The BMJ最新文献

{"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}

{"title":"Orthostatic hypertension in hypertensive patients: should we bother?","authors":"Artur Fedorowski, Jens Jordan","doi":"10.1136/bmj.r493","DOIUrl":"https://doi.org/10.1136/bmj.r493","url":null,"abstract":"Blood pressure should be taken in different positions Although we were taught in medical school that blood pressure should be measured in different body positions, particularly in older patients, an active standing test, in which blood pressure and heart rate are taken in supine, seated, and standing positions, is rarely done. Clinical trials, hypertension guidelines, and daily practice have over many years relied on office blood pressure measurement in the sitting position. Seated blood pressure is a well established cardiovascular risk marker, as evidenced by multiple epidemiological surveys and hypertension trials. However, important clinical information may be lost when we ignore the dynamic blood pressure response to changes in posture, which occurs many times during the day. In a linked study (doi:10.1136/bmj-2024-080507), Juraschek and colleagues report results of a systematic review of interventional trials in hypertension assessing the effect of antihypertensive therapy on occurrence of orthostatic hypertension—that is, a distinct rise in blood pressure on standing.1 The question is relevant because initial studies have suggested that antihypertensive drugs might promote orthostatic hypertension by reducing blood volume and venous return.2 But why bother about orthostatic hypertension at all? When one changes body position from supine to …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"25 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143695558","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":"Art of “holding patient care in general practice” is key to survival of the NHS","authors":"Max Cooper, Carl Fernandes, Jason Heath","doi":"10.1136/bmj.r546","DOIUrl":"https://doi.org/10.1136/bmj.r546","url":null,"abstract":"Data on hospital beds are important1 but must not eclipse upstream priorities for tackling pressures in the NHS. Strengthening general practice is crucial. This calls for medical educators and NHS leaders who value and promote generalist skills—in particular, the art of “holding patient care in general practice.” “Holding” necessitates meeting patients’ health needs as far as possible entirely within the primary care setting and avoiding premature or unnecessary secondary care involvement or specialist investigations. Community presentations such as …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"97 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143677908","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":"Care guided by tissue oxygenation and haemodynamic monitoring in off-pump coronary artery bypass grafting (Bottomline-CS): assessor blind, single centre, randomised controlled trial","authors":"Jiange Han, Wenqian Zhai, Zhenhua Wu, Zhao Zhang, Tao Wang, Min Ren, Ziyue Liu, Daniel I Sessler, Zhigang Guo, Lingzhong Meng, the Bottomline-CS investigation group","doi":"10.1136/bmj-2024-082104","DOIUrl":"https://doi.org/10.1136/bmj-2024-082104","url":null,"abstract":"Objective To assess whether perioperative management guided by near-infrared spectroscopy to determine tissue oxygen saturation and haemodynamic monitoring reduces postoperative complications after off-pump coronary artery bypass grafting. Design Assessor blinded, single centre, randomised controlled trial (Bottomline-CS trial). Setting A tertiary teaching hospital in China. Participants 1960 patients aged 60 years or older who were scheduled for elective off-pump coronary artery bypass grafting. Interventions All patients had multisite monitoring of tissue oxygen saturation (bilateral forehead and unilateral forearm brachioradialis) and haemodynamic monitoring. Both groups received usual care, including arterial blood pressure, central venous pressure, electrocardiography, and transoesophageal echocardiography when indicated. Guided care aimed to maintain tissue oxygenation within 10% above or below preoperative baseline values, established 24-48 hours before surgery, from the start of anaesthesia until extubation or for up to 24 hours postoperatively. In the usual care group, tissue oximetry and haemodynamic data were concealed, and care was routine. Main outcome measures The primary outcome was the incidence of a composite of 30 day postoperative complications, which were cerebral, cardiac, respiratory, renal, infectious, and mortality complications. Secondary outcomes included the individual components of the composite outcome, new-onset atrial fibrillation, and hospital length of stay. Results Of 1960 patients randomly assigned, data from 967 guided care and 974 usual care patients were analysed. During anaesthesia, the area under the curve for tissue oxygen saturation measurements outside the plus and minus 10% baseline range was significantly smaller with guided care than only usual care: left forehead 32.4 versus 57.6 (%×min, P<0.001), right forehead 37.9 versus 62.6 (P<0.001), and forearm 14.8 versus 44.7 (P<0.001). The primary composite outcome occurred in 457/967 (47.3%) patients in the guided care group and 466/974 (47.8%) patients in the usual care group (unadjusted risk ratio 0.99 (95% confidence interval 0.90 to 1.08), P=0.83). No secondary outcomes differed significantly between groups. The largest observed difference was in incidence of pneumonia, which was less frequent in the guided care group (88/967, 9.1%) than in the usual care group (121/974, 12.4%) and not statistically significant after adjusting for multiple comparisons. Conclusions Guided care by use of multisite near-infrared spectroscopy and haemodynamic monitoring effectively maintained tissue oxygenation near baseline levels compared with usual care. However, no clear evidence was noted that this approach reduced the incidence of major postoperative complications. These findings do not support the routine use of near-infrared spectroscopy and haemodynamic monitoring to maintain tissue oxygenation during off-pump coronary artery bypass grafting. Trial registration Cl","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"71 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143677951","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":"PROBAST+AI: an updated quality, risk of bias, and applicability assessment tool for prediction models using regression or artificial intelligence methods","authors":"Karel G M Moons, Johanna A A Damen, Tabea Kaul, Lotty Hooft, Constanza Andaur Navarro, Paula Dhiman, Andrew L Beam, Ben Van Calster, Leo Anthony Celi, Spiros Denaxas, Alastair K Denniston, Marzyeh Ghassemi, Georg Heinze, André Pascal Kengne, Lena Maier-Hein, Xiaoxuan Liu, Patricia Logullo, Melissa D McCradden, Nan Liu, Lauren Oakden-Rayner, Karandeep Singh, Daniel S Ting, Laure Wynants, Bada Yang, Johannes B Reitsma, Richard D Riley, Gary S Collins, Maarten van Smeden","doi":"10.1136/bmj-2024-082505","DOIUrl":"https://doi.org/10.1136/bmj-2024-082505","url":null,"abstract":"The Prediction model Risk Of Bias ASsessment Tool (PROBAST) is used to assess the quality, risk of bias, and applicability of prediction models or algorithms and of prediction model/algorithm studies. Since PROBAST’s introduction in 2019, much progress has been made in the methodology for prediction modelling and in the use of artificial intelligence, including machine learning, techniques. An update to PROBAST-2019 is thus needed. This article describes the development of PROBAST+AI. PROBAST+AI consists of two distinctive parts: model development and model evaluation. For model development, PROBAST+AI users assess quality and applicability using 16 targeted signalling questions. For model evaluation, PROBAST+AI users assess the risk of bias and applicability using 18 targeted signalling questions. Both parts contain four domains: participants and data sources, predictors, outcome, and analysis. Applicability of the prediction model is rated for the participants and data sources, predictors, and outcome domains. PROBAST+AI may replace the original PROBAST tool and allows all key stakeholders (eg, model developers, AI companies, researchers, editors, reviewers, healthcare professionals, guideline developers, and policy organisations) to examine the quality, risk of bias, and applicability of any type of prediction model in the healthcare sector, irrespective of whether regression modelling or AI techniques are used. In healthcare, prediction models or algorithms (hereafter referred to as prediction models) estimate the probability of a health outcome for individuals. In the diagnostic setting—including screening and monitoring—the model typically aims to predict or classify the presence of a particular outcome, such as a disease or disorder. In the prognostic setting the model aims to predict a future outcome—typically health related—in patients with a diagnosis of a particular disease or disorder, or in the general population. The primary use of a prediction model in healthcare is to support individual healthcare counselling and shared decision making on, for example, subsequent medical testing, …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"54 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143677907","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":"Trump 2.0—a backwards step for women’s sexual and reproductive rights","authors":"John Oldroyd, Nancy Shresta, Alison Hughes","doi":"10.1136/bmj.r550","DOIUrl":"https://doi.org/10.1136/bmj.r550","url":null,"abstract":"Buse and McKee discuss the potential changes to global health directions, funding, and structures under a second Trump administration.1 They note the risk to funding of organisations supporting sexual and reproductive health rights. These include the reinstatement of such policies as the “global gag rule,” in which the US government refuses to fund global non-government organisations who provide, refer, or …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"86 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143678084","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":"Combining medicine and mental health: the consultant old age liaison psychiatrist","authors":"Kathy Oxtoby","doi":"10.1136/bmj.r556","DOIUrl":"https://doi.org/10.1136/bmj.r556","url":null,"abstract":"Consultant old age liaison psychiatrist Raja Badrakalimuthu speaks to Kathy Oxtoby about why making a difference to a person with dementia or their family makes his day A love of people and their life stories inspired Raja Badrakalimuthu to specialise in old age psychiatry. “Working with older people, you get to have conversations about their lives,” says Badrakalimuthu, a consultant old age liaison psychiatrist at Royal Surrey County Hospital in Guildford. “Their generation built our society, and we’ve inherited the legacy of their hard work. I find it satisfying to be able to do something for them—to thank them, and show my gratitude.” Old age psychiatry is “the perfect blend of medicine and mental health,” he says. “Older people can have multiple physical conditions and you have to take this into account when diagnosing dementia.” With new dementia drugs becoming incorporated into clinical practice, and new cognitive assessments and scans becoming readily available, “it’s an exciting time to be doing old age psychiatry,” Badrakalimuthu says. Old age psychiatrists also have to be aware of what kind of support is available for older people in the community, such as respite care, he says. “You’re not just intervening at …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"25 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143677909","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":"Anne Bayley: surgical oncologist who recognised the spread of AIDS in Zambia among heterosexual patients","authors":"Jane Hutchinson, Anthony Pinching","doi":"10.1136/bmj.r574","DOIUrl":"https://doi.org/10.1136/bmj.r574","url":null,"abstract":"In 1983 surgeons across East Africa began to compare notes about a new disease, known colloquially as “slim,” which was prevalent across the region. At the time, Anne Bayley was running a clinic at the University Teaching Hospital in Lusaka, Zambia, for patients with endemic Kaposi’s sarcoma, a relatively indolent skin tumour, found mainly in older men. In 1983, however, the number of new cases of Kaposi’s sarcoma doubled to 23—and 13 of these patients (including three women) presented with unusual, more aggressive disease. Eight patients died in less than a year.1 There was also a rise in reports of Kaposi’s sarcoma in the literature, reflecting the emergence of HIV/AIDS among mainly gay men in the West. Bayley realised that HIV was the underlying problem in her patients with aggressive Kaposi’s sarcoma, which she thought implied heterosexual transmission. Not everyone agreed, convinced that it was spread by sex between men. Keeping an open mind and with some personal discomfort, she asked her male patients if they ever had sex with men. Most responded with an emphatic no. In 1984, when an HIV antibody test was developed, Bayley sent samples for testing. Nearly all the patients with aggressive Kaposi’s sarcoma were HIV positive. Bayley’s clinical reports resulted in the US Centers for Disease Control sending a team to Lusaka, leading to …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"17 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143678003","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":"The growing number of prospective doctors given placeholder jobs demands urgent action","authors":"Alastair Paterson","doi":"10.1136/bmj.r587","DOIUrl":"https://doi.org/10.1136/bmj.r587","url":null,"abstract":"Alastair Paterson explores how the increasing number of prospective doctors allocated to placeholder posts is indicative of a growing workforce crisis The growing number of medical students put on a “placeholder” list after applying for foundation year training raises serious concerns about the capacity and foresight of the UK Foundation Programme Office (UKFPO). In 2024, more than a thousand medical school graduates were left without allocated foundation year training posts and faced a prolonged period of uncertainty while emergency posts were created.1 This has left graduates unable to plan the next steps of their careers and personal lives. Early reports suggest that this year hundreds of students have again been given a placeholder allocation.2 The shortage of foundation training posts is indicative of a growing problem, as the number of students graduating from UK medical schools is expected to continue rising.3 …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"71 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143695507","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":"Near-infrared spectroscopy in perioperative medicine","authors":"Igor Feinstein, Martin S Angst","doi":"10.1136/bmj.r539","DOIUrl":"https://doi.org/10.1136/bmj.r539","url":null,"abstract":"Current insights and remaining questions Near-infrared spectroscopy (NIRS), originally described in 1977, entered clinical practice as a non-invasive method to assess regional tissue oxygenation.1 This monitoring technique was initially used in high risk surgeries to measure cerebral oxygenation in real time. After encouraging results that linked intraoperative NIRS guided, goal directed treatment to improved neurological outcomes in cardiac surgery, NIRS use quickly expanded.234 This increased use has sparked the development of multiple competing clinically approved NIRS monitoring systems, highlighting the substantial market interest in this technology.5 Despite the widespread use of NIRS, negative findings from subsequent trials have raised concerns about whether NIRS monitoring truly improves outcomes.678 These concerns have prompted a debate regarding the surgical populations who might benefit from NIRS and the best practices for its use.9 In a linked research paper (doi:10.1136/bmj-2024-082104), Han and colleagues present noteworthy findings from the Bottomline-CS trial, which examined whether perioperative care guided by cerebral and peripheral tissue oximetry enhanced clinical outcomes in patients undergoing off-pump coronary artery bypass graft surgery …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"28 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2025-03-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143677910","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}