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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: Childhood adversity and risk of suicide: cohort study of 548 721 adolescents and young adults in Sweden Charlotte Björkenstam, Kyriaki Kosidou, Emma Björkenstam. 357:doi 10.1136/bmj.j1334

In this paper Björkenstam et al identify correlation between indicators of childhood adversity and suicide. Groups at high risk could potentially be identified through school, the healthcare system, or social services.

To this end, we wish to highlight the largely unrecognised presentation of non-organic hearing loss (NOHL) in children with underlying adversity and psychosocial pathology.

NOHL is also known as Pseudohypacusis and represents the most frequent etiology of sudden hearing loss in children (1).
Mean age at diagnosis is 11 years. Girls are affected twice as often as boys (2).
The prevalence of NOHL can be between 1 and 3% in children with suspected hearing loss (3).
A French study found that 50% of nonorganic hearing loss was likely due to events like adoption, abuse, verbal aggression and school problems (4).

In children with apparent sensorineural hearing loss, we recommend referral to an Audiovestibular Physician or an appropriate specialist for formal assessment.

References:
1: Ioannis, P., Georgios, K., Alexandra, K. et al. Pseudohypacusis: the most frequent etiology of sudden hearing loss in children. Eur Arch Otorhinolaryngol (2009) 266: 1857. doi:10.1007/s00405-009-0983-y
2: Schmidt, CM, Zehnhoff-Dinnesen, A, Deuster, D. Nonorganic (functional) hearing loss in children. HNO (2013) 61: 136. doi:10.1007/s00106-012-2504-3
3: Schmidt, CM et al. Nonorganic hearing loss in children: Audiometry, clinical characteristics, biographical history and recovery of hearing thresholds. International Journal of Pediatric Otorhinolaryngology , (July 2013) Volume 77 , Issue 7 , 1190 – 1193 Volume 77, Issue 7, Pages 1190–1193
4: Drouillard, M. et al. Pseudohypacusis in children: Circumstances and diagnostic strategy. International Journal of Pediatric Otorhinolaryngology , (Oct 2014)Volume 78 , Issue 10 , 1632 - 1636

Competing interests: No competing interests

21 June 2017
T Hampton
ENT Registrar
S. Rangan, Consultant Paediatric Audiovestibular Physician
Wirral University Teaching Hospital NHS Foundation Trust
Arrowe Park Road, Upton, Merseyside, CH49 5PE
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Re: Fungal nail infection: diagnosis and management Samantha Eisman, Rodney Sinclair. 348:doi 10.1136/bmj.g1800

Dear Editors,
Essential oil of Origanum vulgaris hirtum (Greek oregano), containing high quantities of carvacrol, exhibits broad spectrum fungicidal activity, without any side effects, even against fluconazole resistant strains. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]
Fungal nail infections can be treated with warm foot baths of oregano essential oil, in a very short time. [1]
References
[1] http://www.ncbi.nlm.nih.gov/pubmed/17287720
https://www.jstage.jst.go.jp/article/jjmm/48/1/48_1_27/_pdf
[2] http://www.ncbi.nlm.nih.gov/pubmed/20921304
[3] http://www.ncbi.nlm.nih.gov/pubmed/18997851
[4] http://www.ncbi.nlm.nih.gov/pubmed/16506839
[5] http://www.ncbi.nlm.nih.gov/pubmed/15720571
[6] http://www.ncbi.nlm.nih.gov/pubmed/23368893
[7] http://www.ncbi.nlm.nih.gov/pubmed/22538487
[8] http://www.ncbi.nlm.nih.gov/pubmed/22118215
[9] http://www.ncbi.nlm.nih.gov/pubmed/22020493
[10] http://www.ncbi.nlm.nih.gov/pubmed/22016556
[11] http://www.ncbi.nlm.nih.gov/pubmed/21707253
[12] http://www.ncbi.nlm.nih.gov/pubmed/21560241
[13] http://www.ncbi.nlm.nih.gov/pubmed/20835742
[14] http://www.ncbi.nlm.nih.gov/pubmed/20104443
[15] http://www.ncbi.nlm.nih.gov/pubmed/15883716
[16] http://www.ncbi.nlm.nih.gov/pubmed/15476054
[17] http://www.ncbi.nlm.nih.gov/pubmed/14678536
[18] http://www.ncbi.nlm.nih.gov/pubmed/14598221
[19] http://www.ncbi.nlm.nih.gov/pubmed/12428445
[20] http://www.ncbi.nlm.nih.gov/pubmed/11855736
[21] https://www.ncbi.nlm.nih.gov/pubmed/27225838

Competing interests: No competing interests

21 June 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynecology
Kalamaria, Thessaloniki, Greece
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Re: David Oliver: Towards a GP consensus on the future of UK general practice David Oliver. 357:doi 10.1136/bmj.j2949

David Oliver will find there is no consensus among GPs about the future of general practice. This is unsurprising. After all, there is no consensus among the general public about the major issues facing the UK. For example, in the EU Referendum in 2016, 48% of people voted to remain in the EU and 52% voted to leave. In the recent general election, 42% of people voted for the Conservatives and 40% for Labour, two parties with very different policies. Why should GPs be any different about the challenges facing them?

Should GPs be salaried or independent contractors? If salaried, should they be employed on a standard national contract in the same way as hospital doctors? How should general practice be funded? Through capitation as it is now or through activity-based funding? Should GPs continue to work in traditional, small general practices or come together in super-practices? Should general practices be taken over by hospitals as we are seeing in some parts of England? To what extent can work done by GPs be carried out by other professional groups such as nurses, pharmacists, physiotherapists, healthcare assistants and physician assistants? Should GPs lobby for co-payments from patients? Can more health services be made direct access, thereby bypassing the need for a referral from a GP?

On all these important questions about the future of general practice in the UK – and on many others – David Oliver will find there is no consensus among GPs, just a range of opinions.

Competing interests: I am a GP Principal at the practice of Doctor Curran and Partners in Clapham, London.

21 June 2017
Azeem Majeed
Professor of Primary Care
Imperial College London
Department of Primary Care and Public Health, Imperial College London, London W6 8RP
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Re: Trauma staff change routines in wake of terrorist attack Ingrid Torjesen. 357:doi 10.1136/bmj.j2736

Torjesen’s article quotes several eminent British figures on lessons to be learnt from recent mass casualties and major incidents.

Comments regarding hot and cold debrief may have use for institutional memory but should be regarded with caution for health workers coping with stress:

An Australian review revealed a distinct paucity regarding the efficacy of debriefing of clinicians post Critical Incidents (1) and evidence supporting the effectiveness of most interventions used to prevent Post Traumatic Stress Disorder is lacking in patients themselves (2).

The Cochrane review relating to ‘single session’ debriefing for the prevention of post-traumatic stress disorder after traumatic incidents found there to be no benefit (3) and even where debriefs are advocated, a study of post resuscitation debriefing practices within paediatric emergency departments in the United States found 88.0% of trainees had no formal teaching on how to effectively debrief (4).

Instead, we would reiterate the President of the Royal College of Emergency Medicine’s (5) calls for trusts to offer support and furthermore implement holistic working patterns and rotas with leeway. Spare capacity or rota gap ‘reservists’ could allow for such time off in lieu (6).

Even in such trying times, interventions which reduce demand, increase autonomy and encourage managerial support help establish better working relationships and make workers feel more valued (7).

1: Magyar, J. and Theophilos, T. (2010), Review article: Debriefing critical incidents in the emergency department. Emergency Medicine Australasia, 22: 499–506. doi:10.1111/j.1742-6723.2010.01345
2: Gartlehner G, Forneris CA, Brownley KA, et al. Interventions for the Prevention of Posttraumatic Stress Disorder (PTSD) in Adults After Exposure to Psychological Trauma [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Apr. (Comparative Effectiveness Reviews, No. 109.)
3: Rose SC, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000560. DOI: 10.1002/14651858.CD000560
4: Zinns LE, O'Connell KJ, Mullan PC, Ryan LM, Wratney AT. National Survey of Pediatric Emergency Medicine Fellows on Debriefing After Medical Resuscitations.Pediatr Emerg Care. 2015 Aug;31(8):551-4. doi: 10.1097/PEC.0000000000000196.
5: Torjesen Ingrid. Trauma staff change routines in wake of terrorist attack. BMJ 2017; 357 :j2736
6: http://careers.bmj.com/careers/advice/How_junior_doctors_in_New_Zealand_...
7: http://emj.bmj.com/content/early/2016/10/11/emermed-2016-205827

Competing interests: No competing interests

21 June 2017
T Hampton
ENT Registrar
J. Willson (Emergency Medicine Registrar, Bristol Royal Infirmary, Bristol)
Wirral University Teaching Hospital NHS Foundation Trust
Arrowe Park Road, Upton, Merseyside, CH49 5PE
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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

NSAIDs offer no clinical benefit for spinal pain, a systematic review and meta-analysis reveals, level I evidence. [1][3]
Non-drug therapies should be first line treatment for low back pain, according to a revised US guidance to clinicians. [2]
References
[1] https://www.ncbi.nlm.nih.gov/pubmed/28153830
[2] http://www.bmj.com/content/356/bmj.j840
[3] http://www.bmj.com/content/356/bmj.j605

Competing interests: No competing interests

21 June 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
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Re: Doctors can act as advocates on health effects of poverty, says BMA Abi Rimmer. 357:doi 10.1136/bmj.j2976

Every year, hundreds of billions of dollars are spent in useless, counterproductive, or even harmful ventures.
Extreme World poverty could have been quickly and easily eliminated, Millenium Goals achieved, if only corruption was fought against, and logical consensus was achieved in order to channel part of these funds to charitable deeds.
References
http://www.un.org/apps/news/story.asp?NewsID=45816#.WMo59tR941K
https://www.eurekalert.org/pub_releases/2015-01/pfan-bw011215.php
https://www.weforum.org/agenda/2017/01/we-waste-2-trillion-a-year-on-cor...
http://www.thefiscaltimes.com/2015/03/19/85-Trillion-Unaccounted-Should-...
https://www.ibm.com/ibm/files/Y067208R89372O94/11The_worlds_4_trillion_d...
http://www.vistage.com/resource/report-2-9-trillion-wasted-on-worker-fraud/
https://www.medicalrecoveryservices.org/resources/six-wasteful-practices...
http://www.medscape.com/viewarticle/770451
http://daily.financialexecutives.org/nearly-400-billion-lost-annually-du...
http://www.independent.co.uk/news/world/europe/corrupt-european-countrie...
http://www.politico.eu/article/corruption-costs-eu-990-billion-year-rand...
http://www.rand.org/blog/2016/03/the-true-economic-cost-of-corruption-in...
http://time.com/3908457/red-cross-six-homes-haiti/
http://www.huffingtonpost.com/2015/06/04/red-cross-haiti-report_n_751108...
http://www.theguardian.com/world/2015/jun/05/red-cross-haiti-black-hole-...
http://borgenproject.org/how-much-does-it-really-cost-to-eliminate-globa...
http://www.fao.org/3/a-i4959e.pdf
http://www.oecd-ilibrary.org/docserver/download/4313111ec005.pdf?expires...
http://www.theguardian.com/global-development/2015/jul/06/united-nations...

Competing interests: No competing interests

21 June 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
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Re: Margaret McCartney: Nurses must be allowed to exercise professional judgment Margaret McCartney. 356:doi 10.1136/bmj.j1548

The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726
Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests

21 June 2017
Parbatee Siewdass
Assistant Lecturer
The University of the West Indies
St Augustine. Trinidad and Tobago
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Re: David Oliver: Towards a GP consensus on the future of UK general practice David Oliver. 357:doi 10.1136/bmj.j2949

Keep IC status. GMS performs better on quality & price than APMS which also has no hope of delivering the long term continuity or pt advocacy GMS does

Fund core pc & drug budgets based on pt level case mix adjusted pc data. Carr hill useless as not granular enough

DDRB recommendations to be legally binding on SoS

Develop much better routine pc activity metrics & publish case mix adjusted performance, including continuity measures

Practices to have absolute unilateral right to list closure to ensure safety, prevemt GP burnout & force NHSE to actually think properly about pc commissioning rather than threatening contract sanctions & drive proper workforce development

All left shift or new NICE guidance to be accompanied by resource plan that has to be funded ahead of implementation

Geographical colocation social & comm services on a 30k pt footprint & practices to work together on that basis

Shared back office functions between practices

Competing interests: GP Ccg Board Member GP researcher

20 June 2017
David Shepherd
GP
Saffron Health
509 Saffron Lane Leicester
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Re: David Oliver: Towards a GP consensus on the future of UK general practice David Oliver. 357:doi 10.1136/bmj.j2949

Doctors do care about their work and they are not shy at all of the challenges and working hours their job may pose. It is however well known that the key to work happiness is a multitude of factors.

Dan Ariely(1) illustrated wonderfully some of the dynamics involved in happiness at work with his milestone Legos experiment.

To a group of people it was asked to build a Bionicle for three dollars and for a progressively decreasing price afterwards. To another group, on the so called Sisyphic condition, the same type of task was required, but the subject was asked to rebuild instead the Bionicle as the experimenter took apart the one that they just finished. People built far more Bionicles in the meaningful condition--that is, they worked much harder.

Ariely also looked at love for Legos, expecting that this would have had a positive impact on the subjects’ willingness to make Legos constructions. And indeed there was a correlation between the love for Legos and the amount of Legos people built in the meaningful condition. However, in the Sisyphic condition the correlation was zero. This implied that the manipulation of breaking things in front of people's eyes crushed any joy that they could get out of this activity. There is something particularly demotivating in cyclical version task of doing something over and over and over again.

So we have good reason to believe that we are missing the point when thinking about work and believe that motivation and payment are the same thing.

It is my humble opinion that, also when referring to Medicine, we should instead rediscover work autonomy and the doctor-patient relationship in order to give more meaning, creativity, challenges, ownership, identity, and pride to our healthcare professionals.

References
1) Dan Ariely, Emir Kamenica, Drazˇen Prelec. Man’s search for meaning: The case of Legos. Journal of Economic Behavior & Organization 67 (2008) 671–677.

Competing interests: No competing interests

20 June 2017
Edoardo Cervoni
Director
Locumdoctor4u Ltd.
Southport
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Re: Risk of major congenital malformations in relation to maternal overweight and obesity severity: cohort study of 1.2 million singletons Björn Pasternak, Olof Stephansson, Martin Neovius, et al. 357:doi 10.1136/bmj.j2563

Regardless of so many healthy lifestyle campaigns to raise awareness about obesity and motivate healthy lifestyle changes to prevent it, the prevalence of obesity continues to increase. It is considered one of the biggest global public health problems with at least 2.8 million people dying each year [1] of obesity related complications.

Obesity, unhealthy diet and insufficient physical activity is related to high prevalence of non-communicable diseases in the adult population [2]. The increased consumption of high calorific foods without an equal energetic spending increase are factors contributing to obesity [3].

The findings of this cohort study [4] further support the urgency to adress the phenomenon of obesity, as in addition to the well known dangers of the condition it also contributes to congenital malformations in relation to maternal overweight and obesity severity. Knowing that intervention programs for the management of obesity have no consensus [5], this cohort study [4] led me to reflect on the need to engage in the design and implementation of multiple intervention programs and the need for all health care professionals in the efforts to prevent and manage obesity.

As health professionals and researchers our role is to use every opportunity to encourage women of reproductive age, and the entire population to adopt a healthy lifestyle and to achieve an ideal body weight. The outcomes of this cohort study [4] may help to inform the need for more research involving all levels of stakeholders, in order to influence policies and initiatives for obesity prevention in elementary schools and maintaining these initiatives throughout childhood and adolescence. The literature has shown that such early interventions are the most effective strategies to reduce problems associated with sedentary lifestyles and poor eating habits [5].

References

1. World Health Organization. 10 facts on obesity; 2017. http://www.who.int/features/factfiles/obesity/en/

2. Johnson EJ, Rodrigues VJ. Primary health care: Expectations and tasks for public health in Trinidad and Tobago. Journal of Community Health 2016; 41:645–649.

3. Bratanova B, Loughnan S, Klein O, Claassen A, Wood R. Poverty, inequality, and increased consumption of high calorie food: Experimental evidence for a causal. Appetite 2016;100:162-171. DOI10.1016/j.appet.2016.01.028

4. Persson M,, Cnattingius S, Villamor E, Söderling J, Pasternak B, Stephansson O, Neovius M. Risk of major congenital malformations in relation to maternal overweight and obesity severity: cohort study of 1.2 million singletons BMJ 2017; 357:j2563. doi: https://doi.org/10.1136/bmj.j

5. Mello ED, Luft VC, Meyer F. Childhood obesity towards effectiveness. Jornal de Pediatria, 2004;80,3. http://dx.doi.org/10.2223/JPED.1180

Competing interests: No competing interests

20 June 2017
Talita de Cassia Raminelli da Silva
PhD student
University of Sao Paulo
Av Bandeirantes 1300 Ribeirao Preto, Sao Paulo, Brazil
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