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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: Management of chronic pain using complementary and integrative medicine Lucy Chen, Andreas Michalsen. 357:doi 10.1136/bmj.j1284

One must experience it to believe it.

In my own experience, the best painkiller is vitamin C (sodium ascorbate, a non-acidic form of vitamin C).

In the late 1990s I visited Professor Erik Enby in Stockholm. He was known for conducting live blood tests. Within minutes he took a drop of my blood and put it under his microscope. On the screen we could see blood corpuscles bunching and moving sluggishly. He said, this is very bad, the corpuscles are bunching. (I was jetlagged) I said, “OK, I will now take my vitamin c”,which I did (a full, heaped teaspoon of vitamin C powder in little water). He took another drop of my blood two minutes later. The blood looked much better. Another drop of my blood 5 minutes later and the blood was flowy, no bunching of corpuscles. He said,”Have I not seen it I would never have believed it.”

I have been taking vitamin c every day since 1985,when I had my last tonsillitis and decided to stop taking antibiotics. I haven’t had tonsillitis since.

Whenever I have a blood test, I am always asked, are you on a blood thinner?

When I or my friends had a headache or toothache, the pain subsided as we were drinking a teaspoonful of vitamin c, dissolved in little water.

A four months-old baby with a reaction to the second DPT+polio vaccine, moaning in pain, stopped moaning within seconds of swallowing sodium ascorbate, dissolved in a little bit of water (administered PO by his mother via an eye dropper), fell deeply in sleep and with a continued administration of vitamin c for the rest of the night recovered completely without any residual damage.

The added benefit of vitamin c is that it is also healing and non toxic, unlike the chemical painkillers.

Try it on yourselves.

Competing interests: No competing interests

06 August 2017
Dr Viera Scheibner (PhD)
scientist/author retired
Blackheath NSW Australia
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Re: Should doctors work 24 hour shifts? Steven C Stain, Michael Farquhar. 358:doi 10.1136/bmj.j3522

The point is well made that "attending physicians, or at least surgeons, therefore may need to be available for a 24 hour shift to provide the best care for their patients" (1). NHS doctors who are also engaged in private practice recognise this when the welfare of their private patients (and their own livelihoods) is at stake. Given the fact that the specialties which are consistently oversubscribed are the ones which require that sort of commitment, the best time to learn how to manage fatigue and recognise fitness for duty is under supervision, and that supervision should take place during the period of apprenticeship in one's chosen (and oversubscribed) career path. To me it is inconceivable that the trainee who aspires to have a profitable private practice which demands 24 hour commitment should dread the prospect of working a 24 hour shift during his period of apprenticeship. It simply does not add up.

Competing interests: No competing interests

06 August 2017
Oscar M Jolobe
retired geriatrician
manchester medical society
simon building, brunswick street, manchester M13 9PL
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Re: Burnout among doctors Jane B Lemaire, Jean E Wallace. 358:doi 10.1136/bmj.j3360

Individual and organisational interventions will only go so far.

The fundamental problem is the conflict between the system and what the doctor has been trained to do - practise good medicine.

I have just published a book ‘The Tyranny of a System -The NHS ‘. This explains how the NHS has ended up tyrannising the workforce resulting in a dysfunctional and inefficient health service in which burnout is more likely.

The consultants who in the past provided the glue for how hospitals functioned are no longer listened to by anyone other than by their patients.

My suggestion is to reverse the power that management has at the moment in virtue of having the last word where the money goes.

Instead the money should flow from what arises out of what is basic to what looking after patients is about - the doctor/patient encounter - and be seen to do so. This will need medical supervision.

The likely result too is a more efficient NHS.

Competing interests: No competing interests

06 August 2017
Rod Storring
Consultant Physician
Spire Roding Hospital
Ilford, Essex IG4 5PZ
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Re: NICE guidelines could put 12 million UK adults on statins Nigel Hawkes. 358:doi 10.1136/bmj.j3674

NICE guidelines such as these represent a double jeapordy for practitioners.

Firstly, NHS medical directorates now expect practices and individual practitioners to be 'NICE Compliant'. In NHS investigations, failure to comply with such guidance is identified and collected as evidence for performance advisory groups to make recommendations on fitness to practice.

Secondly, there are medicolegal implications, in that not acting in accordance with a Qrisk score of over 10% now identifiably falls outside guidance.

Whatever personal opinions individual practitioners have on the merits or otherwise of these (and other) NICE guidelines, they should be under no illusions that failure to follow the guidance will expose them to risk.

Competing interests: No competing interests

06 August 2017
Martin Breach
GP Principal
Haydock Medical Centre, Woodside HCC, Haydock, WA11 0NA
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Re: Cheap, undervalued, expendable: junior doctors in 2017? Rachel Clarke. 358:doi 10.1136/bmj.j3651

Thank you to Doctor Clarke for (once again) raising the profile of poor morale amongst Junior Doctors.

I would like to raise the topic of incorrect pay, as a factor which over the years has had significant impact upon my morale. Time and time again my pay has been incorrect, frequently as a result of rotating hospital, always within the same deanery.

I have been
- underpaid
- overpaid
- had my pension deductions stopped without consultation
- had arrears from the above deducted from my wages without my permission

Colleagues suffer the same problems but we all just shrug, along with payroll and HR. Again, its 'just the way it is'.

Would others join me in demanding that we get paid the correct amount in a timely manner?

Competing interests: No competing interests

06 August 2017
Kieran D Donnelly
ST7 ICM and Anaesthetics
Worcester Royal Hospital, Worcester
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Re: The antibiotic course has had its day Cliff Gorton, John Paul, Tim E A Peto, Lucy Yardley, et al. 358:doi 10.1136/bmj.j3418

Dear Sir

The authors are to be congratulated on their courage in publishing this excellent discussion. The piece below was published in Clinical Medicine under the pseudonym 'Coegemus' in 1999. [1]

Two of the most intelligent people I have known, Dr Harold Lambert, whose publication of 1999 is referred to in the article, and the Professor of Bacteriology Richard Lacey of BSE fame both held these views nearly 20 years ago.

In my informal article in which the problem is discussed with a fictitious intelligent layman, I made two points that might help in persuading the medical tradionalists and the general public the logic of the author's case. First that relapse due to too short a period treatment must be with a sensitive organism as was shown when establishing duration of two drug therapy in tuberculosis. Secondly the time scale of bacterial reproduction is such that a much shorter period than conventional courses is almost certain to be adequate.

"There has been much concern about drug resistance in the profession and lay media recently. It so happened that Charles and a distinguished though flamboyant professor of Bacteriology came to dine one night. I broke the rule about not introducing shop.

“Are suitable antibiotics going to run out, or do you think the drug manufacturers will always be ahead of the game?“ I asked.
“Some GPs don’t seem to help” said Charles. “Last week my wife caught an infection from my daughter’s family for whom she baby sits. Kate and her two pre-school children had nasty illnesses starting with colds. My wife got so many aches and pains, that she thought she ought to go to the doctor to make sure it wasn’t something different. He prescribed an antibiotic, telling her she must complete the course”.
“Yes,” said the professor. “In a previously fit lady and with the obvious source, the chance of bacterial infection was virtually nil. Doubtless the doctor explained that she had a virus, but was giving a precautionary antibiotic just in case it was bacterial, and claimed that your wife expected a prescription, which I suspect was not true”.

Charles nodded and I interjected “Once I circularised general practitioners, asking what prior chance of an antibiotic being appropriate justified its prescription. I explained that I expected a lower threshold in general than in hospital practice, where observation was easier. Unfortunately most of them didn’t seem to understand the question” .
“That’s no surprise” Charles said, “although, of course, it is the critical question”.
“Yes” I went on “nevertheless whether appropriately prescribed or not, the course should always be completed”.
“I am not sure” said the professor. “I had been known to say that fortunately most people don’t”.

Seeing my surprise, he asked Charles “Has the layman any further thoughts?”
“First I would like to know what determines whether an organism causes an infection, and the time scale involved”.
“A portal of infection, the organisms virulence, and the host’s defences” said the professor. “In the previously fit individual, the window of opportunity may be very short, and the organism very virulent, for example, in pneumococcal and meningococcal disease”.
“How often do these germs divide?”
“They divide about every twenty minutes, so a single organism becomes a mass several millimetres in diameter within twenty four hours”.
“Seventy generations a day, equivalent to two thousand years for the human race. Don't you think that treatment for a day, or two millennia, might be overkill?”
I acknowledged that a single dose may effectively treat simple urinary tract infection, but countered “But surely, we want to be certain to mop up the remaining organisms”.
“How long do you prescribe for? Five or seven, but not six, days. I suspect, for no better reason than that there are five digits on each hand, and seven days in the week” said Charles answering his own question. “The longer you go on surely the more likely you are to be showing the antibiotic to organisms incidentally on body surfaces, than mopping up accessible organisms not already killed by an antibiotic, to which they are exquisitively sensitive”.

He continued “Recently my son did have pneumococcal pneumonia. He was given injections for 24 hours before switching to a lower dose of oral antibiotic, whose absorption was compromised by actually making him sick. His temperature fell to normal after the first injection. If organisms were lurking in nooks and crannies, and were not killed by several injections, one of which was clearly enough for the majority, wouldn’t you require higher, not lower doses, to eradicate them?”
“But what if treatment is just not long enough?” I asked.
“The germ can’t be resistant if the next dose would kill it”.
“So you suggest to avoid inducing antibiotic resistance in other potential pathogens on body surfaces, we should give high doses until recovery and only worry about relapse if it occurs, probably with the organism still sensitive”.
“That’s right, Coe”.

“You have a point” said the professor. “When the MRC conducted the classical studies progressively shortening the course of treatment for TB, relapse did occur with sensitive organisms. On the other hand they did show the value of an intense initiation phase followed by maintenance therapy continued long after clinical recovery. On second thoughts, this may not be applicable to the acute infections that we are thinking about, as tuberculosis is very different. The host element is large, generation time longer and treatment usually started later. Clinical disease, not a one off event, follows a vicious downward circle, which on being reversed improves host resistance and possibly makes the organisms more rather than less accessible”.
“Don’t you think similar experiments should be done with acute bacterial infections?” Charles asked.
“Yes, but cautiously, relapse might be more dangerous”.
“Who would fund them?” I asked.
“Government” Charles replied.
The professor agreed “Cynicism is unnecessary, drug companies have to count the cost of relicencing even where clinical practice exceeds licence indications. A job for NICE?” "

I hope that the ideas given in the informal format might help in persuading sceptics that the authors are absolutely correct so far as the management of acute primary infections is concerned,

Yours faithfully

CK Connolly

1 Coemgenus. Should you complete your course of antibiotics? Journal Of the Royal College of Physicians of London (JCPRL) 1999; 33 (6): 594

Competing interests: No competing interests

06 August 2017
C Kevin Connolly
Retired Respiratory Physician
Aldbrough St John, Richmond, North Yorkshire DL11 7UJ
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Re: Consultant triage cuts emergency admissions by a third, report finds Sophie Arie. 358:doi 10.1136/bmj.j3701

I read Sophie Arie's report "Consultant triage cuts emergency admissions by a third" (1) with dismay. She found that a study concluded that if consultant surgeons triaged "at the font door" emergency admissions would be reduced by a third, saving the NHS £108m a year. What are we doing to our young surgeons? They take responsibility very seriously but are finding their work being taken over by consultants. We are interfering with their experience and self-confidence.

The Royal College of Surgeons of England seems to take a similar view. In "Whos who in the surgical team" (2) they say, "Foundation doctors [FY1 and FY2] with a keen interest in surgery may be given opportunities to assist in minor elements of surgery under close supervision". What are we coming to? These same doctors, who presumably need close supervision when putting in a skin stitch, are left to take life or death clinical duties looking after a couple of hundred in-patients at night with grossly inadequate help (3).

Lay people believe that care by a consultant is always the best care. It is not. As consultants age they begin to fall behind their senior trainees in treating emergency admissions especially at night. When I was a junior consultant I had to rescue a senior colleague who had decided to send his residents home during a political dispute. I found him slumped over the night sister's desk at 1am. He had removed an appendix, clerked a couple of patients, failed to get an intravenous line in and was completely demoralised.

1) bmj 2017;358:j3701
3) Clarke R. Your life in my hands. London: Metro Books 2017

Competing interests: No competing interests

06 August 2017
Roger H Armour
Retired consultant surgeon
Lister Hospital Stevenage
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Re: Attacks with corrosive substances are increasing in UK Johann Grundlingh, Jessie Payne, Taj Hassan. 358:doi 10.1136/bmj.j3640

Prevention is better than cure.

Crimes are increasing, we remember Sarah Payne around 2003, and the two young girls a few months later around the age of 10 years were abducted and killed, then the stabbing, then the corrosives. The law must change to more severe punishment.

If the people's behaviour changes the law must change.

The safety of the nation is more significant than the dignity (never changing) of the Law.

We lost so many innocent lives and the assailants are still living in society.

Competing interests: No competing interests

06 August 2017
Mohamed Tageldin
Retired orthopaedic surgeon, BMA member
Retired doctor
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Re: Epstein Barr virus, abdominal pain, and jaundice Alexandra Khoury, Francois Porté, Masud Haq. 358:doi 10.1136/bmj.j3386

This is an interesting case and from the information given seems to fit EBV-related viral acalculous cholecystitis as you suggest. However there is insufficient detail given in the text of the testing done to specifically confirm EBV in this case, although they may well have been done. Which EBV-specific serology tests were done and which were positive and which (eg anti-EBNA) were negative? White cells were raised, but was there a lymphocytosis and what was the proportion of atypical lymphocytes? You state that hepatitis A, B, and C serology was negative. Serology in the acute phase would not exclude hepatitis C infection. Was HCV serology tested at a later date? Was hepatitis E serology done? There is a case report of HEV infection associated with a heterophile antibody response.

Competing interests: No competing interests

06 August 2017
Kenneth J Mutton
Medical Microbiologist/Virologist
Arrowe Park Hospital, Wirral, UK
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Re: Antidepressants and murder: case not closed Gwen Adshead. 358:doi 10.1136/bmj.j3697

I completely agree with Prof David Healy's comments on this short article. Only the one psychiatrist who considered the drug had no part in the murders, is quoted. Comments from the two others (one of which was Prof Healy) who both took the opposite view, were not mentioned. For many psychotropic drugs, abruptly ceasing the medication is highly inadvisable as it may result in further serious psychiatric symptoms. This would be especially the case for this patient whose dose had been increased, despite the presence of contraindications for doing this.

The author comments that there are no simple answers. Perhaps the answer to this dreadful occurrence, some other murders (and many suicides) are more straightforward than many doctors and the drug companies involved are prepared to face.

Competing interests: No competing interests

06 August 2017
Elizabeth H Price
Retired medical practitioner
London NW11
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