Largest study on this topic suggests that measurement errors lead to potential delays in care and contribute to health disparities

Fingertip monitors known as pulse oximeters that can be used at home to detect low blood oxygen levels (hypoxaemia) give higher readings for patients with darker than lighter skin tones, finds the largest study on this topic published by The BMJ today.

This means that low blood oxygen levels may be missed in patients with darker skin tones, potentially delaying care, while patients with lighter skin tones may get unnecessary treatment.

Pulse oximeters use light to measure the amount of oxygen in the blood (SpO2). For most people, a normal pulse oximeter reading is between 95% and 100%, with readings below 90-92% generally considered low and requiring medical attention.

They are known to be affected by several factors, including skin tone, as pigment in darker skin can absorb more light, making the device “think” there’s more oxygen than there is. But so far, studies have been unable to draw any firm conclusions about the impact of skin tone on diagnostic accuracy.

To address this, researchers set out to test the measurement and diagnostic accuracy of five fingertip pulse oximeters provided by the NHS for use at home in the NHS England COVID oximetry @home scheme.

They drew on data from 903 critically ill adults (average age 56 years; 67% male) on 24 NHS intensive care units in England between June 2022 and August 2024.

Although the fingertip pulse oximeters tested were those used at home, intensive care units were used as the test laboratory as patients have lower blood oxygen values and routinely have their blood oxygen accurately measured using hospital machines.

For each patient, skin tone was measured objectively using a spectrophotometer (a type of camera that measures colour). The researchers then compared pulse oximetry blood oxygen values (SpO2) with “gold-standard” arterial blood gas measurements (SaO2).

SpO2 values were assessed at two thresholds in line with current guidance either to seek medical help (94% or lower) or to attend the emergency department (92% or lower).

A total of 11,018 paired SpO2-SaO2 measurements were analysed. All five pulse oximeters returned higher SpO2 values for patients with darker skin tones than patients with lighter skin tones, at any given level of SaO2 measurement.

SpO2 readings were, on average, 0.6-1.5 percentage points higher for patients with darker than lighter skin tone.

At both SpO2 thresholds assessed, false negative rates (low oxygen missed by the pulse oximeter when present) increased with darker skin tones, while false positive rates (low oxygen indicated by the pulse oximeter when absent) decreased with darker skin tone.

And while absolute differences in readings were small, “they can result in substantially higher rates of false negatives and lower rates of false positives in the diagnosis of hypoxaemia,” note the researchers.

This is an observational study, so no definitive conclusions can be drawn about cause and effect. And the authors acknowledge that the study was conducted in critically ill patients, which may limit the generalisability of the findings.

However, they say this was a large study using sophisticated statistical modelling to assess the performance of the pulse oximeters across multiple domains of both measurement and diagnostic accuracy.

As such, they conclude: “SpO2 readings should be interpreted in the context of other clinical information and trends in SpO2 values given greater importance than single readings, particularly in patients with darker skin tones.”

They add: “Healthcare systems should develop guidance to inform and aid practitioners, patients and the public, particularly in settings where additional clinical readings from other medical measurement devices would not be available.”

In a linked editorial, researchers agree that clinicians must recognise the limitations of current devices and interpret readings for patients with darker skin with care and caution, and they say regulation must now catch up with science to mitigate harm.

“The goal is not to abandon pulse oximetry but to understand its limits and make it equitable, ensuring that the technology designed to measure oxygen does not itself perpetuate inequalities in those who receive it,” they conclude.

14/01/2026

Notes for editors
Research: The impact of skin tone on the performance of pulse oximeters used by the National Health Service COVID oximetry @home scheme: measurement and diagnostic accuracy study doi: 10.1136/bmj-2025-085535
Editorial: Pulse oximetry in people with darker skin tones doi: 10.1136/bmj.s37
Journal: The BMJ

Funding: National Institute for Health and Care Research (NIHR)

Link to Academy of Medical Sciences press release labelling system: http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes (research); No (linked editorial)
Evidence type: Observational; Opinion
Subject: People

The post Home fingertip oxygen monitors less accurate for people with darker skin tones first appeared on BMJ Group.

If high quality clinical trials confirm lasting benefits and key features, apps could become cornerstone of global tobacco control efforts, suggest researchers

Smartphone apps—particularly those based on psychological theories—are 3 times as effective as no/minimal support at helping people who smoke stub out their tobacco use long term, suggests a pooled data analysis of the available evidence, published in the online journal BMJ Evidence Based Medicine.

If high quality clinical trials can confirm lasting benefits and key features, these apps could become a cornerstone of global tobacco control efforts, suggest the researchers.

Smartphone apps offer an accessible and versatile approach to smoking cessation efforts. But the current body of evidence has been hindered by small study numbers and app obsolescence, say the researchers.

Most currently available smoking cessation apps adopt either traditional behavioural frameworks, focused on directly modifying smoking behaviour, or psychological-behavioural theories, targeting cognition, emotion regulation, and motivation through techniques such as cognitive behavioural therapy (CBT), acceptance and commitment therapy, and mindfulness, explain the researchers.

But it’s not clear which approach might be more effective for improving sustained abstinence.

To strengthen and update the evidence base, the researchers assessed the effectiveness of smartphone apps, when used alone or when combined with traditional approaches, such as nicotine replacement therapy and counselling, for helping people quit smoking and stay away from tobacco long term (6 months continuously).

They trawled research databases for relevant randomised controlled trials published up to August 2025 of people aged at least 15 who planned to quit smoking. Comparisons included: no intervention; minimal smoking cessation support; traditional interventions; and apps based on traditional behavioural interventions.

Certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

The data from a total of 31 eligible studies, involving 12,802 participants, were pooled. Low certainty evidence from 4 studies (1402 participants) suggests that smartphone apps used alone may nearly triple the rate of 6-month continuous abstinence, increasing the number of ‘abstainers’ by 40 in every 1000, compared with no or minimal smoking cessation support.

When combined with traditional interventions, these apps may nearly double 6-month continuous abstinence compared with traditional interventions alone (4 studies involving 2163 participants; low certainty evidence).

And based on data from 3 studies (1502 participants; low certainty evidence), these apps plus pharmacotherapy may improve 6-month continuous abstinence by 77% compared with pharmacotherapy alone.

High certainty evidence indicated that apps based on psychological behavioural theories significantly increased abstinence in the short term at 3 months (69%; 2 studies, 2565 participants) and in the long term at 6 months (36%; 4 studies, 3258 participants) compared with apps based on traditional behavioural interventions.

“Smartphone apps can deliver intensive, interactive and real-time behavioural support, exceeding the effect of brief advice. A clear dose–response relationship exists between counselling intensity and quit success, and apps help meet this need while bypassing barriers such as limited clinic capacity, staff time, and declining use of telephone quitlines,” point out the researchers.

“Consequently, smartphone apps represent a scalable alternative or adjunct to traditional cessation services, particularly in resource-limited settings,” they suggest.

But the certainty of the evidence remains low due to limited sample sizes and methodological limitations, including design variations in the apps and their use, caution the researchers, adding that the findings “should be viewed as generating a hypothesis for future research rather than as a definitive conclusion.”

They conclude: “Should future evidence confirm lasting benefits and pinpoint key features, rigorously validated apps could become a cornerstone of global tobacco control efforts.”

13/01/2025

Notes for editors
Research: Efficacy of smartphone apps used alone or with traditional interventions for smoking cessation: a systematic review and meta- analysis Doi: 10.1136/bmjebm- 2025-113971
Journal: BMJ Evidence Based Medicine

External funding: China Association on Tobacco Control for Health

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Systematic review + meta analysis
Subjects: People

The post Phone apps nearly 3 times as good as no/basic support for quitting smoking long term first appeared on BMJ Group.

But data on use, frequency, and consequences for NHS incomplete and haphazard
Currently impossible to fully understand risks of opting for surgery abroad, warn researchers

The postoperative complications of medical tourism may be costing the NHS up to £20,000 per patient, suggest the findings of a rapid review of the available data, published in the open access journal BMJ Open.

But data on the use, frequency, and consequences for the NHS are incomplete and haphazard, making it currently impossible to fully understand the risks of opting for surgery overseas, warn the researchers.

The number of medical tourists has risen steadily over the past several decades, a trend that shows no sign of abating, note the researchers. And treatment of any postoperative complications usually falls to the home country’s health service and can be further complicated by inadequate information about the initial surgery, they add.

Amid an absence of systematically collected data, the researchers wanted to gauge the costs and savings to the NHS of medical tourism as well as the type, frequency, and complications involved, plus any subsequent treatment, care, and use of NHS resources.

They reviewed research databases for relevant studies as well as ‘grey literature,’ such as conference proceedings, discussion papers, editorials, and government, industry, and institutional reports, published between 2012 and December 2024.

Studies that described cases of emergency and urgent surgery abroad; treatment for cancer, infertility, and dentistry; and transplant surgery were excluded from the analysis.

In all, 90 full text articles were selected for review, of which 38 reports describing 37 studies, were eligible for inclusion: 19 described complications due to metabolic/bariatric surgery; 17 complications due to cosmetic surgery; and one complications arising from eye surgery.

The case series and case reports included 655 patients treated by the NHS between 2011 and 2024 for complications arising from metabolic/bariatric (385), cosmetic (265), or eye (5) surgery tourism.

Twenty three studies reported the destination country. Overall, 29 countries from every continent were reported, but Turkey was the most common destination (61%). Most patients were women (90%), and the average age was 38, but ranged from 14 to 69.

The most commonly reported procedures were sleeve gastrectomy–removal of part of the stomach to create a smaller ‘sleeve’–breast surgery enlargement, and ‘tummy tuck’ (abdominoplasty).

Twenty two studies (371 patients) reported some details on complications. No deaths were reported in the included studies, but at least 196 patients (53%) experienced moderate to severe complications.

Treatment for these was not clearly reported in most of the studies, however, and only 14 studies reported on the associated costs, which ranged from £1058 to £19,549 per patient in 2024 prices.

Eight studies (159 patients) reported length of hospital stay for the treatment of complications from metabolic/ bariatric surgery tourism. The combined average length of stay was just over 17 days; the longest was 45 days.

The combined average length of stay for the treatment of cosmetic surgery complications was just under 6 days; the longest was 49 days. For eye surgery tourism, over 50 outpatient appointments and 4 surgical procedures were reported.

Very few studies reported on the use of other resources, such as day case procedures, surgery time, clinic appointments or number and type of diagnostic tests.

The certainty of the evidence obtained from most of the studies was low, primarily because most of the studies were retrospective, with data obtained from medical notes, which can be incomplete or wrongly coded; few studies included demographic details or previous medical history; and not all outcomes were reported by all the studies, explain the researchers.

But this suggests that both the complications arising from medical tourism for elective surgery and the associated costs are likely to be underestimated, they add.

“There are areas of the UK, such as Wales and the South West of England, which are almost unrepresented [in published evidence]. We did not identify any studies that related to other surgical specialties, such as orthopaedic surgery, and we did not identify any eligible studies conducted in primary care or that considered longer-term follow- up,” they point out.

“We still do not know how many people resident in the UK go abroad for elective surgery or how many people subsequently experience complications. Without these data, we cannot fully understand the levels of risk that people seeking surgery abroad are taking,” they emphasise.

“A systematic approach is needed to collecting information on the number of people who travel abroad for elective surgery and the frequency and impact on the UK NHS of treating complications,” they insist.

“Awareness-raising campaigns and interventions are warranted to inform members of the public in the UK considering going abroad for surgery about the potential for complications.” they add.

“Those seeking medical treatment abroad should be made aware of which complications the NHS is responsible for treating, and costs for which the patient may be potentially personally liable, including non-emergency treatment,” they suggest.

13/01/2026

Notes for editors
The authors have previously posted a non-peer reviewed, unedited version of this study for feedback from the research community, on a recognised preprint server.
Research: Complications and costs to the UK National Health Service due to outward medical tourism for elective surgery: a rapid review Doi: 10.1136/bmjopen-2025-109050
Journal: BMJ Open

External funding: Health and Care Research Wales Evidence Centre

Link to Academy of Medical Sciences press release labelling system http://press.psprings.co.uk/AMSlabels.pdf  

Externally peer reviewed? Yes
Evidence type: Rapid review
Subjects: People

The post Postoperative complications of medical tourism may cost NHS up to £20,000/patient first appeared on BMJ Group.

Condition often poorly recognised, diagnosed, managed and researched, say report authors
This has prompted unfounded fears, particularly on social media, that all steroids are harmful

There is little awareness, particularly among clinicians, of the medical and psychological complexities of ‘topical steroid withdrawal’—the body’s adverse response to the prolonged use of these powerful creams to treat inflammatory skin conditions when they are either tapered or suddenly stopped—warn doctors in the journal BMJ Case Reports.

The condition, also known as ‘TSW syndrome,’ ‘steroid addiction,’ and ‘red burning skin syndrome,’ is poorly recognised, diagnosed, managed, and researched, say the report authors, one of whom speaks from direct experience.

This has prompted unfounded fears, particularly on social media, that all steroids are harmful and should be avoided in favour of other often untested, unproven remedies, they caution.

Steroid creams are widely used for the treatment of various inflammatory skin conditions, such as eczema and psoriasis, for which they are very effective, note the report authors.

They are available in 4 different strengths, ranging from mild to very strong.

But withdrawing treatment—particularly the stronger formulations—after protracted use can prompt a rebound flare-up of symptoms, which can be even more severe and debilitating than the original condition, they point out.

These symptoms can spread well beyond the original areas of treatment and additionally trigger insomnia and depression.

The underlying causes are only partially understood, while diagnosis can be tricky because of the highly variable presenting symptoms, they add.

In a bid to promote wider recognition of the syndrome, the report authors present a case exemplifying some of the challenges involved for both clinicians and patients.

The case involved a middle-aged woman with a history of atopic eczema since infancy that  had been treated with varying strengths of steroid creams for sometimes lengthy periods.

She was referred to dermatology for review and explained that she had had a flare-up of symptoms which had persisted for 18 months until she was treated with a gradually tapering 4-week course of steroid tablets.

She had significant skin thinning, particularly on her arms, and thickened leathery skin (lichenification) in the folds of her elbows and wrists.

She was prescribed further steroid creams to ward off future flare-ups, which she decided to stop using a month after her review. Her skin symptoms then significantly worsened as did her general health.

She had widespread skin reddening and experienced a burning sensation and intense itching. Her skin became dry, scaly, thickened and cracked, exposing deep tears in parts.

She also reported swelling in the thighs, feet, ankles, and around the eyes and extensive skin folds and sagging. Systemic symptoms included dizziness, nausea, hair loss, insomnia, low blood pressure, extremes of temperature and sensations of dampness and numbness. She experienced intense nerve pain and sharp jolts of pain akin to an electric shock. Her symptoms were incapacitating.

She suspected topical steroid withdrawal. It took 28 months for her symptoms to resolve, during which time she decided against any further treatment, even skin moisturisers. She has since experienced occasional mild flare-ups but has not applied steroid creams.

Commenting on her experience, she explains that at times the severity and extent of her symptoms left her unable to get out of bed, and feeling like she might die.

She writes: “I should have liked to have been supported to withdraw safely. Without a diagnosis, this was not possible: I was being treated for eczema, which included continued steroid treatment. It is my understanding that TSW patients will not recover while steroids are part of their recovery plan.”

She continues: “I am pleased that more is now known about TSW, but I should like to see TSW diagnoses routinely being considered where steroids are no longer controlling a patient’s skin or when a patient simply feels that something is ‘different’ to usual. More than that, I should like to see TSW prevention a priority, so that there is no new generation of patients who have to endure the suffering that I have endured.”

The report authors acknowledge: “Despite the increasing recognition of TSW within the dermatological community, it remains underdiagnosed in routine practice. Patients often turn to online forums and self-treatment due to diagnostic challenges, which can lead to inconsistent or even harmful practices.”

They continue: “While social media has raised awareness for poorly recognised conditions like TSW, it has significantly contributed to steroid phobia. From our medical experience, exposure to alarming online narratives has led many patients to refuse [topical steroid] management of their conditions, both dermatological and otherwise, despite reassurance by clinicians about their safe and approved use.”

They conclude: “Breaking the cycle of distrust and enhancing patient care requires clinicians to address patients’ concerns with empathy, prioritising patient education. By fostering open discussions about patients’ beliefs and perspectives while simultaneously providing evidence-based recommendations, clinicians can support well-informed decision making and improve treatment outcomes.

16/12/2025

Notes for editors
Please note, personal details of the case reported here aren’t available for reasons of patient confidentiality.

Case report: Topical steroid withdrawal: a serious, under- recognised skin condition Doi: 10.1136/bcr-2024-264476
Journal: BMJ Case Reports

Link to Academy of Medical Sciences press release labelling system http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Case report
Subjects: People

The post Little awareness of medical + psychological complexities of steroid cream withdrawal first appeared on BMJ Group.

Results support use of tai chi for long term management of chronic insomnia in over 50s

Tai chi, a form of mind-body exercise widely practiced in Chinese communities, has similar benefits to talking therapy for middle aged and older people with chronic insomnia, finds a trial from Hong Kong published by The BMJ today.

These results support the use of tai chi for the long term management of chronic insomnia in middle-aged and older adults, say the researchers.

Chronic insomnia is one of the most common sleep disorders in middle aged and older adults and has been linked to increased risks of cardiovascular diseases, mental disorders, and cognitive impairment.

Cognitive behavioural therapy (CBT) is the preferred treatment for chronic insomnia, but access is often limited by the high costs and low availability of therapists.

Previous studies have also shown benefits of tai chi in middle aged and older adults with insomnia, but direct comparisons with active treatments such as CBT are lacking.

To address this gap, researchers set out to assess whether tai chi is comparable (“non-inferior”) to cognitive behavioural therapy for insomnia (CBT-I) for managing chronic insomnia in middle aged and older adults.

Their findings are based on 200 Chinese adults aged 50 years or older diagnosed with chronic insomnia and enrolled at a research centre in Hong Kong between May 2020 and July 2022.

Participants were able to walk without assistance, were free of chronic conditions that may affect sleep, were not taking part in regular aerobic or mind-body exercise, had not received previous CBT-I treatment, and were not working shifts.

Participants were randomised to receive tai chi or cognitive behavioural therapy interventions for insomnia (CBT-I), consisting of one hour group sessions twice a week for a total of 24 sessions.

The Insomnia Severity Index (ISI) was used to assess change in perceived insomnia severity immediately after the 3-month interventions and at 12-month follow-up (month 15) by scoring symptoms such as difficulty falling and staying asleep, waking up too early and being unable to go back to sleep, and impact on daily life.

An ISI threshold of four points was used as the margin to assess non-inferiority.

At the start of the trial, both groups showed moderate levels of insomnia severity. At month 3, the tai chi group showed a reduction of 6.67 points in ISI scores, while the CBT-I group had a reduction of 11.19 points, resulting in a between group difference of 4.52. Tai chi was therefore deemed inferior to CBT-I at month 3 because the upper confidence limit exceeded the non-inferiority margin.

However, at month 15, the reductions for the tai chi and CBT-I groups were 9.51 and 10.18, respectively, with a between group difference of 0.68. At this point, tai chi was considered non-inferior to CBT-I because the upper limit fell within the non-inferiority margin.

Tai chi and CBT-I also had comparable benefits on subjective sleep parameters, quality of life, mental health, and physical activity level. No adverse events occurred during the intervention period.

The authors acknowledge that the positive effects of tai chi may be partially due to participants’ continued practice after the end of the interventions, and say further studies are needed to determine whether the benefits of tai chi can be applied to other countries or regions with different demographic characteristics.

However, they conclude: “Our study supports tai chi as an alternative treatment approach for the long term management of chronic insomnia in middle aged and older adults.”

26/11/2025

Notes for editors
Research: Tai chi or cognitive behavioural therapy for treating insomnia in middle aged and older adults: randomised non-inferiority trial doi: 10.1136/bmj-2025-084320
Journal: The BMJ

External funding: General Research Fund of Research Grants Council, Hong Kong University Grants Committee and Seed Fund for Basic Research of the University of Hong Kong

Link to Academy of Medical Sciences press release labelling system:
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Randomised non-inferiority (comparability) trial
Subjects: People

The post Tai chi as good as talking therapy for managing chronic insomnia first appeared on BMJ Group.

Continued use leads to overall “net clinical benefit” say researchers

Extending anti-clotting drugs beyond the initial treatment period of at least 90 days after a first blood clot is linked to lower rates of new clots developing compared with stopping treatment, finds a US study published by The BMJ today.

Extended treatment was also linked to higher rates of major bleeding (a common side effect of anti-clotting drugs) but the authors say continued use results in an overall “net clinical benefit.”

Guidelines recommend anti-clotting treatment for at least 3-6 months for patients with venous thromboembolism (VTE) and extended treatment if the VTE has no obvious underlying cause. But there is limited evidence on optimal treatment duration and the long term risk of bleeding is unclear.

To address this, researchers drew on information from two national US claims databases for 30,554 patients (average age 74 years; 57% women) taking anti-clotting drugs for a first unprovoked VTE (with no obvious underlying cause or reversible risk factors) for at least 90 days.

Using a technique called target trial emulation, which applies the design principles of randomised trials to observational data, they compared rates of hospital admission for recurrent VTE and major bleeding in patients who continued and discontinued treatment.

The average treatment duration was 357 days in the continued group and 105 days in the discontinued group. Other factors, such as existing conditions and medication use, were also taken into account.

After initial anticoagulation of at least 90 days, compared with patients who discontinued treatment, those who continued treatment had markedly lower (81%) rates of recurrent VTE (equivalent to 26 fewer events per 1,000 person-years) and lower death rates (26%), but higher rates of major bleeding (75%).

Continuing treatment was also associated with a greater net clinical benefit (a combined measure of recurrent VTE and major bleeding) regardless of treatment duration, which persisted among those using anti-clotting drugs for at least three years after VTE.

The authors acknowledge some limitations. For example, the data lacked information on over-the-counter drug use, socioeconomic status, laboratory test results, and reasons for discontinuing anti-clotting drugs, which may have introduced bias.

However, they say this is a large study that used rigorous analytical methods and the results are consistent with previous studies on this topic, which “should help inform decisions on continuation of treatment, which should be individualised for each patient with an unprovoked VTE.”

While this study provides clinicians and patients with good insight on the effectiveness and safety of long term oral anticoagulation treatment, patient preferences are key to weighing the benefits and risks of indefinite treatment, say researchers from Canada in a linked editorial.

They point out that some uncertainty remains, and say additional research to better identify patients who can benefit from continuing oral anticoagulation treatment after a first unprovoked VTE “will help clinicians counsel and support patients who are faced with the prospect of indefinite anticoagulation treatment.”

12/11/2025

Notes for editors
Research: Continued versus discontinued oral anticoagulant treatment for unprovoked venous thromboembolism: target trial emulation doi: 10.1136/bmj-2025-084380
Editorial: Duration of anticoagulation for unprovoked venous thromboembolism doi: 10.1136/bmj.r2334
Journal: The BMJ

External funding: US National Institute on Aging

Link to Academy of Medical Sciences press release labelling system: http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes (research); No (linked editorial)
Evidence type: Observational (target trial emulation study); Opinion
Subjects: People

The post Extending anti-clotting treatment linked to lower rates of new clots first appeared on BMJ Group.

Yet UK and European drug regulators specify access to 2 adrenaline devices at all times
Giving ‘spare’ devices to all schools would be safer and save local health bodies £millions

Less than half of schoolchildren in England who are at risk of a serious and potentially life-threatening allergic reaction (anaphylaxis) to food were prescribed the antidote—an adrenaline [epinephrine] autoinjector, or AAI for short—finds an analysis of national prescribing data, published online in the Archives of Disease in Childhood.

This is despite recommendations by the UK and European medicines regulators that those at risk should have access to 2 AAIs at all times, since some reactions need more than one dose or to allow for incorrect use.

And with 1 in 10 episodes of anaphylaxis occurring in schools, providing all of them with ‘spare’ devices would be safer and save most local health funding bodies £millions, estimate the researchers.

On average, every UK school class will have one or two children at risk of anaphylaxis to a foodstuff, and many schools require these pupils to leave an AAI on the premises, in case they forget to bring one in.

Children with food allergies are not always prescribed AAI. The researchers analysed routinely collected primary care data from the nationally representative Clinical Practice Research Datalink (CPRD) Aurum for children and young people (5-18) diagnosed with a food allergy between 2008 and 2018.

They found that less than half (44%) of schoolchildren with a food allergy in the CPRD had been prescribed at least one AAI, and only a third (34%) had repeat AAIs prescribed. Among pupils who had already experienced anaphylaxis, rates were 59% and 44%, respectively.

To boost access and safety for all school children, UK legislation was changed in 2017 to allow schools to obtain, without a prescription, ‘spare’ AAI devices for use in emergencies—when the pupil’s own AAI is not readily available or they haven’t been prescribed one.

But only around half of schools have done this, possibly because of the prohibitive cost, which often exceeds £100 a device, when the subsidised NHS tariff is around £10 for two devices, suggest the researchers.

As a result, some local health funding bodies (Integrated Care Boards or ICBs) have piloted the provision of spare AAIs to local schools for use on any child. The researchers therefore wanted to compare the potential costs of this approach with that of prescribing AAIs for retention on school premises to pupils on a named-patient basis.

They looked at NHS data on AAI prescriptions issued to primary and secondary school age children with a food allergy during the 2023-4 and 2024-5 academic years—specifically, the number of pupils prescribed more than two AAIs.

The researchers then used these data to estimate the potential annual savings if ICBs were to provide every school in England with four spare AAIs on an annual basis during the 2023-24 academic year, rather than funding AAIs to each at-risk pupil over the same time period.

Nearly two thirds (63%) of pupils prescribed AAIs with a food allergy were dispensed more than two AAIs at an estimated cost of over £9 million in 2023-4. Most of these additional AAIs were most likely provided for retention on school premises, given the spike in prescriptions at the start of the school year, suggest the researchers.

The estimated cost of providing spare AAIs to every school was £4.5 million. And the researchers calculated that if spare AAIs were to replace the supply of named-patient AAIs exclusively for retention on school premises, this would potentially save at least £4.6 million—equivalent to 25% of the total national spend on AAIs.

The researchers acknowledge that the study data only included primary care NHS prescriptions, dispensed by community pharmacies and so excluded AAIs dispensed through hospitals and private healthcare.

But they conclude: “Irrespective, there can be little doubt that if ICBs were to limit dispensing to two unexpired AAIs per pupil at any one time (and so no longer provide additional AAIs on a named- patient basis just for school use), then providing spare AAIs to schools (at no cost to the school) would be a cost-neutral strategy for the vast majority of ICBs—and one that is likely to improve emergency access to AAIs and therefore safety.”

“The National Child Mortality Database shows that 76% of fatal allergic reactions in children involve modifiable factors, including delays in treating with adrenaline,” points out Helen Blythe of the Benedict Blythe Foundation, in a linked editorial.

“Prevention of Future Death reports issued by HM Coroners echo the same failures. Countries like Canada have had laws mandating allergy safety in schools for two decades. In the UK, we’re still shaking buckets to raise money for potentially life-saving medication in our schools,” she adds.

She calls for Benedict’s Law to enter the statute books. First presented to the Department for Education in 2023, this would require schools to hold spare AAIs funded by the government; training for all staff in allergy awareness and emergency response; and the implementation of a school-wide allergy policy.

“Across the country, regional pilots and local initiatives have shown that it’s possible, practical, and financially sound to equip schools with AAIs,” she emphasises. Such a strategy “would improve emergency access to adrenaline to all pupils, irrespective of whether they had been prescribed AAIs.”

21/10/2025

Notes for editors
Research: Economic modelling of providing ‘spare’ adrenaline autoinjectors to all schools to improve the management of anaphylaxis Doi: 10.1136/archdischild-2025-329493
Viewpoint: Spare pens save lives—so why aren’t they in every school? Doi: 10.1136/archdischild-20225-329521

Journal: Archives of Disease in Childhood

External funding: UK Medical Research Council; UK Food Standards Agency (research)

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Observational; Opinion
Subjects: Children + young people

The post Less than half of schoolkids at risk of food anaphylaxis in England prescribed adrenaline ‘antidote’ first appeared on BMJ Group.

Replication in other populations and settings needed to confirm and extend these observations, say researchers

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors used to treat type 2 diabetes are associated with an 11% lower risk of autoimmune rheumatic diseases, such as rheumatoid arthritis and lupus, compared with another group of diabetes drugs called sulfonylureas, finds a study from South Korea published by The BMJ today.

Autoimmune rheumatic diseases occur when the body mistakenly attacks its own healthy tissues, leading to inflammation and damage to joints, skin, muscles, and other organs. Common conditions include rheumatoid arthritis, lupus, and scleroderma.

Previous studies have shown that SGLT-2 inhibitors can inhibit the body’s immune response, but whether these effects are clinically meaningful remains unclear.

To address this, researchers used the Korea National Health Insurance Service database to analyse 2,032,157 adults with type 2 diabetes (average age 59; 60% men) who started taking either an SGLT-2 inhibitor or a sulfonylurea from 2012 to 2022.

Potentially influential factors such as age, sex, income level, existing conditions and drug treatments, healthcare use, and lifestyle factors were taken into account, and two control outcomes (genital infections and herpes zoster) were also included to assess the risk of bias.

A total of 790 participants taking SGLT-2 inhibitors and 840 participants taking sulfonylureas were newly diagnosed with autoimmune rheumatic disease.

Over an average follow-up period of 9 months, SGLT-2 inhibitors were associated with an 11% lower risk of autoimmune rheumatic diseases compared with sulfonylureas, with incidence rates per 100,000 person years of 52 and 58, respectively.

Findings were largely consistent among subgroups analysed by age, sex, type of SGLT-2 inhibitor, baseline cardiovascular disease, and obesity status. The results for control outcomes also suggested that bias was likely minimal.

This is an observational study so no firm conclusions can be drawn about cause and effect, and the authors acknowledge that follow-up was relatively short, and other unmeasured factors may have affected the results.

However, they say this was a large study that applied rigorous methods to nationwide data, and, as such, these results suggest that SGLT-2 inhibitors may contribute to reducing the risk of autoimmune diseases.

“However, this potential benefit should be carefully weighed against known adverse events and concerns about tolerability,” they write. “Replication in other populations and settings, as well as studies in patients with existing autoimmune rheumatic diseases, are warranted to confirm and extend these observations.”

While in isolation, this study is unlikely to change practice, it is the first full length publication to suggest that SGLT-2 inhibitors reduce the risk of autoimmune rheumatic diseases, say researchers from Canada in a linked editorial.

Although this intriguing finding warrants replication in different populations, this study “sets a foundation for future research and provides preliminary evidence to support an additional reason to use an SGLT-2 inhibitor over a sulfonylurea for the management of type 2 diabetes,” they conclude.

15/10/2025

Notes for editors
Research: Sodium-glucose cotransporter-2 inhibitors and risk of autoimmune rheumatic diseases: population based cohort study doi: 10.1136/bmj-2025-085196
Editorial: SGLT-2 inhibitors for the prevention of autoimmune rheumatic diseases doi: 10.1136/bmj.r2121
Journal: The BMJ

External funding: Ministry of Food and Drug Safety, Korea

Link to Academy of Medical Sciences press release labelling system: http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes (research); No (linked editorial)
Evidence type: Observational; Opinion
Subjects: People

The post SGLT-2 diabetes drugs linked to lower risk of autoimmune diseases  first appeared on BMJ Group.

While it likely increases the risk of serious side effects, including heart disease
Potential harms probably outweigh benefits, and use should be minimised, say researchers

The strong opioid painkiller, tramadol, is not that effective at easing chronic pain for which it’s widely prescribed, finds a pooled data analysis of the available research, published online in BMJ Evidence Based Medicine.

And it likely increases the risk of serious side effects, including heart disease, the findings indicate, prompting the researchers to conclude that the potential harms of tramadol probably outweigh its benefits, and that its use should be minimised.

Tramadol is a dual action opioid widely prescribed for the treatment of moderate to severe acute and chronic pain. As such, it’s recommended in several medical guidelines for pain management, note the researchers.

Its use has surged in recent years, and it’s now among the most commonly prescribed opioids in the US, possibly because of its perceived lower risk of side effects and the widespread belief that it is safer and less addictive than other short-acting opioids, they add.

Although tramadol has been included in previous systematic reviews, none has provided a comprehensive assessment of tramadol’s efficacy and safety in a range of chronic pain conditions, they say.

In a bid to plug this knowledge gap, the researchers scoured research databases for randomised clinical trials published up to February 2025 that compared tramadol with placebo (dummy treatment) for patients with chronic pain, including cancer pain.

Nineteen clinical trials involving 6506 participants with chronic pain were eligible for inclusion in the analysis. Five looked at the impact of tramadol on neuropathic pain; nine focused on osteoarthritis; four looked at chronic low back pain; and one focused on fibromyalgia.

The average age of the trial participants was 58, but ranged from 47 to 69. Tablets were the primary formulation used; only one trial included topical cream. Length of treatment ranged from 2 to 16 weeks while length of follow up ranged from 3 to 15 weeks.

Pooled data analysis of the trial results showed that while tramadol eased pain, the effect was small and below what would be considered clinically effective.

Eight of the trials reported on the proportion of serious side effects arising after treatment during follow up periods of between 7 and 16 weeks.

Statistical analysis of these trials results indicated a doubling in the risk of harms associated with tramadol compared with placebo, mainly driven by a higher proportion of ‘cardiac events,’ such as chest pain, coronary artery disease, and congestive heart failure.

Use of tramadol was also associated with a heightened risk of some cancers, although the follow up period was short, making this finding “questionable,” say the researchers.

Pooled data analysis of all the trial results indicated that tramadol treatment was associated with a heightened risk of several milder side effects, including nausea, dizziness, constipation, and sleepiness.

The researchers acknowledge that the outcome results were at high risk of bias, but this increases the likelihood that the findings overestimate the beneficial effects and underestimate the harmful effects of tramadol, they suggest.

They point out: “Approximately 60 million individuals worldwide experience the addictive effects of opioids. In 2019, drug use was responsible for approximately 600,000 deaths, with nearly 80% of these fatalities associated with opioids and approximately 25% resulting from opioid overdose.

“In the United States, the number of opioid-related overdose deaths increased from 49,860 in 2019 to 81,806 in 2022. Given these trends and the present findings, the use of tramadol and other opioids should be minimised to the greatest extent possible.”

They conclude: “Tramadol may have a slight effect on reducing chronic pain (low certainty of evidence) while likely increasing the risk of both serious (moderate certainty of evidence) and non- serious adverse events (very low certainty of evidence). The potential harms associated with tramadol use for pain management likely outweigh its limited benefits.”

07/10/25

Notes for editors
Research: Tramadol versus placebo for chronic pain: a systematic review with meta- analysis and trial sequential analysis Doi: 10.1136/bmjebm-2025-114101
Journal: BMJ Evidence Based Medicine

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Systematic review + meta-analysis
Subjects: People

The post Widely prescribed opioid painkiller tramadol not that effective for easing chronic pain first appeared on BMJ Group.

Over 200,000 patients may be eligible for treatment in the first three years, but some commissioners are already considering tighter prescribing criteria or rationing
Figures confirm the fear that the roll out is not fit for purpose, says expert

Less than half of England has access to tirzepatide (Mounjaro) through their GP, despite the NHS roll-out of the weight-loss jab officially starting over two months ago, an investigation by The BMJ has found.

Due to the large number of people who could benefit from tirzepatide – an estimated 3.4 million people – and the drug’s price, NHS England and its spending watchdog, the National Institute for Health and Care Excellence, agreed the injections would be rolled out in phases over a 12-year period, which commenced on 23 June 2025, explains Elisabeth Mahase. Yet just 18 out of 42 commissioning bodies (43%) across the country confirmed that they have started prescribing tirzepatide in line with this roll-out plan.

The data, obtained through Freedom of Information requests, also shows that despite NHS England stating that it expects 70% of eligible patients to come forward for treatment, just nine Integrated Care Boards (ICBs) – responsible for planning health services for their local population – confirmed they have been allocated enough NHS funding to cover at least 70% of their eligible patients.

Experts are warning that the lack of funding and poor communication to the public about the roll-out are driving “distress and uncertainty both in patients and primary care” and have left ICBs in a difficult financial situation.

Of the 40 ICBs that responded to The BMJ’s request, four reported that the NHS funding they had received covers just 25% or less of their eligible patients, with Coventry and Warwickshire faring the worst at 21% of its patients.

And five ICBs have said they are already considering further tightening the tirzepatide prescribing criteria or rationing the treatment beyond this 12-year phased plan.

Birmingham and Solihull ICB says it received funding to cover just 52% of its eligible patients, and said: “Difficult decisions are having to be made to ensure money is spent in the most effective and efficient way possible and for the greatest patient benefit.”

In London just one out of the five ICBs – South West London – has started prescribing tirzepatide, while notices urging patients not to contact their GP as they cannot provide these drugs have been posted by practices around the country, including in Suffolk and North East Essex – where funding for just 25% of eligible patients has been provided.

Tamara Hibbert, chair of Newham Local Medical Committee, says: “While there is significant potential for these drugs to benefit patients, the messaging needs to be clear about what they can expect in terms of the criteria for accessing them on the NHS and the funding available at an ICB level.”

Ellen Welch, Doctors’ Association UK (DAUK) co-chair, says: “These figures confirm the fear that the roll out is not fit for purpose. There is a huge discrepancy between national messaging and what patients are actually being delivered on a local level.”

Others warn that the underfunding will have a knock-on effect for the following years, especially as more people will become eligible each year.

Jonathan Hazlehurst at the University of Birmingham, says: “NHS England is talking about treating 220,000 patients in the first three years, but we can see that the initial funding for year one clearly only covers approximately 10% of that.” He also warns that there are patients who would “benefit from really urgent and immediate treatment” with tirzepatide, but are not currently considered a priority.

Nicola Heslehurst, president of the Association for the Study of Obesity, says the deficit in funding compared with need “is another blow for people living with obesity who deserve evidence-based care to manage their health needs,” adding that the current commissioning model has set up a “postcode lottery” of who can access obesity care.

The BMJ contacted NHS England for comment, but received no response at the time of publication.

04/09/2025

Notes for editors
News: Mounjaro: less than half of England has NHS access to jab months after roll-out, distressing patients and GPs doi: 10.1136/bmj.r1855
Journal: The BMJ

Link to Academy of Medical Sciences press release labelling system: http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? No
Evidence type: Investigation
Subject: Mounjaro access

The post Less than half of England has access to Mounjaro on the NHS months after roll-out first appeared on BMJ Group.