Re: Influenza vaccination in healthcare professionals. Harish Nair, Alison Holmes, Igor Rudan, Josip Car. 344:doi:10.1136/bmj.e2217

Other rapid responses have neatly pointed out that the authors of this editorial conclude "there's no evidence for immunising healthcare professionals but we still think it should be mandatory".

I won't add to the observations of such a bizarre conclusion, but think it raises two other points.

What other interventions would the authors take resources away from in order to make immunisation mandatory? Not only are there vaccine costs, but there is the adminisatration, bureacratic, human resources, legal and managerial costs, all of which would be substantial. When I last checked there wasn't any spare money or resources lying around.

Second, whilst the BMJ is good at opening up debates on controversial areas like this, an editorial is not the place to do so. I would recommend a review of how something that should go into the Head to Head section got into Editorials (as if to reinforce my point, in the same print journal as the editorial on vaccinating healthcare professionals against influenza there was the Head to Head "Should childhood vaccination be mandatory?").

Competing interests: None declared

Re: Plan to stimulate research in developing countries is put on hold. Anne Gulland. 344:doi:10.1136/bmj.e3771

Dear Sir,

It was very disappointing for us to read that health officials have not come to an agreement on a binding convention on stimulating research and development focusing on the health problems of developing countries as published in your journal [1].

We have recently performed systematic reviews on the role of developing countries in generating Cochrane meta-analyses in the field of paediatrics (neonatology and neuropaediatrics) [2, 3]. We performed a systematic literature review of all Cochrane Reviews published between 1996 and 2010 by the Cochrane Neonatal Review Group (CNRG) and in the field of neuropediatrics. One important outcome parameter was the percentage of reviews that originated from developing countries.

In our study, 262 reviews were enrolled in the field of neonatology, and a total of 112 in the field of neuropediatrics. Only a small fraction (15/262 (5.7%) in neonatology, and 16/112 (14.3%)) in the field of neuropediatrics originated from developing countries. This is of concern for worldwide the vast majority of neonates and children are born and raised in these countries. Moreover, the recommendations issued in Cochrane reviews performed in highly industrialised countries are largely applicable to the field of neonatology and neuropaediatrics as practised in industrialised countries, and will potentially exclude the majority of neonates, infants, and children being born and cared for in the developing world. However, recently efforts ( through initiatives such as the Effective Health Care Alliance and the ‘‘Sea-orchid’’ consortium) have been undertaken to disseminate knowledge from the CNRG to low- and middle-income countries to ensure that care practices are evidence based and scarce resources will be used and allocated appropriately [4, 5]. These programs aim at targeting both generators as well as users and teachers of evidence in order to ultimately ensure the implementation of effective interventions [4, 5].

Our findings strongly suggest that there is an ongoing need for high quality research that specifically addresses specific issues that are most relevant to the medical care of children in developing countries (eg, treatments for drug resistant tuberculosis; paediatric versions of HIV drugs; a test to determine the effectiveness of treatment of Chagas’s disease; new antibiotics, in the face of increasing resistance; and vaccines that do not need to be refrigerated or can be given without an injection) as detailed by A. Gulland (1).

Funding and research agencies will play a pivitol role in selecting the most appropriate research programs for the developing world. Moreover, “developing countries have to be active participants in researching these diseases, otherwise they will not progress. If they invest their own money they have a say in which health problems they want to tackle,” as detailed by Mohga Kamal-Yanni, a senior policy adviser at Oxfam (1).

With kindest regards
Sascha Meyer (MD)1, Christiane Willhelm (MD)1, Wolfgand Girisch (MD)1, Stefan Gräber (MD, PhD)2, Ludwig Gortner (MD, Professor)1
University Hospital of Saarland, Medical School, Department of Paediatrics and Neonatology, 66421 Homburg, Germany1
University Hospital of Saarland, Medical School, Department of Epidemiology, Medical Informatics and Biostatistics2
References
1. Gulland A. Plan to stimulate research in developing countries is put on hold. BMJ 2012; 344 doi: 10.1136/bmj.e3771

2. C. Willhelm, W. Girisch, L. Gortner, Meyer S. Evidence-based medicine and Cochrane reviews in neonatology: Quo vadis? Acta Paediatrica 2012 Apr;101(4):352-3. doi: 10.1111/j.1651-2227.2011.02559.x. Epub 2012 Jan 9. No abstract available.
3. W. Girisch, C. Willhelm, S. Gottschling, L. Gortner, Meyer S. Role of Cochrane reviews in pediatric neurology. Pediatric Neurology 2012; 46:63-69
4. Garner P, Meremikwu M, Volmink J, et al. Evidence into practice: Middle and low income countries get it together. BMJ 2004;329:1036–9
5. Henderson-Smart DJ, Lumbiganon P, Festin MR et al. Optimising reproductive and child health outcomes by building evidence-based research and practice in South East Asia (SEA-Orchid): study protocol. BMC Med Res Methodol 2007; 7:43

Competing interests: None declared

Re: Doctors to take industrial action over pensions in June. Helen Jaques. 344:doi:10.1136/bmj.e3860

I'm sorry; did I misread this? Or is the editorial stance of the BMJ such that we are not to be told another side to this story? The disbelief of a public already astonished at doctors' remuneration; the idea that doctors are not already treated 'preferentially'; the irony that they think they are not condescending when they use terms like 'our patients'; the thought that the public can 'rest assured' because doctors will only withold treatment until the public 'need us most'. We doctors are making me sick.

Competing interests: None declared

Re: My Addison's disease. Kathleen Hilditch. 321:doi:10.1136/bmj.321.7261.645

Although this article was published 12 years ago, I am keen to give a recent acount from an Addison's patient.

I am a fit and healthy 35 year old who has always been a keen sportswoman; football, running and generally keeping fit. 8 months ago I began a new job and put many of my new symptoms which appeared at approximately the same time down to the stress of a new role (which was strange as I was really enjoying the job) - extreme fatigue, not being able to do my job and my sporting hobbies and having to drop those. Around 5 months ago I noticed other physical symptoms, extreme dry lips, small dark freckles appearing on my body, very thirsty. One month ago I went to my GP as I had begun to get very dizzy, particularly when I got up or climbed stairs. I was also very breathless and had lost weight and had an unusually dark tan.

In contrast to many of the other comments here I feel that the NHS did an amazing job. My GP was concerned that she couldn't work out what was wrong but knew 'something wasn't right', especially as I had very low blood pressure on standing. She immediately sent me for a blood test and included a test for my cortisol levels. These indicated that I had an exceptionally low level of cortisol and, in conjunction with an endocrinologist, I was diagnosed with Addison's disease within a week.

I realise that Addison's is a rare condition and that many, many people go months, even years before an accurate diagnosis. I am lucky that I was so fit and well pre-diagnosis which prevented an addisonian crisis, I am sure, but also that I have a fantastic GP who knew what to test for.

Almost immediately after taking 20mg Hydrocortisone (broken into 3 smaller doses) I began to feel better although it has taken a month for me to be back to where I was a few months ago. I'm confident I will be back running soon.

Competing interests: None declared