Medical Journal News

The secretary of state for health and social care, Wes Streeting, has announced NHS league tables to guarantee “no more rewards for failure” in UK healthcare.1 Under the plan, the worst performing hospitals would have turnaround teams installed and managers sacked, while the best would have more freedom to invest capital.2This package of measures mirrors the policy approach of the early 2000s. A wealth of evidence from that period suggests this is no easy fix.3 Designing a ranking that is fair and accurate for organisations as huge and complicated as NHS trusts is difficult. Star ratings in the 2000s saw repeated cycles of a crisis of confidence before major revisions and improvements were made.4Goodhart’s law states that once a measure becomes a target, it stops being a good measure, as managers find ways to hit the target without making anything better.5 Ambulance trusts under star ratings would delay starting the...

The life expectancy gap across different US population groups grew from 12.6 years in 2000 to 20.4 years in 2021, a study has found, showing an increase in racial and geographic health disparities over the past two decades.For the study, reported in the Lancet,1 researchers divided the US population into 10 mutually exclusive groups called “the ten Americas” based on several factors including race and ethnicity, geographic location, income, residential segregation, and metropolitan status. They analysed trends in life expectancy at birth from 2000 to 2021 for each of the 10 Americas by year, sex, and age group.The analysis showed a life expectancy gap of 12.6 years in 2000, growing to 13.9 years in 2010 and 15.6 years in 2019. The covid-19 pandemic increased the gap even further to 20.4 years in 2021.The research updates and expands the 2006 “eight Americas” study,2 adding two “new” Americas that encompass the Latino...

by Carey E. Gleason, N. Maritza Dowling, Firat Kara, Taryn T. James, Hector Salazar, Carola A. Ferrer Simo, Sherman M. Harman, JoAnn E. Manson, Dustin B. Hammers, Frederick N. Naftolin, Lubna Pal, Virginia M. Miller, Marcelle I. Cedars, Rogerio A. Lobo, Michael Malek-Ahmadi, Kejal Kantarci

Background

Findings from Kronos Early Estrogen Prevention Study (KEEPS)-Cog trial suggested no cognitive benefit or harm after 48 months of menopausal hormone therapy (mHT) initiated within 3 years of final menstrual period. To clarify the long-term effects of mHT initiated in early postmenopause, the observational KEEPS Continuation Study reevaluated cognition, mood, and neuroimaging effects in participants enrolled in the KEEPS-Cog and its parent study the KEEPS approximately 10 years after trial completion. We hypothesized that women randomized to transdermal estradiol (tE2) during early postmenopause would show cognitive benefits, while oral conjugated equine estrogens (oCEE) would show no effect, compared to placebo over the 10 years following randomization in the KEEPS trial.

Methods and findings

The KEEPS-Cog (2005–2008) was an ancillary study to the KEEPS (NCT00154180), in which participants were randomized into 3 groups: oCEE (Premarin, 0.45 mg/d), tE2 (Climara, 50 μg/d) both with micronized progesterone (Prometrium, 200 mg/d for 12 d/mo) or placebo pills and patch for 48 months. KEEPS Continuation (2017–2022), an observational, longitudinal cohort study of KEEPS clinical trial, involved recontacting KEEPS participants approximately 10 years after the completion of the 4-year clinical trial to attend in-person research visits. Seven of the original 9 sites participated in the KEEPS Continuation, resulting in 622 women of original 727 being invited to return for a visit, with 299 enrolling across the 7 sites. KEEPS Continuation participants repeated the original KEEPS-Cog test battery which was analyzed using 4 cognitive factor scores and a global cognitive score. Cognitive data from both KEEPS and KEEPS Continuation were available for 275 participants. Latent growth models (LGMs) assessed whether baseline cognition and cognitive changes during KEEPS predicted cognitive performance at follow-up, and whether mHT randomization modified these relationships, adjusting for covariates.Similar health characteristics were observed at KEEPS randomization for KEEPS Continuation participants and nonparticipants (i.e., women not returning for the KEEPS Continuation). The LGM revealed significant associations between intercepts and slopes for cognitive performance across almost all domains, indicating that cognitive factor scores changed over time. Tests assessing the effects of mHT allocation on cognitive slopes during the KEEPS and across all years of follow-up including the KEEPS Continuation visit were all statistically nonsignificant.The KEEPS Continuation study found no long-term cognitive effects of mHT, with baseline cognition and changes during KEEPS being the strongest predictors of later performance. Cross-sectional comparisons confirmed that participants assigned to mHT in KEEPS (oCEE and tE2 groups) performed similarly on cognitive measures to those randomized to placebo, approximately 10 years after completion of the randomized treatments. These findings suggest that mHT poses no long-term cognitive harm; conversely, it provides no cognitive benefit or protective effects against cognitive decline.

Conclusions

In these KEEPS Continuation analyses, there were no long-term cognitive effects of short-term exposure to mHT started in early menopause versus placebo. These data provide reassurance about the long-term neurocognitive safety of mHT for symptom management in healthy, recently postmenopausal women, while also suggesting that mHT does not improve or preserve cognitive function in this population.

While much of the world wrestles with regulations around vapes and their many flavours, Philip Morris International (PMI) and British American Tobacco (BAT) have been pumping flavours into conventional cigarettes and fighting efforts to ban the products throughout Latin America, shows a joint investigation by The Examination and the media outlets Salud Con Lupa (Peru), and LaBot (Chile).Featuring splashy packaging, breezy names, and flavours that taste like blueberry, apple, or menthol, new varieties of cigarettes—known as click, capsule, or crush ball cigarettes (a capsule is crushed to use them, making a clicking sound)—are soaring in popularity in Latin America (fig 1). Both PMI and BAT have released dozens of new flavour capsule brands in the region in recent years—despite promises to phase out cigarettes in favour of newer nicotine products and vows not to market tobacco in ways that appeal to children.bmj;387/nov21_7/q2553/F1F1f1Fig 1Flavour capsule cigarettes in Latin America: market share...

The UK had a shortage of around 176 000 doctors, nurses, and midwives in 2022 and has become over-reliant on international recruitment, warns a report by the Organisation for Economic Co-operation and Development (OECD).1The report, which looked at the state of health in the EU, found that in total EU countries had an estimated shortage of 1.2 million doctors, nurses, and midwives. It cited multiple factors, including ageing populations, difficult working conditions, staff burnout, and challenges presented by the covid pandemic.Significant inequalities also continue to exist between EU member states, with an eight year difference in life expectancy between 84 years (Spain and Italy) and 76 years (Latvia and Bulgaria).Focusing on the UK, the OECD said that the number of doctors was “well below the average across EU countries” at 3.2 per 1000 population in 2022, which compared with an EU average of 4.2. This was because the UK’s number...

AbstractPsoriatic arthritis is an inflammatory arthritis that affects around 30% of patients with psoriasis. The disease spectrum includes peripheral arthritis, enthesitis, tenosynovitis, dactylitis, axial involvement, and skin and nail psoriasis in most patients. In addition to the cutaneous and musculoskeletal manifestations, several comorbidities can complicate the disease course, including cardiovascular disease, diabetes mellitus, metabolic syndrome, gout, anxiety, and depression. The management of patients with psoriatic arthritis begins with a careful assessment of the skin and joints and screening for comorbidities. This review describes the assessment tools and outcome measures used in the evaluation of patients with psoriatic arthritis. It summarizes the approach to therapy, including non-medicinal interventions such as education, lifestyle changes, physiotherapy, and occupational therapy. It discusses the evidence on pharmacologic treatments, including drugs used for symptomatic relief such as non-steroidal anti-inflammatory drugs, and those used to control the disease process; this last group comprises conventional synthetic disease modifying anti-rheumatic drugs (DMARDs), including methotrexate, leflunomide, and sulfasalazine, and biologic and targeted DMARDs, including anti-tumor necrosis factor (TNFα), anti-interleukin-17 (IL-17), anti-IL-12/23, and anti-IL-23 agents, as well as Janus kinase (JAK) inhibitors and phosphodiesterase 4 (PDE4) antagonists. Although these drugs are usually tailored to the clinical profile of the patient, biomarkers predictive of response to therapy are needed so that a more personalized approach can be followed.

bmj;387/nov21_10/q2569/FAF1faChris and Elaine Brooks in a 1904 Quadrant motorbikeChris Brooks was dangling from the hoist of a Sea King helicopter over a fishing trawler 60 miles off the coast of Louisbourg, Nova Scotia. As a flight surgeon with the Royal Canadian Navy he was preparing to rescue a fisherman with a knife wound whose guts were being held in by a sanitary towel. It occurred to him that, should the Sea King ditch, he would be the first to drown.This episode sparked an interest in marine survival. He undertook research into surviving helicopter ditchings, introduced new lifejackets and immersion suits for the Royal Canadian Air Force and Navy, and created emergency breathing apparatus for helicopter crew and passengers.As part of a team at Canada’s Defence and Civil Institute of Environmental Medicine (DCIEM) he helped devise a survival pack for helicopter pilots’ ejection seats. It contained a whistle, knife, chocolate, and...

This previously well teenager presented with a three week history of fever, headache, and a single episode of tonic-clonic seizure. On examination, he responded slowly to verbal commands and motor stimuli, and muscle strength in all four limbs was decreased (graded 4/5 on the Medical Research Council scale). Brain magnetic resonance imaging (MRI) showed multiple contrast enhancing subdural lesions (fig 1). Based on the MRI finding, differential diagnoses included empyema, tuberculosis, neurocysticercosis, and neoplasm.bmj;387/nov21_6/e079362/F1F1f1Fig 1Brain biopsy, metagenomic next generation sequencing, and polymerase chain reaction assay identified empyema caused by Porphyromonas endodontalis. This Gram negative anaerobic bacterium is typically found in infected dental root canals and submucosal dental abscesses, and is not often detected beyond the oral cavity.12 Notably, the patient did not report any signs or symptoms of oral disease. Symptoms resolved completely after surgical drainage and intravenous antibiotics for eight weeks. Owing to the severity of the presentation, the...

Adverse pregnancy outcomes in women with epilepsyA large multinational study in the Nordic countries which compared pregnancy outcomes of women with epilepsy with those of women without epilepsy finds that the risk of a range of serious complications including pre-eclampsia, embolism, disseminated intravascular coagulation, cerebrovascular events, and mental health conditions is substantially raised (JAMA Neurol doi:10.1001/jamaneurol.2024.2375). Women with epilepsy also had a higher risk of death in childbirth than women without epilepsy.Hearing loss and incident Parkinson’s diseaseEarlier this year, Minerva noted a study from the US showing that mortality in people with hearing loss was raised but mitigated by wearing hearing aids (Lancet Healthy Longev doi:10.1016/S2666-7568(23)00232-5). Electronic health records of more than three million US veterans suggest that something similar is true for Parkinson’s disease (JAMA Neurol doi:10.1001/jamaneurol.2024.3568). In the 10 years after a baseline audiogram, cases of Parkinson’s disease were commoner in those with hearing loss than in those...

The year before I started my medical degree, I began wearing hearing aids. I’d never wanted to wear hearing aids, but was having continual communication challenges. Feeling excited to embark on my medical training, I wanted to make the most of all of the learning opportunities without barriers. I believed that wearing hearing aids would enable me to do this, while also acting as a visual cue to others that I am hard of hearing.Despite my initial reluctance, I found that hearing aids had a marked positive impact on my social and personal life. I gained confidence and felt like I was finally enjoying the things I had been excluded from in the past.Once I started medical school, however, I encountered some unexpected challenges, especially when I began my clinical placements. Hearing what doctors are saying when they’re delivering teaching on busy ward rounds can be impossible; lecturers rarely provide...

PICCing the right lineWhen it comes to peripherally inserted lines for outpatient parenteral antimicrobial therapy (OPAT), where should one draw the line? Midline catheters, which end in peripheral veins, are thought to offer lower risks of infection and thromboembolism than peripherally inserted central catheters (PICCs). A new cohort study supports this, finding that, for a device dwell of 14 days or less, midline catheters were associated with a lower risk of major complications (0.9% v 5.3%, adjusted hazard ratio 0.29 (95% CI 0.12 to 0.68)). However, the study design means that confounding by indication—whereby lower risk patients received a midline catheter—is hard to measure and exclude.JAMA Intern Med doi:10.1001/jamainternmed.2024.5984Prostate cancer in men with limited life expectancyDon’t wait until after prostate cancer diagnosis to consider life expectancy, advises an editorial in JAMA. This follows an observational study of veterans in the US that examined over-treatment of men with localised prostate cancer...

Previous research suggests that survival of patients may be associated with hospital organisational culture.1 Organisational factors such as culture, staffing, and retention of staff are crucial to patient safety. In a linked study covering nine years of monthly data from all NHS acute trusts in England, Moscelli and colleagues showed that a high turnover of senior doctors (hospital consultants and specialty associated doctors) and nurses in hospitals is associated with increased mortality for patients admitted for emergencies.2 For the 30 day mortality risk, a 1 standard deviation increase in the monthly turnover rate of nurses was associated with a 0.052 (0.037 to 0.067) percentage point increase and of senior doctors was a 0.019 (0.006 to 0.033) percentage point increase. Extensive robustness checks give credibility to the findings , although such associations cannot be taken as proof of causality.Turnover rates among nurses showed a stronger association with mortality than turnover rates...

AbstractObjectiveTo prospectively assess the effect of endometriosis and uterine fibroids on the long term risk of premature mortality (younger than 70 years).DesignProspective cohort studySettingThe Nurses’ Health Study II, United States (1989-2019).Participants110 091 women aged 25-42 years in 1989 without a history of hysterectomy before endometriosis or fibroids diagnosis, cardiovascular diseases, or cancer.Main outcome measuresHazard ratios (estimated by Cox proportional hazards models) for total and cause specific premature mortality according to laparoscopically confirmed endometriosis or ultrasound or hysterectomy confirmed uterine fibroids reported in biennial questionnaires.Results4356 premature deaths were recorded during 2 994 354 person years of follow-up (27.2 years per person), including 1459 from cancer, 304 from cardiovascular diseases, and 90 from respiratory diseases. The crude incidence of all cause premature mortality for women with and without laparoscopically confirmed endometriosis was 2.01 and 1.40 per 1000 person years, respectively. In age adjusted models, laparoscopically confirmed endometriosis was associated with a hazard ratio of 1.19 (95% confidence interval 1.09 to 1.30) for premature death; these models were strengthened after also adjusting for potential confounders including behavioral factors (1.31, 1.20 to 1.44). Cause specific mortality analyses showed that the association was largely driven by mortality from senility and ill-defined diseases (1.80, 1.19 to 2.73), non-malignant respiratory diseases (1.95, 1.11 to 3.41), diseases of the nervous system and sense organs (2.50, 1.40 to 4.44), and malignant neoplasm of gynecological organs (2.76, 1.79 to 4.26). Ultrasound or hysterectomy confirmed uterine fibroids were not associated with all cause premature mortality (1.03, 0.95 to 1.11), but were associated with a greater risk of mortality from malignant neoplasm of gynecological organs (2.32, 1.59 to 3.40) in cause specific mortality analyses. The risk of mortality caused by cardiovascular and respiratory diseases varied according to joint categories of endometriosis and uterine fibroids, with an increased risk of all cause premature mortality among women reporting both endometriosis and uterine fibroids.ConclusionWomen with a history of endometriosis and uterine fibroids might have an increased long term risk of premature mortality extending beyond their reproductive lifespan. These conditions were also associated with an increased risk of death due to gynecological cancers. Endometriosis was associated with a greater risk of non-cancer mortality. These findings highlight the importance for primary care providers to consider these gynecological disorders in their assessment of women's health.

High monthly turnover rates of nurses and senior doctors are associated with more deaths among patients admitted as emergencies to NHS hospitals in England, an observational study published in The BMJ has found.1Researchers from Cambridge University Hospitals Foundation Trust and the universities of Surrey and Aberdeen looked at the yearly records of 236 000 nurses, 41 800 senior doctors, and 8.1 million patients admitted to hospital in England from April 2010 to March 2019.After adjusting for patient age, sex, and pre-existing conditions, they found that a one standard deviation increase in monthly turnover of nurses at a single trust (equivalent to around 20 nurses quitting) was associated with 35 additional deaths per 100 000 admissions in any given month (0.035 (95% confidence interval 0.024 to 0.045)).Among senior doctors—defined as consultants and specialist, associate specialist, and specialty doctors—a one standard deviation increase was equivalent to about seven doctors quitting and was...

AbstractObjectiveTo investigate the association between monthly turnover rates of hospital nurses and senior doctors and patient health outcomes (mortality and unplanned hospital readmissions).DesignRetrospective longitudinal study.SettingAll 148 NHS acute trusts in England (1 April 2010 to 30 March 2019), excluding specialist and community NHS hospital trusts.ParticipantsYearly records on 236 000 nurses, 41 800 senior doctors (specialist, associate specialist and specialty doctors, and consultants), and 8.1 million patients admitted to hospital.Main outcome measuresThe panel data regression analysis used nine years of monthly observations from administrative datasets at healthcare worker and patient levels. Associations using linear and unconditional quantile regressions were estimated, including controls for seasonality and NHS hospital trust. Four hospital quality indicators (risk adjusted by patient age, sex, and Charlson index comorbidities) were used and measured at a monthly frequency on a percentage scale: mortality risk within 30 days from all cause, emergency, or elective admission to hospital, and risk of unplanned emergency readmission within 30 days from discharge after elective hospital treatment.ResultsA 1 standard deviation (SD) increase in turnover rate for nurses was associated with 0.035 (95% confidence interval 0.024 to 0.045) and 0.052 (0.037 to 0.067) percentage point increases in risks of all cause and emergency admission mortality, respectively, at 30 days. The corresponding values for senior doctors were 0.014 (0.005 to 0.024) and 0.019 (0.006 to 0.033) percentage point increases. Higher nurse turnover rate was associated with higher mortality risk at 30 days in surgical (P<0.01) and general medicine (P<0.01) specialties, as well as mortality for patients admitted to hospital with infectious and parasitic diseases (international classification of diseases, 10th revision; P<0.05) and injury, poisoning, and consequences of external causes (P<0.01). Higher turnover rates for senior doctors were associated with higher mortality risk at 30 days for patients admitted to hospital with infectious and parasitic diseases (P<0.05), mental and behavioural disorders (P<0.05), and diseases of the respiratory system (P<0.05). Turnover rates for hospital nurses and senior doctors were not statistically significantly associated with risk adjusted hospital mortality and unplanned emergency readmissions for elective patients.ConclusionsLower turnover rates for nurses and senior doctors at hospital level were associated with better health outcomes for patients with emergency hospital admissions.Study registrationIntegrated Research Application System project ID 271302.

by Amanda Paust, Claus Vestergaard, Susan M. Smith, Karina Friis, Stine Schramm, Flemming Bro, Anna Mygind, Nynne Bech Utoft, James Larkin, Anders Prior

Background

Potentially inappropriate medication (PIM) is associated with negative health outcomes and can serve as an indicator of treatment quality. Previous studies have identified social inequality in treatment but often relied on narrow understandings of social position or failed to account for mediation by differential disease risk among social groups. Understanding how social position influences PIM exposure is crucial for improving the targeting of treatment quality and addressing health disparities. This study investigates the association between social position and PIM, considering the mediation effect of long-term conditions.

Methods and findings

This cross-sectional study utilized data from the 2017 Danish National Health Survey, including 177,495 individuals aged 18 or older. Data were linked to national registers on individual-level.PIM was defined from the STOPP/START criteria and social position was assessed through indicators of economic, cultural, and social capital (from Bourdieu’s Capital Theory). We analyzed odds ratios (ORs) and prevalence proportion differences (PPDs) for PIM using logistic regression, negative binomial regression, and generalized structural equation modeling. The models were adjusted for age and sex and analyzed separately for indicators of under- (START) and overtreatment (STOPP). The mediation analysis was conducted to separate direct and indirect effects via long-term conditions. Overall, 14.7% of participants were exposed to one or more PIMs, with START PIMs being more prevalent (12.5%) than STOPP PIMs (3.1%). All variables for social position except health education were associated with PIM in a dose-response pattern. Individuals with lower wealth (OR: 1.85 [95% CI 1.77, 1.94]), lower income (OR: 1.78 [95% CI 1.69, 1.87]), and lower education level (OR: 1.66 [95% CI 1.56, 1.76]) exhibited the strongest associations with PIM. Similar associations were observed for immigrants, people with low social support, and people with limited social networks. The association with PIM remained significant for most variables after accounting for mediation by long-term conditions. The disparities were predominantly related to overtreatment and did not relate to the number of PIMs. The study’s main limitation is the risk of reverse causation due to the complex nature of social position and medical treatment.

Conclusions

The findings highlight significant social inequalities in PIM exposure, driven by both economic, cultural, and social capital despite a universal healthcare system. Understanding the social determinants of PIM can inform policies to reduce inappropriate medication use and improve healthcare quality and equity.

In India and Pakistan, schools and many businesses in Delhi and Lahore were closed by official order this week as levels of pollutants on some days rose far beyond the most severe category of the US Air Quality Index (AQI), the most commonly used international scale.The US AQI has six categories, ranging from a “good” score of 0-50 to a “hazardous” score of 301-500. On 19 November the AQI was 22 in Paris, 28 in London, and 38 in New York. On that scale, Delhi reached 1758 at noon on 18 November, its worst day this year. Some monitoring stations in Lahore on 7 November recorded AQI scores above 1900.Countless smaller cities in the region are also under a vast smog cloud, visible both from the ground and from space, that stretches across northern India and southeast Pakistan. The Pakistani city of Multan, which is similarly locked down, reached an...

bmj;387/nov20_8/q2565/FAF1faReutersPolice officers examine the damaged neonatal intensive care unit after 10 newborn babies were killed in a blaze in a hospital in northern India. The fire broke out late last Friday night at the Maharani Laxmi Bai Medical College in Jhansi, in the state of Uttar Pradesh, 450 km south of Delhi. Parents of the 55 babies being treated in the unit had to wait for authorities to carry out DNA testing before discovering whether their children were among the fatalities.Officials told local media that the blaze—believed to have started in a piece of machinery used to enrich the level of oxygen in the atmosphere—spread quickly and suddenly through the ward. An initial inquiry also pointed to lapses in safety protocols, including expired fire extinguishers and non-functioning fire alarms.

A UK coroner has warned of possible future deaths unless providers of unlicensed medicines face stricter requirements to report problems.1Julian Morris, senior coroner for London inner south, delivered the warning after an inquest into the deaths of three babies who died in hospital after consuming contaminated feed. Each baby was one of a set of twins. In each case the babies were receiving total parenteral nutrition (TPN), and Bacillus cereus was recorded as one of the causes of death.Aviva Otte died aged 2 months in January 2014. She had received TPN compounded by the St Thomas’ Hospital pharmacy under an exemption from licensing requirements in section 10 of the Medicines Act 1968. Under the exemption a pharmacist may prepare a limited quantity of a custom made medicine for a specific patient.“There is no requirement for a section 10 exempt entity to report any of its findings to the MHRA [Medicines...

When Labour came to power in July the new health and social care secretary, Wes Streeting, promised a frank report on the current NHS. The report, led by Ara Darzi, pulled no punches about the state of the service and its challenges,12 which led Streeting to say that the NHS was “broken.”3 He also promised a working group to report back next spring on a 10 year plan.4I want the Labour government to succeed in stabilising and improving England’s NHS, and I was glad to see an extra £22.6bn for the NHS promised in the autumn budget.5 However, any welcome for this “plan to have a plan” must be tempered with a healthy “wait and see” scepticism, for several reasons.First, we’ve had NHS long term plans before. Some were transformative—notably, the radical improvement in resource and performance from 2001 to 2010.67 More recent plans didn’t accomplish much of the transformation...