Practical Approaches to Continuous Glucose Monitoring in Primary Care: A UK-Based Consensus Opinion

INTRODUCTION: Type 2 diabetes (T2D) imposes significant personal challenges and societal costs. Continuous glucose monitoring (CGM) is recognised as a state-of-the-art tool, but remains underutilised. Adoption of CGM in primary care should be informed by a broader understanding of the technology's capabilities and limitations. METHODS: An expert panel was convened to review current literature and clinical experience to provide practical approaches to CGM for primary care practitioners and discuss the technology's value in the routine management of T2D. The goals were to review and reach consensus on the current state of CGM in non-specialist practice settings and on strategies for successfully initiating and maintaining people on CGM. RESULTS: Initiation and maintenance of CGM therapy can be successfully conducted in primary care settings. CGM therapy should include proper patient selection, proper setting of expectations, and evidence-based adjustments to therapy. Most patients are likely to see quick, meaningful, and lasting improvements in their diabetes, along with a better understanding of their condition and greater motivation for successful management. Retrospective report interpretation is feasible and intuitive. Barriers to adoption and sustained use include cost, technological limitations, behavioural or psychological factors, and therapeutic inertia. Addressing these barriers is critical to enable better access to CGM. Continuous glucose monitoring can be leveraged by primary care teams to inform treatment decisions and also by patients to inform diabetes self-management. CONCLUSION: CGM should be considered for all people with T2D. The recommendations provided here should simplify adoption and maintenance use of CGM in primary care and maximise the glycaemic and psychosocial benefits of the technology.Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. Journal content freely available via Open Access. Some content may be unavailable due to publisher embargo. Click on the 'Additional link' above to access the full-text

A qualitative exploration of stressors in anaesthesia training in the UK and mechanisms to improve resident wellbeing

INTRODUCTION: High levels of stress and burnout have been identified among resident anaesthetists in UK training programmes. Factors involving clinical roles, workplace culture and training are known stressors, but in-depth research investigating how to improve wellbeing is limited. METHODS: We used a qualitative design in two phases with participants from across the UK. Phase 1 involved semi-structured interviews of resident anaesthetists in the 2nd-5th years of training, and educational stakeholders. Phase 2 involved additional participants in two focus groups, one each for residents and stakeholders. Interviews and focus groups were conducted online, audio-recorded and transcribed for thematic analysis using a framework approach. RESULTS: We interviewed 52 participants in phase 1, comprising resident anaesthetists from England, Wales and Scotland and key educational stakeholders. A further 11 resident anaesthetists and stakeholders participated in the phase 2 focus groups. We identified four overarching themes contributing to stress: clinical work; non-clinical work; structure of training; and workplace culture. We also identified supportive features at individual, local, regional and national levels. Stress and burnout were commonplace, particularly during demanding periods of training. Balancing non-clinical commitments alongside busy workloads was difficult. Clinically, intensive care medicine and obstetrics generated the most stress. Frequent rotations and long commutes increased stress, impacting on working and family relationships. Curriculum changes, examinations and competition for higher training posts caused stress and poor morale. Proposed mechanisms to improve wellbeing include: peer-to-peer support; request-based rotas; adoption of 'lead employers'; decreasing rotation frequency and commuting distances; access to less than full-time working and professional support; and adapting the structure of training to improve the stability of the resident anaesthetist workforce. DISCUSSION: Attention to the factors identified as contributing to stress could improve resident anaesthetists' wellbeing through changes to policy and practice at local, regional and national levels, for which we make research-informed recommendations.This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.RDUH staff can access the full-text of this article by clicking on the 'Additional Link' above and logging in with NHS OpenAthens if prompted

Ear splinting for ear anomalies in infants. Is it worth doing and have we missed the boat? A prospective, cohort study

INTRODUCTION: Ear deformities can cause distress to children as they age, especially with ear deformity surgery not routinely available through the NHS. Ear splinting is a non-surgical method that can obviate the need for surgery; however, it is believed that it can only be provided in the first few weeks of life. There is also little evidence in the literature regarding caregiver-reported outcomes of appearance and adherence. METHOD: Over a 5-year period (2018-2023), pre- and post-splinting questionnaires were provided to caregivers of infants who underwent ear splinting for treatment of congenital ear deformities. Caregiver-reported outcomes assessed the appearance of different anatomical areas of the ear, ease of use, complications and referral pathways. RESULTS: In total, 123 participants were recruited. Following ear splinting, there was a significant improvement in the ratings of appearance (p<0.001), shape (p<0.001) and projection (p<0.001) of the ear. Caregiver ratings of anatomical regions of the pinna also showed significant improvements for the helical rim (p<0.001) and scaphoid fossa (p<0.001). A small number of caregivers encountered difficulty using the splints (5%), which included application of the splints and keeping them clean and dry. Excellent results were reported regardless of age, with the oldest child being one year old, but the duration of splinting positively correlated with age (p<0.05). CONCLUSIONS: Ear splinting showed high satisfaction rates in outcomes and adherence, with a low complication rate. It is still preferable to start ear splinting early, but good results were still being found up to one year of age in this study.RDUH staff can access the full-text of this article by clicking on the 'Additional Link' above and logging in with NHS OpenAthens if prompted

Implementation of a national AI technology program on cardiovascular outcomes and the health system

Coronary artery disease (CAD) is a major cause of ill health and death worldwide. Coronary computed tomographic angiography (CCTA) is the first-line investigation to detect CAD in symptomatic patients. This diagnostic approach risks greater second-line heart tests and treatments at a cost to the patient and health system. The National Health Service funded use of an artificial intelligence (AI) diagnostic tool, computed tomography (CT)-derived fractional flow reserve (FFR-CT), in patients with chest pain to improve physician decision-making and reduce downstream tests. This observational cohort study assessed the impact of FFR-CT on cardiovascular outcomes by including all patients investigated with CCTA during the national AI implementation program at 27 hospitals (CCTA n = 90,553 and FFR-CT n = 7,863). FFR-CT was safe, with no difference in all-cause (n = 1,134 (3.2%) versus 1,612 (2.9%), adjusted-hazard ratio (aHR) 1.00 (0.93-1.08), P = 0.97) or cardiovascular mortality (n = 465 (1.3%) versus 617 (1.1%), aHR 0.96 (0.85-1.08), P = 0.48), while reducing invasive coronary angiograms (n = 5,720 (16%) versus 8,183 (14.9%), aHR 0.93 (0.90-0.97), P < 0.001) and noninvasive cardiac tests (189/1,000 patients versus 167/1,000), P < 0.001). Implementation of an AI-diagnostic tool as part of a health intervention program was safe and beneficial to the patient pathway and health system with fewer cardiac tests at 2 years.CC BY 4.0 (Creative Commons Attribution

Zonal Characteristics of Collagen Ultrastructure and Responses to Mechanical Loading in Articular Cartilage

The biomechanical properties of articular cartilage arise from a complex bioenvironment comprising hierarchically organised collagen networks within the extracellular matrix (ECM) that interact with the proteoglycan-rich interstitial fluid. This network features a depth-dependent fibril organisation across different zones. Understanding how collagen fibrils respond to external loading is key to elucidating the mechanisms behind lesion formation and managing degenerative conditions like osteoarthritis. This study employs polarisation-resolved second harmonic generation (pSHG) microscopy to quantify the ultrastructural organisation of collagen fibrils and their spatial gradient along the depth of bone-cartilage explants under a close-to-in vivo condition. By combining with in-situ loading, we examined the responses of collagen fibrils by quantifying changes in their principal orientation and degree of alignment. The spatial gradient and heterogeneity of collagen organisation were captured at high resolution (1 μm) along the longitudinal plane of explants (0.5 mm by 2 mm). Zone-specific ultrastructural characteristics were quantified to aid in defining zonal borders, revealing consistent zonal proportions with varying overall thicknesses. Under compression, the transitional zone exhibited the most significant re-organisation of collagen fibrils. It initially allowed large deformation through the re-orientation of fibrils, which then tightened fibril alignment to prevent excessive deformation, indicating a dynamic adaptation mechanism in response to increasing strain levels. Our results provide comprehensive, zone-specific baselines of cartilage ultrastructure and micromechanics, crucial for investigating the onset and progression of degenerative conditions, setting therapeutic intervention targets, and guiding cartilage repair and regeneration efforts. STATEMENT OF SIGNIFICANCE: Achieved unprecedented quantification of the spatial gradient and heterogeneity of collagen ultrastructural organisation at a high resolution (1 μm) along the full depth of the longitudinal plane of osteochondral explants (0.5 mm by 2 mm) under close-to-in vivo condition. Suggested new anatomical landmarks based on ultrastructural features for determining zonal borders and found consistent zonal proportions in explants with different overall thicknesses. Demonstrated that collagen fibrils initially respond by reorienting themselves at low strain levels, playing a significant role in cartilage deformation, particularly within the transitional zone. At higher strain levels, more collagen fibrils re-aligned, indicating a dynamic shift in the response mechanism at varying strain levels.This is an open access article distributed under the terms of the Creative Commons CC-BY license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Journal content freely available via Open Access. Some content may be unavailable due to publisher embargo. Click on the 'Additional link' above to access the full-text

Long-term outcomes of Grammont style reverse shoulder arthroplasty at a minimum of 10-year follow-up: A survival analysis

BACKGROUND: Reverse shoulder arthroplasty (RSA) is an established and successful treatment for rotator cuff tear arthropathy. Despite increased popularity, there is a paucity of long-term survivorship data and patient-reported outcome measures. This study aimed to establish the survival at a minimum 10-year follow-up for a Grammont-style reverse shoulder prosthesis. METHODS: A single centre, retrospective case series of 101 primary RSAs in 86 patients, performed between 1999 and 2012 was conducted. The primary outcome measure was all-cause revision. Implant survivorship analysis using the Kaplan-Meier method was conducted. Deaths were censored. Secondary outcomes included up-to-date Oxford Shoulder Score (OSS) in surviving patients, historic OSS scores over time and radiological outcomes. RESULTS: Mean age was 76 years (SD ± 7.29) at time of surgery. The 10-year implant survival was 93.2% (95% confidence interval [CI] 87.8-98.6). The mean OSS was 33 (range 17-48, 95% CI 29.1-36.9) with a minimum of 10-year follow-up (n = 21). Radiographic review showed scapular notching in 79% of implants over 10 years old, but no radiolucency around humeral implants. CONCLUSIONS: The rate of RSA survivorship is high at 93.2% at 10 years. Most patients died with their primary implant in-situ. Functional outcome scores were less predictable over time.All rights reserve

A Time-varying Analysis of General Practice Prescribing in the COVID-19 Era: Lessons from Prescription Dynamics in a Pandemic

BACKGROUND/AIM: Pharmacotherapy is vital in medicine, but inappropriate and inadequate use of medications significantly impacts global mortality and morbidity. Increased prescribing may indicate irrational use or prolonged illness, while decreased prescribing could suggest undertreatment, supply shortages, or the availability of safer and, more effective treatments. The COVID-19 pandemic disrupted health systems, potentially altering prescribing patterns. This study examined its impact on the prescribing patterns of common therapeutic categories and high-risk medicines in general practice in England. MATERIALS AND METHODS: Common therapeutic categories were identified from English General Practice prescription data, and high-risk medicines were identified by mapping the UK pharmacovigilance data onto the English prescribing data. A retrospective analysis compared monthly prescription data pre-pandemic, during the pandemic, and post-pandemic. Significant changes in the prescribing volumes of therapeutic categories and high-risk medicines were tracked to determine persistence, intensification, or diminution post-pandemic. Linear regression models analysed prescribing trends. RESULTS: Among 220 therapeutic categories, 16 experienced significant changes: 14 increased and two decreased during the pandemic. Of 78 high-risk medicines, six showed significant changes: two increased and three decreased. Only three therapeutic categories and two high-risk medicines returned to pre-pandemic levels. CONCLUSION: Despite a reduction in general practice appointments during the pandemic, prescribing for several therapeutic categories and certain high-risk medicines surged, indicating increased treatment, prolonged illness or stockpiling. Post-pandemic downward trends suggest long-term under-treatment or reduced stockpiling. Continuous monitoring, strategic healthcare planning, and regulatory interventions are needed to optimise prescribing. Future research is needed to assess the long-term effects on disease management.This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international licenseRDUH staff can access the full-text of this article by clicking on the 'Additional Link' above and logging in with NHS OpenAthens if prompted

Supporting the bereaved child in the adult ICU: let's take the first step! Author's reply

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An oligodendrocyte silencer element underlies the pathogenic impact of lamin B1 structural variants

The role of non-coding regulatory elements and how they might contribute to tissue type specificity of disease phenotypes is poorly understood. Autosomal Dominant Leukodystrophy (ADLD) is a fatal, adult-onset, neurological disorder that is characterized by extensive CNS demyelination. Most cases of ADLD are caused by tandem genomic duplications involving the lamin B1 gene (LMNB1) while a small subset are caused by genomic deletions upstream of the gene. Utilizing data from recently identified families that carry LMNB1 gene duplications but do not exhibit demyelination, ADLD patient tissues, CRISPR edited cell lines and mouse models, we have identified a silencer element that is lost in ADLD patients and that specifically targets expression to oligodendrocytes. This element consists of CTCF binding sites that mediate three-dimensional chromatin looping involving LMNB1 and the recruitment of the PRC2 transcriptional repressor complex. Loss of the silencer element in ADLD identifies a role for non-coding regulatory elements in tissue specificity and disease causation.Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it.Journal content freely available via Open Access. Some content may be unavailable due to publisher embargo. Click on the 'Additional link' above to access the full-text

Body composition, maximal fitness, and submaximal exercise function in people with interstitial lung disease

BACKGROUND: Cardiopulmonary exercise testing (CPET) is feasible, valid, reliable, and clinically useful in interstitial lung disease (ILD). However, maximal CPET values are often presented relative to body mass, whereas fat-free mass (FFM) may better reflect metabolically active muscle during exercise. Moreover, despite the value of maximal parameters, people with ILD do not always exercise maximally and therefore clinically relevant submaximal parameters must be identified. Therefore, this study assessed peak oxygen uptake (VO(2peak)) relative to FFM, identifying the validity of common scaling techniques; as well as characterising the oxygen uptake efficiency slope (OUES) and plateau (OUEP) as possible submaximal parameters. METHODS: Participants with ILD underwent assessment of body composition and CPET via cycle ergometry during a single study visit. To determined effectiveness of scaling for body size, both body mass and FFM were scaled using ratio-standard (X/Y) and allometric (X/Y(b)) techniques. Pearsons's correlations determined agreement between OUES, OUEP, and parameters of lung function. Cohens kappa (κ) assessed agreement between OUES, OUEP and VO(2peak). RESULTS: A total of 24 participants (7 female; 69.8 ± 7.5 years; 17 with idiopathic pulmonary fibrosis) with ILD completed the study. Maximal exercise parameters did not require allometric scaling, and when scaled to FFM, it was shown that women have a significantly higher VO(2peak) than men (p = 0.044). Results also indicated that OUEP was significantly and positively correlated with DL(CO) (r = 0.719, p < 0.001), and held moderate agreement with VO(2peak) (κ = 0.50, p < 0.01). CONCLUSION: This study identified that ratio-standard scaling is sufficient in removing residual effects of body size from VO(2peak), and that VO(2peak) is higher in women when FFM is considered. Encouragingly, this study also identified OUEP as a possible alternative submaximal marker in people with ILD, and thus warrants further examination.CC BY 4.0 Internationa