Medicine and Science from The BMJ

In response to the turmoil of 2016, with political campaigns being run on, and won on, misinformation - many commentators are disparing that we’ve become a post-truth society. And what is truth anyway? Tracy Brown, director of Sense about Science, the charity set up to champion evidence in everyday life, is less pessimistic about the public's appetite for evidence. http://www.bmj.com/content/355/bmj.i6467 Anders Huitfeldt, a postdoctoral scholar at Stanford University School of Medicine, and has been trying to puzzle out “Is caviar a risk factor for being a millionaire?” http://www.bmj.com/content/355/bmj.i6536

Underneath all of our civilisation and science, we’re still primates - and the connection between patient and doctor can be reinforced by simply taking a hand. Robin Youngson, cofounder of hearts in healthcare, and Mitzi Blennerhassett, who has written extensively on patient engagement, have co-authored an editorial calling for the humanisation of medicine, and we talk to them about the power of touch. Read the editorial: www.bmj.com/content/355/bmj.i6262 Andrew Steptoe is the British Heart Foundation professor of psychology, at University College London. He and colleagues have been using a large cohort study to measure the link between overall happiness and health. Read the full research: www.bmj.com/content/355/bmj.i6267

In an ideal world, policies would be evidence based - but governments are made of humans, who have positions and ideologies and moral bases. In this podcast Anthony Painter, from the RSA will be talking about why universal basic income may work, but who’s proponents cross ideological barriers, and writer and philosopher AC Grayling explains how economic arguments become moral crusades. A universal basic income: the answer to poverty, insecurity, and health inequality? http://www.bmj.com/content/355/bmj.i6473 Morality and non-medical drug use http://www.bmj.com/content/355/bmj.i5850

The BMJ publishes a variety of education articles, to help doctors improve their practice. Often authors join us in our podcast to give tips on putting their recommendations into practice. In this new monthly audio round-up The BMJ’s clinical editors discuss what they have learned, and how they may alter their practice. In our second audio edition, GPs Sophie Cook and Helen Macdonald, surgical trainee Jessamy Baganel, and internalist and methodologist Reed Siemieniuk, talk about the evidence for vitamin D supplements. http://www.bmj.com/content/355/bmj.i6201 The new Rapid Recommendation series in the BMJ http://www.bmj.com/content/354/bmj.i5085 Communication with patients who have learning difficulties, or others who have experienced torture. http://www.bmj.com/content/355/bmj.i5296 http://www.bmj.com/content/355/bmj.i5019 And safety netting of people with low, but not no, risk of cancer. Can safety-netting improve cancer detection in patients with vague symptoms?

Renal transplantation improves quantity and quality of life compared with chronic dialysis. A UK general practice with 8000 patients will have around four patients with a functioning renal transplant, one patient on the transplant waiting list, and several under consideration for transplantation. Many medical problems in renal transplant recipients will be managed by non-specialist clinicians, and this article provides advice for the non-specialist on managing renal transplant patients. In this podcast, Tom Nieto, and Paul Cockwell from the Renal Services unit in the, College of Medical and Dental Sciences at the University of Birmingham, join us to discuss how non-specialists can spot problems early, and when it’s appropriate to talk about the potential for transplantation. Read their full clinical update: http://www.bmj.com/content/355/bmj.i6158

Glasgow GP, writer, broadcaster, and The BMJ's weekly columnist Margaret McCartney joins us to talk about her new book "The State of Medicine: Keeping the Promise of the NHS". Read all of Margaret's columns: goo.gl/iKmmie

Despite high quality systematic reviews reporting ineffectiveness, many guideline groups continue to recommend vitamin D supplementation (with or without calcium) for fall or fracture prevention. Recently Public Health England recommended that everyone needs vitamin D equivalent to an average daily intake of 10 μg (400 IU) to protect bone and muscle health, In this podcast, Andrew Grey, associate professor of medicine at the University of Aukland joins us to discuss what the evidence says for who should, and who shouldn't take vitamin D supplimentation. Read the full uncertainties article: http://www.bmj.com/content/355/bmj.i6201

Allocation concealment - blinding which arm of a trial a patient is randomised to - is being questioned in an analysis published on thebmj.com. David Torgerson, director of the York Trials Unit at the university of York and colleagues have been looking at the way in which trials do this randomisation, and how they subsequently report it - and have found both lacking. Read the full analysis: http://www.bmj.com/content/355/bmj.i5663

Concussion is a clinical diagnosis made after a head injury with consequent associated signs, symptoms, and neurological or cognitive impairment (infographic - http://bmj.co/conrecG). In the absence of strong evidence, most recommendations on the management and recovery from concussion are based on international expert consensus. In this podcast John Brooks, academic clinical fellow in general practice, and Simon Kemp, chief medical officer for the Rugby Football Union take us through the process of guiding a patient through recovery and back into everyday life, including sport. Read the full 10 minute consultation: http://www.bmj.com/content/355/bmj.i5629

Between 13 & 33% of the adult population have regular difficulty in getting to sleep, or staying asleep. It's important to recognise the difference between acute and chronic insomnia, as treatment strategies differ. David Cunnington, director of the Melbourne Sleep Disorders Centre, joins us to explain what non-drug interventions are available to help those with chronic insomnia. Read the full clinical review: http://www.bmj.com/content/355/bmj.i5819

Despite considerable investment and innovation, chemotherapy drugs have had little effect on survival in adults with metastatic cancer. In this podcast, Navjoyt Ladher, clinical editor for The BMJ, talks to Peter Wise, former consultant physician and senior lecturer Imperial College School of Medicine, and author of a recent analysis on TheBMJ.com Read the full analysis: http://www.bmj.com/content/355/bmj.i5792

In the UK, junk food advertising is banned on children’s TV - but manufactures are still able to target children in other ways. A recent report from the WHO "Tackling food marketing to children in a digital world", takes a look at the issue. In this podcast we're joined by João Breda, programme manager for nutrition physical activity and obesity at the regional office for Europe of the World Health Organisation, and Mimi Tatlow-Golden, lecturer in childhood studies and developmental psychology at the open university, and the lead author on the report. Read the full report: http://www.euro.who.int/en/health-topics/disease-prevention/nutrition/publications/2016/tackling-food-marketing-to-children-in-a-digital-world-trans-disciplinary-perspectives-2016

To avoid waste of research, no new studies should be done without a systematic review of existing evidence. That argument has been made for 20 years, yet the lack of reference to a systematic review before designing new studies is still a problem. Hand Lund, professor at the University of Southern Denmark joins us to explain why research before researching is still an issue. Read the full analysis: http://www.bmj.com/content/355/bmj.i5440

In patients with symptomatic severe aortic stenosis but at lower risk of perioperative death, how do minimally invasive techniques compare with open surgery? Prompted by a recent trial, an expert panel produced these recommendations based on three linked rapid systematic reviews. In this podcast we talk to Michael Shapiro who was a patient representative on that panel about what matters to patients, and how he found taking part in creating the recommendation. Read the recommendation in full: http://www.bmj.com/content/354/bmj.i5085

Catherine Calderwood has been chief medical officer for Scotland since March 2015 - her first CMO report, which she titled “Realistic Medicine” has created a stir beyond the borders of Scotland. The BMJ, sat down with Catherine at a the Preventing Overdiagnosis conference to find out what she intended with that report. Read more: http://www.bmj.com/content/355/bmj.i5455

Middle East respiratory syndrome (MERS) is an acute viral respiratory tract infection caused by the novel betacoronavirus. Cases have been limited to the Arabian Peninsula and its surrounding countries, and to travellers from the Middle East or their contacts. The clinical spectrum of infection varies from no symptoms or mild respiratory symptoms to severe, rapidly progressive pneumonia, acute respiratory distress syndrome, septic shock, or multiorgan failure resulting in death. In this podcast Sarah Shalhoub, infectious diseases consultant at King Fahad Armed Forces Hospital, in Saudi Arabia joins us to discuss the history of the disease, clinical presentation, and what can be done to support those infected. Read the full clinical update: http://www.bmj.com/content/355/bmj.i5281

Elizabeth Pisani, visiting senior research fellow at King's College London, collects data on sex workers and injecting drug users in low and middle income countries. For years she has been sharing her data, and joins us to explain why she went from being protective of her research to to making it freely available - and talk about some of the practicalities of keeping participants anonymous. Read the full analysis: http://www.bmj.com/content/355/bmj.i5295

Independent contractor status creates unnecessary stress, argues Azeem Majeed, GP partner and professor of primary care at Imperial College London. Laurence Buckman, GP partner and former head of the BMA GP committee, values his autonomy and distance from a non-benign employer. Read the full head to head: http://www.bmj.com/content/355/bmj.i5064 We also hear from former columnist and current partner in a federated practice, Des Spence, who thinks that the days of small GP surgeries are numbered. Independent or employed? There is a third way. . . http://www.bmj.com/content/355/bmj.i5329

The Preventing Overdiagnosis conference is part of The BMJ's campaign against Too Much Medicine. Helen Macdonald clinical editor for The BMJ was at the conference, and talked to some of the key speakers there about what they believe the key issues are, and what's being done to roll back the harms of too much medicine. http://www.bmj.com/too-much-medicine http://www.preventingoverdiagnosis.net/

Globally each year more than 30 000 people become living kidney donors. Living kidney donation is constantly evolving, with new ways of pooling donors and recipients to maximise opportunity. With increased numbers, there is increasing information regarding the long term outcomes associated with donation. Pippa Bailey, clinical lecturer in renal medicine at the University of Bristol, and Aisling Courtney, consultant nephrologist at Belfast City Hospital join us to explain who can donate, to whom, and the possible impact of donation on the donor’s health. Read the full update: http://www.bmj.com/content/354/bmj.i4746

In a clinical trial, we usually think of risk in terms of the new active compound - will it have unwanted effects. However, two analyses in The BMJ are concerned about the risk associated with the control arm. Robin Emsley is a professor of psychiatry at Stellenbosch University in South Africa, he and colleagues have written about the risk associated with forgoing treatment in patients with schizophrenia. Read the full analysis: http://www.bmj.com/content/354/bmj.i4728 Jonathan Mendel, lecturer in human geography at the University of Dundee, and Ben Goldacre, senior clinical research fellow at the University of Oxford, have examined the ethical approval given to trials, and are concerned that identified risks are not adequately communicated to patients. Read the full analysis: http://www.bmj.com/content/354/bmj.i4626

Alastair Matheson, independant consultant and former ghostwriter, describes how the pharmaceutical publications industry seeks to legitimise ghostwriting by changing its definition while deflecting attention from wider marketing practices in academic publishing. Read his full analysis: http://www.bmj.com/content/354/bmj.i4578

Oversimplification and lack of evidence stigmatise people with mental illness and impede prevention efforts, says Simon Wessley, professor of psychiatry at King's College London, in an editorial published on thebmj.com. Read the full editorial: http://www.bmj.com/content/354/bmj.i4869

Lily was diagnosed at 14 years old with stage four Hodgkin's lymphoma and received six rounds of chemotherapy and two weeks of radiotherapy. She survived but now lives with the long term effects of that therapy - and joins us to discuss how it has impacted her quality of life. We're also joined by Saif Ahmad and Thankamma Ajithkumar, oncologists from Cambridge University Hospitals NHS Foundation Trust, who give advice for generalists on late effects of anticancer chemotherapy that may affect quality of life. Read the full clinical review: http://www.bmj.com/content/354/bmj.i4567

The United Nation's Millennium Development Goals, and the subsequent Sustainable Development Goals, define premature mortality as being a death under the age of 70. As demographic change means more people are living longer than this, Peter Lloyd-Sherlock, professor of social policy and international development at the University of East Anglia, argues that this will lead to discrimination against older people. Read the full analysis: http://www.bmj.com/content/354/bmj.i4514

"I say to all Australian doctors - young, old, the political and the apolitical - that on this depends not just our ethical credibility as a profession, but our shared humanity. " Following the leaked emails published in The Guardian newspaper, alleging abuse of asylum seekers detained by the Australian government on the Pacific island of Nauru, David Berger joins us again to say it is time that doctors take a stand and march to protest against this treatment. Read his full editorial: http://www.bmj.com/content/354/bmj.i4606 Listen to the head to head debating if doctors should boycott working at the detention centres: https://soundcloud.com/bmjpodcasts/should-doctors-boycott-working-in-australias-immigration-detention-centres

The BMJ publishes a variety of education articles, to help doctors improve their practice. Often authors join us in our podcast to give tips on putting their recommendations into practice. In this new monthly audio round-up The BMJ’s clinical editors discuss what they have learned, and how they may alter their practice. In our first audio edition, GPs Sophie Cook and Helen Macdonald, psychiatry trainee Kate Adlington, and HIV and sexual health trainee Deborah Kirkham talk about communication skills – ICE - obtaining a patient’s ideas, concerns and expectations about their health. http://www.bmj.com/content/354/bmj.i3729 They also examine the lack of evidence for cardiovascular examination. http://www.bmj.com/content/354/bmj.i3309 And finally, they talk about how 50% of patients with treatment resistant hypertension may actually be treatment non-adherent, and what that could mean for other conditions. http://www.bmj.com/content/354/bmj.i3268

The European Medicines Agency (EMA) has embraced a new model of drug testing and marketing called “adaptive pathways”, allowing new drugs for “unmet medical needs” to be launched on the market faster, on the basis of fewer data. While industry claims this is necessary, an analysis on thebmj.com looks at the assumptions underlying the new pathway, and raises concerns about the negative impact on patient safety and the cost of healthcare. To discuss, we're joined by Courtney Davis, senior lecturer at King’s College London, Peter Gøtzsche, director of the Nordic Cochrane Centre and Joel Lexchin, a professor at York University in Toronto. Read the full analysis: http://www.bmj.com/content/354/bmj.i4437

Andrew Elder, a professor at the University of Edinburgh talks about likelihood ratios in diagnostic testing, and how they’re helpful in thinking about how context changes the predictive value of a test. This is part of a wider discussion on the evidence behind clinical examination of the cardiovascular system https://soundcloud.com/bmjpodcasts/evidence-for-examination Read the full clinical review: http://www.bmj.com/content/354/bmj.i3309

You may have spent hours practicing for your examination exams, but how evidence based are the techniques taught? Andrew Elder, a professor at the University of Edinburgh, and author of the clinical review “How valuable is physical examination of the cardiovascular system?” joins us to discuss. Read the full review: http://www.bmj.com/content/354/bmj.i3309 Andrew also discussed likelihood ratios; which are useful in understanding the relative use of tests in different clinical scenarios: https://soundcloud.com/bmjpodcasts/likelyhood-ratios-in-diagnostic-tests

It is estimated that 50% of patients who have what appears to be treatment resistant hypertension are actually not taking their drugs as prescribed. Indranil Dasgupta, a consultant nephrologist at the Heart of England NHS Foundation Trust joins us to discuss what factors may influence non-adherence, and how to encourage patients to divulge that information. Read the full article: http://www.bmj.com/content/354/bmj.i3268

“How long have I got, doc” is a TV medical drama cliche - but like all cliches has it’s feet in real life - and it’s medicine’s attempt to answer these questions that the authors of an analysis article on TheBMJ.com are questioning. Kirsty Boyd is a consultant in palliative care in NHS lothian, a trainer and a researcher with the University of Edinburgh. Scott Murray is a GP, and St Columba's Hospice Chair of Primary Palliative Care, also at the University of edinburgh. They argue that it’s time to rethink how we talk about prognosis, and what conversations to have as patients become more unwell. Read the full analysis: http://www.bmj.com/content/354/bmj.i3802

Ivan Oransky, co-founder of Retraction Watch and global editorial director at MedPage Today, discusses which areas of science are most affected by research fraud, and what motivates individuals to risk their careers by fabricating data.

With the emergence of sofobuvir, a new direct acting antiviral, treatment for Hepatitis C infection is currently undergoing it's greatest change since the discovery of the virus 25 years ago. However Gilead, who manufacture the treatment, are under fire for the cost of the druge - around $90 000 for a course of treatment. Victor Roy, doctoral researcher at the University of Cambridge, discusses how the new drug was discovered and came to market, and what happened to the profits from sale. Read the full analysis: http://www.bmj.com/content/354/bmj.i3718

Failures in implementation of data sharing projects have eroded public trust. In the wake of NHS England’s decision to close down its care.data programme, Tjeerd-Pieter van Staa professor of health e-research at the University of Manchester, examines what lessons must be learnt, and what we can do better next time. Read the full analysis: http://www.bmj.com/content/354/bmj.i3636

We’re taught that patients' ideas, concerns, and expectations are central to a successful consultation, but has ICEing gone too far? A “What your patient is thinking” article published this week talks about the pressure that asking questions in the wrong way can put on a patient. Sophie Cook, education editor for The BMJ, is joined by the author of that article - The BMJ’s patient editor, Rosamund Snow, and by Roger Neighbour, former president of the royal college of general practice, and author of "The Inner Consultation". http://www.bmj.com/content/354/bmj.i3729

The "internal market" was created after the 1987 UK general election focused attention on inadequate funding in the NHS, long waiting lists for elective surgery, and large unwarranted variations in clinical care. Economists attributed these problems to a lack of incentives for efficiency, and the remedies offered included increasing competition in the NHS. Twenty nine years later, this interesting experiment is not likely to have been worth it, says Alan Maynard, professor emeritus of health economics at the University of York. But Michael Dixon, a GP and commissioner in Devon, says that if properly funded and liberated from some of the administrative burdens of "red tape," the internal market could increase accountability. Read their full debate: http://www.bmj.com/content/354/bmj.i3825

2.46 million people in England have osteoarthritis of the hip, and many of those go on to eventually have a hip replacement - which is now widely considered one of the most commonly performed and successful operations in the world. Jessamy Bagenal, clinical fellow with The BMJ, talks to Nick Aresti, a specialist registrar in trauma and orthopaedic surgery and one of the authors of a clinical update on hip osteoarthritis, recently published on thebmj.com In a linked podcast, Nick Nicholas, a patient who has hip OA gives us his perspective. Read the full article: http://www.bmj.com/content/354/bmj.i3405 Listen to the linked podcast: https://soundcloud.com/bmjpodcasts/having-hip-osteoarthritis

2.46 million people in England have osteoarthritis of the hip, and many of those go on to eventually have a hip replacement - which is now widely considered one of the most commonly performed and successful operations in the world. Jessamy Bagenal, clinical fellow with The BMJ, talks to Nick Nicholas, an obstetrician who has had OA and one of the authors of a clinical update on hip osteoarthritis, recently published on thebmj.com In a linked podcast, Nick Aresti, a specialist registrar in trauma and orthopaedic surgery to talks about management of the condition. Read the full article: http://www.bmj.com/content/354/bmj.i3405 Listen to the linked podcast: https://soundcloud.com/bmjpodcasts/treating-hip-osteoarthritis

The drug Truvada, licenced for HIV PrEP, costs £350 a month but is shown to be cost effective in preventing infection. However, in the English NHS, a row has broken out about which body should fund the treatment - NHS England claims local authorities have responsibility, local authorities believe NHS England does. In this podcast Jim McManus, director of public health at Hertfordshire County Council, explains why he believes local authorities cannot afford the treatment, and describes the pressure that public health budgets are under. Read the full editorial: http://www.bmj.com/content/354/bmj.i3515

Guidelines usually assume a rational comprehensive decision model in which all values, means, and ends are known and considered. In clinical encounters, however, patients and doctors most often follow “the science of muddling through. Given that clinical knowledge does not follow the narrow rationality of “if-then” algorithms contained in guidelines, alternatives are desperately needed. Glyn Elwyn, professor at the Dartmouth Institute for Health Policy and Clinical Practice, joins us to discuss what we know about how doctors and patients use evidence, and what the alternative to guidelines could look like. Read the full analysis: http://www.bmj.com/content/353/bmj.i3200

When we think about medical evidence, we think of RCTs, registries and meta-analysis. But these EBM tools have yet to filter into the basic science that underpins clinical science. One person changing that is Emily Sena, research fellow in clinical brain sciences at the University of Edinburgh - and one of the few people who’s trying to meta-analyse animal studies.

The same piece of evidence may reach you via a journalist, or via your doctor - but the way in which that evidence is communicated is changed by your relationship between that person. Julia Beluz from Vox and Victor Montori from the Mayo Clinic join us to discuss if it's possible to reconcile those competing points of view.

In every 1000 pregnancies, between two and five infants are born to women with epilepsy. For such women, pregnancy can be a time of anxiety over maternal and fetal wellbeing. In 96% of pregnancies they will deliver a healthy child. However, some women will experience an increase in seizure frequency, which can be harmful for the mother or fetus, and evidence comes from observational study and registry data suggests some antiepileptic drugs are associated with an increased risk of congenital and neurodevelopmental abnormalities. Michael Kinney, specialist registrar in neurology, and James Morrow, principal investigator of the UK and Ireland Epilepsy and Pregnancy Register, both based at the Royal Group of Hospitals in Belfast, join us to discuss how to manage epilepsy in pregnancy. Read the review: http://www.bmj.com/content/353/bmj.i2880 For information on joining the UK epilepsy and pregnancy register, call 0800 389 1248 or visit http://www.epilepsyandpregnancy.co.uk/

Delirium is common in the last weeks or days of life. It can be distressing for patients and those around them. A clinical update explains why successful management involves excluding reversible causes of delirium and balancing drugs that may provoke or maintain delirium while appreciating that most patients want to retain clear cognition at the end of life. Kate Adlington, clinical editor at The BMJ, is joined by the authors of the paper - Christian Hosker, consultant liaison psychiatrist at Leeds and York Partnership Foundation Trust, and Michael Bennett, professor of palliative medicine at the University of Leeds. http://www.bmj.com/content/353/bmj.i3085

Global evidence indicates that mandated treatment of drug dependence conflicts with drug users’ human rights and is not effective in treating addiction. Karsten Lunze, associate professor at the Boston University School of Medicine, joins us to describe the evidence, and why he is convinced seemingly counter intuitive hard reduction works. http://www.bmj.com/content/353/bmj.i2943

How can asking patient to tell us their story improve healthcare? Helen Morant, content lead at BMJ, talks us through her project getting healthcare professionals to sit down with patients and record their conversations, and what on earth this has to do with quality improvement. We also hear some of the recordings she has gathered through the project. Here are links to the other podcasts and projects Helen mentions: Story Corps - https://storycorps.org/ The Listening Project - http://goo.gl/3auSHX Beautiful stories from anonymous people - http://goo.gl/78QSjU

Julian Treadwell, Neal Maskrey and Richard Lehman join us in the studio to argue that new models of evidence synthesis and shared decision making are needed to accelerate a move from guideline driven care to individualised care. Read the full analysis: www.bmj.com/content/353/bmj.i2452

There is insufficient evidence to know whether dressings reduce the risk of surgical site infection in closed primary surgical wounds. Jane Blazeby, professor of surgery at the University of Bristol, and Thomas Pinkney, consultant colorectal surgeon at the University of Birmingham, join us to discusses why there is a lack of evidence, and the implications for patient care. read the full article: http://www.bmj.com/content/353/bmj.i2270

Interviews from the Women deliver conference in Copenhagen. Donna McCarraher, director of reproductive, maternal, newborn and child health at FHI 360, explains why women should be at the centre of efforts to mitigate the effect of Zika Virus in Brazil.