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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: Mortality from different causes associated with meat, heme iron, nitrates, and nitrites in the NIH-AARP Diet and Health Study: population based cohort study Maki Inoue-Choi, Sanford M Dawsey, Christian C Abnet, et al. 357:doi 10.1136/bmj.j1957

Red meat contains N-Glycolylneuraminic acid (Neu5Gc). I am surprised that Drs Potter and Etamadi et al make no mention of it. Neu5Gc occurs in virtually all red mammalian meat – with the exception of humans. In humans, the gene encoding CMP-N-acetylneuraminic acid hydroxylase mutated to an inactive form some three million years ago. It is thought that this conferred protection against an archaic form of malaria1.

When we eat red meat, Neu5Gc is absorbed and gives rise to an innate immune response. In the long term, this creates a chronic a low-grade inflammatory milieu. This will happen even if we eat fresh uncooked raw red meat2.

Such a milieu will promote cancers, insulin-resistance, hyperinsulinaemia and obesity, amongst other diseases.

I suspect that Neu5Gc will prove to be a major driving force of ill health.

01. Chou, H-H, Takematsu, H, Diaz, S et al A mutation in human CMP-sialic acid hydroxylase occurred after the Homo-Pan divergence. Proceedings of the National Academy of Sciences, 1998;95:11751–6.

02. Samraj, AN, Pearce, OM, Läubli et al A red meat-derived glycan promotes inflammation and cancer progression. Proceedings of the National Academy of Sciences. 2015;112:542–7.
doi: 10.1073/pnas.1417508112

Competing interests: No competing interests

25 May 2017
Consultant - retired
Nuffield Department of Anaesthetics
John Radcliffe Hospital, Oxford, OX3 9DU
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Re: Critical thinking in healthcare and education Sandy Oliver, Kevan Collins, Astrid Austvoll-Dahlgren, Tammy Hoffmann, et al. 357:doi 10.1136/bmj.j2234

Walker (2003) highlighted that many individuals believe that the tendency to think critically must be nurtured. We have seen educated healthcare professionals in healthcare facilities but does that mean that they have critical thinking skills? I agree with Jonathan Sharples et al in the article, “Critical thinking in healthcare and education”arguing about the importance for clinicians and patients to learn to think critically and that the teaching and learning of these skills to be explicitly considered.

Critical thinking includes “analysis, inference, interpretation, explanation, synthesis and self –regulation” (Facione, 2011). The healthcare team should be able to utilize their critical thinking skills as they come in contact with their patients daily. Critical thinking has been well documented in nursing but the evidence in medicine is limited (Batool, 2010; Iranfar, Sepahi, Khoshay, Rezaei, Matin, Keshavarzi, & Bashiri, 2012; Mahmoodabad, Nadrian, & Nahangi, 2012; Maudsley & Strivens, 2000). Are nurses the only group of health professionals taking care of patients? Certainly not, other members of the healthcare team work collaboratively with each other to ensure optimal patient care. Thus critical thinking is essential among healthcare professionals.

Critical thinking is integral in caring for patients and before one can teach patients to think critically, he or she needs to model the behavior but how can one model what they do not know? Riddel (2007) emphasized that critical thinking is a complex process and not a single way of thinking. Cottrell (2011) concurred with Riddel and added that critical thinking includes identification of the views of individuals, evaluation of evidence to explore alternate views, being unbiased in weighing the evidence and opposing arguments.

However, Romeo (2010) defines critical thinking as an attribute that strengthens the decision making and problem solving skills of an individual. In order for students to develop critical thinking skills and depositions, the faculty needs to reconsider their philosophy of teaching and implement critical thinking in the curricula (Billings & Halstead, 2012). Educators can design their teaching plans to facilitate critical thinking disposition and critical learning. If students in healthcare professions are taught critical thinking early in their programs, they will be able to develop the skill and will be able to utilize same effectively in their practice.

The healthcare system is evolving and emphasis should be placed on healthcare professionals to develop creative and critical thinking skills so that they can administer optimal patient care and be able to teach their patients how to think critically.

Batool, T. (2010). Hyposkillia and critical thinking: Lost skills of doctors.APS Journal of case reports, 1(1), 9.
Billings, D. M., & Halstead, J. A. (2012). Teaching in nursing: A guide for faculty (4th ed.). St. Louis: Elsevier Health Sciences.
Cottrell, S. (2011). Critical thinking skills: Developing effective analysis and argument. Palgrave Macmillan.
Facione, P. A. (2011). Critical thinking: What it is and why it counts. Insight Assessment, 2007(1), 1-23.
Iranfar, S., Sepahi, V., Khoshay, A., Rezaei, M., Matin, B. K., Keshavarzi, F., & Bashiri, H. (2012). Critical thinking disposition among medical students of Kermanshah University of Medical Sciences. ducational Research in Medical Sciences Journal, 1(2), 63-68.
Mahmoodabad, S. S. M., Nadrian, H., & Nahangi, H. (2012). Critical thinking ability and its associated factors among preclinical students in Yazd Shaheed Sadoughi University of Medical Sciences (Iran). Medical Journal of the Islamic Republic of Iran, 26(2), 50.
Maudsley, G., & Strivens, J. (2000). ‘Science’,‘critical thinking’and ‘competence’ for tomorrow’s doctors. A review of terms and concepts.Medical Education, 34(1), 53-60.
Riddell, T. (2007). Critical assumptions: Thinking critically about critical thinking. Journal of Nursing Education, 46(3).
Romeo, E. M. (2010). Quantitative research on critical thinking and predicting nursing students’ NCLEX-RN performance. Journal of Nursing Education, 49(7), 378-386.
Walker, S. E. (2003). Active learning strategies to promote critical thinking. Journal of athletic training, 38(3), 263.

Competing interests: No competing interests

25 May 2017
Kadene RM. Leslie
Registered Nurse
UWI School of Nursing
9 Gibraltar Camp Road, Kingston.
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Re: US government website for collecting adverse events after vaccination is inaccessible to most users Peter Doshi. 357:doi 10.1136/bmj.j2449

I had been led to believe that here (on either side of the Atlantic) scientific truth is practised. That untruthfulness is the exclusive preserve of dictatorial, communistic, religious fanaticism.
Doshi tells us (or am I mistaken?) that intellectual dishonesty is the norm in vaccine risks.
All in the cause of?

Competing interests: No competing interests

25 May 2017
JK Anand
Retired doctor
Free spirit
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Re: Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study Julia Hippisley-Cox, Carol Coupland, Peter Brindle. 357:doi 10.1136/bmj.j2099

We welcome the publication of the QRisk3 score which includes variables for both severe mental illness (SMI) and antipsychotics. We have published a range of work regarding SMI and cardiovascular disease, including research showing that existing cardiovascular risk scores may perform less well for people with SMI (1). This is important since people with SMI continue to suffer elevated rates of CVD compared to the general population.

Qrisk3 defines SMI similarly to our own work and similarly to NICE, to include schizophrenia, bipolar disorder and other psychoses. However we are interested in the high prevalence of SMI in the QRisk3 cohort which is 4.3% for men and 6.8% for women.  This is far higher than the usual community rates of SMI, the SMI rates in other UK primary care database studies or rates that are quoted in NICE indicators (namely 0.5-2%) (1-3)
Conversely, the levels of second generation antipsychotic  prescribing in the QRisk3 cohort (0.5%) are more in keeping with published SMI rates, although it is of note that around half UK antipsychotics are prescribed to people without  SMI diagnoses (4).
It would be helpful if the authors clarified the diagnoses included within their SMI category, so that the correct conditions can be included when applying and assessing the new QRisk3 score.

Prof David Osborn
Dr Kate Walters

1. Osborn, D. P., Hardoon, S., Omar, R. Z., Holt, R. I., King, M., Larsen, J., . . . Petersen, I. (2015). Cardiovascular risk prediction models for people with severe mental illness: results from the prediction and management of cardiovascular risk in people with severe mental illnesses (PRIMROSE) research program. JAMA Psychiatry, 72 (2), 143-151. doi:10.1001/jamapsychiatry.2014.2133

2. Hardoon, S., Hayes, J. F., Blackburn, R., Petersen, I., Walters, K., Nazareth, I., & Osborn, D. P. J. (2013). Recording of Severe Mental Illness in United Kingdom Primary Care, 2000-2010. PLoS One.

3. National Institute for Clinical Excellence. Standards and Indicators. NM120. (2015) (accessed May 24th 2017).

4. Marston, L., Nazareth, I., Petersen, I., Walters, K., & Osborn, D. P. (2014). Prescribing of antipsychotics in UK primary care: a cohort study. BMJ Open, 4 (12), e006135-?. doi:10.1136/bmjopen-2014-006135

Competing interests: DO and KW have received grant funding from the NIHR and MRC related to the assessment and management of cxardiovascular risk in people with SMI

25 May 2017
David P Osborn
Professor of Psychiatric Epidemiology
Dr Kate Walters, Reader in Primary Care and Epidemiology, UCL
Division of Psychiatry, UCL
Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF.
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Re: Five minutes with . . . Suzy Jordache Tom Moberly. 357:doi 10.1136/bmj.j2371

Perhaps the title gives a clue to one of the underlying problems. Clinical life has become so 'rammed' that we rarely spend more than five minutes doing anything not subject to guidelines and protocols. In reality '5 minutes with ... Suzie Jordache' for many clinicians is probably much less than that. Interesting and important certainly, but complex, incompletely understood and too demanding of thinking time. A task without a target, an unaffordable luxury, but tomorrow's care sacrificed for lack of time to ponder.

Competing interests: No competing interests

25 May 2017
Arjun Ardeshana
CT1 anaesthesia
Mark W Davies, consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust
L8 7XP
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Re: Non-inferiority trials Philip Sedgwick. 342:doi 10.1136/bmj.d3253

Dr. Sedgwick writes in the text of this endgame, as follows:

"Which one of the following statements best describes the null hypothesis for the statistical test of the comparison of pristinamycin with penicillin in the primary end point?.........c) In the population, the cure rate for penicillin is greater than for pristinamycin by 10% or more d) In the population, the cure rate for pristinamycin was no more than 10% below that for penicillin............"

He goes on writing, further............

"Answer c is the best description. ......... The sample size was calculated so that the trial would show that pristinamycin was not inferior to penicillin in efficacy if the cure rate for pristinamycin was no more than 10% below that for penicillin. The difference of 10%, called the non-inferiority margin, was based on clinical judgment. If the cure rate for pristinamycin was lower than that for penicillin by a difference larger than the non-inferiority margin, then pristinamycin would not be considered clinically equivalent to penicillin in efficacy......."

So, in effect, it is answer d which is the best description and not c, which has been erroneously written.

Competing interests: No competing interests

25 May 2017
Neeru Gupta
Scientist F
Jugal Kishore and Neeta Kumar.
Indian Council of Medical Research
Ansari Nagar, New Delhi-110029.
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Re: Health research priorities and gaps in South Asia Sunil De Alwis, Lalit Dandona, et al. 357:doi 10.1136/bmj.j1510

There is no denial that quality and quantity of published medical literature from India is poor. Most of the scientific literature emanates from national level or regional medical institutes, and medical colleges located in metropolitan cities. Besides the lack of infrastructure or funding for conducting such research, the main reason for the lack of medical research and consequent publication is a dilapidated bent of research oriented mind. A careful analysis of published literature would reveal that the main source of these publications is thesis work done by residents during their postgraduate study. The extra mural research is little in quantity.

Although a number of central agencies like ICMR are offering funds, the expertise to design a study and research project is virtually non-existent in medical colleges located in peripheral cities. There is an urgent need to familiarise medical teachers and postgraduate students with research methodologies and designing projects that can result in funding for research. The non-availability of current scientific journals both in print and electronic forms is yet another reason. The libraries of these medical colleges need funds to provide access to both paid and unpaid contents. The cost of publishing in open-access sources is very high (even by Indian standards) and is a barrier in submitting publications to these journals.

There is a need to expand the ICMR through setting up of regional centers located in state capitals to stimulate research at the cutting edge.

Competing interests: No competing interests

24 May 2017
Dinesh Sharma
Retired Medical Teacher
Amritsar-143001 India
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Re: Physician age and outcomes in elderly patients in hospital in the US: observational study Anupam B Jena, et al. 357:doi 10.1136/bmj.j1797

This seemingly simple observational study, based presumably on a huge sample size, generates too many questions to count and too few answers to be useful: it does however appear to be important. As physicians over time move inexorably from one age category to the next, replication of the study at intervals, to see if the observed effect on mortality (& perhaps other outcomes) persisted, would be very interesting. As patients face the prospect of doctors having to work more and more years we need to understand these findings.

Competing interests: No competing interests

24 May 2017
Ben Lane
clinical fellow in anaesthesia
Mark W Davies, consultant in anaesthesia & perioperative medicine
Royal Liverpool & Broadgreen University Hospitals NHS Trust
Liverpool L7 8XP
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Re: Assisted dying for healthy older people: a step too far? Els van Wijngaarden, Ab Klink, Carlo Leget, Anne-Mei The. 357:doi 10.1136/bmj.j2298

Here are some principles I have put together regarding the care of severely ill patients:

1. Never give words of reassurance.
2. The challenge is not just allowing, but enabling the patient to articulate his feelings.
3. Often the patient has strong feelings about his relatives: probe, discuss, but don’t correct or contradict or give suggestions.
4. The pain of the present will usually be coloured, shaped, influenced by pains in the past. And this means that
5. The patient may wish to reminisce, recount, revisit the past – this is not a denial of the present, but a “trip down memory lane” before it is too late for this.
6. Good mood, even jokes, are not to be treated as a denial, but an invitation for a warm, close few minutes – proof that the illness has not decimated all personal qualities.


1. The carer must be seen as equally in need of comfort/support.
2. He/she also experiences pain, but will usually feel “not entitled” to it.
3. Important to investigate what is the carer’s interpretation of the patient’s condition and, above all, what he/she anticipates is the prognosis.
4. Most carers will feel guilty for not giving sufficient support or, even, for being a factor in the patient’s condition and/or present state. Again, reassurance should not be given. Putting it in a formula “he knows he is not guilty, but he feels guilty.” Therefore, questions must be put forward, allowing the carer to recognize how complex and contradictory are his feelings.

Dr A H Brafman, MRCPsych.

Competing interests: No competing interests

24 May 2017
Abraham H. Brafman
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Re: Margaret McCartney: Our politicians are wilfully failing the NHS Margaret McCartney. 357:doi 10.1136/bmj.j2474

Our politicians are wilfully failing the NHS

Certainly the politicians have failed the NHS but the NHS itself has failed both patients and the nation in several ways.

This brought to light by a recent article in the BMJ entitled “Italy recognises patient safety as a fundamental right”

1) This failure of the NHS to implement an effective safety policy to minimize “medical error” is costing £millions if not £billions in reparation costs and legal costs. This could be substantially reduced.

2) The failure to update diagnostic techniques in diseases because “the methods defined 40-50 years ago are considered adequate” is another area where substantial savings could be made. In this regard I am thinking of Type 2 diabetes(TD2). We are always told that early diagnosis is essential to improve the possibility of full recovery yet in practice the current protocol and guidelines continues to rely on methods that are based on hyperglycaemia and HbA1c. Dr JR Kraft (The Diabetes Epidemic and You) has shown on the basis very solid research that early diagnosis should be based on hyperinsulinaemia which predates the appearance of hyperglycaemia and thus provides a greater probability of full recovery.

In turn this would result in considerable financial savings. The current system simply ensures that patients will inevitably end up by having to use insulin as one expert recently claimed. Furthermore if insulin resistance is involved, this addition of insulin to an already hyperinsulinaemic condition, which in itself is damaging to the patient.

All this because fasting blood insulin levels are not measured. While back in the ‘60s and ‘70s when only RIA tests were available with all the legal requirements involved with radio isotopes I can understand hospitals reluctance to become involved with such methodology. Additionally at that time when an apparently suitable methodology was available it seems reasonable.

However science moves on with the development of the ELISA test; kits can be obtained. Thus, the possibility of a much earlier diagnosis of TD2 is possible with a better chance of full recovery (providing that the Ancel Keys contribution is put to rest) with substantial savings in pharmaceutical costs and a minimization of the problems associated with hyperinsulinaemia (such a CVD and cognitive problems such as Type 3 diabetes (aka Alzheimer’s). As commercial medical laboratories can measure insulin blood levels for a mere £39, the NHS, as a non-profit organization could probably do the test for £20 or less.

3) This example raises the issue of what other areas are similarly affected by failure to progress. As a patient one is sometimes left with the impression that Big Pharma’s need for sales and the status of its KOLs is more important than patients’ health. I am reminded of the initial response of the experts to Dr Barry Marshall’s discovery of Helicobacter pylori as a major cause of GI ulcers.

4) The failure of the NHS administration to improve its administrative own practices to a more patient friendly approach is vitally needed.

Thus in conclusion I do not think throwing money at the NHS is the way to go. Human nature being what it is, throwing money at a problem merely removes the imperative to improve and be fiscally aware.

Competing interests: No competing interests

24 May 2017
Michael J. Hope Cawdery
Retired veterinary researcher
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