Medical Journal News

The Lancet. The fertility industry: profiting from vulnerability. Lancet 2024; 404: 215—The discussion of the private clinics in this Editorial should have said that PGT is more likely to be part of IVF treatment in a private equity-affiliated clinic than elsewhere. The references have been updated to refer to the original study on this issue. These changes have been made to the online version as of Oct 31, 2024..

Lorusso D, Xiang Y, Hasegawa K, et al. Pembrolizumab or placebo with chemoradiotherapy followed by pembrolizumab or placebo for newly diagnosed, high-risk, locally advanced cervical cancer (ENGOT-cx11/GOG-3047/KEYNOTE-A18): overall survival results from a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2024; 404: 1321–32—The appendix for this Article has been updated as of Oct 31, 2024.

A 43-year-old man who developed numbness and impaired fine motor skills in his left arm lasting approximately 10 min while chanting during a football match, attended our emergency room. The patient, who was visiting Germany for the UEFA European Football Championship, explained that the problems started at the end of the first half. He said he had been chanting continuously during the game. Despite complete resolution of the symptoms, he was concerned enough to seek help, and at half-time he came to our hospital by ambulance.

Steatotic liver disease is the overarching term for conditions characterised by abnormal lipid accumulation in the liver (liver or hepatic steatosis). Steatotic liver disease encompasses what was previously termed non-alcoholic fatty liver disease (NAFLD), which is now called metabolic dysfunction-associated steatotic liver disease (MASLD). Additionally, steatotic liver disease includes alcohol-related liver disease (ALD) and MetALD, the new classification for the overlap between MASLD and ALD, and rare causes of liver steatosis.

Most individuals use medication during pregnancy. However, decision making on antenatal pharmacotherapy presents considerable ethical and scientific challenges. Amid a sociocultural paradigm prioritising the elimination of fetal risks, available evidence and guidance are limited, and current decision making on antenatal drugs mostly proceeds in an ad-hoc and, often, biased manner. This approach might undermine the health of both mother and child. The need for a systematic approach towards antenatal drug decisions is becoming even more pressing with the growing knowledge of pregnancy-induced changes in drug disposition and effects.

The Australian government must prioritise Aboriginal and Torres Strait Islander people, older people, children, culturally and linguistically diverse communities, and people with disabilities when planning for future pandemics, the country’s covid-19 inquiry report has said.1The 875 page report follows a year long inquiry commissioned by Prime Minister Anthony Albanese to identify ways Australia can improve its preparedness for future pandemics. It considered 2201 public submissions, a community survey with 2126 individual responses, more than 250 consultations and 27 roundtables, and focus groups and interviews with 176 participants.The inquiry team outlined nine recommendations for a successful pandemic response, with 19 immediate actions for the next 12-18 months and a further seven medium term actions that should be carried out before the next national health emergency.One of the recommendations for immediate action is to ensure that priority populations are included in the design and delivery of targeted support and that inequities in...

Academic normsIn order to understand the sources and nature of academic violations, one first has to understand the nature of academic norms.Starting in the 1930s the American sociologist Robert K Merton (1910–2003) described what he considered to be the norms of academic scientific practice, notably in a series of three essays,123 subsequently collected under the general heading “The Normative Structure of Science.4PuritanismIn the first of these three essays, “Motive forces of the new science,”1 later named “The Puritan spur to science,”4 Merton discussed the role of 17th century Puritanism in the development of experimental science. He linked the Protestant work ethic and the Puritan desire to further social welfare with, as Robert Boyle put it in his last will and testament, “Attempts to discover the true Nature of the Works of God ... to the Glory of the Great Author of Nature, and to the Comfort of Mankind.” To this...

bmj;387/nov01_8/q2379/FAF1faAs a young researcher in psychiatry David Goldberg experienced two career defining revelations. The first was that the diagnostic system he had been taught was “top down,” dreamt up by committees of distinguished specialists in Geneva and Washington. “From then on, I was determined to be bottom up,” he said.1The second came when he did research on a gastrointestinal unit. “To amuse the consultant, I would tell him things during our tea break that I had learnt about his patients. ‘How do you learn such fascinating things about patients I have been treating for years?’ he asked.”1This innocent question stopped Goldberg in his tracks.“What I had learnt was to allow patients to speak to me, and to listen to them,” he said.Listening to patients—and teaching others how to do this—was the cornerstone of Goldberg’s career.“Don't guide the patient. Let the patient guide you,” was his unspoken mantra, says Dinesh Bhugra,...

The opioid overdose crisis remains one of the most considerable public health threats in the United States, claiming over 100 000 lives annually in recent years.1 Despite this year’s 12% reduction in overdose deaths,1 the crisis persists, driven by the rise of synthetic opioids such as fentanyl and exacerbated by widening racial inequalities.2 This crisis is central to the 2024 US presidential election,3 with both candidates proposing to tackle it.45 Their positions emphasise criminalisation, tightened border controls, and expanded law enforcement efforts to reduce the supply of illicit opioids. However, to achieve sustained progress in overdose prevention, we need a comprehensive approach grounded in public health.Interventions that are focused on cutting off supply, including using tightened surveillance and controls at the borders, can only provide a temporary reduction in drug availability,678 with suppliers quickly adapting by altering supply routes or substituting novel synthetics such as xylazine into illicit markets. Historically,...

Doctor, I’ve been reading about pubic health and I’m worriedYou mean public health?What happened there?You’ve found the error strewn world of academia.But publishing standards are rising, surely?Not according to analysis of over 32 million research abstracts published over the past 50 years. Eleven of 15 common spelling errors have increased over time, with most showing a strong increase. The total error rate has jumped from 0.1 per 10 000 abstracts in 1970 to 8.7 per 10 000 in 2023.How do we know?Statistics experts Adrian Barnett and Nicole White, from Queensland University of Technology, Australia, analysed trends over time.1 They’d already found researchers were misusing statistical methods then spotted some couldn’t even get the names of the methods right—such as “Fischer’s exact test” instead of “Fisher’s exact test.”How bad is it?Clearly less serious than other bad research writing practices such as plagiarism and spin—however, “We think it’s bad not because we...

bmj;387/nov01_5/q2398/FAF1faFor many years, David Sturgeon was a lecturer in psychiatry at Middlesex Hospital in London, where he encouraged generations of medical students and junior doctors to consider a psychotherapeutic approach when dealing with patients.He was an outstanding teacher, known for his great empathy and understanding. He emphasised that “learning came from patients and not just diseases,” and he encouraged his students to relate to patients as people and to understand the psychological aspects of physical illness, a stance that was groundbreaking at the time.He made many academic contributions, including to First Steps in Psychotherapy, edited by Heinz Wolff, his former teacher. He, Wolff, and Anthony Bateman later successfully revised the well known UCH Textbook of Psychiatry, originally written by Roger Tredgold.Sturgeon also became involved in a joint research project with the University of Heidelberg and the department of psychological medicine at University College Hospital (UCH) London that looked at the...

The right to have an abortion continues to be denied, fought against, and rolled back in nations across the world. In the lead up to the first election since the right to the procedure was overturned, abortion in the US has been politicised to a frightening degree. This common and lifesaving form of healthcare is stigmatised, and we continue to see widening gaps in abortion access worldwide.A new MSI report on abortion care1 sets out global trends. It shows stark numbers of unsafe abortions and increasing threats and abuse faced by abortion providers. Access continues to be restricted and denied in different ways—including, and needing more attention, a risk to the continued provision of surgical abortion. Giving women a choice of how they access abortion, wherever possible, is a crucial component of quality and person centred abortion care, and one we must safeguard.Increased access to medical abortion has been transformative,...

Anybody who has undertaken research involving human participants knows that research ethics has to square some challenging circles. Medical research can be dangerous, even deadly. Improperly conducted it can be disastrous—the thalidomide tragedy ushered in the UK Committee on the Safety of Drugs and the 1968 Medicines Act. We must protect participants. But we must also facilitate essential medical research. Covid-19 vaccines are one of many examples of the benefits that rapid research can bring. Getting the balance right between protection and facilitation is not easy. Bureaucracy and what some perceive to be excessive regulation are often cited as impediments to essential research.1 And there is always a danger that a proper alertness to ethical issues throughout the research cycle decays into regulatory compliance and the ticking of boxes.The Declaration of Helsinki is one of the jewels in the World Medical Association’s (WMA) ethical crown. First developed in 1964, partly...

by Steven Perrin, Shafeeq Ladha, Nicholas Maragakis, Michael H. Rivner, Jonathan Katz, Angela Genge, Nicholas Olney, Dale Lange, Daragh Heitzman, Cynthia Bodkin, Omar Jawdat, Namita A. Goyal, Jeffrey D. Bornstein, Carmen Mak, Stanley H. Appel, Sabrina Paganoni

Background

The interaction of CD40L and its receptor CD40 on activated T cells and B cells respectively control pro-inflammatory activation in the pathophysiology of autoimmunity and transplant rejection. Previous studies have implicated signaling pathways involving CD40L (interchangeably referred to as CD154), as well as adaptive and innate immune cell activation, in the induction of neuroinflammation in neurodegenerative diseases. This study aimed to assess the safety, tolerability, and impact on pro-inflammatory biomarker profiles of an anti CD40L antibody, tegoprubart, in individuals with amyotrophic lateral sclerosis (ALS).

Methods and findings

In this multicenter dose-escalating open-label Phase 2A study, 54 participants with a diagnosis of ALS received 6 infusions of tegoprubart administered intravenously every 2 weeks. The study was comprised of 4 dose cohorts: 1 mg/kg, 2 mg/kg, 4 mg/kg, and 8 mg/kg. The primary endpoint of the study was safety and tolerability. Exploratory endpoints assessed the pharmacokinetics of tegoprubart as well as anti-drug antibody (ADA) responses, changes in disease progression utilizing the Revised ALS Functional Rating Scale (ALSFRS-R), CD154 target engagement, changes in pro-inflammatory biomarkers, and neurofilament light chain (NFL).Seventy subjects were screened, and 54 subjects were enrolled in the study. Forty-nine of 54 subjects completed the study (90.7%) receiving all 6 infusions of tegoprubart and completing their final follow-up visit. The most common treatment emergent adverse events (TEAEs) overall (>10%) were fatigue (25.9%), falls (22.2%), headaches (20.4%), and muscle spasms (11.1%). Mean tegoprubart plasma concentrations increased proportionally with increasing dose with a half-life of approximately 24 days. ADA titers were low and circulating levels of tegoprubart were as predicted for all cohorts. Tegoprubart demonstrated dose dependent target engagement associated and a reduction in 18 pro-inflammatory biomarkers in circulation.

Conclusions

Tegoprubart appeared to be safe and well tolerated in adults with ALS demonstrating dose-dependent reduction in pro-inflammatory chemokines and cytokines associated with ALS. These results warrant further clinical studies with sufficient power and duration to assess clinical outcomes as a potential treatment for adults with ALS.

Trial registration

Clintrials.gov ID:NCT04322149.

The Royal College of General Practitioners (RCGP) made reference to its members survey when changing its position on the role of physician associates (PAs) in general practice, 123 which is regrettable, as it represents poor evidence informed decision making. The response rate of the survey was approximately 10% of the college’s membership, and 40% of all respondents had never worked with PAs. A third of respondents were GP trainees, who would never have had the experience of taking clinical responsibility for another healthcare professional.My practice has been training PA students since 2017. In my 16 years as a full time GP partner (nine clinical sessions a week), I have seen major errors that affected patient health or wellbeing made by GP partners, salaried GPs, locum GPs, GP registrars, advanced nurse practitioners, practice nurses, healthcare assistants, clinical pharmacists, social prescribers, and PAs. We have never employed a paramedic, but it would...

McNally’s article provides examples of environments that can be used to promote or hinder healthy habits.1Many environmental factors—including physical, social, economic, and cultural—can influence health. Clean water and adequate sanitation, for example, are crucial for good health and can in some countries be considered public health intervention success stories, yet many people around the world still lack these basics.2Exposure to obesogenic environments is growing across the globe, and the obesity epidemic is likely to increase if effective actions are not implemented.34 Obesogenic environments have different facets including the foods that are available, the promotion of food, opportunities for physical activity, and social norms.As health and wellbeing are created and sustained in the settings where people live, study, and work, the Institute of Health Promotion and Education calls for the creation of health promoting settings.5 This includes schools, workplaces, and hospitals.567Throughout the country there are examples of hospitals that promote cycling...

The first case of clade Ib mpox in the UK has been confirmed in London in a person who had recently travelled to countries in Africa that are seeing cases in the community, health officials have said.The UK Health Security Agency said that the risk to the UK population remained low and that close contacts of the case were being followed up. The infected person is being treated at the high consequence infectious diseases unit at the Royal Free Hospital in north London. The UKHSA and NHS said that they would not be disclosing any further details about the individual.Clade Ib mpox differs from the clade II mpox that has been circulating at low levels in the UK since 2022, primarily among gay, bisexual, and other men who have sex with men.In August this year the World Health Organization declared mpox a public health emergency after the emergence of clade...

Several political and legal matters have been raised in undergraduate medical education recently—around the apprenticeship model and a four year medical degree. Physician associates (PAs) are another concern.1 Lacking so far in the conversation around PAs and medical training is a clear understanding of future needs that considers the whole multi-professional team and lessons from covid. What are the varied responsibilities, how will they change, and what are the implications for the education and training of all? There will be no progress until these are aligned.The concept of slow and fast thinking might help.2 Experts use fast thinking most of the time. It’s quick, effective, and only occasionally wrong: it’s “pattern recognition.” Slow thinking goes back to basics building up from first principles. It’s slow but more accurate.A phrase helps characterise slow thinking and to define the difference between medical practitioners and other roles: “doctors know what to do when...