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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. 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: Time for a rethink on appraisal and revalidation for older doctors Jonathan D Sleath. 355:doi 10.1136/bmj.i6749

I disagree with Jonathan Sleath, and, it would appear, with most responding to this. After working more than full time as a GP for many years, I came close to burn-out and retired at 60. But I certainly didn’t want to stop work entirely – I just wanted my life back. Since then I have worked part-time for a local GP co-op providing out-of-hours and walk-in centre care. I take more time off for non-medical activities in the summer, but, year-round, I now work an average of three sessions a week.

I have had colleagues say that they were not going to continue to work after retirement because of the appraisal requirements, but I think this is short-sighted. Some requirements are more difficult to meet, but recent changes have allowed for the situation of sessional doctors. Some aspects are much easier – I have far more time available now to do professional reading. I am less likely to fall asleep during an evening lecture, or struggle to find the time for a lunch-time meeting. It has never been easier to study flexibly on-line, and, provided I read critically and with some comment, I can use the hours I spend reading relevant parts of the BMJ; in fact, having the appraisal somewhere ahead reminds me that I must get reading, and once I am doing it, I find much of it very interesting. Furthermore, it became very evident to me that, although I can probably take a history and perform an examination as well as I used to, I have rapidly become less familiar with new drugs and changes in disease management. I may no longer be deciding on how best to manage someone’s diabetes, but I certainly need to know what the Canagliflozin a patient takes is, and what its interactions and side-effects may be. Reduced hours tends to narrow one's experience, but our patients still need us to be fully skilled and up to date. I have made a point of looking up any drug I do not recognise – and believe me, it only takes a couple of years before this starts to happen. I can include such looking-up in my appraisal – and I can allow for the time taken to enter it too.

Some of the mandatory training to comply with CQC requirements is certainly rather boring, but this is only a small part of what I do. So – while I deplore hoop-jumping as much as anyone, and I also recognise that appraisals cannot make me a good doctor, nevertheless, I find that my appraisal is a useful stimulus to maintain a good knowledge base, without which I cannot be a good doctor.

Competing interests: No competing interests

22 February 2017
Mary G Gibbs
Out of hours GP
Manchester
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Re: Off-label prescribing of antidepressants Daniel R Morales, Bruce Guthrie. 356:doi 10.1136/bmj.j849

Administered antidepressants increase suicide risks by 2-5 times. [1][2][3][4][5]
A recent meta-analysis, level I evidence, clearly demonstrated that SSRIs double the risk of suicide and violence in adults. [3]
References
[1] http://journals.sagepub.com/doi/pdf/10.1177/0141076816666805
[2] http://www.bmj.com/content/348/bmj.g3510
[3] http://www.bmj.com/content/352/bmj.i65
[4] http://nordic.cochrane.org/sites/nordic.cochrane.org/files/public/upload...
[5] http://www.bmj.com/content/355/bmj.i6103

Competing interests: No competing interests

22 February 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Thessaloniki, Greece
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Re: Impact of searching clinical trial registries in systematic reviews of pharmaceutical treatments: methodological systematic review and reanalysis of meta-analyses Isabelle Boutron, et al. 356:doi 10.1136/bmj.j448

We read with great interest the article "Impact of searching clinical trial registries in systematic reviews of pharmaceutical treatments: methodological systematic review and reanalysis of meta-analyses" by Baudard M. et al1. It analysed the impact of a search strategy including clinical trial registries on the results of published systematic reviews of pharmacological treatments.

The authors reported that 52% of the selected systematic reviews did not report a search of trial registries. Throughout the consultation of the World Health Organization International Trials Registry Platform (WHO ICTRP) search portal, they found 122 additional randomised clinical trials (RCT). Finally, 14 systematic reviews were reanalysed, including 45 RCTs from registries. The addition of data allowed for increasing the number of patients but none of the changes in the summary effect estimates had a qualitative impact in the interpretations of the results. However, the conclusion of the authors was: “Searching clinical trial registries is essential for identifying additional trials that could increase the value of systematic reviews”.
This conclusion seems to be in contrast with the results of the paper.

We need to consider that the aim of a systematic review is providing evidences of efficacy to support clinical decisions. The value of a systematic review should be measured in relation to the capability of detecting the appropriate clinical behaviour. In fact, the methodology of guidelines development2, as the best tool for clinical appropriateness, puts systematic reviews at the highest level in the hierarchy of evidence.

Therefore, considering that the new research strategy reported by Baudard M et al1, did not affect the qualitative results of the systematic review, it is safe to conclude that this research method did not add value to the clinical results and had no implications for clinical practice.

In our opinion, an exhaustive literature search in systematic reviews could be acceptable if it has an impact on clinical outcomes. Sagliocca L. et al3 compared the traditional systematic reviews research method with a more pragmatic approach based on the review of a selected number of core journals. The authors demonstrated, in a sample of systematic reviews, that reproduction of the literature search restricted to major medical journals in the fields, as well as to the most relevant generalist journals, does not alter the quantitative estimates of efficacy, nor the clinical indications.

Finally, we strongly believe that systematic reviews and guidelines are the most valid instrument in supporting clinical decisions and should be conducted according to an accurate and reliable method. The comprehensiveness of a literature search is the main factor influencing the accuracy but should be assessed considering the implications for clinical practice.

1. Baudard M, Yavchitz A, Ravaud P, et al. Impact of searching clinical trial registries in systematic reviews of pharmaceutical treatments: methodological systematic review and reanalysis of meta-analyses. BMJ 2017;356:j448
2. Developing NICE guidelines: the manual. October 2014
3. Sagliocca L, De Masi S, Ferrigno L, et al. A pragmatic strategy for the review of clinical evidence. J Eval Clin Pract. 2013 Aug;19(4):689-96

Competing interests: No competing interests

22 February 2017
Alessandra Pugi
Pharmacist, Clinical Trial Office
Salvatore De Masi
Meyer Children's Hospital
Viale Pieraccini 24
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Re: Margaret McCartney: General practice is a long game Margaret McCartney. 356:doi 10.1136/bmj.j736

Margaret McCartney, in her article "General Practice is a long game", expressed very clearly the main satisfaction that a doctor can have from being a general practitioner. Having retired from general practice more than 20 years ago, I find that relationships formed with patients and their families still continue and are still a joy. To be reasonably content in general practice it is essential generally to like people.

Competing interests: No competing interests

22 February 2017
J D S Kerr
retired general practitioner
Sittingbourne
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Re: Robert Desmond Abernethy Michael Hawkins. 355:doi 10.1136/bmj.i6707

I would like to thank Mike Hawkins for writing the obituaries of Desmond and Lizzie, and I am glad they appeared side by side - 'Desmond and Lizzie' to the end. How do you sum up the essence of a person in a few short paragraphs? Mike had a particularly hard task as Desmond and Lizzie were truly exceptional. They had an incredible joie be vivre, making every moment worth living. Working with them was fun. The standard was high, with the patient's needs firmly set as the priority. If I had let a patient down, I would have known about it. Desmond was not afraid to take on colleagues, in General Practice or in hospital, if he thought they were wrong. I well remember him striding down the ward declaring loudly, 'This is hopeless!'. He was a leader, acting on his own beliefs and never sheltering below the parapet. Lizzie, too, led the way for women in North Devon when HRT became available, becoming an acknowledged expert locally. Both were shrewd, intolerant of any dishonesty or falseness.

Desmond was charming, a twinkle in his eye; Lizzie was glamorous, totally unsentimental but always kind and prepared to go the extra mile. She was a terrific role model for anyone wanting to be a GP, a wife, a mother; running a beautiful home, reading the Booker prize list every year, playing the violin and going out of her way to help the Vietnamese boat people who arrived in Barnstaple. Both were generous with their time, their home and their gifts.

The surgery showed their individuality, being an old fashioned building which they kept in perfect style, even down to the porcelain knobs on the cupboard doors and the lovely fresh flowers on the staircase. There were no computers then and Desmond would have thought them an abomination, coming between the doctor and the patient, distracting from true listening.

Working in the surgery was always busy, always stimulating, always satisfying. Desmond believed in home visits and we spent quite a lot of time battling through the traffic - the middle of Barnstaple was always gridlocked - but Desmond would zoom down a buses-only road, waving his stethoscope at any policemen. We always met for coffee before going out on visits, sitting signing repeat scripts together whilst the talk ranged from literature to sport (Desmond's great love) to art to rhodedendrons - as well as all the medical chat. It was a shared list, and we all knew most of the patients. At the end of the day, we would go up to the attic for more script signing and time to talk. You didn't ever need to go home with things on your mind.

I hope they are not sounding like any other GP couple, because they were certainly not like any others I have known. When I first started in Barnstaple hospital as a houseman, I quickly discovered that the trainer everyone wanted to have was Desmond. He had the gift of seeing how to help each individual trainee, to bring the best out of them, and no trainee leaving his hands would be inadequate: each would have the highest standards and would put the patient first. Desmond left a huge legacy in the doctors he trained, who are now scattered over the country and keeping the standard of General Practice high. Each of us owes him a tremendous debt for enabling us to have the satisfaction that comes from good General Practice.

Whilst Desmond suffered from the gradual encroachment of dementia, he never lost his Christian faith or his wonderful charm. Lizzie, having to cope with a rapid physical deterioration due to cerebellar degeneration, was characteristically unself-pitying, her main concern being to remain alive whilst Desmond needed care. Her intellect remained razor sharp and her beauty unimpaired.

So much more could be said, and so much added by their children and grandchildren. Their influence far exceeds their apparently quiet life as two GPs in a small town. I would like to have seen them recognised by a full page joint obituary in the BMJ; I don't recall ever seeing GPs on the full page, but perhaps this will show how worthy Desmond and Lizzie are of being honoured in that way.

Competing interests: Desmond Abernethy was my trainer and then I was in partnership with himself and Lizzie before their retirement.

22 February 2017
Jacq Hawkins
GP
Central Lakes Medical Practice
Ambleside
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Re: Off-label prescribing of antidepressants Daniel R Morales, Bruce Guthrie. 356:doi 10.1136/bmj.j849

Prescription of antidepressants - and the inexorable rise of this - is a major issue of concern.

It has become apparent that many patients experience very significant associated issues with side-effects, adverse effects, dependence and withdrawal problems , whether antidepressants prescribed on- or off-label, and these harms have not been adequately acknowledged or recognised.

The BMA Board of Science has highlighted this issue:
https://www.bma.org.uk/collective-voice/policy-and-research/public-and-p...

I would like to draw particular attention to the work of Fava and Carvalho et al:
http://www.karger.com/Article/FullText/370338
http://www.karger.com/Article/FullText/447034

(I have detailed my own observations in my writing and further references – all accessible at and via http://www.bmj.com/content/356/bmj.j268/rr-1 )

Competing interests: No competing interests

22 February 2017
Marion Brown
Psychotherapist and Mediator (Independent)
Garelochhead
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Re: Measles in older children and adults Beatrice Clare Cockbain, Tehmina Bharucha, Dianne Irish, Michael Jacobs. 356:doi 10.1136/bmj.j426

This is a response primarily to Sir Iain Chalmers.

1.You mention Dr Andrew Wakefield and recent publicity by him and some prominent personalities.
I have not seen his name mentioned in British media for a long time. I thought he moved to USA.
If the vaccination coverage is less than what is needed for herd immunity, the reasons must lie elsewhere.

2. I warmly endorse your idea of PROPHYLACTIC antibiotic use in measles. It makes sense.

3. The article advocates reliance, as evidence of immunity in caring staff, on proven history of adequate vaccination. I would rely ONLY on serological evidence.

Competing interests: No competing interests

22 February 2017
JK Anand
Retired doctor
Free spirit
Peterborough
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Re: Manufacturer failed to disclose faulty device in rivaroxaban trial Deborah Cohen. 354:doi 10.1136/bmj.i5131

There has been lot of hue and cry over the recent question raised about the ROCKET AF[1] trial for rivaroxaban which was the only trial used by the company for drug approval from USFDA. This is indeed a very important concern as it directly impacts the well-being of the patients who are at the receiving end of this very highly prescribed anticoagulant drug in 2014.[2] The main concern with this whole confusion surrounding the ROCKET AF trial is that the device used for measuring the INR in trial arm of warfarin patient was faulty and gave lower INR values than it should have, leading to over dosing of warfarin and thereby increasing bleeding problems with the same, compared to the trial arm of rivaroxaban. However, there has been a reanalysis done by the ROCKET AF researchers, which again reinforced the prior result database of the trial and which was accepted by FDA as well[3]. In the reanalysis, the US FDA clearly mentioned that the effect of the faulty device results in causing bleeding episodes, both minor and major, was minimal.[4]

However, following this reanalysis, not everyone who raised the question in the first place was convinced and there was a demand that the data of the complete ROCKET AF trial should be made public for everyone to assess and understand the risks. But since the trial was done and results released before the principles on responsible clinical trial data sharing came into effect, the parent pharmaceutical company for rivaroxaban refused to share the patient level details, citing concerns on privacy and transparency policy [5].

In spite of everything said and written for and against this issue, a simple question arises, regarding the amount of belief, honesty and hard work that goes without questioning when you bring a new chemical entity to the research stage, get it approved and then bring it to market. For this to happen, there have to be maintained a very fine balance between pharmaceutical companies, drug regulatory authorities and marketing people. In this case, after initial suspicions, the drug regulatory authorities have cleared and supported the approval of rivaroxaban after reanalysis and that should have a say, in case we want to continue trust with this process of drug entry into the market.

Rivaroxaban has shown its efficacy and safety both in patients who required adequate anticoagulation e.g. those who had atrial fibrillation and underwent cardioversion. There are few other trials where rivaroxaban has performed better or equally good than warfarin in terms of both efficacy and safety [6]. These results lead us to believe that all was not wrong with the ROCKET AF trial results. All these, combined with personal experiences of those physicians who had been using the drug rivaroxaban for the last couple of years with a hugely favorable result clearly imply that the drug rivaroxaban is holding its side strongly in the midst of all the controversies surrounding its approval and efficacy and it is here to stay. Adding a last word to all this discussion is that rivaroxaban will always hold an upper hand compared to warfarin when prescribed because of its very favorable and easy to use once daily dosing. We cannot discard all the positive reports and positive experiences associated with this drug, based on real time data, only because of the question raised by some, and considering the fact that the question had been satisficatorily answered with a re analysis with no change in the result.

References
1. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365:883-891. Article
2. Top 50 pharmaceutical products by global sales. PMLiVE, Available here.
3. FDA analyses conclude that Xarelto clinical trial results were not affected by faulty monitoring device. https://www.fda.gov/Drugs/DrugSafety/ucm524678.htm
4. ROCKET AF Reanalysis Reviews.http://www.accessdata.fda.gov/drugsatfda_docs/nda/2011/202439Orig1s000Ro...
5. Joint EFPIA-PhRMA Principles for Responsible Clinical Trial Data Sharing Become Effective.http://www.efpia.eu/mediaroom/132/43/Joint-EFPIA-PhRMA-Principles-for-Re...
6. Cappato R, Ezekowitz MD, Klein AL, et al. Rivaroxaban vs vitamin K antagonists for cardioversion in atrial fibrillation. Eur Heart J 2014; 35:3346-3355.

Competing interests: No competing interests

22 February 2017
Sangeeta Bhanwra*
*Associate Professor
Kaza Ahluwalia
*Department of Pharmacology, Government College & Hospital, Chandigarh
Sector 32, Chandigarh
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Re: Royal college welcomes government’s commitment to EU workers Abi Rimmer. 356:doi 10.1136/bmj.j921

Despite acute shortages of medical doctors at home [1] and abroad [2], British politicians engaged in isolationist inflexible chauvinistic Brexit rhetoric, threatening European doctors' work permits, and NHS managers are already panicking to keep old doctors in their posts or frenetically train nurses as "physician associates" to replace missing medical personnel.
Securing the status of EU nationals now working in the UK will not suffice, since thousands more will be needed to cover additional vacancies.
Threatening EU with hard Brexit would not deliver any healthcare consequences abroad, but would inflict catastrophic outcomes in the UK NHS.
References
[1] Acute shortages of medical doctors in the UK
http://www.bmj.com/content/351/bmj.h3993
http://www.bmj.com/content/352/bmj.i1511
http://www.bmj.com/content/355/bmj.i5952
http://www.bmj.com/content/355/bmj.i6535
[2] Shortages of medical doctors in many other foreign Countries
http://www.bmj.com/content/354/bmj.i5169
http://www.bmj.com/content/354/bmj.i4860
http://www.bmj.com/content/350/bmj.h1296

Competing interests: No competing interests

21 February 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Thessaloniki, Greece
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Re: Low back pain and sciatica: summary of NICE guidance Ian A Bernstein, Qudsia Malik, Serena Carville, Stephen Ward. 356:doi 10.1136/bmj.i6748

It is wonderful to see all the acupuncturists in these rapid response who say that acupuncture works. They would become unemployed if they didn't say that, and there cane be no greater incentive to promote acupuncture.

The fact of the matter is that there are no very effective treatments for non-specific low back pain. Drugs don't work and neither does acupuncture. The revised guidance comes as close as one can expect from an official body to admitting the ghastly truth: nothing works well, And the guidance admits that - nothing is recommended apart from general advice to keep moving as much as you can. (even that isn't really shown to work, but it sounds sensible)

It is quite astonishing that, in the 21st century, we should still be discussing acupuncture -something that was revived by Mao Zedong for political reasons, and is now just big business. It has been shown repeatedly that any effects it may have are too small to have any clinical significance. Yet people like Mel Hopper Koppelman go on promoting their business regardless. All I can do is to advise these people to acquaint themselves with ideas of regression to the mean, and the idea of false positive rates in statistical testing. It is failure to understand these ideas that allows quaint medical myths like acupuncture to survive.

References

The acupuncture myth. http://www.dcscience.net/2013/05/30/acupuncture-is-a-theatrical-placebo-...
Regression to the mean. http://www.dcscience.net/2015/12/11/placebo-effects-are-weak-regression-...

False positive rates. http://rsos.royalsocietypublishing.org/content/1/3/140216

Competing interests: No competing interests

21 February 2017
David Colquhoun
Research professor
UCL
WC1E 6BT
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