Medical Journal News

A 17-year-old child with fibrolamellar hepatocellular carcinoma presented for treatment of recurrence in the right hilum and bilateral lungs discovered during routine surveillance imaging; he had reported no symptoms.The patient was first diagnosed at 13 years of age, when he presented with right upper quadrant pain; he underwent an extreme liver resection, and received multiple cycles of chemotherapy to achieve his first remission. Over the next 3 years, he sustained relapses to his peritoneum and brain, warranting further chemotherapy, surgery, and radiotherapy.

I spent most of my 2010 wedding day in the emergency ward of my local hospital. Instead of exchanging vows, I was desperately trying to convince the doctors there not to call elder protective services regarding the woman who was about to become my mother-in-law. She had been preparing for the marriage of her youngest son for weeks. Between cooking for more than 200 guests, pressing all the wedding finery, and trying to educate the American bride who would be joining her family on Vietnamese traditions, she kept telling us she was “so tired”.

Dec 8, 2024, marked the end of the five-decade long regime of Bashir al-Assad and the Assad family in Syria, characterised by systemic repression, human rights abuses, and crimes against humanity.1 After the protests of 2011, Assad's response involved indiscriminate bombings, targeting of health-care facilities and health-care workers, and the use of internationally prohibited chemical weapons, triggering one of the worst humanitarian crises since World War 2.1

Bashar al-Assad, an ophthalmologist who graduated from Damascus University (Syria) and specialised at the Western Eye Hospital in London (UK), had a sudden career shift to politics and became Syria's President in 2000 following the death of his father, Hafez al-Assad.1 Despite his medical training, which undoubtedly included ethics education, his actions while at the helm of a 24-year presidency reflected a complete abandonment of any medical ethics he once learned. His leadership was marked by authoritarian rule and a 13-year long civil war, concluding with the Fall of Damascus by a coalition of opposition groups on Dec 8, 2024.

The outbreak of an undiagnosed disease in DR Congo, reported by WHO on Dec 8, 2024,1 is a pressing global health concern that demands swift and coordinated action. As of Dec 5, 406 cases and 31 deaths have been reported in the Panzi health zone in Kwango province, with influenza-like symptoms and anaemia. Most affected individuals are children aged younger than 5 years, many of whom are severely malnourished.

AbstractObjectivesTo compare the manual dexterity and composure under pressure of people in different hospital staff roles using a buzz wire game. DesignProspective, observational, comparative study (Tremor study).SettingLeeds Teaching Hospitals NHS Trust, Leeds, UK, during a three week period in 2024.Participants254 hospital staff members comprising of 60 physicians, 64 surgeons, 69 nurses, and 61 non-clinical staff.Main outcome measuresSuccessful completion of the buzz wire game within five minutes and occurrence of swearing and audible noises of frustration.ResultsOf the 254 hospital staff that participated, surgeons had significantly higher success rates in completing the buzz wire game within five minutes (84%, n=54) compared with physicians (57%, n=34), nurses (54%, n=37), and non-clinical staff (51%, n=31) (P<0.001). Time-to-event analysis showed that surgeons were quicker to successfully complete the game, independent of age and gender. Surgeons exhibited the highest rate of swearing during the game (50%, n=32), followed by nurses (30%, n=21), physicians (25%, n=60), and non-clinical staff (23%, n=14) (P=0.004). Non-clinical staff showed the highest use of frustration noises (75%), followed by nurses (68%), surgeons (58%), and physicians (52%) (P=0.03).ConclusionsSurgeons showed greater dexterity, but higher levels of swearing compared with other hospital staff roles, while nurses and non-clinical staff showed the highest rates of audible noises of frustration. The study highlights the diverse skill sets across hospital staff roles. Implementation of a surgical swear jar initiative should be considered for future fundraising events.

AbstractObjectiveTo evaluate the cognitive abilities of the leading large language models and identify their susceptibility to cognitive impairment, using the Montreal Cognitive Assessment (MoCA) and additional tests.DesignCross sectional analysis.SettingOnline interaction with large language models via text based prompts.ParticipantsPublicly available large language models, or “chatbots”: ChatGPT versions 4 and 4o (developed by OpenAI), Claude 3.5 “Sonnet” (developed by Anthropic), and Gemini versions 1 and 1.5 (developed by Alphabet).AssessmentsThe MoCA test (version 8.1) was administered to the leading large language models with instructions identical to those given to human patients. Scoring followed official guidelines and was evaluated by a practising neurologist. Additional assessments included the Navon figure, cookie theft picture, Poppelreuter figure, and Stroop test.Main outcome measuresMoCA scores, performance in visuospatial/executive tasks, and Stroop test results.ResultsChatGPT 4o achieved the highest score on the MoCA test (26/30), followed by ChatGPT 4 and Claude (25/30), with Gemini 1.0 scoring lowest (16/30). All large language models showed poor performance in visuospatial/executive tasks. Gemini models failed at the delayed recall task. Only ChatGPT 4o succeeded in the incongruent stage of the Stroop test.ConclusionsWith the exception of ChatGPT 4o, almost all large language models subjected to the MoCA test showed signs of mild cognitive impairment. Moreover, as in humans, age is a key determinant of cognitive decline: “older” chatbots, like older patients, tend to perform worse on the MoCA test. These findings challenge the assumption that artificial intelligence will soon replace human doctors, as the cognitive impairment evident in leading chatbots may affect their reliability in medical diagnostics and undermine patients’ confidence.

Mathew is correct that patients need to understand what is causing musculoskeletal symptoms; she is wrong that the diagnosis lies in expensive magnetic resonance imaging (MRI).1 The advanced nurse practitioners, extended scope physiotherapists, and musculoskeletal physicians in specialty clinics usually do have the understanding of musculoskeletal symptoms and management. What they might need to develop is a way of communicating and explaining to patients how their symptoms are generated and how to treat them and of dealing with patients’ expectations of imaging. Research has shown that patients set a high value on imaging but that clear explanation preceded by a detailed examination usually circumvents unnecessary imaging. Patients need to be informed that MRI, ultrasonography, and radiography should only be used when needed to direct treatment. A patient over 50 years old with a soft tissue knee injury does not need to undergo MRI unless their knee is locking or giving...

What price experience? I have been working across several safety critical industries for years and in terms of the approaches that these industries take to workforce issues there are some stark differences between safety critical industries and healthcare. One of the most striking differences is the failure to value a risk facing, proficient workforce where safety and productivity are two sides of the same coin rather than competing.1 When we think of safety critical industries, there is often a focus on the retention of expertise and experienced workers as they improve the bottom line in terms of productivity and safety, whereas in healthcare the focus is fundamentally one of more hands for least money and a focus on activity rather than outcome.23In their seminal work Dreyfus and Dreyfus describe the novice to expert continuum, through novice, advanced beginner, competency, proficiency, and expertise.4 While expertise is needed, it’s a proficient workforce...

The selective noradrenaline reuptake inhibitor atomoxetine and stimulants (amphetamines and methylphenidate) are the “most effective treatments” for managing the symptoms of attention deficit/hyperactivity disorder (ADHD) in adults, researchers have said.In a meta-analysis published in Lancet Psychiatry researchers looked at 113 randomised controlled trials involving nearly 15 000 adults with ADHD to assess the efficacy of treatments in reducing core symptoms and their safety and acceptability.1Treatments included stimulants (amphetamines such as lisdexamfetamine and methylphenidate), atomoxetine, bupropion, clonidine, guanfacine extended release, modafinil, viloxazine, and non-pharmacological strategies such as cognitive behavioural therapy (CBT). The research team noted that few studies had assessed the effects of these treatments beyond 12 weeks.Using these short term data, the researchers found that at 12 weeks atomoxetine and stimulants were most effective at reducing core ADHD symptoms (inattention, hyperactivity, and impulsivity) when compared with placebo. This was true for both the self-reported (standardised mean difference for atomoxetine –0.38...

Spatial repellents have been used as commercial household bite prevention products since the early 1900s, but significant research into their application for public health only began in the 2000s. Spatial repellents have since evolved from formats requiring frequent replacement (daily or weekly) and external energy sources (such as mosquito coils, or fan–heat assisted release) to spatial emanator formats that passively dispense the active ingredient for months without heat or combustion. This makes them more suitable for public health use as they do not require electricity or regular compliance.

On Nov 22, 2024, WHO identified that mpox remains a global health crisis.1 Meanwhile, financing for pandemic preparedness and response is in a permanent state of emergency. A revolving fund model could offer an alternative solution. The current approach embodied in The Pandemic Fund has three main limitations. First, most beneficiaries are not investors in the fund. The Pandemic Fund has attracted new donors, such as China, India, and Indonesia, and requires the countries receiving funds to match resources; however, the absence of direct investment from beneficiaries reduces their sense of ownership and the impetus for domestic resource mobilisation.

Our trial provides the first evidence of a demonstrative spatial repellent protective efficacy in reducing risk of malaria infection in an African setting characterised by high malaria transmission, pyrethroid resistant malaria vectors, and high coverage of insecticide treated nets. Results support spatial repellent products as a beneficial component of malaria prevention.

by Qingyun Yao, Jiangrong Wang, K. Miriam Elfström, Björn Strander, Joakim Dillner, Karin Sundström

Background

Evidence on invasive cervical cancer prevention among older women is limited, especially with the introduction of human papillomavirus (HPV)-based screening and longer interval. We conducted a long-term follow-up of the first phase of a randomized healthcare policy trial in cervical screening, targeting women aged 56 to 61 years old, to investigate the effectiveness of primary HPV-based screening in preventing invasive cervical cancer (ICC) and the safety of extending screening interval.

Methods and findings

The randomized healthcare policy trial of primary HPV-based cervical screening targeted women residing in Stockholm-Gotland region during 2012 to 2016, aged 30 to 64 years. The trial aimed to investigate the detection rate of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) within 24 months and long-term protection against invasive cervical cancer, comparing primary HPV-based screening to primary cytology-based screening. The initial phase of the trial, which was the focus of this study, targeted women aged 56 to 61 years old in 2012 to 2014 who were randomized to primary cytology arm (n = 7,401) or primary HPV arm (n = 7,318). We used national registries to identify the subsequent cervical tests and all histopathological diagnoses including ICC before December 31, 2022. We calculated cumulative incidence, incidence rate (IR) and IR ratio (IRR) of ICC, by baseline test result. Furthermore, we calculated longitudinal sensitivity and specificity for detecting cervical intraepithelial neoplasia grade 2 or worse (CIN2+) by receipt of primary cytology or primary HPV test for the recommended screening intervals in this age group.We found that the IR of ICC among women in the primary HPV arm was 7.2/100,000 person-years (py) and 3.0 for women who tested HPV negative, compared to 18.4/100,000 py among women in the primary cytology arm and 18.8 for women who tested cytology negative. We further found that the overall point estimate for the risk of ICC over 10 years of follow-up among women in the primary HPV arm was 0.39 compared to women in the primary cytology arm, but this was not statistically significant (IRR: 0.39; 95% confidence interval, CI [0.14, 1.09]; p = 0.0726). However, among women with a negative test result at baseline, women in the primary HPV arm had an 84% lower risk of ICC compared to women in the primary cytology arm (IRR: 0.16; 95% CI [0.04, 0.72]; p = 0.0163). Moreover, primary HPV testing had a higher sensitivity for detecting CIN2+ within a 7-year interval than primary cytology testing within a 5-year interval (89.6% versus 50.9%, p < 0.0001). We were limited by a partial imbalance of invitations during the follow-up between the 2 arms which may have led to an underestimation of the effectiveness of primary HPV-based screening.

Conclusions

In this study, we observed that women over 55 years of age who received a primary negative HPV test result had substantially lower risk of CIN2+, and ICC, compared to women who received a primary negative cytology result. This should apply even if the screening interval were prolonged to 7 years.

Trial Registration

NCT01511328.

With global measles cases surging more than 20% in a year, the spectre of an anti-vaccine leader like Robert F Kennedy Junior at the helm of US health policy has alarmed public health experts. Kennedy, a well-known vaccine sceptic, has long promoted dangerous misconceptions about vaccines, and his influence could worsen an already dire situation.

Africa's low COVID-19 mortality rates concealed important vulnerabilities, including poor health infrastructure and manufacturing constraints,1 highlighting the need for a proactive, continent-wide pandemic response. The emphasis on local solutions to global health challenges was a crucial reason for the Africa Centres for Disease Control and Prevention (CDC) to declare mpox a Public Health Emergency of Continental Security.2 A coordinated and cost-effective continental response platform was created to achieve the 6-month pandemic control goal,3 adopting the Coalition for Epidemic Preparedness Innovations' 100 Days Mission monitoring framework.

War and disease are old friends. In the Napoleonic wars and the American Civil War, more soldiers died from disease than in battle. It was no coincidence that the 1918 influenza pandemic erupted during the first world war or that the final frontier for eradicating polio is in the most insecure regions of Afghanistan and Pakistan. In the Democratic Republic of the Congo, the Ebola outbreak in the relatively stable Équateur province in 2018 took just two months to control, whereas the outbreak in the insecure provinces of North Kivu and Ituri in 2020 took two years.Israel’s wars with Hamas and Hezbollah have had devastating consequences for the health of the people of both Gaza and Lebanon. At the time of writing, more than 43 000 people have been killed in Gaza, more than 10 000 are missing, and more than 102 000 are injured, at least one quarter of...

General practitioner (GP) Victoria Wilson presents a weekly live show on Hospital Radio Exeter after she visits the wards to take music requests and dedications. “It’s a nice way to interact with patients. Some patients want to chat but then don’t request a song,” she tells The BMJ. “But if they've enjoyed the conversation then that's equally as worthwhile.”Wilson explains: “Patients often have magazines and books, but when they’re feeling poorly, listening to something in bed, eyes closed, might take less energy yet it's still entertaining or distracting.”The Hospital Broadcasting Association supports 170 such UK stations, mostly charities, and several thousand volunteers like Wilson with the aim “to aid patient recovery and promote health and wellbeing to all listeners.”Many patients still access the radio through hospital bedside units: on average 1231 a day for 6.2 hours each across the UK in November 2024. But broken bedside units are often not...