BMJ - British Medical Journal

What’s this about?In March 2021, in response to the covid-19 pandemic, more than 20 world leaders and the director general of the World Health Organization proposed that nations should work towards a new international treaty for pandemic preparedness and response.1 The aim was to strengthen resilience to future pandemics and enhance international cooperation. Since then work has continued on drafting an agreement and WHO hopes a legally binding text will be adopted at the World Health Assembly at the end of this month.All sounds very sensibleNot according to Nigel Farage, it isn’t. Together with several Conservative MPs, the former UKIP leader and MEP is lobbying the UK government to block the treaty, claiming that it will give WHO the power to enforce lockdowns, dictate mask wearing, and control vaccine stocks.The latest chapter in the culture wars?It looks like it. Farage is now fronting a new campaign group—Action on World Health—which...

NHS England has set out its latest plans to slash waiting times in urgent and emergency care with an expansion of virtual wards, giving GPs the ability to directly refer patients to same day emergency care, while offering financial incentives to hospitals to cut 12 hour emergency waits.In a letter to integrated care boards (ICBs) and trusts, NHS England thanked staff for progress made over the past year and set out the next steps for its two year recovery plan for urgent and emergency care.1The plans are intended to help hospitals meet two new targets: for at least 78% of patients to be treated, admitted, or sent home from emergency departments within four hours by March 2025; and for ambulances to respond to category 2 calls within an average of 30 minutes this year.Sarah-Jane Marsh, NHS England’s national director for urgent and emergency care, said, “Last year saw considerable progress...

Al-Najjar discusses the challenges of supporting medical practitioners with mental health problems through NHS Practitioner Health (NHSPH), formerly the practitioner health programme (PHP).1 NHSPH strives to provide support, treatment, and psychological safe places.I became an occupational medicine consultant in 2000 and over 80% of my clinics are for medical practitioners. Presentations are becoming more complicated—the world of work now involves blended teams, patient safety considerations, and waiting list pressures—and there are expectations of quick solutions. Financial and psychosocial challenges outside of work are ever present.Any clinician supporting doctors must have a thorough understanding of the current workings of the NHS, including nuances of the workplace and evolving case complexities, the need to deliver across the employer-employee-trainee interface, the NHS long term plan, and emerging interdisciplinary case mix delivery models in primary and secondary care.Occupational health support for NHS employees has been a postcode lottery for some time. NHS England does...

bmj;385/may17_4/q1106/FAF1faOn the day she died Rhona MacDonald was working to have aid delivered to Ukraine, writing a letter to organise a medical evacuation from Gaza, and finalising a theme issue for the Bulletin of the World Health Organization. From the window of her home in Laide, a village on the coast of north west Scotland, she could see the sea, distant hills, birds in flight, and seals on the rocks.After she lost her job as an editor at the Lancet in 2010, over what she saw as a point of principle, MacDonald told the Canadian Medical Association Journal that she wanted her next role to meet two criteria—“helping people, particularly poor and vulnerable populations; and making a significant difference.” She added, “For almost four wonderful years, I felt that I could fulfil these criteria at the Lancet.” Richard Horton, editor in chief of the Lancet, said, “Rhona lit our pages...

Why did the babies die?Young infants are at the highest risk of severe complications and death from whooping cough, a respiratory disease caused by Bordetella pertussis bacteria. Pertussis is included in the 6-in-1 combined vaccine given at 8, 12, and 16 weeks of age. The five babies who died this year were, however, all under 3 months old. Vaccination in pregnancy, which has been used routinely in the UK since 2012, is key to passively protect babies before they can be directly protected by the infant vaccination programme. Adam Finn, professor of paediatrics at the University of Bristol, said, “Receiving a whooping cough vaccine in pregnancy is an effective way to protect newborns from the disease which is most dangerous in the early weeks and months of life. Babies will get protection from receiving vaccines themselves, but this is only fully in place when they are about 5-6 months old.”...

The 2023 report of the United Nations Interagency Group for Child Mortality Estimation shows a remarkable 51% fall in global mortality for children aged under 5 years between 2000 and 2022, from 76 deaths/1000 live births to 37/1000.1 This is a historic low: millions more children are surviving as low and middle income countries advance towards reducing under 5 mortality to ≤25 deaths/1000 live births by 2030, one of the targets set out in the UN sustainable development goal on good health and wellbeing.2The fall is encouraging, but 4.9 million children under 5 years still died in 2022.1 Although 134 out of 200 countries achieved the under 5 mortality target, the rest, most in sub-Saharan Africa and southern Asia, are still struggling. Prevention and treatment of leading causes of deaths in children under 5, including infectious diseases (pneumonia, diarrhoea, and malaria), prematurity, and birth asphyxia or trauma remain inadequate in...

Globally, more than eight million people have type 1 diabetes (T1D) and need multiple daily insulin injections1 and many millions more have other forms of insulin requiring diabetes. Insulin is essential for life, particularly for people with T1D. Children or adults with T1D will most likely die within a week without insulin. In disasters and conflicts, the combination of internal displacement, disruptions to daily routines, food insecurity, emotional trauma and fear, and other illnesses or injuries make people with T1D especially vulnerable to life threatening episodes of hypoglycaemia or diabetic ketoacidosis. Nations must individually and collectively fulfil their obligation to uphold human rights and humanitarian law to ensure access to insulin and medical supplies.Human rights law in relation to people with diabetes includes the right to life and health and particularly focuses on the rights of children, women, older people, and displaced people.23456 Nations have an obligation to respect, protect,...

This is a fundus image of the retina of a woman in her mid 60s with type 2 diabetes who presented with visual disturbances in her left eye (fig 1). She had been diagnosed with diabetes 15 years earlier and had an HbA1c levels consistently above her target range. She had not previously undergone diabetic retinopathy screening. The visual acuity of her left eye had decreased to 20/200 and scattered haemorrhages and exudates were found on funduscopy, with accompanying neovascularisation in the temporal macula (arrow). Initially, the bleeding was confined between the retina and the internal limiting membrane, a membrane that sits between the retina and the vitreous. This resulted in a distinctive boat shaped appearance (*).1bmj;385/may16_10/e077450/F1F1f1Fig 1Haemorrhages confined within the internal limiting membrane are typically less severe and may have a better prognosis than those that breach the membrane into the vitreous cavity.2 These pre-retinal bleeds may resolve spontaneously...

In 2023 fewer graduates of US medical schools applied to residency programmes in states that banned abortions than to those in states where abortion remained legal—the second year in a row this has happened, the Association of American Medical Colleges has reported.1US medical students typically apply for residency positions during their fourth year in medical school, with about 20 000 using the college’s electronic residency application service (ERAS). The analysis was performed for the 2022-23 application cycle.In June 2022 the US Supreme Court ended the constitutional right to abortion and returned decisions to the individual states.2As of 1 April 2024, the association’s report said, 14 of the 50 US states completely ban abortion. About half of the US states ban or severely restrict abortion.The association noted that state decisions such as banning abortions “affect where physicians plan to practice, [and so] state governments and healthcare leaders need to consider the...

Plant based diets protect against progression of prostate cancerA longitudinal study of 2000 men with biopsy proved non-metastatic prostate cancer reports benefits from a plant based diet. Diet and lifestyle had been assessed soon after recruitment. During a median follow-up of 6.5 years, men scoring in the highest fifth for dietary intake of grains, fruits, legumes, and vegetables were only half as likely to experience disease progression as those in the lowest fifth. However, it’s worth noting that people in the top fifth for eating a plant based diet also had a faster walking pace, lower body mass index, lower levels of prostate specific antigen, and were less likely to smoke (JAMA Netw Open doi:10.1001/jamanetworkopen.2024.9053).Plant based diets may prevent diabetesPlant based diets may help prevent diabetes too. Among 12 000 middle aged adults taking part in the Atherosclerosis Risk in Communities study, a third developed type 2 diabetes over 22...

On 15 April 2024, after a public consultation that received over 100 000 comments, the US Equal Employment Opportunity Commission (EEOC) issued final regulations detailing employers’ obligation to provide reasonable accommodation to pregnant workers.1 These new regulations expand access to unpaid time off as a reasonable accommodation during pregnancy, for pregnancy termination, or after childbirth. A coalition of attorneys general from 17 states challenged this ruling on 25 April, focusing on provisions for pregnancy termination.2 Whether these new regulations are implemented or over-ruled by the courts will determine whether millions of pregnant and postpartum workers will get access to unpaid leave.For readers from many countries, this may be surprising. The US is one of the few countries that has no national guarantee of paid maternal leave (the others being Papua New Guinea and five small Pacific island states).3 Moreover, half of all American workers, and more than two thirds of...

Vaping cessationOver the past year we’ve seen various trials that assess vaping as an intervention for smoking cessation. Now we have smoking cessation drugs being studied as interventions to help people stop vaping. Cytisinicline, a plant based alkaloid that targets nicotinic acetylcholine receptors, has been available in the UK since the start of this year. One hundred and sixty non-smokers who use nicotine vapes were randomised to either cytisinicline 3 mg three times a day for 12 weeks or placebo (both groups received behavioural support). Participants were asked to set a quit date seven to 14 days after the start of treatment. Some 31.8% of those in the cytisinicline group, and 15.1% in the placebo group had stopped vaping between nine and 12 weeks (odds ratio, 2.64; 95% CI, 1.06 to 7.10). However, by 16 weeks the gap between the groups had narrowed.JAMA Intern Med doi:10.1001/jamainternmed.2024.1313ZOE team celebrates its METHODZOE,...

ABSTRACTObjectiveTo examine the association between prescriber workforce exit, long term opioid treatment discontinuation, and clinical outcomes.DesignQuasi-experimental difference-in-differences studySetting20% sample of US Medicare beneficiaries, 2011-18.ParticipantsPeople receiving long term opioid treatment whose prescriber stopped providing office based patient care or exited the workforce, as in the case of retirement or death (n=48 079), and people whose prescriber did not exit the workforce (n=48 079).Main outcomesDiscontinuation from long term opioid treatment, drug overdose, mental health crises, admissions to hospital or emergency department visits, and death. Long term opioid treatment was defined as at least 60 days of opioids per quarter for four consecutive quarters, attributed to the plurality opioid prescriber. A difference-in-differences analysis was used to compare individuals who received long term opioid treatment and who had a prescriber leave the workforce to propensity-matched patients on long term opioid treatment who did not lose a prescriber, before and after prescriber exit.ResultsDiscontinuation of long term opioid treatment increased from 132 to 229 per 10 000 patients who had prescriber exit from the quarter before to the quarter after exit, compared with 97 to 100 for patients who had a continuation of prescriber (adjusted difference 1.22 percentage points, 95% confidence interval 1.02 to 1.42). In the first quarter after provider exit, when discontinuation rates were highest, a transient but significant elevation was noted between the two groups of patients in suicide attempts (adjusted difference 0.05 percentage points (95% confidence interval 0.01 to 0.09)), opioid or alcohol withdrawal (0.14 (0.01 to 0.27)), and admissions to hospital or emergency department visits (0.04 visits (0.01 to 0.06)). These differences receded after one to two quarters. No significant change in rates of overdose was noted. Across all four quarters after prescriber exit, an increase was reported in the rate of mental health crises (0.39 percentage points (95% confidence interval 0.08 to 0.69)) and opioid or alcohol withdrawal (0.31 (0.014 to 0.58)), but no change was seen for drug overdose (−0.12 (−0.41 to 0.18)).ConclusionsThe loss of a prescriber was associated with increased occurrences of discontinuation of long term opioid treatment and transient increases in adverse outcomes, such as suicide attempts, but not other outcomes, such as overdoses. Long term opioid treatment discontinuation may be associated with a temporary period of adverse health impacts after accounting for unobserved confounding.

AbstractObjectivesTo replicate previous analyses on the effectiveness of the English human papillomavirus (HPV) vaccination programme on incidence of cervical cancer and grade 3 cervical intraepithelial neoplasia (CIN3) using 12 additional months of follow-up, and to investigate effectiveness across levels of socioeconomic deprivation.DesignObservational study.SettingEngland, UK.ParticipantsWomen aged 20-64 years resident in England between January 2006 and June 2020 including 29 968 with a diagnosis of cervical cancer and 335 228 with a diagnosis of CIN3. In England, HPV vaccination was introduced nationally in 2008 and was offered routinely to girls aged 12-13 years, with catch-up campaigns during 2008-10 targeting older teenagers aged <19 years.Main outcome measuresIncidence of invasive cervical cancer and CIN3.ResultsIn England, 29 968 women aged 20-64 years received a diagnosis of cervical cancer and 335 228 a diagnosis of CIN3 between 1 January 2006 and 30 June 2020. In the birth cohort of women offered vaccination routinely at age 12-13 years, adjusted age standardised incidence rates of cervical cancer and CIN3 in the additional 12 months of follow-up (1 July 2019 to 30 June 2020) were, respectively, 83.9% (95% confidence interval (CI) 63.8% to 92.8%) and 94.3% (92.6% to 95.7%) lower than in the reference cohort of women who were never offered HPV vaccination. By mid-2020, HPV vaccination had prevented an estimated 687 (95% CI 556 to 819) cervical cancers and 23 192 (22 163 to 24 220) CIN3s. The highest rates remained among women living in the most deprived areas, but the HPV vaccination programme had a large effect in all five levels of deprivation. In women offered catch-up vaccination, CIN3 rates decreased more in those from the least deprived areas than from the most deprived areas (reductions of 40.6% v 29.6% and 72.8% v 67.7% for women offered vaccination at age 16-18 and 14-16, respectively). The strong downward gradient in cervical cancer incidence from high to low deprivation in the reference unvaccinated group was no longer present among those offered the vaccine.ConclusionsThe high effectiveness of the national HPV vaccination programme previously seen in England continued during the additional 12 months of follow-up. HPV vaccination was associated with a substantially reduced incidence of cervical cancer and CIN3 across all five deprivation groups, especially in women offered routine vaccination.

When George Floyd died in police custody in Minneapolis in May 2020, the circumstances of his death while being restrained became the focus of significant controversy. Police officers attending the scene said that Floyd was experiencing “excited delirium,” which some people say can cause a person to become so agitated and delirious that they die. That was why he died, the police claimed.The phrase “excited delirium” was used by two doctors working in Miami in the 1980s to describe what at the time were unexplained deaths of several black women.1 The doctors believed that drugs may have played a role in their death. In reality, the dead women weren’t victims of drug overdoses or “excited delirium”: they had been murdered by a serial killer.2Subsequent analyses have never found a reliable medical basis for the use of “excited delirium” in the medical lexicon.3 Yet this and a related phrase more common...

The human papillomavirus (HPV) vaccine protects individuals from HPV strains that cause cancer. Evidence of its effectiveness in eliminating invasive cervical cancers is growing.1234 In a linked paper, Falcaro and colleagues (doi:10.1136/bmj-2023-077341) provide further evidence for the impact of HPV vaccination in eliminating invasive cancers.5 They also answered the vexed question of whether national HPV vaccination programmes magnify or narrow cervical cancer inequities.Women from lower socioeconomic backgrounds share a disproportionately greater burden of cervical cancer incidence and mortality.6 Notably, socioeconomic inequities in cervical cancer are reported across high, middle, and low income countries.789 Falcaro and colleagues’ findings underscore the importance of the HPV vaccine as an effective tool for reducing inequalities in cervical cancer, making a clear case for equitable access to the vaccine.In their nationwide study, Falcaro and colleagues found that HPV vaccination reduced cervical cancer risk and grade 3 cervical intraepithelial neoplasia by 83.9% (95% confidence interval 63.8%...

Patients are often the beneficiaries of medicine, but they can be its victims too. Most people in the western world are likely to know by their 60s that they have at least one chronic condition or risk factor, if not several. As they age further the number of these will almost certainly increase, along with regular check-ups, investigations, and an escalating amount of treatment.Some of the effects of this may be positive in terms of a person’s longevity and quality of life, although good nutrition, housing, education, and a decent income are likely to have been more important. Over time, however, their risks of harm will also become greater. These may include an altered self-image, the iatrogenic effects of overdiagnosis and polypharmacy, and a paradoxical lessening of their overall enjoyment of everyday living.Many interconnected cultural influences have led us to this. One important strand has been the growth of medical...

ABSTRACTIn addition to conventional chemoradiation and targeted cancer therapy, the use of immune based therapies, specifically immune checkpoint inhibitors (ICIs) and chimeric antigen receptor T cell therapy (CAR-T), has increased exponentially across a wide spectrum of cancers. This has been paralleled by recognition of off-target immune related adverse events that can affect almost any organ system including the cardiovascular system. The use of ICIs has been associated with myocarditis, a less common but highly fatal adverse effect, pericarditis and pericardial effusions, vasculitis, thromboembolism, and potentially accelerated atherosclerosis. CAR-T resulting in a systemic cytokine release syndrome has been associated with myriad cardiovascular consequences including arrhythmias, myocardial infarction, and heart failure. This review summarizes the current state of knowledge regarding adverse cardiovascular effects associated with ICIs and CAR-T.

AbstractObjectivesTo evaluate the clinical effectiveness of long acting progestogens compared with the combined oral contraceptive pill in preventing recurrence of endometriosis related pain.DesignThe PRE-EMPT (preventing recurrence of endometriosis) pragmatic, parallel group, open label, randomised controlled trial.Setting34 UK hospitals.Participants405 women of reproductive age undergoing conservative surgery for endometriosis.InterventionsParticipants were randomised in a 1:1 ratio using a secure internet facility to a long acting progestogen (depot medroxyprogesterone acetate or levonorgestrel releasing intrauterine system) or the combined oral contraceptive pill.Main outcome measuresThe primary outcome was pain measured three years after randomisation using the pain domain of the Endometriosis Health Profile 30 (EHP-30) questionnaire. Secondary outcomes (evaluated at six months, one, two, and three years) included the four core and six modular domains of the EHP-30, and treatment failure (further therapeutic surgery or second line medical treatment).Results405 women were randomised to receive a long acting progestogen (n=205) or combined oral contraceptive pill (n=200). At three years, there was no difference in pain scores between the groups (adjusted mean difference −0.8, 95% confidence interval −5.7 to 4.2, P=0.76), which had improved by around 40% in both groups compared with preoperative values (an average of 24 and 23 points for long acting progestogen and combined oral contraceptive pill groups, respectively). Most of the other domains of the EHP-30 also showed improvement at all time points compared with preoperative scores, without evidence of any differences between groups. Women randomised to a long acting progestogen underwent fewer surgical procedures or second line treatments compared with those randomised to the combined oral contraceptive pill group (73 v 97; hazard ratio 0.67, 95% confidence interval 0.44 to 1.00).ConclusionsPostoperative prescription of a long acting progestogen or the combined oral contraceptive pill results in similar levels of improvement in endometriosis related pain at three years, with both groups showing around a 40% improvement compared with preoperative levels. While women can be reassured that both options are effective, the reduced risk of repeat surgery for endometriosis and hysterectomy might make long acting reversible progestogens preferable for some.Trial registrationISRCTN registry ISRCTN97865475.

What are the neurological symptoms of covid-19?Covid may be primarily a respiratory infection, but a common symptom is “brain fog”—problems with memory or concentration—which can persist for weeks or months as part of long covid.1 And it’s not the only neurological effect.Giovanni Schifitto, professor of neurology at the University of Rochester Medical School in New York, explains that neurological symptoms are widespread. “In the acute phase, common things like lack of smell, changes in taste, increase in headaches, cognitive dysfunction, and strokes have been reported, and there are effects on the peripheral nervous system,” he says.Although these complications are more likely in people with severe covid—a 2021 study found that 80% of people admitted to hospital with covid-19 experienced neurological symptoms2—they can also affect people who experience only mild covid symptoms.3 These neurological symptoms were also found to be more likely in people who were older, male, or white and...