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Saurabh Jha: How a fine-tooth comb is entangling Obamacare

30 Jul, 14 | by BMJ

Saurabh_JhaThe Affordable Care Act (ACA), which recently survived a major scare in the Supreme Court over the constitutionality of the individual mandate, has just met another potential nemesis. Halbig vs. Burwell is the latest lawsuit afflicting the ACA.

The suit has been filed by Jacqueline Halbig, former health policy advisor to the Department of Health and Human Services (HHS) under George Bush, and a group of private citizens and small businesses, against Sylvia Burwell, the secretary of HHS. The plaintiffs assert that insurance subsidies only apply when that insurance has been purchased in exchanges established by the states, not in exchanges established by the federal government (of which there are 36). more…

Mary Rance: Loneliness—it’s time to stop talking and start doing

30 Jul, 14 | by BMJ

Mary RanceExtreme loneliness in older people in the UK is a topic that always ignites debate. Partly because the problem is only getting worse as the population ages and, I suspect, partly because for many of us it resonates deeply as a fear we hold about the process of getting older.

The impact of chronic loneliness on health is well documented, with research suggesting that isolation is worse for an older person than obesity or smoking 15 cigarettes a day. Loneliness also means that our older people are less likely to recover successfully from an illness, increasing the chance of an earlier death. The knock on effect of this is, of course, greater demand on our health service. more…

The BMJ Today: Improving vaccination rates

30 Jul, 14 | by BMJ

peter_doshiIn the United States, the Centers for Disease Control and Prevention (CDC) held a press conference to discuss a recent survey, which found that rates of HPV vaccine coverage did not reach the 80% target. This in itself is not a surprise given the vaccination levels of previous years.

But at the press conference, The BMJ reports, officials delivered a message for doctors: forego a conversation with parents about whether or not to get the HPV vaccine, and instead just recommend it outright. US assistant surgeon general Anne Schuchat said “she thought that doctors were recommending the vaccine, just not forcefully enough.” more…

David Zigmond: Depression needs more than formulaic treatment

29 Jul, 14 | by BMJ

david_zigmond2An eminent academic psychologist, Professor David Clark, recently broadcast on the BBC’s Today programme (1 July) authoritative hope to the many sufferers of depression. He informed us how current scientifically formulated, measured, and monitored cognitive behaviour therapy (CBT) is positively transforming the efficiency and economy of care.

To me, this picture is a misleading exaggeration. I know this from several decades of working in the NHS with the mentally anguished. Yes, CBT certainly has much to offer in terms of apparent clarity, comprehensibility, reproducibility, and thus mass production—little wonder then, that it has ready allure for service designers, economists, and politicians. more…

Karen Sumpter: Can MRI help make inaccurate prostate cancer diagnosis a thing of the past?

29 Jul, 14 | by BMJ

Karen SumpterProstate cancer is the most common cancer in men; in the UK, it kills over 10 000 men every year, and currently there are over a quarter of a million men living with—and after—the disease.  If diagnosed early enough, prostate cancer can often be successfully treated. However, the diagnostic process is far from perfect, and it is arguably one of the most widely debated topics surrounding the disease today.

Firstly, the PSA test, which measures the total amount of prostate specific antigen in a man’s blood, can be inaccurate at detecting prostate cancer. A raised PSA level may indicate a problem with a man’s prostate, however, a high PSA level does not always mean the man has prostate cancer, and some men with prostate cancer may not have a raised PSA level at all. more…

The BMJ Today: Bleeding anticoagulants and guerrilla warfare

29 Jul, 14 | by BMJ

rich_hurleyCan we better quantify the risk of upper gastrointestinal and intracranial bleeding among patients who are taking long term oral anticoagulants for venous thromboembolism, systemic embolism, or stroke prevention? This information would help inform treatment, further investigation, or monitoring.

A research paper published yesterday on thebmj.com describes the newly devised “QBleed algorithms.” The researchers, from the University of Nottingham, found that these calculations “provided valid measures of absolute risk . . . in patients with and without anticoagulation.” more…

Neal Maskrey: Feeling the force of the QOF

28 Jul, 14 | by BMJ

neal_maskreyIt’s the season for graduation ceremonies. Proud parents and partners, relieved graduates, and a lump in everyone’s throat as that enormous rite of passage is eased by impressive ceremony, thoughtful words, cheap university wine in plastic glasses, and finally by long, late, cheerful family lunches.

My generation began their medical careers in a different world, where competence was implicit. After several decades of serial NHS disappointments, disasters, and scandals, new doctors—fresh and eager, but apprehensive—enter a brave new world. more…

Richard Lehman’s journal review—28 July 2014

28 Jul, 14 | by BMJ

richard_lehmanNEJM 24 July 2014 Vol 371
371  Long ago I had a patient who kept having odd things happen to her. She infarcted part of her cerebellum, and then did the same to two fingers on her right hand. She was full of pains, her kidneys were failing, and her erythrocyte sedimentation rate (ESR) stayed high. When CRP became available in our little hospital, that stayed high too. Then, finally, somebody ran a brand new test on her—anticardiolipin antibodies. At last we had a diagnosis—antiphospholipid syndrome! Getting this label made absolutely no difference to her since she had already been given all the usual “empirical” treatments, like aspirin which made her bleed, and steroids which made her even huger and more diabetic. She died long ago, but for the last 25 years, I have been reading pieces about antiphospholipid syndrome in the hope of discovering (a) that somebody understands it and (b) that there is an effective treatment. Now a little bit of my hope has been fulfilled. Twelve years ago, some patients whose kidneys had been destroyed by this syndrome received renal transplants and were given sirolimus as an anti-rejection drug. Now 70% of them have functioning allografts, whereas for those who did not get sirolimus the percentage is 11. So sirolimus urgently needs investigating as a treatment for the more severe forms of the syndrome. And from biopsy and autopsy samples, it seems that the destructive process is driven by mTORC through the phosphatidylinositol 3-kinase (PI3K)–AKT pathway, which sirolimus suppresses. Serves me right for wanting to know. more…

The BMJ Today: Dabigatran—the impact of The BMJ’s investigation

28 Jul, 14 | by BMJ

TJackson_09“The results of this investigation are somewhat shocking to me, but, reviewing the information, not entirely surprising.” That was the verdict of David Haines, section head of the Heart Rhythm Center at Beaumont Health System in the United States, on The BMJ’s investigation into dabigatran, the first of the new oral anticoagulants licensed to prevent stroke in patients with non-valvular atrial fibrillation. One of the main findings of The BMJ’s investigation—by investigations editor Deborah Cohen—was that Boehringer Ingelheim, the manufacturer of dabigatran, withheld important analyses from the regulators, which showed that monitoring blood levels and dose adjustment could improve the drug’s safety. more…

Mayank Singh: The euthanasia debate in India

28 Jul, 14 | by BMJ

Mayank_singhThe case of Aruna Ramachandra Shanbaug was a landmark moment for the euthanasia debate in India. Aruna was a nurse working in the King Edward Memorial Hospital (KEM) in Mumbai. On the evening of 27 November 1973, Aruna was brutally raped. She survived, but asphyxiation had cut the blood and oxygen supply to parts of her brain, which resulted in her being in a permanent vegetative state (PVS) ever since. She cannot walk, eat, or even move, and relies on the services of the staff nurses of KEM who have, for more than 40 years, cared for and looked after Aruna. more…

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