A patient can live longer, feel better, or function better—these are direct, patient relevant clinical outcomes.1 Surrogate endpoints, in contrast, are indirect measures intended to predict such benefits. They can be used to shorten the duration of trials and make treatments available sooner, but that comes at the cost of greater uncertainty: improving a surrogate may not improve what ultimately matters to patients.A linked article by Lo and colleagues (doi:10.1136/bmj-2026-100618) presents the REASSurE framework for evaluating a single surrogate against a clinical endpoint.2 Developed through a Delphi survey, consensus meeting, piloting, and finalisation, the framework deserves credit for its transparent methods and reporting. It provides a structured checklist of mandatory or recommended items across four areas. Joint evaluation of multiple surrogates remains outside its scope.REASSurE aims to go beyond existing approaches, including the IQWiG (Institute for Quality and Efficiency in Health Care) framework,3 the Biomarker-Surrogacy Evaluation Schema,4 and the three-level...

US Military mightAs most GPs know from bitter experience, requesting testosterone levels on healthy men creates a lot of extra worry and work, without clinical benefits. In July, US Defence Secretary Pete Hegseth controversially announced that US military personnel aged 30 years and older would be required to have annual testosterone screening. Researchers have estimated how many low testosterone concentration, or low T, results army medics will need to churn through, using cross sectional data from the Military Health and Nutrition Examination Study. Analysing morning testosterone levels from 479 men with a mean age of 30, they estimated that one in four active duty US Army personnel would have a morning testosterone below the American Urology Association’s cut off of 300 ng/dL (10.4 nmol/L). Scaled up to the whole US army, that’s 100 000 positive results.JAMA doi:10.1001/jama.2026.19794What doctors search forOpenEvidence is marketed as an AI copilot for doctors and claims...

Sleep and illnessWhen investigators interrogated accelerometer data from 96 000 UK Biobank participants, they found links between quality of sleep and the incidence of 156 different conditions (Plos Med doi:10.1371/journal.pmed.1005213). On the whole, more REM (rapid eye movement) and deep sleep were associated with lower risk of disease, while sleep irregularity and wakefulness after sleep onset were associated with higher risk. But it’s far from clear whether disturbed sleep contributes to illness or is an early sign of it.GLP-1 drugs and anaesthesiaGlucagon-like peptide 1 (GLP-1) receptor agonists delay gastric emptying, potentially increasing the risk of regurgitation and aspiration during anaesthesia. In a prospective study of 47 000 patients undergoing anaesthesia in UK hospitals, 2.9% were taking these drugs (Anaesthesia doi:10.1111/anae.70380). Regurgitation or pulmonary aspiration occurred in 1.41% of users, compared with 0.12% of non-users. Most events involved regurgitation rather than aspiration.Congenital infections and neurodevelopmentTORCH infections are a group of congenital...

Smart watches, health and fitness apps, and social media have fuelled an explosion in people’s access to health information about themselves and other people. Yet as these innovations serve up ever more individual data, and the reach of influencers and entrepreneurs on social media expands, so the challenges facing health workers accumulate.With social media awash with inaccurate posts about health, should doctors be wading in to offer medical advice or to correct misinformation? When influencers are pushing iron or testosterone supplementation to their followers (doi:10.1136/bmj-2026-101080 doi:10.1136/bmj-2026-101300),12 do doctors need to be more active in outlining the risks and benefits? Our feature on “medfluencers” finds doctors arguing the case for engaging directly with influencers on social media, while others warn about the potential regulatory pitfalls (doi:10.1136/bmj-2026-101156).3 John Dale-Skinner, a medicolegal adviser at the Medical Defence Union, says that he would steer doctors “away from that minefield.”People understandably want to impose some...

A woman in her 30s presented with a six hour history of epigastric pain. She described a sudden onset tearing sensation which developed into a constant sharp pain of eight out of 10 severity, accompanied by pre-syncopal symptoms. She had no relevant medical history.Her blood pressure was 93/58 mm Hg. Vital signs were otherwise normal.Physical examination showed right upper quadrant tenderness and a firm mass at the inferior pole of the liver. Initially, a ruptured liver tumour or liver vascular malformation with haemorrhage was suspected.Liver function and serum tumour markers were tested and showed mildly raised levels of alkaline phosphatase (121.96 U/L; reference 35-100 U/L) and markedly raised levels of alpha fetoprotein (AFP) (2603.78 ng/mL; reference < 9 ng/mL).High levels of AFP raised suspicion of hepatocellular carcinoma (HCC). Abdominal computed tomography showed a cystic solid mass in the right hepatic lobe with capsular rupture and pericapsular fluid (fig 1). Biopsy...

Decades of progress in reducing global tobacco use have come under threat in the past 15 to 20 years because of the multibillion dollar tobacco industry’s backlash against efforts to move beyond controlling the tobacco epidemic to ending it—the “endgame” concept.1 Despite this hiatus, recent developments suggest that an endgame is achievable, but only if governments step up to the mark.In 2025, for example, the Maldives became the first country to implement a tobacco-free generation policy, a birthdate based sales restriction designed to prevent future generations taking up smoking.2 In 2027, the UK is set to become the second through its Tobacco and Vapes Act.2 Both legislative measures also seek to counter the rapid increase in non-therapeutic nicotine (NTN) use, with the Maldives going further by stopping the import and sales of e-cigarettes.2While positive, these developments23 show that endgame policies must now extend beyond tobacco to address NTN products. The...

Patients waiting for specialist care were dropped off the electronic referral service (e-RS) without warning, a national safety watchdog has warned.A Health Services Safety Investigations Body (HSSIB) report earlier this month found that from February to July 2026 over 120 000 referrals, including advice and guidance requests and referrals for review, disappeared from the e-RS.1The watchdog warned that these disappearances came to light only after GPs raised the alarm that patients had not heard from a provider about their referrals and otherwise might have been missed.The HSSIB’s report found no evidence of patients being harmed because of these referral disappearances. However, it acknowledged concerns that some patients could have avoided invasive treatment had they been seen earlier.The e-RS is a web based digital platform supplied by NHS England for referring patients to specialist providers.Responding to the HSSIB’s report, NHS England said that the e-RS was not designed for current referral...

bmj;395/oct30_12/e101175/F1F1f1Initially having qualified in dentistry but changing to medicine, George decided to pursue a career as a maxillofacial surgeon. As no training posts were available, he changed to vascular surgery. He undertook basic surgical training at the Royal Victoria Infirmary in Newcastle. He was awarded a Hunterian professorship by the Royal College of Surgeons (RCS) and the prestigious Jacksonian prize for his research on blood transfusion and transplantation, the subject of his MD thesis. He was a skilled vascular surgeon, joined the transplant team, and was involved in a support group for transplant patients.George had a kindly manner towards patients and staff and was well respected. He was heavily involved in teaching and training and was the regional adviser on surgery for the RCS in London. He opened the first RCS provincial office in Newcastle in 1995. He was much involved in examining trainee surgeons, both in the UK and...

bmj;395/oct30_11/e101174/F1F1f1Rama (known to many of his UK colleagues as “Ron”) was born in Bihar, India, in 1949. His father was an acclaimed general surgeon and, after Rama’s mother died suddenly, he was raised by his beloved second mother, a nurse. The eldest of four siblings, he was raised in Patna, a historic city on the banks of the Ganges. There he attended St Xavier School before transferring to Darbhanga for further college. In his teens he developed a lifelong passion for cinema and at one stage was keen to be an actor himself, before deciding to devote his life to medicine.He graduated from Darbhanga Medical College, Bihar, in 1972. He obtained his masters in general surgery in 1976 and moved to the UK in 1979. He worked in various hospitals and was subsequently appointed as a consultant in emergency medicine at Withybush General Hospital in Wales. From there he moved...

Ministers have scrapped plans to abolish Healthwatch England and local Healthwatch groups, after pushback from health leaders and organisations.Launched in 2012, Healthwatch functions as a statutory independent voice for patients, helping the public hold the NHS accountable and push for patient centred improvements.Plans to abolish the Healthwatch network, consisting of 153 local groups and the national body Healthwatch England, were introduced as part of the Health Bill in May,1 amid wider governmental efforts to “simplify the patient safety landscape” of the NHS.It was proposed that the functions of the local Healthwatch organisations would be transferred to NHS integrated care boards, while the role of Healthwatch England would be transferred to the Department of Health and Social Care.2 This would mean an increased reliance on the NHS App for patient feedback. But critics warned that a loss of independence would have led to “health and care services marking their own homework.”Now,...

“Questions must be asked” about the lack of warning before hundreds of practice websites went offline after an online provider entered administration, GP leaders say.They have also questioned why there doesn’t seem to be a coordinated national contingency plan for the failure of a provider delivering critical NHS infrastructure.Hundreds of general practice websites in England and Wales suddenly went offline on 28 October after their online provider—Silicon Practice—entered administration.The software company claimed on its website to provide services for more than 1000 general practices.NHS England said that less than 500 practices had been affected—under 10% of the total number of practices in England and Wales.Reacting, Sarah Jacques, GP co-lead of the Doctors’ Association UK. said: “The sudden loss of websites and online consultation services across hundreds of [general] practices is deeply concerning.”“These are no longer optional extras; they are essential routes through which patients access care.”A notice of administration was...

An “ethical policy” that prevented assisted dying campaign groups from hosting events at the Royal College of General Practitioners will be “reviewed and amended,” the college pledged today.This reversal comes after the campaign group Dignity in Dying was prevented from hosting a GP led event at the college’s London headquarters, prompting outrage among RCGP members and terminally ill patients.Dignity in Dying said that terminally and incurably ill people had hoped to share their experiences with clinicians, parliamentarians, and policy makers at the event.Until Thursday the RCGP website listed assisted dying alongside various groups and industries, including those involved in arms manufacturing, adult entertainment, and fossil fuel exploration, that are banned from holding events at the college’s 30 Euston Square headquarters.1“30 Euston Square is not permitted to accommodate meetings, events, or corporate membership from any organisation engaged with assisted dying or any event where its purpose is to promote and lobby...

The BMJ’s analysis of Mounjaro’s cost to the NHS is fascinating.1 Kudos to the drug industry for finding a true and perhaps never ending El Dorado. There is no shortage of obese people with medical problems or those with body image issues in need of a quick fix.But the NHS expenditure, representing government expenditure or our tax money, is sadly also a quick fix—£574m a year could fund six Olympic velodromes in six cities in the UK (based on figures from 2011).2 It could also fund approximately 5740 high quality tennis courts in state schools across England.3 Investing in health, in sport, and in young people is more likely to produce sustained impact in the effort to tackle the obesity epidemic.The complex interplay between eligibility, affordability, and effectiveness is likely to be exploited by the drug industry. But as a nation, our preference should be for a healthy, active lifestyle...

Climate change is increasing the frequency, intensity, and duration of hazardous heat, particularly in tropical and subtropical regions, and strong El Niño conditions may push temperatures even higher.12 An estimated 2.41 billion workers are exposed to excessive heat each year, contributing to 22.85 million injuries and 18 970 deaths.3 A meta-analysis of 111 studies from 30 countries and more than 40 occupations found that 35% of workers exposed to heat experienced heat strain and 30% reported productivity losses.4 In 2024, heat caused an estimated 639 billion lost working hours and $1.09tn in lost income.1Temperature is not the only determinant of heat risk. Humidity, radiant heat, air movement, workload, clothing, exposure duration, and acclimatisation interact with access to water, sanitation, shade, and recovery time.The burden is unequal; those with the least bargaining power and weakest protection face the greatest risks. Around two billion people work informally worldwide, often beyond the reach...

International efforts to develop pandemic vaccines within the goal of 100 days must be accompanied by stronger basic infection control, the World Health Summit heard this week.Jean-Jacques Muyembe Tamfum, the leading Congolese scientist who co-discovered Ebola virus disease 50 years ago, was referring to the current outbreak of Bundibugyo Ebola virus in the Democratic Republic of the Congo (DRC).He told the meeting in Berlin that, despite advances in vaccine science, weaknesses in outbreak preparedness continue to persist.Muyembe Tamfum said these weaknesses in providing basic tools are resulting in the infection and death of health workers in the DRC outbreak, in outcomes similar to those of the first Ebola outbreak he witnessed back in the 1970s.“The infection prevention control is not working. We cannot strengthen the health system without improving infection control. There’s no protective equipment in most of our hospitals, or disinfectant, or sometimes running water. Or safe and dignified...

Danish researchers behind a controversial study of hepatitis B vaccination in Guinea-Bissau have defended their plan to explore any potential negative consequences of the jab.Controversy regarding the proposed research project, which was supported by US funding, erupted earlier this year as Guinea-Bissau’s government, the Africa Centers for Disease Control, and the World Health Organization (WHO) all voiced their objections or concerns.1The trial would have given half of the 14 000 children a hepatitis B vaccine at birth, alongside the BCG and oral polio vaccine, and the others would instead get the hepatitis B vaccine jab at age 6 weeks—as is currently standard in Guinea-Bissau—observing health differences between the two cohorts.This brought an international cry of ethical concern, however, with half the cohort at significantly greater risk of hepatitis B infection than the other and some critics labelling the trial “neocolonialist.” Adding to the controversy was the study being championed by...

Safety warnings about antidepressants are to be strengthened to emphasise to doctors and patients the risks of suicidal thoughts and behaviours and sexual dysfunction.The regulator the Medicines and Healthcare Products Regulatory Agency (MHRA) is introducing the measures after a major review. This was initiated after patients and families raised concerns about the way the two key risks were currently communicated in patient information leaflets.However, some experts said the addition of the warnings didn’t “go far enough.”More than nine million people in England are estimated to take antidepressants.1 The drugs are commonly prescribed to treat the symptoms of depression along and also other conditions such as migraine, neuropathic pain, and anxiety.Following the review, patient information leaflets for antidepressants will be updated to include a new boxed warning signposting patients to information on suicidal thoughts and behaviours.The MHRA said the expectation is that a new patient card will be included in or...

Chinese health authorities have moved to strengthen disease surveillance at a major crossing with Russia after the unexplained death of a laboratory worker at an antiplague research institute in Siberia.1The Centre for Disease Control and Prevention (CDC) in Manzhouli, China’s largest land port, held a risk assessment meeting to examine the possibility of imported infections and called for stronger monitoring and coordination with customs and border authorities.The measures follow the death on 2 October of a 28 year old worker at the Irkutsk Antiplague Research Institute of Siberia and the Far East.Russian authorities have reported no evidence of plague or other high threat pathogens, but the cause of the worker’s fatal pneumonia remains undetermined, despite an exhaustive contact tracing and testing effort, according to Russian health authorities and Telegram posts by local officials—at least one of which initially identified plague as the cause.The World Health Organization also said on 10...

The threat of bioterrorism is real and proven. Past incidents are well documented. The willingness of certain countries to engage in biological warfare, in contravention of international treaties, is well established. But it seems that we can’t agree on whether artificial intelligence adds to that risk. How worried should we be?The views of experts broadly divide into three categories (doi:10.1136/bmj-2026-101086).1 One group believes that the risks are existential. Others say that the risks are exaggerated by the industry. They believe that when Anthropic warns that people are already experimenting by using AI to create bioweapons, this is a thinly disguised ruse by a technology company to boast about AI’s capabilities and boost its commercial value. It’s “highly, highly unlikely,” they believe, that AI will cause human mass extinction in the near future. The third group argues that the capabilities of AI aren’t what the technology companies would have us believe:...

bmj;395/oct16_1/e100833/F1F1f1As a young researcher in infant nutrition, Alan Lucas was influenced by two of his colleagues at the MRC Dunn Nutrition Unit in Cambridge, Robert McCance and Elsie Widdowson. These giants in the field had done experimental research on the consequences of early life nutrition in rats and other animals in the 1960s,1 spurring Lucas to do similar work in humans.He set up a multicentre trial in 1982 to look at the differences in growth, development, and health outcomes in preterm infants who received different types of feeding. Mothers were asked about their feeding intentions, and the babies whose mothers didn’t provide breast milk were randomly allocated to receive standard formula, unfortified donor breast milk, or a specially designed, nutrient rich preterm formula. A supplementary trial included babies whose mothers provided breast milk.23This was the first time anyone had conducted an experiment to show that how preterm babies were fed...