Dudley Group NHS Foundation Trust

In 2023, the Intensive Care Unit at the Dudley Group NHS Foundation Trust became the first in the UK to achieve Gold Standards Framework (GSF) accreditation. This study evaluates the impact of GSF implementation on end-of-life care delivery and associated metrics. Coding of end-of-life care increased from 10.7% to 16.1% and the proportion of deaths recognised as GSF Amber/Red rose from 14.5% to 58.1% with an increased number of referrals to Specialist Palliative Care. GSF accreditation was associated with sustained improvements in key end-of-life care metrics in intensive care, enhancing collaboration with Specialist Palliative Care and supporting more individualised, patient-centred care.

Hallux valgus (HV) is a common deformity of the foot, for which various forms of surgical treatment are available. A recent think tank highlighted a lack of understanding about which key outcomes matter most to patients who undergo surgery for HV. The aim of this systematic review was to synthesize the existing evidence to establish whether commonly used outcome measures in foot and ankle surgery adequately reflect what is important to patients. We conducted a systematic review of qualitative studies in which methods such as patients' interviews, questionnaires, or focus groups were used to understand which outcomes are important to adults undergoing surgery for HV. The following databases were searched: CINAHL (Cumulative Index to Nursing and Allied Health Literature), PubMed, MEDLINE, Embase, Emcare, and Cochrane Library, in addition to the reference lists of the studies which were included. The review was prospectively registered with the PROSPERO database and conducted following PRISMA guidelines. Ten studies were included. The four most common themes which were identified as being important to patients were improvements in pain over the hallux, footwear restrictions, restrictions in daily activities and the function of the foot, and cosmesis. The Manchester-Oxford Foot Questionnaire was found to be the only outcome measure which specifically addresses these themes, while also including questions about the psychosocial impact. Cosmesis is under-represented in the outcome measures. Further research is needed to explore the psychosocial factors which are important to patients so that they can be included within the measures which are used to assess outcome after the surgical treatment for HV.

Background: Semaglutide is a Glucagon-like peptide-1 receptor agonist (GLP-1RA) used in the treatment of type 2 diabetes mellitus (T2DM) and weight management. While its clinical benefits are well established, concerns have emerged over off-label use, underreporting of adverse drug reactions (ADRs), and prescribing disparities. Aims: To examine real-world prescribing pattern treatment efficacy and ADRs associated with semaglutide in a socioeconomically deprived United Kingdom (UK) locality, and to compare these with national data. Methods: A retrospective service evaluation was conducted using anonymised data from 1403 patients across 42 GP practices under a data share agreement across a place-based group of practices in the West Midlands. National prescribing data were obtained from OpenPrescribing, and ADR data from the Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card Scheme (01/2020-12/2024). Analyses included demographic trends, treatment efficacy (HbA1c and weight), and socioeconomic comparisons using the Socioeconomic Index for Small Areas (SEISA) deciles. Findings: Semaglutide prescribing in the GP surgeries studied peaked in 2022 and declined thereafter, mirroring national trends. Prescribing of semaglutide mirrored the ethnic make-up of the region studied with a notable exception of White British. Mean HbA1c fell by 10.8 mmol/mol and weight by 4.8%. ADR incidence in the population studied (1.85%) exceeded national reporting rates (0.20%). Prescribing was highest in practices serving the most deprived communities. Conclusions: Semaglutide is effective in reducing HbA1c and weight in real-world settings. However, ADRs remain underreported. Socioeconomic deprivation was strongly associated with higher prescribing rates. Greater attention to equitable access and pharmacovigilance is warranted.

BackgroundAcute pain accounts for 60–90% of presentations to the emergency department (ED), with 20–40% of patients reporting severe pain. Current management practices, including simple analgesics, opiates and anti-inflammatory drugs, are often inadequate or slow to reach peak effect, necessitating the exploration of alternative analgesics. Ketamine, acting primarily through N-methyl-D-aspartate (NMDA) receptor antagonism, presents a promising alternative due to its rapid onset. However, its nebulised form remains underutilised in clinical practice.Aims and objectivesThis review evaluates the efficacy of nebulised ketamine in reducing pain in adult ED patients, alongside its side effect profile, optimal dosing, and potential as an alternative or adjunctive analgesic compared to other treatments.Methods and designA systematic review utilising the PRISMA guidelines was conducted. Searches were carried out in Medline, Embase, PubMed, Science Direct, google scholar and Ovid databases from 2010 to May 2024, including studies containing objective analysis of pain control with nebulised ketamine. A two-sample t-test was used to assess statistical significance. Quality assessment was performed using the CASP tool, and bias was evaluated using the ROBINS-I and ROB2 tool.ResultsOf 99 articles, 9 (5 randomised controlled trials, 3 case series and 1 case report) totalling 453 patients were included. All studies suggested improvement in pain scores with nebulised ketamine, with an average reduction of 42.5% and 70.4% over a 15 and 120-minute period respectively (p < 0.0001). Higher doses (1 mg/kg, 1.5 mg/kg) did not significantly improve pain compared to lower doses (0.7 mg/kg 0.75 mg/kg), with similar overall reductions reported across all four dosing regimens (p < 0.0003 or 0.0001). Nebulised ketamine was non-inferior to intravenous (IV) morphine, IV ketamine, nebulised dexmedetomidine, and Entonox, and had fewer side effects.ConclusionNebulised ketamine offers a viable alternative for pain management in emergency settings, providing effective analgesia with a favourable safety profile. Further multicentre trials with larger populations are recommended to confirm these findings and establish standardised dosing protocols for consideration in national guidance.

Background and objective: Malaria remains a major health issue in Sudan, and physicians' non-adherence to treatment protocols has negatively impacted patient outcomes. The 2023 Sudan Malaria Case Management Protocol advocated new developments per the national and globally WHO-recommended levels, but there are still gaps in clinical practices. To improve physician compliance and standardize malaria care, decision-support tools can be based on artificial intelligence (AI). This study aims to examine the effect of the introduction of an AI-based clinical decision-support system (CDSS) on the adherence of physicians to the 2023 Sudan Malaria Case Management Protocol at Al-Managil Teaching Hospital (Managil, GZ, SDN).Methods: A two-cycle clinical audit was conducted between July and September 2025 (baseline audit followed by AI intervention and then re-audit after AI intervention). The current practice and pre-intervention knowledge (n=50 physicians) were evaluated through questionnaires. An AI-CDSS was implemented together with training, incorporating diagnostics, treatment recommendations, and special group advice (pregnancy, neonatal, and G6PD). Compliance rates before and after the intervention were compared, with statistical testing including effect sizes and 95% confidence intervals.Results: Recognition of the 2023 protocol increased from 38% to 100% (risk difference +62%, 95% CI: 48-76; p<0.001), and awareness of intravenous (IV)/intramuscular (IM) artesunate as first-line treatment rose from 53% to 98% (risk difference +45%, 95% CI: 32-58; p<0.001). Attitudes towards severe malaria improved from 15% to 91% (risk difference +76%, 95% CI: 61-91; p<0.001). The timely initiation of treatment within 24 to 48 hours improved to 100% (p < 0.001). Mean compliance increased from 50.7% (95% CI: 42-59) to 96.8% (95% CI: 92-100, p<0.001). Residual deficiencies persisted in microscopy reporting and G6PD testing.Conclusion: A combination of an AI-driven CDSS and focused training demonstrated a substantial improvement in physician compliance with the 2023 Sudan Malaria Case Management Protocol, particularly in critical care aspects. However, a possible Hawthorne effect and the absence of clinical outcome data (e.g., morbidity, mortality) should be acknowledged as limitations. Greater scale-up of this approach, while addressing infrastructural and digital literacy challenges, could have a major impact on malaria case management and disease burden in Sudan.

<title>Abstract</title> Background: Percutaneous Endoscopy Gastrostomy (PEG) insertion is a long-established intervention in neurodegenerative diseases and aerodigestive malignancies where enteral feeding is required. Transnasal PEG (T-PEG) has been advocated as a safer alternative compared with conventional transoral PEGs for selected patients, although large case series are lacking in the literature. ^{<bold>(1, 2)</bold>} This case series illustrates technique and outcomes for two types of T-PEG procedures; firstly, the using a modified ‘pull-through’ technique and secondly using a gastropexy-assisted ‘push’ technique Methods: Our practice is to use pull-through T-PEGs predominantly for high-risk patients with neurodegenerative disease, and push T-PEGs for patients with aerodigestive malignancies. Patient selection is carried out by a clinical nutrition multidisciplinary team (MDT). The techniques used for both pull-through T-PEG techniques are described. A prospective database of T-PEG cases was analyzed to evaluate outcomes. Results: A total of 55 T-PEG procedures were completed between 2018 and 2024. There were 27 cases of primary neurodegenerative diseases and 21 cases of aerodigestive cancer (remaining 7 cases, miscellaneous). All but one T-PEG was successful at first attempt and with no serious procedural complications. There was one readmission with self-limiting insertion site pain, and 30-day mortality was 1/55 (a cancer case). Conclusions: In our case series of T-PEGs, we have demonstrated a high procedural success rate and low complication and mortality rates. T-PEG can be considered a viable alternative for patients who are not suitable candidates for traditional PEG and a valid alternative to other options such as radiological or surgical gastrostomy.

SummaryBackgroundMasculinizing genital gender-affirming surgery (gGAS) for transgender and gender diverse people encompasses a complex, heterogenous, and modular set of procedures. To enable evidence-based decision-making or meta-analysis, a uniformity of outcome research is needed. Currently, this is hindered by non-standardized outcome reporting. This study aims to develop a core outcome set (COS) for research on masculinizing gGAS to address this issue.MethodsAn international, multidisciplinary study steering group was established, consisting of 16 professional experts (PE) and lived experience experts (LEE), to advise on and support the development of this COS. The steering group convened online on 16 June 2022, 28 September 2023, 2 May 2024, and 29 August 2024. Potential outcomes were identified through interviews and focus groups with LEE and a systematic literature review convened up to September 2023. LEE and PE were recruited globally via websites, social platforms, scientific meetings, patient organizations, and posters and invited to participate in three e-Delphi survey rounds. In the first round, participants rated each outcome's importance on a 5-point Likert scale and provided reasoning for their rating. In subsequent rounds, participants re-rated the outcomes using illustrative quotes and rankings based on prior ratings to refine consensus. Pre-defined criteria guided outcome inclusion and exclusion. A final online consensus meeting with LEE and PE finalized the COS.FindingsInitial outcome gathering identified 384 unique outcomes, of which 38 outcomes were selected for the e-Delphi survey rounds. Thirty-two LEE and 52 PE participants, most from Europe, the UK, and the USA, completed all three survey rounds (February, May, and July 2024). Final consensus was reached in September 2024 on including one clinical outcome, three adverse events, and six patient-reported outcomes in the COS for masculinizing gGAS. The core outcomes are sensibility in the neo-phallus, additional surgery, ability to achieve orgasm, sexual well-being, and satisfaction with neo-genital aesthetics. For urethral lengthening, additional core outcomes include neo-urethral fistula, stricture, and the ability to void while standing. For phalloplasty, additional outcomes are flap necrosis and donor site morbidity.InterpretationDeveloping a COS for masculinizing gGAS is a crucial step towards standardized outcome measurement and reporting in clinical research. Implementation could facilitate data comparison, meta-analysis and evidence-based guideline development, ultimately improving personalized surgical care.FundingNone received.

Abstract Aim To compare outcomes of routine abdominal drainage versus no drainage after distal pancreatectomy (DP). Method A systematic review was performed per PRISMA protocol using MEDLINE, CENTRAL and Web of Science databases from inception to April 2024. All comparative studies of routine abdominal drainage versus no drainage in DP were included. Perioperative complications, clinically-relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying (DGE), postoperative haemorrhage, surgical site infections (SSIs), need for radiological intervention were primary outcomes. Risk of Bias was assessed using ROBINS-I. Results 8 comparative studies of 8164 patients who underwent DP with (n = 6394) or without (n = 1770) routine abdominal drainage were included. Routine drainage was associated with significantly higher rates of CR-POPF (OR 2.87; 95 % CI 2.34–3.52, p &amp;lt; 0.00001), radiological intervention (OR 1.33; 95 % CI 1.10–1.61, p = 0.0003), SSIs (OR 2.47; 95 % CI 1.29–4.72, p = 0.006) or re-admission (OR 1.54; 95 % CI 1.30–1.82, P &amp;lt; 0.00001) compared to no drainage. There was no significant difference in C-D III or higher postoperative morbidities (OR 1.25; 95 % CI 0.98–1.60, p = 0.08), DGE (OR 1.17; 95 % CI 0.81–1.67, p = 0.41), reoperation (OR 1.11; 95 % CI 0.80–1.54, P = 0.53), postoperative haemorrhage (OR 0.59; 95 % CI 0.18–2.00, P = 0.40), or mortality (RD 0.0; 95 % CI -0.01-0.01, p = 0.76) between two groups. Conclusions Our meta-analysis of high-level evidence demonstrates safety of “no drain policy” in distal pancreatectomy considering its lower risk of CR-POPF, re-intervention and hospital re-admission.