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Background There is a lack of consensus regarding the definition of advance care planning (ACP), the people for whom it is most beneficial, how and by whom it should be conducted, its integration in health care, and what appropriate outcomes measures are. Further, there are considerable differences worldwide in the willingness of health care providers, patients and relatives to discuss issues related to disease progression and end-of-life care, and the integration of these discussions in the health care system. Aim To draft a white paper about ACP that is based on scientific evidence and transcultural consensus building that describes a common understanding of the definition the key elements of ACP. This white paper is commissioned by the European Association for Palliative Care (EAPC). Methods and expected results A three-round Delphi study will be conducted by a core group of 14 experts from 8 countries. The first round took place in June 2014 in a 2-day expert meeting. Five core domains were established: concept, content, system, measurements, and challenges/concerns. Subsequently, based on literature, a set of 50 recommendations related to these domains were drafted. These will be assessed in two rounds on its importance by a multidisciplinary expert panel (n = 100 from 16 countries). In addition, a research agenda for future ACP research will be constructed. Conclusion The ACP white paper will provide a comprehensive overview of ACP based on evidence and consensus. It can serve as a framework for clinical practice, policy and research.

A doctor who tried to submit for publication two research papers written by others has been suspended for 12 months by a medical practitioners tribunal. Mohammed Shali, who qualified in Mysore (now Mysuru), India, in 1998, sent an email in February 2013 to the editor of the International Journal of Clinical Skills attaching two papers. He named himself as first author of “An Unusual Cause of Dyspnoea—Mural Thrombus” and as coauthor of “An Unusual Cause of Dyspnoea—Atrial Myxoma.” The first paper had already been published elsewhere under a different title, and Shali had no role in its authorship. He falsely …

Surely the answer to this difference in interpretation of Freemantle and colleagues’ paper is to ask Freemantle and colleagues to respond to Jeremy Hunt in a letter to The BMJ .1 2 It is easy for lay people, such as the health secretary, to misinterpret data in scientific papers, but part of the blame lies with the authors for not making their findings clearer …

Parity of authorship should be a priority for journals, universities, and funding agencies Women have been attending medical school in numbers equal to or greater than those of men since 1996 in the United Kingdom,1 and in nearly equal numbers in the United States since 2003.2 However, despite parity in medical school admissions, substantial gender differences in rank and leadership remain in academic medicine. The progress of women attaining first and senior authorship of original research publications, the currency of success for promotion in academic medicine, will directly translate into equity of academic advancement for women in the future. In a linked paper (doi:10.1136/bmj.i847),3 Filardo and colleagues examined the prevalence of female first authorship among original research articles published over the past two decades (1994-2014) in six high impact general medical journals. This study is notable for its rigor, examining six issues a year for all selected journals throughout the 20 year study period and using online searches of authors to identify gender in those with ambiguous names. The authors report some good news—an …

To mark the 20th anniversary of The BMJ ’s website, the journal asked 20 UK and international readers, authors, friends, and former colleagues to name an outstanding article published since the mid-1990s. The result is an extraordinary mix of editorials, research papers, analysis, and comment, including an investigation, on topics as wide ranging as the MMR vaccine scare, death, evidence based medicine, and the use of stirrups for pelvic examinations. Some represent seminal moments in recent medical history, others are pieces of research that, for their sheer simplicity and focus on patient experience, have inspired our readers to think and work differently. So here is The BMJ ’s top 20 and why, according to our 20 chosen readers, they are the best. “The development of the EQUATOR Network (www.equator-network.org) to improve reports of research and the 2014 Lancet series of papers on ways of increasing value and reducing waste in research (www.researchwaste.net) are just two examples of testimony to the enduring influence of Doug’s 1994 call for “less research, better research, and research done for the right reasons.” Iain Chalmers, health services researcher and a founder of the Cochrane Collaboration “Over the past 30 years we have seen medicine transformed from being based on the opinions of ‘experts’ to being based on systematic collation of evidence from clinical studies. There is still a vast amount to do to improve the evidence base itself. But articles such as this have helped explain to doctors the key principles of evidence based medicine and have inspired a new generation of clinicians and researchers.” Fiona Godlee, editor in chief, The BMJ “This paper and a linked one ( BMJ 1996;313:987, doi:10.1136/bmj.313.7063.987) revealed the profound sense of responsibility that parents felt for their children and how deep seated their fears are of serious …

The UK Research Paper of the Year category recognises outstanding research by one or more UK authors that has potential to considerably improve health and healthcare. Nigel Hawkes describes the shortlisted papers Do stem cells taken from the bone marrow and injected into patients with heart disease improve heart function? Lots of people believe so, and meta-analyses by the Cochrane Collaboration show a significant positive effect. But individual trials produce conflicting results, for no very obvious reason. Darrel Francis, professor of cardiology at Imperial College in London, says: “Some things in the early trials didn’t add up and when we went to the journals that published them, we were fobbed off. So we decided to look at discrepancies in all the published trials.” Discrepancies were defined as two or more reported facts that cannot both be true because they are logically or mathematically impossible. The team’s paper, published in The BMJ, concluded that the more discrepancies a paper contained, the more positive its results. “This field of therapy appears to be most effective in the hands of researchers whose reports contain factual impossibilities,” say Francis and colleague Graham Cole. “Indeed, when the factual impossibilities disappeared, so did any effect of the therapy.” They expected a sharp reaction from researchers with many discrepancies. “We tried to soften the blow by not naming the hundreds of report authors directly,” Francis says. “But it was authors with few discrepancies, and small or zero effect sizes, who criticised the study most vocally.” This includes the Cardiovascular Cell Therapy Research Network, funded by the US National Institutes of Health with $30 million, whose data coordinator, Lem Moye of the University of Texas, told people to disregard the …

The Lancet has retracted a 1992 study by the Canadian self proclaimed “father of nutritional immunology,” Ranjit Kumar Chandra, on the grounds that its reliability “can no longer be assured.”1 The study—a major trial that reported an improvement in older people’s immunity and infection risk after taking nutritional supplements2—was the second of Chandra’s studies to be retracted within the past six months. In October The BMJ retracted his 1989 study into the immune benefits of baby formula after receiving a suppressed report of an inquiry of his research, completed in 1995 by his former employer, Memorial University of Newfoundland, after allegations of data fabrication.3 Doubts about the plausibility of the Lancet study first …

Two papers that reported that the blood pressure drug ramipril was beneficial in patients with intermittent claudication due to peripheral artery disease have been retracted after an investigation found that data were fabricated by the studies’ lead author, Anna A Ahimastos, a researcher at the prestigious Baker IDI Heart and Diabetes Institute in Melbourne, Australia. The first paper,1 published in JAMA in …

Errors are linked to retraction, but are an unreliable marker for fraudulent or harmful research

The use of placebo in clinical practice has been the topic of extensive debate in the bioethics literature, with much scholarship focusing on concerns regarding deception. While considerations of placebo without deception have largely centred on open-label placebo, this paper considers a different kind of ethical quandary regarding placebo without an intent to deceive—one where the provider believes a treatment is effective due to a direct physiological mechanism, even though that belief may not be supported by rigorous scientific evidence. This is often the case with complementary and alternative medicine (CAM) techniques and also with some mainstream therapies that have not proven to be better than sham. Using one such CAM technique as a case study—electroencephalography (EEG) neurofeedback for attention-deficit/hyperactivity disorder (ADHD)—this paper explores the ethics of providing therapies that may have some beneficial effect, although one that is likely due to placebo effect. First, we provide background on EEG neurofeedback for ADHD and its evidence base, showing how it has proven to be equivalent to—but not better than—sham neurofeedback. Subsequently, we explore whether offering therapies that are claimed to work via specific physical pathways, but may actually work due to the placebo effect, constitute deception. We suggest that this practice may constitute unintentional deception regarding mechanism of action. Ultimately, we argue that providers have increased information provision obligations when offering treatments that diverge from standard of care and we make recommendations for mitigating unintentional deception.

BackgroundGenetic research may have therapeutic value for mental and physical disorders and could have an indicative or preventative capacity. Little is known about the extent, form and utility of military-specific genetic research.MethodA systematic review was conducted to evaluate existing genetic well-being studies of service personnel. The review specifically aimed to ascertain the current state of knowledge and feasibility of using genetics to aid recruitment and health management within military populations. Databases searched included MEDLINE, Embase, PsycINFO and Web of Science for relevant studies. Papers were rated using a genetics-specific quality assessment framework.ResultsTen papers were included within the final review, with seven mental-health-focused and three physical-health-focused genetic studies found within military populations. Eight papers considered candidate genes, one gene expression and one study was an outline of a future study of significant interest. Genetic commonalties were derived to yield shared physiological pathways. The 10 reviewed papers revealed moderate quality based on quality assessment.ConclusionsCurrent genetic research within military populations is limited. Further studies on genetics, cost effectiveness, ethics and continual monitoring need to be explored before considering any movement toward clinical translation.

The study aimed to develop evidence-based recommendations regarding the evaluation and use of biosimilars to treat rheumatological diseases. The task force comprised an expert group of specialists in rheumatology, dermatology and gastroenterology, and pharmacologists, patients and a regulator from ten countries. Four key topics regarding biosimilars were identified through a process of discussion and consensus. Using a Delphi process, specific questions were then formulated to guide a systematic literature review. Relevant English-language publications through November 2016 were searched systematically for each topic using Medline; selected papers and pertinent reviews were examined for additional relevant references; and abstracts presented at the 2015 and 2016 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) annual scientific meetings were searched for those about biosimilars. The experts used evidence obtained from these studies to develop a set of overarching principles and consensus recommendations. The level of evidence and grade of recommendation were determined for each. By the search strategy, 490 references were identified. Of these, 29 full-text papers were included in the systematic review. Additionally, 20 abstracts were retrieved from the ACR and EULAR conference abstract databases. Five overarching principles and eight consensus recommendations were generated, encompassing considerations regarding clinical trials, immunogenicity, extrapolation of indications, switching between bio-originators and biosimilars and among biosimilars, and cost. The level of evidence and grade of recommendation for each varied according to available published evidence. Five overarching principles and eight consensus recommendations regarding the evaluation and use of biosimilars to treat rheumatological diseases were developed using research-based evidence and expert opinion.

Objective To identify research priorities that have been answered, six years after being identified as\ud important to people with epilepsy and epilepsy professionals.\ud Background The DUETs database collates key unanswered questions identified by patients and\ud professionals. In 2011, 398 questions were created using focus group methodologies. We wanted to\ud know whether published research has since answered these important questions.\ud Design The top 20 ranked questions for both patients and clinicians were studied. The PubMed and\ud Cochrane databases were searched for published papers and NICE, SIGN and ILAE guidance for\ud authoritative statements. The number of papers targeted at answering these research priorities was\ud recorded.

Purpose The purpose of this study was to assess the publication rate of the abstracts presented at the 6th Mediterranean Emergency Medicine Congress, 2011 and the 7th European Congress on Emergency Medicine, 2012. Materials and methods All abstracts, both posters and oral presentations, from the international emergency medicine congresses held by the European Society for Emergency Medicine (EUSEM) in 2011 and 2012 were identified. To establish whether these abstracts were subsequently published in peer-reviewed medical journals, the names of all the authors and the title of the abstracts were searched for in the databases of Clinical Key/Elsevier, EBSCO Discovery Service, MD Consult, Science Direct, Scopus, EMBASE, Medscape, Google Scholar and local ULAKBIM. The year of publication, consistency of author names and titles, the type of study, the journals in which papers were published and countries from which reports were submitted were all recorded. Results A total of 1721 abstracts were examined; 626 from 2011 (307 oral presentations and 319 posters) and 1095 from 2012 (154 oral presentations and 941 posters). Of all abstracts in 2011, 172 (27.5%) and of all abstracts in 2012, 265 (24.2%) were subsequently published as full-text reports in peer-reviewed journals. Of the 172 papers published in 2011, 152 (88.4%) were accepted by Science Citation Index (SCI) and/or SCI Expanded (SCI-E) journals and 155 (58.5%) of 265 papers were accepted by SCI and/or SCI-E journals in 2012 (p=0.0001). Conclusions The publication rate of abstracts submitted to international emergency medicine congresses held by EUSEM over those 2 years was low compared with that of abstracts presented in other emergency medicine congresses. Presenters should be encouraged to send their studies to peer-reviewed journals. During the selection process by the scientific panel, constructive critics should be notified to the presenters instead of simply accepting or rejecting the studies that submitted to the congress, which may increase the subsequent publication rate.

This year marks the 70th birthday of Thorax and as two septuagenarian ex-editors whose involvement with the journal dates back to 1973, we have been asked by the present editors to select some notable papers published over its lifetime. The choice was ours and our successors’, reflecting our judgement of what has stood the test of time. Originally the journal of the Thoracic Society, Thorax was founded by British cardiothoracic surgeons and physicians, had joint medical and surgical editors and similar numbers of medical and surgical papers, many dealing with cardiac and oesophageal disease. The original publisher was the British Medical Association, but from 1979 this was shared with the Thoracic Society, and subsequently the British Thoracic Society, making a useful contribution to the Society's funds. Chest medicine was largely concerned with TB in the mid-20th century with other lung conditions being dealt with by general physicians. However, as asthma and chronic lung diseases attracted increasing research interest during the 1960s, the scope of respiratory medicine widened and new medical topics contributed increasingly to Thorax as cardiac and surgical papers declined. We have confined our selection to those of interest to today's respiratory physicians, so many excellent non-respiratory papers have been excluded. We have selected papers by going through the indices and rereading those that seem especially important. The task has not been simple, but was greatly aided by access to http://www.thorax.bmj.com. In the 1940s and 1950s, TB made little impact in Thorax save through surgical papers. Lung cancer was on the rise, and the first issue contained a major article by one of the journal's founders, Tudor Edwards, on his unparalleled experience of surgery of this disease.1 Also in that issue was the first article by Doll who was shortly to confirm the cancer–smoking association; he reported …

IntroductionPatient and public involvement (PPI) is inconsistently reported in health and social care research. Improving the quality of how PPI is reported is critical in developing a higher quality evidence base to gain a better insight into the methods and impact of PPI. This paper describes the methods used to develop and gain consensus on guidelines for reporting PPI in research studies (updated version of the Guidance for Reporting Patient and Public Involvement (GRIPP2)).MethodsThere were three key stages in the development of GRIPP2: identification of key items for the guideline from systematic review evidence of the impact of PPI on health research and health services, a three-phase online Delphi survey with a diverse sample of experts in PPI to gain consensus on included items and a face-to-face consensus meeting to finalise and reach definitive agreement on GRIPP2. Challenges and lessons learnt during the development of the reporting guidelines are reported.DiscussionThe process of reaching consensus is vital within the development of guidelines and policy directions, although debate around how best to reach consensus is still needed. This paper discusses the critical stages of consensus development as applied to the development of consensus for GRIPP2 and discusses the benefits and challenges of consensus development.

Grimes and Newton et al have made a number of criticisms of our paper, including that we misrepresent conclusions of the existing literature; do not adequately take account of confounding factors; have used arbitrary cut-offs in categorising the variables; and made an error in reporting the results of the model.1 ,2 We welcome the opportunity to respond to these criticisms and, in particular, address the claim made by Newton et al that we made an error in reporting the results of our model. We acknowledge the substantial problem of poor oral health that affects some children and adults in the UK and do not question that there is substantial good quality evidence to support the topical use of fluorides in toothpaste, nor do we wish to see the removal of effective and safe oral health programmes. The paper is not a discussion of the benefits or otherwise of water fluoridation programmes as these are discussed elsewhere.3–5 The focus of our paper was on whether fluoride levels in drinking water were associated with the prevalence of hypothyroidism. The Journal's restriction on paper length and number of references meant that we were not able to fully discuss the literature on fluoride and the thyroid. Consequently, we referred to the discussion from the NRC report, believing that to provide a sufficient basis to consider a plausible relationship.6 We accept that the primary causes of hypothyroidism are varied, including autoimmune disease and surgical intervention. Grimes1 states that the NRC …

A short cut review was carried out to establish whether low-dose ketamine is better than morphine at safely and effectively reducing pain scores in ED patients with acute pain who do not respond to conventional therapies. One hundred and thirty-two papers were found using the reported searches, of these three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that the evidence is limited, but that ketamine can be an effective alternative or adjunct to intravenous opioid pain medications and in some instances may provide more effective pain relief when compared with opioids.

In this paper I describe how I used my dual position of service user and sociologist to present my research findings at an international conference for surgeons. As a former breast cancer patient I was invited to participate in a study of women9s experiences of having breast reconstruction using their own body tissue. Questions included rating my happiness and confidence on a scale of 1–10 which challenged me as a qualitative researcher. The study also revealed parallels with my own research with 24 women who had been treated for early stage breast cancer, where similar issues had emerged organically through their narratives. When I discussed this with the breast care team I was encouraged to submit an abstract to the conference where the results of the quantitative study were going to be presented. The subsequent paper, entitled ‘Autologous Breast Reconstruction from the Patient9s Perspective: A Qualitative Study,’ was presented at the 5 th International Meeting of Oncoplastic and Reconstructive Breast Surgery in Nottingham in September 2013. My reflections on my experience of presenting to an audience, who were unaccustomed to qualitative research, include the challenges of facing my own intimidation by health professionals as a patient. I will discuss the positive feedback that I received which will hopefully encourage other qualitative health researchers to reach beyond the usual audiences in order to disseminate their research findings.

A short cut review was carried out to establish whether core stability exercises are better than conventional exercise for treating non-specific low back pain. 6 papers were found of which 4 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is the perception that a core stability rehabilitation programme will improve low back pain has not been proven.

China’s Ministry of Science and Technology has said that it is investigating the case of 107 papers from China retracted by the journal Tumor Biology in April this year and that it has “zero tolerance” for academic fraud. The papers were retracted after the journal’s publisher, Springer, conducted a manual screening that showed that the authors had submitted papers with fake email addresses for reviewers. “The incident has had a very bad influence, seriously tarnishing the international reputation of China’s scientific …

Background Study design in the fields of basic and clinical sciences is classified generally into two categories: 1) observational; and 2) Interventional. In observational studies, the researcher just focuses on the status of the study question and describes the current status as well as measuring associations between exposures and outcomes. While, in the interventional studies, the main aim of research is the study of the intervention effects which applied on the eligible persons by researcher that could finally result in prevention and health promotion or treatment of diseases depends on applied interventions. The aim of current study is to determine the frequency of the published study designs in the fields of safety promotion and prevention of injury regarding to the continents during the last three decades (1985-2015). Methods In this review article, all published papers in Pubmed from 1984 to 2015 in the field of safety promotion and injury prevention were studied. We used the following keywords for our search: Road traffic, burning, drowning, fall, and violence. The total number of articles in the field of injury prevention and safety promotion were 115 manuscripts from 1985 to 2015, which were assessed in terms of study design. Results We showed that the most published papers on the safety promotion and injury prevention were conducted in America. About 67% of all studies and 78% of all intervention studies in this area have been conducted in the continent of America and Europe. Asia shared 9% of intervention studies and Iran shared 3.6% of the studies which have been conducted in this area. Conclusions Considering the current situation in developed countries compared to developing countries, in the field of injury prevention and safety promotion, if one of the goals of the national health system to be health promotion in the society, the current status in terms of study design that are running, cannot results in safety promotion and injury prevention, therefore, as long as the frequency of intervention studies with the aim of injury prevention and safety promotion in the developing countries would not as much as developed countries, we could not expect any advances in the field of injury prevention and safety promotion in developing countries.

We read with interest the comments from Corrado and colleagues on our paper related to pre-participation screening in young athletes.1 2 The authors start their critique by suggesting that we are laypersons in the field of sports cardiology. The first author of our paper is a cardiologist with 30 years’ clinical experience. We are all active in critically appraising scientific literature and/or teaching evidence based medicine on a daily, professional basis. We may not be directly involved in sports cardiology, but the absence of conflicts of interest helps in being neutral when assessing scientific evidence. Furthermore, our manuscript has been peer reviewed through our submission to The BMJ by three renowned sports cardiologists from the UK, the US, and Australia. And the report from which our paper was extracted had been reviewed previously by independent Belgian and Dutch experts.3 More recently, two updated recommendations on pre-participation screening have been published, both from trusted sources. The UK National Screening Committee’s recommendation on screening to prevent sudden cardiac death (SCD) in 12-39 year olds, published in July 2015, is clear: “Systematic population screening programme is not recommended.”4 In December 2015 the …

Bofetta and La Vecchia1, in their commentary, state that ‘The paper by Gilham et al , published in Occupational and Environmental Medicine, is important for a number of methodological and substantive reasons…’.2 In fact, there are methodological and substantive flaws in the paper that call into question the study results and authors' conclusions.2 1. The authors rely on occupational history as a key point of reference in asbestos exposure assessment. Lifetime occupational history was obtained through telephone interviews of patients with malignant mesothelioma and from general population and lung cancer controls. The implication is that these interviews were conducted directly with study subjects. However, the authors state that informed consent for …

We read with interest Van Brabandt and colleagues’ review questioning the utility of pre-participation screening in preventing sudden cardiac death (SCD) in sports activity.1 The paper is not a balanced “pro and cons” analysis; rather, it seems to be a direct attack on the Italian screening programme and on the researchers who provided scientific evidence that cardiovascular evaluation of athletes is a lifesaving strategy based on more than 30 years’ experience in the Veneto region, northeast Italy.2 3 4 5 6 The paper was signed by laypersons with no experience in the field of sports cardiology, who provided a personal viewpoint and omitted the “real world” opinion of thousands of international physicians daily involved in athlete evaluation who favoured the need for pre-participation screening.7 The authors started by mistakenly reporting that Italy’s screening of competitive athletes has been mandatory since 1979. Instead, screening has been in place by law in Italy since 1982,8 which would be the correct starting point for evaluating its impact on mortality. This initial inaccuracy jeopardises the entire analysis. The inaccuracy is confirmed by the authors’ statement that the usefulness of ECG screening is confined to detecting athletes with Wolff-Parkinson-White syndrome, when in fact the main strength is …

Background Face to face appointment time between patient and clinician is precious. Patients can wait months between appointments, and usually allow clinicians to take the lead in their consultations. These may concentrate on disease related outcome measures and treatment targets. Patients may not feel able to raise other issues, or may forget to ask about them. Waiting time for appointments is almost inevitable, so to help patients make best use of their waiting time we decided to add a “What Do I Want to Talk About” area. Objectives To assess patient response to “What do I Want to Talk About”. Methods In the centre of patient waiting area we put up an “What Do I Want To Talk About” A4 poster, encouraging patients to write down the questions important for them to discuss within their consultation. We provided A6 paper sheets and pens for patients to take into their consultations. We asked patients to provide feedback by anonymous questionnaire asking these questions: Do you think this is a good idea? Yes/No; Have you used it? Yes/No. Would you use it in future? Yes/No; Other comments? Results 26 patients completed the questionnaire. Of these, 25 patients (96%) thought it was a good idea. 3 (12%) said they had used these slips previously. 18 (69%) said they would use them on their next visit. Comments: 9Good Idea thanks. I usually forget what I want to ask when I get in there and then remember on my way home9; “Why hasn9t this been done before?”; “I always do notes before my appointments as it helps both doctor and patient”; “This is a really good idea, and thanks for the pen” Clinician9s comments: “Really helpful for consultations, patients seem better prepared ”; “I used the same paper to respond to questions and as an aide-memoire for patients” Conclusions 9What do I Want to Talk About9 is a very simple, universally applicable idea which uses minimal resources. It may help some patients better prepare for consultations, and ensure key issues important to patients are addressed during consultations. Disclosure of Interest None declared

Background Person-centred goal setting and shared decision-making are emphasised as essential parts of effective team work and good clinical practice in rehabilitation. Objectives To explore the practice of collaborative goal setting in rehabilitation for adults with rheumatic and musculoskeletal diseases (RMDs), as described in published randomized controlled trials (RCTs). Methods A comprehensive, systematic literature search was undertaken to identify RCTs evaluating the effect of rehabilitation involving health professionals from at least two disciplines. We included trials from the period 1997–2012. Participants in the trials had a RMD with duration of more than three months. Following a deductive approach, four categories and nine keywords were developed from existing theory (1) and prior research about goal setting. The categories were i) goal negotiation, ii) specific goal setting, iii) goal-directed planning, iv) goal evaluation. Keywords were goal, aim, expect, need, tailor, objective, target, plan and outcome. The categories and keywords were used to identify text units in the articles, which were analyzed using a directive and summative content analysis. Results 21 RCTs were included, of which 12 included participants with chronic low back pain and 9 included participants with inflammatory arthropathies, connective tissue diseases or fibromyalgia. The intervention was inpatient or outpatient rehabilitation, and involved group and/or individual sessions. The multidisciplinary teams consisted of 3 to 7 professions. A total of 430 text units were identified, of which 18 (4%) contained descriptions of patients as active participants in the goal setting process. These units came from 8 papers. Goal negotiation was described in 7 of these 8 papers, and specific goal setting in all 8 papers. Goal-directed planning was described in 6 papers, and patient-centred goal evaluation in 3 papers. No papers described a specific instrument or a formal method of goal setting. The remaining text units (96%) did not describe any collaboration in the goal setting process between patients and health professionals. However, content related to predefined treatment goals was identified in 19 papers. These treatment goals were set by health professionals without patient involvement. Conclusions In articles reporting results from RCTs examining the effect of rehabilitation, the occurrence of patients as active participants in collaborative goal setting in general was low, and lower than the occurrence of predefined treatment goals set by health professionals alone. The results indicate that there is a gap between the emphasis on goal setting in rehabilitation theory and its implementation in clinical practice and research. References Scobbie, Dixon, Wyke. Goal setting and action planning in the rehabilitation setting: development of a theoretically informed practice framework. Clin Rehabil 2011; 25: 468–82 Disclosure of Interest None declared

The drug manufacturer Purdue Pharmaceuticals resisted efforts to change the dosing recommendations for its long acting opioid OxyContin to protect its revenues, the Los Angeles Times has alleged in an investigative report published on 5 May.1 The company, however, has strongly rejected the paper’s claims. “In an attempt to resurrect a long-discredited theory, the paper ignores the clinical and regulatory data that directly contradicts their story,” Purdue said in a statement. The report stated that Purdue …

The House of Commons health select committee is expected to consider holding an investigation into whether patients admitted to hospital at weekends face a greater risk of death than those admitted during the week, after an academic called for a review earlier this week. The government has argued that evidence of such a “weekend effect” exists and has used this as the basis of its argument for a “seven day” NHS, one of the key issues in its protracted dispute with junior doctors in England over their new contract. In particular, the health secretary for England, Jeremy Hunt, has cited a paper published in The BMJ to push for changes. The paper, by Nick Freemantle of University College London and colleagues, found that 11 000 more people died each year within 30 days of admission to hospital if they were admitted on a Friday, Saturday, Sunday, or Monday than if they were admitted on other days of the week.1 However, this analysis did …

Aims This paper will examine the slow progress of drug development to treat paediatric cancers beginning in the 1940s with Sidney Farber’s promising development of aminopterin and published 1947 study. Nearly seventy years later there have been very few new drugs to treat either blood or solid tumours in children since the 1980s. The study will include the financial and political issues of this slow progress and will conclude with an overview of the most recent drug launches in the United States in leukemias and neuroblastoma. Methods The sources for this paper included published articles in Paediatric Blood and Cancer, Leukaemia, Cancer: Journal of the National Cancer Institute and press releases of the Cancer Therapy Evaluation Program Paediatric Branch (National Cancer Institute–NCI). The author has also examined the archives of the NCI and primary sources in the National Institutes of Health Library and oral and written sources at the National Institutes of Health Office of History. Results In part because of the nature of childhood cancers as rare diseases national funding for new drug development has greatly lagged behind that of development of drugs to treat breast and colon cancer and other adult cancers. Public groups in cooperation with medical groups have in the last decade put increasing pressure on the United States Congress to look into and fund some of the most recent pipeline drugs for paediatric cancers. Conclusion Public pressure particularly from childhood cancer organisations has resulted in some new drug development, the first in nearly thirty years in the United States. Along with promising personalised and targeted therapies of very recent note these therapeutics come after a long struggle to begin to prioritise funding for children with cancer.

The classic school report comment of ‘could try harder’ could be applied to many of the abstracts submitted with papers to EJHP . It has been encouraging to see the quality and quantity of papers that have been submitted to EJHP improve over the last 3 years. My impression is that more pharmacists are seeking to publish their work and pharmacists who have not previously published have taken up the challenge. In an attempt to raise standards further, I want to focus on the abstract. One of the frequently seen weaknesses in original reports is the quality of the associated abstract. What do we want? Abstracts should restate all the key points of your paper. It will receive far more attention than your main paper as … Correspondence to Professor Phil Wiffen, Pain Research Unit, Churchill Hospital, Old Rd, Oxford OX3 7LE, UK; phil.wiffen{at}ndcn.ox.ac.uk

As a GP registrar who regularly prescribes antibiotics, I read Wong and colleagues’ paper on clarithromycin and cardiovascular outcomes and the associated editorial with interest.1 2 I disagree with the editorial in that the study contains only two, not three, separate study designs. My main concern with the paper is that the second study design simply shows, using two statistical methods, that people with …

A junior doctor who cited her senior colleagues without their knowledge as coauthors in papers that were later retracted for faulty or fabricated data has been suspended for 12 months by the Medical Practitioners Tribunal Service in Manchester. Gemina Doolub was working in cardiology for Oxford University Hospitals NHS Trust in 2013 when she submitted a research paper to ISRN Cardiology 1 and a research abstract to the Journal of the American College of Cardiology .2 In the research paper, submitted in or around February 2013, she cited Erica Dall’Armellina, a clinical research fellow at the John Radcliffe Hospital, as a coauthor, fabricating an email address for her. Neither Dall’Armellina nor …

A shortcut review was carried out to establish whether silibinin is better than conservative management at reducing liver transplantation and death after poisoning with amatoxin-containing mushrooms. Thirty-eight papers were found in Medline and 86 in EMBASE using the reported searches. Of these, five presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that the evidence is limited, but given the lack of alternative treatments in patients with suspected amatoxin-containing mushroom poisoning and the relatively few adverse effects, silibinin should be considered in some patients.

In January, 2015, I became the new Editor-in-Chief for the journal Sexually Transmitted Diseases. Taking over for Julie Schachter, who had been the Editor for 25 years, was a daunting task. He rescued the journal, nurtured it, and established it as a leading journal in our field. My job, simply put, is to maintain and strengthen it. Simultaneously, I will work to ensure that the high quality science in our field gets the attention it deserves. What do you need to do to get your research published in Sexually Transmitted Diseases? First and foremost, do good research. That is the key for publication in any journal. Second, communicate that research clearly and succinctly. Many of us do not write as clearly as we think we do. Third, be responsive to the reviewers. Our reviewers do their best to provide meaningful comments that will strengthen the communication of your work. Respect them. Respond to them. And only rarely should your response be a rebuttal. The best way to ensure that your paper is not accepted, even when it was close, is to dismiss the reviewers’ comments. Going forward, you can expect to see a few minor changes in the journal. We will publish more program-oriented papers, including some from workers in the field who are not necessarily “scientists”. We will also expand our coverage of HIV infection, focusing on HIV transmission, diagnosis, prevention, and monitoring, and excluding purely treatment studies. Generally, we will work to identify papers that will be difference-makers in the field of sexually transmitted diseases. We also will be increasing our focus on young investigators. We hope to facilitate the growth of the type of people attending this meeting – encouraging bright, talented scientists to choose sexually transmitted diseases research as their career.

Introduction Currently Sri Lanka uses a paper based monitoring and evaluation (M&E) system for the antiretroviral therapy (ART) program which was adapted and modified from the system introduced by the World Health Organization (WHO). These modifications have been adapted keeping in mind that significant disparities exist in different regions in the same country. This paper summarises the findings of the M&E system of the ART program in Sri Lanka where HIV epidemic is considered as low prevalent. Methods Information sources of the current ART M&E system was reviewed. Data generated by the M&E system is analysed to evaluate the ART program of the country. Results A cumulative total of 812 people living with HIV (PLHIV) were started on ART since the beginning of the ART program in 2004. Currently there are 647 PLHIV on ART. Of the patients who initiated ART, 75% of PLHIV are on first line ARVs and 5% are switched to second line ARV. The balance 20% comprised of loss-to-follow ups and deaths. The cohorts analysis of PLHIV on ART showed that after 12 months of ART initiation, 91% are Alive and on ART while 86% and 76% are Alive and on ART after 24 months and 60 months respectively. Conclusion A paper based M&E system can give very useful M&E information in a resource poor and low HIV prevalence setting. However, a development of a suitable online M&E system would greatly improve the data collection process as ART provision is a lifelong monitoring process. Disclosure of interest statement No grants were received in the development of this study.

Background Bibliometric analysis helps to determine the quantity and the quality of the research in a specialty or country. For rheumatology field Cheng et al. provided information about worldwide research productivity from 1996 to 2010. Even though, their overall research yields important data about research productivity in the field of rheumatology, as to our knowledge, there is no report was performed about Turkey9s contribution to rheumatology research until now. Objectives To investigate scientific papers published by Turkish Rheumatologists between 2007 and 2011 in the top 5 rheumatology journals according to 5-year impact factor. Methods Top 5 journals of rheumatology field, according to 5-year impact factor was determined from Web of Science as follows: Nature Reviews of Rheumatology, Annals of the Rheumatic Diseases, Arthritis & Rheumatology, Arthritis Care & Research and Arthritis Research and Therapy. These journals screened via their websites and all the scientific papers belong to 2007-2011 were included in the study. Papers such as Editor9s notes or Announcements were not included. Supplementary issues were not investigated neither. All papers were investigated one-by-one for detecting if they have a Turkish named author or Turkish institute. Articles published by a Turkish author or institute from Turkey were analyzed further. Citation counts of articles from Turkish authors were determined via Google Scholar and Web of Science databases. Results A total of 7,907 papers (Nature Reviews of Rheumatology: 672, Annals of the Rheumatic Diseases: 1977, Arthritis & Rheumatology: 2648, Arthritis Care & Research: 1313 and Arthritis Research and Therapy: 1297) were investigated. Totally 175 papers (2.21%) were found as at least one Turkish listed as an author. Annals of the Rheumatic Diseases (67 papers) was the top journal where Turkish authors published most. Among this 175 papers, authors informed that they contributed to the study from Turkey in 70 papers (40%). Other 60% were papers from Turkish origin authors who lives and researches outside of Turkey. USA (45 papers), Switzerland (24 papers) and the Netherlands (18 papers) were the top 3 countries where Turkish origin authors listed as their institution were in that country. These 175 articles were cited totally 18.085 times according to Google Scholar and 10.378 times according to Web of Science. Conclusions The total contribution and cite counts of Turkey are in accordance with the literature. According to our results more than 50% of the Turkish contribution to the rheumatology research comes from authors who research outside of the Turkey. Lack of research resources and other supports, financial issues and the value of the research effort in Turkey might contribute these results. References Cheng T, Zhang G. Worldwide research productivity in the field of rheumatology from 1996 to 2010: a bibliometric analysis. Rheumatology (Oxford). 2013; 52(9):1630-4. Disclosure of Interest None declared

Introduction Patient-reported outcome measures (PROMs) are usually completed on paper. Laptops, electronic (e/)tablets and smartphones are rarely used with palliative care patients and it is not known whether their use is feasible and acceptable in this population. Aim(s) and method(s) We explored whether palliative care patients find the use of e/tablets for PROMs data collection feasible and acceptable. To do this, we embedded a qualitative component within a larger study in two urban UK hospitals. We asked patients who completed PROMs on e/tablets or paper to complete a brief structured telephone survey followed by a semi-structured discussion of any issues experienced. Additionally, research nurses who supported patients during completion were interviewed. Results Ten patients (70% male; age range 33–87; 30% non-cancer diagnosis) and two research nurses took part. Satisfaction with either format was high, and most found both easy to read, use and navigate. Emerging themes highlighted advantages and drawbacks of each format: Those who used paper valued the simplicity and familiarity of this format. Those who used e/tablets particularly liked the immediate transfer of their responses to electronic records and their clinician. However, several issues with e/tablets were also raised, including poor responsiveness to touch, connectivity problems and weight. Conclusion(s) E/tablet use is feasible and has potential to improve collection and use of PROMs by clinicians. However, for maximum utility, e/tablets need to be touch responsive, well connected, and lightweight, and integrated into clinical databases with real time feedback. Funder: the National Institute for Health Research—Programme.

A recent joint publication by the Royal College of Physicians and Royal College of Nursing raised concern regarding the variability in the organisation and quality of documentation during ward rounds [1]. The aim of the study was to evaluate the standard of medical documentation at a University Teaching Hospital. Retrospective manual analysis of patient's paper and electronic paper records (EPR) from the different specialties. Inclusion criteria included in-patient stay of more than two days and admission after 1st July 2013. A VTE assessment was available in 100% of patients. The plan and postoperative instructions were available in 100% of patients. Notes were documented contemporaneously in 75% of cases which increased to 80% in the second following by 89.11% in the third cycle. If a consultant was present on the ward round this was documented in 80% of cases in the first cycle. This subsequently increased to 90% in the second cycle and 100% in the third cycle. Overall the quality of medical documentation was of a reasonable standard but could be improved even further if we continue to document contemporaneously and name every person present at each patient encounter.

Last week I suggested that nutrition was more important in medicine than some of us had thought (doi:10.1136/bmj.g7255). This week we publish letters in response to our most widely read paper of the year so far, on milk consumption and mortality (doi:10.1136/bmj.g6993, doi:10.1136/bmj.g6995, doi:10.1136/bmj.g7000, doi:10.1136/bmj.g7006, doi:10.1136/bmj.g7012). The paper, by Michaelsson and colleagues ( BMJ 2014;349:g6015, doi:10.1136/bmj.g6015), reported analyses from two large prospective Swedish cohorts and raised the possibility that milk could increase the risk of hip fracture in women and cardiovascular and overall mortality in both sexes. When researchers conclude that a ubiquitous and much championed component of …

Introduction People are increasingly mobile for numerous reasons, including healthcare. Patient mobility has vast implications for individuals, communities and whole populations and yet, to date, research on patient mobility has been quite limited. Only a small body of evidence exists on patient mobility between low-income and middle-income countries, instead having focused primarily on cross-border movement between high-income and low-income countries. In this paper, we present a protocol for examining this under-studied phenomenon. Methods and analysis We propose to examine patient mobility between low-income and middle-income countries using a realist synthesis approach. Specifically, we aim to document why patients from low-income and middle-income countries cross international borders for healthcare, by identifying the mechanisms through which patients decide to cross-borders, and the contextual characteristics of domestic health markets that influence this choice. An underlying theory was established, based on the lead author's experience and a brief literature review, which will provide the basis to analyse search results in a subsequent paper. Search results will be obtained from databases (Ovid Medline, EMBASE, Scopus, EconLit, Web of Science) and the grey literature. An expert committee will be enlisted, prior to screening results, to review search results to ensure comprehensiveness. Based on this preliminary theory, we propose that, in some low-income and middle-income country markets, the interaction between demand-side and supply-side determinants results in market imperfections that, in turn, lead to patient movement across borders. Ethics and dissemination The study does not involve primary research and, therefore, does not require formal ethical approval; we do, however, follow the relevant standards of utility, usefulness, feasibility, propriety, accuracy and accountability. The standards of realist and meta-narrative evidence synthesis (RAMESES) will be adhered to in reporting the findings of the review. Once completed, the findings of the resulting manuscript will be published in a peer-reviewed journal. Trial registration number This protocol has been registered with PROSPERO, registration number CRD42014014391.

Researchers have described as “disappointing” a journal’s decision not to retract a paper that they said was skewing the results of meta-analyses and had made guidelines on protecting the heart of patients undergoing surgery unreliable and dangerous. Graham Cole and Darrel Francis, of Imperial College London, called for the New England Journal of Medicine to retract a research paper by Don Poldermans on the use of β blockers to reduce the risk of myocardial infarction in patients having high risk surgery1 after they published an analysis of the research in The BMJ on 29 August this year.2 Poldermans, a prominent professor of perioperative cardiovascular care at Rotterdam’s Erasmus Medical Centre, was suspended from his post in 2010 after a junior researcher raised concerns about studies he had led for 10 years, called the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo (DECREASE) studies. In 2011 Poldermans was dismissed for “serious violations of scientific integrity” in his research and found guilty of research misconduct, although this was not specific to the DECREASE I study,3 on which Cole and Francis have focused. The DECREASE I study, which included 112 patients, found that the β blocker bisoprolol reduced the …

For the early career researcher or PhD student about to have a leading role in a clinical trial, it would be a tremendous help to have a ‘How to’ guide, consisting of advice and key literature to help the researcher move successfully along the initial trial pathway from research question to protocol completion. While the ideal trial team should include experienced trialists, who participate in the preparatory research meetings, this support is not always available. The PREPARE Trial guide is intended to assist the early career researcher in this situation, but not replace an experienced trial team and regular research meetings. The guide may also serve as preparation for research meetings, or part of curricula for courses on research methodology, to be used by experienced PhD supervisor, trialist or lecturer. Evidence from randomised controlled trials (RCTs) is often wasted1 2 (for a collection of papers relating to this issue, please see http://researchwaste.net/). Many trials are not published, and hence the results are not reported, which is indeed a waste. There are many reasons for this waste, but we believe that at least some trials are discontinued because of poor trial planning. Similarly, many completed and published trials suffer from fundamental flaws or poor conduct due to lack of preparation and careful planning. Some flaws in the conception or planning phase prior to the finalised trial protocol and registration are difficult to rectify once the trial starts. For example, patients may decline participation if the study involves delaying or withholding treatment, or if the experimental condition is deemed unfeasible by patients. This can be avoided, for example, by involving patients in the planning of the trial or by conducting pilot or feasibility studies prior to the full-scale trial. In many cases, the planning of a trial is as least as important as …

Many potential therapeutic agents are discarded before they are tested in humans. These are not quack medications. They are drugs and other interventions that have been developed by responsible scientists in respectable companies or universities and are often backed up by publications in peer-reviewed journals. These possible treatments might ease suffering and prolong the lives of innumerable patients, yet they have been put aside. In this paper, we outline a novel mechanism-the Plutocratic Proposal-to revive such neglected research and fund early phase clinical trials. The central idea of the Proposal is that any patient who rescues a potential therapeutic agent from neglect by funding early phase clinical trials (either entirely or in large part) should be offered a place on the trial.

Background Evidence-based medicine (EBM) has evolved over a century. EBM is now the guiding principle of medical practice. High-level EBM usually derives from a well-designed, randomised, double blind, placebo controlled trial of parallel groups and sufficient number of patients enrolled. However, in recent times, concerns of EBM misguiding clinical practice have been on the rise. This paper aims at exploring the root cause of why EBM is perhaps losing its touch as the measuring standard of clinical practice. Method History of EBM and criteria of determining a well-designed and conducted trial were reviewed. The impact of pharmaceutical industry on EBM has been elucidated. The percentage of clinical trials that were sponsored by the pharmaceutical industry was calculated. Some of the wrong motives of conducting clinical research were identified. Result To some extent, EBM may have contributed to overdiagnose or overuse of medicine. Nearly 46% of clinical trials were financed by pharmaceutical companies. About 90% of manuscripts printed might not need to be published. Many trials contained at least one outcome that did not match its initial specification as registered. Conclusions While EBM continues to be the guiding principle, clinicians should be aware of potential tainted results. In the future, big data is likely going to offer us a new aspect of EBM and arm us with more comprehensive data when we make our clinical decisions.

Background Antiretroviral therapy (ART) has significantly altered the pattern of acute and chronic HIV-related disease. However, it is not clear what this means in terms of respiratory symptoms. We sought to investigate the association between HIV status and respiratory symptoms and how these have changed with the availability of ART. Methods We searched Cochrane, Medline and Embase databases for studies published between 1946 and August 2015 comparing the prevalence of respiratory symptoms in populations with and without HIV infection. We undertook random effects meta-analysis of the main symptoms reported. We studied heterogeneity and completed sensitivity analyses and funnel plots. Results From 5788 unique references identified, 24 papers provided relevant data: 18 documented the prevalence of cough and 11 examined the prevalence of breathlessness among other symptoms reported. Compared with the HIV negative, people living with HIV (PLWH) were more likely to have respiratory symptoms with pooled ORs for the prevalence of cough of 3.05 (95% CI 2.24 to 4.16) in resource-limited populations without access to ART; 2.18 (1.56 to 3.18) in resource-rich populations without access to ART and 1.11 (0.99 to 1.24) in resource-rich populations with access to ART. In resource-rich settings, although the availability of ART was associated with a reduction in the difference between HIV-positive and HIV-negative individuals, PLWH were more likely to report breathlessness, OR 1.39 (95% CI 1.11 to 1.73). Conclusions Respiratory symptoms are more common in PLWH than controls. This association persists although at a reduced level in populations with access to ART.

In 2002, Charles Vincent and Angela Coulter published what would become a seminal paper in the field of patient safety.1 Their argument was simple and compelling—that patient safety could be improved through the greater involvement of patients and their families. Over the past decade, the healthcare landscape has evolved, with patients and families now firmly placed at the centre of care design and delivery in both policy, and increasingly practice. However, as highlighted in two papers2 ,3 published in this issue of BMJ Quality & Safety , there remain significant challenges in the meaningful integration of the patient perspective in improving the safety of care. Why does involving patients in safety improvement remain so hard? In this editorial, we propose a number of reasons, before considering some potential future opportunities for improving the involvement of patients and their families. Ocloo and Matthews outline a range of reasons why achieving genuine patient involvement presents challenges, before concluding that “current involvement practices at a national and local level often involve a narrow group of individuals…”.2 While their comments mainly relate to the lack of diversity of patient involvement in healthcare improvement, the same can also be said about the representativeness of patients within the very research that seeks to provide evidence to underpin wider involvement. Some of the most vulnerable patients are often excluded from research exploring the involvement of patients in patient safety—for example, patients unable to speak the host country language or frail elderly patients with delirium or dementia. These research restrictions make ethical sense insofar as patients cannot provide informed consent, but they skew the existing empirical literature by excluding the very patients that are most at risk for experiencing adverse events, such as the elderly4 and non-native language speakers.5 What we know …

Aim Physical activity in children improves cardiovascular, mental, metabolic and skeletal health. Many children fail to meet the national recommendation of at least 60 min per day of moderate-to-vigorous physical activity (MVPA). After-school programmes provide an opportunity to engage children in physical activity. This systematic review and meta-analysis examine the effectiveness of after-school interventions at increasing MVPA levels in children and adolescents. Design Systematic review and meta-analyses. Data sources A literature search was conducted using MEDLINE, EMBASE and PsychINFO databases from January 1950 to April 2015. Eligibility criteria for selecting studies Inclusion criteria—Population: participants aged 5–18 years. Intervention: an after-school programme in a school-based setting as the main component of an intervention to increase physical activity levels. Outcomes: individual-level measure of time spent in MVPA. Study design: quasi-experimental, pilot, non-randomised or randomised trials. Exclusion criteria: conference abstracts, unpublished articles, dissertations and non-English language papers. Results 1387 records were identified through database searching. After removal of duplicates, there were 748 records. 15 articles met the inclusion criteria for the systematic review. 6 studies were eligible for meta-analysis and the pooled intervention effect at end point follow-up was 4.84 min/day of MVPA (95% CI −0.94 to 10.61). The effectiveness of after-school interventions varied considerably and comparisons between studies limited by different methodological study designs. Subgroup analyses within a small minority of studies revealed significant benefits in overweight/obese children and boys. There was a lack of convincing evidence that interventions based on theories of behaviour change were more effective than those with no underlying theory. Conclusions After-school physical activity interventions to date have had mixed effectiveness on increasing MVPA levels. More robust evaluations of extracurricular physical activity interventions are required, particularly studies that use objective assessment of physical activity.

A 6-year-old girl attends your general paediatric outpatient clinic. She describes intermittent pain in both legs over a period of 4 months. The pain is worse at night. She is otherwise well and clinical examination is normal. Blood tests sent by her general practitioner are normal except for a vitamin D level of 35 nmol/L. You make a diagnosis of growing pains and wonder whether there is any evidence to support giving vitamin D in the management of growing pains. Is treatment with vitamin D an effective management option in a 6-year-old girl with growing pains? We searched PubMed and Medline (1946–present) using the key words: ‘Vitamin D’ AND ‘child* OR adoles*’ AND ‘growing pains’. The search was performed in June 2017. The results were filtered to include only English articles. The PubMed search yielded 14 results. Following review of the titles and abstracts five articles were identified for full-text review. The Medline search yielded five results. These were the same five articles identified for full-text review in our PubMed search. After a detailed appraisal of these five articles, we selected four papers which we felt adequately addressed the clinical question. No further …

> ‘To improve is to change; to be perfect is to change often.’ > > —Winston Churchill Health professions regulatory authorities are responsible for assessing the clinical performance of healthcare professionals.1 2 Some of them also have the responsibility for programming remediation interventions for health professionals with deficits in clinical performance.2 3 Available data on medical errors, malpractice claims, disciplinary actions and various other sources suggest that between 6% and 12% of physicians meet criteria for ‘dyscompetence’ in the USA.4 5 Elsewhere, the percentage varies according to the data sources.6 In Ontario, for instance, where the data come from randomly selected physicians, it is estimated that approximately 15% of family physicians and 3% of specialists have considerable deficiencies.4 7 8 Performance problems can have an impact on quality of care and patient safety.5 Consequently, the problems must be addressed promptly and effectively. The present article by Weenink et al provides a systematic review of the outcomes of rehabilitation and remediation programmes for healthcare professionals.6 The authors’ systematic review revealed that the literature comes primarily from North America and that many papers …