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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on 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: Local, local, local: the regeneration project that puts the community in charge of its health Anne Gulland. 359:doi 10.1136/bmj.j4594

What a great article. There are a number of issues I think it is worth pointing out. In these comments I am in no way belittling the great work described in the excellent short article. I've not a doubt it is transformative stuff.

Firstly it's worth pointing out that the concept of community development, or one of the many phrases used to describe the same set of stuff, has been around for a century or so. Many stakeholders, from a very wide variety of backgrounds, have been funding and / or delivering this type of work for many decades before Bromley By Bow and similar.

Similarly with regard to social prescribing. It's a concept not without its ideological problems, but again Lord Mawson is not a pioneer here, nor is it a new concept. With regard to health champions and health trainers, Sheffield has been in this space for a decade or so. It has been championed and delivered by many diverse organisations for a long time now.

Finally, what was more than a little irritating was the opening sentence. Assuming the quote about "liberal Guardian readers writing reports rather than getting things done" - is a direct quote, it is demeaning, factually inaccurate, and insulting to those who have been working in this space for decades.

Competing interests: No competing interests

16 October 2017
Greg Fell
Director of Public Health
Town Hall, Pinstone St, Sheffield,
Re: Mental health services for children fail to meet soaring demand Bernadka Dubicka, Tori Bullock. 358:doi 10.1136/bmj.j4254

I agree with the poignant and well-written editorial by Dr Dubicka regarding failing mental health services (14 October). I have often pondered the interface between where welfare services leave off and the NHS pick up. Queen's University Belfast have just completed new research describing a 'postcode lottery' across the UK, where 'looked-after' and 'protected' children are distributed broadly across a clear social gradient.

I would like to know whether the author thinks that with ongoing cuts to our social, welfare and schooling system, managing vulnerable children through CAMHS services will do much more than try to 'plug the gap' when we are failing children at a much more primitive step. Tees, Esk and Wear Foundation Trust are currently investing heavily in primary health interventions, predicting fewer inpatient admissions and tackling psychiatric illnesses in their preliminary stages. With that in mind, does the author think greater collaboration between social services and CAMHS teams to create an overall more comprehensive and supportive system could be the way forward? Perhaps the way to improve the pitiful 35% treatment target would be to decrease the number of children coming through the door?

Competing interests: No competing interests

16 October 2017
Ellisiv B Clarke
Medical student
Newcastle Medical School
Framlington Place, NE2
Re: There’s no such thing as an unnecessary referral Andrew N Bamji. 359:doi 10.1136/bmj.j4606

Many thanks to Dr Bamji for his wonderful letter. As a Gp and GPwSI, I regularly see both sides of the referral equation. I would be amazed to discover that there were sufficient "incompetent" GPs making "unnecessary referrals" to recoup the finances that NHSE are hoping for (and unfortunately offsetting by paying for referrals to be reviewed). I would be equally amazed to discover multitudes of "incompetent" clinicians in hospitals deliberately discharging patients unsafely and prematurely or indeed delaying their discharge and exposing them to the consequent risks of prolonged stays in hospital.

Perhaps NHSE would save more money by reviewing hospital discharges in a similar fashion? NHSE's approach is demeaning to GPs. If they want GPs to receive more education then most of us would welcome this. However, the way things are now in General Practice makes this difficult to achieve unless NHSE reduces the pressures on us. My hospital colleagues are just as frustrated as my GP colleagues and I don't often hear them complaining about "unnecessary referrals". NHSE please come sit in my surgery and see if you could do better! Or like me, do you not have sufficient time or resources to do so?

Competing interests: No competing interests

16 October 2017
Nicola S. Wright
GP and GPwSI Rheumatology
Re: Are radical changes to health and social care paving the way for fewer services and new user charges? Shailen Sutaria, Peter Roderick, Allyson M Pollock. 358:doi 10.1136/bmj.j4279

Whilst Pollock and colleagues provide a detailed account of the way in which health and social care expenditure by local authorities has been cut over the years, with huge detriment to those who depend on them, they significantly fail to make the case that sustainability and transformation partnerships will of themselves lead to further cuts in services. It is therefore misleading for you to write in your ‘Editor’s choice’ that ‘Rather than being about integration of health and social care, they (and the linked devolution of services to local authorities) are about reducing services and entitlements, increasing private provision of publicly funded services, and, potentially, introducing charges.’

The bulk of the article tells the sorry story of cuts to local authority funding and services. It is only in the penultimate paragraph that a link is made between that and what may happen with the development of STPs. The authors’ argument amounts simply to the fact that they ‘expect the distinction between them (health and social care services) to blur over time and some health services to fall out of commissioning, and out of NHS funding altogether.’

Most commentators, including the BMJ itself, have over the years called for greater integration of health and social care, so for Pollock and colleagues to decry that puts them very much at variance with most informed views. Their expectation that this will lead to services falling out of NHS funding stems, I suggest, less from rational argument and more from a prior prejudice against any health service re-organisation.
A more plausible analysis sees STPs not as a means to deliver cuts to services, but rather as a sensible way to cope with the significant further shortfall in financing of the NHS that has to be faced. The primary purpose of STPs is to promote collaboration between health care organisations, effectively eliminating the purchaser-provider split and internal market and all its associated costs, and make the most of what we can all agree is an inadequate budget overall. It is likely that without STPs the cuts to health services would be significantly greater than if they are successful.

The introduction of STPs can be seen as reversing as much of the 2012 Health and Social Care Act as is possible without primary legislation. They should surely be welcomed by all of us who argued against that misguided legislation. I am not clear whether the article and your ‘Editors Choice’, arise from misinformation, misunderstanding, or simply the desire to make mischief! How otherwise do Pollock and colleagues propose that £26bn of reduction in health care costs should be found?

Competing interests: I am a non-executive director at Chesterfield Royal Hospital, Consultant Clinical Adviser for NICE, and trustee for the Sheffield Hospitals Charity and Medact. Formerly I was Director of Public Health in Sheffield.

16 October 2017
Jeremy P Wight
Public Health Physician
Hope Valley
Re: Sperm counts, testicular cancers, and the environment Niels E Skakkebaek. 359:doi 10.1136/bmj.j4517

It is welcome that Professor Skakkebaek highlights the increasing trend in impairments of the male reproductive system.1 But there are serious errors in his account in relation to the cause(s). He focuses on endocrine disrupting chemicals (EDCs) as the likely culprit. But it is one thing to say that endocrine disrupting chemicals can affect reproduction, which may be true. It is quite another to suggest that they explain the epidemiological findings of observed deterioration. For example, inorganic arsenic is a cause of lung cancer, but nobody suggests that it was behind the lung cancer epidemic of the 20th century – this was due to cigarette smoking.

EDCs are clearly not responsible for the epidemic of the most serious of the conditions, testicular cancer. Its rapid rise started not in “the past few decades”, “recent decades”, or “a couple of generations” ago. It began in the first decade of the twentieth century in north-western Europe,2 and probably earlier in England and Wales.3 This is decades before the introduction of any known endocrine disruptor: widespread exposure started only in the 1950s.

Semen quality impairment is also not mainly due to endocrine disruption: the characteristic type of human male infertility is oligoasthenoteratospermia (OAT) – sperm are too few, motility is low, and abnormal morphology is widespread. In the good-quality studies of semen quality trends, when a decline in sperm concentration and number has been observed, motility and morphology have also deteriorated.4-6 Endocrine disruption, even if it reduces sperm concentration/number, has no plausible effect on motility or morphology.

There are several other grounds to doubt the magnitude of the impact of EDCs on male reproduction.7 These include the actual exposures relative to the toxic levels, and the expected spectrum of effects in contrast to what is observed. 7

The rapid trends, especially in testicular cancer, strongly suggest an environmental cause, as Skakkebaek says. But this does not rule out “alterations in our genome” – “genetic” is here conflated with “inherited”. The genome of germ cells can be damaged by environmental exposures, just as with mutations in somatic tissues. The evidence, experimental and clinical as well as epidemiological (including genetic studies), suggests environmentally caused damage to the genetic apparatus of the germ cells, that can be passed down through the male line.8,9 This fits with the well-established, but frequently disregarded, fact that humans have poorer semen quality, a lower conception probability, an increased aneuploidy risk (e.g. Down syndrome), and a higher risk of embryonic loss (early miscarriage) compared with other mammals; germ-cell testicular cancer is rare in non-human mammals too.9

The endocrine disruption hypothesis has dominated research in this area for 25 years now, despite its clear shortcomings. Yet Skakkebaek claims “little has been done”. I agree with him about the need for more research into reproductive health, but a far broader remit is required.

When miscarriages of justice occur, one tragedy is that innocent people are incarcerated. A second is that the perpetrators go free. By focusing on endocrine disruption, we are failing to discover the true cause(s) of the dramatic deterioration in the health of the male reproductive system in the past 110 years.

Yours sincerely

Michael Joffe


1. Skakkebaek NE. Sperm counts, testicular cancers, and the environment. BMJ 2017;359:j4517 doi: 10.1136/bmj.j4517
2. Bergström R, Adami H-O, Möhner M, et al. Increase in testicular cancer incidence in six European countries: a birth cohort phenomenon. J Natl Cancer Inst 1996;88:727-33.
3. Davies JM. Testicular cancer in England and Wales: some epidemiological aspects. Lancet, 1981;I,928-32.
4. Auger J, Kunstmann JM, Czyglik F, Jouannet P, et al. Decline in semen quality among fertile men in Paris during the past 20 years. N Engl J Med 1995;332:281-85.
5. Van Waeleghem K, De Clercq N, Vermeulen L, Schoojans F, Comhaire F. Deterioration of sperm quality in young healthy Belgian men. Hum Reprod 1996;11:325-29.
6. Irvine S, Cawood E, Richardson D, MacDonald E, Aitken J. Evidence of deteriorating semen quality in the United Kingdom: birth cohort study in 577 men in Scotland over 11 years. BMJ 1996;312:467-71.
7. Joffe M. What harms the developing male reproductive system? In Male-mediated developmental toxicity, ed. Anderson D, Brinkworth MH, 2007, Royal Society of Chemistry, chapter 4, 28-50.
8. Joffe M. Genetic damage and male reproduction, In: Reproduction and Adaptation [AS Parkes Memorial volume], ed. Mascie-Taylor CGN, Rosetta L, 2011, Cambridge University Press, Cambridge, 17-49.
9. Joffe M. What is wrong with the human reproductive system? J Genit Syst Disor 2016;S2.

Competing interests: I am the originator of a rival hypothesis concerning human reproductive and genetic impairment in both sexes, which is based on the synthesis of evidence from diverse sub-disciplines.

15 October 2017
Michael Joffe
Emeritus Reader
Imperial College London
Department of Epidemiology & Biostatistics, St Mary's Campus, Norfolk Place, London W2 1PG
Re: Is herd thinking in medical training leading us astray? Jonathan Glass. 358:doi 10.1136/bmj.j4297

Dr. Glass is to be congratulated for courageously raising the problems in current medical training.[1] I would like to answer his call for an open discussion. I sympathise with the dissatisfying comments made by his colleagues regarding their trainees. But I question how many of his colleagues did anything to change the ways the juniors are trained. For instance, did these surgical consultants give their foundation year doctors and medical students enough hands-on experience and one-to-one teaching on suturing patients? Many medical students and foundation year doctors are keen to practice advanced clinical skills, such as suturing and intubation. Very often, they are declined being given these opportunities, and receive comments such as “you are just a med student / FY1.” Eventually, their enthusiasm is worn down, and their focus becomes achieving the minimum competence in their portfolios and top decile in their medical school and royal college exams. It is unrealistically expected that these juniors will magically pick up their skills when they reach the senior levels.

I agree with Dr. Goh’s comment that many trainers have a mentality of "I have done my bit and it is someone else's fault" whenever things goes wrong.[2] It is ironic that NHS doctors, who are paid to be in a teaching hospital, do not think it is their responsibility to improve the training of their juniors. Rather, they complain how the juniors were not well trained prior to starting in their units. I have seen medical students being refused to join ward rounds because the seniors think students can slow down the workflow. I have also seen foundation year doctors being refused to join ward rounds because the seniors want them to just do the IV cannulas and discharge letters. Similarly, some NHS service users have the same mentality, in which they refuse to let medical students practise taking a history, and expect to be directly managed by consultants.

Dr. Glass has also called for an open discussion in medical and surgical forums. These forums do exist in hospital and at regional levels, in which many trainees have raised their concerns. But what do people do with the concerns raised? Quite often, near the end of their placements, the trainees are still complaining about the same things because no changes have been made. Then, another group of trainees rotate to the placement, and raise the same issues again. The conclusion in these forums could be “that is just how much resource we have” and “it is your responsibility to deal with it.” Eventually, these forums become checkbox exercises to show that the workplaces have addressed trainees’ concerns on a regular basis.

An open discussion is not enough to improve medical training. What we also need to change are the attitude and mentality of the stakeholders of medical training.

1. Glass J. Is herd thinking in medical training leading us astray? BMJ. 2017;358:j4297.
2. It is easy to dodge our responsibilities, but we cannot dodge the consequences of dodging our responsibilities. London: British Medical Journal; 2017 Sep 28; cited [Oct 15 2017]. Available from:

Competing interests: No competing interests

15 October 2017
Eugene Y.H. Yeung
Royal Lancaster Infirmary
Ashton Road, Lancaster, LA1 4RP, UK
Re: Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study Allan S Detsky, Raj Satkunasivam, et al. 359:doi 10.1136/bmj.j4366

Dear Editor,

I read with great interest the paper by Wallis et al. titled “Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study” (1). Indeed, this large, population based, matched cohort study showed that female surgeons consistently performed superior to their male counterparts except in the specialty of Otolaryngology (non-significant difference) and also being in practice for more than 15 years (1.06 [1.00-1.13]). The latter was surprising, as female surgeons with less experience of 10.1-15 years in practice had significantly less adverse postoperative outcomes compared to male surgeons. What is the possible explanation for this significant change? In addition, one would expect that there should be general similarities in the outcome trends related to “Surgeon age” and “Years in practice”, but the results seem to be conflicting (i.e. male surgeons in practice for more than 15 years had less adverse outcomes but female surgeons at all age ranges were superior [or equal] to their matched male counterparts in terms of postoperative outcomes). Further clarification on this matter by the authors would make the paper much more informative.

1 - Wallis, C.J., Ravi, B., Coburn, N., Nam, R.K., Detsky, A.S. and Satkunasivam, R., 2017. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. BMJ, 359, p.j4366.

Competing interests: No competing interests

15 October 2017
Honorary Clinical Senior Lecturer
National Heart and Lung Institute | Imperial College London
Respiratory Epidemiology, Occupational Medicine and Public Health, Emmanuel Kaye Building, 1b Manresa Road, London SW3 6LR
Re: Simon Wessely: “Every time we have a mental health awareness week my spirits sink” Sophie Arie. 358:doi 10.1136/bmj.j4305

I thank everyone who has taken the trouble to reply to the points raised in Sophie Arie’s interview with me (BMJ 2017: 358: j4305). This was an “exit interview” on the occasion of my stepping down as President of the Royal College of Psychiatrists, and covered a wide range of topics. Most attention has naturally focussed on the more eye catching content – that is the nature of good journalism. It is clear also not just from rapid responses, but elsewhere, that there are a wide variety of responses, both pro and anti. However, I think that the differences are more than outweighed by points of agreement, and that actually what we are talking about is more about the question of priorities and emphasis than fundamental disagreements.
As ever in our business, words and definitions so often lead to misunderstanding and misinterpretation. Are we talking mental illness, mental disorder, mental health or mental well being? Are these different - surely they must be. But they are so often used interchangeably – often to avoid the stigma that still accompanied mental illness/disorder. Whilst that is understandable, it is not always helpful.
So let me start with mental disorder. The most recent iteration of the Adult Psychiatric Morbidity Survey ( ) , the gold standard when it comes to knowing what is happening in population terms, now reports that most people who fulfil criteria for mental disorders are aware that they have a mental health problem. If true, this represents progress, but also is I think occasion to reflect. If that is so, then raising awareness in the admittedly narrow sense that I was using the term, may no longer be the most pressing priority. As Isabella Goldie correctly observes, most people still don’t seek help for the commonest mental health disorders. But I suggest that this is no longer due to lack of awareness in its simplest sense, but issues such as shame, guilt, stigma, beliefs about untreatability, lack of access to acceptable services and so on, may now be playing a major role. I agree with Isabella Goldie that “raising awareness of any health issue is the crucial first step towards ensuring that people take action to improve their health”, but if we are getting close to achieving that goal, then it is time to think about the second and third steps. Randomised controlled trials of mental health screening, such as the one we have just concluded with the UK Armed Forces, did not fail because of lack of awareness, but for many other reasons 1
I accept the point made by several commentators that increasing awareness campaigns are also about reducing stigma. The problem may be as Dr Martino wryly observes, “awareness” has become something of a “bingo term” these days. Certainly in my interview, research and in much of my writings as President, stigma and the need to reduce it raises its ugly head on a regular basis. Recent research such as Time to Change and our own in the Armed Forces is starting to show small, but hence believable, reductions, but there is a long way to go. And if “raising awareness” is a short hand for “raising awareness and reducing stigma”, then all well and good.
My second point is simple, and I doubt many would disagree.. If we encourage more people to seek professional help, either by raising awareness or decreasing stigma, this has to accompanied by increasing resource. In the context of mental disorder that largely means more staff, since in 90% of our work no longer takes place in expensive hospitals, we have very little reliance on costly kit, and the drugs that we use when we have to are very cheap compared to other areas. Although there have been some welcome investments (lAPTS, liaison and perinatal come to mind) I am afraid that this is a case of the facts speaking for themselves. Services are increasingly over stretched, investment has yet to reach where it is most needed, patients with the severest illnesses continue to be bussed around the country, and so on. And we are indeed seeing increased sick absence, early retirement, burnout etc, just as we are in general practice. Indeed, when Emma Richardson talks about the rising level of sick leave amongst NHS staff, and the problems of falling recruitment across the board in those who work in mental health, I think this is supporting my case. Improving recruitment was one of the main objectives of my three years as President, and ways to achieve this was probably the longest part of my conservation with Sophie Arie.
But note that I am being very specific when I say “encouraging people to seek professional health”, whether it by from psychiatrists (my obsession for the last three years), psychologists, social workers, nurses and so on. And that seems to be right when the goal is to able to deliver interventions and treatments of proven benefit for those with defined mental health disorders. But of course, that is not the goal for most of the population most of the time, Just as services get overstretched by increased demand, we also need to make sure that we do not over stretch ourselves by either extending the boundaries of mental disorder into the realm of normal emotional reactions and/or variations in personality. In the world of psychological trauma we know that there is a long historical tradition that shows that people are more resilient than professionals, politicians and planners give them credit for 2. We also know that if people like me get involved too early in the aftermath of trauma (by which I mean hours and days), we can actually make things worse. Instead the best resource remains a person’s own social network – their family, friends and colleagues, and it is something of a relief to have shown that this is exactly who people do turn to in adversity as we showed in the aftermath of the 2005 London Bombs 3. One of the most important things we can do to improve population mental health after such tragedies (note I am now not talking about mental disorder) of people is to assist in mobilising social networks. This might mean ensuring that mobile phone networks continue to function after disasters, or that relief centres have an adequate supply of power leads and landlines, or alternatively combating loneliness or homesickness in students by promoting volunteering, sports, drama, peer support or whatever.
And this can be facilitated by programmes such as Mental Health First Aid, which do not seek to create more mental health professionals, but just giving some very basic knowledge to the kind of people you already meet in your normal life – teachers, colleagues etc. We helped pioneer exactly such a system in the Armed Forces 4. I sometimes think that the training is not just about imparting information, but more about saying it’s OK to talk to people in distress, and no, you won’t make things worse as some seem to think. And I read Isabella Goldie as saying much the same. And if encouraging peer support and its variants also comes under the broad heading of awareness, then yes, I am in favour.
I could not help a wry smile when Dr Browker talks about the new alienism which he links to the the rise of “counselling services”, simply because I used almost the same title in an essay in the BMJ 21 years ago 5. And this has indeed come to pass – with psychiatry becoming increasingly seen as dealing only with the severest of mental illness. My prediction that this would lead to a slow but steady shift of resources away from the most severely ill, has also been fulfilled. As the Chief Executive of our largest mental health trust recently observed, mental health funding is like a soufflé which is gradually expanding, but leaving the core weaker and weaker until it suddenly collapses.
One final point that has been picked up by Twitter and also by the BMJ’s own star columnist, Margaret McCartney, is the issue of unintended consequences. I teach medical students that anything that works, no matter what it is, will always have side effects. If something genuinely has no downside, then there is probably no upside either. The question is simply the balance between the two. And I would argue strongly that this must be true of raising awareness, just as it is true of any other public health intervention. Here I am talking about the dangers of professionalisation or medicalisation of normal emotional reactions and/or personality variations. I expect that the benefits will outnumber the risks, but I am certain that risks there will be, and that all of us should know about them

1. Rona R, Burdett H, Khondoker M, Chesnikov M, Green K, Pernet D, Jones N, Greenberg N, Wessely S, Fear N. Post deployment screening for mental disorder and tailored advice about help seeking in the UK military: a cluster randomized controlled trial. Lancet 2017: 389: 1410-1423
2. Jones E, Woolven R, Durodie W, Wessely S. Civilian Morale During the Second World War: Responses to Air Raids Re-examined. J Social History 2004: 17: 463-479
3. Rubin J, Brewin C, Greenberg N, Simpson J, Wessely S. Psychological and behavioural reactions to the bombings in London on 7 July 2005: cross sectional survey of a representative sample of Londoners. British Medical Journal 2005. 311: 606-610
4. Greenberg N, Langston V, Iversen A, Wessely. S. The acceptability of a peer group support system “Trauma Risk Management (TRiM)” within the UK Armed Forces. Occupational Medicine 2011: 61: 184-189
5. Wessely S. The rise of counselling and the return of alienism. Br Med J 1996;313:158-160

Competing interests: No competing interests

15 October 2017
Simon C Wessely
Regius Chair of Psychiatry, IOPPN, KIng's College London
Deptartment of Psychological Medicine, IOPPN, KIng's College London, SE5 9RJ
Re: General practice threatens to withhold repeat prescriptions until patients have flu vaccine Gareth Iacobucci. 359:doi 10.1136/bmj.j4682


Whilst we can’t condone any unfair pressure on patients to have their influenza vaccine at the surgery (1), there is a downside of pharmacist vaccination which this article provides the opportunity to air. The issue is that of data integrity following pharmacist administered vaccination.

The communication from pharmacist to GP after they administer a flu jab is suboptimal. It is often a paper sheet which just states that the immunisation has occurred and does not provide either the vaccine manufacturer or batch number details. The paper communication does not provide any recommendation about the importance of coding the key data into practice computerised medical record (CMR) systems – in contrast to many other communications, even the police, give recommended codes to use around the issue of firearm licences.

The limitations of the current approach are:
• The information, if sent on paper, might just get scanned into the patients records (not coded) and will not be visible when it comes to conducting searches for who is immunised
• There are no recommended codes to ensure consistency of coding
• Missing data about vaccination can affect our ability to monitor vaccine effectiveness. The established method requires us to know accurately whether a patient with flu has or has not been exposed to vaccination (2).
• The lack of information about manufacturer or batch number makes monitoring of adverse events (currently recommended by the European Medicines Agency) more challenging (3); and reduces the chance of being able to link any severe adverse event to brand or batch.
• Whist some pharmacies use a bespoke software that provides a record for the patients General Practice – it does this as a .pdf (Adobe’s Portable Document format). It would be much better if it transferred coded information, in the way for example that blood test results are transferred into general practice CMR systems.

In a health system where patients increasingly enjoy the benefits of electronic prescribing, and much other data are shared electronically, a better way of passing more complete information about pharmacist vaccination back to GP records should be found.

Simon de Lusignan
Professor of Primary Care and Clinical Informatics, University of Surrey
Medical Director Royal College of General Practitioners (RCGP), Research and Surveillance Centre,
Euston Square, London, UK

Matthew Hoghton
Medical Director RCGP Clinical Innovation and Research Centre

Imran Rafi
Chair of Clinical Innovation and Research RCGP

(1) BMJ 2017;359:j4682
(2) de Lusignan S, Correa A, Smith GE, Yonova I, Pebody R, Ferreira F, Elliot AJ, Fleming D. RCGP Research and Surveillance Centre: 50 years' surveillance of influenza, infections, and respiratory conditions. Br J Gen Pract. 2017 Oct;67(663):440-441. doi: 10.3399/bjgp17X692645.
(3) de Lusignan S, Dos Santos G, Correa A, Haguinet F, Yonova I, Lair F, Byford R, Ferreira F, Stuttard K, Chan T. Post-authorisation passive enhanced safety surveillance of seasonal influenza vaccines: protocol of a pilot study in England. BMJ Open. 2017 May 17;7(5):e015469. doi: 10.1136/bmjopen-2016-015469.

Competing interests: Simon de Lusignan as part of his University role is the Medical Director of the RCGP Research and Surveillance Centre - its public health role includes surveillance for influenza and supporting estimates of vaccine effectiveness. Simon is also a member of a number of European vaccine research consortia has a grant from GSK to pilot a system to monitor European Medicines Agency Vaccine side effects; (all of these are through the University of Surrey). These activities are frustrated through an inability to get complete brand-specific vaccination data. Matt Hoghton has no competing interests. Imran Rafi has no conflicts of interest.

15 October 2017
Simon de Lusignan
GP / Professor of Primary Care / Medical Director RCGP Research and Surveillance Centre
Matthew Hoghton, Imran Rafi
University of Surrey
Re: Follow-up brain imaging of 37 children with congenital Zika syndrome: case series study Patricia Jungmann, Luziany Araújo, Marília Abath, Andrezza Fernandes, et al. 359:doi 10.1136/bmj.j4188

Firstly I would like to thank the authors for writing this most interesting article on an this issue which I’m sure will continue to problematic in the international medical community for many years to come.

My main critique is regarding the lack of a subjective quantification of cerebral calcifications. The authors state that they are unaware of any specific software and tried to minimise bias by consensus. I think consensus of 4 experts is likely to be less accurate than the commonly used Agaston Score. This is a standardised scoring system for quantifying calcification using the open access software ImageJ . Calcification has also been quantified in other studies using custom-made programs such as MATLAB . Furthermore, programs designed primarily for 2D image interpretation of histological specimens could also be used similarly for radiological quantification. Given that this is the focus of the article’s investigation it might be helpful to offer a quantitative analysis rather than an subjective assertion of “diminished in number, size, or density or a combination … were no longer present in one child, and remained unchanged in two children. No child had an increase in number, size, or density of calcifications”.

1. Hama Y. Detection of Prostate Calcification with Megavoltage Helical CT. Academic Radiology. 2014;21(5)565-568.
2. Wait et al. Detection of Aortic Arch Calcification in Apolipoprotein E-Null Mice Using Carbon Nanotube-Based Micro-CT System. J Am Heart Assoc. 2013;2(1) e003358.
3. Image-Pro Plus 7. Media Cybernetics. [Online]. Available at: [].

Competing interests: No competing interests

15 October 2017
Josephine Catherine Weaver
Junior Doctor
Melbourne, Australia