bmj.com Rapid Responses published in the past 6 days

RAPID RESPONSES

Think of Rapid Responses as electronic letters to the editor.

To RESPOND to a particular article: Click on the link 'Respond to this article' in the box at the top left hand corner of the article.

To READ responses to a particular article: Click on the link 'Read responses to this article' in the box at the top left hand corner of the article.

All responses published in the past 6 days are shown below. You can also read responses published in the past 2, 3, 4, 5, 6, 7, 14, or 21 days.

Rapid Responses published in the past 6 days:

100 Rapid Responses published for 55 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)
Needless convolutions
peter j mahaffey   (11 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)
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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)
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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)
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NEWS:
Canadian doctors admit earning thousands in trial recruitment fees
Spurgeon (6 March 2009) [Full text]

Informing research subjects regarding accrual dollars.
Frederic W. Grannis   (11 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)
Hypoglycemia in the patients with long lasting T2DM
Gauranga C. Dhar   (11 March 2009)
Aim for good evidence based targets
Rupert A Gude   (11 March 2009)
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RESEARCH:
Adverse drug reactions to tocolytic treatment for preterm labour: prospective cohort study
de Heus et al. (5 March 2009) [Abstract] [Full text] [PDF]

Adverse drug reaction of Tocolytics in India
Vikas Dhikav, et al.   (11 March 2009)
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EDITORIALS:
Tocolytics and preterm labour
Carlin et al. (5 March 2009) [Full text]

Physiology and neonatal transition
David JR Hutchon   (9 March 2009)
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EDITOR'S CHOICE:
Ethics checklists and sharing patients’ information
Godlee (5 March 2009) [Full text]

Ethics in USA v UK
Christopher William Frith   (11 March 2009)
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NEWS:
Sexual violence must be treated as medical emergency, charity says
Wise (5 March 2009) [Full text]

Correction
Lucy J Clayton   (9 March 2009)
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OBSERVATIONS:
Rethinking ward rounds
Sokol (4 March 2009) [Full text]

RN's and Ethics
Caron E. Lumpkin   (14 March 2009)
Mostly Capacity Act requirements, not ethics
Nick J Woodhead   (11 March 2009)
need to 'get ethics'
Angela Fenwick, et al.   (10 March 2009)
Author's response
Daniel K Sokol   (10 March 2009)
Re: Sokols' Stamp
David R Warriner   (10 March 2009)
Better understanding of the purpose of the checklist
Nneka O Mokwunye   (9 March 2009)
Read every Rapid Response to this article

ENDGAMES:
Non-parametric tests
Fletcher (5 March 2009) [Full text]

Answers to nonparametric tests
Michael J Campbell   (11 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)
Re: One more tragedy and one more inquest!
Bridget L Reeves   (9 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)
Supporting for these inappropriate interventions may be weaker than it seems.
C Kevin Connolly   (11 March 2009)
Impact of Polypharmacy on senior citizens
Ediriweera Desapriya   (10 March 2009)
It's the patient's decision
Graeme Mackenzie   (10 March 2009)
Helping elderly individuals to understand the aging process.
Les O. Simpson   (9 March 2009)
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EDITORIALS:
Amendments to the Coroners and Justice Bill
Nathanson (3 March 2009) [Full text]

Trust already gone
Graeme Mackenzie   (10 March 2009)
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LETTERS:
Pay attention to the first week
Campbell (3 March 2009) [Full text]

Reflect on earlier studies
Ann M Wylie   (10 March 2009)
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RESEARCH:
Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study
Ekeberg et al. (23 January 2009) [Abstract] [Full text] [PDF]

Management of suspected rotator cuff disorders in general practice
Ramon PG Ottenheijm, et al.   (9 March 2009)
Read every Rapid Response to this article

RESEARCH:
Abuse of people with dementia by family carers: representative cross sectional survey
Cooper et al. (22 January 2009) [Abstract] [Full text] [PDF]

Doctors need to engage in education and research in elder abuse
Kit M Tan, et al.   (11 March 2009)
Inadequate training: the elephant in the room.
Alexander M Thomson   (10 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? Yes
Gubb (16 January 2009) [Full text]

Patients helped by targets
Rupert A Gude   (11 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

OBSERVATIONS:
What should the US surgeon general do?
Kamerow (13 January 2009) [Full text]

Mandatory discharge from physician care and the metabolic testing of drivers
Richard G Fiddian-Green   (9 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

FEATURE:
Bad blood: gay men and blood donation
Hurley (26 February 2009) [Full text]

Dated attitudes
Benjamin W. Molyneux   (9 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)
Lobbying for a dream
A Rouse   (10 March 2009)
Freedland is made of more resolute protoplasm than I.
A Rouse   (9 March 2009)
Read every Rapid Response to this article

EDITORIALS:
What to do about orchestrated email campaigns
Delamothe and Godlee (24 February 2009) [Full text]

Rx for Feuds
Hugh Mann   (10 March 2009)
My 5 year follow up - a personal response.
Liz Lightstone   (9 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:
Commentary: Standing up for free speech
O’Donnell (24 February 2009) [Full text]

Extremism can be frightening
David Isaacs   (9 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)
The Editor responds to charges of anti-Israel bias in the BMJ
Fiona Godlee   (11 March 2009)
Diabetes in Gaza: Getting the Facts Correct
Paul Z Zimmet   (10 March 2009)
Wolf in Sheeps Clothing
Shawn Malachovsky   (10 March 2009)
To Tony Delamothe Re his rapid response
Elliot Daniel   (9 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

PRACTICE:
Coeliac disease
Jones and Sleet (19 February 2009) [Full text]

Undiagnosed maternal celiac disease in pregnancy and an increased risk of fetal growth restriction.
Fergus P McCarthy, et al.   (11 March 2009)
Read every Rapid Response to this article

NEWS:
Older Americans are not as healthy as older Europeans, study says
Tanne (18 February 2009) [Full text]

Is this study valid ?
Alexander Spiers   (9 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

LETTERS:
Interpreting the rights in the NHS constitution
Heaver and Wainwright (17 February 2009) [Full text]

Jumping off the Merry-go-round
Russell Mayne, et al.   (11 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

PRACTICE:
A 38 year old woman with hypotensive shock at the onset of menstruation: case progression
Serrano Villar et al. (16 February 2009) [Full text]

Re: Toxic shock syndrome
Martin Ferry   (11 March 2009)
Recurrent collapse and hypotension
Plutarco Elias Chiquito   (11 March 2009)
Read every Rapid Response to this article

RESEARCH:
Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)
Williams et al. (10 February 2009) [Abstract] [Full text] [PDF]

Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)
John G. Williams, et al.   (10 March 2009)
More of the same...ho hum
Teresa T. Goodell   (9 March 2009)
Read every Rapid Response to this article

EDITORIALS:
Nurse delivered endoscopy
Norton et al. (10 February 2009) [Full text]

Doctors and Nurses: Delivering endoscopy
Said F Mishriki   (9 March 2009)
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EDITOR'S CHOICE:
Doctors, patients, and the drug industry
Godlee (5 February 2009) [Full text]

Potential conflicts of interest: more information from JAMA
Sharon Davies   (11 March 2009)
Read every Rapid Response to this article

NEWS:
Nine patients are killed as hospital is caught in cross fire in Sri Lankan war zone
Bland (3 February 2009) [Full text]

which Hospital?
Thilli Nathan   (11 March 2009)
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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)
Resting heart rate, blood viscosity and ejection fraction.
Leslie O Simpson   (11 March 2009)
Read every Rapid Response to this article

RESEARCH:
Vulnerability and access to care for South Asian Sikh and Muslim patients with life limiting illness in Scotland: prospective longitudinal qualitative study
Worth et al. (3 February 2009) [Abstract] [Full text] [PDF]

Authors' response Re: The Ethics of Research and Accusations of Racism
Aziz Sheikh, et al.   (9 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

Tissue screening after breast reduction
Needless convolutions 11 March 2009

peter j mahaffey,
consultant plastic surgeon
bedford hospital mk42 9dj
Send response to journal:
Re: Needless convolutions

This paper has 7 authors and a further 3 have been recruited to comment. Everyone seems to tying themselves in knots in a self-imposed dilemma which is practical and does not merit being elevated into the nebulous and often self-indulgent world of ethics.
The operation of breast reduction is not a cosmetic one, at least certainly not when NHS resources are expended on it, and its unfortunate that at least 2 of the commentators are not well enough informed to appreciate that the benefits are intended to be functional. Moreover, outcome studies show that the results rate higher in quality and patient satisfaction outcomes (QUALYS)than a whole host of apparently meritorious general surgical procedures.
As the original 7 authors state, breast tissue has always been sent for histology. The figures they quote show that this intercepts a breast cancer for every 250 operations. Most plastic surgeons will, when briefing a patient about the procedure, inform her that the tissue is routinely sent for analysis. What woman would refuse? And what surgeon would wantonly discard the tissue?
Only Treasure, in his commentary, identifies the real issue, namely one of evidence. What we do not know is the long-term fate of that group of patients who were unexpectedly found to have a tumour, and whether it varies from a control group of women with breast cancer. We also need to address the issue that if tissue is to be analysed, then it needs to be sent to the histologist in a form which enables the most useful reporting of the results. That should be self-evident with any pathology specimen.
Finally, its simply not true for the lay commentator to suggest that the patient whose case history forms the basis of the article went through years of possibly un-necessary misery. The pattern of her treatment really doesn't depart from that which might have been offered for any patient found to have this diagnosis.
The question which we clinicians, who like to think we take a scientific approach to medicine, must ask is whether we really do the patient good by the interventions we offer. We must ALWAYS be asking ourselves this question. I, for example, shudder with horror and embarrassment, to recall all the gastrectomies and vagotomies I performed during my general surgical training, only for a wonderfully determined Australian gastroenterologist (Barry Marshall) to show subsequently that gastric ulceration is infective in origin.That should be a lesson to us all.
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

NEWS:
Canadian doctors admit earning thousands in trial recruitment fees
Spurgeon (6 March 2009) [Full text]

Canadian doctors admit earning thousands in trial recruitment fees
Informing research subjects regarding accrual dollars. 11 March 2009

Frederic W. Grannis,
Assoc Prof. Thoracic Surgrey
City of Hope National Medical Center 1500 E. Duarte Road, Duarte CA 91010 U.S.A
Send response to journal:
Re: Informing research subjects regarding accrual dollars.

Spurgeon provides a good service by notifying BMJ readers of the potential conflict of interest involved when physicians accept money for accruing their patients into research trials. Such dollars are provided to compensate physicians for the work and expense involved to their practices doing this research work. There are a few points that he does not discuss in his letter.
First, at most institutions, institutional review boards do not mandate that research study subjects be informed of the fact that their doctor is being paid to accrue them into a research study. I believe that such disclosure should be an integral part of the informed consent process.
Second, for physicians in an academic research setting, accrual dollars are the coin of success, since they not only allow them to stock their academic discretionary accounts but also provide substantially larger amounts of accrual dollars to their research center. Accordingly, accrual numbers and dollars play a large role in decisions about continued employment and academic promotion within the medical center.
Third, accrual numbers foster national recognition and prominence within regional and national research organizations.
Finally, substantial accrual activity will predictably lead to contacts with pharmaceutical companies with lucrative inclusion on speakers bureaus etc..
Accordingly, research study accrual is a double-sided coin, good for progress in science and medicine, but offering challenges to methods of managing potential conflicts of interest.
Competing interests: I have one paid accrual of a research study subject into a clinical trial sponsored by Glaxo Smith Kline

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
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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
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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
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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
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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

Tight control of blood glucose in long standing type 2 diabetes
Hypoglycemia in the patients with long lasting T2DM 11 March 2009

Gauranga C. Dhar,
Family physician and teacher of Bangladesh Institute of Family Medicine and Research.
Bangladesh Institute of Family Medicine and Research, USTC.01209
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Re: Hypoglycemia in the patients with long lasting T2DM

ACCORD, ADVANCE and VADT trials showed that intensive glycemic control leads to increased incidence of cardiovascular (macrovascular) outcomes.
I think hypoglycemia may play a key role for these vascular events. In normal individuals, hypoglycemia activates sympatho-adrenal system with counter regulatory hormone secretion to balance the situation. In patient with long lasting T2DM who have already developed severe endothelial dysfunction, acute hypoglycemia leads to severe haemodynamic changes leading to major vascular events.
Physicians should be cautious about the glycemic control for the patient of long lasting hyperglycemia.
Competing interests: None declared

Tight control of blood glucose in long standing type 2 diabetes
Aim for good evidence based targets 11 March 2009

Rupert A Gude,
VSO doctor
Kagondo Hospital, Kagera, Tanzania
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Re: Aim for good evidence based targets

Thank you Dr Lehman and Dr Krumholz for an excellent reasoned evidence based article arguing for the retention of the Hbaic level of 7.5. I hope the managers take note.
However to create change in directives, the managers need to be given an alternative target. This could quite simply be '60% of the diabetics to acheive an Hbaic of 7.5'.
On a practical note to those General Practitioners who are struggling to reach these targets they could try screening for diabetes in their overweight hypertensive population (with a predicted pick up rate of about 1 in 6)and thus increase their known diabetic population with mild diabetics whose HBaic is often below 7.5.
I make no predictions about whether their profession of good quality care will lead to them to arrange intensive motivation of these early diabetics to exercise and lose weight.
Competing interests: None declared

RESEARCH:
Adverse drug reactions to tocolytic treatment for preterm labour: prospective cohort study
de Heus et al. (5 March 2009) [Abstract] [Full text] [PDF]

Adverse drug reactions to tocolytic treatment for preterm labour: prospective cohort...
Adverse drug reaction of Tocolytics in India 11 March 2009

Vikas Dhikav,
Senior Research Officer
All India Institute of Medical Sciences, New Delhi-110029, INDIA,
Richa Gupta, Gynecologist, Gaziabad (UP)
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Re: Adverse drug reaction of Tocolytics in India

We read the article by de Heus1 with interest. They have studied prospectively, 1920 women in 28 hospitals and have come up with interesting conclusions. We feel that in India ritodrine, terbutaline and isoxsuprine remains to be the major tocolytics. Hundreds of thousands of women in preterm labour are given these drugs on daily basis. Though, obstetricians using these drugs say that "theoretically, there are many side effects; but practically we do not see many side effects". The side effects which many obstetricians feel are palpitations, restlessness but are not of �serious� nature etc. Routine monitoring of potassium levels is not done. Hypotension, arrhythmias and worsening of ischemic heart disease are rarely seen. Indeed, few studies have reported no significant adverse effects of ritodrine, a beta-2 agonist used for premature labour2. This makes a fit case to initiate the intensive monitoring of side effects of tocolytics in India. We feel that we need to look at the side effect profile of tocolytics in india more closely.
References
1. de Heus R, Mol BW, Erwich JJ, van Geijn HP, Gyselaers WJ, Hanssens M, H�rmark L, van Holsbeke CD, Duvekot JJ, Schobben FF, Wolf H, Visser GH. 2. Sharma A, Suri V, Gupta I. Tocolytic therapy in conservative management of symptomatic placenta previa. Int J Gynaecol Obstet. 2004;84(2):109-13.
Competing interests: None declared

EDITORIALS:
Tocolytics and preterm labour
Carlin et al. (5 March 2009) [Full text]

Tocolytics and preterm labour
Physiology and neonatal transition 9 March 2009

David JR Hutchon,
Consultant Obstetrician
Memorial Hospital, Darlington. DL3 6HX
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Re: Physiology and neonatal transition

This editorial (18) raises a lot of very interesting and controversial questions. They start by raising the importance of our understanding of pathophysiology, and I fully agree. However I am at a loss in understanding why we continue to distort teaching and understanding of the physiology of respiratory and circulatory transition at birth. Virtually every textbook of physiology,(1,2,3) paediatrics,(3,4,5) and cardiology (6) describes the cord clamp as part of the physiological process. This is reflected in the teaching of highly respected authorities who probably do not realise themselves the subconscious prejudice about the cord clamp.(7) Gray�s Anatomy (8) is the only text book to describe a process which is natural.
Preterm labour and birth is not natural but it is not a license to administer an intervention no matter how much we may assume that the intervention should be helpful. The fact that immediate or early cord clamping is also carried out routinely at term birth is also no reason to incorporate it into preterm birth. It should be said that immediate or early cord clamping at term birth is of no advantage to the mother and is harmful to the baby. (9,10,11) Some people may think the continued practice of immediate or early cord clamping is surprising given the recommendation of influential organisations such as WHO. We need to thoroughly review what is our understanding of the physiology during transition at birth and ensure that this is taught correctly in textbooks and medical schools. This will remove the fundamental and institutionalised misunderstanding (12) that exists today.
The rational of giving a tocolytic is to allow time for the antenatal corticosteroids to stimulate the production of surfactant by the lungs and reduce the severity of RDS and other complications of prematurity. At about the same time that Liggins was working on antenatal steroids in Auckland(13), Dunn was working on delayed cord clamping (or a physiological transition) in Bristol (14) and found an improved survival similar to that reported by Liggins. It is a sad fact that it is a lot easier to give medication than to do something like DCC, and a randomised trial was never attempted and the approach largely ignored. Many years later Kinmond (15) showed in a RCT a considerable reduction in anaemia after delayed cord clamping and a reduction in the severity of RDS at a time when the use of antenatal steroids were not universal. The subsequent Cochrane review of delayed cord clamping confirmed the reduced anaemia and also a reduction in IVH and NEC. (16) The results for IVH (Outcome 13 in the timing of cord clamping review and outcome 17 in the Calcium channel blocker review) are almost identical for both reviews. Neither review showed any effect for severe IVH but this may have been due to the small number involved. Improved outcomes for NEC were also similar between the two reviews. Mercer et al (17) has also shown improved morbidity in very preterm babies managed with delayed cord clamping at birth. As Carlin et al (18) point out the diagnosis of preterm labour is imprecise and many patients will get treated unnecessarily with both steroid and tocolytic. Allowing a physiological transition by delayed cord clamping can be targeted to those who actually deliver prematurely.
It should be pointed out that the Cochrane review referenced in this editorial (19) has actually been withdrawn and replaced by an updated version (20) with corrected figures.
� Cochrane Database of Systematic Reviews, Issue 1, 2009 (Status in this issue: Withdrawn, commented) Copyright � 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. DOI:10.1002/14651858.CD000065.pub2 �
Dalziel et al has carried out a long term follow-up of the Auckland trial. (21,22) They showed no adverse outcomes for the treated group however, they also pointed out that there was similar morbidity and similar mortality between the two groups. From this work, if safety is accepted then effectiveness must be questioned. From the results of other trials, if effectiveness is accepted, safety is still an issue. We cannot have it both ways. As the ORACLE II trial showed that reducing infection did not have the expected long term benefit, reducing the severity of RDS may not be without long term risks. Physiology cannot be ignored. Nature does nothing uselessly. (23) Murphy et al have shown that too much corticosteroid medication may be harmful.(24)
References
1. Berne RM and Levy MN (1996) Principles of Physiology 2nd Edition. Mosby, St Louis p 349
2. Lindsay DT (1996) Functional Human Anatomy Mosby, St Louis p 447
3. Samson Wright�s Applied Physiology 12th Edition Revised by Keel C A and Neil E. Oxford University Press 1971
3. Mc Millan JA (1999) Osaki�s Pediatrics. 3rd Edition Lippincott Williams and Wilkins, Philadelphia p 286
4. Behrman RE, Klieghman RM, Jenson HB. (2004) Nelson�s Textbook of Pediatrics 17th Edition Saunders, Philadelphia. p 1479
5. Campbell AGM and McIntosh N (1998), Forfar and Arneil�s Textbook of Pediatrics 5th Edition Churchill Livingstone New York, Edinburgh. pp 106-107
6. Braunwald E, Zipes DP, Libby P. (2001) Heart Disease, A Textbook of Cardiovascular Medicine 6th edition Saunders Philadelphia p 1512
7. Gardiner H M. Response of the heart to changes in load: from hyperplasia to heart failure. Heart 2005;91:871-873
8. Standring S (2005) Gray�s Anatomy, 39th Edition. Elsevier Churchill Livinstone Edinburgh pp 1052-4
9. A. Lalonde a,*, B.A. Daviss b,1, A. Acosta c,2, K. Herschderfer MATERNAL AND NEWBORN CARE Postpartum hemorrhage today: ICM/FIGO initiative 2004�2006 International Journal of Gynecology and Obstetrics (2006) 94, 243�253
10. WHO Technical Consultation on Prevention of Postpartum Haemorrhage Ch�teau de Penthes, Geneva, Switzerland 18�20 October 2006
11. Beyond Survival. Pan American Health Organization Chaparro C et al Essemtial delvery care practices for maternal and newborn health and nutrition.
12. Hutchon DJR NICE is encouraging artificial intervention. BMJ 2007;334:651
13. Liggins GC, Howie RN. A controlled trial of antepartum glucocorticoid treatment for prevention of the respiratory distress syndrome in premature infants. Pediatrics 1972;50:515-25.
14. Dunn P M, Caesarean Section and the prevention of respiratory distress syndrome of the newborn. In: Bossart, H et al (eds) Perinatal Medicine. 3rd Europ. Congr. Perinatal Medicine, Lausanne, 1972,135-45. Bern, Hans Huber
15. Kinmond S, Aitchison T C, Holland B M, Jones J G, Turner T L, Wardrop C A J. Umbilical cord clamping and preterm infants: a randomised trial. BMJ (1993) vol 306 p172 � 175
16. Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database Syst Rev 2004;(4):CD003248
17. Mercer J S, Vohr B R, McGrath M M, Padbury J F, Wallach M, Oh W. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular haemorrhage and late onset sepsis: A randomised controlled trial. Pediatrics 2006 117 1235 � 1242
18. Carlin A, Norman J, Cole S, Smith R. Tocolytics and preterm labour. Editorials BMJ 2009;338:b195
19. Crowley P. Prophylactic corticosteroids for preterm birth. Cochrane Database Syst Rev 2000;(2):CD000065.
20. Roberts D, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004454. DOI: 10.1002/14651858.CD004454.pub2.
21. Dalziel SR, Walker NK, Parag V, Mantell C, Rea HH, Rodgers A et al. Cardiovascular risk factors after exposure to antenatal betamethasone: 30-year follow-up of a randomised controlled trial. Lancet 2005;365:1856-62.
22. Dalziel SR, Lim VK, Lambert A, McCarthy D, Parag V, Rodgers A et al. Antenatal exposure to betamethasone: psychological functioning and health related quality of life 31 years after inclusion in a randomised controlled trial. BMJ 2005;331:665-8.
23. Aristotle, Politics, Greek critic, philosopher, physicist, & zoologist (384 BC - 322 BC)
24. Murphy, K E; Hannah, M E; Willan, A R; Hewson, S A; Ohlsson, A; Kelly, E N; Matthews, S G; Saigal, S; Asztalos, E; Rossi, S; Delisle, M F; Amankwah, K; Guselle, P; Gafni, A; Lee, S K; Armson, B A; MACS Collaborative Group, (2008). Multiple courses of antenatal corticosteroids for preterm birth (MACS): a randomised controlled trial. Lancet, 372(9656):2143-2151.
Competing interests: None declared

EDITOR'S CHOICE:
Ethics checklists and sharing patients’ information
Godlee (5 March 2009) [Full text]

Ethics checklists and sharing patients’ information
Ethics in USA v UK 11 March 2009

Christopher William Frith,
General Practitioner
Greyfriars Surgery, Hereford HR4 0BH
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Re: Ethics in USA v UK

In the USA personal data and hence logically also much medical data is considered property of the state more than it is in the UK. I wonder if that means we can more easily and naturally consider ethics during medical practice in the UK?
Competing interests: None declared

NEWS:
Sexual violence must be treated as medical emergency, charity says
Wise (5 March 2009) [Full text]

Sexual violence must be treated as medical emergency, charity says
Correction 9 March 2009

Lucy J Clayton,
Head of Communications
MSF, 67 - 74 Saffron Hill, London, EC1N 8QX
Send response to journal:
Re: Correction

A correction to some of the figures quoted in the article on MSF's recent report on sexual violence.
In 2007, MSF actually provided health care to 12,791 victims of sexual violence, in 127 projects worldwide.
Lucy Clayton
Head of Communications
MSF UK
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

Rethinking ward rounds
Mostly Capacity Act requirements, not ethics 11 March 2009

Nick J Woodhead,
Mental Health act Coordination manager
Somerset Partnership NHS Foundation Trust, Bridgwater, TA6 4RN
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Re: Mostly Capacity Act requirements, not ethics

Most of the points on this checklist, and the example of looking for an advance decision in the notes, are actually clear-cut requirements of The Capacity Act. There is no need to delve into the murky, interpretive, world of ethics. If people carry out an assessment of capacity and then use the best interests checklist for people who lack it, then most of the ethical checklist points become redundant. Ignoring a properly worded, written advance decision about life sustaining treatment (without using The Mental Health Act to override it) is now illegal, not just unethical.
My experience, which seems to be supported by emerging research, is that doctors, and other staff, in general hospitals have received poor levels of training in The Capacity Act. Hence a confusion between ethics and the law?
Competing interests: None declared

Rethinking ward rounds
need to 'get ethics' 10 March 2009

Angela Fenwick,
SL medical education and ethics
Southampton UK,
Professor Anneke M Lucassen
Send response to journal:
Re: need to 'get ethics'

Whilst we welcome the �ethics man�s� proposed attempt to encourage clinicians to consider a range of ethical issues as part of routine practice (7th March 2009), we also remain �sceptics�. We acknowledge the aim of the checklist is to encourage discussion around pertinent ethical issues related to the case; however, our experience is that checklists often encourage a tick-box mentality rather than discussion and that this sort of approach may be suited to (supposed) avoidance of complaints or legal action rather than encouraging critical engagement with the ethical issues involved. For example, check lists may engender a sense that if you have gone through the list you have covered all the possible ethical concerns and that as long as you have ticked or crossed a box this is evidence of having done so. We would argue that this is unlikely to be the case. We have seen something similar happen with research ethics approval where researchers appear to see ethics as something they need �to get� rather than something they need to engage with. Our worry is that the checklist will just be seen as another piece of paper to be completed or just another procedure to be followed, which may undermine the very purpose of the activity.
Competing interests: None declared

Rethinking ward rounds
Author's response 10 March 2009

Daniel K Sokol,
Lecturer in Medical Ethics
St George's, University of London
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Re: Author's response

Although common sense dictates that it should, I do not know if the ethics checklist will lead to better patient care. This is why it is important to conduct research to investigate its impact on healthcare staff and patients and why I am so grateful to Washington Hospital Center and any others who are willing to pilot the checklist. There is little to lose and much to gain, and I would be more than happy to visit any medical team to offer my thoughts on how to use the checklist in practice.
What is clear is that the ethics checklist will not resolve ethical dilemmas. It identifies the key ethical issues and signals the need for deliberation and sound judgement. However, it is well known that moral perception is the first step towards moral action. Spotting ethical issues does not come naturally to most of us, although we can usually see one when it stares us in the face, if it has startled us in the past or if we have spent time studying its features. Even those who are adept at the exercise will have times when their moral gaze, through fatigue or some other interference, fails to spot certain issues.
The legendary Gary Kasparov, that most precise and meticulous of decision makers, made the occasional blunder on the chess board and most of us, clinicians or ethicists, are no grandmasters of medical ethics. We too blunder, with potentially far greater consequences than losing a game of chess. If a simple checklist can help reduce the frequency of our ethical blunders, it is consistent with the principles of beneficence and non-maleficence, allowing us to benefit our patients with as little harm as possible.
Competing interests: I am the author of the article

Rethinking ward rounds
Re: Sokols' Stamp 10 March 2009

David R Warriner,
CT1 Diabetes
Northern General Hospital, Sheffield, S5 7AU
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Re: Re: Sokols' Stamp

Of course, as scholars of the English language would have realised, I meant Sokol's Stamp.
Competing interests: None declared

Rethinking ward rounds
Better understanding of the purpose of the checklist 9 March 2009

Nneka O Mokwunye,
Director, Center for Ethics, Washington Hospital Center
Washington DC
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Re: Better understanding of the purpose of the checklist

It is necessary for me to begin with informing you of my bias - I'm the Director of the department where Dr. Sokol did his visiting scholarship and developed the checklist stated in this article. What I wanted to comment on is the submission from the person who thinks that the checklist is unnecessary since most competent and humane physicians would be able to pick up the "few" ethical issues in everyday patient care without the need of prompting. Frankly that is just wrong. Not saying that physicians are not able to pick up ethical issues, they are which is why they know to call me when it is more then they can bear, but physicians don't have the time or really the need to address all ethical aspects of everyday care. Saying that there are only few is clear evidence that you don't practice medicine in a hospital that has an ethics infrastructure.
If you did then the understanding that every patient has mulitple ethical concerns would be clear. The pratice of medicine is ethical and moral in nature. We try to do the best for our patients and make choices that have ethical implications. Not to say that the everyday ethics that accompanies the practice of medicine is so great it needs a bioethicist to point them out, but there are enough that if I was a patient I would want my physician to pay detailed attention to the medicine and let the ethics people pay attention to the ethics. Physicians don't need to be ethicists as well as physicians. We complement each other in my institution very well and our physicians have reaped the benefits of having a trusting source of ethicists to assist them with their patient care.
When I took the checklist to our physicians, including the cheif of medicine, the response was unanimous in agreeing this will help the residents (house officers) learn how to think about the issues earlier on and call us to intervene before it becomes so clearly an ethical dilemma anyone could point it out. Providing this service to our patients not only brings our physicians to a higher moral authority it makes their job less complicated because they can see areas for potential conflict and deal with them promptly. If I was a patient in the hospital I would want my physicians to act in my best interests from not only the medical perspective, but from an ethical one as well. The checklist has been adopted by the physicians in my hospital from the MICU to the NICU and now is working its way into surgery, nursing and social work. A 926 bed urban teriatry care trauma 1 center must certainly have compentent physicians - can they all be wrongheaded to feel this checklist is important? Probably not.
Competing interests: None declared

ENDGAMES:
Non-parametric tests
Fletcher (5 March 2009) [Full text]

Non-parametric tests
Answers to nonparametric tests 11 March 2009

Michael J Campbell,
Professor of Medical Statistics
ScHARR University of Sheffield S1 4DA
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Re: Answers to nonparametric tests

I think in (b) the answer should refer to Spearman's rank correlation test, not Pearson's. Although calculation of the statistic does not require any distributional assumptions, for Pearson's correlation coefficient we need to assume a distribution to obtain the statistical significance, especially for small sample sizes, which is what many people will do.
I would be much more concerned about non-linearity, and many people fail to check this before calculating correlation coefficients. In (c) I think one might have specified whether the data were continuous or not since although binary and ordinal data are clearly non-normal, to state non-normally distributed data would make one assume they were continuous. It's like saying 'do not apply resucitation to non-breathers' - well a stone is a non-breather!
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
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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
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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

Inquest begins into deaths after concerns about diamorphine prescribing
Re: One more tragedy and one more inquest! 9 March 2009

Bridget L Reeves,
N/A
London, W3 6AY.
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Re: Re: One more tragedy and one more inquest!

Agreed that in some cases you can expect system failures; it is interesting that this is now a verdict that can be given in inquests. But it should not be used as a way of protecting criminal activity in government establishments. In this instance the families have fought for 10 years to find out the truth of how their relatives died. Evidence and investigations in to the deaths have still not been released into the public domain and we have to ask why after spending public money to have a leading toxicologist review the 92 cases and put them into categories; of which one is serious concerns that we the public or the families are not permitted to view it??
There are sadly and unforgivably situations where the system has failed to protect patients from a doctor's intent to kill. Those systems may indeed fall outside of the NHS. As with this inquest the police have already failed to complete a thorough investigation and the Trust failed to act in 1991 when nurses came forward from the hospital to complain about the killing regime and the heavy use of strong opiods which rendered elderly patients unconscious until dead.
Medical professionals may well learn from this inquest. CHI have already made drastic changes to the practice at the Gosport War Memorial Hospital. But it is important that the families and the victims see justice for any criminal activity. If it was a private nursing home then it wouldn't even be questioned.
Competing interests: Victims family

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
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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
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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
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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.

Let’s not turn elderly people into patients
Supporting for these inappropriate interventions may be weaker than it seems. 11 March 2009

C Kevin Connolly,
retired physician
Aldbrough St John, Richmond, North Yorkshire, DL11 7TP
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Re: Supporting for these inappropriate interventions may be weaker than it seems.

Dr Oliver is to be congratulated on his article. May I be permitted to make further points in favour of his position?
First the elderly, and perhaps even their medical advisers, are at risk of ascribing minor and non specific symptoms to ageing rather than the medication and accept the consequent ill health.
Secondly if one accepts that subjective good health does not necessarily imply the absence of disease and non attendance at the surgery is more often than not a sign of good health, it is incumbent on the doctor to be satisfied that his intervention is likely to be of net benefit. If a problem which disturbs the subject�s healthy equilibrium is uncovered, the prior presumption must be for an anti-placebo and not a placebo effect. Unlike the placebo effect which can never produce a false positive in controlled trials, the former may cause an overall adverse effect in apparently positive trials, when it is greater than the specific therapeutic benefit.
Thirdly, the only proper outcome measure in interventions in the healthy is overall healthy survival and not disease specific mortality or morbidity which are only explanatory variables in this situation. Even the relatively few truly primary prevention studies fail to recognize this or consider the possibility or the potential anti-placebo effect. Instead the primary outcome measures are disease specific and when benefit in overall mortality falls short of that expected from the primary target there is a tendency to try and explain this away. General morbidity is rarely considered.
I do recognize that Dr Oliver was particularly concerned about the healthy elderly, and agree with him in this. I accept that they are a survivor population with a relatively short time to live and so have less to gain and disproportionately more to lose from well intentioned but inappropriate intervention. Nevertheless with the exception of my first point these concerns apply just as much to younger healthy individuals, who rarely if ever go to the doctor. Indeed one could argue that unless some restraint is shown in the approach to this group, in twenty year�s time there will be no-one left in the category about whom Dr Oliver is rightly concerned.
Competing interests: None declared

Let’s not turn elderly people into patients
Impact of Polypharmacy on senior citizens 10 March 2009

Ediriweera Desapriya,
Research Associate
Department of Pediatrics, Centre for Community Child Health Research L 408-4480 Vancouver BC V6H 3V4
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Re: Impact of Polypharmacy on senior citizens

We need to congratulate Dr. Oliver for his insightful article. [1]
Among older adults, falls are the leading cause of injury deaths. They are also the most common cause of nonfatal injuries and hospital admissions for trauma [2, 3, 4] .(Stevens et al; 2006, Pressley et al; 2007, Chen et al; 2008). In addition there is extensive and continually expanding international research literature on older drivers, reflecting concerns that projected increases in the older driver population will increase societal harm from motor vehicle crashes. [5, 6] .(Sims and , O'Neill, 2005, Subzwari et al; 2008)
Polypharmacy is generally understood as a major risk factor for elderly injuries [6, 7, 8] (Subzwari et al; 2008, Tinetti et al; 2006, Hartikainen et al; 2007) Polypharmacy is broadly define as the use of a medical regimen that includes at least one unnecessary medication or the use of five or more medications, or the act of prescribing more medications than are clinically indicated [8, 9](Lotfipour and Vaca ;2007, Hartikainen et al; 2007) It is important to note that majority of older adults regularly use several medications and studies have shown that the use of as few as 3 medications per day can increase the risk of functional decline in older adults by as much as 60% [9, 10]( Lotfipour and Vaca ;2007, Lococo and Staplin, 2006)
There are many definitions on polypharmacy exist in the literature, but as emphasized by the Lotfipour and Vaca [9] there is little disagreement about the effects medications can have on the daily functional aspects of our senior citizens. As Lococo and Staplin [10] noted that the physicians who routinely care for them may not be giving enough consideration to the cognitive and motor impairment attributable to polypharmacy�s placing older adults at increased collision risk [9, 10]. Polypharmacy effects on falls, activities of daily living, cognitive agility, and driving fitness, coupled with older adult physiologic changes, can have a significant impact on our health care system.
References:
[1] Oliver, M. Lets not turn elderly people in to patients. BMJ 2009; 338;873
[2] Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006;12:290�5.
[3] Pressley JC, Barlow B, Quitel L, Jafri A. Improving access to comprehensive injury risk assessment and risk factor reduction in older adult populations. Am J Public Health. 2007;97(4):676-8.
[4] Chen JS, Simpson JM, March LM, Cameron ID, Cumming RG, Lord SR, Seibel MJ, Sambrook PN. Fracture risk assessment in frail older people using clinical risk factors. Age Ageing. 2008;37(5):536-41.
[5] Simms C, O'Neill D. Sports utility vehicles and older pedestrians. BMJ. 2005 ;8;331(7520):787-8.
[6] Subzwari S, Desapriya E, Babul-Wellar S, Pike I, Turcotte K, Rajabali F, Kinney J. Vision screening of older drivers for preventing road traffic injuries and fatalities. Cochrane Database Syst Rev. 2009;21;(1):CD006252.
[7] Tinetti ME, Gordon C, Sogolow E, Lapin P, Bradley EH. Fall-risk evaluation and management: challenges in adopting geriatric care practices.Gerontologist. 2006;46(6):717-25.
[8] Hartikainen S, L�nnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci. 2007;62(10):1172-81.
[9] Lotfipour S, Vaca F. Commentary: Polypharmacy and older drivers: beyond the doors of the emergency department (ED) for patient safety. Ann Emerg Med. 2007;49(4):535-7.
[10] Lococo K. and Staplin L. Literature Review of Polypharmacy and Older Drivers: Identifying Strategies to Study Drug Usage and Driving Functioning Among Older Drivers, National Highway Traffic Safety Association (NHTSA, 2006) Publication No. DOT HS 810558.
Competing interests: None declared

Let’s not turn elderly people into patients
It's the patient's decision 10 March 2009

Graeme Mackenzie,
GP out of hours
North Cumbria
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Re: It's the patient's decision

or it will be when we reach levels of education where risk stats can be presented along with risks of serious side effects and also the risks of living longer such as ending up in residential care, dementia, fractured hip,cancers, incontinence depressed relatives, being remembered as old and failing etc etc etc etc.. I will be in residential care before we are even remotely near that point.
Competing interests: None declared

Let’s not turn elderly people into patients
Helping elderly individuals to understand the aging process. 9 March 2009

Les O. Simpson,
retired experimental pathologist
Dunedin, New Zealand 9077
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Re: Helping elderly individuals to understand the aging process.

Professor Oliver's proposal that the elderly should not be turned into patients has stirred up a significant supportive response. But the response tends to draw attention to the question, "How many GP's are sufficiently informed about the pathophysiology of the aging process to suggest actions with potentially beneficial effects ?"
According to Ajmani and Rifkind (1) of the National Institute of Aging, aging is accompanied by a rise in fibrinogen levels with an increase in blood viscosity, a reduction in red cell deformability and early activation of the coagulation system. In agreement with those observations we found that there was an age-related decline in the filterability of anti-coagulated blood through filters with 5 micron pores. That finding stimulated a scanning electron microscope study of the shape of immediately fixed blood samples from people aged 60 years or older. The results showed a predominance of non-discocytic erythrocytes, which would explain the poor filterability. (2)
So aging is associated with changes in the physical nature of the blood which will impair capillary blood flow. There is a significant literature which records that such blood flow problems can be amplified by smoking and inactivity; can be worsened or improved by dietary factors or improved by regular low-intensity activity such as walking.
Smoking increases blood viscosity and reduces red cell deformability, but such changes are reversed by cessation of smoking. While inactivity is associated with raised blood viscosity, low intensity activity such as walking or gardening has been shown to reduce blood viscosity. Diets rich in saturated fats and junk foods increase blood viscosity. As cholesterol levels rise, so too does the amount of cholesterol in the red cell membrane increase. The effect is to stiffen the cell membrane. The omega -3 fatty acids in oily fish at 35 grams daily reduced the incidence of heart disease by 50% in a 20-year-long follow-up. The fish oil lowers blood viscosity and increases red cell membrane fluidity. Since 1930 there have been several reports which show that blood pressure is correlated directly with blood viscosity and when blood viscosity is reduced, blood pressure is reduced also. There is a sizeable literature which documents the role of increased blood viscosity and reduced red cell deformability in the cardiac and cerebral disorders associated with aging.
Therefore, in order to take cognisance of Professor Oliver's concerns, should GP's meeting with apparently healthy elderly individuals discuss their activities of daily living ? Do they smoke ? What is their level of activity ? What is the nature of their diet,and how frequently is oily fish on the menu ? By taking a blood pressure, the GP has some factual information to relate to the responses to the questions. This would allow the GP to explain why smoking should be stopped; why regular physical activity is important and the importance of diet to sustain good health. For those who are unable to afford a regular intake of oily fish, a daily supplement of 6 grams of fishoil should be suggested. No tests would be arranged and no prescription would be written, and the elderly person would not be a patient.
References.
1. Ajmani RS, Rifkind JM. Hemorheological changes during human aging. Gerontology 1998; 44: 111-20.
2. Simpson LO, O'Neill DJ. Red cell shape changes in the blood pf people 60 years of age and older imply a role for blood rheology in the aging process. Gerontology 2003;49: 310-15.
Competing interests: None declared

EDITORIALS:
Amendments to the Coroners and Justice Bill
Nathanson (3 March 2009) [Full text]

Amendments to the Coroners and Justice Bill
Trust already gone 10 March 2009

Graeme Mackenzie,
Out of hours GP
North Cumbria
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Re: Trust already gone

I have been deeply involved in computerisation of medical records for 10 years +. It was only this weekend when I was talking to a lay friend about medical records that it struck me that any networked computer record breaches the trust and confidentiality as perceived by the vast majority of patients. A simple note jotted on a GP Lloyd George record and then refiled until the next contact probably did meet patients expectations of confidentiality. Adding anything to an accessible networked record breaches confidentiality. There has been no consent. It would not be practical to ask every patient about what we could and could not put on a networked record. Legislation about data sharing is probably a peripheral issue compared to the vast amount of unconsented and unmanaged data sharing now going on within health care.
Competing interests: None declared

LETTERS:
Pay attention to the first week
Campbell (3 March 2009) [Full text]

Pay attention to the first week
Reflect on earlier studies 10 March 2009

Ann M Wylie,
Senior Teaching Fellow
Dept of General Practice & Primary Care, King's College School of Medicine,5 Lambeth Walk SE116SP
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Re: Reflect on earlier studies

I have read with interest the debates regards the concerns about poor uptake of breast feeding. It seems we have difficulty in learning from previous work and would draw attention to a letter I had published in 1992. Currently senior students at this medical school have the opprotunity to consider what factors influence breast feeding and the potential of the multidisciplinary team to be supportive. But unless the qualitaive studies are done and acted upon for the current generation of new mothers and the professionals, we are likley to be seeing similar papers in 18 years time. http://www.bmj.com/cgi/reprint/305/6852/523
Competing interests: None declared

RESEARCH:
Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study
Ekeberg et al. (23 January 2009) [Abstract] [Full text] [PDF]

Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease:...
Management of suspected rotator cuff disorders in general practice 9 March 2009

Ramon PG Ottenheijm,
General Practitioner
Dept. of General Practice, Maastricht University, 6200 MD, Maastricht, the Netherlands,
Ludo Penning, Dept. of Orthopedic Surgery, Geert Jan Dinant, Professor of General Practice, and Rob de Bie, Professor of Physiotherapy Research
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Re: Management of suspected rotator cuff disorders in general practice

Ekeberg and colleagues conducted a well designed trial with a clear presentation of the results. They conclude that after six weeks no difference is found in outcomes between local ultrasound guided corticosteroid injection and systemic corticosteroid injections in rotator cuff disorders. As outlined by professor Koes in his editorial, several explanations can be given for this conclusion, which emphasises the need for more research on the management of shoulder pain in general practice. Two ideas for future research topics are addressed by us.
The effect of corticosteroid injections (local or systemic) is still unconvincing. This might find its reason in the fact that the exact mechanism of pain in rotator cuff disorders is not known. There are several reasons to be reluctant with corticosteroids. Under the current circumstances, administration is performed without any information about the morphology of the rotator cuff. The high recurrence rate in corticosteroid treated patients might be explained by the rapid improvement in pain, which could lead to increased activity and overtaxing the affected shoulder. Decreased pain does not imply that the quality of the affected structures (tissue repair) and their function is improved. Alternatively, corticosteroid injections might be harmful to the tendon. Several animal, histological, and biomechanical studies have supported the argument that the use of corticosteroids may have deleterious effect on collagen, further tendon degeneration, and even tendon rupture.[1-4] The exact mechanism by which corticosteroids might predispose to tendon rupture is not certain. However, there is some experimental evidence indicating that it inhibits the healing process of tendons.[2] This may lead to further tendon degeneration, tear progression, and failure of tendon suturing. In conclusion, there is enough evidence to be reluctant with subacromial corticosteroid injections. Using these drugs, one should keep in mind that it offers only palliative treatment for a short duration and might negatively affect the tendon quality and surgical outcomes. It might be that any substance locally injected in the subacromial space influences histhopathological changes, inflammatory mediators, free nerve endings, and nociceptive agents in the subacromial bursa. This emphasises the need for more studies on the mechanism of pain in rotator cuff disorders, and on how to intervene.
Ekebergs� trial shows once again that diagnosis in patients with shoulder pain is difficult. In 80% of the cases with shoulder pain in general practice, the rotator cuff is the most affected anatomical structure.[5] Unfortunately, physical examination does not allow to differentiate between affected tendons and to diagnose otherwise the disorders.[5] This can be explained by the anatomical structure of the rotator cuff and capsule. In contrast with the description in most anatomical textbooks, there is structural overlap between the tendon fibres and the capsule.[6] This suggests that no test can selectively challenge any one of the rotator cuff tendons. In current usual care, patients are managed without knowledge about the patho-anatomical origin of the symptoms, whereas this is needed to make more adequate decisions regarding treatment. It is likely that solving this diagnostic shortcoming can improve outcome in patients with shoulder pain. Ultrasound imaging can be very useful for detecting rotator disorders[7-9], and is an accurate method for diagnosing rotator cuff tears.[10] It is a relatively inexpensive diagnostic procedure, which allows real time imaging and dynamic assessment of the shoulder. However, before implementation of ultrasound in the management of shoulder pain in general practice can take place, two important questions have to be answered; What is the diagnostic accuracy of ultrasound for the most common rotator cuff disorders?; And in what stage (acute, subacute or chronic) should ultrasound be performed.
References:
1. Alvarez, C.M., et al., A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis. Am J Sports Med, 2005. 33(2):255-62.
2. Halpern, A.A., B.G. Horowitz, and D.A. Nagel, Tendon ruptures associated with corticosteroid therapy. West J Med, 1977. 127(5):378-82.
3. Hugate, R., et al., The effects of intratendinous and retrocalcaneal intrabursal injections of corticosteroid on the biomechanical properties of rabbit Achilles tendons. J Bone Joint Surg Am, 2004. 86-A(4):794-801.
4. Kapetanos, G., The effect of the local corticosteroids on the healing and biomechanical properties of the partially injured tendon. Clin Orthop Rel Res, 1982(163): 170-179.
5. Winters, J.C., et al., NHG-Standaard Schouderklachten. Huisarts Wet, 2008. 51(11):555-565.(Guideline for shoulder complaints of the Dutch College of General Practitioners)
6. Clark, J. and D. Nd, Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am, 1992. 74(5):713 -725.
7. Allen, G.M. and D.J. Wilson, Ultrasound of the shoulder. Eur J Ultrasound, 2001. 14(1):3-9.
8. Mack, L.A., et al., US evaluation of the rotator cuff. Radiology, 1985. 157(1):205-9.
9. Middleton, W.D., et al., Ultrasonography of the rotator cuff: technique and normal anatomy. J Ultrasound Med, 1984. 3(12):549-51.
10. Dinnes, J., et al., The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess, 2003. 7(29):iii, 1-166.
Competing interests: None declared

RESEARCH:
Abuse of people with dementia by family carers: representative cross sectional survey
Cooper et al. (22 January 2009) [Abstract] [Full text] [PDF]

Abuse of people with dementia by family carers: representative cross sectional survey
Doctors need to engage in education and research in elder abuse 11 March 2009

Kit M Tan,
Specialist Registrar
Centre for Ageing, Neuroscience and the Humanities, Trinity College, Dublin 2, Ireland,
Desmond O'Neill
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Re: Doctors need to engage in education and research in elder abuse

The significant levels of elder abuse reported by family members of those with dementia (1) (Jan 22) should prompt scrutiny as to whether those involved with the care of older people, and in particular those with dementia, have adequate training in the prevention, detection and management of elder abuse.
The medical profession in particular may be challenged in this regard. In one study, 45% of junior doctors had never heard the term �elder abuse�, although 85% felt elder abuse was common and all felt it was under-reported: only 5% interviewed had heard of guidelines in place for its management. Hospital-based social workers fared better, but only 58% were aware of management guidelines (2). Any such training needs to be based on a foundation of gerontological skills: Lachs and Pillemer have outlined eloquently how detection and management of elder abuse share many characteristics with the detection and management of other geriatric syndromes (3).
However, an equally important message from Cooper�s paper is that of the need for doctors to continue to engage in research into elder abuse, a subject which is rich in conjecture, but short on data. The United States National Academy of Sciences has lamented this paucity of empirical research, with less than fifty peer-reviewed papers in the elder abuse literature (4). A recent review of the child abuse literature has underscored the need for continuing involvement of physicians in research and practice (5). This need is just as great for a topic as complex and subtle as elder abuse, and the knowledge base for prevention, detection and management of elder abuse needs the insights of all elements of a biopsychosocial model of elder abuse.
References
1. Cooper C, Selwood A, Blanchard M, Walker Z, Blizard R, Livingston G. Abuse of people with dementia by family carers: representative cross sectional survey. BMJ. 2009;338:b155
2. Kennelly S, Sweeney N, O'Neill D. Elder abuse: knowledge, skills, and attitudes of healthcare workers. Ir Med J. 2007;100:326.
3. Lachs MS, Pillemer K. Elder Abuse. Lancet 2004.;364:1263-72
4. National Academies of Sciences , Bonnie R, Wallace R, eds. Elder abuse: abuse, neglect, and exploitation in an aging America. Washington DC: National Academy Press, 2002.
5. Reading R, Bissell S, Goldhagen J, Harwin J, Masson J, Moynihan S, Parton N, Pais MS, Thoburn J, Webb E. Lancet. 2009 24;373:332-43.
Competing interests: Professor O'Neill was the Chair of the Irish government's Working Group on Elder Abuse

Abuse of people with dementia by family carers: representative cross sectional survey
Inadequate training: the elephant in the room. 10 March 2009

Alexander M Thomson,
Consultant Geriatrician
Salford Royal Hospital, M6 8HD
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Re: Inadequate training: the elephant in the room.

The work by Cooper et al is a positive contribution to the evidence base relating to abuse of vulnerable adults, and those with dementia in particular (1). Work like this is essential given the variety in epidemiological work in this field. Current evidence is found across a number of studies, but all with different study populations and sampling techniques (2).
Research in this area of adult protection is vital but, critically in the UK, delivery of training in recognition, investigation and management of cases of abuse remains inconsistent or even absent in some areas. This is true for both undergraduate and postgraduate training in medicine, and is probably also the case in the nursing and allied health professions. Even within my own speciality, proponents of comprehensive care and advocates for the frail and vulnerable, there remains a paucity of training.
Although training in elder abuse was highlighted in the Department of Health�s �No secrets� publication in 2000 (3), it still needs to be addressed more rigorously. This is necessary during early training and, importantly, throughout one�s career. Only then will it become a cornerstone of excellent practice for those at risk and subject to harm.
1. Cooper C, Selwood A, Blanchard M et al. Abuse of people with dementia by family carers: representative cross sectional survey. BMJ 2009;338:b115.
2. Lachs MS, Pillemer K. Elder Abuse. Lancet 2004.;364:1263-72
3. Department of Health. No secrets: guidance on developing multi- agency policies and procedures to protect vulnerable adults from abuse. London: DoH;2000.
Competing interests: None declared

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
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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? Yes
Gubb (16 January 2009) [Full text]

Have targets done more harm than good in the English NHS? Yes
Patients helped by targets 11 March 2009

Rupert A Gude,
VSO doctor
Kagondo Hospital, Kagera., Tanzania
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Re: Patients helped by targets

Dear Editor,
It was disappointing to see James Gubb missing the point that management in the NHS needed to be encouraged to change by being given targets. Too long the NHS has laboured under poor management and underfunding and Gwyn Bevan�s luke warm acceptance of targets does not fit my experience.
I do not seem to inhabit the same universe of Dr Slater where �target culture is universally destructive of good medical practice� and certainly do not inhabit the rarefied atmosphere where Mr Spicer the retired surgeon finds �all clinicians will agree with James Gubb�.
As a General Practitioner for 25 years one of the delights of modern practice in the last 10 years has been an attempt by the Government to make the NHS more responsive to patients� needs by doubling its funding and setting targets. One of my roles was as an advocate for my patients. I had become increasingly frustrated by the inability of the secondary sector to provide adequate care or by some General Practitioners who were not embracing modern therapeutic regimes.
Of particular note was the 2 week wait initiative At last my patients with life threatening disease whether suspected cancer or cardiovascular disease could be seen by a specialist in a reasonable time. We were not expecting a day or two as is customary in many Continental countries but at least they were not languishing on waiting lists for months whilst their bowel cancer grew or they died of ventricular fibrillation.
Then came the Quality outcome framework (Qof) and at last General Practitioners woke up to the fact that being caring and considerate to their diabetic or hypertensive patients was not enough but that had to treat them effectively as well. Those with any management sense quickly arranged that they would meet the targets much to the surprise of Government. The others complained of losing autonomy and that the art of medicine was fading as they held the hand of their hypertensive hemiplegic patient.
Stephen Black quite rightly states that Accident and Emergency departments needed targets to generate change. That some have poor management is not a function of the target but of the attitude of the people employed. That they need some exempting facility, as in Qof, for the 4 hour rule is a factor of a poorly written target rather than targets in themselves. James Gubb�s analysis that local leadership is important is right but no change occurred without targets reflecting the lack of management skills.
That increasing numbers of patients with suspected Myocardial Infarct received thrombolysis was not due to most cardiology departments wishing to provide excellent service. It was due to the targets that made management change the structure of admissions such that ambulances radioed ahead and specific junior doctors and nurses were detailed to meet the patient. Some hospitals were already doing this but targets created the change in the majority.
I do empathise with Dr Stanley and her analysis of the needs of her GUM patients. This is a classical situation of inappropriate targets being insensitively imposed. She needs a new manager or at least a manager who is taught the necessity to look at patient needs first.
Two major factors have prevented change in the NHS neither mentioned by either James Gubb or Gwyn Bevan. Whilst politicians and doctors and their respective wives do not have to endure the waiting time of the ordinary NHS patient then the structure of the NHS would not change. Also whilst consultants relied on private practice for a considerable proportion of their income then there was little incentive to provide first class prompt outpatient care. Hopefully targets have redressed this imbalance a little and made the ordinary citizens� experience more like that of their doctor or politician.
Targets certainly suited my patients and many were truly grateful for the prompt professional service they received whether in primary or secondary care.
Rupert Gude
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
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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
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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

OBSERVATIONS:
What should the US surgeon general do?
Kamerow (13 January 2009) [Full text]

What should the US surgeon general do?
Mandatory discharge from physician care and the metabolic testing of drivers 9 March 2009

Richard G Fiddian-Green,
FRCS, FACS
None
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Re: Mandatory discharge from physician care and the metabolic testing of drivers

Discharging patients from hospital, to clear beds for new admissions especially on those days when on call for emergencies, and from clinics, to make the load managable, was an essential part of surgical care at Groote Schuur. It was a good discipline for it is all to easy to keep patients in hospital longer than is needed, especially in public hospitals such as the VAs and NHS, and to make patients dependent upon physican care and medications of equivocal benefit and possibly even harmful in the long term. It is, however, very good for private practice to keep patients coming back and back for it generates a continuous and ever expanding revenue stream.
Those caring for some chronic diseases have a legitimate reason for making patients physician and medication dependent but "shrinks" have a highly questionable reason for doing so despite their popularity with celebrities. Psychoanalysts and even psychologists must be at the end of this spectrum for the evidence-base supporting the benefits of their interventions is very limited. But people like friends and, for those with time on their hands, renting them can fulfill a need. That need should not, however, be paid insurance or public funds.
There is little doubt that the US public is over treated and over medicated. Witness the many that have become addicted to medications some of which can now be obtained without a prescription. Taking a pill has become a habit or a crutch, as many an article in the lay press will confirm. Taking a ton of them, without having a clue what interactions might occur and what harmful effects might be done in the long term, is extraordinarily common. Mandating the discharge of patients from physician care could be an important part of addressing this massive problem.
Then there is the interactions between exercise, recreational drugs and medications and their impact upon accidents and violent crimes. As previously proposed (1) making metabolic testing before driving a car mandatory, and having the information stored in a "black box" in case of an accident, might go a long way to establishing an evidence-base, with which to make informed decisions, and ultimately to self-policing and healthcare cost reductions. More importantly it might make the public more aware of the very many hidden dangers and costs of current practices and indeed of the current American way of life.
1. Every driver needs metabolic testing and the information needs to be stored in a "black box" Richard G Fiddian-Green (22 July 2004) eLetter re: R A Shults, D A Sleet, R W Elder, G W Ryan, and M Sehgal Association between state level drinking and driving countermeasures and self reported alcohol impaired driving Inj Prev 2002; 8: 106-110
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
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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

FEATURE:
Bad blood: gay men and blood donation
Hurley (26 February 2009) [Full text]

Bad blood: gay men and blood donation
Dated attitudes 9 March 2009

Benjamin W. Molyneux,
F1
Homerton University Hospital
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Re: Dated attitudes

Surely in this age of super political correctness we should be beyond blatant stereotyping? There are prolific heterosexuals who don't use protection and there are long-term monogamous homosexuals who do. Obviously the reverse is also true. In an increasingly diverse population we should be looking at the causes of new HIV and hepatitis diagnoses rather than using dated pigeon holes from the 1980's.
Assessing risky behaviour is an effective way to protect recipients of blood products. If potential donors have engaged in high risk activities in the past year then it is entirely right that they should be deferred a suitable amount of time. Blanket bans on homosexual men donating blood for life demonstrates an overly simplistic and dated attitude towards an essential, volunteer-dependent service. If the blood service wants to increase stocks, they may find their task increasingly difficult as the public reacts to institutional homophobia.
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
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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
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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/
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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
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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
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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

Commentary: Toughen up
Lobbying for a dream 10 March 2009

A Rouse,
Consultant
Heart of Birmingham PCT, B16 9PA
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Re: Lobbying for a dream

Freedman�s suggests that the pro-Israel lobby is similar to other lobbies such as Creationists. It isn�t, for unlike other lobbies, it is amazingly effective. Consider this:
�� the White House was deluged with letters, telegrams and phone calls � Truman�s assistants conducted a study of Palestine correspondence and drew up detailed statistics � from 1947 to 1948 Truman received 48,600 telegrams, 790,575 cards, and 1,200 pieces of other mail. In 1948, during one three week period alone, Truman received 301,900 postcards.� (1)
Now, if as Freedland contends, �Half a dozen real letters has a greater effect on editors than a mass emailing�, are we not entitled to believe that over a million real mailings could have the effect of influencing national policy of the most powerful nation on earth? Otherwise why would Obama declare at the American Israel Public Affairs Committee policy conference?
�Jerusalem will remain the capital of Israel, and it must remain undivided,". (2)
More importantly, the pro pro-Israel lobby differs from others in that it lobbies for a �DREAM�. Unlike a lobby rooted in terra firma that disappears when its objectives are met, the lobby has an eternal purpose; an eternal Israel. Before Israel existed there was a lobby, whilst it exists there is a lobby and, rest assured, should Israel fade away there will remain a lobby forever advocating its return. It is as if, in Richard Dawkin�s parlance, Western society experienced a meme mutation and the pro-Israel lobby became dominant!
1. http://books.google.co.uk/books?id=jmoab5xc9ogC&pg;=PA94&lpg;=PA94&dq;=%22zionist+deluge+the+whitehouse%22&source;=bl&ots;=bsjIjTmyh5&sig;=xHFlE129qqJtHmbu13LSLO9R8MA&hl;=en&ei;=TkC0SeGlIOS1jAeptPn0BQ&sa;=X&oi;=book_result&resnum;=4&ct;=result 2. http://www.jpost.com/servlet/Satellite?cid=1212659672984&pagename;=JPost%2FJPArticle%2FShowFull
Hitherto the international and US recognised capital of Israel is Tel Aviv.
Competing interests: None declared

Commentary: Toughen up
Freedland is made of more resolute protoplasm than I. 9 March 2009

A Rouse,
Consultant
Heart of Birmingham PCT, B153RU
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Re: Freedland is made of more resolute protoplasm than I.

Once upon a time I raised my head above the parapet. I wrote a few pro Palestinian letters and surprisingly, for in the greater scheme of things, who am I? - incurred the wrath of the pro-Israel lobby. The eight hate emails I received disturbed me profoundly. For months I walked around preoccupied and would fall asleep with phrases like, �Dr Rouse, we have your number!� banging in my brain.
Freeman�s view that the �bruisings� dished out by pro-Israel activists were justified because the victims (O�Donnell and Summerfield and others) are guilty of some slight or carelessness is but an insensitive use of the �blame the victim� defence. Would he argue that a girl provoked her own rape by wearing a miniskirt? I hope not.
For Freeland to conclude with a casual, �you�ll get over it�, and dismiss the damages caused by the pro-Israel lobby is, for those like I who did �get over it�, unfeeling; and for those who didn�t �get over it�, arrogant and abhorrent.
Competing interests: None declared

EDITORIALS:
What to do about orchestrated email campaigns
Delamothe and Godlee (24 February 2009) [Full text]

What to do about orchestrated email campaigns
Rx for Feuds 10 March 2009

Hugh Mann,
Physician
Eagle Rock, MO 65641 USA
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Re: Rx for Feuds

The Israeli-Palestinian conflict is an intractable feud impervious to negotiation and in need of a new perspective. I propose that we eschew the polarizing, stigmatizing rhetoric, and instead redefine this conflict as a humanitarian health crisis based on dehydration, hunger, and addiction, all of which aggravate conflict by making people frustrated, angry, and violent. To stop a feud, change the food.
Competing interests: None declared

What to do about orchestrated email campaigns
My 5 year follow up - a personal response. 9 March 2009

Liz Lightstone,
Senior Lecturer in Renal Medicine
Imperial College London, Hammersmith Hospital W12 0NN
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Re: My 5 year follow up - a personal response.

Dear Dr Godlee
I remain astonished at your preoccupation with the response to a dreadful article by Summerfield in 2004. I wrote then (BMJ 2004;329:1101 (6 November), doi:10.1136/bmj.329.7474.1101-a) that the BMJ should be ashamed of publishing a biased, ill written and scurrilous article. You speak of orchestrated campaigns, falling just short of mentioning a Zionist lobby or conspiracy. I have a suggestion - why don't you publish an article celebrating what Israel has achieved in terms of science, medicine, innovation in just 60 years? Then I promise, you will undoubtedly find yourself the subject of vitriol, hate mail, and an orchestrated campaign of outrage that makes the response to the Summerfield article seem tame. You and Dr O'Donnell make claims of being bullied to keep quiet about sensitive issues. Clearly then the orchestrated campaign has failed as there is no evidence that the BMJ has any reluctance in criticising Israel - you have published 3 further articles by Summerfield alone. As Baroness Deech correctly pointed out in Parliament on February 9th, there is a bizarre preoccupation with Israel and all it does and yet little notice taken of far worse outrages around the world, including in Arab and Islamic states.
If you would like to see orchestrated campaigns, see the response to 2 small exhibitions of Israeli science at the Science Museums in Manchester and London this week - letters to the Guardian signed by the usual suspects and calls, once again, for boycotts and demonstrations.[1] [2] What are these responses if not bullying and intimidation of institutions and organisations that support Israel in any shape or form?
There is always room for healthy debate and dialogue. There is no place in proper medical journalism for bias, innuendo and preoccupation with just one subject. Once again, as in 2004, shame on the BMJ for publishing such a piece.
Dr Liz Lightstone
1 http://www.guardian.co.uk/education/2009/feb/16/museums-israel-science
2 http://www.timesonline.co.uk/tol/comment/leading_article/article5841342.ece
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
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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:
Commentary: Standing up for free speech
O’Donnell (24 February 2009) [Full text]

Commentary: Standing up for free speech
Extremism can be frightening 9 March 2009

David Isaacs,
Senior staff specialist
Children's Hospital at Westmead, Westmead, NSW, 2145, Australia
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Re: Extremism can be frightening

Michael O'Donnell's sad story of the threats he and his family received for publishing an anti-Israeli article in World Medicine in 1981 makes sobering reading (1). Vicious attacks on the family are not confined to political opponents. In his recent book, Paul Offit describes how he received hate mail ("we know where your children go to school") for expressing his opinion that vaccines do not cause autism (2). Extremism in all its forms can be frighteningly ugly.
1. O'Donnell M. Standing up for free speech. BMJ 2009;338:a2094.
2. Offitt PA. Autism's false prophets: bad science, risky medicine, and the search for cure. New York, Columbia University Press, 2008.
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
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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
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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
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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
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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
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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
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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

Perils of criticising Israel
The Editor responds to charges of anti-Israel bias in the BMJ 11 March 2009

Fiona Godlee,
editor
BMJ
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Re: The Editor responds to charges of anti-Israel bias in the BMJ

Several responses to the recent article by Karl Sabbagh [1] and other articles in the BMJ,[2,3,4] have charged the BMJ with two counts of bias against Israel . First, that the journal�s editors discriminate against Israeli researchers in decisions about which research papers to accept for publication.[5] Second, that the BMJ�s coverage of conflict zones is dominated by the conflict in Gaza and the West Bank to the exclusion of other conflicts in which larger numbers of civilians have been killed (http://www.honestreporting.com/articles/45884734/critiques/new/BMJs_Bad_Medicine.asp).
Prompted by these concerns, we have looked for evidence of such bias over the past five years.
We compared the acceptance rates of research papers submitted from Israel and four other countries of comparable size and development between 2004 and 2008 (table 1). We have not looked back at the papers themselves and have no gold standard measure of quality, which make these data hard to interpret. However, they do not suggest a systematic bias against Israeli research.
We then searched PubMed for the past five years looking for articles that referred to eight major conflict zones identified by Amnesty and Medicins Sans Frontieres (table 2). We searched using key words for the conflict zones and for terms that would bring up articles relating to conflict (war, casualty, disaster, civilian, violence, humanitarian, human rights, crisis, refugee). We then did the same search limited to articles published in the BMJ. For Sri Lanka, Iraq, and Myanmar, 1-2% of relevant articles in PubMed had been published in the BMJ. For Palestine, Congo, and Somalia, the figure was 4-6%. For Darfur and Zimbabwe, the rates were 15.8% and 17.4%.
Both sets of data are crude. We make no claim that they address the extreme complexities of the political or humanitarian situation in each region, nor do they reflect the number of civilian casualties in each case. However, we believe they show no evidence of bias against Israel either in our selection of research articles or in our coverage of conflict zones over the past five years. The BMJ welcomes research from all parts of the world and aims to publish the very best that we receive, looking especially for research that will help doctors make better decisions. We also aim to highlight threats to health and human rights wherever they occur.
Fiona Godlee, editor, BMJ
1. Sabbagh, K. The perils of criticising Israel. BMJ 2009;338:a2066
2. Delamothe T, Godlee, F. What to do about orchestrated email campaigns. BMJ 2009 338: b500
3. O�Donnell M. Commentary: Standing up for free speech. BMJ 2009 338: a2094
4. Freedland J. Commentary: Toughen up. BMJ 2009 338: b524
5. Siegel-Itzkovich J. British Medical Journal complains of 'obscene' attacks by pro-Israel lobby. Jerusalem Post, February 24, 2009. http://www.jpost.com/servlet/Satellite?apage=2&cid;=1235410704498&pagename;=JPost%2FJPArticle%2FShowFull
Table 1: Rates of acceptance and rejection of research papers submitted to the BMJ from Israel, Italy, Spain, France, and the Netherlands between 2004 and 2008��

Decision

n (%)

Israel

n (%)

Italy

n (%)

Spain

n (%)

France

n (%)

Netherlands

All research papers submitted in 2004

Accept

2 (3.8)

4 (4.1)

1 (1.9)

4 (3.9)

6 (3.4)

Immediate reject

46 (88.5)

84 (86.6)

44 (83)

82 (80.4)

146 (83)

Reject after review

4 (7.7)

9 (9.3)

8 (15.1)

16 (15.7)

24 (13.6)

All research papers submitted in 2005

Accept

2 (4.8)

1 (1.1)

0 (0)

2 (1.8)

7 (3.1)

Immediate reject

34 (80.9)

86 (91.5)

46 (86.8)

91 (82.7)

189 (83.2)

Reject after review

6 (14.3)

7 (7.4)

7 (13.2)

17 (15.5)

31 (13.7)

All research papers submitted in 2006

Accept

0 (0)

2 ( 3.3)

0 (0)

0 (0)

3 (1.3)

Immediate reject

43 ( 97.7)

57 (93.4)

34 (97.1)

69 (90.8)

192 (87.7)

Reject after review

1 (2.3)

2 (3.3)

1 (2.9)

7 (9.2)

24 (11)

All research papers submitted in 2007

Accept

1 (3.8)

0 (0)

0 (0)

2 (2.9)

7 (3.3)

Immediate reject

25 (96.2)

69 (92)

54 (96.4)

63 (92.6)

185 (86.8)

Reject after review

0 (0)

6 (8)

2 (3.6)

3 (4.4)

21 (9.9)

All research papers submitted in 2008

Decision not yet made

0 (0)

2 (2.2)

1 (1.6)

2 (2.2)

2 (0.9)

Accept

0 (0)

4 (4.4)

2 (3.3)

6 (6.5)

17 (7.4)

Immediate reject

24 (88.9)

74 (82.2)

51 (83.6)

74 (80.4)

168 (73)

Reject after review

3 (11.1)

10 (11.1)

7 (11.5)

10 (10.9)

43 (18.7)

Table 2: Results of a search of PubMed and BMJ for citations relating to major conflict zones for the years January 2004 to present��

Conflict zones*

Key words

PubMed search

PubMed search restricted to BMJ (%)

Palestine

palestin* gaza �west bank�

139

8 (5.7)

Sri Lanka

�sri lanka*�

176

3 (1.7)

Congo

congo*

92

4 (4.3)

Darfur

darfur sudan*

63

10 (15.8)

Iraq

iraq*

1154

17 (1.5)

Somalia

somali*

99

5 (5.0)

Myanmar

myanmar burma

burmese

58

1 (1.7)

Zimbabwe

zimbabw*

46

8 (17.4)

�

*identified by Amnesty International and Medicins Sans Frontieres

�

Details of search
Date of search: 6/3/09. The search was limited by date of publication from 01/01/2004 to the present. The keywords above were used to search �all fields� within items stored on Pubmed i.e. title, abstract, author, journal etc. They were also mapped to MeSH terms. Where more than one key word was used for a single conflict zone, the Boolean operator �OR was used within brackets eg. (palestin* OR gaza OR �west bank�). The same qualifier key words were added to all searches, as follows: AND (war OR casualt* OR disaster OR civilian OR violen* OR humanitarian OR "human right*" OR crisis OR refugee). So for the search on Palestine, the full search entry was (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).
Competing interests: I am editor of the BMJ and have overall responsibility for the balance of coverage in the journal.

Perils of criticising Israel
Diabetes in Gaza: Getting the Facts Correct 10 March 2009

Paul Z Zimmet,
Director Emeritus
Baker IDI Institute
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Re: Diabetes in Gaza: Getting the Facts Correct

Tony Delamonthe has challenged my claim that the BMJ has published information that is not factual. In the interim, he has posted the material in question in a Rapid Response above.
Firstly, the use of the Diabetes Voice as an example was inappropriate as the actual facts surrounding the incident belie the way this has been used. You are welcome to check with the International Diabetes Federation as to the actual truth of what happened, and the circumstances of the editor�s �resignation�. In fact, I was either the first or one of the first, to draw this matter to their attention.
Secondly, in relation to the abstract and the four accusations that I have been asked to defend
1. The year 2003 marked the 55th anniversary of Nakba (cataclysm) of the Palestinian people
Most Palestinians refer to the establishment of Israel in 1948 and the concurrent creation of the Palestinian refugees as a-Naqba, which means The Catastrophe, as opposed to The Cataclysm. As such, the article was strictly correct in making the claim of 2003 being 55 years since "Nakba." However, to not add that one of the reasons for the refugees was the invasion of the new state of Israel by five Arab armies shows gross bias.
2. 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.
There are two main factual errors in this statement. The UN Conciliation Commission estimated that there were 711,000 Palestinian refugees (not 760,000), and did not mention whether they were "evicted" or fled the fighting of their own accord or, indeed, as some thousands of Palestinians did, left well in advance of the fighting (at the urging of Palestinian and Arab leaders), expecting to return to a country free of Jews in a few weeks.
There has been much controversy over how many Palestinian refugees were forced to flee by Israeli troops, and how many fled of their own accord. The most widely accepted figure is that just less than half were evicted, and these only after Arab states made clear they were going to invade Israel, and Israel felt it would be destroyed unless it had viable land within which to operate. (Benny Morris, widely credited as being the authority on Palestinian refugee figures writes, "Most of Palestine's 700,000 'refugees' fled their homes because of the flail of war... But it is also true that there were several dozen sites, including Lydda and Ramla, from which Arab communities were expelled by Jewish troops."
While this context need not have been in the original article, the statement that all Palestinian refugees were evicted is patently false, and gives the wrong impression about the goals of each side in the war. Let us remember, Israel was fighting a war of survival; Palestinians and their Arab state allies were fighting a war of liquidation (the statements issued the leaders of all parties prove this beyond doubt).
The relevant article in the UN Conciliation Commission report is from Appendix 4 (Report of the Technical Committee on Refugees), Article 15: "The estimate of the statistical expert, which the Committee believes to be as accurate as circumstances permit, indicates that the refugees from Israel-controlled territory amount to approximately 711,000. The fact that there is a higher number of relief recipients appears to be due among other things to duplication of ration cards, addition of persons who have been displaced from area other than Israel-held areas and of persons who, although not displaced, are destitute."
3. What remains of the Palestinian people's land is now split between the West Bank of the River Jordan and Qita Ghazzah (Gaza Strip) and remains occupied by Israeli armed forces and settlers.
The statement that all the land belongs or belonged to the Palestinians, of which only the West Bank and Gaza Strip remain is both incorrect and evidence of gross bias. The Palestinians didn't and never have 'owned' the land in the sense of the British owning Britain or Australians owning Australia, since the Palestinians have never had, throughout history, an independent state. Israel replaced the British mandate (essentially a colony mandated by the League of Nations to establish a Jewish state), which replaced the Ottoman Empire's control of the area, which replaced (in 1517) the Mamluk's control of the area, and so on.
4. In 2003, the second uprising, or al-Aqsa Intifada against this occupation entered its third year.
This staement is correct.
So, in the context of the above, my statement that the BMJ published information that is factually incorrect and misleading in lack of detail stands. I am quite happy for you to publish this letter. I also think it would be appropriate for the BMJ to issue a statement to the effect that they were provided with incorrect information.
Yours sincerely, Paul Zimmet
Competing interests: None declared
Competing interests: None declared

Perils of criticising Israel
Wolf in Sheeps Clothing 10 March 2009

Shawn Malachovsky,
Attorney
10005
Send response to journal:
Re: Wolf in Sheeps Clothing

The BMJ published a political one-sided article demonizing Israel. Those that care to defend Israel's good name respond to the article with emails. Some use HonestReporting.com as their source. And this author (Karl Sabbagh) attacks the responders by demonizing them as campaigners to stifle debate. In fact this author goes further and conjures up a subtle conspiracy that since the establishment of Israel 60 years ago these campaigns have had a goal to suppress debate. May I remind this author and other readers that in Israel itself criticism of the Israeli Government its Military and Palestinian issues are open and free in the press and in all other forms of expression, that the debate is rich and open and vast. Perhaps the author should rethink his definition of debate, as it is not one sided . . . responding to an article demonizing Israel is not a conspiracy to stifle debate. Instead it is the very expression of debate. Who is suppressing debate? Perhaps the author should look in the mirror.
Competing interests: None declared

Perils of criticising Israel
To Tony Delamothe Re his rapid response 9 March 2009

Elliot Daniel,
Consultant Orthopaedic Surgeon
University College London Hospital NW1 2BU
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Re: To Tony Delamothe Re his rapid response

You have expressed a profound lack of understanding concerning the misinformation of Diabetes voice's article. You quote their article mentioning Arabs leaving Israel as a �Naqba�. You have conveniently not mentioned the one million Jews expelled from Arab countries Aden, Iraq, Libya etc. These Jews were expelled under threat of death. The majority of the Arabs that did not run from their homes in 1948 still live in them as Israeli citizens. Have you ever been to the cities of Acre, Haifa, Jaffa, Ramle, Lod, Jaljulia, Kfar Kassem etc? The Arabs who chose to stay and not flee as instructed by their leaders are still living in their homes today as Israeli citizens. The Jews of Arab lands had no such choice. Not to mention that this was a war of aggression by the Arab countries who rejected the UN's two state solution in 1948. I suggest you research this a little deeper. You do not have to go far London has a community of 5000 Adeni Jews expelled from Aden during the anti-Jewish pogroms there. Israel is a multi-cultural society. One quarter of Israeli citizens are not Jewish, they are Arab Moslems, Christians and Druze amongst others this includes Army officers, members of parliament, Judges, doctors, nurses all walks of life. How many Jews are living and working in Jordan, Libya and Aden? The life expectancy of Israeli Arabs is 80 years of age. That of Palestinians is 73. These figures are a great deal higher than many European countries. Have a guess what the life expectancy is of Jews in Arab countries? Think about all of this a little and maybe you�ll begin to understand that Middle Eastern politics is not for novices. Indeed your comments and those expressed in this article are impertinent in the true sense of the word.
Competing interests: I support peace and reconciliation in the Middle East and not divisive nonsense and incitement

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

PRACTICE:
Coeliac disease
Jones and Sleet (19 February 2009) [Full text]

Coeliac disease
Undiagnosed maternal celiac disease in pregnancy and an increased risk of fetal growth restriction. 11 March 2009

Fergus P McCarthy,
Clinical Research fellow
Anu Research Centre, Cork University Maternity Hospital, University College Cork, Wilton, Cork,
Ali S, Khashan, Eamonn Quigley, Fergus Shanahan, Louise C. Kenny
Send response to journal:
Re: Undiagnosed maternal celiac disease in pregnancy and an increased risk of fetal growth restriction.

We welcome your new series �Easily Missed?� but were disappointed that the article �Easily Missed? Coeliac Disease� failed to highlight the association between undiagnosed coeliac disease and an increased risk of foetal growth restriction (FGR).[1] FGR is a major pregnancy complication responsible for a 5-20 fold increase in perinatal mortality and for considerable perinatal morbidity. In addition, FGR may have lifelong consequences ranging from neurodevelopmental delay to an increased risk of developing hypertension, heart disease and diabetes later in life.[2, 3]
There is a growing body of evidence supporting the association between undiagnosed coeliac disease and foetal growth restriction with odds ratios varying between 1.3 and 6. [4, 5] Treatment of maternal celiac disease reduces the risk of FGR to that of the general population.[6] Two further studies recently carried out in our unit, one using a high risk Irish population and, the second, a large Danish population-based study, confirm this association and highlight the benefits of treatment of coeliac disease with a gluten free diet. In contrast, other interventions to reduce the incidence of foetal growth restriction have met with disappointing results. Therefore, we wish to highlight this association and the availability of an inexpensive, safe intervention for a condition associated with such significant morbidity and mortality.
Dr Fergus P McCarthy MRCPI (corresponding author), Clinical Research Fellow, Anu Research Centre, Cork University Maternity Hospital, University College Cork, Wilton, Cork
Fergus.mccarthy@ucc.ie (email)
Dr Ali S Khashan PhD, Anu Research Centre, Cork University Maternity Hospital, University College Cork, Wilton, Cork, Ireland
Professor Eamonn Quigley, M.D. Professor of Medicine and Human Physiology, Alimentary Pharmabiotic Centre, Dept of Medicine, University College Cork, Cork, Ireland
Professor Fergus Shanahan. M.D. Professor and Chair of the Department of Medicine, University College Cork. Director of the Biosciences Institute, University College Cork, Cork, Ireland.
Dr Louise Kenny PhD, Senior Lecturer, Anu Research Centre, Cork University Maternity Hospital, University College Cork, Wilton, Cork, Ireland
Competing interests: None declared
References
1. Jones R, Sleet S. Coeliac disease. BMJ, 2009. 338: p. a3058.
2. Simeoni U, Zetterstrom R. Long-term circulatory and renal consequences of intrauterine growth restriction. Acta Paediatr. 2005 Jul;94(7):819-24.
3. Osmond C, Barker DJ. Fetal, infant, and childhood growth are predictors of coronary heart disease, diabetes, and hypertension in adult men and women. Environ Health Perspect. 2000 Jun;108 Suppl 3:545-53.
4. Ciacci C, Cirillo M, Auriemma G, Di Dato G, Sabbatini F, Mazzacca G. Celiac disease and pregnancy outcome. The American journal of gastroenterology. 1996 Apr;91(4):718-22.
5. Salvatore S, Finazzi S, Radaelli G, Lotzniker M, Zuccotti GV. Prevalence of undiagnosed celiac disease in the parents of preterm and/or small for gestational age infants. The American journal of gastroenterology. 2007 Jan;102(1):168-73.
6. Ludvigsson JF, Montgomery SM, Ekbom A. Celiac disease and risk of adverse fetal outcome: a population-based cohort study. Gastroenterology. 2005 Aug;129(2):454-63.
Competing interests: None declared

NEWS:
Older Americans are not as healthy as older Europeans, study says
Tanne (18 February 2009) [Full text]

Older Americans are not as healthy as older Europeans, study says
Is this study valid ? 9 March 2009

Alexander Spiers,
Professor of Medicine (retired).
N/A.
Send response to journal:
Re: Is this study valid ?

I have serious doubts about the validity of this study, which purports to show that older Ameicans are not as healthy as older Europeans.
First,the study is based on the participants reporting diagnoses made by their doctors. There can be no guarantee that the patients' memories are entirely accurate. Further, in many cases they may not have fully understood what their doctors told them. Also, we cannot be sure that the diagnoses made by their doctors were uniformly correct.
An additional confounding factor is that the amount of information generally given to patients varies by culture and by country. For example, the incidence of cancer reported by patients was 11% in the United States, 6% in England and 5% in Europe. American patients are more prone to ask questions of their doctors and American doctors are more likely to communicate a diagnosis of cancer, if only for medicolegal reasons. Doctors in England, particularly the older and more traditional members of the profession, are less prone to communicate a diagnosis of cancer or leukaemia to a patient. In some parts of Europe it is quite unusual to inform patients that they have cancer. This practice of witholding the diagnosis increases as one travels east (1).
Surely a more reliable, though far from perfect, way to compare health in different countries is the figures of morbidity and mortality published by many statistical organisations.
(1) Solzhenitsyn, A. Cancer Ward.
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
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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

LETTERS:
Interpreting the rights in the NHS constitution
Heaver and Wainwright (17 February 2009) [Full text]

Interpreting the rights in the NHS constitution
Jumping off the Merry-go-round 11 March 2009

Russell Mayne,
Clinical Lead Physiotherapist
St Thomas' Hospital SE1 7EH,
Mick Thacker
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Re: Jumping off the Merry-go-round

Letter in response to �Interpreting the rights in the NHS Constitution� BMJ 2009;338:b633
Heaver and Wainwright rightly highlight the dangers of a patient being caught on a merry-go-round of fruitless referrals (2009). Indeed the overmedicalisation of self limiting musculoskeletal conditions can be a cause of iatrogenesis, not to mention a waste of resource.
Experience in the clinic focuses attention to another aspect of this issue. While most non-specific low back pain is indeed self limiting, a proportion of these cases fail to resolve (Henschke et al 2008). The reasons for this are clearly complex but it is generally accepted that the both biological and psychosocial factors are at play (Pincus et al 2002).
Patients with non-specific low back pain have questions, concerns and an expectation of an assessment by a specialist in musculoskeletal conditions. While we wholeheartedly agree the patients do not require a routine onward referral, many would benefit from the education and positive message that can be engendered by accessing a specific physiotherapy service. Far from being a Merry-go-round, it can be a vital facet in the return of a patient to full activity, and place them in a better position to manage episodes of back pain in future (Moffett and Mannion 2005). A pragmatic approach to management should always be tempered with clinical judgement of the factors that might cause a non- specific low back pain to become a longer term problem.
Russell Mayne MSc MCSP
Clinical Lead Physiotherapist, Musculoskeletal Outpatients, St Thomas� Hospital, London
Mick Thacker MSc MCSP Grad Dip Phys SRP MMACP
Course Co-ordinator MSc Pain Science and Society, Department of Biomedical and Health Sciences, King's College London
Reference List:
Heaver ES, Wainwright D. Interpreting the rights in the NHS Constitution British Medical Journal 2009 338 b633
Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RD, Bleasel J, York J, Das A, McAuley JH. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. British Medical Journal 2008, 337:a171
Moffett JK, Mannion AF.What is the value of physical therapies for back pain? Best Practice & Research Clinical Rheumatology 2005 19, 4, 623-638
Pincus T; Burton A, Vogel S, Field A, A Systematic Review of Psychological Factors as Predictors of Chronicity/Disability in Prospective Cohorts of Low Back Pain. Spine 2002 27(5), E109-E120
Competing interests: None declared

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
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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
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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

PRACTICE:
A 38 year old woman with hypotensive shock at the onset of menstruation: case progression
Serrano Villar et al. (16 February 2009) [Full text]

A 38 year old woman with hypotensive shock at the onset of menstruation: case progression
Re: Toxic shock syndrome 11 March 2009

Martin Ferry,
Student
G20
Send response to journal:
Re: Re: Toxic shock syndrome

According to the BMJ website, rapid responses should be regarded as letters to the editor. As such there's a reasonable expectation from readers that contributions are prepared in accordance with standard conventions. Dr Bolognesi's contribution bears a striking similarity to the text found on this patient information website: http://www.hipusa.com/webmd/encyclopedia/toxic_shock_syndrome/index.html. Extensive verbatim quotation of such sources should perhaps be acknowledged to avoid any confusion over the origin of text posted on this forum.
Competing interests: None declared

A 38 year old woman with hypotensive shock at the onset of menstruation: case progression
Recurrent collapse and hypotension 11 March 2009

Plutarco Elias Chiquito,
Staff Physician, Emergency Medicine
Erne Hospital, Enniskillen, Northern Ireland BT74 6AY
Send response to journal:
Re: Recurrent collapse and hypotension

This is a very interesting and challenging case and must have been frustrating for the physicians treating a frightened and anxious patient with recurrent collapse without a definitive diagnosis or treatment.
The history of collapse and hypotension responsive to a bolus dose of steroids suggests primary adrenal insufficiency. Life threatening adrenal crisis can present with hypotension or shock, as an acute abdomen or sometimes as sepsis with or without fever. Less severe presentations are often insidious with non-specific symptoms.
Random cortisol levels are often unhelpful and adrenal stimulation with the short synacthen test can be normal in the early stages of the disease. Therefore, I would strongly consider repeating this test.
Anaphylaxis has been mentioned and a serum tryptase level could had been helpful in ruling out this condition.
Reference Arlt W, Allolio B. Adrenal insufficiency. The Lancet; 361: 1881-1893
Competing interests: None declared

RESEARCH:
Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)
Williams et al. (10 February 2009) [Abstract] [Full text] [PDF]

Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution...
Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET) 10 March 2009

John G. Williams,
Consultant Gastroenterologist /Professor of Health Services Research
Swansea University SA2 8PP,
Ian Russell, Dharmaraj Durai, Wai Yee Cheung, Amanda Farrin, Karen Bloor, Simon Coulton and Gerry Richardson
Send response to journal:
Re: Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)

This response raises a few issues which can be clarified.
Firstly, this study was conducted in 2002/03. As a pragmatic trial the procedures and practices used by participating units were not modified. The average time taken for diagnostic endoscopy was the time from one extubation to the next and so reflected the between-patient activities in the participating units. It was not just the time for which each patient was intubated.
We have noted that the combined use of topical spray and sedatives is out of line with BSG recommendations but it was clearly common practice at the time the trial was conducted. Recent evidence suggests that it is more comfortable for patients (Evans LT, Saberi S, Kim HM, Elta GH, Schoenfeld P. Pharyngeal anaesthesia during sedated EGDs: is �the spray� beneficial? A meta-analysis and systematic review. Gastrointest Endosc 2006;63(6):761-6).
We did not collect details of every list, which indeed may be different between doctors and nurses and impact on post-procedure satisfaction. Pressure on space prevented us discussing the fact that nurses tended to diagnose endoscopy as normal less often than doctors and take more biopsies than doctors. This is further discussed in the full report on the study which is available on the HTA website at: http://www.hta.ac.uk/project/1155.asp
Clinical effectiveness is clearly defined as quality of life at one- year and there was no difference between the two groups in this primary outcome. Our finding of an improvement in this quality of life at one year is reflected in other studies including the ENIGMA study http://www.hta.ac.uk/project/957.asp. It does not run counter to the known benefits of test and treat strategies, which also lead to improved quality of life.
We thank Dr Sebastain for raising these issues and giving us the opportunity to clarify them.
John Williams and Dharmaraj Durai
Competing interests: None declared

Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution...
More of the same...ho hum 9 March 2009

Teresa T. Goodell,
assistant professor and ICU nurse
Oregon Health & Science University, 97239
Send response to journal:
Re: More of the same...ho hum

I believe the question regarding whether nurses should perform endoscopies (although we apparently can do so safely and effectively) is a bugaboo; there is no reason why nurses cannot safely and reliably perform screening endoscopies, as this and prior studies have shown. At least in the U.S, nurses are not requesting privileges to perform endoscopic treatments or to evaluate treatment success in people with diagnosed GI illnesses. Rather than impinge on physician practice, nurse endoscopists could free specialist physicians to do the treatment and evaluation functions they ought to do.
This is one in a growing cadre of studies demonstrating the safety and effectiveness of nurse-delivered medical screening and treatment. Often, such studies have shown superior satisfaction among patients. I hypothesize this is attributable to nurses' superior communication and interpersonal skills, a topic taught in nursing educational programs and reinforced in practice. This advantage puts nurses in an ideal position to provide an expanded scope of services in the U.S. and elsewhere, statistically non-significant trends observed in the current study notwithstanding.
Competing interests: None declared

EDITORIALS:
Nurse delivered endoscopy
Norton et al. (10 February 2009) [Full text]

Nurse delivered endoscopy
Doctors and Nurses: Delivering endoscopy 9 March 2009

Said F Mishriki,
Consultant Urological Surgeon
Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB15 6JE
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Re: Doctors and Nurses: Delivering endoscopy

Nurses can do it just as good as doctors, but doctors do it cheaper [1, 2]. The same exercise took place with nurse led flexible cystoscopy (FC) [3]. Adequately trained urology nurse practitioners undertake FC as precisely as consultant urologists [4]. Again, urology nurses were found to be more expensive than doctors between �30, 000 to 48, 000 in 4 months [3]. This was related to more patients having to have general anaesthetic procedures. What has not been audited and should have been is the patient's preference when the diagnosis of cancer is made. Would the patient favour a more experienced doctor? I know under these circumstances whom I would prefer.
1. Williams J, Russell I, Durai D, Cheung WY, Farrin A, Bloor K, et al. Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET). BMJ 2009;338:b231.
2. Richardson G, Bloor K, Williams J, Russell I, Durai D, Cheung WY, et al. Cost effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET). BMJ 2008;337:b270.
3. Nurse-led flexible cystoscopy: experience from one UK centre. Radhakrishnan S, Dorkin TJ, Johnson P, Menezes P, Greene D. BJU Int 2006 98:256-8
4. Gidlow AB, Laniado ME, Ellis BW. The nurse cystoscopist: a feasible option? BJU Int 2000; 85: 651�4
Competing interests: None declared

EDITOR'S CHOICE:
Doctors, patients, and the drug industry
Godlee (5 February 2009) [Full text]

Doctors, patients, and the drug industry
Potential conflicts of interest: more information from JAMA 11 March 2009

Sharon Davies,
letters editor
BMJ
Send response to journal:
Re: Potential conflicts of interest: more information from JAMA

In a letter to JAMA published today (11 March 2009)[1] the lead authors of the study discussed by Leo and Lacasse in their rapid response[2] report and apologise for an incomplete financial disclosure for their study.[3]
Dr Robinson details his involvement with Forest Laboratories and Pfizer, and Dr Arndt his ownership of Pfizer stock.
They end by emphasising that, although Forest Laboratories provided honoraria and expenses through its speakers' bureau to Dr Robinson in 2004 and perhaps 2005, none of the design, analysis, and expenses of their study was supported by funding or any intellectual input from Forest Laboratories.
1 Robinson RG, Arndt S. Incomplete Financial Disclosure in a Study of Escitalopram and Problem-Solving Therapy for Prevention of Poststroke Depression. http://jama.ama-assn.org/cgi/content/full/301/10/1023-a
2 Leo J, Lacasse J. Clinical Trials of Therapy versus Medication: Even in a Tie, Medication wins. 5 March 2009. http://www.bmj.com/cgi/eletters/338/feb05_1/b463#208503
3 Robinson RG, Jorge RE, Moser DJ, Acion L, Solodkin A, Small SL, et al. Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial. JAMA 2008;299(20):2391-400.
Competing interests: None declared

NEWS:
Nine patients are killed as hospital is caught in cross fire in Sri Lankan war zone
Bland (3 February 2009) [Full text]

Nine patients are killed as hospital is caught in cross fire in Sri Lankan war zone
which Hospital? 11 March 2009

Thilli Nathan,
consultant anaesthetist
Watford general Hospital WD18 0HP
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Re: which Hospital?

Part of the area mentioned in this article has imposed a draconian information blackout preventing independent journalists entering there. The journalists are killed, intimidated or kidnapped and disappeared. The news about the tragedies is brought to the outside world by only a few ICRC or other UN agencies, whose offices are attacked for reporting any incidents taking place in above mentioned areas. As a result, these agencies do not want to talk about anything which people might interpret as propaganda. But, unfortunately what is missing in his report was what the reporter meant by hospital.
According to unconfirmed information from these areas, there are about 100 innocent civilians are killed by indiscriminate shelling and bombing daily. Within the last few weeks, 2000 civilians including children and women have been killed. Over 10,000 civilians are injured. There are no more hospitals to be bombed or shelled. The entire areas are made to become a hell, not hospital, to those innocent people caught between the warring parties. This is in the name of war on terror doctrine. The worse insult to mankind is to stand by and witness these tragedies without any pressure on these warring parties to stop. This is not propaganda or news for readers. Let the journalist walk free in these places before reacting with comments as these are inaccurate. When the truth is revealed by independent reporters, it might open another topic which institution should be banned by medical profession. With advancing technology and increasing effect of globalisation, closing our eyes and ignoring this insult to mankind is not appropriate. Adverse effects on health of those living away from these places are inevitable as a result of this war.
Therefore we should not ignore these crimes as local issues or a country�s internal matter. The medical association should explore the ways to minimise these atrocities.
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
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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
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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
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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

Resting heart rate as a low tech predictor of coronary events in women: prospective...
Resting heart rate, blood viscosity and ejection fraction. 11 March 2009

Leslie O Simpson,
retired experimental pathologist
Dunedin, New Zealand 9077
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Re: Resting heart rate, blood viscosity and ejection fraction.

Given that blood viscosity plays an important role in most aspects of heart function, it is unlikely that the importance of resting heart rate can be assessed without recognition of the role of blood viscosity.
In a Health Day interview on February 4, 2009, Professor Judith Hsia, the lead investigator of the resting heart rate study is quoted as stating, "...a higher heart rate in a woman over 50 would indicate a need for the recommended lifestyle modifications needed to prevent cardiovascular problems - a low-fat diet,lower blood pressure, avoiding obesity and more physical activity." Professor Hsia appeared to be unaware that all of the lifestyle changes have similar effects on blood rheology because they lower blood viscosity and/or increase red cell deformability. It is not surprising therefore to find in Table 1 that subjects with more than 76bpm had the highest percentages for hypertension, diabetes mellitus, current smoking, high cholesterol- requiring drugs and the lowest levels of physical activity, all of which share the common feature of increased blood viscosity. It is of some significance that Gullesbrad et al (1) should record in men in the quintile with the highest bpm, the highest levels for smoking, diabetes history,and a history of hypertension. Such changes, in both men and women are associated with higher levels of blood viscosity.
While physical fitness is associated with low resting heart rate and low blood viscosity, in individuals over 50 years of age blood viscosity shows an age-related increase with an increase in resting heart rate. So in physically fit individuals the low blood viscosity and low resting heart rate implies that the reduced vascular resistance will be associated with a large ejection fraction. But in individuals with increased blood viscosity which will raise the resistance to flow,a reduced ejection fraction would require an increased heart rate to provide an adequate volume of blood.
Clements et al (2) hypothesised that, "...within the normal range of resting heart rate, heart rate and left ventricular ejection fraction would be inversely correlated, etc," but made no comment about how blood viscosity changes might influence the situation. It seems that the assessment of resting heart rate could be a surrogate method of assessing blood viscosity, implying that those with high resting heart rates might benefit from a daily supplement of 6 grams of fish oil to lower blood viscosity and to increase the fluidity of red cell membranes. In a study involving 18 men, the effects of placebo or omega-3 fatty acids were assessed in a randomised cross-over study for two 4 month periods. (3) Although the omega-3 fatty acids lowered resting heart rate and improved the heart rate recovery after exercise, there were no other benefits in several other factors. To some extent the results would reflect the great predominance of docosohexanoic acid over eicosapentaenoic acid as it it is the latter acid which has been shown to benefit the flow properties of blood. But no mention was made by the authors of the published information about omega-3 fatty acids and blood flow.
Because of the simple non-invasive nature of resting heart rate, the possible benefits of fish oil in those with high resting heart rates needs to be investigated.
References.
1. Gullesbrad L, Wiksbrand J, Deedwania P, et al. What resting heart rate should one aim for when treating patients with heart failure with beta blockers ? J Am Coll Cardiol 2005; 45: 252-9.
2. Clements IP, Miller WL, Olson LJ. Resting heart rate and cardiac function in dilated cardiopathy. Int J Cardiol 1999; 72: 27-37.
3. O'Keefe JH, Abuissa H, Sastre A, et al. Effects of omega-3 fatty acids on resting heart rate, heart rate recovery after exercise and heart rate variability in men with healed myocardial infarctions and depressed ejection fractions. Am J Cardiol 2006; 97: 1227-30.
Competing interests: None declared

RESEARCH:
Vulnerability and access to care for South Asian Sikh and Muslim patients with life limiting illness in Scotland: prospective longitudinal qualitative study
Worth et al. (3 February 2009) [Abstract] [Full text] [PDF]

Vulnerability and access to care for South Asian Sikh and Muslim patients with life...
Authors' response Re: The Ethics of Research and Accusations of Racism 9 March 2009

Aziz Sheikh,
Professor of Primary Care Research & Development
Centre for Population Health Sciences, University of Edinburgh EH8 9DX,
Allison Worth, Tasneem Irshad, Raj Bhopal, Duncan Brown, Julia Lawton, Elizabeth Grant, Scott A. Murray, Marilyn Kendall, James Adam, Rafik Gardee
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Re: Authors' response Re: The Ethics of Research and Accusations of Racism

We are grateful to Dr Keeley for raising pertinent issues in his response to our paper. We too were shocked by the case referred to, and the authors debated how to deal with it, both in terms of the individual�s care and also in the subsequent reporting and publishing of the details of this important and illustrative case. There are no clear-cut solutions to these ethical dilemmas and we stand by our carefully considered judgement of the case.
It is important to make clear that we use the case as an example of direct, rather than institutional racism. Also relevant to note is that we do not use the term �institutional racism� to label entire institutions as racist, but rather use this term to describe policies and traditions within them which can disadvantage ethnic minorities.1 This in itself is not a new claim with respect to aspects of NHS care;2 in this study, we identified institutional racism in the failure of some institutions in our study to meet basic communication and dietary needs and provide culturally sensitive care. We also point out that such institutional discrimination is usually unwitting.
Turning to the case in point, Dr Keeley asks if the patient�s claims were verified. We were in this study primarily concerned with understanding patient perceptions of care, but that said, verification of the patients� perceptions were possible on two fronts. Firstly, the researcher observed the patient being treated rudely by a member of staff. Secondly, the professional interview provided corroboration of the patient�s wider claims. This professional was subsequently instrumental in ensuring that the patient received better care, within the same institution, with which the patient was extremely satisfied. These observations thus indicate that appropriate action was taken within the institution to improve the care delivered to this individual.
Dr Keeley then suggests it is the responsibility of the research team to confront racism head on. Whilst we of course appreciate and understand this sentiment, respectfully we disagree: the responsibilities of researchers are different to those of clinicians.3 Many of the authors are both researchers and clinicians and are highly aware of the ethical dilemmas of balancing duty of care with maintaining the scientific rigour of the research.4 Reporting the experiences of participants as accurately as possible, with the ultimate aim of improving care for all, is the main aim of research. Researchers often uncover evidence of unsatisfactory care, and have to make a judgement about whether they have an ethical duty to intervene. They rarely do, as they risk doing more harm than good to the individual patient and damaging future access to the field for other researchers. In our paper, we also documented the considerable impact that an individual practitioner had on dramatically improving the quality of care provision to the patient in question. Direct intervention in such a case would have curtailed our opportunity to report and understand this.
Publication of research findings, however uncomfortable to read, can and does contribute to influencing practice. We are aware of at least one Health Board which is now taking action to address the wider issues we raise in the paper. We were encouraged by the willingness of many health and social care professionals in our study to both acknowledge the inadequacies of care for ethnic minority groups and their willingness to learn how to provide better care.
References
1. Macpherson W. Report for the Stephen Lawrence Inquiry. London: The Stationery Office, 1999.
2. Warden J. NHS to come under Race Relations Act. BMJ 1999; 318 (7184): 625.
3. Sheikh A, Hurwitz B, Parker M. Ethical and research dilemmas arising from a questionnaire study of psychological morbidity among general practice managers. BJGP 2001; 51: 32-35.
4. Jubb AM. Palliative care research: trading ethics for an evidence base. J Med Ethics 2002;28:342-346
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
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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
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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
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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

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	ANALYSIS: Commentary: Standing up for free speech O’Donnell (24 February 2009) [Full text]	Extremism can be frightening David Isaacs (9 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) The Editor responds to charges of anti-Israel bias in the BMJ Fiona Godlee (11 March 2009) Diabetes in Gaza: Getting the Facts Correct Paul Z Zimmet (10 March 2009) Wolf in Sheeps Clothing Shawn Malachovsky (10 March 2009) To Tony Delamothe Re his rapid response Elliot Daniel (9 March 2009) Read every Rapid Response to this article

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	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

	PRACTICE: Coeliac disease Jones and Sleet (19 February 2009) [Full text]	Undiagnosed maternal celiac disease in pregnancy and an increased risk of fetal growth restriction. Fergus P McCarthy, et al. (11 March 2009) Read every Rapid Response to this article

	NEWS: Older Americans are not as healthy as older Europeans, study says Tanne (18 February 2009) [Full text]	Is this study valid ? Alexander Spiers (9 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

	LETTERS: Interpreting the rights in the NHS constitution Heaver and Wainwright (17 February 2009) [Full text]	Jumping off the Merry-go-round Russell Mayne, et al. (11 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

	PRACTICE: A 38 year old woman with hypotensive shock at the onset of menstruation: case progression Serrano Villar et al. (16 February 2009) [Full text]	Re: Toxic shock syndrome Martin Ferry (11 March 2009) Recurrent collapse and hypotension Plutarco Elias Chiquito (11 March 2009) Read every Rapid Response to this article

	RESEARCH: Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET) Williams et al. (10 February 2009) [Abstract] [Full text] [PDF]	Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET) John G. Williams, et al. (10 March 2009) More of the same...ho hum Teresa T. Goodell (9 March 2009) Read every Rapid Response to this article

	EDITORIALS: Nurse delivered endoscopy Norton et al. (10 February 2009) [Full text]	Doctors and Nurses: Delivering endoscopy Said F Mishriki (9 March 2009) Read every Rapid Response to this article

	EDITOR'S CHOICE: Doctors, patients, and the drug industry Godlee (5 February 2009) [Full text]	Potential conflicts of interest: more information from JAMA Sharon Davies (11 March 2009) Read every Rapid Response to this article

	NEWS: Nine patients are killed as hospital is caught in cross fire in Sri Lankan war zone Bland (3 February 2009) [Full text]	which Hospital? Thilli Nathan (11 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) Resting heart rate, blood viscosity and ejection fraction. Leslie O Simpson (11 March 2009) Read every Rapid Response to this article

	RESEARCH: Vulnerability and access to care for South Asian Sikh and Muslim patients with life limiting illness in Scotland: prospective longitudinal qualitative study Worth et al. (3 February 2009) [Abstract] [Full text] [PDF]	Authors' response Re: The Ethics of Research and Accusations of Racism Aziz Sheikh, et al. (9 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