510

what should one recommend to colleagues who see a patientwith obvious meningococcal septicaemia? Should one beginantibiotics immediately or not?

Frankly, I do not know, because even the hypothesis(with some backing from animal studies8) that one perhapsshould give dexamethasone to calm hectic inflammation,wait for a while, and then administer antimicrobials is farfrom proven in human studies. In fact, recent US guide-lines do not recommend glucocorticoids for gram-negativesepsis or shock, at least in large doses.9One may criticise comparison of the UK5and the Danish 6

studies, but whatever the arguments, one issue seems clear:we do not have a ready means to distinguish the patientsbenefiting from prompt antimicrobial treatment from thosewhom we put in danger by inducing massive bacteriolysiswith &bgr;-Iactams.1o Clinical studies with a new approach areurgently needed. Meanwhile, let us shift away from

thinking about meningococcal disease only as meningi-tis,3,11 emphasise the clinical significance of petechiae, andstart treatment promptly, if not necessarily before hospitaladmission.

Heikki PeltolaChildren’s Hospital, University of Helsinki, Helsinki, Finland

1 Peltola H. Meningococcal disease: still with us. Rev Infect Dis 1983; 5:71-91.

2 Waage A, Halstensen A, Espevik T. Association between tumournecrosis factor in serum and fatal outcome in patients withmeningococcal disease. Lancet 1987; 1: 355-57.

3 Thomson APJ, Hayhurst GK. Press publicity in meningococcaldisease. Arch Dis Child 1993; 69: 166-69.

4 Kilpi T, Anttila M, Kallio MJT, Peltola H. Severity of childhoodbacterial meningitis and duration of illness before diagnosis. Lancet1991: 338: 406-09.

5 Cartwright K, Strang J, Gossain S, Begg N. Early treatment ofmeningococcal disease. BMJ 1992; 305: 774.

6 Sørensen HT, Møller-Petersen J, Bygum Krarup H, Pedersen H,Hansen H, Hamburger H. Early treatment of meningococcal disease.BMJ 1992; 305: 774.

7 Begg N. Reducing mortality from meningococcal disease. Giveantibiotics before admission. BMJ 1992; 305: 133-34.

8 Friedland J, Griffin G. Tumour necrosis factor, steroids, andmeningitis. Lancet 1990; 335: 300.

9 McGowan EJ Jr, Chesney PJ, Crossley KB, LaForce FM. Guidelinesfor the use of systemic glucocorticosteroids in the management ofselected infections. J Infect Dis 1992; 165: 1-13.

10 Editorial. A nasty shock from antibiotics? Lancet 1985; 2: 594.11 Tarlow M, Geddes A. Meningococcal meningitis or septicaemia: a plea

for diagnostic clarity. Lancet 1992; 340: 1481.

Originality: who is to judge?Academic medicine reveres originality. It is the stuff of

promotion and accolade and a critical commodity in careerdevelopment. But how is it measured and who is to judge?Institutions themselves seldom attempt such assessments.

They note contributions to departmental development,committee function, teaching, and examining, but origin-ality is something for outsiders to assess. In realityjudgment falls to journals and grant-giving bodies, whoseinfluence is critical since ultimately their decisionsdetermine the outcome of the equation:

no publications + no grants = no promotion.We question academia’s practice of delegating responsi-bility in this way.The judging of articles for publication, and the assess-

ment of projects for funding, have much in common. Bothmake originality a necessary criterion for acceptance, define

the area of originality, name the originators, rely on peerreview, and are usually competitive. Let us concentrate onthe issues as they affect publication, although much of whatwe say applies equally to the allocation of grants.What is originality? Whilst journal referees are asked to

assess the originality of a submission, sometimes withinloosely defined bands (originality: "real", "marginal","lacking"), a definition is rarely provided. Is an observationoriginal if, having been made in one cell system, it is foundalso in a second cell system, or shown to apply to a wholeorgan or animal, or found in a different species? How shouldwe score originality if the research allows numbers to be putto older qualitative observations, if computer technologymoves data along a decimal point, or if new techniquesessentially confirm older observations? Does researchbecome original if it provides new data that refute an earlier"original" finding? Is a paper still original if it comes from asecond centre and confirms the initial findings of others?These decisions have no absolute basis but will rely on

the character of the journal, its particular subject, and thequalities of its referees. Thereby arises a dilemma. Thejournal will select articles with an eye to its subscribers,choosing material that is reliable, relevant, and interestingand that gives the journal an edge over any competitor. Thereaders must be satisfied. The scientist, however, wants toprobe, innovate, unravel; for scientists, journal readershipshould not be an issue. Some research, even if "truly"original, may be rejected because it is inconsistent with theagenda of a journal, or an otherwise original paper may beturned down because it is deemed "uninteresting". Readersare unlikely to find ah article interesting if it relates to a drugthat has been withdrawn or to practice that has sincechanged. The interest criterion begins to weaken when thisreasoning leads to the rejection of papers because the resultsare negative or relate to a subject or substance that is

perceived as unfashionable. More difficult is the failure topublish because the article has no obvious journal niche; byits very nature, true originality cuts across established

patterns.Originality may then spawn secondary problems. The

new topic may now become the subject of heightenedinquiry, papers follow, and if established journals cannotcope one dedicated to the topic is launched. Superficiallythe problem of publication seems to have been solved but inreality this may simply be a diversion. The new journal willseldom attract the trust afforded to its established fore-runner and so the articles it publishes will lack impactamong those who judge research success.

Editors and scientists internationally have a symbioticrelationship in which originality is a central commontheme. In such a relationship it would be tempting toassume that they held the same definition of originality, andthat does seem to be an underlying assumption. In practice,however, the definition will vary because it is required toserve the different agendas of publishers and science. Oftenthe outcome of deliberations will coincide; occasionallythere is conflict that may leave science undermined. Webelieve that the different working definitions of originalityused by journal editors and scientists should be recognised.Academia should accept that definitions differ, and con-sider ways of relying less on journal publications as a criticalmeasure of research success.

Joe Collier, Patrick VallanceClinical Pharmacology Unit, St George’s Hospital Medical School, London, UK