NHS bosses reject GPs’ request to close patient lists BMJ (IF 20.7) Pub Date : 2017-09-22 Gareth Iacobucci
A group of general practices in Folkestone, Kent, that applied to formally close their practice lists because of safety concerns have had their request knocked back by NHS bosses, The BMJ has learnt.Earlier this month seven of eight practices in the town applied for permission to close their patient lists on the basis that they were “unable to take on more patients safely.” The action was triggered after one local practice was forced to hand its contract back to South Kent Coast Clinical Commissioning Group in May, prompting the CCG to order that the practice’s 4700 patients be reallocated to other local practices.But the CCG rejected the practices’ application after a meeting held on Thursday 21 September. …
Last ditch effort to repeal Obamacare gathers steam BMJ (IF 20.7) Pub Date : 2017-09-22 Owen Dyer
The Affordable Care Act, Barack Obama’s signature health reform, faces a real and fast developing threat from a fourth Senate repeal bill.As September began, Senate Republicans’ efforts to undo Obamacare were given a small chance of success. But the prospect of definitive failure seems to have galvanized the party, and leaders are sounding increasingly confident, with President Donald Trump and the Senate majority leader, Mitch McConnell, asserting that their new version of “Trumpcare” will pass.The bill, called Cassidy-Graham, is effectively the last chance this Congress will have to repeal Obamacare before the midterm elections in November 2018. Under Senate rules, after 30 September it will require an unattainable 60 vote majority to pass. Until 30 September it may pass as a budget measure with a simple majority. In a 50-50 Senate split the vice president, Mike Pence, would …
In cases of serious injury “scoop and run” improves survival compared with ambulance BMJ (IF 20.7) Pub Date : 2017-09-22 Zosia Kmietowicz
Researchers have discovered what gang members have known all along—that you’re more likely to survive a serious injury if you get yourself to hospital than if you wait for an ambulance.1“Scoop and run” describes the most basic form of prehospital trauma care—transportation with no intervention. A study from 2014 found that patients who used private transportation had improved survival compared with those who waited for an ambulance. But researchers from John Hopkins University School of Medicine …
Should we abandon “finishing the course” of antimicrobials? BMJ (IF 20.7) Pub Date : 2017-09-22 Chris Del Mar, David F M Looke
It depends on the type of infection The recent controversial article in The BMJ 1 wasn’t the first commentary to suggest that we should abandon the notion of a course of antibiotics and rethink the whole strategy of duration of therapy for infections.2 The objectives of treatment go beyond “cure” (kill the pathogen) to include reducing symptom severity and duration, the chances of relapse, and transmission to other people. This can be achieved by suppressing the growth of the pathogen until the host immune system destroys it. How the concept of “the course” evolved is not entirely clear,2 but two strategies probably underlie it. These are to ensure a total adequate dose by spreading a potentially toxic drug over time to avoid high peak levels, and to reduce the chance of resistance evolving within the patient during treatment. We already have information about the duration of treatment needed to get a high probability of cure for some infections. This ranges from a single dose (eg, chlamydia, donovanosis, primary syphilis) through a …
Modern complex care needs longer consulting times BMJ (IF 20.7) Pub Date : 2017-09-22 Peter J O’Donnell
GPs are always running late1 because they think they can deal with patients’ problems in the 10 minute slot allocated to them. They cling to this belief despite years and even decades of experience telling them otherwise. I struggled to run on time and knew GPs who always finished their surgeries 1-2 hours late. …
Women still not being told about pregnancy risks of valproate BMJ (IF 20.7) Pub Date : 2017-09-22 Jacqui Wise
Two thirds of women who take the antiepileptic drug sodium valproate said they had not received new safety warnings about the dangers of taking it during pregnancy, a survey carried out by epilepsy charities has found. A similar survey last year found that half of women taking the drug were unaware it could harm their fetus.1 The new results are to be presented at a public hearing on the safety of valproate drugs organised by the European Medicines Agency on 26 September in London. This is the first time that the EMA has held a public hearing as part of the safety review of a drug, and it will …
Junior doctor is cleared of wrongdoing after patient “misremembered” events BMJ (IF 20.7) Pub Date : 2017-09-22 Clare Dyer
A junior doctor who was accused of wrongly telling a patient that he had cancer has been exonerated after a medical practitioners tribunal found that the patient had become flustered at the mention of the word “cancer” and misunderstood the doctor’s comments. Richard Schofield, who qualified in 2011, waited nearly three years for his hearing, only for the General Medical Council’s case against him to swiftly unravel. The two expert witnesses, one for the GMC and one for Schofield, wrote in a joint statement, “The experts agree that in their experience it is common for patients of all ages, when faced with ‘bad’ news (including, for example, the possibility that they may have cancer), to become less receptive to receiving information. Both experts have witnessed this phenomenon in their working lives.” Schofield, …
Campaigners call for better services for language disorder that affects two children in every classroom BMJ (IF 20.7) Pub Date : 2017-09-22 British Medical Journal Publishing Group
Two children in every classroom are affected by language problems that can stifle their social development and education and increase their risk of depression in later life, academics have said. Developmental Language Disorder (DLD) is now the consensus term used to describe a common learning difficulty where persistent language problems affect a child’s communication or learning. Study findings suggest DLD affects approximately 7.5% of children in year one, which equates to two in every classroom.1 Children with …
Most cases of otitis media should not be treated with antibiotics, says NICE BMJ (IF 20.7) Pub Date : 2017-09-21 Zosia Kmietowicz
Most cases of otitis media in children can be managed with paracetamol or ibuprofen rather than antibiotics, new guidance from the National Institute for Health and Care Excellence (NICE) has said.1 The draft guidance says that most children with symptoms are in less pain within 24 hours and that antibiotics do not help. The evidence shows that antibiotics make little difference to how long symptoms last or the proportion …
One in 12 deaths could be prevented with 30 minutes of exercise five days a week, finds study BMJ (IF 20.7) Pub Date : 2017-09-21 Susan Mayor
Being physically active for 150 minutes a week could prevent one in 12 deaths globally and one in 20 cases of cardiovascular disease (CVD), a large study has found.1 Being even more active was associated with additional benefits. Previous research in high income countries has shown that low levels of physical activity are associated with increased mortality and morbidity from CVD but there has been limited data from low and middle income countries. Researchers prospectively studied 130 843 healthy volunteers aged 30 to 70 years. They measured their physical activity using the …
John Martin Ellison BMJ (IF 20.7) Pub Date : 2017-09-22 Andrew Ellison
John Martin Ellison was born in Leeds. Like most of his family, his parents were doctors. He was educated at Repton School and the University of Leeds Medical School. He qualified as a physician and surgeon in 1964, specialising in obstetrics and gynaecology. In 1965 he met Anne (née Eastwood), a nurse and midwife, at Hillingdon Hospital, London. They married on 23 April 1966 and had two sons, Andrew John (in 1967), and David Martin (in 1969). After practising medicine in various communities throughout England for six years, Martin brought his family to …
Unrelieved uncertainty BMJ (IF 20.7) Pub Date : 2017-09-21 Fiona Godlee
The only certain thing about medicine is its uncertainty. Patients and doctors must make decisions on the available information, which is always incomplete, variably relevant to individual circumstances, hedged around with likelihoods, best bets, and gut feelings, balanced by individual preferences, and constrained by available resources. Somehow, sometimes, good decisions are made.With careful use of evidence, and diligent clinical care, we can reduce uncertainty, but we will never remove it entirely. The BMJ ’s Uncertainties series (bmj.com/specialties/uncertainties-page) explores clinical questions for which …
Increased risk of cancer in children with inflammatory bowel disease BMJ (IF 20.7) Pub Date : 2017-09-20 British Medical Journal Publishing Group
The increase persists well into adulthoodPeople with inflammatory bowel disease worry about developing cancer.1 These concerns stem in part from drug labels warning of the rare but real increased risk, as well as from websites and peer reviewed papers that make their way into the headlines. Families of children with inflammatory bowel disease are particularly fearful after discovering that biological agents and immunomodulators are associated with hepatosplenic T cell lymphoma, particularly among children and young adults.2 Previous studies have identified higher rates of cancer among patients with inflammatory bowel disease than in the general population, but these studies have lacked the population size or follow-up to assess trends in lifetime risks.The linked research paper (doi:10.1136/bmj.j3951), a Swedish nationwide cohort study of children diagnosed with inflammatory bowel disease between 1964 and 2014, reports that children with inflammatory bowel disease have an increased risk of cancer in both childhood and adulthood.3 Through adulthood (median age at end of follow-up was 27 years), 497 people with childhood onset inflammatory …
An older woman with spontaneous bruising BMJ (IF 20.7) Pub Date : 2017-09-21 Muhajir Mohamed, Ajay Prakash
An 85 year old woman attended the emergency department with large bruises on her right forearm and left leg, which had appeared four days earlier. She had not sustained any injuries to account for the bruising. There was no bleeding from any other sites. Her only medical history was hypertension. Her medications included amlodipine and calcium supplements and she wasn’t taking aspirin, anticoagulants, or any over-the-counter medications. On examination there were extensive subcutaneous haematomas on the right forearm extending up to the upper arm and on the left leg extending up to the thigh (fig 1, 2⇓). Initial investigations showed low haemoglobin of 95 g/L with a normal platelet count (369 × 109/L). Coagulation assays showed markedly elevated activated partial thromboplastin time of 74 seconds (reference range 25 to 35 seconds). Prothrombin time was normal (12.2 seconds, reference range: 11 to 13 seconds), however, and fibrinogen assay was within normal limits (3.8 g/L, reference range 1.5 to 4.0 g/L). Mixing studies with 1 part of patient’s plasma and 1 part of pooled normal plasma (1:1 mix) showed no correction of elevated activated partial thromboplastin time. Further tests were performed to determine the reason for the elevated activated partial thromboplastin time. Factor assays revealed very low level of factor VIII (<1 IU/dL, reference range 50 – 150 IU/dL), and factors IX, XI, and XII were within normal ranges.Fig 1 Large subcutaneous haematoma in the right forearm extending to the upper armFig 2 Extensive subcutaneous haematoma in the left foot …
Sudden onset headache in a 50 year old woman BMJ (IF 20.7) Pub Date : 2017-09-21 Divyansh Gulati, Michael William Shea, James Ray
A 50 year old woman presented to the emergency department several hours after the sudden onset of a severe headache with associated neck stiffness, photophobia, and vomiting. She reported having a dental abscess, and was taking norethisterone regularly for persistent vaginal bleeding. She had a 50 pack year smoking history. She was afebrile, alert (Glasgow coma scale 15), and had no focal neurological signs. Blood tests were unremarkable, in particular her white blood cell and neutrophil counts were within the normal range. A non-contrast computed tomography (CT) scan of the head was obtained in the emergency department (fig 1⇓).Fig 1 Non-contrast computed tomography (CT) scan of the head: (A) axial and (B) sagittal views### 1. What is the diagnosis based on the history and CT scan?#### Short answerCerebral venous thrombosis, seen by the “dense triangle sign,” a hyperdensity at the posterior part of the superior sagittal sinus (fig 2a⇓), and the “cord sign” (fig 2b⇓), a homogenous hyperdensity that fills a sinus. Diagnosis is usually made from magnetic resonance (MR) or CT venography.Fig 2 Non-contrast CT scan of the …
Simon Wessely: “Every time we have a mental health awareness week my spirits sink” BMJ (IF 20.7) Pub Date : 2017-09-21 Sophie Arie
The first psychiatrist president of the Royal Society of Medicine is worried that over-awareness of mental ill health will sink an under-resourced serviceOne of the UK’s most prominent psychiatrists has called for an end to public awareness campaigning about mental health. It “massively expands demand” on already stretched NHS services and may be convincing people they are ill when they are not, warns Simon Wessely, who was until June president of the Royal College of Psychiatrists.“Every time we have a mental health awareness week my spirits sink,” says Wessely, who in July became the first psychiatrist to be president of the Royal Society of Medicine. “We don’t need people to be more aware. We can’t deal with the ones who already are aware.”Fresh from his move to the royal society, Wessely remains concerned about the over-reporting and under-resourcing of mental illness, and the lack of integration between mental and physical health services—despite NHS England head Simon Stevens’ affirmation last month that mental health is now “front and centre” of the health service agenda.1“I’m really worried that we will overstretch and demoralise our mental health services if all we do is raise awareness but don’t provide more people, better circumstances, better support, and less burden of regulation,” he told The BMJ .Recent years have seen a major drive by government, the NHS, and mental health charities to change attitudes towards mental health and to raise its profile in line with physical health. In a crescendo of media coverage, royals and celebrities have opened up about their own struggles.Despite having …
Children who miss appointments were not brought rather than did not attend BMJ (IF 20.7) Pub Date : 2017-09-21 Hareth Bader, Mark W Davies
Children who miss appointments might be at risk from lack of follow-up.1 The researchers concluded that communication between …
An unusual palmar eruption BMJ (IF 20.7) Pub Date : 2017-09-21 Rachel Fisher, Penelope Pratsou
A 21 year old woman presented with episodic palmar itching, stinging, and skin peeling after brief exposure to water. Palmar water immersion in the dermatology …
Doctors can withdraw artificial feeding without court approval in some cases, judge rules BMJ (IF 20.7) Pub Date : 2017-09-21 Clare Dyer
Cases in which doctors and the family of a patient in a permanent vegetative or minimally conscious state agree that artificial feeding should be withdrawn need no longer go to court, a High Court judge has declared in a landmark ruling.1Mr Justice Peter Jackson ruled that a decision to withdraw clinically assisted nutrition and hydration in such cases, taken in accordance with professional guidance, will be lawful and that doctors who withdraw the treatment without going to court will be protected under the provisions of the Mental Capacity Act.The ruling came in the case of a woman with Huntington’s disease, who was dependent on clinically assisted nutrition and hydration since 2003. Neither the …
Just 3% of patients with long term conditions have a written care plan, study finds BMJ (IF 20.7) Pub Date : 2017-09-21 Abi Rimmer
Just 3% of patients with long term conditions have a written care plan and large numbers of people are not as involved in their healthcare decisions as they want to be, a study has found.A study by National Voices, a coalition of over 160 health and care charities, collated patient and service user reported data from 19 England-wide surveys.It found that just over half (54%) of the 808 332 respondents to the 2017 General Practice Patient Survey identified themselves as having one or more long term conditions and, of these, 3% said they had a written care …
One in 10 parents with child in neonatal care don’t see consultant in 24 hours, audit finds BMJ (IF 20.7) Pub Date : 2017-09-21 Zosia Kmietowicz
The care delivered in 2016 to around 95 000 babies admitted to UK neonatal units was better than in 2015, but continuing variation in practice meant that babies in some parts of the country were much less likely to get the care they needed, an audit has found.1Results of the National Neonatal Audit Programme, published by the Royal College of Paediatrics and Child Health, showed that among preterm babies 94% (8597) had timely screening for retinopathy of prematurity in England, Scotland, and Wales in 2016. In the Shropshire, Staffordshire, and Black Country neonatal network this outcome improved from 87% in 2015 to 98% in 2016. …
CQC rates 90% of general practices as good or better BMJ (IF 20.7) Pub Date : 2017-09-21 Gareth Iacobucci
Ninety per cent of general practices in England have been rated as “good” or “outstanding” by the Care Quality Commission, making it the highest performing sector that the organisation regulates.In a report the CQC describes as the most detailed analysis to date of the quality and safety of general practice in England, the regulator found that at the end of its first full inspection programme—in which many general practices had been re-inspected—4% were rated “outstanding,” 86% as “good,” 8% as “requires improvement,” and 2% as “inadequate.”1This was an improvement from the first set of ratings awarded to general practices before any re-inspections took place, when 4% …
BMA urges more career flexibility and better occupational support to fight workforce crisis BMJ (IF 20.7) Pub Date : 2017-09-21 Abi Rimmer
Doctors’ career flexibility must be increased, such as more options to work part time, and their health and wellbeing services improved to stop the staff shortage worsening, the BMA has said in a new briefing on the state of medical recruitment.1To tackle what it described as a workforce crisis in medicine, the BMA also said that after Brexit the immigration system should enable the UK to recruit and retain the numbers of doctors it required if it couldn’t find enough in the country.The BMA has gathered figures …
Serious incident investigations for cerebral palsy are “poor quality,” says watchdog BMJ (IF 20.7) Pub Date : 2017-09-21 Gareth Iacobucci
Patients and their families were involved in just 40% of investigations into whether negligent NHS care resulted in children being born with cerebral palsy between 2012 and 2016, a new analysis has found.The report from NHS Resolution, formerly the NHS Litigation Authority, examined 50 cases of cerebral palsy or brain injury between 2012 and 2016 where a legal liability had been established.1 It estimated that the potential financial liability of these cases could surpass £390m (€440m; $530m), excluding defence costs and the wider healthcare costs to the NHS. Obstetric claims accounted for 10% of the 10 686 claims received under NHS Resolution’s indemnity schemes …
YouTube videos promote positive images of alcohol, finds study BMJ (IF 20.7) Pub Date : 2017-09-21 Susan Mayor
YouTube videos featuring alcohol products that are popular with underage drinkers attract large numbers of viewers and often associate drinking with fun and attractive characters, a new study has found.1Researchers analysed the content and use of 137 YouTube videos published between 2006 and 2013 that featured alcohol brands popular with underage drinkers, ranging from beer to vodka.“Although many studies have investigated the effect of alcohol advertisements on Facebook, Twitter and Instagram, little research has been done on video sharing platforms such as YouTube,” wrote the researchers, led by Brian Primack, director of the University of …
Consider corticosteroids for acute sore throat, says BMJ review BMJ (IF 20.7) Pub Date : 2017-09-21 Gareth Iacobucci
The evidence is weak but points to the need for shared decision making, reports Gareth Iacobucci This week The BMJ publishes the latest articles in its Rapid Recommendations series, which aims to accelerate evidence into practice and answer the questions that matter to clinicians quickly and transparently.The latest review examines the evidence for the use of corticosteroids for treating sore throat, one of the commonest reasons for primary care appointments.1International guidance on corticosteroids for sore throats varies, but a trial published in April 2017 indicated that they might be effective.2 After conducting a systematic review and meta-analysis that included data from the April trial,3 the Rapid Recommendation authors make a weak recommendation to use a single dose of oral corticosteroids in patients presenting with acute sore throat. The recommendation …
How should we manage women with unexplained chronic pelvic pain in light of uncertainty about the effectiveness of gabapentin? BMJ (IF 20.7) Pub Date : 2017-09-21 James M N Duffy
Chronic pelvic pain affects 2.1% to 24% of the global female population,12 and up to half of the affected women have no obvious pathology.23 The neuromodulator gabapentin can be used to modulate pain, but the evidence for its effectiveness and safety is limited, as discussed by Andrew Horne and colleagues in a related article (doi:10.1136/bmj.j3520) . Here, James Duffy explores how we should manage women with unexplained chronic pain in light of this uncertainty.Treatment of women with chronic pelvic pain is directed towards achievement of higher function with some pain rather than a cure.4 At the initial consultation, explore and document the severity of …
Is gabapentin effective for women with unexplained chronic pelvic pain? BMJ (IF 20.7) Pub Date : 2017-09-21 Andrew W Horne, Katy Vincent, Roman Cregg, Jane Daniels
This article is linked with a commentary on “What to do in the light of this uncertainty” by James Duffy. #### What you need to knowChronic pelvic pain in women is a common presentation in primary care. Pain persists or recurs over at least six months1 and can be distressing, affecting physical function, quality of life, and productivity.2 Nearly 38 per 1000 women are affected annually in the UK. Global estimates range from 2.1% to 24% of the female population.34Endometriosis, adenomyosis, adhesions, pelvic inflammatory disease, irritable bowel syndrome, bladder pain syndrome, nerve entrapment, and musculoskeletal pain are among the common causes.45 These are often identified by screening for pelvic infection (eg, Chlamydia trachomatis ), pelvic imaging (eg, ultrasound, magnetic resonance imaging), and diagnostic laparoscopy.1 Some 40%-55% of women with chronic pelvic pain in secondary care appear to have no obvious underlying pathology based on clinical history, examination, and investigations.46 Management of this group of women is challenging and there are few established gynaecological treatments. The Royal College of Obstetricians and Gynaecologists recommends a combination of pharmacological interventions, physiotherapy, and cognitive behavioural therapy.1 Often women try several methods sequentially or in combination.478Figure 1⇓ presents a common diagnostic and treatment approach that women with chronic pelvic pain might be offered.Fig 1 Flow diagram showing the possible “treatment journey” (and timelines) for a woman who presents to primary care with …
AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both BMJ (IF 20.7) Pub Date : 2017-09-21 Beverley J Shea, Barnaby C Reeves, George Wells, Micere Thuku, Candyce Hamel, Julian Moran, David Moher, Peter Tugwell, Vivian Welch, Elizabeth Kristjansson, David A Henry
The number of published systematic reviews of studies of healthcare interventions has increased rapidly and these are used extensively for clinical and policy decisions. Systematic reviews are subject to a range of biases and increasingly include non-randomised studies of interventions. It is important that users can distinguish high quality reviews. Many instruments have been designed to evaluate different aspects of reviews, but there are few comprehensive critical appraisal instruments. AMSTAR was developed to evaluate systematic reviews of randomised trials. In this paper, we report on the updating of AMSTAR and its adaptation to enable more detailed assessment of systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. With moves to base more decisions on real world observational evidence we believe that AMSTAR 2 will assist decision makers in the identification of high quality systematic reviews, including those based on non-randomised studies of healthcare interventions . #### Summary pointsWith the rapid increase in biomedical publishing, keeping up with primary research has become almost impossible for healthcare practitioners and policy makers.1 Consequently, healthcare decision …
Obesity surgery achieves long term weight loss and prevents type 2 diabetes, study finds BMJ (IF 20.7) Pub Date : 2017-09-21 Susan Mayor
Gastric bypass surgery achieves long term weight loss and sustained prevention of type 2 diabetes, hypertension, and dyslipidaemia in severely obese patients, a 12 year follow-up study has shown.1Previous studies have shown significant weight loss and improvements in type 2 diabetes and cardiovascular risk factors with bariatric surgery, but follow-up has been relatively short term. There has been limited evidence on the long term effects.The new study prospectively followed up 418 severely obese patients undergoing Roux-en-Y gastric bypass at Rocky Mountain Associated Physicians surgical centre, in the US. Data were …
Training for children with chronic fatigue works better than medical care alone, finds study BMJ (IF 20.7) Pub Date : 2017-09-21 Nigel Hawkes
A widely publicised technique for treating chronic fatigue syndrome (CFS) in children actually works, to the surprise of the researcher who conducted the first randomised controlled trial of it.The Lightning Process, developed by osteopath Phil Parker, has made bold claims that it can cure CFS in children. It is not available on the NHS, and costs around £620 (€702; $837) per case treated.Esther Crawley, professor of child health at the University of Bristol, runs a clinic for children with CFS. She conducted a randomised controlled trial comparing specialised medical care, of the sort her unit already provided, with the same care as well as the Lightning Process.“I never expected it would work,” she told a briefing at the Science Media Centre in London. But the trial, published in Archives of Disease in Childhood ,1 showed positive results. The …
Is herd thinking in medical training leading us astray? BMJ (IF 20.7) Pub Date : 2017-09-21 Jonathan Glass
We are a lesser profession for not having an open discussion about the direction of medical training“We (consultants) do more and more, and we see our registrars less and less.” “I can’t get a decent registrar on our professorial unit.” “We know national selection is not fit for purpose.” “My juniors don’t know how to suture.”I could probably fill pages with similar comments that have been made to me over the past few months by senior consultants—all great trainers with so much to offer, all motivated to teach and to share their experience, yet all distressed by the direction in which they see British medicine going.I recognise that the plural of anecdote is not data. Nevertheless, it can be challenging to gather data to confirm the opinion of the many—particularly when the …
General practice funding rose by 3% last year BMJ (IF 20.7) Pub Date : 2017-09-20 Gareth Iacobucci
Investment in general practice increased by 3% in real terms in the UK last year, official figures have shown. But the BMA has expressed concern that last year’s increase was less than the 5% increase in 2015-16, despite government pledges to invest more in general practice.The data from NHS Digital show that in 2016-17 total investment in general practices increased by 3.2% in England, 2.7% in Wales, 2% in Scotland, and 1.3% in Northern Ireland in real terms.1In cash terms there was a 5.1% increase across the UK (5.2% in England, 4.7% in Wales, …
Patient murders urologist 21 years after receiving diagnosis BMJ (IF 20.7) Pub Date : 2017-09-20 Owen Dyer
A California urologist who helped to diagnose urethral stricture in a patient was murdered two decades later by the same man, who was convinced that the resulting operation—in which the urologist took no part—had ruined his life.Stanwood Elkus, 79, was sentenced to life in prison without parole for the murder of Ronald Gilbert, who was 53 in 2013 when Elkus booked an appointment under a false name, then shot him 10 times as he walked through the consulting room door. He told a nurse as he emerged: “I’m insane. Call the police.”The retired barber’s grudge dated from 1992, …
Credibility and trust are required to judge the benefits and harms of medicines BMJ (IF 20.7) Pub Date : 2017-09-20 David B Menkes, Dick Bijl
Freer and Godlee consider the serious doubts held by both the public and the profession regarding drug efficacy and safety, and they lament the weak recommendations made by the Academy of Medical Sciences to tackle the fundamental problem of conflicts of interest in drug information.12 Medical journals have a key role in accessing clinical trial and other evidence on drugs, …
We want to gain the public’s trust, but are we listening to them? BMJ (IF 20.7) Pub Date : 2017-09-20 P J Gordon, S F Gordon
In his response to the editorial by Freer and Godlee on judging the benefits and harms of medicines, Robinson effectively says that we can only gain the trust of the …
Woman who became infertile after hospital’s negligence is awarded costs for surrogacy BMJ (IF 20.7) Pub Date : 2017-09-20 Clare Dyer
The High Court in London has awarded damages covering the cost of surrogacy for the first time to a woman who lost her fertility through a hospital’s negligence. Whittington Hospital NHS Trust in north London admitted liability in the case of the woman, who was diagnosed as having invasive cervical cancer at the age of 29. The trust failed to detect cancer despite smear tests in 2008 and 2012 and biopsies in 2012 and 2013. The woman underwent chemoradiotherapy, which left her infertile and with severe radiation damage …
Passion for life BMJ (IF 20.7) Pub Date : 2017-09-20 Alison Shepherd
David Scheinmann “I promised myself that only after the birth of my first child would I proceed with the mastectomy. I wanted to know and feel what breastfeeding is all about.” These are …
Corticosteroids for sore throat: a clinical practice guideline BMJ (IF 20.7) Pub Date : 2017-09-20 Bert Aertgeerts, Thomas Agoritsas, Reed A C Siemieniuk, Jako Burgers, Geertruida E Bekkering, Arnaud Merglen, Mieke van Driel, Mieke Vermandere, Dominique Bullens, Patrick Mbah Okwen, Ricardo Niño, Ann van den Bruel, Lyubov Lytvyn, Carla Berg-Nelson, Shunjie Chua, Jack Leahy, Jennifer Raven, Michael Weinberg, Behnam Sadeghirad, Per O Vandvik, Romina Brignardello-Petersen
What is the role of a single dose of oral corticosteroids for those with acute sore throat? Using the GRADE framework according to the BMJ Rapid Recommendation process, an expert panel make a weak recommendation in favour of corticosteroid use. The panel produced these recommendations based on a linked systematic review triggered by a large randomised trial published in April 2017. This trial reported that corticosteroids increased the proportion of patients with complete resolution of pain at 48 hours. Box 1 shows all of the articles and evidence linked in this Rapid Recommendation package. The infographic provides the recommendation together with an overview of the absolute benefits and harms of corticosteroids in the standard GRADE format. Table 2 below shows any evidence that has emerged since the publication of this article. Clinicians and their patients can find consultation decision aids to facilitate shared decision making in MAGICapp (www.magicapp.org/goto/guideline/JjXYAL/section/j79pvn). #### What you need to know: #### Box 1: Linked articles in this BMJ Rapid Recommendations cluster
Few novel antibiotics in the pipeline, WHO warns BMJ (IF 20.7) Pub Date : 2017-09-19 Zosia Kmietowicz
The World Health Organization has reiterated its warning that there is a serious lack of new antibiotics under development to combat the growing threat of antimicrobial resistance. Only eight of the 51 new antibiotics and biologicals in clinical development to treat antibiotic resistant pathogens are innovative treatments that could add value to the current drugs on offer, a new report from the agency has found.1 Most of the drugs in the clinical pipeline are modifications of existing classes of antibiotics and are only short term solutions, …
Mental health services turned down help for 50 000 young people in England last year, report estimates BMJ (IF 20.7) Pub Date : 2017-09-19 Zosia Kmietowicz
Children and adolescents in England face barriers when seeking help for mental health problems, with access and waiting times for treatment varying across the country, a report by the think tank the Education Policy Institute has found.1 The institute sent freedom of information requests to all 67 providers of child and adolescent mental health …
A smoke-free generation? BMJ (IF 20.7) Pub Date : 2017-09-19 John Britton
Unlikely, thanks to complacency, naivety, and impotence in the face of big tobacco In 1854, John Snow carried out a study of the Broad Street cholera epidemic that is now recognised as a classic of epidemiology and public health practice.1 In the same year, Philip Morris made his first cigarette.2 Today, cholera still occurs but is rare, while cigarettes represent the biggest preventable threat to global health. The magnitude of that threat is laid out in the latest World Health Organization report on the global tobacco epidemic.3 The report estimates that tobacco use currently causes around seven million (or one in 10) global deaths each year and details progress implementing the six core tobacco control policies advocated under the MPOWER acronym (Monitor, Protect from smoke, Offer help to quit, Warn about dangers, Enforce bans, and Raise taxes).4 These policies are intended to discourage people from consuming tobacco, much as removing the handle of the Broad Street pump reduced access to contaminated drinking water,1 …
Future of screening for prostate cancer BMJ (IF 20.7) Pub Date : 2017-09-19 Philipp Dahm
Multiparametric magnetic resonance imaging is likely to be part of itFew topics in medicine stir up as much controversy as prostate cancer screening. Prostate cancer is a highly prevalent, potentially lethal disease, making the enthusiasm of the public and health professionals for screening and treatment understandable.1 However, many screen detected cancers have a protracted and indolent natural course with no adverse effects for decades, and patients are at greater risk from the ensuing cascade of diagnostic imaging and unnecessary treatments than from the disease itself.Current best evidence suggests that prostate specific antigen (PSA) testing provides only a small reduction in prostate cancer mortality and no reduction in all cause mortality, while at the same time exposing healthy individuals to the risk of overdiagnosis and overtreatment.2 Recent draft recommendations by the United States Preventive Services Task Force against population based screening (grade C), emphasise the importance of shared decision making between men and their healthcare providers but fall short of providing other actionable guidance.3 Although the results of the CAP …
“It wasn’t a medical miracle—we made our own luck”: lessons from London and Manchester terror attacks BMJ (IF 20.7) Pub Date : 2017-09-19 Anne Gulland
A week after another UK hospital had to declare a major incident as a result of a terror event, Anne Gulland reports on what lessons doctors can learn from how those in London and Manchester have dealt with the spate of attacks this yearLast week London’s St Mary’s Hospital had to declare a major incident after a terror attack on an Underground train at Parsons Green. The explosion once again highlighted the challenges for doctors and medical teams—hospitals in London and Manchester have already been tested by four major terror attacks in 2017: Westminster Bridge, Manchester Arena, London Bridge, and Finsbury Park mosque.The Parsons Green victims mainly sustained burns, but each of the attacks have presented different challenges. The Westminster Bridge attacker rammed a vehicle into pedestrians, and most patients brought to hospital had blunt trauma. At London Bridge, the attackers used both a vehicle and knives and many patients presented with stab wounds. In Manchester the attacker detonated a shrapnel loaded device and patients presented with complex, multiorgan injuries.At a conference at the Royal Society of Medicine in London earlier this month, doctors who treated those patients shared what they have learnt. The NHS was widely praised for its response; however, Duncan Bew, a trauma specialist at King’s College Hospital in south London where many of those injured in the Westminster and London Bridge attacks were treated, told the meeting: “We cannot rest on our laurels. Because we have done well in this incident, it doesn’t mean we’ll do well in the next one.”Early reports of a terrorist attack often say that a major incident has been declared, giving the impression that some magical switch is flipped and a well oiled emergency plan kicks in.Malcolm Tunnicliff, clinical director for emergency and acute care at …
Put more trust in the trustworthy and less in the untrustworthy to improve judgement of medicines BMJ (IF 20.7) Pub Date : 2017-09-19 Mary Madden
The Academy of Medical Sciences recommends involving patients, carers, and the public in research as a means of tackling concerns about the erosion of public trust, overmedication, and conflicts of interest.1 Patient and public involvement, …
Bringing the research community together to improve communication BMJ (IF 20.7) Pub Date : 2017-09-19 John Tooke
I was pleased to see The BMJ discuss12 our latest Academy of Medical Sciences’ report.3 We welcome the synergies between our work and the evidence based medicine manifesto proposed by The BMJ .4Our report calls for changes to the Research Excellence Framework to recognise efforts …
Major report backs overhaul of US dietary guideline process BMJ (IF 20.7) Pub Date : 2017-09-19 Jacqui Wise
The process for updating the US national dietary guidelines should be comprehensively redesigned, with more rigorous evaluation of the evidence and greater transparency, concludes a new report from the National Academies of Sciences, Engineering and Medicine.1The Dietary Guidelines for Americans , issued every five years, are hugely influential in driving nutrition policy in the United States and worldwide. However, they have been heavily criticized in recent years, and concerns have been raised in the US Congress about their trustworthiness.In 2015 The BMJ ran a highly critical review saying that the expert report underpinning the dietary guidelines failed to take account of all the relevant scientific evidence.2 In response, more than 180 researchers, including all the members of the 2015 guideline committee, signed a letter calling on The BMJ to retract the article. After a formal post-publication review The BMJ decided against retraction.3In response to widespread criticism, Congress asked the National Academies of Sciences, Engineering and Medicine to evaluate the entire process used to develop …
Duncan Selbie: Health is wealth BMJ (IF 20.7) Pub Date : 2017-09-19 British Medical Journal Publishing Group
Duncan Selbie’s new mantra is work, work, work. In his speech to Public Health England’s annual conference last week, the agency’s quietly inspirational chief executive said that getting people into work was in everyone’s interests“I saw this poster in Freetown, Sierra Leone [which says “Health is Wealth”]. It seems to me that the most important thing that we have been learning is that health and wealth are inseparable and that a thriving economy is good for the health of the people. It is a virtuous circle.“I want my …
IT glitch forces GPs to cancel shifts BMJ (IF 20.7) Pub Date : 2017-09-19 Gareth Iacobucci
Locum doctors are being forced to cancel scheduled clinics at GP surgeries because of an IT glitch that has led to their “erroneous removal” from the national performers list, GP leaders have warned.The problem has caused staffing problems at practices and meant that locum doctors are missing out on income, said the BMA. It first reported the problem to NHS England and the private company Capita, which manages the list, last year, but has recently noticed a worsening of the situation.GPs wishing to practise in England must be registered on the national performers list to prove that they are suitably qualified, their training is …
Legal aid cuts may have fuelled rise in clinical negligence costs BMJ (IF 20.7) Pub Date : 2017-09-19 Tom Moberly
Cuts to legal aid have helped fuel rises in the amount that clinical negligence costs the NHS, Robert Francis QC has said.Francis, who led the public inquiry into failings at Mid Staffordshire NHS Foundation Trust, raised the issue at a Westminster Health Forum seminar on clinical negligence in London on 14 September. He said that restrictions on access to justice had not helped to contain increases in litigation costs, and may …
Paris Agreement’s ambition to limit global warming to 1.5°C still possible, analysis shows BMJ (IF 20.7) Pub Date : 2017-09-19 Ingrid Torjesen
The ambitious aim, set by the Paris Agreement in 2015, of limiting global warming to less than 1.5°C is still feasible, an analysis shows.1The agreement aims to hold the increase in global average temperature to below 2°C above pre-industrial levels, and countries signing up to it agreed to pursue efforts to limit the increase to 1.5°C.The 1.5°C aspiration was seen as unachievable because analysts predicted that carbon emissions would need to fall to zero within seven years. However, the new analysis, based on the latest …
Registry data show increase in joint replacement surgery BMJ (IF 20.7) Pub Date : 2017-09-19 Susan Mayor
The number of joint replacement procedures is rising, with a low rate of revisions to replace first time joint implants but a higher risk in younger patients, show the latest figures from the orthopaedic joint replacement register for England, Wales, Northern Ireland, and the Isle of Man.1“The consistently high number of joint replacement cases submitted per year suggests continuing high levels of patient confidence and clinical performance, in what is a remarkably successful surgical intervention,” said Martyn Porter, medical director of the National Joint Registry and …
Men over 40 are most at risk of sudden death during triathlons BMJ (IF 20.7) Pub Date : 2017-09-19 Jacqui Wise
Deaths and cardiac arrests during triathlons are not rare with most occurring during the swimming segment, according to a case series reported in the Annals of Internal Medicine .1Triathlon, which combines swimming, cycling, and running, has become increasingly popular in recent years. The study authors said that participants should be aware of the risks and should have adequately trained before taking part. They also said that middle aged and older men should be screened for any underlying cardiovascular disease before taking part.The study found that death or cardiac …
David Oliver: Admission should allow for patient aids BMJ (IF 20.7) Pub Date : 2017-09-19 David Oliver
I’ve never believed that all hospital admissions are undesirable or avoidable. Sometimes admission is the best, only, or safest option. But it shouldn’t avoidably make patients worse for reasons unconnected to the illness causing admission.It’s a bewildering enough start, to be whisked out of your home at short notice into an ambulance, through a busy emergency floor and into the alien environment of a hospital ward. So why compound it?Patients often have walking aids and familiar chairs, as well as moving and handling devices they are practised with. Granted, some are unsafe. But …
Regenerating medicine BMJ (IF 20.7) Pub Date : 2017-09-18 Andrew Webster
New regenerative treatments are on the horizon—can they deliver? The clinical landscape today is being reshaped by a host of biomedical innovations, some of which will make their way to the clinic. One area attracting major interest is that of regenerative medicine, where live cells and tissues are used to treat disease with new, healthy, and specially grown tissue. The belief is that regenerative medicine will provide much needed therapeutic options for patients with conditions such as retinitis pigmentosa and age related macular degeneration.12 Regenerative treatments are often compared to monoclonal antibodies in terms of their potential for clinical and economic benefits.3 Many governments see the field as potentially revolutionary, including those in Australia, Japan, the UK, and the US.4 Commercial investment is also increasing rapidly, although no products are yet widely available on the market. Commissioning new therapies is under increasing budgetary pressure, however, with little spare cash available for innovation, especially in the NHS. A recent House of Commons inquiry called for new incentives to stimulate development and adoption of …
It’s time to fund health and social care properly BMJ (IF 20.7) Pub Date : 2017-09-18 John W Puntis
Majeed correctly points out that restrictions on prescribing and reduced availability of drug treatments on the NHS, as well as stopping prescription of gluten free food products for patients with celiac disease, might have unforeseen negative consequences, particularly in vulnerable groups such as children.12 These might increase healthcare costs in …
Soldier with brain injury can have experimental stem cell therapy, says judge BMJ (IF 20.7) Pub Date : 2017-09-18 Clare Dyer
A High Court judge has provisionally cleared the way for a soldier disabled by a traumatic brain injury to undergo experimental stem cell treatment at a clinic in Belgrade. The application by the lance corporal’s mother was opposed by the Ministry of Defence, which is responsible for his care, and the official solicitor, who acted for him in the case at the Court of Protection. Both argued that there was not enough evidence that the treatment was safe. Mr Justice Baker ruled that the 27 year old soldier, referred to as D, lacked the capacity to make his own decisions about medical treatment. But D was adamant that he wanted the treatment …
Bernie Sanders’ single payer bill gains momentum among Democrats BMJ (IF 20.7) Pub Date : 2017-09-18 Owen Dyer
The US senator Bernie Sanders, who missed out on becoming the Democratic party’s candidate in the presidential election last year, has launched a single payer healthcare bill to deliver health services to the entire country. Although it stands no chance of passing through Congress, whose two houses are controlled by Republicans, the idea of single payer healthcare has seized the middle ground of the Democratic party, to judge from the names co-sponsoring Sanders’ Medicare For All Act. There are 15 co-sponsors to the bill, including five senators often named as potential 2020 presidential candidates: Cory Booker of New Jersey, Kamala Harris of California, Kirsten Gillibrand of New York, Al Franken of Minnesota, and Elizabeth Warren of Massachusetts. Their collaboration with Sanders in calling for single …
Margaret McCartney: Are we reviewing GP referrals for the right reasons? BMJ (IF 20.7) Pub Date : 2017-09-18 Margaret McCartney
NHS England wants all GP referrals to secondary care to be peer reviewed, and it believes that this can reduce referrals by “up to 30%.”1 The plans have met with shock and outrage in the tabloid press. Outrage is justified, but for rather different reasons. This is yet another example of non-evidence based policy making, capable of doing more harm than good. And it’s not a new idea. The NHS has been looking at similar proposals for years. The BMJ reported in January that a third of clinical commissioning groups have employed private companies to scrutinise referrals: three quarters were unable to show whether they’d saved …
New NHS safety watchdog aims to promote openness and avoid “blame culture” BMJ (IF 20.7) Pub Date : 2017-09-15 Clare Dyer
A new independent patient safety watchdog for the NHS in England aims to tackle the “blame culture” that critics say hampers the health service in learning lessons to prevent future harm to patients. The Health Service Safety Investigations Body (HSSIB) is modelled on bodies that investigate air and marine safety, where there is a focus on risks to the public rather than apportioning blame to individuals. It will cover NHS commissioned services in England, including those provided by GPs. The body, to be given statutory powers under a parliamentary bill introduced on 14 September,1 will create a “safe …
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