Alamy These children in London were among those taking part in climate strike marches across the world, organised by Fridays for Future, to …
As doctors, we follow structured guidance for safeguarding concerns that arise in clinical settings. But what about in the community? You could be on a train and witness a restless toddler being pinched, then struck on the arm by a parent who seems at their wit’s end. Do you intervene? You may be in a busy supermarket when you see a preschool child jumping excitedly, a parent turning to and silencing the child with a strike on the face—the child’s resigned whimpering speaking of a …
Big data is central to new developments in global clinical science aiming to improve the lives of patients. Technological advances have led to the routine use of structured electronic healthcare records with the potential to address key gaps in clinical evidence. The covid-19 pandemic has demonstrated the potential of big data and related analytics, but also important pitfalls. Verification, validation, and data privacy, as well as the social mandate to undertake research are key challenges. The European Society of Cardiology and the BigData@Heart consortium have brought together a range of international stakeholders, including patient representatives, clinicians, scientists, regulators, journal editors and industry. We propose the CODE-EHR Minimum Standards Framework as a means to improve the design of studies, enhance transparency and develop a roadmap towards more robust and effective utilisation of healthcare data for research purposes.
Though the causes and ways to treat obesity are many,1 the medical profession in general, and GPs in particular, can do more to tackle the problem. Adiposity now accounts for more deaths in England and Scotland than smoking among people in middle and old age.2 Studies have shown that only 52% of adult patients have had their body mass index (BMI) documented …
Hongchao Li and colleagues explore the global challenges of including economic evaluations in decisions about reimbursement for acupuncture
OBJECTIVE To determine the association between recommended physical activity according to the 2018 physical activity guidelines for Americans and all cause and cause specific mortality using a nationally representative sample of US adults. DESIGN Population based cohort study. SETTING National Health Interview Survey (1997-2014) with linkage to the National Death Index records to 31 December 2015. PARTICIPANTS 479 856 adults aged 18 years or older. EXPOSURES Participant self-reports of the amount of leisure time spent in aerobic physical activity and muscle strengthening activity each week were combined and categorised into four groups: insufficient activity, aerobic activity only, muscle strengthening only, and both aerobic and muscle strengthening activities according to the physical activity guidelines. MAIN OUTCOME MEASURES All cause mortality and cause specific mortality (cardiovascular disease, cancer, chronic lower respiratory tract diseases, accidents and injuries, Alzheimer's disease, diabetes mellitus, influenza and pneumonia, and nephritis, nephrotic syndrome, or nephrosis) obtained from the National Death Index records. RESULTS During a median follow-up of 8.75 years, 59 819 adults died from all causes, 13 509 from cardiovascular disease, 14 375 from cancer, 3188 from chronic lower respiratory tract diseases, 2477 from accidents and injuries, 1470 from Alzheimer's disease, 1803 from diabetes mellitus, 1135 from influenza and pneumonia, and 1129 from nephritis, nephrotic syndrome, or nephrosis. Compared with those who did not meet the physical activity guidelines (n=268 193), those who engaged in recommended muscle strengthening activity (n=21 428; hazard ratio 0.89, 95% confidence interval 0.85 to 0.94) or aerobic activity (n=113 851; 0.71, 0.69 to 0.72) were found to be at reduced risk of all cause mortality; and even larger survival benefits were found in those engaged in both activities (n=76 384; 0.60, 0.57 to 0.62). In addition, similar patterns were reported for cause specific mortality from cardiovascular disease, cancer, and chronic lower respiratory tract diseases. CONCLUSIONS Adults who engage in leisure time aerobic and muscle strengthening activities at levels recommended by the 2018 physical activity guidelines for Americans show greatly reduced risk of all cause and cause specific mortality. These data suggest that the physical activity levels recommended in the guidelines are associated with important survival benefits.
Hypertension is a harbinger of a huge cardiovascular disease burden globally, with an estimated one in three adults in low and middle income countries having hypertension, previously defined as blood pressure ≥140/90 mm Hg.1 The burden is probably greater, given the current definition of ≥130/80 mm Hg.2 Luo and colleagues pooled data from 17 observational studies of more than 4.5 million young adults (18-45 years), with …
Prognostication is crucial in the neurological intensive care unit (neuroICU). Patients with severe acute brain injury (SABI) are unable to make their own decisions because of the insult itself or sedation needs. Surrogate decision makers, usually family members, must make decisions on the patient's behalf. However, many are unprepared for their role as surrogates owing to the sudden and unexpected nature of SABI. Surrogates rely on clinicians in the neuroICU to provide them with an outlook (prognosis) with which to make substituted judgments and decide on treatments and goals of care on behalf of the patient. Therefore, how a prognostic estimate is derived, and then communicated, is extremely important. Prognostication in the neuroICU is highly variable between clinicians and institutions, and evidence based guidelines are lacking. Shared decision making (SDM), where surrogates and clinicians arrive together at an individualized decision based on patient values and preferences, has been proposed as an opportunity to improve clinician-family communication and ensure that patients receive treatments they would choose. This review outlines the importance and current challenges of prognostication in the neuroICU and how prognostication and SDM intersect, based on relevant research and expert opinion.
The legacy of male bias within pharmaceutical research, regulation, and commercialisation needs to be rectified, argue Sundari Ravindran and colleagues
While national level data on mortality from the current heatwave are not yet available, there have beenmedia reports of 25 deaths in thewestern Indian state of Maharashtra, the highest mortality from a heatwave in that region in six years. However, Maharashtra is not particularly badly affected by the current high temperatures, and accurate reporting on mortality rates from heatstroke is largely inadequate in other Indian states.
Progress in developing new reversible male contraception has been slow. While the hormonal approach has been clearly shown to be capable of providing effective and reversible contraception, there remains no product available. Currently, trials of a self-administered gel combination of testosterone and the progestogen Nestorone® are under way, complementing the largely injectable methods previously investigated. Novel long-acting steroids with both androgenic and progestogenic activity are also in early clinical trials. The non-hormonal approach offers potential advantages, with potential sites of action on spermatogenesis, and sperm maturation in the epididymis or at the vas, but remains in preclinical testing. Surveys indicate the willingness of men, and their partners, to use a new male method, but they continue to lack that opportunity.
Background Community emergency medicine (CEM) aims to bring highly skilled, expert medical care to the patient outside of the traditional ED setting. Currently, there are several different CEM models in existence within the UK and Ireland which confer multiple benefits including provision of a senior clinical decision-maker early in the patient’s journey, frontloading of time-critical interventions, easing pressure on busy EDs and reducing inpatient bed days. This is achieved through increased community-based management supplemented by utilisation of alternative care pathways. This study aimed to undertake a national comparison of CEM services currently in operation. Method A data collection tool was distributed to CEM services by the Pre-Hospital trainee Operated Research Network in October 2020 which aimed to establish current practice among services in the UK and Ireland. It focused on six key sections: service aims; staffing and training; job tasking and patient selection; funding and vehicles used; equipment and medication; data collection, governance and research activity. Results Seven services responded from across England, Wales and Ireland. Similarities were found with the aims of each service, staffing structures and operational times. There were large differences in equipment carried, categories of patient targeted and with governance and research activity. Conclusion While some national variations in services are explained by funding and geographical location, this review process revealed several differences in practice under the umbrella term of CEM. A national definition of CEM and its aim, with guidance on scope of practice and measurable outcomes, should be generated to ensure high standard and cost-effective emergency care is delivered in the community.
A woman in her 40s presented to the emergency department late in the evening with dysphagia and discomfort in her throat at the level of the suprasternal notch. Her symptoms had started while she was eating a pork chop for dinner. She was able to swallow saliva and was not drooling, but any attempt to swallow fluids resulted in severe pain and immediate regurgitation. Her airway was assessed and found to be clear; she was able to speak in full sentences, and no change to her voice was discerned. She had no stridor and no difficulty breathing. Observations on admission were Nothing remarkable was seen on examination of the patient’s neck and oral cavity. The patient was otherwise fit and well, …
Objective To investigate whether alignment of strength of recommendations with quality of evidence differs in consensus based versus evidence based guidelines. Design Empirical analysis. Data source Guidelines developed by the American College of Cardiology and the American Heart Association (ACC/AHA) and the American Society of Clinical Oncology (ASCO) up to 27 March 2021. Study selection Recommendations were clearly categorised as consensus or evidence based, were separated from the remainder of the text, and included both the quality of evidence and the strength of the recommendations. Data extraction Paired authors independently extracted the recommendation characteristics, including type of recommendation (consensus or evidence based), grading system used for developing recommendations, strength of the recommendation, and quality of evidence. The study team also calculated the number of discordant recommendations (strong recommendations with low quality evidence) and inappropriate discordant recommendations (those that did not meet grading of recommendations assessment, development, and evaluation criteria of appropriateness). Results The study included 12 ACC/AHA guidelines that generated 1434 recommendations and 69 ASCO guidelines that generated 1094 recommendations. Of the 504 ACC/AHA recommendations based on low quality evidence, 200 (40%) proved to be consensus based versus 304 (60%) evidence based; of the 404 ASCO recommendations based on low quality evidence, 292 (72%) were consensus based versus 112 (28%) that were evidence based. In both ACC/AHA and ASCO guidelines, the consensus approach yielded more discordant recommendations (ACC/AHA: odds ratio 2.1, 95% confidence interval 1.5 to 3.1; ASCO: 2.9, 1.1 to 7.8) and inappropriate discordant recommendations (ACC/AHA: 2.6, 1.7 to 3.7; ASCO: 5.1, 1.6 to 16.0) than the evidence based approach. Conclusion Consensus based guidelines produce more recommendations violating the evidence based medicine principles than evidence based guidelines. Ensuring appropriate alignment of quality of evidence with the strength of recommendations is key to the development of “trustworthy” guidelines.
Old school public health and technology can allow aggressive containment to succeed
The UK is set to pilot genetic sequencing in healthy babies. Genomic screening at appropriate ages could help reduce the burden of genetic disorders, say Leslie Biesecker and colleagues, but David Curtis argues that newborns cannot consent and that our most personal data might be misused
The studyLee SL, Pearce E, Ajnakina O, et al. The association between loneliness and depressive symptoms among adults aged 50 years and older: a 12-year population-based cohort study. Lancet Psychiatry 2021;8:1.To read the full NIHR Alert go to https://evidence.nihr.ac.uk/alert/loneliness-strongly-linked-depression-older-adults/.
Recent proposals to change the p value threshold from 0.05 to 0.005 or to retire statistical significance altogether have garnered much criticism and debate.1 2 As of the writing of our manuscript, the proposal to eliminate statistical significance testing, backed by over 800 signatories, achieved record-breaking status on Altmetrics, with an attention score exceeding 13 000 derived from 19 000 Twitter comments and 35 news stories. We appreciate the renewed enthusiasm for tackling important issues related to the analysis, reporting and interpretation of scientific research results. Our perspective, however, focuses on the current use and reporting of statistical significance and where we should go from here. 1. We begin by saying that p values themselves are not flawed. Rather, the use, misuse or abuse of p values in ways antithetical to rigorous scientific pursuits is the flaw. If p values are a hammer, scientists are the hammer wielders. One would not discard the hammer if the wielder, when using the hammer, repeatedly missed the nail. Similarly, one would not discard the hammer if the wielder used the hammer in a way not suited to the hammer’s purpose, such as in an attempt to drive a screw. Rather, one would expect that the fault lies with the hammer-wielder and recommend ways to refine the hammer’s use. Thus, a focus on …
### What you need to know Extreme preterm birth, defined as birth before 28 weeks’ gestational age (box 1),1 affects about two to five in every 1000 pregnancies, and varies slightly by country and by definitions used. Severe maternal morbidity, including sepsis and peripartum haemorrhage, affects around a quarter of mothers delivering at these gestations.2 For the babies, survival and morbidity rates vary, particularly by gestational age at delivery but also according to other risk factors (birth weight and sex, for example) and by country.34 In this update, we focus on high income countries and provide a broad overview of extreme preterm birth epidemiology, recent changes, and best practices in obstetric and neonatal management, including new treatments such as antenatal magnesium sulphate or changes in delivery management such as delayed cord clamping and placental transfusion. We cover short and long term medical, psychological, and experiential consequences for individuals born extremely preterm, their mothers and families, as well as preventive measures that may reduce the incidence of extreme preterm birth. Box 1 ### Key definitions #### World Health Organization definitions relating to preterm birth #### Preterm #### Moderate to late pretermRETURN TO TEXT
