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All rapid responses

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: Cardiologist convicted of presenting false prescription escapes suspension Clare Dyer. 357:doi 10.1136/bmj.j2845

I could not help comparing the treatment of these two colleagues - both by the journalist and the GMC since the two cases are next to each other and appear on the same page. We are all supposed to be treated equally without bias or prejudice, right?
The article says of Dr Ademola that "she qualified in Nigeria in 1997" but we are not given any such details about Dr Boyle. What subliminal message is the journalist giving, and what is the relevance to the case?

The tribunal found that Dr Boyle "had not acted dishonestly", but he wrote prescriptions for himself using colleagues', and patients' names and worked in his private practice when on call at his hospital. These actions were not provoked, but were deliberate and by choice. The NHS rota was not under his control, but he certainly had control over the scheduling of his private patients. Dr Ademola's action on the other hand was provoked. So the GMC made excuses for Dr Boyle so as not to suspend him, but suspends Dr Ademola despite their own finding that her " misconduct was an isolated incident set against an otherwise unblemished career" , citing “the impressive array of testimonials that speak of you as a dedicated, capable and caring doctor.”

What are we supposed to think?

Competing interests: No competing interests

17 June 2017
EMMANUEL UDEZUE
Locum Consultant Physician
Southmead Hospital, Bristol
22 BOWER ROAD, QUEENS PARK
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Re: Coroner calls for GPs to be allowed to order urgent CT scans after patient death Clare Dyer. 357:doi 10.1136/bmj.j2815

This type of proclamation from a Coroner is unhelpful. There is an implication that the GPs should have done a CT scan but didn't have the ability to request one. However, the A&E department did have access to CT but sent the patient home. Therefore, the call for GPs to have access to CT doesn't make sense. It also looks at an isolated case and makes assumptions and demands that would apply to a large population. It assumes that all GPs want direct access to advanced tests. In many cases such access will result in a great number of patients demanding that their GP sends them for a CT when presenting with vague symptoms. This increases GP workload and also means that GPs will still have to deny many patients a CT and could still end up missing such a case. In my experience this often serves to pass the liability of missed diagnosis onto already overworked and burnt out GPs, but with no evidence of increased patient safety.

Competing interests: No competing interests

17 June 2017
Kaiser Chaudhri
GP &a Medico-Legal Expert Witness
2 Broadway, Preston
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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 first rule of practising evidence-based Medicine is: read the evidence. The respondent below seems to have read a different article in declaiming all these treatments to be useless and dangerous, while under the impression that harms from western Medicine are axiomatically fewer. The lack of discrimination in criticism between any of the different modalities of treatments while branding them all a dangerous threat is also not very convincing.

The article describes a significant body of clinically meaningful RCT evidence - including inflammatory markers - finding that acupuncture may be as effective as DMARDS and may add benefit to DMARD treatment in patients with Rheumatoid Arthritis.
The article also describes a body of relevant evidence of benefit of acupuncture for chronic low back pain. As a USA Orthopaedic surgeon, Steven Zeitzew would know that; "The clinical practice guideline provided by the American College of Physicians and the American Pain Society recommends acupuncture as a non-drug therapy for CLBP patients.".

The harms of acupuncture suggested by the evidence are of the order 0.13%-0.14% for minor adverse events, with no serious adverse events in trials of 31,000 and 35,000 patients. Rather safer than NSAIDs, then.

As a family doctor who practises osteopathy free of charge in the NHS, I was disappointed not to see any mention in the article of the high quality RCTs showing significant clinical benefits of osteopathy, over and above exercise/physio. I have the advantage of continuity of care to know that these patients really do benefit substantially directly from osteopathic treatment, in all of the measures - pain, function, use of analgesics, employment/disability, referrals and reduction in surgery - which one would consider as important outcomes. The positive cost-effectiveness analysis of the UK BEAM trial has been published, so it is a shame to see that the recommendations for manual therapy have been weakened in the revised NICE guideline for back pain. Osteopathy is also safer than NSAIDs.

Where evidence is weak or conflicted, it is sensible to adopt equipoise and learn to tolerate uncertainty while further, better-targeted research evidence is allowed to emerge. Thanks to BMJ for publishing this interesting evidence review, I would recommend contributors read it.

Competing interests: As a medical practitioner of structural osteopathy, I use mechanical, predictable techniques to treat patients' musculoskeletal pain and dysfunction. I believe the evidence base is sufficient for osteopathy to be considered as a first-line treatment alongside or in place of conventional treatments such as physiotherapy.

17 June 2017
Nick Mann
GP & NHS Osteopath
Well St Surgery
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Re: David Oliver: How can we plan for old age if we won’t discuss it honestly? David Oliver. 357:doi 10.1136/bmj.j2759

1. Old Age is not a medical diagnosis.
2. If you decide -regardless of your age - that you do not wish to live any longer ( done all , good or bad you wanted to,) you could become a Jain monk or nun, in Rajputana ( India). You could walk , barefoot of course, to an isolated place, stop eating and drinking. Then you could peacefully shed your mortal coil. No one, but no one, will interfere.
PS. But please, could NHS ENGLAND be prevented from exporting geriatric patients to India?

Competing interests: No competing interests

17 June 2017
JK Anand
Retired doctor
Free spirit
3 Wayford Close, Peterborough
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Re: Development and validation of risk prediction equations to estimate survival in patients with colorectal cancer: cohort study Julia Hippisley-Cox, Carol Coupland. 357:doi 10.1136/bmj.j2497

Dear Sir/Madam,

I read the paper by Hippisley-Cox and Coupland, as well as the accompanying editorial by Usher-Smith et al with great interest.[1, 2] The articles rightly highlight the advantages of the new QCancer 2017 model presented and discuss the potential advantages for clinicians and patients using the model when discussing treatment options for colorectal cancer.

I would further like to point out that the model actually may have an even more significant impact in illustrating what the survival rate may be if the patient decides to undertake no treatment.

The Choosing Wisely UK campaign says this of Shared Decision Making: "It explicitly acknowledges the fact that there is usually more than one way to treat a problem, including ‘no treatment’ and patients may require help to weigh up the benefits and harms of the options in order to determine the best choice for them."[3]

Clinicians generally lack the data to adequately counsel patients on what outcomes might be should they decide not to undertake complex and risky procedures or treatments which may result in iatrogenic complications.

This added information is very much welcome as patients and clinicians become increasingly aware that interventions may sometimes result in Pyrrhic victories where the surgery or chemotherapy has been a "success", but at the cost of good quality of life when that life may be very limited in duration.

References:
[1] J Hippisley-Cox, C Coupland. Development and validation of risk prediction equations to estimate survival in patients with colorectal cancer: cohort study. BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2497

[2] J Usher-Smith, R Miller, S Griffin. Predicting survival in patients with colorectal cancer. BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2772

[3] Shared decision making - Choosing Wisely UK. http://www.choosingwisely.co.uk/i-am-a-clinician/shared-decision-making/ Accessed 17 July 2017.

Competing interests: No competing interests

17 June 2017
Danny J. N. Wong
Anaesthetic Registrar and PhD Research Fellow
National Institute of Academic Anaesthesia Health Services Research Centre
Royal College of Anaesthetists, Churchill House, 35 Red Lion Square, London, WC1R 4SG
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Re: David Oliver: How can we plan for old age if we won’t discuss it honestly? David Oliver. 357:doi 10.1136/bmj.j2759

Editor

Within days of this column being published i see that On 17th June the readers' editor in the Times newspaper reported angry readers complaining about a piece the week before describing people in their forties as "middle aged". "Why should we be insulted in this way? We are older but not THAT old"

This precisely illustrates the issue i was alluding to. Why should being called middle aged be seen as an insult rather than merely a value free description

Age might mean some loss of youthful looks and energy but it also brings life experience, wisdom, perspective and often well earned seniority and credibility in careers. Life evens things up that way

The sum of our parts as humans isn't youth, looks and athleticism and "successful" or "optimal" ageing shouldnt be reduced to how much we can look and act younger than our chronological age

David Oliver

Competing interests: No competing interests

17 June 2017
David Oliver
Consultant Physician
NHS
Berkshire
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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

Progestogens increase weight gain and obesity

Congratulations to Persson and colleagues for confirming an increased risk of congenital abnormalities with maternal obesity.1 A main cause of rapid weight gain leading to obesity is use of progestogen dominant hormonal contraceptives.

. I found in 1968 that the oral contraceptives (OCs) causing most headaches and migraines also thickened endometrial arterioles. These OCs also caused most weight gain, with half of the women gaining an average of 4.5 kg within the first 12 months of use with one combination or norethisterone acetate and ethinyloestradiol.2

Depo medroxyprogesterone acetate (DMPA) caused significantly greater weight gain with longer use in adolescent girls than the Pill. After 18 months of use obese girls gained 9 kg while non-obese girls gained 4 kg. The authors considered that the potential contribution of DMPA to severe obesity in adolescents is concerning.3 DMPA has no inherent oestrogenic or androgenic effects, which suggests that weight gain induced by DMPA is mostly a progestogenic effect.

In 2013 a US study of 30 etonorgestrlel (ENG) implant users, 130 levonorgestrel intrauterine system (LNG-IUS) users, 67 depot medroxyprogesterone acetate (DMPA) users and 100 copper intrauterine device (IUD) users, the mean weight change (in kilograms) over 12 months was 2.1 for ENG implant users; 1.0 for LNG-IUS users; 2.2 for DMPA users and 0.2 for copper IUD users.4 Long-acting levonorgestrel IUS is used to discourage early discontinuation and extend average first year use from 6 to 9 months in teenagers.5

1 Persson M, Cnattlinggius, Villamor E et al. Risk of major congenital malformations in relation to maternal overweight and obesity severity: cohort study of 1.2 million singletons.BMJ 2017;357:j2563

2 Grant ECG. Relation between headaches from oral contraceptives and development of endometrial arterioles. BMJ 1968;3:402-5.

3 Bonny AE, Ziegler J, Harvey R, et al. Weight gain in obese and nonobese adolescent girls initiating depot medroxyprogesterone, oral contraceptive pills, or no hormonal contraceptive method. Arch Pediatr Adolesc Med. 2006; 160: 40-5.

4 Vickery Z, Madden T, Zhao Q, Secura GM, Allsworth JE, Peipert JF. Weight change at 12 months in users of three progestin-only contraceptive methods. Contraception 2013. pii: S0010-7824(13)00090-5.

5 Harel Z, Biro FM, Kollar LM, Rauh JL. Adolescents' reasons for and experience after discontinuation of the long-acting contraceptives Depo-Provera and Norplant. J Adolesc Health. 1996;19:118–23.

Competing interests: No competing interests

17 June 2017
Ellen C G Grant
Physician and medical gynaecologist
Retired
Kingston-upon-Thames. KT2 7JU. UK
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Re: Do doctors have a duty to take part in pragmatic randomised trials? Marion K Campbell, Charles Weijer, Cory E Goldstein, Sarah J L Edwards. 357:doi 10.1136/bmj.j2817

Sir
Surely the most interesting finding in this debate is the fact that all the authors agree on the benefits of doctors participating in pragmatic research; even those who oppose the idea that doctors should be forced to participate agree that participation does benefit society. I would contend that the issue of 'duty' or 'obligation' misses the point. What we need is a system that encourages doctors and patients to participate in pragmatic research. In particular, doctors and patients and health administrators should all be encouraged to participate in comparative effectiveness research. When there are multiple treatments that have been shown to be of benefit for a particular condition, there are benefits to everyone if the medical profession can determine whether one treatment is superior to another, or whether one particular treatment is superior to the alternatives in a specific context. Patients will obviously benefit if they receive the optimal treatment, and the health services will benefit if the correct treatments are given to the correct patients; there will be less prescribing of ineffective treatments, and costs will be reduced if it can be shown that a cheaper treatment is at least as effective as a more expensive treatment. (The one group who would perhaps not benefit are commercial enterprises who market relatively ineffective treatments.)
Unfortunately, there are many obstacles at present to performing multicentre pragmatic randomised controlled trials. I am involved in an international study group - EpiNet - whose goal is to promote large investigator-led observational studies and pragmatic randomised controlled trials to determine the optimal treatment for people with epilepsy. We have been repeatedly surprised how difficult it has been to actually get studies underway; these range from difficulties with obtaining regulatory and ethical approvals, the need to pay for various services, apathy and disinterest from doctors, and suspicion of research by patients.1
I would therefore contend that a better question than: "Do doctors have a duty to take part in pragmatic randomised trials?" would be: "How can the various health services encourage pragmatic randomised trials?"

Peter Bergin, Chairman of EpiNet study group. pbergin@adhb.govt.nz

References
1) Bergin, P.S., Beghi, E., Sadleir, L., Brockington, A., Tripathi, M., Richardson, M., et al for the EpiNet Study Group., 2017. EpiNet as a way of involving more physicians and patients in epilepsy research; validation study and accreditation process. Epilepsia Open. 2017:2(1);20–31 http://onlinelibrary.wiley.com/doi/10.1002/epi4.12033/full

Competing interests: No competing interests

17 June 2017
Peter S Bergin
Neurologist
Auckland City Hospital, Centre for Brain Research
Park Rd, Grafton, Auckland, New Zealand
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Re: Measuring quality of life Anthony Cohn. 354:doi 10.1136/bmj.i3816

As an academic psychologist, I began reading Dr Cohn’s ‘Measuring quality of life’ with more than a little interest. What new insights would this offer?

It became evident that this was a reflection on a life in healthcare, and also a confession. I don't know what I was more appalled by: 1) the idea that any consultant medical professional could understand so little about what constitutes ‘quality of life’?, 2) that Dr Cohn would admit to having previously used his limited understanding of quality of life "to suggest withdrawal of care for sick premature babies or avoiding intensive treatments for children with multiple disabilities”?, or 3) that Dr Cohn felt that he could use such an article to "apologise to those children and their families for whom I have been a two-dimensional doctor”? I am outraged, both personally and professionally.

In my personal life, I have experienced the loss of a child, and witnessed the detached style in which health professionals handle such interactions with families who are in shock, denial and experiencing unbearable grief. I have always credited them for their professionalism and been in awe that they can do this type of work day-in-day-out. Dr Cohn's confession leaves me wondering, yet again, if the "suggested withdrawal of care" was fully justified and I will never know the answer. I am also left second-guessing (possibly unfairly) every other interaction I have with the medical profession, in both my personal and professional life.

In my professional life, I have researched ‘quality of life’ for almost twenty years, and I can assure Dr Cohn that it is anything but two-dimensional. Quality of life is multi-dimensional, subjective, and dynamic. Different things matter to different people, what is important to one person is less important to another, and such evaluations change over time. Health professionals need to be able to take this into account. It can never be their decision to withdraw support for a life or to determine the treatment approach most suited to an individual. Health professionals must support individuals and families in their decision-making about what is best for them in their situation. But, those individuals and families are relying on them to provide fully informed recommendations based not only on evidence but also on a sophisticated, multi-dimensional, understanding of ‘quality of life’.

I know far too many health professionals and health researchers who pay lip service to the whole field of ‘quality of life’, as though I (an academic psychologist), make too much of the nuances of accurate, valid and reliable assessment. They take a reductionist approach, often applying too much weight to such issues as mobility and pain (which are not always relevant or important) and not enough to issues such as spontaneity, independence and confidence. In any given situation, it will only ever be the individual who can determine what matters for his or her own quality of life, and how this is impacted by living with a medical condition or by a particular medical treatment or self-management approach. When that person does not have the means or faculty to answer for him/herself, then they are reliant on family and health professionals to make ‘proxy’ assessments. We know these to be flawed, as they are informed by the proxy reporter's own set of personal values (not by the individual’s). When the health professional is the proxy, we need to be able to trust that he/she has considered ‘quality of life’ in more than two dimensions.

Having, at first, been appalled by Dr Cohn’s admissions, I am now more at ease with the idea that his perspective needed to be published. Dr Cohn now realises that his decisions earlier in his career may have been flawed and the authority of his "position may have silenced any dissenting voices”. If this article can remind just one other health professional of the privilege of their position, and the responsibility they have to think of ‘quality of life’ in multi-dimensional terms, then it will have served an important purpose. I can assure Dr Cohn and any of his like-minded colleagues that ‘quality of life’ matters and, in the end, it is all that matters.

Competing interests: No competing interests

17 June 2017
Jane Speight
Chartered Psychologist
Deakin University, Geelong, School of Psychology, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia; AHP Research, Hornchurch, UK
The Australian Centre for Behavioural Research in Diabetes, 570 Elizabeth Street, Melbourne, Victoria 3000, Australia
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Re: Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies Louisa Degenhardt, Lucas Wiessing, Marica Ferri, Roberto Pastor-Barriuso, et al. 357:doi 10.1136/bmj.j1550

The article authors justify use of an inaccurate and stigmatizing term that could lead to harmful policies and worse patient outcomes by stigmatizing an effective treatment, by noting that 1) it is a MeSH term and that 2) health organizations use it. In my view it is incumbent on us as physician scientists to use correct, accurate and non-stigmatizing terms regardless of what some organizations might say. Organizations can change and they do. MeSH terms can change and they have for many conditions.

The authors also suggest that "opioid agonist treatment" would be confusing because it doesn't specify whether it is for detoxification or maintenance. This argument is not useful. Most medications are just called medications (e.g. for diabetes) without specifying there exact use (for diabetic ketoacidosis vs maintenance of glucose control over time). Further, use of opioids for detoxification is not confused with maintenance treatment of the chronic disease.

Contrary to the statement in my prior rapid response and also contrary to what was stated by the authors in their response, it turns out that the WHO is no longer using the term "substitution." They now refer to it as "opioid agonist maintenance treatment." BMJ and clinical scientists can now follow the WHO if they need an organization to follow, beyond the imperative to use accurate nonstigmatizing terms. Problem solved.
http://www.who.int/bulletin/volumes/91/2/12-111815/en/

Competing interests: Vice President, International Society of Addiction Journal Editors, coordinating committee member International Network on Brief Interventions for Alcohol and Other Drugs, Burroughs Wellcome Fund, Alkermes provided mediation for an NIH funded study, National Institutes of Health (NIH), Department of Veterans Affairs, Editor of Journal of Addiction Medicine, Associate Editor JAMA, Editor and author for UpToDate and the American Society of Addiction Medicine Principles of Addiction Medicine, editor of Evidence-Based medicine last year, consultant to numerous non-profit health care (Kaiser Permanente) and health professional education and research institutions.

16 June 2017
Richard Saitz
Chair and Professor, Department of Community Health Sciences, Boston University School of Public Health
801 Massachusetts Avenue, Ste 433
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