More a hammer than a mirror

Bertolt Brecht wrote that art should influence reality, not merely reflect it. If that is true for the arts, it is certainly true of science. Clinical Medicine (ClinMed) is committed to publishing papers that help clinicians to shape their practice, rather than just reports documenting it. This is illustrated in much of the content in this edition.

For example, the faecal immunochemical test (FIT) has been recommended to replace the older guaiac blood test as screening for colorectal cancer. The place of the test is to potentially decrease the demand for colonoscopy yet, despite this, colonoscopy demand increases. The Royal College of Physicians (RCP) hosted a conference at which cutting-edge data on the contentious topic of setting the cut-off level for the test was presented. An excellent summary of this data is presented in this edition of the journal,¹ allowing the reader to consider the importance of the negative predictive value of these large data sets, and using that to shape colonoscopy practice based on local services and case mix. The article is accompanied by an excellent editorial by the team at Imperial College making the case that, correctly used, the test may indeed be ‘FIT’ for purpose.² Another example of shaping practice comes from a survey report by Bethune and Herriot.³ Immunoglobulin use is increasing across all specialties, both as replacement therapy for patients with immunodeficiency and (in higher doses) for immunomodulation. Switching immunoglobulin products is increasing in health services (related to either withdrawal of some products, supply issues or cost factors). The RCP accreditation unit undertook a census of the UK Primary Immunodeficiency Network of immunology centres, demonstrating that over 800 patients ‘switched’ to alternative immunoglobulin products during 2018. The manuscript presents the results of a concurrent survey, accounting for over 90% of UK centres. It provides objective data on safety and tolerability of switching, which becomes ever more relevant given the lability in immunoglobulin supplies, which may necessitate further rounds of switching.

‘How I do it’ manuscripts are always popular since they usually allow the reader to have an expert on their shoulder when undertaking a procedure or interpreting data. Mercer et al provide a guide in this edition to interpreting pleural fluid results, which will doubtless become a valuable resource for many.4 Coupled with excellent respiratory medicine reviews in the CME section, this edition has much for the trainee.

No reader of ClinMed is unaware of the burden of obesity, and it is a problem that has implications for practice in all specialties. Despite this, knowledge of therapies tends to be the preserve of endocrinologists and specialist surgeons. We are pleased therefore to publish an up-to-date review of the pharmacological, endoscopic and surgical approaches that are currently available.⁵ In addition there is an eye to emerging therapies in this topic that sees approximately 10,000 medical articles published a year.

Frailty is another topic that touches the practice of all physicians. An excellent article by Hale et al addresses the important and poorly studied effects of the determinants of health on the frailty status of an individual.⁶ The corollary of this is resilience, and the authors discuss how an enhanced understanding of the relationship between frailty and social health inequalities can lead to development of policy responses to build resilience in people living with frailty at individual and community level. Research ultimately has to influence policy, and this edition of ClinMed showcases articles that cover aspects of this at several points in that process.