Medicine and Science from The BMJ

Talk evidence - Vitamin D, Oxygen and ethics

Welcome to this, trial run, of a new kind of BMJ podcast - here we’re going to be focusing on all things EBM.
Duncan Jarvies, Helen Macdonald and Carl Heneghan - and occasional guests- will be back every month to discuss what's been happening in the world of evidence.
We'll bring you our Verdict on what you should start or stop doing, geek out about stats, and rant about the unevidence based world in which we live.
This week we talk about:
Vitamin D
https://www.thelancet.com/journals/landia/article/PIIS2213-8587(18)30265-1/fulltext
Oxygen
https://www.bmj.com/content/363/bmj.k4169
The UK parliament's report on clinical trial transparency
https://publications.parliament.uk/pa/cm201719/cmselect/cmsctech/1480/1480.pdf

Adverse drug reactions

Clinical trials for regulatory approval are designed to test efficacy, but new drugs might have adverse reactions - reactions those trials aren’t designed to spot.
To talk about those adverse reactions - how to spot them, how to report them and what to do about them, we're joined by Robin Ferner, from the West Midlands Centre for Adverse Drug Reactions.
Read the full practice article:
https://www.bmj.com/content/363/bmj.k4051

HAL will see you now

Machines that can learn and correct themselves already perform better than doctors at some tasks, but not all medicine is task based - but will AI doctors ever be able to have a therapeutic relationship with their patients?
In this debate, Jörg Goldhahn, deputy head of the Institute for Translational Medicine at ETH Zurich thinks that the future belongs to robot doctors - but Vanessa Rampton, Branco Weiss fellow at McGill Institute for Health and Social Policy, says they'll never be able to emulate the empathy required.
We're also joined by Michael Mittelman, executive director of the American Living Organ Donor Fund, who has had complex healthcare needs for his whole life - to explain what he feels about the prospect of his care delivered by machine.
Read the full debate:
https://www.bmj.com/content/363/bmj.k4669

How much oxygen is too much oxygen?

As the accompanying editorial to this article says, "oxygen has long been a friend of the medical profession Even old friendships require reappraisal in the light of new information."
And that’s what a new rapid reccomendation - Oxygen therapy for acutely ill medical patients - does.
To discuss we're joined by two of the authors, Reed Simieniuk, general internist at McMaster University and Gordon Guyatt, distinguished professor at McMaster University.
Read the full recommendation:
https://www.bmj.com/content/363/bmj.k4169

How does lifestyle affect genetic risk of stroke?

Cardiovascular factors are associated with risk of stroke - and those factors can be mediated by lifestyle and by genetic make up.
New research published by The BMJ sets out to explore how these risks combine, and we're joined on the podcast by two of the authors - Loes Rutten-Jacobs, senior postdoctoral researcher at the German Center for Neurodegenerative diseases, and Susanna Larsson, associate professor at the Karolinska Institutet.
Read the full open access research:
https://www.bmj.com/content/363/bmj.k4168

Talking honestly about intensive care

On the podcast, we’ve talked a lot about the limits of medicine - where treatment doesn’t work, or potentially harms. But in that conversation, we’ve mainly focused on specific treatments.
Now a new analysis, broadens that to talk about patients being admitted to a whole ward - intensive care. The authors of that article contend that, often, patients or their families don’t fully understand the implication of that admission.
To discuss, we're joined by Jamie Gross, consultant in intensive care medicine at London North West University Healthcare NHS Trust, and by Barry Williams, patient representative at the Intensive Care Society.
Read the full analysis:
https://www.bmj.com/content/363/bmj.k4135

Nasal symptoms of the common cold

The common cold is usually mild and self limiting - but they’re very annoying, especially the runny nose and bunged up feeling that form the nasal symptoms.
A new practice article, published on BMJ.com looks at the available evidence for treatment of those nasal symptoms - both pharmacological and alternative.
In this podcast we're joined by Mieke van Driel - GP in Australia and a professor of primary care at The University of Queensland, and An De Sutter - GP in Belgium and professor of family medicine at Ghent University.
Read the full article, and play with the interactive infographic:
https://www.bmj.com/content/363/bmj.k3786

What’s it like to live with a vaginal mesh?

What can we learn from the shameful story of vaginal mesh? That thousands of women have been irreversibly harmed; that implants were approved on the flimsiest of evidence; that surgeons weren’t adequately trained and patients weren’t properly informed; that the dash for mesh, fuelled by its manufacturers, stopped the development of alternatives; that surgeons failed to set up mesh registries that would have identified complications sooner; and that the National Institute for Health and Clinical Excellence and the UK regulators let them off the hook.
The BMJ has a published an investigation into vaginal mesh, which charts some of the issues above.
In this podcast The BMJ talked to three women who have had a vaginal mesh implanted, and all suffered the negative consequences that have prompted these investigations.
We bring you these stories to underline how life altering the situation has been for these woman, and to highlight the need for fully informed consent before anyone else has a mesh implanted.
What we must learn from mesh:
https://www.bmj.com/content/363/bmj.k4254

How to taper opioids

There is very little guidance on withdrawing or tapering opioids in chronic pain (not caused by cancer). People can fear pain, withdrawal symptoms, a lack of social and healthcare support, and they may also distrust non-opioid methods of pain management.
This can mean that patients receive repeat opioid prescriptions for extended periods of time.
In this podcast, Harbinder Sandhu, health psychologist in pain management at Warwick Medical School, Andrea Furlan, associate professor of medicine at University of Toronto, and Sam Eldabe, consultant in pain medicine at The James Cook University Hospital join us to set out the evidence on tapering opioids - and give practical advice on how to support patients. We're also joined by Colin, who was prescribed opioids for a decade, before he decided to reduce his usage.
What you need to know:
For people with chronic pain and who do not have cancer, the benefits of long term opioids are outweighed by the issues of tolerance, dependence, and the requirement for higher doses
Tapering is the gradual reduction of opioids with the aim of limiting withdrawal symptoms; it may target complete discontinuation of the opioid, or on occasion a reduction of the dose
It is not clear how best to support people to taper their opioids; whether it is best done by interdisciplinary pain management programmes, buprenorphine substitution, or behavioural interventions
Read the full uncertainties paper:
https://www.bmj.com/content/362/bmj.k2990

The counter intuitive effect of open label placebo

Ted Kaptchuk, professor of medicine at Harvard Medical school - and leading placebo researcher, has just published an analysis on bmj.com describing the effect of open label placebo - placebos that patient's know are placebos, but still seem to have some clinical effect.
Ted joins us to speculate about what's going on in the body, what this means for designing a more effective placebo, and asking whether it's time to start honestly prescribing placebos in the clinic.
Read his full analysis:
https://www.bmj.com/content/363/bmj.k3889