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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…

Richard Lehman’s journal review—30 June 2014

30 Jun, 14 | by BMJ

richard_lehmanNEJM 26 Jun 2014 Vol 370
2478  Cryptogenic is a good word. It’s up there with “idiopathic” and “pleiotropic” and “diathesis” for covering gross ignorance with a smattering of Greek. “Cryptogenic” sounds as if it was first used to describe the odd symptoms that Superman experienced when exposed to kryptonite. However, its first use was recorded 30 years before the caped crusader first appeared in the skies above Metropolis in 1938. “Cryptogenic stroke” is a fairly recent term, covering 20-40% of incident stroke, and it challenges researchers to hunt around the garden looking for kryptonite hidden under stones. A patent foramen ovale! Ah yes, but it may be an innocent bystander. Atrial fibrillation (AF) then! Possibly, according to the EMBRACE study, but still unlikely to account for most unexplained ischaemic strokes. The Canadian researchers monitored 572 patients who had had an unexplained ischaemic stroke or transient ischaemic attack, half of them using standard 24 hour ECG, and half with a 30 day event monitor. Their mean age was 72, and the detection rate for AF was 3.2% versus 16.1% in the two groups. more…

The BMJ Today: Troubling statistics—and calls for sweeping reforms

27 Jun, 14 | by BMJ

peter_doshiThe BMJ has published some recent statistics that are more than a bit disconcerting.

The first set regard corruption. Surely hard to measure, but “best estimates are that between 10% and 25% of global spend on public procurement of health is lost through corruption,” Anita Jain, Samiran Nundy, and Kamran Abbasi write in an Editorial. In the US, the figure is $82 billion to $272 billion. Even the low end of this estimate is an enormous sum.

It would be nice if a few bad apples were driving the bulk of this corruption, but Jain and colleagues suggest that the problem is at least partly structural. In India, for example, “the payment of bribes or use of influential connections . . . has become ingrained in people’s attitudes.” They call for an international fight against kickbacks. more…

The BMJ Today: Sugar the bogeyman and slim boy fat

26 Jun, 14 | by BMJ

TJackson_09I stopped adding sugar to my tea when I was a teenager. Up until then (which was sometime in the mid 1970s), I had been wont to fill the cup with several heaped spoonfuls. I regularly covered my morning Weetabix with a glacier of granulated. And I drank a can of Coca-Cola or Pepsi (not the diet version) every schoolday with my packed lunch (I was not the only boy to do so, and mine was a stuffy, pompous institution founded in 1553).

Most days I ate crisps, sweets, and cake plastered in icing sugar, and my detestation of any type of sport or exercise was almost pathological. When I started to think a bit more about health, and started drinking orange juice with my morning cereal, it came from a packet in powder form (Kellogg’s Rise & Shine) and had to be mixed with water. And yet I remained as skinny as a stick insect until my late 20s.

Perhaps I was an outlier, but I don’t think my sugar intake was particularly unusual in the 1970s, and obese children seemed a rarity. And the only warning that I can remember about sugar was that it could rot our teeth (and I have the fillings to show for it). Although John Yudkin’s book Pure, White and Deadly about the dangers of sugar had been published in 1972, it faced public rebuttal and instead the Ancel Keys’ low fat hypothesis held sway. Fat was fast becoming the enemy. more…

The BMJ Today: Whooping cough and getting vaccination right

25 Jun, 14 | by BMJ

California is in the grip of a whooping cough epidemic, with 800 cases reported in the first two weeks of June alone. Outbreaks like these are not uncommon in the US.

It’s nothing short of “insane,” fumes political blogger Ezra Klein, founder of news site Vox: “These sentences should only exist in musty newspapers from decades long past. They shouldn’t need to be written in 2014. Whooping cough is a solved problem in medicine.”

Medicine may have “solved” the problem, but—as a prospective cohort study just posted on bmj.com confirms—the question of how best to vaccinate communities remains. more…

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