loss of fingerprints secondary to palmoplantar erythrodysesthesia in a patient on capecitabine chemotherapy Sara Lightowlers, Rubin Soomal. 351:doi 10.1136/bmj.h6023

We read with great interest the article “Loss of fingerprints secondary to palmoplantar erythrodysaesthesia in a patient on capecitabine chemotherapy” by Lightowlers et al. 1 We would like to congratulate the authors on this publication and thank them for posing a relevant question. The article noted that loss of fingerprints due to palmoplantar erythrodysaesthesia (PPE) will affect daily life, especially on occasions that involve fingerprint recognition. Thus, patients at risk for PPE should be notified of the possibility of fingerprint loss. However, it is worrying that in reality, this issue is often neglected as we perform our duties.

Fingerprints are becoming increasingly important in many aspects of public life. Law enforcement officers utilize fingerprints for identity verification and for processing passport and ID card applications; fingerprint recognition is also required to log in to laptops and smart phones and to access safety deposit boxes. In an article published in N Engl J Med in 2015, Yanin et al2 reported a case in which after receiving 3 months of capecitabine and bevacizumab treatment, a stage IV breast cancer patient was refused a wire transfer by a bank due to having unrecognizable fingerprints during the identity verification process. This patient exhibited grade 1 hand-foot syndrome (HFS) during the first cycle of chemotherapy, which worsened during the third cycle of chemotherapy. A PET-CT scan indicated a 50% reduction in lung metastatic activity. After capecitabine treatment was delayed and the patient’s dosage was decreased, no further acute toxicity was observed. However, the patient’s fingerprints faded. The authors stated that the skin reaction associated with HFS may lead to swelling and blisters, which occur in approximately 60% of patients. This adverse reaction is the main cause of fingerprint loss.

A prospective study conducted at the Erasmus Medical Center Cancer Institute3 was published in JAMA Oncology. This investigation demonstrated that capecitabine- and tyrosine kinase inhibitor (TKI)-induced fingerprint loss may not be associated with adverse skin reactions of HFS. This study continued for 7 months and involved the collection of complete fingerprint information from 112 patients; 66 of these patients received capecitabine treatment, and the remaining 46 patients received TKI treatment. Fingerprints were collected from patients before treatment, 6 to 10 weeks after the start of treatment, and after treatment. Changes in fingerprints were accurately captured using a standard fingerprint analysis system. The degree of change in fingerprints was scored from 1-5 points to denote changes from light to severe. The researchers defined 4-5 points as “fingerprint loss” and 1-3 points as “no change in fingerprints”. Additionally, the severity of HFS and hand-foot skin reaction (HFSR) were scored using US National Cancer Institute (NCI) standards. After 8 weeks, fingerprint loss was observed in 9 cases (14%) in the capecitabine group and 1 case (2%) in the TKI group, whereas severe HFS and HFSR were detected in 46 cases (70%) in the capecitabine group and 21 cases (46%) in the TKI group. HFS and HFSR scores did not correspond with fingerprint loss scores; certain patients experienced severe HFS but no changes in fingerprints and vice versa. Thus, it is speculated that fingerprint loss may be a secondary reaction independent of HFS and HFSR. However, there is currently no explanation of the mechanism underlying the occurrence of this type of secondary reaction. Follow-up studies indicated that in the examined context, fingerprint loss was temporary, with fingerprints gradually returning to normal 2-4 weeks following the discontinuation of chemotherapy. The researchers cautioned that although fingerprint loss is regarded as a low-risk side effect, to avoid affecting patients’ daily lives, physicians should notify their patients of this risk prior to chemotherapy!

In the treatment of advanced breast cancer, Jiang and other Chinese experts have proposed the concept of “whole-course management”. This concept is a proposed treatment model based on the characteristics of advanced breast cancer, such as “chronic disease” and “maintenance treatment”. After 6-8 cycles of effective first-line chemotherapy, effective maintenance treatment is administered to delay recurrence; this approach replaces the original treatment model of “cease chemotherapy and await recurrence”. This concept uses the “slow and steady” treatment strategy to achieve the goal of extending survival. Breast cancer treatment is a long-term process in which patient compliance is extremely important. In cases of advanced breast cancer, capecitabine monotherapy has better efficacy than gemcitabine monotherapy or vinorelbine monotherapy. Capecitabine exhibits low haematologic toxicity and cardiotoxicity, is administered orally, is suitable for long-term use, and is the maintenance therapy medication recommended by the Committee of Breast Cancer Society of the Chinese Anti-Cancer Association. 4 Stockler also confirmed that capecitabine monotherapy has high accuracy and safety; thus, capecitabine combination therapy followed by capecitabine maintenance monotherapy (X-based X) is a reasonable choice for the whole-course management treatment model.5 This model includes endocrine therapy and maintenance treatment after effective targeted drug therapy. Capecitabine is a significant chemotherapeutic agent, and its prominence increased after the concept of whole-course management was proposed. In accordance with physicians’ recommendations, the number of capecitabine users and the duration of capecitabine treatment have both increased significantly over time. Do we need to be concerned about fingerprint loss caused by the use of capecitabine? Moreover, advanced-stage patients may require fingerprints for the management of financial affairs. Although the probability of fingerprint loss is low in clinical settings, we often neglect this secondary reaction when obtaining a signature for consent to chemotherapy. However, after it has developed, this reaction could tremendously inconvenience patients in their daily lives. Thus, we believe that irrespective of whether fingerprint loss is associated with HFS, when explaining potential secondary reactions, we should inform patients that fingerprint loss is an independent secondary reaction. In addition, we should urge patients to have their fingerprints collected before the commencement of chemotherapy. In cases involving fingerprint loss, physicians are obliged to provide relevant evidence to relieve their patients’ plight.

1. Lightowlers S, Soomal R, et al. Loss of fingerprints secondary to palmoplantar erythrodysesthesia in a patient on capecitabine chemotherapy. BMJ 2015;351:h6023. doi: https://doi.org/10.1136/bmj.h6023
2. Chavarri-Guerra Y, Soto-Perez-de-Celis E. Images in clinical medicine. Loss of fingerprints. N Engl J Med 2015;372:e22. doi: 10.1056/NEJMicm1409635.
3. Van Doorn L, Veelenturf S, Binkhorst L, Bins S, Mathijssen R. Capecitabine and the Risk of Fingerprint Loss. JAMA Oncol 2017;3:122-123. doi: 10.1001/jamaoncol.2016.2638.
4. Oostendorp LJ, Stalmeier PF, Donders AR, van der Graaf WT, Ottevanger PB. Efficacy and safety of palliative chemotherapy for patients with advanced breast cancer pretreated with anthracyclines and taxanes: a systematic review. Lancet Oncol 2011;12:1053-61. doi: 10.1016/S1470-2045(11)70045-6.
5. Stockler MR, Harvey VJ, Francis PA, Byrne MJ, Ackland SP, Fitzharris B, Van Hazel G, Wilcken NR, Grimison PS, Nowak AK, Gainford MC, Fong A, Paksec L, Sourjina T, Zannino D, Gebski V, Simes RJ, Forbes JF, Coates AS. Capecitabine versus classical cyclophosphamide, methotrexate, and fluorouracil as first-line chemotherapy for advanced breast cancer. J Clin Oncol 2011;29:4498-504. doi: 10.1200/JCO.2010.33.9101

Competing interests: No competing interests

10 August 2017
Bin Zhang
doctor
Xia Zhang, Yajie Gao,Jilai Bian, Jinming Yu
Department of Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China.
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Re: Consultant triage cuts emergency admissions by a third, report finds Sophie Arie. 358:doi 10.1136/bmj.j3701

The above article throws light on the busiest area of the hospital and the cut down in the duration of hospital stay in emergency services. Although the above study results are from the perspective of surgical emergency admissions, the same also happens with medical emergencies. In a large tertiary care hospital in a northern part of India, a resident doctor does the triage and manages the case overnight and the consultant sees the case next morning and decides regarding the further stay of the patient in the emergency department. A consultant managing the triage area would definitely cut down the duration of hospital stay even in medical emergencies. A study of this kind in the medical emergency department would definitely help in decreasing the morbidity of patients in a resource constrained country like ours.

Competing interests: No competing interests

10 August 2017
mohan kumar h
Senior Resident
ashok kumar pannu
Department of Internal Medicine, Post Graduate Institute of Medical Education and Research
sector 12, chandigarh
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Re: Wanted: clinicians with digital and leadership skills Fiona Godlee. 358:doi 10.1136/bmj.j3382

Perhaps one of the problems in the healthcare system is managerial training. With the passage of time, we have included in the course’s programs leadership and social skills, much needed training if we consider the impact of the leader's attitudes on the health outcomes of the organization. But we need another leap in the courses: that of information management. We need clinical managers with basic knowledge of programming and databases who understand the structure of health care information of a hospital or a health system.

In addition, it would be very interesting that training for managers include other much needed fields: data visualization, ethical and social marketing, collective intelligence and web 2.0, knowledge management and risk and crisis management. In this way, the system would have managers much more prepared for the challenges of this century.

Competing interests: No competing interests

10 August 2017
Miguel Angel Mañez Ortiz
Human Resources Department
Madrid Regional Government Health Service
Madrid (Spain)
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

I did not see specific patient age statistics vs physician age groupings. Wouldn't older patients, whose risk of dying soon was higher, want to see their own older doctors? Lots of uncontrolled variables in this study... I also agree with one of the other comments that a patient who knew the end of their life was near would seek care from an older physician that would tend to be more empathetic with a patient of their own age.

Competing interests: No competing interests

10 August 2017
Scott J. Andrea
retired
Pasadena, TX 77505
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