Medical Journal News

AbstractObjectiveTo identify clusters of women with similar trajectories of breast density change over four longitudinal assessments and to examine the association between these trajectories and the subsequent risk of breast cancer.DesignRetrospective cohort study.SettingData from the national breast cancer screening programme, which is embedded in the National Health Insurance Service database in Korea. Breast density was assessed using the four category Breast Imaging Reporting and Data System (BI-RADS) classification. Group based trajectory modelling was performed to identify the trajectories of breast density.ParticipantsWomen aged ≥40 years who underwent four biennial mammographic screenings between 2009 and 2016.Main outcome measuresBreast cancer development was determined to 31 December 2021. Cox proportional hazard models were used to assess the associations between trajectories and breast cancer outcomes after adjusting for covariates.ResultsAmong a cohort of 1 747 507 women (mean age 61.4 years), five breast density trajectory groups were identified. Group 1 included women with persistently fatty breast tissue, group 2 included women with fatty breast tissue at baseline but increased breast density over time, and groups 3-5 included women with denser breasts, with a slight decrease in density over time. Women in group 2 had a 1.60-fold (95% confidence interval 1.49 to 1.72) increased risk of breast cancer compared with those in group 1. Women in groups 3-5 had higher risks compared with those in group 1, with adjusted hazard ratios of 1.86 (1.74 to 1.98), 2.49 (2.33 to 2.65), and 3.07 (2.87 to 3.28), respectively. Similar results were observed across different age groups, regardless of changes in menopausal status or body mass index.ConclusionsThis study identified five distinct groups of women with similar trajectories of breast density change over time. Future risk of breast cancer was found to vary in these groups. Increasingly dense or persistently dense breasts were associated with a higher risk. Changes in breast density over time should be carefully considered during breast cancer risk stratification and incorporated into future risk models.

AbstractObjectiveTo compare the effectiveness and safety of budesonide-glycopyrrolate-formoterol, a twice daily metered dose inhaler, and fluticasone-umeclidinium-vilanterol, a once daily dry powder inhaler, in patients with chronic obstructive pulmonary disease (COPD) treated in routine clinical practice.DesignNew user cohort study.SettingLongitudinal commercial US claims data.ParticipantsNew initiators of budesonide-glycopyrrolate-formoterol or fluticasone-umeclidinium-vilanterol between 1 January 2021 and 30 September 2023 who had a diagnosis of COPD and were aged 40 years or older.Main outcome measuresIn this 1:1 propensity score matched study, the main outcome measures were first moderate or severe COPD exacerbation (effectiveness) and first admission to hospital with pneumonia (safety) while on treatment. Potential confounders were measured in the 365 days before cohort entry and included in propensity scores. Hazard ratios and 95% confidence intervals (CIs) were estimated using a Cox proportional hazards regression model.ResultsThe study cohort included 20 388 propensity score matched pairs of new users initiating single inhaler triple therapy. Patients who received budesonide-glycopyrrolate-formoterol had a 9% higher incidence of first moderate or severe COPD exacerbation (hazard ratio 1.09 (95% CI 1.04 to 1.14); number needed to harm 38) compared with patients receiving fluticasone-umeclidinium-vilanterol and an identical incidence of first admission to hospital with pneumonia (1.00 (0.91 to 1.10)). The hazard of first moderate COPD exacerbation was 7% higher (1.07 (1.02 to 1.12); number needed to harm 54) and the hazard of first severe COPD exacerbation 29% higher (1.29 (1.12 to 1.48); number needed to harm 97) among those receiving budesonide-glycopyrrolate-formoterol compared to fluticasone-umeclidinium-vilanterol. Prespecified sensitivity analyses yielded similar findings to the primary analysis.ConclusionsBudesonide-glycopyrrolate-formoterol was not associated with improved clinical outcomes compared with fluticasone-umeclidinium-vilanterol. Given the added climate impact of metered dose inhalers, health systems seeking to decrease use of these products may consider steps to promote further prescribing of fluticasone-umeclidinium-vilanterol compared with budesonide-glycopyrrolate-formoterol in people with COPD.Study registrationCenter for Open Science Real World Evidence Registry (https://osf.io/6gdyp/).

The incoming US administration has signalled its intent to make large changes to the federal government’s approach to medicine and public health. With Republicans holding control of both houses of Congress and a conservative Supreme Court, the potential for change is high if the administration can address internal disagreements.Much of that change is likely to centre on health insurance coverage, which for most Americans is provided through Medicaid (the federal and state programme for people on low incomes), Medicare (for people over 65 and those with disabilities), or private insurance, obtained either through employers or through the public marketplaces (exchanges) created under the Affordable Care Act (ACA).Most policies available through Medicaid, Medicare, and ACA exchanges are decided at federal level, but healthcare is mostly administered by states. This means health outcomes may largely depend on how individual states can adjust to likely changes in federal policy or funding.Policy challengesMedicare, Medicaid,...

New England Journal of Medicine, Volume 392, Issue 1, January 2, 2025.

New England Journal of Medicine, Volume 392, Issue 1, Page 7-9, January 2, 2025.

New England Journal of Medicine, Volume 392, Issue 1, Page 4-7, January 2, 2025.

New England Journal of Medicine, Volume 392, Issue 1, Page 1-4, January 2, 2025.

The UK government has announced plans to introduce a league table of NHS providers, with rewards for the leaders.1 Managers get more pay for better performance, but what do all the staff get who do the work to produce that better performance? The John Lewis partnership principle of all those in an organisation getting benefits for better performance does have its merits.Personal financial gain for better organisational performance might look good to the politicians, but how do you measure performance effectively in a hospital? Many performance targets, such as time to discharge after surgery, will depend on the health of the population not what you do while they are an inpatient. Emergency department waiting times depend on community services and general practice. After over 40 years working in the NHS, I have seen that performance targets have a habit of unintended consequences, such as operating on patients that “breach targets”...

Israel has reportedly ordered the closure and evacuation of Kamal Adwan Hospital—one of the last semi-functioning hospitals left in northern Gaza—putting the lives of dozens of patients at risk, including babies in incubators.1The hospital has been under attack for weeks, with staff killed, medical aid repeatedly blocked, and water tanks and electricity generators damaged. Now, the hospital’s director, paediatrician Hussam Abu Safiya, has said that they have also been told to evacuate. Israel Defence Forces has told The BMJ it is “unaware of any evacuation order of the hospital.”Speaking to Reuters, Abu Safiya warned that it would be “next to impossible” to safely evacuate the “nearly 400 civilians inside the hospital, including babies in the neonatal unit, whose lives depend on oxygen and incubators.” He continued, “We are sending this message under heavy bombardment and direct targeting of the fuel tanks, which if hit will cause a large explosion and...

The UK Medical Research Council’s plans to redirect funding to new “centres of research excellence” (CoREs) could force existing MRC research units to close, eminent scientists have warned.In an open letter to the science minister Patrick Vallance more than 500 scientists and academics expressed their “deep concern” at a new funding model that will award large “challenge led” grants to tackle specific challenges at newly created CoREs over a time limited 14 year period.12The letter urges the minister to reconsider the decision, warning that the move will threaten the viability of the existing 19 MRC units located at UK universities that have “long and distinguished histories” in medical research.3“MRC units are a unique scientific asset and . . . losing them will have a detrimental effect on the entire medical research sector in this country,” the letter said. “We are extremely concerned that the full impact of closing the units...

This opinion article (BMJ 2024;387:q2791, doi:10.1136/bmj.q2791) contained an error in the sentence, “A measles outbreak the following year infected an estimated 57 000 people, and 83 people, including many children, died.” The estimated number of people infected during the measles outbreak was in fact 5707, and we have corrected this.

In a previous version of this article (BMJ 2024;387:q2661, doi:10.1136/bmj.q2661), Jason O’Rourke was quoted as saying that the British Nutrition Foundation (BNF) “has Nestlé on its board.” O’Rourke was speaking historically about the BNF’s advisory committee—in 2021 the BNF had a Nestlé representative on its advisory committee—and we have amended O’Rourke’s quote to reflect this. At the time of publication, the BNF has a Kellogg’s representative on its board and a PepsiCo representative on its advisory committee.

In the “mRNA technology” section of this feature article by Chris Baraniuk (BMJ 2024;387:q2294, doi:10.1136/bmj.q2294, published 7 November 2024) we have deleted the following sentence and its supporting reference after being advised that Provenge is not an mRNA vaccine: “The first mRNA vaccine ever approved for use in humans was actually a cancer vaccine: Provenge, for treating prostate cancer.”

In 2023, a disturbing milestone was reached: six out of nine planetary boundaries were crossed, signalling an unprecedented threat to Earth's stability.1 Simultaneously, the world grappled with a relentless series of disease outbreaks—Ebola, dengue, Zika, covid-19, Mpox, and Nipah. This convergence of crises is not coincidental. As Tulio de Oliveira, a leading genomics expert, warns, “Over half of known pathogen outbreaks will increase due to climate change.”2 The message is clear: our planet's health and human health are inextricably linked, demanding an urgent, integrated response.Recent years have seen tentative steps towards recognising this interconnection. The COP28 climate talks featured an official health day3 and the World Health Assembly adopted a climate and health resolution.3 The CEPI Global Pandemic Preparedness Summit in Brazil highlighted the cascading effects of climate change on infectious diseases, even impacting marine mammals like sea lions.4However, these initiatives fall short of the substantial shift that is required....

Sudan, Palestinian territories occupied by Israel, Myanmar, and Syria are the countries most at risk of new or worsening humanitarian emergencies, says the International Rescue Committee (IRC) in its Emergency Watchlist for 2025. The aid organisation’s research shows “a world increasingly out of balance,” with 20 countries—home to 11% of the global population—accounting for 82% of the world’s humanitarian needs.SudanIn Sudan, conflict has left 25 million of the population of 47 million in need of humanitarian support; more than 10 million people have been displaced and 18 million are facing severe food insecurity. Healthcare facilities have been repeatedly attacked, looted, and occupied, leaving over 70% non-functional.“The power struggle between the Sudanese Armed Forces and the Rapid Support Forces erupted into a large scale conflict in April 2023 and has been driving humanitarian needs in the country ever since,” the IRC has said. “Conservative estimates say the conflict has killed more...

Research funded by the US National Institutes of Health (NIH) will have to be made publicly available without a period of delay,1 under the agency’s new public access policy.The policy, which is open to consultation until 21 February 2025, has been designed to accelerate access to publicly funded research results as part of the institute’s commitment to transparency and accessibility.The biggest change from the NIH’s existing policy, produced in 2008, is that the 12 month embargo period before manuscripts resulting from NIH funding must be made publicly available will be removed as of 31 December 2025. This meets an expectation set out by the US government in 20222 for publications and supporting data from federally funded research to be made publicly accessible without an embargo.The NIH’s move comes as other research funders across the world make efforts to increase transparency. Earlier this year the European Union removed a deferral mechanism...

The government has released preliminary details of what it wants to include in the new contract for GPs in England, including adding an extra £889m to the existing budget for general practice.Discussions on the new GP contract 2025-26 will also focus on reducing the number of targets in the Quality and Outcomes Framework (QoF) from 76 to 44 to cut bureaucracy, the Department of Health and Social Care said.The government said it would consult the BMA’s General Practitioners Committee for England (GPC England) on the details of its proposals over the coming weeks, before unveiling the new contract in spring 2025.The health and social care secretary, Wes Streeting, said, “General practice is buckling under the burden of bureaucracy, with GPs filling out forms instead of treating patients. It is clear the system is broken, which is why we are slashing red tape, binning outdated performance targets, and instead freeing doctors...

Flu hit early this year, and NHS hospitals are being inundated with respiratory illness.1 Beds are full, and surveillance across primary and secondary care suggests that the rate is increasing steeply.Yet when winter respiratory viruses are circulating it is not just the patients who are affected. Data for the week to 15 December showed that 54 165 staff were off sick, around 4476 more than in the same week in 2023.2 The numbers exemplify why the NHS made an operational decision to offer influenza and covid vaccines to frontline workers (involved in direct care).But there has been a noticeable decline in vaccine uptake among staff in recent years. In England in 2023-24 less than half (42.8%) of staff in NHS trusts involved in direct care of patients had had a flu vaccine—a seven percentage point drop from the previous year.3 This was the third year in a row that the...

Announcing investments in a five year trial ­­­­­­of tirzepatide (a glucagon-like peptide-1 analogue weight loss drug), health secretary Wes Streeting showed support for prioritising patients able to return to work, saying that obesity was not only a health issue but also “holding back our economy.”12 Incorporating the economic benefits of returning people to work sooner echoes concerns raised in the Darzi report, commissioned by Streeting.3 This might sound like low hanging fruit for improving the nation’s health, but there’s a catch.The National Institute for Health and Care Excellence (NICE) currently uses a costing perspective that only counts benefits accrued in the healthcare sector and excludes productivity gains; accounting for the benefit of returning to work extends towards a societal costing perspective.45 After the tirzepatide trial, reimbursement will be decided by NICE, which has previously concluded against switching to a societal costing perspective given the substantial ethical, practical, and methodological challenges...

GPs in Wales have delivered a resounding rejection of the proposed General Medical Services (GMS) contract from the Welsh government.In a BMA ballot of its members in Wales, almost all (98.7% or 1079) doctors rejected the proposed contract for 2024-25, with just 14 doctors voting for it. The ballot had a 68% turnout.The offer included a 6% pay uplift to GP pay, extended to all practice staff, £1.8m for other practice expenses, and an extension of the additional capacity fund for 2025-26, meaning an additional £4m investment next year.1The BMA’s Welsh General Practitioners Committee (GPC Wales) had asked the Welsh government to invest £10.8m into contractor GP pay, £8.9m to allow practices to cover “unavoidable” practice costs, and an overall investment of £27.2m for staff pay.2But although the 6% offer matched the recommended pay uplift intended for GPs from the Review Body on Doctors’ and Dentists’ Remuneration (DDRB), GPC Wales...