Medicine and Science from The BMJ

Talk Evidence - Radiation, fertility, and pneumonia

Helen Macdonald and Carl Heneghan are back again talking about what's happened in the world of evidence this month.
They start by talking about how difficult a task it is to find evidence that's definitely practice changing, what GPs can learn from Malawian children with nonsevere fast-breathing pneumonia, how radiation dosage varies substantially - and consultant radiologist Amy Davies what that means for patients.
They also rail against add-on tests for fertility, and the lack of evidence underpinning their use - will the traffic light system suggested help patients make treatment choices.
Carl's rant this week is based on a new study by Steve Woloshin and Lisa Schwartz which documented 20 years of medical marketing in the USA.
Reading list:
Pneumonia in Malawi - https://www.ncbi.nlm.nih.gov/pubmed/30419120
Variation in radiation dose - https://www.bmj.com/content/364/bmj.k4931
Traffic light fertility tests - https://www.bmj.com/content/364/bmj.l226
Medical marketing - https://jamanetwork.com/journals/jama/fullarticle/2720029

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Safeguarding LGBT+ young people

Recent years have seen political and social progress for people who identify as LGBT+ (lesbian, gay, bisexual, and transgender; the “+” indicating inclusion of other minority sexual and gender identities).
Yet international evidence shows ongoing health and social inequalities in this group, many of which emerge during adolescence and represent unique safeguarding risks.
In this podcast, Kate Addlington, psychiatry trainee and associate editor at The BMJ is joined by Ginger Drage, expert patient educator at University College London, Jessica Salkind, academic clinical fellow in paediatrics & teaching lead for LGBT+, at Imperial College London and Rosanna Bevan, psychiatry trainee from East London Foundation Trust
They discuss the the risks faced by LGBT+ young people, which include increased rates of self harm, suicide, and family rejection or abuse, and what steps clinicians can take to support and intervene if necessary.
Read the full practice article:
https://www.bmj.com/content/364/bmj.l245

Should we be screening for AF?

Current evidence is sufficient to justify a national screening programme, argues Mark Lown clinical lecturer at the University of Southampton, but Patrick Moran, senior research fellow in health economics at Trinity College Dublin, thinks there are too many unanswered questions and evidence from randomised trials is needed to avoid overdiagnosis
Read the full debate:
https://www.bmj.com/content/364/bmj.l43

Chronic Rhinosinusitis

Patients who experience chronic rhinosinusitis may way for a considerable period of time before presenting, because they believe the condition to be trivial.
In this podcast, Alam Hannan, ENT Consultant at the Royal Throat Nose and Ear Hospital in London, explains why that belief is not founded, and describes which treatments can be effective at providing relief.

Assisted dying: should doctors help patients to die?

The Royal College of Physicians will survey all its members in February on this most controversial question. It says that it will move from opposition to neutrality on assisted dying unless 60% vote otherwise.
The BMJ explores several conflicting views. From Canada, palliative care doctor Sandy Buchman explains why he sees medical aid in dying as a compassionate treatment that fully respects patient autonomy. The Canadian Medical Association is neutral on the issue, and Jeff Blackmer, its vice president for international health, shares how that stance enabled it to represent all its members, including doctors with conscientious objections.
But many are unconvinced to say the least. Rob George, a UK palliative care doctor and professor at King's College London, says assisted suicide has no place in medicine. Tony Baldwinson, from the UK campaign group Not Dead Yet, worries for disabled people were society to endorse doctors actively ending lives. And Zoe Fritz, a consultant physician in acute medicine at Addenbrooke’s Hospital, Cambridge, has a proposal that she says would protect the doctor-patient relationship.
Read all our content at https://www.bmj.com/assisted-dying
"Why I decided to provide assisted dying: it is truly patient centred care" by Sandy Buchman https://www.bmj.com/content/364/bmj.l412
"How the Canadian Medical Association found a third way to support all its members on assisted dying" by Jeff Blackmer https://www.bmj.com/content/364/bmj.l415
"Religious and non-religious people share objections to assisted suicide" by Mark Pickering https://blogs.bmj.com/bmj/2019/01/30/religious-and-non-religious-people-share-objections-to-assisted-suicide/
"The courts should judge applications for assisted suicide, sparing the doctor-patient relationship" by Zoe Fritz https://blogs.bmj.com/bmj/2019/01/30/the-courts-should-judge-applications-for-assisted-suicide-sparing-the-doctor-patient-relationship/

Goran Henriks - How an 80 year old woman called Esther shaped Swedish Healthcare

Jönköping has been at the centre of the healthcare quality improvement movement for years - but how did a forested region of Sweden, situated between it's main cities, come to embrace the philosophy of improvement so fervently? Goran Henriks, chief executive of learning and innovation at Qulturum in Jönköping joins us to explain. He also tells us about Esther, and why she figures so centrally in their planning.

Talk evidence - TIAs, aging in Japan and women in medicine

In this EBM round-up, Carl Heneghan, Helen Macdonald and Duncan Jarvies are back to give you an update
Dual vs single therapy for prevention of TIA or minor stroke - how does the advice that dual work better translate in the UK?
Carl explains why Japan can teach us to get active and, how GPs can use that information to "drop a decade" in aging.
Finally, Helen took some time to relax over Christmas - until she read a story in the Christmas edition about gender discrimination in medicine, and it reminded her of her time on the ward.
Reading list:
The BMJ Practice: Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke
https://www.bmj.com/content/363/bmj.k4169
Delaying and reversing frailty: a systematic review of primary care interventions
https://bjgp.org/content/early/2018/11/30/bjgp18X700241

HIV - everything you wanted to know about PeP and PreP

We have had two articles published recently on bmj.com, looking at drug prevention of HIV; PeP - Post-exposure Prophylaxis and PreP - Pre-exposure Prophylaxis, neither prevent the virus from entering the body, but they do prevent the infection from taking hold.
There are lots of questions that doctors have about these - what are the risk profiles of patients who should be offered the treatments? How can they be prescribed? What are the side effects? And if you're in England, where PreP is not yet available on the NHS, can doctors advise their patients to buy it online?
Michael Brady, Sexual health and HIV consultant at Kings College Hospital and Medical Director of the Terrence Higgins Trust, joins us to help answer those questions.
Further reading
BMJ article on PeP https://www.bmj.com/content/363/bmj.k4928
BMJ article on PreP
BASHH guidelines on PreP - https://www.bashhguidelines.org/media/1189/prep-2018.pdf
https://iwantprepnow.co.uk
http://www.aidsmap.com/

HbA1c - when it might not be accurately measuring glycemic control

HbA1c concentration is used as the biomarker for long term glycaemic control, however if the lifespan of red blood cells is altered, that may lead to an over, or under estimation of that control.
In this podcast Ravinder Sodi, consultant clinical biochemist at University Hospitals of Morecambe Bay NHS Foundation Trust, explains when to suspect HbA1c is not an accurate measure of glycemic control, and what alternative tests are available.
Read the full article:
https://www.bmj.com/content/363/bmj.k4723