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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: Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland Abigail R A Aiken, Irena Digol, James Trussell, Rebecca Gomperts. 357:doi 10.1136/bmj.j2011

I am concerned that you claim your study shows telemedicine abortions are safe, and in particular you cite a zero death rate, all on self-reported data (self-reported deaths being rare). You cover for this by writing essentially that a death would have been big news and you would have heard about it somehow. This seems an untenable conclusion. You have no reasonable way of detecting deaths in your methodology, indeed there was no attempt to, and although deaths resulting from these drugs would be very unlikely, this conclusion is simply not warranted. It should be removed.

You go on to write that rates of adverse events, which thankfully could be self-reported, where women sought medical care for 'a symptom of a potentially serious complication' were low at 95.0%, which I assume was another error - but the actual figure of 9.5% does not sound low to me, especially in the context of telemedicine where I imagine there are limits on continuity of care.

Competing interests: No competing interests

19 May 2017
Ross A Kirkbride
GP
Harborne
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Re: Major global cyber-attack hits NHS and delays treatment Adrian O’Dowd. 357:doi 10.1136/bmj.j2357

Between 2013 and 2017, 28 of the 153 acute trusts in England have been placed in special measures(SM) by the Care Quality Commission(CQC). Several more have been investigated(1,2). In the words of the CQC, “The challenge for the staff and leaders of a trust in SM should not be underestimated…..There are few greater leadership challenges in the NHS than turning round a trust in special measures, but it is one of the most important roles in the hospital sector(1).” These challenges include healthcare information management.

Last week, a different challenge in the form of the “ransomware” cyber-attack hit the NHS. Of the 48 trusts affected, 37 were attacked directly and shut down their systems as a precaution(3, 4). 12/37 trusts were in SM at some stage between 2013 and 2017. Acute trusts in SM were three times as likely to be affected by the recent cyber attack as trusts which were not in SM(OR 3.00, 1.26-7.14; p=0.01). Interestingly, 15/37 trusts had come out of SM by March 2017 and yet 7 of these 15 trusts were still affected by the cyber attack (3, 4).

This is a crude, unadjusted odds ratio and there are limitations, including lack of data about severity of disruption, level of “digital maturity” and exact reason for being in SM at each trust. However, given: (i) the scale of resource and effort spent on CQC inspection to ensure quality of care across domains at acute trusts, especially those in SM; (ii) the wide-ranging impact of SM on trusts, their patients and clinicians; (iii) the scale of effects of the cyber attack across the NHS; and (iv) the various theories and conspiracies which are already circulating regarding the cyber attack(4); this observation warrants at least further investigation. There are at least two lines of interpretation and enquiry.

First, it is plausible that poor IT infrastructure and a low level of “digital maturity” (including cyber-security) are among the factors most important in putting a trust “at risk” of poor clinical performance and consequently, SM (as well as cyber attacks). The CQC does already look at IT issues and states that “we have found that trusts with good and outstanding ratings have better digital systems in place”. However, events of last week will undoubtedly mean a far greater level of digital scrutiny during future CQC inspections.

Second, being put in SM can create an adverse environment that threatens IT infrastructure and security. Trusts in SM are already challenged by financial, recruitment and organisational pressures. When budgets are tight, IT costs are usually cut before acute services and the association between SM and lesser cyber security may reflect the relative lack of investment and emphasis on healthcare IT. The impact of IT/informatics on healthcare quality is relatively under-studied in research, and under-recognised in practice, but the cyber attack is a sobering and timely reminder.

Following the Wachter review(5), large-scale NHS health IT improvement programmes are underway, including the Global Digital Exemplars and the NHS Digital Academy. In parallel, Health Data Research UK will represent the largest spend on health informatics research to-date(6). Whether poor healthcare quality (denoted by SM) is a cause or an effect of digital immaturity is just one of the questions which can only be answered by bridging the gap between clinical practice and research.

References
1. Care Quality Commission. The state of care in NHS acute hospitals: 2014 to 2016 http://www.cqc.org.uk/sites/default/files/20170302b_stateofhospitals_web...
2. NHS Confederation. Key statistics on the NHS. http://www.nhsconfed.org/resources/key-statistics-on-the-nhs
3. The NHS trusts hit by malware – full list. The Guardian. 12/5/2017. https://www.theguardian.com/society/2017/may/12/global-cyber-attack-nhs-...
4. Major global cyber-attack hits NHS and delays treatment. BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j23575 (Published 15 May 2017)
5. UK Department of Health. Making IT work: harnessing the power of health information technology to improve care in England. UK Department of Health; 2016 07/09/2016.
6. Medical Research Council. Director appointed for new UK health and biomedical informatics research institute https://www.mrc.ac.uk/news/browse/director-appointed-for-new-uk-health-a...

Competing interests: No competing interests

19 May 2017
Amitava Banerjee
Senior Clinical Lecturer in Clinical Data Science and Honorary Consultant Cardiologist
University College London
Farr Institute of Health Informatics Research, 222 Euston Road, London NW1 2DA
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Re: Beware of geeks bearing gifts Kamran Abbasi. 357:doi 10.1136/bmj.j2390

Beware of geeks bearing gifts

An interesting article with several facets. I must say that I was surprised to hear that the NHS had been held, amongst many others, to ransom by WANNACRY. The next day I got an email from my security program people (AVG) assuring me not to worry because they already had this malware covered. It raises the question as to why the NHS “experts” had not got similar securityware.

It seems that in the NHS, the absence of a credible safety policy for patients is accompanied by an absence of a suitable safety policy for their data.

The old Windows XP OS is one of the more stable systems that I have used over the years (and still do on my older computer). Windows has always been open to attack. I would have thought in such a critical use a more safe OS would have been used.

The BMJ’s late patient editor (http://www.bmj.com/content/346/bmj.j850 `), describes the bereavement she experienced after a spirit crushing diagnosis of type 1 diabetes

I can certainly commiserate with her on this issue. In my case it was a initially a well controlled Type 2 diabetes that over time, with sundry adverse events resulting in drug changes (diarrhoea is no “nocebo” effect) lead me to request an fasting blood insulin test. Rejected as the NHS apparently does not agree with such a test as the old 1972 based system was considered adequate.

Finally my GP suggested getting a commercial test from Medicheks.com (cost £39) . When this test came back it showed a very low level insulin level (even though aided by a sulphonurea) despite a concomitant high FBG. Following up on this I purchased a book by Dr Robert Kraft (The Diabetes Epidemic and you) which was based on some 14,000+ individual insulin with glucose tolerance tests. Roughly his conclusions were that early diabetes was first diagnosed by hyperinsulinaemia; hyperglycaemia was only apparent in late diabetes. This study was based on hard data.

We are always told by the medical establishment that the earlier a diagnosis is made the better the chances of a cure which certainly be achieved with an early diagnosis of diabetes Type 2 with a suitable diet and therapy protocol.

Question: What percentage of Type 2 diabetes have been cured as distinct from “managed” by the current guideline protocol? There would be massive savings were patients diagnosed early and successfully cured.

I wonder what the following may have to do with “managing” rather than “curing”.

In 1975, Henry Gadsden, chief executive of the drug company Merck, expressed in a candid interview his frustration that the potential market for his company’s products was limited to those with some treatable illness – as ideally he would like to ‘sell to everyone’

(Le Fanu, James. The Rise And Fall Of Modern Medicine p. 503).

Competing interests: No competing interests

19 May 2017
Michael J. Hope Cawdery
Retired veterinary researcher
None
Portadown
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Re: Serum creatinine elevation after renin-angiotensin system blockade and long term cardiorenal risks: cohort study Henrik Toft Sørensen, Liam Smeeth, Laurie A Tomlinson, et al. 356:doi 10.1136/bmj.j791

There is a critical issue in this paper which limits its value and leads to likely incorrect conclusions - simply put, the lack of non-treated comparators means the results cannot exclude potential outcome benefits relative to no RAS blockade irrespective of serum creatinine elevations in treated patients. Indeed, randomised trial evidence suggests patients with such elevations do also benefit. Hence, observational data cannot be used for these types of analyses (many treatments might lead to apparent adverse elevations in one or another risk factor but the net effect of the treatment could still be positive relative to no treatment) and thus one must refer to RCT evidence.

Competing interests: No competing interests

19 May 2017
Naveed Sattar
Professor of Metabolic Medicine
University of Glasgow
126 University place
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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

Thank you for this interesting study

What has been shown is an association rather than causation.: A multivariate regression meta -analysis may help clarify.

The study cannot be appropriately standardized for confounders (there was a reason why the prescribing doctor thought steroids were clearly required at that time in the patient) and thus outcomes are not unexpected in the cohort of users vs non-users. At worst this study could possibly be completely misleading.

Hypothetically: if the group prescribed were instead randomized to half prescribed and half not - then we could tell whether steroids in the short term are harmful or beneficial on the outcomes recorded. It is possible steroids could actually shorten length of illness (and immobility) and actually reduced DVTs etc OR perhaps it is indeed harmful.

The study however is valuable in generating hypotheses and also cautioning in the potential indiscriminate use of steroids. Yet it may cause harm if it influences colleagues to refrain from using steroids in short courses for appropriate reasons.

Competing interests: No competing interests

19 May 2017
AKIF GANI
Consultant Geriatrician
Dept Older Peoples Medicine, NUTH
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Re: Effective cybersecurity is fundamental to patient safety Guy Martin, James Kinross, Chris Hankin. 357:doi 10.1136/bmj.j2375

Medical devices can also increase the risks of potential cybersecurity threats.

Digitalisation of individuals' information and their health status reports may be hacked, misused and misinterpreted if there is no tight cybersecurity.

The increased use of wireless technology and software even in medical devices can also increase the risks of potential cybersecurity threats.

This will increase more when medical devices are increasingly connected to the Internet, hospital networks, and to other medical devices.

So medical device manufacturers and health care facilities should take steps to ensure appropriate safeguards in this matter.

Competing interests: No competing interests

19 May 2017
M.A Aleem
Neurologist
A.M.Hakkim
ABC Hospital
Annamalainagar. Trichy 620018. Tamilnadu. India
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Re: Generations divided on whether today’s medical training is up to the job Matthew Limb. 357:doi 10.1136/bmj.j2374

My teachers when I was a young anaesthetist were very remarkable people: fonts of knowledge & wisdom, skilful beyond belief, and with seemingly endless reserves of courage, patience & common sense. Decades later my respect for them is even greater as I realise how well they taught me: they succeeded in making me better than they themselves could be.

Today I have the pleasure to work alongside many colleagues whom I have helped to train. As I stand on the shoulders of my teachers, those whom I have taught stand upon mine. It is intensely satisfying to see that I too have succeeded as a teacher: my trainees have become better than me.

Competing interests: No competing interests

18 May 2017
Mark W Davies
consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust
Liverpool L7 8XP
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Re: Effective cybersecurity is fundamental to patient safety Guy Martin, James Kinross, Chris Hankin. 357:doi 10.1136/bmj.j2375

One of the adverse consequences of the failure of IT systems (including failures attributable to cyber attacks) is the inability to access patients records. This adverse outcome can, in part, be mitigated by generating a paper-based back up system whereby patients are routinely issued with a copy of their discharge summary each time they are discharged from hospital, and a copy of their outpatient clinic letter after each outpatient clinic attendance. Optimally, each clinic letter should include a section which documents the updated problem list and the corresponding drug list so that the patient only needs to provide the healthcare team with the most recent outpatient clinic letter to get them "up to speed" with his health status in the event of an IT systems failure.

Accordingly, in the event of an IT systems failure, instead of advising patients to stay away from A & E, they should be advised to bring with them a copy of their most recent discharge summary and a copy of their most recent outpatient clinic letter. This will enable the healthcare team to put the emergency episode in its proper context even if the previous health record is inaccessible. The recent cyber attack should, therefore, be a wake up call for those hospitals which are reluctant to provide patients with the kind of documentation I have mentioned.

Competing interests: No competing interests

18 May 2017
Oscar M Jolobe
retired geriatrician
manchester medical society, simon building, brunswick street, manchestr M13 9PL
simon building, brunswick street, manchester M13 9PL
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Re: Ongoing vomiting in an infant Neil Chanchlani, Fiona Davis, Kalyaan Devarajan. 357:doi 10.1136/bmj.j1802

Dear Ms Thompson

I am pleased that your health visitor made the correct diagnosis - many think that protein ingested by the mother must get degraded always.

Three points arise:

1. The cow and the buffalo are distinct species.
Have the paediatric allergy specialists studied whether those who are allergic to COW's milk are also, invariably allergic to BUFFALO's milk?

2. Goats' milk is available easily in England. Could the mothers switch to goats' milk and goats' cheese, goats' yoghurt?

3. Many mothers whose children are allergic to COW's milk often travel to the UAE.
There, camel milk is easily obtained. Are they advised to switch to camel milk where possible?

Competing interests: No competing interests

18 May 2017
JK Anand
Retired doctor
Free spirit
Peterborough
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Re: Association between active commuting and incident cardiovascular disease, cancer, and mortality: prospective cohort study Lewis Steell, Yibing Guo, Reno Maldonado, Daniel F Mackay, et al. 357:doi 10.1136/bmj.j1456

Dear Sir,
Statistics show that frequent passenger vehicle use, road use, city traffic, in the UK, are mainly due to work commuting/business/daily shopping.
Thus, if proper citizen health education and promotion of cycling induced permanent changes in existing transportation trends, car industry would be fatally hit.
I list some recent official UK statistics to erase your doubts.
References
http://ec.europa.eu/eurostat/statistics-explained/index.php/File:Commute...(%C2%B9)_(based_on_number_of_persons_in_employment)_RYB2016.png
http://www.citymetric.com/transport/britains-commuting-patterns-one-grap...
http://www.racfoundation.org/assets/rac_foundation/content/downloadables...
http://webarchive.nationalarchives.gov.uk/20160105160709/http:/www.ons.g...
https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
https://www.licencebureau.co.uk/wp-content/uploads/road-use-statistics.pdf

Competing interests: No competing interests

18 May 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
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