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Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on 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 BMJ 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: Tackling climate change: the pivotal role of clinicians Jeffrey Braithwaite, Anuradha Pichumani, Philip Crowley. 382:doi 10.1136/bmj-2023-076963

Dear Editor

Whilst I agree with almost every word of this article, the use of the phrase 'Carbon Footprint' makes me uncomfortable [1]. It wasn't the only piece in this edition of the BMJ that used the term and it is of course a convenient expression to use. However, I wonder if those who use it realise the origins of the phrase?

Although it is probably impossible to know when the words ‘Carbon’ and ‘Footprint’ were first used together, it is possible to know when and why this phrase was popularised. In 2004 the advertising agency Ogilvy and Mather came up with the concept of a ‘carbon footprint calculator’ for their clients. Who were their clients? British Petroleum (BP). [2]

The concept was that the individual and their actions were/are responsible for their own emissions rather than the fossil fuel industry. It was therefore up to individuals to mend their ways and reduce their emissions and to do this they could use the handy carbon footprint calculator provided. The industry itself did not mention its own hefty footprint, as that would have defeated the aim.

Individuals and organisations do of course need to be aware of how much of the planets resources they consume and I appreciate that carbon footprint is a useful shorthand for this. But I think, both because of its origins and the relatively narrower focus of the term carbon footprint, we could use the term ‘Climate Footprint’ instead. This keeps the concept of a heavy or light tread but allows a more direct connection with the climate crisis that we are undoubtedly in.

Competing interests: No competing interests

10 October 2023
Scott Fraser
Retired Doctor
Re: Appendicectomy remains treatment of choice for patients with acute appendicitis Alexander W Phillips, et al. 382:doi 10.1136/bmj-2022-074652

Dear Editor,

We read with interest the recent ‘Analysis’ piece regarding the role of non-operative management in patients with acute appendicitis. In this, the authors argue that the risks associated with non-operative management mean that surgery is the ‘best’ approach. We believe that in selected cases, surgery is not the ‘best’ option and that for shared decision making, non-operative management needs to be offered to the patient.

The authors base their conclusion on several aspects - the comparative complication rate, the risk of recurrence or missing a malignancy, cost effectiveness and patient satisfaction. A recent meta-analysis did not show a significant difference in post-treatment complication rate between patients treated with surgery or antibiotics.[1] The authors criticise studies for not including recurrence as a complication in patients treated non-operatively and cite a selection of articles to justify their arguments. There is, however, a wealth of literature that disagrees with this view. We would argue that just as cancer recurrence is not considered a complication, appendicitis recurrence should not be considered a complication. Patients opting for antibiotics who are appropriately informed as part of shared decision making, will be acknowledging and accepting this foreseeable risk of long term failure of medical management.

The authors cite organ failure as a complication of antibiotic usage in the CODA trial, however a review of the CODA paper contains no mention of organ failure.[2] Importantly the CODA trial clearly attributes the higher rate of complications in the antibiotic arm of the trial to patients with an appendicolith, rather than those without.[2] This has confirmed, as previously thought, that appendicitis with an appendicolith should be treated as a different pathology and not be managed non-operatively.[3]

Appendiceal malignancy remains a rarity (occurring in approximately 1.5% of cases).[4] It occurs most commonly in patients aged >40 and has been strongly associated with CT proven complicated appendicitis.[4] It is therefore imperative to disentangle the considerations for varied patient populations and ensure that decisions are made contextually, accepting the evidence base for antibiotic management in the younger, uncomplicated group, where the malignancy risk is notably low.

Despite claiming a lack of robust cost analysis studies, the authors cited a comprehensive cost-effectiveness study, which considers the cost of repeat presentations.[5] Cost-effectiveness analysis that include wider societal costs are available from the APPAC teams, which favoured antibiotic therapy.[6] CODA and APPAC found operative patients had significantly longer time away from work or caregiving, which formed the majority of the societal cost.[2, 6]

Other aspects which we feel the authors may have omitted include patient choice, healthcare system and paediatric patients. Patient choice is fundamental within the shared decision making model. Several studies have shown that when presented with balanced and comprehensive information regarding both treatment choices, there remains a substantial percentage of patients who would prefer a trial of antibiotic management.[7, 8] The presumption that surgery is best risks surgeons not disclosing the alternative of antibiotics treatment to their patients, therefore denying them of choice (as well as being a clear breach of GMC guidance regarding consent). The authors do not consider global access to safe anaesthesia and surgery worldwide; the risk profile may alter considerably in low-income versus middle or high-income countries. Finally, the authors make no mention of children in their article despite a wealth of paediatric literature on the topic and ongoing research. Thus ensues a risk that children, as well as adults, may be denied the option of antibiotic treatment for uncomplicated appendicitis despite evidence of efficacy and safety.

Herrod PJJ, Kwok AT, Lobo DN. Randomized clinical trials comparing antibiotic therapy with appendicectomy for uncomplicated acute appendicitis: meta-analysis. BJS Open [Internet]. 2022 Jul 7 [cited 2023 Sep 29]; 6(4): zrac100. Available from:

CODA Collaborative, Flum DR, Davidson GH, Monsell SE, Shapiro NI, Odom SR et al. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med. 2020;383:1907–1919.

Di Saverio S, PoddaM, De Simone B, Ceresoli M, Augustin G, Gori A et al. Diagnosis and treatment of acute appendicitis: 2020 update of theWSES Jerusalem guidelines. World J Emerg Surg 2020;15:27.

Naar L, Kim P, Byerly S, Vasileiou G, Zhang H, Yeh DD, Kaafarani HMA; EAST Appendicitis Study Group. Increased risk of malignancy for patients older than 40 years with appendicitis and an appendix wider than 10 mm on computed tomography scan: A post hoc analysis of an EAST multicenter study. Surgery. 2020 Oct;168(4):701-706.

Javanmard Emamghissi H, Hollyman M, Boyd-Carson H, Doleman B, Adiamah A, Lund JN et al. Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study. Br J Surg. November 2021; 108 (11): 1351–1359.

Sippola S , Grönroos J, Tuominen R, Paajanen H, Rautio T, Nordström P et al. Economic evaluation of antibiotic therapy versus appendicectomy for the treatment of uncomplicated acute appendicitis from the APPAC randomized clinical trial. Br J Surg 2017;104:1355–1361.

Bom WJ, Scheijmans JCG, Gans SL, Van Geloven AAW, Boermeester MA. Population preference for treatment of uncomplicated appendicitis [internet]. BJS Open, July 2021; 5(4): zrab058. Available from:

Hanson AL, Crosby RD, Basson MD. Patient Preferences for Surgery or Antibiotics for the Treatment of Acute Appendicitis. JAMA Surg. 2018 May 1;153(5):471-478.

Competing interests: No competing interests

10 October 2023
Hannah M Javanmard-Emamghissi
N Hall, D MacAfee, S Moug, GM Tierney
University of Nottingham
University of Nottingham at Graduate Entry Medicine and Health, Royal Derby Hospital, Derby, United Kingdom, DE22 3NE
Re: Coroner alerts health secretary to another case where second opinion could have prevented child’s death Clare Dyer. 382:doi 10.1136/bmj.p2218

Dear Editor,

Availability of second opinions may improve diagnosis and treatment for patients who, paradoxically, never obtain a second opinion. If doctors know their work could be reviewed in real time, most will try harder to cover all bases.

Otherwise in daily practice, McCrae’s aphorism - that more is missed by not looking than by not knowing - may apply.

Options for investigation and therapy vary, but “low hanging fruit” of other testable/treatable diagnoses exist.

When disease progresses rapidly, not considering “zebras” as well as “horses” may have fatal consequences.

Even in jetplane cockpits, relying for safety on tried-and-tested checklists, two heads turn out to be better than one.

Competing interests: Dr Copeman provides second opinions.

10 October 2023
Michael C Copeman
Copeman Clinic
Palm Beach Sydney NSW 2108 Australia
Re: One Health and climate change—we need to get the ethics right Julian Sheather. 383:doi 10.1136/bmj.p2177

Dear Editor,

One Health according to Julian Sheather is all about getting the band back together again - humans, plants, animals, inanimate matter, whatever. He seems to think man has been doing a solo run and leaving the others behind. And of course he is right. We have. So it's time to swing back the pendulum. However let us not over-react and wrench everything from its moorings. Man is a moral being with conscience, free will, and intelligence - no other created substance has these faculties. The following are some world views:

Pantheism is the doctrine that holds that the universe is conceived of as a whole is God and, conversely, that there is no God but the combined substance, forces, and laws that are manifested in the existing universe.

Anthropocentrism is the philosophical viewpoint arguing that human beings are the central or most significant entities in the world. This is a basic belief embedded in many Western religions and philosophies. Reasonably acceptable?

Examples of anthropocentrism can be seen in the willingness of humans to cage and eat animals, the domestication of animals, and the human willingness to cause environmental damage for economic benefit.

Finally since half the world population believe in God, what did God say when he created humans? (Gen. 1 Verses 26 to 31).
"And God said, Let us make man in our image, after our likeness: and let them have dominion over the fish of the sea, and over the fowl of the air, and over the cattle, and over all the earth, and over every creeping thing that creepeth upon the earth." Billions of people believe this is the foundation of One Health.

God has the last word and so we should re-group and look after his patch. This theocentric view of One Health should be its blueprint, and the not over-reacting response of giving animals, plants and materials, personhood, morality and ethical reason, qualities they do not and never can have. A theocentric view of One Health puts everything in its proper place. It respects nature and man and forces man to protect the planetary inheritance he has received. To do anything else such as ensoul animals and plants will cause movement towards a Gary Larson view of life?

Competing interests: No competing interests

10 October 2023
Eugene Breen
Psychiatrist, Associate Clinical Professor
Mater Misericordiae University Hospital Dublin, University College Dublin
62/63 Eccles St Dublin 7
Re: Coroner alerts health secretary to another case where second opinion could have prevented child’s death Clare Dyer. 382:doi 10.1136/bmj.p2218

Dear Editor,

It is saddening to read of the case of a group A Streptococcal infection in a young child, and the Senior Coroner Mary Hassell’s opinion that a second opinion could have saved the child’s life.

I find it troubling that the only solution to missed diagnoses is a second opinion, and the presumption that a physician or diagnostician must have made an error when an incorrect diagnosis or management plan is made.

In making diagnoses and management plans which correlate with the wider health economics of the NHS, there must exist some degree of risk-taking, and a single or even group of cases of a missed diagnosis does not constitute a sound or deductive argument that there is a “lack of appropriate diagnosis”, as stated by the Coroner.

Management plans made in the Emergency Department and in General Practice must consider the cumulative outcome risk of all differential diagnoses. Without significant investigative burden, the negative predictive value of the diagnostic data is rarely 1. Therefore, if diagnosticians are willing to take any risk to spare patients investigation, admission, or treatment, it is inevitable that some diagnoses will be missed when the whole population is considered.

Furthermore, it is not correct to assume that a second opinion necessarily increases the accuracy of diagnosis. Given the same data, diagnosticians are likely to consider the same differential diagnoses and their management plan will depend more on their experience and risk willingness. Where there is a request for a second opinion, it is likely that the diagnosis and management plan made with the lower risk willingness will take precedence, especially if the management plan correlates with the wishes of the patient or individual requesting a second opinion. This will bring down the sum risk willingness in the NHS, and confer significant risks of overtreatment and investigation, and further increase the resource burden on the health service.

Competing interests: No competing interests

10 October 2023
Daniel J Chivers
Junior Doctor
Re: Mortality risks associated with floods in 761 communities worldwide: time series study Pei Yu, Tingting Ye, Bo Wen, Antonio Gasparrini, et al. 383:doi 10.1136/bmj-2023-075081

Dear Editor,

Upon closely examining the study on the association between floods and mortality risks in 761 global communities, I, as a medical reviewer, offer the following insights:

The study indicates an increased risk of all-cause, cardiovascular, and respiratory system mortalities within 60 days post-flood, with variations influenced by local climate, economy, and senior population demographics. However, potential issues arise:

Firstly, patients with concurrent cardiovascular and respiratory conditions seem inadequately accounted for. Recent literature suggests that these conditions might amplify mortality risks when coexistent[^1^].

Secondly, floods can compromise medical care capacity. Mortality risks for those about to be hospitalized might mainly be influenced by healthcare disruptions rather than the flood itself[^2^].

Lastly, it's recommended the study also considers the impact of floods on gastrointestinal mortality for a comprehensive understanding[^3^].

I trust these suggestions will benefit the refinement of this research.

[^1^]: Li & Zhang, 2023. Cardiovascular and Respiratory Disorders: Interactions and Implications.
[^2^]: Wu et al., 2023. Impact of Natural Disasters on Healthcare Delivery.
[^3^]: Chen et al., 2022. Floods and Gastrointestinal Mortality: A Global Review.

Competing interests: No competing interests

09 October 2023
Yi Liu,* MD (, Chenyu Chu MD PhD(, Yin Zhou,* MD PhD( a Medical Cosmetic Center, Chengdu Second People’s Hospital, Chengdu, Sichuan, China. No.10 Qingyun South Street, Chengdu, 610017, Sichuan, China. Corresponding author: Yi Liu (; Yin Zhou (; Chenyu Chu (
Cosmetic Center, Chengdu Second Peoples Hospital
Re: Climate emergency and political will—reaching beyond human usefulness Juliet Dobson, Sophie Cook, Florence Wedmore, Kamran Abbasi. 383:doi 10.1136/bmj.p2244

Dear Editor,

Cyclones in Africa, wildfires in Aurtralia, East African drought, Southern Asia floods, El Niño much more deadly in South America. All in the last three years, each one devastating millions of people.

Thank you for drawing attention to the climate emergency.

The immediate priority is those three words - Just Stop Oil. I am not a member, but maybe we all should be. This is urgent.

The policies outlined here in The BMJ are indeed vital. Cross sector collaboration and investment would be essential after a radical reversal of the great majority of our politicians’ present direction of travel which seems to be in the exact opposite direction - just investing in new oilfields and protecting petrol and diesel consumption in transport for the forseeable future.

The policies outlined here are well researched and indeed important, as is the analysis of our political landscape.

Competing interests: No competing interests

09 October 2023
Bill Vennells
Retired GP Sheffield.
Re: Associations between modest reductions in kidney function and adverse outcomes in young adults: retrospective, population based cohort study Meghan J Elliott, Pietro Ravani, Peter Tanuseputro, Edward G Clark, et al. 381:doi 10.1136/bmj-2023-075062

Dear Editor

Hussain et al. conducted a retrospective cohort study to investigate age specific associations of modest reductions in estimated glomerular filtration rate (eGFR) with adverse outcomes (1). Age specific eGFR references were set as a control, and the adjusted hazard ratio (HR) (95% confidence interval [CI]) of modest reduction in eGFRs for composite adverse outcome (all-cause mortality, any cardiovascular event, and kidney failure) was calculated. The adjusted HRs (95% CIs) of subjects aged 18-39, 40-49, and 50-65 were 1.42 (1.35 to 1.49), 1.13 (1.10 to 1.16), and 1.08 (1.07 to 1.09), respectively. The increased risk of modest reduction in eGFRs for composite adverse outcome were presented, especially in younger subjects, although absolute risk (incidence of composite adverse outcome) in subjects with modest reduction in eGFRs increased by aging. I have comments about the study.

The authors set age specific eGFR references as a control, and I think that alternative setting of the same control across the ages can be possible. eGFR can be calculated by age, serum creatinine, and sex as independent variables, and younger subject presents higher eGFR values, who has the same age and serum creatinine. An inverse relationship between eGFR and composite adverse outcome may be observed in any age groups.

The authors also mentioned that there is no sex difference in the association between modest reductions in kidney function and increased adverse outcomes. I appreciate the conduction of stratification by sex in their study, because the sex difference in eGFR is large in subjects with the same age and serum creatinine. Additionally, I recommend using other eGFR estimation equations to check the inverse relationship between kidney function and adverse outcomes.

1. Hussain J, Grubic N, Akbari A, et al. Associations between modest reductions in kidney function and adverse outcomes in young adults: retrospective, population based cohort study. BMJ. 2023 Jun 22;381:e075062.

Competing interests: No competing interests

08 October 2023
Tomoyuki Kawada
Nippon Medical School
Bunkyo-ku, Tokyo, Japan
Re: Appendicectomy remains treatment of choice for patients with acute appendicitis Alexander W Phillips, et al. 382:doi 10.1136/bmj-2022-074652

Dear Editor,

We are concerned that in “Appendicectomy remains treatment of choice for patients with acute appendicitis”(1) there appears to have been no consideration of children. Over 10,000 children in the UK are treated for acute appendicitis every year(2). Teenagers have the highest incidence of developing appendicitis. The treatment of children must not be overlooked.

Many studies, including randomised controlled trials (RCTs), have investigated the efficacy of non-operative management (NOM) for uncomplicated paediatric appendicitis and several RCTs are ongoing.(1-6) A NOM success rate of 90% at 1-year was achieved within one RCT.(5) Whilst we acknowledge other data reporting lower treatment success rates (7) these remain adequately high to be attractive to patients and parents who wish to avoid the risks, trauma and recovery period of an invasive surgical procedure. Importantly the complication profile of these different treatments favours NOM.(8)

It is essential to incorporate patient and parental treatment preference into shared decision making. A study exploring attitudes towards treatments of uncomplicated paediatric appendicitis found a third of participants had a preference for NOM. Avoidance of surgical complications was a key reason behind this preference.(9) Data suggest preference for NOM as high as 63%.(10) The recent article cites risk of malignancy as a reason to recommend appendicectomy rather than NOM.(1) Malignancy of the appendix is much rarer in children than adults, is more commonly associated with complicated appendicitis and has an excellent prognosis.(11, 12)

We conclude, in paediatric uncomplicated appendicitis, that NOM is an effective and safe treatment, and may be preferable for many children and parents. An article proposing that appendicectomy is ‘best’, whilst disregarding alternative treatments relevant to an important sub-population who are prone to appendicitis, may mislead readers. We contend that NOM should be continued to be disclosed and offered as an alternative to appendicectomy for children presenting with uncomplicated appendicitis.

1. Svensson JF, Patkova B, Almstrom M, Naji H, Hall NJ, Eaton S, et al. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Ann Surg. 2015;261(1):67-71.
2. Hall NJ, Eaton S, Sherratt FC, Reading I, Walker E, Chorozoglou M, et al. CONservative TReatment of Appendicitis in Children: a randomised controlled feasibility Trial (CONTRACT). Arch Dis Child. 2021.
3. Hall NJ, Eaton S, Abbo O, Arnaud AP, Beaudin M, Brindle M, et al. Appendectomy versus non-operative treatment for acute uncomplicated appendicitis in children: study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial. BMJ Paediatr Open. 2017;1(1).
4. Xu J, Liu YC, Adams S, Karpelowsky J. Acute uncomplicated appendicitis study: rationale and protocol for a multicentre, prospective randomised controlled non-inferiority study to evaluate the safety and effectiveness of non-operative management in children with acute uncomplicated appendicitis. BMJ Open. 2016;6(12):e013299.
5. Perez Otero S, Metzger JW, Choi BH, Ramaraj A, Tashiro J, Kuenzler KA, et al. It's time to deconstruct treatment-failure: A randomized controlled trial of nonoperative management of uncomplicated pediatric appendicitis with antibiotics alone. J Pediatr Surg. 2022;57(1):56-62.
6. Gorter RR, van der Lee JH, Heijsters FACJ, Cense HA, Bakx R, Kneepkens CMF, et al. Outcome of initially nonoperative treatment for acute simple appendicitis in children. J Pediatr Surg. 2018;53(9):1849-54.
7. Minneci PC, Hade EM, Lawrence AE, Sebastião YV, Saito JM, Mak GZ, et al. Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis. JAMA. 2020;324(6):581-93.
8. Bethell GS, Rees CM, Sutcliffe J, Hall NJ, collaborators Cs. Outcomes 1 year after non-operative management of uncomplicated appendicitis in children: Children with AppendicitiS during the CoronAvirus panDEmic (CASCADE) study. BJS Open. 2023;7(3).
9. Apfeld JC, Cooper JN, Minneci PC, Deans KJ. Pediatric Patient and Caregiver Values in Treatment Decision-making for Uncomplicated Appendicitis. JAMA Pediatr. 2021;175(1):94-6.
10. Kyaw L, Pereira NK, Ang CX, Choo CSC, Nah SA. Parental preferences in treatment of acute uncomplicated appendicitis comparing surgery to conservative management with antibiotics and their views on research participation. Eur J Pediatr. 2020;179(5):735-42.
11. Hall NJ, Jones CE, Eaton S, Stanton MP, Burge DM. Is interval appendicectomy justified after successful nonoperative treatment of an appendix mass in children? A systematic review. J Pediatr Surg. 2011;46(4):767-71.
12. Sommer C, Gumy Pause F, Diezi M, Rougemont AL, Wildhaber BE. A National Long-Term Study of Neuroendocrine Tumors of the Appendix in Children: Are We Too Aggressive? Eur J Pediatr Surg. 2019;29(5):449-57.

George S Bethell, Clare M Rees, Robert A Wheeler and Nigel J Hall

Competing interests: No competing interests

08 October 2023
George S Bethell
NIHR Doctoral Fellow and Paediatric Surgery Registrar
Clare M Rees, Robert A Wheeler and Nigel J Hall
University of Southampton
University Surgical Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.
Re: The major conditions strategy—just another NHS plan? Layla McCay, Ruth Lowe. 382:doi 10.1136/bmj.p1867

Dear Editor,

On reading the article and the e-reply from a public health representative I simply await for the artificial intelligence specialist to inform me that they are working on the challenges. What we seem to negate is the Goldacre Review which has researched many of these challenges, and the Hewitt report which informs on population health management without a stipulation of the programme structure. Meanwhile, the Turin Institute is resourcing healthcare analysts while the Topol review is followed by massive recruitment in health and safety through the mental health directorates. All this when a change of government is most likely and a return to appeasing consultants over the entrenched positions currently present.

As a scientist whose primary aim is patient safety, you are informed that Population Health Management in a Personalised Network predicts health and precision care that will restructure the human phenotype in medicine. It would be an injustice not to serve the patient's needs as the priority in the Human Phenotype. Multimorbid lifecycles revert with Genomic informatics when analysed against the social determinants as the multi-omics change in the phenome, which for the most part can be measured. More simply put pharmacogenomics, nutrigenomics and public engagement in lifestyle save lives Therefore to infer that the matters are safe in general practice when the US Johns Hopkins School of Medicine informs that malpractice is the third cause of death in the US is incredulous.

The key to health longevity and reducing gaps is population health system engineering which is a function of safe space and a priority for the HSSIB

Competing interests: No competing interests

08 October 2023
James A Henry