Medicine and Science from The BMJ

Earlier this year, the WannaCry ransomeware attack took control of computers in 40 NHS trusts, blocking access to the data held on them. This wasn’t the first time that NHS computers had been infected by malware, but it brought the danger of cyber attack into the consciousness of doctors and patients. In this podcast we hear from two people who have been thinking hard about cyber security in the NHS - James Kinross, a surgeon and lecturer at Imperial College London, and Chris Hankin, director of Imperial’s Institute for Security Science and Technology. Read the analysis: http://www.bmj.com/content/358/bmj.j3179

The FDA faces perpetual criticism that it is too slow in it’s approval process for getting drugs to market, but one former FDA employee Tom Marciniak, and one professor, Victor Serebruany from Johns Hopkins University have analysed that process and disagree. Tom Marciniak has been a commentator on the approval process, both critical of industry and the FDA in The BMJ - and in this interview he talks about that process, his new analysis, and how he thinks we could be more sure about the safety and efficacy of drugs coming onto the market. Read this full analysis: http://www.bmj.com/content/357/bmj.j2867

Twenty years ago the statistician Doug Altman railed against, “The Scandal of Poor Medical Research,” in an editorial in The BMJ. 10 years later, Iain Chalmers and Paul Glaziou calculated that costs $170 billion annually in wasted research grants. In this podcast, recorded at Evidence Live, we spoke to Altman and Chalmers about their campaigns to improve the design, conduct, and reporting of clinical trials, and why that level of waste still occurs. Reward Alliance - http://rewardalliance.net/ Equator Network - http://www.equator-network.org/ Research publication audit "Getting our house in order" - http://bmjopen.bmj.com/content/6/3/e009285

The Alzheimer’s society, in the UK, predicts that if the rates of dementia remain constant there’ll be 1.7 million people in the country living with the condition by 2050. We also know that things like improvements in cardiovascular health are changing those rates. New research published on bmj.com attempts to model what the outcomes of those changing factors might be, and Sara Ahmadi - Abhari, a research associate in the Department of Epidemiology and Public Health at the University College London, joins us to discuss that model. Read the open access research: http://www.bmj.com/content/358/bmj.j2856

Two articles published on the bmj.com aim to help doctors treat patients who request support with their gender identity. Firstly a practice pointer on how to refer to gender clinic, and secondly a What Your Patient Is Thinking article about trans people's experiences in the healthcare system. In this podcast, two of the authors of that patient experience article, Emma-Ben and Reubs, join us to discuss identity, pronouns and what genderqueer means. I am your trans patient http://www.bmj.com/content/357/bmj.j2963 Gender dysphoria: assessment and management for non-specialists http://www.bmj.com/content/357/bmj.j2866

Findings from a range of prospective cohort studies based around the world indicate that higher intelligence in children is related to a lower risk of all cause mortality in adulthood - and now a new study, published on bmj.com, is trying to dig into that association further, with a whole population cohort and data on cause specific mortality. Ian J Deary, professor of differential psychology at the University of Edinburgh and one of the authors of that study, joins us to discuss what this tells us, and what might be causing that association. Read the full open access study: http://www.bmj.com/content/357/bmj.j2708

"Too many research studies are poorly designed or executed. Too much of the resulting research evidence is withheld or disseminated piecemeal. As the volume of clinical research activity has grown the quality of evidence has often worsened, which has compromised the ability of all health professionals to provide affordable, effective, high value care for patients.” Evidence is in crisis, and Carl Heneghan, director for the Centre for Evidence Based Medicine, and Fiona Godlee, editor in chief of The BMJ set out the 9 points of the Evidence manifesto, which tries to set a road map for strengthening the evidence base. 1) Expand the role of patients, health professionals and policy makers in research 2) Increase the systematic use of existing evidence 3) Make research evidence relevant, replicable and accessible to end users. 4) Reduce questionable research practices, bias, and conflicts of interests 5) Ensure drug and device regulation is robust, transparent and independent 6) Produce better usable clinical guidelines. 7) Support innovation, quality improvement, and safety through the better use of real world data. 8) Educate professionals, policy makers and the public in evidence-based healthcare to make informed choices. 9) Encourage the next generation of leaders in evidence-based medicine. http://www.bmj.com/content/357/bmj.j2973

Stress is one of the leading causes of work absence, recently overtaking back-pain, and an increasing part of a GPs workload. However good quality evidence about how to deal with stress is hard to come by. Alexis Descatha, an occupational/emergency practitioner, at the University hospital of Poincaré, gives some practical advice on what to do when you suspect stress is the underlying cause of a consultation, and what to do once you have confirmed that. Read the full practice article: http://www.bmj.com/content/357/bmj.j2489

Air pollution is a truly damaging environmental insult to the human body. The numbers of premature deaths, in the UK alone, that can be attributed to it are calculated to be 40,000 a year. Yet despite this, action to tackle the problem - as with the other huge environmental issue of our time, climate change - is distinctly lacking. Robin Russel-Jones dermatologist and chair of Help Rescue the Planet - joins us to discuss what should be done to tackle the problem. Read the full analysis: http://www.bmj.com/content/357/bmj.j2713

The 2014 west African Ebola epidemic shone a harsh light on the health systems of Guinea, Liberia, and Sierra Leone. While decades of domestic and international investment had contributed to substantial progress on the Millennium Development Goals, national health systems remained weak and were unable to cope with the epidemic. Margaret Kruk associate professor of global health at the Harvard TH Chan School of Public Health, joins us to discuss what makes a health system resilient, and how Liberia in particular has learned lessons from Ebola. Read the full analysis: http://www.bmj.com/content/357/bmj.j2323

A new study on BMJ.com, examines the effect of moderate drinking on brain structure. We know that heavy drinking has a deleterious effect on our brains, and is linked to dementias. However, for sometime it’s been thought that moderate drinking is actually protective. Anya Topiwala, clinical lecturer in old age psychiatry at the University of Oxford, joins us to discuss the association between alcohol consumption and those structural elements. Read the full research: http://www.bmj.com/content/357/bmj.j2353

The rapid changes in the global environment have led many scientists to conclude that we are living in a new geological epoch—the Anthropocene—in which human activities have become the dominant driving force transforming the Earth’s natural systems. A recent joint publication by the World Health Organization and Convention on Biological Diversity articulated the myriad connections between biodiversity and health and the threats to both posed by environmental change. Andy Haines, professor of public health and primary care, at the London School of Hygiene and Tropical Medicine joins us to talk about a new research platforms present an opportunity to advance understanding of how to safeguard health in the face of global environmental change. Read more: http://www.bmj.com/content/357/bmj.j2358

We're creating a manifesto for better evidence. The centre for Evidence Based Medicine at the University of Oxford, and the BMJ, are asking what are the problem with medical evidence, and how can we fix them? In this third discussion we went to Scotland, to find out what the people who create policy think about the issues with evidence synthesis, and how the information they create is being used in practice. evidencelive.org/manifesto/ - join the discussion, read, and comment on our manifesto.

Available data suggest about 50% of delirium is hypoactive; this and the mixed motor subtype account for 80% of all cases of delirium. It can be more difficult to recognise, and is associated with worse outcomes, than hyperactive delirium. In this podcast, Christian Hosker, consultant liaison psychiatrist at the Leeds Liaison Psychiatry Service outlines when to suspect hypoactive delirium, how to assess, and appropriately manage patients. Infographic explaining diagnosis: http://www.bmj.com/content/bmj/suppl/2017/05/25/bmj.j2047.DC1/hosc038261.wi.pdf Read the full article: http://www.bmj.com/content/357/bmj.j2047

Each individual’s grief process is unique, when confronted with the death of a loved one, most people experience transient rather than persistent distress - however 10% of bereaved individuals, with an increased risk following the death of a partner or child and loss to unnatural or violent circumstances, experience prolonged grief disorder. In this podcast, Paul Boelen, a professor of psychiatry at Utrecht University, and Geert Smid, psychiatrist and senior researcher from the Dutch National Psychotrauma Centre, join us to discuss what constitutes complex grief, how to recognise it, and some strategies for helping patients cope. Read the full practice pointer: http://www.bmj.com/content/357/bmj.j2016

NHS hospitals must be willing to dispose of surplus land to help convince the Treasury to invest in new premises that are fit for purpose, the head of a major government review has urged. Robert Naylor, former chief executive of University College London Hospitals, who was asked by the health secretary, Jeremy Hunt, to produce a review of NHS property and estates - and in this interview we asked him how his plans would work, and what would be done with the land sold. Read Gareth Iacobucci's report: http://www.bmj.com/content/357/bmj.j2072

The BMJ publishes a lot of educational articles, and in an attempt to help you with your CPD, we have put together this round-up. Our authors and editors will reflect on the key learning points in the articles we discuss, and explain how they may change their practice in light of that new understanding. In this month's round up we're discussing: Addiction to exercise http://www.bmj.com/content/357/bmj.j1745 If your patient doesn’t speak the same language as you . . . http://www.bmj.com/content/357/bmj.j1511 Exploring thoughts of suicide http://www.bmj.com/content/356/bmj.j1128 The role of the microbiome in human health and disease http://www.bmj.com/content/356/bmj.j831

Adoption of shared decision making into routine practice has been remarkably slow, despite 40 years of research and considerable policy support. In 2010, the Health Foundation in the UK commissioned the MAGIC (Making Good Decisions in Collaboration) programme to design, test, and identify the best ways to embed shared decision making into routine primary and secondary care using quality improvement methods. In this podcast, Natalie Joseph-Williams from Cardiff University and Richard Thomson from Newcastle University, join us to discuss how the project went, and what key lessons they learned from the pilot. Read their full analysis: http://www.bmj.com/content/357/bmj.j1744

Pharma companies say that money spent on promotion is essential to educate doctors about the best drugs - but when a medical student asked Joseph Ross, associate professor of medicine and public health at Yale, if those companies are promoting the right drugs for that message to be true, the answer wasn't available. Ross and Tyler Greenaway, his medical student, then sat down and used the data from the US Physician Payments Sunshine Act to find out which drugs have the highest promotional budgets. They cross referenced that against prescription databases and measures of value to assess the effectiveness, usefulness, and affordability of the drugs that get the heaviest promotion. Read the full analysis: http://www.bmj.com/content/357/bmj.j1855

Biologics have revolutionised healthcare for some conditions - but have been expensive because of the multistep manufacturing processes required to create these complex molecules. Changes to the manufacturing of biological agents make them more affordable, but can lead to drugs with different components from the original medicine tested in clinical trials, challenging assumptions about safety. David Hunt, honorary consultant neurologist and Wellcome Trust intermediate clinical fellow, at the University of Edinburgh, joins us to describe how that happens and what the result can be. Read the full analysis: http://www.bmj.com/content/357/bmj.j1707

It’s been called “the universal panacea” - exercise has a positive effect on almost all health measures, and governments are actively campaigning for us to do more. But at the opposite end of the scale, the realisation that some people may be addicted to exercise is gaining traction. In this podcast we're joined by Heather Hausenblas - professor of kinesiology at Jacksonville University, James Smoliga - associate professor of physiology at highpoint University, and Katherine Schreiber - who’s experienced exercise addiction, and written about her experience. They describe the condition, and what drives people to become addicted to exercise. They also outline the key indicators of the addiction, and what options there are for treatment. Read their article: http://www.bmj.com/content/357/bmj.j1745

We're creating a manifesto for better evidence. The centre for Evidence Based Medicine at the University of Oxford, and the BMJ, are asking what are the problem with medical evidence, and how can we fix them? In this second discussion we went to Nottingham​ University, to find out what the people who create the bread and butter of EBM - randomised control trials - think about the issues with evidence synthesis, and how the information they create is being used in practice. http://evidencelive.org/manifesto/ - join the discussion, read, and comment on our manifesto.

Thankfully, electrical injuries are relatively uncommon - but that means that lack of evidence regarding the management of patients who have been electrocuted, which can cause concern for clinicians when these patients present. In this podcast, Cath Brizzel, clinical editor for The BMJ, is joined by one of the authors of a clinical update on the management of electrical injury - Kumar Narayanan, a Consultant Cardiologist and Electrophysiologist at MaxCure Hospitals in India. Read that full update, including the free infographic: http://www.bmj.com/content/357/bmj.j1418

Our latest debate asks whether there should be a Royal Commission (a high level enquiry, with statutory powers) into the future of the NHS. A high level inquiry could detoxify the radical changes needed and command wide support, say Maurice Saatchi, conservative peer, and Paul Buchanan, The BMJ's patient editor; but Nigel Crisp, independent peer, thinks that a less formal, more flexible and collaborative approach could be quicker. Read the debate: http://www.bmj.com/content/357/bmj.j1621

The BMJ has published a series of articles, taking an in-depth look at health in South Asia. In this collection, authors from India, Pakistan, Nepal, Bangladesh, Sri Lanka, and Afghanistan collaborate to identify evidence-based solutions to shape health policy and interventions, and drive innovations and research in the region. In this podcast, two of the driving forces behind the series - Dr Zulfiqar Bhutta, from Aga Khan University, and Dr Samiran Nundy from the Ganga Ram Postgraduate institute for Medical Education and research - join Anita Jain to discuss the key issues affecting the region now. Read all of the open access articles: http://www.bmj.com/health-in-south-asia

The NHS Delivery Plan - setting out what’s in store of the English NHS in the coming years, has been delivered by Simon Stevens the chief executive. Key to those are the sustainability and transformation plans (STPs) which have been made in 44 areas, and yet again reorganise care - crucially, this time, with social care included in the mix. In this podcast Hugh Alderwick, senior policy advisor at the King’s Fund explains what STPs are, and what they're planning, and crucially, the cash involved. Read the full analysis: http://www.bmj.com/content/356/bmj.j1541

Around 1 in 10 children and young people worldwide have mental health difficulties that substantially affect their lives. Child mental health services often concentrate on risk reduction, at the expense of the wider aspects of a child's wellbeing. As part of the high integrity healthcare series, this podcast focuses on novel ways of providing support to children and adolescents, and particularly Pause - a city centre drop in centre in Birmingham, England. Read the full analysis: http://www.bmj.com/content/357/bmj.j1500

This week, a new series starts in The BMJ - the aim is to rethink how hospitals, clinics, community services and public health work - with the aim of stopping the perverse blocks and incentives that prevent doctors, and other healthcare professionals, from providing the care that patients want and need. Talking to Navjoyt Ladher, are Albert Mulley - professor of medicine at the Dartmouth Institute, and Jane Druce, an evaluations manger, and Donal Collins, a GP - both of whom work in an NHS Vanguard area, where new ways of delivering care are being tested. Read the full analysis: http://www.bmj.com/content/356/bmj.j1401

Transient symptoms of depersonalisation and derealisation - feeling detached from the world, and feeling as if you are watching events at a remove - are common. However for some, persistent symptoms can make the disorder extremely distressing. In this podcast, Kate Adlington is joined by Elaine Hunter, consultant clinical psychologist, Anthony David, professor of cognitive neuropsychiatry, and by Jane Charlton and Fiona Godlee - who have both experienced depersonalisation/derealisation over a number of years. Read the full education article: http://www.bmj.com/content/356/bmj.j745

For seven years, Republicans have vowed to repeal the Affordable Healthcare Act (Obamacare), and that promise took a central place in President Trump's campaign. The first major vote to replace it was due to happen last week, but was cancelled at the 11th hour. In advance of the potential vote, The BMJ published a debate asking "Should US doctors mourn for Obamacare?". Now we're asking the authors of that debate, what next? Joining Peter Doshi are Adam Gaffney, from Harvard Medical School and Saurabh Jha from the Hospital of the University of Pennsylvania. Read their original debate: http://www.bmj.com/content/356/bmj.j1441

Lady-Jacqueline Aster lives on a 72 foot canal boat. She's been diagnosed with adrenocortical cancer, and is receiving palliative care and is planning to die in the home she loves. In this interview The BMJ's patient editor, Rosamund Snow, talks to Lady-Jacqueline about her cancer, her care and her funeral plans - and why planning one's own death can be fun. Read more about healthcare on the water http://www.bmj.com/content/356/bmj.j245 Since this recording, Rosamund died by suicide, making these discussions about planning for death more poignant. You can read more about Rosamund's life and work in her obituary. http://www.bmj.com/content/346/bmj.j850

The BMJ publishes a lot of educational articles, and in an attempt to help you with your CPD, we have put together this round-up. Our authors and editors will reflect on the key learning points in the articles we discuss, and explain how they may change their practice in light of that new understanding. In this week's round up we're discussing: The offer of an HIV screen for an asymptomatic adult http://www.bmj.com/content/356/bmj.i6656 Two articles on legal highs Novel psychoactive substances: types, mechanisms of action, and effects http://www.bmj.com/content/356/bmj.i6848 Novel psychoactive substances: identifying and managing acute and chronic harmful use http://www.bmj.com/content/356/bmj.i6814 and how to become better at supporting relatives and carers at the end of a patient’s life http://www.bmj.com/content/356/bmj.j367

Viral exanthema can cause rash in a pregnant woman and should be considered even in countries that have comprehensive vaccination programmes. Measles and rubella can cause intrauterine death. Intrauterine infection with rubella can lead to congenital rubella syndrome in the liveborn baby. In this podcast, Jack Carruthers, honorary clinical research fellow at Imperial College London joins us to discuss spotting a viral rash, what steps to take to assess cause, and what advice to give a worried parent. Read the full clinical review: http://www.bmj.com/content/356/bmj.j512

As the NHS strains under pressure from rising patient activity, an ageing population, and financial constraints, The BMJ hosted a discussion on how clinicians should be helping to manage demand at last week’s Nuffield Trust health policy summit. Taking part are: - Eileen Burns, president of the British Geriatrics Society - Andrew Fernando, GP and medical director of North Hampshire Urgent Care - Candace Imison, director of policy at the Nuffield Trust - Martin Marshall, vice chair of the Royal College of General Practitioners - Amanda Philpott, chief officer of two clinical commissioning groups - Maxine Power, director of innovation and improvement science at Salford Royal NHS Foundation Trust - Jeremy Taylor, chief executive of the charities’ coalition National Voices - Judith Smith, director of the Health Services Management Centre - Ashok Soni, chair of NHS England’s local professional network for pharmacy in London Listen to all of our other Nuffield Summit Roundtables: http://www.bmj.com/nuffieldsummit

When a person’s heart or breathing stops and the cause is reversible, immediate cardiopulmonary resuscitation (CPR) offers a chance of life. However, when a person is dying—for example, from organ failure, frailty, or advanced cancer—and his or her heart stops as a final part of a dying process, CPR will not prevent death and may do harm. But conversations around that distinction are difficult. In a this podcast, we explore the ways in which these conversations go wrong, and give some practical advice on carrying them out better. Joining Helen Macdonald are Zoe Fritz, consultant acute physician, and Wellcome Fellow, David Pitcher, former president of the Resuscitation Council, and Kate Masters, whose mothers death led to a change in the law around DNACPR orders. Read the articles discussed in this podcast: Emergency care and resuscitation plans http://www.bmj.com/content/356/bmj.j876 Resuscitation policy should focus on the patient, not the decision http://www.bmj.com/content/356/bmj.j813 My mum’s care means that decisions not to resuscitate must now be discussed with patients http://www.bmj.com/content/356/bmj.j1084

The World Health Organization, the Roll Back Malaria Partnership, and the United Nations, all have a vision of a malaria-free world. The world has already committed to malaria eradication, albeit without a target date. Bruno Moonen, deputy director for malaria at the Bill and Melinda Gates Foundation, thinks that for malaria, eradication is the only equitable and sustainable solution. Where as Clive Shiff, associate professor at the Johns Hopkins Bloomberg School of Public Health, thinks this is a top-down strategy, dependent on massive concentrated funding until finished - funding which could be more effectively spent elsewhere. In this podcast they debate whether malaria should be eliminated, or eradicated, and how that might work. Read the full debate: http://www.bmj.com/content/356/bmj.j916

Scott Murray, professor of primary palliative care at the University of Edinburgh, has written, and talked in this podcast before, about the benefits of early palliative care - and today he’s back to explain how illness trajectory, and the pattern of decline at the end of life, affects 4 main areas of wellness - physical, social, psychological and spiritual or existential. Read his full analysis article: http://www.bmj.com/content/356/bmj.j878

In 2015, community acquired pneumonia (CAP) accounted for 15% of deaths in children under 5 years old globally and 922 000 deaths globally in children of all ages. In this podcast Iram Haq, a registrar and clinical research associate in paediatric respiratory medicine, joins us to discuss the definition of pneumonia, how to assess for the infection, and what treatments are effective. Read the full clinical update: http://www.bmj.com/content/356/bmj.j686

The UK government published its report Childhood Obesity: a Plan for Action, in August 2016. A new analysis article takes them to task for the inadequacy of that response to a growing problem. Neena Modi is a professor of neonatal medicine, at Imperial College London, and president of the Royal College of Paediatrics and Child Health, and joins us to discuss what that report should have contained. Read the full analysis: http://www.bmj.com/content/356/bmj.j762

A new rapid recommendation had concluded that LIPUS makes no different to patients experience of bone healing, and therefore shouldn't be used. In this podcast, we talk to three of those panel members - Rudolf Poolman, orthopaedic surgeon from The Netherlands, Stefan Schandelmaier, a methodologist from McMaster University, and Maureen Smith, a patient representative. Read the full recommendation: http://www.bmj.com/content/356/bmj.j576

All doctors, irrespective of their specialty or the setting in which they work, will care for patients who die. Around half of all deaths occur in hospitals. Evidence suggests that the quality of communication around this process is poorer in hospitals than in other settings, according to responses from relatives who have experienced bereavement. Over half of NHS complaints concern care of the dying. In this podcast, Katherine Sleeman, clinician scientist and honorary consultant in palliative medicine at King's College London, and Jane Harris, counselling and psychotherapy practitioner, and bereaved mother and daughter join us to discuss what support the carers and relatives of a dying patient need, and give practical advice on how to become better at having those difficult conversations. Read the full essentials article: http://www.bmj.com/content/356/bmj.j367

Persistent physical symptoms are common and include those symptoms that last at least three months and are insufficiently explained by a medical condition after adequate examination and investigation. Observational studies in primary care report that women, especially those aged 35-45 years, more commonly present with these symptoms. In this podcast, Madelon den Boeft, a GP and, Nikki Claassen-van Dessel, a GP trainee, both in The Netherlands, join us to explain why listening to a patient is important, and making sure that regular follow up is essential. Read the full uncertainties article: http://www.bmj.com/content/356/bmj.j268

Vivek Murthy, the US surgeon general, has highlighted prescription opioid misuse as a serious public health problem. In this podcast, Richard Hurley speaks to him about what he thinks needs to be done to tackle the issue. http://www.bmj.com/content/356/bmj.j715

Evidence shows using electronic health records can increase efficiency, and reduce preventable medical errors - but only if they are used properly. However, in the US, the president of the American Medical Association calls them almost unusable. In this debate, Richard Hurley is joined by George Gellert, Regional Medical Informatics Officer at CHRISTUS Santa Rosa Health System and Edward Melnick, Assistant Professor of Emergency Medicine at Yale, who debate whether US doctors should be using electronic medical records. Read the related article: http://www.bmj.com/content/356/bmj.j242.

The use of novel psychoactive substances is increasing, however there is little information about what these are, and how they work. Dr Derek Tracy, consultant psychiatrist at Oxleas NHS Foundation Trust, and David Wood, consultant physician and toxicologist at Guy's and St Thomas' NHS Foundation Trust join us to explain that doctors already know how to deal with these, if they think about them in terms of traditional drug use. Read the two related articles: http://www.bmj.com/content/356/bmj.i6814 http://www.bmj.com/content/356/bmj.i6848

http://evidencelive.org/manifesto/ The BMJ, and the Centre for Evidence Based Medicine in Oxford have long collaborated to document the problems with the creation and use of Evidence based medicine - and together we host evidence gatherers, synthesisers and users in the conference Evidence Live. We know what the problems are - but what would positive change, when it comes to the creation and use of medical evidence look like? To find out we’re doing a series of discussions at various places around the world - where we’re talking to people who have a particular insight into one area of the evidence ecosystem. Ultimately we’re collating this into what we’re calling the evidence manifesto. In this discussion we went to the The Farr Institute which is a of 21 academic institutions and health partners in the UK - whose mission is to deliver high-quality, cutting-edge research using ‘big data”.

Should gluten-free foods be available on prescription? A gluten free diet is the main treatment for celiac disease, and gluten-free food has been available on prescription from the NHS. However, as finances become tighter, in some areas patients no longer have that option. Prescriptions of gluten free food is the same as a prescription for a drug, argues David Sanders, professor of gastroenterology from Royal Hallamshire Hospital, but James Cave lambasts a costly system that frustrates patients and doctors alike. Gemma Gleed is the mother of a child with coeliac disease, who has had her prescriptions cancelled. Read the debate: http://www.bmj.com/content/356/bmj.i6810

Surrogate endpoints are commonly used in clinical trials to get quicker results, however Michael Baum, emeritus professor at University College London, worries that by not focusing on real outcomes - length of life, and quality of life - that these are being used to justify expensive treatments which may not benefit patients. Read the full analysis: http://www.bmj.com/content/355/bmj.i6286

State regulation is necessary for safety, says Simon Capewell, professor of public health and policy at the University of Liverpool. Richard Lilford, professor of public health at the University of Warwick, argues that restricting adults’ choice can undermine such aims. Read the debate: http://www.bmj.com/content/355/bmj.i6341

In this year's Christmas BMJ 2016 podcasts, we’ve been discussing morality, compassion, truth. In this final one, it's time for war. After the second world war, there was an attempt to bring a moral sense to conflict - and Julian Sheather, specialist adviser on ethics and human rights to the BMA, and author of the christmas editorial “medicine under fire” is worried about the retrenchment of those ideals. http://www.bmj.com/content/355/bmj.i6464 Peter Wever is a doctor in The Netherlands, and has been uncovering the story of the number 10 stationary hospital, in st-omer in northern france - a British army hospital that was targeted and destroyed during the first world war. http://www.bmj.com/content/355/bmj.i6509