Advances in cancer treatment have affected patients worldwide. However, these advancements have also introduced new risks that must be balanced against the benefits of treatment. One potential complication is cancer therapy related cardiac dysfunction, when certain anticancer agents unintentionally damage healthy heart tissue.1 This leads to impaired cardiac function and occurs through mechanisms such as oxidative stress, mitochondrial dysfunction, disruption of cardiomyocyte signalling, and inflammation.1 For example, anthracyclines generate reactive oxygen species that impair mitochondrial function, leading to toxicity in cardiomyocytes and other cardiac cells. Six out of 100 patients undergoing cancer treatment each year will experience this cardiac dysfunction.2 The incidence increases to 10 out of 100 for adults aged 50 years or older, and it is highest in patients with breast cancer. Treatment interruptions or even discontinuation may result, leading to additional burdens to patients and a lower quality of life.3Risk prediction refers to the likelihood of a...

AbstractObjectivesTo systematically review all prediction models developed or validated for cancer therapy related cardiac dysfunction (CTRCD) and to quantitatively analyse their performance.DesignSystematic review and meta-analysis.Data sourcesEmbase, Medline, and the Cochrane Central Register of Controlled Trials, from inception to 23 August 2024.Eligibility criteria for selecting studiesStudies that developed or externally validated multivariable models to predict CTRCD risk in young people (children, adolescents, and young adults (?39 years)) or older adults (?40 years) with cancer or cancer survivors treated with systemic antineoplastic agents. Studies on radiation induced cardiotoxicity were excluded.MethodsTwo reviewers independently screened studies, extracted data, and assessed risk of bias using the Prediction model Risk Of Bias ASsessment Tool. Performance measures were pooled using random effects meta-analyses.Results56 studies were included, reporting 51 developed models and 12 externally validated models. Most models were developed in adults (n=34/51, 67%), primarily for breast cancer (n=20/34, 59%) or haematological malignancies (n=6/34, 18%) to determine pretreatment risk (n=33/34, 97%). In young people, most developed models (n=16/17, 94%) focused on long term risk assessment, mostly in survivors of haematological malignancies. Discrimination and calibration metrics were reported for 13/51 (25%) developed models and 6/44 (14%) external validations. Nearly all models were at high risk of bias. 12/51 (24%) developed models underwent external validation, four of 17 (24%) in young people and eight of 34 (24%) in adult populations. The Heart Failure Association-International Cardio-Oncology Society (HFA-ICOS) tool was the most frequently validated (11 times), mainly in patients with breast cancer receiving HER2 (human epidermal growth factor receptor 2) targeted therapies (5/11, 45%). Across all external validations, this tool consistently underestimated risk, with observed event rates exceeding predicted risks, especially in studies where mild CTRCD was the most frequently reported outcome. Among patients with breast cancer treated with anti-HER2 agents, the pooled C statistic was 0.60 (95% confidence interval 0.52 to 0.68). In this population, observed pooled event rates were 12% in the low risk group (<2% predicted), 15% in the medium risk group (2-9%), 25% in the high risk group (10-19%), and 41% in the very high risk group (?20%).ConclusionsExisting prediction models for CTRCD need additional evidence before widespread clinical adoption. Poor reporting of key performance metrics and limited external validation studies currently restrict their thorough evaluation. The HFA-ICOS tool shows suboptimal performance, especially when mild forms of CTRCD are included as events. Future research should prioritise validating and updating existing models using large, clustered datasets across various malignancies to enhance the assessment of their performance, generalisability, and clinical utility in routine practice.Systematic review registrationPROSPERO CRD42023475469.

There was standing room only in my hospital’s big lecture theatre for a recent seminar about retirement from the NHS. I recognised many staff, now in their 50s and 60s, who I’ve worked alongside for a quarter of a century. It was palpably sad to see the NHS potentially losing so many experienced, wise people who know how things work and hold the collective memory of an organisation. The event felt like a surreal group lifestyle clinic with colleagues,1 and I sensed a cohort limping through their workload, hoping to reduce some heavy financial burdens and get a chance to breathe.Many doctors assume that perfectionism and presenteeism are the only acceptable ways of working until they suddenly stop for retirement. It’s precisely this approach to work that can lead to burnout, poor retention, and staff retiring earlier than they might. But the NHS now offers more flexible ways of working,...

bmj;390/sep23_12/r1979/FAF1faHugh was born in Rugby on 10 August 1941. He attended Lawrence Sheriff School before going to Bristol University, where he obtained his medical degree followed by a diploma in obstetrics and gynaecology. He worked in general practice for a short period before changing to pathology, working first at the Bristol Royal Infirmary and Frenchay Hospital before going to the John Radcliffe Hospital in Oxford. Here, he mainly worked in pathology of the heart and the breast.He was appointed consultant histopathologist at the Leicester General Hospital in 1978, where he stayed until his retirement in 2003. Much of his work during this period was in renal pathology, where he supported the hospital’s kidney transplant programme, but he was also involved in histopathology for all other departments. For much of his time there he was the hospital’s senior pathologist; he also served a term as head of department, overseeing other specialties...

GPs in England are being advised to make it standard practice to rethink if a patient has had three appointments and not been offered a substantiated diagnosis or has had worsening symptoms.A new initiative—known as Jess’s rule—is being rolled out across England to speed up diagnosis of serious illnesses such as cancer, particularly in young people.It is named after Jessica Brady, who died of cancer aged 27 after 20 appointments at her GP surgery failed to diagnose her condition in 2020. She eventually sought private healthcare and was diagnosed with stage 4 adenocarcinoma later that year. Brady was then admitted to hospital where she died three weeks later.The scheme—overseen by NHS England and the Department of Health and Social Care (DHSC)—advises GPs that if they have not been able to make a substantiated diagnosis, or the patient’s symptoms have escalated, then they should consider taking further steps.These include arranging a...

The UK government was dealt a major blow earlier this month when the US pharmaceutical giant Merck announced that it has halted construction on its £1bn London research centre.This was the latest in a series of setbacks that have thrown the UK’s life science sector—described by the government as “one of the crown jewels” of the country’s economy—into disarray.Merck, known as MSD in Europe, has also cancelled ongoing projects at the Francis Crick Institute in London and will move its life science research to the US. The company accused successive UK governments of not investing enough in the sector and of paying too little for innovative drugs and vaccines.Days after Merck’s announcement, AstraZeneca said it was putting a new £200m laboratory in Cambridge on hold, having in January already cancelled a £450m investment in its vaccine site at Speke, Liverpool.Eli Lilly also recently paused a planned investment in a biotech...

AcronymsThe term “acronym” is widely misused to mean any type of abbreviation, even those that aren’t acronyms.In this case etymology helps to resolve the confusion and improve understanding. “Acronym” comes from two Greek words: the adjective ?????, highest, topmost, outermost, and the noun ?????, a name. So, an acronym is a pronounceable word formed from the first letters of a set of words. There are various types:• Acronyms that are the same as words that already existed when the acronym was formed; medical examples include ACE (angiotensin-converting enzyme) and AIDS (acquired immune deficiency syndrome), not to be confused with AID (artificial insemination by donor or auto-immune disease, or a panoply of others: https://www.acronymfinder.com/AID.html).• Acronyms that form strings that can be regarded as potential words and have therefore been adopted as words; examples include warfarin, which stands for the Wisconsin Alumni Research Foundation plus –arin.• Acronyms that neither are words nor...

“Staggering” competition for some NHS specialty training posts has laid bare a “crisis facing medical training” that is leaving many resident doctors “in limbo,” leaders have warned.Doctors said that newly released NHS statistics on 2025 competition rates—which show that demand for some specialties has almost quadrupled—were “indicative of a broken application system.”The data show that a total of 91 999 applications were made in England for the 12 833 specialty training posts available at all training levels,1 giving an overall competition ratio of 7. This means that there were seven applications overall for every specialty training post in 2025, a rise from 4.7 last year2 and over three times the level in 2019 (1.9).However, some specialties have faced competition of a far greater magnitude (table 1). For example, psychiatry saw 22 applications for every post (10 677 applications for 489 posts), up from 10 applications per post last year.bmj;390/sep19_9/r1981/TBL1T1tbl1Table 1The...

Jha and Psaki compellingly outline supply side breakdowns and demand side erosion in vaccination efforts, advocating for public health to reclaim digital spaces.1 Their recommended strategies—equipping health workers, leveraging community leaders, and dealing with political misinformation—are sound, but we need more transformative approaches targeting the root causes of mistrust in our evolving digital landscape.The traditional vaccine “trust deficit” reflects broader institutional disillusionment, not merely knowledge gaps.2 Expert driven, top-down communication increasingly fails in a world where trust is local, relational, and experiential. Rather than simply “delivering trust alongside vaccines,” we must co-create vaccine narratives with communities. This requires embedding public health professionals in digital communities as peers engaging in dialogue, not authorities delivering monologues, involving not only religious leaders and influencers but authentic community voices.3The authors highlight the outsized influence of the “disinformation dozen” and amplification by foreign actors. Beyond partnerships with technology platforms, we need more ambitious solutions: incentivising...

A GP who was convicted of attempted murder after posing as a community nurse to inject his mother’s partner with a toxin has been struck off the UK medical register.Thomas Kwan, 54, sent Patrick O’Hara false NHS letters pretending to set up an appointment for a covid-19 booster, a medical practitioners tribunal heard. Kwan feared that O’Hara could stand in the way of inheriting his mother’s home in Newcastle after her death.In January 2024, wearing a disguise and speaking in a fake accent, Kwan injected O’Hara with the highly toxic fumigant pesticide iodomethane, causing pain that Kwan dismissed as an allergic reaction, the tribunal was told.O’Hara developed necrotising fasciitis and had to undergo multiple surgeries to excise dead tissue in his upper arm, spending time in intensive care.Kwan, who practised at the Happy House Surgery in Sunderland, pleaded guilty to attempted murder at Newcastle Crown Court in October 2024 and...

The NHS will not be able to deliver new draft guidelines on kidney cancer without major investment in diagnostic procedures and treatments, a leading expert has warned.This week the National Institute for Health and Care Excellence (NICE) published new draft guidance recommending that more people with suspected kidney cancer should have a biopsy to help confirm their diagnosis sooner.1But Pat Price, chair of Radiotherapy UK, warned that while the “long awaited” updated guidance was welcome, successfully implementing it may be “wishful thinking” because of a lack of funding and excessive NHS bureaucracy.“There is a disconnect. NICE is great at doing best practice, but is the NHS able to deliver anymore?” said Price, a surgery and cancer professor at Imperial College London. “NHS England cannot deliver on evidence based medicine because it’s financially constrained,” she said.NICE said that implementation of its guidance on new renal cell carcinoma, the most common kind...

Increasingly, many medics are considering stepping away from traditional training pathways whether that is building a portfolio career or moving into another role completely. Practising medicine does not have to confine you to the four walls of a hospital, and medical school is an opportunity to explore potential jobs that many don’t realise exist. One of these is to work at sea, as a doctor on a cruise ship.What does the role involve?A cruise ship doctor provides healthcare to the crew and guests on board ships. You are there as the first port of call in an acute or emergency situation, as well as managing the long term health conditions of passengers and crew for the duration of their trip.A working day might require a combination of seeing guests in the daily outpatient-like clinics, alongside attending to and managing acutely unwell passengers or crew in the onboard inpatient environment.The range...

The story so farIn my search for the earliest instances of the word “sleuth” and its derivatives in relation to observers of academic misconduct, I have found that there is a wide range of different types of sleuths, together calling out for a taxonomy.The origin of the word has so far been traced back only to a Norwegian word, sl?ð, meaning a track or a trail. However, that word must itself have had an antecedent form with a corresponding theoretical IndoEuropean forerunner. IndoEuropean roots starting with consonants such as K, L, M, P, T, or W sometimes have an S prefixed to them. For example, the root LEU, meaning to loosen or unbind, gives us words such as loose and lost, words ending in –less, implying absence, and lysis and its derivatives; and LEU has a counterpart, SLEU, to relax, giving us words such as sloth, slouch, and slow, sludge,...

NHS patients in England are struggling to access cutting edge cancer treatments because of bureaucracy and inadequate funding, senior doctors have warned.The Royal College of Radiologists (RCR) gave the warning as new analysis by Cancer Research UK (CRUK) showed that only half of people in England diagnosed with cancer after an urgent referral are being diagnosed on time.The RCR, which also represents oncologists, urged the government to overhaul the uneven commissioning and funding structures for cancer treatments that create “a postcode lottery” for access.Nicky Thorp, the RCR’s vice president for clinical oncology, said, “The government’s upcoming cancer plan presents a fantastic opportunity to reconsider how treatments are commissioned and funded.”In a briefing paper1 published on 11 September, the RCR said that “a cumbersome application process” that NHS trusts must undergo can delay the adoption of innovative treatments. It added that the funding received by trusts for delivering some treatments can...

Two part magnetic resonance imaging (MRI) is just as effective at diagnosing prostate cancer as the UK standard three part scan and is almost half the price, a study shows.1The researchers said their results could pave the way for a new standard of care in the UK, at a time when prostate cancer diagnosis tools are being assessed as part of a multimillion pound research programme back by the government.2However, independent experts warn that the alternative scanning method could do more harm than good. They argue that it fails to tackle concerns over prostate cancer overdiagnosis—and in a worst case scenario could actually cause an increased cost and burden to health systems.What did the study find?Funded by the John Black Charitable Foundation and Prostate Cancer UK and conducted by researchers from University College London (UCL), UCL Hospitals NHS Foundation Trust, and the University of Birmingham, the trial was conducted across...

US health secretary Robert F Kennedy Jr has officially unveiled the much anticipated second report of the Make America Healthy Again (MAHA) Commission.1He labelled it a “sweeping plan with more than 120 initiatives to reverse the failed policies that fuelled America’s childhood chronic disease epidemic.”2As with the first MAHA report, published in May,3 the primary focus is on tackling childhood obesity through improved nutrition and promoting physical activity, increasing the oversight of food additives and chemicals, and tackling environmental exposures.However, critics said the report was more of a manifesto than a detailed strategy, pointing to a lack of specific detail and concrete regulatory action.Elizabeth Kucinich, an organic food campaigner, said the pesticide section of the report directs the Environmental Protection Agency to partner with industry on public relations campaigns to convince Americans that the system is “robust.” The section “reads like it was written by Bayer and Monsanto,” she added.4In...

Over half of women giving birth in England, Scotland, and Wales did so by induction or caesarean section, a large scale audit has found.The latest National Maternity and Perinatal Audit (NMPA) of 592 594 births in 2023 shows that 50.6% involved a caesarean section or the use of instruments, compared with 40% in the previous report in 2018-19. In 2023, 49.4% of births were vaginal compared with 60% in 2018-19.The trend was driven by a rise in unplanned caesarean sections, which made up nearly a quarter (23.1%) of births in England, Scotland, and Wales in 2023 compared with 15% in 2018-19.Planned caesarean sections have also increased since the previous report, from 12.1% to 16.4%, the report by the royal colleges of midwives, obstetricians and gynaecologists (RCOG), and paediatrics and child health found.The latest audit, which will be followed by a more detailed report later this year, also found that around...

AbstractObjectiveTo evaluate the clinical effectiveness of the YCMAP intervention (Youth Culturally Adapted Manual Assisted Problem Solving) for adolescents after self-harm in Pakistan.DesignMulticentre, randomised controlled trial that compared YCMAP with enhanced treatment as usual.SettingsGeneral practices, emergency departments, medical wards of participating hospitals, and community centres across Karachi, Hyderabad, Lahore, Multan, and Rawalpindi.ParticipantsAdolescents with a recent history of self-harm identified at participating health centres by treating physicians between 5 November 2019 and 31 August 2021.InterventionThe YCMAP group received up to 10 treatment sessions over three months; the intervention was based on the principles of cognitive behaviour therapy.Main outcome measureThe primary outcome was the repetition of self-harm at 12 months after randomisation. Secondary outcomes were distress, hopelessness, suicidal ideation, and health related quality of life at three, six, nine, and 12 months after randomisation. Participants’ satisfaction with the services was assessed at three and 12 months after randomisation.ResultsThis trial was conducted between November 2019 and February 2023 and included 684 adolescents randomised to YCMAP (n=342) or enhanced treatment as usual (n=342). The YCMAP group had a significantly lower risk of self-harm repetition than the enhanced treatment as usual group at 12 months after randomisation (odds ratio 0.20, 95% confidence interval 0.06 to 0.70, P=0.006). YCMAP participants showed a statistically significant reduction in distress, hopelessness, and suicidal ideation at three months, but these differences were not statistically significant at 12 months. YCMAP participants also reported significantly better quality of life and satisfaction with services at three months, with these effects sustained at all follow-up points.ConclusionThe YCMAP intervention was shown to be beneficial in self-harm prevention among adolescents. Further research and replication of findings in diverse settings are recommended to strengthen the evidence base for this public health intervention.Trial registrationClinicalTrials.gov NCT04131179 and ISRCTN registry ISRCTN57325925.

bmj;390/sep10_1/r1891/FAF1faIn the late 1960s and early 1970s a series of scandals shed much needed light on the plight of people with learning disabilities. Many were living in large institutions, removed from society, and were often treated appallingly by the people meant to care for them.In 1972 Oliver Russell, a child psychiatrist, was asked to provide two sessions a week at Farleigh Hospital in Bristol. The psychiatric hospital had been brought back under the health authority’s control in 1968 after three nurses were jailed for abusing patients. Hospital managers were resistant to the new regime, however, and it took Russell two years to persuade them to allow him to take charge of a single ward. When he eventually took over he found that 10 out of the 22 male patients were detained under the Mental Health Act 1959. Russell and a colleague interviewed the men and reviewed their notes.“By the end...

An industrial action ballot of first year doctors has been launched by the BMA, just days after the union said the majority of its senior doctor members are willing to strike over pay.Faced with the barrage of disputes, Health Secretary Wes Streeting has urged doctors not to let the union “derail” their careers.The ballot, open to BMA members who are foundation year 1 (FY1) doctors in England from 8 September until 6 October, demands the government “act to fix the unemployment crisis affecting resident doctors.”1In July a BMA survey of 4401 resident doctors with a response rate of around 5.7% found that a third of respondents had no planned substantive employment or regular locum work from August.2BMA Resident Doctors Committee co-chairs Ross Nieuwoudt and Melissa Ryan have called the unemployment figures a scandal, saying, “Thousands of doctors have been left in career limbo while patients desperately need them. We are...