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

BMJ No 7086 Volume 314 Saturday 5 April 1997

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

Editorials

987 Discovering the causes of atopy Seif Shaheen

988 Patients in the community Julie K Johnston

989 Should we screen for prostate cancer? Steven H Woolf

991 Facial disfigurement D A McGrouther

992 Authorship: time for a paradigm shift? Richard Smith

990 Correction: Drug delivery from inhaler devices Hans Bisgaard

News

993 Court rules on compulsory caesareans * French doctors' strike hots up * Australian euthanasia law overturned * Children with learning disabilities lack support * US cracks down on healthcare fraud * Mental illness missed among black people * Hillsborough survivor emerges from PVS * Junior doctors object to `training tax' * Hospital services for children are poor * Wine may prevent dementia * European Union tackles AIDS * WHO leadership challenge

Papers

999 Cross sectional retrospective study of prevalence of atopy among Italian military students with antibodies against hepatitis A virus Paolo M Matricardi, Francesco Rosmini, Luigina Ferrigno, Roberto Nisini, Maria Rapicetta, Paola Chionne, Tommaso Stroffolini, Paolo Pasquini, Raffaele D' Amelio

1003 Atopic dermatitis and birth factors: historical follow up by record linkage Anne Braae Olesen, Anne Ringer Ellingsen, Hanne Olesen, Svend Juul, Kristian Thestrup-Pedersen

1009 The vexed question of authorship: views of researchers in a British medical faculty Raj Bhopal, Judith Rankin, Elaine McColl, Lois Thomas, Eileen Kaner, Rosie Stacy, Pauline Pearson, Bryan Vernon, Helen Rodgers

1013 H2 blockers in the intensive care unit: ignoring the evidence? Telephone survey D L A Wyncoll, P C Roberts, R J Beale, A McLuckie

1012 Correction: Lifetime socioeconomic position and mortality: prospective observational study George Davey Smith and others

General practice

1014 General practitioners' knowledge of their patients' psychosocial problems: multipractice questionnaire survey P al Gulbrandsen, Per Hjortdahl, Per Fugelli

Clinical review

1019 Chronic venous ulcer Niren Angle, John J Bergan

1023 Grand Rounds MHammersmith Hospital: Hazards of running a marathon G R Thompson

1026 ABC of clinical haematology: Bleeding disorders, thrombosis, and anticoagulation K K Hampton, F E Preston

Education and debate

1030 Health targets in the NHS: lessons learned from experience with breast feeding targets in Scotland Harry Campbell, Anne Gibson

1033 Integration of hepatitis B vaccination into national immunisation programmes Pierre Van Damme, Mark Kane, André Meheus on behalf of the Viral Hepatitis Prevention Board

1036 Commentary: Antenatal screening and targeting should be sufficient in some countries Philip P Mortimer, Elizabeth Miller

1037 Socioeconomic determinants of health: Health and social cohesion: why care about income inequality? Ichiro Kawachi, Bruce P Kennedy

Letters

1041 Gulf war illness P Beale; P Heaf and N Jones

1041 Chronic forearm pain C M Colles and others; L C Bainbridge

1042 Disorders of spermatogenesis in Finland M Joffe; J Pajarinen and P J Karhunen

1043 Penetrating intraoral trauma may occur in adults as well as children S S Rayatt and others

1043 Suspension of nurse who gave drug on consultant' s instructions J M Kellett; D Curtis

1044 Allowing relatives to witness resuscitation C A J McLauchlan

1044 Medicine, postmodernism, and the end of certainty N Raithatha; J Harrison; P R Hunter; D P Frost

1045 Rationing breast reduction surgery N Horlock and others

1046 Authorship A Barker and R A Powell; R S Bhopal and others

1047 New bill offers control for mentally disordered offenders D J Thompson

1047 Traders' views on sale of cigarettes to children D W Jones and A Charlton

1048 Head up tilt testing has a place in distinguishing certain conditions from epilepsy A Zaidi and others

1048 Prognosis for babies of less than 28 weeks' gestation T H H G Koh

1048 Teleconferencing should be extended to include job interviews G Briars

Obituaries

1049 J S Bailey, A C P Campbell, J F B Carter, P Crann, C E L Freer, J L Freer, J Hazelton, W J Hughes, A R Hunt, B H Kirman, W Love, J Marshall, D Wilkes

Medicopolitical digest

1051 Defence medical services * Juniors' poor food and accommodation * Health of the Nation targets * GP salaried service * Juniors criticise pay review phasing * BMA calls for no discrimination

Views & reviews

1053 Personal views My lonely battle with disease James Owen Drife

Running the New York marathon with diabetes Bjorn Kjeldby

Medicine and the media

1054 Harsh decisions behind closed doors Sandra Goldbeck-Wood Genetics: let the public decide Gail Vines

Medicine and books

1056 Emergency Triage Ed Kevin Mackway-Jones Colin Robertson

Osteoporosis Prevention and Management in Primary Care Colin Waine Cindy L K Lam

Gene Therapy Ed N R Lemoine, D N Cooper Sir David Weatherall

Minerva

1058

S2 Career Focus Classified supplement

Changing partnership Neil Snowise

Editor's choice

Relating published evidence to individual patients

One of medicine's greatest challenges is to relate what you read to how you respond to the patient in front of you. Imagine a 60 year old man asking you whether he should be screened for prostate cancer. What do you say? Steven Woolf considers this question in an editorial (p 989).

The enthusiast for evidence based medicine would probably advise the man not to bother. A test for prostate specific antigen produces many false positives. A third of tumours detected to do not progress. There is no good evidence that treatment improves outcomes. And the complications from screening and treatment may well offset any benefits. So, it's easy.

But - absence of evidence of effectiveness does not equal evidence of ineffectiveness. It remains a plausible hypothesis that screening reduces deaths from prostate cancer. The man, argues Woolf, should be told that. He might then decide that he would like to be screened. In an individualist society like the United States that's exactly what happens, at least with patients who are fully insured. One result has been an "epidemic" of prostate cancer. In contrast, in a country like Britain where people recognise that NHS resources spent on prostate screening will be diverted from somewhere else the man may well decide against screening. Thus does the doctor sit at the centre of a complex web of evidence, individual preference, economic pressures, and cultural values. It can be hard but isn't dull.

The issue of relating evidence to individual patients comes up again in a paper on prophylaxis against the gastroduodenal erosions that are common in patients in intensive care units (p 1013). Both H2 receptor antagonists and sucralfate given prophylactically reduce bleeding from the erosions. But H2 receptor antagonists cause other problems, particularly an increase in nosocomial pneumonia. A meta-analysis published in 1996 showed that sucralfate is associated with a lower incidence of pneumonia and mortality than H2 receptor antagonists. Yet, observed the doctors working at Guy's Hospital, many critically ill patients arriving from other hospitals are being treated with H2 receptor antagonists not sucralfate.

One of the hardest set of circumstances in which to relate published evidence to individual patients is in the case of "diseases that might not be diseases" - like myalgic encephalomyelitis or Gulf war syndrome. On p  1041 Peter Beale, who was surgeon general in Britain from 1991-4, explains why it has taken so long to decide to investigate Gulf war syndrome, while on p  1053 Jim Drife describes his lonely battle with a new syndrome - unilateral left lobe enlargement (ULLE). (We are talking ears, not lungs or livers.) "Because," he observes, "ULLE is not mentioned at medical school doctors think that it does not exist."