East Suffolk and North Essex NHS Foundation Trust

Key content Amniotic fluid volume (AFV) is a vital measurement in the determination of fetal well‐being by means of ultrasound. There are many factors that determine AFV and, in many cases, complications affecting the fetus may manifest through change in its value. Isolated abnormal amniotic fluid index antenatally is relatively common, but its management remains contentious. The prevalence in the United Kingdom for isolated oligohydramnios is up to 5% of pregnancies, and isolated polyhydramnios complicates up to 2% of pregnancies. This article reviews and discusses the maternal and fetal implications of isolated oligohydramnios and polyhydramnios in the antenatal period, intrapartum and neonatal period. Learning objectives Overview of oligohydramnios and polyhydramnios and their aetiologies. Review threshold for timing of delivery and management of isolated oligohydramnios and polyhydramnios. Review of fetal and neonatal complications of oligohydramnios and polyhydramnios and their management.

We welcome the correspondence from O'Sullivan and Shah [1], which comments on our study [2]. I agree broadly with their points and wish to emphasise that our results should not be interpreted as a minimum carbon footprint for total intravenous anaesthesia (TIVA). A common concern about TIVA is the high consumption of single-use plastic compared with volatile inhalational anaesthesia [3]. Anaesthetists might conclude that TIVA has a greater carbon footprint than sevoflurane anaesthesia and our model assumed ‘worst case’ use of consumables for each of our TIVA scenarios. We included all possible consumables that were used so that our calculations of the total carbon footprint of TIVA overestimated actual practices. By using this approach, and by publishing the carbon footprints of individual items used in our scenarios, clinicians can identify how the footprint of their practice might vary from the scenarios we modelled, as O'Sullivan and Shah have done. In our modelling, we assumed that all TIVA cases use processed electroencephalogram (pEEG), as many anaesthetists, particularly during training, choose to use this to minimise the risk of accidental awareness even in the absence of neuromuscular blockade [4]. As discussed in our study, if pEEG is not used for TIVA, the carbon footprint will reduce by 0.83 kgCO2e (excluding the energy required for the pEEG monitor), equating up to 28.1% of the total carbon footprint of TIVA. In this case, after 11 min, both TIVA scenarios have lower total carbon footprints than median consumption inhalational anaesthesia using sevoflurane. Conversely, if pEEG is also used for volatile anaesthesia to reduce recovery time and volatile anaesthetic agent consumption as highlighted by O'Sullivan and Shah [1] and to reduce accidental awareness [4], then the total carbon footprint of volatile sevoflurane anaesthesia will increase by at least 0.83 kgCO2e. Using our modelled scenarios, if pEEG is used for both TIVA and sevoflurane anaesthesia, then, after 20 min, the highest emitting TIVA scenario has a lower total carbon footprint than the most economical sevoflurane scenario. This 20-min threshold is drastically lower than the 44 min for our original high-emission TIVA scenario vs. minimal consumption sevoflurane without pEEG. It should be noted that data used for sevoflurane consumption were derived from a study that did not use pEEG to titrate sevoflurane but instead measured actual consumption using low fresh gas flow [5]. O'Sullivan and Shah highlight several TIVA practices that use resources more efficiently than our modelled scenarios and we encourage anaesthetists to consider how their practices can be leaner and greener while maintaining patient safety.

For the National Health Service (NHS) in England to reach the target of Net Zero by 2040, transformation of the attitudes and behaviours of healthcare staff across all levels to promote systematic change is required. An understanding of current attitudes and barriers to change is vital for healthcare leaders and sustainability professionals to identify how they can support and encourage staff to adopt these changes. We invited staff from an NHS trust in England to participate in an online survey conducted between December 2024 and March 2025, to investigate NHS healthcare professionals' attitudes towards environmental sustainability, current behaviours and perceived barriers to sustainable healthcare practices. We received 154 responses from healthcare staff across all pay bands and grades, representing an array of disciplines. 94.8% of staff were concerned about climate change and the environment; 95.5% and 93.5% believe that NHS staff have a responsibility to be aware of, and minimise the impact of their work respectively; and over 80% were willing to make changes to their personal practice or engage in education and training. The most predominant perceived barrier to sustainable healthcare practices was found to be cost (72.1% of responses), with both time and staff attitudes being reported as perceived barriers by 69.5% of respondents. Our results suggest that among the staff surveyed, while there is a high level of willingness to change practice, increased funding is needed to support these changes, especially where sustainability initiatives have longer term cost-savings. There is a desire for more education to encourage and empower staff, and to make changes to NHS practice and policy. There is also a need for more direct leadership to facilitate change and integrate sustainability into the everyday work of healthcare professionals, rather than placing it as an additional burden on already overstretched staff.

This study evaluates the effectiveness of a newly implemented protocol for the management of permanent childhood hearing impairment in a UK district general hospital. A retrospective closed-loop audit was conducted over two 24-month cycles. Children diagnosed with permanent childhood hearing impairment, through the national hearing screening program, were included. Implementation of the new protocol led to significant improvements between the two cycles. The mean time from diagnosis to first ENT review reduced from 439.4 to 188.1 days. The interval from diagnosis to magnetic resonance imaging acquisition improved from 617.8 to 58.5 days (p < 0.05), whilst the mean age at magnetic resonance imaging reduced from 758.3 to 102.6 days (p < 0.05). Magnetic resonance imaging utilisation increased from 60 per cent to 100 per cent, and genetic referrals rose from 28.6 per cent to 100 per cent. These findings highlight the effectiveness of a streamlined protocol in improving multidisciplinary care for children with permanent childhood hearing impairment, offering a model for broader adoption in similar healthcare settings.

IntroductionThis study evaluates the efficacy and safety of the MINIject (iStar Medical, Wavre, Belgium) supraciliary implant for the treatment of glaucoma.MethodsPatients with medically uncontrolled primary open angle glaucoma, primary angle closure glaucoma and normal tension glaucoma were included. This first in the UK, retrospective, single-centre, interventional study evaluated the implantation of the MINIject in 50 eyes, including 11 stand-alone cases and 39 cases combined with phacoemulsification. The primary outcome was mean reduction of intraocular pressure (IOP) at 6 months. We also report the proportion of eyes that achieved a final IOP ≤ 21 mmHg and > 5 mmHg with an IOP reduction of ≥ 20% with/without medication use.ResultsMean (± standard deviation) baseline IOP was 18.4 ± 4.7 mmHg on 2.1 ± 1.1 medications. There was a significant decrease in IOP at 6 months (−6.3; 95% confidence interval [CI] −2.9 to −9.7 mmHg, P < 0.001). There was no significant association between diagnosis, mode of delivery (stand-alone/combined with phacoemulsification) and the degree of IOP lowering. There was a significant decrease in IOP-lowering medications at 6 months (−2.1; 95% CI −1.6 to −2.6 mmHg, P < 0.001). A total of 88.9% of eyes achieved a final IOP ≤ 21 mmHg and > 5 mmHg, whilst 57.8% of eyes achieved this combined with 20% reduction in IOP. Adverse events occurred in 15.6% (n = 7) of eyes. No sight-threatening events occurred.ConclusionsThis study shows promising IOP-lowering results and medication reduction over 6 months with few adverse events.

Background In England, the Professional Nurse Advocate (PNA) and Professional Midwifery Advocate (PMA) role places nurses and midwives at the centre of workforce retention and transformation. The PNA/PMA role blends professional leadership and clinical supervision through the A-EQUIP model, which is grounded in directing change and steering service development. The overarching impetus for the PNA/PMA role is to improve care quality whilst developing and sustaining cultures of professional wellbeing and nurse/midwife retention. To date, however, little is known about what the impact the PNA/PMA role has on the day-to-day practice of nurses and midwives, nor if it improves quality in practice, professional wellbeing, and retention. This study examines the impact of the PNA/PMA role on nurse/midwife involvement in quality improvement, wellbeing, and retention within one public sector healthcare NHS Trust in England. Methods During 2022, fourteen semi-structured interviews were conducted with PNA’s and PMA’s who had completed their training and are included on the NHS Trust PNA/PMA register. The interviews were transcribed verbatim and analysed through qualitative descriptive analysis. Findings The analysis detected 5 themes and 10 subthemes: (1) Transforming in Tandem (a) Role of Advocacy, (b) Restorative Focus, (2) Creating Safe Spaces, (c) Emotional Support, (d) Interpersonal Relationships, (3) Challenging the Status Quo (e) Counteracting Blame Culture, (f ) Empowering Change (4) Empowerment and Development (g) Building Resilience, (5) Types of Advocacy (h) Educational and Emotional Advocacy (i) Coaching and Conversations. Conclusions The findings suggests that the most effective aspects of the PNA and PMA roles are those that directly empower individuals and create a supportive, reflective environment. However, while building resilience is vital, it is equally important to recognise its limits and ensure that healthcare professionals are not pushed to the point where their resilience becomes a barrier to their well-being and the overall improvement of their work environment.

ABSTRACTBackgroundFibrillary glomerulonephritis (FGN) is a rare glomerulopathy characterized by randomly arranged fibrils within the mesangium and glomerular basement membrane. It has poor renal outcomes and no specific treatment. This retrospective study aimed to identify clinical-pathological predictors of outcomes in a multi-institutional cohort with histopathology performed at a single centre in the UK.MethodsPatients with biopsy proven FGN between 2015 and 2024 were identified using the Cambridge University Hospitals (CUH) histopathology database. Clinical data, including demographics, comorbidities, laboratory parameters, treatments and outcomes, were compared with findings from four other studies. Histological characteristics and DNAJB9 staining, where available, were analysed.ResultsThirty-five patients with FGN (2.8:1 female-to-male ratio) with a mean age of 62.8 years were identified. Autoimmune diseases, diabetes mellitus (DM) and malignancy (solid organ and haematological) were present in 28.5%, 34.2% and 20%, respectively. Nephrotic-range proteinuria was present in 58.8% and renal dysfunction in 91.4% at presentation. The most common histological pattern was mesangial proliferative/sclerosing followed by diffuse proliferative (DPGN). DNAJB9 staining was positive in all 13 tested patients. At a median 39 months follow-up, 51% progressed to end-stage renal disease (ESRD). Female sex, proteinuria and DPGN were significant predictors of ESRD on multivariate analysis. Although rituximab was associated with non-progression of disease, immunosuppression showed no statistically significant impact on outcomes.ConclusionFGN is strongly associated with malignancy, autoimmune disease and DM. Prognosis remains poor, with progression to ESRD significantly influenced by proteinuria, DPGN and female sex.

High thyroid-stimulating hormone receptor antibodies (TSHRAbs) during pregnancy pose clinical challenges, especially for women with a history of thyroidectomy or radioactive iodine therapy. We report a pregnant woman in her 30s with a history of Graves' disease, managed by total thyroidectomy and thyroid replacement therapy 10 years before presentation. Despite lacking a thyroid gland, she had elevated levels of TSHRAb early in her pregnancy. The fetus experienced early-onset intrauterine growth restriction; at 31 weeks gestation, demonstrated signs of thyrotoxicosis, including persistent abnormal fetal umbilical artery Doppler, fetal tachycardia and goitre observed during growth ultrasound scans. Initially, the patient was managed with antithyroid medications but required delivery at 34 weeks gestation due to deteriorating fetal health. This case illustrates that some pregnant women with previously treated Graves' disease may have persistently high levels of TSHRAb, which could cross the placenta to the fetus and result in fetal thyrotoxicosis requiring preterm delivery.

SummaryThe diagnosis of mitochondrial DNA (mtDNA) diseases remains challenging with next-generation sequencing, where bioinformatic analysis is usually more focused on the nuclear genome. We developed a workflow for the evaluation of mtDNA diseases and applied it in a large European rare disease cohort (Solve-RD). A semi-automated bioinformatic pipeline with MToolBox was used to filter the unsolved Solve-RD cohort for rare mtDNA variants after validating this pipeline on exome datasets of 42 individuals previously diagnosed with mtDNA variants. Variants were filtered based on blood heteroplasmy levels (≥1%) and reported association with disease. Overall, 10,157 exome and genome datasets from 9,923 affected individuals from 9,483 families within Solve-RD met the quality inclusion criteria. 136 mtDNA variants in 135 undiagnosed individuals were prioritized using the filtering approach. A focused MitoPhen-based phenotype similarity scoring method was tested in a separate genetically diagnosed “phenotype test cohort” consisting of nuclear gene and mtDNA diseases using a receiving operator characteristic evaluation. We applied the MitoPhen-based phenotype similarity score of >0.3, which was highly sensitive for detecting mtDNA diseases in the phenotype test cohort, to the filtered cohort of 135 undiagnosed individuals. This aided the prioritization of 34 out of 37 (92%) individuals who received confirmed and likely causative mtDNA disease diagnoses. The phenotypic evaluation was limited by the quality of input data in some individuals. The overall pipeline led to an additional diagnostic yield of 0.4% in a cohort where mitochondrial disease was not initially suspected. This highlights the value of our mtDNA analysis pipeline in diverse datasets.