Medicine and Science from The BMJ

The world bank was set up in 1944. In the aftermath of the second world war, the institution was there to give loans to countries rebuilding after the conflict. Their first loan went to France - but with stipulations about repayment that set a tone for future funds. A new series, authored by Devi Sridhar, and her team from the University of Edinburgh, and published on bmj.com, looks at where the World Bank has come. The series is , and the articles will cover; Why the World Bank matters to global health The World Bank’s turn to Universal health coverage How the Bank’s trust funds are being used to fund specific projects - and why it’s hard to know what those are The Global Financing Facility - grants and loans supplied together, and finally, creating a market out of pandemic risk In this third interview, Janelle Winters a PhD student at the University of Edinburgh explains what the bank's trust funds are, and why it can be hard to tell what they're funding. Read the full analysis: http://www.bmj.com/content/358/bmj.j3394

The world bank was set up in 1944. In the aftermath of the second world war, the institution was there to give loans to countries rebuilding after the conflict. Their first loan went to France - but with stipulations about repayment that set a tone for future funds. A new series, authored by Devi Sridhar, and her team from the University of Edinburgh, and published on bmj.com, looks at where the World Bank has come. The series is , and the articles will cover; Why the World Bank matters to global health The World Bank’s turn to Universal health coverage How the Bank’s trust funds are being used to fund specific projects - and why it’s hard to know what those are The Global Financing Facility - grants and loans supplied together, and finally, creating a market out of pandemic risk In this second interview, Marlee Tichenor, postdoctoral research fellow at the University of Edinburgh explains why the bank has embraced universal healthcare. Read the full analysis: http://www.bmj.com/content/358/bmj.j3347

The world bank was set up in 1944. In the aftermath of the second world war, the institution was there to give loans to countries rebuilding after the conflict. Their first loan went to France - but with stipulations about repayment that set a tone for future funds. A new series, authored by Devi Sridhar, and her team from the University of Edinburgh, and published on bmj.com, looks at where the World Bank has come. The series is , and the articles will cover; Why the World Bank matters to global health The World Bank’s turn to Universal health coverage How the Bank’s trust funds are being used to fund specific projects - and why it’s hard to know what those are The Global Financing Facility - grants and loans supplied together, and finally, creating a market out of pandemic risk In this first interview, Devi Sridhar, professor of global health at the University of Edinburgh explains why the bank matters for global health. Read the full analysis: http://www.bmj.com/content/358/bmj.j3339

In our last podcast from Preventing Overdiagnosis 2017, we convened an impromptu roundtable of clinicians who are attending the conference to see how some of the big themes that were discussed at the conference are going to impact their everyday practice. Joining us were; Jessica Otte - Family physician from Canada David Warriner - Cardiologist from the UK. Jack O’Sullivan - Junior doctor from Australia Imran Sajid - GP from the UK To read more, have a look at our Too much medicine campaign - bmj.com/too-much-medicine.

This week we’re at the over diagnosis conference in Quebec Canada, Preventing overdiangosis is a forum to discuss the harms associated with using uncertain methods to look for disease in apparently healthy people - and is part of the BMJ’s too much medicine campaign. One of the ways in which the public’s attitudes and wishes around health is measured are citizen or community juries - set up in a similar way to a criminal jury - with an information gathering, and a deliberation phase - recently one of these citizen juries discussed, whether abortion should be allowed in Ireland (they decided “yes”). We're joined by Rae Thomas, from Bond University and Chris Degeling, from the University of Sydney, who have both been using citizen juries to look at over diagnosis.

The Preventing overdiagnosis conference covers how physicians, researchers and patients can implement solutions to the problems of over diagnosis and overuse in healthcare. If you’re a doctor on twitter, you’ve probably come across our guest - Vinay Prasad, assistant prof. of medicine at Oregon Health and Science University, and author of the book Ending Medical Reversal.

This week we’re at the Preventing Overdiagnosis conference in Quebec Canada, The conference is a forum to discuss the harms associated with using uncertain methods to look for disease in apparently healthy people - and is part of the BMJ’s too much medicine campaign. The literature on overdiagnosis has mostly been published since 2013 - partly because of The BMJ, but in large part because of the work of Rita Redberg, professor of clinical medicine, and a working cardiologist, at UCSF, and editor of JAMA internal medicine who joins us to discuss why less is more.

In this interview from Preventing Overdiagnosis 2017 (preventingoverdiagnosis.net) Stacy Carter, associate professor at Sydney Health Ethics - and the author of a recently written BMJ essay the ethical aspects of overdiagnosis, joins us to talk about how the cultural context of medicine seeps into our decision making processes and affects how people conceptualise the risks of too much medicine. Read Stacy's full essay: http://www.bmj.com/content/358/bmj.j3872

This week the annual Preventing over diagnosis conference is happening in Quebec, Canada. The conference is put together with a wide range of partners, including The BMJ, and aims to tackle the some of the problems of Too Much Medicine. To kick off our content for the conference, this week we’ve published an article looking at some of the drivers - and hence potential solutions for over diagnosis. Two of the authors of that paper. Thanya Pathirana, and Ray Moynihan, both from Bond University’s Centre fro Research in Evidence Based Practice, join us to discuss.

Loss of a loved one can be very painful. When seeking support, some people turn to their doctor. Because of their pivotal role in the community, physicians can provide excellent support for bereaved people and can often direct them to additional resources. Katherine Shear, a physician, and Stephanie Muldberg, a bereaved mother, join us to discuss how grief can play out in the consultation, and explain the importance of doctors acknowledging the death of a patient's loved one. Read their full practice article: http://www.bmj.com/content/358/bmj.j2854

If you’ve listened to more than one of our podcasts, you’ll probably be aware of the problem of the opacity of clinical trial data - trials which are conducted by never see the light of day, or results within those trials which are never published. Pharmaceutical companies have their own policies on what they are willing to make public, when, and for the first time a new audit, published on bmj.com, collates and analyses those policies. To discuss that study I’m joined by two of the authors - Ben Goldacre, senior clinical research fellow at, and Carl Heneghan, director of, Oxford's Centre for Evidence Based Medicine. Read the full audit: http://www.bmj.com/content/358/bmj.j3334

Mike Richards is well known in the UK - former Cancer Tzar, he now heads up the Care Quality Commission - regulator of all health and social care services, and therefore the body responsible for inspecting hospitals and GP practices. In this interview, BMJ’s head of news and views, Rebecca Coombes went to the CQC’s headquarters in London, and spoke to Mike Richards - who defends the record of hospital inspection on his watch. This is an edited version of the interview - read the full write up: http://www.bmj.com/content/358/bmj.j3567

It’s been 10 years since electronic cigarettes hit the shelves in a big way - and since there controversy has reigned about their health effects - are they less unhealthy than smoking traditional tobacco cigarettes, and will they increase nicotine dependence? Its to that last point that new research, published on BMJ.com is looking into - specifically, do e-cigarettes help people quit tobacco? Professor Shu-Hong Zhu, Director of the Center for Research & Intervention in Tobacco Control at the university of California San Diego joins us to discuss what effect ecigarettes have had, at a population level, on smoking cessation rates. Read the open access research: http://www.bmj.com/content/358/bmj.j3262

The increase in life expectancy in England has almost “ground to a halt” since 2010 and austerity measures are likely to be a significant contributor. In this podcast Michael Marmot, director at University College London’s Institute of Health Equity, joins us to discuss what might be causing that drop off, and why a decrease in early life chances is particularly problematic. Read more about the report: http://www.bmj.com/content/358/bmj.j3473

The BMJ has been campaigning for an end to “too much medicine” - the pernicious effect of marketing on the range of tests and treatments that doctors offer patients - tests and treatments which are motivated by the financial reward to the system, than the health of the individual. A new analysis on BMJ.com takes a look at what’s happening in the the first part of that - testing. New biomarkers for disease, and new ways of monitoring, have the potential to diagnose disease more quickly, but is the hype backed by science? Bjorn Hoffman professor of medical ethics at Norwegian University of Science and Technology and one of the authors of that article doesn’t think so - and joins us on the podcast to discuss. Read the full analysis: http://www.bmj.com/content/358/bmj.j3314

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