Medicine and Science from The BMJ

Testing times with James McCormack and Jess Watson

For GPs, testing patients is their “bread and butter”. This week, we discuss the “better safe than sorry” attitude towards testing, which is so common among doctors – are we guilty of over-testing purely out of force of habit, or are we worried about missing something vital, and therefore find reassurance in doing them? How should we interpret test results, and how do these results affect the way we manage our patients? And, with the huge focus on COVID-19 testing in the media, how do we communicate the current risks and uncertainties surrounding it to our patients?
Our guests:
James McCormack is a professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia, and the co-host of a popular weekly podcast called Best Science (BS) Medicine podcast. His work focuses on helping healthcare professionals to understand medical data, by taking the best available evidence and making it as simple and practical as possible.
Jess Watson is a GP, working in Bristol, and an expert on medical testing. She is a researcher with an interest in the use of diagnostic tests in primary care, specifically inflammatory marker blood tests.
Reading list:
James's BS Medicine Podcast
https://therapeuticseducation.org/
Jess's Practice Pointer - Interpreting a covid-19 test result
https://www.bmj.com/content/369/bmj.m1808

Talk evidence covid-19 update - remdesivir redux, the overwhelming volume of research

That remdesivir study has finally been published - what does it say and is it as independant as claimed. Also, as the world's focus turned to covid, so have researchers - and they've produced over 15000 papers. How can we sift through the flood of research and know what's any good?
(2.30) Helen Macdonald talks to Elizabeth Loder about the volume of research we're seeing, and why journals and peer reviewers are struggling to check it all.
(8.15) The study on remdesivir has been published - the trial was stopped early, and the primary outcome switched - we talk about how that increases uncertainty over the results, and could actually delay the treatment.
(26.50) We hear from a couple fo readers who wanted to correct us about averages, means, medians.
Reading list:
The US NIH AID study on remdesivir, published 22nd May in the New England Journal of Medicine
Research - preliminary report https://www.nejm.org/doi/full/10.1056/NEJMoa2007764
NEJM - looking at the dose duration https://www.nejm.org/doi/full/10.1056/NEJMoa2015301
Editorial - an important first step https://www.nejm.org/doi/full/10.1056/NEJMe2018715

Ray Moynihan - Declarations of interest in healthcare leaders

*Non covid content alert*
While the last couple of months have been covid-19 focused, the work of the beforetimes carries on - including a topic the BMJ is perennially interested in, industry funding of medics.
Ray Moynihan, researcher at Bond University, has been looking at financial ties between some healthcare association leaders, and industry, in the US, and reports that in new research published this week in The BMJ.
Read the full open access research;
Financial ties between leaders of influential US professional medical associations and industry: cross sectional study - https://www.bmj.com/content/369/bmj.m1505

Wellbeing – how to write a wellbeing prescription

How might stress affect your performance as a healthcare worker?
That’s the question that Mark Stacey, a consultant obstetric anaesthetist in Cardiff, has been interested in for the past 10 years. He saw similarities in the aviation industry, which uses a theory of human factors to explain why things go wrong when humans interact with complex systems.
Stress was a major culprit, in both aerospace and medicine, so he began to explore wellbeing as a way to reduce stress and, in turn, reduce adverse events. He has developed the idea of writing yourself a wellbeing prescription, which includes practical techniques such as the Baker’s Dozen and a gratitude diary.
Useful tools
Bakers Dozen https://www.cardiff.ac.uk/__data/assets/pdf_file/0003/808950/Bakers-Dozen-Toolkit.pdf
A 30 day plan that Mark has put together http://www.cardiffandvaleuhb.wales.nhs.uk/improving-resilience-in-anaesthesia

Public health response to covid-19 - data integrity and the importance of international comparison

This last week has seen questions raised about the integrity of some of the epidemiological data being produced by US states, and as rates continue to grow in some countries international comparisons are being questioned.
To discuss the implication of that are;
Sridhar Venkatapuram
associate professor global health & philosophy at King's College London
Kathleen Bachynski
Assistant professor of public health at Muhlenberg College
Martin Mckee
Professor of European health at the London School of Hygiene and Tropical Medicine

Talk Evidence covid-19 update - strategies to end lockdown, more testing

This week we're focussing on what kind of information we need to be able to collect and use as the country transitions out of lockdown - and why local lockdowns may be here for some time.
We also hear about the new antibody tests which are available in the UK - are they actually a game changer?
(2.00) Helen explains what some new evidence says about hydroxychloroquine (spoiler; don’t take it for covid-19)
(6.40) *Non covid alert* - Carl tells us about new research on compressions stockings for thromboprophylaxis, and the importance of doing research on non-pharmacological interventions
(10.30) David Nabarro, Special Envoy of WHO Director-General on COVID19,
(28.00) Helen goes back to Jon Deeks, professor of biostatistics at Birmingham, to find out more about these “accurate” tests for covid, endorsed by the government this week.
Reading list:
Clinical efficacy of hydroxychloroquine in patients with covid-19
https://www.bmj.com/content/369/bmj.m1844
Hydroxychloroquine in patients with mainly mild to moderate covid-19
https://www.bmj.com/content/369/bmj.m1849
David Nabarro’s website, with daily briefings
https://www.4sd.info/
News Covid-19: Two antibody tests are “highly specific” but vary in sensitivity, evaluations find
https://www.bmj.com/content/369/bmj.m2066

Talking about dying from covid with Scott Murray and Katherine Shear

With COVID-19 still ongoing, and at the forefront of the minds of doctors, patients and members of the public alike, difficult conversations are taking place - GPs are encouraged to talk about death with those who might not be ready to discuss it, and families are losing loved ones without being able to say goodbye. In this episode, we also look at survivor guilt, the range of emotions that grieving encompasses, and how to address the potentially thorny subject of advance care planning with COVID-19 patients.
Our guests:
Katherine Shear, internist and psychiatrist, is Director of The Center for Complicated Grief at Columbia University’s School of Social Work. She has been involved in research into treatments for grief for over 20 years.
Scott Murray, a recently retired GP, has key interests in disease trajectory and advance care planning. He led the first Primary Palliative Care Research Group and he chairs the International Primary Palliative Care Network. He advocates high-quality palliative care for everyone.
This week's deep breath out is the Viral Counterpoint of the Coronavirus Spike Protein (2019-nCoV) - https://soundcloud.com/user-275864738/viral-counterpoint-of-the-coronavirus-spike-protein-2019-ncov

Pandemics from history - how they inform our response now

Does history count as a non-pharmaceutical intervention? Much of our view on what to do in this pandemic has been influenced by the 1917 Spanish 'flu outbreak - even though covid-19 seems to be acting differently.
In this podcast, we talk to Howard Markel, a professor of pediatrics at Michigan, as well as professor in the history of medicine. He's written books on quarantines and epidemics, and was part of a team that did the medical and historical work that first showed the value of flattening the curve.
This is the first of 4 podcasts from our US colleagues, looking at the disease in that country, which will be published over the next 2 months.
For more on covid-19
www.bmj.com/coronavirus

Adam Kucharski, using viral epidemiology to combat fake news

Hydroxychloroquine is in the news again - as Trump and some news organisations are pushing it as a treatment, despite evidence (published in The BMJ) showing it lacks efficacy, and has a load of potential negative effects - including arrhythmias.
We know that kind of information spreads online - particularly through social media, but how does it do that?
In this podcast we talk to Adam Kucharski, and epidemiologist from the London School of Hygiene and Tropical Medicine, who has used disease modelling tools to look at fake news spread, and has some ideas about creating an online social distance.
For more covid coverage www.bmj.com/coronavirus

Talk evidence covid-19 update - answering questions with big data

Big data is being crunched to help us tackle some of the enormous amount of uncertainty about covid-19, what the symptoms are, fatality rate, treatment options, things we shouldn't be doing.
In these podcasts, we're going to try to get away from the headlines and talk about what we need to know - to hopefully give you some insight into these issues.
This week.
(3.10) Calum Semple, professor of outbreak medicine at the University of Liverpool talks about the ISARIC project - predesigned research brought off the shelf and deployed during a pandemic.
(14.20) Ben Goldacre, doctor, researcher and director of the EBM datalab at the University of Oxford, joins us to talk about how his team have managed to pull together records from 40% of NHS patients to look for patterns in covid-19 morbidity and mortality.
Reading list
OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients.
https://www.medrxiv.org/content/10.1101/2020.05.06.20092999v1
Features of 16,749 hospitalised UK patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol
https://www.medrxiv.org/content/10.1101/2020.04.23.20076042v1