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Take a look at a selection of our recent media coverage:
7th April 2025
With an introduction from Helena Beer, consultant gynaecologist Mr James Tibbott, lead clinician for gynaecology at Leeds Teaching Hospitals NHS Trust, discusses the Trust’s recent endometriosis centre recognition and the technology that helped them achieve it, how robotic surgery is transforming timely patient care and the latest research set to revolutionise diagnostics and treatment for this debilitating condition.
Endometriosis is the second most common gynaecological condition in the UK, after uterine fibroids, and despite its prevalence it is often misunderstood. Awareness and discussion of the condition is ramping up among the public, with the recent approval of relugolix combination therapy (brand name Ryeqo) by the National Institute for Health and Care Excellence being the latest development getting people talking.
But it’s the delays in diagnosis and treatment that tend to dominate the headlines, and this is far from the whole story in endometriosis care. There are inspirational examples of best practice, technological innovations and cutting-edge research that are set to transform patient care for the better and, in some cases, are already making a significant difference.
In January 2025, the endometriosis team at Leeds Teaching Hospitals NHS Trust (LTHT) was awarded provisional status as a British Society for Gynaecological Endoscopy (BSGE) Accredited Endometriosis Centre. This recognition highlights their commitments to excellence in endometriosis treatment, person-centred care and ongoing research and innovation.
One of the driving forces behind the accreditation was the team’s introduction of robotic surgery, which has recently led to the introduction of an Endometriosis Robotic High Intensity Theatre (HIT) list. Led by Mr James Tibbott, consultant gynaecologist and the Trust’s lead clinician for gynaecology, this HIT list offers more patients a less invasive surgical option with greater precision and shorter recovery times. And, crucially, it also reduces waiting lists.
Achieving BSG accreditation puts Leeds Teaching Hospitals Trust at the forefront of gynaecological care for patients with endometriosis. It means that our patients have a quality assurance about the level and standard of care that they receive at Leeds Teaching Hospitals Trust that is independently monitored by a governing body.
I think this is important for patients, as they want the right treatment for them by the right people. It also means that for severe, complex endometriosis, there’s very much a multidisciplinary team-driven approach to their care that the patients can feel reliably that they’re getting a high standard of care.
We have three robots at our Trust: two at the abdominal surgery hospital and one in the head and neck and paediatric surgical specialty, which is extremely underutilised.
We noticed that this underutilised robot gave us a gap in the market to start doing some simpler day cases – simple hysterectomies, simple endometriosis – and it’s improved our day case hysterectomy rate no end. That now means that I can use the technology and join colleagues at our abdominal surgery hospital [for more complex procedures].
Unfortunately, at this moment, we still don’t have a regular theatre list, but I can pick up ad hoc sessions, which improves our theatre productivity and utilisation. More importantly, I can join colleagues in theatre, so I’ve joined a colleague to do a hysterectomy and a ureteric reimplantation. I’ve joined colleagues to do complex colorectal work as well as our own surgeries.
In fact, we’ve already done a case where we’ve had a urology surgeon, colorectal surgeon and gynaecological surgeon doing three different operations on one patient, all using the same modality. We will hopefully expand that to include thoracic surgery as well.
So, for me, robotic surgery gives an unprecedented level of accuracy for our patients with endometriosis. It is my fastest mode of operating, both for hysterectomy and excision of endometriosis full stop. What we can achieve robotically far exceeds what we can achieve laparoscopically.
For example, a complex endometriosis case with bowel excision or resection, usually takes half a day of operating. With the robotic HIT list, we managed to do three complex operations with disc excisions of the rectum during a full day operating. So, we improved efficiency three-fold.
When we operate laparoscopically for a complex endometriosis case, after one of those cases, we’re usually absolutely exhausted, and doing more than one in a day becomes very, very difficult physically and mentally – these are mentally draining procedures.
What we’ve seen is a reduction in operating time due to robotics and a reduction in length of stay due to robotic surgery for complex endometriosis. After having had a robotic hysterectomy, patients seem to experience less pain, and that’s probably because we operate at lower pressures, and their recovery time is significantly quicker.
There are more and more non-invasive tests for endometriosis that are being investigated and piloted, and this really is the key. We need a diagnostic test that doesn’t involve a laparoscopy. Ideally, it should be a point-of-care test that we can then see patients in primary care, get that test and refer to the appropriate person, if needed.
Ideally, if the point-of-care test can give us an idea of how bad their endometriosis is, it would help streamline care so everybody who tested positive for Stage Four endometriosis was referred to, for example, an endometriosis centre in the UK.
Research plays a key role in endometriosis care. It allows us to push the boundaries. For us, the most exciting piece of research that’s happening at the moment is the AMY109 study. This is where we’re taking patients with severe endometriosis and randomising them to a monthly monoclonal antibody infusion. In animal models, this has been curative and if this test of theory works, if we’re able to cure patients of endometriosis with an antibody infusion, the future for endometriosis care may be completely different.
Imagine a scenario where we can do a test that’s positive for endometriosis, perform an ultrasound scan, lavage off some peritoneal fluid, put it in an analyser, work out what complex inflammatory process is driving that patient’s endometriosis, and then arrange for an antibody infusion specifically for that patient. I think that’s a real potential game changer – an extremely exciting future.
Image ©2025 Intuitive Surgical Operations, Inc
3rd April 2025
A recent retrospective evaluation of pleural intervention data in the United Kingdom revealed that inadequate use of thoracic ultrasound contributed to both potential and actual harm from pleural procedures.
Previous national audits of pleural interventions, including chest drain insertions, have revealed deficiencies in care contributing to patient deaths and severe harm. Inadequate out-of-hours staffing by trained operators and related infrastructure issues have been identified as potential risk factors.
Consequently, a new review of patient safety incidents from the National Reporting and Learning System has been undertaken to assess whether the NHS is effectively mitigating these risks.
Patient safety incidents (Levels 3, 4, and 5) involving harm from pleural interventions were obtained for the period between April 2018 and March 2022, excluding general anaesthetic procedures. Incidents specifically related to chest drain insertions and pleural effusion aspirations were analysed. Each event was reviewed for its location, timing, evidence of thoracic ultrasound use, equipment used, and the type of harm reported.
Out of 256 incidents, 21 were directly related to pleural interventions and were included for review. Among these, 17 incidents involved direct organ puncture – mostly of the liver – with various drain types used. This raises serious concerns about procedural accuracy.
Only four incidents explicitly reported the use of thoracic ultrasound, while its use was either unspecified or deemed inappropriate in the remainder. Most events (n= 19/21) occurred outside respiratory environments. Two of the 21 relevant incidents resulted in death.
Reflecting on how these findings should be interpreted, study authors pointed to a likely under-reporting of such incidents. ‘The true the amount of harm in the system is likely to be greater than identified and a more detailed investigation is needed,’ they said.
They also noted that the study focused on Level 3 incidents and above, and that re-expansion pulmonary oedema was excluded from the review, which should be included in future evaluations.
Unequivocal in their recommendations for practice, the study researchers urged a nationwide review of local policies and procedures for pleural interventions. This should be prioritised ‘at a national level by specialty groups and societies, whose clinicians deliver pleural intervention’, they said.
Future, similar audits should be larger, more systematic and should clarify whether inadequate ultrasound use, or other factors contribute to these incidents, the authors concluded.
Commenting further on the implications of this study, lead author Dr Andrew Stanton said: ‘This study highlights the importance for teams in all clinical areas treating pleural effusions that ultrasound must be fully embedded in clinical protocols and used appropriately to provide safe intervention.’
His team concluded that stronger adherence to safety protocols and improved training will be key to reducing patient harm, and urge national organisations and NHS Trusts to take proactive steps to improve safety and standardisation in pleural care.
Reference
Stanton AE et al. Pleural procedural safety in the UK: is everyone’s house in order? Reflections from the BTS National Pleural Service Organisational Audit and a national review of patient safety incidents. BMJ Open Respir Res 2025;12:e002840.
2nd April 2025
A new understanding of how aspirin stimulates the immune system to reduce the metastasis of some early cancers could lead to its targeted use to prevent some cancers from spreading, researchers report.
Writing in the journal Nature, the international research team led by the University of Cambridge explained that metastasising cancer cells were vulnerable to attack from the immune system as they were initially deprived of the immunosuppressive microenvironment within established tumours.
This unique vulnerability to immune attack was of interest to researchers seeking to find therapies that could take advantage of this weakness and prevent recurrence in patients with early cancer at risk of metastasis.
Aspirin was an agent of interest, with previous studies showing people with cancer who took daily low-dose aspirin had a reduction in the metastasis of some cancers, however the mechanism behind its anti-metastatic effect was unknown.
In this study, researchers were able to show cyclooxygenase 1 (COX-1) inhibitors, including aspirin, released T-cells from suppression by platelet-derived thromboxane A2 (TXA2), providing a mechanistic basis for aspirin’s anti-metastatic effect.
The discovery began with work to screen 810 genes in mice, with 15 shown to have effect on cancer metastasis and in particular mice lacking a gene that produced the protein Rho guanine nucleotide exchange factor 1 (ARHGEF1) having less metastasis of various primary cancers to the lungs and liver.
After showing that ARHGEF1 suppresses T-cells, the researchers were then able to determine that ARHGEF1 is switched on when T-cells are exposed to the clotting factor TXA2.
Aspirin was already known to reduce the production of TXA2, an action which leads to its to anti-clotting effects and gives it the ability to prevent cardiovascular events.
Given this, the researchers used a mouse model of melanoma to show that in mice who received aspirin, the frequency of metastases was reduced compared to control mice, and this action was dependent on releasing T-cells from suppression by TXA2.
‘Here we show that platelet-derived TXA2, functions as a potent immunoregulatory molecule that suppresses T-cell immunity to cancer metastasis by inducing the immunosuppressive function of ARHGEF1,’ the study authors wrote.
‘Consequently, COX-1 inhibition, including using aspirin, enhances anti-metastatic immunity by releasing T cells from TXA2- ARHGEF1-mediated suppression.’
The findings revealed a novel immunosuppressive pathway that limits T-cell immunity to cancer metastasis and provided mechanistic insights into the anti-metastatic activity of aspirin, potentially paving the way for more effective anti-metastatic immunotherapies, they concluded.
They noted that although aspirin provided a potentially attractive opportunity for anti-metastatic therapy given its low cost, more selective targeting of the TXA2-ARHGEF1 pathway could enable enhanced anti-metastatic activity and/or reduced bleeding risk and gastric toxicity.
Study senior author Professor Rahul Roychoudhuri, professor of cancer immunology in the Department of Pathology at the University of Cambridge, said many patients with early-stage cancers received potentially curative treatment, but later relapsed due to the eventual growth of micrometastases.
‘Most immunotherapies are developed to treat patients with established metastatic cancer, but when cancer first spreads there’s a unique therapeutic window of opportunity when cancer cells are particularly vulnerable to immune attack,’ he said.
‘We hope that therapies that target this window of vulnerability will have tremendous scope in preventing recurrence in patients with early cancer at risk of recurrence.’
Study first author Dr Jie Yang, senior research associate in the Department of Pathology at the University of Cambridge, said it was a ‘Eureka moment’ when the research team discovered TXA2 was the molecular signal that activated the suppressive effect on T-cells.
‘Before this, we had not been aware of the implication of our findings in understanding the anti-metastatic activity of aspirin,’ Dr Yang said.
‘It was an entirely unexpected finding which sent us down quite a different path of enquiry than we had anticipated.’
The researchers plan to help the translation of their work into potential clinical practice by collaborating with Professor Ruth Langley, professor of oncology and clinical trials at the MRC Clinical Trials Unit at University College London, who is leading the Add-Aspirin clinical trial.
Together, they will work to find out if aspirin can stop or delay early-stage cancers from returning.
Professor Langley commented: ‘This is an important discovery. It will enable us to interpret the results of ongoing clinical trials and work out who is most likely to benefit from aspirin after a cancer diagnosis.’
Hospital Healthcare Europe’s Clinical Excellence in Respiratory Care returns in May for a one-day event examining the latest advances in respiratory care – and registration is now open.
Taking place on 7 May, this event for the multidisciplinary team brings together renowned experts from recognised Centres of Excellence and other UK hospitals to share their experiences of clinical innovations, examples of best practice and how they are improving patient care.
This time, topics include modern smoking cessation with discussions around e-cigarettes and vapes from Dr Zaheer Mangera, respiratory consultant and lung cancer lead at North Middlesex University Hospital NHS Trust, and an overview of the role of pathogens in asthma from Dr Ernie Wong, consultant respiratory physician and clinical lead for asthma at Imperial College Healthcare NHS Trust and honorary clinical senior lecturer at the national heart and lung institute, Imperial College London.
Paul Corris emeritus professor of thoracic medicine at Newcastle University and the University of Oxford, will share his take on the when, why and how of lung transplantation, while Sophie West, consultant respiratory and sleep physician at Newcastle upon Tyne NHS Foundation Trust, will discuss the future of sleep medicine with a focus on diagnostic wearables and artificial intelligence.
This year’s spring respiratory care offering has been developed by the team at Hospital Healthcare Europe and Hospital Pharmacy Europe with guidance from industry experts.
The event is free to attend and comprises individual presentations and sponsored sessions delivered virtually live and on-demand, all tailored to provide maximum convenience and work around your busy schedule.
Select sessions most relevant to your clinical practice, specifically tailoring the day to your needs, and gain CPD hours from the comfort of your computer.
With a whole host of fascinating insights and inspiration for improving patient care, it’s not to be missed. Register now to join us for Clinical Excellence in Respiratory Care on 7 May and on demand in Hospital Healthcare Europe’s Clinical Excellence Catch-up zone.
You can watch a selection of previous Clinical Excellent event sessions in the Catch-up zone now, as well as being able to access a whole host of additional long-reads and interviews with prominent clinicians from Centres of Excellence and beyond in the Respiratory zone – look out for the orange Clinical Excellence tag.
This content includes a two-part series from Dr Mangera on the lung cancer pathway, focusing on early diagnosis and screening and neoadjuvant therapy.
And an interview with Professor Andy Bush, sees the eminent consultant paediatric chest physician at London’s Royal Brompton Hospital, sharing his career highlights, his passion for improving children’s respiratory health and campaigning to ban the promotion of e-cigarettes to young people, as well as his research into the early origins of asthma.
The autumn schedule for Clinical Excellence will be announced soon, so watch this space.
27th March 2025
Mechanical aortic heart valves have an improved long-term survival benefit over biological heart valves for patients aged 50-70 years, according to a new study.
Current international cardiothoracic clinical guidelines advise mechanical aortic valve replacement for patients younger than 50 years and biological valves for those above 65 or 70 years of age.
Between the ages of 50 and 70, decisions rest largely on patient and surgeon preferences. Increasingly, patients in this middle range are now receiving biological prostheses, driven by the rise of transcatheter surgical techniques and the desire to avoid long term anticoagulation. However, uncertainty exists on the long-term outcome data associated with biological aortic valve replacement.
A recent UK study set out to explore this uncertainty around mechanical or biological aortic valve selection for this patient cohort.
The primary endpoint was to compare long-term survival for those receiving either mechanical or biological valves. Secondary endpoints focused on short-term outcomes, reintervention rates and how valve size and patient–prosthesis mismatch influenced long-term results.
All patients aged between 50 and 70 years who had isolated surgical aortic valve replacement at the Bristol Heart Institute between 1996 and 2023 were included. Data from 1,708 patients were analysed, of whom the majority (69.7%) received a biological valve.
Patients receiving mechanical valves tended to be younger, had a lower incidence of diabetes, and were less likely to have undergone percutaneous coronary intervention. They demonstrated better long-term survival than those who received biological valves, yet reintervention rates did not significantly differ between the two groups.
The long-term survival benefit conferred by mechanical aortic prostheses was especially apparent in smaller valve sizes, with a 19 mm mechanical valve providing better long-term survival than both 19 mm and 21mm bioprosthetic valves, and equivalent to 23 mm bioprosthetic valves.
The authors noted that, based on these results, ‘the risk associated with root enlargement and implanting a larger-sized valve could be avoided’.
The study also found that severe patient-prosthesis mismatch was a significant risk factor for poor long-term survival. Expanding on this, the authors surmised: ‘The reduced survival with 19 mm and 21mm bioprosthetic valves is likely secondary to patient-prosthesis mismatch and the resultant effects.’
Its status as a single-centre study, reliance on retrospectively gathered data and absence of randomisation may contribute to potential biases in this research, the authors noted.
Nevertheless, they considered their findings important for future policy and practice regarding the choice of mechanical versus biological aortic valve replacement. ‘Our study underscores the need for a critical re-evaluation of prosthesis selection strategies in this age group,’ they concluded.
Reference
Chan J et al. Long-term clinical outcomes in patients between the age of 50–70 years receiving biological versus mechanical aortic valve prostheses. Eur J Cardiothorac Surg 2025 Feb 4;67(2):ezaf)33.
A newly developed immunoglobulin E (IgE) antibody stimulates the immune system to target cancer cells and slow tumour growth, a study finds, potentially offering new therapy options for treatment-resistant breast and ovarian cancers.
Anti-human epidermal growth factor receptor 2 (HER2) immunoglobulin G1 (IgG1)-based antibody therapies, such as trastuzumab and pertuzumab, were first-line therapy for patients with high tumour expression of HER2.
However, tumours could be resistant to the fragment antigen-binding (Fab)-mediated effects of these IgG1-based antibody therapies, limiting clinical response.
This resistance has prompted researchers at King’s College London to find alternative ways to activate the immune microenvironment. Given these resistant tumours usually retained detectable cell surface levels of HER2 it was thought they would respond to a different type of anti-HER2 therapy, the researcher wrote in the Journal for ImmunoTherapy of Cancer.
Previous studies have shown immunoglobulin E (IgE)-based therapies, which harnesses a distinct arm of the immune system, could significantly reduce tumour burden in in vivo clinical models, including melanoma and ovarian cancer.
In 2023, a clinical trial of a first-in-class IgE antibody known as Mov18 IgE indicated tolerability, with evidence of anticancer activity in one patient with ovarian cancer.
In this latest study, the researchers generated anti-HER2 trastuzumab-equivalent and pertuzumab-equivalent IgE antibodies and conducted both in vitro and ex vivo assessments where they were able to observe immune-mediated and immunomodulatory functions of IgE.
As part of the investigations, they also analysed the effects of the therapies in two trastuzumab-resistant HER2 tumour xenograft models in mice, finding the trastuzumab-equivalent anti-HER2 IgE restricted tumour growth.
Treatment was associated with enriched classical monocyte and lower alternatively-activated macrophage infiltration, they reported, and higher densities of activated CD4+ T-cells and favourable effector T-cell to regulatory T-cell ratios in tumours.
‘Collectively, anti-HER2 IgE maintains Fab-mediated antitumor activity, induces Fc-mediated effects against HER2-expressing tumour cells, and stimulates remodelling of the immune microenvironment in tumours to promote pro-inflammatory cell phenotypes which could translate to improved outcomes for patients,’ the researchers wrote.
Senior study author Dr Heather Bax, postdoctoral research fellow at St John’s Institute of Dermatology at King’s College London, said around 20% of breast and ovarian cancers expressed HER2 and therefore IgE has potential as a new therapy, particularly fot those whose cancers don’t respond to existing therapies.
‘By generating anti-HER2 IgE antibodies equivalent to the clinically used IgGs, for the first time we demonstrate that IgEs harness unique mechanisms to reprogramme the immune microenvironment, switching immune cells to effectively target HER2-expressing cancers, including those resistant to existing therapies,’ she said.
‘Our findings indicate that IgE antibodies could offer a potential new therapy option for patients with HER2-expressing cancer.’
Study co-author Professor Sophia Karagiannis, professor of translational cancer immunology and immunotherapy at the same institution, said after generating a panel of IgE antibodies and studying them in different tumour types, the team consistently found that the human immune system reacted in the presence of IgE to restrict the growth of cancer.
‘The findings of our latest study speak to the potential of applying IgE to stimulate effective responses against hard-to-treat solid tumours,’ she said.
‘This new class of drugs holds promise to benefit different patient groups and opens a new frontier in the battle against cancer.’
The researchers believe that, with the right investment and development, this approach could be used in humans in as soon as three to five years.
The greatest threat to artificial intelligence (AI) uptake across the healthcare system is the ‘off switch’ if clinicians do not see the benefit of it, a new white paper has suggested.
If clinicians see the technology as burdensome, unfit for purpose or are wary of how it will impact on their decision-making, their patients or their licenses, they will not use it, the white paper said.
Published by the research initiative MPS Foundation, which is part of Medical Protection Society, the white paper looked at the impact of AI on clinicians, building on the results of its Shared CAIRE (Shared Care AI Role Evaluation) research project.
It also highlighted a concern that clinicians would absorb legal responsibility for AI-influenced decisions, even when the systems themselves could be flawed.
The report said: ‘We are at a turning point in the deployment of medical AI, as it moves from the margins to the mainstream of healthcare delivery. To unlock and realise AI’s potential for patients, it is essential that we implement and deploy AI technologies in ways that work for those using them – the clinicians.
‘If we fail to do so, we risk exacerbating the very challenges AI is supposed to address: clinician burnout, inefficiency and uneven patient experiences and outcomes.’
It outlined seven recommendations for the the Government and regulators to consider when developing new healthcare AI policy guidance:
‘This white paper proposes recommendations which address the impact of decision-support tools on clinicians. The greatest threat to AI uptake in healthcare is the “off” switch, if frontline clinicians refuse to engage with technology they see as burdensome or unfit for purpose,’ the white paper said.
‘Given competing priorities for funding, political pressures and the need for good governance, it is more vital than ever to focus resources on AI solutions which will generate the most benefit. It is by understanding how AI can genuinely support clinicians that this benefit will most likely be achieved.’
Commenting on the white paper, Professor Gozie Offiah, chair of the MPS Foundation, said: ‘Healthcare is undergoing rapid change, driven by advances in technology that could fundamentally impact on healthcare delivery. The potential opportunities provided by AI are only limited by one’s imagination.
‘There are however real challenges and risks that must be addressed. Chief among those is the need for clinicians to remain as informed users of AI, rather than servants of the technology.’
She added: ‘If AI works well for clinicians, they are more likely to embrace and interact with it, and this will be vital in unlocking benefits to patients. We have written to the regulators and the Government minister to urge them to take on board these important recommendations.’
Along with MPS Foundation, the white paper was also a collaboration with the Centre for Assuring Autonomy at the University of York, and the Improvement Academy hosted at the Bradford Institute for Health Research.
It comes shortly after NHS Shared Business Services announced a new AI framework to optimise clinical workflow.
In October, the University of Cambridge appointed Professor Raj Jena as the UK’s first clinical professor of AI in radiotherapy, signalling a need for, and a commitment to, utilising AI in the fight against cancer.
Last summer, a survey from the Health Foundation found that NHS staff and patients were split on the use of AI in healthcare.
A version of this article was originally published by our sister publication Healthcare Leader.
26th March 2025
Unlocking the key to early prevention of rheumatoid arthritis would be a real game-changer and researchers have found what could be central to this: enhancing the gut microbiome. Dr Chris Rooney and Professor Kulveer Mankia, experts in medical microbiology and rheumatology respectively, speak to Julie Penfold about their latest research and how their findings could positively impact clinical practice and optimise patient care.
The gut microbiome is the largest and most complex microbiome in the human body and understanding of its importance in health is increasing exponentially, with research into its impact on multiple conditions ramping up.
Dr Chris Rooney, medical microbiologist at Leeds Teaching Hospitals NHS Trust and clinical lecturer in microbiology at the University of Leeds, has a longstanding interest in the dynamics of the gut microbiome in inflammatory diseases, particularly rheumatoid arthritis.
A perfect storm of contributing factors led to an ideal opportunity to carry out a longitudinal study into the dynamics of the gut microbiome in patients at risk of developing rheumatoid arthritis and work for the pilot study began in 2017/18.
‘The fact that [the gut microbiome is] constantly lying on the mucosal surface, so there’s always that interaction with the immune system, was a real area of interest,’ Dr Rooney explains. ‘When we began the initial work for this study, sequencing technologies were becoming more widely available and less costly so there was a culmination of my own interest and advancing science at the time.
‘Additionally, Leeds has a strong background in musculoskeletal research and a very unique cohort of individuals that are at risk of rheumatoid arthritis. We rarely can study a disease before its onset, so it was a very unique opportunity to see how the gut microbiome can influence or be influenced by the development of this disease.’
Professor Kulveer Mankia, professor of clinical and translational rheumatology at the University of Leeds and a consultant rheumatologist at Leeds Teaching Hospitals NHS Trust, brought his internationally renowned expertise in rheumatoid arthritis risk factors and early diagnosis to Dr Rooney’s research.
‘We’re getting much better at being able to predict rheumatoid arthritis development in at-risk patients,’ he explains. ‘The main risk factor is having [cyclic citrullinated peptide] CCP antibodies along with joint pain and joint stiffness. We’re now able to use this to inform therapeutic studies with the aim of preventing or intercepting rheumatoid arthritis onset.’
Interception therapy can include giving patients a six-month or one-year drug treatment, then stopping this and assessing whether it’s had an impact on halting the disease progression.
‘There’s been a handful of trials published looking at pharmacotherapies, including the biologic medication abatacept, and also methotrexate and hydroxychloroquine,’ Professor Mankia explains. ‘We’ve seen encouraging results particularly with abatacept showing that you can certainly delay disease progression significantly. It appears to be able to prevent arthritis onset in a subgroup of patients too.’
Patients at risk of rheumatoid arthritis who are experiencing initial symptoms may feel a sense of hopelessness that developing arthritis is inevitable. But Dr Rooney and Professor Mankia’s longitudinal study identified that there are signs in the gut microbiome that can indicate rheumatoid arthritis in evolution several months before a patient will go onto develop the condition, which may mean steps can be taken to halt progression.
‘There have been a number of studies that have shown if you have established rheumatoid arthritis, your gut microbiome is different,’ Dr Rooney explains. ‘But we wanted to learn whether individuals who were at risk of rheumatoid arthritis had a different gut microbiome. In Leeds, we had the unique ability to study this via longitudinal sampling to allow us to see changes over time.’
This change is something that hasn’t previously been studied due to the dynamic nature of the gut microbiome, he says, adding that ‘if you measure your microbiome today and in a month’s time, it will be roughly the same, but it won’t be exactly the same.’
As part of their research study, 19 patients who were at risk of developing rheumatoid arthritis provided five samples over a 15-month period. This enabled Dr Rooney to track changes in their gut microbiome and assess how this translated to disease onset.
‘What we found is that individuals who are at risk of rheumatoid arthritis have an increase in specific strains of prevotella bacteria, which is associated with their underlying risk profile,’ he explains.
Five patients progressed to having clinical rheumatoid arthritis over the study period. The sampling showed they had gut instability, with higher amounts of bacteria, including prevotella, approximately 10 months before the arthritis developed.
Interestingly, the remaining participants who did not progress to rheumatoid arthritis had largely stable amounts of bacteria in their gut.
The aim is to take these observations forward and develop personalised interventions to prevent rheumatoid arthritis onset and progression, explains Professor Mankia.
‘If we can understand microbiome changes that underpin the development of rheumatoid arthritis and compare those to people who appear safe from progression, this would hopefully lead to an interventional approach,’ he says.
‘Once we pin those changes down, we could introduce an intervention such as a probiotic treatment that could shift the microbiome in a favourable direction. I think that’s where this research would be heading towards.’
There are also parallels with other mucosal sites, Professor Mankia adds, particularly with the oral cavity and how this may relate to rheumatoid arthritis onset and the potential for personalised treatment approaches for those at risk.
This could include potentially sampling multiple mucosal sites to see where there are abnormalities and what the target might be for an intervention. For example, opting for a combined gut-oral approach, or focusing more on one site depending on a patient’s individual profile and preference.
‘It could also be an approach that works in parallel with drug treatments,’ says Professor Mankia. ‘The aim is to be able to personalise treatment to offer different types of interventions that are tailored to a patient’s particular situation and risk factors.’
For Dr Rooney, this aligns with his current research into functional changes in the gut microbiome of individuals at-risk of rheumatoid arthritis, looking at the molecules and substances that are either lacking or overabundant.
‘We want to see whether if we change the gut microbiome itself, not just supplementing the molecules, whether this would make a difference,’ he explains. This could be through introducing new strains of bacteria or making changes to an individual’s diet, for example, and it’s where we would like to go with our research.’
In rheumatology, there is a strong interest in non-pharmaceutical approaches to autoimmune condition management. This is being driven by patients asking for a different approach to taking a pill or having an injection, Professor Mankia says, which may relate to concerns about the risk of side effects with rheumatoid arthritis drug treatments.
Clinicians are also becoming increasingly aware of dietary factors and the role they potentially play in autoimmune disease. For example, omega 3 and vitamin D levels and following a low salt diet.
‘These areas, including the links between rheumatoid and periodontal disease, are all growing in terms of the data, and this research very much adds to the evidence that’s emerging,’ explains Professor Mankia. ‘For practising clinicians, I think it’s just having an awareness of those other factors that could be driving autoimmune disease. Being aware that, as we go forward, there will be more data around non-pharmaceutical approaches so they can advise patients about these right from the beginning of their disease.’
Professor Mankia is currently recruiting patients for a drug trial that will test the efficacy of a Janus kinase inhibitor in people at high risk of rheumatoid arthritis. The aim of the trial is to see if the drug prevents disease onset. He is also involved in research looking at the changes that occur in the immune system when patients go from being at risk to developing rheumatoid arthritis.
‘It’s then bringing all this together into understanding how the mucosal surfaces and the microbiome interact with the circulating immune system, and, ultimately, how this affects the joints and tissues that become inflamed and damaged with rheumatoid arthritis,’ Professor Mankia adds.
24th March 2025
The National Child Mortality Database report on child deaths related to asthma and allergies was released in December 2024, providing sobering insights. Ravijyot Saggu offers an expert summary, emphasising key points from the thematic report and discussing necessary future actions.
One in 11 children and young people in the UK has asthma and it is the most common long-term medical condition in children in the UK.1 Additionally, the UK has one of the highest rates of prevalence, emergency admission and death for childhood disease in Europe, and children and young people living in the most deprived areas are the most severely affected.2
The National Review of Asthma Deaths (NRAD) ‘Why asthma still kills’ report from 2014 was a landmark publication.3 Among the nearly 200 deaths reviewed, 28 involved children and young people under 20 years of age. Key findings in this review emphasised that most of these children and young people died before reaching the hospital, with 46% receiving inadequate asthma care. Exposure to second-hand smoke and allergies – especially seasonal allergies – were also contributing factors.
As a result, several recommendations were made to improve asthma care and prevent future deaths for adults, children and young people. Since then, there has been some progress and key changes, including implementation of personal asthma action plans (PAAPs), creation of the National Bundle of Care for Children and Young People with Asthma4, and the publication of the National Capability Framework for Professionals who care for Children and Young People with Asthma and associated training.5
Despite being a decade on from the NRAD report, a high proportion of modifiable factors in asthma deaths continue to be identified by child death overview panels (CDOPs).
The recent National Child Mortality Database (NCMD) thematic report6 analysed deaths over a four-year period from April 2019 to March 2023 in children with confirmed or suspected asthma as the cause of death. The 54 deaths recorded during this period represent approximately one child death from asthma every four weeks.
A range of observations were outlined in the report, covering details such as demographics, risk factors and healthcare contact and medications in the lead up to their deaths.
Mortality was higher in the 15-17-year-old group, followed by the 10-14-year-old group, with the death rates for boys double those of girls.
When it came to geography and deprivation, mortality rates were higher in urban areas than in rural ones, but child death rates in the most deprived areas of England were four-times greater than those in the least deprived areas.
This echoes previous data which have shown that children living in the poorest 10% of areas are up to four times more likely to have an emergency hospital admission compared to those in the least deprived 10%.7
Premature birth and low birth weight are recognised risk factors for asthma. Of the recorded asthma deaths in the NCMD report, 27% of children were born before 37 weeks of gestation or had a lower birth weight.
Seasonality was also observed. Deaths occurred throughout the year in descending order from winter to spring, autumn and then summer, and outdoor air pollution at the home or school was also highlighted as an issue in the deaths.
Risk factors resulting from the home environment were noted as contributory factors, such as overcrowding, excessive mould and dust, pets and dirty, tobacco smoke-filled houses. Indeed, parental or caregiver smoking was reported in 32 reviews and parental drug misuse, including cannabis smoking, was also noted in some cases. Substance misuse by the child was recorded in four reviews, with others identifying child smoking or vaping as contributing factors.
Safeguarding issues (34%), abuse and neglect (13%), and domestic violence (28%) were also recorded.
In total, 65% of the children visited the emergency department or experienced an emergency hospital admission at least once in the year before their death. Some deaths occurred due to cardiac arrest, predominantly outside of hospitals, with 29 children (58%) having unsuccessful cardiopulmonary resuscitation.
When it came to treatment history, 87% of children had three or more dispensed short-acting beta agonist (SABA) inhalers, such as salbutamol, or relievers in the year before their death, with 50% using 12 or more.
It is well known that having more than two SABA inhalers within 12 months is a red flag. As with adults, overuse of SABA is linked to an increased risk of asthma attacks and deaths, suggesting poorly controlled asthma.
Similar to the NRAD report, a lack of adequate inhaled corticosteroid prescriptions was identified as a factor, with 65% of children receiving fewer than nine inhalers dispensed in the year before their death. What’s more, the lack of dose counters on salbutamol metered dose inhalers (MDIs) was implicated as a contributory factor for fatal outcomes.
Service provision includes adherence to guidelines, pathways, and policies. However, issues arose due to a lack of PAAP, insufficient communication between or within services and families, failure to recognise child deterioration, and treatment delays. In five cases, no formal asthma diagnosis was made, yet relievers were prescribed.
The NCMD report also analysed the 19 child deaths due to anaphylaxis during the same period from April 2019 to March 2023.
In five of the deaths, the causes were attributed to both asthma and anaphylaxis. The highest death rate occurred among children aged 15-17 years, followed by those aged 10-14 years, with similar numbers of deaths reported for both females and males.
There were 21 completed reviews of deaths due to anaphylaxis, including cases of children who died before 1 April 2019. Some 76% of the reviews identified at least one modifiable factor. Most children (95%) had known allergies, with the most common food allergies recorded as being nuts – including tree nuts and peanuts – followed by cows’ milk, eggs and seafood. The most prevalent allergens for non-food allergies were house dust, pollen (including tree pollen), grass and animals.
Although the nature of the allergen may not be obvious, it is important to always consider anaphylaxis in someone with a known food allergy who has sudden breathing difficulties, particularly in children with asthma. People with both asthma and allergies are at a higher risk of having a more severe allergic reaction.
Learnings from the CDOPs showed that allergy symptoms were not always communicated to healthcare professionals. However, they should be enquired about during asthma reviews, and food allergy-specific questions should be included in these reviews.
In instances of anaphylactic reactions, only half of the children received an adrenaline autoinjector, and in other cases, the injection was either expired or of suboptimal strength – even in school settings – or not administered.
CDOPs recorded factors related to public safety in a third of the anaphylaxis reviews. Of those, the most common factor was unclear, misleading, or inaccurate food labelling (either packaged or cooked, bought from supermarkets or takeaways).
While NCMD analyses may have limitations and review small numbers of deaths, they highlight significant themes of concern.
Recommendations for key areas of improvement centre around seven domains:
Child deaths from asthma and allergies are preventable. At the time of writing, the National Bundle of Care for Children and Young People with Asthma is currently under review and set to be updated. It serves as a valuable tool for facilitating change, yet more still needs to be done.
Timeliness, knowledge and communication are key areas for improvement. All staff responsible for children with asthma should complete training according to the National Capability Framework for Professionals who care for Children and Young People with Asthma.5
Encouraging smoking cessation, including use of vapes, in parents – and children where this is occurring – to reduce child exposures and improve air quality is important, as is raising concerns sensitively if there are any suspected safeguarding factors.
The British National Formulary and the British National Formulary for Children have recently been updated to include information alerting healthcare professionals to the dangers of inhalers without dose counters and the advice they should provide. The MHRA is working to ensure an integral dose counter is included for future pressurised metered dose inhalers (pMDIs).
All healthcare staff, especially prescribers and pharmacy staff, should review prescribing records to identify patterns of overuse of SABA and underuse of inhaled corticosteroid prescriptions for patients with asthma.
They should also include questions about food allergies in asthma reviews. Additionally, they are well positioned to counsel patients and caregivers of children and young people on the appropriate use of inhalers and approximately how long they should last, using the dose counter (where available) as a guide for usage and when to reorder prescriptions. This is important as without a dose counter there is no reliable way to check how much medicine is left within the inhaler. Methods such as shaking or attempting to float the inhaler cannister are not reliable or recommended.
If the MDI does not have a dose counter, it is important to emphasise that the inhaler may feel and sound like it contains medicine, even appearing to emit upon actuation. However, this is only propellant gas, not medicine, and therefore they should not use the effectively ‘empty’ inhaler.
Adhering to therapy and regularly checking the expiry dates to ensure medications are current is essential. This is also applicable to adrenaline autoinjectors which have an expiry date of roughly one year from dispensing and are unlikely to be used regularly. Expiry checks are additionally important if inhalers or adrenaline autoinjectors are stored in different locations for example, at home, school or other family locations.
Any expired or unwanted inhalers should be returned to pharmacies for correct disposal and/or recycling, where applicable. Having a PAAP, understanding how to use it, and recognising the symptoms of early deterioration, such as asthma or anaphylaxis, is crucial for timely intervention.
The recent joint national UK asthma guidelines8 are expected to reduce reliance on SABA and promote better asthma care by encouraging the use of inhalers with integral dose counters.
Ravijyot Saggu
Respiratory pharmacist, London, UK, chair of the UK Clinical Pharmacy Association Respiratory Committee and NICE medicines and prescribing associate
Medication errors frequently occur in emergency departments (EDs), placing a burden on both patients and healthcare systems. Enhanced integration of pharmacists to multidisciplinary ED teams could alleviate physician workload and improve patient care and safety, a recent study has found.
This qualitative study explored physicians’ experiences of collaborating with pharmacists who joined emergency ED teams in two Norwegian hospitals, while also gauging their views on making such collaboration permanent.
The researchers conducted semi-structured interviews with 20 physicians of varying seniority and specialties. Thematic analysis identified four main themes in which deploying pharmacists in the ED:
However, respondents noted several challenges relating to these themes, including misaligned physician-pharmacist work hours, could limit pharmacists’ availability; space constraints for pharmacists to conduct their tasks; and ambiguities regarding responsibility for medication reconciliation.
Despite trusting pharmacists, some physicians felt uneasy about signing off on medication changes they didn’t perform. This revealed a cultural gap: pharmacists meticulously addressed every detail, while physicians didn’t always consider this necessary. Some favoured a shared-responsibility model, whereas others believed ultimate accountability rests with the physician who signs the chart.
Despite these challenges and their need for attention and solution, the authors concluded that pharmacists should be permanently integrated into ED teams.
One physician participant emphasised the quality-of-care benefits of this approach, saying: ‘It decreases the chance of medication errors. It is, quite frankly a quality assurance, I think. And it has happened many times… that there have been errors in the medication list at admission. Having pharmacists decreases the risk of that. Guaranteed.’
Commenting on how their work furthers the discourse on extended roles and responsibilities of hospital pharmacists, the authors said: ‘Authorities should recognise and leverage pharmacists’ knowledge and competencies, taking appropriate steps empower pharmacists to compile medication lists in EDs.’
They also noted how future work on this topic should address technical barriers to implementation, clarify professional responsibilities and provide adequate workspace to sustain meaningful interprofessional collaboration.
Reference
Johnsgård T et al. Physicians’ experiences with pharmacists as new members of the interprofessional emergency department team. A qualitative study. PLOS ONE. 2025;20(1): e0317298.
This article was originally published by our sister publication Hospital Pharmacy Europe.
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