Hywel Dda University Health Board

A male patient in his mid-sixties with chronic lymphocytic leukaemia (CLL), Binet stage B, receiving the Bruton’s tyrosine kinase (BtK) inhibitor acalabrutinib, presented with fever and other non-specific systemic symptoms. Following the investigation, they were found to have Cryptococcal meningitis. Cryptococcal infections are known to occur in immunocompromised patients, but they are rarely encountered or thought about during the initial acute medical assessment. This case highlights the importance of considering the possibility of opportunistic infections and the atypical presentation of such infections in immunocompromised patients, including those on BtK inhibitors.

Abstract Background Ethnic inequalities exist in the management and outcomes of patients with acute coronary syndrome (ACS) and cancer. These patients are under-represented in clinical trials and, therefore, studied using large national registries and electronic health records (EHR). However, the quality and consistency of ethnicity reporting across these datasets remain unclear. Aim The present study examined the agreement of ethnicity coding and subsequent outcomes for all cancer patients with ACS across four national datasets, namely the National Cancer Registration and Analysis Service (NCRAS), the Myocardial Ischaemia National Audit Project (MINAP), the National Audit of Percutaneous Coronary Intervention (NAPCI), and Hospital Episode Statistics (HES; hospitalisation data). Methods All cancer patients (n=60,793) with an ACS diagnosis between 2010 and 2018 were retrospectively analysed. Three linkages were performed: NCRAS-MINAP, NCRAS-MINAP-NAPCI, and NCRAS-MINAP-HES. Based on agreement in ethnicity coding, three possible categories were created for each linkage: Concordant (same across all datasets), Discordant (different in ≥1 dataset), and Missing (in any dataset). Multivariable logistic regression models were used to examine adjusted odds of 1-year cardiac and cancer-related death for each agreement group. Results Among the NCRAS-MINAP, NCRAS-MINAP-HES, and NCRAS-MINAP-NAPCI linked cohort, more than half of patients’ ethnicities were concordant across datasets (53.8%, 53.6%, and 52.4%, respectively). The highest discordance rate was observed in NCRAS-MINAP-HES (40.8%), while the highest missingness rate was in NCRAS-MINAP (45%).(Figure 1). There was moderate agreement at most between datasets for ethnicity coding, the highest being NCRAS-HES (r=0.714), and the lowest was NCRAS-NAPCI (r=0.318).(Figure 2) The odds of 1-year cardiac death were significantly increased in the Missing group, compared with the Concordant group, across all three linkages (NCRAS-MINAP: odds ratio (OR) 1.09, 95%CI 1.02-1.15; NCRAS-MINAP-NAPCI: OR 1.69, 1.12-2.54; NCRAS-MINAP-HES: OR 1.44, 1.14-1.82). Odds of 1-year cancer death were increased in the Missing (OR 1.29, 1.23-1.36) and Discordant (OR 1.14, 1.02-1.27) groups in NCRAS-MINAP and NCRAS-MINAP-NAPCI linked datasets, respectively. Conclusion The are significant variations in agreement and completeness of ethnicity coding across four linked national datasets for cancer patients with ACS. Nearly half of the cancer patients with ACS had discordant or missing ethnicity data, even when linked to hospitalisation and PCI datasets. Our findings, while observational, demonstrate worse cardiac and cancer-related mortality among patients with missing or discordant ethnicity, which could be a sign of underlying disparities in their care. Inconsistency in ethnicity coding represents a missed opportunity to study patterns and contributors to health inequalities in this high-risk population with cancer and ACS.Agreement in linked datasets Correlation of ethnicity across datasets

<h3>Background</h3> Clinical outcomes for NTM-PD are often poor. The NTM Network UK Standards of Care were launched in 2024 to support consistent, high-quality practice including pharmacological and non-pharmacological treatment. We aimed to document NTM-PD management prior to this to identify opportunities to improve care. <h3>Methods</h3> Centres were invited via the NTM Network UK to complete an online retrospective survey. At each site, anonymised clinical data were recorded from three consecutive adults (≥18) newly diagnosed with NTM-PD from 1 January 2022. <h3>Results</h3> 48 centres participated (Northern England, n=12; Southern England, n=12; London, n=9; Wales, n=7; Midlands, n=6; Scotland, n=2) They reported having the following resources: physiotherapy for airway clearance (n=42/48, 88%), dietitian and pulmonary rehabilitation (each n=32, 67%), specialist nurse (n=30, 63%), and health psychology (n=9, 19%). Respondents contributed data on 137 patients. 72 (53%) were female and 115 (84%) identified as White-British. 45 (34%) were aged 61–70. 62 (45%) had COPD and 55 (40%) bronchiectasis. Common radiological findings were nodular-bronchiectatic change (n=62, 45%), fibro-cavitary disease (n=40, 29%), and emphysema (n=39, 28%). <i>Mycobacterium avium complex</i> (MAC) was identified in 106 (77%), <i>M. kansasii</i>(n=14, 10%) and <i>M. abscessus</i> (n=9, 7%). Eighty-one (59%) patients were discussed in an MDT. Treatment plans included involvement of specialist nurses (n=91, 66%), physiotherapists (n=52, 38%), dietitians (n=34, 25%), and pulmonary rehabilitation (n=16, 12%). Forty-two (31%) were advised on airway clearance using Active Cycle Breathing, 25 (18%) Positive Expiratory Pressure devices, 17 (12%) mucoactive drugs, and 12 (9%) hypertonic saline. Written resources were provided to 39 (28%) patients, 22 (16%) were directed to patient-focused websites, and 13 (10%) signposted to peer-support networks. During a median follow-up from diagnosis of 21 (IQR 14–29) months, 124 (91%) started antibiotics for NTM-PD. Forty-five (33%) remain on follow-up and using antibiotics, 53 (39%) are not on antibiotics, 26 (19%) were discharged, and 12 (9%) died. <h3>Conclusion</h3> This UK-wide assessment of NTM-PD management reveals significant variation in available services and care provided. Most patients started specific antimicrobials, though non-medical health care support and patient information provision were limited. We have identified important areas for re-audit against the 2024 Standards.

Near-infrared fluorescence (NIRF) imaging has emerged as a transformative intraoperative tool in general surgery, helping in vascular surgery interventions, tumor margin detection in different specialties, and biliary anatomy with high sensitivity and safety. Indocyanine green remains the gold-standard fluorescent agent, widely applied in angiography, tumor margin detection, and fluorescence cholangiography, consistently improving surgical safety and efficiency with exceedingly low complication rates. Recent advances and trends include activatable and targeted probes, near-infrared II fluorophores, and nanoparticle-based agents, which expand specificity, depth of imaging, and multiplexing capacity. Integration with robotic systems in general surgery practice and artificial intelligence may further strengthen the precision of fluorescence-guided surgery, providing automated interpretation and workflow integration. Clinical outcomes demonstrate reduced operative times, improved anatomical visualization during operations, and enhanced tumor resection accuracy, while emerging technologies promise broader applications in complex oncologic and hepatopancreatobiliary surgery. Taken together, NIRF imaging represents a rapidly evolving field with the potential to redefine intraoperative guidance and precision in general surgery.

Cervical screening for high-risk Human Papillomavirus subtypes is offered to those eligible in the UK via the NHS cervical screening programmes. However, uptake of cervical screening continues to remain below the national target of 80%. Groups less likely to participate include people from low socioeconomic groups, ethnic minority backgrounds, younger/older age and/or LGBTQ group identity. The cervical screening-eligible population could soon, for the first time in the UK, have a choice of mode between clinician taken or self-sampling. To understand information and decision-support needs of diverse cervical screening-eligible individuals when presented with a choice of cervical screening mode and develop recommendations for a communication strategy to support informed decision-making. Qualitative co-production explored communication preferences and decision-support needs in a diverse sample of cervical screening-eligible individuals using semi-structured interviews with individuals eligible for cervical screening (n = 30) and stakeholders (n = 23). Interviews were transcribed, thematically analysed and mapped to behavioural and decision-making theories to inform a communication strategy for offering choice in cervical screening mode in the UK. Four main themes across both participant groups were identified: misunderstanding of clinician screening, attitudes towards choice, communication launch preferences and decision-support needs. Logic models to inform a communication strategy in preparation for the future launch of choice in cervical screening mode in the UK were developed. The communication launch strategy can inform interventions to support informed decision-making if HPV self-sampling is incorporated into UK cervical screening programmes. Two public partners were involved in the study from inception to completion. They advised on recruitment, participant facing documents and were involved in analysis.

Objective: Oral secretion problems are common yet poorly managed in people living with MND (plwMND). A validated patient-reported outcome for measuring saliva symptoms in this patient group would facilitate better monitoring of individuals. This study aimed to assess the validity, reliability and sensitivity to change of a revised version of the clinical saliva score for MND (CSS-MNDr). Methods: Data were collected as part of a longitudinal, observational saliva management study. The CSS-MNDr, ALS Functional Rating Scale, a Global Rating of Change questionnaire and saliva-specific modified Likert scale were completed at each study visit, each of which probed the severity of saliva symptoms. Construct validity, test-retest reliability and sensitivity of the CSS-MNDr were assessed and the minimal important difference of the instrument was estimated. Results: The CSS-MNDr showed excellent test-retest reliability (intraclass correlation coefficient >0.9). Construct validity showed the CSS-MNDr performed as expected, with bulbar-onset participants scoring significantly higher than those who reported limb-onset across all visits (group mean scores). Strong correlation of total scores with the ALSFRS-R saliva question was demonstrated (−0.8), with the thick subscore correlating less well (−0.5). A minimal important difference in the range of −2.5 to −3.6 over 3 months was estimated for worsening symptoms. Conclusions: The CSS-MNDr has been validated as a reliable patient reported outcome for measuring saliva problems in plwMND. With separate scores for thick and thin secretion problems, the CSS-MNDr is the most comprehensive tool for assessing salivary problems in plwMND reported to date.

Background: AI can provide objective, quantitative data from the operative room to stakeholders to not-only ensure they present accurate and granular data to attendees, but also so they can perform detailed root-cause analysis to identify often opaque or overlooked intraoperative factors that may have impacted the clinical outcomes. This enables the surgical team members to recognize surgical errors and events both during surgery and retrospectively is important in promoting future prevention of such surgical errors. AI-enhanced robotics only have the potential to enable automation in surgery at varying levels of autonomy. One limitation that hospitals and health care systems highlight concerns about medico-legal issues that may arise from capturing and evaluating granular data sources. Other limitation that AI endangers the surgical ethics and affects the patients’ privacy data so that the implications of fairness and taxonomy of algorithmic bias in AI system are important factors in the ethics of AI. The aim of the study is to explore and synthesize existing literature to elucidate the significance and impact of AI on surgical advancements, highlighting its value in improving surgical outcomes, techniques, and overall patient care. Conclusion: The Use of AI in surgery is time saving, decrease surgical malpractice, enhance surgical outcomes for patients with accurate medical documentations and surgical research. However, incorporation of AI into surgery presents unique and challenging problems that necessitate novel regulation

Abstract BackgroundDelay to cancer diagnosis is associated with poorer outcomes. In response to delays to cancer diagnosis in the UK, a number of Rapid Diagnosis Centres (RDCs), Multi-Disciplinary Centres (MDCs) and other pathway reforms have been piloted and implemented in recent years. Prostate cancer is the most commonly diagnosed cancer for men or those assigned male at birth in the UK. In Wales, the recommended time to diagnosis is within 62 days from point of suspicion. For patients served by Hywel Dda University Health Board, current waiting times on the prostate cancer diagnostic pathway are prolonged, falling well outside the 28-day decision to treat and 62-day referral to treatment targets. A revised prostate cancer diagnostic pathway called Prostad (Wesh for “prostate”) has been developed and is currently being implemented with the aim of reducing time to diagnosis (or discharge) for patients referred for investigation. This protocol describes Prostad and the planned evaluation approach.MethodsThis is a mixed-method evaluation. It is shaped by patient and public involvement throughout and incorporates realist interviews with multiple stakeholders (including NHS staff and patients), process mapping, economic evaluation, and monitoring of the intervention against its aims using routinely collected data.DiscussionTo the authors’ knowledge, this is the first project of its kind to combine service aims evaluation, cost-effectiveness analysis and realist evaluation approaches, and as such promises findings applicable to organisations and individuals with regard to various aims and priorities. Continued patient and public involvement throughout the study constitutes one of its strengths.