this week

GPs to convene crisis summit The chair of the BMA’s General sustainability is in serious question, and Chaand Nagpaul said the Practitioners Committee has warned the the ability of GPs to continue with their current crisis in general government that the future sustainability current workload and current pressures practice “can no longer be ignored by politicians” of UK general practice is “in serious is unsustainable. This conference has question,” ahead of a crisis summit later been called because we are in a desperate this month. situation with regards to general practice.” Chaand Nagpaul said that the first Nagpaul added, “The conference is special meeting of local medical bringing to the fore an issue that can no committees (the statutory bodies that longer be ignored by politicians. But it represent GPs locally) in 13 years—due is also about ensuring clear action is to take place on 30 January—highlighted taken to enable general practice to get the severity of the current crisis in general back on its feet.” practice and would bring to the fore “an Peter Holden, a member of issue that can no longer be ignored by Derbyshire Local Medical Committee politicians.” and a former negotiator on the BMA The meeting has been organised by General Practitioners Committee, NEWS ONLINE the BMA in response to growing concern has proposed a motion warning the Wider group of among members of local medical government that industrial action • health professionals committees that rising demand from from GPs was “on the cards” unless should be located patients, stretched resources, and over- the government acted to support the in emergency regulation were harming the care of beleaguered primary care system. departments patients and causing widespread burnout Holden told The BMJ, “The government Drug companies in the profession, leading to ongoing must not think that whatever happens • to pay $39.5m in problems with recruitment and retention. with the juniors isn’t on the cards with OxyContin and GPs will debate a range of motions the GPs. We have to have a restoration of Risperdal cases to decide what action to take to deliver the GP expenses system—also we have to • Government’s “a safe and sustainable service” in the make [general practice] attractive for the U turn on custodial future, including the possibility of taking young ones to want to come in.” healthcare will industrial action against the government. Gareth Iacobucci, The BMJ endanger vulnerable Nagpaul told The BMJ, “We are now at Cite this as: BMJ 2016;352:i14 people, says BMA a juncture where general practice’s future Find this at: http://dx.doi.org/10.1136/bmj.i14 the bmj | 9 January 2016 1 SEVEN DAYS IN

Johann Malawana, chair of the Junior doctors will strike next week BMA’s Junior Doctors Committee Junior doctors are set to take three days of industrial action, aft er negotiations between the association and the government over the terms of the junior doctor contract broke down on Monday, 4 January, the BMA has said. As The BMJ went to press the association announced that the action would take place in January and February, aft er the government failed to meet junior doctors’ concerns over changes to their contract. It said that the government did not recognise the need for robust contractual safeguards for safe working or the need for proper recognition of unsocial hours worked by junior doctors. The BMA said that the fi rst day of industrial action would be Tuesday 12 January, when for 24 hours junior doctors will provide emergency cover only. It said that, unless junior doctors’ concerns were dealt with, the action would be followed by a second, 48 hour period of industrial action, beginning on 26 January. This would be followed by a day of strike action on 10 February, which would see a full withdrawal of junior doctors’ labour between 8 am and 5 pm, the BMA said. In November 98% of junior doctors in a ballot voted in favour of industrial action.

LYNCHPICS/ALAMY Abi Rimmer BMJ Careers Cite this as: BMJ 2016;352:i43

Saturday 2nd cessation aid, will be allowed research showing that children The areas covered were fine BMJ appeal update to be prescribed on the NHS aged 4 to 10 consume over 5500 motor skills, gross motor skills, Readers have so far raised when it becomes available. sugar cubes a year, equal to communication, personal-social £15 000 for Doctors of the World The Royal College of around functioning, and problem solving in The BMJ ’s Christmas appeal, General Practitioners 22 kg—the average ability. (See The BMJ ’s full story at which runs until the end of warned that GPs could weight of a 5 year old. doi:10.1136/bmj.h7028.) January. be overwhelmed The recommended with requests for daily maximum Midlands hospital appoints Councils call for calorie the device, which added sugar intake humanist “pastoral carer” count on alcohol labels is made by British is 19 g for 4 to 6 year Leicester Hospitals appointed The Local Government American Tobacco. Tim olds (five sugar cubes), a humanist pastoral carer to Association, which represents Ballard, vice chair of the royal 24 g for 7 to 10 year olds (six support patients, families, and around 400 councils college, said that he would like cubes), and 30 g for 11 year olds staff with non-religious beliefs. in England and to see e-cigarettes assessed by (seven cubes). The hospital group is thought Wales, said that the National Institute for Health to be the first to make such an the effect of hidden and Care Excellence. (See also: Infertility treatment appointment. Jane Flint, whose calories in alcohol is European watchdog is failing to is not associated with part time post is funded by the contributing to the hold tobacco industry to account developmental delays Leicester Hospitals Charity, has UK’s obesity crisis. Its over smuggling, at doi:10.1136/ A prospective cohort study of qualifications in psychotherapy, demand echoed that bmj.h6973.) 4824 mothers to 5841 children, adult education, and counselling of the Royal Society including 1830 conceived with and is accredited in non-religious for Public Health, Monday 4th infertility treatment and 2074 pastoral support by the British which has called for Campaign launches to twins, found that infertility Humanist Association, with calorie labels to be reduce children’s sugar treatment was not associated which she is also an accredited put in place, as well as intake with the risk of children funeral celebrant. (Full BMJ story MEPs’ calls in 2015 Public Health England failing any of five doi:10.1136/bmj.h7023.) for calorie labels to encouraged parents to take developmental be put on all alcoholic drinks in a control of their children’s domains up Tuesday 5th vote at the European Parliament, sugar consumption with a to age 3. Adult cancer although that vote is not binding. new Sugar Smart survivors are at app that scans risk of cardiac Sunday 3rd barcodes of abnormalities Government gives go ahead products to show A study of 1853 to e-cigarettes on NHS the amount of adults who received The Department of Health sugar they contain either anthracycline confirmed that e-Voke, an in sugar cubes chemotherapy or e-cigarette that has been given and grams. The cardiac directed a UK licence as a smoking campaign followed radiation therapy for

2 9 January 2016 | the bmj SIXTY SECONDS MEDICINE ON . . . a childhood cancer found that MINDFULNESS cardiomyopathy was present in I’M FEELING A BIT DISTRAIT. IS THERE 7.4%, coronary artery disease in A PILL FOR IT? 3.8%, valvular regurgitation or Try mindfulness. It’s the antidote to stress, stenosis in 28%, and conduction distilled from the wisdom of ancient or rhythm abnormalities in Buddhism and brought bang up to date to 4.4%. Often the survivors were ease the travails of the modern world. asymptomatic, with cardiac IT SOUNDS A BIT FLAKY TO ME abnormalities occurring at It’s easy to scoff. But plenty of people find it a younger age than usual, helpful, and it’s inching towards making the suggesting that research into transition from pop psychology to clinical screening this group of patients Candida infection alone could acceptance. is needed, said the researchers in result in pregnancy loss. E-CIGS SUM IT UP IN A SENTENCE the Annals of Internal Medicine. They concluded, “Until more E-Voke is the first (Full BMJ story doi:10.1136/bmj. data on the association are Mindfulness means paying attention in a h7026.) available, cautious prescribing e-cigarette to be particular way—on purpose, in the present of fluconazole in pregnancy may approved as an moment, and non-judgmentally, says Jon Wednesday 6th be advisable.” (Full BMJ story Kabat-Zinn, a student of Buddhist meditation who has been promoting the idea with Antibiotic reduces malaria doi:10.1136/bmj.h7029.) aid to stop risk in adults taking smoking growing success since 1979. The idea is to use meditation techniques to focus your antiretroviral therapy Thursday 7th mind on the here and now instead of having In malaria endemic regions, unhelpful thoughts about the past or the people with HIV infection who future. are treated with antiretroviral therapy do better if they also take BUDDHISM LITE, THEN? the antibiotic co-trimoxazole, That’s what critics say, accusing Kabat-Zinn’s a trial in Kenya published in successors of marketing “McMindfulness,” PLoS Medicine showed. The ripped from its context and lacking soul. World Health Organization NEVER MIND THE PURISTS, DOES IT recommended prophylactic WORK? use of co-trimoxazole in 2006, A bit. A head to head trial designed to see but that guidance predated the which treatment was most effective in widespread use of antiretroviral Disabled children are preventing relapse into depression showed therapy, so it has not been clear at risk after initial that mindfulness techniques did as well but whether it remains appropriate. unsubstantiated referral no better than antidepressants. Neither was The trial, which showed that for neglect especially effective. And a meta-analysis mortality and morbidity were Children with disabilities who have found it moderately to largely effective higher among those in whom an initial unsubstantiated referral for a variety of psychological co-trimoxazole was discontinued, for neglect are at increased risk of problems, including anxiety, backed the continued use of the being maltreated subsequently, a depression, and stress. But WHO guidance. (Full BMJ story research letter published in JAMA study results varied widely, and attrition rates were high, so these doi:10.1136/bmj.i5.) claimed. A total of 12 610 children findings may be overstated, with disabilities and 476 566 in the view of the University of Oral antifungal drug is children without disabilities who York’s Centre for Reviews and linked to spontaneous had first time unsubstantiated Dissemination. abortions referrals for neglect in 2008 were Use of the oral antifungal drug followed up for four years. Children IS IT CHEAP, AND IS IT SAFE? fluconazole during pregnancy was with disabilities were more likely A course of eight weekly sessions associated with a significantly to be re-referred to child protective in Oxford costs £350. And side higher risk of spontaneous services than those without (45% effects, such as re-emergence of traumatic abortion in an analysis of 1.4 versus 36%) and were more likely memories or becoming “depersonalised,” million pregnancies in Denmark to experience substantiated can occur. Their frequency and severity are contested. published in JAMA. However, maltreatment (16% versus 10%). the researchers noted that the (Full BMJ story doi:10.1136/bmj. Nigel Hawkes, freelance journalist, London severity of vaginal candidiasis h7031.) Cite this as: BMJ 2015;351:h6960 might be a confounding Cite this as: BMJ 2016;352:i9 ЖЖEDITORIALS, p 9 factor and that severe vaginal Find this at: http://dx.doi.org/10.1136/bmj.i9

the bmj | 9 January 2016 3 NHS choir’s Christmas hit puts health service in spotlight

“I’m sure more improbable things have happened, but I can’t think of any,” said Eddie Chaloner, a member of the Lewisham & Greenwich NHS Choir, which hit the top of the singles chart this Christmas with the song “A Bridge Over You.” The song clinched the number one slot from Justin Bieber on Christmas Day, outselling the Canadian singer’s song “Love Yourself” by 30 000 copies (127 000 versus 97 000). In the first chart of 2016 the song had dropped to number 29. The choir, which includes all types of NHS staff, was runner up on Gareth Malone’s BBC 2 television show Sing While You Work in 2012. “A Bridge Over You” was arranged by choir masters who took over when Malone left. Released in 2013 to celebrate the NHS, the song did reasonably well in a specialist chart. But it wasn’t until Harriet Nerva, a junior doctor at Hinchingbrooke Hospital in Cambridgeshire and nothing to do with the choir, stumbled across it after a difficult shift that the song really took off. Nerva made it her mission to make the song 2015’s Christmas number one hit. With help from Katie Rogerson, a paediatrician and a choir member, and Joe Blunden, an NHS communications manager, she launched a strategic social media campaign and did just that. The song blends Simon and Garfunkel’s “Bridge Over Troubled Water” and Coldplay’s “Fix You.” “It encapsulates what we feel about what we do,” said Chidi Ejimofo, a consultant in emergency medicine at University Hospital Lewisham and one of the song’s star soloists. “There is real buzz among NHS staff. It feels like a real affirmation about how people feel about the NHS.” That the NHS choir sits alongside other Christmas chart toppers such as The Beatles, Spice Girls, Band Aid, and Elvis Presley, had yet to sink in, he said. The choir chose to donate all sales from the song to charities, in particular Carers UK and the mental health charity Mind, because “the work that they do takes a lot of pressure from the NHS,” said Chidi. Some smaller charities will also be benefiting in the New Year. Zoe Davies, another soloist on the song, told The BMJ, “It is a difficult time for the NHS at the moment. From a junior doctor’s point of view it [the NHS crisis] was at the top of the agenda. “People like the song, and people want to show their support for the NHS and free healthcare. It shows the government that people truly support the NHS.” Although she now works as a medical registrar at St Thomas’s Hospital in London, Davies continues to sing in the choir. She said that the support for the campaign had been “completely overwhelming and positive.” Chidi added: “It will be easier to recruit new choir members.” Zosia Kmietowicz, The BMJ Cite this as: BMJ 2016;352:h7022 Find this at: http://dx.doi.org/10.1136/bmj.h7022

4 9 January 2016 | the bmj “It shows the government that people truly support the NHS” – Zoe Davies CHIDI EJIMOFO CHIDI

Some members of the the Lewisham & Greenwich NHS Choir (left to right), Caroline Smith, children’s community physiotherapist; Petrina Pottinger, IT systems manager; Suzanne Bennet (behind), speech and language therapist; Katie Rogerson, paediatrician; Zoe Davies, registrar; Chidi Ejimofo, consultant in emergency medicine; Katie Evans, doctor, and Caroline Duffy, theatre nurse the bmj | 9 January 2016 5 bmj.com/podcasts ЖЖWhen Margaret met Roger: listen to the podcast online

some universities that are popular breeding grounds for GPs and other universities that hardly seem to produce any. Some senior doctors think that’s because health professionals [in those universities] speak down about GPs sometimes.” The Royal College of General Practitioners is currently running a campaign, “There’s nothing general about general practice,” to try to Support from government stuff for too long,” she says, change negative attitudes. But, says Damoiseaux says that wherever it can referring to GPs becoming involved McCartney, there has long been too the Dutch government supports GPs in commissioning hospital services much public focus on the problems because it sees primary care as its ally under changes introduced in 2004. GPs face rather than the joys of the job. in the effort to save costs in secondary That shift was stressful for a lot of Damoiseaux says that, in contrast, care. Whereas, McCartney says, in GPs and took them away from their the image of the profession is strong the UK the current government’s patients. “I think that changed a lot in the Netherlands. Although many approach to the NHS as a whole of doctors’ perceptions of what it is medical students want to be surgeons has united GPs and specialists in that GPs do or don’t do.” or enter other specialties, all medical opposition to the government and to schools in the Netherlands seem to specific government policies amid a Image of the profession give students positive insights into sense of misdirection. McCartney also feels strongly that general practice and the media do not Damoiseaux explains that in in the UK, the media’s portrayal of overemphasise what’s wrong with the some ways the Dutch insurance general practice, combined with profession. based system gives Dutch GPs attitudes towards the profession in greater power to negotiate between some medical schools, discourages Salaries insurance companies and the some students before they have any McCartney also says uncertainty for government for what they want. direct experience of the job. GPs over their salaries is demoralising “Insurance companies are “I think a lot of doctors coming working GPs and putting off young private companies,” he says. “There through (medical school) will doctors. Whereas Dutch GPs’ salaries are several—five or six—in the have a look at what people have remained stable for years, in Netherlands so there is a certain room think about general the UK they have been falling for to negotiate about things. Sometimes practitioners and won’t the past few years. GPs were given a the union even goes back to the like what they hear,” says large rise because they were earning minister and says, ‘We just don’t want McCartney. “There are far less than specialists, McCartney to do it like this or we will not do the says, but that was then seen as being other things we’ve planned together.’” too much and since then it has been Damoiseaux describes a grass declining. “To a certain extent that roots revolt this year by Dutch GPs, “Our guidelines gives instability because you don’t who refused to cooperate when in general are quite know what’s going to happen insurance companies attempted to given to us from next,” says McCartney. “I would rather impose more box ticking and targets. on high. They just know how much money I had than By contrast, McCartney says, British worry that it is going up and down all are not really GPs are frustrated that the Quality and the time.” written for GPs” Outcomes Framework has reduced Sophie Arie is a freelance journalist, London consultations to a box ticking process. Margaret [email protected]. “I think a lot of GP energy has McCartney, Cite this as: BMJ 2015;351:h6870 been expended doing the wrong Glasgow GP Find this at: http://dx.doi.org/10.1136/bmj.h6870 the bmj | 9 January 2016 7 Why are Dutch GPs so much happier? General practice is similar in the Netherlands and the UK yet it appeals far more to young Dutch doctors than to their British counterparts. In collaboration with the Dutch medical journal Nederlands Tijdschrift voor Geneeskunde, Roger Damoiseaux, professor of general practice in Utrecht, and Margaret McCartney, Glasgow GP and The BMJ columnist, met to try to work out why. Sophie Arie reports

n many ways, the daily work How general practice compares in the UK and the Netherlands of a general practitioner in the UK Netherlands Netherlands and the United Average income: Kingdom is similar. Working Full time GP partner £103 000 (€139 000) £92 000 (€127 000) hours, pay, and time spent Salaried GP £56 800 (€75 000) £48 000-£62 000 (€66 000-€88 000) plus extra for night duties Iwith patients are comparable (table). Change in incomes in recent years Income has fallen by 11% since 2008 Stayed same since 2008 Increasing numbers of GPs work Proportion of GPs who are partners 72% (down from over 90% in 2000) 82% (down from 90% in 1995) part time in both countries, and they Workload struggle with the same pressures Full time partner 60 hours/week 60 hours/week Full time salaried GP 50 hours/week 50 hours/week of caring for an ageing population Average consultation 10 minutes 10 minutes amid constant cuts to welfare, social Average No of patients per day 40 40 services, and healthcare. Change in consultation rate 24% increase since 1998 No change in past 5 years Overnight care GPs can opt in or out All GPs provide overnight care twice a month Yet the job is respected and popular GP training/qualifying 3 years. Training and trainee salary 3 years. Training and trainee salary paid by in the Netherlands, with 1250 young paid by government government medical graduates competing for 750 Popularity of the job 451 GP trainee vacancies unfilled 1200 applicants for 750 trainee vacancies trainee posts last year, whereas 451 GP after 2 recruitment rounds trainee posts were unfilled in the UK Male:female ratio Over 50% female since 2013 45% female in 2014 in 2014. In a wide ranging discussion Information given here is based on data from 2014 unless otherwise stated. The UK information comes from the Royal College of General Practitioners, BMA, and Health and Social Care Information Centre. The Dutch information comes from the Dutch with Roger Damoiseaux, professor of Healthcare Authority and the Netherlands Institute for Health Services Research (NIVEL). general practice at Utrecht University, Glasgow GP Margaret McCartney says the public image of the profession in Strong union primary care. It started with diabetes the UK and the policies of the current “In the Netherlands GPs have a very and now has guidelines on around government are part of the reason. strong position in healthcare,” says 100 conditions. Damoiseaux points to several key Damoiseaux. The National Association “We make them ourselves. They are strengths of the profession in the of General Practitioners (LVH) supported by all GPs. And it’s easy Netherlands that may explain why it is represents 80% of all GPs. to say to specialists, ‘This is what we stronger both politically and in terms “They take care of the salaries, do,’” says Damoiseaux. of status than in the UK. negotiations with the minister, By contrast, guidelines in the UK “In the and also how we organise general are set down by the National Institute practice. So it’s a very strong group for Health and Care Excellence and Netherlands of professionals and I think that is cover both primary and hospital care. GPs have a seen by the public and also by the “Our guidelines in general are very strong students,” he says. given to us from on high. They are position in The strength of the GPs’ union not really written for GPs in the healthcare” to negotiate with government, front line dealing with people with Roger Damoiseaux believes, partly explains undifferentiated symptoms, most of Damoiseaux, why Dutch students are attracted to whom will not have the diagnosis professor the profession. In the UK, GPs have no that the guidelines have been written of general union of their own. Some 31 985 of the about,” says McCartney. practice, 40 584 GPs (79%) are members of the “I think this is key to the way Utrecht British Medical Association, the trade primary care sees itself and the way union for all UK doctors. others see it: not valid enough to do our own research and our own work Respected guidelines with our own stipulations of what’s Another key difference Damoiseaux good and what isn’t. We have terrible points out is that the Dutch College trouble persuading some people of General Practitioners has, since sometimes that not following some 1989, drawn up its own guidelines guidelines is actually very much in on how to treat specific conditions in the best interest of the patient.”

6 9 January 2016 | the bmj EDITORIAL Full disclosure about cancer screening Time to change communication from dodgy persuasion to something straightforward

ommunication about Every article Breast cancer early detection cancer screening is dodgy: and pamphlet by mammography benefits are overstated should provide and harms downplayed. a fact box Mammography screening may reduce the number of women who die from breast cancer, but that does not Several techniques of mean that lives are saved: no reduction has been shown for overall mortality and overall cancer deaths summary (including breast cancer). Among all women taking part in screening, some women will be overdiagnosed C with non-progressive cancer and unnecessarily treated persuasion are used. These include to facilitate using the term “prevention” instead Numbers for women aged  years or older who did or did not participate in screening for about  years informed of “early detection,” thereby wrongly  women  women without screening with screening suggesting that screening reduces the decisions Benets odds of getting cancer. Reductions How many women died from breast cancer?  ’ in relative, rather than absolute, risk How many women died from all types of cancer?   are reported, which wrongly indicate How many women died from any cause? ’ ’ that benefits are large.1 And reporting Harms How many women without cancer experienced false alarms - - increases in 5 year survival rates or biopsies? wrongly implies that these correlate How many women with non-progressive cancer had - - unnecessary partial or complete breast removal? with falls in mortality.2 Prasad and colleagues put their finger on another Source: [] Gøtzsche, PC, Jorgensen, KJ (). Cochrane database of systematic reviews (): CD.pub misleading practice: claiming that Fact box on mammography screening for breast cancer screening “saves lives” despite the lack of proof that overall mortality is of 412 physicians wrongly thought benefits of screening, we cannot decreased.3 that the detection of more cancers provide people with the information in screened than in unscreened required to make an informed Simple, and wrong populations proved that screening choice. We must be honest about A fall in cancer specific mortality saves lives. And 76% wrongly thought this uncertainty.” But even if this alone cannot prove that lives are that if people with screen detected uncertainty cannot be removed, we saved—the cause of death may cancers had better 5 year survival rates can provide people with useful tools, be systematically misclassified or than those with symptom detected such as fact boxes (figure ).6 We use a screening and subsequent cancer cancers, then screening saved lives.5 fact box on mammography screening treatment may increase deaths Given such widespread confusion, it that reports all three measures of from other causes, most likely as can be helpful to report both cancer mortality, based on a Cochrane a consequence of overdiagnosis specific mortality and overall mortality. review.7 It clearly shows that cancer and overtreatment.3 4 To prove that Secondly, overall cancer mortality specific mortality is reduced by 1 in screening saves lives one needs to find should also be reported, where 1000 women and that this difference a difference in overall mortality. Yet possible. If there is a reduction in is not reflected in overall cancer deaths detecting such a difference, if it exists, cancer-specific mortality that does nor in overall mortality. The harms with reasonable statistical power in not result in deaths from other causes are specified numerically so that an the general population would require or from misclassification, then this informed decision about screening is studies with millions of participants. reduction should be reflected in a fall possible. Every article and pamphlet Can we get around this dilemma? in overall cancer mortality (which should provide a fact box summary to Prasad and colleagues propose includes cancer-specific mortality). facilitate informed decisions. reporting overall mortality in addition Because the base rate of overall cancer Rather than pouring resources into to cancer specific mortality and, Gerd Gigerenzer mortality is lower than that of overall “megatrials” with a small chance of if there is no difference in overall director, Harding mortality, tests have a higher power detecting a minimal overall mortality mortality, to stop claiming that Center for Risk to detect such a difference. Overall reduction, at the additional cost of screening saves lives. I agree but Literacy and Center cancer mortality can control for harming large numbers of patients, would like to add some additional for Adaptive systematic errors in classifying cancer we should invest in transparent points to their call for more honesty. Behavior and causes of death.3 It cannot, however, information in the first place. It is time Cognition, Max Firstly, reporting cancer specific capture non-cancer deaths caused by to change communication about cancer Planck Institute and overall mortality is essential for Human treatment, which is a limitation. screening from dodgy persuasion into because not only do patients lack an Development, something straightforward. understanding of what constitutes Berlin, Germany Tools for informed choice Cite this as: BMJ 2016;352:h6967 evidence for “saving lives,” but many gigerenzer@mpib- Prasad and colleagues write, “As Find this at: http://dx.doi.org/10.1136/bmj.h6967 doctors do too. In a US sample, 47% berlin.mpg.de long as we are unsure of the mortality ЖЖANALYSIS, p 22

8 9 January 2016 | the bmj EDITORIAL Does mindfulness work? Reasonably convincing evidence in depression and anxiety

indfulness has (d=0.22-0.23) at three to six months’ Comparable been defined as the follow-up.6 Although these outcomes results to process of paying are more modest, they are comparable treatment with attention to the with results that would be expected antidepressants present moment from treatment with antidepressants in in a primary Min a non-judgmental manner.1 In the a primary care population, but without 6 care population early stages of mindfulness training, the associated toxicity. awareness of breathing is typically Consistent with these findings, used as an attentional anchor to the National Institute for Health and and the validity of the traditional regulate ruminative thinking,2 but Care Excellence and the American view among contemplative traditions mindfulness encompasses much more Psychiatric Association advocate that sustainable improvements to than observing the breath. It derives mindfulness based cognitive therapy health and wellbeing require daily from Buddhist practice and has been for recurrent depression in adults.7 8 mindfulness practice over many the subject of empirical investigation Some evidence suggests that years.9 since the late 1970s, with over 700 mindfulness based interventions may Furthermore, evidence is required scientific papers on mindfulness have a role in treating other psychiatric to determine whether mindfulness published in 2014.3 conditions,9 but there is insufficient in general or specific interventional Evidence is most convincing for its evidence from robustly designed trials approaches is most effective for a given use in the treatment of depression and to support its use for conditions other illness. Numerous interventions have anxiety. Meta-analyses assessing the than depression and anxiety. been formulated with considerable efficacy of mindfulness in these two Evidence from randomised variation in factors such as total disorders have typically reported effect trials suggests that mindfulness participant-facilitator contact hours sizes in the moderate-strong to strong based interventions (particularly (including whether there is one-to-one range (Cohen’s d ≥ 0.5).4 5 However, mindfulness based stress reduction contact), quantity and duration of some of the studies included in these and cognitive therapy) are mildly to guided mindfulness exercises, use of meta-analyses have failed to control for moderately efficacious in treating non-mindfulness psychotherapeutic a placebo effect, so it is unsurprising chronic pain (d=0.33),6 with possible techniques, emphasis on self practice that meta-analyses with more stringent applications for treating pain related (typically supported by a CD of guided inclusion criteria report more modest disorders such as fibromyalgia.11 mindfulness exercises), and use of outcomes. However, it is unclear whether other meditation techniques (such as mindfulness reduces the frequency yoga).2 This time with active control and intensity of pain or simply Interventions also vary in how For example, a recent meta-analysis improves patients’ ability to cope.11 they define and operationalise of 36 randomised controlled trials of mindfulness.12 Substantial variations mindfulness based stress reduction, Unanswered questions in design and pedagogic approach mindfulness based cognitive therapy, Various methodological problems limit make it difficult to generalise and other mindfulness based the overall strength of the evidence findings across the full spectrum of interventions—each with an active on the efficacy of mindfulness. In interventions. control— reported small to moderate particular, findings may be influenced Evidence is growing that effect sizes d( =0.3-0.38) in the by a form of “popularity effect”: mindfulness is effective in increasing treatment of depression or anxiety participants may believe that they are perceptual distance from distressing after eight weeks of mindfulness receiving a “fashionable” or proved psychological and somatic stimuli training, with a reduction in effect size psychotherapeutic technique.9 This and that it leads to functional is a difficult confounding variable neuroplastic changes in the brain.13 Edo Shonin, research director to control for because it is almost However, the “fashionable” status of [email protected] impossible to blind patients from mindfulness among both the general William Van Gordon, principal investigator, the fact they are using mindfulness ЖЖPersonal public and the scientific community Psychology Division, Nottingham Trent techniques. View: Use may have overshadowed the need to University, Nottinghamshire NG1 4BU, UK; hand cleaning and Awake to Wisdom Centre for Meditation We also need greater clarity on examine important methodological and Mindfulness Research, Nottingham, UK whether positive outcomes are to prompt and operational issues concerning its Mark D Griffiths, professor, Psychology maintained over years, rather than mindfulness efficacy. 2 9 Division, Nottingham Trent University, just months, whether mindfulness in clinic. BMJ Cite this as: BMJ 2015;351:h6919 Nottinghamshire NG1 4BU, UK interventions have any adverse effects, 2016;352:i13 Find this at: http://dx.doi.org/10.1136/bmj.h6919 the bmj | 9 January 2016 9 THE BMJ’S WINTER APPEAL 2015 Please help Doctors of the World bring care to the world’s refugees

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10 9 January 2016 | the bmj MEDICINE AND THE MEDIA A doctor who took on the might of American football Anne Gulland discusses a film that tells of the diagnosis of the first case of chronic traumatic encephalopathy

he new filmConcussion tells the story of a naive young Nigerian pathologist who took on the multibillion dollar TNational Football League (NFL) over its record on protecting players from brain injury. Will Smith plays Bennet Omalu, a medical examiner in Pennsylvania, who first came up against the NFL in 2002 when he did an autopsy on “Iron Mike” Webster, a legendary Pittsburgh Steelers’ center for 15 years. Webster died at the age of 50 from a myocardial infarction, but Actor Will Smith Omalu’s story might have remained The film finishes with a statement Omalu wanted to find out what as the medical untold if it were not for Jeanne Marie about NFL’s concussion settlement led to the player’s well documented examiner Bennet Laskas, a journalist at GQ magazine, with more than 5000 former players, Omalu meltdown after his retirement. who discovered him when writing agreed in April 2015. The NFL He ended up living in his car an article about brain injuries among calculates that 28% of players will have and was confused, forgetful, and footballers. some form of brain disease. However, depressed. the film does not point out that some When he examined Webster’s David and Goliath players have refused the deal, saying brain Omalu was surprised to find It’s a classic David and Goliath tale— that the range of diseases covered is too that it showed no obvious after the little guy against the multibillion small. effects from the many knocks and dollar machine that is the NFL, says Omalu is now a pathologist in slams it would have received over Laskas. California but continues his work on a 15 year playing career. There was “It’s about the outsider who tries to CTE with the Brain Injury Research no sign of cortical atrophy, cortical take on big business. You have to think Institute. With researchers at the contusion, haemorrhage, or infarcts. about how huge the NFL is. It’s bigger University of California, Los Angeles, He examined the brain further and than Hollywood; it’s the behemoth of Omalu and Bailes have been working eventually found deposits of Tau entertainment in America,” she says. on scans to diagnose CTE before death proteins and neurofibrillary tangles Just as Omalu received threats after because currently it can be confirmed and diagnosed the first case of he first published his research, Laskas only at autopsy. One of the people chronic traumatic encephalopathy also received hate mail from football scanned was Fred McNeill, a linebacker (CTE). fans accusing her of wanting to water with the Minnesota Vikings for 11 Omalu published his findings and down the game. years, who developed dementia. He diagnosis in the journal Neurosurgery “I didn’t set out to indict the NFL. I died in November at the age of 63 and in 2005, followed by another case just wanted to tell the inspiring story the results of his autopsy are imminent, study in 2006. Both times the NFL of a guy who found out something says Laskas. urged Omalu and his coauthors, who interesting,” she says. The NFL has been talking about included eminent neurosurgeons, to In September Sony Pictures improving helmet design but Laskas retract. Entertainment was accused of making describes this as the “filtered cigarette Smith plays Omalu as an innocent changes to the film to suit the NFL—an of the 21st century.” abroad, a man puzzled that the NFL accusation that Laskas denies, telling “This is the discussion that America would dismiss the science. The risks detractors to wait until the film comes keeps not having. But what’s different of repeated concussion from players The NFL out. Unlike most major Hollywood this time is that there’s a Hollywood slamming heads were known long calculates studios, Sony has no significant ties movie and the subject will be discussed before Omalu became involved, but that 28% of to the NFL. And the film appears not in a way that people will understand,” he was the first to diagnose CTE. to pull its punches, depicting NFL she says. players will The NFL had its own team of doctors high ups as masters of obfuscation, Anne Gulland is a freelance journalist, London looking at brain injuries and did not have some obstructing Omalu and one of his [email protected] like this young upstart pointing out form of brain supporters, neurosurgeon Julian Bailes, Cite this as: BMJ 2016;352:h6856 the flaws in their research. disease at every step. Find this at: http://dx.doi.org/10.1136/bmj.h6856 the bmj | 9 January 2016 11 HEAD TO HEAD Poor people and people with chronic diseases and disabilities are inevitably no adversely affected by copayments

Nancy Loader is a GP partner, Beccles, Suffolk can immediately change the dynamic and [email protected] outcome of the consultation. Copayments can deter doctors from All rich countries face rising healthcare asking patients to return for review or deter costs as life expectancy increases, infant patients from meeting your request. They mortality falls, and more treatments emerge, can deter patients from seeing the GP as regardless of whether they fund these costs advised after medical or surgical discharge by general taxation or through compulsory from hospital. They can encourage patients insurance schemes.21‑24 Extensive to collect multiple problems to discuss in international empirical evidence shows a single consultation and pressure doctors that strong primary care led health systems, to deal with them all at once. And they free at the point of access, are associated can encourage unnecessary prescribing or with improved outcomes, increased quality referral—“I’ve paid, do as I say.” of care, decreased health inequalities, and Some practices may be tempted to lower overall healthcare costs.21 24 deal with complaints from patients by offering a refund of the copayment rather Copayments don’t work than improve their service. They act as a Some countries have tried to limit patient financial deterrent and encourage deferring demand or reduce spending on healthcare attendance until very unwell, with more by introducing copayments. This has likelihood of a need for hospital admission. resulted in increased health disparities Copayments make no discernible with no change in patient demand.25‑28 difference to rates of non-attendance and no Governments in these countries end up difference to attendance rates of the worried reimbursing, capping, and waiving the well. Patients who cannot afford to see a GP copayment to reduce health disparities.24 simply attend free emergency departments. The overall costs of these remedial actions Receptionists gain the additional work are not usually available. However, Germany of collecting fees, and practices often have introduced a fee for service copayment in to use debt collection agencies. 2004, which it scrapped in 2012. It cost the German government €360m (£260m) Conflict of interest a year to run, and on average each year Copayments introduce a conflict of interest for every medical centre the scheme cost for GPs wanting to offer equitable and €4100 in administration and resulted in excellent standards of care to all their 120 hours of extra work.25 29 patients while protecting their income. In other countries, for example, New Most UK GPs are self employed contractors Zealand and the Irish Republic, where working for a practice owner on a fee for patients have always made a copayment service basis at around 55% of total fees. to GPs, it has interfered with initial access Without patients there is no income. Apply to care and deterred preventive care discretion and don’t charge a copayment measures, resulting in greater health fee, then you subsidise the patient out of spending in secondary care.23 26‑ 28 the practice’s and your own income. Poor Charges also have a detrimental effect people, mentally ill people, and people on the doctor-patient relationship. I have with chronic diseases and disabilities are 15 years’ experience as a UK trained GP inevitably adversely affected by copayments. working in several different countries We should keep the NHS free for all at with different levels of copayment. the point of access because it makes good Even in countries that never offered economic sense, is better for healthcare free consultations, many patients outcomes, reduces bureaucracy, and complained about fees or were unable allows for innovative ways to match supply to pay them for many reasons. Financial and demand in general practice. discussions could arise at any stage of the Cite this as: BMJ 2016;352:h6800

IMAGE ZOO/ALAMY IMAGE consultation and on a daily basis. This Find this at: http://dx.doi.org/10.1136/bmj.h6800

the bmj | 9 January 2016 13 HEAD TO HEAD The argument that charges would deter sick people from yes seeking help doesn’t stand up Should David Jones is a foundation year 2 doctor, Charges may offer other benefits. patients diabetes and endocrinology, Worthing Hospital These include a reduction in missed [email protected] appointments, which are estimated to cost the NHS £162m a year.11 Charges pay to see Various calls have been made in recent have been shown to reduce missed years to charge patients for general reservations in other industries,12 13 practice consultations in the United and they might also encourage patients the GP? Kingdom.1 2 In 2014 motions in to take more personal responsibility, Copayments could raise much favour of copayments were defeated leading to fewer people attending with needed funds for the NHS, thinks at meetings of the BMA’s local medical conditions that they could manage committees3 and the Royal College themselves or that would be better David Jones, but Nancy Loader of Nursing.4 In Australia, however, managed through other primary care worries about increased overall patients pay the doctor at the end of services (pharmacists, dentists, nurses, cost and harms to patients general practice consultations. No one etc). This would lead to greater service sees this as unethical—it is the norm. availability and shorter waiting times in The amount depends on the duration general practice. and complexity of the consultation Although demographics differ, annual and on the clinician but is typically GP attendances per person in Australia about £10 for a standard consultation, (mean 5.6) are comparable with those with the remainder of the costs paid by in the UK,14 as are the number of the government.5 emergency department attendances The NHS prides itself on free (mean 0.29/person/year in Australia v healthcare at the point of service, but 0.33 in UK)15‑18 and life expectancy.19 with ever increasing demands, and This suggests that copayments are its inflation adjusted annual budget unlikely to affect care seeking behaviour rising over sevenfold from £15bn to or overall health. Any increase in use £115bn in its 67 year history,6 we of secondary care to avoid fees could need fundamental change to ensure its be countered by effective triage and prosperity and longevity. redirection to an increased provision of hospital based GPs. Drug prescriptions and dentistry People in the UK already pay towards No superior alternative drug prescriptions and dentistry, In a recent poll more than half of 440 which were free at the NHS’s GPs supported implementing charges for inception,7 showing that the public appointments.20 Copayments would not accepts that an entirely free healthcare be a vote winning strategy for politicians, model is not sustainable today. with healthcare unions and the public Prescriptions, despite 90% of items understandably against losing a free being exempt from charges, generate service.3 4 However, with billions of in excess of £400m gross income a pounds of savings needed to keep the year.8 health service afloat, political popularity We should follow many other will be tough whatever the strategy. developed countries and also pay To maintain the highest possible a fee when we see our GP. Given standards for all patients, amid that the average patient visits their ever increasing healthcare costs, we primary physician 5.5 times a year,9 need radical measures to ensure the a £10 fee, which most GPs would find continued success of the NHS. If we acceptable,10 could raise billions of could accept the morality of paying for pounds. Vulnerable groups, including consultations while ensuring strategies children and elderly people, would be to protect vulnerable people, we could exempt from charges as they are for reap the benefits of a more prosperous existing prescription charges. and less strained healthcare system.

12 9 January 2016 | the bmj You are being watched: panopticons in healthcare Ben Wessely and Clare Gerada consider the effect on medical practice of online rating websites

n the late 18th century the To understand doctors’ thoughts British philosopher Jeremy about websites that allow patients Bentham proposed a design for to rate them, one of the authors a prison, the “panopticon,” in (BW) conducted group discussions, which a single watchman could focus groups, and semi-structured Iobserve any of the inmates at any qualitative interviews at a series of time. The fact that the inmates would listening events for NHS staff in 2014 not know who was being watched at and 2015. Doctors at the events any moment meant that they would suggested that, despite their low act as though they were always popularity, these websites had great being watched. The ideas behind influence on doctors’ practice. They Bentham’s panopticon have parallels said that they feared that withholding Patients procedures, and admissions to with the constant scrutiny and non-evidenced or unnecessary do not hospital. A third (34%) reported that observation to which doctors are now treatment might mean disgruntled restrict their they had unnecessarily admitted subjected, though the principle of patients leaving negative comments. comments a patient to hospital because of central inspection, surveillance, and The effect of rating websites on to doctors’ patient satisfaction surveys, and monitoring is becoming ubiquitous health professionals has also been technical skill 18% endorsed a procedure that they across UK society in the digital age. examined in the United States. In a believed to be unnecessary. Research Online healthcare rating study of 155 doctors 78% reported also indicates that patients report websites such as PatientOpinion that patient satisfaction surveys lower levels of satisfaction with (www.patientopinion.org. moderately or severely affected their general practices that have a cautious uk), IWantGreatCare (www. job satisfaction. In addition, 28% approach to antibiotic prescribing. iwantgreatcare.org), and NHS had considered quitting their job or On rating websites patients do not Choices (www.nhs.uk) allow patients leaving the medical profession and restrict their comments to doctors’ to rate services and individual 20% reported their employment technical skill or knowledge. They healthcare professionals, though being threatened as a result of reflect on whether they had a “good currently few patients use them. A patient satisfaction data. emotional experience” and on doctors’ 2012 study in London reported that The findings of the US survey also personality, empathy, politeness, and 15% of people were aware of doctor indicated that rating websites led ability to listen. They also comment on rating sites but that only 3% had used to a change in clinical behaviour. car parking facilities, the comfort of them. Similar rates of use have been Almost half of the respondents the waiting room, waiting times, and reported in the United States, where believed that pressure to obtain better the ease of obtaining an appointment. more than 90% of the comments scores promoted inappropriate care, The websites mean that healthcare left are positive and there is little including unnecessary prescriptions professionals are now potentially evidence of negative reviews. of antibiotics and opioids, tests, under constant observation,

FIVE FACTS ABOUT THE MEDICAL WORKFORCE IN 2016

GENDER MIX The ETHNICITY The pro- DOCTORS FROM AGE GROUP Half of 1proportion of women in 2portion of doctors who are 3ABROAD Between 4doctors (50%) in training the medical workforce is rising, graduates of UK medical schools 2011 and 2013, there was an are aged between 20 and 29 and show data from the GMC’s latest and come from a black and mi- increase in the number of doc- 45% are aged between 30 and “State of medical education and nority ethnic background (BME) tors from Greece, Italy, Portugal, 39. The remaining 5% of junior practice in the UK” report. Wom- has increased. UK BME doctors and Spain gaining a UK licence doctors were aged 40 or over. en account for 57% of doctors in account for 17% of GPs and 15% to practise. During the same pe- The majority of doctors (57%) training, and 33% of specialists. of specialists. BME doctors who riod, there was a decrease in the with a licence to practise were Female GPs outnumber their gained their medical qualifica- number of UK licensed doctors aged between 30 and 49, and male colleagues, accounting for tion overseas made up 17% of from South Africa, by 478, and 27% were aged 50 and over. 63% of GPs under 40, 56% of the workforce, while BME doc- India, by 469. There were also Doctors are now retiring earlier those aged 40-49, and 37% of tors from the European Economic fewer graduates from Nigeria and the proportion of doctors those aged 50 and older. Area made up less than 1%. and Sudan. aged 60 and over has fallen.

14 9 January 2016 | the bmj Autopsy of an audit Christian Schopflin and colleaguesimplemented an audit that went “spectacularly” wrong. Here, they outline the reasons for the failure

he General Medical Council it. But training showed that the app did stipulates that “all doctors in not represent a true one stop shop, and clinical practice have a duty to occasionally additional requests had to be participate in clinical audit.” made. This substantially dampened staff But 56% of audits fail to achieve enthusiasm and staff became less keen to Tchange, and this may be an underestimate use the app. Research investigating the as failed projects often remain unreported. barriers to implementation of evidence We think three specific factors directly based practice widely recognises the contributed to a spectacular audit project importance of staff attitudes and motivation. failure. These were staff sickness, poor We think that staff disengagement with a stakeholder commitment, and leadership proposed change is an absolute red flag change. Awareness of these problems that warrants urgent re-evaluation of the A panopticon, in which inmates are under should help readers who may themselves be strategy. Failure to do so will undermine any constant scrutiny involved in service improvement work. project’s success. The audit evaluated whether preoperative extending beyond moments of formal investigations requested by nursing staff Leadership change observation. adhered to the National Institute for Health During the implementation phase the chief If websites for rating healthcare and Care Excellence guidelines. Results nurse transferred the project leadership professionals mean more showed that 15% of investigations were responsibilities to another staff member. compassionate or better care, then unnecessary. We therefore introduced The new leadership was well informed, but the panoptic model is surely not a an app, which is freely available at www. staffing levels became the department’s first bad thing. But rating websites may preop.uk that auto selects appropriate priority. This diverted attention and project be damaging the care of patients investigations once baseline parameters deadlines were missed. by a move away from the provision have been chosen. We believe that leadership change is an of evidence based medicine or After a trial period of one month our important event that should trigger the treatment, in patients’ best interests, re-audit showed that the app had been used following questions: Is this department towards acquiescence to patient in less than 3% of patients and performance ready for change? Are there more urgent demand. had not improved. Reflecting on the project’s priorities? Is the leadership truly committed Policies should focus on different failure we identified three red flag signals to the proposed change? Does the leadership methods of allowing patients to give that emerged during the implementation receive sufficient support? constructive feedback, rather than phase. These signals should have prompted Our project has been abandoned until promoting worry and even fear among a strategy review, and ignoring these further notice. Once the department is fully staff and organisations. warnings culminated in failure. staffed we may revisit this project. Ben Wessely is a MA student in social work As healthcare professionals we Clare Gerada is a general practitioner, London Staff sickness are expected to participate in service [email protected] We thought that New Year might be a good development and leadership despite having time for departmental change. But higher little or no formal expertise in these areas. We than usual staff sickness levels meant that hope that our experience will help others. FIVE FACTS ABOUT THE MEDICAL WORKFORCE IN 2016 training sessions were poorly attended Christian Schopflin is a year 7 specialist trainee, and raising awareness was difficult. The anaesthesia [email protected] SPECIALTY increased sickness absence in January James Wigley is a year 1 core trainee, anaesthesia 5A quarter (25%) of reflects a wider pattern found within the NHS and nationally. On this basis Anthony Shepherdson is a year 1 core trainee, licensed doctors on the anaesthesia, Salisbury NHS Foundation Trust we recommend spring and summer as specialist register work in Matt Taylor is a year 4 specialist trainee, anaesthesia, favourable periods for change. But August general medicine and 18% University Hospital Southampton NHS Foundation Trust of doctors work in surgery. may be disrupted by school holidays and The proportion of doctors new doctors starting work. Spring in each specialty had may therefore be the best time to remained relatively stable, implement new projects. but the proportion working in public health, pathology, Stakeholder commitment and occupational medicine Before introducing the app we consulted has fallen. nurses, who expressed enthusiasm for

the bmj | 9 January 2016 15 BMJ CONFIDENTIAL Anne Mackie Optimistic and pragmatic What was your earliest ambition? To be a doctor (honestly), though I hope my understanding of what it means to be a doctor has moved on a bit since I was . Less pipes, wires, and answers, and more social, psychological, and mysteries. Who or what has been your biggest inspiration? London. I came in  wide eyed at the mix of people, the excitement, ethnic food shops, and the fact that no one minded much what you did or looked like (within limits), and I still feel that every day. What was your best career move? Moving into national screening work. Very few public health jobs have such a clear link between research, guidance, and people living longer and healthier lives. For example, through work with literally thousands of clinicians, the NHS has one of the lowest rates of HIV transmission from mother to child in the world—an PETER LOCKE PETER achievement of which we should all be justly proud. Where are or were you happiest? Anne Mackie is director of On a beach with my family, eating crab sandwiches, and waiting to swim. programmes for the UK National What single unheralded change has made the most difference in your field Screening Committee an in your lifetime? independent body hosted by Public Health England but that provides Mobile telephony: millions of people worldwide can learn a little more about their advice to all four UK nations She and other people’s worlds, can access and spend money without bank accounts, has worked in public health for the and even get healthcare and advice across huge distances. More parochially, I can past  years including spells as work while travelling between meetings. director of public health in Kent southwest London and the London Do you support doctor assisted suicide? Strategic Health Authority She is I do. I believe that people should decide what’s best for themselves and get help if keen to emphasise that although they need it, though of course it needs to be carefully managed. screening is not o ered unless What book should every doctor read? evidence shows that it will do more good than harm for the target Foucault, Health and Medicine. It provides a way of thinking about prevention, group it is an individual’s right to health promotion, and the dominance of health and wellness as a modern choose screening and that depends preoccupation, and it really helped me to understand or at least analyse how on their being given sound health and wellness are used by policy makers. unbiased advice “Finding stu isn’t always a good thing” she told the What is your guiltiest pleasure? Times while describing current A detective novel I can read in three hours. tests for dementia as un t What television programmes do you like? I love the BBC self parody W A, though it is so excruciatingly embarrassing and on the mark that I mostly have to watch from behind the sofa. We have nominated one of my team as “head of better.” What, if anything, are you doing to reduce your carbon footprint? I cycle everywhere. Though to be honest it’s because I’m too impatient and mildly claustrophobic to enjoy waiting for and travelling on buses or tubes. What personal ambition do you still have? To stay fit and positive and to enjoy my family, friends, and work. Summarise your personality in three words Optimistic, direct, and pragmatic. What is your pet hate? People telling me that cycling is unsafe. Cite this as: BMJ ; :h Find this at: http://dx.doi.org/ . /bmj.h 

16 9 January 2016 | the bmj research update FROM THE JOURNALS Edited highlights of Richard Lehman’s blog on http://bmj.co/Lehman

study was done to assess the effect of delayed than a vague ball park guess about the Chlamydia and Boswell’s syndrome prescription strategies for uncomplicated likely contribution of various treatment I am about to embark respiratory tract infection. “Delayed strategies possibilities (non-pharmacological as on reading a biography were associated with slightly greater but well as pharmacological) to the outcomes of James Boswell, clinically similar symptom burden and of particular people. And most of these best known as a late duration and also with substantially reduced outcomes are binary—you either have a life companion of Dr antibiotic use when compared with an stroke or you don’t. When you put them Samuel Johnson and immediate strategy.” into a risk chart, many sensible people will also famous as a sex ̻̻JAMA Intern Med 2015, http://archinte. look at it and say, “You mean to say that addict who kept getting jamanetwork.com/article.aspx?articleid=2475025 I’d have to be one of 231 people to take gonorrhoea. He probably got chlamydia these pills for 10 years just so that one of too, but that wasn’t recognised as a cause of Carry on Egging us wouldn’t have a heart attack? Sod that.” urethritis until the middle of the 20th century. JAMA ends the year on a rather dull note, Public health doctors will hold up their These two sexually transmitted bacteria although this British study of in vitro hands in horror. Oxford professors will stand at opposite extremes of adaptability fertilisation provides a modicum of seasonal rage at general practitioners (and The BMJ) to antibiotic challenges. This study shows cheer. Perhaps it should be called Carry On for not imposing the supposed good of the that in young offenders’ institutions in the Egging, in honour of Barbara Windsor’s new herd on individuals. But why? It is for each United States, Chlamydia trachomatis is damehood. Although it is customary to stop in of us to play the odds of our lives as we 100% susceptible to doxycycline and 97% vitro fertilisation after three or four goes, UK choose. Many will choose to take the pills susceptible to azithromycin. By contrast, data show that it can be successful all the way and others will not. The only right choice is Neisseria gonorrheae, which is spread rapidly up to six, giving a cumulative live birth rate of informed patient choice. round the world by people with Boswell’s 65.3% after six cycles, with variations by age ̻̻Lancet 2016, doi:http://dx.doi. syndrome, has the genomic wherewithal to and treatment type. org/10.1016/S0140- develop resistance to “all known antibiotics.” ̻̻JAMA 2015, http://jama.jamanetwork.com/article. 6736(15)01225-8 Allegedly. In fact I have heard this claimed aspx?articleid=2478204 repeatedly over the past 30 years. It is always Homeric choices: about to happen—but never to me, I hasten to Blood pressure lowering and the salt versus soap add. meaning of life Here’s a trial that could ̻̻N Engl J Med 2015, www.nejm.org/doi/ A meta-analysis of have come straight out full/10.1056/NEJMoa1502599 blood pressuring of Homer. The epic poet, lowering for the I mean, not Father Simpson. Antibiotics: the Spanish strategy prevention of Let’s imagine there is a version of the Iliad in Spain is a country where cardiovascular disease which Achilles, meeting Hector on the windy antibiotic prescribing is and death appeared plain of Troy, smashes his leg instead of killing roughly similar to that just before Christmas. him outright. Hector’s attendants rush to him in the United Kingdom. The authors concluded: with bowls of water to clean his compound As I keep pointing out, “Our results provide strong support fracture. Some of the offerings are soapy and antibiotic resistance is for lowering blood pressure to systolic some are salty. Which should the surgeon highly organism specific, blood pressures less than 130 mm Hg use? Three thousand years on you would have and for the most part and providing blood pressure lowering thought we might know, but this Canadian respiratory pathogens are rather bad at treatment to individuals with a history of trial seems to be the first to settle the question. developing it. Yet whenever the antibiotic cardiovascular disease, coronary heart “The management of open fractures requires doomsday scenario comes up, everyone from disease, stroke, diabetes, heart failure, wound irrigation and débridement to remove the chief medical officer down to the bloke in and chronic kidney disease.” I think this contaminants, but the effectiveness of various the supermarket queue starts talking about may mark a watershed moment in the pressures and solutions for irrigation remains how general practitioners hand out antibiotics use of blood pressure lowering agents. controversial. We investigated the effects of for colds and flu as if they were Smarties. If But contrary to most commentators, I castile soap versus normal saline irrigation this is true—which it actually isn’t—then it think it will lead to a large and welcome delivered by means of high, low, or very low has made remarkably little difference over decline in their use. Our cardiovascular irrigation pressure.” Forget the pressures: they 60 years to the effectiveness of antibiotics risk prediction instruments fail to make no difference. But the reoperation rate for respiratory tract infections. The true predict most of the absolute risk and was higher in the soap group than in the saline problem lies elsewhere entirely. But let’s go have poor overlap with each other. There group. back to Spain, where this nice primary care is no way that we can produce more ̻̻N Engl J Med 2015, www.nejm.org/doi/ the bmj | 9 January 2016 17 The BMJ is an Open ORIGINAL RESEARCH Prospective, nationwide cohort study Access journal. We set no word limits on BMJ research articles, but they are abridged for print. The full text of each BMJ research article is freely available on thebmj.com. The online version is published along with peer and patient reviews for the paper, and a statement about

how the authors will GUSTOIMAGES/SPL share data from their months before pregnancy onset (that is, recent study. Maternal use of oral contraceptives and risk of birth defects in use); 24.8, use after pregnancy onset). No increase in prevalence of major birth defects The linked Denmark commentaries in was seen with oral contraceptive exposure this section appear Charlton BM, Mølgaard-Nielsen D, Svanström H, Wohlfahrt J, among women with recent use before pregnancy on thebmj.com as Pasternak B, Melbye M (prevalence odds ratio 0.98 (95% confidence editorials. Use the Cite this as: BMJ 2016;352:h6712 interval 0.93 to 1.03)) or use after pregnancy citation given at the Find this at: http://dx.doi.org/10.1136/bmj.h6712 onset (0.95 (0.84 to 1.08)), compared with the end of commentaries to Study question Is oral contraceptive use around reference group. There was also no increase in cite an article or find it the time of pregnancy onset associated with an prevalence of any birth defect subgroup (for online. increased risk of major birth defects? example, limb defects). It is unknown whether women took oral contraceptives up to the date Methods In a prospective observational cohort of their most recently filled prescription. Also, study, data on oral contraceptive use and major birth the rarity of birth defects made disaggregation of defects were collected among 880 694 live births the results difficult. Residual confounding was from Danish registries between 1997 and 2011. possible, and the analysis lacked information on We conservatively assumed that oral contraceptive folate, one of the proposed mechanisms. exposure lasted up to the most recently filled prescription. The main outcome measure was the What this study adds Oral contraceptive number of major birth defects throughout one exposure just before or during pregnancy does year follow-up (defined according to the European not appear to be associated with an increased Surveillance of Congenital Anomalies classification). risk of major birth defects. Logistic regression estimated prevalence odds ratios of any major birth defect as well as categories of birth Funding, competing interests, data sharing BMC was funded by the Harvard T H Chan School of Public defect subgroups. Health’s Maternal Health Task Force and Department of Epidemiology Rose Traveling Fellowship; training grant Study answer and limitations Prevalence of major T32HD060454 in reproductive, perinatal, and paediatric birth defects (per 1000 births) was consistent epidemiology and award F32HD084000 from the Eunice across each oral contraceptive exposure group Kennedy Shriver National Institute of Child Health and Human Development; and grant T32CA09001 from the (25.1, never users; 25.0, use >3 months before National Cancer Institute. The authors have no competing pregnancy onset (reference group); 24.9, use 0-3 interests or additional data to share.

Risk of major birth defects in live births by maternal oral contraceptive use before and after pregnancy onset in 1997- 2011 (n=880 694) Latest oral contraceptive Prevalence odds ratios (95% CI) use before and after pregnancy onset No of live births No of birth defects Unadjusted Adjusted* Never 183 963 4609 1.00 (0.97 to 1.04) 1.06 (1.02 to 1.10) >3 months before 611 007 15 271 Reference Reference 0-3 months before 74 542 1856 1.00 (0.95 to 1.05) 0.98 (0.93 to 1.03) After 11 182 277 0.99 (0.88 to 1.12) 0.95 (0.84 to 1.08) *Adjusted for demographics (maternal age at pregnancy onset, calendar year, place of birth, county of residence, married/living with partner, level of education, and household income), parity, history of birth defects in a previous pregnancy, smoking in pregnancy, and healthcare use (prescription drug use in last six months, hospital admissions in last five years, and outpatient contacts in last five years).

18 9 January 2016 | the bmj Taxing sugar ORIGINAL RESEARCH Observational study

Beverage purchases from which adjusts for both macroeconomic variables stores in Mexico under the that can affect the purchase of beverages over time, and pre-existing trends. The variables excise tax on sugar sweetened used in the analysis included demographic BLOOMBERG/GETTY IMAGES beverages information on household composition (age and and up to a 17% decrease by December 2014 Colchero MA, Popkin BM, Rivera JA, Ng SW sex of household members) and socioeconomic compared with pretax trends. Purchases of Cite this as: BMJ 2016;352:h6704 status (low, middle, and high). The authors untaxed beverages were 4% (36 mL/capita/day) Find this at: http://dx.doi.org/10.1136/bmj.h6704 compared the predicted volumes (mL/capita/ higher than the counterfactual, mainly driven by day) of taxed and untaxed beverages purchased an increase in purchases of bottled plain water. Study question What has been the effect on in 2014—the observed post-tax period—with purchases of beverages from stores in Mexico the estimated volumes that would have been What this study adds The tax on sugar one year after implementation of the excise tax purchased if the tax had not been implemented sweetened beverages was associated with on sugar sweetened beverages? (counterfactual) based on pretax trends. reductions in purchases of taxed beverages and increases in purchases of untaxed beverages. Methods In this observational study the authors Study answer and limitations Relative to the Continued monitoring is needed to understand used data on the purchase of beverages in counterfactual in 2014, purchases of taxed purchases longer term, potential substitutions, Mexico from January 2012 to December 2014 beverages decreased by an average of 6% (−12 and health implications. from an unbalanced panel of 6253 households mL/capita/day), and decreased at an increasing Funding, competing interests, data sharing This providing 205 112 observations in 53 cities with rate up to a 12% decline by December 2014. All work was supported by grants from Bloomberg more than 50 000 inhabitants. To test whether three socioeconomic groups reduced purchases Philanthropies and the Robert Wood Johnson Foundation and by the Instituto Nacional de Salud the post-tax trend in purchases was significantly of taxed beverages, but reductions were higher Pública and the Carolina Population Center. The different from the pretax trend, the authors used among the households of low socioeconomic authors have no competing interests. No additional a difference in difference fixed effects model, status, averaging a 9% decline during 2014, data are available.

COMMENTARY An old idea with a new place in the fight against obesity? A staggering growth of obesity rates in Designing taxes to engineer an be met, and complementary actions put in countries worldwide has left governments improvement in people’s diets place. The single most valuable contribution and other stakeholders scrambling for is complex taxes can make to a public health strategy is effective solutions.1 2 Several countries the signal they give consumers and the entire have chosen to use taxes on foods and confirmation is of the greatest importance for food system, that a government is concerned non-alcoholic beverages in an attempt to governments that have opted to use taxes on about the harms associated with unhealthy improve the quality of people’s diets and sugar sweetened beverages as part of public diets and is serious about tackling them. This curb the spread of obesity.5 Mexico was health strategies, and those considering is the strongest incentive for consumers to one of the latest to join this group, when it. Whether consumers’ reactions will reconsider choices and for players in the food in 2014 it launched a comprehensive lead to healthier diets depends on how supply chain to reorient their production strategy to fight an obesity problem that taxes are designed and what selection of towards healthier options. has reached extraordinary proportions. The products they target. Despite evidence of an Taxes have a place within a broader strategy includes taxes on sugar sweetened increase in purchases of untaxed beverages, menu that includes regulatory measures beverages and on calorie dense foods.7 especially bottled water, the full extent of (for example, nutrition labelling,), health Colchero and colleagues report the first, substitutions made by Mexican consumers education based on a sound behavioural much anticipated, empirical evaluation of the is not known. We also do not know from the understanding of consumers’ food choices, early impacts of Mexico’s excise tax on sugar study whether a 1 peso/L tax is large enough incentives for research and development in sweetened beverages.8 Purchases of taxed to achieve meaningful health benefits. food production, voluntary initiatives with beverages in urban areas in Mexico declined Designing taxes to engineer an agreed targets and independent monitoring, more than expected, while purchases of improvement in people’s diets is complex. changes in the environment of food choice, untaxed beverages increased. Reductions Setting them at sufficiently high levels is and counselling by general practitioners of in purchases of sugar sweetened beverages politically challenging, and increases the risk people at higher risk. Making people pay for were larger and increased over time for of unintended consequences. Taxes cannot be their potentially unhealthy consumption consumers of lower socioeconomic status. viewed as a magic bullet in the fight against choices is not a success for public health. If all These results are not surprising, but their obesity. The claim that sugar is an ideal of the above policies were used systematically candidate for taxation dates back at least to and effectively, the focus of the policy debate Franco Sassi, head, OECD Public Health Programme, Health Division [email protected] Adam Smith’s work on the “wealth of nations” might shift away from taxes in the future. This editorial does not represent the official views of in the 18th century, but for taxes to improve Cite this as: BMJ 2016;352:h6904 the OECD population health, many conditions must Find this at: http://dx.doi.org/10.1136/bmj.h6904

the bmj | 9 January 2016 19 Which treatment strategy for women with symptoms of UTI? ORIGINAL RESEARCH Randomised controlled trial

Ibuprofen versus fosfomycin respective placebo dummies in both groups). for uncomplicated urinary In both groups additional antibiotic treatment tract infection in women was subsequently prescribed as necessary for persistent, worsening, or recurrent symptoms. Gágyor I, Bleidorn J, Kochen MM, Schmiemann G, The primary endpoints were the number of all Wegscheider K, Hummers-Pradier E courses of antibiotic treatment on days 0-28 MARAZZI/SPL P Cite this as: BMJ 2015;351:h6544 (for UTI or other conditions) and burden of What this paper adds Two thirds of Find this at: http://dx.doi.org/10.1136/bmj.h6544 symptoms on days 0-7. The symptom score women with uncomplicated UTI treated Study question Can treatment of the included dysuria, frequency/urgency, and low symptomatically with ibuprofen recovered symptoms of uncomplicated urinary tract abdominal pain. without any antibiotics. Initial symptomatic infection (UTI) with ibuprofen reduce the treatment is a possible approach to be rate of antibiotic prescriptions without Study answer and limitations The 248 women discussed with women willing to avoid a significant increase in symptoms, in the ibuprofen group received significantly immediate antibiotics and to accept a recurrences, or complications? fewer course of antibiotics, had a significantly somewhat higher burden of symptoms. higher total burden of symptoms, and more Funding, competing interests, data sharing German Methods Women aged 18-65 with typical had pyelonephritis. Four serious adverse Federal Ministry of Education and Research (BMBF) symptoms of UTI and without risk factors or events occurred that led to hospital referrals; No 01KG1105. Patient level data are available from the corresponding author. Patient consent was not complications were recruited in 42 German one of these was potentially related to the trial obtained but the data are anonymised and risk of general practices and randomly assigned to drug. Results have to be interpreted carefully identification is low. The authors have no competing treatment with a single dose of fosfomycin 3 g as they might apply to women with mild to interests or additional data to share. (n=246; 243 analysed) or ibuprofen 3×400 mg moderate symptoms rather than to all those Trial registration ClinicalTrialGov Identifier (n=248; 241 analysed) for three days (and the with an uncomplicated UTI. NCT01488955.

COMMENTARY Many women could avoid antibiotics Uncomplicated urinary tract infection (UTI) In women with mild or moderate initially treated with ibuprofen was low is the most common bacterial infection in symptoms, delayed prescribing (0.10 courses per patient). This indicates, women. Most women experience at least might also be feasible, and perhaps not surprisingly, that urine culture one episode during their lives, and each randomised trials should be done can help to identify the individuals most year about 10% receive one or more courses to test this strategy likely to benefit from antibiotics. of antibiotics for UTI.1 2 Those with typical Symptoms of uncomplicated UTI symptoms are treated empirically, though with symptoms of uncomplicated UTI who are uncomfortable, and most women up to half of them do not have clinically were treated with ibuprofen could recover will want to start effective treatment as significant bacteriuria. Many women with without antibiotics, the trade-off being a soon as possible. The challenge is how symptoms will recover without antibiotics.3 moderately higher symptom burden overall. to identify those that need antibiotics. Studies comparing antibiotics with After one week, only 70% of women in the Overtreatment could lead to adverse effects, placebo in women with uncomplicated UTI NSAID group were symptom free compared and most patients are aware that overuse of have reported delayed cure in the placebo with 82% of women in the antibiotic group. antibiotics leads to antimicrobial resistance. group, but most become symptom free More women given the NSAID developed Antimicrobial treatment should therefore within a week.3 4 Prescriptions of antibiotics pyelonephritis (5 v 1). The difference be initiated only if treatment is expected to to patients with self limiting conditions was not significant, but the trial was reduce or shorten the symptom burden or contributes to antimicrobial resistance. WHO underpowered for this uncommon outcome. reduce the risk of complications.6 considers antimicrobial resistance to be one Among women with positive urine Access to point of care testing such as of the three most important public health cultures, those treated initially with urine phase contrast microscopy, culture, problems globally, and initiatives to reduce ibuprofen had a significantly higher and direct susceptibility testing would help inappropriate and superfluous prescribing burden of symptoms than women given to identify women who need antibiotics.7‑9 are essential if we are to maintain effective fosfomycin, and a substantial number of In women with mild or moderate symptoms, antibiotic treatment for future generations. women treated with ibuprofen needed delayed prescribing might also be feasible, Overall, Gágyor and colleagues’ study antibiotics during follow-up (0.49 courses and randomised trials should be done to test suggests that about two thirds of women per patient). Among women with negative this strategy. Delayed prescribing has been results on urine culture, however, there shown to reduce antibiotic prescriptions for Lars Bjerrum [email protected] was no significant difference in burden respiratory tract infections by 50-70%.11 12 Morten Lindbæk of symptoms between the two treatment Cite this as: BMJ 2015;351:h6888 See thebmj.com for authors’ details groups, and antibiotic use in the women Find this at: http://dx.doi.org/10.1136/bmj.h6888

20 9 January 2016 | the bmj full/10.1056/NEJMoa1508502

the bmj | 9 January 2016 21 comment‘ Confidence is an odd thing when combined with inevitable clinical uncertainty. When the evidence is explained, how do we know that more women will want HRT?

‘NO HOLDS BARRED Margaret McCartney Why less confidence is good n any of the exams I’ve ever sat There’s a lovely graph that illustrates I’ve never been asked, “What don’t how confidence and knowledge vary with we know?” Hormone replacement time. We start with lots of confidence and therapy (HRT) is in the news. little knowledge and end up with more The papers say that GPs aren’t knowledge but less confidence. Another Iprescribing it enough.1 2 Further, the curve has yet to be added, of anxiety felt National Institute for Health and Care because of uncertainty, which probably Excellence has said that its new advice starts high and then decreases, only to on menopause is “to help GPs and other wax and wane with spikes and descents healthcare professionals to be more confident in over time—related to what you see, what you think prescribing HRT and women more confident in you see, and what your colleagues tell you they see. taking it.”3 We’re good at setting up systems to get us to Confidence is an odd thing when combined with prescribe more, test more, do more. We’re less inevitable clinical uncertainty. When the evidence inclined to generate systems that make explicit is explained, how do we know that more women the uncertainties of what we’re doing. We’re even will want HRT? How do we know that we should feel unsure, I think, about the best information to help confident about prescribing it? When does it become individual patients make high quality choices. And clinically unreasonable to prescribe HRT? How about we’re unsure about how to do this in the pressure of for the 20th year, to a 70 year old woman who smokes a GP consultation or when people have reading or and has hypertension and a strong family history numeracy problems. of breast cancer, who has had a possible transient Part of improving risk literacy is about ischaemic attack but says that she accepts the risks? acknowledging doubt, margins of error, and Medicine is prone to conflate a lack of knowledge whether the research available fits the patient we’re with stupidity, academic inability, or laziness. “Be applying it to. How certain are you, doctor? And wrong but never in doubt” was a tip for medical how confident are you in that level of certainty? Less school exams that, I’m ashamed to say, I cheerfully confidence may make for higher reliability, more followed definitively. Wouldn’t it have been better to thoughtful medicine, and better choices. ask, “How much more likely is it, do you think, that Margaret McCartney is a general practitioner, Glasgow sitting patients forward and asking them to hold in [email protected] full expiration will make clinically important aortic ̻̻Follow Margaret on Twitter, @mgtmccartney regurgitation audible?” Is this about tradition or Cite this as: BMJ 2015;351:h6321 evidence? Do you know? Do I? Find this at: http://dx.doi.org/10.1136/bmj.h6321

LATEST ONLINE COMMENT AND BLOGS ЖЖRead more articles by Margaret McCartney at bmj.co/margaretmccartney ЖЖRead more articles by David Oliver at bmj.co/davidoliver ЖЖTobacco smuggling: read more smoking related articles at http://bmj.co/smoking the bmj | 9 January 2016 21 ANALYSIS Cancer screening has never been shown to “save lives” Vinay Prasad and colleagues argue that overall mortality rather than disease specific mortality should be the benchmark against which cancer screening is judged

espite growing appreciation 10 000) and the control arm (7109 deaths per of the harms of cancer 10 000; P=0.97). Hazard ratios and Kaplan screening,1‑3 advocates still Meier curves corroborate this finding of no claim that it “saves lives.”4 This mortality difference. For 80% power to detect assertion rests, however, on a difference in overall mortality of 64 deaths Dreductions in disease specific mortality rather per 10 000 (assuming the disease specific than overall mortality. benefit was not offset by other deaths), the The burden falls on providers to provide trial would have needed to be about five times clear information about both disease as large. specific and overall mortality and to ensure However, meta-analyses of fecal occult receive either low dose computed tomography that the overall goal of healthcare—to blood testing have shown a slight increase (CT) or chest radiography. CT was widely improve quantity and quality of life—is not in deaths unrelated to colorectal cancer reported to show a 20% relative reduction undermined.7 associated with screening, which implies that in lung cancer deaths and a 6.7% relative In this article we argue that overall downstream effects of screening may partially reduction in overall mortality.19 However, the mortality should be the benchmark against or wholly negate any disease specific gains.11 absolute risk reduction in overall mortality which screening is judged and discuss how to Such “off-target deaths” are particularly was only 0.46%, and several limitations improve the evidence upon which screening likely among screening tests associated undermine even this narrow margin. rests. with false positive results, overdiagnosis Firstly, chest radiography for lung of non-harmful cancers, and detection of screening is not standard of care—it is well Why cancer screening might not reduce incidental findings. For example, prostate known not to improve disease specific or overall mortality specific antigen (PSA) testing yields numerous overall mortality.20 Discrepancies between disease specific and false positive results, which contribute to Secondly, in the CT group the improvement overall mortality were found in direction or over one million prostate biopsies a year.12 in overall mortality exceeded the gains in magnitude in seven of 12 randomised trials Prostate biopsies are associated with serious lung cancer mortality by 36 deaths (87 fewer of cancer screening.8 Despite reductions in harms, including admission to hospital and deaths from lung cancer and 123 fewer disease specific mortality in the majority of death.12 13 Moreover, men diagnosed with deaths overall). But CT screening did not studies, overall mortality was unchanged or prostate cancer are more likely to have a seem to reduce deaths due to other cancers or increased. heart attack or commit suicide in the year improve cardiovascular survival to account for There are two chief reasons why cancer after diagnosis14 or to die of complications these 36 fewer deaths. If we assume that the screening might reduce disease specific of treatment for cancers that may never have improvement in non-lung cancer mortality mortality without significantly reducing caused symptoms.12 13 was by chance and remove this difference, the overall mortality. Firstly, studies may be The overall effect of cancer screening on overall mortality benefit disappears (P=0.11). underpowered to detect a small overall mortality is more complex than a disease Thirdly, the benefit in lung cancer mortality benefit. Secondly, disease specific specific endpoint can capture, owing to the mortality of CT screening (estimated to avert mortality reductions may be offset by deaths harms of further testing, overdiagnosis, and over 12 000 lung cancer deaths in the US due to the downstream effects of screening. overtreatment. Realisation of this has led annually)25 must be set against the 27 034 Underpowered studies lead to uncertainty to reversal or abandonment of a number major complications (such as lung collapse, and assumptions of benefit rather than of screening campaigns, including chest heart attack, stroke, and death) that follow a scientific evidence of benefit. In the 30 year radiography screening for lung cancer, urine positive screening test (NLST investigators, follow-up of the Minnesota Colon Cancer testing for neuroblastoma, and PSA for personal communication, 2015).19 Control Study, which assessed annual fecal prostate cancer.6 15‑ 18 occult blood testing, there were 128 deaths Public perception of screening from colon cancer per 10 000 participants Mortality benefits of screening trial A systematic review has shown that the in the screened group and 192 per 10 000 require close scrutiny public has an inflated sense of the benefits in the control arm—a statistically significant Arguably the strongest evidence that a single and discounted sense of the harms of difference of 64 deaths per 10 000.10 But there screening test can save lives comes from the mammography screening, the cervical smear was a difference of only two overall deaths National Lung Cancer Screening Trial (NLST), test, and PSA screening.27 In one study 68% between the screened arm (7111 deaths per which randomised 53 454 heavy smokers to of women thought that mammography

22 9 January 2016 | the bmj PERSONAL VIEW Karen Middleton Give patients direct access to physiotherapy services They want it, and it would benefit GPs too

2012 survey found As many as England lags behind potential savings are enormous in that direct referral 30% of GP For patients, direct access to terms of money and appointments. for physiotherapy consultations physiotherapy reduces waiting This is why GPs are increasingly was available in 40 may be for times (in Torbay, for example, it bringing in physiotherapists to countries, including musculoskeletal cut waiting times from 10 weeks work alongside them in their AAustralia, Brazil, South Africa, to just three days or less for 90% practices rather than in outpatient conditions, so the Sweden, and parts of the United of patients);3 it achieves high clinics, where self referral is States.1 potential savings satisfaction levels (for instance, more traditionally found. These Yet a freedom of information are enormous three quarters of patients report physiotherapists see people who audit conducted by the Chartered in terms of being satisfied or very satisfied present with common problems, Society of Physiotherapy in 2014 money and with the ability to self refer); and it such as musculoskeletal conditions, showed a strangely inconsistent appointments improves outcomes through earlier to free up GP appointments for approach in the NHS.2 In Scotland, access to care.4 It helps to stop patients who require more complex 12 of the 14 health boards acute problems becoming chronic medical management. This direct confirmed that they have full self and reduces long term pain and access model is being used to good referral, and the remainder offer it disability.5 And people who self effect in several areas, including partially, either in selected areas refer need less time off work—it can NHS vanguard sites in south or only for specific conditions. cut the average absence by 58%.6 Hampshire and west Cheshire. Patients in Wales can access It makes economic sense, too: physiotherapy directly in five of evidence shows that self referral Strong support for self referral seven health board areas. But cuts costs by an average of £33 It is little wonder, then, that just 46 of England’s 211 clinical a patient,7 saving as much as a support on the ground seems commissioning groups offer full self quarter of the total.8 As many as strong. A yearly poll of primary referral, and another 20 offer self 30% of GP consultations may be for care professionals, in which GPs referral in some cases.2 musculoskeletal conditions,9 so the made up 60% of the sample, found

TOBACCO CONTROL Martin McKee, Anna B Gilmore Philip Morris’s own data Europe is failing to combat indicate that in 2010 almost a tobacco smuggling quarter of illicit cigarettes in Europe were its brands What are agreements with the industry worth? own data indicate that in 2010, six For over a decade the European International to tackle the illicit years into the agreement, almost a Union’s antifraud organisation, OLAF trade.3 Subsequently, the EU signed quarter of illicit cigarettes in Europe (Office Européen de Lutte Antifraude) similar agreements with three were its brands.4 It is clear that the has, controversially, engaged with other big tobacco companies. The tobacco industry has not adequately the tobacco industry, ostensibly to agreement with Philip Morris is about controlled its supply chain and that counter tobacco smuggling. This to expire, and talks on possible the fines detailed in the agreements is despite extensive evidence of renewal have begun. are not enough to deter the industry industry complicity in smuggling,1 a from involvement in illicit trade.3 4 situation that seems to persist.2 It also Lack of transparency An investigation made under represents a U-turn by OLAF, which in These agreements may have freedom of information legislation 2000 filed a lawsuit accusing tobacco undermined OLAF’s judgment.3 showed that OLAF had failed to hold manufacturers of “an ongoing global Analysis has highlighted a lack of the industry to account. One document scheme to smuggle cigarettes.” transparency in how the agreements dated 3 July 2015 set the tone. In it In 2004 OLAF halted this litigation operated, with growing industry Philip Morris noted that it “continues in exchange for a legally binding control over data, making them almost to be extremely pleased with the agreement with Philip Morris impossible to evaluate. Philip Morris’s operation of the agreement.”5

24 9 January 2016 | the bmj The overall effect of cancer screening on mortality is more complex than a disease specific endpoint can capture

Such trials are worth the expense compared with the continued cost of supporting widespread screening campaigns without knowing whether they truly benefit society.5 The cost of adopting CT screening for lung cancer by the Medicare population has been estimated to surpass $6bn a year.46 To reduce costs, trials could target just the highest risk groups, with successful results prompting trials in lower risk groups. For example, the potential benefits of CT screening for lung cancer vary by age and smoking history of the participant.47 Screening trials could also ascertain all causes of death among all participants to monitor any increase in off target deaths.42 GEOFF TOMPKINSON/SPL GEOFF This would be an improvement over current would lower their risk of getting breast results.35 When researchers do examine the standards, but it would not overcome most cancer, 62% thought that screening at harms of screening the results are typically of the concerns we have identified. Primary least halved the rate of breast cancer, and sobering. study data should be made available in a 75% thought that 10 years of screening False positive results on breast cancer usable format for re-analysis.48‑50 would prevent 10 breast cancer deaths per screening have been associated with 1000 women.28 Even the most optimistic psychosocial distress as great as a breast Barriers to trials powered for overall mortality estimates of screening do not approach these cancer diagnosis 6 months after the event.36 Political will, financial resources, and public numbers.29 30 False positive results affect over 60% of perception are common hurdles in building As long as we are unsure of the mortality women undergoing screening mammography support for resource intensive scientific benefits of screening we cannot provide for a decade or more,37 and 12-13% of all endeavours, and developing consensus on people with the information they need men who have undergone three or four these matters will take time and effort. to make an informed choice. We must be screening rounds with PSA.38 In the NLST honest about this uncertainty. 39.1% of people had at least one positive test Conclusion A summary of the Swiss government’s result, of which 96.4% were false positives. We encourage healthcare providers to be decision not to recommend mammography One in 12 (9.4%) of those people had frank about the limitations of screening— shows that for every 1000 women who invasive procedures—such as needle biopsy, the harms of screening are certain, but the undergo screening one breast cancer death is mediastinoscopy, and open thoracotomy—to benefits in overall mortality are not. Declining averted (from five to four), while non-breast learn that they didn’t have lung cancer. screening may be a reasonable and prudent cancer deaths either remain at 39 or may choice for many people. Providers should also increase to 40.34 If non-breast cancer deaths What next? encourage participation in open studies. remain the same, a woman must weigh net How can we know whether screening saves We call for higher standards of evidence, benefit against harms. If screening increases lives? We need trials that are ten times not to satisfy an esoteric standard, but to non-breast cancer deaths to 40, women larger and powered for overall mortality.5 6 enable rational, shared decision making would simply be trading one type of death Researchers have postulated, based on between doctors and patients. As Otis for another, at the cost of serious morbidity, a colorectal cancer trial, that 4.1 million Brawley, chief scientific and medical officer anxiety, and expense. Women should participants would be needed to demonstrate of the American Cancer Society, often be told that to date, with over 600 000 a reduction in overall death, compared with states: “We must be honest about what we women studied, there is no clear evidence 150 000 for disease specific death.42 know, what we don’t know, and what we of a reduction in overall mortality with Studies of this size may be estimated to simply believe.” mammography screening.30 cost upwards of $1bn (£0.7bn; €0.9bn), Vinay Prasad, assistant professor, Division of but conducting such trials in large national Hematology and Medical Oncology, Knight Cancer Harms observational registries would dramatically Institute, Oregon Health and Science University, Consideration of harms becomes more reduce the cost. Large trials should be Portland [email protected] important in the absence of clear overall pragmatic, with inclusion criteria that Jeanne Lenzer, journalist, New York, USA mortality benefit. Empirical analyses show mirror the real world population in which David H Newman, professor, Department of that primary screening studies pay little the intervention is used. The safest way to Emergency Medicine, Icahn School of Medicine at attention to the harms of screening—of 57 introduce or change screening programmes Mount Sinai, New York Cite this as: BMJ 2016;352:h6080 studies only 7% quantified overdiagnosis at the national level is by incorporating Find this at: http://dx.doi.org/10.1136/bmj.h6080 45 and just 4% reported the rate of false positive randomisation. ЖЖEDITORIAL, p 8 the bmj | 9 January 2016 23 ACUTE PERSPECTIVE David Oliver Why I let some inpatients stay longer

that 81% backed self referral for Working together I have a confession: I sometimes allow patients to stay physiotherapy.10 So the bigger To be clear, however, this isn’t an extra day or three in hospital, even when they’re question is, why isn’t self referral about physiotherapists replacing technically stable enough to leave. happening throughout the NHS GPs; it’s about working together Yes: I know that it’s bad. Beds are scarce, as well as cost in England? Two myths may be to to create a new front line in intensive, and newer, sicker patients at the front door will blame. primary care that makes full use always need them more. Firstly, we hear the myth of the talents the NHS has at its Prolonged stays in hospital can harm patients by causing that opening up the service in disposal. Through these new dependence. So, am I a hypocrite for letting people stay for this way could lead to it being teams we can ensure that patients “soft” reasons? overwhelmed by inappropriate see the right professional at the Doctors are in a people business—or they’re in the referrals. The evidence, however, right time to create a truly person wrong job. Population health and system leadership shows no such surge with a well centred system that puts patients matter, but the foundation of our profession is still planned new offering and shows in control of their care in a cost care for individuals. In ethical terms;6 should equity in that any increase soon levels off.4 effective way.12 allocation of scarce resources always outflank respect for Secondly, there is the myth that autonomy, despite all that we hear about person centred Karen Middleton is visiting professor, Leeds patient safety may be put at risk by Metropolitan University; chief executive, care based on individual needs? removing the GP from the process. Chartered Society of Physiotherapy, London Perhaps a patient doesn’t want that Physiotherapists complete [email protected] community hospital because his wife died extensive training, which includes there, and memories abound assessment and clinical diagnosis. thebmj.com Serious pathology should be ̻̻Personal view: Self referral would If patients need ongoing rehabilitation or social care I’d picked up by this process with empower patients and doctors like to ensure that they get it, however full the hospital. detailed questioning and always (BMJ 2016;352:h6844) If not, they risk permanent disability or badly supported, referred on to a medical specialist Cite this as: BMJ 2015;351:h6844 distressing discharge, avoidable readmission, and more 7 8 if concerns arise. Find this at: http://dx.doi.org/10.1136/bmj.h6844 stress to carers struggling for any sense from the system. If it’s late at night and older patients are going home TOBACCO CONTROL Martin McKee, Anna B Gilmore alone, I sometimes keep them until morning, especially after falls. Other reasons include patients needing an extra day Track and trace evidence that this relationship has to regain confidence or to wait until a supportive relative Europe is failing to combat The EU’s Tobacco Products benefited only the industry.3 is around, or if they know from experience of their own tobacco smuggling Directive,7 due to come into force Finally, Philip Morris is condition and multiple admissions that discharge is more in 2016, requires that all tobacco challenging the Tobacco Products likely to work if briefly postponed. Perhaps a patient What are agreements with the industry worth? traded in Europe be identified Directive in the European Court of doesn’t want that community hospital because his wife by “track and trace” systems Justice. Can OLAF justify continuing died there, and memories abound. Maybe a patient’s 85 from May 2019. The industry has its cooperation with a company year old husband prefers a nursing home he can visit on taken the lead, promoting its own whose action, if successful, would public transport. system, Codentify, which has many prevent implementation of the EU’s I’ve had numerous donations, cards, and funeral weaknesses.8 Most worryingly, most important piece of tobacco invitations from families of patients who chose to remain Codentify puts the industry in control legislation in the past on the ward for palliative care even though they had been control of the system, despite its decade? offered support to die out of hospital. Was it wrong to long history of involvement in the exercise some humane discretion? Martin McKee is professor of European illicit trade and of manipulating public health, London School of Hygiene It will be a sad day when we judge acute hospital 9 data about illicit trade. and Tropical Medicine, London doctors’ performance principally by how many admissions Other systems avoid these WC1H 9SH, UK they stop and how quickly they send people home. I’ve problems, but the tobacco industry [email protected] confessed, but I think I’m unrepentant. 10 is lobbying against them. Now, Anna B Gilmore is professor of public David Oliver is a consultant in geriatrics and acute general medicine, OLAF has expressed concern that health, Department for Health, University Berkshire [email protected] any rival technology might disrupt of Bath, Bath, UK ̻̻Follow David on Twitter, @mancunianmedic its relationship with the industry. Cite this as: BMJ 2015;351:h6973 Cite this as: BMJ 2015;351:h5225 This is despite accumulating Find this at: http://dx.doi.org/10.1136/bmj.h6973 Find this at: http://dx.doi.org/10.1136/bmj.h5225

the bmj | 9 January 2016 25 Endre “Andrew” Czeizel Medical geneticist who showed risk of neural tube defects can be reduced if pregnant women take folic acid

Endre “Andrew” Czeizel (b 1935; q Semmelweis participant from the Soviet bloc in meetings University, Budapest, 1959), died from in the West. He did not talk about this, but leukaemia after a long illness on 10 August 2015. it was very obvious—and painful. Naturally he faced many practical limitations in his Life in Hungary was bleak in 1959 when work—for example, in access to laboratory Endre Czeizel, at the age of 24, began his and diagnostic technology—because of his career as a doctor and medical researcher situation.” at Budapest’s National Institute of Hygiene. In 1970 Czeizel established the Hungarian Czeizel, like millions of others at the time, was Congenital Abnormality Registry.6 In 1973 working behind the so called iron curtain, he became head of the newly established the political boundary between democratic Laboratory of Human Genetics, serving western Europe and the Soviet controlled until 1988 when he was named director communist countries of eastern Europe. of the National Institute of Health’s newly Just three years earlier the Soviet army had established Department of Human Genetics crushed an uprising of Hungarians seeking and Teratology. In 1980 he established the independence and freedom. Thousands Hungarian Case-Control Surveillance of of Hungarians were wounded and killed. Congenital Abnormalities, and the Budapest After defeat, hundreds were executed and Monitoring System of Self-poisoned Pregnant thousands imprisoned. Women. By the early 1960s Czeizel, who had trained In 1984 Czeizel was named director in gynaecology and obstetrics, had become BALÁZS/MTI MOHAI of Hungary’s WHO Collaborating Centre fascinated with the emerging specialism of Encountered prejudices as a rare for the Community Control of Hereditary medical genetics. Isolated from the West, participant from the Soviet bloc in Diseases, serving until 1998 and coauthoring Czeizel was hungry for information. He had a meetings in the West numerous WHO genetics reports, including good command of the English language and several with Modell. monitored, as best as he could, international to become a member of the international Czeizel was the author of nearly two dozen research into medical genetics. community of medical geneticists. books and was well known in Hungary He persevered over the next three Before his visit to Denmark, he had used through his own TV series. decades and was able to overcome huge the name E Czeizel for a paper published in In 2000 Czeizel was one of three difficulties not faced by medical geneticists the Lancet in 1963.2 In his next paper, “Effects researchers awarded the Joseph P Kennedy in the West. On Christmas Eve 1992 he was of Influenza on Pregnancy,” published in Jr Foundation’s international award for rewarded with the publication of his most 1967,3 he adopted the first name Andrew— scientific achievement for the discovery influential study in theNew England Journal the anglicized version of Endre. In 1972 the that folic acid could prevent neural tube of Medicine. The landmark paper confirmed first of his many letters and papers published defects.7 But his award was rescinded in that the risk of neural tube birth defects in The BMJ was signed “A Czeizel.”4 Most of 2002 after Czeizel was found guilty in a can be reduced if mothers take folic acid the more than 500 papers he authored during Hungarian court on four counts of being an during the periconceptional period—that is, his life appeared under the name Andrew E accessory in a transatlantic infant adoption shortly before conception and during early Czeizel. scheme and given an 18 month suspended pregnancy.1 Over the years Czeizel would make prison sentence.8 9 Czeizel submitted an Czeizel was born on 3 April 1935 in occasional trips to the West, unlike many impassioned rapid response to The BMJ’s Budapest. He wanted to be a professional eastern European researchers who defected news article, stating his innocence and football player. His father, a painter and during the cold war years, Czeizel remained vowing to appeal the conviction.10 In 2004 decorator, discouraged him, urging him based in Budapest before the iron curtain a Hungarian court dismissed three of the instead to choose a career that would be crumbled in 1989—and after. Despite the charges against Czeizel and reduced the prestigious and last a lifetime. Czeizel chose isolation and difficulties, he gained the fourth count to a violation of Hungary’s medicine, earning his medical degree in 1959 respect of colleagues in the West. adoption code.11 Czeizel again responded to and joining the National Institute of Hygiene “I think Andrew was the nearest thing The BMJ news article.12 as a research fellow. to a great man, although he was not easy Czeizel once said his worst habit was his In 1965 Czeizel completed a doctorate to get close to,” says Bernadette Modell, an inability to “differentiate between work and with a thesis entitled “Investigations into the emeritus professor of community genetics at relaxation.”5 pathogenesis of fetal abnormalities.” In the University College London, who collaborated He leaves three sons, two daughters, and same year, when he was 30 years old, Czeizel regularly with Czeizel during the 1980s and five grandchildren. was allowed to travel to western Europe for 1990s. “This could have been partly because Ned Stafford, Hamburg [email protected] the first time, to visit with researchers in of the amount of prejudice he encountered Cite this as: BMJ 2015;351:h5509 Denmark. He returned home determined in the years before 1990, when he was a rare Find this at: http://dx.doi.org/10.1136/bmj.h5509 the bmj | 9 January 2016 27 OBITUARIES

Sheila Elizabeth Borkett-Jones Doris May Geddes (née Moorhouse) studied neurological journals and monographs. Iris medicine with her fiancé, Sandy Geddes. was widely read, massively knowledgeable, General practitioner (b 1951; q Charing Cross After graduating together in 1955, the with a sharp intelligence that she kept Hospital 1979), died from pancreatic cancer on couple moved to Clacton, Essex, in 1957, to herself. She leaves her husband and 25 October 2014. where she specialised in child health and children. Sheila Elizabeth Borkett-Jones graduated development. As assistant chief medical J M S Pearce, S H S Pearce, D A S Pearce in chemistry from Nottingham University officer for the area, she pioneered the first Cite this as: BMJ 2015;351:h5901 before qualifying in medicine. After 10 contraception clinic within the child and Find this at: http://dx.doi.org/10.1136/bmj.h5901 years in hospital medicine she entered baby clinic and later joined Sandy in the general practice as a partner in Bushey, Wellesley Road practice. An avid reader George Alan Rose Hertfordshire, in 1990. She worked hard to and naturally creative with writing and Consultant chemical pathologist St Peter’s improve clinical pathways in many areas. needlework, Doris was a member of the local Group of Hospitals, Covent Garden, London Her life outside medicine was full, anchored Baptist church from 1957. After serious (b 1925; q Wadham College, Oxford, 1952; in her Christian faith and her family. illness in her 60s, she took early retirement. DM, FRCP, FRCPath, FRSC), d 24 December Always an enthusiast, she loved walking, She died peacefully at home. 2014. theatre, travel, interior design, and people. Jo Peace George Alan Rose was medical registrar at Undaunted by setbacks from a non-Hodgkin Cite this as: BMJ 2015;351:h5908 University College Hospital for five years, lymphoma over 28 years, she remained Find this at: http://dx.doi.org/10.1136/bmj.h5908 before moving to Leeds after a spell in an example of hope, even when faced with the US. In 1965 he was appointed at the the pancreatic cancer from which she died. John Robert McCluggage St Peter’s Group of Hospitals in Covent She leaves her husband, and two Former postgraduate dean Garden, London. Throughout his career he daughters. Northern Ireland (b 1940; specialised in kidney stones and chemical Howard Borkett-Jones q Queen’s University Belfast analysis. From 1965 until he retired in 1990 Cite this as: BMJ 2015;351:h5687 1965; DObst RCOG, FRCP Ed, he ran laboratories, organised his research, Find this at: http://dx.doi.org/10.1136/bmj.h5687 FRCPI), died from pancreatic and prepared publications and lectures for cancer on 31 August 2015. national and international conferences and Arthur Curtis John Robert McCluggage symposiums. In his retirement he General practitioner (“Jack”) entered general practice and then did medicolegal work. Predeceased by a son, Patcham, Brighton (b 1921; became senior lecturer in the Department he leaves his wife, Jean, whom he q Leeds General Infirmary of General Practice at Queen’s University married in 1954; two children; and four 1945), d 20 August 2015. Belfast. He became postgraduate dean, grandchildren. After serving in Singapore guiding his colleagues through the reforms Jean Rose at the end of the war in in training taking place at that time. He Cite this as: BMJ 2015;351:h5837 the Royal Air Force, Arthur Curtis settled in spoke only when he had something useful Find this at: http://dx.doi.org/10.1136/bmj.h5837 Brighton, Sussex, and set up a two person to say, which helped him make a success of practice. In the early years he delivered his 25 years as the elected representative James Richard Young babies, and he would get up in the middle for Northern Ireland on the General Medical Retired general practitioner (b 1957; q Royal of the night to see his patients, especially Council. Outside medicine he was passionate Free Medical School, London, 1982), died children. He remained a GP in Brighton about rugby and collected Irish silver. He from acute liver failure on 17 September for 40 years. After he retired he travelled leaves his wife, Cathryn, and a son from a 2015. extensively with Sheila, his wife of 66 years. previous marriage. James Richard Young (“Rick”) was born He adored his golf until Parkinson’s disease Randal Hayes, Cathryn Gilmore in Kuala Lumpur, Malaysia, and spent his robbed him of his mobility and freedom. The Cite this as: BMJ 2015;351:h5902 childhood growing up in Penang before four years after losing Sheila were lonely, Find this at: http://dx.doi.org/10.1136/bmj.h5902 coming to the UK at age 10. He did a rotation and his health deteriorated. He leaves two in ear, nose, and throat medicine before daughters, five grandchildren, and seven Iris Pearce completing his GP training in Yorkshire. great grandsons. Neurologist (b 1937; q Durham 1960), d 4 A medical elective in Ohio, US, served as Sally Harris October 2015. such a cold shock to this native of a hot Cite this as: BMJ 2015;351:h5907 Iris Pearce (née Swanson) met John Pearce country that he never visited a “sub zero” Find this at: http://dx.doi.org/10.1136/bmj.h5907 in 1962. They married in 1965 and, after country again. Rick worked as a GP in Manby, spending time in Boston in the US, they Lincolnshire, from 1989 until 2009, when Doris May Geddes returned to Yorkshire, where Iris worked he retired; and he was an avid supporter of Former general practitioner in the mineral metabolism unit at Leeds. the local out of hours service. He leaves two Clacton (b 1931; Later she ran the Parkinson’s disease and daughters. q Aberdeen 1955), died from headache clinics at the new Hull Royal Lauren Young liver metastases of unknown Infirmary and was engaged in clinical Cite this as: BMJ 2015;351:h5691 primary on 29 January 2015. research, publishing several papers in Find this at: http://dx.doi.org/10.1136/bmj.h5691

26 9 January 2016 | the bmj LETTERS Selected from rapid responses on thebmj.com. See www.bmj.com/rapid-responses

RESEARCH NEEDS YOU “DOCTOR” AS AN ANACHRONISM LETTER OF THE WEEK Integrating research and Research needs Hierarchy may have a healthcare systems therapeutic role postdoctoral Research engagement by progression Using the title “Doctor” preserves clinicians and healthcare hierarchy in the patient-doctor Gulland (This week, 5 organisations (This week, relationship (Personal view, 5 December) highlights the 5 December) is widely held December). This may not mean lack value to patients of doctors to improve health services of respect, and deference exists being involved in research. performance. However, we in the patient-doctor relationship Such involvement must found the issue to be complex anyway, as it does when we consult include sufficient numbers in our review of 33 studies anyone we respect. In medicine, of doctors taking up for the National Institute for this hierarchy may have a clinical academic careers. Health Research. Twenty eight therapeutic role, and patients tend Progress in healthcare were positive about improved to keep using this title.

requires that medically WEBB NEIL performance, but only seven In our recent survey, most trained academics become identified improved outcomes patients wanted doctors to principal investigators making significant contributions to both rather than improved processes, introduce themselves using research and the translation of outcomes to patient care. which were enacted by diverse their full names (76%) and Yet, despite the efforts of funding bodies, the issue of mechanisms. qualifications (65%). Patients dwindling numbers of clinical academics is not entirely resolved. Increased attention to wanted to be addressed by An area of particular concern is postdoctoral progression. this issue covers not only their first name only (59% on Each year an appreciable number of clinical lecturer posts, clinician participation but also first encounter, 75% on later which enable postdoctoral clinicians to develop research organisational developments in encounters). This suggests that independence, go unfilled. the NIHR and NHS. These seek patients need this differentiation To cast light on the underlying reasons, in 2013 the Oxford to promote better integration of (doctors’ expectation to be on one University Clinical Academic Graduate School established a research and healthcare systems side, not necessarily the upper one, longitudinal study of career decision making among medically by strengthening research while they are on the other side). qualified doctoral students registered at this institution. networks, developing research This is not a call to preserve Preliminary findings indicate that, of UK doctors who intend to capacity, and ensuring that paternalism in the patient-doctor mainly work in clinical academic posts in the long term, healthcare organisations see relationship, but an attempt only 66% are extremely or very likely to seek a clinical research as an integral to show that, although this lectureship in England, which is surprisingly low given their component of their overall relationship is unequal, such stated career plans. structure. Such initiatives need inequality may serve a purpose of UCL is currently collaborating to investigate similar questions to be linked to analysis that its own. among its students, and we hope others will do likewise. This will considers not only the research allow the creation of a national picture, development of evidence Dror Limon ([email protected]) engagement of all relevant Salomon M Stemmer based strategies to enhance clinical academic careers, and actors but also the organisational Cite this as: BMJ 2015;351:h6906 monitoring of the impact of proposed contractual changes. determinants of the Denise Best ([email protected]),,Joana Lopes, Chris Pugh impact on practice of such Cite this as: BMJ 2015;351:h6927 No, mate, using “Doctor” engagement. doesn’t disrespect patients Stephen Hanney ([email protected]) The Nuffield Council on persons’ advisory groups that Medical titles may well reinforce Bryony Soper Bioethics’ recent report on facilitate such involvement. The a clinical hierarchy and inculcate Teresa Jones Annette Boaz children and clinical research UK Department of Health, NHS, deference in Florida, as Kennedy Cite this as: BMJ 2015;351:h6931 concluded that partnership with and Universities UK should protect writes (Personal view, 5 children, young people, and the time needed for experts in December), but such constructs Need for clinical research parents throughout the research child healthcare to contribute to are culture bound. in children endeavour is crucial to ensure research ethics committees. When I worked in outback that children are not placed in Our report provides additional Australia the patients called me Well conducted clinical research vulnerable situations. guidance for researchers and “Mate,” which is what I called (This week, 5 December) in Changes are needed to adopt those responsible for scrutinising them. children and young people this approach. Researchers research to ensure that children’s They still wanted me to be in is essential to improve should be required to involve voices are heard at every step. charge. understanding of childhood children and parents in study Katharine Wright John Doherty disease and provide healthcare development. The commercial ([email protected]) ([email protected]) based on best evidence. sector should help to fund young Cite this as: BMJ 2015;351:h6902 Cite this as: BMJ 2015;351:h6912

28 9 January 2016 | the bmj education education THE ART OF MEDICINE CLINICAL UPDATES Colouring books for Higher risk of CVD in women with diabetes The risk of coronary heart disease is twice as high in adults on the ward women with diabetes as it is in men. By contrast, in people without diabetes the risk is higher in men. Throughout , colouring books The latest American Heart Association statement for adults have topped the UK’s outlines sex differences in cardiovascular risk factors bestselling paperback charts. In and events in people with diabetes. It concludes that our cancer centre’s inpatient wards, women may need a greater frequency and intensity of colouring books are next to many physical activity to prevent cardiovascular events. beds. This phenomenon began  http://bit.ly/ Ngtthl two months ago when one patient started colouring in birds using Assessing concussed children before return to pencils, felt tips, and glitter pens. sport Other patients soon asked sta or relatives to buy them A doctor should assess concussed children before similar books and the accompanying paraphernalia. return to sport or other activities that carry a risk Patients tell us that colouring can make the hours go of concussion. The Sport and Recreation Alliance faster during the long days and nights of an inpatient guidance outlines the concussion management stay. Comments include: “It relaxes the mind and the principles of “recognise, remove, recover, and return” body,” and “While you are doing it, you concentrate safely back to activity. The process should usually only on that one task.” Two small studies found that take at least  days in children, including  days’ colouring signi cantly reduced anxiety, tension, rest from physical and brain activities, such as reading and depression in college students.  A systematic and watching TV, before a graduated return to activity. review of the e ectiveness of creative interventions on The aim is to ensure safe return and minimise the risk psychological outcomes in adults with cancer found of permanent neurological damage. evidence that such interventions help with stress,  http://bit.ly/ QODpRN anxiety, depression, quality of life, mood, coping, and  http://bit.ly/ PPShe anger.  A recent blog by an art therapy masters student suggested that the use of colouring books could identify Topical retinoids for all grades of acne The Primary Care Dermatology Society recommends those who might bene t from the various art therapeutic  the use of topical retinoids to treat all grades of acne. interventions available. These agents can be combined with other treatments, Could colouring help hard working healthcare but oral antibiotics should not be used alone. professionals too? We hope this current trend lasts Targeted treatment aims to reduce the risk of scaring because it provides distraction and seems to bring much in the roughly % of adolescents with acne who seek rapport, joy, and relaxation. treatment. Treatment depends on lesion type and Miriam Rigby, palliative care specialty doctor useful photographs are provided. Mark Taubert, consultant physician, Velindre Cancer Centre, Cardiff Cite this as: BMJ ; :h  http://bit.ly/ TRMfgT Find this at: http://dx.doi.org/ . /bmj.h Cite this as: BMJ ;:h We welcome contributions to this column: email [email protected]. Find this at: http://dx.doi.org/ . /bmj.h

FAST FACT IMAGING IN SEPTIC ARTHRITIS Ruling out septic arthritis in any patient with a hot Although baseline radiographs can help assess swollen joint is crucial but imaging is of little value joint damage they have no place in diagnosing Essential investigations include septic arthritis Similarly magnetic resonance Joint aspiration with synovial  uid cultures and imaging cannot discriminate between infection and microscopy in ammation Blood cultures For more information visit BMJ Learning ( http://ow.ly/UgZM2 ) In ammatory markers

YoucangainCPDpointsfromyourreadingbyrecordingwhatyouhavereadinyourappraisalfolder Youshouldtrytolinkyourreadingbacktoalearningneedandalsoconsiderhowyouplantoimprove yourpracticeasaresultofyourlearninghttp//learningbmjcom

PB 9 January 2016 | the bmj the bmj | 9 January 2016 29 SUMMARY OF NICE GUIDANCE Care of adults in the last days of life Joshua Ruegger,1 Sarah Hodgkinson,1 Antonia Field-Smith,2 Sam H Ahmedzai,3 On behalf of the guideline committee

1National Clinical Guidelines Centre, Royal College of Physicians, London, UK Communication 2Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK Identify the most appropriate team member to discuss 3Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK prognosis with the dying person and those important to the Correspondence to: S H Ahmedzai [email protected] person. In 2013, the UK Department of Health called for the abolition of the Provide the dying person, and those important to the Liverpool care pathway, which was designed to bring a standard of care person, with: for the dying from the hospice sector into other settings. This move was • Accurate information about the prognosis (unless they provoked by an independent review,1 which showed that the pathway do not wish to be informed), explaining any uncertainty had been misused and misinterpreted as a tick box exercise. It called for and how this will be managed individualised care plans and better staff training in all aspects of end of • An opportunity to discuss any fears and anxieties life care.1 Care of dying people should be based on evidence and must be • Information about how to contact members of the care tailored to individual needs and wishes, rather than being protocol driven. team for further discussion, including details of out of This article summarises the most recent recommendations from the hours services. National Institute for Health and Care Excellence (NICE).2 Identify a named lead healthcare professional responsible for communication and shared decision Recommendations making in the last days of life. Ensure that any agreed Recognising dying changes to the care plan are understood by the person, If it is thought that a person may be entering the last days of those important to the person, and others involved in care. life, document information on: The General Medical Council guidance on end of life • The person’s physiological, social, spiritual, and care also provides advice on communication and shared psychological needs decision making and is a useful resource for junior doctors.3 • Current clinical signs and symptoms • Medical history and the clinical context Maintaining hydration • The person’s goals and wishes Support dying people to drink (water, tea, fruit juice, or • The views of those important to the person about future other favourite drink) if they wish and are able to. Check for care. any difficulties, such as swallowing problems and discuss Assess for changes in signs and symptoms that may the risks and benefits of continuing to drink. suggest a person is dying (especially multiple or progressive Offer frequent care of the mouth and lips (including changes) and review any investigation results already management of dry mouth) and encourage people who are reported. These may include: important to the dying person to help with this. • Signs such as agitation, Cheyne-Stokes breathing, Assess, preferably daily, the person’s hydration status, deterioration in level of consciousness, mottled skin, and review the possible need for starting or continuing noisy respiratory secretions, and progressive weight loss clinically assisted hydration (for example, parenterally • Fatigue and loss of appetite through the subcutaneous or intravenous route or enterally • Changes in communication, deteriorating mobility or through a nasogastric tube), respecting the person’s wishes performance status, or social withdrawal. and preferences. Be aware that improvement in signs and symptoms or Advise that, in the last days of life, clinically assisted functional observations could indicate that the person may hydration may relieve distressing symptoms or signs related be stabilising or recovering. to dehydration but may cause other problems (such as fluid Monitor for further changes at least every 24 hours and overload or local irritation at the infusion site). Explain that update the care plan. it is uncertain whether providing or withholding clinically assisted hydration could prolong or shorten the length of WHAT YOU NEED TO KNOW remaining life. • Seek support from more experienced staff, including those in Consider a therapeutic trial of clinically assisted hydration palliative care services, if you are unclear about any aspect of if the person has developed, or is at risk of developing, care of the dying adult, including the recognition of dying and distressing symptoms or signs of dehydration, such as thirst symptom management or delirium, and oral hydration is inadequate. • Assess for and treat any reversible causes of distressing symptoms For people receiving clinically assisted hydration: or signs in people in the last few days of life—for example, • Re-assess preferably every 12 hours for changes in the uncontrolled pain or dehydration causing agitation symptoms or signs of dehydration and continue if there is • Regularly review the care plan (usually daily), discuss any changes clinical benefit. with the dying person and those important to the person; make • Reduce or stop if there are signs of harm to the dying clear documentation in the medical notes person, or if the person no longer wants hydration.

30 9 January 2016 | the bmj WHAT’S NEW IN THIS GUIDANCE? • Guidance on recognition of dying, with the uncertainty around this, and encouragement of open communication and shared decision making • Maintaining hydration (including oral care) as a priority, and offering fluids up until the end of life, regardless of the care setting • Emphasis on individualised prescribing for current and anticipated symptoms, avoiding undue sedation or other side effects

SHARED DECISION MAKING Take into account: Advance statements, advance decisions to refuse treatment, or a lasting power of attorney for health and welfare in those lacking capacity The person’s current goals and wishes, and any cultural, religious, social, or spiritual preferences

Pharmacological interventions prescribed and compatibility and interactions with other Owing to the lack of supporting evidence for the drugs being used. pharmacological management of symptoms in the last few days of life, this guidance can provide only limited Managing anxiety, delirium, and agitation recommendations on the use of specific drugs. Prescribers Treat any reversible causes of agitation, anxiety, or delirium, should follow local prescribing guidance and seek further such as dehydration or uncontrolled pain. Be aware that advice from specialist palliative care if in any doubt. agitation is sometimes associated with other unrelieved For people in the last days of life, consider non- symptoms or bodily needs, such as pain or a full bladder. pharmacological management of distressing symptoms or Consider a trial of a benzodiazepine to manage anxiety or signs, such as facial fans or open windows for breathlessness, agitation, or a trial of an antipsychotic to manage delirium or and repositioning or suction for noisy respiratory secretions. agitation. Consider using a syringe pump to deliver drugs for continuous symptom control if more than two or three doses Managing noisy respiratory secretions of any “as required” drugs have been given within 24 hours. Assess for the likely cause and establish whether the noise Seek specialist palliative care advice if the dying person’s has an impact on the dying person or those important to that symptoms do not improve promptly with treatment or if there person. Reassure them that it is unlikely to cause discomfort are undesirable side effects, such as unwanted sedation. and may be relieved by non-drug based interventions such as repositioning and suction. Managing pain Consider a trial of an antisecretory agent (glycopyrronium, Be aware that not all people in the last days of life experience hyoscine butylbromide, hyoscine hydrobromide, or atropine) pain. If pain is identified, manage it promptly and effectively, to treat noisy respiratory secretions if they are causing distress and treat any reversible causes, such as urinary retention. to the dying person. Follow the principles of pain management used at other Monitor at least twice daily and consider changing or times when caring for people in the last days of life using, stopping drugs if: when possible, the person’s preferences for how it is given. • Noisy respiratory secretions continue and are still causing distress after 12 hours, or Managing breathlessness • There are unacceptable side effects, such as dry mouth, In a person who is not already on long term oxygen, do not urinary retention, delirium, agitation, and unwanted levels routinely start oxygen to manage breathlessness. Offer oxygen of sedation. therapy only to people known or clinically suspected to have symptomatic hypoxaemia. Anticipatory prescribing Consider managing breathlessness with an opioid, Individualise the approach to prescribing anticipatory or “just or a benzodiazepine, or a combination of an opioid and in case” drugs for people who will probably need symptom benzodiazepine. control in the last days of life. Take into account: • The likelihood of symptoms occurring Managing nausea and vomiting • The benefits and harms of prescribing or administering Assess for, and if possible reverse, the likely cause (for these drugs, or of not doing so example, metabolic disturbance, concurrent drugs). • The risk of the person suddenly deteriorating (for example, Consider the side effects, including sedation, of any drugs catastrophic haemorrhage or seizures) and needing urgent P symptom control HOW PATIENTS WERE INVOLVED IN THE CREATION OF THIS • The place of care and the time it would take to obtain the ARTICLE drugs. Committee members involved in this guideline included lay members who Cite this as: BMJ 2015;351:h6631 contributed to the formulation of the recommendations summarised here. Find this at: http://dx.doi.org/10.1136/bmj.h6631 the bmj | 9 January 2016 31 SUMMARIES OF BMJ CLINICAL EVIDENCE Parkinson’s disease: fetal cell or stem cell derived treatments Arnar Astradsson,1 Tipu Aziz2

1Department of Neurorehabilitation, Traumatic Brain Injury Unit, Copenhagen University Hospital of Glostrup, Denmark [email protected] 2Division of Clinical Neurology, Nuffield Department of Surgical Sciences, University of Oxford, UK This series comprises summaries of BMJ Clinical Evidence, a database of systematic overviews of the best available evidence on the effectiveness of selected interventions (available at http://clinicalevidence.bmj.com/). Can Parkinson’s disease now be cured by fetal or stem cell therapy? Media stories of these new treatments are common.1 The main disease process in Parkinson’s disease is progressive loss of cells that produce dopamine from the substantia nigra in Evidence for the effects of fetal cell or stem the brainstem. Treatment aims to replace cell derived therapy in Parkinson’s disease

or compensate for the lost dopamine. Data on the following treatments are SCHOOL/SPL MEDICAL POINDEXTER/UT B BICK, R Levodopa and dopamine agonists have been The death of dopaminergic neurons causes currently insufficient or of inadequate the mainstay of treatment for years, but symptoms of Parkinson’s disease quality: because side effects (such as dyskinesias) Fetal cell therapy v sham surgery often develop or the effects of the drugs relief for over a decade, but randomised Fetal cell therapy v deep brain stimulation wear off, other treatments have been sought. controlled trials thus far have not Stem cell derived therapy v sham surgery Deep brain stimulation into the pallidum confirmed this. Stem cell derived therapy v deep brain or subthalamic nucleus may also alleviate The technology of stem cell therapy has stimulation symptoms, but it does not repair the brain, not yet progressed to clinical use, but it is the and can have side effects such as infection current focus of preclinical research. Although treatment at one to two years or be associated with stimulator failure. cell preparation techniques differ between • Fetal cell transplantation may improve Fetal or stem cell therapy— the two cell types, clinical transplantation the non-clinical outcome of putaminal transplantation of new dopamine methods would probably be similar. uptake of fluoro-DOPA, as measured by producing cells to replace neurones that positron emission tomography have degenerated—is being evaluated as a Key findings: efficacy of interventions • Fetal cell transplantation may be more enduring treatment possibility; some We found two double blind randomised associated with adverse effects such as evidence suggests it may be more effective controlled trials (RCTs) that compared fetal graft induced dyskinesias. in younger patients (<60 years old)2 whose cell transplantation with sham surgery.2 However, some procedures in the two previous good response to levodopa has They included 74 people, all of whom had trials might not have been optimal, and worn off or who have developed side effects. advanced Parkinson’s disease. In contrast follow-up may have been too short in at In fetal cell therapy, cells are taken from to the more favourable outcomes suggested least one of the trials. the ventral midbrain of aborted fetuses by earlier open label and uncontrolled Larger scale RCTs are investigating and transplanted stereotactically into the studies, these RCTs found: the benefits and harms of fetal cell putamen of the brain. Open label studies • No good evidence that fetal cell transplantation in Parkinson’s disease (where researchers and participants know transplantation improved clinical (https://clinicaltrials.gov/ct2/show/study/ which treatment is used) in people with outcomes, such as disease severity, or NCT01898390), and trials using human Parkinson’s disease have shown symptom reduced the need for levodopa or other embryonic stem cells or induced pluripotent stem cells are planned. The box outlines WHAT YOU NEED TO KNOW where we lack high quality comparisons • Neural transplantation with fetal cell or stem cell therapy is being evaluated of these new treatments. Longer term as a treatment for Parkinson’s disease, especially in younger people and those outcomes are needed—one year is not long who previously responded to levodopa enough for human fetal dopamine neurones • Stem cell therapy has not yet been evaluated clinically to grow and integrate or for functional benefit to develop. • However, there is currently insufficient evidence that such therapy improves clinical outcomes, although larger trials are in progress Cite this as: BMJ 2015;351:h6340 Find this at: http://dx.doi.org/10.1136/bmj.h6340

32 9 January 2016 | the bmj Box 2 | Red flags: alarm symptoms and findings in chronic cough65 &257,&$/327(17,$7,21 &RUWH[ 2568335(66,212)&28*+ • Hemoptysis 10 • Smoker with >20 pack year smoking history • Smoker over 45 years of age with a new cough, altered cough, or cough with voice disturbance • Prominent dyspnea, especially at rest or at night %UDLQVWHP &28*+&(17(5 • Substantial sputum production: more than 1063 one tablespoon a day • Hoarseness • Systemic symptoms: fever, weight loss • Complicated GORD symptoms associated with 6(1625< 027255(63216( weight loss, anemia, overt gastrointestinal /DU\Q[ 63 63 bleeding (hematemesis or melena), severe symptoms, dysphagia, odynophagia, or failure of empiric treatment for GORD

Fig 2 | Diagram of key elements in the cough reflex, indicating the association between peripheral • Recurrent pneumonia and central sensitization, the role of motor responses such as cough and paradoxical vocal fold • Abnormal clinical respiratory examination movement, and the place of convergent stimuli in provoking cough.56 Proposed sites of action of speech pathology (SP) and neuromodulator (NM) therapy are indicated • Abnormal chest radiograph of chronic cough21—such as asthma, rhinosinusitis, dyspnea, but with no evidence of lung or lower airway and gastroesophageal reflux disease (GORD)—are disease to explain the dyspnea. Accurate recognition and thought to be different phenotypes of the syndrome.24 diagnosis of PVFM enables the implementation of effective CRC is considered to be a phenotype of the cough treatment.57 58 hypersensitivity syndrome; although the precipitating factor is unknown, it has been hypothesized to be Clinical features of chronic refractory cough gastroesophageal reflux.22 Clinical features include a dry cough that occurs in intermittent bouts throughout the day. The cough often Laryngeal hypersensitivity originates from the laryngeal region. Triggers include non- Laryngeal hypersensitivity is defined as increased tussive stimuli that do not normally trigger cough, such as sensitivity of the larynx to innocuous stimuli resulting in air conditioning and phonation (allotussia), and very low symptoms of laryngeal paresthesia with cough, dyspnea, doses of tussive stimuli (hypertussia). Laryngeal discomfort dysphonia, or laryngeal spasm. Although some features of and paresthesia are also triggers.43 The cough can persist for CRC are encompassed by the term cough hypersensitivity months or years.36 The higher prevalence in women may be syndrome, in many patients symptoms are localized to the explained by a heightened capsaicin cough reflex sensitivity larynx. The term laryngeal hyper-responsiveness syndrome in women compared with men.14 59 In some patients the may therefore be a useful concept that defines a sensory onset of cough may be associated with the menopause, and abnormality.30 This sensation (laryngeal paresthesia) is it is possible that reduced estrogen levels potentiate cough crucial and perhaps more annoying for patients than the reflex sensitivity. Subclinical airway inflammation may also cough itself. The laryngeal hypersensitivity questionnaire be amplified at the time of the menopause.59 can be used to measure laryngeal hypersensitivity.31 Forty two percent of patients report that their cough Cough hypersensitivity syndrome may overlap with other starts with a viral infection and 36-43% of people with a laryngeal hypersensitivity syndromes. In people with cough viral upper respiratory tract infection still have cough three hypersensitivity syndrome and laryngeal hypersensitivity months after the infection.36 60 Viral infection induces the syndrome, several related diseases can act as triggers (fig 1). expression of cough receptors that can be inhibited by tiotropium,37 49 which may explain this clinical observation Paradoxical vocal fold movement (PVFM) and the beneficial effects of anticholinergic agents in CRC has been associated with paradoxical vocal fold chronic cough.61 movement (PVFM),26 an abnormal laryngeal motor pattern Patients often report laryngeal symptoms in addition with adduction of the vocal folds during inspiration to cough (fig 2). Clinically significant dysphonia is seen in after a stimulus. Common symptoms include inspiratory 40% of patients with CRC and talking is a common trigger dyspnea, stridor, and throat tightness. This clinical for coughing episodes.43 27 Laryngeal hypersensitivity and overlap suggests that these symptoms might be features cough reflex hypersensitivity are increased compared with of a single underlying condition.28 The co-occurrence of healthy controls (fig 3). Reflexive closure of the glottis in both conditions can lead to diagnostic confusion because response to a laryngeal irritant, termed the glottic stop patients may present with severe coughing and severe reflex, is also increased in patients with chronic cough.62

34 9 January 2016 | the bmj the bmj | 9 January 2016 35 STATE OF THE ART REVIEW: HIGHLIGHTS Management of chronic refractory cough Peter G Gibson,1 Anne E Vertigan2

1Centre for Asthma and Respiratory Disease, University of Newcastle; Department of Respiratory and Sleep Medicine, John Hunter Hospital; Hunter Medical Research Institute, Newcastle, Australia $67+0$ 2Centre for Asthma and Respiratory Disease, University of Newcastle; Speech Pathology Department, John Hunter Hospital; Hunter Region Mail Centre, Hunter 1 CREDIT Medical Research Institute Correspondence to: P Gibson [email protected] 5()/8; $&(,1+,%,7256 This is an edited version of the state of the art review. The full version is on thebmj.com Cite this as: BMJ 2015;351:h5590 Find this at: http://dx.doi.org/10.1136/bmj.h5590 &28*+/$5<1*($/+<3(56(16,7,9,7<

SUMMARY Chronic refractory cough (CRC) is defined as a cough that persists despite guideline based treatment. It is seen in 20-46% of patients presenting to specialist cough 121$67+0$7,& 5+,126,186,7,6 clinics. Several terms have been used to describe this (26,123+,/,&',6($6( condition, including the recently introduced term cough hypersensitivity syndrome. Key symptoms include a dry irritated cough localized around the laryngeal region. Fig 1 | Proposed association between cough hypersensitivity Symptoms are not restricted to cough and can include syndrome, laryngeal hypersensitivity syndrome, and related globus, dyspnea, and dysphonia. CRC often occurs after diseases; ACE=angiotensin converting enzyme a viral infection. The diagnosis is made once the main diseases that cause chronic cough have been excluded specialist cough clinics in 11 countries found that cough (or treated) and cough remains. Treatments have been was most common in the fifth to seventh decades and developed over the past decade. These include speech was more common in women (66%).14 pathology interventions using techniques adapted from the treatment of hyperfunctional voice disorders, as well as the use of centrally acting neuromodulators such as gabapentin What is chronic refractory cough? and pregabalin. Cough is a reflex activity with elements of voluntary control. It forms part of the somatosensory system that Prevalence involves visceral sensation, a reflex motor response, The community prevalence of cough is estimated at 2.3- and associated behavioral responses. Cough is also a 18% of the adult population.1 2 The prevalence of chronic symptom of many common respiratory diseases, where it cough in respiratory outpatient practice ranges from 10% can be acute (less than three weeks’ duration), subacute to 38%.1 2 A meta-analysis found that the prevalence of (three to eight weeks’ duration), or chronic (more than chronic cough (defined as a cough lasting longer than eight weeks’ duration).1 three months) in the general population was 9.6%.2 The cough persists in 0-46% of patients who present Cough is more common in smokers than in non- to specialist cough clinics despite assessment and smokers,11 12 A survey of 10 032 patients referred to treatment according to an accepted guideline.21 This condition is termed chronic refractory cough (CRC), chronic idiopathic cough, or unexplained chronic WHAT YOU NEED TO KNOW cough.20 21 It can be diagnosed when patients have no • Cough is the most common reason for primary care visits. identified causes of chronic cough (unexplained or idiopathic chronic cough) or when the cough persists • Clinical features of CRC include a dry cough that occurs in intermittent bouts throughout the day. Symptoms can persist for after investigation and treatment of cough related months or years. conditions (refractory chronic cough). Speech pathology treatment for cough consists of four components: • Cough hypersensitivity syndrome education, cough suppression strategies, vocal hygiene training, Cough hypersensitivity syndrome is associated with and psychoeducational counseling. hypersensitivity of the larynx and upper airway. It is Centrally acting neuromodulators (including gabapentin, • considered to be a disorder of sensory airway nerves pregabalin, morphine, amitriptyline, and baclofen) have improved caused by hypersensitivity to innocuous irritants,23 as a cough specific quality of life in patients with CRC, but adverse result of mucosal upregulation of cough receptors such effects can be serious and limit the maximum tolerable dose of as transient receptor potential (TRP) V1 and TRPA1. these agents. Diseases previously evaluated and treated as causes

PB 9 January 2016 | the bmj the bmj | 9 January 2016 33 Diagnosis of chronic refractory cough Treatment of chronic refractory cough Primary assessment Non-pharmacologic therapies The diagnostic approach requires an initial assessment A systematic review found support for cough and investigation for alarm symptoms that suggest a suppression strategies based on speech pathology and serious underlying cause of cough (box 2). If no alarm physiotherapy.74 symptoms are identified assessment can focus on diagnoses associated with chronic cough that have Pathophysiological assessment specific remediable causes or a usually good treatment The first step in speech pathology management of CRC is to response (box 3). In clinical practice it is important evaluate the pathophysiological features of the condition, to distinguish between cough that is truly refractory including cough characteristics, urge to cough, PVFM, or unexplained and cough that can be explained and and voice symptoms. This assessment is conducted by treated effectively.64 the speech pathologist and takes 45-60 minutes. The Because CRC is defined as a cough that persists after information obtained during the assessment provides extensive medical investigation and treatment, it is a baseline measurements and informs the structure and focus diagnosis of exclusion. A guideline based chronic cough of the behavioral management program. assessment is an essential part of the investigation of these patients.64 66 Once this has been completed Speech pathology treatment and the results reviewed, if the cough persists Speech pathology treatment for cough is summarized in box then the patient can be diagnosed as 4 and fig 2.29 46 It consists of four components: education, having CRC. cough suppression strategies, vocal hygiene training, and psychoeducational counseling. It is typically conducted by Secondary assessment speech pathologists with a special interest in the treatment Second stage investigations include nasendoscopy and of dysphagia and voice disorders, and training resources 24 hour pH monitoring. Laryngeal examination using are available to ensure the consistency of the treatment flexible nasendoscopy will identify the presence of program.46 laryngeal lesions or abnormal motor patterns that might The goals of speech pathology interventions are to be contributing to the cough symptoms and laryngeal improve voluntary control over the cough by teaching discomfort.59 If present an alternative management patients to identify sensations that precipitate the cough approach may be needed. Nasendoscopy with odor or and to substitute the cough with another response for exercise challenge can be used to provoke symptoms example, a breathing or swallowing exercise, and to change of PVFM that can help to confirm the diagnosis.30 67 behaviors that contribute to laryngeal irritation. Nasendoscopy can identify signs of laryngopharyngeal reflux, particularly if there is edema or erythema in the Pharmacologic therapy cricoarytenoid region. Neuromodulators A systematic examination of laryngeal structure Centrally acting neuromodulators—including gabapentin, and function may be indicated in those with laryngeal pregabalin, morphine, amitriptyline, and baclofen—act on symptoms. Co-existing muscle tension dysphonia may the heightened neural sensitization that is involved in the be present and may require additional voice therapy pathogenesis of CRC.20 All of these agents have improved techniques. Finally nasendoscopy can identify the cough specific quality of life in patients with CRC (table 2; presence of PVFM and motor paresis.67 69 fig 2). However, although these treatments are promising, The role of esophageal pH and pressure monitoring is adverse effects can be serious and limit the maximum controversial. tolerable dose of these agents.20

 Box 3 | Remediable conditions and conditions not to be missed in patients with 65  chronic cough Remediable conditions  Asthma Gastroesophageal reflux disease  Obstructive sleep apnea

&FDSVDLFLQGRVH + PRO/ Angiotensin converting enzyme inhibitor use Eosinophilic bronchitis Rhinosinusitis

 Serious cough related conditions &&39&0 && +& Cancer of the larynx, bronchus, or lung Parenchymal lung disease: chronic obstructive pulmonary disease, interstitial Fig 3 | Cough reflex hypersensitivity in patients with chronic pulmonary fibrosis, bronchiectasis, sarcoidosis, pneumothorax refractory cough (CRC), CRC plus paradoxical vocal cord movement Cardiovascular disease: left ventricular failure, pulmonary embolism, aortic (PVCM), and healthy controls (HC). Median (interquartile range). aneurysm *P<0.0005 versus healthy controls. C5=capsaicin dose needed to elicit five or more coughs 30 seconds after administration26 Infection: tuberculosis, lung abscess, pertussis

34 9 January 2016 | the bmj the bmj | 9 January 2016 35 Combined pharmacologic and non-pharmacologic therapy Two of three randomized controlled trials of inhaled A randomized controlled trial examined the effect of corticosteroids, including mometasone, budesonide, and combined speech pathology treatment and pregabalin on beclometasone, showed no significant improvement in CRC.51 Forty patients were randomly assigned to combined cough severity.96 97 There were no adverse effects. speech pathology treatment and pregabalin 300 mg or A systematic review to assess whether inhaled combined speech pathology treatment and placebo. corticosteroids could result in cure of chronic unexplained Cough severity, cough frequency, and cough quality of life cough in adults identified eight eligible RCTs with 570 improved in both groups. However, the improvement in participants.99 Treatment with inhaled corticosteroids cough severity and cough quality of life was significantly significantly reduced cough score but analysis of the greater with combined speech pathology and pregabalin primary outcome (cure) was not possible because of study than with speech pathology alone. heterogeneity. Although speech pathology and neuromodulators improve cough they have limitations: speech pathology Other treatments treatment reduces cough but does not eliminate cough, GORD is thought to be a contributory factor to chronic and neuromodulators are limited by side effects and a cough, with reflux of gastric contents (acid and non- non-sustained treatment response. These treatments act acid) into the esophagus and laryngopharyngeal areas on different aspects of the cough pathway and therefore stimulating cough. combined treatments might provide more complete A trial of high dose esomeprazole, a proton pump resolution of the cough. inhibitor, in patients with CRC in the absence of symptomatic GORD found no benefit on cough severity Inhaled corticosteroids or quality of life.100 This suggests that the cough is not Eosinophilic airway inflammation (eosinophilic bronchitis) due to acid reflux and does not support the use of empiric is an important cause of chronic cough that can occur as antireflux treatment. a discrete condition or as part of asthma, cough variant Ipratropium bromide, a bronchodilator used in the asthma, rhinitis, or atopic cough. Inhaled corticosteroids treatment of asthma, has been investigated in CRC. A are effective in eosinophilic airway inflammation. randomized controlled trial found a significant reduction in cough severity and a good safety profile.101 Subsequent Table 2 | Effects of neuromodulator drugs on cough quality of life* work has identified an inhibitory effect of this class of drug Study Tool used Drug Change in score from baseline (points) on neuronal TRPV1 receptors.61 Jeyakumar et al53 CQLQ Amitriptyline 24.53 Guaifenesin-codeine 2.92 Chronic refractory cough in comoroid disease Morice et al52 LCQ† Morphine 3.2 Cancer Placebo 1.2 A systematic review of cough treatments in cancer found Ryan et al49 LCQ† Gabapentin 2.5 some effect of morphine, codeine, dihydrocodeine, Placebo 1.1 Vertigan et al51 LCQ† Pregabalin‡ 6.6 levodropropizine, sodium cromoglycate, and butamirate Placebo‡ 3.3 citrate linctus (cough syrup), although all of the studies 105 Abbreviations: CQLQ=cough quality of life questionnaire; LCQ=Leicester cough questionnaire. had risk of bias. Speech pathology treatment for cough 20 *Adapted from American College of Chest Physicians guideline. suppression in cancer has not been studied. †Minimally important dose is 2. ‡Treatment given simultaneously with speech pathology treatment. Chronic obstructive pulmonary disease Box 4 | Speech pathology treatment for chronic refractory cough46 A fifth of patients with moderate airflow limitation report 106 Education cough as a highly distressing symptom. Patients rank Cough can be triggered by irritation cough as the second most prevalent symptom. Chronic Cough is not always necessary cough with sputum production is common and is often Cough has limited physiological benefit in this condition considered to be the first symptom of chronic obstructive Cough is under automatic and voluntary control pulmonary disease. Patients with chronic cough have an increased risk of disease progression and exacerbations Symptom control techniques that might require admission to hospital. Cough suppression swallow Cough control breathing Paradoxical vocal fold movement release breathing Cough in idiopathic pulmonary fibrosis Cough is estimated to be present in 84% of patients with Release of laryngeal constriction idiopathic pulmonary fibrosis and is more prevalent Reducing laryngeal irritation in patients who have never smoked or who have more Behavioral management of reflux advanced disease.108 The cough can be extremely Reduce phonotraumatic behaviors debilitating, with a detrimental effect on quality of life,109 Hydration and it is an independent predictor of disease progression.108 Minimize exposure to irritating substances The cause of this cough is not clear. Mechanical factors Psychoeducational counseling may be at play, including destruction of the cough Treatment is hard work inhibitory fibers as the lung is distorted by the fibrotic Setting realistic goals process,107 leading to increased cough sensitivity.107 110

36 9 January 2016 | the bmj the bmj | 9 January 2016 PB ENDGAMES For long answers go to the Education channel on thebmj.com @BMJEndgames

CASE REVIEW A man with a murmur and missing heart An 81 year old man presented with increased lethargy over several months and progressive dyspnoea on exertion. He had no orthopnoea, paroxysmal nocturnal dyspnoea, chest pain, palpitations, or syncope. He had hypertension and glaucoma and was a non-smoker. His regular drugs were aspirin, simvastatin, candesartan, omeprazole, and latanoprost eye drops. Clinical examination showed a grade 3/6 ejection systolic murmur heard throughout the precordium, including the aortic region, radiating to the carotids. His pulse was regular, of normal character and good volume. He had no evidence of congestive cardiac failure and the rest of the physical examination was unremarkable. Routine blood tests showed abnormal thyroid function and low serum testosterone. He was referred to endocrinology and transthoracic echocardiography was performed. The parasternal views were poor but indicated moderate to severe aortic stenosis. He had mild left ventricular hypertrophy but good biventricular systolic function, biatrial dilatation, and mild diastolic dysfunction. Electrocardiography showed sinus rhythm with no abnormalities. 1 What is the pathological finding in the computed tomogram? Transoesophageal echocardiography was performed to assess 2 What further investigation would help assess the severity of the the severity of aortic stenosis but the heart could not be seen at cardiac condition? all. Computed tomography of the thorax (figure) was performed to 3 What are the treatment options for the cardiac condition? investigate the reason for this. Patient consent obtained. Submitted by Mithun Chakravorty, Abdallah Al-Mohammad, Peter Brown, Cite this as: BMJ 2015;351:h5386 Amit Allahabadia, and Ever Grech Find this at: http://dx.doi.org/10.1136/bmj.h5386

CASE SCENARIO Epidermal burn at a PEG site We welcome contributions that A patient underwent insertion of percutaneous endoscopic gastrostomy (PEG) after a cerebrovascular would help doctors event. Two weeks later, gastric contents were to be found with postgraduate leaking from the PEG site onto the patient’s abdomen examinations. causing an acidic burn to the surrounding skin and pain. We also welcome A delayed referral was made to the burns team three days later, who assessed the burn to be superficial, mid- submissions dermal, and occupying 0.25% of total body surface area. relevant to primary The skin was irrigated with water and dressed with a silver care. based dressing. It healed within three weeks. See thebmj.com/ Learning points: endgames • Acid burns are an unusual complication of PEG placement that clinicians should be aware of

• The differential diagnosis includes cellulitis and contact Patient consent obtained. dermatitis Cite this as: BMJ 2015;351:h5530

Submitted by Claire Alyss Spolton-Dean, George Lye, and Tom Potokar Find this at: http://dx.doi.org/10.1136/bmj.h5530

Medical therapy or valve replacement, depending on the severity of disease. of severity the on depending replacement, valve or therapy Medical 3

Cardiac magnetic resonance imaging. resonance magnetic Cardiac 2

Large hiatus hernia. hiatus Large 1

A man with a murmur and missing heart missing and murmur a with man A CASE REVIEW CASE answers the bmj | 9 January 2016 41 MINERVA A wry look at the world of research

Unusual presentation of a contained AAA rupture A 90 year old man was transferred to the rehabilitation be missed. Presentation may include increased ward with poor mobility, lower body oedema, and inflammatory markers, from superimposed raised inflammatory markers. He initially presented haematomal infection, and severe lower body oedema, with abdominal pain and haematemesis attributed probably because of inferior vena cava compression to severe gastro-oesophagitis. Contrast enhanced and lymphatic obstruction. computed tomography showed a contained rupture Shavini Weerasekera, foundation year 1 doctor, of a 6.6 cm saccular infrarenal abdominal aneurysm Sanja Thompson ([email protected]), consultant with large heterogeneous para-aortic haematoma. A geriatrician, Department of Geratology, John Radcliffe Hospital, cystic area showed rim enhancement (arrow) consistent Oxford, UK, Raman Uberoi, consultant radiologist, Department of with infection. Surgery was not appropriate because Radiology, John Radcliffe Hospital of frailty. However, he improved with antibiotics and Patient consent obtained. was discharged. About 4% of ruptured abdominal Cite this as: BMJ 2016;352:h6661 aortic aneurysms are contained (“sealed”) and can Find this at: http://dx.doi.org/10.1136/bmj.h6661

Declining meningitis Shared ignorance on sharing Hammer room of safety horrors Adult bacterial meningitis is becoming The new year will see major initiatives to For decades, airline pilots have been trained rarer. In the Netherlands, the incidence promote shared decision making between to identify safety hazards by simulation. in people over 16 years dropped patients and clinicians. But despite the It’s taken a long time for medicine to catch from 1.72 cases/100 000/year in extensive literature on the subject, a new up, but medical students and interns in 2007-08 to 0.94/100 000/year in systematic review found few randomised Chicago are now being exposed to a patient 2013-14 (Lancet Infect Dis 2015, controlled trials in the field with measures safety chamber of horrors and asked to list doi:10.1016/S1473-3099(15)00430- of participation in decision making and at as many potential hazards as possible (BMJ 2). Streptococcus pneumoniae least one health outcome (Med Decis Making Qual Saf 2015, doi:10.1136/bmjqs-2015- caused 72% of infections. This drop 2015, doi:10.1177/0272989X15613530). 004621). Few are good at it, but “learners coincided with the introduction of More focused research is needed as the appreciated the interactive experience and pneumococcal conjugate vaccination democratisation of medicine gathers pace. its clinical utility.” for children, making herd immunity a likely factor. At the same time Inflammatory ultrasound Swaddling: a Mongolian adjunctive dexamethasone, which was Ultrasonography is widely used to assess randomisation study associated with better outcomes, was and monitor inflammation in small joints. When Nahum Tate wrote “While more widely used. Rheumatologists in Boulogne subjected Shepherds Watch’d their Flocks by Night” 207 symptomless citizens of that marine in 1700, swathing, or swaddling, was How do you score for diabetes? town to the same kind of ultrasound a common practice in England. Hence The label “type 2 diabetes” is applied examination of their hands, wrists, and feet his picture of the baby Jesus “all meanly to everyone who crosses a certain as that used in symptomatic clinic patients wrapped in swathing bands.” Swaddling is threshold of glucose measurement. (Ann Rheum Dis 2015, doi:10.1136/ still traditional in Ulaanbaatar, Mongolia. The label “pre-diabetes” is sometimes annrheumdis-2015-208103). Only 25 In a large prospective study, babies born in applied to people judged at higher had entirely pristine joints free of synovial that province were randomly allocated to risk of being given the type 2 diabetes effusion, synovial hypertrophy, or abnormal swaddled or non-swaddled groups within label at some time in the future. Doppler signals. 48 hours of birth (Arch Dis Child 2015, Numerous predictive scoring systems doi:10.1136/archdischild-2014-307908). exist, including QDiabetes, Leicester Parvovirus myocarditis in kids The investigators found that swaddling had Risk Assessment (LRA), FINDRISC, Parvovirus B19 (PVB19) is exchanged no identifiable thermal advantages over and Cambridge Risk Score (CRS) between human beings across the world and sleeping bags during the coldest times in algorithms. These were applied to rarely causes more than a transitory rash traditional tents, and in centrally heated 676 employees aged over 40 years in children. But with the coming of better apartments it could contribute to the risk of (if white) or 25 years (if South Asian) viral identification techniques, PVB19 has overheating during the day. taking part in a workplace based been identified as a rare cause of severe Cite this as: BMJ 2016;352:h7011 initiative in the Welsh county of myocarditis, usually in the first years of life. Find this at: http://dx.doi.org/10.1136/bmj.h7011 Carmarthenshire (Br J Gen Pract 2015, In a series of 17 patients from Great Ormond doi:10.3399/bjgp15X687661). Street Hospital, five died and one underwent Scoring systems varied more than heart transplantation (Arch Dis Child 2015, fourfold in identifying “high risk” doi:10.1136/archdischild-2014-308080). individuals: CRS categorised the Rapid onset and ST elevation are associated highest proportion (13.6%), followed with a bad prognosis, but those with by FINDRISC (6.6%), QDiabetes fulminant disease who survive the first

(6.1%), and the LRA (3.1%). weeks can recover fully. SPRAGUE/ALAMY SEAN

42 9 January 2016 | the bmj the bmj | 9 January 2016 PB