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Rationing in response to NHS deficits: rural patients are likely to
Weight loss is a logical initial management be affected most
for painful knee osteoarthritis but does not obviate the potential benefit of surgery for lost weight or have been able to reduce their Editor—News that pressing financial prob- result in NHS services being subject to a new lems have caused NHS trusts in Suffolk to postcode lottery, in which rural residents are set new “thresholds” to treatments such as Sheena Asthana professor of health policy
utilitarian grounds. For knee replacement, School of Sociology, Politics and Law, University of there is “no evidence that age, gender, or directors of trusts in which over a third of obesity is a strong predictor of functional respondents anticipated reductions of key outcomes.”3 A UK health technology assess- services in response to funding shortfalls.1 2 Alex Gibson innovation and research fellow
Faculty of Health and Social Work, University of obese patients (with a BMI > 30) could ben- cuts in services are far more likely to be felt efit from total primary hip arthroplasties in some parts of the country than others.
1 Coombes R. Rationing of joint replacements raises fears of noticeably increase the operative risk.4 Chan presented as a problem of financial misman- further cuts, BMJ 2005;331:1290. (3 December.) et al found no significant difference in the agement, but the pattern of deficits shows 2 British Medical Association. Funding difficulties in the NHS. A survey of medical directors of trusts in England.
improvement in scores (of quality of life) that the current resource allocation model London: BMA, 2005. www.bma.org.uk/ap.nsf/content/ discriminates against particular communi- nhsfundingdifficulty?OpenDocument&Highlight = 2,NHS, trust,shortfall (accessed 7 Dec 2005).
concluding that relative body weight alone ties. According to the recently published 3 Department of Health. NHS organisations annual accounts does not influence the benefit derived from accounts for 2004-5,3 89 out of 303 (30%) surplus and deficits 2004-05. London: DoH, 2005.
English primary care trusts ended the year www.dh.gov.uk/PublicationsAndStatistics/Publications/ PublicationsPolicyAndGuidance/PublicationsPolicyAnd Since obesity does not increase the risks in deficit. The table shows how 301 of these GuidanceArticle/fs/en?CONTENT_ID = 4119175&chk = or diminish the benefits of joint replace- trusts are distributed accorded to fifths of ment, the trust’s decision to deny such treat- that are in both the most rural and the least Rationing joint replacements
extended, such a policy would deny treat- financial difficulties. Seventeen of the 25 Trust’s decision seems to be based on
patients with HIV infection, and those who (68%) in this category were in deficit. These prejudice or attributing blame . . .
trusts received the lowest funding allocation Editor—The decision of the East Suffolk Nicholas Finer consultant in obesity medicine
per head (£995). By contrast, only 3% (one Addenbrooke’s Hospital, Cambridge CB2 2QQ of 34) of the primary care trusts serving replacements for patients unless the patient populations that are in both the most urban and the most deprived fifths failed to break conservative means have failed to alleviate even in 2004-5. These trusts received the the pain and disability breaches basic princi- 1 Coombes R. Rationing of joint replacements raises fears of ples of health care that do not seek to judge further cuts. BMJ 2005;331:1290. (3 December.) patients for their illness.1 The decision 2 Nevitt MC. Obesity outcomes in disease management: clinical outcomes for osteoarthritis. Obes Res 2002; obesity cause osteoarthritis, does weight loss 3 Department of Health and Human Services. Total knee replacement. Rockville, MD: Agency for Healthcare Research some trusts are in deficit. The pattern of improve it, and is surgery more dangerous and Quality, Department of Health and Human Services, deficits implies that NHS funding provides 2003. (Evidence report/technology assessment No 86.) insufficient resources for rural areas, for Obesity and risk for osteoarthritis of the 4 Faulkner A, Kennedy LG, Baxter K, Donovan J,Wilkinson M, Bevan G. Effectiveness of hip prostheses in primary comparatively affluent areas, and, most par- knee (especially bilateral) are associated, as is total hip replacement: a critical review of evidence and an ticularly, for areas that are both rural and a response of symptoms to weight loss2; the economic model. Health Technol Assess 1998;2:1-133.
5 Chan CL, Villar RN. Obesity and quality of life after primary affluent. The risk is that such measures will links with hip osteoarthritis are less clear.
hip arthroplasty. J Bone Joint Surg Br 1996;78:855-6.
Distribution of primary care trusts in deficit, 2004-5. Values are proportions (percentages) unless stated otherwise Rurality
Average primary care trust per
Deprivation
Most urban fifth
Least urban fifth
head turnover, 2004-5 (£)
BMJ VOLUME 331 17 DECEMBER 2005 bmj.com
. . . and is false economy resulting in
grammes have reported difficulties, includ- overall damage
sense, and those practices that achieve this prisoners and staff. During the transition save costs for commissioners, but it cannot will, no doubt, be the survivors in the world in this timescale save any costs to providers of contestability ushered in by the forthcom- in the NHS—which means, money is wasted.1 ing white paper on care outside hospitals.
although this was used by a small fraction of the populations. To our knowledge, no facili- grounds may increase long term costs.
the provider side of primary care. For the ties that have instituted smoking bans have Personal experience shows that delaying joint replacement surgery causes deterioration of at the level of the practice or primary care health and addictions settings a critical functional capacity, which is difficult or impos- sible to reverse after later operation. What is certainly too small. This size of patient base major effects in behavioural indicators of the evidence that these strict conditions are exhibits too many variations in referral rates and secondary care activity to accommodate patients have repeatedly reported very little “super practices,” if contracting in secondary difficulty with stopping tobacco use, and that spent, if your body mass index is not too care professionals, risk fragmentation and during the initial days and weeks, thoughts high, and you do not have a major disability.
and energy are directed to far more pressing concerns. Stopping is different from quit- Martin W McNicol retired
health and social services integration is best tobacco use by six months after release (R W served by coterminosity of health and local Tuthill et al, 26th national conference on authority boundaries. Local authority popu- correctional health care, Nashville, Tennes- 1 Coombes R. Rationing of joint replacements raises fears of constituent general practices are the ideal further cuts. BMJ 2005;331:1290. (3 December.) model for clinically led joint commissioning District general hospitals have
has been created and has been well accepted a future in truly rural areas
national tariff, and, to an extent, rightly so. At by prisoners and staff, though tobacco use present tariffs are too crude and simplistic to be helpful in a quasi market economy. Their Thomas Lincoln physician
of both England and Wales in tow with his application is too rigid to allow for service Baystate Medical Center, Springfield, MA 01199, rationalise services that may be duplicated in several hospitals within a radius of 10-15 retail price”—which NHS commissioners R Scott Chavez vice president
miles, as may be found in many cities or other would see as a maximum price to pay for a National Commission on Correctional Health Care, 1145 W Diversey Parkway, Chicago, IL 60614, densely populated areas, is certainly sensible.
“unit” of activity, but with local flexibility to However, none of Ham’s ideas answers the Elizabeth Langmore-Avila substance abuse clinician
question, “How do you maintain the skill mix activity is increasingly devolved into the 160 East Hadley Road, Amherst, MA 01002, USA to deal with acute life threatening conditions in a hospital that is 30 miles from the next John Hughes clinical director
district general hospital up the road?’ South East Hants Primary Care Trust Cluster, 1 O’Dowd A. Smoking ban in prisons would lead to more The answer, of course, is that you have to assaults on staff. BMJ 2005;331:1228. (26 November.) 2 Chavez RS, Oto-Kent DS, Porter J, Brown K, Quirk L, maintain it as a district general hospital in its Lewis S. Tobacco policy, cessation, and education in correctional own right. To do that you cannot chip away facilities. Chicago, IL: National Commission on Correc- tional Health Care and National Network on Tobacco Pre- at some services and hope that the others 1 Donaldson C, Ruta D. Should the NHS follow the Ameri- 3 El-Guebaly N, Cathcart J, Currie S, Brown D, Gloster S.
can way? BMJ 2005;331:1328-30. (3 December.) Public health and therapeutic aspects of smoking bans in mental health and addiction settings. Psychiatr Serv 2002; ruptured spleen or a massive haematemesis, 4 National Commission on Correctional Health Care and US experience of smoke-free
National Network on Tobacco Prevention and Poverty.
then you have to accept that you won’t get Tobacco cessation for correctional populations: a health such a person if you expect him or her the education manual. 2005. www.ncchc.org/pubs/catalog.
html[tobacco_cessation (accessed 8 Dec 2005).
rest of the time to deal only with lumps and bumps. We know this well in Pembrokeshire.
ban in prisons would lead to more assaults Peter J Milewski consultant in general surgery
on staff.1 Increasing numbers of correctional Risk of gastrointestinal effects
Withybush Hospital, Haverfordwest, Pembrokeshire facilities in the United States have become with COX-2 inhibitors and
smoke-free and made tobacco, matches, and lighters contraband. Most experience so far Competing interests: PJM is a consultant in a has not shown the feared difficulties arising when facilities become completely tobacco- Study conclusions do not reflect findings
1 Ham C. Does the district general hospital have a future? free. Most programmes note that the issues for celecoxib
BMJ 2005;331:1331-3. (3 December.) around staff tobacco use at the facility are more challenging than those around prison- Hippisley-Cox et al do not accurately reflect Commissioning perhaps shouldn’t
follow the American way
tobacco use for prisoners, although 79% of steroidal anti-inflammatory drugs (NSAIDs) in terms of the risk of adverse gastrointesti- pelling case for the adaptation, rather than nal effects. Specifically, celecoxib was the replication, of US health systems in Eng- some difficulty resulting from this. The tran- only treatment that did not significantly land.1 That general practices should increase sition process is not minimal, and some pro- BMJ VOLUME 331 17 DECEMBER 2005 bmj.com
(adjusted relative risk 1.11, 95% confidence COX-2 inhibitors were thought of as a
interval 0.87 to 1.41) compared with control safe option
Editor—The study by Hippisley-Cox et al number of patients taking celecoxib was low, Bernard G Bannwarth professor of therapeutics
University Hospital, 33076 Bordeaux, France (COX-2) inhibitors and non-steroidal anti- celecoxib is less than the lower limits for inflammatory drugs (NSAIDS) is subject to naproxen (1.73), diclofenac (1.78), other Competing interests: BGB has been an invited speaker at Merck sponsored symposia and has participated in clinical studies sponsored by safer to prescribe in patients at high risk of 1 Hippisley-Cox J, Coupland C, Logan R. Risk of adverse developing gastrointestinal side effects than results of other studies. NSAIDs typically gastrointestinal outcomes in patients taking cyclo- increase by twofold to fourfold the risks oxygenase-2 inhibitors or conventional non-steroidal anti- inflammatory drugs: population based nested case-control their cardiovascular safety.3 Working in gen- of a gastrointestinal bleed. For example, analysis. BMJ 2005;331:1310-6. (3 December.) Mamdani et al studied 1.3 million elderly inhibitors used in primary care patients who Why were patients at major risk
found that celecoxib was not associated with excluded?
increased risk of admission for gastrointes- Editor—One of the strongest risk factors prescribed particularly in elderly people, in whom opiate analgesics often cause signifi- significantly increased risk seen with other cant adverse effects. This practice would The conclusions of the article, as well as its press release, do not fully acknowledge among various arthritis treatment options.
In this study, celecoxib had the lowest risk of gastrointestinal complications—important Joe Feczko chief medical officer
Competing interests: JF is an employee of Pfizer.
tors might well have beengiven to high risk patients who were scribing records from general practices as the main source of prescribing data. This 1 Hippisley-Cox J, Coupland C, Logan R. Risk of adverse subsequently excluded from the analysis.
gastrointestinal outcomes in patients taking cyclo- neglects the confounding influence of over oxygenase-2 inhibitors or conventional non-steroidal anti- the counter drugs which have an important inflammatory drugs: population based nested case-control influence on the prevalence of gastrointesti- analysis. BMJ 2005;331:1310-6. (3 December.) prescriptions of ulcer healing drugs by each 2 Mamdani M, Rochon PA, Juurlink DN, Kopp A, Anderson GM, Naglie G, et al. Observational study of upper gastroin- NSAID. The vast majority of ulcer healing testinal haemorrhage in elderly patients given selective Michael R Lewis general practitioner
cyclo-oxygenase-2 inhibitors or conventional non- patients taking a non-selective NSAID.
steroidal anti-inflammatory drugs. BMJ 2002;325:624-7.
Another issue is the effect of concurrent Diana Kay general practitioner
Cheam Family Practice, Sutton, Surrey SM1 2HD How strong is the evidence?
were adjusted for each other NSAID group, smoking, comorbidity, deprivation, and use the nested case-control study by Hippisley- of selective serotonin reuptake inhibitors, 1 Hippisley-Cox J, Coupland C, Logan R. Risk of adverse gastrointestinal outcomes in patients taking cyclo- Cox et al was that no consistent evidence tricyclic antidepressants, statins, aspirin, and oxygenase-2 inhibitors or conventional non-steroidal anti- ulcer healing drugs. But it is important not inflammatory drugs: population based nested case-control gastrointestinal events with any of the new analysis. BMJ 2005;331:1310-6. (3 December.) 2 Deeks JD, Smith LA, Bradley MD. Efficacy, tolerability, and cyclo-oxygenase-2 (COX-2) inhibitors com- upper gastrointestinal safety of celecoxib for treatment of pared with non-selective non-steroidal anti- osteoarthritis and rheumatoid arthritis: systematic review of randomized controlled trials. BMJ 2002:325:619.
timing, and their nature. The gastrointesti- 3 Jones R. Efficacy and safety of COX-2 inhibitors. BMJ nal adverse effects of NSAIDs may persist of rofecoxib in patients currently taking for a long time, thus interacting with the inflammatory drugs and elderly patients. BMJ 1995;310: aspirin was 2.98 (2.24 to 3.99) whereas it 5 Andersen M, Schou JS. Are H2 receptor antagonists safe over the counter drugs? BMJ 1994;309:493-4.
currently taking aspirin. While denoting a results, at least in part. If patients taking celecoxib were too few what is the sense in What does evidence from randomised
aspirin, these data do not support the view comparing a class of non-selective NSAIDs trials show about celecoxib?
of a significant increased hazard of gas- Editor—With reference to Feczko’s com- ments (first letter in this cluster), Hippisley- Luca Puccetti president
Cox et al’s study was an observational study.1 Promed Galileo Medical Association, Pisa 56011, This occupies a lower place on the hierarchy residual confounding that cannot be fully corrected for. In this respect, the present study was based on drug prescriptions and (patient oriented evidence that matters, or not actual drug consumption. A low compli- 1 Hippisley-Cox J, Coupland C, Logan R. Risk of adverse ance rate with a given drug might result in gastrointestinal outcomes in patients taking cyclo- an improved gastrointestinal safety profile, oxygenase-2 inhibitors or conventional non-steroidal anti- inflammatory drugs: population based nested case-control is the CLASS study.2 CLASS showed no sig- and vice versa. Unfortunately, whether the analysis. BMJ 2005;331:1310-6. (3 December.) nificant difference between celecoxib and BMJ VOLUME 331 17 DECEMBER 2005 bmj.com
the comparators (diclofenac and ibuprofen) antenatal steroids were given from 24 weeks’ from these recessive disorders is huge. Indi- study—gastrointestinal ulcer complications.3 vidual recessive disorders tend to cluster in venous postnatal courses of corticosteroid Only when a post-hoc sub-group analysis of family groups. The simple message for the were prescribed for the very preterm to pre- vent chronic lung disease.1 He then raised taking aspirin was a significant benefit seen marriage is that if a recessive disorder is (with a P value of 0.04). This was one of over found in the family genetic advice must be least one of these to show a difference with a P value slightly less than 0.05).4 Others population a DNA diagnosis is still not pos- sible. This means that many families will embryogenesis. Steer concludes that “giving steroids . . . even as a single course, remains riage as the only way to lower the risk. For disorder, cousin marriage remains a reason- cern, the Cochrane review in 2003 and the John W T Benson consultant paediatrician
College of Obstetricians and Gynaecologists on the use of antenatal corticosteroids to prevent respiratory distress syndrome con- clude that a single course of antenatal corti- continues to increase despite the lack of costeroid has no adverse effect on physical good quality evidence for its usefulness in growth, neurological or cognitive outcome, 1 Dyer O. MP is criticised for saying that marriage of first providing a benefit to patients is disap- cousins is a health problem. BMJ 2005;331: 1292. (3 or infection in child or mother.2 3 The royal college’s guideline synthesises five papers 2 Modell B, Darr A. Genetic counselling and customary con- sanguineous marriage. Nat Rev 2002, 3: 225-229.
the wording of the conclusions of hypothesis 3 Bundey S, Alam H. A five-year prospective study of the health of children in different ethnic groups, with particu- generating data (like those of Hippisley-Cox lar reference to the effect of inbreeding. Eur J Hum Genet antenatal corticosteroids for up to 20 years.
et al). Although such data are interesting, We have reviewed all five papers, together they do not inform our practice in the same with another published since the guideline way that a negative prospective randomised and Dalziel et al’s paper extending follow-up Giving steroids before elective
to 31 years.4 5 We find the college guideline Jonathan L Underhill assistant director, education
caesarean section
National Prescribing Centre, The Infirmary, offering a simple, safe, and effective evidence Authors respond to editorial
sone before elective caesarean section at 1 Hippisley-Cox J, Coupland C, Logan R. Risk of adverse P R Stutchfield consultant paediatrician
gastrointestinal outcomes in patients taking cyclo- Conwy and Denbighshire NHS Trust, Glan Clwyd oxygenase-2 inhibitors or conventional non-steroidal anti- 50% in admission with respiratory distress inflammatory drugs: population based nested case-control for babies delivered at 37-39 weeks (BMJ analysis. BMJ 2005;331:1310-6. (3 December.) 2 Silverstein FE, Faich G, Goldstein GL. Simon LS, Pincus T, R Whitaker trial statistician
Whelton A, et al. Gastrointestinal toxicity with celecoxib vs admitted with respiratory distress, 19 con- Institute of Medical and Social Care Research, nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: a randomized controlled trial. Celecoxib Long-term Arthritis Safety five had respiratory distress syndrome, com- Study. JAMA 2000;284:1247-55.
pared with 10 babies with transient tachyp- 3 Jüni P, Rutjes AWS, Dieppe PA. Are selective COX 2 inhibitors superior to traditional non-steroidal anti- 1 Steer P J. Giving steroids before elective caesarean section.
inflammatory drugs? BMJ 2002;324:1287-8.
syndrome in the intervention group. Four- BMJ 2005;331:645-6. (24 September.) 4 Lu HL. Statistical reviewer briefing document for the 2 Crowley P, Roberts D, Dalziel S, Shaw BNJ. Antenatal corti- advisory committee. Available at: www.fda.gov/ohrms/ teen control babies required intensive care, costeroids to accelerate fetal lung maturation for women at dockets/ac/01/briefing/3677b1_04_stats.doc (accessed 8 risk of preterm birth. (Protocol) Cochrane Database Syst Rev 5 Freemantle N. How well does the evidence on pioglitazone requiring ventilation for two to five days, 3 Royal College of Obstetricians and Gynaecologists Scien- back up researchers’ claims for a reduction in macrovascu- with a 12-18 day stay, whereas only two in tific Advisory Committee. Antenatal corticosteroids to prevent lar events? BMJ 2005;331:836-8. (8 October.) the intervention group received intensive respiratory distress syndrome. 2nd ed. London: RCOG Press, 4 Dalziel SR, Liang A, Parag V, Rodgers A, Hardin JE. Blood pressure at six years of age after prenatal exposure to beta- Recessive disorders and
dence of transient tachypnoea with antena- methasone: follow up results of a randomised controlled trial. Pediatrics 2004;114:e373-7.
consanguineous marriage
tal betamethasone may result from an effect 5 Dalziel SR, Lim VK, Lambert A, McCarthy D, Parag V, on the expression of the epithelial channel Rodgers A, Harding JE. Antenatal exposure to betametha- sone: psychological functioning and health related quality of life 31 years after inclusion in randomised controlled Alison Shaw.1 The doubling of risk from 2% fluid secretion to fluid absorption. Fiori’s trial. BMJ 2005;331:665-8. (24 September.) to 4% with marriage of cousins is for all con- electronic response to our paper provides genital or genetic disorders, not recessive evidence for an additional factor, enhanced surfactant production. The presence of lung European subsidies and
fluid is likely to delay surfactant production, developing countries
12-fold increased risk of recessive disorders compliance seen in transient tachypnoea.
Editor—There is intuitive appeal in sug- 13 new recessive disorders per 1000 births (S Kowariwalla, J Benson, unpublished data, consequences of giving antenatal steroids by 2002). These figures are similar to reported reporting the outcome of follow-up studies compete in the international agricultural BMJ VOLUME 331 17 DECEMBER 2005 bmj.com
however, is how has failure to compete influ- enced the life of country farmers or citizens the vaccine would not generate a sufficient shift pattern changed from an on-call rota (29%) to a partial shift rota (70%). In all, 54% of senior house officers in ear, nose, and are rural dwellers—for example, over 70% of incentives: free scientific advice from the throat medicine cross covered other special- Nigeria’s population.2 Most are subsistence ties. Sixty three per cent thought that the Medicinal Products (EMEA) before registra- directive had reduced their training; 31% local markets. They have never traded inter- tion and at least six years’ market exclusivity nationally and may never do so. However, a teaching sessions from their seniors. The few urban dwellers are professional farmers quality, and efficacy are gathered efficiently these senior house officers were willing to nised farming. These are the few who have so that the product can be registered and opt out of the directive to safeguard care for deployed as quickly and cost effectively as productions never served the needs of the is to destroy the apprenticeship model of suggested changes in the European agricul- surgical training by separating senior house tural policy might improve the outlook for drug on the grounds of insufficient return officer from consultant, and to ensure that obesity and healthy nutrition in developing on investment. It is also the first potentially ear, nose, and throat patients are cared for, at countries, they are likely to widen inequali- widely deployable prophylactic vaccine to be least partly, by doctors or dentists who have ties in developing countries by favouring the had little or no training in the specialty. To already favoured mechanised farmers.
that lack of sufficient return on investment offers a potential route for a vaccine or drug being developed specifically for a disease of increased national political commitment to stimulating growth through sound national particularly important for prophylactic vac- Mohiemen Anwar senior house officer, ear, nose, and
social and economic policy. If, for example, cines where low disease incidence in the EU African leaders subsidised rural agriculture, growth in that sector, as well as eradication Shabina Irfan senior house officer, ear, nose, and throat
Niall Daly consultant, ear, nose, and throat medicine
have similar economics and so also require Furrat Amen specialist registrar, ear, nose, and throat
public funding to secure their development.
West Middlesex University Hospital, Isleworth, Kelechi E Nnoaham specialist registrar in public
same advantages to such projects. We hope North Oxfordshire Primary Care Trust, Adderbury, encourage researchers developing vaccines 1 Devey L. Will modernised medical careers produce a bet- ter surgeon? BMJ 2005;331:1346. (3 December.) route.
T Lang project manager, malaria and TB vaccines
1 Elinder LS. Obesity, hunger, and agriculture: the I can fly light aircraft, therefore
damaging role of subsidies. BMJ 2005;331:1333-6. (3 A V S Hill Wellcome Trust senior principal research
I can anaesthetise?
2 US Library of Congress. Nigeria. Available at http:// countrystudies.us/nigeria/34.htm. (accessed 2 Nov 2005).
H McShane Wellcome Trust senior clinical fellow
Centre for Clinical Vaccinology and Tropical Editor—I suspect that the reason that com- Medicine, Churchill Hospital, University of Oxford, mercial pilots and lorry or coach drivers are more regulated than doctors in respect of New TB vaccine granted
R Shah pharmaceutical consultant
fitness to perform their duties is that one orphan drug status
A Towse director
Editor—We report how orphan drug status C Pritchard health economist
pilots of light aircraft or gliders carrying is also relevant for global diseases most M Garau health economist
passengers. It is up to pilots on a day to day Office of Health Economics, London SW1A 2DY basis to judge their fitness to carry out the (TB), and 500 children die every day.1 The 1 Datta M, Swaminathan S. Global aspects of tuberculosis in same principle should apply to doctors.
children. Paediatr Respir Rev 2001;2:91-6.
2 McShane H, Pathan AA, Sander CR, Keating SM, Gilbert Gordon Pledger retired anaesthetist
SC, Huygen K, et al. Recombinant modified vaccinia virus variable protection against lung disease in Ankara expressing antigen 85A boosts BCG-primed and naturally acquired antimycobacterial immunity in humans.
Competing interests: GP is an ex-anaesthetist 3 European Commission Regulation No 141/2000 of the and flies light aircraft and gliders.
85A gene from Mycobacterium tuberculosis European parliament of the council of 16 December 1999.
1 Park GR. Am I safe to fly? Am I safe to anaesthetise? BMJ the immunogenicity and protective efficacy of BCG.2 This vaccine was recently desig- EWTD has negative impact on
training for surgeons
status because the disease is rare (incidence the future of training with the advent of the We select the letters for these pages from the rapid of less than five in 10 000 people in the responses posted on bmj.com within five days of and the modernising medical careers initia- publication of the article to which they refer. tive.1 We have just completed a national sur- Letters are thus an early selection of rapid responses cially viable.3 Active tuberculosis disease is vey of 100 senior house officers in ear, nose, on a particular topic. Readers should consult the rare in the EU, but as a prophylactic vaccine and throat medicine to assess the impact of website for the full list of responses and any authors' could potentially be given to everyone our replies, which usually arrive after our selection. BMJ VOLUME 331 17 DECEMBER 2005 bmj.com

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