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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: Effective cybersecurity is fundamental to patient safety Guy Martin, James Kinross, Chris Hankin. 357:doi 10.1136/bmj.j2375

We agree with Martin et al. that the NHS must urgently improve the state of cybersecurity in the face of constant threat of cyberattack from a plethora of forms of malware[1]. The recent “Wannacry” ransomware worm is only the latest example of a cyberattack on healthcare organisations, albeit a particularly damaging one.
Much has been made of the impact of Wannacry on the NHS, with c. 47 NHS organisation severely affected. However, it should not be forgotten that there have been an estimated 200,000 victims in approximately 150 countries[2]. Large private sector organisations were also affected e.g. Spain’s Telefonica, a major telecoms company; Nissan, a global car manufacturer, FedEx, an international shipping company & Renault, another major car manufacturer[3].
Infections with Wannacry were not limited to the hard-pressed NHS.
Martin et al. echo the mass media’s focus on the continued use of the obsolete Microsoft Windows XP operating system in the NHS. Windows XP was launched in 2001 & support, including security updates ceased in April 2014. From a cybersecurity point of view, continuing to rely on this 16 year-old operating system is indefensible, but not solely because of Wannacry. To quote a Microsoft’s Director of Security, writing in 2013: “…the security mitigations built into Windows XP (service pack 3) are no longer sufficient to blunt many of the modern day attacks we currently see.”.[4]
The Government has been criticised for ceasing to fund continued software updates for hopelessly outdated Windows XP systems in the NHS in April 2015. This meant no new updates would have been available to NHS computers running Windows XP, increasing their vulnerability.
However, if the Government had continued to pay Microsoft for these updates, the NHS would have had little incentive to finally abandon Windows XP and update to a more modern operating system. Continued funding of these updates would have led to a quite literal false sense of security and perpetuated the use of obsolete, insecure software in the NHS.
Windows XP is not the only version of Microsoft Windows which is potentially vulnerable to Wannacry. More modern versions of Windows up to and including Windows 8.1, and Windows Server 2012 are also vulnerable to Wannacry if unpatched[5]. It is not enough to use relatively modern versions of Windows; these installations must be kept updated with the latest software patches.
Martin et al. say that the governance of cybersecurity in the NHS is unclear. They talk of the (cybersecurity) “…buck being passed from one organisation to another…”.
However, it is clear that NHS organisation have a legal responsibility to protect the confidentiality of the patients they look after[6]. NHS organisations must also maintain business continuity even in adverse conditions in order to effectively deliver healthcare. This means that the cybersecurity of NHS organisations must be of a reasonable standard across the board.
In the aftermath of one of the most significant global cyberattacks in recent memory, the NHS will almost certainly do what is obviously necessary and review the state of cybersecurity across all NHS organisations. This is not a time for finger-pointing or shroud waving at the NHS or Government. It is time for NHS leaders to wake up to the multifarious cyber threats knocking on their digital doors & secure their electronic estates.
[1] Effective cybersecurity is fundamental to patient safety. Martin G, Kinross J, Hankin C. BMJ 2017;357:j2375 doi:
[2] What is WannaCry and how does ransomware work? McGoogan C, Titcomb J, Krol C. The Telegraph 18/5/17
[3] More disruptions feared from cyber-attack; Microsoft slams Government secrecy. Reuters 15/5/17
[4] The risk of running Windows XP after support ends April 2014. Rains T. Microsoft Secure Blog.
[5] Wannacry ransomware campaign exploiting SMB vulnerability. CERT-EU security advisory 2017-012. 18/5/17
[6] Data Protection Act 1998

Competing interests: The views expressed are our own and not those of our employer(s).

20 May 2017
Gee Yen Shin
Consultant Virologist
Rohini J Manuel
Public Health England
Public Health Laboratory London, 3/F Skipton House, 80 London Road, London SE1 6LH
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Re: Abortion by telemedicine: an equitable option for Irish women Wendy V Norman, Bernard M Dickens. 357:doi 10.1136/bmj.j2237

Norman et al. provide an instructive synopsis of the work of Aiken et al(1,2). However the motives of telemedicine abortion providers cannot justify a permissive and uncritical assessment of their methods. Norman et al correctly identify women included in the study as representing a potentially vulnerable cohort. These circumstances cannot vitiate the need for the valid and informed consent process, to which women are entitled; consistent with the principles espoused in Montgomery vs Lanarkshire Healthcare Board (2015)(3). Patients must have communicated to them all material risks of their abortion; in a manner that is intelligible. A material risk is a risk to which a reasonabley prudent patient would attach significance(3). Hence the decision-making process is not paternalistic but shared and patient-centred. Exploration of the Women on Web website ( must raise concern that women have not been adequately consented for their abortions. There is a "Q&A" drop down a la carte menu, with which patients may or may not necessarily engage, a fortiori given the emotive nature of the circumstances involved. For example the site advises against the need for anti-D as immunoprophylaxis to Rhesus alloimmunisation ( Haemolytic disease of the new born, affecting subsequent children with a risk to the neonate's life, may constitute a material risk. This is all the more so given that Ireland has one of the highest prevalences of the Rhesus negative blood group in the world(4).

In the absence of informed consent, following Chester v Afshar (2005) in the UK, telemedicine providers would be liable for the complications that arose. In instances where the abortion did not termindate the pregnancy there would also potentially be liability for the unfortunate tort of wrongful birth.

The provider appears to counsel women to engage in behaviours which potentially undermine the doctor-patient relationship. For example they advise that women need not inform attending doctors that they have attempted medical abortion but rather that they have suffered a spontaneous miscarriage ( Further while correctly advising women to seek medical attention immediately, where they fear that a complication has arisen; WoW seem to add the caveat that where agents have been administered vaginally women "must make sure that they are dissolved", with no further advice on how to proceed should they not have dissolved ( The WoW objective is, in some ways, laudable in that they wish women to avoid prosecution. However practices which foster and breed mistrust between patients and healthcare professionals can only compromise the standard of care globally. There is a consensus that vulnerable and desperate women should not be criminalised. However difficult circumstances cannot arrogate to internet telemedicine providers the power to disregard fundamental rights of informed consent and autonomy.

(1) Norman WV, Dickens BM. Abortion by telemedicine: an equitable option for Irish women. BMJ. 2017 May 16;357:j2237.(

(2) Aiken ARA, Digol I, Trussell J, Gomperts R. Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland. BMJ. 2017 May 16;357:j2011

(3) Chan SW, Tulloch E, Cooper ES, Smith A, Wojcik W, Norman JE.Montgomery and informed consent: where are we now? BMJ. 2017 May 12;357:j2224

(4) Bhutani VK, Zipursky A, Blencowe H, Khanna R, Sgro M, Ebbesen F, Bell J, Mori R, Slusher TM, Fahmy N, Paul VK, Du L, Okolo AA, de Almeida MF, Olusanya BO, Kumar P, Cousens S, Lawn JE.Neonatal hyperbilirubinemia and Rhesus disease of the newborn: incidence and impairment estimates for 2010 at regional and global levels.

Pediatr Res. 2013 Dec;74 Suppl 1:86-100. doi: 10.1038/pr.2013.208. web appendix

(5) Sokol DK. "How can I avoid being sued?". BMJ. 2011 Dec 14;343:d7827

Competing interests: No competing interests

20 May 2017
Chika E Uzoigwe
Luis Carlos Sanchez Franco, Adrian Sanchez Campoy
Harcourt House Sheffield
Sheffield, UK
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Re: Montgomery and informed consent: where are we now? Wojtek Wojcik, Jane E Norman, et al. 357:doi 10.1136/bmj.j2224

Interesting judgment and discussion about the ethics of not informing pregnant patients about facts that are relevant to them. Here in the Netherlands, I am hoping women (or their descendants) will start a few court cases about this, in particular because they were not informed antenatally about the option of a tubal ligation (TL) in case their deliveries became a caesarean section (CS), as FIGO advises to discuss long before term (1), and a study in the Netherlands shows most women with ≥1 children would desire (2). This can have serious consequences because without the TL there is of course much more risk of an unintended/ unwanted pregnancy (such women are regularly seen in abortion clinics, and are often particularly upset (2)). Risks related to pregnancy are larger for these if-given-the-option-would-have-chosen-a-TL-women compared to the risks in average pregnancies because of the uterine scar, because of possible recurrent complications related to the CS indication (e.g. diabetes, hypertension, >BMI) and because these women are on average older(3). On top of that, there are the costs and side effects (e.g. thrombosis on the pill especially in smokers when they get older) and anxieties related to contraception for the next 10-15 years. With leftover sutures from the uterine closure, the TL is gratis, unlike with clips or with hysteroscopic sterilisations later on: and at least as reliable (3). Moreover, a very likely benefit of TL, i.e. a significant reduction in subsequent ovarian carcinoma risk, is withheld ― bilateral total salpingectomy is probably most effective for this effect, and easily performed during a CS. These malignancies apparently often originate in the tubes and there is no good method (like with breast and cervix carcinoma) to detect with screening these neoplasms when still relatively harmless (3). Conversely, serious TL regret is of course a risk, but many gynaecologists, or their mentors, were trained at a time when regret was more likely: women were more easily coerced; under five mortality was higher; serious congenital abnormalities were easier missed antenatally; IVF was not so mainstream; and women were on average much younger when they delivered their ≥2 child. Indeed, regret is not so much related to parity but very significantly to age (3). One can’t help but wonder if one woman with regret who is offered free IVF is worse: ethically; from a medical-complications perspective; and in light of financial considerations, than say 10 unintended pregnancies.
In the Commonwealth countries, Brazil, Spain, Switzerland (reputed to have the lowest induced abortion rate in the world), and the USA, most women know very well that a TL during a CS for a soon-expected-to-be-complete family is a popular option. This TO option is more or less understood to be on the table antenatally. Many doctors in the Netherlands, France, Germany, Eastern Europe and Belgium think it is unwise, unethical or even financially disadvantageous for them to offer the TO option under the above circumstances and most women are not well-informed enough to demand it or to insist. There is also very subtle TO counter-propaganda by cat food producers, where it hurts most, see photo (3). Not giving the TO option also has serious consequences for, for example, Africa where the medical norms are often related to those in Europe, where there is often no guaranteed access to a repeat CSs let alone NIPT and where millions of women have an unmet need for contraception and save abortion. A few court cases in Europe might help. In sub-Saharan Africa uterine scars can carry a similar risk to landmines: they can “explode” even 10 years after the last CS (3). Who knows whether the medical services will be in that particular region adequate then?

(1) Dickens B. Female contraceptive sterilisation: International Federation of Gynecology and Obstetrics (FIGO) Committee for the Ethical Aspects of Human Reproduction and Women's Health. Int J Gynaecol Obstet 2011;115:88–9.
(2) Verkuyl DA, van Goor GM, Hanssen MJ, Miedema MT, Koppe M. The right to informed choice. A study and opinion poll of women who were or were not given the option of a sterilisation with their Caesarean Section. PLoS ONE 2011;6:e14776. doi:10.1371/journal.pone.0014776. PMID: 21445338
(3) Verkuyl DA. Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it. Contraception and Reproductive Medicine (2016) 1:23 DOI 10.1186/s40834-016-0034-1 (open access)

Competing interests: No competing interests

20 May 2017
Douwe A. Verkuyl
CASA Clinics, Leiden, The Netherlands
Leinweberlaan 16, 3971KZ, Driebergen,The Netherlands
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Re: Complementary and integrative medicine in the management of headache Denise Millstine, Christina Y Chen, Brent Bauer. 357:doi 10.1136/bmj.j1805

While I am grateful for this thoughtful and comprehensive review, I worry that the wording of the abstract text, "traditional Chinese medicine including acupuncture, massage, yoga, biofeedback, and meditation" might be misleading or confusing. My training here in the U.S. has always included the following components under the umbrella of traditional Chinese medicine: acupuncture, moxabustion, Chinese herbal medicine, Chinese therapeutic massage (Tui Na), dietary therapy (emphasizing the particular "energetic" properties of specific foods) and energy conscious movement practices such as Tai Chi and Qi Gong. Biofeedback, yoga, most types of massage and even meditation would not then belong under the category of TCM.

Competing interests: No competing interests

20 May 2017
Michael R Barr
Oriental Medicine Practitioner
Park Avenue Holistic
2531 Oakstone Drive, Columbus OH 43231
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797


The findings of this study are interesting and as a 51 year old acute hospital physician i can certainly recognise some of the possible explanations proposed for the small incremental differences in outcomes with age.

However, i would caution against making direct inferences for other systems such as those in the UK

1. There is no direct equivalent of "hospitalist" here but the closest job descriptions are consultants in acute internal medicine, geriatric medicine and general internal medicine - i.e. managing a range of acutely admitted adults as the supervising consultant for their inpatient spell (alongside some ambulatory work)

2. What the authors describe as the threshold for "high volume" of activity in the US system would be a very low volume of activity indeed by UK standards. A full time NHS bed holding consultant in GiM/AIM or Geriatric Medicine would routinely be managing multiples of that number each year and would be kicking their heels wondering why they were there at all at less than 200 finished consultant episodes a year. (Partly because UK medicine is far more dependent on trainee doctors with the consultant as the lead clinician rather than the person doing the bulk of the work)

3. Outcomes in adult acute medical specialities are also determined by availability of support staff, investigations, nursing and allied health professionals and by availability of community services outside hospital and not just by individual senior medical practitioners

4. Even if the same findings pan out in a context outside the US, the implication may simply be that as doctors get older, they need to morph roles from doing as much twilight or night work and as much acute end work towards more ambulatory care or "in hours" roles, teaching, training and management where they can still add great value

5. The study applies only to hospitalists and so its hard to know whether a similar pattern would be seen in other specialities including ones requiring technical skills and procedures

For all my caveats, i can recognise that there is a likely trade off between experience, pattern recognition and judgment born of long experience versus risk of being further away from having been a medical registrar, from being up to date with the latest evidence base for treatments, and the risk of burnout, decision fatigue, lower energy levels or longer recovery times

But as the authors say, its not a function of age alone but regular exposure and experience, volume of patients and up to date skills and knowledge so it would be wrong to make blanket judgments about physicians's suitability for roles based on age alone

David Oliver

Competing interests: No competing interests

20 May 2017
David Oliver
Consultant Physician
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Re: Burden of corticosteroids in children with asthma in primary care: retrospective observational study James S McLay, et al. 324:doi 10.1136/bmj.324.7350.1374

Acute exacerbations of asthma defined as acute episodes of progressively worsening shortness of breath, cough, wheezing, chest tightness or a combination of these symptoms. Treatment of acute exacerbations includes inhaled beta 2 agonist, oxygen along with corticosteroids and anticholinergic drugs.
Acute exacerbations of asthma are an important cause of morbidity, school absenteeism and frequent hospital visits.
Anti-inflammatory property of corticosteroids accounts for their effectiveness in asthma. As there is airway inflammation which cause airway compromise in acute exacerbations, there are proven benefits of steroids in acute asthma in resolving the obstruction of the airways.
Corticosteroids have been used in the treatment of asthma for approximately five decades and their proven benefits in the emergency room in treatment of asthma exacerbations.
Corticosteroids are the first line drug therapies in the management of acute asthma exacerbations. Oral or parenteral corticosteroids have been effective equally but parenteral steroids are preferred for critically ill children.
Short-term use of high-dose steroids usually don’t have significant side effects, but may be associated with hyperglycemia, hypertension and other psychiatric problems.
A Cochrane review demonstrated improved outcomes for children who have received corticosteroids at the earliest in the emergency department. As there is difficulty to decide when steroids should be administered. It has been shown that steroids given for a short duration of 3-7 days in children, improve the symptomatology and reduce the chances of an early relapse.
Guidelines mention use of prednisolone 1-2 mg/kg/dose every 6 h for 24 h then 1-2 mg/kg/day in divided doses every 8-12 hours. The total duration of therapy can be 3-7 days depending upon the response. However 5-day courses of oral corticosteroids have not been shown to be superior to 3-day courses for outpatient management of acute exacerbations in children.In our setup we use 3 days of corticosteroid therapy.
Inhaled corticosteroids are very effective drugs in suppressing airway inflammation.
A Cochrane review did not find a significant reduction in the need for oral corticosteroids in school-aged children.
Intermittent inhaled did show symptomatic improvement and lower likelihood of requiring oral corticosteroids in preschoolers,
Inhaled corticosteroids treatment is generally considered generally safe in children. Inhaled corticosteroids are known to cause local and systemic adverse effects. Inhaled corticosteroids therapy should be started at its lowest effective dose because usually adverse effects are dose-dependent.Inhaled corticosteroids do not offer cure to asthmatic children. But there is proven role for inhaled corticosteroids in asthma exacerbations. There is less evidence to recommend that inhaled corticosteroids can replace systemic corticosteroids in emergency room for acute asthma exacerbations.

In our view as there are studies showing minimal side effects of inhaled corticosteroids which are better than oral corticosteroids in treatment of acute moderate to severe asthma. However, Inhaled medications are only effective if they are used precisely. Inhaled corticosteroids show improved clinical control and better airway responsiveness
Adherence to daily inhaled corticosteroid therapy is most important in control of asthma.
As asthma is not a curable disease but using good hygienic practices and creating awareness with appropriate controlling measures, child with asthma minimize the complications and hospitalizations.

References : 1)Elham Hossny,Nelson Rosario,Bee Wah Lee,Meenu Singh,Dalia El-Ghoneimy,Jian Yi SOH,Peter Le Souef. The use of inhaled corticosteroids in pediatric asthma: update.World Allergy Organization Journal20169:26 DOI: 10.1186/s40413-016-0117-0

2)Edmonds ML, Milan SJ, Camargo Jr CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev. 2012;12, CD002308.

3) Sunil Saharan & Rakesh Lodha & Sushil K. Kabra.Management of Status Asthmaticus in Children.Indian J Pediatr (2010) 77:1417–1423 DOI

4) Chong J, Haran C, Chauhan BF, Asher I. Intermittent inhaled corticosteroid therapy versus placebo for persistent asthma in children and adults. Cochrane Database Syst Rev. 2015;7, CD011032.

5) Chang AB, Clark R, Sloots TP, et al. . A 5- versus 3-day course of oral corticosteroids for children with asthma exacerbations who are not hospitalised: a randomised controlled trial. Med J Aust. 2008;189(6):306–310 [PubMed].

6)Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota GW. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev. 2001; (1): CD002178

7) Fanta CH, Rossing TH, McFadden ER. Glucocorticoids in acute asthma: A critical controlled trial. Am J Med 1983; 74: 845-851

Competing interests: No competing interests

20 May 2017
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Re: Montgomery and informed consent: where are we now? Wojtek Wojcik, Jane E Norman, et al. 357:doi 10.1136/bmj.j2224

Society has to compensate patients harmed by medical procedures without the added burden of proving negligence. Compensation should not be limited to the tenacious few who can navigate the legal maze and win the litigation lottery. Naturally, the legal profession has a conflict of interest in opposing such “no fault “schemes.[1].

But to frame the recent change of law on informed consent, following the Montgomery case, as a clash of patient autonomy versus medical paternalism is disingenuous.[2]. If anything, it is legal paternalism masquerading as patient autonomy. The judges, based on one single case, have decided what the new legal standard is for millions of other future patients without canvassing anyone else’s views. Furthermore, this new standard applies to everyone except the legal profession. The legal profession will not automatically and retrospectively apply this new standard to past cases where “ the bolam” standard has been applied.

Natural justice demands that a professional knows in advance what is legally compliant and an assurance that their actions are not judged retrospectively by a particular patient outcome and future “case law” standards.

To avoid NHS being overwhelmed, directly and indirectly, by “malpractice” claims, the society and parliament need act urgently and enact a statutory law on medical negligence. [3].

1 Capstick B. The future of clinical negligence litigation? BMJ 2004;328:457–9. doi:10.1136/bmj.328.7437.457

2 Chan SW, Tulloch E, Cooper ES, et al. Montgomery and informed consent: where are we now? BMJ 2017;357:j2224. doi:10.1136/bmj.j2224

3 Jena AB, Schoemaker L, Bhattacharya J, et al. Physician spending and subsequent risk of malpractice claims: observational study. BMJ 2015;351:h5516.

Competing interests: No competing interests

20 May 2017
Santhanam Sundar
Consultant Oncologist
Nottingham University Hospital NHS Trust
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Re: Surgeon is struck off after three “never events” Clare Dyer. 357:doi 10.1136/bmj.j2359

When was his last re-certification as a general surgeon? What are the criteria for registration with the GMC, especially, for an individual that completed his training in West Africa? The author stated that he is a senior surgeon and that he has been in the employ of the teaching hospital since 2001. How good was his last performance review? Do you even conduct those reviews in the UK? Quite strange and unbelievable that a senior surgeon would fail in a procedure that is considered simple, even for trainee surgeons, anywhere in the world.

Competing interests: No competing interests

19 May 2017
Murphy Nmezi
1855 W. 44th Street
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Re: Patient data were shared with Google on an “inappropriate legal basis,” says NHS data guardian Gareth Iacobucci. 357:doi 10.1136/bmj.j2439

We must be grateful to Dame Fiona for keeping an eye on the commercial adventures of the NHS and its untrustworty TRUSTS.
The phrase " inapprpriate legal basis" is a little odd. Does it mean " illegal"? Does it mean " ultra vires"?
There is a recent invention, in the United States, of " alternative facts".
Inappropriate legal basis seems to be a stable-mate.
What does the BMA's ethicist have to say?

Competing interests: No competing interests

19 May 2017
JK Anand
Retired doctor
Free spirit
3 Wayford Close, Peterborough
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Re: Disturbed grief: prolonged grief disorder and persistent complex bereavement disorder Paul A Boelen, Geert E Smid. 357:doi 10.1136/bmj.j2016

Grieving is bittersweet. At first, we are overwhelmed with the shock and bitterness of losing a loved one. But after a while, after the shock starts to wear off, we begin to reminisce about the sweetness that we shared with our loved one. Still later, after the bitterness and sweetness begin to recede, we start analyzing our relationship with our loved one, and come to new insights. Since the grieving process is lengthy and complex, but productive, we should give ourselves ample time to go through the whole process and come out a better person. 

Competing interests: No competing interests

19 May 2017
Hugh Mann
New York, NY, USA
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