No abstract

An example of contracting arrangements within the National Health Service (NHS) provides the focus for considering accounts of organisational behaviour and failure. Public accounts of the outcome are contrasted with information disclosed in response to Freedom of Information Act (FOIA) requests. While the former focused on shortcomings in commercial expertise, sometimes at lower levels within organisational hierarchies, the latter suggests a need to consider the environment of social networks and power relationships. The data suggests obstacles to information flows across organisational boundaries were a contributory cause of failure, but a desire to present the implementation of policy in a positive light encouraged subsequent concealment of what Goffman (1959/1990) described as 'dark secrets'. Through this example, the article provides an exploratory use of FOIA to examine social processes that frequently elude investigation.

Sickle cell trait (SCT) is estimated to occur in 6% to 10% of Africans, and the United Kingdom (UK) prevalence rate has been estimated at 3.2%. Although sudden death in sickle cell disease is well known, its occurrence in SCT is rare and requires extremes of physiological stress. We present a case of a 29-year-old black woman who died suddenly during a period of religious fasting. Her medical history was unremarkable, and there was no family history of sickle cell disease. At postmortem, she was found to be dehydrated, and macroscopically, the main abnormal findings were congested lungs and a small spleen. Histological examination revealed extensive vascular congestion with red blood cell sickling in both lungs, the liver, and the spleen. Electrophoresis on a postmortem blood sample confirmed the clinical suspicion that the patient was a carrier of SCT. The case highlights a novel scenario of SCT associated sudden death. We discuss the potential pathophysiological mechanisms that may have led to the patient's demise. We also remind pathologists to consider this diagnosis as potentially contributing to the cause of death in apparently fit young people of ethnic origin during episodes of physiological stress.

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optimal management of blood pressure and full renin-angiotensin blockade. But since we are not satisfied their benefit is proven even in that setting, we do not include corticosteroids in our main treatment recommendations in the table or abstract of our article. What Dr Locatelli et al. regard as 'nihilism', we regard as pragmatic realism avoiding a treatment regimen with some toxicity when evidence in favor of its use is insecure.Unfortunately, these uncertainties will not easily be resolved. Modern management with adequate blood pressure control and renin-angiotensin blockade is reducing proteinuria and slowing the progression of a significant proportion of patients with IgA nephropathy. Proof that treatments additional to this regimen are effective will therefore require larger and more prolonged treatment trials unless surrogate markers of progression become more discriminatory, and our ability to define risk of progression in individual patients becomes more refined.