Worcestershire Acute Hospitals NHS Trust

Human pharmaceuticals are increasingly detected in environments around the world, with growing international calls to mitigate the ecological and human health risks posed by these novel entities. Exposure to pharmaceutical pollutants can negatively affect the behaviour, reproduction, and health of wildlife, contributing towards declining ecological health and global biodiversity loss. Pharmaceuticals in the environment are also driving rising levels of antimicrobial resistance, a major public health threat. Developing strategies to mitigate these public and environmental health risks has been greatly limited by diverse and often conflicting stakeholder interests and the need to retain the major human health and socioeconomic benefits that pharmaceuticals provide. In this Personal View, we propose a multistakeholder, systems-based approach for high-income countries to develop transformational national mitigation strategies. Applying this approach to a UK case study highlighted the growing risks caused by the unsustainability of the current UK health-care pharmaceutical system and enabled us to identify 37 synergistic intervention points that target both the tangible easy wins and the deep-rooted social drivers of the issue. We believe our approach will support high-income countries in minimising the public and environmental health risks associated with pharmaceutical pollution, by driving long-term sustainability across the pharmaceutical lifecycle, for a positive pharmaceutical future.

Background:Catheter-based pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). While cryoballoon ablation (CBA) is a well-validated single-shot thermal technology, pulsed field ablation (PFA) has emerged as a predominantly non-thermal modality that employs high-voltage electric fields to achieve selective myocardial ablation, potentially minimizing collateral damage. However, comparative evidence between PFA and CBA remains limited. Objectives:To systematically review and compare the efficacy, safety, and procedural efficiency of PFA versus CBA for PVI. Methods and Results:A structured systematic database search was conducted up to August 2025, following PRISMA guidelines. Eighteen studies (n = 5638; 2396 PFA and 3242 CBA) were included including two randomized controlled trials. PFA significantly shortened procedure time (mean difference -13.7 min; 95% CI -16.7 to -10.8; p < 0.001), while fluoroscopy time and radiation dose were similar. Both modalities achieved high acute PVI success (95%-100%). At 12-month follow-up, PFA showed lower arrhythmia recurrence (OR 0.73; 95% CI 0.59-0.90; p = 0.003) with no difference in redo ablation. Overall complications were fewer with PFA (OR 0.53; 95% CI 0.32-0.87; p < 0.001), largely due to reduced phrenic nerve injury, though cardiac tamponade occurred slightly more often in the PFA group. Subgroup analyzes yielded consistent results in paroxysmal AF and when 3D mapping was used. Conclusion:PFA offers superior procedural efficiency and safety compared with CBA, achieving shorter procedures, fewer complications, and lower arrhythmia recurrence at mid-term follow-up. Larger multicentre randomized trials with standardized protocols and long-term follow-up are needed to confirm these findings and evaluate evolving PFA technologies.

This study evaluates patient engagement and satisfaction with Everyday Medical Monitoring Ally (E.M.M.A), a purpose-trained artificial intelligence (AI)-powered health coach delivered via WhatsApp. E.M.M.A integrates AI-driven symptom tracking, personalized medical information, and lifestyle guidance to support eye health management in a real-world clinical setting. This pilot study enrolled patients from a UK-based ophthalmology clinic managing chronic eye conditions. Patient interactions with E.M.M.A were logged over a 2-month period. Data collected included chat frequency, temporal patterns, and interaction modality (text or audio). A post-study satisfaction survey was conducted. Human validation of AI-generated question-answer pairs was performed independently by two glaucoma consultants. Ninety-one patients consented to participate, of whom 83 interacted with E.M.M.A, generating 446 analyzed chat sessions. Audio interactions accounted for 28% of chats. A subgroup of 39 users (42%) generated nearly 75% of all chats, while 52% of users were repeat users. Most patient queries related to general eye health and symptoms, comprising 39% of questions. Symptom-related content accounted for 26% of response classifications. The satisfaction survey was completed by 66 users, with 88% reporting being satisfied or very satisfied. A total of 65% would definitely recommend E.M.M.A, while 9% reported mild to moderate anxiety during use. Human expert validation scores exceeded 95% across all assessed domains. Qualitative feedback indicated acceptance of E.M.M.A as a reassuring and valuable adjunct when immediate clinical support was unavailable. AI-driven health coaches such as E.M.M.A may help bridge gaps in ophthalmic care between clinical visits by providing continuous, personalized, and medical record-informed patient support.

PURPOSE:To compare tibial suspensory fixation (TSF) with tibial interference screw (TIS) in anterior cruciate ligament (ACL) reconstruction for clinical and radiological outcomes. METHODS:A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using MEDLINE, PubMed, and Embase databases. The review was registered with the PROSPERO database. Clinical comparative studies of ACL reconstruction with hamstring autograft with TSF and TIS were included. Primary outcome measures include functional outcome in terms of International Knee Documentation Committee, Lysholm and Tegner scores, knee laxity, and radiologic outcomes in terms of tunnel widening. Secondary outcome measures include isokinetic muscle strength and complications like graft failure. Studies were appraised using Cochrane risk of bias tool for randomized controlled trials and Methodological Index for Non-Randomized Studies score. RESULTS:Seventeen clinical comparative studies (TSF, n = 4262; TIS, n = 3085) met eligibility criteria. Of these, 72.9% (TSF) and 75.7% (TIS) of patients were males. Follow-up ranged from 24 to 40 months for clinical outcomes and 6 to 24 months for radiological outcomes. Included studies report no difference in knee functional scores (International Knee Documentation Committee [mean difference, range -3.40 to 5.10], Tegner [mean difference, range -1.20 to 0.60], and Lysholm score [mean difference, range -4.00 to 1.30]) between the TSF and TIS groups. The studies also report no difference in knee laxity (KT-1000 [mean difference, range -0.40 to 1.50]). Two studies revealed superior knee flexor strength at 2 years with TSF compared with TIS (Goyal et al., 25.8 ± 4.2 vs 23.5 ± 2.5 lbs, P = .002). No major complications were reported in most of the studies except 1 which showed a higher revision rate with TIS (TSF 3.4% vs TIS 5.4%, P < .001). Radiologically, the studies show greater tibial tunnel widening with TIS compared with TSF (mean difference, range -2.40 to -1.61). CONCLUSIONS:TSF in hamstring autograft ACL reconstruction shows similar functional outcomes and knee stability when compared with interference screw at a minimum clinical follow-up of 24 months. The present systematic review also highlights superior knee flexor strength with TSF with no major difference in the complications including graft failure rate. The use of TSF using hamstring autograft is a reliable option for ACL reconstruction. LEVEL OF EVIDENCE:Level IV, systematic review of Level I to IV studies.

Abstract Distal radioulnar joint (DRUJ) dysfunction is a complication observed acutely with forearm fractures. However, there is some evidence associating delayed presentation of dysfunction to previous forearm fractures in childhood. The purpose of this to review the presence of delayed DRUJ dysfunction and factors contributing to dysfunction, following metaphyseal or diaphyseal forearm fractures sustained in childhood. Utilizing the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, we conducted a systematic review using the PubMed database. Papers that reported cases of delayed DRUJ dysfunction in the context of metaphyseal or diaphyseal forearm fractures in children < 18 years of age at time of fracture were included. A total of 85 cases fit the inclusion criteria. Onset of dysfunction ranged from 6 weeks to 32 years. Limited supination was seen in 65 cases and pronation in 65. Overall, 76/85 (89%) of patients had deficits in range of motion. A total of 58 cases had both bone fractures. A total of 64/85 (74%) had a concurrent malunion at the time of symptom onset. Symptomatic dysfunction and malunion was treated with corrective osteotomies to one or both bones. Of cases discussing subsequent osteotomies, 50% were treated with computed tomography-guided 3-dimensional customized operative guides for corrective osteotomy. In all cases, there was improvement in dysfunction after osteotomy. Delayed DRUJ dysfunction can be observed following metaphyseal and diaphyseal fractures in childhood. Dedicated wrist radiographs on discharge from follow-up for childhood forearm fractures and advanced imaging if DRUJ dysfunction suspected is recommended. There is a clear lack of research, limiting the ability to assess the relationships between initial intervention, DRUJ dysfunction, and malunion morphologies.