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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: Peaches and cream in a multi-ethnic society Pip Fisher. 357:doi 10.1136/bmj.j1752

Gwinyai Masukume (a,b,c), Euphemia W. Mu (d), Brit Trogen (e), Nicholas M. Mark (f), Alimuddin Zumla (g)

a. Irish Centre for Fetal and Neonatal Translational Research (INFANT), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
b. Gravida: National Centre for Growth and Development, University of Auckland, Auckland, New Zealand
c. Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
d. The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 240 E 38th St, Floor 11, New York, NY 100165, United States of America
e .New York University School of Medicine, New York, NY, United States of America
f. Division of Pulmonary Critical Care Medicine, University of Washington, Seattle, WA, United States of America
g. Division of Infection and Immunity, University College London and NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, United Kingdom

We were delighted to read Dr. Fisher’s article on whether analogies and metaphors describing clinical signs and presentations ‘written by white doctors working with white patients’ stand up in a multi-ethnic society [1]. She raises very important questions using the facial ‘peaches and cream’ complexion, a not uncommon feature of hypothyroidism in fair-skinned individuals.

This contributes further to our ongoing debate on the relevance of metaphors and eponyms in medical textbooks and educational material written by western authors being currently used in African and Asian medical schools as standard texts where these terms may not be culturally or educationally appropriate [2].

Hundreds of food-related and other metaphors have become deeply entrenched in journals [3], medical schools [4], and hospitals, and are used for teaching, learning and in exams [2].
Although blood tests are the basis of diagnosing most thyroid disease, performing these tests is driven by a patient’s history and physical examination findings. Culinary metaphors like ‘peaches and cream’ complexion [3,4,5] thus remain useful in maintaining a high index of suspicion for thyroid disease. Despite some misgivings, medical metaphors permit rapid diagnosis of classic presentations [6].

Rather than move away from their usage, it might be advisable to develop metaphors that are appropriate locally and are culturally relevant. A multi-ethnic society is precisely where a diverse set of old and new metaphors is most useful. Such an approach would also help to ‘close the gap’ in medical education in which students are taught to recognize dermatologic signs of disease using metaphors that are primarily applicable in fair-skinned populations; not only the ‘peaches and cream’ of hypothyroidism, but the ‘slapped cheek’ appearance of parvovirus, the ‘bulls-eye rash’ of Lyme disease, and many more [7].

More research is needed in developing a culturally relevant and evidence-based approach, because medical metaphors are also a critical aspect of communicating with patients and the public [8].

Competing interests
All authors have read and understood BMJ policy on declaration of interests and declare that they have a personal academic interest in eponyms, synonyms and cultural aspects of medical education. GM is a member of GRAPE (Group for Research and Advancement of Palatable Eponyms).

References
1. Fisher P. Peaches and cream in a multi-ethnic society. BMJ. 2017. 357:j1752. https://doi.org/10.1136/bmj.j1752
2. Masukume G, Zumla A. Analogies and metaphors in clinical medicine. Clin Med (Lond). 2012. 12(1):55-6. https://doi.org/10.7861/clinmedicine.12-1-55
3. O'Callaghan JM, Bewick J, Paice A, Ng P. Stabbing? Cause. BMJ Case Rep. 2009. pii: bcr12.2008.1312. https://doi.org/10.1136/bcr.12.2008.1312
4. Milam EC, Mu EW, Orlow SJ. Culinary Metaphors in Dermatology: Eating Our Words. JAMA Dermatol. 2015. 151(8):912. https://doi.org/10.1001/jamadermatol.2014.5416
5. Mark NM, Lessing JN, Buckley SA, Tierney LM Jr. Diagnostic Utility of Food Terminology: Culinary Clues for the Astute Diagnostician. Am J Med. 2015. 128(9):933-5. https://doi.org/10.1016/j.amjmed.2015.03.018
6. Kipersztok L, Masukume G. Food for thought: Palatable eponyms from Pediatrics. Malta Medical Journal. 2014. 26(4):46-50.
7. Fix AD, Peña CA, Strickland GT. Racial differences in reported Lyme disease incidence. Am J Epidemiol. 2000. 152(8):756-9. https://doi.org/10.1093/aje/152.8.756
8. Trogen B. The Evidence-Based Metaphor. JAMA. 2017. 317(14):1411-1412. https://doi.org/10.1001/jama.2016.17219

Competing interests: No competing interests

18 April 2017
Gwinyai Masukume
Research Fellow
Euphemia W. Mu, Brit Trogen, Nicholas M. Mark, Alimuddin Zumla
Irish Centre for Fetal and Neonatal Translational Research (INFANT), Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
5th Floor, Cork University Maternity Hospital, Wilton, Cork, Ireland
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Re: David Oliver: Challenges for rural hospitals—the same but different David Oliver. 357:doi 10.1136/bmj.j1731

As David Oliver has pointed out (this series of responses 16 April):

'In a 450 word column, detail is often sacrificed for narrative flow with readers free to follow links to references'

Only readers who are already interested, I suspect, are likely to follow links to references. Personally, I find it deeply frustrating that within a short piece usually I can either state where I disagree with the 'medical establishment', or else I can suggest a 'solution' to a problem without also 'including my proof': but it is not possible to 'properly develop the case'.

Rarely is it possible, within only a few hundred words, to properly address the sorts of things which bother me about end-of-life behaviour 'as a whole' - although sometimes a short and powerful 'proof' is possible, as was the case when I addressed the 'an advance decision must describe the circumstances in which it is to apply' fallacy:

http://www.bmj.com/content/356/bmj.j1216/rr-4

Detail does 'go against narrative flow' but often you really need both: a 'sort of' 'narrative flow' to define a 'conceptual framework' but also detail to support the framework - a 'narrative sketch' of an aircraft gives you 'an idea of it', but you need the engineering drawings to actually construct the aircraft.

I can't see the solution - I can only clearly see the frustration !

Competing interests: No competing interests

18 April 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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Re: How productive are NHS consultants? . 356:doi 10.1136/bmj.j1520

Until a few years ago, most consultants had medical secretaries who did their typing, sorted out their correspondence, organised their clinics and ensured that their time was used efficiently by making sure tasks were delegated within the workforce appropriately. Lately, many NHS Trusts, especially Mental Health Trusts, have decided to ‘save money’ by making consultants do a significant amount of the work that medical secretaries used to do. For example, while a medical secretary who is paid £15 an hour would be able to type 10 pages within an hour, a consultant who is paid £50 an hour would often only be able to type two pages. Thus typing one page which previously costed £1.5 now costs £25. Moreover, this erodes into the time available for consultants to carry out clinical work.

Appraisal and revalidation, despite all their merits, do take a lot of consultants' time and decrease the amount of time they spend doing clinical work. They may also cause considerable stress affecting productivity.

Consultants are forced to spend many hours every year doing mandatory training, much of which is repetitive and a simple tick box exercise so that management can document provision of training.

Perhaps we could enhance the productivity of consultants by allowing them to do what they are trained to do and paid to do.

Competing interests: No competing interests

17 April 2017
Ann Maria Albert
Foundation Year 1 trainee
West Yorkshire Foundation Program
Pinderfields Hospital, Wakefield WF1 4DG
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Re: Should research ethics committees police reporting bias? Simon E Kolstoe, Daniel R Shanahan, Janet Wisely. 356:doi 10.1136/bmj.j1501

We read with great interest the head to head on reporting bias and the possible role of ethics committees in its control and the 3 accompanying responses available at this time.

Many interesting points have been addressed such as the need for resources, the complex issue of sanctions, the “waste” of research, the necessity to improve the information available in the data base and so on. Still the main question remains, “Should research ethics committee records be used to detect reporting bias?” as Simon E Kolstoe points out.

The research projects evaluated by ethics committees often lack in definition of outcomes, as well as in precise reporting about the interventions to be done and the population to be enrolled. This lack of fundamental informations makes almost impossible the monitoring and the detection of reporting bias, regardless of who is the actor of the monitoring process.

Population, interventions, comparators and outcomes definition, are the essential information to guarantee a valid and reliable judgement process.

The response of Michelle van der Vecht to the head to head recalls the availability of structured tools for the evaluation of research protocols (http://www.spirit-statement.org). These instruments, also inspired to Good Clinical Practice (http://www.ich.org), are also designed for the purpose of reporting bias control and are aligned to similar tools (http://www.consort-statement.org) adopted by all major biomedical journals.

The ethics committee of the Tuscany region is organized in four sections, one exclusively dedicated to clinical research in pediatrics, has adopted the SPIRIT Statement as an evaluation tool for interventional research protocols. The availability of a management software will allow the creation of a database of research projects including a clear definition of outcomes, interventions and populations to be enrolled. This database could be used for the monitoring and detection of reporting bias (and probably Publication bias).

We believe that the role of ethics committees could be crucial in the control of reporting bias since they are in a privileged position to begin the monitoring process. However, the availability of robust evidence to identify the reporting bias can be guaranteed only by an evaluation system of the ethical committees that use validated and standardized tools.

Competing interests: No competing interests

17 April 2017
Alessandro Mugelli
President of the Pediatric Ethics Committee of the Tuscan Region
Salvatore De Masi,Technical-scientific Secretariat of the Pediatric Ethics Committee, Meyer Children’s Hospital, Florence, Italy
Department of Neuroscience, Drug Research and Child's Health (NeuroFarBa), Division of Pharmacology
University of Florence, Florence, Italy
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Re: GPs earned £90 600 on average in 2014-15 Tom Moberly. 354:doi 10.1136/bmj.i5005

Current GP locum hourly rates allow much higher incomes, these days.
Brexit is likely to increase shortages.
References
https://www.theguardian.com/society/2017/apr/14/desperate-hospitals-beg-...
http://www.theweek.co.uk/82827/locum-doctors-make-up-to-43000-a-month-fr...

Competing interests: No competing interests

17 April 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Thessaloniki, Greece
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Re: Is tonsillectomy recommended in adults with recurrent tonsillitis? Jason Powell, James O’Hara, Sean Carrie, Janet A Wilson. 357:doi 10.1136/bmj.j1450

Jason Powell et al write that to get rid of ill health and pain due to recurrent tonsillitis, it is worthwhile to get total tonsillectomy done in adults. However, a very old paper by Chamovitz et al says that it does not prevent sore throats due to group A streptococcus (study was done on military men from 1949 to 1954) and hence rheumatic fever and its complications like valvular diseases.

Reference:
1: CHAMOVITZ R, RAMMELKAMP CH Jr, WANNAMAKER LW, DENNY FW Jr. The effect of
tonsillectomy on the incidence of streptococcal respiratory disease and its
complications. Pediatrics. 1960 Sep;26:355-67.

Competing interests: No competing interests

17 April 2017
Neeru Gupta
Scientist F
KK Jani, Jugal Kishore, Akshun Jani.
Indian Council of Medical Research
Ansari Nagar, New Delhi-110029.
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Re: Next steps on the NHS five year forward view Chris Ham. 357:doi 10.1136/bmj.j1678

The NHS Five Year Forward View (1) when published in 2014 had a major flaw, and this has yet to be noted in Ham`s Editorial as he looks at the next steps in 2017 (2).

A plan - for this is what was presented in 2014 - has, of necessity, to recognise current and near-future constraints, by making guesses about political sentiment, economic capability and sustainability. But setting off on a journey without having a pretty clear idea of the destination, a strategic view, is foolhardy. Once identified, a strategy can be folded back to the present.

The major flaw currently is the failure to identify the dominant independent variable that has - and will continue to have - the greatest impact on the efficient delivery of healthcare. This is `technological innovation`. The history of the NHS is littered with examples where the service has had to do catch-up with technology - reconfiguring its workforce, changing the way care is delivered, and redeploying capital budgets to new locations or for the development of new facilities - often years behind the curve.

Some examples include:
• A failure to anticipate the potential impact of the arrival of phenothiazines in the 1950s on the ability to discharge patients from psychiatric hospitals; and the appalling lack of community mental health services necessary to provide support for vulnerable ex-patients.
• Being unprepared to take advantage of powerful combinational developments in fibre optics and endoscopy, digital imaging and new anaesthetics that reduced nausea, resulting in delays in implementing minimal access and day case surgery.
• Failing to develop the use of telecare, and maximising the shift of available technologies to the home for those who might benefit directly by not being admitted to hospital, or allowing earlier discharge; and developing an adequate district nurse workforce to provide support.

`Substitution research` is a dynamic approach which can be used to challenge current conventional planning methods, which tend to start with a careful analysis of the existing position and so risk limiting the freedom to think creatively. This is evident in `Next steps` It is also very useful when used strategically. `Substitution` is defined as the continual regrouping of resources across and within care settings, to exploit the best and least costly solutions in the face of changing needs and demands (3). Of course this has been happening already, albeit without the title, but reactively for the most part.

One useful typology differentiates three kinds of substitution: the introduction of new technologies; moving the location at which care is given; and changing the mix of staff and skill requirements (4). It is the first of these, as the most frequent long-term independent variable, that requires constant scanning outside of the NHS itself. But with identification of technology innovations goes the consequent need to look at the implications for care location, and workforce training and planning. This is a foresight exercise of the greatest importance, and was identified as such by Sir Michael Peckham, Director of R&D for NHS England in 2000 (5) following the publication of Project SHIFT (6).

Perhaps we might start now with a recent headline in the Times: Sound-wave blood test gives results in minutes (7). It is a few years away, no doubt, but needs to be built into strategic thinking now.

Ham states that Simon Stevens, author of the Forward View and chief executive of NHS England, has `focused minds by emphasising the inevitably of hard choices in healthcare` . But this has always been the case, and has served as the bedrock of a muddling through approach. The public and demoralised healthcare professionals now urgently to be shown some light at the end of what has been a very long tunnel. This could be achieved if a systematic approach to substitution was to be employed, with future technologies given the lead role. A horizon-scanning version of NICE perhaps? Whatever, the NHS needs an evidence based Strategic Direction to give a sense of hope.

1. Five year Forward View. NHS England, Oct 2014.
2. Ham C. Next steps on the NHS Five Year Forward View. Editorial, BMJ 8 April 2017.
3. The expression was first applied to healthcare in the Dekker Report, Changing health care in the Netherlands. The Hague, Ministry of Welfare, Health and Cultural Affairs, 1988.
4. A model of the typology and a more detailed discussion of `substitution` is Warner, MM. Contribution to Saltman RB and Figueras J. European Health Care Reform: Analysis of Current Strategies. WHO Regional Office for Europe 1997, 214-217.
5. Foresight Healthcare Panel, Healthcare 2020 - Making the future Work for You. London: the Department of Trade and Industry 2000. Available at http://www.foresight.gov.uk
6. Warner MM. et al, Can Home be Possible for the Frail Elderly? Substitution of Hospital and other Institutional-focused Technologies (Project SHIFT). Welsh Institute for Health and Social Care, January 2003.
7. The Sunday Times 09 April 2017.

Competing interests: No competing interests

17 April 2017
Morton M Warner
Emeritus Professor of Health Strategy and Policy
Welsh Institute for Health and Social care
Tredodridge, Vale of Glamorgan
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Re: David Oliver: Challenges for rural hospitals—the same but different David Oliver. 357:doi 10.1136/bmj.j1731

Editor

I thank Dr Syme for his intervention around Scottish population density.

There is an alternative possible explanation. i.e. that having been to Scotland many times and read my Geography books, I am well aware that a high percentage of the population is concentrated in the Central Belt, meaning that other areas such as the Highlands, Islands and Borders are much more sparsely populated.

By analogy, I am also aware that both Australia and Canada have a high percentage of their own populations concentrated in a handful of big metropolitan areas, meaning that the remote and rural areas are far less densely populated than the headline figures for the nation might suggest.

I very deliberately cited Scottish reports because Scotland has done more thinking for longer about rurality and healthcare than England.

In a 450 word column, detail is often sacrificed for narrative flow with readers free to follow links to references

David Oliver

Competing interests: No competing interests

16 April 2017
David Oliver
consultant physician
NHS
Berkshire
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Re: Pancreas transplantation Patrick G Dean, Aleksandra Kukla, Mark D Stegall, Yogish C Kudva. 357:doi 10.1136/bmj.j1321

Title: Pancreas Transplantation: The untold origin of the story… the pancreas Donor
Authors: IM Shapey1,2 A Summers1,2, T Augustine1,2, MK Rutter1,3, D van Dellen1,2
Institutions
1) Faculty of Medicine, Biology and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester UK.
2) Department of Renal and Pancreatic Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
3) Manchester Diabetes Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
Article type: Rapid response/Letter
Word Count: 916
Keywords: Pancreas, Islet, Transplantation, Donor, Insulin
Acknowledgements: We would like to recognise the important and life changing gift provided by organ donors and their families which has facilitated the possibility of pancreas transplantation.
Funding: Medical Research Council (UK); Royal College of Surgeons of Edinburgh

Main text

Dear Editor,

We read with interest Dean et. al.’s State of the Art Review of Pancreas Transplantation. It is refreshing to have pancreas and islet transplantation receiving the international attention it urgently deserves. In patients with complex diabetes mellitus, pancreas and islet transplantation can offer life-changing and life-saving therapies. Improving knowledge and understanding amongst referring physicians regarding the potential benefits of pancreas transplantation is important because current referral rates to UK pancreas transplantation centres are low and do not reflect the number that may benefit from transplantation. For many decades, pancreas transplantation has been the forgotten sibling of liver, kidney and cardio-thoracic transplantation. The amelioration of both hyper- and hypo-glycaemia and alleviation of its associated macro- and micro-vascular complications stands to benefit numerous patients affected by diabetes with significant subsequent secondary benefits for healthcare resources.

Dean’s review focuses on the indications for, and outcomes following pancreas and islet transplantation. Unfortunately, this represents only the recipient’s half of the process, and does not acknowledge the major challenges facing pancreas and islet transplantation regarding the organ donor. Pancreas donation comes predominantly from deceased individuals following declaration of neurological (brain-stem) death or donation after circulatory death (formerly known as non-heart beating donation). Living pancreas donation occurs in small numbers in select centres, but, due to the associated morbidity for the donor (15-30%), has not become standard practice internationally.[1-2]

The main factors limiting the success of pancreas transplantation historically have been difficulties in optimising donor selection and achieving successful long-term function. Inappropriate donor organ selection, due to a lack of objective clarity for quality assessment, continues to impact adversely on patient outcomes in pancreas transplantation. Two-thirds of donor pancreata offered for transplantation are currently considered unsuitable.[3] Outcomes remain far from ideal: in the UK, 6 out of 10 pancreas grafts have failed at 5 years when transplanted alone, and 3 out of 10 fail at 5 years when the pancreas is performed simultaneously with a kidney transplant, as occurs in over 80% of cases.[4] The well-documented shortage of organs for transplantation creates an urgent need to improve objective methods for selection of high quality pancreata; and also to identify the ideal physiological environment to enable a transplanted pancreas to thrive in the longer term.

Contrary to other areas of organ transplantation such as the kidney, liver and heart, there is a paucity of research and knowledge in the field of donor organ assessment and viability testing in pancreas and islet transplantation to aid in critical decision making. Reliable and validated donor risk indices exist for both liver [5] and kidney transplantation [6], but the currently available pancreas donor risk index (PDRI) [7] is unreliable. Studies attempting to validate the PDRI as a predictive tool have provided mixed results [8-12], and this may account for its low utility when compared to its liver and kidney counterparts. Apart from cold ischaemic time, the PDRI relies entirely on donor characteristics, and the variable outcomes from validation studies [8-12] are therefore possibly a reflection of the absence of any quantifiable primary measures of the function and quality of the organ itself.

Current decision-making in donor selection is a qualitative process which is multifactorial and largely subjective with significant individual clinician and centre variability. The donor factors reported to have the greatest impact on future graft loss include body mass index, [13] age, [14] donor type [7] and cold ischaemic time [13]. As the donor population grows older and larger, the negative impact of these factors on donor pancreas quality is likely to be an increasing problem. HbA1C and c-peptide are not routinely evaluated in organ donors in part due to limited local access in donor hospitals out-of-hours. Macroscopic features of the pancreas are also an important consideration; the degree of inter- and intra-lobular pancreatic steatosis, fibrosis and calcification are associated with the likelihood of reperfusion pancreatitis and poorer long-term function [15]. Currently, visual assessment coupled with palpation is the best subjective evaluation of the quality of the solid organ pancreas.

In organ donors, the process of brain stem death causes high levels of systemic catecholamines and inflammation affecting all organs [16-18]. These changes, and the routine use of high-dose corticosteroids in intensive care units (ICU) [19], leads to hyperglycaemia in around 50% of donors which is managed with insulin. Traditional teaching suggests that donor hyperglycaemia is a transient phenomenon caused by reversible insulin resistance in the donor [16]. Current and future work is identifying strategies to identify, quantify and correlate the effects of the catecholamine storm generated by brain stem death and the potential deleterious effects on beta-cell function both in the immediate and longer term.

If true progress is to be made in alleviating the devastating sequelae of diabetes, then a co-ordinated and concerted effort is required to improve the success of transplantation. This involves increasing our knowledge of the physiological behaviour of both donors and recipients along with technological advances. Doing so will allow us to identify which patient groups stand to benefit the most from transplantation and to determine which modalities of beta-cell replacement therapy (solid organ, cellular, or bio-artificial pancreas) are appropriate at a given time in a patient’s clinical journey with diabetes. Until we can achieve mass production of therapeutic grade beta-cells, which remains the holy grail of Beta cell replacement therapy, it is critical that we have strong objective criteria to assess the quality of donor pancreata which will maximise the number of patients with complex diabetes who can gain access to this state of the art therapy.

References
1) Kirchner VA, Finger EB, Bellin MD, Dunn TB, Gruessner RW, Hering BJ, Humar A, Kukla AK, Matas AJ, Pruett TL, Sutherland DE, Kandaswamy R. Long-term Outcomes for Living Pancreas Donors in the Modern Era. Transplantation. 2016 Jun;100(6):1322-8.
2) Matsumoto I, Shinzeki M, Asari S, Goto T, Shirakawa S, Ajiki T, Fukumoto T, Ku Y. Evaluation of glucose metabolism after distal pancreatectomy according to the donor criteria of the living donor pancreas transplantation guidelines proposed by the Japanese Pancreas and Islet Transplantation Association. Transplant Proc. 2014 Apr;46(3):958-62.
3) NHS Blood and Transplant (2016) Annual Report on The National Organ Retreival Service and Usage of Organs (2015/2016) http://www.odt.nhs.uk/pdf/activity-report/national_organ_retrieval_servi... accessed 05/04/2017
4) NHS Blood and Transplant (2016) Annual Report on Pancreas and Islet Transplantation (2015/2016) http://www.odt.nhs.uk/pdf/organ_specific_report_pancreas_2016.pdf accessed 05/04/2017
5) Feng S, Goodrich NP, Bragg-Gresham JL et al Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transplant. 2006 Apr;6(4):783-90.
6) Rao PS, Schaubel DE, Guidinger MK, Andreoni KA, Wolfe RA, Merion RM, et al. A comprehensive risk quantification score for deceased donor kidneys: the kidney donor risk index. Transplantation 2009;88:231-236.
7) Axelrod DA, Sung RS, Meyer KH, et al. Systematic evaluation of pancreas allograft quality, outcomes and geographic variation in utilization. Am JTransplant 2010; 10:837–845
8) Maglione M, Ploeg RJ, Friend PJ. Donor risk factors, retrieval technique, preservation and ischemia/reperfusion injury in pancreas transplantation. Curr Opin Organ Transplant. 2013 Feb;18(1):83-8
9) Mittal S, Lee FJ, Bradbury L, Collett D, Reddy S, Sinha S, Sharples E, Ploeg RJ, Friend PJ, Vaidya A. Validation of the Pancreas Donor Risk Index for use in a UK population. Transpl Int. 2015 Sep;28(9):1028-33.
10) Amaral PH, Genzini T, Perosa M, Massarollo PC.Donor risk index does not predict graft survival after pancreas transplantation in Brazil. Transplant Proc. 2015 May;47(4):1025-8.
11) Blok JJ, Kopp WH, Verhagen MJ, Schaapherder AF, de Fijter JW, Putter H, Ringers J, Braat AE. The Value of PDRI and P-PASS as Predictors of Outcome After Pancreas Transplantation in a Large European Pancreas Transplantation Center. Pancreas. 2016 Mar;45(3):331-6.
12) Finger EB, Radosevich DM, Dunn TB, Chinnakotla S, Sutherland DE, Matas AJ, Pruett TL, Kandaswamy R. A composite risk model for predicting technical failure in pancreas transplantation. Am J Transplant. 2013 Jul;13(7):1840-9.
13) Humar A, Ramcharan T, Kandaswamy R, Gruessner RW, Gruessner AG, Sutherland DE. The impact of donor obesity on outcomes after cadaver pancreas transplants. Am J Transplant 2004; 4: 605-10
14) Salvalaggio PR, Schnitzler MA, Abbott KC, et al. Patient and graft survival implications of simultaneous pancreas kidney transplantation from old donors. Am J Transplant 2007; 7: 1561-71
15) van Dellen D, Summers A, Trevelyan S, Tavakoli A, Augustine T, Pararajasingam R. Incidence and Histologic Features of Transplant Graft Pancreatitis: A Single Center Experience. Exp Clin Transplant. 2015 Oct;13(5):449-52.
16) Masson F, Thicoipe M, Gin H, de Mascarel A, Angibeau RM, Favarel-Garrigues JF, Erny P.. The endocrine pancreas in brain-dead donors. A prospective study in 25 patients. Transplantation. 1993;56:363-7.
17) Contreras JL, Eckstein C, Smyth CA, Sellers MT, Vilatoba M, Bilbao G, Rahemtulla FG, Young CJ, Thompson JA, Chaudry IH, Eckhoff DE. Brain death significantly reduces isolated pancreatic islet yields and functionality in vitro and in vivo after transplantation in rats. Diabetes. 2003;52(12):2935-42.
18) Rech TH, Crispim D, Rheinheimer J, Barkan SS, Osvaldt AB, Grezzana Filho TJ, Kruel CR, Martini J, Gross JL, Leitão CB. Brain death-induced inflammatory activity in human pancreatic tissue: a case-control study. Transplantation. 2014 ;97:212-9.
19) Geer EB, Islam J, Buettner C.Mechanisms of glucocorticoid-induced insulin resistance: focus on adipose tissue function and lipid metabolism. Endocrinol Metab Clin North Am. 2014;43(1):75-102.
20) Shapey IM, Summers AM, Augustine T, Rutter MK, van Dellen D. Circulating Cell-Free Unmethylated DNA as a Marker of Graft Dysfunction in Pancreas Transplantation. Am J Transplant. 2016 16: 3064–3065
21) Quality in Organ Donation Consortium (2016) http://www.quod.org.uk/approved-projects.html accessed 05/04/2017

Competing interests: Funding (IS): Medical Research Council (UK); Royal College of Surgeons of Edinburgh

16 April 2017
Iestyn M Shapey
MRC Clinical Research Training Fellow
Angela Summers; Titus Augustine; Martin Rutter; David van Dellen
University of Manchester
Oxford Road, Manchester, UK M13 9PL
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Re: Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study Joshua D Stein, Rory M Marks, John Z Ayanian, Brahmajee K Nallamothu, et al. 357:doi 10.1136/bmj.j1415

Many thanks for your reply - it is great to see detailed responses from authors and I commend them for their responses (and speed of response).

I understand the matching better now, but still feel that we are unlikely to completely match accurately and there will be a degree of confounding, however, I think we may never agree!

And many thanks for calculating correct NNH - I slightly overestimated my figures.

Competing interests: No competing interests

16 April 2017
FERGUS W HAMILTON
Medical Trainee
Weston Area Health Trust
Weston General Hospital, W-S-M, BS23 4TQ
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