19 Rapid Responses published for 15 different articles.

Articles			Rapid Responses
	HEAD TO HEAD: Should geriatric medicine remain a specialty? Yes Flicker (30 June 2008) [Full text]		Should the English be allowed to edit medical journals? Kenneth Rockwood   (18 July 2008) Read every Rapid Response to this article
	HEAD TO HEAD: Should geriatric medicine remain a specialty? No Denaro and Mudge (30 June 2008) [Full text]		'Older People' not 'Geriatrics' Rodger C Charlton   (18 July 2008) Read every Rapid Response to this article
	RESEARCH: Economic evaluation of human papillomavirus vaccination in the United Kingdom Jit et al. (17 July 2008) [Abstract] [Full text] [PDF]		The paradox effects of human papillomavirus vaccination on cervical cancer incidence and mortality Christian A Gericke   (18 July 2008) Read every Rapid Response to this article
	EDITORIALS: Confronting therapeutic ignorance Chalmers (16 July 2008) [Full text]		Human nature seems averse to evidence Arun S. Nanivadekar   (18 July 2008) Read every Rapid Response to this article
	LETTERS: Caring still lives Warriner (15 July 2008) [Full text]		Essential skill N.P. Viswanathan   (18 July 2008) Read every Rapid Response to this article
	OBSERVATIONS: A discriminating judgment Hawkes (14 July 2008) [Full text]		Retirement and not age Abhijit M Bal   (18 July 2008) Read every Rapid Response to this article
	RESEARCH: Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study Henschke et al. (7 July 2008) [Abstract] [Full text] [PDF]		Prognosis of low back pain: depends on the methods and also on conceptual and nosological approach Joel Coste, et al.   (18 July 2008) Authors' reply Robert D Herbert, et al.   (18 July 2008) Read every Rapid Response to this article
	EDITORIALS: Sudden cardiac death in young athletes Drezner and Khan (3 July 2008) [Full text]		Detect risk with Automate Exercise ECG C. Kevin Connolly   (18 July 2008) Should young athletes be screened? Julian Elston, et al.   (18 July 2008) Read every Rapid Response to this article
	RESEARCH: Imported malaria and high risk groups: observational study using UK surveillance data 1987-2006 Smith et al. (3 July 2008) [Abstract] [Full text] [PDF]		Decreasing incidence of imported malaria in the Netherlands and Europe Perry J van Genderen, et al.   (18 July 2008) Read every Rapid Response to this article
	EDITORIALS: Cross border health care in Europe McKee and Belcher (3 July 2008) [Full text]		Do not overlook the potential of cross-border training opportunities Tiago Villanueva   (18 July 2008) Read every Rapid Response to this article
	PRACTICE: Investigating occult gastrointestinal haemorrhage Dalton and Maskell (3 July 2008) [Full text]		Investigating Occult Gastrointestinal Haemorrhage Ossie Ferdinand Uzoigwe, et al.   (18 July 2008) Consider push enteroscopy where upper gastrointestinal bleeding suspected Shivaram Bhat, et al.   (18 July 2008) Read every Rapid Response to this article
	VIEWS & REVIEWS: Ten practical actions for doctors to combat climate change Spiby and Stott (28 June 2008) [Full text] [PDF]		Re: Re: Sermonising Michael Schachter   (18 July 2008) Read every Rapid Response to this article
	PRACTICE: Pulmonary embolism in a patient taking clozapine Srihari and Lee (28 June 2008) [Full text] [PDF]		Joined up atypical thinking Eugene G Breen   (18 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]		Reduced patient access to specialist care may be associated with attendance at medical conferences Joseph Ting   (18 July 2008) true problems Dr Gloria Rieppi   (18 July 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]		Response to Val Hopwood's Post Richard Bartley   (18 July 2008) Read every Rapid Response to this article

HEAD TO HEAD: Should geriatric medicine remain a specialty? Yes Flicker (30 June 2008) [Full text] Should geriatric medicine remain a specialty? Yes Should the English be allowed to edit medical journals? 18 July 2008 Kenneth Rockwood, Professor of Geriatric Medicine Dalhousie University, 1421-5955 Veterans' Memorial Lane, Halifax NS Canada, B3H 2E1 Send response to journal: Re: Should the English be allowed to edit medical journals? I wonder how many other geriatricians shared my viscerally negative reaction to the idea of the BMJ considering whether geriatric medicine should continue as a specialty? (The editors might want to consider a Head to Head along the lines of “should the English be allowed to edit medical journals?” to get some comparable sense of it, and of how the “we merely raise the question” would seem a paltry riposte.) Denaro and Mudge turn to the “we are all geriatricians now” argument, so often used to try and strangle the growth of geriatric medicine.[1] They seem to have been encouraged in this by their success with running a multi-disciplinary team.[2] But there is more to geriatric medicine than team conferences. Geriatric medicine is the complex care of elderly people who are frail. As Prof. Flicker [3] and others [4] have pointed out our discipline has not been its own best advocate. We have relied too much on a simple set of utilitarian values: “we do these things because they seem to work”. Providing a scientific basis for the specialty of geriatric medicine is therefore essential to advancing the care of frail elderly patients. Where it is easy to agree with Denaro and Mudge is that the essence of the case for the special skills that geriatricians need is not age, but complexity. As people get older they are more likely to die. But they do not just drop dead from a state of excellent health – rather most die after the accumulation of the multiple, interacting medical and social problems that make them frail. The multiplicity of problems also makes these patients a poor fit for health care systems that largely have been designed for people who have only one thing wrong at a time. The medical and social problems inherent in being frail are susceptible to quantification. [5] As it turns out, the numbers that are produced by quantifying frailty and social vulnerability can themselves be the object of inquiry. These inquires allow for quantitative models to be built and for the complexity of patients to be understood mathematically – for complexity to be not just a synonym for ‘complicated’. One of the consequences is that clinico-mathematical correlation is now a pressing task in advancing our understanding of how to make care better for older adults who are frail, especially when they become ill. This effort can be shared by all who are willing to take it on, and the resulting knowledge can be shared with all who are willing to learn it. But the understanding of frailty will not happen on its own and the leadership, conceptualization and desire to do this chiefly comes from geriatricians. Fortunately, not all English medical editors gainsay this working with a glad heart in a difficult area,[4] so perhaps the English still should be allowed to edit medical journals. References 1. Denaro CP, Mudge A.Should geriatric medicine remain a specialty? No.BMJ. 2008 Jun 30;337:a515. doi: 10.1136/bmj.39533.696076.AD. 2. Mudge A, Laracy S, Richter K, Denaro C. Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care. Intern Med J 2006;36:558-63 3. Flicker L. Should geriatric medicine remain a specialty? Yes. BMJ. 2008 Jun 30;337:a516. doi: 10.1136/bmj.39538.481273 4. Anon. Who cares for the elderly? Lancet 2008;371:959. 5. Andrew MK, Mitnitski AB, Rockwood K.Social vulnerability, frailty and mortality in elderly people.PLoS ONE. 2008 May 21;3(5):e2232. Competing interests: I am a geriatrician all the time and only occasionally an editor.

HEAD TO HEAD: Should geriatric medicine remain a specialty? No Denaro and Mudge (30 June 2008) [Full text] Should geriatric medicine remain a specialty? No 'Older People' not 'Geriatrics' 18 July 2008 Rodger C Charlton, General Practitioner The Surgery, Marsh Lane, Hampton-in-Arden, Solihull, West Midlands, B92 0BS. Send response to journal: Re: 'Older People' not 'Geriatrics' Two excellent views are provided as to whether ‘geriatric medicine’ should remain a specialty. However, a most important issue has been overlooked and that is the continued use of the word ‘geriatric’. In support of the argument Flicker uses the term "older people" and against the argument Denaro and Mudge make the important point that “health care is a continuum and breaking the journey into arbitrary steps” eg, over 65 is therefore not appropriate. As a GP I would concur that the health needs of older people should be identified and managed optimally, but could a change in terminology be considered from ‘geriatric’? Competing interests: None declared

RESEARCH: Economic evaluation of human papillomavirus vaccination in the United Kingdom Jit et al. (17 July 2008) [Abstract] [Full text] [PDF] Economic evaluation of human papillomavirus vaccination in the United Kingdom The paradox effects of human papillomavirus vaccination on cervical cancer incidence and mortality 18 July 2008 Christian A Gericke, Professor of Public Health Policy The University of Adelaide, Adelaide, SA 5005, Australia Send response to journal: Re: The paradox effects of human papillomavirus vaccination on cervical cancer incidence and mortality The development of the human papillomavirus (HPV) vaccines and their potential for reducing cervical cancer incidence and mortality in the future is generally considered an important step to improve population health worldwide. For countries without well performing cervical cancer screening programmes and lack of treatment options the current epidemiological and economic models seem applicable. However, the assumptions underlying published economic evaluations in countries with high coverage, well functioning screening programmes such as the study published in the BMJ on July 17 by Jit et al1 from the UK neglect a major limitation to the validity of their models: there is a non -negligible risk that a high HPV vaccine coverage in adolescents will lead to a decrease in screening uptake in later years because vaccinated women will see themselves no longer at risk and will consequently avoid the screening procedure, which is not that pleasant after all. As about 30% of cervical cancers are not caused by the current HPV vaccines against HPV types 16 and 18, there is a real risk of increased cervical cancer incidence and mortality rates in women who do not take up screening, counterbalancing the positive effects of the HPV vaccination. This is fuelled by health promotion material from manufacturers, Cancer Councils and Cancer Research UK who market the HPV vaccines as ‘cervical cancer vaccines’. This is reflected in the general media and even in some of the leading scientific journals.2-6 Research investigating the potential impact of the HPV vaccines on screening uptake is urgently needed to establish the magnitude of this paradox effect on cervical cancer incidence and mortality and improve our epidemiological and economic models to guide future policies for cervical cancer prevention. 1. Jit M, Choi YH, Edmunds WJ. Economic evaluation of human papillomavirus vaccination in the United Kingdom. BMJ 2008;337:a769. 2. Kmietowicz Z. Opportunity was missed in choice of cervical cancer vaccine, health campaigners say. BMJ 2008;336(7659):1456-7. 3. Keim B. Controversy over cervical cancer vaccine spurs safety surveillance. Nat Med 2007;13(4):392-3. 4. Cohen J. Public health. High hopes and dilemmas for a cervical cancer vaccine. Science 2005;308(5722):618-21. 5. Rai MA, Ali SH. Cervical cancer vaccine: the Indian sub- continental context. Vaccine 2006;24(49-50):7024. 6. Zimet GD, Shew ML, Kahn JA. Appropriate use of cervical cancer vaccine. Annu Rev Med 2008;59:223-36. Competing interests: None declared

EDITORIALS: Confronting therapeutic ignorance Chalmers (16 July 2008) [Full text] Confronting therapeutic ignorance Human nature seems averse to evidence 18 July 2008 Arun S. Nanivadekar, Medical Research Consultant C-2, Flushel Apts, 21 Road, Bandra (W), Mumbai 400050, India Send response to journal: Re: Human nature seems averse to evidence The last sentence of Sir Iain's essay[1] emphasizes the role of patients and the public in helping doctors to confront therapeutic ignorance. However, seeing the increasing popularity of alternative and/or complementary medicine (ACP) everywhere, I believe modern medicine will fail to confront therapeutic uncertainties unless its practitioners offer their patients what they need most as human beings in distress: time, empathy, and understanding. This is one area in which practitioners of ACP seem to score clearly over those of modern medicine. Besides, as Brown[2] has pointed out, a successful medical man has to exhibit supreme confidence and decisiveness at the patient's bedside whereas a physician- scientist (trying to confront uncertainties) is likely to present a picture of diffidence and self-doubt. Brown says, "Medicine and science require complementary thought processes; the processes that work for one are devastating for the other." If this is so, then we need two kinds of physicians: one, those who will confront uncertainties and try to resolve them; and two, those who will accept and adopt the advice of the former with trust and confidence. Alternatively, our medical education system must train doctors in alternating successfully between rationalism and empiricism throughout their career. It in for such an endeavor that the psychology of patients and the public comes into play. This reminds me of a rare book by Dudley[3], which emphasizes the importance of language, logic, psychology, and statistics in medicine as much as in all other walks of life. Despite these predicaments, I prefer to be hopeful. Arun Nanivadekar, MD MSc 1. Chalmers I. Confronting therapeutic ignorance BMJ 2008; 337: a841 2. Brown MS. The making of a physician-scientist; 2000. In, Grossman DC, Valtin H, ed. Great issues for medicine in the Twenty-first Century. Ann N Y Acad Sci 1999; 882: 247-256. 3. Dudley SF. The Four pillars of Wisdom. London: Watts & Co., 1947. Competing interests: None.

LETTERS: Caring still lives Warriner (15 July 2008) [Full text] Caring still lives Essential skill 18 July 2008 N.P. Viswanathan, Family physician sv clinic,gmpalya,Bangalore-560075,India Send response to journal: Re: Essential skill Sir, I congratulate you for bringing out an important message which is not taught in medical colleges. Certain tools like kindness, love, sympathy, charity are the basic elements which god has given to every one of us. Trust is the essence of all cures. Qhen we incorporate all these elements with the very essential skill Caring we can get wonderful results. Thanks for your wonderful message. N.P.Viswanathan Competing interests: None declared

OBSERVATIONS: A discriminating judgment Hawkes (14 July 2008) [Full text] A discriminating judgment Retirement and not age 18 July 2008 Abhijit M Bal, Consultant Crosshouse Hospital, NHS Ayrshire and Arran, KA2 0BE Send response to journal: Re: Retirement and not age I think the issue can be handled in another manner instead of poring over large volumes of legal text full of clauses and sub-clauses. All retired members no matter how old (or young) should be exempt from the annual retention fee. How much does it cost to keep names on the electronic register? Competing interests: None declared

RESEARCH: Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study Henschke et al. (7 July 2008) [Abstract] [Full text] [PDF] Prognosis in patients with recent onset low back pain in Australian primary care:... Prognosis of low back pain: depends on the methods and also on conceptual and nosological approach 18 July 2008 Joel Coste, Professor of Biostatistcs University Paris Descartes 75014 Paris France, Jean-Baptiste Paolaggi, Académie Nationale de Médecine, Paris Send response to journal: Re: Prognosis of low back pain: depends on the methods and also on conceptual and nosological approach Dear Editor, Henschke et al. [1] repeatedly compare the results of their study of “recent onset” low back pain (LBP) to those of our own study published in the Journal in 1994 [2] and apparently fail to explain the marked difference in the results in terms of delay before recovery. In our opinion, the different results are a consequence of the study methods, which were much more dissimilar than that acknowledged by Henschke et al., and also of conceptual and nosological approaches, which were even more dissimilar. Henschke et al. stated they conducted an “inception cohort” study, as we did both in 1991 [2] and also in 1999 [3]; however, it appears that they included subjects who had been suffering for up to two weeks, a delay which was associated with 90% recovery in our studies (we are thus very surprised that they found “a recovery rate virtually unchanged at two weeks” when considering the subset of subjects whose back pain lasts only for up to 3 days). It also appears that they only required a one-month symptom-free interval for including patients in the cohort (three months in our studies): this lax definition of “recent onset” LBP allows the inclusion of “relapsing- remitting” chronic LBP subjects and may therefore result in the observed prognosis being worse. It also appears that up to 20% of the subjects of their study presented with leg pain (although it was stated patients with radiculopathy were excluded). Obviously this subgroup of patients with mild sciatica or “borderline” LBP did have a worse outcome than the population as a whole. It also appears that 81% of patients were included by physiotherapists or chiropractors. These professionals may provide inadequate and worrying information about LBP and possibly even harmful therapeutic manoeuvres (and, at least, are much more “stigmatizing” than acetaminophen prescribed by GPs); this design is also open to huge selection biases as self- referral to physiotherapists or chiropractors indicates that the subjects are familiar with, and probably even have long-lasting experience of, LBP. We also note that practitioners were encouraged financially to discover “serious pathology”, which necessarily increased the burden of investigation, anxiety and thereby delayed recovery. These are major differences with respect to our studies regarding the selection of patients. Furthermore, it appears that recovery was defined using a question such as “how much LBP have you had during the past week” asked during the first follow-up interview which took place at 6 weeks (in our study we used a diary including standardized instruments which patients filled in prospectively). In the light of these differences, we disagree with the conclusion of Henschke et al. that “prognosis is not as favourable as claimed in patients with acute LBP in primary care” and we disapprove this rhetoric of fear constructed on results from a cohort of subjects accumulating bad prognosis factors, irrespective of whether it is motivated by laudable reasons (fund raising for research) or less laudable ones (defending corporative interests of “professionals of LBP”). We agree with Henschke et al. that “further studies are warranted”, but we believe further studies should make use of optimised methods and appropriately defined concepts. Indeed, it is remarkable that conceptual and nosological thinking has almost disappeared from current clinical research in LBP. Using a “black box” approach instead of refining current classifications [4] and thereby not distinguishing between established nosological entities such as back pain and sciatica (with quite different natural history and kinetics of recovery [5]) and concepts such as “recent onset” and “acute”, can only be detrimental both to medical science and the care of (millions of) patients with these conditions. J. Coste Rheumatologist, Professor of Biostatistics Hôpital Cochin, Université Paris Descartes, Paris, France J.B Paolaggi Professor of Rheumatology Académie Nationale de Médecine, Paris, France References 1. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008 Jul 7;337:a171. 2. Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Delecoeuillerie G, Paolaggi JB. Clinical course and prognostic factors of acute low-back pain. An inception cohort study in primary care practice. BMJ 1994; 308 : 577-580. 3. Coste J, Lefrancois G, Guillemin F, Pouchot J. Prognosis and quality of life in patients with acute low back pain: Insights from a comprehensive inception cohort study. Arthritis Rheum. 2004; 51: 168-76. 4. Coste J, Spira A, Ducimetière P, Paolaggi JB. Clinical and psychological diversity of non-specific low-back pain. A new approach towards the classification of clinical subgroups. J. Clin. Epidemiol 1991; 11 : 1233-45. 5. Paolaggi JB. Natural history of non specific neuralgias of the limbs. Exponential kinetics of the root pain recovery in sciatica and femoral neuralgia; uncertain kinetics for brachial neuralgia. Bull Acad Natl Med. 2003; 187: 1631-45. Competing interests: None declared Prognosis in patients with recent onset low back pain in Australian primary care:... Authors' reply 18 July 2008 Robert D Herbert, Senior Research Fellow The George Institute for International Health, Camperdown NSW 2050, Australia, Nicholas Henschke, Christopher G. Maher, Kathryn M. Refshauge, Robert G. Cumming, Jane Bleasel, John York, Anurina Das, James H. McAuley Send response to journal: Re: Authors' reply Dr McKay is concerned that participants in our cohort study did not receive 'the modern approach to acute back pain as published by McGuirk B, Bogduk N'. He may find it re-assuring that Professor Bogduk was an executive author of the clinical practice guidelines that we asked participating clinicians to use(1). Lorna Gibson asks why there were discrepancies between the sample specified in the protocol (N = 1000)(2) and the paper (N = 973, of whom baseline data were available for 969)(3). The explanation is that we sampled patients with radiculopathy but, because we were interested in the prognosis of non-specific low back pain, we did not include those patients’ data in the analysis. References 1. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence- Based Management of Acute Musculoskeletal Pain. Brisbane: Australian Academic Press, 2003. 2. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, et al. Prognosis of acute low back pain: design of a prospective inception cohort study. BMC Musculoskeletal Disorders 2006;7:54 (Epub). 3. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, et al. Prognosis of recent onset low back pain in primary care. BMJ 2008;337:a171. Competing interests: None declared

EDITORIALS: Sudden cardiac death in young athletes Drezner and Khan (3 July 2008) [Full text] Sudden cardiac death in young athletes Detect risk with Automate Exercise ECG 18 July 2008 C. Kevin Connolly, Retired Respiratory Physician Richmond DL117TP Send response to journal: Re: Detect risk with Automate Exercise ECG The evidence shows that resting ECG fails on both essential criteria for a screening test, high specificity and high sensitivity, in that order. Low specificity inevitably generates unnecessary worry and expense. It is not unreasonable to assume that an exercise ECG satisfies both criteria so far as the target abnormality, induced exercise-induced cardiac arrhythmia, is concerned. An an initially blinded automated system similar to that used in defibrillators provides the solution. The system would allow the test to proceed unless the resting trace showed a clearly dangerous resting abnormality and stop the test if one developed. Although no trace would show the memory would retain it for necessary refence. Required training would be little more than that necessary to understand and operate the accompanying defibrillator. If this practice became prevalent the cost would fall rapidly particularly if the accompanying treadmill was dual purpose being available for general use at other times. Competing interests: None declared Sudden cardiac death in young athletes Should young athletes be screened? 18 July 2008 Julian Elston, Academic Specialist Trainee in Public Health South West region, Ken Stein, Professor of Public Health, Peninsula College of Medicine and Dentistry Send response to journal: Re: Should young athletes be screened? The forty years of careful consideration of screening since Wilson and Jüngner(1) appear to have by-passed Drezner and Khan.(2) Every sudden cardiac death (SCD) is a tragic event and traumatic experience for family and relatives, but in truth the burden to society is small. The death of a high profile athlete is inevitably followed by a loud clamour for pre-participation screening. But carefully consideration of the evidence in relation to the national criteria is essential if screening is to do more good than harm. The benefit of screening has yet to be demonstrated. Drezner and Khan point to evidence from the Italian national screening programme.(3) This describes a nearly five-fold fall in incidence of SCD in athletes over a twenty year period in comparison to a lower stable rate among non athletes. However, observational studies are subject to a range of biases, several of which were not accounted for in this study i.e. changes in training regimes and diet and the absence of blinding in case ascertainment. More significantly, no study has compared the incidence of SCD in athletes with cardiovascular disease who have been screened with those who have not.(4) In Italy, one in eleven athletes screened are referred for specialist assessment, only a quarter of whom are disqualified. Thus, screening results in high numbers of false positives, creating unnecessary anxiety. Indeed, many disqualifications may be unwarranted, as the risk of SCD is poorly characterised in a number of cardiomyopathies, which make up to half of all SCD.(5,6) Thus, the level of unnecessary harms to well-being, insurance costs and future employment remains unknown. There are further uncertainties, not least the cost-effectiveness and organisational implications of screening. The apparent nonchalent advocation of screening is ill-founded, premature and ethically dubious. We advocate a comprehensive synthesis of existing evidence as the basis for an informed debate, rather than Drezner and Khan’s partial approach. Reference List (1) Wilson JMG, Jüngner, G. Principles and Practice of Screening for Disease. Public Health Papers No. 34. WHO Chronicle 1968; 22(11):473. (2) Drezner JA, Khan K. Sudden cardiac death in young athletes. BMJ 2008; 337:a309. (3) Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. J Am Med Assoc 2006; 296(13):1593-1601. (4) Thompson P, Franklin B, Balady G, Blair S, Corrado D, Estes NA et al. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 2007; 115(17):2358-2368. (5) Corrado D, Basso C, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden cardiac death? J Cardiovasc Med (Hagerstown) 2006; 7(4):228-233. (6) Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. J Am Med Assoc 1996; 276(3):199-204. Competing interests: None declared

RESEARCH: Imported malaria and high risk groups: observational study using UK surveillance data 1987-2006 Smith et al. (3 July 2008) [Abstract] [Full text] [PDF] Imported malaria and high risk groups: observational study using UK surveillance... Decreasing incidence of imported malaria in the Netherlands and Europe 18 July 2008 Perry J van Genderen, Consultant Internal Medicine and Tropical diseases Harbour Hospital, Haringvliet 2, 3011TD Rotterdam, The Netherlands, Dennis A. Hesselink, and Jacob M. Bezemer Send response to journal: Re: Decreasing incidence of imported malaria in the Netherlands and Europe Editor, With great interest we read the observational study of Smith and colleagues. (1) They examined trends in incidence of imported malaria in the United Kingdom between 1987 and 2006. In the 20-year study period a significant increase of the incidence of falciparum malaria was reported, whereas the number of vivax malaria cases decreased steadily over the years. The reported increase in falciparum malaria in the UK does not correspond with our own observations on imported malaria in the Netherlands during recent years. We examined all consecutive malaria cases in the Harbour Hospital and Institute for Tropical diseases in Rotterdam, the Netherlands between January 1, 1999 and January 1, 2008. The number of falciparum cases clearly decreased after the year 2000 from 40 patients in 2001 to 20 in 2007. Imported malaria with non-falciparum species also declined in this observational period. Interestingly, the same evolution of imported malaria has been noted in the Netherlands as a whole, where official malaria notifications have decreased from 569 cases in 2000 to 210 cases in 2007.(2,3) Moreover, this trend is not restricted to the Netherlands alone. The WHO data on imported malaria in most European countries show that reported falciparum malaria cases are declining over the past years. (4) Compatible with the UK experience, also in the Netherlands travelers to Ghana and Nigeria account for about half of all imported falciparum cases, suggesting considerable overlap in countries of acquisition of malaria. (3) From table 1 in the paper by Smith and colleagues, it appears that during the last five years of the study period numbers of falciparum malaria cases have decreased compared with the 1996-2001 time period. This is supported by the number of imported falciparum malaria cases in 2007, as reported by the WHO for the UK, (4) that has not been so low since 1994. Since the authors used a linear regression for analysis of linear trend over a much longer period of 20 years, this newly evolving trend of decreasing incidence rates since 2001 may have been lost. International travel is still on the rise and the incidence of malaria does not decline dramatically over the world in general. (5) Decreased incidence rates of imported malaria in the Netherlands and most European countries may suggest that travelers to malaria endemic regions are nowadays better prepared against the transmission of Plasmodium species by mosquito bites, either by adhering more strictly to personal protective measures like insect repellants and/or a more compliant intake of newer and more convenient chemoprophylactic drugs like atovaquone/proguanil. Jacob M. Bezemer, M.Sc. Dennis A. Hesselink, M.D., Ph.D. Perry J.J. van Genderen, M.D., Ph.D. Reference: (1) Adrian D Smith, David J Bradley, Valerie Smith, Marie Blaze, Ron H Behrens, Peter L Chiodini and Christopher J M Whitty Imported malaria and high risk groups: observational study using UK surveillance data 1987- 2006 BMJ 2008;337; a120 (2) van der Eerden LJM , Bosman A , Visser LG . Afname van importmalaria, een overzicht van 2002. Infectieziekten Bulletin 2003 Dec 12 ; 14 : 419 – 423 . (Dutch) (3) Government report on infectious diseases in the Netherlands. (Dutch) [http://www.rivm.nl/cib/binaries/StaatvanInfectieziekten2007_tcm92- 53097.pdf] (Accessed 2008 July 17) (4) WHO data on malaria: [http://data.euro.who.int/cisid] (Accessed 2008 July 10) (5) World Health Organization and UNICEF: World Malaria Report 2005 Roll Back Malaria 2005 [http://www.rbm.who.int/wmr2005/html/exsummary_en.htm] (Accessed 2008 July 10) Competing interests: None declared

EDITORIALS: Cross border health care in Europe McKee and Belcher (3 July 2008) [Full text] Cross border health care in Europe Do not overlook the potential of cross-border training opportunities 18 July 2008 Tiago Villanueva, GP Registrar USF Tornada, 2500-315, Caldas da Rainha, Portugal Send response to journal: Re: Do not overlook the potential of cross-border training opportunities Dear Editor, I read with interest this article, which also pointed out the increasing importance of maintaining minimum standards of clinical competence across European borders, in an era of mobility without limits. I would like to point out the importance of developing formal schemes of cross-border postgraduate training. Since I am a Portuguese GP registrar, I decided this year to become a member of the Spanish Society of General Practice (semFYC), in order to access training opportunities and educational resources that were not available so easily at home, to network, and, ultimately, to become a better, more skilled and knowledgeable professional. This happened by chance, as I learned to realize the potential of cross-border training opportunities, following on from a preliminary visit to the Madrid office of the Spanish Society of General Practice, where I realized there was a massive offer of free presencial courses and training for GP and GP trainees, that could significantly enhance and complement my local training. The following week, I was emailing the Madrid office to request my membership, and a few weeks later I returned to Madrid to try out a Minor Surgery course, something which I had wanted to do for a long time, but never had the opportunity. Since courses are for free, there are plenty of affordable low-cost flights between Lisbon and Madrid, and I have friends to stay with in Madrid, this informal scheme of cross-border training has worked really well for me, and I am quite pleased. Hopefully, and for the sake of the future of cross-border health care sole initiatives such as my own will evolve into fully-fledged formal and official cross-border postgraduate training schemes, with proper funding and protected time. I recommend to everyone wishing to upgrade one's own postgraduate or specialist training to look for cross border training opportunities. It is immensely rewarding, fulfilling, and has far fewer consequences in one's own personal and professional life than relocating overseas permanently. Competing interests: None declared

PRACTICE: Investigating occult gastrointestinal haemorrhage Dalton and Maskell (3 July 2008) [Full text] Investigating occult gastrointestinal haemorrhage Investigating Occult Gastrointestinal Haemorrhage 18 July 2008 Ossie Ferdinand Uzoigwe, Student 8 Harcourt Crescent, Sheffield, S10 1DG Send response to journal: Re: Investigating Occult Gastrointestinal Haemorrhage Dear Editor, I read with interest the informative and compelling article by Dalton and Maskell on the diagnostic utility of capsule endoscopy1. The authors have made an important oversight, however, in failing to mention intraoperative enteroscopy. It is a safe and effective means of investigating obscure gastrointestinal bleeding (OGB). It is classed by The British Society of Gastroenterologists as the gold standard in the evaluation of OGB2. It has consistently been show to have diagnostic yields of 70 to 100%2. In the case described by Dalton and Maskell the presence of telangiectasia throughout the entirety of the small bowel increased the likelihood of capsule endoscopy identifying the underlying pathology. However where the lesion is discrete or localised diagnostic problems may be encountered3. In cases where there is a diagnostic urgency, for example in instances of small bowel neoplasia, the discrete lesion may be missed by the capsule endoscope. In addition the enteroscope may visualise the lesion but the images may not be sufficient to found a diagnosis or worse still lead to an incorrect diagnoiss3. In such cases intraoperative laparotomy can be used as an adjunctive confirmatory investigation to capsule endoscopy. It may be performed laparoscopically or via a small laparotomy2. It also offers the option of tissue biopsy and curative surgical resection. The important message is that capsule endoscopy should not be the last word in OGB. In many ways capsule endoscopy and intraoperative enteroscopy can actually act as complimentary investigations. The latter should be performed before the gastrointestinal tract is abandoned as the source of obscure blood loss. 1. Maskell GF, Dalton HR. Investigating occult gastrointestinal haemorrhage. BMJ 2008; 337 2. Sidhu R, Sanders DS, Morris AJ, McAlindon ME. Guidelines on small bowel enteroscopy and capsule endoscopy in adults. Gut 2008; 57:125-136 3. Ross A, Mehdizadeh S, Tokar J, Leighton JA, Kamal A, Chen A, Schembre D, Chen G, Binmoeller K, Kozarek R, Waxman I, Dye C, Gerson L, Harrison ME, Haluszka O, Lo S, Semrad C. Double balloon enteroscopy detects small bowel mass lesions missed by capsule endoscopy. Dig Dis Sci. 2008; 53:2140 Competing interests: None declared Investigating occult gastrointestinal haemorrhage Consider push enteroscopy where upper gastrointestinal bleeding suspected 18 July 2008 Shivaram Bhat, Specialty Registrar in Gastroenterology Ulster Hospital Dundonald, Upper Newtownards road, Belfast, BT16 1RH, Grant Caddy (consultant gastroenterologist), Tony Tham (consultant gastroenterologist) Send response to journal: Re: Consider push enteroscopy where upper gastrointestinal bleeding suspected The article by Dalton and Maskell is a useful summary for those investing obscure GI bleeding(1). We have a number of points to add. The main learning point in the authors’ article is that capsule endoscopy is the first line investigation in patients with obscure gastrointestinal bleeding with a normal oesophagogastroduodenoscopy (OGD) and colonoscopy. Recent BSG guidelines recommend tailoring next line investigation based on whether upper or lower gastrointestinal blood loss is suspected(2). These guidelines advocate consideration of a second look OGD in those patients with suspected upper gastrointestinal blood loss. Previous studies have shown that 12-64% of lesions detected on push enteroscopy are within reach of a standard endoscope(2). Capsule endoscopy is an excellent modality for visualising the small bowel. However it has a number of drawbacks. Incomplete examination due to poor bowel preparation or slow transit time can occur in 10-25% of cases(2). Reporting is time consuming compared with standard endoscopy (60 -90minutes). Equipment is expensive and may not be available in all centres. Lastly, the inability to perform biopsies or therapy to suspected pathology. Our practice is to perform push enteroscopy in patients with suspected upper gastrointestinal blood loss and negative bi-directional standard endoscopy. This method allows a second look OGD to be performed together with examination of the proximal small bowel. It has the added advantage of allowing biopsy or therapy to suspected bleeding lesions. It is our practice that if push enteroscopy is negative then to proceed with capsule endoscopy. 1) Dalton HR., Maslell GF Investigating occult gastrointestinal haemorrhage British Medical Journal 2008:337:111-3 2) Sidhu R, Sanders DS, Morris AJ, McAlindon ME. Guidelines on small bowel enteroscopy and capsule endoscopy in adults. British Society of Gastroenterology. 2008. Competing interests: None declared

VIEWS & REVIEWS: Ten practical actions for doctors to combat climate change Spiby and Stott (28 June 2008) [Full text] [PDF] Ten practical actions for doctors to combat climate change Re: Re: Sermonising 18 July 2008 Michael Schachter, Senior lecturer in clinical pharmacology St Mary's Hospital London W2 1NY Send response to journal: Re: Re: Re: Sermonising I would probably be walking or on a bus, but not for international travel I think. But "what would Jesus do?" is not a question that comes to my mind regarding this or any other topic. Competing interests: None declared

PRACTICE: Pulmonary embolism in a patient taking clozapine Srihari and Lee (28 June 2008) [Full text] [PDF] Pulmonary embolism in a patient taking clozapine Joined up atypical thinking 18 July 2008 Eugene G Breen, Consultant psychiatrist Adult Psychiatry,Mater Misericordiae Hospital,62/63/Eccles St., Dublin 7, Ireland Send response to journal: Re: Joined up atypical thinking The article by Srihari and Lee is a great example of real time decision making in difficult situations. Their comprehensive literature trall on emboli and clozapine, and then with atypicals and typicals yielded a workable algorithm to decision making. I would broaden the thinking and generalise to atypicals and thromboembolic/genic phenomena throughout the cardiovascular system. The relatively recent black box warning for atypicals in erlderly demented patients due to accelerated risk of death begs the question whether this is also thrombogenic in aetiology. Should anyone taking antipsychotic medication have safety features built in for example should they take salicylate/warfarin/other ? 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?... Reduced patient access to specialist care may be associated with attendance at medical conferences 18 July 2008 Joseph Ting, Staff Specialist Department of Emergency Medicine, Mater Public Hospitals, South Brisbane 4101 Australia Send response to journal: Re: Reduced patient access to specialist care may be associated with attendance at medical conferences The lively debate brought about by two published contrary positions 1, 2 on the merit and drawbacks of attendance at international medical conferences largely focused on their environmental cost on the one hand1 and educational benefits on the other. 2 Even domestic conferences in Australia require some form of medium haul flying, and that is even before considering long haul flights to European and North American destinations where the bulk of international medical conferences are held. As such, the debate is more relevant to internationally isolated Australia and could be extended to domestic conferences in countries which are continental in expanse. The debate has yet to allude to difficulties with referral of patients for specialist care encountered during major conferences, when a large number of that craft group become unavailable for the duration or greater of the conference. This transient shortage of local specialist cover may be critical in resource poor countries. Video and internet-mediated conferencing allow clinicians access to cached presentations in their own (convenient) time, stay within their local practice area and offer a level of health delivery at least better than being in absentia. Some travel with adventures rather than new knowledge acquisition as a priority. Educational benefits, as espoused by Drife, 2 are only possible if the conference registrant attends an “acceptable” number or type of conference sessions. This requires self-discipline and a personal ethic to fulfill. Allow me to extend the “flying doctors” analogy to flightless mechanically powered migratory birds flocking to distant feeding grounds to sate a hunger and thirst for knowledge. Like that other great flightless bird of yesteryear, the dodo, will international conferencing be rendered extinct by powerful information technology resources that yield the same educational benefits, but with our feet firmly planted on terra firma? References: 1. Green M. Are international medical conferences an outdated luxury the planet can’t afford? Yes BMJ 2008; 336: 1466. 2. Drife JO. Are international medical conferences an outdated luxury the planet can’t afford? No BMJ 2008; 336: 1467. Competing interests: None declared Are international medical conferences an outdated luxury the planet can’t afford?... true problems 18 July 2008 Dr Gloria Rieppi, Intensivist teaching public hospital Uruguay Send response to journal: Re: true problems This article causes me to reflect. This paper has emphasised if massive conferences determine some ecologic disasters, this is eventually true. I think other more important aspects could be discussed. Massive medical conferences do not always contribute to updating topics or discussion with other colleagues. Most of the participants take these events as "tourism events". Invitations are in general given to doctors who are experts but most frequently by "laboratory marketing". Many investigators around the world have had serious limitations in their opportunities to communicate their results in the congress or in publications. This is the biggest problem for scientific communication. 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... Response to Val Hopwood's Post 18 July 2008 Richard Bartley, Physiotherapist Wales, UK Send response to journal: Re: Response to Val Hopwood's Post Val Hopwood is right to take a little swipe at dogmatic opponents of complementary medicine. She is also correct to clarify that non-allopathic remedies such as acupuncture are used in the NHS as adjunctive treatments, not as alternative therapies. I also take comfort from the fact that Val is committed to exploring the scientific basis for her own branch of complementary medicine. The first consideration when assessing any treatment, be it orthodox or complementary, is safety. Harm isn't limited to iatrogenic complications following administration of a treatment. Denying a patient access to a better evidenced-based treatment in favour of one founded on weak evidence or hearsay alone also constitutes harm. Hence the need to rigorously test complementary medicine alongside orthodox therapies. The second consideration is effectiveness. In the case of acupuncture, clinical studies and systematic reviews demonstrate conflicting evidence for its use (1). However, as the old adage goes, absence of proof is not proof of absence. Although only a relatively small number of clinical studies with sound methodology have been conducted to date, several positive results justify further enquiry. To condemn this form of adjunctive therapy at this early stage might be considered a bit Luddite. I think the core problem with any complementary therapy is the clinical reasoning used by some practitioners. NHS acupuncturists (anaesthetists, GPs, nurses and physiotherapists) are on shaky ground if they base their treatments on animistic traditions. The NHS does not have an unlimited budget and I would rather see complementary therapy used on the NHS in a scientific manner. 1. Ernst E, Pittler MH, Wider B, Boddy K. (2007). "Acupuncture: its evidence- base is changing". Am J Chin Med. 35 (1): 21–5 Competing interests: None declared