BMJ - British Medical Journal

The US Food and Drug Administration (FDA) has published draft guidance aimed at improving the performance of pulse oximeters across all skin colours, following research suggesting the medical devices may be less accurate in people with darker skin.1Once finalised, the guidance could see a prominent label added to the packaging of pulse oximeters proven to perform “comparably across groups of individuals with diverse skin pigmentation.”It also provides manufacturers with actions they can take to better assess their products, such as increasing the number of clinical trial participants and using the Monk skin tone scale2 alongside other methods for classifying skin pigmentation.Pulse oximeters became more widely used during the covid-19 pandemic as a way for people to monitor blood oxygen levels while at home. But research published in the New England Journal of Medicine in 2020 found that the devices may be missing three times as many cases of occult hypoxaemia...

“Eco-anxiety” is growing worldwide, especially among young people.1 Considerable anxiety about the climate crisis is rational, particularly for young people, for whom even 2100 is a tangible date. Deep concern for future human and ecological wellbeing is justified among all ages, not only because of the disturbing evidence of climate breakdown, but also because of the apparent climate change policy paralysis, especially in so-called developed countries—the global North. Climate policy paralysis and hypocrisy are stark given the disturbing evidence of rising global temperatures in the last 18 months. The primary responsibility for climate change lies with the lifestyles and intransigence of the world’s most affluent people, most of whom live in high-income nations including Europe, the US, Canada, and Australia. Although these populations have, to date, been comparatively insulated from the harm caused by climate change, more extreme climate related weather events are becoming increasingly frequent, such as wildfires in...

The 10 winners of the 2024 Shkreli awards, given annually to the worst examples of profiteering and dysfunction in US healthcare, have been announced by the Lown Institute, a non-profit US think tank.1The winners include an oncologist who subjected a healthy patient to cancer treatment for profit, a hospital accused of demanding upfront payments from patients with cancer, and UnitedHealth, the insurance company that has faced a storm of public indignation after one of its executives was murdered in New York.2This is the eighth year in which the awards have been given. Winners are chosen by a panel including doctors, public health experts, journalists, and patient advocates. The awards are named after Martin Shkreli, the “pharma bro” who became infamous when he bought the maker of the anti-parasitic drug Daraprim and increased the price 50-fold.Speaking at the ceremony, Lown Institute president Vikas Saini said, “All these stories paint a picture...

One of England’s largest hospital trusts has ordered an independent review of its international medical training programmes because of concerns, first highlighted in The BMJ, that overseas doctors were paid substantially less than domestic peers working at a comparable level.University Hospitals Birmingham NHS Foundation Trust (UHB) has already carried out an internal review “following concerns raised by staff members” about the international medical training programmes.A message sent to UHB staff on 8 January from Kiran Patel, the trust’s chief medical officer, said that the internal review had “highlighted a number of issues, including pay parity . . . We will therefore undertake an independent review of each of the international training programmes we are involved in.”Foreign doctors come to English hospital trusts as “fellows” as part of the Academy of Medical Royal Colleges’ medical training initiative scheme.1 The scheme provides experience in the NHS for up to two years for...

I agree with Wolf’s concerns about transfusion in sickle cell disease.12 In developed countries, where the blood donor pool is predominantly white and lacking the Ro antigen, transfusion for sickle cell disease is often affected by alloantibody formation, which complicates future transfusions. Iron overload is a potential complication of chronic blood transfusions in patients with sickle cell disease.Notwithstanding, Howard does recommend simple additive transfusion for acute anaemia (haemoglobin concentration 20 g/L below steady state) in patients with sickle cell disease.3 Similarly, British Committee for Standards in Haematology guidelines recommend that transfusion be considered in uncomplicated painful crises if there is a substantial drop in haemoglobin from baseline (a drop greater than 20 g/L or to a concentration lower than 50 g/L.4In many countries where sickle cell disease is prevalent, the blood donor population is Ro similar and the rate of alloantibody formation lower.5 In addition, blood shortage makes chronic transfusion...

The covid-19 pandemic and the recent cost-of-living crisis have substantially exacerbated pre-existing inequalities in health and social care in the UK.1 Marginalised populations are disproportionately affected, for example by experiencing higher rates of childhood obesity, depression, and maternal and neonatal mortality.2 Paradoxically, those who are most in need of medical care—disadvantaged populations—often face the greatest barriers to accessing it. In England, people living in the most deprived areas are twice as likely to wait over a year for non-urgent treatment compared to others.3For the NHS to make a real difference to health equity, local organisations should not be waiting for a solution to emerge nationally. Instead, they should be looking to, and working with, the local populations they serve. For instance, there is a critical need for better data on healthcare access and outcomes, specifically broken down by income and background. The recent independent investigation into the NHS in England...

Charles and colleagues’ overview of management of acute pain crisis in sickle cell disease is welcome,1 especially as patients move away from city centres to areas that typically have a less ethnically diverse demographic. As a consultant haematologist specialising in haemoglobinopathy and transfusion, however, I must challenge the suggestion that transfusion is recommended when haemoglobin drops by 20 g/L.Transfusion is not a benign treatment, particularly in patients with sickle cell disease. Rates of red cell alloimmunisation are high, especially in countries where the donor population is predominantly white, with rates of almost 20% in a recent UK study2 and up to 30% in some North American studies.3 Transfusion can also lead to serious life threatening consequences of delayed haemolytic transfusion reaction or hyperhaemolysis syndrome, in which patients begin to haemolyse their own cells as well as that of transfused cells. Longer term, repeated transfusion can lead to iron overload and...

How bad is it?Latest NHS England figures show that hospitals had an average 5407 patients a day with influenza, including 256 in critical care, in the week to 5 January.1 This was 3.5 times the number in the same week last year (1548 for the week ending 7 January 2024). NHS staff have told the BBC this is one of the worst winters they have seen, comparing it to 2022-23, which was the worst since modern records began.2 The Royal College of Physicians warned of “chaos” in hospitals, with ever more care provided in corridors and other temporary environments. Saffron Cordery, interim chief executive of NHS Providers, said “winter has been brutal so far” and predicted that “things are likely to get worse before they get better.” The BMA’s chair of council, Phil Banfield, warned that “we are in a national emergency,” adding, “A seasonal flu outbreak is something we...

A new year is meant to bring new hope, and perhaps this one does too, but it’s hard to be thrilled by health services overwhelmed by winter pressures (doi:10.1136/bmj.q2871),1 transatlantic rabble rousing, and insoluble global crises and conflicts. What a new year can certainly bring is a fresh start, with new energy and effort to direct ourselves away from a destructive future, to focus on improving people’s health and wellbeing.Yet with each era the task grows more complex. In Samuel Taylor Coleridge’s Rime of the Ancient Mariner, sailors marooned on a ship drifting near the equator are tortured by “water, water, every where, nor any drop to drink.” Medicine at that time, the end of the 18th century, was replete with untested hypotheses on illness and disease, reliable information was scarce, and therapies were few.That changed—first gradually, then rapidly—with advances in medical science, printing and distribution, and the internet. More...

The BMJ’s articles on helping healthcare providers identify abuse, neglect, and exploitation of children123 are particularly useful in the acute setting, such as the emergency department.On behalf of the adolescent special interest group of the British Association of Sexual Health and HIV (BASHH) I would like to bring to your attention to two further resources offering standardisation of best practice in this field that are used across the United Kingdom and internationally.The Spotting the Signs toolkit was originally developed by Brook, a sexual health charity, and BASHH, aiding the identification of young people at risk of child sexual exploitation.4 This tool has been used in sexual health services since 2014 and has recently been updated to widen its scope to include assessment of child criminal exploitation and online risks using trauma informed and conversational approaches. It will be used by a broader range of professionals, including schools, youth services, and...

This woman in her 50s presented with a three month history of swelling and pain in both ears and multiple joints, recurrent fever, and cough that was unresponsive to antibiotics. Physical examination showed bilateral auricular atrophy (fig 1, left), saddle nose deformity, and joint tenderness. Laboratory test results included raised C reactive protein levels and erythrocyte sedimentation rate, 1+ proteinuria, no UBA1 mutations, and antinuclear antibodies at 1:160 titre with negative extractable nuclear antigen, rheumatoid factor, anti-cyclic citrullinated peptide antibody, and anti-neutrophil cytoplasmic antibody. Cartilaginous inflammation without evidence of vascular involvement or malignancy was identified on positron emission tomography-computed tomography.bmj;388/jan09_8/e081185/F1F1f1Fig 1Differential diagnoses for auricular chondritis include relapsing polychondritis, granulomatosis with polyangiitis, VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammation, somatic) syndrome (an x-linked autoinflammatory disorder caused by somatic mutations in UBA1), infectious chondritis, and traumatic otohaematoma.1Based on McAdam’s criteria, relapsing polychondritis was diagnosed in this patient. Relapsing polychondritis is a rare immune...

London based vascular surgeon Mahim Qureshi decided to join an emergency medical team trip to a Gaza hospital after reading that, every day, 10 or more children in Gaza lose one limb or more. “As a senior registrar in vascular surgery able to do an amputation quickly and safely and control bleeding, I knew I’d be able to help.”She made a 12 day trip to Al Aqsa Hospital in central Gaza in April 2024 and a two week mission to Nasser Hospital in the south of the country in November, both times supported by the International Rescue Committee (IRC), the subject of this year’s BMJ appeal.Providing healthcare safely in Gaza is both a logistical and humanitarian challenge. Israeli airstrikes, bombing, and ground level fighting have left half of its 36 hospitals out of service and killed more than 1000 Palestinian health workers, according to the United Nations, which cites figures...

NutsThe ASPREE study, which started as a trial of low dose aspirin in healthy older adults, morphed into a longitudinal study of ageing (Age Ageing doi:10.1093/ageing/afae239). It recently reported that people who eat nuts every day tend to have a longer disability-free survival. The explanation may be nutritional, because nuts are rich in vitamins, minerals, polyphenols, phytosterols, and unsaturated fats. Another possibility is that the sort of people who choose to eat nuts are the sort of people who have a generally healthy way of life.Antiseizure medication in fathersAlthough valproate is a highly effective treatment for idiopathic generalised epilepsy, guidelines recommend restricting its use to people older than 55 because of the drug’s teratogenicity (NICE https://bnf.nice.org.uk/drugs/sodium-valproate). Where men are concerned, this may be an over-reaction. A systematic review of 10 studies of the offspring of fathers taking antiseizure medication at the time of conception found no consistent evidence of an...

The UK supermarket giant Tesco is being urged to drop an “unethical” pilot of an in-store infant feeding advice service in which midwives funded by the formula milk firm Danone are expected to wear branded uniforms and undergo training by the company.Critics said the initiative, running in a Tesco flagship store and set to be rolled out shortly,1 was a backward step and reminiscent of the “milk nurses” scandal of the 1970s, in which formula industry salespeople dressed as nurses to promote formula milk to parents.One midwife hired by Danone quit the pilot last month at the Tesco Extra store in Cheshunt, Hertfordshire, telling The BMJ that she couldn’t be associated with an “unethical” service.A spokesperson for Danone UK and Ireland said that it intended only to provide “impartial, nutritional expertise,” that the branded uniforms were optional, and that it was happy to “take on board feedback.”Tesco said it intended...

AbstractObjectiveTo summarise available evidence on time to nursing home admission and death among people with dementia, and to explore prognostic indicators.DesignSystematic review and meta-analysis.Data sourcesMedline, Embase, Web of Science, Cochrane, and Google Scholar from inception to 4 July 2024.Eligibility criteria for selecting studiesLongitudinal studies on survival or nursing home admission in people with dementia. Studies with fewer than 150 participants, recruitment during acute hospital admission, or less than one year of follow-up were excluded.Results19 307 articles were identified and 261 eligible studies included. 235 reported on survival among 5 553 960 participants and 79 reported on nursing home admission among 352 990 participants. Median survival from diagnosis appeared to be strongly dependent on age, ranging from 8.9 years at mean age 60 for women to 2.2 years at mean age 85 for men. Women overall had shorter survival than men (mean difference 4.1 years (95% confidence interval 2.1 to 6.1)), which was attributable to later age at diagnosis in women. Median survival was 1.2 to 1.4 years longer in Asia than in the US and Europe, and 1.4 years longer for Alzheimer’s disease compared with other types of dementia. Compared with studies before 2000, survival was longer in contemporary clinic based studies (Ptrend=0.02), but not in community based studies. Taken together, variation in reported clinical characteristics and study methodology explained 51% of heterogeneity in survival. Median time to nursing home admission was 3.3 years (interquartile range 1.9 to 4.0). 13% of people were admitted in the first year after diagnosis, increasing to 57% at five years, but few studies appropriately accounted for competing mortality risk when assessing admission rates.ConclusionsThe average life expectancy of people with dementia at time of diagnosis ranged from 5.7 years at age 65 to 2.2 at age 85 in men and from 8.0 to 4.5, respectively, in women. About one third of remaining life expectancy was lived in nursing homes, with more than half of people moving to a nursing home within five years after a dementia diagnosis. Prognosis after a dementia diagnosis is highly dependent on personal and clinical characteristics, offering potential for individualised prognostic information and care planning.Systematic review registrationPROSPERO CRD42022341507.

For clinicians it is an important and demanding task to inform patients with dementia and their relatives about the prognosis. As with malignant diseases, discussing remaining life expectancy and time to death is a delicate matter. But it is even more challenging to provide information about the timeline for dependency and need for nursing home care because many factors are involved, not only the type of dementia, sex, and age of patients, but also comorbidities, lifestyle, and socioeconomic and cultural factors. Some patients seek all available information about their prognosis, whereas others prefer to know less, and the emotional response to information on the dementia diagnosis and prognosis varies substantially, from catastrophic to pragmatic. Additionally, a substantial discrepancy can exist between what patients and their relatives want in terms of information.The previous reviews on dementia related survival12 and nursing home admission were published more than a decade ago,3 so the...

bmj;388/jan08_7/r11/FAF1faRuth White was a woman of many passions; from antique textiles to singing opera to Aston Villa Football Club she threw herself into everything she committed to. This also translated into her professional life.In 2000 the death of a trainee psychiatrist and her baby led to a huge amount of soul searching across the NHS—the report into the deaths1 highlighted a range of contributing factors, including the lack of specialist mental health services for pregnant women and new mothers.The case prompted White, a community psychiatrist in Worcester, to set up one of the first community perinatal mental health teams in the country, using her considerable passion and drive to cajole the powers that be to give her the money to do it.White was self-taught, seeking out the advice of experts in the field to learn about perinatal mental health and then training community nurses and midwives to identify women at...

Most of us have favourite questions that we like to ask when consulting with patients or that we’re fond of teaching to medical students and resident doctors. One popular question many GPs teach their registrars to ask is, “What made you come today, particularly?” This can sometimes lead patients to disclose a triggering event that was just as important as the long running symptom they first presented with.Personally, I put a different question at the top of my own list for teaching: “How is this conversation going for you so far?” I like this question for several reasons. It helps you to find if you’re on the right track or have missed something important that the patient tried to say and you didn’t fully register. You can then recalibrate your response straight away, rather than finding out too late that you’ve gone badly off track. It’s also a way of...

Just over 10 years ago I was diagnosed with Parkinson’s disease. I had suffered for several years from strange bouts of cramp, stiffness, and a very painful back. A badly torn rotator cuff only confused the issue as I put much of my discomfort down to my shoulder or back problems. Before major back surgery the surgeon expressed doubts and quietly suggested a neurological rather than a musculoskeletal issue. Raising the possibility of a life changing condition with such non-alarmist tact was helpful.A colleague along the corridor was more direct but equally careful. Not everybody would have appreciated this directness, but I was relieved. Knowing what I had gave me a better chance of dealing with it.Facing the figuresDisease progression has been mercifully slow since my diagnosis. However, the intrinsic uncertainty in the condition breeds anxiety: another Parkinson’s gift. A thoughtless remark could cause me to lose confidence, leading to...

This piece comes with a trigger warning. We used to avoid talking about cancer, menopause, periods, or other stigmatised topics—adding to feelings of shame and limiting our understanding. This remains true of suicide, especially among healthcare staff. The writer Adam Kay describes NHS staff suicides as being “brushed under the carpet.”1 But talking about suicide is important, as open conversation reduces its risk.2Some statistics stick in my head. One nurse dies by suicide each week in the UK.3 The suicide rate in women doctors is up to four times that of women in the general population.4 Unfortunately, most colleagues are oblivious to the pain experienced by a huge proportion of their co-workers. But each tragedy can cause guilt, shame, and higher rates of suicide in the loved ones and colleagues affected.4Clare Gerada35 started the NHS Practitioner Health service,6 and she and Ananta Dave have written3 about awareness and prevention of...