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Effect of Digoxin versus Bisoprolol for heart rate control in atrial fibrillation with heart failure on quality of life: a prospective randomised comparative study.Introduction Atrial fibrillation (AF) and heart failure (HF) often co-exist, exerting synergistic adverse effects on patients’ morbidity, quality of life (QOL) and mortality. This also poses a unique management challenge of heart failure in the AF population as compared to the sinus rhythm population. While beta blockers such as bisoprolol have been preferred treatment options for patients with heart failure, digoxin remains a cost-effective yet underrated alternative. However, its overall effect on QOL remains debated, especially in the South Asian population that carries a higher burden of heart failure than any other ethnicity. Objective The objective of this study was to compare the short-term effect of bisoprolol versus digoxin on quality of life in patients with permanent AF and concurrent HF in the South Asian population. Methods This single-centred prospective randomised comparative study was conducted at the outpatient department of Punjab Institute of Cardiology, Lahore, from March to September 2022. A total of 80 patients with permanent AF and established HF were enrolled and randomised in two groups to receive either digoxin (62.5-250 mcg/day) or bisoprolol (1.25-15 mg/day). The 36-Item Short Form Health Survey (SF-36) was administered at baseline and after three months to assess changes in QOL. Data were analysed using SPSS v25.0 (IBM Corp., Armonk, NY, USA), with significance at p ≤ 0.05. Results Both treatment groups significantly improved SF-36 QoL scores after three months (p < 0.001). However, the digoxin group reported significantly greater improvement compared to the bisoprolol group (mean QoL score: 76.68 ± 9.37 vs. 70.90 ± 8.00; p = 0.004). No serious adverse events or digoxin-related toxicities were reported in either group. Conclusion In patients with permanent AF and HF, digoxin resulted in a statistically significant improvement in short-term quality of life compared to bisoprolol. These findings suggest that digoxin may serve as a viable and possibly superior alternative to bisoprolol in patients with permanent AF and HF, with a potential role for digoxin as a first-line agent in select populations. It also highlights the need to re-evaluate current treatment preferences, especially in resource-limited settings. Further multicentric and multi-ethnic studies are needed to substantiate these findings and evaluate long-term clinical outcomes.
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Role of genetics in early-onset cardiovascular diseaseGenetics increasingly comes to the front with early-onset cardiovascular disease (CVD) since researchers investigate the complex interplay of hereditary factors that promote an early manifestation of the disease. CVD is one of the most general causes of morbidity and mortality worldwide, presenting unique challenges when it arises in younger populations many times due to genetic predispositions. The various etiologies in the pathogenesis of early-onset CVD involve genetic factors, including the monogenic disorders of familial hypercholesterolemia (FH) and hypertrophic cardiomyopathy (HCM) of these diseases showing the simple Mendelian patterns of inheritance. These may be mediated through gene variations, including Low-Density Lipoprotein Receptor (LDLR), Apolipoprotein B (APOB), Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9), and Myosin Heavy Chain 7 (MYH7). Disrupted lipid metabolism, myocardial function, or vascular integrity due to mutations could lead to adverse clinical consequences. Moreover, polygenic risk score (PRS) has now become helpful in identifying individuals who are at elevated risk due to the cumulative effect of several genetic variants. Knowledge about gene-environment interactions, epigenetic influences, and complex regulatory networks contributes to understanding the importance of genetic contributions to early-onset CVD. However, the genetic variation is population-specific and underlines the need for research inclusive of diverse genetic backgrounds in developing more inclusive and effective predictive models. Whole genome and exome sequencing have revolutionized early detection, making personalized treatment plans possible, including targeted therapeutic interventions like PCSK9 inhibitors. On the other hand, such scientific progress also provides a lot of ethical challenges, such as utilizing personal data, informed consent, and equal access to genetic services. This review summarizes the genetic basis underlying early-onset CVD, with detailed discussions of monogenic and polygenic contributions, important genetic pathways, and emerging advances in genetic testing and personalized medicine approaches. By highlighting the integration of genetic insights with preventive and therapeutic strategies, this review aims to bring into focus the use of genetic insight in the betterment of outcomes in patients and inform future research in cardiovascular genetics.
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Real-world clinical outcomes of patients with moderate-to-severe rheumatoid arthritis initiating upadacitinib in the United Kingdom: final analysis from a prospective observational cohort study (ENDEAVOUR)Objective Upadacitinib is recommended by National Institute for Health and Care Excellence in the UK in adults with moderate-to-severe rheumatoid arthritis (RA). This observational study assessed real-world clinical outcomes and patient-reported outcomes (PROs) in patients receiving upadacitinib for 6 months in the UK. Methods Patients from 14 centres in whom the decision to initiate upadacitinib had already been made were enrolled. Baseline data were retrospectively collected from patient records. Clinician-reported data were collected at routine clinic visits 3 and 6 months after upadacitinib initiation. Patient-reported data were collected directly from patients using an app (electronic PROs, ePROs). The primary end-point was proportion of patients achieving clinical remission (DAS28 CRP <2.6) after 6 months of upadacitinib. Results Data are available for 63 patients at all three datapoints and for 53 patients for the primary end-point. At 6 months, 40% (21/53) of patients achieved clinical remission and 21% (11/53) achieved low disease activity. Response was seen at 3 months for all efficacy end-points. ePROs allowed the capture of early patient-reported data which demonstrated clinically important improvements in pain and fatigue within 10 days and other PROs within 2 months. Improvements were also seen in metrics of activity, work and quality of life (QOL). Conclusion Patients in ENDEAVOUR showed similar early effectiveness with upadacitinib to that observed in clinical trials. Use of ePROs demonstrated rapid onset of action and meaningful improvements in QOL providing a potential opportunity to reduce outpatient visits for early responders, thus reducing the burden on rheumatology services.
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Novel finding of pulmonary embolism following tirzepatide (Manjaro) use in a young adult without risk factors of venous thromboembolic eventsA woman in her early 40s presented with pleuritic chest pain and shortness of breath, which had progressively worsened over 20 days following initiation of tirzepatide (Manjaro). Her D-dimer level was elevated at 1340 ng/mL, prompting a CT pulmonary angiogram that confirmed right main pulmonary artery pulmonary embolism (PE). The patient had no identifiable provoked or unprovoked risk factors for venous thromboembolisms (VTEs). To our knowledge, this is the first reported case of PE that might be associated with the use of tirzepatide worldwide. The relationship between tirzepatide and VTEs events remains unclear. This case highlights the need for further research to explore the incidence and underlying mechanisms of VTEs in patients receiving tirzepatide.
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Ethical principles and challenges in end-of-life care for frail older adultsProviding end-of-life care to frail, older adults with multiple comorbidities can be ethically complex. As frailty differs from single terminal illness, end-of-life care requires a carefully considered, ethically informed approach. The four core ethical principles of autonomy, beneficence, nonmaleficence and justice need to be applied within this context; they involve challenges specific to frail patients, including fluctuating mental capacity, the risks of aggressive interventions and equitable access to resources. Key ethical issues include do not attempt cardiopulmonary resuscitation orders, confidentiality, mental capacity assessments and palliative sedation. Health professionals require a structured framework for decision-making. By balancing patient dignity, quality of life and legal considerations, practitioners can understand ethical obligations and practical decision-making strategies. For frail, older adults, a compassionate, patient-centred approach that prioritises comfort and dignity, especially as people approach the end of life, ensures care is provided in line with both ethical and legal standards.
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Assessment and management of patients with a rashThis article explores how primary care nurses should approach the care of a patient with a rash. It outlines the main ways of examining a patient with a rash, along with effective management strategies. A thorough and systematic physical examination is essential for the accurate diagnosis and management of dermatological conditions. This process involves a comprehensive inspection, careful palpation and the use of specialised tools or techniques where necessary. Each component provides unique diagnostic insights, enabling clinicians to differentiate between various skin conditions and approach treatment accordingly. Although some of these assessment and treatment techniques will require referral to secondary care, it is useful for practice nurses to be aware of them and mindful of when to seek specialist input.
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Assessing the knowledge, attitude, and practice measures against tuberculosis in patients in ambulatory department facilities in Pakistan: a cross-sectional analysisTuberculosis (TB), at present, is the leading infectious etiology of death globally. In Pakistan, there are approximately 510,000 new cases annually, with more than 15,000 of them developing into drug-resistant TB, making the nation the fifth-leading country in TB prevalence in the world. Due to the ongoing COVID-19 pandemic, the focus has drifted away from TB screening, diagnostic and health awareness campaigns, and therapeutic measures endangering knowledge, attitude, and practices (KAP) towards TB in our population. We conducted a cross-sectional descriptive study in Pakistan to assess the KAP of Pakistani residents attending the adult outpatient departments of public hospitals for any health-related concerns. Our sample size was 856 participants, with a median age of 22 years. Occupation-wise, those who were employed had better knowledge of TB than those who were unemployed [odds ratio (OR): 1.011; 95% confidence interval (CI): 1.005-1.8005]. No differences were observed in TB knowledge between those adherents to common preventive practices versus those not adherent (OR: 0.875; 95% CI: 0.757-1.403). More than 90% of participants agreed that TB is dangerous for the community, and the majority opted against stigmatizing TB patients (79.1%). People who could read and write were 3.5 times more likely to have a good attitude towards TB compared to those who could not (OR: 3.596; 95% CI: 1.821-70.230; p=0.037). Similarly, employed subjects had better attitudes compared to unemployed ones (OR: 1.125; 95% CI: 0.498-1.852; p=0.024) and those with better knowledge of TB had a better attitude grade (OR: 1.749; 95% CI: 0.832-12.350; p=0.020). Age, occupation, and educational status were statistically significant among the two groups (p=0.038, p=0.023, p=0.000). Literate subjects had three times better practice towards TB than illiterate subjects (OR: 3.081; 95% CI: 1.869-4.164; p=0.000). Future education and awareness programs should target specific groups, such as the unemployed and illiterate, with practice-focused approaches. Our study outcomes can enable the concerned officials and authorities to take appropriate evidence-based steps to direct the efforts efficiently to curtail the burden of TB in Pakistan and to limit its progression, which could potentially lead our nation to become a multi drug-resistant TB endemic territory.
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The Microbiota-Human Health AxisTrillions of microorganisms play a pivotal role in maintaining health and preventing disease in humans. Their presence influences daily life, habits, energy levels, and pathologies. The present narrative review synthesized recent studies of microbial diversity across organ systems. The composition of the microbiota regulates the intestinal barrier, modulates the immune response, influences metabolism, and produces essential compounds such as short-chain fatty acids and neurotransmitters. Dysbiosis is associated with numerous pathologies, including metabolic, autoimmune, neurodegenerative, and cardiovascular diseases. The microbiota is key to maintaining physiological balance and reducing disease risk. Therapeutic interventions, such as probiotics, prebiotics, postbiotics, and microbiome transplantation, offer promising perspectives in restoring microbial homeostasis and preventing chronic diseases.
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PRNP E146G mutation inherited prion disease: distinctive clinical, pathological and fluid biomarker featuresInherited prion diseases (IPDs) are phenotypically diverse neurodegenerative conditions caused by mutations in the prion protein gene (PRNP). We describe IPD due to a novel PRNP E146G mutation in a 50-year-old man presenting with slowly progressive dysarthria, prominent myoclonus especially in the lower limbs, and less prominent gait ataxia, pyramidal and extrapyramidal signs. Cognitive impairment was not overt at disease onset. MRI revealed cerebellar atrophy and white matter hyperintensities. His 46-year-old sister carries the mutation and has subtle gait ataxia and dysarthria. Both patients exhibit a distinctive fluid biomarker profile: in CSF S100B is > twofold upper limit of normal, total tau is moderately elevated, and neurofilament light chain, 14-3-3 and RT-QuIC are negative; in plasma there is marked elevation of GFAP but repeatedly normal neurofilament light chain. The proband's father died aged 55 following an 8-year dementing illness with similar presentation. Post-mortem revealed cerebellar cortical atrophy and profuse large PrP amyloid plaques across cerebral and cerebellar grey matter. Immunoblotting identified low molecular weight protease-resistant PrP fragments. E146G mutation IPD broadly fits into the historical Gerstmann-Sträussler-Scheinker disease spectrum but, based on deep clinical phenotyping of this initial pedigree, we highlight some distinctive features, which may aid in identification of this disease.
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Global trends and insights Into the Neurological Manifestations of Sjogren's Syndrome: a bibliometric reviewNeurological symptoms in Sjögren's syndrome (SS) present across a spectrum of severity, posing diagnostic and therapeutic challenges. This bibliometric review adopts a comprehensive approach to analyze the research landscape related to these symptoms. The data source utilized for this bibliometric review was the Web of Science Core Collection. The study selection encompassed English-language articles and reviews published between January 1, 2006, and June 30, 2023. Data extraction involved a systematic analysis of a total of 910 publications, which included 625 research articles and 285 reviews. The publication trends indicate a steady growth in research output, peaking with 122 papers in 2022. Geographic contributions primarily originate from the United States, followed by robust European contributions and increasing input from Asian countries, particularly China and Japan. Influential researchers such as Smith JM from Johns Hopkins University, Brown L from Harvard University, and Wang Q from Peking University have significantly shaped this field. Key institutions driving substantial publication volume and citation impact include Johns Hopkins University, Harvard University, and the University of Tokyo. Furthermore, journals such as Neurology, Journal of Autoimmunity, and Clinical Rheumatology play pivotal roles in disseminating advancements in SS-related neurological research. Future research priorities should focus on primary prevention, emphasizing the need for global cooperation and collaboration in neurological SS workup. There is a call for encouraging interdisciplinary, internationally focused investigative efforts specifically targeting SS neurologists. Key focus areas include potential preventive therapies aimed at significant neural dysfunctions (e.g., sensory neuropathy), mechanisms of microvascular dysfunction, and cognitive profiles/immunomodulation against autoantibodies. This analysis underscores the continued necessity for further research to optimize diagnosis and treatment in cases involving the complexities of neurological involvement with SS.
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Factors predicting conversion from colon capsule endoscopy to conventional optical endoscopy-findings from the CESCAIL studyBackground Colon capsule endoscopy (CCE) has become an alternative to traditional colonoscopy for low-risk patients. However, CCE's low completion rate and inability to take biopsies or remove polyps often result in a CCE-to-conventional colonoscopy conversion (CCC). Objective(s) The aim is to identify the factors that predict issues with bowel cleansing, capsule excretion rates, pathology detection, and the need for CCC. Methods This prospective study analysed data from patients who underwent CCE as part of the CESCAIL study from Nov 2021 till June 2024. Predictive factors were examined for their association with CCC, including patient demographics, comorbidities, medications, and laboratory results from symptomatic and surveillance groups. Statistical methods such as LASSO, linear, and logistic regression were applied. Results Six hundred and three participants were analysed. Elevated f-Hb levels (OR = 1.48, 95% CI:1.18–1.86, p = 0.0002) and smoking (OR = 1.44, 95% CI: 1.01–2.11, p = 0.047) were significantly associated with CCC. The area under the curve (AUC) of elevated f-Hb for predicting CCC was 0.62 after adjusting for confounders. Diabetes was linked to poor bowel preparation (OR = 0.40, 95%CI:0.18–0.87, p = 0.022). Alcohol (p = 0.004), smoking (p = 0.003), psychological conditions (p = 0.001), and haemoglobin levels (p = 0.046) were significantly associated with the number of polyps, whilst antidepressants (p = 0.003) and beta-blockers (p = 0.001) were linked to the size of polyps. Conclusion Non-smokers with lower f-Hb levels are less likely to need conventional colonoscopy (CCC). Patient selection criteria are key to minimising the colonoscopy conversion rate. Our findings would benefit from validation in different populations to develop a robust CCE Conversion Scoring System (CECS) and ultimately improve the cost-effectiveness.
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Diagnostic tools and methods for dermatological assessmentAdvanced clinical practitioners (ACPs) play an essential role in dermatological care but often encounter challenges due to limited training in dermatological assessments and investigations. This two-part series aims to address these gaps by offering a structured approach specifically for ACPs. Part one focused on conducting a thorough history-taking and physical examination to establish a solid foundation for diagnosis. Part two contributes to the existing literature by detailing essential diagnostic tools and emerging technologies that empower ACPs to enhance diagnostic accuracy and patient-centred care. These include traditional methods such as skin biopsies, histopathology, microbiological testing, immunofluorescence, dermatoscopy and relevant blood tests, as well as innovative advancements such as artificial intelligence (AI) tools and imaging techniques. In addition, the integration of quality-of-life (QoL) measures highlights the broader impact of skin diseases on patients' mental and emotional wellbeing. By combining clinical examination skills, diagnostic innovations and holistic assessments ACPs can provide more effective and empathetic dermatological care, ultimately improving outcomes and diagnostic confidence.
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Dermatological assessment: history-taking and examinationNurses of all disciplines will find dermatological complaints one of the most common presentations in their practice. This article looks at effective techniques when assessing dermatological conditions. Skin problems are common, affecting up to one-third of the population during their lifetime, and they are frequently encountered by advanced clinical practitioners (ACPs) in both primary and secondary care settings. Despite the prevalence of dermatological presentations, ACPs often feel unprepared to conduct a thorough dermatological history and examination. This article aims to provide guidance to trainees and qualified ACPs, whether in acute hospital settings or primary care, to perform dermatological assessments and examinations systematically. This is the first article in a two-part series on dermatological assessment.
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Expert opinion on a safe same day discharge strategy as standard of care after leadless pacemaker implantationIntroduction Leadless pacemaker (LPs) is a safe and effective alternative to conventional transvenous pacing. There is currently no guidance on which patients could be safely discharged the same day post-procedure. Purpose To provide guidance to medical teams regarding safe same day discharge (SDD) after LP implantation. Methods An Advisory Board (AB) of 6 expert Micra™ implanters was formed. Interviews were conducted with each member to understand their experience on patient selection, care pathway, complications, and follow-up of Micra™ implanted patients. This information was used to develop a patient pathway for safe SDD after Micra™ implantation. A further survey was conducted to obtain consensus regarding decision points within the pathway. Results The SDD after Micra™ Implantation Patient Pathway consists of four phases: Pre-procedure assessment: Social factors are key in deciding suitability of SDD (6/6 AB members agreed, 100%). Patient’s comorbidities, frailty status and timing of procedure are also important in decision-making for SDD. Micra™ implant: Ultrasound-guidance reduces vascular access-related complications, increasing the likelihood for SDD (100%). Post-procedure observation: Peri-procedural complications such as pericardial effusion, severe vascular complications, bleeding from access site and device complications would prevent SDD (100%). Patients should complete 6 h of observation prior to discharge (100%). Follow-up: First follow-up should be in-person, 1–4 weeks post-procedure (84 %). Long-term follow-up should be organised as per Micra™ standard of care at each centre (100 %). Conclusions SDD after Micra™ Implantation Patient Pathway was developed via expert consensus. Adoption of the pathway in clinical practice may facilitate safe SDD after Micra™ Implantation.
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Friday night acute kidney injury: chest infection masking Antineutrophil Cytoplasmic Antibody VasculitisAntineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) includes a group of autoimmune disorders resulting in the production of autoantibodies to neutrophil proteins (leukocyte proteins, proteinase 3 (PR3)-ANCA or myeloperoxidase proteins (MPO)-ANCA). There are three subtypes of AAV based on ANCA serotypes: PR3+ AAV, MPO+ AAV, and ANCA+. These rare disorders present with a wide spectrum of symptoms with involvement of multiple organs, including the heart, kidneys, eyes, ears, brain, spinal cord, nerves, and musculoskeletal system, making them difficult to diagnose promptly. This impacts the prognosis of AAV, as involvement of major organs can increase recurrence rates and lead to a poor prognosis, while timely diagnosis can lead to full recovery. Treatment options mainly involve immunosuppression with steroids, rituximab, methotrexate, and cyclophosphamide to maintain remission. We discuss a case of granulomatosis with polyangiitis in an adult male. We believe this report will help highlight timely diagnosis and interventions, overall improving the prognosis of patients.
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Mononeuritis Multiplex as a diagnostic challenge in Eosinophilic Granulomatosis with Polyangiitis: implications of early versus delayed recognitionA 63-year-old female patient presented to the acute medical unit with what appeared to be a case of progressive mobility decline, a common and often nonspecific presentation in acute medicine. She described upper and lower limb weakness and numbness affecting her ability to walk. Originally, her upper limb numbness was treated as ulnar nerve compression in the community. She also had multiple episodes of shortness of breath throughout the year, which were initially managed in the community as suspected asthma exacerbations; however, her symptoms were non-specific. Routine investigations revealed severe eosinophilia (13.37 × 10⁹/L), anaemia, and leucocytosis. Neurophysiology confirmed mononeuritis multiplex, and further autoimmune testing revealed positive anti-neutrophil cytoplasmic antibodies (P-ANCA) and elevated myeloperoxidase (MPO) antibodies. This was ultimately diagnosed as eosinophilic granulomatosis with polyangiitis (EGPA), a rare presentation that challenged initial diagnostic assumptions. This case is an example of how not all presentations of EGPA are straightforward and how it might be missed in an acute medical setting. Through this case report, we wanted to emphasise the subtle and often vague nature of mononeuritis multiplex in EGPA. We would also like to highlight the implications of a delayed diagnosis on patients with EGPA and how this affects the long-term health of patients. Lastly, we would like to discuss newer treatments with anti-interleukin-5 (IL-5) target drugs, which are used to reduce relapse rates in the disease.
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Diabetes management during the end of lifeFor individuals with diabetes, maintaining optimal glycaemic control is essential to reduce the risk of long-term complications. However, as patients approach the end of life, the emphasis on tight glycaemic targets becomes less relevant. Instead, the primary goal shifts to maintaining blood glucose levels within a range that minimises the risk of hypoglycaemia and prevents symptomatic hyperglycaemia, thereby ensuring comfort and quality of life. This article explores the transition from disease-focused management to a person-centred approach grounded in comfort, dignity and ethical responsibility. It examines the adaptation of glycaemic targets, deprescribing, nutrition, and monitoring across the recognised phases of dying, and addresses the specific challenges of managing type 1, type 2 and steroid-induced diabetes in palliative contexts. Ethical principles including autonomy, non-maleficence, beneficence, and justice are critically applied to nursing practice, alongside recommendations for interdisciplinary communication and advance care planning. Nurses play a pivotal role in delivering proportionate, compassionate, and ethically sound care for people dying with diabetes.
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Orbital Atherectomy in Calcified Coronary Lesions: a 1-year retrospective observational outcome studyBackground Percutaneous coronary intervention (PCI) has advanced rapidly since its inception. Not only in stent technology, but there have been advancements in adjunctive tools including intra-coronary imaging, stent delivery tools and calcium modification techniques. The interventional community is well aware of the difficulties posed by calcified coronary lesions and their impact on outcomes. More recently, orbital atherectomy (OA) has seen itself on the fore front of managing such complex and challenging situations. Aims This retrospective study analyses a 1-year experience of using OA in a high-volume primary PCI center in a UK district general hospital. Methods Patient demographics, procedural details, and outcomes, including MACE rates and procedural success, were reviewed in all-comers undergoing OA between January 1 and December 31, 2024. Results A total 53 patients were identified that had undergone OA in a 1-year period. Procedural success was achieved in 98.1% of patients. Thirty-days MACE was 5.7% (three patients). One patient experiencing in-hospital procedural related myocardial infarction and two patients had major bleeding events during the follow up period which is not related to OA. No-flow/slow-flow were observed in seven patients (13.2%), and seven patients (13.2%) experienced coronary dissection that were successfully treated with stent implantation. Conclusion OA is a new but safe and effective tool for calcium modification in an all-comers cohort of patients treated in a high-volume UK district general hospital setting.
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Exploring ascites: Its significance, pathogenesis, aetiology, presentation, examinations and management strategiesAscites is characterised by an accumulation of fluid in the peritoneal cavity. While it is commonly associated with liver cirrhosis, it may also result from malignancy, cardiac failure or renal disease. This clinical review explores the pathogenesis, clinical presentation, diagnostic approaches and management strategies for ascites, emphasising its multifaceted nature and clinical implications. The pathophysiology of cirrhotic ascites is largely attributed to splanchnic vasodilation and subsequent sodium and water retention, while non-cirrhotic causes are associated with various underlying mechanisms. Clinical presentations range from abdominal distension and discomfort to systemic signs of underlying diseases. Diagnosis involves imaging, ascitic fluid analysis and advanced laboratory tests to identify the aetiology and guide targeted interventions. Management requires a multidisciplinary approach, integrating sodium restriction, diuretic therapy, paracentesis, albumin infusion and, in some cases, transjugular intrahepatic portosystemic shunts (TIPS). Challenges such as refractory ascites and complications such as spontaneous bacterial peritonitis necessitate a thorough clinical assessment and management. Advanced clinical practitioners and gastroenterology teams play an essential role in optimising outcomes, ensuring patient safety and promoting quality of life.
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Novel insights into pulmonary embolism with negative D-dimer resultsA patient in his mid-40s presented with exertional dyspnoea and pleuritic chest pain persisting for 6 weeks. Despite repeated normal investigations, including D-dimer tests, chest X-rays, serial troponins and ECGs, a CT pulmonary angiogram (CTPA) was performed to rule out pulmonary embolism (PE) or other pulmonary abnormalities, revealing a left main pulmonary artery thrombus with no evidence of right ventricular strain. The patient was managed with oral rivaroxaban 15 mg two times per day for 21 days followed by 20 mg once daily for 6 months. The patient showed full recovery at the 6-month follow-up. This case highlights the diagnostic challenges in patients with persistent symptoms, low risk of venous thromboembolisms (VTEs) and normal initial investigations. It is novel because previous case reports of PE with negative D-dimer results have predominantly involved patients with identifiable risk factors, such as prior VTEs, malignancy or other conditions that increase the likelihood of PE. In contrast, this case demonstrates that PE can occur even in the absence of these risk factors, emphasising the importance of clinical diligence and the use of advanced imaging in diagnosing PE in atypical presentations.