RAPID RESPONSES

Think of Rapid Responses as electronic letters to the editor.

To RESPOND to a particular article: Click on the link 'Respond to this article' in the box at the top left hand corner of the article.

To READ responses to a particular article: Click on the link 'Read responses to this article' in the box at the top left hand corner of the article.

All responses published in the past day are shown below. You can also read responses published in the past 2, 3, 4, 5, 6, 7, 14, or 21 days.


Rapid Responses published in the past day:

12 Rapid Responses published for 8 different articles.

Articles    Rapid Responses
Jump to Rapid Responses for citation
RESEARCH:
Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study
Martínez-González et al. (29 May 2008) [Abstract] [Full text] [PDF]
Jump to Rapid Response Mediterranean eating pattern is possible for all.
Carole A. Bartolotto   (11 June 2008)
 Read every Rapid Response to this article

Jump to Rapid Responses for citation
PRACTICE:
Management of type 2 diabetes: summary of updated NICE guidance
Home et al. (7 June 2008) [Full text] [PDF]
Jump to Rapid Response A Missed Opportunity
Victoria H Corkhill, et al.   (11 June 2008)
 Read every Rapid Response to this article

Jump to Rapid Responses for citation
CLINICAL REVIEW:
Diagnosis and management of hypocalcaemia
Cooper and Gittoes (7 June 2008) [Full text] [PDF]
Jump to Rapid Response Thiazide diuretics are efficient in the chronic management of hypoparathyroidism
Yair Liel   (11 June 2008)
 Read every Rapid Response to this article

Jump to Rapid Responses for citation
HEAD TO HEAD:
Should we use large scale healthcare interventions without clear evidence that benefits outweigh costs and harms? No
Landefeld et al. (7 June 2008) [Full text] [PDF]
Jump to Rapid Response The same coercive forces govern the need of large-scale health-care interventions
Grazyna T Adamiak   (11 June 2008)
 Read every Rapid Response to this article

Jump to Rapid Responses for citation
EDITORIALS:
Patient consent—decision or assumption?
Elwyn (7 June 2008) [Full text] [PDF]
Jump to Rapid Response Re: creep before climb
Laura Hair   (11 June 2008)
Jump to Rapid Response Media&Politician; Subservient GMC
Harold Bourne   (11 June 2008)
Jump to Rapid Response Informed Consent: Of course, we MUST do better.
Philip Harrison   (11 June 2008)
Jump to Rapid Response The patient's agent
Tom H Hughes-Davies   (11 June 2008)
Jump to Rapid Response Who does it?
Daniel Garros   (11 June 2008)
 Read every Rapid Response to this article

Jump to Rapid Responses for citation
VIEWS & REVIEWS:
The case for resurrecting the long case
Teoh and Bowden (31 May 2008) [Full text] [PDF]
Jump to Rapid Response Resurrection in a different form
Stephen P Tyrer   (11 June 2008)
 Read every Rapid Response to this article

Jump to Rapid Responses for citation
NEWS:
Kenyan Muslim clerics decide to campaign against use of condoms
Moszynski (24 May 2008) [Full text] [PDF]
Jump to Rapid Response Condom against AIDS-but what about society?
Andrew PG Mitchell   (11 June 2008)
 Read every Rapid Response to this article

Jump to Rapid Responses for citation
NEWS:
Darzi’s five pledges fail to quell doctors’ anxieties about polyclinics
O’Dowd (17 May 2008) [Full text] [PDF]
Jump to Rapid Response Pledges ignored
Anne Holmes   (11 June 2008)
 Read every Rapid Response to this article
RESEARCH:
Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study
Martínez-González et al. (29 May 2008) [Abstract] [Full text] [PDF]
Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort...
Mediterranean eating pattern is possible for all.
11 June 2008
 Next Rapid Response Top
Carole A. Bartolotto,
Healthcare consultant and RD
01101

Send response to journal:
Re: Mediterranean eating pattern is possible for all.

Hello,

I am responding to some of the rapid responses to this article regarding how difficult it is to stick to this diet in the UK and potentially other areas/countries. This type of diet has been applied to many population groups (Indian, Austrailian, French, Western Europe) and could also be applied to a UK population. The key is to focus on the basic principles of the diet such as: choose the healthier oils such as olive or canola, eat a lot of fruits and vegetables (6 to 10 servings per day). limit red meat to ideally 1 to 2 times a month, eat fatty fish 2 times a week, choose chicken and beans as protein sources, choose whole grains and have fruit in place of other desserts. Thses ideas can be applied to most population groups. It is the principles of the diet and not eating "Mediterranean" foods that is most important.

Sincerely, Carole Bartolotto, MA, RD

Competing interests: None declared

PRACTICE:
Management of type 2 diabetes: summary of updated NICE guidance
Home et al. (7 June 2008) [Full text] [PDF]
Management of type 2 diabetes: summary of updated NICE guidance
A Missed Opportunity
11 June 2008
Previous Rapid Response Next Rapid Response Top
Victoria H Corkhill,
Specialist Registrar, Obstetrics and Gynaecology
Pontefract General Infirmary, Pontefract, Yorkshire, WF8 1PL,
John Jolly , Consultant Obstetrician and Gynaecologist, Pontefract General Infirmary, Pontefract, WF8 1PL

Send response to journal:
Re: A Missed Opportunity

Having read the article ‘Management of type 2 Diabetes: updated NICE guidelines1’ we feel it is important to highlight recent NICE guidelines of Diabetes in Pregnancy2.

As the article states the prevalence of Type 2 diabetes is rising rapidly1 which includes a proportion of women at child bearing age. The recent NICE guideline states that 0.1% of all pregnancies are complicated by Type 2 diabetes which equates to 6500 births a year2.

Women with Type 2 diabetes have the same pregnancy risks as women with type 1 diabetes3 which include stillbirth (five fold increase), neonatal death (three fold), major congenital anomaly (two fold), macrosomia (>4.5kg) and related birth trauma2,3.

All healthcare professional should advise women with type 2 diabetes the importance of avoiding unplanned pregnancies with a particular emphasis on need for proactive preconception glycaemic control and high dose folic acid supplementation (5mg/day).

We feel this article missed an ideal opportunity to inform the readers of this major part of a women’s care with type 2 diabetes.

1 National Institute for Health and Clinical Excellence. Type 2 diabetes: the management of type 2 diabetes (update) (Clinical guideline 66.) London: NICE, May 2008. http://www.nice.org.uk/nicemedia/pdf/CG66NICEGuideline.pdf

2 National Institute for Health and Clinical Excellence. Diabetes in Pregnancy (clinical guideline (CG63) London: NICE: March 2008. http://www.nice.org.uk/nicemedia/pdf/CG063Guidance.pdf

3 Confidential Enquiry into Maternal and Child Health (CEMACH). Pregnancy in women with type 1 and type 2 diabetes in 2002-2003, England, Wales and Northern Ireland. London; RCOG Press; 2005. www.cemach.org.uk

Competing interests: None declared

CLINICAL REVIEW:
Diagnosis and management of hypocalcaemia
Cooper and Gittoes (7 June 2008) [Full text] [PDF]
Diagnosis and management of hypocalcaemia
Thiazide diuretics are efficient in the chronic management of hypoparathyroidism
11 June 2008
Previous Rapid Response Next Rapid Response Top
Yair Liel,
Acting head, Endocrinology Service
Soroka University Medical Center, Beer-Sheva, Israel

Send response to journal:
Re: Thiazide diuretics are efficient in the chronic management of hypoparathyroidism

As mentioned in Cooper and Gittoes' review (1), while oral calcium and active vitamin D analogs (calcitriol or 1-alpha vitamin D) are undoubtely the mainstay of hypocalcemia management in patients with hypoparathyroidism or pseudohypoparathyroidism, this treatment can result in considerable hypercalciuria and urinary caluli formation.

An efficient method to overcome the hypercalciuria related to calcium -active vitamin D analog treatment includes the supplementation of low dose of a thiazide diuretic, which considerably decreases the rate of urinary calcium excretion. This is particularly important in patients with hypercalciuric hypocalcemia due to activating mutations of the calcium sensor-receptor (2).

Not less important, the use of a cheap thiazide diuretic allows to achieve target calcium concentration with lower doses of calcium and the more expensive active vitamin D analog and thus reduce the cost of management of a lasting condition.

References:

1. Cooper MS and Gittoes NJL. Diagnosis and management of hypocalcaemia. BMJ 2008; 336: 1298-302.

2. Sato K, Hasegawa Y, Nakae J, et al. Hydrochlorothiazide effectively reduces urinary calcium excretion in two Japanese patients with gain-of-function mutations of the calcium-sensing receptor gene. J Clin Endocrinol Metab 2002; 87:3068-73.

Competing interests: None declared

HEAD TO HEAD:
Should we use large scale healthcare interventions without clear evidence that benefits outweigh costs and harms? No
Landefeld et al. (7 June 2008) [Full text] [PDF]
Should we use large scale healthcare interventions without clear evidence that benefits...
The same coercive forces govern the need of large-scale health-care interventions
11 June 2008
Previous Rapid Response Next Rapid Response Top
Grazyna T Adamiak,
PhD, MA, MH&W;
Unemployed

Send response to journal:
Re: The same coercive forces govern the need of large-scale health-care interventions

With regard to the need for evidence for conducting large-scale health care interventions, both Authors appear to agree that any intervention should be monitored and successively evaluated. They disagree what regards the conception of health care and the organizational layers contributing to the delivery of health care.

Separation between organisation at a population, functional and institutional level and the individual or group practices of health care professionals at the technical or operational level. While Crumb on the Yes-side, having an experience from a publicly financed and governed health care system clearly separates between clinical or biological evidence regarding the human body and the evidence from social sciences on the social, construct organisation and political institutions, the No-side represents a view that the various kinds of evidence are not separable and they provide examples of interventions aimed at individual patients with consequences for parts of the health care system. While Crumb starts from the top-down or a whole, system or institutional managerial view on healthcare the No-side represents the bottom-up view on the same. The coercive forces they do not mention are the economic situation, epidemiology of diseases and the ongoing technological changes, and following, the need of every health care organisation to adjust to the changing and dynamic environment when the changes are so comprehensive that they have significant implications for the policy.

These kinds of adjustments have the same driving forces, economy and technology, both in the private and in the publicly financed health systems independently of the mode of the delivery. Both kinds and organisation have to adjust to changing health care needs of populations. While tuberculosis was, a large health care problem in the 40-50-ies, later on large-scale vaccination programs eliminated the need of some parts of the health care services to the advantage of others even if these services were efficacious. The same occurred in the case of the day-surgery eliminating the need of excess inpatient beds in hospitals. The driving or coercive forces are market forces, or, with other words, the dynamics of the institutional environment.

Competing interests: None declared

EDITORIALS:
Patient consent—decision or assumption?
Elwyn (7 June 2008) [Full text] [PDF]
Patient consent—decision or assumption?
Re: creep before climb
11 June 2008
Previous Rapid Response Next Rapid Response Top
Laura Hair,
Salaried GP
Pinfold Surgery, Methley, LS26 9AB

Send response to journal:
Re: Re: creep before climb

There seems to be an assumption within this article that consent is a less formal process in primary care. Although standards will vary from surgery to surgery, it seems unfair to imply that the process is less vigorous than in the hospital setting. If anything, the patient is much more likely to have consent taken from the person actually performing the procedure, rather than a hospital junior. The setting may be different, but primary care doctors still follow GMC guidance.

Competing interests: None declared

Patient consent—decision or assumption?
Media&Politician; Subservient GMC
11 June 2008
Previous Rapid Response Next Rapid Response Top
Harold Bourne,
Private Practice
Rome Italy

Send response to journal:
Re: Media&Politician; Subservient GMC

Guidelines betray ignorance of,if not indifference to the psychological needs of seriously ill people.They are usually anxiously dependent,awaiting medical rescue,or even magic,with no appetite for earnest clinical debate.It is realistic to understand this instead of leaning over backwards against paternalism.The GMC,scared of media scandal and of being disempowered by populist politicians,is remarkably lacking in any solidarity with the rest of us out at day and night work in the actual field .. hence these oh so solemn guidelines..

Competing interests: None declared

Patient consent—decision or assumption?
Informed Consent: Of course, we MUST do better.
11 June 2008
Previous Rapid Response Next Rapid Response Top
Philip Harrison,
General Practitioner
New Zealand

Send response to journal:
Re: Informed Consent: Of course, we MUST do better.

Professor Elwyn's thesis may create more problems than answers and create dichotomy in the appropriate use of the written word, but informed consent, is a well worn track and an established province of clinical (therapeutic) trials. If we mistrust the pharmaceutical industry so much what is so perfect about our own profession (whom collaborate so closely).

So what is so difficult? Surely, communication to patients is more important than our own desired endpoints as clinicians? If we cannot take the patient with us in our medical philosophy, are we fit to be their doctors? And, if documentation is "bureaucratic" then so be it. We are in a progressively accountable world and doctors (and other health care workers) are not in a position to know what is right from knowledge alone. What about the patients belief systems? Is it our place to question them even if we vehemently disagree? No we are THEIR servants, they are not ours. We advise them. They accept or reject. And we record what they understand and accept what limitations this process may have. Limited yes! But better than nothing! And, where the alternative could well be confusion, collusion and unethical behaviour. Yes, we may all mean well but IS THAT ENOUGH?

The GMC is scraping the surface of a minefield. Underneath are the skeletons of deceit, misinformation, miscommunication, paternalism, arrogance, incompetence, misguided benevolence and 'professionalism'. Yes, and most of us try to be good doctors. And we all fail. To err is human. Excellence must acknowledge this. Written proof of understanding, even prior to a simple general anaesthetic, for example, allow us busy people to stop and think and say, "what if it was my sister?". What if they do not understand they could die? The publications of Goodyear-Smith *1, following on from Paling*2 and Gigerenzer*3 show we communicate very poorly what evidence supports our intentions. We doctors are also creatures of habit and we need to be more accountable in our own medical belief systems.

The GMC have not really done enough but, perhaps, the process has started and I wait with baited breath as it all evolves into our 'Brave New World' which we appear to fear.

Philip Harrison
General Practitioner
Upper Hutt Health Centre, Wellington, New Zealand

*1 "Patients Prefer Pictures to Numbers to Express Cardiovascular Benefit From Treatment" Goodyear-Smith F; Arroll B, Chan L; Jackson R; Wells S; Kenedy T: Annals of Family Medicine Vol 6, No 3, May/Jun 2008

*2 "Helping Patients Understand Risk" Paling J. BMJ, 2003; 327 (7417): 745-748

*3 "Simple Tools for understanding Risks"; from innumercy to insights. BMJ. 2003; 327 (7417); 741-744

Competing interests: None declared

Patient consent—decision or assumption?
The patient's agent
11 June 2008
Previous Rapid Response Next Rapid Response Top
Tom H Hughes-Davies,
Retired paediatrician
SP6 2EJ

Send response to journal:
Re: The patient's agent

The patient is asking for help, not submitting to another's decision.

We should use request rather than consent forms to make this clear.

Competing interests: None declared

Patient consent—decision or assumption?
Who does it?
11 June 2008
Previous Rapid Response Next Rapid Response Top
Daniel Garros,
Associate Professor of Pediatrics, Pediatric ICU staff
Stollery Children's Hospital, Edmonton AB, Canada T6G 2B7

Send response to journal:
Re: Who does it?

One interesting aspect not addressed in the article about obtaining consent is "who" should obtain it? Within the critical care environment (CCU) for example, procedures done by radiologists and surgeons outside the actual unit are a constant. It is not uncommon that the CCU physician is asked, as the patient is leaving the unit, to quickly obtain consent from families.

If I am not actually the physician doing the procedure, should I obtain consent for it? Should a nurse, in charge of the radiololgy department that day, obtain consent? Should a doctor in training (resident, fellow, junior registrar) obtain consent in behalf of his supervisor?

Informed consent becomes a formality, without real meaning, if the person doing the procedure is not the one obtaining it! Surely this issue is a practical one, and it needs to be properly addressed by hospital administrators.

Competing interests: None declared

VIEWS & REVIEWS:
The case for resurrecting the long case
Teoh and Bowden (31 May 2008) [Full text] [PDF]
The case for resurrecting the long case
Resurrection in a different form
11 June 2008
Previous Rapid Response Next Rapid Response Top
Stephen P Tyrer,
Consultant Psychiatrist
Southland Hospital, Invercargill, 9501, New Zealand

Send response to journal:
Re: Resurrection in a different form

The practice of psychiatry relies, above all, on the ability of the practitioner to obtain a relevant history and mental state examination from a patient. For this reason the Royal College of Psychiatrists has regarded this skill as vital in the assessment of candidates for the MRCPsych Examination and, until very recently, the assessment of a long case interview has been considered to be a cornerstone of clinical assessment (1). However, for the reasons cogently expressed by Brian Jolly, the College relinquished the long case in the format of the MRCPsych in Spring of this year and has replaced this with an OSCE.

We still believe strongly that the ability to interview a real patient and synthesise the information relevantly is important and we will continue to assess this ability but in a different setting. The new regulations for the MRCPsych Examinations require candidates to complete a number of Assessed Clinical Encounters (ACEs) as well as other Workplace Based Assessments during training. A proportion of these ACEs will be assessed by a validated College approved assessor, with these marks counting towards the final summative assessment.

This arrangement overcomes the problems of reliability of a single examination assessment. We might be hesitant to recommend a restaurant on the basis of one good meal but once we have had a number of of equally tasty offerings the confidence of our gustatory beliefs are vastly increased.

1. Tyrer S. Non mors praematura: Commentary on the long case is dead. Psychiatric Bulletin, 2007;31:447-449

e-mail: stephen.tyrer@sdhb.govt.nz

Competing interests: I am a past Chief Examiner of the Royal College of Psychiatrists

NEWS:
Kenyan Muslim clerics decide to campaign against use of condoms
Moszynski (24 May 2008) [Full text] [PDF]
Kenyan Muslim clerics decide to campaign against use of condoms
Condom against AIDS-but what about society?
11 June 2008
Previous Rapid Response Next Rapid Response Top
Andrew PG Mitchell,
Aid worker ,Horn of Africa
Djibouti. B.P.1936

Send response to journal:
Re: Condom against AIDS-but what about society?

Sir, Before putting down these clerics why not consider their fears for their community?

It is well known that:

Teenagers engage in sexual activity hoping to find a relationship which is stable/durable, intimacy. Many do so seeking affection which they have not found from their parents especially their father.

Sexual activity too early in a relationship, before it is deep and properly formed, results in that relationship breaking down. There then follows multiple serial relationships but an inability to form longterm relationships.

Casual sexual activity is dangerous! Not only the dangers and complications of(i) unforeseen pregnancies in young girls(ii) possible abortions(iii)sexually transmitted infections(STI’s)including death(even in the presence of condoms)-but also the emotional trauma of all of these as well as the sadness and rejection of broken relationships for any number of reasons along the way.

Children from broken family backgrounds are not so well adjusted emotionally nor do they achieve so well at school.

By not promoting abstinence and the family our societies are increasingly becoming made up of people who lack cohesive skills. Not only do we see increasing prevalence of STI’s, teenage pregnancies, but also general breakdown of simple respect for self and others followed by increasing violence and crime.

Why then are we as doctors promoting dangerous ,emotionally harmful, relationship weakening activities(with a condom !) which encourage family breakdown and ultimately undermine our society? Why don’t we try promoting preventative measures that encourage relationships and can lead to success in life and stability in our societies? Maybe these clerics have a good point to be considered.

1) Helping our kids to say ‘No’ to sexual pressure-Josh McDowell.

2) The Naked Ape-Desmond Morris.

Competing interests: None declared

NEWS:
Darzi’s five pledges fail to quell doctors’ anxieties about polyclinics
O’Dowd (17 May 2008) [Full text] [PDF]
Darzi’s five pledges fail to quell doctors’ anxieties about polyclinics
Pledges ignored
11 June 2008
Previous Rapid Response  Top
Anne Holmes,
General Practitioner
Tithebarn Medical Centre, Stockton on Tees, TS19 8RH

Send response to journal:
Re: Pledges ignored

Hawkes quotes Lord Darzi’s pledges. I see no evidence that they are being honoured in my practice community.

I work in a small practice which was set up four years ago to provide a service in a deprived and underdoctored area. A PMS contract was awarded to a private, but GP led, company. After four years, the practice has 1250 patients, looks after a prison, teaches medical students and trains foundation programme doctors.

The PCT response to the practice has been to announce, at an unrelated meeting, that they plan to amalgamate it with the Darzi Health Centre. If my employer did not choose to tender for the new service, the PMS contract would be terminated.

Lord Darzi’s first pledge is that of benefit to the patients. As the practice is at the top end of performance indicators (including the prison population), I am unclear as to how our patients can benefit further. The potential detriment from loss of continuity of care when the opening hours more than double is unclear. 83% of patients are satisfied with our current opening hours. Extension of our opening hours is not currently cost effective.

The second pledge is that it will be clinically driven. I am unaware of any evidence to support the plans as having any clinical benefit.

‘All change will be locally led’. The plans are led by the PCT. The consultation exercise has just started and included a leaflet drop containing details of the proposed practice changes. None of our patients were aware of the plans prior to this. The Residents Association had not been consulted. I am not aware of any local need for change.

‘You will be involved’. One might guess that the practice staff would be key partners but have not had any opportunity to have their say, other than through the public consultation process. None of our patients have been consulted.

‘You will see the difference first’. This does not appear to be in the plans and whilst I can understand that the PCT may wish to hasten amalgamation of services on one site to save money, perhaps Lord Darzi should define the meaning of this phrase.

What has been the outcome to date? I do not wish to work in a system which fails to value continuity of care and which I believe will be a poor use of public funds. I am moving to another practice where I can work in a way that I believe in. I also have the more selfish motivation of wanting to ensure an NHS pension. The locality has lost a training practice and may lose more staff who would otherwise have chosen to remain serving that community. The NHS is lucky that there are so many unemployed GPs around who may not have the luxury of choosing the system in which they work.

Competing interests: None declared