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The BMJ Today: More on transparency

24 Jul, 14 | by BMJ

BirteIn recent years, The BMJ has campaigned on transparency—the focus of our Open Data campaign, and an issue of vital importance if modern medicine is to retain the trust of doctors and the public, writes Trevor Jackson in this week’s Editor’s Choice.

Dabigatran was the first of the new oral anticoagulants licensed to prevent stroke in patients with non-valvular atrial fibrillation. It was approved by the US Food and Drug Administration in 2010 and by the European Medicines Agency for this use a year later. The drug’s unique selling point, said its manufacturer, Boehringer Ingelheim, was that it would need no monitoring, unlike warfarin. more…

The BMJ Today: Time to rethink your assumptions about sepsis, Minerva

23 Jul, 14 | by BMJ

When I first arrived at the University of Bath, to study history and philosophy of science, our first lecture was about Sulis-Minerva: the combination of Minerva, Roman goddess of wisdom, and Sulis, the Celtic goddess who lived in the hot springs that gave the city its name.Sulis_Minerva_head_Bath

Sulis-Minerva became the goddess of health in Roman Britain, so it it seemed appropriate when working at The BMJ to ritually read her summary of the big journals each week. The latest edition is called “The progression of rheumatoid arthritis and other stories . . . ” but it’s the note about Chickenpox that makes this worth a read. The virus used to kill 100 US residents of all ages every year, but that number’s dropped after concerted vaccination programmes. And, the fear that this may push the virus into older populations, where shingles is much more severe, hasn’t manifested. more…

Richard Lehman’s journal review—21 July 2014

21 Jul, 14 | by BMJ

richard_lehmanNEJM 17 July 2014 Vol 371
203  Niacin is an abundant natural B vitamin, which lowers bad cholesterol and raises good cholesterol. What’s not to like? Well, niacin, unfortunately. In doses that make any difference to lipid levels, it is very likely to make you feel sick, get flushes and/or rashes, and/or feel muscle pains. So Merck decided to market it in combination with laropripant, a prostaglandin antagonist that is meant to combat its unpleasant effects. Even so, a third of people who were recruited to the present trial could not continue past the run-in phase with the active combination. And now that the full results are out, we have confirmation that this dual agent definitely does not offer any cardioprotection despite its “favourable” effect on lipids. Worse still it causes bleeding, raises blood sugar, and shows a tendency to increase mortality in those who can tolerate taking it for three years. The Clinical Trials Support Unit (CTSU) at Oxford did a great job of running this trial with funding from Merck, following its usual rules of independence. In doing so, it provides a great illustration of the fact that lipid fractions are very unreliable surrogates for cardiovascular outcomes. But we knew that already, and it seems a great pity to me that many superb researchers were tied down for so long on a project that has made such a small contribution to clinical knowledge, whatever it may have contributed to the funds of CTSU. more…

The BMJ Today: Talking shit again

21 Jul, 14 | by BMJ Group

By the end of next month rural India could have an extra 5.2m toilets as part of a pre-election pledge by Narendra Modi, now prime minister, to build “toilets first and temples later.”

Readers of The BMJ will no doubt be heartened by the Indian government’s announcement, coming seven years after sanitation topped a reader poll as the greatest “medical milestone” in the past 166 years  more…

The BMJ Today: Laws on money and sex

16 Jul, 14 | by BMJ

kristina_fisterBeing a doctor can sometimes feel glamorous. Soon after graduating from medical school, I found myself on a high floor of a fancy hotel in downtown Chicago, waking up to the sun rising over Lake Michigan, a perfect view through a glass wall. Yes, not a window, a wall. Plush carpets, marble bathroom, you know—the works. It was beautiful, and someone else was paying for it.

It might have been at that editorial congress that I learned: disclosure is panacea. Get as many “free lunches” as you want, from whomever you want, but let people to whom it might matter know about it. more…

Shalini: India needs those vaccines

15 Jul, 14 | by BMJ

shaliniIndia has just introduced three new paediatric vaccines to its Universal Immunization Program (UIP), extending protection to its children against deadly and crippling diseases (rotavirus, rubella, and polio through an injectable polio vaccine). With an estimated 27 million children born in India each year, this is an unprecedented policy leap by the new government, which is flexing its muscles. Rotavirus diarrhoea alone costs the country 300 crore rupees (£29m; €37m; $50m) each year in terms of healthcare costs. It also causes 80 000 deaths, and up to a million hospitalizations, in children each year. One episode of rotavirus treatment costs 7-8% of annual income for low income Indian families. The situation couldn’t have been more urgent. more…

The BMJ Today: Explaining telomeres

15 Jul, 14 | by BMJ

georg_roegglaTelomeres are getting a lot of attention at the moment. At the 64th Nobel laureate meeting in Lindau two weeks ago, Elizabeth Blackburn (who won the 2009 Nobel prize in medicine) drew my attention to the role of telomeres in the cellular aging process. more…

Richard Lehman’s journal review—14 July 2014

14 Jul, 14 | by BMJ

richard_lehmanNEJM 10 July 2014 Vol 371
107  I was very confused by this paper. It describes two trials of three drugs for premenopausal breast cancer with various permutations, and the bottom line is that all the interventions give the same result. Or, if you are a sponsor of the trial, you can report: “In premenopausal women with hormone-receptor–positive early breast cancer, adjuvant treatment with exemestane plus ovarian suppression, as compared with tamoxifen plus ovarian suppression, significantly reduced recurrence.” That is just about true: 88.8% of the women in the tamoxifen group were recurrence-free at five years, compared with 92.8% in the exemestane group, but there was no difference in mortality. This figure was reached by pooling the two trials, though they were not identical. One of them used a variety of means for ovarian suppression and the other only triptorelin. OK, enough of this. If you are a woman with premenopausal breast cancer, demand an option grid to explain the possible adverse effect of these regimens, as well as their minutely different long term benefits. And if you are unhappy at the summary reporting, just think of the bad old days when that might have been framed as a “30.5% reduction in recurrence at five years.” more…

Lavanya Malhotra: Sex education in India

9 Jul, 14 | by BMJ

Lavanya MalhotraThe website of India’s health minister, Harsh Vardhan, currently states: “So called ‘sex education’ to be banned. Yoga to be made compulsory.” The media has not been impressed, and controversy rages as health professionals and educators debate the merits of age appropriate sex education in schools.

Vardhan has since retracted his original statement, saying: “Crudity and graphic representation of culturally objectionable symbols as manifested in the UPA’s [United Progressive Alliance, a coalition of political parties which governed India for the past 10 years] so called sex education programme cannot be called sex education. Every education system must strive to have an ideal curriculum, and to that extent my stand is valid. Sex education builds societies free of gender discrimination, teenage pregnancy, HIV-AIDS proliferation, pornography addiction.” more…

Richard Lehman’s journal review—7 July 2014

7 Jul, 14 | by BMJ

richard_lehmanNEJM 3 July 2014 Vol 371
11  I don’t envy anyone with central lumbar spinal stenosis. The odds of benefit from surgery are slight. The pain can be there all the time and always gets worse on walking, which can limit activity severely. No wonder epidural steroid injections have proved popular. In this study, they were carefully given with lidocaine using fluoroscopic guidance, and at six weeks they resulted in a small but useful reduction in a disability score and a leg pain score. The control group, who received epidural lidocaine alone, fared equally well. Moral: you don’t need the steroids. It may even be that you don’t need the lidocaine. Saline may be as good. In fact, gowning up and inserting the needle may be enough. In a way, I would rather not know, especially if I had spinal stenosis.

22, 32  My heart sank last week when two papers appeared on the NEJM website with the titles Loss-of-Function Mutations in APOC3, Triglycerides, and Coronary Disease, and Loss-of-Function Mutations in APOC3 and Risk of Ischemic Vascular Disease. I resolved to ignore them. However, Harlan Krumholz ‘s comments on them really have to be read: “This research”, he said, “has absolutely no implications for clinical practice. It might one day be seen as a pivotal study that led to the development of remarkable drugs, but that is far away. I hope people don’t read it and think that it has relevance to their current decisions about treatment.” more…

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