Staff Publication

Survey of the current experience of colonoscopy training for colorectal surgical trainees in the UK (2025)

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Type of publication:

Journal article

Author(s):

Siggens K.; Williams S.; Yiu A.; El Sayed C.; Fletcher J.; Mills S.; Yeadon K.; Reza L.; Rabie M.; Drami I.; Green S.; Tamanna R.; Couderq D.; Javanmard-Emamghissi H.; Argyriou O.; Okocha M.; Khasawneh F.; Kat-Zsummercorn A.; Shakir T.; Anya L.; Bramwell C.; Haji A.; Johnston R.; Joshi H.; Oliphant R.; Piramanayagam B.

Citation:

Frontline Gastroenterology. (no pagination), 2025. Date of Publication: 2025.[epub ahead of print]

Abstract:

Introduction: The primary aim was to understand the current experience of colonoscopy training among general surgical trainees with a subspeciality interest in colorectal surgery. Method(s): An electronic survey was developed and disseminated by members of the Dukes' Club (colorectal trainees network) and Association of Coloproctologists of Great Britain and Ireland colonoscopy subcommittee between February and April 2024 to assess key themes identified through formal and informal feedback from colorectal trainees of endoscopy training experience. Result(s): The survey was completed by 196 participants. This included 13.3% from core trainee (CT) 2-speciality trainee (ST) 4, 28.6% from ST5-ST6, 36.5% from ST7-ST8, 13.3% from post-certificate for completion of training fellows, senior clinical fellows and speciality and specialist (SAS) doctors and 8.7% from early years consultants. The median number of colonoscopies performed by respondents was 121.6 (range 0-8000). Only 33.7% (66/196) reported having one dedicated training list per week, and 56.6% (111/196) were not allocated to any regular training list. The barriers to training were service provision (71.9%), lack of dedicated training lists (69.9%) and access to training lists due to other trainees or healthcare professionals (42.3%). Only 25% of respondents had experience of immersion training, but they consistently reported high numbers of colonoscopy during these periods, with 40% achieving more than 30 colonoscopies. Conclusion(s): There is an urgent need to improve access to colonoscopy training. Regular endoscopy training lists and funding of academies and immersion training centrally are likely to greatly improve the experience of colonoscopy training. Senior colorectal trainees should be prioritised to avoid delay in the completion of training.

DOI: 10.1136/flgastro-2025-103106

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Standardising the administration of joint injections across the Wolverhampton NHS Trust: a service improvement project in rheumatology through the lens of medical education (2025)

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Type of publication:

Conference abstract

Author(s):

*Jayasekera H.; Agunbiade T.; Chalam S.V.

Citation:

Future Healthcare Journal. Conference: Medicine 2025: The future of medicine. RCP annual conference. 11 St Andrews Pl, London United Kingdom. 12(2 Supplement) (no pagination), 2025. Article Number: 100432. Date of Publication: 01 Jun 2025.

Abstract:

Introduction: The Rheumatology Resident Doctors' Forum identified a pressing need to standardise steroid injection training due to varying experience and confidence levels among resident doctors. Many expressed a strong interest in learning injection techniques but faced barriers in accessing training and achieving formal competency. Addressing this gap had the potential to enhance service delivery, support professional development and reduce patient wait times. General practice trainees also highlighted the value of joint injection skills in primary care, helping to alleviate pressure on rheumatology services. The Dreyfus model of skill acquisition describes five levels of competency in skill development, ranging from 'novice' to 'competent' and eventually 'expert'.1 The model shows how individuals progress from rule-based, analytical thinking to experience-driven mastery of a skill.1 A recent study demonstrates that structured training can enhance competency in procedural skills, such as joint injections.2 Methods: A SMART aim was used to design learning outcomes. Fourteen applicants were selected at random. Pre-course surveys collected quantitative and qualitative data on performance challenges, confidence, and baseline knowledge. Process mapping (Fig 1) and radar diagrams (Fig 2) highlighted gaps for intervention. Four trained rheumatology doctors, supervised by a consultant, led a teaching program. Virtual meetings guided plan-do-study-act (PDSA) cycles and driver diagrams to ensure constructive alignment. The goal was to advance learners from the Dreyfus level of 'Novice 1' to 'Competent 1'. The course, conducted in the clinical suite, used training mannikins of knees and shoulder joints, providing real-time feedback. Teaching combined interactive lectures, small-group sessions and individualised feedback. Formative assessments maximised educational impact. Post-course data were compared to baseline, with quality improvement (QI) sustainability tools used to draw portal diagrams, highlight improvement gains and discuss long-term impacts of the project. Results and discussion: Initially, 50% of participants were novices, with none having ever injected a shoulder joint. Confidence in consenting patients increased from 14% to 100% post-course. 64% of participants were unfamiliar with medications used for injections, while 28.6% were unsure of the evidence base. Post-course, both categories improved to 100%. Additionally, 43% initially lacked confidence in clinical decision-making regarding safe joint injection. There was a 100% increase in overall confidence surrounding decision-making (43% 'strongly confident' and 57% 'confident'). All doctors passed the criterion-referenced standard assessment, acquiring formal recognition of skills in their portfolios. The course was oversubscribed and received excellent feedback. QI tools, including radar diagrams, process mapping, and PDSA cycles, had a crucial role in refining training and driving measurable improvements. The structured application of QI methodology successfully upskilled doctors, advancing them from 'Novice' to 'Competent'. Simulation-based learning, combined with real-time feedback, proved to be a highly effective strategy for accelerating skill development while enhancing clinical decision-making and confidence. By integrating this training into departmental inductions, the initiative ensured sustainability and continuous professional development, benefiting both individual practitioners and the wider healthcare service. Conclusion(s): The project led to significant improvements in confidence and competency. It demonstrated sustainability through reproducibility and was incorporated into the rheumatology departmental induction. Positive feedback highlights the course's broader applicability in QI-driven medical training.

DOI: 10.1016/j.fhj.2025.100432

Link to full-text [no password required]

Normal creatinine-kinase levels in post-COVID myositis: insights into localised muscle involvement (2025)

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Type of publication:

Conference abstract

Author(s):

*Jayasekera H.S.; *Elshehawy M.; *Olarewaju J.; Askari A.

Citation:

Clinical Medicine, Journal of the Royal College of Physicians of London. Conference: Medicine 2025: The future of medicine. RCP annual conference. 11 St Andrews Pl, London United Kingdom. 25(4 Supplement) (no pagination), 2025. Article Number: 100437. Date of Publication: 01 Jul 2025.

Abstract:

Introduction: Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2; coronavirus 2019; COVID-19) has been increasingly implicated in post-infectious inflammatory complications, including varied presentations of inflammatory myopathies.1,2 Most literature highlights severe, systemic muscle involvement requiring immunosuppression, whereas localised myositis with normal creatine kinase (CK) levels remains underrecognised.3 This case presents a rare instance of localised paraspinal and proximal thigh myositis post-COVID-19, where CK levels remained normal, despite significant muscle involvement. Method(s): A 41-year-old previously healthy man presented with severe diffuse back and leg pain, muscle cramps, and low-grade fever for 2 weeks after confirmed COVID-19 infection. Examination revealed proximal thigh weakness (MRC Grade 3/5) and tenderness without neurological deficits. Investigations, including blood tests, magnetic resonance imaging (MRI), computed tomography (CT), autoimmune screening, echocardiography, blood cultures and electromyography (EMG) studies. were conducted.1 Management required evaluating the progression of symptoms in the light of test results to identify the aetiology of disease, considering differential diagnosis and early establishment of localised vs systemic inflammatory myopathy.2 The patient was diagnosed as post-viral myositis with a normal CK. Empirical intravenous piperacillin-tazobactam was discontinued after infection was excluded. Simple analgesia and vitamin D sufficed for symptom control. The patient showed resolution of fever, significant improvement in muscle pain and normalisation of inflammatory markers, preventing the need for immunosuppression. Results and Discussion: Laboratory findings showed elevated C-reactive protein (237 mg/L), white cell count (12.0 x 109/L), and neutrophilia (9.4 x 109/L). Alkaline phosphatase (192 U/L) and gamma glutamyl transferase (202 U/L) were mildly elevated, while CK levels were normal (22 U/L, peaking at 56 U/L). MRI revealed diffuse oedema in posterior paraspinal muscles without abscess or infection, and CT imaging confirmed intermuscular oedema in paraspinal and proximal thigh muscles without systemic involvement. Autoimmune screening (antinuclear antibodies, weakly positive; extractable nuclear antigen antibodies and anti-neutrophil cytoplasmic antibodies, negative) and echocardiogram were unremarkable. Blood cultures showed no growth and EMG displayed a myopathic pattern in the right shoulder. This case provides insight into an atypical presentation of post-COVID 19 myositis, where the CK level remains normal despite muscle weakness.3 It evaluates the diagnostic and management challenges in this scenario. Other differentials include amyopathic dermatomyositis (ADM). However, differentiating localised post-viral myositis from ADM is essential, because ADM presents with cutaneous manifestations, which are absent in this case. A detailed history of recent viral illness and advanced imaging (eg, MRI) are critical for identifying myositis and excluding systemic or infectious causes.1Conclusion(s): This case highlights that post-viral localised myositis can present with significant muscle involvement despite normal CK levels, necessitating MRI for diagnosis.1,3 Early rheumatology input can optimise management by differentiating self-limiting inflammatory myopathies from those requiring immunosuppression.

DOI: 10.1016/j.clinme.2025.100437

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Complex lupus management: when multiple organs demand precision (2025)

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Type of publication:

Conference abstract

Author(s):

*Jayasekera H.S.; Askari A.; *Chand S.

Citation:

Clinical Medicine, Journal of the Royal College of Physicians of London. Conference: Medicine 2025: The future of medicine. RCP annual conference. 11 St Andrews Pl, London United Kingdom. 25(4 Supplement) (no pagination), 2025. Article Number: 100376. Date of Publication: 01 Jul 2025.

Abstract:

Introduction: Systemic lupus erythematosus (SLE) is a complex autoimmune disease with a wide spectrum of severity, ranging from mild manifestations to life-threatening organ damage. Its multisystem involvement poses a significant treatment challenge, because interventions targeting one organ system may inadvertently impact another. The Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) is a widely used tool for assessing disease activity, with a score above 12 indicating severe disease. However, studies estimate that approximately 20% of patients present with severe manifestations at diagnosis. One of the most serious complications of SLE is lupus nephritis, which is classified into six classes by the International Society of Nephrology/Renal Pathology Society (ISN/RPS), ranging from Class I (minimal-mesangial lupus nephritis) to Class VI (advanced-sclerosing lupus nephritis). We present a case of a patient newly diagnosed with severe SLE and lupus nephritis, characterised by high disease activity and multisystemic involvement. This case highlights the complex treatment considerations necessary when managing severe lupus.

Method(s): A 62-year-old woman presented with flu-like symptoms followed by a malar rash, mouth ulcers, fatigue, alopecia and pancytopenia. She was diagnosed with SLE with lupus nephritis confirmed by renal biopsy, and SLE on skin biopsy. Management required significant consideration because of high disease activity (SLEDAI 16) complicated by pancytopenia and liver dysfunction. Therapeutic options were systematically evaluated to balance efficacy and safety given the patient's pancytopenia, liver dysfunction and renal involvement. Mycophenolate mofetil (MMF), effective for lupus nephritis, was excluded because of its potential to worsen pancytopenia. Azathioprine, suitable for mild renal involvement, was ruled out because of liver dysfunction. Cyclophosphamide, typically used for severe SLE, was contraindicated because of its haematological and hepatic toxicity. Tacrolimus was considered for renal SLE, given the biopsy Class of I, but was unsuitable for non-renal lupus without MMF. Belimumab, an FDA-approved agent with steroid-sparing effects and a favourable safety profile, was considered but deemed challenging because of its slower onset of action and approval barriers. Hydroxychloroquine (300 mg daily) and corticosteroids (40 mg prednisolone) were ultimately chosen as the safest and most effective initial therapy. Close liaision with the renal team was essential to optimise management. Results and Discussion: Laboratory results revealed low complements (C3 0.38 g/L, C4 0.03 g/L), pancytopenia (WBC 1.2 x 109/L, platelets 126 x 109/L), elevated ferritin (5,490 mug/L), and positive dsDNA. Skin biopsy was consistent with SLE and renal biopsy confirmed lupus nephritis (ISN/RPS Class I). CT-TAP imaging showed axillary lymphadenopathy without malignancy. This case highlights the challenges of managing multisystemic lupus presenting with renal and non-renal SLE symptoms of varying degree, in a patient not already established on baseline treatment. Hydroxychloroquine and corticosteroids formed the cornerstone of treatment, while other options were systematically excluded based on contraindications. Multidisciplinary collaboration was pivotal in tailoring therapy.

Conclusion(s): There are two key learning points highlighted in this case. First, that treating multisystemic lupus requires understanding the degrees of individual organ involvement to determine immunosuppressive needs. Second, that management decisions should balance efficacy and toxicity, guided by interdisciplinary input6 and renal biopsy findings to inform immunosuppression.

Link to full-text [no password required]

Therapeutic Duel of Rifaximin Versus Lactulose in Hepatic Encephalopathy: A Systematic Review (2025)

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Type of publication:

Systematic Review

Author(s):

Oriko, David O; Khawaj, Zainab; Cheema, Muhammad Usairam; Talreja, Anjali; Tayyab, Muhammad Abbas; Zamir, Muhammad Hamza; Iqbal, Maheen; Farooq, Umer; *Ekomwereren, Osatohanmwen; Tariq, Muhammad M; Hasan, Abdul Haseeb.

Citation:

Cureus. 17(6):e86193, 2025 Jun.

Abstract:

This systematic review aimed to compare the clinical efficacy of rifaximinversus lactulose in the management of hepatic encephalopathy (HE) by analyzing evidence from randomized controlled trials (RCTs). A comprehensive search across major databases identified seven eligible RCTs encompassing 693 adult patients diagnosed with overt or minimal HE. Findings demonstrated that rifaximin is at least as effective as lactulose in reversing HE symptoms, with some studies reporting significantly higher HE reversal rates when rifaximin was used in combination with lactulose (e.g., 76% vs. 50.8%, p<0.004), reduced mortality (23.8% vs. 49.1%, p<0.05), and shorter hospital stays (5.8 vs. 8.2 days, p=0.001). While other trials reported similar efficacy between the two agents (e.g., HE improvement: 84.4% vs. 95.4%, p=0.315), rifaximin was generally associated with better tolerability and fewer gastrointestinal side effects. These results support rifaximin as an effective and well-tolerated therapeutic option, either as monotherapy or in combination with lactulose. Further large-scale, multicenter trials are warranted to assess long-term outcomes, recurrence rates, and cost-effectiveness.

DOI: 10.7759/cureus.86193

Link to full-text [open access - no password required]

Treatment-Induced Neuropathy in Diabetes Post Use of Hybrid Closed Loop Continuous Subcutaneous Insulin Infusion in Type 1 Diabetes (2025)

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Type of publication:

Conference abstract

Author(s):

*Basavaraju N.; *Beard N.; *Jones A.; *Moulik P.;

Citation:

Diabetes Technology and Therapeutics. Conference: 18th International Conference on Advanced Technologies and Treatments for Diabetes, ATTD 2025. Amsterdam Netherlands. 27(Supplement 2) (pp e264-e265), 2025. Date of Publication: 01 Feb 2025.

Abstract:

Background and Aims: Treatment-induced neuropathy in diabetes(TIND) is a transient, painful peripheral neuropathy occasionally with autonomic component, occurring with rapid glycaemic improvement. Hybrid closed loop(HCL) continuous subcutaneous insulin infusion(CSII) in type 1 diabetes(T1D) can improve glucose levels rapidly. Method(s): Retrospective review of two cases. Case 1: 27- year-old male, T1D for 16years, disengagement, maculopathy switched from basal-bolus insulin to HCL-CSII(Omnipod5- DexcomG6). Case 2: 44-year-old female, T1D for 42years, disengagement laser treated retinopathy, neuropathy, toe amputation switched from basal-bolus insulin to HCL-CSII(Omnipod5- DexcomG6). Result(s): Case 1: Pre-HCL HbA1c107mmol/mol. 3months post HCL HbA1c 69mmol/mol. He reported neuropathic pain in lower limbs, commenced amitriptyline for 3months with resolution. He also developed proliferative retinopathy. Case 2: Pre- HCL HbA1c96mmol/mol improved to 54mmol/mol in 6months. She developed severe neuralgic pain in both feet, improved with Pregabalin for 3months. There was no deterioration in retinopathy. Conclusion(s): TIND is more common in T1D, pathophysiology may be endoneurial ischaemia and microvascular changes due to relative hypoglycaemic state. Diagnostic criteria include (i)decrease in HbA1c by 2%(22mmol/mol) over 3months (ii)neuropathic pain and/or autonomic symptoms within 8weeks after decrease in HbA1c (iii)acute onset of neuropathic pain and/ or autonomic dysfunction for more than 2weeks requiring medical attention. It is self-limiting, lasting from weeks to months. Symptomatic treatment include antiepileptics(pregabalin) and tricyclic antidepressants are effective. There are no reported cases of TIND with HCL-CSII in literature. Our two cases highlight TIND, like worsening retinopathy, is a potential complication of rapid improvement in glycaemic control with HCL-CSII in patients with pre-existing hyperglycaemia and patients' needs counselling about the potential short-term risks.

DOI: 10.1089/dia.2024.78502.abstracts

Is There a Correlation Between Hybrid Closed Loop(HCL) Continuous Subcutaneous Insulin Infusion(CSII) Glycaemic Improvement in Type 1 Diabetes(T1D) and Worsening Sensorineural Hearing Loss? - A Case Report (2025)

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Type of publication:

Conference abstract

Author(s):

*Basavaraju N.; *Jones A.; *Wilkes V.; *Moulik P.

Citation:

Diabetes Technology and Therapeutics. Conference: 18th International Conference on Advanced Technologies and Treatments for Diabetes, ATTD 2025. Amsterdam Netherlands. 27(Supplement 2) (pp e265), 2025. Date of Publication: 01 Feb 2025.

Abstract:

Background and Aims: T1D is associated with various comorbidities including sensorineural hearing loss (SNHL). HCL CSII treatment in T1D improves glucose levels rapidly. This may cause short-term worsening of retinopathy and neuropathy (treatment-induced neuropathy in diabetes). We present a case of T1D on HCL CSII with worsening hearing loss. Method(s): A 46-year-old gentleman with T1D for 30 years with pre- proliferative retinopathy had mild right sided tinnitus and sensorineural hearing loss (on pure tone audiometry) diagnosed 8 years ago. MRI internal auditory meatus was normal. He was commenced on HCL CSII (Omnipod 5 with Dexcom G6). Result(s): Pre-HCL HbA1c was 75mmol/mol. Glucose management indicator (GMI) after 4weeks rapidly dropped to 53mmol/mol which further reduced to 48mmol/mol in 6months. He reported worsening of right sided tinnitus and hearing loss with development of new left sided tinnitus. He also developed maculopathy. Conclusion(s): Approximately 9.2/1000 people with T1D develop debilitating SNHL every year. In people aged 40-60- years with T1D, hearing threshold in high frequencies(4,000- 8,000Hz) was significantly higher (25-30dB) when compared to age-matched controls (5-10dB). The mechanisms are damage to outer and inner hair cells, loss of spiral ganglion neurons through apoptosis, thickening of basement membrane, and pathologies involving stria vascularis and spiral ligament of the cochlear lateral wall. Whilst causality cannot be inferred from this case, the temporal sequence of rapidly improved glycaemic control with worsening tinnitus and hearing loss raises a possibility of its association. This requires further study preferably with pure tone audiometry, in a randomised clinical trial setting.

DOI: 10.1089/dia.2024.78502.abstracts

Acute coronary syndrome rule-out strategies in the emergency department: an observational evaluation of clinical effectiveness and current UK practice (2025)

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Type of publication:

Journal article

Author(s):

Ingram A.; Boldovjakova D.; Wilson H.; Noble J.; Prentice J.E.B.; Brasnic L.; Papala P.; Waite R.; Hatem S.M.K.; Hamad H.H.M.A.; Lilani M.J.; Hardwick S.; Pritchard W.; Cairns D.; Lamuren E.; Thomas J.; Eve M.; Gabiana P.; Matias S.; Harris S.; Christmas E.; Brockbank J.; Mackinnon L.; Chrysikopoulou M.; Vo O.K.; George R.J.; Alsaarti R.; Mohrsen S.; Macleod C.; Grossi I.; Feetham J.; Almousa O.; Lyle A.; Victoria A.; Fox C.; Mitchell C.; Kara C.; Catley C.; Shea D.; Cranmer K.; Sach L.; Willsher L.; Vitaglione M.; Forsey M.; Fox N.; Arnold R.; Reid S.; Cotterell S.; Smolen S.; Lester Y.; Dean A.; Fitchett J.; Hoyle R.; Duberley S.; Goddard W.; Lunney C.; Ogbeide C.; Mcsorland D.; Gibson M.; Riley M.R.; Bradley P.; Thomas Z.; Giles E.; Patel H.; Pathirana J.; Chappel P.; Balasingam S.; Webb S.; Elshobaky E.; Challen K.; Ibrahim M.; Connor S.; Aprjanto A.; Ghosh A.; Amer E.; Sinclair J.; Smith T.; Freitas T.D.; Smith J.; Peachey J.; Clymer J.; Squire R.; Lee A.R.; Szekeres C.; Jessup-Dunton E.; Irvine G.; Brookman I.; Grant I.; Abbas K.; Wanigabadu L.; Futcher M.; Awadalkarim M.; Parker M.; Thammaiah Y.; Blows G.R.; Evans L.; Rebolledo M.; Macfarlane R.; Felix R.B.; Baker E.; Clarke J.; Dinglasan M.; Aldridge P.; Marshall S.; Helyar S.; Kunnath T.; Baldwin G.; Lowdell J.; Vallotton N.; Dasilva R.; Sharaf T.; Awe A.; Kerr-Winter B.; Anomelechi E.; Emond F.; Sennitt H.; Khan I.; Aderounmu I.; Bath J.; Woods J.; Dudden K.; Rupchandani K.; Mccafferty L.; Aaron L.; Al-Mousa M.; Okere N.; Scott O.; Edwards R.; Copson S.; Burke S.A.; Nawaz S.; Muhammad Y.; Noor A.; Tizon A.; Passalacqua C.; Qureshi E.F.; Malik F.I.; Jaafaru H.I.; Raees H.; Khaliq M.A.; Layawen N.; Shah R.; Torres S.L.G.; Guglani S.; Ramraj S.; Sharma S.; Hassan T.M.; Betos V.; Drexel A.; Sakutombo D.; Mendes F.; Furreed H.; Morris M.G.; James M.; Fong T.; Hartin D.; Lloyd G.; Sundarraj S.T.; Rivers V.; Kelly C.; Sutherland H.; Boast M.; Kisakye E.; Britton H.; Sebastian J.; Puscas M.R.; George S.; Olawale-Fasua W.; Wood D.; Kaur J.; King S.; Heeley C.; Davy G.; Wilson G.; Bennett K.; Allsop L.; Gill M.; Thorpe N.; Turner S.; Whitworth V.; Prendergast A.D.; Jones A.; Sheppard C.; Jones K.A.; Mcgregor K.; Sekar P.; Aeman S.; O'donnell S.P.; Griffin S.; Sheikh A.; Chintamani A.; Shrestha B.; Bisht D.; Saliu E.J.; Fadhlillah F.; Mahmoud M.Y.; Wasil M.; Ragupathy R.; Moghal Z.S.; John A.; Lockett C.; Tomkinson J.; Rose K.; Aziz M.; Keenan N.; Sandhu B.; Bentley C.; Phiri E.; Adams L.; Page M.; Seaman R.; Asnani S.; Taylor C.; Butt M.; Doherty W.J.; Da'costa A.; Adedeji A.D.; Ibeh C.O.; Oduware E.O.; Dolan H.; Ofori L.; Brassington L.; Olusoga O.; Nkala P.; Gurung S.; Williams S.; Ndlovu T.; Akhuemokhan Z.B.; Gulati D.; Akande M.; Oshiotse S.; Chilcott G.; Battishill W.; Wood J.M.; Hendry R.; Pottelbergh T.M.V.; T-Michael H.; Rothwell J.; Connolly K.; Cooper L.; Quli A.; Corr H.; Orourke L.; Pettet A.; Kariyadil B.; Pile J.; Gallamoza K.; Foo M.; O'connell P.; Kirkup A.; Hall J.; Hudson L.; Waddell G.; Mckie H.; Beck J.; Harrison M.; Ternent M.; Crispin P.; Aladesanmi A.; Ahmed A.; Thomson D.; Moth G.; Haslam J.; Killeen J.; Philbin J.; Howard-Sandy L.; Warran S.; Munt S.; Humphrey C.; Langridge E.; Otoole K.; Pule P.; Miln R.; Death Y.; Davies A.; Dunn E.; Brittain E.; Kohler G.; Stacey J.; Bloch M.; Murphy M.; Griffiths O.; Awbery H.; Oyindamola O.; Aor S.S.; Gribbin A.; Edwards C.; Vorwerk C.; Jackman D.; Brown G.; Daly Z.; Naiyeju A.A.; Arrayeh A.; Giubileo A.; Sarvesh B.; Jafferji D.; Thornton H.; Mckenzie I.; Okwori I.; Rudnicka J.; Nasr M.; Hassan M.; Aliu M.; Osunsanya O.; Abdulsalam S.; Mbaekwe S.; Shedwell S.; Wickramanayake U.; Abdullahi Y.; Mcclelland B.; Willshire K.; Knight A.; Beranova E.; Tutt G.; Ramos H.; Mcarthur C.; Khoo E.; Hughes E.; Austin K.; Doran K.; Gordon M.W.G.; Oshaughnessy O.; Worgan R.; Matthews A.; Baddeley A.; Morris A.; Ndungu A.; Peters C.; Walker L.; Tilbury N.; Lubbock S.; Mapatuna C.; Kehlenbeck E.; Curtis K.; Tonkins M.; King P.; Walker R.; Gabriel Z.; Titu H.; Coyle J.; Waddington N.; Chotai C.; Ward C.; Elliott L.; Henshall A.; Pogorodnaja A.; Knowles C.; Mascia G.; Rai S.G.; Bartley S.; Ko S.T.S.; Perera Y.; Conroy E.; Nicholson J.; Taylor J.; Flanagan R.; Wilce A.; Lindsay C.; Bascombe C.; Osey C.; Tiller H.; Rogers L.; Agius N.; Barratt N.; Pitts S.; Mohammed A.; Eihebholo A.; Olaifa A.; Bowyer C.; Sutcliffe E.; Bishop O.J.; Jenkins O.; Kyriakides O.; Thomas S.; Ali S.; Mason S.; Ripsher W.; Cousins E.; Dhande K.S.; Wright L.; Bolus A.; Sykes D.; Faronbi G.O.; Slade L.; Page R.; Maiti M.; Hekal M.; Khadka S.; Border T.; Wilson W.; Lowe A.; Evans C.; Moceivei C.; Mcavoy D.; Hay F.; Homyer K.; Dunne M.; Goldmann N.; Mitchell R.; Geoghegan A.; Entwistle J.; *Marsh A.; *Stephens A.; *O'connell G.; *Gibson H.; *Stickley J.; *Witt J.; *Beekes M.; *Sowailam M.; *Ali N.A.; Stan A.; Boalch A.; Demetriou C.; Flitney C.; Munday C.; Khoory C.; Carter D.; Gould E.; Evans G.; Elghonemy H.; Latham J.; Zamari K.; Ramos L.; Howie L.; Gunning S.; Haskins W.; Ayodeji Y.S.; Potts A.; Kay D.; Perez J.; Holden J.; Pendlebury J.; Cawley K.; Shahedy N.; Doonan R.; Blevings R.; Anthony A.; Trim F.; Hadebe B.; Pherson A.M.; Mphansi E.; Tysoe S.; Masunda B.; Galliford J.; Pestell S.; Patel S.; Pickard A.; Hoare B.; Cox C.; Hart D.; Amarnani D.; Fay E.; Khedarun F.M.; Collins F.; Sysum K.; Fung M.; Corbin N.; Patel N.; Moss P.; Marques R.; Johnson R.; Parmar S.; Sarker S.; Lawrence G.; Romero M.R.; Felix R.M.B.; Raju T.; Clarson S.; Clarke B.D.; Philp E.; Wren G.; Gallacher S.; Sharir A.; Andrews B.; Faint C.; Caines C.; Everett C.; Newman D.; Cruz G.D.L.; Hughes G.; Carey H.; Reavley H.; Ayre J.; Quan J.; Caines L.; Wedge-Bull M.; Alzaatreh M.; Chong N.; Anthony N.; Chandler S.; Walford S.; Sharir T.; White T.; Heslop-Harrison W.; Dunphy A.; Trenwith B.; Coelho B.; Hunter L.; Moran R.; Pemberton A.; Suggitt B.; Pimlott B.; Bates C.; Tibke C.; Pegler D.; Daniel D.; Lamond D.; Pureti G.; Baxter H.; Melville J.; Zai K.F.T.; Mullane K.; Phyu M.P.; Gabriels N.; Mills R.; Bennett S.; Blenkinsop S.; Vikramadhithyan S.; Barnes S.; Hopkins S.; Doherty-Walls T.; Coughlan T.; Kinder J.; Clark M.; Islam M.N.; Gray R.; Ford A.; Florey L.; O'neill M.; Aspa P.; Mercer P.; Ackerley A.; Ironside J.; Haynes L.; Garcia B.; Elkhodair S.; Enegela A.; Leech C.; Hassanali F.; Rashid H.; Lalji J.; Akpoghene M.; Enegela O.A.; Hafeez-Bore O.; Oluwaseun O.; Pelasur R.; Ayres R.; Tariq R.; Mchenry R.D.; Bains B.; Jones B.; Tarant E.; Mundy M.; Pearse R.; Sibtain S.; Day A.; Campbell B.; Stagg C.; Jones D.; Atwal I.; Tompkins K.; Parsons P.; Dancer R.; Balaican A.M.; Ellis C.; Ede C.H.; Joseph J.; Hardaker O.; Ridwan R.; Khan S.; Zhao X.; Wood L.; Tampsett R.; Rao S.; Castillo W.P.H.; Ticehurst F.; Rocha J.G.D.; Chivers K.; Vecchione N.; Kader N.; Wilson S.; Adhikari S.; Ramsundar S.; Felix F.; Johnston R.; Jin Y.; Ingall E.; Rand J.; Solly R.; Naeem S.; Stirrup S.; Priestley V.; Pun A.; Olosho O.Z.; Board S.;

Citation:

Emergency Medicine Journal. (no pagination), 2025. Article Number: 214616. Date of Publication: 2025. [epub ahead of print]

Abstract:

Background: Numerous strategies have been developed to rapidly rule-out acute coronary syndrome (ACS) using high-sensitivity troponin. We aimed to establish their performance in terms of emergency care length of stay (LOS) in real-world practice. Method(s): A multicentre observational cohort study in 94 UK sites between March and April 2023. Recruitment was preferably prospective, with retrospective recruitment also allowed. Adults presenting to the ED with chest pain triggering assessment for possible ACS were eligible. Primary outcome was emergency care LOS. Secondary outcomes were index rate of acute myocardial infarction (MI), time to be seen (TTBS), disposition and discharge diagnosis. Details of ACS rule-out strategies in use were collected from local guidelines. Mixed effects linear regression models tested the association between rule-out strategy and LOS. Result(s): 8563 eligible patients were recruited, representing 5.3% of all ED attendances. Median LOS for all patients was 333 min (IQR 225, 510.5), for admitted patients was 460 min (IQR 239.75, 776.25) and for discharged patients was 313 min (IQR 221, 451). Heterogeneity was seen in the rule-out strategies with regard to recommended troponin timing. There was no significant difference in LOS in discharged patients between rule-out strategies defined by single and serial troponin timing (p=0.23 and p=0.41). The index rate of acute MI was 15.2% (1301/8563). Median TTBS was 120 min (IQR 57, 212). 24.4% (2087/8563) of patients were partly managed in a same day emergency care unit and 70% (5934/8563) of patients were discharged from emergency care. Conclusion(s): Despite heterogeneity in the ACS rule-out strategies in use and widespread adoption of rapid rule-out approaches, this study saw little effect on LOS in real-world practice. Suspected cardiac chest pain still accounts for a significant proportion of UK ED attendances. ED system pressures are likely to be explanatory, but further research is needed to understand the reasons for the unrealised potential of these strategies.

DOI: 10.1136/emermed-2024-214616

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Effects of Race, Ethnicity and Socioeconomic Deprivation on Postpartum Haemorrhage in High-Income Countries: A Systematic Review and Meta-Analysis (2025)

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Type of publication:

Systematic Review

Author(s):

*Elsmore, Amy; Alayande, Gbenga; Mainwaring, Elizabeth; Jafarpour, Mahfam; Rimmer, Michael P; Cockburn, Neil; *Curtis, Jason; *Ilaalagan, Ragave; Al-Wattar, Bassel; Bell, Sarah; *Karunakaran, Bala; *Parry-Smith, William; Wu, Pensee.

Citation:

BJOG: An International Journal of Obstetrics & Gynaecology.  2025 Jul 09.

Abstract:

BACKGROUND: Postpartum haemorrhage (PPH) is a leading cause of mortality and morbidity globally. While individual studies have revealed disparities in outcomes, a comprehensive summary of PPH risk across diverse groups is lacking.

OBJECTIVES: To quantify the association between ethnicity, deprivation and risk of PPH in high-income countries (HICs).

SEARCH STRATEGY: A systematic search of MEDLINE, CINAHL, EMBASE and Google Scholar from inception to 20 August 2024.

SELECTION CRITERIA: Observational and experimental studies from HICs that reported the outcome of PPH in at least two ethnic or socioeconomic groups.

DATA COLLECTION AND ANALYSIS: Two reviewers performed independent data extraction. A random-effects model was used to estimate the risk. A subgroup analysis was performed by geographical region and time period.

MAIN RESULTS: A total of 79 studies with 169 579 388 women were included, spanning 15 HICs. Ethnic minority women experienced a higher risk of PPH compared to the majority White or European group. This was seen across Black (OR 1.16, 95% CI 1.09, 1.23), Asian (OR 1.33, 95% CI 1.27, 1.39), Hispanic (OR 1.20, 95% CI 1.12, 1.29) and women from the minority ethnic group within a given study (OR 1.13, 95% CI 1.03,1.24). Due to data limitations, eight studies on PPH and socioeconomic status were summarised
narratively, indicating a higher PPH risk for those experiencing deprivation.

CONCLUSIONS: Women from an ethnic minority background or exposed to socioeconomic deprivation had an increased risk of PPH in HICs. Standardisation of data collection for ethnicity and socioeconomic status is recommended to accurately quantify and address these disparities.

DOI: 10.1111/1471-0528.18278

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Metformin for patients with metastatic prostate cancer starting androgen deprivation therapy: a randomised phase 3 trial of the STAMPEDE platform protocol (2025)

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Type of publication:

Randomised controlled trial

Author(s):

Gillessen, Silke; Murphy, Laura; James, Nicholas D; Sachdeva, Ashwin; El-Taji, Omar; Abdel-Aty, Hoda; Adler, Amanda I; Amos, Claire; Attard, Gerhardt; Varughese, Mohini; Gale, Joanna; Brown, Simon; *Srihari, Narayanan; Birtle, Alison J; Brown, Mick; Chan, Kitty; Chowdhury, Simon; Cross, William; Dearnaley, David P; Din, Omar; Dutey-Magni, Peter; Gilbert, Duncan C; Gilson, Clare; Gray, Struan; Grist, Emily; Hofmann, Uschi; Hudson, Andrew M; Jain, Yatin; Jeyasangar, Ganesan; Jones, Robert; Kayani, Mahaz; Langley, Ruth E; Malik, Zafar; Mason, Malcolm D; Matheson, David; McAlpine, Connor; Macnair, Archie; Millman, Robin; Murphy, Claire; Padden-Modi, Minal; Parikh, Omi; Parker, Chris; Rush, Hannah; Russell, Martin; Srinivasan, Rajaguru; Sundar, Santhanam; Tanguay, Jacob S; Turco, Fabio; Williams, Patrick; Sydes, Matthew R; Parmar, Mahesh K B; Brown, Louise C; Clarke, Noel W.

Citation:

Lancet Oncology. 2025 Jul 07.

Abstract:

BACKGROUND: Metformin is a widely used anti-diabetic drug. Several studies have suggested that metformin has anticancer activity in some malignancies, including prostate cancer. Metformin might also mitigate the adverse metabolic effects of androgen-deprivation therapy (ADT). We hypothesised that metformin might improve survival in patients with metastatic hormone-sensitive prostate cancer and reduce metabolic complications associated with ADT.

METHODS: The STAMPEDE multi-arm, multi-stage, randomised phase 3 trial recruited patients with high-risk locally advanced or metastatic adenocarcinoma of the prostate staged by conventional imaging with isotope bone and CT scanning. This publication reports findings for the most recent STAMPEDE research question, testing the addition of metformin to standard of care for non-diabetic (glycated haemoglobin [HbA1c] <48 mmol/mol [equivalent to <6.5%]) patients with metastatic disease with adequate renal function (glomerular filtration rate >=45 ml/min/1.73 m2) and WHO performance status 0-2. This trial recruited from 112 hospitals in the UK and Switzerland to the STAMPEDE protocol. Patients were randomly allocated (1:1) to standard of care or standard of care plus metformin 850 mg twice daily. Random assignment was by telephone using minimisation with a random element of 20% (developed and maintained by the MRC Clinical Trials Unit at UCL), stratified for randomising hospital, age (<70 years vs >=70 years), WHO performance status (0 vs 1 or 2), type of ADT, regular long-term use of aspirin or non-steroidal anti-inflammatory drugs (NSAIDs; yes vs no), pelvic nodal status (positive vs negative), planned radiotherapy (yes vs no), and planned docetaxel or androgen receptor pathway inhibitor (ARPI) use (docetaxel vs abiraterone, enzalutamide, or apalutamide vs none). Standard of care comprised ADT with or without radiotherapy and with or without docetaxel or ARPI. The primary outcome measure was overall survival, defined as the time to death from any cause, assessed in the intention-to-treat population. Safety was assessed in patients who started treatment. The trial is registered with ClinicalTrials.gov, NCT00268476 and ISRCTN, ISRCTN78818544.

FINDINGS: Between Sep 5, 2016, and Mar 31, 2023, 1874 patients with metastatic disease were randomly allocated to standard of care (n=938) or standard of care plus metformin (n=936). The median patient age was 69 years (IQR 63-73) and the median PSA was 84 ng/mL (24-352). 1758 (94%) of 1874 patients were newly diagnosed with metastatic disease and 116 (6%) were diagnosed with metachronous relapsing disease. 1543 (82%) of 1874 patients received ADT plus docetaxel and 52 (3%) received abiraterone, enzalutamide, or apalutamide. The median time to most recent case report form follow-up was 60 months (IQR 49-72). 473 deaths were reported in the standard of care group; median survival was 61.8 months (IQR 29.7 to not reached). There were 453 deaths in the metformin group; median survival was 67.4 months (32.5 to not reached; HR 0.91, 95% CI 0.80-1.03; p=0.15). Grade 3 or worse adverse events were reported in 487 (52%) of 938 patients in the standard of care group and 523 (57%) of 921 patients in the standard of care plus metformin group. 61 (7%) patients in the standard of care group and 84 (9%) patients in the standard of care plus metformin group reported at least one grade 3 or worse gastrointestinal adverse event; all other body systems showed no difference in grade 3 adverse events. There were six drug-related deaths in the standard of care group and one in the standard of care plus metformin group.

INTERPRETATION: We did not find significant evidence of an overall survival benefit of adding metformin to standard of care in the overall population of patients with metastatic hormone-sensitive prostate cancer. The side-effect profile of metformin was as expected and consisted mainly of diarrhoea. Adverse metabolic side-effects of ADT were significantly reduced in the metformin group compared with the standard of care group.

FUNDING: Cancer Research UK, Prostate Cancer UK, and UK Research and Innovation Medical Research Council.

DOI: 10.1016/S1470-2045(25)00231-1

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