21 Rapid Responses published for 19 different articles.

Articles			Rapid Responses
	EDITORIALS: Mental capacity and psychiatric admission Dawson (30 June 2008) [Full text]		Beware of fluctuating capacity Jay Sarkar   (3 July 2008) Read every Rapid Response to this article
	FEATURE: How clean is your water? Watts (2 July 2008) [Full text]		Illicit drugs also pollute our waters Pasquale Urbano   (3 July 2008) How clean is clean? Viera Scheibner   (3 July 2008) Read every Rapid Response to this article
	ANALYSIS: A friend in need: why friendship matters in medicine Loxterkamp (1 July 2008) [Full text]		The value of Humanity John P Wattis   (3 July 2008) Read every Rapid Response to this article
	CLINICAL REVIEW: Refeeding syndrome: what it is, and how to prevent and treat it Mehanna et al. (28 June 2008) [Full text] [PDF]		UK Attitudes to NICE guidance on Refeeding Syndrome Aminda De Silva, et al.   (3 July 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]		Inconsistent Comparisons and Unsound Conclusions Michael Spagat   (3 July 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]		Risk Estimation Works for Populations but not for Individuals Tim M Reynolds, et al.   (3 July 2008) Remodelling cardiovascular modelling Eddie Vos   (3 July 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	HEAD TO HEAD: Are international medical conferences an outdated luxury the planet can’t afford?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]		Re: Virtual Congress of family medicine and general practice N.P. Viswanathan   (3 July 2008) Read every Rapid Response to this article
	LETTERS: Breastfeeding tackles both obesity and climate change Myr (28 June 2008) [Full text] [PDF]		The value of breastfeeding James E. Akre   (3 July 2008) Read every Rapid Response to this article
	EDITORIALS: Cardiovascular risk tables Christiaens (28 June 2008) [Full text] [PDF]		Drop the A from the ABCD2 Stroke Score? Owen J. David, et al.   (3 July 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]		Body piercing in England: training and ethical issues NORMAN NOAH, et al.   (3 July 2008) Read every Rapid Response to this article
	RESEARCH: Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial Hout et al. (14 June 2008) [Abstract] [Full text] [PDF]		Is early surgery for radicular pain really better? stuart harrison james, et al.   (3 July 2008) Read every Rapid Response to this article
	ANALYSIS: Best interests and potential organ donors Coggon et al. (14 June 2008) [Full text] [PDF]		Ethical and legal arguments for interventions in NHBD Wendy A Rogers, et al.   (3 July 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]		Zombie arguments against kidney markets James S Taylor   (3 July 2008) Read every Rapid Response to this article
	EDITORIALS: Deficiency of sunlight and vitamin D Holick (14 June 2008) [Full text] [PDF]		Vitamin D Deficiency Mitchell Simson   (3 July 2008) Read every Rapid Response to this article
	FEATURE: Everyone’s a radiologist now Wise (10 May 2008) [Full text] [PDF]		Ultrasound as a teaching tool in medical school Richard D White, et al.   (3 July 2008) Read every Rapid Response to this article
	FEATURE: Should medical journals carry drug advertising? Yes Smith (14 July 2007) [Full text] [PDF]		Re: Re: Faux-papers and Trojan horses Geraint H Lewis, et al.   (3 July 2008) Read every Rapid Response to this article
	PAPERS: Obesity in middle age and future risk of dementia: a 27 year longitudinal population based study Whitmer et al. (11 June 2005) [Abstract] [Full text] [PDF]		Obesity and IGF/GH levels. Edoardo Cervoni   (3 July 2008) Read every Rapid Response to this article
	PRIMARY CARE: 10-minute consultation: Rhinitis Walker and Sheikh (16 February 2002) [Full text] [PDF]		Allergic rhinitis N.P. Viswanathan   (3 July 2008) Read every Rapid Response to this article
	EDITORIALS: Promoting wellbeing among doctors Yamey and Wilkes (3 February 2001) [Full text] [PDF]		Providing a solution focused environment promotes wellbeing among Doctors Carl Plant   (3 July 2008) Read every Rapid Response to this article

EDITORIALS: Mental capacity and psychiatric admission Dawson (30 June 2008) [Full text] Mental capacity and psychiatric admission Beware of fluctuating capacity 3 July 2008 Jay Sarkar, Consultant Forensic Psychiatrist, Personality Disorder Service & Secure Womens Services East Midlands Centre for Forensic Mental Health, Cordelia Close, Leicester LE5 0LE Send response to journal: Re: Beware of fluctuating capacity Dawson refers to capacity in a categorical manner - present or absent. That is most useful when issues of 'gatekeeping' into detention and/or providing treatment urgently are important over-riding factors. This might also be reflected in the diagnoses of patients detained where severe psychosis, mood disorders or dementia often predominate. With regards to personality disordered individuals, especially those who have offended and are diverted into mental health services, the situation is quite different. Most of them retain their capacities for they do not lose 'touch with reality' as psychotic or organically impaired patients might. Or else this loss is limited to brief periods when they become psychotic or experience severe emotional disturbances that might become transient mood disorders. On other occasions they experience post- traumatic stress symptoms or disorder. The applicability of 'appropriateness' test in relation to the Mental Health Act 1983 and the 'best interest' principles of Mental Capacity Act 2005 are limited to brief windows only. Additionally most severely personality disordered individuals fluctuate in terms of stability of symptoms such that such windows replicate themselves throughout their detention. Furthermore, they often retain capacity fundamentally to refuse physically invasive treatments with drugs, ECT, etc., but may have impaired 'best interest' capacity for psychological therapies. They might chose to refuse engagement with any risk assessment, risk management and risk reduction strategies all of which are underpinned by robust psychological frameworks derived from a wide variety of fields ranging from cognitive behavioural to psychoanalytic. It is also not known how one would describe the undesirable side effects of psychological treatments, for often that is not known. Can the patient be expected to make a balanced judgment when the treater is unclear? One cannot 'enforce' psychological treatment either unlike depot medication, often the fall- back resort to harried clinicians when rapid symptom control is necessary. It is also important to highlight that what might be considered 'medical' best interest (the Code of Practice of MHA '83 considers all habilitative treatments to be 'medical' including attending arts and crafts in occupational therapy, for example) might not be the 'social' or 'legal' best interest for the patient. The risk of loss of autonomy and liberty for a far longer period of time brought about by acceptance of psychological treatments (that might highlight risks to others even more glaringly) can quite easily be conceived of as 'undesirable' and 'side effect' by the patient. Should patients be expected to engage in treatments that is likely to prolong their detention and may not be of direct benefit to them anyway, beyond the argument that prevention them from re-offending is a direct medical benefit. Should that not be the work of criminal justice agencies rather than mental health agencies? These issues are even more confusing when patients self harm prolifically within institutions such as maximum secure hospitals and prisons and both refuse treatment -physical and psychological - and carry out random and sometimes strategic assaults on care-givers in order to paradoxically 'seek' care in a traumatic manner, a function of their 'mental disorder'. Often in such cases one has to rely on common law and statutes such as MHA '83 and MCA '05 become meaningless as these statutes are limited in their scope inasmuch they do not cover much of ethical and moral debates necessary for these acts to be really meaningful in all health settings, not merely acute settings with those with severe psychotic symptoms or risk of suicide. Finally, with the imminent arrival of the MHA '07, one where all notions of 'categories' have been abandoned for 'mental disorder' alone, and 'treatability' criterion has been removed, one is likely to see paedophiles being detained as Paedophilia is a recognised mental disorder in the DSM and ICD nomenclatures, however mentally well the individual might be. We are on the anvil of a time when psychiatrists within the community to those working in the most secure institutions are likely to be challenged by statutory agencies to detain sex offenders on the grounds that they are mentally disordered, and that 'appropriate’ treatment exists. Both the acts are completely out of depth in cases such as these and issues such as On the other extreme are those patients detained under the DSPD pilot proposals who are increasingly taking up considerable amount of time, energies and resources of the mental health services through legal challenges and counter-challenges with tribunals appearing more like country courts and patients and hospital authorities both arguing through their respective counsels. Both the patient and the RMO and Social supervisor are being subjected to what has been called 'juridogenic harm', or the harm to therapeutic alliance and collaborative endeavours that so characterise doctor-patient relationships, by the adversarial 'us and them' approach that tribunals are forcing them to go through. Should one ask whether they have the capacity to agree to legal eagles hijacking their agendas and whether this is in their best interest for it clearly involves refusal of treatment or as is now increasingly being referred to as 'treatment resisting' patients as opposed to 'treatment resistance'. Unfortunately neither the academic world nor the Royal College of Psychiatrists appear to have taken such issues as seriously as they ought to have such that busy clinicians are now, in tandem with trust legal teams, trying to do a fire-fighters job. Who is to predict how the Supervised Community Treatment orders would be used for the majority of the DSPD individuals will not be subject to invasive medical treatment and cannot be forced to comply. And they are coming to a community mental health service near you if you are a psychiatrist. The need for greater awareness on legal and ethical issues could not be more acute for psychiatrists in the country and articles such as these raise important issues tangentially and must be lauded for they are so rare in mainstream medical journals. Competing interests: None declared

FEATURE: How clean is your water? Watts (2 July 2008) [Full text] How clean is your water? Illicit drugs also pollute our waters 3 July 2008 Pasquale Urbano, Director, Dept. of Public Health, University of Florence, Italy Viale Morgagni 48, 50134 Firenze, Italia Send response to journal: Re: Illicit drugs also pollute our waters Abuse drugs are excreted into the sewage system and may be found and measured in the environment [1]. Several authors estimate the gross amount of, e.g., cocaine, consumed in large metropolitan areas, building on their concentration in surface water bodies [2]. It would be interesting to reverse the theoretical models of Dr. Johnson, in order to increase the reliability of such estimates. 1: Zuccato E, Castiglioni S, Bagnati R, Chiabrando C, Grassi P, Fanelli R.: Illicit drugs, a novel group of environmental contaminants. Water Res. 2008 Feb;42(4-5):961-8. Epub 2007 Sep 2 2: Bones J, Thomas KV, Paull B. Using environmental analytical data to estimate levels of community consumption of illicit drugs and abused pharmaceuticals. J Environ Monit. 2007 Jul;9(7):701-7. Epub 2007 Competing interests: None declared How clean is your water? How clean is clean? 3 July 2008 Viera Scheibner, Scientist/Author etired self employed Send response to journal: Re: How clean is clean? Geoff Watts raised the issue of medications (pharmaceuticals) ending up in our water supply, and their possibly harmful effect on our health. This is a very timely article since the first results of scientific research are surfacing: basically, even minute amounts of pharmaceuticals can be very harmful, because Nature operates on several energy levels, one of which is sub-molecular (homeopathic). Basically, the lower the dose the stronger the effect. A variety of thresholds apply which homeopathy understands, while those who do not study homeopathy do not. As some recent Australian research demonstrated, that is the reason why fish in some areas are now born predominantly female (the oestrogen overload, mainly the effect of hormonal preparations such as the Pill and HRT and some other materials rich in oestrogen)which is the cause of disappearance of some species of fish, beyond the effect of overfishing. Research into the quality of recycled water also demonstrated that the level of oestrogen in recycled water is very much lower than in the 'normal' tap water. However, what is the 'safe' level in both sources of drinking water? This is a wakeup call for humanity to open its eyes (or rather the scientists)to other, scientific, systems of pharmacological medicine, such as homeopathy. After all, Dr Hannemann, the founder of modern homeopathy, was an orthodox medical doctor who saw the light. Dr Viera Scheibner (PhD), Blackheath, NSW, Australia, Competing interests: None declared

ANALYSIS: A friend in need: why friendship matters in medicine Loxterkamp (1 July 2008) [Full text] A friend in need: why friendship matters in medicine The value of Humanity 3 July 2008 John P Wattis, Retired Consultant Psychiatrist, Visiting Professor of Old Age Psychiatry University of Huddersfield, Queensgate, HD1 3DH Send response to journal: Re: The value of Humanity David Loxterkamp's article made me think. The relational aspect of medicine is vital regardless of whether we justify it in terms of science or humanity. In preparation for my own retirement from clinical practice, I undertook training as a "life and business coach". This provided me with a structure and ethical framework for a new (very part-time) career supporting colleagues and using many of the relationship skills I had developed in clinical psychiatry. It also left me with a conviction that many doctors would benefit from training in coaching as an approach to supporting patients and each other. As a result of that I have been running a training course in coaching skills for clinicians with the Royal College of Psychiatrists.Perhaps, over time, coaching skills will become a regular part of medical training in order to give doctors a framework to understand and exercise the more egalitarian aspects of medical befriending without becoming paternalistic or overstepping boundaries. Competing interests: Since retiring from clinical medicine I run a small coaching practice

CLINICAL REVIEW: Refeeding syndrome: what it is, and how to prevent and treat it Mehanna et al. (28 June 2008) [Full text] [PDF] Refeeding syndrome: what it is, and how to prevent and treat it UK Attitudes to NICE guidance on Refeeding Syndrome 3 July 2008 Aminda De Silva, SpR Gastroenterology & Clinical Nutrition Southampton University Hospital NHS Trust, Tremona Road, Southampton UK SO16 6YD, Trevor Smith and Mike Stroud Send response to journal: Re: UK Attitudes to NICE guidance on Refeeding Syndrome It was welcome to see the article by Mehanna et al(1) raising awareness of the refeeding syndrome (RFS) and highlighting some of the risks and clinical syndromes that can arise when nutritional support is instigated injudiciously. However we feel that there are a few additional points that should be considered. Any discussion relating to risks around RFS should include the increased threat of infection that may often be silent in the context of malnutrition and very malnourished patients may therefore develop infection without showing the usual septic markers such as an increased temperature, white count or CRP. We would therefore advocate septic screening and a low threshold for broad spectrum antibiotic cover for any patients with unexplained hypothermia, hypoglycaemia and evidence of malnutrition. In addition, patients at high risk of RFS may also be at risk of acute renal failure, which may be missed as they only have slightly raised ureas and creatinines due to low muscle mass leading to low production of these metabolites. When this occurs, renal dysfunction may hide low serum and total body electrolyte concentrations, and hence serum potassium, magnesium and phosphate may be reassuringly normal or even high. They are at even greater risk of precipitate falls in these circulating electrolytes once simultaneous nutritional and fluid therapy has started. We agree that clinicians should be alert to the possibility of this syndrome developing in ‘at risk’ patients. We sought to quantify the level of knowledge regarding RFS that currently exists in clinical practice and found there was confusion about its management, even amongst professionals with an expressed interest in nutrition. This survey, yet to be reported, of doctors, nurses, pharmacists and dietitians, (all members of their respective nutrition societies) on their attitudes to the NICE guidance(2) on RFS syndrome, revealed widespread disparities in practice. Only 44% of doctors as opposed to 70% of dietitians actually followed NICE guidance. Thirty nine percent of all responders felt the guidance represented safe practice whilst 36% felt they were excessively cautious. Some responders felt that, ‘NICE guidelines have created an obstacle to providing adequate nutrition,’ and others felt that they had never seen a case of RFS despite starting nutritional supplementation at 100% of estimated requirements throughout their career. These data show that practice relating to RFS is split within the UK and highlight the importance of trying to obtain clinical evidence to inform practice when dealing with groups at risk of RFS. 1 Hisham M Mehanna, Jamil Moledina & Jane Travis. Refeeding syndrome: what it is, and how to prevent and treat it BMJ 2008;336:1495- 1498 (28 June) 2 National Institute for Health and Clinical Excellence. Nutrition support in adults. Clinical guideline CG32. 2006. www.nice.org.uk/page.aspx?o=cg032 Competing interests: None declared

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... Inconsistent Comparisons and Unsound Conclusions 3 July 2008 Michael Spagat, Professor of Economics Department of Economics, Royal Holloway College, University of London, Egham Surrey TW20 0EX, UK Send response to journal: Re: Inconsistent Comparisons and Unsound Conclusions Obermeyer and colleaques1 compare their estimate of 5,393,000 war deaths in 13 countries, 1955-2002, with a PRIO battle-death figure of 2,784,000, a ratio of 1.9 war deaths per battle death, and claim that PRIO data “indicated a figure of only a third” of their own estimate.2 The 3.0 that appears in Table 3 turns out to be an unweighted average of the 13 ratios of the Obermeyer estimates to the PRIO figures: one for each country. Thus, Georgia with 0.6% of the estimated war deaths and a ratio of 12.0 gets the same weight as Vietnam, with 71% of the war deaths and a ratio of 1.8. Without Georgia the mean ratio falls to 2.2, close to the weighted average of 1.9 as well as to the median of the 13 ratios (2.1). The authors also conclude that “there is no evidence to support a recent decline in war deaths.” They base this claim on an extrapolation from 13 data points. Their regression equation is completely dominated by the huge Vietnam point. The equation is: Estimated War Deaths = 27,380 + 1.81*(PRIO Battle Deaths) The estimated constant in this relationship, 27,380, is far from statistical significance. All PRIO figures, 1955–94, are then passed through this equation, including the insignificant constant without which the PRIO trends would have been preserved exactly. In fact, Obermeyer et al.’s own data show a clear decline in war deaths over time. Had they included the Korean War and the two world wars, as did Lacina, Gleditsch & Russett (2006)3, the decline would have been even more evident. 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 This is an “apples versus oranges” comparison since the category of “battle deaths” is substantially narrower than the category of “war deaths”. By PRIO’s definition, battle deaths can only occur during contested combat incidents involving two opposing sides, one of which must be a State. War deaths include many additional types of incidents including massacres and inter-ethnic violence. 3 Lacina B., Gleditsch NP, Russett B. The declining risk of death in battle. Int Stud Q 2006; 50: 673-80. 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... Risk Estimation Works for Populations but not for Individuals 3 July 2008 Tim M Reynolds, Consultant Chemical Pathologist Queen's Hospital, Burton-on-Trent, DE13 0RB, Adie Viljoen , Patrick J Twomey, Anthony S.Wierzbicki Send response to journal: Re: Risk Estimation Works for Populations but not for Individuals The QRISK-2 algorithm[1] improves over the first version and represents a great leap forward over the Framingham equation because it is based on 16 million person years of cardiovascular events and has been validated against 2.22 million people, including a variety of ethnicities. This has allowed assessment of accuracy of the modelling parameters for prediction and improved accuracy when applied to a population. It also means that unlike other risk algorithms it is grounded in its population and does not suffer concordance discrepancies that reduce the validity of methods that attempt to mimic performance of other algorithms [2,3]. Unfortunately, when applied to individuals, all screening algorithms suffer the same problem. Intra-individual variation in lipid and blood pressure measurements mean that the tight estimates of the confidence intervals cited are over-optimistic and are mostly driven by regression dilution in the large sample employed [4] The estimates do not reflect the variation at the individual patient level. Many patients have only a single estimate of cholesterol. Modeling of the Framingham equation-based individual risks using data from published sources on variances shows that any estimated risk has a wide confidence interval meaning that when a patient is advised that their risk for example is 20%, the 95% confidence intervals for that estimate are ±6% (so 95% range is 14% - 26%) [4]. Cardiovascular risk prediction also has many limitations [5]. Consequently, whilst it is easy to identify a population at risk, it is not so easy to identify individuals at risk and risk estimation cannot be reduced to a production line process ignoring the role of detailed clinical assessment and significant medical experience. Most cardiovascular events occur in people who have lipid and blood pressure results similar to the unaffected population. Thus targeting high -risk individuals actually has little effect on the overall burden of disease. It simply consumes resources. Instead, if the average cholesterol of the entire population was reduced by 0.5 – 1.0 mmol/L, which could be achieved by changes in diet, the use of plant stanols and/or the outcome- evidence based approach of low doses of statins (e.g. pravastatin 10mg/day), similar reductions in cardiovascular morbidity and mortality could be generated without the need for costly screening programs [6]. Secondary prevention would then be applied in a similar way to anyone developing cardiovascular disease but this time using high dose potent statins as in the trials. This is the approach that actually underlies the new NICE guideline but the authors did not have the courage to state outright. If statins are the new aspirin for the 21st century then let us use them in the same manner. Timothy M. Reynolds FRCPath: Professor of Chemical Pathology. Queen’s Hospital, Burton-on-Trent Staffordshire DE13 0RB Adie Viljoen FRCPath: Consultant Chemical Pathologist. Lister Hospital, Stevenage Hertfordshire SG1 4AB Patrick J Twomey FRCPath: Consultant Chemical Pathologist. The Ipswich Hospital Suffolk IP4 5BD Anthony S.Wierzbicki FRCPath: Consultant Chemical Pathologist. St Thomas' Hospital, London SE1 7EH References 1) Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Minhas R, Sheikh A, Brindle P. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRisk2. Brit Med J 2008; 336 : 1475 2) Reynolds TM, Twomey P, Wierzbicki AS. Concordance evaluation of the coronary risk scores: Implications for screening. Curr Med Res Opin 2004; 20: 811-8 3) Wierzbicki A, Reynolds T, Gill K, Alg S, Crook M. A comparison of algoriothms for initiation of lipid lowering therapy in primary prevention of coronary heart disease. J Cardiovasc Risk 2000; 7: 63-73 4) Reynolds TM, Twomey P, Wierzbicki AS. Accuracy of cardiovascular risk estimation for primary prevention in patients without diabetes. J Cardiovasc Risk 2002; 9: 183-90 5) Greenland P, Lloyd-Jones D. Time to end the mixed and often incorrect messages about prevention and treatment of atherosclerotic cardiovascular disease. J Am Coll Cardiol 2007; 22: 2133-5 6) Reynolds TM, Mardani A, Twomey PJ, Wierzbicki AS. Targeted versus global approaches to the management of hypercholesterolaemia. J Roy Soc Health 2008; in press Competing interests: None declared Predicting cardiovascular risk in England and Wales: prospective derivation and... Remodelling cardiovascular modelling 3 July 2008 Eddie Vos, maintains www.health-heart.org Sutton (Qc) Canada J0E 2K0 Send response to journal: Re: Remodelling cardiovascular modelling The unexplained ethnic differences in cardiovascular risk modelling using 14 parameters of which arguably only 2 (smoking and weight) are under one's direct control(1) underscore the need to add parameters, preferably modifiable ones dealing with cause.       There is good evidence that arterial architecture is degraded by life-long thiolation (by homocysteine(2)) and by low vitamin D3 status (affecting calcium husbandry and gene expression). The finding of an even more deficient vitamin D status in UK Asians than in Whites(3) may affect cardiac outcomes.(4)       Interestingly, coronary disease is rarely reported at homocysteine levels <7 µM and thus the levels in UK Asians (for example: 13.3 µM in east London Bangladeshis vs. 8.5 µM in Whites(5)) are of concern. This is not only because homocysteine is a biomarker for common low intakes of at least 4 B vitamins (B2, B6, B12 and folate) but also because homocysteine affects the lysine-based structural x-links in both elastin and collagen (the main structural proteins in artery and heart), it degrades protein disulfide bonds and cysteine-based enzyme active sites.       We know that lowering the protein ‘corrosive’ homocysteine with a multivitamin helps but is no quick cure for arterial decline. Artery structure take decades to degrade [corrode] and when looking at the consequences of existing decline as in(1), we may modelling, or treating, symptoms rather than long and shorter-term causes. Other nutrient deficiencies that affect secondary outcomes include common low intakes of plant and fish-based omega-3 fatty acids and magnesium. At least and fortunately so, these nutritional factors are modifiable by supplementation and sometimes by food choices and deserve a place among the modelling parameters. vos{at}health-heart.org 1. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, Minhas R, Sheikh A, Brindle P. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. BMJ. 2008 Jun 28;336(7659):1475-82. Medline 18573856 2. http://www.health-heart.org/why.htm [a homocysteine based hypothesis as to cause] 3. Rhein HM. Vitamin D deficiency is widespread in Scotland. BMJ. 2008 Jun 28;336(7659):1451. Medline 18583649 4. Giovannucci E, Liu Y, Hollis BW, Rimm EB. 25-hydroxyvitamin D and risk of myocardial infarction in men: a prospective study. Arch Intern Med. 2008 Jun 9;168(11):1174-80. Medline 18541825 5. Obeid OA, Mannan N, Perry G, Iles RA, Boucher BJ. Homocysteine and folate in healthy east London Bangladeshis. Lancet. 1998 Dec 5;352(9143):1829-30. Medline 9851391 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?... Re: Virtual Congress of family medicine and general practice 3 July 2008 N.P. Viswanathan, Family physician, S.V.clinic,Gm Palya,Bangalore-560075,India Send response to journal: Re: Re: Virtual Congress of family medicine and general practice I am very happy to inform you that I was given the Best Congress Participant award by Portuguese Association Of general practitioners. Congress was paper free conference. I achieved this without leaving my home or country. BMJ is my guidance for the past 34 years. I am very happy to share my joy through BMJ. N.P.Viswanathan 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 The value of breastfeeding 3 July 2008 James E. Akre, Author; Public Member, Board of Directors, International Board of Lactation Consultant Examiners 1232 Confignon, Geneva, Switzerland Send response to journal: Re: The value of breastfeeding It concerns me that comments made thus far about the relative cost of breastfeeding vs. artificial feeding focus largely on the short-term outlay for related paraphernalia and the perceived ease of one feeding mode over the other. I’m not calling into question the points made so much as their relative importance when compared to the multiple, complex and lifelong implications for the health of mothers, children and thus the entire society of observing or disregarding the biological “hominid blueprint” (1) for nourishing the young of our species. It is virtually impossible to place a precise economic value on breast milk. In addition to being so much more than a mere food, it is rarely traded in the marketplace. Nevertheless, in 1994 the estimated value of human milk traded in milk banks in Norway was set at US$2.2bn (2). Even if this represents only a fraction of human milk’s total value, extrapolated worldwide it promptly gives the lie to the all too common – and frankly absurd, even offensive – assertion that breast milk is somehow free. Meanwhile, breastfeeding itself has at least three price tags attached: a mother’s time, which far too many observers mistakenly consider to be “on the house”; the energy cost of producing milk (though an incomparable value in terms of the benefits derived for both mother and child, the daily additional 500 kcal still need to come from somewhere); and the opportunity cost – the cost of doing something in terms of an opportunity foregone – for example mothers who must choose between staying at home with their children and returning to paid employment outside the home to meet their families’ financial needs. Taken together these three price tags provide additional compelling evidence that breast milk is anything but free (3). At birth the infant’s brain is the most undifferentiated organ in the body (4). If genes and early experience shape the way neurons connect to one another, thereby forming the specialized circuits that give rise to mental processes, it is reasonable to conclude that whether this process is initially fired in a manner that is evolutionarily consistent with who we are as a species or relies on a food that is based on the milk of an alien species will make a significant difference in terms of developmental outcome. It is time to adopt this generic perspective as the nutritional basis for ensuring the full genetic potential for every child’s neural development. In multivariable analyses of the early life determinants of childhood intelligence in a population-based birth cohort of individuals born in Brisbane, Australia, Lawlor et al. (5) reported that the strongest and most robust predictors of intelligence were family income, parental education and breastfeeding, with these three variables explaining 7.5% of the variation in intelligence at age 14. What do we suppose would be the cumulative worth, over a lifetime, of 2 to 10 IQ points (6) for the 136 million children born every year (7) if they were breastfed for 12–18 months? Infant formula will sustain life in a pinch, and thank goodness this is so. But from a nutritional and developmental standpoint, not everyone has understood just how hugely inferior it is to breast milk, with negative implications for both children and their mothers – and thus the whole population – across the entire life course. Infant formula pitched as somehow suitable for routine non-emergency use is immediately denatured, thereby forfeiting its only claim to legitimacy – as a life- sustaining crisis commodity. Moving infant formula, once and for all, from the kitchen pantry and permanently relegating it to where it got its start – in the medicine cabinet, for emergency use only – presupposes a major shift in popular, health-professional and political thinking. This begins by ceasing to emphasise the “benefits of breastfeeding” and concentrating on the “risks of not breastfeeding” for mothers and children alike. James Akre akrej@yahoo.com 1. Dettwyler, K.A. (1995) A Time to Wean: The Hominid Blueprint for the Natural Age of Weaning in Modern Human Populations. In: Stuart- Macadam, P. & Dettwyler, K.A. (eds) Breastfeeding. Biocultural Perspectives pp. 39–73. Aldine de Gruyter, New York. 2. Hatløy, A. & Oshaug, A. (1997) Human milk. An invisible food resource. Food Consumption and Nutrition Division Discussion Paper No. 33. Washington, DC, International Food Policy Research Institute. At: http://www.ifpri.org/divs/fcnd/dp/papers/dp33.pdf (accessed 1 July 2008). 3. Akre, J. The really big money (2006). In: J. Akre The problem with breastfeeding. A personal reflection (pp. 147–154). Amarillo, Texas: Hale Publishing L.P. 4. Siegel, D.J. (1999) The Developing Mind. How Relationships and the Brain Interact to Shape Who We Are. New York: The Guilford Press. 5. Lawlor, D.A. et al. (2006) Early life predictors of childhood intelligence: findings from the Mater-University study of pregnancy and its outcomes. Paediatric and Perinatal Epidemiology 20 (2): 148–162. 6. Daniels, M.C. & Adair, L.S. (2005) Breast-feeding influences cognitive development in Filipino children. Journal of Nutrition 135: 2589–2595. 7. WHO (2005) Chapter 4. Attending to 136 million births, every year. In: World Health Report 2005, Geneva: WHO. Competing interests: None declared

EDITORIALS: Cardiovascular risk tables Christiaens (28 June 2008) [Full text] [PDF] Cardiovascular risk tables Drop the A from the ABCD2 Stroke Score? 3 July 2008 Owen J. David, Consultant Physician in General, Geriatric & Stroke Medicine The Royal Bournemouth and Christchurch Hospitals NHS Trust, Fairmile Road, Christchurch, Dorset, UK, BH23 2JX Send response to journal: Re: Drop the A from the ABCD2 Stroke Score? Christiaens editorial 1 asking the profession to re-think the relationship between age, risk and subsequent treatment is most timely. The National Stroke Strategy 2 is now driving the modernisation of stroke services and advocates the use of age as part of its risk stratification. The ABCD2 score is determined from a points system accruing with age (A), blood pressure (B), clinical features (C), duration of symptoms and diabetes (D). 3 Those with a high score will need to be seen within 24 hours, which is admirable given the marked seven day stroke risk of these patients. While this is a valiant attempt to buffer stroke services from demand, the use of age needs to be questioned. Brey et al. found that removing the age component reduces the number of false positive scores but does not prevent it predicting future stroke risk. 4 As Christiaen warns, including age in risk assessment threatens to under treat younger patients. Stroke medicine is rightly moving forwards, but is it too late for the BCD3 score? Owen David 1 Christiaens T, Cardiovascular risk tables. BMJ 2008;336:1445-6. (28 June.) 2 National Stroke Strategy, Department of Health. 5 December 2007. www.dh.gov.uk/publications 3 Johnston SC, Rothwell PM, Nguyen-Huynh MN et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007; 369(9558):283-292 4 Bray JE, Coughlan K, Bladin C. Can the ABCD Score be dichotomisedto identify high-risk patients with transient ischaemic attack in the emergency department? Emergency Medicine Journal. 2007; 24(2):92-95. 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 Body piercing in England: training and ethical issues 3 July 2008 NORMAN NOAH, PROFESSOR OF PUBLIC HEALTH London School of Hygiene and Tropical Medicine, Fortune Ncube Send response to journal: Re: Body piercing in England: training and ethical issues The information from our paper [BMJ 2008;336;1426-1428] showed that body piercing in England and Wales is not being carried out as well as it could and should be. Even though we found that proportionally more complications occurred after piercings carried out by non-specialists, we are anxious to clarify that the problems are not merely with them, as they are relatively fewer in number. Most problems follow specialist piercing. Most specialist piercers now use pre-sterilized instruments and are aware of the risks of transmitting blood borne viral infections [BBVs], and we would be surprised if BBV transmission by specialist piercers does occur to any extent in the UK. Moreover, Environmental Health Officers throughout England and Wales generally are extremely efficient in ensuring the use of pre-sterilized instruments to prevent BBV and other infections. Nevertheless there remain important gaps in hygiene and training, and there are some ethical issues that also need to be addressed. The following list has been compiled from the experiences of one of us in investigating outbreaks of hepatitis B, in visiting premises of cosmetic skin piercers and producing guidelines for them, as well as involvement as an expert witness in several legal actions taken by members of the public who have developed complications following a piercing. Training: there appears to be no formal training process or diploma. We consider this essential. It should include a basic knowledge of anatomy, microbiology and disinfection, hygiene and sound technique. Hygiene and aftercare advice: Some of the disinfectants used in cleansing the skin before piercing are unsuitable for the purpose. There needs to be consensus on this, with the appointment possibly of an approved national microbiologist adviser who can ensure uniformity and efficiency. The aftercare advice is generally appalling.The bacterial infections that sometimes supervene, occasionally leading to permanent deformity and scarring, are as often, in our opinion, caused by poor aftercare advice as by poor piercing technique. Death has followed piercing in persons with an existing heart condition. There should be an agreed list of pre-existing medical conditions about which each piercer should ask the customer, with clearance from their GP if necessary. Use of ear-piercing instruments [‘guns’]: These must not be used on any part of the body except the external ear. There is no evidence that guns are more likely to cause an infection in the pinna than the needle method, but infections in the pinna are more difficult to treat, and more likely to lead to permanent scarring than earlobe piercing. Use of local anaesthetics: there is no general consensus on these, and some piercers use ethyl chloride which we suspect is more painful than the piercing. There is some confusion among piercers about what needs to be prescribed by a doctor. This could be clarified. Age of consent: except for tattooing, there appear to be no laws governing the age of consent. With the possible exception of the ear lobe, for all other areas of the body including the pinna of the ear, we consider that there should be rules about the age of consent and parental permission. Other ethical issues include ensuring that neither the piercer or customer is under the influence of alcohol or drugs when the piercing is performed. Finally, to protect themselves, we recommend that piercers should inform customers about any complications that may arise, and ensure that this has been recorded. Norman Noah Professor of Public Health London School of Hygiene and Tropical Medicine London WC1E 7HT Fortune Ncube Consultant Epidemiologist Centre for Infections, Health Protection Agency, London NW9 5EQ Competing interests: NN has acted as a paid hygiene consultant to acupuncturists and manufacturers of ear piercing equipment and an unpaid hygiene consultant to tattooists and beauty therapists. He has also acted as an expert witness in judicial cases concerned with the hygiene of skin piercing

RESEARCH: Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial Hout et al. (14 June 2008) [Abstract] [Full text] [PDF] Prolonged conservative care versus early surgery in patients with sciatica from... Is early surgery for radicular pain really better? 3 July 2008 stuart harrison james, Specialist Registrar in Spinal Surgery university Hospital Wales, Cardiff, cf14 4xw, Sashin Ahuja Send response to journal: Re: Is early surgery for radicular pain really better? Dear Sirs, We read with interest the article by Wilert B van den Hout, Wilco C Peul et al titled Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial.BMJ 2008;336;1351-1354. We congratulate the authors on an elegantly presented paper on a difficult and emotive subject matter, however there are several points that we would like to make with regard to this paper. We found it interesting that the authors decided to randomise patients into either the conservative or operative groups at the range of 6 weeks to 12 weeks, which remain the basis of this paper. It seems in our opinion that this would be a rather aggressive management plan to undertake surgery at this time, as there is scope for spontaneous resolution of patients symptoms between these time periods, which give rise to a bias within the results due to a lack of standardisation. The premise of the study is that patients who undertake surgery have a quicker recovery and cost less in terms of financial pressures to the healthcare system, and also have increased Quality adjusted life years. In our practice patients who fail to respond to conservative therapy, typically the first 6 weeks, would then proceed to undertake a nerve root block of the compressed nerve as demonstrated by radiology. The relief of symptoms allows active aggressive physiotherapy, which has been show to improve lumbar symptoms 1. A successfully treated patient in this way firstly costs less to the healthcare provider but also avoids the cost not to mention the morbidity associated with surgery. It is also imperative to know how many patients had concurrent back pain, a commonly associated symptom known to have an effect on the ability of patients to work, as well as final outcome of treatment. This is not mentioned and would affect the overall results of the study. The article also has to make several assumptions particularly with regards to return to work. No data as to the number of people employed is presented, and thus assumes all patients are employed with an average wage used as the model, thus is only attributable to people who are employed. Secondly return to the working environment relies not just on the patient’s physical symptoms, but also their motivation to return. A homogeneous cohort of patients with objective pain assessment, patient cooperation with the study and the patient’s psychosocial environment must be used for an accurate assessment 2 but is appreciably difficult to attain. Finally, the patients presenting a diary of visits for various appointments, and the costing of the time and financial implications of these visits is inherently open to inaccurate reporting, thus potentially skewing the results. 1. Weber H, Holme I, Amlie E. The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam. Spine. 1993;18:1433–1438 2. Kool J, de BR, Oesch P, et al. Exercise reduces sick leave inpatients with non-acute non-specific low back pain: A metaanalysis. J Rehabil Med. 2004;36:49–62. 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 Ethical and legal arguments for interventions in NHBD 3 July 2008 Wendy A Rogers, academic Flinders University, Australia, Bernadette Richards Send response to journal: Re: Ethical and legal arguments for interventions in NHBD To the Editor, Coggon and colleagues (1) argue that, despite the beliefs of some practitioners, current UK law permits non-harmful ante-mortem interventions to improve the prospects of donation after cardiorespiratory death. Their argument is based on the grounds that such interventions are in the patient’s best interests if that person is known to have a desire to donate organs. We agree, and made the identical legal argument in our analysis of the legal and ethical issues raised by non-heart beating donations in Australia. (2) Australian law draws upon British precedents, and like Coggon and colleagues, we used the judgment in Airedale NHS Trust v Bland [1993] AC 789 as part of our argument. In addition to the legal considerations, our paper included two ethical arguments in support of ante-mortem interventions. The first is based upon a view of consent to organ donation that takes such consent to include any necessary technical steps to achieve the desired result. If a person desires to be an organ donor, it is not unreasonable to assume that they would support any non-harmful interventions that are likely to improve the likely success of donation. This is consistent with the legal requirements of general consent to the nature of the treatment as opposed to itemised consent to each individual cut of the scalpel. Second, we argued that as some interventions before death may be harmful, it is only non-harmful interventions that may given in the absence of explicit consent. Wendy Rogers Bernadette Richards 1. Coggon J, Brazier M, Murphy P, Price D, Quigley M. Best interests and potential organ donors. BMJ 336: 1346-7. 2. Richards B, Rogers W. Organ donation after cardiac death: legal and ethical justifications for antemortem interventions. Med J Aust 2007;187:168-170. 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 Zombie arguments against kidney markets 3 July 2008 James S Taylor, Assistant Professor The College of New Jersey 08628 Send response to journal: Re: Zombie arguments against kidney markets In his responses to Koch (1) and Scheper-Hughes (2) Matas reiterates his commitment to introducing a well-defined regulated market in human kidneys, to be introduced “only in situations… 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” (3). Matas’ responses to Koch and Scheper-Hughes are well-taken. But given both the seriousness of the matter at hand and the tendency of (some) opponents of regulated markets in kidneys to obfuscate the critical issues it is useful to outline what precisely Koch’s and Scheper-Hughes’ objections are, and then to address them one by one. The need for this is all the more compelling since even though some of these arguments occur again and again in the debate over kidney markets, and are rebutted each time they appear, they, like zombies, simply refuse to die. Koch offers three objections to Matas’ proposed regulated market in human kidneys. First, that since there is “no commercial organ system in place in North America” Matas’ “solution doesn't fix a market problem at all but instead creats [sic] a market where commercialization has been, in the past, prohibited.” Second, that Matas’ idea of compensating kidney providers through life, or long-term, insurance would “only codify inherent economic inequalities,” for “Only those who can afford these insurances would be eligible as recipients and the contemporary inequalities in the system would be exacerbated, not reduced.” Finally, Koch argues that Matas is incorrect to assert “that arguments against a market in organs fail ‘on detailed analysis’ and in many cases offer ‘illogical" propositions’,” holding that “The first assertion is at best debatable and the second simply incorrect. There is, for example, nothing illogical about Dr. Chapman's response…”. (1) Scheper-Hughes offers four additional objections to Matas’ proposed regulated market in human kidneys. First, that the debate over kidney markets is “unenlightened by the anthropological and ethnographic record on the individual, social, economic, and political consequences of organ selling”. Second, that “The arguments by bioethicists and moral philosophers are based on abstractions that have nothing to do with the everyday realities of desperate transplant patients or their donors and sellers.” Third, that “The Iranian model of regulated kidney selling, which has been suggested as a paradigm for the world to follow, has not ended the black market there,” for “Living donors are still recruited by middlemen and private payments (over and above the government stipend) are negotiated behind the scenes. Thus, claims Scheper-Hughes, “Rather than replace the black market the government of Iran has legalized it.” Finally, she notes that at the recent Istanbul summit on organ trafficking there was near unanimous support “for the ban on commerce in organs and transplant tourism,” which was viewed by the delegates as “hurting their country, demeaning their profession, harming the kidney sellers, and under -serving the real needs of transplant patients for a medically, socially, and politically ethical system.” (2) Let us address these seven objections in turn. It is clear that Koch’s first concern with Matas’ proposal is not an objection, but simply a restatement of what it is. As such, it can be put to one side immediately. His second objection—that Matas’ proposal that kidney providers be compensated through the provision of insurance would “codify inherent economic inequalities” for only persons who could afford to pay for the provision of such insurances to kidney providers would be eligible as kidney recipients—can similarly be dismissed. Koch’s objection here is implicitly based on the view that under a market model of kidney procurement the recipients would be compensating the providers directly. But while this is certainly one way in which a market in kidneys could be organized it is not the only way. Rather than kidney recipients directly compensating kidney providers they could be compensated by medical insurance companies, who would then distribute the kidneys thus procured to their clients. At the same time kidney providers could be compensated by government programmes, such as Medicare or Medicaid in the United States, or the National Health Service in the United Kingdom, who could then distribute the kidneys thus procured on a medical, rather than a market, basis. Similarly, charitable organizations could procure kidneys through the provision of insurance to the providers, and then distribute them according to their own altruistic principles. Given that all of these means of distributing kidneys are compatible with their market-based procurement, Koch is mistaken to claim that markets in human kidneys would exacerbate current economic inequalities, with only the well-off having access to them. Finally, Koch is correct to note that the question of whether markets in human kidneys are ethically acceptable or not is one that is being debated—although it should be noted that this is not to say that he is right to hold that this issue is a “debatable” one, for colloquially this latter characterization holds pejorative connotations. Having noted this, however, it should be recognized that none of the arguments in the two main books that argue in favor of kidney markets—my own Stakes and Kidneys: Why markets in human body parts are morally imperative (Ashgate, 2005), and Mark J. Cherry’s Kidney For Sale by Owner (Georgetown, 2005)—have been rebutted yet. As such, the onus is firmly upon those opposed to markets in human kidneys to defend their view that the freedom of both potential sellers and potential recipients to engage in their life -saving voluntary economic transactions should continue to be proscribed by the ban on this market. It should also be noted that Koch’s response to Matas’ claim that the opponents of markets are often “illogical”—that Dr. Chapman’s response to him is not—is compatible with Koch’s claim that most of those opposed to markets in human kidneys offer illogical objections to them. Ironically enough, then, Koch’s response here to Matas is itself an illogical one—one cannot show that the claim “Most objections to this position are illogical” is false by citing only one that is not! Thus, without additional evidence to the contrary Matas’ claim here stands. Scheper-Hughes’ responses to Matas fare no better than Koch’s. Schepher-Hughes first charges that the debate over kidney sales remains “unenlightened by the anthropological and ethnographic record on the… consequences of organ selling”. There are two responses to be made here. The first is that the “anthropological and ethnographic record” that she refers to pertains to the illegal, unregulated market in kidneys—and so is simply irrelevant to discussions of legal, regulated markets. The second is to note that her charge is simply untrue. Both her own work (4- 6) and that of Madhav Goyal (7) is frequently cited within this debate. Those opposed to kidney markets wrongly hold that it shows what the consequences of any market in kidneys will be, while those in favour of them correctly note that the legalization of markets in kidneys will help prevent the documented abuses by providing a safe legal alternative for would-be kidney providers. While Scheper-Hughes’ first objection is thus both irrelevant and untrue, her second—that “[t]he arguments by bioethicists and moral philosophers are based on abstractions that have nothing to do with the everyday realities of desperate transplant patients or their donors and sellers”—is just untrue. In Stakes and Kidneys, for example, I examine the available data concerning both illegal markets in kidneys and their legal counterparts, together with the data pertaining to the risks of nephrectomy as compared with other dangerous activities to put the risk of kidney selling into its proper context. To do so, I draw on (among other sources) both anthropological and ethnographic data (including Scheper- Hughes’ own), medical data, morbidity and mortality statistics from Government sources, and published interviews with kidney providers and recipients. Moreover, Scheper-Hughes is—or should be—aware of the wealth of evidence concerning “everyday realities” that is marshaled to support markets in kidneys, for she has reviewed (for The Lancet) the pro-market books that present it (including mine) (8). Just as Scheper-Hughes’ second objection is better than her first (being only untrue, rather than both irrelevant and untrue), so too is her third, which is not untrue—just irrelevant. Here, Scheper-Hughes holds that Iran has only legalized a black market, offering as evidence for this the fact that persons sometimes pay more for a kidney than the Government sanctioned minimum. This is simply what has happened; what was previously an illegal market is now legal and regulated, just as the ending of Prohibition in the United States legalized the former black market in alcohol. And, just as the repeal of Prohibition ended the abuses associated with the black market in alcohol, so too has the legalization of the market in Iran made things better and safer for all concerned. Scheper-Hughes is also no doubt right that some people pay more than the Government minimum for kidneys. But it is unclear why this is a moral problem. After all, most people in the United States are paid more than the minimum wage, but I assume that Scheper-Hughes does not think that their employers are acting wrongly in so doing. Scheper-Hughes’ observations of the market in Iran thus do not support her objections to markets at all. What, then, of Scheper-Hughes’ final objection—that many of the delegates to the Istanbul summit are horrified at the effects of transplant tourism and organ trafficking? Again, this objection is irrelevant, for it is based on conflating illegal markets with legal, regulated markets. If one is really interested in eliminating these evils then one should work to legalize and regulate markets in human kidneys, to provide both providers and recipients with a safe, legal, environment in which to engage in their voluntary, life-saving transactions. And this, of course, is precisely what Matas is arguing that we should do (3). James Stacey Taylor Department of Philosophy The College of New Jersey Ewing, NJ 08628 USA (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, Framing the debate, BMJ online, June 25, 2008 (4) Scheper-Hughes, NM, 2008. “The Illegal Organ Trade: Global Justice and the Traffic in Human Organs”, chapter 10, Living Donor Organ Transplantation, R.W.G. Gruessner and E.Bendetti,eds, pp. 106-121. (5) Scheper-Hughes, NM, 2006. “Is it Ethical for Patients to Purchase Kidneys from the World’s Poor? A Debate between Tarif Bakdask and Nancy Scheper-Hughes. PLOS Medicine October 2006 3(10) www.plosmedicine.org (6) Scheper-Hughes, NM, 2003. “Rotten Trade: Millennial Capitalism, Human Values, and Global Justice in Organs Trafficking.” Journal of Human Rights 2 (2): 197-226 (7) Goyal, M. et al., 2002. “Economic and Health Consequences of Selling a Kidney in India,” JAMA 288: 1589-1593. (8) Scheper-Hughes, NM, 2005. “Book Review: The Ultimate Commodity.” The Lancet 366: 1349-1350, October 15. Competing interests: None declared

EDITORIALS: Deficiency of sunlight and vitamin D Holick (14 June 2008) [Full text] [PDF] Deficiency of sunlight and vitamin D Vitamin D Deficiency 3 July 2008 Mitchell Simson, Assistant Professor of Internal Medicine UNM School of Medicine, Albuquerque, NM 87131 Send response to journal: Re: Vitamin D Deficiency Despite living in the sunny southwestern United States with sunshine about 300 days annually, I have found widespread Vitamin D deficiency in my general Internal Medicine population. About a year ago, I began to check Vit. D 25-OH levels on all my patients, no matter what age. I have seen significant deficiency in over 85% (ages 22 through 90). I can guarantee that any patient who works indoors (especially those who sit behind computers), and all patients with diabetes, arthritis and coronary disease have low levels. These have included middle-aged and elderly patients who have been taking routine calcium and vitamin D supplementation (~800 I.U. vitamin D daily). Many patients have required 2 rounds of 50,000 I.U. therapy to get themselves into the low normal range before daily supplementation can continue. One wonders about the amount and/or true bioavailability of the vitamin in such supplements. Competing interests: None declared

FEATURE: Everyone’s a radiologist now Wise (10 May 2008) [Full text] [PDF] Everyone’s a radiologist now Ultrasound as a teaching tool in medical school 3 July 2008 Richard D White, Specialty Registrar in Clinical Radiology Ninewells Hospital, Dundee, UK, DD1 9SY, Katy M Edmonds Send response to journal: Re: Ultrasound as a teaching tool in medical school We read with interest Jacqui Wise’s “Everyone’s a Radiologist Now” feature. Of note, no mention was made of the integration of ultrasound into practical anatomy sessions at Newcastle University Medical School. As former anatomy demonstrators there, we had first-hand experience of the benefits of such teaching.. Students were shown how to visualise a range of structures, including the carpal tunnel, temporomandibular joint and the brachial plexus, and practiced locating such landmarks under supervision. Feedback from students was extremely positive in this respect, with the use of ultrasound stimulating an interest in – and enhancing the understanding of – applied anatomy. Discussions focussing on central line insertion during neck vein examination, for example, meant that students could start to appreciate the clinical applications of ultrasound. However, whilst the use of ultrasound as an adjunct to clinical examination is a good idea in principle, the incorporation of such training into undergraduate medical curricula would be a logistical nightmare. In our experience, even demonstrating how to operate the equipment and supervising groups of students performing basic tasks can be a taxing and time-consuming process, particularly given that there is somewhere in the region of 200 students in a year group. To ensure all students are competent in using ultrasound clinically would require not only a huge input in terms of man hours (presumably such teaching would best be delivered by radiologists or sonographers, the majority of whom will also have not insignificant clinical commitments), but also substantial financial resources. Surely it is not possible for every medical school to benefit from affiliations with GE Healthcare (or similar)? There is also the very real risk that students, once qualified, will act outside their spheres of competence – and who will assume responsibility for potentially serious missed diagnoses? It will be interesting to find out whether or not the University of South Carolina project succeeds – that is, if we can actually gauge the success (or otherwise) of such a project. However, while teaching ultrasound skills to the masses is an admirable concept (and surely there can be little doubt as to its value in clinical assessment), there is a long way to go before such dreams can be realised. The pragmatic approach employed by Newcastle University Medical School in teaching anatomy is ostensibly a good way to start. 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: Re: Faux-papers and Trojan horses 3 July 2008 Geraint H Lewis, Harkness Fellow New York University, 10012, Peter M Hockey, Harvard Medical School Send response to journal: Re: Re: Re: Faux-papers and Trojan horses Thank you for clarifying the BMJ's guidelines for advertorials. However we would question whether the "advertorial" does actually fulfil these criteria: * The pale blue box is <10mm from the side and bottom edges of the page (5mm x 7mm x 6mm) * Being in pale blue, the words “Advertisement Feature” are not prominently displayed. * By using the structure and headings of a research paper, the advertiser has undoubtedly intended to imitate the editorial style of the BMJ. * The two-column grid pattern in the advert is used in BMJ research papers. * The light blue tint in the advertorial is used extensively in the BMJ, thereby causing confusion with editorial matter. Competing interests: None declared

PAPERS: Obesity in middle age and future risk of dementia: a 27 year longitudinal population based study Whitmer et al. (11 June 2005) [Abstract] [Full text] [PDF] Obesity in middle age and future risk of dementia: a 27 year longitudinal population... Obesity and IGF/GH levels. 3 July 2008 Edoardo Cervoni, ENT Specialist Southport Institute of Anti-Aging Medicine Send response to journal: Re: Obesity and IGF/GH levels. This study is particularly interesting as it opens to debate a link between decline of hormons controlling lean mass and dementia. In fact, it could be arugued that cognitive decline may have a hormonal-metabolic background. It is well documented that serum insulin-like growth factor 1 (IGF-1) levels as well as growth hormone secretion decline with advancing age. Low levels of IGF-1 are shown to be associated with low activity of growth hormone, low lean mass, and high body fat mass; the relationship has been confirmed in the elderly population. It would be interesting to assess IGF-1 and GH levels in obese subjects and eventually assessing the effectiveness of IGF-1/GH in prevention and treatment of not vascular dementia. Competing interests: None declared

PRIMARY CARE: 10-minute consultation: Rhinitis Walker and Sheikh (16 February 2002) [Full text] [PDF] 10-minute consultation: Rhinitis Allergic rhinitis 3 July 2008 N.P. Viswanathan, Family Physician S.V.clinic,Gm palya,Bangalore-560075,India Send response to journal: Re: Allergic rhinitis Sir, Seasonal allergic rhinitis is a common problem in Bangalore. Regarding intranasal steroids, How long it can be used without side effects?Now leucotrine inhibitors are used in the treatment of allegic rhinitis.when to initiate leucotrine inhibitors?Please comment on intranasalantihistaminics. Thank you N.P.viswanathan Competing interests: None declared

EDITORIALS: Promoting wellbeing among doctors Yamey and Wilkes (3 February 2001) [Full text] [PDF] Promoting wellbeing among doctors Providing a solution focused environment promotes wellbeing among Doctors 3 July 2008 Carl Plant, National Development Officer UKASFP Send response to journal: Re: Providing a solution focused environment promotes wellbeing among Doctors I have read the article concerning increasing wellbeing amongst medical staff. It is important to consider preventative measures to reduce chance of burn out, fatigue or the emotional impact of such a difficult area to work in. I read with interest the use of "positive psychology" to help professionals deal with the affects of their work. I agree that some of the principles used in positive psychology (which have been borrowed from other approaches) maybe useful, however not easy to translate into daily practice. There are however some very interesting studies on the use of Solution Focused Brief Therapy (SFBT) as a group support framework as well as solution focused priniciples that studies show reduce burn out considerably. It may be worth studying what this therapy/approach has to offer as a preventitive as well as supportive model to use in professional practice. Competing interests: I am the National Development Officer for the UKASFP