• A deep learning approach to case prioritisation of colorectal biopsies.

  Dada, Mahomed

  AIMS: To create and validate a weakly supervised artificial intelligence (AI) model for detection of abnormal colorectal histology, including dysplasia and cancer, and prioritise biopsies according to clinical significance (severity of diagnosis). MATERIALS AND METHODS: Triagnexia Colorectal, a weakly supervised deep learning model, was developed for the classification of colorectal samples from haematoxylin and eosin (H&E)-stained whole slide images. The model was trained on 24 983 digitised images and assessed by multiple pathologists in a simulated digital pathology environment. The AI application was implemented as part of a point and click graphical user interface to streamline decision-making. Pathologists assessed the accuracy of the AI tool, its value, ease of use and integration into the digital pathology workflow. RESULTS: Validation of the model was conducted on two cohorts: the first, on 100 single-slide cases, achieved micro-average model specificity of 0.984, micro-average model sensitivity of 0.949 and micro-average model F1 score of 0.949 across all classes. A secondary multi-institutional validation cohort, of 101 single-slide cases, achieved micro-average model specificity of 0.978, micro-average model sensitivity of 0.931 and micro-average model F1 score of 0.931 across all classes. Pathologists reflected their positive impressions on the overall accuracy of the AI in detecting colorectal pathology abnormalities. CONCLUSIONS: We have developed a high-performing colorectal biopsy AI triage model that can be integrated into a routine digital pathology workflow to assist pathologists in prioritising cases and identifying cases with dysplasia/cancer versus non-neoplastic biopsies.
• Presenting Symptoms Define Time to Diagnosis in Degenerative Cervical Myelopathy: Process Mapping From a Musculoskeletal Triage Unit in the UK.

  Foulds, Stephanie (Wiley, 2025-03)

  STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Tackling delayed diagnosis in degenerative cervical myelopathy (DCM) is a global research priority. On average, it takes 2-5 years, leading to worse outcomes from surgery and greater disability. Many countries in the UK use interface triage units run by specialist physiotherapists that sit between primary and secondary care termed musculoskeletal services. Their role in the efficient diagnosis of DCM is unknown. The aim of this study was to map the journey of the patient in the musculoskeletal service and to establish the presenting signs and symptoms. METHODS: A retrospective review of 2.5 years of clinical notes was performed in a musculoskeletal service. Process mapping was utilised to visualise the patient's journey and identify delays to diagnosis and presenting signs and symptoms. RESULTS: Twenty-seven cases were reviewed. Patients spent an average of three months in the service. There was a wide variety of presenting symptoms. DCM was more often suspected if patients had both upper limb symptoms and gait disturbance or pathological reflexes. Delays occurred when patients had no gait disturbance or a normal or incomplete neurological assessment. Longest delays occurred when patients received electrophysiology tests for differential diagnosis of peripheral neuropathies. Delays were also seen with incorrect triaging of MRI results. CONCLUSIONS: Where DCM is the principal differential diagnosis, diagnosis was faster. Incomplete examination, misinterpretation of MRI findings or delays in other investigations contributed to delays. Improved awareness and protocols of care within musculoskeletal services represent an opportunity to accelerate diagnosis in DCM.
• Development and validation of a gonadotropin dose selection model for optimized ovarian stimulation in IVF/ICSI: an individual participant data meta-analysis.

  Jayaprakasan, Kanna

  BACKGROUND: The ovarian response to gonadotropin stimulation varies widely among women, and could impact the probability of live birth as well as treatment risks. Many studies have evaluated the impact of different gonadotropin starting doses, mainly based on predictive variables like ovarian reserve tests (ORT) including anti-Müllerian hormone (AMH), antral follicle count (AFC), and basal follicle-stimulating hormone (bFSH). A Cochrane systematic review revealed that individualizing the gonadotropin starting dose does not affect efficacy in terms of ongoing pregnancy/live birth rates, but may reduce treatment risks such as the development of ovarian hyperstimulation syndrome (OHSS). An individual patient data meta-analysis (IPD-MA) offers a unique opportunity to develop and validate a universal prediction model to help choose the optimal gonadotropin starting dose to minimize treatment risks without affecting efficacy. OBJECTIVE AND RATIONALE: The objective of this IPD-MA is to develop and validate a gonadotropin dose-selection model to guide the choice of a gonadotropin starting dose in IVF/ICSI, with the purpose of minimizing treatment risks without compromising live birth rates. SEARCH METHODS: Electronic databases including MEDLINE, EMBASE, and CRSO were searched to identify eligible studies. The last search was performed on 13 July 2022. Randomized controlled trials (RCTs) were included if they compared different doses of gonadotropins in women undergoing IVF/ICSI, presented at least one type of ORT, and reported on live birth or ongoing pregnancy. Authors of eligible studies were contacted to share their individual participant data (IPD). IPD and information within publications were used to determine the risk of bias. Generalized linear mixed multilevel models were applied for predictor selection and model development. OUTCOMES: A total of 14 RCTs with data of 3455 participants were included. After extensive modeling, women aged 39 years and over were excluded, which resulted in the definitive inclusion of 2907 women. The optimal prediction model for live birth included six predictors: age, gonadotropin starting dose, body mass index, AFC, IVF/ICSI, and AMH. This model had an area under the curve (AUC) of 0.557 (95% confidence interval (CI) from 0.536 to 0.577). The clinically feasible live birth model included age, starting dose, and AMH and had an AUC of 0.554 (95% CI from 0.530 to 0.578). Two models were selected as the optimal model for combined treatment risk, as their performance was equal. One included age, starting dose, AMH, and bFSH; the other also included gonadotropin-releasing hormone (GnRH) analog. The AUCs for both models were 0.769 (95% CI from 0.729 to 0.809). The clinically feasible model for combined treatment risk included age, starting dose, AMH, and GnRH analog, and had an AUC of 0.748 (95% CI from 0.709 to 0.787). WIDER IMPLICATIONS: The aim of this study was to create a model including patient characteristics whereby gonadotropin starting dose was predictive of both live birth and treatment risks. The model performed poorly on predicting live birth by modifying the FSH starting dose. On the contrary, predicting treatment risks in terms of OHSS occurrence and management by modifying the gonadotropin starting dose was adequate. This dose-selection model, consisting of easily obtainable patient characteristics, aids in the choice of the optimal gonadotropin starting dose for each individual patient to lower treatment risks and potentially reduce treatment costs.
• Development and validation of a gonadotropin dose selection model for optimized ovarian stimulation in IVF/ICSI: an individual participant data meta-analysis.

  Jayaprakasan, Kanna

  BACKGROUND: The ovarian response to gonadotropin stimulation varies widely among women, and could impact the probability of live birth as well as treatment risks. Many studies have evaluated the impact of different gonadotropin starting doses, mainly based on predictive variables like ovarian reserve tests (ORT) including anti-Müllerian hormone (AMH), antral follicle count (AFC), and basal follicle-stimulating hormone (bFSH). A Cochrane systematic review revealed that individualizing the gonadotropin starting dose does not affect efficacy in terms of ongoing pregnancy/live birth rates, but may reduce treatment risks such as the development of ovarian hyperstimulation syndrome (OHSS). An individual patient data meta-analysis (IPD-MA) offers a unique opportunity to develop and validate a universal prediction model to help choose the optimal gonadotropin starting dose to minimize treatment risks without affecting efficacy. OBJECTIVE AND RATIONALE: The objective of this IPD-MA is to develop and validate a gonadotropin dose-selection model to guide the choice of a gonadotropin starting dose in IVF/ICSI, with the purpose of minimizing treatment risks without compromising live birth rates. SEARCH METHODS: Electronic databases including MEDLINE, EMBASE, and CRSO were searched to identify eligible studies. The last search was performed on 13 July 2022. Randomized controlled trials (RCTs) were included if they compared different doses of gonadotropins in women undergoing IVF/ICSI, presented at least one type of ORT, and reported on live birth or ongoing pregnancy. Authors of eligible studies were contacted to share their individual participant data (IPD). IPD and information within publications were used to determine the risk of bias. Generalized linear mixed multilevel models were applied for predictor selection and model development. OUTCOMES: A total of 14 RCTs with data of 3455 participants were included. After extensive modeling, women aged 39 years and over were excluded, which resulted in the definitive inclusion of 2907 women. The optimal prediction model for live birth included six predictors: age, gonadotropin starting dose, body mass index, AFC, IVF/ICSI, and AMH. This model had an area under the curve (AUC) of 0.557 (95% confidence interval (CI) from 0.536 to 0.577). The clinically feasible live birth model included age, starting dose, and AMH and had an AUC of 0.554 (95% CI from 0.530 to 0.578). Two models were selected as the optimal model for combined treatment risk, as their performance was equal. One included age, starting dose, AMH, and bFSH; the other also included gonadotropin-releasing hormone (GnRH) analog. The AUCs for both models were 0.769 (95% CI from 0.729 to 0.809). The clinically feasible model for combined treatment risk included age, starting dose, AMH, and GnRH analog, and had an AUC of 0.748 (95% CI from 0.709 to 0.787). WIDER IMPLICATIONS: The aim of this study was to create a model including patient characteristics whereby gonadotropin starting dose was predictive of both live birth and treatment risks. The model performed poorly on predicting live birth by modifying the FSH starting dose. On the contrary, predicting treatment risks in terms of OHSS occurrence and management by modifying the gonadotropin starting dose was adequate. This dose-selection model, consisting of easily obtainable patient characteristics, aids in the choice of the optimal gonadotropin starting dose for each individual patient to lower treatment risks and potentially reduce treatment costs.
• TOURISM study (Treatment Outcomes in UteRIne SarcoMa): a 10-year retrospective evaluation of practice in the UK.

  Webb, Rebekah

  BACKGROUND: Although rare, uterine sarcomas account for a high proportion of uterine cancer mortality. Treatment options and robust trial data are limited. OBJECTIVES: The TOURISM study (Treatment Outcomes in UteRIne SarcoMa) is a UK-wide study by the National Oncology Trainees Collaborative for Healthcare Research which aimed to characterise this patient cohort. DESIGN: A retrospective descriptive cohort study. Patients with carcinosarcomas/mixed Mullerian tumours, non-uterine gynaecological sarcomas and uterine metastases were excluded. Routine clinical data, including general patient demographics, diagnosis, treatment and outcomes, were collated and pseudonymised. SETTING: Patients diagnosed with uterine sarcoma in the UK National Health Service between 1 January 2008 and 31 December 2017 were identified from electronic records. PARTICIPANTS: A total of 406 patients from eight centres were eligible for inclusion. RESULTS: The median age at diagnosis was 56 years, with leiomyosarcoma the most common diagnosis (54.4%). The majority (57.9%) were diagnosed at the International Federation of Gynecology and Obstetrics stage I, with 19.7% diagnosed at stage IV. Nearly half (45.2%) of the patients received at least one line of chemotherapy, of which most (81.0%) received doxorubicin first-line. In the stage I group 7.4% received adjuvant chemotherapy and 15.0% received adjuvant radiotherapy. Median overall survival was 37 months; however, survival varied significantly by stage at diagnosis (stage I: 105 months; stage II: 33 months; stage III: 19 months; stage IV: 14 months). CONCLUSIONS: Our data highlight the diversity in patient management in uterine sarcoma and a marked survival advantage for patients diagnosed with stage I disease. These data highlight the importance of a multidisciplinary approach and describe real-world trends in systemic therapies, radiotherapy and surgical treatment in this rare cancer type.
• Frequency and Reporting of Complications after Dupuytren Contracture Interventions: A Systematic Review and Meta-Analysis.

  Johnson, Nick

  BACKGROUND: Numerous complications are reported following interventions for Dupuytren contracture; however, their incidence, management, and outcomes remain poorly reported. The aims of this review were to report the proportions of complications, compare likelihood of complications between interventions, and evaluate reporting. METHODS: Patient demographics, interventions, complications, their management, and outcomes were extracted. Analysis of descriptive data enabled review of reporting. Meta-analysis (MA) of noncomparative data sets enabled estimation of proportions of patients experiencing complications. Network meta-analysis (NMA) of comparative studies estimated the relative occurrence of complications between interventions. RESULTS: Twenty-six studies, comprising 10,831 patients, were included. Interventions included collagenase injection, percutaneous needle fasciotomy (PNF), limited fasciectomy (LF), open fasciotomy (OF), and dermofasciectomy (DF). Overall quality and consistency of outcomes reporting was poor. MA enabled estimates of probabilities for 3 common complications across all interventions; the reported rates for LF were 4.5% for infection, 3% for nerve injury, and 3.3% for CRPS. LF, the most common intervention, was used as the reference intervention for comparison of the most common complications via NMA, including hematoma (OF odds ratio, 0.450 [95% CI, 0.277 to 0.695]; PNF odds ratio, 0.245 [95% CI, 0.114 to 0.457]), infection (PNF odds ratio, 0.2 [95% CI, 0.0287 to 0.690]; DF odds ratio, 2.02 [95% CI, 1.02 to 3.74]), and neurapraxia [PNF odds ratio, 0.0926 [95% CI, 0.00553 to 0.737]). CONCLUSIONS: There was limited reporting of complication occurrence, management, and outcomes, contributing to a gap in information for informed patient consent. MA was possible for reporting of proportions for infection, nerve injury, and CRPS. NMA enabled direct comparison of the 6 most common complications between interventions. Improving consistency and quality in complications reporting aids counseling of patients regarding the true rates and consequences of the risks of interventions, which can guide selection.
• Patient-reported outcomes in studies of diabetes technology: What matters.

  Liarakos, Alexandros; Crabtree, Thomas; Wilmot, Emma

  In recent years, diabetes technologies have revolutionized the care of people with type 1 diabetes (T1D). Emerging evidence suggests that people with type 2 diabetes (T2D) can experience similar benefits from these advances in technology. While glycaemic outcomes are often a primary focus, the lived experience of the person with diabetes is equally important. In this review, we describe the impact of diabetes technologies on patient-reported outcome measures (PROMs). We highlight that most of the published studies investigated PROMs as secondary outcomes. Continuous glucose monitoring systems may have an important role in improving PROMs in individuals with T1D, which may be driven by the prevention or proactive management of hypoglycaemia. In people with T2D, continuous glucose monitoring may also have an important role in improving PROMs, particularly in those treated with insulin therapy. The impact of insulin pumps on PROMs seems positive in T1D, while there is limited evidence in T2D. Studies of hybrid closed-loop therapies suggest increased treatment satisfaction, improved quality of life and decreased diabetes-related distress in T1D, but it is unclear whether these benefits are because of a 'class-effect' or individual systems. We conclude that PROMs deserve a more central role in trials and clinical practice, and we discuss directions for future research.
• Prevalence of Emotional and Binge Eating Among Patients With Obesity Attending a Specialist Weight Management Service for Bariatric Surgery in the United Kingdom.

  Holt, Guy; Idris, Iskandar

  BACKGROUND: Emotional eating (EE) is a tendency to consume food in response to positive or negative emotions, leading to obesity and an increased Body Mass Index (BMI). Evidence supports the positive association between EE and binge eating disorder (BED), but little is known about its prevalence among patients referred for bariatric surgery and the psychological characteristics of this patient population. We aim to examine (i) the prevalence of binge eating and EE, (ii) its association with the prevalence of anxiety, depression, diabetes and hypertension and (iii) the correlation between anxiety and depression with emotional and binge eating behaviours among patients attending a regional bariatric service in the UK. METHOD: A cross-sectional case file design involving 285 participants (mean age = 43.88 ± 11.5, female (80.7%) and male (19.3%)) was used. Outcome measures included body weight, BMI, the Weight Loss Readiness (WLR) Questionnaire, Generalised Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire (PHQ-9) and Alcohol Use Disorders Identification Test- Consumption (AUDIT-C). RESULTS: Within this patient group, the prevalence of binge eating and EE were 28.8% and 22.1% respectively. Among these, 19.3% had diabetes mellitus, 24.8% hypertension, 21% harmful alcohol use, 65% had high anxiety score and 77% high depression scores. Most correlations between body weight and variables like AUDIT-C, GAD-7, PHQ-9 scores and WLR scores for hunger, binge eating and EE were not significant. A positive association was observed between depression and anxiety with binge eating, and EE behaviours. CONCLUSION: Patients awaiting bariatric surgery have a wide range of mental and physical health comorbidities, with evidence of positive associations between higher depression and anxiety levels with abnormal eating behaviours. These findings highlight the need for screening for comorbidities in this patient population to optimise patient outcomes postbariatric surgery.
• The effect of pre-operative exercise training on post-operative cognitive function: a systematic review.

  Gordon, Adam L

  BACKGROUND: With population aging and advances in surgical and anesthetic procedures, the incidence of surgery in patients over the age of 65 years is increasing. One post-operative complication often encountered by older surgical patients is post-operative cognitive dysfunction (POCD). Preoperative exercise training can improve the overall physiological resilience of older surgical patients, yet its impact on post-operative cognition is less well-established. METHODS: Six databases (Medline (OVID); EMBASE (OVID); EMCARE (OVID); CINAHL (EBSCOHost), the Cochrane Library, and PubMed) were searched for studies reporting the effect of pre-operative physical training on post-operative cognition. The quality of evidence was assessed using the Mixed Methods Assessment Tool. RESULTS: A total of 3983 studies were initially identified, three of which met the inclusion criteria for this review. Two studies were pilot randomized trials, and one was a prospective randomized trial. Two of the studies were high-quality. Each study used a different type of physical exercise and cognition assessment tool. Across the studies, post-operative cognition (p = 0.005) and attention (p = 0.04) were found to be better in the intervention groups compared to control, with one study reporting no difference between the groups. CONCLUSION: Preoperative physical training may improve post-operative cognitive function, although more research with a consistent endpoint is required. Future studies should focus on patients at high risk of POCD, such as older adults, and explore the impact of different exercise regimes, including frequency, intensity, time, and type.
• Association Between Neutrophil-to-Lymphocyte Ratio and Sepsis Severity in ICU Patients.

  Binliaquat, Saad

  Background Sepsis is a potentially fatal condition that necessitates prompt identification and assessment of its severity for effective management. However, evaluating sepsis severity using the Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores can be complex and costly. This study aimed to assess the association between neutrophil-to-lymphocyte ratio (NLR) and sepsis severity, as well as the role of NLR as a predictive indicator of sepsis severity in ICU patients. Methods This cross-sectional study was conducted among 180 ICU-admitted patients at Benazir Bhutto Hospital (BBH) in Rawalpindi, Pakistan, from January 2022 to January 2023. Participants were enrolled using defined inclusion and exclusion criteria along with consecutive sampling. Following ethical approval and informed consent, data were collected using a self-structured form. The study population was divided into three groups based on sepsis severity, which was assessed via the SOFA score. Data analysis was performed using IBM SPSS Statistics for Windows, Version 25.0 (Released 2017; IBM Corp., Armonk, NY, USA) through chi-squared tests, one-way ANOVA, Pearson's correlation, and a simple linear regression model, with a significance threshold set at p < 0.05. Results In the study population of 180 patients, the frequencies of sepsis, severe sepsis, and septic shock were 69 (38.34%), 86 (47.78%), and 25 (13.88%), respectively. Significant variations were observed among the three study groups in the means of the PaO2/FiO2 ratio, mean arterial pressure, Glasgow Coma Scale score, total bilirubin level, serum creatinine level, platelet count, SOFA score, neutrophil count, lymphocyte count, and NLR (p < 0.05). Pearson's correlation analysis indicated a strong positive correlation between the NLR and SOFA score, with a correlation coefficient (r) of 0.80 and significance at p < 0.001. Furthermore, linear regression analysis identified NLR as a significant predictor of sepsis severity, with a beta coefficient (β) of 3.55 and a 95% CI of 1.92-5.60 (p < 0.001). Conclusions In the current study, a positive and significant correlation was found between the NLR and the severity of sepsis. Higher NLR values were associated with increased SOFA scores, indicating a greater severity of sepsis. This study supports the use of NLR as a complementary and cost-effective tool for the early detection of high-risk patients with sepsis, facilitating timely interventions and improving outcomes, particularly in under-resourced healthcare settings.
• Metoclopramide for analgesia in renal colic: a narrative systematic review.

  Tabner, Andrew; Fakis, Apostolos; Toft, Suzanne; Johnson, Graham

  Metoclopramide, a prokinetic antiemetic with activity at multiple receptor types, may be a useful treatment for renal colic pain. This review investigated whether metoclopramide is an effective analgesic in the management of adults with renal colic.Eligible studies were randomised, quasi-randomised or case-control trials of metoclopramide for the management renal colic pain. Electronic database searches were performed in November 2022. Screening was performed by two authors independently; disagreement was resolved by discussion or by adjudication by a third author. The Cochrane Collaboration Risk of Bias Tool v2.0 was used to assess bias.Two studies were included, enrolling 279 patients. Heterogeneity of primary outcome measurement and comparators rendered meta-analysis inappropriate; a narrative review is presented. Both studies showed some evidence of analgesic effect. The largest study had a low risk of bias in all assessed domains, whilst the smaller study was at a high risk of bias.There is limited evidence that metoclopramide may be an effective analgesic in the management of renal colic, with the highest quality study demonstrating analgesic properties similar to an intravenous non-steroidal anti-inflammatory medication.Protocol registration Prospero (CRD42022346618).
• A Systematic Review and Meta-Analysis of the Effect of Caloric Restriction on Skeletal Muscle Mass in Individuals with, and without, Type 2 Diabetes.

  Oluwaseun, Anyjam; Olakunmi, Olakunmi; Arash, Ardavani; Idris, Iskandar

  BACKGROUND: Severe caloric restriction interventions (such as very-low-calorie diets) are effective for inducing significant weight loss and remission of type 2 diabetes (T2DM). However, suggestions of associated significant muscle mass (MM) loss create apprehension regarding their widespread use. We conducted a systematic review and meta-analysis to provide a quantitative assessment of their effect on measures of MM in individuals with, or without, T2DM. METHODS: EMBASE, Medline, Pubmed, CINAHL, CENTRAL and Google Scholar were systematically searched for studies involving caloric restriction interventions up to 900 kilocalories per day reporting any measure of MM, in addition to fat mass (FM) or body weight (BW). RESULTS: Forty-nine studies were eligible for inclusion, involving 4785 participants. Individuals with T2DM experienced significant reductions in MM (WMD -2.88 kg, 95% CI: -3.54, -2.22; p < 0.0001), although this was significantly less than the reduction in FM (WMD -7.62 kg, 95% CI: -10.87, -4.37; p < 0.0001). A similar pattern was observed across studies involving individuals without T2DM. MM constituted approximately 25.5% of overall weight loss in individuals with T2DM, and 27.5% in individuals without T2DM. Subgroup analysis paradoxically revealed greater BW and FM reductions with less restrictive interventions. CONCLUSIONS: Our review suggests that caloric restriction interventions up to 900 kilocalories per day are associated with a significant reduction in MM, albeit in the context of a significantly greater reduction in FM. Furthermore, MM constituted approximately a quarter of the total weight loss. Finally, our data support the use of less restrictive interventions, which appear to be more beneficial for BW and FM loss.
• N-acetylcysteine Clinical Applications

  Amer, Yahia

  This study aims to evaluate the therapeutic application of N-acetylcysteine (NAC) as a treatment or adjunct therapy for various medical conditions. While its efficacy in treating acetaminophen overdose, cystic fibrosis, and chronic obstructive pulmonary disease is well-established, emerging evidence suggests that NAC may also benefit a broader spectrum of illnesses due to its safety, simplicity, and affordability. A comprehensive review was conducted by searching PubMed, relevant books, and conference proceedings for publications discussing NAC about the specified health conditions. The clinically relevant data were analysed using the American Family Physician Evidence-Based Medicine Toolkit, following a standard integrated review methodology. NAC shows potential as an adjunctive treatment for a wide range of medical conditions, particularly chronic diseases. It may be beneficial for polycystic ovary syndrome, endometriosis, male infertility, cataracts, glaucoma, dry eye syndrome, parkinsonism, multiple sclerosis, Alzheimer's disease, stroke outcomes, non-acetaminophen-induced acute liver failure, Crohn's disease, ulcerative colitis, schizophrenia, bipolar disorder, and obsessive-compulsive disorder. Although evidence for some conditions is less robust, NAC's therapeutic potential warrants further investigation. Given the aging population and the decline in glutathione levels, the use of NAC should be considered across a variety of medical conditions. This paper suggests that NAC supplementation could play a significant role in reducing morbidity and mortality associated with numerous chronic diseases.
• Patient-reported outcomes in studies of diabetes technology: What matters.

  Liarakos, Alexandros

  In recent years, diabetes technologies have revolutionized the care of people with type 1 diabetes (T1D). Emerging evidence suggests that people with type 2 diabetes (T2D) can experience similar benefits from these advances in technology. While glycaemic outcomes are often a primary focus, the lived experience of the person with diabetes is equally important. In this review, we describe the impact of diabetes technologies on patient-reported outcome measures (PROMs). We highlight that most of the published studies investigated PROMs as secondary outcomes. Continuous glucose monitoring systems may have an important role in improving PROMs in individuals with T1D, which may be driven by the prevention or proactive management of hypoglycaemia. In people with T2D, continuous glucose monitoring may also have an important role in improving PROMs, particularly in those treated with insulin therapy. The impact of insulin pumps on PROMs seems positive in T1D, while there is limited evidence in T2D. Studies of hybrid closed-loop therapies suggest increased treatment satisfaction, improved quality of life and decreased diabetes-related distress in T1D, but it is unclear whether these benefits are because of a 'class-effect' or individual systems. We conclude that PROMs deserve a more central role in trials and clinical practice, and we discuss directions for future research.
• Invasive Treatment Strategy for Older Patients with Myocardial Infarction.

  Kelly, Damien

  BACKGROUND: Whether a conservative strategy of medical therapy alone or a strategy of medical therapy plus invasive treatment is more beneficial in older adults with non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear. METHODS: We conducted a prospective, multicenter, randomized trial involving patients 75 years of age or older with NSTEMI at 48 sites in the United Kingdom. The patients were assigned in a 1:1 ratio to a conservative strategy of the best available medical therapy or an invasive strategy of coronary angiography and revascularization plus the best available medical therapy. Patients who were frail or had a high burden of coexisting conditions were eligible. The primary outcome was a composite of death from cardiovascular causes (cardiovascular death) or nonfatal myocardial infarction assessed in a time-to-event analysis. RESULTS: A total of 1518 patients underwent randomization; 753 patients were assigned to the invasive-strategy group and 765 to the conservative-strategy group. The mean age of the patients was 82 years, 45% were women, and 32% were frail. A primary-outcome event occurred in 193 patients (25.6%) in the invasive-strategy group and 201 patients (26.3%) in the conservative-strategy group (hazard ratio, 0.94; 95% confidence interval [CI], 0.77 to 1.14; P = 0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred in 15.8% of the patients in the invasive-strategy group and 14.2% of the patients in the conservative-strategy group (hazard ratio, 1.11; 95% CI, 0.86 to 1.44). Nonfatal myocardial infarction occurred in 11.7% in the invasive-strategy group and 15.0% in the conservative-strategy group (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Procedural complications occurred in less than 1% of the patients. CONCLUSIONS: In older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal myocardial infarction (the composite primary outcome) than a conservative strategy over a median follow-up of 4.1 years. (Funded by the British Heart Foundation; BHF SENIOR-RITA ISRCTN Registry number, ISRCTN11343602.).
• Utilizing both IgA tissue transglutaminase and IgG-deamidated gliadin peptide antibodies offers accurate celiac disease diagnosis without duodenal biopsy.

  Holmes, Geoffrey

  BACKGROUND: Gastroenterologists still raise concerns about adopting a non-biopsy strategy for diagnosing celiac disease (CeD) in adults. AIM: To assess the performance of the concurrent detection of two autoantibodies targeting two independent antigens, tissue transglutaminase (tTG) and deamidated gliadin peptides (DGP). METHODS: This prospective, multicenter, binational study collected consecutive patients with a high pre-test probability for CeD. Between 2018 and 2020, adults were enrolled at four Italian and one Argentinian center. Serology was also blindly analyzed by a central laboratory (Werfen, San Diego, USA) for tTG IgA and DGP IgG by Aptiva Particle-based multi-analyte technology (PMAT) assays. CeD diagnosis required histological confirmation of Marsh 3 damage. RESULTS: 181 adult patients with suspected CeD were enrolled (134 with histological diagnosis of CeD and 47 not histologically confirmed as CeD). Patients positive for both tTG IgA and DGP IgG (double positive) were predictive of CeD in 92.5 % of patients at >1x upper limit of normal (ULN). Double positivity for tTG IgA and DGP IgG, both at >10x ULN, had a 100 % positive predictive value for the presence of Marsh 3 histology. CONCLUSIONS: Incorporating DGP IgG alongside tTG IgA in a single-step approach can be considered a valid confirmatory strategy for definitive non-biopsy diagnosis of CeD.
• 

  Prospective Study of Change in Skin Autofluorescence Over Time and Mortality in People Receiving Hemodialysis

  Taal, Maarten; Selby, Nicholas

  Introduction: Elevated skin autofluorescence (SAF), a measure of tissue accumulation of advanced glycation end products (AGEs), is a strong predictor of all-cause and cardiovascular mortality in the hemodialysis population. However, prospective studies investigating the association between changes in SAF over time and mortality are scarce. We therefore aimed to investigate the prognostic value of SAF trend for predicting mortality in a hemodialysis population. Methods: We enrolled 120 patients on hemodialysis in a 5-year observational, prospective study. SAF was measured at baseline, 3, 6, 9, 12, and 24 months. Rate of change in SAF (i.e., SAF trend) was calculated using linear regression. Time to event was the number of days from baseline to death, kidney transplantation, or March 31, 2022. Results: Mean age, mean baseline SAF, and median SAF trend were 65 ± 14 years, 3.4 ± 0.9 arbitrary units (AU), and an increase of 0.1 (-0.1 to 0.4) AU/yr, respectively. Median observation time was 42 months, during which 59 participants (49%) died. Univariable analysis identified age, history of smoking, lower serum albumin, higher baseline SAF, and increase in SAF as significant predictors of higher mortality. In multivariable analysis, higher baseline SAF (hazard ratio: 1.45; 95% confidence interval: 1.08-1.94; P = 0.01) and increasing SAF trend (2.37 [1.43-3.93]; P < 0.001) were independent predictors of increased mortality. Conclusion: An increasing SAF trend and higher baseline SAF were independent predictors of all-cause mortality in this hemodialysis population, suggesting that monitoring of SAF may have clinical utility. Strategies to improve outcomes by reducing or preventing the increase in SAF should now be investigated in prospective studies.
• 

  The use of technology in type 2 diabetes and prediabetes: a narrative review

  Wilmot, Emma

  The increasing incidence of type 2 diabetes, which represents 90% of diabetes cases globally, is a major public health concern. Improved glucose management reduces the risk of vascular complications and mortality; however, only a small proportion of the type 2 diabetes population have blood glucose levels within the recommended treatment targets. In recent years, diabetes technologies have revolutionised the care of people with type 1 diabetes, and it is becoming increasingly evident that people with type 2 diabetes can also benefit from these advances. In this review, we describe the current knowledge regarding the role of technologies for people living with type 2 diabetes and the evidence supporting their use in clinical practice. We conclude that continuous glucose monitoring systems deliver glycaemic benefits for individuals with type 2 diabetes, whether treated with insulin or non-insulin therapy; further data are required to evaluate the role of these systems in those with prediabetes (defined as impaired glucose tolerance and/or impaired fasting glucose and/or HbA1c levels between 39 mmol/mol [5.7%] and 47 mmol/mol [6.4%]). The use of insulin pumps seems to be safe and effective in people with type 2 diabetes, especially in those with an HbA1c significantly above target. Initial results from studies exploring the impact of closed-loop systems in type 2 diabetes are promising. We discuss directions for future research to fully understand the potential benefits of integrating evidence-based technology into care for people living with type 2 diabetes and prediabetes.
• The Student Grand Round: a peer teaching initiative

  Nazari, Ahmed; Rajesh, Mariya; Antoun, Ibrahim

  Introduction Oral presentation and public speaking skills are poorly emphasised in the medical school curriculum. The student grand round was created to tackle this deficiency by changing the way in which students are taught, from traditional lecture-based learning to interactive small-group peer-to-peer teaching. This approach encourages students to become responsible for their own learning, develop their public speaking and teaching skills, as well as identify and address gaps in their knowledge. Aims The primary aims of this study were to determine the understanding of students before and after peer teaching, including retention of concepts via quiz scores and confidence of students in giving SBAR (Situation, Background, Assessment, Recommendation) handovers. The secondary aim is to determine the place of student-led grand round teaching in the medical curriculum as a means of developing teaching skills and encouraging active learning. Methods A cohort of 21 third-year medical students from Leicester University attended a weekly peer teaching programme where students presented a case they had encountered during their clinical attachment. Peer teachers were required to research some background and pathophysiology regarding the topic and teach in an interactive manner and create discussion regarding the topic. The students then summarised the case and practised the skill of concise handovers using the SBAR format. Knowledge and understanding were assessed with an interactive quiz, and feedback via a survey was gathered before and after sessions. Each student engaged in case discussion and received input from a specialty registrar regarding their presentation skills, case knowledge, and SBAR handover. Results Individual and combined session analysis demonstrated a significant improvement in scores across understanding the topic and confidence in SBAR. Student recommendation for the session cumulatively was significant (p=0.02); however, comparison of medical student recommendations of individual sessions did not yield statistically significant results. There was a significant improvement in the overall quiz score (p=0.045), and average scores improved from 51% to 70% (p=0.043). There was a significant increase in the mean quiz result after the first two sessions (28-55% (p=0.002) and 56-85% (p=0.0001), respectively). Summary The student grand round is a promising teaching initiative that capitalises on peer teaching, a valuable learning theory that centres around students taking on the role of teachers to instruct their peers. Results from this study have shown that this method of collaborative teaching is effective in improving the understanding of medical topics, increases confidence in public speaking and precise handover skills, and therefore better prepares medical students for their career as future clinicians.
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  Associations With Baseline Blood Pressure Control in NURTuRE-CKD.

  Lucas, Bethany; Taal, Maarten

  No abstract provided.

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