BMJ - 16 March 2013

THIS WEEK
BMJ | 16 MARCH 2013 | VOLUME 346

ONEWS, p 4
NEWS
1 Antimicrobial resistance presents an apocalyptic
threat, CMO warns
Financial strains must not risk work of volunteers in
the NHS
2 Judge rules that
decision to close three
childrens heart units
was unfair
New rules on
competition are still a
concern
3 Case against doctor
from Staord hospital
set to start next week
Britons are making
healthier lifestyle
choices than 40 years
ago
4 More than a third of
GPs on CCG boards
have conicts of
interest
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COMMENT
EDITORIALS
7 Is an EMA review on hormonal contraception and
thrombosis needed?
Frans M Helmerhorst and Frits R Rosendaal
8 Cognitive decits and mild traumatic brain injury
V F J Newcombe and D K Menon
O RESEARCH, p 15
9 Regulating the NHS market in England
Chris Ham
10 The new UK antimicrobial resistance strategy and
action plan
Anthony S Kessel and Mike Sharland
FEATURES
16 The hospital bed: on its way out?
John Appleby examines trends in the number of
hospital beds and wonders how low we can go
HEAD TO HEAD
18 Should GPs be ned for rises in avoidable
emergency admissions to hospital?
Commissioning organisations in England face losing
a quarter of the quality premium if they do not
keep down their emergency admissions for specic
conditions. Martin McShane supports the plan, but
Chaand Nagpaul worries about possible unintended
consequences
ANALYSIS
20 Antimicrobial resistance: the true cost
Richard Smith and Joanna Coast argue that current
estimates of the cost of antibiotic resistance are
misleading and may result in inadequate investment
in tackling the problem
M
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RESEARCH
RESEARCH NEWS
11 All you need to read in the other general journals
RESEARCH PAPERS
12 Inuence of initial severity of depression on
eectiveness of low intensity interventions: meta-
analysis of individual patient data
Peter Bower et al
13 Comparative eect sizes in randomised trials from
less developed and more developed countries:
meta-epidemiological assessment
Orestis A Panagiotou et al
14 Features of eective computerised clinical
decision support systems: meta-regression of 162
randomised trials
Pavel S Roshanov et al
15 Cognitive function and other risk factors for mild
traumatic brain injury in young men: nationwide
cohort study
Anna Nordstrm et al
O EDITORIAL, p 8
Caption,
p xx
Sufficient evidence for the oral pill exists,p 7
UK smoking, p 3
More new antibiotics needed, p 20
Kings Fund reports on volunteers in the NHS p 1
THIS WEEK
LAST WORDS
41 Scrap the royal colleges fellowships
Des Spence
On rst name terms
Oliver Ellis
EDUCATION
CLINICAL REVIEW
29 Achilles tendon disorders
Chad A Asplund and Thomas M Best
PRACTICE
QUALITY IMPROVEMENT REPORT
34 Maximising opportunities for increased
antiretroviral treatment in children in an
existing HIV programme in rural South Africa
Ruth M Bland et al
ENDGAMES
40 Quiz page for doctors in training
MINERVA
42 Generating energy from crematoriums, and other
stories
COMMENT
LETTERS
23 Predicted fracture risk; Bisphosphonates and
GI cancers
24 Paracetamol hepatotoxicity; Cap on social care
in England
OBSERVATIONS
MEDICINE AND THE MEDIA
25 Hype and the HIV cure
Margaret McCartney
PERSONAL VIEW
26 After Mid Stas: NHS must look to care of
its own sta
Anonymous
OBITUARIES
27 Ian Greville Tait
Pioneering polymath and Benjamin Brittens general
practitioner
28 Joseph Footitt; Alan William Fowler; Frank Neville
Garratt; Athol Noble Hepburn; William Philip Dowie
Logan; Muhammad Shaq
Time for a break?
Refresh yourself.
masterclasses.bmj.com
Angry NHS staff, p 26
An infected heel ulcer, p 42
THIS WEEK
9.7%
7.1%
6.3%
/.2%
Eschericha coli - 36%
Klebsiella spp - 7.8%
Other Gram negative - 6./%
Pseudomonas spp - /.3%
Proteus spp - 3.1%
Enterobacter spp - 2.2%
Bacteroides spp - 1.5%
Serratia spp - 1.u%
Acinetobacter spp - u.7%
/.2%
Gram negative
Gram positive
1.6%
1./%
1./%
1.2%
36%
7.8%
6./%
/.3%
3.1%
2.2%
1.5%
1.u%
u.7%
Staphylococcus aureus (MRSA) - 9.7%
Non-pyogenic streptococci - 7.1%
Enterococcus spp - 6.3%
Streptococcus pneumoniae - /.2%
Other Gram positive - /.2%
Staphylococcus aureus (MRSA) - 1.6%
Group B streptococci - 1./%
Group A streptococci - 1./%
Diphtheroids - 1.2%
GRAPHIC OF THE WEEK
Gram negative bacteria such as Klebsiella and Escherichia coli (E coli) have overtaken Gram positive bacteria
such as Staphylococcus aureus to become the main organisms causing bloodstream infections in adults
in England, Wales, and Northern Ireland, according to the recent annual report of the chief medical officer
for England (data from the English National Point Prevalence Survey on Healthcare Related Infections
and Antimicrobial Use, 2011, HPA England, 2012). The report points out that the threat to health posed by
Enterobacteriaceae (E coli and Klebsiella related species), which are now the most frequent agents of hospital
acquired infection (36% and 7.8% respectively), is substantial. Kessel and Sharland warn, in their editorial, that
10-20% of these Gram negative bloodstream infections are antibiotic resistant and 30% of patients who acquire
a multidrug resistant Gram negative bloodstream infection are likely to die.
SEE NEWS , p , EDITORIAL, p , ANALYSIS, p
16 March 2013 Vol 346
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RESPONSE OF THE WEEK
It may be significant that students,
lowest in the medical hierarchy, are
able to break into our over-regulated
NHS culture with the simple question
What can I do to improve your stay?
While following prescribed guidelines
will almost always be necessary in
modern practice, its vital that all
staffnot just learnersretain their
authority to attend directly to patient
experience while doing so. And
sometimes the protocol misleads.
As George Orwell said about his own
guidance for writing good English,
Break any of these rules sooner than
say anything outright barbarous.
Sebastian Kraemer, child and adolescent
psychiatrist, Whittington Hospital,
London, UK, in response to IHI Open
Schools quality improvement initiative
(BMJ 2013;346:f1371)
BMJ. COM POLL
Last weeks poll asked:
Should GPs be fined for rises in avoidable
emergency admissions?
65% voted no
(total 858 votes cast)
BMJ lu1!;!/6:f1!39 and
BMJ lu1!;!/6:f1!91
This weeks poll asks:
Are the dangers of antibiotic resistance exaggerated?
BMJ lu1!;!/6:f1/9!
Vote now on bmj.com
MOST SHARED
Locum GP from India is jailed for manslaughter in UK after
failing to spot diabetic ketoacidosis
Health reform alone is pointless
Francis interview: what doctors must learn from my report
Drug company gifts to medical students: the hidden
curriculum
Winding back the harms of too much medicine
THIS WEEK
At the end of the 196us, the then US surgeon general
William H Steward famously declared: The war against
infectious diseases has been won. His optimism might
well have been justied at the time. The discovery of
antibiotics and their widespread introduction had
transformed both medical practice and life expectancy.
Antibiotics still transform lives, butas with so many
of the worlds resourceswe now know that they are not
limitless, and that unless we are careful, their benecial
enects will run out. We have become so accustomed to
the availability of antibiotics that a world without them is
almost inconceivable. Yet this is the world that Englands
chief medical omcer, Sally Davies, demands we
contemplate in the second volume of her annual report
(p 1). The causes of this unfolding catastrophe are many:
overuse of existing antibiotics, increasing resistance
to them, a discovery void regarding new drugs, and a
change in the types of organisms presenting the greatest
threat. If we dont get this right we will nd ourselves in
a health system not dissimilar to the early 19th century,
she says.
Is Davies being overdramatic? Sadly not. Her decision
to focus on antimicrobial resistance has been broadly
welcomed. And this week we publish a report from
Richard Smith and Joanna Coast, long term analysts of
the economics of resistance (p 2u). They suggest that
the picture she paints may even be too rosy. Resistance
is said to present a risk that we will fall back into the
pre-antibiotic era, they say. However, this is perhaps
optimistic.
Their argument is that we have badly underestimated
the cost of resistance. Studies that have tried to
estimate the economic impact have looked at the extra
cost of treating a resistant infection compared with a
susceptible one. But this ignores the bigger picture. The
whole of modern healthcare, including invasive surgery
and immunosuppressive chemotherapy, is based on the
assumption that infections can be prevented or treated.
Resistance is not just an infectious disease issue,
they say. It is a surgical issue, a cancer issue, a health
system issue.
Their revised assessment of the economic burden
of resistance encompasses the possibility of not
having any enective antimicrobial drugs. Under these
circumstances they estimate that infection rates afer
hip replacement would increase from about 1% to
/u-5u%, and that about a third of people with an
infection would die. It seems likely that rates of hip
replacement would fall, bringing an increased burden of
morbidity from hip pain.
The CMOs 17 recommendations include better
hygiene measures and surveillance, greater enorts
to preserve the enectiveness of existing drugs, and
encouragement to develop new ones. As Anthony
Kessel and Mike Sharland point out, only one or two
new antibiotics that target Gram negative organisms
are likely to be marketed in the next decade (p 1u).
Recognising this as a global problem, the CMOs report
also calls for antimicrobial resistance to be put on the
national risk register and taken seriously by politicians
internationally.
As for the cost of such action, Smith and Coast see it
as an essential insurance policy against a catastrophe
that we hope will never happen. And they share the
CMOs urgency. Waiting for the burden to become
substantial before taking action may mean waiting until
it is too late.
Fiona Godlee, editor, BMJ
fodlee@bmj.com
Cite this as: BMJ ;:f
EDITORS CHOICE
Drug resistancean unfolding catastrophe
Resistance is said
to present a risk that
we will fall back into
the pre-antibiotic era
. . . However, this is
perhaps optimistic
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NEWS
BMJ | 16 MARCH 2013 | VOLUME 346 1

Ingrid Torjesen LONDON
Action is needed at both a national and interna-
tional level to avert the ticking time bomb of
antimicrobial resistance, which presents a threat
as grave as climate change, the chief medical
omcer for England has warned.
In the second volume of her annual report for
2011, Infections and the rise of antimicrobial
resistance,
1
Sally Davies spelt out the threat
overuse of existing antibiotics and increasing
resistance to them, a discovery void of new
antibiotics, a change in the types of organism
presenting the greatest threat, and the need
for better training of NHS sta in hygiene and
infection control.
If we dont get this right we will hnd our-
selves in a health system not dissimilar to the
early 19th century, where deaths from infec-
tions will be commonplace because of a lack of
eective treatments, Davies told a press briehng
at the Department of Health. The department
would publish a hve year strategy for action in
the next couple of weeks, she said.
At the chief medical omcers recommenda-
tion, the Department of Health and the Depart-
ment for Environment, Food, and Rural Aairs
have added antimicrobial resistance to their
strategic risk registers. Davies has also requested
that it be added to the National Security Risk
Assessment, alongside pandemic flu and
t errorism, to ensure cross government action.
Governments and organisations across the
world, including the World Health Organization
and G8, need to take this seriously, she said.
This included hnding some way of incentivis-
ing the pharmaceutical industry to develop new
antibiotics. No new antibiotic classes have been
discovered since 1987, and Davies said that no
pharmaceutical companies had any new anti-
biotic classes in their pipeline, and that there
were few new antibiotics of existing classes in
development.
With the pipeline drying up, stewardship of
antibiotics in health, hsheries, and farming had
become increasingly important, she said. In
health, that meant prescribing antibiotics only
when appropriate and ensuring that the patient
completed the course.
Cite this as: BMJ 2013;346:f1597
Zosia Kmietowicz BMJ
Commissioners and service
providers need to better plan
the role of volunteers in both the
health and social care sectors if
they are to avoid alienating the
swathes of people who provide
their time for free and ease
growing tensions with those in
paid jobs, a report from a leading
think tank has said.
1
An estimated three million
people in England volunteer in
the NHS, health charities, and
social care organisations
the same number in paid
employment in the NHS and
social care systems, says the
report from the Kings Fund.
Volunteers play a vital role
in delivering services such
as assisting with mealtimes,
providing support for bereaved
families, and befriending older
people in care homes.
The Institute for Volunteering
Research has suggested that
volunteers are worth around
700 000 a year to hospital
trusts, 500 000 a year to mental
health trusts, and 250 000 a
year to a primary care trust.
The latest report was
commissioned by the
Department of Health to look at
the effect of the current changes
to health and social care sectors
on volunteering. The government
sees volunteering as helping
to achieve its wider ambitions
to decentralise power, reduce
reliance on the state, and
encourage people to take an
active role in their communities.
However, the current
economic climate means that
some tensions have already
emerged, said the report. Some
people are questioning the value
of volunteers, and research has
shown that staff are sometimes
unclear about what volunteers
do. Financial pressures also
risk creating strains with paid
employees who are concerned
about their jobs.
It is for these reasons, the
report said, that commissioners
and service providers need
to focus on how volunteers
will help improve quality and
bring benefits to organisations,
patients, and communities.
To make the most of
volunteers, commissioners and
providers must acknowledge
the value of volunteers, develop
a clear vision of how volunteers
can help organisations and
patients, measure their input,
and clarify the boundaries
between professional and
volunteer roles to allay concerns
of job substitution.
The report said, It is more
important than ever to think
strategically about the role of
volunteering. The health and
social care system will find it
increasingly difficult to meet its
objectives without doing so.
Chris Naylor, fellow at
the Kings Fund, said that
volunteering should be used
to improve quality and not to
reduce short term costs.
Without volunteers the NHS will find it increasingly difficult to meet its objectives, said the Kings Fund
Financial strains must not risk
work of volunteers in the NHS
Antimicrobial resistance
presents an apocalyptic
threat, CMO warns
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UK news First case against doctor from Stafford hospital set to start next week, p
BMJ investigation More than a third of GPs on CCG boards have conflicts of interest, p
OReferences on news stories are in the versions on bmj.com
bmj.com
OJudge overturns
New Yorks ban
on supersize
sweet drinks
NEWS

2 BMJ | 16 MARCH 2013 | VOLUME 346
Clare Dyer BMJ
Campaigners ghting the decision to close the
childrens heart surgery unit in Leeds as part of
an exercise to concentrate operations in fewer
but larger centres have scored a comprehensive
victory at the High Court in London.
Mrs Justice Nicola Davies ruled that the Safe
and Sustainable consultation that recommended
closing three units was flawed by procedural
unfairness and a failure to take into account mate-
rial considerations.
The success for the campaigning group,
Save our Surgery Limited, on both grounds
of its challenge is a signicant setback for the
plans to concentrate surgery at only seven sites:
Bristol, Birmingham, Southampton, Liverpool,
Newcastle, and two in London. Units in Leeds
and Leicester and at Londons Royal Brompton
Hospital in London would be axed under the
consultation recommendations.
The judge ruled that the consultation process

was unlawful in the rst instance because the
Joint Committee of Primary Care Trusts, which
Zosia Kmietowicz BMJ
The UK government has redraed regulations
on procurement, in an attempt to allay concerns
raised by several medical bodies and MPs in the
past few weeks that clinical commissioners would
be forced to put out to competitive tender most of
the services they wanted for their patients.
However, both the BMA and the Royal College
of General Practitioners are still concerned that
commissioners are not completely free to choose
when to use competition and when not to.
The revised regulations, which were laid before
parliament on March, mean that the position
on competition is unchanged from now, said the
Department of Healthcommissioners are able
to oer contracts to a single provider where only
that provider is capable of providing the services.
In explanatory notes, it said, We have
removed the words that inadvertently created the
impression that there were only very narrow cir-
cumstances in which commissioners could award
a contract without a competition.
The department said that the rewording makes
it clear that Monitor, the economic regulator of the
NHS, has no power to force the competitive ten-
dering of services when the regulations come into
force on April, and that decisions about how
and when to introduce competition are solely up
to doctors and nurses in clinical commissioning
groups. It added, Competition should not trump
integrationcommissioners are free to commis-
sion an integrated service where it is in the inter-
est of patients.
The UK Labour Party and the new National
Health party criticised the original secondary leg-
islation published in February.
More than
doctors also urged MPs to force a debate on the
regulations
and the Academy of Medical Royal

Colleges expressed considerable concern at the
regulations, which were published to supplement
section of the Health and Social Care Act.
Clare Gerada, chair of the Royal College of
General Practitioners, said the revised regulations
were a step in the right direction but . . . do not
go far enough in ensuring that commissioners are
genuinely free to decide whether or not to expose
services to competition.
Mark Porter, chair of the BMA Council, said, It
is vital that competition is not allowed to under-
mine integration, innovation, or clinical auton-
omy. There still needs to be a full parliamentary
debate to provide absolute clarity that CCGs [clini-
cal commissioning groups] will have the freedom
to decide how best to secure high quality services
for local populations, he said.
Judge rules that decision
to close three childrens
heart units was unfair
New rules on competition are still a concern
Campaigners to keep services in Leeds said the
reform process had been flawed and unjust
S
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Services are failing people with dementia:
People with dementia who live in care homes
in England are more likely than similar
people without dementia to go to hospital
with avoidable conditions such as urinary
infections, the Care Quality Commission has
said. Once admitted, people with dementia
are more likely than those without dementia
to stay in hospital longer, be readmitted, and
die in hospital.
Disclosure of pharma sponsorship
made compulsory in Portugal: A law
that was enacted on 15 February requires
doctors, scientic societies, and patient
associations in Portugal to publicly disclose
all sponsorship from the pharmaceutical
industry to the national drug regulator
(Infarmed). Failure to disclose conflicts of
interests could result in nes of t2uuu
(17/u) to t/5 uuu.
Regulator rules that
advertisements on plain
packs are misleading: The
Advertising Standards Authority
has ruled that ads run by
Japan Tobacco International
against the introduction of
plain, standard packagingare misleading
and must not be published again. The ads,
placed in the national press in 2u12, stated
that in 2uu8 the government had rejected
plain packaging for tobacco because there
was no credible evidence to support such a
policy. The regulator concluded that the claim
breached the advertising code of practice.
Smoking to be banned from all Dutch cafes:
Dutch health minister Martin van Rijn has
conrmed to MPs that he will bring forward
changes to the law enforcing a smoking
ban throughout the Netherlands hospitality
industry. Most MPs recently voted for a
total ban. Currently some smaller cafs are
exempt. Last year, smoking increased from
25% to 26% in adults.
Partners agree to vaccinate 400 million
children: The Global Alliance for Vaccines
and Immunisation (GAVI) and the Islamic
Development Bank (IDB) have signed a
memorandum of understanding to help
save childrens lives by accelerating the
introduction of vaccines in IDB member
countries. By 2u2u, GAVI plans to vaccinate
more than /uu million children in at least 29
member countries with the aim of preventing
3.2 million deaths at an estimated cost of
$7bn.
IN BRIEF
took the decision, had refused to disclose the
sub-scores that an expert committee had given
in a scoring exercise. Units were given only the
overall scores.
I am satised that fairness did require disclo-
sure of the sub-scores to enable Leeds to provide a
properly focused and meaningful response, said
the judge, who described the committees refusal
to hand over the sub-scores as ill judged.
In addition, the joint committee also failed to
take into account the sub-scores when carrying
out the consultation, although the overall scores
were acknowledged to be close, she said. The sub-
NEWS

Ingrid Torjesen LONDON
British adults are half as likely to smoke as they
were four decades ago and are drinking less
heavily and less frequently, show data from the
Omce for National Statistics (ONS) 2011 General
Lifestyle Survey.
The surveys report, launched at a press con-
ference in London on 7 March, also shows that
despite the ageing population, the proportion of
people in Great Britain living with a longstanding
illness or disability has remained steady over the
past 20 years at just under a third.
1
The 2011 report marks 40 years of the survey.
When the ONS survey hrst included questions
about smoking in 1974, it found that 45% of
adults smoked (51% of men, 41% of women).
Since then, smoking has more than halved and
the gap in prevalence of smoking between men
and women has narrowed; in 2011, 20% of
adults smoked (21% of men, 19% of women).
Although fewer people smoke now than in
the 1970s, women who still do smoke consume
similar numbers of cigarettes (12 per day in 2011
compared with 13 in 1974), and consumption
has fallen only slightly in menfrom 18 ciga-
rettes per day in 1974 to 13 in 2011.
Alongside smoking, the proportion of adults
drinking heavily or frequently has also fallen.
Among 16-24 year olds, the proportion of men
drinking more than eight units (double the rec-
ommended maximum for men) in one day in the
past week fell by almost a third in four years (from
32% in 2007 to 22% in 2011).
The proportion of women drink-
ing more than six units (double
the recommended maximum
for women) in any one day
fell by a quarter over the
same time period, from
24% to 18%.
The proportion of men
drinking on five or more
days in a week fell from 23%
in 1998 to 16% in 2011,
while the proportion of
women drinking at least hve
times per week fell from 13%
to 9%. However, the survey
found that older people were
far more likely than younger
people to drink frequently. In
2011, men aged 45 years or more
were more than twice as likely to drink hve times
or more per week as those aged 16-44 years.
While lifestyle has improved the population
has aged. Between 1971 and 2011, the pro-
portion of the population aged 65 years or over
increased from 13.3% to 16.5%.
2

However, this ageing has not
been reflected in the overall
prevalence of longstand-
ing illness or disability. In
1972, 21% of the popula-
tion reported living with
a longstanding illness or
disability. This proportion
rose to 32% in 1991 and
has remained steady. The
most common longstand-
ing illnesses reported were
musculoskeletal illnesses,
followed by heart and cir-
culatory conditions, respira-
tory illnesses, and endocrine
and metabolic conditions. How-
ever, the proportion of people
living with a longstanding ill-
ness or disability has increased
from 15% in 1975 to 19% in 2011.
Clare Dyer BMJ
A surgeon who worked at Stafford Hospital,
where inquiries uncovered hundreds of excess
deaths and appalling standards of care
between 2005 and 2008, is to face a htness to
practise hearing at the Medical Practitioners
Tribunal Service next week.
Roderic Hutchinson faces allegations of deh-
cient professional performance at a 10 day hear-
ing, which opens at the tribunal in Manchester
on 18 March.
Three medically qualihed managers at Mid
Staordshire NHS Foundation Trust are also set
to appear before the tribunal, although no dates
have yet been hxed. They have been named as
John Gibson, medical director from 2003 to 2006;
his successor, Valerie Suarez, who was appointed
in September 2006 and stepped down in March
2009; and their deputy, David Durrans.
The hearings follow investigations by the General
Medical Council (GMC) into 42 doctors who worked
for Mid Stas trust at the time.
1
Hutchinsons case is
the hrst to be sent for a hearing.
A consultant general surgeon and colorectal
surgeon, he underwent a GMC assessment of
his professional performance in June 2011. The
charges allege that his performance was unac-
ceptable in the area of working with colleagues,
and a cause for concern in the areas of other good
clinical care and relationships with patients.
The surgeon was allowed to continue work-
ing under conditions including supervision by a
named consultant, but the conditions were lihed
in October 2011. He leh Mid Stas in September
2012.
A review of the general surgery department
at Stafford Hospital by the Royal College of
Surgeons in 2009 concluded that the service
provided was inadequate, unsafe, and at times
frankly dangerous.
2
NHS managers who are not doctors are not
subject to regulation, but GMC guidance makes
it clear that those who are medically qualihed
may be held to account on how they fulhl their
management roles.
Case against doctor from Stafford
hospital set to start next week
scores provided the basis for what was ultimately
the dierence of one point in the critical quality
scoring between Leeds and Newcastle.
In my view, and commensurate with their
duty to properly scrutinise and assess all relevant
evidence, the JCPCT [the joint committee] should
have considered the sub-scores, she said.
At a further hearing on 27 March to decide
what remedy should be granted, the Leeds cam-
paigners are expected to argue that the decision
on 4 July 2012 to concentrate childrens heart sur-
gery at the seven sites should be quashed. The
joint committee is expected to seek an appeal.
The Royal Brompton initially succeeded in
a High Court challenge to the plans but lost on
appeal.
2
If the decision is quashed, the Leeds campaign-
ers would argue that surgery should continue at
Leeds and Newcastle, the judge said.
Last October the health secretary, Jeremy Hunt,
referred the decision to close the three units to
the independent reconhguration panel, which
advises on contested changes to health services
in England. The panel was expected to deliver its
decision by the end of March.
3
The units earmarked for closure have argued
that the consultation, which began in 2008, has
been working with outdated hgures.
Britons are making healthier lifestyle choices than 40 years ago
In 1974 the survey found that
41% of women smoked; in 2011
it was 19%
BMJ INVESTIGATION
commissioners who run their own private com-
panies and called on GP commissioners to be
barred from being involved in companies that
they are giving contracts to.
2

But others have said that conflicts are an
inevitable by-product of allowing more clini-
cians into management positions and said that
focusing too much on the issue may prevent
commissioners redesigning services eectively.
The BMJ analysed the registered interests of
176 of the 211 commissioning group boards,
obtained through requests made under free-
dom of information legislation and from CCG
websites. The remaining groups were not able
to disclose their lists, though they must main-
tain and publish them from 1 April.
3

Our analysis also showed that 4% of GPs
on CCG boards were consultants to or advised
private health or pharmaceutical companies,
while 5% were employed by a private health
company as well as working as a GP.
Some 12% of GPs declared links with not for
proht voluntary or social enterprise providers
that represented a conict of interest with their
commissioning role, while 9% of GPs declared
a conict of interest through a family member.
More than a third of GPs on the boards of the new
clinical commissioning groups (CCGs) in England
have a conict of interest resulting from director-
ships or shares held in private companies, a new
analysis by the BMJ has shown.
An examination of the registered interests of
almost 2500 board members across 176 CCGs
provides the clearest evidence to date of the con-
icts that many doctors will have to manage from
1 April, when the GP led groups are handed stat-
utory responsibility for commissioning around
E60bn of NHS healthcare services.
Our investigation shows that conicts of inter-
est are rife on CCG governing bodies, with 426
(36%) of the 1179 GPs in executive positions
having a hnancial interest in a for-proht private
provider beyond their own general practicea
provider from which their CCG could potentially
commission services.
The interests range from senior directorships
in local for-proht hrms set up to provide services
such as diagnostics, minor surgery, out of hours
GP services, and pharmacy to shareholdings
in large private sector health hrms that provide
care in conjunction with local doctors, such as
H armoni and Circle Health.
May
Coalition government is
elected. Andrew Lansley
(right), who had served as
the Conservatives shadow
health secretary for six and
a half years, is appointed
secretary of state for health.
But it is understood that
the Conservatives policy
chief, Oliver Letwin, and the
Liberal Democrat MP Danny
Alexander drew up the new
governments health policy
as part of their hastily devised
programme for government
( BMJ 2012;345:e4833).
July
Government
publishes
its NHS
white paper
Equity and Excellence:
Liberating the NHS . This
proposes handing sweeping
powers to GPs in a major
shake-up of the NHS. The
radical proposals include
the abolition of primary care
trusts and the establishment
of new consortiums, led
by GPs, to manage NHS
commissioning budgets
( BMJ 2010;341:c3796) .
January
Department of Health pub-
lishes the Health and Social
Care Bill, outlining its vision
for healthcare. An accom-
panying impact assessment
identies potential conicts
of interest as a key risk
associated with the proposed
changes
( BMJ 2011;342:d507).
April
Government announces
pause in the passage of
the Health and Social Care
Bill, prompted by concerns
from the Liberal Democrats,
the Labour Party, and the
medical profession. Steve
Field, former RCGP chairman
(below), is put in charge of
the Future Forum set up to
hear such concerns during
the pause
( BMJ 2011;342:d2216).
June
After the listening exercise
conducted during the
pause the government
announces that the GP
consortiums will be renamed
clinical commissioning
groups (CCGs) to reect
the wider clinical
involvement beyond GPs.
It says that each CCG must
have at least two other
clinicians on its governing
body, including at least one
secondary care specialist
doctor
( BMJ 2011;342:d3777).
In some cases most of the GPs on the CCG gov-
erning body have hnancial interests in the same
private healthcare provider.
Some doctors have relinquished interests in
private enterprises because of their new roles
as commissioners. These include GPs linked to
Richard Bransons Virgin Care, which announced
in October 2012 that it planned to end its joint
venture partnerships with over 300 GPs in Eng-
land,
1
aher admitting that many were becoming
increasingly worried about the perception of
potential conicts of interest.
Calls for doctors with interests to step down
But our analysis found that, in total, 555 (23%)
of 2426 clinical, lay, and managerial members
of CCG governing bodies had a hnancial stake in
a for-proht company.
Leading GPs, including a senior government
adviser on commissioning, have called for doc-
tors with conicts that were too great to step
down and have urged the NHS Commissioning
Board to oer tougher guidance to those with
multiple interests. Last week the BMAs UK con-
sultants conference passed a motion expressing
concern at the clear conict of interest of GP
More than a third of
GPs on CCG boards have
conflicts of interest
On the eve of one of the biggest upheavals in the history
of the NHS, Gareth Iacobucci looks at the conflicts at the
heart of clinical commissioning groups
Membership of CCG governing bodies
GPs (n=)
Other (n=)
Total number of board members in CCGs
analysed (n=)
Lay and
managerial
members (n=)
Other clinical
members (n=)
3%
49%
38%
10%

COMMISSIONINGWHAT HAPPENED WHEN
>>> >>> >>> >>> >>>>
N
o

o
f

G
P
s
Consult with or advise a private

company or drug company
Key
Types of interests registered by GPs on CCG boards
Employed by a private company
(aside from their GP practice)
Declared a conflict of interest
relating to a family member
Personal links with not for prot
voluntary or social enterprise
organisations
Directors or have shares in private
companies
426
144
106
55
43
BMJ INVESTIGATION
The NHS Commissioning Board has issued
rules to CCGs stating that board members must
remove themselves from decisions from which
they could materially benet.

Some CCGs have responded to this by includ-
ing a provision to co-opt additional members
if doctors on the governing body have to
remove themselves from decisions. Others
have increased the number of lay members on
boards to try to alleviate potential conicts.
But doctors leaders have expressed concern
that clinical input into commissioning deci-
sions might become diluted if too many doc-
tors were forced to remove themselves from
particular decisions.
CCGs with notable conflicts
Governing bodies with notable conicts include
NHS Leicester City CCG, where seven GPs on
the board have a financial interest in the LLR
(L eicester, Leicestershire and Rutland) GP Provider
Company; NHS Oldham CCG, where ve of the
eight GPs have an interest in the provider Primary
Care Oldham LLP; and NHS Blackpool CCG, where
six of the eight GPs have an interest in the local out
of hours provider Fylde Coast Medical Services.
Ian Wilkinson, a GP and chief clinical o cer
at NHS Oldham CCG, who does not have a nan-
cial stake in a private provider company, said
that the CCGs board had also recruited addi-
tional lay and clinical members to ensure that
decisions could be made if members needed
to remove themselves. He added that so far no
voting members had removed themselves from
governing body or committee proceedings.
Richard Gibbs, a lay board member at NHS
Southwark CCG, told the BMJ that his CCG had
attempted to deal with conicts by appointing
him as a guardian who would judge when it
might be appropriate for members to remove
themselves from decisions (box).
A spokeswoman for Leicester City CCG said
that a signicant proportion of its local general
practices were members of the LLR GP Provider
Company and said that it would co-opt mem-
bers from neighbouring CCGs if its governing
body were conicted. She said, They have to
remain neutral, so we would bring in members
from our fellow CCGsEast Leicestershire and
Rutland/West Leicestershireor bring in a GP
member from a neighbouring county such as
Northamptonshire.
In NHS Chiltern CCG, in Buckinghamshire,
two of the three GPs on the governing body hold
shares in the for-prot provider Chiltern Health,
while in NHS Aylesbury Vale CCG, also in Buck-
inghamshire, both GP voting members of the
board have interests in the private provider Vale
Health. In NHS Southwark CCG, in London, ve
of nine GPs on the governing body have a stake in
various for-prot provider companies.
All these CCGs told the BMJ that they had
robust systems in place for managing potential
conicts, including publishing their policies on
conicts of interest and regularly updating mem-
bers declarations of interest.
Amanda Doyle, a GP and chief clinical o cer
at NHS Blackpool CCG, told the BMJ that her
CCG had sought to tackle potential conicts by
opting to double the number of lay members on
its governing body from the minimum set by the
government, including a lay chairperson (box).
Doyle acknowledged that most of the GPs on
the board would have to step away if the local
out of hours service were to be retendered. But
she warned that the benets of having doctors
leading commissioning might be lost if conicts
of interest gained too much attention.
September
RCGP and NHS
Confederation,
the membership
body for
organisations
that commission
and provide NHS services,
publish joint guidance
on managing conicts
of interest in clinical
commissioning groups
(BMJ Careers,
http://bit.ly/W7y9wK ).

>>> >>> >>> >>> >>>>
February
House of Lords agrees
amendments to the Health
and Social Care Bill stating
that CCGs would have to
publish registers of board
members interests
( http://bit.ly/ wqDqVP ).
June
NHS Commissioning Board
Authority publishes a code
of conduct. This states that
members must remove
themselves from decisions
from which they could
materially benet
October
The private sector company
Virgin Care, owned by
Richard Branson (top
right), announces plans to
dissolve its joint venture
provider partnerships
with GPs, in response to
concerns from GPs over
conicts of interest in
the new commissioning
landscape
( BMJ 2012;345:e7227).
November
NHS Commissioning Board
rejects a call from GP
commissioning leaders for
conicts of interest to be
treated with leniency
( BMJ 2012;345:e7967).
February
In its response to its
consultation Securing the
Best Value for Patients,
health department says that it
will strengthen the powers of
Monitor, headed
by David Bennett
(right), to act
where conicts
may affect the
integrity of a
commissioners
decision.
BMJ INVESTIGATION
A spokesman for NHS Chiltern CCG said that
the group had co-opted additional members to
a decision making panel for the recent procure-
ment of a GP led minor illness and injury unit
where there was potential for perceived conict
of interest, while NHS Aylesbury Vale CCG said
that it had written the ability to co-opt members
into its constitution.
Declaring an interest not enough
However, despite the measures being taken,
James Kingsland, the governments national
clinical lead for NHS clinical commissioning and
a GP on Merseyside, said that he believed some
doctors on local commissioning boards should
step down from one of their roles if they had a
substantial stake in a local private healthcare
company, because their conicts were too acute.
He said, If it is somebody who has got a major
stake in some of the provider services which
the CCG commissions, I dont think excluding
[himself or herself] or declaring an interest is
enoughnot for the public. I think they have got
to step down.
Kingsland said that his stance had been criti-
cised by some doctors, who were concerned that
forcing people to step down could lead to a short-
age of clinicians willing to sit on CCG boards.
But he said, That isnt an excuse to allow con-
ict to go. If they are enthusiasts as both senior
provider and senior commissioner, my answer
would be: make your choice and be accountable
for that choice.
If you can justify a marginal amount of con-
ict that can be declared and managed, then ne.
If you cant marginalise a conict, and you are
excluding yourself from the board week in, week
out because youve got an interest, ultimately it
becomes unaccountable. Where you draw the
line is dicult; if somebody is going to be the
arbiter of that, it should be the public.
The local newspaper test
Michael Dixon, chairman of the NHS Alliance,
which represents organisations and individual
professionals in primary care, has previously
called for more leniency in handling conicts
of interest in the new system.
He warned that
placing too much emphasis on the issue might
prevent clinical commissioners from bringing
more care into community settings.
He said, The priority is to move services out
of hospital and into primary care. The reason this
hasnt happened to date is because of blocks in
the system. Its more important to remove those
blocks than be preoccupied with conflicts of
interest. Dixon said that he believed that trans-
parency is all you need to handle conicts and
urged doctors to use the local newspaper test
when assessing their own interests: You have
got to be happy for everything you do as a GP and
a commissioner to appear on the front page.
Chaand Nagpaul, the BMAs lead GP negotia-
tor on commissioning and a GP in Harrow, called
for the NHS Commissioning Board to issue more
robust guidance on handling conicts.
The Commissioning Boards guidance has
not gone far enough. Their guidance is all about
declaring and managing conicts, rather than
recognising that some conicts of interest are
too great, he said.
Nagpaul said that he supported the idea of
CCGs co-opting additional members to help
make decisions where conicts existed, but he
said that it was crucial that this extra help did
not just focus on lay members, as it could dilute
clinical commissioning.
It would undermine the whole concept of
clinically led commissioning to not have clinical
input, he warned.
A spokeswoman for the NHS Commissioning
Board said that it had already published com-
prehensive guidance on managing conicts of
interest, which clearly sets out that the decision
on whether an individuals conicts of interest
are likely to be so great as to preclude them from
taking a role on the governing body should be
made by the CCG.
But she said that the board was reviewing its
existing guidance and would shortly be publish-
ing nal, comprehensive guidance on managing
conict of interest.
Strengthening the rules
The Department of Health acknowledged in its
response to its consultation Securing the Best
Value for Patients that concerns about con-
icts needed to be answered, and it pledged to
strengthen the power of the healthcare regula-
tor Monitor to act where conicts may aect the
integrity of a commissioners decision.
The department said that this would mean

that Monitor is able to take action where con-
flicts have not been managed appropriately
in awarding a contract, and not only where
M onitor is able to establish that the decision to
award a contract was the result of an interest in
the p rovider.
Niall Dickson, chief executive of the General
Medical Council, said that there were no new
principles involved as far as doctors ethical
conduct was concerned. He added, The con-
siderable additional responsibilities about to be
undertaken by GPs does mean that some face
conicts of interests more oen than in the past.
We expect doctors to be open about any nancial
and commercial interests linked to their work.
NHS Blackpool CCG
NHS Southwark CCG
Richard Gibbs, lay member of
the board of the NHS Southwark
CCG, said that his group
had tried to tackle potential
conflicts by appointing him as
a guardianwith the remit of
exercising judgment on when
it might be appropriate for
members to remove themselves
from decisions.
Gibbs, who has no financial
interests in any private providers,
said that the CCG had also set
up a three person evaluation
panel, comprising himself, the
chief officer, and the director
of public health, to arbitrate
on commissioning decisions
where two or more members
have to remove themselves from
decisions because of conflicts.
We have convened the panel
on three or four occasions,
Gibbs said. If we needed to get
additional expertise then we
would co-opt in someone who
isnt conflicted, presumably from
outside Southwark.
Amanda Doyle, chief clinical
officer at NHS Blackpool CCG,
who has declared an interest in
the local provider of out of hours
services, said that her CCG had
sought to deal with potential
conflicts by opting to have four
lay members on its governing
bodydouble the minimum set
by the governmentincluding a
lay chairperson.
We were very conscious of
the need to demonstrate that
we were not letting conflicts
interfere with our decisions,
she explained.
But Doyle added that it was
important to strike a balance
between managing conflicts
appropriately and ensuring
that we get a full range of clinical
input into service redesign and
commissioning decisions.
She warned, There is a risk of
getting so tied up with worrying
about conflicts of interest that
you dont go ahead and reap
the benefits of having clinicians
leading commissioning.
Doyle acknowledged that most
GPs on the board would have to
step away if the local out of hours
service were to be retendered.
She said that it was unlikely
that the board would co-opt
additional clinicians onto the
board in such a case but said
that it may take clinical input
and advice from outside the
area if this was needed.
TACKLING THE ISSUE OF CONFLICTS OF INTEREST

Editorials are usually commissioned. We are, however, happy to consider and peer review unsolicited editorials
See http://resources.bmj.com/bmj/authors/types-of-article/editorials for more details
EDITORIALS

Is an EMA review of hormonal contraception and thrombosis needed?
Sufficient evidence exists to recommend lightest tolerable second generation pill for all indications
Frans M Helmerhorst professor in clinical
epidemiology of fertility
F.M.Helmerhorst@LUMC.nl
Frits R Rosendaal professor in clinical epidemiology,
Leiden University Medical Center, RC Leiden,
Netherlands
Four recently reported deaths in women using
the Diane-35 contraceptive and a lawsuit against
the French drug authority (LAgence Nationale de
Scurit du Mdicament) aher it banned Diane-
35 led the authority to request that the European
Medicines Agency (EMA) review the safety of
combined oral contraceptives.
1

2
Of particular
concern were third and fourth generation drugs,
including Diane-35 and its generics. This review
was granted on 7 February 2013.
3

4
The Dutch
College for the Evaluation of Medicines (Dutch
EMA) decided that a new study on Diane-35
was in order.
Most oral contraceptives are combination
preparations, containing a progestogen, to
prevent ovulation, and an oestrogen to prevent
breakthrough bleeding. Since the introduction
of the pill, the oestrogen dose, in the form of
ethinyl estradiol, has been reduced (heavy v light
pills) and the type of progestogen has changed
several times (indicating the generation). The
categorisation is imprecise and incomplete. For
example, cyproterone acetate, the progestogen
in Diane-35, does not belong to a generation.
Furthermore, the categorisation assumes that
all side eects of oral contraceptives are class
eects. In our recent network meta-analysis of
all combined oral contraceptives (unpublished
data), we found that the risk of venous thrombo-
sis depended on the dose of oestrogen and the
type of progestogen, even within generations.
Many studies have shown that oral contra-
ceptive users have an increased risk of venous
thrombosis (deep vein thrombosis, pulmonary
embolism) and arterial thrombosis.
5

6
Venous
thrombosis is more common than arterial throm-
bosis, but in young women the incidence of these
side eects is low. Even the safest oral contra-
ceptive increases the risk of venous thrombosis,
however, and the risk is twice as high for oral
contraceptives containing a third generation
progestogen, drospirenone (sometimes called
fourth generation), or cyproterone acetate.
5
This
knowledge is not newthe increased risk for
pills containing third generation progestogens,
cyproterone acetate, and drospirenone has been
known since 1995, 2001,
7
and 2003, respec-
tively.
8
The EMAs public report at the beginning of the
review states that Diane works by blocking the
eects of a class of hormones called androgens,
3

and that this is responsible for its supposed ben-
ehts on acne and hirsutism. However, as early as
2004 (and in three updates) a systematic review
concluded that all types of monophasic com-
bined oral contraceptives are eective against
acne.
9
All combined oral contraceptives are equally
effective in preventing pregnancy. Their side
eects (such as weight gain
10
) and benehts (in
terms of acne and hirsutism) are also similar, so
the only rational strategy is to use the safest one
with regard to venous thrombosis. The common
arguments that the risk of thrombosis is low or
that the risk of thrombosis during pregnancy
is higher than when using oral contraceptives
are flawed. Millions of women in Europe use
oral contraceptives, so use of the pill with the
best safety prohle in terms of thrombosis would
probably prevent thousands of thrombotic events
and hundreds of deaths a year. Because the pill
with the safest thrombosis prohle is as eective
at preventing pregnancy as the less safe ones,
the risk of thrombosis in pregnancy is irrelevant
in the choice of oral contraceptive. The safest
oral contraceptive is one that contains the low-
est tolerable dose of ethinylestradiol (lowest
dose that prevents breakthrough bleeding30
g
11
) together with the second generation pro-
gestogen, levonorgestrel.
Sufficient evidence is already available on
which clinicians and regulatory agencies can
base their decisions, so lengthy evaluations, let
alone new studies, are not needed.
In his 2011 BMJ editorial, Nick Dunn recom-
mended prescribing an oral contraceptive that
contains levonorgestrel unless there is a persist-
ent reason to use another type.
12
Because oral
contraceptives containing levonorgestrel and
the lowest tolerable dose of oestrogen are also
adequate for the treatment of acne or hirsutism,
we can see no reason to use another type. Third
and fourth generation oral contraceptives are
widely overprescribed.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally
peer reviewed.
References are in the version on bmj.com.
Response on bmj.com
It is wise to consider all of the many serious conditions caused by use of hormonal contraception including the increased risks of suicide
and breast cancer. Ellen CG Grant, retired medical gynaecologist, Kingston-upon-Thames, Surrey
Visit the article online and click Respond to this article to have your say.
French drug authority LAgence Nationale de Scurit du Mdicament recently banned Diane-35
B
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EDITORIALS
Cognitive deficits and mild traumatic brain injury
New study identifies risk factors and raises questions about the nature of any implied causal association
V F J Newcombe academic clinical fellow in emergency
and intensive care medicine
D K Menon professor of anaesthesia, Division of
Anaesthesia, University of Cambridge, Addenbrookes
Hospital, Cambridge CB QQ, UK
Between 7% and 33% of patients who have
mild traumatic brain injury (sometimes called
concussion) develop persistent post-concussion
syndrome, which may last weeks to months
aher injury.
1
More than 15% have a measurable
cognitive dehcit at one year.
2 3
There is grow-
ing interest in the syndrome of post-traumatic
encephalopathy,
4 5
which may follow a blast
injury or repeated sports related concussion.
However, despite this growing literature on the
cognitive consequences of mild traumatic brain
injury, our knowledge of risk factors that predis-
pose people to sustaining such injury is limited.
In a linked paper, Nordstrm and colleagues
examine the associations and temporal associa-
tions between a history of concussion, cognitive
function, academic achievement, and measures
of social wellbeing in a cohort of more than
300 000 Swedish conscripts.
6
Given the paucity
of data on premorbid neurocognitive testing in
traumatic brain injury, this paper draws on an
impressively large dataset that allows comparison
of neurocognitive function before and aher such
injury in a nationwide cohort of Swedish men.
The results complement an earlier study from
the same group, which examined the association
between cognitive performance and incidence
of a subdural haematoma.That study concluded
that low global intelligence in adolescence was
a risk factor for subsequent development of a
subdural haematoma.
Although the current study investigates a
more common diagnosis, case ascertainment
was probably less precise than the more clearly
dehnable endpoint of subdural haematoma.
The case ascertainment of concussion that
the authors used was based on the International
Classication of Diseases and probably repre-
sents the best epidemiological approximation
achievable in the administrative databases that
were searched. However, a substantial propor-
tion of patients with mild traumatic brain injury
are never admitted to hospital or seen in the
outpatient setting. Therefore, this study prob-
ably underestimated the incidence of this con-
dition in the study population. Conversely, the
approaches used may not have fully excluded
subjects who sustained a moderate or severe
injury. Cross correlating multiple sources of data
could mitigate against this source of confound-
ing, which is common when administrative data-
sets are analysed.
8
Despite these caveats related to case ascertain-
ment, Nordstrm and colleagues study provides
unique insights into the epidemiology of mild
traumatic brain injury. Unsurprisingly, poor cog-
nitive function, low educational status, and other
risk factors were associated with mild traumatic
brain injury. However, surprisingly, the associa-
tion between cognitive function and concussion
did not depend on the temporal association
between the two and was just as common when
poor cognitive performance preceded concus-
sion. In addition, similar cognitive scores were
seen before and aher injury in twins discordant
for mild traumatic brain injury, which suggests
that both genetic and environmental inuences
contributed to the low cognitive function found.
Other strong independent (but not unexpected)
risk factors for development of mild traumatic
brain injury included a previous episode of brain
injury, hospital admission for intoxication, and
low education and socioeconomic status. Sur-
prisingly, the analysis found no signihcant dier-
ences in cognitive performance before and aher
the index event in men who sustained an injury.
These results are important for several rea-
sons. Firstly, they identify potential risk factors
for mild traumatic brain injury and could help
guide attempts to investigate prevention strate-
gies, perhaps through education initiatives (par-
ticularly in accessible populations such as the
military conscripts investigated here). Secondly,
they provide a context for interpreting studies
that measure cognitive function aher injury only
and compare it with matched controls from the
general population, with the assumption that
those with brain injury have similar pre-injury
characteristics to the general population. The
results of this study suggest that such assump-
tions may be incorrect. Finally, those who subse-
quently sustained a mild traumatic brain injury
had similar cognitive performance to that of
those who had previously sustained such an
injury, which implies that the injury itself may
not reduce cognitive function. However, the tests
used (word recollection; visuospatial geometric
perception; logical and inductive performance;
and mathematical and physics problem solving)
have not been validated as sensitive measures
of changing performance in cognitive areas
thought to be aected by mild traumatic brain
injury. These tests may therefore have missed
important changes.
It is important that additional studies attempt
to replicate these hndings. Suitable populations
for such studies include other military cohorts
and cohorts of people who practise contact
sports, which are associated with a relatively
high incidence of mild traumatic brain injury.
Such studies must take account of gaming
by soldiers and sportspeople, who allegedly
choose to perform suboptimally on pre-injury
cognitive screening to hide evidence of any post-
injury cognitive decrement, thus enabling them
to stay with their units and teams. Although it
may not be easy to control for such confounding,
more studies like the current one will increase
our understanding of the epidemiology, patho-
physiology, and outcome impact of traumatic
brain injury.
peer reviewed.
bmj.com Neurology updates from BMJ Group are at
www.bmj.com/specialties/neurology
Poor cognitive performance linked to concussion
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EDITORIALS
Regulating the NHS market in England
The government must make its intentions clear as it rewrites the regulations on competition
Chris Ham chief executive, Kings Fund, London WG AN,
UK C.Ham@kingsfund.org.uk
The governments drah regulations on procure-
ment, patient choice, and competition, pub-
lished in February, have opened up old wounds
in the debate about NHS reform. The regulations
set out in detail how commissioners should pro-
cure NHS services under section 75 of the Health
and Social Care Act 2012. The stated aim of the
regulations, which will be enforced by Monitor
as the economic regulator, is to ensure that the
NHS Commissioning Board and clinical commis-
sioning groups act to protect patients rights and
to prevent anti-competitive behaviour.
1
The government claims that the regulations
follow from commitments given during the
passage of the 2012 act and are consistent
with the Principles and rules for cooperation
and competition put in place by the previous
administration. Its critics contend that they go
much further and represent a major extension
of market principles in the NHS. In this they
are supported by legal advice, which argues
that commissioners of NHS services will be
expected to make greater use of tendering, with
competition becoming the norm for placing
NHS c ontracts.
2
The governments critics comprise general
practitioner leaders who are worried that clini-
cal commissioning groups will have to use ten-
dering to procure all services; Liberal Democrat
MPs and peers who fear this will make it more
dimcult to promote integrated care; and oppo-
sition politicians who interpret the regulations
as conhrmation that ministers are hell bent on
opening the NHS up to the private sector. In
the face of these concerns, the government has
announced that it will amend the regulations
to ensure that they are not open to misinterpre-
tation. Statements made by ministers indicate
that this means commissioners will not have to
tender all services, Monitor will not force com-
missioners to tender competitively, and compe-
tition will not take precedence over cooperation
and integration.
3
The decision to make these changes less than
a month before the provisions of the 2012 act
come into eect is embarrassing for the govern-
ment. It reects both the inuence of the Liberal
Democrats within the coalition and the need to
retain the support of GP leaders, who will play
a key role in the work of clinical commission-
ing groups. If these leaders had walked away at
this stage, the edihce on which the reforms are
based might well have crumbled to the ground
even before it had come into being.
Underlying the debate about the precise
wording of the regulations is the more impor-
tant question of the governments intentions
regarding the role of markets in the NHS. On
this question there is room for legitimate doubt
in the light of the debate on the 2012 act and the
amendments made aher the work of the NHS
Future Forum. Particularly important was the
change to Monitors role from an original duty
to promote competition to a revised duty to pro-
tect and promote the interests of people who use
healthcare services, and in so doing to prevent
anti-competitive behaviour.
These amendments may have watered down
Andrew Lansleys ambitious plans to apply
market principles to the NHS, but the architec-
ture of economic regulation set out in part 3 of
the 2012 act remains in place. A key element in
this architecture is the role that the Omce of Fair
Trading (OFT) and the Competition Commission
will play in the future NHS. In the debate about
the regulations, the involvement of the OFT in
assessing the proposed merger of two NHS foun-
dation trusts in the south of England has gone
largely unnoticed. The OFT is also investigating
the proposed merger of an NHS foundation trust
and an NHS trust in Torbay, which is designed
to bring about closer integration of services in
an area well known for its innovative approach
to the care of older people.
The question this raises is whether this kind
of market regulation is needed in the NHS in
addition to the new role of Monitor? There are
many dierences between healthcare and the
industries that OFT and the Competition Com-
mission regulate, and there is a danger that
regulators with experience in other sectors will
adopt an approach that is not sensitive to these
dierences. Overexuberant regulation of merg-
ers could delay the implementation of service
changes that may beneht patientsfor example,
by preventing the full integration of care as is
being proposed in Torbay.
It is worrying that fundamental questions of
this kind are unresolved so close to the date of
implementation of the reforms. Evidence that
competition in healthcare is benehcial is both
equivocal and contested.
4

5
Even where benehts
can be delivered, these have to be set against the
considerable transaction costs involved in con-
tract negotiations between commissioners and
providers and the work of the regulators. The well
known limits to markets in healthcare mean that
planning, collaboration, and clinical networks
6

should also play a major role in bringing about
improvements in care.
Where markets are used, regulators need to be
sensitive to the dierent forms of competition in
healthcare. Competition in the market has a role
in situations where patients have the time and
inclination to decide where to obtain treatment
for example, when receiving planned care. Com-
petition for the market should be the preferred
approach when commissioners want dierent
providers to work together under long term con-
tracts to deliver integrated urgent care and care
for groups such as older people and those with
complex needs.
7
A nuanced approach that com-
bines the right kind of competition alongside
planning, collaboration, and clinical networks,
where appropriate, is most likely to deliver the
desired results.
If GP leaders and Liberal Democrats are to
withdraw their opposition, the government
needs to provide reassurance on its intentions
with regard to regulating the NHS market. To
avoid doubt, ministers must be explicit about the
place of markets in the NHS, including the role
of the OFT and Competition Commission, when
they publish the revised regulations. Without
absolute clarity on these questions, there is a risk
of uncertainty and misinterpretation by the com-
missioners and regulators tasked with making the
regulations and the 2012 act work in practice.
There is also every possibility that old wounds
will not heal and will cause even deeper rihs
within the coalition, which will create politi-
cal difficulties for the government as well as
u nwelcome confusion for the NHS.
peer reviewed.
Underlying the debate about the precise wording of the
regulations is the much more important question as to the
governments intentions on the role of markets in the NHS
EDITORIALS
The new UK antimicrobial resistance strategy and action plan
A major societal, political, clinical, and research challenge
New challenges will include screening (by rec-
tal swab) and isolation of any patient admitted to
the NHS who has received inpatient care outside
the UK, with rigorous control of any outbreaks
of multidrug resistant infection inside the NHS.
Acute trusts and their boards will need to con-
sider how to strengthen infection prevention and
control practice using new methods of organisa-
tional and behavioural change.
Antimicrobial prescribing needs to be more
evidence based and more emciently targeted.
New NHS initiatives to provide antimicrobial
stewardship guidance in secondary care (Start
Smart then Focus) and primary care (TARGET
antimicrobial toolkit)
8
need to develop into more
formal quality indicators.
This strategy makes the UK the hrst country to
explicitly announce its intention to develop national
outcome measures in AMR using specihc drug-bug
combination resistance rates (for example, rates of
E coli resistance to third generation cephalosporins).
This is a brave move and should be welcomed. The
chief medical omcer has taken a clear leadership
role by tackling the international dimensions of the
problem, adding AMR to the Department of Health
risk register and calling for AMR to be added to the
national risk register (National Security Risk Assess-
ment) to promote cross government action. Impor-
tant areas that will be covered include antimicrobial
use in animals and new initiatives to encourage the
development of novel antimicrobials.
1
The wider application of molecular microbiol-
ogy, particularly whole genome sequencing, to
detect clonal spread of MDR Gram negative bacteria
within hospitals is providing a rapid explosion of
new data. It is still unclear if this will lead to eec-
tive new control policies. The research agenda is
extensive, but the NHS information technology and
National Institute of Health Research infrastruc-
tures are well placed to provide global leadership
in this area.
9
New technology focusing on rapid
diagnosis of specihc bacteria and resistance genes,
along with combination biomarkers indicating
bacterial or viral infections, especially if adapted
to near patient testing, could have a major impact
on targeting appropriate antibiotic treatment.
Improved surveillance by Public Health England,
using large dataset linkage combined emciently
with observational studies focused on clinical out-
comes, including all infection related deaths, will
also help to dehne new targets for intervention.
Competing interests are in the version on bmj.com.
Provenance and peer review: Not commissioned; externally
peer reviewed.
Anthony S Kessel honorary professor, Faculty of Public
Health and Policy, London School of Hygiene and Tropical
Medicine, London, UK
Mike Sharland professor in paediatric infectious diseases,
Paediatric Infectious Diseases Research Group, St Georges
University London, London SW RE, UK
mike.sharland@stgeorges.nhs.uk
This week the chief medical omcer highlighted in
her report how the rise of antimicrobial resistance
(AMR) poses a threat to healthcare delivery in the
United Kingdom.
1
This will be followed shortly by
the Department of Healths new UK Five Year Anti-
microbial Resistance Strategy and Action Plan,
which will reect the need for a clear change in the
understanding and response to AMR by the public,
the NHS, and the government in the UK. The rise of
AMR as a serious health threat is due to the inter-
national spread of multidrug resistant (MDR) Gram
negative bacteria, the global overuse of antibiotics
in humans and animals, and the almost complete
lack of new antibiotic development.
2
All of these
are now of direct concern to the NHS.
The 85% reduction in rates of meticillin resistant
Staphylococcus aureus (MRSA) bloodstream infec-
tions seen in England between 2003 and 2011
has been remarkable. MRSA is now responsible
for less than 2% of all bloodstream infections in
England. Less remarked on has been the inexora-
ble rise in the number of bloodstream infections
attributable to Gram negative organisms (particu-
larly Escherichia coli), which now comprise more
than half of the around 100 000 of these infections
reported in England annually.
3
Most large NHS
hospitals now identify 50-100 times more patients
with Gram negative bloodstream infections than
those with MRSA, with antibiotic resistance rates
of 10-20% and mortality rates of 30% reported for
MDR forms.
4
In England the successful introduc-
tion of conjugate pneumococcal vaccine means
that the number of reported Klebsiella pneumoniae
bloodstream infections in England is now higher
than for Streptococcus pneumoniae.
In many European countries AMR rates are much
worse. In 2011 the European Centre for Disease Pre-
vention and Control reported a signihcant increase
in multidrug resistant E coli and K pneumoniae (for
example, resistance to third generation cepha-
losporins, uoroquinolones, and aminoglycosides)
in more than a third of European Union/European
Economic Area countries.
5
Klebsiella is an impor-
tant pathogen in the spread of resistance. Many anti-
biotic resistance genes group together in plasmids
easily transferred between bacteria, with particular
clones carrying multiple resistance genes (for exam-
ple, OXA-48 and CTX-M15). Many EU countries are
now reporting Klebsiella MDR rates of 25-40%.
Globally, rates of MDR Gram negative bacterial
infection can be even higher.
6
This has inevita-
bly led to a rapid rise in the use of carbapenem
antibiotics (for example, meropenem) as empiri-
cal treatment for suspected sepsis. In turn, this
has led to a rapid increase in hospital outbreaks
of carbapenemase producing organisms, which
are usually sensitive to only one or two older less
eective antibiotics. In the UK, there has also been
a sharp rise in meropenem use and increasing
reports of carbapenemase producing organisms.
Only one or two new antibiotics that target Gram
negative organisms are likely to be marketed in
the next decade (http://antibiotic-action.com),
which raises the concern that virtually untreatable
i nfections will threaten routine NHS care.
7
The new UK strategy is an important step in rec-
ognising and responding to these concerns. At its
core the strategy recognises that AMR, infection
prevention and control, and antimicrobial steward-
ship are closely interconnected and all need to be
strengthened. The seven aims (table) reect that all
individuals and organisations have unique roles
and responsibilities. Enhanced infection preven-
tion and control are crucial to limiting the spread of
MDR Gram negative bacteria, both into and across
the NHS.
UK antimicrobial resistance strategy: seven action
areas and likely stakeholder involvement in the
health sector
Seven key areas of focus Stakeholders
Promote responsible evidence
based prescribing
Individual prescribers, NHS
providers, national and local
commissioning boards,
ARHAI, PHE, Department of
Health, professional bodies
Improve infection prevention
and control
Individual clinical staff, NHS
providers, national and local
commissioning boards,
ARHAI, Department of Health,
PHE, professional bodies
Raise public and professional
awareness of antimicrobial
resistance threat and promote
behaviour change
Professional bodies,
Department of Health,
ARHAI, patient groups
Research programme into new
diagnostics, alternatives to
antibiotics (such as antiseptics),
pathogenesis, effective
behavioural change to improve
infection prevention and control
and prescribing practice
NIHR, universities,
Department of Health, ARHAI
Facilitate development of new
antimicrobials, vaccines, and
immunomodulators
Department of Health, drug
industry, European Union
Improve surveillance and data
linkage
PHE, ARHAI, Department of
Health
Encourage international
collaboration and data sharing
and learning from best practice
internationally
Department of Health, PHE
ARHAI=Department of Health Expert Advisory Committee on
Antimicrobial Resistance and Healthcare Associated Infection;
PHE=Public Health England. NIHR=National Institute for Health Research.
The BMJ is an Open Access journal. We set no word limits on BMJ research articles, but they
are abridged for print. The full text of each BMJ research article is freely available on bmj.com
Scan this image with your
smartphone to read our
instructions for authors
RESEARCH
RESEARCH NEWS
RESEARCH NEWS All you need to read in the other general medical journals Alison Tonks, associate editor, BMJ atonks@bmj.com
violence has leh us without the means to hnd out.
These authors did what they could with the data
available, but the data are woefully inadequate in
the face of an epidemic of gun violence that has
killed more than 300 000 US citizens since 2001
and seems to be intensifying. No more than a
handful of researchers are currently working in
the held, thanks to a concerted political eort by
the National Rie Association in the early 1990s,
says the editorial. Research must resume now, to
deepen our understanding of this complex prob-
lem and hnd ways to hx it.
JAMA Intern Med lu1!; doi:1u.1uu1/
jamainternmed.lu1!.1lS6
Six women pilot deep brain
stimulation for anorexia nervosa
Six women with intractable and life threatening
anorexia nervosa have been treated with deep
brain stimulation in a preliminary study from
Toronto, Canada. Doctors selected the women for
deep brain stimulation aher many years of unsuc-
cessful conventional management. They had
average body mass indices (BMIs) of 11 to 15 in
the years leading up to the study, accompanied by
multiple medical complications of chronic starva-
tion. Five had psychiatric comorbidities, most ohen
major depression and obsessive compulsive
disorder.
Surgeons placed electrodes just beneath the
corpus callosum. One patient had a self limiting
panic attack during the local anaesthetic phase
of the procedure and one developed a cardiac air
embolus that resolved within hve minutes aher the
operating table was repositioned. A third patient
had a seizure during device programming two
weeks aher the procedure. It was switched o then
restarted one week later with no further problems.
Three of the six women gained weight during
nine months of stimulation (BMIs increased from
11.1 to 21, 14.2 to 16, and 15.1 to 20). They also
reported improved quality of life. Symptom scores
measuring mood, anxiety, and anorexia nervosa
related obsessions and compulsions improved in
four patients.
The pilot was designed to assess safety, not
eectiveness. The authors judge deep brain stim-
ulation to be safe enough for further evaluation.
Lancet lu1!; doi:1u.1u16/Su1/u-67!6(1l)6l1SS-6
Treating depression after acute
coronary syndrome
Depression is common aher hospital admission
for acute coronary syndrome and international
guidelines recommend screening and treat-
ment. A recent trial tested a programme of care
that allowed people with depression symptoms
to choose between psychotherapy, antidepres-
sant drugs, or a combination of the two. The
programme worked well, reducing symptoms
signihcantly more than usual care over six months
(an extra 3.5 point drop in Beck depression inven-
tory score, 95% CI 6.1 to 0.7).
All 150 participants had symptoms of
depression two to six months aher treatment for
acute coronary syndrome. Among 73 assigned to
the new programme, 41 chose psychotherapy,
nine chose drugs, and 17 chose the combina-
tion. Their care was organised by a remote team
of mental health professionals who met once a
week to discuss cases and advise a local doctor or
nurse prescriber. A centralised team also provided
psychotherapy (problem solving therapy) over the
telephone or by video link and followed a stepped
care algorithm that intensihed treatment every six
to eight weeks if required.
This programme contained all the elements
known to work from previous trials and intro-
duced the idea that organisation, coordination,
and support does not have to be local to be suc-
cessful, says a linked comment (doi:10.1001/
jamainternalmed.2013.925).
JAMA Intern Med lu1!;doi:1u.1uu1/
jamainternalmed.lu1!.91'
Whole mummy scans conrm
ancient atherosclerosis
An international team of researchers has found
clear evidence of atherosclerosis among 137
mummies from diverse ancient cultures. Com-
puted tomography showed vascular calcihcation
in 29 of 76 mummies from ancient Egypt, 13 of
51 from ancient Peru, two of hve mummies from a
Puebloan people who lived in south west America
between 1500 BC and AD 1500, and three of hve
mummies from a population of hunter gatherers
who lived more recently on remote islands 500
miles o modern day Alaska.
Overall, a third of the mummies examined had
dehnite or probable atherosclerosis in at least
one vascular bed, usually more. Two mummies
had disease in all hve vascular bedsan ancient
Egyptian princess, Ahmose-Meritamun, who died
in early middle age, and a slightly older woman
from the Aleutian islands who would have been a
hunter gatherer eating mainly hsh and shell hsh.
The researchers and a linked comment agree
that atherosclerosis is not as modern as we think it
is (doi:10.1016/S0140-6736(13)60639-X). Sim-
ilar disease was common in geographically and
culturally dierent populations that spanned at
least 4000 years of human history.
Lancet lu1!; doi:1u.1u16/Su1/u-67!6(1!)6u'9S-X

Stronger gun laws, fewer deaths
US states with the strongest gun laws have the
lowest rates of death caused by hrearms, accord-
ing to a nationwide cross sectional analysis. The
authors ranked 50 states using a score of legis-
lative strength that counted then weighted gun
control laws up to a maximum score of 28. States
in the highest quarter, such as Massachusetts and
Illinois, had 6.6 fewer deaths per 100 000 each
year than states in the lowest quarter, such as
Louisiana and Utah (incident rate ratio 0.58, 95%
CI 0.37 to 0.92). The dierence survived multiple
adjustments for state demographics, including
poverty and population density.
Did gun control save those extra lives? Its impos-
sible to say, says a linked editorial (doi:10.1001/
jamainternmed.2013.1292). The systematic and
deliberate erosion of funding for research into gun
Adapted from JAMA Intern Med ; doi:./jamainternmed..
Legislative strength and mortality by state
.-. .-. .-. .-.
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Hawaii
Mortality rate per , mean
First quarter: - laws
Second quarter: - laws
Third quarter: - laws
Fourth quarter: - laws
Legislative strength score, median
Alaska
IV
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RESEARCH
Correspondence to: P Bower, NIHR
School for Primary Care Research,
Manchester Academic Health
Science Centre, University of
Manchester, Manchester
M PL, UK
peter.bower@manchester.ac.uk
doi: ./bmj.f
Details of the authors affiliations
are given in the full article on bmj.
com
This is a summary of a paper that
was published on bmj.com as BMJ
;:f
STUDY QUESTION Do patients with more severe depression
benefit less from low intensity psychological therapy than
those with milder depression?
SUMMARY ANSWER No, patients with more severe
depression show at least as much clinical benefit from low
intensity interventions as less depressed patients.
WHAT IS KNOWN AND WHAT THIS PAPER ADDS
To better manage the high prevalence of depression in the
community, many services seek to provide simple forms
of psychological therapy (low intensity interventions), but
whether patients with more severe depression are suitable
for such interventions is not known. We found no clinically
meaningful differences in treatment effects between
more and less severely ill patients receiving low intensity
interventions.
SELECTION CRITERIA FOR STUDIES We searched
published systematic reviews, updated with a search of
the Cochrane Library, for randomised controlled trials
of low intensity interventions (such as interventions
provided through written materials or the internet with
limited professional support) in patients with depression.
Primary outcome(s)
Our primary outcome was the relation between initial
depression severity (measured with the Beck Depression
Inventory or Center for Epidemiologic Studies Depres-
sion Scale) and the amount of clinical beneht (change in
depression score) that patients received from low intensity
interventions.
Main results and role of chance
We used individual patient data from 16 trials including
2470 patients. We found a signihcant interaction between
baseline severity and treatment eect (coemcient 0.1
(95% CI 0.19 to 0.002)), suggesting that patients who
are more severely depressed at baseline demonstrate
larger treatment eects from low intensity interventions
than those who are less severely depressed. However, the
magnitude of the interaction was small and may not be
clinically signihcant.
Bias, confounding, and other reasons for caution
We were unable to access all published data on low inten-
sity interventions, obtaining individual patient data from
just over half of the 29 eligible studies. Although we found
no clinically meaningful dierences in treatment eects
between more and less severely ill patients receiving low
intensity interventions, patients with more severe depres-
sion are more likely to continue to show clinically signih-
cant levels of distress aher low intensity treatments and
may require additional care.
Study funding/potential competing interests
The study was funded as part of the UK National Insti-
tute of Health Research (NIHR) School for Primary Care
Research. BM is an employee of GAIA AG, Hamburg, which
owns one of the low intensity interventions considered in
this paper. PB has been a paid consultant to the British
Association for Counselling and Psychotherapy.
Influence of initial severity of depression on effectiveness of low
intensity interventions: meta-analysis of individual patient data
Peter Bower, Evangelos Kontopantelis, Alex Sutton, Tony Kendrick, David A Richards,
Simon Gilbody, Sarah Knowles, Pim Cuijpers, Gerhard Andersson, Helen Christensen,
Bjrn Meyer, Marcus Huibers, Filip Smit, Annemieke van Straten, Lisanne Warmerdam,
Michael Barkham, Linda Bilich, Karina Lovell, Emily Tung-Hsueh Liu
Interactions between baseline severity of depression and
eect of low intensity interventions
CBT=cognitive behavioural therapy; TAU=treatment as usual;
PST=problem solving therapy; Edu=education
Mead 2uu5
Willemse 2uu/
Warmerdam 2uu8 CBT
Warmerdam 2uu8

PST
Lovell 2uu8
Christensen 2uu/

CBT
Christensen 2uu/

Edu
Van Straten 2uu8
Meyer 2uu9
Richards 2uu3
Andersson 2uu5
Vernmark 2u1u
De Graaf 2uu9

CBT+TAU
De Graaf 2uu9

CBT
Liu 2uu9
Bilich 2uu8
Overall enect
Pooled coemcient
-u.1 (-u.19 to -u.uu2)
-1.u -u.5 u u.5 1.u 1.5
Eect size (% CI) for interaction eect
bmj.com Psychiatry updates from BMJ Group are at www.bmj.com/specialties/psychiatry
RESEARCH
STUDY QUESTION Do randomised trials in less developed
countries give different results from those in more developed
countries and, if so, to what extent?
SUMMARY ANSWER Randomised trials from less developed
countries occasionally show significantly different treatment
effects from those from more developed countries, and on
average treatment effects are more favourable in the less
developed countries.
An increasing number of trials are performed in less developed
countries with no longstanding tradition of clinical research.
Discrepancies in treatment effects between trials from more
developed versus less developed countries may often reflect
biases as well as genuine differences and should be taken into
account when generalising evidence across different settings.
Selection criteria for studies
A meta-epidemiological assessment was performed of trials
from less and more developed countries identihed through
the Cochrane database of systematic reviews. We selected
Cochrane meta-analyses with mortality outcomes including
quantitative data from at least one randomised trial from a
less developed country and at least one trial from a more
developed country. For each meta-analysis we compared the
relative risk estimates of more developed versus less devel-
oped countries by calculating the relative relative risk (RRR)
for each topic and the summary relative relative risk (sRRR)
across all topics. Additionally, we performed similar analy-
ses for the primary binary outcome of each eligible topic.
Primary outcome
The primary outcome of the current study was the discrep-
ancy in eect estimates on mortality between trials from less
developed and more developed countries.
Main results and role of chance
139 meta-analyses with mortality outcomes were eligible.
No nominally signihcant dierences between the country
types were found for 128 (92%) meta-analyses. However,
dierences were beyond chance in 11 (8%) cases (ante-
natal corticosteroids, preventive antioxidants, admissions
to hospital for bed rest in multiple pregnancy, steroids in
sepsis, antioxidants for the prevention of gastrointestinal
cancer, antifungals for critically ill patients, postopera-
tive radiotherapy for non-small cell lung cancer, calcium
antagonists in aneurysmal subarachnoid haemorrhage,
intravenous immunoglobulin for preventing infection in
preterm or low birthweight infants, transarterial emboli-
sation in unresectable hepatocellular carcinoma, and
altered fractionation radiotherapy for oral cavity and
oropharyngeal cancer), always showing more favourable
treatment eects in trials from less developed countries.
The sRRR was 1.12 (95% conhdence interval 1.06 to 1.18;
P<0.001; I
2
=0%), suggesting signihcantly more favourable
mortality eects in trials from less developed countries.
Results were similar when focusing on meta-analyses
with nominally signihcant treatment eects for mortality
(sRRR 1.15), excluding meta-analyses of old trials (1.14),
and excluding trials from less developed countries subse-
quently becoming more developed (1.12). For the primary
meta-analysis binary outcomes (127 eligible meta-anal-
yses), 20 topics had dierences in treatment eects in
more developed versus less developed countries beyond
chance (more favourable in less developed countries in
15/20 cases).
Publication bias or selective analysis and outcome report-
ing biases may be inuential in shaping these hndings. A
higher barrier to publication for authors from less devel-
oped countries with no longstanding tradition in clinical
research may further boost selective reporting. Large, well
conducted trials are needed to probe the claims for coun-
try specihc major benehts and they may show that many of
these claims are spurious. Moreover, dierences in treat-
ment eects between less developed and more developed
countries may also be due to genuine dierences rather
than to biases. Low income and middle income countries
face substantial hnancial barriers to their total healthcare
budget, which may limit the implementation of expensive
interventions. However, we did not identify any discrepan-
cies where the implicated intervention was expensive or
dimcult to administer and its emcacy may have depended
largely on sophisticated background standards of care.
Nevertheless, dierentiating between bias and genuine
dierences in baseline risks or treatment implementa-
tion might be dimcult. These concerns should be taken
into account when generalising evidence across dierent
settings.
Comparative effect sizes in randomised trials from less developed
and more developed countries: meta-epidemiological assessment
Orestis A Panagiotou,
1
Despina G Contopoulos-Ioannidis,
l !
John P A Ioannidis
/ '
1
Clinical Trials and Evidence-
Based Medicine Unit, Department
of Hygiene and Epidemiology,
University of Ioannina School of
Medicine, University Campus,
Ioannina, Greece
l
Division of Infectious Diseases,
Department of Pediatrics, Stanford
University School of Medicine,
Stanford, CA, USA
!
Health Policy Research, Palo Alto
Medical Foundation Research
Institute, Palo Alto, CA, USA
/
Stanford Prevention Research
Center, Department of Medicine
'
Department of Health Research
and Policy, Stanford University
School of Medicine, Stanford, CA
9/!u', USA
Correspondence to: J P A Ioannidis
jioannid@stanford.edu
doi: 1u.11!6/bmj.f7u7
lu1!;!/6:f7u7
Statistically significant differences in treatment effects on mortality between trials from less
developed and more developed countries
Topic
Experimental
intervention Outcome
Relative relative risk
(95% CI) for more v less
developed countries
Antenatal prevention in preterm birth Corticosteroids Fetal and neonatal deaths l.uS (1.!u to !.!!)
Antioxidant supplements for prevention Antioxidants Mortality 1.1! (1.u1 to 1.l7)
Multiple pregnancy Admission to
hospital for bed rest
Perinatal death /./l (1.u! to 1S.99)
Treatment of sepsis and septic shock Corticosteroids All cause mortality at lS days l.'S (1.u1 to 6.6!)
Prevention of gastrointestinal cancers Antioxidants Mortality 1.1' (1.u! to 1.l9)
Non-neutropenic critically ill patients Systemic antifungals Mortality !.1S (1.uS to 9./u)
Treatment of non-small cell lung
cancer
Postoperative
radiotherapy
Mortality 1.61 (1.u! to l.'!)
Aneurysmal subarachnoid
haemorrhage
Calcium antagonists
alone
Case fatality '.7! (1.1! to lS.!)
Prevention of infection in preterm or
low birthweight infants
Intravenous
immunoglobulin
All cause mortality 1.9! (1.u1 to !.66)
Unresectable hepatocellular
carcinoma
Transarterial (chemo)
embolisation
All cause mortality 1.76 (1.u' to l.97)
Oral cavity and oropharyngeal cancer Altered fractionation
radiotherapy
Total mortality 1.6u (1.u! to l./S)
RESEARCH
Features of effective computerised clinical decision support
systems: meta-regression of 162 randomised trials
Pavel S Roshanov,
1
Natasha Fernandes,
l
Jeff M Wilczynski,
!
Brian J Hemens,
/
John J You,
/ 6 7

Steven M Handler,
'
Robby Nieuwlaat,
/ '
Nathan M Souza,
/
Joseph Beyene,
/ '

Harriette G C Van Spall,
6 7
Amit X Garg,
/ S 9
R Brian Haynes
/ 7 1u
STUDY QUESTION
What characteristics differentiate computerised clinical
decision support systems that successfully improve clinical
care or patient outcomes from those that do not?
SUMMARY ANSWER
Presenting advice within electronic charting or order
entry systems is not sufficient to derive clinical benefit
and is associated with failure, perhaps from alert fatigue.
Demanding reasons from clinicians before they can over-
ride advice and also providing recommendations to patients
might improve chances of success.
Computerised clinical decision support systems often fail
to improve the process of care and are even less likely to
improve patient outcomes. Our study found that presenting
decision support within electronic charting or order entry
systems is not sufficient to derive clinical benefit and is
associated with failure. Demanding reasons from clinicians
before they can over-ride electronic advice and providing
advice to patients and clinicians might improve chances
of success. Most evaluations have been conducted by the
developers of the systems and such evaluations are more
likely to show benefit than those conducted externally.
Studies and setting
We created a database of characteristics and eectiveness of
computerised support systems in 162 randomised control-
led trials from a recent systematic review.
Design
In this cross sectional study, we conducted logistic regres-
sion analyses to determine the association between charac-
teristics and eectiveness of computerised clinical decision
support systems. We used several statistical methods for
sensitivity analysis.
Primary outcomes
We defined effectiveness as a significant difference in
favour of the system over control for process of care (such
as adherence to prescribing recommendations) or patient
outcomes (such as reduction in blood pressure, mortal-
ity). In a multivariable model, we looked for associations
between system eectiveness and whether the system pro-
vided advice that was automatically within clinical work-
ow, given at the time of care, presented in an electronic
charting or order entry system, required reasons to be given
for over-riding advice, and was also given to patients, and
whether some of the studys authors were also the systems
developers.
Main results and the role of chance
Computerised clinical decision support systems presenting
advice in electronic charting or order entry interfaces were
less likely to succeed than their counterparts (odds ratio
0.37, 95% conhdence interval 0.17 to 0.80). Systems more
likely to succeed than their counterparts provided advice
for patients in addition to practitioners (2.77, 1.07 to 7.17),
required practitioners to give a reason when over-riding
advice (11.23, 1.98 to 63.72), or were evaluated by their
developers (4.35, 1.66 to 11.44).
Though our study was based on data from randomised con-
trolled trials, our analyses were observational. We did not
hnd signihcant associations for the remaining 17 factors
tested in exploratory analyses but cannot rule out confound-
ing by factors that we could not test directly, such as leader-
ship and a culture of quality improvement. Our hndings were
generally robust across dierent statistical methods and in
internal validation, but the estimates of eect were imprecise.
Additional studies are neededideally randomised control-
led trials directly comparing dierent features.
Generalisability to other populations
Commercial products represent only 21% of systems tested
in our trials but will account for nearly all systems clinicians
will use. While we found no association between commercial
status and success, we did not have sumcient data to test
interactions between commercial status and system features
and cannot determine if the associations we discovered are
generalisable to commercial products. Over a third (37%) of
trials were conducted at institutions with an academic his-
tory in medical informatics, but we found no link between
this and eectiveness.
1
Schulich School of Medicine and
Dentistry, University of Western
Ontario, 11'1 Richmond St,
London, ON, Canada N6A !K7
l
Faculty of Medicine, University of
Ottawa, /'1 Smyth Rd, Ottawa, ON,
Canada K1H SM'
!
Department of Health, Aging, and
Society, McMaster University, 1lSu
Main St W, Hamilton, ON, Canada
LSS /K1
/
Department of Clinical
Epidemiology and Biostatistics,
McMaster University, 1lSu Main St
W, Hamilton, ON, Canada LSS /K1
'
Department of Biomedical
Informatics, University of Pittsburgh,
Pittsburgh, USA
6
Population Health Research
Institute, l!7 Barton St E, Hamilton,
Canada LSL lXl
7
Department of Medicine, McMaster
University, 1lSu Main St W,
Hamilton, ON, Canada LSS /K1
S
Department of Medicine,
University of Western Ontario, 11'1
Richmond St, London, ON, Canada
N6A !K7
9
Department of Epidemiology and
Biostatistics, University of Western
Ontario, 11'1 Richmond St,
London, ON, Canada N6A !K7
1u
Health Information Research Unit,
McMaster University, 1lSu Main St
W, Hamilton, ON, Canada LSS /K1
Correspondence to: R B Haynes,
McMaster University, Department
of Clinical Epidemiology and
Biostatistics, 1lSu Main Street
West, CRL-1!!, Hamilton, Ontario,
Canada LSS /K1
bhaynes@mcmaster.ca
doi: 1u.11!6/bmj.f6'7
lu1!;!/6:f6'7
Odds ratios (95% confidence intervals) and P values for adjusted associations between effectiveness and features of computerised
clinical decision support systems
Factors Prespecified model (148 trials) Final primary model (150 trials)
Developed by authors !.'l (1.!/ to 9.l7), u.uuS /.!' (1.66 to 11.//), u.uul
Advice automatically in workflow 1./S (u.6l to !.'l), u.!S
Advice at time of care u.61 (u.l1 to 1.77), u.!'
Advice presented in electronic charting or order entry u.!! (u.1/ to u.76), u.uuS u.!7 (u.17 to u.Su), u.u1
Provides advice for patients l.'/ (u.9S to 6.'7), u.u' l.77 (1.u7 to 7.17), u.u!
Requires reason for over-ride 1u.69 (1.S7 to 61.ul), u.uu1 11.l! (1.9S to 6!.7l), <u.uu1
Response on bmj.com
Can the authors provide a list of
excluded articles? For example,
why was the positive study by
Kucher et al not included?
Robert G Badgett, physician,
Kansas
OVisit the article online and
click Respond to this article
to have your say.
bmj.com
OEditorial:The road to
elective clinical decision
support: are we there yet?
(BMJ lu1!;!/6:f1616)
RESEARCH
STUDY QUESTION
Does a mild traumatic brain injury result in lower cognitive
function?
SUMMARY ANSWER
Cognitive function was similar in men with mild traumatic
brain injuries before and after cognitive testing.
Previous retrospective studies have found lower cognitive
function after a mild traumatic brain injury in several areas
including attention, working memory, episodic memory,
verbal learning, and processing speed. Low cognitive
function was found in men who later sustained mild
traumatic brain injuries, suggesting that low cognitive
function may be a risk factor rather than the long term
consequence of such injuries.
Participants and setting
We studied a nationwide cohort of 305 885 men con-
scripted for mandatory Swedish military service between
1989 and 1994 at a mean age of 18 years.
Design, size, and duration
We constructed a measure of overall cognitive function
from the four dierent tests used at conscription. We inves-
tigated mild traumatic brain injuries occurring before and
aher conscription in relation to cognitive function and
other potential risk factors assessed at conscription and
follow-up.
Main results and the role of chance
In the cohort, 4713 men had sustained one mild trau-
matic brain injury before the tests of cognitive function.
In the rest of the cohort, 11 217 men sustained one mild
traumatic brain injury, and 795 men sustained at least
two such injuries aher cognitive testing, during a median
follow-up period of 19 (range 022) years. Men with one
injury within two years before (n=1988) or aher cognitive
testing (n=2214) had about 5.5% lower overall cognitive
function scores than men with no injury during follow-up
(P<0.001 for both). Men with at least two injuries aher
cognitive testing (n=795) had 15% lower overall cogni-
tive function scores than those with none (P<0.001). Men
with a mild traumatic brain injury within three months
before cognitive testing had similar cognitive function
scores to men with an injury within two years aher the
cognitive tests. Independent strong risk factors (P<110
10
)
for at least one mild traumatic brain injury aher cognitive
testing (n=12 494 events) included low overall cognitive
function, a previous mild traumatic brain injury, hospital
admission for intoxications, and low education and socio-
economic status. In a sub-cohort of twin pairs in which
one twin had a mild traumatic brain injury before cognitive
testing (n=63), both twins had lower logical performance
and technical performance compared with men in the total
cohort with no injury (P<0.05 for all). These results may
suggest a genetic component to the low cognitive function
associated with mild traumatic brain injury.
We evaluated only younger men with mild traumatic brain
injury, so our results are not applicable to women, older
men, or people with more severe traumatic brain injuries.
Generalisability to other populations
The large well characterised nationwide cohort studied
including more than 16 000 diagnosed mild traumatic
brain injuries increases external validity.
Study funding/potential competing interests
The study was funded by the Swedish Research Council.
Cognitive function and other risk factors for mild traumatic brain
injury in young men: nationwide cohort study
Anna Nordstrm,
1
Benoni B Edin,
l
Sara Lindstrm,
!
Peter Nordstrm
/
1
Department of Community
Medicine and Rehabilitation,
Rehabilitation Medicine, Ume
University, SE-9u1 S7 Ume,
Sweden
l
Department of Integrative Medical
Biology, Physiology Section, Ume
University
!
Department of Epidemiology,
Harvard School of Public Health,
Boston, MA, USA
/
Department of Community
Medicine and Rehabilitation,
Geriatric Medicine, Ume University
Correspondence to: A Nordstrm
anna.nordstrom@idrott.umu.se
doi: 1u.11!6/bmj.f7l!
lu1!;!/6:f7l!
EDITORIAL by Newcombe and
Menon
Cognitive function at conscription for total cohort based on mild traumatic brain injury
status at follow-up
No of mild traumatic brain injuries
C
o
g
n
i
t
i
v
e

f
u
n
c
t
i
o
n

s
c
o
r
e
1 before
testing
* Signicantly lower (P<u.u1) for specic test compared with men with one mild traumatic brain injury before cognitive
testing (n=/713)
Signicantly dinerent (P<u.u1) for specic cognitive test compared with all other groups
15
17
19
21
23
Overall function
Logical function
Visuospatial function
Technical function
Word recollection
1 within
2 years
before
testing
1 within
3 months
before
testing
*
*
*
*
*
1 afer
testing
1 within
2 years
afer
testing
>1 afer
testing
None
bmj.com Neurology updates from BMJ Group are at www.bmj.com/specialties/neurology
DATA BRIEFING
In 1967 the King Edwards Hospital Fund
for London, now known as the Kings
Fund, published a new specification for
the design of a hospital bedstead.
1
This
had followed an evaluation of various bed
designs in collaboration with Bruce Archer,
an engineering designer at Londons Royal
College of Art.
2
As Lawrence notes, the
evaluation was intensive and relied on
extensive data collection, mathematical
modelling of solutions, and field trials . . . 1uuu
hospitals completed a televisual survey on
beds, and . . . 2u prototype beds were installed
for three months at Chase Farm Hospital,
Enfield. Trained observers recorded all bed-
related activities from u6uu h to 22uu h daily.
The project cost 35 uuuover 5uu uuu
(t58u uuu; $75u uuu) at todays prices.
3
Over
time the Kings Fund bed came to replace the
many hundreds of different bed designs used
in the NHS.
Fig 1 | Hospital beds by type: English NHS: 1979-80 to 2011-12
4-6
Design classic: the Kings Fund bed
0
1
9
7
9
-
8
0
1
9
8
1
-
8
2
1
9
8
3
-
8
4
1
9
8
5
-
8
6
1
9
8
7
-
8
8
1
9
8
9
-
9
0
1
9
9
1
-
9
2
1
9
9
3
-
9
4
1
9
9
5
-
9
6
1
9
9
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-
9
8
1
9
9
9
-
0
0
2
0
0
1
-
0
2
2
0
0
3
-
0
4
2
0
0
5
-
0
6
2
0
0
7
-
0
8
2
0
0
9
-
1
0
2
0
1
1
-
1
2
T
o
t
a
l

N
o

o
f

b
e
d
s

(
0
0
0
s
)

300
350
400
250
200
150
100
50
1979-2012
All beds
59%
Acute
Geriatric
Mental illness
Learning disability
Maternity
Previous articles in this series
ORises in healthcare spending: where will it end? (BMJ lu1l;!/':e71l7)
OHospitals: what do they do and how much does it cost? (BMJ lu1l;!//:e17'9)
OHow long can we expect to live? (BMJ lu1!;!/6:f!!1)
THE HOSPITAL BED: ON ITS WAY OUT?
John Appleby examines trends in the number of hospital beds and wonders how low we can go
Coincidentally, just as the Kings Fund
embarked on its bed redesign project in
1962, concern was being raised by the then
minister of health, Enoch Powell, and others
at the Ministry of Health about the need to
save money and improve labour efficiency in
the light of a shortage of nurses and general
pressures on health service budgets.
3
As Lawrence reports Enoch Powell at the
time, a key question was what mechanical
and powered assistance would be necessary
if the same quantity of care and attention had
to be given with half the present quantity of
woman-hours?
3
Standardising the hospital
bed to improve nurse productivity and reduce
procurement costs was one project on his list
that, fortuitously, the Kings Fund had started
to address.
Nearly half a century later, concerns
about productivity remainas does, to an
extent, the Kings Fund bed, modified and
redesigned. What has changed and not just
in the English NHS but in most countriesis
the number of beds in use in hospitals.
In England, for example, over the 33 years
since 1979, beds used for acute care fell by
35%, for maternity by 58%, for geriatric care
by 65%, and for mental illness and learning
disability by 7/% and 96%, respectively
(fig 1). If allowance is made for increases
in population, these bed reductions are
proportionately highera drop of /2% in the
number of acute beds per 1uuu population,
for example. And over the decade to 2uu9,
the US and UK have experienced similar
proportionate reductions in acute beds.
The fact that the number of hospital beds
has fallen in almost all countries in the
Organisation for Economic Cooperation and
Development (fig 2) provides some clue to the
reasons for these trends. Changes in medical
practice have shortened the time patients
With more patients being treated
but fewer beds, theres no doubt
that beds are being used more
efficiently. But more intensive use
could be a problem
DATA BRIEFING
Design classic: the Kings Fund bed
Fig 2 | Average annual changes in acute care beds per 1000 population (calculated from total change
from 1995-2010) in selected OECD countries
7

Korea
Turkey (2000-10)
Greece (1995-2009)
Netherlands
Mexico
Portugal
Israel
Germany
Belgium
Austria
Spain
Australia (1995-2008)
Slovenia (1996-2010)
France (1997-2010)
United States (1995-2009)
Poland
Ireland
Slovak Republic
Norway
Denmark (1997-2010)
Czech Republic
Japan
Sweden
Switzerland (1998-2010)
United Kingdom (2000-10)
Finland
Italy
Estonia
-3.0 -2.0 -1.0 0.0 1.0 2.0 3.0 4.0 5.0
% change
Fig 3 | Daily bed occupancy (%) in English NHS, 2011-12
8
80
95
95
80
75
65
60
70
A
p
r
i
l
M
a
y
J
u
n
e
J
u
l
y
A
u
g
u
s
t
S
e
p
t
e
m
b
e
r
O
c
t
o
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e
r
N
o
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e
m
b
e
r
D
e
c
e
m
b
e
r
J
a
n
u
a
r
y
F
e
b
r
u
a
r
y
M
a
r
c
h
Peaks: Midnight Tuesday
Troughs: Midnight Saturday
Good Friday
New Years Eve
Boxing Day
Christmas Day
Christmas Eve
Public holidays

%

o
c
c
u
p
a
n
c
y
spend in hospitalthe average length of
stay for an acute case in England has shrunk
from around . days in to about three
days in . And new practices, drugs, and
diagnostic procedures have helped shift care
from the ward to the outpatient department
and beyond the walls of hospitals.
The introduction of deliberate policies to
move some types of care out of hospital and
into the community has had a dramatic effect
on hospital beds too. In England, for example,
care in the community policies have changed
the proportion of the hospital bed stock taken
up by mental health, learning disability, and
geriatric services from around % to % in
just over years (fig ).
With more patients being treated but fewer
beds, theres no doubt that beds are being
used more efficiently. But more intensive use
could be a problem. Daily bed occupancy data
for England in - reveal that average
occupancy across all hospitals reached
over % on several days (fig ). Such high
occupancy rates reduce the time available for
cleaning between patients and increase the
chances of infection.
Is the hospital slowly but inexorably on its
way out to be replaced perhaps by virtual
wards
and new configurations of care

facilities? Or are we already close to the limit
of substitution and technology development
that would allow significant further
reductions?
John Appleby chief economist, Kings Fund, London, UK
j.appleby@kingsfund.org.uk
Provenance and peer review: Commissioned; externally peer
reviewed.
1 King Edwards Hospital Fund for London. Design of
hospital bedsteads. KEHFL, 1967.
l Lawrence G. Kings Fund beds. Lancet luu1;!'S:S/S.
! Lawrence G. Hospital beds by design: a sociohistorical
account of the Kings Fund bed, 196u-197'. PhD thesis.
University of London, luu1. http://chrisrust.wordpress.
com/luu1/1l/!1/lawrence-hospital-beds-by-design/.
/ Department of Health. NHS hospital activity statistics for
England: 1979-199u-91. Stat Bull 199l;l(1):9l.
' Department of Health. Bed availability and occupancy
overnight: Time series 19S7/S to luu9/1u. lu1l. http://
transparency.dh.gov.uk/?p=197/'.
6 Department of Health. Bed availability and occupancy
overnight: Time series lu1u/11 onwards. lu1l. http://
transparency.dh.gov.uk/?p=197/'.
7 Organisation for Economic Cooperation and
Development. OECD health data lu1l: frequently
requested data. www.oecd.org/els/health-systems/
oecdhealthdatalu1l-frequentlyrequesteddata.htm.
S Campbell D. Dr Fosters report: how does hospital bed
availability change throughout the year? Guardian. lu1l
Dec !. www.guardian.co.uk/news/datablog/lu1l/
dec/u!/dr-foster-report-nhs-hospital-bed-occupancy-
data.
9 Department of Health. Hospital organisation, specialty
mix and MRSA. luu7. www.dh.gov.uk/prod_consum_dh/
groups/dh_digitalassets/@dh/@en/documents/
digitalasset/dh_uS1l9l.pdf.
HEAD TO HEAD
Reducing avoidable emergency
admissions is undoubtedly
a desirable and worthy aim,
not least because it will beneht patients.
Additionally, emergency admissions are
a considerable drain on NHS resources,
representing about 65% of hospital bed days in
England, at an annual cost of E11bn (t13bn;
$17bn).
1
The health data company Dr Foster
estimated that 29% of these admissions
are potentially avoidable and amenable to
interventions in the community.
2
Emergency
admissions also have an adverse eect on
provision of other hospital servicesfor
example, by causing cancellation of elective
operations at short noticeand Dr Foster
says that overoccupancy of hospital beds is at
breaking point, risking patient safety.
2

Annual emergency hospital admissions have
increased by 37% over the past 10 years.
3
The
NHS is required to save E20bn by 2015, and
avoiding emergency admissions is a key policy
to deliver this. Currently, commissioners use
local referral incentive schemes to encourage
general practitioners to reduce their emergency
admissions. Furthermore, the recently
announced quality premium
4
will reward clinical
commissioning groups if they are able to reduce
or prevent an increase in emergency admissions
within a hscal year. Given the hnancially
challenged budgets of commissioning groups,
and reductions in GPs incomes, failing to hit
such targets will in eect be a hnancial penalty.
Unfortunately, there is scant evidence, if any,
that such hnancial levers will have any real
eect on emergency admission rates. We know
that hnancial incentives paid to GPs as part of
practice based commissioning during 2005-
11 were unable to stem the rise in emergency
admission rates. Nor is there any conclusive
evidence that the tools currently used by GPs
and commissioners, such as risk stratihcation
and case management, are eective in reducing
emergency admissions.
5
Solutions go beyond general practice
The fundamental aw in linking hnancial
payments to GPs to emergency hospital
admissions is that the GP is only one player
in a multiplicity of factors that inuence such
admissions. It is therefore inappropriate for
GPs themselves to be held responsible for
emergency admission rates. Evidence has
shown that increasing age, social deprivation,
morbidity, area of residence, self management,
provision of community and social care
services, hospital supply, and internal hospital
organisation and admission policies will all
inuence emergency admissions.
6

Major changes have occurred
in healthcare over the past
30 years. I remember, as a
house omcer, having to admit patients for sev-
eral days just to start them on a new drugthe
angiotensin converting enzyme inhibitor cap-
topril. As a surgeon I became adept at perform-
ing vagotomy and pyloroplasty for duodenal
ulcer and recently winced when a colleague
pointed out that, in eect, we used to perform
surgery for an infectious condition. While a
general practitioner, I witnessed the closure of
long stay geriatric wards and the proliferation
of large residential and nursing home facilities
for which GPs were expected to provide medi-
cal care, looking aher frail elderly patients
with complex comorbidities. We have seen
startling decreases in mortality and morbidity
in cardiovascular disease and improvements
in cancer treatments and survival. Despite
this we have also seen an inexorable rise in
emergency admissions. Financial incentives
will help bring about the changes required to
reverse this trend.
Narrow thinking
As a clinician working in commissioning I have
been struck by how siloed professional and
organisational thinking can be. Emergency
admissions account for a relatively small pro-
portion of overall activity in specialist care, yet
a large proportion of cost. If you look across the
health and care system most activity occurs out-
side hospital but most of the cost is consumed
by hospital services.
1

For a long time there has been the mantra of
moving care closer to home, yet, except in a
few isolated instances, this has not happened.
Talking to a specialist recently, I asked why. His
response was that there is no consistency out-
side hospital. I dont know if my patients will
be safe or get the care they need delivered, he
told me. I was also taken aback by the response
a practice gave me recently when I asked when
it last looked at its emergency admissions. The
staff proudly told me that they had done an
audita year previously.
Many emergency admissions are the result of
exacerbations of long term conditions, failure
of coordinated care, and, increasingly, frail eld-
erly people with comorbidities needing proac-
tive care from primary, community, and social
Should GPs
be fined
for rises in
avoidable
emergency
admissions
to hospital?
Commissioning organisations
in England face losing a quarter
of the quality premium if
they do not keep down their
emergency admissions for
specific conditions.
Martin McShane supports
this, but Chaand Nagpaul
worries about possible
unintended consequences
Martin McShane director for domain , National
Commissioning Board, Leeds LS UE, UK
martin.mcshane@btinternet.com
Chaand Nagpaul general practitioner , Stanmore,
London, UK
chaand.nagpaul@gmail.com
HEAD TO HEAD
Furthermore, the 2004 GP contract
transferred the responsibility for out of hours
care to primary care trusts, and therefore
hospital admissions during the out of hours
period (70% of weekly hours) fall outside the
control of general practices. Additionally,
numerous other primary care access points,
from telephone advice via NHS Direct, to other
unscheduled care settings such as walk-in
centres and new 111 urgent care services
will also refer patients directly to hospitals,
bypassing GPs. Similarly, GPs have no control
of direct patient admissions from emergencies
such as road tramc incidents. And some
increases in admission rates could reect
national policiesfor example, eorts by
emergency departments to avoid breaches of the
target of a four hour maximum wait may have
increased short term hospital admissions.
5

Another problem is that the relatively small
number of patients in general practice lists
could result in variations in admission rates by
chance or volatility in the external environment
(for example, infection outbreaks). Providing
hnancial rewards or penalties to GPs as a result
of erroneous interpretation of admission rates
will unfairly discriminate against patients.
Unwanted effects
The division of GPs and hospital specialists into
commissioners and providers, with payment
of an activity tari to hospitals, provides no
incentive to hospitals to reduce emergency
admissions, nor to collaborate with GPs. This
creates the perverse eect of supplier induced
demand.
5
Making payments to GPs to reduce
emergency admissions may also cause patients
to mistrust the motives of GPs in managing
their care, and risks breaching General Medical
Council principles of good medical practice
by adding a perverse hnancial incentive not to
refer patients to hospital. Overzealous attempts
to reduce hospital admissions could have
unintended consequences. For instance, two
recently published high quality randomised
controlled trials of interventions designed to
keep people out of hospital showed increased
deaths among the intervention groups.
7

8

Nor can we assume that avoiding admission
is always cost eective, since the expense of
keeping patients in the community may not
necessarily reect a cost saving.
The logical way forward should be a whole
system approach, bringing together all
stakeholders so that all inuences on hospital
admissions are aligned. There is evidence
that hospital admissions can be reduced by
integration between health and social care,
as well as between primary and secondary
care, and by improved internal hospital
organisation of admission units staed by
more senior doctors.
6

9

10
We need to jettison
the current unhelpful competitive purchaser-
provider spit between primary and secondary
care and replace the tari system of payment
by results with a system of collaboration and
shared hnancial ownership with goals aligned
across primary, secondary, and social care.
Wider determinants that inuence hospital
admissions must be addressed.
6

9

Proposals to hnancially reward or penalise
GPs as either providers or commissioners
in their own right on the basis of emergency
admission rates is likely to squander precious
public resources on unproved ideology at a
time of harsh hscal austerity. It also carries
the possibility of counterproductive eects
and potential to do harm through unintended
consequences.
Competing interests: I have read and understood the BMJ Group
policy on declaration of interests and declare I am a negotiator
for the BMA General Practitioners Committee with lead roles in
commissioning and IT and a member of BMA Council.
Read the opposing side in the debate by Martin McShane,
doi:./bmj.f.
peer reviewed.
care.
1

2
How many practices systematically ana-
lyse the root causes of emergency admissions?
Opportunity for change
The advent of clinical commissioning groups
and health and wellbeing boards presents an
opportunity to tackle the complex issues rel-
evant to emergency admissions. The recent
analysis of trends in emergency admissions by
Bardsley and colleagues tells us one thingwe
need to ask more and better questions and work
collectively across the continuum of health and
social care, if we are to move care closer to home
and reverse the trend in acute admissions.
3
Clinical commissioning groups will be com-
missioning the community and mental health
care that can support that move, as well as the
acute services, which are under pressure. To
avert emergency admissions to hospital they
will need to work in partnership with social care
and some of the wider services that frail elderly
people and their carers are so dependent on.
The construct of health and wellbeing boards
provides an opportunity to foster and forge
a coherent and consistent common purpose
across primary care. The responsibility of com-
missioning groups and the NHS Commission-
ing Board to improve the quality of primary care
creates a new dynamic in the system which, if
approached in the right way, can build on the
potential of general practice to support collabo-
rative coordinated care and reduce emergency
admissions, especially if aligned with commis-
sioning in the rest of the health system.
Success will require a range of enablers,
levers, and incentives to help leaders to change
attitudes, behaviours, and ways of working
right across the system. The fact that colleagues
say that most emergency admissions are out of
hours or self referrals, as if that absolves them
from any responsibility, is worrying. Clinicians
have a responsibility to improve care no matter
where a patient is on a pathway. There is no bet-
ter way of articulating the role of primary care
than to quote from the Francis report: It will be
important for the future that all GPs undertake
a monitoring role on behalf of their patients
who receive acute hospital and other specialist
services . . . A GPs duty does not end on refer-
ral to hospital but is a continuing relationship.
They will need to take this continuing partner-
ship with their patients seriously if they are to
be successful commissioners of services. They
should exploit to the full this new role in ensur-
ing their patients get safe and eective care.
4

No part of the system is an island. In my expe-
rience, through better use of data, planning,
service redesign, contracting, and monitoring
performancethat is, good commissioningit
will be possible to improve quality while man-
aging costs. The quality premium is one instru-
ment in the toolbox to support new thinking
and ways of tackling deep rooted problems. To
consider the premium in isolation, or to label
it as a hne, perpetuates a fragmented view of
a complex adaptive system in which clinicians
have now got a real opportunity to lead change
and improve outcomes for patients.
Competing interests: I have read and understood the BMJ
Group policy on declaration of interests and declare that I
work for the NHS Commissioning Board and one of my key
objectives is supporting clinical commissioning groups to
reduce emergency admissions.
Read the opposing side in the debate by Chaand Nagpaul,
doi:./bmj.f.
peer reviewed.
Clinicians have a responsibility to
improve care no matter where a
patient is on a pathway
The GP is only one player in a
multiplicity of factors that influence
emergency admissions
ANALYSIS
Antimicrobial resistance: the true cost
Richard Smith and Joanna Coast argue that current estimates of the cost of antibiotic resistance
are misleading and may result in inadequate investment in tackling the problem
A
lmost as soon as antibiotics were dis-
covered, we knew that bacteria were
able to develop resistance to them.
1

This is not necessarily a problem, as
long as there are other antimicrobi-
als to take their place. During the latter half of the
20th century this was the predominant situation,
but no longer.
2
A rapid decrease in the number of
new drugs approved and numerous withdrawals
on quality and safety grounds have leh the well
dry, and it is clear that the existing classes of anti-
biotics are probably the best we will ever have.
3
In light of this, there have been eorts to sup-
port interventions that encourage the more con-
servative and appropriate use of antibiotics in
a bid to halt or slow the progress of resistance.
4

However, this action is ohen too little and may
be too late.
Given that the dangers of resistance are widely
acknowledged, why isnt more being done? One
reason is that antibiotic resistance has fallen
victim to evidence based policy making, which
prioritises health problems by economic burden
and cost eectiveness of interventions.
5
Health
economists have been unable to show that antibi-
otic resistance costs enough to be a health priority.
Limitations of health economic research
Ten years ago we published a systematic review
on the economics of resistance.
6
We asked two
questions: what is the cost of resistance and what
is the cost eectiveness of interventions to reduce
KEY MESSAGES
An increase in resistant organisms coupled
with a big fall in the number of new
antimicrobial drugs suggests an apocalyptic
scenario may be looming
Current estimates suggest antimicrobial
resistance has a low economic impact
Such estimates do not take into account
that antimicrobials are integral to modern
healthcare
We may not ever be able to make an accurate
forecast of the costs
We should view greater investment in
antibiotic resistance as an insurance policy
bmj.com
This weeks poll asks: Are the dangers of antibiotic resistance exaggerated? Cast your vote on bmj.com
Editorial: Improving antimicrobial stewardship and surveillance: the Chennai Declaration (BMJ lu1!;!/6:f'91)
Research: Electiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care (BMJ lu1l;!//:d317!)
their estimates of the actual economic impact
may not be accurate because the research used
to produce these estimates is limited in its scope.
For example, economic estimates are based on
the incremental costs and focus on a specihc
infectious disease or set of diseases: estimates
are based on the cost of extra treatment of a
resistant infection compared with susceptible
infection, such as costs of additional inves-
tigations, more expensive drugs, side eects
from extra treatments, longer hospital stay,
and greater mortality.
9
Some may also include
costs associated with surveillance and activities
associated with trying to control resistance. Most
studies were from the United States and based
it? The lack of research meant we could investi-
gate only the second question.
7
And even here
we concluded that the evidence for the cost eec-
tiveness of interventions for resistance was poor.
We have just performed a rapid review at
the Department of Healths request to take into
account newer information on the hrst question.
The box summarises our methods and further
details are available in the full report.
8
Estimates
of additional cost varied from less than $5 (E3;
t4) to more than $55 000 per patient episode.
This might be explained by type of resistance
and how productivity losses are dealt with.
Although there was little intrinsically wrong
with these papers, we became concerned that
ANALYSIS
Annual cost of illness for selected conditions in US
Health problem
Societal cost
(bn, )
Cardiovascular disease
w1
!Su
Musculoskeletal conditions
wl
!uu
Motor vehicle accidents
w!
l7u
Occupational injury and illness
w/
l66
Mental disorders
w'
l6u
Substance abuse
w6
19'
Cancer (all)
w7
1S'
Diabetes
wS
1/'
Alzheimers disease
w9
7u
Antimicrobial resistance
w1u
''
Skin disease
w11
/S
Urinary incontinence
w1l
l!
Asthma
w1!
16
in hospitals and included the costs related to
additional hospital stay and treatment but not
early mortality.
None of the studies considered the bigger
picturea world in which there are no eective
antibiotics for situations where they are cur-
rently used routinely, such as in hip replacement
or cancer patients. Our concern is that todays
limited estimates will be used to project future
costs. Will the current worst case scenario place
antibiotics high enough up on the health agenda
to ensure adequate action?
Current worst case scenario is still an
underestimate
We took the study that found the highest cost
of antimicrobial resistance, of $55bn ($20bn in
health service costs and $35bn in lost produc-
tivity) per year overall to the US, and compared
it with economic burden hgures for other health
problems in the US. These burden hgures are
taken from a variety of studies, and the dates
range considerably, but it is clear that resistance
rates fairly low down (table).
However, the costs of resistance could be
much higher than these estimates suggest. As
an example we estimated the consequences
of having no antibiotics for patients having a
total hip replacement. Because antibiotics have
been used as prophylaxis and treatment for hos-
pital acquired infection since hip replacements
were hrst performed we looked at information
relating to limb amputation as a proxy for what
infection rates might have been with and with-
out antimicrobials.
The figure shows the care pathway for
patients requiring hip replacement. Currently,
prophylaxis is standard practice, and infection
rates are about 0.5-2%, so most patients recover
without infection, and those who get an infec-
tion have it successfully treated. We estimate
that without antimicrobials, the rate of post-
operative infection is 40-50% and about 30%
of those with an infection will die.
w14-w17
Thus,
removal of antibiotics would increase postoper-
ative infection by 1-50% and deaths by 0-30%.
Of course, at such rates it is likely that the rates
of hip replacement would fall, which would
increase the burden of morbidity from hip pain.
We recognise that this is a simplistic analy-
sis, with many of the data obtained from litera-
ture relating to amputation as a proxy for hip
replacement. However, we use it as an example
to illustrate and provoke, to emphasise the point
that infection rates and their consequences in
terms of health service costs and human health
may be unimaginable. As we struggle to imagine
the clinical consequences, it is easy to see why
the economic burden is at present inestimable.
A world without antibiotics
Modern healthcare was built over the past
century on the basis that infections can be pre-
vented or treated using antimicrobials (exem-
plified by the US surgeon general famously
proclaiming in 1968 that the war against dis-
eases has been won).
10
Resistance is said to present a risk that we
will fall back into the pre-antibiotic era.
11
How-
ever, this is perhaps optimistic. Our health
system is now designed to treat more chronic
conditions. Healthcare has become increas-
ingly technological and invasive, improving
mortality and morbidity significantly, and
antimicrobials have become integrated in many
aspects of such care. For example, antimicro-
bials are given as standard to prevent iatro-
genic infection in surgical care,
11
to women
Poor symptoms
Bad outcome Recover Bad outcome Recover Recover
Severe pain
and reduction
in QALYs
Treatment with antibiotics No antibiotic treatment available
No total hip arthroplasty Total hip arthroplasty
No antibiotics Antibiotic prophylaxis
No infection Infection No infection Infection
Bad outcome Recover Bad outcome Recover Recover
Treatment with antibiotics No antibiotic treatment available
Before surgery
Aer surgery
Care pathway for total hip arthroplasty with and without antimicrobials
Box | Methods used in the review
We searched for the

combinations of terms relating
to resistance, antimicrobial
and costs. Some papers did not
refer to antimicrobial resistance
generally but only to particular
drugs or micro-organisms. We
extended the search terms to
focus on meticillin resistant
Staphylococcus aureus
and vancomycin resistant
enterococci, two of the most
studied and potentially serious
current resistant infections.
We included English language
studies (empirical or modelling)
with data on costs associated
with resistance, since . For
empirical studies, we selected
studies that included a control
group with a susceptible
infection because the aim was
to focus on costs of resistance,
rather than costs of infection.
Data extracted included:
study design; sample size/
modelling approach; relevant
micro-organism and drug; cost
perspective, year, currency, time
frame, discounting approach;
resource use included; valuation
methods; summary of results.
We identified possible
papers, from which were
eventually included in our
analyses.
Vancomycin resistant enterococci
J
A
N
I
C
E

C
A
R
R
/
S
P
L
ANALYSIS
de livering by caesarean section,
12
and to those
having cancer treatment.
13
From cradle to grave,
antimicrobials have become pivotal in safe-
guarding the overall health of human societies.
When viewed in this broader way, the costs
of resistance are not limited to those associ-
ated with additional treatment for a primary
infection , such as a strep throat. Rather, they
must encompass the costs that might relate to
the loss of modern healthcare. In the same way
that health systems need adequate and eective
health workers to function, they also require
eective antimicrobials. Resistance is not just an
infectious disease issue; it is a surgical issue, a
cancer issue, a health system issue.
To calculate the true economic burden of resist-
ance we therefore have to consider the burden
associated with not having any eective antimi-
crobial drugs. And, as witnessed when there are
outbreaks of hospital acquired infection, the sys-
tem can very quickly come to a standstill.
14
In the
future we may need to rethink how the health sys-
tem is developedfor instance, redesigning many
facilities or reintroducing sanatoriums if eective
antibiotic treatments are no longer available.
Planning for an uncertain future
Although we now have more empirical information
on the economic burden of resistance than was
available a decade ago, it is unlikely to help us plan
for the future. Even the highest current estimates
of the costs of resistance provide false reassurance
and this may mean that inadequate attention and
resources are devoted to resolving the problem.
Our illustrative example for hip replacement with-
out antibiotics shows how dimcult it is to forecast
the likely economic burden of resistance. And we
have explained how resistance has the potential to
undermine modern health systems.
Full health systems analyses seem a more
appropriate means to assess the potential impact
of resistance and evaluate measures to stem it.
Although this approach is complex, understand-
ing the threat to the health system overall, not
just for specihc diseases, could be the single most
important step in better understanding the eco-
nomic burden that resistance presents. Analysing
outbreaks of resistant infections and the cost of dis-
ruption to the healthcare system may help produce
future estimates.
15
A change in culture and action is needed to plan
for a future with more antibiotic resistance. Con-
siderable inertia remains regarding radical change
in our stewardship of antimicrobials, precisely
because there is a focus on current economic bur-
den. The same is true with climate change and, to a
degree, the hnancial system. A major driver of this
inertia is likely to be collective uncertainty about
the clinical and hnancial implications of increasing
resistance. But there is a tried and trusted way to
deal with such uncertaintyinsurance. Waiting
for the burden to become substantial before taking
action may mean waiting until it is too late. Rather
than see expenditure on antimicrobial policies as
a cost, we should think of it as an insurance policy
against a catastrophe; albeit one which we hope
will never happen.
9
Richard Smith professor of health system economics ,
London School of Hygiene and Tropical Medicine, London
WC1H 9SH, UK
Joanna Coast professor of health economics, School
of Health and Population Sciences, University of
Birmingham. Birmingham, UK
Correspondence to: R Smith Richard.Smith@lshtm.ac.uk
We thank Callum Hodge, Joseph Grin, and Daniel Haynes for
help with literature searching and Anthony So, Ursula Wells,
Claire Boville, Sally Wellsteed, Ross Leach, Peter Bennett, John
Henderson, David Cohen, Miranda Mugford, and Huseyin
Naci for their comments. This report is independent research
commissioned and funded by the Department of Health Policy
Research Programme (Economic burden of antimicrobial
resistance: a rapid paper, u/1uu!'). The views expressed in this
publication are those of the authors and not necessarily those of the
Department of Health.
Contributors and sources: Both authors have been health
economists for over lu years and have worked together on aspects
related to antimicrobial resistance for more than 1' years. This
article is a culmination of experiences over that time, and is based
particularly on a rapid review, and interaction with colleagues who
commissioned this review at the Department of Health. Both authors
contributed equally to the writing of the paper. RS is guarantor.
Provenance and peer review: Not commissioned; externally
peer reviewed.
1 Courvalin P. Predictable and unpredictable evolution of
antibiotic resistance. J Intern Med luuS;l6/:/-16.
l So AD, Ruiz-Esparza Q, Gupta N, Cars O. !Rs for innovating
novel antibiotics: sharing resources, risks, and rewards. BMJ
lu1l:!//:e17Sl.
! Cormican M, Vellinga A. Existing classes of antibiotics are
probably the best we will ever have. BMJ lu1l;!//:e!!69.
/ World Health Organization. The evolving threat of antimicrobial
resistance: options for action. WHO, lu1l.
' Coast J, Smith RD, Millar MR. Disentangling value: assessing the
benefits of containing antimicrobial resistance. In: Roberts J, ed.
The economics of infectious disease. Oxford University Press,
luu6:lu1-1/.
6 Smith RD, Coast J, Millar MR, Wilton P, Karcher A-M. Interventions
against anti-microbial resistance: a review of the literature and
exploration of modelling cost-effectiveness. WHO, luu1
7 Wilton P, Smith RD, Coast J, Millar M. Strategies to contain the
emergence of antimicrobial resistance: a systematic review of
effectiveness and cost-effectiveness. J Health Serv Res Policy
luul;7:111-7.
S Smith R, Coast J. The economic burden of antimicrobial
resistance. Why it is more serious than current studies suggest.
lu1!. www.lshtm.ac.uk/php/economics/assets/dh_amr_
report.pdf.
9 Coast J, Smith RD, Karcher AM, Wilton P, Millar M. Superbugs
II: how should economic evaluation be conducted for
interventions which aim to reduce antimicrobial resistance?
Health Econ luul;11:6!7-7.
1u Gregor M. Bird flu: a virus of our own hatching. New York,
luu6:S'.
11 Cars O, Hogberg LD, Murray M, Jasper W, Nordberg O, Sivaraman
S, et al. Meeting the challenge of antibiotic resistance. BMJ
luuS;!!7:7l6-S.
1l Bratzer DW, Houck PM. Antimicrobial prophylaxis for surgery:
an advisory statement from the National Surgical Infection
Prevention Project. Clin Infect Dis luu/;!S:17u6-1'.
1! Wild SM. Antibiotic prophylaxis at caesarean section. Lancet
luul;!6u:7l/.
1/ Plowman RP, Graves N, Griffin M, Roberts JA, Swan AV, Cookson
BC, et al. The socioecomic burden of hospital acquired infection.
Public Health Laboratory Service, 1999.
1' Kanerva M, Blom M, Tuominen U, Kolho E, Anttila VJ, Vaara M, et
al. Costs of an outbreak of methicillin-resistant Staphylococcus
aureus. Hosp Infect luu7;66:ll-S.
BMJ BLOG Elizabeth Loder
How can journals help stop
disease mongering?
How can medical journals address their role
in selling sickness and disease mongering?
I suggested two possible strategies at the
Selling Sickness conference held in
Washington last month.
First, why not quarantine apparently
groundbreaking studies about new
treatments or interventions in a special
journal until the findings are replicated
and long term consequences explored?
Print copies of the journal would arrive in
plain brown wrappers that, undone, would
show the journals cover logo of a skull
and crossbones. During quarantine, any
news stories or summaries of research
from this journal would travel with a sternly
worded disclaimer, along the lines of those
that accompany investment company
advertisements. Something like the
following would do nicely:
Warning! Taking any action on the basis
of this research could result in injury or
death. The results described in this study
have not been replicated and the long term
effects of this treatment are unknown.
Past performance is no guarantee of
future results. When subjected to further
investigation, most published research
findings turn out to be false.
To fill the void, medical journals deprived
of these sensational research studies
could instead devote themselves to the
promotion and prioritisation of the less
glamorous medical research that really
matters: replication studies, comparative
effectiveness trials, and long term
pharmacosurveillance and safety studies.
My second suggestion was that several
parts of a typical research paper are too
important to be written by the researchers
or anyone else with a vested interest in the
outcome of the research. These include
the portions where spin is mostly likely
to enter into the papernamely, the title,
abstract, results, and conclusion sections,
and any summary or what this study adds
statements that authors are now sometimes
asked to supply. These portions of research
papers should instead be written by
disinterested parties with subject matter
expertise.
I have no illusion that these things will
come to pass, but I can dream, cant I?
Elizabeth Loder is US research editor, BMJ
ORead this blog in full and other blogs at
bmj.com/blogs.

LETTERS
Letters are selected from rapid responses posted on bmj.com. Aher editing, all letters are
published online (www.bmj.com/archive/sevendays) and about half are published in print
To submit a rapid response go to any article on bmj.com and click respond to this article
judgment that prompted our analysis.
We suggest that the most clinically useful
starting point is to provide doctors and older
patients with three to five year fracture risk
estimates unadjusted for mortality risk, so
that consultations can realistically cover the
projected benefits of treatment for the patient
concerned.
Mark J Bolland senior research fellow
m.bolland@auckland.ac.nz
Rod Jackson professor of epidemiology
Greg Gamble research fellow
Andrew Grey associate professor of medicine,
University of Auckland, Private Bag 9lu19, Auckland
11/l, New Zealand
1 Leslie WD, Lix LM, Wu X. Competing mortality and fracture
risk assessment. Osteoporos Int lu1!;l/:631-3.
l Collins GS, Michaelsson K. Fracture risk assessment: state of
the art, methodologically unsound, or poorly reported? Curr
Osteoporos Rep lu1l;1u:199-lu7.
! Steurer J, Haller C, Hauselmann H, Brunner F, Bachmann LM.
Clinical value of prognostic instruments to identify patients
with an increased risk for osteoporotic fractures: systematic
review. PLoS One lu11;6:e1999/.
.Cite this as: BMJ ;:f
BISPHOSPHONATES AND GI CANCERS
A misinterpretation
Vinogradova and colleagues misinterpreted
the findings of our Danish national cohort study
on the risk of colon cancer in bisphosphonate
users.
1,2
Moreover, they did not account for
possible bias due to the longer survival of
bisphosphonate users in the type of case-control
studies that they performed.
Risk was reduced in long term bisphosphonate
users (more than six months) in our study. We
reported a 31% reduced risk of colon cancer and
a 38% reduced risk of colon cancer mortality
at five years, both of which were significant
before and after adjustment for confounding
(table 2). The authors must have misunderstood
our dose-response analysis, which was not a
comparison with the background population
but a comparison of bisphosphonate users with
different degrees of exposure.
The case-control design is problematic when
survival is linked to exposure. This is perhaps not
immediately obvious, but case-control studies
only include runners in the race if they make it
to the finish line, whereas cohort studies follow
each runner from the start of the race.
Several studies have shown that
bisphosphonate users as a group have lower
mortality,
3-5
thus contributing more patient years
to analyses. This is accurately captured in cohort
PREDICTED FRACTURE RISK
Confused thinking
Bolland and colleagues argue that estimates of
fracture in older people should use a short time
horizon of three to five years yet ignore competing
mortality because it precludes effective treatment
of these patients.
1
They assume that adjustment for mortality risk
in FRAX is based only on average mortality rates
for the population, but the tool accommodates
the fact that many risk factors that predict fracture
risk also influence mortality (older age, previous
fracture, low body mass index, smoking).
2
The
incorporation of competing mortality directly
addresses the concerns raised over the time
horizon used; a three to five year time horizon in
older people is exactly what FRAX produces (table
2 of the article). If life expectancy is less than 1u
years, then the fracture probability equals the
remaining lifetime risk of fracture (table 2).
The authors ignore well recognised systematic
differences in the output of the fracture
prediction tools (fig 2), reflecting differences
in calibration, input risk variables, outcome
fractures, and incorporation of competing
mortality. It is nonsensical to compare the tools
against intervention thresholds that have been
derived for only one of the tools (FRAX).
The real problem is not FRAX, but the setting
of intervention thresholds and the complexities
therein, which Bolland and colleagues do not
address. Fracture rates alone as an outcome
show an exponential rise with age so that
treatment is indicated in all older people. Like
Bolland and colleagues, we are keen to ensure
optimal and appropriate use of osteoporosis
drugs at all ages, but there are risks of both
undertreatment and overtreatment. The authors
also fail to acknowledge the importance of
clinical judgment. An intervention threshold is a
guideline not an absolute; clinical judgment is
espoused within all guidelines, including that of
the National Osteoporosis Guideline Group.
Eugene McCloskey professor of adult bone diseases
and honorary consultant physician, University of
Sheleld, Metabolic Bone Centre, Northern General
Hospital, Sheleld S' 7AU, UK
e.v.mccloskey@shef.ac.uk
Juliet Compston professor of bone medicine and
honorary consultant physician, University of Cambridge
School of Clinical Medicine, Addenbrookes Hospital,
Cambridge, UK
John Kanis emeritus professor, University of Sheleld
Medical School, Beech Hill Road, Sheleld S1u lRX
Competing interests: The authors were involved in the
development of FRAX or the NOGG guideline.
1 Bolland MJ, Jackson R, Gamble GD, Grey A. Discrepancies
in predicted fracture risk in elderly people. BMJ
lu1!;!/6:e3669. (l1 January.)
l Kanis JA, on behalf of the WHO Scientific Group. Assessment
of osteoporosis at the primary health-care level. Technical
report. University of Sheffield, luu3. www.shef.ac.uk/FRAX/
pdfs/WHO_Technical_Report.pdf.
Authors reply
McCloskey and colleagues seem to
misunderstand our analysis and its key
messages. Firstly, fracture risk estimates should
be generated for clinically relevant time frames
we suggest a three to five year interval because
available interventions are effective within that
time frame and it aligns with recommendations
for an initial course of osteoporosis treatment.
Despite their argument, FRAX generates only
1u year risk estimates. Providing patients with
estimates of remaining lifetime risk is clinically
useful only if accompanied by accurate estimates
of remaining lifespan.
Secondly, adjusting for competing mortality
risk is unnecessary when risk estimates are
generated over short time frames because it has
little impact.
1
Thirdly, predicting fracture risk estimates in
older patients over a 1u year time frame using
calculators that incorporate competing mortality
risk can obscure important short term fracture
risks and treatment benefits. Because none
of these messages are influenced by specific
intervention thresholds or practice guidelines,
the comments on those matters are not relevant.
As developers of FRAX, the correspondents
can easily correct misunderstandings about FRAX
methodology by publishing its equations and
algorithms. This deficiency in the development
of FRAX has been criticised,
2

3
has hindered
research,
3
and differs from the approach taken
for other risk calculators. The decision to charge
SFr/uuu (282/; t3266; $/2/6) a month to use
FRAX for research purposes (www.who-frax.org/)
further limits accessibility.
We agree that misdirection of treatment
and clinical judgment are important aspects
of osteoporosis management. It was clinical
LETTERS
studies, which measure event rates, but not in
case-control studies, which estimate relative
risk.
Cohort studies certainly have lower resolving
power for rare outcomes, but they are at much
lower risk of bias and provide clinicians and
researchers with meaningful absolute risk
estimates.
Bo Abrahamsen professor, University of Southern
Denmark, DK 'uuu, Odense C, Denmark
b.abrahamsen@physician.dk
Michael Pazianas visiting senior fellow
R Graham G Russell professor, Oxford University
Institute of Musculoskeletal Sciences, Nuleld
Department of Orthopaedics, Rheumatology and
Musculoskeletal Diseases, Oxford, UK
Competing interests: See www.bmj.com/content/!/6/bmj.
f11//rr/6lS/S!.
1 Vinogradova Y, Coupland C, Hippisley-Cox J. Exposure to
bisphosphonates and risk of gastrointestinal cancers: series of
nested case-control studies with QResearch and CPRD data.
BMJ lu1!;!/6:f11/. (16 January.)
l Pazianas M, Abrahamsen B, Eiken PA, Eastell R, Russell
RGG. Reduced colon cancer incidence and mortality
in postmenopausal women treated with an oral
bisphosphonateDanish National Register Based Cohort
Study. Osteoporos Int lu1l;l!:l69!-7u1.
! Bolland MJ, Grey AB, Gamble GD, Reid IR. Effect of osteoporosis
treatment on mortality: a meta-analysis. J Clin Endocrinol
Metab lu1u;9':117/-S1.
/ Bondo L, Eiken P, Abrahamsen B. Analysis of the association
between bisphosphonate treatment and survival in Danish hip
fracture patientsa nationwide register-based open cohort
study. Osteoporos Int lu1!;l/:l/'-'l.
' Lyles KW, Colon-Emeric CS, Magaziner JS, Adachi JD, Pieper
CF, Mautalen C, et al. Zoledronic acid and clinical fractures and
mortality after hip fracture. N Engl J Med luu7;!'7:1799-
Su9.
Authors reply
Pazianas and colleagues study did show a
31% reduced risk of incident colorectal cancer
in alendronate users compared with non-users
(adjusted hazard ratio u.69, 95% CI u.6u to
u.79), as we noted. The alendronate group in
table 2, however, included all women with one
or more prescription for alendronate, and mean
follow-up was 3./ years, so the analysis seemed
to look at any duration of alendronate use, not
five or more years, as the authors response
implied. There was also no significant dose-
response association in their analysis restricted
to alendronate users (u.89, u.66 to 1.22 when
comparing users exposed to more or fewer than
18u defined daily doses).
We used a nested case-control design
because this can better quantify time dependent
exposures.
1
To account for longer survival for
bisphosphonate users, we matched cases and
controls by age and calendar time, and required
all controls to be alive and registered with the
practice at the date of the first recorded diagnosis
of cancer in their matched case. This ensured
that survival up to the point of the case diagnosis
of cancer would be equivalent between the two
groups, so that the potential for bisphosphonate
exposure would be comparable. All patients
with initial cancer diagnoses were included in
the analysis, whether or not diagnosis was after
death. To ensure an unbiased estimate of relative
risk, our study was based on an underlying
cohort structure, where matched controls are
randomly selected from all remaining subjects
at risk, including potential future cancer cases
(incidence density sampling).
2
Yana Vinogradova research fellow in medical statistics
yana.vinogradova@nottingham.ac.uk
Carol Coupland associate professor and reader in
medical statistics
Julia Hippisley-Cox professor of clinical epidemiology
and general practice, Division of Primary Care,
University Park, Nottingham NGl 7RD, UK
1 Etminan M. Pharmacoepidemiology II: the nested case-
control studya novel approach in pharmacoepidemiologic
research. Pharmacotherapy luu/;l/:11u'-9.
l Lubin JH, Gail MH. Biased selection of controls for case-control
analyses of cohort studies. Biometrics 19S/;/u:6!-7'.
PARACETAMOL HEPATOTOXICITY
Is paracetamol ever safe?
We note that the number of registrations
for hepatic transplantation for paracetamol
overdose found in SALT (Study of Acute Liver
Transplantation) in the UK
1
63 cases in 2uu5-
u7 (5.25 cases per quarter)was the same as
that reported by Hawton and colleagues.
2
However, in the UK and the other European
countries included in the SALT study,
paracetamol had been used in the 3u days
before the first symptoms in several acute liver
failures that led to registration for transplantation
(ALFT) not related to overdose. There were 2/
cases in the UK and /9 in France, for example.
Using the same criteria as for other known
hepatotoxic agents, such as non-steroidal
anti-inflammatory drugs (NSAIDs), we found that
non-overdose paracetamol was associated with
a three times higher rate of ALFT than all NSAIDs
pooled, or individual NSAIDs such as diclofenac
or nimesulide. This was true whether the
denominator was in patient years or individual
patients.
3
Perhaps we should start looking into
hepatotoxicity associated with paracetamol at
normal doses? Does this have anything to do
with chronic glutathione depletion and increased
risk from other toxins, as was hypothesised for
asthma?
/
Nicholas D Moore clinical pharmacologist
nicholas.moore@pharmaco.u-bordeaux2.fr
Ezgi Gulmez associate professor in pharmacoepidemiology
Patrick Blin senior scientihc olcer, Department of
Pharmacology, University of Bordeaux, Inserm U6'7-
CIC-Puu', !!u76 Bordeaux, France
Competing interests: The SALT study was requested and
approved by the European Medicines Agency and funded
by Helsin Healthcare, which had no part in its performance,
publications, or this reply.
1 Gulmez SE, Larrey D, Pageaux GP, Lignot S, Lassalle R, Jove J, et
al. Transplantation for acute liver failure in patients exposed to
NSAIDs or paracetamol (acetaminophen): the multinational
case-population SALT study. Drug Saf lu1!;!6:1!'-//.
l Hawton K, Bergen H, Simkin S, Dodd S, Pocock P, Bernal W,
Gunnell D, Kapur N. Long term effect of reduced pack sizes of
paracetamol on poisoning deaths and liver transplant activity
in England and Wales: interrupted time series analyses. BMJ
lu1!;!/6:f/u!. (7 February.)
! Moore N, Gulmez SE, Larrey D, Pageaux GP, Lignot S, Lassalle
R, et al. Choice of the denominator in case population
studies: event rates for registration for liver transplantation
after exposure to NSAIDs in the SALT study in France.
Pharmacoepidemiol Drug Saf lu1!;ll:16u-7.
/ Shaheen S, Potts J, Gnatiuc L, Makowska J, Kowalski ML,
Joos G, et al. The relation between paracetamol use and
asthma: a GAlLEN European case-control study. Eur Resp J
luuS;!l:1l!1-6.
CAP ON SOCIAL CARE IN ENGLAND
The perfect storm for a lawyer?
The secretary of state for health, Jeremy Hunt,
considers it a scandal that 3u uuu-/u uuu
people have to sell their home each year to pay
for their care costs.
1

2
The real scandal is that
many of those people paying for social means
tested care should be receiving free care paid
for by the NHS to meet their health needs.
Health and social needs have been defined by
the Department of Health.
3
The Department of Healths latest figures
show that there is a postcode lottery for NHS
continuing healthcare funding.
/
Recently, many
primary care trusts and local authorities have
simply been ignoring the law and the Coughlan
ruling. The further blurring of the boundary
between health and social care with the push
towards integration has allowed the costs of
care to be passed from primary care trusts to
individual self funders (and local authorities
when the assets run out). The forthcoming
legislation introducing the 75 uuu (t86 767;
$113 175) cap should set a clear and consistent
boundary between means tested social care
and state funded healthcare.
Those facing a 75 uuu, rather than 35 uuu,
bill for social care would be justified in
seeking legal advice at an early stage when
moving to a care home. This would help
ensure that those making funding decisions
on behalf of the secretary of stateclinical
commissioning groupsare not acting
unlawfully and thereby depriving vulnerable,
frail, often demented older people of their right
to fully funded NHS continuing healthcare.
Nigel Dudley consultant in elderly medicine, St Jamess
University Hospital, Leeds LS9 7TF, UK
nigel.dudley@leedsth.nhs.uk
Competing interests: A relative of ND applied for continuing
healthcare funding.
1 Torjesen I. Government sets 17' uuu cap on social care in
England. BMJ lu1!;!/6:f9S!. (1l February.)
l Watt N. Inheritance tax freeze to fund social care cap of
17' uuu. Guardian lu1! Feb 11.
! Department of Health. National framework for NHS continuing
healthcare and NHS funded care. lu1l.
/ Department of Health. Individuals in receipt of NHS continuing
care. lu1!.
OBSERVATIONS
MEDICINE AND THE MEDIA
Hype and the HIV cure
Some media reports exaggerated the significance of the recent case of a functional cure of a baby with HIV,
but thats a result of publicising unpublished, non-peer reviewed research, says Margaret McCartney
Atul Gawande, the surgeon and author, was
one of the hrst to react. This is huge, stunning,
world changing, he tweeted, linking to a story
of a startling development in the New York
Times titled In medical hrst, a baby with HIV
is deemed cured.
1
The article explained how a
baby in the United States had been treated with
antiretrovirals 30 hours aher birth, and by 18
months of age the baby had no detectable viral
load. The New York Times article explained that
this demonstrated proof of principle . . . if we can
replicate this case.
It also reported that other experts would need
convincing that the baby had truly been infected
and that this may have been a case of prevention
of transmission rather than cure, as the BMJ also
pointed out.
2
It described this development in
the context of other knowledge, such as the now
established prophylactic treatment of babies born
to infected mothers, and it called on seven experts
in the article for their views, two of whom were
coauthors of the original paper. Although the arti-
cle acknowledged potential for excitement, it was
also clear that deep uncertainty existed.
The same couldnt be said for much of the UK
media. Paper 48LB from the 20th Conference
on Retroviruses and Opportunistic Infections,
titled Functional HIV cure aher very early ART
of an infected infant, was
presented in Atlanta at
10 am on 4 March 2013.
3

However, the press release
was issued on 3 March,
4

the same day the New York
Times ran its report, before
the abstract had been
presented. The press release made it clear that
researchers would continue to follow the case
and that they thought that further research is
needed to understand whether the experience of
the child can be replicated in clinical trials involv-
ing other HIV-exposed children.
The press release also hinted that the case was
unusual because the mother had received no ante-
natal care or antiretrovirals when she gave birth
prematurely; additionally, treatment was stopped
when the child was 18 months old for reasons
that are unclear. The press release had the sub-
heading, Discovery provides clues for potentially
eliminating HIV infection in other children. The
uncertaintiesthe unusual nature of this case and
that the hndings are yet to be replicatedwere not
spelt out, but a quotation from one author did say
that this was a promising lead.
This important nuance seems to have been
eroded in several news reports. The Guardian s
headline was US doctors make history by curing
child born with HIV. It continued, Doctors in the
US have made medical history by eectively curing
a child born with HIV . . . the child has a normal life
expectancy and is highly unlikely to be infectious
to others, doctors believe. The researcher was
described as stunned at this extraordinary out-
come.
5
The story ended with a note that patients
should not stop taking antiretrovirals and that
preventive treatments for preg-
nant, HIV positive women were
of proved eectiveness. There
was no reminder of the unpub-
lished nature of the report and
its lack of peer review or the
lack of replication.
Sarah Boseley in the same
newspaper the next day explained the limitations
of the research: Is this the big one? Have doctors
stumbled across the cure for HIV? Unfortunately
not. This is progress . . . but the implications for
those already infected or even the still signihcant
numbers of babies born with the virus in the
developing world are sadly probably slight.
6

The Daily Mail , meanwhile, asked, Have
we found a cure for HIV? Child born with virus
is now free of infection aher miraculous treat-
ment, and commented, There is no guarantee
that the baby will remain disease free, but early
signs do look positive.
7
The Telegraph hosted a
video from a press conference in Atlanta, with one
of the researchers, Deborah Persaud, saying that
the work sets the stage for a paediatric cure.
8

However, the Telegraph also ran another video fea-
turing the HIV researcher John Frater from Oxford
University, who explained the research, its limita-
tions and uncertainties, and the need for patients
taking antiretrovirals to continue taking them.
9

Jon Snow, on Channel News, was right to ask
straight away, How sure are you? Has it been peer
reviewed? Are you sustainably excited? Another
of the researchers answered that the development
had not been published or peer reviewed but that
other researchers need to know.
Publicising conference presentations can
have problems. The abstract had not been peer
reviewed and was presented after the press
release. The press release did not spell out the
inherent uncertainties in the meaning of this
case report. It was leh to doctors not involved in
the case, including many interviewed by the New
York Times , and journalists to unpick the details
and ask harder questions.
The risks of hype expand when unchecked
enthusiasm seeks coverage before publication.
Although research should be published with-
out undue delay, generating press coverage is
not always useful for the research community,
patients, or citizens. Many comparisons in the
press were made with the case of the Berlin
patient, a man with HIV who had a bone marrow
transplantation in 2009 and was subsequently
found to have been functionally cured of HIV. Yet
this has not, so far, been repeated.
9

Margaret McCartney is a general practitioner, Glasgow
margaret@margaretmccartney.com
peer reviewed.
The abstract had not been peer
reviewed and was presented
after the press release. The
press release did not spell out
the inherent uncertainties in
the meaning of this case report
Some stories had more nuance than others: Guardian (top), New York Times (left), and Daily Mail Some stories had more nuance than others: Guardian (top), Guardian (top), Guardian New York Times (left), and Daily Mail
PERSONAL VIEW
After Mid Staffs: NHS must look to care of its own staff
NHS staff can be brutalised by severe pressure of work, which is exacerbated by the poor management
exemplified by Mid Staffs, an anonymous occupational health physician believes
I
worked for many years in several NHS trusts
before the problems at Mid Staffordshire
emerged. I was a consultant occupational
physician, tasked with looking aher the health
and welfare of some 12 000 NHS sta. Other
consultant NHS physicians I have met have had
similar experiences.
I came to the NHS as an outsider, having
trained and specialised in occupational medi-
cine abroad. The hrst post I held in occupational
medicine in the UK, while undertaking training
for membership of the faculty, was in indus-
try. I found that line managers in engineering
regarded the workforce in a similar way to how
they view other parts of the production process: if
someone was getting worn out or damaged, then
the underlying cause should be hxed to prevent it
happening again. Although they were not happy
to see reports on new cases of work related ill
health, they saw them as just as necessary as the
plant engineers report on machine maintenance.
When I started working in the NHS I was
taken aback by the resentment and anger that
sta expressed toward their employer. However,
their feelings became understandable when I
tried to present anonymised statistics about work
related ill health to management, as I had done
in industry. Managers saw my reports as likely to
cause them trouble and to provide ammunition
for sta who were thinking of making compensa-
tion claims. I was told that no other NHS occupa-
tional health department produced such reports,
and they were hled in the bin. NHS managers
seemed not to understand that it had a duty to
protect its sta from the pressures of work. This
was a callous disregard for sta wellbeing.
As I persisted in trying to get trusts to tackle
this problem over several years, I was investi-
gated for spurious reasons such as not getting
on with others and had to leave my position with
a pay-o and a gagging clause. I have applied for
six other consultant posts in the NHS since. On
each occasion I have been interviewed but failed
to secure the post for unexplained reasons.
After leaving the NHS I analysed national
statistics to see how work related ill health in
healthcare sta compared with that in workers
in other industries. What I found conhrmed my
impression that work related ill health was worse
in the NHS. I presented a paper on this topic at a
conference in the early 2000s. It was recorded in
the proceedings, which were brought to the atten-
tion of the Health and Safety Executive, with no
response to tackling the causes.
I found that healthcare workers were some 70%
more likely to have developed work related stress,
depression, or anxiety than was the general work-
force at that time (146/7056 (2.1%) v 818/63179
(1.3%) cases; odds ratio 1.77 (95% conhdence
interval 1.48 to 2.12)).
1
This odds ratio has wors-
ened since then, and it is now 2.10: the 2012 prev-
alence of work related mental health problems in
health professionals was 110% higher than in the
general workforce, as shown in recent government
statistics (2560 v 1220 per 100 000 employees).
2

Why is this?
Firstly, the NHS is a labour intensive indus-
try that is not easily mechanised. Manual han-
dling while maintaining patient dignity in ohen
cramped conditions and under time pressure is
dimcult. The environment is highly emotive, with
near limitless demands but hnite resources.
Secondly, there were more occupational health
resources available in industry compared with
the NHS, despite a much higher requirement in
the NHSsuch as for immunisations and dealing
with exposure to body uids. For example, when
I worked in industry there was one occupational
health physician for every 7000 employees,
compared with one for every 11 000 employees
in the NHS; and there was one occupational
health nurse for every 1000 industry employees
but one for every 2700 NHS employees (personal
observations).
The 2009 Boorman report into what health
interventions would improve the wellbeing of
NHS staff was a lost opportunity.
3
The recom-
mendations dealt only with the need to tackle sta
sickness absences and with providing counselling
and lifestyle changes, none of which have credible
evidence bases. Tackling the underlying causes
of ill health (understamng, poor people manage-
ment, inappropriate targets) was not emphasised.
Thirdly, in most organisations occupational
physicians can appeal to senior managements
altruism to try to obtain resources to promote
employee health and welfare. This does not work
when you are directly competing with the urgent
needs of ill patients and with ongoing government
initiatives to reduce waiting lists.
Fourthly, in the NHS trusts in which I worked,
responsibilities for overseeing safe working prac-
tices were not delegated to people who had the
necessary authority. The board did not consider
any statistics related to work-related ill health; no
director was held responsible.
Fihhly, aher working in these trusts for several
years I realised that most senior managers moved
to new positions in three to four years. Managers
seemed prepared to take the chance that they
would not be in post when the results of their deci-
sions became apparent.
Sixthly, the ability of an organisation to learn
from its mistakes and take corrective action to
prevent recurrence is essential for its survival.
When shown evidence of escalating cases of work
related ill health, senior NHS managers usually
put the increase down to greater awareness of
cases. No action was taken to prevent recurrence.
Eventually, the bearer of bad news was shot.
NHS managers have not grasped the enormity
of this waste. Work related ill health leads not only
to the loss of sta who provide services but also
to then having to treat them as patients. The fac-
tors I have identihed have led to the brutalisation
of some NHS sta so that they no longer respond
appropriately to distress in their patients, as
recorded in the inquiry in what happened at Mid
Stas. If we wish healthcare sta to behave with
compassion they must be treated with such.
bmj ipad
BMJ Mid Stas iPad special issue:
download from iTunes
When I started
working in the
NHS I was taken
aback by the
resentment
and anger that
staff expressed
toward their
employer
OBITUARIES
Ian Greville Tait
Pioneering polymath and Benjamin Brittens general practitioner
and Tait had masterminded his treatment for
diverticulitis, subacute bacterial endocarditis,
and aortic incompetence, liaising with Brittens
cardiologist and recruiting a superb nursing
sister to look aher him at home. Britten had
encouraged him to make statements about
his health, while the medical records were in
the public domainyet a recent biography
had stated as a fact that his heart disease was
caused by syphilis, despite the congenital
defect found at operation and its histology
as well as the previous negative serological
tests. As somebody who had ohen dined at
the composers houseinvitations that were
reciprocatedTait was understandably upset
but sadly died before the controversy had come
fully into the open and the opposite case could
be proved.
Tait leaves a wife, Janet, whom he met at
Barts and to whom he was married for almost 60
years. She also had an important role as a doctor
in the practice, as well as being prominent in the
Liberal Democrat Party; there were three sons
and a daughter and nine grandchildren.
Stephen Lock, former editor, BMJ
splock@globalnet.co.uk
a dowagers message told him that GPs were
received only on Fridays at 11 am, through the
back door. Yet a few years later the practice
was hrmly in the 20th century, with a national
reputation. Not only had it adopted the rapid
developments elsewhere (such as the practice
ancillary team), but Tait had also pioneered a
vocational training scheme, problem oriented
medical records, and practice educational
meetings. Surprisingly the location was
Aldeburgh, the Suolk seaside town that in
E M Forsters words is a bleak little place, not
beautiful. As today, it contained a mixture
of aristocrats, hshermen, former spooks, and
musiciansincluding Benjamin Britten, who
became Taits patient and friend.
Though on call 24 hours most days, Tait
also served the community outside medicine,
becoming a town councillor, for example,
in a (vain) attempt to stop ribbon housing
development along the country roads. His other
interests were wide. A published poet himself,
he helped establish an international poetry
festival, became an accomplished watercolour
painter, and sailed as far and as ohen as
possible, besides succumbing to the local
addiction to golf.
Born in Sussex, Tait had wanted to go into
the Royal Navy but was persuaded to follow
the family tradition of general practice. During
national service in the Royal Naval Volunteer
Reserve (RNVR) at the end of the war, he
was taught navigation in London by being
given a map, a compass, and a tradesmans
bicycle adapted for selling ice cream and
told to hnd specihed locations. He studied
medicine at Cambridge and St Bartholomews
Hospital Medical School, where he held
house appointments before going for a year to
internships at St Lukes Hospital, New York.
Aher a further junior post at Ipswich Hospital,
his lifelong friend John Stevens invited him to
join the practice at Aldeburgh, where he stayed
for the rest of his life.
Firm Quaker principles
Handsome and modest, with a warm smile,
and deeply concerned about the problems of
others, Tait unsurprisingly became a member
of the Society of Friends. Their hrm Quaker
principles enabled him and his wife to stand
unembarrassed in Aldeburgh High Street,
lobbying against the proposed war in Iraq.
Similar principles had emerged earlier when
the practice doctors decided to undertake
attachments in the developing world, working
for 18 months in Swaziland. Taits obsession
was general practice and how to make it ever
better. He became deeply involved with the
emerging college of general practitioners,
becoming regional adviser for East Anglia and
establishing his own trainee scheme linked to
Ipswich Hospital. Later he was to hold three
travelling fellowships, give the Gale Memorial
Lecture, and serve as a visiting professor of
general practice at University College Hospital,
London, and at Canberra. His over-riding
interest in medical records culminated in a
general practice rarity, an MD degree. While in
retirement he took the undergraduate course
in medical history at the Wellcome Institute in
Londonsubsequently playing an important
part in its new faculty of 20th century medical
history.
One of Taits last concerns was that somebody
should refute a contentious claim that Benjamin
Brittens death was due to aortic syphilis. The
composer had been his patient for several years,
A published
poet himself, he
helped establish an
international poetry
festival, became
an accomplished
watercolour painter,
and sailed as far and
as often as possible
Ian Greville Tait (b 1926; q Cambridge 1953),
died from pneumonia on 4 February 2013.
When Ian Tait entered general practice in 1959
Brick Dock from Round Hill,
Aldeburgh. Tait studied
painting with the Aldeburgh
artist Tessa Henderson,
becoming an accomplished
watercolourist
OBITUARIES
degeneration, which intruded on
his great hobbies of reading and
crosswords. He leaves his second
wife, Barbara; four sons; two
daughters; 16 grandchildren; and
four great grandchildren.
Alan Logan
Donald Logan
Ian Logan
Muhammad Shaq
Consultant general surgeon
(b 1935; q Nishtar Medical
College, Multan, Pakistan 1957;
FRCS Edin), d 10 September
2012.
After coming to England in 196/,
Muhammad Shafiq studied at the
postgraduate medical school at
Hammersmith and then became a
senior house officer in trauma and
surgery at the Princess Beatrice
Hospital in Earls Court. He obtained
the Hallet prize from the Royal
College of Surgeons of England and
the Lilly prize as a joint author in
19S!. After several other posts, he
worked for the North Manchester
Health Authority from 197/ until
the last few years. His repertoire
included gastrointestinal and
vascular surgery. He died after an
accident while on holiday in France.
He leaves his wife, Fay, and four
children.
John Clegg
Joseph Footitt
Former Walport clinical lecturer
infection in airway disease
research group, National Heart
and Lung Institute, Imperial
College, London (b 1974; q Guys
and St Thomas Medical School
2000; PhD), died in a road traffic
accident in Bermuda on 13 June
2012.
Joseph Footitt managed to combine
membership of committees of the
Royal College of Physicians and
British Thoracic Society with a
demanding PhD. He was passionate
about chronic obstructive pulmonary
disease, and his research into the role
of rhinovirus in exacerbations was
beginning to spawn a flurry of journal
articles when he died. His popularity
with colleagues and patients is best
illustrated by the fact that two of his
research subjects, on hearing of his
death, donated their participation
fee to Josephs Breath of Life fund.
He leaves his wife, Emma, and a son,
Aneurin Max Joseph, who was born
on lu November lu1l.
Simon Merritt
Alan William Fowler
Consultant orthopaedic surgeon
Bridgend (b 1920; q UCH London,
1943; FRCS Eng), died from a
stroke on 21 January 2013.
Alan William Fowler worked as an
orthopaedic surgeon at Bridgend
General Hospital from 19'! to his
retirement in 19S6. He published
a technique for embedded toenails
by excision of the germinal
matrix in 19'S and for forefoot
reconstruction (Fowlers operation)
for irreversible claw toes in 19'9.
After retirement he was visiting
professor of orthopaedics in Lusaka,
Zambia. In 199' he published a
review paper on the importance of
joint movements in the treatment
of fractures, in which he advocated
the conservative management of
fractures using short splints, thus
allowing for movement at adjacent
joints. His wide ranging interest
in medical research and practice
is reflected in his book Modern
Medicine and the Bible. Predeceased
by his wife, Margaret, in lu1u, he
leaves seven adopted children.
Joseph Fowler
Frank Neville Garratt
Former director of public health
Wolverhampton (b 1928;
q Birmingham 1951; PhD, FFCM),
died from bronchopneumonia and
Parkinsons disease on
13 January 2013.
After house jobs at Birmingham
General Hospital and national service
with the Royal Army Medical Corps in
Antwerp and Belgium, Frank Neville
Garratt completed his PhD and
worked as a lecturer, establishing his
lifelong research interests in mental
illness, learning disability, perinatal
mortality, and their aetiologies. He
was medical officer of health and
then director of public health for
Wolverhampton until his retirement
in 19S9. The Neville Garratt Centre
for Independent Living is a tribute
to his efforts to improve health and
wellbeing in Wolverhampton. He
continued his research in retirement,
as an honorary consultant in Walsall,
with a luu9 publication on maternal
diet and pre-eclampsia. Neville
leaves his wife, Mary; two sons; and
three grandsons.
David Garratt
Anne McConville
Kevin Kelleher
Athol Noble Hepburn
Former occupational physician
Ministry of Defence (b 1931;
q Aberdeen 1954; DPH, FFOM),
d 31 December 2012.
Athol Hepburn did his national
service in the Royal Navy,
specialising in aviation medicine
with the Fleet Air Arm. He then
served in the Royal Naval Reserve
unit at HMS President in London.
After working for the airline BOAC
he became senior medical officer
at the Royal Aircraft Establishment
Farnborough and subsequently
director of civilian medical services
with the Ministry of Defence.
He was a member of the Anglo-
French Concorde aeromedical
subcommittee. In the latter part of
his career he worked part time at
the Atomic Weapons Establishment
in Aldermaston. He leaves his wife,
Julia; two sons; and two grandsons.
Alastair L N Hepburn
William Philip Dowie Logan
Epidemiologist and former
director of the Division of
Health Statistics, World Health
Organization (b 1914; q Glasgow
1939; DPH, MD, PhD, FRCP),
d 11 December 2012.
William Philip Dowie Logan joined
the General Register Office in
19/S as chief medical statistician.
He was adviser on statistics to
the Ministry of Health, head of
the World Health Organizations
centre for classification of disease,
and a panel member for health
statistics for WHO. His statistical
analysis of the consequences of
the great smog of London on '-1u
December 19'l contributed to
the rapid implementation of the
Clean Air Act 19'6. In his later years
he developed bilateral macular
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CLINICAL REVIEW
Achilles does not have a true synovial sheath but has a
paratenon, which is a sheath of exible connective tissue
that allows for a gliding action. The paratenon and Achilles
tendon are innervated by nerves from attached muscles
and small fasciculi from cutaneous nerves, especially the
sural nerve.
4
The paratenon is a highly vascular structure,
and along with the surrounding muscle complex supplies
blood to the Achilles tendon.
5
Cadaveric studies suggest that there is an area 2-6 cm
above the calcaneal insertion with a relatively poor blood
supply, and that this predisposes the region to chronic
inammation and rupture.
5

6
However, in vivo studies
have failed to demonstrate this watershed area. Direct
measurement of forces reveal loading in the Achilles ten-
don to be as high as 9 kilonewtons (up to 12.5 times body
weight) during running, which probably contributes to its
high rate of injury.
7
Tendinitis is a common term used with Achilles disor-
ders. However, chronic overuse tendon injuries are not
caused by inflammationinstead, histology typically
shows tissue degeneration and disorganization.
8
Tendi-
nopathy or tendinosis are therefore more accurate terms,
with tendinopathy the clinical term and tendinosis its
pathological equivalent.
Recently, it has been proposed that tendon injury occurs
along a continuum.
9
Initially, reactive tendinopathy is
caused by overload. This results in a non-inammatory
response that thickens the tendon, reduces stress, and
increases stiness in response to overload. If overload
continues, this leads to tendon dysrepair and highly dis-
organized tissue and, hnally, degenerative tendinopathy,
with even greater cellular disorder.
9
It is unclear if this
degeneration within the tendon is the source of pain
because many asymptomatic tendons show degenerative
changes.
10
Painful tendons, however, show an increase in
sensory and sympathetic nerves from the highly innervated
paratenon and fat pad,
11
which may be the source of pain
in symptomatic tendinopathy.
Who gets Achilles tendon disorders?
Achilles tendinopathy generally occurs in the midsub-
stance of the tendon or less commonly at its insertion in
the calcaneus; this dierentiation is important because
Disorders of the Achilles tendon are common in active
peoplecompetitive and recreational athletes alikebut
they can occur in less active people. As the largest tendon
in the body, the Achilles experiences repetitive strain from
running, jumping, and sudden acceleration or decelera-
tion, so is susceptible to rupture and degenerative changes.
This review aims to describe the anatomy and diagnostic
evaluation of the Achilles tendon, and to discuss the best
available evidence to help in the management of Achilles
tendon disorders.
What are Achilles tendon disorders?
The Achilles tendon is the strongest tendon in the body,
1

serving both the gastrocnemius and soleus muscles. It
begins near the mid-calf and inserts posteriorly at the
calcaneus (hg 1). In the region where the tendon joins
the bone, there is an amalgam called the enthesis organ,
in which the tissue is a composite of bone and tendon.
2

Kagers fat pad is located anterior to the Achilles tendon
and posterior to the calcaneus, forms the superior border
of this enthesis organ, and protects the blood vessels of the
Achilles tendon.
2
The fat pad may also provide a mechani-
cal advantage by increasing the lever angle of the Achilles
tendon during plantar exion.
3
Unlike other tendons, the
Department of Family Medicine,

Eisenhower Army Medical Center,
Fort Gordon, GA , USA
Division of Sports Medicine,

Department of Family Medicine,
Ohio State University, Columbus,
OH , USA
Correspondence to: C A Asplund
chad.asplund@gmail.com
doi: ./bmj.f
Achilles tendon disorders
Chad A Asplund,
Thomas M Best
SUMMARY POINTS
Midsubstance Achilles tendinopathy is more common than the insertional variant
Rupture is most common in men in the fourth and fifth decades of life
Eccentric exercises are the best treatment for Achilles tendinopathy
Other modalities such as shock wave therapy are additive to eccentric exercises in the
treatment of recalcitrant Achilles tendinopathy
Early weight bearing and progressive rehabilitation improve outcomes for the non-operative
management of Achilles tendon rupture
Follow the linkfrom the
online version of this article
to obtain certied continuing
medical education credits
SOURCES AND SELECTION CRITERIA
We searched Medline (to include the Cochrane database)
with the terms tendinopathy, Achilles tendon, tendon
injuries, and Achilles tendon disorders. This was further
limited to Achilles and finally to English language, human
subjects within the past five years, and randomized
controlled trials or evidence based reviews. The search
yielded references. We reviewed the abstracts of these
references and met the inclusion criteria. Further
landmark studies were added.
Subcutaneous calcaneal bursa
Subtendinous calcaneal bursa
Achilles tendon
Calcaneus
Gastrocnemius muscle
Soleus muscle
Lateral view Posterior view
Fig | Anatomy of the Achilles tendon
bmj.com/multimedia
Watch a video
demonstration of
eccentric calf exercises
CLINICAL REVIEW
the treatments dier. Tendon rupture can be complete or
partial and the treatments for both of these will also be
discussed.
Tendinopathy
The most common causes of Achilles disorders are mid-
substance tendinopathy (55-65%), followed by insertional
tendinopathy (20-25%).
12
Achilles tendon disorders can
aect anyone, but they most commonly aect active peo-
ple, especially those who participate in running or jumping
sports. In a cohort study with an 11 year follow-up, Achil-
les tendon overuse injuries occurred in 29% of runners
compared with 4% of non-runners; the age adjusted odds
ratio was 10.0 in runners compared with controls.
13
Age, male sex, and obesity have been cited as risk fac-
tors for Achilles tendon disorders, but a recent study of
athletes over 40 years of age found no inuence of any
of these factors.
14

15
A study of military recruits found
that decreased plantar exion strength and extremes of
dorsiexion (too much or too little) were associated with
Achilles disorders.
16
Abnormal subtalar joint motion has
also been found to contribute to midsubstance tendinopa-
thy.
17
A positive family history raises the risk of Achilles
tendinopathy almost five times, suggesting a possible
genetic link.
15
Medical factors that may be associated with
Achilles injury include hypertension, hyperlipidemia, and
diabetespresumably secondary to glycation or systemic
inammation.
18
Tendon rupture
It is now recognized that most tendinopathies are rarely
associated with one single factor, and the degenerative
process that precedes rupture likely results from a variety
of dierent pathways and causative factors. Degenerative
changes are likely over age 35 years and contribute to the
increased susceptibility to tendon rupture.
10
Achilles ten-
don ruptures are most common in men in the fourth to hhh
decade of life, perhaps because degenerative changes have
started but activity levels are still high.
19
The incidence of
Achilles tendon rupture is seven injuries per 100 000 in the
general population and 12 injuries per 100 000 in com-
petitive athletes.
19
Finally, a history of Achilles rupture
places the person at a higher risk of injury to the contral-
ateral Achilles.
20
Running, jumping, or sudden explosive
or eccentric activities are the usual mechanisms for rup-
ture.
21
Drugs may be associated with Achilles rupture in less
active older adults. A population based cohort study found
that uoroquinolone antibiotics are associated with 12 epi-
sodes of rupture per 100 000 treatment episodes.
22
Another
population based drug safety study found that use of uor-
oquinolones increased risk for tendon disorders (odds ratio
1.7, 95% conhdence interval 1.4 to 2.0) and Achilles rup-
ture (4.1, 1.8 to 9.6), whereas concomitant use of uoro-
quinolones and oral corticosteroids signihcantly increased
the risk of Achilles rupture (43.2, 5.5 to 341.1).
23
How are Achilles tendon disorders evaluated?
A thorough history and physical examination are the hrst
steps in the diagnosis of Achilles tendon disorders. The
history should include pattern of symptomsonset, dura-
tion, cessation, plus alleviating and exacerbating factors.
Ascertain the level of training, previous injury, and previ-
ous treatments. Also determine the presence of risk factors,
such as previous injury, family history, medical history, and
drug use.
Tendinopathy
Patients with tendinopathy generally describe pain or
stiness in the Achilles 2-6 cm above the calcaneal inser-
tion.
24
Morning stiness is common, and the pain is usu-
ally worse with activity, although it may continue into rest.
Less commonly, patients will describe similar symptoms
with point tenderness over the insertion of the Achilles on
the calcaneus.
Inspection of the patients gait may elicit the presence of
overt gait abnormalities. With the patient in a prone posi-
tion, palpate the distal lower leg to assess areas of tender-
ness. Tenderness in the body of the tendon or directly over
the insertion, with or without crepitus, suggests tendin-
opathy. Swelling around the tendon or crepitus with active
motion may indicate inflammation of the paratenon.
Tendinopathy and paratendinopathy may coexist.
25
In
isolated paratendinopathy, there is local thickening of the
paratenon. Finally, assess range of motion (passive and
active) and strength testing to plantar exion, dorsiex-
ion, eversion, and inversion, along with subtalar mobility
to evaluate for restrictions to motion or muscle weakness,
which would predispose to re-injury. It is essential to com-
pare the injured limb with the contralateral non-injured
limb to appreciate subtle dierences.
Severity of tendinopathy, as well as response to treat-
ment, can be assessed by using a validated outcome meas-
ure such as the Victorian Institute of Sport assessment
(VISA-A), which consists of eight items to assess stiness,
pain, and function.
26
Rupture
Classically patients with complete tendon rupture will
describe the feeling of being shot or hit in the back of the
leg, typically while performing an explosive running or
jumping maneuver, with immediate pain and an inability
to continue their current activity.
Because gravity and activity of the tibialis posterior,
peroneals, and long toe exors can cause active plantar
exion, examine patients for suspected rupture while they
are prone. Ecchymosis suggests tendon rupture, and a
A PATIENTS PERSPECTIVE
I am a year old competitive runner. When running on the
beach while on vacation I suddenly felt a burning pain in my
left mid-calf. This was followed by a sudden pop and I was
unable to finish the run. Examination showed ecchymosis
and a small palpable defect in the lateral border of the left
Achilles tendon near the myotendinous junction with a
negative calf squeeze test. Magnetic resonance imaging
demonstrated a -% tear of the Achilles tendon at the
myotendinous junction. After an initial period of limited
weight bearing, ice, and compression, I underwent an
ultrasound guided platelet rich plasma injection. I was
placed in a walking boot for six weeks followed by a
progressive rehabilitation eccentric exercise program. Four
months after the initial injury, I have started running again.
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CLINICAL REVIEW
palpable defect may exist within the hrst hours of rupture.
Tendon rupture can be conhrmed with the calf squeeze
test, where the examiner gently squeezes the patients calf
muscles with the palm of the handif the tendon is intact,
plantar exion will occur, if torn the ankle will remain still.
Test both legs to assess for dierences. Sensitivity and spe-
cihcity of this test have been measured at 0.96 (0.91 to
0.99) and 0.93 (0.76 to 0.99), respectively.
27-29
What is the differential diagnosis of posterior heel pain?
Posterior heel pain can be a diagnostic challengeconsider
Achilles tendinopathy (midsubstance or insertional) and
tendon rupture (partial or complete). Achilles disorders
will localize pain to the Achilles tendon, typically along
its course from the insertion on the heel to its transition
into the conjoined tendon of the gastrocnemius and soleus.
However, dierential diagnoses include retrocalcaneal bur-
sitis or enthesitis, plantaris muscle injury, posterior ankle
impingement, and sural nerve impingement or entrap-
ment.
Retrocalcaneal bursitis may occur near the distal inser-
tion of the Achilles and may mimic insertional tendin-
opathy, and both disorders can occur simultaneously. In
Achilles enthesitis, in addition to the tendon hndings, an
eusion is ohen present in the retrocalcaneal bursa. This
condition can be investigated using three hnger palpation.
The middle hnger and thumb are placed on each side of the
Achilles while the index hnger palpates the distal tendon;
uctuation palpated with the index hnger can indicate
eusion of the retrocalcaneal bursa.
30
The plantaris muscle
is a vestigial rope-like structure seen in 7-20% of the popu-
lation.
31
It lies deep to the proximal lateral gastrocnemius
muscle, travels obliquely, and inserts near the medial bor-
der of the Achilles tendon; in some cases it fuses with the
Achilles.
32
Injury to the plantaris can mimic the symptoms
seen with Achilles tendon disorders and can be diagnosed
with magnetic resonance imaging (MRI) or ultrasound.
33

34

Posterior impingement of the ankle refers to impingement
of the posterior talus by the posterior aspect of the tibia
when the ankle is in extreme plantar exion. In this con-
dition, pain occurs in the posterior ankle but increases
with passive plantar exion of the ankle, unlike in Achil-
les tendinopathy, in which the pain lessens. Finally, sural
nerve entrapment or impingement may cause pain in the
posterior distal leg and may mimic Achilles pathology.
What is the role of imaging in Achilles tendon disorders?
Most Achilles disorders are diagnosed clinically. Imaging
may be useful, however, when the diagnosis is unclear or
when trying to dierentiate between complete or partial
tendon rupture. Ultrasound and MRI are useful when clini-
cal examination does not yield a dehnitive diagnosis.
MRI is useful in the diagnosis of tendon disorders
because it can detect abnormalities in the entire locomotor
unit, including the tendon, calcaneus, Achilles insertion,
retrocalcaneal bursa, peritendinous tissues, and musculo-
tendinous junction. MRI hndings also correlate with hnd-
ings at surgery and may be useful for surgical planning.
35
Ultrasound, however, can provide a dynamic assessment
of the tendon and can evaluate for tissue neovasculariza-
tion. Perhaps more importantly, it can be used to guide per-
cutaneous procedures and is therefore becoming a popular
imaging tool. In a prospective blinded comparison study of
ultrasound and MRI for identihcation of Achilles tendinop-
athy, both had similar specihcity, but MRI had better sensi-
tivity (95% v 80%).
36
However, a recent retrospective study
comparing MRI with physical examination found that MRI
was less sensitive in the diagnosis of Achilles tendon rup-
ture and may be useful only for operative planning.
37
In a
prospective longitudinal cohort study, ultrasound was used
to measure neovascularization before and aher eccentric
exercises to help predict patient outcome, with a decrease
in neovascularity corresponding to patient improvement.
38

It has been suggested that, in trained hands, ultrasound is
better for focused examinations or for guiding intervention,
whereas MRI is better for global assessment of the tendon
or for operative planning.
39
What are the treatment options?
Figure 2 shows an algorithm for the treatment of Achilles
tendon disorders. Consider conservative treatment hrst for
most Achilles tendon disorders. The aims of treatment are
load reduction and pain management. Advise patients with
tendinopathy to reduce or discontinue the oending activ-
ity, weight bear as tolerated, use a heel lih to eectively
Patient presents with Achilles pain
Consider referral to sports medicine specialist for advanced modality
(low energy shock wave treatment, injection, laser therapy)
Calf squeeze test to exclude rupture
Surgical consultation Conservative management
Begin eccentric exercise program, consider physiotherapy referral
Order imaging to better evaluate
Continue maintenance program - months Consider adding glyceryl trinitrate patch
Unclear
Response No response
No response
Negative
If no improvement in - days
Positive
Fig | Algorithm for the treatment of Achilles tendon disorders
ADDITIONAL EDUCATIONAL RESOURCES
Resources for healthcare professionals
American Academy of Orthopaedic Surgeons. The diagnosis and treatment of acute Achilles
tendon rupture: guideline and evidence report. . www.aaos.org/research/guidelines/
atrguideline.pdf
Carcia CR, Martin RL, Houck J, Wukich DK. Achilles pain, stiffness, and muscle power
deficits: Achilles tendinitis clinical practice guidelines linked to the international
classification of functioning, disability, and health from the orthopaedic section of the
American Physical Therapy Association. J Orthop Sports Phys Ther ::A-.
Maffuli N, Almekinders LC. The Achilles tendon. Springer,
Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new
treatment options. Br J Sports Med ;:-
Resources for patients
Kreher JB. Achilles tendinopathy: everything you need to know (and more). What you should
know about Achilles tendinopathy to prevent its occurrence and to stop it in its tracks before
it stops you. www.beginnertriathlete.com/cms/article-detail.asp?articleid=
Beginnertriathlete.com (www.beginnertriathlete.com/cms/article-detail.
asp?articleid=)Video case study on Achilles tendonitis
CLINICAL REVIEW
Insertional tendinopathy
Much of the evidence is for the treatment of midsubstance
tendinopathy, and it is unclear if it directly translates to
treatment of insertional tendinopathy. A systematic review
of 11 studies concluded that conservative treatment,
including eccentric loading exercises and shock wave
therapy, should be attempted before operative interven-
tion.
49
A small pilot study to evaluate the eect of painful
eccentric loading exercises without dorsiexion (dierent
from eccentric loading exercises for midsubstance tendi-
nopathy) found that two thirds of the patients who per-
formed such exercises improved clinically. Interestingly,
combined disease (such as tendon, bursa, or enthesitis)
at the insertion does not exclude a satisfactory response to
this training regimen.
50
Finally, a larger RCT of people with
chronic insertional tendinopathy found that low energy
shock wave therapy may be superior to eccentric loading
exercises in improving functional outcome scores.
51
This
treatment may be useful in patients with a poor initial
response to eccentric loading exercises.
Achilles rupture
Complete rupture
Surgery is ohen recommended for complete Achilles rup-
ture, but there is some controversy about its long term eec-
tiveness. A meta-analysis of six RCTs comparing minimally
invasive surgery with conventional approaches found no
signihcant dierence in outcomes, although minimally
invasive surgery resulted in fewer infections and greater
patient satisfaction.
52
In a Cochrane systematic review,
open surgery was associated with a much lower rate of re-
rupture than conservative treatment but had a higher rate
of complications.
53
If surgical repair is performed, current
evidence supports a minimally invasive technique, and evi-
dence supports early weight bearing to improve functional
outcome scores.
54
Although surgery is generally considered the gold stand-
ard, two RCTs comparing surgery to conservative manage-
ment with immobilization for complete tendon rupture
showed no signihcant dierence aher one year in func-
tional outcomes.
55

56
Another RCT of operative versus non-
operative (accelerated functional rehabilitation program)
treatment of Achilles tendon rupture found that all outcome
measures, including rate of re-rupture, were similar in both
groups.
57
In this study, all patients wore a walking boot with
a 2 cm heel lih two weeks aher injury; early range of motion
and weight bearing as tolerated started at four to six weeks
and strength exercises at six to eight weeks. Finally, an RCT
of early motion plus surgery versus early motion without
surgery suggested that controlled early motion is an impor-
tant part of treatment for a ruptured Achilles tendon.
58

Therefore, recent studies indicate that good outcomes may
be achieved without surgery, especially with accelerated
functional rehabilitation and early motion. Maintain a high
level of suspicion for deep venous thrombosis, the incidence
of which is high aher complete rupture.
59

Because outcomes can be similar for conservative or
surgical management, it is useful to know which patients
are most suitable for surgery. Non-surgical management is
generally best for older less active patients or those with
poor skin integrity or wound healing problems.
53
Surgical
shorten the Achilles and reduce load, and use acetami-
nophen (paracetamol) as needed for pain. Refer patients
with complete rupture to a surgeon for advice about treat-
ment options. Additional treatments for specihc Achil-
les tendon disorders are outlined below. If conservative
measures fail, refer to a sports medicine or orthopaedic
specialist.
Midsubstance Achilles tendinopathy
Eccentric calf exercises have the most evidence and best
outcomes for the treatment of midsubstance Achilles
tendinopathy. A meta-analysis of 11 randomised control-
led trials (RCTs) found that eccentric exercises improved
pain, patient function, and satisfaction compared with
control treatments, such as concentric exercises, stretch-
ing, splinting, and ultrasound.
40
Another systematic review
of 16 RCTs of non-operative treatments for midportion
Achilles tendinopathy found that eccentric exercises had
the most evidence of eectiveness.
41
Furthermore, a hve
year follow-up study of an RCT found sustained long term
improvement with eccentric exercises performed according
to Alfredsons heel drop program.
42
Currently, we recom-
mend Alfredsons method of performing three sets of 15
repetitions, twice a day, every day for up to 12 weeks (see
video).
43
Does the addition of other treatments to eccentric exer-
cises improve results? Two RCTs found that the addition of
low energy shock wave treatment to eccentric exercises is
more eective than eccentric exercise alone.
44

45
Finally,
the addition of low level laser therapy to eccentric exer-
cises accelerated clinical recovery.
46
Therefore both of
these treatments may be additive to eccentric exercise and
may be useful in patients who do not respond to the initial
eccentric exercises.
Topical glyceryl trinitrate has been used to treat tendi-
nopathies, but is it eective for Achilles tendinopathy? A
meta-analysis of seven studies showed that glyceryl trini-
trate reduces pain during activities of daily living in chronic
tendinopathies, with an odds ratio of 4.44 (2.34 to 8.40),
and in acute and chronic phases combined, with an odds
ratio of 4.86 (2.62 to 9.02).
47
For the specihc treatment of
Achilles tendinopathy, another systematic review found
two RCTs of topical glyceryl trinitrate alone in the treatment
of chronic (more than six weeks) Achilles tendinopathy.
One trial found a beneht of glyceryl trinitrate in terms of
pain on activity or at night and tendon tenderness, but the
other trial found no dierence from placebo at six months
on pain at rest or with activity.
47
Finally, another RCT com-
paring physical therapy plus topical glyceryl trinitrate with
therapy alone found that addition of glyceryl trinitrate was
of questionable beneht.
48
Despite evidence at the cellular
level of the role of nitric oxide in tendon healing, results
of clinical studies in human Achilles tendons have been
conicting, so further validation is needed. If glyceryl trini-
trate is used, we recommend cutting a 5 mg 24 hour patch
into four and placing one quarter over the area of maximal
tenderness or pain. Leave the patch in place for 24 hours
and then replace the patch daily until pain subsides or 12
weeks of treatment have been completed, when patient
centered outcomes such as pain and function should be
re-evaluated.
CLINICAL REVIEW
successful return to sports and long term outcome aher
treatment of a partial Achilles rupture with the injection
of platelet-rich plasma followed by a progressive rehabili-
tation program.
62

63
Platelet-rich plasma may be a useful
addition to the current conservative management options
for partial Achilles tendon ruptures, although more dehni-
tive studies are needed before it can be recommended.
What is the prognosis?
Most people who develop Achilles tendinopathy will
improve with conservative treatment. In general, signih-
cant decreases in pain and improvement in function occur
aher 12 weeks of intervention.
64
A long term follow-up study
showed that 85% of patients with Achilles tendinopathy had
full normal function and continued to be asymptomatic eight
years aher injury.
65
Surgery for tendinopathy is reserved for
patients who do not respond aher six months of conservative
measures. Nevertheless, 24 of the 83 patients in the long
term follow-up study did not respond to conservative treat-
ment and underwent surgery.
65
Treatment of complete Achilles rupture is controversial,
but good outcomes have been seen aher both operative
and non-operative approaches.
55-57
Regardless of treat-
ment approach, functional dehcits may persist for up to
two years.
66
It is therefore important to advise patients of
the potential for a long recovery.
Contributors: CA and TB conceived and designed the article. CA performed
the literature search and wrote the initial dra. TB revised this and further
dras. All authors approved the nal version. CA is guarantor.
Competing interests: None declared
Provenance and peer review: Commissioned; externally peer reviewed.
Patient consent obtained.
management is recommended for young people, active high
level athletes, and those in whom non-surgical manage-
ment has been unsuccessful.
Partial rupture
Much of the research into the treatment of Achilles rupture
has been performed on complete tendon rupture rather
than partial rupture. It is dimcult to dierentiate partial
tears from tendinopathy. Imaging may help, but MRI hnd-
ings can overlap substantially.
60
Ultrasound can dier-
entiate full thickness tears from partial thickness ones or
tendinosis of the Achilles tendon with 92% accuracy,
36

61

so should be used in this situation.
Tendon repair can be slow and incomplete, and par-
tial tendon ruptures ohen respond poorly to conservative
measures. Surgery has therefore been the recommended
treatment,
41
even though it has a long recovery period and
greater incidence of complications. Recently, despite the
apparent lack of eectiveness of platelet-rich plasma for
treating Achilles tendinopathy, two case reports found a
AREAS FOR FUTURE RESEARCH
The role of biological agents in the treatment of Achilles
tendon disorders
The role of ultrasound or advanced imaging techniques as
prognostic tools in Achilles disorders
TIPS FOR NONSPECIALISTS
Eccentric exercise programs have the best success rate for
Achilles tendinopathy
Consider surgical referral if no response after six months of
conservative treatment or for acute complete rupture of the
Achilles tendon
ANSWERS TO ENDGAMES, p 40 For long answers go to the Education channel on bmj.com
CASE REPORT
An unexpected finding after a fall from a horse
A white blood cell count greater than
/L is caused by a primary
haematological disease or, less commonly at such a high value, a leukemoid
reaction. A leukemoid reaction may be lymphoid or myeloid in nature and is
a physiological response of the bone marrow to a strong stimulus, such as
infection, drugs, or an underlying solid cancer.
The chronic phase of chronic myeloid leukaemia (CML).
In addition to blood count and differential, examination of a blood film and
bone marrow biopsy will help to exclude other differential diagnoses, such
as other myeloproliferative disorders (polycythaemia rubra vera, essential
thrombocytopenia, myelofibrosis) or chronic myelomonocytic leukaemia, and
will help determine the stage of CML. Further confirmation can then be obtained
using cytogenetics to look for the presence of the Philadelphia chromosome
(t(;)(q;q)) and of the BCR-ABL transcript.
Treatments include disease control with targeted treatmentthe tyrosine kinase
inhibitors, such as imatiniband potential cure with allogeneic haematopoietic
stem cell transplantation.
To reduce the risk of gout and tumour lysis syndrome in response to cytoreductive
treatment.
STATISTICAL QUESTION
Normal ranges
Statement b is true, whereas a and c are false.
PICTURE QUIZ
Peri-oral papules
This cluster of papules in a peri-oral distribution is
molluscum contagiosum.
It is unusual to find multiple molluscum lesions
on the face of a healthy adult so look for causes of
immunocompromise. Investigations should include a
full blood count and HIV serology.
Treatment is not usually needed in children or young
adults because molluscum contagiosum resolves
spontaneously in most cases. In atypical infections
topical imiquimod or cryotherapy can be used.
Skin disease may be the first sign of HIV infection.
Cutaneous infections and skin malignancies are more
common in HIV positive patients.
PRACTICE
1
Africa Centre for Health and
Population Studies, University of
KwaZulu-Natal, South Africa
l
School of Medicine, Glasgow
University, Glasgow G1l 3XX, UK
!
Centre for Paediatric Epidemiology
and Biostatistics, University College
London Institute of Child Health,
London WC1E 6BT, UK
Correspondence to: R Bland, Africa
Centre for Health and Population
Studies, University of KwaZulu-
Natal, PO Box 193, Mtubatuba,
KwaZulu-Natal, !9!', South Africa
rbland@africacentre.ac.za
doi: 1u.11!6/bmj.f''u
Problem Infants and young children infected with HIV
as a result of mother to child transmission are not being
identied or started with antiretroviral treatment (ART) in
line with HIV guidelines in resource limited settings.
Design Retrospective analysis of data from a paediatric
cohort before and afer an intervention strategy.
Setting Rural public HIV treatment programme in the
province of KwaZulu-Natal, South Africa.
Key measures for improvement Increase in the number of
HIV infected infants and children who start HIV treatment
each year; increase in the proportion of children starting
ART with less immune suppression, shown by higher CD/
counts and less advanced World Health Organization
clinical stages for HIV.
Strategies for change Late 2uu8: training in paediatric
HIV for all stan in contact with mothers and children;
campaigns for increased HIV testing at immunisation and
clinics; routine testing of children with tuberculosis and
malnutrition for HIV, and HIV testing of all children admitted
to hospital. The establishment of a family HIV clinic in late
2uu7.
Eects of change The number of children (1 year to 15
years) starting ART each year increased from /3 in 2uu/ to
25/ in 2u11; the corresponding number of infants (<1 year)
starting treatment increased from 2 to 59. A trend towards
increasing CD/ counts at the start of treatment was found.
Lessons learnt It is possible to improve the identication
of HIV infected children and ensure a prompt start on ART
where needed with relatively simple measures and limited
implications for stamng and budgets.
The setting is an HIV treatment and care programme in Hla-
bisa, a rural sub-district of the province of KwaZulu-Natal,
South Africa. In 2011, the population of Hlabisa was about
220 000 people, of whom an estimated 37.8% (83 160) were
children aged 1 year to 15 years and 2.4% (5280) infants
aged <1 year. The area has a high burden of both HIV and
tuberculosis,
1

2
with an estimated overall HIV prevalence
in 2010 of 23% among adults, with no evidence of a sub-
stantive decline in HIV incidence.
3
In 2011 there were about
5000 deliveries, of which an estimated 2000 were to HIV
positive women (Africa Centre Surveillance, www.africa-
centre.com). The notihcation rate of adult tuberculosis in
Hlabisa more than doubled between 2003 and 2008, from
an estimated 707 per 100 000 a year to 1700 per 100 000;
75% of those adults were HIV positive.
Since 2004 the Africa Centre for Health and Population
Studies (www.africacentre.com), funded by the Wellcome
Trust, has partnered with the local Department of Health
in implementing and running a comprehensive HIV pro-
gramme in Hlabisa.
4
From inception, additional funding
was provided by PEPFAR, the United States Presidents
Emergency Plan for AIDS Relief, to support activities includ-
QUALITY IMPROVEMENT REPORT
Maximising opportunities for increased antiretroviral treatment in
children in an existing HIV programme in rural South Africa
Ruth M Bland,
1 2
James Ndirangu,
1
Marie-Louise Newell
1 3
ing monitoring and evaluation, sta training, and manage-
ment of the programme. The programme was initially based
at the local 250-bed hospital but rapidly decentralised,
with clients accessing HIV services at their nearest clinic,
along with other primary care services, including antenatal
services, child growth, immunisation clinics, tuberculosis
services, and management of undernutrition. Attendance at
clinics for antenatal and child health monitoring in Hlabisa
is high, with over 95% of pregnant women attending for at
least one antenatal visit
5
and primary vaccination in the hrst
6 months of life being achieved in over 80% of children.
6

The programme is led by nurses and counsellors, with doc-
tors (mostly without postgraduate specialisation) visiting
clinics to start antiretroviral treatment (ART) and manage
clinical problems during follow-up. Most clinics are typical
of small facilities in rural South Africa, with limited physical
space and shortages of healthcare workers. One or two HIV
counsellors and one to four primary healthcare nurses cov-
ering all services are allocated to each clinic, with a ratio of
795 HIV positive patients receiving ART per nurse, and 386
per counsellor (Till Barnighausen, personal communication,
2012). Numbers of people starting ART have increased sub-
stantially since the start of the programme, from 1800 at
the end of 2006 to over 17 000 at the end of 2011, 73% of
whom were female and 10% of whom were children aged
<15 years.
The clinics in the programme follow national and pro-
vincial guidelines (reecting international World Health
Organization recommendations
7
) for starting and con-
tinuing treatment in HIV positive children. Healthcare and
medications, including antiretroviral drugs, are free for chil-
dren in South Africa and are provided by the government.
Testing for HIV in pregnancy is on an opt-in basis, with
high rates of testing (>90%); HIV testing using polymer-
ase chain reaction at age 6 weeks is recommended for all
infants born to HIV infected mothers, with results available
two weeks later. Children aged >18 months not previously
tested or with clinical signs or symptoms suggestive of HIV
are tested using HIV antibodies with immediate results.
Antiretroviral drugs are started on the basis of a combination
of clinical and immunological criteria, dependent on age.
The South African guidelines for paediatric HIV treatment
were updated in 2010
8
in response to revised WHO recom-
mendations,
9
including HIV treatment of all HIV infected
infants (aged <12 months) irrespective of their clinical or
immunological status.
In South Africa the estimated number of children starting
ART each year has risen from 4200 in 2004 to 152 000 in
2011. However, assessing the proportion of eligible children
who have started ART is challenging in this setting. Cover-
age of HIV treatment in children in South Africa has been
estimated in ongoing work by Johnson and colleagues at the
Centre for Infectious Disease Epidemiology and Research,
bmj.com
Previous articles in
this series
A general practitioner
and nurse led approach
to improving hospital care
for homeless people
(BMJ lu1l;!/':e'999)
Lessons from the
Johns Hopkins Multi-
Disciplinary Venous
Thromboembolism (VTE)
Prevention Collaborative
(BMJ lu1l;!//:e!9!')
An integrated
paediatric to adult clinical
service for young adults
with kidney failure
(BMJ lu1l;!//:e!713)
Improving MMR
vaccination rates: herd
immunity is a realistic goal
(BMJ lu11;!/!:d'7u!)
Intraoperative fluid
management guided by
oesophageal Doppler
monitoring
(BMJ lu11;!/l:d!u16)
PRACTICE
aged <1 year.
21
Using local facility and population based
data and a deterministic model, we also calculated the
number of children in need of treatment
22
and estimated
that by the end of 2007 only two thirds of children who were
in need of treatment and were still alive had started ART; this
represents a huge unmet need.
We recognised that many opportunities were missed in
the existing system to identify infants and children who were
HIV positive, and we postulated that this was the result of
problems in the health system rather than lack of resources,
unclear guidelines, or unwillingness of parents to bring their
children to clinics for testing. Here we describe initiatives
introduced in late 2008 to improve early detection of HIV
positive infants, to increase diagnosis of older children who
missed being identihed in infancy, and the impact of these
strategies on the number and characteristics of children
starting ART.
Key measures for improvement
Our aim was to identify perinatally infected HIV positive
children as early as possible and start ART as appropriate;
to diagnose older HIV positive children who had missed
being tested as infants; to start ART in children before they
were clinically unwell; and to ensure sustainability of these
improvements.
Key outcomes measured were:

Number of HIV positive infants (children aged <12
months) starting ART

Number of HIV positive children aged 1 to 15 years
starting ART

Proportion of children starting ART with higher CD4
counts or CD4% values (indicating less immune
suppression) and at WHO stages 1-2 rather than stages
3-4 (indicating better health).
As discussed above, providing an accurate denominator
for children eligible for ART, and thus being able to report on
the proportion of eligible children receiving HIV treatment,
poses a problem in our setting. It relies on accurate numbers
of HIV infected pregnant women (and thus accurate num-
bers of HIV exposed infants) and on accurate numbers of
HIV exposed infants known to be HIV infected in utero and
during delivery. We have good estimates of the proportion
University of Cape Town.
10
Their models (rather than data
collected from treatment sites) are available for national
trends and indicate that increasing numbers of children
have started ART since 2004. However, these modelled
estimates cannot be split down to provincial or local level,
and rural areas are probably lagging behind urban centres.
Problem
Worldwide, in 2008 an estimated 430 000 children became
infected with HIV (mostly via mother to child transmission),
of whom 90% live in sub-Saharan Africa.
11
Without treat-
ment children progress rapidly to disease, with about 20%
of perinatally infected infants dying within the hrst year of
life, and 50% by their second birthday.
12
However, early ART
leads to increased survival, improved morbidity, and immu-
nological benehts.
13-15
Despite the roll-out of prevention of mother to child trans-
mission programmes and increasing availability of HIV
testing with polymerase chain reaction to identify perina-
tally infected infants at age 4-8 weeks, follow-up of infants
remains inadequate in resource limited settings.
16

17
Prob-
lems cited include vertical systems in primary healthcare
facilities and lack of integration of prevention of mother to
child transmission programmes with other maternal and
child health initiatives, such as immunisation and growth
monitoring; missed opportunities to identify HIV positive
children postnatally; poor turnaround time of results owing
to lack of capacity in laboratories and transport problems
from rural areas; and lack of training of primary healthcare
sta to recognise and refer potentially HIV positive children,
particularly older children, who have little routine contact
with the health facilities. Although guidelines exist, putting
these into practice in already overburdened health sys-
tems remains an enormous challenge. As a result, outside
research settings many children die before diagnosis, and
those who progress more slowly are diagnosed relatively
late, usually presenting with illness at an advanced stage
of disease.
18-20
We have previously reported on the hrst four years (2004-
08) of our decentralised nurse and counsellor driven HIV
treatment programme in rural South Africa, in which 477
children had started receiving ART, of whom very few were
Table | Children (aged years) starting antiretroviral treatment (ART) each year, -
Year
No of children
Proportion of all
children (out of total
No in programme) (%)
Estimated mother to child
transmission rate at age
weeks (%)
Estimated No of new
paediatric cases of HIV
infections*
Aged
< year
Aged
- years Total
Jun luu/ to Sep luu' l /! /' 9 1/ lSu
Oct luu' to Sep luu6 1 99 1uu S 1/ lSu
Oct luu6 to Sep luu7 6 161 167 S 1l l/u
Oct luu7 to Sep luuS lu l'1 l71 S S 16u
Oct luuS to Sep luu9 61 /1/ /7' 1! 6 1lu
Oct luu9 to Sep lu1u '9 lS7 !/6 9 / Su
Oct lu1u to Sep lu11 '9 l'/ !1! 7 !** 6u
*Out of total of luuu HIV positive women.
Data from a large mother to child transmission programme in Hlabisa sub-district.
l!
Increasing numbers of HIV positive women with low CD/ counts started ART between luu/ and luu6, resulting in an estimated decrease in the rate of mother to child
transmission of HIV.
New guidelines were introduced in February luuS, including provision of zidovudine to all pregnant women not already receiving ART from lS weeks gestation. By this
period the ART programme was well established for adults, with no waiting times for treatment, and most women with CD/ counts <luu cells/L had started ART for life.
Estimated further decrease in the rate of mother to child transmission of HIV as more women with low CD/ counts had started ART for life, and the guidelines rolled out in
February luuS had been fully implemented across the Hlabisa sub-district.
**In August lu1u new guidelines for prevention of mother to child transmission were introduced, including: zidovudine for all pregnant women not already receiving ART
from 1/ weeks gestation; all pregnant women with CD/ counts <!'u cells/L (rather than <luu cells/L) to start ART for life; and all infants aged <1 year to start ART.
PRACTICE
initial roll-out of the programme there have been no wait-
ing lists for patients needing ART. A prevention of mother
to child transmission programme had been operating in
the Hlabisa area since 2001, with provision for all pregnant
HIV positive women to receive appropriate management at
their nearest local clinic. Before 2010 women received sin-
gle dose nevirapine in labour; this was changed in August
2010 to: (a) combination ART for life for women with CD4
counts of 350 cells/L, and (b) for the remaining women,
zidovudine monotherapy from early pregnancy plus single
dose nevirapine and a dose of emtricitabine plus tenofovir
in labour and oral daily nevirapine for their infants for at
least six weeks.
Analysis and interpretation
In the hrst four years of the programme (June 2004 to Sep-
tember 2008) we identihed two problems:

Few of the children starting ART were aged <1 year
(table 1)

Children starting ART had low CD4%, low CD4
counts, high WHO clinical stages (suggesting immune
compromise at start of treatment), and CD4 counts well
below the eligibility criteria for treatment (table 2).
Therefore, we examined the cascade of HIV care from
pregnancy to early childhood to identify why so few infants
were starting ART despite our estimates of expected need.
22

As clinic waiting times and the cost of antiretroviral drugs
of pregnant women who are HIV infected from anonymous
surveillance at the Africa Centre and from the Department
of Health. However, we do not know the exact number of
HIV exposed infants who are HIV infected as some may not
have been tested for HIV and others may have died before
having the opportunity to be tested for HIV. Therefore, our
denominator for eligible children remains an estimate based
on several assumptions (table 1), and we provide our hrst
two key outcomes as numbers rather than proportions.
Process of gathering information
Baseline clinical and laboratory data of all children start-
ing ART in the HIV programme are collected from paper
based records stored at clinics and entered into a secure,
electronic database hosted at the Africa Centre. We analysed
data from all children in the programme from June 2004 to
September 2008 before implementing our intervention, and
from October 2008 to September 2011 aher introducing the
improvement strategies. Characteristics at the start of ART
included age and sex, CD4 count and CD4%, WHO clinical
HIV stage, weight for age z score, and haemoglobin and
albumin (both predictors of mortality). All analyses were
performed in Stata (version 11.0).
Since the programmes inception, all drugs and health-
care have been provided free of charge in the primary health-
care clinics and health workers have had access to clear
guidelines for managing HIV positive children. Aher the
Table 2 | Clinical markers in infants and children starting antiretroviral treatment, by age group and period in which treatment started
Age group and period in which
treatment started
CD4% CD4 count WHO stage 3 or 4
Median
(interquartile range)
No (%) with
count missing
Median
(interquartile range)
No (%) with count
missing No (%)
No (%) with
count missing
Infants (<1 year), n=208
Jun luu/ to Sep luu6,* n=! 1' (1l-19) 1 (!!) 7!! (/u!-1u6!) 1 (!!) u l (66)
Oct luu6 to Sep luu7, n=6 1/ (1u-l1) 1 (17) 7ul (/9l-1u7u) 1 (17) ' (S!) u
Oct luu7 to Sep luuS, n=lu 1! (11-lu) S (/u) 7l1 (/S'-11!1) S (/u) 16 (Su) u
Oct luuS to Sep luu9, n=61 lu (16-lS) 16 (l6) 1/'/ (/6/-1/'/) 16 (l6) /9 (Su) / (7)
Oct luu9 to Sep lu1u, n='9 l! (1/-!!) 1' (l') S!6 (l'6-1'9') 1' (l') l/ (/1) 1! (ll)
Oct lu1u to Sep lu11, n='9 lu (11-!1) l6 (//) 1u6! (!7S-1'S6) l6 (//) l' (/l) 1/ (l/)
Children 1 to 5 years, n=613
Jun luu/ to Sep luu6, n=!9 1/ (9-16) 1u (l6) 'uS (1S7-1796) 7 (1S)
Oct luu6 to Sep luu7, n=61 1l.' (7.'-16) ' (S) /'/ (lS!-S!l) / (7)
Oct luu7 to Sep luuS, n=1u' 1' (11-lu) 16 (1') 'l/ (!ll-7!7) 16 (1')
Oct luuS to Sep luu9, n=19! 16 (1l-ll) lu (1u) 6!' (/u6-1uu!) lu (1u)
Oct luu9 to Sep lu1u, n=11S 19 (1/-l/) 1/ (1l) 69u (/u9-11u/) 1/ (1l)
Oct lu1u to Sep lu11, n=97 1S (11-l/) lu (l1) 61S (l6!-1uu/) 19 (lu)
Children >5 to 15 years, n=896
Jun luu/ to Sep luu6, n=1u! 9 ('-1') 16 (16) 1S/ (9l-!6u) 1! (1!)
Oct luu6 to Sep luu7, n=1uu 1u ('-1/) 1l (1l) 1SS (1u1-l99.') S (S)
Oct luu7 to Sep luuS, n=1/6 11 (6-16) 11 (S) 17' (Sl-!S/) 9 (6)
Oct luuS to Sep luu9, n=ll1 1! (7-lu) 1' (7) l9!.' (1'/.'-/S7) 1! (6)
Oct luu9 to Sep lu1u, n=169 1/ (9-l!) 1l (7) l76 (1!7-/6/) 9 (')
Oct lu1u to Sep lu11, n=1'7 1/.' (6-lu) !' (ll) l19 (11l-/!') !/ (ll)
Children 1 to 15 years, n=1509
Jun luu/ to Sep luu6, n=1/l S9 (6!) 1' (11)
Oct luu6 to Sep luu7, n=161 11/ (71) 17 (11)
Oct luu7 to Sep luuS, n=l'1 19S (79) lu (S)
Oct luuS to Sep luu9, n=/1/ !!7 (S1) l/ (6)
Oct luu9 to Sep lu1u, n=lS7 1S9 (66) !S (1!)
Oct lu1u to Sep lu11, n=l'/ 1l7 ('u) 6! (l')
*The period Jun luu/ to Sep luu6 is longer than the others because of small numbers of infants.
Data not currently available separately for age groups 1 to ' and >' to 1'.
PRACTICE
One day training for lay HIV counsellors
This included the following topics:
Immunological eligibility criteria for starting ART in
children. Counsellors received charts of the CD/ counts
and CD/% cut-offs for starting ART and practised
reading laboratory reports to work out if children of
different ages were eligible
Clinical eligibility criteria for starting ART in children.
Counsellors received charts of the WHO HIV clinical
stages for children; clinical scenarios were presented,
and counsellors practised staging the children.
Although staging is done by nurses and doctors, this
exercise emphasised to counsellors the importance
of staging children clinically and not relying only on
immunological eligibility criteria. This is particularly
important for children with tuberculosis, who are WHO
clinical stage 3 but often have CD/ counts above the
immunological threshold for treatment.
The one day training was repeated annually, with special
emphasis in 2u1u, when the guidelines changed
to include giving ART to all infants, irrespective of
immunological or clinical criteria. The counsellors received
printed leaflets containing the new guidelines, and all
the clinics received leaflets for their notice boards and
consulting rooms.
Documentation of HIV status for all children
At all training sessions staff were trained on the
importance of ensuring that an HIV status was recorded
on the clinic card of all young children (which was held by
the mother). If the status was missing on the card of any
HIV exposed child being seen in primary healthcare, the
nurses referred the child immediately to a counsellor for
testing (polymerase chain reaction if aged <18 months;
rapid test if aged 18 months).
HIV testing during immunisation campaigns
Annual primary healthcare campaigns in KwaZulu-
Natal are organised by the Department of Health and
provide opportunities for children who have missed
immunisations or scheduled vitamin A supplements to
receive these. The campaigns focus on the targeted task
and do not consider other child health matters. Nurses
and counsellors were trained to use this opportunity
to check the HIV status of HIV exposed children and to
ensure that HIV positive children had been referred to the
HIV treatment programme. We chose immunisations and
vitamin A supplements for the campaigns as these health
interventions are usually targeted at children under age 5
years, are conducted at least annually, and thus provide
an excellent opportunity to catch children whose HIV
diagnosis had been missed previously.
Clinical staging for all HIV positive children
After the training mentioned above, the counsellors
were instructed to refer all HIV positive children to the
clinic nurse or doctor for clinical staging without waiting
(potentially for two weeks) for the results of CD/ counts.
All counsellors received this instruction at every annual
training meeting; the counsellor supervisor who visited
the clinics to conduct inhouse training reinforced this.
Referral of all sick HIV exposed children for medical
assessment
HIV exposed children were considered a vulnerable group.
Nurses and counsellors were instructed to refer all children
with clinical features suggestive of HIV whose mothers
were HIV positive, for immediate medical assessment
(for example, for failure to thrive, oral thrush beyond
the neonatal period, persistent diarrhoea, chronically
discharging ears). The WHOs Integrated Management of
Childhood Illness (IMCI) strategy is a method of assessing
and managing sick children in resource limited settings with
a shortage of medical staff. The South African adaptation
of the IMCI guidelines includes a section on identifying
HIV in children and includes a list of signs and symptoms.
The adapted IMCI guidelines were included in the one day
training for counsellors and a similar one day training for
nurses. Many of the nurses had been trained in IMCI, and
this section of the course was re-emphasised.
2/

25
Link with tuberculosis and malnutrition programmes
Tuberculosis and malnutrition are associated with HIV,
so linking with these services and the HIV treatment
programme is important. The link with the tuberculosis
service was part of an initiative that encompassed both
adult and paediatric tuberculosis services.
26
Anyone in
Hlabisa with tuberculosis had an HIV test (or confirmation of
a previous HIV test) as part of their management. This was
documented on the paediatric tuberculosis initiation card
that is given to all children starting tuberculosis treatment
in the province. Any child with an unknown HIV status was
referred immediately for HIV testing and the subsequent
result written on the childs card.
Nurses from all the clinics and the dietitian from the sub-
district received specific training on malnutrition. Nurses
were instructed to refer any children with malnutrition and
an unknown HIV status to the counsellors for testing.
HIV testing for children in hospital
Hospital admissions for malnutrition, tuberculosis,
pneumonia, or chronic diarrhoea provide a good
opportunity to identify children with undiagnosed HIV.
Hospital staff conducted HIV testing in the childrens ward
of Hlabisa Hospital, and documented HIV status for each
child on admission in the case file. Results were retrieved
from the laboratory for children who had been tested (with,
for example, polymerase chain reaction) but whose result
was not documented on their clinic card and whose mothers
were unaware of the result. Children who had not been
tested for HIV were tested in the ward, with appropriate
consent.
Feedback of progress to clinic staff
Feedback to the clinic staff took various forms:
Annual programme meetings: feedback on numbers of
children who began ART (data similar to those in table 2)
was presented to counsellors and nurses
Monthly monitoring and evaluation meetings: feedback
to clinic staff on monthly and cumulative data on
numbers of children and infants starting ART
Regular programme meetings: presentation of statistics
stratified by clinic (meetings were attended by all
programme staff).
Measures taken in late to improve early identification of young children with HIV and ensure treatment
of all eligible children
PRACTICE
year increased from 2 to 59 over the same period (table 1).
Of all 1134 children and infants starting ART from Septem-
ber 2008 onwards, 70 (6%) started ART at the hospital, the
rest at the primary healthcare clinics. Obtaining an accu-
rate denominator for the number of children eligible for
treatment is problematic and relies on the number of HIV
exposed infants who are estimated to be infected, rather
than the number of infants actually testing HIV positive.
This is because HIV infected but untreated infants are at
risk of dying in the hrst month of life before there has been
an opportunity to test them. Table 1 gives the estimated
number of new cases of HIV infection annually in infants
and the number of children who started ART.
The hgure (top panel) shows the cumulative number of
children and infants starting ART, with sharp increases
observed from early 2008 onwards. Similar annual
increases were observed in children and infants, especially
in the one year period immediately aher the interventions
were introduced (fig 1(bottom panel)). Thereafter the
number of infants starting ART has stabilised at around
50 a year. With the changes in the prevention of mother
to child transmission regimen for pregnant women, the
mother to child transmission rate in infants at age 6 weeks
has fallen from 14% in the early years of the prevention
programme (2001-06)
23
to 3% in 2011. With an estimated
2000 deliveries to HIV positive women annually in the Hla-
bisa sub-district, fewer than 60 infants annually would
be expected to be vertically infected with HIV from 2011
onwards. The number of children aged 1 year to 15 years
starting ART peaked in 2008-09 and then declined, which
we assume is a result of a large number of older children
being identihed with HIV during the early months of the
intervention, and subsequently children being picked up
at a younger age. In year 7 (October 2010 to September
2011) 59 infants started ART, with an estimated 60 new
paediatric HIV infections over the same period.
Most of the infants and children, both before and aher
the quality improvement interventions, were in WHO clini-
cal stage 3 or 4 when they started ART, mainly owing to
diagnosis with comorbid pulmonary tuberculosis (stage
3) or severe acute malnutrition (stage 4) (table 2). One of
the intervention strategies was to provide HIV testing for
all children admitted to the local hospital, and all those
presenting to clinics with tuberculosis or malnutrition; this
mopping up of older sick children will have accounted
for many of those in WHO stage 3 or 4, and from 2009
to 2011 a trend emerged towards starting treatment
in less advanced disease in children aged 1 year to 15
years (table 2). We cannot comment on any such trends
in infants as the changing guidelines in 2010
8
meant that
all infants were eligible for HIV treatment irrespective of
their clinical or immunological stage. This is corroborated
by the trend of higher CD4 counts and CD4% seen in the
later years of the programme, particularly in those aged
1-5 years, suggesting that children were being identihed
when they were in better health (table 2).
Next steps
Our results show that in a rural health district it is pos-
sible to improve identihcation of children needing ART
and improve early diagnosis of HIV positive infants with
presented no barrier, we thought the problem probably
resulted from missed opportunities to test and diagnose
young children with HIV, rather than HIV positive children
not receiving treatment; this thinking was in line with hnd-
ings from other sites in sub-Saharan Africa.
16

17
Strategy for change
We implemented a series of measures from late 2008 to
improve early identihcation of HIV positive infants and
fast track them for treatment, and to ensure that older
children had a dehnitive HIV test result recorded on their
health card and were receiving treatment if eligible (box).
We employed no additional sta, conducted all training
in-house, and used no external laboratory services.
Additionally, in late 2007 one of the authors (RMB)
established a weekly multidisciplinary family clinic at the
busiest government clinic in the Hlabisa sub-district. It was
established primarily as an HIV clinic, but other paediatric
problems are also managed at the clinic, and children pre-
senting with diseases such as tuberculosis and malnutri-
tion can also be tested for HIV. Referrals from other clinics
in the area are accepted, ART can be started immediately
if necessary, discharges from hospital are followed up, and
the child acts as an index case to ensure that other mem-
bers of the family, particularly siblings, are tested for HIV
and receive appropriate care.
Effects of change
We compared data from the period before the interven-
tion strategies with those from September 2008 onwards.
The number of children (aged 1 to 15 years) starting ART
each year increased from 43 in 2004 to 254 in 2011, with
the largest increases from September 2008 onwards. The
number of infants (aged <1 year) starting treatment each
N
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Age <1 year
Age 1 to 15 years
Top panel: Cumulative
number of children and
infants starting antiretroviral
treatment (ART): June
to September . Bottom
panel: Annual numbers of
children and infants receiving
ART June to September

PRACTICE
Provenance and peer review: Not commissioned; externally peer reviewed.
1 Houlihan CF, Mutevedzi PC, Lessells RJ, Cooke GS, Tanser FC, Newell ML.
The tuberculosis challenge in a rural South African HIV programme. BMC
Infect Dis lu1u;1u:l!.
l Welz T, Hosegood V, Jaffar S, Batzing-Feigenbaum J, Herbst K, Newell ML.
Continued very high prevalence of HIV infection in rural KwaZulu-Natal,
South Africa: a population-based longitudinal study. AIDS luu7;l1:1/67-
7l.
! Tanser F, Brnighausen T, Grapsa E, Newell ML. Effect of ART coverage on
rate of new HIV infections in a hyper-endemic, rural population: South
Africa. Conference on Retroviruses and Opportunistic Infections. Seattle,
US, lu1l. www.retroconference.org/lu1lb/Abstracts//'!79.htm.
/ Houlihan CF, Bland RM, Mutevedzi PC, Lessells RJ, Ndirangu J, Thulare
H, et al. Cohort profile: Hlabisa HIV treatment and care programme. Int J
Epidemiol lu1u;/u:!1S-l6.
' Wilkinson D, Cutts F, Ntuli N, Abdool Karim SS. Maternal and child health
indicators in a rural South African health district. S Afr Med J 1997;S7:/'6-
9.
6 Ndirangu J, Barnighausen T, Tanser F, Tint K, Newell ML. Levels of childhood
vaccination coverage and the impact of maternal HIV status on child
vaccination status in rural KwaZulu-Natal, South Africa. Trop Med Int Health
luu9;1/:1!S!-9!.
7 World Health Organization. Antiretroviral therapy of HIV infection in infants
and children in resource limited settings: towards universal access. luu6.
www.who.int/hiv/pub/guidelines/WHOpaediatric.pdf.
S National Department of Health, South Africa. Guidelines for the
management of HIV in children. lnd ed. lu1u. www.hivfshealth.org/
document/lu1u/uS/19/guidelines-for-the-management-of-hiv-in-
children-lnd-edition-lu1u.
9 World Health Organization. Antiretroviral therapy for HIV infection in
infants and children: towards universal access. Recommendations for a
public health approach: lu1u revision. www.who.int/hiv/pub/paediatric/
infantslu1u/en/.
1u Johnson L. Access to antiretroviral treatment in South Africa, luu/-11.
Southern African Journal of HIV Medicine lu1l;1!(1).
11 Joint United Nations Programme on HIV/AIDS. AIDS epidemic update
luu9. http://data.unaids.org/pub/Report/luu9/JC17uu_Epi_
Update_luu9_en.pdf.
1l Newell ML, Coovadia H, Cortina-Borja M, Rollins N, Gaillard P, Dabis F.
Mortality of infected and uninfected infants born to HIV-infected mothers
in Africa: a pooled analysis. Lancet luu/;!6/:1l!6-/!.
1! Newell ML, Patel D, Goetghebuer T, Thorne C. CD/ cell response to
antiretroviral therapy in children with vertically acquired HIV infection: is it
associated with age at initiation? J Infect Dis luu6;19!:9'/-6l.
1/ Prendergast A, Mphatswe W, Tudor-Williams G, Rakgotho M, Pillay
V, Thobakgale C, et al. Early virological suppression with three-class
antiretroviral therapy in HIV-infected African infants. AIDS luuS;ll:1!!!-
/!.
1' Violari A, Cotton MF, Gibb DM, Babiker AG, Steyn J, Madhi SA, et al. Early
antiretroviral therapy and mortality among HIV-infected infants. N Engl J
Med luuS;!'9:ll!!-//.
16 Ginsburg AS, Hoblitzelle CW, Sripipatana TL, Wilfert CM. Provision of care
following prevention of mother-to-child HIV transmission services in
resource-limited settings. AIDS luu7;l1:l'l9-!l.
17 Rollins N, Little K, Mzolo S, Horwood C, Newell ML. Surveillance of mother-
to-child transmission prevention programmes at immunization clinics: the
case for universal screening. AIDS luu7;l1:1!/1-7.
1S KIDS-ART-LINC Collaboration. Low risk of death, but substantial program
attrition, in pediatric HIV treatment cohorts in Sub-Saharan Africa. J Acquir
Immune Defic Syndr luuS;/9:'l!-!1.
19 Bolton-Moore C, Mubiana-Mbewe M, Cantrell RA, Chintu N, Stringer EM,
Chi BH, et al. Clinical outcomes and CD/ cell response in children receiving
antiretroviral therapy at primary health care facilities in Zambia. JAMA
luu7;l9S:1SSS-99.
lu Kiboneka A, Wangisi J, Nabiryo C, Tembe J, Kusemererwa S, Olupot-Olupot
P, et al. Clinical and immunological outcomes of a national paediatric
cohort receiving combination antiretroviral therapy in Uganda. AIDS
luuS;ll:l/9!-9.
l1 Janssen N, Ndirangu J, Newell ML, Bland RM. Successful paediatric HIV
treatment in rural primary care in Africa. Arch Dis Child lu1u;9':/1/-l1.
ll Cooke GS, Little K, Bland RM, Thulare H, Newell ML. Need for paediatric
HIV treatment within primary health care in rural South Africa. PLoS ONE
luu9;/:e71u1.
l! Rollins NC, Coovadia HM, Bland RM, Coutsoudis A, Bennish ML, Patel D, et
al. Pregnancy outcomes in HIV-infected and uninfected women in rural and
urban South Africa. J Acquir Immune Defic Syndr luu7;//:!l1-S.
l/ Horwood C, Liebeschuetz S, Blaauw D, Cassol S, Qazi S. Diagnosis of
paediatric HIV infection in a primary health care setting with a clinical
algorithm. Bull World Health Organ luu!;S1:S'S-66.
l' Horwood C, Voce A, Vermaak K, Rollins N, Qazi S. Experiences of training
and implementation of integrated management of childhood illness (IMCI)
in South Africa: a qualitative evaluation of the IMCI case management
training course. BMC Pediatr luu9;9:6l.
l6 Coovadia H, Bland R. From Alma-Ata to Agincourt: primary health care in
AIDS. Lancet luuS;!7l:S66-S.
Accepted: l/ December lu1l
relatively simple measures and limited implications for
stamng and budgets. Guidelines are in place, but vertical
health programmes present barriers to ensuring holistic
assessment of children, including early HIV diagnosis.
This applies particularly to children attending tuberculosis
services and presenting with malnutrition and to infants
attending immunisation and growth clinics. All these points
of care represent opportunities to determine the HIV status
of a child and refer them for treatment and care. One of the
key elements of our initiatives has been regular feedback of
results to clinic and programme sta, ohen ignored in set-
tings where monitoring and evaluation are under-resourced
or poorly conducted.
Our hndings show that most children still presented in
WHO clinical stage 3 or 4, which probably reects the high
prevalence of tuberculosis in the area. However, we found
suggestions of a trend towards treatment starting at lower
WHO clinical stages and higher CD4 counts; this trend may
be linked to earlier diagnosis of HIV.
With the introduction of new regimens for prevention of
mother to child transmission (including expanded eligibility
criteria for ART for pregnant women) and immediate ART
for all infants aged under 1 year with conhrmed HIV sta-
tus, there is now the real possibility to eradicate mother to
child transmission of HIV and to identify and treat the few
children who are HIV positive within the hrst three months
of life.
In February 2013 the management of the Hlabisa HIV
programme changed. The funding to South Africa by the US
emergency AIDS plan PEPFAR, always intended for a limited
time period, was substantially reduced, and the programme
is now managed wholly by the local Department of Health.
Systems are now well established to continue this optimal
treatment and care of HIV infected children in Hlabisa: the
Department of Health sta are trained, integration with the
paediatric tuberculosis services is in place, and the pro-
gramme has followed a decentralised model from inception.
We will continue to monitor the prevention of mother to
child transmission programme and the follow-up of HIV
exposed infants in Hlabisa, and we are aiming to achieve
virtual eradication of mother to child HIV transmission
over the next hve years and to start ART in all HIV positive
infants in the hrst four months of life. Our hndings should be
encouraging to other rural areas of sub-Saharan Africa with
equally high HIV prevalence and limited resources.
Contributors: RMB drahed the manuscript; JN analysed the data; all authors
contributed to interpretation of results and reviewed the manuscript.
Competing interests: All authors have completed the ICMJE uniform disclosure
form at www.icmje.org/coi_disclosure.pdf (available on request from the
corresponding author) and declare: The Africa Centre for Health and Population
Studies is supported by a core grant from the Wellcome Trust (u'u'l/). The
Hlabisa HIV Treatment and Care Programme is made possible through the US
Agency for International Development (USAID) and the Presidents Emergency
Plan (PEPFAR) under the terms of Award No 67/-A-uu-uS-uuuu1-uu. The
opinions expressed herein are those of the authors and do not necessarily
reflect the views of USAID or the US government. The funders played no part in
the analysis or writing of this manuscript. We declare no hnancial relationships
with any organisations that might have an interest in the submitted work in the
previous three years; no other relationships or activities that could appear to
have influenced the submitted work.
Ethical approval: The authors obtained ethical approval from the Biomedical
Ethics Committee of the University of KwaZulu-Natal for the retrospective
analysis of anonymised data from the HIV Treatment and Care Programme
(BEu66/u7); the Research Olce of the KwaZulu-Natal Department of Health
also granted approval.
ENDGAMES
We welcome contributions that would help doctors with postgraduate examinations
OSee bmj.com/endgames for details
CASE REPORT
An unexpected finding after a fall
from a horse
A 37 year old jockey was admitted with left sided abdominal
pain and fullness one week after a fall from a horse. Before
this he had been fit and well. On examination, he was tender
in the left upper outer quadrant of his abdomen and his
blood pressure was 9u/55 mm Hg. A computed tomography
scan showed an area of active bleeding in the parenchyma of
the spleen and a large subcapsular haematoma.
Blood tests showed a white blood cell count of 2591u
9
/L
(reference range /-11) with the following differential: blasts
3%, promyelocytes 11%, myelocytes 28%, metamyelocytes
19%, neutrophils 21%, basophils 1u%, lymphocytes /%,
and eosinophils /%. His haemoglobin was 1u9 g/L (13u-
18u), mean cell volume was 8u fL (76-96), and platelets
were 2u11u
9
/L (15u-/uu). Lactate dehydrogenase was 563
IU/L (7u-25u; 1 mmol/L=9.u1 mg/dL) and uric acid was 6uu
mol/L (3uu-/7u; 1 mol/L=u.u3 mg/dL).
He underwent emergency splenectomy. Macroscopically,
the spleen was greatly enlarged, at 22131u cm, and
microscopically it showed a dense infiltrate of left shifted
immature myeloid cells.
1 What are the possible causes of a raised white blood cell
count?
2 Given the clinical findings, what is the likely diagnosis?
3 What further investigations should be considered?
/ What are the treatment options?
5 Why might allopurinol be started in this patient?
Submitted by Sophie Raby, Daniel Greaves, Joseph Padayatty, and Brian Huntly
STATISTICAL QUESTION Normal ranges
Researchers used cardiac magnetic radial images with radial long axis orientation
to establish normal ranges of left ventricular function. Participants were /u
apparently healthy people (2u men, average age 32.3 years, age range 19-58; 2u
women, average age 37./ years, age range 21-5/). Investigations were conducted
using a steady state free precession pulse sequence.
Measurements of left ventricular function included end diastolic volume
adjusted for body surface area. Men had a sample mean volume of 9u.9 mL/m
2

(standard deviation 1/.3) and women 8u.7 mL/m
2
(11.2). Normal ranges for left
ventricular volume were calculated as two standard deviations either side of the
sample mean. The normal ranges for left ventricular end diastolic volume were
62.3-119.5 mL/m
2
for men and 58.3-1u3.1 mL/m
2
for women.
Which of the following statements, if any, are true?
a) Any person with a left ventricular volume outside the sex specific normal range
has an abnormal measurement
b) About 95% of the sample measurements are contained within the sex specific
normal ranges
c) To calculate the normal ranges, it was assumed that the distribution of
measurements of left ventricular volume was normally distributed
Submitted by Philip Sedgwick
FOLLOW ENDGAMES ON TWITTER
@BMJEndgames
FOR SHORT ANSWERS See p 33
FOR LONG ANSWERS
Go to the Education channel on bmj.com
A /u year old woman, originally from sub-Saharan Africa, was referred to
dermatology by her general practitioner. She had noticed the appearance of
several itchy papules around her mouth five months ago (figure). She was
otherwise well and had no relevant medical history. She was taking no drugs.
1 What is the diagnosis?
2 What investigations would you do?
3 How would you treat this condition?
/ What other skin diseases are associated with the underlying disease?
Submitted by Catriona Maybury and Emma Craythorne
PICTURE QUIZ Peri-oral papules
LAST WORDS
They are a product
of yesteryears
deference, club
mentality, and
divisiveness,
celebrating
superiority and
elitism, and they
reinforce hierarchy
celebrating superiority and elitism,
and they reinforce hierarchy.
Some doctors also complain that
those who pursue their medical careers
ohen do so to the detriment of their col-
leagues who are leh holding the on-call
pager. Some even suggest that fellow-
ships are a cynical conspiracy to make
money by preying on middle aged
insecurity. A fellowship of the Royal
College of General Practitioners, for
example, costs E620 along with some
truly dreadful but expensive polyester
merchandising tat. The bottom line
is that many ordinary, hard working
consultants and general practitioners
never receive a gong or recognition.
What value do fellowships add to
the profession? Arent fellowships a
potential barrier to challenging author-
ity and the establishment? Isnt it time
to review our medical honours system?
Des Spence is a general practitioner, Glasgow
destwo@yahoo.co.uk
We are all a product of our time, a
morass of contradictions, conflicts,
and prejudices. I was raised on a iso-
lated Scottish island, attended a com-
prehensive school, and worked in
many dierent jobs. I pride myself on
my ordinariness and the ordinariness
of my medical work. Egalitarianism is
branded in my psyche. I am intent on
never appearing intimidatedeven
when I am. I am respectful but not
deferential. I dislike titles, includ-
ing Doctor, reasoning that these
are merely a weapon of intimidation.
Success and contentment are not in
the gih of others, or possessions, but a
purely personal perspective.
So I have mixed emotions towards
honours, knighthoods, and the rest.
These are from a class ridden past,
mere baubles designed to amrm sepa-
ration and superiority. Today honours
strive to be more egalitarian, with the
odd postal worker and teacher recog-
nised for their daily dedication. But
honours are still part political patron-
age, closed but to a select elite few. It
is the powerful and privileged, not
the hardworking teacher, who have
the highest honour of falling asleep in
ermine and claiming expenses in the
House of Lords.
What of medical gongs, the fellow-
ships to the medical royal colleges,
presented in gowns at ceremonies with
curling cucumber sandwiches? Doctors
are awarded these through nomination
by colleagues and subject to committee
review. Fellowships are seen as a tradi-
tionharmless and an important recog-
nition of hard work and commitment.
I am not angry that I have never
been nominated (or perhaps I am just
in denial). But arent fellowships out-
dated, just like those badly painted
portraits of past presidents, all look-
ing the same irrespective of sex, hang-
ing on the college walls? They are a
product of yesteryears deference,
club mentality, and divisiveness,
My hrst proper job was as a salesman
at a big chain of electrical shops.
During my induction the manager
introduced himself as John Clark. I
had just leh school, and my only retail
experience was from watching reruns
of the 1970s British sitcoms Are You
Being Served and Open All Hours, so
I had no idea whether I should call
him John or Mr Clark. I spent the next
week addressing him as Excuse me
and desperately listening out for cues
from my colleagues.
Seven months into my hrst job as a
doctor, and aher six years of medical
school, I still feel a bit uncomfortable
about how to address my seniors
especially consultants. To my ear,
calling doctors by their surnames
has a whi of Are You Being Served.
But calling consultants by their hrst
name, without hrst being explicitly
invited to, would be unthinkable.
Ive recently been experimenting
with Boss. It does make me sound
screw ups could have been averted
if juniors had had the courage to
challenge what they were being told.
Perhaps more commonly, being able
to question your seniors clinical
reasoning helps you to learn why they
are doing what they are doing. Getting
rid of the rigid interpersonal hierarchy
can only help this happen.
Of course, the boss still makes the
hnal call. But your seniors derive
their authority from their experience
and knowledge, not from outdated
etiquette. The few consultants I have
known who preferred to be called
by their hrst names still had the full
respect of their juniors.
So lets be on hrst name terms. Itll
make work a nicer place, and it might
make medicine better.
Oliver Ellis is foundation year doctor,
Mersey Deanery
oli.ellis@googlemail.com
Ive recently been
experimenting with
Boss. It does make
me sound a bit like a
doomed henchman
in a 1980s action
movie but has the
advantage of having
just one syllable
a bit like a doomed henchman in
a 1980s action movie but has the
advantage of having just one syllable
and being a bit less stuy.
The world has become a less
formal place. Politicians dont wear
ties, gardeners dont do their caps,
and people use hrst names.
What patients and doctors call
each other is a dierent matter. Many
patients prefer to use surnames.
But when patients arent in the
room, why cant our interactions
catch up with the rest of the world?
As a medical student I was once
given a comprehensive telling o for
the way I was standing. When you
present a patient, stand up straight,
feet a shoulder width apart, hands
behind your back. Stand at ease, in
other words, which was odd, because
I had no memory of ever joining the
army.
Doctors are increasingly recognised
not to be gods. So many scandals and
FROM THE FRONTLINE Des Spence
Scrap the royal colleges fellowships
LAYING FOUNDATIONS Oliver Ellis
On first name terms
Twitter
Follow Des Spence on
Twitter @des_spence
bmj.com
Previous articles by
Oliver Ellis are available at
http://bit.ly/YVRqY

MINERVA
Send comments or suggest ideas to Minerva: minerva@bmj.com
A year old woman,
with several itchy papules
around her mouth
Try the picture quiz in
ENDGAMES, p
The installation of 1u6 solar panels on the
roof of a crematorium in Hereford, United
Kingdom, is expected to generate over 15 uuu
units of electricity a year, saving more than
12 tonnes of carbon dioxide emissions and
saving taxpayers nearly 5uuu (t58uu;
$75/u) per year. Solar panels are well suited
to crematoriums, according to the local energy
company, because they are silent, and wont
disrupt the business of the site (Pharos
International Spring 2u13;79:38).
Early laparoscopic cholecystectomy is
encouraged for most people with acute
cholecystitis. But what happens to those who
are discharged on first admission without
surgery? Using data from over 1u uuu patients
who did not undergo cholecystectomy on
first admission, Canadian researchers found
a 19% probability of a subsequent gallstone
related event or hospital visit within 12 weeks
of discharge. This risk increased in younger
patients aged 18-3/ years (Journal of Trauma
and Acute Care Surgery 2u13;7/:26-31,
doi:1u.1u97/TA.ubu13e3182788e/d).
In a comparison study of 97 children with
epilepsy and 69 healthy children, IQ was
significantly lower in children with epilepsy
than in controls. However, IQ did not
differ significantly between the parents of
both groups. Children with epilepsy had
significantly lower IQ scores than their
biological parents, which was not observed
in the control group. The researchers suggest
that the parent-child IQ difference is a
marker of the effect of epilepsy, independent
of familial IQ and of the type of epilepsy
(Developmental Medicine and Child
Neurology 2u13;55:278-82, doi:1u.1111/
dmcn.12u/u).
The proportion of medical graduates in the
United Kingdom who choose to specialise in
psychiatry has remained at about 5% over
the past 35 years. In a questionnaire study of
nearly 3/ uuu respondents, the main reasons
for choosing psychiatry included experience of
the subject at medical school, self appraisal of
skills, and inclinations even before applying
to medical school. Of graduates who did not
choose psychiatry, 72% gave job content
as their reason for rejection, compared with
33% of those who considered but rejected
other specialties (British Journal of Psychiatry
2u13;2u2:228-3/, doi:1u.1192/bjp.
bp.112.111153).
Minerva fondly remembers the adventures of
Laura Ingalls in the Little House on the Prairie,
and the tears she wept when Lauras sister Mary
went blind at the age of 1/. Marys sight loss
was blamed on scarlet fever in the novels, but in
Laura Ingalls Wilders memoirs, she recalls Mary
being taken suddenly sick with a pain in her
head and then being delirious with an awful
fever, with her face drawn out of shape. It
was recorded as spinal sickness and brain
fever, period terms for meningoencephalitis
(Pediatrics 2u13;131:/u/-6, doi:1u.15/2/
peds.2u12-1/38).
Postdural puncture headaches (PDPH) occur
in up to /u% of people who undergo lumbar
puncture, typically starting within 15 min
of sitting up, and resolving within 15 min of
lying down again. In a prospective study of
16u people with migraine headaches and
53 matched healthy controls, risk factors for
PDPH were identified as young age and low
body mass index, but not having migraines
(Neurology 2u13;8u:9/1-8, doi:1u.1212/
WNL.ubu13e31828/ubf6). Duration of PDPH
was prolonged if multiple attempts at lumbar
puncture were made, and if patients perceived
their lumbar puncture experience as stressful.
Men with high risk prostate cancer who undergo
robot assisted radical prostatectomy could
have just as good oncological outcomes as
those who undergo open surgery, according to
a retrospective analysis of over /uu patients at
one United States institution (British Journal
of Urology International 2u13, doi:1u.1111/
j.1/6/-/1uX.2u12.11/93.x). Recurrence free
survival was similar in both groups at two
years (open procedure 8/% v robot assisted
procedure 79%) and four years (68% v 66%).
But robot assisted patients had less
blood loss and underwent complete bilateral
nerve sparing more often than patients with
open surgery.
Preoperative magnetic resonance imaging
(MRI) could underestimate the size of articular
cartilage defects compared with what is actually
found at arthroscopy. In one cohort study of
77 patients undergoing knee arthroscopy, MRI
scans underestimated the defect area by an
average of 7u%; therefore, many patients were
not well informed preoperatively about the best
repair strategies on offer. The authors suggest
that such discrepancies are predictable,
and should be reflected in the treatment
strategies discussed before surgery (American
Journal of Sports Medicine 2u13;/1:59u-5,
doi:1u.1177/u3635/6512/72u//).
PCV7a seven valent, pneumococcal conjugate
vaccinewas introduced in Australia in two
phases, in 2uu1 and 2uu5. In the five years
after its introduction, admission rates for
all childhood pneumonias fell significantly;
however, admissions for empyema rose more
than expected, although this increase was
significant only among children aged 1-/
years. There is a concern that empyema may
have emerged as a replacement disease,
produced by non-vaccine related serotypes
of Streptococcus pneumoniae (Bulletin of the
World Health Organization 2u13;91:167-73,
doi:1u.2/71/blt.12.1u9231).
This plain radiograph shows the right foot
of a 69 year old man with type 2 diabetes,
who presented with an infected heel ulcer
that did not respond to oral antibiotics.
The radiograph clearly shows extensive
subcutaneous emphysema of the foot.
There is also a curvilinear lucency in the
calcaneum extending to the cortex, with
thinning of the cortex adjacent to the ulcer
site. The bony changes were deemed to be
secondary to osteomyelitis affecting the
calcaneum.
Jonathan D Evans, foundation year trainee,
Adrian M Jennings (adrian.jennings@qehkl.nhs.uk),
consultant physician , Department of Diabetes and
Endocrinology, Queen Elizabeth Hospital, Kings Lynn
PE ET, UK
Patient consent obtained.

BMJ - 16 March 2013

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