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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: How should mandatory sex education be taught? Pandora Pound. 357:doi 10.1136/bmj.j1768

I was delighted to hear about the government’s new plans to make sex and relationship education (SRE) compulsory in schools (1). Having left school not long ago, it was of uniform opinion amongst students that there was not enough provision of the subject. Even when we had the occasional lesson it was far from useful. Reading this article’s suggestions on how SRE should be implemented has made me reflect on what I believe could be improved from my own experiences.
I spent 2 weeks this year studying sexual health as part of my medical school curriculum, and was quite surprised at my own ignorance. I had never realised to what extent sexually transmitted illnesses (STIs) were prevalent, even though there were numerous people my own age coming into the walk-in sexual health clinics with histories of chlamydial and gonorrhoeal infections. In hindsight, this was not abnormal; a comprehensive survey of the U.K. found that almost one in twenty women aged 18-19 and one in thirty men aged 20-24 have chlamydia (2). Reflecting on my own sexual education at school, although we were taught how to use condoms, this was always with the focus of not getting pregnant as opposed to not contracting STIs. Obviously, this may not be the case in every school, but perhaps it would be good if there were a larger focus on the incidence and symptoms of STIs, to increase awareness of the importance of using protection. This is especially important as approximately 30% of those surveyed aged 16-24 claimed they had sex before the age of 16 (2), so school will be their only source of information at that age.
I really liked the idea the article put forward of employing a specific SRE teacher who delivers this information. I remember being taught about relationships by a teacher at school, as me and my colleagues squealed with embarrassment. This was subsequent to having an I.T. lesson in the same room with her just previously. It felt extremely uncomfortable and although she had good intentions, it was never going to be effective enough to help guide our decisions. In addition, as the article highlighted and as was found in this survey, there have been new developments in sexual behaviour. The average number of partners females have in a lifetime has more than doubled, and the number of females are having same-sex experiences quadrupled between 1990 and 2010 (2). It is difficult for school teachers to keep updated with these changes and know how to teach such sensitive issues.
The article also proposed another model, whereby external sexual health professionals collaborate with teachers to deliver SRE. I have had first hand experience of this model, as I took part in a volunteering scheme run by my university called Sexpression (3). Sexpression is a network of student-led projects based in over 25 universities which sends volunteers into schools to provide SRE. This worked really well because we were not dissimilar in age to the secondary school students we were teaching, and I certainly observed them learn a lot in the sessions we delivered. However I could not help but notice that the students kept peering behind at their teacher, feeling too embarrassed to answer or ask questions. Having said that, I wonder if that was because it was their teacher or whether this was because it was a girl’s school and the teacher in question was male. Perhaps this is another consideration: would it be best to separate girls and boys and have them be taught by a teacher of the same gender to reduce embarrassment? More research into this would be useful to ensure the best possible provision of SRE.
I have barely touched on the content that encompasses sexual and relationship education, yet it is clear that the sensitive nature of the topics means that it is difficult finding the optimal way to deliver the information. As sexual health services are currently experiencing cuts in their funding (4), it is more important than ever to empower young individuals with the information they need to make sensible choices. I look forward to seeing how the government plans to do this.

1. Pound P. How should mandatory sex education be taught?. BMJ. 2017;:j1768.
2. Mercer CH, Tanton C, Prah P, et al. Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). Lancet 2013;357:1781-94.
3. Home [Internet]. Sexpression:UK. 2017 [cited 13 April 2017]. Available from: http://sexpression.org.uk
4. Iacobucci G, Torjesen, I. Cuts to sexual health services are putting patients at risk, says King’s Fund. BMJ. 2017;:j1328.

Competing interests: No competing interests

13 April 2017
Tara N Amin
Medical student
Jack L Benson
University College London
Gower St, Bloomsbury, London WC1E 6BT
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59
Re: A woman with lower back pain Tobenna J Oputa, Jamie A’Court. 356:doi 10.1136/bmj.j1117

How satisfying for Messrs Oputa and A’Court to have their clinical diagnosis of an L4/5 intervertebral disc displacement confirmed on an MRI scan! But what did they do with the result?

With the typical history of an acute onset of lumbar pain radiating to one leg with weakness of the muscles supplied by the L5 root, presumably also with limited straight-leg raising and possibly a sensory deficit in the L5 dermatome, the diagnosis is – or should be – obvious. (I take it that the findings were as explained in the discussion in the online version; the abbreviated history in the print version of ‘weakness in the leg’ implying the whole leg was weak is a different matter entirely.)

The treatment, we are informed, is ‘initial rest and analgesia followed by physiotherapy’ – in other words, doing nothing. But this is fine because, according to a citation from thirty years ago, ‘symptoms usually resolve within six weeks’. They should have gone back a little further for evidence of the superior effectiveness of epidural local anaesthesia in this situation (1).

symonds@tokyobritishclinic.com

(1) Coomes, EN. Comparison between epidural local anaesthesia and bed rest in sciatica. BMJ 7 Jan 1961, 20-24.

Competing interests: No competing interests

13 April 2017
Gabriel Symonds
General practitioner
Tokyo
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31
Re: What’s the point of happiness research? Sophie Arie. 357:doi 10.1136/bmj.j1767

While it may sound frivolous, Patrica Neville's address made me happier when looking at her address for a response on Hapiness Research: it could hardly have been more (or less) apt!

Competing interests: No competing interests

13 April 2017
Andrew J Ashworth
GP
Bonhard House, Bo'ness EH51 9RR
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Re: Doctors can withdraw life support from baby with rare genetic disorder, says judge Clare Dyer. 357:doi 10.1136/bmj.j1857

The case of Charlie is not unusual. It seems from the BMJ reports that curative treatment is unavailable at present. The situation therefore is one of life sustaining treatments - nutrition and hydration and artificial ventilation. The first two are basic human necessities and even if they have to be given artificially do not constitute unnecessary burden for patient or carers. Artificial ventilation at home is now commonplace with an estimated 20,000 cases in UK and USA each. The technology is rapidly advancing and is projected to even reach "wearable" device level in the not too distant future. 1 As such what is the difference between peritoneal dialysis, cardiac pacemakers, insulin pumps, peg feeding and home ventilation? The judge should get expert advice on the feasibility of home-care for Charlie at the very least. To switch off a ventilator in the absence of imminent death is the same as taking an innocent life and no judge can do that.

1. K Garber, M Guertin. Home Mechanical Ventilation: Bringing patients home with improved ventilation options. RT For Decision Makers in Respiratory Care. Aug 23 2012.

Competing interests: No competing interests

13 April 2017
maria Olazabal
psychiatrist
Strait Street
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Re: What’s the point of happiness research? Sophie Arie. 357:doi 10.1136/bmj.j1767

As a sociologist, I was interested to see a commissioned article entitled ‘What’s the point of happiness research?’ appear in the BMJ. In my discipline, there has been much debate and critique as to the value and purpose of happiness research. While some dismiss the field as a ‘fad,’ emotions and other psychological states have acquired significant social currency of late. For instance, researchers have produced happiness metrics like the Gross National Happiness1 and annual World Happiness Reports2. These reports help to objectify happiness as an observable and measurable psychological state, that is desirable to attain. Undoubtedly, happiness and well-being confer personal and interpersonal value. However, as the title of this article suggests, we need to question the purpose of research that is interested in making something that was previously considered a private concern into a matter of public and collective interest.
For sociologists, uncovering ‘the point of happiness research’ starts with looking at the social, political, historical and economic contexts that shaped this field of enquiry. Interestingly, the origins of happiness research coincide with the rise of neo-liberalism and its associated values of ‘free will’, ‘self-responsibility’ and ‘individual choice’.3,4 There is an eagerness in this political ideology to reduce complex social problems to individual choice and with it a tendency to promote the notion that individual agency is more powerful than the structural forces shaping their lives. Neoliberal governments have been found to use psychometrics to legitimate their social policies of financial cuts and austerity, blaming individuals for their marginalisation, rather than acknowledging the structural and systemic issues with the distribution of wealth and resources in the country.5 Happiness research too is inclined to ignore the role that social/structural factors play in our configurations of well-being. Issues around access to resources, the gap between rich and poor, and living in a society with adequate job opportunities, are equally, if not more, important social determinants of health and well-being than the mere possession of ‘happiness’. In fact, decades of health sociology research confirm access to resources as the most consistent determinant of health and well-being. This sociological understanding of happiness research is important to medicine, because though health, happiness and well-being are experienced individually, they also resonate as a collective phenomenon shaped by social factors. As Virchow(1848) once said, “Medicine is a social science, and politics is nothing else but medicine on a large scale”6. The bedrock of health is not happiness, but equality.
References
1. Center for Bhutan Studies and Gross National Happiness Research. 2017. http://www.grossnationalhappiness.com
2. World Happiness Report. 2017. http://worldhappiness.report/
3. Davies W. The Happiness Industry: How the Government and Big Business Sold Us Wellbeing, London: Verso, 2015.
4. Frawley S. Happiness Research: A Review of Critiques. Sociological Compass 2015; 9(1), 62-77.
5. Cromby J, Willis MEH. Nudging into Subjectification: Governmentality and Psychometrics, Critical Social Policy 2013; 34(2), 241-259.
6. Virchow R. Virchow Rudolf quotations. 2017. https://todayinsci.com/V/Virchow_Rudolf/VirchowRudolf-Quotations.htm

Competing interests: No competing interests

13 April 2017
Patricia N Neville
Lecturer in Social Sciences
University of Bristol
School of Oral and Dental Sciences, Lower Maudlin Street
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43
Re: Time to ReSPECT personal resuscitation plans for adults? Toni Wolff, William P Whitehouse. 356:doi 10.1136/bmj.j1634

I have clicked ‘to like’ the recent response by Regnard, Fritz, Pitcher and Spiller (1) and in so far as it goes, I completely agree with it.

However, I still have my fundamental objection that ReSPECT promotes decision-making by 999 paramedics when the family carer who summoned 999 is probably better-informed to make decisions ‘during emergencies’ (2): so my issue hinges on

‘sharing decision-making requires respect for the individual’s wishes, preferences, beliefs and values’

and where exactly family carers ‘fit in’ with decision-making when end-of-life patients are in their own homes.

As I wrote in reference 2:

To Close: (hypothetical)

I have been sharing a home with my now ‘dying partner’ for 20 years, although my partner has only been ‘dying’ for about six months. I have talked to my partner a lot during this six months, and during those 20 years. The GP has talked to my partner a little, especially recently. We both talk to the district nurses who have visited a couple of times a week for the last 6 weeks – but they are often different nurses each visit.

My partner has just collapsed. I have called 999 to find out why my partner has collapsed. I am now standing over a 999 paramedic, who is doing something to my unconscious partner. Why on earth, should I accept that this paramedic decides what happens next ?

1 http://www.bmj.com/content/356/bmj.j1634/rr

2 http://www.bmj.com/content/356/bmj.j876/rr-7

Competing interests: No competing interests

13 April 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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45
Re: A bleeding socket after tooth extraction Isabelle J Moran, Libby Richardson, Manolis Heliotis, Alex Bewick. 357:doi 10.1136/bmj.j1217

Unless it is an emergency situation such as the patient actively haemorrhaging post-dental extraction, medical professionals should not manage dental problems. Patients often present to their GP in order to avoid their dentist because of dental anxiety or perceived risk of cost; however, this does not mean that GPs are trained or indemnified to provide dental care and care of this kind is not within the sphere of GPs competence. Suggesting otherwise in a '10 minute consultation' is unsafe and risks giving the false impression that GPs ought to be managing this dental problem, and can do so within ten minutes. Any post-operative dental problems should be managed by a dentist, ideally the dental surgeon responsible for the operation.

Competing interests: No competing interests

13 April 2017
Sarah EE Mills
GP Partner
Garrett Mills
University of Dundee, NHS Fife
Viewfield, Blebocraigs, Cupar, Scotland KY15 5UG
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Re: Continuing to deliver: the evidence base for pre-implantation genetic screening Jamie Grifo, Ariel Hourvitz, Svetlana Rechitsky, Janine Elson, et al. 356:doi 10.1136/bmj.j752

The evidence base for pre-implantation genetic screening

Raoul Orvietoa* and Norbert Gleicher,b,c,d,e

aInfertility and IVF Unit, Department of Obstetrics and Gynecology, Sheba Medical Center (Tel Hashomer) and the Tarnesby-Tarnowski Chair for Family Planning and Fertility Regulation, Sackler Faculty of Medicine, Tel-Aviv University, Israel.
bThe Center for Human Reproduction, New York, N.Y. 10021, USA
cThe Foundation for Reproductive Medicine. New York, N.Y. 10022, USA
dStem Cell Biology and Molecular Embryology Laboratory, Rockefeller University, New York, N.Y. 10016, USA
eDepartment of Obstetrics and Gynecology, Vienna University School of Medicine, 1009 Vienna, Austria

*Corresponding author. E-mail address: Raoul.orvieto@sheba.health.gov.il
We read with interest the letter to the-editor by Griffin et al. on "Continuing to deliver: the evidence base for pre-implantation genetic screening" (1). Throughout their letter, Griffin et al presented preimplantation genetic screening (PGS) as an established clinical procedure that improves in vitro fertilization (IVF) outcome, based on "extensive evidence …. more than 20 retrospective studies and four randomised controlled trials".
Such extensive evidence, however, does not exist; indeed, recent evidence not only demonstrates that PGS does not improve IVF outcomes but the procedure adversely affects IVF.

All published studies claiming outcome benefits, without exception, were performed with reference point embryo transfer. (2,3) Such statistical analyses are, of course, greatly flawed because they exclude poorer prognosis patients who do not make it to embryo transfer. Correctly performed outcome analyses, should include results of fresh plus subsequent frozen/thawed transfers with reference point cycle start (i.e., intent to treat).
This was recently well demonstrated by Kang et al, when reporting PGS 2.0 effects on IVF above age. With reference embryo transfer, they found significant improvements in clinical pregnancy and live birth rates. With reference point cycle start, results, however, differed remarkably (4): here the authors reported significantly lower clinical pregnancy and live birth rates (21.5% and 19.9%) in comparison to non-PGS patients (49.5% and 39.8%).

Considering the complete absence of properly conducted prospective clinical trials and, as noted by the authors, since "randomised controlled trials would be prohibitive and far too late for many," a theoretical model was recently published, relying on evidence- based data in the literature on blastulation and aneuploidy rates, the rate of mosaicism, technical errors and implantation/live birth rates of PGS and non-PGS cycles at cleavage and blastocyst stages. It demonstrated clear superiority of non-PGS over PGS cycles for cumulative live birth rates, with ranges of 18.2 – 50.0% in comparison to 7.6 - 12.6% (5).

In explaining the switch from an earlier form of PGS (PGS 1.0) to the procedure’s second generation (PGS 2.0) (6), Griffin et al. claim that, reflecting "evidence based medicine …., PGS has now moved on to improved procedures, including trophectoderm (TE) biopsy, whole karyotype screening and higher quality embryological practice" (PGS 2.0 generation), to improve IVF success/pregnancy rates. They, however, fail to note that most of the authors of this manuscript promoted PGS 1.0 as they are now promoting PGS 2.0 until PGS1.0 was formally found to be ineffective in improving IVF outcomes (7-9). Only then, did the PGS laboratory community decide to move on to PGS 2.0.

PGS 2.0 now, however, finds itself in a similar situation as it precursor in that its true utility in improving IVF outcomes on many different levels is increasingly questioned. For example, the literature has been reporting false-negative trophectoderm biopsies (TEBs) in cases of spontaneous miscarriages after PGS, which upon chromosomal reassessment were found to be aneuploid (10). Concerns about false-positive TEBs arose in relative good prognosis patients who repeatedly underwent IVF cycles without ever reaching embryo transfers because all embryos were reported as aneuploid. Suspicion that such patients may erroneously discard false-positive embryos, led us (11,12) and others (13) to transfer such embryos, resulting in surprisingly high normal non-mosaic euploid live birth rates. Studies of multiple TEB biopsies in same embryos offered further evidence for much higher degrees of mosaicism in trophectoderm than had previously been reported, demonstrating up to 50 percent divergence between biopsies of same embryos in same laboratories, and up to approximately 80 percent divergence between multiple biopsies in different laboratories (11,12,14). A recently published study in addition revealed discordance between trophectoderm and inner cell mass in in 3/8 embryo (15). A trophectoderm biopsy, therefore, does not necessarily reflect on the make-up of the inner cell mas, from which the embryo arises.

We recently challenged all five assumptions on which PGS is based (3), and demonstrated them all to be mistaken: (i) In view of high reported live birth rates after transfer of allegedly aneuploid (i.e., likely mosaic) embryos (11-13), the long-held belief that trophectoderm aneuploidy is associated with IVF failure must be reevaluated. (ii) Reliable elimination of presumed aneuploid embryos prior to embryo transfer appears unrealistic. (iii) Mathematical models demonstrate that a single 6-cell TEB cannot provide reliable information about the chromosomal constituency of the total trophectoderm (16), and larger biopsies reduce blastocyst implantation potential (17). (iv) Trophectoderm, as site of every embryo biopsy in PGS 2.0, does not reliably reflect the inner cell mass. And (v) embryos, with great likelihood, still have strong innate abilities to self-correct downstream of blastocyst stage, with the inner cell mass doing so better than trophectoderm (18).

In summary, considering that not one properly analyzed study has been able to demonstrate clinical outcome benefits for PGS 2.0 and that the procedure, indeed, likely reduces pregnancy and live birth chances, it is difficult to understand why PGS 2.0 should still be performed in association with IVF. Griffin et al. mostly represent the opinions of PGS laboratories with strong commercial interests in the performance of PGS, as was clearly stated in the letter footnotes: "The other authors (except of Griffin) are clinicians and PGS practitioners as well as members of laboratories whose business is to process PGS samples". As here briefly outlined, their viewpoints do not reflect, as claimed, the evidence base for PGS because such an evidence base does not really exist. Patients and colleagues, therefore, do not need advice on when to use PGS but, instead, on why PGS should no longer be offered at significant additional cost as a routine add-on to IVF, which already is a procedure unaffordable to many.


REFERENCES

1. Griffin DK, Fishel S, Gordon T, Yaron Y, Grifo J, Hourvitz A, Rechitsky S, Elson J, Blazek J, Fiorentino F, Treff N, Munne S, Leong M, Schmutzler A, Vereczkey A, Ghobara T, Nánássy L, Large M, Hamamah S, Anderson R, Gianaroli L, Wells D. Continuing to deliver: the evidence base for pre-implantation genetic screening. BMJ 2017;356:j752.
2. Orvieto R, Gleicher N. Should preimplantation genetic screening (PGS) be implemented in routine IVF practice? J Assist Reprod Genet 2016;33:1445-1446
3. Gleicher N, Orvieto R., 2017. Is the hypothesis of preimplantation genetic screening (PGS) still supportable? A review. J Ov Res 2017;10:21.
4. Kang HJ, Melnck AP, Stewart JD, Rosenwaks Z. Preimplantation genetic screening: who benefits? Fertil Steril 2016;106:597-602
5. Orvieto R. Preimplantation genetic screening- the required RCT that has not yet been carried out. Reprod Biol Endocrinol. 2016;14:35
6. Mastenbroek S, Twisk M, van Echten-Arends J, et al. In vitro fertilization with preimplantation genetic screening. N Engl J Med 2007;356:9-17.
7. ACOG Committee Opinion No. 430: preimplantation genetic screening for aneuploidy. Obstet Gynecol 2009;113:766-7.
8. Preimplantation genetic testing: a Practice Committee opinion. Fertil Steril 2008;90:S136-43.
9. Harton G, Braude P, Lashwood A, et al. ESHRE PGD consortium best practice guidelines for organization of a PGD centre for PGD/preimplantation genetic screening. Hum Reprod 2011;26:14-24.

10. Maxwell SM, Colls P, Hodes-Wertz B, McCulloh DH, McCaffrey C, Wells D, Munné S, Grifo JA. Why do euploid embryos miscarry? A case-control study comparing the rate of aneuploidy within presumed euploid embryos that resulted in miscarriage or live birth using next-generation sequencing. Fertil Steril. 2016;106(6):1414-1419
11. Gleicher N, Vidali A, Braverman J, Kushnir VA, Albertini DF, Barad DH. Further evidence against use of PGS in poor prognosis patients: report of normal births after transfer of embryos reported as aneuploid. Fertil Steril 2015; 104; (Suppl 3): e9
12. Gleicher N, Vidali A, Braverman J, Kushnir VA, Barad DH, Hudson C, Wu YG, Wang Q, Zhang L, Albertini DF. Accuracy of preimplantation genetic screening (PGS) is compromised by degree of mosaicism of human embryos. Reprod Biol Endocrinol 2016;14:54
13. Greco E, Giulia Minasi M, Florentino F., 2015 Healthy babies after intrauterine transfer of mosaic aneuploid blastocysts. N Engl J Med 373:2989-2090
14. Tortoriello DV, Dayal M, Beyhan Z, Yakut T, Keskintepe L. Reanalysis of human blastocysts with different molecular genetic screening platforms reveals significant discordance in ploidy status. J Assist Reprod Genet. 2016;33(11): 1467-1471.
15. Orvieto R, Shuly Y, Brengauz M, Feldman B. (2016) Should preimplantation genetic screening be implemented to routine clinical practice? Gynecol Endocrinol 2016;32:506-508
16. Gleicher N, Metzger J, Croft G, Kushnir VA, Albertini DF, Barad DH. A single trophectoderm biopsy at blastocyst stage is mathematically unable to determine embryo ploidy accurately enough for clinical use. Reprod Biol Endocrinol 2016;14:54.
17. Neal SA, Franasiak JM, Forman EJ, Werner MD, Morin SJ, Tao X, Treff NR, Scott RT Jr. High relative deoxyribonucleic acid content of trophectoderm biopsy adversely affects pregnancy outcomes. Fertil Steril 2017;107:731-736.
18. Bolton H, Graham SJL, Van der Aa N, Kumar P, Theunis K, Gallardo EF, Voet T, Zernicka-Goetz M. Mouse model of chromosome mosaicism reveals lineage-specific depletion of aneuploid cells and normal development potential. Nature Communications 2016; 7:11165

Competing interests: No competing interests

13 April 2017
Raoul Orvieto
Physician
aInfertility and IVF Unit, Department of Obstetrics and Gynecology, Sheba Medical Center (Tel Hashomer) and the Sackler Faculty of Medicine, Tel-Aviv University, Israel.
Tel Hashomer, Ramat-Gan, Israel
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Re: The growing problem of co-treatment with opioids and benzodiazepines Pinar Karaca-Mandic, Ellen Meara, Nancy E Morden. 356:doi 10.1136/bmj.j1224

The editorial by Karaca-Mandic is an interesting read, measuring the opioid-benzodiazepine co-prescription as a potentially dangerous low-value care. We appreciate that the author could speak out the need of practice change with regards to this unsafe combination.

Regarding the improvement of the quality of care, we would like to echo the same as also commented by Sun et al. (1). Just like opioids, there should be multilevel target approaches in combating this near epidemic unsafe use of drug combination. In other words adding Benzodiazepines to all campaigns against opioids may be more effective. These can be ranging from patient education, physician awareness, developing new clinic or hospital strategies and policy changes by the government (2).

Using non-opioids or non-benzodiazepines as an initial or alternative therapy, discussing goals of treatment with patients, cessation of the dosage or combination of medications as appropriate may help in decreasing morbidity and mortality (3. 4)

References:
1. Sun EC, Dixit A, Humphreys K, Darnall BD, Baker LC, Mackey S. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ (Clinical research ed). 2017;356:j760.

2. http://www.bmj.com/content/356/bmj.j760/rapid-responses
3. Tvete IF, Bjorner T, Aursnes IA, Skomedal T. A 3-year survey quantifying the risk of dose escalation of benzodiazepines and congeners to identify risk factors to aid doctors to more rationale prescribing. BMJ open. 2013;3(10):e003296.

4. Alford DP, Cohen ML, Reynolds EE. How Would You Manage Opioid Use in These Three Patients?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Annals of internal medicine. 2017;166(7):506-13.

Competing interests: No competing interests

13 April 2017
Himabindu Gandam Venkata
Anesthesiology resident
Henry Ford Health System
2799 West Grand Blvd, Detroit, Michigan 48202
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20
Re: Palliative care from diagnosis to death J Amblàs-Novellas, K Boyd, et al. 356:doi 10.1136/bmj.j878

The prevention is inside the palliative care concept and represents the possibility to prevent the increase of new symptoms and bad control of previously existent symptoms and crises in the palliative care patients. Since the beginning of the study of palliative care Cicely Saunders calls for the attention to act proactively to improve the control of pain to avoid its worst control and its consequences (1). The article “Palliative care from diagnosis to death” from Professor Murray and coworkers emphasizes the need to act preventively, showing evidences to support the early palliative care. Sadly in Brazil we are far from this point.

The current identification model and focus of care unfortunately cannot manage the growing demand for palliative care. The model focused in hospital care with an identification in the last phase of disease brings a health system that acts less preventively than necessary. We can assume that the inexistence of an appropriated care in an appropriated time certainly brings more suffering for sick people and their families and more costs for the health system.

This is the result of an equation elaborated above the difficulty of the provision, integration and continuity of care. As the article of Professor Murray and his colleagues defends, Early palliative care offered accordingly to the needs of the person and his family through an early identification, a good following and adequate communication, support and monitoring during all the period of disease, doesn’t matter how long that period is, posibly will cover and protect this disease people for more time. That protection is the prevention we need to understand and apply in Brazil.

Some numbers show the huge demand for changes in the actual mode of palliative care. The estimate of 30 millions of aging people with dementia in 2020 (2), 600 thousand of new cancer cases per year (3) and more than 1 million of deaths per year shows the great necessity of offering more palliative care. The last “The Quality of Death Index” (4) points poor access to palliative care for the most of population and beyond these numbers it is possible to add another situations as the low investments of Government in the health of all Brazilian population, just 4,6% of GDP in 2016, an absence of public health policy related with palliative care and a non-recognition of palliative care as a health problem.

As the article comments the use of identification tools and the recognition of trajectories can help to start to fix the actual situation of poor access of Brazilian people to palliative care. By using those tools we can identify people with palliative care physical needs on our daily routine on primary care and the other levels of attention and also think about major population strategies and policies. If the National Program of Primary Care, the Family Health Strategy (FHS), with almost 40 000 teams distributed for all country and covering 123 million of people (5) identify just the 1% of general population approaching the last year of life we could have 1,23 million of people needing palliative care without receiving it. The use of identification tools as SPICT by those teams could be a great step to improve the access to the major population who needs palliative care less complex and it´s not receiving it. Besides it, Brazil will need more specialists to solve the problem of the rise of demand of complex cases and a network structured to integrate the 3 levels of attention. Surely, using the identification tools we can think about population´s strategies to offer more palliative care.

However we need to be careful to apply coldly the identification tools (even after the boom ocurred in Brazil after the publishing of article and the fantastic video explaining the article´s content). Different cultures, different socio economics realities between the origin´s countries of the identification tools and Brazil and even inside Brazil “a country with many coutries inside” can add more people than the groups shown in the identification tools. An example: Brazil has 18% of its population living in extreme poverty (6) and the social economic condition of disease people will pressure and add social, pyschological and spiritual challenges to be identified and worked above. As the article comments Early palliative care is more than simply seing some clinical guide and apply it. The people who needs palliative care are deeper than clinical diagnosis, lines and tools. This guide will help us a lot but we need to be aware and don’t forget our Brazilian reality is particular and we need to adapt all the tools to our context.

Other point is if we apply the palliative care as a philosophy for all chronic diseases since the beginning probably more people will have some benefit on receive some palliative approach. That point brings us the prevention argument again. We need to think for Brazil education´s strategies, palliative care policies and a system of work integrating the three levels of attention but focusing on primary care and community because until that moment we have few experiences between the 40 000 FHS teams distributed for all country (7). Then discuss the application of palliative care since the diagnosis as the articles comments and study how to follow this group of patients, during years sometimes, more than six months- one year proposed by the current reasoning line and focus of research and learning. The philosophy of care needs to be above the prognostic and time questions and have to pass through all the community and levels of attention.

As showed above Brazil has many challenges to face to offer paliative care for the most of population and improve the access to this model of care. The recognition of the necessity to do it perhaps is the greatest one. The reasoning line of Early palliative care, the use of identification tools respecting our differences can offer some of the answers we need.

References:

1. Clark D. `Total pain', disciplinary power and the body in the work of Cicely Saunders, 1958±1967. Social Science & Medicine 49 1999; 727-736

2. Burlá C, Camarano AA, Kanso S, Fernandes D, Nunes R. Panorama prospectivo das demências no Brasil: um enfoque demográfico. Ciênc.saúdecoletiva [Internet]. 2013 Oct [cited 2017 Apr 12] ; 18( 10 ): 2949-2956. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232013001.... http://dx.doi.org/10.1590/S1413-81232013001000019.

3. Estimativa 2016: incidência de câncer no Brasil / Instituto Nacional de Câncer José Alencar Gomes da Silva – Rio de Janeiro: INCA, 2015.

4. The Economist and Intelligence Unit. The 2015 Quality of Death– Ranking end-of-life care across the world. 2015. Available from:https://www.eiuperspectives.economist.com/sites/default/files/2015%20EIU.... Accessed: 12/04/2017

5. Brasil. Ministério de Saúde. Departamento de Atenção Básica. Histórico Cobertura da Saúde da Família. Available from: http://dab.saude.gov.br/dab/historico_cobertura_sf/historico_cobertura_s...

6. Comissão Econômica para a América Latina e o Caribe (CEPAL). Panorama Social da América Latina, 2014. Santiago de Chile, 2014. Available from: http://repositorio.cepal.org/bitstream/handle/11362/37626/S1420729_es.pd....

7. Corrêa SR, Mazuko C, Floss M, Mitchell, G, Murray SA. Brazil: time for palliative care in the community!. EurJPalliatCare, 2016; 23(2): 94-96

Competing interests: No competing interests

13 April 2017
Santiago R. Corrêa
Family physician ( Projeto Estar ao Seu Lado- Cuidados Paliativos na Atenção Primária)
Carla Mazuko
street: 15 de novembro 1201; city: Jaguarão; state: RS; country: Brazil; postal code 96300-000
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