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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 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: 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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Re: David Oliver: Keeping older doctors in the job David Oliver. 355:doi 10.1136/bmj.i6260

Editor

For someone usually keen to supply a long list of references to accompany his BMJ responses, Dr Saripanidis has been rather selective on this occasion

The paper to which he refers shows that for hospitalists (the right US equivalent of Internal Medicine Consultants, acute physicians and geriatricians) in America and not for any other health system or specialism, there were marginally worse outcomes linked with growing age of physician but that these disappeared for hospitalists dealing with large volumes of patients. It is hard to draw any more general conclusions from this work.

Also, its possible that someone trained as a hospitalist or equivalent speciality in other systems might remain very effective in the final third of their career playing modified roles requiring less resident out of hours shift work and more ambulatory, teaching and management work.

And besides which, with rota and recruitment gaps highly prevalent in NHS medicine, we can't afford to toss way experienced clinicians and should do all we can to keep them working at least for some of the week, so long as they want to.

BMJ rapid responses readers will see that many of Dr Saripanidis' letters are in effect about the need for the NHS to offer more jobs to doctors from Southern Europe where there is sometimes an oversupply and comparatively worse terms and conditions.

On this point, I am in total agreement. We need all the help we can get and Brexit won't help

David

Competing interests: No competing interests

18 May 2017
David Oliver
Consultant Physician
NHS
Berkshire
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Re: Ongoing vomiting in an infant Neil Chanchlani, Fiona Davis, Kalyaan Devarajan. 357:doi 10.1136/bmj.j1802

This article highlights the possibility of cmpa for bottle fed infants, however it seems to neglect to mention this is also possible in breastfed infants. My son who was exclusively breastfeed was diagnosed with cmpa at 3 months by the health visitor and I know a large number of parents who have had difficulty getting a diagnosis because their GP is unaware that the cows milk protein can be transferred through the mother's milk. It would be good if this can also be highlighted so that more GPs are aware of this and infants can be diagnosed and the correct support can be provided to mothers to remove dairy from their diet and alleviate the symptoms.

Competing interests: No competing interests

18 May 2017
Jenny K Thompson
Customer Support
BMJ
London
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Re: Seven days in medicine: 3-9 May 2017 . 357:doi 10.1136/bmj.j2263

We teach anaesthetists-in-training to always check the face validity of any drug calculations they make. 'Does the dose I've just worked out seem reasonable for a child of about one third/quarter/fifth the weight of a normal adult?' 'Does the amount of intravenous fluid I'm giving seem reasonable, in terms of teacup equivalents, for this frail elderly lady?' We encourage them to do the same when reading medical journals: 'Do the numbers presented seem to add up?

The short article headed, 'Quinine for muscle cramps may increase death risk' was eye-catching and quoted study data in some detail. Unfortunately not knowing the sample size of the non-quinine group (& not realising that it was quoted later in the journal) left us unable to assess the face validity of this unexpected and seemingly important finding. The numbers of course might be correct but we'd have to assume a much larger control group - and why would that be? We went to the JAMA abstract to seek clarification and found the number in the non-quinine group was indeed much larger, but yet again were presented with data that superficially appeared discordant - lacking in face validity. Patients in the study and control groups appeared to be broadly similar in most respects but were frequently reported as being statistically very significantly different ('p' often <0.001). Also, although more than 40% of patients were listed as hypertensive, the median number of prescriptions for diuretics, B-blockers, calcium channel blockers & statins was in each group and every case shown as zero; but with the differences between the two groups for all these medicines being reported as highly statistically significant. Possible - but odd. With no immediate access to the full text of the paper, we segued to the next article leaving the issue of quinine unresolved - and quite likely to be forgotten.

As the needs to keep up-to-date and also to guard against research fraud and 'fake news' become ever more important, perhaps in addition to encouraging readers to check face validity, we should also remind writers that its lack in abstracts, excerpts and articles may prove a stumbling block for an otherwise excellent paper.

Competing interests: No competing interests

18 May 2017
Simon Ali
ST6 anaesthesia
Mark W Davies, consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust
Liverpool L7 8XP
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Re: The hackers holding hospitals to ransom Krishna Chinthapalli. 357:doi 10.1136/bmj.j2214

Although we had thought it ‘behind the times’ that the computers controlling our anaesthetic machines were not wifi enabled or network connected - and so would not allow remote upgrading of operating software - following the ‘Wannacry’ ransomware cyber-attack we were relieved and reassured to know that our stand-alone, life-critical systems were safe from harm and safe to use. We now wonder if with anaesthetic machines, it’s best that contact with the ether be restricted to filling of the vaporisers.

Competing interests: No competing interests

18 May 2017
Ian J Nelson
PA(Anaesthesia) trainee
Mark W Davies, consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust
Liverpool L7 8XP
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