BMJ - British Medical Journal

AbstractCritical illness is a complex condition that can have a devastating impact on health and quality of life. Nutritional support is a crucial component of critical care that aims to maintain or restore nutritional status and muscle function. A one-size-fits-all approach to the components of nutritional support has not proven beneficial. Recent randomized controlled trials challenge the conventional strategy and support the safety and potential benefits of below-usual calorie and protein intakes at the early, acute phase of critical illness. Further research is needed to define optimal nutritional support throughout the intensive care unit stay. Individualized nutritional strategies relying on risk assessment tools or biomarkers deserve further investigation in rigorously designed, large, multicenter, randomized, controlled trials. Importantly, although nutritional support is crucial, it might not be sufficient to enhance the recovery of critically ill patients. Thus, achieving the greatest efficacy may require individualized nutritional support combined with early, prolonged physical rehabilitation within a multimodal, holistic care program throughout the patient's recovery journey.

Are you making a meal over New Year’s resolutions?Absolutely. As the name suggests, Veganuary encourages people to go vegan at the start of every year.Turning over a new leaf?Exactly! And eating more leaves too. The benefits of a plant based diet are well documented.1 It’s good for the planet: plant based foods produce fewer greenhouse gas emissions than animal based foods. And it’s good for human health, reducing the risk of chronic disease, including cardiovascular conditions. Abstinence, you might say, makes the heart grow stronger.I don’t like fadsA vegan diet isn’t a fad. Neither is Veganuary a flash in the pan, as it’s now marking its 10th year. Veganism is now baked into our culture.OK, veggie burgers here I comeSteady on. A study published in the Proceedings of the National Academy of Sciences ranked 24 meat and milk alternatives in terms of nutrition, health, environmental, and cost perspectives.2 It found...

A consultant psychiatrist has been struck off the UK medical register after a tribunal found that he had engaged in “scaremongering” over coronavirus vaccines in an online video.Daniel Armstrong accused governments, health authorities, and drug companies of mounting a “monumental cover-up operation” to hide vaccine harms in his video, entitled Navigating the Truth-Deception Duality Brought to you by Dr Daniel Armstrong MBChB. The video was reported to the General Medical Council (GMC) by an anonymous email.“I am using my doctor title, my registration under the GMC in the UK, to bring you this message about what the truth is, but also highlight the deception,” said Armstrong in his video. “You’ve a doctor here, he’s got his licence on the line—given it up. Don’t take any more of the injections. These guys are evil.”The European Convention on Human Rights guarantees the right to free speech, and case law has upheld the...

Pilot medical apprenticeship programmes in England, which were being trialled as a new route into the profession, have been paused by the government.Peninsula Medical School in Plymouth, one of the universities in the pilot scheme, has been told not to recruit for the course—due to start in September 2025—pending a review of doctor apprenticeships, which were intended to widen access to medical careers. The arm’s length agency Skills England told course leaders at the medical school that it would review and “discuss areas where funding for level 7 apprenticeships will be restricted, and a decision will follow in due course.”Laura Bowater, head of the Peninsula Medical School, described the government’s move as “disappointing.” She told The BMJ that the change was part of the government’s cooling towards level 7 apprenticeships, which include medicine.Anglia Ruskin University has 25 medical apprentices on its course, which started in September 2024. The University of...

Davis and colleagues highlight the critical need for clearer and more accessible information about medicines for patients.1 As an anaesthetist, I often encounter challenges in communicating the risks and benefits of perioperative drugs, particularly as we cannot always predict every medication that might be required during an operation.A key example is sugammadex, a neuromuscular blockade reversal agent that can reduce the efficacy of hormonal contraceptives by binding to steroidal molecules, thus increasing the risk of unintended pregnancy. Patients must be advised to use alternative contraceptive measures for up to seven days after its administration. Such vital information is often overlooked, however, creating a potential gap in patient understanding. This emphasises the need for accessible drug information that can be easily conveyed in time critical scenarios.The unpredictability of anaesthetic practice further complicates the consent process. It is often not possible to foresee every medication that might be given during surgery, such...

Preliminary laboratory findings suggest that a mystery illness in the Democratic Republic of the Congo is a combination of common and seasonal viral respiratory infections and malaria, the World Health Organization (WHO) has said.1WHO described the previously undiagnosed disease as “acute respiratory infections complicated by malaria,” which had led to an increase in severe infections and death when compounded by acute malnutrition.A broad surveillance case definition was established in absence of a diagnosis, which included patients who presented with fever, cough, body weakness, and runny nose. Other signs and symptoms may include chills, headache, difficulty breathing, malnutrition, and body aches.From 24 October to 16 December a total of 891 cases and 48 deaths from the Panzi health zone in the Kwango province met the case definition. More cases occurred in females (58%), especially adults (66%). The disease disproportionately affected children under 5 years old, who made up 47% of all...

The last major hospital in northern Gaza is now out of commission after a raid by Israeli forces left its surgical unit, medical store, and laboratory “burnt and severely damaged.” Staff and critically ill patients have been forced to leave, and the hospital’s director, Hussam Abu Safiya, has been detained.The World Health Organization (WHO) said that it was “appalled” by the raid, which “put the last major health facility in North Gaza out of service,” and was “deeply concerned” for the patients moved to a hospital that cannot care for them, as well as for Abu Safiya. “Kamal Adwan is now empty,” said WHO. “Some people were reportedly stripped and forced to walk toward southern Gaza.”Since early October WHO has confirmed at least 50 attacks on healthcare that took place on or around the hospital. It said, “Attacks on the hospitals and on health workers have occurred almost daily. This...

Davis and colleagues share their concern about the lack of accessible information on both the magnitude and nature of the benefits of new drugs.1 Without such information, it is impossible for patients, or clinicians, to balance the benefits against the adverse effects of the medicine and so arrive at an informed choice.I have been an independent adviser for the UK medicines regulator, the Medicines and Healthcare Products Regulatory Agency, for 40 years and have for many years urged the agency to explore ways of filling this astonishing gap. Almost insurmountable problems exist in two forms: current information for patients is almost entirely with the manufacturers, who would have to be persuaded to invest in the initiative, and many of the clinical rating scales used in the pivotal clinical trials cannot readily be translated into language that means much to patients. These are huge problems, but as the article points out,...

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,...

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...