Heart of England NHS Foundation Trust (HEFT) was one of the largest organisations running NHS hospitals in England. The hospitals and services run by HEFT included Heartlands Hospital, Solihull Hospital and Community Services, Good Hope Hospital in Sutton Coldfield and Birmingham Chest Clinic. The trust was under the leadership of chair Jacqui Smith and chief executive David Rosser, who succeeded Julie Moore on 1 September 2018.In September 2016 HEFT announced plans to merge with the University Hospitals Birmingham NHS Foundation Trust. The merger took place on 1 April 2018. The combined organisation will have a turnover of £1.6bn and 2,700 beds across four main hospitals.
Introduction Teledermatology is increasingly used to triage urgent suspected skin cancer referrals. A direct-to-surgery pathway allows selected patients to proceed directly to biopsy or excision without a preliminary face-to-face consultation. This study evaluated the safety, efficiency and diagnostic performance of a direct-to-surgery teledermatology pathway within a large National Health Service (NHS) skin cancer service.Methods A service evaluation was conducted at the University Hospitals of North Midlands. All teledermatology referrals received between February 2022 and July 2024 were reviewed. Demographics, pathway intervals, surgical outcomes, cancellations, histopathology and complications were extracted from electronic records. The primary outcome was compliance with the 28-day Faster Diagnosis Standard. Secondary outcomes included compliance with the 62-day referral-to-treatment target, surgical complications, cancellation rates and diagnostic concordance between teledermatology assessment and histopathology.Results Of 18 587 teledermatology referrals, 5120 were triaged to the direct-to-surgery pathway. Following exclusion of 20 miscoded entries and 1 duplicate record, 5099 patients were included. A total of 4830 patients underwent surgery and 4825 had definitive histopathological diagnoses. The median time from referral to histology reporting was 46 days. Compliance with the 28-day Faster Diagnosis Standard was 99.86% (5092/5099), substantially exceeding the national target of 75%. Among patients diagnosed with melanoma or squamous cell carcinoma, 75.5% (440/583) commenced treatment within the 62-day referral-to-treatment target. Histopathology identified malignant pathology in 35.5% of lesions and premalignant pathology in a further 15.5%. Among lesions with both a recorded teledermatology diagnosis and definitive histology, overall concordance was 41.5% (1113/2679) with fair agreement (Cohen’s κ=0.34). The overall complication rate was 1.3%.Conclusions This large single-centre evaluation demonstrates that a direct-to-surgery teledermatology pathway can safely support high-volume skin cancer surgery while achieving excellent compliance with the Faster Diagnosis Standard. Low complication rates and efficient progression through the diagnostic pathway support the use of teledermatology as an effective risk-stratification tool within contemporary skin cancer services.
Alzheimer’s disease is a devastating neurodegenerative disorder with a complex pathogenesis. One main pathological feature utilised in diagnosis is neurodegeneration or neuronal injury, which is reflected in reductions in cerebral glucose metabolism measured by [18F]Fluorodeoxyglucose ([18F]FDG) positron emission tomography (PET). Here we evaluated the involvement of glial reactivity measured with magnetic resonance spectroscopy (MRS) and cerebral blood flow measured with arterial spin labelling (ASL) on [18F]FDG PET as a measure of cerebral glucose metabolism. 123 people living with early Alzheimer’s disease who completed baseline evaluations on the evaluating liraglutide in Alzheimer’s disease trial were enrolled. Participants completed [18F]FDG PET scans with arterial input, T1 weighted MRI, single-voxel 1 HMRS, and pulsed ASL scans at Imperial College London Clinical Imaging Facility. The Totally Automatic Robust Quantitation in NMR (TARQUIN) package was used to process MRS scans and identify the concentration of myo-inositol within the posterior cingulate cortex (PCC), a marker of glial activation. Oxford-ASL was utilised to process ASL and quantify cerebral blood flow in the PCC. Finally, spectral analysis was performed on the [18F]FDG PET scans to assess the cerebral metabolic rate of glucose in the PCC. Pearson’s correlations were performed between the cerebral metabolic rate of glucose, cerebral blood flow and glial activity measured by the level of myo-inositol in the PCC. Increased cerebral glucose metabolism was correlated with higher myo-inositol in this sample of Alzheimer’s disease participants. In contrast, cerebral blood flow was not associated with cerebral glucose metabolism. Here we demonstrate that increased glial reactivity contributes to [18F]FDG PET signal in the early stages of Alzheimer’s disease. In response to early neuronal injury, astrocytes and microglia may become activated and enhance regional rates of glucose consumption. Hence, the contribution from these cells in addition to neurons should be considered in interpreting [18F]FDG PET as a measure of cerebral glucose metabolism. Interestingly, cerebral blood flow did not influence glucose metabolism. Microglia and astrocyte reactivity may contribute to an increase the cerebral glucose metabolism while neuronal loss and synaptic function may contribute to lower glucose metabolism measured by [18F]FDG in the early stages of Alzheimer's disease.
Background: Over 15,000 transurethral resections of the prostate (TURP) are performed annually in the United Kingdom. It is therefore vital that every aspect of peri-operative care be optimised. Our centre favours the use of two-way catheters post-operatively without the use of continuous bladder irrigation (CBI). Objectives: To evaluate our practice of using two-way catheters without irrigation post-TURP and to determine impact on patient care compared with standard three-way catheterisation. Our primary outcome was duration of admission, but multiple secondary outcomes were also analysed. Design, setting, and participants: This was a prospective observational study. Every patient undergoing TURP at our centre from 2009 to 2019 was included. Following TURP patients were catheterised with two-way catheters. Prospective patient data were collected pertaining to peri-operative factors. These data were then compared with the data published in the literature. Results: 687 patients underwent TURP at our centre between 2009 and 2019. The average age of patients was 71.42 (±7.89). 87.17% (n = 598) had two-way catheters placed post-operatively. Average duration of admission was 1.61 (±1.35) days, increasing to 2.20 days if patients required three-way catheters or 2.53 days if requiring CBI. TWOC was successful in 97.71% of patients. Complication rate was 8.73% (n = 60). When compared with other centres, our method reduced lengths of admission and transfusion rates (1.6 days versus 3.1 days and 0.87% versus 2.83%, respectively). Conclusion: Our method is safe and is associated with a reduced length of admission. We recommend this practice to the wider urological community. Patient summary: This study looked at whether there was any impact on patients if two-way catheters were used following TURP. We found that use of two-way catheters reduced length of admission and duration of catheterisation. We also found that it did not increase likelihood of peri-operative complications in comparison with other centres.
Preclinical evidence in transgenic models of Alzheimer’s disease (AD) suggests that liraglutide, a GLP1 analogue, exerts neuroprotective effects by reducing amyloid oligomers, normalising synaptic plasticity and reducing insulin resistance, and increasing the proliferation of neuronal progenitor cells. ELAD is a 12-month, multi-centre, randomised, double-blind, placebo-controlled, phase IIb trial of liraglutide in participants with mild to moderate AD conducted at 24 centres in the UK. As a part of this study, a total of 204 Alzheimer’s participants were randomised to receive either liraglutide or placebo as a daily subcutaneous injection for 12 months. All subjects underwent volumetric MRI scans at baseline and during follow up. Volumetric changes from baseline to follow up in MRI scans were evaluated using both regional volume analysis and voxel based morphometric analysis MRI analysis demonstrated that temporal lobe volume, total grey matter volume and frontoparietal volume change was lower in liraglutide treated patients compared to the placebo group. Voxel based morphometry (VBM) analysis demonstrated that liraglutide-treated participants showed a slower reduction in whole cortical grey matter, frontal, temporal and parietal lobe volume in participants treated with liraglutide compared to placebo. In the ELAD study, participants with mild to moderate AD who received liraglutide had slower reduction in MRI volume and cognition compared to the placebo demonstrating a potential benefit of liraglutide in the treatment of Alzheimer’s disease. These findings highlight the potential of GLP-1 analogues in the treatment of Alzheimer’s disease
Magnetic resonance spectroscopy (MRS) is a non-invasive method of evaluating metabolite levels in the cerebral cortex. Measurable metabolites can provide markers of neuronal damage, glial activation and, neurotransmission, pathological features of Alzheimer’s disease. Here we sought to establish the effectiveness of several metabolites as biomarkers for Alzheimer’s disease. 198 participants with a single-voxel 1 H MRS scan were enrolled (n = 170 participants living with Alzheimer’s disease, n = 28 healthy controls). All participants underwent 3-tesla magnetic resonance imaging and cognitive assessment with the Alzheimer’s Disease Assessment Scale–Cognitive Subscale (ADAS-cog). An experienced radiographer placed an 8cm 3 voxel within the posterior cingulate cortex for single-voxel 1 H MRS acquisition. Scans were then processed to evaluate levels of N-acetylaspartate, myo-inositol, choline, and glutamate. Creatine peak was additionally evaluated as a reference. N-acetylaspartate/creatine, myo-inositol /creatine, choline/creatine ratios and glutamate were compared between Alzheimer’s participants and controls to calculate the effect size. Correlations were then performed between metabolite ratios and ADAS-cog scores. N-acetylaspartate/creatine effectively distinguished between Alzheimer’s patients and healthy controls (Cohens D = 0.83) with a lowered ratio in Alzheimer’s participants. Elevated glutamate signal and myo-inositol/creatine ratios were also displayed in Alzheimer’s patients (Cohens D = 0.62 and 0.69, respectively). Choline/creatine ratio displayed no significant difference between groups (Cohens D = 0.26). Lower N-acetylaspartate /creatine and glutamate correlated with higher ADAS-cog scores (r = -0.29, p < 0.001, CIs: -0.42 to -0.14 and r = -0.30, p < 0.001, CIs: -0.44 to -0.16, respectively). Myo-inositol and choline failed to correlate with cognitive impairment. N-acetylaspartate, a signature of neuronal damage, is an effective biomarker of Alzheimer’s disease and associated cognitive decline. Enhanced glial activity, measured with myo-inositol, was shown in Alzheimer’s disease, suggesting that glial-reactivity markers deserve consideration in the diagnosis of Alzheimer’s disease. Glutamate demonstrated the strongest association with cognitive impairment, despite showing a smaller effect size than N-acetylaspartate and myo-inositol in distinguishing between Alzheimer’s patients and controls. Together we establish MRS is a useful, non-invasive biomarker of several pathological processes involved in the development of Alzheimer’s. Evaluation of N-acetylaspartate, glutamate, and myo-inositol may aid in the diagnosis of neurodegenerative disease, detecting markers undetectable by conventional MRI methodology.
