- Email: [email protected]
Fertility preservation in women undergoing cancer treatment
CORRESPONDENCE
3
4
Mallon PW, Miller J, Cooper DA, Carr A. Prospective evaluation of the effects of antiretroviral therapy on body composition in HIV-1-infected men starting therapy. AIDS 2003; 17: 971–79. Moyle G, Sutinen J. Managing HIV lipoatrophy. Lancet 2004; 363: 412–14.
Authors’ reply Sir—Rodrigo Cavalcanti and colleagues note the increases in limb fat seen in both groups of our trial, which contrast with published data that show a relentless loss of limb fat over the first 3 years of therapy. Our participants had a much longer total duration of therapy than those of previous trials. All participants not receiving stavudine or zidovudine had received one or both drugs and had ceased these drugs before baseline. We have reported previously an 11% increase in limb fat mass over 24 weeks in those who switched from stavudine or zidovudine to abacavir, and stable fat mass in those who did not switch.1 Additional analysis of our rosiglitazone study now shows that there was a mean 0·36 kg (SD 0·62) increase in limb fat at week 48 for all participants not receiving stavudine or zidovudine, compared with a 0·02 kg (0·61) increase for all participants receiving one of these drugs (difference 0·34 kg [95% CI 0·10–0·60], p=0·01 at week 48; t test). The increase in limb fat mass in participants not receiving stavudine or zidovudine at baseline in our study is consistent between these two studies, as is the stable fat mass in those receiving either drug. We reiterate that the 0·14 kg increase from baseline seen with rosiglitazone (–0·04 kg relative to placebo) was unlikely to be clinically significant, being substantially less than the hoped-for 0·5 kg increase, and less than the 0·4 kg increase 6 months after the switch from stavudine or zidovudine to abacavir.2 Although this switch is not risk-free, long-term management of drug toxicity is probably best managed by removing the cause rather than the addition of drugs. Furthermore, we also noted the negative or inconclusive outcomes from pilot studies of rosiglitazone for HIV-1 lipoatrophy, the lipid toxicities of rosiglitazone in our study, and now note more recent data that show the inability of rosiglitazone to reverse proteaseinhibitor-induced lipoatrophy in a murine model.2 We agree, however, that one negative study should not dissuade other investigators from investigating
the potential of this class of therapy, particularly for groups that we did not study, including women, children, and patients receiving no thymidine nucleoside analogue and no protease inhibitor. Unfortunately, the latter group represents only a small proportion of HIV-1-infected adults receiving therapy. Our data suggest that rosiglitazone is unlikely to have any benefit and will be relevant to few patients with HIV-1 lipoatrophy. The key message of our study remains, namely that prevention of lipoatrophy requires starting with less toxic antiretroviral therapy. AC has received research grants or funding from Boehringer Ingelheim, Roche, and Schering-Plough, consultancy fees from Boehringer Ingelheim, Bristol-Myers Squibb, and GlaxoSmithKline, lecture sponsorships from Abbott, Boehringer Ingelheim, Bristol-Myers Squibb, and GlaxoSmithKline, and served on advisory boards for Bayer, Bristol-Myers Squibb, GlaxoSmithKline, and Roche. HW has no conflict of interest.
*Andrew Carr, Handan Wand, for the Rosey Investigators *St Vincent’s Hospital, Sydney, 2010 New South Wales, Australia (AC); and National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, 2010 New South Wales, Australia (HW) (e-mail: [email protected]) 1
2
Carr A, Workman C, Smith D, et al. Abacavir substitution for nucleoside analogs in patients with HIV lipoatrophy: a randomized trial. JAMA 2002; 288: 207–15. Goetzman ES, Tian L, Nagy TR, et al. HIV protease inhibitor ritonavir induces lipoatrophy in male mice. AIDS Res Hum Retrovirus 2003; 19: 1141–50.
Fertility preservation in women undergoing cancer treatment Sir—Kutluk Oktay and colleagues (Mar 13, p 837)1 report encouraging news for the 1·2 million women diagnosed with breast cancer worldwide each year, of whom 10–20% are of childbearing age. Ovarian cryopreservation is one of the options that we give to patients referred to us, and we have done the procedure for at least a dozen patients. However, before transplantation of cryopreserved ovarian tissue is incorporated into clinical practice, more knowledge and evidence is needed.2 For example, there is a chance of activation of dormant micrometastasis after transplantation of frozen thawed tissue, and therefore more reliable and sophisticated technology for detecting residual disease is needed. Additionally, the effects of receiving
supraphysiological concentrations of oestradiol after ovarian stimulation on the recurrence of hormone-sensitive cancer should be investigated, as should improved freeze-thaw techniques and minimisation of reperfusion ischaemic injury. In the published report, the young woman had eight cycles of in-vitro fertilisation, of which six were with hormonal stimulation with doses ranging from 3525 IU to 5850 IU. Only 20 oocytes were collected, of which two were fertilised (both from immature oocytes), one being abnormal and the other morphologically normal but resulting in no pregnancy after transfer. The procedure is therefore not very efficient. An alternative that we offer in our reproductive centre for women undergoing chemotherapy or radiotherapy for cancer is oocyte vitrification before gonadotoxic therapy. We retrieve immature oocytes from the ovary without stimulation,3 thereby avoiding the delay that stimulation would involve and the concern about aggravating a hormonesensitive disease. These immature oocytes are matured in vitro and vitrified,4 or if the woman has a partner, fertilised and the resulting embryos cryopreserved. As an example, a 33-year-old woman diagnosed with stage II breast cancer came to us on day 10 of her cycle regarding her options with respect to fertility preservation before she underwent chemotherapy the following week. She was counselled, and on day 12 of her cycle she underwent oocyte retrieval without hormonal stimulation. 19 immature oocytes were collected, and six matured in vitro the next day and 11 more the day after. We therefore managed to freeze 17 mature oocytes for her. The following week she underwent chemotherapy without delay. We therefore suggest that women diagnosed with cancer be offered various options of fertility preservation such as immature oocyte retrieval, invitro maturation of oocytes, and oocyte vitrification or embryo cryopreservation. Ovarian tissue cryopreservation should be an option offered in conjunction with the above. *G Durga Rao, R C Chian, W S Son, L Gilbert, S L Tan McGill Reproductive Center, 687 Pine Avenue West, Royal Victoria Hospital, Montreal, Quebec H3A 1A1, Canada (e-mail: [email protected]) 1
Oktay K, Buyuk E, Veeck L, et al. Embryo development after heterotopic
THE LANCET • Vol 363 • May 29, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
1829
CORRESPONDENCE
2
3
4
transplantation of cryopreserved ovarian tissue. Lancet 2004; 363: 837–40. Sale B, Demirci B, Franck M, Berthollet C, Lornage J. Long term follow up of cryopreserved hemi-ovary autografts in ewes: pregnancies, births, and histologic assessment. Fertil Steril 2003; 80: 172–77. Chian RC, Buckett WM, Tan SL. In vitro maturation of human oocytes. Reprod Biomed Online 2004; 8: 148–66. Chian RC, Kuwayama M, Tan L, Tan J, Kato O, Tan SL. High survival rates of bovine and human oocytes matured in vitro following vitrification. 49th Annual Meeting of the Canadian Fertility and Andrology Society 2003; abstract TP-23.
1
2
3
4
5
Sir—On the cover of The Lancet of Mar 13, in which our article1 was published, ovarian transplantaion was erroneously cited for fertility preservation in ovarian cancer. Presence of primary or metastic cancer in the ovary is a contraindication for this technique. Fortunately, ovarian transplantation can be used for most cancers of women of reproductive age because the risk of ovarian involvement is low or negligible in the absence of other systemic involvement. In the Commentary that accompanied our report,2 Johan Smitz argued that deaths have occurred after ovarian transplantation in sheep. However, these deaths were either due to prematurity or dystocia and no congenital abnormalities were identified in these and other studies.3 Ovarian transplantation is an experimental procedure; however, it is not clear whether a prospective randomised trial of transplantation versus observation would be feasible since gonadotoxicity of chemotherapeutics is already known. In-vitro maturation could become an option, especially in those with ovarian involvement, but epigenetic changes are of concern since lengthy and complex culture techniques are needed with human primordial follicles. An ideal strategy would be chemoprevention, but there is no effective agent to prevent chemotherapyinduced gonadotoxicity. Ovarian suppression by analogues of gonadotropin-releasing hormone fails to protect gonads, but antiapoptotic agents4 could have potential for this purpose. Data have indicated the presence of germ stem cells in the rodent ovaries;5 ovarian cryopreservation might also preserve the ability of these cells to replenish ovarian reserve. *Kutluk Oktay, Erkan Buyuk Center for Reproductive Medicine and Infertility, Weill Medical College of Cornell University, 505 East 70th Street, Suite HT-300, New York, NY 10021, USA (e-mail: [email protected])
1830
Oktay K, Buyuk E, Veeck L, et al. Embryo development after heterotopic transplantation of cryopreserved ovarian tissue. Lancet 2004; 363: 837–40. Smitz J. Oocyte development competence after heterotopic transplantation of cryopreserved ovarian tissue. Lancet 2004; 363: 832–33. Wang X, Chen H, Yin H, Kim SS, Lin Tan S, Gosden RG. Fertility after intact ovary transplantation. Nature 2002; 415: 385. Morita Y, Perez GI, Paris F, et al. Oocyte apoptosis is suppressed by disruption of the acid sphingomyelinase gene or by sphingosine-1-phosphate therapy. Nat Med 2000; 6: 1109–14. Johnson J, Canning J, Kaneko T, Pru JK, Tilly JL. Germline stem cells and follicular renewal in the postnatal mammalian ovary. Nature 2004; 428: 145–50.
Bridging schools of public health between Iran and the USA Sir—In their 2002 Commentary, Stuart Spencer and David Sharp1 complimented the quality of the existing standards of medical education in Iran and argued that further development of medical education in Iran needs to be encouraged and supported. Here, we demonstrate the feasibility of bridging public health education between Iran and the USA. The Iranian Federation of Public Health Schools has 18 schools in the country, of which two are epidemiology training centres. Iran publishes 76 medical journals,2 of which six are in English, but none is recognised by the world’s major indexing and citation organisations.1 This situation leads to poor information sharing in the area of medicine and public health between Iran and the rest of the world. The tragic events surrounding the Bam earthquake in 2003 demonstrated the importance of sharing public health information in Iran and worldwide for preventing excessive morbidity and mortality after natural and manmade disasters. One of us (AA) recently presented a lecture dedicated to the Bam earthquake to students on the chronic disease epidemiology course at the University of Pittsburgh Graduate School of Public Health. The audio component of the lecture was delivered over the telephone from Tehran University of Medical Sciences, and a teaching assistant in Pittsburgh operated the PowerPoint slides. The US students had a chance to ask questions about the earthquake. The interaction with Iran greatly enhanced the students’ learning
experience and stimulated their understanding of earthquake prevention and Iran itself. To our knowledge, this was one of the first efforts to conduct a distance education lecture between an Iranian instructor and US students. The costeffectiveness of this approach was remarkable: instead of spending thousands of dollars to bring a faculty member to Pittsburgh, only US$50 were spent on a long-distance phone call to Tehran. There is a growing need for better information exchange mechanisms in the area of public health internationally. Supercourse, the online library of lectures funded by the US National Library of Medicine (http://www.pitt.edu/~super1), offers one way to exchange prevention information. The Supercourse network has more than 13 000 participants in 150 countries who worked together to establish a library of more than 1700 lectures. The importance of establishing Supercourse networks in the Islamic world has already been discussed.3 Distance education with Supercourse, PowerPoint, and the telephone offers a very cost-effective mechanism for the globalisation of classroom education. The Bam lecture (http://www.pitt.edu/ ~super1/lecture/lec15221/index.htm) may be used by anyone. In addition, AA ([email protected]) is available to present the lecture to interested parties using the teaching technology discussed above. We thanks Eugene Shubnikov (Novosibirsk, Russia) for his help in preparation of the Bam lecture.
Ali Ardalan, *Faina Linkov, Kourosh Holakouie Naieni, Ronald E LaPorte, Eric Noji Department of Epidemiology and Biostatistics, School of Public Health and Institute of Public Health Research, Tehran University of Medical Sciences, Iran (AA, KHN); *Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA (FL, REL); and Centers for Disease Control and Prevention, Atlanta, GA, USA (EN) (e-mail: [email protected]) 1 2
3
Spencer S, Sharp D. Bridges to Iran. Lancet 2002; 359: 1960. Latest approved list of journals by Medical Journal Commission, Ministry of Health and Medical Education. http://www.hbi.ir/ persian/fa_hbi/fa-commision/contact.htm (accessed Apr 10, 2004). Husseini A, Saad R, LaPorte RE. Health Supercourse to end Arab isolation. Nature 2002; 417: 788.
DEPARTMENT OF ERROR Leinster S. Assessment in medical training. Lancet 2003; 362: 1770—In the fourth paragraph of this Education and practice article (Nov 22), the penultimate sentence should read: “There is often a trade off between face validity and reliability”.
THE LANCET • Vol 363 • May 29, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
3
4
Mallon PW, Miller J, Cooper DA, Carr A. Prospective evaluation of the effects of antiretroviral therapy on body composition in HIV-1-infected men starting therapy. AIDS 2003; 17: 971–79. Moyle G, Sutinen J. Managing HIV lipoatrophy. Lancet 2004; 363: 412–14.
Authors’ reply Sir—Rodrigo Cavalcanti and colleagues note the increases in limb fat seen in both groups of our trial, which contrast with published data that show a relentless loss of limb fat over the first 3 years of therapy. Our participants had a much longer total duration of therapy than those of previous trials. All participants not receiving stavudine or zidovudine had received one or both drugs and had ceased these drugs before baseline. We have reported previously an 11% increase in limb fat mass over 24 weeks in those who switched from stavudine or zidovudine to abacavir, and stable fat mass in those who did not switch.1 Additional analysis of our rosiglitazone study now shows that there was a mean 0·36 kg (SD 0·62) increase in limb fat at week 48 for all participants not receiving stavudine or zidovudine, compared with a 0·02 kg (0·61) increase for all participants receiving one of these drugs (difference 0·34 kg [95% CI 0·10–0·60], p=0·01 at week 48; t test). The increase in limb fat mass in participants not receiving stavudine or zidovudine at baseline in our study is consistent between these two studies, as is the stable fat mass in those receiving either drug. We reiterate that the 0·14 kg increase from baseline seen with rosiglitazone (–0·04 kg relative to placebo) was unlikely to be clinically significant, being substantially less than the hoped-for 0·5 kg increase, and less than the 0·4 kg increase 6 months after the switch from stavudine or zidovudine to abacavir.2 Although this switch is not risk-free, long-term management of drug toxicity is probably best managed by removing the cause rather than the addition of drugs. Furthermore, we also noted the negative or inconclusive outcomes from pilot studies of rosiglitazone for HIV-1 lipoatrophy, the lipid toxicities of rosiglitazone in our study, and now note more recent data that show the inability of rosiglitazone to reverse proteaseinhibitor-induced lipoatrophy in a murine model.2 We agree, however, that one negative study should not dissuade other investigators from investigating
the potential of this class of therapy, particularly for groups that we did not study, including women, children, and patients receiving no thymidine nucleoside analogue and no protease inhibitor. Unfortunately, the latter group represents only a small proportion of HIV-1-infected adults receiving therapy. Our data suggest that rosiglitazone is unlikely to have any benefit and will be relevant to few patients with HIV-1 lipoatrophy. The key message of our study remains, namely that prevention of lipoatrophy requires starting with less toxic antiretroviral therapy. AC has received research grants or funding from Boehringer Ingelheim, Roche, and Schering-Plough, consultancy fees from Boehringer Ingelheim, Bristol-Myers Squibb, and GlaxoSmithKline, lecture sponsorships from Abbott, Boehringer Ingelheim, Bristol-Myers Squibb, and GlaxoSmithKline, and served on advisory boards for Bayer, Bristol-Myers Squibb, GlaxoSmithKline, and Roche. HW has no conflict of interest.
*Andrew Carr, Handan Wand, for the Rosey Investigators *St Vincent’s Hospital, Sydney, 2010 New South Wales, Australia (AC); and National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, 2010 New South Wales, Australia (HW) (e-mail: [email protected]) 1
2
Carr A, Workman C, Smith D, et al. Abacavir substitution for nucleoside analogs in patients with HIV lipoatrophy: a randomized trial. JAMA 2002; 288: 207–15. Goetzman ES, Tian L, Nagy TR, et al. HIV protease inhibitor ritonavir induces lipoatrophy in male mice. AIDS Res Hum Retrovirus 2003; 19: 1141–50.
Fertility preservation in women undergoing cancer treatment Sir—Kutluk Oktay and colleagues (Mar 13, p 837)1 report encouraging news for the 1·2 million women diagnosed with breast cancer worldwide each year, of whom 10–20% are of childbearing age. Ovarian cryopreservation is one of the options that we give to patients referred to us, and we have done the procedure for at least a dozen patients. However, before transplantation of cryopreserved ovarian tissue is incorporated into clinical practice, more knowledge and evidence is needed.2 For example, there is a chance of activation of dormant micrometastasis after transplantation of frozen thawed tissue, and therefore more reliable and sophisticated technology for detecting residual disease is needed. Additionally, the effects of receiving
supraphysiological concentrations of oestradiol after ovarian stimulation on the recurrence of hormone-sensitive cancer should be investigated, as should improved freeze-thaw techniques and minimisation of reperfusion ischaemic injury. In the published report, the young woman had eight cycles of in-vitro fertilisation, of which six were with hormonal stimulation with doses ranging from 3525 IU to 5850 IU. Only 20 oocytes were collected, of which two were fertilised (both from immature oocytes), one being abnormal and the other morphologically normal but resulting in no pregnancy after transfer. The procedure is therefore not very efficient. An alternative that we offer in our reproductive centre for women undergoing chemotherapy or radiotherapy for cancer is oocyte vitrification before gonadotoxic therapy. We retrieve immature oocytes from the ovary without stimulation,3 thereby avoiding the delay that stimulation would involve and the concern about aggravating a hormonesensitive disease. These immature oocytes are matured in vitro and vitrified,4 or if the woman has a partner, fertilised and the resulting embryos cryopreserved. As an example, a 33-year-old woman diagnosed with stage II breast cancer came to us on day 10 of her cycle regarding her options with respect to fertility preservation before she underwent chemotherapy the following week. She was counselled, and on day 12 of her cycle she underwent oocyte retrieval without hormonal stimulation. 19 immature oocytes were collected, and six matured in vitro the next day and 11 more the day after. We therefore managed to freeze 17 mature oocytes for her. The following week she underwent chemotherapy without delay. We therefore suggest that women diagnosed with cancer be offered various options of fertility preservation such as immature oocyte retrieval, invitro maturation of oocytes, and oocyte vitrification or embryo cryopreservation. Ovarian tissue cryopreservation should be an option offered in conjunction with the above. *G Durga Rao, R C Chian, W S Son, L Gilbert, S L Tan McGill Reproductive Center, 687 Pine Avenue West, Royal Victoria Hospital, Montreal, Quebec H3A 1A1, Canada (e-mail: [email protected]) 1
Oktay K, Buyuk E, Veeck L, et al. Embryo development after heterotopic
THE LANCET • Vol 363 • May 29, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
1829
CORRESPONDENCE
2
3
4
transplantation of cryopreserved ovarian tissue. Lancet 2004; 363: 837–40. Sale B, Demirci B, Franck M, Berthollet C, Lornage J. Long term follow up of cryopreserved hemi-ovary autografts in ewes: pregnancies, births, and histologic assessment. Fertil Steril 2003; 80: 172–77. Chian RC, Buckett WM, Tan SL. In vitro maturation of human oocytes. Reprod Biomed Online 2004; 8: 148–66. Chian RC, Kuwayama M, Tan L, Tan J, Kato O, Tan SL. High survival rates of bovine and human oocytes matured in vitro following vitrification. 49th Annual Meeting of the Canadian Fertility and Andrology Society 2003; abstract TP-23.
1
2
3
4
5
Sir—On the cover of The Lancet of Mar 13, in which our article1 was published, ovarian transplantaion was erroneously cited for fertility preservation in ovarian cancer. Presence of primary or metastic cancer in the ovary is a contraindication for this technique. Fortunately, ovarian transplantation can be used for most cancers of women of reproductive age because the risk of ovarian involvement is low or negligible in the absence of other systemic involvement. In the Commentary that accompanied our report,2 Johan Smitz argued that deaths have occurred after ovarian transplantation in sheep. However, these deaths were either due to prematurity or dystocia and no congenital abnormalities were identified in these and other studies.3 Ovarian transplantation is an experimental procedure; however, it is not clear whether a prospective randomised trial of transplantation versus observation would be feasible since gonadotoxicity of chemotherapeutics is already known. In-vitro maturation could become an option, especially in those with ovarian involvement, but epigenetic changes are of concern since lengthy and complex culture techniques are needed with human primordial follicles. An ideal strategy would be chemoprevention, but there is no effective agent to prevent chemotherapyinduced gonadotoxicity. Ovarian suppression by analogues of gonadotropin-releasing hormone fails to protect gonads, but antiapoptotic agents4 could have potential for this purpose. Data have indicated the presence of germ stem cells in the rodent ovaries;5 ovarian cryopreservation might also preserve the ability of these cells to replenish ovarian reserve. *Kutluk Oktay, Erkan Buyuk Center for Reproductive Medicine and Infertility, Weill Medical College of Cornell University, 505 East 70th Street, Suite HT-300, New York, NY 10021, USA (e-mail: [email protected])
1830
Oktay K, Buyuk E, Veeck L, et al. Embryo development after heterotopic transplantation of cryopreserved ovarian tissue. Lancet 2004; 363: 837–40. Smitz J. Oocyte development competence after heterotopic transplantation of cryopreserved ovarian tissue. Lancet 2004; 363: 832–33. Wang X, Chen H, Yin H, Kim SS, Lin Tan S, Gosden RG. Fertility after intact ovary transplantation. Nature 2002; 415: 385. Morita Y, Perez GI, Paris F, et al. Oocyte apoptosis is suppressed by disruption of the acid sphingomyelinase gene or by sphingosine-1-phosphate therapy. Nat Med 2000; 6: 1109–14. Johnson J, Canning J, Kaneko T, Pru JK, Tilly JL. Germline stem cells and follicular renewal in the postnatal mammalian ovary. Nature 2004; 428: 145–50.
Bridging schools of public health between Iran and the USA Sir—In their 2002 Commentary, Stuart Spencer and David Sharp1 complimented the quality of the existing standards of medical education in Iran and argued that further development of medical education in Iran needs to be encouraged and supported. Here, we demonstrate the feasibility of bridging public health education between Iran and the USA. The Iranian Federation of Public Health Schools has 18 schools in the country, of which two are epidemiology training centres. Iran publishes 76 medical journals,2 of which six are in English, but none is recognised by the world’s major indexing and citation organisations.1 This situation leads to poor information sharing in the area of medicine and public health between Iran and the rest of the world. The tragic events surrounding the Bam earthquake in 2003 demonstrated the importance of sharing public health information in Iran and worldwide for preventing excessive morbidity and mortality after natural and manmade disasters. One of us (AA) recently presented a lecture dedicated to the Bam earthquake to students on the chronic disease epidemiology course at the University of Pittsburgh Graduate School of Public Health. The audio component of the lecture was delivered over the telephone from Tehran University of Medical Sciences, and a teaching assistant in Pittsburgh operated the PowerPoint slides. The US students had a chance to ask questions about the earthquake. The interaction with Iran greatly enhanced the students’ learning
experience and stimulated their understanding of earthquake prevention and Iran itself. To our knowledge, this was one of the first efforts to conduct a distance education lecture between an Iranian instructor and US students. The costeffectiveness of this approach was remarkable: instead of spending thousands of dollars to bring a faculty member to Pittsburgh, only US$50 were spent on a long-distance phone call to Tehran. There is a growing need for better information exchange mechanisms in the area of public health internationally. Supercourse, the online library of lectures funded by the US National Library of Medicine (http://www.pitt.edu/~super1), offers one way to exchange prevention information. The Supercourse network has more than 13 000 participants in 150 countries who worked together to establish a library of more than 1700 lectures. The importance of establishing Supercourse networks in the Islamic world has already been discussed.3 Distance education with Supercourse, PowerPoint, and the telephone offers a very cost-effective mechanism for the globalisation of classroom education. The Bam lecture (http://www.pitt.edu/ ~super1/lecture/lec15221/index.htm) may be used by anyone. In addition, AA ([email protected]) is available to present the lecture to interested parties using the teaching technology discussed above. We thanks Eugene Shubnikov (Novosibirsk, Russia) for his help in preparation of the Bam lecture.
Ali Ardalan, *Faina Linkov, Kourosh Holakouie Naieni, Ronald E LaPorte, Eric Noji Department of Epidemiology and Biostatistics, School of Public Health and Institute of Public Health Research, Tehran University of Medical Sciences, Iran (AA, KHN); *Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA (FL, REL); and Centers for Disease Control and Prevention, Atlanta, GA, USA (EN) (e-mail: [email protected]) 1 2
3
Spencer S, Sharp D. Bridges to Iran. Lancet 2002; 359: 1960. Latest approved list of journals by Medical Journal Commission, Ministry of Health and Medical Education. http://www.hbi.ir/ persian/fa_hbi/fa-commision/contact.htm (accessed Apr 10, 2004). Husseini A, Saad R, LaPorte RE. Health Supercourse to end Arab isolation. Nature 2002; 417: 788.
DEPARTMENT OF ERROR Leinster S. Assessment in medical training. Lancet 2003; 362: 1770—In the fourth paragraph of this Education and practice article (Nov 22), the penultimate sentence should read: “There is often a trade off between face validity and reliability”.
THE LANCET • Vol 363 • May 29, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.