BMJ - 4 May 2013

THIS WEEK
BMJ | 4 MAY 2013 | VOLUME 346

CLINICAL REVIEW, p
NEWS
1 Nearly half of UK young doctors say stress levels
rose last year
New trials of gene therapy for heart failure start
2 BMA calls for meeting after health secretary blames
GPs for pressure on emergency care
Children to get vaccines against u and rotavirus
Peers reject bid to annul new NHS rules on
competition
3 Blood test detects genes that drive breast cancer
4 Private Eye sends up tobacco industrys attack
on plain packets
Medical leaders are considered to have gone
over to dark side
5 Makers of anticancer drugs are proteering,
say 100 specialists
Checklists can reduce errors in intraoperative
emergencies
6 Health eects of Greeces austerity are
worse than imagined
Evening primrose oil and borage oil do not help
eczema symptoms
Belfast childrens heart surgery unit should close,
says health board

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COMMENT
EDITORIALS
7 Measles in the UK: a test of public health
competency in a crisis
Felix Greaves and Liam Donaldson
OBSERVATIONS, p
8 Orlistat: should we worry about liver inammation?
John Wilding
RESEARCH, p
9 Recognising and responding to victims of human
tracking
Sharon Doherty and Rachel Morley
10 Understanding patterns in maternity care in the NHS
and getting it right
Lucy C Chappell et al
FEATURES
16 Research Paper of the Year award 2013
This annual BMJ award recognises outstanding
original research with potential to contribute
considerably to improving health and healthcare.
Trish Groves introduces the shortlist
17 Making the digital future a reality
Jon Hoeksma looks at the candidates for the
Transforming Patient Care Using Technology award
ANALYSIS
18 Innovate or die
Health systems must innovate to survive the
pandemic of non-communicable disease but many
innovations do not spread easily. Paul Corrigan,
Christopher Exeter, and Richard Smith examine why
this is so and how to help them spread
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RESEARCH
RESEARCH NEWS
11 All you need to read in the other general journals
RESEARCH PAPERS
12 Orlistat and the risk of acute liver injury: self
controlled case series study in UK Clinical Practice
Research Datalink
Ian J Douglas et al
EDITORIAL, p
13 When to remeasure cardiovascular risk in untreated
people at low and intermediate risk: observational
study
Katy J L Bell et al
14 Predictive value of S-100 protein for prognosis in
patients with moderate and severe traumatic brain
injury: systematic review and meta-analysis
Eric Mercier et al
15 Can trial quality be reliably assessed from published
reports of cancer trials: evaluation of risk of bias
assessments in systematic reviews
Claire L Vale et al
Caption,
p xx
Orlistat is still a useful option in some patients, p
China has introduced innovative measures to fight NCDs, p
A half of young doctors say workplace stress is rising, p
THIS WEEK
Join your
colleagues.
masterclasses.bmj.com
The MMR vaccine, p
COMMENT
LETTERS
21 Doctors and the alcohol industry
22 Clarithromycins adverse eects; Patient reported
outcome measures; Health and Social Care Act
OBSERVATIONS
PUBLICATION ETHICS
23 The UK should lead the way on research integrity
Elizabeth Wager
MEDICINE AND THE MEDIA
24 The private clinics advertising unlicensed
measles jabs
Mary McCartney
BMJ BLOG
25 An immensely delicate balance: the challenges
for CCGs
Richard Vize
PERSONAL VIEW
26 No doctor should be untouchable
Peter Wilmshurst
27 Caring for patients with dementia:
an exceptional case
Kate Sartain
OBITUARIES
28 Thomas Dormandy
Chemical pathologist who studied free radicals and
wrote an acclaimed book on tuberculosis
29 James Reginald Searle Barton; David James Martins
Buddery; John Denys Campling; David Malcolm
Milne; John Joseph Smirke Herbert Ruston; Carl
Ludwig Scholtz; Julian Stanley Martyn Toms
LAST WORDS
39 Bad medicine: the way we manage diabetes
Des Spence
Portfolio of pap Oliver Ellis
EDUCATION
CLINICAL
REVIEW
30 Adolescent
idiopathic
scoliosis
Farhaan Altaf et al
PRACTICE
A PATIENTS JOURNEY
35 Visual agnosia Anonymous and Anna Basu
10MINUTE CONSULTATION
36 Vasectomy S Jamel et al
ENDGAMES
38 Quiz page for doctors in training
MINERVA
40 Army musicians, and other stories
Measures to make dementia patients happy in hospital, p
Scoliosis testing, p
THIS WEEK
PICTURE OF THE WEEK
A three dimensional computer simulation of a mans head and neck is unveiled by Paul Anderson,
director of the Digital Design Studio at the Glasgow School of Arts. The project, funded by NHS
Education in Scotland, could revolutionise anatomical training, its creators say. Data from scans of
individual patients can be overlaid on the simulation, which could help surgeons during difficult
operations, they add.
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4 May 2013 Vol 346
The Editor, BMJ
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RESPONSE OF THE WEEK
Palliative care has shown us a lot of
good thingsholistic and realistic
care, integration across community
and hospital, and a framework of well-
judged and appropriate use of medical
intervention. End of life care is within
the skill set of most geriatricians, and
other physicians, but they need an
environment and working systems that
are radically different from those current
in UK hospitals. Not least, they need
considerably more time to communicate,
make decisions, and engage families.
Providing this would benefit numerous
vulnerable groups, such as those who
are cognitively impaired, who populate
our hospitals.
Rowan H Harwood, consultant geriatrician,
Nottingham University Hospitals, UK, in
response to Caring for a dying patient in
hospital (BMJ 2013;346:f2174)
BMJ. COM POLL
Last weeks poll asked:
Do patients need
to know they are
terminally ill?
87.5% voted yes
(total 1 172 votes cast)
This weeks poll asks:
Should the legal age for buying tobacco be raised to 21?
BMJ lu1!;!/6:fl693
Vote now on bmj.com
MOST SHARED
Doctor who lied on his CV is allowed to return to work
Liverpool care pathway is a nice ideapity about the
practice
Reducing sodium and increasing potassium intake
Vitamin D sufficiency in pregnancy
Publishing your research study in the BMJ
THIS WEEK
The question society has to answer is whether it is
ethically acceptable to tolerate any serious complication,
or death, from measles when an enective vaccine is
available. So say public health specialists Felix Greaves
and Liam Donaldson in their editorial reflecting on the
recent epidemic of measles in south Wales and the
prospect of large outbreaks in England (p 7). With large
cohorts of children and teenagers unvaccinated against
measles, mumps, and rubella, health systems have been
playing catch up as measles cases soar. Greaves and
Donaldson turn the spotlight on the public health sector
as it undergoes fundamental change.
In a public health emergency, which is what the
current measles threat is, it is vital that the response
is well coordinated, they say. But strategic health
authorities and primary care trusts that have been key
in previous crises have been devolved and swept
away and public health teams are scattered across
local authorities. While Public Health England is charged
with protecting the populations health, resources for
immunisation are with NHS England, an entity devoid of
public health expertise at board level, say Greaves and
Donaldson.
They are also concerned that if England fails to act
resolutely, it will set a poor example to other countries,
given the UKs history of calling for better vaccination in
low and middle income countries. More dynamism and
innovation as well as good organisation is needed, they
say.
From communicable to non-communicable diseases,
and another call for innovation. Paul Corrigan and
colleagues say that the pandemic of chronic diseases
threatens the sustainability of health systems worldwide
(p 18). The main reason is the escalating costs of looking
afer people with multiple chronic conditions such as
diabetes and asthma. Corrigan and colleagues look at
seven innovative approaches to reducing the burden
of such diseases, including widespread uptake of the
polypill (containing aspirin, a statin, and folic acid),
an idea that was launched in the BMJ a decade ago
(BMJ 2uu3;326:1/27). The polypill, which is currently
undergoing trials for primary prevention, could promote
the sustainability of health systems by reducing the
burden from stroke and myocardial infarction, they
say. They acknowledge that drug companies might be
resistant to something that could undercut markets, and
that public health professionals may regard the pill as
an alternative rather than a supplement to a healthy
lifestyle. But they say, If as some studies suggest, half
of heart attacks and strokes could be prevented, the
savings could be enormous.
Pills for modern ills come under scrutiny elsewhere in
this weeks BMJ. A paper by Douglas and colleagues nds
an association between orlistat, the only prescription
drug available to treat obesity, and abnormalities in liver
function (p 12). But in an accompanying editorial, John
Wilding concludes that orlistat remains useful for the
treatment of obesity, with an overall positive benet-
risk prole (p 8). And in his weekly column, Des Spence
takes issue with the drug model of type 2 diabetes, a
modern plague largely brought on by lifestyle (p 39).
The therapeutic approach in diabetes is upside down,
he says.
Trevor Jackson, deputy editor, BMJ
tjackson@bmj.com
Cite this as: BMJ 2013;346:f2819
EDITORS CHOICE
Measles and stroke show why
healthcare must innovate
The question society
has to answer is
whether it is ethically
acceptable to
tolerate any serious
complication, or death,
from measles when
an effective vaccine is
available
Sign up today using
your smartphone
follow these steps:
ODownload a free QR reader
from your handset's app store
OHold your smartphone over
the QR code
OYou will then be forwarded
to the email sign up page
OTo receive Editors Choice
by email each week, visit
www.bmj.com/newaccount
Rapid responses
FAO: the editor
Read e-letter responses to the latest articles
or submit your own and get published.
bmj.com
Visit
fao: the editor
NEWS
BMJ | 4 MAY 2013 | VOLUME 346 1
Geo Watts LONDON
The British Heart Foundation has announced the
launch of two new trials of gene therapy for heart
failure. They represent the culmination of 20 years
of laboratory research by staff at Imperial College
London and the Royal Brompton Hospital, London,
and will be the first of their kind carried out in the
United Kingdom, the researchers said.
Alexander Lyon, a consultant cardiologist at the
Royal Brompton and the UK lead investigator, said:
In the UK alone we have somewhere between
750 000 and a million patients we know about.
And theres a 30% mortality in the first year.
The therapy itself relies on the use of a modified
adenovirus as a vector to insert a gene, SERCA2a,
directly into the heart. SERCA2a plays a part in
the control of calcium signalling in heart cells.
Introducing extra copies of the gene into failing
heart cells should, in theory, boost their activity.
Sian Harding, professor of cardiac
pharmacology at Imperial, has studied the
performance of individual myocytes in the
laboratory and shown that a protein called SERCA
can fail in its task of moving enough calcium
through the cell. Weve used an adenovirus to
convey the gene for SERCA into myocytes from a
failing human heart, she said. We put in a gene
rather than the protein because a gene will keep
on producing SERCA. The technique restores the
failing myocytes to normality.
The two trials are intended to find out whether
laboratory success can be replicated in patients.
One of the two, called CUPID2, has just recruited its
first patients. It will assess the benefits of a single
dose of gene therapy in some 200 patients with
severe chronic heart failure.
The second and smaller trial, SERCA-LVAD, will
test the effects of the same therapy in 24 other
heart failure patients fitted with left ventricular
assist devices to allow researchers to measure the
quantity of the gene successfully introduced into
the patients heart muscle.
CUPID1, a safety trial carried out in the US,
offers grounds for optimism. There were fewer
deaths or requirements for an urgent transplant
. . . and improvement in the symptoms and
exercise capacity of the patients, said Lyon.
Helen Jaques BMJ CAREERS
Specialty trainees and newly qualihed GPs are
experiencing rising levels of stress and a deter-
iorating work-life balance, while changes to the
structure of the NHS and to the NHS pension
scheme are eroding morale, research published
on Thursday 2 May has found.
Nearly half (44%) of the 368 doctors that the
BMA surveyed last September said that their
stress levels were worse or much worse than they
were a year before, while similar proportions said
that work-life balance and morale had worsened
(39% and 40%, respectively).
The BMA suggests that the rapid, evolving
change that the NHS experienced in 2011 and
2012with the reorganisation of the NHS and
of medical education in Englandand poor job
security for trainee doctors could have a role in
these hndings.
Each year the BMA surveys a group of doctors
who qualihed in 2006 to assess trends in the
UK medical workforce. The 2012 survey, which
was completed by 368 of the 435 doctors in the
cohort (85% response rate), included for the hrst
time questions about doctors workplace morale,
work related stress, and work-life balance.
A quarter (26%) of the specialty trainees and a
third (34%) of the newly qualihed GPs who com-
pleted the BMAs seventh annual cohort study
said that they had experienced high or very high
levels of work related stress.
Almost half (44%) of the doctors in the cohort
reported that their stress levels had risen during
2012. One in hve (20%) respondents said that
they experienced unacceptable levels of stress
in the workplace.
More than a quarter (28%) of respondents said
that they did not have enough time to deliver the
quality of care that patients deserved, a hnding
the BMA describes as troubling. Just over half
(54%) said that there were problems with sta-
ing shortages in their workplace; and a shortage
of doctors in the workplace was one of the top
three sources of stress for the cohort doctors.
The BMA said that the reported stamng short-
ages could be a product of poor rota planning by
employers, although it was possible that stamng
shortages were a result of doctors not training in
the right specialties.
A half (54%) of the newly qualihed GPs and
a third (32%) of the specialty trainees surveyed
said that they had a good or very good work-life
balance, but a third (39%) said that their work-
life balance had worsened.
Three quarters (79%) of the cohort doctors
said that their working hours interfered with
their private life, with work related administra-
tion the biggest factor.
Forty hve per cent of doctors rated their work-
place morale as moderate, while 40% said that
morale had deteriorated over the past 12 months
and 32% said that morale had improved and was
now much better.
Changes to the NHS pension scheme and to
the structure of the NHS were the factors that
respondents said were most likely to negatively
aect their morale (68% and 62%, respectively).
New trials of gene
therapy for heart failure
start recruiting patients
Two in five young doctors
said their work-life
balance had worsened in
the past year
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UK news Private Eye sends up tobacco industrys attack on plain packets, p
World news Health effects of Greeces austerity measures are worse than imagined, p
OReferences on news stories are in the versions on bmj.com
bmj.com
OReport reveals wide
variation in outcomes
among English
maternity units
Nearly half of UK young doctors
say stress levels rose last year
NEWS
Zosia Kmietowicz BMJ
The BMA has written to secretary of state Jeremy
Hunt asking for an urgent meeting to discuss
the best way to manage increasing demands on
emergency departments and rising emergency
care admissions.
In a speech to Age UK on 25 April, Hunt
blamed disastrous changes to general prac-
titioners contracts made in 2004 under the
Labour government for the decline in the qual-
ity of out of hours care and four million extra
people a year using emergency services.
He said that it was time to rethink the role
of primary care to prevent emergency admis-
sions and to make sure people with long term
conditions are better looked aher outside the
hospital system. Hunt said that there would be
an announcement on plans for local pioneer
sites to lead the way on this shortly.
Too ohen people with long term conditions
are leh to their own devices, without the help,
care, and guidance that local services should
provide, Hunt said. Then something goes
wrong and they end up straight back in hospital
needing emergency care.
However, earlier in the day, Hunt denied that
there was a crisis in emergency departments
during an interview on Radio 4s Today pro-
gramme, although he admitted that services
were very much under pressure. He said:
Were still seeing 90% of people within the four
hour target, and the average wait is 53 minutes.
The shadow health secretary, Andy Burnham,
told Today: Jeremy Hunt needs to ask himself
why two million more people are coming to
[emergency departments]. Might it be because
theyve closed NHS walk-in centres, might it be
that theyve broken up a successful NHS Direct
service, or might it be that theyve cut social care
funding to the bone?
Mark Porter, chair of BMA Council, accused
Hunt of taking a completely simplistic view
of what has caused increased pressure on emer-
gency care.
Singling out individual parts of the health
service and engaging in a blame game is unhelp-
ful and misses the point. Spending on health-
care is squeezed, patient demand is rising, and
stamng levels are ohen inadequate, he said.
Porter said that general practitioners were
conducting more consultations, and hospitals
were facing similar levels of high demand that
were likely to rise as the population grows and
people live longer. He said that the BMA had
written to the secretary of state, asking for an
urgent meeting to discuss the best way of meet-
ing this challenge.
Clare Gerada, chair of the Royal College of
General Practitioners, said: Once again, gen-
eral practitioners are being used as a scapegoat
and it is not acceptable.
Cite this as: BMJ ;:f

2 BMJ | 4 MAY 2013 | VOLUME 346
Children to get vaccines
against flu and rotavirus
starting from July
BMA calls for meeting after health secretary
blames GPs for pressure on emergency care
There is no evidence that the 2004 GP contract has
increased pressure on A&E, said Clare Gerada
J
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Peers reject bid
to annul new
NHS rules on
competition
Adrian ODowd LONDON
Peers have rejected a motion that would have
annulled new rules governing competition when
GPs are commissioning health services.
In a vote in the House of Lords on 24 April 254
peers rejected the motion put forward by Labours
health spokesman, Philip Hunt, to annul the
regulations, while 146 voted to support him.
During a two and a half hour debate peers put
forward arguments about the extent to which the
section 75 regulations in the Health and Social
Care Act would open up all NHS services to market
competition and result in possible legal challenges
to clinical commissioning groups (CCGs) from the
private sector.
There has been significant opposition to the
regulations from the BMA,
1
the Royal College of
General Practitioners, and other bodies, which
claim that they will force almost every part of the
NHS to be opened up to compulsory competition.
Last month the health minister Norman Lamb
said that the regulations would be rewritten to make
clear that no CCG will be forced into competitive
tendering, and new regulations were published on
11 March.
2
However, critics said that the rewritten
rules showed no significant improvement on the
previous version; and on the day of the debate the
Daily Telegraph published a letter signed by more
than 60 doctors, professors, healthcare workers,
and NHS campaigners calling for the regulations to
be dropped.
3
All children aged 2 years in the UKaround
650 000 in totalwill be offered a nasal flu
vaccine from September 2013 as part of new
vaccines schedules announced by the Depart-
ment of Health and Public Health England.
A small number of pilots to vaccinate primary
and pre-school aged children will also run this
year, and pilots for secondary school children
will run in 2014, to make sure that the NHS is
ready to roll out the programme to vaccinate
these two groups of children in 2014 and 2015
respectively.
Infants under 4 months old are also to be
vaccinated against rotavirus from July. Every
year rotavirus causes around 140 000 cases
of diarrhoea in under 5s and around 14 000
hospitalisations. It is estimated that the rota-
virus vaccine will halve the number of cases
caused by rotavirus and reduce hospital stays
by up to 70%.
Mary Ramsay, head of immunisation at Public
Health England, said, In the countries where
the vaccine has already been introduced, the
uptake has been high and has resulted in rapid
and sustained reductions in childhood rotavirus
hospitalisations.
Aher evaluating the evidence the Joint Com-
mittee on Vaccination and Immunisation has
also decided to recommend a shingles vaccina-
tion programme for people aged 70, starting in
September. There will also be a catch-up pro-
gramme for those aged up to and including 79;
an estimated 800 000 people will be eligible
for the vaccine in the hrst year. A 2005 study
found that vaccinating adults 70 years or older
reduced the incidence of shingles by 38% and
reduced the burden of illness by 55% in those
who developed shingles.
1
A change is also being introduced to the
meningitis C schedule. Starting in September
a new teenage booster jab at age 12-13 years
will replace the booster that is currently given
at 4 months.
NEWS
New blood test can detect genes that drive breast cancer
The new blood test, dubbed liq-
uid biopsy, builds on previous
research showing that patients
blood samples contained trace
amounts of DNA from their tumour
cells. Researchers at the Institute of
Cancer Research in London and the
Royal Marsden NHS Foundation
Trust took this one step further and
investigated whether analysing cir-
culating free DNA could detect gene
amplihcations known to cause cancer growth.
They took blood samples from 58 women with
recurrent breast cancer and used digital polymer-
ase chain reaction techniques to
detect HER2 amplification. The
test was able to accurately identify
HER2 positive breast cancer 64%
of the time and HER2 negative
cancer 94% of the time.
1
Alan Ashworth, chief execu-
tive of the Institute of Cancer
Research, said, This new liquid
biopsy has exciting potential as a
means of analysing tumour DNA
in the bloodstream, allowing clinicians to track
genetic changes as they happen.
BMJ | 4 MAY 2013 | VOLUME 346 3
From left: Philip Hunt, Sheila Hollins, and David Owen, who voted to annul the regulations, and Norman Warner and Shirley Williams, who voted to keep them
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The BMA said last week that the regulations
should be replaced with new rules that
unambiguously reflect government assurances that
commissioners will not be forced to use competition
when making their commissioning decisions.
Opening the debate in the Lords, Hunt said,
There is a genuine fear in the system among
advisers to clinical commissioning groups and in a
lot of other organisations that the regulations will
create a culture of defensive contracting, where
commissioners will go out to tender if there is any
doubt that a failure to do so will expose them to a
possible damages claim.
They [the regulations] are part of the
governments drive to shift the culture of the NHS
from a public service into a public marketplace
and are at a piece with a number of other ominous
developments which is sending the NHS along the
same path. NHS services were likely to be placed
in the middle of a costly bidding war with private
companies cherry picking discrete services for profit
while the NHS would be left to run the more complex
and expensive services with less money.
Responding, the Liberal Democrat peer Timothy
Clement Jones said, The rules in the regulations
simply and accurately reflect the rules that are
already imposed by EU [European Union] law on the
NHS. These rules were put in place long before the
coalition came to power in May 2010.
The fact is that these revised regulations are
as good as it gets within the constraints of EU
procurement law. Commissioners will not be forced
to tender and will not be forced to create a market
where none exists.
The Labour peer Norman Warner, a former health
minister, who voted to keep the regulations, said,
This set of contexts in which the NHS has to operate
means that we have rather a complex area for NHS
commissioners to operate in. They need a clear set
of rules to guide their conduct on procurement and
competition, and that is provided for in section 75 of
the legislation, which we passed after a great deal of
discussion and debate.
The crossbench peer David Owen, who voted to
annul the regulations, said, In this regulation we
are presented with the full impact of the 2012 act. It
has been hitherto denied, but within this act is the
potentialand I agree somewhat with the remarks
that it will take some years for it to evolveto have a
fully marketised NHS. If that is the choice, the people
of this country should be told about it.
I warn this house: do not think that this is a minor
step. If this goes through, the NHS as we have seen it,
believed in it, and persuaded the electorate that we
support it, will be massively changed.
The Liberal Democrat peer Shirley Williams, who
voted to keep the regulations, said, I cannot find
in the most careful reading of the regulations and
our long debate on these two sets of regulations
anything that bears out the widely spread view
extensively spread by the social networksthat this
is all about bringing to an end the NHS as a public
How some leading peers voted on the motion
For
Philip Hunt (Labour)
David Owen (crossbench)
Sheila Hollins (crossbench)
Leslie Turnberg (Labour)
John Davies (Labour)
Against
Earl Howe (Conservative)
Timothy Clement Jones (Liberal Democrat)
Shirley Williams (Liberal Democrat)
John Walton (crossbench)
Norman Warner (Labour)
Judith Jolly (Liberal Democrat)
service and introducing overall privatisation.
The crossbench peer Sheila Hollins, the current
BMA president, who voted to annul the regulations,
said, Given that major NHS change took place
earlier this month, there is a pressing urgency
to address once and for all the issue of whether
commissioners will be forced to use competition.
We cannot risk commissioners being unclear
about what they can and cannot do.
Speaking after the vote, Clive Peedell, co-leader
of the National Health Action Party,
4
told the BMJ,
The result is disappointing but expected because
of the government majority.
Researchers have developed a new blood test
that they say could be used to identify women
whose breast cancer was being driven by the
HER2 gene and who could beneht from treatment
with trastuzumab (Herceptin) and similar drugs.
They believe that the test could be adapted to a
range of other cancers and drug targets.
At the moment women whose breast cancer
relapses need to have a biopsy to determine
which treatments the cancer will respond to. But
cancers can acquire and lose genes over time, and
because biopsies cannot be repeated too ohen the
genes driving their growth can be missed.
Herceptin binds to breast
cancer cell (pink)
NEWS
The magazine Private Eye (right) couldnt resist
sending up Japan Tobacco Internationals
eorts (leh) to derail the UK governments plan
to reduce the take-up of smoking among young
people by introducing plain packaging.
The antismoking group Ash has complained
to the Advertising Standards Authority about
advertisements from JTI (the trading name for
Gallagher) that have appeared recently in the
national press. The advertisement features
an email from the Department of Health to
the Australian Government and highlights in
pink the phrase, there isnt any hard evidence
to show that it [plain packaging] works. The
advertisement said: We couldnt have put
it better ourselves. But Ash said that the
email is two years out of date and is mislead-
ing. Last April a systematic review commis-
sioned by the Department of Health for
England con-
cluded that there
was strong evi-
dence that plain
packaging would
help to reduce
the prevalence of
smoking.
In the fake Pri-
vate Eye advertise-
ment Big Fags Inc,
also highlighted in
pink, declares: We
are trying to pretend
4 BMJ | 4 MAY 2013 | VOLUME 346
Scottish doctors can refuse role in
abortions: Conscientious objectors to
abortion can refuse to delegate, supervise,
or support stan carrying out terminations,
as well as refusing to perform terminations
themselves, three appeal judges in Scotland
have ruled. The Court of Session Inner House
ruled in favour of two Catholic midwives in a
judgment that also applies to doctors.
Inequality in breast cancer diagnosis
costs lives: If breast cancer in women living
in Englands poor areas was diagnosed
at the same stage as that in women in
anluent areas, /5u more women every year
would survive ve years with the disease,
researchers have shown.
1
They analysed
data on 2u 738 women with complete stage
information from the east of England and
extrapolated the ndings.
Inspections start of hospital trusts with
higher than expected mortality: Teams of
doctors, nurses, and patients representatives
are set to visit the 1/ trusts in England
whose mortality ratios have been higher than
expected for the past two years,
2
starting on 7
May. The inspections are the prime ministers
response to part of Robert Francis QCs
inquiry into the Mid Stans scandal and are
being led by the medical director of the NHS,
Bruce Keogh.
3

Taiwan reports case of H7N9 avian u: A
5/ year old man who had returned to Taiwan
from Jiangsu province was conrmed on 2/
April as the rst human case of H7N9 avian
flu outside mainland China. Since the rst
infections were announced on 31 March,
China has conrmed 1u8 cases and 22
deaths. Hong Kong is stepping up screening
of visitors at its border ahead of the May day
holiday week, when thousands of mainland
Chinese visitors are expected to arrive.
Practice manager is jailed for fraud: A
general practice manager in Manchester who
defrauded her employer of 15u uuu has
been sentenced to 18 months in prison afer
an investigation supported by NHS Protect.
Alison Westley, 62, was employed rst
at the Archwood Medical Practice, Woodley,
and then at Woodley Health Centre, Hyde
Road, afer a merger. She created large
numbers of ctitious invoices to the practice,
had been consistently paying herself an
inflated salary and overtime payments, and
drew cheques made payable to herself from
practice accounts.
IN BRIEF
Private Eye sends up tobacco
industrys attack on plain packets
sioned by the Department of Health for
help to reduce
the prevalence of
Pri-
advertise-
ment Big Fags Inc,
also highlighted in
pink, declares: We
are trying to pretend
it better ourselves. But Ash said that the
email is two years out of date and is mislead-
ing. Last April a systematic review commis-
Gareth Iacobucci BMJ

The NHS must hll the vacuum in medical leader-
ship in the health service by creating more desir-
able and attractive leadership roles for doctors,
a new report has concluded.
1

Research by the University of Birminghams
Health Services Management Centre and the
health think tank the Kings Fund aimed to pro-
vide an up to date picture of medical leadership
structures in NHS trusts in England. It said that
progress had been made in involving doctors
in leadership roles since the Grim ths report in
1983 (the hrst report of its kind). But the study,
funded by the National Institute for Health
Research, added that the journey was by no
means complete and that the health service
needed to initiate a step change to break
down the barriers to involving doc-
tors eectively in leadership roles.
The researchers used a ques-
tionnaire survey of NHS trusts in
England; case studies of nine NHS
trusts that responded to the survey; and
a medical engagement scale in the case
studies to establish the extent to which doctors
felt engaged in the work of their organisations.
Medical leaders are considered
to have gone over to dark side
hits [plain packaging] wont work and that mar-
keting and advertising arent a big deal.
In March the advertising watchdog banned
another campaign by Gallagher claiming that
there was no credible evidence that plain
packets would reduce smoking in young
people. And in April another ruling said that
Gallagher had misled the public in advertise-
ments claiming that plain packaging would be
easier to fake and that switching to plain pack-
ets would cost taxpayers more than the E3bn
in unpaid duty last year because of increased
sales on the black market.
NEWS
They found that several fac-
tors put off doctors taking on
leadership positions. These
included a preference for
clinical work, a lack of
adequate training and
support, an absence of
defined career paths,
and a culture in the
NHS that failed to
value and reward
doctors who took on
leadership roles.
The r epor t
also identified
an engage-
ment gap
b e t we e n
m e d i c a l
leaders and their colleagues who chose to focus
on service provision, education, and research
and said it was vital that the NHS moved beyond
the perception that doctors who took on lead-
ership roles were going over to the dark side.
Chris Ham, chief executive of the Kings Fund
and coauthor of the report, said that the research
supported Robert Francis QCs hndings in his
report into failings of care at Mid Staordshire
NHS Foundation Trust suggesting that poor
medical leadership could weaken the quality
and safety of patient care.
2
In a blog post accompanying the research
Ham wrote, There are clear echoes of Robert
Francis warnings of doctors and other clini-
cians being disengaged from management and
of the risks this poses to the quality and safety
of patient care.
3
Ham said that every NHS trust should place a
high priority on promoting medical leadership
and engagement and commit time and resources
to make it happen, such as by investing in the
development of medical leaders, and pairing
them with experienced managers.
He added, Above all, there is a need to move
beyond the perception that doctors who go into
leadership roles are going over to the dark side.
This can be done by attracting credible individu-
als into these roles, rewarding them both hnan-
cially and in other ways, and supporting them
through expert mentoring and coaching.
Becoming a medical leader must [be] seen
as a prize to be won, rather than a burden to
be borne, in organisations where there is an
expectation that those in leadership are among
the brightest . . . A few NHS trusts are moving in
this direction but most have a long way to go.
Krishna Chinthapalli BMJ
Dealing with intraoperative emergencies can be
much improved by use of a checklist, says Atul
Gawande, the lead adviser on the World Health
Organizations Safe Surgery Saves Lives pro-
gramme and a surgeon at Brigham and Womens
Hospital in Massachusetts.
At a talk at University College Londons Insti-
tute of Child Health in London on 26 April,
Gawande outlined the results of his groups
study earlier this year.
1
He said, We tested this
in a randomised trial by bringing teams into a
simulator . . . They went from a 25% likelihood
of missing key lifesaving steps to a 6% likeli-
hood: a 75% reduction in errors.
He said he believed that crisis checklists
were the next step in surgical safety, following
on from his earlier development of WHO surgi-
cal safety checklists, which are used for routine
checks before, during, and aher an operation.
WHO believes that the use of these checklists in
every operation would prevent over half a mil-
lion deaths, aher a number of studies conhrmed
reductions in complications and mortality.
2
If we are getting our act together about how
we handle prevention in our normal cases, then
how do we do when things go abnormal, when
an emergency crisis develops? Multiple studies
have shown how chaotic and how poorly dis-
organised we typically hnd ourselves, he said.
And so we worked with the same team and
then a wide range of experts to identify the most
common ways in which disasters happen in the
operating room. Using the same design format
and structure of cockpit checklists, we designed
them to be easily read and walked through so
that steps might not be forgotten.
Gawande and colleagues developed the new
operating room crisis checklists at Ariadne Labs,
part of the Harvard School of Public Health.
Twelve checklists cover topics such as anaphy-
laxis, cardiac arrest, failed airway, haemorrhage,
hypotension, and unstable tachycardia.
3
How-
ever, there has been criticism that they require
clinicians to undergo instruction and training,
especially for use during an emergency, and that
even with checklists key steps were missed.
4
Gawande said that the checklists and an
implementation guide were now being rolled
out in three organisations in the US.
Checklists can reduce errors
in intraoperative emergencies
Atul Gawande (above) said surgeons who tested
the checklist in a simulator reduced errors by 75%
BMJ | 4 MAY 2013 | VOLUME 346 5
Medical leaders are considered
to have gone over to dark side
Makers of anticancer
drugs are profiteering,
say 100 specialists
Jeremy Laurance THE INDEPENDENT
More than 100 specialists in chronic myeloid
leukaemia from around the world, including
nine from the United Kingdom, have warned
that the high prices that drug companies charge
for anticancer drugs are leaving patients without
access to treatments that could save their lives.
The group said that the drug industry was
guilty of prohteering and compared its actions
to those of unethical speculators who raise the
price of grain aher a natural disaster.
What determines a morally justihable just
price for a cancer drug? they asked in a paper
published in Blood.
1
A reasonable drug price
should maintain healthy pharmaceutical indus-
try prohts without being viewed as prohteering.
Of the 12 anticancer drugs approved by the
US Food and Drug Administration in 2012, 11
were priced above $100 000 (E65 000; t80 000)
per patient a year, they wrote. In addition, the
price of existing drugs of proved eectiveness
has been increased by up to threefold.
Three new drugs for chronic myeloid leu-
kaemiaponatinib, bosutinib, and omacetax-
inewere approved by the FDA last year and
are awaiting a licence in the United Kingdom
and Europe. But their prices were astronomi-
cal, the authors said. Imatinib, one of the best
known and most eective of the modern anti-
cancer drugs, has been on the market for over
a decade and recouped its development costs
in two years, said Daniel Vassella, former chief
executive of Novartis, its manufacturer.
NEWS
6 BMJ | 4 MAY 2013 | VOLUME 346
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A
Y
I
O
T
I
S

T
Z
A
M
A
R
O
S
/
D
E
M
O
T
I
X
/
P
A
Health effects of Greeces austerity
are worse than imagined
A 35 year old deaf woman threatened to commit suicide in Omonia Square, Athens, in December after her
disability allowance was cut. Firefighters persuaded her to come down
Sophie Arie LONDON
Greeces severe economic crisis has had a substan-
tially negative eect on public health that provides
a warning for other countries faced with similar
challenges, the authors of a report published in
the American Journal of Public Health have said.
1
Researchers at the Aristotle University of
Thessaloniki in Greece and the University of
New Mexico in the United States said that a
sharp deterioration in major indicators of public
health had accompanied the worsening of the
Greek economy over recent years, as incomes fell
and unemployment soared.
Suicide and murder rates rose by 22.7% and
27.6%, respectively, between 2007 and 2009,
while deaths from infectious diseases rose by
13.2% in the same period. Sharp increases in
substance abuse and mental health problems
were also recorded.
The authors said that evidence from Greece
and from previous economic crises elsewhere
implied that reduced household incomes and
purchasing power, as a result of unemployment
and cuts in real wages, could lead to reduced
health expenditure by households, lower use of
private health services, and greater use of public
sector services, especially those that are free or
low cost at the point of delivery.
In Greece, these trends have happened at a
time when government spending on healthcare
has been slashed. Compared with 2010, use of
public inpatient and primary care services in
2011 rose by 6.2% and 21.9%, respectively.
Meanwhile, government health spending was
cut by 23.7% between 2009 and 2011, with
many services being privatised and sta levels
in the public sector being cut dramatically.
Elias Kondilis of Aristotle University, lead
author of the study, said: We were expecting
that these austerity policies would negatively
aect health services and health outcomes, but
the results were much worse than we imagined.
The authors said their hndings indicated austerity
policies were likely to cause deteriorating health
conditions elsewhere in Europe and in the US.
Evening primrose oil and
borage oil do not help
eczema symptoms
Evening primrose oil and borage oil do not
improve the symptoms of eczema, a review of
the evidence has found. Furthermore, both can
cause harm, mainly to the gastrointestinal tract.
The authors, who published their review in
the Cochrane Library, concluded that it would be
hard to justify further studies on the treatments.
1
Some people take evening primrose oil and
borage oil because they contain linolenic acid,
which was once thought to have anti-inam-
matory properties. The Cochrane review cites
research that found that in 2007 nearly four in 10
adults (38%) and one in 10 children with eczema
took some form of complementary treatment.
The researchers found 27 randomised con-
trolled trials that looked at the eects of either
evening primrose oil (19 trials) or borage oil (8)
in 1596 adults or children with eczema. They
were treated for between three and 24 weeks.
The researchers were able to carry out a meta-
analysis of some studies of evening primrose oil.
They found that patients and doctors did not
judge symptoms to have improved in compari-
son with placebo on a visual analogue scale of 0
to 100 (mean dierence for patients 2.2 (95%
conhdence interval 10.5 to 6); doctors 3.3 (7
to 0.5)). Treatment with borage oil also failed to
improve symptoms, although the researchers
were unable to conduct a meta-analysis
because of the dierent way the
results were reported.
The reviews lead author,
Joel Bamford, said, Given
the strength of the evidence in
our review, we think further
studies on the use of
these complementary
therapies to treat eczema
would be hard to justify.
Belfast childrens heart surgery unit should close, says health board
Clare Dyer BMJ
Children born with congenital heart
defects in Northern Ireland should
have their surgery carried out in future
in Dublin rather than Belfast, a report
from the provinces Health and Social
Care Board has recommended.
Northern Irelands health minister,
Edwin Poots, is expected to make
a final decision within a few weeks,
but his approval is thought to be a
formality.
Campaigners have battled to
keep the surgery in Northern Ireland,
and more than 80 members of the
legislative assembly have signed a
petition to retain services at the Royal
Belfast Hospital for Sick Children.
But the boards report said that
although no immediate safety
concerns had been identified, the
surgical services in Northern Ireland
were not sustainable because of the
small population served. Standards
developed for Englands Safe and
Sustainable review recommended
that a unit should perform at least
400 surgical procedures a year,
1
but
Belfasts number falls short of that.
The report, from a working group
that included clinicians, recommends
that children requiring surgery or
interventional cardiology should
travel to Dublin but that cardiology
services in Northern Ireland should be
expanded and enhanced. Around 110
children a year are expected to travel
to Dublin for surgery and some 40 for
interventional cardiology.
bmj.com Open letter to the Greek government
(BMJ ;:f)
BMJ | 4 MAY 2013 | VOLUME 346 7

Editorials are usually commissioned. We are, however, happy to consider and peer review unsolicited editorials
OSee http://resources.bmj.com/bmj/authors/types-of-article/editorials for more details
EDITORIALS
Measles in the UK: a test of public health competency in a crisis
Can new agencies work effectively together to meet the challenge?
Felix Greaves honorary clinical research fellow,
Department of Primary Care and Public Health, Imperial
College London, London W6 3RF, UK
felix.greaves@imperial.ac.uk
Liam Donaldson professor of health policy, Institute
for Global Health Innovation, Imperial College London,
London, UK
The recent surge in measles cases in south Wales
signals a discomhting failure by a G8 nation to
control an easily preventable disease. Far from the
measles virus being holed up in outposts in poor
countries, the spectre of large outbreaks of mea-
sles in England is now looming large. By contrast,
elimination of endemic measles in the Americas
has been achieved by treating it as an emergency.
1

Prevention of more measles cases in the United
Kingdom, and avoidance of embarrassment for
the government, will turn on the eectiveness of
the public health delivery system.
In the north of England there have been 354
cases in 2013 so far.
2
The pool of vulnerable chil-
dren nationally is worrying: 8% of those aged
10-16 years have had no measles, mumps, and
rubella (MMR) vaccine, and 8% have had only one
of the required two doses.
3
Susceptible children
are distributed throughout the country, making
the site of the next outbreak impossible to predict.
In London, where immunisation levels for all vac-
cines are traditionally lower,
4
there have been few
cases so far. However, London is a prime location
for a major outbreak, with its transient and diverse
population and its pockets of low MMR vaccination
coverage.
It is hard to manage risk in epidemics, is even
harder to explain risk to the public. In a well nour-
ished population, with good healthcare services,
measles has a much lower mortality rate than in
developing countries. Furthermore, within living
memory, it was seen as a natural part of child-
hood. For most of those who catch it, measles is
an unpleasant self limiting illness. That said, so far
in England in 2013, 18% of patients with the dis-
ease have been admitted to hospital, and in a small
but important minority,
3
the possibility of further
complications and permanent disability, or even
death, is real. The question society needs to answer
is whether it is ethically acceptable to tolerate any
serious complication, or death, from measles when
an eective vaccine is available.
In a public health emergency, which is what
the current measles threat is, it is vital that the
response is well coordinated. All organisations
and professionals involved in managing it must
know their own role and each others, and they
must work well together. Strong leadership, excel-
lent communication, and a modicum of command
and control are also essential. There is a concern
that, with the recent health system reforms in
England, bodies that were key in crises like severe
acute respiratory syndrome, pandemic inuenza,
and foot-and-mouth disease (such as strategic
health authorities and primary care trusts) have
been devolved and swept away. Public health
teams are now spread across local authorities,
with links to the NHS much weaker than in the
past. A newly established agency, Public Health
England, is charged with protecting the popula-
tions health, but resources for immunisation are
with NHS England,
5
an entity devoid of public
health expertise at board level. It is not acceptable
for the elements of this new public health system to
learn on the job. An agreed operating relationship
is needed quickly. There is the opportunity for a
natural experiment to compare the performance
of the more mature Welsh system and its brand
new English equivalent. Rigorous evaluation of
health sector reforms in their early stages would
be a novel event in recent British public policy.
Although the risks of serious complications
from measles are low, it is not easy for public
health policy makers in modern times to justify
inaction on grounds of low risk, because public
expectation is rightly that any avoidable child
death should be secured. And measles will almost
certainly be the next disease to be targeted for
global eradication once polio has followed small-
pox into the history books. Moreover, the current
cohort of unvaccinated teenagers is also vulner-
able to mumps and rubella, and as they edge
towards adulthood the threat of the devastating
congenital rubella syndrome is also a real danger.
Aher the inuenza A/H1N1 epidemic of 2009,
the government was accused of over-reaction
because of the mildness of the disease, as money
was spent buying unused vaccine and stockpiling
antivirals. Yet 70 children died in England.
6
With-
out the robust action that was taken more may
have died. Seventy child deaths is a major incident,
particularly in light of the new national patient
safety initiatives aim of zero harm. It would be
complacent and irresponsible if we failed to act res-
olutely in the current threat on grounds of low rela-
tive severity. It would set a poor example to other
countries given the UKs global health positioning
as a voice calling for better vaccination perform-
ance in low and middle income countries. It would
sit uneasily with the UKs prominent commitment
to initiatives such as the decade of v accination.
7
The governments catch-up immunisation cam-
paigns must build on the lessons learnt from other
vaccination programmes around the world. The
hrst phase of the emergency response in England,
which will target a third of a million older chil-
dren, will probably take some months to achieve.
In India, millions are vaccinated in a few days,
which is a powerful demonstration of what it takes
to get ahead of the proverbial curve. Perhaps more
dynamism and innovation as well as good organi-
sation is needed in the UK if Wakehelds legacy is
to become a footnote in public health history rather
than a tragedy writ large in the public psyche.
Competing interests: LD has previously served as chief medical
olcer for England and is currently chair of the independent
monitoring board for the Global Polio Eradication Initiative. FG has
an honorary contract with Public Health England and takes part in
regular on-call activity.
Provenance and peer review: Commissioned; not externally peer
reviewed.
References are in the version on bmj.com.
OOBSERVATIONS, p 24
ONews: Government launches campaign to give MMR vaccine to a million children in England (BMJ lu1!;!/6:fl696)
OObservations: MMR, measles, and the South Wales Evening Post (BMJ lu1!;!/6:fl'93)
Catch-up campaign to target
1
/3 million children
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8 BMJ | 4 MAY 2013 | VOLUME 346
EDITORIALS
Orlistat: should we worry about liver inflammation?
Events are rare and a causal link unproved; still a useful option for some obese patients
John Wilding professor of medicine and head ,
Department of Obesity and Endocrinology, Institute of
Ageing and Chronic Disease, Clinical Sciences Centre,
University Hospital Aintree, Liverpool L9 7AL, UK
j.p.h.wilding@liv.ac.uk
In a linked paper, Douglas and colleagues used
data from the UK Clinical Practice Research Data-
link and Hospital Episodes Statistics to explore
the possible association between orlistat use and
abnormalities of liver function in 94 695 patients
who received orlistat over a 12 year period.
1
Orli-
stat is an inhibitor of intestinal and pancreatic
lipases that was hrst licensed for the treatment of
overweight and obesity in 2008 and became avail-
able in the United Kingdom in 2009. It is currently
the only prescription drug available for the treat-
ment of obesity and is also available over the coun-
ter in a lower strength form, with slightly reduced
emcacy. The drug acts within the gastrointestinal
tract and less than 1% is absorbed systemically.
As a result, circulating concentrations of orlistat
are low (<0.02 mol/L), and at this concentration
it has no systemic eects on other lipases.
A meta-analysis of more than 10 000 patients
in clinical trials showed a mean placebo sub-
tracted weight loss of 2.9 kg over 12 months of
treatment.
2
Weight loss was maintained long term
for subjects in one study, as long as four years for
some.
3
As with all weight loss drugs, weight regain
is common when orlistat is stopped.
4
Other clini-
cally important outcomes associated with orlistat
use are improved lipid prohle (for example, 0.26
mmol/L reduction in low density lipoprotein cho-
lesterol), lowered blood pressure (about 1.5 mm
Hg in systolic and diastolic blood pressure), and a
0.38% reduction in glycated haemoglobin (HbA
1c
)
in patients with diabetes.
2

Adverse eects that relate to orlistats mecha-
nism of action include gastrointestinal side eects
due to increased faecal fat; these include fatty
stools (14% of patients) and faecal incontinence
(4% of patients). Small reductions in circulating
concentrations of the fat soluble vitamins (A, D,
E, K) and carotene (mostly within the reference
ranges) are also seen. These are not thought to be
clinically important for most patients, however,
especially because relevant markers such as cal-
cium, parathyroid hormone, and international
normalised ratio are not altered during treat-
ment. Orlistat may interfere with the absorption
of some drugsnotably warfarin, thyroxine, oral
contraceptives, anticonvulsants, and ciclosporin.
Appropriate precautions such as monitoring of
international normalised ratio or thyroid func-
tion and institution of additional or alternative
contraception are needed in patients taking these
agents. Orlistat should not be used in patients
ta king ciclosporin.
5
Use of orlistat in the NHS was supported by a
National Institute for Health and Care Excellence
(then the National Institute for Clinical Excellence)
technology appraisal in 2001, which was updated
when orlistat was included as a recommended
option for the treatment of obesity in the more
comprehensive guideline published in 2006.
6

This recommendation was made on the basis of
projected reductions in obesity related comorbid-
ity with long term orlistat treatment. The drug was
considered clinically and cost eective overall
when used within its licensed indications.
Concerns about potential liver toxicity with orli-
stat were hrst raised in 2001, and sporadic case
reports have appeared in the literature since.
7
The
most recent comprehensive review from the Euro-
pean Medicines Agency in 2012 identihed a total
of 21 reports of severe liver injury worldwide asso-
ciated with orlistat use between 2007 and 2011.
However, in many of these cases an alternative
cause could not be excluded, and these have to be
put in the context of widespread use of the drug
more than 53 million people worldwide have
taken orlistat since its introduction.
8
It seems that
if idiosyncratic reactions that cause severe liver
injury do occur with orlistat, they are very rare.
Obesity itself is also associated with non-alcoholic
fatty liver disease, and evidence from case series
suggests that orlistat might improve liver function
in such patients,
9
although the only randomised
trial found no beneht.
10
Douglas and colleagues found that, although
patients who were prescribed orlistat had a higher
rate of liver function abnormalities, these abnor-
malities were as likely to occur in the 90 days
before starting the drug as in the period aher its
initiation. They also found no evidence of a higher
rate of severe events of liver impairment in those
using orlistat.
1
The study provides reassurance
that, although abnormal liver function is com-
mon in patients who are obese, it is unlikely to be
caused by orlistat. This study would, however, be
unlikely to detect very rare idiosyncratic events
of severe liver toxicity that, on the available evi-
dence, might be expected to occur in less than one
in two million people taking the drug.
Because obesity can have substantial adverse
eects on health and quality of life, interventions
to support body weight reduction are important.
These should always incorporate lifestyle and
behaviour changes but, for many, lifestyle modi-
hcation does not result in weight loss, and if it
does weight regain is common. Although orlistat
has some limitations, about a third of obese and
overweight patients who start treatment as an
adjunct to lifestyle changes can lose and main-
tain clinically meaningful weight loss, with asso-
ciated improvements in disease risk and quality
of life.
6
Most of the adverse eects and potential
interactions with orlistat are well characterised,
and as long as prescribing guidelines are fol-
lowed (including stopping the drug if a clinically
worthwhile weight loss is not achieved), it remains
useful for the treatment of obesity, with an overall
positive beneht-risk prohle.
Competing interests: : I have given lectures and acted as
consultant for Roche (manufacturers of orlistat) and have also
received a research grant for my institution (not related at all
to the drug), although my last contact with Roche in relation
to orlistat was more than hve years ago. I have consulted
for Roche and other companies in relation to obesity and
diabetes drug development.
Provenance and peer review: Commissioned; not externally
peer reviewed.
ORESEARCH, p 12
Although orlistat has some limitations, about a
third of obese and overweight patients who start
treatment as an adjunct to lifestyle changes can
lose and maintain clinically meaningful weight loss
bmj.com Gastroenterology articles
from the BMJ Group are at
bmj.com/specialties/gastroenterology
<1% of orlistat is absorbed systemically
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BMJ | 4 MAY 2013 | VOLUME 346 9
EDITORIALS
Recognising and responding to victims of human trafficking
New guidance for health professionals in the UK
Sharon Doherty consultant clinical psychologist
sharon.doherty@ggc.scot.nhs.uk
Rachel Morley consultant child and adolescent clinical
psychologist, Compass Team for Asylum Seekers and
Refugees, NHS Greater Glasgow and Clyde, Glasgow
Gl1 /SF, UK
Recent data suggest that 2077 people, almost
a quarter of whom were children, were victims
of human tramcking in the United Kingdom in
2011.
1
Because tramckers go to great lengths to
maintain secrecy, these hgures are probably an
underestimate.
1
The tramcking of human beings
for sexual and labour exploitation is one of the
most highly prohtable illegal trades worldwide.
2

Human tramckers prey on the vulnerable and use
abduction, deception, threat, violence, and other
abuses of power to control their victims. Victims
are forced to work in the sex industry or in fac-
tories, agriculture, or domestic servitude, ohen
over prolonged periods.
3
Recognising the gross
violation of human rights that tramcking repre-
sents,
4
the UK government ratihed the Council of
Europe Convention on Action against Tramcking
in Human Beings in 2009,
4
and it opted in to the
European Union Directive on Preventing and
Combating Trafficking in Human Beings and
Protecting its Victims in 2011.
5
This EU direc-
tive, which becomes law in the UK in April 2013,
requires that member states provide necessary
medical treatment [and] psychological assist-
ance to those who have been tramcked.
As outlined in a BMJ editorial in 2009,
6
human
tramcking is clearly a health issue. Victims of traf-
hcking may experience severe physical, sexual,
and psychological abuse. This may result in
sexually transmitted diseases and unwanted
pregnancies, and in health complications linked
to injury, untreated chronic medical conditions,
chronic deprivation, and exposure to hazardous
working environments.
7
Research suggests that
depression, anxiety, and post-traumatic stress
disorder are prevalent in those tramcked for sex-
ual exploitation.
8
Victims of tramcking may also
display a complex trauma presentation similar to
that seen in those who have experienced other
forms of repeated trauma, such as torture.
9
Front line health professionals may come into
contact with victims of trafficking during the
course of their work and may therefore be well
placed to identify victims and to oer information
on available support services.
10
To raise aware-
ness of tramcking, the Scottish government has
issued guidance for health workers.
11
Drawing on
international guidance,
7
this advice highlights
red ags that should arouse suspicion that a
patient has been tramcked, and provides local
advice and referral options. The guidance is to be
followed by an e-learning module.
The Department of Health in Northern Ireland
has also issued guidance for sta, jointly with the
Department of Justice, Social Services and Public
Safety,
12
and guidance and an e-learning module
have recently been issued by the Department of
Health in England.
13
Wales is likely to follow with
its own guidance, which will include local refer-
ral options.
Red ags include symptoms associated with
physical abuse, untreated chronic medical con-
ditions, and symptoms and signs of psycho-
logical trauma. A patients demeanour and the
circumstances around the consultation may
arouse suspicion. Patients may seem fearful and
mistrustful; they may be accompanied by a boy-
friend or friend who prefers to speak or inter-
pret for them and to whom they defer. Details of
personal history may be vague, and there may be
a mismatch between a patients reported medical
history and the clinical presentation.
As with any situation where ongoing abuse is
possible, it is important to explain that a private
examination is normal practice and to ensure that
any interpreting is carried out through a profes-
sional interpreter. It is good practice for clinicians
to conduct a full physical examination, to ask
about history of sexual trauma, and to assess the
patients mental health.
The use of gentle inquiry around health and liv-
ing circumstances is advised. For example, ques-
tions such as, Are you being forced to do things
you dont want to do?, Are you free to leave your
situation or job if you wish?, or Are you paid for
the work you do? may be appropriate. However,
be aware that victims of tramcking may face seri-
ous risks if they disclose their situation. They may
have been threatened with deportation, imprison-
ment, or death, and the lives of family members
may have been threatened. Care should be taken
to prioritise the safety of the patient and to take
seriously the risks they say they face.
When a child is a suspected victim of tramck-
ing, it is important to follow local child protec-
tion guidelines.
14-16
For adult victims, follow
local guidance.
11-13
If possible, arrange a follow-
up appointment. In case patients are unable to
return, let them know that they are entitled to
healthcare and that support is available to help
them escape their situation. In Scotland, health
professionals are advised to seek the consent of
the patient before calling the police unless the
threat or danger to the patient is such that you
need to do so.
11
Health professionals play an important role
in recognising and responding to the needs of
vulnerable patients. Victims of tramcking are
exceptionally vulnerable, have important health
needs, and they can and do come into contact
with health services. By helping to identify
potential victims of tramcking and by treating
their physical and psychological injuries, health
professionals challenge this form of exploita-
tion. Our collective responses may go some way
towards making the UK less hospitable to human
tramckers.
Competing interests: SDs current post and part of RMs
current post is funded by the Scottish Government. Both
authors currently work in the COMPASS Mental Health
Team, NHS Greater Glasgow and Clyde. We both work with
victims of tralcking for sexual and labour exploitation of all
ages in the COMPASS mental health team. We also work in
partnership with the Tralcking Awareness Raising Alliance
Project (Glasgow Community and Safety Services) in Glasgow.
This joint initiative has involved co-locating a psychological
service within an anti-tralcking support service to identify
and respond to the mental health needs of women who have
been tralcked for sexual exploitation.
Provenance and peer review: Not commissioned; externally
peer reviewed.
Cite this as: BMJ 2013;346:f2657 Red flag: signs of physical abuse
bmj.com
OEditorial: Meeting the health needs of tralcked persons (BMJ luu9;!!9:b!!l6)
OEditorial: Fears of an influx of sex workers to major sporting events are unfounded (BMJ lu1l;!/':e'3/')
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10 BMJ | 4 MAY 2013 | VOLUME 346
EDITORIALS
Understanding patterns in maternity care in the NHS and getting it right
Its important to choose the right indicators, use high quality data, and engage all stakeholders
Lucy C Chappell clinical senior lecturer in maternal and fetal
medicine, Womens Health Academic Centre, Kings College
London, London SE1 7EH, UK lucy.chappell@kcl.ac.uk
Catherine Calderwood national clinical director for
maternity and womens health, NHS England , NHS England,
PO Box 167!3, Redditch, UK
Sara Kenyon senior lecturer, School of Health and Population
Sciences, University of Birmingham, Birmingham, UK
Elizabeth S Draper professor of perinatal and paediatric
epidemiology , Department of Health Sciences, University of
Leicester, Leicester, UK
Marian Knight National Institute for Health Research
professor in public health , National Perinatal Epidemiology
Unit, University of Oxford, Oxford, UK
This week, the Royal College of Obstetricians and
Gynaecologists published its report on patterns of
maternity care in English NHS hospitals during
2011 to 2012.
1
The stated aim was to examine
the validity of potential performance indicators,
and to determine how successfully these could be
used to compare performance between maternity
units using available data. Data from inpatient
admissions and day cases collected routinely from
English NHS trusts through Hospital Episode Sta-
tistics (HES) were analysed to provide an initial 11
performance indicators,
all related to intrapartum
care (box). The report
presents the data as risk
adjusted estimates for
each maternity unit within
a funnel plot showing the
national mean. If variation
occurred at random, only
one in 20 or one in 500
units would be expected to
lie outside the limits repre-
senting two (inner funnel
limits) or three (outer lim-
its) standard deviations,
respectively.
The launch of this drive
is welcome, and a great
amount of work has gone
into devising the indica-
tors, collating the data,
and producing the report,
but what does it tell us
about current maternity care in England? The
report acknowledges the wide disparity in the qual-
ity of data. Units were excluded if data for an indica-
tor were missing, inconsistent, or implausible (even
though up to 45% of units had to be dropped for
some indicators). Completeness of maternity data
in the HES dataset is still alarmingly low, with key
data helds such as gestational age and birthweight
missing in over 20% of records.
1
Despite this data
cleaning step, 16-56% of units still lay outside
the outer funnel limits for all indicators relating to
induction of labour and mode of delivery, with vari-
ability far greater than expected. The report stated
that the funnel plots are only to show where there
are substantial systematic (non-random) dier-
ences between maternity units, but it is likely that
this complex analysis using data of limited quality
will be used out of context and be open to misinter-
pretation. Until data quality greatly improves, HES
data cannot be used to for this kind of analysis.
Although the report states that the intention is
not to label hospitals outside the outer limits as out-
liers, it is debatable whether those who read it will
follow that suggestion. There is already an accepted
and validated protocol from the Healthcare Qual-
ity Improvement Partnership for engaging with a
unit that has potentially outlying performance.
2

The hrst stage, before publishing data, is to contact
units directly and allow them to correct any data
quality problems. This method is already used rou-
tinely by the Paediatric Intensive Care Network.
3
We
suggest that similar protocols are adopted for mater-
nity care data. In the new era of the NHS Outcomes
Framework,
4
it should be
fundamental that all units
submit complete accurate
data, as the report recom-
mends. Clinicians must
take ownership of their
own data so that they can-
not argue that the derived
indicators are wrong. Reg-
ular audits of the quality of
units data would facilitate
this process and the col-
lege is right to engage its
members directly in this.
One key objective already
established for NHS Eng-
land is the development
of a national clinical audit
for maternity services
(to include stillbirths),
concurrent with the intro-
duction of a national
maternity dataset.
5
It is
only through using these data that we will achieve
outcome driven improvements in the new NHS,
with users and clinicians as the drivers
The indicators chosen are principally process
measures, justihed as a reasonable alternative to
direct measurement of outcomes. However, pro-
cess indicators are not without their problems;
it is unclear whether they provide a meaningful
measure of quality, what the correct rate should
be, and how they can be interpreted without
a cc ompanying outcome data. Several outcome
measures are already available in relation to
maternity care. Stillbirth and neonatal death are
regrettably not rare events, with a rate of 5.2 and
2.9 per 1000 in 2011, respectively.
6
Maternity units
already have direct access to these outcome data
and they should be included. There are also several
neonatal outcome datasets and a National Neona-
tal Audit Programme,
7
elements of which could be
incorporated. The report states that maternal mor-
tality is too rare to be used as an outcome indicator;
the alternative is to use measures of maternal mor-
bidity, which have already been developed and val-
idated using routinely collected data in Australia.
8
In developing the indicators to be included,
wider representation could be sought, includ-
ing consultation with women themselves, mid-
wives, anaesthetists, and those who commission
maternity care. A more inclusive and consultative
approach might have led to a more varied and bal-
anced list of indicators. Integration with patient
reported measures, such as results from the sur-
vey currently being undertaken by the Care Quality
Commission on womens experiences of maternity
care,
9
will provide additional context for interpre-
tation of numerical indicators. A positive experi-
ence of care is a high level national outcome for
NHS England.
Despite the many caveats on data quality, when
this report enters the public domain, commission-
ers, healthcare professionals, and women them-
selves may use the data to try to identify outlying
units (although no unit is named) to help inform
choice of maternity unit or patient referral path-
way. There is always considerable interest from
professionals and the public when an outlier is
identihed, even if subsequent events provide an
explanation for temporarily outlying data. To
avoid units disowning indicators based on the pro-
vided data, sta must be engaged to provide high
quality source data through a mandated national
dataset. Once this is achieved, further work across
multidisciplinary and multiagency teamsinclud-
ing service users, professional bodies, and exist-
ing data sourcesis needed to identify the most
appropriate indicators and to use these in context
to drive up quality and safety across the new NHS.
See COI statement on bmj.com.
Provenance and peer review: Commissioned; not externally
peer reviewed.
Indicators chosen for inclusion in the report
Induction of labour rate
Proportion of induced labours resulting in
emergency caesarean section
Proportion of spontaneous labours resulting
in emergency caesarean section
Elective caesarean section rate
Proportion of elective caesareans performed
before weeks of gestation without clinical
indication
Instrumental delivery rate
Proportion of instrumental deliveries carried
out by vacuum extraction (vacuum to forceps
delivery ratio)
Proportion of attempted instrumental
deliveries resulting in emergency caesarean
section
Third and fourth degree perineal tear rate
after unassisted vaginal delivery
Third and fourth degree perineal tear rate
after assisted vaginal delivery
Emergency maternal readmission within
days of delivery
Clinicians must take ownership of their
own data so that they cannot argue
that the derived indicators are wrong
BMJ | 4 MAY 2013 | VOLUME 346 11
The BMJ is an Open Access journal. We set no word limits on BMJ research articles, but they
are abridged for print. The full text of each BMJ research article is freely available on bmj.com
Scan this image with your
smartphone to read our
instructions for authors
RESEARCH
RESEARCH NEWS
RESEARCH NEWS All you need to read in the other general medical journals Alison Tonks, associate editor, BMJ atonks@bmj.com
with later and more serious disease. The authors
did a series of analyses accounting for dozens
of confounding factors including smoking and
exposure to ultraviolet radiation. They studied
46 237 male health professionals and 107 339
female nurses who developed almost 30 000
new cancers during follow-up.
People with non-melanoma skin cancers still
have a low absolute risk of a second primary,
say the authors (176/100 000 person years for
men; 182/100 000 person years for women), so
theres no need for active surveillance yet.
PLoS Med lu1!;1u;e1uu1/!!
Biventricular pacing for adults with
AV block and heart failure
Patients with atrioventricular (AV) block, heart
failure, and leh ventricular dysfunction usually
need a ventricular pacemaker. Right ventricular
pacing restores heart rate but may disturb leh
ventricular function in the long term. Biven-
tricular pacing is technically harder to achieve
but worked better in a head to head trial that
tracked patients over three years. A primary
outcome combining deaths, emergency visits for
heart failure, and worsening heart failure was
signihcantly less common in patients managed
with biventricular pacing (45.8% (160/349) v
55.6% (190/342); hazard ratio 0.74, 95% cred-
ible interval 0.60 to 0.90). Two secondary com-
posite outcomesdeath or hospital admission
for heart failure, and death or urgent care visit
for heart failurewere also less common in the
biventricular pacing group.
The trial began in 2003, and the protocol was
adjusted in 2005 to allow implantable cardio-
verter dehbrillators for eligible patients. Primary
results were less secure for this subgroup (haz-
ard ratio 0.75, 0.57 to 1.02). All participants
were given a device capable of pacing one or
both ventricles and were randomised one to two
months aher a run in period of right ventricu-
lar pacing and stabilisation of drug treatments.
One in seven participants had a serious adverse
event within 30 days of the procedure (14%;
113/809). One in 16 had complications related
to the leh ventricular lead (6.4%). The trial was
funded by Medtronic.
N Engl J Med lu1!;!6S:1'S'-9!
Swimming improves tness in
children with asthma
Swimming is a good way for children with
asthma to keep ht, according to a systematic
review of eight trials. Swimming was well tol-
erated by children with stable symptoms and
helped improve aerobic htness and lung func-
tion compared with no prescribed exercise or
golf (one trial). Swimming training made no
dierence to quality of life in one small study
and little dierence to asthma symptoms in two
small studies. Trial data on exacerbations were
limited and inconclusive.
In combined analyses, swimming several
times a week for at least half an hour improved
childrens FEV
1
(forced expiratory volume in
one second) by 100 mL more than usual care
(95% CI 0 to 200). The dierence was modest
but clinically meaningful, say the authors, and
comparable to the kind of improvements associ-
ated with low dose uticasone. Swimming had a
more noticeable impact on htness (25% greater
improvement than controls in maximal oxygen
consumption: an extra 9.67 mL/kg/min, 95%
CI 5.84 to 13.51).
The 262 children and adolescents in these
trials had stable asthma of varying severity. Tri-
als reported few side eects, although only four
of the eight specihed whether pools contained
chlorine. Bigger, better trials looking at quality
of life and asthma control are now needed, say
the authors. Parents and children still want to
know how swimming compares with other forms
of exercise.
Cochrane Database Syst Rev lu1!;/:CDuu96u7
Emerging epidemiology of H7N9
avian u
Enhanced surveillance for the new H7N9 avian
u identihed 82 conhrmed cases in six areas of
China between 25 March and 17 April 2013.
Seventeen infected people died of respiratory
complications or multiorgan failure a median of
11 days aher the hrst signs of illness, according
to the hrst epidemiological study of the outbreak.
Sixty others were still critically ill on 17 April.
Most of those affected were older (median
age 63 years, interquartile range 50-73), men
(60/82), and had a history of recent exposure to
live animals (59/77), usually chickens or ducks.
Fihy four of the 71 cases with data available had
underlying medical conditions, most commonly
hypertension, diabetes, or heart disease. Only
two patients were under 5 years old and both
had mild upper respiratory symptoms only.
Researchers identihed three clusters of cases
within families and cant rule out human to
human transmission.
Infected poultry is the most likely source of
the outbreak, and public health authorities
should consider early control measures, such
as disinfecting or even closing live poultry mar-
kets, while we wait for further conhrmation, say
the researchers. A separate study reported close
genetic similarities between H7N9 viruses iso-
lated from cases and from local chickens.
N Engl J Med lu1!; doi:1u.1u'6/NEJMoa1!u/617
Lancet lu1!; doi:1u.1u16/Su1/u-67!6(1!)6u9u!-/
Slightly higher risk of another cancer
after a rst non-melanoma skin cancer
White men and women with non-melanoma skin
cancers have a slightly increased risk of subse-
quently developing other cancers. A nalyses of
two long running cohorts from the US report
an overall relative risk of 1.11 (95% CI 1.05 to
1.18) for men and 1.20 (1.15 to 1.25) for women
during more than 20 years of follow-up. These
hgures exclude melanomas from the count of
second cancers.
The new study conhrms and hne tunes previ-
ous work linking non-melanoma skin cancers
Adapted from N Engl J Med ; doi:./NEJMoa
Geographical distribution of HN cases
in China
km
Beijing
Henan
Anhui
Zhejiang
Shanghai
Jiangsu
12 BMJ | 4 MAY 2013 | VOLUME 346
RESEARCH
Faculty of Epidemiology and
Population Health, London School
of Hygiene and Tropical Medicine,
London WC1E 7HT, UK
Correspondence to: I Douglas
ian.douglas@lshtm.ac.uk
doi: 1u.11!6/bmj.f19!6
This is a summary of a paper that
was published on bmj.com as BMJ
lu1!;!/6:f19!6
STUDY QUESTION
Is treatment with orlistat (Xenical; Roche) associated with
hepatic injury?
SUMMARY ANSWER
The incidence of acute liver injury was higher in the periods
both immediately before and immediately after the start of
orlistat treatment.
WHAT IS KNOWN AND WHAT THIS PAPER ADDS
Since early reports of liver injury associated with
orlistat have accumulated, raising concerns about its
safety. In a large population based cohort, the rate of
adverse liver events was temporarily increased both
immediately before and immediately after treatment
with orlistat started, suggesting the risk is associated with
underlying health changes associated with the
decision to begin treatment rather than a causal effect of
the drug.
Participants and setting
Participants were all patients registered in the UK Clini-
cal Practice Research Datalink between 1999 and 2011,
receiving prescribed orlistat and having a recorded inci-
dent liver injury event.
Design, size, and duration
Of 94 695 patients prescribed orlistat, 988 were identihed
as having incident liver injury, with a mean observation
time of 10.1 years and mean duration of orlistat use of 0.9
years. A self controlled case series analysis compared the
incidence of liver injury during periods of orlistat use with
periods of non-use.
Main results and the role of chance
An increased incidence of liver injury was detected during
the 90 day period before orlistat was hrst started compared
with other periods of non-use of orlistat (incidence rate
ratio 1.50, 95% conhdence interval 1.10 to 2.06). The inci-
dence remained raised during the hrst 30 days of treatment
(2.21, 1.43 to 3.42), before reverting to baseline levels with
prolonged treatment. No increase in the incidence of liver
injury was seen when the risk during the hrst 90 days of
treatment was compared with the 90 days preceding hrst
treatment (1.02, 0.67 to 1.56). Over 99% of the events
occurring during orlistat use were of raised liver function
test results or jaundice, with few cases of severe liver events
(one case of hepatitis).
Bias, confounding, and other reasons for caution
We accounted for confounding by using a design where
each patient acts as his or her own control, so we can be
conhdent the results are not explained by important dif-
ferences between participants. Drug use may have been
misclassihed to some extent, as it is based on prescribing
rather than consumption. The most likely eect of this
would be to bias the results towards the null.
Generalisability to other populations
The study was UK population based and the results are
likely to be generalisable to other similar populations.
Study funding/potential competing interests
IJD is funded by a Medical Research Council methodol-
ogy fellowship, KB is funded by a National Institute for
Health Research postdoctoral fellowship, and LS is funded
by a Wellcome Trust fellowship. IJD holds stock in Glaxo-
SmithKline and consults for GlaxoSmithKline, Takeda,
and Gilead on topics not related to orlistat. LS consults for
GlaxoSmithKline on topics not related to orlistat.
Orlistat and the risk of acute liver injury: self controlled case series
study in UK Clinical Practice Research Datalink
Ian J Douglas, Julia Langham, Krishnan Bhaskaran, Ruth Brauer, Liam Smeeth
OEDITORIAL by Wilding
Self controlled case series analysis for orlistat use and risk of
liver injury in definite and probable cases (n=988)
Orlistat use
Patient
years
No of
events
Age adjusted rate
ratio (95% CI)
Primary analyses:
Absence of orlistat SS7l S'l
9u days before prescription l/1 /l 1.'u (1.1u to l.u6)
1-!u days S1 l1 l.l1 (1./! to !./l)
!1-6u days Su 1u 1.u6 (u.'7 to 1.99)
61-9u days 7S 1l 1.!l (u.7' to l.!/)
>9u days 9S6 '1 u.7S (u.'S to 1.u')
Secondary analyses:
9u days before prescription l/1 /l
1-9u days l/u /! 1.ul (u.67 to 1.'6)
!u days before prescription S1 19
1-!u days S1 l1 1.11 (u.'9 to l.u6)
bmj.com O Gastroenterology updates from BMJ Group are at bmj.com/specialties/gastroenterology
BMJ | 4 MAY 2013 | VOLUME 346 13
RESEARCH
STUDY QUESTION
To estimate the probability of becoming at high risk of
cardiovascular disease for low and intermediate risk
people not receiving treatment for raised blood pressure
or lipid levels.
SUMMARY ANSWER
Repeat cardiovascular risk estimation before eight to
years is not warranted for most people unless their initial
risk is -%, when remeasurement within a year is
warranted.
Increasingly decisions to start blood pressure and
lipid lowering treatment are made on the basis of an
individuals absolute cardiovascular risk rather than
their blood pressure or cholesterol level, and people
are regularly screened for a raised risk level.
Remeasurement of cardiovascular risk may be safely
done much less often than most guidelines recommend:
eight to years for those initially at <% risk for a
cardiovascular event.
We included 13 757 and 3855 participants of two stud-
ies: the Tokyo health check-up and Framingham studies.
Included participants were aged 30 to 74 years, had com-
plete data on risk equation covariates, were not receiving
blood pressure or lipid lowering treatment, and had an
estimated risk of cardiovascular disease within 10 years
<20%. We stratihed participants on the basis of baseline
risk: <5%, 5-<10%, 10-<15%, and 15-<20%.
Design, size, and duration
Observational study of two cohorts not at high cardio-
vascular risk at baseline. Follow-up measurements in
the Tokyo study were done annually over three years
(2006-10), whereas follow-up visits in the Framingham
study were done between eight (1968-75) and 19 years
(1990-95) aher baseline. We used these visit measures to
estimate and track changes in the 10 year risk of a cardio-
vascular event >20% using the Framingham equation for
both cohorts.
At baseline most participants had <5% risk (61% and 46%
of Tokyo and Framingham cohorts) or 5-<10% risk (24%
and 28%) of a cardiovascular event within 10 years. Aher
three years for both the very low (<5%) and low baseline
risk (5-<10%) groups the proportion crossing the treat-
ment threshold was less than 1%. For the intermediate
baseline risk (10-<15%) group the proportion crossing
the threshold was 5.7% (95% conhdence interval 4.5% to
7.0%). By contrast in the high-intermediate baseline risk
(15-<20%) group 16.1% (13.4% to 19.0%) had crossed
the threshold by one year. Aher eight years 9.1% (7.1%
to 11.3%) of the low baseline risk group had crossed the
treatment thr eshold, whereas for the intermediate and
high inter mediate baseline risk groups it was over 10%
(32.1%, 27.6% to 36.8% and 73.5%, 67.2% to 79.1%,
respectively). For those with an initial very low baseline
risk, even aher 19 years of follow-up the proportion cross-
ing the treatment threshold remained low, with 6.8%
(5.5% to 8.2%) crossing the treatment threshold.
The hndings are based on two separate cohorts with dier-
ent lengths of follow-up.
While further examination is warranted in other popula-
tions, repeat risk estimation before 8-10 years is not war-
ranted for most people. However, remeasurement within a
year seems warranted in those initially at 15-20% risk.
The authors declare that: KJLB, AH, LI, and PG have sup-
port from the Australian National Health and Medical
Research Council (program grant No 633003, early career
fellowship No APP1013390) for the submitted work; no
hnancial relationships with any organisations that might
have an interest in the submitted work in the previous three
years; no other relationships or activities that could appear
to have inuenced the submitted work.
When to remeasure cardiovascular risk in untreated people at low
and intermediate risk: observational study
Katy J L Bell,
1
Andrew Hayen,
l
Les Irwig,
!
Osamu Takahashi,
/ '
Sachiko Ohde,
/
Paul Glasziou
1
1
Centre for Research in Evidence
Based Practice, Bond University,
QLD /ll9, Australia
l
School of Public Health and
Community Medicine, University of
New South Wales, NSW, Australia
!
Screening and Test Evaluation
Program, School of Public Health,
University of Sydney, NSW, Australia
/
Centre for Clinical Epidemiology, St
Lukes Life Science Institute, Tokyo,
Japan
'
Internal Medicine, St Lukes
International Hospital, Tokyo, Japan
Correspondence to: K J L Bell
katy.bell@sydney.edu.au
doi: 1u.11!6/bmj.f1S9'
lu1!;!/6:f1S9'
Probability of crossing % cardiovascular disease
treatment threshold for year cardiovascular event
risk over years of follow-up
Years of follow-up
P
e
r
c
e
n
t
a
g
e

w
i
t
h

r
i
s
k

%
Baseline risk

High intermediate (-<%)

Tokyo health check-up Framingham study
Intermediate (-<%)
Low (-<%)
Very low (<%)
bmj.com
OResearch: Comparisons
of established risk
prediction models for
cardiovascular disease (BMJ
lu1l;!//:e!!1S)
bmj.com O Cardiology updates from BMJ Group are at bmj.com/specialties/cardiology
14 BMJ | 4 MAY 2013 | VOLUME 346
RESEARCH
Predictive value of S-100 protein for prognosis in patients with moderate and
severe traumatic brain injury: systematic review and meta-analysis
Eric Mercier,
1
Amlie Boutin,
1
Franois Lauzier,
1 l !
Dean A Fergusson,
/
Jean-Franois Simard,
1

Ryan Zarychanski,
'
Lynne Moore,
1 6
Lauralyn A McIntyre,
/ 7
Patrick Archambault,
S

Franois Lamontagne,
9
France Lgar,
S 1u
Edward Randell,
11
Linda Nadeau,
1l
Franois Rousseau,
1u 1l
Alexis F Turgeon
1 l
STUDY QUESTION
Is the concentration of S-
protein a valid and accurate predictor
of prognosis after moderate or severe
traumatic brain injury?
SUMMARY ANSWER
Raised serum S- protein
concentrations are significantly
associated with unfavourable
prognosis after moderate or severe
traumatic brain injury, though
optimal discrimination thresholds
remain unclear.
WHAT IS KNOWN AND WHAT
THIS PAPER ADDS
S- protein concentrations
increase in blood and cerebrospinal
fluid after a wide range of diseases
or conditions leading to brain
damage. The review shows that
concentrations are significantly
correlated with unfavourable
prognosis in patients with moderate
or severe traumatic brain injury,
as defined by mortality, score
on the Glasgow outcome scale, or
brain stem death, with and without
concomitant traumatic injuries. This
finding could inform a decision aid
in the evaluation of patients with
traumatic brain injury.
1
Centre de Recherche du Centre
Hospitalier Universitaire (CHU) de
Qubec (Hpital de lEnfant-Jsus),
Traumatologie - Urgence - Soins
Intensifs (Trauma - Emergency -
Critical Care Medicine), Universit
Laval, Qubec City, QC, Canada
l
Department of Anesthesiology,
Division of Critical Care, Universit
!
Department of Medicine, Universit
/
Clinical Epidemiology Unit, Ottawa
Hospital Research Institute, Ottawa,
ON, Canada
'
Department of Internal Medicine,
Section of Critical Care Medicine,
University of Manitoba, Winnipeg,
MB, Canada
6
Department of Social and
Preventive Medicine, Universit
Laval, Qubec, QC, Canada
7
Department of Medicine, Division
of Critical Care, University of Ottawa,
Ottawa, ON, Canada
S
Department of Family and
Emergency Medicine, Universit
Laval, Qubec, QC, Canada
9
Centre de Recherche Clinique
tienne-Le Bel du CHUS, Universit
de Sherbrooke, Sherbrooke, QC,
Canada
1u
Centre de Recherche du CHU de
Qubec, Knowledge Transfer and
Health Technology Assessment,
Universit Laval, Qubec City, QC,
Canada
11
Department of Laboratory
Medicine, Memorial University,
St Johns, NF, Canada
1l
Department of Molecular
Biology, Medical Biochemistry and
Pathology, Universit Laval, Qubec
City, QC, Canada
Correspondence to: A F Turgeon,
Centre de Recherche du CHU de
Qubec (Hpital de lEnfant-Jsus),
Traumatologie - Urgence - Soins
Intensifs (Trauma - Emergency - Critical
Care Medicine), 1/u1, 1Se rue, local
H-u1la, QC, Canada G1J 1Z/
alexis.turgeon@fmed.ulaval.ca
doi: 1u.11!6/bmj.f17'7
lu1!;!/6:f17'7
Raabe 1998
/5
Raabe 1998
/6
Jackson 2uuu
51
Chateld 2uu2
5/
Woertgen 2uu2
57
Li 2uu/
62
Ucar 2uu/
63
Vos 2uu/
6/
Sawauchi 2uu5
65
Wang 2uu6
67
Ghori 2uu7
68
Lavicka 2uu7
7u
Olivecrona 2uu9
73
Rainey 2uu9
7/
Wiesmann 2u1u
Murillo-Cabezas 2u1u
76
Vos 2u1u
77
Stein 2u12
81
Total (95% CI)
Test for heterogeneity:
2
=u.2/,
2
=8u.5/, df=17,
P<u.uu1, I
2
=79%
Test for overall enect: z=7.u6, P<u.uu1
6
2u
25
8
2/
18
3/
/u
12
15
13
/1
23
5u
38
32
36
7
//2
9
2/
5
12
3u
22
1/
//
29
19
15
57
25
5u
22
55
/3
16
/91
1./5 (u./7)
1.3u (u.75)
u.65 (u.5/)
1./2 (u.21)
1.38 (u.2/)
u.55 (u.3u)
u./1 (u.23)
u.69 (u.3u)
2.66 (u.3/)
u.97 (u./5)
u.6/ (u.2/)
1.u8 (u.18)
u.13 (u.27)
1.u/ (u.19)
1.17 (u.21)
u.19 (u.16)
u.75 (u.18)
1.7u (u.59)
u.2 1 5 2u
Unfavourable
outcome
Study
>
Mean (SE)
dierence in
In concentration
(g/L)
Geometric mean
ratio (% CI)
No of patients
by Glasgow
outcome score
Association between S- protein and Glasgow outcome score in patients with
moderate and severe traumatic brain injury
u.u5
Favourable
outcome
Selection criteria for studies
We included cohort studies and randomised controlled
trials evaluating the prognostic value of S-100 protein in
patients with moderate or severe traumatic brain injury.
Primary outcomes
Outcomes evaluated were mortality, score on Glasgow out-
come scale, and brain stem death.
Main results and role of chance
Forty one studies were eligible for inclusion. There was a
signihcant positive association between S-100 protein con-
centrations and mortality (12 studies with 770 participants:
geometric mean ratio 2.55, 95% conhdence interval 2.02 to
3.21, I
2
=56%) and Glasgow outcome score 3 (18 studies
with 933 participants: 2.62, 2.01 to 3.42, I
2
=79%). Sensitiv-
ity analyses based on sampling time, sampling type, blind-
ing of outcome assessors, and timing of outcome assessment
yielded similar results. Ranges of serum threshold values of
1.38-10.50 g/L and 2.16-14.00 g/L were associated with
100% specihcity for mortality and a Glasgow outcome score
3, respectively.
We observed signihcant heterogeneity for all outcomes
of interest. Sensitivity analyses did not fully explain the
observed heterogeneity for the Glasgow outcome score. We
could not perform sensitivity analyses related to age, pupil-
lary reactivity, or the motor component of the Glasgow coma
scale, which are known indicators of prognosis in such
patients, because of the variable presentations or absence
of these data in included studies. The quality of evidence of
the association between S-100 protein concentrations and
both mortality and neurological outcome was moderate.
bmj.com
OResearch: Predicting
outcome aher traumatic brain
injury (BMJ luuS;!!6:/l')
BMJ | 4 MAY 2013 | VOLUME 346 15
RESEARCH
STUDY QUESTION
How reliable are risk of bias assessments based on
publications of randomised controlled trials in cancer, for
use in systematic reviews?
SUMMARY ANSWER
Use of trial publications alone to assess risk of bias could
be unreliable, therefore systematic reviewers should be
cautious about their use as a basis for trial inclusion in
meta-analysis.
Poor reporting of randomised controlled trials does not
necessarily reflect poor methodological quality of
the trial design, conduct, or analysis. Obtaining
additional information from trials could ensure a more
accurate assessment of risk of bias and, if available,
summary statistics can reduce or overcome some
potential biases.
We included 95 published randomised controlled trials in
cancer that had been included in 13 systematic reviews
and meta-analyses based on individual participant data
(IPD), and for which publications and completed forms or
trial protocols had been collected during the IPD process.
Design
Two authors completed risk of bias assessments using the
Cochrane risk of bias tool and following guidance from
the Cochrane Handbook. Assessments were conducted
for individual domains, and overall for each trial, hrst
using information from trial publications alone and then
using supplementary information alongside the published
information.
Primary outcome(s)
We compared the two approaches to assessing risk of bias
by calculating percentage agreement (low <66%; fair
66%; good 90%). The approaches were considered to
be similarly reliable only when agreement was good.
Percentage agreement between the two methods for
sequence generation and incomplete outcome data was
fair. For allocation concealment, selective outcome report-
ing, and overall risk of bias, percentage agreement was
low. Supplementary information reduced the proportion
of unclear assessments for all individual domains. This
reduced proportion increased the number of trials assessed
as having a low risk of bias, and therefore available for
inclusion in meta-analyses, from 23 (23%) based on pub-
lications alone to 66 (66%).
The included cancer trials represented a selected group.
Risk of bias assessments were for overall survivala sin-
gle, objective and commonly well reported outcome
rather than all possible outcomes, as is recommended.
Our results might therefore represent an optimistic view
of the reliability of the risk of bias assessments using
published information alone. Also, the additional infor-
mation supplied was sometimes limited; even with
additional information, around a third of the included
studies were still classihed as having unclear risk of
bias.
All of the included trials were cancer trials. These are, in
general, well conducted and ohen well reported. Therefore,
for some other healthcare areas, where trials are less well
conducted or reported, risk of bias assessments based on
publications alone could be even less reliable.
This work was supported by the United Kingdoms Medi-
cal Research Council. None of the authors have received
support from any organisation for the submitted work,
nor do they have any hnancial relationships with any
organisations that might have an interest in the submit-
ted work in the previous three years, or any other relation-
ships or activities that could appear to have inuenced
the submitted work.
Can trial quality be reliably assessed from published reports
of cancer trials: evaluation of risk of bias assessments in
systematic reviews
Claire L Vale, Jayne F Tierney, Sarah Burdett
Meta-analysis Group, MRC Clinical
Trials Unit, London WClB 6NH, UK
Correspondence to: C L Vale
cv@ctu.mrc.ac.uk
doi: 1u.11!6/bmj.f179S
lu1!;!/6:f179S
Outcomes and comparison of risk of bias assessments
Risk of bias domain
No of assessments based on
publications only
No of assessments based on publications
plus supplementary information
Percentage agreement
(%; 95% CI) Low Unclear High Low Unclear High
Sequence generation /l '! u 69 l6 u 69.' (6u.l to 7S.7)
Allocation concealment /u '' u S9 6 u /S./ (!S./ to 'S.')
Incomplete outcome data 7/ 1u 11 9u 1 / Su.u (7l.u to SS.u)
Selective outcome reporting !7 1u /S 9u u ' /l.1 (!l.l to 'l.u)
Overall risk of bias for trial l! 7u l 6/ !1 u '/.7 (//.7 to 6/.7)
bmj.com
OResearch: Assessment of
publication bias, selection
bias, and unavailable data in
meta-analyses using individual
participant data
(BMJ lu1l;!//:d776l)
OResearch: Observer bias in
randomised clinical trials with
binary outcomes
(BMJ lu1l;!//:e1119)
OResearch Methods and
Reporting: The impact of
outcome reporting bias in
randomised controlled trials on
a cohort of systematic reviews
(BMJ lu1u;!/u:c!6')
16 BMJ | 4 MAY 2013 | VOLUME 346
BMJ GROUP IMPROVING HEALTH AWARDS 2013
included online and practical training as well
as feedback on each practices dispensing
and resistance data. Christopher Butler
and colleagues study found that practices
randomised to the programme signicantly
reduced their total oral antibiotic dispensing
over the next year compared with control
practices.
6
The intervention did not increase
the rate of admission to hospital or of
reconsultation for a respiratory tract infection
within the next week.
The external judges who have to choose
just one Research Paper of the Year from this
formidable shortlist are Richard Lehman, journal
blogger and former general practitioner in
Oxfordshire; Dinesh Selvarajah, honorary con-
sultant diabetologist at Shemeld Teaching Hos-
pital and 2u11 BMJ Award winner; and Sarah
Hedderwick, consultant in infectious disease at
the Royal Victoria Hospital Belfast and deputy
chair of the BMA Consultants Committee.
Trish Groves deputy editor, BMJ tgroves@bmj.com
The Research Paper of the
Year award is sponsored
by GlaxoSmithKline.
1 Makkar RR, Fontana GP, Jilaihawi H, Kapadia S, Pichard
AD, Douglas PS, et al. for the PARTNER Trial Investigators.
Transcatheter aortic-valve replacement for inoperable severe
aortic stenosis. N Engl J Med lu1l;!66:1696-7u/.
l Wilt TJ, Brawer MK, Jones KM, Barry MJ, Aronson WJ, Fox S, et
al for the Prostate Cancer Intervention versus Observation
Trial (PIVOT) Study Group. Radical prostatectomy versus
observation for localized prostate cancer. N Engl J Med
lu1l;!67:lu!-1!.
! Krogsbll LT, Jrgensen KJ, Grnhj Larsen C, Gtzsche PC.
General health checks in adults for reducing morbidity and
mortality from disease: Cochrane systematic review and
meta-analysis. BMJ lu1l;!/':e7191.
/ Simmons RK, Echouffo-Tcheugui JB, Sharp SJ, Sargeant
LA, Williams KM, Prevost AT, et al. Screening for type l
diabetes and population mortality over 1u years (ADDITION-
Cambridge): a cluster-randomised controlled trial. Lancet
lu1l;!Su:17/1-S.
' Zauber AG, Winawer SJ, OBrien MJ, Lansdorp-Vogelaar I, van
Ballegooijen M, Hankey BF, et al. Colonoscopic polypectomy
and long term prevention of colorectal cancer deaths. N Engl J
Med lu1l;!66:6S7-96.
6 Butler CC, Simpson SA, Dunstan F, Rollnick S, Cohen D,
Gillespie D, et al. Effectiveness of multifaceted educational
programme to reduce antibiotic dispensing in primary
care: practice based randomised controlled trial. BMJ
lu1l;!//:dS17!.
This years judges of the Research Paper of the
Year award have to choose between six very
dinerent papers. All six papers tackle common
and important challenges in healthcare in well
resourced settings, and several show that we
need less medicine, not more. Which study will
the judges decide has the greatest potential to
improve health and healthcare; to help doctors
make better decisions about clinical practice,
public health, research methods, or health
policy; and to improve health outcomes for
patients or populations?
Transcatheter aortic valve replacement for
inoperable severe aortic stenosis
In the original Placement of Aortic Transcatheter
Valves (PARTNER) trial patients in their 8us
with a greater than 5u% risk of death or serious
irreversible complications from conventional
aortic valve surgery were randomised to either
transcatheter aortic valve replacement or
standard medical therapy: survival at one year
was signicantly higher afer valve replace-
ment. Raj R Makkar and colleagues report of
the two year outcomes of this international trial
was shortlisted for the BMJ award because it
provides patients and doctors with high quality,
real life evidence to weigh up the benets and
risks of this procedure.
1
Patients with replaced
valves were still at high risk (and /3.3% had
died), but they were doing signicantly better
than patients in the control group (of whom
68% had died).
Radical prostatectomy versus observation for
localised prostate cancer
Observational studies suggest that most men
with early stage prostate cancer die with, rather
than from, their tumours and that early treat-
ment ofen has serious harms. Timothy J Wilt
and colleagues randomised controlled trial with
12 years follow-up, found that mortality from
all causes was the same among men who had
radical prostatectomy as among those who were
simply observed.
2
And men who had surgery
were signicantly more likely to report urinary
and erectile dysfunction two years afer their
operations.
General health checks in adults
Checking adults to see if they have signs,
symptoms, or risk factors for disease might
seem a good idea. But Lasse T Krogsbll and
colleagues Cochrane review and meta-analysis
of 1/ randomised trials with more than 18u uuu
people in the US and Europe found no evidence
to support general health checks.
3
Harms were
not well studied in the trials, but routine health
checks almost certainly lead to some overdiag-
nosis and overtreatment.
Screening for type 2 diabetes
Population screening for type 2 diabetes
another intervention that might seem worth-
whiledidnt fare well in Rebecca K Simmons
and colleagues randomised controlled trial
in UK primary care.
/
Screening of more than
15 uuu patients at increased risk did not reduce
all cause, cardiovascular, or diabetes related
mortality within the next 1u years.
Surveillance of colorectal cancer
While were waiting for the results of large trials
of colonosopic screening for colorectal cancer,
follow-up data from old studies can provide
useful guidance. Ann G Zauber and colleagues
long term follow-up of the US National Polyp
Study looked at the death rate among patients
who had had adenomatous polyps removed
compared with mortality from colorectal cancer
in the general population and in an internal
concurrent control group of patients with non-
adenomatous polyps.
5
Median follow-up was 15
years, and the study suggested that polypec-
tomy signicantly reduced the risk of death from
colorectal cancer.
Training to reduce antibiotic prescribing
The Stemming the Tide of Antibiotic Resistance
(STAR) programme for general practitioners
bmj.com
OFeature: Safer sport,
shock treatment, stroke
care, and safety triumph
at the BMJ Group awards
(BMJ lu1l;!//:e!7/1)
Research Paper of the Year award
This annual BMJ award recognises outstanding original research with potential to contribute
considerably to improving health and healthcare. Trish Groves introduces the shortlist
Raj R Makkar; Timothy J Wilt and colleagues; Lasse T Krongsbll; Type 2 diabetes screening; Ann G Zauber; Christopher Butler and colleagues
BMJ | 4 MAY 2013 | VOLUME 346 17
BMJ GROUP IMPROVING HEALTH AWARDS 2013
measures (PROMs) provide a
remote clinical assessment of the
patients pain and function afer
the procedures.
Orthopaedic surgeons can use
these assessments in conjunction
with radiographs to advise
patients and GPs on whether
further follow-upeither in person
or remotelyis needed. Data
generated by the PROM tool has
been assessed as more robust
than previous pen and paper
collection.
Using the PROM tool, Royal
Cornwall Hospitals NHS Trust has
created a new patient pathway,
generating 11 uuu assessments
from 22uu patients, which it
estimates will save 1uuu follow-up
patient appointments a yeara
saving of 86 uuu (t1uu uuu;
$13u uu). Clinic appointments can
be used for those patients who
most need them.
HIV screening
Chelsea and Westminster
Hospitals Dean Street at Home
shows how existing web based
services can be fused together to
create an entirely new model for
HIV screening. The new service
provides a true online extension of
the physical Dean Street Centre, in
Soho. Gay men at high risk of HIV
who live within the M25 London
orbital are targeted through social
media network Gaydar, plus the
smartphone application Grindr,
and onered a postal mouth swab
HIV sampling kit; samples are
Health secretary Jeremy Hunt has
committed the National Health
Service to becoming paperless by
2u18, using the term as shorthand
for adopting digital technologies to
improve the quality and emciency
of healthcare.
Its a huge challenge, but
examples of the future digital
health service can already be found
in many parts of the country. The
four shortlisted entries for the
Transforming Patient Care Using
Technology category provide a
snapshot of what is already being
achieved by leading healthcare
providers.
Local eye care
The shortlist included the i-van, a
general practice led initiative by
Saxmundham Health in
Sunolk. This set out to shif
ophthalmic services into the
community, by taking them out
on the road in a van equipped
to provide a comprehensive
assessment in a single
appointment. Bringing care closer
to home is particularly important
for older patients with chronic
stable glaucoma, a condition that
accounts for 1u% of blindness
registrations in the UK.
As tests are done in a single
appointment, i-van halves the
number of patient appointments
needed annually. Clinical
data and images are stored
digitally and can be assessed
remotely, improving monitoring
and audit.
Faster test results
West Middlesex Hospital shows
the emciencies that can be
achieved by networking point of
care testing machines in emergency
departments with the hospitals
Integrated Clinical Environment
(ICE) system for ordering tests. In
most hospitals, there is no direct
electronic link between the two
and patient data have to be printed
on or transcribed into case notes,
with an obvious risk of errors. The
benets of connectivity include
improved speed and accuracy,
which is particularly important in
managing patients with sepsis.
For patients with sepsis, the
proximity of the point of care
analysers enabled doctors to
receive a full blood count result
within three minutes of delivery
of the blood sample. The same
three minute turnaround time was
achieved for serum potassium
results in patients presenting with
dangerous cardiac arrhythmias.
With 2uu NHS trusts
currently using the ICE order
communications system, the
benets of integration have the
potential to be widely replicated.
Remote follow-up
Myclinicaloutcomes, meanwhile,
shows how web based remote
follow-up of patients who have
had total hip or knee replacement,
reported live to their general
practitioners, can contribute to
better patient outcomes. The
online patient reported outcomes
Making the digital future a reality
Jon Hoeksma looks at the candidates for the Transforming Patient
Care Using Technology award
returned by post. Patients with
positive results are contacted for
conrmatory testing and care by an
NHS HIV specialist.
The National Institute for
Health and Care Excellence (NICE)
estimates that preventing one
onward HIV transmission saves
between 28 uuu and 36u uuu
in lifetime treatment costs.
Dean Street at Home compared
favourably with other Department
of Health pilots to increase HIV
diagnosis. The service performed
1/39 tests and identied /2
new cases at a cost of 1113
per diagnosis. The cost of an HIV
diagnosis in primary care is 38uu.
Of those tested, 3/% had never
been tested for HIV before. NICE
guidance recommends that men
who have sex with men test at least
once a year.
Turning these innovative ideas
into new models of healthcare that
are delivering proven benets to
patients has required dedication
and hard work. To paraphrase
science ction writer William
Gibson: the digital future NHS is
already here, its just unevenly
spread.
Jon Hoeksma editor, eHealth Insider,
London, UK Jon@e-health-media.com
Competing interests: None declared.
For more about the BMJ Group awards
go to http://groupawards.bmj.com.
The Transforming Patient Care Using
Technology Award is sponsored by Datix.
The i-van; faster test results in West Middlesex; Myclinicaloutcomes; Dean Street at Home
18 BMJ | 4 MAY 2013 | VOLUME 346
ANALYSIS
INNOVATE
OR DIE
Health systems must innovate
to survive the pandemic of
non-communicable disease,
but many innovations do not
spread easily. Paul Corrigan,
Christopher Exeter, and
Richard Smith examine why
this is so and how to help
them spread
The pandemic of non-communicable disease
(NCD) aecting low and middle income countries
is well recognised.
1

2
In high income countries
multiple chronic conditions already account for
the lions share of expenses.
3

4
Health systems
are threatened by the escalating costs of NCD
and must innovate to keep their systems func-
tioning and deliver improved care. We discuss
the drivers and diusion mechanisms needed to
promote the spread of innovations using seven
novel approaches to reducing the burden of NCD.
Examples of innovations to counter NCD
In preparing the report from which this article
is derived we compiled over 200 innovations
aimed at reducing the burden of NCD and cat-
egorised them under a new taxonomy (table,
see bmj.com).
5
Box 1 (see bmj.com) describes
how we devised the taxonomy and collected
the innovations.
From our database we selected seven innova-
tions (box 2) that illustrate dierent problems in
spreading innovations, which we discuss below.
All have evidence to support them, but as we
deliberately selected early stage innovations, this
mostly falls short of randomised trials. Clearly
further evaluation is needed. Innovations that
seem promising may not deliver value in the long
term and resources may be wasted by pu rsuing
them for too long.
Professionals may feel threatened
Diusing new methods of service delivery for
patients, such as nurse led care in Primary Care
101 or encouraging self management in the
Tonga programme, are likely to prove most dif-
hcult in countries that have long established and
well entrenched health systems. Community
Box | Seven innovations to reduce the burden of non-communicable disease
Weqaya programme
6

7
The United Arab Emirates has measured the risk of cardiovascular disease in every
Emirati citizen in Abu Dhabi aged over 18. The results are fed back to individuals together with advice on
action to take. Anonymised data can be provided to the government, local authorities, and employers to
develop and monitor public health and workplace programmes.
China Rural Health Initiative
8
A platform to test low cost sustainable interventions for the prevention
and management of cardiovascular disease in 12u villages in northern China, using village doctors (once
known as barefoot doctors) and community health workers.
Tonga asthma self management programme
9

1u
The programme aims to enable patients to manage their
condition with little or no clinical supervision. Patients are given instruction on using peak expiratory flow
(PEF) meters, a plan on how to manage their asthma according to their PEF rates, and guidelines on how to
respond to problems.
Polypill
11

12
The polypill combines drugs that work in different ways to reduce the risk of heart attack
and stroke into one tablet. Trials have shown that the polypill will reduce blood pressure, blood lipids,
and platelet stickiness as effectively as drugs given individually and that adherence is much improved.
The polypill is available in several low and middle income countries but not yet in a high income country,
although it may be licensed soon in the US for secondary prevention of cardiovascular disease. Some have
advocated offering the polypill to everybody when they reach age 55 without any testing or monitoring.
CollaboRhythm
13
A speech and touch controlled collaborative interface that can be accessed by phone,
tablet, or computer and allows doctor and patient to make shared decisions based on the patients data.
Importantly, patients own their data, and everything they see in the doctors office is available at home or
when they visit another doctor or are travelling. The idea is that continuous monitoring helps patients to
live a healthier life, making them less likely to need more intensive therapy.
Primary Care , South Africa
1/

15
A set of evidence based guidelines that cover all the conditions likely
to affect adults attending primary care clinics in South Africa. These clinics are staffed mainly by nurses,
who have considerable experience of treating patients with HIV infection but little training in managing
patients with NCD and other conditions common in primary care. Unlike most guidelines, they are
symptom based rather than disease based. The nurses also receive non-didactic, case based training in
their places of work.
Discovery Vitality, South Africa
16- 18
The Vitality programme of the South African insurance company
Discovery provides incentives for people to live a healthier life. Those in the programme begin with a full
health review, which assigns them a Vitality age and prescribes a pathway to better healthcovering
disease management, smoking, mental health, preventive health, nutrition, and physical activity. The
Vitality age is easy for patients to understand: a Vitality age higher than your chronological age is clearly
a bad thing, and the reverse is clearly good. Through following their prescribed pathway, participants can
reduce their Vitality age and earn Vitality points, which can be exchanged for benefits.
In China a rural health programme tested low cost interventions to manage cardiovascular disease
BMJ | 4 MAY 2013 | VOLUME 346 19
ANALYSIS
services led by non-physicians may be viewed
as a threat, especially in countries where hos-
pital care dominates. Hospital based services
for patients with NCD enjoy high status in many
systems, and the professionals who run them are
likely to feel aronted by the suggestion that com-
munity based care led by non-physicians might
be equally eective as well as cheaper. So long
as community services remain local, clashes are
avoidable, but expanding community based serv-
ices nationally, as the Chinese project aims to do,
requires a new strategy to reassure or overcome
the objections of existing service providers.
This must include a case for change that is sci-
entically sound and resonates with the public
and, as far as possible, with clinicians. Evidence
is needed that the new service can reduce mortal-
ity and morbidity and provide a return on invest-
ment. Leading professionals need to champion
the new approach and to get patient groups to
argue the case with existing providers.
Programmes that promote self management,
such as the Tonga project for patients with
asthma, tend to remain small because health
professionals see them as a threat to job security.
Professionals may react defensively by question-
ing the safety of the new approach, which could
undermine the condence of patients and hinder
the diusion of innovations. Finding profession-
als who will argue in favour of self management
is important.
Sound economic case for change
The widespread uptake of the polypill (contain-
ing aspirin, a statin, and folic acid) to prevent
coronary heart disease could promote the sus-
tainability of health systems by reducing the
burden from stroke and myocardial infarction. Its
role in secondary prevention is widely accepted,
and trials are underway to test its role in primary
prevention. If, as some studies suggest, half of
heart attacks and strokes could be prevented,
the savings would be enormous. But to be most
cost eective polypills need to be manufactured
in volume from the beginning (large scale pro-
duction lowers unit cost) and adherence must be
promoted.
Similarly, innovations to improve self manage-
ment will help health systems only if potential
savings are realised. Increasing patients capac-
ity to self manage in the Tonga asthma initiative
resulted in a fall in emergency visits and hospi-
tal admissions. This suggests savings from roll-
ing out this innovation may be appreciable and
could free resources for other health activities.
Its worth noting, however, that in many health
systems, resources that are saved are oen in
dierent budgets from the investment and are not
attributed to the initial investment.
Most health systems undervalue new forms
of communication between patient and medical
sta, such as the CollaboRhythm platform. Use
of mobile phones in healthcare is mainly being
developed outside normal payment systems. If
greater use of e-technologies reduces the need
for face to face consultation it represents not just
a challenge to orthodox methods but also, poten-
tially, a loss of income for health professionals.
Consumer demand and social movements
Traditionally, healthcare is less driven by con-
sumer demand than other activities, but this
might be changing. Better self management
oers people with NCD much greater control
over their lives, less reliance on medical inter-
ventions, and reduced morbidity
so patients
are likely to want more of it. Some patient
groups, notably in the UK the Richmond Group
of C harities, are organising patients to demand
more self m anagement.
Innovations that use mobile phones to facili-

tate the search for diagnosis or treatment may
become popular with patients and should dif-
fuse easily and rapidly. Resistance to their use by
health professionals, in high income countries in
particular, will have to be overcome.
Similarly, uptake of the polypill could meet
resistance from drug companies that see markets
being undercut, and public health professionals,
who regard the polypill as an alternative rather
than a supplement to a healthy lifestyle. It might
take an international clinical and social move-
ment to establish its legitimacy. The argument will
have to be made in dierent parts of health sys-
tems and a wide range of champions mobilised,
including patients, patient groups, clinicians, and
scientists.
The advantage of social movements as agents
of change is that they can challenge existing
healthcare business models from the plausible
perspective of a large patient population. They
can also spur interest in and demand for a new
model of disease prevention, which avoids hav-
ing to mount an expensive marketing campaign.
Buy-in from local communities
In some Chinese communities many people still
believe that developing cardiovascular disease
is inevitable and interest in prevention is low.
Strong public health leadership will be needed
to convince the public that there will be benets
to health (and wealth) from adopting innovations
in the China Rural Health Initiative.
Diusion may also fail if the innovation seems
to be imposed from outside. When the salt reduc-
tion and health promotion part of the project in
China was implemented community health
educators strove to represent themselves as
local community leaders rather than as external
agents.
New innovations also need to be promoted.
Promoters must not assume that a national pro-
gramme will gain the same support from com-
munity leaders as a successful local programme.
When local leaders have less inuence, commu-
nities may benet from the help of social mar-
keting organisations. Social marketing changes
behaviour because precise messages reach tar-
geted groups through specic channels of com-
munication. This segmentation is most useful
when the innovation is focused on a high risk
group, such as people with hypertension.
Over the past decade the communication and
culture sector has been successful in changing
the consumption behaviour of many hundreds
of millions of people. Given this success the pri-
vate sector has considerable expertise in the use
of persuasive communications to change con-
sumer behaviour, and it usually makes sense for
government and health organisations to use their
skills rather than try to change behaviour alone.
Patients add value
The innovations that we were sent show grow-
ing professional and public support for self
management of NCD. The Tongan, Chinese, and
bmj.com
OEditorial: How to judge the value of innovation (BMJ lu1l;!//:e1/'7)
OEditorial: Cost electiveness of interventions to tackle non-communicable diseases
(BMJ lu1l;!//:d733!)
OAnalysis: Global response to non-communicable disease (BMJ lu11;!/l:d!3l!)
C
U
H
K
20 BMJ | 4 MAY 2013 | VOLUME 346
ANALYSIS
Co llaboRhythm examples suggest that patients
can add considerable value to their healthcare
by improving their capacity to self manage. But it
requires investment in improving the capacity of
patients and their communities to add that value.
If governments are to make the case for uni-
versal screening linked to targeted personal
interventions, such as in the Weqaya project, they
may need the support of relevant patient organi-
sations. Visible government support for a health
policy is necessary, but probably not sucient
to diuse the innovations across the healthcare
system.
Role of governments
New innovations, along with established service
delivery models, depend on having an adequate
workforce with the required skills. The China
Rural Health Initiative teaches local primary
healthcare workers to screen, classify, and man-
age high risk patients. It has also set up simple
case management record systems within local
clinics and a digitised central database and per-
formance feedback system for health workers.
Governments need to assess the skills mix and
distribution of their workforce, their resources
for training, and ability to monitor performance.
Attempts to introduce new national policies must
also take account of local, regional, and cultural
dierences. Economic incentives may be more
eective in poorer parts of country than in au-
ent areas, for example. Although village health
workers in the Chinese initiative were prepared
to take on the care of high risk patients, it cannot
be guaranteed that workers in other areas will do
the same.
Then there are regulatory considerations. In
many countries, the use of medical devices is
subject to regulation, but mobile communications
and the increasing use of apps have given rise to
new forms of screening, diagnosis, self manage-
ment, and therapy, and these developments call
for new types of regulation.
Finally, governments must take condentiality
of health data seriouslyand be seen to be doing
so. To succeed in scaling up universal interven-
tions, such as the Weqaya cardiovascular risk
assessment programme, governments need to
engage with their populations and argue strongly
for the benets of collecting universal data, guar-
antee its security, and understand that individu-
als have a right to own their own data.
International organisations
Each national healthcare system has distinctive
national and regional characteristics. Attempts
to transplant innovations from one national sys-
tem to another oen fail. International organisa-
tions need to pay more attention to these national
dierences when advocating diusion across
nations. They also need to recognise the scope for
promoting diusion of innovations from low and
middle income countries, which promise much
greater value for money and sustainability than
those being pursued in high income countries.
Businesses
Companies that insure their workforce against
ill health and promote healthy behaviour benet
the company as well as individual workers. The
same is true for health insurers. The South Afri-
can insurance company Discovery is seeking to
improve the health of its customers by providing
them with incentives to do so. When incentives
work, the insurer is encouraged to extend the
programme to a larger section of the population.
Competition between health insurance compa-
nies may promote the spread of incentives for
behavioural change.
Conclusion
The NCD pandemic threatens the sustainability
of health systems. They must identify and imple-
ment new evidence based policies to survive. But
to have a major impact innovations must spread.
Professionals, markets, consumers, governments,
international organisations, and businesses can
encourage the spread of innovationbut can also
block spread. We need perhaps to spend less time
studying innovations and more time studying
and when appropriate promotingtheir spread.
Paul Corrigan adjunct professor
Christopher Exeter senior fellow
Richard Smith adjunct professor, Imperial College
Institute of Global Health Innovation, London, UK
Correspondence to: R Smith richardswsmith@yahoo.co.uk
Contributors and sources: The authors wrote the hrst drah of
dilerent sections of the report from which this paper is derived.
Many written and verbal comments were received from the
working group (listed in acknowledgments), and the report then
revised. RS shortened and edited the report to the present paper,
and all three authors approved the hnal version.
Competing interests: All authors have completed the unihed
competing interest form at www.icmje.org/coi_disclosure.pdf
(available on request from the corresponding author) and declare:
CE is an employee of Imperial College Institute for Global Health
Innovation. PC and RS are unpaid adjunct professors. RS works for
the UnitedHealth Group, which helped sponsor the Global Health
Policy Summit where the report from which this article is derived
was presented. The UnitedHealth Group together with the National
Heart, Lung, and Blood Institute funds the China Rural Health
Initiative and Primary Care 1u1. RS is an enthusiast for the polypill,
takes the pill, and participated in a recently reported trial. PC was
health adviser to Tony Blair when he was prime minister of the UK.
Members of the NCD working group: Paul Corrigan (cochair),
Imperial College London; Richard Smith (cochair), UnitedHealth
Chronic Disease Initiative; Stephen Bloom, Imperial College
London; Richard Bohmer, Harvard Business School; Kacey
Bonner, British Consulate-General, Los Angeles; Andres Cabrera,
University of Granada; Catalina Denman Champion, El Colegio de
Sonora, Mexico; Prabhakaran Dorairaj, Centre for Chronic Disease
Control, India: Christopher Exeter, Imperial College London;
Catherine Gordon, US Centers for Disease Control and Prevention;
Sian Grilths, Jockey Club School of Public Health and Primary
Care, Chinese University of Hong Kong; John Grumitt, Diabetes
UK and International Diabetes Federation; Christine Hancock,
C! Collaborating for Health; Oliver Harrison, Abu Dhabi Health
Authority; Mike Hobday, Macmillan Cancer Support; Alex Jadad,
Centre for Global E-Health Innovation, University of Toronto;
Desmond Johnson, Imperial College London; Sneh Khemka, BUPA;
Dinky Levitt, University of Cape Town; Lijing Yan, George Institute
for Global Health, China; Michael Macdonnell, Global Health Policy
Forum; Stephen MacMahon, George Institute for Global Health,
Australia; Victor Matsudo, Physical Fitness Research Laboratory of
Sao Caetano do Sul, Brazil; Sarah Morgan, KPMG; Andy Murdock,
Lloydspharmacy; Venkat Narayan, Rollins School of Public Health;
Robyn Norton, George Institute for Global Health, Australia; Anand
Parekh, US Department of Health and Human Services; Parashar
Patel, Boston Scientihc Corporation; Neil Pearce, London School of
Hygiene and Tropical Medicine; Rodamni Peppa, Boston Scientihc
Corporation; Cristina Rabadan-Diehl, Olce of Global Health,
National Heart, Lung and Blood Institute, US National Institutes
of Health; Hilary Thomas, KPMG; Denis Xavier, St.Johns National
Academy of Health Sciences, India.
Provenance and peer review: Not commissioned; externally
peer reviewed.
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assembly on the prevention and control of non-communicable
diseases. lu11. www.un.org/ga/search/view_doc.
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lu11. www.who.int/nmh/publications/ncd_reportlu1u/en.
! Center for Medicare and Medicaid Services. Chronic conditions
among Medicare beneficiaries, chart book. CMS, lu11.
/ Barnett K, Mercer SW, Norbury M, Watt GCM, Wyke S, Guthrie B.
Epidemiology of multimorbidity and implications for health care,
research, and medical education: a cross-sectional study. Lancet
lu1l;!Su:!7-/!.
' Smith R, Corrigan P, Exeter C. Countering non communicable
disease through innovation. lu1l. www.georgecentre.ox.ac.
uk/news/GHPSlu1lNCDREPORT.pdf.
6 Weqaya. www.weqaya.ae/en/index.php.
7 Hajat C, Harrison O, Shather Z. A profile and approach to chronic
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S George Institute. The China rural health initiative. www.
georgeinstitute.org/global-health/improving-healthcare-poor-
rural-communities-china.
9 Gibson PG, Powell H, Wilson A, Abramson MJ, Haywood P,
Bauman A, et al. Self-management education and regular
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1u Foliaki S, Fakakovokaetau T, DSouza W, Latu S, Tutine V, Cheng
S, et al. Reduction in asthma morbidity following a community-
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Tuberc Lung Dis luu9;1!:1/l-7.
11 Lonn E, Bosch J, Teo KK, Pais P, Xavier D, Yusuf S. The polypill
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1l Wald NJ, Law MR. A strategy to reduce cardiovascular disease by
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Zwarenstein M, et al. Task shifting of antiretroviral treatment
from doctors to primary care nurses in South Africa (STRETCH): a
pragmatic cluster randomised trial. Lancet lu1l;!Su:SSu-9S.
1' Fairall LR, Zwarenstein M, Bateman ED, Bachmann M, Lombard
C, Majara BP, et al. Effect of educational outreach to nurses on
tuberculosis case detection and primary care of respiratory
illness: pragmatic cluster randomised controlled trial. BMJ
luu';!!1:7'u-/.
16 Lambert EV, da Silva R, Fatti L, Patel D, Kolbe-Alexander T,
Derman W, et al. Fitness-related activities and medical claims
related to hospital admissions, South Africa, luu6. Prev Chronic
Dis luu9;6:A1lu.
17 Patel DN, Lambert EV, da Silva R, Greyling M, Nossel C, Noach A,
et al. The association between medical costs and participation
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1S Patel D, Lambert EV, da Silva R, Greyling M, Kolbe-Alexander
T, Noach A, et al. Participation in fitness-related activities of
an incentive-based health promotion program and hospital
costs: a retrospective longitudinal study. Am J Health Promot
lu11;l':!/1-S.
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definition, outcomes, and mechanisms. Ann Behav Med
luu!;l6:1-7.
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al. Developed-developing country partnerships: benefits to
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BMJ | 4 MAY 2013 | VOLUME 346 21

LETTERS
Letters are selected from rapid responses posted on bmj.com. Aher editing, all letters are
published online (www.bmj.com/archive/sevendays) and about half are published in print
O To submit a rapid response go to any article on bmj.com and click respond to this article
1 World Bank. The growing danger of non-communicable
diseases. Acting now to reverse change. lu11.
What partnership working
means to the alcohol industry
It is an oversimplification to say that the
ideological schism that divides the public health
community is between those who are prepared
to work alongside the industry and those who
are not.
The community recognises that the

alcohol industry is a stakeholder and can help
reduce harm in its role as producer and retailer.
However, the industry seeks a role in areas that
go beyond its responsibilities and in which it has
no expertise. It promotes partnerships because
this allows it to influence policy in ways that favour
business interests.
The most effective strategies involve the

reduction of alcohol consumption at the
population level.
A senior Diageo spokesperson

said recently, We need to tackle alcohol harm but
population approaches dont work.
In Scotland, the industry was enthusiastic about

partnership working that resulted in responsible
drinking campaigns. When the Scottish
government signalled its intention to introduce
minimum pricing legislation, the industry
immediately launched a campaign against the
measure, calling on the government to drop
minimum pricing and work in partnership with
the industry. Unable to prevent the legislation,
the industry followed in the footsteps of the
tobacco industry and mounted a legal challenge.
Marcus Grant says the industry cannot
increase taxation or limit availability because
these are government actions. But that doesnt
stop it lobbying against these measures.
In reality, what partnership working means for

the alcohol industry is steering discussion away
from effective measures like controls on price
and availability and ensuring that governments
adopt less effective measures.
If the alcohol industry is serious about reducing
harm, it should stop lobbying against the most
effective measures. It is entirely reasonable for
the public health community to insist on this as a
precondition for any partnership working.
Evelyn Gillan chief executive, Alcohol Focus
Scotland, Glasgow G1 lLW, UK
evelyn.gillan@alcohol-focus-scotland.org.uk
DOCTORS AND THE ALCOHOL INDUSTRY
WHOs response to article
WHO agrees with many, but not all, points made
in the BMJ articles on the alcohol industry.

References to the WHO Global Strategy to Reduce
the Harmful Use of Alcohol require clarification,
particularly claims that industry is simply doing
what WHO asked for in the strategy. Not so.
The strategy, which was unanimously
endorsed by WHO member states in ,
restricts the actions of economic operators
in alcohol production and trade to their core
roles as developers, producers, distributors,
marketers, and sellers of alcohol. It stipulates
that member states have a primary responsibility
for formulating, implementing, monitoring, and
evaluating public policies to reduce harmful use
of alcohol. The development of alcohol policies
is the sole prerogative of national authorities. In
WHOs view, the alcohol industry has no role in
formulating policies, which must be protected
from distortion by commercial or vested interests.
WHO is grateful to the many researchers and
civil society organisations that carefully watch
over the behaviour of the alcohol industry. This
behaviour includes direct industry drafting of
national alcohol policies, or drafting through the
International Center for Alcohol Policies, other
entities, or public health consultants, which
it funds. As recent reports document, some of
the most effective policy options to reduce the
harmful use of alcohol, as defined by WHO, are
absent in these policies.
WHO appreciates the Global Alcohol Policy

Alliances statement of concern and has invited
author representatives to meet senior WHO
management to explore the concerns in detail.
Conflicts of interest are an inherent risk in any
relationship between a public health agency
and industry; conflict of interest safeguards
are in place at WHO and have recently been
strengthened. WHO intends to use these
safeguards stringently in its interactions with the
alcohol industry.
Margaret Chan director-general, World Health
Organization, 1l11 Geneva l7, Switzerland
chanm@who.int
1 Gornall J. Doctors and the alcohol industry: an unhealthy mix?
BMJ lu1!;!/6:f1339. (l April.)
l Groves T. Promises, promises [Editors Choice]. BMJ
lu1!;!/6:fl11/. (! April.)
! Bakke O, Endal D. Alcohol policies out of context: drinks
industry supplanting government role in alcohol policies in
sub-Saharan Africa. Addiction lu1u;1u':ll-3.
/ Jernigan DH. Global alcohol producers, science, and policy:
the case of the International Center for Alcohol Policies. Am J
Public Health lu1l;1ul:3u-9.
Industrys reply to WHO
We are disappointed by Chans negative
reaction to the commitments of leading beer,
wine, and spirits producers, which are a sincere
contribution to reducing harmful use of alcohol
(previous letter). The commitments were
developed in response to WHO, and Chan
personally, encouraging the alcohol industry to
do more in this area.
We agree that national authorities are primarily
responsible for developing their alcohol policies.
In our experience, however, many governments
do not agree with WHOs view that the private
sector has no role in policy formulation
governments often invite private companies
from many sectors to contribute their views and
expertise to this process.
It is increasingly recognised that the
involvement and mobilisation of a range of
actors, including the private sector, is needed to
tackle serious societal problems effectively. The
World Bank recently acknowledged this, saying
that non-communicable disease risk factors
can rarely be modified through policies and
interventions within the health sector alone.
Rather, prevention measures that address these
risk factors typically embrace a range of different
sectors . . . along with civil society and the private
sector.
We welcome constructive debate on the most

effective policies to reduce harmful alcohol use
and believe in the merit of including a range of
stakeholders in discussions. Groups such as
the Global Alcohol Policy Alliance, which seek to
exclude those with views different from their own,
do a disservice to the serious work of tackling
harmful drinking worldwide, and we encourage
them to adopt a more inclusive approach.
Mark R Leverton director general, Global Alcohol
Producers Group, London SW3 1RL, UK
mark.leverton@gapg.org
P
A
22 BMJ | 4 MAY 2013 | VOLUME 346
LETTERS
1 Gornall J. Doctors and the alcohol industry: an unhealthy mix?
BMJ lu1!;!/6:f1SS9. (l April.)
l Babor T, Robaina K. Public health, academic medicine, and the
alcohol industrys corporate social responsibility activities. Am J
Public Health lu1!;1u!:lu6-1/.
! Babor T, Caetano R, Casswell S, Edwards G, Giestrecht N,
Graham K, et al. Alcohol: no ordinary commodity: research and
public policy. lnd ed. Oxford University Press, lu1u.
/ Parsons R. Q&A with Diageos global CMO Andy Fennell.
Marketing Week lu1!. www.marketingweek.co.uk/news/
qa-with-diageos-global-cmo-andy-fennell//uu'99l.article.
' Jernigan DH. Global alcohol producers, science and policy: the
case of the International Center for Alcohol Policy. Am J Public
Health lu1l;1ul:Su-9.
CLARITHROMYCINS ADVERSE EFFECTS
Reconsider in rhinosinusitis?
Schembri and colleagues found an increased
risk of cardiovascular events and acute coronary
syndromes with the use of clarithromycin in
patients with acute exacerbations of chronic
obstructive pulmonary disease.
Although the
length of treatment correlated with the increase
in risk, the dose of clarithromycin was not
mentioned, only the duration of treatment.
Chronic rhinosinusitis is one of the most
prevalent otolaryngological conditions in the UK,
affecting an estimated .% of the population.

European guidelines on the management of
chronic rhinosinusitis without nasal polyps
recommend, among other drugs, low dose
macrolides for weeks.
This recommendation is based on one

randomised controlled trial where symptom
scores and endoscopic appearances were
significantly improved in patients receiving
low dose daily roxithromycin for three months
compared with those given placebo.
However, a
more recent trial using azithromycin in a similar
number of patients recalcitrant to standard
treatment found no evidence of benefit.
It may therefore be prudent to reconsider the

guidelines on prescription of clarithromycin for
chronic rhinosinusitis, especially in patients
who have concurrent lower respiratory and
cardiovascular disease, until a retrospective
review of patients is performed.
As we change to clinical commissioning
group financing, it is imperative that indications
for the use of long term macrolides in chronic
rhinosinusitis are robust. We suggest avoiding
the use of clarithromycin for this disease in
primary care until endoscopic and radiological
investigations are performed.
Nicholas E Gibbins consultant otolaryngologist,
nicholas.gibbins@nhs.net
Chris Theokli specialist registrar in otolaryngology,
University Hospital Lewisham, London SE1! 6LH, UK
Claire Hopkins consultant otolaryngologist, Guys and St
Thomas Hospitals NHS Trust, London SE1 9RT,UK
1 Schembri S, Williamson PA, Short PM, Singanayagam A, Akram
A, Taylor J, et al. Cardiovascular events after clarithromycin use
in lower respiratory tract infections: analysis of two prospective
cohort studies. BMJ lu1!;!/6:f1l!'. (ll March.)
l Jarvis D, Newson R, Lotvall J, Hastan D, Tomassen P, Keil T, et al.
Asthma in adults and its association with chronic rhinosinusitis:
the GAlLEN survey in Europe. Allergy lu1l;67:91-S
! Fokkens WJ, Lund VJ, Mullol J, Bachert C, Bachert C, Alobid I, et
al. European position paper on rhinosinusitis and nasal polyps.
Rhinology Suppl lu1l;l!;1-l9S.
/ Wallwork B, Colman W, Mackay-Sim A, Greiff L, Cervin A. A
double-blind, randomized, placebo-controlled trial of macrolide
in the treatment of chronic rhinosinusitis. Laryngoscope
luu6;116:1S9-9!.
' Viedeler WJ, Badia L, Harvey RJ. Lack of effectiveness of long-
term clarithromycin in chronic rhinosinusitis: a randomized
controlled trial. Allergy lu11;66:1/'7-6S.
PATIENT REPORTED OUTCOME MEASURES
More harm than good?
Black points out that patient reported outcome
measures (PROMs) were developed for use in
research and subsequently adopted to support
clinical management.
I have advocated the

use of these measures in Child and Adolescent
Mental Health Services (CAMHS) for the past
decade (www.corc.uk.net). However, I have
become increasingly worried that unless the
tension between the two aims of data collection
(informing generalisable findings v informing
individual care) is resolved, widespread
mandatory implementation of PROMs may harm
rather than help individual patient care.
The NHS is currently rolling out a new form of
monitoring with the use of PROMs, but without
training people in the use of these data in
individual patients. Clinicians do not know the
answers to key questions, including how best to
safely interpret and report the data, how often to
use these data in clinical practice, and when not
to use them.
Although PROMs may have a role in clinical

practice to help enhance collaborative working,

this needs careful support and training, and
recognition that we are in the early stage of our
knowledge about appropriate clinical use.

The situation is not helped by trusts imposing
measures without adequate input from clinicians
and patients on the usefulness of these
measures, the lack of appropriate information
technology infrastructure, or the inappropriate
use of PROMs data as stand alone measures of
performance.
Unless we develop the evidence base on how
to use PROMs in direct clinical work they may
continue to be just one more bureaucratic burden
and may end up doing more harm than good.
Miranda Wolpert Director, CAMHS Evidence Based
Practice Unit (EBPU), Anna Freud Centre and
University College London, London NW! 'SD, UK
miranda.wolpert@annafreud.org
Competing interests: MW is a founding member and paid
director (one day a week) of the CAMHS Outcomes Research
Consortium (CORC), a not-for-proht learning collaboration
committed to using PROMs to inform service development.
She has developed with colleagues a training package in
the clinical use of PROMsUsing Patient Reported Outcome
Measures to Improve Service Electiveness (UPROMISE).
1 Black N. Patient reported outcome measures could help
transform healthcare. BMJ lu1!;!/6:f167. (lS January.)
l Glasziou P, Irwig L, Aronson JK. Evidence-based medical
monitoring: from principles to practice. Blackwell, luuS.
! Wolpert M, Fugard AJB, Deighton J, Grzig A. Routine
outcomes monitoring as part of children and young peoples
improving access to psychological therapies (CYP IAPT)
improving care or unhelpful burden? Child Adolesc Ment
Health lu1l;17:1l9-!u.
/ Freely available training materials and emergent thinking
on use of outcome measures and data in context of child
and adolescent mental health provided by EBPU. UCL.
www.ucl.ac.uk/clinical-psychology/EBPU/presentations/
presentations.php.
HEALTH AND SOCIAL CARE ACT
Training in the brave new NHS
Having recently been on a course entitled How
does the NHS work . . . quick before it changes
again (yes, really), I am worried about the impact
of the latest changes on doctors training and
doctors and medical students ignorance of how
the NHS works.
Will commissioning bodies have an obligation

for medical training or will this come down
to providers? How will this work for private
companies competing for tender? What about the
impact of moving routine surgical cases out of
NHS hospitals on surgical trainees exposure to
different conditions? Where do our deaneries fit
into this?
The latest version of the General Medical
Councils Best Medical Practice reminds us to
check our privacy settings; shouldnt there also
be a section dealing with the need for doctors to
understand the system within which they work?
Is it not rather late to consider this only when
consultant interviews are approaching?
The BMA champions junior doctors as agents
for change. To maintain training high on the
agenda, I think that we need to be more involved
in the changes. We must consider generations
of doctors yet to come, how their training will be
influenced, and ultimately what kind of service
they will be providing. We risk missing the
opportunity to shape future healthcare.
Abigail T Clark-Morgan orthopaedic registrar,
Salisbury District Hospital, Salisbury SPl SBJ, UK
abigailclarkmorgan@gmail.com
1 Edwards N. Implementation of the Health and Social Care Act.
BMJ lu1!;!/6:flu9u. (! April.)
BMJ | 4 MAY 2013 | VOLUME 346 23
OBSERVATIONS
A recent study from the University
of Leuven bemoaned the lack of
regulation of research integrity in
European countries.
1
Twelve countries
had no guidelines, it found, and even
when guidelines existed they were
often hard to locate or inconsistent. A
map categorising countries by how they
handled misconduct neatly illustrated
the confusion. Along with Germany
and Sweden, the United Kingdom
fell into the second best category:
countries with a national framework.
Only Denmark and Norway were in the
top category of countries that had a
framework established by law.
There is clearly no room for
complacency in Europe, but can we
at least take comfort from the fact
that the UK is doing better than some
other countries? Before we start
congratulating ourselves, we should
remember that the so called national
framework in the UK actually consists
of a voluntary agreement that doesnt
cover all funders and has no central
mechanism or funding for enforcement.
Along with many others I welcomed
Universities UKs publication of
the Concordat to Support Research
Integrity in July 2u12.
2

3
Its an excellent
document, but thats all it is: a piece
of paper. Its good that it has been
endorsed by many major funders, such
as the National Institute for Health
Research, the Higher Education Funding
Council for England, and the Wellcome
Trust.
/-6
Its even better that some
funders propose making adherence
to the concordat a condition of grant.
These are all positive moves, but they
hardly merit the title of a national
framework.
The concordat states that research
institutions should be responsible for
investigating misconduct, echoing
guidelines of the international
Committee on Publication Ethics
(COPE).
7

8
However, a decentralised
system, relying on individual
institutions, raises the age old
question, Who guards the guardians?
Doubtless many UK universities take
their responsibility seriously, but
anecdotal evidence indicates that
not all do.
9
Investigating misconduct
properly is an onerous responsibility,
and institutions have few incentives to
devote scant resources to such tasks.
Universities may also fear negative
publicity if research misconduct is
proved, so the temptation to cover up
is great.
Even if most UK universities handle
suspected research misconduct well,
they should be publicly accountable
and open to scrutiny. Although
confidentiality is required during an
investigation, information should be
shared when it has concluded. One
reason that COPE developed guidance
on cooperation between institutions
and journals
7
was that editors reported
difficulties in getting information from
universities.
9
Another area of concern is that
employers may be unaware of findings
of research misconduct when hiring
researchers. The UK currently has no
system for checking the credentials
of applicants except by contacting
previous employers. Anecdotal
evidence suggests that a better system
is needed. For example, Jatinder
Ahluwalia, who was found to have
fabricated data by an investigation
at University College London, had
been dismissed from the University
of Cambridge for a similar offence but
later obtained a post at the University
of East London, from which he was
subsequently dismissed.
1u

11
It is therefore excellent news
that the concordat recommends
that institutions make a high-level
statement on any formal investigations
of research misconduct that have been
undertaken . . . publicly available. This
would be wonderful, but it will probably
only happen if funders monitor it as a
condition of grant.
Looking beyond Europe, the United
States, with its Office of Research
Integrity, is often cited as an example
of strong regulation, yet even it does
not have a truly national system. With a
staff of 2/ and an annual budget of just
under $1um (6.5m), the office covers
only federally funded health research
and relies on institutions to investigate.
PUBLICATION ETHICS Elizabeth Wager
The UK should lead the way on research integrity
The United Kingdom does better than some other European countries, but there is no room for complacency
But a recent case shows the importance
of having a body that can ensure that
institutions investigate misconduct
properly. In late 2u12 the office forced
Ohio State University to reinvestigate
a case, resulting in six articles being
retracted for image manipulation,
although the initial university inquiry
had found no misconduct.
12

13
Another important role of the US
Office of Research Integrity is to provide
guidance and promote good practice
running an inquiry is no easy matter,
and institutions often need advice.
Here again the UK system looks weak:
we have the UK Research Integrity
Office (UKRIO), which does sterling
work but has no national recognition or
funding. UKRIO is a charity that relies on
donations from universities and short
term funding from the Department of
Health and employs just two people. In
2u11 the UK Research Integrity Futures
Working Group recognised the need for
a national body to lead on . . . research
integrity.
1/
The fact that UKRIO receives
over 7u cases a year from all academic
disciplines and its guidelines are used
by at least 5u UK universities also
indicate the demand for a such a body.
Given the increasingly international
scope of science, global alignment
of guidelines on research integrity is
essential.
15
Before we can seek such
a unified approach we need to set
high standards in research integrity
in the UK. I want to be proud of British
research and institutions. I want us
to be recognised as world leaders in
research and in its governance and
integrity. I would love to be able to say
that we have a properly funded national
framework for research integrity, but Im
afraid thats simply not the case.
Elizabeth Wager is a publications consultant,
Princes Risborough, UK
liz@sideview.demon.co.uk
Competing interests: EW is a member of
the UKRIO advisory board and has received
expenses to attend meetings; is in discussion
with Universities UK about funding for a
small study to investigate the concordats
implementation; and chaired COPE luu9-1l.
A version of this article originally appeared as a
blog. See http://blogs.bmj.com/bmj/
A longer version with references is on bmj.com.
Investigating
misconduct
properly is
an onerous
responsibility, and
institutions have
few incentives
to devote scant
resources to such
tasks
bmj.com
Editorial: Research
misconduct in the UK
(BMJ lu1l;!//:d3!'7)
24 BMJ | 4 MAY 2013 | VOLUME 346
OBSERVATIONS
MEDICINE AND THE MEDIA
The private clinics advertising unlicensed measles jabs
Some private clinics advertising the single measles jab to parents have upped their activity since the measles outbreak
in south Wales, even though the combined MMR vaccine is safe and effective. Margaret McCartney reports
I
n the midst of the measles outbreak in
Swansea, the Childrens Immunisation
Centre, a private company with clinics in
several UK cities, set up a temporary clinic
in the city over the weekend of 20 April; it is
still advertising availability in Swansea. Unlike
the free mass vaccination offered by Public
Health Wales, the centre oers single measles
vaccinations at E110 each.
On its website it says that the single vacci-
nation is for children whose parents had con-
cerns regarding the safety of the MMR [measles,
mumps, and rubella] vaccination oered to
them by their NHS GPs. The website goes on
to say that single vaccination is the only safe
way for MMR.
1
Under the question Does the
MMR jab cause autism? the site links to three
newspaper reports that allege a link between
autism and MMR
2-5
but not to NHS or Cochrane
review advice about safety. Beneath these links
is the line for peace of mind.
Use of the single measles vaccine comes with
potential problems. It does not have a licence
from the Medicines and Healthcare Products
Regulatory Agency (MHRA). More vaccina-
tions are needed for complete coverage than
with the combined MMR vaccine, meaning
that the default rate is likely to be higher. The
total cost of the vaccinations is several hundred
pounds. Mumps vaccine is not available singly
in the United Kingdom, meaning that the com-
plication of mumps, including the risks of male
infertility, meningitis, and deafness, are carried
by an unprotected
group, and outbreaks
have occurred in the
recent past in the UK.
6
The Chi l dren s
Immunisation Cen-
tre is not the only private clinic advertising
single vaccines in the UK. Independent Fam-
ily Healthcare oers single measles vaccines
while announcing that there is a measles
outbreak warning,
7
and Clarion Health says,
We believe that every parent should have the
right to choose what they feel is best for their
investigating the claims of the Childrens Immuni-
sation Centre which seem to suggest this. We will
act against any clinic that advertises medicines
with false and potentially misleading claims.
The MHRA explained that a doctor may use
an unlicensed medicine only when there is a
special clinical need, and this action would be
bound by the principles of good medical prac-
tice as dehned by the General Medical Council.
10

So what would such a special clinical need be?
David Elliman, spokesman for the Royal College
of Paediatrics and Child Health, told the BMJ,
There is no good medical indication to give one
or other single vaccine and never has been.
In other words, clinically there is no good
rationale behind the use of single vaccines
rather than the triple vaccine. Niall Dickson, the
chief executive of the GMC, told the BMJ, Any
doctor who makes false and misleading claims
child. To this end, we offer a comprehensive
Single Vaccination Programme as an alternative
to the MMR.
8
Another clinic, the MMR Private
Vaccination Clinic, confusingly asks customers to
sign a form to conhrm that unless my/our child
is immunised using measles, mumps and rubella
vaccines separately, I/
we will not have him/her
vaccinated with the com-
bined MMR vaccine.
9
An MHRA spokesper-
son said, We agree with
the Department of Health [for England] that the
combined MMR vaccine is the best way to protect
people from the potentially serious consequences
of measles, mumps, and rubella.
There is no evidence to show that the sin-
gle measles vaccination gives better protection
against measles than the MMR vaccine. We are
Single vaccination clinics exist
because of fear and misinformation.
This is compounded by misleading
advertising on some websites
Fear of the combined MMR vaccine, being given here, is still pushing some parents to seek alternatives
R
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bmj.com
Medicine and the Media: MMR, measles, and the South Wales Evening Post (BMJ lu1!;!/6:fl'93)
News: Government launches campaign to give MMR vaccine to a million children in England (BMJ lu1!;!/6:fl696)
News: Largest group of children alected by measles outbreak in Wales is 1u-13 year olds (BMJ lu1!;!/6:fl'/')
News: Wales sets up drop-in vaccination clinics to tackle measles outbreak (BMJ lu1!;!/6:fl/'l)
BMJ | 4 MAY 2013 | VOLUME 346 25
OBSERVATIONS
BMJ BLOG Richard Vize
An immensely delicate balance:
the challenges for CCGs
The mood among clinical commissioners
less than a month into the new system in
England is characterised by a determination
to move care out of hospitals, frustration at
legal and financial impediments to change,
and considerable confidence that they can
make a difference.
At the first conference of NHS Clinical
Commissioners (an independent group
launched by the NHS Alliance, NHS
Confederation, and National Association of
Primary Care) introspection was refreshingly
absent. While there were concerns about
workload and the risk of conflicts of interest
as commissioners invest in primary care,
the focus was on the big picture of their new
role. In particular, fears voiced by the BMA
that commissioning could lose GPs the trust
of their patients did not surface as a major
issue.
Instead, commissioners recognise that
one of their risks is a divide opening between
themselves and their member practices.
Winning GPs trust and involvement is
already proving tough. If the new emphasis
on providing care in the community and
reducing emergency hospital admissions
is not to lead to excessive GP workloads,
clinical commissioning groups (CCGs)
know they have to encourage practices to
adopt new ways of working, such as greater
collaboration, a bigger role for practice
nurses and pharmacies, and more effective
use of technology to interact with patients
and other clinicians, notably hospital
consultants.
So CCGs need to get GPs to see
advantages in the new system, feel part of
developing a new patient centred approach,
take on new work, and change the way they
run their practices. And they have to do all
this while GPs are angry about changes
to their contracts. So it was not surprising
to hear concerns among commissioners
that they risked being braver in reforming
hospitals than changing GP services.
Alongside the competition regulations,
the greatest object of loathing for CCGs is
the Payment by Results system. At the NHS
Clinical Commissioners conference they
left the health secretary, Jeremy Hunt, in no
doubt that as long as the system continued,
trusts would have an incentive to game
the system and be uncooperative with
commissioners. Hunt agreed that it was a
barrier to integrating care. NHS England is
reviewing the funding allocation system for
CCGs, but their appetite for radical change is
far from clear.
The determination among
commissioners to move care out of
hospitals is palpable, but for some CCGs
building a meaningful picture of existing
services is being severely hampered by
inadequate financial and clinical data. It
is impossible to plan change if you dont
trust the numbers. As well as increasing the
danger of service failures, data weaknesses
stand in the way of beginning a discussion
with local people and trusts about what
needs to change.
One thing that needs to change is
the attitude of NHS England. There are
already numerous examples from around
the country of demands for data without
offering a reason, instructions to attend
meetings at short notice, and a general
lack of recognition that the hierarchical
relationship that existed between the centre
and primary care trusts is supposed to have
been replaced by a more balanced and
mutually respectful approach. NHS England
is going to build up resentment if that sort
of behaviour continues. GPs will quickly
express their dissatisfaction if the promise
of local autonomy lacks substance.
The need to engage with the public
and local MPs and councillors early and
relentlessly is almost universally recognised.
Some commissioners detect a subtle change
in public perceptions about the NHS in the
wake of the Mid Staffordshire scandal. There
is anecdotal evidence of greater sensitivity
to questions around quality and safety and
somewhat less willingness to assume that
everything is perfect in their local hospital.
Such a change would of course be helpful
to commissioners as they try to generate
discussion around the future of local
services, but it must not tip into undermining
confidence as a means to secure change
an immensely delicate balance.
Richard Vize is a journalist and communications
consultant specialising in health and local
government. He was the editor of the Health
Service Journal from to .
Read this blog in full and other blogs at
bmj.com/blogs.
about the treatments or services they provide
should be in no doubt that they are putting
their registration at risk. We are unequivocal
on thiswhen advertising services, doctors
must always make sure the information they
publish is factual, can be checked, and does
not exploit their patients vulnerability or lack
of medical knowledge.
In addition, when it comes to unlicensed
medications, he said that it must be in the
patients best interest, and the doctor must
be satished that there is sumcient evidence to
show that it is safe and eective.
Meanwhile, the Childrens Immunisation
Centre says on its website, All our thousands
of patients are healthy, with no autism, no
hospitalizations or hts (anaphylaxis shock),
no febrile convulsions. We have a 100% Safety
Record and have given over 70 000 vaccina-
tions (over 18 000 patients).
11
In support of this claim Fiona Dickson,
the centres director, told the BMJ that the
centre would know if any of its patients later
had a diagnosis of autism because parents
are spending E600 on vaccinesthey would
sue us if they did. She was unable to cite any
audit or follow-up study that the clinics had
done to support the claim, saying that they
relied on parents to tell them of any diagnoses
aher vaccination.
In September 2012 the MHRA upheld a
complaint about the Childrens Immunisation
Centres advertising when its website pub-
lished an unbalanced view of the safety and
emcacy of an unlicensed mumps vaccine. Its
website was subsequently amended.
12
Additionally, the MHRA told the Breakspear
Medical Group and Clarion Health to amend
their advertising when it was found to be mis-
leading or incomplete.
13 14
The BabyJabs clinic,
based in London, had three complaints against
it upheld by the Advertising Standards Author-
ity in 2012 aher it falsely claimed that the MMR
vaccine could be causing autism in up to 10%
of autistic children in the UK.
15
Single vaccination clinics exist because of
fear and misinformation. This is compounded
by misleading advertising on some websites.
Their argument is that single vaccines oer
a valid choice to parents who are concerned
about the triple vaccine. Yet the ethics of using
an unlicensed and expensive product that
leaves gaps in vaccination coverage, when an
evidence based and licensed one is available,
should require the GMC to investigate now.
Margaret McCartney is a general practitioner, Glasgow
margaret@margaretmccartney.com
OEDITORIALS, p 7
26 BMJ | 4 MAY 2013 | VOLUME 346
PERSONAL VIEW
No doctor should
be untouchable
Even very senior doctors must be
subject to the same codes of conduct,
and to the same sanctions when
they are breached, says seasoned
whistleblower Peter Wilmshurst
A
llegations that Jimmy Savile
sexually abused children and
vulnerable hospital patients
surfaced aher his death, when
he was no longer protected by
the English defamation laws. These laws
were designed to protect the wealthy and
famous from allegations by poorer citizens by
making it dimcult and expensive to defend a
defamation claim, even if you are telling the
truth. Should we blame the cover-up entirely
on the libel laws?
There were those in authority at the BBC
(where Savile had star status), in hospitals
where he had unprecedented access, and in
the criminal justice system who had heard
reports of his misconduct but failed to act.
Victims were told that their testimony would
count for little compared with the word of
the television star and charity fundraiser.
Savile was valuable to the organisations and
his victims were not. Savile himself bragged
that he was untouchable. Other organisations
that have covered up misconduct include
the Catholic church over child abuse by
priests, and the South Yorkshire Police over
their failings at the Hillsborough disaster.
Organisations protect their members, and
senior members are, like Savile, ohen
powerful and untouchable.
I believe, based on observation of the
outcomes in several cases in which I have
been involved, that the medical establishment
is no dierent, with senior doctors being
untouchable. Indeed, once, when I raised
concerns at a meeting at the Department of
Health about a senior doctor, I was even told
that he was untouchable. I know that over
many years the General Medical Council had
refused three times to investigate allegations
about him from other doctors (not from me).
On 23 November 2012, the Department of
Health wrote to me that the current chief
medical omcer is unable to discuss the issue
with me due to pressure on her time. Refusal
to hear allegations will allow later denial of
knowledge of them.
The GMC investigates serious allegations
about doctors, but in my experience it will
ohen refuse to investigate the most senior
doctors.
I reported Clive Handler to the GMC for
hnancial misconduct. When he appeared
before the professional conduct committee,
the chairman of the committee, Peter Richards,
had to stand down from the hearing because,
in his role as medical director of Handlers
hospital, Richards had agreed to conceal
Handlers misconduct from the GMC.
1

2
The
GMC refused requests from its own solicitors
and from me to take action against Richards,
who had clearly broken the GMCs rules
on reporting misconduct by other doctors.
Richards, who held many senior positions,
including chairman of the Council of Deans of
UK Medical Schools and Faculties, returned to
chair hearings at the GMC aher Handler was
suspended from the medical register.
Senior managers at the Royal Brompton
Hospital knew that over many years Professor
Peter Collins had used qualihcations he had
not been awarded.
1

2
They knew that he had
obtained three posts using false qualihcations
and that he put them on his letters. The
whistleblower was informed by letter from
the chairman of the board of governors that
unless he dropped the matter his career might
suer. I reported Collins to the GMC. The
GMC informed me that no public hearing was
required because it had accepted a private
assurance from Collins that he would not use
false qualihcations again. In the few years
before and aher the GMCs decision on Collins,
seven more junior doctors faced public
hearings for claiming qualihcations they
had not been awarded. Six (Rashid Rhalife-
Rahme, Seth Atardo, Ashoka Prasad, Afolabi
Ogunlesi, Abu Shah, and Ashutosh Jain) were
removed from the medical register and one
(Sahmin Pandor) received a reprimand.
2
They
diered from Collins (educated at Cambridge
and St Thomas) in many respects, including
the fact that most had only once claimed
qualihcations they had not been awarded.
The GMC does not allow a doctor to
voluntarily remove his or her name from the
medical register when he or she is under
investigation. However, twice, when I reported
heads of medical institutions to the GMC for
concealing research misconduct within their
institutions, the GMC informed me that, as a
result of administrative errors, each had been
allowed to remove their names voluntarily, so
the GMC could not investigate my allegations.
Despite legislation meant to protect
whistleblowers, I am aware that an NHS trust
and a health authority spent more than E2.5m
in legal fees before getting a whistleblower
(a junior doctor) to accept a legal settlement
that included a gagging clause preventing the
whistleblower from revealing illegal activity
by a senior doctor. A deanery was complicit in
the victimisation of the trainee. Allowing for
additional management time and the hnancial
settlement with the doctor, the protection of
this senior doctor probably cost the NHS more
than E5m.
If we are genuinely going to put patients
hrst, then nobody, no matter how senior
they are, can be untouchable. However, this
will only happen when we have a cultural
change in healthcare, with promotion
of real openness and real protection for
whistleblowers, together with reform of the
English libel laws to provide a genuine public
interest defence.
Peter Wilmshurst is an honorary consultant cardiologist,
University Hospital of North Staffordshire, Stoke on Trent
peter.wilmshurst@tiscali.co.uk
Competing interests: I have defended three libel claims
brought by a US medical device company, and I have reported
several doctors to the GMC.
An NHS trust and a health authority
spent more than 2.5m in legal fees
before getting a whistleblowing doctor
to accept a gagging clause preventing
the whistleblower from revealing illegal
activity by a senior doctor
J
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BMJ | 4 MAY 2013 | VOLUME 346 27
PERSONAL VIEW
Caring for patients with dementia: an exceptional case
Specialist wards for patients with dementia can benefit patients, carers, and staff, says Kate Sartain
R
owan Williams, former archbishop of
Canterbury, said in his last speech to the
House of Lords in December 2012, Old
people are too often treated with con-
tempt and exasperation . . . too ohen we
want older citizens to accept a marginal and humil-
iating status, tolerated but not valued, while we
look impatiently . . . for them to be o our hands.
In September 2011 it became obvious that
Dad was developing dementia. Mum had died six
months before. Her dementia was diagnosed in
2006, aher years of us not quite realising what we
were dealing with. The second time round it was
easier to detect.
During the years when Dad cared for Mum, the
government produced the national strategy Living
Well with Dementia. Local strategic health authori-
ties ran workshops where medical professionals,
social workers, commissioners, and providers
met with service users and carers to determine
how best to deliver care for people with dementia.
People were encouraged to tell their stories of living
with dementia. I attended as a carer.
A picture emerged that caring for people with
dementia is a highly skilled job in very short supply.
One consultant commented that living well was
impossible. Through tears, elderly carers spoke in
desperation about isolation and exhaustion cop-
ing with a spouse whose character changed from
minute to minute. A woman with dementia shared
fears of losing her capacity and identity.
People with dementia hnd change particularly
challenging, so stories of deterioration in physical
health and hospital admissions were heartbreak-
ing. It was therefore with trepidation that I accom-
panied my very confused father to hospital one day
aher he had fallen. In the emergency department
he was treated emciently, and aher 24 hours in an
admissions unit he was moved to a ward.
What a relief. This ward had a striking sense
of order, peace, and calm professionalism. A
large sign gave the day and date and described
the weather. By each bed stood a glass-fronted
cabinet where visitors could securely place per-
sonal eects; reminding patients of something
familiar, these things gave a sense of security.
A nurse approached me,
gently explaining that Dad
had dementia and a problem
with his blood pressure. She
explained the treatment for
the physical illness but also
wanted to understand who
my dad was; what he liked and disliked; and
what I knew about dementia. Did I realise what
this really meant for him in the long term? I was
amazed that a busy ward sister had the time and
patience to deal not only with her patients but
also to assess their carers. The two words voiced
most by people who are involved with dementia
care, I found, are time and patience, and
these are in short supply. For the hrst time for
many months, I was able to relax. Dad was being
treated by people who understood the problems. I
even dared to consider that perhaps the outcomes
of the workshops were being put into practice.
During his three week admission, Dad was
treated as a whole person. The sta treated him
medically but also with compassion and respect as
a human being. And they did the same for my sister
and me. They had time to treat the family unit, not
just a confused man with wobbly blood pressure
to tick a box. When he was discharged into a care
home, Dad was at ease. It had been wonderful.
We didnt realise the true value of this experi-
ence until weeks later, however. Aher another fall,
Dad was admitted to a dierent, non-specialist
ward in the same hospital. Here, we were struck
by the reality of sta trying desperately to deliver
good care but in an atmosphere so fraught it was
exhausting. I wrote to the hospital asking why these
two experiences were so dierent. The chief execu-
tive explained that the hrst ward was funded by
research to investigate ways of
treating people with both physi-
cal and mental health problems.
This hrst, specialist ward had
found ways to understand and
put into place care that bene-
hts patients, sta, and carers.
Maybe it was the provision of an activities room,
a place of stimulation, where patients are oered
a variety of recreations. I was comforted by the
time and space I was given to hnd a new home
for Dad, and the discharge direct from the ward to
the new home with Dad accompanied by a face
he had become accustomed to eased that change
enormously. Whatever, throughout Dads stay, sta
oered that something, which all the workshop
storytellers were seeking for their loved ones, and
for themselves. This something is intangible,
p ossibly unmeasurable, but is immeasurable.
Dad did fall again, his health deteriorated, and,
at 92 years old, he had multiple physical problems.
The time he spent on the specialist ward was an
excellent experience during which we were able
to calm down and come to terms with what the
future meant, and we were prepared for what we
all knew would be a gradual decline. Patients with
dementia are not going to get better, but they can
be enabled to be ill with dignity. The research ward
made huge progress in dehning how to deliver
excellent care. Carers became part of the whole
package. Hospital sta can deliver patient centred
care and leave their shihs fulhlled and satished.
If we are to develop good practice so that
patients can live well with dementia, experiences
such as ours must be celebrated and disseminated,
sooner rather than later. We learnt that care of
ill older people with dementia is dimcult, time
consuming, and skilled. But it is not impossible.
Hospital care can be inspiring.
Kate Sartain is a carer, Southwell, Nottinghamshire
Acknowledgment: I thank Margaret Kerr, my sister.
Since writing this article I have become a volunteer in dementia
care with the University of Nottingham Public and Patient
Involvement Group at the Queens Medical Centre Nottingham.
I was amazed that a busy
ward sister had the time
and patience to deal not
only with her patients but
also to assess their carers
bmj.com Clinical Review: Dementia (BMJ 2009;338:b75)
F
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A

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Each patient on the ward had a glass-fronted cabinet to display familiar objects, giving a sense of security
28 BMJ | 4 MAY 2013 | VOLUME 346
OBITUARIES
Thomas Dormandy
Chemical pathologist who studied free radicals and wrote an acclaimed book on tuberculosis
if he had just operated on someone he would be up
half the night worrying about them and go and see
their relatives.
Dormandy wrote leaders for the Lancet in the
1950s and 60s and continued writing clinical
papers, the last of which was published in 2010.
But it was not until his retirement that he was able
to give full rein to his writing. He wanted to write
a book on talent in old age, as displayed by art-
ists such as Michelangelo, Goya, and Monet, all
of whom did major work in their 70s.
However, publishers were not interested at
hrst, so he wrote The White Death: A History of
Tuberculosis (1999) instead, which considers
the diseases social, artistic, and human impact
and which reviewers acclaimed. A review in the
Spectator said it could well be the dehnitive his-
tory of tuberculosis and described Dormandys
ashes of wit and impressive intellectual ver-
satility which is forever spilling over into a stream
of erudite and entertaining footnotes.
2
The writer
Peter Ackroyd described it as a model of how
medical history ought to be written, lucid in its
analysis and perspicacious in its commentary.
3

This erudition didnt surprise colleagues or
family. Dormandy was a real polymath and intel-
lectual, who was also a talented painter, and
would give lectures without the aid of slides but
with the aid of a steady stream of cigarettes.
Aher the critical success of his book on tuber-
culosis he got a publishing deal for his original
literary baby, Old Masters: Great Artists in Old
Age (2000). More books fol-
lowed: Moments of Truth: Four
Creators of Modern Medicine
(2003) and The Worst of Evils:
the Fight against Pain (2006).
His final book was pub-
lished last year, Opium: Real-
itys Dark Dream, and he was
working on a short history of medicine when he
died. His book on opium harked back to his The
White Death as it covered society and culture as
well as disease.
A Daily Telegraph reviewer wrote: Thomas
Dormandy has written an unrhapsodic, sceptical,
vividly documented history of the drug. He has an
eye for quotation . . . and a man of the world tone,
dry, witty, not easily impressed.
4
He leaves his wife, Elizabeth, a public health
specialist; two sons; and two daughters.
Anne Gulland freelance journalist, London
annecgulland@yahoo.co.uk
Thomas Dormandy was the newly appointed
consultant chemical pathologist at the Whit-
tington Hospital in north London when he hrst
started to work on the study of free radicals.
These had been recognised by chemists work-
ing in industrial research, but it was not until
the 1960s that their role in biology or clinical
medicine was acknowledged.
Dormandys research was focused mainly
on the study of trace metals in health when he
began to look at the link with free radicals. He
appointed a postgraduate biochemist, and they
undertook a clinical study on red blood cells
taken from patients with blood disorders in
which cells broke down.
1

When these red blood cells were incubated
with hydrogen, peroxide free radicals spontane-
ously formed. The potential damaging eect of
free radicals is limited by the presence of anti-
oxidants, and Dormandy studied the dierent
antioxidants present in normal human plasma.
Professor Malcolm Jackson, head of the Insti-
tute of Ageing and Chronic Disease at Liverpool
University, undertook collaborative work with
Dormandy, examining the potential role of sele-
nium in skeletal muscle disorders. He says that
Dormandys role was important as he was one of
the hrst people in the early days of research into
free radicals who recognised their potential role
in medicine. The fact he was working in the NHS
was important as he had access to clinical sam-
ples, and he was one of the hrst to look for evi-
dence in samples. There was an assumption that
free radicals had to be damaging, and Tom was
one of the people active in the early days to under-
stand the role of anti oxidants, says Jackson.
Dormandy became president of the Society for
Free Radical Research and was recognised inter-
nationally for his work. Professor Joseph Lunec,
a biochemist whose PhD was supervised by
Dormandy, describes him as a father hgure
on the subject. Tom had this hypothesis that
free radicals were mediators for many diseases,
although that may be overegging the pudding a
bit. I myself have spent the past 25 years work-
ing on free radicals, and there are many others
who are now professors and who were my PhD
students. And thats quite a legacy, he says.
Dormandy carried out research into how
changes in the joints of people with rheuma-
toid arthritis were caused by free radicals and
changed the way people thought about how the
disease came about, says Lunec. He also devel-
oped an interest in reperfusion injuries, when
the blood supply returns to the tissues aher it
has been restricted. During reperfusion a large
amount of free radicals are generated, and Dor-
mandy worked on ways of studying this.
1
Dormandy was born in Budapest, Hungary, in
1926. With his younger brother and sister and his
parents he went into hiding when the Germans
occupied Hungary in 1944 as
the family had a Jewish back-
ground. When the Russians
arrived the family went to Cluj
(now in Romania but at the
time in Hungary) and then to
Geneva and Paris before set-
tling in London in 1948.
Dormandy sat his medical examinations once
in Cluj, again in French in Geneva, and, for a
third time, in English at the Royal Free Hospital
in Hampstead, where he met his wife Katharine.
She became a haematologist but died of breast
cancer at the age of 52; the Katharine Dormandy
Haemophilia Centre and Thrombosis Unit at the
Royal Free was named aher her. They had three
children together, one of whom died from cancer
at the age of 22.
Dormandy trained at Guys Hospital and the
Middlesex and started a career in surgery, although
his younger brother, John, who went on to become
a surgeon, said that he found it too much of a
strain: He got very involved with his patients, and
Dormandy was a real
polymath and intellectual
who would give lectures
without the aid of slides
but with the aid of a steady
stream of cigarettes
Thomas Louis Dormandy, consultant
chemical pathologist (b ; q Society of
Apothecaries of London ), died from
respiratory failure on February .
BMJ | 4 MAY 2013 | VOLUME 346 29
OBITUARIES
Carl Ludwig Scholtz trained in
pathology in Sydney and
Manchester. At the London
Hospital, he ran a service worthy of
a prestigious department, gained a
PhD, and made many contributions
to neuropathology and its literature.
He was diagnosed as having motor
neurone disease in 19S9 and
returned to Australia in 199l, with a
wheelchair and voice synthesizer (to
crack jokes with my children again).
Family, several caring organisations,
and his own spirit shown in his
poetry sustained him through
increasing paralysis. He leaves
his wife, Geraldine, and two children.
Anne Marshall
Julian Stanley
Martyn Toms
Former general practitioner
(b 1946; q Cambridge 1970;
MA (Cantab), FRCP, FRCGP, DCH,
DRCOG), died from glioblastoma
on 3 January 2013.
Julian Stanley Martyn Toms
took his first GP post in the
singlehanded practice at Muasdale
in Kintyre, where he worked for
eight years. However, to the
disappointment of the practice
population, he then re-entered
hospital medicine, working in
neurology in Dundee and
obtaining his MRCP. Subsequently,
he moved to join the Portree
medical practice and community
hospital team on the Isle of Skye in
19S/, where he was integral to the
development of new premises
and the enlargement of the practice.
After retiring in luu6 he did
much out of hours and GP locum
work, but he also increased his
active commitment to community
works. He leaves his wife,
Christine; four daughters; and four
grandchildren.
Charles L Crichton
James Reginald Searle
Barton
Ophthalmic surgeon Taunton
(b 1924; q 1965; FRCS Edin),
d 16 November 2012.
When newly qualified as a
consultant ophthalmic surgeon,
James Reginald Searle Barton
(Jim) moved his family from
Manchester to rural Somerset.
During Jims career, intracapsular
cataract surgery to place intraocular
lenses came into common use,
which improved patient outcomes.
Jim had on his appointment
introduced the Amoils cryoprobe
(used in the cryoextraction method
of cataract surgery) to Taunton
after its development in 196l;
he continued with intracapsular
surgery, using anterior chamber
intraocular lenses as these
became mainstream in the
19Sus. His wife, Sheila (Flick),
predeceased him in 199l. He left
four sons, one daughter, and 1!
grandchildren.
Andrew Barton
David James Martins
Buddery
Clinical assistant department
of oral surgery, James Paget
University Hospital, Gorleston
(b 1922; q 1945), died from
pneumonia on 23 January 2013.
David James Martins Buddery trained
at the University of Sheffield in the
early 19/us and established a
practice initially on the Cliffs
of Scratby in Norfolk and then
at Great Yarmouth. He was
subsequently appointed as clinical
assistant in Great Yarmouth and later
at the James Paget Hospital.
He was extremely successful in
treating patients with seemingly
intractable facial pain and similar
neuralgia-like symptoms. In
retirement he became voluntary
curator of the hospital museum and
was a keen amateur radio enthusiast
and Savoyard. Predeceased by his
wife, Joycelyn, in luu/, he leaves a
son, a daughter, two grandchildren,
and two brothers.
Caroline Buddery
John Denys Campling
(b 1929; q St Marys Hospital
Medical School 1953; MRCS,
FRCGP), d 9 February 2013.
John Denys Campling was the first
GP trainer in Northampton and
medical officer at the local college of
education. As county surgeon for St
John Ambulance and a Hospitaller, he
supported the St John Eye Hospital
in Jerusalem and was awarded
commander of the Order of St John
in luu7. He was a past master of the
Worshipful Company of Pewterers
and, as a parish councillor and deacon
at the local Baptist church, for many
years also school governor and active
amateur actor and director. He leaves
his wife, Angela; three children; and
four grandchildren.
Angela Campling
David Malcolm Milne
London (b 1950; q Bristol 1973),
d 21 December 2012.
David Malcolm Milnes early medical
interest was pathology, which brought
him work in Jamaica, New Zealand,
and London. Later he joined a general
practice near Heathrow, where he
also looked after guests at the airport
hotels. Subsequently he worked as an
out of hours doctor in Perth, Australia,
and later in London and Newcastle.
Ill health forced him to retire, and he
settled in Mallorca. A literary man,
he enjoyed classic authors, such
as Somerset Maugham. His great
knowledge and intimate relationship
with the fermented grape made him
a bon viveur, who was never happier
than in good company in a restaurant. A
seasoned and adventurous traveller, he
had visited 1u! countries. He leaves his
wife, Marlene; a daughter; and a sister.
John Taylor
John Joseph Smirke
Herbert Ruston
Consultant anaesthetist Royal
Free Hospital, London (b 1955; q
Royal Free Hospital, London, 1978),
d 21 January 2013.
During his first house job in Hastings,
John Joseph Smirke Herbert Ruston
developed an interest in anaesthesia
and met his wife, Mandy. He moved
to London to work at Barts and then
became a senior registrar at the Royal
Free, where he was appointed as
consultant in 199!. Calm, methodical,
and totally unflappable, he could
quickly resolve a clinical crisis. John
was extremely well informed, often
about the most surprising, diverse,
and quirky topics. He had cardiac
surgery in lu1l and seemed to
have made a full recovery. Having
returned to work, he was undertaking
a full clinical workload. He died
unexpectedly in his sleep. He leaves
Mandy and their two sons.
Richard Marks, Michael Pegg
Carl Ludwig Scholtz
Former senior lecturer in
neuropathology Royal London
Hospital (b 1939; q St Vincents
Hospital, Melbourne, 1964; MD,
PhD), died from motor neurone
disease on 4 January 2013.
30 BMJ | 4 MAY 2013 | VOLUME 346
CLINICAL REVIEW
50 progressed at an average of 1 a year, thoracolumbar
curves progressed at 0.5 a year, and lumbar curves pro-
gressed at 0.24 a year. Thoracic curvatures of less than
30 did not progress.
7
Previous long term retrospective observational studies
of idiopathic scoliosis presented a poor prognosis (respira-
tory failure, cardiovascular risk, and mortality).
8
This has
created a misinterpretation that all types of idiopathic sco-
liosis inevitably lead to disability from back pain and seri-
ous cardiopulmonary compromise. These studies included
patients with mixed diagnoses, which could explain the
poor outcomes reported. In a more recent prospective
case-control study describing the 50 year natural course of
untreated idiopathic scoliosis, there was no evidence link-
ing untreated AIS with increased rates of mortality in gen-
eral, and cardiopulmonary compromise in particular.
9
Progressive scoliosis can result in the development of a
worsening deformity and cosmesis.
10
The physical deformi-
ties seen include the development of chest wall abnormal-
ity, rib prominences, asymmetry in shoulder height, and
truncal shih.
How does adolescent idiopathic scoliosis present?
Patients with AIS most ohen present with unlevel shoul-
ders, waist line asymmetry (one hip sticking out more
than the other), or a rib prominence. This is usually hrst
identihed by the patient, family member, general practi-
tioner, or a school nurse.
Back pain is sometimes the presenting complaint. The
association between scoliosis and back pain has been dem-
onstrated in a retrospective study of 2442 patients with
idiopathic scoliosis,
11
which found that 23% of patients
with AIS had back pain at initial presentation, and another
9% developed back pain during the study. An underlying
pathological condition was identihed in 9% (48/560) of
the patients with back pain, mainly spondylolysis and
spondylolisthesis and only one case of an intraspinal
tumour.
11
How is adolescent idiopathic scoliosis diagnosed?
On presentation of a patient with scoliosis to primary care,
a detailed history, examination, and radiological investiga-
tions should be undertaken before referral to a specialist.
The history should include a detailed birth history,
developmental milestones, family history of spinal deform-
ity, and assessment of physiological maturity. Dimculties
Scoliosis is a three dimensional deformity of the spine
dehned as a lateral curvature of the spine in the coronal
plane of more than 10.
1
It can be categorised into three
major typescongenital, syndromic, and idiopathic.
Congenital scoliosis refers to spinal deformity caused by
abnormally formed vertebrae. Syndromic scoliosis is asso-
ciated with a disorder of the neuromuscular, skeletal, or
connective tissue systems; neurohbromatosis; or other
important medical condition. Idiopathic scoliosis has no
known cause and can be subdivided based on the age of
onsetinfantile idiopathic scoliosis includes patients aged
0-3 years, juvenile idiopathic scoliosis includes patients
aged 4-10 years, and adolescent idiopathic scoliosis aects
people aged >10 years.
Adolescent idiopathic scoliosis (AIS) is the most common
spinal deformity seen by primary care physicians, paedia-
tricians, and spinal surgeons.
2
This review is focused on
AIS and reviews the diagnosis, management, and contro-
versies surrounding this condition based on the available
literature.
What causes adolescent idiopathic scoliosis?
The diagnosis of AIS is one of exclusion, and is made only
when other causes of scoliosis, such as vertebral malfor-
mations, neuromuscular disorders, and other syndromes
have been ruled out. According to epidemiological studies,
1-3% of children aged 10-16 years will have some degree
of spinal curvature, although most curves will not require
surgical intervention.
3

4
Suggested causes of AIS include mechanical, metabolic,
hormonal, neuromuscular, growth, and genetic abnormali-
ties.
5

6
These factors are not yet well accepted as a direct
cause for this condition. The current view is that AIS is a
multifactorial disease with genetic predisposing factors.
What is the natural course of adolescent idiopathic
scoliosis?
The natural course of scoliosis was studied in a prospective
case series of 133 patients. The patients were followed for
an average of 40.5 years (range 31-53 years), and 68% of
adolescent idiopathic curvatures were found to progress
beyond skeletal maturity. Thoracic curvatures greater than
Spinal Surgery Unit, Royal National
Orthopaedic Hospital, Stanmore,
London HA7 /LP, UK
Correspondence to: F Altaf
farhaanaltaf@hotmail.com
doi: 1u.11!6/bmj.fl'u3
Adolescent idiopathic scoliosis
Farhaan Altaf, Alexander Gibson, Zaher Dannawi, Hilali Noordeen
SUMMARY POINTS
Scoliosis is a lateral curvature of the spine measuring > in the coronal plane
Several different types of scoliosis exist, and idiopathic scoliosis occurs in .-.% of the
paediatric population
Initial evaluation should involve a focused history and physical examination. The Adams
forward bend test is particularly useful for detection
Factors predicting curve progression include maturity (age at diagnosis, menarchal status,
and the amount of skeletal growth remaining), curve size, and position of the curve apex
Bracing is used to treat scoliosis in many European countries, but practice is divided in the
UK and US, and elsewhere
Surgery is recommended in adolescents with a curve of a Cobb angle more than -
Follow the linkfrom the
online version of this article
to obtain certied continuing
medical education credits
SOURCES AND SELECTION CRITERIA
We searched Medline and the Cochrane Library using MeSH
terms adolescent idiopathic scoliosis, and scoliosis
bracing. We included systematic reviews, randomised
controlled trials, and good quality prospective observational
studies mainly from the past years but did not exclude
seminal papers from before this time.
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BMJ | 4 MAY 2013 | VOLUME 346 31
CLINICAL REVIEW
during labour can be associated with a diagnosis of cer-
ebral palsy, which can lead to neuromuscular scoliosis. A
history of developmental delay can be indicative of a non-
idiopathic cause for the scoliosis.
Assessment of maturity includes inquiry about the
growth spurt and the menarchal status in girls, as
menarche indicates a point at which the growth starts to
decrease over a period of two years from its onset.
12
The patients presenting complaint should be elicited,
including back pain, neurological symptoms, and any con-
cerns regarding cosmesis. The presence of constant pain,
night pain, or radicular pain indicates that further investi-
gations are required to exclude underlying pathology.
13
When examining a patient with suspected scoliosis,
adequate exposure is required to assess the spine appro-
priately. Boys should be examined in their underwear or
shorts; girls should be wearing underwear and a bra. Gait
and posture should be evaluated, looking in particular for
a short-leg gait due to leg length discrepancy and listing to
one side seen in severe curves.
The patients upright posture should be evaluated from
the front, back, and sides. The relative heights of the iliac
crests and the shoulders should be observed for any asym-
metry that could be indicative of curve severity. The pelvis
should be level and any lower limb discrepancy compen-
sated with a lih (a series of wooden blocks may be placed
under the short leg until the hips are level). If a curvature of
the spine is seen, the location and direction of the curve(s)
should be noted. The curve is designated according to the
direction of the curve convexity.
The back should be inspected for the presence of cafe
au lait spots, subcutaneous nodules, and axillary freck-
les, which are seen in neurohbromatosis. The presence of
hairy patches or skin dimples over the lower back can be
an underlying sign of spinal dysraphism (a constellation
of congenital abnormalities including defects of the spinal
cord and vertebrae).
The balance of the thorax over the pelvis is assessed by
dropping a plumb line from the C7 spinous process, which
normally falls within the gluteal cleh. In cases of coronal
imbalance the distance from the plumb line to the gluteal
cleh is measured in centimetres and the direction of devia-
tion noted.
The Adams forward bend test
14
is carried out to assess
the degree of rotational deformity associated with the sco-
liosis. The patient is asked to bend forward at the waist
with the knees straight and the palms together (hg 1). The
examiner looks down the back for the presence of asymme-
try in the rib cage (rib prominence) or deformities along the
back indicative of a structural scoliosis. A non-structural
curve (postural scoliosis) normally disappears on bending
forwards.
A scoliometer is an instrument that is placed on the back
and can be used to provide an objective measure of curve
rotation.
15
In primary care the use of a scoliometer is not
required for the diagnosis of scoliosis, and suspected cases
should be referred for specialist opinion on diagnosis.
A detailed neurological examination should be per-
formed testing motor and sensory function and reexes.
Asymmetries in reexes can be a sign of an intraspinal
disorder.
16
The abdominal reex refers to the neurologi-
cal reex stimulated by stroking the abdomen around
the umbilicus. This usually involves a contraction of the
abdominal muscles, resulting in the umbilicus mov-
ing towards the source of the stimulation. An abnormal
abdominal reex may be suggestive of an intraspinal disor-
der and is ohen absent on the convex side of the curve.
What imaging is required?
Full length standing posteroanterior and lateral radio-
graphs of the spine are required in order to assess the
degree of deformity. These are taken with the patient in
a standing position in order to assess the eect of gravity
on the deformity. Patients are instructed to remove their
shoes, and any lower limb discrepancy is compensated
with a shoe lift before the radiograph is taken. Radio-
graphs are taken with the patient looking straight ahead,
legs apart for stability and with their hands on clavicles.
If a radiograph is normal the patient and family can be
reassured that there is no scoliosis. A referral can still be
made if there is concern about pain, axial tenderness, or
neurological abnormalities. If x ray facilities are not avail-
able, the patient may be referred directly to the specialist
without radiographs.
On a full length posteroanterior plain radiograph, the
magnitude of a scoliosis curvature is determined with the
Cobb technique (hg 2). Firstly, it is important to identify
the superior and the inferior end vertebraethe vertebrae
with the greatest tilt at the proximal and distal ends of the
curve. The angle between them is measured by drawing
a line from the top of the superior end vertebra parallel
to the upper endplate, and another line from the bottom
Fig | The Adams forward
bend test performed by (left)
a patient without scoliosis,
and (right) a patient with
scoliosis showing a rib
prominence
a
b
Fig | Cobb technique
for determining size of a
scoliosis curvature. On a
posteroanterior view of the
spine, tangents (dashed-
dotted lines) are drawn along
the superior endplate of the
superior end vertebra and
the inferior endplate of the
inferior end vertebra. The
angle formed (angle a) by
the intersection of these two
lines is the Cobb angle. This is
more conveniently measured
as the angle (b) formed by
the intersection of two lines
drawn perpendicular to the
tangents. Adapted from Kim
et al
32 BMJ | 4 MAY 2013 | VOLUME 346

CLINICAL REVIEW
of the inferior end vertebra parallel to the lower endplate.
Perpendicular lines are then constructed at right angles
to the lines along the endplates. The angle formed by the
intersection of the perpendicular lines dehnes the Cobb
angle (hg 2).
If surgery is considered, hlms of lateral bending view
(full length posteroanterior plain radiographs with patient
bending to the right and to the leh) are hrst taken to deter-
mine curve exibility, which is important in the preopera-
tive evaluation and surgical planning.
The presence of a leh thoracic curve or an abnormal
neurological hnding are most predictive of the presence
of an underlying disease and warrant referral for further
imaging.
11
Magnetic resonance imaging is useful for the
identihcation of tumours and other pathological lesions
associated neural axis abnormalities such as syrinx (a uid
hlled cavity within the spinal cord) and Arnold-Chiari
malformations.
18
What are the risk factors for curve progression?
For decisions about choosing conservative or surgical treat-
ment, the childs maturity and the severity of the curvature
are the two most important factors. It is important to evalu-
ate maturity because the younger the child the greater is
the likelihood of curve progression, equally the larger the
curve magnitude the greater is the risk of progression.
9
Scoliosis with a high risk for rapid progression must be
detected as early as possible. In a retrospective case series of
205 patients (163 girls and 42 boys) with idiopathic scolio-
sis at skeletal maturity, the surgical risk for a curve of 20 at
the onset of puberty was at 16%. This surgical risk increased
to 100% for curves 30 at the onset of puberty.
19
The table
summarises the risk factors for curve progression.
Scoliosis curve progression increases markedly at the
time of the adolescent growth spurt in idiopathic curves
and markedly slows or ceases at the time of completion
of growth.
20-22
Spinal growth is closely associated with
increase in height, but the measurement of height veloc-
ity at sequential visits is ohen associated with inaccura-
cies. Other maturity markers are therefore ohen used to
measure the growth rate. The use of these maturity markers
allows us to determine which curves are at risk of progres-
sion. This information allows the clinician to dierentiate
between curves that require careful regular monitoring and
ones that require active treatment.
The total growth spurt has a duration of about 2.5-3.0
years,
3
with the mean age for peak height velocity being
about 14 years in boys and 12 years in girls.
23
Sexual maturity can be evaluated with the Tanner grad-
ing scale,
24
which is based on the extent of development
of secondary sexual characteristics. It is important to ask
about menarche because curve progression is less common
aher its onset.
Skeletal age is a more accurate marker of maturity. The
Risser sign,
25
which refers to the appearance of the iliac
apophysis of the pelvis, can be used to determine skeletal
age. There are six Risser stages, from zero to hve, denot-
ing the course of the apophysis from the anterior to the
posterior iliac spine, and then the fusion with the iliac
bone (hg 3, see bmj.com).
23
The incidence of progression
of untreated AIS has been correlated with Risser sign and
curve magnitude.
26
For curves of 20-29 in a immature
child with a Risser sign of 0 or 1, the incidence of progres-
sion was 68%. For curves <19 in a mature adolescent
with a Risser sign of 2, the incidence of progression was
1.6%. For small curves <19 in an immature child (Risser
sign 0 or 1), and larger curves (20-29) in a mature child
(Risser sign 2), the incidence of progression was about
the same, at 22% and 23% respectively.
26
The disadvan-
tages of the Risser sign are that it correlates with skeletal
age dierently in boys and girls and it typically appears
aher the peak height velocity.
Skeletal age can also be assessed by evaluating the
development of the leh hand and wrist on a radiograph:
the bones are compared with those of a standard atlas
compiled by Greulich and Pyle.
27
Sanders found that the
scoring of the metacarpals and phalanges more closely
related to scoliosis progression than other maturity indi-
cators, including Tanner stage and Risser sign.
23
Dimeglio
et al described elbow maturation as being more precise
than hand maturation.
28
How is adolescent idiopathic scoliosis managed?
Observation for AIS is the most common approach used
for patients with mild deformity (such as a Cobb angle
measurement <25). Depending on the degree of skeletal
maturity, patients are assessed every four to six months
at a specialist clinic to watch for curve progression. The
interval of follow-up will be determined on an individual
basis, based on the age of the patient, degree of curve,
and skeletal maturity. Posteroanterior radiographs only
are taken during each follow-up visit in order to minimise
the exposure to radiation.
Bracing
Bracing in AIS is controversial, with treatment eective-
ness remaining questionable based on available evidence,
with most published studies being of low methodological
quality. The rationale for the use of braces has been that
external forces can guide the growth of the spine. Brace
treatment is not necessarily benign in terms of the psy-
chosocial and body image concerns it causes for many
patients and their families. Bracing is used for the treat-
ment of scoliosis in many centres in continental Europe,
but practice is divided in the UK and US, and elsewhere.
Advocates of bracing quote level 2 evidence based infor-
mation from prospective controlled studies
29-31
as well as
other studies with level 3 and 4 information
32-34
in sup-
port of bracing emcacy. In a meta-analysis a total of 1910
patients had non-operative treatment for idiopathic scol-
iosis, with 129 patients managed with observation only.
34

Risk factors for curve progression in adolescent idiopathic scoliosis
Risk factor Comment
Age The younger the age at diagnosis, the greater potential for curve progression at the
onset of adolescent growth spurt
Sex Progression is more common in girls
Menarche Progression is least common after menarche
Remaining skeletal growth More skeletally immature the greater risk of curve progression
Curve pattern Double curves are more likely to progress than single curves
Curve magnitude The risk of progression increases with curve magnitude
BMJ | 4 MAY 2013 | VOLUME 346 33
CLINICAL REVIEW
parents is needed to improve adherence. Families must
be counselled that there is a risk that bracing may not be
successful, but that the chances of success are improved
with discipline and adherence to wearing the brace for the
recommended time. Patients who have passed the peak
height velocity, are within a year of skeletal maturity, or
are a year or more aher menarche are unlikely to beneht
from use of a brace.
When should surgery be considered?
About 10% of adolescents with idiopathic scoliosis will
progress to a level requiring consideration of surgery.
36

Surgery is generally indicated to treat a signihcant clinical
deformity or to correct a scoliotic deformity that is likely
to progress. Surgery is recommended in adolescents with
a curve that has a Cobb angle greater than 45-50. This
recommendation is derived from studies that have shown
that curves >50 tend to progress slowly aher maturity.
11

The decision to proceed with surgical correction therefore
needs to take into consideration the clinical assessment,
comorbid conditions, the wishes of the patient, and the
eects the scoliosis has on the patients quality of life. It
is not clear that surgery is an eective treatment for back
pain associated with scoliosis.
The aims of surgery may be to arrest curve progression
by achieving a solid fusion, to correct the deformity, and
to improve cosmetic appearance. If the decision is taken
to operate, the usual approach in AIS is posterior (hg ). In
this approach a longitudinal posterior midline incision is
used. Pedicle screws are inserted into the spine and two
metal rods are measured and contoured. Curve correc-
tion is achieved as the two metal rods are attached and
tightened on to the pedicle screws. An anterior fusion is
used in AIS either as the sole approach in thoracolumbar
or lumbar curves or in conjunction with posterior fusion
in special cases.
Surgical treatment of AIS has a low rate of non-union
and other complications. The incidence of neurological
complications for spinal deformity surgery has been esti-
mated by the Scoliosis Research Society at <1%.
10
A more
recent prospective clinical case series of 1301 patients
reported a neurological complication rate of 0.69%.
37
A
long term case-control study of scoliosis curves fused to the
lumbar spine evaluated pain and functional status of AIS
patients with a minimum of 10 years follow-up (average
19 years).
38
These patients were compared with a control
population matched for work, age, and recreational activi-
ties. The two groups did not dier with respect to func-
tional status or pain.
The analysis concluded that bracing was eective in alter-
ing the natural course of scoliosis. In 1995, a prospective,
multicentre, non-randomised, non-blinded study also
showed the eectiveness of bracing in girls with curves
of 25-35.
30
Other studies have shown less positive results. A pro-
spective case series of 102 immature patients with idi-
opathic scoliosis reported that bracing provided curve
correction in only 15% of patients, while 42% later became
surgical candidates.
35
The primary goal of bracing for scoliosis is to halt curve
progression. The most widely accepted practice for brace
treatment suggests that patients with curves of 25-45
and in the most rapidly growing stage (Risser stage 0 or
1) should be oered a brace on initial evaluation. Curve
progression is dehned as an increase in the magnitude of
the deformity by more than 5 at consecutive follow-up
appointments of between four and six months.
Various factors can hinder successful brace treatment.
Poor adherence is common. A meta-analysis reported
that a protocol of 23 hours/day was more successful than
protocols of 16 hours/day or night time use.
34
A multi-
disciplinary team approach involving the patients gen-
eral practitioner, surgeon, orthotist, physiotherapist, and
Fig | Preoperative (left) and postoperative (right) radiographs of an adolescent boy with
idiopathic scoliosis, showing correction of the scoliosis by posterior instrumented fusion of the
spine
ADDITIONAL EDUCATIONAL RESOURCES
Resources for healthcare professionals
Scoliosis Research Society website. www.srs.org
AAOS American Academy of Orthopaedic Surgeons. Adolescent idiopathic scoliosis: etiology,
anatomy, natural history, and bracing. Instructional Course Lectures ;:-.
Resources for patients
Scoliosis Association United Kingdom (SAUK). www.sauk.org.ukProvides patient
information on the condition and treatments
Scoliosis Research Society. www.srs.org/patient_and_familyPatient and family section
provides information on the condition, treatments, and outcome
TIPS FOR NONSPECIALISTS
Postural scoliosis can be differentiated from structural
scoliosis with the Adams forward bend test: the curvature
will disappear on forward bending in postural scoliosis
If scoliosis is seen in a premenarchal female there is a
higher risk of curve progression, and early referral to a
specialist is advised
Patients undergoing brace treatment for scoliosis must be
encouraged to adhere with brace treatment. Patients must
be informed that the brace can be removed for washing
and swimming
34 BMJ | 4 MAY 2013 | VOLUME 346
CLINICAL REVIEW
16 Zadeh HG, Sakka SA, Powell MP, Mehta MH. Absent superficial abdominal
reflexes in children with scoliosis. An early indicator of syringomyelia. J Bone
Joint Surg Br 199';77:76l-7.
17 Kim H, Kim HS, Moon ES, Yoon CS, Chung TS, Song HT, et al. Scoliosis
imaging: what radiologists should know. Radiographics lu1u;!u:
1Sl!-/l.
1S Barnes PD, Brody JD, Jaramillo D, Akbar JU, Emams JB. Atypical idiopathic
scoliosis: MR imaging evaluation. Radiology 199!;1S6:l/7-'!.
19 Charles YP, Dimeglio A. Progression risk of idiopathic juvenile scoliosis
during pubertal growth. Spine luu6;!1:19!!-/l
lu Duval-Beaupere G. Maturation indices in the surveillance of scoliosis [in
French]. Rev Chir Orthop Reparatrice Appar Mot 197u;'6:'9-76.
l1 Duval-Beaupere G. Pathogenic relationship between scoliosis and growth.
In: Zorab PA, ed. Scoliosis and growth. Churchill Livingstone, 1971:'S-6/.
ll Duval-Beaupere G. Maturation parameters in scoliosis. Rev Chir Orthop
197u;'6:'9.
l! Sanders JO. Maturity indicators in spinal deformity. J Bone Joint Surg
luu7;S9-A(suppl 1):1/-lu.
l/ Buckler JM. A longitudinal study of adolescent growth. Springer, 199u.
l' Risser JC. The iliac apophysis: an invaluable sign in the management of
scoliosis. Clin Orthop 19'S;11:111-lu.
l6 Lonstein JE, Carlson JM. The prediction of curve progression in untreated
idiopathic scoliosis during growth. J Bone Joint Surg 19S/;66A:1u61-71.
l7 Greulich WW, Pyle SI. Radiographic atlas of skeletal development of the
hand and wrist. lnd ed. Stanford University Press, 19'9.
lS Dimeglio A, Canavese F, Charles P. Growth and adolescent idiopathic
scoliosis: when and how much? J Pediatr Orthop lu11;!1(suppl 1): SlS-
!6.
l9 Weiss HR, Weiss G, Petermann F. Incidence of curvature progression in
idiopathic scoliosis patients treated with scoliosis inpatient rehabilitation
(SIR): an age and sex matched controlled study. Ped Rehab luu!;6:l!-!u.
!u Nachemson AL, Peterson LE. Effectiveness of treatment with a brace in girls
who have adolescent idiopathic scoliosis. A prospective, controlled study
based on data from the Brace Study of the Scoliosis Research Society. J
Bone Joint Surg Am 199';77:S1'-ll.
!1 Danielsson AJ, Hasserius R, Ohlin A, Nachemson AL. A prospective
study of brace treatment versus observation alone in adolescent
idiopathic scoliosis: a follow-up mean of 16 years after maturity. Spine
luu7;!l:l19S-lu7.
!l DAmato CR, Griggs S, McCoy B. Night-time bracing with the providence
brace in adolescent girls with idiopathic scoliosis. Spine luu1;l6:
luu6-1l.
!! Wiley JW, Thomson JD, Mitchell TM. Effectiveness of the Boston brace in
treatment of large curves in AIS. Spine luuu;l':l!l6-!l.
!/ Rowe DE, Bernstein SM, Riddick MF, Adler F, Emans JB, Gardner-Bonneau
D. A meta-analysis of the efficacy of nonoperative treatments for idiopathic
scoliosis. J Bone Joint Surg Am 1997;79:66/-7/.
!' Noonan KJ, Weinstein SL, Jacobson WC, Dolan LA. Use of the Milwaukee
brace for progressive idiopathic scoliosis. J Bone Joint Surg Am
1996;7S:''7-67
!6 Lonstein JE, Carlson JM. The prediction of curve progression in untreated
idiopathic scoliosis during growth. J Bone Joint Surg Am 19S/;66:1u61-71.
!7 Diab M, Smith AR, Kuklo TR; Spinal Deformity Study Group. Neural
complications in the surgical treatment of adolescent idiopathic scoliosis.
Spine luu7;!l:l7'9-6!.
!S Bartie BA, Lonstein JE, Winter RB. Long-term follow-up of idiopathic
scoliosis patients fused to the lower lumbar spine. Orthop Trans
199!;17:176.
Aer surgery it is important to check for abnormal neu-
rology and for bowel and bladder symptoms. Back pain
aer surgery is not uncommon, especially if it is mechani-
cal in nature. In the presence of continuous or night pain,
infection or non-union should be considered, and referral
to a specialist is advised.
Postoperative follow-up oen involves clinical and radio-
logical reviews at six weeks, three months, six months, and
one year. These intervals will vary between institutions, but
follow-up until completion of growth is common.
Contributors: All authors contributed to the design and writing of the article.
Competing interests: We have read and understood the BMJ Group policy
on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; externally peer reviewed.
1 Terminology Committee of the Scoliosis Research Society. A glossary of
terms. Spine 1976;1:'7-S.
l Lonstein JE. Adolescent idiopathic scoliosis. Lancet 199/;!//:S9!/.
! Kesling KL, Reinker KA. Scoliosis in twins: a meta-analysis of the literature
and report of six cases. Spine 1997;ll:luu9-1/, discussion lu1'.
/ Parent S, Newton PO, Wenger DR. Adolescent idiopathic scoliosis: etiology,
anatomy, natural history, and bracing. Instructional Course Lectures
luu';'/:'l9-!6.
' Wang S, Qiu Y, Zhu Z, Ma Z, Xia C, Zhu F. Histomorphological study of
the spinal growth plates from the convex side and the concave side in
adolescent idiopathic scoliosis. J Orthop Surg luu7;l:19.
6 Do T, Fras C, Burke S, Widmann RF, Rawlins B, Boachie-Adjei O. Clinical
value of routine preoperative magnetic resonance imaging in adolescent
idiopathic scoliosis. A prospective study of three hundred and twenty-
seven patients. J Bone Joint Surg Am luu1;S!-A:'77-9.
7 Weinstein SL, Ponseti IV. Curve progression in idiopathic scoliosis. J Bone
Joint Surg Am 19S!;6'://7-''.
S Pehrsson K, Larsson S, Oden A, Nachemson A. Long-term follow-up of
patients with untreated scoliosis. A study of mortality, causes of death, and
symptoms. Spine 199l;17:1u91-6.
9 Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti
IV. Health and function of patients with untreated idiopathic scoliosis. A
'u-year natural history study. JAMA luu!;lS9:''9-67.
1u Scoliosis Research Society. Report of Morbidity Committee . SRS,
199!.
11 Ramirez N, Johnston CE, Browne RH. The prevalence of back pain
in children who have idiopathic scoliosis. J Bone Joint Surg Am
1997;79:!6/-S.
1l Lonstein JE, Carlson JM. The prediction of curve progression in untreated
idiopathic scoliosis during growth. J Bone Joint Surg 19S/;66:1u61-1u7.
1! Feldman DS, Straight JJ, Badra MI, Mohaideen A, Madan SS. Evaluation
of an algorithmic approach to pediatric back pain. J Pediatr Orthop
luu6;l6:!'!-7.
1/ Fairbank MJ. Historical perspective: William Adams, the forward bending
test, and the spine of Gideon Algernon. Spine luu/;l9:19'!-'.
1' Lee CF, Fong DY, Cheung KM, Cheng JC, Ng BK, Lam TP, et al. Referral criteria
for school scoliosis screening. Assessment and recommendations based
on a large longitudinally followed cohort. Spine lu1u;!':E1/9l-S.
ANSWERS TO ENDGAMES, p 38 For long answers go to the Education channel on bmj.com
STATISTICAL
QUESTION
Correlation
versus linear
regression
Statements a, c,
and d are true,
whereas b is
false.
Haemorrhage within the midline of the pons and large prominent lateral ventricles.
Hypertension, cerebrovascular malformations, trauma, primary or secondary tumours.
Magnetic resonance imaging of the brain, cerebral angiography, computed tomography angiography, and
magnetic resonance imaging angiography. Blood tests to identify vasculitic, haematological, and coagulopathic
causes are indicated if the diagnosis is unclear.
Assess with the ABC (airway, breathing, circulation) approach and manage the patient in a centre with immediate access
to neurosurgical expertise. The Glasgow coma scale score and pupil size should be monitored regularly to allow for
reimaging and prompt action if deterioration occurs. Consider treatment of associated hydrocephalus with an external
ventricular drain if the patient has signs of increased intracranial pressure. Conservative treatment with serial imaging
and watchful waiting. Longer term management includes blood pressure management (also important in the primary
phase) and consideration of surgical intervention after initial recovery.
PICTURE QUIZ A pain in the neck type of headache
BMJ | 4 MAY 2013 | VOLUME 346 35
PRACTICE
Northumberland, UK
Sir James Spence Institute, Royal

Victoria Infirmary, Newcastle upon
Tyne NE LP, UK
Correspondence to: A Basu
anna.basu@ncl.ac.uk
Cite this as: BMJ ;:e
doi: ./bmj.e
This is one of a series of occasional
articles by patients about their
experiences that offer lessons
to doctors. The BMJ welcomes
contributions to the series. Please
contact Peter Lapsley (plapsley@
bmj.com) for guidance.
This patient was left with visual agnosia after
developing herpes simplex encephalitis at
a young age. She describes her strategies
for coping with this visual disability
When I was months old I developed herpes simplex
encephalitis aer coming into contact with a cold sore,
which damaged the areas of the brain responsible for
processing vision. I was le with visual agnosia and had
severe diculties in recognising people by their faces. I
cannot remember the details of the earliest events sur-
rounding my illness, but I have talked about them a lot
with my family and this is my story.
During the illness I lost my sight as well as my ability to
sit and walk. It took me about six months to relearn to walk
unaided. During this time my vision gradually improved,
but I had to rely on my other senses to interact with the
environment. I would sni, touch, and taste things around
me, including the oor, furniture, and peoples clothing,
which some found unnerving.
My speech development was good. I found changes in
routine upsetting and puzzling. Mum had the support of
medical and educational professionals and on their advice
I was taught at home by an educational service (Portage)
for preschool children with additional support needs and
their families, and I had a support assistant at play school.
Around this time mum noticed I was making mistakes in
recognising family members. Once I was seen talking to my
brothers friend, mistaking him for my brother (who looks
completely dierent).
A PATIENTS JOURNEY
Visual agnosia
Anonymous,
1
Anna Basu
2
It wasnt just a problem with recognising family mem-
bers, or people in generalmum had painted a Postman
Pat mural on my wall and despite being familiar with his
character through books and DVDs I just could not rec-
ognise him. However, it was when mum realised that I
couldnt even recognise her that things came to a head.
This happened on a Portage course for parents. As the
parents entered the crche, the children got up and went
to their mums and dads. I got up too, studied the adults
and then returned to my carer rather than going to my
mum. Although mum had been standing close to me, it
wasnt until she spoke that I got up and took her hand.
Mum talked about this to a teacher for visually impaired
people at my nursery. He said he thought I might have a
facial agnosia. This was discussed with the child neurolo-
gist at my next appointment, and subsequently with a
neuropsychologist.
My lack of recognition of family members caused all
sorts of diculties. Mum will never forget the time I was
on a childs amusement ride in the supermarket while she
was close by paying for her shopping. When the ride had
nished she heard me calling for her and then saw me
being lied out by a woman. This stranger was reluctant
to hand me back to my mum because she didnt see the
ash of recognition she was expecting from me.
I also had problems with object recognition. No one
could understand how I managed to nd small objects
dropped on the oor but wasnt able to recognise pictures
of everyday objects. When given a verbal clue I would
always get the object right. I couldnt visually distin-
guish between animals such as a cat and dog or a cow
and sheep. This problem only improved aer many visits
to farms and zoos.
When I rst started school my eye contact was poor and
despite constant encouragement from my family, teach-
ers, and carers to li my head I found it hard to look at
people. My condence was lowered further by the reper-
cussions when I misread facial expressions.
Some aspects of my condition have improved but not
the facial agnosia and I continue to nd the recognition
and identication of faces dicult. Recognition is even
harder when people are out of context or a particular
feature such as hair colour has changed. School was on
occasions frustrating, not least because everyone wore
the same uniform. Finding friends both in and out of the
classroom could be dicult, so I had to rely on my other
senses. Things became easier when I moved into sixth
form, as students could wear casual clothing. Teach-
ers found my disability dicult to understand. Some
believed it didnt exist and others didnt understand that
the problem arose from my brain not my eyes. Unbeliev-
ably, at a parents evening a teacher asked mum whether
all her children were blind, to which (after taking a
deep breath) she replied On my last count, none of my
ch ildren is blind.
A DOCTORS PERSPECTIVE
Visual agnosia is a specific failure of visual recognition of objects not explained by elementary
visual deficits. The agnosia can be category specificfor example, prosopagnosia is a specific
agnosia for faces. Pure visual agnosia is a rare condition, particularly in young people, but
visual agnosias can also occur as part of neurodegenerative conditions.
This patients visual agnosia was secondary to early acquired herpes simplex encephalitis,
which caused bilateral damage to the occipitotemporal regions. Those brain areas specifically
involved in processing faces were affected, and although the patient made a good recovery
overall, face recognition remains problematic on a day to day basis. Her story is remarkable on
several levels. One of the most striking aspects is the invisible nature of the condition. It is
not surprising that people may be confused by the fact that someone can see well enough to
go horse riding but cannot distinguish between family members by their faces. What people
dont understand they often refuse to believe and this has clearly led to some awkward
situations. This patients drive to study the condition in detail and to explain it to others is
both understandable and commendable. Her ability to perceive the world differently can also
be viewed as a strength and has led to some original artwork.
Doctors can help those with visual agnosia by being alert to the possibility of disorders
of higher visual function, facilitating appropriate neuropsychological assessments, and
providing explanations and accessible strategies for families and schools. To achieve all this,
however, requires awareness of such conditions.
Most remarkable of all are the sheer courage and determination shown by this patient and
her family to help overcome her difficulties, enabling her to succeed both in and out of school
and in holding down a job. I have learned much from sharing this part of her journey and am
proud to know her.
Anna Basu
36 BMJ | 4 MAY 2013 | VOLUME 346
PRACTICE
tional magnetic resonance imaging scans to look for any
changes in the brain. When babies and children study
faces intently their brains are learning to calculate the
distance between eyes, nose, and mouth and the width
and length of faces, which are the basics of expertise in
recognising faces. The training programme required me to
categorise faces based on dierences in these distances.
Involvement in the study has improved my eye contact
and conhdence. My training scores have also improved
but I still have trouble recognising faces. Despite this I am
becoming more conhdent in my day to day recognition of
friends and family using all available means.
Competing interests: The authors declare: AB received funding from the
Special Trustees, Newcastle Healthcare Charity as well as funding for a
Wellcome Trust vacation student and a Newcastle University vacation
student for the study of the elect of face training on face perception in
prosopagnosia and in healthy controls; no hnancial relationships with
any organisations that might have an interest in the submitted work in the
previous three years, no other relationships or activities that could appear
to have influenced the submitted work.
Provenance and peer review: Not commissioned; not externally peer
reviewed.
Accepted: l' August lu1l
Getting teachers to complete the simplest of tasks, such
as using a black pen on the whiteboard and enlarging
worksheets, was a test all of its own and made life in the
classroom problematic. Despite these challenges I was
successful at GCSE level, with 10 good grades. Subse-
quently I studied English language, art, and psychology
at A level. As part of my psychology course I studied face
perception and its disorders and was asked to give a series
of talks to the other psychology classes. For my art A level
I brought together elements of Cubism and still life and
incorporated texture to give my work a more original and
interesting direction, reecting the importance of touch
in helping me to understand my su rroundings in my early
life.
Over time I have built up my own strategies for rec-
ognising my family and friends and those I am in daily
contact with like my work colleagues; for example, by
remembering their style of walk, hairstyle, and hair col-
our. I have also become good at recognising voices and
scents, including the perfume worn by particular people.
Recently I have become more sensitive to sounds such
as those made by jewellery and keys. I am able to hnd
mum in crowded places by the sound of her bangles
and dad by the sound of his car keys. This has increased
my c onhdence in public places. I remember when I was
around seven years old being perturbed at meeting iden-
tical twins who were also identically dressed. Although
neither I nor anybody else could distinguish the twins by
sight, for once my personal strategies for distinguishing
between people by voice, scent, etc, failed me. I was leh
so scarred by this experience that months later I avoided
a close family friend because she might have a twin.
A few years ago I was approached by my neurolo-
gist, Professor Eyre. She asked if I would take part in a
research study of face training, with the aim of relearn-
ing the mathematics of face recognition and using func-
USEFUL RESOURCES FOR PATIENTS AND CLINICIANS
Farah M. Visual agnosia. nd ed. MIT Press, A
classic text on disorders of visual recognition
National Portage Association (www.portage.org.uk/)A
home-visiting educational service for preschool children
with additional support needs and their families
National Institute of Neurological Disorders and Stroke
(www.ninds.nih.gov/disorders/prosopagnosia/
Prosopagnosia.htm)Patient information on
prosopagnosia, or face-blindness
Faceblind.org (www.faceblind.org/)Information from
researchers and opportunities for those affected to take
part in research
10MINUTE CONSULTATION
Vasectomy
S Jamel,
1
S Malde,
1
I M Ali,
2
S Masood
1
1
Department of Urology, Medway
NHS Foundation Trust, Gillingham
ME7 'NY, UK
l
Halfway Surgery, Chatham
ME/ /QR, UK
Correspondence to: S Malde
sachmalde@gmail.com
doi: 1u.11!6/bmj.f167/
This is part of a series of occasional
articles on common problems in
primary care. The BMJ welcomes
contributions from GPs.
A 40 year old man attends your clinic with his 37 year
old wife to discuss long term contraceptive options. They
inform you that they have three children and have com-
pleted their family. The wife has been taking oral contra-
ception for the past hve years but does not want to continue
with this. They have both considered other contraceptive
options and have decided on vasectomy.
What you should cover
Patient selection and counselling is crucial. To determine
if vasectomy is suitable for them, consider the following
points.

Ideally both partners should be present.

Establish the patients age, relationship status or
stability, and number of children. Young, single men
with no children are more likely to regret their decision
and request a reversal later in life.

Discuss other contraceptive methods. Female sterilisation
(tubal ligation) can be done hysteroscopically under
local anaesthesia; or laparoscopically or through a mini-
laparotomy, under general anaesthesia. Consequently,
the morbidity of the procedure is higher than for
vasectomy, and some studies suggest that the reported
lifetime failure rate is higher, at 1 in 200.

Emphasise the need to use alternative contraception
aher vasectomy until semen analysis conhrms the
absence of sperm (usually three months).

Ask about any current systemic or sexually transmitted
infection, coagulation or other blood disorders, and
chronic testicular pain, as these will inuence the
timing of and preparation for surgery. A small number
of patients will develop chronic testicular pain aher
this procedure, which can interfere with their quality
of life. This typically occurs in 1-2% of men.
bmj.com
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BMJ | 4 MAY 2013 | VOLUME 346 37
PRACTICE

Examine the testis and both vasa deferentia for any
abnormality that may interfere with the procedure,
such as a large hydrocele, inguinoscrotal hernia, or
testis tumour.

Emphasise the need for post-vasectomy semen analysis
three months aher vasectomy. Some sperm may still
be present in the semen for a few months, and so the
patient should continue other methods of contraception
until the semen analyses show azoospermia.

Inform the patient that 100% guarantee cannot be
given of permanent sterility as there is a rare chance
of early failure (0.2-5.3%) and late recanalisation
(0.03-1.2%).

Explain the operation and complications (box).

Provide the couple with leaets or booklets or other
printed material outlining the information covered in
the counselling session.

If there is any doubt, ask the couple to return for a
further consultation once they have had time to make
their decision.
How it works
Vasectomy is an eective, reliable, and permanent form of
male sterilisation with no serious long term side eects.
It is usually done under local anaesthesia and very occa-
sionally under general anaesthesia. In the conventional
incisional technique one or two small incisions are made
with a scalpel on the scrotum and both vasa deferentia
are exposed. The no-scalpel method involves puncturing
the skin with a sharp haemostat. A small segment of vas
is removed from both sides and the ends are ligated with
sutures. Soh tissue is interposed between the two ends of
vas to prevent recanalisation.
Aftercare
Aher the procedure there is usually some discomfort and
bruising for a few days, which can be improved by wear-
ing tight htting underwear. Patients are advised not to
work on the day aher the operation and that a return to
normal activity is usual within a week. Three months aher
va sectomy a semen analysis is required. If no spermatozoa
are detected in the ejaculate, give the patient clearance to
stop using other methods of contraception. If motile sper-
matozoa persist at the six month follow-up, a repeat vasec-
tomy is advisable. Other contraceptive methods should be
continued until clearance is given.
Contributors: SJ was involved in the initial conception and drahing of the
article and was involved in hnal approval of the version to be published. S
Malde and IMA were involved in revising the article critically for important
intellectual content and in hnal approval of the version to be published. S
Masood is guarantor for the paper and was involved in initial conception,
literature review, revising the article critically for important intellectual
content, and in hnal approval of the version to be published.
Competing interests: All authors have completed the Unihed Competing
Interest form at www.icmje.org/coi_disclosure.pdf (available on request
from the corresponding author) and declare: no support from any
organisation for the submitted work; no hnancial relationships with any
organisations that might have an interest in the submitted work in the
previous three years; no other relationships or activities that could appear
to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer
reviewed.
Accepted: 19 December lu1l
Complications
Vasectomy has an associated low complication rate; patients should be informed about the
following complications.
Common
Scrotal bruising, haematoma
Chronic testis pain affecting quality of life (-%) and sperm granuloma
Occasional
Bleeding requiring further surgery
Rare
Infection of testis or epididymis requiring antibiotics
Early recanalisation resulting in persistence of motile sperm in the ejaculate for which repeat
vasectomy is indicated (.-.%)
A risk of about in of pregnancy resulting from late recanalisation after previous
clearance
FREQUENTLY ASKED QUESTIONS
Q: How effective is vasectomy?
A: Vasectomy is a safe and reliable procedure. However,
in men can become fertile again due to rejoining
of the two ends of the vas, so vasectomy is not %
effective.
Q: Can I stop using contraception immediately after the
procedure?
A: No. Sperm can still be present for a few months and so a
semen analysis is done three months after vasectomy. If it
is clear of sperm you can stop using contraception.
Q: Will it affect my sex drive?
A: No. The sex hormones will still be produced by the testes
so libido and erectile function are unaffected.
Q: What will happen to the sperm?
A: Sperm will still be produced by the testis but will get
dissolved in the body.
Q: What if I change my mind after the operation?
A: You should regard vasectomy as a permanent procedure.
The success rate of vasectomy reversal is only -%,
with a lower success rate in men who have a later reversal.
Q: Does the operation hurt?
A: It is done under local anaesthesia. You may experience
some discomfort during the injection and the procedure
but not severe pain.
Q: How soon after the operation can I have sexual
intercourse?
A: You can resume sexual activity as soon as it is
comfortable. You have to use other methods of
contraception until the semen analysis shows no sperm in
the specimen.
Q: Is there any risk of prostate or testis cancer after
vasectomy?
A: No. Several studies have shown no relation between
vasectomy and cancer.
FURTHER READING
For patients
Patient.co.uk (www.patient.co.uk/health/Vasectomy.htm)
NHS Choices (www.nhs.uk/conditions/vasectomy/pages/introduction.aspx)
British Association of Urological Surgeons (www.baus.org.uk/Resources/BAUS/Documents/
PDF%Documents/Patient%information/Vasectomy.pdf)
For healthcare professionals
European Association of Urology Guidelines on Vasectomy (www.europeanurology.com/
article/S-%%-/fulltext)
American Urological Association Guidelines on Vasectomy (www.auanet.org/content/
media/vasectomy.pdf)
bmj.com
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38 BMJ | 4 MAY 2013 | VOLUME 346
ENDGAMES
We welcome contributions that would help doctors with postgraduate examinations
OSee bmj.com/endgames for details
PICTURE QUIZ
A pain in the neck type of headache
A year old right hand dominant chef presented to the emergency department
with a four day history of feeling not normal. He was sent home from work
because of a gradual onset of dull pain on the left side of his neck radiating up
into his head, which was getting progressively worse, as well as seeing two of
everything. The pain was not influenced by changes in posture. In addition, his
right side felt numb and he was dropping things at work. He felt unsteady on his
feet, which prompted him to seek medical advice. He thought all his symptoms
had come on suddenly and were gradually getting worse. He denied any recent
alcohol consumption, illicit drug use, seizure activity, head injury, or loss of
consciousness. He had no medical history of note, apart from hypothyroidism, for
which he was taking thyroxine.
On examination, he was alert and orientated. His blood pressure was /
mm Hg and other vital signs were normal. He had moderate weakness on the
right side (Medical Research Council grade ), mainly in the upper limb, with
pronator drift, and reduced sensation to pinprick, light touch, and proprioception
on the same side. There was evidence of a resting and intention tremor, with
dysdiadochokinesia of the upper limbs, which was more evident on the right side
than the left. Furthermore, he had a broad based gait consistent with cerebellar
ataxia when attempting to walk. He had an upgoing plantar response on the right
and a downgoing one on the left. His pupils were equal and reactive to light,
but he had diplopia on both extremes of gaze, although there was no clinical
evidence of ocular palsy. Papilloedema was not detected on examination of his
fundi.
Given his history and the constellation of findings on examination, a posterior
fossa lesion was suspected. Because computed tomography was the only
imaging modality available out of hours, a head scan was performed to rule out
any serious disease (figs and ).
What abnormalities does the computed tomogram show?
What are the causes of this pathology?
What other investigations would be useful?
How should this condition be managed generally?
Submitted by Rafiqu Rahman Shabiyulla
FOLLOW ENDGAMES ON TWITTER
@BMJEndgames
FOR SHORT ANSWERS See p 34
FOR LONG ANSWERS
Go to the Education channel on bmj.com
STATISTICAL QUESTION
Correlation versus linear regression
A recent statistical question described how researchers
investigated the association between right ventricular size
and pulmonary hypertension. A cross sectional study design
was used. Participants were patients referred to a
pulmonary hypertension clinic.
Measurements of right ventricular size included
right ventricular end systolic area (RVESA) recorded
echocardiographically. Pulmonary artery systolic pressure
(PASP) was used to indicate the extent of pulmonary
hypertension. A scatter plot of pulmonary artery systolic
pressure against right ventricular end systolic area was
presented (figure). Linear regression analysis was used to
examine the association between right ventricular size and
degree of pulmonary hypertension, with the resulting fitted
linear regression line given by PASP=.RVESA+..
A significant correlation existed between right ventricular
end systolic area and pulmonary artery systolic pressure
(r=.; P<.).
Which of the following statements, if any, are true?
a) The regression line facilitated the prediction of pulmonary
artery systolic pressure from right ventricular end systolic
area
b) The regression line implied there was a causal association
between pulmonary artery systolic pressure and right
ventricular end systolic area
c) Correlation quantified the strength of the linear
association between pulmonary artery systolic pressure
and right ventricular end systolic area
d) Pearsons correlation coefficient may be used to quantify
the variability in pulmonary artery systolic pressure
described by right ventricular end systolic area
Submitted by Philip Sedgwick
RVESA (cm
)
P
A
S
P

(
m
m

H
g
)

PASP=.RVESA + .
r=., P<.
Scatter plot of pulmonary artery systolic pressure (PASP) against
right ventricular end systolic area (RVESA).
Fig 1 Fig 2
BMJ | 4 MAY 2013 | VOLUME 346 39
LAST WORDS
Billions of pounds
are being spent
chasing a ghostly
surrogate endpoint:
low blood sugar
been withdrawn; pioglitazone has been
linked to bladder cancer; and exenatide
and sitagliptin double the risk of acute
pancreatitis.
13

14
All this is an exam-
ple of the scientihc illusion that is so
called evidence based medicine, where
research is just mechanically reclaimed
statistics pulped into junk educational
nuggetsmere marketing by another
name.
There remains another fundamen-
tal question. Can diabetes be reversed
or cured by weight loss? A small, well
designed study of 11 patients irrefu-
tably showed that it can.
15
And clini-
cal eect is more important than any
statistically significant yet clinically
undetectable eect that a huge study
funded by the drug industry might hnd.
The therapeutic approach in diabetes
is upside down. The complicity of doc-
tors and lack of dissent against the drug
model of diabetes care is bad medicine.
Des Spence is a general practitioner, Glasgow
destwo@yahoo.co.uk
Type 2 diabetes is a modern plague
largely brought on by lifestyle and is
considered a progressive, non-revers-
ible condition. The polypharmacy
of chronic disease is the drug indus-
trys lottery win, and no more so than
in diabetes, with new drugs and the
increasing use of analogue insulin in
type 2 diabetes worth tens of billions of
pounds worldwide.
1

The drug industrys business plan for
diabetes follows a familiar pattern:
1) Conduct questionable research
and control the original data.
2) Schmooze the politicians, health
regulators, and patient groups to
suggest undertreatment and need for
urgent action.
3) Recruit tame diabetologists, mas-
sage them with cash, and get them to
present at marketing events that mas-
querade as postgraduate education.
4) Pay doctors to switch to newer
drugs in dubious international post-
marketing trials.
2

5) Seek endorsement from the
National Institute for Health and Care
Excellence to bully doctors to treat
diabetes aggressively with drugs.
3

And so the complexities of diabetes
are reduced to simply lowering blood
sugar.
What is the annual cost of this
approach? In the past decade, spending
on insulin in the UK has risen 300%,
to E311m,
4
and on oral anti-diabetes
drugs 400%, to E277m. And have you
ever wondered why companies gener-
ously give away glucose meters? Test
strips are a E166m market, the value
of which has risen 300% in 15 years.
4

But do analogue insulins, new drugs,
and self monitoring of blood glucose
improve outcomes? Does even tight
glycaemic control make a dierence? No
data on mortality or morbidity exist for
the new therapeutics.
5-11
Likewise inten-
sive glycaemic control is not superior
with respect to mortality and cardiovas-
cular disease.
12
So billions of pounds
are being spent chasing a ghostly surro-
gate endpoint: low blood sugar. Worse,
there is evidence that these new drugs
cause harm. Rosiglitazone has already
We lived for three months in a rolled
up newspaper in a septic tank. We used
to have to get up every morning at six
oclock and clean the newspaper, go to
work down the mill, fourteen hours a day,
week-in week-out, for sixpence a week,
and when we got home our Dad would
thrash us to sleep with his belt.
1

Every time doctors tell me about their
working hours before the European
working time directive came into force
I think of the At Last The 1948 Show
sketch.
A bit of exaggerating aside, working
100 hour shihs sounds like a pretty
horrible existence. Good riddance to it.
But at least you got high quality, on the
job training, and you got paid for it.
Unfortunately, its been partially
replaced with silly online quizzes and
fatuous portfolios that need to be done
in your own time. Here is an actual quote
from the e-LfH (e-Learning for Healthcare)
too enraged to properly take it in. You
could strip out most of the material and
lose nothing of value.
Junior doctors want a decent
education. We dont want our time
wasted with box ticking work. It feels as
though whoever is in control of junior
doctors training has too little regard for
our time and is all too willing to throw
another acronymed assessment onto
the pile.
We must demand a more active role
in designing our curriculum. We need
to scrap the quantity and focus on the
quality. Those who set the standards
must be made to justify every minute
of training they ask of us. Box ticking
doesnt help anyone.
Oliver Ellis is a foundation year doctor,
Mersey Deanery
oli.ellis@googlemail.com
online training course, as endorsed
by the UK Foundation Programme:
Click on the Poetry Archive website
and choose a poem from the sections
on Death and Grief. Listen to it and then
consider these questions: How did it
make you feel? . . . These mild feelings
may help you to understand how
complex overwhelming untreated grief
can bring about quite profound physical
changes and have an impact on health
over months or years.
2
How did it make me feel? Mostly
patronised. A little outraged. The aim
was to simulate feeling sad, so you can
empathise with bereaved patients and
relatives. Anyone who needs sadness
explained to them wont be hxed by an
online course.
There are some useful bits in that
module, and scattered throughout the
e-LfH site, but its so padded out with
this sort of pap that my brain becomes
FROM THE FRONTLINE Des Spence
Bad medicine: the way we manage diabetes
LAYING FOUNDATIONS Oliver Ellis
Portfolio of pap
Twitter
Follow Des Spence on
Twitter @des_spence
Anyone who needs
sadness explained
to them wont be
fixed by an online
course
40 BMJ | 4 MAY 2013 | VOLUME 346

MINERVA
Send comments or suggest ideas to Minerva: minerva@bmj.com
A pain in the neck
type of headache
Try the picture quiz in
ENDGAMES, p
Weve damp coming down our walls, doctor, and
my chests never been so bad. Can you do us a note
for housing? Doctors responding to such requests
can now cite a good longitudinal study to back
them up: the European Community Respiratory
Health Survey (Occupational and Environmental
Medicine 2u13;7u:325-31, doi:1u.1136/oemed-
2u12-1uu963). In the study, 71u/ young adults
from 13 countries who did not report respiratory
symptoms or asthma at baseline were followed
prospectively for nine years. There was an excess
of new asthma in participants in homes with
reports of water damage (relative risk 1./6, 95%
confidence interval 1.u9 to 1.9/) and indoor
moulds (1.3u, 1.uu to 1.68) at baseline, and a
dose-response effect was observed. Dickensian
landlords take note.
For decades, the tablets that doctors have given
people with osteoarthritis have damaged their
upper gastrointestinal tracts, predisposed them
to have heart attacks, and made little difference
to their pain. What if there was a substance
that actually reversed the disease process and
promoted the repair of articular cartilage? A study
from Japan reports on a novel disease modifying
drug that seems to repair cartilage when injected
into joints (Annals of the Rheumatic Diseases
2u13;72:7/8-53, doi:1u.1136/annrheumdis-
2u12-2u17/5). It works by upregulating the
expression of Runx1. For those of you who think
this probably refers to the mating call of the
Vietnamese pot bellied pig, I should explain that
Runx1 and other runt related transcription factors
are vital for collagen differentiation. And for people
with arthritis waiting for a quick fix, I might opine
that another 1u years will be needed to test the long
term efficacy and safety of these compounds.
Many medical terms date from the time when
textbooks were written in Latin; many more
from the time when most doctors learnt Latin
and Greek at school; still others have been
invented in our own time, simply to baffle us.
An article in the Journal of Allergy and Clinical
Immunology (2u13;131:1u/1-7.e3, doi:1u.1u16/j.
jaci.2u12.u9.u28) seeks to determine whether
the clearance of apoptotic inflammatory cells
(efferocytosis) by airway macrophages was
associated with altered inflammation and reduced
glucocorticoid sensitivity in obese asthmatic
patients. Macrophage is a reasonable 19th
century word from the Greek meaning big eater.
Apoptotic is a late 2uth century coinage, also
based on Greek and meaning liable to give up and
die. And now for efferocytosis. Think Latin for bear
(fero) and away (e). Bearing away cells. Minerva
has never heard of this word before, but evidently
efferocytosis happens less often in the airways
of obese people with asthma, than in non-obese
people with asthma. Their air passages get clogged
up with dead gunk, if youll pardon my Greek.
Perfection is not attainable by mortals, and even
Minerva herself sometimes has trouble reaching
it. But in Italian, perfezionamento can mean
improvement rather than perfection. The Parkinson
Institute of the Istituti Clinici di Perfezionamento in
Milan looks at ways of improving the lot of patients
with Parkinsons disease who have developed
dopamine dysregulation syndrome (Journal of
Neurology, Neurosurgery and Psychiatry with
Practical Neurology 2u13, doi:1u.1136/jnnp-
2u12-3u3988). The institute found that better
outcomes were strongly related to good caregiving.
The technical fixes were tricky: duodenal levodopa
infusion can be used, or deep brain stimulation of
the subthalamic nucleus.
If you strain any chamber of the heart, the
myocytes will produce a surge of short lived
peptide hormone: atrial natriuretic peptide if its
a strained atrium, or B type natriuretic peptide
(BNP) if its a ventricle. And with heart failure
being the largest cause of hospital admission and
readmission throughout the developed world,
its tempting to think that daily measurement
of BNP in high risk patients at home might be a
good way of anticipating (and hence preventing)
cardiac decompensation. In the HABIT trial
reported in the Journal of the American College of
Cardiology (2u13;61:1726-35, doi:1u.1u16/j.
jacc.2u13.u1.u52), patients were given a finger
stick test to measure their BNP every day. But in
people with heart failure, natriuretic peptide levels
go up and down from hour to hour: so although this
study found that daily BNP certainly gives a signal,
it is difficult to separate from noise.
The shrinkage of modern standing armies means
that army musicians, when not playing dirges for
dead prime ministers, are increasingly deployed in
combat roles. The occupational health department
of the United Kingdoms Ministry of Defence
thought that it was important to determine whether
its musicians were experiencing hearing loss as
a result of their day job (Occupational Medicine
2u13, doi:1u.1u93/occmed/kqtu26). Sampling
of 8/ military musicians suggested that they
were at no greater risk of hearing loss than their
administrative counterparts after 8-12 years in
service, and that there was no difference between
the various instruments played. It seems to
Minerva, however, that it is essential to be deaf
before taking up the bagpipes.
A young woman presented with painful vesicular
and ulcerative lesions on her oral mucosa, tongue,
and lips with associated crusting. She also had
low grade pyrexia and vesicular lesions on her
fingertips with an erythematous base, which had
appeared a few days after the oral lesions. Swabs
from both sites were positive for herpes simplex
virus type 1 (HSV1) using polymerase chain
reaction. She was managed symptomatically.
The course of primary HSV1 infection is usually
uncomplicated in an immunocompetent host, and
the lesions last 1u-1/ days. Lesions are usually
at one anatomical site, although autoinoculation
can cause lesions at different sites.
Suneeta Teckchandani (suneetatec@doctors.org.uk),
consultant physician, C Papafio, consultant
dermatologist, Medical Assessment Unit, Calderdale
and Huddersfield NHS Foundation Trust, Huddersfield
Royal Infirmary, Lindley HD EA, UK
Patient consent obtained.

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