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James Raftery: Sofosbuvir for hepatitis C—moving to country specific prices

20 Aug, 14 | by BMJ

The National Institute for Health and Care Excellence (NICE) has provisionally approved sofosbuvir (brand name Sovaldi) for the treatment of hepatitis C, a decision that has surprised some commentators given its high price. The drug’s price in the United States of $84k for a 12 week course would be £54.6k at the current exchange rate of $/£0.65. But Gilead has priced sofosbuvir at £34 983 for England, which is 36% less than the US price. This is the price used in the NICE appraisal.

Pharmaceutical companies have tended to charge a single global price, but it is based on the US market, which accounts for over half of all branded pharmaceutical sales. This might be termed the Apple strategy, in that an iPhone costs more or less the same in all countries. While this can ensure enormous profits, its application to effective drugs is often seen as unethical. more…

The BMJ Today: In search of goodness

20 Aug, 14 | by BMJ

kristina_fisterMark Clarfield, an Israeli doctor, writes to his imagined Palestinian colleague. Izzeldin Abuelaish, a real Palestinian doctor living in Canada, writes back. As both yearn for peace, and attempt to show much professional and human compassion, the views expressed about the conflict that is ruling both their children’s lives seem somewhat elusive. Still, a recurring theme in these letters, as well as in the rapid responses, is hatred.

Having lived through the bloodshed that followed the break up of Yugoslavia, I wholeheartedly support the examination of hatred as a prerequisite of armed conflict. Right now, there is nothing more to want for Israel and Gaza than for the shelling to stop, and remain stopped. In my country, Croatia, the shelling stopped nearly 20 years ago. The war, it seems, still hasn’t ended though, as the battle continues in international courts. more…

Samir Dawlatly: The slippery slope of general practice

19 Aug, 14 | by BMJ

I live at the top of a hill. One winter it snowed after a hard frost, just a thin layer of snow on top of the existing ice. The morning after the snowfall, I jumped into my car, put the radio on, and was into second gear before I knew what I was doing.

Better check the brakes, I thought. They didn’t work. I tried dabbing them, pumping them, squeezing them, praying for them, but quickly realised that I had picked up too much momentum and was simply sliding down the hill. I managed to somehow avoid the haphazardly parked cars and slithered towards the T-junction at the bottom of our road. It all happened in slow motion, either because time was playing a trick on me, or because I was actually just gently sliding. more…

Desmond O’Neill: Elective Dreams

19 Aug, 14 | by BMJ

desmond_oneillWith every elective student that joins our unit, I get a vivid flashback of my own electives. No matter how much water has flowed under the bridge since then, something particularly special endures about these less structured educational episodes. Even if undertaken in a local hospital, the elements of summer holiday, change of routine, and freshness suffuse the experience for both student and clinician.

My “formal” electives were a blast. Hamburg in the summer is green, leafy, and sunny—with water a constant presence from the huge harbour to the Alster lakes in the centre of the city. The first summer was spent in a large hospital there, St Georg, whose Wilhelmine ward blocks radiated the spirit of the great German pioneers of 19th century medicine. The second elective was in the racier setting of the small Harbour Hospital beside the red light district of the Reeperbahn, transvestites and sailors prominent among the clientele. more…

The BMJ Today: Tranexamic acid and inferring significance of treatment effects

19 Aug, 14 | by BMJ

georg_roegglaTranexamic acid is a synthetic analog of the amino acid lysine. It is used to treat or prevent excessive blood loss during surgery and in various other medical conditions. An older analogue, epsilon aminocaproic acid, was temporarily withdrawn worldwide in 2007 after studies suggested that its use increased the risk of complications or death. Tranexamic acid, on the contrary, is considered to be a very promising drug. It is inexpensive and has been included in the WHO list of essential medicines.

Jashvant Poeran and colleagues have evaluated the effectiveness and safety of perioperative tranexamic acid use in patients undergoing total hip or knee arthroplasty in the United States in a large retrospective cohort study, which includes 872 416 patients. They report that tranexamic acid was effective in reducing the need for blood transfusions, while not increasing the risk of complications, including thromboembolic events and renal failure. more…

Aser Garcia Rada and Laura Reques Sastre: Fever after a trip to the Caribbean? Think of chikungunya

18 Aug, 14 | by BMJ

Aser García Rada_BMJIn Spain we are beginning to attend to a growing number of suspected cases of chikungunya—a disease most of us have never faced before—among patients coming from the Caribbean region. Chikungunya (a Makonde word for “that which bends up”) is a viral disease transmitted by mosquitoes of the Aedes Aegypti and Aedes Albopictus (tiger mosquito) variety. The disease causes fever and severe joint pain for several days. It is usually self-limiting, but it can cause severe chronic ocular, neurological, cardiac, or gastrointestinal complications. more…

Richard Lehman’s journal review—18 August 2014

18 Aug, 14 | by BMJ

richard_lehmanNEJM 14 August 2014 Vol 371
601  The usual wisdom about sodium chloride is that the more you take, the higher your blood pressure and hence your cardiovascular risk. We’ll begin, like the NEJM, with the PURE study. This was a massive undertaking. They recruited 102 216 adults from 18 countries and measured their 24 hour sodium and potassium excretion, using a single fasting morning urine specimen, and their blood pressure by using an automated device. In an ideal world, they would have carried on doing this every week for a month or two, but hey, this is still better than anyone has managed before now. Using these single point in time measurements, they found that people with elevated blood pressure seemed to be more sensitive to the effects of the cations sodium and potassium. Higher sodium raised their blood pressure more, and higher potassium lowered it more, than in individuals with normal blood pressure. In fact, if sodium is a cation, potassium should be called a dogion. And what I have described as effects are in fact associations: we cannot really know if they are causal. more…

The BMJ Today: Computed tomography—to scan or not to scan?

18 Aug, 14 | by BMJ

wim_weberAs reported in the News section today, a group of experts has called attention to the dramatic rise in the use of computed tomography (CT) scanning.

The Committee on Medical Aspects of Radiation in the Environment said that English hospitals carried out almost five million CT scans in 2012-13, a fivefold rise of the numbers in 1996-97. This year saw an additional rise of 13%.

Quite spectacular numbers, as they suggest that almost 1 in ten of all people will have undergone a CT scan in 2014. These figures are by no means unique to England. I looked up the numbers for the Netherlands, and they are similar. more…

Julie Browne: Word counts, words count—how do we want things to be in medical education?

15 Aug, 14 | by BMJ

Julie BrowneI have just come across a neat little web tool from the New York Times. You can type in any word, and see a line graph showing how frequently it’s been used in the New York Times by year right back to 1860. You can also compare several words simultaneously. It’s a fascinating insight into the degree of public debate surrounding news stories in the United States over the last 150 years.

Take, for example, “influenza.” The graph shows a huge rise in mentions during the Spanish influenza pandemic of 1918, and more peaks mark the outbreaks of 1957, 1968, and the H5N1 bird flu scare of 2005. Some medical words make a dramatic appearance—like “antibiotic” in the 1940s or “anorexia” in the 1970s—while others disappear entirely, such as “scrofula,” which last showed up in 1899, and “phthisis,” which faded away in 1917. more…

Stuart Buck: Are scholars or journalists more to blame when correlation and causation are confused?

15 Aug, 14 | by BMJ

Stuart_BuckNews stories about everything from nutrition to epidemiology to family behavior often confuse correlation with causation. Drink coffee, we are told, and you will lower your risk of dying (or perhaps raise it, depending on the week). Get married, and you will have stronger bones.

Sophisticated news consumers in the know understand that it’s best to discount such stories, which do not report on randomized experiments or any other statistical model that could show causation. The articles are invariably about correlations—akin to demonstrating that sunburn goes up along with accidental drowning, which is true not because either one causes the other, but because both occur in the summer. more…

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