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28th April 2025
Exposure to indoor pollutants is a significant asthma trigger, and recent guidelines from the European Academy of Allergy and Clinical Immunology assess the effects of key indoor air pollutants on the development of asthma and on asthma-related outcomes. Here, Professor Ioana Agache, one of the lead authors, discusses how asthma management can be improved by following these recommendations, while emphasising that broader action is also necessary to achieve meaningful progress in enhancing indoor air quality and asthma prevention and control.
Allergies and asthma are diseases influenced by environmental factors, both in their onset and progression. Among the many triggers for asthma, indoor exposure to pollutants is particularly significant, as people often spend a large part of their time indoors. Approximately 2.4 billion people, especially in low- and middle-income countries, are exposed to dangerous levels of indoor air pollutants.
Environmental control plays a vital role in asthma management. Given the complexity of the indoor exposome, an intervention approach that targets multiple indoor aggressors is likely to be an effective strategy.
Incorporating the evaluation of indoor exposure along with personalised adaptation and mitigation measures into the asthma management plan is highly recommended. Particular attention should be given to the most vulnerable groups: children, pregnant women, the elderly with multiple comorbidities, individuals with disabilities and those who are socio-economically disadvantaged.
Environmental-driven asthma endotypes – that is, individuals susceptible to environmental factors rather than genetic influences – could also benefit from this approach.
The 2025 European Academy of Allergy and Clinical Immunology (EAACI) Guidelines on Environmental Science For Allergy And Asthma emphasise management in the context of indoor pollution.
Previous guidelines have a broader focus on general health or respiratory health and are, therefore, not particularly specific for managing patients with asthma. Additionally, this guideline is evidence-informed, adhering to the GRADE system – the highest-quality framework for guideline development – unlike many documents based on expert opinion.
The 2025 guideline highlights the importance of distinguishing between different types of exposure that can occur over the course of a lifetime:
The EAACI guidelines recommend reducing exposure to indoor pollutants through frequent indoor air monitoring and the use of smart ventilation systems. They advise preparedness for adverse asthma-related outcomes, such as loss of control, exacerbations and lung function decline, in settings with high levels of indoor pollution. For healthcare professionals, the evidence suggests incorporating environmental measures into their clinical advice for patients with asthma.
Adaptation measures to reduce the impact of indoor air pollutants on asthma-related outcomes at an individual level include:
Guidance from healthcare professionals in applying and monitoring the efficacy of these measures is warranted.
The guideline provides recommendations on the risk provided by exposure to major indoor pollutants, such as volatile organic compounds, cleaning agents, dampness/mould and pesticides, on developing asthma, asthma symptoms, impaired lung function, deterioration of asthma control and exacerbations, together with adaptation and mitigation measures, thus facilitating both asthma prevention and control.
Additionally, the guideline discusses indoor pollutants of emerging concern, including phthalates, microplastics, lead, radon, asbestos and emissions from particulate matter such as cooking stoves, indoor fireplaces and heaters. It also mentions perfluorocarbons, UV filters, synthetic musk, parabens, siloxanes, neonicotinoids and drug residues.
The EAACI guideline advocates for assessing each patient’s vulnerability to environmental aggressors and, where possible, for improving resilience to these aggressions. Three key pillars to enhancing resilience are a healthy diet, a healthy microbiome and a healthy immune system.
The guidelines recommend concomitant assessment of exposure and of the patient’s vulnerability to environmental aggressors in judging the risk of adverse outcomes and in planning the adaptation and mitigation measures. The potential for adaptation should be individually evaluated in each patient with asthma and a personalised plan should be co-created together with the patient and their family.
The guideline provides a checklist for healthcare professionals managing patients with asthma, recommending that all indoor settings be evaluated: home, school, work and indoor recreational areas. Furthermore, we provide information on advanced ventilation techniques contributing to optimal indoor air quality.
Lastly, the EAACI guideline highlights the importance of integrating all individual exposures into the complex configuration of the indoor exposome, by including indoor allergens and infectious agents that interact synergistically with pollutants. This configuration is continuously influenced by outdoor pollution levels, human activities and the characteristics of the building.
The combined effects of outdoor and indoor air pollutants are linked to seven million premature deaths each year. Vulnerable populations are disproportionately impacted.
There is a significant transgenerational effect of pollutants, impacting the foetus during pregnancy and continuing throughout an individual’s lifetime, as well as being transmitted to offspring. In fact, allergies are among the first environmentally driven chronic diseases that arise during a person’s life, highlighting the impact of environmental factors that may lead to other chronic diseases in adulthood.
The epidemic rise in allergies reported in recent decades parallels an increase in autoimmune disorders, cancer and metabolic disorders. All are chronic diseases arising from excessive environmental aggression along with a dysregulated resilient response of the human body.
Climate change intensifies the impacts of both outdoor and indoor pollution. There is a clear synergy between pollutants and heat or cold stress, as well as extreme weather events, that undermines the body’s resilient response. Due to extreme weather conditions, people are more likely to remain indoors, thus increasing their exposure to indoor pollution.
The traditional method of monitoring indoor pollutants involves air and dust analysis. Therefore, the range of analytical techniques must be continuously expanded. It is highly recommended to combine classical indoor analytics with human biomonitoring to promptly detect indoor pollutants using the exposome approach.
Continuous indoor air quality monitoring offers the best way to obtain real-time data on indoor air pollutant levels, while air cleaners and smart ventilation systems are vital tools for achieving optimal indoor air quality. However, challenges persist regarding the maturation of technologies, data mining and their interpretation. Therefore, healthcare professionals recommending adaptation and mitigation plans must collaborate closely with environmental health professionals, engineers, architects and others.
Furthermore, to develop an effective intersectoral model of the public health system, governments must collaborate with academia, media, business, community-based organisations and local communities.
We hope the evidence provided by these EAACI guidelines supports the establishment of legally binding standards and goals for indoor air quality at international, national and local levels.
Asthma management recommended by the current EAACI guidelines can improve asthma-related outcomes, but community and governmental measures to enhance indoor air quality are necessary to achieve a significant impact.
Policies aimed at promoting greater adaptation, such as reducing adaptation costs or enhancing indoor air quality, can deliver immediate benefits. There is an urgent need for increased awareness of the risks associated with poor indoor air quality and for the implementation of suitable regulations for public spaces.
Public health policies must undergo significant changes to adapt to the new understanding of the ecology of health and the interconnectedness of the biological, behavioural and physical domains. Therefore, it is essential to transform national health policies by incorporating the principles of environmental health.
Ioana Agache MD PhD
Professor of allergy and clinical immunology, Transylvania University of Brasov, Romania
25th April 2025
Measuring troponin levels alongside cholesterol significantly boosts the accuracy of cardiovascular risk prediction, a UK-funded study has found.
The researchers modelled risk using conventional measures such as age, blood pressure and cholesterol, with or without troponin, in more than 62,000 patients who had taken part in studies in Europe and the US.
Adding troponin results increased the prediction accuracy of myocardial infarction or stroke within 10 years by up to four times.
The researchers then used UK data to model the implications on statin prescribing should troponin be added to the risk calculators.
On an individual basis, the difference was small but impactful at the population level, the researchers said.
For people currently found to be at intermediate risk on routine cardiovascular health assessments, the tests would prevent one myocardial infarction or stroke for roughly every 500 people tested.
Reporting the results in the Journal of the American College of Cardiology, the team said the troponin test was especially effective at spotting danger in the 35% of people currently assessed to be at intermediate risk of cardiovascular problems.
The addition of troponin tests to the calculation meant that up to 8% of people were moved from intermediate risk to high risk, making them eligible for preventive treatment.
Lead author Professor Anoop Shah, clinical cardiologist and epidemiologist at Imperial College NHS Trust and professor of cardiovascular medicine at the London School of Hygiene and Tropical Medicine, said: ‘Troponin, even in the normal range, is a powerful indicator of silent heart muscle damage. As such, the test provides an extra layer of information that we can use to boost our accuracy when predicting people’s risk.
‘We want to identify as many high risk people as possible, so that no one misses out on the opportunity to get preventative treatment.’
Professor Bryan Williams, chief scientific and medical officer at the British Heart Foundation, which funded the research, said: ‘Developments in risk prediction have helped doctors to build effective algorithms that can spot those most at risk of heart attacks and strokes.
‘But, with around 100,000 hospital admissions for heart attacks alone in the UK each year, it’s clear that there is still plenty of room for improvement.
‘This new data suggests adding this blood test to current risk prediction models could help medical professionals identify more people who are at higher risk and deliver advice and treatment to reduce their risk of future heart attack and strokes.’
A version of this article was originally published by our sister publication Pulse.
24th April 2025
Lung cancer remains the leading cause of cancer-related mortality in the UK. A recent report from the UK Lung Cancer Coalition (UKLCC) underscores the impact of lengthy genomic testing turnaround times, which may hinder access to life-prolonging targeted therapies for many patients. Professor Robert Rintoul, the UKLCC clinical lead, examines the report’s findings and proposes actionable strategies to optimise the delivery of timely, accurate and high-quality genomic testing across the UK to support more effective and prompt treatment decisions.
Genomic testing identifies the molecular characteristics of cancer, enabling patients to access targeted therapies that can significantly improve survival rates and quality of life. For clinicians, knowledge of mutations is a prerequisite for making optimal treatment decisions, including eligibility for perioperative or neoadjuvant chemo-immunotherapy.
Delays in genomic testing can significantly hinder patient treatment decisions and impact subsequent survival outcomes, especially in cases of rapidly fatal disease such as lung cancer where timely intervention is crucial. Delays not only affect the physical health of patients but also add to their emotional distress as they await critical information.
The UK Lung Cancer Coalition (UKLCC) report, Faster Testing, Better Outcomes: Genomic Testing in Lung Cancer, is a pivotal document for clinicians, policymakers and patients as it underscores the critical role of timely genomic testing in lung cancer care for up to 30,000 lung cancer patients each year.
The report highlights the need for streamlined and expedited processes to ensure clinicians make the right treatment choices for their patients based on receiving accurate and timely genomic test results. Policymakers can use the findings to address systemic inefficiencies, such as staffing shortages and outdated infrastructure, while patients benefit from reduced waiting times and improved access to life-extending treatments.
The report aims to instigate several key changes in the genomic testing pathway via 12 key recommendations, which can be summarised as follows:
The report also suggests practical solutions, such as implementing a seven-day working model for genomic labs, improving training for healthcare scientists, and introducing a single digital tracking system for patient samples.
Technology can play a transformative role in expediting genomic testing. The integration of tools such as digital tracking, advanced IT systems and AI diagnostics within the pathway will not only lead to more timely and accurate genomic test results but also ensure more personalised and efficient care and better patient outcomes.
By implementing these and other changes, the report seeks to create a more efficient and equitable system, ultimately improving outcomes for lung cancer patients across the UK.
Several barriers are preventing genomic testing from achieving the recommended 14-day turnaround time. These include:
The good news is that we have observed hospitals and regions employing successful strategies to expedite test results at every stage of the genomics pathway. For example, in terms of the pre-genomics phase – specifically tissue acquisition, sample transportation and tracking – a number of strategies have been adopted to reduce genomic testing turnaround times.
In Northern Ireland, the health system has made significant investments in the lung cancer care pathway by ensuring the presence of a pathologist or cytologist during tissue sample collection for most endobronchial ultrasound procedures.
These specialists provide real-time analysis to assess the quality of the samples and determine if additional samples are required. However, while this approach is commendable, workforce limitations may make it difficult to implement in all regions across the UK. Therefore, it is crucial for local health services and respiratory physicians performing the procedure to prioritise accuracy of tissue sampling and ensure high-quality samples are collected from the outset.
In Wales, all lung cancer tissue samples are systematically tracked from acquisition, through pathology testing and up until the sample reaches the genomics lab. This is via an interconnected IT system, which everyone involved in a lung cancer patient’s care can access.
Another successful strategy that has expedited the pathway can be witnessed in Torbay and South Devon NHS Foundation Trust. Previously, samples were transported from NHS pathology labs to the Bristol genomics hub using Royal Mail tracked delivery – a process that could take up to four days. By switching to an existing hospital transport service, which was already transporting human papillomavirus samples to the Bristol hub, the transit time was reduced to a maximum of one day.
It is clear that it can often be the simplest of changes or strategies which can make the most significant impact. Further examples of best practice covering different stages of the pathway are given in the report.
The NHS and Government have made significant strides in supporting genomic testing, but there are still gaps that need addressing to enable quicker turnaround times. While initiatives like the NHS Genomic Medicine Service in England and the National Genomic Test Directory demonstrate commitment to advancing genomic healthcare, challenges remain in areas such as staffing, technology and transport.
It is pleasing that NHS England launched a Cancer Genomic Improvement Programme to assess regional performance of turnaround times from tissue acquisition to genomics reporting – and that the national lung cancer pathways in Scotland and Wales have recently been updated with more ambitious turnaround times in mind. But it is vital that the data that feed into these programmes, or result from them, are published so that learnings can be taken forward and progress made.
With the planned abolition on NHS England, it will be important to ensure that the current focus on improving genomic testing turnaround times in England is maintained.
By working collaboratively, multidisciplinary teams (MDTs) can create a more cohesive and efficient testing pathway, ultimately ensuring patients receive timely and accurate results with the potential for better treatment outcomes. MDTs bring together pathologists, oncologists, respiratory physicians and genomic scientists to align on testing priorities and reduce delays caused by miscommunication or fragmented processes.
Collaboration allows for real-time discussions and decision-making, ensuring that tissue samples are collected, processed and analysed efficiently without unnecessary back-and-forth.
MDTs can advocate for and implement shared digital platforms to track samples and results, reducing bottlenecks in the testing pathway. Pathologists and cytologists can provide immediate feedback during procedures, ensuring high-quality samples are obtained, which minimises the need for repeat biopsies.
However, one key recommendation within the UKLCC report is that reflex genomic testing is initiated as soon as a diagnosis of non-small cell lung cancer is made – without waiting for MDT meeting confirmation.
The UKLCC recommends that the devolved NHS and Government administrations adjust genomic laboratory turnaround-time targets for lung cancer samples to seven days. Several changes in clinical practice would be necessary to effectively achieve this.
First, the genomic laboratory hubs would need to be sufficiently resourced, operating a seven-day working model. This would require staggered shifts and flexible scheduling to avoid overburdening an already stretched NHS workforce.
Enhanced training would be needed. Increasing the number of training programmes for healthcare scientists and technicians would help address staffing shortages. Upskilling existing staff to take tissue efficiently would also alleviate pressure.
IT systems, such as digital tracking platforms, would also streamline the testing process by reducing administrative burdens and improving sample management.
The UKLCC report serves as a vital call to action, highlighting the transformative impact of timely genomic testing on patient outcomes and quality of life. By addressing systemic challenges, the report paves the way for a more efficient, equitable and personalised approach to lung cancer care across the UK.
Clinical lead for the UKLCC, professor of thoracic oncology at the University of Cambridge, and honorary consultant respiratory physician at Royal Papworth Hospital NHS Foundation Trust
An at-home saliva test that assesses genetic risk of prostate cancer is more accurate at detecting clinically significant disease than prostate-specific antigen (PSA) level or magnetic resonance imaging (MRI), UK researchers have reported.
The test developed at the Institute for Cancer Research provides men with a polygenic risk score on the bases of 130 gene variants known to be associated with in increased chance of prostate cancer.
A UK trial of the test in men aged 55-69 years found it was better at detecting disease that required treatment than PSA testing and had fewer false positives, the researchers reported in the New England Journal of Medicine.
It also accurately identified men with prostate cancer that was missed by an MRI scan.
A total of 6,393 participants had their polygenic risk score calculated using the test. Of those, 745 had a risk score in the 90th percentile or higher and were invited to have further screening.
The researchers said 468 underwent MRI and prostate biopsy, with cancer detected in 187, equating to 40%.
By comparison, 25% of men with a high PSA level will actually have prostate cancer, they said.
Of the 187 men who were found to have cancer, 118 (63.1%) had a PSA level below 3.0ug/L, which would usually indicate that no further screening is required.
Results showed 55% (n=101) of this group had an intermediate or higher risk of cancer that indicated treatment, but in 74 of those their cancer would not have been detected by current screening approaches of PSA test followed by MRI.
Overall, 125 men had prostate cancer confirmed by a biopsy that was not detected by the MRI.
The team also found 40 patients with aggressive cancers they otherwise would not have known about.
The researchers said the saliva test could offer an additional screening tool to be offered to men at higher risk of prostate cancer, or those presenting with symptoms.
Future studies will follow-up the men with high scores to monitor if they go on to develop prostate cancer. The test has also been updated after more variants were detected in men of Asian and African ancestry.
Last week, health secretary Wes Streeting week told MPs he wants to see a national screening programme for prostate cancer for men at high risk but that it must be evidenced based.
The National Screening Committee is currently evaluating several options for a targeted approach.
Evidence collection includes the UK TRANSFORM trial, which is directly comparing the saliva test to PSA and MRI scan, to assess whether those with a low genetic risk may benefit from an alternative screening tool.
Professor Ros Eeles, professor of oncogenetics at the Institute of Cancer Research and consultant in clinical oncology and cancer genetics at The Royal Marsden NHS Foundation Trust, said: ‘We have shown that a relatively simple, inexpensive spit test to identify men of European heritage at higher risk due to their genetic makeup is an effective tool to catch prostate cancer early.
‘Building on decades of research into the genetic markers of prostate cancer, our study shows that the theory does work in practice – we can identify men at risk of aggressive cancers who need further tests and spare the men who are at lower risk from unnecessary treatments.’
Naser Turabi, director of evidence and implementation at Cancer Research UK, said: ‘Right now, there’s no reliable method to detect aggressive prostate cancer, but this study brings us a step closer to finding the disease sooner in those people who need treatment.
‘It’s encouraging to see that genetic testing might help to guide a more targeted approach to screening based on someone’s risk of developing prostate cancer.
‘More research is now needed to confirm if this tool can save lives from the disease so that it can be rolled out to improve diagnosis.’
A version of this article was originally published by our sister publication Pulse.
Early combination lipid-lowering therapy with statins and ezetimibe significantly improves prognosis after myocardial infarction compared with later adding ezetimibe or not giving it at all, a study finds.
Current treatment guidelines recommended giving statins immediately after a myocardial infarction to lower low-density lipoprotein cholesterol (LDL-C) levels, researchers from Sweden’s Lund University and the UK’s Imperial College London wrote in the Journal of the American College of Cardiology.
However, most patients needed an additional therapy, such as ezetimibe, to reach target lipid levels, and this ‘stepwise’ approach to additional lipid-lowering therapy often meant a delay in patients attaining recommended LDL-C levels.
The researchers used Swedish registry data from almost 36,000 lipid-lowering naive patients hospitalised between 2015 and 2022 for myocardial infarction and discharged on a statin. They conducted statistical modelling to emulate a trial comparing cardiovascular outcomes and cardiovascular death from three lipid-lowering strategies.
Outcomes were analysed for 6,040 patients (16.9%) who received statins and ezetimibe within 12 weeks of a myocardial infarction, compared with 6,495 patients (18.1%) who received statins with ezetimibe added at between 13 weeks and 16 months post-myocardial infarction, and a final group of 23,291 patients (65%) who only received statins.
They found ezetimibe combination therapy, either early or late, resulted in a greater proportion of patients reaching an LDL-C of <1.4 mmol/L compared with no add-on ezetimibe.
Early combination therapy was associated with a greater absolute and relative benefit in terms of major adverse cardiovascular events (MACE) compared with delaying combination therapy.
The researchers highlighted that approximately two-thirds of patients had not received add-on therapy with ezetimibe by 16 months post-myocardial infarction, and those patients experienced the highest risk of MACE and death.
Using the study population, they modelled that if 100% of patients received ezetimibe early, an estimated 133 myocardial infarctions could be avoided in a population of 10,000 patients in three years.
In the UK, which has an estimated 100,000 hospital myocardial infarction admissions annually, this would equate to an estimated 5,000 myocardial infarctions being prevented over a 10-year period.
Professor Margrét Leósdóttir, associate professor of internal medicine at Lund University and senior cardiology consultant at Skåne University Hospital, Malmö, Sweden highlighted that guidelines recommend the stepwise addition of lipid-lowering treatment with ezetimibe.
‘But it’s often the case that this escalation takes too long, it’s ineffective and patients are lost to follow-up,’ she said.
‘By giving patients a combination treatment earlier, we could help to prevent many more heart attacks.’
Combination therapy was not being applied up-front because it was not included in guidelines and clinicians were cautious about potential side effects and overmedication.
‘However, there are positive effects from applying both medicines as soon after the infarction as possible. Not doing this entails an increased risk,’ Professor Leósdóttir said.
‘In addition, the drug we have examined in the study causes few side effects and is readily available and inexpensive in many countries.’
Professor Leósdóttir hoped the research would provide support for changes in the recommendations to include early initiation of ezetimibe, and she noted a treatment algorithm had already been introduced at Skåne University Hospital with positive results.
Patients had achieved their treatment goals earlier and two months after the myocardial infarction twice as many patients have reduced their bad cholesterol to the target level, compared with outcomes under previous practice.
Co-investigator Professor Kausik Ray, professor of public health at Imperial College London’s School of Public Health, UK, said post-myocardial infarction care pathways must change given the study results.
‘Our findings suggest that a simple change in treatment guidelines could have a huge impact on patients and reduce the demand on the NHS. Ezetimibe is already widely available and prescribed for relatively low cost,’ he said.
‘This add on therapy could be rolled out for around £350 a year per patient, which is a huge cost saving compared to the lasting impacts of treating heart attacks and the impact they have on patients’ lives.’
Previous research by Sweden’s Uppsala University using the Swedish National Prescribed Drug Registry found that women were less likely than men to be prescribed cholesterol-lowering drugs despite identical guidelines, with 5% of women treated with statin plus ezetimibe compared with 8% of men. This article was originally published by our sister publication Hospital Pharmacy Europe.
23rd April 2025
Timing the use of a commonly prescribed asthma inhaler in the mid-afternoon could lead to improved clinical outcomes, according to new research led by the University of Manchester.
The study, published in the journal Thorax, found that a once-daily dose of inhaled beclomethasone was most effective when taken between 3pm and 4pm.
The findings suggest that aligning asthma medication with the body’s natural circadian rhythms could enhance its effectiveness without increasing the dose.
Conducted at the Medicines Evaluation Unit at Wythenshawe Hospital and funded by the Jon Moulton Charity Trust, this study builds on previous research by the same team, which found that immune cells displayed heightened steroid sensitivity at 4pm compared to 4am.
The researchers believe the latest findings add further support to the hypothesis that the body’s inflammatory cascade tends to intensify in the mid-afternoon.
Lead researcher Dr Hannah Durrington, honorary consultant physician at Manchester University NHS Foundation Trust and senior clinical lecturer and Medical Research Council clinician scientist at the University of Manchester, said the findings could have implications for both patient outcomes and treatment planning.
‘Up to three quarters of patients experience worsening symptoms overnight, and up to 80% of fatal asthma attacks occur at night,’ she said.
‘This study shows that aligning the timing of beclomethasone with the body clock could have significant impacts on treatment outcomes, and this occurred without any of the associated adverse effects or costs of taking higher doses of steroids.’
The randomised cross-over study – which was supported by the NIHR Manchester Biomedical Research Centre (BRC) and the NIHR Oxford Health BRC – involved 21 patients who each received three different dosing regimens over 28-day periods, separated by two-week washouts.
Participants were administered 400µg once-daily between 8am and 9am for regimen one, once-daily between 3pm and 4pm for regimen two, and the third was 200µg twice-daily (8am/8pm) – the standard regimen in UK practice.
Researchers assessed lung function blood eosinophil counts and serum cortisol levels.
The mid-afternoon dose led to the largest overnight improvement in lung function and significantly greater suppression of eosinophils, compared to both morning-only and standard twice-daily regimens.
Dr Durrington believes the results offer promising avenues for developing personalised approaches to asthma care.
‘Our findings provide key opportunities for novel chronotherapeutic development in asthma, leading to the possibility of tailored therapy based on individuals’ preference in timing of drug administration and their biological rhythm in disease,’ she said.
The research team is now calling for larger-scale trials to assess the to establish clinical feasibility in a real-life setting and to evaluate the health and economic impacts.
A version of this article was originally published by our sister publication Nursing in Practice.
17th April 2025
A recent UK study evaluating the safety of pleural procedures analysed incidents related to pleural interventions, particularly chest drain insertions and aspirations. Lead author Dr Andrew Stanton provides expert insight into the study’s findings and emphasises the need for better compliance with guidelines, standardised training and improved hospital protocols, including mandatory appropriate use of ultrasound, to enhance safety.
The 2021 British Thoracic Society’s pleural services organisational audit highlighted ongoing risks of harm from pleural procedures. It analysed data from 111 institutions, including 85 Trusts, and raised significant concerns regarding patient safety and clinical governance.
A total of 62% of sites reported a patient safety incident related to thoracic ultrasound or pleural procedures, with 33% of these incidents resulting in severe harm and 20% in catastrophic harm or death.
We were understandably concerned about the report’s findings and sought to gain a deeper understanding of the underlying factors contributing to these issues by reviewing patient safety incidents from the National Reporting and Learning System (NRLS).
Our study requested incident-level patient safety data from NRLS for any Level 3 (moderate harm), 4 (severe harm) and 5 (catastrophic harm/death) incidents resulting from chest drain insertion or pleural aspiration submitted between 1 April 2018 and 30 March 2022.
A total of 256 incidents were identified, with 21 deemed relevant, including two fatalities. Of the incidents, 17 involved direct organ puncture, and 13 of those involved the liver.
Only four instances clearly detailed the use of an ultrasound-assisted approach. In the other cases, ultrasound usage was largely unmentioned, or the methods employed were unclear or inappropriate. Most of the events (n=19) took place outside of respiratory settings.
We believe that anyone undertaking thoracic ultrasound or pleural procedures requires appropriate training. Trusts should ensure that anyone using thoracic ultrasound is properly trained, and the British Thoracic Society has published a training standard to facilitate this.
Our paper raised concerns that ultrasound may not have been used appropriately in certain instances, potentially contributing to incidents. We need to gain a better understanding of this. However, Trusts must ensure that individuals using ultrasound do so correctly and that pleural procedures are conducted either by those performing the procedure or by those guiding the procedure.
If an ultrasound is conducted by someone else, the proceduralist must witness the findings directly. Any remote or prior ‘X-marks the spot’ approach must be avoided.
According to the standards for ultrasound training, any operator conducting an ultrasound scan who is unsure of their findings must consult a more experienced operator before performing any invasive procedures.
We are fully aware that providing emergency-level operators for both thoracic ultrasound and pleural procedures in out-of-hours settings is challenging, particularly in hospital environments lacking a specific respiratory on-call service. Nonetheless, we hope that the training standards for thoracic ultrasound will allow for a broader pool of emergency operators to be trained, promoting multidisciplinary collaboration in emergency, critical care and acute medicine to facilitate this process.
Facilitating conversations at the local level is essential for promoting close collaboration among all providers of pleural interventions.
It is crucial to recognise the need for a thoracic ultrasound before any pleural intervention for fluid. Leadership from speciality groups and societies is required to ensure that these safety protocols are integrated into practice across all areas where pleural interventions occur.
Our study primarily reinforces national guidelines regarding appropriate safety standards, particularly in the use of ultrasound. We still need to gain a better understanding of why these instances are occurring to provide actionable recommendations for organisations to improve safety standards. We hope the upcoming National Confidential Enquiry into Patient Outcome and Death (NCEPOD) study will achieve that.
Andrew Stanton MBChB MD FRCP
Consultant respiratory physician, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK
16th April 2025
Delayed or missed doses of time critical medication (TCM) in emergency departments (EDs) is putting patient safety at risk, according to a new report by the Royal College of Emergency Medicine (RCEM).
Its ‘Time Critical Medication QIP 2023-24’ report found that less than half of eligible patients (46.6%) taking TCM for conditions such as diabetes and Parkinson’s disease were identified within 30 minutes of their arrival in ED.
Out of 10,850 eligible doses, only 32.4% were administered within 30 minutes of the expected time, increasing the risk of patient harm.
The findings come from the first year of RCEM’s three-year Quality Improvement Programme (QIP), which runs until 2026 and is supported by Parkinson’s UK and Diabetes UK.
Collating and analysing data from 136 EDs across the UK, the QIP seeks to improve the timely administration of medication in EDs, focusing particularly on drugs such as insulin and levodopa.
The report highlights three clinical standards that were included as part of the QIP:
The majority of patients on TCM were identified by their named clinician (39.2%), however the named clinicians’ average time to TCM identification was 182 minutes.
Triage nurses identified 38.3% of patients on a TCM within an average time of 35 minutes. Only 0.27% of patients on a TCM were identified by a pharmacist.
From mid-August 2024, the report findings show a positive shift in patients identified as being on a TCM within 30 minutes of arrival in the ED to 53.13%, which the RCEM said signalled significant improvements.
The report lists a series of recommendations for departmental, Trust and national levels. This includes TCM being part of all ED inductions so that the process of patients getting all of their doses while in the ED can be started as early as possible.
EDs are also advised to ensure patients who have been identified to be on TCM, and have no medical reason not to give them, have an alert or task added by the triage nurse, assessment team, ED nurse or ED pharmacist, highlighting that all TCM doses need to be prescribed.
A further recommendation is for systems to be in place that will facilitate the timely administration of TCM, including self-administration, such as nursing staff having access to portable digital devices that alert when a TCM dose is due.
‘We need to allow and empower patients to manage their own TCM in the ED when appropriate, as this will reduce the risks of missed and delayed doses whilst their care needs are being assessed,’ the report said.
This follows the recent publication of a joint advisory statement on TCMs between the RCEM, the Association of Ambulance Chief Executives and the UK Clinical Pharmacy Association. It provides clear and practical guidance on allowing patients who are able to self-administer their own time critical medications to do so.
The report also stresses the need for EDs to ensure they are working towards previous RCEM recommendations regarding embedding clinical pharmacy services to support timely access to time critical medications.
Dr Jonny Acheson, an emergency medicine consultant at the Leicester Royal Infirmary who is leading the QIP and lives with Parkinson’s himself, said the findings should ‘serve as a call to action… to ensure no dose is ever missed in A&E’.
He added: ‘These medicines are critical to the quality of these patients’ lives, and we have a duty of care to ensure that they receive them when they should.
‘Despite continued pressure on ED staff, they have shown great commitment and resolve as we strive for further improvements nationally.’
Dr Ian Higginson, RCEM president elect who also leads on clinical quality at the College, added: ‘Missing doses of medication for illnesses such as Parkinson’s or diabetes is not just inconvenient, it is dangerous; and missing multiple doses can have serious consequences.
‘This first-year report reveals there is already some good work happening across the country. Now we just need to ensure that it is replicated in every ED and becomes embedded so that no one fears not being able to access their medication while in our care.
‘It is really critical we get this right – and we are determined to do so.’
Patient organisations have welcomed the spotlight on TCM management. Juliet Tizzard, director of external relations at Parkinson’s UK, said: ‘People with Parkinson’s are at risk of significant harm if they don’t receive their medication on time, every time, and so we are proud to support the college’s vital work in this field.
‘We have long called for people with Parkinson’s in hospital to get their medication on time but have found that over half don’t.’
Helen O’Kelly, assistant director of services, communities and improvement at Diabetes UK, said the positive shift seen in the first year of the QIP is ‘encouraging’, adding that the charity ‘[looks] forward to seeing the results as the programme continues.’
A washable, textile-based sensor array combined with deep learning can identify six distinct sleep states, including sub-healthy and high-risk patterns, with up to 98.6% accuracy, according to a new study.
Sleep disorders affect health, productivity and quality of life worldwide, yet conventional methods like polysomnography are invasive and impractical for daily monitoring.
Current wearable devices often struggle with motion artifacts or require multiple sensors, limiting their capacity for long-term, comfortable use.
This study aimed to address this unmet need by developing a user-friendly ‘diagnostic e-textile’ that detects subtle extrinsic laryngeal muscle vibrations, while ignoring regular sleep movements such as tossing and turning, to classify various sleep disorders while remaining comfortable, robust and scalable for home use.
These sleep disorders range from normal nasal breathing, mouth breathing, snoring, bruxism, central sleep apnoea to obstructive sleep apnoea.
The research team integrated a strain sensor array onto the collar of a standard garment using specialised printing processes and chemical treatments. The sensors captured minuscule vibrations without requiring tight skin contact or precise positioning, before feeding these signals into a deep learning neural network called SleepNet.
The SleepNet analysis model was ‘trained’ on five participants and then applied to a dataset from two new participants. Simulated conditions for bruxism and sleep apnoea were established under clinical guidance.
Of the tested conditions, the garment-algorithm combination achieved 98.6% overall accuracy. The sensor array performed reliably against motion artifacts, without the need for precise positioning. SleepNet classified sleep abnormality episodes in real time and performed robustly, the authors concluded.
By providing a comfortable, single-modality garment with high fidelity in classifying multiple sleep disorders, this system could improve early detection and management of sleep issues. The authors consider their innovation as ‘ultimately improving understanding and management of sleep disorders’.
Commenting on the results, Professor Luigi Occhipinti, principal investigator of the study, said: ‘Sleep is so important to health, and reliable sleep monitoring can be key in preventative care. Since this garment can be used at home, rather than in a hospital or clinic, it can alert users to changes in their sleep that they can then discuss with their doctor.’
Small sample sizes and partly simulated data for complex apnoea states underscore the need for broader, real-world evaluations, the authors said. Ongoing work should extend testing to larger, more diverse populations, they added.
The upcoming Clinical Excellence in Respiratory Care event includes a session from Sophie West, consultant respiratory and sleep physician at Newcastle upon Tyne NHS Foundation Trust, who will discuss the future of sleep medicine with a focus on diagnostic wearables and artificial intelligence.
Register now to attend on 7 May 2025, or watch on-demand shortly after the event via our Clinical Excellence Catch-up zone.
Reference
Tang C et al. A deep learning–enabled smart garment for accurate and versatile monitoring of sleep conditions in daily life. Proceedings of the National Academy of Sciences, 122(7): e2420498122 (2025).
Providing patients with a specific appointment time for lung cancer screening results in higher attendance than sending them an open invitation, a recent study has revealed.
Although UK lung cancer screening uptake stands at 20.4-52.6%, it still lags behind breast cancer (64.6%) and bowel cancer (68.9%) screening programmes.
This observational study evaluated how timed appointments and opt-out reminders influenced participation in the North-Central London Targeted Lung Health Check programme, compared with opt-in open invitations.
Adults aged 55-74 with a recorded smoking history were recruited in two waves for lung cancer screening: open invitations between December 2022 and July 2023, followed by timed appointments between July 2023 and February 2024.
Individuals who did not respond received up to three reminders, and those deemed ineligible or who had a recent computed tomography scan were excluded from further screening.
The primary analysis compared response rates by invitation method and assessed the benefit of reminders, while secondary analyses focused on under-represented groups in screening.
Of 66,964 individuals included in the analysis, significantly more participants who received a timed appointment responded immediately (53%) compared with those who were sent an open invitation (29.8%, p<0.0001).
Among individuals who initially did not respond, reminders prompted a greater response from those who had been sent open invitations (19.2%) than from those who received timed appointments (9.3%).
Furthermore, response rates after a reminder were higher in certain subgroups, including those of black ethnicity, those from deprived areas and current smokers.
Timed appointments and reminders for lung cancer screening are strongly advocated to increase participation in national lung cancer screening programmes, the study authors said.
These results align with previous research in trial settings, reinforcing the need for accurate primary care records to better identify and engage high-risk individuals.
The study authors recommended future initiatives to refine invitation strategies and integrate novel data-collection methods, such as mobile apps or messaging systems.
Reference
Bhamani A, Naidu SB, Patrick T, et al. Improving uptake of lung cancer screening: an observational study on the impact of timed appointments and reminders. Thorax. 2025 Mar 3:thorax-2024-222433.
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