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  The Derby Hospital Medical Museum

  Rawson, Beth (Derbyshire Archaeological Society, 2024-08)
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  Selective Genicular Artery Embolisation for Recurrent Hemarthrosis Following Total Knee Arthroplasty: A Case Report

  Aakanksha, Garlapati; Rasul, Shahmeen; Ashwood, Neil; Hayward, Keith

  Recurrent hemarthrosis following total knee arthroplasty (TKA) is an uncommon complication, with an incidence of less than 1%. It can lead to pain, swelling, joint stiffness, and functional impairment. Selective genicular artery embolisation (GAE) has emerged as a minimally invasive treatment for managing such cases. We report the case of a 79-year-old female with recurrent atraumatic hemarthrosis of the left knee following TKA, complicated by long-term anticoagulation with Edoxaban for unprovoked pulmonary embolism. Despite multiple aspirations and arthroscopic washouts, symptoms persisted. Angiography revealed synovial hypervascularity, and GAE was performed to reduce bleeding. Although the procedure initially improved symptoms, recurrence occurred while the patient was maintained on full-dose Edoxaban. Following a multidisciplinary review, the anticoagulant dose was reduced, resulting in complete resolution of haemarthrosis. GAE represents an effective, minimally invasive treatment for recurrent hemarthrosis post-TKA. Anticoagulation management and multidisciplinary coordination are essential to balance bleeding risk and thromboembolic protection in such patients.
• An ethnographic study of pharmacist prescribers' competencies, collaboration, and barriers in hospital settings.

  El Nsouli, Dayana

  OBJECTIVES: This ethnographic study explores hospital pharmacist prescribing practices in an inpatient multidisciplinary team (MDT) setting. This study aimed to identify the underlying mechanisms, including competencies, facilitators, and inhibitors, related to pharmacist prescribing practices in hospital settings. METHODS: Non-participant observations were conducted over six half-day sessions with three experienced prescribing pharmacists. Data were analysed using framework and thematic analysis. The RPS Competency Framework guided framework analysis, while thematic analysis identified overarching themes related to emotional intelligence and hierarchical dynamics. KEY FINDINGS: Key competencies frequently observed included interpreting patient records and collaborating with MDT members. Facilitators of effective prescribing included strong interdisciplinary collaboration and access to comprehensive patient information. Barriers such as fragmented IT systems, high workloads, and hierarchical constraints affected the pharmacists' ability to efficiently manage and document patient care. Emotional intelligence was identified as a critical skill for managing professional identity within hierarchical structures and handling the emotional toll of systemic inefficiencies. CONCLUSIONS: Pharmacist prescribers significantly enhance patient care through collaboration and proactive engagement in MDTs. However, systemic barriers, particularly IT-related inefficiencies and hierarchical dynamics, limit their full potential. Training in emotional intelligence and improved interdisciplinary support may enhance the effectiveness of prescribing pharmacists. Addressing systemic issues, especially IT infrastructure, could optimize prescribing efficiency and reduce cognitive load.
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  Weighing the impact of evidence in orthopaedic trauma registries: a systematic review of national and international registry data.

  George, Akhshay John; Ashwood, Neil; Dekker, Andrew; Crawford, Adrian; Mukherjee, Arnov

  OBJECTIVES: Worldwide, there are 15 established trauma databases collecting data to better understand the patterns of injury and effectiveness of interventions, but interpreting the information is hampered by the varied approaches. The aim of this study was to determine the impact, practices, evolution in design and methods of analysis that are standardised and comparable within registries. DESIGN: A thematic analysis using a narrative synthesis was used to develop threads for future study and identify the limitations in current practice. DATA SOURCES: PubMed, Ovid, Scopus and EMBASE were searched on the 2 October 2025. At the same time, ChatGPT (Open artificial intelligence) identified the most cited articles in orthopaedic trauma registries, cross-referencing lists as a form of triangulation to aid in snowballing references. ELIGIBILITY CRITERIA: The review included 174 papers from trials and observational studies that analyse data from established trauma orthopaedic registries published in English. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers used standardised methods to search, screen and code included studies assessing the papers using the Strengthening the Reporting of Observational Studies in Epidemiology checklist to assess the observational and cohort studies and the Downs and Black Quality Criteria for the remaining papers. RESULTS: Outcome measures other than mortality are poorly collected, undermining the value of registries. Trauma patients reported considerable impairment 6 and 12 months after injury. Association between level of trauma care and mortality is evident for major trauma populations, but does not hold for general trauma populations. Level I trauma centres produce improved survival in severely injured, but this association could not be proven for non-fatal outcomes in general populations. There is a disparity between resources allocated to save and salvage cases within major trauma units, and hence, routine cases often have lower priority and delayed care. CONCLUSIONS: There is a need to develop a standardised and reproducible method to evaluate data quality in trauma registries. National performance guidelines and trauma centre audits are integral steps towards optimum results. Routine collection of postinjury outcome measures beyond mortality will enable the development of quality improvement metrics that better reflect patient outcomes.
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  Comparative effectiveness of educational interventions in neurological disease for healthcare workers and students: a systematic review.

  Bateman, AH

  OBJECTIVES: To assess the comparative effectiveness of educational interventions in neurological disease for healthcare workers and students. DESIGN: Systematic review. DATA SOURCES: Medline, Embase and Cochrane through to 1 June 2025. ELIGIBILITY CRITERIA: Studies evaluating neurological disease educational interventions with a comparator group (observational cohort/randomised controlled trial (RCT)) were included. DATA EXTRACTION AND SYNTHESIS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review was conducted (PROSPERO: CRD42023461838). Knowledge acquisition and educational methodologies were collected from each study. Study outcomes were classified using the Kirkpatrick and Kirkpatrick four-level model (learner reaction, knowledge acquisition, behavioural change, clinical outcome).1 Risk of bias was assessed using the Newcastle-Ottawa scale for non-randomised studies and the Cochrane Risk of Bias tool for RCTs.2 3 RESULTS: A total of 67 studies involving 4728 participants were included. Of these, 36 were RCTs, and 31 were observational studies. Virtual interventions were the most common (67.2%, n=45 studies), primarily targeting either medical students (46.3%, n=31 studies) or specialists (40.3%, n=27 studies). Overall, 70.1% (n=47) of studies demonstrated outcomes in favour of the intervention. However, few studies used K&K level 3/4 outcomes, with two studies evaluating behaviour change (level 3) and three assessing clinical outcomes (level 4 combined with other levels). No study exclusively assessed level 4 outcomes. Meta-analysis of 22 RCTs with calculable standardised mean differences (SMDs) (n=1748) showed a significant benefit of interventions (SMD 0.75, 95% CI 0.22 to 1.27, p=0.0056). CONCLUSIONS: This review highlights a growing body of research particularly focusing on virtual techniques, specialist audiences and treatment-oriented content. Few studies assessed changes in practice or patient care. Non-specialists remain underrepresented. Future studies should prioritise assessing the clinical impact of educational interventions within non-specialist audiences.
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  Preventing kidney injury using carbon dioxide (KID trial): trial protocol for a multicentre randomised controlled trial.

  Selby, Nicholas

  INTRODUCTION: Peripheral arterial disease (PAD) commonly coexists with chronic kidney disease (CKD). Patients with symptomatic PAD often require endovascular revascularisation to relieve pain or salvage limbs. However, the iodinated intra-arterial contrast routinely used in these procedures is nephrotoxic, placing patients with CKD at increased risk of acute kidney injury (AKI) and long-term renal decline. Carbon dioxide (CO₂) delivered via automated injection is a potential alternative imaging contrast medium. This trial will evaluate whether using CO₂ instead of iodinated contrast reduces the risk of AKI and short-term renal function decline in this high-risk group. METHODS AND ANALYSIS: This is a multicentre, open-label, prospective randomised controlled trial across six secondary-care National Health Service (NHS) vascular surgery centres. A total of 174 patients with PAD and CKD undergoing endovascular intervention will be randomised 1:1 to receive iodinated contrast (standard of care) or CO₂ via automated injector (Angiodroid). All perioperative care will follow local NHS protocols.The primary outcome is log serum creatinine at 2, 30 and 90 days postprocedure. Key secondary outcomes include: incidence and severity of AKI within 48 hours postprocedure, major adverse kidney events (death, dialysis or >25% estimated glomerular filtration rate decline) by 90 days, inpatient length of stay, procedural pain, quality of life, procedural success, reinterventions, acceptability and feasibility (patient/practitioner questionnaires) of using CO2, and cost-effectiveness (healthcare resource use analysis). A mixed-methods process evaluation will be undertaken with patients and clinicians. ETHICS AND DISSEMINATION: The trial has been approved by an NHS ethical review committee (24/WA/0332) and patients have been involved in trial design. Findings will be disseminated to participants, clinicians and the wider public through patient groups, lay summaries, social media, conferences, peer-reviewed journals and NHS policy channels. TRIAL REGISTRATION NUMBER: ISRCTN23564393.
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  Surgical margins in breast conserving surgery for ductal carcinoma in situ of the breast and clinical outcomes: a national audit with long term follow-up.

  Robertson, JF

  BACKGROUND: Optimal surgical margin width in breast conserving surgery (BCS) for ductal carcinoma in situ (DCIS) is not established. The United Kingdom (UK) Association of Breast Surgery (ABS) recommended a 1 mm margin, whereas a minimum of 2 mm has been recommended in the United States of America (USA). This paper uses precise histological margin width data from UK national datasets to understand the impact of surgical margins on time to recurrence (TTR). METHODS: Patients were included if aged ≥45-years with a new diagnosis of DCIS alone, between 2003 and 2014, within the English National Health Service (NHS) Breast Screening Programme. Primary treatment included BCS and a minimum histological excision margin width recorded. Exclusion criteria included: prior history of DCIS; prior history of invasive cancer or its diagnosis within 3-months of initial surgical treatment for DCIS. Data was extracted from NHS England National Disease Registration Service (NDRS), ABS and Sloane Project audits. FINDINGS: 16,907 patients diagnosed with DCIS having definitive BCS surgery were identified between 2003 and 2014. TTR was found to be significantly shorter for patients with surgical margins <1 mm vs ≥ 1 mm (adjusted hazard ratio (aHR) = 1·32; 95% (confidence interval) CI:1·06-1·63; p = 0·012); <2 mm vs ≥ 2 mm (aHR = 1·19; 95% CI:1·05-1·35; p = 0·0062) and ≥1-<2 mm vs ≥ 2 mm (aHR = 1·18; 95% CI:1·01-1·38; p = 0·032). There was no evidence that increasing the surgical margin width beyond 2 mm significantly improved TTR (aHR = 0·96; 95% CI: 0·86-1·08; p = 0·52 for ≥5 mm vs ≥ 2-<5 mm). The rate of recurrence across 14 years following BCS + radiotherapy was 1·2% per annum, 2129 (13%) patients had a recurrence of which 78% were invasive breast cancers. INTERPRETATION: Patients with DCIS with histological margins of <2 mm, adjusted for other clinical factors, have significantly worse TTR compared to margins ≥2 mm. These findings may inform optimum treatment of patients with DCIS. FUNDING: An ABS grant covered the cost of data extraction by NHS England and medical writing assistance. The latter was provided by Edge Health, supervised by the co-authors.
• Surgical site infections in the head and neck: a multicentre retrospective cohort study.

  Ijaz, Ali

  OBJECTIVES: Surgical site infections (SSIs) are one of the most common post-operative complications and can be associated with significant morbidity and mortality. They place a significant burden on healthcare system. Existing guidelines are based on non-head and neck procedures. This study aims to investigate factors affecting SSIs in the head and neck. METHODS: A multi-centre retrospective cohort across otolaryngology departments in Yorkshire (Bradford, Doncaster, Hull, Leeds). All patients undergoing an operation requiring a skin incision in the year 2021 were included. Electronic patient notes were used as the data source. Data on demographics, comorbidities, smoking and alcohol use, operation undertaken, diagnosis, closure material and use of antibiotic prophylaxis were recorded. RESULTS: 827 patients were included. The mean age was 51.4 years. The rate of SSI was 4.2% (n = 34/827). 30-day mortality was 0.6% (n = 5/827). There was no significant difference in development of SSI depending on antiseptic preparation choice. Diabetes significantly increased the risk of SSI. Suture choice did not affect rate of SSI. Intravenous drug use and cardiovascular disease were not significantly associated with 30-day mortality. CONCLUSION: This is the only study that assessed the rate of SSIs in the head and neck region. The NICE guidance for antiseptic preparation choice is not applicable in the head and neck. Absorbable sutures should be used when appropriate. Peri-operative comorbidities should be optimised. For more robust evidence, a larger cohort would be recommended or a randomised controlled trial assessing individual factors can be considered. LEVEL OF EVIDENCE: - Level 3.
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  Comparative Effectiveness of the Proximal Femoral Nail and Dynamic Hip Screw Fixation in Intertrochanteric Femur Fractures: A Systematic Review and Meta-Analysis.

  Rasul, Shahmeen; Shetty, Shashwat; Bencharles, Osasenaga; Hassan, Jouni

  This systematic review and meta-analysis compared the clinical effectiveness of proximal femoral nail (PFN) versus dynamic hip screw (DHS) fixation in patients with intertrochanteric femur fractures. A comprehensive literature search was conducted across multiple databases from January 2010 to September 2025, identifying studies that directly compared PFN and DHS fixation outcomes. Thirty-three studies met the inclusion criteria, comprising randomized controlled trials, prospective cohorts, and retrospective comparative studies from diverse geographic regions. The pooled analysis demonstrated several significant advantages favoring PFN fixation. Operative time was significantly shorter with PFN compared to DHS (mean difference (MD): -12.30 minutes, 95% confidence interval (CI): -17.33 to -7.28), while intraoperative blood loss was substantially lower (MD: -115.01 mL, 95% CI: -132.05 to -97.98). Patients treated with PFN achieved full weight-bearing significantly earlier than those receiving DHS. Safety outcomes showed PFN was associated with significantly lower total complication rates (risk ratio (RR): 0.46, 95% CI: 0.31-0.68) and reduced infection risk. However, no significant differences were observed between groups regarding implant failure rates, mortality, or long-term functional outcomes, as measured by the Harris Hip Score. High heterogeneity was noted across most outcomes, reflecting variations in study populations and methodologies. These findings suggest that PFN offers superior perioperative outcomes and early recovery advantages compared to DHS, while maintaining comparable long-term functional results and survival rates in patients with intertrochanteric femur fractures
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  Association Between Metabolic Dysfunction-Associated Steatotic Liver Disease and Sarcopenia: A Systematic Review and Meta-analysis.

  Rahman, Mohammed Abdul

  This systematic review and meta-analysis evaluated the prevalence of sarcopenia in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) compared to controls. A comprehensive search across PubMed, Embase, Cochrane Library, and Web of Science databases was conducted from January 2015 to August 2025, identifying studies that compared the prevalence of sarcopenia between MASLD patients and non-MASLD controls. Sixteen studies comprising diverse populations from Korea, China, the United States, Italy, the Netherlands, and the United Kingdom were included, with sample sizes ranging from 57 to 18,815 participants. Sarcopenia assessment methods varied across studies, including dual-energy X-ray absorptiometry (DXA), bioelectrical impedance analysis (BIA), computed tomography (CT), and functional tests. Statistical analyses were performed using RevMan 5.4 (The Cochrane Collaboration, London, England, UK) with random-effects models to calculate pooled odds ratios (ORs). The meta-analysis revealed a significantly higher prevalence of sarcopenia in MASLD patients (14.86%) compared to controls (6.49%), with a pooled OR of 2.24 (95% CI: 1.74-2.89, p < 0.001). Substantial heterogeneity was observed (I² = 95%) across studies. Subgroup analyses demonstrated stronger associations in cohort studies versus cross-sectional studies, in populations under 50 years of age, and in studies from Korea and the United States. The bidirectional relationship between MASLD and sarcopenia is supported by shared pathophysiological mechanisms, including insulin resistance, chronic inflammation, and altered protein metabolism. These findings suggest that MASLD patients should undergo routine sarcopenia screening, and interventions targeting muscle health may benefit both conditions. The substantial burden of sarcopenia in MASLD patients highlights the need for integrated management approaches addressing both hepatic and muscular manifestations.
• Is open pyeloplasty still a practical option for pediatric patients in resource-limited settings compared to laparoscopic and robotic approaches?

  Sharma, Gaurev

  OBJECTIVE: To explore the feasibility of open pyeloplasty (OP) for treating pediatric pelviureteric junction obstruction in resource-limited settings in the era of robot assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP). METHODS: A total of 168 patients (56 each) were randomized to receive RALP, LP, or OP, respectively. RESULTS: The operative time for the RALP was significantly higher (P < 0.001) compared to LP and open OP. The length of stay (LOS) for RALP and LP was substantially lower (P < 0.001) compared to the OP, with average stays of 2.8 ± 1.5 days, 3.1 ± 1.2 days, and 6.4 ± 8.1 days, respectively. In the RALP group, 54 (96.4%) had a non-obstructed drainage pattern post-operatively compared to 52 (92.8%) in the LP group, and 53 (94.6%) patients in the OP group (P = 0.363). Only 2 (3.6%) patients in the RALP group and 4 (7.1%) patients in the LP group, and 3 (5.3%) patients in OP group, exhibited obstructed drainage on dynamic nuclear scan. Grade II complications (urine leakage) occurred in 2 patients in the RALP cohort, and in 3 patients in the LP cohort. The leakage typically resolved within 10 days and did not require further intervention. Higher-grade complications (Clavien Grade 3 and 4a), such as hydronephrosis, were identified in both the RALP and OP groups (one case each). CONCLUSION: Due to comparable success rates and minimal complications, OP is a viable alternative to minimally invasive RALP and LP in treating pediatric patients with PUJO, particularly where cost and equipment availability are limiting factors.
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  Tailored performance of additively manufactured titanium TPMS bone scaffold

  Vance, Aaron; Ashwood, Neil; Arjunan, Arun

  Triply periodic minimal surfaces (TPMS), exemplified by the Schwarz geometry, provide an optimal platform for bone scaffolds due to their high surface-to-volume ratio, continuous porosity, and bone-analogous mechanical response. Here, titanium TPMS scaffolds were additively manufactured via laser powder bed fusion (L-PBF) with precise control over geometric parameters. A data-driven surrogate model, informed by experimental and numerical analyses, was developed to map the relationship between design variables and mechanical performance. The model enabled the design of scaffolds with tailored stiffness matching that of native bone, while revealing the dominant roles of wall thickness and cell size. Porosity varied from 47 % to 68 %, governed inversely by wall thickness, while elastic modulus scaled from 6 to 24 GPa, driven primarily by wall thickness and secondarily by cell size. Yield and ultimate strengths exhibited strong positive correlations with wall thickness, spanning 240–655 MPa and 320–784 MPa, respectively. This study provides a predictive framework for engineering 3D printed titanium scaffolds with targeted mechanical properties, offering a basis for next-generation load-bearing orthopaedic implants.
• Continuous glucose monitoring and microvascular complications in diabetes: Bridging glycemic metrics with clinical outcomes.

  Liarakos, Alexandros

  Continuous glucose monitoring (CGM) has emerged as a complementary and more dynamic method for evaluating glycemic control in people with diabetes. Relevant studies examining the association between CGM parameters, including time in range (TIR), glycemic variability (GV), and time in tight range (TITR), and diabetic nephropathy, retinopathy, and neuropathy, were reviewed. Evidence consistently demonstrates that lower TIR and TITR, as well as higher GV, are associated with increased risk and severity of microvascular complications in both type 1 and type 2 diabetes. Studies employing corneal confocal microscopy and sudomotor function testing further support these associations for small-fibre neuropathy. Although CGM-guided therapy improves TIR and GV, data directly linking optimisation of these metrics to reduced complication rates remain limited. Most available studies are cross-sectional or retrospective, with short CGM durations and heterogeneous methodologies. CGM-derived indices provide valuable insights into glycemic quality beyond HbA1c and may serve as complementary tools for early risk stratification and individualised management of diabetic microvascular disease. However, prospective and interventional trials are required to confirm whether improving CGM metrics can translate into clinically meaningful reductions in microvascular morbidity. Broader access to CGM and standardisation of its key metrics will be essential to fully realise its potential in modern diabetes care.
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  Efficacy of Platelet-Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review and Meta-Analysis.

  Nawaz, H

  The study was conducted to evaluate the safety and effectiveness of platelet-rich plasma (PRP) injections for knee osteoarthritis. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were performed in PubMed, Scopus, Web of Science, and the Cochrane Database for studies published between January 2015 and June 2025. Only randomized controlled trials (RCTs) published in the English language were included, while reviews, case reports, and non-randomized studies were excluded. Six high-quality RCTs were identified, including a total of 1,162 patients with mild-to-moderate knee osteoarthritis. PRP injections were compared with hyaluronic acid, corticosteroid injections, or placebo. Pain and function were assessed using standardized tools such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the International Knee Documentation Committee (IKDC) score, the Knee Injury and Osteoarthritis Outcome Score, and the Visual Analog Scale. Significant improvements with PRP were observed at 6 and 12 months. The WOMAC pain score was reduced by an average of -8.5 points, and the IKDC score increased by +6.2 points. Both results were statistically significant. Moderate variability was found between studies, but sensitivity analyses confirmed stability of the results. Subgroup analysis did not show consistent differences between leukocyte-rich PRP and leukocyte-poor PRP. Reported side effects were minor and self-limiting. Overall, PRP demonstrated significant improvements at 6 and 12 months. Pooled analysis indicated moderate pain reduction (standardized mean difference (SMD) = -0.32, 95% confidence interval (CI) = -0.48 to -0.15; I² = 46%) and functional improvement (SMD = -0.28, 95% CI = -0.44 to -0.12; I² = 52%) compared with control groups. However, long-term structural improvement was not demonstrated. Larger trials are still needed to confirm benefits, optimize preparation methods, and assess cost-effectiveness.
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  Evaluating the Readability and Quality of Bladder Cancer Information from AI Chatbots: A Comparative Study Between ChatGPT, Google Gemini, Grok, Claude and DeepSeek.

  Patel, Kunjan; Radcliffe, Robert

  Background/Objectives: Artificial Intelligence (AI)-based chatbots such as ChatGPT are easily available and are quickly becoming a source of information for patients as opposed to traditional Google searches. We assessed the quality of information on bladder cancer, provided by various AI chatbots such as ChatGPT 4o, Google Gemini 2.0 flash, Grok 3, Claude Sonnet 3.7 and DeepSeek R1. Their responses were analysed in terms of Readability Indices, and two consultant urologists rated the quality of information provided using the validated DISCERN tool. Methods: The top 10 most frequently asked questions about bladder cancer were identified using Google Trends. These questions were then provided to five different AI chatbots, and their responses were collected. No prompts were used, reflecting natural language queries that patients would use. The responses were analysed in terms of their readability using five validated indices: Flesch Reading Ease (FRE), the Flesch-Kincaid Reading Grade Level (FKRGL), the Gunning Fog Index, the Coleman-Liau Index and the SMOG index. Two consultant urologists then independently assessed the responses of various AI chatbots using the DISCERN tool, which rates the quality of the health information on a five-point LIKERT scale. Inter-rater agreement was calculated using Cohen's Kappa and the intraclass correlation coefficient (ICC). Results: ChatGPT 4o was the overall winner in readability scores, with the highest Flesch Reading Ease score (59.4) and the lowest average reading grade level (7.0) required to understand the material. Grok 3 was a close second (FRE 58.3, grade level 8.7). Claude 3.7 Sonnet used the most complex language in its answers and therefore scored the lowest FRE score of 44.9, with the highest grade level (9.5) and also the highest complexity on other indices. In the DISCERN analysis, Grok 3 received the highest average score (52.0), followed closely by ChatGPT 4o (50.5). The inter-rater agreement was highest for ChatGPT 4o (ICC: 0.791; Kappa: 0.437), while it was lowest for Grok 3 (ICC: 0.339, Kappa 0.0, Weighted Kappa 0.335). Conclusions: All AI chatbots can provide generally good-quality answers to questions about bladder cancer with zero hallucinations. ChatGPT 4o was the overall winner, with the best readability metrics, strong DISCERN ratings and highest inter-rater agreement.
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  The Effect of Leucine-Enriched β-Lactoglobulin Versus an Isonitrogenous Whey Protein Isolate on Skeletal Muscle Protein Anabolism in Young Healthy Males.

  Paul, Melanie; Wall, Jillian; Lund, Jonathan

  BACKGROUND: β-lactoglobulin (BLG) is a protein found within whey protein (WP) that is rich in essential amino acids, most notably, leucine (LEU). LEU is considered the most potent EAA in the postprandial stimulation of muscle protein synthesis (MPS), such that suboptimal protein/essential amino acid (EAA) doses containing higher LEU content elicit muscle anabolism comparable to larger protein doses. Our objective was to test the effects of naturally LEU-rich BLG (~10 g protein) versus isonitrogenous whey protein isolate (WPI, ~10 g) on MPS. METHODS: Ten healthy young men (26 ± 2 y; 179 ± 2 cm; 81 ± 3 kg) received BLG (1.57 g LEU) or WPI (1.02 g LEU) in a randomised double-blind cross-over fashion. A primed constant intravenous infusion of [1,2 13C2] LEU was used to determine MPS (isotope ratio mass spectrometry) at baseline and in response to feeding (FED) and feeding-plus-exercise (FED-EX; 6 × 8 unilateral leg extensions; 75% 1-RM). Plasma insulin and EAA's were quantified. RESULTS: Plasma EAA, branched-chain amino acid (BCAA), and LEU concentrations increased rapidly following both protein supplements but exhibited a significantly greater EAA/BCAA/leucinemia following BLG (p < 0.05 for all). MPS increased significantly in both FED (~52%) and FED-EX (~58%) states, with no significant differences between supplements. CONCLUSIONS: Both BLG and WPI effectively stimulated MPS doses in young healthy males, with BLG offering an advantage in EAA/BCAA/LEU bioavailability. It follows that future research should explore the potential of BLG in populations exhibiting anabolic resistance and exercise anabolism deficiency, such as older adults as well as frail and clinical populations, to assess its utility in preserving muscle mass under conditions of suboptimal protein intake.
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  Carcinoid Heart Disease Revealing the Burden of a Neuroendocrine Tumour: A Case Report.

  Sajeev, Dabeet

  Carcinoid heart disease (CHD) is a rare but serious complication of carcinoid syndrome (CS), typically arising in patients with metastatic neuroendocrine tumours (NETs). Prolonged exposure of the right side of the heart to vasoactive substances such as serotonin leads to progressive valvular fibrosis, predominantly affecting the tricuspid and pulmonary valves, and often culminates in right-sided heart failure. We report the case of a 67-year-old woman with a metastatic small bowel NET who developed CS and later presented with worsening exertional dyspnoea and peripheral oedema. Echocardiography demonstrated severe tricuspid regurgitation and moderate pulmonary regurgitation with preserved left ventricular systolic function. Despite aggressive diuretic therapy, her condition deteriorated, and she developed refractory right-sided heart failure with generalised anasarca. She was not a candidate for valve replacement or further disease-directed therapy due to advanced metastatic disease and frailty and was therefore managed palliatively until she passed away. This case highlights the severe burden of CHD in patients with serotonin-secreting NETs and emphasises the importance of early recognition and regular echocardiographic surveillance to facilitate timely intervention and potentially improve outcomes.
• Ten-Year Survival after Postmastectomy Chest-Wall Irradiation in Breast Cancer.

  Woodings, P

  BACKGROUND: The role of postmastectomy chest-wall irradiation in patients with breast cancer classified as pN1 (with involvement of one to three axillary nodes) or pN0 (pathologically node negative) with additional risk factors is uncertain. METHODS: In this international, phase 3, randomized trial, we evaluated the omission of chest-wall irradiation in women with "intermediate-risk" breast cancer - defined as cancer that was stage pT1N1, pT2N1, or pT3N0 or stage pT2N0 with a histologic grade of 3, lymphovascular invasion, or both (tumor size: T1, ≤2 cm; T2, >2 cm to 5 cm; or T3, >5 cm) - that was treated with mastectomy, an axillary procedure, and systemic therapy. Patients were assigned to undergo chest-wall irradiation (40 to 50 Gy; the irradiation group) or not to undergo chest-wall irradiation (the no-irradiation group). The primary end point was overall survival, with 10 years of follow-up. Chest-wall recurrence, regional recurrence, disease-free survival, distant metastasis-free survival, causes of death, and radiation-related adverse events were also assessed. RESULTS: The intention-to-treat population included 808 patients in the irradiation group and 799 in the no-irradiation group. The median follow up was 9.6 years. Overall survival was 81.4% with chest-wall irradiation and 81.9% with no chest-wall irradiation according to 10-year Kaplan-Meier estimates (hazard ratio for death, 1.04; 95% confidence interval [CI], 0.82 to 1.30; P = 0.80). A total of 29 patients had a chest-wall recurrence - 9 (1.1%) in the irradiation group and 20 (2.5%) in the no-irradiation group (between-group difference, <2 percentage points; hazard ratio, 0.45; 95% CI, 0.20 to 0.99). Disease-free survival was 76.2% in the irradiation group and 75.5% in the no-irradiation group (hazard ratio for recurrence or death, 0.97; 95% CI, 0.79 to 1.18), and distant metastasis-free survival was 78.2% and 79.2%, respectively (hazard ratio for distant metastasis or death, 1.06; 95% CI, 0.86 to 1.31). CONCLUSIONS: In this trial, chest-wall irradiation did not result in higher overall survival than no chest-wall irradiation among patients with intermediate-risk, early breast cancer treated with mastectomy and contemporary adjuvant systemic therapy. (Funded by the Medical Research Council and others; SUPREMO ISRCTN Clinical Study Registry number, 61145589.).
• Epidemiological and clinical landscape of nasopharyngeal carcinoma over two decades (2000-2021): a retrospective analysis of 10419 cases.

  Khalil, A
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  Investigating the potential association between tattoos and lymphoma: an exploratory systematic review and meta-analysis.

  Xu, Jimmy

  BACKGROUND: The tattooed population has risen significantly over the last few decades, leading to increased scrutiny into potential side effects. The recent publication of scientific articles linking tattooing to lymphoma has led to a systematic review being conducted to investigate if an association exists. METHODS: Following the PICO framework, we formed a systematic review comparing tattooed to non-tattooed adults belonging to any region of the world and investigated the likelihood of lymphomagenesis. The protocol was pre-registered on PROSPERO (ID: CRD42024586505). Relevant studies were searched for in PubMed, Web of Science, Embase, Google Scholar, and CENTRAL on 10/09/2024 and updated on 16/07/25. The inclusion criteria consisted of primary studies, including observational studies and case reports which investigated the association between tattoos and non-Hodgkin lymphoma. Exclusion criteria were publications involving subjects under 18 and non-English papers. Data extraction was performed using published numbers from individual papers after requesting raw data. Study quality was assessed using ROBINS-E, and evidence certainty using GRADE. Outcomes assessed were any odds/risk/incidence ratios that associated tattooing with non-Hodgkin lymphoma. FINDINGS: A total of four observational studies, totalling 17,941 participants (2485 cases and 15,456 controls) and three case reports were identified. None of the included studies demonstrated a statistically proven link between lymphomagenesis and tattooing. ROBINS-E showed relatively low bias for our three included studies; however, the certainty of our evidence is low due to the lack of high-quality studies with similar methodologies. The meta-analysis conducted for non-Hodgkin's lymphoma, with subtypes follicular lymphoma and diffuse large B-cell lymphoma, produced odds ratios of 1.01 (95% CI 0.82-1.24), 1.01 (95% CI 0.77-1.33) and 0.89 (95% CI 0.54-1.46), respectively. INTERPRETATION: No significant association was found between tattooing and lymphoma. Due to limitations in the data quality and lack of standardised measurable outcomes, further high-quality research is needed. FUNDING: There was no funding for this study.

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