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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: Indications for anticoagulant and antiplatelet combined therapy Christopher N Floyd, Albert Ferro. 359:doi 10.1136/bmj.j3782

We thank Kuczynska for highlighting the European Society of Cardiology update on the use of dual antiplatelet therapy [1]. The recommendations were published after the acceptance of our manuscript and were therefore not considered during its drafting. The update does however contain a number of points that are relevant to our Practice Pointer considering the combination of antiplatelet and anticoagulant therapy [2].

In patients with an indication for oral anticoagulation undergoing percutaneous coronary intervention, the duration and choice of antithrombotic therapy are largely the same as previous recommendations. An absence of safety and efficacy data mean that the use of prasugrel and ticagrelor in triple therapy should still be avoided. Similarly, in patient treated with warfarin a target INR in the lower part of the recommended range should be considered, and in patients treated with a direct oral anticoagulant the ‘lowest effective tested dose for stroke prevention’ should be considered [1].

The recommendation for choice of stent in patients with a high bleeding risk who require long-term anticoagulation has been updated as indicated by Kuczynska. Data from the DAPT trial and others has indicated that second generation drug-eluting stents are superior to bare metal stents where antithrombotic therapy needs to be terminated [4,5]. Second generation drug-eluting stents should therefore be the ‘default choice in patients with high bleeding risk’ [1].

1. Valgimigli M, et al. Eur Heart J 2017; 0, 1–48
2. Floyd CN and Ferro A. BMJ 2017;359:j3782
3. Lip GY , Windecker S, Huber K et al. Eur Heart J 2014; 359:3155-79
4. Kereiakes DJ, et al. JAMA. 2015 Mar 17;313(11):1113-21

Competing interests: No competing interests

11 October 2017
Christopher N Floyd
Clinical Lecturer in Clinical Pharmacology and Therapeutics
A Ferro
King's College London
Department of clinical pharmacology, cardiovascular division, British Heart Foundation Centre of Research Excellence, King’s College London, London, UK
Re: Alabama “pill mill” doctors get 20 year prison sentence Owen Dyer. 357:doi 10.1136/bmj.j2717

More than 4,000 Greek doctors, mainly employed in public hospitals, are accused of corruption charges, after leaked Pharmaceutical Company documents reveal consistent bribes they allegedly received. [1][2][3][4]
Hospital doctors in Greece often slide unpunished after lengthy investigations.
Let us hope that, this time, those 4,000 corrupt Greek doctors also receive prison sentences.

Competing interests: No competing interests

11 October 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Re: Corticosteroids for sore throat: a clinical practice guideline Geertruida E Bekkering, Arnaud Merglen, Mieke van Driel, Mieke Vermandere, et al. 358:doi 10.1136/bmj.j4090

We thank Dr. Linder for taking the time to consider and respond to our recommendation. A focus on hypothesis testing (and p-values) within individual studies can be misleading for a variety of reasons. Individual studies might be underpowered or overpowered, and p-values tell us nothing about the effect size or the importance of the outcomes. Instead of vote counting significant p-values, we and the GRADE approach suggest a focus confidence intervals around the absolute treatment effects for each patient-important outcome. We perform this assessment across the whole body of evidence, including the study by Hayward and colleagues, which provided the impetus for this Rapid Recommendation. The Hayward study's results are for the most part consistent with the results of the other nine randomised trials. As summarized in our infographic and in the systematic review supporting this recommendation (, we also considered other factors contributing to the certainty of effects, namely the risk of bias, indirectness, inconsistency, and publication bias. Our panel considered all these factors across the entirety of the evidence base to issue the Rapid Recommendation.

Competing interests: No competing interests

11 October 2017
Bert Aertgeerts
Siemieniuk Reed, Agoritsas Thomas, Romina Petersen
KU Leuven
Re: Time to put health at the heart of all policy making John Middleton. 357:doi 10.1136/bmj.j2676

Accordng to a BBC report today, Public Health England is patting England on the back for world leading efforts in reducing sugar intake.

Putting public health at the heart of policy making will be a good idea. To implement it we need, POSSIBLY, a couple of people who can be the Good Guys who can toss down a glass of the best Scotch and a few pints of your best bitter, mine host. And they can write a report thanking the industry (fattening industry) for understanding the need of public health philosophy.

But more than anything else we need the public health experts, the local authority directors of public health to get out of the closets and as the BAD BOYS, tell their planning colleagues and the chief executives well as the leaders of their councils that the proliferation of fast food outlets, take aways, tobacconists, off-licences, is in effect, murdering the good folk who pay their salaries, etc. Yes. Until they cut down these businesses, they are promoting fat Britons, with bad livers, bad lungs.

If you, the public health advisors of the local authorities do not make yourselves heard, you are not makng yourselves unpopular. And you remain useless to the public.

Competing interests: No competing interests

11 October 2017
JK Anand
Retired doctor
Free spirit
Re: Katherine Rich replies to Martin McKee Katherine Rich. 349:doi 10.1136/bmj.g6447

Professor Connor has said I made a "telling" error referring to Professor Sellman as a media spokesman for Alcohol Action. She writes, "Professor Doug Sellman is not " the media spokesperson" but " a medical spokesperson" for AANZ. There are in fact 5 medical spokespeople for the group". In referring to Professor Sellman as the media spokesperson for Alcohol Action NZ, I wish to make clear that I correctly quoting Alcohol Action's own information pamphlet, where both Professor Sellman and Professor Connor are listed and described as "media spokespeople". A copy of this pamphlet ( as presented for the New Zealand Parliamentary record) is here:
It's a small issue, but it's important to put the record straight since Professor Connor saw fit to specifically raise this point as a perceived error.

Yours sincerely

Katherine Rich
Chief Executive

Competing interests: No competing interests

11 October 2017
Katherine Rich
Chief Executive
New Zealand Food & Grocery Council
Level 6, 99-105 Customhouse Quay, Wellington, 6012
Re: Do cancer drugs improve survival or quality of life? Vinay Prasad. 359:doi 10.1136/bmj.j4528

The skyrocketing prices for drugs have nothing to do with either economic realities (misrepresented cost of research, top ranking price-earning ratio …) or common sense (lack of relevant clinical benefit, scarcity of resources for the society…). Prasad, once more, as some others, showed evidence that the present system regulation is a devastating shame for cancer drugs.(1,2) The Journal has been raising serious concerns too for a long time, and they are not limited to cancer drugs.(3) However, no improvement yet.

Why are we looking for evidence again and again? The system is so inefficient and corrupted that 37% of Americans think the Food and Drug Administration intentionally suppresses natural cures for cancer because of drug company pressure?(4)

Worst, the 30th World Oncology Forum convened by the European School of Oncology in 2012 with the task of evaluating progress to date in the war against cancer concluded that current strategies for controlling cancer are clearly not working and issued a remarkable action plan: concise, only 10 actions, war on tobacco being the first.(5) Nevertheless, only one-half of patients with cancer who smoke are counselled to quit although smoking cessation is an important factor in the outcome (cancer treatment effectiveness, overall survival, risk of second primary malignancies, and quality of life).(6) Regulatory agencies are far from being the sole problem.

Hijacking a quote from Einstein may offer a cornerstone for solutions: “Problems cannot be solved with the same people that created or nurtured them.”

1 Prasad V. Do cancer drugs improve survival or quality of life? BMJ 2017;359:j4528.

2 Kim C, Prasad V. Cancer drugs approved on the basis of a surrogate end point and subsequent overall survival: An analysis of 5 years of US Food and Drug Administration approvals. JAMA Intern Med 2015;175:1992-4.

3 Counsell CE. Orphan drugs. Regulation is flawed. BMJ 2010;341:c7016.

4 Oliver JE, Wood T. Medical conspiracy theories and health behaviors in the United States. JAMA Intern Med. 2014. Published online Mar 17. doi: 10.1001/jamainternmed.2014.190.

5 The Lancet. Stop Cancer Now! Lancet 2013; 381: 426–27

6 Ramaswamy AT, Toll BA, Chagpar AB, Judson BL. Smoking, cessation, and cessation counseling in patients with cancer: A population-based analysis. Cancer 2016;122:1247-53.

Competing interests: No competing interests

10 October 2017
alain braillon
senior consultant
University hospital. 80000 Amiens. France
Re: Explaining and apologizing to patients after errors does not increase lawsuits, finds study Susan Mayor. 359:doi 10.1136/bmj.j4536

Is the BMJ switching to American English?

Competing interests: No competing interests

10 October 2017
Peter C Arnold
Retired GP
Sydney, Australia
Re: Corticosteroids for sore throat: a clinical practice guideline Geertruida E Bekkering, Arnaud Merglen, Mieke van Driel, Mieke Vermandere, et al. 358:doi 10.1136/bmj.j4090

I remain stunned that the JAMA paper by Hayward and colleagues was considered "positive" and was the impetus for this updated, rapid review.

This was a negative study. The primary outcome, complete resolution at 24 hours, was negative. Only 1 -- complete resolution at 48 hours -- of about 8 secondary outcomes was positive. This was probably due to the play of chance. There was no difference in the time to resolution of symptoms between the steroid and placebo groups. "There were no significant differences between groups in the use of pain relief medications (topical and oral), antibiotics for sore throat, or antibiotics for other conditions and no differences in the proportion of participants missing any time away from work or education."

Even if the benefit at 48 hours were "real" -- and I am not allowing that it is because all of the other outcomes are negative -- in absolute terms, at 48 hours, only 35% of patients were better compared to 27% in the placebo group, a very small difference with a NNT of 13.

Again, this was a negative study and should not be included in this meta-analysis.

Hayward GN, Hay AD, Moore MV, Jawad S, Williams N, Voysey M, Cook J, Allen J, Thompson M, Little P, Perera R, Wolstenholme J, Harman K, Heneghan C. Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in AdultsA Randomized Clinical Trial. JAMA. 2017;317(15):1535–1543. doi:10.1001/jama.2017.3417

Competing interests: No competing interests

10 October 2017
Jeffrey A Linder
Northwestern University Feinberg School of Medicine
Chicago, Illinois, USA
Re: Children seen by GP in emergency department less likely to be admitted, study found Zosia Kmietowicz. 359:doi 10.1136/bmj.j4644

I read your article "Children seen by GP in emergency department less likely to be admitted, study found" with interest. I support the idea of GPs based in Emergency Departments but I don't think we can say that GPs reduce waiting times and admissions based on this study, as the article suggests.

My major concern is that the "natural experiment" used in the study does not provide two reasonably comparable groups. The patients included in the GP sample presented to the Emergency Department between 1400 and 2200 P , the ED group simply outside these times. I suspect that use of GPs is targeted at times when the highest number of GP-suitable patients are attending the Emergency Department. This is reflected by the high number of patients seen in the GP group (2821) compared to the ED group (2402) despite the ED group covering double the amount of time (16 hours compared to 8 hours). The concern must be that patients seen between 1400-2200 are pre-selecting themselves by attending at peak times. This may reflect timing of School days, parent and carer work schedules and levels of anxiety about the presenting complaint. Staffing levels in the Emergency Department may also vary between the two groups.

Given the paucity of evidence around this topic this is an interesting study but I agree with the authors that further research is needed to guide evidence-based practice in the future.

Competing interests: No competing interests

10 October 2017
Andrew D. I. Charlton
Emergency Medicine Registrar
Bradford Royal Infirmary
Re: WHO advises blanket anti-worming treatment for children despite lack of benefit Nigel Hawkes. 359:doi 10.1136/bmj.j4589

Evidence is not sufficient these days: you also need eminence! Those of us who practise in tropical countries where hygiene is the last priority with added cultural behavior, many suffer from nutritional deficiencies. Retardation of growth and anemia is seen in most of children, particularly female children. I practise in an urban set up and also see a lot of children and adults from slums where anemia is common. It is always worth treating empirically as worm infestation induced condition rather than diagnosing fancy diseases. We can never expect in the near future that there will be improvement in hygiene and availability of potable water. At least deworming is a simple approach to treat the majority of patients with nutritional deficiencies. The plight of the poor/nutrition is known only by those who see and have seen.

Competing interests: No competing interests

10 October 2017
Mohan Devegowda
613 2nd main first stage Indiranagar Bangalore 560038