Medicine and Science from The BMJ

Is medicine trying to learn too much from aviation? Kevin Fong, consultant anaesthetist at UCLH is currently working with Kent, Surrey and Sussex air ambulance. At Risky Business he talked to The BMJ about why he thinks medicine is trying to learn too much from aviation.

Screening tests were central to many of the discussions taking place at the Preventing Overdiagnosis conference (preventingoverdiagnosis.net) To sum up some of the problems with screening we’re joined by Carl Heneghan, director of the Centre for Evidence Based Medicine at the University of Oxford, and John Broderson, associate professor in the Research Unit and Section of General Practice at the University of Copenhagen. For more on over diagnosis, visit www.bmj.com/too-much-medicine

A recent clinical review in The BMJ discusses diagnosis and management of prolactinomas and non-functioning pituitary adenomas. One management option is surgery to remove the tumour, often this can done trans-sphenoidally. Though major complications of this type of surgery are low (~1%), there are still effects that can be distressing to patients, and should be discussed. In this interview the patient wished to remain anonymous, so we have re-recorded her words. She describes the way in which attempts to reassure her about the surgery made he under-estimate the risks involved. Read the full review: http://www.bmj.com/content/349/bmj.g5390

Stephen Martin, an associate professor at the University of Massachusetts Medical School, thinks we're overtreating otherwise healthy patients who have mild hypertension. In this podcast he sets out his argument, and explains why prescribing drugs to these people may actually be doing more harm than good. Read the full analysis article: http://www.bmj.com/cgi/doi/10.1136/bmj.g5432

Demand for better access to primary care is ever rising, but is email the answer? In this podcast, Elinor Gunning, a clinical teaching fellow in London says that patients want it and that careful planning can mitigate worries about safety and security. Emma Richards, trainee academic GP, is not so sure and thinks clearer guidance and resourcing are needed first. Read the head to head online: http://www.bmj.com/content/349/bmj.g5338

David Heymann, professor of infectious disease epidemiology, and head and senior fellow, at the Chatham House Centre on Global Health Security was sent to investigate the first outbreaks of Ebola in 1976. In this podcast he gives a longer term perspective on the disease, and talks about the importance and challenges of introducing novel treatments. For more information on ebola virus disease, including working in a front line clinic, visit bmj.com/ebola David Heymann's analysis article, Prevention is better than cure for emerging infectious diseases: http://www.bmj.com/content/348/bmj.g1499

A new rational testing article, published on thebmj.com, looks at how to diagnose an immediate food allergy. Mabel Chew, The BMJ's practice editor, is joined by Cathal Steele from the Belfast Trust Regional Immunology Service - they discuss which tests are appropriate, and the common pitfalls in diagnosis. Read the full article: http://www.bmj.com/content/349/bmj.g3695

Management of spasticity requires a balanced approach, weighing the benefits of treatment against the usefulness of the spasticity. Current interventions to treat spasticity lack a robust evidence base, and guidelines often depend on expert recommendations. A new clinical review published on thebmj.com discusses the assessment and treatment of spasticity in adults. In this podcast we're joined by one of the authors of that review, Siva Nair, from the Department of Neurology at The Royal Hallamshire Hospital, and by a patient with spasticity, Ian, who is chairman of the Hereditary Spastic Paraplegia (HSP) Support Group. Read the clinical review: http://www.bmj.com/content/349/bmj.g4737 For more information on HSP visit http://hspgroup.org/

Global endorsement as a WHO essential medicine is big step. But Corrado Barbui, from the Department of Public Health and Community Medicine at the University of Verona, has found that the quality of applications for antidepressants and antipsychotics is poor and calls on applicants and WHO to raise standards. Read the analysis article: http://www.bmj.com/content/349/bmj.g4798

Pre-diabetes is an umbrella term and the most widely used phrase to describe a blood concentration of glucose or glycated haemoglobin (HbA1c) that lies above normal but below that defined for diabetes. John S Yudkin, emeritus professor of diabetes at University College London, thinks this is over-medicalisation and will only increase the burden on individuals and the health system. Read the full analysis article: http://www.bmj.com/content/349/bmj.g4485

Research fraud, the deliberate falsification of research data, undermines science and can lead to horrible outcomes, as exemplified by Andrew Wakefield and the MMR/Autism scandal. A new Head to Head in The BMJ sets out the case for and against making research fraud a crime. Arguing yes is Prof. Zulfiqar Bhutta, from the Hospital for Sick Children in Toronto, who says that criminal sanctions are necessary to deter growing deliberate research misconduct, which can ultimately harm patients. Prof. Julian Crane, from the University of Otago Wellington, disagrees: he doubts that sanctions will have any deterrent effect and worries that criminalisation would undermine trust. Read the full debate: http://www.bmj.com/content/349/bmj.g4532

HIV testing is now being routinely offered in increasingly diverse health settings, including primary care. In this podcast we talk to HIV consultant Mike Rayment, from Chelsea and Westminster NHS Foundation Trust, and Paul, a patient diagnosed with HIV infection 4 years ago. They discuss how to go about offering testing, and what matters to patients when they receive the diagnosis. Read the clinical review discussed: http://www.bmj.com/content/349/bmj.g4275

Devi Sridhar, population health researcher and lecturer, joins us to discuss why an independent organisation to co-ordinate international health concerns is absolutely necessary. Read more in her analysis article, Global rules for global health: Why we need an independent, impartial WHO

Whichever country hoists aloft the World Cup trophy on 13 July, the real winner will be the alcohol industry. In this podcast Jonathan Gornall explains why FIFA promotes the interests of the alcohol industry, and the extraordinary demands countries comply with in order to host the World Cup. World Cup 2014: festival of football or alcohol? http://www.bmj.com/content/348/bmj.g3772

Drugs to encourage weight loss have a chequered past, with many of them having been withdrawn from the market due to increased morbidity and mortality. In this podcast Raj Padwal, associate professor of medicine at the University of Alberta, takes us through the remaining therapy Orlistat, and discusses the potential for two new therapies, Phentermine-ER topiramate, and Lorcaserin, which are being licensed in some countries Read the full article: http://www.bmj.com/content/348/bmj.g3526

Two articles on bmj.com look at helicobacter pylori; a systematic review and meta-analysis examines if eradication treatment reduces rates of gastric cancer, and an uncertainties article asks who we should be testing and treating for the infection. Two of the authors of those articles, Alex Ford from the Leeds Gastroenterology Institute, and Paul Moayyedi from the Gastroenterology Division of McMaster University, join us to discuss the bacterium. Read the full articles www.bmj.com/content/348/bmj.g3174 www.bmj.com/content/348/bmj.g3320

New NICE guidance says that smokers should be encouraged to cut down on the number of cigarettes they smoke, as well as trying to quit. In a head to head, published on bmj.com, Paul Aveyard, professor of behavioural medicine at the University of Oxford, says that reducing smoking is a worthwhile step towards cessation, but Gerard Hastings, professor of social marketing at Stirling and Open Universities, argues that the lifelong nicotine replacement therapy being recommended in support may benefit industry more than public health. Read the full head to head: http://www.bmj.com/content/348/bmj.g2787

UTIs are often diagnosed in secondary care, but often that diagnosis isn't accurate. In this podcast Gavin Barlow from the Department of infection and tropical medicine at Hull & East Yorkshire Hospitals NHS Trust joins us to discuss when and how to test for the infection​. Read the full clinical review Investigation of suspected urinary tract infection in older people http://www.bmj.com/content/348/bmj.g3861

The BMJ has been investigating the “cosy relationship” between the alcohol industry and the British government. In a series of articles Under the influence, journalist Jonathan Gornall has been looking into UK government’s consultation into introducing a minimum unit price for alcohol in England and Wales, and also at the wider responsibility deal between government and industry which is meant to champion public health. In his latest article, he looks at the billion unit pledge, and how it's actually being used as a marketing tool to attract new drinkers. Read all of the articles discussed on www.bmj.com/alcohol

A new analysis article on bmj.com discusses the story of a surgical colon cancer trial, that was started 30 years ago and then abandoned, and the data lost. In this podcast Helen Macdonald talks to Tom Treasure from Imperial College London, who has unearthed the data and now published the research. Also joining the discussion is Peter Doshi, one of the instigators of the RIAT initiative set up to encourage this kind of work to correct the scientific record. Read the full article: http://www.bmj.com/content/348/bmj.g2085

Digital technology introduces new concerns for confidentiality and information security. In this podcast Bradley Crotty and Arash Mostaghimi, both from Harvard Medical School, outline the regulations governing confidentiality and medical privacy and provide practical advice on how to safeguard patient information Read their article for more details: http://www.bmj.com/content/348/bmj.g2943

The International Olympic Committee (IOC) and other international sports federations have recently introduced policies which require a medical investigation of women athletes known or suspected to have hyperandrogenism. Women who are found to have naturally high testosterone levels and tissue sensitivity are banned from competition unless they have surgical or pharmaceutical interventions to lower their testosterone levels. But a recent analysis published on bmj.com says that these tests and procedures are at best not medically necessary, and at worst totally unethical. In this podcast we're joined by two of the authors, Rebecca Jordan-Young, professor women’s gender and sexuality studies at Barnard College, and Katrina Karkazis, bioethicist at Stanford centre for biomedical ethics. Read the full analysis article online: http://www.bmj.com/content/348/bmj.g2926

Michael Farrell, professor and director of the National Drug and Alcohol Research Centre at the University of New South Wales in Sydney, talks to Mabel Chew, The BMJ's practice editor, about prescription of cannabinoids. They discuss the latest evidence on nausea and appetite, when cannabinoids may be effective for chronic pain, and which common problems to watch out for. Read the full article: http://www.bmj.com/content/348/bmj.g2737

Glycated Haemoglobin (HbA1c) is used to measure glucose control in patients with diabetes, but can now be used as an alternative test to glucose concentration for diagnosing type 2 diabetes or identifying people at high risk of developing the disease. in this podcast Eric Kilpatrick, from the Department of Clinical Biochemistry at Hull York Medical School, and Stephen Atkin, from Weill Cornell Medical College Qatar, describe when testing HbA1c may be appropriate for diagnosis, and what comorbidities would rule it out. Read the full rational testing article: http://www.bmj.com/content/348/bmj.g2867

First seizure covers a wide range of manifestations, but picking up the minor events can prevent a patient from experiencing a major event, so early diagnosis is key. Heather Angus-Leppan, consultant neurologist and epilepsy lead at the Royal Free Hospital in London, talks to Navjoyt Ladher about how to manage the first seizure in an adult. Read the full clinical review at: http://www.bmj.com/content/348/bmj.g2470

Tamiflu (oseltamivir) is a neuraminidase inhibitor, developed by Roche, for the treatment of seasonal and pandemic influenza. Yet for the first time a comprehensive review of the data, by independent researchers, has shown that the claims for Tamiflu’s effectiveness have been overestimated, and that harms have been underreported. Here is the audio of a recent press conference where researchers and the BMJ's editors describe the findings of that research, and the systematic regulatory failures those findings expose. Taking part were: Fiona Godlee - BMJ editor in chief Carl Heneghan - Director of Oxford University's Centre for Evidence Based Medicine Peter Doshi - Assistant Professor of Pharmaceutical Health Services Research Elizabeth Loder - The BMJ clinical epidemiology editor David Tovey - Editor in chief, Cochrane Library Ben Goldacre - Founder of the AllTrials campaign

Mabel Chew talks to Tamara Pringsheim, from the University of Calgary, about the use of triptans for acute treatment of migraine. When, how, and what contraindications a physician should be aware of. Read the full article: http://www.bmj.com/content/348/bmj.g2285

The NHS has been collecting data on patients’ experience of care for over 10 years but few providers are systematically using the information to improve services. Angela Coulter joins us to discuss the new Friends and Family test, and why it will fail to change services until it asks the right questions. read the full paper: http://www.bmj.com/content/348/bmj.g2225

Meticillin resistant Staphylococcus aureus (MRSA) remains one of the foremost hospital acquired pathogens. Patients colonised or infected with MRSA provide a reservoir within hospitals, although infection prevention and control measures minimise the risk of transmission. Although there is broad agreement on the control measures required for patients colonised or infected with MRSA, there is considerable controversy over who, when and how to screen for the bacteria. John Coia, a consultant microbiologist at Glasgow Royal Infirmary, discusses when screening may be appropriate, how it should be carried out, and the best strategy for decolonisation. Read the full article: http://www.bmj.com/content/348/bmj.g1697

Read the full analysis of ParkinsonNet: http://www.bmj.com/content/348/bmj.g1838 Patients with Parkinson’s disease need long term support to manage their condition. In this podcast Bastiaan Bloem, medical director at the Parkinsons Institute in Nijmegen, and Marko van der Vegt, a Parkinsons patient, describe the benefits of ParkinsonNet; a model of integrated care provided by a network of specialists and suggest it has promise for other long term conditions

Subdural haematoma is more common in elderly patients, yet the condition is easy to miss in this group. John Young, a consultant geriatrician at Bradford Teaching Hospitals NHS Foundation Trust, describes what clinical signs to look out for, and what tests can confirm a diagnosis of subdural haematoma.

Each year at the Nuffield Trust Health Policy Summit, The BMJ hosts a breakfast roundtable. It has been one year since the Health and Social Care Bill for England was enacted, and the reconfiguration of the NHS continues, so this year we asked our panel to give the bill an end of year report. Taking part were: John Richards – Southampton Clinical Commissioning Group Nigel Edwards - CEO Nuffield Trust Jennifer Dixon - CEO Health Foundation Terence Stephenson - president Academy of Medical Royal Colleges Maureen Baker - Chair RCGP Hugh Taylor - Chairman Guys and St Thomas' Foundation Trust Nick Hicks - CEO COBIC Ltd Jeremy Taylor - National Voices Tim Ferris - VP for population health management, Partners Healthcare, MA Nick Timmins - Senior Associate Nuffield Trust

Read the open access research: http://www.bmj.com/cgi/doi/10.1136/bmj.g1458 Australia was one of the first countries to introduce HPV vaccination, and due to it's cervical cancer screening programme, is one of the first to be able to measure the effectiveness of the vaccine. In this podcast, 3 of the authors of a new paper on bmj.com discuss their findings and talk about implications for cervical cancer screening in Australia.

Most doctors are familiar with patients who describe chronic pain all over the body, which is associated with a range of other symptoms including poor sleep, fatigue, and depression. This complex of symptoms is sometimes referred to as fibromyalgia. Management of patients with this condition is often complex and challenging. The diagnosis of fibromyalgia has long been controversial, with some experts questioning whether it exists as a separate entity In this podcast Anisur Rahman, professor of rheumatology at University College London, joins us to discuss diagnosis and management of the condition. Read the full clinical review article: http://goo.gl/MYryTJ

Complete implementation of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) recommends policies in China that would prevent almost 13m smoking related deaths by 2050, suggests a paper published on bmj.com. China is home to about one third of the world’s smokers and reducing smoking in China could have an enormous public health impact, even on a global scale. To discuss their research, we are joined by three of the paper's authors, David Levy from Georgetown University, Teh-Wei Hu from University of California at Berkeley, and Andrew Moran from Columbia University Medical Center. Read the full open access research: http://www.bmj.com/cgi/doi/10.1136/bmj.g1134

Controversy rages over the relative benefits or harms of screening for breast cancer, with evidence suggesting that in younger women at least it does more harm than good. Now a new paper on bmj.com reports the results of 25 years of follow up of women who have taken part in a breast cancer screening trial in Canada, and suggests that annual screening does not cut breast cancer deaths. Anthony Miller, Professor Emeritus at the Dalla Lana School of Public Health, University of Toronto, lead author on the paper, and director of the trial, joins us to discuss the results.

Read the full article online: http://www.bmj.com/content/348/bmj.g401 When you prescribe a drug, do you ever stop to wonder if it's suitable for vegetarians? Kinesh Patel and Kate Tatham from Imperial College London have found that 74 of the 100 drugs most commonly prescribed by GPs in the UK contain ingredients which may have been derived from animals.

Read the full article: http://www.bmj.com/content/348/bmj.g129 Erectile dysfunction is a common problem, and novel treatments mean that patient’s options have widened. In this podcast Asif Muneer, consultant urological surgeon and andrologist at University College Hospital in London, explains the aetiology, treatment, and prognosis for the condition.

Two articles on bmj.com look at high risk devices for rare conditions, and how the US Food and Drug Administration regulates them. Joining us to discuss the problems are Rita Redberg, professor of medicine at the University of California San Francisco, and Aaron Kesselheim, assistant professor of medicine at the Harvard School of Public health. Read the articles Presumed safe no more: lessons from the Wingspan saga on regulation of devices http://www.bmj.com/content/348/bmj.g93 Assessment of US pathway for approving medical devices for rare conditions http://www.bmj.com/content/348/bmj.g217

Read the article: http://www.bmj.com/content/348/bmj.f7003 The 2013 World Health Organization guidelines continue to recommend rapid fluid resuscitation for children with shock, despite evidence from the FEAST trial that this can increase mortality. Katheryn Maitland, professor of tropical paediatric infectious disease at Imperial College London, who led the FEAST trial, joins us to discuss it.

Read the head to head: http://www.bmj.com/content/348/bmj.g171 The BMJ no longer publishes research funded by tobacco companies. Richard Smith says that research funded by drug companies is also flawed and published to encourage sales, but Trish Groves says that the industries are fundamentally different and that moves are afoot to increase integrity Join the authors live on Twitter to debate the issue on 21 January, 1200-1230 GMT at #pharmaban.

When searching for clues to reach a diagnosis, neurologists often empathise with the detective who is trying to solve a case, write Peter Kempster and Andrew Lees in BMJ sister journal Practical Neurology bit.ly/1dqReQq. In this podcast, journal editor Phil Smith and Andrew Lees, director of the Queen Square Brain Bank in London, discuss how neurologists draw upon detective skills. They also talk about neurologists who have turned these skills to crime fiction writing, and the use of narrative in clinical case histories. The expert witnesses called upon are: - Oliver Sacks, best selling author and professor of neurology at NYU School of Medicine - Peter Gautier Smith, now retired from consulting at Queen Square and author of 31 detective novels - Chris Goetz, who worked at Rush University Medical Centre with Harold Klawans, crime fiction writer and authority on Parkinson’s disease Listen to the full interviews here: Andrew Lees bit.ly/1cPaoxM Peter Gautier-Smith bit.ly/1d5HhKj Harold Klawans bit.ly/19cXR Oliver Sacks bit.ly/1hBsbgz

It is generally agreed that sex is useful when getting pregnant, but is it necessary? Professors Amy Herring, and Carolyn Halpern from the University of North Carolina explain how they found virgin births in the US for their Christmas BMJ paper. Also Gareth Jones, emeritus professor of anaesthesia at Cambridge University, recalls his early life in the City Lodge Hospital – formerly Cardiff Union Workhouse Finally, does being right always make you happy? Bruce Aroll, professor of primary care at the University of Auckland wanted to know, and so designed a pilot study. See also: Like a virgin (mother): analysis of data from a longitudinal, US population representative sample survey (http://www.bmj.com/content/347/bmj.f7102) Being right or being happy: pilot study (http://www.bmj.com/content/347/bmj.f7398) Growing up over the shop (http://www.bmj.com/content/347/bmj.f6922)

James Bond, legendary secret agent, marksman, womaniser, smoker, but perhaps most famously, drinker. Neil Guha and Patrick Davies from Nottingham University Hospitals NHS Trust, and Graham Johnson from the Royal Derby Hospital, have documented Commander Bond's drinking in a Christmas BMJ paper, and join us to discuss its findings. Also this week, Doctors of the World, The BMJ's Christmas charity, has a role beyond emergency response to humanitarian crises, helping undocumented migrants in the UK access healthcare. Richard Hurley visits its clinic in the east end of London to find out out more. See also Were James Bond’s drinks shaken because of alcohol induced tremor? http://www.bmj.com/content/347/bmj.f7255

This year The BMJ has chosen Doctors of the World as it's Christmas appeal. This week we hear about the charity's international work. Deputy magazine editor Richard Hurley talks to some of the doctors who are working in Syria and the camps surrounding the stricken country. Also this week, a clinical review on BMJ.com looks at polymyalgia rheumatica. Clinical reviews editor Sophie Cook asks Sarah Mackie, from the Leeds Institute of Rheumatic and Musculoskeletal Medicine, how she explains this difficult condition to patients. After the typhoon: how volunteer doctors are bringing medical care to those most in need http://www.bmj.com/content/347/bmj.f7193 Polymyalgia rheumatica http://www.bmj.com/content/347/bmj.f6937

Professor Sir John Oldham, from the Institute of Global Health Innovation at Imperial College London, talks about reforming reform, and why he worries that research agendas are more influenced by career aspirations than patient care. Tom Kenny, director of external relations at the Evaluation, Trials, and Studies Coordinating Centre at the National Institute for Health Research, explains how the NIHR is trying to put patients at the centre of the research it funds. Finally doctors' health - Michael Peters from the BMA's Doctors for Doctors Unit, explains why life's everyday struggles are hard for doctors to cope with. See also: Reform reform: an essay by John Oldham http://www.bmj.com/content/347/bmj.f6716 Doctors’ health: taking the lifecycle approach http://www.bmj.com/content/347/bmj.f7086

The latest NCEPOD (National Confidential Enquiry into Patient Outcome and Death) report examines the management of aneurysmal subarachnoid haemorrhage, in England's National Health Service. Two of the report's clinical co-ordinators, Mike Gough, a vascular surgeon at Leeds General Hospital, and Alex Goodwin, anaesthetist at the Royal United Hospital in Bath, join us to discuss the reports findings and recommendations. Read the full report: http://www.ncepod.org.uk/sah.htm

The population timebomb: The idea that an ageing population is making it harder and harder to fund pensions, social care, and healthcare, as the number of older people grows in proportion to the working population. Jeroen Spijker, senior research fellow at the School of Social and Political Science in the University of Edinburgh, explains why he thinks the risk has been overblown. Also, Michael Kidd, current president of WONCA – the world organisation of family doctors - talks about the pressures on primary care, and how he would like to attract the best medical talent to the specialty. http://www.bmj.com/content/347/bmj.f6598

A modelling study on bmj.com suggests that a 20% tax on sugar sweetened drinks would reduce the number of obese adults in the UK by 1.3%, and by 0.9 for those who are overweight. The health gains are fairly similar across all income groups. Oliver Mytton, one of the study's authors, describes why a 20% figure was chosen and how the modelling was done. Also, liver function tests follow a different normal range during pregnancy. Catherine Williamson, professor of women’s health at King's College London, explains why. Read the articles: Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK - http://www.bmj.com/content/347/bmj.f6189 Abnormal liver function tests in pregnancy - http://www.bmj.com/content/347/bmj.f6055

Professor Michael Marmot has spearheaded WHO Europe’s Health 2020 report, which looks at the disparity in the social determinants of health across the region. He joins us to explain why he’s hopeful for change. Also, Spencer Ellis, consultant rheumatologist at Lister Hospital in Stevenage, explains when and why to order antinuclear antibody (ANA) tests.