Dear Editor

This article continues a concerning pattern of publishing the results of surveys based solely on a press release, without critical evaluation of their methodology or acknowledgement of potential limitations (1-3). The Medical Defence Union (MDU) survey reports that “Nearly 90% of respondents … say they feel sleep deprived at work” (4). The significance of the phrase "of respondents" in survey reports is frequently overlooked or underappreciated, including by the journalist covering this story (5).

The accuracy of surveys depends on the response rate and the representativeness of respondents compared to the entire target population; in this instance, doctors. The lower the response rate, the greater the risk of overestimating the true prevalence, in this case particularly if those suffering sleep deprivation were more motivated to participate in the survey (6,7). The MDU survey has multiple other limitations, including self-reporting and the lack of a control group.

Neither the BMJ article nor the MDU press release from which it is derived provides the essential details about the survey’s methodology and response rate. In answer to my request for clarification from the MDU about the sample from which the 481 respondents were drawn, their reply was: “we are unable to share this information with you”.

When reporting surveys, it is incumbent upon the BMJ to scrutinise their methodological rigour, particularly those from organisations that may have conflicts of interest in the outcomes they report. Once published by a reputable journal, such as the BMJ, survey results gain unwarranted legitimacy, leading other media outlets to disseminate the findings without appropriate diligence or mention of critical methodological limitations, including the crucial caveat "of respondents" (8).

Sleep deprivation among doctors is unquestionably a serious concern, with significant implications for patient safety and physician wellbeing (9,10). However, publishing survey results without rigorous methodological scrutiny, particularly when they fail the ‘pub test’, risks overstating the issue or misrepresenting the extent of the problem, misleading the public, and eroding trust in scientific research. To maintain public confidence in science and effectively highlight important issues, medical journals like the BMJ have a responsibility to ensure methodological transparency and critical evaluation when reporting survey results.

1. Curtis N. Rapid response to Kmietowicz Z. Nearly all doctors have faced a complaint in their career, survey finds. BMJ. 2021;372:n707.
https://www.bmj.com/content/372/bmj.n707/rr-1

2. Curtis N. Reporting survey results without mention of the potential impact of low response rate is misleading. Response to Iacobucci G. Third of people in Balkans, Caucasus, and central Asia used antibiotics without a prescription last year, finds survey. BMJ. 2023;383:p2773.
https://www.bmj.com/content/383/bmj.p2773/rr

3. Curtis N. Bad data is worse than no data: sensationalised headlines reporting surveys with low response rates risks eroding public trust in science. Response to Mahase E. Almost a third of UK doctors are considering moving abroad soon, survey suggests. BMJ. 2024;385:q856.
https://www.bmj.com/content/385/bmj.q856/rr

4. Medical Defence Union (MDU). Doctors more sleep deprived now than after the pandemic, MDU survey finds. 3 Mar 2025.
https://www.themdu.com/press-centre/press-releases/doctors-more-sleep-de...

5. Iacobucci G. Doctors' lack of sleep is affecting patient care, defence body warns. BMJ. 2025 Mar 3;388:r438. doi: 10.1136/bmj.r438. PMID: 40032328.
https://doi.org/10.1136/bmj.r438

6. Surveys with a low response rate are unreliable for estimating prevalence. Pediatr Infect Dis J. 2025; 44: e66-e68.
https://journals.lww.com/pidj/fulltext/2025/02000/surveys_with_a_low_res...

7. Curtis N. Long COVID in a highly vaccinated but largely unexposed Australian population following the 2022 SARS-CoV-2 Omicron wave. Med J Aust. 2025. doi: 10.5694/mja2.52619.
https://onlinelibrary.wiley.com/doi/10.5694/mja2.52619

8. Gregory A. One in three NHS doctors so tired their ability to treat patients is affected, survey finds. The Guardian 3 Mar 2025.
https://www.theguardian.com/society/2025/mar/03/one-in-three-nhs-doctors...

9. Bryant PA, Trinder J, Curtis N. Sick and tired: Does sleep have a vital role in the immune system? Nat Rev Immunol. 2004;4(6):457-67. doi: 10.1038/nri1369. PMID: 15173834.
https://www.nature.com/articles/nri1369

10. Bryant PA, Curtis N. Sleep and infection: no snooze, you lose? Pediatr Infect Dis J. 2013;32(10):1135-7. doi: 10.1097/INF.0b013e3182a4d610. PMID: 24067554.
https://journals.lww.com/pidj/fulltext/2013/10000/sleep_and_infection__n...

Dear Editor,

While the COVID-19 pandemic cannot be considered yet behind our shoulders, due to the repeated appearance of new SARS-CoV-2 variants and subvariants able to bypass the population's immunity conferred by infection and/or vaccination, the highly pathogenic avian influenza (HPAI) A(H5N1) virus is increasingly perceived as a global threat.

Since its first description in 1959 in Scottish poultry farms (1), the A(H5N1) virus was subsequently identified in 1996 in intensively reared ducks and chickens from China (2), with the first human infection case having been additionally reported in 1997.

Nowadays, approximately 1,000 disease episodes caused by HPAI A(H5N1) virus (mostly characterized by severe pneumonia and, occasionally, by encephalitis) have been ascertained in people on a global scale, with a 50% case-fatality rate and with 23 different Countries being also affected (3).

Within this framework, the recent migratory bird-driven spread of A(H5N1) virus clade 2.3.4.4b to a huge and progressively growing number of domestic and wild avian and mammalian host species from Eurasia, North and South America, up to the Arctic and Antarctica regions - including South American sea lions and a polar bear in Alaska (4) - is of concern, according to the Scientific Community, the World Health Organization, the World Organization for Animal Health and the public health Authorities from many European and extra-European Countries. More in detail, the consistent viral neurotropism and neuropathogenicity (4,5), coupled with a high infection's lethality rate and the well-established propension of influenza viruses to undergo mutations (6) - especially at the level of haemagglutinin and polymerase genes - are of crucial relevance, given the already threatened health and conservation status of several A(H5N1) virus-susceptible wildlife species. Indeed, the aforementioned mutations have allowed, and continue still to allow, a successful pathogen's adaptation to a consistent and progressively growing number of avian and mammalian hosts, including species that are phylogenetically distant from each other. The last one in chronological order is represented by the ovine species, with a case of A(H5N1) viral infection having been recently reported in a sheep from Yorkshire (7).

Within such context, cattle are of significant concern, given their well-known susceptibility to HPAI A(H5N1) viral clade 2.3.4.4b. As a matter of fact, since the bovine mammary gland may be targeted by both avian and human origin viruses - with viral infectivity having been clearly shown in unpasteurized milk - this could "accreditate" cattle as a further "mixing vessel" allowing the genetic reassortment and recombination between avian and human viruses, similarly to swine.

Cases of severe respiratory and neurological A(H5N1) viral disease have been also described in cats following the consumption of raw milk from infected cattle (8) as well as in farm workers from Texas, Michigan and other USA regions, in whom a bilateral conjunctivitis is commonly observed, sometimes accompanied by a febrile syndrome with mild respiratory signs (9).

Despite the hitherto available "absence of evidence" towards HPAI A(H5N1) virus interhuman transmission, the recently demonstrated susceptibility of mice and ferrets to a viral strain recovered from the conjunctiva of a patient in Texas should be viewed as another serious concern issue. Such experimentally challenged animals developed, in fact, a lethal systemic infection characterized by severe bilateral pneumonia and encephalitis (10).

Finally, since we are dealing with a zoonotic infection, in a similar manner to what happens with "emerging infectious diseases", whose proven or suspect origin lies for two thirds of them in one or more animal reservoirs, the main take-home messages for efficiently tackling and counteracting HPAI A(H5N1) virus spread among birds and mammals as well as from birds and mammals to humans, with special emphasis on interhuman transmission, may be summarized by the following key words:

Multidisciplinarity, intersectorial cooperation, predictive epidemiology, tracking of viral genetic mutations, open data and, last but not least, One Health.

References

1) USA Centers for Disease Control and Prevention (CDC). 1880-1959 Highlights in the History of Avian Influenza (Bird Flu) Timeline. DOI: https://www.cdc.gov/bird-flu/avian-timeline/1880-1959.html.

2) USA Centers for Disease Control and Prevention (CDC). Emergence and Evolution of H5N1 Bird Flu. (2024). DOI: https://www.cdc.gov/flu/avianflu/communication-resources/bird-flu-origin....

3) USA Centers for Disease Control and Prevention (CDC). About Bird Flu. (2024). DOI: https://www.cdc.gov/flu/avianflu/communication-resources/bird-flu-origin....

4) Di Guardo G. (2024). Central Nervous System Disorders of Marine Mammals: Models for Human Disease? Pathogens 13(8):684. DOI: 10.3390/pathogens13080684.

5) Bauer L., Benavides F.F.W., Veldhuis Kroeze E.J.B., de Wit E., van Riel D. (2023). The neuropathogenesis of highly pathogenic avian influenza H5Nx viruses in mammalian species including humans. Trends Neurosci. 46(11):953-970. DOI: 10.1016/j.tins.2023.08.002.

6) McKie R. (2024). Next pandemic likely to be caused by flu virus, scientists warn. The Observer. DOI: https://www.theguardian.com/world/2024/apr/20/next-pandemic-likely-to-be....

7) Mahase E. (2025). H5N1: UK reports world's first case in a sheep. BMJ 388: r591. DOI : https://doi.org/10.1136/bmj.r591.

8) Burrough E.R., Magstadt D.R., Petersen B., Timmermans S.J., Gauger P.C., Zhang J., Siepker C., Mainenti M., Li G., Thompson A.C., Gorden P.J., Plummer P.J., Main R. (2024). Highly Pathogenic Avian Influenza A(H5N1) Clade 2.3.4.4b Virus Infection in Domestic Dairy Cattle and Cats, United States, 2024. Emerg. Infect. Dis. 30(7):1335-1343. DOI: 10.3201/eid3007.240508.

9) Garg S., et al. (2025). Highly Pathogenic Avian Influenza A(H5N1) Virus Infections in Humans. N. Engl. J. Med. 392(9):843-854. DOI: 10.1056/NEJMoa2414610.

10) Gu C., Maemura T., Guan L., et al. (2024). A human isolate of bovine H5N1 is transmissible and lethal in animal models. Nature 636:711-718. DOI: https://doi.org/10.1038/s41586-024-08254-7.

Dear Editor

Professor Masud Husain makes a compelling argument in his Opinion article from 12th March 2025 (1) to rescue clinical research in the UK, highlighting the need for closer collaboration between universities and NHS organisations to streamline bureaucracy. However, at the heart of this struggling relationship lie the significant financial pressures for healthcare services and research support because of years of underfunding, Brexit, the recent pandemic, and other challenges, with partnered institutions, in essence, competing for clinical trials as a potential source of income.

But not all is gloom. Clinical trials research is key to improve patient care and belongs in the NHS (2) whilst higher education institutions and universities drive innovation and knowledge dissemination, with institutions complementing each other’s aims. Professor Husain rightly points to the need for partnered institutions to move in tandem and suggests the removal of honorary contracts with researchers being considered equal regardless of employing organisation (1). Indeed, current financial models hinder progress. The Research Excellence Framework (REF) outcomes used to inform the allocation of research funding, providing accountability for public investment, and insights into health research (3) apply solely to universities but not to honorary staff. In essence, research active (academic) clinicians employed by an NHS organisation and holding an honorary contract with a partnered university are not considered within the REF framework, with the consequent loss of potential income to both institutions. Similarly, clinically active academics may find their chances of promotion at their employing universities affected because of their research being considered too clinical or service delivery centred, decreasing in effect their fundability appeal. These scenarios can be solved by an improved dialogue between Research England and the NHS.

A new approach to commercial trial design is desperately needed. The last two decades have seen enormous growth on the number of advanced drug therapies with targeted, highly precise mechanisms of action in many disease areas. Yet, simplified study designs are warranted whereby new use of old drugs including treatment strategy trials, head-to-head studies, or new indications of existing therapies, have streamlined, feasible, open label designs aligned to NHS practice. This will improve recruitment strategies and minimise current ethical considerations when offering double-blind interventions in clinical trials of commercially available drugs, one of main hurdles to recruitment in western countries. This simplified approach will lead to fast change with swifter set up times and more cost-effective delivery benefiting both NHS and independent trial sites (4).

In the same line, investigator initiated clinical trials, currently dwindling, need dedicated avenues of funding that could come through extended collaboration between the NHS and pharma. Indeed historically, grant award bodies have looked down on observational, real world phase IV trials which are otherwise essential to offer insights in the long-term effectiveness and safety of treatments and interventions in diverse patient populations, complementing phase III clinical trials. The ultimate push to cost-effective research delivery would be the adoption of an open electronic health care record at national level to facilitate sharing and rapid implementation of know-how and new knowledge which can immediately translate into improved patient outcomes. To this end, the recently created NHS Digital is a step in the right direction (6).

All in all, the answers to the current foes faced by clinical research in the UK lie within. Improving the dialogue between the NHS and universities, rethinking clinical trial design, and standardising the electronic health care record systems are already within reach. The time to start implementing change is now.

Professor Helena Marzo-Ortega MRCP PhD
Consultant Rheumatologist and Honorary Professor of Clinical Translational Rheumatology

References
1. Masud H. Clinical research in the UK is failing: universities and NHS trusts need to change. BMJ 2025;388:r469.
2. Marzo-Ortega H. Placing research at the centre of UK health-care delivery to fix clinical academia. The Lancet 2025 (in press)
3. https://www.ukri.org/publications/explainer-qr-research-funding-and-the-.... Accessed 4th April 2025.
4. Smith I. Commercial clinical trials are growing in the UK BMJ 2025;388:r469/rr
5. Ingram, D; Kalra, D; Austin, T; Darlison, MW; Modell, B; Patterson, D. Towards an interoperable healthcare information infrastructure - working from the bottom up. BT Technol J 2006;24 (3) 17 - 32. 10.1007/s10550-006-0071-4.
6. https://www.gov.uk/government/organisations/nhs-digital. Accessed 4th April 2025.

Dear Editor

In September 2024, I suggested that this case should be appealed to the High Court [1]. In fact, it was appealed and the High Court handed down its judgment on 3rd April this year [2].

In my response, among other things, in relation to rejection of alleged racial harassment, I said, “it appears, the MPT has failed to give sufficient, logically sustainable reasons to support such conclusion” [1]. This issue was taken pursued on appeal and the High Court concluded (58):
“I accept Mr. Hare KC's submission. The Tribunal's definition of harassment is muddled and yet the charge was straightforward: that the comment made to Ms I about a patient during an organ retrieval procedure "look at all that fat, this is what happens when you eat chapatti" constituted harassment (related to race) as defined in section 26(1) of the EA, in that Mr. Gilbert engaged in unwanted conduct related to race, which had the effect of creating a degrading or offensive environment for Ms I.” [2].

The outcome on appeal is a “suspension of 12 months” (145)[2] rather than 8 months which the MPTS imposed initially. Whether extending the suspension by 4 months amounts to a proportionate level of justice remains arguable.

References
[1] https://www.bmj.com/content/386/bmj.q1881/rr-3
[2] https://www.bailii.org/ew/cases/EWHC/Admin/2025/802.html