Medicine and Science from The BMJ

Shivani Misra, clinical research fellow and specialist trainee in metabolic medicine from Imperial College London, joins us to discuss diagnosis and management of diabetic ketoacidosis in adults. She talks us through UK and US guidelines, and explains what the latest evidence tells us about prescribing fluid and insulin. Read the full clinical review: http://www.bmj.com/content/351/bmj.h5660

Europe's common agricultural policy (CAP) on sugar is due to change, and Emilie Aguirre, from the UKCRC Centre for Diet and Activity Research at the University of Cambridge, argues that an influx of cheap high fructose corn syrup (HFCS, isoglucose) into the European market will have a negative effect on on the health of the continent. Read the full analysis here: http://www.bmj.com/content/351/bmj.h5085

“The people of the UK are right to treasure their NHS,” writes Mark Britnell in his new book In Search of the Perfect Health System (Palgrave Macmillan). Currently chairman of KPMG Global Health, Britnell has worked in healthcare systems in over 60 countries. For his book he analysed 25 healthcare systems in search of what was working and what wasn’t in times of challenging demographic and economic change. He doesn’t find perfection, but against the others the NHS measures up pretty well. Buy the book: http://www.amazon.co.uk/In-Search-Perfect-Health-System/dp/1137496614

Thousands of NHS staff have demonstrated against the government’s threatened “imposition” of an “unsafe and unfair” contract for junior doctors. At a London rally on Saturday 17 October junior doctors and supporters noisily defended their trade union, as speakers accused England’s health secretary, Jeremy Hunt, of misleading the public about research evidence on weekend mortality rates in hospitals and the nature of contract negotiations. Matt Limb was there for the BMJ, finding out why junior doctors are so angry. Read more: http://www.bmj.com/content/351/bmj.h5572

Given the number of effective treatments for type II diabetes, which have good evidence about safety and efficacy, should any new drugs for the condition be subject to a higher regulatory bar? In this podcast, Huseyin Naci from the London School of Economics, John Yudkin from Univerity College London, and Ben Goldacre from the University of Oxford, explain why they believe the current process is inadequate, and suggest some ways in which it could be improved. Read the full analysis article: http://www.bmj.com/content/351/bmj.h5260

The current orthodoxy is that home is the best and preferred place of death for most people, but in this podcast, Kristian Pollock a sociologist from Nottingham University questions these assumptions and calls for greater attention to improving the experience of dying in hospital and elsewhere. Read the full analysis: http://www.bmj.com/content/351/bmj.h4855

The “correct” rates of discretional interventions are difficult to define. However, David Hamilton and Colin Howie point out that discrepancies in usage of knee arthroscopy within the UK suggest the organisation of the care pathway may be an important determinant Read their full analysis: http://www.bmj.com/content/351/bmj.h4720

With improved survival and and ageing population, the number of people living with coronary heart disease in the UK has increased to an estimated 2.3 million. There is increasing evidence that cardiac rehabilitation benefits these patients, and as such it has been included in international clinical guidelines. To discuss cardiac rehabilitation in this podcast, we're joined by Hasnain Dalal, a GP and honorary clinical associate professor at the University of Exeter Medical School, Rod Taylor, academic lead for Exeter Clinical Trials Support Network and NIHR senior investigator, and Jenny Wingham, a senior clinical researcher in cardiac rehabilitation. Read the full clinical review online: http://www.bmj.com/content/351/bmj.h5000 Listen to our podcast with a patient who's been through cardiac rehabilitation: https://soundcloud.com/bmjpodcasts/cardiac-rehab-patient

With improved survival and and ageing population, the number of people living with coronary heart disease in the UK has increased to an estimated 2.3 million. There is increasing evidence that cardiac rehabilitation benefits these patients, and as such it has been included in international clinical guidelines. ​In this podcast, we're joined by Kevin Paul, who explains what it's like to receive cardiac rehabilitation, and what doctors should be aware of when they recommend it to patients. Read the full clinical review online: http://www.bmj.com/content/351/bmj.h5000

They have a big impact on the diet of American citizens, and those of most Western nations, so why does the expert advice underpinning US government dietary guidelines not take account of all the relevant scientific evidence asks Nina Teicholz. Read the full investigation: http://www.bmj.com/content/351/bmj.h4962

Around two fifths of the world’s population (those in tropical and subtropical countries), or up to 2.5 billion people, are at risk of dengue infection. An estimated 50 million infections occur annually worldwide, with 0.5 million of these cases being admitted to hospital for dengue haemorrhagic fever. Approximately 90% of these cases are in children aged less than 5 years. The epidemiology is, however, changing both regionally and globally. In this podcast, Senanayake A M Kularatne, senior professor of medicine at the University of Peradeniya in Sri Lanka, joins us to discuss which symptoms should make doctors consider a diagnosis of Dengue fever. Read the full clinical review: http://www.bmj.com/content/351/bmj.h4661 Read the best practice monograph: http://bestpractice.bmj.com/best-practice/monograph/1197.html

Pleural effusions are common, with an estimated 1-1.5 million new cases in the United States and 200 000-250 000 in the United Kingdom each year. Rahul Bhatnagar, academic clinical lecturer at the University of Bristol, describes how pleural effusions may be investigated and treated in the community and secondary care, with a particular focus on the emerging phenomenon of ambulatory management. We're also joined by Ron who boasts that he could have filled his car twice over, with the fluid drained over the two years he had a catheter in situ. Read the full clinical review: http://www.bmj.com/content/351/bmj.h4520

Ovarian cancer is the 7th most common cancer in women world wide, and 5 year survival continues to remain low - in the UK this has been attributed to delayed diagnosis. In this podcast Sophie Cook is joined today by two women who have had, and been treated for, ovarian cancer. Adele and Rosemary describe their experience, and what they think doctors should know about what patients are feeling. Read the full clinical review: www.bmj.com/content/351/bmj.h4443 Listen to the podcast on diagnosing ovarian cancer: https://soundcloud.com/bmjpodcasts/diagnosing-ovarian-cancer

Ovarian cancer is the 7th most common cancer in women world wide, and 5 year survival continues to remain low - in the UK this has been attributed to delayed diagnosis. In this podcast Sudha Sundar, senior lecturer in gynaecological oncology at the University of Birmingham, discusses how doctors can identify women at risk, and who to refer for specialist evaluation. Read the full clinical review: http://www.bmj.com/content/351/bmj.h4443 Find out what patients are experiencing: https://soundcloud.com/bmjpodcasts/being-diagnosed-with-ovarian-cancer

Although overuse in medicine is gaining increased attention, many questions remain unanswered. At the Preventing Overdiagnosis conference in Washington, Dan Morgan, associate professor at the University of Maryland School of Medicine, and Sanket Dhruva, research fellow at Yale University, propose an agenda for coordinated research to improve our understanding of the problem. Read the full agenda at: http://www.bmj.com/content/351/bmj.h4534

Hepatic encephalopathy constitutes a spectrum of neuropsychiatric abnormalities, beginning with subtle psychomotor changes and progressing to confusion with asterixis, somnolence, and then coma, arising in patients with impaired liver function. In this podcast, Tim Cross, a consultant hepatologist from the Royal Liverpool University Hospital, describes how to diagnose and manage the condition. We're also joined by Ralph Crawford, who suffers from hepatic encephalopathy, to talk about the burden of the disease and the treatment from a patient's perspective. Read the full review: http://www.bmj.com/content/351/bmj.h4187

Following on from the clinical review "Caring for sex workers", we spoke to the team at Open Doors, a sex worker outreach clinic in east London, run from the Homerton University Hospital NHS Foundation Trust. Kim Leveret and Anca Doczi join us to give practical advice on reaching out to sex workers, what barriers exist to them accessing care, and how to take a sex worker sexual history. Listen to the author of the clinical review, Michael Rekart, talk about the infectious disease side of sex worker health in our accompanying podcast: https://soundcloud.com/bmjpodcasts/sex-worker-health Read the full review: http://www.bmj.com/content/351/bmj.h4011 Practical advice for sex workers and health professionals, including links to Ugly Mugs: http://www.opendoors.nhs.uk/ The historic reasons for high abortion rates in Romania, from the journal of family planning and reproductive healthcare: https://soundcloud.com/bmjpodcasts/romanian-womens-fertility

Sex workers are unique population with specific health needs, caring for them can present non-specialists with a challenge, and there are important health promotion opportunities which should no be missed. Michael Rekart, clinical professor of infectious disease at the University of British Columbia, joins us to discuss his clinical review on caring for sex workers. Read the full article: http://www.bmj.com/content/351/bmj.h4011 Listen to outreach workers from Open Doors, a sex worker healthcare initiative in east London, give practical tips on caring for sex workers: https://soundcloud.com/bmjpodcasts/open-doors-for-sex-workers

Elder abuse is often the result of the organisation of health systems rather than the fault of individuals, argue Jolanda Lindenberg and Rudi Westendorp, two authors of a recent analysis paper. They call for system abuse to be acknowledged and addressed by incorporating older people’s views when designing health services. Read the full analysis: http://www.bmj.com/content/350/bmj.h2697

For decades research has shown that discrimination, harassment, and exclusion are pervasive experiences for staff from black and minority ethnic (BME) backgrounds in the National Health Service. In this podcast, the authors of a recent analysis article in The BMJ talk about the evidence for discrimination, what the NHS has done and is doing, and what has worked to promote equality in the wider world. Read their full analysis at: http://www.bmj.com/content/351/bmj.h3297

A recent review by the Australian National Health and Medical Research Council concluded that “there are no health conditions for which there is reliable evidence that homeopathy is effective”, but Europe currently spends €1bn annually on such remedies - often at the recommendation of doctors. So a recent head to head debate in The BMJ asks, should doctors recommend homeopathy? Peter Fisher, director of research, Royal London Hospital for Integrated Medicine argues yes, and Edzard Ernst, emeritus professor of complementary medicine at the University of Exeter argues no. Read their full arguments: http://www.bmj.com/content/351/bmj.h3735

Many doctors may believe that acute rheumatic fever is a disease of the past, but it's estimated that, worldwide, there are 500,000 new annual cases, and that 15 million have chronic rheumatic heart disease. Rachel Helena Webb, paediatric infectious diseases specialist at the Starship Children’s Hospital in Auckland, joins us to discuss diagnosis and management of this condition. Read the full clinical review: http://www.bmj.com/content/351/bmj.h3443

Read the full analysis: http://www.bmj.com/content/351/bmj.h3021 The prevalence and mortality of chronic obstructive pulmonary disease (COPD) is increasing globally. However, Martin Miller, honorary professor of medicine at the University of Birmingham, and Mark Levy, GP with a special interest in respiratory medicine, argue that the GOLD (Global Initiative for Obstructive Lung Disease) criteria used for diagnosis may be leading to misdiagnosis.

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has been examining the treatment of acute GI bleeds in England's NHS. Two of the authors, Martin Sinclair, consultant surgeon, and Simon McPherson, consultant vascular radiologist, join us to talk about their findings. Read the full report: http://www.ncepod.org.uk/gih.htm Read The BMJ news story: http://www.bmj.com/content/351/bmj.h3488

Bias and peer review are of universal importance to all those that produce scholarly work. Fiona Godlee and Rob Tarr, editors in chief of The BMJ and JNIS respectively, share their insights and experience on these highly topical issues with Joshua Hirsch. Read the related paper: http://jnis.bmj.com/content/early/2015/04/17/neurintsurg-2015-011781.full

By 2050 an estimated 135 million people worldwide will have dementia. Of all chronic diseases, dementia is one of the most important contributors to dependence and disability. In this part of a 2-part podcast, Sue, who cared for her mother who had dementia, and Louise Robinson, GP and professor of primary care at Newcastle University, join us to discuss what GPs can do to support carers. Listen to part 1 of the podcast: https://soundcloud.com/bmjpodcasts/diagnosis-and-management-of-dementia Read the full clinical review: http://www.bmj.com/content/350/bmj.h3029

Cervical screening programmes in many countries stop at around the age of 65 and much of the focus is often on younger women. However, comparatively little attention has been given to older women despite the fact that they account for about a fifth of cases each year and half of deaths. In this podcast Susan Sherman, a senior lecturer in psychology at Keele University, and Esther Moss, consultant gynaecological oncologist at University Hospitals of Leicester NHS Trust, argue that the upper age limit for cervical screening needs revisiting and call for awareness campaigns to target older as well as younger women. Read the full analysis: http://www.bmj.com/content/350/bmj.h2729

By 2050 an estimated 135 million people worldwide will have dementia. However, increasing evidence showing that dementia may be preventable. In this part of a 2-part podcast, Sue, who cared for her mother who had dementia, and Louise Robinson, GP and professor of primary care at Newcastle University, join us to discuss how to diagnose and manage the condition. Listen to part 2 of the podcast: https://soundcloud.com/bmjpodcasts/how-gps-can-help-dementia-carers Read the full clinical review: http://www.bmj.com/content/350/bmj.h3029

Martin McShane, medical director of long term conditions at NHS England, questions the validity of the Quality and Outcomes Framework and suggests how it should change in the future. Read the related article: http://www.bmj.com/content/350/bmj.h2540

Caesarean delivery can improve maternal and child health, and even save lives. But recent research points to latent risks for chronic disease: children delivered by caesarean have a higher incidence of type diabetes, obesity, and asthma. Jan Blustein, from New York University, joins us to discuss why she and colleage Jainmeng Liu believe this evidence should be examined and taken into account when considering elective caesarean. Read their full analysis: http://www.bmj.com/content/350/bmj.h2410

Information on the effectiveness and safety of healthcare should be valid, precise, up to date, clear, and freely available. Currently none of these criteria are fully satisfied, and Cochrane systematic reviews are not the solution. Ian Roberts, co-director of the clinical trials unit at the London School of Hygiene and Tropical Medicine, joins us to describe what the Cochrane Injuries Group is doing to address some of these problems. Read the full analysis article: http://www.bmj.com/content/350/bmj.h2463

In Glaziers and Window Breakers: the Role of the Secretary of State for Health in Their Own Words, published by the Health Foundation, Nicholas Timmins and Edward Davies find out what 10 of our recent health secretaries think the job is about. Read the feature on The BMJ http://www.bmj.com/content/350/bmj.h2954

The BMJ website is 20 years old this week - the first general medical journal online. Launch editor Tony Delamothe discusses with fellow digital pioneers Richard Smith and John Sack how the internet transformed doctors’ reading habits and the journal’s international reach. David Payne reports www.bmj.com/twenty

The movement to make data from clinical trials widely accessible has achieved enormous success, and it is now time for medical journals to play their part. From 1 July The BMJ will extend its requirements for data sharing to apply to all submitted clinical trials, not just those that test drugs or devices. The BMJ's Elizabeth Loder explains what this means for authors, and how we expect researchers to make their data available. Read the full editorial: http://www.bmj.com/content/350/bmj.h2373

Attention deficit hyperactivity disorder, or ADHD, presents with persistent symptoms of inattention, hyperactivity, and impulsivity causing impairment in multiple settings. It is a disorder that attracts considerable debate and controversy. The this part of this podcast, focused on the diagnosis of ADHD, two of the authors of the review, Mina Fazel, consultant psychiatrist at Oxford University Hospitals NHS Trust, and Nienke Verkuijl, specialty trainee at the University of Oxford and Rachel, a parent of a child who has a diagnosis of ADHD. Read the full review: http://www.bmj.com/content/350/bmj.h2168 Listen to the second part of the podcast: https://soundcloud.com/bmjpodcasts/adhd-in-childhood-treatment

Attention deficit hyperactivity disorder, or ADHD, presents with persistent symptoms of inattention, hyperactivity, and impulsivity causing impairment in multiple settings. It is a disorder that attracts considerable debate and controversy. The this part of this podcast, focused on the treatment of ADHD, two of the authors of the review, Mina Fazel, consultant psychiatrist at Oxford University Hospitals NHS Trust, and Nienke Verkuijl, specialty trainee at the University of Oxford and Rachel, a parent of a child who has a diagnosis of ADHD. Read the full review: http://www.bmj.com/content/350/bmj.h2168 Listen to the second part of the podcast: https://soundcloud.com/bmjpodcasts/adhd-in-childhood-diagnosis

Speech and language therapists Cristina McKean and Angela Morgan join us to discuss their clinical review "Identifying and managing common childhood language and speech impairments", published on thebmj.com. They talk about the prevalence, the steps to take if parents believes their child has a speech problem, and the importance of knowing which resources are locally available to support children. Read the full review: http://www.bmj.com/content/350/bmj.h2318

Paul Lennon, a specialist registrar at University Hospital Limerick, and Michael Crotty, general practitioner from the Synergy Medical Clinic in Canada, join Emma Parish to answer some frequently asked questions about infectious mononucleosis. Read their full clinical review: http://www.bmj.com/content/350/bmj.h1825

The future of health and social care looks certain to be a defining issue in the forthcoming UK general election. Social care has been subject to deep public spending cuts, raising concerns about the sustainability of services in the future. Whoever wins the next election will need to grapple with providing joined up health and social care services in an era of continued austerity. A recent debate (heathdebate.net) with key spokespeople from across the political spectrum took place this week, and we assembled a panel of experts to discuss how they think the debate went, and the key promises and gaps in the parties plans for the NHS. Taking part were: Fiona Godlee, editor in chief of The BMJ Jeremy Taylor - chief executive of National Voices Johnny Marshall - director of policy at the NHS Confederation Jane Dacre - president of the Royal College of Physicians Anita Charlesworth - chief economist at the Health Foundation Mark Porter - chair of council at the BMA Nigel Edwards - chief executive of the Nuffield Trust Chris Ham - chief executive of The King's Fund For more analysis of the election's health promises, read Gareth Iacobucci's Election Watch column: http://www.bmj.com/content/350/bmj.h2165

Nicki Ward-Abel, a lecturer practitioner in MS at Birmingham City University, joins us to explain how to treat patients who are experiencing a relapse of their MS symptoms. She discusses what constitutes a relapse, which treatments are available, and what effect a relapse can have on a patient. Read more at: http://www.bmj.com/content/350/bmj.h1765

Some apps have the potential to encourage healthier habits and are accessible to most people, argues Iltifat Husain, but Des Spence notes the lack of any evidence of effectiveness and the potential for encouraging unnecessary anxiety. Read more about in our head to head "Can healthy people benefit from health apps?" - http://www.bmj.com/content/350/bmj.h1887

Doctors are witnessing increasing numbers of patients seeking referrals to food banks in the United Kingdom. Rachel Loopstra, a post-doctoral researcher at the University of Oxford and colleagues have been asking if that rise is due to supply or demand? Read their full analysis: http://www.bmj.com/content/350/bmj.h1775

Peter Lepping, consultant psychiatrist and honorary professor at Betsi Cadwaladr University Health Board in North Wales, joins us to discuss his experience dealing with patients who have delusional infestations. He talks about how to broach the diagnosis, and gives practical tips on how to investigate this difficult condition. Read his practice pointer: http://www.bmj.com/content/350/bmj.h1328

Flaws in the Department of Health’s interim evaluation of an alcohol industry pledge to remove one billion alcohol units from the market raise questions about the claimed success argue John Holmes, Colin Angus and Petra Meier from the Sheffield Alcohol Research Group at the University of Sheffileld. They say that the report should be withdrawn and revised targets set Read the full analysis: http://www.bmj.com/content/350/bmj.h1301

Sudden cardiac death in athletes aged less than 35 years is the leading cause of medical death in this subgroup, with an estimated incidence of 1 in 50 000 to 1 in 80 000 athletes per year. it is most commonly caused by an underlying genetic heart disorder, such as hypertrophic cardiomyopathy. In this podcast Christopher Semsarian, professor of medicine at the University of Sydney, joins us to discuss the diagnosis of cardiac changes and prevention of death in this population. Read the full clinical review: http://www.bmj.com/content/350/bmj.h1218

A BMJ Clinical Evidence systematic overview looks at the evidence for medical and surgical treatments of trigeminal neuralgia, and the uncertainties that exist due to gaps in the evidence. This has been summarised in The BMJ. The authors of the overview and bmj.comsummary, Prof. Joanna Zakrzewska from the Facial Pain Unit at the Eastman Dental Hospital, London, and Mark Linskey, Professor of Neurological Surgery at the University of California Irvine, discuss the evidence, the issues around it, and put this all into a clinical context. Read the full systematic overview: http://clinicalevidence.bmj.com/x/systematic-review/1207/overview.html Disclaimer: The purpose of this podcast is to educate and to inform. The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement, patient care or treatment. The views expressed by contributors are those of the speakers. BMJ does not endorse any views or recommendations discussed or expressed on this podcast. Listeners should also be aware that professionals in the field may have different opinions. By listening to this podcast, listeners agree not to use its content as the basis for their own medical treatment or for the medical treatment of others. BMJ does not warrant the accuracy of the information contained in the podcast and to the fullest extent permitted by law, BMJ Publishing Group Limited is not responsible for any loss whatsoever resulting from the application of, or reliance upon, the information contained in this podcast.

In the US the licence, or marketing authorisation, for alteplase is limited to 0-3 hours after onset of stroke, but some other countries - including the UK and Australia - have extended the licence to 4.5 hours. In an analysis article on thebmj.com Brian Alper, vice president of evidence based medicine research and development at Dynamed, and colleagues, interpret the evidence to suggest increased mortality with uncertain benefit for its use beyond three hours. Read their full analysis: http://www.bmj.com/content/350/bmj.h1075

Chris Moulton is VP of the Royal College of Emergency Medicine and an A&E consultant in the Royal Bolton Hospital. He believes that the majority of patients who attend A&E cannot be adequately treated elsewhere, and that measures to try and reduce emergency presentations may be counterproductive. If you would like to contribute to this collection, please email a brief audio recording to [email protected] or phone +44 (20) 3058 7427 and tell us what your main concern for the NHS is. Please include your name, job title, and place of work.

BMJ Voices is a collection of readers’ experiences of working in the NHS. For this, The BMJ is seeking short audio submissions from UK listeners. These submissions will be published on thebmj.com. Patrick Keating, a GP from Enfield, is concerned that small practices are under pressure to increase list size, but aren't able to muster resources to meet this increased demand. If you would like to contribute to this collection, please email a brief audio recording to [email protected] or phone +44 (20) 3058 7427 and tell us what your main concern for the NHS is. Please include your name, job title, and place of work.

Obioma Ezekobe is a GP in an urgent care centre in Central Middlesex Hospital. She believes that the public need to be educated about the use of NHS resources, and be taught when it is appropriate to seek care. If you would like to contribute to this collection, please email a brief audio recording to [email protected] or phone +44 (20) 3058 7427 and tell us what your main concern for the NHS is. Please include your name, job title, and place of work.