Opioid use disorder during pregnancy poses substantial risks of harm to maternal and fetal health, including overdose, preterm birth, neonatal complications, and maternal and fetal death.12 Methadone and buprenorphine are the recommended medications for opioid use disorder (MOUD).123 Methadone has been the standard treatment in pregnancy for more than three decades, but buprenorphine is increasingly used in many settings.3 This shift reflects buprenorphine’s pharmacological advantage as a partial opioid agonist2 with a lower risk of sedation and respiratory depression, together with early evidence suggesting favourable neonatal outcomes.12 Yet, uncertainty has persisted about the comparative effects of opioid use on the neurodevelopment of children.The linked study by Friedrich and colleagues (doi:10.1136/bmj-2025-087321) addresses this evidence gap.4 Using nationwide Medicaid data from the US, the authors compared the risk of neurodevelopmental disorders during the first eight years of life among children prenatally exposed to buprenorphine versus methadone. Their findings are reassuring: exposure to...

AbstractObjectiveTo compare the incidence of neurodevelopmental disorders among children with prenatal exposure to buprenorphine versus methadone.DesignPopulation based cohort study.SettingUS nationwide Medicaid data on >2.5 million live births from 2000 to 2018.Participants18?612 pregnancies exposed to buprenorphine or methadone, of which 587 were excluded from the analysis owing to exposure to the comparator drug.Main outcome measuresThe primary outcome was a composite of neurodevelopmental disorders (autism spectrum disorder, attention deficit/hyperactivity disorder, developmental speech or language disorder, developmental coordination disorder, behavioural disorder, learning difficulty, or intellectual disability). Individual neurodevelopmental disorders were considered secondary outcomes. Cumulative incidences were obtained using Kaplan-Meier analyses, and hazard ratios using Cox proportional hazards regression. Propensity score overlap weighting was applied to adjust for confounding, including personal characteristics, maternal medical and mental health comorbidities, exposure to medications and other substances, proxies for severity of opioid use disorder, healthcare utilisation, and adequacy of prenatal care utilisation.Results12?635 children were exposed to buprenorphine and 5390 to methadone prenatally. The crude cumulative incidence of any neurodevelopmental disorder at age 8 years among those exposed to buprenorphine was 34% (95% confidence interval (CI) 30% to 38%) and among those exposed to methadone was 33% (29% to 37%). Adjusted analyses suggested slightly lower hazards of any neurodevelopmental disorder associated with exposure to buprenorphine versus methadone (adjusted hazard ratio 0.81, 95% CI 0.70 to 0.94). Similar results were obtained for the individual neurodevelopmental disorders such as attention deficit/hyperactivity disorder (0.89, 0.65 to 1.21) and autism spectrum disorder (0.74, 0.46 to 1.21). With prevalent use, prenatal exposure to buprenorphine was associated with lower hazards of any neurodevelopmental disorder compared with prenatal exposure to methadone (adjusted hazard ratio 0.62, 0.51 to 0.76). This association was not observed with treatment initiation during pregnancy (adjusted hazard ratio 1.13, 0.90 to 1.42). Further sensitivity analyses indicated results consistent with no increased risk of neurodevelopmental disorders among pregnancies exposed to buprenorphine versus methadone.ConclusionsThe findings of this study suggest no increased risk of long term adverse neurodevelopmental outcomes among children with prenatal exposure to buprenorphine versus methadone, further supporting buprenorphine as a safe treatment option for opioid use disorder during pregnancy.

AbstractObjectivesTo identify the effective components of interventions to increase vaccine uptake and to explore variations in effectiveness by population group and in relation to the covid-19 pandemic.DesignComponent network meta-analysis.SettingSystematic review of randomised controlled trials in high and upper middle income countries.Participants237 studies with 570 intervention arms and 4?361?717 participants.InterventionsAny intervention targeting vaccine recipients or their caregivers aiming to increase demand for, or access to, vaccinations on the UK immunisation schedule. Key content and delivery features of interventions were identified using a bespoke coding framework co-developed with stakeholders.Main outcome measuresThe outcome of interest was vaccine uptake. Bayesian component level meta-regression estimated relative effects of intervention components as ratios of odds ratios with 95% credible intervals (CrIs).ResultsOf the included studies, 110 were at low risk of bias, 96 had some concerns, and 31 were at high risk. 40% (n=1?744?686) of the participants were male. For children, there was evidence of beneficial effects for payments to cover costs (ratio of odds ratios 3.01, 95% CrI 1.49 to 6.06) and decision aids (2.73, 1.14 to 7.06), and some evidence for extended opportunities (1.37, 0.98 to 1.95) and social factors (1.27, 0.99 to 1.65). For adolescents and young adults, there were beneficial effects for personal delivery formats (2.13, 1.09 to 4.40), delivery by community members alongside healthcare professionals (6.42, 1.94 to 25.62), and social factors (2.62, 1.45 to 5.04), and negative effects for decision aids (0.43, 0.18 to 0.98) and human versus non-human interaction (0.47, 0.21 to 1.02). For adults, beneficial effects were shown for human interaction (1.86, 1.42 to 2.45), extended opportunities (1.63, 1.35 to 2.00), help with appointment scheduling (1.38, 1.06 to 1.78), payments to cover costs (1.47, 1.03 to 2.16), and motivational interviewing (1.79, 1.21 to 2.64), and there was some evidence for financial incentives (1.15, 0.99 to 1.35) and information on vaccine safety and/or efficacy (1.15, 0.99 to 1.32). For adults, evidence also showed a negative effect of non-human interaction versus no interaction (0.72, 0.57 to 0.92). Subgroup analyses showed variation for underserved populations and in relation to the covid-19 pandemic (before 2020 and 2020 onwards).ConclusionOverall, extended opportunities, appointment scheduling help, financial incentives, payments to cover costs, and motivational interviewing were effective content components of interventions to increase vaccine uptake. Effective delivery components overall were human interaction and delivery by community members alongside healthcare professionals. However, effective components varied by age group, for underserved populations, and in analyses investigating the impact of the covid-19 pandemic. These findings have important implications for designing, optimising, and implementing targeted interventions, highlighting which components are effective across different populations and contexts. Consideration of the economic data on interventions should further support resource informed decision making.

Kickbusch’s call to reframe artificial intelligence (AI) governance through a planetary health lens is timely and compelling.1 As AI systems—particularly large language model (LLM) applications—move rapidly into use, we must ask how governance can be operationalised in healthcare practice.One of the most practical and underused levers for responsible AI is robust evaluation. In healthcare, evaluation standards have long aligned innovation with patient safety, quality, and equity. Encouragingly, this is a growing area of AI research, with emerging frameworks for assessing clinical performance,23 extensions to trial reporting such as CONSORT-AI,4 and examples of structured safety testing in real world tools.5A critical gap remains, however. Current evaluation frameworks rarely consider the computational and environmental costs of LLM powered systems, with environmental impact absent from criteria even in otherwise comprehensive approaches.6 Although recent frameworks such as FUTURE-AI7 have broadened evaluation, environmental and computational impact remain largely neglected. Each LLM query carries an energy...

Six months after the Gaza ceasefire was announced Palestinians are still experiencing “extreme deprivation, hunger, injury, and death” as Israeli attacks and aid restrictions continue, charities have warned.1Five major humanitarian organisations—the Danish Refugee Council, the Norwegian Refugee Council, Oxfam, Refugees International, and Save the Children—have assessed the progress made against the ceasefire plan and produced a scorecard. They conclude that the ceasefire announced in October 2025, with the promise of an end to attacks and an increase in aid, is failing.At least 738 Palestinians have been killed since the ceasefire came into effect, said the UN.2 At least 70 000 Gazans have been killed in Israeli attacks since 7 October 2023, although experts say that the true number is probably much higher.3The UN’s human rights chief, Volker Türk, said that Palestinians were still unsafe amid routine Israeli attacks. “The unrelenting pattern of killings reflects continuing disregard for Palestinian lives, enabled...

bmj;393/apr02_10/s609/FAF1faJohn was born in Northern Rhodesia (now Zambia) where his parents were working with a Church of Scotland mission, his father as medical officer. After his mother contracted poliomyelitis, the family moved with their four children to a general practice south of Edinburgh. From George Watson’s College John proceeded to the University of St Andrews and, for his clinical years, to Dundee. St Andrews—the little grey town by the grey North Sea—was always a “region of his heart’s desire” and it was where he met and married Christine Davidson, a fellow medical student.After hospital posts, the Martins settled in Inverness, both in general practice. For many years John was a GP trainer and had a particular interest in the expectations of, and challenges faced, by sixth formers considering a life in medicine and by medical students planning their careers. Towards the end of his years in Inverness he took a...

A preschool child presented with a three day history of painless, non-pruritic pustules on her right palm (fig1). She was otherwise well, with no relevant medical history. The family reported keeping a pet rabbit at home.bmj;393/apr02_9/e086736/F1F1f1Fig 1Physical examination showed erythema, vesicles, and pustules localised to the ulnar aspect of the right palm. Bacterial culture of the pustule fluid showed negative results, whereas the results of the fungal culture were positive for Trichophyton mentagrophytes. Direct microscopic examination of skin scrapings showed abundant fungal hyphae. A fur sample taken from the rabbit was positive for the same fungal species when tested with a fungal culture.A diagnosis of inflammatory tinea manuum was made.T. mentagrophytes is a common causative pathogen in dermatophytosis, which affects about 25% of the global population, with markedly higher prevalence in tropical and subtropical regions.1Rodents and rabbits serve as primary reservoir hosts for zoophilic T. mentagrophytes. When humans are infected,...

The covid-19 pandemic exposed three longstanding problems with pulse oximetry. Firstly, pulse oximeters can produce inaccurate readings in some patients.12 Secondly, even small levels of inaccuracy can harm patients when clinicians follow guidelines in which critical clinical decisions are based on an absolute or narrow range of oxygen saturation values.3 Thirdly, many clinicians are unaware of the potential for pulse oximeters to produce inaccurate readings and the factors that can cause this (including patients with darker skin tones), as well as the importance of interpreting and evaluating oxygen saturation readings in their clinical context and with an understanding of the limitations and imperfections of pulse oximetry.1456Since the pandemic, the focus has been on improving the performance, testing, and regulation of pulse oximeters. But improvements in accuracy must be accompanied by improvements in training in pulse oximetry.Most clinicians have little, if any, training in pulse oximetry and no national guideline or...

The theme of World Health Day 2026, on 7 April, is “Together for health. Stand with science.”1 It marks the beginning of a year long campaign “celebrating the power of scientific collaboration to protect the health of people, animals, plants, and the planet.” This could not be more timely. In the immediate aftermath of the 2024 US presidential election, we warned that a second Trump administration would be a grave threat to evidence informed public health.2 But we, like many others, had no idea just how bad things would become.The damage to US science has been immense. The Trump administration has targeted the foundations of the science-policy interface, taking control of appointments, advisory processes, data access, and funding rules. The health consequences are already apparent, with the vaccine scepticism that has become an article of faith among the president’s acolytes contributing to outbreaks and some deaths from measles.3 Looking ahead,...

Few developments in psychopharmacology attract as much attention among clinicians, researchers, and the public alike, as psychedelics. The psychoactive compounds psilocybin and 3,4-methylenedioxymethamphetamine (MDMA), which produce profound alterations in consciousness and mental state, have reached phase 3 trials for treatment resistant depression and post-traumatic stress disorder (PTSD) respectively. These advances reflect a resurgence of interest after decades of regulatory prohibition,1 with few trials conducted before 2017, rising to over 134 registered for psilocybin alone by 2023.2 Today, what makes these drugs fascinating is their unconventional treatment model: rather than prolonged and sometimes lifelong daily dosing, psychedelics are hypothesised to produce acute and enduring change after only one to three doses.A recent review on psychedelic medicine in TheBMJ synthesises a complex body of data on the mechanisms, clinical findings, and translational challenges, and discusses key challenges including mechanistic uncertainty, functional unblinding, inconsistent adverse event monitoring, and scalability (doi:10.1136/bmj-2024-081723).3 Although findings from...

There are at least 996 shisha cafes in the UK, an increase of 33% in the past five years, and London has more shisha cafes than branches of McDonald’s.1 Yet the smoking of shisha tobacco (see box 1) continues to be overlooked as a public health matter, contributing to the widening of existing inequalities.Box 1What is shisha?Shisha, also known as hookah, narghile, and hubble bubble, is a waterpipe that is used to smoke a charcoal heated tobacco mix. Smoke passes through water before being inhaled through a hose-like pipe. The origin of shisha dates back centuries and it is especially common across the Middle East and South Asia.Shisha tobacco is generally flavoured and has become increasingly popular in the UK,2 especially among young people and those from Middle Eastern, North African, and South Asian backgrounds. It is primarily smoked socially and, though it can be smoked in homes, it is...

Just a few weeks apart, parliaments in Scotland and Jersey voted on assisted dying legislation with very different outcomes. The Assisted Dying for Terminally Ill Adults Bill was rejected in Scotland, while a draft law on assisted dying was approved in Jersey.12 The Terminally Ill Adults (End of Life) Bill for England and Wales is likely to fall in the House of Lords despite being approved by the House of Commons, and the prospect of it returning in the future is uncertain.34 It is important to consider the factors contributing to varying outcomes and reflect on what can be learnt from Jersey and Scotland.The legislative proposals in Scotland and Jersey have key differences.12 The Scottish bill bears greater similarity to the one going through the Westminster parliament. Two doctors must assess eligibility, approve the assisted dying decision, and then one doctor prescribes the medication that the patient self-administers. The Jersey...

A Colorado state ban on conversion therapy for minors likely violates constitutional protections of free speech, the US Supreme Court has ruled.The decision—widely criticised by LGBTQ+ advocacy groups—will send the case to the lower courts to determine whether therapists can resume offering gender conversion therapy to minors.This could have implications for similar laws in states across the US.The case was brought by Kaley Chiles, a counsellor from Colorado Springs, who argued that the state’s 2019 ban on licensed doctors or mental health professionals “converting” lesbian, gay, or transgender people unlawfully restricted her ability to provide talk therapy to clients who sought to change their sexual orientation or gender identity.The court voted 8-1 to side with Chiles, with liberal justices Elena Kagan and Sonia Sotomayor joining the conservative majority.Justice Neil Gorsuch said in his written decision, “While the First Amendment protects many and varied forms of expression, the spoken word is...

If you ask any doctor how their day is going, they’ll almost certainly reply “busy.” It’s an almost universal state of being in medicine, and we declare it like a kind of tic. But what if being perpetually busy isn’t just a symptom of being under pressure but one of its principal causes? Bob Klaber—a paediatrician at Imperial College Healthcare NHS Trust and its director of strategy, research, and innovation—argues that our collective busy-ness is a barrier to all the changes we say we want. When every minute is ridiculously full there’s no space for reflection, human connection, or the careful conversations from which better care emerges—and no time for teaching the next generation.Klaber invites us to adopt a different attitude to our work, one that de-emphasises frantic activity and multitasking and gives priority to being available for people and listening. As a clinician, he seems to practise what he...

Social media use makes it hard to separate a genuine rise from diagnostic inflation, but blaming it is an oversimplification—Annabeth P Groenman, Tessa Copp, Kirsten McCaffery, and Jesse JansenThe Lancet Psychiatry commission on youth mental health has called for action on a global “youth mental health crisis.”1 Rates of diagnosed mental health conditions have been rising in young people. For example, 11.4% of children in the US currently have a classification of attention deficit/hyperactivity disorder (ADHD). In specific groups this figure is even higher: around 22% of 17 year old boys in the US have received an ADHD classification at some point in their life.2This raises the question of whether young people’s mental health is actually worse than in the past, or whether we’re simply recognising and labelling what was always there.Many academics point to social media as a key driver for the rise in mental health conditions among young...

Yamey and Shaffer discuss how Trump and Robert F Kennedy Jr have promoted misinformation.1 Vaccine scepticism in the US is long standing, but recent revisions to the childhood immunisation schedule and other vaccine policy shifts risk intensifying public confusion and reinforcing discredited safety claims.2345Misinformation provided by the government heightens physicians’ responsibility to counter vaccine myths and misunderstandings. Fact based counselling remains vital. But innovative communication strategies are also needed to rebuild trust in routine childhood immunisations to prevent avoidable illness and restore population level immunity.Physicians can reclaim the narrative by pairing rigorous epidemiological data with human stories, translating statistics into tangible outcomes. A de-identified clinical vignette, for example, might describe a young adult with swollen lymph nodes, fatigue, and jaundice whose advanced cirrhosis from chronic hepatitis B necessitates a liver transplant. Timely vaccination could have prevented this condition.Physicians can use visual aids, displaying lifetime risks of vaccine preventable illnesses with...

A Kent hospital has admitted to being too slow to alert the UK Health Security Agency (UKHSA) to a suspected case of meningitis.There is a legal requirement for suspected cases of acute meningitis to be reported to the UKHSA immediately without waiting for laboratory confirmation of the disease.1 However, it has now emerged that this did not happen for the first known case of the Kent outbreak, which eventually included dozens of cases and the deaths of two young people.2The hospital’s delay in reporting meant that the UKHSA did not start investigating a potential outbreak as soon as it could have. It also led to delays in contacting and treating any close contacts of the patient.The Kent outbreak of meningitis B now seems to have passed its peak, with no new cases reported for the past five days. As of 24 March the confirmed number of cases of invasive meningococcal...

The scandal over student loan debt and interest has rightly dominated headlines in the past few weeks.12 The plan from chancellor Rachel Reeves to freeze loan repayment thresholds represents yet another burden placed on a financially beleaguered generation. For doctors, this new hit to our income feels like two steps back in the ongoing struggle for pay restoration. Something needs to change to relieve the financial strain on doctors.Last month I made the brave decision to check my student loan balance. I should have prepared myself more for the shock. Over my six year degree in medicine, I borrowed £44 000 but by my graduation I had accrued an additional £11 000 of interest before I had even started earning. My current balance sits at £63 500 and I’m only now close to paying off as much per month as I’m being charged in interest. I suspect most younger doctors...

The UK government must set out clear national standards to tackle “serious inadequacies” and staff shortages in children’s palliative care services, a group of MPs has urged.The House of Commons Health and Social Care Committee’s report on palliative care in England1 says that people enter a “postcode lottery” of care in their most vulnerable moments at the end of life. This variability is compounded by a workforce declining in numbers, the MPs warned.The report calls for a plan to increase the numbers of specialist doctors, nurses, and other healthcare professionals working across the palliative care sector. It emphasises that action is most urgently needed in children and young people’s palliative care, and it urges the government to include specific standards in its upcoming modern service framework later this year.The charity Together for Short Lives has estimated that 99 000 UK children were seriously ill in 2025.2 The committee’s report says...

Campaigners have criticised a midwifery journal for sending out an “inappropriate” prize survey targeting health professionals that was sponsored by a formula milk company.The survey of midwives and health visitors was shared by the British Journal of Midwifery in February. It is sponsored by SMA infant formula, owned by food and beverage giant Nestlé.Healthcare professionals who completed the survey and provided their personal details were entered into a prize draw for £100 of Amazon gift vouchers.Although the British Journal of Midwifery states at the beginning of the survey they “firmly believe that breastfeeding is always the best option for a baby,” all the questions relate to formula feeding and infant gut health.Victoria Thomas, a consultant paediatrician and co-chair of the Hospital Infant Feeding Network, said the survey reads as “a thinly veiled marketing exercise.”“I do not think it is appropriate for a scientific journal to send out a survey such...