I read with great interest the article titled "Spatial analysis of health effects of large industrial incinerators in England, 1998-2008: a study using matched case-control areas" by Nicola F Reeve et al, published in BMJ Open 2013;3:e001847. The issue is of great relevance. The paper, however, contains some critical points that need to be underlined.

1. The definition of "control" circles does not exclude the presence, in these areas, of other environmental pressure factors able to produce emissions similar to those from incinerators. A qualitative and quantitative analysis of pollutants was not available in the study from Authors, neither in case nor in control regions. Furthermore, it has to be reported that the European Pollutant Release and Transfer Register (http://prtr.ec.europa.eu) reveals the presence, in all the "control" regions selected by Authors, of a number of facilities producing environmental pollution potentially affecting human health and the outcomes explored by Authors in their paper: Doncaster: 40 facilities, including manufacture of glass, treatment and disposal of hazardous and non-hazardous waste, manufacture of wire products, chain and springs, metallurgical, chemical or electrolytic production of non ferrous metals, industrial scale production of basic organic chemicals, production of non-ferrous crude metals from ore, concentrates or secondary raw materials, surface treatment of metals and plastics using electrolytic or chemical processes, production of carbon or electro-graphite through incineration or graphitization. Wolverhampton: 22 pollution producing facilities, including surface treatment of metals and plastics using electrolytic or chemical processes, disposal of non-hazardous waste, surface treatment of substances, objects or products using organic solvents, application of protective fused metal coats, incineration of non-hazardous waste included in Directive 2000/76/EC Derby: 25 pollution producing facilities, including disposal or recovery of hazardous and non-hazardous waste, surface treatment of substances, objects or products using organic solvents, industrial scale production of basic organic chemicals, urban waste-water treatment plants, thermal power stations and other combustion installations, industrial scale production of basic inorganic chemicals, production of non-ferrous crude metals from ore, concentrates or secondary raw materials. Manchester: 66 pollution producing facilities, including disposal of hazardous and non-hazardous waste, manufacture of paints, varnishes and similar coatings, printing ink and mastics, surface treatment of metals and plastics using electrolytic or chemical processes, landfills, thermal power stations and other combustion installations, gasification and liquefaction, industrial scale production of basic organic chemicals, mineral oil and gas refineries, thermal power stations and other combustion installations, metallurgical, chemical or electrolytic production of non ferrous metals. Sunderland: 14 pollution producing facilities, including gasification and liquefaction, disposal of hazardous and non-hazardous waste, surface treatment of substances, objects or products using organic solvents, opencast mining and quarrying.

2. Authors did not take into account a series of diseases previously linked to pollutant emission from incinerators, such as all cancer combined, stomach cancer, colorectal cancer [1, 2], sarcoma [3], breast cancer [4], congenital abnormalities [5].

3. The analysis about the effect of distance is strongly limited by the lack of an adequate dispersion modelling of emissions and by the absence of a qualitative and quantitative analysis of pollutants. As demonstrated by several previous papers, the dispersion modelling of emissions can provide a better surrogate measure of exposure than distance [3-8]. Furthermore, a comprehensive analysis of confounding factors has not performed both in case and in control areas.

4. Conclusions drawn by Authors ("our results show no elevated risk for individuals living in areas containing an incinerator compared to individuals living in matched areas without an incinerator") are not consistent with their results, which showed in case areas: - "a statistically significant increase in risk for each unit increase in IMD of 1.7% for infant mortality, 1.5% for lung cancer incidence and less than 1% for liver cancer incidence and mortality and all-cause mortality (table 3)". - "The RR of living in a case circle compared with living in a control circle for leukaemia incidence was 1.137 (95% CI 1.065 to1.213)" - Figure 2: SMR>100 for infant mortality (apparently all case sites), liver cancer mortality (3/5 case sites), all cause mortality (4/5 case sites) - Table 2: increased leukaemia incidence (1.135, 95%CI 1.080 to 1.192) and infant mortality (1.118, 95%CI 1.054 to 1.186) - Table 2: increased trend over time for leukaemia, liver cancer and lung cancer incidence, and all-cause, infant and liver cancer mortality (see also Figure 3)

5. In the discussion section, Authors state that "One might have anticipated a dose- response relationship with distance from the incinerator if the incinerators were responsible for causing an elevation in disease or mortality risk. The fact that no such relationships emerged supports our general conclusions". A "dose-response relationship with distance from the incinerator" has never been fully documented in previous works, mainly in the absence of adequate models (see point 3). It has been suggested that this assumption can lead to significant exposure misclassification [9].

In conclusion, the methodological concerns in the study design and the discrepancy between the results and the conclusions drawn by Authors might be considered important limitations of this study. There is a growing interest on the health effects of waste burning and, although the issue is currently under debate, a number of previous studies well documented major environmental and sanitary consequences deriving from incineration. Other scientific papers aimed to clearly and correctly address the health impact of various waste treatments, mainly incineration, are certainly expected. On the other hand, it is strongly needed to consider the recent recommendation of the European Parliament (text tabled A7-0161/2012, adopted at May 2012, http://www.europarl.europa.eu/sides/getDoc.do?type=TA&reference=P7-TA-2012 -0223&language=EN&ring=A7-2012-0161 ), to take into account "the waste hierarchy and the need to bring residual waste close to zero", and to undertake the "phasing-out, by the end of this decade, of incineration of recyclable and compostable waste". In this respect, a convinced phasing-out of incineration and sustainable policies [10] aimed at eliminating waste and at viewing waste as a potential economic resource are rapidly diffusing [11-14] and necessary. Best regards

Agostino Di Ciaula, MD, internist

References

1 Elliott P, Shaddick G, Kleinschmidt I, Jolley D, Walls P, Beresford J et al. Cancer incidence near municipal solid waste incinerators in Great Britain. British journal of cancer 1996;73:702-10. 2 Ranzi A, Fano V, Erspamer L, Lauriola P, Perucci CA and Forastiere F. Mortality and morbidity among people living close to incinerators: a cohort study based on dispersion modeling for exposure assessment. Environmental health : a global access science source 2011;10:22. 3 Zambon P, Ricci P, Bovo E, Casula A, Gattolin M, Fiore AR et al. Sarcoma risk and dioxin emissions from incinerators and industrial plants: a population-based case-control study (Italy). Environ.Health 2007;6:19. 4 Ranzi A, Fano V, Erspamer L, Lauriola P, Perucci CA and Forastiere F. Mortality and morbidity among people living close to incinerators: a cohort study based on dispersion modeling for exposure assessment. Environ.Health 2011;10:22. 5 Cordier S, Lehebel A, Amar E, Anzivino-Viricel L, Hours M, Monfort C et al. Maternal residence near municipal waste incinerators and the risk of urinary tract birth defects. Occup.Environ.Med. 2010;67:493-9. 6 Viel JF, Arveux P, Baverel J and Cahn JY. Soft-tissue sarcoma and non- Hodgkin's lymphoma clusters around a municipal solid waste incinerator with high dioxin emission levels. Am.J.Epidemiol. 2000;152:13-9. 7 Viel JF, Floret N, Deconinck E, Focant JF, De PE and Cahn JY. Increased risk of non-Hodgkin lymphoma and serum organochlorine concentrations among neighbors of a municipal solid waste incinerator. Environ.Int. 2011;37:449 -53. 8 Forastiere F, Badaloni C, de Hoogh K, von Kraus MK, Martuzzi M, Mitis F et al. Health impact assessment of waste management facilities in three European countries. Environmental health : a global access science source 2011;10:53. 9 Goria S, Daniau C, de Crouy-Chanel P, Empereur-Bissonnet P, Fabre P, Colonna M et al. Risk of cancer in the vicinity of municipal solid waste incinerators: importance of using a flexible modelling strategy. Int.J.Health Geogr. 2009;8:31. 10 Kriebel D. Incinerators, birth defects and the legacy of Thomas Bayes. Occup.Environ.Med. 2010;67:433-4. 11 Curran T and Williams ID. A zero waste vision for industrial networks in Europe. Journal of hazardous materials 2012;207-208:3-7. 12 Young CY, Ni SP and Fan KS. Working towards a zero waste environment in Taiwan. Waste management & research : the journal of the International Solid Wastes and Public Cleansing Association, ISWA 2010;28:236-44. 13 Zotos G, Karagiannidis A, Zampetoglou S, Malamakis A, Antonopoulos IS, Kontogianni S et al. Developing a holistic strategy for integrated waste management within municipal planning: challenges, policies, solutions and perspectives for Hellenic municipalities in the zero-waste, low-cost direction. Waste management 2009;29:1686-92. 14 Chang YM, Liu CC, Hung CY, Hu A and Chen SS. Change in MSW characteristics under recent management strategies in Taiwan. Waste management 2008;28:2443-55.

Conflict of Interest:

None declared

It was with great interest that I read Dr. Sara Bleich's study on primary care physicians' perspectives on treating obesity. Unfortunately, I wasn't shocked by the findings.

Obesity is an incredibly challenging condition to treat, and when facing a crisis as great as the United States' obesity epidemic, extraordinary steps are called for.

Primary care physicians need to be aware of the current recommendations on body mass index screening, and understand that treating obesity takes diligence, empathy, creativity, and persistence.

Also, primary care physicians need to be aware of the resources available to them, such as the American Academy of Family Physicians' efforts to equip its members with evidence-based tools and information to promote healthy lifestyle practices among their patients.

The AAFP's Americans In Motion -- Healthy Interventions (AIM-HI) program, which was created by family physicians for family physicians, seeks to position fitness as the "treatment of choice" for the prevention and management of chronic conditions.

Behavioral changes require motivation, and patients perceive physicians who practice healthy personal behaviors themselves as more credible and better able to encourage healthy lifestyle choices. With this in mind, clinicians and office staff are encouraged to use the AIM-HI educational tools and resources to improve their personal fitness, defined as physical activity; healthy eating; and emotional well-being, and to promote fitness for their patients.

To support their patients in achieving better health, AIM-HI offers physicians a set of helpful tools including: * a fitness inventory, which gauges a patient's confidence about their fitness and their readiness to change; * a food and activity journal, which helps patients track nutrition and fitness goals; and * a fitness prescription, through which the patient and the physician establish mutually agreed-upon goals that are assessed periodically.

Research shows the AIM-HI program leads to successful outcomes across a wide-range of patient populations from rural, suburban, and inner-city clinics and among a wide-range of ethnic populations. Fitness improvements for the patients were found in following three areas from baseline to 10 months:

* a 10 percent increase in the number of patients reporting the same amount of physical activity; * a nearly 42 percent increase in the number of patients who ate at least a half serving more of healthy foods each week, and a nearly 45 percent increase in the number of patients who ate at least half a serving less of unhealthy foods each week; * and nearly 12 percent of patients lost 10 pounds or more.

Helping obese patients adopt the lifestyle changes necessary for them to lose weight is certainly difficult, but it is not impossible. Primary care physicians are in an excellent position to educate and motivate their patients and they should be aware of the educational and motivational resources available.

Conflict of Interest:

Chair of the AIM-HI Advisory

Pharmaceutical procurement is a specialized professional activity that requires a lot of knowledge, skill and experience. It is therefore mandatory that staff involved in key procurement and distribution positions be well trained and highly motivated, with the capability to manage the procurement process efficiently. Pharmaceutical procurement is a complex process, which involves many steps, agencies and manufacturers. Existing government policies, rules and regulations for procurement as well as institutional structures prove frequently inadequate and sometimes hinder overall efficiency in responding to the modern pharmaceutical market1. There are many steps in the procurement cycle. No matter what model has been adopted to manage the procurement and distribution system, efficient procedures should be in place to select the most cost-effective essential drugs to treat commonly encountered diseases; to quantify the needs; to pre-select potential suppliers; to manage procurement and delivery; to ensure good product quality; and also to monitor the performance of suppliers and the procurement system. Failure in any of these areas leads to lack of access to appropriate drugs and to waste. In many public supply systems, breakdowns regularly occur at multiple points in this process. In India, various organizations follow different operating procedures for effective pharmaceutical procurement. Absence of comprehensive documented, systematic and uniform procurement procedures, guidelines and proper delegation of power become utopian. In some organizations, purchase manual is either unavailable or available at an obsolete state. Even some institutions deploy these procurement staff by having negligible or no training or education leading to procurement system in jeopardy. Staff becomes vulnerable to audit and vigilance issues. In West Bengal, there are no Pharmacists in most of the store purchase section. There are few hospitals in India where a professionally qualified pharmacist heads medical store or Pharmacy Therapeutic Committee determines medical pharmacologist and selection of drugs. We are fortunate to have essential drug list of 348 drugs but it is not in the line of British National Formulary like database. It is quite a tedious process to achieve an unbiased conclusion on different types of branded drug, branded generic drug or the MRP. Non-existence of computerized database, lack of co-ordination and collaboration lead to failure of rational procurement at the most competitive price and in a fair, just and transparent manner. Indian pharmaceutical jungle is flooded with more than 90,000 formulations with having little control on price regulation. A recent study published in Indian Journal of Pharmacology shows that there is no remarkable variation of quality between branded and branded generics in India. Glimpses of study shown in the following chart: Trade name of medicine Pharmacological name, strength and dosage form Manufacturer PTR (1x10) MRP (1x10) Mark-up (retailer) Alerid tablets (B) Cetirizine HCL 10 mg/tab Cipla INR 27.16 INR 35.31 30 Cetcip tablets (B/G) Cetirizine HCL 10 mg/tab Cipla INR 2.24 INR 25.00 1016 Fludac capsules (B) Fluoxetine HCL 20 mg/cap Cadila INR 29.80 INR 37.26 25 Cadflo capsules (B/G) Fluoxetine HCL 20 mg/cap Cadila INR 6.00 INR 28.00 367 Ciprobid tablets (B) Ciprofloxacin 500 mg/tab Cadila INR 54.84 INR 68.56 27 Ciprodac tablets (B/G) Ciprofloxacin 500 mg/tab Cadila INR 15.00 INR 68.56 357 Lanzol-30 capsule (B) Lansoprazole 30 mg/cap Cipla INR 42.36 INR 53.77 27 Lansec-30capsule (B/G) Lansoprazole 30 mg/cap Cipla INR 15.68 INR 47.25 201 Restyl tablets (B) Alprazolam 0.25 mg/tab Cipla INR 11.85 INR 14.82 25 Tranex tablets (B/G) Alprazolam 0.25 mg/tab Cipla INR 2.20 INR 11.34 415 Branded medicine (B) Branded-generic medicine (B/G), Price to the retailer (PTR) Maximum Retail Price (MRP)

Findings of the present study indicate that both the branded and branded-generic versions of the five paired medicines had identical quality and they fulfilled all the criteria prescribed by the Indian Pharmacopoeia. Hence, the general notion and doubt regarding the quality of the branded-generic version of medicines need to be erased conducting more such studies and publishing them widely. Suitable changes in the drug price policy may be adopted to lower the prices for branded-generic versions. Transparency in fixing the MRP by the manufacturer and clear guidelines for mark-ups at least for branded-generics is required in pharmaceutical trade. Availability of generics or branded-generics in the market with lower price tag and assured quality is the need of the hour to make the medicines affordable3. The government must conduct more and more promotional events in favour of generic drug, arrange general awareness programs on quality of generics to increase confidence amongst prescribers, pharmacists, and consumers.

The corrective measures as follows: Easy availability of valid Good Manufacturing Practice Certificate (GMP), approved product list and loan license details for the manufacturers whose products are produced elsewhere. A procedure to have knowledge on more number of brands available for the same medicine Open access of last purchase rate of different organizations More stringent provisions in tender documents relating to 'liquidated damages', 'pre-qualification norms', 'packaging', 'performance security', 'warranty period', 'imposition of penalty for delay in supply, 'remaining life' and 'bid security', etc. Updated list of substandard drug in the website of CDSCO(Central Drug Standard Control Organization/India) and state drug control Appropriate time-frame at each stage of procurement and accountability of staff involved in procurement procedure Central Public Sector Enterprises may be more encouraged to manufacture all essential drugs at low cost Enhancement of quantity and quality of approved drug testing labs Steady flow of government funding towards procurement of drug Either the allotted fund may be spent in the stipulated year and the unspent fund may be carried forward to the next year Increased monitoring on performance of distributors and manufacturers Decentralization (fragmented drug procurement in different levels- district, state, central, public sector undertaking etc.) of procurement Unbiased market information on product availability, comparative pricing, product quality and supplier performance Incentive and out of turn career development in procurement section Increased exposure to latest market situations for tackling different crisis Strengthening the existing regulatory system especially for enabling more detailed and universal classification of drugs and chemicals between branded generic and generic. Strengthening the public information system to reach out more consumers for simple drugs.

When and where needed, pragmatic and rational procurement and inventory management always ensure choice of right drug in right quantities, doses and formulations, good quality, safe and efficacious. All organizations should prepare codified purchase manuals, containing detailed purchase procedures, guidelines and also proper delegation of powers, so as to ensure systematic and uniform approach in decision-making areas pertaining to procurements.

1. Chapter 13: Managing procurement. Management Sciences for Health (MSH) in collaboration with the World Health Organization, Action Programme on Essential Drugs. Managing drug supply, second edition. Edited by J.D. Quick, J. Rankin, R. Laing, R. O'Connor, H.V. Hogerzeil, M.N.G. Dukes and A. Garnett. Hartford, CT: Kumarian Press; 1997. 2.A comparative evaluation of price and quality of some branded versus branded-generic medicines of the same manufacturer in India-G.L. Singal, Arun Nanda, Anita Kotwani, Indian Journal of Pharmacology | April 2011 | Vol 43 | Issue 2 131 3. Department-related parliamentary standing Committee on health and family welfare Fifty- ninth report on the functioning of the central drugs standard control organization (cdsco) (presented to the rajya sabha on 8th may, 2012) (laid on the table of the lok sabha on 8th may, 2012)

Conflict of Interest:

I am a Procurement Pharmacist in Indian Railway

Dear Editor,

This excellent paper?s conclusions concur my earlier findings on the effects of cadmium on the urinary proteoglycan excretion (1). It seems that changes are e.g. related with proteinuria (2) and thus be considered as markers for more generalized vascular effects as predicted in the current investigation.

1 Savolainen H. Studies on urinary proteoglycan excretion in occupational cadmium exposure. Pharmacol Toxicol 1994; 75: 113

2 Savolainen H. A sensitive method for the analysis of urinary proteoglycans. Biochem Int 1992; 28: 475

Conflict of Interest:

None declared