The BMJ最新文献

{"title":"Computer aided detection and diagnosis of polyps in adult patients undergoing colonoscopy: a living clinical practice guideline","authors":"Farid Foroutan, Per Olav Vandvik, Lise M Helsingen, Mette Kalager, Matt Rutter, Kevin Selby, Nastazja Dagny Pilonis, Joseph C Anderson, Annette McKinnon, Jonathan M Fuchs, Casey Quinlan, Maaike Buskermolen, Carlo Senore, Pu Wang, Joseph J Y Sung, Ulrike Haug, Silje Bjerkelund, Konstantinos Triantafyllou, Dennis L Shung, Natalie Halvorsen, Thomas McGinn, Tandekile Lubelwana Hafver, Valerie Reinthaler, Gordon Guyatt, Thomas Agoritsas, Shahnaz Sultan","doi":"10.1136/bmj-2024-082656","DOIUrl":"https://doi.org/10.1136/bmj-2024-082656","url":null,"abstract":"Clinical question In 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 practice Colorectal 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. Evidence Evidence 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. Recommendation For adults who have agreed to undergo colonoscopy, we suggest against the routine use of CADe (weak recommendation). How this guideline was created An 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 recommendation Understanding the recommendation The 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 unce","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"37 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143713075","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sharp Scratch Episode 131: Are you really listening?","authors":"George Webster","doi":"10.1136/bmj.r433","DOIUrl":"https://doi.org/10.1136/bmj.r433","url":null,"abstract":"In this episode of Sharp Scratch, the panel got together to discuss the importance of properly listening to patients. The panel was joined by guest Rageshri Dhairyawan to explore how medical students and doctors can work …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"14 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143703332","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Children will suffer from changes to US research system","authors":"Colleen A Kraft, Michael Weitzman, Donna Koller, Jeffrey Goldhagen, Francis Rushton","doi":"10.1136/bmj.r572","DOIUrl":"https://doi.org/10.1136/bmj.r572","url":null,"abstract":"As paediatricians working in the US, we view the changes being made to our healthcare and education systems, research enterprise, and regulatory agencies1 as truly dystopian. The damage is clear to us. The breakdown of information from the Centers for Disease Control and Prevention; unjustified firing of workers from the National Science Foundation, US Department of Agriculture, Food and Drug Administration, and Environmental Protection Agency; decreasing the funding of university …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"13 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143703287","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Development of ROBUST-RCT: Risk Of Bias instrument for Use in SysTematic reviews-for Randomised Controlled Trials","authors":"Ying Wang, Sheri Keitz, Matthias Briel, Paul Glasziou, Romina Brignardello-Petersen, Reed A C Siemieniuk, Dena Zeraatkar, Elie A Akl, Susan Armijo-Olivo, Dirk Bassler, Carrol Gamble, Lise Lotte Gluud, Jane Luise Hutton, Luz M Letelier, Philippe Ravaud, Kenneth F Schulz, David J Torgerson, Gordon H Guyatt","doi":"10.1136/bmj-2024-081199","DOIUrl":"https://doi.org/10.1136/bmj-2024-081199","url":null,"abstract":"Recent innovations in evidence based medicine methods, in particular instruments assessing risk of bias in randomised trials, have focused on methodological rigour at the expense of simplicity and practicability. Such a focus could lead to challenges in application and loss of reliability of instruments. To deal with these shortcomings, the Risk Of Bias instrument for Use in SysTematic reviews-for Randomised Controlled Trials (ROBUST-RCT) was created—a rigorously developed, simply structured, and user friendly instrument for assessing risk of bias of randomised controlled trials included in systematic reviews. This paper describes the development of ROBUST-RCT and provides associated documents and a manual of instructions. Although systematic reviews of randomised controlled trials provide the best evidence for the effects of healthcare interventions,1 flaws in trial design and conduct may result in biased estimates of effects, and hence misleading conclusions.2 As a result, risk of bias assessment of randomised controlled trials has become an essential step in the systematic review process. Furthermore, risk of bias represents one domain in the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system of rating certainty of evidence, and trial limitations resulting in risk of bias may lead authors of systematic reviews to rate down the certainty of evidence.34 Although many instruments for assessing risk of bias in randomised controlled trials are available,5 most have important limitations. A systematic survey found that existing instruments often include items that do not deal with risk of bias.5 To be suitable for use in systematic reviews, risk of bias instruments should include only items that deal with risk of bias problems rather than other GRADE domains.3 The most popular and rigorously developed instruments include those offered by the Cochrane Collaboration. The first Cochrane risk of bias instrument6 included an “unclear” response option that …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"16 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143695505","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"UK welfare reforms threaten health of the most vulnerable","authors":"Gerry McCartney, Lucinda Hiam, Katherine E Smith, David Walsh","doi":"10.1136/bmj.r593","DOIUrl":"https://doi.org/10.1136/bmj.r593","url":null,"abstract":"Cuts to disability benefits will worsen health and the economy The chancellor of the exchequer, Rachel Reeves, will set out the UK government’s spending plans in her spring statement on 26 March.1 The consultative green paper, Pathways to Work ,2 has already outlined plans to cut several billion from the welfare budget, with the aim of saving £5bn by 2029-30.3 The plans include stricter criteria for personal independence payments (PIP) for people with disabilities; halving incapacity benefit payments under Universal Credit for new claimants; and restriction of incapacity benefit top-ups to those aged 23 years and older. Ministers have argued there is a “moral case” for these cuts, and that “people that can work [should be] able to work.”3 However, the chancellor’s approach is unlikely to achieve this goal for two key reasons. First, high rates of economic inactivity in the UK reflect its almost unique failure among industrialised countries to recover population health after the pandemic,456 which came on top of over a decade of declining health linked to austerity,7 as well as long term …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"96 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143695559","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Increasing suicides of female healthcare workers indicate a population and economy at risk","authors":"Carla Peeters","doi":"10.1136/bmj.r558","DOIUrl":"https://doi.org/10.1136/bmj.r558","url":null,"abstract":"Bambra and colleagues suggest an approach that links health and skills to tackle health related worklessness.1 But when the health of those who look out for people’s health is at risk, so are the whole population and the economy. In the pandemic, and even before, women working in the healthcare system have become increasingly desperate.2 As …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"35 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143695508","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Preventing ill health requires dismantling of the structures that have failed","authors":"John Ashcroft","doi":"10.1136/bmj.r560","DOIUrl":"https://doi.org/10.1136/bmj.r560","url":null,"abstract":"Salisbury is right that preventing ill health requires investment,1 but we have been here before. In October 2014 Simon Stevens brought out his Five Year Forward View : “The first argument . . . is that the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.”2 The next …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"57 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143695509","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Are “copycat” compounded weight loss drugs safe?","authors":"Katharine Lang","doi":"10.1136/bmj.r429","DOIUrl":"https://doi.org/10.1136/bmj.r429","url":null,"abstract":"Growing demand for weight loss drugs means that gaps are being filled by compounded versions. Katharine Lang asks if these can safely make up the shortfall In the UK more than 3 in every 1000 people are taking glucagon-like peptide-1 (GLP-1) agonist drugs, says Kevin McCarroll, consultant physician and geriatrician at St James Hospital, Dublin.1 Depending on the region, 77-179 in 100 000 people are using the leading GLP-1 drug semaglutide (Ozempic for type 2 diabetes, Wegovy for obesity), he says.1 And these are just the official prescribing figures—anecdotal evidence suggests many are purchasing the drugs from unofficial sources. Growing evidence of the drugs’ efficacy for weight loss2 is fuelling demand worldwide. The number of patients in the US approved for GLP-1 agonist treatment for obesity rose from 190 000 a month in 2021 to 1.8 million in 2024.3 Analysis of the US market shows that 5.2% of women and 4.2% of men with obesity are being prescribed the drugs, although access varies. “The global supply shortage seen in 2024 was at least partly because of a surge in off-label prescriptions for semaglutide for weight loss,” says Eamon Laird, assistant lecturer in nutritional science at ATU Sligo in Ireland. He added that use of the drug for weight loss by people without obesity and those who do not have any weight related health problems is exacerbating the situation. “Manufacturers are trying to upscale production, but it’s taking time. This is a global shortage with global demand. Similar shortages are reported in Ireland, the UK, the EU, and the US.” To try to increase availability the US Food and Drug Administration (FDA) has allowed pharmacies to manufacture and sell “compounded” versions of the drugs—these are copies of approved drugs or drugs under patent, allowed when licensed drugs are …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"183 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143695557","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Equitable energy transitions for a healthy future: combating air pollution and climate change","authors":"Yuan Yao, Michael Jerrett, Tong Zhu, Frank J Kelly, Yifang Zhu","doi":"10.1136/bmj-2025-084352","DOIUrl":"https://doi.org/10.1136/bmj-2025-084352","url":null,"abstract":"Yifang Zhu and colleagues argue that equitable energy transitions are critical to improving public health and reducing health inequalities Energy systems—the entire network of processes, technologies, and infrastructure involved in producing, converting, distributing, and consuming energy—are the largest single source of greenhouse gas emissions. The emissions come mainly from the combustion of fossil fuels, which also contribute to ambient air pollution.1 Alarmingly, nearly the entire global population (99% of 8.2 billion) resides in areas that fail to meet the World Health Organization’s air quality guidelines, with low and middle income countries experiencing the highest levels of fine particulate matter (PM2.5).2 Adding to this concern, WHO estimates that 3.6 billion people live in areas highly susceptible to climate change.3 Both air pollution and climate change pose threats to human health that can be addressed through coordinated and synergistic measures (fig 1). Fig 1 The nexus of equitable energy transitions, air quality, climate change, and public healthEnergy transitions, such as phasing out fossil fuels and adopting renewable energy sources (eg, solar, wind, hydro, wave, tidal, and geothermal), are effective strategies to reduce air pollution and improve health. These transitions also contribute to the United Nations’ goal of achieving carbon neutrality by 2050. Energy transitions, however, need to be equitable, which means that everyone should have access to energy that is affordable, safe, sustainable, and capable of supporting a decent lifestyle. Equitable energy transitions should also empower individuals to participate in, and lead, energy decision making processes with the authority to enact change.4 Action is urgent as “health is at the mercy of fossil fuels”5 Climate change is arguably the greatest global health threat of the 21st century. Its health effects are extensive, including direct exposure to extreme weather events, disruption of food and healthcare systems, and …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"10 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143695562","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effects of intensive blood pressure treatment on orthostatic hypertension: individual level meta-analysis","authors":"Stephen P Juraschek, Jiun-Ruey Hu, Jennifer L Cluett, Carol Mita, Lewis A Lipsitz, Lawrence J Appel, Nigel S Beckett, Barry R Davis, Rury R Holman, Edgar R Miller, Kenneth J Mukamal, Ruth Peters, Jan A Staessen, Addison A Taylor, Jackson T Wright, William C Cushman","doi":"10.1136/bmj-2024-080507","DOIUrl":"https://doi.org/10.1136/bmj-2024-080507","url":null,"abstract":"Objective To determine the effects of intensive blood pressure treatment on orthostatic hypertension. Design Systematic review and individual participant data meta-analysis. Data sources MEDLINE, Embase, and Cochrane CENTRAL databases through 13 November 2023. Inclusion criteria Population: ≥500 adults, age ≥18 years with hypertension or elevated blood pressure; intervention: randomized trials of more intensive antihypertensive drug treatment (lower blood pressure goal or active agent) with duration ≥6 months; control: less intensive antihypertensive drug treatment (higher blood pressure goal or placebo); outcome: measured standing blood pressure. Main outcomes Orthostatic hypertension, defined as an increase in systolic blood pressure ≥20 mm Hg or diastolic blood pressure ≥10 mm Hg after changing from sitting to standing. Data synthesis Two investigators independently abstracted articles. Individual participant data from nine trials identified during the systematic review were appended together as a single dataset. Results Of 31 124 participants with 315 497 standing blood pressure assessments, 9% had orthostatic hypotension (that is, a drop in blood pressure after standing of systolic ≥20 mm Hg or diastolic ≥10 mm Hg), 17% had orthostatic hypertension, and 3.2% had both a rise in systolic blood pressure and standing blood pressure ≥140 mm Hg at baseline. The effects of more intensive treatment were similar across trials with odds ratios for orthostatic hypertension ranging from 0.85 to 1.08 (I2=38.0%). During follow-up, 17% of patients assigned to more intensive treatment had orthostatic hypertension, whereas 19% of those assigned less intensive treatment had orthostatic hypertension. Compared with less intensive treatment, the risk of orthostatic hypertension was lower with more intensive blood pressure treatment (odds ratio 0.93, 95% confidence interval 0.90 to 0.96). Effects were greater among non-black versus black adults (odds ratio 0.86 v 0.97; P for interaction=0.003) and adults without diabetes versus those with diabetes (0.88 v 0.96; P for interaction=0.05) but did not differ by age ≥75 years, sex, baseline seated blood pressure ≥130/≥80 mm Hg, obesity, stage 3 kidney disease, stroke, cardiovascular disease, standing systolic blood pressure ≥140 mm Hg, or pre-randomization orthostatic hypertension (P for interactions ≥0.05). Conclusions In this pooled cohort of adults with elevated blood pressure or hypertension, orthostatic hypertension was common and more intensive blood pressure treatment modestly reduced the occurrence of orthostatic hypertension. These findings suggest that approaches generally used for seated hypertension may also prevent hypertension on standing. Study registration Prospero CRD42020153753 (original proposal). The data associated with this paper were used with institutional agreements between the NHLBI BioLINCC repository of institutions that conducted the original trials. The data use agreements do not permit pu","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"18 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143695506","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}