British medical bulletin最新文献

Background: The National Health Service (NHS) in England is facing a workforce crisis. A new Long Term Workforce Plan (LTWP) seeks to address this, setting out ambitious proposals to expand and reform domestic medical education and training in England. However, there are concerns about their feasibility.

Sources of data: In September 2023, over 60 individuals representing medical education and training in the UK participated in an exercise run by UK Medical Schools Council by using systems theory to identify risks.

Areas of agreement: The UK does need more 'home grown' doctors, but the LTWP has important gaps, including lack of attention to postgraduate training, absence of reference to the need for more educators and capital investment and risk of inadequate clinical placement capacity, particularly in primary care settings.

Areas of controversy: There are unresolved differences in the understanding of a proposed medical apprenticeship model and no scheme has, as yet, been approved by the General Medical Council. Participants were unable to determine who the beneficiaries of this scheme will be (apart from the apprentices themselves).

Growing points: While the LTWP represents a welcome, although overdue, commitment to address the NHS workforce crisis, we identified significant gaps that must be resolved.

Areas timely for developing research: First, the development of the LTWP provides a case study that adds to literature on policymaking in the UK. Second, while we only examined the expansion of medical training, the method could be applied to other parts of the LTWP. Third, a prospective evaluation of its implementation is necessary.

Background: Over the last two decades, inherited cardiac conditions (ICC) centres have emerged with the aim of improving outcomes for patients and their families, through early diagnosis, genetic testing, risk assessment and specialist treatment.

Sources of data: A literature search was performed using PubMed (https://pubmed.ncbi.nlm.nih.gov/). Commissioned ICC service reviews from NHS England, NHS Improvement and PHG Foundation were evaluated.

Areas of agreement: ICC patient management requires a multi-disciplinary approach. ICC services are predominantly based within tertiary centres. Despite expansion, provision of care remains inadequate to meet rising demands. Access to services is inconsistent, partly due to geographic variation and lack of standardized pathways.

Areas of controversy: The optimal ICC care model remains undecided, although there is growing interest in 'hub-and-spoke' networks, which could aid secondary and tertiary service integration and repatriation of care.

Growing points: Genetic mainstreaming is a priority for the Genomic Medicine Service Alliance. The benefits of telehealth and virtual clinics have been validated by their use during the COVID-19 pandemic. Other innovations to improve resource efficiency, such as clinical scientist-led and nurse-led clinics, show promise.

Areas timely for developing research: An update for the NHS ICC service specifications is planned that appears well timed given the rapid evolution of the ICC landscape in the decade since last review. This has the potential to address needs including national audit, standardized pathways and ICC networks to improve governance and equity of care. Delegation of commissioning for specialist services to integrated care systems may also provide opportunity for increased regional direction.

Introduction: a sizable proportion of the working population has a disability that is not visible. Many choose not to disclose this at work, particularly in educational workplaces where disability is underrepresented. A better understanding of the barriers and facilitators to disclosure is needed.

Sources of data: this scoping review is based on studies published in scientific journals.

Areas of agreement: the reasons underpinning disclosure are complex and emotive-in-nature. Both individual and socio-environmental factors influence this decision and process. Stigma and perceived discrimination are key barriers to disclosure and, conversely, personal agency a key enabler.

Areas of controversy: there is a growing trend of non-visible disabilities within the workplace, largely because of the increasing prevalence of mental ill health. Understanding the barriers and facilitators to disability disclosure is key to the provision of appropriate workplace support.

Growing points: our review shows that both individual and socio-environmental factors influence choice and experience of disclosure of non-visible disabilities in educational workplaces. Ongoing stigma and ableism in the workplace, in particular, strongly influence disabled employees' decision to disclose (or not), to whom, how and when.

Areas timely for developing research: developing workplace interventions that can support employees with non-visible disabilities and key stakeholders during and beyond reasonable adjustments is imperative.

Background: Disparities in health care delivered to marginalized groups are unjust and result in poor health outcomes that increase the cost of care for everyone. These disparities are largely avoidable and health care providers, have been targeted with education and specialised training to address these disparities.

Sources of data: In this manuscript we have sought out both peer-reviewed material on Pubmed, as well as policy statements on the potential role of cultural competency training (CCT) for providers in the surgical care setting. The goal of undertaking this work was to determine whether there is evidence that these endeavours are effective at reducing disparities.

Areas of agreement: The unjustness of health care disparities is universally accepted.

Areas of controversy: Whether the outcome of CCT justifies the cost has not been effectively answered.

Growing points: These include the structure/content of the CCT and whether the training should be delivered to teams in the surgical setting.

Areas timely for developing research: Because health outcomes are affected by many different inputs, should the effectiveness of CCT be improvement in health outcomes or should we use a proxy or a surrogate of health outcomes.

Background: Female genital schistosomiasis (FGS) is a chronic gynaecological disease affecting girls and women in sub-Saharan Africa (SSA), caused by the parasite Schistosoma (S.) haematobium. FGS is associated with sexual dysfunction, reproductive tract morbidity and increased prevalence of HIV and cervical precancer lesions.

Source of data: Key peer-reviewed published literature.

Areas of agreement: FGS screening and diagnosis require costly equipment and specialized training, seldom available in resource-limited settings. FGS surveillance is not included in wider schistosomiasis control strategies. The interplay of FGS with other SRH infections is not fully understood. Integration of FGS within sexual and reproductive health (SRH) control programmes needs to be explored.

Areas of controversy: There are no standardized methods for individual or population-based FGS screening and diagnosis, hindering accurate disease burden estimates and targeted resource allocation. Treatment recommendations rely on public health guidelines, without rigorous clinical evidence on efficacy.

Growing points: Integrating FGS screening with SRH programmes offers an opportunity to reach at-risk women with limited access to healthcare services. Home-based self-sampling coupled with handheld colposcopes operated by primary healthcare workers show promise for FGS diagnosis and surveillance at scale.

Areas timely for developing research: There is growing interest in decentralizing strategies for FGS screening and diagnosis. The accurate predictions on the 'cost-effectiveness' of these approaches will determine their affordability and feasibility within the overburdened health systems in SSA. Clinical trials are needed to optimize FGS treatment. Longitudinal studies can expand on the epidemiological knowledge on co-morbidities and integration within other SRH interventions.

Background: Parkinson's disease (PD) is the second most common neurodegenerative disorder and is clinically characterized by the presence of motor (bradykinesia, rigidity, rest tremor and postural instability) and non-motor symptoms (cognitive impairment, autonomic dysfunction, sleep disorders, depression and hyposmia). The aetiology of PD is unknown except for a small but significant contribution of monogenic forms.

Sources of data: No new data were generated or analyzed in support of this review.

Areas of agreement: Up to 15% of PD patients carry pathogenic variants in PD-associated genes. Some of these genes are associated with mendelian inheritance, while others act as risk factors. Genetic background influences age of onset, disease course, prognosis and therapeutic response.

Areas of controversy: Genetic testing is not routinely offered in the clinical setting, but it may have relevant implications, especially in terms of prognosis, response to therapies and inclusion in clinical trials. Widely adopted clinical guidelines on genetic testing are still lacking and open to debate. Some new genetic associations are still awaiting confirmation, and selecting the appropriate genes to be included in diagnostic panels represents a difficult task. Finally, it is still under study whether (and to which degree) specific genetic forms may influence the outcome of PD therapies.

Growing points: Polygenic Risk Scores (PRS) may represent a useful tool to genetically stratify the population in terms of disease risk, prognosis and therapeutic outcomes.

Areas timely for developing research: The application of PRS and integrated multi-omics in PD promises to improve the personalized care of patients.

Background: England and Wales experienced a stagnation of previously improving life expectancy during the 2010s. Public bodies cited influenza as an important cause.

Sources of data: We used data from the Office for National Statistics to examine mortality attributed directly to influenza and to all influenza-like diseases for the total population of England and Wales 2010-19. Several combinations of ICD-10 codes were used to address the possibility of under-counting influenza deaths.

Areas of agreement: Deaths from influenza and influenza-like diseases declined between 2010 and 2019, while earlier improvements in mortality from all causes of death were stalling and, with some causes, worsening. Our findings support existing research showing that influenza is not an important cause of the stalling of mortality rates 2010-19.

Areas of controversy: Influenza was accepted by many as an important cause of stalling life expectancy for much of the 2010s, while few in public office have accepted austerity as a key factor in the changes seen during that time.

Growing points: This adds to the mounting evidence that austerity damaged health prior to COVID-19 and left the population more vulnerable when it arrived.

Areas for developing timely research: Future research should explore why so many in public office were quick to attribute the change in trends in overall mortality in the UK in this period to influenza, and why many continue to do so through to 2023 and to deny the key role of austerity in harming population health.

Background: Older adults' use of social care and their healthcare utilization are closely related. Residents of care homes access emergency care more often than the wider older population; however, less is known about emergency care use across other social care settings.

Sources of data: A systematic review was conducted, searching six electronic databases between January 2012 and February 2022.

Areas of agreement: Older people access emergency care from a variety of community settings.

Areas of controversy: Differences in study design contributed to high variation observed between studies.

Growing points: Although data were limited, findings suggest that emergency hospital attendance is lowest from nursing homes and highest from assisted living facilities, whilst emergency admissions varied little by social care setting.

Areas timely for developing research: There is a paucity of published research on emergency hospital use from social care settings, particularly home care and assisted living facilities. More attention is needed on this area, with standardized definitions to enable comparisons between studies.

Introduction: Family members are the primary source of support for the growing number of people living with dementia (PLWD) worldwide. However, caring for a person living with dementia can have detrimental impacts on the carer quality of life (QoL). This review of systematic reviews explored the factors associated with the QoL of family carers of PLWD and interventions aimed at improving their QoL.

Sources of data: Several health-related databases (PUBMED, Psychinfo, Google Scholar and COCHRANE) were consulted in November 2022. Nineteen systematic reviews were included, and their methodological quality was assessed via AMSTAR-2.

Areas of agreement: Better carer physical and mental health, provision of formal support, relationship quality between carers and PLWD, as well as positive psychological traits were associated with better carer QoL. There is no one-size-fits-all intervention that can improve the QoL of all carers, but promising results were found in most of the interventions.

Areas of controversy: There is inconsistency in evidence on the association between the carer age and QoL. The use of a wide range of QoL measures, particularly generic QoL scales, has contributed to inconsistencies when comparing the efficacy of interventions.

Growing points: Evidence suggests the need for a person-centred approach to improving carer QoL, considering individual and contextual needs as well as the continuum and progressive nature of dementia care.

Timely areas for developing research: Future research should be focused on understanding how to best implement and measure person-centred care approaches to carer QoL, including cost-effectiveness. More qualitative studies are necessary to explore carer negative and positive experiences of QoL.

Introduction: The existing treatment modalities for knee osteoarthritis (OA) do not actually address the pathology. Biological therapies, including those using material derived from perinatal tissues, represent a ground-breaking approach to alleviating the symptoms of OA of the knee.

Source of data: Current scientific literature published in PubMed (MEDLINE), Embase and Scopus databases. Trials registered in various clinical trial databases.

Areas of agreement: Perinatal tissues including Wharton's jelly (WJ) and associated mesenchymal stem cells (MSCs) can be used for the management of knee OA.

Areas of controversy: The efficacy of WJ and associated MSCs in the management of knee OA is still controversial.

Growing points: The use of WJ and associated MSCs in the management of knee OA is safe and appears to be effective.

Areas timely for developing research: The present published evidence suggests that WJ tissue and associated MSCs offer an encouraging alternative for the management of knee OA. The published in vitro, preclinical and clinical investigations demonstrate the therapeutic potential of WJ and promote further research in this field to provide symptomatic relief to patients suffering from OA, aiming also to regenerate the osteoarthritic hyaline cartilage, with disease-modifying effects. Future adequately powered randomized controlled trials should be undertaken to establish whether WJ is helpful in the management of OA of the knee.