Medicine and Science from The BMJ

What can we learn from the shameful story of vaginal mesh? That thousands of women have been irreversibly harmed; that implants were approved on the flimsiest of evidence; that surgeons weren’t adequately trained and patients weren’t properly informed; that the dash for mesh, fuelled by its manufacturers, stopped the development of alternatives; that surgeons failed to set up mesh registries that would have identified complications sooner; and that the National Institute for Health and Clinical Excellence and the UK regulators let them off the hook. The BMJ has a published an investigation into vaginal mesh, which charts some of the issues above. In this podcast The BMJ talked to three women who have had a vaginal mesh implanted, and all suffered the negative consequences that have prompted these investigations. We bring you these stories to underline how life altering the situation has been for these woman, and to highlight the need for fully informed consent before anyone else has a mesh implanted. What we must learn from mesh: https://www.bmj.com/content/363/bmj.k4254

There is very little guidance on withdrawing or tapering opioids in chronic pain (not caused by cancer). People can fear pain, withdrawal symptoms, a lack of social and healthcare support, and they may also distrust non-opioid methods of pain management. This can mean that patients receive repeat opioid prescriptions for extended periods of time. In this podcast, Harbinder Sandhu, health psychologist in pain management at Warwick Medical School, Andrea Furlan, associate professor of medicine at University of Toronto, and Sam Eldabe, consultant in pain medicine at The James Cook University Hospital join us to set out the evidence on tapering opioids - and give practical advice on how to support patients. We're also joined by Colin, who was prescribed opioids for a decade, before he decided to reduce his usage. What you need to know: For people with chronic pain and who do not have cancer, the benefits of long term opioids are outweighed by the issues of tolerance, dependence, and the requirement for higher doses Tapering is the gradual reduction of opioids with the aim of limiting withdrawal symptoms; it may target complete discontinuation of the opioid, or on occasion a reduction of the dose It is not clear how best to support people to taper their opioids; whether it is best done by interdisciplinary pain management programmes, buprenorphine substitution, or behavioural interventions Read the full uncertainties paper: https://www.bmj.com/content/362/bmj.k2990

Ted Kaptchuk, professor of medicine at Harvard Medical school - and leading placebo researcher, has just published an analysis on bmj.com describing the effect of open label placebo - placebos that patient's know are placebos, but still seem to have some clinical effect. Ted joins us to speculate about what's going on in the body, what this means for designing a more effective placebo, and asking whether it's time to start honestly prescribing placebos in the clinic. Read his full analysis: https://www.bmj.com/content/363/bmj.k3889

We want clinical trials to be thorough - but Vinay Prasad, assistant professor of medicine at Oregon Health Science University, argues that the problem of overdiagnosis may be as prevalent, in the way we measure disease in our research, as our practice. In this podcast he joins us to discuss the problem, and why he thinks what qualifies as disease in clinical trials may be getting so broad that outcomes are becoming less meaningful and harder to interpret. Read the full analysis: https://www.bmj.com/content/362/bmj.k3783

Brits have a reputation as Europe’s boozers - and for good reason, with alcohol consumption higher than much of the rest of the continent. That reputation is extended to our young people too - but is it still deserved? Joanna Inchley, senior research fellow at the University of St Andrews, explains new research on decreasing drinking - http://www.hbsc.org/ Also this week, as part of our coverage of the 70th anniversary of the founding of the NHS, we’ve been running a series of articles exploring this unique institution’s future. Neena Modi, professor of neonatal health, and Jonathan Clarke, clinical research fellow, from Imperial College London, passionately believe that the NHS needs to be publicly financed - and importantly, publicly provided. https://www.bmj.com/content/362/bmj.k3580

Last week we heard about how evidence in policy making is imperilled - but today we’re hearing about a plan to make evidence about health central to all aspects of government. Laura Webber, director of public health modelling at the UK Health Forum, Susie Morrow, chair of the Wandsworth Living Streets Group and Brian Ferguson, chief economist at Public Health England join us to discuss a “health in all policies” approach, with protected funding for preventive interventions. Read their full analysis: https://www.bmj.com/content/362/bmj.k3377

This week a very different kind of conversation on the Recommended Dose – one that considers the art of medicine more than the science. Iona Heath is a long-time family doctor who has worked in a London GP clinic for over 30 years, and at one time became President of the Royal College of General Practitioners. With an international profile, gained in part through her much-loved writing in the BMJ, Iona is unlike many of our previous guests. For a start, she loves words more than numbers, and literature more than clinical guidelines. Host Ray Moynihan caught up with Iona at a recent conference in Helsinki – where she'd just presented little data but much food for thought from the likes of novelists EM Forster and James Baldwin. Here, she shares more of her love of literature and thoughtful commitment to the best kind of patient care.

If you’re of a scientific persuasion, watching policy debates around Brexit, or climate change, or drug prohibition are likely to cause feelings of intense frustration about the dearth of evidence in those discussions. In this podcast we're joined by Chris Bonell, professor of public health sociology - in this podcast he airs those frustrations, and worries that the rise of populism is pushing evidence even further out of policy decision. Read the accompanying essay: https://www.bmj.com/content/362/bmj.k3827

More than ½ of patients leave hospital with changes to four or more of their long-term medications - but how appropriate are those changes? New research published on bmj.com looks at antihypertensive medication prescription changes to try and model that - and found that more than half of intensifications occurred in patients with previously well controlled outpatient blood pressure. To discuss what they found, we're joined by Timothy Anderson, primary care research fellow, and Michael Steinman, professor of medicine, both from UCSF. Read the open access research: https://www.bmj.com/content/362/bmj.k3503

We at The BMJ care about food, and if our listener stats are to be believed, so do you. In this podcast we’re looking at quality as an important driver of a good diet. At our recent food conference - Food For Thought - hosted in Zurich by Swiss Re we brought researchers in many fields of nutritional science together. We asked people with competing ideas to write articles to elucidate where there’s agreement, and where there is still contention. There was lots of disagreement - but one thing that was widely agreed on was that, quality of food matters. Quality is as, if not more, important than quantity. In this podcast we’ll be exploring what quality is, how industrial food production affects it, and how we conceptualise quality. Joining us are Martin White, Mathilde Touvier, Jean Adams, Nicola Guess and Alan Levinovitz. For the last podcast in the food series: https://soundcloud.com/bmjpodcasts/nutritional-science-why-studying-what-we-eat-is-so-difficult? For more on the Food for Thought series https://www.bmj.com/food-for-thought