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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on thebmj.com. Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: . 318:doi

Outrageous !

Competing interests: No competing interests

01 February 1999
Richard T James
Editor, Practical Pointers
400 Avinger Lane #203 Davidxon NC 28036 USA
Re: . 318:doi

31 Jan. 1999

The dismissal of Dr. George Lundberg, editor of JAMA by the AMA.

Reviewing the current correspondence on the BMJs world wide web
pages, I note that there is no comment on this matter by the following
societies of which I am a member. Society of Nuclear Medicine (J Nucl.
Med.); British Society of Nuclear Medicine (Nucl. Med. Comm.); European
Association of Nuclear Medicine (Euro. J Nucl. Med.); British Institute of
Radiology (Brit. J Radiol); Royal College of Radiologists (Clin. Rad.);
Royal College of Paediatrics and Child Health (Archives Dis. Child.) and
the European Society of Paediatric Radiology (Ped. Radiol.)

The AMA’s decision is a dangerous breach of editorial freedom and
should be decidedly condemned by all editors of medical journals.
Further, a search committee has been set up to look for a new editor of
JAMA, headed by Roger N Rosenberg MD, professor of neurology at University
of Texas South-western Medical Centre, Dallas. He is also the editor of
Archives of Neurology. Surely concerted effort should be put on Professor
Rosenberg and his search committee to resign. Failing this they should
obtain written confirmation of the editorial independence of any future
editor of JAMA.

As a single voice in the medical fraternity, exerting any influence
on such matters is limited. But by the combined action of the medical
fraternity, I hope every organisation of which I am a member and has a
journal will not only condemn Dr. Lundberg’s dismissal, but will unite
with all other medical journals to exert pressure on the officers of the
AMA to acknowledge their error. Furthermore I am sure that members of the
AMA will also voice their opposition to prevent such unacceptable
practices.

From:
Dr. Isky Gordon FRCP, FRCR, FRCP&CH
Consultant Radiologist, Great Ormond Street Hospital for Children, London
WC1N 3JH, England.

Sent to:
The editors of Journals of which I a member of the society:
BMJ.; J Nucl. Med.; Nucl. Med. Comm.; Euro. J Nucl. Med.; Brit. J Radiol.;
Clin. Rad.; Archives Dis. Child.; Ped. Radiol.

Competing interests: No competing interests

01 February 1999
I Gordon
Consultant Radiologist
Great Ormond Street Hospital for Children
Re: Observational study of defibrillation in theatre Jonathan M Fielden, Neil S Bradbury. 318:doi 10.1136/bmj.318.7178.232

No one denies the fact that timely and properly performed
cardiopulmonary resuscitation and defibrillation save many a life. (1)
Here the first few moments and minutes form the narrow window of
opportunity.

While pre-hospital cardiac care is gaining momentum, it is time to
set the in-house (in-hospital) cardiopulmonary resuscitation care right!
Amidst the rampant compartmentalization of health care in hospitals,
provision of cardiopulmonary resuscitation should not be limited to a few
individuals in any hospital. Various studies brought to light the
shortcomings of physicians.(2) However, the clinically relevant study by
Fielden & Bradbury (3) sends a signal that some thing be done before
it is too late for some cardiac arrest victims in hospital settings.

The resuscitation councils and the national health services should
enforce a pragmatic policy to provide basic life support resuscitation in
every area and advanced life support in some priority areas of our
hospitals. First theatres and emergency rooms should be recruited into
this process. Initially at least one trained person in advanced life
support resuscitation should be available in every active operating
theatre. In emergency rooms, at least one trained staff member in advanced
life support resuscitation should be available at all times. Another
avenue is to tag the requirement of Advanced Life Support Certification to
Medical License renewal for surgeons, anaesthetists and physicians working
in operating theatres and emergency rooms.

Only with the enforcement of such mandatory policies, would any
hospital be in a position to provide the proper health care. No individual
or their families should be left to reconcile to a situation in which
surgical procedures were carried out in less than ideal settings and vital
resuscitation is left to inadequately trained staff. I presume there is no
dearth of the will. Let us find a way to restore and maintain the
public's trust in our health care systems!

References:

1. Advanced Life Support working Party of the European Resuscitation
Council. Guidelines for advanced life support. Resuscitation. 1992; 24:
111-22

2. Chin D, Morphet J, Coady E Davidson C. Assessment of
cardiopulmonary resuscitation in the membership examination of the Royal
College of Physicians. J R Coll Physicians Lond 1997 Mar - Apr; 31(2): 198
-201

3. Fielden JM, Bradbury NS. Observational study of defibrillation in
theatre. BMJ 1999; 318: 232-233

Competing interests: No competing interests

01 February 1999
V M K Bhaskarabhatla
Research Associate, Internal Medicine Associates
Mt. Sinai Medical Center, New York, USA
Re: . 318:doi

The Ama by this decision has maintained its political integrity and
neutrality .Surely medical journals should be concerned with clinical
medical matters rather than contemporary politics. The Bmj hopefully might
learn a lesson from this , and concentrate more fully on the world of
medicine, and leave its politically biased campaigns to other media.

Competing interests: No competing interests

01 February 1999
R Pidsley
District Medical Officer Australia
N.W.AUstralia
Re: . 318:doi
I firmly agree with every word in Sackett's letter.
I am shocked and disappointed: How can I read JAMA and believe in reading an independent and uncensorized journal in the future?!

I support the idea to establish an award for editorial integrity named after Prof.Lundberg.

Ursula R. Pfister, editor in chief, Gazette Médicale, Switzerland

Competing interests: No competing interests

01 February 1999
Ursula R Pfister
Editor in chief Gazette Médicale, Switzerland
Basel/Switzerland
Re: Microalbuminuria as predictor of outcome G Evans, I Greaves. 318:doi 10.1136/bmj.318.7178.207

Microalbuminuria as a tool for diagnosis of meningitis -
could this not be a valuable way of diagnosing meningitis in that terribly
difficult stage for general practice - when the child (or adult) appears
ill but there are no definite signs of anything more than a viral
infection. If the test could be done in a doctor's surgery, or even at
home, it would help to reduce evry GPs nightmare - "GP sent child home
with meningitis" stories in the press, as well as improve survival. A very
large trial would have to be done to pick up the few cases amongst the
millions of viral infections seen in primary care.

Competing interests: No competing interests

01 February 1999
Elizabeth Evans
GP Principal
Tudor Gate surgery Abergavenny
Re: Microalbuminuria as predictor of outcome G Evans, I Greaves. 318:doi 10.1136/bmj.318.7178.207

Dear Editor,

The editorial by Evans and Greaves (1) highlight the importance of
microalbuminuria as a predictor of outcome in various clinical situations.
However, microalbuminuria is more commonly associated with well
established renal and cardiovascular complications (2) and it is also
important to stress the significance of evaluating renal function.

The pathogenesis is unclear but it is known that, regardless of the
initiating cause, capillary leakage of proteins may affect the composition
and structure of the extracellular matrix with subsequent micro- and macro
-vascular damage (2) which may result in subtle alterations in renal
function that may co-exist with or precede the onset of microalbuminuria.
Failure to detect renal dysfunction is usually due to the poor sensitivity
of serum creatinine which is routinely used as a marker of renal function.

Serum Cystatin C estimation has promise as a better marker of
nephropathy than the ubiquitously used serum creatinine (3). In a study of
65 patients referred for the determination of creatinine clearance, serum
cystatin C showed better correlation (Spearman rank correlation (rs) = -
0.90) with creatinine clearance than serum creatinine (rs = -0.57).
Although estimation of serum cystatin C is more expensive (50 pence per
test) than that of serum creatinine (2 pence per test), cystatin C is not
influenced by the non-renal factors which affect serum creatinine and it
is more clinically reliable for detection of subtle changes in the
glomerular filtration rate (GFR). Although serum cystatin C is a marker of
GFR, several studies have shown that proteinuria induces
tubulointerstitial damage which often parallels the degree of glomerular
damage in patients with proteinuria (4).

While one welcomes the use of a simple, quick and non-invasive test
for microalbuminuria, large scale prospective trials on its clinical
usefulness (especially in the ambulatory setting) in different clinical
situations should also involve investigation of sensitive endogenous
markers of renal function such as serum cystatin C. Finally, as the
authors pointed out, microalbuminuria is a non-specific marker. The
technique also has the disadvantage of being affected by several pre-
analytical factors which include wide daily intra-individual variability
resulting from changes in posture, physical activity, protein intake and
haemodynamic factors. These factors should be borne in mind when using a
mobile equipment for estimation of microalbuminuria to determine
prognosis.

References

1. G Evans and I Greaves. Microalbuminuria as predictor of outcome.
BMJ 1999; 318: 207-208.

2. Deckert T; Kofoed-Enevoldsen A; Nørgaard K; Borch-Johnsen K; Feldt
-Rasmussen B; Jensen T. Microalbuminuria. Implications for micro- and
macrovascular disease. Diabetes Care1992; 15:1181-91.

3. Newman DJ; Thakkar H; Edwards RG; Wilkie M; White T; Grubb AO;
Price CP. Serum cystatin C measured by automated immunoassay: a more
sensitive marker of changes in GFR than serum creatinine. Kidney Int 1995;
47:312-8.

4. Bruzzi I; Benigni A; Remuzzi G. Role of increased glomerular
protein traffic in the progression of renal failure. Kidney Int 1997;
62:S29-31.

Competing interests: No competing interests

01 February 1999
Olusegun A Mojiminiyi
Assistant Professor
Department of Pathology, Kuwait University
Re: . 318:doi

As a medical student, who is a little older than most, who has
children and who has had a life outside of medicine, I am continually
surprised by the actions and motivations of those in the medical
profession - and I firmly believe that most of those in medical authority
live in another time (perhaps another place).

Conservatism has a place in the running of things - but power (and
remember absolute power corrupts absolutely) has no place in the
distribution of information, the views of others and open debate. Sacking
a editor because he was going to publish a survey is the absolute
corruption of power of the Chairperson and obviously the charter of the
AMA (or perhaps it's not?).

Sex is a natural act and more investigation of this act and the
modern views of the generation for which sex is an open subject, is
important in the care and management of the sexual health for this
generation - open discussion should be encouraged from the top of the tree
- not hidden in a back alley where "deals are done" by a few elite.

It may surprise the Chairperson of the AMA, but there are people
having and discussing sex all over the world and it needs to be discussed
by the medical profession in a professional environment, the fact that the
president of the USA is in trouble for having (or not having) sex is not
the concern of the journal - but it might make the article topical and
more widely read than it may have previously been.

I wonder if the BJM might publish the manuscript so I can have the
pleasure of reading it?

Competing interests: No competing interests

01 February 1999
Gabi Caswell
Medical student
University of Queensland
Re: . 318:doi

While everyone concerned has clearly judged the firing of Dr Lundberg
to be wrong- I am surprised that none of the commentaries suggest a
solution. - At the risk of being called extremely naive I am suggesting
the obvious- the best way to correct the mistake is to reinstate the
esteemed editor - that will be the easiest way the integrity of journal
and its association could be at least partially restored.

Competing interests: No competing interests

01 February 1999
Jayant S Vaidya
Hon. Lecturer
University College London
Re: Nicotine replacement therapy for a healthier nation Liam Smeeth, Godfrey Fowler. 317:doi 10.1136/bmj.317.7168.1266

Dear Editor: In reading the response made by Dr. Robert Bunney I am
pleased finally to read about the acknowledgement that local community
pharmacists play a role in smoking cessation.

In my community practice, I currently see between 25 to 50 clients
weekly who are attempting to quit smoking. The value of contact with a
pharmacist willing to spend time counselling on appropriate use of
Nicotine Replacement Therapy or other means of cessation, behavioral
modification and timely follow-up is well worth the aforementioned
"prescription charges". In fact, follow-up by pharmacists may be more
cost-effective than the current alternatives. Perhaps governments should
be analyzing the value of paying pharmacists to provide cessation
couselling to the lower socioeconomic groups in terms of "benefits
expressed as cost per life year saved".

Pharmacists are accessible, are well-versed in pharmacological
training, over-the-counter and prescription medications, maintain complete
computerized databases that often allow for flagging for followup, and are
well-connected with appropriate organizations, cessation clinics and
physicians in their communities if referral is necessary.(1) There are
many opportunities for pharmacists to have an large impact when it comes
to intervention strategies for both cessation and prevention of smoking
altogether.(2)

In many areas, pharmacists are specializing in smoking cessation.
For instance, our local health authority is sponsoring workshops for the
health professionals and lifestyle consultants in our area which are being
developed and presented by myself, a local community pharmacist. The
workshop will review current literature and guidelines on cessation
interventions that potentially could impact more smokers than physicians
could see in 6 months.

It is time to acknowledge that smoking cessation is an area that
health professionals must provide seamless care as members of a team. It
is essential to evaluate value of interventions in terms of access to
smokers and education and skill level of the health professional rather
than by professional discipline.(3) The largest impact in terms of
decrease in mortality and morbidity will be realized only when all members
of the health care team work in cooperation.

Yours truly,

Lisa A. DeVos B.Sc. Pharm
Pharmacist Consultant

References:
1. F.S. Layton. Clinical Discussion on Smoking Cessation. Counselling your
patients. Medscape [medscape.com]

2.W.Steven Pray. US Pharmacist 23(7) 1998.

3.Coleman et al. Smoking cessation: evidence based recommendations
for the healthcare system
BMJ 1999;318:182-185 ( 16 January )

Competing interests: No competing interests

01 February 1999
Lisa A DeVos
Pharmacist, Member of Wood Buffalo Tobacco Reduction Coalition
Morrison Centre Pharmacy, Fort McMurray, AB Canada

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