BMJ - British Medical Journal

The evolution of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) has been shaped by the continuous challenge of balancing ischaemic protection with bleeding risk. While prolonged DAPT confers thrombotic risk reduction, it invariably increases bleeding complications, which are themselves associated with adverse prognostic implications.1 This dilemma has prompted the exploration of de-escalation strategies—gradual tapering of antiplatelet intensity or duration—as a means of optimising patient outcomes. Currently, the concept of DAPT de-escalation refers to the strategy of discontinuing aspirin after a short period of dual antiplatelet therapy after PCI, leaving patients on monotherapy with a potent P2Y12 inhibitor—typically ticagrelor, as supported by available evidence.234 The rationale behind this approach is to maximise ischaemic protection during the initial months after PCI, when the thrombotic risk is highest, while simultaneously mitigating the bleeding risk, which remains relatively constant and is directly associated with DAPT duration.5 In a previous meta-analysis from our...

Tuberculosis (TB) is the world’s oldest pandemic, accounting for around a billion deaths in the past two centuries.1 In the UK, after more than a decade of declining incidence, numbers are on the rise. In 2024, 5480 people became unwell with TB in England—up 13% from 2023, the largest increase recorded since 1970, and reflecting a trend that started in 2021.2 The TB Action Plan for England 2021-263 commits the country to meet the World Health Organization target of eliminating TB by 2035.4 But achieving the required 18% annual rate reduction from 2025 is not certain.TB is linked to conditions of poverty. People who become unwell with the disease face stigma, financial precarity, digital exclusion, language barriers, and housing insecurity.5 They need the scaffolding provided by support networks to enable them to receive the health and social care required to complete treatment successfully. TB exists on a spectrum between asymptomatic...

Over the past two decades my research has centred on systematic reviews. Developing and evaluating statistical and research methodology for reviews has been a focus, but I have also collaborated on many reviews. These collaborations inevitably reveal the importance of complete, clear, and accurate reporting of primary studies. At best, incomplete and inaccurate reporting wastes research investment—often substantial in the case of large randomised trials—and at worst, it may lead to incorrect conclusions with far reaching consequences.Primary studies that are reported well contribute maximally to the evidence base and can be fairly assessed. The opposite is true when reporting is unclear or incomplete. I have spent countless hours scouring trial reports for information that should be present but is not; trying to decipher unclear text; or trying to decide what to do when the information reported is inconsistent within or across reports of the same study. This time adds up...

AbstractObjectivesTo investigate whether a less intense antiplatelet regimen could be used for people receiving drug coated balloons.DesignMulticentre, randomised, open label, assessor blind, non-inferiority trial (REC-CAGEFREE II).Setting41 hospitals in China between 27 November 2021 and 21 January 2023.Participants1948 adults (18-80 years) with acute coronary syndrome who received treatment exclusively with paclitaxel-coated balloons according to the international drug coated balloon consensus.InterventionsParticipants were randomly assigned (1:1) to either the stepwise dual antiplatelet therapy (DAPT) de-escalation group (n=975) consisting of aspirin plus ticagrelor for one month, followed by five months of ticagrelor monotherapy, and then six months of aspirin monotherapy, or to the standard DAPT group (n=973) consisting of aspirin plus ticagrelor for 12 months.Main outcome measuresThe primary endpoint was net adverse clinical events (all cause death, stroke, myocardial infarction, revascularisation, and Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding) at 12 months in the intention-to-treat population. Non-inferiority was established if the upper limit of the one sided 95% confidence interval (CI) for the absolute risk difference was smaller than 3.2%.ResultsThe mean age of participants was 59.2 years, 74.9% were men, 30.5% had diabetes, and 20.6% were at high bleeding risk. 60.9% of treated lesions were in small vessels, and 17.8% were in-stent restenosis. The mean drug coated balloon diameter was 2.72 mm (standard deviation 0.49). At 12 months, the primary endpoint occurred in 87 (8.9%) participants in the stepwise de-escalation group and 84 (8.6%) in the standard group (difference 0.36%; upper boundary of the one sided 95% CI 2.47%; Pnon-inferiority=0.013). In the stepwise de-escalation versus standard groups, BARC type 3 or 5 bleeding occurred in four versus 16 participants (0.4% v 1.6%, difference −1.19% (95% CI −2.07% to −0.31%), P=0.008), and all cause death, stroke, myocardial infarction, and revascularisation occurred in 84 versus 74 participants (8.6% v 7.6%, difference 1.05% (95% CI −1.37% to 3.47%), P=0.396). Treated as having hierarchical clinical importance by the win ratio method, more wins were noted with the stepwise de-escalation group (14.4% wins) compared with the standard group (10.1% wins) for the predefined hierarchical composite endpoint of all cause death, stroke, myocardial infarction, BARC type 3 bleeding, revascularisation, and BARC type 2 bleeding (win ratio 1.43 (95% CI 1.12 to 1.83), P=0.004). Results from the per-protocol and the intention-to-treat analysis were similar.ConclusionsAmong participants with acute coronary syndrome who could be treated by drug coated balloons exclusively, a stepwise DAPT de-escalation was non-inferior to 12 month DAPT for net adverse clinical events.Trial registrationClinicaltrials.gov NCT04971356

bmj;388/mar31_1/r624/FAF1faSt Bartholomew’s medical school had only been accepting female students for eight years when Coral Sharpe (née Knight) began studying in 1955. Sharpe was not an obvious trailblazer, but in her quiet, resolute way she was determined to study medicine and keep working as a doctor when society might have expected her to concentrate on being a wife and mother.Medicine was in Sharpe’s blood. Her father, Bryant, was a GP in north west London and the whole family was immersed in the practice—Sharpe’s mother, Gladys, was, in effect, the receptionist; the waiting room was in Sharpe’s bedroom; and Sharpe, along with her sister Heather and brother Anthony were born either above or next door to the surgery.Sharpe was, in the parlance of the time, a delicate child. She was prone to ear infections and sudden, mysterious fevers; she was also diagnosed with a heart murmur. Gladys’s letters to Bryant, who...

An error in ranking applicants for radiology specialty training programmes has led to job offers for some doctors being retracted.Resident doctors who applied for radiology were sent the outcomes of their applications on 24 March. They later received an update telling them that the offers had been made in error, as only one component of the multistage selection process had been taken into account. Offers based on the correct rankings were reissued two days later.Ahmed Mohamed had applied for radiology for the second time, having failed to secure a job offer last year. He told The BMJ that he was “so, so happy and excited” when he got an email telling him that he had been successful this time. But, after calling his family to celebrate, he had to tell them hours later that his offer was in question. He then spent two days constantly checking his emails. When the...

The latest YouTube craze?Thankfully not. Instead, this is good news. Surgeons have linked the move to a cashless society to a dramatic drop in children needing operations for accidentally swallowing small items such as coins.Cash isn’t king?Researchers reviewed hospital episode statistics (HES) between 2000 and 2022 for procedures to remove foreign bodies from the alimentary tract, respiratory tract, and nasal cavity in 0-14 year olds. The study, published in the Annals of the Royal College of Surgeons of England, found the total number of procedures fell from 2405 in 2012 to 1716 in 2022—a 28% reduction.1 Lead study author Akash Jangan, an ear, nose, and throat registrar, said, “Our research shows that using cashless payment methods instead of coins has potentially helped keep children safe and reduced the need for surgery.”The penny dropsThere are likely to be fewer lying around the house. Contactless payments were first introduced in the UK...

“What has happened has the potential to bring about massive retrogression. I’m very, very scared for the future,” Deborah Ikeh, executive director of the Debriche Health Development Centre, a non-governmental organisation (NGO) that supports community led monitoring of tuberculosis (TB) in Nigeria, says about US cuts to foreign aid.On 20 January President Donald Trump signed an executive order pausing foreign development assistance, including the United States Agency for International Development (USAID) and the President’s Emergency Plan for AIDS Relief (PEPFAR), for 90 days, pending a programme by programme review.A brief respite came a week later when the US State Department signed a waiver preserving funding for “life saving humanitarian assistance.” But then in late February the Trump administration added further confusion by terminating nearly 10 000 contracts, including some with organisations that had previously been covered under the waiver.The result is panic and uncertainty. Johns Hopkins University is reportedly being...

In the past two years we have been involved in an expert panel convened by the Royal Society of Canada and the Canadian Academy of Health Sciences on Canada’s past and future global health role. Our report, published on 27 March 2025, aims to provide strategic insights and advice on Canada’s role in global health for the next two decades.1 The need for global leadership in health is clear: growing economic and climate threats, divisive politics, backlash against human rights, and powerful waves of misinformation threaten past gains in global health and cooperation. As we enter a new era shaped by isolationist geopolitics and the US retreating in global affairs, Canada’s role as a middle power, actively engaged in multilateralism, is more important than ever.2Greater clarity around Canada’s global health role is also relevant to current domestic affairs. The new leader of the Liberal party, Mark Carney, was appointed as...

Vaccination has been so successful in protecting whole populations from disease that it is now an often-repeated phrase that vaccines are victims of their own success. As vaccination rates rise, vaccine-preventable diseases become less common within society, creating the illusion that vaccination against these diseases is no longer necessary. This means that the more successful vaccines are, the harder health authorities must work to make their value apparent. During the covid-19 pandemic the need to vaccinate against SARS-CoV-2 was paramount, but uptake was nevertheless a challenge. It would be wrong, however, to view vaccination failures as being only the fault of those who do not want to vaccinate. Government failings should also be considered.These failings have been highlighted by the ongoing UK covid inquiry. Module four, which focused on vaccines and treatments, concluded in January 2025.1 The inquiry emphasised that the covid-19 vaccination is a success story from the pandemic,...

AbstractIdentifying patients with chest pain that is of cardiac origin is crucial owing to the high mortality and morbidity of cardiovascular diseases. History, electrocardiogram, and cardiac biomarkers are the core elements of the assessment. High sensitivity cardiac troponins (hs-cTn) are the preferred biomarkers for diagnosing acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury. However, elevations in hs-cTn can occur in patients who are not experiencing acute myocardial infarction. Therefore, it is important for clinicians to recognize how to integrate hs-cTn levels into their clinical decision making process. Structured risk assessments, using evidence based diagnostic protocols, should be employed to estimate the risk of acute coronary syndrome and adverse events in patients with chest pain. Clinical decision pathways should be used routinely in emergency departments. Patients at intermediate or high risk of obstructive coronary artery disease might benefit from cardiac imaging and further testing. Patients should be involved in decision making, with information provided about risks, radiation exposure, costs, and alternative options to facilitate informed decision making.

Unlike true experiments that are conducted by researchers for scientific purposes, natural experiments occur when infrastructure, policies, or services are introduced or changed by governments or healthcare systems. Interventions of this kind are sometimes amenable to randomised controlled trials, for example, if the advantages of randomisation can be negotiated with policy makers or providers at the planning stage and the findings are likely to be transferable across several contexts. Although the randomised controlled trial remains an important method, there are occasions when a trial will not be appropriate or feasible for answering questions about infrastructure, policy, or service changes. However, provided that the intervention divides a population into groups that are otherwise similar, researchers can evaluate the health effects of the changes in a natural experimental evaluation. Natural experiments therefore generate valuable opportunities for evaluating population health, health systems, and other interventions, including those that are, for practical or ethical...

BiographiesJohn-Arne Røttingen was appointed chief executive officer (CEO) of the Wellcome Trust in October 2023. A doctor-scientist, he was previously Norway’s ambassador for global health, chief executive of the Research Council of Norway, and was the founding CEO of the Coalition for Epidemic Preparedness Innovations. His research encompasses epidemiology, clinical trials, and global health policy.Victor Adebowale has been chair of the NHS Confederation in a personal capacity since April 2020. He is the former CEO of Turning Point, a social enterprise, and has been a crossbench peer at the House of Lords since 2001. He has led commissions on mental health and housing. He holds an MA in advanced organisational consulting from City University and the Tavistock Institute of Human Relations and founded the Race and Health Observatory.VA: You’ve had a distinguished career in research funding, including leading Norway’s research efforts. How did issues of race, diversity, and equity play...

In November 2024, the Terminally Ill Adults (End of Life) Bill was passed in the UK House of Commons by a majority of 330 to 275. One key consensus in the debates surrounding the bill was that while palliative care in the UK can be excellent, its provision and funding are often inconsistent, inadequate, and must be improved. In response, a commission on palliative care has been established by Rachael Maskell MP to drive improvements in palliative and end-of-life care in the UK. More recently the Expert Panel of the parliamentary Health and Social Care Committee has announced it is undertaking an independent evaluation of the state of palliative care in England. The 1946 NHS Act established a health service focused on improving physical and mental health and treating illness. This wording led many to assume that palliative care, which puts the person and their concerns before their illness,...

A group of whistleblowing doctors who raised the alarm about patient safety in the emergency department at Scotland’s largest hospital have had their concerns upheld.An investigation by Healthcare Improvement Scotland (HIS) into conditions at Glasgow’s Queen Elizabeth University Hospital concluded that NHS Greater Glasgow and Clyde seemed “to have allowed an abrasive culture to develop, with evidence of poor and disrespectful behaviours, which makes it very difficult for staff at all levels of the organisation to feel safe to challenge and appropriately address this culture.”1Staff complained of insufficient capacity to meet demands for emergency care, leading to long delays in treatment and patients being cared for in unsuitable areas such as corridors. After two years of trying and failing to get senior management to act a group of 29 doctors raised their patient safety concerns directly with HIS.HIS decided to review conditions at all three of the health board’s emergency...

A rise in antibiotic resistant cases of gonorrhoea, including extensively drug resistant (XDR) strains, risks making the sexually transmitted infection (STI) “untreatable” if the problem is not tackled, health officials have said.While most gonorrhoea infections can be treated effectively, increased resistance to ceftriaxone—the most common antibiotic used to treat it in injection or tablet form—poses risks, the UK Health Security Agency (UKHSA) said.Katy Sinka, a consultant epidemiologist and head of the STI section at the UKHSA, called for people to use condoms to protect against STIs and to get tested after unprotected sex, including after having sex abroad.Figures from the UKHSA show that there were 17 cases of ceftriaxone resistant gonorrhoea recorded between January 2024 and 20 March 2025 (13 in 2024 and four in 2025 so far). This compares with 16 during the whole of 2022 and 2023. There were nine cases reported between 2015 (when ceftriaxone resistant gonorrhoea...

Decades of improvements in mortality are coming undone as public health funding is eroded and trust in evidence based treatment is undermined. At the same time, commercial interests are pushing people away from healthy lifestyles, as companies work to ensure that government policies don’t undermine their business models (doi:10.1136/bmj.r487).1 And millions of the most powerless people in the world will be harmed in the wake of the US’s sudden withdrawal of foreign aid (doi:10.1136/bmj.r518).2Can some of the new ideas and technological advances discussed in this week’s articles on bmj.com help us turn the tide and progress towards a new age of enlightenment? Should we, for instance, do away with the ancient practice of cadaveric dissection and embrace modern training tools—or will we then miss an essential aspect of the way in which students learn human anatomy (doi:10.1136/bmj.q2829)?3In other areas of medicine, the advantages of new tools and techniques may be...

AbstractClinical questionIn adult patients undergoing colonoscopy for any indication (screening, surveillance, follow-up of positive faecal immunochemical testing, or gastrointestinal symptoms such as blood in the stools) what are the benefits and harms of computer-aided detection (CADe)?Context and current practiceColorectal cancer (CRC), the third most common cancer and the second leading cause of cancer-related death globally, typically arises from adenomatous polyps. Detection and removal of polyps during colonoscopy can reduce the risk of cancer. CADe systems use artificial intelligence (AI) to assist endoscopists by analysing real-time colonoscopy images to detect potential polyps. Despite their increasing use in clinical practice, guideline recommendations that carefully balance all patient-important outcomes remain unavailable. In this first iteration of a living guideline, we address the use of CADe at the level of an individual patient.EvidenceEvidence for this recommendation is drawn from a living systematic review of 44 randomised controlled trials (RCTs) involving more than 30 000 participants and a companion microsimulation study simulating 10 year follow-up for 100 000 individuals aged 60-69 years to assess the impact of CADe on patient-important outcomes. While no direct evidence was found for critical outcomes of colorectal cancer incidence and post-colonoscopy cancer incidence, low certainty data from the trials indicate that CADe may increase positive endoscopy findings. The microsimulation modelling, however, suggests little to no effect on CRC incidence, CRC-related mortality, or colonoscopy-related complications (perforation and bleeding) over the 10 year follow-up period, although low certainty evidence indicates CADe may increase the number of colonoscopies performed per patient. A review of values and preferences identified that patients value mortality reduction and quality of care but worry about increased anxiety, overdiagnosis, and more frequent surveillance.RecommendationFor adults who have agreed to undergo colonoscopy, we suggest against the routine use of CADe (weak recommendation).How this guideline was createdAn international panel, including three patient partners, 11 healthcare providers, and seven methodologists, deemed by MAGIC and The BMJ to have no relevant competing interests, developed this recommendation. For this guideline the panel took an individual patient approach. The panel started by defining the clinical question in PICO format, and prioritised outcomes including CRC incidence and mortality. Based on the linked systematic review and microsimulation study, the panel sought to balance the benefits, harms, and burdens of CADe and assumed patient preferences when making this recommendationUnderstanding the recommendationThe guideline panel found the benefits of CADe on critical outcomes, such as CRC incidence and post-colonoscopy cancer incidence, over a 10 year follow up period to be highly uncertain. Low certainty evidence suggests little to no impact on CRC-related mortality, while the potential burdens—including more frequent surveillance colonoscopies—are likely to affect many patients. Given the small and uncertain benefits and the likelihood of burdens, the panel issued a weak recommendation against routine CADe use.The panel acknowledges the anticipated variability in values and preferences among patients and clinicians when considering these uncertain benefits and potential burdens. In healthcare settings where CADe is available, individual decision making may be appropriate.UpdatesThis is the first iteration of a living practice guideline. The panel will update this living guideline if ongoing evidence surveillance identifies new CADe trial data that substantially alters our conclusions about CRC incidence, mortality, or burdens, or studies that increase our certainty in values and preferences of individual patients. Updates will provide recommendations on the use of CADe from a healthcare systems perspective (including resource use, acceptability, feasibility, and equity), as well as the combined use of CADe and computer aided diagnosis (CADx). Users can access the latest guideline version and supporting evidence on MAGICapp, with updates periodically published in The BMJ.

A new deal for GPs in Scotland which promised to transform their working lives has been a failure, says a damning report from Audit Scotland.A contract agreed with the Scottish government in 2018 envisaged GPs working at the head of expanded primary care teams to deliver improved services.1 It sought to tackle the financial pressures and growing workloads facing family doctors and improve access to care for patients.Audit Scotland analysis found, however, that the contract failed to deliver on several of its commitments.2 Pressures on general practice have increased, investment as a proportion of overall NHS spending has fallen, the number of full time GPs has reduced, patients report finding it more difficult to access care, and proposals to support GPs with more nurses, physiotherapists, and other specialists have not materialised as originally intended.The report says that the Scottish government’s commitment to increase the number of GPs in Scotland by...

The “Hello, my name is” campaign, set up by geriatrician and cancer patient Kate Granger in 2015, encourages all staff to introduce themselves to patients.12 The campaign stemmed from her experience as a patient and the lack of introductions she received from the healthcare staff looking after her.3 It reflected the simple need to know who was providing her care. However, it is now often conflated with use of the first name of healthcare professionals, both in introductions and on name badges, which can cause confusion about names, titles, and roles. The “Hello, my name is” campaign needs updating.Names matter for patients, but introductions using first names alone are insufficient. Introductions and badges should include a healthcare professional’s full name, title, and role. Healthcare delivery has diversified, so role recognition is more difficult and important than ever. Like Kate Granger,1 my usual introduction is “I am Professor Tim Cook, consultant...