Urghh medical news again? - if that’s you, I worry for you. You engaging in self-destructive behaviour a cry for help? I can’t SOCRATES this, but I can feed you the latest happenings the NHS and research. Will that ease the pain?

👋 Happy Friday.

Here’s what we got:

• 🥳 Rejoice ! UKMG Get Priority For Speciality Training.

• 🚬 The Taboo of A Pregnant Smoker. Is Medical Management So Bad?

• 🔪 Skip The Knife? Less May Be More In Breast Cancer Surgery

• #TheMoreYouKnow: Other Top Stories of The Week

NHS NEWS

Rejoice 🥳 UKMG Get Priority For Speciality Training.

Streeting Responds. UK Grad Prioritisation Confirmed 🥳 Fears of joblessness can now somewhat be relieved.

The Health Secretary confirmed in an interview with Doctors.net.uk that UK grads will get priority over IMG’s for speciality posts going forward. 

He said this plan will be confirmed in the upcoming 10 Year Health Plan, scheduled for July. His reasons for the change were:

“We will prioritise UK graduates because we spend a lot of time and money training great doctors and other NHS staff here in Britain, whether they're home students or international students,” - spoken like a true altruist. Heaven forbid all that taxpayer money goes to waste, eh Wes?

The Health Sec first flagged the issue back in April, in an interview with GBnews. He said he was looking into the “bizarre” situation where UK medical graduates are having to compete directly with international doctors for NHS jobs. Speaking to GB News, he called it “crazy” that students trained in the UK aren’t being prioritised for the jobs they trained for. oH rEAlLy

The BMA has been telling him for ages. The situation is bleak. Applications to specialty posts ballooned, from 23,000 in 2019 to nearly 60,000 in 2024. The number of training posts have been pretty static. 20,000 doctors are set to miss out on speciality training this year. 

The BMA’s UK Resident Doctors Committee says the system’s overreliance on international recruitment is part of the problem. They’re asking the government to increase the number of posts, prioritise UK grads, and protect international medical graduates already here.

Who knows though… With potential strikes on the horizon, it seems he’s pulled all the stops to calm the troops.

We asked a while ago if strikes should go ahead. 86% of you said it should go ahead. With the recent development has there been a change of heart or are standing firm? Let us know in the pole below 👇

RESEARCH UPDATE

🚬 The Taboo of A Pregnant Smoker. Is Medical Management So Bad?

You’re Pregnant. You have a problem. You smoke. 

You’re told to be strong for baby. You do behavioural therapy. You go cold turkey. You hide your lighter. You grit your teeth. 

But the cravings don’t care about good intentions. They crawl back in the middle of the night. When you can’t sleep and the morning sickness hits. Oh, and no crutches either - no NRT, no prescription pills. Will will-power alone cut it?

Not very likely. About 60% of pre-pregnancy smokers continue to smoke during pregnancy according to Public Health England.Outside of a supportive midwife and a pep talk, there isn’t much else on offer. The jury is out over NRT, Varenicle and Bupriripon in the UK. The harms of smoking must be less than the harms of quitting meds

Turns out, that might not be true.

This retrospective cohort study, published in JAMA Internal Medicine wanted to see if that was true. The primary objective was to assess whether first-trimester exposure to NRT, varenicline or bupropion was associated with an increased risk of MCMs. That's major congenital malformations. This includes all sorts of birth defects - from cleft lips and palates to congenital heart defects. 

They took data from Australia, New Zealand, Norway and Sweden. Then selected 391,000 infants born to 267,522 women born between 2001-2020. These women had either

1. Smoked during the first trimester

2. Prescribed NRT, varenicline or bupropion 90 days pre-conception or during the first trimester.

They delved into the health records and found mothers 9,325 on NRT, 3,031 with varenicline and 1,042 on bupropion, overlapping the first trimester. This was matched against those who smoked but had no pharmacological help 1:10. 

The primary outcome measure was presence of MCMs within 18 months of birth. 

The findings were pretty interesting:

• Overall MCM risk: There was no significant increased risk in any of the groups. NRT was 37.6 per 1000 live births vs 34.4 per 1000 in the unexposed group. Varelincine: 32.7 vs 36.6. Bupropion: 35.5 vs 38

• Subgroup data: Each medication carried their own risk, but after adjustment, there was no significant difference.

  NRT: With a higher risk of digestive organ malformation (3.8 vs 2.5 per 1000) but not significant after adjustment (P=0.41)

  Varenicline: High risk of kidney/urinary tract formation(11.5 vs 4.2 per 1000), also not significant after adjustment (P=0.09)

What does this all mean? It’s obviously still better to not smoke at all. Where it can be stopped, please stop 🙏. Additionally, the study fails to consider the adherence to varenicline, bupropion or NRT in the real world setting. The compound effect of smoking AND a drug may not be pretty…

All the same, this study provides pretty robust evidence that where a relapse is looking inevitable medicine could be considered(in the first trimester at least).

Sometimes a crutch is exactly what you need to walk away from a bigger problem.

RESEARCH UPDATE

🔪 Skip The Knife? Less May Be More In Breast Cancer Surgery

Breast cancer is (quite bluntly) a pain in the arse.

For the woman staring down the diagnosis, it’s already more than enough to handle: the shock, the dread, the medical jargon coming at you like a freight train.

All this talk about chemotherapy beforehand. Then a surgery, where they may or may not take out the whole breast. Then radiotherapy. Then hormone drugs. Is that all?

Not quite. 
Next up: your armpits. Gotta prod and poke around to feel if any cells went AWOL.
Can’t feel anything? Time to do an ultrasound. 
Can’t see anything? Sorry miss, we still have to do a ‘sentinel biopsy.’ 

After all that, they find more cancer cells. Back to the scalpel to take out the lymph nodes. Now you're left with a swollen arm that doesn’t work quite right. The cure, sometimes, feels suspiciously like a punishment. 

Now, lymph node removal is still important. Lymph nodes infested with cancer cells have got to go . But what if we could cut the tension, skip the build-up… and maybe even skip the knife altogether when it’s safe to do so? No more sentinel biopsies. No more axillary clear outs.

That’s what the INSEMA trial, published in the New England Journal of Medicine, aimed to investigate. They took 5500 women, with early stage(T1/T2) breast cancer scheduled for wide local excision. Crucially, all these women had clinically node-negative invasive breast cancer. This means that on palpation and ultrasound, nothing was found. 

This was a randomised non-inferiority trial that split these women 1:4 into either:

• Surgery-omission group: Breast surgery done, but no axillary surgery (962 patients)

• Surgery group: Those undergoing sentinel lymph node biopsy and ensuing treatments (3,896 patients)

The big question: If we leave those perfectly innocent-looking lymph nodes alone, how long before the cancer comes back? This was measured as invasive disease-free survival(IDFS) - covering recurrence, new cancers or deaths. And how does this stack up against the standard approach?

What did they find?

• Invasive disease-free survival (IDFS): After a 6 year follow up, invasive disease-free survival in the surgery-omission group(91.9%) was found to be non-inferior to the surgery group(91.7%). Statistically, there's no significant difference. Hazard Ratio was 0.91 (95% CI, 0.73–1.14). 

• Recurrence Pattern: Axillary recurrence was found to be 1.0% (no surgery) vs 0.3%(surgery). Deaths were actually lower in no surgery(1.4%) compared to surgery(2.4%). A nice side-benefit

• Side effects: No surprises. No surgery = fewer side effects. Lymphedema rates were lower in the surgery-omission group. Arm mobility is higher in the surgery-omission group

The INSEMA trial won’t scrap sentinel biopsies overnight. Old habits die hard in medicine. For those with early breast cancer and clear scans, skipping axillary surgery could spare them unnecessary swelling, stiffness, and pain. All without giving up survival odds.

Less cutting. Fewer problems. Sometimes, less really is more.

OTHER NEWS YOU SHOULD KNOW

• Alzheimer's Revolutionary Med Disapproved By NICE. It’s too expensive.

• Assisted Dying Now Backed By MPs

• Abortion Now Decriminalised In The UK

• Faecal Transplant = Vancomycin in treatment of C.diff

Handover Over 🫡 

If you liked it, tell your mates(please forward this this news to them!)
If you hated it, tell your enemies.

See you on Sunday, for the next “Breaking The Bottleneck” Interview.

Also, If you haven’t yet told me a bit about yourself, please do so in the pole below! Have a good rest of your weekend!