Information science

To the Editor: Like Haley’s father,1 I too lament the fact that Latin terms have fallen out of use in medical terminology. I also think it retrograde that Latin is being taught to fewer and fewer of our secondary students, as they are missing out on an opportunity to learn so much more about our own language, let alone terms that they might use later in their clinical practice. However, I do not think that it was Latin that helped the young teacher out of a difficult predicament in the 1950s. I can assure Haley that “pseudocyesis” is all Greek to me.

Peter Piazza

To the Editor: Thank you for the charming letter about “non-pseudocyesis” published in the 19 March issue.1 It reminded me of the Brander Matthews quote: “A gentleman need not know Latin, but at least he should have forgotten it.” This is particularly apt, as the term “pseudocyesis” is from Greek.

James Mitchell

To the Editor: The tale told by Katherine Haley’s father about his clever advice on how to protect the privacy of a young pregnant woman makes a good story.1 However, while “non” is a Latin word, “pseudocyesis” is very good Ancient Greek (ψευδοκύησις). Queen Mary I (“Bloody Mary”), who was believed for many months to be with child but ultimately returned to court childless, may have suffered from pseudocyesis. I agree with Dr Haley’s opinion about the lamentable decline in the use of both Latin and Greek terms in medical practice. I take the time to teach my students, residents and registrars enough Latin and Greek to render classical plurals correctly (eg, fistulae, diverticula, carcinomata). Whether they take any notice of this classical teaching is another matter.

William E M Renton-Power

To the Editor: I was both delighted and a little perturbed to read the recent letter by Katherine Haley about her general practitioner father who outsmarted the Department of Education by a medical sleight of hand, stating that his patient had “non-pseudocyesis”.1 However, it was not Latin, but Greek, that did the trick. Despite Dr Haley’s background in Latin, he, like all physicians, had unwittingly used Greek during his medical course. I was fortunate to do a year of Ancient Greek during my undergraduate medical course and, like my late GP father, also did Latin for matriculation. It is unfortunate that Greek is no longer taught in Queensland schools, and Latin only in a few. I believe that we are the poorer for this, and it shows in all sorts of ways, including a general decline in literacy even at the tertiary level. A classical grounding demands scholarship and precision. I have found that knowledge of both Greek and Latin has enriched my knowledge of English literature and Western philosophy, as well as French. Such a grounding also trains the mind in analytical and ordered thought and provides greater insight into the workings of syntax and grammar and a greater facility with words — the building blocks of our language, many of which are derived from Greek and Latin. At the risk of stating the obvious, I will remind readers that anatomical words in medicine are predominately Latin or Greek and that the names of nearly all symptoms and diseases are Greek (with some exceptions, such as “angina pectoris”). In Dr Haley’s time, it was common for potential doctors to receive an arguably more “polished” education that embraced one or two languages, including Latin and, in some private schools, Greek. Alas, the current system of medical student selection favours those “idiots savants” who excel in mathematics and science and not the arts. With respect, I would like to point out that in the term “non-pseudocyesis”, the only Latin component is “non”, the rest being Greek (ψευδής, false; κύησις, pregnancy). For both the enthusiast and the non-classicist, may I recommend my father’s 5th edition of Gould’s medical dictionary (1943), which contains the etymology of every medical word.

Roger K A Allen

Re: “Management outcomes of patients with type 2 diabetes: targeting the 10-year absolute risk of coronary heart disease”, by Tuck Y Yong, George Phillipov and Patrick J Phillips, in the 18 June issue of the Journal (Med J Aust 2007; 186: 622-624). There was an editing error introduced in the Results section of the Abstract of this article. The first sentence should have read: Results: 42%, 61% and 43% of patients were receiving medication to treat hyperglycaemia, hypertension and hypercholesterolaemia, respectively; 46%, 29% and 15% of patients, respectively, had achieved the recommended RACGP target values for HbA1c, blood pressure, and total cholesterol; and 22% of patients were current smokers. The html and pdf versions of this article have been corrected. Re: “Research misconduct: can Australia learn from the UK’s stuttering system?”, a letter to the Editor by Peter T Wilmshurst in the 18 June issue of the Journal (Med J Aust 2007; 186: 662-663). In the editing of this letter, we incorrectly stated that the “Editor’s choice” column in the British Medical Journal, entitled Corruption in medicine,1 was only published online and thus was no longer available, as it had been removed, to avoid litigation, from the online version (together with the article by Wilmshurst that it was linked to). However, the column was also published in the paper journal and is still available there (as is the article2). The html and pdf versions of this article have been corrected.

An update on the requirements of ICMJE’s clinical trial registration policy In 2005, the International Committee of Medical Journal Editors (ICMJE) initiated a policy requiring investigators to deposit information about trial design into an accepted clinical trials registry before the onset of patient enrolment.1 This policy aimed to ensure that information about the existence and design of clinically directive trials was publicly available, an ideal that leaders in evidence-based medicine have advocated for decades.2 The policy precipitated much angst among research investigators and sponsors, who feared that registration would be burdensome and would stifle competition. Yet, the response to this policy has been overwhelming. The ICMJE promised to re-evaluate the policy 2 years after implementation. Here, we summarise that re-evaluation, specifically commenting on registries that meet the policy requirements, the types of studies that require registration, and the registration of trial results. As is always the case, the ICMJE establishes policy only for the 12 member journals (a detailed description of the ICMJE and its purpose is available at http://www.icmje.org), but many other journals have adopted our initial trial registration recommendations, and we hope that they will also adopt the modifications discussed in this update. Key summary points In addition to accepting registration in any of the five existing registries, the International Committee of Medical Journal Editors (ICMJE) will accept registration of clinical trials in any of the primary registers that participate in the World Health Organization’s International Clinical Trials Registry Platform. Registration in a partner register only is insufficient. The ICMJE will begin to implement the WHO definition of clinical trials for all trials that begin enrolment on or after 1 July 2008. This definition states that a clinical trial is “any research study that prospectively assigns human participants or groups of humans to one or more health-related interventions to evaluate the effects on health outcomes.” The ICMJE will not consider results posted in the same clinical trials registry in which the initial registration resides to be previous publication if the results are presented in the form of a brief, structured (< 500 words) abstract or table. The research community has embraced trial registration. Before the ICMJE policy, ClinicalTrials.gov, the largest trial registry at the time, contained 13 153 trials; this number climbed to 22 714 one month after the policy went into effect.3 In April 2007, the registry contained over 40 000 trials, with more than 200 new trial registrations occurring weekly (D Zarin, Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health, Bethesda, Md, USA, personal communication). The four other registries that meet the ICMJE criteria have also grown, as scores of journals have adopted the ICMJE clinical trials registration policy. In response to burgeoning registration, many investigators, sponsors, and government agencies have asked the ICMJE to recognise their local registries as databases that meet the policy requirements. Fortunately, the World Health Organization’s International Clinical Trials Registry Platform (ICTRP), which was nascent when the ICMJE began to require trial registration, has matured rapidly and provides options for those who desire a wider array of registries. The ICTRP has taken the first steps toward developing a network of primary and partner registers that meet WHO-specified criteria.4 Primary registers are WHO-selected registers managed by not-for-profit entities that will accept registrations for any interventional trials, delete duplicate entries from their own register, and provide data directly to the WHO. Partner registers, which will be more numerous, will include registers that submit data to primary registers but limit their own register to trials in a restricted area (such as a specific disease, company, academic institution, or geographic region). The ICMJE strongly supports the WHO’s efforts, through the ICTRP, to develop a coordinated process for identifying, gathering, de-duplicating, and searching trials from registries around the world, thus eventually providing a one-stop search portal for those seeking information about clinical trials. In addition to the five existing registries, the ICMJE will now also accept registration in any of the primary registers that participate in the WHO ICTRP. Because it is critical that trial registries are independent of for-profit interests, the ICMJE policy requires registration in a WHO primary register rather than solely in a partner register, since for-profit entities manage some partner registers. As previously, trial registration with missing or uninformative fields for the minimum data elements is inadequate.1 Initially, the ICMJE required registration of all clinically directive trials, which it defined as “any research project that prospectively assigns human subjects to intervention or comparison groups to study the cause-and-effect relationship between a medical intervention and a health outcome”.1 In May 2005, the ICMJE clarified this definition to exclude preliminary trials designed to study pharmacokinetics or major unknown toxicity (phase I trials).5 However, the ICMJE recognises the potential benefit of having information about preliminary trials in the public domain, because these studies can guide future research or signal safety concerns. Consequently, the ICMJE is expanding the definition of the types of trials that must be registered to include these preliminary trials and adopts the WHO’s definition of a clinical trial: “any research study that prospectively assigns human participants or groups of humans to one or more health-related interventions to evaluate the effects on health outcomes”.4 Health-related interventions include any intervention used to modify a biomedical or health-related outcome (eg, drugs, surgical procedures, devices, behavioural treatments, dietary interventions, and process-of-care changes). Health outcomes include any biomedical or health-related measures obtained in patients or participants, including pharmacokinetic measures and adverse events. As previously, purely observational studies (those in which the assignment of the medical intervention is not at the discretion of the investigator) will not require registration. The ICMJE member journals will start to implement the expanded definition of clinically directive trials for all trials that begin enrolment on or after 1 July 2008. Those who are uncertain whether their trial meets the expanded ICMJE definition should err on the side of registration if they wish to seek publication in an ICMJE journal. Over the time during which registration of trial methods has become common practice, several forces have begun advocating for registration of trial results. We recognise that the climate for results registration will probably change dramatically and unpredictably over coming years. For the present, the ICMJE will not consider results posted in the same primary clinical trials register in which the initial registration resides as previous publication if the results are presented in the form of a brief, structured (< 500 words) abstract or table. The ICMJE favours a standard abstract format for results reporting, and the CONSORT (Consolidated Standards of Reporting Trials) group’s forthcoming guidelines for abstracts related to trials may be one such option. The ICMJE believes that parties interested in results registration should consider requiring the deposition of such an abstract in the registry 24 months after closure of data collection if results are not published in a peer-reviewed venue by that time. The registered abstract should either cite any related full, peer-reviewed publications or include a statement that indicates that the report has not yet been published in a peer-reviewed journal. Researchers should be aware that editors may consider more detailed deposition of trial results in publicly available registries to be prior publication. When submitting a paper, authors should fully disclose to editors all posting in registries of results of the same or closely related work. Three years ago, trial registration was the exception; now it is the rule. Registration facilitates the dissemination of information among clinicians, researchers, and patients, and it helps to assure trial participants that the information that accrues as a result of their altruism will become part of the public record. The WHO’s global efforts towards comprehensive trials registration and the ICMJE’s requirements for registration aim to increase public trust in medical science.

Christine Laine MD, MPH, Senior Deputy Editor · Richard Horton FMedSci, Editor · Catherine De Angelis MD, MPH · Jeffrey M Drazen MD · Frank A Frizelle MB ChB, MMedSc · Fiona Godlee MB BChir, BSc · Charlotte Haug MD, PhD, MSc · Paul C Hébert MD · Sheldon Kotzin MLS · Ana Marusic MD, PhD · Peush Sahni MD, PhD · Torben V Schroeder MD, DMSc · Harold C Sox MD · Martin B Van Der Weyden MD · Freek W A Verheugt MD

To the Editor: In his article on research misconduct,1 Marcovitch cited my article on institutional corruption in medicine, which was published in the BMJ in 2002.2 He states: Readers of the MJA will have to find the paper version in their libraries, as the electronic version has been replaced on the BMJ’s website . . . with the bald statement that it has been removed for legal reasons. In case any of your readers are concerned that the article has been retracted, I would like to point out that the article was removed from the website on 10 June 2004, when Dr Richard Smith was editor of the BMJ. Dr Smith cited my article in his own article on research misconduct in 2006.3 He would not have done so if the article had been retracted. Neither would Marcovitch.1 My article described how some senior individuals in British academic medicine had concealed misconduct for a decade. The article had an editorial footnote stating: “Documentary evidence corroborating this article was made available by Dr Wilmshurst to the BMJ.” It was cleared for publication by the BMJ’s lawyers. An “Editor’s Choice” column entitled Corruption in medicine accompanied my article online.4 That column has also been removed from the website. It stated: “The article by Wilmshurst has its origins in a seminar he gave to the BMJ in 1996. For years he had been informing us of misdemeanours. Fear of libel stopped us from publishing.”4 Ironically, it was fear of libel actions that caused the BMJ to remove the article from the website. Soon after publication, the BMJ received threats of libel actions from academics and their institutions. Dr Smith and I spent considerable time working with lawyers to counter these challenges. None came to court, but the legal costs for the BMJ’s insurers mounted. It was pointed out that a libel action must be started within 1 year of publication. Because the article was on the website it was constantly being republished. If it was removed from the website there could be no more threats of litigation after 1 year. Therefore, the insurance company that covers the BMJ against libel insisted that the article be removed from the website. If readers are unable to get a copy, they can email me and I will send a PDF version.

Peter T Wilmshurst

Authors of articles reporting clinical trials should discuss the results of their trial in the context of existing evidence. This approach is encouraged by the CONSORT statement (Box 1).1 A trial’s contribution to the evidence can be pinpointed by seeking answers to questions such as: How do the results apply in a broader clinical context and patient population? Do they confirm or contradict the existing evidence? Do they confirm current clinical practice or suggest that a change may be needed? Do they point to the next question that should be studied? A complete picture of the trial results includes how the findings apply to other patients, how they guide or change practice, how they relate to prior knowledge (possibly by a systematic review of the evidence), and any new questions raised. What do the results mean in real-world clinical practice?Are the trial participants representative of the patients being considered for treatment?Trials usually focus on single interventions, but clinical practice is complex, and the features of the clinical practice environment — intercurrent illnesses, use of other drugs, mood, compliance, and access to services — need to be taken into account. This can limit our understanding of how widely the results can be safely applied. For example, trials aiming to prevent stroke using antithrombotic therapies among patients with atrial fibrillation have recruited as few as 20% of eligible patients — often excluding older patients, women and people with previous cerebrovascular disease,2 leading to uncertainty about the net benefit of such treatment in these groups. Does the study question relate to the patients being considered for treatment?It is worth reflecting on the question addressed by the study, as results may be misconstrued. One of the Women’s Health Initiative (WHI) group’s large studies of hormone replacement therapy (HRT) for postmenopausal women serves as an example.3 The study was undertaken to determine whether, compared with placebo, long-term combined oestrogen and progestin would reduce cardiovascular events. It was already known that short-term HRT relieves symptoms of menopause, such as hot flushes. It was also known that long-term HRT increases the risk of breast cancer, but it was hoped that this risk might be offset by better cardiovascular outcomes. However, the trial of combined HRT, over an average of 5.2 years (the trial was stopped early), showed an increase in breast cancer and cardiovascular events with HRT use.3 When the WHI reported the results,3 widespread confusion followed, because many people interpreted these findings as relating to short-term use of HRT to relieve menopausal symptoms. Many women stopped using short-term and long-term HRT. The WHI trial was well designed and might, of itself, be regarded as sufficient evidence for clinicians to no longer consider HRT to prevent cardiovascular disease. The research question was not “What are the effects of short-term use of HRT in newly menopausal women with significant symptoms?”; the safety of short-term HRT for control of menopausal symptoms is still unresolved.4 Randomised trial or systematic review?Individual randomised trials and systematic reviews (including meta-analyses) are similar but not identical means of arriving at health care evidence, and each has its place. They have different strengths within the broad common purpose of establishing the efficacy (or otherwise) of interventions. Thus, a highly specific clinical question (Is X mg of a therapy better than Y mg after a heart attack?) would probably best be answered by a single appropriately powered study. But even where relatively large trials have been done, treatment effects can be modest, and a meta-analysis of several trial results may be a useful way of showing that there is statistically robust evidence to support a change in clinical practice. For example, before a large-scale review of early breast cancer trials,5 it was known that postoperative tamoxifen is effective in preventing recurrence of cancer in postmenopausal women, but it was unclear whether this applied to premenopausal women. The review, which included an updated meta-analysis of all available trials, was able to show a clear benefit (2P < 0.00001) in the premenopausal group. The same dataset definitively answered a subsidiary question: survival was longer after 5 years of treatment than 2 years of treatment. These two observations changed clinical practice, and thousands of lives were potentially saved. Meta-analyses may further refine conclusions by also considering variation in the treatment dosages.6,7 Randomised trial with a meta-analysisPresenting a meta-analysis as part of the study report helps to show the consistency of the new results with other existing evidence. A forest plot of the results with the published trial evidence will help readers judge the consistency of the results of individual trials and the reliability of the accumulated evidence (Box 2).8 Do the results confirm current clinical practice or suggest a change?Trial results that confirm results of previous studies (particularly in a different patient population) might justify a change in clinical practice or even discontinuing further trials of the same clinical question. For example, lipid-lowering statins given to patients after myocardial infarction are known (from trial evidence) to reduce subsequent cardiovascular events in a general, predominantly male population. A trial substudy testing statins in women also shows possible efficacy.9 Given what was known previously, the burden of proof may be lower, such that this trial may be sufficient to affect clinical practice. On the other hand, if the findings of the current study contradict those of previous studies, possible explanations for the discrepancy should be acknowledged and discussed. A change in clinical practice would only be advocated if the results of the new trial significantly outweighed previous evidence in terms of design, adequacy of follow-up, and statistical strength (Box 3). There will always be some legitimate disagreement about the overall significance of individual trial results; one person’s “definitive” results will be another’s “interesting”, “thought-provoking” or “hypothesis-generating” results. Extensive extrapolation may lead to erroneous conclusions; too little or slow extrapolation may retard improvements in clinical practice. However, there are some helpful guidelines, illustrated by the following examples. Look for biological plausibility: A randomised placebo-controlled trial of folate supplementation during pregnancy confirmed benefits in neonatal outcomes. After decades of follow-up, an unexpected increase in mortality from breast cancer was found. This could be related to the folate therapy, but the result may be a chance finding, and would not be considered biologically plausible at our current level of understanding. In this scenario, women should probably be advised to maintain adequate folate intake around the time of conception, unless further evidence about breast cancer risk emerges.10 Interpret the statistical findings for clinical relevance: If multiple outcomes in a single trial are similarly affected by the treatment, some effects may be significant and some non-significant simply because of the differing numbers of events and by the play of chance. For example, a trial in early breast cancer reported that treatment with an aromatase inhibitor resulted in fewer recurrences of the cancer (measured as the disease-free survival period) than treatment with tamoxifen (P = 0.003).11 There was no statistically significant treatment effect for overall survival (P = 0.16). At first glance, this might be interpreted as statistical inconsistency across the two outcomes (Box 4). However, the confidence interval for the effect of treatment on mortality extends to plausible worthwhile clinical benefits, so it would be incorrect to rule out a useful survival benefit. Given that that there were relatively few cancer recurrences, a significant survival advantage might still emerge with longer follow-up. A reasonable conclusion would be that “there were fewer deaths in the aromatase inhibitor arm of the trial, but this difference was not beyond the play of chance”. Efficacy is not the only issue: Adverse effects are always important, but take on added significance when efficacy is modest or when we are treating essentially well patients to modify the risk of some future adverse event. Lipid-lowering drugs to prevent heart attacks, blood pressure drugs to prevent strokes, adjuvant chemotherapy to reduce the risk of cancer recurrence, and tamoxifen to prevent a first breast cancer are all examples where large trials have shown modest efficacy. Drug efficacy is usually more carefully measured and reported than toxicity or quality of life and, perhaps understandably, is more readily trumpeted. Nevertheless, once we have established the biological effect of a drug and how confident we are about this, we should then consider at what cost this was achieved. This might involve formal and complex analyses, such as health economics studies and synthesis of quality-of-life data, but in the shorter term we should also be prepared to make a rough and ready judgement. Financial cost, extra time spent in hospital or doctors’ rooms, extra blood tests and x-rays, as well as adverse effects, all count as costs against which to judge any improvements in clinical outcomes. The patient may also have strong views that need to be taken into account. Cancer patients, when asked, will often accept significant inconvenience and drug toxicity for surprisingly small benefits.12 Do the results point to the future or new questions that should be studied?Randomised trials are the critical units of evidence when the average benefits and harms of interventions are considered. In addition to a statement of the generalisability of the findings,13 the overall context of the trial results must be incorporated into the discussion. The authors’ pragmatic conclusions on the immediate implications for everyday clinical practice (or regulatory decisions), as well as what might constitute the next scientific or clinical question to arise from the current findings, are integral to a report of new evidence. 1 CONSORT checklist of items to include when reporting a randomised trial1 Section and topic Item no. Descriptor Discussion Overall evidence 22 General interpretation of the results in the context of current evidence 2 Forest plot of a meta-analysis of a new study (LIPID) with previous studies (4S, CARE) of statin therapy for preventing further cardiovascular events in people with diabetes and existing coronary heart disease8 Combining results from these trials leads to a statistically significant finding of a beneficial treatment effect for statins. For stroke, statin therapy has no significant treatment effect in the individual trials; when data for all patients are combined, a reduction in risk with statin therapy is seen. The black squares are proportional to the number of events (here, CHD events or strokes) in the analysis. CHD event = death from coronary heart disease or non-fatal myocardial infarction. 4S = Scandinavian Simvastatin Survival Study (Arch Intern Med 1999; 159: 2661-2667). CARE = Cholesterol and Recurrent Events (Circulation 1998; 98: 2513-2519). LIPID = Long-Term Intervention with Pravastatin in Ischemic Disease (N Engl J Med 1998; 339: 1349-1357). 3 Various trial result scenarios and possible implications for clinical practice Trial outcome Population studied Implications of the results in clinical practice Benefit First studied Is there sufficient evidence to change practice or are confirmatory trials needed? The trial report should propose and discuss these questions. Confirms previous results Same as previous population Change practice (if therapy is cost-effective) Confirms previous results New population Is there enough evidence or are more data needed to extend the treatment indication to the new population? Apparently contradictory results, compared with previous studies Same as previous population Is there an explanation for the result? Is there evidence of significant heterogeneity between the trials? Does not confirm previous results New population Is the difference in effect of treatment between populations biologically plausible? How strong is the evidence from the trials? Are more trials needed before the evidence is enough to support different guidelines in different populations? 4 Forest plot showing hazard ratios for disease-free survival (time to recurrence of breast cancer) and overall survival for an aromatase inhibitor, letrozole (4003 patients), compared with tamoxifen treatment (4007 patients)11 The median follow-up was about 2 years. The graph shows that disease-free survival was better in the letrozole group. Fewer women died in the letrozole group, but overall survival appears not to differ between the treatment groups. The black squares are proportional to the number of events (here, recurrences and deaths) in the trial.

Nicholas R Wilcken MB BS, PhD, FRACP · Val J Gebski BA, MStat · Rhana Pike MA, ELS · Anthony C Keech MB BS, FRACP, MSc(Epi)

Verbal medicine. Twenty-one contemporary clinician–poets of Australia and New Zealand Tim Metcalf, editor. Canberra: Ginninderra Press, 2006 (148 pp). ISBN 1 74027 369 9 When I sit on medical curriculum advisory committees, I hear that the subjects studied and examined to gain entry to medical courses, and the courses themselves, have become too focused, too narrow, too mechanistic, too concentrated on sciences and biology. I hear that our students lack sufficient exposure to literature and philosophy to cope with the intense emotional impact of the blessing and the curse that is the life of a doctor. I worry that so many colleagues are at risk of emotional burnout. It has been said that there is no greater tragedy than an unexamined life. This book of poems by 21 contemporary Australasian clinician–poets is a delight, but it is no light read. I could not read it all in one sitting as each poem is strong and powerful. Verbal medicine goes a long way towards examining what it means to be a doctor, and how it feels to deal with the joys and sorrows, frustrations and successes of practice. It does not stop there; painfully, ruthlessly, thoroughly, it examines the role of doctor as patient and mortal human being. I believe that more doctors should be encouraged to write poems as a way of examining their own lives, and this book is a great example. The MJA editor took a chance on asking me, as a poet, to review a book on poetry. So I cannot let the opportunity pass without a poem of my own. Why? Why do we write, why do we dare? Do we think that there’s someone there? Have we a message, have we a thought? On a piece of our lives that fortune brought? Why do we write? Do we want to be heard? Or just carve order from the great absurd? To tear a pain from our inside? Or see a terror that no more can hide? To release our anger and give it vent? Until our passion and frustration’s spent? Or play with words and toy with sound? And admire the pretty game we’ve found.

Christopher D Hogan

In preparing an article reporting a clinical trial, the authors are expected to provide a reasoned interpretation of the results and place them into a broader clinical context. “Interpretation” (Item 20 of the CONSORT statement) refers to how the authors account for their results (Box 1).1 Although it has been suggested that authors often have a vested interest in their data and may be biased towards a positive result,2 they nevertheless have first-hand experience of the design and conduct of the trial, and can offer a unique insight into interpretation of the results. Elements of an interpretationAuthors are generally encouraged to summarise the extent to which the results and findings are consistent with their original hypothesis,3 and to comment on the robustness of the results for drawing conclusions and making recommendations. This should involve discussion of: the suitability of the study design to answer the questions examined; the ultimate quality of the trial as conducted; the extent to which missing follow-up or imputed data contributed to the reported results; and the potential influence of any protocol violations or other biases that may have affected the clinical experiment.4 Beyond this, specifically addressing the key aspects of internal validity (such as the fairness of the comparison of treatment groups in the trial) will help the reader assess the results. For example, the reader’s confidence in the results is increased by reassurance about the adequacy of randomisation,5 consistency across treatment arms of the methods used to measure outcomes,6 and similar levels of background care in the treatment arms. Additionally, if results are derived from multiple comparisons, the dangers of over-interpretation of a variety of endpoints should be acknowledged.7,8 Even if a study has strong internal validity, the results may be surprising or unexpected. Therefore, the plausibility of the results in relation to expectations, and speculation as to possible mechanisms of action of the intervention should be discussed.7 The sensitivity of the findings to any departures from the assumptions in the design (eg, compliance levels, unblinding, losses to follow-up, and missing data) should be mentioned.4 Any other limitations or drawbacks of the study design or conduct should be acknowledged, and their influence, or lack of influence, on the outcomes should be argued. This will help the reader to compare these results with other relevant findings. The strength of the findings (shown by P values and confidence intervals around the estimates) signifies their robustness. The size of the estimates of effect and their plausible variability (such as the risk reduction or hazard ratio and confidence intervals) show the potential importance of the intervention in clinical use. After validity has been discussed, the potential ramifications of the results are usually presented. These include the value of the intervention beyond the trial, including the likely generalisability of the findings,9 the balance of benefits and harms,10 and any potential changes to clinical practice that may be appropriate. How consistent the results are with other findings, and how biologically and clinically plausible the interpretation is, will influence this discussion. The results may raise new questions directing further research. These might arise from the findings for the main outcome, from a subset of patients, or from ancillary analyses. As the authors have an intimate knowledge of the study and the data, their views on the direction of such research may carry weight. Recommended structure of a DiscussionWe recommend an ordered structure for the Discussion section (Box 2). Statement of the findingsA simple declaration of the meaning of the results should introduce the authors’ interpretation. For example, the following sentence introduces the Discussion section of the LIPID study report:11 Our results provide strong evidence that lowering cholesterol levels with pravastatin in patients with a broad range of initial cholesterol levels and a history of myocardial infarction or unstable angina reduces the risk of death from CHD, cardiovascular disease, and all causes combined. What follows extends this discussion with a brief statement of which patient groups benefited, and the extent and nature of these benefits. Strengths and weaknessesThe strengths of the trial may include its representative sample, its rigorous design and its clinical relevance. The account of the weaknesses should aim to explain any flaws in the study identified by the authors, and outline the attempts made to minimise and compensate for these limitations. Identifying weaknesses in the study and discussing their likely influences will help readers appreciate the limitations of interpreting the study results. Discussion of weaknesses should include methodological aspects (eg, possible biases, the meaning of imprecision in the findings, and the number of multiple comparisons) as well as clinical aspects, such as any problem in translating statistical results to clinical importance. An example is the study comparing hot water immersion with ice packs to relieve the pain of bluebottle (Physalia jellyfish) stings in participants recruited from beach first aid facilities.12 Hot water immersion for 20 minutes, unlike ice, was highly effective. The Discussion described study weaknesses, such as bias: there was a possibility that, with simultaneous recruitment of family members, treatments could have been allocated after randomisation on the basis of severity. We suspect in some cases when two or three patients were simultaneously recruited (often one parent consenting for multiple children), the research assistants may have allocated hot water treatment to the more severe stings once the envelopes were open. However, this was likely to be rare, and a post-hoc analysis using simulations of matched treatment subgroups still showed a highly significant outcome at 20 minutes. The Discussion also dealt with the subjectivity of pain and the problems of choosing how to measure it. The measurement of pain is problematic because it is subjective and is influenced by numerous factors. However, pain is the most important and distressing effect of bluebottle stings, so it was essential that we establish the effect of treatment on pain. The VAS has become a standard tool for the measurement of pain in research, and has been validated in numerous settings. Mechanisms and explanationsIt is important that the authors consider all possible mechanisms underlying the results and explain how they might relate to the outcomes. For example, in the bluebottle study:12 It might be argued that the hot water immersion may be a symptomatic treatment for jellyfish stings, rather than providing definitive treatment by inactivating venom . . . We demonstrated a time-dependent effect of hot water immersion, with a barely significant effect at 10 minutes and a highly significant effect at 20 minutes. In addition, pain did not recur. This leads us to suggest that the mechanism of reducing pain by heat treatment is inactivation of venom. However, unlikely or implausible hypothetical mechanisms should not be proposed merely so that they can be disproven. Relation to other studiesAll clinical trials start from a background of previous work. Authors should indicate where results extend, agree with or differ from those of other studies (a forest plot may help readers with interpretation). If there are differences, are these related to differences in methods or the characteristics of participants? An important finding of the Women’s Contraceptive and Reproductive Experiences (CARE) Study was new evidence on breast cancer risk:13 In conclusion, high parity and early age at first birth were associated with a reduction in risk only for ER+PR+ tumours. Breastfeeding was associated with a reduction in risk for both ER+PR+ and ER–PR– tumours. Combined with previous research, this suggests that parity and age at first birth act through different mechanisms than breastfeeding. All reproductive factors showed similar associations with both ductal, ductolobular and lobular tumours, suggesting that these tumours have similar aetiologies. Implications for clinical practice and future researchReaders may not have the authors’ background and experience in the research area. Their own interpretations are aided by the authors’ commentary, which may include how far the results can be applied in different clinical situations. For example, in the Heart Protection Study:14 As people with blood creatinine concentrations above 200 μmol/L were excluded from the present study, further large trials are required to determine prospectively whether statin therapy can prevent clinically relevant changes in renal function among people at particular risk of developing end-stage kidney disease. Interpretations, not just interpretationMost clinical trial reports for publication draw together the expertise and interests of several authors, and the Discussion section is where their views are most likely to diverge. Authors bring different perspectives to interpreting the results.15 The Discussion needs to reflect a consensus view of all the contributors. 1 CONSORT checklist of items to include when reporting a randomised trial1 Section and topic Item no. Descriptor Discussion Interpretation 20 Interpretation of the results, taking into account study hypotheses, sources of potential bias or imprecision, and the dangers associated with multiplicity of analyses and outcomes 2 Suggested framework for the Discussion section A brief statement of the findings; Strengths and weaknesses (limitations) of the study, and methods used to minimise and compensate for the limitations; Possible mechanisms of action of the intervention, and explanations of these mechanisms; Comparison with relevant findings from other published studies; Clinical and research implications of the work, as appropriate.

Anthony C Keech FRACP, MSc(Epi) · Rhana Pike MA, ELS · Renee E Granger BA, BSc(Hons) · Val J Gebski BA, MStat

It is that time of year again when we publicly thank all our reviewers for their efforts in ensuring that the MJA publishes only the best possible articles. In the 12 months from November 2005 to October 2006, 1757 reviewers have helped us in our quest for quality — they are listed below and we thank them enormously for their assistance and diligence. We do not send all manuscripts out for review — many are returned to their authors after being discussed at our Editors’ meetings, mostly for reasons of poor science or presentation, or content that is not suited to the broad general readership of the MJA or that would be more appropriately published elsewhere. Reviewers are asked to complete their reviews within 3 weeks (2 weeks for letters) and most manage to meet this deadline, as evidenced by a mean time to complete reviews (for all article types) of 16 days. The range, however, is from an extraordinary 1 hour (this was for a letter, but we think this reviewer must need a busier day job!) to a more tardy 10 weeks (fortunately this sort of delay is very infrequent). These times are, of course, from the day a reviewer agrees to review — it may take us a few weeks to find a willing reviewer. The Box shows the fate of the manuscripts we received between July 2005 and June 2006. Virtually all our communication with authors and reviewers is now by email, and our relatively new online submission system (http://www.editorialmanager.com/mja) has streamlined many of our office procedures. Although the system seems to be popular with reviewers, we note that some authors have found the initial login process to be complicated and time consuming — we will pass these comments on to the programmers but we would like to reassure authors that any subsequent submissions will be much simpler as all your details will already be on the system. Under the auspices of our parent company, the Australasian Medical Publishing Company, MJA staff have worked on several other publications this year: we have taken on the publishing side of the journal Critical Care and Resuscitation, in addition to ADF Health and Australian Health Review. We have also published Looking good (a fully illustrated and detailed consumer’s guide to cosmetic medicine and surgery), Teaching on the run (based on our very popular Journal series of teaching tips for busy doctors), Caesarean section: a manual for doctors, and a second revised edition of MJA Practice Essentials — Dermatology, all available through the MJA bookroom (http://www.mja.com.au/public/bookroom/buybooks.html). In April 2007, the MJA will be hosting the annual meeting of the International Committee of Medical Journal Editors (ICMJE) for the first time. In fact, it will be the first time that this committee of editors of eminent journals, formed in 1978 and previously known as the “Vancouver Group”, has ventured to the southern hemisphere. The ICMJE maintains and updates the (http://www.icmje.org). This document is essential reading for anyone wanting to learn “the rules” of medical publishing or optimise the chance of getting published. The Committee has gradually broadened its concerns to include ethical principles of reporting research in biomedical journals and, most recently, the public registration of all clinical trials. This year, authors and reviewers may have missed the straightshooting and insightful editorial advice of one of our Deputy Editors, Dr Mabel Chew. She left us at the end of 2005 to pursue travel, clinical work and an editorial role at the BMJ. Dr Tanya Grassi has rejoined the Editorial team, returning to the Journal after several years in the wilderness of veterinary and private medicine. At the end of the year, the MJA will be most reluctantly farewelling Craig Bingham, Manager of Communications Development, who has been a pivotal member of the Editorial team for 16 years. Craig has made major contributions to MJA editing and style, and to our book publishing, and he has been responsible for almost every technological advance at the Journal since we traded our blue pencils for computer keyboards. He has also been recognised internationally as a pioneer in the development of Internet-based open peer review. We wish him every good fortune for the future. We wish all our readers a happy holiday season. We hope you enjoy this special double issue, and we look forward to keeping you informed and entertained again next year. Manuscripts received 2005–2006 Total(accepted/received) 606/1389 (44%) Research 108/457 (24%) Cases 20/147 (14%) Reviews 12/41 (29%) Letters 201/304 (66%) Mean time (days) To reject 34 To accept 69 Number of reviewers used 1757 Impact factor 2.125 Content Review Committee Craig S Anderson Leon A Bach Flavia M Cicuttini Jennifer J Conn Marie-Louise B Dick Mark F Harris Paul D R Johnson Tom Kotsimbos Campbell Thompson Tim P Usherwood E Haydn Walters Owen D Williamson Jane Young Jeffrey D Zajac Reviewers 01/11/2004 – 31/10/2005 Peter J Abbott Walter P Abhayaratna John Abraham Stephen P Ackland Karen Adams Stephen Adelstein Michael A Adena Peter B Adkins R James Aitken Tim Albert Rebecca M Albury Frank Alderuccio Rosemary Aldrich Frank P Alford Jean-Pierre Allain Jeremy Allgrove Mohammad Al-Ubaydli Luis Álvarez Shanthi Ameratunga Janaki Amin Lisa H Amir Gary P Anderson Ian P Anderson Robert P Anderson Gavin Andrews James A Angus Nicholas M Anstey Sanchia Aranda Bruce K Armstrong Ruth M Armstrong Peter C Arnold Jeffrey K Aronson Deborah Anne Askew John J Atherton William (Bill) Atkin Robert C Atkins V Judy Atkinson Robyn G Attewell John R Attia Jehannine Austin Peter D Baade Christopher J Baggoley Brian P Bailey Paul M Bailey Ross S Bailie Robert A Bain Christopher S Baker Kathy E Baker Maureen Baker Philip R Baker Ross I Baker David L Ball Zsolt Balogh Jangu Banatvala Lilon G Bandler Agnes Bankier Siobhan Banks Paul R Barach Gilbert O Barbezat Robert A Barish Cameron A Barnes Ross StC Barnetson Bruce H Barraclough Alexandra L Barratt Andrew Bartholomaeus Michael B Barton Ivan B Bastian Diana Battistutta Paul A Bauert Peter E Baume Louise A Baur Margaret Bearman Spencer W Beasley James G Beeson Stephen Begg Justin J Beilby James R Bell John Bell Stephen W Bell Christine C Bennett Derrick A Bennett Stan Bennett Jill Benson Alan Bensoussan Michael Berk Andrew D Bersten James Donovan Best J H Nicholas Bett Jen Bichel-Findlay Barbara E Biggins Beverley-Ann Biggs A Michael Bilous Colin W Binns Donald J Birkett Deborah A Black Peter N Black Robert J Black Christopher Bladin Stephen L Blamey Grant A Blashki Ilse Blignault Sidney Bloch Peter A Blombery Zeev Blumenfeld Ruth Boaden Felix Bochner Terry D Bolin Michael D Bollen Stephen N C Bolsin Patrick G M Bolton Catriona Bonfiglioli Yvonne Bonomo Dorret Boomsma Heather S Boon Barbara J Booth Michael L Booth Robert Booy Craig S Boutlis Steven C Boyages Neil W Boyce Phillip M Boyce Ian W Boyd Andrew N Boyden Richard S Boyle George Braitberg Jeffrey Braithwaite David J Brand Roland Brandt Annette J Braunack-Mayer Kerry J Breen Joan M Brewster Julie Brice David Brieger Jo-anne E Brien Kathy Briffa Esther M Briganti Peter J Bristow Helena C Britt Kaye Brock Peter M Brooks Julia M L Brotherton Mark A Brown Ngiare J Brown David G Bruce Peter D Brukner Nicholas A Buckley Anne E Buist Max K Bulsara Jonathan G W Burdon C Paul Burgess John R Burgess Margaret A Burgess David Burgner Christopher J Burrell Graham D Burrows Peter W Burvill James R G Butler Linda Butler Julie E Byles Petra T Bywood Victor I Callanan Adrian J Cameron Ian D Cameron Peter A Cameron Donald A Campbell John Campbell Lesley V Campbell Terence J Campbell Christopher H Cantor Susan M Carden Andrew D Carr Vaughan J Carr Jordi Carratala Hugh Carter John N Carter Owen B J Carter Alan Cass David J Castle Amanda J Caswell Antonio Celenza David S Celermajer Steven J Chadban John P Chalmers Albert K F Chan Raymond C Chan Anne B Chang Jeremy R Chapman Michael G Chapman Simon Chapman Allen C Cheng Ian R Cheong David A Cherry Colin N Chesterman Derek P B Chew Tanya Chikritzhs Andrew G Child Donald J Chisholm Patty Chondros Peter F M Choong Keryn J Christiansen Flavia M Cicuttini Kenneth F Clark Sean P Clarke Moira A Clay Mark Clements Peter M Clifton Jacqueline C T Close Alan R Clough Gordon J A Clunie Harvey L C Coates Damian Coburn Alex K Cohen Marc M Cohen Milton L Cohen Richard J Cohn Enrico W Coiera Stephen Colagiuri Judith M Cole Stephen A Cole Merrole F Cole-Sinclair John P Collins Veronica R Collins Brian T Collopy Peter G Colman David M Colquhoun Elizabeth J Comino Christopher A Commens John R Condon Jennifer J Conn Ian J Constable Kathryn A Cook W Graham E Cooksley Nicholas B Cooling Alan J Cooper Celia M Cooper David M Cooper David (Gus) M Cooper Pauline Louise Cooper Richard A Cooper Michael D Coory William Coote David L Copolov Christopher Cordner Stephen M Cordner Michael A Corkeron Teresa Cosgriff Yvonne E Cossart Douglas J Coster Kingsley Coulthard Sophie Couzos Brian Cox Terry Coyne Alex J Crandon Darrell H G Crawford T John Croese J Nick Crofts John L Crompton David B Cross Gary Crosthwaite Caroline A Crowther Ji-Sheng (James) Cui Robert G Cumming James M Cummins Chris Cuneen Joan Cunningham Bart J Currie Kathy Currie Kay Currie Henry Cutler Peter H N d'Abbs Geoffrey W Dahlenburg Phil Dalgarno Scott K D'Amours Mark Daniell Brian A Darlow Anthony M Dart Richard C Dart Margot J Davey Geoffrey P Davidson Leo Davies Susan R Davis Timothy M E Davis Angus J Dawson Richard O Day Caroline M De Costa Lachlan J de Crespigny Nicholas H de Klerk David M de Kretser Stephen A Deane Keith B G Dear Christopher B Del Mar Tom R DeMeester Lisa L Demos Jack (John) L Dempsey Andrew W Dent Catherine A D'Este Philip J Devereaux Peter G Devitt Patrick (Paddy) A Dewan Terrence H Diamond James A Dickinson Paul M Dietze Timothy A Dobbins Peter J Dobson Anthony J Dodds Dorota A Doherty Kenneth J Donald Susan M Donath Neil J Donnelly Charles D Douglas Jo A Douglass Susan M Dovey John S Dowden Christopher Dowrick S Bruce Dowton Kathleen Dracup Stephen J Duckett Francis J Dudley Michael J Dudley Johan A Duflou Seeta Durvasula Dominic E Dwyer Peter Dwyer Creswell J Eastman Peter R Ebeling John W Eikelboom Damon P Eisen John A Eisman Alec J Ekeroma George H Elder John H T Ellard Susan L Elliott Niki Ellis Pete M Ellis David A Ellwood J Mark Elwood Sean Emery Dallas R English Edzard Ernst Guy D Eslick Adrian J Esterman Jennifer R Evans Peter Evans Wendell Evans Karen Facey Paul P Fahey Christopher K Fairley Anthony D Falconer Michael C Falk H John Fardy Elizabeth A Farmer Annabelle Farnsworth Geoffrey C Farrell Daniel M Fatovich Thomas A Faunce John K Ferguson Lynnette R Ferguson Mark J Ferson David W Firman Colleen M Fisher Jane R W Fisher Malcolm McD Fisher Paul D Fitzgerald Michael P Fitzharris Louisa Flander John I Fleming Peter J Fletcher Robert H Fletcher Leon A Flicker Joanna M Flynn Kwun M Fong Simon J Foote Andrew B Forbes Brett H R Forge Richard M Fox David R Fraser John D Fraser Saul B Freedman Frank A Frizelle Michael S Frommer Jeffrey D Fuller Belinda J Gabbe Lance A Gable John Galati Alexander S Gallus Eugene Garfield Paul A Gatenby Melina Gattellari Matt D Gaughwin Paul H Gavel Paul Gerber Dorota M Gertig Davina Ghersi Robert W Gibberd Kay L Gibbons Peter R Gibson Alan J Gijsbers Andrew L Gilbert Gwendolyn L Gilbert Michelle L Giles Sabrina Gill Timothy P Gill Marisa T Gilles Amanda K Gilligan Rod Givney Allan R Glanville Paul A Glare Nicholas J Glasgow Christopher Glatthaar Peter J Goadsby Alan J Goble Martyn S Goddard Karen Goebel Julian Gold Robert D Goldney John M Goldsmid David Goldstein Clayton L Golledge Jonathan Golledge Felicity Goodyear-Smith Chris D Gordon David L Gordon Iain B Gosbell Kerry J Goulston Michael S Gracey Leonard C Gray Natalie J Gray M Lindsay Grayson Anthony J Green David Green Sally Green Mark L Greenberg Peter B Greenberg David W Gronow David I Grove Russell L Gruen Andrew E Grulich Jeanne-Marie R Guise Jane M Gunn Lyle C Gurrin Gordon Guyatt Femida Gwadry-Sridhar Paul S Haber Paul Haidet David M Hailey Anthony J H Hall Robert H Hall Robert G Hall Wayne D Hall P Shane Hamblin Ian R Hamilton-Craig Rohan J H Hammett Alan W Hampson Elizabeth Handsley Graeme J Hankey Jeffrey N Hanna Liz Hanna Terry J Hannan Winita Hardikar John G Harding Jock Harkness Paul L Harper Richard W Harper Anthony H Harris Mark F Harris Phillip J Harris Roger D Harris Bernie T Harrison Roger J Hart Thomas F Hartley Ken J Harvey Michael P Harvey Charlotte Haug Phillipa J Hay Andrew M Haydon Noel E Hayman Richard B Hays Philip L Hazell David L Healy Judith M Healy Geoffrey S Hebbard Richard F Heller Mary Hemming David R F Henderson J Michael Henderson Michael A Henderson David J Henderson-Smart Barbara R Henry David A Henry Sue Henry-Edwards Bernard J Hering Patrick D Hertnon Basil S Hetzel Diana M S Hetzel Martha Hickey Ian B Hickie Rodney J Hicks Geoff Higgins Rosemary D Higgins Peter G Higgs David J Hill Janet E Hiller Kenneth M Hillman Don Hindle Ian Hindmarch Geoffrey H L Hirst Barbara M Hocking R Bruce Hocking John Hoey Christopher D Hogan Patrick G Hogan William Hogg Brien A Holden Carol A Holden Stephen R Holdsworth Juliette Holland Immy Holloway Peter Holmes Peter M Hopkins Diana G Horvath Jonathan O'B Hourihane Anthony K House Elizabeth J Hovey Benjamin P Howden Bernard J Hudson Clare Hughes Clifford F Hughes Thomas Hughes W Roderic Hume Michael D Humphrey John S Humphreys Jennifer M Hunt Leonie G Hunt Ernest Hunter Peter C Hunter Mark Hurwitz Francesco L Ierino Donald Hamilton Irvine David Isaacs Nicole M Isbel Geoffrey K Isbister James P Isbister Ralf Itzwerth Rebecca Q Ivers Claire L Jackson Peter A Jacoby Andrew W Jakobovits W Philip T James Konrad Jamrozik Stephen Jan Tania (Tatiana) Janusic Martyn Jeggo George A Jelinek V Michael Jelinek Grant A Jenkin Christine R Jenkins Lance C Jennings Richmond W Jeremy George Jerums Fengyi Jin David Johnson Paul D R Johnson William R Johnson Brian Johnston Ian R Johnston Damien J Jolley Brian C Jolly Nick S Jones Roger H Jones Anthony F Jorm Anthony P Joseph Joanne Joseph Catherine M Joyce Stephen J Judd Stephen M Jurd Jon N Jureidini R S Brian Kable Richard Kahn John M Kaldor Ross Stewart Kalucy Max Kamien Alka M Kanaya Peter H Katelaris David J Kavanagh Thomas W H Kay Joey M Kaye Megan A Keaney Richard F Kefford Marc J N C Keirse Nicholas A Keks Anne-Maree Kelly Brian J Kelly Heath A Kelly John W Kelly Mark D Kelly Michael J Kelly Robert I Kelly Andrew S Kemp Mark Kendall Michael C Kennedy Stephen J Kent Ian H Kerridge Alison M Kesson Selva Ketharanathan Natkunam Ketheesan Desmond Kidd Rosalind Kidd Warren J Kidson Christine Kilpatrick James F King Bronwyn Kingwell Scott Kinlay Simon C Kitto Andrew W Knight Rosemary Anne Knight Sheila M Knowlden Paul A Komesaroff Melvyn G Korman Robert J Kosky Steven Kossard Jaro Kotalik Mark A Kotowicz Gabor T Kovacs Emma Kowal Vicki L Krause Anne Kricker Henry Krum Paul A Kubler Dennis L Kuchar Jennifer J Kurinczuk Justin T La Brooy Ronald Labonte Antony R A Lafferty Fiona R Lake Trevor Lambert Louis I Landau Marissa N Lassere Matthew G Law Ian C Lawrance Glenda Lawrence Paul D Lawton Richard T Le Mesurier Lucian L Leape Bee Wah Lee Philip G Lee Stephen R Leeder Barbara A Leggett Sue Lenthall Rosemary Lester Christopher R Levi Florence Levy Michael H Levy Steven J Lewis George T Lewith Joel Lexchin Siaw-Teng Liaw Danny Liew Lyndell Lim Meng Kin Lim Mats Lindberg Peter S Lipski Wendy L Lipworth J Miles Little Mark Little Bebe Loff Yoon Loke Daniel R Longo David F M Looke Alan D Lopez Julie A V Lord Charles W Lott Thomas Louie William J Louis Anthony W Love Julia M Lowe Michael P Lowy Dan I Lubman Yolande Lucire Joanne Ludlow Judith M Lumley Kehui Luo Stephen V Lynch Stuart M Lyon Glen F Maberly Peter J Macardle Graeme A MacDonald Graham J Macdonald Peter S MacDonald Wendy Macdonald C Raina MacIntyre Pamela E Macintyre Kerri Mackay Tamara Mackean Roderick A Mackenzie Dorothy E M Mackerras Alastair H MacLennan Finlay A Macrae Guy J Maddern Anthea M Magarey Graeme P Maguire Donna B Mak Laurence A Malcolm Kathy Malera-Bandjalan Derelie Mangin Linda Mann Andrea Mant Dror Maor Lynette M March Harvey Marcovitch Ashfaq A Marghoob Peter G Markey Martin N Marshall Peter Marshall Roderick I Marshall Andrew J Martin Frank Martin Ana Marusic Rebecca S Mason Colin L Masters Colin D Mathers Timothy H Mathew John D Mathews Claire Mayhew Alan Maynard Danielle Mazza Jeremy M McAnulty W John H McBride James S McCarthy Stanley W McCarthy Daniel J McCarty Geoffrey W McCaughan Kieran A McCaul Philip I McCloud Geoffrey J McColl Christopher J McCormack Joseph G McCormack Ronald Brett McCoy Dennis R McDermott Robyn A McDermott Christine F McDonald Aidan McElduff Patrick McElduff Heather J McElroy Suzanne P McEvoy John McEwen Alexander C McFarlane Neil W McGill Katherine M McGrath Andrew McIntosh Peter B McIntyre Dean McKenzie Joanne E McKenzie Robert I McLachlan Rick McLean Vivienne McLoughlin I Chris McManus Anthony J McMichael Gabrielle M McMullin Donald McNeil John J McNeil Paul M McNeill John R McPhee Jean V McPherson Robert J McRitchie Graham N Meadows Nicholas Medland Richard M Mendelson John A Mendoza Scott W Menzies Angela Merianos Desiree Mesaros Antonina A Mikocka-Walus J Alasdair Millar Graeme C Miller Jacques F A Miller Mark K Miller Michelle Miller Roger L Milne Ruairidh Milne Adrian Mindel Gita D Mishra Geoffrey K Mitchell Philip B Mitchell Paula J Mohacsi Diane P Mohen Michael Montalto Robert Moodie Gavin H Mooney Michael R Moore Michael Moore Graeme J Morgan Helen J Moriarty Peter Morley Philip L P Morris Robin H Mortimer Robert G Moses Kathy Mott Robert F W Moulds David Mountain Bryan Mowry Alison M Mudge Brian P Mulhall Paul E Mullen Raymond J Mullins Wendy J Munckhof Craig Munns Lindsay M Murray Richard B Murray Kenneth A Myers Sydney M L Nade Lucie Nadeau Balakrishnan (Kichu) R Nair Jackob Moses Najman Denise Nardelli-Haefliger Peter T Nash Geraldine A Naughton Gregory I C Nelson Mark R Nelson Paul J Nestel Tuan V Nguyen Kathleen M Nicholls Dianne Nicol Graeme R Nimmo Paul Nisselle Steven Nissen James W Nixon Peter F Nixon Jacqui Norris Robert E Norton Len Notaras Anna K Nowak Caryl Nowson Don Nutbeam Magne Nylenna Godfrey P Oakley Jr Jeremy J N Oats Dianne L O'Connell Liam F O'Connor Tim O'Connor Maree F O'Keefe David Oliver Ian N Olver John K Olynyk Susanne P O'Malley Colm O'Morain John W Orchard Michael F O'Rourke Sharon R O'Rourke M Kevin Outterson A John P M Overbeke Pamela Palasanthiran Didier J Palmer Kathryn S Panaretto Nirmala Pandeya Gordon B Parker Neil R Parker Lynne Parkinson Patrick Parkinson Trevor R Parmenter Julie A Pasco Dennis R Pashen Anushka A Patel David J Paul Hedley G Peach Louis G Peachey Brian B Peat Andrew G Penman Paul L Pers Andrew F Pesce Tri Giang Phan Peter D Phelan Christine B Phillips Gregory Phillips Paddy A Phillips Patrick J Phillips Avinesh Pillai Peter I Pillans S Praga Pillay Louis S Pilotto Carole B Pinnock Marie V Pirotta Leon Piterman Aileen J Plant Nicholas A Pocock Cliff Pollard Rene G Pols C Dimity Pond Solomon Posen Julia M Potter Jennifer R Powers Sridhar Prathikanti Ric N Price Mike Pringle Paul Prociv Thomas M Proebstle Joseph Proietto Patrick M Purcell Robert M Puy Carolyn Quadrio John L Quintner Shanti Raman Paul Ramchandani Duncan W Ramsay William D Rawlinson Simone Raye Donald A Redelmeier Brian G Regan Michael Regan Alison M Reid Sharon Reid David M Reith Drummond Rennie Joseph M Rey Alun H Richards Drew B Richardson Malcolm D Riley Thomas V Riley Ian T Ring Jan E Ritchie David C Rivett David C K Roberts Rosemary F Roberts Andrew Robertson Kaye Roberts-Thomson Peter C Robinson Gary D Rogers Naomi Rogers Wendy A Rogers Kathlyn J Ronaldson Stephen J Rosenman Glynis P Ross Stuart Ross George L Rubin Tilman A Ruff Richard E Ruffin Andrew D Rule William B Runciman David Russell Richard C Russell Michael D Ryan Peter F J Ryan Perminder S Sachdev Krystian R Sadkowsky Peter Sainsbury Glenn P Salkeld Jo Salmon Deborah C Saltman Philip N Sambrook Matthew R Sanders Sally J Sandover (nee Reagan) Norma Suely de Oliveira Santos Catherine Saxelby Geoffrey P Sayer Lionel Schachna Peter L Schattner Carlos D Scheinkestel Peter Schiff Deborah J Schofield Peter R Schofield Knut Schroeder Torben V Schroeder Udo Schuklenk Michael J Schull Max A Schwarz Ian A Scott Katrina J Scurrah J Paul Seale Judith Searle Anthony Seaton Peter Selby Warwick S Selby Linda A Selvey James B Semmens Jillian R Sewell Jamie E Seymour Smita Shah David R Shaw Jonathan E Shaw Glenn Shea Sasha Shepperd John Shine David W Sibbritt Stan B Sidhu Malcolm R Sim David Simmons Leon A Simons Judy M Simpson Andrew Sinclair Rodney D Sinclair Bruce S Singh Sankar N Sinha David D Sless David H Small Richard A Smallwood Brian J Smith David E Smith Dennis S Smith Julian A Smith Richard S W Smith Paul L Snelling John A Snowdon Michael J Solomon Ronald L Somers Ernest R Somerville Helen Somerville Amnon Sonnenberg Tatiana Sourjina Richard Speare Bryan R Speed Denis W Spelman Allan D Spigelman Arn Sprogis Nicola J Spurrier D James B St John Rosemary A Stanton Margaret P Staples Barbara Starfield Jochanan Stessman Ian D Steven Christopher E Stevenson Mark R Stevenson Bernard W Stewart Gregory J Stewart Michael Stewart Jim R Stockigt Timothy R Stockwell Johannes U Stoelwinder Elizabeth Stojanovski Elsdon Storey Simone I Strasser Alan C Street Alison M Street Annette F Street Christina O Stubbs David Studdert David R Sullivan Francis J Sullivan Kendra J Sundquist David C Sutherland Ashwin Swaminathan Karl Swedberg Melissa Sweet Boyd A Swinburn Nicholas J Talley Hiroshi Tanaka John W Tapsall Richard Tarala Daniel Tarantola Martin H N Tattersall David Taverner David McD Taylor Hugh R Taylor Natalie Taylor Elizabeth Tchacos Charles Teo Susan Tett David E Theile Francis C K Thien Mark A B Thomas Merlin C Thomas Jane Thomason Peter L Thompson Christine D Thomson Colin J H Thomson Julian Thomson Richard Thomson W Murray Thomson Andrew M Thornett Karin Thursky Dominic S Thyagarajan Susan M Tiley David J Tiller Joseph Y S Ting Joe J Tjandra Bernadette M Tobin Ronald P Tomlins Guy C Toner Anne L Tonkin Les J Toop Duncan J Topliss Siranda Torvaldsen Paul J Torzillo Huy A Tran Carla J Treloar Julia Tresidder Lyndal J Trevena Julian N Trollor A Stewart Truswell Justin Tse Bernard E Tuch Gillian M Turner John D Turnidge Dimitra Tzioumi Owen A Ung Timothy P Usherwood Margarite Julia Vale Hugo P S van Bever Helen Van Gessel Kees C van Gool Chris van Weel Antony J Veale Phillip C Vecchio Karen Vickery Charlie H Viiala Elmer V Villanueva Charles A Vincent John M Violanti Agnes I Vitry Susan A Vlack Jitu K F Vohra Gerard V Wain Melissa A Wake Ruth B Walker Euan M Wallace Mark Walland Tom Walley Ronald S Walls Ian R Walpole John P Walsh Laurence J Walsh Kieran Walshe Garry J Walter Darren L Walters E Haydn Walters Merrilyn Walton Handan Wand Han Wang Mei Wang Michael Ward Robert S Ware Peter A B Wark David Warrell Grant W Waterer Alan B Watson David O Watson Katrina J R Watson David A K Watters Gerald F Watts Ian T Watts John R Waugh Bruce P Waxman Edward W Weaver Ian W Webster David D Weedon Hope Weiler John M Weiner Philip Weinstein Timothy A Welborn David P Weller Beres C A Wenck Rachel M Werner Steven L Wesselingh Kevin Whelan R Michael Whitby Craig A White Harvey D White Julian White Paul White Harvey A Whiteford Roy A Whittaker Richard J Whittington Gordon S Whyte Bridget Wilcken David E L Wilcken Garry J Wilkes David Wilkinson Simon M Willcock Ian R Willett Nicholas J Williams Trevor J Williams Ian G Williamson Lorna M Williamson Owen D Williamson Andrew D Wilson Concepción S Wilson D Andrew Wilson Keith Wilson Nick Wilson Ross McL Wilson John Windsor Lindon M H Wing Kenneth D Winkel Margaret A Winker Tania M Winzenberg John H Wlodarczyk Alex D Wodak Alan M Wolff William Wong Timothy O Wood Richard Wood-Baker Paul D Woodhouse Marion L Woods Alistair J Woodward Christopher J Worsnop Frederick Wu Brenton R Wylie Derek Yach Bu Yeap Jonathan Yeoh Danny Youlden Anne F Young Doris Y L Young Iven H Young Jane M Young Louise Young Jeffrey D Zajac John R Zalcberg Ehud Zamir John B Ziegler Paul Z Zimmet Nicholas A Zwar Anthony B Zwi

Bronwyn Gaut

In this, our 23rd and final issue for 2007, we would like to take the opportunity to reflect upon the past year and thank all those who have made the MJA’s continuing pursuit of excellence a reality. Our current reviewers (all 1183 of them) are listed below. We are constantly amazed by the thoughtful and incisive comments we receive, and are most grateful for the time and energy expended on behalf of the Journal by this distinguished throng. Our manuscript decision statistics, which are similar to last year’s, can be seen in the Box. A highlight this year was hosting the meeting of the International Committee of Medical Journal Editors (the “Vancouver Group”) in Sydney in April. Although our Editor, Martin Van Der Weyden, is a regular star at these meetings, it was the first opportunity the deputy editors had to observe the machinations of this lively and effective committee. We were also able to meet face-to-face with the members of our Content Review Committee for the first time this year (we usually meet by monthly teleconference), via two meetings at mutually convenient locations in Melbourne and Sydney. We discussed a wide range of topics at these meetings, including the future of the eMJA, improving content and quality, politics in the Journal and other thorny issues. We were also able to confirm that the Content Review Committee members, whose names appear below, are not only hard working and dedicated but also good looking! Throughout the year, the MJA editors have also enjoyed attending and presenting at various conferences and meetings around the country. These events keep us fresh and enthusiastic. As well as the core work of the biweekly Journal, we produced two theme issues (Indigenous Health and General Practice) and four supplements, and participated in the global Poverty and Human Development initiative, in which science journals throughout the world simultaneously published articles on this topic. We published two new MJA books, Interpreting and reporting clinical trials: a guide to the CONSORT statement and the principles of randomised controlled trials and The motor neurone disease handbook, both available, along with more than 1200 other books and products, from our newly revamped eMJA shop <http://shop.mja.com.au>. We continue to provide editorial and publishing services to several external journals and newsletters — Critical Care and Resuscitation, ADF Health, Australian Health Review and Healthcare Brief — and are always on the lookout for more titles. There have been a few temporary changes to the MJA editorial team this year. Deputy Editor Bronwyn Gaut is on 6 months’ sabbatical leave with her family in Ireland. Her emails are full of castles, laundry and the virtues of Australian weather. In her absence, our old friend Tania Janusic is ably dealing with the peer review and editing duties, and enriching us with her calm demeanour and clinical connections. Senior Assistant Editor Helen Randall is also on leave. Another long-term Assistant Editor, Kerrie Lawson, has stepped into Helen’s managerial role, and we have purloined Rhana Pike to undertake a 4-month secondment from her usual job to work on the front line of manuscript editing for the Journal. Meanwhile, earlier in the year, our Editorial Assistant Christine Hooper added another member to the MJA family (a baby girl), and Laelie Macbeth joined the team to assist our Editorial Administrator, Kerrie Harding, an organisational dynamo around whom all editorial activities revolve. All being well, early next year, the MJA, along with our parent company, AMPCo, will be moving from funky Pyrmont into our own more sedate building at 277 Clarence Street, Sydney, which we hope to make the Fleet Street of medical publishing. The Journal has been somewhat nomadic since the sale of AMPCo’s building in Glebe in 1990. The purchase of the new building is a significant event in the company’s history, and we are looking forward to making our home there. Sydneysiders may want to drop in to browse in our proposed ground-floor shop. As you can see from the Box, the MJA’s impact factor has now risen to 2.582. We hope that this reflects a true improvement in our relevance to you, our readers, and that we have been effective this year in informing, instructing and amusing you, and providing comment on important issues relating to health and health care. We remain committed to, and fearless in, our pursuit of this goal. Manuscripts received 2006–2007 Total (accepted/received) 611/1407 (43%) Research 95/394 (24%) Cases 29/149 (19%) Reviews 15/37 (40%) Letters 219/328 (67%) Mean time (days) To reject 31 To accept 75 Number of reviewers used 1183 Impact factor 2.582 Content Review Committee Craig S Anderson Leon A Bach Flavia M Cicuttini Jennifer J Conn Marie-Louise B Dick Mark F Harris Paul D R Johnson Tom Kotsimbos Campbell Thompson Tim P Usherwood E Haydn Walters Bruce P Waxman Owen D Williamson Jane Young Jeffrey D Zajac Reviewers 01/11/2006 – 31/10/2007 Peter J Abbott Suzanne F Abraham Stephen P Ackland Karen Adams Stephen Adelstein Michael A Adena Ammish Adu Hairul A Ahmad Ananthila Anandacoomarasamy Robert Anderson Gavin Andrews Rachel A Ankeny Nicolas M Anstey Adrian A Anthony Raqib Anwar Bruce K Armstrong Kylie Armstrong Peter C Arnold Leonard F Arnolda Constantine N Aroney Raimondo Ascione Michael A Ashby Deborah A Askew David N Atkinson R Leigh Atkinson Marcus D Atlas Robyn G Attewell Mark S Awerbuch Philip E G Aylward Peter D Baade Leon A Bach Marilyn Baetz Ian J Baguley Paul M Bailey Ross S Bailie Jennifer Baker Robert A Baker Matthew Baldock David L Ball Zsolt Balogh Emily Banks Michael P Barbato Cameron A Barnes David J Barnes Adrian G Barnett Ian G Barr Bruce H Barraclough Michael B Barton Ivan B Bastian Jennifer A Batch Shannon M Bates Deborah J Bateson Diana Battistutta Stuart Baulk Adrian E Bauman Peter E Baume Robert W Beal Peter J Beaumont Justin J Beilby Sally J Bell Richard A V Benn Derrick A Bennett Alan Bensoussan Vasili Berdoukas Michael Berk Samuel F Berkovic Jonathan Berman J H Nicholas Bett Colin W Binns Sara Bird Donald J Birkett Jonathan I Bisson Carol M Black Deborah A Black Robert J Black Tim Blackmore Caroline C Blackwell Grant A Blashki Alex Blaszczynski Jane Bleasel Sidney Bloch Frank H Boehm E Leslie Bokey Terry D Bolin Michael D Bollen Stephen N C Bolsin Barbara J Booth Michael L Booth Robert Booy Soufiane Boufous Neil W Boyce Ian W Boyd Edward W Boyer David L Bradford Clare Bradley George Braitberg Caroline A Brand David J Brand Annette J Braunack-Mayer Stephen Brealey Kerry J Breen David A Brent Jo-anne E Brien Esther M Briganti Peter J Bristow Helena C Britt Peter M Brooks James M Brophy Julia M L Brotherton Anthony M Brown Mark A Brown Sonya Brownie Jeffrey N Bruce Rachelle Buchbinder Nicholas A Buckley Michael D Buist Max K Bulsara Jonathan G W Burdon John R Burgess Margaret A Burgess David Burgner John R Burnett Fiona Burns Jane Burns Robert Burton Linda Butler Roger W Byard Julie E Byles Peter I Cairney David G E Caldicott A Scott Cameron Adrian J Cameron Ian D Cameron Peter A Cameron A John Campbell David Campbell Emily M Campbell Terence J Campbell Leslie Cannold Gideon A Caplan Jonathan R Carapetis Verna B Carson Gregory L Carter John N Carter Owen B J Carter Peter A Castaldi David J Castle Ian D Caterson Stanley Catts Steven J Chadban Elizabeth M Chalmers John P Chalmers Albert K F Chan Annabelle C Chan Anne B Chang Jeremy R Chapman Michael G Chapman Simon Chapman Duncan Chappell Adrian K Charles Peter L Charlton Deborah Charnock Barry E Chatterton Allen C Cheng Colin N Chesterman Janice Chesters Winston Cheung Andrew G Child Marcia Day Childress Donald J Chisholm Christopher Y P Choong Peter F M Choong Helen M Christensen Keryn J Christiansen Louis E Christie Christopher Christophi Flavia M Cicuttini Kathleen F Clapham Robyn A Clark Caroline F Clarke Christina A Clarke Roger Clarke Rufus M Clarke Simon D Clarke Stephen J Clarke Moira A Clay Geoff J Cleghorn Leslie G Cleland Peter M Clifton Jacqueline C T Close Alan R Clough Mark Cobb Mervyn D Cobcroft Alex K Cohen Jeffrey Cohen Joshua T Cohen Enrico W Coiera Stephen Colagiuri Graham A Colditz Andrew M Cole Catherine H Cole Peter J Collignon John P Collins Brian T Collopy Christopher A Commens John R Condon Jennifer J Conn Luke B Connelly Frances L Connor Ian J Constable David A Cook Robin A Cooke Alan J Cooper Chris W Cooper David M Cooper Peter Cooper Michael D Coory William Coote David L Copolov John R Coppock Stephen J Corbett Marisa Cordella Douglas J Coster Richard T L Couper Sophie Couzos Brendon Coventry Brian Cox Helen S Cox Paul S Craft Maria E Craig Peter R Crampton Julian Crane Helen M Creasey Patricia Crock Alan J Crockett Ashley M Croft John L Crompton David B Cross Brendan J Crotty Ji-Sheng (James) Cui Robert G Cumming Margaret C Cummings Ross C Cuneo Joan Cunningham Farr A Curlin Bart J Currie Timothy P Daaleman Geoffrey W Dahlenburg Jane Dahlstrom E R David Dammery Lalit Dandona Shane G Darke Anthony M Dart Richard C Dart Peteris J Darzins Mike M Daube Nicholas Daunt Peter Davis Stephen M Davis Timothy M E Davis Richard O Day David J de Carle Caroline M de Costa Lachlan J de Crespigny Julien P de Jager Nicholas H de Klerk Sarah Dean Keith B G Dear Louisa J Degenhardt Christopher B Del Mar Martin B Delatycki Elizabeth A Delbridge Leigh W Delbridge Michael C D'Emden Sarah M Dennis Andrew W Dent Patricia M Desmarchelier Catherine A D'Este Rachel E Dew Patrick (Paddy) A Dewan David A Diamond Terrence H Diamond James A Dickinson Geoffrey J Dobb Timothy A Dobbins Hilary M Dobson Chris Doecke Dorota A Doherty Con Dolianitis Susan M Donath Basil J Donovan David R Dossetor Jennifer A Doust John S Dowden S Bruce Dowton Kathleen Dracup Brian M Draper Stephen J Duckett Francis J Dudley Michael J Dudley Anne E Duggan James A Dunbar Gillian A Durham Dominic E Dwyer Peter Dwyer Sandra J Eades Creswell J Eastman Peter R Ebeling Simon D Eckermann John A Eden Paula Edgill Christopher J Edwards Garry J Egger Anke Ehlers Frederick Ehrlich John W Eikelboom Robert H Eikelboom Diann S Eley Ron Elisha John H T Ellard David W Ellis Niki Ellis Christopher G Ellison J Mark Elwood Sean Emery Michael W N Epstein Adrian J Esterman W Douglas Evans Evan R Everest Daniel P Ewald Paul P Fahey Christopher K Fairley Elizabeth A Farmer Alan E Farnsworth Omar Farouque Cynthia M Farquhar Geoffrey C Farrell Robert G Fassett Daniel M Fatovich Thomas A Faunce Michael R Fearnside Robert Ferrari Michael Field Caroline F Finch John (Jock) Findlay Simon R Finfer Thomas E Finucane David W Firman Marty J Firth David G Fish John Fisher Dominic A Fitzgerald Michael P Fitzharris M Andrew Fitzpatrick Brendan T Flanagan Louisa Flander John I Fleming Judith Fleming Janice M Fletcher Leon A Flicker Eleanor M Flynn Kwun M Fong Therese (Terri) M Foran Simon P Forehan Roberto Forero Brett H R Forge Kevin Forsyth Jonathan Foulds Richard M Fox Brad Frankum Saul B Freedman Lin Fritschi Gordian W O Fulde John W Funder Janet A M Fyfe John Galati Alexander S Gallus T Eng Gan Robert (aka Frank) A Gardiner Melina Gattellari Paul H Gavel Jacob George Paul Gerber Bibi Gerner Simon M Gianotti Robert W Gibberd Kay L Gibbons Nathan J Gibbs John Gibson Heather Gidding Andrew L Gilbert Gwendolyn L Gilbert Peter N Gilchrist Mark Gillies Amanda K Gilligan P Ken Gillman Dean Giustini Paul A Glare Nicholas J Glasgow Katie Glass Geoffrey Glassock Paul P Glasziou Peter J Goadsby Martyn S Goddard Michael S Gold Ivan Goldberg John M Goldsmid Clayton L Golledge Stephen Goodall Chris D Gordon J Jill Gordon Iain B Gosbell Tom Gottlieb Kerry J Goulston Paul J Gow Ian S Graham Leonard C Gray Nigel J Gray M Lindsay Grayson Carol F Grbich Peter B Greenberg William Griggs Keith Grimwood Paul F Gross David I Grove Michele A Groves Russell L Gruen Charles S Guest Jane M Gunn Lyle C Gurrin Michael K Gusmano Ian D Gust Paul S Haber David (Ted) W Hackstadt Kay Haig David M Hailey Alistair Scott Hall Daniel E Hall Gillian V Hall Robert H Hall Stephen T Hall Wayne D Hall John D Hamilton Ian R Hamilton-Craig Rohan J H Hammett Alan W Hampson Kenwyn Hand Peter J Hand Graeme J Hankey Jeffrey N Hanna Terry J Hannan Jenny Hargreaves Paul L Harper Richard W Harper Anthony H Harris Anthony W F Harris Mark F Harris Phillip J Harris Bernie T Harrison James E Harrison Roger J Hart Ken J Harvey Andrew T Hattersley Jason Hawrelak Phillipa J Hay Noel E Hayman Richard B Hays Philip L Hazell Christopher H Heath Geoffrey S Hebbard Robert J Heddle William F Heddle Richard F Heller David R F Henderson Douglas W Henderson David J Henderson-Smart David A Henry Wayne M Herdy Peter Hersey Andrew Herxheimer Ian B Hickie David J Hill Terrence D Hill Janet E Hiller Lynne Hillier Kenneth M Hillman Geoffrey H L Hirst Maria T Ho Barbara M Hocking Jane S Hocking R Bruce Hocking Christopher D Hogan Brien A Holden Chris B Holmwood Caroline S E Homer Roderick S Hooker Joe Hooper Peter M Hopkins Keith W A Horsley Kenneth F Hossack Warwick Hough Anthony K House Douglas M Howarth Wendy E Hoy Bernard J Hudson Rosalie Hudson Clifford F Hughes Peter Hughes Michael A Hull John S Humphreys Joseph Hung Jennifer M Hunt Alexander P Hunyor Thomas H Hurley Niels C Hvidt Francesco L Ierino Donald H Irvine David Isaacs Geoffrey K Isbister Ralf Itzwerth Nicholas Jabbour Claire L Jackson Stephen Jackson Terri J Jackson Ian Jacobs Peter A Jacoby W Philip T James Konrad Jamrozik Edward D Janus George A Jelinek V Michael Jelinek Grant A Jenkin Christine R Jenkins George Jerums Moyez Jiwa Paul D R Johnson William R Johnson Ian R Johnston Damien J Jolley Brian C Jolly Graham R D Jones Sandra C Jones Timothy W Jones Jens Jordan Anthony F Jorm Anthony P Joseph David J L Joske Rodney T Judson Jon N Jureidini Richard Kahn John M Kaldor Max Kamien Constance H Katelaris Peter H Katelaris Megan A Keaney Marc J N C Keirse Nicholas A Keks Anne-Maree Kelly Heath A Kelly John W Kelly Michael J Kelly Robert I Kelly Andrew S Kemp Peter Kennedy Peter J Kennedy Ross K Kerridge Ngaire M Kerse Paula Kersten Alison M Kesson Frank E Kette Levon M Khachigian Soo Keat Khoo Michael R Kidd Warren J Kidson James F King Sally Kingsland Scott Kinlay D Kerry Kirke Scott J Kitchener Simon C Kitto Andrew W Knight John L Knight Rosemary A Knight Jonathan C Knott Merril L Knudtson Dennis L Kodner Harold G Koenig Fay Kohn Tony M Korman Robert J Kosky Steven Kossard Gabor T Kovacs Vicki L Krause Jerome Kroll Henry Krum Susan E Kurrle Justin T La Brooy Antony R A Lafferty Fiona R Lake George R Laking Stephen B Lambert Louis I Landau Sarah L Larkins Ann-Claire Larsen Gillian Ann Laven Matthew G Law Ian C Lawrance Ross M Lazarus Richard T Le Mesurier Julie Leask Karin S Leder Stephen R Leeder David Legge Diana Lennon Christopher R Levi Michael H Levy George T Lewith Joel Lexchin J Norelle Lickiss Craig M Lilienthal Vivian Lin Peter S Lipski Wendy L Lipworth Andrew F Little J Miles Little Mark Little Andrew R Lloyd John V Lloyd Robert H Loblay Bebe Loff Robert F Loneragan David F M Looke Karl J Looper Julie A V Lord Charles W Lott Julia M Lowe Raymond M Lowenthal Michael P Lowy Deborah Loxton Christine Y Lu Joanne Ludlow Judith M Lumley George D Lundberg Glen F Maberly Graeme A MacDonald Graham J Macdonald C Raina MacIntyre Andrew I MacIsaac Ian R Mackay Dorothy E M Mackerras Alastair H MacLennan Colin MacLeod Stephen W MacMahon Paul U Macneill Finlay A Macrae Richard Madden Guy J Maddern John B Maddison Anthea M Magarey Parker J Magin Graeme P Maguire Leo J Mahar Donna B Mak Linda Mann Peter R Mansfield Ashfaq A Marghoob Peter G Markey Tania P Markovic Guy B Marks John E Marley Robert G Marr Debbie J E Marriott Andrew G Marsden Barry J Marshall Nathaniel S Marshall Roderick I Marshall Andrew J Martin Carmel M Martin Graham Martin Isobel R Martin Jane E Martin T John (Jack) Martin Ana Marusic Lynn Massey Colin D Mathers Timothy H Mathew John D Mathews Gail Matthews J Allan Mawdsley Ross G Maxwell Bongani M Mayosi Danielle Mazza Brian R McAvoy W John H McBride James S McCarthy William H McCarthy Geoffrey W McCaughan Kieran A McCaul Anne-Louise McCawley Philip I McCloud Peter J McCluskey Christopher J McCormack Joseph G McCormack Peter McCrorie Robyn A McDermott Christine F McDonald Joseph McDonnell Michael J McDowell Aidan McElduff Heather J McElroy Suzanne P McEvoy John McEwen Lynne McFarland Jessie McGowan Barry P McGrath Fran McInerney Andrew McIntosh Mary E McIntyre Peter B McIntyre Dean McKenzie Rebecca McKetin Moira McKinnon Brian McKinstry Michelle McLaughlin James S McLay Rick McLean I Chris McManus Alan A McNab Peter McNair Michelle E McPherson William R McWhirter Alan P Meagher Alan C Meek Craig M Mellis Richard M Mendelson Scott W Menzies Angela Merianos Sally Merry Desiree Mesaros Nicola Metrebian Lynn L Meuleners Frank O Meumann Peter Middleton Antonina A Mikocka-Walus Graeme C Miller Michelle Miller Roger L Milne I Harry Minas Adrian Mindel Michael W Mira Brian L Mishara Charles A Mitchell Christopher D Mitchell David H Mitchell Philip B Mitchell Ramon Mocellin Paula J Mohacsi Mohammed A Mohammed Diane P Mohen Mohammed Mohsin Gavin H Mooney Hannah C Moore Christopher J Morgan Helen J Moriarty Philip L P Morris Wayne A Morrison Robin H Mortimer Kathy Mott Robert F W Moulds Paul Mueller Roger T Mulder Raymond J Mullins Craig Munns John C Murdoch Richard B Murray George A C Murrell Marc A Musick Arthur (Bill) W Musk Kenneth A Myers Ludomyr J Mykyta Lucio Naccarella Balakrishnan (Kichu) R Nair N Martin Nakata K M Venkat Narayan Matthew T Naughton Bruce C Neal Mark R Nelson Jonathan W Newbury Christopher J Newell Henry S Newland Louise K Newman Graham L Newstead Tuan V Nguyen Kathleen M Nicholls Graeme R Nimmo Paul Nisselle James W Nixon Merete Nordentoft B E Christopher Nordin Robyn N Norton Gustav J V Nossal Len Notaras Caryl Nowson Jeremy J N Oats Paul E O'Brien Robert P O'Brien Christopher J O'Callaghan John F X O'Dea Morris Odell Robyn E O'Hehir Brian F Oldenburg Edward V O'Loughlin Ian N Olver John K Olynyk Susanne P O'Malley Paul A O'Neill Richard H Osborne Don Packham Gordon G Page Deborah Paltridge Kathryn S Panaretto Yin Paradies Gordon B Parker Michael W Parker Neil R Parker Robert Parker Dennis R Pashen Moira Paterson Elizabeth Patterson George C Patton David J Paul Hedley G Peach Louis G Peachey Graeme R Peel Andrew G Penman Mark Perrin Andrew F Pesce Raymond F Peterson Peter D Phelan Christine B Phillips Paddy A Phillips Patrick J Phillips Peter I Pillans S Praga Pillay Marie V Pirotta Geoffrey Playford Adrian L Polglase C Dimity Pond Stephen Porter Solomon Posen Richie Poulton Jennifer R Powers David A Powis Naomi Priest H Miles Prince Richard L Prince Margot R Prior Paul Prociv Joseph Proietto Peter T Pullan Patrick M Purcell Bruce A Pussell Ken Quarrie Allan J Quigley Michael A Quinn Christopher Quirk Janette C Radford Mahbubur Rahman David L Ranson Beverley Raphael Peter M Ravdin Evan J Rawstron Simon Raymond Stephen J Read Daniel Redwood Tom S Reeve Michael Regan Alison M Reid Christopher M Reid Peter L Reilly David M Reith Joseph M Rey Chris Reynolds Liza M Ricote Malcolm D Riley Ian T Ring Paul G Rippon David C Rivett Chris Roberts David C K Roberts Andrew G Robertson Colin F Robertson Peter C Robinson Philip J Robinson David M Roder Alan Rodger Eugene C Roehlkepartain Maureen Rogers Charles Roland Kathlyn J Ronaldson Jeffrey V Rosenfeld Stephen J Rosenman William Rosner Stuart Ross Elizabeth E Roughead Kevin G Rowley George L Rubin Tilman A Ruff Richard E Ruffin Bruce D Rumbold William B Runciman Darren B Russell Grant M Russell Julie E Rust Christopher J Ryan Michael D Ryan Michael Ryan Peter F J Ryan Krystian R Sadkowsky Peter Sainsbury Glenn P Salkeld Ruth N Salom Katherine Samaras Hugh Sampson Wallace Sampson James Samuel Lena A Sanci Matthew R Sanders Kristy Sanderson Sally J Sandover W Peter Saul Douglas M Saunders Michael G Sawyer Geoffrey P Sayer Ulrich Schall Peter L Schattner Anthony G Schelleman Peter Schiff Robert E Schoen Deborah J Schofield Peter R Schofield Leslie Schrieber Torben V Schroeder Stephan A Schug Udo Schuklenk Rosalie Schultz Lambert W T Schuwirth Ian A Scott Judith Searle Hiran C Selvadurai Linda A Selvey Jillian R Sewell William A Sewell Jamie E Seymour Gilbert C Shardey Jennifer J Shaw Jonathan E Shaw Dale C Sheehan Aziz Sheikh Chris Sherlaw-Johnson Bruce H Short Stephen Shumack Beverly M Sibthorpe William Sievert Jerzy (George) M Sikorski William Silvester Leon A Simons Rodney D Sinclair Vitali Sintchenko John Skelton Loane L C Skene Clare A Skinner James Skinner David D Sless Richard A Smallwood David E Smith David W Smith Denis A Smith Dennis S Smith Julian A Smith Malcolm D Smith Mitchell M Smith Peter J Smith Richard S W Smith William B Smith Gregory I Snell Paul L Snelling Ernest R Somerville Harold C Sox Andrew L Speirs David Spratt D James B St John Edward G Stafford Carolyn Staines Fiona J Stanley Richard A Stapledon Margaret P Staples Richard J Stark Mike Startup Richard J Stawell Catherine H Stein Richard A Stein Matthew Stevens Christopher E Stevenson Mark R Stevenson Bernard W Stewart Cameron Stewart Gregory J Stewart Jim R Stockigt Timothy R Stockwell Johannes U Stoelwinder Gordon S Stokes Robin Stott Simone I Strasser Alison M Street Annette F Street Rhonda L Stuart David Studdert Allan D Sturgess Joachim P Sturmberg David R Sullivan Francis J Sullivan Boyd A Swinburn Rodney R A Syme Brian Symon Jeffrey Szer Nicholas J Talley K M Tan Benjamin M Tang Daniel Tarantola Carolyn Tarrant Charles Tator Martin H N Tattersall David McD Taylor Hugh R Taylor Roscoe Taylor David E Theile Jill E Thistlethwaite David P Thomas Julian E Thomas Mark A B Thomas Merlin C Thomas Paul A Thomas Ranjeny Thomas Paul D Thompson Sandra C Thompson Julian Thomson James Tibballs Stephen B Ticehurst Mark L H Tie Joseph Y S Ting Bernadette M Tobin Robert J Todd John A Toews Shilu Tong Steven Y C Tong Andrew M Tonkin Anne L Tonkin Nicholas A Tonti-Filippini Les J Toop Duncan J Topliss Antonio Torello Paul J Torzillo Jane Tracy Carla J Treloar Ronald J A Trent Lyndal J Trevena Ian A Trounce Stephen C Trumble Graeme R Tucker Jaakko Tuomilehto David R Turner Gillian M Turner Jane Turner John D Turnidge Timothy P Usherwood Ingrid van der Mei Helen Van Gessel Chris van Weel Alasdair Vance Charlie H Viiala Elmer V Villanueva Ruth Vine Fred R Volkmar Eric T Vos Elizabeth Wager Gerard V Wain Melanie Wakefield John Wakerman Amanda M Walker Euan M Wallace Mark Walland Tom Walley John P Walsh Garry J Walter Barry N J Walters D Randal Walton Merrilyn Walton Handan Wand Han Wang Zhiqiang Wang Robert S Ware Peter A B Wark Tim H Warnock David Warrell Lachlan J Warren Grant W Waterer Alan S Watson Alan B Watson David I Watson Katrina J R Watson Lyndsey F Watson Ian T Watts John R Waugh Bruce P Waxman Susan M Wearne Ian W Webster David D Weedon Lynn M Weekes Tarun S Weeramanthri Peter Wein John M Weiner Timothy A Welborn David P Weller Beres C A Wenck Michel J P Wensing Johanna I Westbrook R Michael Whitby Harvey D White Julian White Paul White Harvey A Whiteford Judith A Whitworth Alison Wicks Wouter Wieling Manel K D S Wijesundare David Wilkinson Dominic Wilkinson Simon M Willcock Joanne Williams Katrina Williams Nicholas J Williams Trevor J Williams Andrew D Wilson D Andrew Wilson David H Wilson Ian Wilson Nick Wilson Thomas G Wilson Lindon M H Wing Kenneth D Winkel Michael Winlo Tania M Winzenberg Max Wolf Hugh D Wolfenden Richard Wood-Baker Paul D Woodhouse Peter W H Woodruff Marion L Woods Alistair J Woodward Michael C Woodward Ian J Woolley Paul S Worley Mark Worwood Barry G Wren J Murray Wright Elizabeth J Wylie Mark W Yates Choong-Siew Yong Danny Youlden Doris Y L Young Jeffrey D Zajac Christopher Zeitz Yuejen Zhao John B Ziegler Stephen R Zubrick Tamara L Zutlevics Nicholas A Zwar

Ruth Armstrong

Quotes from MJA contributors in 2006 Journal style incorporates many elements — for example, defined formats for abstracts, specified subsections for different article types, the obligatory statistical results; and, at the “micro-level”, a particular use of punctuation and capitalisation, and of preferred words or phrases. However, journal style is but one aspect of writing style. In Strunk and White’s classic guide, The elements of style, White devotes a chapter to the broader aspects of writing style: “style in the sense of what is distinguished and distinguishing”. Here, warns the famous “little book”, we leave the solid ground of what is correct, or acceptable, in the use of English. A writer will find no satisfactory explanation, no infallible guide to good writing, and no inflexible rule by which to shape his or her course. “He [or she] will often find himself steering by stars that are disturbingly in motion.” After all, “Who can confidently say what ignites a certain combination of words, causing them to explode in the mind?” At the MJA, we are principally interested in the novelty and clinical relevance of our contributions, but we are also intimately concerned with all matters of style, firstly Journal style but then, more generally, writing style and the impact on readers. We would like to share with you the supernovas, some style-related, that passed through our ever-expanding galaxy this year. All creatures great and small“I’m well aware of the likely costs to me of publication of this letter, so on reflection I’ve decided that while I’m prepared to be hung for a sheep, it’s not worth it for a lamb (ie, a shorter letter). I would therefore like to withdraw my submission.” “This particular tome is a dog’s breakfast (think: pack of feral canines) of a production that doesn’t warrant publicising . . .” Cruising“The inertia of the socio-economic system means that, as for [an] ocean liner, we cannot expect to be able to turn it around more quickly in future than we can now.” Americana“The article will need to be ‘cleansed’ of some North American terms or concepts to make it more comprehensible to down-under readers. I don’t believe the Mafia control our waste disposal services here, unlike New Jersey, although they are welcome to them.” EntitlementsReviewer: “If this article is to be an update, the subjective comments and flowery language should be removed.” Author’s response: “The reviewer is entitled to [his/her] personal aesthetic but there is no requirement in general or specifically in the Journal’s Instructions to Authors for any scientific article to be written in dull and lifeless prose.” First impressionsWith the current information overload, an author needs to grab the readers’ attention during their first quick perusal of an article. Some inadvertently send the wrong signals, as one reviewer noted. “Ronald Reagan advised us (among other things) never to begin a speech with an apology. The present version of the manuscript is testament to the effect of not heeding Reagan’s advice. By excessively emphasising their non-support of several issues in the Introduction, the reader is left wondering whether the article is of any significance at all. By the time the reader reaches the Results, he or she would have been met with so many of the authors’ caveats about the study that I wouldn’t be surprised if readers were to put the article down without going any further.” Limitations unlimitedPeer reviewers encourage authors to acknowledge the limitations of their study, and occasionally, they point out that the authors have gone a little overboard in this duty. Rarely is this advice given in such a spectacular fashion as follows. “Think of this in terms of medical publishing’s answer to The Gong Show. It is traditional for us to hand authors a large stick and ask them to hit themselves repeatedly over the head — a process we affectionately term ‘describing the limitations of the study’ — at which point the editors bang the gong to put an end to the spectacle and assign the performance a score. Usually this bloody demonstration takes place AFTER the authors have performed their dance routine. “In the manuscript’s present form, the authors start hitting themselves just as they’re called on stage to perform. They inflict so much punishment on themselves that they become extremely dazed, resulting in a predictably lacklustre dance performance, after which they engage in more self-punishment. In fact, the present version of the manuscript is written in such a manner that the limitations tend to overshadow the findings — akin to the authors adding glass shards on the club head to inflict more pain. As scores are dependent on their performance of the dance, the authors don’t earn themselves extra points for the extra round of savage clubbing they receive.”

Ann T Gregory

At the MJA we are constantly delighted, fascinated and amazed by the submissions we receive. Our Christmas contributions this year did not disappoint: the range of articles reflects the journey through medical life from the fresh-faced idealism of the medical student to the world-weary demeanour of the experienced physician. For some, the journey involves an attempt to transform the lives of others. Many new doctors set out enthusiastically with a desire to help people and change the world with their new-found knowledge. But as Cheng points out, in her eye-opening account of Medicine along the Mekong, sometimes the world just reaches out and changes us. Our journey as Australians often takes us to distant lands, like Dr Pat Hodgson who touched a Scottish village and a future doctor with her humour and vitality during World War II, (→ Sandeman). We are armchair travellers too — sports enthusiasts in danger of injury when watching football on the lounge with a beer or two (→ Bauman et al), but ultimately we give it a go, hoping it will be “orright mate”, even if it involves transporting a seriously ill neonate in an open aircraft, as Anthony Hodgkinson did in the 1950s (→ Hodgkinson). Living in a global society, the onslaught on our daily lives of the cult of celebrity and commercialism is represented by both Ernst and Pittler (Celebrity-based medicine), and psychiatry’s answer to Superman, Garry Walter (The Directors). As with all travellers’ tales there are stories that make us laugh — sometimes so hard that the cutlery is in danger (→ Beldholm and Lee) — and those that help us realise that sometimes there is little left to do but accept that we are powerless and finally let go, a theme touched on by both Leeder and Mohajeri. But ultimately a decision was made by our intrepid MJA staff and, although every submission received at least one mention, there were two that shone in the judges’ opinion. Bromley and Buckley’s x-tremely interesting research on the x-factor in prescribing of medications in hospital was a clear winner, along with Mohajeri’s moving poetic description of a patient’s final journey through the eyes of a medical student. These lucky winners will each receive a Christmas hamper with compliments of the MJA. We would like to thank all our fellow travellers who contributed to the competition this year, and ask that more of you join us on the journey next year. Do send us your ideas for next Christmas — we always want more presents to open!

Tanya Grassi

Objective: To determine how commonly articles are retracted on the basis of unintentional mistakes, and whether these articles differ from those retracted for scientific misconduct in authorship, funding, type of study, publication, and time to retraction.Data source and study selection: All retractions of English language publications indexed in MEDLINE between 1982 and 2002 were extracted.Data extraction: Two reviewers categorised the reasons for retraction of each article as misconduct (falsification, fabrication, or plagiarism) or unintentional error (mistakes in sampling, procedures, or data analysis; failure to reproduce findings; accidental omission of information about methods or data analysis).Data synthesis: Of the 395 articles retracted between 1982 and 2002, 107 (27.1%) were retracted because of scientific misconduct, 244 (61.8%) because of unintentional errors, and 44 (11.1%) could not be categorised. Compared with articles retracted because of misconduct, articles with unintentional mistakes were more likely to have multiple authors, no reported funding source, and to be published in frequently cited journals. They were more likely to be retracted by the author(s) of the article, and the retraction was more likely to occur more promptly (mean, 2.0 years; 95% CI, 1.8–2.2) than articles withdrawn because of misconduct (mean, 3.3 years; 95% CI, 2.7–3.9) (P < 0.05 for all comparisons).Conclusions: Retractions in the biomedical literature were more than twice as likely to result from unintentional mistakes than from scientific misconduct. The different characteristics of articles retracted for misconduct and for mistakes reflect distinct causes and, potentially, distinct solutions.

Sara B Nath PhD, MSW · Steven C Marcus PhD · Benjamin G Druss MD, MPH

Objective: To determine temporal trends in PubMed publications for Australian authors compared with changes in funding for health and medical research (HMR).Design: Retrospective observational study.Setting: Internet-based bibliometric study that collated Australian HMR expenditure from the Australian Institute of Health and Welfare and Australian (and other) research publications from PubMed.Main outcome measures: Australian expenditure on HMR and numbers of PubMed-cited publications from 1980 to 2004, with subgroup analyses for universities, clinical trials, and genetic and biotechnology research, and comparison with similar results from the United Kingdom and New Zealand.Results: From 1980–81 to 2003–04, Australian HMR expenditure increased from $66 million to $1503 million and total Australian PubMed publications increased from 844 to 13 836. From 1995–96 to 2003–04, Australian publications for university-derived research and for clinical trials increased at a fairly constant rate. Genetic and biotechnology publications increased about fivefold (49 to 277) between 1990–91 and 2003–04. Between 1990 and 2004, total publications increased from 1754 to 3288 for New Zealand and from 12 401 to 19 600 for the UK.Conclusions: There is an association between increased funding for HMR and increased publications, as determined using PubMed, in the past 10 years. Using PubMed may be a simple way to track output from HMR expenditure.

Kumara Mendis MB BS, MSc, MD · Rick McLean MD, FRACP

CorrectionRe: “Sackings at the Canadian Medical Association Journal and editorial independence”, by Martin B Van Der Weyden, in the 5 June issue of the Journal (Med J Aust 2006; 184: 543-545). References 8, 12 and 13 of this editorial were incorrect. The corrected references are: The html and pdf versions of the article were corrected on 20 June 2006.

Martin B Van Der Weyden

Objective: To identify characteristics of submitted manuscripts that are associated with acceptance for publication by major biomedical journals.Design, setting and participants: A prospective cohort study of manuscripts reporting original research submitted to three major biomedical journals (BMJ and the Lancet [UK] and Annals of Internal Medicine [USA]) between January and April 2003 and between November 2003 and February 2004. Case reports on single patients were excluded.Main outcome measures: Publication outcome, methodological quality, predictors of publication.Results: Of 1107 manuscripts enrolled in the study, 68 (6%) were accepted, 777 (70%) were rejected outright, and 262 (24%) were rejected after peer review. Higher methodological quality scores were associated with an increased chance of acceptance (odds ratio [OR], 1.39 per 0.1 point increase in quality score; 95% CI, 1.16–1.67; P < 0.001), after controlling for study design and journal. In a multivariate logistic regression model, manuscripts were more likely to be published if they reported a randomised controlled trial (RCT) (OR, 2.40; 95% CI, 1.21–4.80); used descriptive or qualitative analytical methods (OR, 2.85; 95% CI, 1.51–5.37); disclosed any funding source (OR, 1.90; 95% CI, 1.01–3.60); or had a corresponding author living in the same country as that of the publishing journal (OR, 1.99; 95% CI, 1.14–3.46). There was a non-significant trend towards manuscripts with larger sample size (≥ 73) being published (OR, 2.01; 95% CI, 0.94–4.32). After adjustment for other study characteristics, having statistically significant results did not improve the chance of a study being published (OR, 0.83; 95% CI, 0.34–1.96).Conclusions: Submitted manuscripts are more likely to be published if they have high methodological quality, RCT study design, descriptive or qualitative analytical methods and disclosure of any funding source, and if the corresponding author lives in the same country as that of the publishing journal. Larger sample size may also increase the chance of acceptance for publication.

Kirby P Lee PharmD, MA · Elizabeth A Boyd PhD · Jayna M Holroyd-Leduc MD · Peter Bacchetti PhD · Lisa A Bero PhD

The recent publication, in prestigious scientific journals, of two major studies that were subsequently shown to contain fabricated data may compel reviewers and editors to adopt a more rigorous policy in accepting articles for publication. The current manner of peer reviewing research articles provides no assurance that the proffered work is not the result of fraud. The present guidelines for contributors in large team investigations may need to be updated to avoid giving credit to co-authors who may have made little, if any, contribution to the work.

Paul Gerber LLB, DJur

A clash of purpose between a journal’s editors and its owner 20 February 2006 may well be the day that marked the beginning of the decline of the CMAJ (Canadian Medical Association Journal) as a widely respected national and international journal. On that day John Hoey, Editor-in-Chief of the CMAJ for 10 years, and his Deputy Editor Anne Marie Todkill were summarily dismissed by Graham Morris, the president of CMA Media Inc which publishes the CMAJ.1 As to the reasons for the firings, Morris said, “I felt that after 10 years it was time for a fresh approach.”2 His rationale was greeted with disbelief and derision from leaders in the publishing field. Frank Davidoff, Editor Emeritus of the Annals of Internal Medicine was reported as saying, “Oh, come on! A summary firing without a cause? I mean, how naïve do they think people are?”, adding, “I think it could be the death knell of this Journal”.3 The dismissal of Hoey and Todkill provoked editorial comments in the Lancet4 and the British Medical Journal (BMJ),5 and condemnations from the Council of Science Editors, the World Association of Medical Editors and the International Committee of Medical Journal Editors — all parties called for the Canadian Medical Association (CMA) to respect editorial independence.4 Within 3 weeks, the CMAJ was reduced to a shell of its former self. The journal’s Acting Editor-in-Chief, Stephen Choi, resigned, along with its Editorial Fellow and a number of Associate Editors. Their resignations were provoked by the failure of the CMA to agree to Choi’s request that the publisher and the owner of the journal, CMA Holdings, a commercial subsidiary of the CMA, not interfere with editorial content.6 In dire straits, the CMA turned to Bruce Squires, the previous Editor-in-Chief, to resume this role in an acting capacity. Seventy-one-year-old Squires declined and urged the CMA to heed Choi’s request for editorial independence. Finally, 16 of the 19 members of the CMAJ editorial board resigned.6,7 There was dismay and disquiet in the Canadian medical community. Anger among academics, researchers and clinicians followed, with calls for a boycott of submissions to the CMAJ and the activation of a worldwide petition for editorial autonomy at the CMAJ, and the reinstatement of Hoey and Todkill. There was even talk of setting up an open-access journal in competition with the CMAJ.7,8 Caught in this imbroglio, the CMA desperately needed a circuit breaker. This came with two announcements. The first announced yet another Acting Editor, Noni MacDonald (a former Dean of Medicine), the assembly of a new editorial board, and the release by the CMA of nine interim principles for editorial governance, including editorial independence.9,10 The second was more striking, announcing the formation of a panel of eminent authorities to “review the Canadian Medical Association Journal’s (CMAJ) governance structure and to provide objective recommendations to further the CMAJ’s continued commitment to editorial independence and maintaining excellence in reporting on the science and art of medicine.”11 The review panel, chaired by Antonio Lamer, a former Chief Justice of the Canadian Supreme Court, is to report soon. Despite these measures, dissatisfaction remains. It is obvious the current turmoil was driven by matters other than the desire to seek new directions.2 What then was behind the sacking of Hoey and Todkill? During Hoey’s tenure, there were smouldering tensions between the CMAJ and CMA as to who should have control over the journal’s content, particularly if this was politically or commercially awkward for the CMA.6,7 These tensions reached a climax in the months immediately before the sackings, with two CMAJ news items — the Plan B story (a CMAJ investigation of over-the-counter dispensing of the newly approved emergency contraceptive pill by Canadian pharmacists) and the Tony Clement story (an article commenting on his appointment as Minister of Health in the Conservative Canadian Government, which was critical of his stance on privatisation of health services).12 In late 2005, reporters from the CMAJ began an investigation into the circumstances surrounding over-the-counter dispensing of the emergency contraceptive pill — the investigation became know as the Plan B story. They asked 13 women to purchase the pill and report the conditions for its procurement. They found that the women had been asked private and personal questions by pharmacists, in accordance with the guidelines of the Canadian Pharmacists Association (CPhA). On learning of the investigation, the CPhA complained to the CMA that the exercise was not investigative journalism, but research, and thus should have had ethical approval. They also objected to what they considered to be covert observation of pharmacists. Hoey was instructed by CMA executives to pull the article; he did not, but when it appeared, details of the personal questions had been expunged. This was tantamount to censorship. After complaints by privacy commissioners following the publication of the story, the CPhA instructed its members to desist from extracting private information from consumers. However, the damage to CMAJ editorial independence had been done. This blatant breach was publicly exposed in a CMAJ editorial in December 2005, which noted that, “As a serious vehicle for science, news and opinion, CMAJ cannot avoid the discussion of contentious issues. It is not unexpected for tensions to arise between the association and the journal from time to time, for our mandates are not the same.”13 To bring the matter to a head, Hoey asked an ad hoc committee of the editorial board to review matters related to the handling of the Plan B story. During its deliberations, the committee’s attention was drawn to further instances of tampering with another news item — the Tony Clement story. This article, which was critical of Clement’s stance on privatisation of health services, was published electronically on 7 February 2006, but was subsequently removed from the website. It reappeared on 22 February 2006 as a different report, less critical of the Minister and more in harmony with the CMA stance on privatisation. The full texts of both versions are detailed in the final report of the ad hoc committee, chaired by Jerome Kassirer, the previous Editor-in-Chief of the New England Journal of Medicine, and with high-level individuals in medical publishing, journalism and academic medicine as members.12 After duly examining all relevant issues, the committee dismissed the complaints of the CPhA and reaffirmed the legitimacy of responsible journalism as an integral part of modern medical journals, drawing attention to this practice in the Lancet, BMJ, Science, Nature and the Journal of the American Medical Association. Significantly, it suggested that the CMA and CMA Holdings had a decision to make: either support editorial independence or run the risk of the CMAJ degenerating into “an association rag.” The committee also noted that, “Despite claims by the CMA, . . . the editorial autonomy [of the CMAJ] is to an important degree illusory” and that “Publishers have the option of dismissing an editor who exhibits a pattern of incompetence, misconduct or fiscal irresponsibility. As long as editors hold their position, however, they must be free to make editorial decisions independently of the ideological, strategic or commercial interests of the publisher. The editor’s conduct should be judged against the ideals of the medical profession and against standards of accuracy, precision and fairness. Editorial decisions should not be judged against the particular aims of the CMA.”12 In this context, the CMA President, Ruth Collins–Nakai, more recently revealed that “irreconcilable differences” between the editors and the publisher of the CMAJ were the real reasons for the sacking of Hoey and Todkill.14 Publishers and editors worldwide now await with interest the findings of the Lamer panel. Meanwhile, what can we learn from the CMAJ crisis? Editorial independence will only work if there is a clear understanding between owners and editors of journals as to a journal’s mission, and the empowerment of an editor or groups of editors to implement this mission and to be responsible for the cover-to-cover content of the journal. Essential to this process is the trust that editors will realise the stated ideals by making sound decisions and, at the same time, enjoy the freedom to publish controversial material, even when this is at odds with the purpose, politics and practices of the body owning the journal. In short, editorial independence is built on mutual respect, open communication and a clear understanding of boundaries.15 These appear to have been in short supply in the Hoey affair.

Martin B Van Der Weyden MD, FRACP, FRCPA

Objective: To examine media stories on research presented at scientific meetings to see if they reported basic study facts and cautions, and whether they were clear about the preliminary stage of the research.Design and setting: Three physicians with clinical epidemiology training analysed front-page newspaper stories (n = 32), other newspaper stories (n = 142), and television/radio stories (n = 13) identified in LexisNexis and ProQuest searches for research reports from five scientific meetings in 2002–2003 (American Heart Association, 14th Annual International AIDS Conference, American Society of Clinical Oncology, Society for Neuroscience, and the Radiological Society of North America).Main outcome measures: Media reporting of basic study facts (size, design, quantification of results); cautions about study designs with intrinsic limitations (animal/laboratory studies, studies with < 30 people, uncontrolled studies, controlled but not randomised studies) or downsides (adverse effects in intervention studies); warnings about the preliminary stage of the research presented at scientific meetings.Results: 34% of the 187 stories did not mention study size, 18% did not mention study design (another 35% were so ambiguous that expert readers had to guess the design), and 40% did not quantify the main result. Only 6% of news stories about animal studies mentioned their limited relevance to human health; 21% of stories about small studies noted problems with the precision of the finding; 10% of stories about uncontrolled studies noted it was not possible to know if the outcome really related to the exposure; and 19% of stories about controlled but not randomised studies raised the possibility of confounding. Only 29% of the 142 news stories on intervention studies noted the possibility of any potential downside. Twelve stories mentioned a corresponding “in press” medical journal article; two of the remaining 175 noted that findings were unpublished, might not have undergone peer review, or might change.Conclusions: News stories about scientific meeting research presentations often omit basic study facts and cautions. Consequently, the public may be misled about the validity and relevance of the science presented.

Steven Woloshin MD, MS · Lisa M Schwartz MD, MS

Each Indigenous health problem calls for its own unique mix of descriptive and intervention research in both clinical and public health fields The Aboriginal and Torres Strait Islander Social Justice Commissioner, Tom Calma, has challenged all governments to commit to achieving Indigenous health outcomes equal to those of non-Indigenous Australian people within 25 years.1 Governments have set similar goals in the past, but have avoided such clear deadlines. What role should research play in a properly funded program for Aboriginal and Torres Strait Islander health equality? Research can provide useful evidence to better target health policy and strategy, and to guide more effective health services. Researchers can also intervene with empirically-based good sense when the debate gets sidetracked by slogans from all points in the political spectrum. The debate will not be depoliticised, but researchers may help in moving it along. In fact, researchers would be wise to be humble about their impact. They only act as small — if sometimes crucial — wheels in the complex social and political machinery that drives the necessary changes to health services and to the broader social determinants of health. They also must bear the legacy of unhelpful or damaging past health research that fuels Indigenous distrust of research and researchers today.2 Since the social changes of the late 1960s, Australian researchers have increasingly turned their attention to the health of Aboriginal and Torres Strait Islander peoples. Indigenous health publications occupied less than one per cent of the pages of the Medical Journal of Australia in the years before 1970, but by the 1990s this had risen to more than four per cent.3 In this issue of the Journal, Sanson-Fisher and colleagues describe the trends in the numbers of Indigenous health publications in Australia, New Zealand, Canada and the United States since 1987 (Indigenous health research: a critical review of outputs over time).4 They do not tell us who wrote these publications, nor do they tell us much about what was written. Nevertheless, they report that the greatest increase in the number of Indigenous health publications was in Australia, where the total number rose from 28 in 1987–1988 to 167 in 1997–1998 then fell to 147 in 2001–2003. Original research publications were dominated by descriptive research. We agree with their concern about the much smaller (albeit increasing) number of publications assessing health interventions, and the consistently low number assessing measurement tools. How do we find the right balance between these different types of research? We need research that assesses new interventions for diseases or clinical syndromes, such as chronic suppurative otitis media, that are common among Aboriginal and Torres Strait Islander peoples, but relatively uncommon in other Australians. We may also need to evaluate the transferability of some well tested interventions when we suspect that they will work differently in an Indigenous health setting, which is the case for chronic disease programs. Often, however, we can readily apply research from other settings without the need for new research. Some descriptive research can still be necessary when it fills gaps in knowledge that undermine the capacity to make good policy decisions. Different problems will require research programs with different mixes of descriptive and intervention research, and different research methods. Health-service providers, policy makers and Indigenous communities can tell us which uncertainties are impeding action to improve Indigenous health, and so need answers from new research programs. The “road map” produced by the National Health and Medical Research Council (NHMRC) describes what areas of new research are agreed to be most useful: from patterns of risk factors to researching resilience and well-being.5 The NHMRC has also produced guidelines to help non-Indigenous researchers build more ethical relationships with Aboriginal and Torres Strait Islander communities.6 The Journal has not just been a passive recipient and publisher of an increasing number of manuscripts about Aboriginal and Torres Strait Islander health. The first of many special supplements on Aboriginal health was published in 1975.7 This issue, like several earlier issues, is devoted to Aboriginal and Torres Strait Islander health. There are other less visible changes at the Journal: editors can now usually recruit at least one Indigenous reviewer for every Indigenous health manuscript. No longer is Indigenous health research only a matter of white researchers writing about Aboriginal people for a white readership:8 there are slowly more and more Indigenous people involved in all stages of the research process — from setting the research question, to doing the research, to writing, reviewing and reading the final publication. There have been changes in how Indigenous health problems are framed in the Journal. Sixty years ago, the Journal reported a conference paper which compared the falling Australian Aboriginal population with the increasing indigenous populations of the United States, Canada and New Zealand.9 The author did not call for more research on health interventions but for more scientific research on “hybrid vigour”, reflecting the prevalent but misguided political obsession with the “half-caste problem”. However, he then moved to a more familiar issue. He linked the unfavourable international comparisons to the “outstandingly mean, neglectful and backward” approach of Australian governments to Aboriginal people: the 63 shillings of Australian government annual spending per Aboriginal person compared with much higher spending in the United States (£23) and Canada (£10). Recent research has documented that Australia now spends only 18% more on health services for each Aboriginal and Torres Strait Islander person than for each non-Indigenous person, in spite of the much greater burden of illness among Indigenous people, and the higher costs of providing services to them, especially in remote areas.10 This descriptive research on expenditure has been invaluable in cutting across polemical argument about the “buckets of money” that are “thrown” at Indigenous health. This descriptive work now needs to be complemented by research that will evaluate financial and administrative interventions in Indigenous health against progress towards the other goal set by the Social Justice Commissioner: equal access to primary health care and health infrastructure within 10 years.

David P Thomas PhD, FAFPHM · Ian P Anderson MB BS, FAFPHM

Objective: To determine the number and nature of publications on Indigenous health in Australia, Canada, New Zealand and the United States) in 1987–1988, 1997–1998 and 2001–2003.Data sources: MEDLINE and PsychLit databases were searched using the following terms: Aborigines or Aboriginal; Torres Strait Islander; Maori; American Indian; North American Indian, or Indian, North American; Alaska/an Native; Native Hawaiian; Native American; American Samoan; Eskimos or Inuit; Eskimos or Aleut; Metis; Indigenous.Study selection: Publications were included if they were concerned with the health of Indigenous people of the relevant countries. 1763 Indigenous health publications were selected.Data extraction: Publications were classified as either: original research; reviews; program descriptions; discussion papers or commentaries; or case reports. Research publications were further classified as either measurement, descriptive, or intervention. Intervention studies were then classified as either experimental or non-experimental.Data synthesis: The total number of publications was highest in 1997–1998 for most countries. The most common type of publication across all time periods for all countries was research publications. In Australia only, the number of research publications was slightly higher in 2001–2003 compared with other time periods. For each country and at each time, research was predominantly descriptive (75%–92%), with very little measurement (0–11%) and intervention research (0–18%). Overall, of the 1131 research publications, 983 were descriptive, 72 measurement and 76 intervention research.Conclusions: The dominance of descriptive research in Indigenous health is not ideal, and our findings should be carefully considered by research organisations and researchers when developing research policies.

Robert W Sanson-Fisher BPsych, MPsych, PhD · Elizabeth M Campbell BPsych, PhD · Janice J Perkins PhD · Steve V Blunden GradDipHealth Admin · Bob B Davis GradDipEpidemiol

Christina V T Ng Specialist and Lecturer — Medical Oncology, Department of Medicine, University Malaya Medical Centre, Jalan Universiti, Lembah Pantai, Kuala Lumpur, 59100, Malaysia. christinavtngAThotmail.com To the Editor: I would like to clarify several issues pertaining to the case report published in the 7 February 2005 issue of the Journal.1 The patient reported was under the care of Dr Craig Underhill and Dr Kerrie Clarke, who are medical oncologists at Albury Base Hospital, Albury, New South Wales. Their contribution to the reporting of this rare and interesting case must be acknowledged. I regret any misconceptions arising from this article, and I would like to thank Dr Underhill and Dr Clarke for their support and professionalism.

Christina V T Ng

To the Editor: Last year was the 60th anniversary of the liberation of the Nazi concentration camps. We would like to draw your attention to an anatomy textbook, Atlas of topographical and applied human anatomy, authored by a Nazi physician, Eduard Pernkopf, and the alarming evidence which has emerged about the source of subjects used for the illustrations of this book. The context of raising this issue is that this text is listed as available for loan in a general collection on the catalogue of several university libraries around Australia, including the University of Sydney, the University of New South Wales, the University of Adelaide, the University of South Australia, La Trobe University, the University of Western Australia, the Queensland University of Technology and the University of Tasmania, often with multiple copies, which suggests that it may be held as teaching material. Evidence overwhelmingly suggests that the Pernkopf anatomical atlas contains pictures of victims of the Nazi regime. An investigation into this issue by the University of Vienna in the mid 1990s revealed that at least 1377 bodies of murdered victims, including children, were accepted by the Institute of Anatomy.1 The bodies of the victims were used, without the victims’ or their families’ consent, for research and teaching, including by Pernkopf for his atlas.1,2 Pernkopf, an enthusiastic Nazi, took over as Dean of the Vienna Medical School after the annexation of Austria by Nazi Germany, and led the expulsion of the then majority Jewish faculty, including several Nobel laureates.3 He is known to have willingly accepted specimens from murdered children and adults. Original editions, even as recently as 15 years ago, contained swastikas painted at the bottom of the pictures. These have been airbrushed out in more recent editions.4,5 Internationally, there have been a number of different approaches to managing this item within library collections. Some have asked their libraries to remove this book from their general collections. For example, a US physician, upon finding the book in his centre’s library, convinced them to expunge it from their collection. He also resigned from editorial responsibilities to the publisher of the atlas, and cancelled his subscriptions to their journals.1 Another approach has been placing a summary of the report from the University of Vienna’s investigation inside the front cover of the book, so that library patrons are given the context for the drawings and can make an informed choice.1 While acknowledging the need to preserve freedom of access to information, the unethical use of executed victims for this atlas leads us to believe that it has no place as a general anatomy text in an academic setting. The atlas may have a role as a reminder of the atrocities committed in the name of medical science during the Nazi era, and could remain available for researchers examining abuse of human rights, medical ethics and history. We have contacted our library (the University of Sydney library) about this atlas and asked them to take appropriate action. They have elected to move copies held in high usage collections to special collections. We urge others whose institutions hold this text to do the same.

C Raina MacIntyre · Catherine L King · David Isaacs