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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. 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: Priority setting for new technologies in medicine: qualitative case study . 321:doi 10.1136/bmj.321.7272.1316

The study is done for the Province of Ontario and does not apply to other provinces, and as such is not generalizable. It is subjective and biased as well, because it is not the patients that are describing the benefits of the medicine but the Doctors that prescribed the medicine. Why could not the patient provide this data. Furthermore, the six categories add confusion rather than clarity to the study. The data collected is neither transparent nor transferable.

Lay members' opinions are rather obscure and add no important knowledge to the report or to the study. The gem-like study leaves me confused.

Competing interests: No competing interests

19 March 2017
Shaheda Rizvi
Student
University of Oslo
Montreal
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Re: David Oliver: Why shouldn’t nurses be graduates? David Oliver. 356:doi 10.1136/bmj.j863

The research quoted in the article found that graduate nurses lowered patient mortality. Unsurprisingly the research also mentioned lower patient to nurse ratios as improving patient mortality. Did the research differentiate between nurses who had achieved their degree post-qualification as a nurse?

The push towards the degree program had strong financial motives. It enabled NHS funding of nursing students to be fazed out, a move which will have huge implications on future nursing recruitment.

I left school with only GCSEs. At 18 I was accepted to read for a Diploma in Adult Nursing. After a year I was promoted to the degree program.

Today, I would not be accepted on to the degree program, as I have no A-levels. During my studies I met many other students without A-levels, many of them women trying to return to work after having a family. The move towards the degree program, the introduction of tuition fees and the removal of the bursary will deter many from studying nursing. In a climate of increased nursing shortages, this will not remedy the issue. Furthermore, many will be put off by the length of study if they are required to gain A-levels or a BTEC prior to undertaking the degree in order to meet higher entry requirements.

The research quoted in the article highlighted the way to reduced patient mortality is graduate nurses and/or more nurses. Nurses should be highly trained. However we should not be closing the door on some potentially great nurses because they lack level 3 qualifications or the financial means, especially in this time of shortage. Training needs to be flexible, financially viable and inclusive, if we are to encourage more people to train as nurses.

Competing interests: No competing interests

19 March 2017
Emily C Mandlik
Trust Grade Doctor
NHS
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Re: Spondyloarthritis: diagnosis and management: summary of NICE guidance Katherine McAllister, Nicola Goodson, Louise Warburton, Gabriel Rogers. 356:doi 10.1136/bmj.j839

The statement in key facts (also included in the main text) "Axial spondyloarthritis affects similar numbers of women and men, is not always apparent on plain x ray, and occurs in people who are seronegative for human leucocyte antigen B27 (HLA-B27)" could be interpreted to mean that it is necessary to be seronegative for HLA B27 to have a diagnosis of a spondyloarthritis when in fact the text is intended to stress that HLA B27 need not be positive. This is further complicated by the fact that the term "seronegative spondyloarthritis" refers to seronegatitivity for rheumatoid factor (not HLA-B27).

Competing interests: No competing interests

19 March 2017
David Ahearn
Consultant Physician/Geriatrician
University Hospital of South Manchester NHS Foundation Trust
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Re: How to access and process FDA drug approval packages for use in research Erick H Turner. 347:doi 10.1136/bmj.f5992

One of the goals of this article was to provide cookbook-like steps one could follow to navigate to an FDA review. Unfortunately, the outlined steps will no longer work due to a restructuring of the Drugs@FDA website undertaken last fall.

Competing interests: No competing interests

19 March 2017
Erick H Turner
Physician-researcher
Oregon Health & Science Univ
3710 SW US Veterans Hospital Rd, P3MHDC, Portland, Oregon 97239 USA
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Re: Expanding primary care in South and East Asia Chris van Weel, Ryuki Kassai. 356:doi 10.1136/bmj.j634

The incumbent Government of India proposes this place to be an attractive medical tourism destination ( 1 ) ( 2 ). What it forgets momentarily is that we have one of the worst health and social indicators in the world among similar economies. That fact should make us rethink our health care policies. Here the onus is on the poor primary care infrastructure. While we have still unfinished challenges of malnutrition and communicable diseases – including tuberculosis and emerging threats of microbes changing their forms, e.g. flu viruses and drug resistant pathogens -- the prevalence of non communicable diseases ( NCDs ) is rapidly rising ( 3 ) ( 4 ).

Notwithstanding what our colleague of Greece writes on this web-page, a risk factor reduction strategy, e. g. controlling high blood pressure and blood sugar in diabetes, is known to reduce the risk of future events, and turn the tide of the wave of the NCDs ( 5 ) ( 6 ). And sometimes simple preventive medicines are not available here ( 7 ).

Our Greek colleague believes that nagging visits to GPs for smoking (cessation) don’t avoid the disease (COPD). Our observation is that due to lack of awareness and health education, and (false) glorification of the habit, the masses inadvertently indulge in the practice, resulting in the morbidity and mortality which usually have a long latency period. If GPs (or somebody else) explains the link between the two (addiction and disease), the behavior of the population changes ( 8 ). Of course, that should not be the only strategy to combat the epidemic, even then that fact should also not underestimate the potentially long lasting impact of an apparently simple visit.

Then there are our compatriot colleagues who suggest a few weird ideas to address the challenge of the shortage of doctors in rural areas. In 3 tier system of Health Care Delivery, we believe that by District Health Centers, they mean District Hospitals. In his perspective on NEJM, the Chief of Public Health Foundation of India refers to our tiered system. Here he uses the term District Hospital in the same connotation ( 9 ). Then these colleagues write that around 24000 PHCs are supposedly manned by 1 MBBS doctor. Here we want to replace the term ‘supposedly’ by another word ‘actually’. In fact IMA demands Government of India to post 3 doctors for every PHC. The IMA President recently wrote a letter to the Prime Minister of our country in this regard, and its point number 8 is ‘Strengthen primary health care / rural health services ( 10 ). Its point number 3 (of the demands) is 'To post minimum of three MBBS Doctors in PHCs instead of the present system of posting one MBBS Doctor.'

However, the most wonderful imagination is to select/nominate students of the local population for training. Perhaps our colleagues may not be aware of the long-fought battle for selection for training in Medical Colleges. It ultimately resulted in a centralized examination, called NEET, and is a landmark step for improving the quality of medical education ( 11 ). What dangers lurk in the dark there if we revert back to that previous system of dubious nominations - by money, power or aquaintance - should be borne in mind before such adventurous steps are taken to practice.

Also we want to highlight that favoritism and nepotism are the traits, not entirely owned by urban folks but also by rural community here. It may be exemplified by the fact that when government plans to deliver benefits to the poor, its large portion is cornered by the elites of the our society. In some of the States the majority of BPL cards and MNREGA cards are owned by well-to-do people, and those who are already marginalized, get further marginalized ( 12 ) ( 13 )( 14 ).Similarly if deserving students - who are capable of clearing a fair examination - are subjected to such process of nomination, who will be excluded first, may be anticipated beforehand.

Another potentially dreadful impact of proposal of nomination may be aggravation of existing barriers of casteism and gender discrimination ( 15 ). These social evils already hinder our development by excluding our bright minds from the race. If the village head (Gram Pradhan) nominates only (for example) male students belonging to a specific caste/religious group, its consequences should be carefully considered. Whether such doctors have the same world view as us should be a subject of open debate. What values they imbibe since their childhood, and believe that to be norms in their milieu, may be disturbingly reflected in their medical practice later on as well.

We have very strong and deep rooted foundation of gender injustice, unknowingly costing a lot to us. Prime Minister of my country acknowledges the fact in one of his monthly radio talks, entitled Mann Ki Baat ( 16 ). Due to these pre existing biased social norms, if village head does not nominate, or nominates only a few girl students, its impact will be felt only after a gap of 6 years as that’s the duration of MBBS training here. After completion of that ‘incubation period’ when a male student (for example) starts referring obstetric cases to higher centers, rural population will start recognising its past mistakes only then.

Then our colleagues write that at CHCs, thousands of posts of specialists are lying vacant. Here we want to add that not only in CHCs, even in newly opened rural Medical Colleges and AIIMS too, that fact holds true ( 17 ). But that topic needs another separate discussion. What we firmly believe is that merit based selection process is virtuous and provides the maximum opportunity to hardworking and laborious students, otherwise being regularly (unfairly) snatched from them.

References –

(1 ) Naqvi M A . India has all potentials to become world’s medical tourism hub. Twitter feed 2017 Feb 19 , available at https://twitter.com/naqvimukhtar/status/833234380256591872

(2 ) Correspondent . Positioning India as the next medical tourism hub. 2017 Mar 14 , available at http://www.biovoicenews.com/positioning-india-next-medical-tourism-hub/

(3 ) Rukmini S. Bansal S. Child stunting declines, but still high, data show. Hindu 2016 Jan 21, available at http://www.thehindu.com/news/national/Child-stunting-declines-but-still-...

(4 ) PIB .Health Ministry releases results from first phase of NFHS 4. 2016 Jan 19 , available at http://pib.nic.in/newsite/PrintRelease.aspx?relid=134608

(5 ) Hunter D J, Reddy K S. Noncommunicable diseases . N Engl J Med. 2013 Oct 9, available at . http://www.nejm.org/doi/full/10.1056/NEJMra1109345#t=article

( 6 ) Reddy K S. Regional roadmaps for reducing premature deaths from NCDs. Lancet 2015 Oct 20 ,3 (12) e725- e726 , available at http://dx.doi.org/10.1016/S2214-109X(15)00212-0

(7 ) Manganavar B. Reimagining the response to NCD in India 2014 Dec 30 .BMJ blog ,available at http://blogs.bmj.com/bmj/2014/12/30/bheemaray-manganavar-re-imagining-th...

(8 ) Reddy K S , Arora M. Tobacco use among children in India : A burgeoning epidemic . Indian Pediatrics 2005: 42; 757 -761 available at http://www.indianpediatrics.net/aug2005/aug-757-761.htm

( 9 ) Reddy K S. India’s aspiration for universal health coverage. 2015 July 2. N Engl J Med 2015 :373 ;1-5 , available at http://www.nejm.org/doi/full/10.1056/NEJMp1414214#t=article%5C

( 10 ) Memorandum of demands of IMA , available at http://www.imabihar.org/wp-content/uploads/2015/11/Memorandum-of-Demands...

( 11 ) IMA State wing bats for NEET , 2016 May 15 ,Times of India ,available at http://timesofindia.indiatimes.com/city/chandigarh/IMA-state-wing-bats-f...

( 12 ) Davel K. Gujrat to remove undeserving from BPL list . Times of India 2016 Apr 21 , available at http://timesofindia.indiatimes.com/city/ahmedabad/Gujarat-to-remove-unde...

( 13 ) Prabhu N. Three fourths of Karnataka poor . Times of India 2015 Aug 12 , available at http://www.thehindu.com/news/national/karnataka/threefourths-of-karnatak...

( 14 ) SC gives nod to CBI probe of alleged misuse of NREGA funds . First Post 2014 Mar 14, available at http://www.firstpost.com/india/sc-gives-nod-to-cbi-probe-of-alleged-misu...

( 15 ) India ranks 148th in the world for numbers of women MPs ,says a new UN report .Scroll 2017 Mar 16 ,available at https://scroll.in/latest/831953/india-ranks-148th-in-the-world-for-numbe...

( 16 ) Jha P. An India for girl child: Modi’s Mann Ki Baat echoes in Haryana village . Hindustan Times 2016 May 28 ,available at http://www.hindustantimes.com/india/an-india-for-the-girl-child-modi-s-m...

( 17 ) Mishra A. Huge doctor shortage hits AIIMS regional chapters . Hindustan Times 2016 Aug 21, available at http://www.sundayguardianlive.com/news/6151-huge-doctor-shortage-hits-ai...

All the WebPages are accessed at the time of submission of this rapid response.

Competing interests: No competing interests

19 March 2017
Dr. Harish Gupta
Assistant Professor, Dr Bidyut Roy , Dr Anil Kumar Gangwar JR 3,Department of Medicine , KGMC Lucknow 226 003 UP North India
Dr Sunil Kumar Verma , Associate Professor, Department of Cardiology, AIIMS New Delhi 110029 ksunilverma02@gmail.com
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Re: A historic disease still prevalent today Lorne V Mitchell, Matthew R Wilson, Susan Holmes. 356:doi 10.1136/bmj.j1013

Silly of me to be wise after the event, but as soon as I read the title of the article, I just knew this was going to be about Scurvy. Much of the detail totally escapes me, and I can appreciate that the differential diagnosis was difficult to say the least. Especially when only common things are common. But there have been several other recent findings of Scurvy re-appearing, though I'm notable to cite the references. More worrying, perhaps, would be a case rabies, from an illegally imported infected dog, which is inevitable in the UK sooner or later. And smallpox having been eradicated almost 30 years ago, that disease is all but invisible, but must somehow remain a threat while there are rumoured to be secret stores of the virus in rogue states and elsewhere. All very well being ever vigilant, but how many doctors would be certain of what they are looking out for all the time is an interesting question that I'm not posing; a tall order.

Competing interests: No competing interests

19 March 2017
John G Gooderham
locum lollipop lady
none
none
Billingshurst
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Re: Storing up problems for the future Fiona Godlee. 356:doi 10.1136/bmj.j1332

GP led triage in BMJ 18 March 2017. I add that there should be specialists in A/E departments: this will speed up the work.

Competing interests: No competing interests

19 March 2017
Mohamed Tageldin
Retired orthopaedic surgeon , BMA member
Retired doctor
London
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Re: Serum creatinine elevation after renin-angiotensin system blockade and long term cardiorenal risks: cohort study Henrik Toft Sørensen, Liam Smeeth, Laurie A Tomlinson, et al. 356:doi 10.1136/bmj.j791

Schmidt et al in this article report on the limitations of ACEI/ARB therapy when used as antihypertensive therapy especially as it applies to the potential nephrotoxicity of these agents 1. They demonstrated that increases in creatinine after the start of angiotensin converting enzyme inhibitor/angiotensin receptor blocker treatment were associated with adverse cardiorenal outcomes in a graduated relation, even below the guideline recommended threshold of a 30% increase for stopping treatment 1. Furthermore, they showed that that creatinine increases after the start of ACEI/ARB treatment were associated with cardiorenal risks in a “dose-response” relation, with no distinct cut-off at 30%, as previously suggested 1. We very responsibly share these concerns.

In 2005, we described, for the first time, the previously unknown syndrome of late-onset renal failure from angiotensin blockade (LORFFAB) 2. Subsequently over the last ten years, we have variously described the features of this syndrome in various journal publications, book chapters and editorial pieces as well as in professional academic intellectual forums 3-8. It was indeed our work at the Mayo Clinic Health System in Northwestern Wisconsin that spurred the work of El Nahas and his group from the Sheffield Kidney Institute, Sheffield, in the United Kingdom 9. And the final result is that now we will have a RCT to determine whether withdrawal of ACEI/ARB in patients with advanced chronic kidney disease would result in improved cardiorenal outcomes - the ongoing STOP ACEi Trial 10,11. While we support the use of ACEI/ARB in the various pharmaceutical indications, we will continue to call for caution in the use of these agents, more so in older (>65-year old) patients with advanced stages of chronic kidney disease 12.

REFERENCES
1. Schmidt M, Mansfield KE, Bhaskaran K, Nitsch D, Sørensen HT, Smeeth L, Tomlinson LA. Serum creatinine elevation after renin-angiotensin system blockade and long term cardiorenal risks: cohort study. BMJ 2017;356:j791.
2. Onuigbo MA, Onuigbo NT. Late onset renal failure from angiotensin blockade (LORFFAB): a prospective thirty-month Mayo Health System clinic experience. Med Sci Monit. 2005 Oct;11(10):CR462-9. Epub 2005 Sep 26.
3. Onuigbo MA, Onuigbo NT. Late onset azotemia from RAAS blockade in CKD patients with normal renal arteries and no precipitating risk factors. Ren Fail 2008;30:73-80.
4. Onuigbo MA, Onuigbo NT. Late-onset renal failure from angiotensin blockade (LORFFAB) in 100 CKD patients. Int Urol Nephrol. 2008;40(1):233-9. doi: 10.1007/s11255-007-9299-2. Epub 2008 Jan 15.
5. Onuigbo MA. Reno-prevention vs. reno-protection: a critical re-appraisal of the evidence-base from the large RAAS blockade trials after ONTARGET—a call for more circumspection. QJM 2009;102:155-167.
6. Onuigbo MA. Analytical review of the evidence for renoprotection by renin-angiotensin-aldosterone system blockade in chronic kidney disease - a call for caution. Nephron Clin Pract. 2009;113(2):c63-9, discussion c70. doi: 10.1159/000228536. Epub 2009 Jul 14.
7. Onuigbo MA. The impact of stopping inhibitors of the renin-angiotensin system in patients with advanced chronic kidney disease. Nephrol Dial Transplant. 2010 Apr;25(4):1344-5. doi: 10.1093/ndt/gfp678. Epub 2009 Dec 27.
8. Onuigbo MA. Can ACE inhibitors and angiotensin receptor blockers be detrimental in CKD patients? Nephron Clin Pract. 2011;118(4):c407-19. doi: 10.1159/000324164. Epub 2011 Mar 7.
9. Ahmed AK, Kamath NS, El Kossi M, El Nahas AM. The impact of stopping inhibitors of the renin-angiotensin system in patients with advanced chronic kidney disease. Nephrol Dial Transplant 2010;25:3977-82. doi:10.1093/ndt/gfp511.
10. Bhandari S, Ives N, Brettell EA, Valente M, Cockwell P, et al. Multicentre Randomized Controlled Trial of Angiotensin-Converting Enzyme Inhibitor/Angiotensin Receptor Blocker Withdrawal in Advanced Renal Disease. Nephrol Dial Transplant. 2016;31(2):255-261.
11. Onuigbo MA. The STOP-ACEi Trial - Apt timing for this long awaited randomised controlled trial - Validation of the syndrome of late-onset renal failure from angiotensin blockade (LORFFAB)? Int J Clin Pract. 2017 Jan;71(1). doi: 10.1111/ijcp.12916. Epub 2016 Dec 9.
12. Oh YJ, Kim SM, Shin BC, Kim HL, Chung JH, Kim AJ et al. The Impact of Renin-Angiotensin System Blockade on Renal Outcomes and Mortality in Pre-Dialysis Patients with Advanced Chronic Kidney Disease. PLoS One. 2017 Jan 25;12(1):e0170874. doi: 10.1371/journal.pone.0170874. eCollection 2017.

Competing interests: No competing interests

19 March 2017
MACAULAY A ONUIGBO
Physician - Nephrologist/Hypertension Specialist
Mayo Clinic, Rochester
Mayo Clinic Health System, 1221 Whipple Street, Eau Claire, WI 54702
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Re: GP training in mental health needs urgent reform Elizabeth England, Vicki Nash, Kamila Hawthorne. 356:doi 10.1136/bmj.j1311

Dear Editor

I write with regards to the article “ GP training in mental health needs urgent reform”. Whilst this article raises several interesting points I feel it takes a narrow approach to the process of curriculum reform.

In his widely regarded work on curriculum mapping Harden likens a curriculum to a map of a country you wish to visit, it contains details on the key points of interest and the links between them with an ever increasing level of detail and interaction the closer you explore a specific area. To plan learning activities, assessment and all the other key elements of an educational program an understanding of this map and its relevance to the learner (Harden, 2001). On this basis to understand what a GP curriculum should look like we should be able to describe what the role of a modern GP is. This is where I feel this articles key failing comes in. What is a GP? A medical practitioner, a respiratory physician, a paediatrician, a palliative care physician, a social worker, a councillor, an advocate or any one of a hundred other roles. Whilst it could be argued that they are all these things and more we must consider their relevance to practice and how this fits into the greater healthcare landscape.

To return to our example of a map it may be reasonable for our practitioner to have an excellent knowledge of the streets of Birmingham if they usually work there but to direct to someone who understands the transport system of Manchester when that knowledge becomes relevant. For this reason it seems unreasonable to suggest that a GP should require detailed knowledge of the process of application for housing benefits and instead that they should signpost to suitable services when the need arises. Is it reasonable and practical for relevant training in “areas outside healthcare” to be fitted to an already congested curriculum simply to adjust for the inadequacies in funding of other services? Over half the patients seen in General practices are female and yet there is no requirement for GP training to encompass time in Obstetrics and gynaecology, similarly for paediatrics, oncology and many other medical disciplines. All of these may be relevant on a day to day basis. For this reason, I would propose that rather then suggesting further things that GP trainees should become expert in the Royal College would be better investing their time in helping to define what the role of a modern GP is and then agreeing how these requirements can be met within an already congested timetable.

Reference:
Harden, R. M. (2001). AMEE Guide No. 21: Curriculum mapping: a tool for transparent and authentic teaching and learning. Medical teacher, 23(2), 123-137.

Competing interests: GPST2 Currently working in mental health.

18 March 2017
Robert. J. Jay
GPST2
Leicstershire Partnership NHS Trust
Gwendolin House, Leicester
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Re: Suspected sepsis: summary of NICE guidance Andreas Freitag, Margaret Constanti, Norma O’Flynn, Saul N Faust. 354:doi 10.1136/bmj.i4030

Whilst working on a summary of the Sepsis guidelines I noted that your helpful infographic includes one or elements that do not concord with the NICE paper. I hope you do not mind me pointing them out. I have only examined the Under 5 elements. I have not reviewed the criteria for other ages.

1) Under 'Behaviour and history', the High risk criterion of 'No response to social cues' has been omitted.
2) Under 'Breathing', The Moderate to High risk for 3-4 year olds is quoted in the infographic as 30-39 should be 35-39
3) Under 'Temperature', 'Temperature elevated above 38C' under 3 months should be High risk, not Moderate to High risk.
I hope this is helpful.
Dr Pete Smith

Competing interests: No competing interests

18 March 2017
Peter S Smith
GP
Churchill Medical Centre, Clifton Road, Kingston, KT2 6PG
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