Your weekly BMJ digest – 29/4/17

So to do these summaries I go to my hospital library and use their copy of the BMJ (there’s less distraction in the sacred silence of a medical library, and with such awful hospital wifi, there’s absolutely no chance of loading the distracting influence of Netflix). Imagine, to my surprise, when opening this week’s BMJ four days after its release, I find all the supplements still floating around inside it. It’s like no one (not even the librarian) looks inside this thing! If that sounds familiar to you, well don’t worry, I worked up the courage and delved in. Here’s what I found…

Cover Story – The NHS does Spooks: So the BMJ have definitely done their utmost to get readers to open the magazine with an arresting cover story “Is the NHS the place for counterterrorism?” Goodness! Although A&E can seem like hostile territory most of the time, is terrorism really the right word for it? Ah no, that’s not quite what they mean.

Given the events of the last few years, a 2015 initiative was put in place with the Orwellian name of “Prevent.” As a result, there is now a legal requirement that academic bodies and NHS Trusts flag up any suspected terrorists to Prevent so that the individual can be put into a pathway for further investigation and help. So far, so safe-guardingey.

However the article outlines the nuances of the situation including the fact that different Trusts have varying amounts of training as to how to “spot a terrorist” (and the training itself is dubious, according to Charlotte Heath-Kelly, a politics professor at the University of Warwick). There is also a lack of feedback as to what becomes of patients referred to Prevent (again, George Orwell springs to mind) – even Metropolitan Police Chief Mark Rowley concedes this point.

Furthermore, there are some worries that patients with mental health issues and of certain ethnicities and religions will be unfairly referred due to bias. There is also dispute whether the possibility of referral to Prevent endangers the sanctity of the patient-doctor consultation and inhibits patients from being open with their doctors. It’s not an easy situation but then things to do with terrorism rarely are.

Think twice about installing that update: This interesting article (p184) with an appreciated philosophical bent details the pros and cons of drug evolution and improvement. Maybe I was naïve to think that drugs stayed static in their formulation but this article reveals that pharmaceutical companies tend to continue to work on drugs after they’ve been introduced to make them better, more efficacious, safer and with fewer side effects. However, this is not always successful. For one thing the “tweaked” drugs may have new worse side effects e.g. the new upgrade on erythropoietin led to more cases of red cell aplasia compared to the original epo.

In addition, the system for evaluating the side effects of upgraded drugs tends to be more short term and involve fewer patients compared to when introducing a brand new drug. Interferon-β underwent alteration in 2003 and 2007 and although it was thought to be better tolerated than the original INF-β, over time more people developed devastating thrombotic microangiopathy.

So to not miss important new outcomes (good or bad) in new drug preparations we should a) know when a new formulation of the drug is being introduced b) monitor patients for long periods of time and report any outcomes good or bad to any appropriate drug effect registries c) keep drug registries up to date and relevant d) analyse said registries for trends and patterns.

The perils of ignoring our scientific brethren: In an impressive week of Science Marching, the BMJ calls for us to listen more to regulators and our scientific colleagues, who critique our journals and articles. After a number of high profile cases where science, methodology and outcomes were checked and disputed by the scientific community <ahem, oseltamivir not necessarily being the wonder-drug for flu> there are stronger calls for us to not do a Trump but instead, listen to the experts.  

The Sciencey Bit of the BMJ: Now designated by a purple banner, the research articles of the BMJ have now been highlighted for easier reference. Do read the articles for the fine print but the findings include:

• A multicentre randomised controlled trial of 1350 patients undergoing bowel surgery (open and lap for all sorts of bowel conditions) showed reduced rates of post-op vomiting when given a shot of 8mg IV dexamethasone in addition to routine induction antiemetics.
• A meta-analysis headed by the happy sounding trio of Sordo, Barrio and Bravo, looked into mortality rates of patients using methadone and buprenorphine as substitution drugs for “hard opioids.” A review of 19 cohorts studies (involving >140000 patients if you pool the 19 “n”s) showed reduced mortality if patients were in a substitution program as opposed to not. However, this short article doesn’t get into the stats or the actual quality of the data behind the meta-analysis and the happy trio have some competing interests listed so “pinch of salt” this until further studies show unbiased decreases in mortality.
• A Danish team have looked into whether low levels of LDL (using a study group of people with genetically low LDL) lead to higher risk of dementias. Apparently there is isn’t a causal link between the two, with a possible link that lower LDL levels might even reduce the risk of Alzheimer’s. The study used Mendelian randomisation design as opposed to the gold-standard in research, randomised controlled trials, and essentially means that the population was studied and those with genetic variations, in this case genes causing low LDL levels, were analysed to see whether they were more likely to develop particular diseases, in this case dementias.

Swiss schistosomes: And to end I’ll leave you with the amusing mental image of a parasitic worm floating on Lake Geneva. No, Jeremy Hunt didn’t visit Switzerland last week, rather a giant blow-up schistosome was paraded on the lake to highlight the WHO’s battle against neglected tropical diseases like bilharzia. Their achievements, amongst 1 billion others, include reducing cases of sleeping sickness from 37000 in 1999 to less than 3000 in 2015. Now if only they could diversify their interests and start tackling other unwanted pests like our Jeremy…