55 Rapid Responses published for 35 different articles.

Articles			Rapid Responses
	EDITOR'S CHOICE: Seeing things differently Godlee (28 January 2010) [Full text]		People never seeking medical help Mario Vitale   (8 February 2010) Read every Rapid Response to this article
	LETTERS: Part of beneficial host response? Dixon et al. (26 January 2010) [Full text]		Sharpening Occam’s razor Mark Struthers   (8 February 2010) Read every Rapid Response to this article
	NEWS: Palestinian doctor’s tragedy prompts plans for women’s college in Gaza Jeffay (25 January 2010) [Full text]		Re: Palestinian doctor’s tragedy prompts plans for women’s college in Gaza, BMJ 2010;340:c486, 25 January 2010 Zeev Rotstein   (9 February 2010) Read every Rapid Response to this article
	RESEARCH: Myocardial infarction and stroke associated with diuretic based two drug antihypertensive regimens: population based case-control study Boger-Megiddo et al. (25 January 2010) [Abstract] [Full text] [PDF]		Which combination is better for each patient with hypertension? Carlos Escobar, et al.   (8 February 2010) Should beta-blockers really be second-line antihypertensives? Jamal N Khan, et al.   (8 February 2010) Read every Rapid Response to this article
	CLINICAL REVIEW: Managing and preventing depression in adolescents Thapar et al. (22 January 2010) [Full text]		Managing depression in adolescents: A barrier in primary care? Tami Kramer, et al.   (8 February 2010) Read every Rapid Response to this article
	EDITORIALS: Smoking cessation Treasure and Treasure (21 January 2010) [Full text]		A unique approach to smoking cessation. Bridget A N Wilson   (9 February 2010) Read every Rapid Response to this article
	EDITORIALS: Preventing alcohol related harm to health Groves (20 January 2010) [Full text]		Much to learn from smoking. Alexander SD Spiers   (9 February 2010) Read every Rapid Response to this article
	RESEARCH METHODS & REPORTING: The routine use of patient reported outcome measures in healthcare settings Dawson et al. (18 January 2010) [Abstract] [Full text]		And so PROMs are the answer but what’s the question? Stirling Bryan, et al.   (8 February 2010) Read every Rapid Response to this article
	ANALYSIS: Practical challenges of introducing WHO surgical checklist: UK pilot experience Vats et al. (13 January 2010) [Full text]		Things should only get better? - it's our responsibility Dilnath Gurusinghe, et al.   (8 February 2010) Read every Rapid Response to this article
	PRACTICE: Long QT syndrome Abrams et al. (21 January 2010) [Full text]		Hearing loss with long QT syndrome Tira Galm, et al.   (8 February 2010) Read every Rapid Response to this article
	EDITORIALS: Synaesthesia Eagleman (8 January 2010) [Full text]		Other Visual Perceptual Phenomenon Fabida Noushad   (8 February 2010) Read every Rapid Response to this article
	ANALYSIS: NICE and new: appraising innovation Ferner et al. (5 January 2010) [Full text]		Radical innovation aimed at serious diseases a priority Peter H.M. Brooks   (8 February 2010) Read every Rapid Response to this article
	NEWS: Emasculating hypothetical oddities? Watts (5 February 2010) [Full text]		Editorial judgments Henry H. Bauer   (8 February 2010) Read every Rapid Response to this article
	EDITOR'S CHOICE: MMR and other controversies Godlee (4 February 2010) [Full text]		Re: 'The Next MMR' and the present one - how not to restore trust Michael D Innis   (8 February 2010) Read every Rapid Response to this article
	OBSERVATIONS: The double face of discrimination Heath (4 February 2010) [Full text]		Saying the unsayable Ben Bradley   (8 February 2010) Discrimination John K Johnson   (8 February 2010) Two faces of age discrimination Robert C Baldwin, et al.   (8 February 2010) The Double Face of Age Discrimination Ian Philp   (8 February 2010) Read every Rapid Response to this article
	VIEWS & REVIEWS: Bad medicine: osteoporosis Spence (3 February 2010) [Full text]		Never too late for a confessional remedy Abdul Jaleel   (9 February 2010) Risk Assessment - A fractured Art Des Spence   (9 February 2010) Thanks Des Ben Bradley   (8 February 2010) The pitfalls of a single risk factor Simon J Vanlint   (8 February 2010) Shoud be read with mea culpa Dorasami Raman   (8 February 2010) Read every Rapid Response to this article
	OBSERVATIONS: Reflections on investigating Wakefield Deer (2 February 2010) [Full text]		Reflections of a grateful patient Sophie E L Puritz   (8 February 2010) Read every Rapid Response to this article
	OBSERVATIONS: Why did the Lancet take so long? Greenhalgh (2 February 2010) [Full text]		Evidence, statistical lessons and bias. Peter J Flegg   (9 February 2010) The good, the bad and the ugly side of medical science Mark Struthers   (8 February 2010) Re: Re: Re: Statistical lessons to be learned as well John Stone   (8 February 2010) Judgement on what’s good for science? Mark Struthers   (8 February 2010) Re: Re: Statistical lessons to be learned as well Peter J Flegg   (8 February 2010) Unfounded and unjust Mark Struthers   (8 February 2010) Read every Rapid Response to this article
	NEWS: Rise in US teen pregnancies and births is "deeply troubling" Tanne (2 February 2010) [Full text]		The Teenage Pregnancy Strategy in the UK Mohammed A Yusuf   (8 February 2010) Read every Rapid Response to this article
	EDITORIALS: Rising hospital admissions Gillam (2 February 2010) [Full text]		Admission avoidance Aruni Sen   (9 February 2010) Who is admitting and why john sharvill   (8 February 2010) Subtle Changes in Approach May Have a Profound Effect Graeme Mackenzie   (8 February 2010) Read every Rapid Response to this article
	LETTERS: What parliamentary witnesses also said about homoeopathy Mathie and Fisher (2 February 2010) [Full text]		nanopharmacology Michael Tremblay PhD   (8 February 2010) Read every Rapid Response to this article
	NEWS: Author calls for UK to set up tribunal for assisted suicide Dyer (2 February 2010) [Full text]		Assisted Suicide Kathryn E Grant   (9 February 2010) Read every Rapid Response to this article
	MINERVA: Simpson and Burd (2 February 2010) [Full text]		Erythema ab laptop Narayan D K Randev, et al.   (8 February 2010) Read every Rapid Response to this article
	CLINICAL REVIEW: Current management of clubfoot (congenital talipes equinovarus) Bridgens and Kiely (2 February 2010) [Full text]		Is the great Denis Browne forgotten? John Squire Kirkham   (9 February 2010) The Excellent Results of Current Clubfoot Management and Implications for Antenatal Diagnosis Matthew P Newton Ede, et al.   (8 February 2010) Read every Rapid Response to this article
	RESEARCH: Effect of a collector bag for measurement of postpartum blood loss after vaginal delivery: cluster randomised trial in 13 European countries Zhang et al. (1 February 2010) [Abstract] [Full text] [PDF]		Collector bag cannot be an isolated criterion to reduce severe haemorrhage Souhail Alouini   (8 February 2010) Read every Rapid Response to this article
	PRACTICE: Unrecognised scurvy Choh et al. (17 September 2009) [Full text]		Neurodisability: An unrecognised risk factor for scurvy Vijay Palanivel, et al.   (8 February 2010) Read every Rapid Response to this article
	VIEWS & REVIEWS: Poet scorner Dalrymple (28 October 2009) [Full text]		Constructive Conversations Hugh Mann   (9 February 2010) Read every Rapid Response to this article
	NEWS: First of 1.3 million trees are planted in NHS forest Kmietowicz (6 October 2009) [Full text]		The Tree of Life Hugh Mann   (8 February 2010) Read every Rapid Response to this article
	RESEARCH: Screening for postnatal depression in primary care: cost effectiveness analysis Paulden et al. (22 December 2009) [Abstract] [Full text] [PDF]		Economic model misrepresents NICE guidance Stephen Pilling, et al.   (8 February 2010) Read every Rapid Response to this article
	EDITORIALS: Management of open fractures of the lower limb Louie (17 December 2009) [Full text]		Management of open fractures of the lower limb. Are children different? Nikolaos Gougoulias, et al.   (8 February 2010) Read every Rapid Response to this article
	EDITORIALS: In praise of the physical examination Verghese and Horwitz (16 December 2009) [Full text]		Re: In praise of Physical Examination Roswitha Goetze-Pelka   (8 February 2010) Read every Rapid Response to this article
	EDITORIALS: Secret remedies: 100 years on Colquhoun (15 December 2009) [Full text]		A dynamic and fluid order Richard Bartley   (9 February 2010) Well-meaning armwaving does not cure patients David Colquhoun   (9 February 2010) Svetlana l. Pertsovich Edzard Ernst   (8 February 2010) The Dying Paradigm William House   (8 February 2010) This is scientists' opinion. Svetlana I. Pertsovich   (8 February 2010) Read every Rapid Response to this article
	PRACTICE: Commentary: Managing clinicians’ assessment Reuß et al. (10 December 2009) [Full text]		Anti-AQP4 ab might be relevant in pregnancy Reinhard Reuß, et al.   (8 February 2010) 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]		QOF for diabetes: action overdue Richard Lehman, et al.   (8 February 2010) Read every Rapid Response to this article
	VIEWS & REVIEWS: The Magic Mountain Rütten (5 January 2009) [Full text]		Library of Rudolf Virchow: location unknown Sergei V. Jargin   (8 February 2010) Read every Rapid Response to this article

EDITOR'S CHOICE: Seeing things differently Godlee (28 January 2010) [Full text] Seeing things differently People never seeking medical help 8 February 2010 Mario Vitale, Affectionate reader Via Cintia 16B - Napoli - Italy Send response to journal: Re: People never seeking medical help I'm wondering if any term exists to identify people that never ask the opinion of a doctor when they are faced with little medical problems. Few old ladies I know (> 80 years old) belong to this category. Competing interests: None declared

LETTERS: Part of beneficial host response? Dixon et al. (26 January 2010) [Full text] Part of beneficial host response? Sharpening Occam’s razor 8 February 2010 Mark Struthers, GP and prison doctor Bedfordshire, mark.struthers@which.net Send response to journal: Re: Sharpening Occam’s razor The human immune system is probably very complex. However, it is possible that high fevers simply reflect a healthy, responsive and ultimately more effective immune system and lower body temperatures a struggling immunity. And there already exists scientific evidence to show that hypothermia actually impairs that natural immune response or ‘nature’s engine’ as Thomas Sydenham was wont to call it. [1] The highly feverish patient will naturally expect the infectious disease clinician to determine ways of enhancing the body’s natural defence against infection rather than pursuing research that is already known to detract from it. [2] [1] Direct Influence of Mild Hypothermia on Cytokine Expression and Release in Cultures of Human Peripheral Blood Mononuclear Cells. Stefan Russwurm et al, July 2004. http://www.liebertonline.com/doi/abs/10.1089/107999002753536185 [2] What does meningococcus do at other temperatures? Peter J Flegg, 1 February 2010. http://www.bmj.com/cgi/eletters/340/jan26_2/c450#230656 Competing interests: None declared

NEWS: Palestinian doctor’s tragedy prompts plans for women’s college in Gaza Jeffay (25 January 2010) [Full text] Palestinian doctor’s tragedy prompts plans for women’s college in Gaza Re: Palestinian doctor’s tragedy prompts plans for women’s college in Gaza, BMJ 2010;340:c486, 25 January 2010 9 February 2010 Zeev Rotstein, CEO and Director Sheba Medical Center at Tel Hashomer Send response to journal: Re: Re: Palestinian doctor’s tragedy prompts plans for women’s college in Gaza, BMJ 2010;340:c486, 25 January 2010 BMJ suspiciously seems to get very short of space when it comes to compliments for Israel or any fact that might portray Israel in a good light. Thus, I was so disappointed to see that a key part of your story on my friend and colleague Dr. Izzeldin Abuelaish was cut from the printed edition of BMJ on January 25. The full story, as it appears on your web site, describes Dr. Abuelaish's intact "warmth for Israelis" and his active fundraising for a project in memory of his daughters at our hospital, the Sheba Medical Center at Tel Hashomer in Israel: Dr. Abuelaish: Sheba “is the place where everything melts… There is diversity and everyone is equal: Palestinians, Jews, Christians, Muslims, Druze. All are equal, and that is a message we can learn from medicine—the message of equality and justice. In the end [the conference facility] will help human beings there, it will help sick patients, and this hospital serves Palestinians and Israelis and we must promote more collaboration, more partnership." Dr. Abuelaish's humanitarian message reflects the compassionate approach to medicine and people-to-people peace-building that is at the core of our mission. We stand alongside him in his tragedy, and march with him in his quest for reconciliation and inter-communal outreach. It would be appropriate that Dr. Abuelaish's admirable sentiments appear in your next printed issue through publication of this letter. Prof. Zeev Rotstein, M.D., M.H.A. Director, Sheba Medical Center zeev.rotstein@sheba.health.gov.il Competing interests: None declared

RESEARCH: Myocardial infarction and stroke associated with diuretic based two drug antihypertensive regimens: population based case-control study Boger-Megiddo et al. (25 January 2010) [Abstract] [Full text] [PDF] Myocardial infarction and stroke associated with diuretic based two drug antihypertensive... Which combination is better for each patient with hypertension? 8 February 2010 Carlos Escobar, Cardiologist Hospital Infanta Sofia, 28702, San Sebastian de los Reyes, Madrid, Spain, Rocio Echarri, Vivencio Barrios Send response to journal: Re: Which combination is better for each patient with hypertension? Since the majority of patients with hypertension need at least two antihypertensive agents to achieve blood pressure (BP) objectives, it may have no sense to discuss which first-line antihypertensive drug is better, but which combination is preferable [1]. Current European guidelines for the treatment of arterial hypertension recommend combined therapy when monotherapy fails to attain BP targets and as a first-line therapy in subjects at high or very high cardiovascular risk [2]. As it is known, the advantages of combined therapy include an earlier and higher antihypertensive efficacy because of complementary mechanisms of action, and a lower incidence of side effects due to the possible compensatory responses and, in many cases, the lower doses used [3]. However, as ACCOMPLISH trial showed, not all antihypertensive combinations have the same impact on cardiovascular outcomes. In this trial, the benazepril–amlodipine combination was superior to benazepril–hydrochlorothiazide in reducing cardiovascular events in a hypertensive population with a high proportion of patients with diabetes and obesity [4]. It should be reminded that in this situation, a thiazide may worsen glucose and lipid profiles and this could influence outcomes. In the manuscript of Boger-Megiddo and cols., the combination diuretics plus calcium channel blockers was associated with a higher risk of myocardial infarction than other common two drug treatment regimens (diuretics plus beta blockers and diuretics plus angiotensin converting enzyme inhibitors or angiotensin receptor blockers) in a hypertensive population [5]. Although, as authors stated, a large trial is needed to confirm these data, it is likely that in patients with a history of myocardial infarction, the combination diuretics plus calcium channel blockers should be used with caution. Although more data are needed, these findings and other ongoing studies will help to better clarify the role of each combination in the management of hypertension. Because, in the next future, we should try to define which combination could be preferable for each hypertensive patient. 1. Escobar C, Echarri R, Barrios V. Combined therapy in the treatment of hypertension: but which? J Hypertens. 2009;27:1331. 2. Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et al. 2007 guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2007; 25:1105–1187. 3. Escobar C, Barrios V. Combined therapy in the treatment of hypertension. Fundam Clin Pharmacol. 2009 Aug 14. [Epub ahead of print] 4. Jamerson K, Weber MA, Bakris GL, Dahlo¨ f B, Pitt B, Shi V, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high -risk patients. N Engl J Med 2008; 359:2417–2428. 5. Boger-Megiddo I, Heckbert SR, Weiss NS, McKnight B, Furberg CD, Wiggins KL, et al. Myocardial infarction and stroke associated with diuretic based two drug antihypertensive regimens: population based case-control study. BMJ. 2010;340:c103. Competing interests: None declared Myocardial infarction and stroke associated with diuretic based two drug antihypertensive... Should beta-blockers really be second-line antihypertensives? 8 February 2010 Jamal N Khan, Specialist Registrar in Cardiology Sandwell & West Birmingham Hospitals NHS Trust, Dudley Rd, Birmingham, B18 7QH, Abhishek Chauhan Send response to journal: Re: Should beta-blockers really be second-line antihypertensives? 'Should beta-blockers really be second-line antihypertensives?' Chauhan A, Khan JN. We read with interest the article by Boger-Megiddo stating that in patients with hypertension, the combination of diuretics plus calcium- channel blockers (D and CCB) was associated with a significantly higher risk of myocardial infarction than diuretics plus beta-blockers (D and BB, odds ratio 1.98) [1]. The authors imply that beta-blockers are a better second line agent for management of hypertension than calcium-channel blockers. Firstly, we feel that this does not add to what is already known about beta blockade in primary and secondary prevention of myocardial infarction. It is well known that in the post myocardial infarction patient, beta blockade confers prognostic benefit through reduction in infarct size, risk of reinfarction and mortality [2-6]. Conversely, calcium channel blockers and in particular dihydropyridines (commonest CCBs used for hypertension) do not match this improvement in prognosis [7]. Therefore, we feel that studying the risk of re-infarction in patients on beta blockers, which are already known to reduce re-infarction rates independently of blood pressure to judge optimal blood pressure control, is suboptimal. Secondly, the relative ineffectiveness of beta blockers to effectively control blood pressure is well established. A large meta- analysis (total n=133348) illustrated that beta blockers were sub-optimal agents for blood pressure control and that they actually increased the risk of stroke when compared with other agents (n=27433) [8]. This sentiment was echoed by the British Hypertension Society (BHS), prompting a revision of guidelines for management of hypertension by The National Institute for Health and Clinical Excellence (NICE). As a result, beta- blockers have been removed from the list of first-line agents as from 2006 [9]. Finally, Boger-Megiddo and colleagues illustrate that there is essentially no difference in the reduction in systolic blood pressure in the two groups (D and CCB vs D and BB). We thus agree with the guidelines issued by the BHS and NICE, that beta-blockers are not superior to calcium -channel blockers in the management of hypertension, and hence should not be used routinely as second-line antihypertensives. A large trial of second line antihypertensive treatments in patients already on low dose diuretics is required to provide a solid basis for treatment recommendations, as suggested by Boger-Meggido and colleagues. References 1. Boger-Megiddo I, Heckbert SR, Weiss NS, McKnight B, Furberg CD, Wiggins KL, Delaney JA, Siscovick DS, Larson EB, Lemaitre RN, Smith NL, Rice KM, Glazer NL, Psaty BM. Myocardial infarction and stroke associated with diuretic based two drug antihypertensive regimens: population based case-control study. BMJ. 2010 Jan 25;340:c103. 2. Yusuf S, Lessem J, Pet J et al. Primary and secondary prevention of myocardial infarction and strokes. An update of randomly allocated controlled trials. J Hypertens. 1993;11:(Suppl. 4):S61–S73. 3. Freemantle N, Cleland J, Young P, Mason J, Harrison J. Beta- blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. 1999. 26;318(7200):1730-7. 4. Harjai KJ, Stone GW, Boura J, Grines L, Garcia E, Brodie B, Cox D, O'Neill WW, Grines C. Effects of prior beta-blocker therapy on clinical outcomes after primary coronary angioplasty for acute myocardial infarction. Am J Cardiol. 2003 Mar 15;91(6):655-60. 5. The beta-blocker heart attack study group. The beta-blocker heart attack trial. JAMA. 1981. 246:2073–4. 6. The CAPRICORN investigators. Effect of carvedilol on outcome after myocardial infarction in patients with left ventricular dysfunction. The CAPRICORN randomised trial. Lancet 2001. 357:1385–90. 7. Yusuf S, Held P, Furberg C. Update of effects of calcium antagonists in myocardial infarction or angina in light of the second Danish Verapamil Infarction Trial (DAVIT-II) and other recent studies. Am J Cardiol. 1991. 67(15):1295-7. 8. Lindholm LH, Carlberg B, Samuelsson O. Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet. 2005. 366(9496):1545-53. 9. National Institute for Clinical Excellence (NICE). Nice Guidance: Hypertension - management of hypertension in adults in primary care. CG34. 2006. (website:http://www.nice.org.uk/CG34) Competing interests: None declared

CLINICAL REVIEW: Managing and preventing depression in adolescents Thapar et al. (22 January 2010) [Full text] Managing and preventing depression in adolescents Managing depression in adolescents: A barrier in primary care? 8 February 2010 Tami Kramer, Consultant Child & Adolescent Psychiatrist/ Senior Clinical Research Fellow Imperial College London/ CNWL NHS Foundation Trust, Academic Child & Adolescent Psychiatry, W2 1PG, Steve Iliffe, Lisa Miller, Julia Gledhill, and Elena Garralda Send response to journal: Re: Managing depression in adolescents: A barrier in primary care? Dear Editor Thapar et al’s 1 comprehensive clinical review describes the importance of identifying adolescent depression given the serious adverse implications of significant under-diagnosis and treatment, including the impact on current and future functioning, high rates of recurrence, and raised risk of suicide. They highlight the key role for primary care in the detection and initial management of depression in adolescents and allude to first line pragmatic psychosocial approaches. However, attempts to improve the involvement of primary care in identification and management are impeded by concerns about the ‘medicalization’ of depression 2,3 . Those favouring demedicalization of adolescent depression suggest that current diagnostic criteria fail to differentiate normal sadness or ‘common emotional turmoil’ in response to stressful events from ‘genuine’ depressive disorders; they are concerned about the high false positive rate that may result from mass screening programmes using questionnaires; they fear stigmatisation through targeted intervention for milder symptoms by health professionals, and favour broader treatment options such as school and family interventions 2,3. In response, Brent’s 4 recent cogent editorial acknowledges the limitations of current diagnostic criteria but highlights empirical evidence that clinical interview can distinguish depressive disorder even in the context of stresses such as bereavement, when guided by symptomatology, severity, functional impairment as well as a personal and family history of depression. Furthermore he presents evidence to demonstrate that life events and depression are not independent, but rather that psychological disorder arises from the interaction of stress and personal vulnerability. This means that using external stressors alone to account for symptoms of sadness is insufficient and inaccurate, since when these feelings are enduring and associated with impairment they are associated with increased risk of future episodes of depression. The NICE guidelines on depression in children and young people could be considered to add further confusion by recommending depression screening in primary care by targeting those exposed to single recent life events such as severe disappointments; in addition to the fact that young people do not usually present to primary healthcare services with stress reactions to distressing events, there is little evidence to support the benefit of this intervention 5. Primary care practitioners’ fears about the medicalization of depression perpetuate the failure to explore psychological problems in young people even when these are perceived to be present 6,7. This limits their ability to both identify severely depressed young people (including those with suicidality who require referral for specialist intervention) and provide support for those with mild to moderate symptoms. Efforts to enhance practitioners’ confidence in talking to young people about their emotional state, skills in identification of depressive disorder and therapeutic techniques for managing depression might allay these fears. Our collaboration between child psychiatrists and GPs has developed, piloted 8 and feasibility tested a programme to address this. The TIDY programme (Therapeutic Identification of Depression In Young People) 9 is a package of training and tools developed to support primary care practitioners to engage young people (who almost exclusively present with physical complaints), in conversations about their emotional well being. Guidelines are given to facilitate identification of depression as opposed to ‘normal moodiness’ and a repertoire of intervention strategies are provided that can be offered within the consultation for milder cases; TIDY implementation also helps to differentiate depressed young people requiring specialist referral. Since adolescents attending primary care have increased rates of depression (usually unrecognised)10 and primary care is the only medical setting to which they have ready access, we have worked to develop a ‘single dose’ intervention that provides advice on self help strategies and encourages adolescents to seek support from within their family and wider social environment. Preliminary analysis of the feasibility study suggests that selective, opportunistic use of TIDY is followed by a small but statistically significant increase (from a very low baseline) of recognition of depression in young people attending general practice. The therapeutic components of TIDY are used by practitioners selectively in consultations and are acceptable to young people. Further research is required to further evaluate the clinical and cost effectiveness of this approach. Additionally the views, wishes and experiences of young people themselves, including the healthy, the moody and the seriously depressed should be included in the debate about which interventions are most helpful. Reference List (1) Thapar A, Collishaw S, Potter R, Thapar AK. Managing and preventing depression in adolescents. BMJ 2010; 340(jan22_1):c209. (2) Horwitz AV, Wakefield JC. Should Screening for Depression Among Children and Adolescents Be Demedicalized? Journal of Amer Academy of Child & Adolescent Psychiatry 2009; 48(7). (3) Finlayson J. Depression in younger people. British Journal of General Practice 2009; 59:542. (4) Brent DA. Medicalize depression, not sadness. J Am Acad Child Adolesc Psychiatry 2009; 48(7):681-682. (5) Hodes M, Garralda E. NICE guidelines on depression in children and young people: not always following the evidence. Psychiatric Bulletin 2007; 31(10):361-362. (6) Martinez S, Reynolds S, Howe A. Factors that influence the detection of psychological problems in adolescents attending general practices. British Journal of General Practice 2006; 56:594-599. (7) Iliffe S, Williams G, Fernandez V, Vila M, Kramer T, Gledhill J et al. General practitioners? understanding of depression in young people: qualitative study. Primary Health Care Research & Development 2008; 9(04):269-279. (8) Gledhill J, Kramer T, Iliffe S, Garralda ME. Training general practitioners in the identification and management of adolescent depression within the consultation: a feasibility study. J Adolesc 2003;245-250. (9) Therapeutic Identification of Depression in Young People: Identification and Treatment Manual. 2009. http://www1.imperial.ac.uk/resources/E1A08677-A38D-49AB-A138-F1E1C97178EF/ (10) Kramer T, Garralda ME. Psychiatric disorders in adolescents in primary care. Br J Psychiatry 1998; 173:508-13.:50 t.kramer@imperial.ac.uk Competing interests: None declared

EDITORIALS: Smoking cessation Treasure and Treasure (21 January 2010) [Full text] Smoking cessation A unique approach to smoking cessation. 9 February 2010 Bridget A N Wilson, Medical Student The University of Auckland Send response to journal: Re: A unique approach to smoking cessation. As established in the smoking cessation editorial, no credible health professional needs more evidence to convince them of the harms of smoking. Each and every health professional sees the damage of smoking first hand on a daily basis. The question then becomes how best to assist patients in successfully quitting smoking in a variety of settings. This year we hope to work with the University of Auckland Faculty of Medical and Health Sciences in a new approach to smoking cessation delivery, with the development of Student ASH. Action on Smoking and Health (ASH) NZ is a NGO dedicated to the eradication of tobacco related disease, by advocating for policy measures to reduce to harm of tobacco in New Zealand. Student ASH will target membership to tertiary students engaged in medical and health science degrees. Student ASH aims to educate and involve health students in smoking cessation and wider tobacco control advocacy, and shares many common aims with ASH NZ. One specific aim of Student ASH is to work with the University of Auckland School of Medicine, and School of nursing, to get clinical students undertaking smoking cessation advice with patients while on clinical placements both in the hospital and primary health care settings. Medical and nursing students are very well placed to deliver smoking cessation advice and represent an underutilised resource in the fight against tobacco. While health students have adequate knowledge about the harms of smoking and the range of support which is available for smokers wanting to quit, they are likely to be far less intimidating than fully qualified health professionals. Health students typically have more time to spend with each patient than their fully qualified counterparts. This encourages a strong patient- student relationship, which is beneficial when approaching cessation advice, it also allows adequate time to discuss issues around smoking fully. Giving smoking cessation advice is one of the few skills which has such an enormous effect of the health of patients, while still being simple and easily performed by health students. Obviously to undertake smoking cessation advice with patients professionally and successfully, health students will need to be trained in smoking cessation techniques. As part of Student ASH we hope to provide students with the opportunity to attend workshops run by experts in smoking cessation to supplement and extend what students should be learning within the curriculum. As smoking is one of the biggest public health problems in New Zealand smoking cessation is an integral skill that every health professional needs to be competent in. Including smoking cessation as part of clinical training not only has benefits for patients but also ensures that by the time health professionals graduate they are already competent in smoking cessation. An additional benefit may be that students become more interested in advocacy regarding tobacco control. We hope that by developing a student ASH, and including tobacco cessation advice within the curriculum of health degrees, medical and nursing students can be utilised to deliver ongoing smoking cessation advice to patients on their placements. We believe that if the problem of tobacco is to be successfully tackled in New Zealand, a truly multidisciplinary approach needs to be implemented. Smoking cessation advice being delivered by health students will complement the advice given by fully qualified health professionals, and is another valuable route by which smoking advice can be delivered to patients. Competing interests: I am a third year medical student, and have just finished a 10 week summer studentship at Action on Smoking and Health (ASH) NZ, working to develop a student ASH.

EDITORIALS: Preventing alcohol related harm to health Groves (20 January 2010) [Full text] Preventing alcohol related harm to health Much to learn from smoking. 9 February 2010 Alexander SD Spiers, Professor of Medicine (Retired) N/A Send response to journal: Re: Much to learn from smoking. One must agree with Trish Groves that alcohol misuse is a huge public health problem. Apart from its effects on health,it has major effects on social relationships and also on crime, accidents and injuries. Hogarth's Gin Lane, and the BMJ's adaptation of it for the front cover, well delineate the ill effects of excessive drinking. While alcohol use costs the NHS and society as a whole vast sums of money, it is also a major source of tax revenue. With a crisis in government finances, this fact is not easily ignored. In tackling the problem of alcohol abuse we can learn much from the significant success of antismoking campaigns. It is proposed that a minimum price be set for alcohol by increasing taxes. In theory this might keep the Chancellor happy, because a decline in alcohol consumption would not be accompanied by an equal decline in revenues. On the other hand, higher taxes and more expensive alcohol would not curb everyone's drinking. In the case of the hardened alcoholic the higher prices might simply accelerate the descent of the drinker and his family into penury. Furthermore, as with cigarettes, costlier alcohol would encourage smuggling because it becomes more profitable, as happened with cigarettes in Canada. Further, the illicit production of alcohol within the United Kingdom would flourish, an option that is not readily available to the tobacco smoker. The United Kingdom's very expensive cigarettes have not greatly reduced smoking in Britain. More effective was the remorselessly progressive prohibition of alcohol promotion by advertisement and by sponsorship. The recent prohibition of smoking in pubs, restaurants and on public transport was a further step forward and surely is helping to remove the aura of maturity, glamour and sophistication that once attached to smoking and profoundly affected the young. It is not practicable to prohibit the consumption of alcohol; in the United States that did far more harm than good. Prohibition is also unreasonable, because unlike smoking, consuming alcohol is not universally harmful to society or to health. The regulatory measures listed by Trish Groves as effectively reducing alcohol consumption should all be pursued. In addition, there should be an intensive campaign to destroy the aura of masculinity and glamour that surrounds the practice of excessive drinking, binge drinking and antisocial behaviour that accompanies drunkenness. Competing interests: None declared

RESEARCH METHODS & REPORTING: The routine use of patient reported outcome measures in healthcare settings Dawson et al. (18 January 2010) [Abstract] [Full text] The routine use of patient reported outcome measures in healthcare settings And so PROMs are the answer but what’s the question? 8 February 2010 Stirling Bryan, Professor of Health Economics University of British Columbia, V5Z 1M9, Jennifer Davis Send response to journal: Re: And so PROMs are the answer but what’s the question? The paper by Dawson and colleagues1 provides an interesting overview of the routine use of patient reported outcome measures (PROMs) in health care, with a check-list of issues to be considered by those embarking on a PROMs study. The authors make two statements that do not appear to us to be highly evidence-based. We are not aware of any empirical work that can support the claim that the systematic use of PROMs improves patient outcomes. In fact the empirical papers and reviews of routine use of PROMs in clinical practice suggest that outcomes are not improved.2 3 A firmer research base is required, to establish the costs and benefits associated with routine measurement of PROMs, before the further roll-out of such initiatives. The second strong statement by Dawson and colleagues1 is that ‘clinicians are very positive about the usefulness of collecting PROMs’. A major PROMs initiative undertaken in Vancouver and Richmond, British Columbia, and reported in Wright and colleagues,4 sought to determine the feasibility of routine evaluation of indications for and outcomes of elective surgery. They collected PROM data before and after surgery from 5313 patients (across five hospitals) who underwent one of six elective procedures (e.g. cataract replacement, hysterectomy). A total of 138 surgeons participated and were asked at the end of the study whether the PROMs initiative was worthwhile and whether they wished to continue receiving routine reports on patients’ outcomes.4 The authors indicate that ‘Most surgeons were not enthusiastic about this type of evaluation.’ Perhaps surgeons in the UK are a different breed to those in British Columbia but it might be wrong to assume universal support for PROM-type work from all stakeholders, especially those whose performance might be ‘judged’ using such data.5 This brings us to the main point of our letter. Before embarking on the routine collection of PROMs data, as encouraged by Dawson and colleagues,1 we encourage researchers to spend some time understanding the problem they wish to address and consider whether routine PROM data will help to address it. Don’t start with the solution! There is the potential to squander considerable resource on such data collection activity; Browne and colleagues6 estimate the cost to be £6.50 per patient. We are, however, supporters of PROMs initiatives and see routine PROM data as potentially being useful to address questions posed by four different stakeholders in the health care system: the patient, the clinician, the manager/policy maker and the researcher. For example:  The patient who has undergone surgery asks: Is my recovery post-surgery similar to that of other patients or should I be worried?  The surgeon asks: Which of my patients are experiencing on- going health problems and might benefit from early clinical review?  The health sector manager asks: Which are the high performing surgical teams and what lessons can they offer to other groups?  The health service researcher asks: How variable are surgical health outcomes and what are the main drivers of such variation? We challenge Dawson and colleagues1 claim that routine collection of PROMs data in clinical cohorts can be used to assess the impact of health care interventions on patient outcomes and to guide resource allocation. Such questions require data (and more than just PROMs) from well controlled comparative studies rather than data from clinical cohorts. And so our message to would-be PROMs researchers is to proceed in a considered and thoughtful manner, understanding the questions you want to answer and building in rigorous evaluation work to generate research evidence on the value-for-money of PROMs initiatives. Stirling Bryan, PhD Professor, School of Population & Public Health, University of British Columbia Director, Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute stirling.bryan@ubc.ca Jennifer Davis, MSc PhD Candidate, University of British Columbia Centre for Clinical Epidemiology & Evaluation jcdavis@interchange.ubc.ca References 1. Dawson J, Doll H, Fitzpatrick R, Jenkinson C, Carr AJ. The routine use of patient reported outcome measures in healthcare settings. BMJ 2010;340:c186. 2. Marshall S, Haywood K, Fitzpatrick R. Impact of patient-reported outcome measures on routine practice: a structured review. J Eval Clin Pract 2006;12(5):559-68. 3. Valderas JM, Kotzeva A, Espallargues M, Guyatt G, Ferrans CE, Halyard MY, et al. The impact of measuring patient-reported outcomes in clinical practice: a systematic review of the literature. Qual Life Res 2008;17(2):179-93. 4. Wright CJ, Chambers GK, Robens-Paradise Y. Evaluation of indications for and outcomes of elective surgery. CMAJ 2002;167(5):461-6. 5. Bellan L. Evaluating elective surgery. CMAJ 2003;168(4):397-8; author reply 398-400. 6. Browne J, Jamieson E, Lewsey J, van der Meulen J, Black N, Cairns J. Patient Reported Outcome Measures(PROMs) in Elective Surgery – Report to the Department of Health: London School of Hygiene & Tropical Medicine, 2007. Competing interests: None declared

ANALYSIS: Practical challenges of introducing WHO surgical checklist: UK pilot experience Vats et al. (13 January 2010) [Full text] Practical challenges of introducing WHO surgical checklist: UK pilot experience Things should only get better? - it's our responsibility 8 February 2010 Dilnath Gurusinghe, Registrar in Plastic surgery & Burns Pinderfields General Hospital, Stephen Southern, Consultant Plastic Surgeon Send response to journal: Re: Things should only get better? - it's our responsibility The article by Vats et al(1) raises many positives shared by ourselves in implementing the WHO checklist in plastics and burns theatres. It is our opinion that developed and utilized correctly, an appropriate checklist is a valuable tool for improving patient safety. The timing, compliance and validity of the checklist are brought into question by some of the responses. It is also our practice to conduct a briefing prior to the operating list when the patients have been seen, procedures confirmed and therefore equipment requirements identified. In particular, this eliminates the occurrence of equipment issues being raised once a patient has been anaesthetized and brought into theatre. It is not in the patient’s best interest for problems to be identified once the patient has been given their anaesthetic. This also serves to minimize duplication of the checklist points and therefore improve its effectiveness. The dynamic nature of healthcare surely dictates that introducing new tools such as this is met with support, positive feedback and a degree of adaptability. Our clinical feedback provided within the framework of clinical governance allows us to identify weaknesses and strengthen them. In our practice, performing this pre-list briefing is a logical step towards augmenting the WHO checklist. To include this and other positive suggestions into the format is surely the correct way to maximize the intended benefits. 1. Vats A, Vincent CA, Nagpal K, Davies RW, Darzi A, Moorthy K. Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ. 2010; 340: b5433v Competing interests: None declared

PRACTICE: Long QT syndrome Abrams et al. (21 January 2010) [Full text] Long QT syndrome Hearing loss with long QT syndrome 8 February 2010 Tira Galm, ENT SpR Heartland Hospital, Birmimgham, BSS 5ST Send response to journal: Re: Hearing loss with long QT syndrome Abrams DJ et al(1) recent paper on long QT interval was very informative. I thought it would be of interest to the authors to mention that when taking a history from patients suspected of prolonged QT interval, was to ask the patient about personnel and family history of hearing loss. Jervell Lange – Nielsen syndrome is a rare cause of severe hearing loss with widened QT intervals. Jervell Lange – Nielsen syndrome is an autosomal recessive syndrome, with high incidence in consanguinity. The genetic defect is mutation of KCNE1 and KCNQ1, which are important in potassium transport channels in cell membranes. 1. Abrams DJ, Perkins MA, Skinner JR. Long QT syndrome. BMJ 2010;340 Competing interests: None declared

EDITORIALS: Synaesthesia Eagleman (8 January 2010) [Full text] Synaesthesia Other Visual Perceptual Phenomenon 8 February 2010 Fabida Noushad, ST5(LAT)General Adult Psychiatry Bradgate Mental Health Unit, Leicestershire Partnership Trust, LE3 9EJ Send response to journal: Re: Other Visual Perceptual Phenomenon Synaesthesia is a fascinating phenomenon. As Eagleman (1) says, patients do get mistakenly diagnosed to have schizophrenia. Synaesthesia has also been associated with use of hallucinogens like Lysergic acid diethylamide (LSD) and mescaline(2). Perceptual experiences in patients may present in any field of medicine and awareness can help in early diagnosis. For example, in ‘Hallucinogen Persisting Perception Disorder’, patients re-experience, following having stopped using the hallucinogen, one or more of the perceptual symptoms that were experienced while intoxicated with the hallucinogen (e.g., geometric hallucinations, false perceptions of movement in the peripheral visual fields, flashes of colours, intensified colours, trails of images of moving objects, positive afterimages, halos around objects, macropsia, and micropsia(3). Some patients report persistence of episodes for many years after having discontinued the hallucinogen. In Charles Bonnet syndrome, people with visual impairment present with complex visual hallucinations. Reassurance to the patient that it is a benign condition and not mental illness has powerful therapeutic effect(4). We are once again reminded that there is no short cut to taking a good history. References 1. Eagleman DM. Editorial.Synaesthesia .BMJ 2010;340:b4616 (Jan 8) 2. Ramachandran V.S.1; Hubbard E.M.Synaesthesia -- A window into perception, thought and language. Journal of Consciousness Studies, Volume 8, Number 12, 2001 , pp. 3-34(32) 3. Diagnostic and Statistical Manual of Mental Disorders. (DSM- IV)American Psychiatric Association.1994 4.Menon G, Rahman I, Menon.S,Dutton.G.Complex Visual Hallucinations in the Visually Impaired The Charles Bonnet Syndrome.Survey of Ophthalmology, Volume 48, Issue 1, Pages 58-72,2003 Competing interests: None declared

ANALYSIS: NICE and new: appraising innovation Ferner et al. (5 January 2010) [Full text] NICE and new: appraising innovation Radical innovation aimed at serious diseases a priority 8 February 2010 Peter H.M. Brooks, non-medical South Africa Send response to journal: Re: Radical innovation aimed at serious diseases a priority Innovation for its own sake makes no sense. Many drugs fail to make it through clinical trials because they are not good candidates in the first place - but are, rather, marketing ploys by the pharmaceutical company. These should be discouraged, stricter guidelines for initial entry make sense to exclude these. Radical innovation that has shown substantial improvement in animal models for serious diseases are, though, certainly worth attention. Obesity, for example, a growing epidemic, is a dangerous and expensive condition since it appears to be the cause of many other expensive conditions. Reducing the incidence of obesity ought to reduce costs to the NHS substantially over many years. Existing obesity drugs target the brain. Mikhail Kolonin, in Nature Medicine 10, 625 - 632 (2004) "Reversal of obesity by targeted ablation of adipose tissue", pioneered an innovative and radical approach that showed quite remarkable results in animal studies. This is exactly the sort of research that ought to be fast-tracked. As it is, this has been take up commercially by Zafgen (www.zafgen.com) and is currently going through clinical trials in Australia. Even now, close to commercial release, a deal to fast-track the approvals process for these drugs might well, accompanied by a price agreement, reduce the huge cost to the NHS earlier as well as making the treatments themselves cheaper. I think it worth considering. Competing interests: None declared

NEWS: Emasculating hypothetical oddities? Watts (5 February 2010) [Full text] Emasculating hypothetical oddities? Editorial judgments 8 February 2010 Henry H. Bauer, Emeritus Virginia Tech 24061 USA Send response to journal: Re: Editorial judgments Editors use their judgment, whether a journal is peer-reviewed or not. Everyone who has published in scientific journals ought to know that acceptance or rejection of a manuscript is decided in practice by the editorial choice of "peer" reviewers. Any experienced editor can deliberately choose reviewers who will OK a MS, and others who will turn thumbs down. Moreover, editors can decide whether or not to accept the advice given by the reviewers, they are not obliged to accept it. They can always ask for further reviews, too. One indication of the ever-present danger of bias and lack of objectivity in peer review is the attempt by some journals to use "blind" reviewing, taking authors' names off MSs before review, a usually quite ineffective device given that reviewers are familiar with the work of other researchers and given the inferences that can be drawn from the references cited in the MS. Some journals allow authors to suggest potential reviewers, and some even allow them to give names of individuals who should NOT be reviewers; and editors, of course and inevitably, decide whether or not to heed such suggestions. The greatest deficiency in peer reviewing is the typical practice that reviewers' names are not revealed to the MS authors. By being anonymous, reviewers may be less careful than otherwise in how they judge and especially the terms in which they express their judgments. (Imagine how dysfunctional the legal system would be if witnesses could testify anonymously.) At any rate, Bruce Charlton is not the only editor whose decisions determine acceptance or rejection: that's so with ALL editors, albeit not always as openly and directly. Competing interests: Co-author of the Duesberg article in Medical Hypotheses

EDITOR'S CHOICE: MMR and other controversies Godlee (4 February 2010) [Full text] MMR and other controversies Re: 'The Next MMR' and the present one - how not to restore trust 8 February 2010 Michael D Innis, NA NA Send response to journal: Re: Re: 'The Next MMR' and the present one - how not to restore trust John I fear you are not going to get a reasoned response from the MMR advocates. BIG PHARMA caries a BIG STICK. Michael Competing interests: None declared

OBSERVATIONS: The double face of discrimination Heath (4 February 2010) [Full text] The double face of discrimination Saying the unsayable 8 February 2010 Ben Bradley, GP Hackney Send response to journal: Re: Saying the unsayable Thank you, Dr Heath, for questioning the doctrine of 'equality' and the cardinal sin of discrimination. The fact that discrimination,in your positive sense, is practiced daily by every competent doctor is not acknowledged by most despite being clear and obvious with minimal refelection. The extrapolation of this to the elderly needs to be formalised in national guidelines before someone ends up being hauled over the coals. Competing interests: None declared The double face of discrimination Discrimination 8 February 2010 John K Johnson, Consultant Biochemist Retired Send response to journal: Re: Discrimination Iona Heath rightly points out the two meanings of “discrimination”, one being prejudice and the other making exact distinctions between two sets of people. In dealing with the inevitability of death she states “there comes a point too when an individual has simply sustained too many losses – of friends, spouse, children, health, energy, hope – to want to struggle on much longer.” This sentiment can also be used as an argument in favour of euthanasia or assisted suicide. “Why was this mother in court?” This was the front page headline in the Daily Telegraph on Monday 25th January following Kay Gilderdale’s conditional discharge for aiding and abetting her daughter Lynn’s suicide. The answer is because she acted against the law. This will probably result in a widespread debate between politicians, doctors and the public that may well lead to a change in this law. The second question raised by this case is “Why did Lynn want to end her life?” The answer is that she was suffering from a severe form of M.E. that made it intolerable. This call should lead to a widespread debate between doctors and health service providers to see whether any steps can be taken to prevent this happening again. There was no mention of it, however, in Friday’s BMJ. M.E. and the related condition fibromyalgia bring misery to thousands of people. The causes are unknown and there is no satisfactory treatment. As few people die, there is little specialist medical provision or research funding. Sufferers usually look well so elicit little public sympathy. They feel neglected, misunderstood, and often become resigned to a gradual deterioration in their condition. Especially in fibromyalgia, their symptoms can often mask other serious illnesses. There have been few articles on M.E. and fibromyalgia over the past ten years in the BMJ or BMJ Learning which suggests some discrimination against patients with this group of diseases. I hope that this letter will stimulate discussion and lead to action that will promote a better understanding and prevent further tragic actions like Lynn’s. Competing interests: None declared The double face of discrimination Two faces of age discrimination 8 February 2010 Robert C Baldwin, Consultant Psychiatrist Edale House, Manchester Royal Infirmary M139WL Send response to journal: Re: Two faces of age discrimination Iona Heath, who likes to quote others, knows that the Roman God Janus (‘The double face of discrimination’, BMJ 2010; 340:296) could see both beginnings and ends. At the start of my career as an Old Age Psychiatrist in the 1980s, I recall a conversation with a senior radiologist in which I was informed that CT scans of people with possible dementia were pointless because most were old. For the past 10 years across the NHS there has been routine age discrimination against older people with mental health disorders preventing them from accessing services available to anyone under 65. Without age equality legislation this is what we face. Being thoughtful and reasonable, as Heath undoubtedly is, never brought discrimination to an end; only the law does that. Competing interests: None declared The double face of discrimination The Double Face of Age Discrimination 8 February 2010 Ian Philp, Medical Director, NHS Warwickshire Westgate House, Warwick, CVV34 4DE Send response to journal: Re: The Double Face of Age Discrimination When good people argue in favour of age discrimination in the NHS (Iona Health, bmj 2010; 340: c578) it is time to despair, or to act, to protect the rights of older people. This was my rationale in advocating for legislation on age discrimination in the NHS. There were two important caveats: public health programmes for disease prevention could target age-specific groups based on evidence for cost-effectiveness, and individual decision-making not to treat, made in the privacy of the consultation room, on grounds of personal choice, or lack of capacity to benefit, for example as a result of frailty, would not be challenged. It is only the denial of access to individual treatment, based on chronological age, which would be out-lawed through the proposed legislation. If passed into law, many will welcome the protection it will afford in later life. I hope this will include Dr Heath, aged 80 and in excellent health, when she might otherwise be been turned down for cost-effective treatment of a life-threatening illness. Ian Philp, Professor of Health Care for Older People (i.philp@sheffield.ac.uk) Competing interests: I was the National Clinical Director for Older People (2000-8), responsible for rooting out age discrimination in the NHS

VIEWS & REVIEWS: Bad medicine: osteoporosis Spence (3 February 2010) [Full text] Bad medicine: osteoporosis Never too late for a confessional remedy 9 February 2010 Abdul Jaleel, Retired Consultant rheumatologtist County Durham. UKL Send response to journal: Re: Never too late for a confessional remedy Many thanks for a more lucid presentation , Dr. Spence. Now some of us can sit down and review our strategies on the diagnosis of osteoporosis and prevention of resultant fragility fractures, and measure the outcomes. Very pleased to read your last line : you are most welcome to the "mea culpa " group . One can only wish you and your co-prescribers every success in trimming the use of Bisphosphonates in the 20% of your practice patients under the age of 60 to which you referred in your original contribution . That said , festina lente please. Competing interests: None declared Bad medicine: osteoporosis Risk Assessment - A fractured Art 9 February 2010 Des Spence, gp G20 9DR Send response to journal: Re: Risk Assessment - A fractured Art Risk calculation is fraught. It often takes observed risk factors and then applies this as if drawn from interventional data. What are the confidence /error intervals on the calculations for FRAX (registered trademark) - I could find no reference. Although a recent revised version saw 43% reduction in hip fracture risk prediction in the young [1]. Have those patients started on treatment on early versions stopped their unnecessary medication? In general there is great debate around the use of risk calculators in heart disease  , with wide variants in results using different scores.  Also if the disease prevalence is changing as it seems to be with Hip Fracture, all these calculations are off . Finally remember the treatment paradox. A 1% absolute risk reduction means that 99 people per hundred  take treatment without benefit , other than making them anxious and exposing them to the risk of side effect. We should not be seduced by relative risk.   In respect to the use of Bisphosphonates for pr imary prevention I have gone to the landmark studies. A key study that is often quoted in respect to primary prevention is from 2001 [2]  . This took a study population with T score of 4  (which is the frailest 0.03% of the population) with an average age of 74. In patients without a previous fracture the absolute reduction was 0.6 % over 2 years . This was non significant statically, but even if we accept this number this would have a NNT of around 400 per year. But interestingly the follow for the whole study data was only 64 %, so even these poor conclusions are difficult to confirm. A worthy read for all those that advocate DEXA scanning and treatment - check out the confusing table of results.   I am keen to see robust interventional prospective data for reduced mortality and  reduced rates of dependence for the use of Bisphonates – not mere extrapolations , modeling or regurged reanalysis. Likewise, if anyone can direct me to primary prevention  research in women under the age of 60 with osteopenia/osteoporosis and I would be very interested to read this. We are over diagnoisising and over treating osteoporosis  and stealing away millions of patients well being. Bad Medicine? You bet.   [1] http://www.ars.usda.gov/research/publications/Publications.htm? seq_no_115=243105 [2] Michael R. McClung.  Effect of Risedronate on the Risk of Hip Fracture in Elderly Women . NEJM Volume 344:333-340 Competing interests: None declared Bad medicine: osteoporosis Thanks Des 8 February 2010 Ben Bradley, GP Hackney Send response to journal: Re: Thanks Des Thanks for another thought provoking critique - definitely time to tighten up on those DEXA requests and bisphosphonate scripts. Picking the malign effects of big pharma out of medical thinking and practice seems a never ending task... Competing interests: None declared Bad medicine: osteoporosis The pitfalls of a single risk factor 8 February 2010 Simon J Vanlint, General Practitioner Adelaide, SA 5005 Send response to journal: Re: The pitfalls of a single risk factor Des Spence is quite right to point out that osteoporosis is not really the issue - it is fractures that matter. I must disagree with his assertion that the available treatments are of limited efficacy, as published trials suggest a fall in relative risk of fracture by up to 20-25% for calcium and vitamin D, and 30-50% for antiresorptives. Of course, these figures only apply if patients actually take their medicine, but I haven't noticed that this deters us from prescribing medicines with similar compliance rates (statins, antihypertensives). We err if we think that measuring BMD is the last word in fracture risk assessment. Falls risk is probably much more important. Age (as noted by Dr Spence) is crucial. Other factors such as family history, smoking, previous fracture(s) (often overlooked!) and use of medications (e.g. steroids) must be considered if we want to get a realistic idea of absolute fracture risk. Osteopenia should NOT be struck from our lexicon, but it should be qualified. A smoker aged 70 with past history of fracture and a maternal history of fractured neck of femur has an absolute 10 year risk of fracture of 14% (hip) or 32% (all major osteoporotic) at a T-score of -2.2. (www.shef.ac.uk/frax). This osteopenic patient may well be worth treating, especially if avoiding a fracture keeps her out of a care home. Careful, wholistic assessment should guide best treatment. Competing interests: I have a research interest in vitamin D, and have received supplies of calcium & vitamin D tablets for use in clinical trials; I provide consultancy input to a DEXA testing service in Adelaide, South Australia Bad medicine: osteoporosis Shoud be read with mea culpa 8 February 2010 Dorasami Raman, Retd. Consultant Rheumatologist HSE Northwest, Ireland. Send response to journal: Re: Shoud be read with mea culpa An excellent article. Osteoporosis is as much a pharmaceutical industry creation as high cholestrol. We doctors at all levels also have had an active part in propagating these commercial myths. Hopefully the recession, self-realization and common sense may still prevail. Competing interests: None declared

OBSERVATIONS: Reflections on investigating Wakefield Deer (2 February 2010) [Full text] Reflections on investigating Wakefield Reflections of a grateful patient 8 February 2010 Sophie E L Puritz, SHO (CT1) medicine University Hospital of Wales Send response to journal: Re: Reflections of a grateful patient I was glad to see, in the journalist Brian Deer's 'Reflections on investigating Wakefield' that he gave some consideration to the two doctors 'left in the shadows', Dr. Simon Murch and Professor Walker-Smith. As a former patient of Professor Walker-Smith at the Royal Free, I have often felt sorry that this should have happened. Thirteen years ago, he turned a sick, miserable little girl back into a happy, optimistic one. What is more, he inspired her to become a doctor; "you don't need to lower your sights" he said. I am just one amongst hundreds of children that Professor Walker- Smith must have treated during his long career, and I'm sure there will be many who feel just as grateful towards him as I do. Whatever has happened since, I still hold him and Dr. Murch in high regard and will always be thankful for their care and expertise. Competing interests: None declared

OBSERVATIONS: Why did the Lancet take so long? Greenhalgh (2 February 2010) [Full text] Why did the Lancet take so long? Evidence, statistical lessons and bias. 9 February 2010 Peter J Flegg, Consultant Physician Blackpool, FY3 8NR Send response to journal: Re: Evidence, statistical lessons and bias. John Stone has plainly failed to understand my point, so I will try again: He and others are at great pains to point out that Andrew Wakefield’s Lancet study is merely a small, hypothesis-generating series of illustrative cases. This being so, what on earth was the evidence for Dr Wakefield’s claims following its publication that MMR vaccine should be avoided? An answer to this question would be appreciated. Mr Stone seems particularly churlish when he accuses Stanley Young of being “ill informed” about statistics when he discusses the relevance of statistical differences between 2 groups of study subjects and of not reading the Lancet paper. It actually appears to be Mr Stone who has not read the paper, for in the “Laboratory tests” section it clearly refers to the statistical differences in laboratory biomarkers including urinary methylmalonic-acid levels between a study group of 8 children and a group of age-matched controls. Clearly these are 2 different groups, and they are what Stanley Young was referring to. It is worth emphasising that the cases were not “consecutively referred” through normal channels, but the majority were specifically referred to the Royal Free either at the behest of Wakefield himself after parents had contacted him directly or because of their involvement in vaccine damage litigation. This means the study subjects were massively affected by selection bias towards children whose symptoms were allegedly due to MMR vaccine. This should have made Dr Wakefield extremely circumspect in drawing any causal inferences about the vaccine’s role. I note that in 8 of the cases symptoms were allegedly temporally related to MMR vaccine, and in one case to natural measles infection. Unlike Stanley Young (and like Mr Stone) I am no statistician, but I wouldn’t mind knowing the statistical odds of Dr Wakefield encountering a case of measles-linked as opposed to vaccine-linked autism when in 1996 there were only 112 cases of measles documented nationally(1), yet there would have been approximately 570,000 thousand MMR vaccines administered (92% of 620,000 infants). To me it would seem that having natural measles appeared to be a far, far riskier prospect than having an MMR vaccine, so I am surprised that Dr Wakefield didn’t alert people to this finding when he spoke at his press conference after the release of his Lancet study, and that he didn’t take the opportunity to reinforce the importance of MMR vaccination. (1) http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733833790 Competing interests: None declared Why did the Lancet take so long? The good, the bad and the ugly side of medical science 8 February 2010 Mark Struthers, GP and prison doctor Bedfordshire mark.struthers@which.net Send response to journal: Re: The good, the bad and the ugly side of medical science Dr Ben Goldacre, sometime correspondent for the BMJ and author of the ‘Bad Science’ column in Guardian once wrote, "Now, even though popular belief in the MMR scare is - perhaps - starting to fade, popular understanding of it remains minimal: people periodically come up to me and say, isn't it funny how that Wakefield MMR paper turned out to be Bad Science after all? And I say: no. The paper always was and still remains a perfectly good small case series report, but it was systematically misrepresented as being more than that, by media that are incapable of interpreting and reporting scientific data." [1] While acknowledging that the case series provides weak scientific evidence, Professor Greenhalgh, in her widely acclaimed book on the basics of evidence-based medicine, gives a good example of the case report providing an early warning of vital importance to science and public health, “A doctor notices that two babies born in his hospital have absent limbs (phocomelia). Both mothers had taken a new drug (thalidomide) in early pregnancy. The doctor wishes to alert his colleagues worldwide to the possibility of drug-related damage as quickly as possible.” [2] Professor Greenhalgh goes on to say that “anyone who thinks ‘quick and dirty’ case reports are never scientifically justified should remember this example.” I am therefore somewhat surprised that Professor Trisha Greenhalgh should have considered the retraction of a perfectly good small case series report a good thing for science. [1] Ben Goldacre. Don't dumb me down. We laughed, we cried, we learned about statistics ... 8 September 2005. http://www.guardian.co.uk/science/2005/sep/08/badscience.research [2] Trisha Greenhalgh. How to Read a Paper. BMJ Publications, Third edition 2006 Sections 3.7 & 3.8, Pages 52-53. Competing interests: None declared Why did the Lancet take so long? Re: Re: Re: Statistical lessons to be learned as well 8 February 2010 John Stone, Contributing editor: Age of Autism London N22 Send response to journal: Re: Re: Re: Re: Statistical lessons to be learned as well I do not see how Peter Flegg can hope to recuperate the ill-informed remarks of S Stanley Young. I could only conclude that Young had not even seen the paper he was criticising since it referred to "two groups" when there was only ever one. This was not a statistical paper. I note Flegg's extreme and unscientific bias against the possibility that MMR or measles vaccination could be implicated in autism/Pervasive Development Disorder or bowel disease. On what principle would even a single child be denied investigation if their medical history indicated it? Regardless of what the GMC panel claim to have found it is beyond credibility that a doctor of Prof Walker-Smith's experience and seniority would have ordered invasive tests on children with no symptoms. I note that that the histopathology results were positive for inflammation in 11 out of 12 cases. Perhaps, if we are to have a real doctors' purge the GMC ought to go after the signatory histopathologists now? And, I don't know what conclusions we can draw about referral - is Flegg suggesting that there ought to have been other children that he knows about included in the sequence, and on what basis? It was never supposed to be a random group. Competing interests: Autistic son Why did the Lancet take so long? Judgement on what’s good for science? 8 February 2010 Mark Struthers, GP and prison doctor Bedfordshire mark.struthers@which.net Send response to journal: Re: Judgement on what’s good for science? In 2003, Richard Horton, editor of the Lancet, wrote these words about the 1998 Wakefield et al paper, "The MMR vaccine paper was published not because peer review indicated that the findings were true - peer review can never prove truth, only indicate acceptability to a few experts, as was indeed the case with Wakefield’s findings - but because the issue raised was so important for public health and so in need of urgent verification that not to publish with appropriate caveats would, in my view, have been an outrageous act of censorship." [1] And even Ben Goldacre, in 2005, said that he thought "the paper always was and still remains a perfectly good small case series report." [2] And yet in 2010, Trisha Greenhalgh, professor of primary health care at UCL, believes that the recent retraction of the peer reviewed paper, published in 1998, "can only be a good thing for science." Why? Professor Greenhalgh doesn't provide a credible explanation. However, it is more than obvious that that what has happened to Andrew Wakefield will have taught scientists that it's safer not to rock the boat. Many doctors will be scared to speak for fear that what happened to Andrew Wakefield could happen to them. Can this state of affairs really be good for science? Andrew Wakefield doesn't think so, and I, for one, would strongly agree with him. [3] Over to you, Professor Greenhalgh. [1] Richard Horton glorifies Wakefield, with "no regrets" over discredited MMR paper. Richard Horton, Second Opinion, Granta Books, 2003 http://briandeer.com/mmr/horton-wakefield.htm [2] Ben Goldacre. Don't dumb me down. We laughed, we cried, we learned about statistics ... The Guardian, 8 September 2005. http://www.guardian.co.uk/science/2005/sep/08/badscience.research [3] Sally Beck. Judgement day for MMR rebel: an investigation that has blighted doctor's life for 12 years finally approaches conclusion. Daily Mail, 23 January 2010. http://www.dailymail.co.uk/news/article-1245518/Judgement-day-MMR-rebel- investigation-blighted-doctors-life-12-years-finally-approaches- conclusion.html Competing interests: None declared Why did the Lancet take so long? Re: Re: Statistical lessons to be learned as well 8 February 2010 Peter J Flegg, Consultant Physician Blackpool, UK FY3 8NR Send response to journal: Re: Re: Re: Statistical lessons to be learned as well The difficulty arises because Dr Wakefield himself drew the conclusion that vaccination was associated with enterocolitis/autism, and declared at a press conference that MMR might be causal. Yet we are now to believe that the publication was not meant to be a comparative study and represented merely a series of consecutively referred anecdotal problems. So on what possible evidence basis did Wakefield come to his bizarre conclusion? We also now know that the cases were not actually consecutively referred through normal channels, and there was considerable deliberate selection bias in favour of children with autism in whom there was a specific concern about symptoms linked to vaccination. Whilst Wakefield might have been impressed by their clinical stories, he should have realised that this bias should have made him even more circumspect about drawing any conclusions about MMR's causal role. Competing interests: None declared Why did the Lancet take so long? Unfounded and unjust 8 February 2010 Mark Struthers, GP and prison doctor Bedfordshire, mark.struthers@which.net Send response to journal: Re: Unfounded and unjust I think it is now established that the study design was a small case series report and a perfectly good one, according to Dr Ben Goldacre. [1] But the Wakefield et al paper did not state a hypothesis, a flaw considered serious enough for Trisha Greenhalgh to invent one, “The administration of MMR vaccine to infants increases their risk of developing (a) a particular pattern of inflammatory damage in the gastro- intestinal tract and (b) autism or an autism-like syndrome.” [2] In her 2004 critical appraisal of the paper, Professor Greenhalgh then asks herself whether this design was an appropriate way to test the hypothesis. No, she says, “if the hypothesis was that there is a causal link between MMR and autism-bowel syndrome, this study design was incapable of proving that link one way or the other.” And the knowledge that case reports do only provide weak scientific evidence for such causal links, was probably why, in their paper, Wakefield et al stated, “We did not prove an association between measles, mumps, and rubella vaccine and the syndrome described.” And why, in the last paragraph, they wrote, “We have identified a chronic enterocolitis in children that may be related to neuropsychiatric dysfunction. In most cases, onset of symptoms was after measles, mumps, and rubella immunisation. Further investigations are needed to examine this syndrome and its possible relation to this vaccine.” [3] [1] Ben Goldacre. Don't dumb me down. We laughed, we cried, we learned about statistics ... 8 September 2005. http://www.guardian.co.uk/science/2005/sep/08/badscience.research [2] Professor Trisha Greenhalgh. Analysis of Wakefield MMR study asks why flaws weren't spotted by Lancet editors. April 2004. http://briandeer.com/mmr/lancet-greenhalgh.htm [3] Early report. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. A J Wakefield, et al. THE LANCET • Vol 351 • February 28, 1998 637. http://www.theoneclickgroup.co.uk/documents/ME- CFS_docs/The%20Wakefield%20Paper,%20THE%20LANCET,%20Vol%20351,%20February%2028,%201998.pdf Competing interests: None declared

NEWS: Rise in US teen pregnancies and births is "deeply troubling" Tanne (2 February 2010) [Full text] Rise in US teen pregnancies and births is "deeply troubling" The Teenage Pregnancy Strategy in the UK 8 February 2010 Mohammed A Yusuf, Medical Student King's College London School of Medicine, Guy's Campus, London, SE1 1UL Send response to journal: Re: The Teenage Pregnancy Strategy in the UK It is pleasing to note the fall in teenage pregnancy rates in the US by 47 per 1,000 women over the period between 1990 and 2005, and it is a shame that it has not continued. From the various studies conducted looking into the efficacy of national and regional teenage pregnancy prevention strategies, it seems evident that such initiatives can prove beneficial. In the UK, the National Teenage Pregnancy Strategy was initiated in 1999 with the aim, amongst others, of halving the rate of conceptions in the under-18 age group by 2010. Although this target has not been met, we have seen a decline of 10.7% between 1998 and 2007; it is worth mentioning however that the change in actual fingers is not quite as impressive (41,089 in 1998 to 40,298 in 2007) [1]. A study by Wilkinson and colleagues looking at the outcomes of the first five years of the strategy showed that the biggest decrease in rate of conceptions in under-18s was found in regions where the rates had been highest at the baseline in 1998, and therefore where more funding had been provided [2]. One of the key campaigns run by the strategy has been to increase awareness of contraception as well as improve access to it. It has been noted that increased access to contraception was a key factor in the decline in rates in the 1970s [3]. This may add weight to the argument made by the Guttmacher Institute in the US, alluded to in the article. [1] Office for National Statistics (England and Wales) [2] Wilkinson P, French R, Kane R, Lachowycz K, Stephenson J, Grundy C, Jacklin P, Kingori P, Stevens M, Wellings K. Lancet 2006; 368: 1879–86. [3] Singh S, Darroch JE. Adolescent pregnancy and childbearing: levels and trends in developed countries. Family Plann Perspect 2000; 32: 14–23. Competing interests: None declared

EDITORIALS: Rising hospital admissions Gillam (2 February 2010) [Full text] Rising hospital admissions Admission avoidance 9 February 2010 Aruni Sen, Consultant in Emergency Medicine Wrexham Maelor Hospital, LL13 7TD Send response to journal: Re: Admission avoidance Sir, Rising emergency admissions are related to rising attendances at ED with higher dependance. The other factor is the anxiety of inexperienced juniors. Alternative care in the community is much aspired, just as expensive and rare as gold dust. Dr Gilliam mentions GPs in ED as an admission avoidance measure, which is not supported by data or experience. This might be true if the comparison is with ED juniors. He should include the presence of clinically active (as opposed to office based) ED cosultants on the shop floor as a much more effective measure against admission. The 5 wrexham ED consultants have been providing such service since 2003. An audit in 2006 showed that the consultants (compared to juniors and middle grades) see more no of patients, of higher triage category (higher dependance), investigate less and admit far less. A repeat audit in 2009 tells the same story. The department has the lowest admission rate in North Wales. In order to make acute care/admission more efficient, there is no subsitute to upfront assessment by an EM consultant. This needs investment - but is likely to pay more dividends than tinkering round the edges with GP, referral guidelines, specialist nurses, etc. Competing interests: None declared Rising hospital admissions Who is admitting and why 8 February 2010 john sharvill, GP deal england ct14 7au Send response to journal: Re: Who is admitting and why This article raises many points. Is it known the time of day for this apparent increase and what proportion are self referrers ie have not beed 'screened' by their own gp? From our own practice data the vast majority of emergency admissions are either self dialled 999 or directed to 999 by the ooh care triage system. They are required by nhs rules to identify and move all 'life threatening conditions' within 3 minutes. That does not leave time for a medical history from an experienced clinican. This gets the patient to the accident department where the perverse targets and payments within the nhs leads to them being admitted often for a very short period. At the other end of the scale the pressure for early discharge is leading to recurrent admissions as patients are not 'sorted out' on their first stay.Whilst the politicans are encouraging increased demand it is unlikely that the tide can be stemmed. Maybe by moving back to block contracts the 'costs' may not rise as much as demand?. Competing interests: None declared Rising hospital admissions Subtle Changes in Approach May Have a Profound Effect 8 February 2010 Graeme Mackenzie, GP working in AE Norht Cumbria Send response to journal: Re: Subtle Changes in Approach May Have a Profound Effect I have worked in "normal" general practice for 2 decades. I followed this up with 2 years full time out of hours work. I now am privileged to have the opportunity to work as GP in an A&E department as part of an admission prevention programme. I have been in post for 10 months and it has been a steep learning curve! However there are some key messages which I have gleaned from my time working in this new area. Admission decisions are often made too soon in the assessment process. We have developed an "escape" philosophy whereby you can "escape" from the chosen pathway. This works either way and "admissions" can be turned into "discharges" and visa versa. It is crude at the moment but systems need to be tuned to allow this to happen. Just putting a "brake" in the system can prevent many admissions. The reasons people are presented for admission often change very quickly. The brake allows the decision to be changed. The brake allows reconsideration of the issues rather than just copying of the "admission reason" from one contact to the next. Maintaining true "assessment" status in a busy hospital is difficult. Assessment with a view to more appropriate outcomes is hard intensive work. It needs multitasking skills and the need to plan for one outcome while still moving down another direction. Thus we will sometimes have all the community care options in place and then at the last moment choose to admit because of new information. Similarly we may be planning admission but changing information may result in us having to rapidly cobble together a discharge plan. Simple diagnostics can change the outcome but need to be readily available. I would include CT scans in this group Transport issues are a prosaic but powerful driver to admit. Not being able to transport people home results in admission. Saftey netting is crucial. Admission is a crude response to risk. Ther are other ways of addressing risk. Perhaps GPs can be more outward looking in terms of risk managment. Inevitably hospital staff look into the hospital for a solution to the risk. Iatrogenic harm should always be factored into admissions Some admissions can be stopped at source and need to be. Once an older frail person is in a hospital, admission is much harder to avoid. The deskilling of older people begins at the door. The NHS continuing care process is now complex and time consuming. Knowledge of this has motivated me. An admission may address some relatively minor diagnostic point but if you put that beside the costs of the discharge process, the iatrogenic harm and deskilling and the negative outcomes which patients often acquire from admission, in hind sight the decision to admit can look rather irrelevant! GPs are guilty of picking up the phone to resolve an relatively minor uncertainty and as a result of that admission costs can approach 6 figures. The system can encourage this. Old age palliative care is a huge issue. Not only do very frail older people probably have little to benefit from admission, removal to the hospital and the processes which that involves immediately outweigh any harm which may have resulted from not addressing risk by admission. Once you have a 90 year old demented patient in an A&E department it is very difficult to discharge if there are active and acute health issues, even if those issues could be dealt with back at the home. It is arrival at the hospital which creates so many problems. The staffing of the assessment service may not be that important as long as the admission process has appropriate blocks in it which allow everyone to reconsider the options. A mixed team from community and secondary care may be the best skill mix but there is the risk of clash of philosophies. Much of this work can be nurse led. Giving a new ring fenced team the remit of "admission avoidance" as an outcome measure probably has empowered our work because without avoiding admissions we have no raison d'etre. There are risks in this but they can be addressed with good governance. Competing interests: Working as GP in A&E.

LETTERS: What parliamentary witnesses also said about homoeopathy Mathie and Fisher (2 February 2010) [Full text] What parliamentary witnesses also said about homoeopathy nanopharmacology 8 February 2010 Michael Tremblay PhD, policy and technology advisor UK TN25 6RJ Send response to journal: Re: nanopharmacology Without wanting to get drawn into the specifics of homeopathy itself, I would only want to draw attention to a field of study, referred to as nanopharmacology. This examines medicines at nanoscale (1–100 nanometers), where quantum effects are present. It may be that there is something of a paradigm issue with respect to our perspective of causal and other factors being influenced by biochemical models of disease, which are quite different when looked at from a physical perspective (MRI spectrograph for instance). It is worth adding that some commentators are linking homeopathy to nanopharmacology, which may be an attempt to give it scientific legitimacy. However, given the skeptical views about the former and the research and scientific interest in the latter with peer- reviewed research and development (nano biomarkers, molecular diagnosis, nanoscale drug delivery systems and so on) perhaps it would be appropriate to have any possible overlapping claims clarified, to ensure at least that the good science is not hijacked. Competing interests: None declared

NEWS: Author calls for UK to set up tribunal for assisted suicide Dyer (2 February 2010) [Full text] Author calls for UK to set up tribunal for assisted suicide Assisted Suicide 9 February 2010 Kathryn E Grant, GP locum West Sussex Send response to journal: Re: Assisted Suicide How I applaud Terry Pratchett's view that "It seems sensible to me that we should look to the medical profession, that over the centuries has helped us to live longer and healthier lives, to help us die peacefully among our loved ones in our own home.." Iona Heath (as always) was talking sense too in 'The double face of discrimination' when she says that "many older people.....prioritise the needs of those younger than themselves-and especially the very young-in the allocation of healthcare resources. There comes a point too when an individual has simply sustained too many losses-of friends, spouse, children, health, energy, hope-to want to struggle on much longer." It is surely the mark of a humane society that we should be able to choose the time and place of our departure, in comfort and dignity, rather than having to struggle on, using scarce resources which could be better spent in improving the lives of others. drkathygrant@gmail.com Competing interests: None declared

MINERVA: Simpson and Burd (2 February 2010) [Full text] Erythema ab laptop 8 February 2010 Narayan D K Randev, Teenager School, Pawan Randev Send response to journal: Re: Erythema ab laptop Hello, I am a 16 year old boy who was reading this article, and it struck me that a common problem with laptops may have caused this rash on the skin. If the laptop was resting on his thigh, the laptop's fan may have been obstructed, wihch would result in the computer overheating. A problem that regularly occurs with laptops is that their fans can become blocked with dust, etc and this leads to the computer slowing down and emitting a lot of noise. In order to prevent this condition, the fan outlet must be cleaned using a small vacuum cleaner or compressed air to remove the dust or blockage. This is an effective way of preventing Erythema ab laptop. Competing interests: None declared

CLINICAL REVIEW: Current management of clubfoot (congenital talipes equinovarus) Bridgens and Kiely (2 February 2010) [Full text] Current management of clubfoot (congenital talipes equinovarus) Is the great Denis Browne forgotten? 9 February 2010 John Squire Kirkham, Retired Surgeon Garden Cottages, Water Lane, Drayton Saint Leonard, Oxfordshire, OX10 7BE Send response to journal: Re: Is the great Denis Browne forgotten? One of the many delights afforded to a surgical SHO at Great Ormond Street in 1962 was attending the great "DB", by then well retired but still an enthusiast who just couldn't help teaching. Bridgens and Kiely describe the shift from surgery for congenital club foot in the last decade , to less invasive (manipulative) methods. Credit is given, and I am sure correctly, to Ponseti, but the statement "although manipulation and casting were used in the past, this was not performed according to a formal protocol,and extensive surgery was often used" suggests ignorance of "DB"s great contribution. DB had described carefully and fully the use of a 3-piece splint over a prolonged period, each arm of the splint serving gradually to correct one aspect of the deformity, No pain was caused, as no force was used , with each limb of the splint merely maintaining the position of maximum correction for each of the three aspects for some days, after which the whole gentle process was repeated and continued as long as necessary. DB stressed that the key to success was adhering precisely to the method, in which the foot was strapped gently to the first splint limb in maximum attainable (without pain) correction, then similarly to the second splint piece . The two were then fitted together, the foot/ankle bandaged similarly to the third piece and that assembled to the first two. A brace or strap connecting the two feet was not used. When this protocol was followed , excellent results were achieved, even if slowly. The parent, physiotherapist or whoever was to apply the splints had to be trained to apply the method scrupulously and meticulously. Understandably, orthopaedic surgeons sought methods less tedious, and not requiring the obsessive repeated gentle application of these simple, but I believe, inspired contraptions, which also demanded commitment of vast time from a physiotherapist or an understanding, trainable parent. In the long term follow-up clinics were largely excellent results. I find it sad that in a clinical review in the BMJ, this great contribution from Sir Denis Browne, the Father of British Paediatric Surgery, is not recognised. This simple method, once properly understood and then meticulously applied, was probably as good or better than Ponseti, and in not requiring analgesia, plaster casts, or strut, was surely kinder to both child and parent: once the technique had been mastered the child could be bathed frequently , and even crawl about a bit without the inhibiting strut. There are are many instances of the wheel having to be reinvented, but surely the original wheelwright should be given some credit where possible. JOHN SQUIRE KIRKHAM, Retired Consultant Surgeon. Garden Cottages, Water Lane, Drayton Saint Leonard, OXON< OX10 7BE johnsquirekirkham@yahoo.co.uk Competing interests: None declared Current management of clubfoot (congenital talipes equinovarus) The Excellent Results of Current Clubfoot Management and Implications for Antenatal Diagnosis 8 February 2010 Matthew P Newton Ede, Specialist Registrar Trauma and Orthopaedic Surgery Royal Manchester Childrens Hospital, M13 9WL, Naomi Davis Send response to journal: Re: The Excellent Results of Current Clubfoot Management and Implications for Antenatal Diagnosis We were delighted to read the Clinical Review of Bridgens and Keily(1) regarding the current management of clubfoot. It is heartening to see the Ponseti method presented to the wider clinical community in such clear and concise terms, it having only gained widespread awareness and support within the orthopaedic community in the last decade. Undoubtedly the Ponseti method has lead to a change from a condition associated with lifelong disability to an entirely treatable one in the vast majority of cases. Indeed we assert that the success rates are higher than 85% quoted by the authors in the review [Tips for non-specialists](1). A recent evaluation in Iowa (the “birthplace” of the Ponseti method) reported successful clubfoot correction in 98% with a rate of recurrence of just 11%. In their series only 2.5% required tibialis anterior transfer(2). It is imperative that these excellent outcomes are given to expectant mothers. Antenatal trans-abdominal ultrasonic diagnosis of clubfoot is increasingly common. However accuracy is only 60-70% (3,4). Such an antenatal diagnosis, if considered against the now historical belief of a congenital condition associated with the potential for life-long disability, tragic decisions could be made regarding the continuance of the pregnancy. Therefore it is mandatory that this condition instead be presented to expectant mothers as a "Transient Developmental Deformation", with excellent rates of successful treatment within the first few years of childhood. We commend the authors of the Clinical Review for taking steps in disseminating the positive message to the clinical community and the wider population. 1. Bridgens J, Kiely N. Current management of clubfoot (congenital talipes equinovarus). BMJ.340:c355. 2. Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics. 2004 Feb;113(2):376-80. 3. Bar-On E, Mashiach R, Inbar O, Weigl D, Katz K, Meizner I. Prenatal ultrasound diagnosis of club foot: outcome and recommendations for counselling and follow-up. J Bone Joint Surg Br. 2005 Jul;87(7):990-3. 4. Keret D, Ezra E, Lokiec F, Hayek S, Segev E, Wientroub S. Efficacy of prenatal ultrasonography in confirmed club foot. J Bone Joint Surg Br. 2002 Sep;84(7):1015-9. Competing interests: None declared

RESEARCH: Effect of a collector bag for measurement of postpartum blood loss after vaginal delivery: cluster randomised trial in 13 European countries Zhang et al. (1 February 2010) [Abstract] [Full text] [PDF] Effect of a collector bag for measurement of postpartum blood loss after vaginal... Collector bag cannot be an isolated criterion to reduce severe haemorrhage 8 February 2010 Souhail Alouini, Obstetrican and Gynaecologist Centre Hospitalier Régional d'Orléans, 45000, France Send response to journal: Re: Collector bag cannot be an isolated criterion to reduce severe haemorrhage Zhang et al. (1) report that the use of collector bags after vaginal deliveries did not reduce the incidence of severe postpartum haemorrhage (PPH). However, the criteria of severe PPH used in this study such as transfusion, plasma expansion, embolisation and surgery were confusing. Indeed, plasma expansion and transfusion may be indicated for minor PPH (500 to 1000 ml) and embolisation or surgical treatments for the moderate one (1000 to 2000 ml) (2). Criteria of the best PPH management such as the availability of uterine embolisation in each unit and the ability of each local obstetrician to perform surgical procedures were not mentioned whereas half of the maternities were small (< 1600 deliveries/year). Each maternity managed only 1.61 severe PPH/month (189 PPH/39 maternities/3 months) on average and one embolisation or surgical procedure every 70 days (50 women/39 units/3 months). These data demonstrate that many maternities were not accustomed to manage major PPH. Finally, as criteria of severe PPH and its best management were not met, the conclusion that collector bags did not reduce severe PPH is not founded. References 1. Zhang WH, Deneux-Tharaux C, Brocklehurst P, Juszczak E, Joslin M, Alexander S; EUPHRATES Group. Effect of a collector bag for measurement of postpartum blood loss after vaginal delivery: cluster randomised trial in 13 European countries. BMJ. 2010;340:c293. doi: 10.1136/bmj.c293. 2.Royal College of Obstetricians and Gynaecologists. Postpartum Haemorrhage, Prevention and Management (Green-top 52). 2009.http://www.rcog.org.uk/womens-health/clinical-guidance/prevention-and -management-postpartum-haemorrhage-green-top-52 Competing interests: None declared

PRACTICE: Unrecognised scurvy Choh et al. (17 September 2009) [Full text] Unrecognised scurvy Neurodisability: An unrecognised risk factor for scurvy 8 February 2010 Vijay Palanivel, Specialist Registrar in Paediatric Neurodisability Great Ormond Street Hospital for Children, London WC1 3JH, Anjay MA Send response to journal: Re: Neurodisability: An unrecognised risk factor for scurvy We read with great interest the paper by Choh et al on unrecognised scurvy.(1) We would like to highlight some aspects of the modern epidemiology of scurvy which the authors have failed to mention. Although sporadic cases have been described throughout history, the evolution of scurvy in the developed world can be broadly described under three distinct eras: a. Scurvy in sailors due to extreme dietary depletion at sea which was successfully prevented following pioneering studies by James Lind, b. Scurvy in large populations affected by social upheaval (eg.wars and famines) in subsequent years and c. Re-emergence of scurvy towards the end of 19th century in infants from affluent families due to usage of heated milk and proprietary foods.(2) The understanding that scurvy is caused by a biochemical deficiency followed by the landmark event of isolation of vitamin C led to changes in dietary practices and widespread food supplementation. This led to the near eradication of scurvy in the latter half of 20th century. The authors suggest that in the current era, scurvy is confined to people with poor social status, malnutrition and alcoholism. We would like to propose neurodisability and neuropsychiatric illness as a previously undescribed risk factor for developing scurvy. Further to late diagnosis of scurvy in a child with cerebral palsy, we conducted a literature review on cases of scurvy reported in the 21st century.(3) A Medline search performed through Pubmed interface in April 2009 with the keyword “scurvy” revealed 237 articles in English published in the previous 9 years. Further analysis of these articles revealed 68 reports about new clinical cases of scurvy. Of these case reports, where the age of the patient could be verified, 25 were adults and 30 were children. Most of the adults fell into the risk categories alluded to by Choh et al. However half of the children had varying degrees of neurodisability (cerebral palsy, seizures, developmental delay, autism etc). This population group is not yet widely recognised as an at-risk group for scurvy. Subtle signs of early scurvy are even more difficult to pick up in this group due to learning and communication difficulties. Feeding problems (neurological or behavioural) which are widely prevalent in these children might be a contributing factor. Children with neurodisability who are otherwise thriving and seem to have an adequate caloric intake are still at risk for undetected vitamin C deficiency.(4) The small number of cases identified by our review might represent the proverbial “tip of the iceberg”. The authors also suggest that scurvy is a diagnosis of exclusion based on history and clinical features. However scurvy has classic radiological features which can be recognised on x ray and Magnetic Resonance Imaging (MRI) of the limbs.(5,6) References 1. Choh CT, Rai S, Abdelhamid M, Lester W, Vohra RK. Unrecognised scurvy. BMJ 2009; 339:b3580. 2. Rajakumar K. Infantile scurvy: a historical perspective. Pediatrics 2001; 108(4):E76. 3. Anjay MA, Palanivel V, Chaudhary R, Stocks R. Paediatric Scurvy: old wine in new bottles. Arch Dis Child 2009; 94: A65-A66 4. Noble JM, Mandel A, Patterson MC. Scurvy and rickets masked by chronic neurologic illness: revisiting "psychologic malnutrition". Pediatrics 2007; 119:e783-e790. 5. Park EA, Guild HG, Jackson D, Bond M. The recognition of scurvy with especial reference to the early x-ray changes. Arch Dis Child 1935; 10: 265-294 6. Choi SW, Park SW, Kwon YS, Oh IS, Lim MK, Kim WH et al. MR imaging in a child with scurvy: a case report. Korean J Radiol 2007; 8:443-447. Competing interests: None declared

VIEWS & REVIEWS: Poet scorner Dalrymple (28 October 2009) [Full text] Poet scorner Constructive Conversations 9 February 2010 Hugh Mann, Physician Eagle Rock, MO 65641 USA Send response to journal: Re: Constructive Conversations Conversations are defined by context and driven by purpose. The context of a conversation is its background, which involves the past and present. The purpose of a conversation is its goal, which involves the future. So when you're having a conversation, try to ascertain its context (past and present) and purpose (future). This will make your conversations more meaningful, constructive, and satisfying. Competing interests: None declared

NEWS: First of 1.3 million trees are planted in NHS forest Kmietowicz (6 October 2009) [Full text] First of 1.3 million trees are planted in NHS forest The Tree of Life 8 February 2010 Hugh Mann, Physician Eagle Rock, MO 65641 USA Send response to journal: Re: The Tree of Life People are like trees. With their roots planted firmly in the soil, trees stand tall and straight, and survive inclement weather. Likewise, people whose roots are firmly planted in family grow up strong and healthy, and survive adverse events. But without strong roots, both people and trees become weak and frail. Ideally, society is like an orchard, in which the strong and healthy shelter the weak and frail, so that all life has a chance to be fruitful. Competing interests: None declared

RESEARCH: Screening for postnatal depression in primary care: cost effectiveness analysis Paulden et al. (22 December 2009) [Abstract] [Full text] [PDF] Screening for postnatal depression in primary care: cost effectiveness analysis Economic model misrepresents NICE guidance 8 February 2010 Stephen Pilling, Professor National Collaborating Centre for Mental Health, UCL, WC1E 6BT, Dr IIfigeneia Mavranezouli Send response to journal: Re: Economic model misrepresents NICE guidance The paper by Paulden et al (2010)1 concludes by stating that the recommendations of the NICE (2007) 2 guideline on Antenatal and Postnatal Mental Health relating to case identification and assessment “do not result in value for money in the NHS.” This conclusion is based on the findings of the economic model presented in the paper. However, in our view, the economic model does not appropriately capture all the events in the care pathway associated with identification, assessment and treatment of women with postnatal depression. Moreover, the authors’ conclusion is based on an incomplete reading of the recommendations in the NICE guideline. Specifically the model assumes that a positive response to the Whooley questions (the recommended first step for case identification in the guideline) would result in the provision of individual psychological therapy. This is not the case; the guideline recommends that a positive response to the Whooley questions should be followed by a further assessment in order to determine what, if any, intervention should be offered. This leads to our second criticism; such further assessment would, of course, lead to an adjustment of the false positive rate for the Whooley questions (or similar tool) that significantly determines the outcome of the model. The Paulden et al. model does not consider the possibility of a reduction in the rate of false positives following further assessment; in contrast it assumes a zero rate for false positives for routine care, which is a rather unrealistic estimate. For example, Mitchell et al (2009)3 suggest that the false positive rate may be in the region of 15%. The superiority of routine care over formal identification methods in the model by Paulden et al depends in significant part on this unrealistic assumption of a zero rate for false positives in the routine care arm. In addition to these two important points, the paper also fails to take into account that a number of alternative and substantially less costly treatment options than individual psychological therapy are recommended in the NICE guideline such as guided self-help, exercise and computerised cognitive behavioural therapy. Looking at the results of base -case and sensitivity analyses, we suspect that the reason that routine care is first in terms of cost effectiveness is mainly because the model assumes that treating identified cases is expensive (£860), thus increasing the cost for identification strategies that have higher sensitivity than routine care. Treating false positives, which are assumed to be zero in the routine care arm, incurs extra (high) costs (£414) when formal identification strategies are used; in contrast, managing unidentified cases (false negatives), which are considerable in the routine care arm given its low sensitivity, is inexpensive (only £25). Economic models have an important part to play in the development and evaluation of clinical guidelines but in order to do so they need to be based on a proper understanding of care pathways and the use of accurate and appropriate data to support the model assumptions. Unfortunately in the case of Paulden et al neither of these criteria have been met. Professor Stephen Pilling, Director Dr Ifigeneia Mavranezouli, Senior Health Economist National Collaborating Centre for Mental Health Research Department of Clinical , Educational and Health Psychology, UCL, WC1E 6BT, 1. Paulden, M. Palmer, S. Hewitt, C. Gilbody S. (2010) Screening for postnatal depression in primary care: cost effectiveness analysis BMJ,; 339: b5203. 2. National Institute for Clinical Excellence (NICE)( 2007) Antenatal and postnatal mental health: Clinical management and service guidance, Clinical Guideline No. 47. London, National Institute for Clinical Excellence. 3. 2. Mitchell A, Vaze, A Sanjay Rao, S (2009) Clinical diagnosis of depression in primary care: a meta-analysis The Lancet 374, pp 609 - 619, Competing interests: SP receives funding from NICE for the development of clincial guidelines and led the development of the NICE guidleine on antetnatal and postnatal mental health.

EDITORIALS: Management of open fractures of the lower limb Louie (17 December 2009) [Full text] Management of open fractures of the lower limb Management of open fractures of the lower limb. Are children different? 8 February 2010 Nikolaos Gougoulias, Locum Consultant Orthopaedic Surgeon Frimley Park Hospital, Portsmouth Road, Frimley, Surrey, GU16 7UJ, Nicola Maffulli Send response to journal: Re: Management of open fractures of the lower limb. Are children different? Dear Editor, We read with great interest the editorial on ¡Management of open fractures of the lower limb¢,1 (published 17/12/2009, doi:10.1136/bmj.b5092 BMJ 2009;339:b5092). The article, very clearly, highlights the basic principles of open fracture management in adults. We would like to supplement its content, focusing on the paediatric population, as the issue of open fractures in children has not been dealt with. In a recent systematic review, we found that no clear guidelines regarding the management of open tibial fractures in children exist, and the quality of the published studies was poor.2 Analysis of the data in 643 paediatric patients with an open tibial fracture showed that management varied among different institutions. Cast immobilization was used in 52%, external fixation in 27%, internal fixation in 10% and flexible nails in 3%. Wounds were closed primarily in 32.5%. Complication rates were not unremarkable, with non-union (4.7%), delayed union (10.8%), mal-union (6.6%), leg length discrepancy (9.2%), neurovascular compromise (4.2%), deep infection (5.0%) and compartment syndrome (3%) being the most common, with a mortality rate was 1.6%. Most studies reported a high rate of bone healing problems and complications in patients older than 10 years (comparable to those in adults).3 The studies were characterized by short follow up periods (average 13 months), and did not assess the long term effects of the open tibial fracture on general health outcomes and function. Elastic intramedullary nailing is a new method of managing closed and open fractures in children, but published outcomes are inadequate to validate its efficacy. Obviously, research is needed to improve our knowledge of the interaction between age, severity of injury, concomitant injuries, type of fracture fixation and soft tissue management as they relate to outcome. References 1. Louie KW. Management of open fractures of the lower limb. BMJ 2009;339:b5092. 2. Gougoulias N, Khanna A, Maffulli N. Open tibial fractures in the paediatric population: a systematic review of the literature. Br Med Bull 2009;91:75-85. 3. Giannoudis PV, Papakostidis C, Roberts C: A review of the management of open fractures of the tibia and femur. J Bone Joint Surg Br 2006;88:3:281- 289. Competing interests: None declared

EDITORIALS: In praise of the physical examination Verghese and Horwitz (16 December 2009) [Full text] In praise of the physical examination Re: In praise of Physical Examination 8 February 2010 Roswitha Goetze-Pelka, psychiatrist, ret, student of translational medicne IV20 1XH Send response to journal: Re: Re: In praise of Physical Examination I am so glad that you mention the white coat. I am a German doctor living in Scotland and have recognized the abolition of the white coat which I think rather unhygienic. I have additionally learned as a student and young doctor again and again: Close your coat examining a patient in respect of the sense of shame of the patient and signalling that you are a medical doctor and not any man or woman. I could not understand why UK doctors do not wear coats anymore but have been told that they were contaminated as you tell. So I have to ask now: Did you abolish the source of contamination, too? How did you do that?? If you weren' t able to abolish that source (I suppose ill patients) where does this contamination now land on? Your skirt, tie, suit? Probably. How do you wash those? I know that it is far easier and more hygienic to wash a medical coat than i.e. woolen trousers. A white coat is only a source of contamination when do not change and wash it! I think the 'problem solving' chosen by the NHS made the problem (contamination in hospitals)worse. Competing interests: None declared

EDITORIALS: Secret remedies: 100 years on Colquhoun (15 December 2009) [Full text] Secret remedies: 100 years on A dynamic and fluid order 9 February 2010 Richard Bartley, Physiotherapist Wales Send response to journal: Re: A dynamic and fluid order Sounds like a combination of integrationist babble and management speak to me. Magic medicine advocates now couch their language in just this way. It all sounds plausible, but meaningless at the same time. I can only assume it is meant for lay people, as I can't believe anyone with a medical (or paramedical) background would fall for it. Competing interests: None declared Secret remedies: 100 years on Well-meaning armwaving does not cure patients 9 February 2010 David Colquhoun, Research Professor UCL WC1E 6BT Send response to journal: Re: Well-meaning armwaving does not cure patients Oh dear, what are we to make of William House's quasi-religious outburst? I think I'd regard it as a good example of DC's rule number 2 "Never trust anyone who uses the word paradigm" (rule number 1 is "never trust anyone who uses the word stakeholder"). It is obvious that medicine has huge areas in which little help can be offered, and even bigger areas where help is far from perfect. Medical research has been going, in any serious way, for barely 100 years, a very short time indeed. The problems are very complicated. Nothing seems less surprising than that many problems have not yet been solved. The effort to improve things can only be hindered by vague armwaving statements about " . . . conception of a dynamic and fluid order". The words have no detectable meaning. They sound more like something you'd expect from a flower-power hippy than from a "GP commissioner". It really is a bit tedious that people who deplore the efforts of science so often invoke in their support giants of science like Max Planck. Competing interests: None declared Secret remedies: 100 years on Svetlana l. Pertsovich 8 February 2010 Edzard Ernst, Director of Complementary Medicine Peninsula Medical School, Universities of Exeter & Plymouth Send response to journal: Re: Svetlana l. Pertsovich Sadly, I am unable to make the slightest sense of Pertsovich’s post. It seems to be directly aimed at attacking my reputation. Is she saying that a professor of toxicology, for instance, should have the remit of promoting poisons for general consumption? In academia, we (scientists working in the UK) are in the business of critically analysing our respective subject areas. At least that is what I had always hoped. Competing interests: None declared Secret remedies: 100 years on The Dying Paradigm 8 February 2010 William House, GP commissioner Bath Practice Based Commissioning Consortium, Clara Cross Lane, Bath BA2 5RP Send response to journal: Re: The Dying Paradigm It may be most constructive to view Professor David Colquhoon’s polemical editorial and some subsequent letters as distress calls from a dying paradigm (1). It is clear to very many ordinary people that modern biomedicine based on the classical natural sciences is not meeting their needs. It is ruinously expensive, dominated by large institutions and corporations, produces too much iatrogenic illness and allows the individual person to be overlooked. Most of all it is unsustainable. Many people now look elsewhere for help. Meanwhile a new paradigm is developing which will eventually subsume the present one. It will incorporate ecological theory and complex causation, and at its core will be a conception of a dynamic and fluid order rather than the static mechanical structures bequeathed to us by the Enlightenment pioneers. Paradigm shifts are painful and unsettling. As Max Planck wrote: ‘..a new scientific truth does not triumph by convincing its opponents and making them see the light…’ (2). We have to be patient. 1. Colquhoun D. Secret remedies: 100 years on. BMJ 2009;339:b5432 (15 December 2009.) 2. Quoted in Kuhn T, The Structure of Scientific Revolutions Chicago, University of Chicago Press 1962 (3rd Ed) p151. Competing interests: None declared Secret remedies: 100 years on This is scientists' opinion. 8 February 2010 Svetlana I. Pertsovich, scientist aka boffin MSU, Moscow, 119991 Send response to journal: Re: This is scientists' opinion. Mr. Ernst's comment looks odd. And his latest phrase simply perplexes: "I would be happy to join the discussion." I am forced to quote Prof. Colquhoun, forasmuch as his distinct idea has remained incomprehensible for public: "Perhaps it is time he listened to the views of scientists too." I stress, he said - "scientists"! The question arises - how does it concern Mr.Ernst? Is he a scientist? He is constantly declaring that he is a professor of complementary medicine, moreover, specialist in homeopathy, i.e. he is a representative of the business, which was determined (and even here, on these pages!) as anti-scientific and dangerous. What is his post? He is a "Director of Complementary Medicine" as he pointed himself here. In other words, he leads the courses, which Prof. Colquhoun exhorts to abolish in all universities. Is Mr.Ernst busy at his Chair with a business, which is antipathic to complementary medicine? But why does he retain still the term "complementary medicine" both for himself and his courses? Probably he has some personal, private opinion about this phenomenon. OK! He could discuss his opinion with minister in personal, private discussion. But mentioned above discussion is not for him. He is not a scientist. Moreover, as we saw, he was listened already by UK authorities. He took part in parliament's discussions. But the representative of science wasn't still listened by government and the time has come. Probably Prof. Colquhoun, who so actively proposes his candidature for this mission, will express SCIENTISTS' opinion, won't he? We hope on it and wouldn't like to fall into disenchantment with him. Competing interests: Scientist, pharmaceutist

PRACTICE: Commentary: Managing clinicians’ assessment Reuß et al. (10 December 2009) [Full text] Commentary: Managing clinicians’ assessment Anti-AQP4 ab might be relevant in pregnancy 8 February 2010 Reinhard Reuß, Physician Department of Neurology, University of Rostock, 18147 Rostock, Germany, Paulus S Rommer, Wolfgang Brück, Sven Jarius, Michael Bolz, and Uwe K Zettl Send response to journal: Re: Anti-AQP4 ab might be relevant in pregnancy Reinhard Reuß, Paulus S Rommer, Wolfgang Brück, Sven Jarius, Michael Bolz, and Uwe K Zettl We very much appreciate these interesting questions. As for the histological description, there were numerous small infarcts observable in the placenta. AQP4 immunostaining showed a complete loss of immunoreactivity compared to a normal placenta, in which AQP4 is ubiquitously expressed in a cell-type-specific and stage-dependent manner with a decrease in the syncytiotrophoblast from the first to the third trimester (then moderate) and an increased expression in endothelial cells and villous stroma (then moderate).1 There are two possible reasons for this. The cells originally expressing AQP4 might have been destroyed by immunoreaction;2-4 alternatively, endocytosis and subsequent degradation of the water channel, initiated by cross-linking of surface AQP4 by IgG, might have occured.4 C9neo deposits were seen in the perivascular space of placental blood vessels. In particular, we observed onion bulb-like staining around placental vessels. Additionally, the syncytiotrophoblast cell membrane was strongly marked. The appropriate controls were performed (negative control with omitting the first antibody; we also used several antibodies that recognised the C9neo epitope). The control placenta shows no indications (figure). It is still unclear whether this complement-activating antibody is pathophysiologically relevant and able to initiate CNS lesions, but there is increasing evidence that the anti-AQP4 ab is directly involved in the autoimmune pathogenesis of neuromyelitis optica.5-7 Taking into account the histologically observed similarity of lesions, anti-AQP4 ab may also have caused the placental pathology found in our patient, yet this is speculative. References 1. De Falco M, Cobellis L, Torella M, Acone G, Varano L, Sellitti A, et al. Down-regulation of aquaporin 4 in human placenta throughout pregnancy. In Vivo 2007;21:813-7. 2. Roemer SF, Parisi JE, Lennon VA, Benarroch EE, Lassmann H, Bruck W, et al. Pattern-specific loss of aquaporin-4 immunoreactivity distinguishes neuromyelitis optica from multiple sclerosis. Brain 2007;130:1194-205. 3. Misu T, Fujihara K, Kakita A, Konno H, Nakamura M, Watanabe S, et al. Loss of aquaporin 4 in lesions of neuromyelitis optica: distinction from multiple sclerosis. Brain 2007;130:1224-34. 4. Hinson SR, Pittock SJ, Lucchinetti CF, Roemer SF, Fryer JP, Kryzer TJ, et al. Pathogenic potential of IgG binding to water channel extracellular domain in neuromyelitis optica. Neurology 2007;69:2221-31. 5. Jarius S, Paul F, Franciotta D, Waters P, Zipp F, Hohlfeld R, et al. Mechanisms of Disease: aquaporin-4 antibodies in neuromyelitis optica. Nat Clin Pract Neurol 2008;4:202-14. 6. Bradl M, Misu T, Takahashi T, Watanabe M, Mader S, Reindl M, et al. Neuromyelitis optica: Pathogenicity of patient immunoglobulin in vivo. Ann Neurol 2009;66:630-43. 7. Bennett JL, Lam C, Kalluri SR, Saikali P, Bautista K, Dupree C, et al. Intrathecal pathogenic anti-aquaporin-4 antibodies in early neuromyelitis optica. Ann Neurol 2009;66:617-29. Competing interests: None declared

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 QOF for diabetes: action overdue 8 February 2010 Richard Lehman, General Practitioner Hightown Surgery, Banbury, OX16 9DB, Harlan M Krumholz Send response to journal: Re: QOF for diabetes: action overdue Almost one year ago, we wrote an editorial pointing out the lack of evidence from interventional trials to support a lowering of the glycaemic target in type 2 diabetes to below 7% glycated haemoglobin (gHb)(ref 1). Based on this lack of evidence for benefit, and some evidence of harm in patients treated vigorously to achieve the a target below 7% (ref 2), we called for an abandonment of this target in the Quality and Outcomes Framework (QOF) which came into force in April 2009. At this point, the measure still stands. A large observational study has just been published which examines the effect of additional glucose lowering medication given to nearly 29,000 patients with type 2 diabetes in the UK (ref 3). The level of gHb associated with the lowest mortality in these primary care patients is 7.5%. Levels below 7% are associated with a higher mortality which is only matched at the other end of the scale by levels above 9%, whether the additional treatment was another oral drug or insulin. Although these findings are not definitive, they are consistent with some of the trial evidence and reflect what is occurring in clinical practice. The accumulating evidence is suggesting the potential for an important safety problem with a strategy to achieve a gHb below 7%. If these data had been published for a particular drug, a moratorium on its use would in all likelihood be declared until more reassuring information became available. At this point the burden of proof is on proponents of the intensive strategy to generate data that such a course is safe and effective for older patients with established type II diabetes. And the effectiveness should refer to patient outcomes. Accordingly, we would like to recommend that the UK follow the lead of the National Committee on Quality Assurance in the United States and suspend this measure. We cannot risk harm by quality measures that encourage practice patterns that the evidence cannot support and that may even compromise patient safety. The QOF targets which encourage this should be abandoned before they come into force for a further year. Richard Lehman Harlan M Krumholz 1. 1 Lehman R, Krumholz HM. Tight control of blood glucose in long standing type 2 diabetes. BMJ 2009;338:b800. 2. Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008;358:2545-59 3. Currie CJ, Peters JR, Tynan A et al Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study. Lancet 2010;375;481-489 Competing interests: None declared

VIEWS & REVIEWS: The Magic Mountain Rütten (5 January 2009) [Full text] The Magic Mountain Library of Rudolf Virchow: location unknown 8 February 2010 Sergei V. Jargin, Pathologist Clementovski per 6-82; 115184 Moscow, Russia Send response to journal: Re: Library of Rudolf Virchow: location unknown In the last years there were at least 2 publications about Rudolf Virchow in the Russian journal for pathologists „Arkhiv Patologii“ (2). The authors, who know so much about Rudolf Virchow, are probably informed where his library is. The library of Rudolf Virchow, comprising 12.689 volumes, was united in 1909 with the library of Berlin Medical Society. In 1944 the Library was transferred to the castle Boitzenburg (land Brandenburg), and from there, according to some witnesses, it was taken away by Soviet military trucks. The present location of the library is unknown. We shall be grateful to everybody, who will provide information on the present location of the Rudolf Virchow Library or the library of the Berlin Medical Society. References: 1. Anichkov NM, Perov IuL. [Rudolf Virchow: the 150th anniversary of the cellular pathology teaching] [Article in Russian] Arkh Patol. 2009;71(1):3-8. 2. Stochik AM, et al. [From the history of the 19th century pathology. Rudolf Virchow and his view of disease] [Article in Russian] Arkh Patol. 2009;71(5):11-6. Competing interests: None declared