14 Rapid Responses published for 13 different articles.

Articles			Rapid Responses
	PRACTICE: Depression in adults, including those with a chronic physical health problem: summary of NICE guidance Pilling et al. (27 October 2009) [Full text]		Depression: its pathophysiology and treatment. Les.O Simpson   (20 November 2009) Medical illnessess and depression. Gnanie Panch   (20 November 2009) Read every Rapid Response to this article
	RESEARCH METHODS & REPORTING: The tyranny of power: is there a better way to calculate sample size? Bland (6 October 2009) [Full text]		A different test ? Peter H FITTON   (20 November 2009) Read every Rapid Response to this article
	EDITOR'S CHOICE: The power of stories Groves (20 November 2009) [Full text]		If thought corrupts language, language can also corrupt thought. BM Hegde   (20 November 2009) Read every Rapid Response to this article
	NEWS: Poor care in hospital is delaying discharge of patients with dementia, charity says Kmietowicz (18 November 2009) [Full text]		Sound findings but confusing statistics David E Stewart   (20 November 2009) Read every Rapid Response to this article
	EDITORIALS: Is primary care research a lost cause? Mar (18 November 2009) [Full text]		Neglected virgin areas in primary health care basic and applied research. Rodolfo J. Stusser   (20 November 2009) Read every Rapid Response to this article
	NEWS: Hospitals are criticised for yielding to pressure over human rights lecture Dyer (17 November 2009) [Full text]		Pressures on UK medical institutions regarding coverage of Israel-Palestine derek a summerfield   (20 November 2009) Read every Rapid Response to this article
	NEWS: Patents on breast cancer genes are illegal and stymie research, say scientists Lenzer (17 November 2009) [Full text]		Claims and uses are the real problem, not patenting Robert M Cook-Deegan   (20 November 2009) Read every Rapid Response to this article
	VIEWS & REVIEWS: Politics, science, and the White House Smith (17 November 2009) [Full text]		Harold Varmus and The Art of Politics and Science Felix ID Konotey-Ahulu   (20 November 2009) Read every Rapid Response to this article
	VIEWS & REVIEWS: Learning to teach Jackson (12 November 2009) [Full text]		Practical Teaching Tips Avtar Singh   (20 November 2009) Read every Rapid Response to this article
	RESEARCH: Slow walking speed and cardiovascular death in well functioning older adults: prospective cohort study Dumurgier et al. (10 November 2009) [Abstract] [Full text] [PDF]		Good study; few questions DR.Indranil Banerjee, et al.   (20 November 2009) Read every Rapid Response to this article
	EDITORIALS: Slow walking speed in elderly people Harwood and Conroy (10 November 2009) [Full text]		Sprint your way to immortality Michael O'Donnell   (20 November 2009) Read every Rapid Response to this article
	NEWS: Battle against hospital acquired infections has been too limited, MPs’ report says Mayor (11 November 2009) [Full text]		Infection Control - what is the point? Jenna L Morgan, et al.   (20 November 2009) Read every Rapid Response to this article
	RESEARCH: Aspirin for primary prevention of cardiovascular events in people with diabetes: meta-analysis of randomised controlled trials De Berardis et al. (6 November 2009) [Abstract] [Full text] [PDF]		Re: Aspirin. A long life with always a new fashion Les O. Simpson   (20 November 2009) Read every Rapid Response to this article

PRACTICE: Depression in adults, including those with a chronic physical health problem: summary of NICE guidance Pilling et al. (27 October 2009) [Full text] Depression in adults, including those with a chronic physical health problem: summary... Depression: its pathophysiology and treatment. 20 November 2009 Les.O Simpson, retired experimental pathologist Dunedin New Zealand 9077 Send response to journal: Re: Depression: its pathophysiology and treatment. The article by Pilling et al discusses treatment of depression without reference to the pathophysiology. However, there are a number of published reports which raise the possibility that depression is a consequence of impaired cerebral blood flow. Possibly such studies have been rejected because of their small size. But a PubMed search for "Depression and impaired cerebral blood flow," produced 60 titles. Even though many of such studies involve animals, they show a common thought pattern. In 1995, Bench et al reported a study in which patients underwent brain scans while depressed, and were rescanned on remission. The report concluded, "Thus, recovery from depression is associated with increases in regional cerebral blood flow in the same area in which focal decreases in regional cerebral blood flow are described in the depressed state, in comparison with normal subjects." It is difficult to ignore such direct observations as they imply that depression has a blood flow-related cause. While there is general acceptance that stressful events are triggers for episodes of depression, it seems not to be recognised that the stress hormones stiffen the red blood cells. The resulting reduction in cell deformability will increase blood viscosity. For example, the English translation of a paper in Italian (Psychological stress and sudden death, 2002) included the statement, "...the second mechanism acts through adverse health behaviours, such as poor diet, alcohol consumption or smoking in case of acute psychological stress, the mechanisms involved are mainly the ability to trigger myocardial ischemia, to promote arrhythmogenesis, to stimulate platelet function and to increase blood viscosity." It seemed not to be recognised that the increased blood viscosity was the primary agent. As similar statements have been made by other authors, it is not surprising that a PubMed search for "Depression and blood viscosity," should produce 83 titles. This raises the pertinent question, "Could treatments aimed at reducing blood viscosity be helpful for those suffering from depression?" As Stoll has reported that fish oil was an excellent mood stabiliser in bipolar disorder, and 6 grams of fish oil daily has been found to be an effective treatment for hypertension, would 6 gams of fish oil daily help those suffering from major depressive disorder ? Competing interests: None declared Depression in adults, including those with a chronic physical health problem: summary... Medical illnessess and depression. 20 November 2009 Gnanie Panch, consultant in chronic pain managment and anaesthesia Whittington hospital London N195NF Send response to journal: Re: Medical illnessess and depression. NICE guidelines 90, 91 and 88 The nice guidelines published by Pilling et al come 14 years after the publication of the joint recommendations by the royal colleges of physicians and psychiatrists – The psychological care of medical patients, recognition of need and service provision document. It is a timely reminder at a time when the CG 88 has caused so much of controversy. It emphasizes the need for considering emotional factors as co-morbidity among patients who fail to show predictable response to treatment of physical conditions. The document emphasizes the reality - under recognition being the major problem, particularly in those suffering from physical illnesses. The continuing acceptance in the 21st century of the Descarte’s philosophy of mind body dualism inevitably leads to an under recognition of depression in secondary care. The authors have described the consequences to patients and the wider society of continuing to ignore depression and have outlined the recommendations for the clinical assessment, screening and treatment. It is worth emphasizing that the “Two questions depression screen” is 97% sensitive and 59% specific. Therefore its use on a target group of physically ill patients whose care fails to result in expected improvement is to be highly recommended. Unfortunately the NICE GDG for the CG 88 have not included the recommendations for screening, severity scoring, monitoring or the use of pharmacological treatments for those who are diagnosed to be severely depressed. It is clear that the CG90and 91 recommendations could be applied to chronic pain care. All clinicians, even within the limited time available, could administer screening and severity scoring questionnaires. Emotional factors being a major component in chronic pain, its improvement is worth measuring as a response to chronic pain treatments. Finally it is worth reiterating Lord Darzi’s slogan – “we can only aim to improve on what we actually measure” Competing interests: None declared

RESEARCH METHODS & REPORTING: The tyranny of power: is there a better way to calculate sample size? Bland (6 October 2009) [Full text] The tyranny of power: is there a better way to calculate sample size? A different test ? 20 November 2009 Peter H FITTON, GP Lepton surgery, Highgate Lane,Huddersfield HD8 0HH Send response to journal: Re: A different test ? Has anyone noticed that this article is exceptionally well written? Not only is is well organised, structured,and argued ; with exactly the right examples in precisely the right places: but the prose is lucid, simple and spare. It is in fact quite beautiful This may not make it right, but it does make it unusual! Competing interests: Martin taught me statistics nearly thirty years ago

EDITOR'S CHOICE: The power of stories Groves (20 November 2009) [Full text] The power of stories If thought corrupts language, language can also corrupt thought. 20 November 2009 BM Hegde, Editor in Chief, Journal of the Science of Healing Outcomes Mangalore-575004 Send response to journal: Re: If thought corrupts language, language can also corrupt thought. Dear Trish Groves, Robert McKee, the world renowned writer and the author of the famous book “Story”, who runs one of the most successful story telling seminars in the world, writing on the power of story telling, has this to say. “As children we were naturally good at telling stories about events or topics that mattered and learning from others via their stories, but as we became older we were taught that serious people relied only on presenting information and "the facts." Accurate information, sound logic, and the facts are necessary, of course, but truly effective leaders in any field — including technical ones — know how to tell "the story" of their particular research endeavor, technological quest, or marketing plan, etc. There are very few people talking about the importance of storytelling these days. I am happy that BMJ started it for adults and serious doctors! Good luck. If we want the readers to enjoy medical research we better find a story telling method in place of the usual statistical IMRAD (introduction, materials, results and discussion). More doctors will then enjoy reading the BMJ to improve their standard of patient care. Yours ever, bmhegde Competing interests: None declared

NEWS: Poor care in hospital is delaying discharge of patients with dementia, charity says Kmietowicz (18 November 2009) [Full text] Poor care in hospital is delaying discharge of patients with dementia, charity says Sound findings but confusing statistics 20 November 2009 David E Stewart, FY2 Public Health NHS Walsall Public Health Department, Jubilee House, Bloxwich Lane, Walsall WS2 7JL Send response to journal: Re: Sound findings but confusing statistics Dear Editor, I read with interest the Alzheimer's society report regarding dementia. While its premise and conclusions seem sound, its use of statistics seems confusing. The Executive Summary states that "Over a third of people with dementia who go into hospital from living in their own homes are discharged to a care home setting". From the data provided, this figure could be closer to a sixth. In the full report, Table 5 shows a reduction in those in their own home from a pre-hosptial 60%, to post-hospital 36%, giving us "over a third". However, we see that a total of 33% of patients admitted to hospital come from a care home, and on discharge 42% now reside there - an increase of just 9% residing in a care home overall, representing a sixth of those previously in their own homes. A total of 6% return to “other” and 9% “not applicable”, with the latter group consisting of those who have not been discharged, or have died while an inpatient. A number of those previously in a care home would fall into these categories, however it does not seem likely to fully explain the discrepancy. Competing interests: None declared

EDITORIALS: Is primary care research a lost cause? Mar (18 November 2009) [Full text] Is primary care research a lost cause? Neglected virgin areas in primary health care basic and applied research. 20 November 2009 Rodolfo J. Stusser, Freelance PHC GFM Research Consultant (Retired from MINSAP), International Member of AAFP & NAPCRG. Primary Care e-Research Collaboration Center http://havanacenter.familydoctors.net Havana, Cuba. Send response to journal: Re: Neglected virgin areas in primary health care basic and applied research. I agree with Del Mar's crucial and valiant editorial that primary health care (PHC) researchers need to know what to research in general family medicine (GFM),[1] when in the last 64 years all the classified diseases have progressively become handled and focused in depth by vertical hospital and lab specialists. Coming from cardiovascular and cancer research centers to PHC, I have been working, studying and reflecting in my last 20 years on a GFM own agenda,[2] and think that on the basis of an integration philosophy of science, I can suggest some more exclusive areas for the generalist researcher. The great influence of the specialist researcher's fragmentation philosophy on PHC GFM has meant that generalist researchers have lost focus on the possibility of research in at least three neglected virgin basic and applied areas, impossible to be approached by any specialists. These are as follows: 1) Founding a Science of Multi-System Connectedness. 2) Developing a Unified Primary Living and Health Care System. 3) Creating a Lifelong Health Maintenance Semiology-Nosology. Strangely, recently discussed very interesting and basic science information and models--at similar top levels to those of bio-molecular labs--argue that community-oriented PHC GFM is the only horizontal specialty capable of connecting the patient parts and the wholes, going in depth in the systems hierarchy (levels of organization) or holarchy of health care, through the pyramid of healing and transcendence, prioritized care, integrated care, and fundamental health care.[3] Hollnagel and Malterud discussed 9 years ago that Paul Backer in 1977 defined the 'health equation' as a formula weighing the balance between the patient's strains and resources. Reading the health equation, the generalist can understand why a person becomes sick when his strains are larger than his resources if he is not able to restore the balance by reducing the strains or increasing resources. According to this model, the generalist's task is to assist people in restoring the balance, not only by decreasing the negative points, but also to strengthen the positive ones.[4] Of course, the strains and resources should be both internally perceived by the patient and externally observed by the generalist. I think that great devotion from Graunt to Cullen's classification and nosology philosophies, has stagnated the classifications family up to ICD-10, ICPC 2, and ICF, as well as the health status assessment instruments supported by WHO, WONCA and NAPCRG.[5] Most of them, still are only negative-health dependent, static-discrete, independent of positive-health resources, outside Leavell and Clark's dynamic-continuous view for GFM health promotion and disease-disability preventive levels. Thank you. 1. Del Mar C. Is primary care research a lost cause? BMJ 2009;339:b4810. http://www.bmj.com/cgi/content/full/339/nov18_2/b4810 2. Stusser RJ. The creation of family medicine new research spaces. Havana: Plaza Community Polyclinic, 1996. http://rational.fortunecity.com/artfam2.html 3. Stange KC. A science of connectedness. Ann Fam Med 2009;7:387-395. http://www.annfammed.org/cgi/content/full/7/5/387 4. Hollnagel H, Malterud K. From risk factors to health resources in medical practice. Med Health Care Philos. 2000;3(3):257-64. http://www.springerlink.com/content/q4230jv133361x3p/ 5. Salomon JA, Mathers CD, Chatterji S, Sadana R, Ustun TB, Murray CJL. Quantifying individual levels of health: definitions, concepts and measurement issues. In: Murray & Evans. eds. Health systems performance assessment: debates, methods and empiricism. Geneva: World Health Organization 2003, 301-318. Competing interests: None declared

NEWS: Hospitals are criticised for yielding to pressure over human rights lecture Dyer (17 November 2009) [Full text] Hospitals are criticised for yielding to pressure over human rights lecture Pressures on UK medical institutions regarding coverage of Israel-Palestine 20 November 2009 derek a summerfield, Hon Sen Lect, Institute of Psychiatry Maudsley Hospital, London SE5 8BB Send response to journal: Re: Pressures on UK medical institutions regarding coverage of Israel-Palestine Your report on the 2 UK hospitals sufficiently pressurised by Zionist groups into cancelling a human rights lecture by Physicians for Human Rights-Israel (PHRI), recalls my own experience, also reported in the BMJ .(1) In 2007 pro-Israel doctors threatened the Royal Society of Medicine, no less, that they would challenge the constitution of the RSM as a charity if my participation in a forthcoming conference, arranged months before, was not cancelled. At one point the RSM asked me to withdraw in order to save the conference. I do not know if protesters were aware that the Israeli Medical Association recently declared that they were severing all ties with PHRI on the grounds that their activities were encouraging "anti-Israeli attitudes" abroad. I regard PHRI as currently unsurpassed anywhere in relation to the combination of their hands-on clinical work with their principled humanitarian witness. They have compiled a telling archive of reports about violations of the Fourth Geneva Convention and of international medical ethical codes by Israel in the Occupied Territories. The harrassment of these 2 UK hospitals smacks of McCarthyism. Similar pressures have for years been applied to the editors of medical journals in UK regarding their coverage of Israel-Palestine. We are meant to be in the era of evidence-based medicine, yet where Israel-Palestine is concerned we encounter efforts to prevent its presentation in the first place. Indeed there is a refusal even to consider as admissible evidence which in other settings would be judged decisive and begging urgent attention: witness the reception currently being afforded the Goldstone report on war crimes during the assault on Gaza. 1 .Summerfield D. Royal Society of Medicine under attack by pro- Israel doctors. BMJ 2007;335:842. Competing interests: 17 years involvement in human rights in Israel-Palestine

NEWS: Patents on breast cancer genes are illegal and stymie research, say scientists Lenzer (17 November 2009) [Full text] Patents on breast cancer genes are illegal and stymie research, say scientists Claims and uses are the real problem, not patenting 20 November 2009 Robert M Cook-Deegan, Research professor Duke University Send response to journal: Re: Claims and uses are the real problem, not patenting It is great that BMJ is covering the US lawsuit over BRCA gene patents, as it is an important case no matter how it turns out. I did want to clarify my statement. I am pretty sure Myriad did find some DNA molecules that were new, useful and not obvious, and therefore patentable. I think some of the *claims* in their patents are broader than what they had found, however, and should not have been granted in the form they were. I also believe that many of the problems the plaintiffs in the suit raise are indeed caused by restrictive practices, and could be eliminated without litigation or change of law if Myriad merely had formal policies that permitted verification testing, basic and clinical research, clarified reimbursement and payment, and if they collaborated with some of the breast cancer constituencies they have alienated. Competing interests: Our Duke team did analysis of how patenting and licensing affect clinical access to genetic testing for the Secretary's Advisory Committee for Genetics, Health and Society, US Department of Health and Human Services

VIEWS & REVIEWS: Politics, science, and the White House Smith (17 November 2009) [Full text] Politics, science, and the White House Harold Varmus and The Art of Politics and Science 20 November 2009 Felix ID Konotey-Ahulu, Kwegyir Aggrey Distinguished Professor of HumanGenetics, University of Cape Coast, Ghana Consultant Physician Genetic Counsellor Sickle/Haemoglobinopathies, 10 Harley St, London W1G9PF Send response to journal: Re: Harold Varmus and The Art of Politics and Science Harold Varmus and The Art of Politics and Science Excellent international Editors, past and present, medical and non- medical, have a way of making much of what they write encourage people, politicians, and others to some kind of action. The action that Dr Richard Smith, immediate past editor of the British Medical Journal by his article (17 November) on Nobel Laureate Harold Varmus [1] encouraged me to take, was to rush to Amazon and buy a copy of the latter’s book [2]. FOUR THINGS THAT ATTRACTED MY ATTENTION First, Harold Varmus is said to have “worked in a mission hospital in Uttar Pradesh as a medical student” [1]. I must read more about that. Is he a Christian I wonder? I am keen to find out. Next, he is on the WHO Commission on Macroeconomics on Health [1]. I wonder what they do. Does that mean they make sure the European Union does not put a ban on our raw materials, or/and that the USA does not dump rice at heavily subsidized prices on African markets making our farmers broke, and leading to further poverty? I am keen to know. Thirdly, the interest in Global Health of Harold Varmus stems from “a longstanding concern about disadvantages between rich and poor” [1]. He certainly would have seen poverty in India’s Uttar Pradesh, and I am keen to read what he describes about poverty. Fourthly, and this thrills me to bits, Varmus has “a passion for open access publishing” [1]. Gone (or nearly gone) are the days when powerful Editors decide whom they will publish and whom not. If you discover something that has not been known about before, and the thing comes from your own little tribe somewhere in Africa, the powerful Editors in Europe look round their little domain for “Experts” to check on what you have offered them. Of course they find none, so they reject your paper with some very kind words like “We hope some other journal publishes it soon for you”. No kidding, this has happened to me and not a few others. Prove me wrong by just GOOGLE-ing the words “Mid Pitch Arrest” or “Three Semitone Gap” and find whose name comes up. This discovery of mine in Tonal Linguistics with a medical dimension in Glosso-genetics was sent to the two front runners in international medical journalism, but neither was interested, only for Open Access Publishing to send it out to the world [3, 4]. To hear that Harold Varmus had something to do with this open access publishing endeavour, and that Dr Richard Smith is also ‘related’ to Public Library of Science (PLoS) gladdens my heart. I am keen to read more from the book [2]. SCIENTIFIC ADVISOR TO PRESIDENT BARACK OBAMA Here comes the fourth reason which makes me want to read the book: For appointing this man, Harold Varmus, his “scientific advisor” [1] President Barack Obama has confirmed my very high estimation of his good judgment. New African, the widely read London based international monthly published 21 comments from all over the world in a special SOUVENIR ISSUE on the election of Senator Barack Obama as the 44th President of the United States of America. I was hugely flattered when I found my comments alongside those of President Nelson Mandela, Dr Kofi Annan, and Prime Minister Gordon Brown [5, page 22]. The last sentence of my long comment capsulated what I perceived Barack Obama was capable of – “For my part, with my enormous interest in history, placing that subject above even medical science, I make bold to say this: It is not at all hyperbolic of me to prognosticate that, God preserving him, President Obama will one day find himself the recipient of two Nobel Prizes, one for literature and the other for peace” [5, page 23]. I said that in December 2008. Within 10 months Barack Obama got one Nobel Prize, and during that time his perspicacity led him to appoint Harold Varmus his Scientific Advisor. MY NEXT WISH IS FOR THEM TO HELP TACKLE GENETIC COUNSELLING My next wish is for ‘Global Health’ to spare a thought for Genetic Counselling and Voluntary Family Size Limitation (GCVFSL). One in 3 of us healthy Ghanaians are walking about with a beta-globin gene trait (NORMACHE), so 1 in every 9 matings between man and wife (as in the case of my own NORMACHE parents) is a union that results in increasing the genetic disease load (ACHEACHE) thereby dragging down Global health [6]. The reason I feel none of Bill Gates Global Health money has trickled down to tackling this genetic public health time bomb is because Family Planning is an extremely sensitive subject capable of being properly handled only by the natives themselves [7, 8]. I sincerely hope Richard Smith will, please, speak to Professor Harold Varmus to, please, speak to President Barack Obama, to help us tackle in our own way, using our own methods, with all the Ethical Sensitivity required, Genetic Counseling and Voluntary Family Size Limitation (GCVFSL) both in the USA, and in Africa, not to mention the needs of hundreds of thousands of at risk families in the United Kingdom and Europe. Felix I D Konotey-Ahulu MD(Lond) FRCP(Lond) DTMH(L’pool) FGA, Order of The Volta. Kwegyir Aggrey Distinguished Professor of Human Genetics, University of Cape Coast Ghana, and Consultant Physician Genetic Counsellor in Sickle & Other Haemoglobinopathies, 10 Harley Street, London W1G 9PF felix@konotey-ahulu.com Competing interests: None declared 1 Smith Richard. Politics, science, and the White House. BMJ 2009; 339: b4848 doi: 10. 1136/bmj.b4848 http://www.bmj.com/cgi/content/full/339/nov17_3/b4848 2 Varmus Harold. The Art of Politics and Science. ISBN 798- 0393061284 W W Norton & Co, 315 pages. 2009. 3 Konotey-Ahulu FID. Social pathology of cleft palate in the African: Mathematical precision of pitch gaps in tribal tonal linguistics. Ghana Medical Journal 2008; 42: 89-91. http://www.ghanamedicalassociation.org/Journal/June%202008/Social%20Pathology%20Cleft%20palate.pdf http://www.pubmedcentral.nih.gov.articlerender.fcgi?artid=2631266 4 Konotey-Ahulu FID. The Remarkable African Ear: Phenomenon of Mid Pitch Arrest in Krobo-Dangme/Gã Tonal Languages of South East Ghana. African American Museum of Philadelphia (AAMP) Award Lecture May 5 2007 http://blog.konotey-ahulu.com/blog_archives/2007/5/5/301434.html 5 Konotey-Ahulu FID. World Rejoices. New African. Dec. 2008 (No 479), pp 22-23 http://www.exacteditions.com/exact/browsePages.do?issue=4520&size=1&pageLabel=23 6 Ringelhann B, Konotey-Ahulu FID. Hemoglobinopathies and thalassemias in Mediterranean areas and in West Africa: Historical and other perspectives 1910 to 1997 – A Century Review. Atti dell’Accademia dell Science di Ferrera (Milan) 1998; 74: 267-307. 7 Konotey-Ahulu FID. Sickle Cell Disease: The Case for Family Planning. ASTAB Books, Ltd 1973; 32 pages 8 Konotey-Ahulu FID. Need for ethnic experts to tackle genetic public health. Lancet 2007; 370: 1836 doi: 10. 1016/50140-6736(07)6177- 1 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61771- 1/fulltext Competing interests: None declared

VIEWS & REVIEWS: Learning to teach Jackson (12 November 2009) [Full text] Learning to teach Practical Teaching Tips 20 November 2009 Avtar Singh, 4th year medical student College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT Send response to journal: Re: Practical Teaching Tips Jackson’s article (1), highlighting the difficulties in teaching from the junior doctor’s perspective, certainly made for an interesting read. Perhaps ironic then that this reply comes from a student (especially one located around the corner at Birmingham Medical School!). We can all recall personal examples of outstanding medical teaching that we have received in a variety of different clinical settings; from the patient’s bedside on a ward round to standing next to the surgeon in theatre, and from the outpatient clinic to primary care. So, as Jackson mentions, one could utilise the knowledge gained from these past experiences to guide us in our own teaching roles (1). However, applying educational theory in the clinical arena is often easier said than done. Outlined below are some practical tips that may assist the newly qualified junior doctor in helping his students get the most out of their teaching session: • Time devoted to clinical educational activity in hospitals is often variable or even absent, ranging from 0 – 25% of students’ time spent on the wards (2). So junior doctors would greatly improve the learning experiences of their students simply by trying to find more time to teach them. However, if not all the material can be covered in a time-constraint teaching session, providing a summary handout or pointing to areas of further reading is also useful. • Failure to utilise the assets of the clinical environment is commonplace. Many doctors revert towards didactic impartment of factual knowledge best left in the lecture theatre or seminar room, thereby losing the clinical context for teaching skills of history taking and examination. This is reflected in a study on teaching rounds, where only 11% of the time was spent at the patient’s bedside, the rest of the time being spent in the conference room or discussing in hallways (3). This is particularly surprising when bedside teaching and medical clerking are considered the most valuable teaching methods amongst both students and practicing doctors (4). • Interruptions on the ward (e.g. being bleeped when on-call, restricted times for patients at mealtimes and during visiting hours) should be taken into account so as to minimise the disruption to bedside teaching arrangements. • Be prepared to be opportunistic in clinical teaching, since cases never occur in a logical order. • Set clear learning goals. Discuss objectives with learners to avoid covering topics they have already met; especially since medical students, even within the same medical school, will have had completely different learning experiences (5). This also enables learners to point out areas of weakness and to help them focus on the salient points of the lesson. At the end, review the aims, clarify any misunderstandings and summarise the key information. • The motivation of learners can be difficult to maintain at times. Simple ways of achieving this include varying the teaching stimulus (e.g. mixing up the teaching of practical skills with recall of medical knowledge) and utilising tasks that are more engaging and interactive (e.g. bedside detective work and games for teaching physical examination (6)). Moreover, it has been shown that one of the features of good clinical teaching is enabling the student to be an active participant (7); so a good teacher would involve the students on the ward round by getting them to write in the patient notes, take a patient’s blood and getting them to listen to the heart sounds before the consultant does. • A good teacher would frequently ask relevant open questions, avoid answering his own questions, and question the answers of his students (8). • Giving personal feedback is an important factor in student satisfaction (9). So spend time supervising their physical examinations and reviewing their histories. Medicine is different to other professions, in that teaching, whether it be to students, fellow doctors or other healthcare professionals, is an expectation. Furthermore, the General Medical Council state that those involved in teaching should “develop the skills, attitudes and practices of a competent teacher” (10). However, few doctors have had any formal training in educational method, though many express an interest in receiving it (11). Thus, there is a need for recognised training on how to teach within the medical curriculum. This has been acknowledged in recent years with some medical schools offering Special Study Modules in teaching, as well as assessing medical students on a given teaching performance to peers. Postgraduate qualifications in medical education and teacher training courses also exist for those wishing to further their skills; however, only 6% of actively teaching doctors have ever attended masters or other short courses on teaching (12). Patient-centred medicine to student-centred teaching seems a simple enough transition to make, but many find it a daunting prospect. So adequate training in educational methods should be in place for anyone who takes a keen interest in their teaching roles. However, being a good clinical teacher often goes beyond the theoretical teaching methods, and is characterised by being enthusiastic, inspiring and supportive (13). References: (1) Jackson P. Learning to Teach. BMJ 2009;339:b4554 (2) Jolly B, Rees L. Medical education in the millennium. Oxford: Oxford Medical Publications; 1998 (3) Miller M, Johnson B, Greene HL, Baier M, Nowlin S. An observational study of attending rounds. J Gen Intern Med 1992;7:646-8 (4) Ward B, Moody G, Mayberry JF. The views of medical students and junior doctors on pre-graduate clinical teaching. Postgrad Med J 1997;73:723-5 (5) Kowlowitz V, Curtis P, Sloane PD. The procedural skills of medical students: expectations and experiences. Acad Med 1990;65:656-8 (6) Ramani S. Twelve tips for excellent physical examination teaching. Med Teach 2008;30:851-6 (7) Stritter FT, Hain JD, Grimes MD. Clinical teaching re-examined. J Med Educ 1975;50:876-82 (8) Spencer J. Learning and teaching in the clinical environment. BMJ 2003;326:591-4 (9) Chesser A, Brett M. Clinical teaching in context: a factor analysis of student ratings. Research in Medical Education, Proceedings of the twenty-eighth annual conference. Washington: Association of American Medical Colleges; 1989. p49-54 (10) General Medical Council. Good Medical Practice [online]. 2006 [cited 2009 Nov 18]. Available from URL: http://www.gmc- uk.org/guidance/good_medical_practice/index.asp (11) Wilson DH. Education and training of preregistration house officers: the consultants’ viewpoint. BMJ 1993;306:194-6 (12) Lawson M, Seabrook M, Jolly BC, Pettingale KW. Teachers at King’s: who teaches and how? Paper presented at the annual conference of the Association for the Study of Medical Education. Med Educ 1996;30:71-2 (13) Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med 2008;83:452-66 Competing interests: None declared

RESEARCH: Slow walking speed and cardiovascular death in well functioning older adults: prospective cohort study Dumurgier et al. (10 November 2009) [Abstract] [Full text] [PDF] Slow walking speed and cardiovascular death in well functioning older adults: prospective... Good study; few questions 20 November 2009 DR.Indranil Banerjee, MD(P.G.T) B.M.C.H,, 713104 Send response to journal: Re: Good study; few questions At first I would like to thank the entire team of researchers for conducting study on this much needed yet neglected topic. This study has surpassed the limits of previous studies (e.g. Study to find relation between low walking speed and stroke) by performing careful baseline assessment. However certain points in the method and conclusion section deserve more clarification. The present study considered walking velocity over a short distance (6m) which indicates motor control, strength, balance and adaptation in gait pattern.(1) Timed walking distance (e.g. distance walked in 6 minutes) provides a better measure of endurance, fatigability and cardiovascular fitness.(2))The study did not mention the rationale of choosing walking velocity instead of timed walking distance. The title and conclusion of the research article repeatedly mentions the words “Slow walking speed” which drags controversies. It appears that the message of the study is the persons who walk slowly than their usual pace are at increased risk of cardiovascular mortality. A careful reading of the text informs us that it is actually “low walking speed “which is a simple yet reliable indicator of increased cardiovascular mortality as chronic exposure to vascular risk factors is associated with both increased cardiovascular mortality and reduced speed of walking.With regards (1)J.Dumurgier et al.Slow walking speed and cardiovascular death in well functioning older adults:prospective cohort study.BMJ 2009;339:b4460 (2)Dobkin B.Short distance walking speed and timed walking distance:Redundant measures for clinical trials? Neurology 2006;66:584-586 Competing interests: None declared

EDITORIALS: Slow walking speed in elderly people Harwood and Conroy (10 November 2009) [Full text] Slow walking speed in elderly people Sprint your way to immortality 20 November 2009 Michael O'Donnell, Journeyman writer Loxhill GU8 4BD Send response to journal: Re: Sprint your way to immortality Language is a way of communicating thought and sloppy language is an expression of sloppy thinking. So what are we to make of the first sentence of this editorial? “People who walk faster are less likely to die than slow walkers, especially from vascular disease.“ One one way to write clear and interesting prose is to think carefully about the meaning of each word you use. Clearly the authors had neither the time nor inclination to do this but surely someone on the editorial staff could have offered them a helpful hint. Michael O'Donnell FRCGP mod@doctors.org.uk Competing interests: None declared

NEWS: Battle against hospital acquired infections has been too limited, MPs’ report says Mayor (11 November 2009) [Full text] Battle against hospital acquired infections has been too limited, MPs’ report says Infection Control - what is the point? 20 November 2009 Jenna L Morgan, CT1 general surgery Yorkshire and Humber Deanery, Roshan A. Rao, F2 ENT surgery Yorkshire and Humber Deanery Send response to journal: Re: Infection Control - what is the point? We read with interest the article on hospital infections(1). Finally a sensible comment by MPs regarding healthcare acquired infections (HCAIs) as they realise that bacteria other than meticillin resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C.dif) exist. Edward Leigh MP, quite rightly states that although the Department of Health has made progress in reaching its targets regarding MRSA bloodstream and C.dif infections, “it has taken its eye of the ball regarding all other healthcare associated infections – which actually constitute most by far (four-fifths) of all infections(2)”, something that many doctors have been saying for a while. What is it about MRSA and C.dif that has prompted action by the government and the NHS, while they ignore infections caused by other organisms? Surely the public “scare stories” promoted by the press over so -called “superbugs”. It seems, however, that it is time to take a good, hard look at the whole picture – prompted, no doubt, by the £1 billion HCAIs cost the NHS per year – not to mention the element of patient safety. What has been done so far? The main response by the Department of Health has been as follows: Introduction of mandatory reporting of MRSA bloodstream and C.dif infections in 2001 and 2004, respectively. Several national initiatives aimed at reducing HCAIs, such as the Deep Clean, modern matrons and the cleanYOURhands campaign. Screening patients for colonisation of MRSA is currently being rolled out in hospitals across the country so they can be pre-emptively treated. On a “shop-floor” level, this has meant greater use of alcohol gel, a ban on white coats, long-sleeves and wrist-watches, barrier nursing, changes in practice to simple procedures, such as obtaining blood cultures and prescribing antibiotics. Surely all of these measures should have an effect on microbes other than MRSA and C.dif? It seems not, as Edward Leigh also warns that “the best available evidence is that other just as deadly but also avoidable infections, such as surgical site infections and pneumonias, have increased”. So we must ask the question – do these things work? Do trusts even care, or are they only interested in hitting targets or in “being seen” to be reducing HCAIs? Medics commonly discuss the next possible “infection control drive” and whether there will be any evidence to back it up. A common initiative being introduced in some trust involves forcing doctors to wear a uniform, despite the fact that said uniforms are washed at home in the same way as normal clothing. This seems to be an example of trusts spending a lot of money based on little or no evidence. However, reading Edward Leigh’s report, it is likely that the Department of Health is likely to be forced to report on all HCAIs in the future and this can only mean more infection control initiatives of this kind. References: 1. BMJ 2009;339:b4680 2. Reducing Healthcare Associated Infections in Hospitals in England, 10 November 2009. www.parliament.uk/pac Competing interests: None declared

RESEARCH: Aspirin for primary prevention of cardiovascular events in people with diabetes: meta-analysis of randomised controlled trials De Berardis et al. (6 November 2009) [Abstract] [Full text] [PDF] Aspirin for primary prevention of cardiovascular events in people with diabetes:... Re: Aspirin. A long life with always a new fashion 20 November 2009 Les O. Simpson, retired experimental pathologist Dunedin New Zealand 9077 Send response to journal: Re: Re: Aspirin. A long life with always a new fashion The contribution of Carbone et al to this debate shows clearly that the published information about the changes in the physical properties of the blood in cardiovascular events in both diabetics and non-diabetics, continues to go unrecognised. Should they wish to get a measure of the extent of the relevant published material, they could refer to my book, "Blood viscosity factors-the missing dimension in modern medicine." It is many years since John Hobbs reported that pre-eclampsia was associated with increased blood viscosity. It is not coincidence that increased blood viscosity occurs in hypertension, as shown by the reports of Harris and Mcloughlin, Tibblin et al and Letcher et al, for example. Such observations raise the intriguing question of whether or not it is possible have a meaningful discussion of any topic if a major contributing factor is ignored ? Competing interests: None declared