NHS Greater Glasgow and Clyde

BACKGROUND:Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency with evolving demographics and management strategies, particularly in medical/endoscopic therapy and transfusion strategies. OBJECTIVE:To provide key data of the most recent 2022 UK audit and compare it with the preceding audit in 2007. DESIGN:Prospective multicentre audit conducted from 3 May to 2 July 2022, including adults (≥16 years) with AUGIB across 147 UK hospitals (response rate 86% vs 84% in 2007). AUGIB was defined by clinical symptoms (haematemesis, haematochezia, coffee ground vomiting or melaena confirmed by medical personnel). Patients were followed until discharge, death or 28 days, with re-admissions during the study period counted as new episodes. RESULTS:Among 5141 patients (59% male; median age 69), 15% had cirrhosis, 19% reported excess alcohol use, 7% used non-steroidal anti-inflammatory drugs (NSAIDs) and 46% were on antithrombotics. Most (77%) were new admissions, who were younger with fewer comorbidities, while the remainder bled during hospitalisation. Peptic ulcer disease accounted for 32% of cases, varices for 10% and no abnormality was found in 33%. Pre-endoscopic risk stratification was not performed in 42%.Compared with 2007, patients in 2022 had higher comorbidity (67% vs 50%), more cirrhosis (15% vs 9%), greater anticoagulant use (31% vs 13%) and higher transfusion rates (50% vs 43%). In 2022, among early transfusions (pre-endoscopy or within first 24 hrs; 38%), 43% were given at haemoglobin (Hb)>70 g/L, with 24% classified as inappropriate due to haemodynamic stability. A signal of harm was observed: while inappropriate transfusion was not associated with rebleeding at either 70 or 80 g/L, at 80 g/L it was linked to higher adjusted mortality (adjusted OR (aOR) 1.60, 95% CI 1.00 to 2.56).Inpatient endoscopy was more common (83% vs 74%), though endotherapy use remained modest (27% vs 23%). Salvage therapy rates were unchanged (3.3% vs 3.1%) but shifted from surgery to interventional radiology. Outcomes improved, with lower rebleeding (9.7% vs 13.3%), reduced in-hospital mortality (8.8% vs 10.0%) and shorter median stay (5 vs 6 days). In multivariate analysis, mortality was independently predicted by older age (≥80 years: aOR 2.32, 95% CI 1.64 to 3.30), shock (aOR 2.22, 95% CI 1.53 to 3.17) and comorbidity, while lower Hb at presentation increased risk (≤70 g/L: aOR 1.56, 95% CI 1.15 to 2.11). Anticoagulant use was associated with increased mortality (aOR 1.43, 95% CI 1.11 to 1.85), whereas NSAID use (aOR 0.49, 95% CI 0.25 to 0.96) and antiplatelet use (aOR 0.68, 95% CI 0.54 to 0.87) were associated with lower mortality. CONCLUSIONS:Despite a higher-risk case mix and incomplete adherence to guidelines (notably in transfusion thresholds and risk stratification), outcomes in AUGIB have improved. The observation of increased mortality with liberal transfusion above 80 g/L in stable patients reinforces the importance of restrictive transfusion practice. Quality improvement initiatives focused on risk stratification, endoscopic training and multidisciplinary care could further enhance outcomes in the UK and internationally.

Improvements in critical care treatments have led to an increased number of survivors of critical illness and an enhanced recognition of the problems which these patients encounter. Despite this, the ideal strategies to both prevent and manage the problems which people face are yet to be fully elucidated. This review explores the current methods employed to help mitigate problems encountered by survivors of critical illnesses and current barriers that limit their implementation. We will explore the effect of these issues on under-represented communities and the feasibility of delivering these strategies globally, as well as recent advances in mechanistic research and methodological innovation as promising areas for further work. In doing so, it summarises the potential avenues for future research with a view to advancing clinical care and outcomes in survivors of critical illness.

Proton magnetic resonance spectroscopy (1H MRS) enables non-invasive biochemical sampling of tissues, potentially aiding diagnosis, prognosis and monitoring of various pathologies, while providing novel imaging biomarkers. Ultra-high-field (UHF) imaging at 7 tesla (7T) benefits from improved spectral dispersion due to an increase in chemical shift differences between metabolites, and a higher signal-to-noise ratio (SNR), making 1H MRS at 7T a particularly promising diagnostic tool for identifying and separating metabolites not clearly resolved at lower field strengths. However, 1H MRS at UHF presents technical challenges related to the short RF wavelength at 7T, resulting in B1 transmit field inhomogeneity, and the increased magnetic susceptibility gradients leading to B0 field inhomogeneity. Appropriate MRS methods are required to address these issues. In this article, we describe the technical aspects and challenges of 1H MRS at 7T, based on the experience in our centre, where single voxel 1H MRS has featured prominently in clinical 7T research applications for several years. We present data from six patients with glial tumours, including three who were post-operative, in whom post-surgical metalware affects the specific absorption rate (SAR), along with two patients with neuroinflammatory conditions and two with neurodegenerative diseases. The potential clinical use of 1H MRS for these pathologies and its possible integration as a promising biomarker into advanced imaging pathways are discussed.

The traditional, size-based, RECIST 1.1 guideline is the standard for assessing tumour response, but has notable limitations, particularly for breast tumours treated with radiotherapy (RT). RT often induces fibrosis, leading to a persisting measurable abnormality on T1W/T2W MRI sequences despite an underlying pathological response. As pre-operative RT trials expand and omission of surgery is being tested, having anatomico-functional MRI response criteria may facilitate more accurate response evaluation. We propose modified RECIST 1.1 criteria based on 3 sequences of multiparametric MRI (mpMRI): unenhanced T2W, contrast-enhanced (CE) T1W and diffusion-weighted imaging (DWI). Key recommendations include complete response defined as 1) resolution of tumour mass on all sequences, or 2) evidence of residual T2 abnormality with CE images showing no enhancement above background parenchymal enhancement (BPE) and DWI signal consistent with necrosis/fibrosis, or 3) minimal evidence of enhancement above BPE with DWI in keeping with fibrosis. Criteria are also defined for other response categories (partial response/stable disease/progression). These recommendations can be tested in future trials and offer guidance on the interpretation of mpMRI sequences when breast tumours are treated in situ with radiation, a scenario in which little published data currently exists. They highlight how DWI can aid RT response assessment and help overcome some limitations with current RECIST criteria.