Background Pulmonary embolism (PE) is a condition with significant morbidity and mortality. Diagnostic imaging aims to identify patients with a PE so that they can receive anticoagulation. There is evidence, predominantly from the USA, that the number of diagnostic scans for PE has increased over time and the diagnostic yield (the percentage of positive scans) has decreased. There is limited evidence on whether this is also true in the UK. Aim To describe the pattern of diagnostic imaging for acute PE and investigate whether there has been a change in the diagnostic yield over the last 10 years. Methods All adult patients who underwent either computed tomography pulmonary angiogram (CTPA) or ventilation-perfusion (V/Q) scan as an investigation for acute PE at Cambridge University Hospitals NHS Foundation Trust (CUH) between 2015 and 2024 were included. This was a retrospective study using data extracted from the hospital electronic health record (EHR) system. Results 25,672 scans were included, comprising 23,908 CTPA and 1,764V/Q scans. The annual number of scans increased slightly over the time period, with an average increase of 1.2% per year (p < 0.05). The overall diagnostic yield was 17.0%, with no clear trend over time. There was also no clear trend in the proportion of subsegmental PE detected over time. Conclusions The overall number of scans performed and diagnostic yield for PE have remained relatively stable over the last decade. This is the largest study of its kind in the UK and, uniquely, also covers the entire timeline of the COVID-19 pandemic and its aftermath.
Study Objective Interest in medical research and clinical academic careers amongst medical students is concerningly low, posing a threat to the long-term sustainability of the clinical researcher workforce. A likely contributing factor is a lack of knowledge and teaching about medical research. To address this, we developed and evaluated the MEDICORE teaching programme; a dedicated clinical academia training programme designed to address these gaps. Design The MEDICORE programme consisted of six biweekly in-person sessions from January-March 2024, targeting UK medical students. The learning outcomes addressed educational gaps about research identified by a prior national survey and the GMC Outcomes for Graduates. Main Outcome Measures Pre- and post-session assessments measured students’ improvement in knowledge and attitudes towards medical research and clinical academic careers. Results 534 student responses were collected overall, with on average 89 participants attending each session. Seven UK universities were represented, with 83.3% from one institution. Students reported that the MEDICORE programme addressed a curriculum gap in research training (81.5%). There was a significant increase in the number of students who felt confident completing a full research project and disseminating research through publications or presentations. Post-MEDICORE, students felt more confident in the structure of clinical academic training (mean Likert scale increase 1.45±1.44, p<0.0001). The number of students interested in pursuing a clinical academic career increased from 39.1% to 85.8% (p<0.0001). Conclusion MEDICORE demonstrates that dedicated research teaching is an effective intervention to promote research skills and the pursuit of future academic careers amongst medical students. Such efforts may help address predicted shortages in the clinical academic workforce.
Foundation Year (FY) doctors consistently report feeling underprepared when applying intravenous fluid (IVF) guidelines due to inadequate training, resources and an underemphasis of evidence-based bedside assessment techniques. Given IVFs are the most commonly prescribed substance in the NHS, especially by FY1 doctors, inappropriate patient assessments and written prescriptions are a patient safety threat. Whilst the NICE IVF guideline exists, it is not without nuance and there remain challenges in delivering effective IVF education and sustainable learning interventions over time. From a FY doctor perspective discussed, senior clinicians demonstrating use of guidelines more explicitly may help address the gap between guidelines and clinical practice. Ultimately, given the widespread use of IVF, there is a need for improved education to develop FY doctors’ clinical reasoning and ensure patient safety.
Tuberculosis (TB) is the deadliest leading infectious disease globally. Approximately 10.7 million people worldwide were estimated to have developed TB in 2024. TB rates have increased in the UK over the last three years. Vigilance in acute care settings and across medical subspecialties is essential to ensure early recognition and control of TB particularly given the significant proportion of extrapulmonary presentations. Advances in diagnostic tools have significantly improved detection, with rapid PCR now becoming the standard for timely case identification. Whole genome sequencing (WGS) is now routinely in place to identify drug resistance, track transmission and guide public health responses. In parallel, treatment strategies are evolving, with shorter and more effective regimens available for latent TB, active disease, and multidrug-resistant TB. This review provides an overview of the epidemiology, clinical presentation, diagnosis, and management of TB, with a focus on recent advances relevant to clinical practice in the UK.
BACKGROUND:Accumulating evidence demonstrates associations between clonal hematopoiesis of indeterminate potential (CHIP) and increased risks of haematological and non-haematological health outcomes. Although adverse health consequences of CHIP have become well-documented, large knowledge gaps exist regarding the aetiology of CHIP. OBJECTIVE:To investigate risk factors for CHIP using large-scale phenotypic data and Mendelian randomisation analysis. METHODS:We utilised rich phenotypic and genomic data from the UK Biobank (UKB) to perform a cross-sectional study to systematically investigate risk factors of CHIP, including around 460,000 participants recruited from 2006 to 2010. We used Logistic regression to estimate odds ratios (ORs) of CHIP in relation to risk factors (sociodemographic factors, lifestyle factors, history of diseases, blood cell count, blood biochemistry parameters, proteomics biomarkers and metabolomics biomarkers). In addition, we conducted Mendelian Randomisation (MR) analyses to assess causality between the studied risk factors and CHIP, using publicly available summary statistics of genome-wide association studies (GWAS). RESULTS:We found that advanced age, smoking, history of several diseases (including breast cancer and leiomyoma of uterus), as well as several serum biomarkers (monocyte count, proteins LY75, SIGLEC6, SIRPB1 and CYB5R2) were associated with CHIP. CONCLUSION:Our findings expanded existing knowledge base by demonstrating novel risk factors of CHIP, especially history of several diseases and serum biomarkers. These findings advance understanding of the aetiology of CHIP.
BACKGROUND:We investigated the association between food-derived dietary magnesium intake and all-cause mortality among adults with chronic kidney disease. METHODS:We analysed data from adults aged ≥20 years with CKD who participated in the National Health and Nutrition Examination Survey between 1999 and 2018. Mortality status was ascertained through linkage to the National Death Index through 31 December 2019. Multivariable Cox proportional hazards models were used to evaluate the association between dietary magnesium intake and all-cause mortality. Restricted cubic spline analysis, Kaplan-Meier survival analysis, subgroup analyses, and sensitivity analyses were also performed. RESULTS:A total of 8,104 CKD patients were included in this cohort study with a median follow-up of 85 months, during which 3,134 (38.7%) died from all causes. In the fully adjusted Cox model, each 100 mg/day increase in dietary magnesium intake was associated with a 7.5% lower risk of all-cause mortality (HR = 0.925, 95% CI 0.881-0.971; P = 0.002). Compared with the lowest quartile, adjusted hazard ratios were 0.978 (95% CI 0.883-1.083) for Q2, 0.904 (95% CI 0.804-1.016) for Q3, and 0.866 (95% CI 0.744-1.007) for Q4, with a significant trend across quartiles (P for trend = 0.036). RCS analysis demonstrated a significant overall association with no evidence of nonlinearity (P for overall association = 0.009; P for nonlinearity = 0.472). Kaplan-Meier analysis showed higher survival probabilities among participants with higher dietary magnesium intake. CONCLUSIONS:Higher dietary magnesium intake was independently associated with a lower risk of all-cause mortality among adults with CKD. These findings suggest that adequate dietary magnesium intake may represent an important nutritional factor associated with prognosis in CKD. Further prospective studies and randomised clinical trials are warranted to determine whether increasing dietary magnesium intake can improve clinical outcomes. SUMMARY STATEMENT:Higher dietary magnesium intake was independently associated with lower all-cause mortality among patients with chronic kidney disease in NHANES 1999-2018. These findings highlight the potential protective role of adequate magnesium intake in improving long-term survival in this population.
Clinical research underpins almost everything we do in the NHS, from diagnostics and therapeutics to service design and workforce development, while also driving economic growth through the life sciences sector. Yet the UK clinical research workforce is in decline, at a time of rising patient need. Financial pressures on universities, increasing clinical demand, fragile funding routes and inflexible training pathways, are making academic careers harder to enter and sustain. Valuable research delivered by resident doctors, consultants, SAS and locally employed doctors is also unrecognised and unsupported. Research should not be seen as an optional extra. It is mandated in policy, embedded in professional standards, and essential to improving outcomes. A whole workforce approach is needed. At the Royal College of Physicians, we are supporting doctors making the case for research in job planning and training, strengthening recognition and funding opportunities for early clinical research, and addressing structural barriers to academic careers through national policy engagement.
Point-of-care ultrasound (POCUS) has emerged as an essential bedside tool for the rapid assessment and management of critically ill patients. This review outlines the evolution of POCUS from a focused, rule-in/rule-out modality to an advanced, integrative diagnostic approach capable of supporting complex haemodynamic evaluation. Technological advances, including handheld devices and artificial intelligence, have enhanced accessibility, diagnostic accuracy, and training efficiency. In the intensive care setting, echocardiographic interpretation must be contextualised within dynamic physiological variables such as preload, ventilation, vasoactive support, and metabolic status. POCUS plays a pivotal role in differentiating shock phenotypes-cardiogenic, distributive, hypovolaemic and obstructive-by integrating structural and functional cardiac assessment with lung and systemic venous ultrasound findings. Key haemodynamic parameters, including left ventricular outflow tract velocity time integral (LVOT VTI) and Doppler-derived indices, enable evaluation of cardiac output and fluid responsiveness, while dynamic tests such as passive leg raising further refine management decisions. The review also highlights the role of POCUS in assessing hypoxaemia through combined cardiopulmonary evaluation and introduces the 'POCUS pyramid' framework, integrating cardiac, pulmonary, and venous domains into a unified physiological model. Ultimately, when performed by appropriately trained clinicians, POCUS and critical care echocardiography enhance diagnostic precision, guide therapy, and improve bedside decision-making while recognising inherent limitations and the need for structured training and governance.
HIV has become a manageable chronic condition, one of the major successes of modern medicine. People living with HIV can now expect near-normal life expectancy with effective treatment, yet important challenges remain. Comorbidities, prevention of new infections, and the persistence of stigma continue to affect outcomes. Addressing these issues requires coordinated care, with general practice, hospital services, and specialist HIV teams working closely together. This article aims to support healthcare professionals by summarising current best practice in treatment, outlining advances in prevention and early diagnosis, and exploring how stigma can be reduced both within healthcare and in the wider community. These efforts are essential if the UK is to meet its goal of ending new HIV transmissions by 2030.
Background Asthma is a heterogeneous chronic respiratory disease with persistent morbidity and mortality despite effective therapies. The UK continues to report high asthma-related deaths, underscoring the need for improved care. Objective To review recent advances in asthma management, identify ongoing challenges, and outline future directions for clinical practice. Methods This narrative review integrates recent guideline updates (BTS/SIGN 2024, GINA 2024), audit data (NACAP), and emerging evidence on diagnostics, phenotype-driven therapy, and novel treatments. Findings Innovations include biomarker-guided phenotyping, anti-inflammatory reliever (AIR) therapy, biologics targeting Type 2 inflammation, and structured frameworks like A2BCD. Foundational care—such as adherence, inhaler technique, and self-management—remains essential. Systemic improvements, including virtual wards and the BTS Asthma4 bundle, enhance continuity of care. The NHS Green Agenda supports sustainable asthma practices. Conclusions Asthma care is evolving toward personalised, integrated, and environmentally conscious approaches. Clinicians should combine precision therapies with system-level strategies to optimise outcomes.
Blood pressure (BP) varies continuously dependent on numerous personal and external factors as well as on the way it is measured and the methodology used. A casual BP reading may give some clues about a person’s cardiovascular health, but risk can only be determined with repeated careful measurements. If high (≥140/90), systematic measurement following approved guidelines using a validated monitor is necessary, especially if the person is symptomatic and/or BP ≥180/120. A low casual BP (<90/60) should be similarly rechecked, especially if related symptoms are present. Despite the availability of guidelines for measuring BP, there is often poor compliance with these standards leading to less-than-ideal risk assessment. The lack of regulation of what BP home monitors are available to purchase, ignorance about how to measure BP accurately, the use of unvalidated monitors and of incorrect cuff sizes may lead to significant under- or over-assessment of BP with potentially avoidable consequences. Casual BP measurements, especially if elevated, need a systematic non-casual approach to remeasurement and interpretation.
BACKGROUND:Lipoprotein(a) [Lp(a)] has emerged as an important cardiovascular risk factor. However, the prevalence and determinants of elevated Lp(a) in people living with HIV (PLHIV) remain insufficiently characterised. Since PLHIV have an increased cardiovascular risk even under effective virological control, our aim was to explore the prevalence of elevated Lp(a) and its association with cardiovascular risk in this population. METHODS:We conducted a single-centre observational study in adult PLHIV with sustained virological suppression and without active oncological or infectious comorbidities. According to most international consensus statements, elevated Lp(a) was defined as levels >50 mg/dL. RESULTS:A total of 186 PLHIV were included. Of these, 21% had Lp(a) levels >50 mg/dL. Individuals with elevated Lp(a) had significantly higher total cholesterol, Low-density lipoprotein cholesterol (LDL-C) and apolipoprotein B levels, as well as a higher odds of a cardiovascular event [odds ratio (OR) 5.3, p = 0.018]. Although the proportion of patients receiving lipid-lowering therapy was significantly higher among those with elevated Lp(a), the percentage achieving LDL-C targets according to cardiovascular risk was significantly lower compared with patients with Lp(a) <50 mg/dL. No association was observed between elevated Lp(a) and antiretroviral therapy regimens, CD4 count, CD4/CD8 ratio or duration of HIV infection. CONCLUSIONS:In our study, elevated Lp(a) was present among 21% of virologically suppressed PLHIV and was associated with an adverse lipid profile and cardiovascular events, whereas no association was observed with HIV-related factors. Lp(a) may represent a marker of residual cardiovascular risk in this population and could help refine cardiovascular risk stratification beyond traditional lipid parameters.
We present what appears to be the first documented case worldwide of bilateral avascular necrosis (AVN) of the femoral heads in a young adult with the rare co-occurrence of congenital factor V (FV) deficiency and heterozygous FV Leiden mutation.
Background: National smoking prevalence is declining and new legislation, such as the Tobacco and Vapes Act, will reduce the number of people who take up smoking. However, there are profound disparities in the prevalence of people who currently smoke in the population, and further measures are required to prevent and treat tobacco-related inequality. Methods: The recently published RCP report 'Smoking, health and social justice outlines the drivers of smoking inequality, significant gaps in national data collection, the economic impact of smoking and measures to mitigate this wholly preventable cause of disadvantage. Conclusion: By introducing opt-out treatment of tobacco dependency across the NHS, raising the price of tobacco and applying cross-governmental actions to health-harming industries, the persistent gap in smoking-related inequality can be reduced.
STUDY OBJECTIVE:To evaluate the impact of a diabetes specialist nurse (DSN)-led perioperative optimisation service on glycaemic control in adults undergoing elective surgery. DESIGN:Retrospective service evaluation. SETTING:Manchester Royal Infirmary (Manchester University NHS Foundation Trust), a large UK teaching hospital and regional specialist centre. PARTICIPANTS:398 adults with diabetes (mean age 62.2 years; 76.3% type 2 diabetes) referred to the preoperative pathway between 2020 and 2024. INTERVENTIONS:A structured pathway involving DSN-led outpatient consultations, blood result monitoring, and targeted education to support self-management and guideline adherence. MAIN OUTCOME MEASURE(S):Change in HbA1c from referral to the perioperative period (within 12 weeks of surgery) and predictors of glycaemic improvement. RESULTS:Participants had a median baseline HbA1c of 75 mmol/mol. Over a median 16-week interval with two DSN contacts, HbA1c decreased by a median of 18 mmol/mol. Multivariable analysis identified higher baseline HbA1c (p < 0.001) and frequency of DSN contacts (p < 0.001) as independent predictors of improvement. Notably, medication intensification and diabetes technology use were not significantly associated with HbA1c reduction. CONCLUSIONS:A structured DSN-led pathway achieves clinically meaningful HbA1c reductions in high-risk surgical patients. These gains were associated with specialist engagement rather than complex medication adjustments, suggesting that focused education is a safe, effective strategy for perioperative optimisation that minimises pharmacological burden in the secondary care setting.
STUDY OBJECTIVE:To evaluate the prognostic value of the C-reactive protein/albumin (CAR) for mortality in older adults with sepsis. DESIGN AND SETTING:Prospective observational cohort study conducted at General Hospital Zone No. 21, León, Guanajuato, Mexico (Nov 2023-Aug 2025). PARTICIPANTS:Consecutive patients aged >60 years with Sepsis-3-defined sepsis or septic shock, excluding those with prior ICU care, transfers, malignancies, cirrhosis, autoimmune disease, or non-septic shock. INTERVENTIONS:None. The CAR and Sequential Organ Failure Assessment (SOFA) scores were measured at diagnosis and 72 h. MAIN OUTCOME MEASURES:28-day all-cause mortality, with predictive performance assessed via area under the ROC curve (AUC). RESULTS:CAR was higher in septic shock versus sepsis. In patients with sepsis, both initial (AUC = 0.867) and 72-h (AUC = 0.852) ratios predicted mortality better than SOFA (AUC = 0.786). In septic shock, SOFA was superior (AUC = 0.785 vs. 0.637). An initial ratio in the highest tertile independently predicted mortality (HR 2.88, 95% CI 1.15-5.19, p < 0.001). CONCLUSIONS:The CAR is a strong, independent mortality predictor in older adults with sepsis, outperforming SOFA in sepsis but not in septic shock. This simple biomarker can aid early identification of high-risk patients to guide timely intervention.
