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[NAME],  MD, MPH  Medical College of Wisconsin |  |  | Tabas and colleagues recent article "Clinician attitudes about commercial support of continuing medical education" (CME) is an important contribution to our understanding of the barriers to minimizing commercial bias in the information that physicians receive during CME activities.1 They reaffirm that physicians believe they are not influenced by the bias they recognize is present in industry supported presentations. They also show that physicians markedly underestimate CME costs, perhaps because they don't bear those costs.   Drs. Dorman and [NAME]'s accompanying commentary2 suggests that large group conferences "require" industry funding. They suggest the profession explore alternative approaches to CME including peer coaching, performance improvement CME and others. While I applaud efforts to develop innovative, more effective approaches to CME, it seems that large group conferences will continue, at least in the short term. With this reality in mind, I would like to provide a counter-example to their thesis that total separation from industry is impracticable. Since 2007, the annual meeting of the Society of General Internal Medicine (SGIM) has been held entirely without industry support. The most highly rated workshops are interactive small group sessions, which evidence suggests are more effective educationally than didactic lectures.3,4 Details can be found on the meeting website.5   How is this possible? First, over 400 member volunteers perform rigorous peer review of proposed presentations; review criteria emphasize the educational value of content and format. Except invited plenary presenters, honoraria and travel support is not available. Cost considerations drive where SGIM meets; the 2011 meeting was in Phoenix, not San Francisco. Other cost cutting measures include reducing the number of events where food is served (e.g., beverages, not food, at breaks), no giveaway items, and careful attention to audiovisual costs. The President’s reception for the program committee is the only reception with a hosted bar; others have cash bars.   Despite these measures, registration fees are comparable to other CME meetings - $595 for the four-day 2011 meeting, exclusive of travel costs, which certainly doubled that cost. It is unclear why this cost is acceptable to SGIM members. However, mean academic general internist annual income exceeds the $166,200 that marked the 95th percentile of US household incomes in 2010; the cost of the meeting, which provides 19.5 hours of CME, is less than 1 percent of their income. They apparently judge that this a realistic price to pay for high quality, peer reviewed education presented without direct commercial support.   References   1. Tabas JA, [NAME], [NAME], Volberding PA, Baron RB. Clinician attitudes about commercial support of continuing medical education: Results of a detailed survey. [NAME]   2. Dorman T, Silver IL. Continuing medical education: Is perception Reality?   3. [NAME], McKena M, [NAME] models for large- group continuing medical education activities Fam Med 2011;43(5):334-337.   4. [NAME], [NAME], [NAME], et [NAME]. Randomized controlled trials of continuing medical education: what makes them most effective? J Contin Educ Health Profess 2002; 22(4):214-221   5. SGIM 34th Annual Meeting website. http://www.sgim.org/index.cfm?pageId=1093&CFID=611301&CFTOKEN=88244229 Accessed June 4, 2011    Conflict of Interest: Member of the Society of General Internal Medicine |  | P |  |  | 171 | 9 | 840
[NAME],  DDS, PhD  University of Geneva |  |  | Let me first thank the authors for initiating a discussion of this issue in the peer-reviewed scientific literature. However, it seems that the authors did not collect any data of their own or do any experiments. It is very easy to measure the effects of the radiation of these scanners on cells using methodology that my laboratory and other laboratories have developed (for example, [NAME] et al., Journal of Cell Biology 151: 1381- 90, 2000). The amount of DNA damage induced by these scanners could then be accurately determined. Why not do these studies?    Conflict of Interest: None declared |  | P |  |  | 171 | 12 | 1112
[NAME],  MD  School of Medicine |  |  | The statement within the article "Naturally occurring radiation is higher at the altitudes of commercial air flights because of the greater proximity to the sun" is incorrect. The Sun is 150x10E6 Km away from the earth and commercial airliners cruise at altitudes of around 10 Km, where "closer" in this context only applies for airliners cruising within daylit areas of the earth, and for non-sunlit areas the airliners are in fact slightly further away from the sun than observers on the ground beneath them. In either case, the extra distance created by the airliner's cruising altitude is infinitesimal compared to the average Sun-Earth distance.   The reason for the higher background ionizing radiation at higher altitudes is due to the increasingly rarefied atmosphere, which provides less scattering and absorption of incoming radiation from astronomical sources (including but not limited to the Sun).    Conflict of Interest: None declared |  | P |  |  | 171 | 12 | 1112
[NAME],  BSEE/MSEE  Johns Hopkins University |  |  | It is appalling that the researcher would find 11 deaths per year acceptable when an equally effective alternative is available that poses no health risks. No deaths are acceptable in the presence of a demonstrably safe option. The millimeter wave scanners are proven to be safe, are currently in use and have been equally effective in detecting threats although both systems have serious security flaws and limitations along with the privacy issues that accompany both technologies.   It is troubling that a medical professional would be so indifferent to the health and welfare of innocent people in order to profit from this flawed study. She did not test operating backscatter x-ray scanners actually in service so her findings are meaningless. The risk lies in the lack of regular and competent local testing, recalibration of the output device and limitations operator intensity adjustment .   She is unquestionably violating her Hippocratic Oath, which requires that she “first do no harm”. By deeming this technology safe, she is needlessly placing 11 passengers per year at risk of death. She is a disgrace to the medical community and should be disciplined by the University and local medical society for this placing profit ahead of her obligation to protect public health.   [NAME]    Conflict of Interest: None declared |  | NR |  |  | 171 | 12 | 1112
[NAME],  MD  Mount Sinai School of Medicine |  |  | There have been a number of well-publicized incidents of radiation- emitting equipment malfunctioning, causing inadvertent but excessive irradiation of patients from both diagnostic and therapeutic equipment.   Inasmuch as equipment in medical centers might be expected to undergo checking with higher frequency than that in airports, have measures been taken to assure the regular testing of radiation output of such scanners to avoid any potential for radiation in excess of the minimal amounts you cite?    Conflict of Interest: None declared |  |  |  |  | 171 | 12 | 1112
Professor Pranab [NAME],  MD(cal) FIc path(ind.)  Professor and Head, Department of Pathology, RegionalInstitute of Ophthalmology Medical College,,  Bhattacharya Rupak, Bhattacharya Ritwik,[NAME], Miss [NAME]; [NAME]; Miss [NAME] mukherjee; Surajit sarkar Tridibeswar Mandal , |  |  | Survivors of Cancer in Kolkata, West Bengal, India- a scenario Authors_: *Professor Pranab kumar [NAME]) [NAME], FIc Path(Ind.),Presently Professor and Head, Department of Pathology, RegionalInstitute of Ophthalmology , The Medical college, Kolkata -73 ,W.B and Ex-Additional Professor of Department of Pathology, Institute of Post Graduate Medical Education & [NAME], Kolkata-20, West Bengal, India** Mr. [NAME]), Msc(JU), 7/51 [NAME], [NAME], Dist 24 Parganas(north) Kol-110,West Bengal, India **Mr.[NAME] Bhattacharya B.com(cal), **Mr [NAME] MBA of residence7/51 [NAME], [NAME], Dist 24 parganas(north) ,[NAME] 110,WestBengal, India*Miss Upasana Bhattacharya- Student, Mahamayatala, Garia, kol-86, only daughter of Prof.[NAME]*** Mrs. [NAME] Mukherjee BA(hons) Cal, Swamiji Road, South Habra, 24 Parganas(north) WestBengal, India***Miss [NAME] ,Swamiji Road, South Habra, 24 Parganas(north), West Bengal, India****; Mr. [NAME] DMLT, Technician Pathology, Institute of Post Graduate Medical Education & Research,244 a AJC Bose Road, Kolkata-20, West Bengal, India , Kolkata-20 Dr ****Tridibeshawr Mandal MD(cal) Biochemistry IPGME&R Kol -20   The Indian subcontinent is today home to 16.5% of the world's population [census 2011 shows it's population increased 122 cores next to China and West Bengal it is approximately 9.6 cores] and at any one time it is estimated that there may be not less but over 3.5 million or people with cancers in different age group from childhood to aged. Number of Cancer Patients at present in West Bengal approx. 3,50,000. Number of Cancer Patients increasing every year in West Bengal approx. 69,000. Radiotherapy needed every year for patients approx. 60,000 when Radiotherapy capacity of West Bengal at present approx. 22,000. Fatal consequences for want of essential treatment approx 30,000. Cancer had never been a prominent healthcare issues in kolkata, West Bengal, as per first author, compared with other diseases in West Bengal and in Kolkata. But the fact is that as a histopathologist of the city in tertiary medical colleges of the city, the first author's last 26 years experience while diagnosing biopsies, is that various histological types of cancers, like [NAME], Breast, Cervical, Neck cancer, [NAME], [NAME] cancer, [NAME] cancers, child hood leukemia, [NAME], soft tissues sarcomas are also emerging today as a significant health problem in kolkata and suburban people of West Bengal. Peculiarly, [NAME] patients, for some unknown reasons, are most prominently found amongst low socioeconomic class people, possibly due to their diet, consumption of bidi, other form of tobacco, local made alcohol, STDs, HPV poor vitamin and antioxidants use and other habit or some kinds of genetic susceptibility and their very low financial capability for purchasing health, and pocket expenditure, access towards any three or five star hotel private health care institutions, where gadgets for advanced treatment and diagnostic facility may be available but with complete business and huge amount profit outlook and nonetheless family members illiteracy also contribute towards their advanced stages of disease on presentation to public tertiary care hospitals clinics, and due to very high cost chemotherapy, Immunotherapy, biological therapy [Chemotherapy not only kills the patient ultimately and their family members too economically] and most of people accepts Homeopathy, Traditional, Complementary and Alternative Medicines (TCAM) are often the only therapies available for low socioeconomic people in West Bengal, as they are less costly and in affordable reach to poor socioeconomic class of West Bengal. India has just 48-50 doctors per 100,000 people compared to the UK with 230 and the US with 256. The poor provision of public sector healthcare in cancer diagnosis and therapy in tertiary care Medical colleges means many people (even a section of the poor) turn to the private sectors cancer treatment centers, those are far distant of all kinds of human face towards the cancer and terminally ill and they understands in terms of only business and money making centers. The number of cancer patients are steadily increasing also in India due to early and improved histopathological diagnosis and improved modality of treatment facilities only for the upper class and rich class societies. The majority of Indian cancer patients present late stage incurable diseases (75% to 80%) when first diagnosed. Chemotherapy [The authors really doubt how much the costly chemotherapy is beneficial for ultimate survivors except in few histological type cancers and when diagnosed most early] or [NAME] or targeted biological & immunological therapy of Cancer patients with both solid and hematological malignancy including Stem Cell Transplantation facility [in infancy] are today available in certain centers of Kolkata, West Bengal.   Presently in India, out of a million newly diagnosed cancer patients each year, more than 60% die within 12-24 months of diagnosis and another one million cancer survivors show progressive disease within five years of diagnosis.5 The number of U.S. cancer survivors however increased from 9.8 million in 2001 to 11.7 million in 2007, according to an analysis of new cancer cases and follow-up data from NCI's Surveillance, Epidemiology, and End Results (SEER) program published in march 11th 2011 report.6 According to that report, it were however breast, prostate, and colorectal cancers were the most common types of cancer amongst those survivors in US, accounting for 51 percent of total cancer diagnoses in USA. In that study, among all cancer survivors, 54.3 percent were female, 45.7 percent were male, nearly 7 million were 65 years of age or older, and 4.7 million received their diagnosis 10 or more years earlier. The increase seen over the past 4 decades is attributable to a variety of factors, including an aging U.S. population, most earlier detection of cancer by CT MRI and with help of immunochemistry, PCR, Flowcytometry, expert histopathologists services and more &and ;more sophisticated treatments that allow individuals to live longer following initial diagnosis.1 As for the incidence of gliomas is increasing worldwide, including India and in one study from West Bengal, India, in which only 7.9% of brain tumors were GBMs, while 46.8% were astrocytomas. Low grade gliomas (LGGs) typically occur in younger adults, normally before age 40, and encompass a spectrum of histological subtypes that resemble differentiated macroglial cells, without evidence of anaplasia. Diffuse astrocytomas represent 60 - 70% of the LGGs and are the most common of LGGs The subtypes of low-grade astrocytomas include fibrillary, protoplasmic, pilocytic, and gemistocyticastrocytoma. The fibrillary subtype is the most common in adults while thegemistocytic subtype is less common, but has a higher potential for anaplastic transformation. Other histological subtypes of the LGGs includethe juvenile pilocytic astrocytoma (JPA), which usually occurs before age 25, oligodendroglioma/oligoastrocytoma (LGO/LGOA), ganglioglioma, pleomorphic xanthoastrocytoma (PXA), subependymal giant cell astrocytoma (SEGA), subependymomas, and desmoplastic gangliomas. Different gliomas occur in differentage groups and some entities such are PXA are more common in adolescents, while others are more common in the elderly, such as GBM3 But cancer survivors must faces several health related issues, Health risks, poor mental, financial, physical, and social and sexual Quality of life [QOL]that must be looked for. Of these many QOL domains,the largest disparity is often found in the area of mental health which cancer people often reported   A] psychosocial issues- many cancer survivors complain that there are little emotional support or financial support from the government or family or relatives. Many patients even losses their services when they are detected cancer and they are severely depressed. They faces mental trauma and shock when they hear about their cancer. They fear of their recurrences of the cancer and follow up visit and further expenditure. They are afraid of severe pain. The city of kolkata so needs awareness about the disease particularly in rural and sub urban cities and there might be mobile cancer detection units from department of health and family planning west Bengal roaming at villages at free of cost but never by the private institutions Such system are non existent even in Kolkata city and a far off concept for the rural village and suburban. People spend often Rs 60,000 on a treatment at private health care institutes that can be easily undertaken for Rs 3,000 if there was government level vigilance on mush rooming private health care systems, with law and bill for extreme punishment for such malpractices with terminally ill. To combat cancer, one needs strong emotional support, from family and other cancer survivors."   B] In the Childhood Cancer Survivor are of median time of survivors for 14 years in one study.2 But they are likely developing thyroid related cancers and other thyroid related problems like hypothyroidism[17%]. Radiation-related thyroid cancer doubles for every gray (Gy) of exposure to the thyroid. Radiation-related risk of thyroid cancer increased with increasing I-131 dose and was greatest for those individuals who were younger at the time of exposure. Risk appeared similar for men and women. As for example, Treatment for Hodgkin's disease (HD) is found to be associated with a variety of thyroid abnormalities, including hypothyroidism, hyperthyroidism, and thyroid neoplasm like papillary carcinomas   C] The incidence rate of contra lateral breast cancer positive for the estrogen receptor (ER) We know from randomized trials that drugs like tamoxifen significantly can reduce the risk of a contra lateral breast cancer, by about 40 percent, Tyrosine inhibitors may be used with good results   D] Skin cancer is one of the most common secondary neoplasms amongst many childhood cancer survivors. Behavioral interventions addressing lifestyle factors, including sun safety behaviors, among adolescent survivors of childhood cancer should be integrated into long-term care to reduce the risk for secondary malignancies and diseases.   E] The incidence of major congenital birth abnormalities was slightly higher in the offspring of male cancer survivors compared with children of fathers with no history of cancer, The increasing number of male cancer survivors has given rise to concerns about the health of their offspring. Although previous studies on children conceived naturally have been reassuring about the health of the children, the researchers found that a paternal history of cancer was associated with a 17% increased relative risk of major congenital malformations. For example in hematological malignancies, generally when treated with chemotherapy, were associated with a non-statistically significant increased risk of congenital abnormalities in children with a paternal history of cancer compared to those without, no such increased risk was seen with children with a paternal history of testicular seminoma.   References   1. [NAME] Have Slightly Higher Risk of Congenital Birth Abnormalities" Journal of National Cancer Institute [EMAIL] ??[PHONE]   2. [NAME], [NAME], [NAME], [NAME], [NAME], [NAME], [NAME], [NAME] and [NAME] "Abnormalities of the Thyroid in Survivors of Hodgkin's Disease: Data fromthe Childhood Cancer Survivor Study "The Journal of Clinical Endocrinology& Metabolism Vol. 85, No. 9 3227-3232 doi:10.1210/jc.85.9.3227   3. [NAME], [NAME], Vogelbaum M, Suh JH, [NAME] "Evidence-based adjuvant therapy for gliomas: Current concepts and newer developments" Indian Journal of Cancer Vol. 46, No. 2, April-June, 2009, pp. 96-107   4. Mays D, Black JD, Mosher RB, Shad AT, Tercyak KP Improving short-term sun safety practices among adolescent survivors of childhood cancer: a randomized controlled efficacy trial. [JOURNAL ARTICLE] J Cancer Surviv 2011 Feb 27   5. [NAME], KR [NAME],Philip Tovey,[NAME], [NAME], [NAME], [NAME] Indian Cancer Patients' use of Traditional, Complementary and Alternative Medicine (TCAM) and delays in presentation to Hospital OMJ. 24, 103-107 (2009); doi:10.5001/omj.2009.24   6. U.S. Cancer Survivors Increase to Nearly 12 Million- National cancer Institute Bulletin-A trusted source for cancer research bulletin- cancer research Highlights March 11,2011 Morbidity and Mortality Weekly Report.    Conflict of Interest: None declared |  | P |  |  | 169 | 14 | 1274