.
Abstract Introduction Despite the UK’s increasing life expectancy, and increase in the elderly population, there is an overwhelming lack of Geriatricians in the UK; as of 2022, there is only 1 consultant Geriatrician per 8031 individuals over the age of 65 (BGS, 2023). To meet the complex care needs of this population, there must be a focus on increasing the interest that doctors have towards Geriatric Medicine, with the overall aim being to recruit more doctors into the speciality. Method The aim of this review was to investigate what factors medical students perceive as barriers to pursuing a career in Geriatric Medicine and then, from identifying these, generate a set of comprehensive suggestions as to how to tackle these barriers at a medical school level to increase the interest and ultimately uptake of Geriatric Medicine. The qualitative review contains literature published between 2003 and 2023 accessed using MedLine. Results Six themes were identified in answering our question: (a) high emotional burden, (b) caring for patients with complex needs, (c) negative preconceptions of non-clinical factors (prestige, salary, career progression), (d) negative influence of clinical educators, (e) lack of intellectual stimulation and (f) lack of exposure to the speciality and the elderly. Conclusion The barriers perceived by medical students when considering Geriatrics as a speciality are complex and multifaceted; these barriers must be tackled promptly in order to secure the next generation of Geriatricians. We suggest that this work can be used as a foundation for further qualitative studies with UK medical students to investigate barriers that are specific to UK students. From this, interventional courses designed to increase Geriatric Medicine uptake could be developed to strengthen the UK Geriatric Medicine workforce.
Introduction Immune checkpoint inhibitors (ICIs) have revolutionised cancer treatment through targeted disruption of the physiological pathways that maintain tissue tolerance, but which are co-opted by cancers to evade immunosurveillance. Thus, the resultant T-cell activity often causes immune-related adverse events including immune checkpoint inhibitor-induced inflammatory arthritis (ICI-IA). ICI-IA results in functional impairment that frequently persists, even after ICI discontinuation, with substantial quality-of-life impacts for cancer survivors.A high-quality body of evidence to guide ICI-IA management remains an unmet need. Pharmacological treatment may be prolonged, typically begins with non-specific immunosuppression, including systemic steroids, and is usually only rationalised to more targeted therapy in resistant cases. Moreover, retrospective data suggest the high dose glucocorticoids sometimes used in new-onset ICI-IA may be associated with worse cancer outcomes.Tumour necrosis factor (TNF) inhibition strategies are well established with excellent efficacy and safety profiles in ‘spontaneous’ inflammatory arthritides including rheumatoid and psoriatic arthritis. Mechanistic evidence from ex vivo and murine studies also supports the utility of anti-TNF therapy for steroid-refractory cases of ICI-IA. Although good clinical responses have been reported in this setting, the REACT trial (REmission induction of Arthritis caused by Cancer ImmunoTherapy) aims to provide randomised and robust clinical evidence for deploying targeted therapy earlier in ICI-IA management. It will test whether up-front anti-TNF therapy can more effectively and quickly control symptoms, reduce glucocorticoid exposure, prevent early ICI discontinuation and increase the frequency of drug-free ICI-IA remission.Methods and analysis REACT is a prospective, multicentre, open-label, superiority, two-arm, randomised controlled clinical trial to guide initial therapy for patients with ICI-IA. The trial will compare the current standard of care (initial prednisolone; Arm A) with the anti-TNF drug, adalimumab without glucocorticoids (Arm B).The primary outcome is glucocorticoid-free arthritis remission rate at 24 weeks where remission is defined as: (i) No use of systemic or intra-articular glucocorticoids (except when used for adrenal insufficiency) within 4 weeks prior to assessment at 24 weeks; and (ii) absence of synovitis on clinical examination.Ethics and dissemination The protocol was approved by East Midlands—Leicester South Research Ethics Committee on 31-Oct-2024 (Ref: 24/EM/0202). Participants are required to provide written informed consent. The results of this trial will be disseminated through national and international presentations and peer-reviewed publications.Trial registration number ISRCTN18217497.
Incretin-based therapies, including GLP-1 receptor agonists and dual GLP-1-GIP receptor agonists, have transformed obesity management, producing substantial weight loss and cardiometabolic benefits, with potential improvements in obesity-related complications, physical function, quality of life, and psychological wellbeing for many individuals. However, reduced appetite, rapid weight loss, gastrointestinal adverse effects, and changes in eating behaviour might create nutritional, functional, or psychological risks in some individuals. This EASO-EFAD-ECPO Consensus Statement outlines pragmatic nutritional, functional, and psychological considerations during incretin-based therapy treatment. We synthesise evidence on medical nutrition therapy, including protein targets during weight loss, dietary quality, and mitigation of gastrointestinal adverse events. We discuss pragmatic approaches that could help support preservation of fat-free mass and physical function during weight loss, including adequate protein intake and progressive resistance exercise. We emphasise the psychological and identity-related challenges during incretin-based therapy, including shifts in food reward, coping, and social connection, and recommend psychological screening, with integrated support where needed. We propose pragmatic monitoring during weight loss, including diet quality, micronutrient risk, and functional measures, with body-composition assessment where indicated. We suggest approaches to address disparities in access and adherence to ensure equity. We discuss the importance of shared decision making with the patient in decisions to start, up-titrate, delay, pause, down-titrate, or discontinue incretin-based therapies, considering the physical and psychological risks of treating versus not treating. Finally, we identify future research priorities, including longitudinal research on micronutrient status, macronutrient requirements, changes in dietary patterns and food choices, musculoskeletal outcomes, unique dosing schedules, and post-cessation maintenance to optimise safety, efficacy, and the patient experience.
Metabolic dysfunction-associated steatohepatitis (MASH), a potentially progressive form of metabolic dysfunction-associated steatotic liver disease (MASLD), increases risk of fibrosis progression, cirrhosis, and liver-related and cardiometabolic morbidity. The first licensed pharmacotherapies, resmetirom and semaglutide, mark a shift in management but practical guidance for real-world implementation is lacking. The British Association for the Study of the Liver and British Society of Gastroenterology MASLD special interest group developed consensus recommendations on patient selection, lifestyle management, and follow-up for MASLD-MASH-specific pharmacotherapy. 37 participants participated in a Delphi process where draft statements developed in working groups were anonymously rated, discussed, and refined. Consensus (≥80% agreement) was reached for 49 statements. The group agreed on the following general recommendation. Two-step non-invasive tests, including the Fibrosis-4 index and vibration-controlled transient elastography, are recommended to identify patients with presumed stage F2-F3 fibrosis (ie, at-risk MASH). Individuals with liver stiffness more than 10 kPa but without evidence of cirrhosis should be considered eligible for treatment. Lifestyle behaviour change intervention should accompany pharmacological treatment, delivered by suitably trained practitioners without delaying access to medication. Treatment discontinuation is advised with evidence of disease progression, cirrhosis development, or drug-induced liver injury. These recommendations offer pragmatic guidance to clinicians and consensus clinical opinion to regulatory bodies to support equitable and effective use of new MASLD-MASH therapies.
Introduction Obesity affects over a quarter of the UK population and can lead to serious health issues. NHS Specialist Weight Management Services (WMS) offer treatments including lifestyle advice, psychological support and medications, but access and availability vary by region. Although around 4 million people could be eligible for NHS Specialist WMS annually, capacity is limited to 35 000, severely limiting overall access for those who need it. While digital technology has started to be used in WMS, more evidence is needed to confirm its long-term effectiveness, acceptability and cost-effectiveness. This study explores the use of Gro Health W8Buddy, a digital platform and app providing remote Specialist WMS. It aims to determine the long-term health benefits of remote WMS pathway Gro Health W8Buddy compared with standard NHS WMS delivered in hospitals, and to improve patients access to services.Methods and analysis The study is a real-world evaluation with observational data collection. We will recruit 450 study participants from four NHS specialist WMS who will choose either standard NHS WMS or the digital pathway Gro Health W8Buddy. Participants are being given the option to choose their pathway to generate real-world evidence. We will measure and analyse health outcomes including weight loss, time taken to be treated and cost-effectiveness, at 18 months and follow up at 24 months for later analysis (outside of this core funding). We will gather experiential data from patients and healthcare professionals through surveys, observation and interviews.Ethics and dissemination Ethical approval has been obtained from NHS Health Research Authority (HRA) and Health and Care Research Wales (HCRW) (Supplementary Figure 3) (REC reference: 25/EM/0147). Our findings will be disseminated through academic publications, conference presentations and stakeholder engagement.Trial registration ISRCTN89168871; Pre-results.
