26 Rapid Responses published for 23 different articles.

Articles			Rapid Responses
	EDITORIALS: Prostate specific antigen for detecting early prostate cancer Ilic and Green (24 September 2009) [Full text]		The PSA screening editorial defies the evidence Charles J. Wright   (27 November 2009) Read every Rapid Response to this article
	PRACTICE: Metformin associated lactic acidosis Fitzgerald et al. (16 September 2009) [Full text]		D-lactate acidosis due to metformin Heikki Savolainen   (27 November 2009) Read every Rapid Response to this article
	PRACTICE: Tennis elbow Mallen et al. (2 September 2009) [Full text]		Exorcise your tennis elbow Gary Stack   (27 November 2009) Read every Rapid Response to this article
	RESEARCH: Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial Murphy et al. (29 October 2009) [Abstract] [Full text] [PDF]		Hawthorne Effect L Sam Lewis   (27 November 2009) Read every Rapid Response to this article
	PRACTICE: Chest radiographs in pregnancy O’Connor et al. (9 October 2009) [Full text]		Re: Chest Radiographs in Pregnancy - why not? Sally J O'Connor   (27 November 2009) Re: To be less invasive and less irrational. Sally J O'Connor   (27 November 2009) Read every Rapid Response to this article
	RESEARCH: Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial Kuijper et al. (7 October 2009) [Abstract] [Full text] [PDF]		author's reply Barbara Kuijper, et al.   (27 November 2009) Read every Rapid Response to this article
	NEWS: Giving homoeopathy on the NHS is unethical and unreliable, MPs are told O’Dowd (27 November 2009) [Full text]		The Evidence is Sufficient Stephen J Gordon   (27 November 2009) Read every Rapid Response to this article
	NEWS: Series of studies highlights health benefits of action on climate change Kmietowicz (25 November 2009) [Full text]		The global warming lobby will damage our ability to improve health stephen black   (27 November 2009) Read every Rapid Response to this article
	EDITORIALS: Public health benefits of strategies to reduce greenhouse gas emissions Griffiths and Rao (25 November 2009) [Full text]		The public health strategies being promoted are seriously flawed. Richard G Fiddian-Green   (28 November 2009) Read every Rapid Response to this article
	RESEARCH: Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies Strazzullo et al. (24 November 2009) [Abstract] [Full text] [PDF]		Fast food and stroke Rizaldy Pinzon   (27 November 2009) Re: Mammalian salt requirement Les.O Simpson   (27 November 2009) Read every Rapid Response to this article
	NEWS: First cases of spread of oseltamivir resistant swine flu between patients are reported in Wales Gulland (23 November 2009) [Full text]		CMO, DH and GPC should read from the same page. Hendrik J Beerstecher   (28 November 2009) Read every Rapid Response to this article
	CLINICAL REVIEW: Diagnosis and management of dengue Teixeira and Barreto (18 November 2009) [Full text]		Prevention of vector breeding through community engagement Biji T Kurien   (27 November 2009) Read every Rapid Response to this article
	VIEWS & REVIEWS: Rhyme and reason Moore (17 November 2009) [Full text]		Re: Oliver Wendell Holmes and puerperal fever Wendy Moore   (27 November 2009) Read every Rapid Response to this article
	RESEARCH: Pre-eclampsia, soluble fms-like tyrosine kinase 1, and the risk of reduced thyroid function: nested case-control and population based study Levine et al. (17 November 2009) [Abstract] [Full text] [PDF]		Can Thyroid function tests predict preeclampsia and what proportion of hypothyroid women have a history of preclampsia in their pregnancies ? Neeru Gupta, et al.   (27 November 2009) Read every Rapid Response to this article
	NEWS: Poor service provision is blamed for overuse of antipsychotics in dementia patients Mashta (17 November 2009) [Full text]		Both conventional and atypical anti- psychotics are dangerous Zekria Ibrahimi   (27 November 2009) Considering the alternatives Wiiliam R Jones, et al.   (27 November 2009) Read every Rapid Response to this article
	FEATURE: Doctors in management Stephenson (17 November 2009) [Full text]		Health management education for UK medical students Timothy D Heymann, et al.   (27 November 2009) Read every Rapid Response to this article
	NEWS: Australia operates "closed shop" to restrict doctors from overseas, say critics Sweet (16 November 2009) [Full text]		Something worth Protecting Peter A West   (27 November 2009) Read every Rapid Response to this article
	RESEARCH: Slow walking speed and cardiovascular death in well functioning older adults: prospective cohort study Dumurgier et al. (10 November 2009) [Abstract] [Full text] [PDF]		Validity of the results Edward M Absoud   (27 November 2009) Read every Rapid Response to this article
	EDITORIALS: Slow walking speed in elderly people Harwood and Conroy (10 November 2009) [Full text]		Fast walking and the mind Evan L Lloyd   (27 November 2009) Read every Rapid Response to this article
	LETTERS: Never mind the treatment, what about the tests? Bamji (10 November 2009) [Full text]		Cervical radiculopathy, never mind the tests what about the treatment? Laurie Allan   (27 November 2009) Read every Rapid Response to this article
	RESEARCH: Combining insulin with metformin or an insulin secretagogue in non-obese patients with type 2 diabetes: 12 month, randomised, double blind trial Lund et al. (9 November 2009) [Abstract] [Full text] [PDF]		Re: Is repaglinide really suitable for combination therapy with insulin? Søren S. Lund, et al.   (27 November 2009) Read every Rapid Response to this article
	EDITORIALS: Treatment of enteric fever Parry and Beeching (3 June 2009) [Full text]		Chronic carriage and mucosal health. Richard G Fiddian-Green   (27 November 2009) Read every Rapid Response to this article
	SHORT CUTS: All you need to read in the other general journals (1 July 2008) [Full text]		Re: New oral agents vs subcutaneous alternatives - has the DTB drawn the correct conclusion? Shirley Kuo, et al.   (28 November 2009) Read every Rapid Response to this article

EDITORIALS: Prostate specific antigen for detecting early prostate cancer Ilic and Green (24 September 2009) [Full text] Prostate specific antigen for detecting early prostate cancer The PSA screening editorial defies the evidence 27 November 2009 Charles J. Wright, consultant Toronto, Canada, M5T2Y9 Send response to journal: Re: The PSA screening editorial defies the evidence Dear Sir, The papers on pages 784 and 793 of the October 3rd BMJ, and also the first column of Dr Ilic's editorial in the same journal were very interesting, but his conclusions are incongruous. It is as if, having summarised all the evidence to date on the validity of PSA screening, it was decided to ignore most of it and basically state that what we need is more research. The more time we spend conducting more research the more men will continue to be subjected to major interventions with the accompanying high risks of serious complications including incontinence, impotence and even death (I must admit to some bias here in view of the death of a close friend from a massive pulmonary embolus on day 7 following radical prostatectomy, recommended to him because of a raised PSA level - the pathology in retrospect showed a prostate problem that would almost certainly never have bothered him if left alone). How could an editorial on this subject possibly avoid the conclusion that seems now very clear from the evidence, namely that PSA screening should be abandoned. It may continue to be useful in managing symptomatic patients but surely it is now clear that it leads to substantially more harm than benefit as a screening test for normal healthy men. We have known for decades that prostate "cancer" can be found at autopsy in up to 80% of elderly men who have died of unrelated causes. In other words, pathologists are currently incapable of predicting the prognosis for clinical disease from microscopic appearances (again, not news). We now know also from the large published trials that the "benefit" from PSA screening lies somewhere between vanishingly small and non-existent Yes, we certainly need the research focus to turn towards the molecular biology of prostate "cancer" wherein a solution to this problem may lie, but until then it is doing a serious disservice to men to state the kind of timid and insipid conclusion of this editorial, rather than a clear cease and desist recommendation on PSA screening. Yours sincerely, Charles J. Wright, MD,MSc,FRCS(C,E,Ed) Consultant in medical and academic affairs, program planning and evaluation Suite 704, 211 St Patrick Street, Toronto, Ontario, Canada, M5T 2Y9 email: cjwright@rogers.com Competing interests: None declared

PRACTICE: Metformin associated lactic acidosis Fitzgerald et al. (16 September 2009) [Full text] Metformin associated lactic acidosis D-lactate acidosis due to metformin 27 November 2009 Heikki Savolainen, Prof. Dept. of Occup. Safety & Hlth., POB 536, FIN-33101 Tampere, Finland Send response to journal: Re: D-lactate acidosis due to metformin Dear Editor, The article describing metformin-induced lactate acidosis (1) contains a figure which might be amended for clarity. The case is that metformin increases the D-lactate formation from the methylglyoxal, a glucose break-down product, through the methylglyoxalase system (2). The increase can be demonstrated even in clinically stable diabetes patients receiving the drug. This distinction is important as D-lactate is slowly metabolized by a high Km mitochonrial D-lactate oxidase contributing thus to the duration of acidosis. Propylene glycol in IV drugs also gives rise to D-lactate so that this could also be its source in critically ill patients. 1 Fitzgerald E, Mathieu S, Ball A. Metformin associated lactic acidosis. BMJ 2009; 339: b3660 2 Talasniemi JP, Pennanen S, Savolainen H, et al. Assay of D-lactate in diabetic plasma and urine. Clin Biochem 2008; 41: 1099-1103 Competing interests: None declared

PRACTICE: Tennis elbow Mallen et al. (2 September 2009) [Full text] Tennis elbow Exorcise your tennis elbow 27 November 2009 Gary Stack, GP Park Medical Practice, Killarney, Co Kerry Send response to journal: Re: Exorcise your tennis elbow I totally agree with Dr O'Connor, I have been extremely disappointed with the results of injection. I advise the patient of same and suggest the following exercises learnt from a sports physician many years ago: 1. WRIST ON WRIST, FLEX & EXTEND x 25 (Place the wrist of the painful forearm on top of the other wrist & move it up & down 25 times) 2. = 1. UPSIDE DOWN x 25 (Turn turn "bad" wrist in the opposite direction and again move it up & down 25 times) 3. = 1. and 2. HOLDING CAN OF BEANS x 25 (Do 1 & 2 holding a weight) 4. WRING A TEA TOWEL x 25 5. SQUEEZE A TENNIS BALL x 25 6. APPLY AN ANTI-INFLAMMATORY GEL (May well be the massage of the area rather than the medication that helps!) Do all of the above 3 times a day until resolution To my financial detriment I have had excellent results. Competing interests: None declared

RESEARCH: Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial Murphy et al. (29 October 2009) [Abstract] [Full text] [PDF] Effect of tailored practice and patient care plans on secondary prevention of heart... Hawthorne Effect 27 November 2009 L Sam Lewis, GP Trainer Surgery, Newport, Pembrokeshire, SA42 0TJ Send response to journal: Re: Hawthorne Effect Perhaps this study should be re-titled "Effect of Academia taking an interest in General Practice, with regular pep-talks", and subtitled "Subliminal messaging re: managing Hospital Admission Rates" ? It is interesting that this effect did not depend on the putative interventions; there was no measurable difference in effect on cholesterol or BP process measures, yet hospital admissions declined. That's benefit enough, you might think.. until you ask " What happened to patient well-being, morbidity and mortality ? " Perhaps people who needed hospital admission didn't get it ?? One could focus further study on CHD morbidity. Such advice and keen interest as was shown in this study , also pertains under the QOF incentive scheme. Yet Des Spence is unimpressed with any outcomes change.. Perhaps this is a new "Toyota Way" ? Give me academic "personalised interest" anytime ( and some away-days !), instead of blanket overburden with muda, mura, and muri ? References Grimshaw et al. "Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations." The Lancet, Volume 342, Issue 8883, Pages 1317-1322 Parsons HM: What caused the Hawthorne effect? A scientific detective story. Adm Soc 1978, 10:259-283. Publisher Full Text Des Spence: Dr Doom BMJ 2009;339:b4663, doi: 10.1136/bmj.b4663 (Published 12 November 2009) Jeffrey Liker (2003), The Toyota Way: 14 Management Principles from the World's Greatest Manufacturer, First edition, McGraw-Hill, ISBN 0-07- 139231-9. Competing interests: None declared

PRACTICE: Chest radiographs in pregnancy O’Connor et al. (9 October 2009) [Full text] Chest radiographs in pregnancy Re: Chest Radiographs in Pregnancy - why not? 27 November 2009 Sally J O'Connor, Respiratory SpR Kingston Hospital, Surrey, KT2 7QB Send response to journal: Re: Re: Chest Radiographs in Pregnancy - why not? The points made by Dr McCann et al are valid and welcomed. The criteria mentioned in the article are those from the BTS guidelines: Recommendations for the management of cough in adults. These guidelines state that a chest radiograph should be performed in all adults with a chronic cough (greater than 8 weeks duration), or with atypical symptoms including haemoptysis, breathlessness, fever, chest pain or weight loss. The article aimed to highlight that pregnancy itself should not affect a clinician's decision to perform a chest radiograph. We agree that pregnant women should be assessed as if they were not pregnant. However, the understanding of the low foetal risk posed by chest radiographs is not yet common knowledge amongst patients. Concern regarding any radiation in pregnancy is prevalent. Until patients are better informed, it remains prudent to discuss and document the decision to perform a chest radiograph. In the process it is possible to educate patients and facilitate informed decision-making. Competing interests: None declared Chest radiographs in pregnancy Re: To be less invasive and less irrational. 27 November 2009 Sally J O'Connor, Respiratory SpR Kingston Hospital, Surrey, KT2 7QB Send response to journal: Re: Re: To be less invasive and less irrational. Dr Ali's comments are welcomed. In hindsight the neck swelling should have been actively investigated - biopsy may have allowed an earlier and/or less invasive diagnosis. Nonetheless, the chest radiograph aided staging and choice of further imaging - it should have been performed on admission. The inclusion of fever in the BTS Cough Guidelines allows serious conditions such as pneumonia, tuberculosis and lymphoma to be diagnosed early. The chest radiograph is a highly effective screening tool in these cases, although admittedly patients with simple upper respiratory tract infections and persistent fever may end up being unnecessarily radiographed. Competing interests: None declared

RESEARCH: Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial Kuijper et al. (7 October 2009) [Abstract] [Full text] [PDF] Cervical collar or physiotherapy versus wait and see policy for recent onset cervical... author's reply 27 November 2009 Barbara Kuijper, neurologist Rotterdam, The Netherlands, 3078 HT, Barbara Kuijper, Jos Tans, Anita Beelen, Frans Nollet and Marianne de Visser Send response to journal: Re: author's reply We very much appreciate Dr Jacks’ comments regarding our article 1. His main concern is that we studied patients with other conditions than cervical radiculopathy. The patients in our study were referred by their general physician to the neurology outpatient clinic of the participating hospital because a cervical radicular syndrome was suspected. The diagnosis cervical radiculopathy was confirmed by a neurologist, who subsequently verified that the patients satisfied our inclusion and exclusion criteria. All patients had arm pain radiating distal to the elbow with an average VAS-score of 70 mm on the 0-100 mm scale, indicating quite severe pain. Sensory disturbances with a dermatomal irradiation pattern were found in 80 to 90 percent of cases, hyporeflexia and muscle weakness in corresponding myotomes were present in lower percentages, as is usually the case in this medical condition 2-4 . We are confident that the combination of the typical clinical picture and the imaging findings showing root compression in 74-82 % of the cases, are compatible with cervical radiculopathy only. For a comprehensive description of the clinical signs of cervical radiculopathy we refer to our review article 4. 1. Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial. Bmj 2009;339:b3883. 2. Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain 1994;117 ( Pt 2):325-35. 3. Yoss RE, Corbin KB, Maccarty CS, Love JG. Significance of symptoms and signs in localization of involved root in cervical disk protrusion. Neurology 1957;7(10):673-83. 4. Kuijper B, Tans JT, Schimsheimer RJ, van der Kallen BF, Beelen A, Nollet F, et al. Degenerative cervical radiculopathy: diagnosis and conservative treatment. A review. Eur J Neurol 2009;16(1):15-20. Competing interests: None declared

NEWS: Giving homoeopathy on the NHS is unethical and unreliable, MPs are told O’Dowd (27 November 2009) [Full text] Giving homoeopathy on the NHS is unethical and unreliable, MPs are told The Evidence is Sufficient 27 November 2009 Stephen J Gordon, A practising homeopath and General Secretary of the European Central Council of Homeopaths Norfolk Clinic NR3 4AG Send response to journal: Re: The Evidence is Sufficient The evidence base for homeopathy is easily sufficient for it to remain in the NHS. Taking a range of evidence including systematic reviews, RCTs, outcome studies and trials comparing its effectiveness with conventional treatments gives homeopathy an evidence profile that matches or surpasses those of a whole range of interventions currently practised in the NHS. If homeopathy is to go, then the so-called experts who gave opposing evidence at this highly unbalanced hearing must, by their own criteria, have the integrity to raise their hands and admit that there is a whole raft of other interventions used daily in the NHS that must go too. http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp Competing interests: A practising homeopath and General Secretary of the European Central Council of Homeopaths

NEWS: Series of studies highlights health benefits of action on climate change Kmietowicz (25 November 2009) [Full text] Series of studies highlights health benefits of action on climate change The global warming lobby will damage our ability to improve health 27 November 2009 stephen black, management consultant london sw1w 9sr Send response to journal: Re: The global warming lobby will damage our ability to improve health There is something extremely sad about the world when genuinely good ideas for improving public health need to be bundled with the global warming bandwagon in order to gain attention. In fact, we face a significant risk that the attention spent on global warming will damage world health. Even if I believed the world was about to enter another ice age, I would regard the replacement of indian wood-burning stoves as a good public health intervention. Even the skeptics who don't believe in global warming would agree that London's health would improve if the population did more exercise. Pretending that either have much if anything at all to do with climate change is both nonsense and an outrageous distraction from the actual public health case for the ideas (and this is probably true for the other interventions: i've just picked the easiest to ridicule). But there is a worse effect. The current case for the health impact of warming itself is far far more tenuous than the case for the existence of warming. The case for avoiding warming rather than adapting to it is also pretty poor. In both cases we are urged by the lobby to spend extraordinary amounts of money for small and highly uncertain gains. If we spent a fraction of the proposed sums on intervention where we are certain health and quality of life could be improved, we could guarantee to achieve much larger benefits. The risk of attaching such good projects to the warming bandwagon is that they will be squeezed out of the portfolio by the vast expenditure on warming avoidance projects of dubious benefit. In addition, urging health professionals to campaign specifically on climate change will take time away from the pursuit of easily reachable health gains. Hitching good public health projects to the climate bandwagon will ultimately damage public health. Competing interests: None declared

EDITORIALS: Public health benefits of strategies to reduce greenhouse gas emissions Griffiths and Rao (25 November 2009) [Full text] Public health benefits of strategies to reduce greenhouse gas emissions The public health strategies being promoted are seriously flawed. 28 November 2009 Richard G Fiddian-Green, FRCS, FACS None Send response to journal: Re: The public health strategies being promoted are seriously flawed. I remain unconvinced by the popular formulation of the climate change hypothesis and believe the public health benefits of strategies that have been proposed to reduce greenhouse gas emissions are seriously flawed. In the first place the data upon which the current formulation of the climate hypothesis are based have been obtained from focal observational points and do not exclude the possiblity that changes in these regions might indeed be man-made, but made by, for example, pulsed laser beams directed from satellites. From what I read some years ago in National Geographic, as I recall, the reduction in the arctic icecap might be the product of an increase in the temperature of Arctic currents induced by focal increases in water temperature. My recollection is that even Al Gore was aware of the annomalous, focal and warm currents that had been detected in the Arctic Ocean. There is a good economic and political motive for wanting to melt the Arctic icecap, making the Arctic ocean navigable in all seasons. The proposal that meat consumption should be reduced is particularly naive for it ignores the greater efficiency in nutrient utilization achieved by eating animals that can be grown eating food, such as the by products of maize harvesting that is fed to cattle and the slop that is fed to pigs, that is not fit for human consumption. Belching tractors and decaying rice paddies are a just as important, if not more important, source of carbon emissions as that that generated by herbivores. Both can be reduced by promoting the continued dependence upon a mixed diet in preference to switching to a more vegitarian one, despite the health advantages of a completely vegitarian diet clearly demonstrated by the increased longevity of Seventh Day Adventists. I submit that ground water and river delta pollution is of far greater concern to health than greenhouse gas emissions because of its adverse effects upon algae blooms, aquatic oxygenation and fish stocks. Lake Victoria in Uganda is but one of many examples of the adverse effects this can have upon food supplies. Competing interests: None declared

RESEARCH: Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies Strazzullo et al. (24 November 2009) [Abstract] [Full text] [PDF] Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies Fast food and stroke 27 November 2009 Rizaldy Pinzon, Neurologist Bethesda hospital Yogyakarta Indonesia 55224 Send response to journal: Re: Fast food and stroke There is changing way of life in many developing countries. There is a trend of changing diet pattern also. There is a rapid growth of fast food consumption. The fast food contains relatively higher salt compared with home made food. Some of the the quick and easy option foods were loaded with salt and incur harmful consequences. This study showed clearly that a difference of 5 g a day in habitual salt intake is associated with a 23 percent difference in the rate of stroke and a 17 percent difference in the rate of total cardiovascular disease.Based on the evidence, the authors estimate that reducing daily salt intake by 5 g at the population level could prevent one and a quarter million deaths from stroke and almost three million deaths from cardiovascular disease each year.Previous study showed that people who consumed more than 4 grams of sodium per day had an 84 percent greater likelihood of having such a stroke than did people consuming 2.4 grams or less sodium daily. The American Heart Association recommends 2.4 grams as the upper daily limit for sodium intake. Most sodium is consumed in the form of salt.These results support the role of a substantial population reduction in salt intake for the prevention of cardiovascular disease. Competing interests: None declared Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies Re: Mammalian salt requirement 27 November 2009 Les.O Simpson, retired experimental pathologist Dunedin New Zealand 9077 Send response to journal: Re: Re: Mammalian salt requirement Professor Mitchell stated, "Meanwhile the key question is what level of sodium intake is necessary to avoid the age-related rise in blood pressure which is regarded as normal, but is avoided at lower intakes consistent with nutritional requirement." According to Ajmani and Rifkind (1998) blood viscosity increases as a part of the aging process, mainly due to rising levels of fibrogen. Many studies have shown a relationship between blood pressure and blood viscosity. Before a sodium effect on blood pressure can be confirmed it would be necessary to eliminate the contribution of blood viscosity. Competing interests: None declared

NEWS: First cases of spread of oseltamivir resistant swine flu between patients are reported in Wales Gulland (23 November 2009) [Full text] First cases of spread of oseltamivir resistant swine flu between patients are reported... CMO, DH and GPC should read from the same page. 28 November 2009 Hendrik J Beerstecher, GP principal 111 Canterbury Road, Sittingbourne, Kent, ME10 4JA Send response to journal: Re: CMO, DH and GPC should read from the same page. Dear editor, We just received advice not to start vaccinating the new eligible group as no agreement has been reached over payments. (1) The Department of Health seems to be retracting from their position that all UK citizens will be offered vaccination. (2) The details of the Designated Enhanced Service, issued 3 weeks after the arrival of the vaccine in our surgery, reveal that no payments will be made for patients that do not fall in the at risk categories, including the under-5's. The result is that there is unused vaccine in our refrigerator, we offered this to other local practices, but everyone has enough. We have the vaccine, we have the capacity to vaccinate our practice population, it seems perverse that it is lying idle because the DH will not commit to the promises made earlier in the year. (1) GPC newsletter 20-11-2009. http://www.kentlmc.org/kentlmc/website10.nsf/0/087b97d13ad4ea7f802576790044481d/$FILE/News%204%20 -%20November%202009.pdf (2) NHS Choices. Enough vaccine has been ordered for the whole population. http://www.nhs.uk/Conditions/Pandemic-flu/Pages/Vaccine.aspx Competing interests: None declared

CLINICAL REVIEW: Diagnosis and management of dengue Teixeira and Barreto (18 November 2009) [Full text] Diagnosis and management of dengue Prevention of vector breeding through community engagement 27 November 2009 Biji T Kurien, Senior Research Scientist OMRF, Oklahoma City, OK 73104, USA Send response to journal: Re: Prevention of vector breeding through community engagement The article ‘Diagnosis and management of dengue’ gives a comprehensive review of dengue, detailing cause, transmission, clinical features, treatment and prevention (1). With respect to prevention, the authors discuss about vaccine development, community involvement strategy, vector control using chemicals, biologicals and traps. According to the authors, the strategy to control vector population is centred mainly on the use of chemicals, a counterproductive measure. Therefore, efforts should focus on community involvement to control Aedes aegypti, the principal vector, which breeds in discarded containers (that collect rainwater) and in other water storage containers. When DDT had been widely in use about 41 years ago (2) Aedes aegypti had almost disappeared from many countries. With diminished use of DDT, the menace of DHF has now returned (2). The problem has become more pronounced with urban expansion, increased use of non-biodegradable products (that can hold rain water and allow mosquitoes to lay eggs), lack of water supply via pipes (this makes water storage in containers and tanks a necessity) among other factors (2). A community involved environmental management for dengue prevention study carried out in Guantanamo, Cuba showed Aedes infestation reduction by 50-75% (3). However, as the authors suggest (1), this study did not investigate the effect of the intervention on dengue virus transmission (1). Notwithstanding this, persistent reduction in vector infestation is bound to reduce dengue virus transmission. Cans, plastic bottles, tires, car batteries (4) and flower containers in cemeteries have been found to be good breeding places. Latex collection cups, in rubber growing countries, cocoa pods, coconut shells, tree holes, plant stumps, mud pots, flower pots, grinding stones, water tanks etc are good breeding ground for mosquitoes (5). Care needs to be taken to turn latex collection cups upside down during rainy season to prevent vector breeding. Use of flower holding vases with drain holes or bronze vases, in cemeteries, has been suggested to limit mosquito spread (6). Community participation programme focusing on eradicating or reducing breeding containers at homes, weekly emptying of storage containers (weekly emptying can disrupt mosquito life cycles, since newly hatched larvae require 9 days under favorable conditions to develop into the adult stage or complete the cycle), encouraging larval control by using larvicide (temephos or Abate 1% sand granules), introducing larvivorous fish into water containers, covering larger containers with lids to prevent egg laying by mosquitoes and encouraging the use of predacious copephods of the genus Mesocyclops as a biological control agent will help stop the spread of dengue and DHF (7,8). A novel insecticide delivery instrument named the Mossie-Buster has been developed to control mosquito larvae from urban breeding places in Townsville, Australia (9). References 1. Teixeira GM, Barreto ML. Diagnosis and management of dengue. BMJ 2009;339:b4338 2. Vu SN, Nguyen TY, Kay BH, Marten GG, Reid JW. Eradication of Aedes aegypti from a village in Vietnam, using copepods and community participation. Am J Trop Med Hyg. 1998; 59:657-60. 3. Vanlerberghe V, Toledo ME, Rodríguez M, Gomez D, Baly A, Benitez 33 JR, et al. Community involvement in dengue vector control: cluster randomised. BMJ 2009;338:1959b. 4. Mazine CA, Macoris ML, Andrighetti MT, Yasumaro S, Silva ME, Nelson MJ, Winch PJ. Disposable containers as larval habitats for Aedes aegypti in a city with regular refuse collection: a study in Marilia, Sao Paulo State, Brazil. Acta Trop. 1996; 62:1-13. 5 Thenmozhi V, Hiriyan JG, Tewari SC, Philip Samuel P, Paramasivan R, Rajendran R, Mani TR, Tyagi BK. Natural vertical transmission of dengue virus in Aedes albopictus (Diptera: Culicidae) in Kerala, a southern Indian state. Jpn J Infect Dis. 2007;60:245-9. 6. O'Meara GF, Gettman AD, Evans LF Jr, Scheel FD. Invasion of cemeteries in Florida by Aedes albopictus. J Am Mosq Control Assoc. 1992 ;8:1-10. 7. Effectiveness of dengue control practices in household water containers in Northeast Thailand.Trop Med Int Health. 2005;10:755-63. 8. Vu SN, Nguyen TY, Tran VP, Truong UN, Le QM, Le VL, Le TN, Bektas A, Briscombe A, Aaskov JG, Ryan PA, Kay BH. Elimination of dengue by community programs using Mesocyclops(Copepoda) against Aedes aegypti in central Vietnam. Am J Trop Med Hyg. 2005;72:67-73. 9. Canyon DV, Hii JL. The Mossie-Buster: a hose-driven insecticide delivery tool for the control of container-breeding mosquitoes. J Am Mosq Control Assoc. 1997 ;13:389-94. Competing interests: None declared

VIEWS & REVIEWS: Rhyme and reason Moore (17 November 2009) [Full text] Rhyme and reason Re: Oliver Wendell Holmes and puerperal fever 27 November 2009 Wendy Moore, author London Send response to journal: Re: Re: Oliver Wendell Holmes and puerperal fever I'm grateful to Peter Bennett for reminding us of Alexander Gordon's pioneering research on puerperal fever. Space prohibited my mentioning him but I did detail his role in an earlier column 'Now wash your hands', on 25 August 2007 (BMJ 2007;335:402 (25 August), doi:10.1136/bmj.39314.598854.59). Anyone interested in more information on Gordon should read the excellent novel 'Touching Distance' by Rebecca Abrams. Wendy Moore Competing interests: None declared

RESEARCH: Pre-eclampsia, soluble fms-like tyrosine kinase 1, and the risk of reduced thyroid function: nested case-control and population based study Levine et al. (17 November 2009) [Abstract] [Full text] [PDF] Pre-eclampsia, soluble fms-like tyrosine kinase 1, and the risk of reduced thyroid... Can Thyroid function tests predict preeclampsia and what proportion of hypothyroid women have a history of preclampsia in their pregnancies ? 27 November 2009 Neeru Gupta, Deputy Director General and scientist E Indian Council of Medical Research, Ansari Nagar, New Delhi-110029, Nivedita Gupta, Manjula Singh and KK Jani Send response to journal: Re: Can Thyroid function tests predict preeclampsia and what proportion of hypothyroid women have a history of preclampsia in their pregnancies ? Soluble fms like tyrosine kinase, an antiangiogenic factor is associated with subclinical hypothyroidis in pregnancy. It remains to be determined that at what levels the risk of hypothyrodism occurs. For determining the cut-off values a Reciever Operating characteristic curve (ROC curve) should have been plotted (sensitivity vs false positivity/1- specificity. Pre-eclampsia is also associated with many circulating biomarkers (VEGF, calcitonin gene-related peptide, parathyroid hormone related peptide etc). The study tells an association but not causation. It is not clear that fms-like soluble tyrosine kinase is cause or an effect of the hypothyroidism and whether hypothyroidism is also associated with changed levels of other circulating biomarkers of preeclamsia or not. It is also observed in the study that preeclampsia in the pregnancy (population based part of the study) can lead to hypothyroidism in later life. A complimentary study should be planned to study whether hypothyroid women had a history of pre-eclampsia. Alternatively, all women with pre- eclamsia/soluble fms like tyrosine kinase positive women should be followed to see whether hypothyroidism develops, which will be able to prove causation. Competing interests: None declared

NEWS: Poor service provision is blamed for overuse of antipsychotics in dementia patients Mashta (17 November 2009) [Full text] Poor service provision is blamed for overuse of antipsychotics in dementia patients Both conventional and atypical anti- psychotics are dangerous 27 November 2009 Zekria Ibrahimi, psychiatric patient Coombs Library, Southall, UB13EU Send response to journal: Re: Both conventional and atypical anti- psychotics are dangerous The atypical anti- psychotics such as olanzapine and risperidone were condemned by the FDA as being involved in a higher death rate for those with dementia. But the conventional first generation anti psychotics, particularly haloperidol, are implicated in even larger hazard ratios (HR) (1). All anti- psychotics, old or new, are unsafe for the elderly. Anti- psychotics were designed for schizophrenia and have no appropriate receptor profile for Alzheimer's. Schizophrenics may be worried meanwhile that they are being given drugs damaging those who are weak and vulnerable. It is part of schizophrenia that its sufferers are less likely to look after themselves and are in bad health. Anti- psychotics are not so benign as aspirin and to overprescribe them is dangerous for the old in nursing homes- or indeed for schizophrenics in psychiatric units. REFERENCES: (1) All- cause mortality associated with atypical and conventional antipsychotcis among nursing home residenst with dementia: a retrospective cohort study. Rosa Liperoti et al. J. Clin Psychiatry. 2009:70 (10):1340- 1347 Competing interests: None declared Poor service provision is blamed for overuse of antipsychotics in dementia patients Considering the alternatives 27 November 2009 Wiiliam R Jones, ST4 in Psychiatry Yorkshire Centre for Eating Disorders, Newsam Centre, Leeds LS14 6UH, John F Morgan, Katherine Murphy Send response to journal: Re: Considering the alternatives The report led by Professor Banerjee is welcome and timely given the widespread off-label use of antipsychotics to treat behavioural and psychotic symptoms due to dementia (BPSD).[1] Commissioning specialist older people’s mental health services to support primary care and care homes and developing a curriculum to train GPs will go some way to meeting the proposed targets. However, given the current economic climate and lack of realistic evidence-based alternatives it seems unlikely that antipsychotic use will drop to the extent predicted by Professor Banerjee. The report recommends that “the Improving Access to Psychological Therapies (IAPT) programme should ensure that resources are made available for the delivery of therapies to people with dementia and their carers”. This seems unrealistic given the lack of evidence-based non- pharmacological methods of treating BPSD. The National Institute for Health and Clinical Excellence (NICE) guidance on the use of antipsychotics for BPSD has been heavily criticised for the inclusion of non-pharmacological measures such as animal-assisted therapy and massage which lack an evidence base.[2] More emphasis should be placed on the need for further research in assessing the clinical and cost-effectiveness of non-pharmacological methods of treating BPSD and of other pharmacological approaches as an alternative to antipsychotic medication. Similarly, there is only a strand of the IAPT initiative that focuses on older people and it has been more focused on adults of a working age. It seems that the lion's share of the £173m budget for IAPT will not be ring-fenced as mental health experts had originally believed. Instead the remaining £100m yet to be allocated will be spent at the discretion of individual PCTs. Few older people and even fewer people with dementia and their carers are likely to benefit from the programme as it is currently designed and delivered. Furthermore, the report recommends “the need to develop a curriculum for the development of appropriate skills for care home staff in the non- pharmacological treatment of behavioural disorder in dementia, including the deployment of specific therapies with positive impact.” Like many of us, care home owners have felt the financial strain of the current economic recession. It is unlikely that they will invest scarce resources into such developments anytime soon. Finally, we can learn from the United States where concern about the overuse of antipsychotics was highlighted over twenty years ago. This led to the introduction of legislation (Omnibus Reconciliation Act 1987) requiring all nursing facilities to have a medical director and each resident having an attending doctor who visits them at specified intervals. This had a considerable impact on the prescribing of antipsychotics to residents of nursing homes[3,4] and the government should consider how these policies could be adopted in the United Kingdom. References 1. Banerjee S (2009) The use of antipsychotic medication for people with dementia: Time for action. A report for the Minister of State for Care Services Department of Health: London 2. Haw C, Yorston G, & Stubbs J (2009) Guidelines on antipsychotics for dementia: are we losing our mind? Psychiatric Bulletin; 33: 57-60 3. Shorr RI, Fought RL, & Ray WA (1994) Changes in antipsychotic drug use in nursing homes during implementation of the OBRA-87 regulations. JAMA; 271: 358-62. 4. Semla TP, Palla K, Poddig B, & Brauner DJ (1994) Effect of the Omnibus Reconciliation Act 1987 on antipsychotic prescribing in nursing home residents. J Am Geriatr Soc; 42: 648-52. Competing interests: None declared

FEATURE: Doctors in management Stephenson (17 November 2009) [Full text] Doctors in management Health management education for UK medical students 27 November 2009 Timothy D Heymann, Reader in Health Management Imperial College London, London SW7 2AZ, Jenny Higham Send response to journal: Re: Health management education for UK medical students We read with interest Jo Stephenson’s review [1] of approaches to management training for clinicians. She describes in detail initiatives in continental Europe, the United States and Australasia. She quotes Professor Ham in observing that we need to invest in training and support for those who want to take on clinical leadership roles. Here at Imperial College London we have been offering an intercalated year in heath management since 2002 [2]. For the last two years we have introduced all 320 final year students to some of the management challenges they may face in the National Health Service as part of a ‘practical medicine’ module. Our health management BSc is one of Imperial medics’ most popular choices for their intercalated year. The course also attracts many talented intercalating students from other medical schools. Whilst we agree with Professor Ham that “[the development of more clinical leaders] is not going to happen through spontaneous combustion”, many of the doctors of tomorrow already appear to sense that management skills and knowledge will help them in their careers and want to seize the opportunity to develop them. [1] BMJ 2009;339:b4595 [2] http://www3.imperial.ac.uk/ugprospectus/facultiesanddepartments/businessschool/undergraduatecourses/bscprogramme Competing interests: The authors both work at Imperial College London

NEWS: Australia operates "closed shop" to restrict doctors from overseas, say critics Sweet (16 November 2009) [Full text] Australia operates "closed shop" to restrict doctors from overseas, say critics Something worth Protecting 27 November 2009 Peter A West, Senior Research Associate York Health Economics Consortium Send response to journal: Re: Something worth Protecting Readers of the article on restricted doctor entry to Australia should bear in mind that GPs and hospital doctors are paid fees for every patient (not in all cases for hospital but consistently for GPs). More doctors means one of two things, less fees for current doctors, which the doctors would not like, or more fees paid by the health system, which tax payers and government will not like. A free market in doctors' services could see incomes fall and perhaps lead to more competition on fees. But it is hard to see turkeys voting for Christmas, even in Australia's warmer Christmas climes! Competing interests: None declared

RESEARCH: Slow walking speed and cardiovascular death in well functioning older adults: prospective cohort study Dumurgier et al. (10 November 2009) [Abstract] [Full text] [PDF] Slow walking speed and cardiovascular death in well functioning older adults: prospective... Validity of the results 27 November 2009 Edward M Absoud, Retired Consultant Surgeon Pilgrim Hospital, PE21 9QS Send response to journal: Re: Validity of the results This research is fundamentally flawed. As the walking speed equals: length of pace multiplied by number of paces per unit time, but the length of pace is determined only by the length of lower limbs in fit persons. Therefore, a more accurate assessment of speed and mobility, would be the number of paces per unit time. Competing interests: None declared

EDITORIALS: Slow walking speed in elderly people Harwood and Conroy (10 November 2009) [Full text] Slow walking speed in elderly people Fast walking and the mind 27 November 2009 Evan L Lloyd, Retired 72 Belgrave Road Edinburgh EH12 6NQ Send response to journal: Re: Fast walking and the mind Dear Sir In this review the authors have omitted one major factor involved in fast walking. Fast walking speed certainly involves good cardiorespiratory condition and good musculoskeletal status. However it is also associated with good psychological/cerebral function. If a person is depressed, lonely or bored he/she is likely to walk slowly. Those who walk fast usually do so because they have something to do which is important to them. This is likely to keep them healthy. It is a similar situation to assessing the risk of developing hypothermia in an elderly person alone at home. The standard question is "When last did someone come to see you?" A much more valid question is "When last did you go to see someone?" This second question differentiates between those who still have the mental capacity to think about someone else, as well as indicating a reasonable physical and physiological function level, from those who are selfish and expect other people to run to them. These latter are at a much higher risk of developing hypothermia. Evan L Lloyd FRCPE, FRCA Competing interests: None declared

LETTERS: Never mind the treatment, what about the tests? Bamji (10 November 2009) [Full text] Never mind the treatment, what about the tests? Cervical radiculopathy, never mind the tests what about the treatment? 27 November 2009 Laurie Allan, Consultant Anaesthetist Northwick Park Hospital, Watford Road, Harrow, MIDDX, HA1 3UJ Send response to journal: Re: Cervical radiculopathy, never mind the tests what about the treatment? Andrew Bamji raises the real dilemma of expensive and unnecessary tests emerging with the introduction of open access magnetic resonance imaging to primary care in some areas1. He correctly states that persistent symptoms for six weeks or four weeks with motor signs require investigation, but scanning all cases is pointless when only 1% require surgery. However this leaves the unanswered question of what to do for all these symptomatic patients. In primary care, application of the World Health Organisation analgesic stepladder is helpful and indeed many patients are helped, if not optimally, by oral anti-inflammatory drugs2. This may predict a more useful response to targeted anti-inflammatory therapy by cervical steroid epidural. There is systematic review evidence of efficacy for this 3 and evidence-based practice guidelines 4 and a Cochrane review of medicinal and injection therapies for mechanical neck disorders5.This approach should be known by healthcare staff and more available to patients as in skilled hands this technique is carried out under local anaesthetic as a daycase with few problems6. Unfortunately the full spectrum of multidisciplinary pain services are too frequently forgotten and primary care commissioning teams would do well to balance diagnostics and therapies within care plans that deliver not just the diagnosis but all the options for symptom control which ultimately is what we would all want as patients. Similarly, the apparent failure to consider all the evidence for injection therapies as well as other options has resulted in the President resigning from the Pain Society and the National Institute for Clinical Excellence reconsidering its recommendations for back pain. 1. Andrew N. Bamji. Never mind the treatment, what about the tests? BMJ 2009; 339: b4619. 2. World Health Organisation. Cancer pain relief, 2nd ed. Geneva: WHO, 1996. 3. Benyamin RM, Singh V, Parr AT, Conn A, Diwan S, Abdi S. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician. 2009 Jan-Feb;12(1):137-57. 4. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N,Shah RV. Singh V, Benyamin RM, Patel VB, Buenaventura RM, ColsonJD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L. Interventional techniques: Evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007:10:7-111. 5. Peloso PMJ, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie SJ, Cervical Overview Group. Medicinal and injection therapies for mechanical neck disorders. Cochrane Database Syst Rev 2007; 3:CD000319. 6. Derby R, Lee SH, Kim BJ, Chen Y, Seo KS. Complications following cervical epidural steroid injections by expert interventionalists in 2003. Pain Physician 2004;7:445-449 Competing interests: None declared

RESEARCH: Combining insulin with metformin or an insulin secretagogue in non-obese patients with type 2 diabetes: 12 month, randomised, double blind trial Lund et al. (9 November 2009) [Abstract] [Full text] [PDF] Combining insulin with metformin or an insulin secretagogue in non-obese patients... Re: Is repaglinide really suitable for combination therapy with insulin? 27 November 2009 Søren S. Lund, MD Steno Diabetes Center, 2820 Gentofte, Denmark, Allan A. Vaag Send response to journal: Re: Re: Is repaglinide really suitable for combination therapy with insulin? We welcome the discussion raised by Dr. Malinverni. We believe that achieving good glycaemic control is not a natural consequence of aiming for it. Factors, such as hypoglycaemia might prevent achieving good glycaemic control also when it has been aimed for. Hence, aiming for and achieving good glycaemic control as in our study supports the conclusion that treatments, including insulin and repaglinide, can be used succesfully. We agree with Dr. Malinverni that other factors such as beta- cell failure, weight-gain or dosage schedules could be of clinical importance. We believe that hard endpoint studies will be needed to address these issues appropriately. Competing interests: SSL and AAV have reported equity in Novo Nordisk A/S. AAV have received funds from Novo Nordisk A/S for research. SSL and AAV have received fees from Novo Nordisk A/S for speaking and AAV has received fees from Novo Nordisk A/S for organising education. SSL and AAV are employees at Steno Diabetes Center, Gentofte, Denmark. Steno Diabetes Center is an independent academic institution owned by Novo Nordisk A/S and the Novo Nordisk Foundation.

EDITORIALS: Treatment of enteric fever Parry and Beeching (3 June 2009) [Full text] Treatment of enteric fever Chronic carriage and mucosal health. 27 November 2009 Richard G Fiddian-Green, FRCS, FACS None Send response to journal: Re: Chronic carriage and mucosal health. Resistence to infection to gut organisms depends upon antigen presentation, the secretion of IgA, and T cell competence. All are impaired when there is a chronic energy deficit for they are highly energy dependent. Inf Crohn's disease, for example, "lazy" T cells are implicated it the pathogenesis. A chronic energy defict is accompanied by alterations in the gaseous milieu in the lumen of the gut, a potentially important variable in the case of microaerophilic and anaerobic organisms such as H pylori and C difficile (1). The energy deficit could be due to mucosal ischaemia induced, for example, by dehydration in an hot climate. It could also be due to a nutritional deficit particularly in regard to those nutrients necessary for the de novo resynthesis of ATP. Prolonged carriage may, therefore, be partially or wholly the product of a mucosal energy deficit. 1. Richard G Fiddian-Green. Chronic intestinal ischaemia and Hirschsprung’s disease. Archives of Disease in Childhood 2007;92:185. 2. Virchow's cell theory in action? Richard G Fiddian-Green (23 March 2009) rapid response re: Jo C Dumville, Gill Worthy, J Martin Bland, Nicky Cullum, Christopher Dowson, Cynthia Iglesias, Joanne L Mitchell, E Andrea Nelson, Marta O Soares, David J Torgerson on behalf of the VenUS II team. Larval therapy for leg ulcers (VenUS II): randomised controlled trial. BMJ 2009; 338: b773 Competing interests: None declared

SHORT CUTS: All you need to read in the other general journals (1 July 2008) [Full text] All you need to read in the other general journals Re: New oral agents vs subcutaneous alternatives - has the DTB drawn the correct conclusion? 28 November 2009 Shirley Kuo, Associate Editor, Drug and Therapeutics Bulletin WC1H 9JP, David Phizackerley, Deputy Editor, Drug and Therapeutics Bulletin Send response to journal: Re: Re: New oral agents vs subcutaneous alternatives - has the DTB drawn the correct conclusion? In their response to Shortcuts (1) Dr Cohen and Ms Gates take issue with the conclusion of our article in DTB (2), arguing that the new anticoagulants dabigatran etexilate and rivaroxaban should be promoted for first-line use as thromboprophylaxis following hip or knee joint replacement surgery. These views were raised and carefully considered during the editorial process, to which Dr Cohen and Ms Gates made a major contribution. Indeed, some of the points are reflected in the final piece. Oral routes of administration of the new agents can offer practical advantages over existing preparations, and this is discussed in the Practical issues section of the article. Also, as stated in the conclusion to the article, the new drugs could provide a useful alternative to existing anticoagulants for thromboprophylaxis under the licensed indications. However, DTB’s review of the published evidence (which Dr Cohen and Ms Gates do not appear to challenge) lead us to conclude that more robust clinical efficacy and safety data were needed for both drugs. At the time the article was published, three randomised controlled trials had been published for dabigatran etexilate and four for rivaroxaban. These studies demonstrated that dabigatran etexilate may be as effective as enoxaparin, and rivaroxaban may be more effective than enoxaparin. However, the studies had several key limitations and these and important unknowns about the drugs were discussed in the article. These included the large proportion of patients with “non-evaluable” data due to the lack of assessable venography (up to 39% for one drug); the use of surrogate markers for the detection of venous thromboembolisms; the inclusion criteria used could have potentially misrepresented the risk of bleeding for one drug; and that the drugs have not been compared with low molecular weight heparins other than enoxaparin, or with fondaparinux. It is also important to remember (as Dr Cohen and Ms Gates acknowledge) that these new drugs are under close post-marketing surveillance for unwanted effects and potential toxicities. Rates of major bleeding or serious unwanted effects appeared low in the trials. However, these are low-frequency events and clinical trials published to date have not been powered to investigate the occurrence. In the absence of clear data, some caution about this issue seems reasonable. We recognise that other groups and bodies have reached a different conclusion about the place of dabigatran etexilate and rivaroxaban in thromboprophylaxis after joint replacement surgery. However, we also believe that our article clearly sets out the basis of our view. 1. All you need to read in the other general journals BMJ 2008; 337: a582 2. Anticoagulation with dabigatran or rivaroxaban. DTB 2009; 47: 116–20. Competing interests: None declared