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Take a look at a selection of our recent media coverage:
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 inquired 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.
21st March 2025
A recent study examining the viability of a temperature-controlled ablation system for ventricular tachycardia found that using a temperature-controlled irrigated radiofrequency ablation catheter was safe and effective, with a low rate of recurrence at six months.
Tissue temperature is a key factor in creating successful lesions when catheter ablation using radiofrequency energy is performed. However, due to the cooling effect of saline irrigation, it is difficult to measure during conventional radiofrequency ablation.
The TRAC-VT study tested the use of an irrigated radiofrequency ablation system that modulates power levels based on real-time tissue temperature.
Temperature-controlled irrigated radiofrequency could reduce the risk of overheating during catheter ablation, particularly where longer ablations were required for deeper lesions.
The researchers enrolled 38 patients (68 ± 12 years of age and 84% male) with sustained monomorphic ventricular tachycardia and structural heart disease. The patients had an average of 1.7 ± 1.2 ventricular tachycardias targeted per patient.
Catheter ablation was performed in temperature-control mode, with a saline irrigation rate of 8ml/min and temperature set points of 55 or 60°C, power output ≤ 50 W and radiofrequency application time of up to 45 seconds per application.
The patients were monitored for heart-related conditions for 30 days after the procedure. In addition, the researchers determined efficacy through ‘acute success’ when the clinicians could no longer induce relevant ventricular tachycardias after the procedure.
Each patient received an average of 41 radiofrequency ablation applications. The procedure was successful in 100% of cases, with no adverse safety concerns.
At six months follow-up, which was completed in 92% of patients, 81% of patients remained free from ventricular tachycardia, with just three patients needing a repeat ablation due to ventricular tachycardia recurrence.
The findings confirmed that the novel temperature-controlled radiofrequency ablation system was safe and highly effective, with a low rate of ventricular tachycardia recurrence at six months.
The researchers said further direct comparative studies to other ablation technologies may help elucidate the potential clinical benefits of a temperature-controlled radiofrequency ablation strategy for the treatment of ventricular arrhythmias.
Reference
Kautzner, J et al. Safety and efficacy of a temperature-controlled ablation system for ventricular tachycardia: Results from the TRAC-VT study. J Interv Card Electrophysiol 2025; Feb 01: DOI: 10.1007/s10840-025-01995-z.
20th March 2025
There has been a significant lack of progress in improving survival rates for muscle-invasive bladder cancer, even with radical treatment, and delays in receiving definitive treatment are common. Professors Rik Bryan and Nicholas James – collaborators on the recent BladderPath trial – explain how incorporating an image-directed pathway prior to standard care significantly reduces the time to correct treatment and improves outcomes for these patients.
Bladder cancer is the tenth most common cancer worldwide, responsible for 3% of annual cancer cases and 2.1% of cancer-related deaths, while also imposing high healthcare costs.1–3
Standard management approaches include outpatient flexible cystoscopy, followed by transurethral resection of bladder tumour (TURBT),4 which is derived from a pathway established over a century ago.5
TURBT is the preferred treatment for non-muscle-invasive bladder cancer (NMIBC), frequently removing the tumour(s) completely and followed by single or multiple doses of adjuvant intravesical therapy directly into the bladder.4
However, for patients with muscle-invasive bladder cancer (MIBC), TURBT is a hybrid diagnostic and partial staging procedure (See Table 1) that needs to be followed by correct treatment with more radical therapies such as systemic chemotherapy, chemoradiotherapy or cystectomy.6,7
Table 1: Staging conventions for non-invasive and invasive bladder cancer
T = tumour
While TURBT is generally well-tolerated, a minority of patients experience significant complications –including bladder perforation or haemorrhage – with the need for extended hospitalisation. TURBT also frequently under-stages the depth of invasion, with up to 30% of MIBCs initially staged as NMIBC.8 There are also concerns that TURBT could lead to tumour dissemination through bladder perforation or venous emboli generated by the piecemeal resection process.9
In contrast to many cancers, the survival rates for MIBC have not improved in over 30 years.2 These poor outcomes may reflect, in part, slow diagnostic pathways. TURBT significantly contributes to this delay, regardless of the healthcare structure.
For instance, in the UK, patients with MIBC waited an average of 144 days from GP referral to radical therapy between 2013 and 2016, according to NHS data.10 Additionally, a national audit reported that 48% of patients waited more than 180 days from diagnosis to cystectomy between 2017 and 2019.11
In the US, patients waited an average of 69 days from TURBT to starting radical treatment (the time from referral to TURBT is unknown),12 whereas in Canada, the wait was up to 56 days to see a urologist before TURBT,13 followed by an additional 65 days from TURBT to cystectomy.14
The situation is worse for women, who are frequently initially misdiagnosed with bacterial cystitis and see their GP up to five-times more than men before urological referral.13,15
In stark contrast, UK patients with breast cancer averaged 40 days from referral to treatment between 2013 and 2018.16 These delays contribute to worse prognoses for patients with MIBC.12,17
A better approach could be to separate NMIBC from MIBC patients early in the care pathway. MIBC patients could then receive faster, more accurate modalities for local staging and expedited correct treatment.18 This could improve outcomes and reduce clinical costs.
Imaging advances show that multiparametric magnetic resonance imaging (mpMRI) enables precise differentiation between NMIBC and MIBC,19,20 theoretically providing a safer and faster path to the appropriate treatment than TURBT.
With cystoscopic assessment of tumours accurate in predicting lower grade and stage NMIBCs,21 triage of patients into likely NMIBC or possible MIBC early in the diagnostic pathway is possible and complemented by small tumour biopsies obtained during flexible cystoscopy that yield enough material to permit histopathological diagnosis. Such an approach is rational and aligns with the diagnostic pathways of other malignancies
We undertook the BladderPath randomised controlled trial to investigate whether MIBC patients can be safely expedited to correct treatment using an outpatient biopsy and mpMRI for local staging rather than TURBT. The primary outcome of the trial was time to correct treatment (TTCT).22
The study’s novel aspects included the randomised comparison of clinical pathways, rather than comparing the sensitivity and specificity of TURBT or mpMRI. It also emphasised the use of clinicians’ expertise in distinguishing NMIBC from MIBC during cystoscopy to facilitate early patient management in the clinical pathway.
The study randomised 143 patients with suspected MIBC to one of two pathways:
In an initial feasibility stage of the study, 36 of 39 possible MIBC participants (92%) in Pathway 2 underwent mpMRI post-randomisation and the overall proportion of participants who correctly followed their respective protocol pathway was 96% in each pathway.
Given the potential benefits of an outpatient-based diagnostic pathway during the Covid-19 pandemic, feasibility data from the BladderPath trial were published online in February 2021.18
In the main stage of the study, the median TTCT for the mpMRI pathway was 53 days – some 45 days sooner than the median TTCT for the conventional TURBT pathway (98 days; P = 0.02).22
Importantly, this time reduction occurred without affecting NMIBC patients whose TTCTs were no different between the two pathways (P = 0.668).22
Furthermore, when evaluating the TTCT for all patients, the mpMRI pathway was again significantly quicker. The median time for the mpMRI pathway was 25 days compared to 37 days for the TURBT pathway (P = 0.030).22
We demonstrated that an mpMRI-based pathway resulted in patients with MIBC receiving correct treatment over six weeks sooner without negatively impacting the TTCT for NMIBC patients.22
It would be reasonable to surmise that this ‘expedited’ management of MIBC patients would lead to survival advantages, potentially reversing the 30-year stagnation in outcomes for bladder cancer patients.
With initial outpatient cystoscopic triage, any impact on departmental MRI workload remains relatively modest. It should also be noted that a proportion of patients in the mpMRI pathway still underwent TURBT for various reasons following mpMRI, such as assessment of carcinoma in situ and debulking prior to radiotherapy, without compromising TTCT.
With accurate staging information before TURBT, these procedures can be assigned to the appropriate surgeon and prioritised to meet the needs of MIBC patients.
We recommend considering the incorporation of mpMRI ahead of TURBT into the clinical pathway for all patients with suspected MIBC. This approach may allow TURBT to be avoided in some patients and enhance decision-making, resulting in faster treatment initiation. Consequently, this could lead to improved long-term outcomes, and we await further data on this.
Richard Bryan MBChB PhD MRCS FAcadTM
Professor in urothelial cancer research and director of the Bladder Cancer Research Centre at the University of Birmingham, UK
Nicholas James MBBS PhD FRCP FRCR
Professor of prostate and bladder cancer research at the Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
19th March 2025
Dilated cardiomyopathy is diagnosed twice as often in males than in females. A new three-part study, which included a systematic literature review, meta-analysis and a population study, examined the reasons behind this.
The researchers considered whether dilated cardiomyopathy is more common in one sex than the other, how genetics contribute to this difference, and whether diagnostic practices account for any differences between the sexes.
The findings revealed that the sex ratio disparity of diagnoses arose from a combination of underdiagnosis in women and a greater susceptibility for men, driven by additional genetic or environmental factors that increase disease manifestation in genetically predisposed individuals.
The researchers examined multiple data sources to identify potential biases or biological influences on disease prevalence. A literature search identified existing studies with sex ratio data for patients with dilated cardiomyopathy.
Meta-analysis and metaregression analysis were used to compare the proportion of female participants in an overall dilated cardiomyopathy cohort and the following subtypes: all genetic, individual selected genes (TTN and LMNA), and gene-elusive.
In addition, population dilated cardiomyopathy sex ratios were analysed from diagnostic codes and compared with those obtained from sex-specific means, such as International Classification of Diseases-coded, novel imaging-first, and genotype-first data from the UK Biobank imaging cohort.
Considering 99 studies, the researchers analysed data from 37,525 participants with dilated cardiomyopathy, 30% of whom were female, giving a male-to-female ratio of 2.38:1.
Within subgroup cohorts, similar patterns emerged. In patients with identified dilated cardiomyopathy genetic variants, the male-to-female ratio was 2.22:1. For patients with no genetic variants, the male-to-female ratio was 2.29:1.
The UK Biobank data showed a 4.5:1 ratio of men to women with dilated cardiomyopathy. However, when the researchers used sex-specific diagnostic techniques, such as imaging-first and genotype-first diagnostic approaches, the ratios changed to 1.7:1 and 2.3:1, respectively.
The results showed that the condition is more common in men, and, even after adjusting diagnostic criteria to account for sex, the male predominance in the development of the disease persists.
The researchers suggested that future work should evaluate sex-specific dilated cardiomyopathy diagnostic criteria and examine the genetic, reproductive and environmental factors contributing to differences in disease risk in male and female patients.
Reference
Bergen, N et al. Systematic Review, Meta-Analysis, and Population Study to Determine the Biologic Sex Ratio in Dilated Cardiomyopathy. Circulation 2025; Feb 03: DOI: 10.1161/CIRCULATIONAHA.124.070872.
17th March 2025
Women aged 50 or older, who are three years post-breast cancer diagnosis and cancer-free, show non-inferior results when given less than annual mammography compared to annual screening, a new study has revealed.
Less frequent breast cancer screenings were found to be equally effective in terms of breast cancer-specific survival, recurrence-free interval and overall survival. These findings suggest that leaving more time between mammograms could be a suitable option for this group of women.
The research was undertaken as part of Mammo-50 – a phase three randomised trial running across 114 NHS hospitals in the UK. Between 2014 and 2018, some 5,000 women who had undergone curative surgery were randomly assigned to a cohort of either annual mammography (n=2,618) or less frequent mammography (n=2,617), with a median follow-up of 5.7 years.
The co-primary outcomes were breast cancer-specific survival, with a 3% absolute non-inferiority margin, and cost-effectiveness. The results of the latter will be published separately. Additional outcomes analysed included recurrence-free interval, overall survival and referrals back to the hospital system.
Nearly three-quarters of the women (n= 3,858, 73.6%) were aged 60 years or older. The majority had undergone breast conservation surgery (80.3%), 87.4% had invasive disease, 2.1% had cancer that spread to the lymph nodes, and 82.7% had oestrogen receptor-positive tumours.
During the study and follow-up period, 343 women died. This included 116 who died of breast cancer, 61 from the annual mammography group and 55 in the less frequent mammography group.
The researchers found the five-year breast cancer-specific survival was 98.1% in the annual mammography group and 98.3% in the less frequent mammography group, providing evidence that less frequent mammograms did not negatively affect breast cancer rates.
After five years, 94.1% of the annual mammography group and 94.5% of the less frequent mammography group remained cancer-free. Survival from any cause was 94.7% for the annual mammography group and 94.5% for the less frequent mammography group.
The researchers suggested that less frequent mammograms for breast cancer-specific survival, recurrence-free interval and overall survival should be recommended for patients aged 50 years or older.
Reference
Dunn, J et al. Annual versus less frequent mammographic surveillance in people with breast cancer aged 50 years and older in the UK (Mammo-50): a multicentre, randomised, phase 3, non-inferiority trial. The Lancet 2025; Feb 01: DOI: 10.1016/S0140-6736(24)02715-6.
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