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The terms “standard error” and “standard deviation” are often confused.1 The contrast between these two terms reflects the important distinction between data description and inference, one that all researchers should appreciate. The standard deviation (often SD) is a measure of variability. When we calculate the standard deviation of a sample, we are using it as an estimate of the variability of the population from which the sample was drawn. For data with a normal distribution,2 about 95% of individuals will have values within 2 standard deviations of the mean, the other 5% being equally scattered above and below these limits. Contrary to popular misconception, the standard deviation is a valid measure of variability regardless of the distribution. About 95% of observations of any distribution usually fall within the 2 standard …

Academic medicine has a critical role in consumer health care. Patients can thank academic medicine for research leading to improved health care, education of medical professionals, and leadership in patient care, research, and education. But times have changed. The growing disincentives to participate in academic medicine and demanding financial, political, demographic, consumer, and technology trends are cause for concern. If academic medicine is to remain a leading player in the business of health, it has to do better. I applaud the International Campaign to Revitalise Academic Medicine for prompting strategic introspection and global action.1 Patients have had an integral role in the campaign …

EDITOR—Esmail is looking at things from the wrong end of the telescope when claiming that the General Medical Council has failed to grasp the issue of scrutinising doctors' performance.1 Surely the main lesson that has emerged from the various recent inquiries is that employers of doctors (including primary care trusts) need to ensure that they have in place local systems that can deal …

In almost all controlled trials treatments are allocated by randomisation. Blocking and stratification can be used to ensure balance between groups in size and patient characteristics.1 But stratified randomisation using several variables is not effective in small trials. The only widely acceptable alternative approach is minimisation,2 3 a method of ensuring excellent balance between groups for several prognostic factors, even in small samples. With minimisation the treatment allocated to the next participant enrolled in the trial depends (wholly or partly) on the characteristics of those participants already enrolled. The aim is that each allocation should minimise the imbalance across multiple factors. Table 1 shows some baseline characteristics in a controlled trial comparing two types of counselling in relation to dietary intake.4 Minimisation was used for the …

The cognitive processes we use in making diagnoses are characterised by heuristics and biases that are similar to those that underpin much human decision making.1 Although these processes are error prone, they have evolved as rapid and effective ways of making decisions in conditions of uncertainty and they are deeply ingrained in our psyche. Reducing such errors may be difficult and, indeed, some commentators are sceptical about whether such cognitive errors can be reduced at all. Nevertheless, some strategies have been proposed to deal directly with cognitive errors, and these merit more consideration and field testing.2 These strategies involve what is sometimes …

Editor—Rather than arguing that nakedness is bad like Abbasi,1 in our article on the democratisation of science we urge transparency advocates to be specific about the body parts that should be displayed publicly.2 As scientific advisory councils find themselves at the intersections of science and society, they necessarily transgress the boundaries of science. This makes them vulnerable to the politicisation of their work. Sound scientific advice is urgently needed in a time where our societies are overwhelmed with new technologies. Therefore, we think that science advisory boards do well in taking utmost care in shaping their relations with policy actors and the citizenry. The experience of the Health Council of the Netherlands in dealing with scientific elements (colliding knowledge claims, etc), can be inspiring to develop methods and procedures to allow societal elements into the advisory process.3 Transparency about one's arguments, allowing your readership to join you in (or dissent from) a line of reasoning, is one of these fragile new procedures that enables the council to be both scientific and useful to policy and public debate. Scientific journals should publish dissenting voices, as this is important for the advancement of science (although journals also have their backstage processes, as McCabe says in her rapid response4). Science advisory boards, however, are to advise government on the state of the art. Debates in the committee further that goal, as this is useful in mobilising the expertise of committee members. Confidentiality of the committee process is essential for the production of such debates (public scrutiny during the process might deter openness among experts). Whereas it goes without saying that lasting dissent is not to be concealed, it seems unwise to bring temporary dissent into the open, as this would be easily taken up to politicise the advice and thus render it ineffective.

The studentBMJ editor travels to Israel and the occupied territories, trying to make sense of an impenetrable situation. This is her diary I'd always meant to go to Israel but somehow had never got round to it. So I jumped at the chance when I was offered the opportunity to go on a press trip to Israel and the Palestine territories occupied by Israel with Medecins du Monde (MDM), a French medical organisation that has several projects dotted around the area. Admittedly I was nervous about going but convinced myself that if it were all that dangerous MDM wouldn't risk the lives of its staff—after all, many non-governmental organisations (NGOs) have withdrawn from Iraq. But what bothered me more was how I'd report what I see, and if people disagreed—and they're bound to—that I'd be dismissed as pro-Israeli and a Zionist or pro-Palestinian and a self hating Jew. ### The team Accompanying me is Andy Aitchison, a freelance photojournalist, and Michelle Hawkins from MDM UK. We've communicated daily on the phone, trying to arrange the complex logistics, but only manage to meet for the first time at the airport. Before leaving I received a brief warning that I'd probably be in for harsh scrutiny on arrival at Ben Gurion airport. So I was relieved to be welcomed only with a glower, a few quickfire questions, and the request for evidence that I was from the press. Jean Sebastien Dy, the [now former] general administrator of MDM in Jerusalem, and Sebastien Laplanche, general coordinator, meet us at the airport and take us to our accommodation in an MDM marked car with flags flying from the back. Our base is the newly refurbished MDM staff house in East Jerusalem, the predominantly Palestinian part of Jerusalem. Most of the other NGOs and UN buildings are located …

As a family therapist, I applaud Timimi's broadly systemic approach to childhood unhappiness.1 In my experience, young people aged 14-16 are most likely to present to clinicians with depression, and he is right to emphasise the sociocultural roots of their unhappiness. However, I am concerned at the underemphasis on possible consequences of depression, such as school failure, social withdrawal, antisocial behaviour, substance misuse, family disharmony, and suicide, which are more than just potential …

Rising costs of drugs is universal. From 1998 to 2001, prescription costs in the United States and England increased by 62% and 30%, respectively. Could the essential drugs concept help rich countries to control the rise in drug costs? Hogerzeil1 cites Australia as an example, although experience there is hardly encouraging: spending on medicines rose by 69% between 1998 and 2002,2 and the political difficulties of the process have been widely reported.3 But containing costs is not the only aim of the essential drugs concept, which primarily aims to increase access and efficiency and to promote better health and equity. These are also aims in rich countries, which already apply many of the principles of …

Straus et al provide a conceptual framework for evaluation of strategies for teaching evidence based medicine (EBM).1 They correctly state that there is little evidence of effectiveness of teaching EBM, a deficiency frequently identified by critics.2,3 The authors' assumption is that provision of a conceptual framework will lead to better studies. But will it? Is it really the case that a conceptual framework leads naturally to well designed studies? If so, this represents a reorientation of the first author, who previously stated that “no investigative team has yet overcome the problems of sample size, contamination and blinding that such a trial raises,”3 which puts the problem squarely in the court of methodology. And I think she is at least partially right.4 It is well nigh impossible to conceive of an effective educational intervention where the teachers were standardised and participants were blinded, hence unaware that they had received the intervention. This does not preclude the possibility that a conceptual framework may help. But it seems to me that the major consequence may be to so impress upon potential researchers the daunting nature of the task facing them that it may stimulate abandonment of research rather than initiation. A quick calculation from Straus et al's table 1 shows that, if you were serious about doing a study aimed at “doers,” you would have to get reliable and valid information from each of 5×5 = 25 cells. And that is a substantial problem. While the authors claim that the article's focus is on “psychometrically strong measurements,” that is the last time that psychometric issues are raised. Others have suggested that EBM studies suffer from a “lack of validated outcome measures,” particularly those that focus on learner behaviours,5 but there is no mention of that here. In the end, I suspect that if a trial, using good design and psychometrically defensible instruments, showed that those who had a course in EBM actually delivered better care than those who did not, all the assessment of attitudes, knowledge, and skills elucidated in this article would probably be viewed as irrelevant. I await the day.

EDITOR—Jones and Bamford express surprise and frustration that their study was temporarily halted after they introduced an interview to the existing protocol without research ethics committee approval.1 They seem not to have recognised that introducing a new aspect to their project may bring additional ethical considerations and problems for their existing research aims. They say that they did not …

EDITOR—Jamrozik discusses the lost plot of research ethics paperwork in the issue of 31 July highlighting that ethics committees are out of control and discouraging research.1 NHS research ethics committees comprise volunteers who give up their time freely to mediate society's desire to protect potential research participants. If anything can be learnt from recent high profile cases, such as …

Internal documents show that British American Tobacco's racing team has been successful in promoting the company's products, especially in emerging countries. Tougher worldwide action is needed to counter the tobacco industry's influence in Formula One

Wald's description of his encounter with the new research ethics committee forms provides a graphic illustration of the frustration and bemusement of most researchers when faced with the hurdles that must now be surmounted to conduct a clinical trial.1 As well as the expansion in the volume of paperwork, the need to understand and comply with the regulatory requirements for good clinical practice, reporting of adverse events, and the supply and labelling of trial drugs make it almost impossible for a clinician to undertake a clinical trial without support. This is not necessarily a bad thing if it leads to better quality studies that are safer for patients, but training and support must be funded and provided if clinical trials in the public interest are to …

If there were any information in my family's medical history that would allow me to find out whether I was likely to get cancer and how I could minimise the risk, I would certainly want to know about it. Clinical red tape about consent and next of kin when a patient is dead seems completely unreasonable when it holds back …

Early sexual intercourse is commonly associated with a higher number of lifetime sexual partners1 and, consequently, a higher risk of contracting sexually transmitted infections. From the perspective of sexually transmitted infection, sexual encounters include not only present partners but also past partners and all of their partners' partners. Thus voluntarily delaying sexual debut is of key importance in the prevention of sexually transmitted infections and the promotion of long term health. The ABC approach to changing sexual behaviour described by Shelton and colleagues can be used as a primary strategy for tackling all sexually transmitted infections. Since the World Health Organization estimates that two thirds of sexually transmitted …

EDITOR—As leaders in the NHS Modernisation Agency, we were delighted to see the paper by Young et al summarising three key approaches to improving manufacturing systems.1 Improvement programmes in the agency have been adapting these approaches successfully to NHS healthcare systems for several years.2 We now refer to this body of knowledge as “clinical systems improvement.” At its …

Editor—Neuberger and Price make a good case that living liver donation should be available in the NHS, and one might well ask why this is taking so long when the procedure has been in use so widely over the past five years.1 There is certainly a need for more liver transplant operations as the figures quoted for 2002 show: 62 deaths in patients on the waiting list and another 25 patients removed from it because they had become too ill. The waiting list for recipients requiring blood group O cadaver organs in some transplant centres is now around 12 months, which is unacceptable. The UK transplant rate is already one of the lowest in the West, and the chief medical officer in his annual report two years ago drew attention to the substantial and worrying increase in the number of deaths from cirrhosis in men of working age. Cases may not be referred for a variety of reasons. Eligibility criteria are strict, and many believe it is reasonable that these should be relaxed in the context of living liver donation. The small number of transplant centres in this country also perpetuates the view that liver transplantation is a very difficult procedure, whereas in many countries elective grafting with cadaver organs has become almost a routine procedure. Neuberger and Price also refer to “a few” living liver transplants having been done in the United Kingdom. In the programme at the Cromwell Hospital, which I started in October 1998 with Nigel Heaton, Mohamed Rela, and the surgical team from King's College Hospital, we have now treated 17 patients. Survival among recipients is 77%, and no major complications have occurred in the donors.2 It was set up for overseas patients because of the time they were having to wait for a cadaver organ graft.

EDITOR—Baker et al monitored mortality in general practice after Shipman.1 A statistical monitoring process with high enough sensitivity to detect murder would almost certainly give many false positive signals. This could cause severe damage both to practitioners and to their relationships with their patients. A statistical monitoring process with high enough specificity to avoid false positive signals may …

EDITOR—Hastings and MacFadyen's paper about tobacco advertising tried to establish that the tobacco industry targeted those below the legal age for smoking, but the conclusion seems uncertain.1 They wrote: “The precise definition of ‘young’ remains contentious.” Later they said “Whether the industry is deliberately targeting under 16 years olds remains a matter for dispute.” Words like “contentious” and “dispute” imply uncertainty. The industry insisted that it only targeted young adults—young but adults nevertheless—and there is no concrete evidence from industry documents to disprove this. Documents …

Cost of illness studies are a type of economic study common in the medical literature, particularly in specialist clinical journals. The aim of a cost of illness study is to identify and measure all the costs of a particular disease, including the direct, indirect, and intangible dimensions. The output, expressed in monetary terms, is an estimate of the total burden of a particular disease to society.1 It is widely believed that estimating the total societal cost of an illness is a useful aid to policy decision making, and indeed organisations such as the World Bank and the World Health Organization commonly use such studies.2 However, cost of illness studies have been the cause of much debate among economists.1 3 4 Two methods of costing illness exist—the prevalence and incidence …

Editor—After the publication of our paper in the BMJ of 29 May on why mortality from heart disease is low in France (the French paradox),1 it was drawn to our attention that the time lag explanation that we set out in our paper had previously been put forward, by Marion Nestle, in a letter to the Lancet in 1992.2 We were not aware of this attribution, and we would have cited it if we had been.

EDITOR—Pfeffer discusses the complexities of theories of race, ethnicity, and culture.1 Surveys in the United Kingdom (UK) rely on the census question that first appeared in the 1991 census (incorporating colour and country of origin2) to define ethnic groups. The Office of Management and Budget's classification is dominant in the United States.3 Does the menu of terms given to people included in such classifications offer a good choice? Using data from the south Tyneside heart study,4 we compared respondents' identification of their ethnicity using the census question, a description in an open question, country of birth, and country of family …

This is the fourth in a series of occasional notes on economics The pursuit of efficiency in the healthcare sector requires priority to be given to those treatments which provide the greatest benefit per unit of cost. Alternative interventions often have to be compared to determine whether a change in the mix of interventions would increase efficiency. Although economic evaluations approach costs in a common format, they differ in the way they approach benefits. These differences play a critical role in developing criteria for efficiency.1 Cost benefit analysis involves measuring costs and benefits in commensurate terms, usually monetary. Welfare economics shows that under certain conditions any net excess of monetary benefits over costs represents the gain in welfare by society.1 Cost benefit analysis makes it possible to determine, firstly, whether an individual intervention offers an overall net welfare gain and, secondly, how …

The dream of a conflict-free and completely harmonious existence is an old one, and from time to time schemes, which usually end in abuse or disaster, are proposed to bring it about. The latest shortcut to human perfection is through the neurosciences. The advances in these sciences have beyond doubt been dramatic and unprecedented, and in popular expositions are said to promise vast benefits for humankind. The technological wonders of functional magnetic resonance images have disarmed scepticism, let alone criticism. Hitherto intractable problems will be dissolved by the application of the right combination of sophisticated diagnosis and treatment, pharmacological and otherwise. We now have drugs that are better than any available before. Do you want a new and fuller personality? Fluoxetine will do the job for you. It is capable not only of restoring your depressed mood to normal but also of …

It is difficult carrying out a research project in sub-Saharan Africa if you are local doctors. The clinical workload is heavy and there are few trained staff, and because of the lack of supporting infrastructure every task requires more energy than you anticipate. We tried to answer one question: “What are the obstacles to safe anaesthesia in the rural districts of our catchment area?” We are based in an urban centre on the southern shores of Lake Victoria in Tanzania, east Africa, in the tertiary referral hospital for a population of eight million. We knew from informal feedback from the anaesthetists in the outlying districts that there were many problems, but we wanted hard data, not anecdotes. Where were the obstacles? Was it lack of drugs, equipment, or personnel? With the help of funds from the Irish Government aid agency, HEDCO, we did a survey of an area of 67 500 square kilometres with a population of four million. This survey was no easy task. It meant that one of us (EK) had to visit the 27 hospitals in the region, some in very remote …

EDITOR —The series of articles on health needs assessment provided insights into how the approach could be used to describe health problems in populations and to identify inequalities in health and access to services.1 The authors of the articles failed to recognise, however, that prioritising healthcare services on the basis of need can lead to inefficient use of resources. Allocating finite healthcare resources according to the total amount of ill health in the population —whether this is measured by lives …

Users of clinical practice guidelines and other recommendations need to know how much confidence they can place in the recommendations. Systematic and explicit methods of making judgments can reduce errors and improve communication. We have developed a system for grading the quality of evidence and the strength of recommendations that can be applied across a wide range of interventions and contexts. In this article we present a summary of our approach from the perspective of a guideline user. Judgments about the strength of a recommendation require consideration of the balance between benefits and harms, the quality of the evidence, translation of the evidence into specific circumstances, and the certainty of the baseline risk. It is also important to consider costs (resource utilisation) before making a recommendation. Inconsistencies among systems for grading the quality of evidence and the strength of recommendations reduce their potential to facilitate critical appraisal and improve communication of these judgments. Our system for guiding these complex judgments balances the need for simplicity with the need for full and transparent consideration of all important issues.

Although the Labour government has repeatedly pledged its commitment to the NHS, its latest reforms pave the way for multiple providers of health care The Health and Social Care (Community Health and Standards) Bill 2003 is the most controversial piece of legislation to come out of the government's 10 year strategy for the NHS in England.1 The bill, which abolishes government control of NHS trusts by turning them into competing independent corporations called foundation trusts, is a major policy reversal. It could lead to considerable local variation in services and endangers one of the NHS's founding principles–to provide equal care for equal need. The new bill allows both NHS and non-NHS bodies, including private companies, to apply to become foundation trusts. Although their principal purpose is to provide goods and services to the NHS, they will be able to carry out any type of business. With guaranteed independence from direct government control, their sole statutory general duty will be to operate “effectively, efficiently, and economically.” They will not have shareholders but will be expected to make and retain surpluses for new investment or for servicing loans raised on the financial markets.2 The scale of such borrowing will depend on their ability to make surpluses.3 The government has given them several new powers to generate surpluses (box 1). These powers, taken together with changes to the methods of allocating resources,4 threaten to destabilise the provision of health services and systematically widen inequalities of access to care. In the face of growing opposition to the bill from the BMA, trade unions, and the public, the government claims that regulatory safeguards in the bill will protect the core principles of universality and access on the basis of need (see bmj.com). However, as we show below, careful scrutiny shows that …

Health funding is increasingly based on the results of economic evaluation. But current methods fail to consider all society's health objectives and are too complex for policy makers to use

Several studies have investigated medical intervention in common aspects of lifestyle, and the subject has been discussed from a legal, ethical, and practical point of view.1 Fluoridation of water supplies, legal enforcement of safety measures such as compulsory wearing of seat belts or helmets, and restriction of unhealthy habits such as drinking alcohol or smoking are typical examples of paternalistic programmes—actions that aim to prevent harm or promote the good of others, irrespective of the individual's own wishes. 2 3 What is the position, however, when a doctor's action is neither solicited nor part of his or her contractual duties? In such a situation—which we define as unsolicited medical intervention—the doctor can only speculate about whether his or her action will be welcomed and hence understood as an act of beneficence or whether it will be regarded as an unjustified paternalistic intrusion into privacy.4 According to the 1949international code of medical ethics of the World Medical Association5 and to legislation in many different countries, doctors are obliged to offer first aid in an emergency. However, apart from this relatively clear situation, dilemmas in relation to unsolicited medical intervention have rarely been discussed. The European Code of Medical Ethics, issued in Paris in January 1987by representatives of the medical associations of the European Community, emphasises the principle that “doctors can only use professional knowledge to improve and maintain the health of those who put themselves in their care.”5 We aimed to assess the attitudes of doctors and the expectations of the lay public to unsolicited medical intervention by asking them to consider the ethics of unsolicited medical intervention in three scenarios. We believed that a comparison of the responses of doctors, subgroups of doctors, and lay people would help us to identify gaps between expectations and reality. …

Use of composite end points as the main outcome in randomised trials can hide wide differences in the individual measures. How should you apply the results to clinical practice?

Decisions about screening can be more complex than those about treatment. Well designed decision aids could help patients understand the risks as well as the benefits

On behalf of Oxford Vision 2020, a partnership dedicated to preventing the forecast worldwide growth of chronic diseases, the authors suggest that 12 lessons learnt from attempts to control tobacco smoking could be used to tackle the chronic disease epidemics evolving from unhealthy diets and a lack of physical activity This year three new books have been published about the progress made globally in research, policy, and actions to control tobacco smoking.1-3 In addition, Sir Richard Doll reported this year on 50 years of following British doctors to document the impact of smoking on their health.4 We have reviewed the evidence and approaches taken to control tobacco smoking, well described in these new texts, because of the rapid global increase in the risk factors of unhealthy diets and lack of physical activity. As part of the Oxford Vision 2020 process,5 we have proposed 12 lessons from tobacco control that might speed up progress in tackling these new public health threats. We also drew on other recent insights from tobacco control in addressing other chronic disease risks.6-8 This issue pervades debates on the role of government versus that of the individual, and both sides of the issue need to be addressed. However, the World Health Organization's statement in its Ottawa charter remains valid: “Healthy choices need to be the easy choices.”9 Individual responsibility can have its full effect only in a society where governments, private interests, and other sectors work together to support individuals making healthy choices. In all societies special support is required for children, who are neither competent nor legally able to make fully informed decisions about behaviours with lifelong …

General practice p 994 Older people frequently fall. This is a serious public health problem, with a substantial impact on health and healthcare costs.1 These guidelines translate trial evidence about prevention of falls into recommendations that can be implemented in different settings, with the aim of reducing the rate of falls and injurious falls in people over 65 (see boxes 2 3). #### Summary points Multifaceted interventions reduce falls in older people (those over 65) Home assessment of older people at risk of falls without referral or direct intervention is not recommended Assessment of high risk residents in nursing homes with relevant referral is effective Evidence from well designed single trials shows that assessment and modification of risk factors of older people who have presented to an accident and emergency department after a fall and the provision of hip protectors in residents of nursing homes are effective We updated two previous systematic reviews to include any new evidence up to March 1998. 4 5 We electronically searched Medline for all randomised controlled trials and systematic reviews by using the terms fall(s), accidental falls, fracture, elderly, aged, older, and senior. We followed up relevant references in papers, and we contacted researchers in prevention of falls for information about other trial evidence and about studies from journals not catalogued by the National Library of Medicine. For inclusion, studies had to be randomised controlled trials of interventions designed to minimise or prevent exposure to the risk factors for falling (or fracture) in people aged 65 years or over living in either community or residential care. Outcomes had to include the number of people who had fallen or the number of falls or fractures. We excluded drug or dietary treatments for the prevention of fractures. Trials that fulfilled the inclusion criteria were reviewed and summarised …

The duties of research ethics committees are becoming increasingly difficult—what skills and knowledge do their members need to evaluate protocols that contain elements that are not in the patient's interests?

The United Kingdom is trying to bring more non-governmental funding into NHS research through partnerships with the commercial and voluntary sectors. But it is still unclear exactly how the reforms in England will work and how trusts will resolve the tensions between patients' needs, financial viability, and the commercial exploitation of research findings Essential research into health services is often unattractive to commercial sector funders and requires government support.1 Although appreciable NHS funding has been earmarked for this purpose, critics have argued that much of the budget has disappeared into the general funds for service delivery.2 In 2000, the Department of Health announced a major overhaul of health related research within the NHS aimed at providing a clearer strategic direction.3 The reforms signal an increased role for the commercial sector in the identification of strategic objectives, setting priorities, and in the delivery and exploitation of clinical research. This paper provides an overview of the new funding and organisational arrangements for NHS research in England. Funding of health research in the United Kingdom is complex. Although most health related research is funded from the commercial sector, the Department of Health is a major contributor (table). In 2002-03 the Department of Health contributed £540m to research on health.4 The current pattern of funding (fig 1) reflects the work of the Culyer review, which was carried out because of concerns over the financial viability of large teaching hospitals after the introduction of the internal market in the NHS. In 1994, the Culyer taskforce recommended that Department of Health funding of health related research should be allocated to support research and development activity in NHS trusts and be clearly identifiable and distinct from funding for clinical services.5 Some 77% (£418m in 2002/03) of research funding is currently allocated to …

Life expectancy and poorer outcomes associated with ethnicity are important issues for many countries. National and local developments are making a difference in New Zealand Life expectancy for indigenous people in colonised countries is shorter than it should be. In New Zealand, Maori die on average 10 years younger than people of Anglo-European descent.1 The usual suspects of poverty and poor socioeconomic opportunities contribute to inequity, but failures in service organisation and delivery are part of the picture. New Zealand is not the only colonised nation with higher rates of illness and premature death, but it is making concerted efforts to address the disparity. The starting point in identifying inequality in health outcomes is ensuring accuracy of data. The 2001 census indicates that 14.1% of New Zealand's population is Maori, 6.2% Pacific people, and 6.4% Asian.2 Each of these groups is actually growing at a faster rate than pakeha (the white descendants of colonial settlers). Until recently, documentation of ethnic origin in relation to health was not routinely collected. Even when ethnic group was recorded, it tended to be based on health workers' assessments of the appearance of the service user. Addressing health needs and planning appropriate …

Recent claims that pioglitazone prevents macrovascular events are based on a secondary outcome measure. But ignoring the primary outcome is statistically unsound Last month, members of the steering committee of the prospective pioglitazone clinical trial in macrovascular events (Proactive) presented the results at the European Association for the Study of Diabetes meeting in Athens.1 The audience, which overflowed from the meeting room, heard John Dormandy, chair of the steering committee, conclude that the trial had shown that pioglitazone, “Reduces the composite of all cause mortality, non-fatal myocardial infarction, and stroke.” He commented: “We have now shown for the first time that oral glucose lowering medication can prevent macrovascular events.” The audience seemed excited by these results and a consensus emerged that the results would change practice. The presentation was certainly positive and upbeat (as readers may judge for themselves from the webcast made available with the support of the study sponsors, Eli Lilly and Takeda1). Unfortunately, these conclusions are not based on robust standards for the interpretation of evidence from clinical trials. The trial studied over 5000 patients with inadequately controlled type 2 diabetes randomised to receive pioglitazone or matched placebo. Participants had raised cardiovascular risk, and most were receiving treatment for cardiovascular disease. The minimum planned exposure to study treatment was 2.5 years. The trial seems to have been carried out to a high standard, as we should expect from an industry sponsored trial that was conducted largely to answer safety concerns among regulatory agencies. So why are the conclusions unsafe? The answer lies with the …

In response to a recent expert advisory group report to the chief medical officer, the government has announced the setting up of two pilot schemes to assess the feasibility of a Chlamydia trachomatis screening programme in the United Kingdom.1–3 Chlamydia is the most common, curable, sexually transmitted infection in the Western world. Chlamydia infection is largely asymptomatic, but if it is left untreated it can have particularly severe long term consequences for women. These sequelae include pelvic inflammatory disease, ectopic pregnancy, and infertility.4 The expert advisory group has recommended that the following groups be targeted for screening: everyone with symptoms of chlamydia infection, all those attending genitourinary medicine clinics, and women seeking termination of pregnancy.1 There should also be opportunistic screening of young sexually active women under 25 years and of women over 25 with a new sexual partner or two or more sexual partners in the past year. The report identifies family planning clinics and general practice as key sites for screening. It also emphasises the importance of follow up management of infected individuals, which should be carried out in conjunction with genitourinary medicine clinics. #### Summary points The rationale behind targeting women for this screening programme is based on health benefits, cost effectiveness, and accessibility. Firstly, and most importantly, the purpose of the programme is to reduce the morbidity associated with pelvic inflammatory disease. Evidence from countries …

Canada's healthcare system, commonly known as Medicare, took shape in the 1950s and '60s. Founded on the principles of universality, accessibility, comprehensiveness, portability, and public administration, the system was considered the crown jewel of Canadian social programming and enjoyed both massive public support and international admiration. Its achievements seemed particularly impressive compared with those of its US neighbour, which realised none of these five principles despite much higher costs. The issue seemed settled, and health care ranked very low on policymakers' list of concerns, particularly at the national level. Times have changed, and a decade of turbulence has transformed Medicare from icon of Canadian values and organisational know how to an apparent state of crisis.1 A further blow to an already-shaken collective psyche was the publication of the World Health Organization report that rated Canada's healthcare system 30th in the world in terms of achievement relative to potential.2 (The media chose to downplay its seventh place ranking in terms of goal attainment, further promoting the air of crisis.) Has Medicare gone wrong, and, if so, what went wrong? #### Summary points Canadians continue to favour a publicly funded, comprehensive healthcare system but seem pessimistic about whether it is sustainable Increasing privatisation, in numerous forms, has crept into the system Numerous reports have called for substantial reforms, but achieving a consensus based solution remains elusive To date, the government has simply given more resources to the system, while largely ignoring calls to enhance its comprehensiveness and accessibility To understand the evolution of Canadian health care, one must understand its constitutional arrangements and political culture. Canada is a federal system whose powers are formally and sometimes contentiously divided between the national and provincial governments. Section 92 of the Constitution Act of 1982 confirms the British North America Act of 1867 assignment of responsibility …

When discussing treatment with patients, doctors may not mention newly licensed drugs that are not yet funded by healthcare schemes. Although their motives are good, the ethics are questionable The development of new drugs can be a lengthy process, requiring initial laboratory and animal testing and then a course of clinical studies.1 Clinical assessment involves phase I testing, which focuses on determination of side effects and an appropriate dose for later study; phase II studies, which assess efficacy in people with a particular condition; and phase III studies, which generally compare a new, experimental treatment with an existing standard treatment. Once a therapeutic benefit has been shown, the drug company can apply for approval from the relevant regulatory body. An extensive review follows, which may take many months or years. If the drug is approved, further delays may occur before funding arrangements permit the drug to be widely available. We consider some of the ethical dilemmas surrounding this process, using the example of drugs to treat people with cancer. In Australia, the cost of most prescription medicines is subsidised by the government through the pharmaceutical benefits scheme. New drugs that have been approved by the Therapeutic Goods Administration are assessed for inclusion in the scheme by the Pharmaceutical Benefits Advisory Committee, an independent expert committee consisting of medical practitioners and pharmacists. The committee considers several issues before recommending a drug, including efficacy, safety, quality of life benefits, and cost effectiveness. The committee may apply restrictions on how drugs can be prescribed. Long delays can occur between the Therapeutic Goods Administration approving a new drug and listing on the pharmaceutical benefits scheme. Similar delays between approval and subsidisation exists in other countries. In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) has been accused of considerable …

This is the last in a series of three articles Series editors: Catherine Pope and Nicholas Mays The barriers to the uptake of the findings of traditional quantitative biomedical research in clinical practice are increasingly being recognised. 1 2 Action research is particularly suited to identifying problems in clinical practice and helping develop potential solutions in order to improve practice.3 For this reason, action research is increasingly being used in health related settings. Although not synonymous with qualitative research, action research typically draws on qualitative methods such as interviews and observation. #### Summary points Action research is increasingly being used in healthcare settings It is a style of research rather than a specific method Three elements are important: the participatory character of action research; its democratic impulse; and its simultaneous contribution to social science and social change ![][1] (Credit: LIANE PAYNE) Action research is not easily defined. It is a style of research rather than a specific method. First used in 1946 by Kurt Lewin, a social scientist concerned with intergroup relations and minority problems in the United States, the term is now identified with research in which the researchers work explicitly with and for people rather than undertake research on them.4 Its strength lies in its focus on generating solutions to practical problems and its ability to empower practitioners—getting them to engage with research and subsequent “development” or implementation activities. Practitioners can choose to research their own practice, or an outside researcher can be engaged to help them identify problems, seek and implement practical solutions, and systematically monitor and reflect on the process and outcomes of change. Most definitions of action research incorporate three important elements: its participatory character; its democratic impulse; and its simultaneous contribution to social science and social change.5 Participation is fundamental to action research: it is … [1]: pending:yes

When the body is invaded by pathogens, each individual reacts with a battery of non-specific and specific immune defence mechanisms. Sex hormones play an important part in the host's resistance to sexually transmitted infections. This is shown by sex differences,1 variations in detection of infection according to phase of the menstrual cycle,2 increased susceptibility during pregnancy,3 and evidence that use of hormonal contraception predisposes to infection. 4 5 The mechanisms by which specific sex hormones modulate the immune system have been reviewed.6 This is a complex subject, and it is unfortunate that, in spite of its potential importance, no clear message about sex hormones has emerged or been harnessed to the development of strategies for controlling infection. This paper revisits some of the evidence that hormonal status influences susceptibility to sexually transmitted infections, especially in adolescents, and considers the practical implications of this evidence. #### Summary points Sex hormones influence susceptibility to sexually transmitted infections, especially in adolescents Anatomical differences do not adequately explain sex differences in the epidemiology of genital herpes and HIV infection The host's hormonal status, rather than high risk sexual behaviour, may govern the course of infection after a primary exposure to chlamydia or human papillomavirus Menstrual irregularities indicate hormonal disturbance in adolescent girls Strategies for preventing infection could be improved if the actions of sex hormones were better understood The best example of sex differences in rates of infection and disease for …

The stigma surrounding domestic violence means that many of those affected are reluctant or do not know how to get help. A systematic review of screening for domestic violence in healthcare settings concluded that although there was insufficient evidence to recommend screening programmes, health services should aim to identify and support women experiencing domestic violence.1 The review highlighted the importance of education and training of clinicians in promoting disclosure of abuse and appropriate responses.1 We argue that a strong case exists for routinely inquiring about partner abuse in many healthcare settings.

Earlier this year a 15 year old girl had her decision to refuse a heart transplant overruled by the High Court,1 highlighting the issue of partnership with children. The case is the latest of several2 that have shown how children's participation in decision making and recognising their autonomy and rationality 3 4 can conflict with the need to protect them from making decisions that are not in their long term interests.5 Court cases dramatically show the problems of involving children in decision making, but they tend to deal with extreme and unusual examples and have led to uncertainty and anxiety about routinely involving children in decision making. Away from the courts a movement is growing to promote children's rights. Proponents have argued from a position of moral obligation and have called for a code of practice which would emphasise children's rights to information, to express views, and to give or withhold consent provided the child is considered competent by a doctor.6 Professional bodies and others concerned with children's wellbeing seem to have accepted many of these principles,7–10 which are based on ethical and moral principles of autonomy, free will, choice, and compassion and have the laudable aim of allowing children's opinions to be voiced, heard, and acted on wherever possible. However, the evidence suggests that partnership with children enjoys only limited success. Children are given little voice in medical consultations 8 11 and are rarely consulted as partners in the evaluation and planning of health services.12 13 The …

The reform of healthcare services is a priority in transitional Hungary, but managing these changes is fraught with difficulties due to the political climate and managerial inexperience

Armed conflict is a major cause of injury and death worldwide, but we need much better methods of quantification before we can accurately assess its effect Armed conflict between warring states and groups within states have been major causes of ill health and mortality for most of human history. Conflict obviously causes deaths and injuries on the battlefield, but also health consequences from the displacement of populations, the breakdown of health and social services, and the heightened risk of disease transmission. Despite the size of the health consequences, military conflict has not received the same attention from public health research and policy as many other causes of illness and death. In contrast, political scientists have long studied the causes of war but have primarily been interested in the decision of elite groups to go to war, not in human death and misery. We review the limited knowledge on the health consequences of conflict, suggest ways to improve measurement, and discuss the potential for risk assessment and for preventing and ameliorating the consequences of conflict. #### Summary points Conflict related death and injury are major contributors to the global burden of disease Information systems break down during conflict, leading to great uncertainty in the magnitude of mortality and disability The World Health Survey may provide a reliable and valid basis for assessing conflict related mortality and disability Forecasting models may provide a plausible basis for assessing risk of conflict and thus prevention Improved collaboration between political scientists and experts in public health would benefit measurement, prediction, and prevention of conflict related death The impact of war on populations arises both from the direct effects of combat—namely, battle deaths—and from the indirect consequences of war, which may occur for several years after a conflict ends.1 Indirect effects of conflict on mortality can be formally …