BMJ - British Medical Journal

bmj;388/jan23_1/r120/FAF1faBRACIn 1967 newly qualified doctor Richard Cash was sent to East Pakistan (now Bangladesh) to respond to one of the many cholera epidemics that swept through the region. The treatment at the time was intravenous therapy to replace lost fluids, but such a resource intensive process was inappropriate in a country where funding and trained personnel were not available at anywhere near the scale needed.A simple, inexpensive, and easy to administer treatment did, however, exist: oral rehydration therapy (ORT), just salt and sugar in clean water. This had already been shown to be effective in laboratory studies but Cash and David Nalin, his colleague at the US National Institutes for Health, decided to test it on a much larger scale.They faced objections from colleagues who weren’t sure patients would be able to swallow the fluid or that the treatment would work—but their multiple clinical trials of ORT proved the doubters...

The view that the hyperglycaemia associated with type 2 diabetes is inexorably progressive was challenged by the publication of the DiRECT study in 2018.12 Through a mean weight loss of 10 kg achieved by a period of total diet replacement (often referred to as the “soups and shakes” diet), 46% of participants achieved remission of type 2 diabetes at 12 months. The longer term sustainability of the remission achieved is less clear, with 36% still in remission at two years in the DiRECT study but only 13% at five years with continued support.34 The English NHS Type 2 Diabetes Path to Remission Programme provides access to similar interventions in the real world for people within six years of diagnosis of type 2 diabetes and body mass index >27 (appropriately adjusted according to ethnicity), with 12 month remission rates of approximately 30%.5 Around 35 000 people have now been referred into...

AbstractObjectiveTo assess the effect of dapagliflozin plus calorie restriction on remission of type 2 diabetes.DesignMulticentre, double blind, randomised, placebo controlled trial.Setting16 centres in mainland China from 12 June 2020 to 31 January 2023.Participants328 patients with type 2 diabetes aged 20-70 years, with body mass index >25 and diabetes duration of <6 years.InterventionsCalorie restriction with dapagliflozin 10 mg/day or placebo.Main outcome measuresPrimary outcome: incidence of diabetes remission (defined as glycated haemoglobin <6.5% and fasting plasma glucose <126 mg/dL in the absence of all antidiabetic drugs for at least 2 months); secondary outcomes: changes in body weight, waist circumference, body fat, blood pressure, glucose homoeostasis parameters, and serum lipids over 12 months.ResultsRemission of diabetes was achieved in 44% (73/165) of patients in the dapagliflozin group and 28% (46/163) of patients in the placebo group (risk ratio 1.56, 95% confidence interval (CI) 1.17 to 2.09; P=0.002) over 12 months, meeting the predefined primary endpoint. Changes in body weight (difference −1.3 (95% CI −1.9 to −0.7) kg) and homoeostasis model assessment of insulin resistance (difference −0.8, −1.1 to −0.4) were significantly greater in the dapagliflozin group than in the placebo group. Likewise, body fat, systolic blood pressure, and metabolic risk factors were significantly more improved in the dapagliflozin group than in the placebo group. In addition, no significant differences were seen between the two groups in the occurrence of adverse events.ConclusionThe regimen of dapagliflozin plus regular calorie restriction achieved a much higher rate of remission of diabetes compared with calorie restriction alone in overweight or obese patients with type 2 diabetes.Trial registrationClinicalTrials.gov NCT04004793.

AbstractObjectiveTo estimate the relative efficacy of individual and combinations of prehabilitation components (exercise, nutrition, cognitive, and psychosocial) on critical outcomes of postoperative complications, length of stay, health related quality of life, and physical recovery for adults who have received surgery.DesignSystematic review with network and component network meta-analyses of randomised controlled trials.Data sourcesMedline, Embase, PsycINFO, CINAHL, Cochrane Library, and Web of Science were initially searched 1 March 2022, and updated on 25 October 2023. Certainty in findings were assessed using the Confidence in Network Meta-Analysis (CINeMA) approach.Main outcome measuresTo compare treatments and to compare individual components informed by partnership with patients, clinicians, researchers, and health system leaders using an integrated knowledge translation framework. Eligible studies were any randomised controlled trial including adults preparing for major surgery who were allocated to prehabilitation interventions or usual care, and where critical outcomes were reported.Results186 unique randomised controlled trials with 15 684 participants were included. When comparing treatments using random-effects network meta-analysis, isolated exercise (odds ratio 0.50 (95% confidence interval (CI) 0.39 to 0.64); very low certainty of evidence), isolated nutritional (0.62 (0.50 to 0.77); very low certainty of evidence), and combined exercise, nutrition, plus psychosocial (0.64 (0.45 to 0.92); very low certainty of evidence) prehabilitation were most likely to reduce complications compared with usual care. Combined exercise and psychosocial (−2.44 days (95% CI −3.85 to −1.04); very low certainty of evidence), combined exercise and nutrition (–1.22 days (–2.54 to 0.10); moderate certainty of evidence), isolated exercise (–0.93 days (–1.27 to –0.58); very low certainty of evidence), and isolated nutritional prehabilitation (–0.99 days (–1.49 to –0.48); very low certainty of evidence) were most likely to decrease length of stay. Combined exercise, nutrition, plus psychosocial prehabilitation was most likely to improve health related quality of life (mean difference on Short Form-36 physical component scale 3.48 (95% CI 0.82 to 6.14); very low certainty of evidence) and physical recovery (mean difference in meters on the six min walk test 43.43 (95% CI 5.96 to 80.91); very low certainty of evidence).When comparing individual components using component network meta-analysis, exercise and nutrition were the individual components most likely to improve all critical outcomes. The certainty of evidence for all comparisons across all outcomes was generally low to very low due to trial level risk of bias and imprecision; however, results for exercise and nutritional prehabilitation were robust with exclusion of high risk of bias trials.ConclusionsConsistent and potentially meaningful effect estimates suggest that exercise prehabilitation, nutritional prehabilitation, and multicomponent interventions including exercise may benefit adults preparing for surgery and could be considered in clinical care. However, multicentre trials that are appropriately powered for high priority outcomes and that have a low risk of bias are required to have greater certainty in prehabilitation’s efficacy.RegistrationInternational prospective registry of systematic reviews CRD42023353710.

Earlier this year I gave birth to a bouncing baby girl, an 8 lb 4 oz bundle of joy. The euphoric moment was made even more special by its contrast with a gruelling pregnancy. This was my third pregnancy but my first experience of following a high risk care pathway. Although I’ve rarely had a body mass index (BMI) below 35, my first two pregnancies managed to slide under the medical radar. This time I was much older, and somewhat fatter, with a BMI of 41. I was referred to a consultant led clinic and assigned to the high risk category.We know that risk operates on a continuum, but my categorisation as high risk during this pregnancy was entirely binary. It defined me for those nine life changing months. I felt helpless. Even if I had wanted to take action to reduce my weight, no one recommends dieting or a...

For the past 18 months staff at Plymouth University’s Peninsula Medical School have been working hard to develop a medical apprenticeship programme, an alternative route into medicine beyond the current medical degree course.1 In partnership with NHS employers, the university came up with a radical four year programme that would allow apprentices to work and study mainly where they lived.The programme was aimed at graduates already in healthcare who hadn’t previously had the opportunity to become doctors, says Laura Bowater, head of the medical school (box 1). But late last year, just as the team was about to seek the first cohort of apprentices to start this September, they were told by the government to pause recruitment.2Box 1What are medical apprenticeships?Medical apprenticeships (also called medical doctor degree apprenticeships or NHS doctor apprenticeships) aimed to open an alternative route into medicine beyond the current medical degree course.“The main difference between the...

I have been in a lot of spaces over the years where people were not convinced about patient engagement in research. They often feel that they already have enough to do, or that this is “yet another” hoop that funding agencies are requiring them to jump through. I am writing this for you. I am not entirely sure that I will change your mind, but hopefully I can get you to think about some of your objections and why patient engagement in research is generally a good thing.Patients are vulnerable in most systemsFirstly, I would ask you to consider that patients are pretty much at the bottom of the pecking order in most situations or settings. In healthcare, they are beholden to healthcare providers and are obliged to behave like a “good patient.”` A good patient asks questions gently or strategically (or not at all!), avoids being too “difficult,” and...

Boytchev and colleagues investigate the fossil fuel industry’s influence on medical research.1 We deeply appreciated The BMJ’s bold decision in 2020 to ban advertising and research funded by companies producing fossil fuels—a ban now being extended to other BMJ Group journals.23 This principled action sets an important precedent for medical publishing and underscores the critical need to tackle the profound conflicts of interest tied to such funding.The external costs associated with the global energy system, primarily driven by fossil fuels, are staggering. Estimates, such as the maximum of $169.43tn calculated by Sovacool et al,4 vastly surpass the entire annual global gross domestic product. These external costs include extensive damage to health, ecosystems, and economies, disproportionately affecting vulnerable populations. We acknowledge that the energy transition is complex and there is potential for responsible innovation in the energy sector, but the sheer scale of these costs highlights the urgent need for systemic...

bmj;388/jan22_11/r97/FAF1faSanath graduated in 1997 and obtained a diploma in orthopaedics in 1999 from Manipal Academy of Higher Education, Mangaluru, India. He trained and worked at St John’s Medical College, Bangaluru, from 1999 until 2003.He married his classmate, Usha Rao, in May 2000 and they came to the UK in 2003. Sanath did further training in orthopaedics and took up a specialty doctor post in trauma and orthopaedics at the Glan Clwyd Hospital, Bodelwyddan, North Wales. He was integral to the working and development of the department and was also associated with University of Liverpool School of Medicine, training juniors and acting as an examiner.Besides medicine, both Sanath and Usha, a consultant obstetrician and gynaecologist and dance teacher, took a keen interest in community activities, organising social and cultural events. They believed that children should be versed in the arts and culture of the land of their parents. Sanath was a...

bmj;388/jan22_10/r90/FAF1faEric was born in Dundee, first son to William and Annie Mackay and one of eight children. He was brought up in the city, attending Morgan Academy. At the tail end of the second world war Eric trained to “tattie rogue”—finding potatoes that are diseased—progressing to work as a potato inspector.He then studied medicine at St Andrews, where he found he preferred the practical side, becoming a sharp diagnostician. He was a member of the Christian Union and through its international links he met Leonard Van Valen, who became a lifelong friend. In his fourth year of medical school he became president of the union and met his future wife, Joyce Thicknesse, known as Lis.Eric was posted to Egypt for his national service, acting as a medical officer in the Royal Air Force.He married Lis in 1956 and they moved to Matlock in Derbyshire, where he worked as a junior...

Eating disorder services have become worse rather than better over the past few years, MPs have said in a report that says some trusts are discharging patients with a body mass index (BMI) of less than 15 and even as low as 11.1The report from the all party parliamentary group (APPG) on eating disorders calls for a national strategy to tackle an “alarming rise” in eating disorders, which accounted for more than 31 000 admissions in 2023-24. The Royal College of Psychiatrists has also called for a national strategy on eating disorders, saying that “services are struggling to manage demand.”The APPG gathered oral and written evidence over six months from people with experience of eating disorders, as well as clinicians, managers, and academics. It also submitted freedom of information (FoI) requests asking for information about BMI at discharge from January to October 2024.Most trusts said either that they did not...

It is right to highlight that NHS staff felt the “strain and trauma” of caring for patients with covid-19.1 Although the risks of this viral infection have lessened, it is still a hazard for healthcare workers and their patients.Recent advice from the Joint Committee on Vaccination and Immunisation (JCVI)2 does not make provision for healthcare workers in forthcoming rounds of covid-19 vaccination. This advice lacks its previous explicit qualification that separate considerations may apply for this group.3Both good occupational health practice and UK Health and Safety Law4 warrant a more protective and precautionary approach “to ensure health, safety, and welfare at work.”5 That healthcare workers have more than double the of risk of the general population of contracting covid-19 is well recognised, as are the post-acute consequences.6 Furthermore, the acknowledgment3 that measures such as vaccination are “reasonably practicable,”7 as well as WHO advice,8 would weigh heavily in any court judgment...

A police civic volunteer accused of raping and murdering a female junior doctor at the hospital where she worked has been sentenced to life imprisonment by an Indian court.The doctor’s murder last August, and the initially slow response by authorities, made international headlines and triggered nationwide protests, doctors’ strikes, and rioting.1The sentence has prompted outrage from activists, politicians, and the victim’s parents, who asked why the death penalty had not been applied. Capital punishment by hanging was introduced for the most egregious crimes of lethal sexual violence after a national outcry over the 2012 gang rape and murder of a female physiotherapy student on a Delhi bus.But Judge Anirban Das told the court on 20 January, “I do not consider [the doctor’s murder] as a rarest-of-rare crime” that would put it in that category. This went against a submission requesting the death penalty from India’s Central Bureau of Investigation (CBI)....

In this paper by Dell-Kuster and colleagues (BMJ 2020;370:m2917, doi:10.1136/bmj.m2917, published 25 August 2020), the author name “Orestis Ioannidis” was ordered the wrong way round in the submitted manuscript. This has since been corrected in the article and PDF.

I still remember receiving my first letter from Harvard Medical School—and no, it wasn’t an acceptance letter. I was a student in the thick of pre-med requirements, trying to decide on the next institution I would trust with my dream of becoming a doctor. The letter was from Harvard’s Office of Recruitment and Multicultural Affairs, with information to help students like me, who are under-represented in medicine, apply to medical school. I revisited the list of medical schools I was applying to and added Harvard.Initiatives like this one, which are aimed at promoting diversity, equity, and inclusion (DEI), made it clear that I am needed and belong in medicine as a black woman. Today, DEI is under attack—and the effects of anti-DEI rhetoric and legislation on medicine will further marginalise black women, both seeking and providing healthcare, for years to come.In June 2023, the US Supreme Court ruled that race...

Donald Trump declared two national emergencies and issued a spate of executive orders as he was sworn in as US president for the second time on 20 January. At his inauguration Trump immediately declared a national energy emergency and an illegal immigration emergency at the border with Mexico.123This was swiftly followed by a string of executive orders (box), including withdrawing the US from the Paris climate accord and the World Health Organization. The US is the biggest donor to WHO and also contributes scientific expertise.4 The order said the US would withdraw from the WHO “due to the organization’s mishandling of the covid-19 pandemic that arose out of Wuhan, China, and other global health crises, its failure to adopt urgently needed reforms, and its inability to demonstrate independence from the inappropriate political influence of WHO member states.”It said WHO “continues to demand unfairly onerous payments from the United States, far...

A legal challenge to a refusal by the UK General Medical Council to draw up guidance on safe and lawful practice for physician associates and anaesthesia associates is to be heard in the High Court within the next four months, after a judge gave permission for the case to go ahead and ruled that it should be expedited.Anaesthetists United, a doctors’ advocacy body, is bringing the case together with Marion and Brendan Chesterton, the parents of Emily Chesterton, who died aged 30 from a blood clot on her lungs after two appointments with a physician associate who she thought was a GP. The GMC took over the regulation of associates in December but argues that it is not the right body to create guidance on practice and that it should be left to the medical royal colleges and faculties, which are experts in clinical practice.Anaesthetists United is crowdfunding its costs...

The new NHS hospital buildings promised by former prime minister Boris Johnson will not be completed until at least a decade after the original deadline, the government has announced.1The promise of 40 new hospitals in England by 2030 was made by Johnson in 2019,2 but has been repeatedly delayed.3 When starting his role as health secretary last year, Wes Streeting said he discovered that “funding for the programme was to run out in March this year, with no provision for future years whatsoever. The money simply was not there.”The Labour government has now set out a new plan to deliver the hospital buildings, which it said will be backed up with “up to £15bn over each consecutive five year wave, averaging around £3bn a year from 2030.”Under the plan, 16 hospitals allocated to wave one will start construction between 2025 and 2030, while the nine hospitals in wave two will...

Dean’s profile of consultant cardiologist Rob Egdell is interesting and insightful.1 Unfortunately, it truly highlights how far training has fallen.Egdell acknowledges that the rotational nature of being a resident doctor hinders us from forming interpersonal relationships at work—under the guise of a more “varied” training of course. I agree—in our forced rotation, we do not feel integrated into departments, often not considered “ward staff” and shunned from staffrooms. Many of my colleagues and I can attest to feeling lost, isolated, and transient.I have little reason to doubt Egdell’s ongoing support for his team, and I hope that his current care for them continues. This letter is more a plea to any other consultant or senior registrar who may be reading: it is your responsibility to ensure your resident doctors are supported and welcomed into your departments. We may no longer have firms, but you have the power to reinstate the...

The new plan to improve NHS elective care includes creating and expanding surgical hubs.1 As a surgeon, I feel conflicted. It’s positive if patients with treatable conditions can move forward from the waiting list. But we need to do this with great care to avoid negatively affecting the rest of the NHS, especially for patients deemed ineligible or due to the diversion of staff, training capacity, and funding from existing NHS sites.2We already have over 100 surgical hubs, some delivering 11-20% more efficiency.3 Hubs tend to take patients with few other conditions and relatively low operative risk, whereas patients with more underlying medical conditions and higher risk must wait for a site with medical back-up for their operation. It’s important to consider that half of the patients having procedures are over 604— of whom 63% have multiple comorbidities5 and 32% have obesity.5 We must be careful to avoid surgical hubs...