BACKGROUND:Creatine kinase (CK) reference intervals (RIs) derived from predominantly White cohorts do not account for well-documented ethnic differences in CK. This misclassification may lead to unnecessary investigations or inappropriate treatment. We aimed to characterise age-, sex- and ethnicity-related variation in CK and establish RIs for a multi-ethnic population. METHODS:Deidentified CK results of primary care requests between 2008 and 2024 from a laboratory in the West Midlands (UK) were partitioned into six groups (male and female of White, Asian and Black ethnicities). Indirect RIs were derived from 58,096 individuals (33,879 female; 24,217 male) with the refineR algorithm. Derived RIs were verified in two independent datasets. RESULTS:Median CK and upper reference limits (URLs) were highest in Black, intermediate in Asian and lowest in White groups. Female URLs for ≥13 years were 389 IU/L (Black), 188 IU/L (Asian) and 170 IU/L (White); male URLs were 757 IU/L, 357 IU/L and 314 IU/L, respectively. Applying the UK Pathology Harmony sex-specific RIs to all ethnicities classified 22.6-30.3% of results from Black individuals as high, versus 5.1-7.7% of White individuals. Using the new ethnicity-specific RIs reduced high-result rates in Black men and women. In individuals of mixed ethnicity, CK levels aligned more closely with the parent group with higher CK. After excluding outliers, the 97.5th percentile CK values for female and male children <13 years of Black ethnicities were 1.22 and 1.28 times higher, respectively, than those of White ethnicities. CONCLUSIONS:Adoption of CK RIs stratified by sex and ethnicity will allow more precise interpretation of the results, supporting equitable clinical decision-making and appropriate use of healthcare resources.
Hypertension remains the leading cause of premature mortality. Its effective management is hindered by sub-optimal monitoring from intermittent measurement of blood pressure which often lacks important prognostic data such as patterns of blood pressure variability. This article provides a summary of the technologies used in wearable devices, an evaluation of their emerging role in the management of hypertension, and current challenges to their utility. Unlike traditional cuff-based devices, cuffless technology utilises range of sensors and physiological principles including peripheral pulse wave characteristics and photoplethysmography together with algorithms to estimate blood pressure. Cuffless devices are unobtrusive and can be worn continuously providing longer-term data. As such they can bridge gaps in identifying and monitoring high-risk hypertension profiles, sleep periods data, dipping status, and blood pressure variability, which can guide individualised clinical decision making. However, due to rapid innovation and technological heterogeneity and associated lack of appropriate validation frameworks, there remain significant concerns on the accuracy and reliability of cuffless wearables for clinical use. Despite their potential and market availability, professional society guidelines do not recommend the use of cuffless devices for clinical decision making until more robust and complete real-world evidence is available.
Coronary artery disease has a high degree of morbidity and mortality internationally and, after a cardiovascular event, patients require intensified management of modifiable risk factors, with optimal lipid control being an important cornerstone of secondary prevention. This is both a primary and a secondary care responsibility. Familiarity with indications for and prescription of non-statin medications, including injectables, is vital for patient outcomes. Fewer than 30% of patients reach LDL-c targets with statins alone. This is a public health matter, and non-statin therapies that all clinicians need to be aware of are oral therapies such as ezetimibe and bempedoic acid, and injectable therapies such as inclisiran and PCKS9 inhibitors. Icosapent ethyl is also available in those with high fasting triglycerides with specific LDL-c values. Understanding when to refer to the lipid clinic enables patients to be managed appropriately in the correct setting. Future therapies under development include cholesterol ester transfer protein inhibitors, oral PCSK9 inhibitors, and gene editing therapy targeting ANGPTL3 and PCSK9. Lipid optimisation leads to significant reduction in major adverse cardiac events, and familiarity with all available treatment options - including non-statins and injectables - will facilitate best primary and secondary care.
Introduction: Rheumatic heart disease (RHD) arises from acute rheumatic fever (ARF) following group A streptococcal infection. While its prevalence has declined in high-income regions, it remains a major health burden in low-resource settings. Objective: This research reported the burden of RHD from 1990 to 2021, utilising data from the Global Burden of Disease (GBD) 2021 study. Methods: Publicly available data were analysed to determine absolute counts, age-standardised rates and percentage changes in prevalence, deaths and disability-adjusted life years (DALYs) from 1990 to 2021. Results: In 2021, global RHD cases numbered 54,785,119, with an age-standardised prevalence of 684.2 per 100,000, reflecting a 12.6% increase since 1990. Deaths totalled 373,345, with an age-standardised rate of 4.5 per 100,000, marking a 56.2% decline over the period. In 2021, Eritrea (1,865.4) had the highest prevalence rate and Finland (17.4) the lowest. In 2021, Micronesia reported the highest death rate (9.6 per 100,000), and Guatemala the lowest (0.2). Women exhibited higher prevalence estimates across all ages, peaking in the 25-29 age range. Although prevalence declined with age, it remained higher in females than among males. The relationship between the Sociodemographic Index (SDI) and RHD burden was non-linear, peaking at an SDI of 0.42, before declining sharply. Conclusion: RHD remains a major public health challenge, characterised by rising prevalence and significant health and economic impacts. Despite reductions in mortality and DALY rates, the increasing prevalence underscores the urgent need for improved prevention and management strategies.
Fat embolism syndrome (FES) is a rare but likely underdiagnosed complication of sickle cell disease (SCD) characterised by multi- or single-organ involvement secondary to embolism of fat and/or necrotic bone marrow. It is one of the most devastating acute complications of SCD and historically the diagnosis has often been made on the basis of post-mortem findings. Literature on FES in SCD is scarce, although most reported cases are individuals with non-HbSS genotypes for reasons which have not yet been fully elucidated. Even fewer data exist regarding the potential association with parvovirus B19 (B19V) and the mechanisms by which B19V infection could trigger FES in SCD. Management is largely supportive, with early intensive care team involvement for close monitoring and potential organ support. Emerging evidence, albeit limited, suggests that early exchange transfusion has an important role in improving clinical outcomes. We describe two life-threatening cases of FES in patients with SCD of differing genotypes, who required intensive care unit admission but who both recovered with supportive management and early exchange transfusion.
BACKGROUND:Clinical Decision Support Systems (CDSS) - software programs that provide patient-specific recommendations to assist in clinical decision-making - have evolved considerably since 2020, with increasing integration of artificial intelligence (AI) and machine-learning features. Modern AI-powered CDSS (AI-CDSS) no longer rely on static algorithms but instead create adaptive, data-driven insights to be used for diagnostics, prognosis and therapy. Exposure in the clinical setting and attention from regulators have increased, yet uncertainty persists about how clinicians view the risks, benefits and integration of such systems within their everyday practice. OBJECTIVES:Our objective in this research was to assess AI‑CDSS perception in 2025 and to explore cross-temporal patterns relative to earlier reports. Specifically, we sought to: (1) examine cross-temporal trends in perceived benefits and harms; (2) describe clinician subgroups by adoption intentions; and (3) examine professional and regulatory concerns following real-world experience with AI. METHODS:A cross-sectional online survey was administered to UK and Italian clinicians (N = 215). The instrument maintained thematic continuity with a 2020 survey while incorporating AI-specific constructs. The questions spanned five themes: perceived advantages, hazards, regulation, clinical utility, and ethical concerns. Cluster analysis (Ward's method, z-scored items) was used to identify attitudinal clusters. Comparison through time with 2020 data prioritised thematic concordance and relative frequencies. RESULTS:AI‑CDSS are now more commonly used for diagnostic support (32.6%) compared to primarily administrative purposes in 2020. Greater endorsement was found for AI benefits such as improved diagnostics (63.3%) and medicine management (62.8%). Concerns moved from technological performance to professional issues, such as de-skilling of trainees (59.5%) and automation bias (67%). Regulatory concerns moved from device-focused agencies to evidence synthesis organisations (eg NICE: 31.2%). Hierarchical cluster analysis identified three distinct attitudinal profiles: The Optimists (n = 113), who reported high perceived benefits and low risk; The Balanced Sceptics (n = 83), with moderate scores across dimensions; and The Concerned (n = 19), who reported low perceived benefits and elevated risk perception. CONCLUSION:Clinicians tend to display more nuanced, context-specific views of AI‑CDSS following real-world exposure. Clinicians in 2025 reported moderate to high trust in AI-based tools; however, as trust was measured in 2025 only, no direct cross-temporal trust comparison can be made. Persistent concerns regarding ethics, explainability and professional education remain. Specialised regulatory frameworks and training models are needed to optimise safe, effective integration into modern practice.
Recently there have been initiatives to ban or reduce the use of smartphones in children and young people. While exemptions are typically made for those for whom smartphones constitute an essential medical device, these groups have not been sufficiently considered in discussions to date. These people include children living with type 1 diabetes and young carers, as well as some with heart conditions and epilepsy. Research urgently needs to examine the consequences of smartphone use and restriction in children in general, but this is particularly urgent when smartphones constitute an essential medical device. While restricting use and negative messaging surrounding campaigns could cause harm to these children, the negative impacts of devices (eg providing opportunities for bullying or distraction) may also be amplified in these populations. Four clinical and research recommendations on this topic are proposed.
Hypertension is a major risk factor for cardiovascular (CV) disease and progression in chronic kidney disease (CKD). Blood pressure (BP) measurement should be standardised and supplemented by ambulatory and home BP monitoring. BP goals are generally <140/90 and <130/80 mmHg for those at higher risk of CV disease or CKD progression. Lifestyle modification includes restricting salt intake to <5 g/day. Most people with hypertension and CKD, especially those with a urine albumin:creatinine ratio ≥3 mg/mmol, should be treated with a renin-angiotensin system inhibitor to which, in selected individuals, a sodium-glucose co-transporter inhibitors type 2 and non-steroidal mineralocorticoid receptor antagonist may be added, followed by additional antihypertensives to achieve goal BP. Strategies to manage hyperkalaemia (eg low potassium dietary advice and oral potassium binders) should be employed to avoid stopping prognostically beneficial medications. A range of emerging therapeutics, including aldosterone synthase and endothelin antagonists, and renal denervation are briefly discussed.
Objective: To examine how GPs understand their working conditions and to consider what significance this holds for medical education. Design: Data were collected through online interviews with GPs, conducted between April and July 2023. These data were then subjected to thematic analysis. Participants: Fifteen GPs were interviewed, including two practice partners, seven salaried GPs, one locum GP and five GPs in training. Participants were recruited through professional networks using purposive sampling. Results: GPs described intense pressure from increasing demand, large administrative burden and erosion of professional autonomy. Practitioners viewed working full-time as unsustainable, with experienced GPs actively discouraging trainees from taking on such work. The primary coping mechanism that GPs used was reducing their working days, which they considered necessary to continue in practice. The working conditions shape what is understood and transmitted about the profession: that general practice is a fundamentally unsustainable full-time career. Conclusion: GPs understand their working conditions as untenable and that they must be managed at a personal level. However, these conditions are products of specific political and economic arrangements rather than natural features of medical practice. Medical educators should actively consider what the workplace is teaching and what effects this might have on the future workforce.
Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) remains underrecognised in diabetes care due to the lack of structured detection pathways in primary healthcare. Objective: To evaluate the feasibility and performance of a stepwise diagnostic pathway for identifying the full spectrum of MASLD in adults with type 2 diabetes in primary healthcare settings. Methods: A diagnostic pathway for early detection across the MASLD spectrum, including steatosis, metabolic dysfunction-associated steatohepatitis (MASH), liver fibrosis risk and significant fibrosis, was integrated into a multicomponent diabetes care programme within the public health system. A secondary exploratory analysis used multivariable logistic regression to identify factors independently associated with MASLD. Results: Among 454 adults with type 2 diabetes, MASLD was identified in 51.5% and MASH in 22.2%. Through stepwise assessment, 22.7% showed intermediate-to-high fibrosis risk, and among those who underwent transient elastography, significant fibrosis was confirmed in 27.9% of individuals with increased risk, yielding an estimated prevalence of 10.6% in the MASLD group and 5.9% overall. In multivariable analysis, female sex, elevated liver enzymes and higher body mass index were independently associated with MASLD, with a non-linear association across BMI categories. Conclusion: Implementing structured care pathways for the identification and management of MASLD is feasible and essential to mitigate the burden of diabetes and liver disease. Strengthening primary care capacity remains crucial for systematic integration of MASLD identification in routine care.
This article briefly reviews the latest hypertension guidelines and how they should be individualised in patients with heart failure (HF), including the two specific phenotypes: HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Key recent trials and guidelines show that HF medications remain beneficial and safe to use even in patients without overt hypertension, provided that they are tolerated. We also outline practical strategies for titration and selection of HF medications, most of which affect BP, in an outpatient setting. These strategies are applicable to both normotensive patients and those with pre-existing hypertension.
The evidence for non-invasive ventilation (NIV) is clear; however, real-world outcomes fall short of those demonstrated by clinical trials. We developed a five-step care bundle in line with BTS quality standards to standardise management and guide clinicians through the first few hours of NIV care. This was combined with staff training initiatives. The project aimed to reduce acute NIV mortality to 10%. Although this target was not met, the project delivered a 7% reduction in mortality from 28% to 21%, equating to 143 fewer deaths in 2023 compared to 2022. The project also delivered increased staff confidence. Through this project we have demonstrated that early, effective NIV, in appropriate patients, delivered in a standardised way by confident and competent staff, improves outcomes.
Despite the widespread availability of effective anti-hypertensive medications, blood pressure control remains unsatisfactory in a large number of patients, often due to avoidable dosing misconceptions rather than actual treatment resistance. This educational review aims to facilitate continuing medical education and clinical practice by exploring existing challenges in the pharmacological management of hypertension, focusing on the common drugs prescribed to manage hypertension. After reading this article, clinicians should be able recognise non-linear dose-response relationships, select appropriate medications and doses to achieve better blood pressure control, improve compliance alongside managing side effects that have led to premature discontinuation of beneficial medications. The review further explores how pharmacokinetic properties and patient-specific considerations, such as renal function and ethnicity, might influence choice of anti-hypertensive medications. This article aims to strengthen clinical choice, medication adherence, and long-term management of blood pressure.
STUDY OBJECTIVE:To determine life expectancy among UK physicians using the Royal College of Physicians' (RCP) Munk's Roll and to identify demographic or professional factors associated with longevity. DESIGN:Retrospective observational study of biographical records. SETTING:Munk's Roll, RCP. PARTICIPANTS:Random sample of 1,000 fellows from Volume XII (2005-2023). MAIN OUTCOME MEASURES:Age at death; associations with sex, birthplace, place of qualification, specialty and hobbies. RESULTS:995 fellows (915 male, 80 female) were included. Median age at death: 84.0 years (range 34.7-105.0). Men lived longer than women (84.2 vs 80.5 years, p = 0.033). Fellows with obituaries mentioning gardening lived longer than those without (86.0 vs 83.5 years, p = 0.0008). Median age at death varied by region of qualification: North America 94.0, Europe 92.9, Australasia 87.5, Ireland 87.7, UK 84.1, and Indian subcontinent 76.0 years. Age at death differed significantly by region of qualification (p < 0.0001), with fellows qualifying in the Indian subcontinent living notably shorter lives. There were no consistent differences in longevity across specialty groups after adjustment, although pathologists had longer survival (+8.0 years vs cardiologists, p = 0.004). CONCLUSIONS:UK physicians recorded in the Munk's Roll have substantially higher life expectancy than the general population. Sex differences favouring male physicians and longevity advantages associated with gardening and certain qualification regions were observed. Specialty was not a major determinant of survival. These findings highlight historical inequalities within the profession and the potential importance of wellbeing-related activities in supporting physician longevity.
Primary aldosteronism (PA) is a common yet significantly underdiagnosed cause of secondary hypertension, estimated to affect around 9.4% of hypertensive adults. This is critical because patients with PA face markedly higher rates of adverse cardiovascular and renal outcomes, risks substantially mitigated by targeted treatment (surgery or medical therapy). Despite this, screening rates remain critically low. This article provides a practical, evidence-based approach to PA screening specifically for generalist settings, focusing on contemporary test interpretation and mitigating common pitfalls. Screening involves a simple blood test for plasma aldosterone and renin. The diagnostic hallmark is renin-independent aldosterone production, demonstrated by suppressed renin. While most antihypertensives interfere, the initial approach is to test patients on their current regimen. If results are inconclusive, medication withdrawal is warranted. Specialist referral is necessary when results are suggestive of PA, or in complex cases like chronic kidney disease. Improving PA screening offers a significant opportunity for substantial global benefit in reducing hypertension-related morbidity and mortality.
Obstructive sleep apnoea (OSA) is a common, underdiagnosed disorder characterised by upper airway collapse, intermittent hypoxia and sympathetic activation. Hypertension frequently coexists with OSA, with evidence supporting OSA-driven hypertension mediated by sympathetic overactivity, RAAS (renin-angiotensin-aldosterone system) activation and endothelial dysfunction. OSA-related hypertension often manifests as nocturnal hypertension and is linked to adverse cardiovascular outcomes. Prevalence is high in resistant hypertension, supporting targeted screening. Diagnosis should be considered in patients with daytime somnolence or refractory hypertension, using validated screening tools and sleep studies. Continuous positive airway pressure (CPAP) is the cornerstone of OSA management and can modestly lower blood pressure with cardiovascular benefit. Pharmacological management should follow hypertension guidelines, favouring agents that target relevant mechanisms (eg RAAS blockade and beta-blockade). Aldosterone antagonists are recommended in resistant hypertension. Emerging therapies, including endothelin receptor antagonists and GLP-1 receptor agonists, show promise but require further trials. This article reviews the epidemiology, mechanisms, diagnosis and management of OSA-related hypertension.
Background: Although post-surgical radiotherapy is common in keloid management, factors influencing its efficacy remain unclear. The aim of this study is to investigate postoperative electron beam radiotherapy's impact on recurrence and adverse effects. Methods: A retrospective study was conducted to evaluate the recurrence rates and complications across three radiation schemes: 17.5 Gy / five fractions, 20 Gy / four fractions, and 18 Gy / two fractions. Results: The overall recurrence rate was 6.5%, with the lowest recurrence (2.8%) observed in the 18 Gy / two-fraction regimen. Radiation schemes, lesion condition (type, location, and duration), and family history were associated with post-surgical recurrence. Furthermore, hyperpigmentation (32%) and dermatitis (11.8%) were identified as significant adverse events. No radiation-related cancers were observed during follow-up. Conclusion: The 18 Gy / two-fraction regimen post-surgical electron beam radiotherapy emerged as the most effective and safe option for keloid recurrence prevention. Features, including lesion type, location, family history and disease duration should be combined to guide therapeutic strategy.
Medication adherence refers to the extent to which a person’s medication-taking behaviour corresponds with agreed recommendations from their clinician. Research shows that more than one-third of patients are non-adherent to their prescribed medications. Non-adherence is particularly significant in hypertension, as it complicates chronic disease management and may result in apparent treatment-resistant hypertension (aTRH), in which blood pressure remains uncontrolled despite appropriate pharmacological therapy and lifestyle measures. It is therefore important to assess adherence routinely, as non-adherence is one of the leading causes of aTRH. This article outlines a practical approach to recognising and assessing non-adherence using objective chemical adherence testing, and to managing medication non-adherence through non-judgemental, patient-centred discussion. Identifying non-adherence is vital, as failure to do so may lead to unnecessary treatment escalation, inappropriate investigations, and avoidable healthcare costs; while addressing it can support and improve patient-centred outcomes.
Background: Peripheral lymphadenopathy (LA) has diverse causes and may indicate malignancy, particularly in referred patients. Aim: To characterise patients referred for unexplained LA to a quick diagnosis unit, and identify independent predictors of malignancy. Design and methods: We conducted a retrospective study of 485 consecutive adults evaluated for unexplained LA between 2017 and 2023. The primary outcome was malignancy. Secondary outcomes included diagnostic delay and time to oncology referral. Demographic, clinical and laboratory variables were compared across aetiological groups. A parsimonious multivariable logistic regression model included five clinically relevant predictors identified in univariable analyses and supported by biological plausibility. Results: Median age was 46 years, and time to first visit was 11 days. Cervical nodes were most frequent (51.9%), followed by supraclavicular (18.6%). Malignancy was diagnosed in 20.8% of patients, with diagnostic delay of 26.5 days (15.5-42). Other specific diagnoses were established in 35.5% of cases, while 43.7% were reactive. Malignant cases were older (60.8 vs 42 years), predominantly male (68.3% vs 44.5%), had higher drug exposure (50.0% vs 29.8%), and shorter symptom duration (45 vs 90 days). In multivariable analysis, independent predictors of malignancy were: age (odds ratio (OR) 1.71 per 10-year increase), male sex (OR 3.25), lymph node size (OR 1.36 per 5 mm increase), indurated consistency (OR 3.42), and supraclavicular location (OR 4.96). Median time to oncology evaluation was 47 days. Conclusion: The QDU model enables timely diagnosis and detects malignancy in over 20% of cases. Recognising clinical predictors may help prioritise high-risk patients and streamline diagnostic pathways.
Incidence of falls related trauma in the older adult is exponentially increasing and requires a multidisciplinary approach at all stages of the encounter to optimise patient outcome. Orthogeriatric services bridge the gap between the older person, their acute presentation, and their chronic frailty and bone fragility. Despite improvements of fragility fracture pathways between surgical and medical teams, significant gaps of knowledge and communication remain. These gaps manifest as missed opportunities to address crucial medical issues, therapy needs, and bone health management in this vulnerable population.Here, we discuss themes to consider when approaching an older person at high falls risk or when presenting post fall. We emphasise the importance of delirium prevention, appreciation of frailty, and initiating bone fragility assessment and therapy in this vulnerable demographic.
