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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 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: Pregnant and nil by mouth David Harvie, Brendan Murfin. 358:doi 10.1136/bmj.j3463

Intesting case.

Could you kindly provide reference for the use of insulin in the condition ?

Competing interests: No competing interests

19 August 2017
Piero Baglioni
Centre Hospitalier Saint Jean d'Angely France
21, rue de la mer, 17400 Saint-Jean d'Y.
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Re: An unusual cause of chest pain Kevin Conroy, Abdul Aziz. 358:doi 10.1136/bmj.j3438

In a patient with a 40 pack year smoking history and chest discomfort on exertion(1), the differential diagnosis of a chest xray consistent with either lymphangitis carcinomatosa or unilateral pulmonary oedema should include cardiogenic oedema attributable to mitral regurgitation(2)(3)(4)(5) . The latter was the eventual diagnosis in an 86 year old woman who presented with a chest x ray which showed unilateral right-sided pulmonary oedema predominantly affecting the right upper lobe(2). In another patient with unilateral right-sided cardiogenic pulmonary oedema the the oedema predominantly affected the lower lobe region(3). In one study unilateral pulmonary oedema represented 2.1% of cardiogenic oedema in one study( 4). . In 16 out of cases the distribution was right sided(4) as in the reported case of lymphangitis carcinomatosa(1). The entire right lung was involved in 4 cases(4). Unilatral cardiogenic pulmonary oedema is attributable to mitral regurgitation which may either be organic or functional(4). Accordingly the initial assessment of the reported case(1) should have been cardiac auscultation for the murmur of mitral regurgitation. Occasionally the murmur may be absent, as was the case in a patient who presented with chest pain attributable to myocardial infarction complicated by papillary muscle rupture(5). The latter constitutes a medical emergency requiring urgent cardiac surgery. Accordingly, when a cigarette smoke presents with effort dyspnoea and chest pain related to exertion, I would urge clinicians to consider a treatable disorder such as organic mitral regurgitation. as the first diagnosis. If a non treatable disorder such as lymphangitis carcinomatosis proves to be the eventual diagnosis, one can take comfort in knowing that a treatable disorder has been ruled out non invasively. This vignestte should, therefore, be a template for the first rule of differential diagnosis, namely, to consider treatable disorders first and foremost.
(1) Conroy K and Aziz A
An unusual cause of chest pain
BMJ 2017;358:j3438
(2)Muthalaly RG and Nasis A
Unilateral pulmonary oedema : A case report of a commonly missed and highly consequential condition
International Journal of Cardiology 2016;207:62-63
(3) Ogunbayo GO., Thambiaiyah S., Ojo AO., Obaji A
Atypical pneumonia: Acute mitral regurgitation presenting with unilateral infiltrate
Am J Med 2015;128:e5-e6
(4) Attias D., Manseneal N., Auvert B et al
Prevalence, charcteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema
Circulation 2010;122: 1109-1115
(5) Efthimiou J., Pitcher M., Ormerod O et al
Severe "silent" mitral regurgitation after myocardial infarction; a clinical conundrum
BMJ 1992;305:105-106

Competing interests: No competing interests

18 August 2017
oscar,m jolobe
retired geriatrician
manchester meical society
simon building, brunswick street, manchester M13 9PL
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Re: Is it possible to recruit 21 000 extra staff for mental health services? Gareth Iacobucci. 358:doi 10.1136/bmj.j3880

Given the BMJ quote that 'psychiatry is currently the speciality with the highest number of unfilled training posts at 35%', is it time to consider whether consultants can come from a non-medical background akin to the model adapted in Public Health? Psychology has long been one of the top ten most popular degree choices, and a career path from this to Consultant Psychiatrist might be possible if planned well?

Competing interests: No competing interests

18 August 2017
M. Justin S. Zaman
Consultant Cardiologist
James Paget University Hospital
Gorleston-on-Sea, Norfolk, UK
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Re: Diagnosis and early management of inflammatory arthritis Joanna Ledingham, Neil Snowden, Zoe Ide. 358:doi 10.1136/bmj.j3248

We applaud the work of Ledingham et al. (2017) but encourage them to address ‘work’ more explicitly in their next clinical update.(1) Many people with inflammatory arthritis experience challenges working and most will try to keep working as long as they can. Several initiatives exist to inform patients about what it is they can do regarding work issues. Most professional guidelines, however, do not.(2) Clinicians may still be unaware of their important role in helping patients with managing challenges and expectations related to work.(3) Based on the Dutch multidisciplinary guideline ‘Rheumatoid Arthritis and work participation’, our clinical and non-clinical physicians are advised to ask four simple screening questions:

I. Are you working at the moment?, II. Is your work fulltime?, III. How are you doing at work?, IV. In case of work-related issues: do you need help?(4)

Referral to vocational or job loss prevention interventions should then be considered to empower those workers that need assistance to stay at work.(5) European initiatives like Fit for Work ( has led to the launching of Target@Work by the Dutch Society for Rheumatism, providing tools and training to arthritis nurses and rheumatologists to manage work as a patient-related outcome in patients with arthritis.

(1). Ledingham J, Snowden N, Ide Z. Diagnosis and early management of inflammatory arthritis. BMJ 2017;358:j3248 doi: 10.1136/bmj.j3248.
(2). Hulshof CT. Working for a healthier tomorrow (Editorial). Occup Environ Med 2009;66:1-2
(3). Hoving JL, van Zwieten MC, van der Meer M, Sluiter JK, Frings-Dresen MH. Work participation and arthritis: a systematic overview of challenges, adaptations and opportunities for interventions. Rheumatology (Oxford) 2013;52(7):1254-64.
(4). Boonen A, Lems W. [Worker participation as a treatment goal: new guideline "Rheumatoid Arthritis and Participation in Work"]. Ned Tijdschr Geneeskd. 2015;159:A9593.
(5). Hoving JL, Lacaille D, Urquhart DM, Hannu TJ, Sluiter JK, Frings-Dresen MHW, Non-pharmacological interventions for preventing job loss in workers with inflammatory arthritis. COCHRANE DB SYST REV 2014;2014 (11):CD010208.

Competing interests: No competing interests

18 August 2017
Jan L. Hoving
Carel T. Hulshof; Judith K. Sluiter
Academic Medical Center, University of Amsterdam, Dept. Coronel Institute of Occupational Health, Amsterdam Public Health research institute, Amsterdam, the Netherlands.
Meibergdreef 9, K0-112, 1105 AZ Amsterdam, The Netherlands
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Re: Why I’ve changed my views on assisted dying David Nicholl. 358:doi 10.1136/bmj.j3566

Dr Nicholl has found the courage to publish his thoughts on assisted dying after a very touching experience, losing a close friend after many years of struggle against a rare, incurable diesease. I think most of us after years of practice can easily imagine a situation, in which they for themselves, or for somebody close to them, might take steps to get a good supply of barbiturates. Still, this is a personal decision, not a professional duty or medical treatment. Some countries, we learned, have recently decided to provide euthanasia or assisted suicide within health care.

However, the major cocern that needs to be adressed, at least in Germany with her history of medical mass murder under Nazi rule, is the fear of a slippery slope towards euthanasia as something like a "routine service" (*) provided to anybody requesting it in terminal distress and with some ability to give consent, be it by proxy. There will be many frail, demented, weak, mostly elederly people around in the next decades. Should they too be offered the opportunity to get killed by a doctor, when pain, breathlessness or delirium get out of hand ?

I agree that assisted suicide in exceptional cases should not be prosecuted under criminal law. But to label assisted dying an "option" in terminal care is, in my view, a transgression.

* Madeline Li, M.D., Ph.D., Sarah Watt, Marnie Escaf, H.B.B.A., M.H.A., Michael Gardam, M.D., Ann Heesters, M.A., Gerald O’Leary, M.B., and Gary Rodin, M.D; Medical Assistance in Dying — Implementing a Hospital-Based Program in Canada; N Engl J Med 2017; 376:2082-2088.

Competing interests: Employee of a catholic hospital trust

18 August 2017
Joerg Wiesenfeldt
Staff Grade Neurologist
Verbundkrankenhaus Bernkastel-Wittlich
Koblenzer Str. 91, D 54516 Wittlich, Germany
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Re: Margaret McCartney: Alarm overload makes a difficult job harder Margaret McCartney. 358:doi 10.1136/bmj.j3593

Margaret McCartney makes a very good point, and it seems alarm overload is spreading.

An alert or alarm should be a good thing, a well-designed prompt that makes a clinician think. However, many alerts feel like an exercise in data input or an irrelevant false positive, rarely is an alert a useful clinical challenge or nudge that could improve care or safety for patients.

Dr Robert Wachter has looked at how the airline industry manages alerts and alarms to pilots to help with safety. There are thousands of things that could be alerted to a pilot during a flight, but most just aren't relevant to the pilot and are an unnecessary distraction.

Wachter explains how Boeing have an experienced systems safety team that analyse all alert requests and judge which make it through. They also decide how an alert is presented, from an advisory appearing quietly in the corner of a screen, to full on red lights and voice prompts. In addition, Boeing have made a big effort to engineer out false positives to avoid alarm fatigue.

As a result, Boeing say that less than 10% of flights have an alert reported to the pilot during the flight.

Quite a stark contrast to ITU, most patients have multiple alerts in any one shift, most of which are unhelpful and could be engineered away. For example, the patient record system that makes daily demands for a dementia assessment on a patient it also shows to be intubated, ventilated and sedated, or the monitor that simultaneously screams asystole yet shows a healthy arterial trace.

Getting clinicians more involved in the design, content and logic behind alerts and alarms could actually make them more helpful for patient care, and reduce the impact they have on already time-pressured patient consultations and interactions.

Competing interests: No competing interests

18 August 2017
Chris Russell
ITU Clinical Fellow, with an interest in health informatics
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Re: What it feels like to be compulsorily detained for treatment Anonymous. 358:doi 10.1136/bmj.j3546

It is good to see space given to the voices of those detained under the Mental Health Act, and particularly the experience of what that means in reality for people.

It does need to be remembered, though, that while doctors can make recommendations to detain they cannot actually 'section' anyone beyond 72 hours (and only then in limited circumstances). The final decision, taking into account all circumstances of the case, belongs to the Approved Mental Health Professional (AMHP). It is important that we are open and honest about the individual responsibilities of those who perform different functions under the Act. It is equally important to convey why there is a separation of these responsibilities and powers and how important it is that the AMHP is able to exercise their powers with autonomy and free of undue influence. Not every Mental Health Act assessment results in admission, not every medical recommendation is acted upon.

If we are to develop truly open and accountable processes and practices around these often difficult moments in people's lives, we should be trying to reassure those who become subject to our services that the promotion of their fundamental rights are as important to us as well evidenced clinical intervention and timely responses to need.

Competing interests: No competing interests

17 August 2017
Robert Lewis
Approved Mental Health Professional
Wonford House Hospital, Dryden Road, Exeter, EX2 5AF
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Re: Advances in the diagnosis and management of neck pain Steven P Cohen, W Michael Hooten. 358:doi 10.1136/bmj.j3221

I read with a particular interest the review “Advances in the diagnosis and management of neck pain” by Steven P. Cohen and W. Michael Hooten.[1] It represents an excellent state of the art of diagnosis and treatment of neck pain, except for work adaptation required among patients who are working.[2,3] Indeed, the authors stated the potential occupational factors involved in neck pain by differentiating:

- the axial non-radicular cause corresponding to perceived stress at work (“low job satisfaction and poorly perceived work support”), both associated with onset and poor prognosis and sometimes prolonged active posture (also called tension neck syndrome, or non-specific neck pain).[4,5]
- from the radicular cause that might be related only to extreme biomechanical factors (athletes, aviators/astronauts) or trauma, but not to minor repetitive trauma or carrying loads.[2,6] Stress at work might also be a poor prognosis factor.

Taking these factors into account, the authors should include them in the treatment to avoid recurrence and improve outcomes. In non-radicular cause, management of stress at work is probably effective,[7] as the opposite of decreasing biomechanical loads is not (except for some cases of posture). For radicular cause, considering that work is not a major risk factor, work adaptation should not be recommended, except for extreme conditions where prevention of trauma is important and sometimes a short decrease of constraints for pain management purposes.

1 Cohen SP, Hooten WM. Advances in the diagnosis and management of neck pain. BMJ 2017;358:j3221.
2 Cote P, van der, Cassidy JD, et al. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine Phila Pa 1976 2008;33:S60–74.
3 Roquelaure Y, Petit A. Surveillance médico-professionnelle du risque lombaire pour les travailleurs exposés à des manipulations de charges. Recommandations de Bonne Pratique. ArchMalProfEnviron 2014.
4 Sluiter BJ, Rest KM, Frings-Dresen MH. Criteria document for evaluating the work-relatedness of upper-extremity musculoskeletal disorders. ScandJ Work EnvironHealth 2001;27 Suppl 1:1–102.
5 McLean SM, May S, Klaber-Moffett J, et al. Risk factors for the onset of non-specific neck pain: a systematic review. J Epidemiol Community Health 2010;64:565–72. doi:10.1136/jech.2009.090720
6 Nouri A, Tetreault L, Singh A, et al. Degenerative Cervical Myelopathy: Epidemiology, Genetics, and Pathogenesis. Spine 2015;40:E675-693. doi:10.1097/BRS.0000000000000913
7 Despréaux T, Saint-Lary O, Danzin F, et al. Stress at work. BMJ 2017;357:j2489.

Competing interests: No competing interests

17 August 2017
Alexis Descatha
Professor in occupational medicine, epidemiologist, emergency doctor
Paris Hospital (AP-HP), Versailles St-Quentin University (UVSQ), Inserm; Occupational Health Unit, EMS (Samu92), Inserm UMS 011 UMR-S 1168
University hospital of West Suburb of Paris, Poincaré site, F92380 Garches, France
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Re: Margaret McCartney: The cult of CPR Margaret McCartney. 358:doi 10.1136/bmj.j3831

I cannot entirely agree with Dr McCartney – although I am 100% with:

‘It was acceptable 20 years ago to tell patients and families that
dying was inevitable and imminent. Side wards were organised,
if possible. Families were called to bedsides at home. Syringe
drivers with generous morphine were obtained. Relatives often
stayed with their dying family member at all hours.’

And that is still both acceptable, and also good behaviour.

However, as is almost always the case when clinicians write about CPR, Dr McCartney concentrates on the situation of DNACPR when CPR would be clinically ineffective [and I have always been puzzled by the ‘logic’ there – if CPR would not re-start the heart, and the patient requests that CPR should be attempted, why not attempt it?].

Dr McCartney does not cover the situation of a patient – especially a patient who is at home, and not close-to-death – who has considered a cardiopulmonary arrest, and wants to forbid attempted CPR when such an attempt might be clinically successful. This is, as I have pointed out (1, 2), somewhere between difficult and impossible for the patient to achieve, if there is also a desire to involve the 999 services to ascertain that an arrest has actually occurred.

At the heart of this ‘CPR issue’ is the combination of the near-impossibility of the clinical situation after most arrests being describable in advance, and the consideration of the acceptability of that future situation, as compared to being dead, being for either the patient or ‘best interests’. As I have written (3): ‘Without CPR, 'alignment of mindsets' between relatives [who, I believe, tend to see 'my dad doesn't want you to attempt CPR' as the justification for DNACPR] and clinicians [who, it seems to me, are much more concerned with 'could CPR be successful'] would not be a problem for CPR decision making’.

Dr McCartney has got this, I think, wrong:

‘… with the charade of seeking “consent” for not doing CPR’.

The objective should not be one of seeking consent for DNACPR – we should all be working towards allowing adequately-informed patients to make their own decisions about CPR, which amounts to patients refusing CPR: ‘conceptually different’ from seeking consent for DNACPR. In England, that amounts to ‘ideally we need more Advance Decisions refusing CPR’ (4).

I must say, that I tend to agree with Kate Masters (response 16 August): and the 'solution' Kate asks for (...I am flummoxed as to why I keep reading articles such as this that explain the barriers, but offer few ideas for solutions) is for clinicians to stop making quality-of-life decisions (put 'legally', that amounts to what I've written above: obtain Informed Consent, or embark of a proper, inclusive of family and friends, best-interests decision-making process about CPR).






Competing interests: No competing interests

17 August 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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Re: Hundreds of Chinese researchers are sanctioned after mass retraction Owen Dyer. 358:doi 10.1136/bmj.j3838

The series of retraction scandals happening in China actually revealed the weak points of the current Chinese physician promotion system and reward polices. So far all of the municipal level hospitals and teaching hospitals in China already respectively developed very detailed promotion rules, mainly based on working years and academic achievements composed of original articles, acquired researching projects and scientific rewards. On the other hand, if people presented papers in high profile journals, especially top class journals, then they will earn very considerable cash prizes (1, 2). And in turn the above mentioned incentive mechanisms were definitely to stimulate publishing activities and to pursue financial benefits for each person involved.

Regrettably, this paid-to-publish phenomenon dramatically jeopardizes our clinical system, in which the performance of physicians or surgeons should be evaluated mainly on clinical experiences or the number of difficult cases rather than by academic projects or highest educational degree. It could also very easily induce academic corruption events by purchasing or plagiarizing papers. In fact, a well-organized and lucrative papers polishing industry has already been established, and only in 2015, the total article processing charges paid by Chinese researchers to open access journals already reached $72.17 million(3).

It is obvious that the Chinese government and healthcare administration should realize the academic crisis and take steps to erase the underlying industry chain. However, one of the most important urgent points in rebuilding Chinese academic justice and fairness should not be neglected -- i.e. reform of the personal promoting system, which should be developed into muliti-modules based not only on academic achievements but also on clinical experiences, and always with highest supervision as well as penalty rules in order to meet the requirement of "zero tolerance" to fraud events.

Collectively, the scandal revealed a “black hole”. Therefore, long term rectification should be anticipated and ultimately accomplished.

1. Alison McCook. Paid to publish: It’s not just China. Retraction Watch 10. August 2018.
2. Stephen Chen. The million-dollar question in China’s relentless academic paper chase. South China Morning Post 15 July 2017.
3. Academics pay journals to publish ghost-written articles to get promotions. 10 October 2016 Globaltimes.

Competing interests: No competing interests

17 August 2017
Wei Huang
Critical Care Medicine
1st Affiliated Hospital of Dalian Medical University
222 Zhongshan Road, Dalian 116023 CHINA
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