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Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.

From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.

The word limit for letters selected from posted responses remains 300 words.

Re: Stop doctors from retiring to boost elective recovery workforce, says NHS England Adele Waters. 377:doi 10.1136/bmj.o1145

Dear Editor,

“Something is rotten in the state of Denmark” - the bard remarked (1). I have read the news piece about NHS England wanting to stop doctors from retiring (2). When the “City” workers do well they get a bonus. After the effort of past two years, what did we get? A clap. But it is not just about the money. NHS England may be too far removed from the front lines. Doctors are leaving the NHS before the retirement age. Many of my friends and colleagues have left the profession they love and the relative financial security it offers. Why? The system is on the verge of collapse. People are tired, they are traumatised by the battlefield of the pandemic. The chronicity of under-resourcing is evident in the Ockenden Report that another article in the same issue of BMJ deals with (3). Dusting off a few senior clinicians, dragging them away from a well earned rest is not a solution. A solution is in reforming the work environment. Learn the lessons from the industry e.g. Google. Reform the attitudes, revitalise professionalism to allow people to flourish, innovate and inspire and move away from the production line of waiting lists. Failing that people will vote with their feet.

1. Shakespeare W. Hamlet. Act I, Scene 4.
2. Waters A. Stop doctors from retiring to boost elective recovery workforce, says NHS England. BMJ 2022; 377 doi:
3. Wilkinson E. Implementing Ockenden: What next for NHS maternity services?BMJ 2022;377:o1120

Competing interests: No competing interests

22 May 2022
Piotr Szawarski
Consultant in Intensive Care Medicine
Wexham Park Hospital
Wexham Park Hospital, Slough, UK
Re: Covid-19: Mexico City gave ivermectin kits to people with covid in “unethical” experiment Owen Dyer. 376:doi 10.1136/bmj.o453

Dear Editor,

I certainly understand the unethical nature of experimenting an unproven treatment on people without informed consent. The criticisms levied at such an action by a Major city government (or any for that matter) seem wholly valid.

It is not fully clear, however, what the results of the experiment are, unethical as it may have been. Given such a large sample size, do we have a better understanding of the value, if any, in using Ivermectin to treat COVID-19?

Furthermore, the fact that the article was taken down due to public pressure, which is what appears to have been the case according to the article, is somewhat concerning. Surely, the only factor in making such a decision should be the quality of the research. Public pressure, which is not in and of itself considered scientific critique, shouldn't be influencing publishing decisions in scientific journals.

Competing interests: No competing interests

22 May 2022
Mohamed A Elmaazi
Re: Venovenous extracorporeal membrane oxygenation in patients with acute covid-19 associated respiratory failure: comparative effectiveness study Heidi J Dalton, Niall D Ferguson, Silver Heinsar, Carol L Hodgson, et al. 377:doi 10.1136/bmj-2021-068723

Dear Editor

Having read this interesting article including its supplement, I could not discern the fraction of the 844 patients receiving ECMO treatment who actually fulfilled the criterion of PaO2/FiO2 < 80 mm Hg.
I would be most grateful for this information.

Competing interests: No competing interests

21 May 2022
Johann Reisinger
Ordensklinikum Linz Barmherzige Schwestern
Seilerstätte 4, 4010 Linz, Austria
Re: Generating evidence during a pandemic: what’s reliable? Joshua D Wallach, Osman Moneer, Joseph S Ross. 377:doi 10.1136/bmj.o1229

Dear Editor, Well stated and concluded. It is obvious that in times of crisis, such as COVID 19 pandemic in the earlier phases, with high morbidity and unusual mortality, treatment with what is ' probably known ' exemplified by Hydroxy Q , was commenced, soon followed by Ivermectin. This was an act of commission -(therapeutic) , and no serendipity. Awaiting results from an RCT could be a luxury against the passage of crucial time. Clinical observations / observational research acquired an elevated status and importance in the intermediate time gaps, as response and experience demonstrated. Though considered gold standard, limitations against the time frame, need to be accepted and acknowledged, Further, the matching of some results between the RCTs and observational research lends credence to the utility of later in specific situations, with the population component considered. Generating evidence may be time/situation specific and disregarding / underestimating observational findings may turn erroneous and could deprive some of 'legitimate' care. Dr Murar E Yeolekar, Mumbai.

Competing interests: No competing interests

21 May 2022
Murar E Yeolekar
Consultant Physician
Fmr Prof & Head of Internal Medicine, KJSMC&LTMMC
Sion, Mumbai 400 022.
Re: Fewer ethnic minority doctors are referred to GMC after cases are anonymised Ingrid Torjesen. 377:doi 10.1136/bmj.o1153

Dear Editor,
There has been negligible national media coverage and minimal response in the BMJ since the publication two weeks ago of what should ordinarily be a piece of welcome news. This deafening silence speaks volumes considering the broad readership of the BMJ. One cannot but wonder whether the apparent silence is because of disinterest by the majority or the minority’s lack of faith in the system to effect significant changes following the piece of work and positive outcomes.
Hopefully, other trusts across the UK will work with the NHS’s workforce race equality standard to tackle racial inequality and discrimination issues concerning doctors and other healthcare professionals to eventually make the national picture mirror the East of England’s.

Competing interests: No competing interests

21 May 2022
Babatunde A. Gbolade
Retired NHS Consultant Gynaecologist; Fitness To Practise Proceedings Consultant & McKenzie Friend
BLG Assist
Suite 28129, PO Box 6945, London W1A 6US
Re: Erosion of healthcare for those who need it most Theodora Bloom. 377:doi 10.1136/bmj.o1234

Healthcare Ecosystem in India in Future

Now a days healthcare delivery in India has witnessed a renewed focus on leveraging digital technology during the COVID-19 pandemic and after.

Various healthcare reforms launched before and during the pandemic such as, National Health Digital Mission (NDHM) and teleconsulting guidelines combined with burgeoning health tech start-up ecosystem, have evolved to make healthcare journey better for Indian population.

The new normal in Indian healthcare ecosystem will be about how healthcare delivery will innovate in the coming decade and what it means for both patients and healthcare providers. 

Digitization, technological enablement, and automation are affecting industries today in profound ways. Healthcare is no exception. The paradigm of healthcare delivery in India is changing and is poised for a big leap forward. Healthcare and drug innovation have come into sharp focus as never before in India 
[21/05, 9:34 am] MA: The COVID-19 pandemic has demonstrated that health care organizations become more resilient, agile, and innovative through digitally enabled business models with data at the core. The pandemic added urgency and accelerated the process of change for healthcare to become more digitally enabled.

In India healthcare delivery is moving outside the four walls of traditional health system . Health care providers have realized that products or services alone, no matter how strong they are technically, will not be enough in future. They should look into the future to engage with their users across the health care value chain, whether that be physicians or patients, and deliver to them not just a better care product or care service, but a better care experience. Also, one needs to keep an eye on developments coming from non-core sources like technology companies which could further help in diagnosis or early detection and aid the healthcare ecosystem.

Hence, as health care organizations consider to move ahead, creating the right data environment to support a more human-centered approach to health care is an urgent need.
[21/05, 9:34 am] MA: In India  the explosion of health care data requires a new ecosystem to be built around the needs of an individual enabled by technical standards, open data models and empowered by governance systems that deliver trust.

In our country,rising technologies generating data will need equally powerful tools to organize, interpret and draw insights from them — Artificial  intelligence (AI)is critical in this journey to turn complex information into usable insights, including individualized wellness solutions and show how to efficiently provide care across the ecosystem.

To keep up with the velocity and variety of health data generated today in India, the health information infrastructure must enable providers to connect, combine, analyze, and share health and social data.

Trusted intelligence systems also will emerge to secure confidence and participation of consumers and other stakeholders in India in near future. 
[21/05, 9:35 am] MA: In India clinicians will need to leverage medical, data and behavioral science knowledge and skills in the near future to deliver a personalized care demanded by patients. To support this shift, healthcare entities must decide now where to invest in education, training and recruiting.

Healthcare delivery in India witnessed a renewed focus on leveraging digital technology during the pandemic. The sector, predominantly recognized for sick care delivery, has looked at building next-gen capabilities that will be a differentiator in the decade ahead. Several reforms launched before and during the pandemic such as National Health Digital Mission (NDHM), teleconsulting guidelines combined with burgeoning health tech start-up ecosystem enabled by innovation, have evolved to make the healthcare journey better for Indian population. It is good that the private equity/ Venture capital funding is also coming to support the health tech start up eco system.
[21/05, 9:36 am] MA: Maximizing the clinical, financial, and operational value of these new digital offerings and services requires biopharma, medtech and other health care stakeholders to reinforce digital as an entirely new business model and ecosystem to deliver better outcomes and drive stakeholder awareness, adoption, engagement, and growth.

Competing interests: No competing interests

21 May 2022
M.A. Aleem
Emeritus Professor of Neurology * Visiting Specialist in Neurology ** Consultant Neurologist ***
The Tamilnadu Dr.M.G.R. Medical University * Dhanalakshami Srinivasan Medical College ** ABC Hospital ***
Chennai 600032* Perambalure 621212** Trichy 620018*** Tamilnadu India
Re: Seven monkeypox cases are confirmed in England Elisabeth Mahase. 377:doi 10.1136/bmj.o1239

Re-emerging monkeypox: an old disease to be monitored
Rujittika Mungmunpuntipanitp1, Viroj Wiwanitkit2
1. Private Academic Consultant, Bangkok Thailand
2. Honorary professor, Dr DY Patil University, Pune, India; Adjunct professor, Joseph Ayobabalola University, Ikeji-Arakeji, Nigeria

Dear Editor, we agree that the imported monkey pox into Europe becomes an emering interesitng public health issue [1]. The monkey pox is a kind of atypical pox disease and zoonosis is believed to be the cause of remerging of this old viral disease [2]. The human to human transmission becomes the current issue to be monitored. An increasing number of reported cases in mnay countries draws attention to the medical community,. Lesson learnts from COVID-19, there should be a rapid response, prompt investigation and early containment for the possible outbreak. Monkey pox is an old disease but it might have a change of newly occured genetic aberration that might cause the more problematic disease and wide scale outbreak. The present need might include a) investigation of clinical issues of newly emerging cases including in depth molecular investigaton on the pathogen, b) implementation of disease control system including to a good case screening aiming at blocakage of imported disease from endemic area and c) preparedness for possible widescale outbreak correspondence.

1. Mahase E. Seven monkeypox cases are confirmed in England. BMJ 2022; 377 doi:
2. Wiwanitkit S, Wiwanitkit V. Atypical zoonotic pox: Acute merging illness that can be easily forgotten. J Acute Dis2018;: 7:88-89.

Competing interests: No competing interests

21 May 2022
mungmunpuntipantip rujittika
medical scientist
Viroj Wiwanitkit
private academic consultant
Bangkok, thailand
Re: Seven monkeypox cases are confirmed in England Elisabeth Mahase. 377:doi 10.1136/bmj.o1239

Dear Editor

Monkey pox - new outbreak with potentially novel mode of spread

We read with keen interest the BMJ report of seven cases of monkeypox that were confirmed in the UK by the 16 May 2022. Since then, 13 more cases of monkeypox have been identified by The UK Health Security Agency (UKHSA) bringing the total number of monkeypox cases confirmed in the UK to 20 as of 20 May 2022. Why are these cases generating so much interest globally and provoking urgent public health action? It is because there have been some unprecedented events in this outbreak, which have also been reported in several other European countries as well as in the US, Canada, and Australia. Firstly, The World Health Organization (WHO) has announced that many of the cases in the UK and other European countries have occurred in young, gay, bisexual or men who have sex with men (MSM). Secondly, all except the first case detected in the UK on May 7, 2022, have had no recent travel history to central or west Africa where monkeypox is endemic. Thirdly, there have been no proven connections between most of these cases. This has raised the possibility of a novel community spread and sexual contact is now considered a likely route of transmission.

The first human case of monkeypox was recorded in 1970 in the Democratic Republic of the Congo (DRC), and cases of monkeypox have been reported in west Africa or central Africa, with large outbreaks in Nigeria. Monkeypox is an emerging zoonotic disease transmitted by monkeys, Gambian poached rats, dormice and squirrels. The reservoir species are suggested to be rodents. Fever, headache, muscle aches and lymphadenopathy are common symptoms which precede the rash which often begins on the face and then spreads to involve other parts of the body including the genitals. The rashes develop sequentially from macules to papules, vesicles, pustules, and crusts during a 2–3-week period. Monkeypox is usually a mild self-limiting illness and virus entry into humans is thought to occur via the oropharynx, nasopharynx and intradermally. Close contact between infected humans, or contaminated clothes, towels or furniture, and respiratory droplets is the established mode of transmission of monkeypox. However, the current outbreak is exposing gaps in our knowledge of this disease. The case fatality rate, derived largely from African cohorts, is 5% and this is higher in children, immunosuppressed and persons infected with the central African variant of monkey pox virus. Smallpox vaccination provides 85% protection for those at risk and the decline in smallpox vaccine immunity is thought to account for monkeypox outbreaks in 2017-2020.

This unprecedented change in epidemiology of human monkeypox has thrown up several issues. Some of the UK and other European cases have been characterized by a lack of prodromal symptoms and herald skin lesions at point of sexual contact which are both strongly suggestive of sexual transmission. There are concerns that the media’s projection of MSM as the at-risk population for this infection may lead to disproportionate stigmatisation of these groups. Case definitions have had to be rapidly revised to reflect possible cases as not necessarily having a history of travel to West or Central Africa. New clinical guidelines are required to address issues such as appropriate personal protective equipment to be used in sexual health clinics and revision of standard operating procedures in laboratories.
With cases of monkeypox now identified in Europe, North America and Australia, the apprehension about cross-border spread of this disease appear to be well founded. It will be vital to establish robust health surveillance and control measures to address the threat posed by monkeypox.

Competing interests: No competing interests

20 May 2022
Akaninyene Otu
Medical Doctor
Bassey Ebenso, Josep Mercader Barceló, John Walley
Leeds Teaching Hospitals NHS Trust, Leeds, UK
22 Tall trees
Re: Matt Morgan: The death of the dictaphone Matt Morgan. 377:doi 10.1136/bmj.o1192

Dear Editor
It is with piqued interest I read Dr Morgan’s assessment of the death of the dictaphone and wider patient-experience enhancing functions of the modern secretary. I discussed this very topic with my secretary this week when deciding cutaneous allergy terms from my patch testing letters such as methylisothiazolinone, chlorocresol, methyldibromoglutaronitrile, methylacrylates and decyl glucosides would surely never be “learnt” 100% correctly by a digital dictation system. After spending 5 minutes extra per letter making corrections, spending an extra half hour, she decided it’s quicker just to type the letter from the available recording. Normally the complex allergy letters are 100% correct requiring me to make no changes to ensure GPs and patients have exact allergen names to check ingredients in everyday products. The jury is still out and perhaps we all should be happy to give this a go. Just don’t ask us to do our own corrections in between seeing patients and I really hope there are no typos in this letter. I agree more and more of these administrative tasks taking up our valuable time would be better spent training others in the workforce to ultimately help our patients.

Competing interests: No competing interests

20 May 2022
Mahbub M.U. Chowdhury
Consultant Dermatologist
Department of Dermatology , University Hospital of Wales, Cardiff
Cardiff CF14 4XW
Re: Visualising harms in publications of randomised controlled trials: consensus and recommendations Tim P Morris, Siobhan Creanor, Catherine Hewitt, Sharon Love, et al. 377:doi 10.1136/bmj-2021-068983

Dear Editor
Again and again, many thanks to BMJ editor committee.
The main objective of statistical analysis in medicine is to make conclusions or inferences about the existence or not of associations between two or more variables, or about the presence or not of a general law or norm, based on data obtained after exploring a limited and calculated representative sample. The use of statistical models for analysis of information is an important part of processes for the proper treatment of data obtained as a result of scientific research in medicine.
The final results report of any scientific research is presented in form of an article containing several sections, a title, a summary, an abstract or a short text of no more than 50 words called annotation. Much of the text is presented in an IMRAD format, an acronym constructed with the initials of the words Introduction, Methodology, Results, Analysis of results and Discussion. At the end there is always a list that contains citations to main documentary references and links that contain addresses of sites from where information was extracted to write the article. In results section, static or dynamic graphs, applet graphs are always presented, which result from data statistical analysis obtained in the study.
Before becoming of new electronic technologies, in final reports or articles that were written, much of information was presented mainly in tables format, or through the use of simple figures, lines, dots and various kinds of geometric symbols. With the Office’s arrival began the progressive increase, in scientific journals, of research articles, in which data are represented in a graphic format. In a graph we can better see the trends of a process, the relationship between objects or facts over time and on surface. There are elementary, applied graphics, which can be raster, vector or block. Visual forms of representation of information allow it to be assimilated and analyzed more quickly and strengthen the understanding of a process or a natural phenomenon.
Due to the great development of information and communication technologies, traditional graphic in paper format was changed to digital or electronic hypertext. The great need arose to use the most of these resources to better represent data, in a more comfortable, easy way: bar charts, pie charts, histograms, linear regression graphs, time series, etc. This trend grew and gave way to a more dynamic presentation after becoming of scripts languages. In dynamic or applet graphs shape and figure change when data are modified. It means, they are graphs whose template allows their appearance to change depending on dataset values. It is not necessary to know the graph equation to calculate the value that corresponds to a dependent variable, given a certain value of independent one, that is, great potential that these computers have to make calculations is exploited, it is not necessary to know the function or formula, in order to calculate the value that corresponds to y for a certain value of x.
Currently the visualization of information in a graphic format is an important part in analysis of data obtained in research. We are living a time of flowering of information visualization, mainly, for two reasons, the first one, every day level of information in the great reservoir of knowledge - the powerful internet, increases more and more. We cannot analyze information using traditional methods. The presentation of information in an applet dynamic graphic format is a great possibility. On the other hand, the human brain faster and easier processes information that is presented in form of applet animated graphics better than statics ones.
It is very important to maintain balance that must be between the logic of data, statistical model to be applied in research and type of graph to be displayed. Any imbalance or error in visualization can give an erroneous data representation, which in health sector can lead to conclusions that can generate very serious problems in people’s health.

Competing interests: No competing interests

20 May 2022
Emilio Polo Ledesma
Ph.D. in Biochemistry - Proteolytic Enzymes. Researcher and Teacher of Clinical Biochemistry at Medicine Program of Health`s Faculty
CeSurCafe Research Center - Universidad Surcolombiana - Neiva - Huila - Colombia.
Calle 9 con Carrera 14 - Barrio Altico Facultad Salud USCO Neiva - Huila - Colombia S.A.