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6th March 2025
New research examining the climatic impact of gas emissions from operating theatres reinforces that anaesthetic gases such as desflurane significantly contribute to the carbon footprint of healthcare systems and highlights considerations for reducing this.
Researchers conducted a bottom-up purchase analysis of inhalation anaesthetics used in Dutch hospitals and surveyed anaesthesiologists online about their preferences for anaesthetic agents. The study aimed to quantify the climatic impact of inhaled anaesthetics in the Netherlands, examine the preferred anaesthesia techniques of Dutch anaesthesiologists and explore possible opportunities for reducing emissions.
Over 88% of hospital organisations in the Netherlands (n=61/69) provided purchase data for volatile anaesthetic agents. Inhaled anaesthetics contributed 12.2 kilotons of CO₂ equivalent emissions in 2019, making up 0.07% of the total emissions from the Dutch healthcare system. This is comparable to the annual emissions of approximately 6,700 cars.
The most commonly used inhaled anaesthetic was sevoflurane, which accounted for 93.4% of the total volume (9,178 litres). Other inhaled anaesthetics included desflurane and isoflurane, accounting for 4.1% (404 litres) and 2.5% (245 litres) respectively.
The survey also revealed that clinicians preferred intravenous anaesthetics over inhaled gasses. Propofol was the first choice of anaesthetic for 70% of the 182 respondents. The inhalation anaesthetic desflurane was only available in 16% of hospitals and 83% of anaesthesiologists reported never using it.
Nitrous oxide was also not commonly used, with 63% of respondents reporting they never used it and 27% of participants reporting usage in less than 5% of their cases.
The low use of high-emission anaesthetics such as desflurane and nitrous oxide, combined with the strong preference for intravenous propofol, contributes to the relatively low greenhouse gas emissions from inhaled anaesthetics in the Netherlands compared to other countries.
In the UK, for example, anaesthetic and analgesic gases were responsible for around 2% of all NHS emissions in 2023. The NHS committed to lowering this by 40% through the transformation of anaesthetic practices such as the nationwide decommissioning of desflurane, which came into force in April 2024.
Anaesthetic gases can have a significant environmental impact, with desflurane having a global warming potential (GWP) 2,500 times greater than carbon dioxide, while sevoflurane has 130 times GWP of carbon dioxide.
This study supports the continued reduction of high-emission inhaled anaesthetics and the promotion of intravenous alternatives as a way to transition to more sustainable anaesthetic practices.
The researchers also suggest that implementing guidelines, improving education on the environmental impact of anaesthesia choices, and optimising gas capture and recycling systems could further reduce the carbon footprint of anaesthetic procedures.
Reference
Friedericy, H. J. et al. Greenhouse gas emissions due to inhalation anaesthetics in the Netherlands, usage data and a survey of preferences among Dutch anaesthesiologists. European Journal of Anaesthesiology and Intensive Care. 2025, Feb.:DOI: 10.1097/EA9.0000000000000065.
5th March 2025
A new framework agreement for artificial intelligence (AI) in healthcare is being planned by NHS Shared Business Services (NHS SBS).
The framework, called the Healthcare Artificial Intelligence Solutions, will replace the AI Software in Neuroscience for Stroke Decision Support and AI Imaging and Radiotherapy Equipment, Associated Products and Diagnostic Imaging frameworks, which are both due to expire in September 2025.
Though still under development, the new framework is set to be split into six ‘lots’, including radiology and diagnostic imaging, predictive analytics and operational efficiency. These are provisionally:
Lot 1: Radiology and diagnostic imaging
Early detection and diagnostic through data analysis and medical imaging for radiology and diagnostic imaging such as neurology, oncology, cardiology, urology and ophthalmology.
Lot 2: Pathological diagnosis and early detection
Early detection and diagnostic through data analysis and medical imaging for pathology such as haematology, virology and dermatology.
Lot 3: Predictive analytics
Solutions that improve patient flow and experience by making well informed decisions based on health records (system interoperability), hospital admissions and discharge and patient appointments.
Lot 4: Research and development
Applications to support cross institution collaboration and research such as drug discovery and clinical trials.
Lot 5: Operational efficiency
Solutions to optimise clinical workflow such as resource management and supply chain management.
Lot 6: Specialist support
AI specialist support such as consultancy, implementation and training.
Those with an interest in AI or who are looking to implement it in the future have been asked to contribute to the framework agreement by the NHS SBS, which provides business support services to the NHS in England.
Kelly Bevington, senior category manager for digital and IT at NHS SBS, said: ‘AI has the potential to transform NHS patient care, speeding up diagnosis and treatment times by ensuring that expert clinical resource is targeted where it has the greatest impact for the patient.
‘Our new framework agreement will focus on the application of AI in different specialities by providing new efficient ways to prevent, diagnose, treat illness and optimise clinical workflow.’
It comes after it was announced that AI will be used to help detect breast cancer in 30 sites across the England as part of a new trial to test how AI tools can be used to help early diagnosis.
The Government has also set out a new AI action plan this year, to try and help the public sector spend less time on admin and more on delivering services. While health secretary Wes Streeting has previously said that shifting from analogue to digital is the priority within this parliament.
Last year, three quarters of the public reported supporting the sharing of their personal health data to aid the development of AI systems in the NHS.
A version of this article was originally published by our sister publication Healthcare Leader.
Despite significant clinical and scientific advancements, pulmonary embolism remains a challenge to diagnose and manage. Evidence-based guidelines address the intricacies, but recommendations can vary and appear inconsistent, potentially complicating the management pathway. Here, Dr Marco Zuin shares personal experience and key guideline recommendations for managing the condition according to international standards.
As a cardiovascular specialist, I have witnessed first-hand the challenges and complexities of managing acute pulmonary embolism. It is a condition that demands rapid, decisive action, a keen understanding of risk stratification and a willingness to adapt treatment strategies based on the individual patient’s needs.
Pulmonary embolism remains a leading cause of cardiovascular mortality. However, its timely recognition can be challenging. It is estimated that around 20% of patients with the condition are diagnosed more than 10 days after the onset of symptoms.1 As it can be fatal if untreated, prompt and accurate diagnosis is crucial.2
Turning to evidence-based clinical practice guidelines can support the diagnosis and management of pulmonary embolism, but heterogeneity in recommendations can lead to uncertainty. In a recent review of international PE guidelines, we highlighted key areas of consistency and divergence, emphasising critical clinical and research needs.
Early diagnosis of pulmonary embolism is emphasised by many of the major guidelines. The diagnostic approach begins with a comprehensive patient assessment. As clinicians, we utilise validated tools, such as the Wells Score3 or Geneva Score,4 to determine the pre-test probability of pulmonary embolism.
In patients with low pre-test probability and negative D-dimer results, we can confidently exclude pulmonary embolism. However, imaging becomes essential in cases with elevated D-dimer levels or high pre-test probability.
Computed tomographic pulmonary angiography (CTPA) remains the gold-standard imaging modality for acute pulmonary embolism diagnosis, providing detailed visualisation of the pulmonary vasculature.5 However, alternative approaches, such as V/Q scanning or bedside echocardiography can be valuable in haemodynamically unstable patients when CTPA is not feasible or is contraindicated.5
Once a diagnosis is confirmed, risk stratification becomes critical.5 Validated tools, such as the Pulmonary Embolism Severity Index (PESI)6 are used. The PESI score is complex and based on 11 different variables, so a simplified version known as sPESI, which evaluates six variables, is also used to categorise patients into low-, intermediate- or high-risk groups.7
However, these tools have limitations. While PESI and sPESI accurately identify one-third of low-risk patients with acute symptomatic PE, they may overestimate the risk for some patients. Indeed, both scores exhibit only moderate discriminative ability, and may misclassify patients. For instance, sPESI tends to overestimate risk, potentially leading to unnecessary hospitalisations for some low-risk individuals. Furthermore, PESI and sPESI rely on clinical variables that may not fully capture the heterogeneity of intermediate-risk patients, who might benefit from more advanced risk stratification methods incorporating biomarkers or imaging.
These limitations highlight the need for integrating broader clinical information and developing improved predictive models for pulmonary embolism management.
Anticoagulation is the cornerstone of treatment across all risk levels. Empiric therapeutic anticoagulation should be initiated while awaiting diagnostic results for patients with suspected pulmonary embolism and an intermediate or high pre-test probability.
According to the European Society of Cardiology (ESC) guidelines,8 direct oral anticoagulants have transformed treatment protocols for low-risk patients. They offer home treatment and an efficient, predictable management strategy that is non-inferior to vitamin K antagonists while being associated with a lower risk of bleeding.
Patients at intermediate risk present a greater challenge.
The ESC guidelines classify these patients as intermediate-low risk in the presence of a right ventricular dysfunction or biomarker elevation, but not both, or intermediate-high risk in the presence of a right ventricular dysfunction and biomarker elevation.8
For intermediate-low risk, standard anticoagulation is the initial treatment.5
When it comes to intermediate-high risk patients, treatment options beyond anticoagulation with unfractionated heparin, such as catheter embolectomy, catheter thrombolysis or surgical embolectomy, are considered due to the risk of sudden clinical deterioration, particularly within the first 48–72 hours after symptom onset.5,9
High-risk patients with pulmonary embolism, defined as those haemodynamically unstable at admission, demand aggressive intervention, including systemic thrombolysis, surgical embolectomy and, in select cases, even extracorporeal membrane oxygen therapy.5,10
In these patients, we must be meticulous in assessing contraindications to thrombolysis to prevent potentially catastrophic complications and to avoid delays in the reperfusion process.
As the field evolves, especially with the emergence of new catheter-based technologies, cardiovascular specialists will take on a more active role in managing patients with pulmonary embolism. We must embrace these innovations and continue to refine our treatment strategies to enhance the lives of these patients.
At the same time, we must encourage a multidisciplinary approach by creating local pulmonary embolism response teams.5 These teams, comprising experts from various specialties, collaborate to assess and develop patient treatment plans, functioning similarly to stroke or ST segment elevation myocardial infarction teams.
This strategy will promote the use of advanced diagnostic and therapeutic tools, prioritise person-centred care and continuously improve outcomes for patients with pulmonary embolism.
Marco Zuin MD MS
Cardiology Unit, Department of Translational Medicine University of Ferrara and Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
A new study has demonstrated how advanced techniques such as cell-free DNA (cfDNA) sequencing can uncover the complex genetic and epigenetic factors that cause aggressive paediatric cancers and their recurrence. This could support diagnosis, provide prognostic information and pave the way for new targeted novel therapeutics.
Oncologists from the Institute of Cancer Research in London showed that cfDNA sequencing can give a more complete picture of how a tumour develops over time and how it can adapt and change in response to treatment.
They profiled a large, diverse cohort of children with relapsed or progressive solid tumours, analysing matched samples taken at diagnosis and relapse. They sampled both tumour tissue and paired plasma-derived cfDNA, which contains fragments of circulating tumour DNA (ctDNA).
Both sampling methods revealed the same types of genetic mutations, and serial tumour sequencing identified genetic and epigenetic drivers of relapse. However, if sufficient ctDNA was present, cfDNA sequencing captured a wider spectrum of mutant alleles and a higher degree of intra-tumour heterogeneity. Heterogeneity can explain why some tumours resist treatment.
In some patients, cfDNA sequencing could detect additional DNA mutations missed by the original tumour biopsy. Since cfDNA sequencing only requires a blood sample from the patient, it is much less invasive than a tumour biopsy, which usually requires a general anaesthetic, and can offer enhanced clinical information. It is also relatively low cost and has the potential to be applied serially and at scale, the researchers said.
This study, the Stratified Medicine Paediatrics (SMPaeds1) programme, shows the value of cfDNA analysis for children with cancer. It offers multiple potential applications including supporting diagnosis, providing prognostic information, identifying epigenetic targets for novel therapeutics, and the potential for serial sampling to understand how specific therapies alter epigenetic programming, the researchers concluded.
They are now working with colleagues across Europe to transfer the availability of cfDNA sequencing from research to clinical settings.
A future study, SMPaeds2, will investigate blood cancers and solid tumours in children and young people, including cancers of the brain, muscle and bone, which can be more challenging to access, diagnose and treat.
Reference
George, S. L. et al. Stratified Medicine Pediatrics: Cell-Free DNA and Serial Tumor Sequencing Identifies Subtype-Specific Cancer Evolution and Epigenetic States. Cancer Discovery. 2025, Feb. 04: DOI: 10.1158/2159-8290.CD-24-0916.
3rd March 2025
Aspergillus spp. are abundant environmental and residential fungal pathogens associated with negative outcomes in patients suffering from chronic respiratory diseases. Individuals with COPD are particularly vulnerable to Aspergillus infection. In this context, Professor David Denning evaluates the clinical spectrum of aspergillosis in COPD, emphasising that timely and accurate diagnosis is essential for managing the associated burden of exacerbations and mortality.
Chronic obstructive pulmonary disease (COPD) is a significant clinical and public health problem and very burdensome for those affected. One of the underrated drivers of ill health and death in COPD is the airborne and colonising fungus Aspergillus fumigatus (A. fumigatus).1
Human exposure to Aspergillus is common, and some of the inhaled species will be A. fumigatus. In most people, airway macrophages and epithelial cells kill most, if not all, of these spores before they can germinate. The protein coat of Aspergillus spores elicits no discernible immune response; the immune system starts to take notice and respond only if the spores swell and then germinate.
However, the airways are not typical in those with COPD and Aspergillus spores can persist for longer, leading to germination. This fungal persistence results from compromised epithelial cells and probably inhaled or systemic corticosteroid use, which further impairs cell activity.2 Mucus in the airway prevents phagocytes from reaching all spores, thereby aiding Aspergillus surviving and growing in the airways in those with COPD and severe asthma.
The consequences of this shift in the relationship between inhaled Aspergillus and COPD lungs can be profound:
The first extensive study documenting invasive aspergillosis in hospitalised COPD patients was conducted in Madrid.3 Between 2000 and 2007, 53 out of 239 (22%) patients with a positive Aspergillus culture (A. fumigatus 83%) were found to have invasive aspergillosis, and 72% died. Most of the patients were taking corticosteroids upon admission.
This was followed by a case-control study from Guangzhou of 30 COPD patients with invasive aspergillosis in which progressive infiltrates, systemic corticosteroids, comorbidity and increased antibiotic use were remarkable.4 COPD patients had 43% mortality compared with 11% in the control group. In both studies, bacterial pathogens were frequently found in sputum, and fever was usually absent.
COPD is the most common underlying diagnosis observed in patients with chronic pulmonary aspergillosis (CPA) in developed countries. Tuberculosis and non-tuberculous mycobacterial infection are the leading causes in other regions. However, CPA is a rare complication of COPD, considering the number of patients with COPD worldwide.1
CPA typically manifests radiologically as upper lobe cavitation accompanied by pleural thickening. A fungal ball (aspergilloma) is seen in less than 40% of patients and is better visualised on CT scans. More commonly, a cavity has an irregular interior surface, indicating fungal growth. The key diagnostic test for CPA is Aspergillus IgG (precipitins), which has a sensitivity of 80–92%.
A less common finding is one or more Aspergillus nodules. In COPD patients, a new nodule sparks consideration of malignancy.
In a Danish study assessing chest CT scans in patients with potential malignancy, 16 of 992 patients (1.6%) had an Aspergillus nodule.5
Clearly, the prognosis and management of carcinoma of the lung or Aspergillus nodule are quite different. If resected, antifungal therapy both before and during surgery reduces the risk of relapse, whereas administration after surgery does not.6
Most cases of Aspergillus bronchitis occur in patients with established bronchiectasis, cystic fibrosis or follow lung transplantation.7
Defined as two or more positive respiratory cultures or positive Aspergillus polymerase chain reaction (PCR) tests in a symptomatic patient without evidence of other forms of aspergillosis, affected individuals are typically highly symptomatic.
Excess sputum and mucus, along with mucous obstruction, are common and often accompanied by mild haemoptysis, significant breathlessness, chronic cough and concurrent bacterial bronchitis. The response to antifungal therapy, typically administered for four months, is encouraging. Unfortunately, relapses are relatively common.
Many factors drive COPD exacerbations. These include:
A recent study from Singapore and Vancouver found a direct relationship between environmental A. fumigatus and exacerbation frequency, as well as for one of the major allergenic proteins of A. fumigatus.8
Sputum fungal cultures may or may not be positive, but a history of recent potential fungal exposure, such as damp housing conditions or a dusty environment, may provide clues for future avoidance strategies. It is not known if antifungal therapy would reduce exacerbation frequency, but it is likely to be beneficial in colonised patients. Corticosteroids given to suppress exacerbations may be key drivers of the development of invasive or chronic pulmonary aspergillosis.
A history of mould and damp exposure should alert clinicians to the possibility of aspergillosis in patients with COPD. Corticosteroid dose and duration both independently increase the risk of invasive aspergillosis.
Three tools help identify the patients with aspergillosis:
Detecting Aspergillus antigen (galactomannan) in serum may be helpful in severely ill patients who are being considered for intensive care support. If bronchoscopy is not contraindicated, it is very helpful in diagnosing Aspergillus bronchitis and for collecting samples for direct microscopy, fungal culture, Aspergillus PCR and Aspergillus antigen, as well as testing for other pathogens.
In patients experiencing a COPD exacerbation, minimising residential exposure to mould, treating Aspergillus colonisation with an oral antifungal (in the author’s opinion) and giving only short courses of systemic corticosteroids are appropriate.
In those with possible invasive aspergillosis, immediate antifungal therapy with voriconazole, posaconazole or isavuconazole is indicated. Stopping corticosteroids is important as the risk of death increases by 250% if continued,11 and full supportive care is necessary.
The usual steps in those with CPA are referral to a specialist with expertise in this challenging condition, treatment of concurrent bacterial infection, immunisation against Pneumococcus (preferably with Prevenar), avoidance of corticosteroids, addressing haemoptysis and giving antifungal therapy.
With an estimated 200–500 million patients with COPD globally, over 50 million admissions to hospital12 and multiple forms of aspergillosis, emergency, general medical and respiratory consultants will see these patients in various guises. Aspergillosis tends to be clinically ‘quiet’, and, unless appropriate diagnostics are sought, it can be entirely overlooked.
Judicious use of corticosteroids and modern azole antifungal therapy has the potential to really reduce mortality and morbidity in COPD.
Professor David Denning FRCP FRCPath FMedSci
Principal investigator, Manchester Fungal Infection Group, University of Manchester, UK
28th February 2025
A recent study comparing the performance of artificial intelligence (AI) to certified electrocardiogram (ECG) technicians in analysing ambulatory ECG recordings found that AI outperformed technicians, significantly reducing missed diagnoses while slightly increasing false alarms.
The group of international researchers suggested that using AI to analyse ECGs could facilitate direct-to-physician reporting, cutting costs, improving access to care and enhancing patient outcomes.
The AI model called DeepRhythmAI correctly diagnosed more cases than technicians in ECG analysis, demonstrating a 98.6% sensitivity in detecting critical arrhythmias compared to the 80.3% sensitivity achieved by technicians. However, the technology also increased the rate of false positive cases where arrhythmias were incorrectly identified (12 vs five events per 1,000 patient days).
The risk of a false-negative rate was significantly lower using DeepRhythmAI (3.2 vs 44.3 per 1,000 patients). However, the study showed that technicians were 14.1 times more likely to miss a diagnosis (95% CI = 10.4–19.0) than the AI technology.
The study population was a random sample of 14,606 patients (mean age = 65.5 ± 10 years, 42.8% males) being monitored in the United States for clinical indications of heart disease such as palpitations, syncope, dizziness, and examination for atrial fibrillation. The patients were observed between 2016 and 2019 for a mean of 14 ± 10 days using an ambulatory ECG monitor and were referred by 1,079 physicians from 166 clinics.
Beat-by-beat annotation of 14,606 individual ambulatory ECG recordings was analysed by one of 167 certified ECG technicians. To compare the performance of the AI model and the technicians, a random sample of 5,235 rhythm events – of which 2,236 events were identified as critical arrhythmias – was selected for annotation by one of 17 cardiologist consensus panels.
The researchers concluded that the AI model showed excellent negative predictive value for critical arrhythmias, substantially reducing false-negative findings, but this came at a modest cost of increased false-positive findings.
With the development of ECG technology, large amounts of ECG data have become available, which need to be interpreted by human technicians. The DeepRhythmAI model can save technicians time and improve the rate of missed diagnoses, while facilitating direct-to-physician reporting. This can potentially reduce costs and improve access to care and outcomes in patients who need ambulatory ECG monitoring, the researchers said.
Reference
Johnson, L.S. et al. Artificial intelligence for direct-to-physician reporting of ambulatory electrocardiography. Nature Medicine. 2025, Feb. 10: DOI: doi.org/10.1038/s41591-025-03516-x.
A tool that can integrate breast cancer transcriptomic datasets could help clinicians to more accurately diagnose the disease and better target treatment, a study has found.
High throughput transcriptomic profiling had refined subtyping of breast cancer and diagnostics, the researchers wrote in npj Breast Cancer, however its wider use has been hampered for a range of reasons including difficulties in integrating different sources of molecular data.
To develop a new integrated model, researchers initially focused on patients with early-stage breast cancer and used bulk ribonucleic acid (RNA)-sequencing and microarray data from the Cancer Genome Atlas Program and the Molecular Taxonomy of Breast Cancer International Consortium cohorts.
To integrate the datasets, they looked at the expression levels of 1,044 genes of interest, using various mathematical approaches to test different numerical schemes that best explained the data.
This unified space of breast cancer transcriptomes, known as EMBER, was able to predict phenotypes of transcriptomic profiles on a single sample basis, they explained, with key biological pathways, such as oestrogen receptor signalling and cell proliferation, determining sample position.
‘The localisation of a patient sample in the EMBER space provides a novel way to interpret the molecular subtypes as a continuum and find candidate biological pathways of resistance to endocrine therapy,’ they wrote.
The model was validated in four independent breast cancer patient cohorts and with samples from a window trial called POETIC, which showed the model could capture clinical responses to endocrine therapy.
‘We observed that high androgen receptor signalling and low TGFβ scores were associated with a poor response to endocrine therapy,’ the researchers wrote.
Furthermore, they said an oestrogen-receptor signalling score from the model was superior to the immunohistochemistry-based oestrogen-receptor index that clinicians currently use to select patients for endocrine therapy.
‘By not assigning a singular molecular subtype to a sample but rather a position in the EMBER space, we embrace the characteristics of a sample on a continuous scale thereby providing a high-resolution view of the entire neighbourhood,’ the researchers said.
‘We have shown here how all the data generated in large independent cohorts can be combined and used both in clinical practice and research, further enabling the use of genomics.’
The research was led by scientists from The Institute of Cancer Research (ICR), London, UK, and funded by the European Union’s Horizon 2020 Research and Innovation Programme Marie Skłodowska-Curie and the charity Breast Cancer Now.
Commenting on the research in February 2025, Dr Syed Haider, second author of the study and group leader of the Breast Cancer Research Bioinformatics Group at the ICR, said there had ‘previously been many efforts to integrate big data in breast cancer datasets, but their application to clinical samples had been somewhat limited’.
This transcriptomic tool was different in that it provided ‘a formal basis for understanding the aggressivity of a new patient’s tumour against a large knowledge base created from retrospective patient cohorts’, Dr Haider said.
‘Now, in theory, any time a patient is diagnosed with breast cancer and RNA sequencing can be performed on their biopsy, the sample can be placed in the EMBER space, and different prognostic and predictive factors can be determined,’ he said.
‘Until now, this has not been feasible because large numbers of samples must be accumulated and run in a single batch in order to extract enough information about the tumour to guide clinical decision making.’
The University of Cambridge’s Professor Raj Jena, the UK’s first clinical professor of AI in radiotherapy, has predicted that AI tools could use genomic information to help personalise cancer treatment.
‘Personalised medicine is very interesting to us because we now get so much information when a cancer is diagnosed, including genomics, which can highlight mutations and indicate a patient may benefit from some kind of targeted drug,’ he said in a recent interview with Hospital Healthcare Europe.
He added: ‘I think the paradigm changes around AI in medicine will come within the areas of precision medicine or drug discovery.’
27th February 2025
The Government has made ‘limited progress’ in achieving its vision of containing antimicrobial resistance (AMR), the National Audit Office (NAO) has warned.
The public spending watchdog investigated how the Government is addressing AMR in light of it being a ‘serous public health threat’, after the Covid-19 pandemic showed that the UK was ‘not as resilient’ to such threats ‘as it expected to be’.
In its newly published report, the watchdog said that the Government is taking the problem ‘seriously’, with AMR identified as one of 26 chronic national risks, but that it remains ‘a long way away’ from meeting targets set in 2019 as part of the National Action Plan (NAP19-24), which included:
The Government spent around £567m directly on AMR programmes between 2020/21 and 2023/24, while much more public money was spent on ‘relevant activities’ like purchasing antibiotics and cleaning hospitals, the report said.
Despite this, only one of the five domestic targets set in 2019 was met: reducing the use of antibiotics in food producing animals.
Drug-resistant infections in humans were found to have increased by 13% since the 2018 baseline, despite the target to reduce them by 10%.
The report also found that:
The NAO report found that human usage of antibiotics fell significantly in 2020 and 2021 before rising, so that the level in 2023 was only slightly lower than in 2018.
The Government attributed this to a post-pandemic increase in circulating infections, which increased demand for antibiotics, but the report noted that a ‘shift from face-to-face to online GP appointments’ may also have contributed, with ‘some research’ suggesting GPs may be ‘more likely to prescribe antimicrobials during virtual interactions’.
It is also of concern, and indicative of rising resistance, that prescriptions for the most important antibiotics, those designated ‘watch’ and ‘reserve’, where usage is recommended to be limited, has been increasing since 2020, the report added.
The fifth target was to create a way to count the proportion of prescriptions supported by diagnostic
tests, which was not achieved due to continuing unaddressed data limitations. NHS England reported to the NAO that this included ongoing use of paper prescriptions, diagnostic tests not being digitally recorded, pathology systems not being linked to electronic prescribing systems and the lack of a standardised national digital pathology system in hospitals.
The NAO report reiterated the NAP19–24 concern around the challenging nature of achieving such change, which it said explains the limited progress.
‘The UK’s fight against AMR is further complicated by the fact that its population is ageing and spending more years in ill health, both currently correlated with increased antimicrobial use,’ it said.
‘Sharp reductions in the sales of antimicrobials for animal use show that major changes can be achieved.
‘But the UK remains a long way from the 20-year vision the Government expressed in 2019: to control, contain and mitigate AMR through a lower burden of infection, the optimal use of antimicrobials and new treatments so that everyday illnesses can continue to be cured.’
Commenting on the report’s findings, head of the NAO Gareth Davies said: ‘Antimicrobial resistance presents a major public health threat and addressing it is a multifaceted challenge.
‘Government is responding but, so far, the results have been limited and the country needs to become more resilient to this long-term risk.
‘Government needs to consider whether its existing commitments and other efforts across the public sector will be enough to achieve its 20-year vision to contain and control AMR.’
Voicing its support for the healthcare workforce in addressing AMR, the British Society for Antimicrobial Chemotherapy said: ‘BSAC calls on the Government to invest in NHS infrastructure, which the report warns has “deteriorated in recent years” making it harder to keep buildings clean and isolate infectious patients.
‘There is also an urgent need to establish an independent body to oversee implementation of the UK’s AMR National Action Plan and to provide an annual progress report. To ensure coordinated and effective delivery, we reiterate our call for a named minister responsible for AMR.
‘As ever, BSAC stands ready to support the Government in tackling this growing global threat and ensuring the healthcare workforce is fully equipped to save and improve lives.‘
Public accounts committee chair Sir Geoffrey Clifton-Brown MP added: ‘The world needs to take the problem of antimicrobial resistance seriously, and the UK Government must lead by example.
‘While the UK has been bold in its ambitions to try to address this issue, progress so far has been limited and public awareness is low.
‘In the shadow of Covid-19, this silent pandemic deserves equal attention to safeguard public health and the NHS.
‘Unless measurable change to reduce the spread of antimicrobial resistance is achieved, there remains a grave threat to human life and society as we know it.’
UK public health officials recently updated the list of first-option antibiotics, as part of efforts to tackle antimicrobial resistance.
Last year, research aimed at quantifying excess antibiotic use in an acute UK hospital found that nearly a quarter of antibiotic days of therapy were unnecessary.
A version of this article was originally published by our sister publication Pulse.
Left ventricular outflow tract (LVOT) obstruction is the most prevalent structural heart defect leading to neonatal collapse presenting to an emergency department, but a significant proportion of cases are initially misdiagnosed, UK research finds.
Cardiac abnormality was one of the most common causes of neonatal collapse, the research team wrote in the journal BMJ Paediatrics Open, with early recognition crucial for timely interventions and referral.
There were different types of cardiac pathology that could cause collapse, requiring different management, but there was minimal literature on the proportions of these presenting to emergency departments and how they were managed prior to being transferred to critical care, they said.
To fill this knowledge gap, the researchers designed a retrospective cohort analysis of cardiac-related neonatal collapses referred to the South Thames Retrieval Service (STRS) of the Evelina London Children’s Hospital – a regional paediatric intensive care retrieval team based in London.
Over the course of the nine-year study (2013-2021), the researchers found LVOT obstruction was the most prevalent cause of cardiac-related neonatal collapse referred to the retrieval service.
In addition, a significant proportion of cardiac-related neonatal collapses were misdiagnosed as non-cardiac pathology at referral, particularly those with LVOT obstruction and cardiomyopathy/myocarditis.
There were 71 neonates identified who met the study inclusion criteria of whom 49 (69%) had a structural heart defect, 12 (17%) had arrhythmia and 10 (14%) had cardiomyopathy/myocarditis.
Among those who had structural defects, the majority were related to decreased systemic flow due to LVOT obstruction (71%), followed by abnormal and mixing of circulation (22%).
At referral, the referring team identified a potential cardiac cause in 49 neonates, which accounted for 69% of cases.
In the remaining 22 neonates, the documented provisional diagnoses included sepsis in 12 cases, bronchiolitis in four cases, ‘neonatal collapse’ in four cases, metabolic cause in one case and shock in one case.
Patients with cardiomyopathy/myocarditis (30%) and LVOT obstruction (63%) were under-recognised compared with patients with abnormal mixing of circulation who were all recognised.
The researchers noted that the group with cardiomyopathy/myocarditis remained challenging to diagnose at all time points.
They also found that less than half of neonates with duct-dependent lesions received prostaglandin at referral, however, this improved to 97% during retrieval.
The number of patients requiring intubation and inotropic support also increased at various time points throughout the patient journey.
Among patients with structural defects, 48 (98%) required cardiac interventions at a median of one day after admission, the study found.
The median age at the time of referral was 11 days and the median weight at referral was 3.5kg, which ranged from 1.8kg to 5kg.
Senior author Dr Jon Lillie, consultant in paediatric care at Evelina London Children’s Hospital, and co-authors concluded that the study had identified a gap in diagnostic accuracy among cardiac-related neonatal collapses.
They noted that nearly all patients in the study cohort needed early cardiac interventions, adding that these conditions were likely to deteriorate without timely and appropriate surgical or cardiac catheter invention.
‘Therefore, it is imperative to optimise respiratory and cardiovascular support at presentation and minimise delay in transfer to the cardiac centre to improve survival and clinical outcomes,’ they wrote.
High clinical vigilance should be promoted among healthcare professionals who might encounter neonatal collapse, the authors added. There was also a need for comprehensive assessment, including femoral pulse evaluation, measurement of pre-ductal and post-ductal blood pressures and oxygen saturation levels.
The study authors also recommended a lower threshold for initiating prostaglandin therapy and timely referral for cardiac assessment.
‘Training sessions and clinical guidelines on indications and preparation of prostaglandin infusions may facilitate early administration of the medication,’ they concluded.
Last year, a simple cheek swab test showed promise in giving clinicians an understanding of a child’s risk of arrhythmogenic cardiomyopathy so sudden cardiac deaths can be prevented.
25th February 2025
A new study has found a major drop in respiratory syncytial virus (RSV) related hospitalisations following vaccination among eligible age groups in Scotland.
The study, from Public Health Scotland and the University of Strathclyde, showed a 62% reduction in RSV-related hospitalisations among those who received the vaccine and concluded that the vaccine is effective in reducing such hospitalisations in older adults.
Described as one of the first real-world investigations from the UK and Europe into the impact of the RSV vaccine on older people, the study focused on a period of high seasonal RSV circulation.
Dr Sam Ghebrehewet, head of immunisation and vaccination at Public Health Scotland, said the results showed the importance of RSV vaccine uptake in protecting older groups.
‘Vaccinations have played a major role in protecting the health of people across the globe over the last 50 years and the success of the RSV programme marks another significant step in protecting the population of Scotland against preventable diseases,’ he said.
Estimates from the UK in 2022 pointed to a disproportionate clinical effect of RSV infection in older people, with an annual average of 71 respiratory hospital admissions per 100,000 adults during the winter months.
Hospitals across the UK have faced unprecedented levels of respiratory viruses in recent months, with NHS England tackling a ‘quad-demic’ of RSV, flu, norovirus and Covid-19 over winter.
Scotland launched an RSV vaccination programme in August 2024, with local adults aged between 75 and 79 invited to come forward for their free RSV vaccination before winter.
By the end of November 2024, there was a 68% uptake of the vaccine in this older adult population.
A separate programme was also run for pregnant women in their third trimester of pregnancy to protect infants from the virus.
The national RSV vaccination rollout in England, Wales and Northern Ireland for eligible groups began on 1 September 2024.
The study is the first to demonstrate the positive impact of the RSV vaccination programme in reducing hospital admissions in Scotland and shows the importance of older adults coming forward for their vaccine, the authors said.
Commenting on the results, Neil Gray, Scottish cabinet secretary for health and social care, said: ‘I’d urge all those eligible to come forward for their vaccine when called. It is incredibly important for older adults and pregnant women to protect their new born babies from RSV.’
A version of this article was originally published by our sister publication Nursing in Practice.
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