With head and heart and hand
  Portraits of 20th century British doctors by Nick Sinclair


BMJ No 7084 Volume 314 Saturday 22 March 1997

This Week in BMJ | Editor's Choice | Press releases | Advertisement details

Editorials
839 A wake up call for sleep disordered breathing John A Fleetham

840 Scientific imperialism Peter Wilmshurst

841 All doctors are problem doctors Richard Smith

843 Sudden cardiac death in the young J F Goodwin

844 Maternity services: the Audit Commission reports James Drife

News
845 Routine pregnancies and obstetrician care * Twins may protect against breast cancer * Paris restricts use of cars * Radioactive pollution exposed in France * Doctor with HIV struck off medical register * European parliament calls for human cloning ban * Dutch will buy costly anticancer drugs * Smokers are misled about low tar * Patients die after managers' decision * Poverty has effect on young people's health * Young people's mental health neglected * Stockings reduce thrombosis complications * High Court detains girl with anorexia * Germany introduces more health reforms * Consultants blamed over complaints

Papers
851 Health effects of obstructive sleep apnoea and the effectiveness of continuous positive airways pressure: a systematic review of the research evidence John Wright, Rachel Johns, Ian Watt, Arabella Melville, Trevor Sheldon

860 Snoring and breathing pauses during sleep: telephone interview survey of a United Kingdom population sample Maurice M Ohayon, Christian Guilleminault, Robert G Priest, Malijai Caulet

864 Effectiveness of the public health policy for breast cancer screening in Finland: population based cohort study Matti Hakama, Eero Pukkala, Minna Heikkilä, Mervi Kallio

868 Timing of paediatric deaths after trauma J P Wyatt, L McLeod, D Beard, A Busuttil, T F Beattie, C E Robertson

869 Drug points: Quinolones may induce hepatitis S E Jones, R H Smith

Hypoglycaemia associated with formestane treatment E Brankin, A Gallagher, M Soukop

General practice
870 Why general practitioners and consultants change their clinical practice: a critical incident study Lynne A Allery, Penny A Owen, Michael R Robling

Clinical review
875 Fortnightly review: Diagnosing and managing genitourinary prolapse Simon Jackson, Phillip Smith

880 Lesson of the week: Acute non-cardiogenic lung oedema after platelet transfusion A E Virchis, R K Patel, M Contreras, C Navarrete, R S Kaczmarski, R Jan-Mohamed

883 ABC of clinical haematology: The myelodysplastic syndromes David G Oscier

Education and debate
887 An ethical dilemma: Availability of antiretroviral therapy after clinical trials with HIV infected patients are ended Peter E Cleaton-Jones

888 Strident, but essential: the voices of people with AIDS Peter Busse

889 Drug companies have a duty to continue treatment Sean Emery, David A Cooper

890 A case for goodwill G R McLean

890 A partnership to resolve the conundrum Peter King

891 Surgical training: an objective assessment of recent changes for a single health board T J Crofts, J M T Griffiths, S Sharma, J Wygrala, R J Aitken

895 Primary care - opportunities and threats: The changing meaning of the GP contract Jane Lewis

Letters
899 Malignant cerebral glioma M Brada and others; D Guerrero and others; J Chappell; P Salander and others; N G Burnet and R E Taylor; E Davies and others

901 Presentational skills are taught in some hospitals D Cummins

901 Hillsborough television drama D Slater

902 Suicides after pregnancy C Ll Morgan and others; S Mitchison; M Gissler and others

903 What clinical information do doctors need? T D Kennedy and others; K W Moody; G Brooks; A Nobili and others; D C Slawson and A F Shaughnessy; B M Doran; A Verhoeven

905 Management of needlestick injuries would be easier if consent for "donor" testing was not necessary E Walker and P Wright

905 Sri Lankan refugees are not at risk of persecution Signed by 14 Sri Lankan doctors working in Britain

Obituaries
833 D R Bromham, R de Mowbray, J L Griffin, C Glancy

Medicopolitical digest
908 NHS management costs Accident and emergency services Training in general practice Cohort of preregistration house officers

Personal views
909 Small is beautiful Liam Farrell

An axeman writes Irvine Loudon

Medicine and the media
910 Trust me - I'm a doctor Naomi Craft

Medicine and books
911 From Hogarth to Rowlandson: Medicine in Art in Eighteenth Century Britain Fiona Haslam
J H Baron

Minerva
912

S2 Career Focus Classified supplement
Opportunities for a career in clinical pharmacology Nigel Baber, Morris J Brown and David Webb

Editor's choice

Deep and shallow truths

A deep truth, said physicist Niels Bohr, is just as true as its opposite. In contradistinction, the opposite of a trivial truth is false. Christopher Martyn tells us this on p 874, describing how Bohr would quote his grandfather to illustrate his theme. The teacher Peter George Bohr explained to his class that the biblical quotation "man having put his hand to the plough, and looking back is fit for the kingdom of God" meant that "you must be guided by ancient wisdom." But, said a student, the text actually reads: "No man, having put his hand to the plough, and looking back is fit for the kingdom of God." "Of course," said Peter Bohr, "and it means that you must be ready to move on without being constrained by the past." Niels Bohr believed that the task of science was to reduce deep truths to trivialities.

Perhaps this story will help us understand sleep apnoea. Is this a disease or not? Many readers of the BMJ graduated from medical school before sleep apnoea was "invented." But in the past 10 years they will have grown used to the idea that sleep apnoea - ranging from chronic snoring through obstructive sleep hypopnoea to severe obstructive sleep apnoea - is common and associated with severe consequences. It causes daytime sleepiness and has been linked with premature death, hypertension, ischaemic heart disease, stroke, and road traffic accidents. Sleep apnoea, says the New England Journal of Medicine, may be as big a public health hazard as smoking.

Now a systematic review tells us that the harmful effects of sleep apnoea may have been greatly exaggerated (p 851). This may not be a disease at all. The authors found 54 studies that linked sleep apnoea with health related outcomes. Most were poorly designed and did not adjust adequately for confounding factors like obesity, smoking, age, and alcohol consumption. The evidence linking sleep apnoea to harmful effects is thus inconclusive. And the few trials of treatment have not shown any improvement in morbidity, mortality, and quality of life. An editorial from a professor of medicine argues that the time has come to produce much higher quality evidence (p 839).

An equally difficult question - faced by ethics committees in the developing world - is whether to allow a trial of a treatment if that treatment will not be available to those in the trial at its end (p 887). This problem arises with expensive treatments, like those for HIV infection. They are available within a trial, funded by a pharmaceutical company, but not outside the trial. Peter Cleaton-Jones's committee in South Africa has not allowed trials unless treatment can be continued when the trial ends. Others take a different view in an ethical debate, while the redoubtable Peter Wilmshurst accuses some researchers of scientific imperialism (p 840).

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