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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on 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: Gabapentinoids should not be used for chronic low back pain, meta-analysis concludes Jacqui Wise. 358:doi 10.1136/bmj.j3870

So Gabapentinoids, like NSAIDs offer no clinical benefit for spinal pain, a systematic review and meta-analysis reveals, level I evidence. [1][3]
Non-drug therapies should be first line treatment for chronic low back pain, according to a revised US guidance to clinicians. [2]

Competing interests: No competing interests

17 August 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
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Re: E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys Gary J Tedeschi, et al. 358:doi 10.1136/bmj.j3262

Bruce Baldwin makes a good point. It is misleading to talk of e-cigarettes as a way to stop smoking – they are merely another way of continuing nicotine addiction. E-cigarette users typically suck into their lungs vapourised nicotine together with propylene glycol, glycerine and flavourings many times a day, every day, for years on end. Whether this is safe is unknown.

In this paper it is arbitrary that quit attempts and successful quitting are defined as not smoking for at least twenty-four hours and three months, respectively. Intermittent smokers are still smokers and the concept of a ‘quit attempt’ is meaningless (1). With smoking there are only two states you can be in: either you smoke, or you don’t.

Even with the authors conflating quit attempts with successful quitting, the study showed only an increase in quit rates from 4.5% to 5.6%. That means the vast majority of the study population was still smoking.

If governments are serious about ending the smoking epidemic, they should think about closing down the cigarette factories.


Competing interests: No competing interests

17 August 2017
Gabriel Symonds
General practitioner
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Re: We read spam a lot: prospective cohort study of unsolicited and unwanted academic invitations Lynn Sadler, et al. 355:doi 10.1136/bmj.i5383

Highly <>

Greetings for another day!!!!!!

The Academic Spam Study1 investigators have not been idle. Between considering invitations to give presentations at Petrochemistry 2017 and submit manuscripts to Advances in Recycling & Waste Management, we have relentlessly been vigilant in enlightening the lamp of Spam research. We have identified Impact Spam, a novel variant of academic spam.

On June 14 2017 the 2016 journal impact factors were released. Between June 15 and August 1 2017, we received 40 emails that primarily or prominently advertised journal impact factors. 28/40 (70%) were from journals listed in Journal Citation Reports (JCR). Two were duplicates received by the same investigator, 1 a duplicate received by each of two investigators and 1 a duplicate received by each of three investigators. 12/40 (30%) emails were from journals not listed in JCR. Two were duplicates received by the same investigator, and 1 a duplicate received by each of three investigators. Thus, 31 unique emails (23 from JCR journals, 8 from non-JCR journals) were assessed.

The accuracy of impact factor measurement was impressive. Among the 27 emails that reported the metric, 23 (85%) did so to 3 decimal places, the other 4 (15%) did so to 2 decimal places. Punctuational enthusiasm for the new journal impact was modest – only 7/31 (23%) emails contained an exclamation mark, although 5 of these 7 did so in the subject line!! We were thrilled to read about new records – the impact factor of Diabetes, Obesity and Metabolism reached “an all-time high”, while that of Diabetes Care “leapt” to “the highest impact factor ever achieved by an American Diabetes Association journal”. Research Journal of Social Science and Management, from which we received 3 emails at different times, deserves special mention – its impact factor increased from 5.38 on 15 June 2017 to 6.86 on 2 July 2017, an annualised increase of 30.01.

Research on academic spam often presents challenges. Thus, we would dearly like to know the impact factors of non-JCR journals such as International Journal of Computational Engineering Research, International Journal of Pharmaceutical Research and Applications and IOSR Journal of Pharmacy, each of which is a self-proclaimed “top” or “best” impact factor journal but unfortunately forgot to include the metric in its email. We were uncertain about the visibility of publications in International Journal of Pharmaceutical Research and Applications, where “all published papers are indexed in well repute Indexing of world”. Our excitement about the stunning increase in impact factor of the World Journal of Pharmaceutical and Medical Research (from 3.535 to 4.103) was diminished when we read that it had been “positively evaluated by Scientific Journal Impact Factor Organisation, Morocco”, an organisation that unfortunately has no internet presence. We thought that Immunology and Cell Biology might have updated last year’s spam email – its subject line this year announced its 2015 impact factor.

Mindful of the modern imperative to promulgate the influence of our research, we raced to assemble manuscripts to submit to these journals which had so helpfully informed us of their impressive impact. To enhance the crafting of our personal impact statements, we determined how much the journals’ impact had burgeoned. We extracted data from JCR and calculated the change in impact factor and discipline-specific ranking of each journal between 2015 and 2016. Our enthusiasm bubbles were initially burst! The median (interquartile range) change in impact factor was 0.427 (-0.118, 0.847, n=23); for change in journal ranking it was 0 (-3.25, 3.25, n=22). Perhaps this explains why only 5/23 (22%) of the JCR-listed journals provided both the 2015 and the 2016 impact factors in their emails.

However, our enthusiasm returned when we discovered that the median (95% CI) change in impact factor between 2015 and 2016 among all 11,021 journals in JCR was 0.1 (-0.7, 1.3). This means that the impact factor trajectory of the journals which kindly sent us Impact Spam emails is 427% more positive than that of the journals which did not. Our personal impact statements can benefit after all!

Especially-eminent colleagues, Impact Spam might be more frequently served by ‘establishment’ (JCR-listed) organisations than other organisations. It might also hype minor or no changes in impact and ranking of the issuing journal. Impact Spam might become theme for major novel international conference!

1. Grey A, Bolland MJ, Dalbeth N, Gamble G, Sadler L. We read spam a lot: prospective cohort study of unsolicited and unwanted academic invitations. BMJ. 2016;355:i5383.

Competing interests: AG, MB, TC, ND and GG face imminent scrutiny of their research impact by the New Zealand Performance-Based Research Funding process, even though many spam emails attest to their awesomeness. LS wishes fervently to retain Iconic Professor status

17 August 2017
Andrew Grey
Associate Professor
Mark J Bolland, Tim Cundy, Nicola Dalbeth, Greg Gamble, Lynn Sadler
University of Auckland
Private Bag 92019, Auckland, New Zealand
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Re: Margaret McCartney: The cult of CPR Margaret McCartney. 358:doi 10.1136/bmj.j3831

The history in this piece is missing some detail. CPR was introduced in the 1960s, an emergency life saving treatment. Then doctors decided there were times when CPR should not be used such as the natural end of life, and introduced secret codes.

As patients we expect CPR to be provided if we collapse with a cardiac arrest, yet most of us have no idea how unlikely it is to work. That's because doctors decided CPR is important and special enough to be elevated to the status of not needing consent, whatever the likelihood of it working. This means we miss the description of the procedure and the 'burdens and benefits' chat. That’s a lot of vital missing information about what has often been described as a brutal process. Maybe if we knew the likelihood of CPR working when we are well, we'd understand why it will not work when we are dying.

20 years ago we did not have the Data Protection Act (just, it came in in 1998) which gives patients access to their records; we did not have information at our fingertips in the form of Google and we did not have social media to share our experiences more widely than our family and social circle. Patients were more likely to trust their doctor without question to do what was right for them, and the doctor was more likely to know more about the patient than just their clinical situation. It was a very different world to the one we live in today.

It is clear that – even more than 20 years ago – it was not acceptable to some patients that the decision to withhold CPR were recorded with secret codes. In the early 1990s the PHSO upheld a complaint about the secrecy around withholding CPR.

If at that time it had been made clear that the problem was the secrecy around the issue the 'cult' of CPR we have today would not be so. But doctors decided that a form was the way forward, giving it numerous acronyms along the way, DNAR, DNR, DNACPR, without addressing the root cause which is that whether a 'code' or a ‘form,’ it’s the communication of what that means for the patient that counts.

Add to this some doctors deciding that DNACPR means 'do not treat' it's easy to see how DNACPR has got such a terrible reputation over the years.

From a patient’s point of view, if the doctor thinks something so important it needs a name, code, documenting in their records, or form, then it is something they want to know. And these days, they often want to know everything in minute detail.

DNACPR is often that first decision that indicates that someone’s life is coming to an end. Knowing you’re dying opens chances – where to die, who you want to be with you, putting your house in order. Saying goodbye. Not knowing denies all these things and much more, and is a legacy my family live with every day since my mum died.

Maybe the detail is not important to every person, maybe that’s where the harm described by the judge comes in? It is a well advertised fact that doctors should do no harm so I’d hope it is something that can be differentiated from distress. I hate DNACPR forms, and still have nightmares about them. It was always in doctors hands to get this right, and chance after chance over the years has been missed. When secrecy reigns where openness is vital, eventually something drastic has to happen. This was always going to end up in court at some point, and I am very proud of my dad for securing the rights of patients to know about DNACPR decisions, for in the wider context I hope that this means that the conversation mum was denied will be offered to others so they get the choices she did not. And their families get the chances we did not.

I am flummoxed as to why I keep reading articles such as this that explain the barriers, but offer few ideas for solutions, especially as I have seen so much good practice in the process of attending DNACPR focus events. How about articles in the future sharing all the ideas and great practice I know is out there aimed at getting the dialogue right?

Competing interests: daughter of David Tracey who took the legal case mentioned in the article.

16 August 2017
Kate Masters
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Re: Global climate is warming rapidly, US draft report warns Michael McCarthy. 358:doi 10.1136/bmj.j3824

Dear Sir,

McCarthy reports that global climate is warming rapidly1. Warmer temperatures and increased rainfall are likely to cause important changes in the incidence and distribution of infectious diseases, including vector-borne and zoonotic diseases, water- and food-borne diseases and diseases with environmental reservoirs.

Increased temperature shortens pathogen development time in vectors. This increases the duration of infectiousness, allowing for prolonged periods of transmission to humans2. Many studies have reported associations between climate and tick-borne diseases, including tick-borne encephalitis in Sweden. In North America, there is good evidence of northward expansion of the distribution of the tick vector (Ixodes scapularis) in the period 1996–2004 based on an analysis of active and passive surveillance data3. Temperature, humidity, and rainfall are positively associated with dengue incidence. The strongly nonlinear response to temperature means that even modest warming may drive large increases in transmission of malaria, if conditions are otherwise suitable3. During the Medieval Warm Period, mention of malarialike illness was common in the European literature from Christian Russia to caliphate Spain and the English word for malaria was ague4.

In China, the modeling of medium-scenario warming indicates that the transmission zone of freshwater snail–mediated schistosomiasis will put another 20 million people at risk by 2050, as the mid-winter freezing line moves northward5.

The association between warmer temperatures and disease suggests that rates of water and food-borne illness are likely to increase with rising temperatures. Human exposure to climate-sensitive pathogens occurs by ingestion of contaminated water or food. Climate may act directly by influencing growth, survival, persistence, transmission, or virulence of pathogens. In countries with endemic cholera, there appears to be a robust relationship between temperature and the disease. Temperature is directly linked with risk of enteric disease in Arctic communities, as melt of the permafrost hastens transport of sewage (which is often captured in shallow lagoons) into groundwater, drinking water sources, or other surface waters. Increasing temperature favored growth of toxic over non-toxic strains of Microcystis in lakes in the USA3.
Ecological and meteorological changes may affect local soil ecology, hydrology and climate, resulting in the persistence of invasive fungal pathogens in the environment and release of infectious spore forms. Warmer, drier summers may have facilitated the establishment of Cryptococcus gattii in Canada. This fungus had previously been seen only in tropical and subtropical regions, but emerged on Vancouver Island in 1999, where it has caused more than 100 cases of human illness in addition to illness in domestic animals2.

Although in less developed countries, changes in infectious disease burden due to climate change will be greater than those seen in the developed world, climate change will increase the risk of infectious disease globally by expanding the ranges of species known to carry zoonotic diseases, changing pathogen dynamics in environmental reservoirs and altering pathogen transmission cycles. Climatic changes may also permit establishment of novel imported infectious diseases in regions that were previously unable to support endemic transmission2.

The best defence against increases in infectious disease burden related to climate change lies in strengthening existing public health infrastructure. Physicians, as opinion leaders, can also influence public policy related to greenhouse gas emissions.

Ricardo Pereira Igreja

1 McCarthy M. Global climate is warming rapidly, US draft report warns. BMJ 2017;358:j3824 doi: 10.1136/bmj.j3824.

2 Greer A, Victoria Ng V, Fisman D. Climate change and infectious diseases in North America: the road ahead. CMAJ 2008;178:715-22.

3 Smith KR, Woodward A, Campbell-Lendrum D, Chadee DD, Honda Y, Liu Q, Olwoch JM, Revich B, Sauerborn R. Human health: impacts, adaptation, and co-benefits. In: Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to the Fifth AssessmVRent Report of the Intergovernmental Panel on Climate Change [Field, CB, Barros, Dokken DJ, Mach KJ, Mastrandrea MD, Bilir TE, Chatterjee M, Eb KLi, Estrada YO, Genova RC, Girma B, Kissel ES, Levy AN, MacCracken S, Mastrandrea PR, White LL(eds.)]. Cambridge University Press, Cambridge, United Kingdom and New York, NY, USA, pp. 709-754, 2014.

4 Reiter P. From Shakespeare to Defoe: Malaria in England in the Little Ice Age. Emerging Infectious Diseases 2000;6:1-11.

5 McMichael AJ. Globalization, Climate Change, and Human Health. NEJM 2013; 368: 1335-43. DOI: 10.1056/NEJMra1109341

Competing interests: No competing interests

16 August 2017
Ricardo P. Igreja
Faculdade de Medicina da Universidade Federal do Rio de Janeiro
Rua von Martius 325, Rio de Janeiro, RJ, Brazil
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Re: New concepts in the management of restless legs syndrome Diego Garcia-Borreguero, Irene Cano-Pumarega. 356:doi 10.1136/bmj.j104

In our clinical practice as neurosurgeons dealing with peripheral nerve surgery, we have noticed that approximately 20-30% of patients with tarsal tunnel syndrome refer to what clinically may be considered as "restless feet syndrome". More so it is present in those patients with tarsal tunnel syndrome with a neuropathic background, such as diabetic neuropathy with overlapping entrapment neuropathies: tarsal tunnel and/or common and superficial peroneal nerve entrapment syndromes. The careful neurological examination and decompression of these tunnel syndromes, in our experience, gives a great deal of relief from the discomfort in feet and toes, especially during the night, in the short and long term.

I believe that on clinical neurological grounds, in cases of "restless leg syndrome", the clinician should search for signs of entrapment neuropathies in the lower limb and ask for electrophysiological studies. The latter do not always give useful information especially in the case of irritative stage of tarsal tunnel in particular, also due to technical difficulties. We believe that future study of this subject may yield interesting results.

Competing interests: No competing interests

16 August 2017
Ridvan Alimehmeti
Consultant Neurosurgeon
Crotti Francesco
University of Medicine, Tirana
Kongresi Manastirit, 270
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Re: Margaret McCartney: The cult of CPR Margaret McCartney. 358:doi 10.1136/bmj.j3831

I whole heartedly agree with this article. In my experience, these conversations are often mis-timed and clumsy and distressing for patients. My father, faced with such a conversation when his father died of end stage pulmonary fibrosis was startled that clinicians could not make decisions without "asking his permission" and struggled, even 30 years on, not to feel that he had, in some small way, hastened his father's demise, or perhaps even been responsible for his death.

In my practice, I endeavour to discuss end of life care with patients at annual health reviews from aged 70 - at least every couple of years. I have also had patients who feel so strongly opposed to needless end of life care go so far as to have medi-alert jewellery comissioned.

This broo-ha-ha is not necessary and the corollary between this and other "life-saving" treatments is well made. The recent interference of these judgements is also unhelpful.

Competing interests: No competing interests

16 August 2017
Elaine Tickle
39 Harley Street
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Re: Margaret McCartney: Alarm overload makes a difficult job harder Margaret McCartney. 358:doi 10.1136/bmj.j3593

I agree with the comments made in this article. The multiplicity of alerts, of varying degrees of importance from many sources, contribute to information overload and could lead to paralysis in safe decision making. Interestingly all relevant information needs to be synthesised and acted on within the confines of a 10-15 minute consultation. No other profession works under such mental duress. The GP needs to come up with the right and safest answer each time and which accords with the patient views, CCG guidance, restriction policies etc!

While one does not seek to condone sub-optimal practice there would be genuine mistakes which arise from errors of judgement. These need to be considered by those who sit in judgement of GPs when mistakes occur.

Of course it is too much to ask a free press to give a balanced view to its readers.

Competing interests: No competing interests

16 August 2017
Ken Menon
The Ongar Health Centre, Fyfield Road, Ongar, Essex CM5 0AL
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Re: Burnout among doctors Jane B Lemaire, Jean E Wallace. 358:doi 10.1136/bmj.j3360

Spurred on by an article from BMJ Careers in November 2015 on Balint groups (1), as well as recognition of our own rising stress levels, we set up a monthly discussion group open to all oncology registrars in our centre, and facilitated by a medically qualified member of the chaplaincy team (SH). This has evolved into a monthly sandwich lunch taken together with accompanying reflection on any problems arising.

Topics have been wide-ranging, reflecting on all the 3 dimensions of burnout from Lemaire and Wallace’s opening paragraphs (depersonalisation, exhaustion, and professional inefficacy) (2). The group has covered handling of high stress situations (on call, at night), decision-making under pressure, working with uncertainty and rehearsal of difficult discussions. The impact of underfilled rotas, unsupportive colleagues and the absence of ‘team’ have been aired as well as the challenges of combining research and clinical work, dealing with the pressures of raising a young family, revision for exams and coping with emotionally demanding patients. Discussions have also featured the effect of patient complaints and exploration of personal strategies for self-care.

As part of the process, we have asked participants to complete the Oldenburg Burnout Inventory (OLBI), a validated instrument for assessing burnout (3). 11 responses were returned. The median score was 42 (range 29-56, maximum possible score 64); with exhaustion component scores being generally higher than disengagement component scores. 80% of the registrars’ scores were “high to very high” for burnout, according to BMA online OLBI banding.

However, the survey feedback on the value of the debriefing group was highly positive; themes emerging from the comments were those of ‘sharing/openness/honesty’, ‘discussing difficulties/inadequacies’ and ‘support/community’. ‘Silo- demolition’ and ‘abolition of fearful autonomy’ were articulated as well as ‘team building’, ‘catharsis’ and ‘permissive disclosure in an open, non-judgemental environment’.

In contrast to the mention in Lemaire and Wallace’s article of juniors adopting their seniors’ maladaptive behaviours, this reflective peer support group has become embedded in our department, presaging redefinition of the ‘hidden curriculum’. The consultants in the oncology department are now involved in their own similar ‘Safety Net’ group, an opportunity to address the unique challenges faced at this level. The chaplaincy facilitator for our group has also encouraged other departments in the hospital to start their own groups, including paediatrics and neurology. ‘Human resources are the most important asset of any organisation’: our belief is that peer debrief groups will become more widely established across our organisation and others, and that healthcare quality indicators should include the presence of such system level interventions aimed at maintaining doctors’ wellbeing.

1. Murphy CL, Perry J, Luthra VS, Boyle A. How to encourage reflection on the doctor-patient relationship. BMJ Careers 2015. Available from: [accessed 15th August 2017]
2. Lemaire JB, Wallace JE. Burnout among doctors. BMJ 2017;358:j3360.
3. Halbesleben JRB, Demerouti E. The construct validity of an alternative measure of burnout: Investigating the English translation of the Oldenburg Burnout Inventory. Work Stress 2005;19:208–220.

Competing interests: No competing interests

16 August 2017
Sara V Lightowlers
Specialty registrar clinical oncology
Mareike K Thompson, Susannah Hunt
Addenbrooke's Hospital
Cambridge University NHS Foundation Trust
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Re: Sex robots: the irreplaceable value of humanity Federica Facchin, Giussy Barbara, Vittorio Cigoli. 358:doi 10.1136/bmj.j3790

I am pleased to say that the names of the authors of this letter "Sex robots: the irreplaceable value of humanity" are now correct as listed both online and in print:

Federica Facchin, Giussy Barbara, Vittorio Cigoli

I apologise again for the original error.

Competing interests: No competing interests

16 August 2017
Sharon Davies
letters editor
The BMJ, London WC1H 9JR
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