Medical Journal News

by Raphaele Houlbracq, Camille Le Ray, Béatrice Blondel, Nathalie Lelong, Anne Alice Chantry, Thomas Desplanches, ENP2021 Study Group

Background

The French guidelines have recommended a restrictive policy of episiotomy since 2005. We aimed to assess variations in the prevalence of both episiotomy and obstetric anal sphincter injury (OASI) from the 2010, 2016, and 2021 National Perinatal Surveys.

Methods and findings

A total of 29,750 women who had given birth to a live infant by vaginal delivery were included. For instance, in 2021, 22.3% of women were over 35 years old, 17.7% were born outside of France, 11.3% had a body mass index (BMI) of 30 kg/m2 or higher, and 39.9% were primiparous. Episiotomy and OASI (third- and fourth-degree tears) were identified from medical records. We described the overall prevalence of outcomes, and then by obstetrical clinical contexts using a seven-group obstetric classification of women. Variations between 2010 (reference), 2016, and 2021 were analyzed by Cochran–Armitage tests and using Poisson regression models adjusted for maternal age, BMI, country of birth, antenatal classes, suspicion of fetal macrosomia, and neuroaxial analgesia during labor, the professional who attended the birth, the annual number of deliveries, and the maternity unit status to account for changes in women’s characteristics and obstetric practices.The overall prevalence of episiotomy decreased significantly from 25.8% (95% confidence interval (CI) 25.0 to 26.7) in 2010, to 20.1% (95% CI 19.3 to 20.9) in 2016, and 8.3% (95% CI 7.8 to 8.9) in 2021 (adjusted risk ratio (aRR) 0.33, 95% CI 0.30 to 0.35). This reduction was observed in all groups of the classification (Cochran–Armitage tests P < 0.001), ranging from −33.0% in Group 2a [nulliparous term cephalic singleton with forceps delivery] to −94.0% in Group 7 [multiple pregnancy]. The difference in overall prevalence of OASI between 2010 (0.7%) and 2021 (1.0%) was not statistically significant after adjustment (aRR 1.24, 95% CI 0.91 to 1.68). By groups of classification, the prevalence of OASI increased significantly only in Group 2b [nulliparous term cephalic singleton with spatula delivery] from 2.6% (95% CI 1.2 to 5.6) in 2010 to 9.6% (95% CI 6.2 to 14.7) in 2021 (aRR 3.69, 95% CI 1.50 to 9.09), and did not differ statistically significantly in Group 2a [nulliparous term cephalic singleton with forceps delivery] from 3.2% (95% CI 1.8 to 5.7) in 2010 to 5.7% (95% CI 3.4 to 9.5) in 2021 (aRR 1.78, 95% CI 0.81 to 3.90).The main limitations of this study include the failure to take into account some potential confounding factors and the inability to analyze some groups of the studied population (8.5% of the sample) because of the very small number of events in these groups.

Conclusions

The significant overall reduction in the prevalence of episiotomy in France has not been followed by an overall increase in OASI. However, subgroup analyses revealed a significant rise in OASI among nulliparous women giving birth by spatula (Group 2b), and a clinically relevant but statistically nonsignificant rise among nulliparous women delivering by forceps (Group 2a), while the prevalence of episiotomy significantly decreased. These results should be interpreted with caution given the low prevalence of OASI in some subgroups. Further research is needed to predict the optimal rate of episiotomy for instrumental deliveries. In hospitals with high episiotomy rates, our findings suggest that episiotomy could be safely reduced for spontaneous vaginal deliveries to comply with international guidelines and women’s requests.

New roles in healthcare provision, such as physician associates (PAs), have been introduced too quickly and without proper preparation, a review has found.The review of new staff roles in the NHS in England,1 carried out by the health think tank the Nuffield Trust, found that too often they had been introduced before agreement on issues such as regulation, training, supervision, and communication.The study, commissioned by NHS Employers, looked at the history of how different roles have been introduced, how the mix of staff skills in the NHS compares with other countries, and what needs to be tackled if the government’s plans to expand the workforce and invest in new roles are to succeed.The NHS has a long history of introducing new roles, said the authors—recently including PAs, nursing associates, and advanced nurse practitioners to tackle staff shortages, financial constraints, and changing health needs.The report drew on published data throughout England...

An employment tribunal has ordered an NHS trust to pay just over £100 000 to a trauma surgeon with post-traumatic stress disorder (PTSD) after deciding that he was unfairly dismissed.1The Cambridge tribunal found a “wholesale failure” by East and North Hertfordshire NHS Trust to follow its own illness policy when it decided to dismiss Vladimir Filipovich, who worked at the Lister Hospital in Stevenage, at the age of 60.Filipovich, who represented himself at the tribunal, had worked for the trust for nearly 20 years when he was sacked in July 2019. He had conducted over 25 000 operations without any deaths. Before coming to the UK he had been a trauma surgeon in the Bosnian war, exposed to severely injured and dying patients.He experienced an inability to concentrate, memory loss, exhaustion, and flashbacks. In November 2016 a psychiatrist made a preliminary diagnosis of PTSD.In January 2017 Filipovich turned up for...

Reports that a “mysterious” covid-like virus is overwhelming Chinese hospitals have made international headlines. Is human metapneumovirus (HMPV) a common winter bug that is following an expected seasonal outbreak pattern or something more serious?Could it be the next pandemic?That is extremely unlikely. HMPV is not a new virus like SARS-CoV-2 and has been circulating in its current form for decades.12 The Dutch researchers who first isolated it in 2001 found antibodies in almost all of the children they tested aged 5 and older.3Unlike respiratory syncytial virus (RSV), from which it is almost clinically indistinguishable, there is no vaccine against HMPV. But patients usually recover after a few days of mild illness. Immune treatment and antivirals are occasionally used, but bed rest and fluids are the primary treatment.HMPV can be more serious in infants, elderly people, and people who are immunocompromised, who may develop bronchiolitis or pneumonia. It kills at about...

The true number of people who have died directly from war in Gaza is around 41% higher than the official figures reported by Palestine’s health ministry, a study published in the Lancet has found.1The health ministry reported that 37 877 people had died during the first nine months of Israel’s air and ground operations in Gaza, but the real figure is closer to 64 260, the researchers estimated after analysing several overlapping datasets.The estimated total would mean that nearly 3% of Gaza’s population was killed between October 2023 and June 2024.“The UN Human Rights Office has already condemned the high number of civilians killed in the war in Gaza, and our findings suggest that the traumatic injury death toll is underreported by around 41%,” said Zeina Jamaluddine, an epidemiologist at the London School of Hygiene and Tropical Medicine (LSHTM) and the study’s lead author. “These results underscore the urgent need...

AbstractObjectiveTo assess whether intra-arterial tenecteplase administered after successful endovascular recanalisation improves outcomes in patients with acute arterial occlusion of the posterior circulation.DesignMulticentre randomised controlled trial.Setting31 hospitals in China, 24 January 2023 to 24 August 2023.Participants208 patients with successful recanalisation (grade 2b50-3 on the extended thrombolysis in cerebral infarction scale) of an occlusion in the V4 segment of the vertebral artery; proximal, middle, or distal segment of the basilar artery; or P1 segment of the posterior cerebral artery: 104 were randomly allocated to receive tenecteplase and 104 to receive standard care.InterventionsIntra-arterial tenecteplase (0.0625 mg/kg, maximum dose 6.25 mg) administered proximal to the residual thrombus (if still present) or distal to the origin of the main pontine perforator branches over 15 seconds, or endovascular treatment only (control group).Main outcome measuresThe primary outcome was freedom from disability (modified Rankin scale score 0 or 1) at 90 days after randomisation. Primary safety outcomes included symptomatic intracranial haemorrhage within 36 hours and all cause mortality at 90 days. All efficacy and safety analyses were conducted by intention to treat and adjusted for age, pre-stroke modified Rankin scale score, time from onset of moderate to severe stroke (National Institutes of Health stroke scale score ≥6) to randomisation, hypertension, and baseline stroke severity.ResultsAt 90 days, 36 patients (34.6%) in the tenecteplase group and 27 (26.0%) in the control group had a modified Rankin scale score of 0 or 1 (adjusted risk ratio 1.36, 95% confidence interval 0.92 to 2.02; P=0.12). Mortality at 90 days was similar between the tenecteplase and control groups: 29 (27.9%) v 28 (26.9%), adjusted risk ratio 1.13, 0.73 to 1.74. Symptomatic intracranial haemorrhage within 36 hours occurred in eight patients (8.3%) in the tenecteplase group and three (3.1%) in the control group (adjusted risk ratio 3.09, 0.78 to 12.20).ConclusionsIn patients with acute ischaemic stroke due to acute posterior large or proximal vessel occlusion, intra-arterial tenecteplase administered after successful recanalisation was not associated with a statistically significant reduction in combined disability and mortality at 90 days.Trial registrationClinicalTrials.gov NCT05684172.

The government has reportedly ceased further funding of the controversial doctor apprenticeship programmes.1 The scheme has faced considerable opposition from the medical community and lobbying by the BMA from the start. Proponents initially argued that these programmes would widen access into medicine, but this argument began to fall apart as further details emerged. Medical doctor apprenticeships would not have delivered on the aim of expanding access into medicine, instead we need effective widening participation schemes in medical education.The timelines to deliver the medical apprenticeships were always tight. In 2022, NHS England set out a tender for medical schools to develop a new programme offering the use of the apprenticeship levy funding for the first time to medical degrees. The pilot medical schools were confirmed in January 2023. NHS England then needed to find willing local employment providers, adapt a medical curriculum, seek regulatory scrutiny for the degree and apprenticeship aspect,...

Alser K, Mallah SI, Gilbert M, Shaikh Z, Alser O. A case series on trauma care in Gaza: reflections—Authors' reply. Lancet 2025; published online Jan 6. https://doi.org/10.1016/S0140-6736(24)02807-1—In this Correspondence, the month of Khaled Alser's abduction should have been reported as March, 2024. This correction has been made to the online version as of Jan 13, 2025.

The BMA has called on the agency responsible for issuing NHS pensions savings statements to urgently rectify “completely unacceptable” errors that are making it impossible for doctors to accurately report their tax status to HM Revenue and Customs.At least 757 doctors have received inaccurate statements for 2023-24 from the NHS Business Services Authority (NHSBSA), which potentially prevents them from being able to complete self-assessment tax returns before the deadline at the end of this month, the BMA said.Examples of errors include miscalculations of pension savings that were distorting total amounts, the BMA added.In light of the situation the association has urged the NHSBSA to report itself to the pensions regulator over the mistakes.In a letter to the NHSBSA sent on 10 January, Vishal Sharma, chair of the BMA’s pensions committee, said, “This is completely unacceptable. Failing to provide accurate pension savings information to scheme members in a timely fashion means...

by Sun Kim, Melike Hazal Can, Tefera B. Agizew, Andrew F. Auld, Maria Elvira Balcells, Stephanie Bjerrum, Keertan Dheda, Susan E. Dorman, Aliasgar Esmail, Katherine Fielding, Alberto L. Garcia-Basteiro, Colleen F. Hanrahan, Wakjira Kebede, Mikashmi Kohli, Anne F. Luetkemeyer, Carol Mita, Byron W. P. Reeve, Denise Rossato Silva, Sedona Sweeney, Grant Theron, Anete Trajman, Anna Vassall, Joshua L. Warren, Marcel Yotebieng, Ted Cohen, Nicolas A. Menzies

Background

Globally, over one-third of pulmonary tuberculosis (TB) disease diagnoses are made based on clinical criteria after a negative bacteriological test result. There is limited information on the factors that determine clinicians’ decisions to initiate TB treatment when initial bacteriological test results are negative.

Methods and findings

We performed a systematic review and individual patient data meta-analysis using studies conducted between January 2010 and December 2022 (PROSPERO: CRD42022287613). We included trials or cohort studies that enrolled individuals evaluated for TB in routine settings. In these studies, participants were evaluated based on clinical examination and routinely used diagnostics and were followed for ≥1 week after the initial test result. We used hierarchical Bayesian logistic regression to identify factors associated with treatment initiation following a negative result on an initial bacteriological test (e.g., sputum smear microscopy (SSM), Xpert MTB/RIF).Multiple factors were positively associated with treatment initiation: male sex [adjusted odds ratio (aOR) 1.61 (1.31, 1.95)], history of prior TB [aOR 1.36 (1.06, 1.73)], reported cough [aOR 4.62 (3.42, 6.27)], reported night sweats [aOR 1.50 (1.21, 1.90)], and having HIV infection but not on ART [aOR 1.68 (1.23, 2.32)]. Treatment initiation was substantially less likely for individuals testing negative with Xpert [aOR 0.77 (0.62, 0.96)] compared to smear microscopy and declined in more recent years. We were not able assess why clinicians made treatment decisions, as these data were not available.

Conclusions

Multiple factors influenced decisions to initiate TB treatment despite negative test results. Clinicians were substantially less likely to treat in the absence of a positive test result when using more sensitive, PCR-based diagnostics.

A coroner has questioned whether enough information is provided about the risk of suicide associated with selective serotonin reuptake inhibitors (SSRIs) after the son in law of Prince and Princess Michael of Kent shot himself after taking the antidepressant drugs.Thomas Kingston, 45, died of a self-inflicted shotgun wound to the head last February while visiting his parents in Kemble, Gloucestershire.Katy Skerrett, senior coroner for Gloucestershire, has sent a regulation 28 report, intended to prevent future deaths, to the National Institute for Health and Care Excellence (NICE), the Medicines and Healthcare Products Regulatory Agency (MHRA), and the Royal College of General Practitioners. The bodies must respond by 3 March with proposals for action.Her report questions if there is adequate communication of the risks of suicide associated with SSRIs and if “the current guidance to persist with SSRI medication or switch to an alternative SSRI medication is appropriate when no benefit has...

Gabriela Alvaro’s blood was flowing through a dialysis machine when the power in Ecuador went out nationwide.“Generators can take up to a minute and a half to start,” says Alvaro, 31, whose kidneys stopped functioning eight years ago. She relies on dialysis three times a week. “That minute and a half felt eternal. I remember being afraid that my blood would clot and they wouldn’t be able to return it to my body. That would kill me, of course. I don’t remember much else—I fainted.”It was 5 August 2024, and the latest in a series of scheduled blackouts that left the country in darkness for at least 70 days, with some outages lasting 14 hours. Every Friday the government announces the power outages scheduled for the following week. Life is planned around the affected areas and times.By government mandate, public healthcare facilities are exempt from power cuts, although private hospitals...

Establish boundaries earlyAshley Simpson, medical education fellow, NHS Lothian, says, “Being asked to undertake a task you believe is outside your role can be challenging. Navigating these situations is often context dependent, requiring a balance between your professional responsibilities, team working, and patient safety.“Delivering healthcare is a team effort, with each professional holding specific responsibilities. There is often overlap in competencies, however, meaning that some tasks can be undertaken by multiple team members.“As a resident doctor rotating though departments, it’s important to clarify the typical responsibilities of team members in each setting. A task outside your role in one department may fall within it in another. Establishing role boundaries can empower you to handle situations like this more effectively.“Occasionally you may be asked to complete tasks typically assigned to others—for example, phlebotomy—because of workload or staffing pressures. In these instances, working collaboratively may be the best approach for patient care....

A group of UnitedHealth Group shareholders has asked the company to report costs and patient risks related to denial of medical care. The demand comes in the wake of the murder of Brian Thompson, head of the firm’s health insurance business, on 4 December 2024.12Thompson’s murder evoked widespread public criticism of the US healthcare industry and even praise for the man accused of the murder, Luigi Mangione.3“Shareholders recommend that the report evaluate how company practices impact access to healthcare and patient outcomes, including analyses of how often prior authorisation requirements or denials of care lead to delay or abandonment of medical treatment, and serious adverse events for patients,” said the shareholders in their request.The proposal could be voted on at UnitedHealth Group’s annual meeting later this year.News stories about denials of care are common in the US. Reports include that of a man who was denied a replacement for his...

bmj;388/jan13_1/r24/FAF1faObstetrician and gynaecologist Rupert Fawdry was an original thinker, dismissed by some as a Luddite and acclaimed by others as a maverick genius. If computers had been invented first, he suggested, paper and pen might have been considered the greatest IT breakthrough since the dawn of civilisation.This may seem an odd and even illogical observation by a charming eccentric who had an “affair” with the computer, according to his Canadian born first wife Judy. This passionate, obsessive affair reflected a love of structure and an overwhelming desire to organise the world—in particular, medical records.Fawdry highlighted dozens of inconsistencies in some 70 maternity datasets. The Körner model, for example, lacked an option for a breech birth by caesarean, he said, while the “place of birth” option seemed to differ in each dataset.Perhaps it was the depth of his knowledge and experience that ultimately made him appreciate the limitations of computerised medical...

New England Journal of Medicine, Volume 392, Issue 3, January 16, 2025.

New England Journal of Medicine, Volume 392, Issue 3, Page 214-215, January 16, 2025.

New England Journal of Medicine, Volume 392, Issue 3, Page 209-211, January 16, 2025.

“The COVID-19 crisis may have passed, but a harsh lesson remains: the world is woefully unprepared for the next pandemic”, said António Guterres, UN Secretary-General, on the International Day of Epidemic Preparedness, Dec 24, 2024. His remarks resonated with those of WHO Director-General Tedros Adhanom Ghebreyesus when asked whether the world is better prepared for the next pandemic. He noted that while some painful lessons have been learnt, many of the same weaknesses and vulnerabilities that allowed COVID-19 to gain a foothold 5 years ago still exist.

Chimeric antigen receptor (CAR) T-cell therapy has revolutionised immunotherapy;1 however, prolonged manufacturing times, high cost, and limited accessibility remain a challenge.2 Allogeneic products offer a readily available off-the-shelf therapeutic modality with healthy donor cells that can be dosed multiple times.3 However, allogeneic therapies have their own limitations, including donor-specific variability in composition and efficacy, limited persistence due to allogeneic rejection, and the risk of graft-versus-host disease (GVHD).