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All rapid responses

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: Prospective, hospital based study of fever in children in the United Kingdom who had recently spent time in the tropics John L Klein, Guy C Millman. 316:doi 10.1136/bmj.316.7142.1425

This subject is only going to get more important. As authors say: "Access to specialists in tropical medicine is limited".

The US organisation Center for Disease Control maintains an outstandingly detailed website with up to date information about health (and non-health) hazards in every country in the world.

I use it mainly to check whether or not malaria can be caught in an area. The information is very detailed indeed. For instance advice about malarial risks in Brazil gives details of individual states and includes this passage "Travellers who will only visit the coastal states from the "horn" south to the Uruguay border including Iguassu Falls, are not at risk and need not take preventive drugs".

The website is at http://www.cdc.gov/travel/travel.html

Competing interests: No competing interests

08 May 1998
Ben Lloyd
Consultant Paediatrician
Royal Free Hospital, London, UK
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Re: Does the WHO have a role in Europe? Martin McKee. 316:doi 10.1136/bmj.316.7142.1402

Prof McKee classically begs several Questions. Of course there are health issues in Europe which are not being addressed by the incumbent governments. But that does not of itself mean that outsiders should intervene. Neither does it follow that if they do they will be successful.Most particularly, what is the evidence that WHO is the most appropriate vehicle for such intervention? One might at least have expected an analysis of the various successes of interventions by WHO, World Bank,ODA,OECD, and other more parochial organisations

Competing interests: No competing interests

08 May 1998
David Costain
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Re: Treating shoulder complaints in general practice . 315:doi 10.1136/bmj.315.7109.680
I agree with the authors that studies like pain in the shoulder joint require specific diagnosis and merely generalising to some non-specific categories will mislead many readers. This is true not only for the shoulder joint, where conditions like supraspinatus tendinitis is entirely different from lesions of the infraspinatus muscle and even different from lesions of the supraspinatus muscle.
The same is true with all types of pain in the low, mid or upper back, where nearly all the structures can produce pain. Treatments therefore must differ from place to place and structure to structure.
So it is unwise to include such different problems within a single study. Every lesion should be individually diagnosed and studied separately.

Competing interests: No competing interests

08 May 1998
Tariq Maqsood Khan
Private Practice in manipulation Therapy
Lahore, Pakistan
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Re: Knowing when to say “no” on the student elective Nicholas Banatvala, Len Doyal. 316:doi 10.1136/bmj.316.7142.1404

Medical elective studies in developing countries should be considered an important part of clinical education and not be thought as a holiday. It allows students from developed nations not only to see, feel and value the importance of being a 'medic' but also gives them an insight into rural and tropical medicine.

Therefore time spent on elective should reflect that, this can only occur if a student is allowed to assist, make clinical diagnosis and suggest treatment where possible, if he or she is able to do so.

To date no harm and no legal action has been taken against any medical students and for this reason one should not list conditions for those going on electives.

Competing interests: No competing interests

08 May 1998
M A Rohman
Junior Doctor (PRHO)
Birmingham, West Midlands, U.K.
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Re: Gimme five—books, that is . 315:doi 10.1136/bmj.315.7123.1712

I'm not a member of the medical profession, but I love reading the BMJ. I wish to suggest a couple of books:

1. Those Folk of Bulboro' by Edgar Wallace
I'm not very sure of the year of publication - 1926 or thereabouts, I should think. Published by Digit Books, I believe and now out of print! It's a study of society, such as it is, in a small place as Bulboro' and what a doctor thinks of it all. It's a good book to remind doctors (and incidentally, patients) that they too are human.

2. Tales of Medical Life by Conan Doyle
which appears in a collection of short stories. Again I don't know the year of publication, nor the publishers.
This collection of humour, instruction and pathos is not to be missed.

I'm looking forward to hearing what people have to say about these books.

Competing interests: No competing interests

07 May 1998
Shanti M Bharatan
Junior Research Fellow
Centre for Cellular and Molecular Biology, Hyderabad, India.
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Re: Genetic counselling—does the terminology matter? Hilary J Harris. 315:doi 10.1136/bmj.315.7117.1241a

Dear Dr. Harris,

having come across a case of Tay Sachs and a case of polycystic kidneys recently I wonder which structured approach for genetic counselling and antenatal care is available in Britain and especially in this region (S.Yorkshire).

Maybe a bias due to personal experience and previous training in radiology - but is it possible that Britain or at least this region of Britain has a higher incidence of malformations of the skeleton, deafness and middle ear infections (e.g. marble bone disease) than elsewhere in Europe ?

Yours sincerely

Rainer Kumm

Competing interests: No competing interests

07 May 1998
Rainer Kumm
GPVTS Doncaster
SHO Obs/Gynae W.Hospital Doncaster
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Re: The politics of alcoholism in India Vikram Patel. 316:doi 10.1136/bmj.316.7141.1394a

It seems that history is repeating itself - what is happening in India today took place in the United States in the 1930s. Rather than trying to ban alcohol, women should join forces and demand changes in the law to protect them and give them more rights.

Competing interests: No competing interests

07 May 1998
M A Rohman
Junior Doctor (PRHO)
Birmingham, West Midlands, U.K.
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Re: All troops sent to Gulf should be randomised to receive anthrax vaccination or placebo Andrew R Ness, Ian Harvey, David Gunnell, George Davey Smith. 316:doi 10.1136/bmj.316.7140.1322

Pulmonary anthrax is nearly 100% fatal. To our knowledge, Gulf War Syndrome
(GWS) has no known disease associated mortality rate (1). To implicate the
anthrax vaccine as a possible etiology of GWS, Ness et. al. (2) proposed
risking unvaccinated human exposure to anthrax. The authors state they
understand those not receiving vaccination may be deprived of potential
protection "in case of conflict." They cite the precedent of a human study
which evaluated risk of gastroenteritis from sea water exposure.
[paragraph 2]Predicting the likelihood of gastroenteritis from sea bathing is reasonable.
Risking an almost certain death from pulmonary anthrax to associate vaccination
with GWS is unreasonable. Anthrax may take 3 forms in humans,
the mortality from which are in no way comparable to gastroenteritis. GI
and pulmonary anthrax have the mortality rates of >50% and ~ 100%
respectively, regardless of treatment . Even untreated anthrax of the skin
has a 20 % mortality rate which decreases to <_1 if="if" treated="treated" _3.="_3." paragraph="paragraph" _3="_3" their="their" proposal="proposal" is="is" carried="carried" further="further" we="we" suggest="suggest" both="both" trial="trial" groups="groups" receive="receive" a="a" quinalone.="quinalone." this="this" will="will" control="control" for="for" quinalone-associated="quinalone-associated" adverse="adverse" drug="drug" effects="effects" _4="_4" as="as" quinalones="quinalones" may="may" be="be" used="used" prophylactically="prophylactically" in="in" the="the" gulf.="gulf." it="it" also="also" serve="serve" to="to" increase="increase" number="number" of="of" survivors="survivors" non-vaccinated="non-vaccinated" group="group" should="should" there="there" an="an" exposure="exposure" anthrax="anthrax" spores="spores" _5.="_5." p="p"/> * Historically, the anthrax bacillus is known to look like railroad box cars under the light microscope.
We respectfully now refer to the disease as "the box cars of death."

RA Piepenbrink, Internist

LS Bowling, Cardiologist

WM Hall, Internist

LA Parker, Internist

Pensacola, Florida, USA
-----

1. Kang H and T Bullman. "Mortality among US veterans of the Persian Gulf War" NEJM 1996 335:1498-1504(14NOV).

2. Ness et. al. "All troops sent to the gulf should be randomized to receive anthrax vaccination or placebo" BMJ 1998 316:1322 (25 April).

3. Mandell, G. et. al. (eds). Principles and Practice of Infectious Diseases. 1995. 4th ed., p. 1885-1889.

4. Pirmohamed, M. "Clinical Review: Adverse Drug Reactions" BMJ. 1998; 316: 1295-1298 (25 April ).

5. Fauci, A. et. al. (eds). Harrison's Principles of Internal Medicine. 1998. 14th ed. p897-899.

Competing interests: No competing interests

07 May 1998
Roger A Piepenbrink
Internal Medicine Staff
Naval Hospital; Department of Internal Medicine; Pensacola, Florida, USA
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Re: Plant based vaccines move a step closer Jacqui Wise. 316:doi 10.1136/bmj.316.7141.1333f

Dear sirs,

Having visited Bangladesh during my elective whilst at medical school, I can truly see the good that will come out of plant-based vaccines.

Competing interests: No competing interests

07 May 1998
M A Rohman
Junior Doctor (PRHO)
Birmingham, West Midlands, U.K.
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Re: Randomised controlled trial of the READER method of critical appraisal in general practice Domhnall MacAuley, Evelyn McCrum, Conor Brown. 316:doi 10.1136/bmj.316.7138.1134

Critical reading is becoming increasingly important in an era of abundance of information. MacAuley and coworkers have undertaken an admirable job by studying one method of critical appraisal of medical literature.

The apparent strength of this READER method is its simplicity. However, there are a number of drawbacks. Items are not independent. When relevance is absent in the eye of the reader, little energy will be invested in assessing the methodological qualities of the paper.

Serious problems arise in the 'discriminative' component of the checklist. Here we find a strange mix of design type and design quality. A randomised double blind trial with serious flaws may be far less informative than a good descriptive study. In the READER method however, the first will be valued 7 or 8 points, whereas descriptive studies cannot get more than 4 points. The impression that this list has ordinal or even interval scale properties, as given by the presentation of means, is not justified.

A major problem of the study, in my view, is the choice of the outcome measure. The outcome measure we really should be curious about, is the discriminatory power of the reader using this method. The choice of papers, all from the 'General practice' section of the BMJ, does not allow conclusions about the readers' ability to discriminate according to relevance for general practice, which is one of the four items of the READER checklist.

Furthermore, numerical scores on three papers do not give us much information about the ability of the reader to pick the relevant and applicable conclusions from these papers.

In summary, I do not think that this study properly answered the questions that it posed.

Competing interests: No competing interests

07 May 1998
Johannes C van der Wouden
research coordinator
Dept. of General Practice, Erasmus University
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