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'We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness', thus wrote Thomas Jefferson in the Declaration of Independence. The statement was renewed by Abraham Lincoln in his Gettysburg address of 1863, which highlighted the contradiction between the American Declaration of Independence and the issue of slavery which had vexed the new born country into a bloody civil war. There were clearly more pressing issues on Lincoln's mind than the relevance of healthcare to the ideals of American society in 1863, however, in 2008 his prospective successors to office must consider the issue of whether the United States should ensure that its citizens enjoy access to universal high quality healthcare and if so, how this should be achieved. Onlookers might ponder the relevance of good health to life, liberty and the pursuit of happiness.

Summary Introduction: Priapism is a urological emergency which is commonly classified into low-flow and high-flow priapism. Immediate intervention is required for low-flow cases as the development of ischaemia ultimately leads to long-term erectile dysfunction. Stuttering or recurrent priapism is less well understood. This subtype is characterised by short-lived painful erections and is commonly encountered in patients with sickle cell disease. Methods: A systematic review of the treatment options available for stuttering priapism is presented combined with our own experience in managing this condition over a period of 25 years. Results: Although numerous medical treatment options have been reported, the majority are through small trials or anecdotal reports. Conclusions: Stuttering priapism is a condition which is still not well understood and there is no standardised algorithm for the management of this condition. A multicentre randomised trial is required to evaluate the treatment options.

Summary Background: Communication between healthcare professionals and patients is suboptimal and the measures to improve patient satisfaction such as sharing correspondence have been reported in different settings. Methods: A review of published literature was undertaken to specifically examine patient satisfaction and the professional healthcare provider experience across a range of specialities and settings. Results: Patients generally report high rates of satisfaction when receiving copies of correspondence although both patient and professional experience within general psychiatry indicates that further consideration may be required before routinely adopting the practice of copying letters in this discipline. Conclusions: Dictating letters in the presence of patients can improve patient satisfaction accuracy and modalities such as the use of audio or video recordings may be useful in more specialised settings.

The quality and independence of clinical practice guidelines developed by professional societies has previously been assessed as unsatisfactory. Calls for explicit methodological standards have lead to international consensus on standards for guideline development. The methodological quality of current British cardiovascular guidelines produced by six professional societies is assessed with reference to internationally recognised criteria (Appraisal of Guidelines Research and Evaluation) for evaluating the quality of clinical guidelines. When evaluated with reference to a recognised quality framework for guideline development, current Joint British Societies guidelines for the prevention and treatment of cardiovascular disease contain serious deficiencies, are of low quality and should not be recommended for clinical practice.

Health policy in the U.S. has long been defined by competing principles and ideas that have led to the highly fragmented current system. On 7 November 2009, a new healthcare bill was passed by the House of Representatives, and, 2 weeks later, the Senate opened the healthcare debate with a vote of 60 to 39. On Christmas Eve 2009, Senate Democrats passed the healthcare bill with the same tight majority. After the loss of their super-majority in the Senate as a consequence of the Massachusetts election Democrats are now beginning face-to-face negotiations to merge the two bills. The consensus version would need final approval from each chamber before the bill could finally be signed by Obama into law. With lawmakers' debating of alternative proposals, it is important to recognise the underlying causes of institutional complexity in the healthcare system and how the system's foundational principles can be reformed to make it more comprehensive.

Priapism is a urological emergency which is commonly classified into low-flow and high-flow priapism. Immediate intervention is required for low-flow cases as the development of ischaemia ultimately leads to long-term erectile dysfunction. Stuttering or recurrent priapism is less well understood. This subtype is characterised by short-lived painful erections and is commonly encountered in patients with sickle cell disease.A systematic review of the treatment options available for stuttering priapism is presented combined with our own experience in managing this condition over a period of 25 years.Although numerous medical treatment options have been reported, the majority are through small trials or anecdotal reports.Stuttering priapism is a condition which is still not well understood and there is no standardised algorithm for the management of this condition. A multicentre randomised trial is required to evaluate the treatment options.

Variations in healthcare quality are pervasive (1,2), and demonstrating effective improvement interventions through research and publication is challenging (3,4). Academic curiosity, scientism and vested interests also promote strategies to improve the 'performance' of the healthcare system. Whether these strategies reflect evidence-based management (5) that does not cause harm or waste scarce resources is the subject of intense debate (6―12).