BMJ: British Medical Journal

Publications
European case-control studies of residential radon and lung cancer
Percentage increase in risk of lung cancer per 100 Bq/m 3 increase in measured radon concentration by study, age, sex, smoking, and histological type. Squares have areas inversely proportional to the square of the standard error of the percentage increase. For the Spanish study, the present non-significantly negative estimate differs from a previously published positive estimate based on quartiles of radon distribution. 16 The negative estimate, based on individual radon concentrations, is dominated by three cases and 17 controls with measured radon ≥400 Bq/m 3  
Relative risk of lung cancer by radon concentration (Bq/m 3 ) in homes 5-34 years previously
To determine the risk of lung cancer associated with exposure at home to the radioactive disintegration products of naturally occurring radon gas. Collaborative analysis of individual data from 13 case-control studies of residential radon and lung cancer. Nine European countries. 7148 cases of lung cancer and 14,208 controls. Relative risks of lung cancer and radon gas concentrations in homes inhabited during the previous 5-34 years measured in becquerels (radon disintegrations per second) per cubic metre (Bq/m3) of household air. The mean measured radon concentration in homes of people in the control group was 97 Bq/m3, with 11% measuring > 200 and 4% measuring > 400 Bq/m3. For cases of lung cancer the mean concentration was 104 Bq/m3. The risk of lung cancer increased by 8.4% (95% confidence interval 3.0% to 15.8%) per 100 Bq/m3 increase in measured radon (P = 0.0007). This corresponds to an increase of 16% (5% to 31%) per 100 Bq/m3 increase in usual radon--that is, after correction for the dilution caused by random uncertainties in measuring radon concentrations. The dose-response relation seemed to be linear with no threshold and remained significant (P = 0.04) in analyses limited to individuals from homes with measured radon < 200 Bq/m3. The proportionate excess risk did not differ significantly with study, age, sex, or smoking. In the absence of other causes of death, the absolute risks of lung cancer by age 75 years at usual radon concentrations of 0, 100, and 400 Bq/m3 would be about 0.4%, 0.5%, and 0.7%, respectively, for lifelong non-smokers, and about 25 times greater (10%, 12%, and 16%) for cigarette smokers. Collectively, though not separately, these studies show appreciable hazards from residential radon, particularly for smokers and recent ex-smokers, and indicate that it is responsible for about 2% of all deaths from cancer in Europe.
 
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To identify modifiable factors associated with longevity among adults aged 75 and older. Population based cohort study. Kungsholmen, Stockholm, Sweden. 1810 adults aged 75 or more participating in the Kungsholmen Project, with follow-up for 18 years. Median age at death. Vital status from 1987 to 2005. During follow-up 1661 (91.8%) participants died. Half of the participants lived longer than 90 years. Half of the current smokers died 1.0 year (95% confidence interval 0.0 to 1.9 years) earlier than non-smokers. Of the leisure activities, physical activity was most strongly associated with survival; the median age at death of participants who regularly swam, walked, or did gymnastics was 2.0 years (0.7 to 3.3 years) greater than those who did not. The median survival of people with a low risk profile (healthy lifestyle behaviours, participation in at least one leisure activity, and a rich or moderate social network) was 5.4 years longer than those with a high risk profile (unhealthy lifestyle behaviours, no participation in leisure activities, and a limited or poor social network). Even among the oldest old (85 years or older) and people with chronic conditions, the median age at death was four years higher for those with a low risk profile compared with those with a high risk profile. Even after age 75 lifestyle behaviours such as not smoking and physical activity are associated with longer survival. A low risk profile can add five years to women's lives and six years to men's. These associations, although attenuated, were also present among the oldest old (≥ 85 years) and in people with chronic conditions.
 
Kendal and colleagues found a strong overall survival advantage at 10 years’ follow-up for patients undergoing metal-on-metal hip resurfacing compared with those undergoing total hip replacement.1 The authors analysed all cause mortality, unlike many studies, which confine research to disease specific end points, thereby masking unanticipated consequences of …
 
Communication is the cornerstone of medicine, without which we cannot interact with our patients.1 The General Medical Council’s Good Medical Practice states that “Doctors must listen to patients, take account of their views, and respond honestly to their questions.”2 However, we still often interact with patients who do not speak the local language. In the United Kingdom most hospitals have access to translation services, but they are expensive and often cumbersome. A complex and nuanced medical, ethical, and treatment discussion with patients whose knowledge of the local language is inadequate remains challenging. Indeed, even in a native language there is an element of translation from medical to lay terminology. We recently treated a very sick child in our paediatric intensive care unit. The parents did not speak English, and there were no human translators available. Reluctantly we resorted to a web based translation tool. We were uncertain whether Google Translate was accurately translating our complex medical phrases.3 4 Fortunately our patient recovered, and a …
 
Who is driving the process?Except for drugs (where policy has been driven largely by industrial concerns), the EU itself has a limited role in quality of care. In other areas, the situation reflects fundamental differences in health systems and the interests and influence of the various stakeholders. Governments are, at least in theory, able to play a greater role where they employ health professionals directly, as with hospital doctors in countries with national health services. Government involvement is often less where doctors are self employed. Quality assurance activities seem to be more common where health professionals work in multidisciplinary teams, presumably because it is easier to organise peer review with colleagues than with competitors when practising singlehandedly. Professional associations can also have an important role. In general, these associations work in three broad areas: negotiating on behalf of their members, tackling unprofessional behaviour, and actively enhancing professional standards. The nature and power of such associations vary considerably. A key factor is the priority that associations give to enhancing professional standards, which may be minimal if their efforts are focused on financial negotiations. In Denmark, the Netherlands, and the United Kingdom (where they have initiated a number of national audits), professional organisations have been active in a range of quality assurance activities.1819In countries where health care is funded through social insurance, insurance funds have established organisations to provide technical support for including quality in contracts with providers—for example, the National Institute for Sickness and Disability Insurance (RIZIV-INAMI) in Belgium. In Germany, the Federal Office for Quality Assurance (BQS) was established by the corporate actors to support the development and implementation of measures for external quality assurance in hospitals.International influences have been important, as exemplified by the adoption of the Joint Commission International’s accreditation model. In countries such as Hungary, quality assurance associations arose through participation in collaborative projects funded by the EU, with Dutch teams being especially influential.20 Approaches also vary within countries, reflecting differences between those where the health system is organised centrally and those where it is decentralised. Thus, the Spanish autonomous regions Catalunya and Andalucia have implemented systems to accredit hospitals, Aragon and Cantabria are applying the EFQM model, and Navarra has developed its own quality management programme.21 Similarly, there is considerable diversity among Italian regions.
 
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Forest plot for polysomnographic sleep latency under random effects assumptions  
Forest plot for subjective sleep latency under random effects assumptions  
Figures  
To investigate the effectiveness of non-benzodiazepine hypnotics (Z drugs) and associated placebo responses in adults and to evaluate potential moderators of effectiveness in a dataset used to approve these drugs. Systematic review and meta-analysis. US Food and Drug Administration (FDA). Randomised double blind parallel placebo controlled trials of currently approved Z drugs (eszopiclone, zaleplon, and zolpidem). Change score from baseline to post-test for drug and placebo groups; drug efficacy analysed as the difference of both change scores. Weighted raw and standardised mean differences with their confidence intervals under random effects assumptions for polysomnographic and subjective sleep latency, as primary outcomes. Secondary outcomes included waking after sleep onset, number of awakenings, total sleep time, sleep efficiency, and subjective sleep quality. Weighted least square regression analysis was used to explain heterogeneity of drug effects. 13 studies containing 65 separate drug-placebo comparisons by type of outcome, type of drug, and dose were included. Studies included 4378 participants from different countries and varying drug doses, lengths of treatment, and study years. Z drugs showed significant, albeit small, improvements (reductions) in our primary outcomes: polysomnographic sleep latency (weighted standardised mean difference, 95% confidence interval -0.57 to -0.16) and subjective sleep latency (-0.33, -0.62 to -0.04) compared with placebo. Analyses of weighted mean raw differences showed that Z drugs decreased polysomnographic sleep latency by 22 minutes (-33 to -11 minutes) compared with placebo. Although no significant effects were found in secondary outcomes, there were insufficient studies reporting these outcomes to allow firm conclusions. Moderator analyses indicated that sleep latency was more likely to be reduced in studies published earlier, with larger drug doses, with longer duration of treatment, with a greater proportion of younger and/or female patients, and with zolpidem. Compared with placebo, Z drugs produce slight improvements in subjective and polysomnographic sleep latency, especially with larger doses and regardless of type of drug. Although the drug effect and the placebo response were rather small and of questionable clinical importance, the two together produced to a reasonably large clinical response.
 
Structure and content of educational programme aimed at parents of children with atopic dermatitis and adolescents with atopic dermatitis 
Baseline characteristics of groups receiving educational intervention for atopic dermatitis or no education (control) 
Outcome variables using analysis of covariance at baseline and 12 months' follow-up for groups receiving an educational programme in atopic dermatitis or no education 
To determine the effects of age related, structured educational programmes on the management of moderate to severe atopic dermatitis in childhood and adolescence. Multicentre, randomised controlled trial. Seven hospitals in Germany. Parents of children with atopic dermatitis aged 3 months to 7 years (n = 274) and 8-12 years (n = 102), adolescents with atopic dermatitis aged 13-18 years (n = 70), and controls (n = 244, n = 83, and n = 50, respectively). Group sessions of standardised intervention programmes for atopic dermatitis once weekly for six weeks or no education (control group). Severity of eczema (scoring of atopic dermatitis scale), subjective severity (standardised questionnaires), and quality of life for parents of affected children aged less than 13 years, over 12 months. Significant improvements in severity of eczema and subjective severity were seen in all intervention groups compared with control groups (total score for severity: age 3 months to 7 years - 17.5, 95% confidence intervals - 19.6 to - 15.3 v - 12.2, - 14.3 to - 10.1; age 8-12 years - 16.0, - 20.0 to - 12.0 v - 7.8, - 11.4; - 4.3; and age 13-18 years - 19.7, - 23.7 to - 15.7 v - 5.2, - 10.5 to 0.1). Parents of affected children aged less than 7 years experienced significantly better improvement in all five quality of life subscales, whereas parents of affected children aged 8-12 years experienced significantly better improvement in three of five quality of life subscales. Age related educational programmes for the control of atopic dermatitis in children and adolescents are effective in the long term management of the disease.
 
Progress through the meta-analysis
Frequency of symptoms and signs in children with intracranial tumours Analysis by age and neurofi bromatosis status. ICP=intracranial pressure. NOS=not otherwise specifi ed. CNP=cranial nerve palsy.  
CNS tumour presentation *Symptom or sign caused by raised intracranial pressure (ICP).  
Healthcare professionals caring for children need to promptly identify the child or young person with a serious underlying condition from the majority who present with minor self limiting illness. Recognising when a child might have cancer can be particularly difficult. Despite the perception that cancer is rare in children, an average general practice will see a child or young person with a new cancer every six years, and a quarter of the tumours will be brain tumours. Early diagnosis can be crucial—evidence from cohort studies shows that it can improve short term and long term outcomes. This review summarises current evidence on the presentation and recognition of brain tumours in children and young adults and provides an overview of the treatment and long term care strategies for this population.
 
Life expectancy at birth (in years) in selected countries, 1990 to 2008 (or latest available year) 3  
Public expenditure on health as percentage of gross domestic product in selected countries, 1994 to 2009 5  
Number of nurses versus number of doctors per 100 000 population in Hungary and selected countries and averages in 2008 (or latest available year) 3  
Figures
Our recent review of the Hungarian health system laid bare some of the major challenges it faces today. Although Hungary’s problems are not unique, their size sets this nation of 10 million people apart. The country has some of the worst health indicators in Europe, and public funding of its health system, which has long been inadequate, is currently in decline. Out of pocket expenses are high and the system encourages informal payments. At the same time, the health workforce in Hungary is shrinking because of migration of skilled professionals, threatening the sustainability of the system. In this article we look at some of the successes and failures of recent health reforms and suggest a way forward.
 
Over a five-year period 86 patients presented to a renal unit with a history of prolonged analgesic abuse and no other obvious cause of renal damage. Anaemia and peptic ulceration were common, and neurological states suggestive of chronic analgesic intoxication occurred in 22 patients. Thirty-two patients died during follow-up, but the prognosis was much better in patients who ceased abuse of compound analgesics, and improvement could occur even in advanced renal failure. While 84 patients had taken mixtures containing both aspirin and phenacetin, papillary necrosis was also found in two patients who had abused only aspirin, and when phenacetin was withdrawn from several leading compound analgesics, renal function continued to deteriorate in patients ingesting those preparations.
 
Anorexia nervosa remains challenging to treat and difficult to prevent. Nearly 5% of affected individuals die of this disease and 20% develop a chronic eating disorder. Anorexia nervosa may be associated with several medical complications of varying severity, including dysfunction of the renal system. Though there are some reports of renal failure in patients with anorexia nervosa, few reports are available concerning patients who required maintenance dialysis. We report a case of a patient with long-term untreated anorexia nervosa-binge eating/purging type who started psychiatric treatment when in a life-threatening situation (renal failure requiring dialysis), with unsuccessful weight recovery while on dialysis and died of septicaemia. The mechanisms that seem to be involved in the development of end-stage renal disease in this patient and the challenges associated with her treatment are reviewed. Patients with anorexia nervosa should be carefully monitored to discover the subtle manifestations of early renal failure.
 
I thank Professor Sharpe for his comments on the COINCIDE trial report and related editorial.1 2 3I agree that we should not conclude that all collaborative care approaches are equivalent and that the COINCIDE results are the best that can be achieved for patients with complex mixes of mental and physical health problems. The point I would emphasise, and that we drew out in our discussion, is that the kind of collaborative care we tested was modelled on a more pragmatic approach than had previously been tested in primary care, both in the US and UK. In COINCIDE usual care providers (practice nurses and psychologists employed by Improving Access to Psychological Therapies) delivered the care and were supervised within their service. We therefore not only tested the effectiveness of an integrated care model for people with long term conditions but also the effectiveness of a model that could potentially be delivered at scale in health services such as the NHS.We agree that the effect size for reductions in depressive symptoms was modest, but it was no worse than that achieved in comparable primary care trials of collaborative care included in our Cochrane review. And, moreover, this was achieved in people with high levels of mental and physical multimorbidity and deprivation. The alternative view is to wonder how we achieved comparable treatment effects to other primary care trials of collaborative care in such a difficult to treat population, and despite most patients not receiving the “full” treatment dose of this low intensity intervention. The gains in self management skills were considerable and may be the bigger story here in a group who need support from both physical and mental health practitioners to engage in self care.Clearly there is more to done and further questions to answer, not least as Gunn asked,2 why these patients engaged in only about half of the allotted treatment sessions and why only half participated in joint treatment sessions. I think we can all agree, as the remarkable success of the SMaRT Oncology trials has shown, that patients with mental and physical multimorbidity do better when their mental and physical healthcare is brought together. How we do that and meet the needs of large numbers of (primary care) patients with long term conditions whose mental healthcare has previously gone unmet is a question that our trial has only begun to answer.NotesCite this as: BMJ 2015;350:h1288
 
To quantify the risk and severity of negative effects of treatment for localised prostate cancer on long term quality of life. Population based, prospective cohort study with follow-up over three years. New South Wales, Australia. Men with localised prostate cancer were eligible if aged less than 70 years, diagnosed between October 2000 and October 2002, and notified to the New South Wales central cancer registry. Controls were randomly selected from the New South Wales electoral roll and matched to cases by age and postcode. General health specific and disease specific function up to three years after diagnosis, according to the 12 item short form health survey and the University of California, Los Angeles prostate cancer index. 1642 (64%) cases and 495 (63%) eligible and contacted controls took part in the study. After adjustment for confounders, all active treatment groups had low odds of having better sexual function than controls, in particular men on androgen deprivation therapy (adjusted odds ratio (OR) 0.02, 95% CI 0.01 to 0.07). Men treated surgically reported the worst urinary function (adjusted OR 0.17, 95% CI 0.13 to 0.22). Bowel function was poorest in cases who had external beam radiotherapy (adjusted OR 0.44, 95% CI 0.30 to 0.64). General physical and mental health scores were similar across treatment groups, but poorest in men who had androgen deprivation therapy. The various treatments for localised prostate cancer each have persistent effects on quality of life. Sexual dysfunction three years after diagnosis was common in all treatment groups, whereas poor urinary function was less common. Bowel function was most compromised in those who had external beam radiotherapy. Men with prostate cancer and the clinicians who treat them should be aware of the effects of treatment on quality of life, and weigh them up against the patient's age and the risk of progression of prostate cancer if untreated to make informed decisions about treatment.
 
| Number and percentage of children with cerebral palsy by region 
| Associations between participation on each domain and impairment and pain in final multilevel multivariable model Life-H domain Characteristics of children for whom parents reported lower participation Daily activities Mealtimes Walking ability, fine motor skills, intellectual ability, feeding ability 
| Multilevel, multivariable regression models, relating participation for each Life-H domain in daily activities to type and level of impairment and pain of 799 children with cerebral palsy. Figures are odds ratios* (95% confidence intervals) unless stated otherwise 
To evaluate how involvement in life situations (participation) in children with cerebral palsy varies with type and severity of impairment and to investigate geographical variation in participation. Cross sectional study. Trained interviewers visited parents of children with cerebral palsy; multilevel multivariable regression related participation to impairments, pain, and sociodemographic characteristics. Eight European regions with population registers of children with cerebral palsy; one further region recruited children from multiple sources. 1174 children aged 8-12 with cerebral palsy randomly selected from the population registers, 743 (63%) joined in the study; the further region recruited 75 children. Children's participation assessed by the Life-H questionnaire covering 10 main areas of daily life. Scoring ignored adaptations or assistance required for participation. Children with pain and those with more severely impaired walking, fine motor skills, communication, and intellectual abilities had lower participation across most domains. Type of cerebral palsy and problems with feeding and vision were associated with lower participation for specific domains, but the sociodemographic factors examined were not. Impairment and pain accounted for up to a sixth of the variation in participation. Participation on all domains varied substantially between regions: children in east Denmark had consistently higher participation than children in other regions. For most participation domains, about a third of the unexplained variation could be ascribed to variation between regions and about two thirds to variation between individuals. Participation in children with cerebral palsy should be assessed in clinical practice to guide intervention and assess its effect. Pain should be carefully assessed. Some European countries facilitate participation better than others, implying some countries could make better provision. Legislation and regulation should be directed to ensuring this happens.
 
Characteristics of studies included in meta-analysis 
Selection process for studies included in meta-analysis
Effect of exercise training on death or admission to hospital  
To determine the effect of exercise training on survival in patients with heart failure due to left ventricular systolic dysfunction. Collaborative meta-analysis. Inclusion criteria Randomised parallel group controlled trials of exercise training for at least eight weeks with individual patient data on survival for at least three months. Studies reviewed Nine datasets, totalling 801 patients: 395 received exercise training and 406 were controls. Death from all causes. During a mean (SD) follow up of 705 (729) days there were 88 (22%) deaths in the exercise arm and 105 (26%) in the control arm. Exercise training significantly reduced mortality (hazard ratio 0.65, 95% confidence interval, 0.46 to 0.92; log rank chi(2) = 5.9; P = 0.015). The secondary end point of death or admission to hospital was also reduced (0.72, 0.56 to 0.93; log rank chi(2) = 6.4; P = 0.011). No statistically significant subgroup specific treatment effect was observed. Meta-analysis of randomised trials to date gives no evidence that properly supervised medical training programmes for patients with heart failure might be dangerous, and indeed there is clear evidence of an overall reduction in mortality. Further research should focus on optimising exercise programmes and identifying appropriate patient groups to target.
 
| (a) Balance exercise with medicine ball (assistant stands on two legs and player on one leg: assistant throws ball to player, who catches ball overhead and returns it below knee); (b) balance exercise with medicine ball (on one leg players throw and catch ball from side of body); (c) balance board exercise with stick and ball on one leg; (d) three dimensional leg hops over sticks; (e) leg split squat; and (f) isometric side and front bridge 
| Compliance of female floorball teams (n=14) receiving neuromuscular training intervention Variable Mean (SD, range) volume of training
| Number (percentage) of female floorball players in intervention group participating in scheduled neuromuscular training during each training period
Objective To investigate whether a neuromuscular training programme is effective in preventing non-contact leg injuries in female floorball players. Design Cluster randomised controlled study. Setting 28 top level female floorball teams in Finland. Participants 457 players (mean age 24 years)—256 (14 teams) in the intervention group and 201 (14 teams) in the control group—followedup for one league season (six months). Intervention A neuromuscular training programme to enhance players’ motor skills and body control, as well as to activate and prepare their neuromuscular system for sports specific manoeuvres. Main outcome measure Acute non-contact injuries of the legs. Results During the season, 72 acute non-contact leg injuries occurred, 20 in the intervention group and 52 in the control group. The injury incidence per 1000 hours playing and practise in the intervention group was 0.65 (95% confidence interval 0.37 to 1.13) and in the control group was 2.08 (1.58 to 2.72). The risk of non-contact leg injury was 66% lower (adjusted incidence rate ratio 0.34, 95% confidence interval 0.20 to 0.57) in the intervention group. Conclusion A neuromuscular training programme was effective in preventing acute non-contact injuries of the legs in female floorball players. Neuromuscular training can be recommended in the weekly training of these athletes. Trial registration Current Controlled Trials ISRCTN26550281.
 
Researchers examined the association between trends in antidepressant prescribing and suicide rates between 1991 and 2000 in Australia.1 A retrospective analysis of national databases was undertaken. Participants were aged 15 years or more. The primary outcomes were trends in suicide rates and antidepressant prescribing, according to sex and 10 year age groups. The trend in suicide within each age group was measured by the difference between the suicide rates per 100 000 people in two five year periods (1986-90 and 1996-2000). Trends in antidepressant prescribing were assessed by the change in defined daily dose per 1000 days, as indicated by the difference between 1991 and 2000. A positive trend in suicide rates or antidepressant prescribing within an age group represented an increase from 1991 to 2000. The researchers reported that although overall national rates of suicide did not fall significantly, the incidence decreased in older men and women and increased in younger adults. Rates of antibiotic prescribing increased across all age groups in both men and women. The association between trends in suicide rates and antidepressant prescribing were measured by Spearman’s rank correlation coefficient. There was an inverse correlation between trends in antidepressant prescribing and suicide; with the largest declines in suicide in the age groups with the greatest increase in exposure to antidepressants. The association was significant in women ( rs =−0.74; P<0.05) but not in men ( r s=−0.62; P<0.10). It was concluded that an increase in antidepressant prescribing may be a proxy marker for improved overall management of depression. If so, increased prescribing of selective serotonin reuptake inhibitors in general practice may have a quantifiable benefit on the mental health of the population. Which of the following statements, if any, are true?
 
Four patients are reported in whom perforation of the colon followed exchange transfusion for haemolytic disease of the newborn. This association seems to be more than coincidental, and possibly the perforation is due to a vascular accident occurring as a mechanical result of the exchange transfusion. The insidious onset of colonic perforation may be recognized early by the passage of blood per rectum. There is no place for conservative treatment, and once the diagnosis has been made treatment must include broad-spectrum antibiotics and laparotomy.
 
| Characteristics of the included studies of interventions primarily to promote cycling 
| Characteristics of the included studies on individualised marketing of "environmentally friendly" modes of transport (walking, cycling, and public transport) 
| Characteristics of the included studies on interventions to change travel behaviour in general 
To determine what interventions are effective in promoting cycling, the size of the effects of interventions, and evidence of any associated benefits on overall physical activity or anthropometric measures. Systematic review. Published and unpublished reports in any language identified by searching 13 electronic databases, websites, reference lists, and existing systematic reviews, and papers identified by experts in the field. Review methods Controlled "before and after" experimental or observational studies of the effect of any type of intervention on cycling behaviour measured at either individual or population level. Twenty five studies (of which two were randomised controlled trials) from seven countries were included. Six studies examined interventions aimed specifically at promoting cycling, of which four (an intensive individual intervention in obese women, high quality improvements to a cycle route network, and two multifaceted cycle promotion initiatives at town or city level) were found to be associated with increases in cycling. Those studies that evaluated interventions at population level reported net increases of up to 3.4 percentage points in the population prevalence of cycling or the proportion of trips made by bicycle. Sixteen studies assessing individualised marketing of "environmentally friendly" modes of transport to interested households reported modest but consistent net effects equating to an average of eight additional cycling trips per person per year in the local population. Other interventions that targeted travel behaviour in general were not associated with a clear increase in cycling. Only two studies assessed effects of interventions on physical activity; one reported a positive shift in the population distribution of overall physical activity during the intervention. Community-wide promotional activities and improving infrastructure for cycling have the potential to increase cycling by modest amounts, but further controlled evaluative studies incorporating more precise measures are required, particularly in areas without an established cycling culture. Studies of individualised marketing report consistent positive effects of interventions on cycling behaviour, but these findings should be confirmed using more robust study designs. Future research should also examine how best to promote cycling in children and adolescents and through workplaces. Whether interventions to promote cycling result in an increase in overall physical activity or changes in anthropometric measures is unclear.
 
Editor—Long et al report a high prevalence of viral and other sexually transmitted diseases in Irish prisons and conclude that use of injecting drugs could be the single most important factor for the high infection with hepatitis C virus there.1 They suggest that increased infection control and harm reduction measures are needed in Irish prisons. But they fail to acknowledge other, similar reports, particularly from the countries where HIV infection is highly epidemic. I and colleagues from the Indian subcontinent conducted a study in 1998 among Indian prisoners.2 Altogether 240 male and nine female prison inmates in a district prison near Delhi were screened for sexually transmitted and bloodborne diseases including HIV, syphilis, and hepatitis B and C viral infections. The inmates were aged 15-50 (mean (SD) 24.8 (0.11)). Of the 240 male prisoners, 115 were married and 184 gave a history of penetrative sex. Of the 184, 53 were homosexual or bisexual and the remainder had sex with women only. Sixty of 131 prisoners were faithful to their partners, while 124 gave a history of having multiple sexual partners and 100 of them had unprotected sex. Eighty three of these 100 had had sex with commercial sex workers. Altogether 126 were addicted to alcohol and 44 to smack/charas; only eight had a history of injecting drug use. On examination 28 of the 240 had active hepatitis with or without a history of jaundice in the past two years, 25 had active pulmonary tuberculosis, and 11 had syphilitic ulcers on the penis. Four fifths of the teenagers confined to a particular barrack had moderate to severe scabies. Three male prisoners (1%) were positive for HIV-1 (confirmed by western blotting) while 28 (11%) male and two (22%) female prisoners were positive for hepatitis B surface antigen. Twelve (5%) male but no female prisoners were positive for antibodies to hepatitis C virus. Of the three HIV positive prisoners, one was an injecting drug user, one was a drug user and frequent commercial sex worker, and the third was homosexual. This study showed that sexually transmitted and bloodborne infections are highly prevalent in prisons in India and may spread rapidly because of injecting drug use and homosexuality. Interestingly, unlike Long et al we found more hepatitis B than hepatitis C infection. Injecting drug use was less frequent than in Irish prisons, and homosexuality was probably the most important risk factor in Indian prisons. The study emphasised that more awareness about HIV and hepatitis virus infection is needed in Indian prisons.
 
Graded compression ultrasound image showing compressed sigmoid colon loop (star) with diverticulum (small arrow) with inflamed pericolic fat (large arrow). Ultrasound transducer is marked with circle  
Computed tomogram showing loop of sigmoid colon (star) with pericolic abscess with fluid (small arrow) and air (large arrow). Inflamed pericolic fat is marked with circle  
Figures
de Korte and colleagues make the case for using ultrasonography as the first investigation to confirm the diagnosis in patients with suspected diverticulitis #### Learning points A 55 year old man presented to the emergency department with a two day history of progressive pain in the left lower quadrant. On physical examination he had a temperature of 38°C and marked tenderness in the left lower quadrant and some tenderness in the suprapubic area. No rebound tenderness was present. Laboratory testing showed a C reactive protein concentration of 25 mg/L and a white cell count of 13.8 ×109/L. This patient is suspected of having a left sided diverticulitis. Diagnosis based solely on clinical and laboratory parameters is imperfect. The sensitivity for diagnosing acute diverticulitis on …
 
The Belgian Scientific Institute for Public Health reported 10% excess mortality in June 2013 (700 additional deaths a month) in those aged 65 and older.1 No likely cause was identified because climatic circumstances, air pollution levels, and physician visits for influenza-like illnesses were unremarkable. However, it is expected that July’s heat wave …
 
MRI of the brain (A) T1-weighted images showing hypointensities in the left caudate, external capsule and insular cortex, (B) and (C) T2-weighted MRI and T2 FLAIR (Fluid Attenuated Inversion Recovery) images show heterogenous hyperintensities in left caudate, thalamus, globus pallidus, internal capsule, external capsule and insular cortex, (D and E) show restriction on DWI in the above mentioned regions. (F) MRI contrast shows patchy enhancement of the left caudate. 
Varicella zoster virus (VZV)-induced vasculopathy is an uncommon cause of stroke in a young immunocompetent host. Owing to scarcity of data of VZV-induced vasculopathy and lack of awareness about this condition and its diagnostic test, these cases may be easily missed. In this case, we report an immunocompetent host presenting right-side hemiplegia with motor aphasia and complete loss of vision in the left eye due to complete occlusion of the left common carotid artery without any history of skin rash preceding stroke. Cerebrospinal fluid analysis for varicella antibody revealed very high titres and CT aortogram demonstrated aortoarteritis with occlusion of left common carotid artery. To our knowledge, varicella zoster vasculopathy-associated aortoarteritis has not been described in the literature.
 
A clinical study was undertaken using honey in oral rehydration solution in infants and children with gastroenteritis. The aim was to evaluate the influence of honey on the duration of acute diarrhoea and its value as a glucose substitute in oral rehydration. The results showed that honey shortens the duration of bacterial diarrhoea, does not prolong the duration of non-bacterial diarrhoea, and may safely be used as a substitute for glucose in an oral rehydration solution containing electrolytes. The correct dilution of honey, as well as the presence of electrolytes in the oral rehydration solution, however, must be maintained.
 
We disagree with this alarming picture of increasing availability of illegal alcohol in the UK market and its potential impact on health owing to various contaminants.1 The World Health Organization estimates that unrecorded consumption in the UK is relatively stable, at 2 L (or less) of pure alcohol per person (2.0 L in 2000, 1.7 L in 2004, 1.7 L in 2009).2 3 According to HM Revenue & Customs,4 the illicit beer market is not increasing, with estimates of 6% in 2007-8 and 2008-9, and 5% in 2009-10. Illicit beer mainly comes from diversion or drawback fraud, so substantial differences in beer composition are unlikely to lead to more pronounced detrimental health effects. The discussion about the health effects of illicit spirits neglected basic principles of regulatory toxicology and risk assessment.1 For example, the legislative limit for methanol in vodka is not a toxicological threshold but a technological threshold based on good manufacturing practices. Toxicological thresholds for higher aliphatic alcohols also cannot be exceeded in home produced spirits.5 Unless there is empirical evidence, we should assume that unrecorded alcohol in the UK has similar health effects to recorded alcohol. Alcohol prices in the UK are currently comparably low, so that even the marginalised consumer has little incentive to switch to surrogate alcohol products. We see no need for a policy on unrecorded alcohol (except as a way to reduce fraud), and efforts in the UK should focus on measures that have been shown to reduce total alcohol consumption, such as price increases.
 
To systematically determine the most efficacious approach for preventing pain on injection of propofol. Systematic review and meta-analysis. PubMed, Embase, Cochrane Library, www.clinicaltrials.gov, and hand searching from the reference lists of identified papers. Randomised controlled trials comparing drug and non-drug interventions with placebo or another intervention to alleviate pain on injection of propofol in adults. Data were analysed from 177 randomised controlled trials totalling 25,260 adults. The overall risk of pain from propofol injection alone was about 60%. Using an antecubital vein instead of a hand vein was the most effective single intervention (relative risk 0.14, 95% confidence interval 0.07 to 0.30). Pretreatment using lidocaine (lignocaine) in conjunction with venous occlusion was similarly effective (0.29, 0.22 to 0.38). Other effective interventions were a lidocaine-propofol admixture (0.40, 0.33 to 0.48); pretreatment with lidocaine (0.47, 0.40 to 0.56), opioids (0.49, 0.41 to 0.59), ketamine (0.52, 0.46 to 0.57), or non-steroidal anti-inflammatory drugs (0.67, 0.49 to 0.91); and propofol emulsions containing medium and long chain triglycerides (0.75, 0.67 to 0.84). Statistical testing of indirect comparisons showed that use of the antecubital vein and pretreatment using lidocaine along with venous occlusion to be more efficacious than the other interventions. The two most efficacious interventions to reduce pain on injection of propofol were use of the antecubital vein, or pretreatment using lidocaine in conjunction with venous occlusion when the hand vein was chosen. Under the assumption of independent efficacy a third practical alternative could be pretreatment of the hand vein with lidocaine or ketamine and use of a propofol emulsion containing medium and long chain triglycerides. Although not the most effective intervention on its own, a small dose of opioids before induction halved the risk of pain from the injection and thus can generally be recommended unless contraindicated.
 
Despite its popularity,1 concerns exist about the safety of the Wii console in patients with cardiac pacemakers because of the possibility of electromagnetic interference. The Nintendo Wii’s remote control uses Bluetooth technology (2.4 GHz) to communicate with the gaming console, and cardiac pacemakers often incorporate similar technology. This frequency falls within the range of electromagnetic interference …
 
Summary pointsPresentation of acute leukaemia can be non-specific, and not always have the classic signs and symptoms of anaemia, bruising, bleeding, hepatosplenomegaly, and lymphadenopathy. Diagnosis can be difficult, and delays can contribute to additional, sometimes life threatening problems during the period of initial treatment.Relatively simple, inexpensive tests—a full blood count and examination of the blood film—will diagnose acute leukaemia in most cases.Overall survival has risen from less than 5% in the 1960s to over 85% today.Acute leukaemia is the commonest malignancy of childhood. In the United Kingdom, one in 2000 children develop the disorder, with around 450 new cases being diagnosed annually.1 However, most general practitioners will see a case of childhood leukaemia only once or twice in their careers2 and, since management generally takes place in tertiary referral centres, non-specialist paediatricians will encounter relatively few patients.Compared with the 1970s, the outcome today for children with acute leukaemia has improved dramatically. Numerous high quality randomised controlled trials have shown that over 85% of children can now be cured.3 4 Goals for the future should focus on keeping treatment and side effects to a minimum for patients at low risk of recurrent disease, and improving the outcome for the small proportion of children at high risk of relapse.5In this review, we summarise current knowledge about the presentation, diagnosis, and optimum management of children with acute leukaemia. We also suggest strategies for early diagnosis of the disease in primary care, which should minimise avoidable complications and allow for early supportive care.What causes acute leukaemia?Acute leukaemia arises from genetic mutations in blood progenitor cells. These mutations generate both an uncontrollable capacity for self-renewal and the developmental arrest of the progenitor cells at a particular point in their differentiation.6 The body is therefore overwhelmed by immature cells …
 
As Hammond said,1 and my website shows in the wart section (www.chestersexualhealth.co.uk), genital warts are not just an annoying nuisance. Both human papillomavirus (HPV) vaccines are so far equally effective for HPV 16 and 18, but it …
 
This exhibition of art that exploits the latest radiographic techniques continues a tradition as old as radiography itself, says Arpan K BanerjeeInstead of using paint and brushes to depict life Franz Fellner, an Austrian radiologist at the general hospital in Linz, has used modern investigative radiological tools to create unique images of the human form and of inanimate objects. His exhibition, Ars Intrinsica, shows the inside of the human body in detail. These depictions of the internal organs, the brain, and the body’s vast network of arteries and veins are reminiscent of images from Andreas Vesalius’s great anatomical opus of 1543, De Humanis Corporis Fabrica.Fellner has used the latest techniques in digital imaging, such as multislice computed tomography and diffusion and tensor weighted magnetic resonance imaging. Modern scanners allow fast, three dimensional visualisation of the internal organs …
 
The POPADAD trial shows no benefit from daily prophylactic aspirin (hazard ratio 0.98; P=0.87) in people who have diabetes and early peripheral arterial disease. However, no firm conclusions should be drawn from a single trial, but the result be incorporated in a meta-analysis of all available evidence from relevant trials.1The absence of evidence of benefit is not surprising as the trial was seriously underpowered. The annual …
 
The landmark millennium development goals provide a road map for reducing the disease, poverty, and hunger faced by millions worldwide. Unfortunately, the progress they have instigated is at risk of being undermined by new threats.1Cancer, cardiovascular disease, diabetes, and other non-communicable diseases (NCDs) currently claim more than 35 million lives each year, accounting for 60% of all deaths worldwide. When measured in disability adjusted life years (DALYs), they also account for nearly …
 
New generation bisphosphonates such as zolendronic acid, pamidronate, and alendronic acid have various indications in medicine. Initially, their use was restricted to patients with metastatic bone malignancy secondary to breast cancer, lung cancer, prostate cancer, or multiple myeloma. Their benefit in these conditions led to wider application for other bone pathologies, such as osteoporosis and Paget's disease.1 Their main effect is to inhibit osteoclast activity; however, they also seem to have antiangiogenic effects, …
 
This is the fourth in a series of five articlesThis article reviews our current understanding of the cognitive processes involved in diagnostic reasoning in clinical medicine. It describes and analyses the psychological processes employed in identifying and solving diagnostic problems and reviews errors and pitfalls in diagnostic reasoning in the light of two particularly influential approaches: problem solving1, 2, 3 and decision making.4, 5, 6, 7, 8 Problem solving research was initially aimed at describing reasoning by expert physicians, to improve instruction of medical students and house officers. Psychological decision research has been influenced from the start by statistical models of reasoning under uncertainty, and has concentrated on identifying departures from these standards. Summary points Problem solving and decision making are two paradigms for psychological research on clinical reasoning, each with its own assumptions and methods The choice of strategy for diagnostic problem solving depends on the perceived difficulty of the case and on knowledge of content as well as strategy Final conclusions should depend both on prior belief and strength of the evidence Conclusions reached by Bayes's theorem and clinical intuition may conflict Because of cognitive limitations, systematic biases and errors result from employing simpler rather than more complex cognitive strategies Evidence based medicine applies decision theory to clinical diagnosis Problem solving Diagnosis as selecting a hypothesis The earliest psychological formulation viewed diagnostic reasoning as a process of testing hypotheses. Solutions to difficult diagnostic problems were found by generating a limited number of hypotheses early in the diagnostic process and using them to guide subsequent collection of data.1 Each hypothesis can be used to predict what additional findings ought to be present if it were true, and the diagnostic process is a guided search for these findings. Experienced physicians form hypotheses and their diagnostic plan rapidly, and the …
 
“And they all lived happily ever after,” happens only in fairy tales. The clever hospital doctors have made a fascinating physiological diagnosis, and the patient has stopped vomiting and returned to normal life. Cured. Wouldn't it be great if life was like this all the time? Most general practitioners will suppress a wry smile, knowing that this is likely to describe a chapter in Mr Neville's life.1 His general practice file is already substantial, and his hospital notes bulging. The pattern of morbidity leading up to this admission is perhaps likely to continue long into the future.Our …
 
As a child I remember eating well and enjoying my food, although I did get heartburn now and again. That all changed in 2001 when I started to bring up what I ate. At first this was occasional, but then my stomach settled into a new routine. On eating even small amounts I felt unpleasantly full, then I had to belch and the food came back to my mouth. I usually spat this out, but sometimes I swallowed it again. If I tried to eat larger amounts my stomach hurt and I had to vomit everything up. …
 
Kenneth Neville's case raises the question whether we should teach general practitioners and medical students about functional oesophageal disorders.1 This question is particularly important now that most medical schools are implementing a problem based or case based curriculum. The philosophy of these courses is to focus on key concepts and reduce detail in the subject matter. Conditions such as rumination syndrome will not be considered important and will be omitted.Interestingly, major medical textbooks also show a deficiency in this area. For example, the last editions of Harrison's Principles of …
 
A recent patient under my team needed anticoagulation. On day three of warfarin dosing, the patient, who was receiving other drugs, wanted to know what things interacted with warfarin. I named …
 
Top-cited authors
Lyndal Bond
Graham F Moore
  • Cardiff University
Daniel Wight
  • University of Glasgow
Wendy Hardeman
  • University of East Anglia
Suzanne Audrey
  • University of Bristol