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All rapid responses

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: Anne Johnson: A niche in population health . 356:doi 10.1136/bmj.j1095

I read the BMJ Confidential most weeks: am so pleased to see the response "I might have done" to the question "Do you have any regrets about becoming a doctor?" Most of the medics you interview are at the top of their field (they have to be, to be of interest to the BMJ!) and usually respond with "no regrets". It is heartening and encouraging for some of us who are not so enthusiastic about medicine to read that there is a niche for almost anyone in medicine! I do believe this is true.

Competing interests: No competing interests

18 March 2017
Elizabeth So
CASH Speciality doctor
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Re: RCP survey highlights workload, morale, and patient safety concerns Abi Rimmer. 356:doi 10.1136/bmj.j1313

Having worked in busy EDs over more than three decades, I see another major factor that affects both morale and workload increasingly - it is risk aversion and fear. More and more is done to rule out less and less likely diagnoses in well-looking people, based on a single presentation to ED. ED clinicians can be crucified for "missing something" (a significant diagnosis - even if it is not time-critical) - but we are rarely held to account for the costs or harms of over-investigation or over-admission to hospital.

A huge culture change is required to return to good history taking and realistic risk-assessment, understanding that diagnosis in ED settings can never be perfect, and that trying to drive down error rates to vanishingly low levels leads to the reciprocal harms of over-diagnosis. We need to explain pathophysiology to our patients, validate their concerns, and come to a joint understanding of risk, and help patients understand that not testing does not mean not caring. Then, we need to stop the intra-professional blame that leads to clinicians taking the most risk-averse approach.

Competing interests: No competing interests

18 March 2017
Sue Ieraci
Emergency Physician
Bankstown Hospital
Sydney Australia
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Re: Government should raise taxes to fund NHS and social care, say experts Gareth Iacobucci. 356:doi 10.1136/bmj.j1381

The recent capitulation of the Government in the face of criticism from the self-employed, who were being asked to increase their social insurance contributions in line with the employed, demonstrates the difficulty with which many segments of the population have with raising income taxes.
I resent my taxes being squandered by inefficient bureaucracies. The NHS is a case in point. The NHS has been over-capitalised for decades, resulting in an organisation, if it was run as business, would have been declared bankrupt years ago.
Probably as much as 25% of spend is waste, not adding but rather subtracting from patient welfare. There is an ever-diminishing return.
Polypharmacy, the lack of adequate patient examinations, too much specialisation, the inability of the medical profession to make timely diagnoses, too much symptomatic treatment without identifying the offending causes, bureaucracy for bureaucracy's sake and complacency of the healthcare system, the public and the medical profession are all to blame for the present state of affairs.
Britain and Britons need to smarten up.
This week's edition of The Economist, notes the reluctance of governments to raise taxes. Government debt is ever rising to levels which may be unsustainable. People can no longer do without, refuse to discipline themselves, and demand more bang for their buck without paying for it. We have all become spoilt.
Not-for-profit, privatisation of the healthcare system is the only realistic outcome; sustainable, quality care at an affordable price.

Competing interests: No competing interests

18 March 2017
Timothy Jordan
Medical Doctor
Edmonton, Alberta
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Re: Recommendations to improve adverse event reporting in clinical trial publications: a joint pharmaceutical industry/journal editor perspective Michael Berkwits, Christian Klem, Ananya Bhattacharya, Leslie Citrome, et al. 355:doi 10.1136/bmj.i5078

Response to Dr. Matheson:

We thank Dr. Matheson for acknowledging the worthwhile goals of our publication and the “probity of everyone involved in the project, their careful thinking and commitment to improving journal publications,” and for stating that he has “every confidence in the integrity of the authors.” Indeed, all authors participated in developing the recommendations, vetted the examples to illustrate them, fulfilled ICMJE criteria for authorship, and submitted conflict of interest disclosures per journal requirements. Our objective was to provide a guide to more clinically relevant and informative adverse event reporting. We welcome feedback from those skilled in clinical trial design and hope that our recommendations trigger a heightened interest in reporting adverse events in a clinically meaningful manner.

Medical Publishing Insights & Practices (MPIP) was founded in 2008 by medical publication professionals in the pharmaceutical industry and members of the International Society for Medical Publication Professionals (ISMPP) to elevate trust in and the transparency and integrity of published results of industry-sponsored research. The major goal of MPIP is to encourage more effective partnerships between trial sponsors and medical journals to raise standards in medical publications and expand access to research results. For a detailed description of MPIP objectives, funding and resources, please see the MPIP website:

Competing interests: JAB, AB, TC, SG, CK, NL, and BM are employees of companies sponsoring MPIP, as shown by their individual affiliations. As well as the reported links with MPIP, BM is a shareholder at GlaxoSmithKline, and serves as chair of MPIP; SG owns stock and stock options in Johnson and Johnson Common Stock; MB reports salary support from the American Medical Association, outside the submitted work; CK held stocks in AstraZeneca; CL is employed by the American College of Physicians as editor in chief of Annals of Internal Medicine, a medical journal that publishes clinical trials; and LC has received consulting or speaking fees outside the submitted work from Acadia, Alexza, Alkermes, Allergan, AstraZeneca, Avanir, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Forum, Genentech, Janssen, Jazz, Lundbeck, Merck, Medivation, Mylan, Neurocrine, Novartis, Noven, Otsuka, Pfizer, Reckitt Benckiser, Reviva, Shire, Sunovion, Takeda, Teva, Valeant, and Vanda, and has stock ownership in Bristol-Myers Squibb, Eli Lilly, J and J, Merck, and Pfizer.

17 March 2017
Jesse A. Berlin
Vice President, Global Epidemiology
Neil Lineberry, Bernadette Mansi, Susan Glasser, Michael Berkwits, Christian Klem, Ananya Bhattacharya, Leslie Citrome, Robert Enck, John Fletcher, Daniel Haller, Tai-Tsang Chen, Christine Laine
Johnson & Johnson
1125 Trenton-Harbourton Road, PO Box 200, Mail Stop TE3-15, Titusville, NJ 08560, USA
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Re: Empowering women protects them from domestic violence . 333:doi 10.1136/bmj.333.7580.1213-b

Domestic violence costs $8,000,000,000,000 annually!

Competing interests: No competing interests

17 March 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Thessaloniki, Greece
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Re: Healthcare on the water . 356:doi 10.1136/bmj.j245

This is such a beautifully written story. Thank you so much for sharing it.

Competing interests: No competing interests

17 March 2017
Carolyn Newman
Clinical Research
WIRB Copernicus Group
212 Carnegie Center, Suite 301
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Re: Exposure to low dose computed tomography for lung cancer screening and risk of cancer: secondary analysis of trial data and risk-benefit analysis Monica Casiraghi, Giulia Veronesi, Lorenzo Spaggiari, Massimo Bellomi, et al. 356:doi 10.1136/bmj.j347

We thank Prof. Ruano-Ravina for taking the time to comment on our work.

We agree that differences between COSMOS study and NLST study are related both to different inclusion criteria (> 20 pack/year for COSMOS and >30 pack/year for NLST) and to different nodule management (threshold for positive results: nodules >5 mm for COSMOS study and >4 mm for NLST study).

As underlined in our paper, the results of cumulative radiation exposure and related cancer risk are specific to the COSMOS study: obviously, different enrollment criteria and nodule management may lead to dissimilar radiation exposure.

However, we would emphasize that radiation dose estimated by Prof. Ruano-Ravina from NSLT data (43.4mSv) has been calculated over 25 years: if we rescaled the estimated dose to 10 years of exposure, as reported in our study, we obtain a substantial lower estimation of 17.4 mSv.

We also think that additional results from other CT screening trials will be useful to weigh the potential benefits and harms of lung cancer screening.

Competing interests: No competing interests

17 March 2017
Cristiano Rampinelli
De Marco Paolo, Origgi Daniela
Milan - Italy
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Re: Rethinking brief interventions for alcohol in general practice Jim McCambridge, Richard Saitz. 356:doi 10.1136/bmj.j116

Having read the important article of Jim McCambridge and Richard Saitz [1] and following responses [2], I would like to respond to their hope for a broad discussion, including practitioners. Screening and brief intervention (SBI) for alcohol in general practice is not easily compatible with the basic nature of the consultation: to be there only for the patient, free from predetermined agendas, sometimes called the first commandment of the GP. The systematic nature of SBI for alcohol also risks displacing other potentially relevant factors as tobacco, diet, social situation, working conditions, etc.

A patient centred perspective starts with understanding the patient's motives for the visit, what are the patient's concerns and expectations for help? It is the patient who owns the time and determines the agenda. This is followed by a medical differential diagnostic phase, with a medical history and a physical examination, the doctor’s agenda. The last phase is establishing a common understanding about the cause of disease and its further management. Only in these last phases can alcohol certainly be introduced when potentially relevant to the disease or interfering with treatment.

However, it is only meaningful to introduce alcohol if it can be made relevant to the patient. Else we cannot expect a changed drinking behaviour. In a situation of hazardous or harmful use, it is not likely that the patient beforehand is aware about health implications. Making it relevant requires that the doctor not only has the understanding but also has the pedagogical skill and can produce explanations and models that can make an alcohol connection understandable and relevant to the patient. Else it might seem more like moral statements on alcohol.

It is not surprising that health professionals trained in patient centredness, but short in knowledge to make individual assessments on alcohol's health effects, are reluctant to screen or give brief advice in this stigmatized area.

1. McCambridge J, Saitz R. Rethinking brief interventions for alcohol in general practice. BMJ 2017;356:j116
2. BMJ 2017;356:j116

Competing interests: No competing interests

17 March 2017
Sven Wåhlin
Senior consultant
Riddargatan 1, 114 35 Stockholm
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Re: Units of sampling, observation, and analysis Philip Sedgwick. 351:doi 10.1136/bmj.h5396

Dr. Sedgwick writes:
The multistage sampling consisted of three stages. At the first stage a sample of postal districts in the UK was selected at random, with the probability of selection proportional to size.

We don't understand that WHO 30-cluster sampling is also probability proportional to size (PPS), although it is systematic random sampling. Systematic sampling is a type of probability sampling method in which sample members from a larger population are selected according to a random starting point and a fixed periodic interval. This interval, called the sampling interval, is calculated by dividing the population size by the desired sample size. In PPS we write the names of units along with their population size in an order (e.g. literacy levels if they were to stratified by literacy or just by your own choice). Their cumulative frequencies are written against the name of each district and then taking a random no. from zero to the no. of sampling interval and first district with that falling in the cumulative population-size will be identified; then on wards adding sampling interval to first number will identify the next district and so on and so forth.

What we want to emphasize is why not call PPS as systematic sampling with PPS instead of just calling it as PPS alone.

Competing interests: No competing interests

17 March 2017
Neeru Gupta
Scientist F
Jugal Kishore.
Indian Council of Medical Research
Ansari Nagar, New Delhi-110029.
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Re: Particulate air pollution and mortality in 38 of China’s largest cities: time series analysis Maorong Fan, Chang Liu, An Xue, Tong Liu, et al. 356:doi 10.1136/bmj.j667

Air Pollution in Children

Children face much higher health risks from air pollution than adults. Children breathe twice as quickly, taking in more air in relation to their body weight, while their brains and immune systems are still developing and vulnerable. Tiny particulate matter in polluted air can cause lung cancer, strokes and heart disease over the long term, as well as triggering symptoms such as stroke and heart attacks that kill more rapidly.

About 600,000 children younger than 5 across the world are dying every year from air pollution-related diseases. Millions more are suffer from respiratory diseases that diminish their resilience and affect their physical and cognitive development.

Counting 2 billion children breathing unhealthy air—out of a total 2.26 billion world population of children—means the vast majority are being exposed to levels of pollution considered by the world Health Organisation to be unsafe.

About a third of the 2 billion children in the world who are breathing toxic air live in northern India and neighboring countries, risking serious health effects including damage to their lungs, brains and other organs.

Out of that 2 billion breathing toxic air, about 620 million of them are in South Asia—mostly in northern India. Another 520 million children are breathing toxic air in Africa, and 450 million are in East Asia, mainly China.

The WHO categorised air pollution as the sixth biggest cause of deaths in India, triggering an alarm with studies showing breathing ailments were on the rise in Indian cities.

Competing interests: No competing interests

17 March 2017
M A Aleem
A M Hakkim
ABC Hospital
Annamalainagar, Trichy 620018, Tamilnadu.India.
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