Medical Journal News

by Rhys D. R. Evans, Sanjib K. Sharma, Rolando Claure-Del Granado, Brett Cullis, Emmanuel A. Burdmann, FOS Franca, Junio Aguiar, Martyn Fredlund, Kelly Hendricks, Maria F. Iturricha-Caceres, Mamit Rai, Bhupendra Shah, Shyam Kafle, David C. Harris, Mike V. Rocco

Background

The International Society of Nephrology proposes an acute kidney disease (AKD) management strategy that includes a risk score to aid AKD identification in low- and low-middle-income countries (LLMICs). We investigated the performance of the risk score and determined kidney and patient outcomes from AKD at multiple LLMIC sites.

Methods and findings

Adult patients presenting to healthcare facilities in Bolivia, Brazil, South Africa, and Nepal were screened using a symptom-based risk score and clinical judgment. Those at AKD risk underwent serum creatinine testing, predominantly with a point-of-care (POC) device. Clinical data were collected prospectively between September 2018 and November 2020. We analyzed risk score performance and determined AKD outcomes at discharge and over follow-up of 90 days. A total of 4,311 patients were at increased risk of AKD, and 2,922 (67.8%) had AKD confirmed. AKD prevalence was 80.2% in patients enrolled based on the risk score and 32.5% when enrolled on clinical judgment alone (p < 0.0001). The area under the receiver operating characteristic curve was 0.73 for the risk score to detect AKD. Death during admission occurred in 84 (2.9%) patients with AKD and 3 (0.2%) patients without kidney disease (p < 0.0001). Death after discharge occurred in 206 (9.7%) AKD patients, and 1865 AKD patients underwent reassessment of kidney function after discharge; 902 (48.4%) patients had persistent kidney disease including 740 (39.7%) patients reclassified with de novo or previously undiagnosed chronic kidney disease (CKD). The study was pragmatically designed to assess outcomes as part of routine healthcare, and there was heterogeneity in clinical practice and outcomes between sites, in addition to selection bias during cohort identification.

Conclusions

The use of a risk score can aid AKD identification in LLMICs. High rates of persistent kidney disease and mortality after discharge highlight the importance of AKD follow-up in low-resource settings.

A Canadian adolescent is in a critical condition in a British Columbia hospital after becoming infected with a new genotype of H5N1 highly pathogenic avian influenza (HPAI).The patient, who has not been publicly identified, developed conjunctivitis on 2 November, followed by fever and coughing. While these symptoms have been common in people infected with H5N1 bird flu in North America—until now, all US cases—the teenager in Canada then developed acute respiratory distress syndrome and was admitted to intensive care on 8 November. The diagnosis of avian flu was confirmed, and the genotype identified, on 13 November.“This was a healthy teenager prior to this, so no underlying conditions,” said British Columbia’s health officer, Bonnie Henry, at a news conference. “It just reminds us that in young people this is a virus that can progress and cause quite severe illness, and the deterioration was quite rapid.”The patient has been treated with “multiple...

The UK government is to press ahead with adding folic acid to flour to try to prevent hundreds of babies each year from being born with neural tube defects.Folic acid deficiency is a leading cause of neural tube defects, which can cause serious and debilitating brain and spine conditions, including spina bifida, to babies in the womb. Fortifying non-wholemeal wheat flour with folic acid as a public health measure would prevent around 200 cases of such defects each year, the government said.The UK wide changes were first proposed in 2021 under the previous Conservative government.12 The Labour government has now said that it will take the plans forward.New legislation for England introduced on 14 November will require millers and flour producers to fortify non-wholemeal wheat flour with 250 µg of folic acid per 100 g of flour from the end of 2026. Wales, Scotland, and Northern Ireland will introduce their...

As the 29th UNFCCC Conference of the Parties (COP29) unfolds, it highlights yet another year where action to tackle the intensifying climate crisis falls short. Some international steps have been undertaken to reduce carbon emissions,1 transition to renewable energy sources, and enhance adaptation measures,2 but structural drivers of climate change and related inequities remain largely unchallenged, with severe consequences for public health.We must look beyond climate mitigation and adaptation towards long term transformation of economic and health systems.3 It is critical to act beyond energy transitions by tackling the structural drivers of inequities—especially along intersecting axes of discrimination, including economic, sex, age, race, ethnicity, migratory status, disability, and geography. This transition requires focusing on the root causes of inequalities, such as patriarchy, neocolonial extractive industries, and neoliberal economic policies, while prioritising gender equality and women’s empowerment.Efforts to reshape social and economic systems while building resilience are gaining momentum under the...

On 6 November Donald Trump was re-elected president of the United States after an election campaign characterised by fear, lies, and disinformation. Trump’s campaign featured his insistence that he was cheated out of winning in 2020—a lie that has left many Americans distrustful of their voting system.Martin McKee and colleagues describe how the rapid spread of such disinformation, particularly on social media, poses a threat to societies and democracies everywhere (doi:10.1136/bmj.q2485). They argue that it can be countered only if social media platforms are adequately regulated and if we can effectively expose disinformation and not be afraid to speak out.1Trump’s pre-election threats that he would curb press freedoms and target journalists suggest that speaking out may become harder (www.theguardian.com/us-news/2024/nov/10/trump-journalist-media-press-freedom).2 In his victory speech he referred to the media as the “enemy camp” (www.theguardian.com/us-news/2024/nov/06/trump-media-enemy-camp-speech).3 Even before he won the election, the possibility of his victory had a silencing effect on some...

At the start of 2024, a GP practice in Northern Ireland began offering private appointments during the evening to people who weren’t on its NHS list. The decision was forced on the GP partners at Abbey Medical, in Derry (Londonderry), because the practice was in financial crisis.“We were knee deep in debt,” says Tom Black, one of the partners. “It was obvious that we were about six months from bankruptcy and that was because of underfunding.“Over the previous 12 months we’d tried to maximise our income by working harder, and we’d tried to minimise our costs by making cuts, but it wasn’t working, it was just getting worse and worse.”“Political incompetence was going to close down a practice which had been running for 100 years,” says Black who has been a GP for more than 35 years.“It made me angry and frustrated, and I decided to embarrass myself by contravening...

A previously well woman in her 60s presented with left hip pain, limited mobility, and unintentional weight loss of 5 kg. Her full blood count, C reactive protein, and alkaline phosphatase results were within normal limits, but erythrocyte sedimentation rate was raised, at 120 mm in the first hour (range 0-38 mm in the first hour). Results of tuberculosis antibody and T-SPOT tests were negative. Pelvic radiographs showed unilateral bony destruction characterised by a shallow left acetabulum with “moth-eaten” changes and disappearance of the left femoral head (fig 1, arrow).bmj;387/nov14_5/e080572/F1F1f1Fig 1The differential diagnosis for isolated femoral head destruction includes tuberculosis; Charcot arthropathy, which tends to be painless; Gorham-Stout disease, which is more common in those younger than 40 years; malignancy; and rapid destructive hip osteoarthritis, where radiographs show complete femoral head loss with hatchet deformity.1 Multidisciplinary consensus was a probable diagnosis of tuberculosis for this patient. She underwent hip joint...

A House of Lords committee has called on the government and NHS England to act to reduce preterm births and provide greater support for the parents of babies born before 37 weeks.The Preterm Birth Committee’s report, Preterm birth: reducing risks and improving lives,1 says the evidence is “unequivocal” that the national target to reduce the rate of preterm birth in England to 6% by 2025 will not be met. The target was introduced in 2017 when the rate was 8% but there has been little progress since then, with 7.9% of babies born preterm in 2022.The committee gathered evidence from parents, charities, academics, healthcare professionals, NHS England, and the Department of Health and Social Care. Many witnesses expressed concern about the disparities in preterm birth rates and outcomes that exist between different socioeconomic and ethnic groups. The report calls on the government to set out how it will revise the...

New England Journal of Medicine, Ahead of Print.

More than 800 million adults around the world now have type 1 or type 2 diabetes, a global analysis has estimated—more than four times the number in 1990.Almost six in 10 adults aged over 30 with diabetes, equal to around 445 million people, did not receive treatment in 2022, three and a half times as many as in 1990, research in the Lancet found.1 The study found that while treatment rates had improved in many high income and industrialised nations and some emerging economies, treatment had stagnated at low levels in many low income countries where diabetes has drastically increased.Majid Ezzati, senior author and a professor of global environmental health at Imperial College London, said that the results highlighted “widening global inequalities” in diabetes treatment. “This is especially concerning as people with diabetes tend to be younger in low income countries and, in the absence of effective treatment, are at...

In 2013, the WHO set global targets aimed at alleviating some of the of the burden of non-communicable diseases (NCDs), including one to halt the rise in diabetes prevalence by 2025.1 In The Lancet, the NCD Risk Factor Collaboration (NCD-RisC)2 show that the world is far from reaching that target, despite previous studies showing how action on shared risk factors could have been effective.3 This longitudinal modelling study presents a comprehensive account of the evolution of diabetes prevalence and treatment worldwide over the last three decades using the largest compilation of diabetes survey data to date.

In most countries, especially in low-income and middle-income countries, diabetes treatment has not increased at all or has not increased sufficiently in comparison with the rise in prevalence. The burden of diabetes and untreated diabetes is increasingly borne by low-income and middle-income countries. The expansion of health insurance and primary health care should be accompanied with diabetes programmes that realign and resource health services to enhance the early detection and effective treatment of diabetes.

The current system for delivering NHS cardiovascular disease (CVD) health checks is not working effectively and must be reviewed to ensure that it reaches people with the highest risk, the National Audit Office has said.1In a review of the commissioning, delivery, and performance of CVD health checks the watchdog found that just over one in 12 people (8.8%) who were eligible attended a health check in 2023-24—which, if maintained, would equate to a five year coverage of 44%.Health checks were first introduced in 2009, with the aim of reducing ill health from CVD by offering everyone aged 40-74 without a pre-existing heart condition a check-up every five years. However, problems have arisen since the responsibility for commissioning these checks was transferred to local authorities in 2013, said the National Audit Office.The move led to the Department of Health and Social Care (DHSC) losing its ability to influence local authority performance,...

bmj;387/nov13_11/q2490/FAF1faDavide Bonaldo/SOPA/Sipa/AlamyThe devastating power and impact of the flash floods that swept through eastern Spain from 29 October is captured in this image from the city of Valencia. More than 200 people are known to have been killed—and around 100 are still missing—in floods caused by rivers and normally dry canals bursting their banks after torrential rain across the region.Medical sites have been severely hit, with several towns setting up temporary clinics in sports centres for essential services. A local GP told Medscape Network that because many roads were closed it was difficult for people to reach these makeshift facilities.In an effort to combat this the Valencia region’s health ministry has established a register of volunteer health professionals available to help in affected areas. It has also launched a public health campaign warning of the spread of infectious diseases made possible by damage to the sanitation infrastructure, including leptospirosis, tetanus,...

At one of my first meetings as an elected council member of the Royal College of Surgeons of England, we approved a report called Access All Ages. It encouraged less ageist thinking and bias among healthcare staff that might lead to them denying older people surgery.1 But sometimes an operation isn’t the best option. Among patients who have surgery, 14% express regret and 15% experience complications, which are at least four times as likely if they’re frail or physically inactive.2 The Centre for Perioperative Care has published information on the importance of exercise before surgery,3 but that alone may not be enough.We need shared decision making,4 including asking patients what matters to them. The public should be primed to ask about BRAN—the benefits, risks, and alternatives to surgery and the likely result from doing nothing.4 A slew of data supports this approach, especially from the POPS initiative (Perioperative Care of...

New England Journal of Medicine, Volume 391, Issue 19, Page 1822-1836, November 14, 2024.

New England Journal of Medicine, Volume 391, Issue 19, Page 1860-1862, November 14, 2024.

New England Journal of Medicine, Volume 391, Issue 19, Page 1863-1864, November 14, 2024.

New England Journal of Medicine, Volume 391, Issue 19, Page 1850-1851, November 14, 2024.

New England Journal of Medicine, Volume 391, Issue 19, Page 1848-1849, November 14, 2024.