BMJ - British Medical Journal

bmj;389/apr17_21/r745/FAF1faVicky Evans played a leading role in developing the discipline of forensic medicine as an academic specialty, establishing a training programme as well as professional standards and competencies: elements that were missing when she began working as a police surgeon, as forensic physicians were known when her career began in the 1980s.She was also instrumental in establishing standards of care for those who had been sexually assaulted, as one of the first four female physicians to be recruited to St Mary’s Sexual Assault Referral Centre (SARC) in Manchester in 1986. The centre—the first in the UK and only the second in the world after Perth, Western Australia—was founded by GP Raine Roberts and heralded a revolution in the treatment of those making allegations of rape or sexual assault.Before this, treatment was patchy. Victims would be seen in police stations, sometimes with the perpetrator of the assault in the next room....

The UK Supreme Court has ruled that doctors in two children’s end-of-life cases may be named, to allow the parents to tell their story about what happened to them and their child in hospital and in court.1The court lifted High Court injunctions barring anyone for an indefinite period from naming the doctors involved in the cases of Zainab Abbasi and Isaiah Haastrup. The children were at the centre of High Court disputes between their parents and NHS trusts over whether it would be in their best interests to receive life sustaining treatment. Isaiah died aged 12 months in 2018 and Zeinab at the age of 6 in 2019.Robert Reed and Michael Briggs, delivering judgment in the Supreme Court, said that injunctions should be for a limited period only. They said, “A reasonable duration would be until the end of the proceedings and, in the event that they terminate with the...

Doctor or physician?I was surprised when I first learnt, some time ago, that in the summaries of product characteristics (SmPCs; previously called data sheets) of certain drugs it is specified that they should be used “at the discretion of the physician,” often when advising about use in special groups, such as pregnant women or children. Surprised, not because advice was required, but because a physician was specifically required, not just any doctor. Indeed, I estimate that the term “physician” occurs 3–4 times more often in such sources than the word “doctor.” Furthermore, the two terms often seem to be being used interchangeably. In at least one case, for example, they were used as if they were synonymous, with advice that the product was to be used “under the direction of a physician” followed almost immediately by the instruction that “if the usual dose [was] less effective or its duration of...

The UK population’s health is getting worse. Health inequalities are widening and obesity rates rising, particularly among children in deprived areas (doi:10.1136/bmj.q2819 doi:10.1136/bmj.r525 doi:10.1136/bmj.q2457 doi:10.1136/bmj.r593).1234 A new investigation by The BMJ explores the influence of industry on some of these trends (doi:10.1136/bmj.r667).5The investigation finds that the advertising industry is lobbying local authorities to delay or scrap plans to ban junk food advertising on bus stops and billboards, using well rehearsed industry tactics of “deny, delay, and dilute.” With many local authorities facing significant debts, advertising companies are warning councils of the financial impact of restricting junk food advertising, telling them that they risk a substantial drop in advertising revenues. The areas targeted have some of the highest rates of childhood obesity in England. As a result, some councils have already paused or restricted plans to ban advertising of foods high in fat, salt, or sugar.The government is leaving local authorities...

On 16 September 2024 Jimi Olaghere became the first person with sickle cell disease to reach the summit of Mount Kilimanjaro. The 39 year old could hardly believe it as he contemplated his achievement from nearly 6000 m above sea level.“I was in shock. Five years ago, I couldn’t get out of bed,” Olaghere tells The BMJ. People with sickle cell disease are discouraged from venturing to areas above 3000 m, let alone to the top of Africa’s highest peak.Olaghere was one of the participants in Vertex Pharmaceuticals’ trial of exagamglogene autotemcel (exa-cel, brand name Casgevy), which works by editing a patient’s blood stem cells before they’re re-injected. In the phase 3 trial 29 of 30 (97%) participants with repeated vaso-occlusive crises—episodes when “sickled” red blood cells get stuck in blood vessels and cause pain—reported no crises and no related hospital admissions for at least a year.1Exa-cel isn’t the only...

WorkforceExtra 1500 GPs appointed in past six monthsMore than 1500 additional GPs, equating to 851 full time doctors, have been recruited to England’s workforce in the past six months under the Additional Roles Reimbursement Scheme, the government announced. The scheme was opened to doctors last year with an £82m funding allocation to allow primary care networks to hire GPs in 2024-25. Katie Bramall-Stainer, chair of the BMA’s General Practitioners Committee, said, “We are making steps in the right direction, but we are a long way from a destination as we are still painfully aware of far too many GPs facing unemployment across England.” (Full story doi:10.1136/bmj.r715)Resident doctors re-enter pay disputeThe BMA’s UK Resident Doctors Committee has re-entered a pay dispute with the government because the Review Body on Doctors’ and Dentists’ Remuneration (DDRB), which advises the government on doctors’ pay, has been late in publishing this year’s recommendation.1 The BMA...

AbstractObjectiveTo take advantage of the arbitrarily timed increase in firearm and ammunition availability brought on by the start of deer hunting seasons to study its impact on hunting, and importantly, non-hunting related firearm incidents.DesignQuasi-experimental analysis using start of hunting season in United States.SettingPopulations of US states with highest number of hunting accidents reported in the Gun Violence Archive for deer hunting seasons between 2016 and 2019.Participants10 US states (Alabama, Indiana, Michigan, Minnesota, Missouri, New York, Ohio, Pennsylvania, Texas, and Wisconsin).Main outcomes and measuresAverage per capita weekly rates of firearm incidents overall and among specified categories of firearm incidents in the periods before, during, and after the opening of deer hunting seasons combined into a single analysis across four years and 10 states, adjusting for state fixed effects.ResultsCompared with control periods before and after the opening period, the start of the hunting season was associated with a 12.3% relative increase in the rate of firearm incidents overall (absolute change 1.34-1.50 incidents per 10 million population; 95% confidence interval for relative change 3.0% to 21.6%, P<0.01). Relative increases were observed for incidents categorized as hunting incidents (absolute change <0.01-0.05 per 10 million; relative change 566%), suicide (0.70-0.77; 11.1%), incidents involving alcohol or other substances (0.07-0.13; 87.5%), domestic violence (0.13-0.16; 27.4%), defensive use (0.08-0.10; 27.8%), home invasion or robbery (0.13-0.17; 30.4%), and incidents related to firearm carry licenses (0.40-0.48; 19.4%). No differences were observed for incidents involving children or police officers.ConclusionsThe start of hunting season was associated with increased rates of hunting and non-hunting related firearm incidents, most plausibly because of the increased availability of firearms and ammunition. The results suggest that efforts to promote firearm safety at the beginning of hunting season could help reduce hunting and non-hunting related firearm incidents.

The UK government has launched an independent review to examine how hundreds of children in England were given a misdiagnosis by NHS hearing services.1Camilla Kingdon, a consultant neonatologist at the Evelina London Children’s Hospital and former president of the Royal College of Paediatrics and Child Health, will lead the review of how service failures in paediatric audiology led to many children’s hearing tests not being conducted properly or followed up effectively.So far, 107 children have been found to have been given a misdiagnosis from 2018 to 2023, and a further 2000 children are being re-examined.2Commenting on the launch of the review, a spokesperson for the Department of Health and Social Care said, “Families across the country have been let down by unacceptable failings in paediatric audiology, exacerbated by a culture that has buried problems instead of tackling them.“NHS England has been recalling children for testing as quickly as possible, and...

Darcie is a woman in her early 20s with migraine, hypermobile Ehlers-Danlos syndrome, anorexia, irritable bowel syndrome, postural orthostatic tachycardia syndrome, autism, attention deficit/hyperactivity disorder (ADHD), depression, and anxiety. She was referred to the neurologist Suzanne O’Sullivan because she developed seizures. O’Sullivan, who specialises in psychosomatic conditions, ran elaborate tests, and, as she expected, found no brain disease in Darcie. She emphasises, however, that Darcie is not faking her seizures and that they are “as disruptive to life as a brain disease like epilepsy.”Seeing many patients like Darcie disabled by multiple diagnoses has been one stimulus that has led O’Sullivan to write her new and important book, The Age of Diagnosis: Sickness, Health and Why Medicine Has Gone Too Far.1 Why are people, particularly young people, accumulating so many diagnoses? Another stimulus has been the huge increases in numbers of people having a disability, receiving a widening range of diagnoses,...

NHS outpatient care is “archaic, disjointed, and inefficient” and needs radical reform to bring down waiting lists, the Royal College of Physicians and the Patients Association have said.1The two organisations said in a joint report that the current approach to providing planned clinical investigations, tests, treatments, and diagnoses confuses patients trying to navigate services and is riven by delays, poor communication, missed appointments, and poorly targeted follow-up care. They said that outpatient care should be more personalised and innovative, geared to prevention and early intervention, and use data and technology more effectively to prioritise patients’ needs.The report said, “A significant cultural shift will be needed to move outpatient care away from appointments as the single way to deliver care, towards an approach that enhances cross-system and multidisciplinary working and reconsiders the optimal ways to manage risks.”The plan needs to be properly staffed and resourced across outpatient care services, including primary,...

An Israeli attack on Al-Ahli Hospital in northern Gaza forced critically ill patients out onto the street, killing at least one patient who relied on oxygen, and destroyed vital equipment, including the hospital’s only x ray machine, Medical Aid for Palestinians (MAP) has said.1The attack took place at dawn on 13 April, when some patients received calls from the Israeli military telling them to leave immediately. This forced staff and patients, some critically ill, outside. This was the fifth attack on Al-Ahli Hospital since October 2023.MAP said, “They were left lying on the streets near the hospital. Israeli forces then targeted the hospital’s emergency department, almost destroying it and causing significant damage to the reception area, laboratory, pharmacy, and physiotherapy unit.”Ismail Al-Qudra, a healthcare worker present at the hospital during the attack, said, “I was startled by the sound of two loud missiles striking the hospital. We rushed out and...

I’ve been sitting on my hands over the topic of assisted dying. Not because I’m scared, or irritated, or confused. I’ve purposely not spoken out owing to something much more serious.Because of my writing, I’m often expected to have opinions on everything that touches medicine. Talks that I give often end with a tough question, such as, “Should we experiment on animals?” or “Is the NHS broken?” And I love these tough questions—although I still prefer tough answers, “No” or “Yes.”But it’s also OK not to have an opinion on some, or even many, issues involving medicine. In today’s fractured world, where small streams of difference swell to gulfs of conflict, I’d argue that it’s essential not to have an opinion on things that are “not for you.” And to say so. Or to say nothing. Hubris can be deadly.On assisted dying, it’s not even that I don’t have opinions....

Afghanistan’s health system is on the brink of disaster. The system heavily depends on external funding, and 80% of its health facilities face closure owing to a severe funding shortfall.12 Afghanistan remains one of the most protracted humanitarian emergencies in the world. The population is grappling with entrenched poverty, climate induced crises, and barriers to women’s equality and participation in public life following the political transition in August 2021 when the Taliban regained control of the country.3 If international donors do not intervene to fill funding gaps, Afghanistan’s fragile health system will crumble, with deadly consequences.The collapse of the previous government resulted in the suspension of international development assistance, which previously accounted for 75% of public expenditure, including maintenance of the public health system.3 The Basic Package of Health Services was developed in 2003 with support of multilateral agencies to improve access and deliver effective, equitable, and sustainable primary care...

Donald Trump’s US government has turned its attention to HIV prevention, eliminating almost all departments and offices that focus on reducing transmission of the virus both abroad and in the United States.The Trump administration is also dismissing all members of the Presidential Advisory Council on HIV and AIDS (PACHA), a group of outside experts that has helped to guide federal AIDS policy for 30 years.At least 145 HIV studies have lost their funding in the past month, either because they investigate issues of care affecting ethnic minorities—thus falling foul of the administration’s ban on “DEI” (diversity, equity, inclusion) initiatives—or because they involve LGBTQ+ populations.Reports emerged last month that the administration planned to shut down the HIV prevention division of the Centers for Disease Control and Prevention, possibly relocating it elsewhere in the Department of Health and Human Services. The division still exists in name but has since been hollowed out,...

Shanghai’s municipal health authorities have issued a “negative list” of nine types of online behaviour that doctors should avoid, from unlawful advertising to criticising government policy, in what they say is part of a push to promote public health literacy.It came as doctors in the city face political censure for raising quality and transparency concerns about low cost generic drugs supplied under centralised drug procurement, in a central government initiative intended to ease pressure on China’s overburdened medical insurance system.1The list singles out unlawful livestream selling of health products, spreading health misinformation, exaggerating the efficacy of treatments, fraud, plagiarism, and privacy infringement. It also proscribes more vaguely defined behaviour, such as posting content that “violates national laws, regulations, and policies,” threatens “public order and morality,” or is “detrimental to the development of healthcare.”The list applies to “Shanghai medical and health institutions at all levels, and their staff,” though the announcement...

Mumtaz Patel has been elected president of the Royal College of Physicians for the next four years with a promise to “modernise the college and re-establish the RCP as the voice of our membership and of medicine.”Patel received 43% of the votes cast in the election (2239 of 5151), winning by a margin of 682 votes. The 36.3% turnout was the highest since 2002. Eight candidates ran for election.1“As president, I will lead the RCP to be the best organisation it can be, supporting our members throughout every career stage to deliver the best possible healthcare for our patients. I will bring passion, commitment, vision, a values driven approach, and more than 20 years of RCP experience to the role,” said Patel, whose start date as president will be announced shortly.Patel is a consultant nephrologist who is based in Manchester. She has been acting president since June 2024 and holds...

Nasopharyngeal carcinoma (NPC) is an epithelial malignancy that is associated with the Epstein-Barr virus and is characterised by distinct epidemiological patterns that are prevalent in China, Southeast Asia, and north Africa.1 In early stage NPC, excellent outcomes have been achieved with radiotherapy alone. The application of intensity modulated radiotherapy has increased locoregional control and overall survival rates at five years to over 90% in these patients.23 However, more than 70% of patients receive NPC diagnoses at a locally advanced stage.4 Despite the technological advances in intensity modulated radiotherapy, the treatment of locally advanced NPC still relies on the combination of chemotherapy and radical radiotherapy.Neoadjuvant chemotherapy, alternatively termed induction chemotherapy, involves the administration of chemotherapy for NPC before the initiation of radiotherapy. Concurrent chemoradiotherapy for NPC is a therapeutic approach that entails the simultaneous application of chemotherapy agents and radiotherapy.5 In the era of intensity modulated radiotherapy, neoadjuvant chemotherapy combined with...

“Readers should not have to infer what was probably done; they should be told explicitly.” Douglas G Altman1Well designed and properly executed randomised trials provide the most reliable evidence on the benefits of healthcare interventions. Biased results from poorly designed and poorly reported trials are wasteful2 and can mislead decision making in healthcare at all levels, from treatment decisions for the individual patient to formulation of national public health policies.Critical appraisal of the quality of randomised trials is possible only if their design, conduct, analysis, and results are completely and accurately reported. However, there is overwhelming evidence that the quality of reporting of randomised trials is not optimal.3 Without transparent reporting of methods and results, readers cannot evaluate the reliability and validity of trial findings or extract information for systematic reviews. Trials with inadequate methods are also associated with bias, especially exaggerated treatment effects.4 Having a transparent trial protocol is...

AbstractBackgroundWell designed and properly executed randomised trials are considered the most reliable evidence on the benefits of healthcare interventions. However, there is overwhelming evidence that the quality of reporting is not optimal. The CONSORT (Consolidated Standards of Reporting Trials) statement was designed to improve the quality of reporting and provides a minimum set of items to be included in a report of a randomised trial. CONSORT was first published in 1996, then updated in 2001 and 2010. Here, we present the updated CONSORT 2025 statement, which aims to account for recent methodological advancements and feedback from end users.MethodsWe conducted a scoping review of the literature and developed a project-specific database of empirical and theoretical evidence related to CONSORT, to generate a list of potential changes to the checklist. The list was enriched with recommendations provided by the lead authors of existing CONSORT extensions (Harms, Outcomes, Non-pharmacological Treatment), other related reporting guidelines (TIDieR) and recommendations from other sources (eg, personal communications). The list of potential changes to the checklist was assessed in a large, international, online, three-round Delphi survey involving 317 participants and discussed at a two-day online expert consensus meeting of 30 invited international experts.ResultsWe have made substantive changes to the CONSORT checklist. We added seven new checklist items, revised three items, deleted one item, and integrated several items from key CONSORT extensions. We also restructured the CONSORT checklist, with a new section on open science. The CONSORT 2025 statement consists of a 30-item checklist of essential items that should be included when reporting the results of a randomised trial and a diagram for documenting the flow of participants through the trial. To facilitate implementation of CONSORT 2025, we have also developed an expanded version of the CONSORT 2025 checklist, with bullet points eliciting critical elements of each item.ConclusionAuthors, editors, reviewers, and other potential users should use CONSORT 2025 when writing and evaluating manuscripts of randomised trials to ensure that trial reports are clear and transparent.

The update of the Consolidated Standards of Reporting Trials (CONSORT) statement has now been published.12 It reflects a systematic examination of new evidence about the reporting of randomised controlled trials, methodological advancements in the conduct of randomised controlled trials and statistical approaches, and feedback from a broad spectrum of users since the last update in 2010. Douglas Altman was a massive contributor to CONSORT before his death in 2018. Many of those contributions are obvious as he was a member of the CONSORT executive and coauthor of all the CONSORT papers from 1997 to 2018. Many contributions, however, are not well recognised, because he was not an author of the first CONSORT paper in 1996, or its precursor, Standards of Reporting Trials (SORT).34 While not on the bylines, his influence permeated that work. We think his contributions should be noted in the story of how CONSORT came to be.The inadequate...