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William Cayley: Resilience, obstreperousness, and grit

1 Aug, 14 | by BMJ

bill_cayley_2Some people keep going, and going, and going . . . and some don’t. What makes the difference? I’m not sure we know, but I think it has something to do with resilience, obstreperousness, and grit.

This week there has been a bit of a debate going on in our department over appropriate blood pressure targets for the elderly. This debate started in light of the eighth Joint National Committee (JNC 8) guidelines, and has revolved mainly around balancing outcomes with adverse effects, NNTs, and patient engagement in medical decisions. As I’ve observed (and participated just a bit in) this debate, in the back of my mind I keep thinking of my patients who do not fit the expectations of JNC 8—or any other guidelines for that matter. more…

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…

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…

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…

Tracey Koehlmoos: Regenerative medicine—where miracles and science overlap

17 Jul, 14 | by BMJ

traceykoehlmoosRegenerative medicine. I did not know it existed until I began working with the Marine Corps. Even writing “regenerative medicine” reminds me that I am not in Bangladesh anymore, trying to produce miracles by scaling up a 20 cent zinc intervention aimed at every child under the age of 5 with diarrhea, or figuring out the best way to get the simplest forms of primary care to the urban homeless, or strengthening access to vaccines. For a health systems scientist, it is a bit of a leap of faith to go into a laboratory that works on the discovery end of the research continuum. more…

The BMJ Today: Monday’s reflections on alcohol

14 Jul, 14 | by BMJ

wim_weberNothing seems more appropriate on a Monday than to think about the after effects of alcohol. We know that drinking too much is bad for health, but many have always taken comfort in the “fact” that moderate daily intake is associated with a lower cardiovascular risk. The question remains whether light to moderate drinking will actually reduce this risk. Observational studies cannot help us here, but a recent Mendelian randomisation study sheds new light on this controversy. more…

William Cayley: Awkward is when they need us

8 Jul, 14 | by BMJ

bill_cayley_2“I just hate this sort of thing.” When I overheard that at a recent funeral, as we waited in line to greet the bereaved family, I thought to myself, “How sad . . . and how true.” Sad, because times of grief are when others need us most, but also true, because most of us find talking with the grieving awkward, and we don’t like it.

Before entering medicine, I trained as a hospital chaplain. One of my wise teachers impressed on me the principle that—when talking with patients—if something difficult, challenging, or awkward about the situation crosses your mind then the patient is probably already aware of it. For example, if you think a patient may be concerned about cancer, they probably already are, and broaching the topic may actually be more of a source of comfort that someone is actually listening, rather than a distressing introduction of a new worry. Listening to our own inner sense of discomfort can be a decent indicator as to when a patient is in particular need of comfort, support, or companionship. 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…

Leigh Daynes: Healthcare access in the West—fact, not fiction

3 Jul, 14 | by BMJ

leigh_daynesWhat do America, France, the UK, and most of the richest countries in the world all have that they should not have? The answer I’m looking for is not nuclear weapons, national debts, or billionaire bankers. It’s a large (and growing) number of people who are unable to access essential healthcare—many of them extremely vulnerable.

At the Royal Society of Medicine tonight I’m discussing the film Remote Area Medical, which is about the eponymous charity set up by Stan Brock to provide healthcare to some of the most in need countries in the world—such as America.

“We cut back on places like Guatemala, Honduras, Dominican Republic, Africa, simply because we’re overwhelmed with the need here,” says Stan. “Welcome to America.” more…

David Kerr: Silicon is the new black

1 Jul, 14 | by BMJ

david_kerrRecently the big four titans of technology (Apple, Microsoft, Samsung, and Google) have, almost simultaneously, thrown their hats into the wearable sensor ring. Apparently, consumers now want to wear devices to record personal physiological data, which can then be synchronized with their smartphones. Through cloud computing, this can then be shared with their doctors and nurses as well. The early adopters of wearable technology are, unsurprisingly, young, wealthy, and tech savvy—while also fashion conscious enough to want the technology to resemble jewelry. more…

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