52 Rapid Responses published for 31 different articles.

Articles			Rapid Responses
	CLINICAL REVIEW: Investigating the thyroid nodule Mehanna et al. (13 March 2009) [Full text]		Investigation of Thyroid Nodules Piero Baglioni, et al.   (14 March 2009) Read every Rapid Response to this article
	VIEWS & REVIEWS: Studies on Hysteria Lucas (11 March 2009) [Full text]		Theories of Personality Hugh Mann   (14 March 2009) Read every Rapid Response to this article
	VIEWS & REVIEWS: Too much information Dalrymple (11 March 2009) [Full text]		Balancing freedom of press and respect. Antoine Kass-Iliyya   (14 March 2009) Read every Rapid Response to this article
	FILLERS: A fine thread Drabu (11 March 2009) [Full text]		I assume it is a typographical error Kesavan Sri-Ram   (14 March 2009) Stamp of Kashmir Romesh Khardori   (14 March 2009) absolutely right dr mohan devegowda   (14 March 2009) Read every Rapid Response to this article
	RESEARCH: Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study Bushnell et al. (10 March 2009) [Abstract] [Full text] [PDF]		Migraine and stroke Rizaldy Pinzon   (13 March 2009) Read every Rapid Response to this article
	ANALYSIS: Tissue screening after breast reduction Keshtgar et al. (10 March 2009) [Full text]		Screening for breast reduction Adhip Mandal   (13 March 2009) Pre-operative assessment Louise Gaunt   (12 March 2009) Read every Rapid Response to this article
	LETTERS: Heart failure is in need of a diagnosis Lloyd (9 March 2009) [Full text]		About time we recognised the heart failure under-diagnosis Farrukh Baig   (13 March 2009) Read every Rapid Response to this article
	LETTERS: Targets destroy morale and do not help patients Spicer (11 March 2009) [Full text]		We do agree on targets Richard D Spicer   (14 March 2009) love to agree, but......................... Bob Bury   (13 March 2009) Read every Rapid Response to this article
	RESEARCH: Appendicitis, mesenteric lymphadenitis, and subsequent risk of ulcerative colitis: cohort studies in Sweden and Denmark Frisch et al. (11 March 2009) [Abstract] [Full text] [PDF]		Might immunization against endotoxin prevent ulcerative colitis and peptic ulceration? Richard G Fiddian-Green   (12 March 2009) Read every Rapid Response to this article
	EDITORIALS: Tight control of blood glucose in long standing type 2 diabetes Lehman and Krumholz (5 March 2009) [Full text]		In defence of QOF targets Richard A Brice   (13 March 2009) Re: Hidden dangers in rebound hyperglycaemia. Gauranga C. Dhar   (13 March 2009) Whose idea was this ? Harry Hall   (12 March 2009) Hidden dangers in rebound hyperglycaemia. Richard G Fiddian-Green   (12 March 2009) The individual patient should decide what their target hbaic should be. Katharine M Morrison   (12 March 2009) Read every Rapid Response to this article
	OBSERVATIONS: Rethinking ward rounds Sokol (4 March 2009) [Full text]		RN's and Ethics Caron E. Lumpkin   (14 March 2009) Read every Rapid Response to this article
	NEWS: Inquest begins into deaths after concerns about diamorphine prescribing Dyer (3 March 2009) [Full text]		A fixed comment of experts could be under question Reza Afshari   (14 March 2009) Prescribing Error James A Smith   (13 March 2009) Read every Rapid Response to this article
	EDITORIALS: Sun protection in teenagers Thieden (3 March 2009) [Full text]		Sun protection in teenagers -protection or abuse? Richard Quinton, et al.   (12 March 2009) Read every Rapid Response to this article
	VIEWS & REVIEWS: Let’s not turn elderly people into patients Oliver (3 March 2009) [Full text]		..and increased insurance premiums Beena J Raschkes, et al.   (12 March 2009) Not in my neck of the woods, anyway. Julian Moore   (12 March 2009) Read every Rapid Response to this article
	PRACTICE: High doses of deferiprone may be associated with cerebellar syndrome Beau-Salinas et al. (22 January 2009) [Full text]		Too little is as bad as too much with iron Jecko Thachil   (13 March 2009) Read every Rapid Response to this article
	HEAD TO HEAD: Have targets done more harm than good in the English NHS? No Bevan (16 January 2009) [Full text]		Re: Targets - good or bad stephen black   (12 March 2009) Read every Rapid Response to this article
	RESEARCH: Impact of presumed consent for organ donation on donation rates: a systematic review Rithalia et al. (14 January 2009) [Abstract] [Full text] [PDF]		Trust is important Vasiliy V Vlassov   (12 March 2009) Read every Rapid Response to this article
	VIEWS & REVIEWS: 'I’ll bet you a fiver it’s not' Patel (6 January 2009) [Full text]		Re: The answer Dipak Mistry   (12 March 2009) Read every Rapid Response to this article
	NEWS: NICE updates guidance on early and advanced breast cancer Mayor (25 February 2009) [Full text]		Re: NICE should be challenged on its updated guidance that all women advised to have a mastectomy should be offered immediate breast reconstruction Zoe E Winters   (12 March 2009) Read every Rapid Response to this article
	ANALYSIS: Commentary: Toughen up Freedland (24 February 2009) [Full text]		Reply to Dr Summerfield Jonathan Freedland   (13 March 2009) Response from B'Tselem Sarit Michaeli   (13 March 2009) A tip for a tip Michael O'Donnell   (12 March 2009) Re: Lobbying for a dream William Bilek   (12 March 2009) Read every Rapid Response to this article
	RESEARCH: Combined effects of overweight and smoking in late adolescence on subsequent mortality: nationwide cohort study Neovius et al. (24 February 2009) [Abstract] [Full text] [PDF]		Death, (indirect) taxes and chocolate Richard J Partington   (14 March 2009) Read every Rapid Response to this article
	ANALYSIS: Perils of criticising Israel Sabbagh (24 February 2009) [Full text]		Re: Re: The Editor responds to charges of anti-Israel bias in the BMJ Fiona Godlee   (13 March 2009) Re: The Editor responds to charges of anti-Israel bias in the BMJ Jonathan Hasleton   (13 March 2009) Re: Diabetes in Gaza: Getting the Facts Correct Tony Delamothe   (12 March 2009) Lies and facts about the conflict A Sabra   (12 March 2009) Re: The fallacy of some democracies Sheila F Raviv   (12 March 2009) More on the fallacy of some democracies Bassem R Saab Saab   (12 March 2009) Read every Rapid Response to this article
	NEWS: Obama’s stimulus package includes funds for public health, nutrition, and effectiveness research Tanne (23 February 2009) [Full text]		Universal Healthcare Hugh Mann   (13 March 2009) Read every Rapid Response to this article
	RESEARCH: Combined effect of health behaviours and risk of first ever stroke in 20 040 men and women over 11 years’ follow-up in Norfolk cohort of European Prospective Investigation of Cancer (EPIC Norfolk): prospective population study Myint et al. (19 February 2009) [Abstract] [Full text] [PDF]		Life style and Risk of Stroke Rizaldy Pinzon   (14 March 2009) Read every Rapid Response to this article
	OBSERVATIONS: "Nothing is too good for ordinary people" Heath (17 February 2009) [Full text]		Iona Heath & the Finsbury Health Centre Wendy D Savage   (13 March 2009) Read every Rapid Response to this article
	ANALYSIS: Patient and public involvement in chronic illness: beyond the expert patient Greenhalgh (17 February 2009) [Full text]		Patient as a partner in care Billy Boland   (14 March 2009) Curious priority Martin W McNicol   (13 March 2009) Read every Rapid Response to this article
	RESEARCH: Resting heart rate as a low tech predictor of coronary events in women: prospective cohort study Hsia et al. (3 February 2009) [Abstract] [Full text] [PDF]		Heartbeat Bank Peter AF Watson   (14 March 2009) What about absolute risks? Michael J Campbell, et al.   (13 March 2009) Not every stress is evil - about heart rate and shear stress Christian Seiler, et al.   (13 March 2009) Read every Rapid Response to this article
	RESEARCH: Outcome of depression in later life in primary care: longitudinal cohort study with three years’ follow-up Licht-Strunk et al. (2 February 2009) [Abstract] [Full text] [PDF]		Who is older, 55 or 65? Dr Qaiser Javed   (14 March 2009) Read every Rapid Response to this article
	OBITUARIES: Roger Patrick Doherty Elliott (2 September 2008) [Full text]		Memorable leadership in an emergency Raj Bhopal   (13 March 2009) Read every Rapid Response to this article
	PRACTICE: Obesity and pregnancy Stotland (15 December 2008) [Full text]		Anaesthetic Considerations Jeremy A Stone   (12 March 2009) Read every Rapid Response to this article
	EDUCATION AND DEBATE: Systematic reviews in health care: Systematic reviews of evaluations of diagnostic and screening tests Deeks (21 July 2001) [Full text] [PDF]		Corrected Correction William T Stevenson   (14 March 2009) Read every Rapid Response to this article

CLINICAL REVIEW: Investigating the thyroid nodule Mehanna et al. (13 March 2009) [Full text] Investigating the thyroid nodule Investigation of Thyroid Nodules 14 March 2009 Piero Baglioni, Consultant Physician Prince Charles Hospital, Merthyr Tydfil CF47 9DT, Oneybuchi Okosieme, Consultant Physician, Prince Charles Hospital, Merthyr Tydfil CF47 9DT Send response to journal: Re: Investigation of Thyroid Nodules As practicing clinicians, we acknowledge the authority of the advice in Mehanna's review [BMJ 2009; 338 : b733] but also believe that due to its potential public health implications it should be accompanied by a formal cost-benefit analysis which is missing from their report. As the authors acknowledge, ultrasonography will detect thyroid nodules in 50-70% of unselected adults in the general population but cannot obviate to the need for fine needle aspiration cytology [FNA] cytology, which dictates further management. Since FNA cytology, even when performed and interpreted by experienced operators [a precondition not to be taken for granted outside dedicated institutions] has a false negative rate of up to 6% and a non-diagnostic rate which may reach 30%, we cannot help sharing some uneasiness at the advice that patients should be subjected to an hemithyroidectomy [with its inherent risks, costs, and unavoidable scars] if two aspiration procedures prove non diagnostic. The need to confirm that the required diversion of resources is indeed worthwhile would be even more urgent if the authors's advice [not supported by current British and American Thyroid Associations guidelines,as the article acknowledges] to investigate all patients with non palpable incidentally detected nodules inferior to 10 mm were to be implemented. Competing interests: None declared

VIEWS & REVIEWS: Studies on Hysteria Lucas (11 March 2009) [Full text] Studies on Hysteria Theories of Personality 14 March 2009 Hugh Mann, Physician Eagle Rock, MO 65641 USA Send response to journal: Re: Theories of Personality Notwithstanding the many well-reasoned theories of personality, we remain a mystery to ourselves and others. Nevertheless, these theories, which represent the work of physicians and psychologists, provide us with a language and structure that elucidates personality. Sometimes one theory is more applicable to a particular situation. So it is wise to familiarize oneself with as many theories of personality as possible, including those of Freud, Meyer, Rank, Sullivan, Horney, Adler, Reik, Deutsch, Jung, Erikson, Frankl, Hartmann, Kris, and Lowenstein. In order to understand a patient�s disease, we must understand the patient. Competing interests: None declared

VIEWS & REVIEWS: Too much information Dalrymple (11 March 2009) [Full text] Too much information Balancing freedom of press and respect. 14 March 2009 Antoine Kass-Iliyya, CT1 T&O; Darlington Memorial Hospital, Darlington, DL3 6HX Send response to journal: Re: Balancing freedom of press and respect. I strongly agree with the author's view, I think revealing unnecessary little information especially if they distort or hurt our perceived image of a great person, would hardly serve any purpose, we all know that people with dementia can be incontinent and very demanding, we all know how burdened and troubled the carers of such people can be, we deeply appreciate their suffering and we truly feel for their pain, but one important question to ask here is what those same people would have thought of revealing these embarrassing indecent details about themselves if they had a chance to foresee the future at some point during their careers' peaks?. I would not think any great person would have appreciated changing his perceived image of creativity, ingenuity and respect in the minds of his admirers whatsoever, nor the admirers would have done for that matter. Competing interests: None declared

FILLERS: A fine thread Drabu (11 March 2009) [Full text] A fine thread I assume it is a typographical error 14 March 2009 Kesavan Sri-Ram, SpR - Orthopaedics RNOH - Stanmore Send response to journal: Re: I assume it is a typographical error This is an interesting article on cultural differences. I am a little concerened about the spelling of Gujarati (Gujarthi in the article). I assume this is a simple typographical error. However, if not, it does unfortunately suggest a hint of ignorance and may even cause some offence. Even if is is a typographical error, it is a shame it escaped the editorial team. Competing interests: None declared A fine thread Stamp of Kashmir 14 March 2009 Romesh Khardori, Professor of Medicine Southern Illinois University School of Medicine; Springfield, IL 62794-9636;USA Send response to journal: Re: Stamp of Kashmir I am curious to know where did Dr. Drabu get stamp of Kashmir on passport while traveling abroad ? As a native Kashmiri from Kashmir (India),I know Kashmir as hotly contested territory claimed both by India as well as Pakistan, but not as a free standing country. Thanks Romesh Khardori, MD.,PhD. Competing interests: None declared A fine thread absolutely right 14 March 2009 dr mohan devegowda, GP 613 2nd mian first stage indiranagar Bangalore India 560038 Send response to journal: Re: absolutely right You have put it very aptly. Why can't every one think like this? In my practice I come across many youngsters who have been brought up very conservatively are getting married to boys/girls of different caste. Caste menace which is rampant can be solved only by this. As you have put it most of us never think of a patient as where he/she belongs but only think of how to relieve his disease process. I hope everyone who has read your filler takes the cue. Competing interests: None declared

RESEARCH: Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study Bushnell et al. (10 March 2009) [Abstract] [Full text] [PDF] Migraines during pregnancy linked to stroke and vascular diseases: US population... Migraine and stroke 13 March 2009 Rizaldy Pinzon, Neurologist Bethesda hospital Yogyakarta Indonesia 55224 Send response to journal: Re: Migraine and stroke This interesting study confirmed that people who suffer from migraine may have a slightly greater risk of stroke. Migraines during pregnancy were linked to a 15-fold increased risk of stroke. Migraines also tripled the risk of blood clots in the veins and doubled the risk of heart disease. Vascular risk factors were also strongly associated with migraines. These included diabetes, high blood pressure and cigarette smoking. However, stroke is generally caused by a number of factors working in combination. The higher risk for stroke may be related to reduced blood flow in the brain during a migraine, but the exact mechanism for this association is unknown. A theory suggest that strokes can occur as the result of a syndrome called "reversible cerebral vaso-constriction syndrome" (RCV). Other factors which can increase the risk of stroke include the use of oral contraceptives and cigarette smoking should be concerned. A young woman who experiences frequent migraine should minimize the risk of stroke by quitting cigarettes and using other forms of birth control.Lifestyle modification should be done in people with classic migraine. They should stop smoking, eat fruit and vegetables and have high blood pressure control Competing interests: None declared

ANALYSIS: Tissue screening after breast reduction Keshtgar et al. (10 March 2009) [Full text] Tissue screening after breast reduction Screening for breast reduction 13 March 2009 Adhip Mandal, Clinical Research Fellow, Breast Surgery Colchester Hospital University NHS Foundation Trust, CO4 5JL Send response to journal: Re: Screening for breast reduction All breast reduction specimens should undergo pathological screening for occult cancer as all women are at risk of breast cancer. In the event that a specimen is not examined and does actually have malignant tissue, means an opportunity to diagnose an early cancer is missed with possible disasterous consequences in the future. The surgical procedure for reduction mammoplasty is not effected in anyway with the intent for tissue biopsy. The women should be counselled prior to surgery with the possibility of diagnosis of cancer in the specimen and need for further surgery or treatment. Early diagnosis of breast cancer has advantages in terms of cure and long term prognosis and every oppertunity to maximise results should be seized. Competing interests: None declared Tissue screening after breast reduction Pre-operative assessment 12 March 2009 Louise Gaunt, Consultant radiologist Princess Elizabeth Hospital, Guernsey GY4 6UU Send response to journal: Re: Pre-operative assessment As a radiologist specialising in breast imaging, I am surprised there is no mention of pre-operative mammography. I know the patient considered in the article was aged 37, and there are some doubts about the accuracy of mammography in younger women, but I feel it is appropriate to consider mammography prior to breast reduction surgery, to assist in the potential identification of unsuspected malignancy. With the increasing use of digital techniques the radiation dose to the patient is less than previously, and due to the ability to manipulate the digital image there is the potential for greater diagnostic accuracy. I acknowledge that not all cancers will be identified, but I would encourage all surgeons planning breast reduction surgery to consider pre-operative imaging. From personal experience through my practice I know many centres in Europe routinely request mammography prior to surgery and I feel it is something we should consider in UK. I also agree there needs to full explanation to the patient of the implications of histological examination of the excised tissue - the detection of unsuspected cancer is a recognised consequence of breast reduction surgery and therefore needs to form part of the informed consent process Competing interests: None declared

LETTERS: Heart failure is in need of a diagnosis Lloyd (9 March 2009) [Full text] Heart failure is in need of a diagnosis About time we recognised the heart failure under-diagnosis 13 March 2009 Farrukh Baig, Consultant Physician Royal Shrewsbury Hospital Send response to journal: Re: About time we recognised the heart failure under-diagnosis I could not agree more with the author! Day in and day out I see older patients with almost textbook features of heart failure, only to be frustrated by the negative (normal-ish) echocardiography result! I have even taken up the issue with our cardiologists and cardiorespiratory technicians and I do sympathise with the practical limitations of the investigation. One of the problems we face is with regards to the heart failure guidelines outlining the central role and reliance on echocardiography (1). Some general practitioners perhaps rightly expect a black or white diagnosis from the hospital consultants. From a practical point of view I believe that we need to treat heart failure based upon clinical findings alone, and even better if some supportive evidence from chest x-rays and echo helps re-assure our clinical colleagues. The bottom line is that such an important diagnosis could not be missed simply by a normal report of echocardiography alone, which has so many patient and operator dependent variables. 1- Cheesmana M G, Leechb G, Chambersc J, et al. Central role of echocardiography in the diagnosis and assessment of heart failure; Heart 1998; 80(Suppl 1):S1-S5 (July) Competing interests: None declared

LETTERS: Targets destroy morale and do not help patients Spicer (11 March 2009) [Full text] Targets destroy morale and do not help patients We do agree on targets 14 March 2009 Richard D Spicer, Retired consultant surgeon BS65SR Send response to journal: Re: We do agree on targets I don't think we disagree, Bob. I was speaking from the point of view of a paediatric specialist to point out that targets designed for certain adult conditions do not apply to all specialities. Colleagues in other surgical disciplines have encountered exactly the same counterproductive effects of targets imposed by politicians who seem to have no concept of the complexity and diversity of medical practice. Competing interests: None declared Targets destroy morale and do not help patients love to agree, but......................... 13 March 2009 Bob Bury, Consultant Radiologist Leeds General Infirmary LS1 3EX Send response to journal: Re: love to agree, but......................... 'All clinicians will agree that targets do more harm than good' writes Mr Spicer, and while I'd love to agree, I can't. For example, it would be difficult to argue with the fact that target-driven reductions in waiting times for scans in my field of radiology have been anything other than good for patients. Don't get me wrong - I have been in print on a number of occasions decrying this Government's blinkered adoption of target-setting as a solution to all problems. The answer is not to do away with targets altogether, but to ensure that when targets are set, they are set after consultation with those who have to deliver them and that there is consensus on both the need for, and the appropriateness of, the target in question. If Mr Spicer wants us all to agree with a statement on targets, how about: 'All clinicians agree that targets set by politicians to give the impression of doing something and with no thought as to whether the targets are useful or achievable do more harm than good'? Competing interests: None declared

RESEARCH: Appendicitis, mesenteric lymphadenitis, and subsequent risk of ulcerative colitis: cohort studies in Sweden and Denmark Frisch et al. (11 March 2009) [Abstract] [Full text] [PDF] Appendicitis, mesenteric lymphadenitis, and subsequent risk of ulcerative colitis:... Might immunization against endotoxin prevent ulcerative colitis and peptic ulceration? 12 March 2009 Richard G Fiddian-Green, FRCS, FACS None Send response to journal: Re: Might immunization against endotoxin prevent ulcerative colitis and peptic ulceration? This interesting study has shown that, "appendicitis and mesenteric lymphadenitis during childhood or adolescence are linked to a significantly reduced risk of ulcerative colitis in adulthood. Appendicectomy itself does not protect against ulcerative colitis" (1). Might the protection have been conferred by the development of antibodies to endotoxin? Both appendicitis and ulcerative colitis were extremely uncommon in the Zulu population when I worked at the KEVIII hospital in Durban a few decades ago and yet amoebic and bacillary dysentery were extremely common. The late Professor Wilmot, on whose amoebiasis unit I worked as an HP, used to say that he had never seen a case of ulcerative colitis in his Zulu and Indian patients that had not had an antecedent attack of dysentery. Might that mean that dysentery protects Zulus and Indians from developing ulcerative colitis in the same way that appendicitis protected patients in Sweden and Denmark in this study? The mortality risk in fulminant colitis is said to be greatest with the first attack and to be far less in subsequent attacks. If true might the risk of dying from ulcerative colitis also be reduced by developing an immunity to the systemic effects of endotoxin during the first attack? The systemic effects of endotoxin are well known. It is also common to experience difficulty in cross-matching blood for patients requiring surgery for ulcerative colitis because of all the funny antibodies these patients tend to have developed. The endotoxin in H pylori has been implicated in the pathogenesis of peptic ulceration (2). Might endotoxin have a similar effect upon colonic mucosa which is exposed to very much large amounts of endotoxin produced by E coli? But the endotoxin does not damage healthy colonic mucosa and so some degree of antecedent cellular dysfunction must be required for it to do so [Virchow's cell theory](3). There are gaps in this line of thinking but if the underlying hypotheses are correct then immunizing healthy people against endotoxin should reduce the risk both gastric and colonic mucosal ulceration in addition to reducing the risk of death from acute abdominal catastrophes including fulminant ulcerative colitis. 1. Morten Frisch, Bo V Pedersen, and Roland E Andersson Appendicitis, mesenteric lymphadenitis, and subsequent risk of ulcerative colitis: cohort studies in Sweden and Denmark BMJ 2009; 338: b716. 2. Richard G. Fiddian-Green. Helicobacter pylori eradication and L- dopa absorption in patients with PD and motor fluctuations. Neurology. 2007 Mar 27;68(13):1085. 3. Virchow's Cell Theory vs Pasteur's Germ Theory Richard G Fiddian-Green (3 September 2004) eLetter re: Nosocomial infections: What needs to be done? CMAJ 2004; 171: 421 Competing interests: None declared

EDITORIALS: Tight control of blood glucose in long standing type 2 diabetes Lehman and Krumholz (5 March 2009) [Full text] Tight control of blood glucose in long standing type 2 diabetes In defence of QOF targets 13 March 2009 Richard A Brice, GP Whitstable Medical Practice, Whitstable, Kent, CT5 1BZ Send response to journal: Re: In defence of QOF targets This editorial, and most of the rapid reponses to date seem to ignore the fact that the QOF only asks that a practice ensures 50% of it's registered population of diabetics has an HbA1c of less than or equal to 7.0%. Whilst I accept that ACCORD, and to some extent VADT, showed it is harmful for those with long standing diabetes or a previous history of cardiovascular disease to have their HbA1c driven to a target of < 6.0% (the goal in ACCORD), this is a very different target to the 7.0% or less being asked for by the QOF. The 10 year follow up data from UKPDS conversely showed a lasting benefit from intensive early treatment of newly diagnosed diabetics. General Practitioners are nothing if not pragmatic, and I would hope that this attribute will result in an attempt to get the relatively newly diagnosed diabetics on little or no oral hyoglycaemic therapy to 7.0% or less, but a realism that for those with long standing, difficult to control diabetes, the aim of 7.0% or less can be ignored. This way, the target of 50% can still be acheived, without the potential of harming those for whom it would be inappropriate. Competing interests: None declared Tight control of blood glucose in long standing type 2 diabetes Re: Hidden dangers in rebound hyperglycaemia. 13 March 2009 Gauranga C. Dhar, Family physician and teacher of Bangladesh Institute of Family Medicine and Research. Dhaka 01209 Send response to journal: Re: Re: Hidden dangers in rebound hyperglycaemia. I extremely appreciate Richard G Fiddian-Green�s point on rebound hyperglycemia. In fact both hypoglycemia and hyperglycemia are dangerous. In all three trials, more incidences of severe hypoglycemic episodes were found in intensive regimens in comparison to standard arms. In ACCORD trial, incidence of severe hypoglycemia was found in 10% in intensive arm and 3.5% in standard. In ADVANCE, 2.7% vs 1.5% and in VADT, 21% vs 10%. From these findings hypoglycemia may be the possible explanation of macro vascular outcomes. Rebound hyperglycemia, may be Somogyi effect can be found in response to prolonged, mainly nocturnal hypoglycemia followed by secretion of glucagon, epinephrine and cortisol. Glucagon by releasing glucose from liver and stress hormones by increasing insulin resistance cause very high level of plasma glucose. Hyperglycemia probably cause damage to endothelium through production of advanced glycosylation end products (AGEs) and mechanically as well. AGEs cause oxidative stress and activate protein kinase C (PKC) which consequently increases the expression of transforming growth factor beta (TGF-beta). May be hyperglycemia related endothelial damage is slow and long lasting. Hypoglycemia related neuroglycopenia and related increased release of inflammatory cytokines, leucocyte activation and vasoconstriction may be the reasons of increased macrovascular events in the above three trials. I also think that more research is required on rebound hyperglycemia which is also a very important topic. Competing interests: None declared Tight control of blood glucose in long standing type 2 diabetes Whose idea was this ? 12 March 2009 Harry Hall, Retired physician and diabetologist EX1 2HW Send response to journal: Re: Whose idea was this ? The formulation of this policy was apparently made by a joint committee of GP's and NHS officials. In the light of the information provided in this editorial this was contrary to the evidence available at the time. Those responsible should now either justify their advice or withdraw it. Incentives to provide incorrect treatment are insupportable, and will further undermine patients' trust that the advice they are getting is truly impartial. Competing interests: None declared Tight control of blood glucose in long standing type 2 diabetes Hidden dangers in rebound hyperglycaemia. 12 March 2009 Richard G Fiddian-Green, FRCS, FACS None Send response to journal: Re: Hidden dangers in rebound hyperglycaemia. In his rapid response to this editorial (1) Gauranga C. Dhar drew attention to the adverse effect tight glycaemic control had upon outcomes in the ACCORD, ADVANCE and VADT trials. Might part of the problem in these trials have been caused by hyperglycaemic rebound (2) rather than by hypoglycaemia per se? How then might rebound hyperglycaemia cause adverse effects? By inducing reperfusion injury in tissues in which an energy deficit has been created by an inadequacy of nutrient delivery rather than of oxygen delivery, there still being sufficient oxygen delivered to generate free radicals upon reperfusion? In the study of paediatric ICU patients considered by Levy and Rhodes the point was made that most of the patients had cardiac operations and were cared for in a very closely monitored unit that was very experienced in tight glycaemic control. The inference is that rebound hyperglycaemia might be very difficult if not impossible to avoid in an ambulatory setting. 1. Richard Lehman and Harlan M Krumholz Tight control of blood glucose in long standing type 2 diabetes BMJ 2009; 338: b800 2. Levy MM, Rhodes A. The ongoing enigma of tight glucose control. Lancet. 2009 Feb 14;373(9663):520-1. Epub 2009 Jan 26. Comments on: Lancet. 2009 Feb 14;373(9663):547-56. Competing interests: None declared Tight control of blood glucose in long standing type 2 diabetes The individual patient should decide what their target hbaic should be. 12 March 2009 Katharine M Morrison, General Practitioner Ballochmyle Medical Group, Mauchline, East Ayrshire, KA5 5EQ Send response to journal: Re: The individual patient should decide what their target hbaic should be. Healthy people who don't have diabetes have hbaics of 5.7% or below. Risk of increased cardiovascular events start at even lower levels than this and microvascular complications increase above this level. Achieving strict glycaemic control has its challenges, but so does living with the complications of diabetes. The target hbaic should therefore be decided by the person with diabetes with informed guidance from their doctor. It should not be set at some arbitary standard that may be dangerous for some to achieve but at the same time hopelessly inadequate for others who seek to avoid or reverse complications. Achieving normal blood sugars for diabetics is a straightforward procedure with choice points along the way. Restricting the amount and type of carbohydrate in the diet is the key intervention. Meticulous monitoring and medication adjustment is essential for safety in insulin users and those on oral hypoglycaemics. Of course, this option is not necessary or desirable for everyone. My belief about the ACCORD study is that the results are not directly comparable with low carbing diabetics who get their blood sugars regularly far lower than in the ACCORD study. In ACCORD a lot of drug and insulin therapies were used but the diet was the standard high carb/low fat. Thus people were vulnerable to the side effects of the drugs, higher blood sugar levels than ideal especially post prandially and also increased hyopoglycaemic events compared to the low carbing diabetics. There are higher cardiovascular mortality rates with gliclazide and certain glitazones compared to non users. Thus low carbers will automatically have lower post prandial blood sugars, lower rates of hypos, need less insulin and other drugs. All of these things are protective. Apart from these effects weight, blood pressure and insulin resistance are also lowered by a low carb diet. References: Dr Richard Bernstein "Diabetes Solution." Nielsen and Jonsson, "A Low Carbohydrate Diet in Type 1 Diabetes : Clinical Experience � A Brief Report (2007)". Competing interests: None declared

OBSERVATIONS: Rethinking ward rounds Sokol (4 March 2009) [Full text] Rethinking ward rounds RN's and Ethics 14 March 2009 Caron E. Lumpkin, L&D; RN/HS Health & Biology Teacher 30127 Send response to journal: Re: RN's and Ethics As an RN (20 years)in Perinatology/Labor & Delivery, I've seen nurses are dealing with ethical dilemas quite often. Patients can introduce the spouse vs. father of the baby vs. current boyfriend or fiancee all within a single 12 hour shift with various visitors at the bedside. Patients can know about their own medical history including previous pregnancies that ended with either abortions or giving the baby up for adoption that they "don't want anyone else to know about". Most women delivering 3rd of 4th baby may progress on a different timeline than a woman delivering a 1rst baby. Women who know about their own health status and are aware of transmissable infections like Chlamydia, Gonorrhea and others will accept antibiotics but "don't say what the medicine is for" and women with active Herpes requiring a c-section will instruct the staff to "make up a reason why I need to have a c-section to tell them". Competing interests: None declared

NEWS: Inquest begins into deaths after concerns about diamorphine prescribing Dyer (3 March 2009) [Full text] Inquest begins into deaths after concerns about diamorphine prescribing A fixed comment of experts could be under question 14 March 2009 Reza Afshari, Assistant Professor & Consultant Physician Medical Toxicology Research Centre, Mashhad, 913 791 3316, Iran Send response to journal: Re: A fixed comment of experts could be under question I have read with interest and concern the report of Clare Dyer in which based on "inappropriate combined subcutaneous administration of diamorphine, midazolam and haloperidol" experts concluded this "could carry a risk of excessive sedation and respiratory depression in older patients, leading to death" [1]. They also deducted "the use and combination of drugs was "excessive and outside normal practice." While this may be true, establishment of causality in these tragedies should be conducted on individual basis, and a releasing a general comment is probably not enough. Medical guidelines are usually produced for average people. For obvious reasons, they are relatively more conservative for older people. On the other hand, it might also be the case that higher doses could be acceptable for example for opioid dependent subjects. I believe clinical findings of each patient at the time of medical orders should also be taken into account for decision making. It can be assumed that they are not similar for all of those cases. Based on the report [1], I presume no blood level data is available. Inter individual discrepancies as well as timing of administration and half life of medications should be taken into account in regard of the time of death. A fixed comment of experts for all of these cases could be under question. Reference: 1 Dyer Clare Inquest begins into deaths after concerns about diamorphine levels. BMJ 2009;338:b903 [7 March] Competing interests: None declared Inquest begins into deaths after concerns about diamorphine prescribing Prescribing Error 13 March 2009 James A Smith, Employed Belgium Send response to journal: Re: Prescribing Error Dear Dr Prabhu, "Recently there was an error due to a doctor clicking the wrong key in the computer prescription. Doctor clicked Morphine 100 mg three times a day when he actually meant to click Morphine 10mg three times a day". Do you have any more details about this astonishing claim, please? Competing interests: None declared

EDITORIALS: Sun protection in teenagers Thieden (3 March 2009) [Full text] Sun protection in teenagers Sun protection in teenagers -protection or abuse? 12 March 2009 Richard Quinton, Consultant & Senior Lecturer in Endocrinology Endocrine Research Group, University of Newcastle-on-Tyne. NE1 4LP, John L Sievenpiper, Simon HS Pearce Send response to journal: Re: Sun protection in teenagers -protection or abuse? Thieden's editorial is remarkable for the number of serious issues arising therein that are simply left unaddressed. Thieden highlights a recent study of "sun sails" on the outdoor behaviour of Australian teenage schoolchildren (1). She fails to consider whether studies derived from children of Anglo-Celtic origin, living in a region of exceptionally high solar radiation, provide useful lessons for other communities worldwide (such as multi-ethnic north west Europe) or merely constitute an interesting (but non-extrapolatable) experimental model. Thieden describes the detrimental effects of solar radiation as being "well known". They are certainly well-publicised, but it is worth reiterating that the proven effects are acute sunburn, accelerated skin ageing (keratoses, loss of elasticity, etc), dermal naevi and non-melanoma skin cancer (2). Thieden states that the "only" beneficial effect of solar radiation is Vitamin D photosynthesis. Given that she then goes on to describe a "widespread global insufficiency of Vitamin D", use of the word "only" carries echoes of Monty Python's "Life of Brian" ("Well apart from the aqueduct, new roads, sewage disposal, law & order and public sanitation, what have the Romans done for us?"). Thieden states that Vitamin D insufficiency is better counteracted by oral supplementation than by sunlight. She has obviously never tried the chalky, dyspeptic and constipating Calcium-and-Vitamin-D preparations that constitute the only widely-available therapy in the UK pharmacopoea. Unless fortification of foods with Vitamin D is mandated at governmental level (unlikely given the track record of argument and policy paralysis over public mass medication with Folic acid and fluoride), oral correction of the Vitamin D deficiency pandemic is just not going to happen. Finally, Theiden mistakenly states that the non skeletal benefits of having optimal Vitamin levels "remain controversial". In fact Vitamin D insufficiency is associated with type 1 diabetes, multiple sclerosis and major cancers (oesophagus, breast, colorectal and prostate), not to mention cardiovascular death and overall mortality. Given the sheer number and variety of mammalian genes that comprise vitamin D responsive elements, the existence of widespread extra-skeletal affects of Vitamin D should come as no surprise (3). What controversy there is relates to a paucity of decent intervention studies. Given that oral Vitamin D is cheap (and indeed "solar" Vitamin D is completely free), there is understandably no incentive for Industry to fund large scale intervention studies as it has done for statins, etc. The widespread prevalence of Vitamin D deficiency and its observed association with life-limiting disease, suggests that these intervention studies need to be funded and undertaken with some urgency. Until then, the principle of "primum non nocere" applies, such that blunderbuss sun avoidance strategies for our children must not be implemented until/unless we can be reassured that they will not cause an increased future disease burden. 1. Thieden E. Sun Protection in Teenagers. BMJ 2009; 338:a2997. 2. Shuster S. Is sun exposure a major cause of melanoma? BMJ 2008;337:764. 3. Holick MF. Deficiency of sunlight and vitamin D. BMJ 336:1318-9. Competing interests: None declared

VIEWS & REVIEWS: Let’s not turn elderly people into patients Oliver (3 March 2009) [Full text] Let’s not turn elderly people into patients ..and increased insurance premiums 12 March 2009 Beena J Raschkes, GP Bridge of Earn Surgery, Main St Bridge of Earn, PERTH PH2 9LN Send response to journal: Re: ..and increased insurance premiums Last week I recieved notification that my insurance priums will increase " due to increased claims by non smokers over 87 years of age"! This suggests that as GPs we are actually doing our job very well - keeping people living longer- but the really immeasurable outcome is acheiving quality as well as quantity, in the process. Competing interests: None declared Let’s not turn elderly people into patients Not in my neck of the woods, anyway. 12 March 2009 Julian Moore, GP Principal Seal Medical Group, Selsey, PO20 0QG Send response to journal: Re: Not in my neck of the woods, anyway. I was alerted to Michael Oliver�s article by an online news item a day before having any opportunity to read it. Based upon the online summary, it seemed so pertinent to debate in my own practice as the QoF deadline approaches and I so completely shared the views I understood it to expound that I quoted from the summary version in an internal e-mail (which I have now forwarded to Michael Oliver). I wish I had waited 24 hours. Whilst I certainly share Michael Oliver�s sentiments, I cannot agree with those who regard the article as well written, and none of whom advertise any experience of primary care. That I had imagined a review or research article is my own fault. However, I am astonished that an article which makes scurrilous generalisations without presenting a shred of evidence was ever considered worthy of publication. Perhaps I am in a minority, and most other doctors really do behave in the way he implies. Alternative explanations are that the relationship he assumes we have with patients reflects his ignorance of general practice, and/or reflects his own pre-retirement style of practice? �Many� patients are told to have more investigations.� I never tell my patients to do anything, nor am I in a position to do so. I advise, suggest and discuss options. �Many busy family doctors seem not to understand the difference between relative and absolute risk� et seq. What is his evidence? How many doctors did he test or interview? I not only understand this, but frequently explain it to patients. Often this is done precisely to deflecting clamour for statins in primary prevention and comparable interventions from patients malignly influenced by the media. This is an important factor which Michael Oliver misses entirely, just as he overlooks the unfortunate influence of the current medicolegal climate on interventions to minimise vascular risk �Reliability of cuffs�..is often unchecked.� Definitely not true of my practice. What is his evidence? �Isolated finding of [SBP >140]�.conclusion is to tell the patient that [they] have raised blood pressure and that it must be treated�. Firstly, in the absence of additional risk factors and particularly in the elderly, I do not believe many GPs would regard SBP<150 as raised (although some doctors might argue that we should). Secondly, I can scarcely imagine of a GP not arranging multiple readings. My own practice is usually to undertake additional 24hr ambulatory BP monitoring before any �labelling,� a better standard of assessment than many hospitals provide. Indeed, it is in hospital outpatient clinic letters that readings on a single day in a stressful environment are followed by advice to start or increase medication. Thirdly, I would never attempt to tell a patient that something must be treated. �Often, scant attention is paid to potential side effects.� Again, what is his evidence? I hope he is not falling into the facile trap of regarding patients who presented to him with side effects in secondary care as representative of the large majority with whom he had no involvement. The diagnostic criteria for diabetes are well known, and that of two fasting glucose results >7 is most commonly used. I cannot accept that anything other might occur �often� unless he has evidence of this. For a later HbA1c later to be below 6.5% would be highly unusual in my practice, but below 7% perhaps. A result obtained after dietary or other intervention is of course irrelevant in diagnostic terms, and in no circumstance should HbA1c be used to either diagnose or exclude diabetes. �Are doctors willing to discontinue treatment?� Certainly, and I delight in this. It also overlooks the fact, of which I suspect GPs are more aware than hospital doctors, that de facto treatment is discontinued as soon as the patient wishes it to be. The first prescription may be signed, but the repeat slip may never be employed, or the drug flushed away or dangerously stockpiled. I am sure all doctors would prefer agreed discontinuation that these futile outcomes. �It may be difficult for doctors when individuals decline to be treated.� I can think of a few instances when it has been, but in the domain of risk-modification in the elderly it is largely a pleasure. That some of the generalisations speak of �many� or �most� GPs without any apparent evidence is bad enough. That some imply universality is a disgrace, and merits an apology. Competing interests: JM is a GP principal who finds that QoF influences his bank balance positively but his job satisfaction negatively.

PRACTICE: High doses of deferiprone may be associated with cerebellar syndrome Beau-Salinas et al. (22 January 2009) [Full text] High doses of deferiprone may be associated with cerebellar syndrome Too little is as bad as too much with iron 13 March 2009 Jecko Thachil, Researcher University of Liverpool Send response to journal: Re: Too little is as bad as too much with iron The cerebellar adverse effects of high doses of deferiprone reported by Beau-Salinas et al give important clues to the importance of cellular iron transport in iron overload and its therapy with chelating agents [1]. Excess removal of iron, in much the same way as iron overload, can affect the membrane iron chanelling in different cells. This is highlighted by the fact that arthralgia, a common symptom in haemochromatosis (hereditary iron overload), is also a common adverse effect with higher doses of deferiprone [2,3]. In iron overload, the metal deposition also occurs in the cerebellum in addition to the joints, heart and the liver [4]. This concept has been utilised to suggest the use of deferiprone in the treatment of Friedrichs ataxia, a cerebellar degenerative disease [5]. It may mean that the excess iron removal by higher doses of deferiprone is affecting the mitochondrial iron transport and causing the cerebellar problems. In the case of iron, too little is as bad as too much. 1. F Beau-Salinas, M A Guitteny, J Donadieu, A P Jonville-Bera, and E Autret-Leca. High doses of deferiprone may be associated with cerebellar syndrome. BMJ 2009; 338: a2319 2. Pietrangelo A. Hereditary hemochromatosis--a new look at an old disease. N Engl J Med. 2004 Jun 3;350(23):2383-97. 3. Maggio A. Light and shadows in the iron chelation treatment of haematological diseases. Br J Haematol. 2007 Aug;138(4):407-21. 4. Brittenham Gary. Disorders of iron metabolism: Iron deficiency and iron overload. Chapter 36, pages 460- 67. 5. Boddaert N, Le Quan Sang KH, Rotig A, et al: Selective iron chelation in Friedreich ataxia: biologic and clinical implications. Blood 2007, 110(1):401-408. Competing interests: None declared

HEAD TO HEAD: Have targets done more harm than good in the English NHS? No Bevan (16 January 2009) [Full text] Have targets done more harm than good in the English NHS? No Re: Targets - good or bad 12 March 2009 stephen black, management consultant london sw1w 9sr Send response to journal: Re: Re: Targets - good or bad The idea that pursuing a target must cause deteriorating performance in areas where there are no targets seems logical when resources are finite. And it sometimes seems to be what happens. But--and it is a big but--there is a hidden assumption in the logic that is rarely made explicit as it critically undermines the argument. The assumption is that the services in the department or hospital are currently being delivered at the maximal possible efficiency. If we don't believe most hospitals are operating at this peak manner, then it should be possible for good managers or doctors to improve the performance of some services with no tradeoffs. And that is what good management (from managers or from medics) achieves. Only bad management delivers targets not by improving but by trading off the measured for the unmeasured. Competing interests: None declared

RESEARCH: Impact of presumed consent for organ donation on donation rates: a systematic review Rithalia et al. (14 January 2009) [Abstract] [Full text] [PDF] Impact of presumed consent for organ donation on donation rates: a systematic review Trust is important 12 March 2009 Vasiliy V Vlassov, Professor Moscow Medical Academy, Trubetskaya 8, Moscow, 101000 Send response to journal: Re: Trust is important The analysis is very teaching. I would like to add another story - from Russia. After the fall of the USSR transplantologists had a great chance to influence the new legislation, and it was based on the presumed consent for donation. The law is so straightforward, that even not describe how one may opt out. The life brought new balance: later the new law was enacted - on burial practice - and patients as well as relatives received back their right of decision. At last, series of scandals of malpractice with donor death declaration and taking the organs (most not proved in court) brought Russia transplantology almost to the nonexistence. Of course, the poverty of the system is important, but absence of the public control eroded the trust of citizens - despite the 'nice' law. Competing interests: None declared

VIEWS & REVIEWS: 'I’ll bet you a fiver it’s not' Patel (6 January 2009) [Full text] 'I’ll bet you a fiver it’s not' Re: The answer 12 March 2009 Dipak Mistry, ST3 Emergency Medicine Newham General Hospital, E13 Send response to journal: Re: Re: The answer Dr Patel, I read your point of view with some interest. Whilst, I completely agree that specialty Membership examinations should be a prerequisite for Higher training, I fear this clause has crept in to accommodate pre-Tooke report trainees. Due to the huge selection pressure in the current job climate, I think that you'll find short listing of current candidates ensures that they possess the academic prerequisites. Perhaps, you were hinting at an insulinoma with or without MEN inclusion? Dipak MISTRY. Competing interests: None declared

NEWS: NICE updates guidance on early and advanced breast cancer Mayor (25 February 2009) [Full text] NICE updates guidance on early and advanced breast cancer Re: NICE should be challenged on its updated guidance that all women advised to have a mastectomy should be offered immediate breast reconstruction 12 March 2009 Zoe E Winters, Consultant Senior Lecturer in Breast Surgery University of Bristol and University Hospitals of Bristol NHS Trust Send response to journal: Re: Re: NICE should be challenged on its updated guidance that all women advised to have a mastectomy should be offered immediate breast reconstruction The tenet that immediate breast reconstruction universally improves health related quality of life (HRQL) underlines the increasing practice of breast reconstruction in the UK and the USA1,2. However, there is no good clinical evidence to support this. A systematic review of relevant journals demonstrated a woeful lack of level I evidence, with few randomised controlled trials (2%), compared to cohort studies (not specified as prospective versus retrospective) (15%), with the majority of publications as case-reports (80%), therefore lowering the threshold of methodological rigour to that of levels IV to V3. A further systematic review to assess whether breast reconstruction improves HRQL for women facing mastectomy as well as the issues relating to the optimal type and timing of breast reconstruction did not support the facts that all women undergoing immediate breast reconstruction improve in all domains of their quality of life4,5. Two single-centre randomised controlled trials showed no difference in HRQL between immediate and delayed breast reconstruction and between types of delayed breast reconstruction regardless of radiotherapy4. The 9 prospective longitudinal cohort studies similarly do not support a universally improved HRQL after immediate breast reconstruction with 23 retrospective cross-sectional studies showing variable and conflicting results5. In the field, there is a heightened awareness of the need to produce the highest levels of scientific evidence to inform the correct choice for both patients and clinicians. This has precipitated the recently successful national breast reconstruction audit conducted by the Association of Breast Surgery at BASO (British Association of Surgical Oncology) and the Royal College of Surgeons6. Currently there is also progress being made with the launch of a feasibility study evaluating the acceptance of randomisation in women undergoing Latissimus Dorsi breast reconstruction in the immediate and the delayed context. The proposed Cancer Research UK and BUPA Foundation funded multicentre Quality of Life after Mastectomy and Breast Reconstruction trial (QUEST) in the UK will assess the impact of the type and timing of breast reconstruction on quality of life after mastectomy. The results of this study will have the potential for a pan-European collaboration as the first international attempt to achieve level I evidence in this field in 2 decades7,8. Zo� Ellen Winters Consultant Senior Lecturer in breast surgery, Head of the Breast Reconstruction HRQL group, level 7 Research, Clinical Science South Bristol and the University of Bristol Hospitals NHS Trust, Bristol, BS2 8HW Zoe.winters@bristol.ac.uk Competing interests: ZEW is the Chief Investigator of QUEST 1. Mayor S. NICE updates guidance on medical and surgical treatment for early and advanced breast cancer. BMJ 2009; 338: b815. 2. Cordeiro PG. Breast reconstruction after surgery for breast cancer. NEJM 2008; 359 (15): 1590-1601. 3. McCarthy CM, Collins ED, Pusic AL. Where do we find the best evidence? PRS 2008; 122 (6): 1942-1947. 4. Potter S, Winters Z. Psychosocial and health-related quality of life outcomes in breast reconstruction. A systematic review of randomised controlled trials. EJSO 2008; 34 (10): 1182, abstr. P67. 5. Potter S, Winters Z. Does breast reconstruction improve quality of life for women facing mastectomy? A systematic review. EJSO 2008; 34 (10): 1181, abstr. P63. 6. www.rcseng.ac.uk/publications/docs/national-mastectomy-and breast- reconstruction-audit-report-2008 7. Potter S, Winters ZE. The QUEST study: a multicentre randomised trial to assess the impact of the type and timing of breast reconstruction on quality of life after mastectomy. Breast Cancer Res 2008; 10 (Suppl 2): abstr. P87. 8. The Association of Breast Surgery at BASO Yearbook 2009: 79. Competing interests: Dr ZE Winters is the Chief Investigator of QUEST

ANALYSIS: Commentary: Toughen up Freedland (24 February 2009) [Full text] Commentary: Toughen up Reply to Dr Summerfield 13 March 2009 Jonathan Freedland, columnist Guardian, London N1 9GU Send response to journal: Re: Reply to Dr Summerfield Derek Summerfield suggests that, by relying on data from the Israeli human rights organisation B�Tselem, I am "at risk of uncritically recycling figures that promote self serving IDF mantras." After all, he asserts, "B�Tselem must depend in part on what the IDF tells them." This is a serious charge to level at an organisation that has won international praise for its fearless monitoring of the Israeli occupation. Fortunately, it is false. I showed Summerfield�s letter to B�Tselem�s communications director, Sarit Michaeli. Here�s an extract from her reply; the full version is published on bmj.com[1]: �B�Tselem�s modus operandi in cases of Palestinians killed by the Israeli security forces is to send a field worker to the scene of the killing, or if that isn�t possible, to the hospital or family home. The purpose of the field research is to get as much information as possible about the event, in the form of eyewitness testimonies, videos, pictures, maps, medical and other documentation, etc ... �Although B�Tselem tries to get a hold of all relevant information, it does not accept at face value statements by either Palestinian or Israeli sources. Therefore, it goes without saying that B�Tselem does not depend on information from the Israeli army�quite the opposite: B�Tselem often refuses to accept the military�s version of events, and this refusal has enabled it to expose many cases in which Israeli soldiers and Border Police officers unlawfully killed and injured Palestinians.� On that basis, B�Tselem�which, to reiterate, is involved in extensive, on-the-ground, forensic work on this topic�says that �approximately half� of those Palestinians killed were combatants. Derek Summerfield, an academic based in Britain, insists that such combatants make up only "a small minority." B�Tselem puts the Palestinian civilian death toll for the period under discussion at 1508. Summerfield insists it exceeds 3000. I know whose figures I would prefer to rely on. 1 Michaeli S. Response from B�Tselem. Rapid response to Freedland J. Commentary: Toughen up. http://www.bmj.com/cgi/eletters/338/feb24_2/b524#210531 Competing interests: JF is a director and trustee of Index on Censorship, which campaigns for freedom of expression. His mother was born in Palestine in 1936. Commentary: Toughen up Response from B'Tselem 13 March 2009 Sarit Michaeli, B�Tselem Communications Director http://www.btselem.org/ Send response to journal: Re: Response from B'Tselem B�Tselem�s modus operandi in cases of Palestinians killed by the Israeli security forces is to send a field worker to the scene of the killing, or if that isn�t possible, to the hospital or family home. The purpose of the field research is to get as much information as possible about the event, in the form of eyewitness testimonies, videos, pictures, maps, medical and other documentation, etc. We also try to get some basic information about the person killed (such as their full name, exact age, especially if a minor, place of residence, etc.). This is used for two primary purposes: one is B�Tselem�s casualty database, listing all victims of the conflict in the OPT (Israeli, Palestinian and International). Secondly, this information is used by B�Tselem as the basis for extensive correspondence the organization engages in with the relevant investigative bodies (primarily the Military Advocate General�s office, the Investigative Military Police and the Ministry of Justice�s Department for Police Investigations) in our ongoing work to ensure accountability where there is suspicion that the killing has been in violation of the law. B�Tselem office staff then cross-referenced the results of the field research with other sources, including official Israeli and Palestinian statements, media reports, Palestinian militant group statements, and so on. When B�Tselem is satisfied that it has determined whether a person was killed while participating in the hostilities or not, we will enter the name in our database, along with the relevant classification. If we are not sure as to the facts, or are unable to determine the legal position, we will classify them under the �not known� rubric. All data is available here: http://www.btselem.org/English/Statistics/Casualties.asp Although B�Tselem tries to get a hold of all relevant information, it does not accept at face value statements by either Palestinian or Israeli sources. Therefore, it goes without saying that B�Tselem does not depend on information from the Israeli army � quite the opposite: B�Tselem often refuses to accept the military�s version of events, and this refusal has enabled it to expose many cases in which Israeli soldiers and Border Police officers unlawfully killed and injured Palestinians. Regarding what is considered by B�Tselem to be participation in the hostilities: Broadly speaking, Palestinians employing potentially lethal force (guns, rockets, explosives, Molotov cocktails) are listed as having participated in hostilities at the time they were killed. The fact that a person carried a weapon but did not actually take it out and use it does not make that person a combatant. Likewise with regard to stone-throwing; in most situations, stone-throwing does not constitute lethal force. In those cases, where stone-throwing does indeed endanger lives (a person killed while dropping cinder blocks from a roof, for example) this is classified as participation in hostilities. As to the recent hostilities in and around the Gaza Strip, especially regarding the Palestinian police cadets who were killed in Gaza on the first day of Israel�s aerial bombardment: B�Tselem has written to the Israeli Attorney General to express its grave concerns about this and similar operations, and to demand that the decision to target the police cadets is investigated. It is clear from the following letter that B�Tselem has not accepted unconditionally Israel�s justification for the bombing: http://www.btselem.org/English/Gaza_Strip/20081231_Gaza_Letter_to_Mazuz.asp As to the issue of how many Palestinians took a direct part in hostilities, B�Tselem�s figures, broadly speaking, indicate that approximately half of the casualties of the conflict, since Sept 2000, and until the Gaza assault, were non participants. We have not yet finished the task of categorizing the enormous number of people killed in the Gaza offensive. It must be emphasized, though, that when B�Tselem lists a Palestinian casualty in its database as having not participated in the hostilities when killed, this does not indicate that those responsible for the killing necessarily violated the law, or that any other legal or moral conclusion can be drawn from the facts. It does mean, however, that Israel is obligated to hold an effective, impartial and prompt investigation to determine whether members of its security forces acted unlawfully, and to hold accountable those responsible for violations. Competing interests: B'Tselem is the Israeli Information Center for Human Rights in the Occupied Territories Commentary: Toughen up A tip for a tip 12 March 2009 Michael O'Donnell, Jorneyman writer Loxhill GU8 4BD Send response to journal: Re: A tip for a tip It was so kind of Jonathan Freedland to offer me tips on how to write I hope he won�t think it impertinent if I offer him one in return. When reviewing an article, it�s a good idea to look at, or even read, the reference the writer puts at the end of a sentence. My article [1] began: �Critics of the BMJ, and of other medical journals, sometimes complain that editorial decisions are influenced by sinister outsiders. The usual suspects are advertisers, political agencies, and academic oligarchies. Less often named as villains are lobbyists who try to suppress or distort data that might damage their cause and who seek to �silence� editors who publish those data.� I used the phrase �sinister outsiders� to echo the vernacular of the conspiracy theorists who bombard editors. (Not for the first time I wish there were a typeface, equivalent to italic, called ironic.) Freedland writes that in using the phrase, �He clearly has pro-Israel lobbyists in mind�. So clearly, Jonathan, that at the end of the paragraph I add a reference [2] which even a quick glance would reveal makes no mention of Israel. It describes an incident in which Californian �health activists�, backed by lobbyists with an alleged financial interest, mounted a campaign to pressurise the Chancellor of the University of California Davis and the Dean of its Medical School to fire the editor and deputy editor of the Western Medical Journal. Their crime? Publicising data that contradicted the lobbyists� claims. In short I was making the point Freedland himself makes that malevolent attacks on editors are not confined to pro-Israel lobbyists. I don�t know Freedland so I can�t judge whether he was being mischievous or disingenuous. I�m happy to assume he was just careless and I write now only because I�m weary of responding to correspondents who use his article as their authority for attributing to me opinions I do not hold and attitudes that are not mine. 1. O�Donnell M. Commentary: Standing up for free speech. BMJ 2009; 338: a2094 2. Wilkes M, Yamey G. PSA storm. BMJ 2002;324:431 Competing interests: As stated in my original article Commentary: Toughen up Re: Lobbying for a dream 12 March 2009 William Bilek, recently retired montreal Send response to journal: Re: Re: Lobbying for a dream Mr. Rouse's comments are inaccurate in several respects. Firstly, not all writers of letters and responses are part of a "lobby". I certainly write on my own behalf; (unless sharing a belief with hundreds of thousands of others, and expressing it, makes one a member of a "lobby".) Secondly, the state of Israel is not a "DREAM". It was a reality for a thousand years; the reality was forcibly suspended, but, over 2000 years was, and continues to be, supported by a PRAYER. Israel is a reality, once again, and is embodied in its national anthem as a HOPE (HATIKVAH). It is as Theodore Herzl said, "If you will it, it is no dream." Finally, why does it seem to so disturb Mr. Rouse that Israel claims Jerusalem, once again, as its re-newed capital? In its entire history, Jerusalem has never been the capital of anything other than a Jewish state? Does its re-newed stature as such affect the lives or well-being of Mr. Rouse, his patients, or affect his care of those patients? Competing interests: None declared

RESEARCH: Combined effects of overweight and smoking in late adolescence on subsequent mortality: nationwide cohort study Neovius et al. (24 February 2009) [Abstract] [Full text] [PDF] Combined effects of overweight and smoking in late adolescence on subsequent mortality:... Death, (indirect) taxes and chocolate 14 March 2009 Richard J Partington, Foundation Year One Doctor Manchester Royal Infirmary M13 9WL Send response to journal: Re: Death, (indirect) taxes and chocolate A recent motion, the suggestion to tax chocolate, put forward at the Scottish Local Medical Committee Conference in Clydebank created significant national publicity. Alongside this, three population based studies published in the BMJ 14/03/09, added evidence to guide physicians when advising patients regarding lifestyle choices. They related that exposure to secondhand smoke may be a factor associated with increased odds of cognitive impairment 1. That male and female smokers in all social positions had poorer survival than those who had never smoked in even the lowest social positions 2. And that mortality risk was increased in men who were both overweight and obese in late adolescence as well as in those who smoked 3. Currently beer is taxed at a rate of �16.15 per hectolitre per cent of alcohol, cigarettes at a rate of 22 per cent of the retail price plus �112.07 per thousand cigarettes and chocolate at the standard rate of VAT (15%)4. The current level of taxation is high but clearly does not diminish the enthusiasm of the general populace in the consumption of these products. A recent meta-analysis showed a significant negative correlation between alcohol tax or price and indices of sales and consumption 5. Would it be unreasonable to suggest a taxation on ALL products high in saturated fats would not produce similar results? If the levies that currently exist are purely revenue streams rather than an attempt to guide public health, perhaps they should be repealed and the wealth they generated could be replaced with fairer direct taxation. If however they are part of a desire to improve the lifestyles of the general public then surely rather than being half hearted the taxes should be raised to punitive levels that would significantly reduce rates of consumption. The opposition this move would generate would be large to say the least but so could the numbers of lives saved. 1 Llewellyn D, Lang I, Langa KM, Naughton F, Matthews F. Exposure to secondhand smoke and cognitive impairment in non-smokers: national cross sectional study with cotinine measurement. BMJ 2009;338:b42 doi:10.113/bmj.b462 2 Gruer L, Hart CL, Gordon DS, Watt, GCM. Effect of tobacco smoking on survival of men and women by social position: a 28 year cohort study. BMJ 2009;338:b480 doi10.1136/bmj.b480 3 Neovius M, Sundstrom J, Rasmussen F. Combined effects of overweight and smoking in late adolescence on subsequent mortality: nationwide cohort study. BMJ 2009;338:b496 doi:10.1136/bmj.b496 4 http://customs.hmrc.gov.uk 5 Wagenaar AC,Salois MJ Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction, Feb 2009, vol./is. 104/2(179-90), 1360-0443 Competing interests: None declared

ANALYSIS: Perils of criticising Israel Sabbagh (24 February 2009) [Full text] Perils of criticising Israel Re: Re: The Editor responds to charges of anti-Israel bias in the BMJ 13 March 2009 Fiona Godlee, Editor in chief, BMJ BMA House,Tavistock Square, London WC1H 9JR Send response to journal: Re: Re: Re: The Editor responds to charges of anti-Israel bias in the BMJ The rapid response posted in 2003 containing the comment "Israel is a pariah nation" has today been removed from bmj.com.[1] I agree that this was a purely political statement that did not add substance to the topic under discussion, which was the disputed appointment of Dr Yoram Blacher as president of the World Medical Association. Dr Hasleton suggests that the data presented in my 11 March rapid response above are unsound because we did not include Israel as a search term. While reiterating my view expressed earlier that these data are crude and are intended only to answer the criticism of bias levelled against the journal, we have repeated the search presented in table 2 with "Israel" as a search term. This reduces the proportion of PubMed articles referring to the conflict in Israel and Palestine that were published in the BMJ. Since January 2004 there were 804 articles published in PubMed for the search (israel OR palestin* OR gaza OR �west bank�) AND (war OR casualt* OR disaster OR civilian OR violen* OR humanitarian OR "human right*" OR crisis OR refugee), of which 19 appeared in the BMJ: 2.3% compared with the 5.7% reported in my rapid response. 1. http://www.bmj.com/cgi/eletters/327/7414/561#36333 Competing interests: I am the editor of the BMJ and am responsible for its content Perils of criticising Israel Re: The Editor responds to charges of anti-Israel bias in the BMJ 13 March 2009 Jonathan Hasleton, Cardiology Research Fellow University College London, WC1E 6HX Send response to journal: Re: Re: The Editor responds to charges of anti-Israel bias in the BMJ Godlee's response to her critics is disingenuous. In her attempt to try and prove any lack of 'anti-Israel bias' at the bmj she fails to use 'Israel' as a search term. Godlee calls this 'crude' data, I would call it unsound data. Although Godlee claims to champion publication ethics, she has failed to respond adequately to concerns raised about the integrity of data in a number of papers/editorials in the bmj written by Rytter, Summerfield, Sabbagh and Delamothe. However undesirable the publication of unsound data is, the consequences of such publication are made far worse by the subsequent failure of the people involved to react appropriately to valid concerns and correct the scientific record where necessary. (1) Godlee and Delamothe fail in a number of their responsibilities as laid down by the Committee on Publication Ethics.(2) The integrity of the academic record of the bmj remains in question as does the bias shown by Godlee and Delamothe. It may be that anti-Israel bias is the least of their worries when a simple search for the term 'Israel' on their website brings up a comment that 'Israel is a pariah nation, and its representatives have no place in 21st century society.'(3) This is not anti-Israeli, rather antiSemitic. This is a far more serious charge and one that ought to be dealt with independent of the Editors of the bmj. Yours sincerely, Dr Jonathan Hasleton (1)Godlee F. Dealing with editorial misconduct. BMJ 2004 Dec 4;329(7478):1301-2. (2)Committe on Publication Ethics Code of Conduct. http://publicationethics.org/code-conduct. Accessed 12/3/2009. (3)http://bmj.com/cgi/eletters/327/7414/561#36333, 6 Sep 2003 Competing interests: Jew, Zionist and Fully paid member of BMA Perils of criticising Israel Re: Diabetes in Gaza: Getting the Facts Correct 12 March 2009 Tony Delamothe, deputy editor, BMJ BMA House, London WC1H 9JR Send response to journal: Re: Re: Diabetes in Gaza: Getting the Facts Correct Professor Zimmet writes that the use of "Diabetes Voice" as an example was inappropriate "as the actual facts surrounding the incident belie the way this has been used." Most of the details of this incident are in the public domain.[1] What the International Diabetes Federation's apology doesn't say is that it was subject to an orchestrated email campaign against the offending paragraph. A spokesperson confirmed that it received hundreds of similarly worded emails, many including text drafted by NGO Monitor (still available on its website.[2]) When it comes to the offending paragraph that cost Philip Home his editorship of Diabetes Voice, I accept that there may have been one substantial error. Instead of reading "In 1948, according to the UN Conciliation Commission, 760000 Palestinians were evicted from their cities and villages, hundreds of which were razed to the ground," the correct wording would have been, "In 1948, according to the UN Conciliation Commission, 711 000 Palestinians were either evicted from or fled their homes." Regarding the third accusation: try as I might I can't see what's problematical about the use of the term "Palestinian people's land" to refer to land that Palestinian people have been living on for hundreds of years. [1] L�febvre P, Silink M, Home P. Editor�s note�an apology. Diabetes Voice 2004;49(3):17. [2] http://www.imra.org.il/story.php3?id=21620 Competing interests: I co-authored the editorial, "What to do about orchestrated email campaigns" Perils of criticising Israel Lies and facts about the conflict 12 March 2009 A Sabra, EM UHBristol NHS Trust Send response to journal: Re: Lies and facts about the conflict Follow the link for more facts about the conflict: http://mitworld.mit.edu/video/645 Yet,if you continue to doubt, you should go and see the facts with your bare eyes just like O'Hara1 did. 1.http://www.bmj.com/cgi/eletters/338/feb24_2/a2066#210323 Competing interests: None declared Perils of criticising Israel Re: The fallacy of some democracies 12 March 2009 Sheila F Raviv, Retired home 96956 Send response to journal: Re: Re: The fallacy of some democracies Israel is a democracy and in her Capital City Jerusalem 52 Christian denominations and 6 Moslem denominations live side by side with the great variety of Jewish opinion and belief. Israel has a specific clause in her constitution declaring freedom of prayer to all faiths. I would ask the writer which other country in the entire region has a record of religious freedom which compares. Why is it considered undemocratic for Israel to declare herself a Jewish State when every other country in the region declares itself a Moslem State? Competing interests: None declared Perils of criticising Israel More on the fallacy of some democracies 12 March 2009 Bassem R Saab Saab, Professor of Family Medicine American University of Beirut, P.O.Box 11-0236 Send response to journal: Re: More on the fallacy of some democracies I am pleased to see that Sabbagh�s article is creating strong emotions and diverse discussions. Yesterday I noted the response of my colleague Dr. Bernstein to what I have written. Dr. Bernstein introduces himself as a �Jewish, Zionist, son of a Holocaust survivor and supporter of 2 state solution to the Israel-Palestine conflict�. I agree with him that Lebanon is not a perfect democracy (even far from democracy). In fact perfect democracy, in my opinion, can be found only in dictionaries and may be in few countries. Dr. Bernstein believes that Palestinians have the right to vote in Lebanon. The Palestinians in Lebanon are registered under the United Nations Relief and Works Agency (UNRWA). This means that they are refugees who were expelled by force from their towns and villages in Dair Yasin, Haifa, Jerusalem, and many others. I agree with Dr. Bernstein that the Palestinians should have the right to vote, but we disagree on where they should vote. The UN gives the Palestinians the right to return to their homes where they should have access to the ballot box. In my life time I have witnessed several massacres perpetuated in the name of religions and Zionism in Lebanon. The end to suffering may be achieved by separating religion from state affairs in Lebanon and everywhere. I support a one secular state solution where Jews, Moslems, Christians, atheists, and others enjoy equal rights and duties. Competing interests: None

NEWS: Obama’s stimulus package includes funds for public health, nutrition, and effectiveness research Tanne (23 February 2009) [Full text] Obama’s stimulus package includes funds for public health, nutrition, and effectiveness... Universal Healthcare 13 March 2009 Hugh Mann, Physician Eagle Rock, MO 65641 USA Send response to journal: Re: Universal Healthcare Universal healthcare is more than a noble ideal; it is a sine qua non of modern civilization. While the financial costs must be borne fairly by everyone, the key ingredient is the personal responsibility of the patient, who must maintain a healthy lifestyle, free of all self-destructive habits, such as alcohol, tobacco, and junk food. Universal healthcare needs universal self-care. Competing interests: None declared

RESEARCH: Combined effect of health behaviours and risk of first ever stroke in 20 040 men and women over 11 years’ follow-up in Norfolk cohort of European Prospective Investigation of Cancer (EPIC Norfolk): prospective population study Myint et al. (19 February 2009) [Abstract] [Full text] [PDF] Combined effect of health behaviours and risk of first ever stroke in 20 040 men... Life style and Risk of Stroke 14 March 2009 Rizaldy Pinzon, Neurologist Bethesda hospital Yogyakarta Indonesia 55224 Send response to journal: Re: Life style and Risk of Stroke This study confirm that smoking, drinking too much alcohol, and eating few vegetables and little fruit contribute to the chances of a stroke. Stroke is the most leading cause of death and disability. The incidence of stroke is rapidly increase in many developing countries. The lifestyle changes is commonly observed in developing countries. This study remind us that even small changes to our lifestyle factors, such as an improved diet, drinking alcohol in moderation, not smoking and being active, can reduce the risk of stroke. Changes in lifestyle relating to tobacco and diet might make important contributions to further reductions in the incidence of stroke. The future study should analyze subgroup without alcohol consumption. In many developing countries, alcohol consumption was not very common. This study is very helpful for the clinicians to make an advice for the high risk population for reducing the burden of stroke. Competing interests: None declared

OBSERVATIONS: "Nothing is too good for ordinary people" Heath (17 February 2009) [Full text] "Nothing is too good for ordinary people" Iona Heath & the Finsbury Health Centre 13 March 2009 Wendy D Savage, Retired SL in O&G;, Wolfson Institute, QMUL EC1 Send response to journal: Re: Iona Heath & the Finsbury Health Centre Iona Heath as ever gets to the kernel of the problem rergarding the restructuring of the NHS. PCTs are unelected and largely unresponsive to the population they serve and they are controlled, one might even say bullied by the Department of Health. The indecent haste to impose polyclinics in every PCT ignoring the perfectly good services that already exist as in the historic Finsbury Health Centre makes a mockery of the prinicples that Ara Darzi stated would guide the implementation of his proposals-locally driven, clinically led and no services would be closed until the alternatives were ready. I attended and addressed the meeting where the PCT explained their plans for selling this historic grade 1 listed building and rehousing the two GPs in a new building by demolishing an existing building they do not yet own in a conservation area where they may not get planning permission to do this. The proposed plans for the relocation of the other services were sketchy and probably unworkable. The many architects present and English Heritage presented a powerful case for refurbishing the building including one who had done the partial upgrading in the early 1990s who refuted their contention that a lift could not be installed. It is clear that they want to seel to a developer to make money regardless of the views of the public they are supposed to serve. Every doctor should find out what is happening in her or his area by ensuring that someone attends the PCT and Overview and Scrutiny meetings (I am sure there are retired doctors who could do this) to find out what is planned and point out the deficiencies of the process if they are as evident as they are in Islington. Keep Our NHS Public (KONP) sees the underlying problem as the government's obsession with using PFI to encourage private companies into the health field, and increasing competision by using ISTCs and now US corporations to provide GP services. There is no doubt that these new and often unnecessary and usually unwanted and inappropriate polyclinics are being forced through in a ridiculouly short time scale. They are not evidence based and need to be resisted. We would appreciate any information about these plans which can be sent to konpadmin@keepournhspublic.com. Do visit our website www.keepournhspublic.com and join us either as individuals or by getting your BMA Division to affiliate. Remember that at the ARM in 2006 a motion to support the aims and principles of KONP was passed and this support was reaffirmed in 2008 in motion 33. Competing interests: Co-chair of Keep Our NHS Public

ANALYSIS: Patient and public involvement in chronic illness: beyond the expert patient Greenhalgh (17 February 2009) [Full text] Patient and public involvement in chronic illness: beyond the expert patient Patient as a partner in care 14 March 2009 Billy Boland, Consultant Psychiatrist Hertfordshire Partnership Foundation Trust, St Albans, AL1 1NG Send response to journal: Re: Patient as a partner in care Prof Greenhalgh's analysis of lay person involvement in the management of chronic disease rightly challenges the evidence behind health policy changes from the Department of Health with the extension of expert patient programmes. However a focus on treatment efficacy diverts attention from important changes in relationship between healthcare providers and patients such programmes represent. Innovative treatment strategies including the disease management programmes highlighted in the article have promoted a new dialogue between service users and health care providers, deepening their understanding of each other. The recovery model of mental health care draws on each of the four approaches outlined by Greenhalgh of patient and public involvement. It is recognised as good practice for modern mental healthcare provision, recommended by mental health think tanks such as the Sainsbury Centre (1) and incorporated as strategy into the business plans of Mental Health Trusts. Efficacy is still being explored, but experience suggests recovery methods have benefits. Elements which involve changes in style of practice, such as a transition over the course of recovery from the practitioner as expert to practitioner as coach or mentor, may develop patients engagement with their conditions and their health service providers. Whilst efficacy may be an important outcome measure for examining chronic illness approaches, other dimensions including patient satisfaction and engagement with health services, as well as empowerment through education may be valuable if costs are limited. Improvements in these areas could develop patient's trust of services and perhaps lead to better uptake and utilisation of interventions that have more recognised efficacy. 1 Shepherd, G., Boardman, J., Slade, M., Making Recovery a Reality, Sainsbury Centre for Mental Health, 2008 Competing interests: None declared Patient and public involvement in chronic illness: beyond the expert patient Curious priority 13 March 2009 Martin W McNicol, retired (former physician) HU17 8HP Send response to journal: Re: Curious priority Would it not be better if we had the patient's view first before all of the others, particularly in an issue carrying Greenhalgh's article on rethinking patient involvement? Competing interests: None declared

RESEARCH: Resting heart rate as a low tech predictor of coronary events in women: prospective cohort study Hsia et al. (3 February 2009) [Abstract] [Full text] [PDF] Resting heart rate as a low tech predictor of coronary events in women: prospective... Heartbeat Bank 14 March 2009 Peter AF Watson, General Practitioner Links Medical Practice Aberdeen AB24 5AU Send response to journal: Re: Heartbeat Bank I read with interest Hsia et al's(1) research on resting heartbeat in women as a low tech predictor of coronary events. One of my patients is an engineer. His mechanistic view of the heart leads him to believe that humans only have so many predetermined heart beats. When they are all used up we die. Clearly fitter healthier people have a lower resting heart rate and so live longer. 1 Hsia et al. Resting heart rate as a low tech predictor of coronary events in women: prospective cohort study. BMJ 2009; 338:b219 Competing interests: None declared Resting heart rate as a low tech predictor of coronary events in women: prospective... What about absolute risks? 13 March 2009 Michael J Campbell, Professor of Medical Statistics Medical Statistics Group, ScHARR, University of Sheffield S1 4DA Send response to journal: Re: What about absolute risks? It is a fundamental principle in public health that one should never quote a relative risk without also giving the absolute risk1. Failure to follow this simple precept results in the weekly health scares that engage the popular press, when an increased relative risk is taken as a threat to the individual. Hsia et al2 flagrantly ignore this principle when they claim that �resting heart rate� independently predicts myocardial infarction or coronary death in women�. They base this assertion on a hazard ratio of 1.26 (95% CI 1.11 to 1.42) for these events in women above the top quintile for heart rate compared to women below the bottom in a cohort of women. They do not quote absolute risks. Based on some simplifying assumptions (equating hazard rate to relative risk, assuming total events in lower fifth and upper fifth is proportional to the number of subjects in these groups) I estimated that the absolute risk of myocardial infarction or coronary death in the 7.8 years of follow up for a woman to be 0.0194 for those in the top fifth, and 0.0154 in those in the bottom fifth. This equates to an absolute difference of 0.4% or a NNTH of 250 (95% CI 167 to 539). In other words, in those we deemed at a higher risk, out of 250 women only one extra woman would have an event in about 8 years. This is not what the public think of as a 'predictor'. Those in the top fifth should not be unduly concerned. 1. Campbell MJ, Machin D and Walters SJ. Medical Statistics : A Textbook for the Health Sciences. (4th Ed) Chichester: John Wiley & Sons 2007, p24 2. Hsia J, Larson JC, Ockene JK, Sarto GE, Allison MA, Hendrix SL, Robinson J, LaCroix AZ, Manson J.Resting heart rate as a low tech predictor of coronary events in women: prospective cohort study. BMJ 2009;338:b219 doi:10.1136/bmj.b219 Competing interests: None declared Resting heart rate as a low tech predictor of coronary events in women: prospective... Not every stress is evil - about heart rate and shear stress 13 March 2009 Christian Seiler, Professor of Medicine; Co-Chairman of Cardiology University Hospital Bern, 3010 Bern, Switzerland, Pascal Meier, Steffen Gloekler, Tobias Traupe, Stefano de Marchi Send response to journal: Re: Not every stress is evil - about heart rate and shear stress We would like to commend Hsia J. et al.(1) on their very interesting and well done study demonstrating a predictive role of heart rate (HR) on mortality which is confirming previously published observations. Despite this consistency, such observational studies generally entail the difficulty to untangle cause from association. A plausible underlying mechanism certainly would invigorate causality. Previously, authors hypothesized that increased HR could damage heart and vessels due to increased shear forces. Indeed, we strongly suggest that shear forces play an underlying role, but in the opposite direction. The common misconception of a negative effect of shear stress requires revision. Low HR comes along with increased stroke volume and prolonged diastole. The resulting increased shear stress in turn stimulates arterial growth in general and collateral growth in particular and reduces atherosclerotic progression. (2-4) These pro-arteriogenic and anti-atherogenic processes distinctively improve long-term outcome.(5) Consequently, we hypothesize that the association of outcome and HR is causal rather than casual, and it may be mediated by higher shear stress on coronary endothelial cells. However, in order to corroborate causation, interventional studies have to follow. What if we change HR long term, do we influence mortality? Trials inducing HR reduction by different means in order rule out direct or confounded influence of the intervention on outcome are meaningful. References 1. Hsia J, Larson JC, Ockene J, Sarto GE, et al. Resting heart rate as a low tech predictor of coronary events in women: prospective cohort study. BMJ 2009 338(b219 ). 2. Seiler C, Kirkeeide RL, Gould KL. Basic structure-function relations of the epicardial coronary vascular tree. Basis of quantitative coronary arteriography for diffuse coronary artery disease. Circulation 1992;85(6):1987-2003. 3. Pipp F, Boehm S, Cai WJ, Adili F, et al. Elevated fluid shear stress enhances postocclusive collateral artery growth and gene expression in the pig hind limb. Arterioscler Thromb Vasc Biol 2004;24(9):1664-8. 4. Traub O, Berk BC. Laminar shear stress: mechanisms by which endothelial cells transduce an atheroprotective force. Arterioscler Thromb Vasc Biol 1998;18(5):677-85. 5. Meier P, Gloekler S, Zbinden R, et al. Beneficial effect of recruitable collaterals: a 10-year follow-up study in patients with stable coronary artery disease undergoing quantitative collateral measurements. Circulation 2007;116(9):975-83. Potential Financial Conflicts of Interest: None. Competing interests: None declared

RESEARCH: Outcome of depression in later life in primary care: longitudinal cohort study with three years’ follow-up Licht-Strunk et al. (2 February 2009) [Abstract] [Full text] [PDF] Outcome of depression in later life in primary care: longitudinal cohort study with... Who is older, 55 or 65? 14 March 2009 Dr Qaiser Javed, Core trainee level 1(Psychiatry) Clatterbridge Hospital,CH63 4JY Send response to journal: Re: Who is older, 55 or 65? Without any doubt, this study is very impressive & I appreciate Lich-Stunk et al for their detailed longitudinal cohort study in primary care setting. What I strongly believe that in order to get good number of patients they have included patients aged 55 in the group of older people or probably they have not done the power calculation prior to that study otherwise they would have got the results with significant difference statistically in table 2 (Univariable & multivariable Cox survival analyses for potential predictors of no recovery from major depressive disorder, measured at baseline with follow up for three years). Ideally they should have included patients aged 65 or more in order to consider older patients in this study or preferably aged 75 or more to get clear picture of possible outcome of depression in older patients in primary care. Reference 1. E Licht-Strunk, H W J Van Marwijk, T Hoekstra, J W R Twisk, M De Haan, and A T F Beekman. Outcome of depression in later life in primary care: longitudinal cohort study with three years� follow-up. BMJ 2009; 338: a3079 Competing interests: None declared

OBITUARIES: Roger Patrick Doherty Elliott (2 September 2008) [Full text] Roger Patrick Doherty Memorable leadership in an emergency 13 March 2009 Raj Bhopal, Prof of public health Medical School, Teviot place, University of Edinburgh, EH8 9AG Send response to journal: Re: Memorable leadership in an emergency I was a surgical house officer at St Bernard Hospital and I would like to share an abiding memory. Late one evening about six men were rushed to the emergency department, having almost drowned in sewage, after the scaffolding collapsed in the sewer they were repairing. These men were at death's door. There was an emergency call-out for all medical staff to assist. Although Doctor Doherty was not the consultant on call, on his arrival he appraised the situation and the evident need for his leadership. He took charge, and the frantic activity prior to his arrival, became purposeful and directed. He was a fine consultant and a great example to the juniors. Competing interests: None declared

PRACTICE: Obesity and pregnancy Stotland (15 December 2008) [Full text] Obesity and pregnancy Anaesthetic Considerations 12 March 2009 Jeremy A Stone, Specialist Registrar in anaesthetics Leicester Royal Infirmary, LE1 5WW Send response to journal: Re: Anaesthetic Considerations Stotland writes an excellent article about the risks of obesity inpregnancy and correctly points out some of the anaesthetic implications [1]. However to suggest that failed intubation and aspiration are frequent contributors to maternal anaesthetic deaths is a little misleading. in the last CEMACH report (confidential enquiry into maternal and child health) there were no deaths from unrecognised oesophageal intubation at Ceasarean section for which we are all thankful [2]. There were anaesthetic deaths due to respiratory failure post-operatively in obese women but these were due to suboptimal management of their condition, not failed intubation or aspiration. Whilst epidural analgesia and anaesthesia are indeed more difficult in the obese parturient one recent study demonstrated that a BMI of over 35 was not a risk factor for failure of conversion of labour epidural analgesia to epidural anaesthesia for Caesarean section [3]. Why might this be? Anaesthetists are highly actively involved in the management of obese parturients. This ranges from seeing women with a booking BMI of over 40 in the anaesthetic clinic all the way to ensuring the adequacy of a labour epidural. The ultimate aim is to avoid the scenario of of either an obese or morbidly obese woman presenting for an operative delivery, out of hours, with either a poorly functioning or non existant epidural necessitating a general anaesthetic and all the associated airway risks. So far we are doing well but ongoing further effort is required as this population's BMI continues to rise. [1] Stotland NE. Obestiy and Pregnancy. BMJ 2009;337:107-110. [2] Lewis, G (ed) Saving Mothers Lives: reviewing maternal deaths to make motherhood safer - 2003-2005. The seventh report on confidential enquiries into maternal deaths in the United Kingdom. London: CEMACH [3] Halpern SH, Soliman A, Yee J et al. Conversion of epidural labour analgeisa to anaesthesia for Caesarean section: a prospective study of the incidence and determinants of failure. BJA 2009;102 240-243 Competing interests: None declared

EDUCATION AND DEBATE: Systematic reviews in health care: Systematic reviews of evaluations of diagnostic and screening tests Deeks (21 July 2001) [Full text] [PDF] Systematic reviews in health care: Systematic reviews of evaluations of diagnostic... Corrected Correction 14 March 2009 William T Stevenson, Consultant Radiologist Royal Lancaster Infirmary LA1 4RP Send response to journal: Re: Corrected Correction This is hardly a Rapid Response, being 8 years overdue. The correction, prompted by readers and the author, leaves the impression that the sensitivity is given by (false positives)/(true negatives + false positives), whereas it was correctly stated in the original article as (true negatives)/(true negatives + false positives). The problem arises because the points to be plotted have been calculated from the false positive fraction. The correction should really be corrected to make it clear that it is (1-sensitivity) that is being plotted. What is really required is a new figure 2. Competing interests: None declared