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Objective To compare the effectiveness of social behaviour and network therapy, a new treatment for alcohol problems, with that of the proved motivational enhancement therapy. Design Pragmatic randomised trial Setting Seven treatment sites around Birmingham, Cardiff, and Leeds. Participants. 742 clients with alcohol problems; 689 (93.0%) were interviewed at three months and 617 (83.2%) at 12 months. Interventions Social behaviour and network therapy and motivational enhancement therapy. Main outcome measures Changes in alcohol consumption, alcohol dependence, and alcohol related problems over 12 months. Results Both groups reported substantial reductions in alcohol consumption, dependence, and problems, and better mental health related quality of life over 12 months. Between groups we found only one significant difference in outcome, probably due to chance: the social network group showed significantly better physical health at three months. Non-significant differences at 12 months in the motivational group relative to the social network group included: the number of drinks consumed per drinking day had decreased by an extra 1.1 (95% confidence interval −1.0 to 3.2); scores on the Leeds dependence questionnaire had improved by an extra 0.6 (−0.7 to 2.0); scores on the alcohol problems questionnaire had improved by an extra 0.5 (−0.4 to 1.4); but the number of days abstinent from drinking had increased by 1.2% less (−4.5% to 6.9%). Conclusion The novel social behaviour and network therapy for alcohol problems did not differ significantly in effectiveness from the proved motivational enhancement therapy.

Allergic rhinoconjunctivitis is a common chronic disorder in children, especially in developed countries. It does not cause nasal symptoms only (such as congestion and sneezing) but may also cause general complaints such as fatigue and cough (box 1). It can also cause learning problems1 and has a great impact on quality of life. Uncontrolled allergic rhinoconjunctivtis may aggravate the symptoms of asthma.2 Although classic “hay fever” is easily recognised in children who have a runny nose, sneezing, and itchy eyes during the pollen season, the diagnosis of allergic rhinoconjunctivitis is often missed in children with perennial nasal congestion. #### Box 1: Key symptoms of allergic rhinoconjunctivitis in children ##### Nasal ##### General The term allergic rhinoconjunctivitis is preferable to allergic rhinitis because most patients also have ocular symptoms. In this review, we discuss the prevalence of allergic rhinoconjunctivitis in children, its causes, how it is diagnosed, and how it can be treated. We used the Cochrane library to identify relevant systematic reviews on drugs for allergic rhinoconjunctivitis in children. Medline was searched for systematic reviews on diagnosis and treatment of allergic rhinoconjunctivitis in children using the keywords “rhinoconjunctivitis”, “systematic review”, “meta-analysis”, “diagnosis”, and “treatment”. We limited our searches to “all child”. We took additional references from our personal files. #### SUMMARY POINTS

Problem Prophylactic treatment and follow-up after exposure to HIV, hepatitis B, and hepatitis C outside hospital needs to be improved. Background and setting Until January 2000, people in Amsterdam could report exposure outside hospital to either a hospital or the municipal health service. If they reported to the municipal health service, they were then referred to hospitals for HIV prophylaxis, whereas the municipal health service handled treatment and follow-up related to hepatitis B and hepatitis C and traced sources. For cases reported to a hospital, hospital staff often did not trace HIV sources or follow up patients for hepatitis B and hepatitis C. Key measures for improvement Providing adequate treatment for HIV, hepatitis B and hepatitis C after exposure for all reported exposures outside hospital. Strategies for change On 1 January 2000, a new protocol was introduced in which three Amsterdam hospitals and the municipal health service collaborated in the treatment and follow-up of exposures outside hospital. Both municipal health service and hospitals can decide whether HIV prophylaxis is necessary and prescribe accordingly. All people exposed in the community who report to hospitals are subsequently referred to the municipal health service for further treatment and follow-up. Effects of change The protocol is effective in that most people comply with treatment and follow-up. When indicated, HIV prophylaxis is started soon after exposure. In nearly two thirds of cases the municipal health service traced and tested the source. Lessons learnt Provision of treatment and follow-up in one place enables treatment, tracing and testing sources, and follow-up, including counselling and registration of all reported exposures in Amsterdam, which allows for swift identification of emerging epidemiological trends. Since May 2004 all Amsterdam hospitals have participated in the protocol.

Reviews of undergraduate medical education cautiously support the short term and long term outcomes of problem based learning compared with traditional learning. The effectiveness of problem based learning in continuing medical education, however, has not been reviewed. This review of controlled evaluation studies found limited evidence that problem based learning in continuing medical education increased participants' knowledge and performance and patients' health. There was moderate evidence that doctors are more satisfied with problem based learning.

Objective: To evaluate the safety of withholding anticoagulant treatment from patients with clinically suspected deep vein thrombosis but normal findings on compression ultrasonography. Design: Compression ultrasonography was done with a simplified diagnostic procedure limited to the common femoral vein in the groin and the popliteal vein extending down to the trifurcation of the calf veins. Patients with normal ultrasonography findings at presentation were retested 1 week later. Main outcome measure: The incidence of venous thromboembolic complications during follow up for 6 months in patients in whom anticoagulant treatment was withheld on the basis of normal results on two ultrasonography tests 1 week apart. Setting: University research centres in four hospitals. Results: A total of 1702 patients were included in the study. Abnormal results on compression ultrasonography at presentation or at 1 week were found in 400 and 12 patients, respectively, for a prevalence of deep vein thrombosis of 24%. None of the patients were lost to follow up. Venous thromboembolic complications during the week of serial testing occurred in a single patient and in eight patients during 6 months9 follow up, resulting in a cumulative rate of venous thromboembolic complications of 0.7% (95% confidence interval 0.3% to 1.2%). The mean number of extra hospital visits and additional tests required per initially referred patient was 0.8. Conclusion: It is safe to withhold anticoagulant treatment from patients with clinically suspected deep vein thrombosis who have a normal result on compression ultrasonography at the time of presentation and at 1 week. Key messages Clinical diagnosis of suspected deep vein thrombosis is notoriously unreliable and objective diagnostic tests are indicated to confirm or refute the presence of this condition Ultrasonography with vein compressibility of the common femoral and popliteal vein is the non-invasive test of choice for the diagnostic management of patients with suspected deep vein thrombosis It is safe to withhold anticoagulant treatment from patients with suspected deep vein thrombosis who have normal results on compression ultrasonography on presentation and on a single repeat test 1 week later With the simplified compression ultrasound strategy the number of repeat tests can be safely reduced to a single test performed a week after presentation Most patients with deep vein thrombosis can be identified at presentation, making this strategy convenient to patients and less costly

Evaluation of screening should reflect consumer priorities. We need to make more effort to find out what they really are

Should be mandatory There is clear evidence that healthcare workers play an important role in transmitting infections to their patients.1 The World Health Organization and national immunisation guidelines in 60% of developed and emerging economies strongly recommend annual vaccination against seasonal influenza for all healthcare workers in acute and long term care facilities.2 However, unlike other prophylactic measures targeted at healthcare workers, such as hepatitis B vaccination, the uptake of flu vaccine has been generally poor. In the United States, two decades of consistent advocacy by the Centers for Disease Control and Prevention achieved a self reported vaccine coverage of only 64% among healthcare workers by 2010-1.3 In the United Kingdom, despite recommendations by the Department of Health, uptake of seasonal flu vaccine was a dismal 35% among frontline healthcare workers in the same year.4 Flu contributes greatly to global mortality and morbidity and has important economic consequences. Each year, seasonal flu affects 5-10% of the world’s population, causing 3-5 million severe infections and resulting in 250 000-500 000 deaths. Young children (especially those under 1 year); pregnant …

I have moved back to live in east London and am gutting my Victorian terraced house in newly fashionable Bow, just a short bike ride from the stadium soon to be used for the Olympic and Paralympic games. I am getting acquainted with my Victorian lead water pipes, well preserved sewers, and the occasional coin left by the builders in 1858. That was the year of the “great stink,” when the smell of raw sewage was so overpowering in central London that curtains soaked in chloride of lime were draped across …

A 30 year old mechanic attends with a scaly rash on both his palms. He describes cuts on his skin which are painful and affect his grip strength. This has caused him to have time off work. Common causes of diffuse scaly rashes on the hands are eczema (atopic, irritant or allergic contact dermatitis, and pompholyx), psoriasis, scabies, and tinea. A patient can have more than one diagnosis (such as atopic eczema plus an occupational allergic contact dermatitis). To help identify the cause(s) and effects of the rash, inquire about

Objective To assess the risk of adverse cardiovascular events in women who discontinue hormone replacement therapy after myocardial infarction compared with those who continue. Design Nationwide register based cohort study. Setting All hospitals in Denmark. Population All 3322 women aged 40 years or over who survived 30 days after a myocardial infarction and were prescribed hormone replacement therapy at the time of myocardial infarction in the period 1997 to 2008. Main outcome measures Reinfarction, cardiovascular mortality, and all cause mortality 30 to 360 days after discharge . Results A total of 282 (8.5%) women had a reinfarction, 218 (6.6%) died of cardiovascular causes, and 357 (10.7%) died of any cause during follow-up. Women who discontinued overall hormone replacement therapy in the first year after myocardial infarction did not have a significantly different risk of reinfarction (hazard ratio 0.90, 95% confidence interval 0.68 to 1.19), cardiovascular mortality (1.21, 0.90 to 1.62), or all cause mortality (1.22, 0.97 to 1.53) than women who continued use. However, discontinuation of vaginal oestrogen was associated with a lower risk of reinfarction (hazard ratio 0.54, 0.34 to 0.86). Conclusion No certain conclusions can be drawn regarding increased or decreased risk of adverse cardiovascular events with continuing hormone replacement therapy after myocardial infarction. The results rule out neither a modest benefit nor a worrisome increase in risk. These figures may be valuable when a possible cardiovascular risk of hormone replacement therapy needs to be balanced with menopausal symptoms for the individual patient.

A recent consensus conference organised by the Royal College of Physicians of Edinburgh recommended opportunistic pulse checking of people over 65 years by GPs, followed by electrocardiography for those with an irregular pulse.1 The aim is to identify people at an increased risk for stroke …

Three small points for us all to consider.1 Firstly, only England is changing its NHS as part of the current parliamentary mess. The rest of the UK is wisely treading a very different path and delivering more effective care. Secondly, the focus on objectives by …

A 45 year old woman presents to her general practitioner complaining of troublesome urinary symptoms increasingly affecting her quality of life. She is currently voiding more than 10 times a day and rising three times at night. In addition she notices a sudden urgent desire to void and on two occasions has leaked urine before reaching the toilet. She gives no history of urinary tract infection or haematuria. Her periods remain regular. In the past she has had two vaginal deliveries, has no significant medical history, and is not taking any medication. Pelvic examination is unremarkable and urine analysis normal. Ultrasound examination shows no post-void residual urine. Based on the history, clinical examination, and basic investigations you make a symptomatic diagnosis of overactive bladder. After discussing her bladder symptoms, you offer lifestyle advice including the moderation of fluids and reduction of caffeine intake. In addition you refer her for bladder retraining and start treatment with antimuscarinic drugs. Overactive bladder is the term used to describe the symptom complex of urinary urgency, usually accompanied by frequency and nocturia, with or without urge urinary incontinence, in the absence of urinary tract infection or other obvious pathology.1 Epidemiological studies in North America have reported a prevalence of overactive bladder in women of 16.9%, and the prevalence increases with age—from 4.8% in women under 25 years to 30.9% in those aged over 65 years.2 Prevalence data from Europe are similar, with frequency the most commonly reported symptom (85%), and 54% reporting urgency and 36% urge incontinence.3 The symptoms of overactive bladder are most likely due to involuntary contractions of the detrusor muscle during the filling phase of the micturition cycle; abnormalities in afferent sensation may also play a role. Detrusor overactivity1 is mediated by acetylcholine induced stimulation of muscarinic receptors …

Objectives To determine the effect of human papillomavirus (HPV) quadrivalent vaccine on the risk of developing subsequent disease after an excisional procedure for cervical intraepithelial neoplasia or diagnosis of genital warts, vulvar intraepithelial neoplasia, or vaginal intraepithelial neoplasia. Design Retrospective analysis of data from two international, double blind, placebo controlled, randomised efficacy trials of quadrivalent HPV vaccine (protocol 013 (FUTURE I) and protocol 015 (FUTURE II)). Setting Primary care centres and university or hospital associated health centres in 24 countries and territories around the world. Participants Among 17 622 women aged 15–26 years who underwent 1:1 randomisation to vaccine or placebo, 2054 received cervical surgery or were diagnosed with genital warts, vulvar intraepithelial neoplasia, or vaginal intraepithelial neoplasia. Intervention Three doses of quadrivalent HPV vaccine or placebo at day 1, month 2, and month 6. Main outcome measures Incidence of HPV related disease from 60 days after treatment or diagnosis, expressed as the number of women with an end point per 100 person years at risk. Results A total of 587 vaccine and 763 placebo recipients underwent cervical surgery. The incidence of any subsequent HPV related disease was 6.6 and 12.2 in vaccine and placebo recipients respectively (46.2% reduction (95% confidence interval 22.5% to 63.2%) with vaccination). Vaccination was associated with a significant reduction in risk of any subsequent high grade disease of the cervix by 64.9% (20.1% to 86.3%). A total of 229 vaccine recipients and 475 placebo recipients were diagnosed with genital warts, vulvar intraepithelial neoplasia, or vaginal intraepithelial neoplasia, and the incidence of any subsequent HPV related disease was 20.1 and 31.0 in vaccine and placebo recipients respectively (35.2% reduction (13.8% to 51.8%)). Conclusions Previous vaccination with quadrivalent HPV vaccine among women who had surgical treatment for HPV related disease significantly reduced the incidence of subsequent HPV related disease, including high grade disease. Trial registrationsNCT00092521 and NCT00092534

Objective To compare the effects of free nicotine replacement therapy or proactive telephone counselling in addition to standard smoking cessation support offered through a telephone quitline. Design Parallel group, 2×2 factorial, randomised controlled trial. Setting National quitline, England. Participants 2591 non-pregnant smokers aged 16 or more residing in England who called the quitline between February 2009 and February 2010 and agreed to set a quit date: 648 were each randomised to standard support, proactive support, or proactive support with nicotine replacement therapy, and 647 were randomised to standard support with nicotine replacement therapy. Interventions Two interventions were offered in addition to standard support: six weeks’ nicotine replacement therapy, provided free, and proactive counselling sessions (repeat telephone calls from, and interaction with, cessation advisors). Main outcome measures The primary outcome was self reported smoking cessation for six or more months after the quit date. The secondary outcome was cessation validated by exhaled carbon monoxide measured at six or more months. Results At six months, 17.7% (n=229) of those offered nicotine replacement therapy reported smoking cessation compared with 20.1% (n=261) not offered such therapy (odds ratio 0.85, 95% confidence interval 0.70 to 1.04), and 18.2% (n=236) offered proactive counselling reported smoking cessation compared with 19.6% (n=254) offered standard support (0.91, 0.75 to 1.11). Data validated by carbon monoxide readings changed the findings for nicotine replacement therapy only, with smoking cessation validated in 6.6% (85/1295) of those offered nicotine replacement therapy compared with 9.4% (122/1296) not offered such therapy (0.67, 0.50 to 0.90). Conclusions Offering free nicotine replacement therapy or additional (proactive) counselling to standard helpline support had no additional effect on smoking cessation. Trial registration ClinicalTrials.gov NCT00775944.

In the first of a new occasional series highlighting the exaggerations, distortions, and selective reporting that make some news stories, advertising, and medical journal articles “not so,” Lisa M Schwartz and Steven Woloshin challenge the claims made for the new 23 mg dose of donepezil

In response to your two articles,1 2 Professor Harrington has examined the work capability assessment in two extensive reviews. All recommendations made to Atos Healthcare in the first review have been implemented. We are now working with the Department for Work and Pensions (DWP) to implement those made in the second review. In his second review, Harrington examined LiMA, …

I accept my body is mine to do with as I please—heaven knows, no one else would want it. And no, this is not a moment of existential angst. But the question that strikes me is how much should the information about me be mine?⇑ I’ve taken some time off the clinical treadmill, which is driving me relentlessly forward to a consultant job, where the managers won’t think I need any more of that pesky training that interferes so with service delivery. I’m doing a research degree for the next couple of years, which …

Spawned of large families, they have an inbuilt social support system. Defined by silly, long beards, love ins, 10 minute long rock tracks, rayon, wholemeal bread, vegetarians, social mobility, communes, radical left wing politics (reserved only for middle class members), and final salary pension schemes. These are the spoilt baby boomers. Born after the war till 1965 they are a large demographic bulge. They bought houses for a few shells and beads, which are now worth millions. Baby boomers hold 80% of the country’s wealth.1 They enjoyed professional freedom, …

Poly Implant Prosthese (PIP) breast implants were removed from the market after the discovery that non-medical grade silicone had been used; the company declared bankruptcy. The UK government advised the removal of PIP implants in symptomatic women.1 2 The NHS agreed to pay for the removal and replacement of implants for …

The CLOSURE 1 trial recruited patients who were not representative of most of those who are usually given the treatment it was investigating

Implementation will be as important as legislation in determining its impact To summarise the contents of the Health and Social Care Bill in a BMJ editorial is akin to paraphrasing War and Peace on Twitter (box). The provisions of the original bill, already long and comprehensive, have been made even more complex after about 50 days of parliamentary debate. Some 2000 amendments have been made to the bill in response to the work of the Future Forum and the concerns of peers.1 2 #### The Health and Social Care Bill explained ##### Main legislative changes ##### Key amendments

The composition of routine laboratory test profiles varies between laboratories, causing confusion and unnecessary expense. W S A Smellie describes the Association for Clinical Biochemistry’s draft proposals for unifying profiles and invites medical opinion

Objective: Cost containment is exerting pressures on the hospital nurse workforce that may conflict with quality and safety improvement. Europe is an ideal laboratory for determining how to realign organisational behaviors to achieve good patient and workforce outcomes in a context of finite resources. Design: Cross-sectional surveys of patients and nurses.Setting: Nurses were surveyed in 488 general acute care hospitals in 12 European countries and 617 general acute care hospitals in the United States. Patients were surveyed in a subset of 210 of the European hospitals and 430 of the United States hospitals.Participants: 33,659 nurses and 11,318 patients in Europe and 27,509 nurses and over 120,000 patients in the United States.Measurements: Hospital staffing, nurse work environments, burnout, dissatisfaction, intentions to leave, patient safety, quality of care, patient satisfaction overall and with nursing care and willingness to recommend their hospitals.Results: The percentage of nurses reporting poor or fair quality of patient care varied substantially by country from 11% (Ireland) to 47% (Greece) as did the percentage that gave their hospital a poor or failing safety grade (4% in Switzerland to 18% in Poland). High nurse burnout ranged from 10% (Netherlands) to 78% (Greece), job dissatisfaction from 11% (Netherlands) to 56% (Greece), and intent to leave from 14% (United States) to 49% (Finland and Greece). Percent of patients rating their hospitals highly varied considerably across countries from 35% (Spain) to 61% (Finland and Ireland), as did the percentage of patients that were willing to recommend their hospital (53% in Greece to 78% in Switzerland). Better work environments and lower patient-to-nurse ratios were associated with higher care quality and higher patient satisfaction. After adjusting for hospital and nurse characteristics, nurses in European hospitals with better work environments were half as likely to report poor or fair care quality (adjusted odds ratio 0.56, 95% confidence interval, 0.51 to 0.61) and to give their hospitals poor or failing grades on patient safety (adjusted odds ratio 0.50, 0.44 to 0.56). Each additional patient per nurse increased the odds on nurses reporting poor or fair quality car (adjusted odds ratios 1.11, 1.07 to 1.15) and poor or failing safety grades e (adjusted odds ratio 1.10, 1.05 to 1.16). Patients in hospitals with better work environments were more likely to rate their hospital highly (adjusted odds ratio 1.16, 1.03 to 1.32) and to recommend their hospital (adjusted odds ratio 1.41, 1.22 to 1.62), while patients in hospitals with higher patient-to-nurse ratios were less likely to rate their hospital highly (adjusted odds ratio 0.94, 0.91 to 0.97) or recommend their hospital (adjusted odds ratio 0.95, 0.91 to 0.98). Findings were similar in the United States. Nurses and patients agreed on which hospitals provided good care and could be recommended.Conclusions: Hospital care quality deficits were common in all countries. Improving hospital work environments may be a relatively low cost lever to produce safer and higher quality hospital care and higher patient satisfaction.

Only if there is a culture that supports whistleblowers should doctors be struck off for not raising concerns

To summarise evidence on the association between white rice consumption and risk of type 2 diabetes and to quantify the potential dose-response relation.Meta-analysis of prospective cohort studies.Searches of Medline and Embase databases for articles published up to January 2012 using keywords that included both rice intake and diabetes; further searches of references of included original studies.Included studies were prospective cohort studies that reported risk estimates for type 2 diabetes by rice intake levels.Relative risks were pooled using a random effects model; dose-response relations were evaluated using data from all rice intake categories in each study.Four articles were identified that included seven distinct prospective cohort analyses in Asian and Western populations for this study. A total of 13,284 incident cases of type 2 diabetes were ascertained among 352,384 participants with follow-up periods ranging from 4 to 22 years. Asian (Chinese and Japanese) populations had much higher white rice consumption levels than did Western populations (average intake levels were three to four servings/day versus one to two servings/week). The pooled relative risk was 1.55 (95% confidence interval 1.20 to 2.01) comparing the highest with the lowest category of white rice intake in Asian populations, whereas the corresponding relative risk was 1.12 (0.94 to 1.33) in Western populations (P for interaction=0.038). In the total population, the dose-response meta-analysis indicated that for each serving per day increment of white rice intake, the relative risk of type 2 diabetes was 1.11 (1.08 to 1.14) (P for linear trend0.001).Higher consumption of white rice is associated with a significantly increased risk of type 2 diabetes, especially in Asian (Chinese and Japanese) populations.

Zosia Kmietovicz introduces the sports and exercise medical teams shortlisted for the 2012 BMJ Group award

I am concerned about your recent article,1 which quotes a representative of the medical devices industry saying that clinical studies take up to 18 months to be approved in the UK. This …

Hawkes states that minimum pricing of alcohol as proposed in Scotland “would not be much of a deal” because it increases profit for the alcohol industry and reduces excise duty for the government,1 although this would be compensated in part by an increase in VAT income. However, this isn’t the …

Summary points Female genital mutilation (FGM), also known as female circumcision or cutting, is thought to affect 100-140 million women worldwide.1 It describes a range of procedures, often involving partial or total excision of the external female genitalia, that are carried out for non-medical reasons (box 1; figs 1-4⇓ ⇓ ⇓ ⇓).2 FGM breaches international human rights law, in particular the United Nations Convention on the Rights of the Child,3 and has been criminalised in much of the world, including many African countries in which it is traditionally practised. The United Kingdom is one of several Western countries that have enacted specific legislation in response to international migration (box 2).4 #### Box 1 Classification of female genital mutilation5

The one statistic quoted by Bernal and McKee as evidence against the proposed changes to motorway speed limits is presented misleadingly.1 I too would agree that a policy that led to 16.6% more deaths on the roads would be a …

Smith and Mays’s clear analysis of the large problems facing GP led commissioning did not mention the involvement of the private sector.1 Why so coy? Their crucial point is that management support must be heavily invested in for devolved commissioning in the NHS to succeed. “However, the NHS currently faces a reduction in …

The claim of a dramatic reduction in hot flushes fails to mention that symptoms recur when hormone replacement therapy (HRT) is stopped and that the largest trial (Women’s Health Initiative) showed no benefit on quality of life.1 The graphs seem to have been …

Key points A 38 year old man was referred by his general practitioner to our diabetes foot clinic with a swollen red foot (fig 1⇓). He had had type 1 diabetes for 25 years, complicated with retinopathy, peripheral neuropathy, and nephropathy, and was being worked up for dialysis following a failed pancreas-kidney transplant. The absence of pain together with preserved pulses and intact skin raised a suspicion of acute Charcot foot. A plain radiograph of the foot showed fractures through the necks of the first three metatarsals (fig 2⇓). We offloaded the foot in a total contact cast and advised the patient to limit weight bearing. Magnetic resonance imaging (MRI) subsequently confirmed neuroarthropathic changes of acute Charcot (fig 3⇓). Fig 1 Acute Charcot foot Fig 2 Plain radiograph of the foot showing fractures through the necks of the first three metatarsals Fig 3 Axial T1 weighted MRI showing pathological fractures through the necks of the first three metatarsals (arrows) with oedema in metatarsal shafts and lateral cuneiform bones (arrow heads). These features, in a patient with diabetes and no history of trauma, suggest acute Charcot foot Charcot’s neuroarthropathy is a destructive process of bone and joint, typically seen in a foot that …

Despite recent amendments to English health bill in response to opposition, Allyson Pollock, David Price, and Peter Roderick argue that it will enable charging for health services that are currently free

Objectives To determine if patients with rheumatoid arthritis have increased risk of atrial fibrillation and stroke. Design Longitudinal nationwide register based cohort study. Setting Inpatient and outpatient hospital care in Denmark from 1997 to 2009. Participants Entire Danish population aged over 15 years without rheumatoid arthritis, atrial fibrillation, or stroke before 1997. Participants with rheumatoid arthritis were identified by individual level linkage of diagnoses and rheumatoid arthritis treatment. Main outcome measures Rates of atrial fibrillation and stroke. Results Of 4 182 335 participants included in the cohort, 18 247 were identified as having rheumatoid arthritis during follow-up, with a mean age at disease onset of 59.2 years and a median follow-up of 4.8 years. A total of 156 484 people, including 774 with rheumatoid arthritis, were diagnosed as having atrial fibrillation (age and sex matched event rates of 8.2 per 1000 person years in rheumatoid arthritis patients and 6.0 per 1000 person years in the general population), with an adjusted incidence rate ratio of 1.41 (95% confidence interval 1.31 to 1.51). In addition, 165 343 people, including 718 with rheumatoid arthritis, had a stroke (7.6 per 1000 person years in rheumatoid arthritis and 5.7 per 1000 person years in the general population), with a resultant rate ratio of 1.32 (1.22 to 1.42). For both atrial fibrillation and stroke, relative risks were increased in all strata based on thirds of sex and age, with higher relative risks in younger patients but higher absolute risk differences in older patients. Conclusions Rheumatoid arthritis was associated with an increased incidence of atrial fibrillation and stroke. The novel finding of increased risk of atrial fibrillation in rheumatoid arthritis suggests that this arrhythmia is relevant in cardiovascular risk assessment of these patients.

Objective In view of mobile phone exposure being classified as a possible human carcinogen by the International Agency for Research on Cancer (IARC), we determined the compatibility of two recent reports of glioma risk (forming the basis of the IARC’s classification) with observed incidence trends in the United States. Design Comparison of observed rates with projected rates of glioma incidence for 1997-2008. We estimated projected rates by combining relative risks reported in the 2010 Interphone study and a 2011 Swedish study by Hardell and colleagues with rates adjusted for age, registry, and sex; data for mobile phone use; and various latency periods. Setting US population based data for glioma incidence in 1992-2008, from 12 registries in the Surveillance, Epidemiology, and End Results (SEER) programme (Atlanta, Detroit, Los Angeles, San Francisco, San Jose-Monterey, Seattle, rural Georgia, Connecticut, Hawaii, Iowa, New Mexico, and Utah). Participants Data for 24 813 non-Hispanic white people diagnosed with glioma at age 18 years or older. Results Age specific incidence rates of glioma remained generally constant in 1992-2008 (−0.02% change per year, 95% confidence interval −0.28% to 0.25%), a period coinciding with a substantial increase in mobile phone use from close to 0% to almost 100% of the US population. If phone use was associated with glioma risk, we expected glioma incidence rates to be higher than those observed, even with a latency period of 10 years and low relative risks (1.5). Based on relative risks of glioma by tumour latency and cumulative hours of phone use in the Swedish study, predicted rates should have been at least 40% higher than observed rates in 2008. However, predicted glioma rates based on the small proportion of highly exposed people in the Interphone study could be consistent with the observed data. Results remained valid if we used either non-regular users or low users of mobile phones as the baseline category, and if we constrained relative risks to be more than 1. Conclusions Raised risks of glioma with mobile phone use, as reported by one (Swedish) study forming the basis of the IARC’s re-evaluation of mobile phone exposure, are not consistent with observed incidence trends in US population data, although the US data could be consistent with the modest excess risks in the Interphone study.

The Leveson inquiry into the culture, practice, and ethics of the UK newspaper industry is running like a tabloid scoop, with daily, star studded exposes. But it has taken a new turn. Incestuous relationships between public institutions and the media are alleged to have bred a culture of illegal undisclosed payments to public officials. This is clearly intolerable and wrong but results from a cultural change. Such change is driven by unpredictable events, in spite of the government’s attempts to change culture through crude and expensive initiatives. And change is coming to a profession near you too. …

Last week the BMJ and Nuffield Trust brought together some of the leading voices in healthcare to consider what life in the NHS will be like after the Health and Social Care Bill passes into legislation. Rebecca Coombes presents the highlights

It is a year since the revolution in Syria erupted on 15 March 2011. Is the subject of health still relevant for discussion, as deaths approach 9000, tens of thousands of people have been arrested, and thousands remain detained? Do the notions we use as health professionals of care, determinants, equity, and rights retain a meaning in the context of shelling of residential areas, sniper shooting of demonstrators, execution of activists, and restrictions on access to basic living needs? Can a health sector stand with the ongoing destruction of the fabric of society? Not claiming to know the answers to these questions, I offer a few snapshots of real life stories that, perhaps, can begin to provide some answers. Because the current crisis didn’t start a year ago, the stories start much earlier too. February 1976 : The 10 year old boy stands up straight like other kids in the yard of his primary school at the end of a long day. He does not have enough clothes on and feels cold. His left ear hurts. He gets frozen blood when he tries to clean it. He cannot move because everyone is saluting the flag and the “leader father.” (All children are, by default, part of “talaa’eh el Baath,” inculcated with Baath principles and love for the “leader father.” The late Hafez Assad brought this idea from North Korea after a visit to Kim Il-Sung.) The boy would have recurrent ear infections for years to come. March 1981 : Two tenth graders develop a journal which they call “Maabad” (temple, meaning of knowledge). It includes only mild social critique and no political messages. Members of the Revolutionary Youth Union (Baath affiliates in secondary school) made it …

For far too long the pseudoscience behind so called complementary and alternative medicine (CAM) has been lent false authority by the teaching of such nonsense in academic institutions.1 The failure to find evidence of benefit for CAM modalities such as acupuncture, homeopathy, and chiropractic, despite many years of research and the attention …

I am all for dropping the bill, but I think we need a broader debate and to be clear about what happens next.1 Do we have a vision for what the 21st century NHS should look like? Defining ourselves by what we do not want is not the same as knowing what is needed. The role of the private sector …

I’m quite surprised that David Peters dares to show his head in the BMJ after the revelation of some of the dangerous nonsense that is taught in some of the courses run in his department.1 This is the man who tolerates dowsing …

Orrell and colleagues confirm that group and individual cognitive stimulation therapy (CST) improves cognitive function in dementia but that the effect size is modest, and they do not mention the possibly large placebo effect of social engagement.1 In their own trial of group CST, they state that controls received usual …