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Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The ݮƵ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.

From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.

The word limit for letters selected from posted responses remains 300 words.

Re: Pulmonary embolism Jeffrey A Kline, et al. 384:doi 10.1136/bmj-2022-071662

Dear Editor,

I was interested to read Maughan and colleagues’ education piece on pulmonary embolism, particularly the factors that predict a delayed diagnosis and the impact of early anticoagulation.

I would like to draw attention to the use of positive likelihood ratios when describing elements from the patient history and examination in this article.

In a defined population, the positive likelihood ratio describes the proportion of patients with a positive finding (such as “patient has dyspnoea”) that are subsequently diagnosed with pulmonary embolism, divided by those with the finding who have an alternative diagnosis (1).

However, likelihood ratios consider all potential diagnoses, and cannot inform a comparative diagnostic exercise between the relatively few competing differentials that remain after history taking and examination. Furthermore, positive predictive values rarely allow us to exclude a diagnosis with confidence; a necessary part of the diagnostic process.

For example, even if the positive likelihood ratio is very high, a finding such as “syncope” may not help the diagnostician distinguish between differentials, such as pulmonary embolism and myocardial infarction.

Additionally, likelihood ratios apply only to a defined population. The parameters of this population are not defined in the article, though perhaps we may infer from author affiliations that these ratios apply to emergency department attendees. Such information should be clarified for the benefit of the reader.

1. Llewelyn H, Ang AH, Lewis K, Abdullah A. The Oxford Handbook of Clinical Diagnosis. 2nd ed. Oxford University Press, 2009:754-60

Competing interests: No competing interests

29 February 2024
Daniel J Chivers
Foundation Year 2 Doctor
Sheffield Teaching Hospitals
Sheffield
Re: What are the chances of having a second epileptic seizure? Helen Saul, Brendan Deeney, Samantha Cassidy, Aidan Neligan. 383:doi 10.1136/bmj.p2285

Dear Editor

The results of a Cochrane review of seizure recurrence following first seizure have been recently reported (1,2). Fifty eight studies in adults and children underwent meta-analysis. Seizures recurrence rate was 27% at 6 months, 36% 12 months and 43% percent at 24 months.

A striking finding was the great variation in the results ranging from 8% to 58% at 6 months. In a previous authoritative review recurrence was 24% to 65% at one year(3). People with focal seizures, a structural cause or an EEG with generalised spike and wave are likely to have a higher recurrence rate. The prognosis is slightly worse in children. Treatment probably reduces the recurrence rate by one half. Recurrence rate is likely to be higher if seen in primary rather than secondary care. In established epilepsy the second seizure follows the first within a month in 30% of people. By the time patients are seen in hospital many will have already developed epilepsy and the remaining cases will have a lower recurrence. We found in neurology clinics the recurrence rate was of the order of 40% to 50% at one year, but as high as 70% for those presenting in primary care(4).

The authors of the Cochrane review acknowledge that clinical heterogeneity is probably an important reason for the varying results. For the same reason the results of the Cochrane review should be treated with caution when counselling individual patients.

Robert Elwes MD FRCP, Consultant Neurologist, King’s College Hospital
Edward Reynolds, MD FRCP, Retired Consultant Neurologist, King’s College Hospital

1.ݮƵ 2023;383:p2285

2.Neligan_A, Adan_G, Nevitt_SJ, Pullen_A, Sander_JW, Bonnett_L, Marson_AG.
Prognosis of adults and children following a first unprovoked seizure.
Cochrane Database of Systematic Reviews 2023, Issue 1. Art. No.: CD013847.
DOI: 10.1002/14651858.CD013847.pub2.
3.Berg AT, Shinnar S The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology 1991 Jul;41(7):965-72. doi: 10.1212/wnl.41.7.965.
4.Elwes RDC, Chesterman P, Reynolds EH. Prognosis after a first untreated tonic-clonic seizure. Lancet 1985; 326(8458): 752-3. PubMed ID:2864487. DOI: 10.1016/S0140-6736(85)90631-2.

Competing interests: No competing interests

29 February 2024
Robert Dudley Cary Elwes
Consultant Neurologist and Clinical Neurophysiologist
Edward H Reynolds
King's College Hospital, London
King's College Hpspital, Denmark Hill, London SE5 9RS
Re: GMC admits error in decision over whether to investigate doctor’s claims over covid vaccine Jacqui Wise. 384:doi 10.1136/bmj.q433

Dear Editor

Unfortunately, this news item fails to identify the exact error which the GMC made at first instance when considering the complaint against Dr Malhotra[1]. If we know the nature of the error, then it would help commenting with greater accuracy as to possible outcomes upon reconsideration. It is certainly possible, upon correcting the original error, the outcome could be the same, thus the GMC’s reconsideration would be a hollow victory for the complaining doctor.

With regard to the view, this should “not be an area which the GMC should be adjudicating on”[2], it is reasonably clear that the GMC as a professional regulator has a legal duty to consider complaints irrespective of the nature or complexity of a complaint. In fact, the GMC has already adjudicated on at least two cases of promoting harmful misinformation [3] and one involved an allegation that covid-19 was a conspiracy [4]. The appeal against the GMC’s decision to impose a suspension was unsuccessful [4], thus confirming judicial approval of the GMC’s jurisdiction to adjudicate matters of competing and controversial opinions particularly in relation to covid-19.

Prima facie, the allegations against Dr Malhotra do not suggest that his opinions and claims are so egregious as to merit a referral to MPTS. However, MPTS as a first-tier tribunal has sufficient medical and legal expertise to decide on matters of this nature as it has done in relation to historical cases of controversial medical and scientific opinions of doctors. Of course, both the GMC and MPTS can obtain relevant expert advice where necessary, so there are no legally or logically sustainable grounds to suggest that the GMC should not adjudicate allegations against Dr Malhotra.

References
[1] ݮƵ 2024;384:q433
[2] /content/384/bmj.q433/rapid-responses
[3] /content/382/bmj.p1568/rr-3
[4]

Competing interests: Have responded to a previous news item on this matter before the GMC admitted an error at first instance consideration.

28 February 2024
Jay Ilangaratne
Founder
www.medical-journals.com
Yorkshire
Re: Short term exposure to low level ambient fine particulate matter and natural cause, cardiovascular, and respiratory morbidity among US adults with health insurance: case time series study Joel Schwartz, Francesca Dominici, Amruta Nori-Sarma, Shengzhi Sun, et al. 384:doi 10.1136/bmj-2023-076322

Dear Editor

I read the article of Sun et al. with great interest, and I would like to suggest a possible mechanism that can contribute to higher hospital admissions and death rates for cardiovascular and cardiac diseases following exposure to short-term high ambient air pollution concentrations.

A recent study has identified an association between short-term exposure to particulate matter (PM10/PM2.5) and mortality from nervous diseases, as well as short-term exposure to nitrogen oxides (NO2) and metabolic mortality (1). Furthermore, the research has confirmed associations of particulate matter with natural, cardiovascular, cardiac, and respiratory causes of death and NO2 with respiratory mortality. The study has also hypothesized biological mechanisms through which air pollution could increase the risk of short-term death from metabolic and nervous diseases. The authors suggested that the adverse effects of PM and NO2 on the nervous and metabolic systems may be attributed to inflammatory pathways and oxidative stress. These, along with other unknown factors, could also contribute to short-term death from cardiovascular and cardiac disease by acting through a mechanism mediated by an increase in blood pressure during acute exposure to high-level air pollution.

Indeed, short-term exposure to high-level ambient PM2.5 has been associated with a significant increase in central systolic blood pressure (cSBP) in a Chinese community-based population (2). This observation is important because cSBP is a key determinant of cardiovascular risk and has been associated with adverse cardiovascular outcomes. The study found that an interquartile range change (80.25 μg/m3) in PM2.5 at high exposure level on the day of central aortic BP measurement was associated with a 2.54 mm Hg increase in cSBP. This association suggests that short-term exposure to high levels of PM2.5 can have immediate effects on central blood pressure.

The study findings are consistent with previous research in different populations, which reported associations between particulate matter exposure and central aortic pulse pressure in hypertensive patients and increased central systolic blood pressure in older women. The study also introduced the exposure-response curve model and found that there may be threshold effects between air pollution exposure and central hemodynamics. This effect suggests that the impact of particulate matter exposure on central blood pressure may not be linear and that there may be a threshold beyond which exposure leads to significant increases in cSBP. The study results also indicate that the effects of PM2.5 on cSBP were observed at high concentration exposures of PM2.5.

If further research confirms this hypothesis, tight blood pressure control is advisable for individuals with high blood pressure during exposure to high-level air pollution, and it would have significant implications for clinical practice.

1. Fan, F., Wang, S., Zhang, Y., Xu, D., Jia, J., Li, J., ... & Huo, Y. (2019). Acute effects of high-level PM2.5 exposure on central blood pressure. Hypertension, 74(6), 1349-1356. doi:10.1161/HYPERTENSIONAHA.119.13408

2. Fan, F., Wang, S., Zhang, Y., Xu, D., Jia, J., Li, J., ... & Huo, Y. (2019). Acute effects of high-level PM2.5 exposure on central blood pressure. Hypertension, 74(6), 1349-1356. doi:10.1161/HYPERTENSIONAHA.119.13408

Competing interests: No competing interests

28 February 2024
Giovanni Ghirga
Pediatrician
Claudia Orchi, MD
International Society of Doctors for the Environment (ISDE, Italy)
Civitavecchia (Rome)
Re: Why medical students should learn about prison health Hannah Calvelli, Olivia Duffield, Brian Tuohy. 384:doi 10.1136/bmj.q213

Dear Editor,

I was pleased to read this piece highlighting the lack of education on prison populations, and hope that it will be read by those who wield editing rights to our medical school curricula.

However, I must disagree with the statement that "not all medical students will work directly with prison populations in their future clinical practice", and would challenge this as a reason for its absence from the curriculum. I would be surprised to meet any NHS medical professional who has not seen and treated a person who is incarcerated.

Furthermore, the social determinants of health which unfavourably apply to prison populations may also apply to populations of people who are not incarcerated. People who have previously been incarcerated or are at risk of incarceration also have unique health needs. Learning to manage and subvert the challenges faced by these populations when interacting with healthcare will be of benefit to clinicians and their patients.

Developing the skills and confidence to manage incarcerated patients and fostering an appreciation for the social determinants of health will be valuable to medical students and trainees of all grades.

Competing interests: No competing interests

28 February 2024
Daniel J Chivers
Foundation Year 2 Doctor
Sheffield
Re: John Launer: Israel and Gaza—recognising shared human values John Launer. 383:doi 10.1136/bmj.p2768

Dear Editor,

I recently returned from Limmud, an international Jewish Learning Conference. I attended two sessions hosted by peace groups; The 49% and the Interfaith Encounter Association. There were people there from many other peace groups, a couple of examples being Yachad ("together") and Women Waging Peace. They have continued meeting throughout the current hostilities, online. Some people even managed to join from Gaza, via Whatsapp.

Very quickly the question was asked: "Does this peace activity do any good?". I offered that it would be difficult to measure this as it is preventative work. A call for data on this followed rapidly.

There is some anecdotal evidence that it works. The host of the Interfaith Encounter session says that he was informed by his Muslim colleague that he had been approached to become a suicide bomber. Our host responded: "Then you would have killed me and my kids". "That's why I didn't do it" was his colleague's answer.

I find this incredible. Never mind his own life, he was more worried about a friend on the other side of the conflict. People's altruism never ceases to astonish me.

Is there anyone out there who could design a study to measure the impact of these grassroots peace groups? Whether it is lives saved, reduction of hatred or of ill treatment of civilians by military authorities.

And if it has no impact, even that might help us to develop a process that does.

Competing interests: I have family living in Israel

28 February 2024
Elinor Stanton
GP
Birmingham UK
Re: Why GMC’s apology to LGBTQ+ doctors is everything and nothing Kamran Abbasi. 384:doi 10.1136/bmj.q454

Dear Editor

Many would agree that apologies offered by public bodies including NHS and GMC, usually for offending acts/omissions of their employees, are not worth the paper it’s written on. It is not uncommon at all for actual perpetrators to get away with a mild slap on the wrist; even findings of unlawful acts under employment tribunal judgments do not seem a barrier for perpetrators to maintain the same employment or find alternative employment particularly within the NHS. It appears, individual culpability is still well sheltered by organisations.

Judging by the widely publicised islamophobic and racist expressions of present-day politicians, it is now not surprising at all, why those ancient politicians with bigoted mindsets, unashamedly legislated utterly degrading and inhumane homophobic laws.

As for the remark that the GMC’s “failure to consider a complaint against cardiologist Aseem Malhotra”[1], it is not accurate. In fact, the GMC did initially consider the relevant complaint but has now admitted that it made “an error” and “will now reconsider” whether to review the alleged misleading covid vaccine claim [2]. Openly admitting an error in decision making is certainly not a bad thing, nor should it be a reason to sneer at the GMC.

References
[1] /content/384/bmj.q454
[2] /content/384/bmj.q433

Competing interests: No competing interests

28 February 2024
Jay Ilangaratne
Founder
www.medical-journals.com
Yorkshire
Re: Marc de Leval: founder of the heart transplant unit at Great Ormond Street Hospital Joanna Lyall. 378:doi 10.1136/bmj.o1759

Dear Editor

So very sorry to learn of the death of Marc de Leval, who operated on my son in the 1970s for transposition of the great vessels.

instead of using a plastic shunt to redirect the blood he shaved the skin from around the outer sac to redirect the blood supply because he said the the plastic shunt hardened over time. My son is now approaching his 50s and l will always be so grateful to Marc de Leval

Competing interests: No competing interests

28 February 2024
Linda M Hall
Retired
Southwell
Re: Changes to the UK foundation programme add further challenges for doctors pursuing clinical academic careers Marina Politis, Kate Womersley, Charlotte Summers. 384:doi 10.1136/bmj.q485

Intercalation degrees have long been recognized for their numerous benefits, as extensively documented in the literature1. Despite this, there has been a significant nationwide decrease in intercalating students in recent years, with the underlying factors largely remaining undocumented2. While Politis, Womersley and Summers highlighted that the introduction of preference-informed allocation for academic foundation posts3 does not explain why a declining number of students are undertaking intercalated science degrees4, it is evident that the decline is concerning. Historically, intercalating medical students have shown a notable interest in academia. However, recent changes in the allocation of academic foundation posts, which fail to acknowledge applicants' research interests and achievements, will likely discourage students from investing an additional year in pursuing an extra qualification. This lack of recognition in foundation job applications significantly diminishes the incentive for medical students to undertake intercalated degrees, contributing to a downward trend in intercalation rates nationwide.

Intercalation is vital in nurturing a cohort of future clinician-academicians poised to translate scientific breakthroughs from the laboratory to bedside patient care. Medical students considering intercalating are already grappling with the soaring cost-of-living crisis and inflation pressures5. Failure to provide recognition for intercalated degrees in the allocation of academic foundation posts would undoubtedly deter students from pursuing such endeavours, resulting in a further decline in intercalation nationwide. A concerted effort is required from all stakeholders to rectify the multifaceted nature of students' decision-making process around intercalation to ensure the continuity of the pipeline of undergraduate medical research and the nurturing of future academic clinicians.

1. Jones M, Hutt P, Eastwood S, Singh S. Impact of an intercalated BSc on medical student performance and careers: a BEME systematic review: BEME Guide No. 28. Med Teach. 2013;35(10):e1493-510.
2. House of Lords Science and Technology Committee. Clinical academics in the NHS inquiry. 26 Jan 2023.
3. Lynn É. Changes to academic foundation jobs spark concern. ݮƵ2024;384:q423. doi:10.1136/bmj.q423. pmid:38373794
4. Politis M, Womersley K, Summers C. Changes to the UK foundation programme add further challenges for doctors pursuing clinical academic careers ݮƵ 2024; 384 :q485 doi:10.1136/bmj.q485
5. Murray A. Medical students across the UK are feeling the financial heat: BMA 2022 [Available from: .

Competing interests: No competing interests

28 February 2024
Jun Jie Lim
Specialised foundation doctor in medical education
School of Medicine and Population Health, The University of Sheffield
University of Sheffield, Beech Hill Rd, Broomhall, Sheffield S10 2RX
Re: Changes to academic foundation jobs spark concern Éabha Lynn. 384:doi 10.1136/bmj.q423

As an academic foundation trainee with a widening participation background, I was struck by a mix of emotions upon learning of the recent announcement1. The decision made by UKFPO undoubtedly presents challenges, particularly from the perspective of widening participation, and I empathize deeply with the concerns raised by both junior colleagues and seasoned clinical academicians.

Reflecting on my own journey, I recognize the value of the academic foundation programme in fostering my development within the field of medical education. Having studied in a medical school in the global south where academia often takes a backseat due to limited opportunities and financial constraints, I have found the opportunities and resources afforded by the programme immensely beneficial in honing my academic skillset. These opportunities have been pivotal in my growth, opportunities which would have been far less accessible within the standard foundation programme.

However, I share the sentiment that the current approach of randomising the allocation of these valuable academic positions may not fully optimize their potential impact. In light of this, I propose a nuanced solution: the allocation of a specific proportion of posts with adjusted criteria tailored to candidates with limited or no prior exposure to research opportunities during their medical education.

By implementing this approach, we can achieve two crucial objectives. Firstly, it maintains a competitive selection process within the main pool of candidates, allowing those with prior research experience to continue enhancing their skill sets during their foundation years. Secondly, it opens doors for students who, like myself, may lack formal research experience but demonstrate a genuine passion and potential for academic pursuits. By providing such individuals with access to academic opportunities during their foundation years, we can effectively advance the cause of widening participation.

In essence, this approach aims to strike a balance between meritocracy and inclusivity, ensuring that academic pathways remain accessible to all who possess the drive and determination to pursue them. I believe that by adopting a more targeted and tailored approach to allocation, we can not only preserve the integrity of academic foundation programmes but also foster a more diverse and vibrant academic community within the medical profession.

1. Lynn É. Changes to academic foundation jobs spark concern. ݮƵ2024;384:q423. doi:10.1136/bmj.q423. pmid:38373794

Competing interests: No competing interests

28 February 2024
Jun Jie Lim
Specialised foundation doctor in medical education
School of Medicine and Population Health, The University of Sheffield
University of Sheffield, Beech Hill Rd, Broomhall, Sheffield S10 2RX

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