Suicide and euthanasia paradox

Effects of candesartan in patients with chronic heart failure and reduced left- ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARMAdded trial. Lancet 2003;362:767-71. 4 Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, et al; Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005;352:1539-49. 5 Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D, et al; HeartMate II Investigators. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med 2009;361:2241-51. Cite this as: BMJ 2010;341:c4280

CDC/SPL

Author’s reply CONGESTIVE HEART FAILURE

Advances in management Arroll and colleagues’ review of the management of congestive heart failure1 disregards much of the progress made since the previous BMJ review of this topic in 2002.2 They concentrated on established pharmacotherapy at the expense of groundbreaking developments that have occurred over this time. Angiotensin II receptor blockade has been shown to benefit patients with low ejection fraction heart failure who already take or are intolerant of angiotensin converting enzyme inhibitors.3 Cardiac resynchronisation therapy now plays a major role in improving morbidity and mortality in patients with advanced4 and, more recently, milder symptoms. Ventricular assist devices have emerged as a life changing treatment in selected patients with end stage heart failure.5 Despite advances in treatment, morbidity and mortality in heart failure remain high. It is therefore crucial that important advances are relayed promptly and accurately to generalists and non-heart failure specialists involved in the management of heart failure who decide on the appropriateness of potentially crucial specialist referral. Jonathan R Dalzell specialty registrar in cardiology, Victoria Infirmary, Glasgow G42 9TY [email protected] Mark C Petrie consultant cardiologist Roy S Gardner consultant cardiologist, Scottish Advanced Heart Failure Unit, Golden Jubilee National Hospital, Glasgow G81 4HX Competing interests: None declared. 1 2 3

Arroll B, Doughty R, Andersen V. Investigation and management of congestive heart failure. BMJ 2010;341:c3657. (14 July.) Cowie MR, Zaphiriou A. Management of chronic heart failure. BMJ 2002;325:422-5. McMurray JJ, Ostergren J, Swedberg K, Granger CB, Held P, Michelson EL, et al; CHARM Investigators and Committees.

BMJ | 14 AUGUST 2010 | VOLUME 341

LETTERS

bmj.com To submit a rapid response go to any article on bmj.com and click “respond to this article”

These letters are selected from rapid responses posted on bmj.com. Selection is usually made 12 days after print publication of the article to which they respond.

We did mention candesartan in table 2, although we did not specifically reference the CHARM studies.1  2 Our focus was on the generalist physician and GP, and in primary care and cardiological care evidence shows that angiotensin converting enzyme (ACE) inhibitors and β blockers are not being initiated or titrated to maximal doses. We know this is still a problem from our audit work in Auckland. We therefore focused on the distinction between preserved and low ejection fraction and the use of brain natriuretic peptide in diagnosing heart failure. Unlike the 2002 BMJ paper, we pointed out that 50% of those with heart failure may have preserved ejection fraction, the need and evidence for high versus low dose ACE inhibitors and angiotensin receptor blockers, and safety problems around the use of spironolactone. We also recommended starting treatment while waiting for echocardiography. All these points are essential for the generalist. We recommended a low threshold for referral so that patients can get treatment with the devices that Dalzell and colleagues describe.2 But patients need to be diagnosed in the first place and treated adequately, and this probably has greater benefit at population level than that gained by the minority from devices. Our review covered a huge topic and we focused on the important issues for generalists rather than specialist cardiologists. Bruce Arroll professor and head, Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand [email protected] Competing interests: BA is on the educational committee for Pharmac, the New Zealand government purchasing agency for drugs. He was on the primary care advisory board for the Future Forum from 2003 to 2008. This forum is funded by Astra Zeneca (UK). 1 2

Arroll B, Doughty R, Andersen V. Investigation and management of congestive heart failure. BMJ 2010;341:c3657. (14 July.) Dalzell JR, Petrie MC, Gardner RS. Advances in management. BMJ 2010;341:c4280.

Cite this as: BMJ 2010;341:c4282

Don’t forget rehabilitation Arroll and colleagues did not mention the benefits of cardiac rehabilitation.1 A recent Cochrane review confirmed that cardiac rehabilitation reduces heart failure related hospital readmissions and results in clinically important improvements in quality of life.2 Guidelines from the National Institute for Health and Clinical Excellence, the American College of Cardiology, American Heart Association, and European Society of Cardiology recommend cardiac rehabilitation as being effective and safe for heart failure. Cardiac rehabilitation programmes should aim to enhance self management and not be restricted to exercise but should include education, psychological input, and drugs. In the UK around 900 000 people have heart failure but few participate in cardiac rehabilitation.3 Between April 2007 and March 2008, only 1% of patients in rehabilitation programmes were referred for heart failure.4 Preliminary results of our recent survey of cardiac rehabilitation centres in the UK point to a lack of funding and failure to commission as the main impediments to providing rehabilitation for heart failure. A particular challenge for NHS planners is the setting for these services: should patients take part in conventional centre based programmes or do home based programmes fit better with their pathways, needs, and preferences? What are the costs and benefits of the different methods and does rehabilitation in or nearer patients’ homes affect outcomes? Our current research will allow us to examine some of these questions. Hasnain Dalal chief investigator, REACH HF study group, Peninsula Medical School (Primary Care), Truro TR1 3HD [email protected] Jackie Austin (Monmouthshire), Russell Davis ( Birmingham), Kate Jolly (Birmingham), Colin Green (Exeter), Bob Lewin (York), Rod Taylor (Exeter), David Thompson (East Melbourne, Australia), Robert Williams (Glamorgan), Jenny Wingham (Truro); on behalf of the REACH HF Study Group Competing interests: The REACH HF (Rehabilitation Enablement in Chronic Heart Failure) Study Group is funded by the National Institute of Health Research. 1

Arroll B, Doughty R, Andersen V. Investigation and management of congestive heart failure. BMJ 2010;341:c3657. (14 July.) 2 Davies EJ, Moxham T, Rees K, Singh S, Coats AJ, Ebrahim S, et al. Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis. Eur J Heart Fail 2010;12:706-15. 3 Bethell HJ, Evans JA, Turner SC, Lewin RJ. The rise and fall of cardiac rehabilitation in the United Kingdom since 1998. J Public Health (Oxf) 2007;29:57-61. 4 British Heart Foundation Cardiac Care and Education Research Group. The national audit of cardiac rehabilitation. Annual statistical report 2009. 2009. www. cardiacrehabilitation.org.uk/. Cite this as: BMJ 2010;341:c4286 315

LETTERS

STROKE AND ENDARTERECTOMY

Pathway for transient ischaemic attacks

SOVEREIGN, ISM/SPL

The results of the UK audit of vascular surgical services and carotid endarterectomy must be seen in context.1 The audit describes the care of a small subset of patients with transient ischaemic attack in the NHS—namely, those with identified symptomatic carotid stenosis. Of these, only patients with symptoms related to high grade carotid stenosis benefit from urgent carotid endarterectomy. Although carotid endarterectomy is most beneficial within two weeks of stroke symptoms, patients are likely to still benefit up to three months after symptoms. This is not an excuse to wait, but carotid endarterectomy between 2 and 12 weeks after symptoms may still be appropriate. Timing of carotid endarterectomy after stroke needs careful consideration and is influenced by factors such as the degree of neurological deficit from the presenting stroke and the rate of recovery. Operating on all patients with stroke due to carotid stenosis is not appropriate. Neither do patients with completely blocked arteries need the procedure. Patients with narrowed carotid arteries but no stroke symptoms do not need urgent carotid endarterectomy but may still benefit from it in selected cases. Patients with transient ischaemic attack must be promptly assessed and diagnosed by a stroke specialist (stroke physician or neurologist).2 Any subsequent decision to perform carotid endarterectomy on symptomatic stenosis of the internal carotid artery needs to be made jointly by the stroke physician/neurologist and the surgeon.3 The Department of Health’s vital signs on transient ischaemic attack for England and Wales and the most recent audit round from the Royal College of Physicians4 describe the overall

316

performance of the management of transient ischaemic attack. Anthony Rudd consultant physician in stroke; chair, RCP Intercollegiate Stroke Working Party, St Thomas’ Hospital, London SE1 7EH [email protected] Geoff Cloud consultant physician in stroke; associate director, sentinel stroke audit; member, BASP clinical standards committee, St George’s Hospital, London SW17 0RE Competing interests: None declared. 1

Kmietowicz Z. Too few people in UK at high risk of stroke are getting carotid endarterectomies. BMJ 2010;341:c3879. (21 July.) 2 Royal College of Physicians. Stroke—National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). London: RCP, 2008. 3 National Institute for Health and Clinical Excellence. Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). 2008. www.nice.org.uk/ CG68. 4 Royal College of Physicians. National sentinel stroke audit; organisational audit. London: RCP, 2009. Cite this as: BMJ 2010;341:c4299

•   Twice daily independent update of the shared record. Our critical incident study in NHS24 confirms improvements to patient care by making decisions safer because many people cannot detail their drug treatment, especially in an emergency when they are ill or confused. Libby M M Morris general practitioner, Edinburgh EH10 4RP [email protected] Jonathan Cameron programme manager, National Services Scotland, Edinburgh EH12 9EB Colin Brown general practitioner, Glenburn Health Centre, Paisley PA2 8DX Jeremy C Wyatt professor of ehealth innovation and director, Institute for Digital Healthcare, University of Warwick, Coventry CV4 7AL Competing interests: None declared. 1

Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Potts HWW. Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study. BMJ 2010;340:c3111. (16 June.) Cite this as: BMJ 2010;341:c4305

SHARING SUMMARY CARE RECORDS

Same risks whichever way

Results from Scottish emergency care summary

Push and pull approaches to sharing patient records both pose risks to patient confidentiality.1 The push approach “pushes” data into a “physical” centralised database where they are available when needed. The pull approach “pulls” data directly from local systems, which collectively form a “virtual” centralised database, but records do need to be potentially available via the “virtual” database before the information is needed. There will be a risk of misuse and loss of patient confidentiality whichever approach is adopted. If there are concerns about using implied consent for the initial data upload, which makes only drug and allergy information potentially available, it seems out of the question to use implied consent to make complete GP records available via a pull approach. The UCL report found it difficult to show benefit for a variety of reasons, including unavailability of records.2 This is probably the most important problem because motivation to resolve other technical and organisational issues will most likely be lacking if records simply are not there. The use of implied consent for the initial data upload makes it more feasible that a large proportion of patients could have their records available within the next year. Longer term, the pull approach could be used to improve sharing of GP records, but it will be some time before all GP data are held on enterprise systems and available at all times.1

Disappointingly, Greenhalgh and colleagues did not compare England’s summary care record with Scotland’s emergency care summary.1 Established in 2006, the emergency care summary store currently automatically receives twice daily all prescribing and adverse reaction updates from all Scottish practices. Over 200 000 records are accessed every month by clinicians working in NHS24, accident and emergency departments, and out of hours teams—over 5.1 million accesses in total, with a 37% increase from 2008 to 2009. Feedback from users is overwhelmingly positive. Our survey in three acute receiving units found that clinical decisions can be more timely, accurate, and patient centred. Hospital pharmacists use it increasingly for medicines reconciliation, the 24 pharmacists surveyed rating its information as useful or extremely useful. The success of Scotland’s programme has been dismissed, seemingly because of Scotland’s small population. However, the emergency care summary has several distinctive features: •   A clear purpose: to make key medical details available to clinicians providing unplanned care •   Leadership from the start by the clinical groups that agreed this purpose •   Control of any proposed extension is by a programme board with full consultation •   Early incorporation of patients’ views from focus groups led by the Scottish Consumer Council •   Two stage consent model to give patients control of their emergency care summary record: “consent to view” is requested at the point of care, and patients can opt out completely and simply by directly notifying their general practice

John R Nicholas general practitioner, Queens Park Medical Centre, Stockton on Tees TS18 4DT [email protected] Competing interests: None declared. 1 2

Foad R. Time for a rethink. BMJ 2010;341:c3707. (21 July.) Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Potts HWW. Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study. BMJ 2010;340:c3111. (16 June.) Cite this as: BMJ 2010;341:c4304 BMJ | 14 AUGUST 2010 | VOLUME 341

What about advance directives? The summary care record was marketed to the public as a way for accident and emergency staff to check up on unconscious patients.1 The most important information I would want staff to have is that contained in my advance directive, drawn up in accordance with the Mental Capacity Act 2005, signed by witnesses, and lodged with my general practitioner. It specifies the conditions under which I refuse cardiopulmonary resuscitation, ventilation, and other forms of life preserving treatment. I discovered that advance directives are not among the core information initially included in summary care records, which seems to be only medication, allergies, and severe reactions in the first stage. An opportunity has been missed, and those of us with advance directives are left anxious and dismayed that summary care records may make available just enough clinical information to keep us alive against our wishes. I have of course withheld permission for my clinical data to be transferred to a summary care record. The broader issue is the apparent lack of awareness about patients’ right to make advance refusals of medical treatment, and the national implementation of a system of summary care records designed in a way that ignores and overrides that right. Celia C Kitzinger professor of sociology, University of York, York YO10 5DD [email protected] Competing interests: None declared. 1

Anderson R. Do summary care records have the potential to do more harm than good? Yes. BMJ 2010;340:c3020. (16 June.) Cite this as: BMJ 2010;241:c4307

PRIVATE FINANCE INITIATIVE

Public finance indiscretion Private finance initiative (PFI) hospitals are simply huge public sub prime mortgages. PFI perpetuates debt at exorbitant rates (interest is fixed at pre-credit crunch rates, I think), and in some cases the government is paying money to banks that it owns. Payments are for 30 years or longer. As Davies points out, the cumulative debt repayment is gigantic.1 Worse still, hospitals must cover their expenditure with income. Before a reorganisation in my own locality, the finance directors of four hospitals produced a report stating that the costs of the three PFI hospitals could not be met from income under payment by results. We now have a situation where two PFI hospitals (one pulled out) are joined with a third, non-PFI hospital (mine), which is immediately vulnerable—it’s like a row of three terraced houses where the owner of one is told by the other two owners that he will have to sell BMJ | 14 AUGUST 2010 | VOLUME 341

up so they can pay their mortgages. As income is squeezed by primary care trusts trying to persuade GPs not to refer, the income projected is not reached, making matters even worse. The banks were prevented from collapse by the government bailing them out. Perhaps it should now do the same with hospitals, whatever the pain, and buy out the PFIs. If not, at least it should compel the banks to reduce their interest demands to current market rates. Andrew N Bamji consultant rheumatologist, Queen Mary’s Hospital, Sidcup, Kent DA14 6LT [email protected] Competing interests: None declared. 1

Davies P. Hard times: is this the end of the road for the private finance initiative? BMJ 2010;341:c3828. (20 July.)

Cite this as: BMJ 2010;341:c4295

Who owns these PFI contracts? Davies does not deal with an important question about private finance initiative (PFI) contracts: Who are they with?1 It would be interesting to know which banks have loaned the money. From my peripheral involvement, I recall that some of these banks are now owned, or part owned, by the government. If that is the case, then renegotiating those contracts should be simple. The Treasury might not be too happy if the value of these banks partly depends on those lucrative contracts, however, because if the contracts were lost the Treasury would recoup much less in a future reprivatisation. Richard G Richards assistant director of public health, Babington Hospital, Belper, Derbyshire DE56 1WH [email protected] Competing interests: None declared. 1

Davies P. Hard times: is this the end of the road for the private finance initiative? BMJ 2010;341:c3828. (20 July.) Cite this as: BMJ 2010;341:c4289

PERFORMANCE INDICATORS

How valid are the indicators? Reeves and colleagues explained the rationale behind removing eight performance indicators from the UK Quality and Outcomes Framework.1 But how valid are performance indicators? In collaboration with the Comprehensive Cancer Centre West in the Netherlands, we tested the validity of tumour positive margin rate after breast conserving surgery for breast neoplasm as an indicator in relation to the used definition (rate of focal involvement, extensive involvement, or re-resection) and adjustment for case mix and random variation.2 Tumour positive margin rates were evaluated in nine affiliated hospitals. The rates seemed to vary widely between the hospitals, but most variation was random, as shown in the funnel plot (figure).3 After adjustment for case mix, the variation decreased further.

Tumour positive margin or re-resection (%)

LETTERS

100

Standard Focal and extensive involvement Re-resection Extensive involvement

80 60 40 20 0 0

20

40

60

80

100 120 140 160

Hospital volume of breast conserving resections

Funnel plot of rates of margin involvement and re-resection in nine hospitals in the Netherlands, 1 July 2008 to 30 June 2009. Results for each hospital are presented vertically. Standard is consensus of maximum 20% margin involvement after breast conserving surgery for breast cancer with 95% and 99.8% confidence intervals (red and blue lines). Hospitals outside confidence limits perform significantly better or worse than standard

A hospital could be considered an outlier depending on the definition used and case mix adjustment. However, two hospitals remained identifiable as outliers. Were they performing better or worse than the others, or was there a registration bias? We observed large discrepancies in rates of focal involvement, extensive involvement, and re-resection, indicating differences in interpreting tumour margin positivity among the hospitals. Hospitals thus did not use uniform definitions, undermining valid comparison between them. To ensure indicators are valid, data should be reliable, results should be comparable, and random variation should be taken into account.4 Quality indicators are usually not registered in a uniform way, and control over whether registration is complete and reliable is limited. Validity is further undermined by not adjusting for case mix. The validity of quality must be taken into account when indicators are developed and revised. G A Gooiker medical doctor and PhD student [email protected] R A E M Tollenaar professor of surgical oncology, Department of Surgery, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, Netherlands Competing interests: None declared. 1

Reeves D, Doran T, Valderas JM, Kontopantelis E, Trueman P, Sutton M, et al. How to identify when a performance indicator has run its course. BMJ 2010;340:c1717. (6 April.) 2 Gooiker GA, Veerbeek L, van der Geest LG, Stijnen T, Dekker JW, Nortier JW, et al. [The quality indicator ‘tumour positive surgical margin following breast-conserving surgery’ does not provide transparent insight into care]. Ned Tijdschr Geneeskd 2010;154:A1142. 3 Mayer EK, Bottle A, Rao C, Darzi AW, Athanasiou T. Funnel plots and their emerging application in surgery. Ann Surg 2009;249:376-83. 4 Dimick JB. What makes a “good” quality indicator? Arch Surg 2010;145:295. Cite this as: BMJ 2010;341:c4284 317

LETTERS

EXPERT WITNESSES

Hearings in camera are bad public policy The suggestion that witnesses in child protection proceedings should be heard in camera is dismaying.1 Traditionally, anonymity for witnesses has been reserved for very few cases such as official secrets, when the lives of police officers and their families may be threatened, and when the safety of rape victims is threatened. None of these situations applies to child protection hearings involving reputable doctors. The sole reason for the demand seems to be to protect expert witnesses from accountability for their testimony, when their job is to present impartial testimony to the trier of fact, regardless of which side the legal chips fall. If expert witnesses testify honestly to their perceptions of the truth they have nothing to fear from the legal system even if their testimony is misguided or erroneous. However, if expert witnesses knowingly testify to a falsity they may have potential legal problems that transcend simple concerns about reputation. However, saying “I don’t know” or “I don’t have any science to support my belief, but it’s just my opinion” can make the witness even more credible. Often testimony in child injury cases is based on a default diagnosis arising from what the witness was taught decades ago by a revered professor or on “my vast clinical experience” rather than modern scientific evidence based medicine. If not widely reported, hearings in camera will simply protect the witness from the accountability to the public that the open court system was set up to do. Members of the public can decide on the credibility of doctors, lawyers, and judges only when all testimony (defence and prosecution) is clearly and accurately reported. Peter J Stephens consultant in forensic pathology, Burnsville, NC 28714, USA [email protected] Competing interests: PJS has presented expert witness testimony in forensic pathology over the past 40 years, including for the prosecution and defence in child trauma cases. 1

Dyer C. Expert witnesses above the parapet. BMJ 2010;341:c3672. (20 July.) Cite this as: BMJ 2010;341:c4294

RULING ON MERCY KILLING

Suicide and euthanasia paradox Ironically, the BMJ issue of 24 July reported that Tony Nicklinson is seeking assurance that someone who ends his life at his request will not be prosecuted1 but also included articles on suicide prevention.2‑4 Nicklinson stated that he needs “help in almost every aspect of life,” has “no privacy or dignity left,” and is “fed up with life.”1 The implication is that he wants to die because he feels his life has 318

lost meaning, purpose, and dignity. Presumably people who commit suicide feel the same. While we strive to prevent suicide, repeated attempts have been made to legalise and facilitate euthanasia and assisted suicide in the UK for people with terminal illness and now those with permanent physical disability leading to loss of independence. Why this difference in attitude? We increasingly assume that the value and dignity of human life depends on independence, physical ability, and mental agility. This is not true. Life has dignity in and of itself—it is “inherent.”5 When anybody expresses a desire to die, we should be sympathetic but respectfully insist that although they believe their lives have lost meaning, purpose, and dignity, they are mistaken. Accompany this by trying to identify and tackle the causes of their hopelessness. The alternative is to agree and help the person to die. This confirms their despair and tells others that loss of attributes currently prized by society is a valid reason to think that life is not worth living. Adopting this approach to people who are “dependent” is discriminatory and suggests that the value and dignity of life is pegged to ability. Surely such a response to suffering amounts to a rejection of the “inherent dignity . . . of all members of the human family [which] is the foundation of freedom, justice, and peace.”5

style of management that has caused problems in the NHS,2 and would avoid any challenges to it. As the Francis report has recently reinforced,3 staff need to feel confident that they can raise genuine concerns and that these will be taken seriously. Fear of being called rude, or worse, in such circumstances also poses a threat to patient safety and quality of care, as does rudeness itself. D B Double consultant psychiatrist, Victoria House, Lowestoft NR32 1PL [email protected] Competing interests: None declared. 1 2

Flin R. Rudeness at work. BMJ 2010;340:c2480. (31 July.) Ham C. Improving the performance of the English NHS. BMJ 2010;340:c1776. (7 April.) 3 Department of Health. Robert Francis inquiry report into Mid-Staffordshire NHS Foundation Trust. 2010. www. dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_113018. Cite this as: BMJ 2010;341:c4301

CHOCOLATE AND BLOOD PRESSURE

Chocolate dose may be too much

Ian J MacCormick specialist trainee year 1, ophthalmology, Raigmore Hospital, Inverness IV2 3UJ [email protected] Competing interests: None declared.

Minerva referenced an article on dark chocolate as a treatment for high blood pressure.1  2 We recently published a meta-analysis that investigated some of the questions she raises.1‑3 Our results suggested that dark chocolate is superior to placebo in reducing blood pressures of more than 140 mm Hg systolic or more than 80 mm Hg diastolic. Rather than comparing the brand of chocolate, we compared the content of flavanol or polyphenol, the compounds responsible for the blood pressure lowering action of chocolate. Daily flavanol dosages ranged from 30 mg to 1 g (equivalent to 6.3 g to 100 g of milk or dark chocolate), and interventions ran for two to 18 weeks. Data were insufficient to provide confident answers on optimal dosage and time frame. However, the practicability of chocolate as a long term treatment is debatable. We found that 50 g daily of 70% cocoa chocolate was significantly less acceptable to participants as a long term treatment for high blood pressure than one capsule daily of placebo or tomato extract (73% v 100%).4

RUDENESS AT WORK

Karin Ried research fellow, [email protected] Oliver R Frank lecturer Nigel P Stocks head, Discipline of General Practice, University of Adelaide, Adelaide, SA 5005, Australia Competing interests: None declared.

1

Dyer C. “Locked in” patient asks for ruling on mercy killing. BMJ 2010;341:c3943. (20 July.) 2 Sinyor M, Levitt AJ. Effect of a barrier at Bloor Street Viaduct on suicide rates in Toronto: natural experiment. BMJ 2010;341:c2884. (6 July.) 3 Runeson B, Tidemalm D, Dahlin M, Lichtenstein P, Långström N. Method of attempted suicide as predictor of subsequent attempted suicide: national long term cohort study. BMJ 2010;341:c3222. (13 July.) 4 Gunnell D, Miller M. Strategies to prevent suicide. BMJ 2010;341:c3054. (6 July.) 5 United Nations. Universal declaration of human rights. www.un.org/Overview/rights.html. Cite this as: BMJ 2010;341:c4291

It’s rude to argue? Flin describes disagreements and aggression in the operating theatre as though they are the same thing.1 I am not suggesting that scrub nurses should have to tolerate surgeons’ bad temper and tantrums. But her example of two airline pilots becoming engrossed in a heated discussion over airline policy, with no evidence that they were rude to each other, highlights the difference between disagreement and rudeness. Abuse, rudeness, and incivility have no place at work. However, this does not mean that disagreements can be eradicated. Her proposal for harmony would suit the command and control

1 2

Minerva. BMJ 2010;341:c3675. (13 July.) Egan BM, Laken MA, Donovan JL, Woolson RF. Does dark chocolate have a role in the prevention and management of hypertension? Commentary on the evidence. Hypertension 2010;55:128995. 3 Ried K, Sullivan T, Fakler P, Frank OR, Stocks NP. Does chocolate reduce blood pressure? A metaanalysis. BMC Med 2010;8:39. 4 Ried K, Frank OR, Stocks NP. Dark chocolate or tomato extract for prehypertension: a randomised controlled trial. BMC Comp Alt Med 2009;9:22. Cite this as: BMJ 2010;341:c4176

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