The UK’s medicines regulator has approved the first immunotherapy to be licensed to delay the progression of type 1 diabetes in patients who are in the early stages of the disease.The Medicines and Healthcare Products Regulatory Agency (MHRA) said teplizumab (Tzield), manufactured by Sanofi, can be given to adults and children aged 8 years and older who have stage 2 of the condition1 and are at high risk of progressing to stage 3.Patients who have reached stage 3 have usually started to have blood sugar problems and are then diagnosed with type 1 diabetes, which requires lifelong insulin treatment.A 14 day course of daily infusions of teplizumab has been shown to delay patients at high risk of developing the condition from reaching stage 3 by an average of three years, the MHRA said. It works by binding to certain immune cells, and may deactivate the immune cells that attack insulin...

Doctors will be able to prescribe a new treatment for people with inflammatory bowel disease (IBD), after the UK medicines watchdog approved guselkumab (Tremfya) for use on the NHS.The National Institute for Health and Care Excellence (NICE) has recommended the biological treatment as an option for patients with moderate to severe ulcerative colitis or moderately to severely active Crohn’s disease who have not responded well to other treatments or have experienced unacceptable side effects.Ulcerative colitis and Crohn’s disease—two types of IBD that cause inflammation and ulcers in the large bowel or gut—together affect an estimated 500 000 people in the UK, said the charity UK Crohn’s and Colitis UK. Inflammatory bowel diseases can develop at any age but are most often diagnosed in people under 30.Guselkumab is currently approved to treat plaque psoriasis and psoriatic arthritis, but clinical studies have shown that it is also effective in treating adults with...

Recent publication of the NHS’s 10 Year Health Plan for England, with its renewed emphasis on pay for performance, presents an important moment to reflect on past models like the Quality and Outcomes Framework (QOF) and to learn from international experience.QOF, launched in 2004, was a pioneering effort to improve primary healthcare through a pay for performance model. The framework financially rewards providers for high performance or quality. Two decades later, however, the limitations of this approach have become evident. The initial gains in quality have plateaued, a trend that has been interpreted as “incentive fatigue.”1 General practitioners are increasingly demoralised with their work as the administrative burdens and job complexity continue to rise,12 emphasising that financial incentives are only effective when they reinforce professional purpose and promote cohesive teams, autonomy, and good working conditions.If pay for performance models are to help overcome the current challenges in primary care, they...

Doctors working with Médecins Sans Frontières (MSF) in Sudan have treated more than 2300 cholera patients in the past week and have seen 40 people die from the infection.Sudan, which has been engulfed by civil war since April 2023,1 has been experiencing a cholera outbreak for over a year, with around 100 000 suspected cases and more than 2470 related deaths reported.Tawila, North Darfur State, has seen the worst impact, as 380 000 people have fled fighting in the nearby city of El Fasher. People in the town are currently surviving with just three litres of water a day—less than half the emergency minimum of 7.5 L needed for drinking, cooking, and hygiene.Sylvain Penicaud, MSF project coordinator in Tawila, said, “In displacement and refugee camps, families often have no choice but to drink from contaminated sources and many contract cholera. Just two weeks ago, a body was found in a...

bmj;390/aug15_6/r1745/FAF1faKen was born in Pontefract, West Yorkshire, as a second son. His elder brother Roger had died at birth two years earlier, but his existence was acknowledged right throughout Ken’s life and influenced his upbringing. Ken’s birth involved an emergency caesarean section and post-natal infection, and a recommendation of no further pregnancies for his parents.After being unsuccessful in his preferred choice of study as a vet, Ken decided to focus on patients of the two legged variety, graduating from Manchester medical school in 1963. House and junior doctor jobs followed around the north west of England, before he became a respected consultant surgeon at Bury General Hospital and latterly at Fairfield, before retiring in 2001.He was one of the last of the truly general surgeons, where his skills ranged from stripping veins and removing lumps and bumps, to complex colorectal and hepatobiliary procedures. Many of the consultants and GPs who...

The recent drop in the NHS waiting list hailed by ministers as a sign of progress in tackling the treatment backlog has given a “misleading” impression of the service’s ability to meet demand, a report from two healthcare think tanks has concluded.Last month NHS England and the government reported the waiting list had dropped to a 26 month low, with health secretary Wes Streeting saying that the drop was “not a coincidence—it is because this government has delivered on the Plan for Change.”1But an analysis from the Nuffield Trust and the Health Foundation concluded that the statistics “do not necessarily mean that more need is being met.”2 Instead, the drop was driven by “unreported removals” rather than the number of patients being treated exceeding new additions to the list.“Unreported removals” refers to patients who are removed from the waiting list without being treated. This can occur, for example, if a...

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.