- Email: [email protected]
That smile
CORRESPONDENCE
Recognising letters in systematic reviews Sir—It is ironic that The Lancet, of all journals, should publish a systematic review, the one by Sarah Capes and colleagues (March 4, p 773),1 that omits data published as letters. The Lancet has had a tradition of publishing research as letters, now formally codified as “research letters”. This means that research can be published quickly and succinctly. Systematic reviews that omit such publications will do harm in that authors will strive even more wholeheartedly to publish formal articles, thus expanding the amount we need to read. It also introduces the possibility of bias since I suspect negative results are more likely to be published as letters than as formal articles. I must declare an interest in this subject since I was one of a series of coauthors to accept your offer to publish our work as a short letter on the subject of Capes and colleagues’ paper in 1978.2 A C Burden Leicester General Hospital NHS Trust, Leicester LE5 4PW, UK 1
2
Capes SE, Hunt D, Malmberg K, Gerstein HC. Hypoglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000; 355: 773–78. Burden AC, Kupfer R, Davies MK, Pole JE. Blood sugar and prognosis in myocardial infarction. Lancet 1978; i: 820–21.
A vote for open refereeing Sir—During a long career I have refereed many papers and research applications in my specialised field of interest but anonymous refereeing has always left me uneasy. In an ideal world, science would be collaborative and not competitive but that is not so, hence the danger in exposing unpublished novel ideas and hypotheses. I have occasionally been able to recognise hostile referees of my own applications from their reports and wondered at their motives. In the interests of openness and fairness I would accept that I might have to defend my own decisions. Is there anyone reading this who has a view? Robert J Leeming 32 Wootton Green Lane, Balsall Common, Coventry CV7 7EZ, UK (e-mail: [email protected])
2170
That smile Sir—I shall never forget her smile. She smiled the day she had begun to walk again and that smile had been the most beautiful thing I had seen in Woldia, Ethopia. Unhindered by the translation difficulties between us, it spoke of the elation that freedom of pain and an erect posture can bring to one long denied either. She had arrived 6 weeks earlier from Menza on the Sudan—Ethiopian border 500 km west of us, bowed by a hip fixed in a disabling flexion deformity. A thin woman aged 24 years, her face had been drawn in pain by the sinuses around her hip joint. I learnt her story with difficulty. She spoke only the language of her Guzima tribe. Dr Wassie put my questions in Amharic to her companion who passed them on in Guzima. Her replies came back through the two translators: the hip had become painful 2 years earlier and was shortly followed by discharging sinuses in her flank, groin, buttock, and thigh. With the severe flexion deformity walking became impossible; she could not work in the fields and was barely able to look after her husband and young son. The nearest clinic 50 km away, run by Medecins sans Frontieres (MSF), arranged her referral to Woldia. Diagnosis had been easy, even with Woldia’s limited resources; she was HIV negative and radiographs showed the bone rarefaction of tuberculous arthritis. Surgery too had been simple and non complex; curettage and drainage of the sinuses and incision of the anterior capsule produced drainage of the joint and release of its contracture. Anti-tuberculosis therapy began and after 6 weeks of traction the hip, with its sinuses healed, was painless. I have long believed that access to surgery is a primary health need lying close behind the priorities of immunisation, clean water, and infant nutrition. Africa had taught me that without surgery untreated wounds can kill as can untreated infections of soft tissues, bones, and joints. Without access to surgery, intestinal obstruction is a death sentence, and obstructed labour leads always to the death of the child and often the mother too. Thus, I was spending some of my retirement with MSF in rural Ethiopia. Ethiopia has few surgeons and most of those are in Addis Ababa; in the rural areas there is one surgeon per million population and he is always working in suboptimal conditions where shortage of resources will limit
work. Add to this an almost roadless mountainous terrain—and northern Ethiopia becomes the region in which access to surgery is just about as poor as anywhere in the world. Which is why, 4 years ago, MSF began in Woldia a pilot project aimed at cheaply and quickly improving rural surgical services. In its small hospital they have trained recently qualified doctors to become emergency surgeons, competent in the management of all common surgical and obstetric emergencies. By September last year seven emergency surgeons had been trained. Teaching was provided by MSF surgeons, each like me, spending 2 months in Woldia providing practical and theoretical tuition. I had been pleased to join the project; the conscientious and enthusiastic trainees were, in their eighth month, already surprisingly mature in judgment and skilled in technique. That a small rural hospital could rapidly and inexpensively produce good surgeons vindicated the vision of those at MSF and that it was achieved in this remote area with very poor communications shows the universality of the project. But Woldia had other troubles which dwarfed those we were trying to address. Can any infrastructure development occur when famine is present? Should any development be attempted in countries whose scarce resources are being deployed in senseless, expensive, and bloody wars? I still ponder these questions and my memories of Kultum’s smile make their resolution no easier but I do know that without MSF’s surgical project there would have been no smile on her face. John Craven 20 Main Street, Nether Poppleton, York YO26 6HS, UK (e-mail: [email protected])
DEPARTMENT OF ERROR Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy—In this Article by P A Barber and colleagues (May 13, p 1670), there is an error in table 1. In the section on the ASPECTS score, the rows 聿7 and >7 were wrongly attributed. The correct numbers of patients in these categories should read as follows (the values given for sensitivity and specificity were correct): Test
Functional outcome
ASPECTS >7 (n=89)* ⭐7 (n=65)
Symptomatic haemorrhage
Independent Dependent Yes or dead
No
71 3
99 56
18 62
1 9
*n=91 for symptomatic haemorrhage analysis.
THE LANCET • Vol 355 • June 17, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
Recognising letters in systematic reviews Sir—It is ironic that The Lancet, of all journals, should publish a systematic review, the one by Sarah Capes and colleagues (March 4, p 773),1 that omits data published as letters. The Lancet has had a tradition of publishing research as letters, now formally codified as “research letters”. This means that research can be published quickly and succinctly. Systematic reviews that omit such publications will do harm in that authors will strive even more wholeheartedly to publish formal articles, thus expanding the amount we need to read. It also introduces the possibility of bias since I suspect negative results are more likely to be published as letters than as formal articles. I must declare an interest in this subject since I was one of a series of coauthors to accept your offer to publish our work as a short letter on the subject of Capes and colleagues’ paper in 1978.2 A C Burden Leicester General Hospital NHS Trust, Leicester LE5 4PW, UK 1
2
Capes SE, Hunt D, Malmberg K, Gerstein HC. Hypoglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000; 355: 773–78. Burden AC, Kupfer R, Davies MK, Pole JE. Blood sugar and prognosis in myocardial infarction. Lancet 1978; i: 820–21.
A vote for open refereeing Sir—During a long career I have refereed many papers and research applications in my specialised field of interest but anonymous refereeing has always left me uneasy. In an ideal world, science would be collaborative and not competitive but that is not so, hence the danger in exposing unpublished novel ideas and hypotheses. I have occasionally been able to recognise hostile referees of my own applications from their reports and wondered at their motives. In the interests of openness and fairness I would accept that I might have to defend my own decisions. Is there anyone reading this who has a view? Robert J Leeming 32 Wootton Green Lane, Balsall Common, Coventry CV7 7EZ, UK (e-mail: [email protected])
2170
That smile Sir—I shall never forget her smile. She smiled the day she had begun to walk again and that smile had been the most beautiful thing I had seen in Woldia, Ethopia. Unhindered by the translation difficulties between us, it spoke of the elation that freedom of pain and an erect posture can bring to one long denied either. She had arrived 6 weeks earlier from Menza on the Sudan—Ethiopian border 500 km west of us, bowed by a hip fixed in a disabling flexion deformity. A thin woman aged 24 years, her face had been drawn in pain by the sinuses around her hip joint. I learnt her story with difficulty. She spoke only the language of her Guzima tribe. Dr Wassie put my questions in Amharic to her companion who passed them on in Guzima. Her replies came back through the two translators: the hip had become painful 2 years earlier and was shortly followed by discharging sinuses in her flank, groin, buttock, and thigh. With the severe flexion deformity walking became impossible; she could not work in the fields and was barely able to look after her husband and young son. The nearest clinic 50 km away, run by Medecins sans Frontieres (MSF), arranged her referral to Woldia. Diagnosis had been easy, even with Woldia’s limited resources; she was HIV negative and radiographs showed the bone rarefaction of tuberculous arthritis. Surgery too had been simple and non complex; curettage and drainage of the sinuses and incision of the anterior capsule produced drainage of the joint and release of its contracture. Anti-tuberculosis therapy began and after 6 weeks of traction the hip, with its sinuses healed, was painless. I have long believed that access to surgery is a primary health need lying close behind the priorities of immunisation, clean water, and infant nutrition. Africa had taught me that without surgery untreated wounds can kill as can untreated infections of soft tissues, bones, and joints. Without access to surgery, intestinal obstruction is a death sentence, and obstructed labour leads always to the death of the child and often the mother too. Thus, I was spending some of my retirement with MSF in rural Ethiopia. Ethiopia has few surgeons and most of those are in Addis Ababa; in the rural areas there is one surgeon per million population and he is always working in suboptimal conditions where shortage of resources will limit
work. Add to this an almost roadless mountainous terrain—and northern Ethiopia becomes the region in which access to surgery is just about as poor as anywhere in the world. Which is why, 4 years ago, MSF began in Woldia a pilot project aimed at cheaply and quickly improving rural surgical services. In its small hospital they have trained recently qualified doctors to become emergency surgeons, competent in the management of all common surgical and obstetric emergencies. By September last year seven emergency surgeons had been trained. Teaching was provided by MSF surgeons, each like me, spending 2 months in Woldia providing practical and theoretical tuition. I had been pleased to join the project; the conscientious and enthusiastic trainees were, in their eighth month, already surprisingly mature in judgment and skilled in technique. That a small rural hospital could rapidly and inexpensively produce good surgeons vindicated the vision of those at MSF and that it was achieved in this remote area with very poor communications shows the universality of the project. But Woldia had other troubles which dwarfed those we were trying to address. Can any infrastructure development occur when famine is present? Should any development be attempted in countries whose scarce resources are being deployed in senseless, expensive, and bloody wars? I still ponder these questions and my memories of Kultum’s smile make their resolution no easier but I do know that without MSF’s surgical project there would have been no smile on her face. John Craven 20 Main Street, Nether Poppleton, York YO26 6HS, UK (e-mail: [email protected])
DEPARTMENT OF ERROR Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy—In this Article by P A Barber and colleagues (May 13, p 1670), there is an error in table 1. In the section on the ASPECTS score, the rows 聿7 and >7 were wrongly attributed. The correct numbers of patients in these categories should read as follows (the values given for sensitivity and specificity were correct): Test
Functional outcome
ASPECTS >7 (n=89)* ⭐7 (n=65)
Symptomatic haemorrhage
Independent Dependent Yes or dead
No
71 3
99 56
18 62
1 9
*n=91 for symptomatic haemorrhage analysis.
THE LANCET • Vol 355 • June 17, 2000
For personal use only. Not to be reproduced without permission of The Lancet.