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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: Encouraging young and old to interact in care settings Anne Gulland. 357:doi 10.1136/bmj.j1862

DNA angels
with ancestry, destiny,
and best clemency.

Competing interests: No competing interests

18 April 2017
Hugh Mann
New York, NY, USA
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Re: David Oliver: Challenges for rural hospitals—the same but different David Oliver. 357:doi 10.1136/bmj.j1731

David has hit the nail on the head in so many ways. In remote and rural Scotland many of our specialist visiting services are being reduced or withdrawn, leaving patients with a Hobson's choice between long (and expensive and unreliable) journeys for appropriate care (at their own expense), or leaving it up to fate and declining to go. In just 4 years on Arran I have witnessed the withdrawal of General Surgery, Gynacology and ENT clinics, and Care of the Elderly clinics reduce to once a year (despite a staggering 17% of our population being over 75 years of age!). In many cases, the GPs (or as I prefer, Primary Care Physicians) are the only ones who can pick up the pieces. Many Island and rural Primary Care Physicians do extra training to take up special interest rolls. I myself have been training in Dermatology to fill the void left when the clinics stopped several years ago. Other colleagues have additional skills in Gynaecology and Sexual Health, Orthopaedics, Ultrasound, Palliative Care, Pre-hospital Emergency Care.

And as for rural hospitals - I am currently writing this at 11:30 at night in the duty room of our island hospital, waiting for the ambulance. The hospital currently has 16 beds including an A&E and an HDU facility for high risk patients. Many high risk patients are transferred by ferry or helicopter to mainland units for specialist treatment. Sometimes the weather has other plans and nothing can sail or fly for days. So it is up to us, the GPs, to look after sick patients when there is nowhere to go. But we care for the majority of the patients ourselves, acute and rehabilitation, community admissions and interhospital transfers. Without this service, many people would have died waiting hours for transfer to mainland hospitals.

As David says, there are strong Rural Generalist schemes developing in Australia and Canada, with advanced training in Anaesthetics, Obstetrics, Emergency Medicine, and others. Indeed, Australia now has the Australian College of Remote and Rural Medicine (ACRRM). This new breed of Rural Generalists are Primary Care Physicians, GPs, being supported by their Colleges, politicians, and most of all, their specialist colleagues.

The future for British Rural Generalists is already here - we just need the political willpower, colleague support for training, communications with specialists, and the hospital facilities to bring a quality 21st century health service to rural and remote communities.

Dr Cathy Welch,
Primary Care Physician
Isle of Arran

Competing interests: No competing interests

18 April 2017
Catherine J Welch
Arran Medical Group, Isle of Arran
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Re: Peaches and cream in a multi-ethnic society Pip Fisher. 357:doi 10.1136/bmj.j1752

Dr Fisher herslf is using terminology that is confused and confusing.

" Asian", White", " Multi-ethnic", " Black"

Asia starts IN Turkey, only a sliver of Turkey is in Europe. Asia continues to the East - and Hawai, a part of the UNITED STATES OF AMERICA, is in Asia.

Dr Fisher may be aware that in Japan, an Asian country, there are the minority Ainu people who are "Caucasian".

When the South African apartheid regime made the Japanese visitors "honorary Whites", they were not thinking of the Ainu. They were impressed by the Rising Yen.

"White" and " Black" beloved of the mighty Americans are again meaningless. It is sometimes a matter of "passing". You do not conduct the pencil in the hair test. The one drop test too is long gone from folk memory.

"Multi-ethnic" is meaningless too. Do you mean a society where some are, say, natives of Upper Nile, some are natives of Tibet, some are natives of and descendants of the natives of Barmouth?

I respect the late Julian Huxley but I feel his introduction of the term "ethnicity" as a substitute for "race" did no long-term good.

Now to the peaches and cream. Unless my memory is deceiving me, there was an Oxford graduate, a young poet named Moraes, of Goan parentage, who may have had a dash of Portuguese blood in him, but who was generously endowed with melanin, whose wife was as pink as any north European, and who described the complexion of his new born son as "peaches and cream". There was no question of hypothyroidism there.

To end, I would plead that Dr Fisher and other teachers should forget "ethnicity", concentrate on CULTURE, on PEDIGREE (though they do say that no one can really assume that the father described on the birth certificate is really the father).

Competing interests: No competing interests

18 April 2017
JK Anand
Retired doctor
Free spirit
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Re: Removal of all ovarian tissue versus conserving ovarian tissue at time of hysterectomy in premenopausal patients with benign disease: study using routine data and data linkage Jemma Mytton, Felicity Evison, Peter J Chilton, Richard J Lilford. 356:doi 10.1136/bmj.j372

April 18, 2017

To the BMJ Editor:

With regard to the report by Mytton and colleagues:

Mytton et al in an extensive retrospective study reported that women who had hysterectomy with ovarian conservation had a significantly lower risk of all-cause mortality and mortality from ischemic heart disease and cancer (1). They noted that removal of both ovaries protects against ovarian cancer while increasing the risk of cardiovascular mortality. Their observations contradict a detailed report of a cohort of 2873 Framingham Study female participants prospectively followed for 24 years (2). The 1978 study provided prospective evidence that menopause associates with a highly significant two-fold increase in the incidence of heart disease. Detailed data from the older study showed that cardiovascular protection diminished after surgical menopause regardless of whether or not oophorectomy had been performed.

Recently, Muka et al reported an overall higher mortality rate in women who experience premature or early on-set menopause and notably a higher risk of cardiovascular disease mortality for these women (3). However, postmenopausal women on hormones had a doubled risk of coronary heart disease.

We suggest that observed considerable increases in serum ferritin levels at menopause marks a dramatic shift in iron metabolism possibly linked to increased iron stores or with heightened inflammatory responses (4). We invite investigators to consider that the observed significant increased risk of cardiovascular disease in postmenopausal women is associated with altered iron homeostasis and potential increase in body iron stores after menstrual blood flow cessation (4).

The hypothesis that increased cardiovascular disease results from oxidative stress catalyzed by excess iron accumulation was tested in the VA Cooperative Study Trial 410, The Iron and Atherosclerosis Study (FeAST). The effects of phlebotomy on clinical outcomes were tested in peripheral arterial disease (PAD) with iron store reduction, estimated by serum ferritin; to levels approaching 25 ng/mL as occur in healthy menstruating women (5). Data from this prospective randomized study demonstrated that lower ferritin levels (76-78 ng/mL) predicted improved outcomes in younger men with (PAD) upon removal of an amount of iron represented by approximately a liter of blood. Lower ferritin levels strongly predicted improved clinical outcomes, regardless of randomization group, with a threshold for benefit below 76-78 ng/mL.

The striking relationship between menopause, whether surgical with or without oophorectomy, or natural, and coronary disease risk needs clarification. Dramatic changes during menopause in iron metabolism and hormone levels require prospective, granular studies to better understand and characterize the complex relationships seen during this transition. One possibility is that iron in catalytic form stimulates inflammatory responses and leukocyte activity and associates with elevation of IL-6 and other inflammatory biomarkers based on our findings of direct associations (6) between elevated ferritin and inflammatory biomarkers, predominantly IL 6, and mortality.

Data from multiple sources support a need for additional studies testing the relationship between increased cardiovascular disease risk related to changing iron homeostasis, the role of inflammation and hormone status in women during and after surgical or natural menopause. Additionally, Gordon et al (2) reported an alteration in lipid metabolism with cessation of menses, most evident with bilateral oophorectomy plus hysterectomy, and may supply insight into metabolic changes prompting increased cardiovascular disease risk. We recommend prospective serial measurements hormone replacement therapy (HRT) with estrogen and progestin or with estrogen alone, along with serial measures of hormone levels, lipid panels, ferritin, iron, hepcidin and inflammatory biomarkers in pre and postmenopausal women to better understand unique factors contributing to increased cardiovascular mortality. (4). Better understanding of the biological basis for menopausal effects on cardiovascular disease offers important insights into prevention and treatment of cardiovascular disease generally.


Virginia W Hayes, MS, APN, BC: VA Sierra Nevada Health Care System, Reno Nevada
Ralph G DePalma, MD: VA Office of Research and Development, Washington, DC
Leo R Zacharski, MD; VA White River Junction Health Care System, White River, Vermont.

The authors are employees of the Department of Veterans Affairs and report no financial conflicts or interests. The opinions expressed are those of the authors and not necessarily those of the Veterans Administration or the Government of the United States.

1. Mytton J, Evison F, Lilford, LJ. Removal of all ovarian tissue versus conserving ovarian tissue at time of hysterectomy in premenopausal patients with benign disease: study using routine data and data linkageBMJ 2017;356:j372

2. Gordon, T, Kannel WB, Hjortland, C, McNamara PM. Menopause and the risk of cardiovascular disease. The Framingham Study. Ann Intern Med 1978; 89 (2): 157-161

3. Muka T, Oliver-Williams C, Kunutsor S, et al. Association of age at onset of menopause and time since onset of menopause with cardiovascular outcomes, intermediate vascular traits, and all-cause mortality: A systematic review and meta-analysis. JAMA Cardiol 2016; Sep 14: oi:10.1001/jamacardio.2016.2415

4. Hayes VW, DePalma RG, and Zacharski LR. Menstrual suppression, iron homeostasis, and disease risk. The Journal for Nurse Practitioners 2011; 7 (8): 660-664

5.. Zacharski LR, Shamayeva G, Chow, BK. Effect of controlled reduction of body iron stores on clinical outcomes in peripheral arterial Disease. Am Heart J 2011; 162: 949-957.
6. DePalma RG, Hayes VW, Chow BK, Shamayeva G, May PE, Zacharski LR. Ferritin levels, inflammatory biomarkers, and mortality in peripheral arterial disease: A sub study of the Iron (Fe) and Atherosclerosis Study (FeAST) Trial. J Vasc Surg. 2010; 51(6): 1498–1503.

Competing interests: No competing interests

18 April 2017
Virginia W Hayes
Nurse Practitioner, researcher
Ralph G. DePalma, MD and Leo R Zacharski, MD
VA Sierra Nevada Health Care System
875 Kirman Ave, Reno, NV 89502
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Re: Electrical injury Victor Waldmann, Kumar Narayanan, Nicolas Combes, Eloi Marijon. 357:doi 10.1136/bmj.j1418

Dear Sir,

We read with interest the Cover Features article on Electrical Injury by Waldmann et al in this month's BMJ. As Plastic and Reconstructive surgeons that have dealt with spectrum of electrical burns in adult and paediatric patients, we feel the article, although wide in scope, under emphasises the potential serious surgical consequences of these injuries.

Firstly, it makes no reference to standardised emergency management of these patients as per Advanced Trauma Life Support (ATLS) and Emergency Management of Severe Burns (EMSB) precepts, crucial for the correct management of these potentially critically ill patients. This is widely practised by Emergency Department physicians, Trauma Surgeons as well as Burns and Plastic Surgeons around the world, daily. Also, quiet simply electrical injuries are burn injuries.

Secondly, only a token image (Fig 2) and part of a cartoon (Fig 3) is dedicated to the actual burn injury itself, which although small in terms of total body surface area, can be limb threatening due to the circulatory compromise in the upper and lower limbs requiring emergent escharotomies and fasciotomies under general anaesthetic. Furthermore, early tangential excision, debridement and skin grafting under general anaesthetic along with multiple dressing changes in theatre and on the ward, may be required to ensure correct healing of the burn. Importantly, modern Burns Units provide total patient care with HDU/ICU beds and staff and have identical means of invasive cardio-respiratory and circulatory support as most Level 3 Critical Care Units. They are not merely a debridement and grafting service.

Thirdly, there is no comment on fluid resuscitation and the need to maintain a high urine output of more than 1.5ml/kg/hr to abrogate the effects of rhabdomyolysis and acute kidney injury due to release of myoglobin from muscle damaged by the electrical injury. Rhabdomyolysis also affects cardiac as well as skeletal muscle and there is the potential for continuous damage to deeper tissues and bone due to the dynamic nature of the electrical burn injury.

We feel the above points add further important information that was missing from the original article,

Yours sincerely

Competing interests: No competing interests

18 April 2017
Vikram P Sharma
Plastic Surgery SpR
Mr Ian King, Plastic Surgery SpR, St George's Hospital, London; Mr Jorge Leon-Villapalos, Consultant Burn, Plastic and Reconstructive Surgeon, Chelsea and Westminster Hospital, London
St Thomas' Hospital
Westminster Bridge Road, London SE1 7EH
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Re: David Oliver: Choosing to be honest about patient choice David Oliver. 357:doi 10.1136/bmj.j1829


Unusual though it may be for an author to respond to his own column, I just wanted to draw readers' attention to an excellent piece by Dr Natalie Joseph-Williams and several co-authors on Implementing Shared Decision-Making in the NHS and some of the lessons from the MAGIC programme in several sites around the country. This article and some of the references it contains provide some good counterarguments to some of mine which are well worth following.

Whilst at the same time it does agree with my view that people should be as activated or as involved in shared decision making or supported self management as they either want to be or feel capable of being.

The authors' point that we could and should do more to enable them to be more involved by educating and empowering them, by changing the way we operate as professionals is well-taken. It's easy for learned helplessness to develop in a traditionally paternalistic system.

On the other hand, we cannot duck the very real concerns they raised about pressures on a depleted workforce and competing demands on clinicians' time and of course the clinicians' own health and potential for burnout.

David Oliver

Competing interests: No competing interests

18 April 2017
David Oliver
Consultant Physician
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Re: David Oliver: Challenges for rural hospitals—the same but different David Oliver. 357:doi 10.1136/bmj.j1731

As rural general surgeons we welcome David Oliver’s article outlining challenges in healthcare provision for rural areas. Oliver correctly cites a number of problems which urgently need to be addressed including strains on patient transport, reconfiguration of health services to a ‘one size fits all’ urban model, and the fact that medical schools deliver limited exposure to rural medicine.

Quality of life is high in rural areas, with varied leisure opportunities and excellent standards of school education. However, there are rural community planning issues that do need addressed, such as employment opportunities for partners of health care professionals, and the provision of high speed broadband. Public bodies must work together to achieve community resilience.

If service provision in Rural General Hospitals are downgraded, the recruitment difficulties to hospital posts and general practice positions in the remoter areas would be further compounded.

“Standards informing delivery of care in rural surgery” is a report by the Royal College of Surgeons of Edinburgh which has defined a way to provide safe and appropriate local general surgical services in a rural hospital setting. This will involve close collaboration between rural consultants and visiting specialists who can share decision making and provide opportunities for additional operating in a high-volume centre. Some adaptation of national guidelines will be necessary in rural settings and do not need to diminish quality.

The maintenance of appropriate healthcare in rural areas requires a will by the politicians to facilitate and fund these recommendations to provide a robust and appropriate rural healthcare system.

Gordon McFarlane FRCSEd Gilbert Bain Hospital, Lerwick

David Sedgwick FRCSEd Badabrie, Fort William

Competing interests: No competing interests

18 April 2017
David M Sedgwick
Consultant General Surgeon
Gordon McFarlane
Badabrie, Fort William
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Re: International medical graduates and quality of care Aneez Esmail, Julian Simpson. 356:doi 10.1136/bmj.j574

It is really a matter of life and death.
The penultimate para of Prof Konotey-Ahulu's letter tells the readers that NICE is giving WRONG ADVICE in the management of sickle cell patient.
Probably the item escaped notice of haematologists and NICE.
If Prof Konotey-Ahulu is right, then NICE is wrong and whosoever follows NICE guidance could unkowingly put a patient's life at risk.
It seems therefore that:
1. NICE should look into the matter.
2. The three medical defence societies in the UK should alert their members.
3. The Chief Medical Officer should call for a report from NHS England. (I am assuming that NHS England is within the domain of the CMO).

Competing interests: No competing interests

18 April 2017
JK Anand
Retired doctor
Free spirit
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Re: Exploring thoughts of suicide Lindsey Sinclair, Richard Leach. 356:doi 10.1136/bmj.j1128

Suicides and self-harm traumatisms are the sixth leading cause of death, but GPs could not reduce them [1], probably because recent evidence reveals that administered antidepressants actually increase suicide risks by 2-5 times. [2][3][4][5][6]
A recent meta-analysis, level I evidence, clearly demonstrated that SSRIs double the risk of suicide and violence in adults. [4]
Another meta-analysis published in the British Journal of Psychiatry has found that even patients with the most severe depression can expect to get as much benefit from cognitive behavioural therapy (CBT) as those with less severe symptoms. [7]
Even Behavioural Activation effectively decreases depressive symptoms. [8]

Competing interests: No competing interests

18 April 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Thessaloniki, Greece
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Re: Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study Joshua D Stein, Rory M Marks, John Z Ayanian, Brahmajee K Nallamothu, et al. 357:doi 10.1136/bmj.j1415

Some points should be added to the article, that Corticosteroids can induce severe adverse events such as psychiatric disorders. Affective disorders (depression, bipolar disorders like hypomania) and psychosis are the most common manifestations [2]. Adverse reactions also include insomnia, anxiety or panic attacks [3]. No factors have been identified that allow for the accurate prediction of development of these disorders, but a dose-dependent relationship (increased risk when the daily prednisone-equivalent dose is ≥40 mg) has been observed in most cases, although there have been case reports with lower doses. I think Hamilton FW is absolutely right. [4]

Although there is evidence that daily doses of corticosteroids can have neuro-psychological effects, only a few studies have investigated the role of cumulative doses in the short- and long-term for psychiatric effects/disorders [5]. In a Cochrane review [6] the authors reported about patients with a primary diagnosis of a psychotic disorder, or persons with a high risk of developing a psychotic disorder. HPA (hypothalamic-pituitary-adrenal) axis dysregulation has been implicated in psychotic disorders. Elevated cortisol secretion has been positively linked with symptom severity in psychosis. Dose and duration of use of oral corticosteroids, differences between patients with a new-onset psychiatric disorder [7] and a longer established illness are relevant factors.

1) Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ 2017; 357: j1415
2) Bhangle SD et al. Corticosteroid-induced neuropsychiatric disorders: review and contrast with neuropsychiatric lupus. Rheumatol Int. 2013; 33(8):1923-32
3) Abadie D et al. Drug-induced panic attacks: Analysis of cases registered in the French pharmacovigilance database. J Psychiatr Res. 2017; 90:60-6
4) BMJ 2017; 357: j1415
5) Pépin AJ et al. Adverse neuropsychological effects associated with cumulative doses of corticosteroids to treat childhood acute lymphoblastic leukemia: A literature review. Crit Rev Oncol Hematol. 2016;107:138-48
6) Garner B et al. Antiglucocorticoid and related treatments for psychosis. Cochrane Database Syst Rev. 2016 Jan 4;(1):CD006995. doi: 10.1002/14651858.CD006995.pub2.
7) Nishimura K et al. New-onset psychiatric disorders after corticosteroid therapy in systemic lupus erythematosus: an observational case-series study. J Neurol. 2014; 261(11):2150-8

Competing interests: No competing interests

18 April 2017
Detlef Degner
Department of Psychiatry, University of Göttingen, Germany
D- 37075 Goettingen, Germany
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