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  • Towards the new frontier
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Fiona Godlee

    Anyone working in healthcare will be feeling the pressure of rising demand and limited resources. Being asked to rethink how you do things may be the last straw. But this is what the sustainability and transformation partnerships (STPs) are asking clinicians in England to do. So far the outcome has been mixed at best. As Jennifer Richardson reports this week (doi:10.1136/bmj.j5130), the prevailing view among hospital doctors is unengaged and unenthusiastic, with many who responded to a recent survey doubting the motives behind …

    更新日期:2017-11-09
  • Countdown tracks progress on health effects of climate change
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Alexander Tin-Han Yu, Mona Sarfaty

    Year on year, we can now see the work that must be done Last week, the Lancet published its 2017 Countdown report on understanding, preventing, preparing for, and acting on the threat to human health from climate change.1 It follows a 2015 Commission on Health and Climate Change, which concluded that climate change was a “potentially catastrophic risk to human health,” but also “the greatest global health opportunity of the 21st century.”2 This inaugural annual report details 40 baseline indicators to measure progress, threats to progress, the consequences of inaction, and essential steps for the healthcare sector to mitigate negative health effects of climate change.The Countdown draws on data and expertise from every continent, updating key indicators in five categories roughly divided into research, adaptation and resilience, mitigation, economics and finance, and engagement by politicians and the public. This breadth includes input from climate scientists, engineers, economists, and doctors, to name a few, capturing the vast scope of the …

    更新日期:2017-11-09
  • An unstable knee
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Fidel Peat, Michael Barrett, Stephen M McDonnell

    A 28 year old man was brought to hospital after a road traffic incident. He described hearing a “pop” as his right knee impacted against the dashboard at the time of collision, and he subsequently experienced extreme pain. On examination in the emergency department, his knee was swollen and tender, and range of movement was severely limited. After initial management in the emergency department, he was admitted under the orthopaedic team. Once the swelling was resolved, his knee was re-examined, and was found to be grossly unstable (fig 1⇓).Fig 1  Clinical photograph of the patient’s right knee### 1. What sign is shown in the clinical photograph?#### Short answerPosterior sag sign suggesting injury to the posterior cruciate ligament.#### DiscussionThe posterior cruciate ligament serves as the main restraint to posterior displacement of the tibia relative to the femur. Secondary functions include resisting excessive valgus, varus, and external rotation movements. Disruption of the posterior cruciate ligament can be seen via posterior draw testing or by assessing for posterior sag (fig 2⇓). Normally, the anterior surface of the tibia lies around 1 cm anterior to the femoral surface when the knee is held in 90° of flexion. Any …

    更新日期:2017-11-09
  • A young man with palpitations and pre-syncope
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Debjit Chatterjee

    A 20 year old man presented to the emergency department with palpitations lasting half an hour. He was also feeling dizzy and felt close to fainting. He denied any chest pain. He had no known cardiac history.Examination revealed blood pressure of 70/50 mm Hg. Oxygen saturation was 91% on room air. There was no murmur on auscultation of the chest. The man underwent electrocardiography (ECG) (fig 1⇓). What rhythm does the ECG show?Fig 1  Electrocardiography (ECG) on presentation to the emergency departmentAtrial fibrillation with very fast ventricular response as a result of antegrade conduction through an accessory pathway (pre-excited atrial …

    更新日期:2017-11-09
  • Tropical cyclones and public health: how climate change is driving increasingly extreme weather—an essay by Fintan Hughes, Jack Hodkinson, and Hugh Montgomery
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Fintan Hughes, Jack Hodkinson, Hugh Montgomery

    Doctors must advocate for less use of fossil fuel, write Fintan Hughes , Jack Hodkinson , and Hugh Montgomery , if the harms to public health seen in this year’s hurricane season are not to become more regular occurrences Throughout the 60 million years of the carboniferous period, which ended 300 million years ago, carbon dioxide was drawn down from the atmosphere and sequestered in fossil fuels. These fuels have only recently been burnt at scale. Cars first outnumbered horses in New York City just over 100 years ago, but there are now 1.2 billion vehicles on the road worldwide, and airlines carry over 400 000 passengers every hour. Burning fuels has increased atmospheric carbon dioxide substantially from 280 to 406 ppm since 1850.In 1896, Nobel Laureate and physical chemist Svante Arrhenius predicted that such rises could increase global surface temperatures. By 1970 climate scientists widely recognised this causal relation. In 2016, the average land surface temperature was 1.42°C higher than the 20th century average, with an increase in average global temperature of 1.1°C.1Food shortages and the spread of disease resulting from climate change have been well described.2 However, the oceans have also been affected: water and ice have absorbed 93% of the net global energy gain caused by carbon dioxide and other greenhouse gases, and their surface temperatures have risen by 0.7°C since preindustrial times.3 Polar sea ice is melting—its surface area 2 000 000 km2 smaller in 2017, the minimum Arctic sea ice extent in September being 44% lower than the 1981-2010 average—and sea levels are rising by 3.4 cm a decade.Heat in our atmosphere and oceans causes air to rise and water to evaporate. This water precipitates as rain, and rising air creates pressure differences that cause wind. The resulting dynamic system is …

    更新日期:2017-11-09
  • Should doctors support restrictions on anti-abortion protests?
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Francesca Robinson

    The idea of buffer zones to prevent picketing around abortion clinics is gaining traction. Francesca Robinson reports on the feelings of doctors on both sides of the fenceOn the 50th anniversary of the Abortion Act, on October 27, more than 100 MPs put their names to a letter urging the government to introduce buffer zones to prevent anti-abortion activity outside women’s and reproductive health clinics.It follows a groundbreaking vote by Ealing Council to explore the possibility of introducing a public space protection order to stop activists picketing women and staff outside its local Marie Stopes reproductive health and abortion clinic.These moves are welcomed by doctors who provide abortion care, but some people argue that such restrictions on the activities of anti-abortion pressure groups amount to a ban on free speech.The British Pregnancy Advisory Service, which runs more than 40 abortion clinics and sexual health centres in England, Wales, and Scotland, has campaigned for the introduction of buffer zones since 2014. It says anti-abortion activists carry large banners of dismembered fetuses, distribute leaflets containing misleading information about abortion, and follow and question women as they enter or leave the clinics. It claims that anti-abortion activity is escalating in the UK. Caroline Gazet, a surgeon and deputy medical director at reproductive health and abortion service provider Marie Stopes, agrees. “I have provided abortion care for 10 years and I have definitely noticed that over the past few years there are more protesters outside clinics, particularly at times such as Advent and Christmas,” Gazet says.Retired obstetrician and gynaecologist Wendy Savage says that although there have been violent incidents outside clinics in America, so far nothing similar has …

    更新日期:2017-11-09
  • Wanted: clinicians to avert NHS transformation failure
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Jennifer Richardson

    The partnerships charged with overhauling services will fail spectacularly without clinical engagement and scrutiny, say hospital doctors—the very things the new groups most lack, according to a new research. Jennifer Richardson reportsThe latest vehicle for overhauling NHS services is either “progress on the road to better care” or “destined to fail,” senior hospital doctors say. Either “an opportunity to introduce major improvements to the quality and effectiveness of NHS services” or “a fundamental threat to services.”A report published on 9 November by the Hospital Consultants and Specialists Association (HCSA) finds little prospect of middle ground for the outcome of sustainability and transformation partnerships (STPs),1 the 44 collaborations of local NHS organisations charged with improving care and financial stability in their geographical areas by 2021.There is still opportunity and time, says the HCSA, a professional body and trade union for hospital doctors, to ensure that the positive of the two extremes prevails. However, that will depend extensively on one thing largely missing so far: clinician input.The report is damning on this front. In a survey of members with 454 respondents, 95% thought that they had not been consulted on or had sufficient involvement in STPs, which have each set out a five year plan to meet local challenges and needs. This lack of clinical scrutiny is “condemning [STPs] to be another damaging and short lived reorganisation,” says HCSA chief executive and general secretary, Eddie Saville.Some respondents said that they had not heard of STPs before the survey despite, as the HCSA points out, the partnerships representing an important change in the way that the NHS in England will plan and run its services. Others felt that what clinician involvement existed was mere “window dressing,” with “no intention of genuine consultation.” This …

    更新日期:2017-11-09
  • Flu vaccination by pharmacists leads to suboptimal medical records
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Simon de Lusignan, Matthew Hoghton, Imran Rafi

    We don’t condone unfair pressure on patients to have their flu vaccine at their general practitioner’s surgery,1 but pharmacist vaccination leads to problems with data integrity.The communication from pharmacist to general practitioner is suboptimal. It is often on paper and states only that the vaccination has occurred, without the vaccine manufacturer or batch number. In contrast to many other communications, it does not include a …

    更新日期:2017-11-09
  • Deviation from national guidance can have better results
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Mark Temple

    McCartney asks when she can start running again after a microdiscectomy.1 I wonder if she missed an alternative approach to finding the best advice. Following guidance based on evidence from randomised controlled trials is recognised to …

    更新日期:2017-11-09
  • How are junior doctors supposed to learn without the opportunity?
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Eugene Y H Yeung

    Glass quotes some of his colleagues’ dissatisfying comments about junior doctors.1 But I wonder how many of his colleagues did anything to change the training of their juniors. Did these surgical consultants give their medical students and foundation year doctors enough hands-on experience and teaching on suturing? Many juniors are keen to practise clinical procedures, such as suturing …

    更新日期:2017-11-09
  • Prayer sign due to diabetic cheiroarthropathy
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Katie Yoganathan, Alexander Stevenson, Marcus Martineau

    A 52 year old man with type 2 diabetes for 15 years developed stiffness and limited joint movements in both hands (fig 1 …

    更新日期:2017-11-09
  • Government faces legal challenge over data agreement that may put “migrants at risk”
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Anne Gulland

    A charity has launched a legal challenge to the data sharing agreement between the Home Office, Department of Health, and the NHS, which it says puts immigrants’ healthcare at risk by deterring them from seeking care.The agreement, signed in January, enables the Home Office to access data such as a patient’s home address. The Migrants’ Rights Network says that the agreement was written in secret, without consultation with NHS staff, medical organisations, or the public.The network says that the agreement …

    更新日期:2017-11-09
  • Uganda’s hospitals doctors strike over low pay
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Henry Wasswa

    Patients in Uganda have been left without clinical care as hospital doctors began a strike on 7 November in protest at low wages, drug shortages, and lack of equipment.“Our welfare is very low. We called the strike over many things that are lacking,” said Mukuzi Muhereza, secretary general of the Uganda Medical Association (UMA).Muhereza said that Ugandan doctors are paid …

    更新日期:2017-11-09
  • Government launches scheme to deliver five “breakthrough technologies” a year
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Nigel Hawkes

    Is the promise of faster access to transformative medicine a good deal for patients or an inducement to keep drug companies in the UK? Nigel Hawkes reportsThe government has promised NHS patients faster access to new drugs or technologies at no additional cost and without compromising safety.1The Accelerated Access Review follows almost 20 reports and reviews of innovation in the NHS over the past decade. Its aims have been generally welcomed despite doubts that all or any of them can be achieved, never mind all three at once.Barbara Harpham, chair of the Medical Technology Group, which works to improve access to technology, said she sincerely hoped that the measures would deliver. But she said that mandatory funding had not been promised for all guidance from the National Institute for Health and Care Excellence (NICE), adding that the aim of fast tracking just five new drugs or devices a year was not ambitious enough.Roy …

    更新日期:2017-11-09
  • GMC to push for erasure of paediatrician convicted of manslaughter
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Clare Dyer

    The General Medical Council is to press ahead with an appeal in the High Court against what it considers a too lenient regulatory sanction on a paediatrician convicted of gross negligence manslaughter, despite a letter signed by more than 100 doctors urging the GMC to reconsider.Last June a medical practitioners tribunal found that Hadiza Bawa-Garba’s failings were a causative factor in the death of 6 year old Jack Adcock from sepsis. But the tribunal decided not to accede to the GMC’s call to strike her off the UK medical register.Instead, the tribunal opted for a 12 month suspension from the register, citing “multiple systemic failures,” her unblemished record before and since, and evidence from colleagues and consultants that she was …

    更新日期:2017-11-09
  • Patients’ views were sidelined as STPs were launched, says Healthwatch England
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Tom Moberly

    Public engagement with NHS changes went into “paralysis” when plans for sustainability and transformation partnerships (STPs) were launched in December 2015, the deputy director of Healthwatch England has said.Neil Tester said that communications between NHS bosses and the public went into “lockdown” and a “period of stasis” at a local level as plans for STPs were rolled out. The head of the organisation set up to represent NHS patients’ views was speaking at an event at the King’s Fund on 7 November.Tester spoke …

    更新日期:2017-11-09
  • Number of UK patients with metastatic breast cancer isn’t known
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Jane Feinmann

    Two thirds of NHS hospitals in England don’t accurately record the number of patients who receive a diagnosis of metastatic breast cancer, despite the fact that trusts were told to collect the data as far back as 2012.In December 2012 the then National Cancer Intelligence Network, now merged into Public Health England’s National Cancer Registration and Analysis Service, wrote to hospital trusts requiring them to “ensure that data are collected on breast cancer recurrences and metastases at the time of patient contact.”1“The policy was unfortunately introduced with no support plan in place to help hospitals implement the change,” said Gunes Kalkan, head of policy at the UK breast cancer charity Breast Cancer Care, at the Advanced Breast Cancer (ABC4) International …

    更新日期:2017-11-09
  • “Weekend effect” is not reduced by clinical standards designed to tackle it, study finds
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Abi Rimmer

    Clinical standards designed to reduce mortality at the weekend have not made any overall difference, researchers have found.In a paper published in the Emergency Medicine Journal , researchers from the University of Manchester said that four NHS priority standards for emergency care have not reduced excess deaths on Saturdays and Sundays.1The four standards were originally developed in 2013 by the NHS Services, Seven Days a Week Forum. They were introduced in 2015 and form part of the government’s aim to reduce the “weekend effect”—when patients admitted to hospital at a weekend have greater mortality than patients admitted on weekdays—through increased …

    更新日期:2017-11-09
  • NHS should be “first port of call” for potential Brexit savings, says Hunt
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Abi Rimmer

    The NHS should be first in line to receive any financial savings that come about as the result of Britain leaving the European Union, England’s health secretary has said.Speaking at the NHS Providers conference in Birmingham on 8 November, Jeremy Hunt said that, despite no government commitment to increase NHS funding because of Brexit, this should happen if possible.Referring to a proposal by the Vote Leave campaign to increase NHS funding by £350m (€396m; $458m) a week if Britain left the EU, Hunt said, “As you know, it wasn’t a government promise; it was a promise by the Leave campaign, but what I very much agree with is [that] if there is a Brexit dividend [and] if we end up having less pressure on public finance because of not making contributions to the EU, I believe that the NHS should be the first port of …

    更新日期:2017-11-09
  • GP appointments last less than five minutes for half the world’s population
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Gareth Iacobucci

    Primary care consultations last less than five minutes for half of the world’s population, a large international analysis has found.The research,1 published in BMJ Open , reveals wide variation in the average consultation length across the globe, with examples ranging from just 48 seconds in Bangladesh to 22.5 minutes in Sweden.Researchers from a range of academic institutions reviewed the data on consultation length from 178 relevant studies covering 67 countries and more than 28.5 million consultations.The analysis included peer reviewed research and “grey literature”—defined as research …

    更新日期:2017-11-09
  • Risk of breast cancer recurrence remains for years after endocrine treatment ends, study finds
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Susan Mayor

    Women treated for oestrogen receptor (ER) positive breast cancer have a persistent risk of recurrence for at least 15 years after being disease free with the current standard of five years’ endocrine therapy, a large meta-analysis of long term follow-up studies has reported.1“This finding has implications for long term follow-up strategies and highlights the need for new approaches to reduce late recurrence,” the researchers, led by Hongchao Pan, from the University of Oxford, UK, said. They added, “The risk could be reduced by extending the duration of …

    更新日期:2017-11-09
  • Margaret McCartney: General practice can’t just exclude sick people
    BMJ (IF 20.7) Pub Date : 2017-11-09
    Margaret McCartney

    GP at Hand, an NHS general practice in west London, is offering to register patients for virtual consultations. It may also permanently destabilise English general practice.One partner of GP at Hand is Mobasher Butt, medical director of the health IT company Babylon, and the practice uses the Babylon symptom checker app. This app, the practice says, gives patients “useful medical information and accurate triage advice.”1Interesting, because it also says that “The GP at Hand practice shall not be responsible for the artificial intelligence symptom checker which is a separate service provided by Babylon via the App.”2 The results of a pilot study of this app in north London do not yet seem to be published. Babylon has claimed to have independent evidence of safety, but I’ve yet to see it.3 Babylon says that the app “enables your purchase of healthcare and other products sold by our third party product partners.”2GP at Hand …

    更新日期:2017-11-09
  • Antibiotics or NSAIDs for uncomplicated urinary tract infection?
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Paul Little

    Pain relief and a delayed antibiotic prescription is a pragmatic and balanced approach Urinary tract infection (UTI) is second only to respiratory tract infection in the use of antibiotics. It is an international priority to rationalise antibiotic use in primary care given the dangers of antibiotic resistance and the evidence that prescribing in primary care is likely to be a key driver of antibiotic resistance.1 The trial by Kronenberg and colleagues (doi:10.1136/bmj.j4784)2 provides a welcome addition to the literature, providing a head-to-head comparison of an antibiotic compared with a non-steroidal anti-inflammatory drug (NSAID, diclofenac) and extending the findings of a previous German trial of antibiotics compared with the NSAID ibuprofen.3 The results show that an initial prescription for antibiotics is superior to NSAIDs for symptomatic management and inferior in terms of net antibiotic usage. However, the difference in symptom control may not be as stark as the 27% absolute difference in symptom resolution by day 3 would suggest, since the reduction in symptom score …

    更新日期:2017-11-08
  • Faltering growth in children: improving early detection of cleft palate
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Sophie Butterworth, David Sainsbury, Peter Hodgkinson

    Gonzalez-Viana and colleagues summarise NICE guidelines on faltering growth in children.1 We acknowledge that this paper is not intended to focus on specific medical or surgical problems that cause faltering growth but rather on a general approach of assessment and management in these children.1 But we think that one further guideline might be beneficial to your audience. Ineffective suckling, clicking sounds, or nasal regurgitation while …

    更新日期:2017-11-08
  • NHS will have workforce plan for first time in 17 years, Hunt announces
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Abi Rimmer

    The NHS will have a workforce plan for the first time since 2000, England’s secretary of state for health has announced. Speaking at the NHS Providers conference in Birmingham on 8 November, Jeremy Hunt said that a draft plan would be published by the end of the year. He said that recent initiatives, such as plans to increase medical student numbers, would form part of a wider NHS workforce …

    更新日期:2017-11-08
  • Delhi fights for air under toxic smog
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Alison Shepherd

    Sushil Kumar/Hindustan Times/Getty Images The Indian Medical Association last week declared a public health emergency in Delhi as air pollution reached “severe” levels and smog engulfed the conurbation. The association advised residents to stay indoors and asked for schools to be closed as …

    更新日期:2017-11-08
  • US doctors voice concern over plans to raid public health fund to pay for children’s healthcare
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Owen Dyer

    A US Republican bill to extend the popular Children’s Health Insurance Program will strip money from efforts to prevent infectious disease, lead poisoning, and opioid addiction, say public health advocates. The Clinton era program known as CHIP—which for 20 years has insured millions of lower income US children—expired on 30 September, halting federal payments to states that administer the program. All states are currently continuing the program using unspent dollars from previous transfers, but these funds will run out in over 30 states by the end of spring 2018. The Community Health and Medical Professionals Improve Our Nation (CHAMPION) Bill, sponsored by an Oregon Republican, Greg Walden, aims to restart CHIP …

    更新日期:2017-11-08
  • Doctors are less likely to be struck off for dishonesty than other health workers
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Clare Dyer

    The stresses of work and the influence of a malfunctioning workplace are important factors when doctors and other healthcare professionals are charged with professional misconduct, research has concluded.1 An analysis of 6714 cases of professional misconduct brought by three healthcare regulators, including the General Medical Council (GMC), identified three types of perpetrators. These are described as: the self serving “bad apple”; the individual who is corrupted by falling standards in the workplace; and the depleted perpetrator struggling to cope with the pressures of life. The study, led by Rosalind Searle, professor of organisational behaviour and psychology at the University of Coventry, looked at professional misconduct cases from 2014 to 2016 seen …

    更新日期:2017-11-08
  • Trump’s promises on opioids not backed by funds
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Owen Dyer

    Two weeks after President Donald Trump declared the US opioid epidemic a national public health emergency,1 and nearly a week after his special commission on combating drug addiction released 56 recommendations on ways to tackle the crisis, there are few signs that money will be forthcoming to turn words into action. Most experts and advocates have praised the commission’s recommendations, which included better pain management training for doctors, use of less punitive drug courts that swap treatment for incarceration, an advertising campaign that draws on research to find a more effective message than “just say no,” and a focus on stopping imports of deadly fentanyl.2 But neither Trump nor the commission’s head, New Jersey governor Chris Christie, put a figure on the funding that would be needed to enact these measures and to reduce the toll of deaths from overdose, which is …

    更新日期:2017-11-08
  • GP is suspended for three months after “improper relationship” with patient
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Clare Dyer

    A GP who sought to end a professional relationship with a patient while pursuing an “improper emotional relationship” with him has been suspended for three months by a medical practitioners tribunal. Julien Nash, 54, a civilian doctor working at an air force base, RAF Cosford, urged “Patient A,” a serviceman, to find a new doctor when she realised that “a line had been crossed” after sharing a kiss with him in November 2015. But, the tribunal found, this approach breached the General Medical Council’s good practice guidance, …

    更新日期:2017-11-08
  • Uncertain overseas recruitment is threatening care, NHS leaders warn
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Gareth Iacobucci

    Continuing uncertainty over the recruitment of staff from other countries in the wake of Brexit is threatening the provision of safe, high quality care in the NHS, hospital leaders have warned. In a new report NHS Providers, which represents NHS trusts, says that domestic “quick fixes” are not an option for solving severe workforce shortages in the NHS.1 The report warns that any significant reduction in the number of overseas staff in the next few years would have a “serious and damaging impact” on services. NHS Providers criticises the Department of Health for England and its national arm’s length bodies for a …

    更新日期:2017-11-08
  • GPs lose millions from mis-sold financial products
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Gareth Iacobucci

    General practices have had to pay out millions of pounds after they bought interest rate hedging products mis-sold to them by banks, The BMJ has learnt. In some cases the deals have left GPs struggling to retire or to sell their practices. Interest rate hedging products, or “swaps,” are designed to help buyers manage fluctuations in interest rates with fixed rate deals. They were sold to small businesses seeking loans from 2001. But in 2013 the Financial Conduct Authority found that there had been “serious failings” in the sale of these products and that 90% had been mis-sold.1 The BMJ has learnt of at least 10 medical centres hit by the scandal, with experts predicting that dozens or even hundreds may have been affected. One affected practice, the Ridge Medical Practice in Bradford, paid out an estimated £3.6m (€4m; $4.7m) to the Royal Bank of Scotland in interest between 2007 and 2015 after it took out a 26 year swap along with a £9.5m loan to fund new premises. The bank has refused to pay any compensation to the practice. Nick Nurden, the Ridge practice’s business manager, who oversaw the deal in 2008, told The BMJ , “We were presented with what was effectively a fait accompli by the bank. They presented it to us as really the only option, but from what I now know there were far better products that would have been easily affordable and would’ve actually still done the same job of providing that security. …

    更新日期:2017-11-08
  • Cannabinoids offer alternatives to opioids for pain relief, experts say
    BMJ (IF 20.7) Pub Date : 2017-11-07
    Bob Roehr

    Alternatives to opioids can be used alone or in combination with opioids for pain relief, to help prevent medical exposure to narcotics being an entry point to misuse, said experts at a medical education forum in Washington, DC on 3 November. Endocannabinoid compounds found in marijuana can greatly enhance the potency of opioids in relieving pain. The synergy from using these drugs together can result in more effective pain relief from lower doses of opioids, explained Donald Abrams, an oncologist at the University of California, San Francisco, who conducted some of the US’s first clinical research on …

    更新日期:2017-11-08
  • David Ian Hamilton
    BMJ (IF 20.7) Pub Date : 2017-11-08
    James L Wilkinson

    David Ian Hamilton was born in Stockton on Tees. His father was a civil engineer whose area of expertise was bridge building. The family moved to London when David was 6, and where the building of the stone Wandsworth Bridge, over the Thames, was his father’s responsibility. David was a keen rugby player at school—being selected for the English Schools’ XV to play against a French schools’ team in April 1949. He decided that he wanted to become a surgeon because it would allow him to use the manual skills, learned from his father, who was an expert handyman. After national service, he studied medicine …

    更新日期:2017-11-08
  • Early psychosis for the non-specialist doctor
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Musa Basseer Sami, David Shiers, Saqib Latif, Sagnik Bhattacharyya

    #### What you need to know A general practitioner may support four to eight patients with psychotic disorder and see one new presentation each year.12 Other non-specialist doctors will encounter patients presenting to an emergency department or complicating comorbid illness. Psychosis often emerges for the first time in adolescence and young adulthood.3 In around four out of five patients symptoms remit, but most experience relapses and further difficulties.4 The first two to five years of psychosis are considered a critical period for intervening to improve long term outcome.567 The non-specialist plays a key role in early identification. The challenge is to identify a relatively rare but serious disorder and distinguish this from more common but less severe disorders, occurring in a typically young population experiencing developmental and often stressful transitions. #### Methods We searched the Medline database over 10 years (1 January 2007 to 31 January 2017) for review articles on “early psychotic illness” or “early psychosis.” This yielded 779 including Narrative and Systematic Reviews and Meta-analyses. 125 articles were reviewed for relevance and methodology and analysis of data. Fig 1   Where the soft winds blow by Bryan Charnley (1949-1991), who had schizophrenia (www.bryancharnley.info). ©The estate of Bryan Charnley, reproduced with permission The term psychosis embraces a constellation of symptoms characterised by hallucinations, delusions, or disorganised behaviour or thought (“positive …

    更新日期:2017-11-08
  • How to approach psychotic symptoms in a non-specialist setting
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Musa Basseer Sami, David Shiers, Saqib Latif, Sagnik Bhattacharyya

    #### What you need to know Fig 1   Puppet Schizophrene by Bryan Charnley (1949-1991), who had schizophrenia (www.bryancharnley.info). © The estate of Bryan Charnley, reproduced with permission Identification of psychotic symptoms in non-specialist settings is key to initiating timely pathways to care. A systematic review of 30 observational studies of pathways to care of first-episode psychosis showed that first contact was more usually through a physician than through emergency services.1 This article is aimed at generalists, primary care physicians, and hospital doctors, who play a critical role and who require a low threshold for referral for specialist assessment, sometimes before diagnosis is certain.2 Prompt intervention is key to improving outcome. However, patients rarely present complaining of hallucinations or delusions. Concerns that something is not quite right may first be raised to the generalist by family members, friends, neighbours, and school teachers.1 In very early stages, perceptual abnormalities and thought disorder may not be apparent, nor delusions well formed. Features may include: Hallmark features are increasing distress and decline in functioning.456 An overview of symptoms is shown in figure 2⇓. Psychosis maybe preceded by …

    更新日期:2017-11-08
  • Maternal mental health: Handle with care
    BMJ (IF 20.7) Pub Date : 2017-11-08
    British Medical Journal Publishing Group

    A mother describes how opportunities were missed to identify her postpartum psychosis “Have you tried getting out more?” the health visitor asked. I explained again that stairs had been impossible since my emergency caesarean section a month ago. “I manage, and I have osteoarthritis,” she replied. “You really should try.” It felt like a slap. The lack of empathy for my physical pain meant I felt unable to share my more serious worries, such as my suspicion that my baby daughter had been swapped at birth. Nor did I unveil my growing conviction that social workers, dressed as ninjas, were planning to murder me and steal her. That was the first missed opportunity to identify my postpartum psychosis. The next came two weeks later. My mother and husband became concerned by my anxious pacing and rapid speech, which I now know are common symptoms of postpartum psychosis, and made an appointment for me with a GP. The fact that I didn’t make the appointment myself was a clue that I wasn’t coping. Leaving the house had become terrifying, and the thought of letting …

    更新日期:2017-11-08
  • Stopping five low value surgical procedures could save NHS £135m a year
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Susan Mayor

    Stopping five common surgical procedures that are costly and provide limited benefit to patients, including inappropriate gastroscopy and inguinal hernia repair without troublesome symptoms, could save the NHS £135m (€153m; $177m) a year, a study has estimated.1 “Identifying and stopping low value services represents a significantly greater opportunity for efficiency savings than previously thought,” said the researchers, led by Humza Malik, clinical research fellow at Imperial College London, …

    更新日期:2017-11-08
  • Study pinpoints symptom pattern that indicates endometriosis
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Jacqui Wise

    GPs should look out for a specific pattern of symptoms to enable endometriosis to be diagnosed much earlier, says research in the British Journal of General Practice .1 Endometriosis can be difficult to diagnose clinically as its symptoms are common and non-specific. As a result, often a long time elapses between the first primary care consultation and diagnosis. Distinct episodes of gynaecological pain and combinations of gynaecological pain with menstrual symptoms …

    更新日期:2017-11-08
  • No difference in efficacy of opioids and non-opioid analgesics for arm or leg pain
    BMJ (IF 20.7) Pub Date : 2017-11-07
    Jacqui Wise

    Patients with sprains or fractures appear to get as much pain relief with a combination of ibuprofen and paracetamol as with opioid medications, a study in JAMA concludes.1 The authors say that prescribing non-opioid analgesics first line in emergency departments may help combat the current opioid epidemic in the US. The double blind randomised clinical trial was conducted at two urban emergency departments in New York. Researchers randomly assigned 416 patients presenting with moderate to …

    更新日期:2017-11-08
  • David Oliver: An argument against more NHS funding? I don’t buy it
    BMJ (IF 20.7) Pub Date : 2017-11-08
    David Oliver

    The NHS faces an unprecedented financial crisis. A Nuffield Trust report has shown a deficit of £3.7bn in acute trusts, compared with a target of £580m set by NHS England.1 The King’s Fund found in June that 43% of NHS finance directors planned to overspend their budget this financial year.2 It also found that 50% of clinical commissioning group finance leads would have to delay or cancel spending to achieve the set financial “control totals.”2 NHS performance is stalling or falling in several key areas.23 Independent analyses of sustainability and transformation partnerships (STPs) have questioned their ability to deliver anything like the scale of savings they promise.456 The Office for Budget Responsibility forecasts that NHS spending per person will fall …

    更新日期:2017-11-08
  • The global abortion policies database: knowledge as a health intervention
    BMJ (IF 20.7) Pub Date : 2017-11-08
    Joanna Erdman

    Abortion laws are often written in vague terms, breeding uncertainty about what is allowed In 2012, after being refused an abortion, Savita Halappanavar died in an Irish hospital from complications following a miscarriage. The treating physicians believed that because the fetus still had a beating heart their “hands were tied.” Under Irish law, abortion is a criminal offence unless necessary to save the life of the pregnant woman, yet there is little clarity on this exception. Following nationwide protests, the government introduced the Protection of Life During Pregnancy Act 2013 to clarify the law and to regulate access under it. Years earlier, the European Court of Human Rights called for precisely such regulation, moved by the position of doctors who “faced criminal charges, on the one hand, and an absence of clear legal, ethical, or medical guidelines, on the other.” The circumstances in Ireland are tragic, but not uncommon. Abortion laws are often written in vague terms, …

    更新日期:2017-11-08
  • The unofficial vaccine educators: are CDC funded non-profits sufficiently independent?
    BMJ (IF 20.7) Pub Date : 2017-11-07
    Peter Doshi

    Vaccines are considered one of public health’s greatest success stories. But is all promotion of vaccines necessarily a good thing, or does it depend on the details? Peter Doshi investigates the semi-transparent world of vaccine advocacy organizationsVaccination programs have long been a centerpiece of public health activity. But policies of compulsion have always been controversial. Against a backdrop of recent measles outbreaks, France and Italy moved this year to mandate certain vaccines for school entry.12 There’s even a renewed push for mandates in the UK,3 where public health leaders have long resisted compulsory vaccination on the grounds that it undermines the trust between the public and healthcare professionals and is ultimately counterproductive.4The debate is also alive in the US. Although all states require vaccination as a condition for entry to school, most also allow exemptions for families with non-medical philosophical or religious objections. Overall, childhood vaccination levels remain at or near historically high levels, with under 1% of toddlers receiving no vaccines.56 But beneath the broad national trends there is geographic variation in coverage,6 and survey data have documented that parental concerns over vaccination safety and timing are common, even among those whose children receive all recommended vaccines.7In 2015, a US federal advisory committee warned that public confidence in vaccines cannot be taken for granted,5 and some prominent vaccine advocacy organizations are pushing for greater compulsion. But are these groups—which present themselves as reliable sources of information—providing the public with independent information?Two years ago, California state legislators passed a law removing the personal belief exemption that had previously allowed families to defer or decline mandated childhood vaccinations.8 In doing so, California became the third state to remove non-medical exemptions, following Mississippi and West Virginia.The debate …

    更新日期:2017-11-07
  • UK’s first emergency department for patients over 80 to open in Norwich
    BMJ (IF 20.7) Pub Date : 2017-11-07
    Zosia Kmietowicz

    The UK’s first emergency department that is dedicated to patients over the age of 80 will open at Norfolk and Norwich University Hospital (NNUH) at the end of November.When they arrive at the hospital’s emergency department, patients over 80 will be directed to the Older People’s Assessment Service, which will be staffed by emergency consultants, consultant geriatricians, and emergency and older people’s medicine nurses. GPs will …

    更新日期:2017-11-07
  • Woman in minimally conscious state should be allowed to die, says judge after hearing evidence from family
    BMJ (IF 20.7) Pub Date : 2017-11-07
    Clare Dyer

    A 72 year old woman in a minimally conscious state who was kept alive by artificial feeding would have found her situation “not only intolerable but humiliating” and it would be in her best interests to withdraw feeding, a High Court judge has said.1“Mrs P” was being fed through a nasogastric tube, which she had pulled out around 50 times, after suffering a subarachnoid haemorrhage following a fall a year ago. Salford Royal NHS Foundation Trust applied to the Court of Protection for a ruling that continuing the feeding was in her best interests, although her daughter, “Q,” opposed it.The official solicitor, representing Mrs P, originally took a neutral stance. But by the end of the hearing, after several family members had given evidence, he accepted …

    更新日期:2017-11-07
  • Electronic consultations offer few benefits for GP practices, says study
    BMJ (IF 20.7) Pub Date : 2017-11-07
    Jacqui Wise

    Electronic consultations appear to offer some benefit to patients but increase the workload of GPs, research published in the British Journal of General Practice shows.1Policy makers have suggested that online consultations could ease pressure on GP practices and improve patient access, but there is limited research on whether they are able to deliver such improvements. Only around 6% of practices have used some form of electronic consultation but a further 20% have plans to do so in the future. There are currently two main e-consultation systems being used in primary care in the …

    更新日期:2017-11-07
  • Doctors should lead the fight against environmental plastics
    BMJ (IF 20.7) Pub Date : 2017-11-06
    James Szymankiewicz

    I welcome Wright and Kelly’s Editorial on the health implications of environmental plastics,1 but I disagree with the conclusion that we need to establish safe thresholds for exposure—the urgent need is to stem the tide of plastic entering the environment in the first place. We must …

    更新日期:2017-11-06
  • Medical regulators could merge in government shake up
    BMJ (IF 20.7) Pub Date : 2017-11-06
    Abi Rimmer

    Plans to overhaul the way doctors, nurses, and other healthcare professionals are regulated have had a mixed response. A key aim of the Department of Health’s plans to reform medical regulation is to ensure that organisations have a “consistent and flexible range of powers that allow them to take a prompt and proportionate approach to concerns about an individual’s fitness to practise.”To meet that objective, the department has proposed shrinking the number of medical regulators from the current nine to three or four.Consultation documents on upgrading the regulation of healthcare professions were launched at the end of October,1 with a remit for the four UK governments to look into which professions needed statutory regulation.Other proposals include promoting more joint working among regulators and having a single database …

    更新日期:2017-11-06
  • Surgical registrar is struck off for refusing to examine three deteriorating patients
    BMJ (IF 20.7) Pub Date : 2017-11-06
    Clare Dyer

    A surgical registrar who repeatedly refused appeals from junior doctors to attend and examine three deteriorating patients has been struck off by a medical practitioners tribunal in Manchester.Abayomi Sanusi, who did not attend his hearing, was also found to have lied in a job interview after being dismissed by South Tees NHS Foundation Trust for his clinical failings in three cases at Friarage Hospital in Northallerton, North Yorkshire.Sanusi was found to have been rude and aggressive to junior doctors and senior nurses who called him asking for help. He failed to examine sick and deteriorating patients when he had a clear duty to do so as the doctor on call, and he did not keep proper …

    更新日期:2017-11-06
  • Ophthalmologists should be able to prescribe bevacizumab, says royal college
    BMJ (IF 20.7) Pub Date : 2017-11-06
    Deborah Cohen

    Ophthalmologists should be able to prescribe the most appropriate treatment for wet age-related macular degeneration, including off-label bevacizumab (Avastin), provided that patients give their informed consent, the Royal College of Ophthalmologists has said.The college said that it has long petitioned for a review to find out how bevacizumab could be more widely available in the NHS to treat wet AMD.Using bevacizumab rather than the far more expensive ranibizumab or aflibercept would have “the potential to release funds for much-needed reinvestment into over-stretched hospital eye services,” it said.Mike Burdon, the college’s president, called for all relevant parties to come together to resolve the issues.Ophthalmologists have said that the General Medical Council’s guidance, which says that doctors cannot …

    更新日期:2017-11-06
  • More F2 doctors are choosing a career break
    BMJ (IF 20.7) Pub Date : 2017-11-06
    Abi Rimmer

    Trends in what the UK’s second year foundation (F2) doctors intend to do once they have completed their foundation training is shown in new data from the Department of Health.1The proportion of doctors who choose to take a career break after completing their foundation training has nearly tripled …

    更新日期:2017-11-06
  • Gian Franco Bottazzo
    BMJ (IF 20.7) Pub Date : 2017-11-06
    Ned Stafford

    Pioneering researcher into type 1 diabetes and legendary lecturerIn 1969, at the age of 23, Gian Franco Bottazzo—a medical student at the University of Padua in Italy—travelled to London on a quest for knowledge. The young Italian was fascinated by immunology and spent countless hours in a university laboratory. To advance in the specialism, he wanted to learn the latest laboratory techniques.In London, Bottazzo visited Middlesex Hospital and appeared before Deborah Doniach, an acclaimed researcher of autoimmune diseases (read obituary: http://www.bmj.com/content/328/7435/351.1), who had not met the charming young man before.“I would like to learn immunopathology,” Bottazzo said.With no hesitation, the world famous researcher replied: “Come tomorrow morning, nine o’clock.”1After learning the techniques used in Doniach’s laboratory, Bottazzo went back to Padua to finish his medical studies. He returned to London in the autumn of 1973 to work with Doniach as a research fellow in the department of immunology at Middlesex Hospital.A year later Bottazzo was the lead author, and Doniach a co-author, of a landmark paper published in the Lancet , which showed for the first time that type 1 diabetes is associated with the development of antibodies directed against insulin producing β cells.2 In simpler terms, Bottazzo showed that type 1 diabetes was an autoimmune disease.The paper, according to PubMed, was only the second in Bottazzo’s research career and his first in English. In 1972 he had published a paper in an Italian journal.3The discovery shown in Bottazzo’s study opened the door for …

    更新日期:2017-11-06
  • Warfarin is associated with lower cancer incidence, finds study
    BMJ (IF 20.7) Pub Date : 2017-11-06
    Jacqui Wise

    Use of the anticoagulant warfarin was associated with a lower risk of new cancers in people over 50 in a large observational study published in JAMA Internal Medicine .1Researchers used national registry data to identify 1 256 725 people born from 1924 to 1954 who were living in Norway from 2006 to 2012. Of this cohort, 92 942 (7.4%) were taking warfarin. Warfarin users were older, …

    更新日期:2017-11-06
  • Margaret McCartney: Pointless paperwork, not patients, is what GPs should avoid
    BMJ (IF 20.7) Pub Date : 2017-11-06
    Margaret McCartney

    Winter’s coming, there’s flu in the southern hemisphere, and the canaries have stopped singing in general practice. I have a visceral sense of dread.Jeremy Hunt recently spoke to GPs about “the 26% of GP appointments that GPs themselves say are potentially avoidable.”1 He talked about 10 “high impact actions” aimed at releasing capacity, which form part of the Releasing Time for Care programme, put together at a cost of £30m.Essentially, says NHS England, “most common potentially avoidable consultations were amenable to action by the practice, often with the support of the clinical commissioning group.”2 Some 7% of patients could be diverted elsewhere in the practice, 6% …

    更新日期:2017-11-06
  • Practices’ viability is threatened by Capita’s failings, warns BMA
    BMJ (IF 20.7) Pub Date : 2017-11-03
    Abi Rimmer

    The viability of general practices is threatened by failings by the private company Capita, which provides primary care support services for NHS England, the BMA has warned.In a letter sent on 30 October to Simon Stevens, chief executive of NHS England, the BMA highlighted what it called Primary Care Services England’s “ongoing issues due to poor delivery” by Capita. However, Capita said that the BMA’s letter did not accurately reflect its role and involvement in providing the services.Richard Vautrey, chair of the BMA’s general practitioners committee, wrote that significant issues were affecting the practice support system, which had been “causing much distress to practices and putting patients at risk” for over two years.In the letter, Vautrey said that the BMA was very concerned about preparations for Capita to run new systems for cervical screening and for …

    更新日期:2017-11-05
  • Developing reliable dietary guidelines
    BMJ (IF 20.7) Pub Date : 2017-11-03
    Lisa Bero

    Robust measures to reduce bias and improve methods are required The National Academy of Sciences (NAS) recently published two reports critiquing the process used to develop the US dietary guidelines.12 The reports identify important deficiencies in the process, including a lack of transparency in forming guideline committees, problems with the methods of systematic reviews underpinning guidelines, and a lack of clarity about how evidence is finally translated into public health recommendations. These deficiencies have received considerable attention already. Our recent analysis of the methods used to synthesise evidence and grade recommendations in 32 national food based dietary guidelines found similar problems, suggesting that improvements are required globally.3 The NAS reports’ headline recommendation is a complete redesign of the guideline development process into three steps conducted by separate groups. Federal staff and consultants would start by gathering data—conducting new systematic reviews and identifying existing reviews, meta-analyses, and descriptive datasets. A dietary guidelines scientific advisory committee would then evaluate and integrate all this evidence and develop recommendations for a scientific report. Finally, government employees would use this report …

    更新日期:2017-11-03
  • Hospital doctors call for inquiry into future of NHS as patient care deteriorates
    BMJ (IF 20.7) Pub Date : 2017-11-03
    Zosia Kmietowicz

    A body representing hospital consultants has called for an independent inquiry into the NHS’s future after a survey found that half of trust finance directors (41 of 85) said that patient care in their area had deteriorated over the past year. The quarterly monitoring report from the think tank the King’s Fund1 found that just 6% (5 of 85) of finance directors thought that patient care in their area had improved. Of 233 NHS trust finance directors in England, 85 completed the survey (response rate 36%). The report authors said that the NHS was heading into winter on …

    更新日期:2017-11-03
  • Patients report worse care at GP clinics owned by limited companies
    BMJ (IF 20.7) Pub Date : 2017-11-03
    Gareth Iacobucci

    Patients registered at general practices in England that are owned by limited companies, including large organisations, reported worse experiences of care than other patients, a study has shown. The research, published by the Journal of the Royal Society of Medicine ,1 examined data on 7949 general practices in England that were included in the General Practice Patient Survey 2013-14. Researchers from Imperial College London examined …

    更新日期:2017-11-03
  • People at risk of familial hypercholesterolaemia should have DNA test, says NICE
    BMJ (IF 20.7) Pub Date : 2017-11-02
    British Medical Journal Publishing Group

    Primary care medical records should be systematically examined to identify people with familial hypercholesterolaemia, says updated guidance from the UK National Institute for Health and Care Excellence (NICE).1 Up to 260 000 people in the UK are thought to have the condition, but only a minority, around 15%, of cases have been diagnosed.2 NICE’s guideline recommends that records of patients who have a total cholesterol concentration greater than 7.5 mmol/L if they are under 30 years old or 9.0 mmol/L if they are aged 30 or over should be scrutinised. NICE said that these thresholds …

    更新日期:2017-11-03
  • Helen Margaret Johnson
    BMJ (IF 20.7) Pub Date : 2017-11-03
    Anne M Johnson, Elizabeth N Johnson, Richard F N Johnson

    After training at the Royal Free and Newcastle hospitals, Helen Noble worked in Sunderland, at the Central Middlesex Hospital, and in Coventry, with a varied wartime caseload. After a stint in general practice, she returned to the Royal Free and Gateshead to complete training …

    更新日期:2017-11-03
Some contents have been Reproduced with permission of the American Chemical Society.
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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