50 Rapid Responses published for 37 different articles.

Articles			Rapid Responses
	RESEARCH: Fifty years of violent war deaths from Vietnam to Bosnia: analysis of data from the world health survey programme Obermeyer et al. (28 June 2008) [Abstract] [Full text] [PDF]		Is this a true figure of violent war death in the world? Dewan S. Billal Ph.D, et al.   (24 June 2008) Read every Rapid Response to this article
	RESEARCH: Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2 Hippisley-Cox et al. (28 June 2008) [Abstract] [Full text] [PDF]		Medications associated with cardiovascular disease Weekitt Kittisupamongkol   (25 June 2008) Read every Rapid Response to this article
	HEAD TO HEAD: Are international medical conferences an outdated luxury the planet can’t afford? Yes Green (28 June 2008) [Full text] [PDF]		Virtual Congress of family medicine and general practice Dr.N.P. VISWANATHAN   (27 June 2008) Read every Rapid Response to this article
	NEWS: Mobile phones do not pose health risk, German survey shows Tuffs (28 June 2008) [Full text]		Misleading spin Alasdair MacLean Philips   (27 June 2008) Read every Rapid Response to this article
	NEWS: Government official wants school style inspections of general practices White (28 June 2008) [Full text]		School inspections for GPs? Nigel Higson   (27 June 2008) Read every Rapid Response to this article
	NEWS: UK aid has helped reduce maternal mortality in Bangladesh and Nepal by 40% Yadav (28 June 2008) [Full text] [PDF]		Revolution in child and maternal mortality in Bangladesh Dewan S. Billal Ph.D   (27 June 2008) Read every Rapid Response to this article
	NEWS: Opportunity was missed in choice of cervical cancer vaccine, health campaigners say Kmietowicz (28 June 2008) [Full text] [PDF]		How can we know if we can't scrutinise the details? Peter M English   (24 June 2008) Read every Rapid Response to this article
	NEWS: Government announces review of copayments in the NHS O’Dowd (28 June 2008) [Full text] [PDF]		Sharing scarce resources Iain M Inglis, et al.   (27 June 2008) Read every Rapid Response to this article
	LETTERS: Why so many open windows? Smith (28 June 2008) [Full text] [PDF]		A breath of fresh air Michael Wiliams   (27 June 2008) Read every Rapid Response to this article
	LETTERS: Breastfeeding tackles both obesity and climate change Myr (28 June 2008) [Full text] [PDF]		Breastfeeding is not always cheap Lynne Schyma   (27 June 2008) Read every Rapid Response to this article
	LETTERS: Vitamin D deficiency is widespread in Scotland Rhein (28 June 2008) [Full text] [PDF]		D & C? David G Connell   (27 June 2008) Read every Rapid Response to this article
	EDITORIALS: Cardiovascular risk tables Christiaens (28 June 2008) [Full text] [PDF]		Risk is in the eye of the beholder James P McCormack   (27 June 2008) Risk scores should not dictate treatment choices J. Lennert Veerman   (27 June 2008) Read every Rapid Response to this article
	VIEWS & REVIEWS: Women on the verge of a nervous breakdown Hurley (21 June 2008) [Full text] [PDF]		Buried or incarcerated? Stephen H Raymond   (24 June 2008) Read every Rapid Response to this article
	VIEWS & REVIEWS: Is it about the patients? (21 June 2008) [Full text] [PDF]		Is it about patients – what has happened to the Redress Scheme? Graham Neale   (25 June 2008) Read every Rapid Response to this article
	CLINICAL REVIEW: Recent changes in the management of community acquired pneumonia in adults Durrington and Summers (21 June 2008) [Full text] [PDF]		Practical Guide for the Management of Community Acquired Pneumonia Moises A. Santos Peña MD MSc, et al.   (27 June 2008) What about viral community-acquired pneumonias? G Y Shin   (25 June 2008) Read every Rapid Response to this article
	RESEARCH: Body piercing in England: a survey of piercing at sites other than earlobe Bone et al. (21 June 2008) [Abstract] [Full text] [PDF]		Re: Double standards for obtaining consent for piercings Paul R Coleman   (26 June 2008) Body piercing: Health and Regulation Issues Umo I Esen   (24 June 2008) Read every Rapid Response to this article
	OBSERVATIONS: Manners in medicine Richards (21 June 2008) [Full text] [PDF]		Re: What's in a name? Dr. Herbert H. Nehrlich   (26 June 2008) What's in a name? Anke Medrington (Ms)   (25 June 2008) Read every Rapid Response to this article
	HEAD TO HEAD: Should the drug industry work with key opinion leaders? Yes Buckwell (21 June 2008) [Full text] [PDF]		How it really works Bernard J. Carroll   (24 June 2008) Read every Rapid Response to this article
	FEATURE: Key opinion leaders: independent experts or drug representatives in disguise? Moynihan (21 June 2008) [Full text] [PDF]		Key opinion leaders: the doctors leading double lives Terri Beswick   (26 June 2008) Industry Influences on Key Opinion Leaders and Risks of Undermining Commisssioning Priorities Su Sethi   (25 June 2008) Re: Re: KOLs – Devils or Angels? Joseph A Sonnabend   (25 June 2008) Re: KOLs – Devils or Angels? Paula J Whittaker   (24 June 2008) Tobacco and pharmaceutical business Hiroshi Kawane   (24 June 2008) Is this Conspiracy? Josep A. Mungai   (24 June 2008) Read every Rapid Response to this article
	NEWS: Government insists on second public consultation before regulating complementary medicine Kmietowicz (21 June 2008) [Full text] [PDF]		Regulation of herbal medicine and acupuncture Robert M Pittilo   (25 June 2008) A very bad report David Colquhoun   (24 June 2008) Read every Rapid Response to this article
	EDITORIALS: Preventing injury in childhood Kirkwood and Pollock (21 June 2008) [Full text] [PDF]		no such thing as an 'accident'? helene brandon   (25 June 2008) Read every Rapid Response to this article
	EDITORIALS: Vitamin A supplements in newborns and child survival Tielsch (21 June 2008) [Full text] [PDF]		Supplements to improve newborn and child survival, why not nutrition education ? sudershan kumari   (27 June 2008) Read every Rapid Response to this article
	EDITOR'S CHOICE: Key opinion leaders, your time is up Godlee (21 June 2008) [Full text]		Re: Something missing Fiona Godlee   (25 June 2008) Haiku Big Pharma Loves You Hugh Mann   (24 June 2008) Read every Rapid Response to this article
	PRACTICE: Management of invasive meningococcal disease in children and young people: summary of SIGN guidelines Theilen et al. (14 June 2008) [Full text] [PDF]		Near-patient testing of respiratory specimens Derek J. Fairley, et al.   (24 June 2008) Read every Rapid Response to this article
	CLINICAL REVIEW: Preventing malaria in travellers Lalloo and Hill (14 June 2008) [Full text] [PDF]		Is mefloquine an option for prevention for malaria? Cesar Augusto Guevara-Cuellar   (27 June 2008) Read every Rapid Response to this article
	ANALYSIS: Best interests and potential organ donors Coggon et al. (14 June 2008) [Full text] [PDF]		An expanded interpretation of best interests is just one aspect of NHBOD which requires high-level endorsement M D Dominic Bell   (24 June 2008) Read every Rapid Response to this article
	HEAD TO HEAD: Should we pay donors to increase the supply of organs for transplantation? Yes Matas (14 June 2008) [Full text] [PDF]		Framing the debate Arthur J Matas   (25 June 2008) Read every Rapid Response to this article
	LETTERS: Time to label sodium in drug treatments? Jarrett (14 June 2008) [Full text] [PDF]		A mole in your letter Paul Fernandes   (25 June 2008) Sodium content of medicines Joanne E McEntee   (24 June 2008) Read every Rapid Response to this article
	LETTERS: NICE’s simplified approach to lipids will not work Laurie (14 June 2008) [Full text] [PDF]		Simvastatin 40 mg - a baseline of acceptable practice William E Moody   (24 June 2008) Read every Rapid Response to this article
	EDITORIALS: Measuring blood pressure in children Bird and Michie (14 June 2008) [Full text] [PDF]		Hypertension in Childhood ; should there be pressure to look for it routinely? Suneela Nayak, et al.   (25 June 2008) Read every Rapid Response to this article
	EDITORIALS: Deficiency of sunlight and vitamin D Holick (14 June 2008) [Full text] [PDF]		Challenges in Prevention and treatment of Vitamin D deficiency. vijay bangar, et al.   (27 June 2008) Unlicensed vitamin D can be prescribed if licenced high dosed vitamin D is unavailable Helga M Rhein   (24 June 2008) Read every Rapid Response to this article
	CLINICAL REVIEW: Diagnosis and management of hypocalcaemia Cooper and Gittoes (7 June 2008) [Full text] [PDF]		Hypocalcaemia and Electrocardiographic changes Muhammad M Mahmood   (27 June 2008) Read every Rapid Response to this article
	ANALYSIS: Universality, equity, and quality of care Delamothe (7 June 2008) [Full text] [PDF]		Re: Geographical variations in cancer spend Tony Delamothe   (27 June 2008) Read every Rapid Response to this article
	EDITORIALS: Patient consent—decision or assumption? Elwyn (7 June 2008) [Full text] [PDF]		Tower of Babel Alexander Franklin   (24 June 2008) Read every Rapid Response to this article
	ANALYSIS: What is "quality of evidence" and why is it important to clinicians? Guyatt et al. (3 May 2008) [Full text] [PDF]		A consistent and transparent assessment of evidence Charles Young, et al.   (24 June 2008) Read every Rapid Response to this article
	ANALYSIS: Development of palliative care and legalisation of euthanasia: antagonism or synergy? Bernheim et al. (19 April 2008) [Full text] [PDF]		Religiosity and Euthanasia: in reply to Drs Chambers & Evans Jan L Bernheim, et al.   (25 June 2008) Read every Rapid Response to this article
	FEATURE: Should medical journals carry drug advertising? Yes Smith (14 July 2007) [Full text] [PDF]		Re: Faux-papers and Trojan horses: buying your way into peer-reviewed journals Tony Delamothe   (27 June 2008) Read every Rapid Response to this article

RESEARCH: Fifty years of violent war deaths from Vietnam to Bosnia: analysis of data from the world health survey programme Obermeyer et al. (28 June 2008) [Abstract] [Full text] [PDF] Fifty years of violent war deaths from Vietnam to Bosnia: analysis of data from... Is this a true figure of violent war death in the world? 24 June 2008 Dewan S. Billal Ph.D, Postdoctoral Fellow Department of Otolaryngology, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8509, Japan, Assistnt Professor Muneki Hotomi, MD, Professor Noboru Yamanaka MD Send response to journal: Re: Is this a true figure of violent war death in the world? The study by Obermeyer and colleagues1 reported that the war leading up to the liberation of Bangladesh in 1971 killed 269,000 people- nearly five times the number previously estimated (58,000 people). The authors have concluded that Uppsala/PRIO database has consistently underestimated casualty figures in the world. Information from the Uppsala/PRIO database, produced by collaboration between Uppsala University in Sweden and the Peace Research Institute in Oslo, Norway, has suggested that 58,000 people died in the secessionist conflict caused when the Pakistan Army was ordered by the country`s military ruler, General Yahya Khan, to crack down on dissidents in East Pakistan. While no historian would treat the 58,000 figure for Bangladesh seriously, even the revised figure of 269,000 given in the article will be considered an underestimate by many1. There are many sources that put the true figure at anywhere between one and three million. Death By Government, a much quoted book by political scientist, R.J. Rummel2, says that ?gthe human death toll over only 267 days was incredible. Just to give for five out of the eighteen districts some incomplete statistics published in Bangladesh newspapers or by an Inquiry Committee, the Pakistani army killed 100,000 Bengalis in Dacca, 150,000 in Khulna, 75,000 in Jessore, 95,000 in Comilla, and 100,000 in Chittagong. For eighteen districts the total is 1,247,000 killed?h although there are 64 districts in Bangladesh2. Rummell2 goes on: ?gthis was an incomplete toll, and to this day no one really knows the final toll. Some estimates are much lower - one is of 300,000 dead - but most range from 1 million to 3 million.?h The authors concluded that based on house to house surveys, between 1955 and 2002 an estimated 5.4 million violent war deaths occurred in 13 countries, ranging from 7000 in the Democratic Republic of Congo to 3.8 million in Vietnam. In conclusion, the estimated deaths will be 5-10 times higher than those of the currently reported violent war deaths in the world such as Bangladesh. The household data should consider all the regions in the survey country rather than a specific site to represent the actual magnitude of death due to war violent. Note: Dewan S. Billal is supported by Japan Society for Promotion of Science (JSPS). We declare that we have no conflict of interest *Dewan Sakhawat Billal Ph.D Muneki Hotomi MD, Ph.D Noboru Yamanaka MD, Ph.D billalds@wakayama-med.ac.jp Division of Infection and Immunity research Center, Department of Otolaryngology-Head and Neck Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8509, Japan. References 1. Obermeyer Z, Murray CJL, Gakidou E. Fifty years of violent deaths related to war from Vietnam to Bosnia: analysis of data from world health survey programme. BMJ 2008 doi: 10.1136/bmj.a137. 2. Rummel RJ. Death by government, New Brunswick, NJ: Transaction Publishers, 1994. Competing interests: None declared

RESEARCH: Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2 Hippisley-Cox et al. (28 June 2008) [Abstract] [Full text] [PDF] Predicting cardiovascular risk in England and Wales: prospective derivation and... Medications associated with cardiovascular disease 25 June 2008 Weekitt Kittisupamongkol, General Practitioner Hua Chiew Hospital, Bangkok 10100, Thailand Send response to journal: Re: Medications associated with cardiovascular disease Hippisley-Cox et al evaluate risk factors for cardiovascular disease (1). Apart from statins which the authors exclude in the article, certain drugs known to increase such risk e.g. oral contraceptives, COX-2 selective inhibitor, could be prescribed during the study. I was wondering if the authors are aware that the participants still used such drugs while they perform this cohort study. Reference 1. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Minhas R, Sheikh A, et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. BMJ 2008; 336: a332. Competing interests: None declared

HEAD TO HEAD: Are international medical conferences an outdated luxury the planet can’t afford? Yes Green (28 June 2008) [Full text] [PDF] Are international medical conferences an outdated luxury the planet can’t afford?... Virtual Congress of family medicine and general practice 27 June 2008 Dr.N.P. VISWANATHAN, Family physician S.V.clinic GMpalaya Bangalore-560017 India Send response to journal: Re: Virtual Congress of family medicine and general practice I had the occasion to participate in the Virtual world congress of family practice and General practice at Portugal. It started in april 2008 and will conclude on june 30 th. More than 1600 family physicians from 65 countries are participating.There were lot of symposiums,E-oral communications,e- posters,E- learning,Discussion forum, interactive sessions.Every week on mondays and thurs days new topics were posted. I am staying in India thousands of miles away from Portugal.I have very actively participated in the congress for the past three months.It was a very unique way of learning without leaving my country or house.I have asked more than 100 questions. So advances in tele communication and technology have opened new avenues for learning and updating medical knowlege.The Cost paid to the speakers and travellingcost and other expenses for the participants is almost nil.It is a paperless conference.All the communication were done by e-mail to arrange the conference.There is overwhelming response to the conference.Next 2 virtual congress of family medicine and general practice will be conducted from September 2009. The registeration for the 2 virtual congress will start from september 2009. congress website; congressovirtual mgf.com No competing interest Dr.N.P.VISWANATHAN Competing interests: None declared

NEWS: Mobile phones do not pose health risk, German survey shows Tuffs (28 June 2008) [Full text] Mobile phones do not pose health risk, German survey shows Misleading spin 27 June 2008 Alasdair MacLean Philips, Director Sutton, Cambridge, CB6 2PZ Send response to journal: Re: Misleading spin The first paragraph of Annette Tuffs BMJ News story states that: "Mobile phones, cordless phones, and cordless base stations next to beds are safe, pose no risk of cancer to adult users, and do not cause headaches or sleeping problems. These are the findings of a decade long German programme of studies." The press release on the German website actually states: "High frequency electromagnetic fields such as those found, for example, near transmitters (e.g. radio frequency towers and mobile telephone base stations) or when using mobile end devices (cell phones) are suspected of having adverse health effects on man. There is some indication that such electromagnetic fields can cause biological effects even when the levels are below required German limit values. However, the question of whether or not they pose a health risk to the general public cannot be completely determined at this time. Research in this area must be intensified and co- ordinated. The Federal Office for Radiation Protection (BfS) has developed the DMF1 for this purpose." I consider this misleading reporting by her in the BMJ. Such biased reporting does not help doctors make good decisions. I leave it to other readers to make their own judgement. Competing interests: Director of Powerwatch (UK NGO) www.powerwatch.org.uk

NEWS: Government official wants school style inspections of general practices White (28 June 2008) [Full text] Government official wants school style inspections of general practices School inspections for GPs? 27 June 2008 Nigel Higson, GP Goodwood Court Medical Centre, 52 Cromwell Road, Hove BN3 3Er Send response to journal: Re: School inspections for GPs? Will the Health Service reimburse the rent for the extra room space that we will require in order to place the lockable cupboards that will be necessary to hide all the "schoolwork" that we don't want the inspectors to see? Or will the inspections not be along the lines of school inspections after all? Competing interests: None declared

NEWS: UK aid has helped reduce maternal mortality in Bangladesh and Nepal by 40% Yadav (28 June 2008) [Full text] [PDF] UK aid has helped reduce maternal mortality in Bangladesh and Nepal by 40% Revolution in child and maternal mortality in Bangladesh 27 June 2008 Dewan S. Billal Ph.D, Postdoctoral Fellow Department of Otolaryngology, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8509, Japan Send response to journal: Re: Revolution in child and maternal mortality in Bangladesh In news Siddhartha Yadav1 reported that UK aid has helped Bangladesh to reduce maternal death by 44% from 1990 to 2007. The author discusses only maternal death but Bangladesh has also improved in child mortality in previous year. Bangladesh with 130 million people is the world's most densely populated country. About 2.5 million babies are born in every year in Bangladesh. Although Bangladesh is one of the 42 least developed countries but it has been impressive progress in health and nutrition in the last decades. Due to the integrated program on immunization (EPI), integrated management on childhood illness and other governmental health related services such as introducing skilled birth-attendance during birth and education, the mortality rate of under-5 and under-1 declined 2.9% and 1.4% during 2001 to 2007 respectively2,3,4. Awareness, nutritional status and facility of treatment in urban and rural are main factors to reduce diarrhoea, acute respiratory diseases, injury, drowning and vaccine related diseases in children. The mothers are much more aware about the breastfeeding newborn infants due to government campaign. Not only child mortality but also the maternal mortality has been rapidly decreased during this time. The child mortality rate of under-5 declined from 940 per 10,000 in 2001 to 650 per 10,000 in 2007. The total child mortality rate has decreased 2.9% in last 7 years2,3,4. According to the World Health Organization, over half of the country's children are fully immunized with antigens (diphtheria, pertussis, tetanus tuberculosis, measles) included in the EPI and no cases of polio have been reported since 2001. The stunting, wasting has also been decreased within this time2,3. Recently a comprehensive study reported that infant immunization substantially decrease the childhood mortality in Bangladesh4. In another study reported that suboptimum breastfeeding represented 1.4 million child deaths and 44 million DALYs (10% of DALYs in children younger than 5 years) in the developing countries including Bangladesh6. To achieve the United Nations millennium development goals by 2015, Bangladesh might aware to eradicate extreme poverty and hunger, fulfil universal primary education, combat HIV/AIDS and other diseases, promote gender equality and empower women, ensure environmental sustainability, reduce child mortality, improve maternal health and develop a global partnership for development. The other developing countries can gain knowledge from Bangladesh to reduce maternal and childhood mortality. We declare that we have no conflict of interest. *Dewan Sakhawat Billal, Ph.D billalds@wakayama-med.ac.jp Department of Otolaryngology, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8509, Japan References 1.Yaduv S. UK aid has helped cut maternal deaths in Bangladesh. BMJ 2008;336:1459. 2.UNICEF Bangladesh. http://www.unicef.org/bangladesh/index.html (accessed June 26, 2008) 3.Ministry of Health and family planning, Government of the people?fs republic of Bangladesh. Kamal ATMM, Director of mother and child health services (MCH-S), Ministry of family planning, Bangladesh. 4.The daily Amader shomoy, February 28, 2008. http://amadershomoy.com/online/news.php?id=22036&sys;=3 5.Breiman RF, Streatfield PK, Phelan M, Shifa N, Rashid M, Yunus M. Effect of infant immunisation on childhood mortality in rural Bangladesh: analysis of health and demographic surveillance data. Lancet 2004; 364:2204-11. 6.Black RE, Allen LH, Bhutta ZA, et al. for the Maternal and Child Undernutrition Study group. Maternal and child undernutrition: global and regional exposure and heath consequences. Lancet 2008; 371:243-60. Competing interests: None declared

NEWS: Opportunity was missed in choice of cervical cancer vaccine, health campaigners say Kmietowicz (28 June 2008) [Full text] [PDF] Opportunity was missed in choice of cervical cancer vaccine, health campaigners... How can we know if we can't scrutinise the details? 24 June 2008 Peter M English, Consultant in Public Health Medicine Surrey, KT19 9XF Send response to journal: Re: How can we know if we can't scrutinise the details? Ministers - and the officials who persuaded them to do so - are to be applauded for agreeing to implement such an expensive vaccination campaign, especially given the long-term nature of the benefits. It must be very difficult for politicians, who are unlikely to be in power by the time the benefits start to accrue, to commit such funds, even when there will clearly be long-term benefits that justify the cost. Nevertheless, their decisions should be open to public and professional scrutiny. In the case of this decision, we are told: "The contract has been awarded for the vaccine that scored best overall against a number of pre-agreed criteria and offers best overall value to the NHS... The vaccination programme has always been about cervical cancer protection, irrespective of which vaccine was chosen."[1] And "The criteria used for the adjudication had been shared in advance with the companies which tendered. Based on this assessment, the Department of Health has chosen to purchase Cervarix... The cost of the vaccine is commercially confidential."[2] Since both the pre-agreed criteria and the prices offered by the two companies involved during during the tendering process seem to be secret, we have no way of scrutinising the decision. Was, as seems to have been hinted ("The ... programme has always been about cervical cancer protection"), cervical cancer the only benefit considered in a cost-utility analysis? It is quite possible, for example, that ministers were unsettled by concerns that this is a vaccine to prevent a sexually transmitted infection; and that consideration of the benefits of preventing genital warts, with their high "yeuch" factor and perceived triviality, was ruled out for fear of a backlash from the "moral majority". One can understand that the tenders offered should be a secret during the negotiating and tendering process. But why should they remain a secret afterwards? Does the public not have the right to ask what was on offer? It is quite possible that the best and most appropriate decision was made; but by keeping these secrets, how will we ever know? Without answers to these questions, how can we be sure if a full cost-benefit analysis was undertaken, looking both at all the costs, and all the likely benefits? How can we know that the decision was not based on a more narrow cost-minimisation or cost-utility analysis that did not consider all the likely benefits, and which may have resulted in the choice of a product which, while cheaper, will not provide overall best-value? The medical profession should be at the forefront of asking these questions. As a secondary issue, as a doctor employed by the state I am very anxious to ask these questions, and dare not state exactly which state body employs me while doing so for fear of disciplinary action for daring to question the decisions of the Department of Health. 1. BBC News. Row over cervical vaccine choice. 2008; Accessed: 2008(23 June 2008)(http://news.bbc.co.uk/1/hi/health/7462028.stm). 2. Department of Health. Press release: Department of Health awards contract for HPV vaccine. London: Department of Health, 2008(http://nds.coi.gov.uk/environment/fullDetail.asp?ReleaseID=371095&NewsAreaID;=2&NavigatedFromDepartment;=False). Competing interests: I have given occasional lectures for, received expenses for professional conferences from, and participated in advisory boards for various pharmaceutical companies, including Glaxo SmithKline, Sanofi Pasteur MSD, and others.

NEWS: Government announces review of copayments in the NHS O’Dowd (28 June 2008) [Full text] [PDF] Government announces review of copayments in the NHS Sharing scarce resources 27 June 2008 Iain M Inglis, GP The Medical Centre, Dog Lane, Bewdley, Worcestershire, DY12 2EG Send response to journal: Re: Sharing scarce resources The operation and function of the NHS is predicated on the population sharing resources to best effect. Allowing co-payments for treatments considered not cost effective or outside the sphere of NHS care effectively allows those with their own money to take a greater share of the shared resource. Some argue that co-payments allows extra cash into the NHS system - I disagree; co-payments for non-NHS will actually take resources away from the NHS eg an expensive cancer drug will still need clinical supervision, laboratory monitoring, clinical expertise - all of which might be better deployed looking after another patient with a more curable condition. Co-payments may actually lead to a more fractured and disorganised pattern of care and increasingly leads individuals to see NHS health care resources as a personal right, not something that needs to be shared and used responsibly for the greatest good. Competing interests: None declared

LETTERS: Why so many open windows? Smith (28 June 2008) [Full text] [PDF] Why so many open windows? A breath of fresh air 27 June 2008 Michael Wiliams, A patient patient Tokyo, 164-0001 Send response to journal: Re: A breath of fresh air As Dr Smith correctly points out, hospital windows are often open even on "a particularly chilly day". He also cites some reasons as to why this may be, but omits one: which is that hospital wards - including shiny new PFI ones - tend to be poorly ventilated. It is not unusual to see an extract vent that would not be out of place in a small bathroom, serving a 6-bedded ward. This is "more than inadequate" to cope with the heat output of equipment, lights, and people, and solar heat gain. Likewise it provides very few air changes an hour to refresh the "breathable air". Whilst it is easy to use a blanket to keep warm, it is difficult to "cool off" - notice the number of patients who sleep under just a sheet, and the number of portable oscillating fans located in clinical and ward areas! Perhaps it is true that wards are kept so warm and soporific so that patients are more docile? Competing interests: None declared

LETTERS: Breastfeeding tackles both obesity and climate change Myr (28 June 2008) [Full text] [PDF] Breastfeeding tackles both obesity and climate change Breastfeeding is not always cheap 27 June 2008 Lynne Schyma, Doctor on maternity leave My house, EH5 2GL Send response to journal: Re: Breastfeeding is not always cheap Whilst I wholeheartedly agree with the need to support exclusive breastfeeding, I am not sure it is always necessarily cheap, nor environmentally friendly. Having breastfed my son well past six months, and now my daughter (as I type this!)I am only too aware that is has not come cheaply and without environmental impacts. I have amassed a variety of equipment that was essential for me, that includes nursing bras (at least £30 a time, in different sizes as my shape changed), between 2 and 6 breast pads per day (disposable or reusable ones which would require washing), plastic breast shells, creams, several books on breastfeeding and umpteen leaflets on the subject from the health visiting team. In order to express milk for a bottle so I could have a few hours away from the baby occasionally I needed a breast pump (more plastic), a bottle and a sterilising unit, as well as hot water and washing up liquid. There was also the small order of the extra calories I consumed whilst breastfeeding. I am sure the midwives will argue that some will not need these supplies, I have found that I did, as did other in my breastfeeding peer group. I am sure that the environmental impact is still less than that of bottle feeding (I would love to undertake that study!) but I don't believe breastfeeding should ever be presented as a 'free' option as it certainly isn't. Competing interests: None declared

LETTERS: Vitamin D deficiency is widespread in Scotland Rhein (28 June 2008) [Full text] [PDF] Vitamin D deficiency is widespread in Scotland D & C? 27 June 2008 David G Connell, GP Principal Fyvie Oldmeldrum Medical Group, Health Centre, Oldmeldrum, AB51 0JZ Send response to journal: Re: D & C? I was interested to read Dr Rhein's response regarding Vitamin D deficiency in Scotland It seems we have a way to go yet in getting universal basic nutritional supplementation in place, and I fear the 'heat or eat' dilemma will only worsen the situation. I write to note my own anecdotal experience of the fairly common finding, particularly in the elderly widower who has long since finished the last of his seasonal new tatties,of the coiled pig tail like hairs suggestive of Vitamin C deficiency. David G Connell Competing interests: None declared

EDITORIALS: Cardiovascular risk tables Christiaens (28 June 2008) [Full text] [PDF] Cardiovascular risk tables Risk is in the eye of the beholder 27 June 2008 James P McCormack, Professor Faculty of Pharmaceutical Sciences, University of British Columbia V6T1Z3 Send response to journal: Re: Risk is in the eye of the beholder Dr Christiaens is correct in suggesting the key problem with risk tables is how we use them when making individual treatment decisions in practice. I also very much share his concern with guidelines that suggest specific risk percentage thresholds for treatment. (1) Paradoxically, Dr Christiaens appears, near the end of his article, to come up with an almost equally arbitrary recommendation with his example of using a risk of three times the minimal risk for the patient’s age as a treatment threshold. It seems to me, treatment decisions should only be made after a discussion with the patient of his/her specific risks and the potential benefits and harms associated with treatment. For example, if someone was to train two individuals in a similar fashion to skydive, the two individuals would likely have a similar risk of harm should they decide to jump out of an airplane. However, despite virtually identical risks some people choose to skydive while others would never consider such an endeavour. This is because, as individuals, we all have an inherent system of values that affect the decisions we make. With the selection of any arbitrary threshold we lose the concept of individual patient values and the ability for shared-informed decision making. (1) In my opinion, we should use cardiovascular risk tables/calculators to make a reasonable estimate of, say, a patient’s 10-year risk of cardiovascular disease. If desired, one could also show the patient how that risk compares to an “average” patient of a similar age. Then, and most importantly, we need to provide the patient with a reasonable estimate of the potential benefit (and harms) in absolute terms of a specific treatment. This is not difficult and really doesn’t take a lot of time. (2) If, after this discussion, they choose to take a medication we should fully support them and if they do not wish to take the treatment we should also fully support that decision. In my experience almost all patients are capable of making decisions once they are given this type of information. However, a number of patients will still also ask me “well, what would you do”, and then I tell them. Doing this type of shared-informed decision-making is, in my mind, what the “art” of clinical practice is all about. The sooner guidelines give up creating specific treatment breakpoints (i.e; blood pressure or specific percent risk levels) and using terms like “high risk” the better. (1) 1) McCormack JP, Loewen P. Adding “value” to clinical practice guidelines. Can Fam Physician 2007;53:1327-35 2) Therapeutics Initiative Letter #63. Using Framingham for primary prevention cardiovascular risk assessment. http://ti.ubc.ca/en/node/152 Competing interests: None declared Cardiovascular risk tables Risk scores should not dictate treatment choices 27 June 2008 J. Lennert Veerman, Research Fellow University of Queensland, School of Population Health, Herston Rd, Herston QLD 4006, Australia Send response to journal: Re: Risk scores should not dictate treatment choices Christiaens posits that treatment decisions should not be based directly on cardiovascular risk tables. His arguments are that the decision at what level to treat should be based on consensus and that ageing means that nearly all older people would qualify for treatment, which leads to medicalisation. I share his conclusion but not his argumentation. The fact that cut- off values for risk scores based on concensus are necessary is not an argument against the use of such scores. The argument that older people should be treated less than the risk score indicates amounts to ageism. If a treatment has proven effectiveness, it seems unfair to deny people that benefit just because they are old. The only argument that holds is that few drugs are tested in that age group. However, taking a health economic perspective, I would agree that risk scores do not even give half of the information needed to decide whether to treat or not. Firstly, the costs of treatment should be taken into account. For an expensive treatment the threshold should be high, and it can be lower for a cheap drug. Secondly, I would argue that not only the number of events that are prevented matter, but also the gains in quality and years of life (Essink-Bot, Kruijshaar et al. 2007). The risk score values an event at age 90 equal to one at age 50, but the 50-year old loses many more potential life years. An economist would do a cost-effectiveness analysis to determine who should have what treatment. Professor Christiaens will be glad to learn that this analysis will show that older people need a higher risk score to qualify: with increasing age, the potential health gain diminishes and the cost-effectiveness of treatment becomes less favourable. After NHS has decided what society will pay for, concensus on whether to treat should be between patients and their doctors. Reference: Essink-Bot, M. L., M. E. Kruijshaar, et al. (2007). "Evidence-based guidelines, time-based health outcomes, and the Matthew effect." Eur J Public Health 17(3): 314-7. Competing interests: None declared

VIEWS & REVIEWS: Women on the verge of a nervous breakdown Hurley (21 June 2008) [Full text] [PDF] Women on the verge of a nervous breakdown Buried or incarcerated? 24 June 2008 Stephen H Raymond, Staff Specialist Obstetrics & Gynaecology Royal Hobart Hospital, Tasmania, 7000 Send response to journal: Re: Buried or incarcerated? Those women whose stories were recounted in "Hysteria" reviewed by Richard Hurley, probably don't care now, but "interred" is not the same as "interned". As Mark Anthony is said to have declaimed "...the good that men do is oft interred with their bones". Fie, Richard, you are an editor and are supposed to know these things! You meant "interned" as I was able to infer from the context. Competing interests: None declared

VIEWS & REVIEWS: Is it about the patients? (21 June 2008) [Full text] [PDF] Is it about the patients? Is it about patients – what has happened to the Redress Scheme? 25 June 2008 Graham Neale, Visiting professor Dept of Surgery, Imperial College, St Mar's Hospital London W2 1NY Send response to journal: Re: Is it about patients – what has happened to the Redress Scheme? As a medical tutor helping with a course on professional development the importance of communication frequently arises. In an anonymous Personal View “Is it about patients?”(1), the author describes how a hospital trust repeatedly blocked the attempts of clinicians to communicate with a patient who had required hysterectomy to stop life- threatening post-partum bleeding and who was subsequently unhappy about the end-result. This must have been extremely frustrating for the clinician involved. However, perhaps the situation could have been pre- empted by a caring and sensitive clinical discussion with the patient and her husband before she was discharged from hospital care. The effects of the formulaic process of current hospital practice are shown by the statement “She (the patient) did not attend her post-natal follow-up but no further appointment or letter was generated.” And this serves to remind me that in November 2006 Parliament passed the NHS Redress Act which was aimed to encourage open-ness by hospital trusts when a patient suffers an adverse event as a result of clinical intervention rather than the disease process. The Act was aimed at providing a prompt explanation of how things had gone wrong and why; to offer an apology where appropriate; to describe proposals to prevent or limit a recurrence of a similar event; to provide optimal rehabilitation and to negotiate limited financial compensation (2). The Bill was due to be enacted soon after April 2008 but the silence over the past 18 months has been profound - so is it about patients? 1. Anon. Is it about patients? BMJ 2008; 336; 1438. 2. Furness R Osmond-Walshe S. An alternative to the clinical negligence scheme. BMJ 2007; 334: 400-2. Competing interests: None declared

CLINICAL REVIEW: Recent changes in the management of community acquired pneumonia in adults Durrington and Summers (21 June 2008) [Full text] [PDF] Recent changes in the management of community acquired pneumonia in adults Practical Guide for the Management of Community Acquired Pneumonia 27 June 2008 Moises A. Santos Peña MD MSc, Epidemiology Department Gustavo Aldereguia Lima University Hospital. Cienfuegos. Cuba, Rocha Hernández Juan F. MD MSc, de Pazos Carrazana Juan L MD, Fragoso Marchante MC MD, Hernández Fernández Juana MSc, Solano López Edita MSc, Jiménez Estrada G MD Send response to journal: Re: Practical Guide for the Management of Community Acquired Pneumonia Due to the challenging discussion developed at our department in regard to the Clinical Review entitled Recent Changes in the Management of Community Acquired Pneumonia in Adults, published in the BMJ last June 21st by Hannah J Durrington and Charlotte Summers, we would like to share some considerations about this important health problem in our institution. Pneumonia has been considered a health problem for ages. Sir William Osler’s phrases have become famous since the early times of modern medicine when he referred in the first books about Internal Medicine how this entity had been affecting human beings. Later on, after the introduction of antibiotics in the medical practice, there was a dramatical change, however, this pathology is still the most important cause of morbidity and mortality due to infectious diseases nowadays. In countries such as US and UK it is considered the sixth cause of death and about 99% of deaths due to infectious diseases are caused by Community Acquired Pneumonia. Although its incidence differs from one country to the other and changes according to seasons it has been calculated in about 2-15 per 1000 yearly, increasing its importance economically since it is considered the leading cause of absence to jobs, incapacity and activity restriction in western countries. Cuba is not an exception. Pneumonia has been includend between the main fourth causes of death since the year 2001, together with influenza due to the number of death it causeshence becoming the principal cause of death due to infection. In our hospital which gives medical assistance to around 400 000 inhabitants Community Acquired Pneumonia (CAP) is a frequent cause of hospital admission. In a research which was started in the year 2006, 1477 patients were admitted because of this disease and 32 % of them died due to severely ill stages of the disease and complications. In order to decrease this risk in our hospital, physicians began to use Clinical Practical Guidelines for the management of this entity. This guide stratifies patients into five groups according to the severity of the disease, its clinical presentation, prognosis and associated pathologies amongst some important factors, which determine the place of the patient’s admission (open wards or ICUs) as well as the therapeutic management. After achieving a correct diagnosis, the second step is to define if the patient will receive outpatient treatment or hospitalization. Hospital admission is one of the most important clues in the treatment of a patient who suffers from CAP. Admission decision is a complex and difficult fact that depends on the severity of the patient’s illness and on some specific circumstances such as social conditions, home support, patient or relatives’ preferences which may become determinant factors in decision taking. In general there is no rule for exact categorizing patients in risk groups and probably this situation won’t change in the future so at present hospital admission depends on the physician’s clinical reasoning, whose interpretation of the problem is related to the physician’s knowledge, experience, environment, and comprehension of the dynamics of the medical services. The consequences of using the clinical reasoning can lead to a great variety in the management of CAP in different countries worldwide. Therefore, achieving a balance between the clinical thinking and sistematizing Clinical Guidelines is a need We recognize the way in which British Society of Diseases of the Thorax (BTS) has recently updated its Clinical Guidelines with more operative statements that allow the right identification of severely ill Penumonias. All the Clinical Guidelines agree in the fact that the clinical syndromes are not specific and that the diagnostic tests are too slow or insufficiently fiable to help physicians select an initial treatment. An adequate empirical approach lies on a correct knowledge of the most frequent local pathogen agents and on the fact that a small amount of antibiotics (or a simple agent) would usually be effective. This approach has the advantage that it avoids a long time to start treatment meanwhile lab tests are at disposal. The assessment of the severity of the patient who suffer from pneumonia allow to predict the follow up of the disease, to orient treatment, microbiological studies and empirical antimicrobial treatment. We suggest to stratify patients according to different risk types, by using the best method according to the context. Clinical reasoning and medical experience should be over the predictive models which are not infallibles. References: 1. Durrington HJ, Summers Ch. Recent changes in the management of community acquired pneumonia in adults. BMJ 2008; 336: 1429-33 2. Mills GD, Oehley , Arrol B. Effectiveness of âlactam antibiotics compared with antibiotics active against atypical pathogens in non-severe community acquired pneumonia: meta-analysis. BMJ 2205; 330: 456. 3. File TM, Tan JS. International guidelines for the treatment of community- acquired pneumonia in adults: the role of macrolides. Drugs 2003; 63: 181-205. 4. Oosterheert JJ, Bonten MJM, Schneider MME, Buskens E, Lammers JWJ, Hustinx WMN, Kramer MHH, Prins JM, Slee PH, Kaasjager K, Hoepelman AIM. Efefectiveness of early switch from intravenous to oral antibiotics severe community acquired pneumonia: multicentre randomised trial. BMJ 2006; 333: 1193. 5. Diaz A, Barria P, Niedermen M et al. Etiology of community- acquired pneumonia in hospitalized patients in Chile: the increasing prevalence of respiratory viruses among classic pathogen. Chest 2007; 131 (3): 779-87. Competing interests: None declared Recent changes in the management of community acquired pneumonia in adults What about viral community-acquired pneumonias? 25 June 2008 G Y Shin, Locum consultant virologist Infection & Immunity, 5/F North Wing, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH Send response to journal: Re: What about viral community-acquired pneumonias? Sir, As an erstwhile Microbiologist, I read the recent review of community acquired pneumonia (CAP) by Durrington and Summers with interest[1]. As a Virologist, I was somewhat disappointed by it. The authors appear to have virtually disregarded respiratory viruses in their review. Yet the authors' have conceded that viruses are a cause of CAP, as they list "Respiratory viruses" as a cause of CAP in outpatients and inpatients. I was intrigued by the absence of “Respiratory viruses” as a cause of CAP in the Intensive Care Unit setting. Are the authors implying that respiratory viruses do not cause CAP of a severity that requires intensive care unit admission? I suspect many readers would beg to differ. A quick PubMed review of the literature (limited to articles in English, papers on adult patients, in the last 3 years) confirms that viruses are an important cause of CAP. The frequency of viral aetiologies in a sample of studies of CAP published in this period were 15%, 29%, 32%, 23% and 56% respectively[2-6]. Durrington and Summers are not alone in neglecting respiratory viruses during a discussion of CAP. I note that in the most recent update to the British Thoracic Society guidelines on CAP, the word “virus” appears only once in the entire 19-page document[7]. I believe that there is a common misconception that the term community acquired pneumonia refers only to bacterial infections. Perhaps this is historical. However, as diagnostic techniques improve, in particular with the increasing availability of nucleic acid amplification tests, it is time to challenge this convention. This misconception has potentially deleterious clinical consequences. If clinicians do not even think of a viral aetiology in-patients with CAP, it is unlikely they will consider investigations to diagnose respiratory viruses. The costs of not recognising the possibility of viral aetiologies in CAP are clear: inappropriate use of antibiotics for a viral infection, missing the opportunity to consider antiviral therapy in cases of influenza infection and a failure to institute appropriate infection control measures when CAP is viral in origin. I suggest that in retrospect, the authors should have specified that the scope of their review was limited to bacterial CAP. References 1. Durrington HJ, Summers C. Recent changes in the management of community acquired pneumonia in adults. BMJ 2008;336:1429-33 2. Charles PG, Whitby M, Fuller AJ et al. The etiology of community- acquired pneumonia in Australia: why penicillin plus doxycycline or macrolide is the most appropriate therapy. Clin Infect Dis. 2008;46(10):1513-21 3. Jennings LC, Anderson TP, Beynon KA et al. Incidence and characteristics of viral community-acquired pneumonia in adults. Thorax 2008;63(1):42-8 4. Diaz A, Barria P, Niederman M et al. Etiology of community-acquired pneumonia in hospitalized patients in Chile: the increasing prevalence of respiratory viruses among classic pathogens. Chest 2007; 131(3):779-87 5. Angeles Marcos M, Camps M, Pumarola T et al. The role of viruses in the aetiology of community-acquired pneumonia in adults. Antivir Ther 2006;11(3):351-9 6. Templeton KE, Scheltinga SA, van den Eeden WC et al. Improved diagnosis of the etiology of community-acquired pneumonia with real-time polymerase chain reaction. Clin Infect Dis. 2005;41(3):345-51 7. British Thoracic Society Guidelines on the management of community acquired pneumonia in adults – 2004 update. Available at http://www.brit- thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/MACAPrevisedApr04.pdf (accessed 25/6/08) Competing interests: None declared

RESEARCH: Body piercing in England: a survey of piercing at sites other than earlobe Bone et al. (21 June 2008) [Abstract] [Full text] [PDF] Body piercing in England: a survey of piercing at sites other than earlobe Re: Double standards for obtaining consent for piercings 26 June 2008 Paul R Coleman, Father SS0 7PJ Send response to journal: Re: Re: Double standards for obtaining consent for piercings My then 14 year old daughter managed to obtain a body piercing at the top of her chest. This was done at a local tattoo shop with no parental consent. A phone call to the local envirnmental health department and shop quicly decured a refund of the fee charged. I have since journeyed into the lack of regulation in this area and have involved my local MP in investigating the apparent lack of enforcement and weak regulation. When all other professions are well regulated it seems time to take body piercings under the wing of a body such as the Health Professions Council. Competing interests: None declared Body piercing in England: a survey of piercing at sites other than earlobe Body piercing: Health and Regulation Issues 24 June 2008 Umo I Esen, Consultant Obstetrician and Gynaecologist South Tyneside NHS Foundation Trust,Harton Lane South Shields, NE34 OPL Send response to journal: Re: Body piercing: Health and Regulation Issues The article by Bone et al (1) makes the point that the prevalence of body piercing is increasing. The body piercing industry is poorly regulated and practitioners within the industry require no formal qualifications and there are no formal training programmes. The Local Government Act of 2003 (2) which came into force in 2004 was supposed to remedy the situation, but enforcement is patchy and not much has changed since the Act, despite the growth in the industry. Body piercing is a significant public health problem with risks especially to people with underlying health problems (3 ). It can also lead to unnecessary investigations and inappropriate treatments when patients present with persistent and "unexplained" signs and symptoms(4,5) Piercing of the lips, nostrils and tongue can present difficulties during resuscitation especially in emergency situations as value able time is lost trying to remove the piercing and jewellery within them for effective resuscitation, more so as many doctors are unfamiliar with the release mechanisms of these devices (6). Modern day “genital mutilation” (multiple genital piercing) is occurring under the guise of body piercing. Bone et al (1) limited their survey to the age group 16-24 years, however a lot of children and indeed toddlers are undergoing body piercing as there is no minimum age of consent for body piercing.When does the piercing of children become abuse of children ? References. 1. Bone A , Ncube F, Nichols C, Noah ND. Body piercing in England: a survey of piercing at sites other than earlobe. BMJ 2008; 336:1426-8 2. Local Government Act 2003: Regulation of cosmetic piercing and skin colouring businesses. (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsLegislation/DH_4076283. Accessed 24th June 2008 ) 3. Ochsenfahrt C, Friedl R, Hannekum A, Schumacher BA.Endocarditis after nipple piercing in a patient with bicuspid aortic valve. 2001 . Ann Thorac Surg. 71 (4): 1365-6 4. Modest GA, Fangman JJ. Nipple piercing and hyperprolactinaemia. N Engl J Med. 2002, 347 (20): 1626-7 5. Esen UI, Orife S. Penile Jewellery: a cause of post-coital bleeding. J Obstet Gynaecol. 2006 ,26(5):483-4 6. Khanna R, Kumar SS, Raju BS, Kumar AV. Body piercing in the accident and emergency department. J Accid Emerg Med. 1999, 16:418-21 Competing interests: None declared

OBSERVATIONS: Manners in medicine Richards (21 June 2008) [Full text] [PDF] Manners in medicine Re: What's in a name? 26 June 2008 Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia Send response to journal: Re: Re: What's in a name? What Anke Medrington describes can indeed be unsettling to some of us. I too, hail from the Fatherland and it took a while to become accustomed to having complete strangers call me by my first name the moment they ascertained what it was. After nearly forty years in the English speaking world (including America and Australia), I no longer mind this familiarity . However, it is an entirely different kettle of fish when it comes to the interaction between physician and patient (note the order I chose). There is method to the madness, believe me. When 29 year old Doc Arrog Confid addresses 89 year old Mrs. Lucy Oldmoney as "Lucy" he places himself on an invisible but very real pedestal from which he can look down. This forces Lucy to look up if she wants to hear what Doctor A.C. chooses to tell her.Thus, she becomes fully and acutely aware of the difference in altitude and she senses that this entails certain traditional rules. While the doctor (and the "system")is (are) most likely going to succeed in having "Lucy" surrender some of her dignity because of the illness and the situation caused by it, he initiates this by starting off on the right foot. It's all about body language put to use. Now, when the doctor wants to signal Lucy that he wants her out of there he simply points one or both feet toward the exit.To increase the strength of the signal he takes his glasses off and places them on the table (no he won't polish them, that would signal the start of a new consultation). Yes, I do find it demeaning to choose this setting with any patient.I had a professor who was fond of pointing out that the doctor who sits not across from the patient, separated by a huge desk, but next to the patient will not have to fear malpractice suits. In closing, may I say it is a good thing we don't speak Latin anymore in front of George, Lucy and Dick. Competing interests: None declared Manners in medicine What's in a name? 25 June 2008 Anke Medrington (Ms), Interpreter & Translator 11 Rosedale Rd, Stockport SK4 2QU Send response to journal: Re: What's in a name? I am writing as a patient who is quite taken aback that whenever I’ve seen a doctor recently they have called me by my first name whilst introducing themselves by their title and surname. I was therefore very interested when my partner, who is a GP, showed me your recent article: 'Manners in medicine'. You wrote: "Seeking or undergoing medical care is stressful business. If frontline staff can muster good manners…it helps… " I realise that I am quoting you slightly out of context, but I find it distinctly unhelpful in my interaction with another adult to be addressed like a child by their teacher when the experience of illness is already making me feel unsettled, vulnerable and anxious. Whenever I have summoned up the courage and energy to raise this matter of unequal address during a consultation, it has been met with surprise and the mention of wanting to make me feel at ease…. I'd also like to say that I am German and that my partner is English, but worked in Germany for many years. We both agree that it would be unthinkable for a doctor there to introduce himself as Dr Schmidt to a new patient whilst summoning them from the waiting room by calling out "Helmut" or "Angela"! I've also asked some non-medical British friends about this custom, who've all replied along the lines of: "Actually, now that you mention it, it does seem a bit odd, it's just I've never thought about it before…." As a lay person I’m curious as to whether there have been any recent guidelines to encourage this practice in Britain, why it seems to be the norm and why so few people question, let alone challenge it when at the same time there is so much talked and written about patient's dignity, the doctor-patient partnership, respect, empowerment, etc.? I'd be very interested in your thoughts. Competing interests: None declared

HEAD TO HEAD: Should the drug industry work with key opinion leaders? Yes Buckwell (21 June 2008) [Full text] [PDF] Should the drug industry work with key opinion leaders? Yes How it really works 24 June 2008 Bernard J. Carroll, Consultant Pacific Behavioral Research Foundation, P.O. Box 223040, Carmel, California 93922-3040, USA Send response to journal: Re: How it really works Charlie Buckwell (YES) pleads for an idealized state of transparent relations between the industry and KOLs. Would that it were so. His tone is similar to that of George Lundberg, editor in chief of the commercial medical information company Medscape a few days ago, making the case that the “educational” output of Medscape through KOLs is clean, transparent, and in the interests of patients (see http://hcrenewal.blogspot.com/2008/06/medscapes-cme-ethics-part-ii.html#links). This link also provides a case study of how inappropriate KOL behavior can become, with the collusion of outlets that survive by skimming corporate dollars while laundering honoraria to KOLs. The reality is different. Here is a description from an internationally recognized clinical scientist about his experience with the industry. Here I respect his confidentiality and that of the corporation. My colleague’s experience is not atypical. "When [the company] first began trumpeting the success of [their drug], I was asked to be on their speaker's bureau. In a large audience … I departed from the script I was given for the published data to note that the effect size … was significantly lower than the [alternative treatments]. Since most [of the audience] had no idea what "effect size" is, I gave a brief explanation. That evening I received a phone call in my hotel room from [the company’s] director of the program. He chastised me for being off message and warned me not to make these intrusive statements. I told him that I did not work for [the company], and that presumably I was asked to give these talks because I was a respected researcher in the field and had participated in some of the early trials of their drug, including meetings to develop a protocol for their FDA submissions. I repeated my performance the next day, and was never asked to talk for them again." For myself, over the years I cheerfully gave many talks sponsored by corporations, but I gave my talk, using my slides, and choosing my topic. These presentations were designed for educational impact, and the company’s drugs were never the central focus. They were extremely popular. About 5 years ago I was informed that henceforth I must use the company’s topics and slides, with no deviations allowed. The corporate material provided was mediocre in quality and infomercial in tone. That is when I stopped giving company-sponsored lectures in the US. Competing interests: None declared

FEATURE: Key opinion leaders: independent experts or drug representatives in disguise? Moynihan (21 June 2008) [Full text] [PDF] Key opinion leaders: independent experts or drug representatives in disguise? Key opinion leaders: the doctors leading double lives 26 June 2008 Terri Beswick, Communications Officer Health Action International, Overtoom 60/III. 1054 HK. Amsterdam. The Netherlands Send response to journal: Re: Key opinion leaders: the doctors leading double lives The infiltration of pharmaceutical marketing into the world of healthcare practitioners and medical science has been put front and centre by publications such as the British Medical Journal (BMJ). A number of recent articles in the BMJ have given well-deserved attention to the issue of medicine promotion and the controversial strategies employed by drug companies, and in particular, the use of key opinion leaders (KOLs). The most damaging aspect of the KOL trend is the intrinsic conflict between the interests of pharmaceutical companies’ marketing departments and the interests of patients. As the middle men in this relationship, doctors and medical researchers hold a position of inviolable trust. Treading the fine line between duties to patient health and duties as a KOL for a pharmaceutical company will inevitably place a strain on a physician’s independence. It would be naïve to assume that success as a KOL for the pharmaceutical industry does not divide loyalties between profession and pay cheque. Pharmaceutical companies would not, and could not afford to continue employing experts who failed to achieve their marketing objectives. As a minimum, more stringent transparency regulations for KOLs would provide a clearer picture of the conflicts of interest and allow other doctors and medical scientists to make informed judgments about the credibility of their message. However, transparency is no substitute for independence. Highly paid KOLs in a long-term relationship with a pharmaceutical company are more likely deliver information that has passed through the dubious filter of the company’s marketing department than they are to present reliable comparative data. Clearly, this represents a real obstacle to informed decision-making by patients and doctors alike. The influence wielded by KOLs creates a distorted picture of therapeutic value and worse still, helps to extend the reach of that distortion to those responsible for public health and well-being. To counter the influence of KOLs and measure the real value of a medicine, we need more independent voices to discuss new medicines in context, side-by- side with other available treatments and with the fullest possible appreciation of its benefits and potential risks. A return to independence and integrity must be championed and underpinned by unambiguous regulations to govern interaction between business and medicine. Drawing a line between the market and the research will ensure that the interests of public health trump the interests of the pharmaceutical industry. Competing interests: None declared Key opinion leaders: independent experts or drug representatives in disguise? Industry Influences on Key Opinion Leaders and Risks of Undermining Commisssioning Priorities 25 June 2008 Su Sethi, consultant in publih health medicine Northwest Specialised Services Commissioning Team, Warrington WA4 6HL Send response to journal: Re: Industry Influences on Key Opinion Leaders and Risks of Undermining Commisssioning Priorities Key opinion leaders (KOLs) sought by industry are not only targeted for the promotion of new drugs but also technical devices developed for minimally invasive surgical approaches. Our commissioning experience suggests that clinicians are offered training and mentoring by an expert if they can guarantee purchasing in advance of a certain number of interventional devices by their trust or commissioning body. Approaches are then made to commissioners and specialty clinical networks. In national priority areas such as cancer and cardiology some commissioners do accede to persistent clinical demands even though the devices themselves may be at a developmental or evaluation stage. Often training,experience, education and service infrastructure requirements for the new devices are still unclear including the optimum numbers of procedures that should be carried out for the development and maintenance of individual operator and institutional skills. By their acquiescence a few commissioners inadvertently exert indirect pressure on their colleagues in other geographical areas. This is brought to bear by their clinicians and trusts anxious not to lag behind in the race for the latest technological advance. In the unstoppable momentum that develops an evidence based clinically and cost effective commissioning strategy based on an objective critique of the limited evidence and recommendations for further research becomes the casualty. Commissioners are inevitably left to pursue a rear guard damage limitation exercise by constructing retrospective clinical governance controls to supplement the short term outcomes from case series. The losers are inevitably the patients at the receiving end of an intervention with short term outcome data, generally good technical placement results but no information on medium and long term clinical outcomes, quality of life, durability of device and reintervention rates. Another victim is medical science. The phase three trials that are needed will probably not be done or if done will report so late that their results will be meaningless as the technological goalpost will have shifted by that stage. Commissioners must stand firm that only well researched interventions backed up by economic evaluation will be considered for new developments. Also conflicts of interest and financial links with the industry by proposers of new clinical developments must be clarified at the start. Competing interests: None declared Key opinion leaders: independent experts or drug representatives in disguise? Re: Re: KOLs – Devils or Angels? 25 June 2008 Joseph A Sonnabend, retired NW8 9UG Send response to journal: Re: Re: Re: KOLs – Devils or Angels? The influence of KOLs has been particularly felt in the field of HIV medicine. In a field where crucial questions need to be addressed by appropriate clinical trials, instead answers are provided by guidelines committees. Industry then produces KOLs, to bolster the recommendations of these committees. An example of such a question is when, in the course of HIV disease it is best to start antiretroviral therapy. More than 10 years after these agents were introduced we still have no clear answer to this question. We only have the changing opinions of the guidelines committees, opinions legitimized by KOLs in providing industry supported educational activities, activities that can provide CME credits in the US. Although "evidence based" is a phrase much used by KOLs, in HIV medicine at least, their activities can have the effect of stifling efforts to provide reliable evidence, in the assumption that sufficient evidence already exists. The objectivity of guidelines committees' recommendations is already in question because of the industry affiliations of many of their members. One can only wonder how much hands on clinical experience KOLs can actually acquire, as their lectures and other educational activities must occupy much of their time. Then again, maybe their presentations are written for them by their paymasters. Not to mince words, KOLs are marketing agents for the companies that employ them. It is sad, for us as physicians, and for our patients that we have allowed clinical practice to be influenced by sources, whose primary obligation is to their shareholders, not to the health of the public. Competing interests: None declared Key opinion leaders: independent experts or drug representatives in disguise? Re: KOLs – Devils or Angels? 24 June 2008 Paula J Whittaker, Specialist Registrar Public Health Manchester PCT M21 9WN Send response to journal: Re: Re: KOLs – Devils or Angels? Well done to Hamish McAllister-Williams for engaging in this debate as someone who is paid to give talks by the pharmaceutical industry. I am surprised though, that having read Ray Moynihan's illuminating article describing how the pharmaceutical industry values opinion leaders such as yourself(1), and Buckwell and Fava's Head To Head(2) that you feel encouraged to continue your current practice. You admit to using company slides and tailoring your talk to suit the company's marketing goals to ensure you are invited back to speak again. You say your motivation for doing such work is to alter practice so that it is more in line with guidelines and improved patient outcomes. Really? So not the money then; you'd happily give these talks for free if it wasn't for all the travelling etc? If your motivation is to improve practice, then there are plenty of opportunities to speak at non- pharmaceutical CPD events and to engage with clinical leads in your field. Building up a network of other experts that you can share views and debate evidence with, and allowing free copying and distribution of your teaching material can help ensure your message is widely heard. You might also find that people give your opinion more weight when it's untarnished by corporate sponsorship. The unbiased opinion of an expert given freely, now that is worth it's weight in gold. (1) Moynihan R. Key opinion leaders independent experts or drug representatives in disguise? BMJ 2008;336:1402-03 (2) Fava GA. Should the drug industry use key opinion leaders? No. BMJ 2008;336:1405 Competing interests: None declared Key opinion leaders: independent experts or drug representatives in disguise? Tobacco and pharmaceutical business 24 June 2008 Hiroshi Kawane, professor Japanese Red Cross Hiroshima College of Nursing, Hatsukaichi City, Hiroshima, 738-0052, Japan Send response to journal: Re: Tobacco and pharmaceutical business It is a great problem in Japan that the government helps Japan Tobacco, Inc (JT) to promote sales of cigarettes. Although JT, Japan's former monopoly, was privatised in 1985, the ministry of finance still owns 50 percent of the company's stock. JT advanced into pharmaceuticals in 1987 and they are working to foster their pharmaceutical operations as a main pillar of their business in the future[1]. The Smoking Research Foundation was established in 1986, and universities and institutes are easily able to accept laundered tobacco money[2]. JT has also spent a large amount of money on pharmaceutical-related research and development. Key opinion leaders might not be independent from the tobacco company in Japan. References [1]JT delight world. Pharmaceutical Business Web page. http://www.jti.co.jp/JTI_E/outline/pharma1.html. Accessed June 24,2008 [2]Kawane H. Universities and tobacco money. Japan has laundered tobacco money. BMJ 2001;323:869 Competing interests: None declared Key opinion leaders: independent experts or drug representatives in disguise? Is this Conspiracy? 24 June 2008 Josep A. Mungai, Registered Nurse Currently disabled Send response to journal: Re: Is this Conspiracy? It seems like the article speaks to conspiracy. Are there laws governing this in Britain? Competing interests: None declared

NEWS: Government insists on second public consultation before regulating complementary medicine Kmietowicz (21 June 2008) [Full text] [PDF] Government insists on second public consultation before regulating complementary... Regulation of herbal medicine and acupuncture 25 June 2008 Robert M Pittilo, Vice-Chancellor Robert Gordon University, Aberdeen, AB10 1FR Send response to journal: Re: Regulation of herbal medicine and acupuncture In the same week that the Report to Ministers from the Department of Health Steering Group on the Statutory Regulation of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and other Traditional Medicine Systems Practised in the UK (1) was published the Medicines and Healthcare products Regulatory Agency (2) (MHRA) issued a further alert on poor practice causing serious harm in the herbal medicines sector. Colquhoun (3) criticises our Report and the Department of Health for advocating regulation to protect the public because of the absence of evidence for efficacy. The evidence from the MHRA coupled with survey data suggesting that as many as 10.6% of adults in England have accessed the more established therapies (4), demonstrates that there is a need for regulation to protect the public. This should be pursued alongside research on efficacy and not be a pre-requisite. The Report stated that any NHS funding should be dependent upon demonstrable benefit with evidence of efficacy, safety and quality assurance. Colquhoun also asserts that my University runs courses that will benefit from the recommendation that practitioners should take Honours degrees. In fact my University offers no qualifying courses in complementary or alternative medicine nor has any current plans to do so. The few courses that exist seek to broaden the experience of orthodox healthcare practitioners. The General Medical Council has specified that because many patients choose alternative and complementary therapies, medical graduates should be aware of these, why patients use them, and how they may interact with other types of treatment (5). The continuing reports of serious harm from therapies covered by the report merit immediate action rather than further consultation. 1 Report to ministers from the Department of Health Steering Group on the Statutory Regulation of acupuncture, herbal medicine, traditional Chinese medicine and other traditional medicine systems practised in the UK http://hdl.handle.net/10059/176 2008 (16 June) 2 More evidence of poor professional practice in the herbal medicine sector. Medicines and Healthcare products Regulatory Agency 2008 (20 June) http://www.mhra.gov.uk/Howweregulate/Medicines/Herbalandhomoeopathicmedicines/Herbalmedicines/HerbalSafetyNews/Currentsafetyissues/CON018174 3 Colquhoun D. A Very Bad Report. Rapid Response BMJ 24 June 2008. 4 Thomas KS, Nicholl JP, Coleman PC. Use and expenditure on complementary medicine in England: a population based survey. Complementary Therapies in Medicine 2001;9:2-11 5 Tomorrow’s Doctors. Genral Medical Council 2003 http://www.gmc- uk.org/education/undergraduate/GMC_tomorrows_doctors.pdf Competing interests: 1 Chair, Department of Health Steering Group on the Statutory Regulation of Practitioners of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and Other Traditional Medicine Systems Practised in the UK 2 Trustee, Prince’s Foundation for Integrated Health 3 Vice-Chancellor of University with some complementary and alternative medicine provision Government insists on second public consultation before regulating complementary... A very bad report 24 June 2008 David Colquhoun, Research Professor of Pharmacology UCL WC1E 6BT Send response to journal: Re: A very bad report I think that in this instance the Department of Health is right to think again about the recommendations in Professor Pittilo's report. Both the DoH and the report have tried to separate the question of safety from the question of efficacy. But that is surely nonsense, You can't consider the cost-benefit ratio for any course of action without knowing something about the benefit. In fact the report does consider the efficacy of herbalism and acupuncture, but its assessment of the evidence is execrably bad. The steering group who wrote the report consists mainly of people with a vested interest in extending alternative medicine. Prof Pittilo's university runs several courses that will, no doubt, benefit from his recommendation that alternative practitioners should all take honours degrees. It is obviously just silly to say that everyone must do honours degrees while at the same time saying that we don't know yet whether the treatments work. Do you really want Bachelor of Science students being taught that "amethysts emit high yin energy"? Actually, that already happens. One advantage of the upsurge in public interest in magic medicine is that we now have quite a lot of good trials of acupuncture. The upshot is that in most (SIngh and Ernst, 2008), or even all (Bausell, 2007), cases it turns out to be no more than a rather theatrical placebo This serious research is ignored in Pittilo's report, but it is crucial for the decisions about regulation and training. For example, there is now really very good evidence that it doesn't matter where you stick the needles, so all the talk of meridians and Qi is so much mumbo-jumbo. Being 'trained' to mouth the mumbo-jumbo does not safeguard the public, it endangers them. There is another consideration too. The new EU rules about unfair commerce, described recently in the BMJ have some teeth. "If a trader cannot prove scientifically that the product works, this will be treated as an unfair commercial practice to the detriment of the consumer. It can cover products that claim to give you energy, improve your concentration, diminish depression, or strengthen your physical and mental wellbeing," The Department of Health, and the Health Professions Council (which requires "Practice based on evidence of efficacy") are going to look pretty silly if they create new registers of 'professionals', only to find that its members are in court because they can't produce the evidence. Fortunately there is a simpler and probably cheaper, solution to protecting the public from dangerous and/or fraudulent practitioners. All you have to do is to apply laws that already exist. It is already illegal to sell contaminated food or medicines. It is already illegal to sell goods that are not as described on the label. It is now illegal to make claims that cannot be backed by scientific evidence. The only problem is that the law has many loopholes that means the alternative medicine industry gets away with murder. Remove these and apply existing laws and the problem is solved. It would cost a bit to make sure the law was obeyed, but not nearly as much as it would cost to maintain registers and to pay for thousands of people to do degrees in non-science at public expense. Singh, S and Ernst E (2008) Trick or Treatment. Bantam Press Bausell, B. (2007) Snake Oil Science Oxford University Press Inc, USA Competing interests: None declared

EDITORIALS: Preventing injury in childhood Kirkwood and Pollock (21 June 2008) [Full text] [PDF] Preventing injury in childhood no such thing as an 'accident'? 25 June 2008 helene brandon, consultant obstetrician and gynaecologist Gateshead Health NHS Foundation Trust, NE9 6SX Send response to journal: Re: no such thing as an 'accident'? Whatever happened to the BMJ's prinicpled and much-vaunted policy of never allowing the word 'accident' in its pages? This editorial includes the word at least three times! I was impressed when you anounced this decision, and although others have been slow to follow, I had hoped that you would remain strong: injury and trauma happens for a reason, not 'by accident'. Helene Brandon Competing interests: I lead on risk management issues

EDITORIALS: Vitamin A supplements in newborns and child survival Tielsch (21 June 2008) [Full text] [PDF] Vitamin A supplements in newborns and child survival Supplements to improve newborn and child survival, why not nutrition education ? 27 June 2008 sudershan kumari, neonatologist sunderlal jain hospital,ashok vihar, delhi 110052, India Send response to journal: Re: Supplements to improve newborn and child survival, why not nutrition education ? The article highlights the role of vitamin A supplements in newborns in reducing neonatal and child mortality.The two studies show contradictory results,while Indian study showed improved infant survival with neonatal vitamin A supplementation, other study from africa failed to show any benefit on survival. Longitudinal studies involve funds, personnel and take a lot of time. I wonder why there is paucity of studies of health and nutrition education to mothers during antenatal /postnatal period. The fact is that during first 6 months a mother with her baby has a contact with health personnel at least 4-5 times for immunisations,which are now accepted by majority of populations.A short time,say about 5-10 minutes, given individually to mother at first contact (hospital, home or clinic)can resolve the problems of breast feeding and keeping baby warm. At the same time she can be informed about danger signs in the newborn and when to contact health personnel, which has long term survival benefits also. emphasing to eat for two in early infancy with whatever diet is affordable helps better lactation. In my personal experience , a study of nutrition education and its implications in malnutrition carried out in a busy underfive clinic in Northern India(Kumari S.Jour Trop Peditr 1982; 28; 216-17)it was seen that nutrition education was more effective in improving nutritional status at follow up than in supplemented group.In Northern India ,there is a custom of giving a diet rich in fats, protein and nuts with cereals and sugar to breast feeding mothers in postpartun period. It was observed that mothers who consmed more than 5 kg of extra fat in addition to family diet , their babies weighed 300gm nore at 3 months than when fat intake was less than 4 kg(unpublished data). Public health programmes should emphasize the role of educating adolescent girls and young mothers about breast feeding, pregnacy risk factors, nutrition and basic neonatal care, which will hopefully reduce incidence of mortality and low birth weight as well. How long and how many supplements to infants,there is no limit, they are difficult to reach to all infants. May be at some time, such simple trials can be undetaken and tried. Competing interests: None declared

EDITOR'S CHOICE: Key opinion leaders, your time is up Godlee (21 June 2008) [Full text] Key opinion leaders, your time is up Re: Something missing 25 June 2008 Fiona Godlee, Editor, BMJ BMA House, London WC1H 9JR Send response to journal: Re: Re: Something missing I'm grateful to Graham Kyle for giving me another opportunity to emphasise the difference between overt advertising in journals (or indeed sponsorship of trials) and covert and often disproportionate payment of medical leaders to influence other doctors' prescribing decisions. He's right that the BMJ, and therefore my salary, depends in part on revenue from drug advertising, which has the potential to introduce conflict of interest. However, the long established Chinese wall between the BMJ's editorial and advertising sales teams means that editorial decisions are as free from commercial influence as it's possible to make them. He's also right that medical education is currently heavily dependent on money from the pharmaceutical industry. Moves to reduce this dependence deserve active support. In the meantime, greater transparency around who is being paid what by whom and for doing what will help us to work out what is and is not acceptable about the current relationship between industry and the profession. I would be interested to hear the exact arrangement for Dr Kyle's employment as a KOL in September if he is willing to share this. Competing interests: None declared Key opinion leaders, your time is up Haiku Big Pharma Loves You 24 June 2008 Hugh Mann, Physician Eagle Rock, MO 65641 USA Send response to journal: Re: Haiku Big Pharma Loves You Medical journals: the key opinion leaders indubitably. Competing interests: None declared

PRACTICE: Management of invasive meningococcal disease in children and young people: summary of SIGN guidelines Theilen et al. (14 June 2008) [Full text] [PDF] Management of invasive meningococcal disease in children and young people: summary... Near-patient testing of respiratory specimens 24 June 2008 Derek J. Fairley, Research Scientist Belfast Health & Social Care Trust, Royal Hospitals, Grosvenor Road, Belfast, BT12 6BA, Kathy Dunlop, James McKenna, Paul Jackson, Michael Shields, Peter V. Coyle. Send response to journal: Re: Near-patient testing of respiratory specimens The SIGN guidelines (1) and commentary by Isaacs (2) highlight early diagnosis and referral for improving clinical outcomes in meningococcal disease (MD). They also highlight management difficulties when children present without ‘classical’ symptoms and early treatment options are missed. The SIGN guidelines recommend a formal reassessment within 6 hours, implying the use of clinical deterioration as a diagnostic indicator. Current HPA guidelines (3) advise on the use of several specimens, including respiratory secretions, as part of a diagnostic algorithm for confirming invasive MD. Unfortunately no laboratory tests, whether culture or molecular based, are useful in the initial diagnosis of MD (3). We believe that in children this represents a missed opportunity for initiating early treatment that needs to be reassessed. Our data suggest that a rapid molecular test for meningococci in throat and nasal swabs would be useful in the diagnosis of MD in young children, with or without classical symptoms. To be most effective this would need to be delivered as a point-of-care test. Previously we have shown (4) that in most cases of MD there is no evidence to link respiratory virus infection with presentation and that the prodromal flu-like symptoms were caused by meningococcal replication. Of 104 suspected MD cases (median age 2.2 years; range 0.04 to 15.2) direct molecular detection of meningococci in respiratory specimens was feasible, with PCR detection of the ctrA and porA genes being strongly associated with a subsequent diagnosis of MD (PPV 100%, 17/17; NPV 92%, 44/48; sensitivity 81%, 17/21; specificity 100%, 44/44). We have also confirmed (using porA gene sequencing) that the meningococcal strains identified in blood and respiratory secretions in these children were identical. Conversely the asymptomatic carriage rate of meningococci, detected by PCR testing of nasopharyngeal swabs, was very low (2.2%). This suggests that the small risk of treating carriage in young children is heavily outweighed by the diagnostic value of early molecular detection of meningococci in respiratory swab specimens. We are currently addressing the problem of applying suitable molecular tests with rapid turnaround times in near-patient settings. While we support the SIGN advice to clinically reassess after 6 hours, identifying meningococci in a child’s nasopharynx at initial assessment could eliminate this delay. A negative result would not exclude the diagnosis, but a positive one would allow early referral and treatment. Development of effective near-patient test formats and critical assessment of whether molecular detection of capsular meningococci in respiratory specimens is a useful diagnostic indicator should be the focus of further research. References. 1. Theilen U, Wilson L, Wilson G, Beattie JO, Qureshi S, Simpson D. Management of invasive meningococcal disease in children and young people: summary of SIGN guidelines. BMJ 2008;336:1367-70. 2. Isaacs D. Commentary: Controversies in SIGN guidance on management of invasive meningococcal disease in children and young people. BMJ 2008;336:1370-1. 3. Health Protection Agency Meningococcus Forum. Guidance for public health management of meningococcal disease in the UK, 2006. Health Protection Agency UK. http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947389261 4. Dunlop KA, Coyle PV, Jackson P, Patterson CC, Shields MD. Respiratory viruses do not trigger meningococcal disease in children. J Infect. 2007;54:454-8. Competing interests: We have been funded by the Meningitis Research Foundation to develop a rapid molecular test for detection of meningococcus in clinical specimens.

CLINICAL REVIEW: Preventing malaria in travellers Lalloo and Hill (14 June 2008) [Full text] [PDF] Preventing malaria in travellers Is mefloquine an option for prevention for malaria? 27 June 2008 Cesar Augusto Guevara-Cuellar, Assistant Professor University of Valle 25360 Send response to journal: Re: Is mefloquine an option for prevention for malaria? Perhaps mefloquine is effective for prevention for malaria but maybe is not the best clinical option. In a recent systematic review published in Cochrane (1) that involved 2750 non immune participant travellers, mefloquine prevented malaria episodes in comparation to placebo (odds ratio 0.04, 95% confidence interval 0.02 to 0.08). However, the main factor of success in prevention of malaria is the adherence to chemoprophylaxis and mefloquine has more and severe adverse effects than placebo with more withdrawal rates. 1. Croft AM, Garner P. Withdrawn: Mefloquine for preventing malaria in non -immune adult travellers. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD000138. Competing interests: None declared

ANALYSIS: Best interests and potential organ donors Coggon et al. (14 June 2008) [Full text] [PDF] Best interests and potential organ donors An expanded interpretation of best interests is just one aspect of NHBOD which requires high-level endorsement 24 June 2008 M D Dominic Bell, Consultant in Intensive Care / Anaesthesia The General Infirmary at Leeds LS13EX Send response to journal: Re: An expanded interpretation of best interests is just one aspect of NHBOD which requires high-level endorsement As Coggan and colleagues allude to, the reintroduction of NHBOD [non- heart-beating organ donation] has proved contentious, and their multi- disciplinary analysis will hopefully promote meaningful debate within the broader profession and interested parties. Certain of their attributions are questionable however and as an early advocate of an expanded interpretation of best interests to facilitate viable organ retrieval after death,[1] I remain curious at being referenced as “challenging the lawfulness” and considering these manoeuvres “inappropriate” as justification for the authors’ position. The actual reference used, [2] reviews ‘uncontrolled’ donation, declared not to be under discussion by the authors, and it remains unclear therefore whether Coggan and colleagues believe the position expressed on the difficulties in this particular scenario to “have no solid foundation”, and be “needlessly costing the lives of patients who die awaiting transplantation”. The significance of such difficulties within ‘uncontrolled’ donation is however independently emphasised by recent reports within the lay press.[3] Regarding ‘controlled’ donation, before dismissing concerns as ‘illusory’, the authors should consider that only a minority of the population have expressed a wish to donate via the register, that little detail is provided on the various donation scenarios as part of that process, contrary to the principles within the Human Tissue Act on informed consent, and that in the common scenario where the patient is not on the register, the next-of-kin are asked for their assent to manoeuvres prior to death, despite having no formal authority under the Mental Capacity Act. These aspects do challenge an expanded interpretation of best interests in most cases and the associated professional concerns as to conflict of interest, defining futility and the elusiveness of a robust diagnosis of death, make it apparent that NHBOD requires endorsement at the highest legal and governmental level to ensure wider professional uptake.[4] A unilateral declaration of lawfulness by the authors will therefore predictably not assuage current concerns, which are amplified by the persistent failure of that higher level ratification and the associated delay in endorsing criteria for the certification of cardio- respiratory death. Whilst most practitioners would wish to support the ethical good of both organ donation and transplantation, the critical care community is naturally mindful of previous donation initiatives such as elective ventilation,[5] subsequently declared unlawful,[6] and requires confidence therefore that any activity will be ethically defensible and not generate professional vulnerability. The efforts of Coggan and colleagues need to extend beyond the BMJ therefore and be translated into lobbying at the relevant level if inroads are to be made on this issue and consequently into the divide between organ availability and unmet need. 1. Bell MDD. Non-heartbeating organ donation – clinical process and fundamental issues Br J Anaesth 2005; 94: 474-78 2. Bell, MDD. Emergency medicine, organ donation and the Human Tissue Act. Emergency Medicine Journal. 2006; 23(11):824-827. 3. John Lichfield. 'Dead' patient comes around as organs are about to be removed. The Independent Thursday, 12 June 2008 4. Bell MDD. Non-heart beating organ donation – in urgent need of intensive care. Br J Anaesth 2008; 100(6): 738-41 5. NHS Executive HSG(94)41: 1994 Oct. 6. Riad H, Nicholls A. An ethical debate: elective ventilation of potential organ donors. BMJ 1995;310(6981):714-715. Competing interests: None declared

HEAD TO HEAD: Should we pay donors to increase the supply of organs for transplantation? Yes Matas (14 June 2008) [Full text] [PDF] Should we pay donors to increase the supply of organs for transplantation? Yes Framing the debate 25 June 2008 Arthur J Matas, Professor of Surgery University of Minnesota Send response to journal: Re: Framing the debate The biggest problem in kidney transplantation today is the shortage of organs. Five decades of trying to increase conventional organ donation has only resulted in longer waiting lists and longer waiting time for a transplant. A regulated system of compensation for donation has the potential to eliminate this problem. Those who oppose consideration of compensation for living kidney donation often confuse and conflate discussion regarding regulated and unregulated compensation systems. Both Koch (1) and Scheper-Hughes (2) have continued this tradition; both seem out of touch with the realities of the organ shortage, and both have created “straw man” arguments. Koch and Scheper-Hughes accept living kidney donation (and its risks), so their concern must be the compensation itself. Koch seemingly misunderstands my description of a regulated system. He points out that there is no unregulated market in North America and suggests I am therefore providing a solution to a false problem; he then goes on to imply that there would be systematic inequalities of graft distribution if my suggestions were implemented. Scheper-Hughes provides a passionate and poignant argument against all the abuses of unregulated black markets with no oversight and no protection for either the donor or the recipient. I agree with her. In fact, Scheper-Hughes partly responds to Koch’s first point. There is no unregulated market in North America but the tremendous organ shortage in much of the world has led to development of unregulated markets in many parts of the world; it is these unregulated markets that Scheper-Hughes correctly condemns. As to Koch’s second point, I have, in great detail, described the principles and potential design of a regulated system of compensation (3, 4, 5). In that system, the government (or government agency) would evaluate and compensate the donor; there would be oversight and long-term donor follow-up; and the kidney would be allocated to those on the waiting list in the same way that deceased donor kidneys are allocated. There would be no contact between donor and recipient (and no personal payment); and all those on the waiting list would have an opportunity to be transplanted. My support of Scheper-Hughes’ concern about the outcomes of unregulated markets that have no oversight, no donor protection, and no follow-up in no way eliminates consideration of a trial of a regulated system of compensation in the parts of the world where we can provide oversight, donor protection, long-term donor care, and long-term follow- up. No such trial has been done. The underlying problem that we have is the tremendous shortage of organs; our patients are suffering and dying while waiting for a transplant. Because of the markedly increased waiting time, in parts of the United States (and in other parts of the world) the odds are now higher that an accepted transplant candidate will die while waiting than he or she will receive a transplant. Neither Koch nor Scheper-Hughes (nor any others who object to a trial of a regulated system of compensation) has put forth a realistic alternate solution. It is because of this organ shortage (and its resulting suffering and death) that there are unregulated black markets; increasing the number of available organs will eliminate (or minimize) these markets. It is time for a trial of a regulated system of compensation to determine if we can increase the number of available organs while protecting the health and dignity of the donors. It is also time to frame this debate correctly. If we are to have a meaningful discussion, we can not distort or confuse the issues. I have proposed a (well-defined) regulated system – to be instituted only in situations (or parts of the world) where we can provide donor protection, appropriate oversight, long-term donor follow-up and care, and an algorithm for allocation to all those on the waiting list. We all agree that there are problems with unregulated markets; solely depicting these problems distracts from the issues that I have raised and prevents meaningful discussion. 1) Koch T, The logic of organ payments, BMJ online, June 18, 2008. 2) Scheper-Hughes, A world cut in two, BMJ online, June 21, 2008 3) Matas AJ., The case for living kidney sales: rationale, objections and concerns. Am J Transplant, 4:2007-17, 2004. 4) Matas AJ, Why we should develop a regulated system of kidney sales: a call for action! Clin J Am Soc Nephrol. 1:1129-32, 2006. 5) Matas AJ, Design of a regulated system of compensation for living kidney donors. Clin Transplant. 22:378-84, 2008. Competing interests: None declared

LETTERS: Time to label sodium in drug treatments? Jarrett (14 June 2008) [Full text] [PDF] Time to label sodium in drug treatments? A mole in your letter 25 June 2008 Paul Fernandes, SpR Anaesthesia Queen Alexandra Hospital, Portsmouth. PO6 3LY Send response to journal: Re: A mole in your letter Dr. Jarrett raises an important problem, in the high (and hidden) sodium content of many medications. I fear he must have substituted mmol for mg - as 388mmol of sodium would equate to about 8 grammes of sodium, or about 20 of sodium chloride. Obviously more than the tablet can weigh before the paracetamol is even added! 8 tablets containing 388mg of sodium would add up to 3.1 grammes over a day. Competing interests: None declared Time to label sodium in drug treatments? Sodium content of medicines 24 June 2008 Joanne E McEntee, Medicines Information Pharmacist North West Medicines Information Centre, Liverpool, L69 3GF Send response to journal: Re: Sodium content of medicines The potential problems caused by the high sodium content of soluble paracetamol tablets have been highlighted [1]. The UK Medicines Information Service (UKMi) receives many enquiries about sodium in medicines and is aware that healthcare professionals can have difficulty in finding this information. UKMi has published a document describing the sodium content of a large range of effervescent tablets, soluble analgesics and other preparations with potentially high levels of sodium. This document is updated every two years and can be freely accessed via the National electronic Library of Medicines [2]. Since 2003, the European Medicines Evaluation Agency requires that the sodium content of oral and injectable medicines, containing 1mmol or more per dose, is stated in the Summary of Product Characteristics (SmPC), labelling and package insert [3] – however, this only applies to newly launched products or those submitted to the regulatory authorities for amendment. Joanne McEntee, Medicines Information Pharmacist, North West Medicines Information Centre, Liverpool, L69 3GF. druginfo@liv.ac.uk 1. Jarrett DRJ. Time to label sodium in drug treatments? BMJ 2008; 336: 1324. 2. McEntee J. Medicines Q&A;: Sodium content of medicines. June 2008. Accessed via www.nelm.nhs.uk/Documents/QA145.2_Sodium_content.doc?id=573370 on 24/06/2008. 3. European Commission. Medicinal products for human use: safety, environment and information. Excipients in the label and package leaflet of medicinal products for human use. July 2003. Reference 3BC7A. Accessed via www.emea.europa.eu/pdfs/human/productinfo/3bc7a_200307en.pdf on 23/05/2008. Competing interests: None declared

LETTERS: NICE’s simplified approach to lipids will not work Laurie (14 June 2008) [Full text] [PDF] NICE’s simplified approach to lipids will not work Simvastatin 40 mg - a baseline of acceptable practice 24 June 2008 William E Moody, ST1 CMT trainee, Heart of England NHS Foundation Trust Birmingham Heartlands Hospital Send response to journal: Re: Simvastatin 40 mg - a baseline of acceptable practice In our recent departmental audit drawn from a large central teaching hospital in the West Midlands, nearly a third of all patients with established coronary risk factors admitted with chest pain were being treated with low dose atorvastatin 10 mg or 20 mg rather than simvastatin 40 mg (1). This practice persists despite the call from James Moon, now more than 2 years ago, to switch statins to generic simvastatin as first line in an attempt to produce the largest single drug saving in NHS history(2). Most clinical trials concentrate on low-density lipoprotein (LDL) lowering as being central to the beneficial effects of statins on morbidity and mortality. Epidemiological studies together with data from fibrates suggest that raising HDL also plays a critical role. Whilst simvastatin 40 mg is slightly inferior to atorvastatin 20 mg for LDL lowering, it increases HDL more than any other dose of atorvastatin (3). A 28 day supply of simvastatin 40 mg daily costs our Trust £1.32, whilst a 28 day supply of atorvastatin 10 mg daily and atorvastatin 20 mg daily costs £18.50 and £26.32, respectively. As controlled dosing studies have proven (STELLAR and CURVES), simvastatin is not merely the cheapest option in terms of absolute cost but it is also cheapest in terms of %LDL reduction (4, 5). Laurie rightly states that there will be a proportion of patients in whom simvastatin is insufficiently potent to meet the increasingly aggressive latest targets set by the JBS-2 (6). Primary care performance will always be measured in terms of achieving such targets. From a secondary care perspective, we strongly advocate the approach of regarding the relative reduction in cholesterol and LDL levels as being more important than any achieved absolute levels. Intensive lipid therapy should be reserved for patients at highest risk such as those following an acute coronary syndrome. Recent guidelines estimate roughly 1 in 4 of the population between the ages of 30 and 75 are eligible for statin therapy. With such huge numbers implicated, I concur with Burrill’s adoption of the KISS acronym (7). The importance of keeping our strategy simple is paramount. In order to avoid the sort of prescribing practice highlighted by our audit and in keeping with latest NICE recommendations (8), simvastatin 40 mg should be considered as the baseline of acceptable practice. At the same time, atorvastatin 10 mg and 20 mg should not be made available from pharmacies. 1. Moody WE, Beattie J. Your money or your statin! Audit examining the statin prescribing practice for in-patients at Birmingham Heartlands Hospital, December 2007. 2. Moon JC. Switching statins. BMJ 2006;332:1344-5. 3. Moon JC. More on switching statins. BMJ 2006;333:655-656. 4. Jones P, Kafonek S, Laurora I, Hunninghake D. Comparative dose efficacy study of atorvastatin versus simvastatin, pravastatin, lovastatin, and fluvastatin in patients with hypercholesterolaemia (the CURVES study). Am J Cardiol 1998;81:582-587. 5. Jones PH, Davidson MH, Stein EA, Bays HE, McKenney JM, Miller E, et al. Comparison of the efficacyand safety of rosuvastatin versus atorvastatin, simvastatin, and pravastatin across doses (STELLAR Trial) Am J Cardiol 2003;92:152-60. 6. Laurie SJ. NICE’s simplified approach to lipids will not work. BMJ 2008; 336:1324. 7. Burrill PB. NICE’s simplified approach can’t not work. BMJ Rapid Response to (6), 13 June 2008. 8. NICE. Clinical Guideline 67: Lipid modification (full guideline). May 2008 Competing interests: Acting cardiac network representative Birmingham Sandwell and Solihull PCT, NHS Heart Improvement Programme October 2006.

EDITORIALS: Measuring blood pressure in children Bird and Michie (14 June 2008) [Full text] [PDF] Measuring blood pressure in children Hypertension in Childhood ; should there be pressure to look for it routinely? 25 June 2008 Suneela Nayak, Specialist Registrar Paediatrics Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, CF72 8XR, Anjum Gandhi, Consultant Paediatrician Send response to journal: Re: Hypertension in Childhood ; should there be pressure to look for it routinely? The editorial by Bird and Michie on measuring blood pressure in children makes an interesting read. The subject frequently evokes strong responses with different reasons sited by the proponents and opponents of this view. While the American Academy of Pediatrics (AAP) recommends that blood pressure (BP) measurement should be part of routine clinical contact in all children greater than 3 yrs of age and has published detailed age and height related BP centiles1 this is not currently recommended practice in the United Kingdom (UK). Till recently the only normative BP data available to the UK professional was based on European studies2. More recently BP data for British children have been published3. These however have suggested a new definition for hypertension and have raised considerable controversy4. We therefore felt that it was timely to explore current practice amongst paediatricians regarding routine BP measurements in the out patient setting. In parallel we also decided to measure BP of all children attending the paediatric outpatient department in our hospital to determine what proportion have high BP and therefore might benefit from intervention. The point raised by Bird et al regarding rising numbers of obese children and their increased risk of hypertension was also a concern5. With this in mind we conducted a 2 part study in SouthWales valleys. The first part focused on assessing current clinical practice regarding routine blood pressure measurements. For this a short questionnaire was designed and emailed to all the consultant paediatricians in Wales. Out of a total of 120 consultants only 30 replied despite reminders. Of those who did respond, 23% never measured BP as a routine in the outpatient setting while 50% measured BP in less than 50% of clinical episodes. Only 15% always included BP measurement as a routine part of clinical assessment. The second part of the study attempted to estimate the prevalence of high blood pressure in children attending paediatric outpatients. Appropriate arrangements were made in the paediatric outpatient of our hospital – a medium sized District General hospital. We prospectively measured the blood pressure and body mass index of all the children aged 3 years or older attending paediatric outpatient during July 2006 and Jan 2007. A designated clinic nurse measured these parameters using standardised equipment, after the child had been in the department for at least 10 minutes. The Blood pressure measurements were plotted against height on charts by Andre et al.6 and BMI on the standard BMI centile charts developed by Child Growth Foundation (CGF). Children were classed as overweight and obese, as indicated on the BMI centile charts. The International Hypertension society guidelines were used to classify hypertension as a systolic blood pressure >95th centile and prehypertension as systolic blood pressure between 90th - 95th centile. The final study population comprised of 918 children including 429 boys and 489 girls (boy/girl ratio 1:1.1). An astonishing 253 (27%) were either Overweight/ Obese. The BP was noted to be above the 90th centile in 56 (6%) of the study population. Of these 29 (3.5%) were prehypertensive and 27 (2.6%) hypertensive. 665 children had normal BMI. In this group BP was noted to be above the 90th centile in 32(4.8%). This included 16 (2.4 %) with hypertension and 16 (2.4%) with prehypertension. In contrast of the 253 children with high BMI, 24 (9.4%) had blood pressure above the 90th centile. This included 11 (4.3%) with hypertension and 13 (5.1%) with prehypertension. The proportion of children who had hypertension or prehypertension was significantly higher in the group with high BMI compared to the group with normal BMI (p=0.013; OR 2; CI 1.2-3.6). The overall prevalence of high blood pressure (hypertension and pre- hypertension) in the study population was 6%. The prevalence in children with normal BMI was 4.8%, compared to those with high BMI in whom it was 9.4%. Our study suggests that a significant number of children attending the clinics have high blood pressure. This is specially so in the case of overweight and obese children. Currently blood pressure measurement does not appear to be part of routine paediatric practice in the outpatient setting. We would support the view expressed by Bird et al that measurement of blood pressure should be done routinely in the acute paediatric setting. References 1. National High Blood Pressure Education Program Working Group on High Blood pressure in children and adolescents. The Fourth report on the diagnoses evaluation and treatment of high blood pressure in children and adolescents. Pediatrics 2004. 2. De Man SA et al Blood pressure in childhood: .pooled findings of six European studies. J Hypertension 1991 Feb;9(2):109-14. 3. Jackson et al, Blood pressure centiles for Great Britain. Arch Dis Child 2007;92(4) :298-303. 4. Gandhi A, Uzun O. Blood pressure centiles for Great Britain – can they be safely applied in clinical practice. Arch Dis Child 2007;92: 1046. 5. Paradis G, et al. Blood pressure and adiposity in children and adolescents, Circulation Sep 2004; 110(13): 1832-8. 6. Andre JL et al Arterial blood pressure in 17,067 children and adolescents. Variation with age and height. Arch Fr Pediatr.1980 Aug-Sep; 37(7): 477-82. Competing interests: None declared

EDITORIALS: Deficiency of sunlight and vitamin D Holick (14 June 2008) [Full text] [PDF] Deficiency of sunlight and vitamin D Challenges in Prevention and treatment of Vitamin D deficiency. 27 June 2008 vijay bangar, Consultant Physician Calderdale and Huddersfield Foundation Trust, Halifax, Wset Yorkshire, HX3 OPW, Fisher JP, Haig R, Hungin APS Send response to journal: Re: Challenges in Prevention and treatment of Vitamin D deficiency. The article by Sievenpiper et al1 highlighted the lack of awareness of the severity of symptoms and methods of presentation of vitamin D deficiency (VDD) and the potential dangers of misdiagnosis. It also highlighted the excellent outcomes achievable with correct treatment. However, treatment is proving impossible at present and delivery systems are beset with confusion. Despite reference in the BNF2 and a review by Holick 3 there is a near impossible challenge in translating strategies into action. Sievenpiper et al 1 used intramuscular Vitamin D (IMVD) to treat their patients. IMVD is available in a 300,000 i.u. and 600,000 i.u. preparations containing vitamin d3 (ergocalciferol). It is well recognised that the number of patients with Vitamin D deficiency, requiring treatment doses, is huge, approaching 100% in the high risk populations (particularly migrants from the tropical world and their offspring) . IMVD is licensed in patients who have intestinal malabsorbtion or chronic liver disease2 . This excludes most of the patients in this group. Moreover, the manufacturer recommends that IMVD be administered using glass syringes, although many practitioners have reported use of IMVD using plastic syringes without any problem. Despite enquires with syringe manufacturers; we have not managed to obtain glass syringes. The use of IMVD in this population requires these issue to be addressed by the manufacturers and by regulatory bodies. As a fallback there is available an oral preparation of 250 mcg or 10,000 i.u (HDVD) of Vitamin d3 (ergocalciferol). This preparation can be used within licence although this is not very clear in the BNF. Holick 3 recommends 50,000 i.u. per week. Using HDVD 5 days per week, delivers a dose of 50,000 i.u. per week. In our locality (West Yorkshire) we developed a guideline using this approach at primary care level. However, the HDVD preparation has not been available since the start of this year and IMVD treatment but this also has been unavailable since February. We welcome the publicity drawn to the issue of Vitamin D deficiency by these articles. There are large populations in the United Kingdom who need treatment and prevention for this condition. We would urge the pharmaceutical authorities to clarify the issues around IMVD, and make suitable preparations available. We would also urge them to address the problem of non-availability of HDVD. Reference List (1) Sievenpiper JLMEAVM, Quinton R, Pearce S.H.S. Unrecognised severe vitamin D deficiency. BMJ 336, 1371-1374. 14-6-2008. (2) Vitamin d. British National Formulary 53, 513-514. 1-3-2007. (3) Holick MF. Vitamin D deficiency. New England Journal of Medicine 357, 266-281. 2008. Competing interests: None declared Deficiency of sunlight and vitamin D Unlicensed vitamin D can be prescribed if licenced high dosed vitamin D is unavailable 24 June 2008 Helga M Rhein, GP Sighthill Health Centre, 380 Calder Road, Edinburgh EH11 4AU Send response to journal: Re: Unlicensed vitamin D can be prescribed if licenced high dosed vitamin D is unavailable John Dent, Girija Kottalgi and colleagues mention the present dearth in the UK of high dosed vitamin D tablets or injections to treat deficient patients. I had similar experiences some months ago but have now started prescibing unlicensed medication, with the agreement of local prescibing advisors, as I find it unacceptable to let people with osteomalacia go without treatment. Our local pharmacist located capsules of 20 000 IU Cholecalciferol ("Dekristol" from Germany). I prescribe about 20, initially, one to take every second day, check U+Es after the first week of taking them, in case of rare hypersensitivity, and re-check vitamin D concentration, PTH, U+Es, Ca, PO4 after the course is finished. Hope this can be of help to anyone wanting to treat osteo- malacic patients. Helga Rhein, GP Competing interests: None declared

CLINICAL REVIEW: Diagnosis and management of hypocalcaemia Cooper and Gittoes (7 June 2008) [Full text] [PDF] Diagnosis and management of hypocalcaemia Hypocalcaemia and Electrocardiographic changes 27 June 2008 Muhammad M Mahmood, Specialist registrar Department of Diabetes and Endocrinology, Southmead Hospital. Bristol. BS10 5NB Send response to journal: Re: Hypocalcaemia and Electrocardiographic changes Dear Sir, In relation to the recently published comprehensive clinical review on “Diagnosis and management of hypocalcaemia” [1] by M S Cooper & N J L Gittoes, we wish to emphasise the importance of obtaining a standard Electrocardiogram (ECG). The effect of Hypocalcaemia on ECG has long been recognised [2]. The ECG hallmark of hypocalcaemia is QT interval prolongation secondary to a prolonged ST segment. This is a result of increase in the duration of phase two of the action potential of cardiac muscle. QTc interval prolongation is directly proportional to the degree of hypocalcaemia [3]. Other Electrocardiographic abnormalities reported include T wave changes, cardiac dysrrhythmias and ECG changes mimicking Acute Myocardial Infarction [4]. The associated Hypokalemia and Hypomagnesaemia make sole attribution of some of these changes to Hypocalcaemia somewhat controversial. Electrocardiographic changes, therefore, can serve as an added marker of severity of Hypocalcaemia (& need for urgent intervention) along with symptoms, rapidity of onset and biochemical severity (Calcium level <1.9 mmol/l) [1] of hypocalcaemia. [1].Cooper MS, Gittoes NJL. Diagnosis and management of hypocalcaemia BMJ 2008;336:1298-302 [2]. Wofford CP, Ernstene AC. Diagnostic significance of increased Q- T interval in Electrocardiogram. Cleveland Clinic Quarterly. 1941;8:12-16 [3].RuDusky BM. ECG abnormalities associated with hypocalcemia. Chest 2001;119:668-669 [4].Lehmann G, Deisenhofer I, Ndrepepa G, Schmitt C ECG changes in a 25-year-old woman with Hypocalcemia due to Hypoparathyroidism:Hypocalcemia mimicking acute Myocardial Infarction Chest 2000;118:260-262 Dr Muuhammad Muzaffar Mahmood SPR, Department of Diabetes and Endocrinology. Southmead Hospital. Bristol BS10 5NB. Competing interests: None declared

ANALYSIS: Universality, equity, and quality of care Delamothe (7 June 2008) [Full text] [PDF] Universality, equity, and quality of care Re: Geographical variations in cancer spend 27 June 2008 Tony Delamothe, Deputy editor BMA House, London WC1H 9JR Send response to journal: Re: Re: Geographical variations in cancer spend Thank you for pointing out the error in my article and Civitas's pamphlet. We'll publish a formal correction to my article. Civitas - and my - point still holds. Enormous (? indefensible)geographical variation still exists in resources devoted to various conditions. Dorset now may be in last place on spending on cancer treatment(at £5259 per patient), but this is still less than one third the spending of the top PCT. Could you give us the correct figure for spending by the Oxfordshire PCT? Competing interests: I wrote the article with the error

EDITORIALS: Patient consent—decision or assumption? Elwyn (7 June 2008) [Full text] [PDF] Patient consent—decision or assumption? Tower of Babel 24 June 2008 Alexander Franklin, Physician Toronto,M5P 2X9 Send response to journal: Re: Tower of Babel Toronto prides itself on having 100 different languages spoken in a population of 2.5 million. Many do not speak a word of English. Translation is usually through a family member who may edit what the patient says and also edit what the doctor tells the patient. I know this as I speak French,Italian & Russian and can judge the value of amateur translators. In situations where important decisions have to be made it is important,, for both doctor and patient,that a Certified Translator be present and that a transcript of the discusssion be signed by all concerned. There is also the problem of 48% functional illiteracy in the general Canadian population according to Statistics Canada. Some immigrants are unable to read or write in any language. Thus the doctors have to bear the medico-legal risk of Federal Immigration policy with regard to knowledge of English,(French in Quebec),and literacy. Competing interests: None declared

ANALYSIS: What is "quality of evidence" and why is it important to clinicians? Guyatt et al. (3 May 2008) [Full text] [PDF] What is "quality of evidence" and why is it important to clinicians? A consistent and transparent assessment of evidence 24 June 2008 Charles Young, Editor, BMJ Clinical Evidence BMA House, Tavistock Square, London WC1H 9JR, David Tovey, Alison Martin Send response to journal: Re: A consistent and transparent assessment of evidence Visitors to the BMJ Clinical Evidence website may be forgiven for some bemusement at the debate between Dr Buckley and the members of the GRADE working group, since they will notice that neither of the poisoning reviews authored by Buckley and colleagues have any formal assessment of the quality of the evidence. The reason for this is that despite our best efforts we were unable to persuade the authors to consider using the GRADE approach. BMJ Clinical Evidence publishes regularly updated systematic reviews assessing the evidence relating to over 3000 important clinical interventions. Each review is created in close collaboration with one or more international experts, who guide the editorial team about which interventions should be included, and guide the search and appraisal criteria. In January 2008, following discussions with members of the GRADE working group, we launched our modified version of the GRADE process with the aim of improving the transparency, consistency and clarity of our reviews. In our modified GRADE process, we evaluate the evidence we have already selected for inclusion into our reviews, without performing additional literature searches, and consider only those outcomes our contributors have defined as being most clinically relevant. When, as in the two reviews in question, we have searched for and included observational studies to assess specific outcomes for relevant treatment comparisons, we are able to include them in a GRADE analysis. Our pragmatic approach to GRADE has led to useful discussions with the authors of many of our reviews, and these discussions have always helped us improve the quality of our publications. In this context, it was a great shame that, despite our efforts, we were not able to discuss the issues of GRADE directly with Dr Buckley and colleagues. We agree wholeheartedly with Guyatt and colleagues, that, in the case of paracetamol poisoning, there probably is a strong case for adjusting upwards the assessment of the quality of the evidence for acetylcysteine, given the strength of the observational evidence. Indeed, it is this flexibility of approach, incorporating the potential to adjust downwards the quality scoring for flawed randomised evidence, or adjust upwards credible observational evidence, that is one of the prime attractions of GRADE. Because we were unable to either to negotiate or agree an evaluation of the quality of the evidence with the authors, we felt it necessary to continue to use the non-GRADE versions of the reviews whilst we seek new contributors.. In conclusion, our view is still that it is crucial to apply a consistent and transparent approach to evaluating the quality of evidence upon which we are basing recommendations for patient management,. We consider that our modified GRADE approach is the best method to achieve such transparency at present. Competing interests: The authors are part of the editorial team of BMJ Clinical Evidence, which publishes a modified GRADE analysis of the evidence for over 250 systematic reviews, including those to which Dr Buckley and Dr Eddlestone contributed.

ANALYSIS: Development of palliative care and legalisation of euthanasia: antagonism or synergy? Bernheim et al. (19 April 2008) [Full text] [PDF] Development of palliative care and legalisation of euthanasia: antagonism or synergy? Religiosity and Euthanasia: in reply to Drs Chambers & Evans 25 June 2008 Jan L Bernheim, Oncologist, retired prof. of medicine Vrije Universiteit Brussel, Arsène Mullie, Palliativist, President , Flemish Palliative Care Federation Send response to journal: Re: Religiosity and Euthanasia: in reply to Drs Chambers & Evans In response to our April 19th BMJ paper on synergy between palliative care and euthanasia, Dr Evans, a defender of merciful life ending, jestingly wrote that religion is a competing interest in the euthanasia debate. Dr Chambers, an opponent to euthanasia, sternly stated religion had nothing to do with it. We happen to have data from robust death-certificate studies on this question (1). Not surprisingly, the evidence is more subtle. A bibliography of physician ATTITUDES is to be found in that paper: on aggregate, religious faith, especially catholic, is associated with opposition to (voluntary) euthanasia (1). However, the PRACTICES of Belgian doctors differ little depending on their life stance, and then only in more complex ways. The frequency of performing (voluntary) euthanasia was similar between the majority catholic doctors and the minority (33%) unreligious. However, compassionate life-abbreviation without explicit request (almost always in extremis and in patients having become comatose or otherwise unable to express themselves) occurred three times more frequently when the doctor was non-religious (2). This suggests that, at least in Flanders (Belgium), religion does not reduce the practice of euthanasia, but is associated with higher demands of patient autonomy and less willingness to act in a paternal beneficent way. Is Flanders (Belgium) exceptional? Maybe somewhat. Godfried Cardinal Danneels of Belgium for example said the Catholic Church (contrary to e.g. Islam) had been privileged to benefit from the French revolution. When asked whether he didn’t rather mean the Enlightenment, he said "Both": religious modernity was shaped by the Enlightenment, which put science and faith in different realms and by the French Revolution, which separated church from state. However, there is also a strong universal undercurrent for disenfranchising the bedside from state and religious constraints. The catholic physician-bioethicist Tristram Engelhardt proposed secular humanism as a common language between moral strangers (3). As for the European general public, during the 1980s and 1990s, acceptance of euthanasia, though inversely related to religiosity (4), increased more than to the extent that religiosity decreased (5). This indicates that some believers become more tolerant or proponents of euthanasia themselves. The debate following our paper seems to be petering out. Beyond scientific evidence, it also dealt with personal beliefs. This may be our last opportunity to communicate some of ours, and to reply to a repeatedly encountered question when we presented our data in e.g. the USA: “How does it feel to perform euthanasia?” Both of us adhere to the legal and procedural ethical conditions of life ending, trying to act beneficently, non-maleficently and with respect of patients’ autonomy. We probably do not differ in practice. We endeavour to enhance the solemnity of patients’ deaths. AM belongs to the Christian spiritualistic tradition. Helping a patient to die has a sacral dimension for him. JB is an atheist. After performing euthanasia, he feels tired, but satisfied to have given his best professionally. Both of us often felt gratified by the appreciation that the relatives most often express. 1 Mortier , Bilsen J, Vander Stichele RH, Bernheim J, Deliens L. Attitudes, Sociodemographic Characteristics, and Actual End-of-Life Decisions of Physicians in Flanders, Belgium. Medical Decision Making, 23 (6) 502-10, 2003. 2 Deliens L, Mortier F, Bilsen J, Cosyns M, Vander Stichele RH, Vanoverloop J, et al. End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey. Lancet 356:1806-11, 2000. 3 Engelhardt HT. Bioethics and secular humanism.SCM Press, London, 1991. 4 Cohen J, Marcoux I, Bilsen J, Deboosere P, van der Wal G, Deliens L. European public acceptance of euthanasia: Socio-demographic and cultural factors associated with the acceptance of euthanasia in 33 European countries. Soc Sci Med 63: 743-56, 2006. 5 Cohen J, Marcoux I, Bilsen J, Deboosere P, van der Wal G, Deliens L. Trends in acceptance of euthanasia among the general public in 12 European countries (1981-1999). European Journal of Public Health, 16 (6): 663-9, 2006 Competing interests: None declared

FEATURE: Should medical journals carry drug advertising? Yes Smith (14 July 2007) [Full text] [PDF] Should medical journals carry drug advertising? Yes Re: Faux-papers and Trojan horses: buying your way into peer-reviewed journals 27 June 2008 Tony Delamothe, Deputy editor BMA House, London WC1H 9JR Send response to journal: Re: Re: Faux-papers and Trojan horses: buying your way into peer-reviewed journals We're sorry that you were misled, particularly since one of the main principles of our advertising policy is that readers must immediately be able to tell what is advertising and what is editorial material. Another principle is that "readers understand that advertising is different from editorial material. They know that the claims made in advertising are not endorsed by the BMJG." The full list of principles is at: http://group.bmj.com/group/advertising/policy Specific guidelines for advertisement features (advertorials), include: * The whole advertisement should appear in a box, which should be centred on the page. A minimum of a 10 mm gap should separate the box and the edge of the page. * The words “Advertisement Feature” should be prominently displayed between the top of the box and the top of the page. * Advertisers should have no intention to imitate the editorial style of the BMJ or any of the BMJ Journals. * The typefaces Plantin, Baskerville, and any other typeface closely resembling these must not be used in body count, headlines, and crossheads. * Copy should not be presented on any grid pattern that matches part of the BMJ or the BMJ Journals. *Tints that commonly appear in the BMJ must not be used, thereby avoiding confusion with editorial matter. For the full document, see: http://group.bmj.com/group/advertising/policy/acceptance-of-adverts ** The advertisments in question fulfilled these criteria, and looked nothing like BMJ articles. (Although they used a serifed font, it was several point sizes larger than we use in the print BMJ.) We have a horror of advertisements becoming hard to distinguish from research papers, and will maintain our already high levels of vigilance. Competing interests: I pass all advertisements that appear in the BMJ Group's publications.