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Richard Lehman’s journal review—5 December 2016

5 Dec, 16 | by BMJ

richard_lehmanNEJM  1 Dec 2016  Vol 375
Can genes prove how drugs work?
Medicine is the application of neat science to a messy world. We love it when it works simply: for example, when a single gene controls a single biochemical process, which we can then block with a single chemical. Statins are often cited as an example: they block 3-hydroxy-3-methylglutaryl–coenzyme A reductase, an enzyme that is governed by the HMGCR gene. By doing so, they reduce circulating levels of low density lipoprotein cholesterol (LDL-C) and, bingo, down goes your cardiovascular risk. But for less obvious reasons, they also raise blood glucose slightly and cause muscle symptoms in many people. If your glucose is highish to start with, they may cause you to “get diabetes,” i.e. cross an artificial threshold and bundle you together with millions of different people with this scary label. But can all this really be put down to the HMGCR gene? Here’s a population study, which concludes that it can, provided you throw in a second gene locus governing LDL-C levels. more…

Elizabeth Anderson and Simon Bennett: Are we serious about changing culture?

5 Dec, 16 | by BMJ

Healthcare education has enormous capacity to equip future practitioners with the right mindset to promote supportive team-based cultures within the NHS. By this we mean that during training all practitioners should develop skills needed to work in a community that is then manifest when working in clinical and other care situations. They should know how to: form a team; use each other’s skills appropriately; place patients and families at the centre of care; and support colleagues. Proactive, forward-thinking team players stand the best chance of identifying latent errors (incidents and accidents-in-waiting). [1] Foresight and proaction reduce the risk of death and harm. Following the Francis report there have been numerous initiatives within the NHS, some of which, like the rise and recognition of quality-improvement activities, are reactive, while in contrast, education is proactive. [2,3]

more…

Jeffrey Aronson: When I use a word . . . Gross negligence

2 Dec, 16 | by BMJ

jeffrey_aronson

The charge of gross negligence manslaughter, a criminal offence, is rarely invoked in medical cases. In the most recent, a surgeon, Mr David Sellu, was convicted but released after serving half of a 30 month sentence, the judge having failed to instruct the jury on the difference between gross and simple negligence. Liam Donaldson, Clare Dyer, and others have discussed this and other cases in The BMJ. But how do different types of negligence differ?

“Gross” is from the IndoEuropean root GWERTSO, thick or fat, and a related root GHER, to scratch or scrape, connoting roughness. They also give us grain, gravel, grind, grist, gristle, grit, groats, gruel, and gruesome. more…

Gareth Iacobucci: Jeremy’s firm hand casts a shadow

2 Dec, 16 | by BMJ

gareth_iacobucci2Jeremy Hunt caught a few people off guard at this week’s NHS Providers conference when he unexpectedly announced a flurry of new policies.

Those who have heard the health secretary give dozens of speeches over the past four years had their usual game of “Jeremy Hunt bingo” (key watchwords: patient safety, technology, Virginia Mason [The award winning Seattle hospital that Hunt loves to name check]) interrupted by a spate of new announcements geared towards addressing the low motivation and morale among NHS staff and enhancing leadership and flexible working opportunities.  more…

Jonathan Glass: Irrational numbers in surgical training

2 Dec, 16 | by BMJ

jonathan glassI enjoy numbers. I enjoy the accuracy they provide; the guidance they give in the practise of clinical medicine; and, though very far from being a mathematician, I like reading of their discovery throughout history, their quirkiness, and I like being shown their logic even though I know I won’t be able to remember or explain all I hear.

Just as I enjoy numbers, I get distressed when numbers are used to distort facts. It distresses me when they are misinterpreted to imply one football manager is better than another, when they are used erroneously to suggest one country’s healthcare outcomes are better than another’s, or when they are used by politicians to lie to the population. more…

James Raftery: Changes to how NICE appraises drugs and other health technologies

2 Dec, 16 | by BMJ

The recent proposals by NICE and NHS England to change arrangements for evaluating and funding drugs and other health technologies not only tidy up the processes, but introduce some important new elements.

The four proposed elements are to:

  1. Introduce a “fast track” NICE technology appraisal process for the most promising new technologies, which fall below an incremental cost-effectiveness ratio of £10,000 per QALY (quality adjusted life year).
  2. Operate a “budget impact threshold” of £20 million, set by NHS England, to signal the need for a dialogue with companies to agree special arrangements to better manage the introduction of new technologies recommended by NICE.
  3. Vary the timescale for the funding requirement when the budget impact threshold is reached or exceeded, risking disruption to the funding of other services.
  4. Automatically fund, from routine commissioning budgets, treatments for very rare conditions (highly specialised technologies) up to £100,000 per QALY (5 times greater than the lower end of NICE’s standard threshold range), and provide the opportunity for treatments above this range to be considered through NHS England’s process for prioritising other highly specialised technologies.

more…

Students are the key to addressing the gap between academia and action in global health

2 Dec, 16 | by BMJ

abraarThe last decade has seen an unprecedented growth in the number of students from England, the United States, and other high-income countries involved in global health and development projects in emerging economies around the world. The barriers that traditionally created significant separation between the classroom and the field in global health and development, such as transportation and the lack of easy access to information, are no longer relevant today. more…

Paul Buchanan: On being the token patient

1 Dec, 16 | by BMJ

peb-photo-jpgHealthcare systems have been built with hierarchies, processes, and models of engagement that are designed to distill policy, research, therapy, diagnostics, treatment, and support down to the patient. The patient and their treatment is the “end-game.

But how well does the system work? Let’s take a look from a patient’s perspective. Several recent examples weeks spring to mind. more…

Daniel Whitney: Mental health has still not achieved “parity of esteem”—even among some medical professionals

1 Dec, 16 | by BMJ

daniel_whitney

It’s late morning; little piles of lists and notes from assessments carried out in the past 24 hours are littered between me and the PC. The assorted paraphernalia that seems to accumulate around me after a night on-call clutters my surroundings: a dictaphone, the British National Formulary, Maudsley guidelines, and the semi-completed audit I glance at guiltily every time I find something more urgent to do.

The medical students enter. I welcome them and realise that I had agreed one could present a history they had taken. I had felt guilty earlier; they had been struggling to find patients who met their tick box quota of “cases,” more…

Vineet Chopra et al: Motivational interviewing for healthcare providers

30 Nov, 16 | by BMJ

Improving patient safety through behavioral change is something that all healthcare providers strive to achieve. Supported by a three year grant, we are involved in a new way of doing this by using motivational interviewing (MI) among staff to improve patient outcomes.

A technique typically used by clinicians for patients, MI aims to empower and guide individuals towards health behavior change. Research studies have shown that MI achieves superior results compared to traditional patient education interventions for health behaviors including tobacco use, physical inactivity, and weight gain/obesity. more…

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