BMJ - British Medical Journal

This woman in her 50s presented with a three month history of swelling and pain in both ears and multiple joints, recurrent fever, and cough that was unresponsive to antibiotics. Physical examination showed bilateral auricular atrophy (fig 1, left), saddle nose deformity, and joint tenderness. Laboratory test results included raised C reactive protein levels and erythrocyte sedimentation rate, 1+ proteinuria, no UBA1 mutations, and antinuclear antibodies at 1:160 titre with negative extractable nuclear antigen, rheumatoid factor, anti-cyclic citrullinated peptide antibody, and anti-neutrophil cytoplasmic antibody. Cartilaginous inflammation without evidence of vascular involvement or malignancy was identified on positron emission tomography-computed tomography.bmj;388/jan09_8/e081185/F1F1f1Fig 1Differential diagnoses for auricular chondritis include relapsing polychondritis, granulomatosis with polyangiitis, VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammation, somatic) syndrome (an x-linked autoinflammatory disorder caused by somatic mutations in UBA1), infectious chondritis, and traumatic otohaematoma.1Based on McAdam’s criteria, relapsing polychondritis was diagnosed in this patient. Relapsing polychondritis is a rare immune...

London based vascular surgeon Mahim Qureshi decided to join an emergency medical team trip to a Gaza hospital after reading that, every day, 10 or more children in Gaza lose one limb or more. “As a senior registrar in vascular surgery able to do an amputation quickly and safely and control bleeding, I knew I’d be able to help.”She made a 12 day trip to Al Aqsa Hospital in central Gaza in April 2024 and a two week mission to Nasser Hospital in the south of the country in November, both times supported by the International Rescue Committee (IRC), the subject of this year’s BMJ appeal.Providing healthcare safely in Gaza is both a logistical and humanitarian challenge. Israeli airstrikes, bombing, and ground level fighting have left half of its 36 hospitals out of service and killed more than 1000 Palestinian health workers, according to the United Nations, which cites figures...

NutsThe ASPREE study, which started as a trial of low dose aspirin in healthy older adults, morphed into a longitudinal study of ageing (Age Ageing doi:10.1093/ageing/afae239). It recently reported that people who eat nuts every day tend to have a longer disability-free survival. The explanation may be nutritional, because nuts are rich in vitamins, minerals, polyphenols, phytosterols, and unsaturated fats. Another possibility is that the sort of people who choose to eat nuts are the sort of people who have a generally healthy way of life.Antiseizure medication in fathersAlthough valproate is a highly effective treatment for idiopathic generalised epilepsy, guidelines recommend restricting its use to people older than 55 because of the drug’s teratogenicity (NICE https://bnf.nice.org.uk/drugs/sodium-valproate). Where men are concerned, this may be an over-reaction. A systematic review of 10 studies of the offspring of fathers taking antiseizure medication at the time of conception found no consistent evidence of an...

The UK supermarket giant Tesco is being urged to drop an “unethical” pilot of an in-store infant feeding advice service in which midwives funded by the formula milk firm Danone are expected to wear branded uniforms and undergo training by the company.Critics said the initiative, running in a Tesco flagship store and set to be rolled out shortly,1 was a backward step and reminiscent of the “milk nurses” scandal of the 1970s, in which formula industry salespeople dressed as nurses to promote formula milk to parents.One midwife hired by Danone quit the pilot last month at the Tesco Extra store in Cheshunt, Hertfordshire, telling The BMJ that she couldn’t be associated with an “unethical” service.A spokesperson for Danone UK and Ireland said that it intended only to provide “impartial, nutritional expertise,” that the branded uniforms were optional, and that it was happy to “take on board feedback.”Tesco said it intended...

AbstractObjectiveTo summarise available evidence on time to nursing home admission and death among people with dementia, and to explore prognostic indicators.DesignSystematic review and meta-analysis.Data sourcesMedline, Embase, Web of Science, Cochrane, and Google Scholar from inception to 4 July 2024.Eligibility criteria for selecting studiesLongitudinal studies on survival or nursing home admission in people with dementia. Studies with fewer than 150 participants, recruitment during acute hospital admission, or less than one year of follow-up were excluded.Results19 307 articles were identified and 261 eligible studies included. 235 reported on survival among 5 553 960 participants and 79 reported on nursing home admission among 352 990 participants. Median survival from diagnosis appeared to be strongly dependent on age, ranging from 8.9 years at mean age 60 for women to 2.2 years at mean age 85 for men. Women overall had shorter survival than men (mean difference 4.1 years (95% confidence interval 2.1 to 6.1)), which was attributable to later age at diagnosis in women. Median survival was 1.2 to 1.4 years longer in Asia than in the US and Europe, and 1.4 years longer for Alzheimer’s disease compared with other types of dementia. Compared with studies before 2000, survival was longer in contemporary clinic based studies (Ptrend=0.02), but not in community based studies. Taken together, variation in reported clinical characteristics and study methodology explained 51% of heterogeneity in survival. Median time to nursing home admission was 3.3 years (interquartile range 1.9 to 4.0). 13% of people were admitted in the first year after diagnosis, increasing to 57% at five years, but few studies appropriately accounted for competing mortality risk when assessing admission rates.ConclusionsThe average life expectancy of people with dementia at time of diagnosis ranged from 5.7 years at age 65 to 2.2 at age 85 in men and from 8.0 to 4.5, respectively, in women. About one third of remaining life expectancy was lived in nursing homes, with more than half of people moving to a nursing home within five years after a dementia diagnosis. Prognosis after a dementia diagnosis is highly dependent on personal and clinical characteristics, offering potential for individualised prognostic information and care planning.Systematic review registrationPROSPERO CRD42022341507.

For clinicians it is an important and demanding task to inform patients with dementia and their relatives about the prognosis. As with malignant diseases, discussing remaining life expectancy and time to death is a delicate matter. But it is even more challenging to provide information about the timeline for dependency and need for nursing home care because many factors are involved, not only the type of dementia, sex, and age of patients, but also comorbidities, lifestyle, and socioeconomic and cultural factors. Some patients seek all available information about their prognosis, whereas others prefer to know less, and the emotional response to information on the dementia diagnosis and prognosis varies substantially, from catastrophic to pragmatic. Additionally, a substantial discrepancy can exist between what patients and their relatives want in terms of information.The previous reviews on dementia related survival12 and nursing home admission were published more than a decade ago,3 so the...

bmj;388/jan08_7/r11/FAF1faRuth White was a woman of many passions; from antique textiles to singing opera to Aston Villa Football Club she threw herself into everything she committed to. This also translated into her professional life.In 2000 the death of a trainee psychiatrist and her baby led to a huge amount of soul searching across the NHS—the report into the deaths1 highlighted a range of contributing factors, including the lack of specialist mental health services for pregnant women and new mothers.The case prompted White, a community psychiatrist in Worcester, to set up one of the first community perinatal mental health teams in the country, using her considerable passion and drive to cajole the powers that be to give her the money to do it.White was self-taught, seeking out the advice of experts in the field to learn about perinatal mental health and then training community nurses and midwives to identify women at...

Most of us have favourite questions that we like to ask when consulting with patients or that we’re fond of teaching to medical students and resident doctors. One popular question many GPs teach their registrars to ask is, “What made you come today, particularly?” This can sometimes lead patients to disclose a triggering event that was just as important as the long running symptom they first presented with.Personally, I put a different question at the top of my own list for teaching: “How is this conversation going for you so far?” I like this question for several reasons. It helps you to find if you’re on the right track or have missed something important that the patient tried to say and you didn’t fully register. You can then recalibrate your response straight away, rather than finding out too late that you’ve gone badly off track. It’s also a way of...

Just over 10 years ago I was diagnosed with Parkinson’s disease. I had suffered for several years from strange bouts of cramp, stiffness, and a very painful back. A badly torn rotator cuff only confused the issue as I put much of my discomfort down to my shoulder or back problems. Before major back surgery the surgeon expressed doubts and quietly suggested a neurological rather than a musculoskeletal issue. Raising the possibility of a life changing condition with such non-alarmist tact was helpful.A colleague along the corridor was more direct but equally careful. Not everybody would have appreciated this directness, but I was relieved. Knowing what I had gave me a better chance of dealing with it.Facing the figuresDisease progression has been mercifully slow since my diagnosis. However, the intrinsic uncertainty in the condition breeds anxiety: another Parkinson’s gift. A thoughtless remark could cause me to lose confidence, leading to...

This piece comes with a trigger warning. We used to avoid talking about cancer, menopause, periods, or other stigmatised topics—adding to feelings of shame and limiting our understanding. This remains true of suicide, especially among healthcare staff. The writer Adam Kay describes NHS staff suicides as being “brushed under the carpet.”1 But talking about suicide is important, as open conversation reduces its risk.2Some statistics stick in my head. One nurse dies by suicide each week in the UK.3 The suicide rate in women doctors is up to four times that of women in the general population.4 Unfortunately, most colleagues are oblivious to the pain experienced by a huge proportion of their co-workers. But each tragedy can cause guilt, shame, and higher rates of suicide in the loved ones and colleagues affected.4Clare Gerada35 started the NHS Practitioner Health service,6 and she and Ananta Dave have written3 about awareness and prevention of...

bmj;388/jan08_2/r17/FAF1faMeena was born in Mantuvi, a tiny island off the east coast of Sri Lanka, in 1930, the youngest of four children. She was delivered by her father, a doctor, whom she revered and adored.In 1946 she met Shelly, the second man after her father to have a pivotal role in her life. In 1950 they entered medical school together at the University of Colombo. He was her strength and support and, for the next 78 years, they formed a happy and loving relationship.Meena began her training in pathology in 1962 at the General Hospital in Colombo, before moving to the UK. In 1965 she continued her training in pathology and microbiology at the West Middlesex, West London, and Charing Cross hospitals. Here she met Henry Winner, professor of microbiology at Charing Cross, who became her mentor. She loved, enjoyed, and embraced her career as a consultant medical microbiologist until...

bmj;388/jan08_1/r16/FAF1faGeorge Delfas was born in Athens and qualified at the top of his class in medicine at the University of Athens. After two years of national service, largely with the Greek delegation to NATO in Izmir, Turkey, he trained in general medicine and cardiology at the Evangelismos Hospital in Athens. He married Magda in 1966 and left for the UK after the colonels’ coup in 1967.George found the UK immediately congenial and started work at Orpington Hospital, moving to positions in cardiology at Glasgow’s Western Infirmary and then Walsgrave Hospital in Coventry. He became a GP in Earlsdon, Coventry, with specialist clinics in rheumatology at Coventry and Warwickshire Hospital. He was a caring and hard working family doctor, seeing the out-of-hours call outs of those days as a natural part of the job. On top of his general practice work he enjoyed working as a medical expert for the Tribunal...

2025 is here and medicine has continued to move away from the utopian vision of our admission essays for medical school. We are spending countless hours on electronic health records scrolling through layers of data to find the information we need, receiving vital information through fax machines, and listening to on-hold music as we try to help patients progress through labyrinthine treatment pathways so that they can get the care that they need. The administrative burden of modern medicine has become overwhelming.Healthcare providers face relentless obstacles in their workflows and inefficient technologies that impede patient care and contribute to suboptimal patient outcomes and physician burnout.1 Clearly, the labour of clinical practice is ripe for disruption and transformation. In response, the purveyors of artificial intelligence (AI) have promised solutions to overcome these seemingly intractable obstacles and inefficiencies. Given past experiences with the introduction of technology, such ambitious promises may understandably elicit...

The US has reported its first human death from avian influenza H5N1 in a person who had been admitted to hospital in Louisiana after being exposed to a non-commercial backyard flock and wild birds.1The patient was over 65 and reported to have underlying medical conditions. “The department expresses its deepest condolences to the patient’s family and friends. Due to patient confidentiality and respect for the family, this will be the final update about the patient,” the Louisiana Department of Health said in a statement on 6 January.The department added that its “extensive public health investigation” identified no additional H5N1 cases or evidence of person-to-person transmission. The US has reported around 66 human cases of H5N1 since the start of 2024.2“This patient remains the only human case of H5N1 in Louisiana,” it said. “While the current public health risk for the general public remains low, people who work with birds, poultry,...

bmj;388/jan07_8/r18/FAF1faCharles was born in London and was evacuated to Biggin Hill during the second world war. He studied medicine at University College London, then worked on the house staff at University College Hospital (UCH) before joining the Royal Air Force Institute of Aviation Medicine in 1955 with the rank of flight lieutenant.He had stints working in clinical practice at Hammersmith Hospital and UCH, and research roles in Sheffield and at Harvard Medical School, where he worked in the Biophysical Laboratory under Arthur K Solomon.Having met his future wife Gillian in the US, he returned to the UK in 1963 and the couple married and raised a family. Charles rejoined UCH as a consultant physician and senior clinical scientist with the Medical Research Council (MRC).While remaining with the MRC and in charge of the thyroid clinic at UCH, he was appointed consultant endocrinologist at Northwick Park Hospital and Clinical Research Centre...

The 1990s are firmly back in style. From bucket hats to Britpop playlists, the last decade of the 20th century is being celebrated across social media and pop culture. But alongside the harmless nostalgia, a far more unwelcome trend has been revived: the glamorisation of smoking.Recent headlines have highlighted how smoking is creeping back into the spotlight, particularly through influencers and celebrities with massive youth followings. Charli XCX, for example, whose music and aesthetic shaped the “brat summer” trend, described the vibe as “a pack of cigs, a Bic lighter, and a strappy white top with no bra.” At New York Fashion week last year, models strutted down the catwalk smoking cigarettes. There’s even an Instagram account dedicated to showing pictures of high profile, attractive celebrities smoking. This normalisation of smoking risks re-igniting a harmful cultural association between cigarettes and coolness, to which young people are particularly vulnerable.History repeating itself?The...

It was a familiar scene in the lead-up to Christmas: husbands looking lost in highly perfumed, dazzlingly lit shops. An expensive lipstick or cashmere scarf, seldom actually wanted, was bought as a surrogate object to represent “I love you.” Parents strained to understand the latest craze in overpriced plastic toys that promised more quality time with their children, away from digital distractions, but which often led to less. I too stood in those shops and bought those scarves and toys for my wife and children. But I’d already bought the perfect present for my friends—a gift that no one wants. For Christmas last year I bought my friends a funeral.This may seem a strange gift, and in many ways it is. Over the past 20 years, while caring for patients who are in the thick fog between life and death, I’ve met hundreds of people who have died, were resuscitated,...

The prime minister, Keir Starmer, has unveiled new plans to radically transform the NHS in a bid to cut waiting lists.1 One new element is the promise that GPs will be able to order more tests directly, including MRI and CT scans.2 This may speed up the process of reaching a diagnosis, as the relevant investigation will have already been performed by the time the patient sees a specialist, and if no abnormality is found it may be possible to reassure the patient without a hospital appointment.Discussions among GPs on social media reveal huge variations around the country in the kinds of tests they currently can and can’t order. GPs’ appetites for increased access also vary, with some keen to just get on and request the tests they know their patients will need, while others are wary of yet another transfer of work to GPs from hospitals, coupled with the...

The UK government has committed to leading the world in clinical trials and to “transforming treatment for dementia.”1 This commitment continues implementation of O’Shaughnessy’s recommendations on commercial clinical trials in the UK.2 It includes establishing “clinical trial delivery accelerators”—multidisciplinary teams working to widen access to research, hasten recruitment, and embed trials in the UK medical research infrastructure. The first of these to be announced was the dementia trial accelerator.3 A core component of the dementia accelerator is the trial ready cohort, a pool of pre-screened potential trial participants. We argue that the potential of trial ready cohorts is unproven and suggest that their ability to contribute to dementia research relies on tackling the distinctive ethical challenges that they present.Accelerating dementia trialsThe dementia field has been the “graveyard of drug discovery.”4 Clinical trials in the field have had an almost 100% lack of success, involving nearly 200 000 participants and costing...

After six months in power, the UK government has finally set out how it intends to tackle the longstanding and well documented challenges of adult social care. This should be welcomed. The centrepiece proposal is to establish an independent commission “to build a national consensus around a new National Care Service able to meet the needs of older and disabled people into the 21st century.”1We have been here before—the past 27 years have seen two government commissions, one shorter government commissioned review, three independent commissions, five white papers, and 14 parliamentary committee inquiries on social care reform. They have had little impact.2 Many have questioned whether yet another review is needed. But the choice of Louise Casey, a skilled Whitehall operator and cross bench peer, as chair of the commission creates an opportunity to bring a fresh perspective that avoids retreading old ground, helps build public support for a poorly...