Papers

The “effective reproduction rate” (R) is the average relies on health workers and parents’ cooperation to BMJ: first published as 10.1136/bmj.319.7223.1467 on 4 December 1999. Downloaded from number of new infections that each case generates. If R immunise sufficient numbers of children. is 1 then a state of equilibrium exists. If R is less than 1 Despite recent further evidence of vaccine safety, then the disease in question will eventually become health scares about the measles, mumps, and rubella extinct. For measles R is about 16. This means that vaccine have contributed to a 5% reduction in the each case of measles can expect to generate about 16 number of children being immunised with this vaccine new cases in a susceptible population. The aim of herd in the United Kingdom. This reduction is sufficient to immunity is to reduce R to less than 1 for each disease allow the reproduction rate to start rising again, and as thus stopping the disease from propagating in the a result a new measles epidemic has been predicted in community. the United Kingdom within the next two years.2 Over time, as the proportion of children who are Abi Berger science editor, BMJ immunised in a population increases, the number of new cases of a disease should drop. If, however, enough 1 Begg NT, Gay NJ. Theory of infectious disease transmission and herd parents decide not to have their children vaccinated, immunity. In: Balows A, Sussman M, eds. Topley and Wilson’s microbiology and microbial infections. Vol 3. 9th ed. London: Edward Arnold, 1997. more cases will start to appear and then the entire 2 Fall in MMR vaccine coverage reported as further evidence of vaccine population is put at risk. Successful herd immunity safety is published. CDR Weekly 1999;9:227-30.

The SCOFF questionnaire: assessment of a new screening tool for eating disorders John F Morgan, Fiona Reid, J Hubert Lacey

Eating disorders are among the most common psychi- Department of Psychiatry, atric disorders in young women. Early detection and The SCOFF questions* St George’s treatment improves prognosis, but presentation is Hospital Medical often cryptic—for example, via physical symptoms in Do you make yourself Sick because you feel School, London uncomfortably full? SW17 0RE primary care. Ability to diagnose the condition varies John F Morgan 1 Do you worry you have lost Control over how much and can be inadequate, and existing questionnaires for clinical research fellow 23 you eat? detection are lengthy and may require specialist J Hubert Lacey interpretation. No simple, memorable screening Have you recently lost more than One stone in a professor

3 month period? http://www.bmj.com/ instruments are available for non-specialists. In alcohol Department of misuse the CAGE questionnaire4 has proved popular Do you believe yourself to be Fat when others say you Public Health are too thin? Sciences, with clinicians because of its simplicity. We developed St George’s and tested a similar tool for eating disorders— Would you say that Food dominates your life? Hospital Medical School with questions designed to raise suspicion that an eat- *One point for every “yes”; a score of >2 indicates a Fiona Reid ing disorder might exist—before rigorous clinical likely case of or bulimia lecturer in medical assessment. statistics Correspondence to: J F Morgan on 1 December 2019 by guest. Protected copyright. Participants, methods, and results jmorgan@sghms. No significant differences existed between cases ac.uk We developed five questions addressing core features and controls for age or ethnicity. As expected, more of anorexia nervosa and using focus cases than controls were in the highest socioeconomic BMJ 1999;319:1467–8 ÷2 groups of patients with eating disorders and specialists groups ((P < 0.001, = 47.4, df = 3), and cases were in eating disorders; we tested the questions in a more likely to be single, separated, or divorced ÷2 feasibility study of patients and staff at an eating disor- (P < 0.001, = 13.0, df = 1). Mean length of illness for ders unit. None of these participants was involved in cases was 8 years (SD 4.81; range 1-25). Mean body 2 the subsequent study. We created the acronym SCOFF mass index (weight(kg)/(height(m) )) for controls, from the questions (box). bulimic cases, and anorectic cases was 22.3 (SD 1.90), We recruited cases sequentially from referrals to a 24.4 (1.77), and 15.1 (0.76) respectively. All scores on specialist clinic: 116 women aged 18-40 years who the inventory and the BITE scale were were confirmed as having either anorexia nervosa consistent with published data for women with or with- 23 (n = 68) or bulimia (n = 48), according to the criteria out eating disorders. specified in the Diagnostic and Statistical Manual of Men- All participants found the questions and the term tal Disorders, fourth edition. We recruited 96 women SCOFF acceptable. Setting the threshold at two or aged 18-39 as controls; these women, recruited more positive answers to all five questions provided through advertising by local colleges, were confirmed 100% sensitivity for anorexia and bulimia, separately as not having an eating disorder. Cases and controls and combined (all cases, 95% confidence interval were asked the SCOFF questions orally; they also com- 96.9% to 100%; bulimic cases, 92.6% to 100%; anorec- pleted the eating disorder inventory3 and the BITE self tic cases, 94.7% to 100%), with specificity of 87.5% rating scale for bulimia.2 (79.2% to 93.4%) for controls (table).

BMJ VOLUME 319 4 DECEMBER 1999 www.bmj.com 1467 Papers

Further work is needed to establish and BMJ: first published as 10.1136/bmj.319.7223.1467 on 4 December 1999. Downloaded from Numbers of cases (true positives) and controls (true negatives) identified by SCOFF questionnaire* as being likely to have eating reliability in a wider population, and particularly in disorder those at risk of eating disorders in the general popula- tion. None the less, there is sufficient evidence of valid- No of participants identified Total No of by SCOFF as likely to have ity for it to be used routinely in all patients considered subjects eating disorder at risk of eating disorders. Cases We thank Professor Martin Bland, professor in medical statistics, All cases 116 116 for guidance in planning the research methodology. Bulimic cases 48 48 Contributors: JFM initiated and coordinated the study, Anorectic cases: 68 68 discussed core ideas, designed the study protocol, and “Bingeing” 35 35 participated in data collection and analysis and in the writing of “Restricting” 33 33 the paper. JHL discussed core ideas, participated in protocol Controls 96 12 design and interpretation of data, and contributed to the writing of the paper. FR led the statistical analysis, participated in data *If participants gave positive responses to at least two of the five questions (see box). interpretation, and contributed to the writing of the paper. JFM will act as guarantor of the paper. Funding: None. Comment Competing interests: None declared. The SCOFF questionnaire seems highly effective as a 1 King MB. Eating disorders in a general practice population. Prevalence, screening instrument for detecting eating disorders; it characteristics and follow-up at 12 to 18 months. Psychol Med Monogr is simple, memorable, and easy to apply and score, and Suppl 1989;16:191-4. 2 Henderson M, Freeman CPL. A self-rating scale for bulimia. The “BITE.” it is designed to raise suspicion of a likely case rather Br J Psychiatry 1987;150:18-24. than to diagnose. 3 Garner DM, Olmstead MA, Polivy J. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and We consider that the SCOFF questionnaire bulimia. Int J Eating Disorders 1983;2:15-34. performed well against the 10 questions suggested by 4 Ewing JA. Detecting —the Cage questionnaire. JAMA 5 1984;252:1905-7. Greenhalgh to assess screening tests. The false 5 Greenhalgh T. Papers that report diagnostic or screening tests. BMJ positive rate of 12.5% is an acceptable trade off for very 1997;315:540-3. high sensitivity. (Accepted 16 August 1999)

A memorable period A small United Nations

In King’s Cross in London in 1856 a small dominated by the sharp wit of Sir Reginald Murley, independent, voluntary hospital assembled in a modest later president of the Royal College of Surgeons, and house, 11 York Way. Sherard Freeman Statham, his team, and the postgraduate dean, Dr Geraint James,

assistant surgeon at University College, founded the and his team. These gatherings were occasions of http://www.bmj.com/ institution and named it the Great Northern Hospital. sophisticated, intellectual debate, lightened by On 17 July 1888 the hospital moved to a new building agreeable repartee. I recall these weekly meetings as in the Holloway Road and was formally opened by the the most lively and rewarding in Britain. During my Prince and Princess of Wales. It received a royal charter three years I was fortunate to meet and exchange ideas on 2 November 1921. On its first centenary the with Nobel laureates Peter Medawar and Baruch hospital had 279 beds and a bustling outpatient Blumberg; geneticist Alexander Bearn; hepatologist department. The later half of the present century saw Sheila Sherlock; gastroenterologist Christoper Booth; the Royal Northern Hospital transform into a major surgeon Dickson Wright; endocrinologists Raymond

centre of clinical excellence and postgraduate Greene and Sir John McMichael; sarcoidologists Guy on 1 December 2019 by guest. Protected copyright. education. The reputation was based on the century Scadding, Sven Lofgren, and Louis Siltzbach; and old tradition started by medical luminaries such as Dr immunologist Jan Costa Waldenstrom. The Royal Robert Bridges, who later became poet laureate; Sir Northern Hospital was closed as a result of a game of Andrew Clark, president of the Royal College of political chess. There were three other important Physicians; and Sir William Savory, president of the hospitals in north London—the Royal Free, University Royal College of Surgeons. These outstanding College, and the Whittington. A process of personalities were to be followed by surgical teachers, including Sir Lancelot Barrington-Ward, Mr Hamilton amalgamation united all three, and the Royal Bailey, and Mr McNeil Love, and physicians, such as Dr Northern lost out in the reshuffle. The site is now a Clifford Beale and Dr Tommy Horder (later Lord large and expensive block of flats. I hope the present Horder). My association with the hospital started in residents enjoy themselves as much as we did. October 1966. A Prophit Research Scholarship from Om P Sharma, professor of medicine, Los Angeles the Royal College of Physicians made it possible for me to stay there for three years and carry out clinical We welcome articles of up to 600 words on topics such and immunological studies in sarcoidosis. In 1953 Dr as A memorable patient, A paper that changed my practice, David Geraint James spearheaded the My most unfortunate mistake, or any other piece multidisciplinary sarcoidosis clinic, the first clinic of its conveying instruction, pathos, or humour. If possible kind. It was unique because he involved clinicians, the article should be supplied on a disk. Permission is physiologists, and immunologists. Scattered among needed from the patient or a relative if an identifiable them were residents, postgraduate and medical patient is referred to. We also welcome contributions students, and international visitors. Our patients came for “Endpieces,” consisting of quotations of up to 80 from all walks of life. The sarcoidosis clinic became words (but most are considerably shorter) from any and remained for more than three decades a small source, ancient or modern, which have appealed to the United Nations. Weekly staff conferences were reader.

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