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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: Children are being failed by substandard mental health services Matthew Limb. 358:doi 10.1136/bmj.j3641

Mental illness is sensitivity with frightful insights. Troubled with demons and fears, but bubbling with dreams and ideas, sensitivity enlightens us with creative insights. So let’s listen, learn, solace, and support, but not stigmatize, marginalize, ostracize, or hospitalize. Sensitivity is creativity, not negativity.

Competing interests: No competing interests

07 August 2017
Hugh Mann
New York, NY, USA
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Re: NHS England’s plan to reduce wasteful and ineffective drug prescriptions Azeem Majeed. 358:doi 10.1136/bmj.j3679

I thank Trevor Bhatt for his helpful response. The high cost of generic drugs is an important issue for the NHS. Many generic drugs have increased in cost substantially in recent years.[1] If these increases in cost could be reversed, this would generate substantial savings for the NHS and help the NHS meet its target for efficiency savings.

1. Pym H. Generic prescription drugs: Are prices excessive? BBC News Online. 3 June 2016.

Competing interests: I am a GP principal in an NHS general practice in Clapham, London.

07 August 2017
Azeem Majeed
Professor of Primary Care
Imperial College London
Reynolds Building
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Re: UK doctors re-examine case for mandatory vaccination Tom Moberly. 358:doi 10.1136/bmj.j3414

Dear Mr Moberly

I note your recent article in the BMJ, “UK doctors re examine case for mandatory vaccination” with great interest. In particular I note the opening sentence “arguments over the best way to persuade all parents to protect their children from preventable disease”.

One aspect which seldom comes under scrutiny when considering how best to persuade parents to vaccinate their children, is the historical performance of the Vaccine Damage Payment Scheme in acknowledging damage and providing financial assistance to families following an adverse reaction which results in a permanent disablement.

A robust, easily accessible, responsive scheme to assist with a financial payment in times when vaccination has gone wrong, is something of a must to instill confidence in parents that help will be forthcoming in the event that vaccination results in a lasting disability for their child. In this way, parents might view vaccination more favourably.

Unfortunately, far from conveying the message of a scheme which is receptive and responsive in providing monetary assistance to affected children and their families, the statistics paint a picture of a scheme which more times than not, refuses applications from vaccine damaged individuals.

Since its inception, a total of 6,026 have been submitted under the Vaccine Damage Payments Act 1979 with only a mere 931 awards being made.

Additionally, it is not immediately apparent to applicants how significant the requirement to satisfy the 60% disablement threshold is. It is the case that applicants can and have been acknowledged as vaccine damaged, but are still refused a payment on the grounds that they are not, in the opinion of the assessors, damaged enough. It follows that the UK supports a scheme which does not address all acknowledged claims of injury caused through vaccination but only those which cause a greater than 60% level of disablement. Currently parents whose children are vaccine damaged and acknowledged as such, but who do not meet the 60% disablement threshold, are left to shoulder the financial burden through some other means with no payment from the VDPU. In short, it is incredibly difficult to secure a payment under the Vaccine Damage Payments Act 1979.

A recent revelation in the press may go some way to explaining why it is so very difficult to satisfy the 60% disablement threshold and the shockingly low level of payments awarded by comparison to the number of claims submitted.

In February 2017 the Court of Appeal ruled, following consideration of the provisions in the 1979 Act, that the assessment of disablement, had to include assessment in respect of the individual’s future burdens. Clearly it is a serious omission that claimants have not had assessment of their future burdens included in their overall assessment and there is no way of knowing how the exclusion of the future burdens might have impacted on the number of payments made down through the years.

Back in 1982 Lord Mischon highlighted the advantages of vaccination but was also mindful of the burden on the “legislators” to address a duty of care in respect of the children who sustained disablement as a result.

“But there is no doubt that immunisation is an advantageous step to take and an advantageous step to promote. What we must obviously do—and this is very much the lawyers' concern—is to ensure that the proper social duty we owe to those children who unfortunately suffer damage is carried out by us as legislators.”

Sadly, the numbers of claims refused by the VDPS, the fact that claims are being refused on the basis that the individual is not disabled enough, (even when acknowledged as vaccine damaged), and the failure since 1979 to include an individuals future burdens as part of an assessment, are not evidence of a society which has fully embraced a social duty owed to vaccine damaged children.

Whilst an award under the Vaccine Damage Payments Act 1979 will never replace the loss sustained by the applicant, it can assist with the many difficulties an injured person and their families will have to face throughout their lives as a result of a vaccine induced disability.

Those considering vaccination might just feel more inclined to think favourably towards the process if they were reassured that in the event that their child suffers a permanent and lasting adverse effect, there will, at the very least, be help available to assist with the financial burden.

In a recent comment Peter Todd, a solicitor at Hodge Jones and Allen sums it up perfectly when he stated that ……

“The uptake of vaccines is likely to increase where consumers can be confident that not only is disablement exceedingly rare but. in the extremely unlikely event that it occurs, that there is a safety net.”

The reality is, irrespective of how the role of the Vaccine Damage Payment Unit is portrayed in NHS vaccination advertising campaign leaflets, it is incredibly difficult and time consuming to secure a payment in respect of vaccine damage. Conveying a message that financial assistance swiftly follows in the wake of vaccine damage could not be further from the truth and as the statistics show, more times than not, the parents are burdened with not only a disabled child and the additional difficulties that introduces into family life, but also the financial burden the disability brings with it.

Creating a society which more readily addresses the plight of all recognised vaccine injured individuals might just, as suggested by Peter Todd, increase the uptake in vaccination. Will the BMJ include a suggestion to re examine the vaccine damage payment scheme in any discussions involving a proposal for mandatory vaccination as a viable means of increasing confidence in vaccination and vaccine uptake levels?

Yours sincerely

Wendy Stephen

(Mother of the young woman in The Times article)

Competing interests: No competing interests

07 August 2017
Retired nurse
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Re: How much should we spend on healthcare? Fiona Godlee. 358:doi 10.1136/bmj.j3714

It is good to read Editor's Choice on "How much should we spend on healthcare? "

"How much" - on healthcare? The health care needs & demands vary at each level (Medical institute, State & National), and accordingly the budget allocation. It is different in developing and developed nations.

For budget allocation the following information is needed:

Diseases & their prevalence - epidemiological profile of disease.
Pharmacoeconomics and essential drug list have an important role.
Health education & awareness in society.
Information technology & its role in the health care system.
Knowledge, attitudes & practices - role of health care provider.
Health care services, activities and heath policies at each level.
National heath care system and its priorities - health statistics and peer pressure at international level.

In developing nations, "SWOT" (Strength, Weakness, Opportunity & Threats) analysis is very significant and plays an important part in deciding "How much".


Competing interests: No competing interests

07 August 2017
Dr. Rajiv Kumar
Dr.Sangeeta Bhanwra, Faculty, Dept. of Pharmacology, Government Medical College & Hospital Chandigarh 160030. India.
Dept. of Pharmacology, Government Medical College & Hospital Chandigarh 160030. India.
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Re: Large case series documents chronic brain damage in players of American football Michael McCarthy. 358:doi 10.1136/bmj.j3602

Dear Dr Mann,

I agree with your rapid response [1] and statement that contact sports are atavistic and anachronistic bacchanalia. I think, it´s necessary to see the evolution of human beings and the genetic background. It can be explained in relation to a number of factors, relating to interaction, identity, legitimacy, power and expressions of strong emotional ties to a football team or a boxer, which may help to reinforce a supporter’s sense of identity. Boxing was a popular spectator sport in Ancient Rome with gladiator fights (“panem et circenses”). Perhaps a second reason for the popularity of full-contact sports with injuries, blood and excessive brutality with cerebral concussion (knockout or death)..

Concussion and other types of repetitive play-related head blows in American football and soccer [2] have been shown to be the cause of chronic traumatic encephalopathy (CTE), which has led to player suicides and other debilitating symptoms after retirement, including memory loss, depression and dementia. The risk of boxer of a punch-drunk syndrome (dementia pugilistica) as a late effect of chronic traumatic brain injury is associated with the duration of a boxer’s career and with his earlier knockouts.. Alzheimer’s and CTE are both linked to depositions of tau protein in the brain, but the way tau is distributed in the brain is different in CTE. There are similarities (increased risk with ApoE4-polymorphism, beta-amyloid pathology) and differences (more tau pathology in boxers) compared with Alzheimer’s disease [3]. CTE has been found in about 100% of the brains of boxers, but only 6% of the general population, There is a causal relationship between CTE and the repetitive head impacts of playing football [2,3] and case histories of footballers found to show CTE post-mortem, respectively.

The role und the meaning of physicians is very different. Amateur boxers undergo regular medical examinations once a year and prior to matches. Professional boxing matches are staged without these extensive medical protective measures. The World Medical Association (WMA), the American and the British Medical Association recommended a general ban on boxing. During bouts, the doctor (“medical officers”) may be called on by the referee, but it will be only the referee’s decision, to stop a fight.

A statement of the American Medical Society for Sports Medicine [4] tries to assist physicians with the management of sports concussion and to establish the level of evidence and knowledge gaps. The conclusions are primary and secondary preventions, demands to legislate to provide a uniform standard sports organisations and future directions with additional research to validate current assessment tools, delineate the role of neuropsychological testing and improve identification of those at risk of prolonged post-concussive symptoms or other long-term complications and evolving technologies for the diagnosis, such as newer neuroimaging techniques or biological markers. But I think there is a lot of money in contact sports, even at the highest level. American football matches and boxing fights have been broadcast on public television networks during prime time. At the moment, a ban has no chance, even if the fighters were to cry like the gladiators in Rome “Ave, Caesar, morituri te salutant”.

1) Mez J et al. Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football. JAMA. 2017 Jul 25;318(4):360-370. doi: 10.1001/jama.2017.833
2) Stewart W, Kim N, Ifrah C, et al. Symptoms from repeated intentional and unintentional head impact in soccer players. Neurology2017;356:1-8
3) McKee AC, Cantu RC, Nowinski CJ, et al.: Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol 2009; 68: 709–35.
4) Harmon KG et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013 Jan;47(1):15-26. doi: 10.1136/bjsports-2012-091941.

Competing interests: No competing interests

07 August 2017
Detlef Degner
Associate Professor of Psychiatry, assistant medical director
Department of Psychiatry, University Medical Center, Georgia Augusta University, Goettingen
Von-Siebold-Str5, D-37075 Göttingen, Germany
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Re: Acne Sarah Purdy, David de Berker. 333:doi 10.1136/bmj.38987.606701.80

I would like to underline and remind colleagues about the extremely powerful broad spectrum fungicidal and bactericidal activity, of carvacrol rich essential oil of oregano that has proved to be active, even against antibiotic and antimycotic resistant strains, without any side effects. [1][2]
Concomitant topical administration of carvacrol rich emulsions of essential oil of oregano, or other herbal monoterpenes, with current systemic pharmacologic therapies must be investigated and pursued, in order to achieve synergistic effects.
Carvacrol has also antinociceptive[5] and potent anti-inflammatory activity[3][4].
No bacterial resistance has ever been observed.

Competing interests: No competing interests

07 August 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
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Re: Health workers are vital to sustainable development goals and universal health coverage Lara Fairall, Eric Bateman. 356:doi 10.1136/bmj.j1357

It will be extremely difficult to find enough and adequate candidates to train as health workers by 2030, if large percentages of available employees continue to lack basic numeracy and literacy skills, as OECD reports indicate.
In Developing Countries things might be even worse.

Competing interests: No competing interests

07 August 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
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Re: NHS England’s plan to reduce wasteful and ineffective drug prescriptions Azeem Majeed. 358:doi 10.1136/bmj.j3679

The current high acquisition cost of liothyronine should be tackled via the recently passed Health Service Medical Supplies (Costs) Act 2017 ( ) - A mechanism with a firm legal basis and not a flawed locally based approach which will be time-consuming for NHS clinicians.
The 2017 act was introduced to:
1. put beyond doubt that the government can require companies to make payments to control the cost of health service medicines
2. enable the government to require companies to reduce the price of an unbranded generic medicine, or to impose other controls on that company’s unbranded medicine, even if the company is in the voluntary scheme (the Pharmaceutical Price Regulation Scheme) for their branded medicines

Competing interests: No competing interests

07 August 2017
Trevor H Batt
Aneurin Bevan University Health Board , Newport NP19 0BH
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Re: Impact of searching clinical trial registries in systematic reviews of pharmaceutical treatments: methodological systematic review and reanalysis of meta-analyses Isabelle Boutron, et al. 356:doi 10.1136/bmj.j448

I thank Alessandra Pugi for drawing attention to our article.

We are aware that our meta-analytic results showed that the direction and statistical significance of each summary effect does not changed for any meta-analysis once the new RCTs are included. However, the change in summary statistics varied from 0% to 29% and was greater than 10% for five of 14 systematic reviews and greater than 20% for two.

Despite these results, we believe that is probably worth spending time to search clinical trial registries and that searching trial registries should continue to be a recommendation with strategy to improve adherence to this recommendation. Clinical trial registries have been developed and enforced by editors and policy makers to reduce waste in research and publication bias. They have been considered an important step toward more transparency and increasing research value.

In fact,
1) Lack of searching trial registries implies that we could have missed evidence (in our study evidence was missing in 41 of 95 systematic reviews) while the objective of a systematic review is to collate all empirical evidence (Cochrane handbook, JPT Higgins, 2011).

2) Knowing the amount of unpublished and not available data is very important information as to understand what is under “the tip of the iceberg”. This step is important to grade the quality of evidence in systematic review with meta-analysis. In our study, among the 122 RCTs identified, 63 (52%) had results available.

3) Searching trial registries allowed the inclusion of new RCTs in meta-analyses in 14 of 95 (15%) systematic reviews in our study. However, the addition of new RCTs in these meta-analyses did not change the statistical significance but increased precision. Further, some trials results were still missing and could not be included in the new analyses. Searching registry may become even more important if posting results improve and the protocol and statistical analysis plan become available.

Finally, searching in trial registries represents a low burden. The number of records to screen by systematic review was limited (median [Q1-Q3] = 23 [6-150]) except for 3 systematic reviews with more than 1000 records to screen (respectively 1661, 2680 and 3576).

Actually, the effort of searching trial registry is counterbalanced by the lack of results. In our study, in half of the 14 selected meta-analyses, only a part of the RCTs retrieved by the trial registry search had available results, resulting in “incomplete evidence meta-analysis”.

In our study, among the 122 RCTs retrieved from trial registry search, 1) 41 had their results posted; 2) 21 had a publication available identified by a reference reported on the registry and 10 from a complementary search and 3) 31 had results available on the company’s Web site.

This should change in the near future because the policy of trial registration changes in favour the posting of results and of protocol. In the final rule of trial registration in, the FDAAA of 2007, made publicly available on September 16, 2016, requires submission of full protocol and statistical analysis plan at the same time as submission of results information (Zarin nejm 2016). Registry could be a more important source of results in the future.

Amelie Yavchitz , MD, PhD
Centre de Recherche Epidémiologie et Statistique,
INSERM U1153, Paris, France

Competing interests: No competing interests

07 August 2017
Amélie Yavchitz
physician and researcher
Centre de Recherche Epidémiologie et Statistique, INSERM U1153, Paris, France
1 place du Parvis Notre Dame, 75004 Paris, France
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Re: Management of chronic pain using complementary and integrative medicine Lucy Chen, Andreas Michalsen. 357:doi 10.1136/bmj.j1284

The article by Chen et al (1) has given comprehensive information on the role of various complementary and integrative medical approaches to chronic pain management. The evidence based on scientific studies deals with most of the available complementary medicine groups. However, the role of Homeopathy has not been given enough information. Homeopathy seems to be effective in many chronic conditions especially rheumatic diseases (2). Though research in homeopathy is limited, evidence from other conditions such as fibromyalgia, osteoarthritis and rheumatoid arthritis showed to be inconclusive due to lack of high quality evidence (3-6). Positive results were obtained for fibromyalgia using homeopathy (7). Our individual experience showed getting relief from back ache with homeopathy without any side effects, though it took about two weeks to get relief from the pain and with no recurrence till one year. We think that there is a lot of scope in the practice of homeopathy in chronic pain relief. The limitation of homeopathy is that it functions on individualisation of treatment with no specific regimen which can be universalised due to individual differences in body reactions, behaviour and emotions.


1. Chen L, Michalsen A. Management of chronic pain using complementary and integrative medicine. BMJ 2017;357:j1284.
2. Jonas WB, Linde K, Ramirez G. Homeopathy and rheumatic disease. Rheumatic Disease Clinics of North America, 2000; 26: 117–123.
3. Perry R, Terry R, Ernst E. A systematic review of homoeopathy for the treatment of fibromyalgia. Clinical Rheumatology, 2010; 29:457–464.
4. Boehm K, Raak C, Cramer H, Lauche R, Ostermann T. Homeopathy in the treatment of fibromyalgia – A comprehensive literature-review and meta-analysis. Complementary Therapies in Medicine, 2014; 22: 731–742.
5. Long L, Ernst E. Homeopathic remedies for the treatment of osteoarthritis: a systematic review. British Homeopathic Journal, 2001; 90: 37–43.
6. Saha, Koley M, Medhurst R. A meta-analysis of the randomized controlled trials of individualized homeopathy in rheumatoid arthritis. World Journal of Pharmacy and Pharmaceutical Sciences, 2013; 2: 2097-2117.
7. Aaranowsky J, Klose P, Musial F, Haeuser W, Dobos G, Langhorst J. Qualitative systemic review of randomized controlled trials on complementary and alternative medicine treatments in fibromyalgia. Rheumatol Int 2009;30:1–21.

Competing interests: No competing interests

07 August 2017
Mongjam Meghachandra Singh
Reeta Devi
Department of Community Medicine, Maulana Azad Medical College, New Delhi & co-author: School of Health Sciences, Indira Gandhi National Open University, New Delhi (India)
Department of Community Medicine, Maulana Azad Medical College, New Delhi & co-author: School of Health Sciences, IGNOU, New Delhi (India)
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