The multi-specialty recruitment assessment (MSRA) is widely used to shortlist doctors in the UK for specialty training. This exam was initially introduced for general practice (GP) applicants, but a number of specialties, including anaesthetics, emergency medicine, radiology, and surgery now use it as a key—or even the sole—criterion for deciding which applicants to interview.1 How can a single exam be an appropriate screening tool for 11 different specialties? It doesn’t make sense that specialties as different as psychiatry and anaesthetics use the same exam for recruitment despite requiring completely different skill sets. The MSRA’s use has become a marker of an oversubscribed system that is prioritising administrative convenience over testing candidates’ competence and suitability to a specialty.The one-size-fits-all nature of the MSRA allows candidates to apply to multiple specialties simultaneously. A strong overall score may secure a candidate several interview invitations, even in specialties where the applicant has limited portfolio...

UK maternity care is at a turning point after successive reviews into services locally and nationally. It has the opportunity to tackle the underlying drivers of failures and poor care. Many of these were identified in the recent review of Nottingham University Hospitals NHS Trust.1 They are systemic in nature—racism, lack of governance, failures in leadership, underresourcing, toxic workplace culture—but also clinical. In Nottingham, factors contributing to the many failures to escalate were not ideological but rather contextual and structural.Focusing on “normal birth ideology”2 as the root cause of failures in care takes attention away from the pressing systemic issues that must be tackled and denigrates the midwifery profession and physiological birth skills. Midwifery led models of care are recognised by the World Health Organization as proved, cost effective solutions to maternal and neonatal mortality globally.3 Continuity of care has an important role in the provision of safe, personalised care,...

AbstractObjectiveTo directly test the generalisability of cardiovascular disease (CVD) risk predictor effects across populations in a high income versus non-high income country, derive comparable risk equations, and identify more effective strategies for prediction across populations.DesignPopulation based cohort study.SettingPrimary prevention cohorts in New Zealand and China.ParticipantsEquivalent New Zealand and Chinese cohorts of people aged 30-74 years with diabetes and no CVD based on electronic health records.Main outcome measuresCountry specific five year equations were derived using standardised methods to predict first cardiovascular events; predictor hazard ratios were compared. New Zealand equations were applied to the Chinese cohort, with performance assessed before and after standard recalibration, followed by the updating of predictor hazard ratios that differed statistically significantly.ResultsBetween 2004 and 2018, 47?958 New Zealand participants had 5622 (11.7%) first CVD events. Between 2010 and 2018, 46?558 Chinese participants had 3650 (7.8%) first CVD events. Sex specific equations included 16 predictors. Hazard ratios for most predictors were similar between New Zealand and Chinese equations but differed markedly for age (eg, women: 1.61, 95% confidence interval 1.51 to 1.71 per 10 years in New Zealand, 2.51 (2.32 to 2.72) per 10 years in China). Standard recalibration of New Zealand equations did not improve calibration in the Chinese cohort (expected to observed ratio: 0.938 in men, 0.809 in women). Replacing New Zealand age coefficients with Chinese coefficients noticeably improved calibration (expected to observed ratio 1.027 in men, 1.025 in women).ConclusionsApplying a high income country derived CVD risk prediction equation to a population from a non-high income country with diabetes may introduce systematic errors, primarily driven by differences in the effect of age. Moving beyond simple recalibration to updating key predictor coefficients, particularly age, should be considered for more accurate risk stratification. This study highlights potential limitations of high income country equation updating practices and proposes a feasible approach to improve their accuracy when used in populations from non-high income countries.

New data have highlighted the serious risks to young people from meningitis B, which was responsible for almost all invasive meningococcal disease cases in 15 to 24 year olds last year.The UK Health Security Agency (UKHSA) data show that meningitis B was responsible for 93 of 96 cases of invasive meningococcal disease cases in this age group in England during 2025 to 2026.The UKHSA’s Invasive Meningococcal Disease (IMD) Report for England also shows that the bacterium was the leading cause of meningococcal disease across almost all age groups under 25, including infants (34 of 37) and 1 to 4 year olds (35 of 35).1Overall, 26 deaths were recorded among the 348 confirmed cases of total invasive meningococcal disease during the year.An outbreak in March in Kent was linked to 21 cases in students and other young people in the Canterbury area, and this was followed by two further outbreaks in...

The government could drop or modify plans to abolish Healthwatch England in order to retain an independent voice for patients, a minister has indicated.Karin Smyth, health minister, said that the government would review the plans to ensure that they “deliver for patients and service users,” after a debate on proposed amendments to the Health Bill this week.Healthwatch was launched in 2012 as a statutory independent voice of patients to ensure that the NHS at the national and local level is accountable to its users.The bill, published in May, set out plans to abolish Healthwatch England and local Healthwatch networks in their current form to “simplify the patient safety landscape.”12 But critics, including some MPs during the debate, have warned that the move risks removing a vital mechanism for giving patients and communities a say in decision making.3What did the minister say about Healthwatch’s future?MPs discussed4 two suggested amendments to the...

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.

This study investigates emergency department visits for violence-related injuries occurring at home and outside the home in Cardiff, Wales, before and after COVID-19 lockdown measures were instituted in March 2020.