Medicine and Science from The BMJ

With changes to the NHS such as cuts, competition and tendering, secondary care will need to adapt. Joining BMJ features editor Rebecca Coombes to discuss how, are: Yi Mien Koh, chief executive of Whittington Health, London Jan Filochowski, chief executive of West Hertfordshire Hospitals NHS Trust Fergus Gleeson, divisional director of Critical Care, Theatres, Diagnostics and Pharmacy at Oxford University Hospitals Nigel Edwards, senior fellow at the King’s Fund Derek Greatorex, chair of the South Devon and Torbay Clinical Commissioning Group Kate Hall, policy advisor, Monitor, London This is the full version of the roundtable. See the podcast above for highlights.

The healthcare landscape in the England is shifting, with cuts, competition and tendering some of the major changes. Secondary care must adapt to these, but how? Joining BMJ features editor Rebecca Coombes to discuss the issues are: Yi Mien Koh, chief executive of Whittington Health, London Jan Filochowski, chief executive of West Hertfordshire Hospitals NHS Trust Fergus Gleeson, divisional director of Critical Care, Theatres, Diagnostics and Pharmacy at Oxford University Hospitals Nigel Edwards, senior fellow at the King’s Fund Derek Greatorex, chair of the South Devon and Torbay Clinical Commissioning Group And BMJ practice editor Mabel Chew talks to Ruth Reed (specialty registrar in child and adolescent psychiatry, Warneford Hospital, Oxford) and Mina Fazel (postdoctoral research fellow, Warneford Hospital Oxford) about why post-traumatic stress disorder is easily missed, and what clinicians should look out for.

Barack Obama saw his Affordable Care Act remain law last week, as the US Supreme Court ruled it is constitutional. Ed Davies (BMJ US news and features editor) talks to Janice Hopkins Tanne (freelance journalist based in New York) about the ruling’s implications. And what are the options for tackling childhood obesity? Li Ming Wen (research and evaluation manager at Sydney University) believes intervention needs to be early, and has demonstrated that giving new mothers simple nutrition messages reduces their child’s BMI at age two. BMJ assistant editor Helen MacDonald speaks to him.

It seems the race to implement telehealth is on – the UK government’s response to its Whole System Demonstrator pilot has been very positive. But has it been over-hyped? We find out from Jennifer Dixon, Director of the Nuffield Trust, which has evaluated the pilot. Also, alcohol: beneficial or detrimental? Evidence shows it depends on what aspects of health you look at. Research published on bmj.com this week adds to the picture by looking at the association between alcohol consumption and the risk of developing arthritis. Alicja Wolk, professor of nutritional epidemiology at the Karolinska Institutet, explains her study.

It has been almost exactly a year since Anders Breivik bombed government buildings in Oslo, and then carried out a mass shooting on the island of Utøya, where he killed 69 people, mostly teenagers. In that time there has been much discussion about his mental state. Vivienne Nathanson and Julian Sheather from the BMA join us to discuss the moral and ethical problems that a diagnosis of insanity bring to the case. Also this week, seven articles on bmj.com look at the science behind sports product adverts. We hear from Matthew Thompson, from the Centre for Evidence Based Medicine in Oxford, who criticises the quality of the evidence submitted to the European Food Safety Authority to back these claims

Daniel Hackam, associate professor at Western University in Canada, explains how shift patterns can have a detrimental effect on the vascular health of workers. Also this week Seena Fazel, Wellcome Trust senior research fellow in clinical science at the University of Oxford, queries the predictive value of the risk assessment tools routinely used to predict violent behaviour

A feature this week asks "Should patients be able to control their own records?". The website renalpatientview.org allows patients to do exactly that. Neil Turner, a professor of nephrology at Edinburgh Royal Infirmary, explains how he and colleagues developed the resource. Also Steven Woloshin and Lisa Schwartz, authors of the "Not So Stories" column have turned their statistical scrutiny onto a recent advert by Susan G. Komen for the Cure®, the breast cancer charity. They explain how the case for mammography has been massively oversold.

This week we’ll hear why Donald Light, professor of comparative health systems research at the University of Medicine and Dentistry of New Jersey, thinks the innovation crisis in the development of drugs is more marketing rhetoric than reality. Also this week, a research paper on bmj.com looks at how subclinical psychological distress affects mortality. Tom Russ, Alzheimer Scotland clinical research fellow at the University of Edinburgh and one of the paper's authors, explains what they found.

Marion Nestle is the Paulette Goddard Professor of Nutrition, Food Studies, and Public Health at New York University. She has written widely about food and nutrition, and is an iconoclast in the world of food politics. In this podcast she explains how economic forces have changed the food industry, and how that change is fuelling the obesity epidemic.

Over the decades public health has had many incarnations. Geof Rayner and Tim Lang (Center for Food Policy) argue that public health today needs an overhaul, and to focus on our co-existence with nature and relationships with each other. They explain why, and how. Many of the issues Dr Rayner and Professor Lang are concerned about are being taken up by the People's Health Movement. Member Jonny Currie explains what he wants the movement to achieve, and others involved talk about actions they are taking.

In 2008 the rates of suicide in the UK began to increase. Is it a coincidence that this was also when the financial crisis hit? Ben Barr, research fellow in the department of Public Health and Policy at the University of Liverpool, explains what his study found. Those who've attempted to kill themselves once are at high risk of doing so again, but interventions to prevent this have been hard to find. Merete Nordentoft, professor at the Mental Health Centre Copenhagen, University of Copenhagen, talks us through the results of her study examining a promising candidate.

It's increasingly obvious that acutely ill patients have received less than gold standard care. Deficiencies in training are often blamed. Paul Frost, consultant in intensive care medicine at the University Hospital of Wales, takes us through the admission of an acutely ill patient. Also this week, BRCA mutations and ionising radiation both increase the risk of developing cancer, but how do these risk factors combine? Anouk Pijpe, an epidemiologist at the Netherlands Cancer Institute, explains the results of her retrospective cohort study.

A BMJ head to head article this week asks: "Are the causes of obesity primarily environmental?" John Wilding, Head of the Department of Obesity and Endocrinology at the University of Liverpool, and Tim Frayling, professor of human genetics at the University of Exeter, argue their cases. Also this week, David Williams, a consultant obstetric physician at University College Hospital London, explains why pre-eclampsia is easily missed.

This week we concentrate on diabetes "The difference between insulin management in type 1 and type 2 diabetes is rather like the difference between driving a sports car and driving a lorry," says Edwin Gale, emeritus professor of diabetes at the University of Bristol. He tells us why this means the newer insulins that have benefits in the treatment of type 1 diabetes may not be as good for type 2. Sripal Bangalore, director of research at the New York University School of Medicine, discusses his research into the relative effectiveness of different types of stents in diabetes patients

Schemes which reduce emergency admissions sound like a good thing, but Martin Rowland, professor of health services research, Cambridge Centre for Health Services Research, University of Cambridge, explains how they can go off track. And Mabel Chew gets some advice on the prognosis of children with acute coughs from Matthew Thompson, a senior clinical scientist in the Department of Primary Care Health Sciences, Oxford University.

A head to head article this week asks: "Does celebrity involvement in public health campaigns deliver long term benefit?”. The British Heart Foundation’s Hands Only CPR campaign, featuring Hollywood actor Vinnie Jones, seems to be having positive effects. Maura Gillespie, head of policy and advocacy at the BHF, explains why. Also this week, care for the homeless is often fragmented and transient. A team at University College Hospital in London is trying to unite the disparate agencies involved to ensure long term medical and social care for these vulnerable people. They tell us how their pilot service has improved outcomes and reduced costs.

In the US, overly aggressive treatment is estimated to cause 30 000 deaths among Medicare recipients alone each year. Reporter Jeanne Lenzer has investigated the problem for the BMJ, and explains why she thinks profit driven healthcare is to blame. And, experience of treating rare conditions can take time to build. Rej Bhumbra, a surgical trainee in orthopaedic oncology, explains how his time in India fast tracked his learning.

Bariatric surgery is under scrutiny from NCEPOD, the National Confidential Enquiry into Patient Outcome and Death, Ian Martin, NCEPOD's clinical co-ordinator for surgery, takes us through the highlights of its latest report. Also this week, Julie Paik, instructor and physician at Harvard Medical School, tells us about a new risk factor for primary hyperparathyroidism. And finally, some neuromuscular agents may lead to respiratory complications after surgery. Matthias Eikermann, director of research in the surgical intensive care unit at Massachusetts General Hospital, explains how they investigated this vexed problem.

Deborah Cohen explains how a joint BMJ and Daily Telegraph investigation helped uncover problems with device regulation in Europe. Previous research has shown smoking reduces life expectancy by about a decade, but only by four years if you are Japanese. Sarah Darby, from the University of Oxford, explains why her new research shows they are actually just as unhealthy as their British counterparts.

Rajiv Chowdury, a research associate from the Department of Public Health and Primary Care at the University of Cambridge, explains why eating whole fish is better than fish oil - at least when it comes to cerebrovascular disease. Also this week Peter Doshi and Tom Jefferson from the Cochrane Collaboration talk about the BMJ's open data campaign, and how publishing correspondence with Roche, the WHO and Centers for Disease Control and Prevention might reveal the missing data on Tamiflu.

This week, Al Mulley, Dartmouth Center for Health Care Delivery Science, and Tessa Richards, BMJ associate editor, discuss the silent misdiagnosis: that of patient preferences. Removing pre-cancerous cells spotted through screening is the foremost defence against cervical cancer. However, a recent BMJ paper has shown that women who go through this have a fourfold risk of going on to develop cancer compared to women who’ve only ever had normal smears, even if they complete follow up and are given the all clear. Matejka Rebolj, postdoctoral researcher, Department of Public Health, University of Copenhagen, and Chris Meijer and Maaike Bleeker, pathologists in the Department of Pathology, VU Medical Centre, Amsterdam, discuss what could be done to mitigate the risk.

Last year 125 people died in Pakistan after taking contaminated cardiac medication. The disaster is one example of the dangers of counterfeit and substandard medicines, an issue the WHO is struggling to control. In this podcast we hear from Amir Attaran, Canada research chair in law, population health, and global development policy at the University of Ottawa, on the international wrangling he sees at the political level. And Sania Nishtar, president of Heartfile, an independent think tank based in India, discusses what went wrong in Pakistan, and how to prevent it happening again.

Lasse Krogsbøll, from the Nordic Cochrane Centre, explains research into whether general health checks improve mortality and morbidity in the population. Also, the European Medicines Agency (EMA) this week announced plans to make trial data used as the basis for its decisions publicly available. BMJ Deputy editor Trish Groves finds out more from some of the key players in the campaign for open data.

Helen Macdonald, assistant editor at the BMJ, talks to Neil Marlow, professor of neonatal medicine at University College London, about his update to the EPICure study looking at outcomes for extremely premature babies. Jane Feinmann talks to writer and surgeon Atul Gawande, about Lifebox – which has been chosen again as the BMJ’s Christmas appeal for 2012.

Is too much oxygen a good thing? Christine Roffe, consultant physician, Stoke Stroke Research Group, North Staffordshire Combined Healthcare NHS Trust, talks Mabel Chew, BMJ associate editor, through the evidence for routinely treating stroke patients with oxygen. And Russell Gruen, professor of surgery and public health, Alfred and Monash University, Melbourne, explains how and when tranexamic acid should be used after trauma.

Many patients are following a wheat free diet, which they believe helps with their gastrointestinal symptoms, yet they don't exhibit markers of coeliac disease. Mabel Chew finds out from David Sanders, a professor of gastroenterology at the Royal Hallamshire Hospital, about non-coeliac gluten sensitivity. Also, Fiona Godlee gives us an update on the open data campaign.

We know that speed bumps have an important public health role, but a Christmas BMJ paper shows they're also clinically useful, and can help diagnose appendicitis. Helen Ashdown, academic clinical fellow in general practice, University of Oxford, and Mike Puttick, consultant surgeon, Stoke Mandeville Hospital, explain. And want to know how many carrots you need to eat to balance out that festive champagne? David Spiegelhalter, Winton professor for the public understanding of risk, University of Cambridge, tells us how to work it out.

The final article in the analysis series examining prison health in England and Wales is published this week. To sum up, Francis Crook, Director of the Howard League for Penal Reform - the UK's oldest charity examining prison conditions - joins us to discuss prison reform. Also this week, Myasthenia gravis; Jennifer Spillane, clinical research associate at the Institute of Neurology in London, explains why it's easily missed.

You may well assume that a programme supported by organisations such as the World Bank and the World Health Organization does what it says on the tin. However, it turns out this is not the case with deworming initiatives in countries such as Africa and India. Paul Garner, co-author of the Cochrane review on the topic, explains what's going on. And Michael Wilson, instructor of medicine at the Mayo Clinic, gives us some advice on diagnosing Klinefelter's syndrome.

The authors of the recent meta-analysis on dietary sugar and body weight, Lisa Te Morenga, and Jim Mann, from the Departments of Human Nutrition and Medicine at the University of Otago, join us to discuss their findings. Also this week, the BMA wants doctors to be more involved in influencing policy on recreational drugs. Vivienne Nathanson, its director of professional activities, explains its new report, and how individual testimony can combine to convince governments to change policy.

An epidemiological investigation on bmj.com discusses the first probable case of human to human transmission of novel avian influenza A (H7N9). The author of the accompanying editorial, James Rudge, from the London School of Hygiene and Tropical Medicine, explains what this means for public health. Also this week, we know that standardised mortality rates are tricky and have to be interpreted carefully. David Spiegelhater, Winton Professor for the Public Understanding of Risk at the university of Cambridge, explains why a figure of 13 000 excess deaths in NHS hospitals is “number abuse”. Read the articles: http://www.bmj.com/content/347/bmj.f4730 http://www.bmj.com/content/347/bmj.f4893

US Health in International Perspective: Shorter Lives, Poorer Health produced by the National Research Council and Institute of Medicine of the National Academies, has found that on almost every comparative measure, Americans fare worse than their counterparts from other developed countries. Steve Woolf, from the Department of Family Medicine at Virginia Commonwealth University, who chaired the report, joins us to discuss its findings, and the implications.

In this practice special podcast, Timothy Wilt, professor of medicine at Minneapolis VA Center for Chronic Disease Outcomes Research, explains how to talk to patients about prostate cancer screening. Benjamin C Thomas, senior clinical fellow at Addenbrooks Hospital in Cambridge then talks us through androgen deprivation therapy.

How can you treat a young person who is exhibiting the first signs of psychosis? Mabel Chew talks to Professor Tim Kendall a consultant psychiatrist and director of the National Collaborating Centre for Mental Health at the Royal College of Psychiatrists. Professor Kendall is co-author of both a systematic review and meta-analysis into early treatments to prevent psychosis, and co-author of a new set of NICE guidelines into management of the condition.

The Francis report into care standards at Mid Staffordshire NHS Foundation Trust was published this week. Triggered by deaths at a hospital in England, Robert Francis QC was appointed by the government to look into why the quality of care in some wards was so low, and what can be done to make sure that this doesn’t happen in other hospitals. Also this week, research has unearthed data hidden for 40 years on magnetic tapes. It casts new light on the link between consumption of unsaturated fatty acids and secondary prevention of cardiovascular events. We hear from Christopher Ramsden, a clinical investigator at the US National Institutes of Health, who dug up the data.

The BMJ held a round table in January 2013 to discuss the future of primary care in England and Wales. The wide ranging topics included out of hours care, commissioning, education, time management, and integration. This is the full version, lasting one hour and 20 minutes. Edited highlights are available in this week's podcast. Chair: Domhnall MacAuley, primary care editor, BMJ. Participants: Helen Thomas, former GP partner, and current GP Strategic Health Authority lead for the south west of England Clare Gerada, chair of the Royal College of General Practitioners. Nav Chana, postgraduate dean of GP and community based education at the London Deanery. Judith Smith, director of policy at the policy think tank, the Nuffield Trust.

How involved are doctors in the non medical aspects of patient care? An analysis on bmj.com this week examines the problem of nutrition and fluid balance in hospitalised patients. Helen Macdonald, a junior doctor and editor at the BMJ, asks Richard Leach, clinical director of Guy's and St Thomas' NHS Foundation Trust, about how it should best be handled. Also this week, a summary of the BMJ round table on the future of primary care, which is available in full on the podcast page.

Of the myriad of clinical decision support tools, what features actually improve patient outcomes? Pavel Romanov, medical student at Western University in Canada, discusses his research. Also this week: Is it feasible to get governments to consider the public health impact of every policy decision they make? Politicians in Wales have drafted legislation to make the devolved nation the first in the world to implement this WHO recommendation. Adam Fletcher, senior lecturer in social science and health at Cardiff University, has written an editorial about the plan, and joins us to discuss the practicalities of enshrining public health in law.

In the wake of the Francis report, the BMJ gathered experts to discuss compassion in the health service. This is the discussion in full. Taking part are: Domhnall MacAuley, BMJ primary care editor Anthony Silverstone, consultant at UCH Peter Carter, chief executive for the Royal College of Nursing Jocelyn Cornwall, director, The Point of Care programme, The King's Fund Joanne Watson, consultant at Musgrove Park Hospital Sean O'Brien, head of the patient experience group at Musgrove Park Hospital

If patients living in one area have more diagnoses than those living in another, use more care, but have similar mortality rates, you would think they were simply sicker, but that the extra care they were receiving must be good and making them better. Not so, says new research published on bmj.com. John Wennberg, emeritus professor of community and family medicine at the Dartmouth Institute in the US, joins us to explains how this flawed logic is harmfully perpetuating overdiagnosis and variation in care. Also, post Mid Staffs, how do we put compassion back at the heart of care? A BMJ round table discusses this, and we have edited highlights. The full round table is also available on the podcast page.

Andrew Witty is the CEO of GlaxoSmithKline. He’s been credited with taking on a pharma company with a history of behaving badly in the past – as shown by a record $3bn fine levied by the US government last year. How much is he able or willing to change the culture of an industry, which is under pressure to alter its practices? Rebecca Coombes finds out. Also this week, Michael Dowling, president and CEO of the North Shore-LIJ Health System in New York, has built his organisation up from two hospitals undergoing a difficult merger into a giant integrated system. He explains his no-nonsense approach to making change work.

Recorded at the recent Nuffield health policy summit, this round table asks how to impliment the Francis reports recommendations. Taking part were: Robert Francis, chair of The Mid Staffordshire NHS Foundation Trust Public Enquiry Simon Stevens, president of global health at the UnitedHealth Group Sam Barrell, chief clinical officer of South Devon and Torbay CCG Niall Dickson, CEO of the General Medical Council Stephen Dorrell MP, chair of the HOC Health Select Committee Nigel Edwards, director of the Global Healthcare Group, KPMG Jan Filochowski, chief executive, Great Ormond Street Hospital for Children NHS Foundation Trust Julie Moore, chief executive of University Hospitals Birmingham Bruce Keogh, medical director of the NHS Alastair McLellan, Editor of Health Services Journal Jeremy Taylor, chief executive, National Voices Ruth Thorlby, senior fellow at the Nuffield Trust.

Are all calories equal? Thermodynamics would say that energy is energy, be it derived from carbohydrate, fat, or protein. But things get more complicated when appetite is taken into consideration , says Robert Lustig, professor of pediatric endocrinology at the University of California, San Francisco. Also this week, life expectancy in Europe is increasing, but at the same time health inequalities are widening. Claudia Stein, director of the Division of Information, Evidence, Research, and Innovation at the World Health Organization's regional office for Europe, talks about a new report that highlights both the good and the bad of Europe's health.

A clinical review this week looks at the diagnosis and treatment of carotid atherosclerosis, including when to screen and the threshold for intervention. Alun Davies, professor of vascular surgery at Imperial College London, also answers how useful or harmful screening offered commercially is. Also this week, the BMJ’s editorial board met to discuss how patient participation should be represented and encouraged by the journal. We captured some of their views.

The issues of hidden data are well known, and the BMJ’s open data campaign page documents some of the problems which have arisen as a result of clinical trial data remaining undisclosed. At Evidence Live 2013 in Oxford this week, Fiona Godlee, BMJ editor in chief, convened a group of those closely involved with the AllTrials campaign, to discuss where we are now and what still needs to be done

The World Health Organization has chosen hypertension as the public health threat it will focus on for the next year. The problem is particularly pressing in India, and Anita Jain, the BMJ's India editor, spoke to François Decaillet, Coordinator for Health Programs, WHO India, about what needs to be done to tackle hypertension in the country's population.

Delirium is often missed in primary and secondary care. Edison Vidal, assistant professor in internal medicine at the Universidade Estadual Paulista, Brazil, advises on diagnosing and managing the condition. Rheumatoid arthritis, non-biological drug treatments, or both, might suppress tumour surveillance and in theory increase the risk of melanoma. Pauline Raaschou, consultant in clinical pharmacology at the Karolinska Institutet, Sweden, explains what she found while investigating the association.

This week, we discuss how Australia’s national human papillomavirus (HPV) vaccination programme has caused a dramatic drop in genital warts. Does this foretell elimination of all disease caused by HPV in the country? And some advice on how to diagnose and manage pulmonary hypertension.

Patients are increasingly going online to find and discuss information about their condition. What are they getting on the web that they’re not getting from clinicians, and how is this changing healthcare? Also, how to care for a dying patient in hospital.

Mabel Chew, practice editor at the BMJ, talks to Tushar Kotecha, a cardiology specialist registrar at Charing Cross Hospital in London, about when to suspect heart failure, and how to diagnose the condition.