Search all rapid responses

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: Prenatal antidepressant use and risk of attention-deficit/hyperactivity disorder in offspring: population based cohort study Emily Simonoff, Phyllis K L Chan, Wallis C Y Lau, Martijn J Schuemie, et al. 357:doi 10.1136/bmj.j2350

The consequences of prenatal antidepressant use to treat or prevent depression is a relevant question of risk versus benefit. Antidepressant use in pregnancy has been associated with malformations, neonatal problems and septal heart defects. The BMJ published a new study about the association with autism [1]. Although small risks within a population might seem too high from an individual’s perspective.

The message of the study of Man and colleagues [2] about risk of attention-deficit/hyperactivity disorder confuses physicians and women. I think the nature and severity of maternal mental disorder must be taken into a greater account. There are strong limitations in the study. The role of confounding by underlying maternal psychiatric disease remains unanswered. The groups of serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants are very heterogeneous regarding their affinities for the serotonin transporters. The question of co medication is unclear, especially the use of atypical antipsychotics (for example, quetiapine with high serotonergic effects and the use of mood stabilizers like lithium and valproate, with a high risk of teratogenic effects). In this study, there was an absence of detailed measures to assess trimester specific effects and discrepancies between specific types and severity of depressive disorders.

1) Rai et al. Antidepressants during pregnancy and autism in offspring: population based cohort study BMJ 2017;358:j2811
2) Man KKC, Chan EW, Ip P, et al. Prenatal antidepressant use and risk of attention-deficit/hyperactivity disorder in offspring: population based cohort study. BMJ2017;357:j2350SUB

Competing interests: No competing interests

26 July 2017
Detlef Degner
senior consultant, Psychiatrist
Department of Psychiatry, Medical School of Georg-August University, Goettingen
D-37075 Göttingen, Germany
Click to like:
4
Re: Patients harmed by mesh implants address emotional parliamentary meeting Rebecca Coombes. 358:doi 10.1136/bmj.j3585

The Final Report of the "Independent Review of Transvaginal Mesh Implants" commissioned by the Scottish Government, was published on the 27 March 2017 (1). This "Final Report" is itself now under review (2) due to accusations of official interference in the process of the review and concerns raised by the petitioners and others that financial conflicts of interest in NHS Scotland may have influenced the process of "informed consent".

The "Final report" of the "Independent Review of Transvaginal Mesh Implants" was considered at an Evidence Session in the Scottish Parliament on the 18 May 2017. This was also emotionally charged. The full transcript can be read (3) and the Evidence session can be watched via Scottish Parliament recording (4)

I have followed the Mesh petition to the Scottish Parliament given my longstanding interest in ethics and consent. I should make it clear that I have no expertise in this specialist surgical area.

I submitted this short consideration ahead of the Evidence Session of the 18 May 2017 (5). I said in my submission:

"I agree with the Independent Review that 'robust clinical governance must surround treatment'. I am concerned that if the current situation continues, where 'education' of health professionals may be significantly based on marketing, further examples of iatrogenic harm may occur in NHS Scotland."

I concluded my submission:

"The Independent Review concluded that 'informed consent is a fundamental principle underlying all healthcare'. If the advice given to patients is based on marketing, either partially or wholly, then informed consent may be denied patients. Further examples of Iatrogenic harm may then unfortunately occur and healthcare in Scotland may risk being considered as unrealistic rather than 'realistic'."

At the Evidence Session of the 18 May 2017, those giving evidence, including Scotland's Cabinet Minister for Health, the Chief Medical Officer for Scotland, and the Chair of the Final Report talked about the importance of "truly informed consent" by describing that which has been set out by the General Medical Council in "Good Medical Practice".

References:
(1) http://www.gov.scot/Publications/2017/03/3336/downloads
(2) http://www.parliament.scot/S5_PublicPetitionsCommittee/Submissions%20201...
(3) http://www.parliament.scot/parliamentarybusiness/report.aspx?r=10958&mod...
(4) http://www.scottishparliament.tv/Archive/Index/43dd0e19-2b6d-46bf-9bbc-c...
(5) http://www.parliament.scot/S5_PublicPetitionsCommittee/Submissions%20201...

Competing interests: I submitted a petition to the Scottish Parliament to consider a Sunshine Act for Scotland: http://www.parliament.scot/GettingInvolved/Petitions/sunshineact

26 July 2017
Peter J Gordon
Psychiatrist for Older Adults
NHS
Bridge of Allan
Click to like:
4
Re: David Oliver: When “resilience” becomes a dirty word David Oliver. 358:doi 10.1136/bmj.j3604

I used to think that resilience was about how many knocks you could withstand before you fell down. Some innate quality, perhaps a product of one's upbringing or even genetics. However, following exposure to Coaching, quality improvement and colleagues willing to have a coffee and listen - I realised that resilience is something that can be built, learnt and taught and something that can, nay, must be designed into every system within our healthcare. It is due to lack of incorporating resilience that we have patients on corridors in winter, that we have doctors falling asleep on their drive home and such a recruitment crisis.
We can start to improve resilience by making it a fundamental ideal as opposed to a retrospective downfall.

Schwartz rounds and effective reflection is a part of this. Teaching and learning about how to become more resilient is another. Asking what do our people need to be at their best rather than how can we squeeze the most out of them would be a great start.

Competing interests: No competing interests

26 July 2017
Gurjit S Chhokar
Geriatrician SpR
York
Click to like:
3
Re: UK doctors re-examine case for mandatory vaccination Tom Moberly. 358:doi 10.1136/bmj.j3414

As a concerned parent I felt compelled to write a response to the raising concerns of many parents regarding mandatory vaccination rolling across Europe. I am highly disturbed that this is now being disscussed here in the UK.

My family have two vaccine injured children as a result of following the recommended vaccine schedule. Niether parent received full information of the serious side effects. No vaccine insert was given nor more than a 5 minute discussion. No questions were asked about past medical history or family genetics. Only that they are "safe and effective" .I am sure they would of appreciated a more in depth assessment of their medical history before being given a life sentence of disability for the sake of a week or two of say.. measles...

In the 70's and 80's I remember measles well. It was classed as a "normal part of childhood " in my day. That's not to say that it can't cause serious problems in a small sub set of children or adults whose immune systems are compromised. However, the vast majority came through it just like the chicken pox. Why are we swapping normal childhood illness with vaccine damage and waning herd immunity? Most of us know that natural herd immunity is far superior to the artificial version that requires numerous boosters. Which we now know will need an adult schedule to fill the gap. America and Australia are already trying to implement it. There must be a better way. Are heading towards cradle to grave?

Due to waning natural immunity pregnant mothers are now being injected with vaccines which have never been tested for safety. Once upon a time mothers passed on immunity to their babies through breastmilk.

The vaccine damage payment scheme in this country requires 60% damage to of been caused before being awarded a one off payment of £120,000. That is not enough to cover lifetime costs of a disability. What if your child is only 55% damaged? Where does the burden then lie? What happens to these children when they become adults and the parents pass away? Who picks up the bill then? The UK to date has payed out over £74 million in vaccine damage. However, how many more under the 60% threshold are being supported through welfare payments and hospital treatments?

Is there not a way with our technological and medical advances that children can be screened BEFORE being given a cocktail of antigens and chemicals to assess their suitability? Can parents not discuss family genetics and concerns with their GP's without fear? This is not a way to gain a patients trust.

If the UK were to mandate vaccination that strips away our parental rights of making a fully informed medical decision. To allow government to roll out a one size fits all vaccine schedule would strip away our freedom to make a decision based on our child's own individuality. We have a duty of care above all others to our children. We know our children and their history best. No one else has a right to take that away.
I see it as neglectful if we DON'T raise these concerns about the safety and efficacy of vaccination. There are 100's of scientific studies which raise serious questions. These are accessible to the public and anyone can read them.

There are approx 200 new vaccines in development and approval stages .. When will this madness end?

Competing interests: No competing interests

25 July 2017
Emma Sansom
Full time mother
Oxford
Click to like:
8
Re: “Independent” reanalysis of landmark starch solutions trial was published by original authors Peter Doshi. 358:doi 10.1136/bmj.j3552

In the letter ‘ “Independent” reanalysis of landmark starch solutions trial was published by original authors’ by Peter Doshi, I was quoted as stating that I did not know whether the Duke Clinical Research Institute (DCRI) had the right to publish independently. I would like to clarify. When my response was emailed to Dr Doshi, I was under the impression the article was on the way to publication and I did not feel comfortable assuming anything about a contract without first verifying. My emailed response was to let him know I could not get him an answer at that moment. Since the ability to publish independently is discussed in Dr. Doshi’s letter as a component of the definition of independent review, I would like to have on record that the DCRI does indeed have the right to publish the results that we generated for this reanalysis study.

Competing interests: No competing interests

25 July 2017
Karen S Pieper
Biostatistician
Duke Clinical Research Institute
2400 Pratt St, Durham, NC 27705
Click to like:
25
Re: Prenatal antidepressant use and risk of attention-deficit/hyperactivity disorder in offspring: population based cohort study Emily Simonoff, Phyllis K L Chan, Wallis C Y Lau, Martijn J Schuemie, et al. 357:doi 10.1136/bmj.j2350

I very much enjoyed reading the article by Man et al. The article highlighted the need to consider antidepressant treatment and the impact this may subsequently have on risk of ADHD diagnosis in offspring. It was very helpful to learn about the different categories of medication, further sub-categorisation would be helpful to discern specifically which medications to advise pregnant mothers about the risk of ADHD. In further studies it would be helpful to understand how the severity of maternal mental illness relates to the severity of ADHD in offspring.

Competing interests: No competing interests

25 July 2017
Sophie Clark
Medical Student
Dr. Mallika Punukollu (CAMHS Psychiatry Consultant)
University of Glasgow
University Avenue, Glasgow, G12 8QQ
Click to like:
24
Re: Patients harmed by mesh implants address emotional parliamentary meeting Rebecca Coombes. 358:doi 10.1136/bmj.j3585

Evidence against use of vaginal meshes is widespread. [12]
Lawsuits should also be extended to Surgeons and Gynecologists who persist in using them.
Women older than 50, with uterine prolapse, do not need to engage in strenuous abdominal and laparoscopic sacrospinous hysteropexies, just to keep an atrophic-non functioning organ, and sustain pressure onto their doctors to retain their uteruses at all costs. A quick vaginal hysterectomy, with or without anterior repair, is the best treatment, in my opinion. [2]
Minimally invasive types of hysterectomy evolved to become the only major abdominal surgical operations not associated with intra-operative or medium post-operative term mortality.
In fact, in certain age groups, even reduced mortality trends are evidenced. [1]
Various available hysterectomy techniques compete for operative times, length of hospitalization, hospital costs, blood transfusions, antibiotic use, antinociceptive medications, etc. [2]
Vaginal hysterectomies are better, faster, cheaper, preferred by women, definitive therapeutic interventions, compared to other available alternatives for benign conditions. [3][4][5][6][8][9][11]
Hysterectomies even increase sexual function and sexual pleasure. [7][10]
References
[1] http://www.bmj.com/content/330/7506/1482
[2] https://www.ncbi.nlm.nih.gov/pubmed/27523922
[3] http://www.bmj.com/rapid-response/2011/11/03/hysterectomies-save-even-mo...
[4] http://www.bmj.com/rapid-response/2011/11/03/do-we-mention-women-prefer-...
[5] http://www.bmj.com/content/344/bmj.e2564/rr/584268
[6] http://www.bmj.com/rapid-response/2011/11/03/mirena-disadvantages-omitted
[7] http://www.bmj.com/content/327/7418/774
[8] http://www.bmj.com/content/330/7506/1457
[9] http://www.bmj.com/content/328/7442/730.5
[10] http://www.bmj.com/content/327/7418/0.2
[11] BMJ 2010;341:c3929
http://www.bmj.com/content/341/bmj.c3929
[12] http://www.bmj.com/content/352/bmj.i822

Competing interests: No competing interests

25 July 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
Click to like:
30
Re: UK government’s response to refugee children is “shameful,” say health leaders Susan Mayor. 355:doi 10.1136/bmj.i5958

70% of all available international funds for refugees were wasted in Greece. [1][2][3]
Corruption and inefficiency caused embezzlement of vital humanitarian aid.
Is it more shameful to deny access to refugee children in need because of lack of proper establishments and funds, or to accept all refugee children in need and waste 70% of available international funds?
References
[1] http://www.ekathimerini.com/216968/gallery/ekathimerini/community/how-mi...
[2] https://www.theguardian.com/world/2017/mar/09/how-greece-fumbled-refugee...
[3] http://www.dw.com/en/eus-mishandled-millions-not-reaching-refugees/a-372...

Competing interests: No competing interests

25 July 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
Click to like:
27
Re: Increase in life expectancy in England has halted, new figures show Gareth Iacobucci. 358:doi 10.1136/bmj.j3473

In the BMJ 22 July 2017 page 129 in seven days in medicine Gareth Iacobucci refers to the dwindling resources available to the NHS. He writes, “We have made a political decision to reduce the proportion of our national income that goes into public expenditure”. For many people this affects the standard of treatment they can expect form the NHS. Iacobucci also writes that leading causes of death are dementia and Alzheimer’s disease. The insoluble dilemma is that if we find an answer to these two diseases, something else will kill us. Life, as we understand it, is a uniformly fatal disease, and we naturally find that unacceptable.

Joseph Lister discovered the beneficial effects of Carbolic Acid in preventing post operative sepsis and his first article on this, ‘On a New Method of Treating Compound Fracture, Abscess, etc., with Observations on the Conditions of Suppuration’ was published in The Lancet, 1867, Vols i and ii. The paper deals with the stormy course and eventually successful outcome of several cases of surgical sepsis. The careful application of nitric acid and then carbolic acid was practised with wonderful results but with no idea of the microscopic cause of the suppuration. The reception by other surgeons of his antiseptic method was sluggish and sceptical to say the least, as Sir Rickman Godlee’s biography of his uncle, Lord Lister, makes clear’. (Lord Lister by Sir Rickman John Godlee, Bt. Third Edition, Oxford at the Clarendon Press 1924)

Pasteur made clear the bacterial cause of putrefaction and laid the basis for aseptic surgery replacing Lister’s antiseptic technique. Today this is universally accepted but life still remains a fatal disease and we are faced ever more uncomfortably with this fact, even if less terrifying than the suppuration of Lister’s day.

Bacteria are microscopic at one level but beyond them lies the even more mysterious ultra-microscopic quantum world. Resuscitation techniques have made near death experiences (NDE’s), or in other words the experience of ‘life’ after death, more common, but as in Lister’s day his reports of the effects of antiseptics were met with scepticism, so are today’s reports of NDE’s, and thus have little influence on medical practice. The study and increasing understanding of the nature of ultra-microscopic structure of the brain itself may help to undermine this scepticism and make it easier view death as non fatal and less terrifying.
Sir John C. Eccles in his short book ‘How the SELF controls ITS Brain’. (Springer-Verlag 1994) and especially in chapter 9 by him and F. Beck, (a quantum physicist and Head of the Theoretical Nuclear Physics at the Technical University of Darmstadt) makes clear the quantum world is not subject to entropy, the second laws of thermodynamics. Eccles and Beck suggest that consciousness, the formation of the will, is the product of the quantum receptors in the cerebral cortex, linking the entropic world of the physical brain with the timeless, space-less and ‘energy free’ quantum world, or in more ordinary language the spiritual world, which we experience after death of the body. With death we become like photons, our ‘mass’ disappears and we become subject to the laws of probability and timelessness. As Schrödinger points out the ‘ψ’ (psi) wave function needs to be multiplied by its conjugate, before it enters existence. Up until then, like Schrödinger’s cat, its existence is a balance of probabilities. When people leave their bodies it is not possible to say of what they are made. They seem to be made of pure consciousness, a state of perfect health without bodily aches or pains, a wonderful solution to the problems of the death of the body faced by the creaking apparatus of the NHS. It just needs to be more widely believed, and the consequences applied.

Competing interests: No competing interests

25 July 2017
David Lister
Retired Surgeon
Bramshill
Click to like:
25
Re: Management of patients after primary percutaneous coronary intervention for myocardial infarction Fatima Dalal, Hasnain M Dalal, Christos Voukalis, Manish M Gandhi. 358:doi 10.1136/bmj.j3237

The recent review (BMJ 2017; 358) provides a concise update on the pharmacological and behavioural follow-up management after a myocardial infarction. It is unfortunate in this otherwise holistic approach that the risks and means of prevention of gastrointestinal bleeding in this population was not mentioned. This is important as GI bleeding in this patient population is associated with poorer prognosis. It is well known that aspirin monotherapy increases the risk of acute GI bleeding: overall rates of 0.6-1.0% are probably reasonably accurate (1) but recent data have highlighted that antiplatelet agent induced GI haemorrhage is not only much commoner with advancing age but such bleeds are associated with death or significant functional disability in the majority of the most elderly patients: in those aged > 75, 62% of upper GI bleeds were associated with death or disability (2). Dual anti-platelet therapy as usually employed in this patient group approximately doubles the risk of bleeding compared to aspirin alone and the addition of an anti-coagulant drug, such as warfarin further doubles the risk (3,4,5).

Against this background, gastroprotection with a proton pump inhibitor (PPI) is both safe and effective. The original COGENT trial showed that the addition of omeprazole to aspirin-clopidogrel dual therapy reduced GI bleeding by a large amount (0.6% to 0.1%) (6) and more recent post-hoc analysis of these data, examining specifically the post-acute coronary syndrome groups, again showed significant benefit (bleeding reduced from 1.2% to 0.24% at 180 day follow-up) (7), without any adverse cardiovascular effects. PPI-cotreatment also reduces (by about 45%), but does not abolish the bleeding risk associated with antiplatelet-warfarin combinations (8).

The effectiveness of PPI gastroprotection can be judged from follow-up studies of patients post-coronary stenting: in a cohort where most had PPI treatment (88%), the overall rate of GI bleeding of all types was 1.52% per year but acute lower GI bleeding was the major source (74%) being now three times commoner than upper GI bleeding (4). Therefore although the authors have clearly outlined the rationale for pharmacological treatment post-myocardial infarction, it is important to additionally consider a PPI to reduce the risk of clinically significant GI bleeding and this approach is supported by international guidelines (9).

References

1. Prevention of upper gastrointestinal haemorrhage: current controversies and clinical guidance. Brooks J, Warburton R, Beales IL. Ther Adv Chronic Dis. 2013 Sep;4(5):206-22.

2. Age-specific risks, severity, time course, and outcome of bleeding on long-term antiplatelet treatment after vascular events: a population-based cohort study. Li L, Geraghty OC, Mehta Z, Rothwell PM; Oxford Vascular Study. Lancet. 2017 Jun 13. pii: S0140-6736(17)30770-5.

3. Risk of upper and lower gastrointestinal bleeding in patients taking nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants. Lanas Á, Carrera-Lasfuentes P, Arguedas Y, García S, Bujanda L, Calvet X, Ponce J, Perez-Aísa Á, Castro M, Muñoz M, Sostres C, García-Rodríguez LA. Clin Gastroenterol Hepatol. 2015 May;13(5):906-12.

4. Casado Arroyo R, Polo-Tomas M, Roncalés MP, et al. Lower GI bleeding is more common than upper among patients on dual antiplatelet therapy: long-term follow-up of a cohort of patients commonly using PPI co-therapy. Heart 2012;98:718-723

5. Combination therapy with aspirin, clopidogrel and warfarin following coronary stenting is associated with a significant risk of bleeding. Khurram Z1, Chou E, Minutello R, Bergman G, Parikh M, Naidu S, Wong SC, Hong MK. J Invasive Cardiol. 2006 Apr;18(4):162-4.

6. Clopidogrel with or without omeprazole in coronary artery disease. Bhatt DL, Cryer BL, Contant CF, Cohen M, Lanas A, Schnitzer TJ, Shook TL, Lapuerta P, Goldsmith MA, Laine L, Scirica BM, Murphy SA, Cannon CP; COGENT Investigators. N Engl J Med. 2010 Nov 11;363(20):1909-17.

7. Efficacy and safety of proton-pump inhibitors in high-risk cardiovascular subsets of the COGENT trial. Vaduganathan M, Cannon CP, Cryer BL, Liu Y, Hsieh WH, Doros G, Cohen M, Lanas A, Schnitzer TJ, Shook TL, Lapuerta P, Goldsmith MA, Laine L, Bhatt DL; COGENT Investigators. Am J Med. 2016 Sep;129(9):1002-5.

8. Association of Proton Pump Inhibitors With Reduced Risk of Warfarin-Related Serious Upper Gastrointestinal Bleeding. Ray WA, Chung CP, Murray KT, Smalley WE, Daugherty JR, Dupont WD, Stein CM. Gastroenterology. 2016 Dec;151(6):1105-1112.

9. ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB, Furberg CD, Johnson DA, Kahi CJ, Laine L, Mahaffey KW, Quigley EM, Scheiman J, Sperling LS, Tomaselli GF; ACCF/ACG/AHA. Am J Gastroenterol. 2010 Dec;105(12):2533-

Competing interests: No competing interests

25 July 2017
Ian L. P. Beales
Consultant Gastroenterologist
Norfolk and Norwich University Hospital
Norwich
Click to like:
24

Pages