More than ½ of patients leave hospital with changes to four or more of their long-term medications - but how appropriate are those changes? New research published on bmj.com looks at antihypertensive medication prescription changes to try and model that - and found that more than half of intensifications occurred in patients with previously well...

This week the Trump administration has banned the sale of flavoured vapes in the USA. The reason for that is the sudden rash of cases of pulmonary disease, including deaths, linked to vaping. The mechanism by which vaping may be causing damage to the lungs is as yet unclear, and our understanding is hampered by the heterogeneous nature of the...

The BMJ in partnership with The Harvard Global Health Institute has launched a collection of articles exploring how to achieve effective universal health coverage (UHC). The collection highlights the importance of quality in UHC, potential finance models, how best to incentivise stakeholders, and some of the barriers to true UHC. One of those...

In quality improvement, measurement is seen as a key driver of change - how well do you know you’re doing, if you can’t actually measure it. So, when something changes in the NHS (say a new guideline) how can you tell how quickly that’s filtering down to the front line. Ben goldacre, from the Nuffield Department of Primary Care Health Sciences...

As we cover the covid-19 outbreak, we want to hear some of the stories from the frontline - And who better to heart of what this pandemic is doing to the profession in the UK, than some of the people who write regularly for The BMJ? In this first one, we wanted to look specifically at acute care - those at the sharp end of the response, so we're...

Samar I. Itani
Jul 1, 2002; 51:2005-2011
Rapid Publications

Patrice D. Cani
Jun 1, 2008; 57:1470-1481
Metabolism

THE EDITOR, Madam: THE JAMAICAN economy has been underperforming for the last 40 years, during which economic growth averaged approximately one per cent per annum. One of the main reasons for this poor performance is the non-competitive nature of...

¹⁸F-DCFPyL (2-(3-{1-carboxy-5-[(6-¹⁸F-fluoropyridine-3-carbonyl)-amino]-pentyl}-ureido)-pentanedioic acid) is a promising PET radiopharmaceutical targeting prostate-specific membrane antigen (PSMA). We present our experience with this single-academic-center prospective study evaluating the positivity rate of ¹⁸F-DCFPyL PET/CT in patients with biochemical recurrence (BCR) of prostate cancer (PC). Methods: We prospectively enrolled 72 men (52–91 y old; mean ± SD, 71.5 ± 7.2) with BCR after primary definitive treatment with prostatectomy (n = 42) or radiotherapy (n = 30). The presence of lesions compatible with PC was evaluated by 2 independent readers. Fifty-nine patients had scans concurrent with at least one other conventional scan: bone scanning (24), CT (21), MR (20), ¹⁸F-fluciclovine PET/CT (18), or ¹⁸F-NaF PET (14). Findings from ¹⁸F-DCFPyL PET/CT were compared with those from other modalities. Impact on patient management based on ¹⁸F-DCFPyL PET/CT was recorded from clinical chart review. Results: ¹⁸F-DCFPyL PET/CT had an overall positivity rate of 85%, which increased with higher prostate-specific antigen (PSA) levels (ng/mL): 50% (PSA < 0.5), 69% (0.5 ≤ PSA < 1), 100% (1 ≤ PSA < 2), 91% (2 ≤ PSA < 5), and 96% (PSA ≥ 5). ¹⁸F-DCFPyL PET detected more lesions than conventional imaging. For anatomic imaging, 20 of 41 (49%) CT or MRI scans had findings congruent with ¹⁸F-DCFPyL, whereas ¹⁸F-DCFPyL PET was positive in 17 of 41 (41%) cases with negative CT or MRI findings. For bone imaging, 26 of 38 (68%) bone or ¹⁸F-NaF PET scans were congruent with ¹⁸F-DCFPyL PET, whereas ¹⁸F-DCFPyL PET localized bone lesions in 8 of 38 (21%) patients with negative results on bone or ¹⁸F-NaF PET scans. In 8 of 18 (44%) patients, ¹⁸F-fluciclovine PET had located the same lesions as did ¹⁸F-DCFPyL PET, whereas 5 of 18 (28%) patients with negative ¹⁸F-fluciclovine findings had positive ¹⁸F-DCFPyL PET findings and 1 of 18 (6%) patients with negative ¹⁸F-DCFPyL findings had uptake in the prostate bed on ¹⁸F-fluciclovine PET. In the remaining 4 of 18 (22%) patients, ¹⁸F-DCFPyL and ¹⁸F-fluciclovine scans showed different lesions. Lastly, 43 of 72 (60%) patients had treatment changes after ¹⁸F-DCFPyL PET and, most noticeably, 17 of these patients (24% total) had lesion localization only on ¹⁸F-DCFPyL PET, despite negative results on conventional imaging. Conclusion: ¹⁸F-DCFPyL PET/CT is a promising diagnostic tool in the work-up of biochemically recurrent PC, given the high positivity rate as compared with Food and Drug Administration–approved currently available imaging modalities and its impact on clinical management in 60% of patients.

In glioma patients, differentiation between tumor progression (TP) and treatment-related changes (TRCs) remains challenging. Difficulties in classifying imaging alterations may result in a delay or an unnecessary discontinuation of treatment. PET using O-(2-¹⁸F-fluoroethyl)-l-tyrosine (¹⁸F-FET) has been shown to be a useful tool for detecting TP and TRCs. Methods: We retrospectively evaluated 127 consecutive patients with World Health Organization grade II–IV glioma who underwent ¹⁸F-FET PET imaging to distinguish between TP and TRCs. ¹⁸F-FET PET findings were verified by neuropathology (40 patients) or clinicoradiologic follow-up (87 patients). Maximum tumor-to-brain ratios (TBR_max) of ¹⁸F-FET uptake and the slope of the time–activity curves (20–50 min after injection) were determined. The diagnostic accuracy of ¹⁸F-FET PET parameters was evaluated by receiver-operating-characteristic analysis and ² testing. The prognostic value of ¹⁸F-FET PET was estimated using the Kaplan–Meier method. Results: TP was diagnosed in 94 patients (74%) and TRCs in 33 (26%). For differentiating TP from TRCs, receiver-operating-characteristic analysis yielded an optimal ¹⁸F-FET TBR_max cutoff of 1.95 (sensitivity, 70%; specificity, 71%; accuracy, 70%; area under the curve, 0.75 ± 0.05). The highest accuracy was achieved by a combination of TBR_max and slope (sensitivity, 86%; specificity, 67%; accuracy, 81%). However, accuracy was poorer when tumors harbored isocitrate dehydrogenase (IDH) mutations (91% in IDH-wild-type tumors, 67% in IDH-mutant tumors, P < 0.001). ¹⁸F-FET PET results correlated with overall survival (P < 0.001). Conclusion: In our neurooncology department, the diagnostic performance of ¹⁸F-FET PET was convincing but slightly inferior to that of previous reports.

Posttreatment high-grade gliomas are usually monitored with contrast-enhanced MRI, but its diagnostic accuracy is limited as it cannot adequately distinguish between true tumor progression and treatment-related changes. According to recent Response Assessment in Neuro-Oncology recommendations, PET overcomes this limitation. However, it is currently unknown which tracer yields the best results. Therefore, a systematic review and metaanalysis were performed to compare the diagnostic accuracy of the different PET tracers in differentiating tumor progression from treatment-related changes in high-grade glioma patients. Methods: PubMed, Web of Science, and Embase were searched systematically. Study selection, data extraction, and quality assessment were performed independently by 2 authors. Metaanalysis was performed using a bivariate random-effects model when at least 5 studies were included. Results: The systematic review included 39 studies (11 tracers). ¹⁸F-FDG (12 studies, 171 lesions) showed a pooled sensitivity and specificity of 84% (95% confidence interval, 72%–92%) and 84% (95% confidence interval, 69%–93%), respectively. O-(2-¹⁸F-fluoroethyl)-l-tyrosine (¹⁸F-FET) (7 studies, 172 lesions) demonstrated a sensitivity of 90% (95% confidence interval, 81%–95%) and specificity of 85% (95% confidence interval, 71%–93%). For S-¹¹C-methyl)-l-methionine (¹¹C-MET) (8 studies, 151 lesions), sensitivity was 93% (95% confidence interval, 80%–98%) and specificity was 82% (95% confidence interval, 68%–91%). The numbers of included studies for the other tracers were too low to combine, but sensitivity and specificity ranged between 93%–100% and 0%–100%, respectively, for ¹⁸F-FLT; 85%–100% and 72%–100%, respectively, for 3,4-dihydroxy-6-¹⁸F-fluoro-l-phenylalanine (¹⁸F-FDOPA); and 100% and 70%–88%, respectively, for ¹¹C-choline. Conclusion: ¹⁸F-FET and ¹¹C-MET, both amino-acid tracers, showed a comparably higher sensitivity than ¹⁸F-FDG in the differentiation between tumor progression and treatment-related changes in high-grade glioma patients. The evidence for other tracers is limited; thus, ¹⁸F-FET and ¹¹C-MET are preferred when available. Our results support the incorporation of amino-acid PET tracers for the treatment evaluation of high-grade gliomas.

Invitation Only Research Event

23 January 2020

The project purpose is to ensure emissions reduction and resilience strategies, policies and decision-making - both in China and globally - are better informed by an evidence-based perspective on climate-change risks.

Research Event

Event participants

President Trump has made reshaping the U.S. immigration system a top priority. Yet the fragmented nature of policy-making in the United States—with power split between branches and levels of government—has made it difficult to pursue some of his most ambitious proposals. This report explores the evolution of migration policy under Trump, and what these changes may mean in the long run.

Discussion at this event focused on findings from MPI's report examining the interior immigration enforcement system in the United States, including ICE data on deportations and arrests, and the responses of state and local governments, civil society, and consulates.  

Marking the release of an MPI study, this discussion examines the operation of today’s interior enforcement system and how state and local governments, civil society, and consulates are responding.    

Large outflows of educated young people escaping high levels of unemployment, in tandem with inflows of unauthorized migrants, pose a fresh set of challenges for Greek policymakers. This Transatlantic Council on Migration report examines Greek emigration, and its economic implications, before exploring policy directions to minimize the costs and maximize the benefits of this mobility.

In the face of an uptick in unauthorized arrivals in Italy from Tunisia in 2017, the European Union dusted off earlier policy proposals such as funding to increase Tunisia’s border-control capabilities and the creation of disembarkation platforms. This article explores why contemporary developments, including a fragile Tunisian political system, suggest the need for a different approach.

With a history of encouraging workers to emigrate to relieve unemployment at home, Tunisia now has 11 percent of its population living abroad. The factors underlying the 2011 revolution that sparked the Arab Spring have also fueled emigration desires for many Tunisians. This country profile explores historical and current trends in Tunisia from colonial settlement to the aftermath of the Arab Spring, and the new focus on migrant rights at home and abroad.

Nearly 50,000 asylum seekers have entered Canada irregularly via land crossing from the United States since spring 2017—contributing to a doubling in the overall number of asylum requests seen in 2016. Based on interviews with asylum claimants, this article analyzes their motivations for making the journey and the political implications of rising irregular migration to Canada.

The impact of climate change as a driver of human migration is expected by many to dwarf all others. Still, certain frequently repeated forecasts of the number of people who stand to be displaced by climate change are not informed by a complete understanding of migration dynamics, as this report explains.

This policy brief explores the relationship between environmental change and migration to Europe in light of recent scholarship challenging the notion that environmental change triggers mass migration. It presents an overview of European policy response in this area and summarizes the spectrum of proposed solutions.

Environmental change is likely to affect global migration flows in a number of ways. Both long-term trends such as increased flooding and the increasing scarcity of resources as well as shorter term trends like severe weather are likely to contribute to displacement and increased migration for individuals already in vulnerable situations. While often viewed as a negative outcome of climate change, planned migration can also serve as a strategy for mitigating its impact.  

Discussion at launch of this MPI-IOM Issue in Brief, Human Rights, Climate Change, Environmental Degradation and Migration: A New Paradigm, which focuses on the vulnerability of environmental migrants and how the international legal framework can better ensure their protection, particularly in the Asia-Pacific region.

This issue brief addresses the rights of migrants whose movement is induced by environmental degradation or climate change, particularly in the highly vulnerable Asia-Pacific region. The brief evaluates the current international legal framework, identifies gaps in the framework and its implementation, and reviews options available to the international community.

This MPI event, in partnership with the International Organization for Migration (IOM), discusses the critical issue of climate-related displacement in the Asia-Pacific region, focusing on the vulnerability of environmental migrants and how the international legal framework can better ensure their protection.

From earthquakes to drought, natural disasters and climate change played a key role in migration flows in 2015. Climate-induced migration surfaced as a concern at the United Nations Climate Change Conference (known as COP21) as international organizations and policymakers have begun to recognize the growing challenges, and potential protection obligations, of such movement.

Climate-related displacement is not hypothetical: An average of 21.5 million people per year have been displaced since 2008 by natural disasters, and thousands more have fled slow-onset environmental hazards. While migration can serve as a safety valve to adapt to changing conditions, few orderly, legal channels exist for climate migrants (also known as environmental migrants), as this article explores.

While media and academic discussions of "climate refugees" paint a picture of mass displacement of millions, in reality many communities vulnerable to climate change may choose to stay as a result of strong cultural, historical, and spiritual attachments to place. This article explores this "voluntary immobility" and its implications in the Pacific Islands.

Michigan coach Jim Harbaugh is urging the NFL and NCAA to amend their rules and provide flexibility to college football players who consider making the jump to the next level.

How did the U.S. border enforcement picture go in the span of two years from the lowest levels of illegal immigration since 1971 to a spiraling border security and humanitarian crisis? This report draws on enforcement and other data as well as analysis of changing migration trends and policies to tell this story. The authors outline key elements for a new strategy that can succeed over the long term.

Kellee M. Miller
Jun 1, 2015; 38:971-978
Type 1 Diabetes at a Crossroads

OBJECTIVE

To evaluate the contemporary prevalence of diabetic peripheral neuropathy (DPN) in participants with type 1 diabetes in the T1D Exchange Clinic Registry throughout the U.S.

The coronavirus pandemic dramatically reshaped how human mobility is managed just as the Global Compact for Safe, Orderly, and Regular Migration was beginning to move from paper to implementation. As governments face pressing public-health, economic, and other concerns in responding to COVID-19, this MPI Europe commentary explores whether the first comprehensive global agreement on migration can adjust to a changed reality.

Testimony of Andrew Selee, President of MPI, before Senate Committee on Homeland Security and Governmental Affairs on April 4, 2019 regarding response to changing migration flows at the Southwest border.

The 2021 Code on Dental Procedures and Nomenclature — better known as the CDT Code — could include changes or additions to codes regarding oral/oropharyngeal cancer, caries management by risk assessment, laboratory surface scanning for diagnostic purposes, and counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use.

Dr. Emily Mattingly, chair, New Dentist Committee, 6th District, shares her experience as a new dentist in a rural Missouri town. Three other NDC members also shared new dentist perspectives.

The ADA has received updated information from the Small Business Administration regarding grant advances on Economic Injury Disaster Loans during the COVID-19 pandemic.

Average fuel prices in the United States started the week at $2.26 per gallon, showing little change from the last month or last week, and may remain flat.

In the three years since the European migration and refugee crisis vividly captured public attention, a wave of innovative initiatives has emerged to help newcomers settle into receiving societies. Now, as the sense of crisis abates, this report explores what these initiatives will need to do to outlast the hype and produce lasting change on key integration issues such as housing, economic inclusion, and community building.

Over the last 40 years, climate change has been influencing where tropical cyclones form, according to a new study.

There are no major changes coming to Britain's current coronavirus lockdown orders anytime soon, a government official said Friday as health officials reported 626 more deaths from COVID-19.

In the two years since President Trump entered office, U.S. immigration policy has changed in many ways. Some actions have received significant media attention and public scrutiny, and others have been implemented with little fanfare. This document chronicles these wide-reaching policy changes, covering immigration enforcement, the immigration courts, humanitarian admissions, visa processing, and more.

As technological developments—from automation to artificial intelligence and machine learning—reshape the world of work, governments face the challenge of updating how they attract, select, and retain economic-stream immigrants. This report, concluding a series on building migration systems for a new age of economic competitiveness, lays out the key considerations for "future-proofing" immigrant selection systems.

The Houston metro area, home to 1.6 million immigrants, is diverse and rapidly growing. This report sketches the area's immigrant population, examining top origin countries, key socioeconomic measures, and more. It also explores how Hurricane Harvey affected the immigrant population, and how national policy changes under the Trump administration are being felt locally, including by DACA recipients and asylum seekers.

There are two ways to think about the staggering amounts of money given by special interest groups to politicians -- the type of contributions that were detailed for the last quarter in reports filed yesterday by presidential candidates and members of Congress.

Fostering the social and economic inclusion of refugees has long been the domain of governments and NGOs. In the wake of the 2015–16 European migration and refugee crisis, however, new actors have emerged and taken on important roles in integrating newcomers. This report describes key discussions and takeaways from an MPI Europe conference on these developments.