12 Rapid Responses published for 10 different articles.

Articles			Rapid Responses
	VIEWS & REVIEWS: Why the culture of medicine has to change Hayward (13 October 2007) [Full text] [PDF]		Re: Change yes......but incrementally! Sam Lewis   (13 October 2007) Change yes......but incrementally! peter j mahaffey   (13 October 2007) Read every Rapid Response to this article
	PRACTICE: An unusual cause of jaundice Owen et al. (13 October 2007) [Full text] [PDF]		A Manifestation of Gilbert's Syndrome? Ossie F Uzoigwe   (13 October 2007) Read every Rapid Response to this article
	NEWS: Tooke inquiry calls for major overhaul of specialist training Eaton (13 October 2007) [Full text] [PDF]		Post-CCT "Specialist" ! Stuart H McClelland   (13 October 2007) Read every Rapid Response to this article
	EDITORIALS: Screening for abdominal aortic aneurysm Greenhalgh and Powell (13 October 2007) [Full text] [PDF]		Screening for abdominal aortic aneurysm Hisato Takagi, et al.   (13 October 2007) Read every Rapid Response to this article
	EDITORIALS: Participation in mammography screening Schwartz and Woloshin (13 October 2007) [Full text] [PDF]		False positives don�t result in overdiagnosis Christian Weymayr   (13 October 2007) Read every Rapid Response to this article
	ANALYSIS: Adding fluoride to water supplies Cheng et al. (6 October 2007) [Full text] [PDF]		Fluoridation and aluminium Christopher Exley   (13 October 2007) Read every Rapid Response to this article
	OBSERVATIONS: An age old problem Richards (6 October 2007) [Full text] [PDF]		Self Management :An age old solution to an age old problem Arun K Chopra   (13 October 2007) Read every Rapid Response to this article
	FEATURE: Should general practitioners resume 24 hour responsibility for their patients? Yes Jones (6 October 2007) [Full text] [PDF]		Not either or... Steven Ford   (13 October 2007) GP Land Dr. Raja Baber Sheraz   (13 October 2007) Read every Rapid Response to this article
	FEATURE: Industry funded patient information and the slippery slope to New Zealand Toop and Mangin (6 October 2007) [Full text] [PDF]		Anecdotal instance of positive effects of drug advertising Charles L. Rogerson   (13 October 2007) Read every Rapid Response to this article
	PRACTICE: Using a combination inhaler (budesonide plus formoterol) as rescue therapy improves asthma control Barnes (8 September 2007) [Full text] [PDF]		A SMART choice for primary care asthma therapy ? Brian J Lipworth, et al.   (13 October 2007) Read every Rapid Response to this article

VIEWS & REVIEWS: Why the culture of medicine has to change Hayward (13 October 2007) [Full text] [PDF] Why the culture of medicine has to change Re: Change yes......but incrementally! 13 October 2007 Sam Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ Send response to journal: Re: Re: Change yes......but incrementally! I am busy writing a short piece for my 'Policy Analysis' course, contrasting the 'rationalistic' with the 'incrementalist' approach to decision-making... and then you come along , Richard, with a proposal that takes my breath away with its rational and incremental simplicity :- [ask the clinicians] "Look, what do you need to get your waiting lists down to a managable length?" - they would have done it, and at a cost of one hundredth of what has been spent Wow !! Didn't Gerry Robinson ask exactly that ? and didn't he hit a wall ?? so tell me Richard, how is it done ?? Competing interests: a doctor and a taxpayer Why the culture of medicine has to change Change yes......but incrementally! 13 October 2007 peter j mahaffey, consultant plastic & reconstructive surgeon bedford hospital Send response to journal: Re: Change yes......but incrementally! Any analysis of the present woes of the UK medical profession from a working clinician (rather than medical or government politician) is a breath of fresh air in an environment where most of us seem to have been cowed into submission. And Richard Hayward is absolutely right to focus on what it is that spurs a doctor to enjoy his or her daily work....to solve a problem by using one's skills, with beneficial fall-out for patient, doctor and health service. But after that, his analysis breaks down. The stimulus for the massive changes in our NHS were 'local' (getting down waiting lists etc) and 'big-picture', ie grappling with the spiralling health costs which have afflicted all nations. But the problem was not 'the culture of medicine' which, as Hayward defined, is about the self-gratification involved in diagnosis and treatment. Rather, it was the government of the day's error in inflicting repeated, wholesale, brutal changes to a complex ecosystem which had evolved over 60 yrs since 1947. No system could ever have withstood such an upheaval. All that was really needed was for wise government to make progressive nudges to the tiller. For better or worse, clinicians are far and away the best educated section of the NHS workforce. If someone had simply come to them and said "Look, what do you need to get your waiting lists down to a managable length?" they would have done it, and at a cost of one hundredth of what has been spent in the past 10 years. Moreover, doctors mostly also enjoy efficiency, and a similar direct appeal to them to 'help us get our budgets down for the good of us all' would very likely also have appealed to those self-same qualities. But now the damage wrought by those seeking to weaken the profession is too great. And we are almost in the end-game where the politicians need only to wrest the last powerful card from our hand, the doctor-patient relationship. Infection crises, generic referrals, clinical guidelines, repeated 'fat-cat' allegations.... and soon we will be fully fledged state employees just as in Scandinavia! And then perhaps the state will realise that it wasn't the 'culture of medicine' that lost it the priceless asset of an independent profession. Competing interests: None declared

PRACTICE: An unusual cause of jaundice Owen et al. (13 October 2007) [Full text] [PDF] An unusual cause of jaundice A Manifestation of Gilbert's Syndrome? 13 October 2007 Ossie F Uzoigwe, Student University of Leeds Send response to journal: Re: A Manifestation of Gilbert's Syndrome? Dear Editor, Icterus in the context of thyrotoxicosis is an interesting phenomenon. Given that jaundice is such a rare feature of hyperthyroidism it is unlikely that there exists a direct causal link. It is more probable that there is an underlying hepatic dysfunction which is unmasked and potentially exacerbated by the thyrotoxic state1. The most likely cause is Gilbert�s syndrome. Its prevalence may be as high as 12.4% in Caucasian men2. The disease is generally latent but becomes evident during times of illness. In the present case it is worth considering this possibility. If the true mechanism was thyroxine-induced oxidative damage, one would suspect considerable hepatocellular injury with a significant irreversible element if the bilirubin rose to levels of 581umol/l, as in the instant case. Indeed 300umol/l is the threshold for liver transplantation in cases of paracetamol overdose. This is notable given that oxidative stress is also the mechanism of paracetamol�s hepatotoxicity3. Such injury would not be consistent with such a radical recovery. The rapid resolution of symptoms, seen in this case, once euthyroidism was established would be classical of the Gilbert�s syndrome. 1. Greenberger NJ, Milligan FD, Degroot LJ, Isselbacher KJ. Jaundice and thyrotoxicosis in the absence of congestive cardiac failure. Am J Med. 1964; 36:840-6. 2. Sieg A, Arab L, Schlierf G, Stiehl A, Kommerell B. Prevalence of Gilbert's syndrome in Germany. Dtsch Med Wochenschr. 1987 31;112:1206-8. 3. Jaeschke H, Knight TR, Bajt ML. The role of oxidant stress and reactive nitrogen species in acetaminophen hepatotoxicity. Toxicol Lett. 2003; 144:279-88. Competing interests: None declared

NEWS: Tooke inquiry calls for major overhaul of specialist training Eaton (13 October 2007) [Full text] [PDF] Tooke inquiry calls for major overhaul of specialist training Post-CCT "Specialist" ! 13 October 2007 Stuart H McClelland, SpR anaesthetics Queen's Medical Centre, Nottingham, NG7 2UH Send response to journal: Re: Post-CCT "Specialist" ! Has no one else noticed that in recommendation 37 of the MMC report, in a diagram of the proposed structure of postgraduate training, after the award of CCT is a box titled "Specialist"? Before advancing to the "Consultant" box there is a further hurdle: "Optional higher specialist exams". Will this be the final step in our journey towards a post-CCT sub- consultant post? Competing interests: None declared

EDITORIALS: Screening for abdominal aortic aneurysm Greenhalgh and Powell (13 October 2007) [Full text] [PDF] Screening for abdominal aortic aneurysm Screening for abdominal aortic aneurysm 13 October 2007 Hisato Takagi, Consultant cardiovascular surgeon Shizuoka Medical Centre, Shizuoka 411-8611, Japan, Norikazu Kawai and Takuya Umemoto Send response to journal: Re: Screening for abdominal aortic aneurysm In their Editorials, Greenhalgh and Powell(1) cited a recent Cochrane review(2) which reported that screening asymptomatic people for abdominal aortic aneurysm (AAA) significantly reduced not all-cause but AAA-related mortality in men aged 65-79 years. The review,(2) however, excluded the more recent over 15-year follow-up in the Chichester study,(3) median 9.6-year follow- up in the Viborg Country study,(4) and mean 7.1-year follow-up in the Multicentre Aneurysm Screening Study (MASS).(5) Therefore, we(6) performed a meta-analysis of currently available longest follow-up results (both AAA - related and all-cause mortality) of randomized controlled studies of screening for AAA in men. Our comprehensive search identified four reports: the Chichester study (over 15-year follow-up),(3) the Viborg Country study (median 9.6-year follow- up), (4) the Western Australia study (median 3.6-year follow-up),(7) and the MASS (mean 7.1-year follow-up).(5) Pooled analysis of the four reports demonstrated a statistically significant reduction in both AAA-related (risk difference, �|0.25%; 95% CI, �|0.46% to �|0.04%) and all-cause (risk difference, �| 1.06%; 95% CI, �|1.81% to �|0.31%) mortality with screening relative to control in a random-effects model.(6) In conclusion, our meta-analysis,(6) an update of the Cochrane review,(2) demonstrated that screening for AAA significantly reduced not merely AAA- related but also all-cause mortality in men aged ��65 years. 1 Greenhalgh R, Powell J. Screening for abdominal aortic aneurysm. BMJ 2007; 335:732-3. 2 Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev 2007;(2):CD002945. 3 Ashton HA, Gao L, Kim LG, Druce PS, Thompson SG, Scott RA. Fifteen - year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms. Br J Surg 2007;94:696-701. 4 Lindholt JS, Juul S, Fasting H, Henneberg EW. Preliminary ten year results from a randomised single centre mass screening trial for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2006;32:608-14. 5 Kim LG, P Scott RA, Ashton HA, Thompson SG; Multicentre Aneurysm Screening Study Group. A sustained mortality benefit from screening for abdominal aortic aneurysm. Ann Intern Med 2007;146:699-706. 6 Takagi H, Tanabashi T, Kawai N, Umemoto T. Screening for abdominal aortic aneurysm reduces both aneurysm-related and all-cause mortality. J Vasc Surg (in press). 7 Norman PE, Jamrozik K, Lawrence-Brown MM, Le MT, Spencer CA, Tuohy RJ, et al. Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm. BMJ 2004;329:1259. Competing interests: None declared

EDITORIALS: Participation in mammography screening Schwartz and Woloshin (13 October 2007) [Full text] [PDF] Participation in mammography screening False positives don�t result in overdiagnosis 13 October 2007 Christian Weymayr, medical journalist, author of Mythos Krebsvorsorge 44623 Herne, Germany Send response to journal: Re: False positives don�t result in overdiagnosis Sir, I loved to read the editorial by Schwartz and Woloshin. But one thing is not quite correct, I think: In the table one can find the sentence "Patient has at least one false positive screening examination that results in unnecessary diagnosis and treatment for breast cancer". Overdiagnosis results from in situ- cancer and invasive cancer, that means they result not from false but from true positives. This differentiation is important because even cancer experts sometimes regard false positives and overdiagnosis as the same. Competing interests: None declared

ANALYSIS: Adding fluoride to water supplies Cheng et al. (6 October 2007) [Full text] [PDF] Adding fluoride to water supplies Fluoridation and aluminium 13 October 2007 Christopher Exley, Reader Keele University ST5 5BG Send response to journal: Re: Fluoridation and aluminium I was surprised that no mention was made of the role that fluoride plays in increasing human exposure to aluminium via gastrointestinal absorption? Aluminium binds fluoride with great avidity and fluoride in drinking water will both facilitate the gastrointestinal absorption of aluminium which is coincidentally present in drinking water but more importantly it will increase the absorption of aluminium from ingested foodstuffs and other beverages. Fluoridation of the potable water supply will lead to higher human body burdens of aluminium. Whether a higher body burden of aluminium should be avoided is, of course, another debate. Competing interests: None declared

OBSERVATIONS: An age old problem Richards (6 October 2007) [Full text] [PDF] An age old problem Self Management :An age old solution to an age old problem 13 October 2007 Arun K Chopra, Special Lecturer,Nottingham University QMC,Derby Road,Nottingham,NG7 2UH Send response to journal: Re: Self Management :An age old solution to an age old problem Dear editor, There is no doubt that the demographic changes which we are currently living through will have a major impact on health and social policy in the years to come. An increasingly older population will be more likely to suffer from one or more chronic diseases. Coupled with this, is the rise of depression which is projected to be the largest cause of morbidity by 2020 and which has recently been shown to cause the greatest decrement in health as compared to other chronic diseases, asthma, angina,arthritis and diabetes. The combination of depression with any of these illnesses leads to a greater health decrement than any other combination amongst these illnesses (Moussavi et al,2007). One possible solution to this increasingly complicated scenario is strenghtening the position of self management of chronic illness through models of healthcare delivery such as the collaborative care model. (www.improvingchroniccare.org-accessed 11/10/07)This model has demonstrated effectiveness in both physical and mental ill-health, although its application outside of research trials remains limited. More recently, concerns have been expressed over the value of self monitoring in Diabetes, with researchers reporting no significant gains from such practice(Farmer et al, 2007). In order to bring this possible solution to bear, professionals need to be supportive of patients who collaboratively self manage, there needs to an improved response to problems identified through self management and research is needed to elucidate the patient pathways to self management in order to ensure that the appropriate self management package is provided to a patient at the right stage of their illness course and tailored to the degree of psychological readiness they have to tackle the challenges of living with a chronic illness. References Farmer,A. et al (2007)Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial.BMJ ;335: 132 Moussavi,S. et al (2007)Depression, chronic diseases, and decrements in health: results from the World Health Surveys.The Lancet;370:851-858 Competing interests: None declared

FEATURE: Should general practitioners resume 24 hour responsibility for their patients? Yes Jones (6 October 2007) [Full text] [PDF] Should general practitioners resume 24 hour responsibility for their patients? Yes Not either or... 13 October 2007 Steven Ford, GP Haydon & Allen Valleys Medical Practice Send response to journal: Re: Not either or... Editor There need be no contest here, merely the flexibility to adopt the approach that best suits the patients, doctors and geography. My own practice did its own OOH until confronted by 'force majeur' and I only stopped doing OOH altogether when it degenerated into a call centre operation. A diversity of provision arrangements is the right approach. Yours sincerely Steve Ford Competing interests: I am a GP Should general practitioners resume 24 hour responsibility for their patients? Yes GP Land 13 October 2007 Dr. Raja Baber Sheraz, GP ST2 Staff hostel, West cumberland hospital, Whitehaven, CA28 8JG. Send response to journal: Re: GP Land Gp treats the whole patient, not "chest pain", "ankle fracture" or "another neck of femur". Thats what we call as "Holistic approach" in our GP land. Even if the GP works from 0800 to 1700 it does not mean that he/she is not owning the patient. GP gets the feedback from the patient very next day that is not the case in minimum three monthly hospital consultation. At the moment the balance is right between the primary & secondary care. Yes i do support the transition of some specialist work into community, closer to patients own home provided by their own doctor. GPWSI Cardiology is an example! To maintain & improve the quality of general practice we need to give our GP`s a suitable work life balance by giving them the choices of opting in or out of out of hours work. General practice has become a emerging popular choice among our post foundation programme doctors. Bringing out of hour work into primary care "24 hours responsibility" may affect the future career choices! In the current setting General practitioners are doing a great job in providing excellent healthcare to the local community. Suggestion: Why not make small primary care zones & GP`s can do out of hour work in their own practice zones. The benefit would be that patient requiring home visit won`t see a new face! I am sure with this healthy debate we might find an acceptable solution to all which continues to provide the best primary care to our local communities. The important bit would be to include hospital Consultants, GP`s, Current out of hour providers, media & most importantly our own patients! Competing interests: None declared

FEATURE: Industry funded patient information and the slippery slope to New Zealand Toop and Mangin (6 October 2007) [Full text] [PDF] Industry funded patient information and the slippery slope to New Zealand Anecdotal instance of positive effects of drug advertising 13 October 2007 Charles L. Rogerson, Clinical Data Architect slough sl1 1th Send response to journal: Re: Anecdotal instance of positive effects of drug advertising I think this article doesn't give enough weight to the intelligence of patients and their interest in getting information about their medications. Anecdotally, an older acquaintance of mine in the States who was a very active hiker developed fairly rapid onset of bilateral leg weakness which increased over a year to the point where he could only walk very short distances. He consulted his GP and several specialists and was finally referred for spine surgery, which he declined. He then saw an ad for a statin he was taking on television, in which the narrator at the end listed the side-effects, which included muscle weakness. He immediately went to his GP, who DC'd the statin. The leg weakness immediately improved, though unfortunately not completely. Somehow his physicians had missed this rather obvious possibility. I believe this may demonstrate that in a clinical environment where clinicians do not communicate fully to their patients the mechanisms and side-effects of prescribed medications, televised medication advertisements similar to those published in medical publications can play a positive role in educating patients. Competing interests: None declared

PRACTICE: Using a combination inhaler (budesonide plus formoterol) as rescue therapy improves asthma control Barnes (8 September 2007) [Full text] [PDF] Using a combination inhaler (budesonide plus formoterol) as rescue therapy improves... A SMART choice for primary care asthma therapy ? 13 October 2007 Brian J Lipworth, Consultant Chest Physician Asthma and Allergy Research Group ,University of Dundee,and Tayside Centre for General Practice, Catherine Jackson Send response to journal: Re: A SMART choice for primary care asthma therapy ? Professor Barnes makes an apparently cogent argument for using SMART single flexible combination inhaler therapy as the preferred treatment for moderate to severe asthma .Unfortunately his arguments are likely to be rather biased due to the inherent flawed selection criteria used for inclusion into these clinical trials. This is because the SMART trials [and indeed other long acting beta2-agonist trials] selectively exclude patients who are non responders to formoterol, because inclusion requires patients to have demonstrable beta-2-adrenoceptor agonist reversibility . There will always be a heterogeneous response to formoterol due to the predictable development of tolerance ,especially for protection against bronchoconstrictor stimuli ,which may in part be genetically determined [1] .In everyday clinical practice ,especially in primary care ,we do not commonly see such patients who have marked beta-2 agonist reversibility ,as seen in the clinical trials, so it is not possible to extrapolate the results of these studies to what happens out there in the real world . The blanket prescribing of SMART to patients as advocated by Professor Barnes is a slippery slope ,unless perhaps one restricts using the SMART regimen to those who demonstrate beta-2 agonist reversibility ,which is unlikely to happen on a routine basis in the busy setting of primary care ,where most patients with asthma are treated in the UK . The other concern for primary care prescribing is that the routine use of SMART will inevitably creep back in the guidelines from step 3 to step 2 ,whereas most patients with mild to moderate disease can be adequately controlled on an optimised dose of inhaled steroid alone ,which is considerably cheaper . References 1.Lipworth BLong-acting beta(2)-adrenoceptor agonists: a smart choice for asthma? Trends Pharmacol Sci. 2007 Jun;28(6):257-62. Epub 2007 Apr 26 Competing interests: BJL and the Asthma and Allergy Research Group has received payments for performing clinical trials ,educactional support ,equipment ,speaking and consulting from : AstraZeneca ,GlaxoSmithKline,Teva,Mundipharma,Nycomed,Cipla,Neolab,Schering ,Plough,Merck,Trinity-Chiesi,Innovata .