What are your burning issues for 2018?
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k9 (Published 04 January 2018) Cite this as: BMJ 2018;360:k9
All rapid responses
Heading the ball in soccer is a classical example of repetitive sub-concussive head injury but it has been largely ignored by the medical community and should now be given priority as one of the burning issues for 2018. During the last 20 years there has been a steady trickle of items in the media reporting a link between heading a football and the eventual development of dementia in soccer players. A startling revelation which had extensive media coverage was the news that the manager and three of the 1986 England World Cup team had Alzheimer's disease and a fourth member had severe memory problems. A recent example was a documentary shown on BBC One in November 2017, “Alan Shearer: Dementia, Football and Me”.
Despite media attention, the medical profession has been reluctant to address the issue. However in February 2017 Ling et al¹ published the first paper in the world to show a definite link between heading the ball in soccer and the development of dementia. It described 14 all excellent headers of the ball who developed dementia. Post postmortems were carried out in 6 together with detailed neuropathological studies; 4 had chronic traumatic encephalopathy (CTE) and 2 had Alzheimer’s disease (AD). Concussion was extremely rare in these players and the brain trauma was caused by repetitive sub-concussive head injuries from heading the ball.
A year has elapsed since this study was published and not a great deal has happened. Little is likely to happen until an epidemiological study is published which clearly demonstrates that the prevalence of neurodegenerative disease is significantly higher in ex- footballers than in the general population. On 23 November 2017 the Football Association (FA) announced that it would be funding jointly with the Professional Footballers Association (PFA) a study of approximately 15,000 ex-footballers and comparing them with a similar group from the general population to find out if the ex-footballers have a higher prevalence of neuro-degenerative disease. The study will be over a period of 2 to 3 years and will be led by Dr Willie Stewart, a Glasgow neuropathologist.
It is disappointing that the footballing authorities and the medical community have not already accepted that this is a significant problem particularly when three factual imperatives are kept in mind. Firstly the human brain is a very delicate fragile structure, with the consistency of jelly or blancmange. Alan Turing, the genius who worked at Bletchley Park likened the brain’s grey matter to tepid porridge. It is highly protected by three membranes and is bathed in cerebro-spinal fluid within the confined space of the strong boney cranium. The brain is not tethered within the skull it is able to move and oscillate within this hard rigid case.
The second factor was introduced in 1960 when the brain was first compared to a computer. During the subsequent 50 years there has been a prodigious development in information technology and miniaturisation to create a highly sophisticated computer in the form of a smart phone. As a result it is now much easier to accept the idea that the brain is the most advanced computer in existence. No one would expect a smart phone to escape severe damage if it was whacked repeatedly over many years.
The third factor is the parallel between heading the ball and the brain injury incurred in boxing. This analogy is compelling. Over the years it had been assumed that the brain damage in boxing was caused by memorable bouts, such as the Floyd Mayweather versus Conor McGregor bout on 26th August 2017, when both fighters took terrific punishment. This is no longer received wisdom. It is now known that the damage is caused by repetitive sub-concussive trauma, which occurs in sparring and is repeated week in week out over many years of training. These mild repetitive head injuries in sparring are virtually identical to heading the ball in soccer. In 2016 this journal published two articles side by side, ‘for’ and ‘against’ boxing², both articles were in agreement that sparring was the cause of the mental deterioration in the sport.
Despite the reluctance of the FA and PFA I have title doubt that two steps should be taken without delay. The first involves the welfare of demented former players. The game of soccer, particularly the Premier League, is awash with money derived mainly from big television companies who are eager to have an almost continuous flow of high quality sport, particularly soccer, on their schedules. It is long overdue for some of this money to be channeled into an earmarked fund to ensure that ex-players with dementia receive high quality care and that their relatives have easy access to an effective support network.
The second step involves children. During the last few years more attention has been given to sports injuries, the problem of concussion in rugby is a good example. As a result parents are now beginning to ask should their children be heading the ball. Although there is no conclusive evidence that heading the ball in children leads to neuro-degenerative disease in later life, nevertheless a child’s brain is still developing and does not have the same level of protection as the adult’s brain. Bearing this in mind and using the Precautionary Principle, the logical next step is for heading the ball to be banned altogether in children under the age of 11, as it is in the United States. At the same time a public education programme should be embarked upon to draw attention to the fragile nature of the human brain.
As soccer is the most popular game in the world and dementia is such a horrific illness serious consideration should be given for soccer and dementia to be adopted by this journal as one of the burning issues for 2018.
References:
1. Ling, H., Morris, H.R., Neal, J.W. et al. Acta Neuropathol (2017) 133: 337. https://doi.org/10.1007/s00401-017-1680-3
2. Should we ban boxing? BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i389
Competing interests: No competing interests
My vision for 2018 and beyond is to influence the development of Safe Houses in Scotland for people who experience psychosis, alternatives to psychiatric inpatient treatment, offering a range of therapies and activities for mental wellbeing and recovery, including minimum prescribing of neuroleptics and help with tapering meds. Therefore I am researching safe haven crisis houses in other countries to evidence good practice, leadership and management, and to hear the stories from the people involved.
Now aged 65, I’ve experienced puerperal psychosis twice, in 1978 and 1984, a menopausal psychosis in 2002, voluntarily entering psychiatric wards on all 3 occasions to be coercively drugged, eventually tapering meds myself, making a full recovery. More of my story can be found in a Psychosis Journal Opinion Piece, October 2017: 'Risk of relapse in psychosis: facing the fear, resisting mental illness' (1) and other stories in my main blog (2).
I’ve supported my 3 sons, 41, 39 and 33, when they experienced psychosis/psychiatry, helped them taper meds as I did. Then in 2015 I transitioned a 4th psychosis after years of campaigning for justice after my son's negative treatment as a psychiatric patient in February 2012, this time avoiding psychiatric treatment (3). This was a much more positive and life affirming experience from which I emerged a stronger, more confident, person.
I believe that psychosis is transitional, can be a journey, an escape, a positive and uplifting experience if reasoned out, worked through and helped by companions, friends who are equals, without agendas. People who are willing to share in an Other's pain and imaginings, and in so doing may become part of the psychosis journey themselves.
(1) Risk of relapse in psychosis: facing the fear, resisting mental illness: https://doi.org/10.1080/17522439.2017.1381757
(2) Chrys Muirhead Writes blog: http://chrysmuirheadwrites.blogspot.co.uk/
(3) Hospital Horrors: Patient locked in cell with no toilet, food or water; Scottish Sunday Express, 5 October 2014: https://www.express.co.uk/news/uk/518869/Patient-locked-in-cell-with-no-...
Competing interests: No competing interests
Dear editor,
Most of the responses to the call for papers so far seem to mention the R word (rationing) as something that has not been implemented well in the NHS. One of the respondents even claims to be draining pension monies from the public purse and NHS because a lack of rationing condemned him to an ever longer existence instead of quietly passing away after three years of retirement.
Rationing is not new, it was recognised as a necessity soon after the inception of the NHS with the removal of free teeth and glasses and the introduction of prescription charges. As a result of the uncoordinated approach to rationing we are left with an illogical list of more or less random health conditions qualifying patients for exemption to prescription charges.
In 2018 the government is likely to implement another short sighted policy of removing a number of random medications from the NHS, akin to the random exclusion of Sildenafil in 1997.
Instead of concentrating on the supply side, it is time to attend to the demand side. A modest reduction of demand will mean the NHS can cope on 90% capacity, instead of failing trying to run at 110%.
The editorial mentions healthcare abroad, but the NHS is the only system claiming to provide universal care without co-payments. The idea is so illogical that it has remained unique on the planet.
The only evidence in relation to reduction of demand comes from the RAND experiment in the way of co-payments. I think patients would be much happier having a service that provides good quality care, is accessible, and I think patients would not object to paying a small fee proportionate to their means to access improved services.
http://www.nationalarchives.gov.uk/cabinetpapers/alevelstudies/managemen...
Competing interests: No competing interests
Nowadays, CRISPR-cas9 gene editing has quickly and successfully managed to engineer Anopheles mosquitoes resistant to Plasmodium malaria parasites, stable transmission of mutant alleles to progenies, reduced fertility mosquitoes, etc. [1][2][3][4]
Even necessary funding for breeding and distribution of these genetically modified mosquitoes is provided by Charities. [5][6][7][8][9][10]
Only 3 billion pounds, paid in several years, are necessary in order to eliminate malaria deaths worldwide.
In the meantime, 72 billion pounds are gathered and collected, annually, from English and Welsh Charities alone, [11] and $390 billion from US Charities! [12][13]
Only political will, cooperation between various Countries, and elimination of corruption remain, in order to completely eradicate malaria from the Planet.
References
[1] http://www.nature.com/nbt/journal/v34/n1/full/nbt.3439.html
[2] http://www.nature.com/news/gene-drive-mosquitoes-engineered-to-fight-mal...
[3] http://www.pnas.org/content/112/49/E6736.full.pdf
[4] http://www.bmj.com/content/353/bmj.i2548
[5] https://www.gov.uk/government/news/3-billion-pledge-to-help-end-malaria-...
[7] https://www.theguardian.com/society/2016/jan/25/british-government-and-b...
[8] http://www.wired.co.uk/news/archive/2016-01/25/government-bill-gates-end...
[9] http://www.reuters.com/article/malaria-funding-idUSL8N1591PN
[10] http://www.telegraph.co.uk/news/12119166/Bill-Gates-and-George-Osborne-a...
[11] https://www.thetimes.co.uk/article/1-of-charities-get-most-of-the-cash-m...
[12] http://www.cnbc.com/2017/06/13/americans-gave-390-billion-to-charity-las...
[13] https://www.forbes.com/sites/niallmccarthy/2017/06/13/where-are-americas...
Competing interests: No competing interests
Thanks for inviting readers (Editor's choice 6.1.18) to raise burning issues for the BMA to tackle in 2018.
I have found that the BMA is not doing as much as I would have expected re. health and alcohol. We did better with smoking, with the result that each packet carries a health warning. Today's Guardian informs us that there is public support for warning labels to be put on cans and bottles.
Now that routine operations have been postponed and A/E departments are dealing with people with alcoholism in 'drunk cabins' to ease the pressures, I hope the BMA will do the impossible and take on the alcohol lobby.
Competing interests: No competing interests
With its liberal use of psychiatric drugs, psychiatry - which includes the work of GPs with psychiatric patients - does far more harm than good (1). Yet, not a single country has taken the UN’s handicap convention seriously, although it is impossible to argue, ethically or scientifically, that it is in the patients’ best interest to be subjected to forced treatment with neuroleptics (1).
According to the prevailing paradigm, psychiatric drugs have specific effects against specific disorders; their actions provide more good than harm; and it is often necessary to take them for years or perhaps even lifelong. Furthermore, many psychiatrists still tell their patients that they suffer from a chemical imbalance, and that taking a psychiatric drug is similar to taking insulin for diabetes (1).
This has been the paradigm in psychiatry since chlorpromazine came on the market in 1954. However, when the research in support of the paradigm is critically appraised, it becomes clear that the paradigm is unsustainable.
Firstly, the effects of psychiatric drugs are not specific. They impair higher brain functions and cause similar effects in patients, healthy people and animals, which is far from causing specific effects in specific disorders (1,2).
Secondly, the research in support of the paradigm is flawed (1-3).
Thirdly, the widespread use of psychiatric drugs has been harmful for the patients. In every country where this relationship has been examined, the increased usage of psychiatric drugs has been accompanied by an increase in the number of chronically ill people and the number of people on disability pensions (3). This speaks strongly against the idea of having specific drugs for specific disorders.
Fourthly, all attempts at showing that psychiatric disorders cause brain damage that can be seen on brain scans have failed. This research area is intensely flawed and very often, the researchers have not even considered the possibility that any brain changes they observe could have been caused by the psychiatric drugs their patients have taken for years (1,2). In contrast, it has been shown in many reliable studies - most clearly for neuroleptic drugs - that psychiatric drugs can cause permanent brain damage (1-3).
There are four main problems with psychiatric drug trials:
1) Almost all placebo-controlled trials are flawed due to their cold turkey design (1) Patients who are already in treatment first go through a wash-out period, when everyone is removed from the drug they had been on, and they are then randomised to placebo or drug. The wash-out period is too short to avoid withdrawal symptoms in the placebo group(1,4). These withdrawal symptoms can be the same as those that define the disorder, e.g. depression in depression trials, and the withdrawal effects can be very pronounced. One-third of patients in long-term treatment with sertraline or paroxetine who had been well for 4 to 24 months after remission of their depression had an increase in their Hamilton score of at least 8 during a 5-8 day period where the drug was substituted with a placebo (5).
2) The trials are insufficiently blinded (1).The drugs have conspicuous side effects and many patients and doctors have therefore guessed whether the drug is active or placebo. This is an important problem when the outcomes are subjective (1), which they virtually always are in psychiatric drug trials.
3) Psychiatrists assess the effect using rating scales, the relevance of which for the patients is often uncertain (1).
4) Selective reporting of outcomes is very common and can be very serious (1). As just one example, only about half of the suicides and half of the total number of deaths are reported in published drug trials compared with available data in trial registers (6), and we have found in our research that trial registry data may also be incomplete.
Psychiatry needs a revolution. Reforms are not enough. We need to focus on psychotherapy and to hardly use any psychiatric drugs at all.
Disclaimer: these are my views, based on ten years of research on psychiatric drugs. But they are shared by many patients.
1. Gøtzsche PC. Deadly psychiatry and organised denial. Copenhagen: People’s Press; 2015.
2. Breggin PR. Brain-disabling treatments in psychiatry: drugs, electroshock, and the psychopharmaceutical complex. New York: Springer; 2008.
3. Whitaker R. Anatomy of an epidemic. New York: Broadway Books; 2015.
4. Fava GA, Gatti A, Belaise C, Guidi J, Offidani E. Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: a systematic review. Psychother Psychosom 2015;84:72-81.
5. Rosenbaum JF, Fava M, Hoog SL, et al. Selective serotonin reuptake inhibitor discontinuation syndrome: a randomised clinical trial. Biol Psychiatry 1998;44:77-87.
6. Hughes S, Cohen D, Jaggi R. Differences in reporting serious adverse events in industry sponsored clinical trial registries and journal articles on antidepressant and antipsychotic drugs: a cross-sectional study. BMJ Open 2014;4:e005535.
Competing interests: No competing interests
Dear Dr Tweedie
You are just a few years younger and therefore you have seen the NHS through similar changes.
You will recall the original, 1948, model of Nye Bevan. An ideal to yearn for.
Back in the '60s, Sheldon had to raise charity money for renal dialysis. Later Her Majesty found the money for dialysis and agreed to fund machines for home dialysis WHERE the local authority agreed to fund the building costs for conversion to house the machines. A pretty obvious example of local authority and NHS collaboration.
When the contraceptive pill was "born", at first - quite rightly in my view - it was NOT prescribed on the NHS. The ladies (they were not patients) paid a GP for the private prescription and bought it from the chemist. And the men? There was the barber, more elegantly described as the hair dresser, who had a supply of "Something for the weekend, Sir?"
I see no justification for turning pleasure in to DIS ease and pouring NHS money into the so-called family planning services. Mrs Barbara Castle was responsible - in the name of women's liberation.
The GPs who had previously shunned contraception provision now vied to provide it. Even those who had, previously, cited religious objections, now lapped up filthy lucre.
Previously, in the pre-1974 model, the local authority-based medical officers of health had contracts with the Family Planning Association, for the provision of the contraceptive services, TO THOSE women who resided within the boundaries of the local authority concerned. " Plan 5" it was, in the local authority which I served.
And, did you know that Mrs Castle then agreed that even whole-time consultants who carried out family planning work (be it IUCD insertion or removal, vasectomies, salpingectomies, or histological confirmation that the specimen sent was indeed a bit of the fallopian tube or the vas, or that no motile sperms were to be seen in the semen after vasectomy) would be paid extra? As you were an anaesthetist, you were no doubt aware.
I too have had the benefit of artificial knees, artificial hip, a cataract removed. I thank Nye Bevan.
The minister has the choice -
Ban such surgery (as I have had) and let the patient become immobile, house-bound, dependent
OR
Allow people like me to retain the ability to look after themselves a little longer.
One thing is certain. Free contraceptive services have not abolished the demand for abortion services in THIS COUNTRY.
Competing interests: No competing interests
1. Should mammography breast cancer screening be abolished?
It seems to me that when experts cannot agree (1), any benefits are likely to be small and therefore the costs of providing the service in the UK, including the costs to the participants, are likely to be poor value for money.
2. Gabapentin and Pregabalin.
I come from the pre-Pregabalin era and find it hard to remember patients whose quality of life would have been improved had these drugs been available then. Widely used in fibromyalgia, an unlicensed indication. Prescriptions and deaths associated with overdoses have increased exponentially in the past few years (2).
Does anyone know a doctor who has found these products personally helpful? Have they seen this BBC Video (3)?
I am reminded of the successful voluntary ban by family doctors on the prescription of barbiturate sleeping tablets in the 1960s.
3. Influenza Immunisation.
Does it work? The hardy campaigner JK Anand has reasonably asked the question which has fallen on deaf ears (4).
4) Antidepressants.
Antidepressants - including the drugs that “increase serotonin levels in the brain” (5) - are said by some to be ineffective if not positively harmful (6). Stavros Saripanidis – another correspondent who won’t go away - has pointed this out (7). Des Spence has proposed that prescribing of antidepressants in primary care should be stopped for the same reasons (8).
So, Madam Editor, if by the end of 2018 you have provided answers to one or two of these topics you may have at least a handful more happier readers.
References
1. http://www.bmj.com/content/359/bmj.j5224 and discussion.
2..https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri...
3. http://www.bbc.co.uk/news/av/uk-england-devon-40937449/prescription-drug...
4. http://www.bmj.com/content/359/bmj.j5629/rr-1
5. https://www.nhs.uk/conditions/ssri-antidepressants/
6. http://www.bmj.com/content/358/bmj.j3697/rr-4
7. http://www.bmj.com/content/356/bmj.j336/rr
8. http://www.pulsetoday.co.uk/views/dr-des-spence/we-need-to-stop-prescrib...
Competing interests: No competing interests
I would like to see the pharmaceutical industry out of the heart of government and state [1,2].
There needs to be an urgent and fearless investigation into the causes of the rising tide of neuro-developmental disorders in young children [3,4].
[1] 'Tom Jefferson: The UK turns to Witty, Vallance, and Van Tam for leadership: revolving doors?'
http://blogs.bmj.com/bmj/2017/12/06/tom-jefferson-the-uk-turns-to-witty-...
[2] Tom Moberly, 'The pharma deals that CCGs fail to declare', 4 January 2018, http://www.bmj.com/content/360/bmj.j5915
[3] John Stone, 'Re:'US government website for collecting adverse events after vaccination is inaccessible to most users' 29 May 2017, http://www.bmj.com/content/357/bmj.j2449/rapid-responses
[4] John Stone, 'The writing is on the wall', 19 July 2017, http://www.bmj.com/content/357/bmj.j2449/rr-16
Competing interests: No competing interests
Re: What are your burning issues for 2018?
Dear Editor
12 months ago you asked us, the readership, to suggest examples of topics the BMJ should focus on during 2018.
Below, I have tried to summarise the “rapid responses” received at the time, roughly in chronological order.
1. Using trained para-medical staff for cataract and other surgery
2. Ethical rather than scientific approach to healthcare
3. Reducing income inequality to improve health
4. Non-NHS bodies in health and social care
5. Inform the public about privatisation of NHS
6. Antidepressants: Over prescribing and risks/benefits. Comparison with psychotherapy
7. Avoiding “too much medicine”
8. Help for patients with prescribed-drug dependence
9. Establish NHS priorities: role of co-payments by patients
10. Eliminate poverty
11. The incidence and causes of neuro-developmental disorders (particularly Autism and ADHD)
12. Should mammography breast cancer screening be abolished?
13. The role of Gabapentin and Pregabalin in chronic pain
14. Influenza Immunisation. Does it work?
15. Reduce influence of Pharmaceutical Industry on Government
16. Examine provision of free contraception under NHS
17. The influence of the Alcohol Lobby
18. Malaria eradication
19. Safe Houses for people who experience psychosis
20. Heading the ball in soccer: does it cause dementia?
It would be interesting know whether this exercise influenced the journal content, and whether the BMJ proposes to repeat the exercise this year.
Competing interests: No competing interests