Salisbury NHS Foundation Trust

Introduction:Intra-articular steroid injection for thumb carpometacarpal joint (CMCJ) osteoarthritis (OA) is routinely offered with evidence of its short-term effectiveness only. One of the factors for reduced effectiveness could be the lack of accuracy of the intra-articular injection. Therefore, this scoping review sought to examine the accuracy of thumb CMCJ injection and examine if clinical effectiveness improves with accuracy by using image guidance. Method:A literature search was undertaken using databases Medline, Emcare, AMED and CINAHL, along with Google Scholar and reference searching. All studies on adults examining accuracy of thumb CMCJ injection and image-guided injections published in English up to the end of 2023 were selected. Results:15 studies met the inclusion criteria. Cadaver studies observed lower accuracy rate of landmark-based injection particularly in presence of thumb CMCJ arthritis. Studies on patients observed an accuracy rate of around 50% with landmark-based injection. Fluoroscopy-guided injection was observed to be more accurate (near 100%) than ultrasound guidance. Clinical effectiveness of accurate intra-articular injection was observed to last from 3 months (DASH 26.7 for intra-articular vs 37.5 for extra-articular, p < 0.05 and VAS score for intra-articular 26.5 vs 39.0 for extra-articular, p < 0.05) up to 6 months (15%-10/66 patients reporting pain relief). Some studies observed accuracy of landmark-based thumb CMCJ injection increased with experience of the clinician. Conclusion:Accuracy of landmark-based thumb CMCJ injection is indeterminate. However, there is lack of robust evidence to support use of image guidance to improve accuracy and clinical effectiveness of steroid injection for thumb CMCJ and warrants further research.

Background Circulating tumour DNA (ctDNA) detects minimal residual disease (MRD) and predicts recurrence in resected colorectal cancer (CRC), with implications for adjuvant chemotherapy (ACT) decision-making. Longitudinal ctDNA quantification and dynamics are less well studied. We present results from the ongoing prospective multi-centre TRACC study using a tumour-informed ctDNA assay. Methods TRACC Part B recruited stage I-III CRC patients undergoing curative surgery +/- neo-adjuvant (chemo)radiotherapy and ACT. Blood samples were collected pre-treatment, post-operatively, 3-monthly for year 1 and 6 monthly for years 2–3, with annual imaging. We report a cohort with stage II-III CRC ( n = 122), including a subset with locally advanced rectal cancers ( n = 23). Plasma samples were analysed using a personalisedmultiplex polymerase chain reaction next-generation sequencing (mPCR-NGS) ctDNA assay (Signatera™) targeting mutated loci identified in tumour tissue. The primary endpoint was recurrence-free survival (RFS) by ctDNA status. Exploratory objectives included ctDNA quantification and dynamics. Median follow-up was 35 months (range: 2–64). (NCT04050345) Results Of 122 patients, library preparation for whole exome sequencing of primary tumour tissue was possible in 116. Pre-treatment ctDNA detection rate was 94.0% (109/116). ctDNA detection rate 2–8 weeks post-operatively (MRDpos) was 12.1% (14/116); 10.9% in stage III (23.8% high-risk, 4.7% low-risk) and 13.5% in stage II (23.5% high-risk, 8.6% low-risk). Of MRDpos patients, 78.6% (11/14) recurred. Overall, 18.6% (19/102) MRD negative (MRDneg) patients recurred. Twenty-four-month RFS was 30.8% in MRDpos versus 88.1% in MRDneg patients (HR 8.4, 95% CI 4–18; p < 0.001). In a multivariate analysis, ctDNA detection remained the most significant prognostic factor (HR 7.2, 95% CI 2.94–17.6; p < 0.001)followed by nodal stage (HR 2.58, 95% CI 1.01–6.6; p = 0.047). Among high-risk CRC, ACT conferred survival benefit only in MRDpos patients. Longitudinal ctDNA sampling identified relapse with 80% sensitivity. ctDNA concentration increased exponentially prior to recurrence ( n = 11). ctDNA growth rate was prognostic of RFS (p = 0.021). ctDNA detection was lower in patients with lung-only metastases. Conclusions Post-operative and longitudinal tumour-informed ctDNA testing identifies patients at high CRC recurrence risk and may guide ACT decisions. Further studies are needed to establish the interpretation and utility of longitudinal ctDNA quantification and dynamics to personalise patient management.

Prion diseases, of which Creutzfeldt-Jakob disease is the most common, are fatal neurodegenerative disorders and are often rapidly progressive. They are associated with a significant palliative care burden for patients and families, ranging from prognostic uncertainty to complex symptom management to caregiver distress. Healthcare professionals face unique pressures when caring for these patients, which can include a lack of familiarity with this rare diagnosis and rapidly evolving symptom needs due to accelerated clinical deterioration. We convened a multidisciplinary panel of experts from around the UK, including palliative care doctors, general practitioners, physician and nurse specialists in prion diseases, and a lived experience representative to compile practical, consensus-based recommendations for managing prion diseases, much of which can also be applied to other rapidly progressive dementias. In this article, we examine the available evidence base for managing various aspects of prion diseases. Where evidence is limited, we suggest best practices informed by decades of our collective experiences.

Background: Balanoposthitis is a common presentation within sexual health services and encompasses a broad spectrum of infective, inflammatory, premalignant, and systemic conditions affecting the glans penis and foreskin. Accurate diagnosis is essential to ensure appropriate management, avoid unnecessary antimicrobial use, identify sexually transmitted infections (STIs), and recognise conditions requiring specialist referral. The 2025 guideline update was developed to strengthen recommendations on the diagnosis and management of infective balanoposthitis while improving recognition of important non-infective dermatoses and systemic disease presentations. Methods: The guideline update was informed by a review of the current evidence base, emerging clinical data, and expert multidisciplinary consensus. Existing recommendations were reviewed and revised to reflect advances in diagnostic approaches, antimicrobial stewardship, and the management of inflammatory and premalignant penile dermatoses. Particular emphasis was placed on improving diagnostic accuracy, identifying clinical features suggestive of STIs or systemic disease, and clarifying indications for biopsy and specialist referral. Discussion: The updated guideline highlights the importance of a structured clinical assessment supported by targeted investigations where appropriate. Infective causes remain an important consideration, including candidal balanoposthitis, bacterial infection, and STIs; however, the guideline also emphasises the need to recognise common inflammatory dermatoses such as lichen sclerosus, psoriasis, eczema, and Zoon balanitis, as well as premalignant and malignant conditions. The recommendations promote evidence-based treatment strategies, reduce unnecessary empirical antimicrobial prescribing, and encourage earlier identification of patients requiring dermatology, urology, or penile cancer specialist input. Conclusion: This 2025 guideline update aims to support clinicians in the earlier recognition and accurate diagnosis of balanoposthitis and related penile dermatoses. By promoting evidence-based management, antimicrobial stewardship, and timely referral for specialist care where indicated, the guideline seeks to improve patient outcomes and standardise care across sexual health and related clinical services.