- Email: [email protected]
Sharing honours when referencing
THE LANCET
Live broadcast of surgery through the Internet SIR—We have tested the feasibility of broadcasting surgical procedures live, via the Internet, in what seems to have been the first such use of the system. On August 29, 1996, a laparoscopic cholecystectomy in a 72-year-old woman was transmitted from our facility in Pontiac to Saddleback Memorial Medical Centers, Laguna Hills, California, via the Internet. On Sept 3, 1996, two laparoscopic tubal ligations on women aged 32 and 35 years were broadcast to the Hospital Santojanni, Buenos Aires, Argentina, during a concurrent medical meeting. Surgeons at the remote sites were given the opportunity to engage in dialogue with our broadcasting unit while they were receiving video and sound of the operations. Before the transmissions, the broadcasting and receiving parties arranged the exchange via e-mail of a special identification number or IP (Internet protocol) address. This number was randomly assigned, as occurs each time a computer logs on to the network. No other third party was able to receive images unless our broadcasting computer’s IP was revealed. This procedure was intended to deny access by undesired participants. Before surgery, all patients were briefed about the Internet, and informed about broadcast of the operations. A detailed consent form, was signed by the patients, whose identities were not disclosed. The hardware used to transmit all three procedures consisted of a Pentium 75 MHz personal computer, loaded with multimedia capabilities and 16 MB of RAM. A 28 800 baud modem was used to gain Internet access via the telephone. Video images were transmitted at one to two frames per s and displayed in a 320⳯240 pixels window to the remote sites. The loss of audio packets averaged 17% with a delay of 0·5–2·0 s. The broadcasting computer station was also able to receive video and sound from the distant computers, allowing complete interaction between both parties over the duration of each transmission session. The average broadcast duration was 1·5 h, and the cost of each transmission was equal to that of a local telephone call. We feel that the Internet is a truly viable means of delivering medical information and of including remotely situated surgeons in the intra-operative decision-making process. Medical images—eg, radiographs, ultrasound, and CT-scans—could also be broadcast to obtain an on-line consultation from experts at major medical centres.1 *Alejandro Gandsas, Mark Pleatman, Rodolfo Altrudi, George Migliarini, Yvan Silva Department of Surgery, North Oakland Medical Centers, Pontiac, MI 48341-1651, USA
1
Fisk NM, Vaughan JI, Wootton R, Harrison MR. Intercontinental fetal surgical consultation with image transmission via Internet. Lancet 1993; 341: 1601–02.
Sharing honours when referencing SIR—We feel that references are an important part of scientific publications. In accordance with the policy of each journal, they are numbered consecutively in the order of first mention in the text (Vancouver system), or by name and year of publication in the text and then listed in strictly alphabetical order at the end of the paper (Harvard system). There are also other minor variants such as round brackets, square brackets, and superscripts (when numbers), which are used in both systems.1,2 In the past few years there has been an increasing number of articles in which we can read “the first two authors contributed equally to this work” or “the order of the first
1314
two authors is indistinct”. This fact reflects a rise in the number of scientists whose contribution is equal, because multicentre efforts are sometimes necessary. We suggest that when two authors contributed equally to work, both should be referenced in the text, with the symbol & followed by et al with the Harvard system (eg, White & Black et al, 1996). Note that the symbol & is distinguishable from the word and, which is exclusively used when only two authors are cited and both names are given. For the widely used Vancouver system, the references could be: White W & Black B, Red R, Blue B, et al. We hope that this suggestion may be of use to editors so that scientists’ efforts will be effectively recognised. *Pablo Lapunzina, Virginia Soler Vigil Children’s Hospital, Darwin 1154 D1A, 1414 Buenos Aires, Argentina
1
2
International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. N Engl J Med 1991; 324: 424–28. Halsey MJ. References. In: Hall GM, ed. How to write a paper. London: BMJ Publishing Group, 1995: 42–51.
The politics of disclosure SIR—I congratulate The Lancet1 for drawing attention to possible so-called expert bias creeping into scientific discourse in favour of commercial bodies. It is human nature that we feel obliged to the hands that feed us, but whether consciously or subconsciously, it is not right that the expert doctors should allow this to creep in and bias their judgment, especially when what is at stake is the wellbeing of millions of patients and the clinical practice of thousands of colleagues. I suggest a few criteria on how to select unbiased experts. The same criteria ought to be considered and adopted by scientific committees who invite review lecturers in congresses, and by organisers of industry-sponsored satellite symposia. The first criterion is a statement of the obvious, that the expert selected should be knowledgeable and unbiased. It is being unbiased that is most difficult to detect. A necessary criterion, I propose, for a medical scientific expert to be accepted as being unbiased is whether the individual has ever published a negative result of a pharmaceutically sponsored study. Non-publication of negative results is well known, and is the reason why we should insist that, for instance, in any meta-analysis a published negative result carries five to ten times the weight of a corresponding positive result because it is that much more difficult to get a negative result published. Similarly, to give a fair presentation any expert who dares to state important negative aspects of a drug in a forum organised by the manufacturer of the drug should qualify for the unbiased club. The second criterion is that clinical interpretation of data, especially of clinical studies sponsored by commercial megadollars, should not be made by the investigators or their close collaborators, unless they have fulfilled my first criterion of stating negative results. They should confine themselves to presentation of factual data. Interpretation and suggested application of the results into clinical practice, especially of megatrials, should be made by independent informed practising clinicians. It is galling to see experienced clinicians being lectured about how to treat patients by epidemiologists or by laboratory-based professors who seldom or no longer treat patients. The third suggestion has resource implications and is difficult to implement. Similar to the yellow card system for adverse drug reactions, I propose that the UK General Medical Council or similar organisation should start a
Vol 348 • November 9, 1996
Live broadcast of surgery through the Internet SIR—We have tested the feasibility of broadcasting surgical procedures live, via the Internet, in what seems to have been the first such use of the system. On August 29, 1996, a laparoscopic cholecystectomy in a 72-year-old woman was transmitted from our facility in Pontiac to Saddleback Memorial Medical Centers, Laguna Hills, California, via the Internet. On Sept 3, 1996, two laparoscopic tubal ligations on women aged 32 and 35 years were broadcast to the Hospital Santojanni, Buenos Aires, Argentina, during a concurrent medical meeting. Surgeons at the remote sites were given the opportunity to engage in dialogue with our broadcasting unit while they were receiving video and sound of the operations. Before the transmissions, the broadcasting and receiving parties arranged the exchange via e-mail of a special identification number or IP (Internet protocol) address. This number was randomly assigned, as occurs each time a computer logs on to the network. No other third party was able to receive images unless our broadcasting computer’s IP was revealed. This procedure was intended to deny access by undesired participants. Before surgery, all patients were briefed about the Internet, and informed about broadcast of the operations. A detailed consent form, was signed by the patients, whose identities were not disclosed. The hardware used to transmit all three procedures consisted of a Pentium 75 MHz personal computer, loaded with multimedia capabilities and 16 MB of RAM. A 28 800 baud modem was used to gain Internet access via the telephone. Video images were transmitted at one to two frames per s and displayed in a 320⳯240 pixels window to the remote sites. The loss of audio packets averaged 17% with a delay of 0·5–2·0 s. The broadcasting computer station was also able to receive video and sound from the distant computers, allowing complete interaction between both parties over the duration of each transmission session. The average broadcast duration was 1·5 h, and the cost of each transmission was equal to that of a local telephone call. We feel that the Internet is a truly viable means of delivering medical information and of including remotely situated surgeons in the intra-operative decision-making process. Medical images—eg, radiographs, ultrasound, and CT-scans—could also be broadcast to obtain an on-line consultation from experts at major medical centres.1 *Alejandro Gandsas, Mark Pleatman, Rodolfo Altrudi, George Migliarini, Yvan Silva Department of Surgery, North Oakland Medical Centers, Pontiac, MI 48341-1651, USA
1
Fisk NM, Vaughan JI, Wootton R, Harrison MR. Intercontinental fetal surgical consultation with image transmission via Internet. Lancet 1993; 341: 1601–02.
Sharing honours when referencing SIR—We feel that references are an important part of scientific publications. In accordance with the policy of each journal, they are numbered consecutively in the order of first mention in the text (Vancouver system), or by name and year of publication in the text and then listed in strictly alphabetical order at the end of the paper (Harvard system). There are also other minor variants such as round brackets, square brackets, and superscripts (when numbers), which are used in both systems.1,2 In the past few years there has been an increasing number of articles in which we can read “the first two authors contributed equally to this work” or “the order of the first
1314
two authors is indistinct”. This fact reflects a rise in the number of scientists whose contribution is equal, because multicentre efforts are sometimes necessary. We suggest that when two authors contributed equally to work, both should be referenced in the text, with the symbol & followed by et al with the Harvard system (eg, White & Black et al, 1996). Note that the symbol & is distinguishable from the word and, which is exclusively used when only two authors are cited and both names are given. For the widely used Vancouver system, the references could be: White W & Black B, Red R, Blue B, et al. We hope that this suggestion may be of use to editors so that scientists’ efforts will be effectively recognised. *Pablo Lapunzina, Virginia Soler Vigil Children’s Hospital, Darwin 1154 D1A, 1414 Buenos Aires, Argentina
1
2
International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. N Engl J Med 1991; 324: 424–28. Halsey MJ. References. In: Hall GM, ed. How to write a paper. London: BMJ Publishing Group, 1995: 42–51.
The politics of disclosure SIR—I congratulate The Lancet1 for drawing attention to possible so-called expert bias creeping into scientific discourse in favour of commercial bodies. It is human nature that we feel obliged to the hands that feed us, but whether consciously or subconsciously, it is not right that the expert doctors should allow this to creep in and bias their judgment, especially when what is at stake is the wellbeing of millions of patients and the clinical practice of thousands of colleagues. I suggest a few criteria on how to select unbiased experts. The same criteria ought to be considered and adopted by scientific committees who invite review lecturers in congresses, and by organisers of industry-sponsored satellite symposia. The first criterion is a statement of the obvious, that the expert selected should be knowledgeable and unbiased. It is being unbiased that is most difficult to detect. A necessary criterion, I propose, for a medical scientific expert to be accepted as being unbiased is whether the individual has ever published a negative result of a pharmaceutically sponsored study. Non-publication of negative results is well known, and is the reason why we should insist that, for instance, in any meta-analysis a published negative result carries five to ten times the weight of a corresponding positive result because it is that much more difficult to get a negative result published. Similarly, to give a fair presentation any expert who dares to state important negative aspects of a drug in a forum organised by the manufacturer of the drug should qualify for the unbiased club. The second criterion is that clinical interpretation of data, especially of clinical studies sponsored by commercial megadollars, should not be made by the investigators or their close collaborators, unless they have fulfilled my first criterion of stating negative results. They should confine themselves to presentation of factual data. Interpretation and suggested application of the results into clinical practice, especially of megatrials, should be made by independent informed practising clinicians. It is galling to see experienced clinicians being lectured about how to treat patients by epidemiologists or by laboratory-based professors who seldom or no longer treat patients. The third suggestion has resource implications and is difficult to implement. Similar to the yellow card system for adverse drug reactions, I propose that the UK General Medical Council or similar organisation should start a
Vol 348 • November 9, 1996