The BMJ最新文献

{"title":"What happens to me if a PA makes a mistake on my watch?","authors":"Abi Rimmer","doi":"10.1136/bmj.q2722","DOIUrl":"https://doi.org/10.1136/bmj.q2722","url":null,"abstract":"As physician associates (PAs) fall under the regulation of the General Medical Council, what are the supervising doctors’ responsibilities, Abi Rimmer asks Mark Swindells, assistant director, standards and guidance, GMC, says, “Modern healthcare is delivered through multiprofessional teams, and the delivery of good patient care is reliant on effective communication around supervision and delegation. If you’re a named supervisor for a PA or anaesthesia associate (AA), you’ll have specific responsibilities. There is no one-size-fits-all approach because individuals develop their skills and experience over time. “You should agree an appropriate level of supervision and make sure there’s a managed support system in place, with clear escalation protocols. Your employer should support you by ensuring you have the skills, time, and training needed. “We have general expectations of all our registrants when it comes to the day-to-day supervision of colleagues and delegation of tasks. If you can’t be certain of the competence of a PA or AA colleague, you’ll need to ask them about this before using your professional judgment to establish if you can delegate care or if you need to supervise. “Day-to-day supervision involves overseeing tasks and responsibilities that a colleague undertakes. This includes giving advice and guidance, as well as direct supervision of a specific task. You must give clear instructions about what is expected and be available to answer questions or provide help when needed. “Delegation involves asking a colleague to take responsibility for providing care or treatment on your behalf. If you’re confident you can delegate, then as well as giving clear instructions and encouraging questions you must ensure your colleague knows how to escalate safety concerns. You’re not accountable for the decisions and actions of PAs and AAs, provided you’ve acted in line with the professional standards set out in delegation and referral. “If you use …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"2 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142809263","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":"Aortic valve replacements … and other research","authors":"Tom Nolan","doi":"10.1136/bmj.q2764","DOIUrl":"https://doi.org/10.1136/bmj.q2764","url":null,"abstract":"Tom Nolan reviews this week’s research Established surgical treatment for people with severe aortic stenosis who have obstructive coronary artery disease is surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG). A new trial, published in the Lancet , suggests that transcatheter aortic valve implantation (TAVI) and fractional flow reserve (FFR) guided percutaneous coronary intervention (PCI) may be a better option. Four of the 91 patients (4%) in the TAVI group of the multicentre European study and 17 of the 77 (23%) in the SAVR group reached the composite primary endpoint of the study of all-cause mortality, myocardial infarction, disabling stroke, clinically driven target vessel revascularisation, valve reintervention, and life threatening or disabling bleeding at one year after treatment (hazard ratio 0.17 (95% confidence interval 0.06 to 0.51)). This was in large part due to …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"13 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142809216","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":"Association for Palliative Medicine and its members’ dissenting views","authors":"Sam H Ahmedzai, Samuel Fingas","doi":"10.1136/bmj.q2746","DOIUrl":"https://doi.org/10.1136/bmj.q2746","url":null,"abstract":"We do not contest the figures provided by the Association for Palliative Medicine (APM) in response to us,1 but we want to express our concern that the views of the one in four or five who dissent are being overlooked by our professional body in APM communications.2 We disagree that the APM’s position statement on assisted dying acknowledges the variation in members’ views: it says only that there is dissent.3 It mainly repeats the APM’s opposition to …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"230 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142809256","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":"Overcoming gender gaps in health leadership","authors":"Jocalyn Clark, Sarah Hawkes","doi":"10.1136/bmj.q2768","DOIUrl":"https://doi.org/10.1136/bmj.q2768","url":null,"abstract":"Trust in women’s leadership is declining when it is most needed for health International data show a concerning increase in regressive attitudes towards women leaders, especially among young men. This has grave implications for health globally at a time of economic, social, and climate crises and recent political upheavals threatening human rights. Tackling these complex challenges requires trust in both institutions and leaders, irrespective of gender, not least because public faith in government, media, and parts of the corporate sector is declining in many countries.1 In particular, loss of trust in women as leaders must be overcome to improve health. The Reykjavik index on leadership, an annual survey of 18-65 year olds across 10 countries and 23 economic sectors, reports a notable decline in equality in terms of how the public views women and men and their suitability for leadership. A score of 100 means respondents trust men and women’s leadership equally. Across the G7 nations (Canada, France, Germany, Italy, Japan, UK, and US), the index score for 2024 is 68, the lowest in seven years.2 In the US, only 47% of those surveyed said they were very comfortable with a woman being a head of government, and across the G7 just half were comfortable with a woman …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"28 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142809261","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":"Tender erythematous plaques with fever","authors":"Changyi Yang, Jianjun Qiao","doi":"10.1136/bmj-2023-076856","DOIUrl":"https://doi.org/10.1136/bmj-2023-076856","url":null,"abstract":"A man in his 50s was referred to a community hospital with a 15 day history of fever (38.5°C) and a one week history of painful cutaneous eruptions on his forearms and the crown of the scalp. Before this he had a three month history of abdominal pain and diarrhoea, and a one month history of 3 kg weight loss, but did not seek medical care at that time. The patient underwent blood tests, the results of which showed neutrophilia and raised C reactive protein. The patient was started on an empirical oral cephalosporin for one week, but showed no improvement. On presentation to our clinic, physical examination identified tender oedematous erythematous plaques with a pseudovesicular appearance on the head and dorsal aspect of his forearms and hands (fig 1). Repeat laboratory investigations showed an increased …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"21 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-12-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142809260","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":"Assisted dying: safety and access are not balanced in practice","authors":"K Sonu Gaind","doi":"10.1136/bmj.q2733","DOIUrl":"https://doi.org/10.1136/bmj.q2733","url":null,"abstract":"Downar and colleagues wrongly claim that “eligibility criteria have little effect on who actually receives an assisted death,”1 which erases evidence that the expansion of medical assistance in dying (MAID) in Canada has led some people to seek death as an escape not from illness but from life and social suffering. Within six years of introducing MAID for terminal conditions (track 1) in 2016, Canada became the number one euthanasia provider in the world.2 In 2021 the expansion …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142805305","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":"Doubts over landmark heart drug trial: ticagrelor PLATO study","authors":"Peter Doshi","doi":"10.1136/bmj.q2550","DOIUrl":"https://doi.org/10.1136/bmj.q2550","url":null,"abstract":"A top selling antiplatelet drug has never quite shaken off doubts about its advantage over cheaper rivals. With generic versions of ticagrelor about to launch, Peter Doshi takes a fresh look at the evidence Over the past decade the antiplatelet drug ticagrelor (Brilinta in the US and Brilique in Europe) has become firmly established in the treatment of acute coronary syndrome, recommended in guidelines from cardiology societies across the world.123 As the only P2Y12 inhibitor still under patent in the US, the public expenditure is substantial, accounting for around two thirds of the total cost of P2Y12 inhibitors despite less than 10% of total prescriptions.4 In 2022, the US federal government spent more than $750m (£593m; €712m) on ticagrelor. But since its 2011 approval by the US Food and Drug Administration (FDA) doubts have grown about its apparent advantage over cheaper, off patent P2Y12 inhibitors like clopidogrel and prasugrel. While AstraZeneca, ticagrelor’s manufacturer, reported superior efficacy to clopidogrel in the phase 3 trial that brought the drug to market, studies in the post-licensure period have repeatedly reported disappointing results,567891011121314 showing similar efficacy to clopidogrel but with increased bleeding and dyspnoea, prompting calls for a reappraisal of guidelines.1516 With generic versions of ticagrelor expected soon in the US, The BMJ took a fresh look at the evidence. Our investigation found AstraZeneca’s drug was approved over the emphatic objections of FDA scientific review staff, and that ticagrelor’s major clinical trial, named PLATO, was the focus of a long and rancorous dispute over its basic reliability. The BMJ can also disclose new details on the controversy after obtaining primary PLATO trial records and unpublished data through a freedom of information request that shows further problems in data …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"119 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142809257","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":"Scarlett McNally: Improving our health will reduce the strain on social care","authors":"Scarlett McNally","doi":"10.1136/bmj.q2743","DOIUrl":"https://doi.org/10.1136/bmj.q2743","url":null,"abstract":"We’re stuck in a vicious cycle. Hospital beds are full. Over 12% of hospital inpatients no longer meet the criteria to be there.12 This has knock-on effects for emergency departments and leads to cancellation of elective operations. The costs of social care are unaffordable for many and are increasing massively.34 Adult social care accounts for half of some local councils’ revenue budgets,4 meaning that many are making drastic cuts in the things that keep people healthy45—such as swimming pools, play parks, and walkable streets. Being physically active reduces the need for social care,6 and a person’s fitness is the major determinant of how much care is needed.26 Yet our default model of healthcare creates passivity for patients. Many …","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"28 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142809213","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":"How did the RCP get into a mess over physician associates?","authors":"Adele Waters","doi":"10.1136/bmj.q2729","DOIUrl":"https://doi.org/10.1136/bmj.q2729","url":null,"abstract":"The Royal College of Physicians has been at the centre of the UK row over physician associates. Adele Waters explores what happened and where it leaves the college now In March 2024 the Royal College of Physicians was forced to hold an extraordinary general meeting (EGM), only the third in its more than 500 year history.1 The issue that prompted it was physician associates (PAs), specifically their regulation, scope of practice, and expansion across the health service. The meeting was ill tempered and fraught, with participants describing it as “really aggressive” and an “unmitigated disaster.”2 Such was the concern about the meeting’s conduct and the level of hostility in the room that the RCP was forced to admit it had failed its membership and ordered an independent review to establish what had gone wrong.3 That review, carried out by the health think tank the King’s Fund and published in September,2 found a “pervasive lack of trust and confidence” in the RCP’s governance and that its governing council had been operating ineffectively. After the EGM the college saw several high level resignations: its former president Sarah Clarke,4 registrar Cathryn Edwards,5 former deputy registrar Jamie Read,6 and, after the King’s Fund review, the chair of the board of trustees, David Croisdale-Appleby.7 In 2015 the college had established the Faculty of Physician Associates (FPA), in conjunction with Health Education England (as it was then called) and other medical royal colleges (box 1). Several members of the FPA’s board also resigned en masse after the EGM, including its president and vice president.8 The FPA will close at the end of this year, although the RCP will continue to oversee the annual PA exam. Box 1 ### Timeline—RCP and PAsRETURN TO TEXT","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"25 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142805381","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":"Inequalities in uptake of childhood vaccination in England, 2019-23: longitudinal study","authors":"Aidan Flatt, Roberto Vivancos, Neil French, Sophie Quinn, Matthew Ashton, Valérie Decraene, Daniel Hungerford, David Taylor-Robinson","doi":"10.1136/bmj-2024-079550","DOIUrl":"https://doi.org/10.1136/bmj-2024-079550","url":null,"abstract":"Objective To quantify changes in inequalities in uptake of childhood vaccination during a period of steadily declining overall childhood vaccination rates in England. Design Longitudinal study. Setting General practice data for five vaccines administered to children (first and second doses of the measles, mumps, and rubella vaccine (MMR1 and MMR2, respectively), rotavirus vaccine, pneumococcal conjugate vaccine (PCV) booster, and six-in-one (DTaP/IPV/Hib/HepB) vaccine covering diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b, and hepatitis B) from the Cover of Vaccination Uptake Evaluated Rapidly dataset in England. Participants Children aged <5 years eligible for vaccinations between April 2019 and March 2023 registered at primary care practices in England. 2 386 317 (2 309 674 for rotavirus vaccine) children included in the study were eligible at age 1 year, 2 456 020 at 2 years, and 2 689 304 at 5 years. Main outcome measures Changes in quarterly vaccine uptake over time and compared by deprivation level. Regression analyses were used to quantify the change in inequalities in vaccine uptake over time—expressed as changes in the slope index of inequality (SII). Cumulative susceptibility to measles and rotavirus disease at age 5 years was estimated. Analyses were repeated at regional level. Results The absolute inequality in vaccine uptake at baseline (2019-20) was largest for MMR2 in children at age 5 years (SII −9.6%, 95% confidence interval (CI) −10.2% to −9.0%). For all vaccinations studied, the SII for uptake increased over the study period: from −5.1% to −7.7% for the six-in-one vaccine, −7.4% to −10.2% for rotavirus, −7.9% to −9.7% for PCV booster, −8.0% to −10.0% for MMR1 at age 2 years, −3.1% to −5.6% for MMR1 at age 5 years, and −9.6% to −13.4% for MMR2 at age 5 years. The number of children susceptible to measles by the end of the study period increased 15-fold in the least deprived group (from 1364 to 20 958) and 20-fold in the most deprived group (from 1296 to 25 345). For rotavirus, a 14-fold increase was observed in the least deprived group (from 2292 to 32 981) and a 16-fold increase in the most deprived group (from 2815 to 45 201). Regional analysis showed greatest inequalities in uptake in London and the northern regions. Conclusion The findings of this study suggest that inequalities in childhood vaccination are increasing in England, as uptake rates for five key childhood vaccinations decreased between 2019 and 2023, below the World Health Organization’s recommended 95% uptake target, and with noticeable regional differences. Urgent action is needed to strengthen systems for childhood vaccination, with a key focus on reducing inequalities. All data are open access and available through original sources at the UK Health Security Agency (<https://www.gov.uk/government/collections/vaccine-uptake#cover-of-vaccination-evaluated-rapidly-programme>) and the Office for Health Improvement and Disparities (<https://","PeriodicalId":22388,"journal":{"name":"The BMJ","volume":"74 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142809214","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}