NEWS
UK news Surgeon is struck off for behaviour said to be “incompatible” with being a doctor, p 2
World news Australian doctors face two years in jail for reporting asylum seekers’ health, p 4
ЖЖReferences and full versions of news stories are on thebmj.com
thebmj.com
ЖЖConsultant
vacancies in
Scotland up by
26% in a year
IN BRIEF
UK Biobank data from nearly 500 000 people were used to develop the “Ubble age” predictor
Self rated “health score” can predict risk
of death in next five years, researchers say
Matthew Limb LONDON
Researchers have developed a
score calculated from self reported
information that predicts the
risk of death within five years
for UK people aged between 40
and 70. But some scientists have
questioned its practical value and
have said that the researchers’
claims that it could be of major
benefit to people, influence health
policy, and add to clinicians’
knowledge may be overstated.
A Swedish study showing how
the score was developed from an
analysis of data in the UK Biobank
was published in the Lancet on
4 June.1 One of the coauthors,
Andrea Ganna, a research fellow at
Stockholm’s Karolinska Institute,
said that enabling people to
estimate their personalised risk
without any need for laboratory
tests or physical examinations was
an “exciting development.”
He and Erik Ingelsson, from
Uppsala University, analysed UK
Biobank data collected between
2006 and 2010 from nearly half
a million adults aged 40-70.
Biobank participants gave a range
the bmj | 6 June 2015
of information about their medical
history, health, lifestyle, and
socioeconomic status and took
part in physical and biological
assessments. Of the 498 103
people whose data were included
in the study, 8532 died and
489 571 survived during a median
follow-up of just under five years.
The researchers looked at
associations between 655
demographic, lifestyle, and health
measures and deaths from all
causes in men and women and
assessed the probability that the
measures could “predict” death.
Self rated overall health emerged
as the single most powerful
predictor of death from all causes
in men, and previous diagnosis of
cancer was the strongest predictor
in women. When people with
serious diseases or disorders were
excluded, smoking habit was the
strongest predictor of mortality
from any cause.
Self reported information
such as usual walking pace and
illness and injuries in the past two
years was generally a “stronger
predictor” of death and survival
than biological measurements
such as pulse rate and blood
pressure. For example, the risk of
death among men aged 40-52 who
reported a “slow” usual walking
pace was 3.7 (95% confidence
interval 2.8 to 4.8) times that
among men who reported a steady
average pace.
The researchers developed a
score for a person’s risk of dying
in the next five years that was
based on the “most predictive”
self reported information,
including 13 questions for men
and 11 for women (ubble.co.uk).
The authors hoped that the score
might eventually enable doctors
to quickly and easily identify their
highest risk patients, although
more research would be needed to
determine whether the score could
be used in this way in a clinical
setting, Ganna said.
Commentators in the Lancet
wrote, “Whether this will help
individuals improve self-awareness
of their health status . . . or only lead
to internet-based ‘cyberchondria,’
is a moot point.”
Cite this as: BMJ 2015;350:h3028
GP surgery to be run by
NHS trust for a year: The
Priory Avenue Surgery in
Caversham, Reading, is to be
run by Berkshire Healthcare NHS
Foundation Trust for a year after
it was rated “inadequate” in three
of five categories by the Care
Quality Commission last year.
New law backs German
health card: Germany’s federal
cabinet has approved a new
law designed to ensure that
the new electronic health card
system is operating by 1 July
2018 (BMJ 2015;350:h2991).
The card was first proposed in
2002. Doctors and insurers who
use the e-health card system
and meet deadlines will
be rewarded
financially,
while those
that don’t will
be penalised.
Monitor urges GP services
to improve: Commissioners,
including NHS England and local
clinical commissioning groups,
can improve services and
ensure that patients can access
them more easily, says a report
from the healthcare regulator
Monitor. It found that although
81% of patients were satisfied
with their general practice, a
third were unhappy with some
aspects, such as ease of getting
an appointment (30%), being
offered appointments online
(34%), and being able to see the
same doctor every time (35%).
1
IMAGE BROKER/ALAMY
J C REVY, ISM/SPL
Cancer is now biggest killer of
UK men: Almost a third (32%)
of deaths of men in 2012-13
were caused by cancer, more
than the 29% resulting from
cardiovascular disease, shows an
analysis in Heart (doi:10.1136/
heartjnl-2015-307516). Among
women cardiovascular disease
remained the biggest killer,
claiming 28% of lives, compared
with 27% for cancer.
NEWS
IN BRIEF
More patients wait for bowel cancer test: The number
of patients waiting for a colonoscopy rose by 23.3% from
March 2014 to March 2015, from 28 578 to 35 245, figures
from NHS England show, while the number waiting for flexisigmoidoscopy rose by 20.5%, from 15 354 to 18 496 patients.
Over the same period the proportion of patients waiting
more than six weeks for the tests rose from 2.3% to 5.7% for
colonoscopy and from 1.8% to 6.8% for flexi-sigmoidoscopy.
Sale of laughing gas and other legal highs to be banned
in UK: The Psychoactive Substances Bill, announced by the
government on 29 May, will ban the production and supply
of “any substance intended for human consumption that is
capable of producing a psychoactive effect.” The ban will cover
nitrous oxide, although the legitimate sale of “laughing gas”
will not be affected.
Admissions for smoking related conditions are more
common in men: In 2013-14 around 454 700 or 4% of
admissions to hospitals in England of adults aged 35 years
or over were estimated to be attributable to smoking. The
proportion attributed to smoking was twice as high in men
(6%) as in women (3%). The overall figure was a slight fall on
the 447 300 admissions in 2003-04 (6% of all admissions).1
Eye testing app could provide affordable vision tests in
poor countries: The Peek (the Portable Eye Examination Kit),
which runs on a smartphone, is as accurate as traditional eye
charts and could provide an affordable eye testing solution
for low income countries,
says research published in
JAMA Ophthalmology.2 The
app was developed by the
London School of Hygiene
and Tropical Medicine, the
University of Strathclyde,
and the NHS Glasgow Centre
for Ophthalmic Research.
Nigeria outlaws female genital mutilation: Female genital
mutilation has been made illegal in Nigeria as one of the final
acts of outgoing president Goodluck Jonathan. Campaigners
hope it will encourage other African countries to take similar
measures. The UK international development secretary, Justine
Greening, said, “This is fantastic news and a landmark moment.
We are now one step closer to ending this harmful practice.”
Alcohol related hospital admissions of young people are
falling: Alcohol specific hospital admissions of under 18s were
41% lower in the three years 2011-12 to 2013-14 than in
2006-07 to 2008-09 (13 725, compared with 22 890), figures
from Public Health England show. But 59% of English local
authorities saw a slight rise in hospital admissions of adults
where alcohol was the main reason for admission. The rise was
larger in women (2.1%) than in men (0.7%).
Surgeon is struck off for behaviour said to be
“incompatible” with being a doctor
Clare Dyer THE BMJ
A general surgeon who botched
a cancer operation, failing
to remove an easily palpable
tumour and leaving the patient
with a distorted chest, has been
struck off the medical register
after persistently refusing to
acknowledge his mistakes.
Mutasim Mohammed failed
to show any insight into his
shortcomings or to provide
evidence of remediation
despite two 12 month periods
of suspension, a Medical
Practitioners Tribunal Service
panel concluded.
He was originally suspended
in December 2012 for working
beyond the limits of his surgical
competence in performing breast
cancer surgery when he had little
experience of the procedure.
During the operation at
Aberdeen Royal Infirmary in
2009, he left the easily palpable
tumour in place, failed to properly
dissect the axilla, failed to retrieve
enough lymph nodes, took twice
as much tissue as necessary,
and unnecessarily removed
skin, leaving the patient’s chest
distorted which required a second
operation.
The panel’s chairwoman, Sara
Fenoughty, said, “Whilst the
original [panel’s] findings arose
from a single catastrophic event
which caused patient harm, the
doctor’s continued refusal to
accept these findings, coupled
with his persistent failure to
comply with the regulatory
requirements of the GMC,
amounts to behaviour which is
fundamentally incompatible with
being registered as a doctor.”
Cite this as: BMJ 2015;350:h3005
Sheffield NHS trust and council pay £27 000
in damages after failing to agree care budget
Clare Dyer THE BMJ
A vulnerable woman who had
both legs amputated and was
left for more than 14 months
without funds to pay for her care
package because of a dispute
between the NHS and social
services is to receive £27 000 in
compensation.1 2
The parliamentary and health
service ombudsman and the local
government ombudsman jointly
recommended that Sheffield City
Council and Sheffield Health
and Social Care NHS Foundation
Trust, a mental health trust, pay
compensation to the unnamed
woman, referred to as “Ms D.”
Ms D, who has moderate
to severe depression,
myeloproliferative disorder,
atherosclerosis, and an
underactive thyroid, had an
annual personal budget of nearly
£7000, funded by the NHS, to
meet the social care needs arising
from her mental health problems.
But she was left without funding
between October 2013 and March
2015 after a hospital admission.
The trust and city council
agreed to pay Ms D £14 000 for the
costs that she incurred; £12 000
for not having a budget in place;
and £1000 for “avoidable stress.”
Cite this as: BMJ 2015;350:h2949
South Korea confirms first MERS deaths and China its
first case: South Korea has confirmed that two people have
died from Middle East respiratory syndrome, which has killed
hundreds of people in the Middle East. Twenty five cases of
the disease were reported in South Korea in the past month,
since a man returned from the Middle East with the condition.
China has confirmed its first case of MERS. The patient is a
South Korean national and is a close contact of a confirmed
MERS case in South Korea.
Cite this as: BMJ 2015;350:h3010
2
Sheffield Council and the trust left Ms D without a care budget for 14 months
6 June 2015 | the bmj
NEWS
Office workers told to stand up for at least two hours a day
company, Active Working, asked
an international group of experts to
develop guidelines for employers
to promote avoidance of prolonged
periods of sedentary work.
The guidance, published in the
British Journal of Sports Medicine,
recommends that people whose work
is mainly desk based should aim to
accumulate a total of two hours a day
of standing and light activity, such
as walking, during working hours.
They should increase this to four
hours a day by breaking up periods
Antiretroviral
therapy may be
recommended
from diagnosis of HIV
Adrian O’Dowd LONDON
Experts look set to recommend
that people with HIV should
receive antiretroviral treatment
on diagnosis, as early results of
a global trial show that their use
lowers risk of developing AIDS or
other serious illnesses.
Results from the Strategic
Timing of Antiretroviral Treatment
(START) study, expected to finish
at the end of next year, were
published early on 27 May.
They showed that people
had a considerably lower risk of
developing AIDS or other serious
illness if they started taking
antiretroviral drugs sooner, when
their CD4+ T cell count was higher,
instead of waiting until the CD4+
cell count dropped to a lower level.
Current World Health
Organization guidelines
recommend that people with
HIV start antiretroviral treatment
when their CD4 count falls to 500
cells/mm3—but some guidelines,
including the current British
HIV Association guidelines, still
recommend waiting until CD4
counts fall below 350 cells/mm3.
The START study was conducted
at 215 sites in 35 countries, and
the trial involved 4685 men
and women aged 18 and older
with HIV, who had never taken
antiretroviral therapy and were
enrolled with CD4+ cell counts of
above 500 cells/mm3.
the bmj | 6 June 2015
of sedentary working with work done
standing up, using a desk that can be
used either sitting or standing or by
taking short, active standing breaks.
The expert group, led by John
Buckley, of the Institute of Medicine
at University Centre Shrewsbury and
the University of Chester, found that
sedentary behaviour now accounts
for 60% of people’s waking hours in
the United Kingdom and that office
workers spend 65-75% of their
working hours sitting.
Cite this as: BMJ 2015;350:h2961
Report calls for primary care at A&Es
KRISTA KENNELL/ZUMA/CORBIS
Susan Mayor LONDON
People whose jobs are predominantly
desk based should be encouraged to
stand up and walk about for at least
two hours during each working day,
says the first UK guidance developed
to reduce the health risks of prolonged
sitting at work.1
Growing evidence has shown links
between a sedentary lifestyle and
an increased risk of cardiovascular
disease, diabetes, and some cancers.
To help reduce this risk Public Health
England and a UK community interest
Current WHO guidelines are to start
antivirals when CD4 count falls
to 500 cells/mm3
Jacqui Wise LONDON
Primary care services should
be located alongside hospital
emergency departments, a new
report from the Royal College
of Emergency Medicine and the
Patients Association concludes.1
The report said that patients
continued to go to emergency
departments even when they
were aware of the alternatives.
Co-location of urgent care
services on one site would enable
patients to be triaged to the
appropriate emergency or urgent
care service, it said.
Co-location of services was
recommended by Bruce Keogh,
medical director of England’s NHS,
in 2013.2 But a recent survey by
the Royal College of Emergency
Medicine found that only 43% of
hospital emergency departments
in the UK had a co-located primary
care facility.
The report was based on a
survey by the Patients Association
of people who had previously
attended an emergency
department for an urgent
healthcare need. Nearly 40% said
they had been advised to attend
the emergency department by
other healthcare providers.
The survey also showed
that patients were unwilling to
wait even a short time for a GP
appointment if they thought their
problem was urgent. Almost a
quarter of patients (23%) had
contacted their GP surgery to make
an appointment before presenting
to the emergency department, and
45% had been told that they could
be seen the same day.
Around half of the study
participants were given
antiretroviral treatment
immediately (early treatment),
and the other half had treatment
deferred until their CD4+ cell
count declined to 350 cells/mm3.
Participants in the study were
followed for three years.
The researchers’ interim analysis
found that the risk of developing
serious illness or death was 53%
lower in the early treatment group
than in the deferred treatment
group. Rates of serious AIDS
related events (such as AIDS
related cancer) and serious
non-AIDS related events (major
cardiovascular, renal, and liver
disease and cancer) were also both
lower in the early treatment group
than the deferred treatment group.
Adrian Palfreeman, vice chair
of the British HIV Association,
told The BMJ that the association
was likely to change its stance
on recommending when to start
treatment in its latest updated
guidance, due to be published
in the next two months. “Clearly,
these new findings need to be
taken into account in the final
draft,” he said.
Gareth Iacobucci THE BMJ
Plans to implement seven day working and to generate £22bn of efficiency savings
in the NHS in England by 2020 are at risk of being derailed by staff burnout, a
leading healthcare think tank has warned.
In a briefing published on Tuesday 2 June the Nuffield Trust said that the
government’s ambitious targets would not be realised unless it “prioritises
reconnecting with the NHS workforce and ensuring staff feel valued in their work.”1
It added that the NHS needed to reduce its reliance on agency staffing, highlighting
the fact that NHS hospital and foundation trusts increased their spending on
contract agency staff by £800m in the last financial year to £3.3bn.
On 2 June the health secretary, Jeremy Hunt, pledged to introduce a maximum
hourly rate for agency doctors and nurses, ban the use of staffing agencies that
are not approved, and require specific approval for any management consultancy
contracts over £50 000.
“It’s outrageous that taxpayers are being taken for a ride by companies charging
up to £3500 a shift for a doctor,” he said.
Cite this as: BMJ 2015;350:h2963
Cite this as: BMJ 2015;350:h3004
Cite this as: BMJ 2015;350:h3011
NHS must tackle burnout and agency costs
3
NEWS
Australian doctors
face two years in jail
for reporting asylum
seekers’ health
GP cancer referral
delays may explain
UK’s low cancer
survival rates
Michael Woodhead SYDNEY
Doctors in Australia have vowed
to fight a new law that threatens
them with two years in jail if they
speak out about abuse and poor
conditions in detention centres for
asylum seekers.
The new legislation has been
enacted as part of the Australian
government’s hardline “stop the
boats” policy that transfers people
arriving by boat in Australian
waters to offshore detention
centres on distant Pacific islands
such as Nauru. Conditions in
the immigration detention
centres have been condemned as
“appalling” by healthcare workers,
who have reported unhygienic
and overcrowded accommodation
in tents, substandard medical
care, sexual and physical abuse
of children, and mental health
problems among asylum seekers
subject to indefinite detention.
The Royal Australasian College
of Physicians last week called for
an end to the mandatory detention
of asylum seekers. President Nick
Talley described the policies as
“inhumane” and said that they
were damaging people’s health.
However, healthcare staff
employed by IHMS, the private
medical service provider
responsible for healthcare in the
detention centres, are forbidden
from speaking to the media
ЖЖEDITORIAL, p 7
Adrian O’Dowd LONDON
Lower cancer survival rates
in the United Kingdom than in
other similar countries could
be due to delays in general
practitioners referring patients
for tests, claims a new study
published in BMJ Open.1
The researchers analysed
responses to an online survey
of 2795 GPs on how they would
manage different scenarios of
patients coming to them with
possible cases of lung, colorectal,
or ovarian cancer, and what access
they had to specific tests and
cancer specialists.
More than 70% of GPs in
England, Wales, and Northern
Ireland said that they had direct
access to blood tests, x rays, and
ultrasound for possible cancer
diagnosis, which was similar in the
other countries (Australia, Canada,
Denmark, Norway, and Sweden).
However, only around a fifth of GPs
in England reported having direct
access to computed tomography
and magnetic resonance imaging
scans, while their fellow primary
care physicians in all other
countries reported having at least
twice the level of direct access to
these tests.
UK GPs also reported some
of the longest waiting times for
test results.
Cite this as: BMJ 2015;350:h3008
Cite this as: BMJ 2015;350:h2926
Conditions in camps, such as the one on Manus Island, are said to be “appalling”
or third parties and must sign
confidentiality contracts. Despite
this, last year a group of 15 doctors
who had worked with asylum
seeker detention centres went
public with their concerns after
working at one centre, citing “gross
departures from generally accepted
medical standards which have
posed significant risk to patients
and caused considerable harm.”1
Two official inquiries into
Australia’s immigration detention
regime have also criticised
conditions in the camps.
The government has repeatedly
rejected the criticisms, with the
immigration minister, Peter
Dutton, last month saying that
detention centres provided a high
standard of care, similar to that in
facilities in Australia. However, he
has refused all media requests to
visit the centres.
On 20 May the government
enacted new legislation making it
a criminal offence, punishable by
imprisonment of up to two years,
for any person working directly or
indirectly for the Department of
Immigration and Border Protection
to reveal anything that happens
in Australian run detention
centres.2 The Australian Lawyers
Alliance said the laws will have
“far reaching and disturbing
consequences” for any healthcare
worker who contracted to work
on behalf of the Department of
Immigration.3
At the Australian Medical
Association’s annual conference
last week, delegates voted
unanimously to call on the
Australian parliament to amend
the law “to provide an exemption
(from prosecution) for medical
practitioners who disclose, in
the public interest, failures in
healthcare delivery in immigration
detention centres.”
The association’s president,
Brian Owler, said “The legislation
has already been passed, but we
will be taking this matter further
with the government.”
Scottish parliament rejects “right to die” for terminally ill
Patrick Harvie: clear public desire for choice
Bryan Christie EDINBURGH
Campaigners fighting to legalise assisted suicide
have vowed to fight on after the Scottish parliament
voted against allowing people with terminal and life
shortening conditions to seek medical help to die.
A bill on legalising assisted suicide was defeated
by 82 votes to 36 after being criticised for lacking
4
clarity, increasing the risk of coercion for vulnerable
people, and potentially making suicide more
acceptable in society. Members of the Scottish
Parliament (MSPs) who supported the bill argued
that the proposed legislation could be improved and
that it was wrong to deny people the right to choose
the way they end their own life.
It is the second time in five years that the
parliament has rejected such legislation, which polls
show is backed by around two thirds of people in
Scotland. But supporters of change were encouraged
that more than twice as many MSPs voted in favour of
legislation as in 2010.
A number of MSPs expressed disquiet at the
status quo, saying that it leaves people who want
to end their life with no support or dignity and that
anyone providing assistance risks prosecution.
Around 50 people a year with a terminal illness are
thought to die by suicide in Scotland.
Patrick Harvie, the Green MSP who proposed the
bill, said he hoped that clear prosecution guidance
would now be issued in Scotland. “Clearly the
detail of this bill wasn’t good enough to convince
parliament, but I think it’s awoken more people to the
problems of the current law. The significant support
in the chamber reflects the clear public desire for
people to have choice and for the law to be clarified.”
Cite this as: BMJ 2015;350:h2928
6 June 2015 | the bmj
NEWS
RESEARCH NEWS
PETER USBECK/ALAMY
Blood flow conditioning
reduces kidney injury
ANTIDEPRESSANTS IN PREGNANCY
Linked to rise in respiratory
disorder in newborns
Use of antidepressants in late pregnancy
may be associated with a small increased
risk of persistent pulmonary hypertension of
the newborn (PPHN), a US study involving
more than three million women published
in JAMA has found.1 PPHN is a rare but life
threatening condition that occurs when a
newborn’s circulation system does not adapt to
breathing outside the womb. Around 10-20%
of affected infants will not survive, and those
who do face serious long term consequences,
including chronic lung disease, seizures, and
neurodevelopmental problems.
Researchers from Boston looked at data on
3 789 330 pregnant women enrolled in the
Medicaid programme from 2000 to 2010. A
total of 128 950 women (3.4%) had used an
antidepressant in the 90 days before delivery.
PPHN occurred in 20.8 in 10 000 infants
(95% confidence interval 20.4 to 21.3) not
exposed to antidepressants in the last 90 days
of pregnancy, compared with 31.5 in 10 000
infants (28.3 to 35.2) whose mother had taken
an SSRI antidepressant during this period and
29.1 in 10 000 infants (23.3 to 36.4) whose
mother had taken a non-SSRI antidepressant.
Associations between antidepressant use
and PPHN decreased after adjustment for
confounders. With SSRIs the unadjusted
odds ratio for the condition was 1.51 (1.35
to 1.69), which fell to 1.10 (0.94 to 1.29)
after restricting the findings to women
with depression and adjusting for the high
dimensional propensity score. With non-SSRIs
the corresponding odds ratios were 1.40 (1.12
to 1.75) and 1.02 (0.77 to 1.35), respectively.
The researchers said, “Clinicians and
patients need to balance the potential small
increase in the risk of PPHN, along with
other risks that have been attributed to SSRI
use during pregnancy, with the benefits
attributable to these drugs in improving
maternal health and wellbeing.”
Cite this as: BMJ 2015;350:h2980
the bmj | 6 June 2015
Remote ischaemic preconditioning, which
involves alternately inflating and deflating a
blood pressure cuff around a limb to restrict
and restore blood flow, reduces kidney injury
and the need for dialysis in high risk patients
undergoing cardiac surgery, a study reported
in JAMA has shown.1
As many as 30% of patients develop acute
kidney injury after cardiac surgery, and no
interventions investigated so far have been
shown to reduce this risk. Research has shown
that remote ischaemic preconditioning from
brief episodes of ischaemia and reperfusion in
distant tissue may protect against subsequent
injury. Researchers tested this approach in 240
patients at high risk for acute kidney injury who
were undergoing cardiac surgery in Germany.
Results showed that patients who had
ischaemic preconditioning were less likely to
develop acute kidney injury within 72 hours
after surgery (37.5% v 52.5%; absolute risk
reduction 15% (95% confidence interval
2.56% to 27.44%); P=0.02), and less likely to
need kidney dialysis than those in the control
group (5.8% v 15.8%; absolute risk reduction
10% (2.25% to 17.75%); P=0.01). They also
had shorter stays in intensive care units (3
days (interquartile range 3 to 5) v 4 days (2 to
7); P=0.04). There were no differences in rates
of myocardial infarction, stroke, or mortality
between the two groups of patients.
Cite this as: BMJ 2015;350:h2934
BREAST CANCER
Removing more tissue
avoids further surgery
Removing additional tissue around the cavity
left after excising a tumour during partial
mastectomy halves the rate of positive margins
that require further surgery, a study in the New
England Journal of Medicine has shown.1
Survival in women with early stage breast
cancer who undergo partial mastectomy
is equivalent to survival in those with total
mastectomy. Margin status, which assesses
whether cancer cells extend to the edge of the
apparently healthy tissue removed around a
tumour, is a critical determinant of the risk of
local recurrence requiring further surgery.
Around 20-40% of women have positive
margins after partial mastectomy and require
a second operation to remove further tissue.
Studies have shown that removing additional
tissue circumferentially around the cavity that
is left after surgery—known as cavity shave
margins—may reduce positive margins.
Researchers randomised 235 patients
with early stage breast cancer (stages 0 to III)
undergoing partial mastectomy, to cavity shave
margin resection or to a control group.
Results showed similar rates of partial
mastectomy in the two groups before
randomisation (36% in the group having
additional resection and 34% in the control
group; P=0.69). But the rate of positive
margins was significantly lower in patients
who then underwent cavity shave margin
resection than in the no shave group (19% v
34%; P=0.01), and the cavity shave group also
had a lower rate of second surgery for margin
clearance (10% v 21%; P=0.02).
Cite this as: BMJ 2015;350:h2989
METASTATIC MELANOMA
Combined immunotherapy
improves survival
A combination of two immunotherapy agents
improves the time to disease progression in
patients with previously untreated metastatic
melanoma when compared with either drug
alone, a study has shown.
Reported in the New England Journal of
Medicine,1 the study randomly assigned 945
patients with unresectable stage III or IV
melanoma to treatment with either nivolumab
alone, nivolumab plus ipilimumab, or
ipilimumab alone.
Results showed that median progressionfree survival was 11.5 months (95%
confidence interval 8.6 to 16.7 months) with
combination therapy, which was nearly twice
as long as with nivolumab alone (6.9 months
(4.3 to 9.5)). Median progression-free survival
with ipilimumab was 2.9 months (2.8 to 3.4).
Serious adverse events (grade 3 or 4) were
more common with the combination therapy,
affecting 55% of patients, compared with
16.3% of patients treated with nivolumab and
27.3% in the ipilimumab group.
Cite this as: BMJ 2015;350:h2993
Kaplan-Meier curve for progression-free
survival in intention to treat population
Progression-free survival (%)
HIGH RISK CARDIAC SURGERY
100
Nivolumab plus ipilimumab
Nivolumab
Ipilimumab
80
60
40
20
0
0
2
4
6
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10
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BMJ CONFIDENTIAL
Sarah Clarke
Determined and convivial
PETER LOCKE
SARAH CLARKE is an interventional
cardiologist at Papworth Hospital,
Cambridge, who has achieved
considerable success at the British
Cardiovascular Society, becoming the first
woman to be elected to the presidency
in the society’s 80 year history. For her,
all roads lead to Cambridge: she trained
there, was a fellow at Massachusetts General
Hospital, and then returned as a consultant
cardiologist. As clinical director for cardiac
services and then strategic development she
established primary angioplasty
across the east of England and
has a major role in planning the
trust’s move to the Cambridge
Biomedical Campus in 2017.
What book should
every doctor read?
“There are many, but
I’d choose a recent
read—Talk Like
TED, by Carmine
Gallo. It will change
the way you give
presentations
and will keep your
audience with you”
What was your earliest ambition?
I was born the year Tomorrow’s World started, and as a
child my earliest ambition was to be a presenter on the
programme. I was always interested in science.
Who has been your biggest inspiration?
My late father, who instilled hard work and determination
in me as a means to success; and Iain Simpson,
consultant cardiologist and current president of the
British Cardiovascular Society, who I have known for over
14 years: a great inspiration, mentor, and friend to me. I
have succeeded him in many roles at the society and am
delighted to have been elected the first female president
of the society since it started as a “Cardiac Club” in 1922.
What was your best career move?
Having a career in interventional cardiology with the
opportunity to develop other interests along the way. As
a clinical director at Papworth Hospital over the past nine
years I’ve been fortunate to lead many projects, including
the development of primary angioplasty, across the east of
England. I am now involved in the transition of Papworth
to its new site on the Biomedical Campus in Cambridge
in 2017. Working with the British Cardiovascular Society
for 14 years has been very rewarding and has included
delivering the annual conference.
Who would you most like to thank and why?
My husband and best friend, Sebastian Alexander. I
could not have achieved all I have, professionally and
personally, without him.
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To whom would you most like to apologise?
My mother: I wish I lived closer so I could see her every
day, but she’s happy and safe where she is, and she
expects me to get on with my work.
If you were given £1m what would you spend it on?
Something tangible—a new lifeboat for the Royal
National Lifeboat Institution, which is fundraising in
Norfolk. The volunteers should go out in the best boat
that money can buy.
Where are or were you happiest?
Professionally, I am happiest when we achieve a good
primary angioplasty result for a heart attack patient, even
at 3 am. Otherwise, I’m happiest by the sea, whether
under the big blue skies of the deserted foreshore in
north Norfolk or in the warm sunshine and clear waters of
the Caribbean on an SUP [stand-up paddleboard].
What single unheralded change has made the most
difference in your field in your lifetime?
[Charles] Dotter’s accidental catheter recanalisation
of a peripheral artery in 1963 ushered in the era of
intervention. This was crowned by [Andreas] Gruentzig’s
balloon angioplasty in the mid-1970s and led to today’s
panoply of devices used percutaneously to revascularise
coronary arteries and treat structural heart disease. It’s
an exciting time to be in interventional cardiology.
What book should every doctor read?
There are many, but I’d choose a recent read—Talk Like
TED, by Carmine Gallo. It will change the way you give
presentations and will keep your audience with you.
What is your guiltiest pleasure?
Shopping at Sandra Kent in Cambridge. She keeps me
smart.
If you could be invisible for a day what would you do?
Watch the world go by from the International Space
Station.
Mary Beard or Mary Berry? Classic civilisations or
classic cakes: which would you rather watch? What other
television programmes do you like?
Mary Berry, but not for the cakes! I enjoy cooking and
entertaining and am a Masterchef addict. If I had more
time I would have a go.
What, if anything, are you doing to reduce your carbon
footprint?
Buying a new bike and cycling to work.
What personal ambition do you still have?
To design and build our own “grand design” to enjoy
in later years; I’d learn the tools of the trade and roll my
sleeves up. Also, to take the Yachtmaster exams and sail.
Summarise your personality in three words
Conscientious, determined, and convivial.
Where does alcohol fit into your life?
It doesn’t, apart from pouring it into others’ glasses at
dinner parties—but I enjoy the party.
What is your pet hate?
Inefficiency.
If you weren’t in your present position what would you be
doing instead?
I would study for an MBA—something I’ve always wanted
to do.
Cite this as: BMJ 2015;350:h2878
6 June 2015 | the bmj