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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: A smoke-free generation? John Britton. 358:doi 10.1136/bmj.j3944

Tobacco is an addictive depressant that tricks and traps us by creating the fleeting euphoria of relaxation and aeration, but the sustained sickness of desperation and suffocation. The euphoria of relaxation and aeration, and the sickness of desperation and suffocation, are polar opposites that reinforce each other: the euphoria blinds us to the sickness, and the sickness makes us crave the euphoria. Perversely but predictably, tobacco creates, aggravates, and perpetuates the very sickness of desperation and suffocation that it falsely seems to cure, thus placing all tobacco products in a very bad light.


Competing interests: No competing interests

19 September 2017
Hugh Mann
Physician
Retired
Re: WHO report says countries should do more to prevent suicides Gareth Iacobucci. 349:doi 10.1136/bmj.g5461

Clinical research evidence shows that religious/spiritual awareness-practice drastically reduces symptoms of depression and suicides.
Countries should include religious/spiritual interventions in mainstream practice.
References
https://www.ncbi.nlm.nih.gov/pubmed/26200715
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921896/
https://www.ncbi.nlm.nih.gov/pubmed/23420279
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5474022/

Competing interests: No competing interests

19 September 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynecology
Re: Working when exhausted is unacceptable Paul D McGovern. 358:doi 10.1136/bmj.j4191

As someone who trained in the bad old days I for one haven't forgotten the miserable long shifts that we endured in the name of service.

The reality is that we wasted the best years of our lives propping up the NHS which (as now) was under doctored compounded in those days by derisory rates of pay that say some juniors being paid the lowest hourly rate of pay in the hospital. No wonder when UMTs were paid at rates that wouldn't get a domestic.

Falling asleep standing up and in the bath are delights I would rather not repeat.

Now some fools wish to bring that back in the name of training and continuity. No doubt management hope it will help to cover the gaps.

Training is more about quality than quantity but in an era training is measured by counting ticks in boxes there will those who don't understand that repetitive mundane tasks that juniors still end up doing like chasing bloods, phlebotomy and giving drugs because there aren't enough trained nurses is not not training.

For pity's sake we are losing Drs from the profession at an alarming rate already and even more to other countries. Poor pay, poor training, overwork are not enough: now some want to add sleep deprivation into the mix!

Competing interests: No competing interests

19 September 2017
Andrew P Moltu
GP
Narborough
Re: Beating type 2 diabetes into remission Naveed Sattar, Mike E J Lean, et al. 358:doi 10.1136/bmj.j4030

Diabetes is a metabolic dysfunctional state where there is a defect in insulin production/synthesis/release or in its action, receptor number, post-receptor defect or what we call insulin resistance.

It is not a battle of wits but it is a state of health that challenges your mental resolve and balance - say, keeping your blood glucose levels with minimal fluctuations, controlling your diet and developing a mental state of considering diabetes a normal state of your body. What I mean is instead of taking it as a pathophysiological manifestation it needs to be taken as a life style adjustment of an individual to the blood glucose level or HbA1c changing one's perspective to suit the needs and demands of the state of health.

There is no question of a remission or precipitation of adverse outcomes of diabetes if one considers the metabolic state of diabetic patient as one that has to be dealt with as one deals with the normal routine of life.

Competing interests: No competing interests

19 September 2017
DHASTAGIR Sheriff
Professor
Independent consultant and Faculty of Medicine
Benghazi
Re: Margaret McCartney: Nuclear weapons do harm, even if never used Margaret McCartney. 358:doi 10.1136/bmj.j3978

Sir,

McCartney makes the controversial claim that “Even if the nuclear weapons are never used, they do harm.”[1].

The whole point of a strategic nuclear deterrent is to deter any enemy from considering a nuclear first strike, a strategy predicated on the concept of mutually assured destruction (MAD). Given that no nuclear weapons have been used in anger since the end of World War Two and that we are alive to have this debate is testament to the success of the nuclear deterrent, including Britain’s Trident missile system.

The absence of any use of nuclear weapons in the last 72 years can hardly be considered a harm. Quite the opposite in fact. The Cold War stayed “cold” precisely because both the North Atlantic Treaty Organisation (NATO) and the Soviet Union possessed a credible nuclear arsenal. The concept of MAD worked then and continues to work today.

McCartney and the nuclear disarmament lobby ignore the fact that whether they like it or not, the UK’s Trident system provides ongoing employment of approximately 7,000 people in Scotland (4,700 military, 2,250 civilian) and between 30,000 and 40,000 jobs across the UK[2,3]. The fact that the UK strategic nuclear deterrent supports tens of thousands of long-term jobs, including highly skilled ones, cannot be seen as “harmful”.

Finally, McCartney refers to the £31 billion cost of renewing the Trident missile system. The new Trident submarines will be expected to serve for over 30 years once they are introduced. The current quartet of Vanguard class nuclear submarines entered service in c. 1992[4]. They have already been in continuous service (in rotation) for a quarter of a century, defending us against strategic nuclear threats on a 24/7 basis.

They will only be replaced by their successors, the Dreadnought class ballistic missile submarines from the early 2030s[5]. The new Trident submarines will have very long service lives and the procurement costs must be viewed in this context.

As McCartney rightly points out, we live in an increasingly complex geopolitical environment. North Korea is racing to develop nuclear-armed intercontinental ballistic missiles (ICBM), which have the range to reach the United States and Europe[6,7]. Now is absolutely not the time to be arguing against the maintenance and renewal of Britain’s strategic nuclear deterrent. To abandon Trident now would be to put ideology before national security at a time when the international nuclear threat landscape is growing more hostile, not less.

I would prefer that we did not need a strategic nuclear deterrent and indeed that nuclear weapons did not exist. However, the nuclear Pandora’s Box has been opened and we don’t live in Utopia. To abandon Trident now would be injurious to national security. I am relieved that the British Parliament approved the renewal of the Trident nuclear system in 2016 by a significant majority[8].

References:
1. Margaret McCartney: Nuclear weapons do harm, even if never used. McCartney M. BMJ 2017; 358:j3978 doi: https://doi.org/10.1136/bmj.j3978
2. Ruth Davidson attacks Labour over Trident jobs pledge ‘farce’. Johnson S. The Telegraph newspaper online 28/4/16 http://www.telegraph.co.uk/news/2016/04/28/ruth-davidson-attacks-labour-...
3. Opponents clash over Trident job numbers at Faslane. McCall C. The Scotsman newspaper online 8/2/17 http://www.scotsman.com/news/politics/opponents-clash-over-trident-job-n...
4. Dreadnought class submarine programme: the facts. Ministry of Defence 28/10/16 https://www.gov.uk/government/collections/dreadnought-submarine-programm...
5. BAe Systems to begin building new British nuclear submarines. Reuters UK 1/10/16 https://www.reuters.com/article/us-britain-defence/bae-systems-to-begin-...
6. North Korean missiles ‘could reach Europe sooner than expected’. Whiteside P. Sky News online 6/9/17 http://news.sky.com/story/north-koreas-missiles-could-reach-europe-soone...
7. North Korea missiles could hit U.S., Europe ‘within months’ in nuclear strike, France says. Lowe J. Newsweek online 1/9/17 http://www.newsweek.com/north-korea-missiles-strike-us-europe-france-mon...
8. Commons votes for Trident renewal by majority of 355. Mason R, Asthana A. The Guardian newspaper online 18/7/16. https://www.theguardian.com/uk-news/2016/jul/18/mps-vote-in-favour-of-tr...

Competing interests: I am writing in a personal capacity. The views expressed are my own and not those of my employers.

19 September 2017
Gee Yen Shin
Consultant Virologist
Public Health England
London
Re: New settlement procedures: changing the way the NHS resolves negligence claims Clare Dyer. 358:doi 10.1136/bmj.j4134

Dyer's observation that Obstetrics accounts for 10% of the claims made against trusts, but 50% of the overall value of claims raises an interesting point. Intrapartum care in the UK involves a mixed Obstetric-midwifery model of care, providing care for both a low risk and high risk birthing population (1). Several of the Royal Colleges have advocated consultant led care on the labour ward to improve patient safety (2). However, a recent Cochrane review found that there is no reliable evidence of the effects of 24-hour resident consultant presence on the labour ward on to suggest improved intrapartum outcomes. This suggests a multidisciplinary approach is required to target care provision on the labour ward, which should be prioritised by trusts given these claims are the most expensive ones they face. A robust annual training programme should be in place in all trusts for all staff working on the labour ward as well as improving reporting mechanisms when things go wrong.

Standardising the layout of labour ward, facilities available and practical procedures across the UK may also go some way to minimising harm. Visibly involving staff members in risk management reporting and recommendations may also reduce adverse care outcomes for both mothers and babies. In short, unless a practical and proactive multidisciplinary approach to intrapartum care is taken urgently, the next decade will see trusts seriously question whether they are able to afford to deliver babies.

References

1 Birthplace in England Collaborative Group, Brocklehurst P, Hardy P, Hollowell J, Linsell L, Macfarlane A, et al. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400.

2 Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Royal College of Anaesthetists, Royal College of Paediatrics and Child Health. Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. RCOG Press: London, 2007.

3 Resident Consultant Obstetrician Presence on the Labour Ward Versus Other Models of Consultant Cover: A Systematic Review of Intrapartum Outcomes J Henderson et al. BJOG 124 (9), 1311-1320. 2017 Feb 28

Competing interests: No competing interests

19 September 2017
Shreelata T Datta
Consultant Obstetrician and Gynaecologist
King's College Hospital NHS Foundation Trust
London
Re: Margaret McCartney: Are we reviewing GP referrals for the right reasons? Margaret McCartney. 358:doi 10.1136/bmj.j4240

Here we go again, yet again.

It is an intrinsic feature of a hierarchical system, such a sthe NHS, that at every level of management, those in office, try to draw authority up to themselves and pass responsibility down to those beneath them, it's good managing.

NICE after hours of reading, talking, thinking and deliberating produce guidelines! Not rules, not laws, not bans. They accept no responsibility.

This is about risk. The patient has a problem, it is unlikely to indicate a serious pathology, but it might. At what level of risk does someone somewhere, decide to take the chance and carry the responsibility?
Managers are hoping to see a reduction in costs, with gongs all round ,while the GPs face the GMC.

Those refusing the referral will probably not communicate directly with the patient, and frame the refusal in terms indicating a failure on the part of the GP. Indeed the refusal will probably be from an institution or committee, making identification of an individual difficult.

GPs will need to explain clearly to the patient the nature of the game being played at the outset. They will need a fast efficient system for bouncing refusal letters back to the patient, explaining clearly who has refused.

Generally in these situations putting an irate patient directly in contact with the manager responsible, preferably face to face, resolves the situation with gratifying efficiency.

Competing interests: No competing interests

19 September 2017
tom robinson
gp
none
Penarth
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 Editor

This is a well-written editorial with a valid message [1]. However, we believe that the authors have ignored the experience with selective digestive decontamination (SDD) and the emergence of antimicrobial resistance [2,3]. Critically ill children who have received SDD, such as those treated on the intensive care unit (ICU) [2] and those receiving intensive chemotherapy, [3] rarely develop the emergence of resistant potentially pathogenic micro-organisms (PPMs). They generally clear overgrowth with PPMs from the throat and gut during SDD treatment.

If overgrowth is eradicated successfully, resistance is unlikely to emerge. However, if overgrowth is not eradicated, resistance is more likely to occur.

The intravenous component of SDD, Cefotaxime, is excreted into the throat via saliva in high concentrations and clears Streptococcus pyogenes and Staphylococcus aureus overgrowth. The oral components of SDD, polymyxin E and tobramycin, clear overgrowth of aerobic Gram-negative bacilli (AGNB) from the gut [4]. Oral polyenes, e.g., amphotericin B and nystatin effectively eradicate fungal overgrowth.
The oropharyngeal and intestinal overgrowth of potential pathogens (≥105 PPMs per mL) has recently been shown to promote the emergence of antimicrobial resistance and is associated with increased spontaneous mutations and polyclonality of both sensitive and resistant clones [4].

Intravenous antimicrobials, which are excreted via saliva and intestinal fluids into the gut in sub-lethal concentrations, are more likely to select resistant clones

The editorial presumably mainly refers to patients in general practice, in whom we know of few data on gut PPM overgrowth. This contrasts with extensive studies in the critically ill. General practice patients do not suffer overgrowth as they have peristalsis, which also guarantees drug absorption. Following absorption, oral antibiotics are subsequently excreted via saliva and bile. Absorption is impaired in critically ill patients who require parenteral antibiotics. The non-absorbable antimicrobials of SDD are designed to prevent and clear the overgrowth of PPMs in the alimentary canal during critical illness.

In conclusion, we believe that the development of microbial overgrowth in the gut during antimicrobial therapy, rather than the non-completion of a prescribed antibiotic course, is likely to promote the emergence of antimicrobial resistance.

References
1. Llewellyn MJ, Fitzpatrick JM, Darwin E et al. The antibiotic course has had its day. BMJ 2017; 358: j3418. doi: 10.1136/bmj.j3418
2. Sarginson RE, Taylor N, Reilly N et al. Infection in prolonged pediatric critical illness: A prospective four-year study based on knowledge of the carrier state. Crit Care Med. 2004; 32: 839-847.
3. Paulus SC, van Saene HKF, Hemsworth S et al. A prospective study of septicaemia on a paediatric oncology unit: a three-year experience at The Royal Liverpool Children's Hospital, Alder Hey, UK. Eur J Cancer 2005; 41: 2132-2140.
4. Taylor N. The addition of enteral to parenteral antibiotics may prolong the antibiotic era. MPhil Thesis 2014. University of Liverpool.
5. van Saene HKF, Taylor N, Damjanovic V, Sarginson RE. Microbial gut overgrowth guarantees increased spontaneous mutation leading to polyclonality and antibiotic resistance in the critically ill. Current Drug Targets 2008; 9: 419-421.

Competing interests: No competing interests

19 September 2017
Hendrik K van Saene
Honorary Senior Fellow
Sarginson RE, Pizer BL, Taylor N, Nunn A
University of Liverpool
Liverpool
Re: Do patients at risk of infective endocarditis need antibiotics before dental procedures? Thomas J Cahill, Mark Dayer, Bernard Prendergast, Martin Thornhill. 358:doi 10.1136/bmj.j3942

Baker and Alderson emphasise elements of the available data to support the decision made by NICE to withdraw antibiotic prophylaxis for patients at risk of infective endocarditis in the UK. Differing interpretations of best practice in the context of limited data are the essence of the ‘uncertainty’ which underlies the BMJ’s series and are to be welcomed. As outlined explicitly in our Uncertainties article,(1) Baker and Alderson reiterate that dental procedures account for a minority of cases, that the absolute risk of infective endocarditis after a given procedure is low, and that there are potential risks associated with antibiotic prophylaxis (although contemporary UK data suggest that there has never been a death associated with amoxicillin antibiotic prophylaxis).(2) We acknowledge these caveats.

However, given the evidence of possible benefit and very low risk of harm, we believe that decisions concerning the use of antibiotic prophylaxis should be devolved to individual patients and not taken at national level. This approach, that is supported by European and American guidelines, allows those at highest risk to make decisions regarding their care with support from general practitioners, cardiologists and dentists.

We are in complete agreement that the rising incidence of infective endocarditis observed in multiple countries is a cause for concern, and that research funding is required to understand this. Furthermore, research needs to not only clarify the role of antibiotic prophylaxis for invasive dentistry, but also investigate other novel preventative strategies.

References
1. Cahill TJ, Dayer M, Prendergast B, Thornhill M. Do patients at risk of infective endocarditis need antibiotics before dental procedures? BMJ 2017;358.
2. Thornhill MH, Dayer MJ, Prendergast B, Baddour LM, Jones S, Lockhart PB. Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis. Journal of Antimicrobial Chemotherapy 2015;70:2382-8.

Competing interests: See original article

19 September 2017
Thomas J Cahill
Cardiology Specialist Registrar
Dr Mark Dayer, Professor Bernard Prendergast, Professor Martin Thornhill
Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford
Re: Over 65s flu vaccination programme was ineffective, data show Nigel Hawkes. 358:doi 10.1136/bmj.j4146

Once again this dramatically illustrates the problem that vaccine science can fail [1,2] just when its main proponents are calling for the programme to be made compulsory . I have no doubt that GP surgeries will be as blocked as ever this autumn with elderly people getting their shots, meanwhile the NHS and PHE will be pushing the products vigorously despite the negative evidence for the intervention: the very same people who insist upon the universal benefits and safety of all the other vaccine products. Moreover, in this instance the weakness of the evidence for has long been highlighted.

Only a few intransigents so far dare to question publicly the demands of vaccine lobbyists for compulsion [3, 4, 5] but the reality is that this science is at best messy: there are no immutable laws, vaccines fail and there are risks - these surely mount up as the programme gets longer (but the industry has many more products in the pipeline and needs a captive market). Ordinary citizens and medical professionals would show judgement by viewing the claims of the lobby with a pinch of salt, and the lobby would show judgement if it did not parade as invincible all the time.

[1] Nigel Hawkes, 'Over 65s flu vaccination programme was ineffective, data show', 5 September 2017, BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4146

[2] Responses to Hawkes: ' Re: 'Over 65s flu vaccination programme was ineffective, data show', http://www.bmj.com/content/358/bmj.j4146/rapid-responses

[3] Responses to Moberly, 'UK doctors re-examine case for mandatory vaccination', http://www.bmj.com/content/358/bmj.j3414/rapid-responses

[4] Responses to Arie,'Compulsory vaccination and growing measles threat', http://www.bmj.com/content/358/bmj.j3429/rapid-responses

[5] Responses to Cave 'Re: Debating the future of mandatory vaccination' ,http://www.bmj.com/content/358/bmj.j4100/rapid-responses

Competing interests: No competing interests

18 September 2017
John Stone
UK Editor
AgeofAutism.com

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