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Rapid Responses: Rapid Responses published:
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Be bold, sensible, but especially clever: the pre-metabolic syndrome.
- Sergio Stagnaro (5 September 2003)
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Rationing and prioritising
- Peter J Allmark (5 September 2003)
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'NICE' also involves Wales!
- Robert CM Stephens (6 September 2003)
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My apologies to the Welsh--together with a question for Northern Ireland, Scotland, and Wales
- Richard Smith (6 September 2003)
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A rose by any other name would smell as sweet
- John Hopkins (8 September 2003)
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Wales matters
- susanne McCabe (8 September 2003)
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Is it being bolder or being more sensible? or both?
- Dr. Sindhu Singh, New Delhi-110029 (9 September 2003)
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Be NICE and simple
- James Curran (9 September 2003)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8. 16037 Riva Trigoso (Genoa) Italy.
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Sir, Famously, Virgilio wrote “Fortuna adjuvat audaces” (1), but Petronio stated “Suam habet fortuna rationem”. Here it is. In any medical field, at the base of all events, there is clearly what the Greeks called “logos”. For instance, under the same conditions only some people, but not all, are involved by chronic pulmonary disorders, and/or coronary artery diseases, and/or cancer, a.s.o. Without any doubt, there is a reason that accounts for such as reality. We must certainly be bold and sensible; however,we must be also clever and think that “They are not direct environmental causes of disease, like smoking, but they may be seen as biochemical or biophysical variables, under partial genetic control, that are intermediates between environmental factors and disease itself” (2). In this regard, See my site HONCode ID. N°233736, http://digilander.iol.it:semeioticabiofisica: Biophysical-Semeiotic Constitutions, URL: http://digilander.libero.it/semeioticabiofisica/constitutions.htm, as well as the Page, I hold weekly in the italian site www.katamed.it, Semeiotica Biofisica, the article N° 13 “Oncological Terrain” (3, 4, 5, 6). As a matter of fact, smokers without oncological constitution, i.e. “Oncological Terrain”, are and will surely not be affected by any cancer, as allows us to state a very large number of clinical evidence. Certainly, interventions to lower blood pressure, serum cholesterol, and other risk factors [such as IIR (!)] reduce the risk of cardiovascular disease regardless of initial levels, even reducing them as much as possible (2). However, in my opinion, we must go “beyond the risk factors”, i.e., know the Pre-Metabolic Syndrome (in above-cited site, URL: http://digilander.libero.it/microangiologia/Documenti/Eng/Pre- metabolic%20syndrome%20engl.doc). In fact, Primary Prevention of the most common and dangerous human pathologies, e.g. malignancies, depends clearly by easy and quick bed-side detecting individuals at "real" risk, i.e. involved by well- defined biophysical-semeiotic constitution, assessed clinically in “quantitative” way, in well defined part of a biological system (6). 1) Smith R. Be bold and be sensible. BMJ 2003;327 (6 September) 2) Law MR., Wald NJ. Risk factor thresholds: their existence under scrutiny. BMJ 2002;324:1570-1576 ( 29 June ). 3)Stagnaro S. Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. [PubMed –indexed for MEDLINE]. 4) Stagnaro-Neri M., Stagnaro S., La “Costituzione Colelitiasica”: ICAEM- a, Sindrome di Reaven variante e Ipotonia-Ipocinesia delle vie biliari. Atti. XII Settim. It. Dietol. ed Epatol. 20, 239, 1993. 5) Stagnaro-Neri M., Stagnaro S., Diagnosi Clinica Precoce dell’Osteoporosi con la Percussione Ascoltata. Clin.Ter. 137, 21-27, 1991 [Pub-Med indexed for MEDLINE] . 6) Stagnaro-Neri M., Stagnaro S., Cancro della mammella: prevenzione primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It. – Arch. Sc. Med. 152, 447, 1993. Competing interests: None declared |
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Peter J Allmark, Senior Nursing Lecturer School of Nursing, Sheffield University, SFH, NGH S5 7AU
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Richard Smith tells us that NICE should not fear using the "r" word (rationing) that politicians will not use. The latter, of course, prefer terms such as "priorities" and "prioritisation". This muddies a useful distinction. Someone, such as a nurse, "prioritises" a set of patients' needs when she intends to meet all of them but in a certain order of priority. She rations when she decides that some patients' needs cannot be met. It follows that when NICE decide that a treatment is effective but not cost-effective it is rationing, not "setting priorities" or whatever. This may well be a necessary task but we should not be mealy-mouthed about it. Furthermore, we may question NICE's ability to make such decisions. It can, as Richard Smith says, decide whether a treatment is effective "purely on the evidence". By contrast, deciding that, say, the needs of infertile couples trump some needs of people with Parkinson's disease is an ethical or value judgement. Whence derives NICE's expertise in making such judgements? Competing interests: None declared |
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Robert CM Stephens, Reserach Fellow w1
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Dear Editor, Dr Smith's 'Editors choice' strikes a chord: we should be bold, but he is wrong to describe the National Institute for Clinical Excellence as 'England's'. A glance at the website reveals half of it is in Welsh! (http://www.nice.org.uk/) Best Wishes
Competing interests: None declared |
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Richard Smith, Editor BMJ
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I apologise to the people of Wales for not making clear that the National Institute of Clinical (NICE) belongs to Wales as well as England--particularly as I knew that it did. But I want to explain my thinking and ask for guidance from the peoples of Northern Ireland, Scotland, and Wales (please note that these are in alphabetical order). Because the BMJ has more readers outside Britain than inside it I didn't want to write simply "The National Institute of Clinical Evidence." I didn't want to write "Britain's National Institute of Clinical Evidence" because that would be wrong. I wondered about writing "England and Wales's National Institute of Clinical Evidence," but this created two problems. Firstly, it's an ugly phrase, almost impossible to say with even half a pint of good Welsh beer in your belly. My editor's choice is a chatty, journalistic piece: I want to make it as easy to read as possible. Secondly, although I knew that NICE doesn't cover Scotland, I wasn't sure about Northern Ireland. I could have looked it up, but it just didn't seem that important. And if it did--as I think it may in a roundabout sort of way--what would I write? I couldn't write "England, Wales, and Northern Ireland's National Institute of Clinical Evidence...," but I could perhaps have written: " The National Institute of Clinical Evidence, which covers England, Wales, and Northern Ireland..." But does it matter that much? That's the question I want to ask the peoples of Northern Ireland, Scotland, and Wales. Richard Smith, editor, BMJ Competing interests: I'm the editor of the BMJ and accountable for all that it contains, including insults to the peoples of Northern Ireland, Scotland, and Wales |
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John Hopkins, GP Jubilee Medical Group Newton Aycliffe
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Dear Dr Smith It’s good that many people around the world read the BMJ. Presumably most of them know where its Editor is based and assume that, in the absence of clarification, he is referring to what goes on in Britain. Certainly the CNN web site doesn’t spend time telling people the Food and Drug Administration is based in Washington. And it’s always helpful to be reminded that London is in England. Yours sincerely, John Hopkins Competing interests: None declared |
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susanne McCabe, retired home
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Yes it does matter - even now when asked where I am from - I say Wales - the response can be is 'O from England'! No from WALES. Perhaps if NICE and other bodies made a deliberate effort to recruit members from all parts of the UK it would help. London is still seen as the centre of the universe perhaps because so many UK institutions have been based there. How about the U.K. Institute for Clinical Excellence. Sorry I cannot spell it in Welsh! Competing interests: I am a Welsh person who has spent most of my life in London when Wales was treated like an outpost of England. |
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Dr. Sindhu Singh, Resident All India Institute of Medical Sciences, New Delhi-110029
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Contemporary medicine is full of stories of such courage wherein people have relentlessly fought against all odds to search for newer ways and means to treat diseases and relieve human suffering. Morton, a rather obscure name in medicine brought ether into medical practice when all others thought that it was a joke to do painless surgeries. Frossman catheterized himself while just being 25 and it was his effort that led to discovery of one of the important tool in interventional cardiology. Similarly, Banting and Best spent their college days searching for an obscure element, which was later discovered to be insulin. On the same ground, I guess, these and many other stories are based. We would continue to see, till the end of time, a search, which is ceaseless and unending. Few days back BMJ published a report that morphine can be used in undiagnosed abdominal pain; is a similar finding. In the same way, against the prevalent dictum, if we come to know that morphine can be used to relieve the incessant or refractory dyspnoea; the finding comes as a respite for millions of cases of chronic obstructive lung disease worldwide. Therefore, I guess, it’s a combination of being bolder, innovative but being sensible at the same time. If we were to make a choice between these two; the former is likely to overpower the latter. Competing interests: None declared |
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James Curran, GP G41 3LQ
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I think John Hopkins put it well, so there is little to add except to say that sometimes the BMJ ties itself in knots trying to needlessly explain things like this to readers outside of the UK, which seems like a needless waste of energy. If there happens to be more than one body in the world with the same name it is easy simply to qualify it by referring to its location, for example "NICE (London)". By the way, there was a news item a few months ago which referred to something called the "English Parliament" What's that? Competing interests: None declared |
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