Warwick Hospital on Lakin Road in the northwest of Warwick, Warwickshire, England is run by South Warwickshire NHS Foundation Trust.
BACKGROUND:Pathogenic bacteria such as Streptococcus pyogenes, Staphylococcus aureus, and methicillin-resistant S. aureus (MRSA) are frequently isolated from skin ulcers. Their presence may signify colonisation, subclinical (covert) infection, or overt clinical infection. While antibiotic therapy is indicated for infection, it is inappropriate for simple colonisation. However, the clinical distinction between these states often lacks a clear-cut demarcation, representing a significant diagnostic challenge. METHODS:This study utilised Etiologic Predictive Value (EPV) to estimate the probability that the presence of these bacteria represents clinical infection rather than colonisation. Skin swabs from 387 patients presenting to an emergency department were analysed using conventional culture and nucleic acid amplification tests (NAAT). Bacterial growth and detection rates were compared between patients with (n = 70) and without (n = 317) skin ulcers to calculate the EPV. RESULTS:The positive EPV for bacterial detection yielded wide 95% confidence intervals (CIs), suggesting that these microbiological tests have limited utility for confirming (ruling in) clinical infection. Conversely, the negative EPV was 97-100% with very narrow CIs, indicating that these tests are highly effective for excluding (ruling out) subclinical or overt infection. CONCLUSIONS:We conclude that conventional culture and, more notably, NAAT are valuable tools for antimicrobial stewardship. They are particularly useful for excluding infection and preventing unnecessary antibiotic prescription in cases where compelling clinical signs of overt infection are absent.
Abstract Healthcare delivery contributes substantially to climate change, accounting for approximately 4–5% of global greenhouse gas emissions. Melanoma is a fatal cancer with rising incidence in the UK, where advanced-stage disease is associated with significant morbidity and mortality and escalating healthcare costs. While the clinical and economic burden of melanoma increases markedly with advancing stage at diagnosis, its environmental impact remains unquantified. The NHS has committed to achieve net zero emissions by 2040. Therefore, estimating the stage-specific carbon footprint of melanoma care provides critical evidence to show that prevention and early detection can reduce the clinical harm, healthcare costs and environmental burden of cancer care, supporting the delivery of sustainable healthcare systems. Our aim was to estimate the stage-specific carbon footprint of melanoma care. Using published 2023 UK data on stage-specific melanoma costs and NHS reference costs, average healthcare costs for each stage of melanoma treatment were calculated. These costs were converted to estimated carbon emissions for each stage by applying a standard UK healthcare carbon intensity factor derived from environmentally extended input–output analysis. In 2023, average treatment costs for stage I, II, III and IV melanoma were £9512, £77 813, £179 274 and £213 801, respectively. Estimated carbon emissions rose sharply with advancing stage, from around 1482 kgCO₂e for stage I to around 33 310 kgCO₂e for stage IV, representing a difference of approximately 31 828 kgCO₂e and a 22.5-fold increase. This study provides the first UK stage-specific estimates of the carbon footprint of melanoma care, demonstrating exponential increases in emissions with advancing stage and the disproportionate environmental burden of late-stage disease. These findings underscore the urgent value of prevention, early detection and timely intervention to maximize clinical benefit while reducing healthcare costs and carbon emissions. We emphasize the importance of incorporating environmental impact alongside economic and clinical outcomes to guide more sustainable cancer care in line with the NHS net zero commitment.
Abstract Ritlecitinib has demonstrated efficacy for severe alopecia areata in randomized controlled trials; however, real-world safety and treatment persistence remain less well characterized. We conducted a retrospective, multicentre review of patients treated with ritlecitinib (n = 54), summarizing clinician-recorded adverse events (AEs) and rates of treatment interruption and discontinuation. Outcomes were benchmarked against published safety data from the 50-mg once-daily arm of pivotal clinical trials. Adverse events were documented in 31 of 54 (57%) patients. Laboratory abnormalities occurred in 9 of 31 (29%), most commonly anaemia (n = 3) and dyslipidaemia (n = 3). Less frequent abnormalities included elevated white cell count or neutrophils, transaminitis, raised alkaline phosphatase, thrombocytosis, and elevated creatine kinase or urea. Nonlaboratory AEs were predominantly mild and included fatigue or malaise (n = 8), gastrointestinal symptoms (n = 7), acne (n = 5), infective episodes (n = 5) and headache (n = 4). Additional reported events were heterogeneous. Only two patients experienced treatment interruption or discontinuation: one permanent discontinuation at 3 months due to cumulative adverse-event burden and one temporary interruption related to a pharyngeal abscess. Overall AE reporting was lower than in the reference trial population (57% vs. 75%; Fisher’s exact test, P = 0.02). Permanent discontinuation rates were comparable between cohorts (1.9% vs. 1.5%; P > 0.99). Temporary interruptions were numerically lower in routine practice but did not reach statistical significance (1.9% vs. 10.0%; P = 0.07). Combined interruption or discontinuation rates were similarly low (3.7% vs. 11.5%; P = 0.16). Our study demonstrates that ritlecitinib has a favourable real-world tolerability and safety profile in severe alopecia areata, with low rates of clinically meaningful adverse events and treatment discontinuation, supporting sustained treatment persistence in routine clinical practice. Differences in AE frequency compared with trial data likely reflect less intensive surveillance and protocol-driven reporting.
Abstract Introduction Parastomal hernias are challenging to manage and can lead to significant reductions in quality of life. This study examines parastomal hernia repairs in a hospital with a high volume of colorectal resections and stoma formations. Methods This observational study retrospectively analysed five years of data from 2020 to 2025 for patients undergoing parastomal hernia repair. The primary objective was to evaluate risk factors, predictive findings on CT imaging, operative techniques, and surgical outcomes. Results A total of 35 parastomal hernia repairs were performed: 8 emergency and 27 elective surgeries. Ages ranged from 33 to 83 years, with 20 males and 15 females. 6 were sutured repairs and 29 involved mesh repairs with Sugarbaker technique (41%), dynamic funnel (13%), SMART (13%) and simple onlay mesh (31%). Of the repairs, 54% were primary and 46% were for recurrent hernias. A statistically significant difference in body mass index (BMI) was observed between the primary- mean BMI 26 (range 22.7 to 44) and recurrent mean 34 (range 23.9 to 46.6) (p<0.05). Comorbidities, age, and sex did not significantly impact recurrence. CT findings including stoma passage through the rectus muscle, rectus muscle thickness, subcutaneous fat and psoas muscle index showed no significant differences between the groups. 2 patients had complications following surgery: stoma site infection and superficial ischaemia treated conservatively. Conclusion A high-volume district hospital is able to manage parastomal hernias with different techniques and good outcomes. BMI is a significant modifiable risk factor in the management and prevention of parastomal hernia recurrence.
