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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: David Oliver: Towards a GP consensus on the future of UK general practice David Oliver. 357:doi 10.1136/bmj.j2949

Interesting article and responses that return to two basic facts: there is underfunding of general practice and there is no consensus.

GP principals are becoming an endangered species, because who wants to take responsibility for a sinking ship? There are two hats for a GP partner, on the one hand to deal with the individual patient's clinical needs, and on the other to monitor, audit and improve the care services provided for the community (or at least for their registered list of patients). Current demands and lack of support means simply dealing with the former is taking more time than available. We are working in what could be considered "normal-illegal" (cutting corners by reading letters and results faster than probably we should; squeezing more patients into clinics, so far from the suggested 15 minutes' time current complex patients need, according to the RCGP; and having patients wait for weeks to see a GP for issues like a concern about a symptom that could mean cancer, so a 2 week referral could become a 6 week referral in the making, to name but a few serious examples).

The importance at present is not about consensus, it is not about what model to be applied, because we must accept that one path does not fit all. At present, what is important is that a career as a GP partner is challenging but not a risk, is enjoyable and not a constant worry, allows time to process the amount of information we deal with having appropriate time rather than working regularly at 100% capacity, having time to read and question previous decisions rather than doing the minimum requirements for appraisal, etc.

Every year more GPs are promised by politicians who aim to protect the NHS, but there is no delivery of them. GP practices are closing down around the country and more patients are put at risk because of it.
Before any consensus we need funding so general practice does not disappear. Then there will be time to discuss how we improve services on a bigger scale, sharing approaches among the different models available in general practice, adapting to the different communities and demands.

Competing interests: I am a GP partner.

23 June 2017
Pablo Millares Martin
GP
Whitehall Surgery, Leeds
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Re: Specific antidotes for bleeding associated with direct oral anticoagulants Allison Burnett, Deborah Siegal, Mark Crowther. 357:doi 10.1136/bmj.j2216

Dear Editor,
We appreciate the contribution by Burnett et al on specific antidotes for direct oral anticoagulants.1 Their reference to the phase III, industry-sponsored, Reversal Effects of Idarucizumab on Active Dabigatran (RE-VERSE AD) study regarding the time to establishment of hemostasis and idarucizumab as an antidote for hemorrhage following therapeutic dabigatran dosing merits further discussion.

The effectiveness of idarucizumab 5 grams to neutralize the body dabigatran burden and correct clotting times following therapeutic dabigatran dosing was demonstrated in the first 90 patients enrolled in the RE-VERSE AD study.2 However, the rapid neutralization of dabigatran activity and normalization of coagulation assays do not appear to rapidly establish hemostasis as the median time to bleeding cessation was 11.4 hours following idarucizumab administration. This dissociation between normalization of coagulation parameters and establishment of effective hemostasis is unsettling. In an update that included information on 494 patients enrolled in the RE-VERSE AD study,3 there were 298 patients with “uncontrolled bleeding” of which 201 patients had extracranial hemorrhage and 97 patients had intracranial hemorrhage. The median time to effective hemostasis in the 158 (78.6%) patients with extracranial hemorrhage was 3.5 to 4.5 hours; 43 (21.4%) patients were not evaluable. This update did not inform on the median time to effective hemostasis in patients with intracranial hemorrhage, which comprised 32.6% of patients with “uncontrolled bleeding.” If we were to impute the time to hemostasis is the same for patients with extracranial and intracranial hemorrhage, the revised median time to hemostasis of 3.5 to 4.5 hours, albeit less than 11.4 hours, by excluding patients with intracranial hemorrhage, remains a significant dissociation between normalization of coagulation parameters following idarucizumab administration and establishment of hemostasis.

Is it clinically reasonable to administer only idarucizumab to a patient who is hemorrhaging while on therapeutic dabigatran dosing? We believe most clinicians would be apprehensive with the sole treatment being idarucizumab and hope their patient does not succumb while waiting for hemostasis to be established. Perhaps, a more reasonable approach would be to administer blood component therapy (e.g., pack red blood cells, four-factor prothrombin complex concentrate, and activated prothrombin complex concentrate), as clinically indicated, in addition to idarucizumab. The rationale is neutralization of body dabigatran burden precedes clinical hemostasis by a median of 11.4 hours; 3.5 to 4.5 hours if excluding patients with intracranial hemorrhage. Blood component therapy is a reasonable bridge between normalization of coagulation parameters and establishment of hemostasis based on in vitro and preclinical data.4 In the RE-VERSE AD study, blood products (e.g., packed red cells, fresh frozen plasma, cryoprecipitate, aPCC, platelets, tranexamic acid, and whole blood), in addition to idarucizumab, were administered to 55.6% of patients.2 The reported overall mortality was 20.0%; 27.8% being fatal hemorrhagic events. The causes of death included hemorrhagic shock and acute or progressive intracranial hemorrhage. However, the reasons for hemorrhagic shock and acute or progressive intracranial hemorrhage following administration of idarucizumab and blood products are not reported. It is possible that variables such as inadequate blood products administration and delayed in blood products administration were contributory to these deaths. It can be reasonably argued that in selected patients the establishment of effective hemostasis with blood component and idarucizumab therapy outweigh its potential risk of thrombotic adverse events in patients who are hemorrhaging.

While idarucizumab is effective in neutralizing dabigatran activity, it is not an “antidote” for hemorrhage associated with therapeutic dabigatran dosing given the dissociation between normalization of coagulation parameters and establishment of effective hemostasis. Thus, it is reasonable to administer blood component therapy to bridge the time between normalization of coagulation parameters and establishment of hemostasis.

References
1. Burnett A, Siegal D, Crowther M: Specific antidotes for bleeding associated with direct oral anticoagulants. BMJ 2017 May 25;357:j2216. doi: 10.1136/bmj.j2216.

2. Pollack CV Jr, Reilly PA, Eikelboom J, et al: Idarucizumab for dabigatran reversal. N Engl J Med 2015;373:511-220.

3. Pollack CV Jr: Idarucizumab for dabigatran reversal: Updated results of the REVERSE-AD study. In: Scientific Sessions. New Orleans, Louisiana, USA; 2016.

4. Siegal DM: Managing target-specific oral anticoagulant associated bleeding including an update on pharmacological reversal agents. J Thromb Thrombolysis 2015;39:395-402.

Authors:
Luke Yip, MD*
Denver Health
Rocky Mountain Poison and Drug Center
Department of Medicine, Section of Medical Toxicology
777 Bannock Street, MC 0180
Denver, CO 80204-4507

Jou-Fang Deng, MD
Veterans General Hospital-Taipei, Medicine
201, Shih-pai Road, section 2
Taipei, Taiwan 11217

*Corresponding author: Email: luke.yip@rmpdc.org

Competing interests: No competing interests

23 June 2017
Luke Yip
Medical Toxicologist and Emergency Physician
Joug-Fang Deng, MD
Denver Health, Rocky Mountain Poison and Drug Center, Department of Medicine, Section of Medical Toxicology
777 Bannock Street, MC 0180, Denver, CO 80204-4507, USA
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Re: Evidence based medicine manifesto for better healthcare Helen Macdonald, Duncan Jarvies, et al. 357:doi 10.1136/bmj.j2973

Poor evidence leads to poor clinical decisions, overdiagnosis, and overtreatment [1]. The tool against scientific misconduct is commenting on supposedly forged or biased works, conflicts of interest or ideological biases. Names of researchers who commit fraud may be disclosed [2]. Unfortunately, published criticism may be ignored in spite of personal communications and debates at conferences… [3]

1. Heneghan C, Mahtani KR, Goldacre B, Godlee F, Macdonald H, Jarvies D. Evidence based medicine manifesto for better healthcare. BMJ. 2017;357:j2973.
2. Eggertson L. Names of researchers who commit fraud may be disclosed. CMAJ 2015;187(15):1120-1.
3. Jargin SV. A Scientific misconduct and related topics: a letter from Russia. Am J Exp Clin Res 2017;4(1):197-201: https://www.researchgate.net/publication/317036805_Scientific_misconduct...

Competing interests: No competing interests

23 June 2017
Sergei Jargin
medical reviewer
Clementovski per 6-82
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Re: Smoking ban in psychiatric hospital led to drop in violent assaults Anne Gulland. 357:doi 10.1136/bmj.j2952

Tobacco is an addictive depressant that tricks and traps us by creating the fleeting euphoria of relaxation and aeration, but the sustained sickness of desperation and suffocation. The euphoria of relaxation and aeration, and the sickness of desperation and suffocation, are polar opposites that reinforce each other: the euphoria blinds us to the sickness, and the sickness makes us crave the euphoria. Perversely but predictably, tobacco creates, aggravates, and perpetuates the very sickness of desperation and suffocation that it falsely seems to cure, thus placing all tobacco products in a very bad light.


Competing interests: No competing interests

22 June 2017
Hugh Mann
Physician
Retired
New York, NY, USA
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Re: Impact of total knee replacement practice: cost effectiveness analysis of data from the Osteoarthritis Initiative Sita M A Bierma-Zeinstra, Madhu Mazumdar, et al. 356:doi 10.1136/bmj.j1131

Letter to the Editor

Dear Editor,

Re: Impact of total knee replacement practice: cost effectiveness analysis of data from the Osteoarthritis Initiative

All patients with painful osteoarthritis, mild or severe need to be given the appropriate treatment to reduce pain, improve function and thus improve quality of life. Though deemed by the authors to be economically unjustifiable when done on patients with mild disease, it is unethical to withhold available treatment from a patient that is known to improve his/her health and well-being. From an evidence based point of view, this study is useful. There will be patients with mild OA of the knee for whom the cost of surgery is prohibitive and for whom some significant financial readjustment/planning is necessary to allow them to afford the surgery (as seen in patients in countries with developing economies). Having the understanding that the outcome of improved quality of life is not as great for patients with mild disease, surgery could be delayed, to allow time for the financial and other arrangements.

I agree with the authors that further research is needed possibly using patients outside of the United States of America and more conservative interventions such as physiotherapy.

Reference
1. Ferket et al. Impact of total knee replacement practice: cost effectiveness analysis of data from the Osteoarthritis Initiative BMJ 2017;356:j1131

Competing interests: No competing interests

22 June 2017
Sonja Williams
Physiotherapist
University of the West Indies, Mona Camous
Mona, Kingston 7, Jamaica, West Indies
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Re: US government website for collecting adverse events after vaccination is inaccessible to most users Peter Doshi. 357:doi 10.1136/bmj.j2449

There were half a dozen responses (including mine).

All of us expressed disquiet.

Neither the manufacturers nor the government agencies with interest or responsibilities in the subject wrote to allay the disquiet.

Competing interests: No competing interests

22 June 2017
JK Anand
Retired doctor
Free spirit
Peterborough
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Re: Evidence based medicine manifesto for better healthcare Helen Macdonald, Duncan Jarvies, et al. 357:doi 10.1136/bmj.j2973

I thank the authors for their thoughtful approach and invitation to join forces in moving forward an “Evidence based medicine manifesto for better healthcare”

Two years after the passing away of our colleague, Dr David Sackett (https://en.wikipedia.org/wiki/David_Sackett) , I welcome their call for expanding the role of patients, health professionals, and policy makers in research and more importantly for expanding their role in the development, dissemination, and implementation of better evidence for better healthcare. This would be greatly supported and fostered by adding a new priority (10th) that would read as: Ensure that patients, health professionals and policy makers have accessed to patients decision aids. The recently updated Cochrane review of patients decision aids found 105 studies involving 31,043 participants. People exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation (http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001431.pub5/abstra...). Therefore, in addition to improved and more usable clinical practice guidelines, this manifesto should include a priority focusing on patients decision aids as they are well defined evidence based knowledge tools that can contribute greatly to better evidence based practices for better healthcare.

Competing interests: No competing interests

22 June 2017
France Légaré
Family physician and clinical scientist
Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval
Cité universitaire, Quebec City, Quebec, Canada
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Re: Margaret McCartney: Remember that doctors are more trusted than journalists Margaret McCartney. 357:doi 10.1136/bmj.j2608

Despite a circulation of approximately 1.5 million, and hence an ability to influence patient perceptions greatly, in our experience the Daily Mail is not widely read by doctors. Many in the profession may be blissfully unaware of such sensationalist articles and might therefore leave false, misleading or potentially damaging statements unchallenged and free to circulate. Our silence could well be misconstrued as tacit acceptance that the stated claims are true and the position indefensible. The BMJ undoubtedly monitors the press for this kind of article: perhaps a weekly roundup of such 'fake news' would alert readers to this type of threat and better allow them to resist and counter it.

Competing interests: No competing interests

22 June 2017
Maxime Gibbons
CT2 anaesthetist
Mark W Davies, consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust
Liverpool L7 8XP
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Re: London mayor, Sadiq Khan: how cities can act on air pollution . 357:doi 10.1136/bmj.j2842

Sir,

We acknowledge and welcome the Mayor of London, Sadiq Khan’s leadership on air pollution in London. We support all the initiatives he has launched and his future plans to tackle this major threat to public health e.g. the proposed ultra-low emissions zone (ULEZ), cleaner, greener buses etc.[1]

However, as Mr Khan knows, some of his international counterparts have gone much further and will ban all (or most) diesel vehicles from Athens, Madrid, Mexico City and Paris by 2025[2,3].

As the Mayor of London states, air pollution “is responsible for the premature deaths of more than 9,000 people in London every year”.

We urge the Mayor to emulate the bold leadership of the mayors of Paris, Mexico City, Madrid & Athens by introducing a ban on all diesel vehicles in London within the next decade. The London ULEZ is a commendable first step in the right direction. However, it should be seen as part of the journey and not the final destination.

Air pollution poses a serious and immediate threat to health. In our opinion, a ban on diesel vehicles in London will be a logical and highly effective countermeasure to this threat.

References:

[1] Sadiq Khan: how cities can act on air pollution. Godlee F. BMJ 2017;357:2842 https://doi.org/10.1136/bmj.j2842

[2] Four of the world’s biggest cities to ban diesel cars from their centres. Harvey F. The Guardian website 2nd December 2016 https://www.theguardian.com/environment/2016/dec/02/four-of-worlds-bigge...

[3] Four major cities move to ban diesel vehicles by 2025. McGrath M. BBC News website 2nd December 2016 http://www.bbc.co.uk/news/science-environment-38170794

Competing interests: We are writing in our personal capacities. Any opinions expressed are our own and not those of our employers.

22 June 2017
Gee Yen Shin
Consultant Virologist
Dr Rohini J Manuel
Public Health England
Public Health Laboratory London, 3/F Skipton House, 80 London Road, London SE1 6LH
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Re: CBT can benefit patients with severe depression, say researchers Jacqui Wise. 356:doi 10.1136/bmj.j336

Suicides and self-harm traumatisms are the sixth leading cause of death, but GPs could not reduce them [1], probably because recent evidence reveals that administered antidepressants actually increase suicide risks by 2-5 times. [2][3][4][5][6]
A recent meta-analysis, level I evidence, clearly demonstrated that SSRIs double the risk of suicide and violence in adults. [4]
All pharmaceutical Companies must be obbliged to incude this warning in every antidepressant preparation sold.
Another meta-analysis published in the British Journal of Psychiatry has found that even patients with the most severe depression can expect to get as much benefit from cognitive behavioural therapy (CBT) as those with less severe symptoms. [7]
Even Behavioural Activation effectively decreases depressive symptoms. [8]
References
[1] http://www.bmj.com/content/355/bmj.i6761
[2] http://journals.sagepub.com/doi/pdf/10.1177/0141076816666805
[3] http://www.bmj.com/content/348/bmj.g3510
[4] http://www.bmj.com/content/352/bmj.i65
[5] http://nordic.cochrane.org/sites/nordic.cochrane.org/files/public/upload...
[6] http://www.bmj.com/content/355/bmj.i6103
[7] http://bjp.rcpsych.org/content/210/3/190.long
[8] http://www.bmj.com/content/356/bmj.j914

Competing interests: No competing interests

22 June 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
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