bmj;389/apr17_21/r745/FAF1faVicky Evans played a leading role in developing the discipline of forensic medicine as an academic specialty, establishing a training programme as well as professional standards and competencies: elements that were missing when she began working as a police surgeon, as forensic physicians were known when her career began in the 1980s.She was also instrumental in establishing standards of care for those who had been sexually assaulted, as one of the first four female physicians to be recruited to St Mary’s Sexual Assault Referral Centre (SARC) in Manchester in 1986. The centre—the first in the UK and only the second in the world after Perth, Western Australia—was founded by GP Raine Roberts and heralded a revolution in the treatment of those making allegations of rape or sexual assault.Before this, treatment was patchy. Victims would be seen in police stations, sometimes with the perpetrator of the assault in the next room....

The UK Supreme Court has ruled that doctors in two children’s end-of-life cases may be named, to allow the parents to tell their story about what happened to them and their child in hospital and in court.1The court lifted High Court injunctions barring anyone for an indefinite period from naming the doctors involved in the cases of Zainab Abbasi and Isaiah Haastrup. The children were at the centre of High Court disputes between their parents and NHS trusts over whether it would be in their best interests to receive life sustaining treatment. Isaiah died aged 12 months in 2018 and Zeinab at the age of 6 in 2019.Robert Reed and Michael Briggs, delivering judgment in the Supreme Court, said that injunctions should be for a limited period only. They said, “A reasonable duration would be until the end of the proceedings and, in the event that they terminate with the...

Doctor or physician?I was surprised when I first learnt, some time ago, that in the summaries of product characteristics (SmPCs; previously called data sheets) of certain drugs it is specified that they should be used “at the discretion of the physician,” often when advising about use in special groups, such as pregnant women or children. Surprised, not because advice was required, but because a physician was specifically required, not just any doctor. Indeed, I estimate that the term “physician” occurs 3–4 times more often in such sources than the word “doctor.” Furthermore, the two terms often seem to be being used interchangeably. In at least one case, for example, they were used as if they were synonymous, with advice that the product was to be used “under the direction of a physician” followed almost immediately by the instruction that “if the usual dose [was] less effective or its duration of...

The UK population’s health is getting worse. Health inequalities are widening and obesity rates rising, particularly among children in deprived areas (doi:10.1136/bmj.q2819 doi:10.1136/bmj.r525 doi:10.1136/bmj.q2457 doi:10.1136/bmj.r593).1234 A new investigation by The BMJ explores the influence of industry on some of these trends (doi:10.1136/bmj.r667).5The investigation finds that the advertising industry is lobbying local authorities to delay or scrap plans to ban junk food advertising on bus stops and billboards, using well rehearsed industry tactics of “deny, delay, and dilute.” With many local authorities facing significant debts, advertising companies are warning councils of the financial impact of restricting junk food advertising, telling them that they risk a substantial drop in advertising revenues. The areas targeted have some of the highest rates of childhood obesity in England. As a result, some councils have already paused or restricted plans to ban advertising of foods high in fat, salt, or sugar.The government is leaving local authorities...

On 16 September 2024 Jimi Olaghere became the first person with sickle cell disease to reach the summit of Mount Kilimanjaro. The 39 year old could hardly believe it as he contemplated his achievement from nearly 6000 m above sea level.“I was in shock. Five years ago, I couldn’t get out of bed,” Olaghere tells The BMJ. People with sickle cell disease are discouraged from venturing to areas above 3000 m, let alone to the top of Africa’s highest peak.Olaghere was one of the participants in Vertex Pharmaceuticals’ trial of exagamglogene autotemcel (exa-cel, brand name Casgevy), which works by editing a patient’s blood stem cells before they’re re-injected. In the phase 3 trial 29 of 30 (97%) participants with repeated vaso-occlusive crises—episodes when “sickled” red blood cells get stuck in blood vessels and cause pain—reported no crises and no related hospital admissions for at least a year.1Exa-cel isn’t the only...

The UK government has launched an independent review to examine how hundreds of children in England were given a misdiagnosis by NHS hearing services.1Camilla Kingdon, a consultant neonatologist at the Evelina London Children’s Hospital and former president of the Royal College of Paediatrics and Child Health, will lead the review of how service failures in paediatric audiology led to many children’s hearing tests not being conducted properly or followed up effectively.So far, 107 children have been found to have been given a misdiagnosis from 2018 to 2023, and a further 2000 children are being re-examined.2Commenting on the launch of the review, a spokesperson for the Department of Health and Social Care said, “Families across the country have been let down by unacceptable failings in paediatric audiology, exacerbated by a culture that has buried problems instead of tackling them.“NHS England has been recalling children for testing as quickly as possible, and...

This Viewpoint discusses policies the Biden administration can enact to reduce costs, including benchmarking Medicare Part B drug payments to the lowest price paid in similar countries, preventing Part D plans from negotiating confidential rebates with manufacturers, and patent reform to promote generic drug use.

This Viewpoint reviews evidence that higher hospital prices reflect greater market power more than higher-quality services and proposes that backstop price caps can mitigate harms from the most excessive prices without constraining or distorting competitive health care markets.

This narrative review summarizes the epidemiology, pathophysiology, diagnosis, management, and prognosis of irritable bowel syndrome.

In this narrative medicine essay an infectious diseases physician shares the sense of forgiveness she brings to anyone possibly involved in COVID-19 transmission, having learned as a child the healing power of family absolution after she witnessed the death of a cousin.

I will work. I will work without a mask. I will mask the work of courage. I will say there is a reason, bury my aunt, and say it again. I will walk on any street without a graveyard without a mask. I will let our children play there. I will see them share the sand. I will let them touch each other. I will see them slip in soil. I will remember I played dead. I will forget two hundred thousand bodies. I will sift anything but ash.

This randomized trial compares the effects of blinatumomab, an antibody construct that links CD3+ T cells to CD19+ leukemia cells, vs consolidation chemotherapy as a third consolidation block before allogeneic hematopoietic stem cell transplant (HST) on event-free survival in children with high-risk first-relapse B-cell acute lymphoblastic leukemia (B-ALL).

This randomized trial compares the effects of postreinduction therapy consolidation using blinatumomab, an antibody construct that links CD3+ T cells to CD19+ leukemia cells, vs chemotherapy on disease-free survival among children, adolescents, and young adults with first relapse of B-cell acute lymphoblastic leukemia (ALL).

In Reply Dr Kim and colleagues state that the results of our study are not comparable with those of PLATO and suggest that our findings may differ because patients enrolled in PLATO had a higher proportion of prior myocardial infarction. First, as we mention in our article, PLATO failed to show benefit in North America and included few Asian patients. It did show that ticagrelor reduced ischemic events and increased the rate of nonprocedural bleeding. However, several studies have demonstrated that high-risk patients with ACS do not have a net benefit with ticagrelor. For example, the SWEDEHEART registry showed that ticagrelor was associated with higher rates of bleeding and increased mortality in patents with ACS who were aged 80 years or older. A reduction in ischemic outcomes from ticagrelor was also not observed in this study. The open-label randomized clinical trial POPular AGE demonstrated that clopidogrel is favored for older patients with non–ST-elevation ACS, a high-risk subgroup. The TICA-KOREA trial showed that ticagrelor use was not associated with fewer ischemic events but was associated with increased risk of bleeding in Korean patients with ACS treated with PCI.

In Reply Our recommendations for initial antiretroviral therapy are based on evidence from randomized clinical trials demonstrating superiority of InSTI-based therapy vs comparators that included boosted protease inhibitors or efavirenz. Additional benefits of dolutegravir-based and bictegravir-based therapies include a low risk of treatment-emergent resistance, lack of need for pretreatment genotype results, few significant drug interactions, and a highly favorable tolerability profile, along with a very low rate of discontinuation due to adverse effects.

In Reply We agree with Dr Donzelli that reforming health care payment is an essential step in reducing the delivery of low-value services. This is core to our argument around the economic forces that guide the de-adoption of low-value care. Within this realm of economic levers, Donzelli makes an important distinction between pay-for-performance and pay-for-health models, noting some inconsistent results from the former. Although there is evidence that targeted payment policies can reduce the provision of low-value care, we agree that more holistic value-based payment models are needed. Our understanding of how to best pay for health continues to evolve and requires precise measurement of and alignment around the definition of health. One approach raised by Donzelli is to move toward risk-adjusted capitated payments, an approach already used at scale within the Medicare Advantage program. There is also some evidence to suggest that other global payment structures influence the provision of low-value services. As the adoption of value-based payment continues to grow, it will be important to rigorously evaluate the impact on low-value care.

To the Editor A recent retrospective cohort analysis by Dr You and colleagues demonstrated that compared with clopidogrel, ticagrelor was not associated with better outcomes in patients from the US and South Korea with acute coronary syndrome (ACS) undergoing percutaneous intervention (PCI). However, there are several important discrepancies between this cohort analysis and the randomized Platelet Inhibition and Patient Outcomes (PLATO) trial.

To the Editor As HIV clinicians, we read with interest the new antiretroviral treatment guidelines published on behalf of the International Antiviral Society–USA. Nevertheless, we believe these guidelines failed to integrate emerging evidence and may have reflected implicit commercial bias.

To the Editor In their Viewpoint, Dr Powers and colleagues analyzed 3 forces governing de-adoption of low-value care: evidence, eminence, and economics. A common denominator underlies them: the interest and convenience of the health care producers, providers, and purchasers. Fee-for-service creates strong incentives to continue delivering low-value but profitable care and technological abuse. More generally, it incentivizes provision of services with a profitable differential between the production costs and the fee applied by purchasers. The production cost is physician- or hospital team–specific, based also on specific skills and preferences, whereas the applied fees are not hospital- or physician-specific, further limiting targeted tariff policies. Aligned with pressure from patients and induced by technology producers and professional societies, fee-for-service multiplies outputs, which translates into financial and career benefits for hospitals, physicians, and producers. Therefore, low-value care for patients and society can be of high value for the producers, hospitals, and physicians selling it. A distorted rewarding model for health players puts the health systems in structural conflict of interest with health.