Page 19 - portfolio_Fabry_2019_grafika_web

January 2015
Vol 26, No 232 ISSN 1106-5028
Thinking about Why are we failing
the burden of young people
treatment with ADHD?
A bill of rights Rules tighten on
for patients and use of electronic
families cigarettes

BMJ Middle East

Vol 26 No 232 January 2015 ISSN 1106 -5028

British Medical Association

EDITORIALS
Meniere’s disease thebmj.com
GU
Ж Research: Risk of preterm birth after treatment for cervical intraepithelial neoplasia among women attending colposcopy in England (BMJ
2012;345:e5174)
Ж Research: Risk of cervical cancer after completed post-treatment follow-up of cervical intraepithelial neoplasia (BMJ 2012;345:e6855)
EDITORIALS
THIS WEEK
ЖResearch: Cost effectiveness of human papillomavirus test of cure after treatment for cervical intraepithelial neoplasia in England (BMJ 2012;345:e7086)
thebmj.com THIS WEEK
Recognition and initial management of ovarian cancer: summary of NICE guidance (BMJ 2011;342:d2073)
Ж
THIS WEEK Safety of modern treatment for cervical pre-cancer
Ж
Simple ultrasound rules to distinguish between benign and malignant adnexal masses before surgery (BMJ 2010;341:c6839)
Ж
Easily missed? Ovarian cancer (BMJ 2009;339:b4650)
THIS MONTH
THIS WEEK
Most women can be reassured about future pregnancies
Articles appearing in this print journal have already been published Predicting ovarian malignancy
on thebmj.com, and the print version may have been shortened Articles appearing in this print journal have already been published EDUCATION PRACTICE
on thebmj.com, and the print version may have been shortened
Björn Strander director, Cervical Screening, Regional extensive resection or destruction of cervical tissue
The latest model looks promising as a triage tool for women with ovarian masses
Cancer Centre, West Sweden; consultant, Department and may, in experienced hands, be non-existent.
deviated nasal septum will be firm. Nasal airflow can be
of Obstetrics and Gynaecology, Institute of Clinical thebmj.com Two other clinical lessons can be learnt from
in a tertiary centre by an experienced gynaeco-
Ioannis Biliatis subspecialty fellow, BartsHealth NHS
Previous articles in this
assessed easily and simply using a metal tongue depres-
Trust, Gynaecological Oncology Centre, London, UK
Science, Sahlgrenska Academy, University of Gothenburg, logical oncologist it could spare the need for a sor or spoon. This is held beneath the anterior nares to
series
Castanon and colleagues’ study. Firstly, with
2
giannisbil@hotmail.com
Ж
Perthes’ disease
Göteborg, Sweden second staging procedure. 6 look for the presence of two spots of condensation.
Nithya Ratnavelu subspecialty fellow, Gateshead NHS Trust,
The model also discriminated well between
(BMJ 2014;349:g5584)
proper supervision and follow-up, excessive treat-
Northern Gynaecological Oncology Centre, Gateshead, UK
bjorn.strander@rccvast.se Ж benign and borderline tumours. Even though How is a nasal septal haematoma managed?
Kawasaki disease
Nasal septal haematomas need to be drained immedi-
Jan Adolfsson associate professor of urology, SBU-Swedish (BMJ 2014;349:g5336) ment margins may not be necessary. If residual
some borderline tumours could be managed
Following the Calman-Hine report in 1995, the
ately and intravenous antibiotics started to prevent nasal
Ж
Postnatal depression
United Kingdom decided to establish a central-
CIN is diagnosed, the risk of preterm delivery is
Council on Health Technology Assessment, Stockholm, locally, most should be treated in tertiary centres. deformity and serious infective complications. This can
This is because women with such tumours usually
ised healthcare system for the management of
be done using local anaesthetic in adults, but in children
Sweden; Department of Clinical Science, Intervention and Ж present at a younger age and should be consulted a general anaesthetic is usually required. Necrotic carti-
Motor neurone disease
apparently not increased by repeat treatment
all gynaecological and other malignancies. 1
(BMJ 2014;349:g4052)
p70
p30
p
Technology, Karolinska Institutet, Stockholm, Sweden p25 CAMAL, ISM/SPL (BMJ 2014;349:g4500) SPL in itself, but rather by the combined sizes of all
p
lage should be excised and, if infected, the area should
p
p22
p
This movement introduced tertiary centres in
carefully about management options that include
Copper deficiency
Ж
be thoroughly irrigated and pus sent for culture and sen-
fertility preserving surgery.
an attempt to improve the survival outcomes of
(BMJ 2014;348:g3691)
p¤ p› patients with ovarian cancer by providing the Diagnostic accuracy is imperative p¤¤ Inevitably ADNEX has limitations. One poten- resections. However, we should also bear in mind
sitivity testing. To prevent re-accumulation, a corrugated
p¤
“Will this affect my ability to become pregnant?”
drain can be sutured into the haematoma cavity, drain-
Size of resection matters
best available treatment from specialist oncology
tial problem is the level of expertise required by
age holes can be created and nasal packing inserted, or
might be the most common question asked by
data suggesting an increased risk of invasive
23 Thienopyridines and acute Fig 2 | Nasal septal haematoma: a red, fluctuant swelling
surgeons and nurses in a secure multidisciplinary EDITORIALS
NEWS
RESEARCH
The data were analysed and correlated with ultrasonographers for the model to be reliable and
EDUCATION
NEWS
EDITORIALS
3 RESEARCH
quilting sutures can be fashioned. Nasal packs can be
coronary syndrome without that obstructs the nasal cavity bilaterally. With
environment. Although no randomised trial has
women recommended treatment for cervical with treatment. This contrasts with studies using cancer after long term follow-up as treatment of
left in place for 2-3 days. The patient will usually require
final histology to develop a prediction model for reproducible. Women in the International Ovarian
Insiders say NICE is being told
1
permission from M Kotb (www.drmkotb.com/EN/index.php?pa
compared the results of this new scheme, many the discrimination of ovarian tumours. The meth- ST elevation
CLINICAL REVIEW
broad spectrum antibiotics for at least one week postop-
7 Future shape of general
26 Anticoagulant therapy
Tumour Analysis (IOTA) cohorts, who were used
6 EDITOR’S PICK
7
11 Evaluating the risk of ovarian ge=students&case=&A=2&B=6&C=0)
intraepithelial neoplasia (CIN). Attempting to population based external controls or internal CIN has become less radical over time. Treated
It’s time to rethink an ageing
eratively and might benefit from a short course of intra-
to favour industry more
13 Less than half of people
during primary percutaneous
practice in England
odology was sound and the model was temporally to develop and validate ADNEX were examined by
Nabil T. Nassar
population cohort and retrospective studies have
NEWS EDITORIALS answer this question, among others, two linked EDUCATION cancer before surgery proportion of them are thought to be related to previous venous treatment.
26 The diagnosis and
RESEARCH
strategy

women need careful long term follow-up, a need
controls when pregnancies before and after treat-
WHO will review its response to
undergoing leg amputation
Poorly planned policies could
coronary intervention for
using the ADNEX model
experienced sonographers with specialist exper-
management of hiatus hernia
19 Thinking about the burden of
get good care, a study shows
Ebola once the outbreak is under
officer, Princess of Wales Hospital, Bridgend, for his initial help with this
3 4 tise. It is known that expert (level III) sonogra-
can occur as early as three days after the formation of
a team, compared with management by general tion between the most important pairs of ovarian
1 MPs call for review of NHS 7 NHS England’s five year plan shown that the management of women by such validated. The results showed excellent discrimina- Jeffrey J Rade septal haematomas. 4 5 Infection of a septal haematoma Acknowledgment: We would like to thank Richard Thomas, senior house
to di†erentiate between
papers cover a range of potential harms to CLINICAL REVIEW

acute myocardial infarction: a
hasten its decline

Sabine Roman and P eter J
Ü RESEARCH, p 33
ment are compared. There are thus indications that might increase with smaller resections. Sec-

11 Reappraisal of thienopyridine treatment
article and Zareena Jedaar, emergency medicine consultant, University
benign, borderline, early and a haematoma, and it can intensify subsequent septal
control
Stephen Gillam
metaanalysis of randomized

More than 100 cancer
health checks Full realisation of the vision will gynaecologists or surgeons, results in better sur- tumours—benign versus all types of cancer (area phers are performing better than routine (level II) Hospital of Wales, Cardiff, for her feedback on the manuscript from a

Should it be regarded as an
Kahrilas
vival outcomes. 2 3 pretreatment in patients
primary care perspective.
24
advanced stage invasive, and necrosis and resorption owing to bacterial proteolytic
human reproduction associated with treatments Management of arteriovenous
that women with CIN have something in common ondly, a superficial but wide excision also seems
under the receiver operating characteristic curve ultrasonographers at identifying malignant ovar-
24 Antibiotics, renin-angiotensin

experts attack Saatchi bill as

2 Surgeon who swore at
trials in the era of stents and

indicator of the quality of care?

 PERSONAL VIEW p
Follow link from online
Scotland to bring in tougher cost an extra £8bn However, for such a costly system to work effi- 0.94), as well as between benign and stage 1 can system blockers, and sudden enzymes. 5 A nasal septal abscess is a serious medical con- Contributors: LNS revised and edited the initial draft of the article, updated
ian tumours (sensitivity 88% v 40%). 7 Van Calster
with non-ST elevation
- secondary metastatic tumours:

potentially dangerous
colleagues is suspended
it with up to date evidence, and prepared and submitted final article. SEJF

fistulas
P2Y 12 inhibitors
article for CPD/CME hour
dition. It requires urgent surgical management because it
to increase the risk of preterm delivery.
that increases the preterm delivery risk, regard-
1 2
Frances S Mair and Carl R May
8 Predicting ovarian malignancy
death
Sripal Bangalore et al
drink driving law Gareth Iacobucci for CIN, including fertility. cer (0.92) and benign versus borderline tumours and colleagues believe that level II sonographers had the initial idea for the article and prepared initial draft, performed the
ciently, referrals of patients from general practition-
prospective multicentre
Kyrgiou and colleagues’ meta-analysis of 15 Abul Siddiky et al
can result in substantial morbidity and mortality. Poten-

initial literature search, and was involved in preparation of final article. PJC
Living with a smoker is

16 Cases of assisted dying must
less of treatment. Could human papillomavirus
Is there a cause for concern?
ers and secondary care to the tertiary centres need (0.85). The discrimination between borderline will be expert enough to comply with the strict
The latest model looks
acute coronary syndrome: a 20 Quality in primary care
diagnostic study
systematic review and meta-
equivalent to living in a heavily
28 Variation in doctors’
2 Doctor who claimed sick leave 8 Milk and mortality cohort studies found no evidence that large loop Follow link from online tially life threatening complications—such as meningitis, provided senior, consultant, supervision by analysing the work and helping
Individual doctors matter, and
to write early drafts and revisions of the manuscripts. LNS and SEJF are the
to be well designed. The key concept in this setting and stage 1 ovarian cancer and between advanced ultrasonographic techniques, terms, and defini-
be approved by a judge,
PRACTICE
Mahyar Etminan and James M

promising as a triage tool for
International Ovarian Tumour intracranial abscesses, orbital cellulitis, and cavernous

guarantors.
communication skills
infection itself contribute to the development of Excess second trimester miscarriages
polluted city, say researchers
pay for performance may reduce
sinus thrombosis—can develop because of the venous
analysis
peers say
women with ovarian masses
while working is struck o Genetic studies could help us is accuracy. Patients need to be referred as accu- stage and metastatic ovarian cancer was fair. Brophy tions set out by the IOTA team. This will, however, Competing interests: We have read and understood BMJ policy on

Analysis (IOTA) group
article for CPD/CME hour
within and between general
excision of the transformational zone or any other
preterm labour? Studies are needed to explore the Kyrgiou and colleagues report an excess risk of
declaration of interests and declare the following interests: none.
THERAPEUTICS It therefore requires
5
3 M ore than 1700 FGM cases seen
need to be assessed and audited in the future.
hospital admissions
drainage of the nasal septum. 5 14
Ioannis Biliatis and Nithya
Anne Bellemain-Appaix et al

MPs demand action on GP
Project aims to halve stillbirths interpret a biologically plausible rately as possible to avoid benign tumours being The current referral policy in the United King- Ü RESEARCH, p 34 urgent surgical management. Provenance and peer review: Not commissioned; externally peer reviewed.
 EDITORIALS p
practices: analysis of patient
Bruce Guthrie and Tobias
31 Novel drugs and drug
operated on by specialist surgeons and patients dom for suspicious ovarian tumours is based on
Further external validation is also needed to
in past six months

Ratnavelu
Patient consent not required (patient anonymised, dead, or hypothetical).
conflicts of interest
25 Predicting ovarian
during labour but preliminary association with ovarian cancer being operated on locally. clinical impres possible involvement of human papillomavirus and second trimester miscarriage associated with
EDITORIAL p ›
survey data
combinations for treating
Dreischulte
PRACTICE

procedure impairs fertility or increases the risk sion, radiological findings, or the make sure that the model performs well in dif-

GPs are o†ered £20 000 to work
Patient consent obtained for figures.
12 Re-evaluating cost

 RESEARCH p
How is a nasal septal haematoma diagnosed?
malignancy
1
Baring DE, Bowyer DJ, Adamson R. Patient self-assessment of nasal
tuberculosis
Martin J Roberts et al
Ü RESEARCH, p 28,29
1
The latest model looks promising Clinical features
1 risk of malignancy index. This index is the best ferent countries and healthcare systems outside
This is exactly the point where a prediction
17 Women who have breast
Doctors’ leaders back call for C Mary Schooling of early spontaneous pregnancy loss. Treated CIN in the biology of labour, as well as the possible treatment for CIN. Although this is unquestion-
e†ectiveness of universal

in Leicester

fractures and self referral to an ear, nose, and throat department: a
Ü EDITORIAL, p 20
the IOTA group. A direct comparison with current

prospective study. Otolaryngol Head Neck Surg 2012;146:913-7.
conserving surgery often

Melinda L Munang et al
12 Co-trimoxazole and sudden 9 Self harm in young people

known prediction model, with a sensitivity for iden- meningitis vaccination
model that discriminates between several types 21 Safety of modern treatment
greater NHS investment RESEARCH p ¤ women did have a higher risk of second trimester RATIONAL IMAGING as a triage tool for women with The presenting symptoms of a nasal septal haematoma are 2 Mondin V, Rinaldo A, Ferlito A. Management of nasal bone fractures. Am
4 CMO defends decision to
biological effects of treatment. Moreover, studies ably a correct conclusion on the basis of the stud-
generally non-specific, but the most common presenting
of ovarian tumour becomes extremely impor-
tification of malignant ovarian tumours of 65-75% prediction methods is also advisable to ensure
Ü RESEARCH, p 28
need further surgery
A worrying problem about which
death in patients receiving
J Otolaryngol 2005;26:181-5.
(Bexsero) in England:
for cervical pre-cancer
stockpile Tamiflu
Ü ANALYSIS, p 37
ALL THINGS CONSIDERED
29 Imaging of neck lumps ovarian masses
symptoms are nasal obstruction (95%), pain (50%), rhi-

and specificity of 80-90%. 5 ADNEX proved to be improved or at least comparable results. Ideally,
3
Lee SJ, Liong K, Lee HP. Deformation of nasal septum during nasal
tant for the maintenance and good function of
we know far too little
3 Cancer charity demands miscarriage than controls. They also had more resembling Castanon and colleagues’ should be ies in their meta-analysis, some of these studies
trauma. Laryngoscope 2010;120:1931-9.
Ioannis Biliatis and Nithya
modelling study
inhibitors of renin-angiotensin Most women can be reassured
35 Welcome the governance
norrhoea (25%), and fever (25%). 12 They can occur after
Charges for assisting death are

Smokers come to accept

Allan House

29 Effect of a national primary
conducted in other settings, with other human go back almost 50 years and include women who
Hannah Christensen et al
about future pregnancies

Paula Bradley et al
extension of drug fund 9 Thienopyridines and acute a centralised cancer network. In a linked paper much more sensitive in identifying malignancy, as it should be evaluated whether incorporating the 4 Dispenza C, Saraniti C, Dispenza F, Caramanna C, Salzano FA.
pregnancies, ectopic pregnancies, and termina-
Ratnavelu
minor trauma, and patients tend to present after nasal
plain packaging
inspectors
Management of nasal septal abscess in childhood: our experience. Int J
less likely if patients are not
system: population based
its sensitivity was almost 96%, maintaining at the new model into clinical practice actually improves
Van Calster and colleagues present a prediction
Pediatr Otorhinolaryngol 2004;68:1417-21.
care pay for performance
injury to either primary care or a minor injuries depart-

Ü RESEARCH, p 30,31
Ü RESEARCH, p 36
 RESEARCH p

Michaela Mensah

study
known to doctors
tions than controls, suggesting unadjusted dif- GUIDELINES
outcomes for women, including survival.
model with the ability to discriminate between
papillomavirus infected women as controls and had the kind of large resections that used to be
Drug firms ran trials in East coronary syndrome without ST 17 First prostate cancer audit same time a good specificity (73%). 13 Clinical and social outcomes of ment. 10 15 Any patient presenting to primary care with a his- 5 Alshaikh N, Lo S. Nasal septal abscess in children: from diagnosis
scheme on emergency
to management and prevention. Int J Pediatr Otorhinolaryngol
-
22 Milk and mortality
different types of ovarian tumour. 4 Several mod-
tory of nasal trauma, however minor, should be assessed
2011;75:737-44.
10 Big strides in Europe towards
5 The BMJ launches seventh
Germany without patient elevation ferences between groups in sexual behaviour or Diagnosis and management of ADNEX may well prove a useful tool in improv standard practice. Even so, larger resections seem
32

calls for wider use of modern
adolescent self harm:
Michael Fralick et al
hospital admissions for
well standardised measurement of resection size.
Flint PW, Haughey BH, Lund VJ, Niparko JK, Richardson MA, Robbins
ing triage of women with ovarian masses to differ
6
population based birth cohort for the presence of a nasal septal haematoma. All patients
-
Genetic studies could help us

annual awards and calls for

clinical trial transparency
els have been introduced for this purpose in the ADNEX is better

ENDGAMES
imaging
ambulatory care sensitive
consent It’s time to rethink an ageing past; however, the ADNEX model proposed here With its novel ability to provide discrimination ent levels of management. The model may also help KT, et al. Cummings otolaryngology—head and neck surgery. 5th ed.
suspected of having a septal haematoma should be
gallstone disease:
interpret a biologically plausible but

Mosby, 2010.
The EMA, EU, and UK HRA
other lifestyle confounders.
We need an answer when women ask, “Does likely to increase a woman’s risk, not only of pre-
EDITORIAL p œ
nominations in 13 categories
conditions: controlled
study
36 Quiz page for doctors
preliminary association
in more detail (borderline, early and late stage, to save limited resources and reduce uncertainty
is novel, as it is not only binary (benign versus
Sequelae after nasal septum injuries in children. Auris Nasus Larynx
usher in an age of evidence
4 Medicines to remain with EC strategy Finding an appropriate control group is a summary of NICE guidance referred urgently for an ear, nose, and throat assessment. 7 Alvarez H, Osorio J, De Diego JI, Prim MP, De La Torre C, Gavilan J.
longitudinal study
term delivery but also of late miscarriage.
Becky Mars et al

C Mary Schooling
Je„ rey J Rade
2000;27:339-42.
BMJ CONFIDENTIAL
a modern, superficial excision of the transforma-aining
13 Milk intake and risk of

and anxiety for women and their families; both
enlightenment

Wright RJ, Murakarmi CS, Ambro BT. Pediatric nasal injuries and
8
Mark J Harrison et al
health directorate malignant tumours) but also polytomous (differ- as well as metastatic ovarian cancer), ADNEX  EDITORIALS p Investigations in tr Until we know more, we can, cautiously, tell
Sheryl Warttig et al
Ü RESEARCH, p 35
management. Facial Plast Surg 2011;27:483-90.

Worsening bilateral nasal obstruction after nasal trauma
entiates between benign, borderline, early stage,
tional zone entail a risk for my baby in a future
becomes a better tool for enabling clinicians to deserve further study. The risk of malignancy index
6 David Oliver
Trish
mortality and fractures in
Chukuezi AB. Nasal septal haematoma in Nigeria. J Laryngol Otol
Ü EDITORIAL, p 20
advanced stage, and metastatic ovarian cancer).
provide the best management and guidance for is a good prediction model, but ADNEX may per-
Lighter evenings increase kids’ RESEARCH p  recurring problem for researchers trying to Groves should immediately raise the suspicion of a septal hae- 9 10 Olsen KD, Carpenter RJ, Kern EB. Nasal septal injury in children.
1992;106:396-8.
Loquacious, energetic, and kind
MINERVA
Ü RESEARCH, p 29
ALL THINGS CONSIDERED
evaluate possible harms of treatments for CIN.
women and men: cohort

pregnancy?” Most previous studies have indi-
most women requiring a resection of less than
matoma. It is diagnosed clinically on direct anterior rhi-
The study included a large number of women their patients. For example, a subgroup analysis form better when it comes to prediction: the better
activity 10 Antibiotics, renin-angiotensin (almost 6000) who presented with a persistent of the Adjuvant ChemoTherapy in Ovarian Neo- the model the better the outcomes for the patients, 11 Agrawal N, Brayley N. Audit of nasal fracture management in accident
Diagnosis and management. Arch Otolaryngol 1980;106:317-20.
noscopy (fig 2). A red, fluctuant swelling that obstructs
33 Next of kin
38 The benefits of central heating,
studies
cated that the answer is “yes.” The research
Castanon and colleagues report an association
3 4
10 mm that “This limited resection and the follow-
the nasal cavity bilaterally is seen arising from the nasal
and emergency in a district general hospital. J Eval Clin Pract
Doctors query ethics of £55 system blockers, and sudden ovarian tumour and underwent surgery. Data on plasm (ACTION) study has shown that patients their families, and the healthcare system. and other stories 12 Canty PA, Berkowitz RG. Hematoma and abscess of the nasal septum in

2007;13:295-7.
Max Kamath

Karl Michaëlsson et al
septum. Unilateral presentation has also been reported.
Provenance and peer review: Commissioned; not externally peer
clinical characteristics (age, CA-125 level, type of with stage I ovarian cancer may benefit from an
In a primary care setting, an otoscope can be used to visu-
dementia payments death between risk of preterm birth and large, but not by Castanon and colleagues suggests that it may up we recommend will prevent you from getting
children. Arch Otolaryngol Head Neck Surg 1996;122:1373-6.
Vol 25, No 232 ISSN 1106-5028
January 2015
reviewed.

EDITORIAL p ž
small, excisions of the cervical transformation
alise the nasal septum. The main differential diagnosis
13 Wilson SW, Milward TM. Delayed diagnosis of septal haematoma and
Thinking about
instead be “no” (absolute risk of preterm birth for cervical cancer without impairing your ability to
Why are we failing
the burden of
young people
consequent nasal deformity. Injury 1994;25:685-6.
sonogram were collected prospectively on consecu-
5 Campaign is launched to reverse Is there a cause for concern? centre) and morphology of the tumour on ultra- optimal surgical procedure that includes sam- Competing interests and references are on thebmj.com. 14 Huang PH, Chiang YC, Yang TH, Chao PZ, Lee FP. Nasal septal abscess.
pling of pelvic and para-aortic lymph nodes.
with ADHD?
treatment
A bill of rights
Cite this as: BMJ 2014;349:g6076 of a nasal septal haematoma is a deviated nasal septum.
Rules tighten on
ENDGAMES
women with shallow excision 7.5% versus 7.2% become pregnant. Also, it is very unlikely that you
use of electronic
zone. They attempted to overcome the problem
for patients and
Otolaryngol Head Neck Surg 2006;135:335-6.
families
general practice in “hypoactive sexual The enigma of
cigarettes
25 October 2014
349:1-38 No 7980 | ISSN 1759-2151
To the fullest extent permitted by law, the BMJ Publishing Group shall not be
the trend of diminishing activity Mahyar Etminan and James M 2 tive cases from 24 different centres in 10 countries. Thereby, if index surgery is performed upfront ЖRESEARCH, p 11 The two conditions can easily be distinguished by gen- 15 Matsuba HM, Thawley SE. Nasal septal abscess: unusual causes,
The BMA grants editorial freedom to the Editor of The BMJ. The views
Return of female
Future shape of
tle probing with a blunt instrument, such as a cotton
desire disorder”?
expressed in the journal are those of the authors and may not necessarily
34
complications, treatment, and sequelae. Ann Plast Surg 1986;16:161-6.
England
drug combinations self harm in
Diagnosis and
New drugs and
for women with punch biopsy only; relative risk will deliver earlier in a future pregnancy as an effect
bud. A septal haematoma is a boggy swelling, whereas a
management of
EU appoints Ebola chief Brophy of control groups by comparing two groups of Quiz page for doctors liable for any loss, injury, or damage resulting from the use of The BMJ or any Accepted: 18 August 2014
information in it whether based on contract, tort, or otherwise. Readers are
comply with BMA policy. The BMJ follows guidelines on editorial
hiatus hernia
for tuberculosis
young people
25 October 2014 | the bmj
in training
BMJ Middle East
8
advised to verify any information they choose to rely on.
independence produced by the World Association of Medical Editors
2 6

in e ort to tackle disease RESEARCH p ¥ women—cases with preterm birth and controls 0.96 (95% confidence interval 0.73 to 1.27). of this treatment and extremely unlikely that it will 4 | the bmj

EDITORIAL p
8 November 201
(www.wame.org/wamestmt.htm#independence) and the code on good
©BMJ Publishing Group Ltd ’“”• All Rights Reserved. No part of this
34
The enigma
publication may be reproduced, stored in a retrieval system, or transmitted
publication practice produced by the Committee on Publication Ethics
of self harm in
without—nested in a cohort of women who had Why the difference? In addition to using other harm your baby.” However, we also need to spread

RESEARCH p
young people
(www.publicationethics.org.uk/guidelines/).
in any form or by any other means, electronic, mechanical, photocopying,
JOSEY CORY WRIGHT
The BMJ is intended for medical professionals and is provided without
BMJ CONFIDENTIAL all been referred for colposcopy. Their findings are MINERVA recording, or otherwise, without prior permission, in writing, of The BMJ.
women with atypical smears as controls, this
this message to the clinical community: “We can
warranty, express or implied. Statements in the journal are the responsibility Published weekly. US periodicals class postage paid at Rahway,
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Vol 25 No 232 January 2015 ISSN 1106 -5028 British Medical Association
6 Alan Maryon-Davis thus a comparison of the effect of different sizes study was conducted by trained and licensed do harm. We have to be good at this.” We must be
36 Ischaemic preconditioning, and
Airfreight International Ltd Inc, ˜™š Blair Road, Avenel, NJ “›““”,
Publishing Group, or the BMA unless otherwise specified or determined by
Remarkably cheerful, considering GU Meniere’s disease law. Acceptance of advertising does not imply endorsement USA. œ›ž™. Weekly. Printed by Polestar Limited
other stories
of treatment compared with untreated women colposcopists within a high quality, modern pro- careful to avoid all unnecessary treatments in fertile
BMJ (British Medical Journal), 2015 January with abnormal smears. This is an appropriate gramme that limits resection size and additional women, learning when to treat and when to watch
3
| January 2015 | VOLUME 26
the bmj | 25 October 2014
design, although it also has limitations. Treated
diathermy owing to the perceived risks and meas-
Flipping
and wait. Many countries still need to focus their
The BMA grants editorial freedom to the Editor of The BMJ. The views
To the fullest extent permitted by law, the BMJ Publishing Group shall not be
1 November 2014
349:1-36 No 7981 | ISSN 1759-2151
Imaging of neck
NHS England’s
lumps
ures specimens uniformly. No other study fulfils efforts on improving colposcopic skills, establish-
and untreated women might still have different
Management of
Milk intake and
risk of mortality five year plan Healthcare expressed in the journal are those of the authors and may not necessarily liable for any loss, injury, or damage resulting from the use of The BMJ or any
arteriovenous
and fractures: fistulas
cohort studies CPD/CME hours comply with BMA policy. The BMJ follows guidelines on editorial information in it whether based on contract, tort, or otherwise. Readers are
all these criteria.
viral loads (human papillomavirus), degrees of
ANALYSIS p  independence produced by the World Association of Medical Editors advised to verify any information they choose to rely on. ing basic professional requirements, and introduc-
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Castanon’s findings add to evidence of an
CIN, and immunological factors that favour per-
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increased risk of preterm delivery, and perhaps
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and untreated women with CIN have also shown
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