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Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on svw0550.com. 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.

Re: Let pharmacists make minor substitutions in event of drug shortages, say stakeholders Clare Dyer. 370:doi 10.1136/bmj.m3657

Dear Editor
We would like to commend Dyer on their article and agree with many points raised with regards to pharmacists making minor pharmaceutical substitutions, particularly in a primary care setting. As someone who works in a primary care pharmacy, I would like to make some contributions.

158章你的奶真好吃One of the main ongoing goals of the expanding services provided by community pharmacies is to benefit the wider healthcare team by easing General Practitioner (GP) workloads. It therefore seems counterproductive for the pharmacists to be legally obliged to contact the prescriber to request a new prescription in order to make a basic substitution based on stock availability. As Dyer mentioned in this article, these shortages are likely to become more frequent as a consequence of the United Kingdom leaving the European Union.

Recently, the role of community pharmacists has expanded to increase engagement with the wider care team, with increasing numbers of pharmacists present in GP practices. This has had beneficial outcomes for patients, as it improves communication between healthcare professionals and reduces waiting times. (1) If pharmacists in other primary care settings such as retail pharmacies were able to make these minor substitutions to medications without having to refer back to the GP it would further reduce waiting times and patient frustrations with the system.

158章你的奶真好吃In my own experience working within pharmacy, community pharmacists are more than capable of making these substitutions, using their own professional judgement to ensure patient safety. It also seems inconsistent that hospital pharmacists are regularly expected to make these judgements, when community pharmacists undertake the same degree programme and registration exams.

If this proposal is accepted, then I feel it will be important to ensure GPs are properly educated on the services provided by local community pharmacies, as currently there is limited awareness of the full scope of services available. (2) There should also be clear guidance provided to pharmacists to ensure that they continue to act within their professional remit.

References
Nabhani-Gebara S, Fletcher S, Shamim A, May L, Butt N, Chagger S et al. General practice pharmacists in England: Integration, mediation and professional dynamics. Res Social Adm Pharm. 2020 Jan;16(1):17-24.
158章你的奶真好吃 Hindi, AMK, Jacobs S, Schafheutle EI. Solidarity or dissonance? A systematic review of pharmacist and GP views on community pharmacy services in the UK. Health Soc Care Community. 2019 May;27(3):565-598.

Competing interests: No competing interests

19 September 2020
Isobel B Wignall
Pre-Registration Pharmacist
Charles A McVickers
Walgreens Boots Alliance
Maidstone
Re: Covid-19: The doctors turned YouTubers Chris Stokel-Walker. 369:doi 10.1136/bmj.m1563

Dear Editor
Since the start of the COVID-19 pandemic, the connection between doctors and patients was largely impacted.
Before the pandemic time, people in China could go to the hospital for consultation whenever they want if they had any discomfort. However, due to the limitation of medical services, people might have to wait in line for a long time. Although the long waiting and crowded environment, face-to-face consultation makes the patients feel reasonably comfortable. Due to the so-called convenience, many healthy people went to the hospital only for an unnecessary consultation or confirmation of a medical rumor.
Most of the hospitals in China during the pandemic time adopted the preconception appointment policy to avoid crowds in the hospital. Owing to the clinical patients shrank during the pandemic time, the people who have health problems might have to adopt the new policy, while healthy people postpone their consultation. The telemedicine was not a novelty, it had provided a platform by which Chinese doctors could serve 0.38 patients per online doctor per day on average before the pandemic[1]. Whereas, according to data from online medical service provider AliHealth, its service homepage received nearly 400,000 visits within 24 hours after launching, with 97 percent of them from central China's Hubei Province, where the epidemic is most severe[2].
Furthermore, the short video platforms like TikTok have revolutionized the spread of medical information[3]. With the development of short video platforms like TikTok, the media has become the primary resource of their medical information.
But the information on platforms is patchy. Incredible information on the platform might mislead the people. According to the report of TikTok official, 29,000 coronavirus videos in Europe were removed. Approximately 3,000 of those contained medical misinformation[4]. Unfortunately, parts of the untrusted information might be created by some unprofessional medical workers, even a fake doctor. TikTok and other social media platforms like Facebook and YouTube are attempting to fight against the spread of misinformation[5]. At the same time, authentic doctors, as the provider of professional knowledge, should hold the responsibility for eliminating rumors.
Many doctors have registered their accounts during the pandemic time, and according to our observation, parts of them even acquired tens of millions of followers. Many accounts of registered nurses and official accounts of hospitals also play a significant role in pandemic time[6]. They not only eliminated the untrusted information but also provided the information for the healthy people who usually acquire knowledge from face-to-face consultation before the epidemic.
Furthermore, with the development of online consultation Apps, people with moderate disease transformed their consultation into an online form. Through several leading online consultation apps, doctors logged in their accounts and provided online consultation services.
The online consultation service mainly fills the gap of consultation due to the new policy in the pandemic.
Since the pandemic might sustain for a long time, the new form of information transform might be mastered by doctors. First, as the much more mass information and rapid spread of a new short video platform, the short video platform is a double-edged sword. We should take sufficient responsibility for the spreading of trusted medical knowledge. Second, the new form of information transform should be reserved even after the pandemic. Cause of the high convenience and accessibility, the online service should be an adequate substitution of formal consultation.
In the end, with the rebalanced connection between doctors and patients, we hope that during the pandemic time, even after the pandemic time, the new role of doctors in short video platforms should continue to develop and the online consultation service should also be sustained.

Xin Zheng*, Xin Zhang*, Yao Xu, Li Jiang
xinzheng@northwestern.edu mike.zheng@163.com Department of Urology, Beijing Youan hospital
13263372236@163.com Department of Urology, Beijing Chaoyang hospital
18611908765@163.com Department of Orthopedics, Beijing Friendship hospital
faithjiang1994@126.com Department of Obstetrics, Beijing hospital
*The Xin Zheng and Xin Zhang are the joint first authors.

References:
[1] Ramakrishna R, Zadeh G, Sheehan JP, Aghi MK. Inpatient and outpatient case prioritization for patients with neuro-oncologic disease amid the COVID-19 pandemic: general guidance for neuro-oncology practitioners from the AANS/CNS Tumor Section and Society for Neuro-Oncology. Journal of Neuro-Oncology. 2020;147(3):525-529 'doi': 10.1007/s11060-020-03488-7['2020-04-09].
[2] China Focus: Free online medical services help curb coronavirus outbreak - Xinhua | English.news.cn. Retreved 2020-9-18 from
[3] Creative Production of ‘COVID‐19 Social Distancing’ Narratives on Social Media. Retreved 2020-9-18 from
[4] Coronavirus: TikTok deletes 29,000 rule-breaking videos. Retreved 2020-9-18 from
[5] TikTok says it has removed 29,000 coronavirus videos in Europe. Retreved 2020-9-18 from
[6] How Health Communication via Tik Tok Makes a Difference: A Content Analysis of Tik Tok Accounts Run by Chinese Provincial Health Committees. Retreved 2020-9-18 from

Competing interests: No competing interests

19 September 2020
Zheng Xin
Doctor
Xin Zhang, Yao Xu, Li Jiang
Department of Urology, Beijing YouAn Hospital, Capital Medical University
No.8 YouAnMenWai XiTouTiao, Beijing YouAn Hospital
Re: Covid-19: Flying before we can walk Navjoyt Ladher. 370:doi 10.1136/bmj.m3598

Dear Editor
A non-specific and unreliable 'Test' seems to have assumed a kind of magical status: the intranasal wand, wielded by the PPE-cloaked magician, divining the future of the nation, rather like crystal ball-gazing or tealeaf-reading.
And, seemingly, the medical profession has fallen under its spell, as if red or green, which changes from day to day on a whim, has become the guiding light of medical progress.
158章你的奶真好吃 £100 billion for epidemiology may perhaps appease the gods of irrationality or bolster belief in the power of the imagination, but perhaps it could be better spent treating the neglected sick who continue to suffer despite the healing properties of rainbows?

Competing interests: No competing interests

19 September 2020
Janet Menage
GP retired
None
Wales, UK
Re: Why we . . . deskercise Helen Jones. 370:doi 10.1136/bmj.m3524

Dear Editor

158章你的奶真好吃 My favourite Deskercise of 5 minutes comes from Thai Health, a Thai government department.

Short, snappy, catchy music, moments of humour, delightful toddler trying to join in. No language needed. Free for everyone.

Dr Judith Mackay
Hong Kong

Competing interests: No competing interests

19 September 2020
Judith M Mackay
Doctor
Asian Consultancy on Tobacco Control
Hong Kong
Re: Going from evidence to recommendations Gunn E Vist, Alessandro Liberati, Holger J Schünemann, et al. 336:doi 10.1136/bmj.39493.646875.AE

158章你的奶真好吃Dear Editor

Maybe this 12 years old BMJ article [1] is not outdated because it is still one of the first downloadable from the website () of the inventors of GRADE (Grading of Recommendations Assessment, Development and Evaluation) who authored this BMJ article. It is also obvious that these definitions copied below from this article are quite clever: “GRADE classifies recommendations as strong or weak:
1.Strong recommendations mean that most informed patients would choose the recommended management and that clinicians can structure their interactions with patients accordingly,
2.Weak recommendations mean that patients’ choices will vary according to their values and preferences, and clinicians must ensure that patients’ care is in keeping with their values and preferences”.
In more recent articles, GRADE tended to replace the adjective “weak” by “conditional”, which is also clever in my view.
On the other hand, maybe this 12 years old BMJ article [1] is outdated because in GRADE leading members' recent real life, the words “most informed patients” may apparently not mean (as I have always believed they meant, because I tended to believe in the wisdom of the inventors of GRADE) “more than 95% of the informed patients at the very least”. For example, in quite recent guidelines endorsed by GRADE, it is stated: “for asymptomatic women aged 50 to 69 with an average risk of breast cancer, mammography screening is recommended in the context of an organised screening programme (strong recommendation, moderate certainty in the evidence)” [2, 3]. The authors of this recommendation also report “possibly important uncertainty about or variability in how much people value the main outcomes” [2, 3]. In patients' real life, this uncertainty or variability is shown by the fact that participation rates among women who are invited to take part in organized screening programs rarely (and barely) exceed 70%.

More recently leading members of GRADE insisted, again, that these recent breast-cancer guidelines strictly stick to the GRADE principles and methods [3]. Therefore maybe it is now time for the inventors of GRADE to update their 12 years old BMJ article, and clarify that “most informed patients” means in fact something like “more than 50% of the informed patients” [1]? (wich would be quite hazardous in my view)

References:
[1] Guyatt GH, Oxman AD, Kunz R, Falck-Ytter Y, Vist GE, Liberati A, Schünemann HJ, GRADE working group. Going from evidence to recommendations. BMJ 2008;336:1049. http://www.svw0550.com/content/336/7652/1049
[2] Schünemann HJ, Lerda D, Dimitrova N, et al; European Commission Initiative on Breast Cancer Contributor Group. Methods for development of the European Commission Initiative on Breast Cancer guidelines: recommendations in the era of guideline transparency. Ann Intern Med 2019;171:273-80.
158章你的奶真好吃 [3] Schünemann HJ, Alonso-Coello P, Gräwingholt A, Quinn C, Follmann M, Langendam M, Saz-Parkinson Z. Development of the European Commission Initiative on Breast Cancer Guidelines. Ann Intern Med 2020; 172: 72-73.

Competing interests: 158章你的奶真好吃 No competing interests

19 September 2020
Joseph Watine
consultant, laboratory medicine
hôpital de Villefranche-de-Rouergue
Avenue Caylet, F-12200 Villefranche-de-Rouergue
Re: Assisted dying: doctors challenge RCGP’s “irrational” interpretation of poll Richard Hurley. 370:doi 10.1136/bmj.m3679

Dear Editor
I support the legal challenge being made regarding the interpretation of this vote which appears to be undemocratic.
The votes against continued opposition by the RCGP to assisted dying, were in the majority. These votes were split into two camps, supporters of assisted dying and those wanting a neutral stance by the College, the Council seems to have used the outcome to support their personal views to continue opposition to assisted dying. The minutes of the Council meeting where this was decided seem to show a cursory, polarised discussion not fitting to this very important decision affecting the real, tragic lives of the public that are paid to serve.

Competing interests: No competing interests

19 September 2020
Parrish Alison
GP
None
Selsey MP
Re: An annular plaque on the hand Fei Han, Bo Guo. 370:doi 10.1136/bmj.m2209

Dear Editor
The word is 'anular', with one 'n' - ring-like, like the anus.
Not to be confused with 'annual'.
Do we blame the spell-checker? Try that notorious computer 'aid' with my occupation: 'grandparenting.

Competing interests: No competing interests

19 September 2020
Peter C Arnold
Retired GP
Nil
N/A
Sydney, Australia
Re: Appraisal and revalidation for UK doctors—time to assess the evidence Victoria Tzortziou Brown, Margaret McCartney, Carl Heneghan. 370:doi 10.1136/bmj.m3415

To the Editor,
158章你的奶真好吃 The American justice, Oliver Wendell Holmes, said, " Hard cases make bad law ". The billion-pound responsible officer/appraisal/revalidation bureaucracy sprang from a once-in-a-lifetime case but Parliament and the GMC's expiation of perceived failure to prevent or detect a rogue doctor goes on. And it will continue to do so, and rogue doctors like Paterson will still emerge from time to time. In the meantime, all doctors are treated as embryonic Shipmans and made to engage in a window-dressing process which is enforced by threat of being struck off. Because make no mistake, if this process had merit we'd know it by now, just as we'd know if "bare below the elbow " and putting no-brainer cases through interminable MDT's had such. It costs money and time with patients to engage with appraisal and revalidation with no proven upside. The BMA must poll its members on this issue and take action with the legislature with the anticipated result. Amazingly, doctors do reflect on their practices--- every day. We do not have time to tick-box our way through a political exercise. Shipman is dead; let his legacy die, too.

Competing interests: 158章你的奶真好吃 No competing interests

19 September 2020
Mark J Moskowitz
Medical Oncologist
Christie NHS Trust
Wilmslow Road, Manchester M204BX
Re: Don’t torment me with hope Alexandra Filby. 370:doi 10.1136/bmj.m3016

158章你的奶真好吃Dear Editor

In defence of hope

158章你的奶真好吃Alexandra Filby’s painful experience illustrates the need for more open and upfront, albeit difficult, conversations about prognosis and death. [1]. The society, as a whole, doesn’t embrace death in a rational manner and oncologists are no exception. [2]. As observed in an ethnographic study, doctors and patients do sometimes collude in avoiding discussions about death.[3].

158章你的奶真好吃Nevertheless, honest conversations about death don’t mean extinguishing hope when discussing treatments for incurable disease.[4]. This is because hope helps to dissipate anger and frustration. Hope keeps the cloud of despair at bay as the painful journey progresses towards acceptance of death.

158章你的奶真好吃Along with discussions about prognosis, many patients do prefer “cup half-full” type of hopeful honesty rather than “cup half-empty” type of dark pessimism. Many cancer patients go through palliative chemotherapy for small survival benefits even after an open honest conversation about benefits and risks.[5].

Furthermore, Oncologists are not terribly good at accurate prognostication.[6]. Not all cancers behave in the same manner. Some cancers are quite aggressive. Some can be indolent. Some respond well to treatment. Prognosis of advanced cancers is actually quite dependent on response to treatment. An incurable cancer diagnosis doesn’t always spell doom and gloom as exemplified by advanced prostate cancer patients having a prognosis typically measured in years. So when there are significant uncertainties about anticipated treatment outcome, hoping for an optimistic outcome is the default coping mechanism of many patients as well as their oncologists.

158章你的奶真好吃References:

158章你的奶真好吃1 Filby A. Don’t torment me with hope. BMJ 2020;370. doi:10.1136/bmj.m3016

158章你的奶真好吃2 Enkin M, Jadad AR, Smith R. Death can be our friend. BMJ 2011;343. doi:10.1136/bmj.d8008

158章你的奶真好吃3 The A-M, Hak T, Koëter G, et al. Collusion in doctor-patient communication about imminent death: an ethnographic study. BMJ 2000;321:1376–81. doi:10.1136/bmj.321.7273.1376

4 Kirk P, Kirk I, Kristjanson LJ. What do patients receiving palliative care for cancer and their families want to be told? A Canadian and Australian qualitative study. BMJ 2004;328:1343. doi:10.1136/bmj.38103.423576.55

158章你的奶真好吃5 Slevin ML, Stubbs L, Plant HJ, et al. Attitudes to chemotherapy: comparing views of patients with cancer with those of doctors, nurses, and general public. BMJ 1990;300:1458–60. doi:10.1136/bmj.300.6737.1458

6 Glare P, Virik K, Jones M, et al. A systematic review of physicians’ survival predictions in terminally ill cancer patients. BMJ 2003;327:195. doi:10.1136/bmj.327.7408.195

Competing interests: 158章你的奶真好吃 No competing interests

19 September 2020
Santhanam Sundar
Consultant Oncologist
Nottingham University Hospitals NHS Trust
Re: Covid-19: Do many people have pre-existing immunity? Peter Doshi. 370:doi 10.1136/bmj.m3563

Dear Editor
I agree with the proposal that initial assumption of universal susceptibility to SARS-CoV-2 can be misleading. The existence of a non-susceptible population (be it due to immunity or to other causes) can have profound implications. However, this population would be hard to define and study: how can we recognize a group that has been in contact with SARS-CoV-2 but did not get measurable COVID-19?
Patients with COVID-19 associated perniosis are a proxy for non-susceptible population. Not the optimal one, because they have shown this mild skin sign, but an accessible one. Association of perniosis with COVID-19 has been a topic of intense debate: it coincides in time and place with COVID-19 outbreaks, some patients had confirmed COVID-19 and good prognosis1,2, and familiar clusters have been described suggesting an association with COVID-191. However, most of them do not show any other sign of disease and PCR and serologic tests are usually negative2-4. The hypothesis of COVID-19 perniosis being a marker for natural resistance to SARS-CoV-2 has been raised5. Several recent papers are a strong support for it, showing that patients with COVID-19 perniosis, even if testing negative by PCR and serology, might have virus particles in the endothelium of skin vessels. In one of the patients, the presence of SARS-CoV-2 has been confirmed both by immunohistochemistry and electron microscopy6,7. These initial findings should be replicated in larger samples but can have profound implications. These results indicate that in some of the patients viral replication is low and is not detected by PCR nor serology. This is associated with a strong interferon response8, that can be age-related. We don´t have incidence data for COVID-19 perniosis, but it might represent more than 20% of the cases with skin manifestations1, a size large enough to be relevant. Furthermore, COVID-19 perniosis could be just the tip of the iceberg of non-susceptibility, an iceberg of unknown magnitude.
Describing this population of non-susceptible (using COVID-19 perniosis as a proxy), their prevalence, and their characteristics and mechanisms of non-susceptibility is a priority. Its results might give insights into therapy and can lead to very important changes in the interpretation of serological results, epidemiological models, and future vaccination strategies.

References

1 Galvan Casas C, Catala A, Carretero Hernandez G et al. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases. Br J Dermatol 2020; 183: 71-7. 10.1111/bjd.19163
2 Freeman EE, McMahon DE, Lipoff JB et al. Pernio-like skin lesions associated with COVID-19: A case series of 318 patients from 8 countries. J Am Acad Dermatol 2020; 83: 486-92. 10.1016/j.jaad.2020.05.109
3 Herman A, Peeters C, Verroken A et al. Evaluation of Chilblains as a Manifestation of the COVID-19 Pandemic. JAMA Dermatol 2020. 10.1001/jamadermatol.2020.2368
4 Roca-Gines J, Torres-Navarro I, Sanchez-Arraez J et al. Assessment of Acute Acral Lesions in a Case Series of Children and Adolescents During the COVID-19 Pandemic. JAMA Dermatol 2020. 10.1001/jamadermatol.2020.2340
5 Lipsker D. A chilblain epidemic during the COVID-19 pandemic. A sign of natural resistance to SARS-CoV-2? Med Hypotheses 2020; 144: 109959. 10.1016/j.mehy.2020.109959
6 Colmenero I, Santonja C, Alonso-Riano M et al. SARS-CoV-2 endothelial infection causes COVID-19 chilblains: histopathological, immunohistochemical and ultrastructural study of seven paediatric cases. Br J Dermatol 2020. 10.1111/bjd.19327
7 Santonja C, Heras F, Nunez L et al. COVID-19 chilblain-like lesion: immunohistochemical demonstration of SARS-CoV-2 spike protein in blood vessel endothelium and sweat gland epithelium in a polymerase chain reaction-negative patient. Br J Dermatol 2020. 10.1111/bjd.19338
158章你的奶真好吃 8 Magro C, Mulvey JJ, Laurence J et al. The differing pathophysiologies that underlie COVID-19 associated perniosis and thrombotic retiform purpura: a case series. Br J Dermatol 2020. 10.1111/bjd.19415

Competing interests: 158章你的奶真好吃 No competing interests

19 September 2020
Ignacio Garcia-Doval
Dermatologist, Epidemiologist
Complexo Hospitalario Universitario de Vigo.
Vigo, Spain

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