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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: Smoking prevalence falls among adults in England Susan Mayor. 357:doi 10.1136/bmj.j2953

Mayor commented in the research news section the decrease in the proportion of people in England aged over 18 who smoke: from 19.9% in 2010 to 15.5% in 2016.(1) This is neither research nor news: smoking prevalence has been continuously declining over 5 decades, by two-thirds (http://www.pnlee.co.uk/Downloads/ISS/ISS-UnitedKingdom_120111.pdf).

Mayor should have reported the French case. Smoking prevalence (15-85 y) increased from 31,6% in 2010 (27,3% daily) to 34,5% (28,7% daily) in 2016 (http://inpes.santepubliquefrance.fr/Barometres/index.asp). Indeed, it is news as the French Monitoring Centre for Drugs and Drug Addiction did not publish data about smoking prevalence in its 10 page report issued in 2017.(2)

Moreover, it is research and, although pragmatic, it is long term. Raffarin, President Chirac’s Prime Minister, announced a moratorium on tobacco taxes in 2004, fully implemented by successive governments.(3) However, I must confess there are confounding factors: a) as French tobacco experts rely on e-cigarettes for smoking cessation, flying in the face of common sense;(4,5) b) health minister Xavier Bertrand banned varenicline from the reimbursement by the mandatory healthcare scheme, without consulting the appropriate regulatory agency.(6)

The Journal despite its name has an international audience (120,000 doctors in the UK but many more overseas), accordingly selective reporting about England’s achievements is unfair. England has not achieved yet the lowest smoking prevalence among rich countries, although its efforts must be commended. In contrast, France has succeeded in being the chimney of rich countries.

1 Mayor S. Smoking prevalence falls among adults in England. BMJ 2017;357:j2953

2 Lermenier-Jeannet A, OFDT. Tabagisme et arrêt du tabac en 2016. Fev 2017. OFDT. Available at http://www.ofdt.fr/ofdt/fr/tt_16bil.pdf.

3 Braillon A, Mereau AS, Dubois G. [Tobacco control in France: effects of public policy on mortality]. Presse Med. 2012 Jul;41:679-81.

4 Braillon A. [e-cigarette: who cannot see the wood for the tree? Letter on the article "Electronic cigarette: reliable and efficient?"]. Presse Med. 2015;44:124-5.

5 Braillon A. Electronic cigarettes: from history to evidence-based medicine. Am J Prev Med. 2014;47:e13.

6 Braillon A. When will French smokers be concerned by varenicline's benefit-to-risk ratio? Lancet Respir Med 2016;4:e13.

Competing interests: No competing interests

20 June 2017
alain braillon
senior consultant
University Hospital. 80000 Amiens. France
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Re: How new fact boxes are explaining medical risk to millions Gerd Gigerenzer, Kai Kolpatzik. 357:doi 10.1136/bmj.j2460

Response to Workman’s response to Gigerenzer & Kolpatzik, How new fact boxes are explaining medical risk to millions. BMJ 2017,357:j2460

Why do doctors screen for ovarian cancer and harm women?

Gerd Gigerenzer and Kai Kolpatzik

There is no evidence that ovarian cancer screening with transvaginal ultrasonography (TVU) and cancer antigen (CA-125) testing saves lives, but instead evidence that it produces large numbers of false alarms. These lead to severe harms for women whose healthy ovaries are removed.(1) Given the evidence, the FDA recommends against ovarian cancer screening, as does the USPSTK. Physicians and patients can more easily understand this and other risks when these are presented in a fact box.(2) Nevertheless, 28% of US physicians reported non-adherence to this recommendation and screen women at no risk for ovarian cancer, while 65% reported screening women at medium risk.(3) In Germany, it is estimated that over 10,000 women had their healthy ovaries removed in 2014 as a consequence of this harmful screening practice.(1) Why do doctors continue to screen for ovarian cancer?

The answer can be found in what is known as the SIC Syndrome, which plagues much of current health care.(4)

The “S” in SIC stands for self-defence, that is, physicians practice defensive medicine, defined as deviation from sound medical practice for fear of liability. In one study of 824 U.S. emergency physicians, radiologists, obstetricians/gynaecologists and surgeons—specialists at high risk of being sued—, 93% of them admitted to sometimes or often practising defensive medicine.(5) One frequent cause for litigation is failure to diagnose cancer early, and attorney firms such as “Ovarian Cancer Misdiagnosis Attorneys” advertise their legal services to women if doctors fail to diagnose ovarian cancer in a timely fashion.(6) Similarly, physicians may be concerned about their reputation if they overlook a cancer, whereas producing false positives and unnecessary surgery is not perceived as a similar threat. Thus, to protect themselves against their patients, many physicians feel that they have no choice but to ignore guidelines and risk harming patients through overdiagnosis and overtreatment.

The “I” stands for innumeracy, specifically statistical illiteracy. Studies indicate that many physicians do not understand health statistics relevant for screening, or uphold beliefs uninformed by the evidence from randomized trials.(7) For instance, in a study of 1574 U.S. physicians, 30% wrongly believed that TVU is a clinically effective test for ovarian cancer screening for women at average risk, and 18% thought the same of CA-125.(8)

The “C” stands for conflicts of interest. Numerous companies market tests that screen for ovarian cancers, with costs varying widely between $35 and $250. In a business-driven fee-for-service system, not screening means loss of income for physicians and clinics. Thus, physicians who practice evidence-based medicine find themselves in a conflict between their financial interests and best practice. Ovarian cancer screening generates a steady source of income, not only from the costs of the test but also from the downstream consequences of false alarms, including unnecessary removal of ovaries and the treatment of resulting complications such as cardiovascular disease.

As the term SIC Syndrome indicates, these three causes are interconnected. A physician who recommends screening with TVY and CA-125 may be motivated by fear of litigation, by financial or reputational concerns, or both. These motives are often hard to distinguish. The third cause, innumeracy, can serve as a moral blindfold so that physicians who recommend screening do not even notice that they are violating the Hippocratic Oath of “first do no harm.” Not knowing the evidence preserves the illusion that a harm done to patients is in their best interest.

1. Buys SS, Partridge E, Black A, et al. PLCO Project Team. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening randomized controlled trial. JAMA 2011; 357:2295-303.
2. Gigerenzer G, Kolpatzik, K. How new fact boxes are explaining medical risk to millions. BMJ 2017,357:j2460.
3. Baldwin LM, Trivers KF, Matthews B et al. Vignette-based study of ovarian cancer screening: do U.S. physicians report adhering to evidence-based recommendations? Ann Intern Med. 2012, 156(3):182-94.
4. Gigerenzer G. Risk savvy: How to make good decisions. NY: Viking 2014.
5. Studdert DM, Mello MM, Sage WM et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 2005, 293, 2609-17.
6. http://www.danknermilstein.com/failure-to-diagnose-ovarian-cancer/
7. Gigerenzer G, Muir Gray JM, eds. Better doctors, better patients, better decisions. MIT Press 2011.
8. Miller JW, Baldwin LM, Matthews B et al. Physicians’ belief about effectiveness of cancer screening tests: A national survey of family physicians, general internists, and obstetrician-gynecologists. Prev. Med. 2014, 69, 37-42.

Competing interests: No competing interests

20 June 2017
Gerd Gigerenzer
Director,
Kai Kolpatzik, Department of Prevention, General Local Health Insurance Fund (AOK-Bundesverband), Berlin, Germany
Harding Center for Risk Literacy/Center for Adaptive Behavior & Cognition, Max Planck Institute for Human Development
Lentzeallee 94, 14195 Berlin, Germany
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Re: NHS providers achieve “the impossible” and cut their deficit by two thirds . 357:doi 10.1136/bmj.j2967

Congratulations would be in order IF there were no losers.

Are no more patients waiting for treatment, for care, if cure not possible?

Are the clinical staff (doctors, nurses, therapists, diagnostic staff AND their secretarial support staff) now drained of blood, soaked in sweat, in tears as they curse the government? Can these slaves continue to toil?

Are the junior doctors singing paeons of praise for the peerless S o S?

Competing interests: No competing interests

20 June 2017
JK Anand
Retired doctor
Free spirit
Peterborough
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Re: Air pollution in the UK: better ways to solve the problem Robin Russell-Jones. 357:doi 10.1136/bmj.j2713

To the editor

We have read with a great interest the analysis provided by Mr. Robin Russell-Jones.[1] As numerous scientific articles focus on effects of pollution on population's health, he promotes drastic actions aiming to decrease pollutants emission by transport vehicles, in particular diesel vehicles.[2] Some of those actions are targeted at limiting access to specific zones, such as urban or suburban ones. We completely agree with his conclusions. Nevertheless, most of the studies have focused on specific pollutant or disease, whereas pollution impact is, without any doubt, much larger. In addition, achieving all proposed recommendations, although essential, might take a long, long time. In the meantime, focusing only on pollutants concentration cutoffs (rarely respected, whatever the country) could be insufficient to forecast the go for exceptional corrective actions as speed or circulation limiting.

Our Center for the Reception and Regulation of Medical Calls (CRRMC) is situated in the northeastern part of Paris, in the 93rd department, a 236 km2 area inhabited by approximatively 1.6 million people. The aim of our CRRMC (SAMU 93) is to manage all medical calls, whatever their reason or level of severity, in the related area. The latter is characterized by a dense network of streets, roads and speedways, as many sources of pollutants from exhaust gases. Moreover, our geographical situation exposes us to Parisian emissions carried by the prevailing winds from west to east. Therefore, we wanted to determine whether indices able to forecast the need for exceptional actions as we previously described could be found.[3] We analyzed the relationship between air pollution levels (recorded and classified according to five levels by local authorities) and the number of calls. 639,576 calls were managed in a period of 1,134 consecutive days, from December 30, 2013 to February 5, 2017. The results showed that the number of calls was strongly correlated with air pollution levels (R2=0.9). The median number of calls was 564 (507-643) per day. It increased from 502 (494–621) to 650 (540–704) respectively during the days with the best (N=7) and the worst air quality (N=60). 

Such a global analysis based on a large population, regardless of the pathology or its severity, shows a strong relationship between air pollution levels and the need for health care, including primary care. Thus, global request for healthcare can be a useful tool to evaluate or even forecast both, pollution as well as corrective action impacts on population's health.

References
1. Russell-Jones R. Air pollution in the UK: better ways to solve the problem. BMJ. 2017 Jun 14;357:j2713. PMID: 28615170
2. Anenberg SC, Miller J, Minjares R, Du L, Henze DK, Lacey F, Malley CS, Emberson L, Franco V, Klimont Z, Heyes C. Impacts and mitigation of excess diesel-related NOx emissions in 11 major vehicle markets. Nature. 2017 May 15
3. Lapostolle F, Fleury M, Crocheton N, Galinski M, Cupa M, Lapandry C, Adnet F. Determination of early markers of a sanitary event. The example of the heat wave of August 2003 at the Samu 93-centre 15 in France. Presse Med 2005;34:199-202

Competing interests: No competing interests

20 June 2017
Tomislav Petrovic
MD
GOIX Laurent, LAPOSTOLLE Frédéric
125 route de Stalingrad - 93009 BOBIGNY Cedex
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Re: Do doctors have a duty to take part in pragmatic randomised trials? Marion K Campbell, Charles Weijer, Cory E Goldstein, Sarah J L Edwards. 357:doi 10.1136/bmj.j2817

Randomised controlled trials (RCT) in surgery are frequently pragmatic due to unique challenges related to complex interventions. Whilst once described as “comic opera”, surgical research in the United Kingdom has advanced significantly in recent years due to dedicated surgical trials units, integrated academic-clinical career pathways and trainee-led research collaboratives (1-4). Within established and supported networks, we agree that all patients should be afforded the opportunity to engage in pragmatic, randomised trials.

Unfortunately, research waste is increasingly recognised in academic literature. In surgery, one in five RCTs are discontinued early and one in three completed trials remain unpublished (5). Similar problems are encountered in other medical and allied specialties. It is estimated that up to 85% of all health research is avoidably wasted, equivalent to $170 Billion (6). Failure to disseminate research findings leads to hidden trial data, unrealised knowledge and the risk of unnecessary duplication. It also raises ethical concerns related to futile participation for both patients and clinicians. The AllTrials campaign aims to address these issues by calling for mandatory registration and dissemination of research findings.

Investigators can, and must, do more to encourage participation in pragmatic trials. It is their duty to eliminate waste by ensuring timely and complete dissemination of research findings and facilitating open, patient-level meta-analysis. In surgery, this is important to ensure greater research activity is translated into increased outputs. By reducing waste, it will empower clinicians and patients to participate in future trials with confidence and assurance.

Stephen J Chapman, @SJ_Chapman; NIHR Academic Clinical Fellow, University of Leeds, UK
James CD Glasbey, @DrJamesGlasbey; NIHR Academic Clinical Fellow, University of Birmingham, UK

References
1. Horton R. Surgical research or comic opera: questions, but few answers. Lancet 1996;346:984-985.
2. Clough S. Fenton J. Harris-Joseph H. et al. What impact has the NIHR Academic Clinicsl Fellowship (ACF) scheme had on clinical academic careers in England over the last 10 years? A retrospective study. BMJ Open 2017;7:e015722.
3. Royal College of Surgeons of England. Surgical Trials Initiative. Available at : https://www.rcseng.ac.uk/standards-and-research/research/surgical-trials... [Accessed 16th June 2017].
4. Bhangu A. Kolias AG. Pinkney T. et al. Surgical research collaboratives in the UK. Lancet 2013;382:1091-1092.
5. Chapman SJ. Shelton B. Mahmood H. et al. Discontinuation and non-publication of surgical randomised controlled trials: observational study. BMJ 2014;349:g6870.
6. Chalmers I. GLasziou. Avoidable waste in the production and reporting of research evidence. Lancet 2009;376:86-89.

Competing interests: No competing interests

20 June 2017
Stephen J Chapman
NIHR Academic Clinical Fellow & Surgical Trainee
James CD Glasbey
University of Leeds
Leeds Institute of Biomedical and Clinical Sciences (LIBACS), University of Leeds, Leeds, LS9 7TF
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Re: Serum uric acid levels and multiple health outcomes: umbrella review of evidence from observational studies, randomised controlled trials, and Mendelian randomisation studies Konstantinos K Tsilidis, P A Ioannidis, Harry Campbell, Evropi Theodoratou, et al. 357:doi 10.1136/bmj.j2376

We read with great interest the umbrella review by Li et al.1 As an anaesthetist with scientific interest for perioperative medicine and postoperative complications, I would like to discuss the association between preoperative high serum uric acid level and postoperative acute kidney injury. Perioperative high serum uric acid levels were frequently found in the surgical patients who develop acute kidney injury (AKI).2-6 There has been debate whether preoperative hyperuricemia is an independent risk factor or one of the causal factor of postoperative AKI. The renal elimination of serum uric acid means that serum uric acid level will increase as glomerular filtration rate (GFR) declines, with the possibility that increasing preoperative uric acid level may simply reflect decreased GFR, a well-established risk factor for AKI after cardiac surgery. Also, there is a gender-difference regarding the normal range of serum uric acid (7.0 mg/dL for male and 6.0 mg/dL for female). Despite this difference, many previous studies did not consider this difference in their data analysis. Most importantly of all, most of the previous studies were observational or retrospective study, which means the results could only show an association, not causation.

As we know, to prove a causal relationship between a potential predictor and an outcome variable, Hill’s criteria should be met such as strength, consistency, specificity, temporality, biological gradient (does-response relationship), biological plausibility, coherence, experiment, and analogy.7 8 As an effort to find a causal relationship between hyperuricemia and postoperative AKI, a previous small single-center randomized trial evaluated the effect of rasburicase, a uric acid lowering agent, on the incidence of AKI after cardiovascular surgery. However, there was no benefit on postoperative serum creatinine, although the authors found that a biomarker of AKI, NGAL, tended to be lower in rasburicase-treated subjects.9 Actually, there has been only limited success to date in the translation of the potentially modifiable risk factors into a reduced burden of cardiac surgery associated AKI, which was the same for hyperuricemia. However, to our knowledge, there are few randomized trials with sufficient power to demonstrate the effect of the uric-acid lowering agent on the incidence of postoperative AKI. Also, this seems to be similar for the association between hyperuricemia and contrast-induced AKI.10 Therefore, at least for the AKI after cardiac surgery or contrast-induced AKI, further research is required to determine whether uric acid lowering agent has beneficial effects for reducing AKI to conclude the association between serum uric acid levels and AKI after cardiac surgery.

Won Ho Kim M.D.,Ph.D.
Jae-Hyon Bahk, M.D.,Ph.D.
Department of Anesthesiology and Pain Medicine
Seoul National University Hospital, Seoul, Republic of Korea

1 Li X, Meng X, Timofeeva M, et al. Serum uric acid levels and multiple health outcomes: umbrella review of evidence from observational studies, randomised controlled trials, and Mendelian randomisation studies. BMJ 2017;357:j2376. doi:10.1136/bmj.j2376.
2 Ejaz AA, Kambhampati G, Ejaz NI, et al. Post-operative serum uric acid and acute kidney injury. J Nephrol 2012;25:497-505. doi:10.5301/jn.5000173.
3 Joung KW, Jo JY, Kim WJ, et al. Association of preoperative uric acid and acute kidney injury following cardiovascular surgery. J Cardiothorac Vasc Anesth 2014;28:1440-7. doi:10.1053/j.jvca.2014.04.020.
4 Lapsia V, Johnson RJ, Dass B, et al. Elevated uric acid increases the risk for acute kidney injury. Am J Med 2012;125:302 e9-17. doi:10.1016/j.amjmed.2011.06.021.
5 Ejaz AA, Beaver TM, Shimada M, et al. Uric acid: a novel risk factor for acute kidney injury in high-risk cardiac surgery patients? Am J Nephrol 2009;30:425-9. doi:10.1159/000238824.
6 Xu X, Hu J, Song N, Chen R, Zhang T, Ding X. Hyperuricemia increases the risk of acute kidney injury: a systematic review and meta-analysis. BMC Nephrol 2017;18:27. doi:10.1186/s12882-016-0433-1.
7 Hill AB. THE ENVIRONMENT AND DISEASE: ASSOCIATION OR CAUSATION? Proc R Soc Med 1965;58:295-300.
8 Karkouti K. Transfusion and risk of acute kidney injury in cardiac surgery. Br J Anaesth 2012;109 Suppl 1:i29-i38. doi:10.1093/bja/aes422.
9 Ejaz AA, Dass B, Lingegowda V, et al. Effect of uric acid lowering therapy on the prevention of acute kidney injury in cardiovascular surgery. Int Urol Nephrol 2013;45:449-58. doi:10.1007/s11255-012-0192-2.
10 Zuo T, Jiang L, Mao S, Liu X, Yin X, Guo L. Hyperuricemia and contrast-induced acute kidney injury: A systematic review and meta-analysis. Int J Cardiol 2016;224:286-94. doi:10.1016/j.ijcard.2016.09.033.

Competing interests: No competing interests

20 June 2017
Won Ho Kim
Professor
Jae-Hyon Bahk
Seoul National University Hospital
101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
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Re: NHS providers achieve “the impossible” and cut their deficit by two thirds . 357:doi 10.1136/bmj.j2967

Jeremy Hunt says the NHS Confederation has achieved “the impossible", but I disagree that we should be proud of cost-savings. Clinically, from the shop floor, we have not become more efficient. "Maintaining a focus on patient safety, compassion, and outcomes” does not have anything to do with this, we always strive to that.

No, what we in the NHS have done have just stripped services to the bone. We have not replaced staff that have left; we have not invested in new, and not developed old services; we have not improved our facilities, in fact, sometimes we have simply started to over-use them (splitting clinic rooms into two for instance).

All this to pay for the continuing austerity from the Bankers' Credit Crunch. Every consultant governance meeting we have is a depressing agenda of where we need to save money. Never on the agenda is how we might improve services, how we can innovate new ways to care for patients, things which will be needed as the population ages and morbidity increases.

Let's not be proud of it. You tell us to do it, so our managers guide us how. We are tolerating it. Cost-savings is the main outcome of the NHS at the moment. When will that change back to getting the best healthcare for our patients?

Competing interests: No competing interests

19 June 2017
M. Justin Zaman
Consultant Cardiologist
James Paget University Hospital
Lowestoft Road, Gorleston-on-Sea, Norfolk.
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Re: Stress at work Thomas Despréaux, Olivier Saint-Lary, Florence Danzin, Alexis Descatha. 357:doi 10.1136/bmj.j2489

Dear Sir / Madam,

I read with great interest the article on work related stress since it is such a common scenario encountered in general practice.

I was however a little alarmed that taking blood pressure was recommended in the routine assessment of a consultation relating to stress at work. Whether or not the patient has hypertension will not affect his / her ability to deal with stress. However taking the patient's blood pressure ( which will be frequently up as he/she is stressed from talking about stress ) will quite likely results in an above normal blood pressure. Patients associate the term blood pressure with "pressure" i.e feeling stressed and so are likely to then get quite upset if their blood pressure is up. They then feel that they must do their utmost to avoid all feelings of stress and might then ask for absence from work to deal with the "pressure".

Taking a blood pressure is good in the context of looking for risk factors for cardiovascular disease but probably not indicated in the management of a patient suffering from stress unless specifically requested by the patient. In such cases the blood pressure may be taken with the proviso shared with the patient that anxiety does not cause long term hypertension but that spikes of raised blood pressure may occur.

Yours sincerely,

Anne Pauleau.

Competing interests: No competing interests

19 June 2017
Anne Pauleau
GP
London
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Re: Coroner calls for GPs to be allowed to order urgent CT scans after patient death Clare Dyer. 357:doi 10.1136/bmj.j2815

The coroner presumes too much, l fear. As Giles pointed out, waiting time for urgent CT are already well beyond 4 weeks in many areas. Kaiser pointed out that the patient attended A&E the week before death, where a Same-day CT was not thought necessary. If we are to request urgent CT for assurance in all cases of Migraine, the effect will be more deaths and delays, not less, sadly. Unless there is a massive increase in CT resource.

Competing interests: No competing interests

19 June 2017
Leslie Lewis
Retired GP
NHS
Newport
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Re: Long term gluten consumption in adults without celiac disease and risk of coronary heart disease: prospective cohort study Peter H R Green, Alfred I Neugut, Eric B Rimm, Laura Sampson, et al. 357:doi 10.1136/bmj.j1892

There are so many studies that prove there IS a higher risk of heart disease after long term gluten exposure! I am living proof of this and yes, I'm highly disgusted by your article. Just as MANY get upset when they read an article mocking the existence of gluten. In my case, I was only 39 yrs. Old with no prior family history of heart disease and I was in excellent health. Aerobics was part of my weekly routine and I ate wheat regularly. I had no cholesterol build up of any kind, even during my hospital stay after my heart attack! Maybe some people are more at risk than others but I do believe...Scratch that, I know inflammation is a major risk to the heart and gluten causes inflammation!!!!!! I'm now gluten free for almost 5 yrs. and am a minimal risk for future heart attacks according to my doctors!! More and more young adults are having heart attacks and many have celiac disease! There is a link!!!!!

Competing interests: No competing interests

19 June 2017
Flora Patin
Administration Assistant
Livingston, LA
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