Medical Journal News

The National Institute for Health and Care Excellence (NICE) has decided to reconsult on draft guidance for Alzheimer’s treatments donanemab and lecanemab, six months after initially rejecting the drugs, in light of new evidence provided by the manufacturers.The new draft guidelines, published on 6 March,12 have again not recommended the treatments be available on the NHS as they do not provide “good value” with “relatively small” benefit and high rollout costs, including regular infusions and side effect monitoring.However, the guidelines are now undergoing public consultation during which manufacturers and other stakeholders can “submit new evidence or commercial proposals that might tackle the problems that have so far been a barrier to the use of these new treatments in the NHS.”The consultations will close on 27 March and the NICE committee will consider all responses during a meeting in May, after which their recommendations will be finalised.The re-review of the drugs...

For the first time ever the UK has more female than male doctors, with 164 440 women (50.04%) and 164 195 men (49.96%) registered with a licence to practise, show data from the General Medical Council (fig 1).bmj;388/mar07_2/r458/F1F1f1Fig 1Proportion of doctors able to practise medicine in UK who are womenThe 2024 data show variation across the four UK countries. There are more women than men working as doctors in Scotland (54.8% versus 45.2%) and Northern Ireland (53.5% v 46.5%) but fewer women than men in England (49.7% v 50.3% male) and Wales (47.3% v 52.7%), though it is expected women will outnumber men in all four countries in the near future.One of the factors driving the trend has been more women going to study medicine. Since 2018-19 there have been more female than male medical students in all four UK countries. In 2023-24 the UK medical student intake was 60%...

bmj;388/mar07_1/r449/FAF1faMalcolm Faulk was a pioneering forensic psychiatrist who was instrumental in the development of regional secure units, which were developed to bridge the gap between prisons and the NHS. In 1972 Faulk was appointed consultant psychiatrist to the Home Office and the Wessex regional health authority—these joint posts were new and they were viewed with suspicion by other staff. Prison doctors saw them as a threat to their authority and NHS psychiatrists worried that their hospitals would be filled with dangerous patients.Faulk and his fellow newly appointed psychiatrists met up regularly, and their self-described “dream” was a system of treatment for disturbed offenders “which would permeate the penal system, dealing with the problems there, supported by clinics and outpatients in the NHS—a unified approach rather than a split one.”1 Faulk described the kind of problems he saw in prisons: “We saw neuroses, emotional turmoil, loss of control, pathological anger, and...

Humanitarian assistance has saved millions of lives, improved public health outcomes, and strengthened communities in crisis.1 From responding to armed conflicts and natural disasters to advancing disease control and poverty reduction, the humanitarian and development sectors have played an indispensable role in reducing suffering worldwide. However, despite these successes, the existing humanitarian system is not fit for purpose in today's rapidly evolving geopolitical landscape of conflict and displacement.

The ceasefire in Gaza presents an opportunity to rebuild and redesign its health system to include long-term sustainability and autonomy. In Gaza, over 90% of homes and schools have been destroyed; hospitals have been reduced to rubble; and medical personnel have been displaced, arrested, and killed. Temporary emergency aid cannot compensate for the structural weaknesses that have long defined Gaza's health sector. The focus must be on creating a system that is more resilient, equitable, and independent of external factors.

In healthcare we trust—or do we? A breakdown in trust, like the schism in the transatlantic alliance, should make us think again about whether the current model requires reinvention. An anonymous scientist continues to reveal the extent of the shocking attack on health and science in the US (doi:10.1136/bmj.r392).1 The professionals and public betrayed by their president’s purge must feel, as Nick Cave sang, like a microscopic cog in a catastrophic plan—designed and directed by his red right hand. Trust and rights (doi:10.1136/bmj.r372)2 are eroding in many if not all health systems worldwide, albeit not as dramatically as in the US. Crises—financial, workforce, and disease burden—strain every sinew of every health system.In the UK, the NHS is no different. Yes, some progress is being made. For example, a newly agreed contract offers hope of a gradual restoration of general practice (doi:10.1136/bmj.r426 doi:10.1136/bmj.r435).34 The alarming events at Moorfields Eye Hospital in...

Individuals in the UK with health conditions may be entitled to two types of benefits: incapacity benefits (for those whose condition prevents them from working) and disability benefits (to help with living costs arising from the disability). The cost of health related benefits for people of working age is now £48 billion this year.1 This is predicted to increase to £63 billion by 2030.1 If spending on health related benefits continues to grow as forecast, the UK will likely become one of the highest spenders on health related benefits among comparable countries. The latest figures show there are currently 2.83 million people who are “economically inactive,” primarily due to long term sickness. This reached a near-record high in the period of December 2023 to February 2024.2 Given the right incentives and support from GPs, this group could go back to work.Obtaining a fit note is the first step in the...

What you need to knowMost closed, stable hand fractures do not require surgery and heal well with immobilisation or protected early range of motion to prevent stiffening as well as dedicated hand therapyWash out open fractures thoroughly and promptly in the acute care setting and administer antibiotics to prevent infection, according to local guidelinesWith the exception of uncomplicated tuft fractures, refer all fractures to a hand surgeon for evaluation, ideally within a week of injury; bite wounds, open fractures, and irreducible fractures/joints warrant more urgent evaluationHand fractures represent roughly 20% of all fractures, with a global incidence of 179 per 100 000 individuals.12 In adults, the metacarpals are most commonly fractured, especially the neck of the fifth metacarpal—a boxer’s fracture—which is often a consequence of striking an object or person with a closed fist. Fractures of the phalanges, particularly the fifth, fourth, and third, are common and often result from...

More than half of England’s integrated care boards (ICBs) are planning to cut spending on services for young people with eating disorders from April, an analysis by the Royal College of Psychiatrists has found.1The planned spend for young people’s eating disorder services in England for 2024-25 is £101m, a real terms increase of 2.9% (or £2.9m) on the 2023-24 spend (£98.1m). But after analysing the NHS mental health dashboard for the first quarter of 2024-25 the college found that 24 out of 42 ICBs have reported planned spending cuts for the coming year compared with last year of more than £835 000.The college said that the planned cuts come amid 7933 new referrals for children and adolescents with eating disorders in the quarter ending December 2024, an increase of 13% from 7003 in the same quarter in 2023.There are also high thresholds to access services, which results in more young...

Fenton and Prochaska call for more restrictions on gambling advertising.1 GambleAware, the leading charity and commissioner of gambling harms prevention and treatment services in Great Britain, is supportive of the points raised and has been working to highlight the evidence that gambling advertising disproportionately affects children, with those exposed to it being 2.3 times more likely to experience “problem gambling” in their lifetime. Based on evidence, we think that stricter gambling advertising and marketing regulations would substantially help to protect children from gambling harm.To tackle the link between gambling advertising and harm, GambleAware is calling for three new measures. Firstly, we would like to see the introduction of a pre-watershed ban on all broadcast gambling advertising, including sports sponsorships. Countries like Australia, Germany, and Ireland have successfully implemented similar bans, with public surveys showing support.Secondly, all gambling advertising, marketing, and sponsorship activity should contain evidence led health warnings to communicate...

NHS EnglandChief executive Pritchard resignsNHS England’s chief executive, Amanda Pritchard, has announced that she will step down at the end of March after three and a half years in the role. The surprise announcement followed recent strong criticism by two parliamentary committees that questioned NHS leaders’ ability and “dynamism” to implement the government’s desired changes to the health service. Pritchard, who has also been chief operating officer at NHS England since 2019, said that now was the time for her to leave, with the NHS continuing to make progress in its recovery from the covid-19 pandemic. (Full story doi:10.1136/bmj.r399)CancerDeprivation is linked to higher death ratesPeople living in the UK’s most deprived areas are much more likely to die from cancer, with death rates almost 60% higher than in the most affluent areas, an analysis by Cancer Research UK found. Around 28 400 extra deaths from cancer a year were linked...

by John P. Quattrochi, Kevin Croke, Caleb Dohou, Luca Stanus Ghib, Yannick Lokaya, Aidan Coville, Eric Mvukiyehe

Background

Diarrhea and growth faltering in early childhood reduce survival and impair neurodevelopment. We assessed whether a national program combining (i) funds for latrine and water upgrades; (ii) institutional strengthening; and (iii) behavior change campaigns reduced diarrhea and stunting, and strengthened local institutions.

Methods and Findings

We collaborated with program implementers to conduct a cluster-randomized controlled trial in four provinces of the Democratic Republic of Congo (DRC). Three hundred thirty-two rural villages were grouped into 121 clusters to minimize geographic spillovers. Between 15 March and 30 June 2018, we randomly assigned, after stratifying by province and cluster size, 50 intervention and 71 control clusters. Masking of participants and interviewers was not possible. Primary outcomes were length-for-age Z-score among children under 5 years of age, caregiver-reported diarrhea in last 7 days among children under 5 years of age, and an index of community WASH institutions. The primary analysis was on an intention-to-treat basis, using a binary variable indicating whether the participant was in an intervention or control cluster. Three thousand two hundred eighty-three households were interviewed between November 2022 and April 2023, median 3.6 years post-intervention. The intervention had no effect on diarrhea (adjusted mean difference −0.01 [95% −0.05 to 0.03]). Diarrhea prevalence was high overall, at 38% in the treatment group and 42% in the control group. The intervention had no effect on length-for-age Z-scores in children (adjusted mean difference −0.01 [95% CI −0.15 to 0.12]). In the control group, the mean length-for-age Z-score was −2.18 (1.60 SD). Villages in the intervention group had a 0.40 higher score on the WASH institutions index (95% CI 0.16–0.65). The percentage of villages in the intervention group with an active water, sanitation, and hygiene (or just water) committee was 21 pp higher than the control group. Households in the intervention group were 24 pp (95% CI 12–36) more likely to report using an improved water source, 18 pp (95% CI 10–25) more likely to report using an improved sanitation facility, and reported more positive perceptions of water governance (adjusted difference 0.19 SD [95% CI 0.04–0.34]). The trial had several limitations, including incomplete (86%) adherence in the implementation group, the absence of baseline measures, and the reliance on self-reported outcomes for some measures.

Conclusions

The DRC’s national rural WASH program increased access to improved water and sanitation infrastructure, and created new WASH institutions, all of which persisted for at least 3.6 years. However, these effects were not sufficient to reduce diarrhea or growth faltering.

Trial registration

The Pan African Clinical Trials Registry PACTR202102616421588 (https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=14670).The American Economics Association RCT registry AEARCTR-0004648 (https://www.socialscienceregistry.org/trials/4648).

US president Donald Trump has begun his attack on women’s health. In his first two weeks as president, he began taking action as detailed in Project 2025, the blueprint for his second presidency developed by right wing think tank The Heritage Foundation.1 He signed an executive order to withdraw the US from the World Health Organization; reinstated the global gag rule2; condemned and abolished equality, diversity, and inclusion initiatives; instructed the censorship of scientific publications that include reference to LGBTQ+ or gender “forbidden terms”3; attempted to end the US President’s Emergency Plan for AIDS Relief (PEPFAR); and began his assault on US foreign aid, public health, and disease control abroad and in the US.4 Sexual and reproductive health organisations are predicting and experiencing the harm of these measures. According to Guttmacher, the 90 day freeze in United States Agency for International Development (USAID) funding will lead to 11.7 million women...

Assisted dying for terminally ill people is set to soon become lawful in the Isle of Man.1 It is on the legal horizon in England and Wales too, as the Terminally Ill Adults (End of Life) Bill is currently proceeding through parliament.2 Introducing its second reading in November 2024, the bill’s proposer, Kim Leadbeater, emphasised its unique “layers of safeguarding,” specifically “a thorough and robust process involving two doctors and a High Court judge.”3Having heard evidence at committee stage, Leadbeater now proposes dropping the layer of scrutiny by a High Court judge and having an Assisted Dying Review Panel instead,4 like the model already adopted in Spain.5 The panel would include a senior legal professional, such as a current or former judge, along with a psychiatrist and social worker. It would be overseen by a voluntary assisted dying commissioner, who would be a serving or retired judge. The panel proposal...

Last year a 17 year old, Patient X, was admitted to Kamuzu Central Hospital, a tertiary referral centre in Malawi, with generalised peritonitis. An examination found that a stick had perforated and remained in the patient’s uterus and that the organ was pus filled and necrotic: the result of a botched backstreet abortion. Patient X underwent a total abdominal hysterectomy and in the following weeks developed a fever and fascial dehiscence, a serious complication that occurs when the abdominal wall separates after surgery. Throughout, the patient and her mother denied that she had visited one of Malawi’s thousands of clandestine abortion providers.1The teenager didn’t die, so her fate could have been worse: more than 1000 women a year die as a result of unsafe abortion in Malawi,2 a country that criminalises abortion except when the pregnant individual’s life is in danger. As in aid dependent nations throughout the global south,...

This man in his late 30s, who was otherwise well, presented with a five month history of episodic right facial pain, right nasal discharge, and halitosis. He had undergone an extraction of his upper right maxillary molar six months earlier. He was initially diagnosed with chronic maxillary sinusitis and received multiple courses of antibiotics, with no improvement. Oral examination showed a 2 × 2 mm opening at the extraction site (fig 1). A computed tomography scan confirmed the diagnosis of an oroantral fistula (OAF). bmj;388/mar06_7/e083050/F1F1f1Fig 1 A communication between the oral cavity and the maxillary sinus post-extraction is called oroantral communication; left untreated, it will epithelialise to become an OAF.1 Oral debris and bacteria can enter the maxillary sinus through this opening, resulting in chronic sinusitis.1 Sinusitis can also be associated with chronic dental infections,2 highlighting the importance of ruling out dental causes in patients presenting with unilateral maxillary...

In the farmlands of India—the country with the highest rate of snakebite deaths in the world, at nearly 58 000 a year—a unique initiative once held great promise. Gnaneswar CH, a wildlife conservationist, spearheaded a project in Tamil Nadu’s Tirunelveli district from December 2019 to May 2020 to equip farmers with simple tools designed to reduce the occurrence of snakebites: boots, gloves, flashlights, and mosquito nets. The kits, each costing about 1000 rupees (£10; €11; $12), aimed to protect members of vulnerable communities from deadly encounters with snakes.Months later, however, Gnaneswar was left puzzled. The mosquito nets were being used for fishing and the boots lay untouched, gathering dust. What had gone wrong? The answer, he says, is an essential truth about public health interventions: even the best solutions can falter if they clash with local customs and practices.Culture clashIndia accounts for nearly half the global deaths from snakebite each...

Digoxin in atrial fibrillationFor rate control in older people with established atrial fibrillation, low dose digoxin saves £500 each year compared with beta blockers. It’s not the cost of the drugs—both digoxin and beta blockers are cheap—but the number of adverse events in those taking digoxin is substantially lower, so savings are made because there’s less use of primary and secondary healthcare. Patient reported quality of life is better with digoxin too (Heart doi:10.1136/heartjnl-2024-324761).Cardiovascular disease after twin pregnanciesPregnancy places considerable demands on the maternal cardiovascular system. These demands are higher still in twin pregnancies and pregnancies complicated by pre-eclampsia. A huge database study from the US that investigated hospitalisations for cardiovascular disease in the year after delivery finds that, compared with uncomplicated singleton pregnancies, women with twin pregnancies or who developed hypertension in pregnancy were at higher risk (Eur Heart J doi:10.1093/eurheartj/ehaf003). Nonetheless, the absolute rates were low—even after a...