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Take a look at a selection of our recent media coverage:
4th November 2024
The initiation of biological and targeted synthetic disease-modifying antirheumatic drugs (DMARDs) among patients with newly diagnosed rheumatoid arthritis varies widely with age and ethnicity, researchers have found.
In a new study in England and Wales led by King’s College London (KCL), older patients and patients with Asian heritage were found to be missing out on effective treatments.
The researchers showed that patients over 65 years of age were 60% less likely to be given highly effective biological and targeted synthetic DMARDs to treat symptoms compared to patients aged under 40. Asian women were also less likely to be prescribed these drugs than Asian men and white men.
Socioeconomic status, other health conditions, or the response to conventional treatments did not explain the differences, the researchers said.
Using data from the National Early Inflammatory Arthritis Audit (NEIAA), the researchers identified 6,098 patients enrolled in the audit between May 2018 and April 2022 who had rheumatoid arthritis and 12-month follow-up data available.
Statistical methods were used to examine whether factors such as age, sex, ethnicity, health and economic status were associated with the initiation of biological and targeted synthetic DMARDs within 12 months of initial rheumatology assessment.
The mean age of the patients was 59.2 years, and just under two-thirds were women. The majority of the participants were white (86.2%), 2.5% were Black, 7.9% were Asian and 3.3% were mixed or other ethnicities.
Within 12 months of initial diagnosis, 8.3% of patients started biological and targeted synthetic DMARDs. Patients under 40 were nearly two and half times more likely to start treatment than patients who were over 65 (multivariable-adjusted risk ratio 2.41 [95% CI 1.83–3.19]; p<0.0001), and Asian women were about half as likely to start treatment than white individuals (0.52 [0.36–0.76]; p=0.0007).
The study also found that Black individuals were more likely to be started on biological and targeted synthetic DMARDs than white individuals (1.54 [1.10–2.16]; p=0.012), which was at least partly explained by worse disease severity at diagnosis in these individuals.
The findings highlight the problems of a ‘one-size-fits-all’ approach to treatment and the need for personalised information to be considered. The researchers say equitable access to biological and targeted synthetic DMARDs and quality care for underserved groups is needed.
Lead author Dr Mark Russell, NIHR clinical lecturer in rheumatology at King’s College London, said: ‘Rheumatoid arthritis is a progressive, debilitating condition with no cure. This study highlights marked differences in who gets started on advanced therapies for rheumatoid arthritis.
‘Access to these drugs in England and Wales is defined by need. Despite this, we found that Asian women and older adults were far less likely to be initiated on these treatments. Biologics are incredibly effective at improving quality of life and preventing complications from rheumatoid arthritis.
‘It is therefore crucial to develop a better understanding of what underlies these disparities if we are to ensure all patient groups receive equitable access to the best available care.’
Reference
Russell, M et al. Factors associated with biological and targeted synthetic disease-modifying antirheumatic drug initiation for rheumatoid arthritis in underserved patient groups in England and Wales, UK: a national cohort study. The Lancet Rheumatology 2024; Oct 15: DOI: 10.1016/ S2665-9913(24)00221-2.
31st October 2024
The use of low frequency ventilation (LFV) during cardiopulmonary bypass (CPB) for patients undergoing valvular surgery is feasible and safe, a new study has concluded.
LFV led to better postoperative lung function and improved exercise ability in patients undergoing surgery for heart valve disorders.
Researchers randomly assigned 63 patients with severe mitral or aortic valve disease undergoing surgery to LFV or usual care (33 LFV vs 30 usual care). The mean age of patients was 66.8 years and 30% were female.
Patients were assessed for generic inflammatory and vascular biomarkers and the lung‐specific biomarker soluble receptor for advanced glycation end-products (sRAGE) up to 24 hours after surgery. They then undertook pulmonary function tests and six‐minute walking tests up to eight weeks after discharge.
Overall, patients who received LFV showed better preservation of lung function and respiratory health, the researchers said.
Some 10 minutes after surgery, patients who received LFV showed elevated sRAGE levels, approximately three times above base level (geometric mean ratio, 3.05; [95% CI, 1.13– 8.24], suggesting damage to the lungs.
However, sRAGE levels gradually reduced over 24 hours, with measurements of 1.07, 0.84, 0.67 and 0.62 at two, four, six, 12 and 24 hours post-CPB, respectively, showing an overall reduction in lung injury and recovery over time. All results had a confidence level of 95%. The researchers observed no changes for any of the generic biomarkers tested.
Lung function tests highlighted significant improvement in lung function in patients who had LFV. The mean difference in FEV1/FVC ratio (forced expiratory volume in 1 second/forced vital capacity ratio) was improved by 0.050 six to eight weeks post-surgery for the LFV group, and forced vital capacity was also better preserved in the LFV group, with patients able to walk 63.2 metres further than those in the control group.
The researchers concluded that the use of LFV led to a significant improvement in exercise capacity and overall physical recovery.
A more extensive phase III trial will take place across the UK to allow the researchers to investigate further.
Reference
Roger, C et al. Low Frequency Ventilation During Cardiopulmonary Bypass to Protect Postoperative Lung Function in Cardiac Valvular Surgery: The PROTECTION Phase II Randomized Trial. Journal of the American Heart Association 2024; Sept 30: DOI: 10.1161/JAHA.124.035011.
30th October 2024
With another successful ESC Congress under its belt, the European Society of Cardiology’s new president Professor Thomas Lüscher speaks to Helen Quinn about the current challenges and opportunities in European cardiology, his highlights from the congress and his thoughts on the future of cardiovascular care.
In September 2024, at the European Society of Cardiology (ESC) annual congress, delegates welcomed Professor Thomas F. Lüscher as their new president and it’s a role he is excited about taking on.
Professor Lüscher is a world-renowned cardiologist, ranking in the top 0.5% globally of most cited scientists and currently a consultant cardiologist and director of research, education and development at the Royal Brompton and Harefield hospitals in London and professor at King’s College London, UK.
Having been involved with the ESC for many years, Professor Lüscher has chaired various working groups, became vice president in 2003 and then editor-in-chief of the European Heart Journal in 2008 – a position he held for 11 years. He describes the society as ‘a fantastic success story’ that has evolved from ‘a small club of friends into the largest and most influential society in medicine’.
With seven associations, seven councils, 15 working groups, 57 national societies, 47 affiliated national societies, 17 journals, 18 textbooks, an annual congress and nine speciality congresses, the ESC works hard to improve cardiovascular care and patient outcomes throughout Europe.
‘[It’s] an institution that dominates the field in a positive manner by providing guidelines, education and registries to improve the burden of cardiovascular disease. So, it’s a really exciting position I have,’ Professor Lüscher says.
Cardiovascular disease is still the leading cause of morbidity and mortality in Europe, and there are significant challenges facing the field. In the past, support from the EU has favoured oncology over cardiovascular healthcare. To try to change this imbalance, the ESC has responded by putting together a cardiovascular health plan, which has been submitted to the EU Council of Health Ministers to raise the profile of research and increase the quality and equality of care patients receive.
‘We hope this will impact the support for cardiovascular science and education in the future,’ Professor Lüscher says. ‘Europe has had a fantastic history. Most of the interventions have been invented in Europe, starting with pacemakers, atrial fibrillation ablation, percutaneous coronary intervention, transcatheter aortic valve implantation and MitraClip. It’s quite an amazing story.’
Today, however, innovation and development are hampered by regulations, according to Professor Lüscher. At the same time, the Food and Drug Administration in the US has become more lenient and much quicker and effective in approving drugs and trials.
‘I’m concerned that the speed and impressive innovation we have delivered over the last 200 years may be fading a little bit. There has been a bit of a shift from Europe to the US. [There are] a lot of rules and regulations in the EU and the UK,’ explains Professor Lüscher.
A lack of centralised device regulation in Europe is also impeding developments in field. Consequently, the ESC is working constructively with the European Medicines Agency and the Notified Bodies to make Europe fitter for innovation.
For some patients, differences in access to care is one of the main barriers to improving cardiovascular health across the continent. Such inequalities are highlighted in the ESC’s publication ‘Atlas of Cardiology’, which gives a picture of the current state of cardiovascular across Europe and shows vast differences in modern management options for cardiovascular conditions in different countries.
Patients in countries like Germany, Switzerland, Scandinavia and the Netherlands have good access to the latest treatments and medications. In other European countries, access is much more difficult, with many patients – particularly those in Eastern Europe – missing out.
And in the UK, for example, there is a concern that lower social classes have limited access to the latest cardiovascular treatments, Professor Lüscher explains, with deprived areas experiencing worse levels of care and, in turn, worse outcomes.
‘If you have severe heart failure, you might need a left ventricular assist device and in many countries that’s not available. Also, some novel, more expensive drugs are not available in certain countries,’ Professor Lüscher says. ‘There’s a huge heterogeneity in access to treatment across European countries. These are ethical concerns for medicine that, by nature, is a humanistic profession. The ESC tried to address this problem.’
The European Union has tried to overcome these inequalities in care by putting pressure on the prices of medications. There is also pressure on patent durations to make generic therapies available more easily and earlier, which is beneficial in the short term, but it is something that Professor Lüscher worries will obstruct innovations in the long term.
‘In the end, this is an economic problem,’ Professor Lüscher says. ‘There’s a close correlation between gross national product and availability of medical services, and currently in Europe the economy is not doing well. In many countries, we have issues with the economy that reflect on the service for patients.’
There is, however, much to be excited about in the field of cardiology, with many innovations and new research shared at the ESC Congress 2024. For Professor Lüscher, two significant potential developments excited him the most.
The first is the development of genetic tools as therapeutic agents to treat and prevent cardiovascular disease. This cutting-edge approach focuses on the use of antisense oligonucleotides (ASOs) and small interfering RNAs (siRNAs), which can block the production of certain proteins in the body and currently mainly target the liver.
‘The liver has specific receptors, in particular the asialoglycoprotein receptor, mainly expressed in hepatocytes. So, once linked with a GalNac residue, you can direct these double-stranded RNAs specifically to the hepatic cells. Then they bind to the RISC complex within the cell and inhibit the translation of a transcript to a protein over several months,’ Professor Lüscher explains.
This process enables a long-lasting therapeutic approach. There are now siRNAs for PCSK9, which lower low-density lipoprotein (LDL) plasma levels for six months, and others, including a new development for lipoprotein(a). In addition, siRNA therapies can target angiotensinogen to lower blood pressure for several months. Other siRNAs, like those that reduce transthyretin (TTR), help treat ATTR amyloidosis by preventing the formation of harmful amyloid deposits.
Gene editing tools, such as CRISPR-Cas9, are also emerging, which can precisely modify nucleoid acid sequences in the DNA. In animal trials, this tool has been used to permanently block the production of PCSK9, preventing it from binding to LDL receptors and thus lowering cholesterol levels and potentially offering a one-off, lifelong treatment.
‘The long-term vision is that we cure rather than treat. These genetic tools are a completely new chapter in pharmacotherapy,’ Professor Lüscher says.
A second area of innovation that will continue to be incredibly influential in cardiovascular medicine is the development of artificial intelligence (AI) and machine learning. As part of his presidency, Professor Lüscher has set out his vision for the digital transformation of cardiology in Europe.
Beginning with online consultations, he believes AI has much to offer clinicians and patients. ‘With an algorithm, you can analyse the face of a person, see the pulse, see the wrinkles, see the amount of sweat, and you can make outcome predictions,’ he says.
‘AI analyses any sort of picture, not just faces, but echocardiograms, CT scans, MRIs, nuclear scans, pathology specimens, biopsies – anything that’s visual and can also diagnose patients,’ he adds.
Analysing the human voice is also possible using AI, which can be incredibly helpful for cardiovascular diagnosis by identifying atrial fibrillation and arrhythmias through variations heard in the vocal cords as well as congestion caused by heart failure.
Professor Lüscher believes AI algorithms will become important ‘co-pilots’ for clinicians, prompting them to think about diagnoses they may have missed. Other algorithms can read reports shared as part of a referral, giving summaries and analysing volumes from images in seconds that would otherwise take clinicians significant chunks of time.
‘It makes us faster and more precise, provided the algorithms are good,’ Professor Lüscher says. ‘Algorithms that are not good or false can potentially kill patients. These algorithms have to travel well and work in different geographical areas and countries, otherwise it’s not acceptable.’
As such, the ESC is involved in developing quality standards for algorithms across Europe and only uses algorithms that they can show are well-verified in independent cohorts.
Amidst the innovations and new pathways, there will inevitably be challenges ahead, but there is much to look forward to in cardiology as Professor Lüscher begins his two-year presidential journey.
29th October 2024
A study has identified subtle changes in how immune cells respond to different severe febrile illnesses in children, which could lead to improved treatments.
A range of pathogens and inflammatory triggers could cause severe febrile illnesses in children, researchers wrote in the journal Nature Communications, however it was difficult for clinicians to identify the exact cause as the illnesses tended to share clinical features.
Diagnosis required time-consuming microbiological testing, which could lead to delays in clinicians starting appropriate treatment, the UK research team said.
Using immunophenotyping with mass cytometry and cell stimulation experiments, they followed the path of immune dysfunction in a group of 128 children: 74 children with multi-system inflammatory syndrome in children (MIS-C) associated with SARS-CoV-2, 30 with bacterial infection, 16 with viral infection, eight with Kawasaki disease and a further 42 controls.
They further explored the findings using gene expression data from whole blood RNA sequencing in a separate cohort of 500 children with these severe febrile illnesses and 134 healthy controls.
The study found that neutrophil activation and apoptosis were prominent in MIS-C, and that this was partially shared with bacterial infection.
In addition, memory T cells from patients with MIS-C and those with bacterial infection were exhausted.
In contrast, viral infection was characterised by a distinct signature of decreased interferon signalling and lower interferon receptor gene expression.
‘Our data support an important role for neutrophil and monocyte activation in the pathology of MIS-C and highlight T cell exhaustion upon presentation of MIS-C,’ the researchers concluded.
‘Neutrophil activation and features of T cell activation and exhaustion were shared with severe bacterial infection, while severe viral infection was characterised by downregulated STAT signalling pathways, highlighting shared and distinct features of immune dysregulation in these disparate severe febrile illnesses of childhood,’ they added.
Study co-author Professor Michael Levin, chair in paediatrics and international child health from the Department of Infectious Disease at Imperial College London, said: ‘For decades we have been working to unpick the granular detail of febrile illnesses, so we can improve treatments and reduce the impact these conditions have on children.
‘As clinicians, we may often see a child in the hospital or clinic with a fever and no other real defining symptoms, making an accurate diagnosis and targeted treatment difficult.’
By providing a clearer picture of the immune mechanisms in febrile illnesses, this study and others like it might ultimately help clinicians to diagnose and treat children earlier, he said.
The team was motivated to investigate immune dysfunction in febrile illnesses after an increase in the number of children being admitted to hospitals worldwide with MIS-C – a life-threatening condition following SARS-CoV-2 exposure characterised by symptoms including fevers, rash, conjunctival infection, severe cardiac dysfunction, multi-organ involvement and intense inflammation.
They noted that clinically MIS-C shared similarities with severe bacterial infection, including toxic shock syndrome and Kawasaki disease, adding that both MIS-C and Kawasaki disease could cause coronary artery aneurysms.
Study co-author Dr Michael Carter, from King’s College London and the Evelina London Children’s Hospital, said: ‘We saw that severe bacterial infection and MIS-C overlapped immunologically, although they are caused by very different things.
‘In the clinic currently, our treatments for dysfunctional immunity are poor and not targeted to individual children. Going forwards, by looking at the immune system in much more detail, we hope we’ll be able to develop therapies that can treat the immune response in a much more targeted way and improve outcomes for our patients.’
The latest findings build on related work led by Imperial College London researchers which aimed to develop a blood test to rapidly diagnose the cause of paediatric febrile illnesses by using the differences in the levels of expression of 161 genes in patients’ blood to distinguish between 18 infectious and inflammatory diseases.
28th October 2024
A randomised clinical trial of an mRNA vaccine against norovirus will be launched in the UK by the end of October 2024, it has been announced.
It will evaluate the efficacy, safety, and immunogenicity of an investigational norovirus vaccine, mRNA-1403, which if successful could be the first licensed norovirus vaccine in the world.
The trial is sponsored by Moderna and will be conducted in collaboration with the UK Health Security Agency (UKHSA) on behalf of the UK Government.
It will use the Be Part of Research portal from the National Institute for Health and Care Research (NIHR) Research Delivery Network to help recruit volunteers.
In particular, researchers are seeking participants aged 60 years and older, ‘as this age group of people are generally more likely to be severely affected by norovirus and so benefit most if the vaccine is shown to be effective‘, the NIHR said.
Some 2,500 participants will be recruited from across the UK between late October and early 2025, and will be given either a placebo or the investigational vaccine at one of 39 sites, including 27 NHS primary and secondary care sites.
Dr Patrick Moore, co-director of Wessex Research Hubs and chief investigator of the trial in the UK, said: ‘Outbreaks of norovirus have huge consequences, both on our health systems and our economy. This innovative trial is crucial in helping us advance healthcare.‘
Sarah Collins, UKHSA commercial director, added: ‘Norovirus isn’t just a nasty tummy bug – it can have serious consequences for vulnerable people, and cause a large amount of disruption in social care, hospital settings and education settings.‘
Commenting on the clinical trial announcement, health and social care secretary Wes Streeting said the virus ‘puts the NHS under huge strain every winter, costing taxpayers around £100 million a year‘.
Finding a successful vaccine would ‘help shift our health system away from sickness and towards prevention – reducing pressure on the NHS and keeping people well during the colder months‘, Mr Streeting added.
And he described the trial as ‘a huge vote of confidence in the UK’s life sciences sector‘.
Meanwhile, Professor Lucy Chappell, NIHR chief executive and chief scientific adviser to the Department of Health and Social Care, said that the trial would be delivered ‘at pace, so that people across the UK and the world can benefit sooner‘.
mRNA vaccine trials are also underway for colorectal cancer, with trial sites across the UK including at Queen Elizabeth Hospital Birmingham.
A version of this article was originally published by our sister title The Pharmacist.
25th October 2024
A local treatment route for severe asthma biologics in Brighton, UK, is bringing significant benefits to patients, staff and the wider NHS. Eight months on from the launch of this new service, Dr Harpreet Ranu discusses its positive impact on accessibility of care, improved patient outcomes and cost savings, as well as looking to the future of the service.
Historically, adults with severe asthma in Brighton and the Sussex area faced an inconvenient four-hour round trip to the severe asthma centre at the Royal Brompton Hospital in London for assessment and potential biologic therapy – a feat easier said than done when experiencing an exacerbation.
The opening of the Louisa Martindale Building at Royal Sussex County Hospital in Brighton in May 2023 paved the way for much needed change. A new respiratory ward and Same Day Emergency Care (SDEC) unit enabled the severe asthma team to develop a local service to ensure eligible patients receive life-changing biologic therapies close to home.
Launched in February 2024, the service involves multidisciplinary assessment from a specialist nurse, a physiotherapist and a consultant in respiratory medicine – Dr Harpreet Ranu, who is also the severe adult asthma lead.
This assessment then gets fed into a monthly virtual multidisciplinary team (MDT) meeting with their colleagues at the Royal Brompton Hospital’s severe asthma centre before deciding whether the patient is suitable for asthma biologics.
‘It means those patients can be started on the treatment locally, usually within a few weeks, sometimes even a few days,’ says Dr Ranu. Once set up on their treatment regimen, some patients are even able to self-inject, meaning they can administer it from the comfort of their own home.
This is a stark contrast to the previous system that would involve up to two years of waiting with repeated visits to Brighton and London before a treatment decision could be made and biologic injections at the specialist centre could begin.
In breaking down this barrier to timely and effective treatment, Dr Ranu and her colleagues have seen significant improvements in patient outcomes in just the few months since the service launched.
‘Severe asthma for a patient essentially means they’re having recurrent exacerbations of their asthma, where they’re requiring three or more courses of oral steroids with a 12-month period, which can have significant side effects,’ says Dr Ranu. ‘They may also require hospital admissions, including an intensive care admission if they’re unwell, and this has a significant implication in terms of their physical health, but also in terms of their mental health and time off work.’
In contrast, the minimally invasive biologic injections are thought to have little to no side effects and Dr Ranu says they can lead to a reduction in exacerbations by as much as 50%.
‘I’ve had some patients say that they feel like they’ve got the life back – they can go to work, they can do things they enjoy,’ Dr Ranu explains. ‘Certainly, for one patient, he is now able to play with his grandchildren, so it’s really heartening to hear these responses from patients that we’ve seen and looked after who’ve been so unwell.’
The feedback from patients about the service itself and the continuity of care it offers has been very positive, too. ‘Certainly, patients are very relieved to know they don’t need to travel to London for this treatment, and they can come to the local hospital and see healthcare professionals that have been involved in their care,’ Dr Ranu adds.
The buy-in from this local team of healthcare professionals is one of the key reasons for the service implementation being possible – and for its success, according to Dr Ranu.
‘We have a very experienced asthma specialist nurse, Jenny Beaumont, and myself, and we also have asthma physiotherapists and an asthma MDT coordinator,’ she explains. ‘These are key parts of the service to make sure the pathway for these patients and the timeline are as short as possible, but also to make sure that we look at the patients holistically.’
And the MDT input doesn’t end there as the service requires support from the hospital’s divisional and operational teams, the wider respiratory department to free up space and staff, and virtual support from the severe asthma centre.
‘With all new services, it obviously involves additional work and developing competencies – mainly around assessing patients on SDEC, close monitoring of patients on biologics and day-to-day administration of the service including entry to Severe Asthma Registry. Having the support from our colleagues at the Royal Brompton is invaluable,’ Dr Ranu adds.
This collaborative effort means increasingly more patients are able to enjoy timely and efficient access to these biologic injections – along with the subsequent improved quality of life – and the apparent scope is significant.
Nearly 130 asthma patients have been seen in the respiratory SDEC unit and 40 patients have been started on biologics so far. But, as Dr Ranu explains, ‘if we look at the potential number of patients that could be suitable for asthma biologics within the Sussex area alone, this could be as high as 1,300 patients’.
Having the potential to improve the lives of so many people with severe asthma is significant, but Dr Ranu is keen to point out the positive impact on the wider health economy, too.
‘In terms of this treatment, there are significant savings to be made. If you look at the modelling, the potential cumulative savings over a five-year period could be as high as £2m. And that may be a conservative estimate,’ Dr Ranu says.
But that’s not all. Asthma is estimated to cost the UK public sector at least £1.1bn every year and is responsible for over six million primary care consultations, 100,000 hospital admissions and the loss of 17 million working days annually.
With the NHS currently working at – and beyond – its limits, this new service is one of the many ways in which efficiencies can be made and pressure can be relieved. Reducing GP visits, A&E attendances, hospital admissions and the need for mental health provision are all possible and have wide-reaching benefits for the staff, system and patients involved.
With the cost savings and value for all stakeholders speaking for themselves, funding for the continuation of the service is a top priority for Dr Ranu.
‘The funding is currently fixed for a period of time, and that will run out in 2025, so it’s ensuring that we have long-term funding to continue to deliver this for patients that we know are out there and need biologic treatment,’ she says.
Another priority that will contribute to future funding discussions is around expanding the scope of the service beyond its current secondary care remit.
‘Looking at the percentage of patients with severe asthma, if you look at various studies, it may be 3.8% of patients have asthma coding in primary care, but it may even be as high as 8%,’ Dr Ranu says. ‘We would hope to work with our colleagues in primary care to essentially find patients and bring them through the system to shorten their treatment pathway.’
How the severe asthma service continues to develop will also be dependent on the different asthma biologics that are going through clinical trials.
‘Currently, most of the asthma biologics are delivered either two- or four-weekly, or there’s one that’s delivered eight-weekly,’ Dr Ranu explains. ‘But, moving forward, there may be ones that could be delivered on a six-monthly basis, which, again, will have a significant positive impact for patients.’
A new hand-held 3D photoacoustic scanner can produce detailed microvascular images in seconds, UK researchers have found, with the technology having the potential to assist with earlier detection of conditions including diabetes, arthritis and cancer.
Photoacoustic tomography (PAT) scanners use laser-generated ultrasound waves to visualise subtle changes in veins and arteries, however, earlier generations of the technology took several minutes to acquire images, which was too slow to be useful in a clinical setting.
In this study, published in the journal Nature Biomedical Engineering, researchers at University College London (UCL), UK, tested a custom-built photoacoustic scanner engineered to produce high-quality 3D scans in a few seconds or less.
Researchers said they used a parallelised sensor readout scheme, high-pulse repetition frequencies excitation lasers and compressed sensing techniques to enable significantly faster acquisition times from the new scanner.
During the investigations, they tested the scanner on volunteers and hospital patients at a variety of anatomical locations, including the wrist and nail bed, and showed it could visualise and quantify microvascular changes associated with diabetes, skin inflammation and rheumatoid arthritis.
‘These studies demonstrated that high-resolution 3D images to depths approaching 15 mm can be acquired, revealing capillary loops, venules, arterioles and large mm-scale arteries and veins, as well as other structures such as venous valves, skin sulci and hair follicles,’ the researchers wrote.
‘The level of image detail that it provides suggests that it could find application as a tool for the clinical detection, diagnosis and treatment monitoring of diseases such as diabetes or cancer that are characterised by microcirculatory abnormalities.’
Lead author Professor Paul Beard of UCL Medical Physics and Biomedical Engineering and the Wellcome/Engineering and Physical Sciences Research Council’s Centre for Interventional and Surgical Sciences, led earlier UCL research which was integral to the first development of this technology.
‘We’ve come a long way with photoacoustic imaging in recent years, but there were still barriers to using it in the clinic,’ he said.
‘The breakthrough in this study is the acceleration in the time it takes to acquire images, which is between 100 and 1,000 times faster than previous scanners.’
Professor Beard said the speed avoided motion-induced blurring during the scan and meant that rather than taking five minutes or longer, images could be acquired in real time, visualising dynamic physiological events.
‘These technical advances make the system suitable for clinical use for the first time, allowing us to look at aspects of human biology and disease that we haven’t been able to before,’ he said.
Senior study author Dr Andrew Plumb, associate professor of medical imaging at UCL and consultant radiologist at UCLH, said photoacoustic imaging could give clinicians more detailed information to facilitate early diagnosis, as well as a better understand of disease progression.
Previously, clinicians had not been able to see visualise the microvascular damage in the lower legs and feet of patients with diabetes, or characterise how it developed, he noted.
‘In one of our patients, we could see smooth, uniform vessels in the left foot and deformed, squiggly vessels in the same region of the right foot, indicative of problems that may lead to tissue damage in future,’ he said.
Dr Nam Huynh of UCL Medical Physics and Bioengineering, who was one of the photoacoustic scanner developers, said the technology had the potential to detect and monitor tumours.
‘It could also be used to help cancer surgeons better distinguish tumour tissue by visualising the blood vessels in the tumour, helping to ensure all of the tumour is removed during surgery and minimising the risk of recurrence,’ he said.
Further research is now needed with a larger group of patients to confirm the findings and the scanner’s clinical utility, the researchers said.
Image credit: Photoacoustic tomography image of diseased vasculature in the foot of a patient with type 2 diabetes – UCL.
More patients are experiencing delayed discharges from hospitals, but integrated care boards (ICBs) are working with system partners to develop new and innovative ways to address this. In this fourth and final case study, Kathy Oxtoby reports on how Leeds Health and Care Partnership is approaching this longstanding issue with their person-centred HomeFirst model.
Work is taking place across the West Yorkshire Health and Care Partnership integrated care system (ICS) to help address patient discharge issues.
A person-centred ‘home-first’ model of intermediate care across Leeds that is joined up and promotes independence is the vision of the HomeFirst programme run by Leeds Health and Care Partnership – one of the five places under the ICS.
The programme was prompted by the need to improve the delivery of intermediate care in Leeds. ‘As partners working in Leeds, we knew that by working together we could support people better and that they were not always getting the best possible outcomes,’ says Megan Rowlands, programme director for the Leeds HomeFirst programme.
In Autumn 2022, more than 200 people across the Leeds system worked together to complete a system-wide diagnostic review of outcomes from the intermediate care available and the interaction of acute, community and social care services.
The diagnostic work involved the detailed review of over 220 cases, data analysis of more than 50,000 patient journeys, the views of over 600 patients, service users, families and carers, and input from eight organisations across Leeds.
The findings from the diagnostic review included that too many people were spending more time in hospital than they needed to or could have avoided hospital altogether.
The review also found that short-term care in the community was provided across many different services and that people also spent more time than they needed to in many of these services. Capacity challenges in these services meant many people who could benefit from intermediate care were going straight into long-term care with lower levels of independence than they might otherwise have achieved.
There was a relatively high use of bed-based care, and more people could have been supported to stay at home with a greater level of independence. And many older people could have reduced or avoided the deconditioning that has an impact on their independence and long-term care needs, the review found.
To help address these issues, five core projects have been established within the HomeFirst programme, starting in May 2023.
Within each project, design groups of system experts have come together to shape the changes required. These range from progress changes, digital tools and new ways of working through to new models of service delivery.
These changes have then been piloted and iterated with individual teams, using evidence gathered on the performance of key measures, staff feedback and patient/service user feedback, before being scaled up across the system.
As of June 2024, 100 more people were able to go home after their time in intermediate care instead of a long-term bedded care per year. There was a 7.3 day reduction in the average length of stay in short-term beds. Some 478 additional people have benefitted from reablement each year. There are 422 more people going directly home each year after their stay in hospital instead of a bedded setting. And 1,082 fewer adults are being admitted to hospital each year.
‘Supporting more people to go home rather than into long-term residential care is better for people and often what people want. People are more independent and supported in their own environment,’ says Ms Rowlands. The HomeFirst approach ‘allows us to use our resources more effectively, and hospital beds are freed up sooner’, she says.
A huge enabler to the success of the programme has been building on the culture and relationships across all partners in the system, including healthcare organisations, social care providers and third sector organisations. ‘It’s been a real team effort,’ says Ms Rowlands. ‘All of our partners – not just at executive level but also those involved in delivering services – have been working together to deliver the programme,’ she says.
She says similar initiatives are happening across West Yorkshire to help address similar challenges with patient discharge and supporting people at home.
One of the initiatives that complements HomeFirst is the Carers Hospital Discharge Toolkit.
NHS West Yorkshire ICB’s unpaid carers programme has produced the toolkit and resources to support NHS trusts in carrying out their statutory duty to involve unpaid carers in discharge pathways and to improve unpaid carers’ experiences of discharge through increased identification, support, signposting, and referral. The toolkit has been co-produced with NHS staff, voluntary sector carer organisations and people with lived experience.
The toolkit also supports reducing health inequalities for Core20PLUS5 populations with its co-production and engagement from ethnically diverse carers and young carers. Post-launch evaluation of the toolkit has already shown that 80% of carers stated they were more involved in conversations about discharge, and as a result, 71% of carers felt more prepared for the discharge of their family member they supported.
A carer who was involved in developing the toolkit says: ‘I really welcome this resource. It’s so important that carers are kept informed and involved when those they care for are in hospital, especially when they’re due to be discharged. They may leave hospital needing additional care or new equipment, for example, so their carer may need advice or extra support. They may not even have thought of themselves as carers previously, or they may be new to caring, so making sure they’re aware of services that can help is vital.’
‘Collaboration is pivotal in addressing patient discharge challenges across West Yorkshire,’ says Helen Lewis, director of pathway integration for the Leeds Health and Care Partnership.
‘It’s great that the HomeFirst model we have introduced in Leeds has already made a difference. Providing the right care at home and better ways of working on the wards means more people are getting out of hospital sooner into places where they can continue their recovery safely and enhance their longer-term wellbeing. We are also improving our alternatives to admission, supporting people to stay at home rather than be admitted to a hospital bed,’ she says.
‘Although we recognise the ongoing challenges in workforce and funding, by implementing a person-centred, HomeFirst model and enhancing intermediate care services in Leeds, we are not only improving patient outcomes but also promoting greater independence and reducing unnecessary days in hospital. We are seeing similar initiatives across West Yorkshire, reflecting our shared commitment to delivering high-quality, sustainable care for our communities.’
Read more about tackling delayed hospital discharge and improving patient flow in this analysis, and discover some of the other inspirational work being done across England in the first three case studies of this series:
This case study was originally published by our sister publication Healthcare Leader.
24th October 2024
Mineralocorticoid receptor antagonists (MRAs) should be considered for all patients with heart failure, say Scottish researchers who found benefits across the board.
The drugs, which include spironolactone, had already shown clear benefit for patients with heart failure and reduced ejection fraction but their use in other categories had been unclear.
Now, a meta-analysis of four trials with more than 13,800 patients presented at the European Society of Cardiology Congress 2024 has also shown positive results in patients with mildly reduced or preserved ejection fraction.
The results, which were also published in The Lancet, support use of the drugs in all heart failure patients without a contraindication, the researchers concluded.
Data was analysed from four placebo-controlled trials which either looked at spironolactone, eplerenone or finerenone.
It showed that MRAs reduced the risk of cardiovascular death or hospitalisation for heart failure by 23%.
The treatment did show greater efficacy in patients with heart failure and reduced ejection fraction with a 34% reduction in the death or hospitalisation.
But there was a 13% reduction in heart failure with mildly reduced or preserved ejection fraction.
The effects were consistent in all subgroups across the four trials and in all categories of heart failure, the researchers from the University of Glasgow said.
Significant reductions in hospitalisation for heart failure were observed in the trials of reduced ejection fraction (37%) and mildly reduced or preserved ejection fraction (18%).
And the same pattern was seen for total heart failure hospitalisations with or without cardiovascular death, they found.
The risk of hyperkalaemia was doubled with an MRA compared with placebo, but the incidence of serious hyperkalaemia, defined as a laboratory potassium >6.0 mmol/L, was low and the risk of hypokalaemia was halved.
Study leader Professor Pardeep Jhund, professor of cardiology and epidemiology at the University of Glasgow’s School of Cardiovascular and Metabolic Health, said that MRAs were widely available but several studies had shown they were underused.
‘This analysis confirms the benefits of MRAs in patients with heart failure, across the spectrum of ejection fractions,’ he said. ‘Our findings indicate that treatment with an MRA may be considered in all patients with heart failure without a contraindication.
‘In patients with mildly reduced or preserved ejection fraction, management should include finerenone in addition to a SGLT2 inhibitor,’ he said.
Meanwhile, a recent study found semaglutide could be beneficial in helping to treat patients with type 2 diabetes and obesity-related heart failure. In the trial of more than 600 patients with obesity-related heart failure with preserved ejection fraction and type 2 diabetes, semaglutide led to several benefits after one year.
A version of this article was originally published by our sister publication Pulse.
23rd October 2024
A novel point-of-care (POC) test can be used to diagnose or rule out myocardial infarction without the need for laboratory involvement and could improve the treatment of people presenting with chest pain in emergency departments (EDs), a trial has suggested.
The randomised controlled trial saw a new eight-minute blood test reduce the average length of stay for patients with chest pain when seen quickly by a doctor and those diagnosed with non-ST-elevation myocardial infarction (NSTEMI), compared to patients who received central laboratory testing.
The study involved 1,494 patients (median age 61 years, 43% female) presenting with symptoms suggestive of acute coronary syndrome (ACS) at Haukeland University Hospital in Norway between March 2022 and March 2024.
Researchers randomised the patients into two groups: one received standard investigations following the European Society of Cardiology 0/1h protocols for centralised high-sensitivity cardiac troponin (hs-cTn) T measurements (n=766) and the other received the intervention using a 0/1h POC hs-cTnI algorithm (n=728).
The average length of stay in the ED was 174 minutes for the POC testing group compared to 180 minutes in the standard testing group. However, among patients who were seen by a doctor within 60 minutes, POC testing reduced the length of stay in the emergency department by 15 minutes (147 vs 162 minutes).
The POC test provided the most benefit for patients with NSTEMI, which does not show ST-segment elevation on an ECG but requires urgent care. For these patients, the ED stay was shortened by an average of 43 minutes compared to the standard test (median 137 vs 180 minutes), and they were admitted to the cardiac ward faster.
POC testing did not compromise patient safety. Rates of combined deaths, myocardial infarction and acute revascularisations within 30 days were similar between the groups (11.4% POC vs 9.4% laboratory) and between discharge to 30-days follow-up (0.8% POC and 0.5% laboratory), indicating that both pathways have high and similar safety, with very few patients experiencing events after being discharged.
To realise the full potential of POC tests in the ED, inefficiencies that affect patient flow, such as lack of discharge staff or inefficient discharge procedures, must be addressed, the researchers concluded.
Reference
Thulin, I et al. Aiming toWards Evidence baSed inTerpretation of Cardiac biOmarkers in patients pResenting with chest pain using Point of Care Testing (WESTCOR-POC): study design. Scandinavian Cardiovascular Journal 2023; Oct 31: DOI: 10.1080/14017431.2023.2272585.
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