Citation of SIR,-Although




work in unrelated


of biomedical

have become increasingly aware of a failure to acknowledge previous relevant observations by other workers, in both oral and written scientific communications. We suspect that this regrettable tendency correlates with the growing difficulty in acquisition of resources for the conduct of research. The consequent increase in competitiveness between scientists leads to a short-term outlook. Through either cursory and inadequate review of publications, or an unconscious (and perhaps sometimes conscious) neglect, pertinent reports are ignored. The drive to seem to be first prevails. At its worst, this trend may result in the biased review of research papers and grant applications, so that the work of competitors is suppressed. Although these hazards may not be new, we believe that they are becoming more common. Although difficult to achieve, a return to a more ethical scientific approach is desirable. We offer some suggestions. First, journals could require a short separate section, following the abstract and before the introduction, which would be termed background. Here authors would cite relevant work of others, as well as their own. In this way, errors or omissions would become more obvious. Alternatively, authors could merely be instructed to include key citations in their introduction, and to verify, in writing, that they have fully reviewed published work. Second, bias in reviewing papers and grants is more difficult to resolve, since it may derive from conflict of interest, or even personal hostility. Authors and grant applicants, at the time of their submissions, could be encouraged to provide the name of any institute to which they consider their work should not be sent for review. At the very least this would give warning of possible research



and ankles was normal apart from soft-tissue swelling of the left little finger. There were no radiological changes of the long bones to suggest hypertrophic pulmonary osteoarthropathy. Initial treatment with ibuprofen was ineffective. A prolonged course of prednisolone 25 mg on alternate days prevented further episodes for 2 years but recent attempts to reduce this dose coincided with exacerbations of her joint disease during periods of increased chest symptoms. Intravenous antibiotic treatment has been needed to control respiratory and joint symptoms. We have since successfully treated two other children with episodic arthritis with a course of intensive intravenous antibiotics. We suggest that this treatment should be considered in episodic arthritis associated with cystic fibrosis. Regional Cystic Fibrosis Unit, St James’s University Hospital, Leeds LS9 7TF, UK 1. 2.



Phillips BM, David TJ. Pathogenesis and management of arthropathy in cystic fibrosis. J R Soc Med 1986; 79 (suppl 12): 44-50. Moss RB, Yao-Pi Hsu MS, Lewiston NJ. 125I-Clq-binding and specific antibodies as indicators of pulmonary disease activity m cystic fibrosis. J Pediatr 1981; 99: 215-22.

3. Bourke

S, Rooney M, Fitzgerald M, Bresnihan B. Episodic arthropathy in adult cystic

fibrosis. Q J Med 1987; 64: 651-59.

Hepatitis A vaccination MR,—You report in your May 16 editorial the launch in March, 1992, of the first inactivated hepatitis A vaccine. This launch has

prompted discussion of the indications for the use of this product, especially its role in protecting travellers.1,2 The decision to immunise an individual traveller should be based risk and cost benefit analyses. These take into account the risk of disease, which seems to be different from the risk of infection, the cost of the vaccine, and the economic and other costs of morbidity.3 The incidence of travel-related hepatitis A in the UK can only be estimated from data available from laboratory reporting of confirmed cases to the Public Health Laboratory Service. In 1988 14% of all reported cases gave a history of recent travel. In the same year 5-04 million UK residents travelled4 to destinations where hepatitis A immunisation is recommended-ie, the Meditteranean (excluding Spain and Portugal), and Italy, North Africa, and the tropics.s Prescription data for 1990, the closest available year, showed that passive prophylaxis with gammaglobulin was given to an estimated 600 000 individuals.6 In 1988, 566 cases of hepatitis A were associated with travel.7 Even in view of gross underreporting, the incidence of clinical hepatitis A in returning UK travellers seems to be moderately low. The price of the primary course is around 40. There are additional administrative expenses. Current immunisation recommendationss would encompass more than 5 million UK travellers annually. The potential national costs and benefits of hepatitis A and other travel vaccines need to be considered alongside other calls on the limited National Health Service purse. Without more precise data on region-specific disease incidence and cost of morbidity from hepatitis A a sensible strategy for this expensive new resource cannot be made. on

Neurodegenerative Disorders Centre, University of British Columbia,


Vancouver, Canada

Department of Surgery, University of Cambridge, Cambridge CB2 2QQ, UK

Episodic arthritis



cystic fibrosis

arthritis associated with

cystic fibrosis is SIR,-Episodic characterised by acute polyarthralgia, especially in large joints, resulting in limited active movement but without residual joint destruction.1 An immunological process seems to be the most likely pathogenesis. However, despite the increased immune activity during a respiratory exacerbation of cystic fibrosis,2 it is surprising that reports of episodic arthritis do not associate joint symptoms with the chest infection.1,3 We report a 13-year-old girl with cystic fibrosis who has had frequent episodes of painful arthritis from 2 years of age. The main joints affected are the hips, knees, and ankles. Erythema nodosum has often been concurrent. The symptoms occur with exacerbations of her respiratory infection and improve strikingly with antibiotic therapy. There is no family history of joint disease or psoriasis, and no association with any medication. She has not received quinolone antibiotics but has grown Pseudomonas aeruginosa from her sputum from age 11. She has moderate clubbing and a Chrispin-Norman chest radiograph score of 14. Flexion of both knees is considerably limited. However, rather than being due to joint disease, this seems to be because ofcontractures of the quadriceps muscles, probably as a result of intramuscular cloxacillin given during the neonatal period after laparotomy for meconium ileus. The proximal interphalangeal joint of the left little finger is also permanently swollen, but all other joints have no limitation of movement or swelling, apart from during an episode of arthropathy. The neutrophil count was increased during the episodes of arthralgia (maximum 11.1 1 109/1), as was the erythrocyte sedimentation rate (maximum 19 mm/h) and immunoglobulin IgG (17-4 g/1), but complement levels were normal (C3 I’ll g/1, C4 0 315 g/1. The IgG rheumatoid factor, antinuclear factor, antibodies to brucella, and Mantoux test were negative. Plasma uric acid was normal (013 mmol/1). Radiology of the hands, wrists, pelvis, knees,

Department of Immunisation and Vaccination, PH LS Communicable Disease Surveillance Centre, London NW9


Travel Clinic Hospital for Tropical Diseases, London W1 P 9EJ, UK



Hegarty MA. Recommendations for the use of hepatitis A vaccine. BMJ 1992; 304:


Tilzey AJ,



4. 5.

6. 7.

Palmer SJ, Barrow S, et al. Clinical trials with inactivated hepatitis A vaccine and recommendations for its use. BMJ 1992; 304: 1272-76. Weiderman G. Is vaccination worthwhile before travel. In: Steffen R, Lobel HO, Haworth J, Bradley DJ, eds. Travel medicine. Heidelberg: Springer-Verlag, 1988: 208. Central Statistical Office. Overseas travel and tourism. In: Business monitor MA6 London: HM Stationery Office, 1991. Lea G. Advice for travellers. Commun Dis Rep 1992; 2: R82-R83. Tilzey AJ, Banatvala JE. Hepatitis A [editorial] BMJ 1991; 302: 1552-53. Polakoff S. Reports of clinical hepatitis A from public health and hospital laboratories to PHLS Communicable Diseases Centre during the period 1980-88. J Infect 1990; 21: 111-17.

Citation of original research.

244 Citation of SIR,-Although we original research work in unrelated areas of biomedical have become increasingly aware of a failure to acknow...
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