Forces of nature

时间：2017-12-14

发布：Sophie Cook, UK research editor, Navjoyt Ladher, head of scholarly comment

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We have another bumper crop of Christmas articles in The BMJ this year, so read on as you raise a glass to the festive season—but not too big a glass (doi:10.1136/bmj.j5623).

The natural world features in several papers, exploring links between environmental conditions and health: from weather and joint pain (doi:10.1136/bmj.j5326) to thunderstorm asthma (doi:10.1136/bmj.j5636) and the effect of a full moon on deaths of motorcyclists (doi:10.1136/bmj.j5367).

The built environment is key too. Evidence is growing for the health benefits of green spaces, and Juliet Dobson explores how hospital gardens, common before the second world war, are making a comeback (doi:10.1136/bmj.j5627).

Benjamin Mazer describes how our built surroundings can help us make sense of the medical landscape, as he draws an analogy between brutalist architecture and the drive to utility often underlying modern healthcare (doi:10.1136/bmj.j5676).

On to toddler favourite Peppa Pig. Catherine Bell asks whether the paternalism and questionable prescribing practices of the television series’ resident GP, Dr Brown Bear, could be promoting overuse of healthcare (doi:10.1136/bmj.j5397). We wonder how Dr Brown Bear might approach the much debated phenomenon of “man flu,” which Kyle Sue concludes may have some basis in fact (doi:10.1136/bmj.j5560).

Though we can’t always change the factors in our environment that affect our health, acknowledging their role is important—as is helping people affected by adverse conditions, whether environmental or not. Our Christmas appeal this year is raising money for Médecins Sans Frontières, whose staff and volunteers bring medical aid to some of the people around the world who need it most, such as those trapped by the crossfire in Yemen (doi:10.1136/bmj.j5722). Please support them with your usual generosity (www.msf.org.uk/bmj).

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5765 (Published 14 December 2017)
Cite this as: BMJ 2017;359:j5765

Finding a road to recovery

时间：2017-12-07

发布：Rebecca Coombes, head of news and views

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This week The BMJ publishes a trio of education articles and an infographic that deal with the diagnosis and management of eating disorders in young people (doi:10.1136/bmj.j5245; doi:10.1136/bmj.j5328; doi:10.1136/bmj.j5378; http://bit.ly/2jqgBO8).

As Helen Bould and colleagues report (doi:10.1136/bmj.j5245), the UK’s annual incidence of eating disorders diagnosed in primary care among people aged 10-49 rose from 32.3 per 1000 in 2000 to 37.2 in 2009. Eating disorders are now fairly common among adolescent girls. A recent Dutch study found a lifetime prevalence among 19 year old women of 5.7%, compared with 1.2% in men. Despite this prevalence, anorexia, bulimia, and binge eating disorder are often dangerously misunderstood. Population studies consistently find that many people meeting diagnostic criteria do not get any kind of treatment.

Bould and colleagues emphasise the importance of intervening early for better treatment outcomes. Outcomes in anorexia are especially poor if the patient does not receive effective treatment within the first three years. One characteristic of treating eating disorders is that the doctor must build a therapeutic relationship with the family, not just with the patient. What can be effective, they write, is “conceptualising eating problems as separate from the young person, so that parent and child can ‘team up’ against the disorder.”

The tensions and benefits in this family dynamic are laid bare in Caitlin and her mother Sally’s account of the 17 year old’s struggle with anorexia (doi:10.1136/bmj.j5378). The BMJ’s What Your Patient is Thinking articles are usually told in the first person, but this week’s double header shows how perceptions differ between patients with an eating disorder and their carers.

Caitlin, who lost 10 kg in six months, thought she wasn’t thin enough to be anorexic and took pride when people liked her skinny selfies on Instagram. Sally was able to offer insights Caitlin wasn’t aware of, such as her total withdrawal from social groups offline. Good, structured care can make a difference: after a year in treatment, and with a detailed relapse prevention strategy, Caitlin is now in recovery.

Her advice to doctors? Explain that social media images are often altered or unrealistic: “I often wonder, if I had known about Photoshop, would I have become ill? If I knew these women were not real, would I have wanted to change so much?”

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5660 (Published 07 December 2017)
Cite this as: BMJ 2017;359:j5660

Putting innovation to the test

时间：2017-11-30

发布：Fiona Godlee, editor in chief，The BMJ

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NHS staff and patients face the prospect of continued austerity after the chancellor fell short of meeting NHS England’s request for at least £4bn to meet growing demand (doi:10.1136/bmj.j5422). How should we respond? (Watch The BMJ’s Facebook Live event at http://bit.ly/2AtfCGS for health policy experts’ response to the autumn budget.)

Tight budgets can, of course, stimulate innovation, as Caroline White found when investigating the effect of cuts to England’s sexual health services (doi:10.1136/bmj.j5395). Local authorities have responded innovatively, absorbing rising demand within fixed budgets through efficiencies and new ways of working, says White’s report (which has an accompanying interactive map showing county by county changes in sexual health service budgets). Moving some services online, integrating others, and changing payment structures have secured clinical provision, despite diminishing resources.

But innovation has its limits. White quotes David Buck of the health think tank the King’s Fund. “The fat has already gone,” he says. “We are about at the limit now, and in some places have gone beyond it.” This is especially true as needs become more complex. Syphilis is on the rise, White explains, and “chemsex” and other social changes bring new challenges. Restrictions and closures are already happening below the radar, and prevention and promotion are likely to be particularly badly hit. Some losses are hidden within the data. Chlamydia diagnoses have fallen, for example, but perhaps because fewer tests are being done. “It’s a mixed picture, and not all bad,” says Buck, “but no one was expecting this level of austerity.”

Technological innovation can be particularly appealing when the aim is to stretch resources while also improving care. Characteristically, David Oliver calls for caution in his perspective on telehealth (doi:10.1136/bmj.j5108). Anything that helps people stay at home, retain their independence, manage their health, or avoid admission to hospital is worth trying, he says. But new technologies should be tested to the same standards of evidence as other innovations, he says. Evidence of benefit is often limited, that of cost effectiveness even less so. In the absence of randomised controlled trials, he asks for large quality improvement studies, with independent scrutiny, release of all data, and, crucially, no commercial spin.

We need the same independent scientific approach to innovations in primary care, says Rebecca Rosen (doi:10.1136/bmj.j5470). “GP at Hand” is the newest kid on the block, offering ready access to primary care through a smartphone. But will this merely fuel demand from the worried well? Worse, by cherry picking the young and healthy at the expense of most patients’ more complex needs, will it fragment and undermine the NHS’s famously cost effective primary care?

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5539 (Published 30 November 2017)
Cite this as: BMJ 2017;359:j5539