23 June 2016 - It’s good to see new NICE guidance on major trauma.

Our summary of it focuses on assessment of patients with major trauma and management of patients who are actively bleeding. It carries some new take home messages: avoid preliminary imaging when patients need immediate computed tomography; allow “permissive hypotension” in patients who are actively bleeding; and use blood rather than crystalloids or colloids.

The evidence base for managing trauma hasn’t always been good and in some areas remains controversial: think of the continuing bitter debate over crystalloid versus colloid. But the evidence has improved in quantity and confidence over recent years.

Not so for rare diseases. Efforts to develop treatments for these conditions are bedevilled by low return on investment and difficulty recruiting patients for large enough trials. Drugs tend to be approved on the basis of small, short term, placebo controlled trials that use surrogate endpoints. Regulators justify this leniency on the understanding that manufacturers will follow up with post-marketing studies. But does this happen, and what’s the result?

View BMJ editorial