NHS Lothian

Neutrophils are short lived innate immune cells, critical for pathogen control. They are the most abundant type of leucocyte in the circulation and, in response to inflammatory stimuli, are rapidly recruited into the tissues with the circulating population being replenished from the bone marrow. Although traditionally considered simplistic antimicrobial cells with limited heterogeneity, recent studies have highlighted the diversity of neutrophil phenotypes and their potential as therapeutic targets. Neutrophils rewire their metabolism in response to nutrient availability and inflammatory cues in order to function in diverse, and often hostile, inflammatory environments. In this review we highlight how metabolism fuels neutrophil effector function in diverse tissues and how this can impact disease processes including infection, inflammation and malignancy but also presents novel therapeutic targets.

To explore missed opportunities for PrEP use among people with recently acquired HIV in the United Kingdom. Data were derived from CASCADE, an international, longitudinal, mixed-methods study of adults (≥16 years) with recently acquired HIV (≤12 months). Individuals were recruited from nine UK clinics (08/2022-09/2024) to self-complete a questionnaire; a subset participated in semi-structured interviews (SSIs). 46 questionnaires were completed (39 cisgender men and 7 women, including 2 transgender women) and 11 SSIs (1 cisgender woman). Among men, 22 perceived HIV risk before diagnosis; 21 had ≥5 sexual partners and 17 reported group sex in the 3 months before diagnosis. Thirty (29 men and 1 woman) reported sexualized drug use. Twenty men had ever used PrEP; seven of them had not used it in the 6 months prior to diagnosis. No women had ever used PrEP. Most gay, bisexual and other men who have sex with men (GBMSM) were aware of PrEP; however, risk perception, social meanings of PrEP and concerns about side effects hindered utilization. Among five men using event-based dosing (EBD), three described difficulty predicting sexual activity that led to missed or mistimed pre-/post-sex doses - while others were reluctant to take daily PrEP. For women, the biggest barrier was lack of awareness. PrEP barriers vary by population. For GBMSM, addressing barriers to uptake/adherence (e.g., EBD challenges) are key, highlighting the potential benefit of long-acting injectables. However, awareness of PrEP remains a key challenge for women to achieve equity in prevention.

BackgroundRecognising how human factors shape workplace behaviour and patient safety, as well as appreciating their medicolegal consequences, is essential for the modern medical graduate.This study examines medical students' and resident doctors' practices, attitudes, and experiences in relation to patient safety and human factors. MethodsA national cross-sectional survey of UK medical students and resident doctors was done between April and June 2025.Results were compared with a pilot group of students from underrepresented backgrounds who participated in a tailored human factors and medico-legal workshop. ResultsOf 1,274 survey respondents, 942 (74.0%) were medical students and 332 (26.0%) were resident doctors.Human factors frequently reported were time pressures (57.0%), fatigue (56.2%) and ineffective handover (43.8%).Preparedness to manage human factors (mean 3.2/5) and confidence to speak up (mean 3.2/5) were significantly lower among comprehensive/state-educated respondents (confidence-adjusted odds ratio 0.70, 95% confidence interval 0.57-0.87,vs grammar/private/international schools).Most respondents lacked clear institutional guidance on the legal implications of error (62.2%), and nearly half did not know where to seek support.Workshop participants (n=21) reported higher preparedness to recognise and manage human factors and confidence raising concerns (p<0.001). ConclusionsDespite frequently encountering patient safety related human factors, UK resident doctors and medical students are only moderately prepared and supported to address them.In a healthcare environment with increasing workloads, resource limitations, and errors, greater training and exposure to key concepts is required.Educational interventions could be drawn from other high-reliability organisations such as aviation to reduce the incidence of patient safety and medical errors.

Purpose This study aims to conduct an extended evaluation of the emotional resources group (ERG), a brief emotion regulation group intervention routinely delivered in a secondary care adult mental health setting in NHS Scotland. Design/methodology/approach The service evaluation used a within-subjects repeated measures design to assess change in emotional regulation, self-efficacy, well-being and functioning for those who attended the ERG. Findings Analysis of those who completed the programme found highly statistically significant improvements in measures of emotion regulation, self-efficacy, well-being and functioning. Large effect sizes were observed on all measures other than functioning, which was moderate to large. Analysis of a conservative intent to treat sample mirrored these findings with highly significant improvements on all measures. Moderate to large effect sizes were also observed on all measures other than functioning, which was moderate. In addition, good rates of reliable and clinically significant change were found for the primary measure of emotional regulation across both completers and the intent to treat sample. In addition, good rates of reliable and clinically significant change were found for the primary measure of emotional regulation across both completers and the intent to treat sample. Originality/value This evaluation builds on previous research by extending the evidence of ERG’s effectiveness in an extended real-world NHS clinical setting. It establishes the credibility and acceptability of the intervention in secondary care outpatient adult mental health service settings.

Abstract Background: Mammographic screening programmes reduce breast cancer mortality but detect many small good-prognosis tumours which may not progress. Screen-detected cancers are currently treated with standard surgery and adjuvant therapies, with associated morbidities. There is a need to reduce overtreatment of good prognosis tumours and numerous studies are evaluating omission of radiotherapy in low-risk disease. However, there is little evidence for surgical de-escalation, although percutaneous minimally invasive treatment approaches have been described. Vacuum-assisted excision (VAE) is in widespread use for management of lesions of uncertain malignant potential and benign lesions. SMALL (ISRCTN 12240119) aims to determine the feasibility of using this approach to treat small invasive tumours detected within the UK NHS Breast Screening Programme. Methods: SMALL is a phase III multicentre RCT comparing standard surgery with VAE for screen-detected cancers. Main eligibility criteria are age ≥47 years, unifocal grade 1 tumours with maximum diameter 15mm, strongly ER/PR+ve and HER2-ve, with negative axillary staging. Patients are randomised 2:1 to VAE or surgery, with no axillary surgery in the VAE arm. Completeness of excision is assessed radiologically, and if excision is incomplete, patients undergo surgery. Adjuvant radiotherapy and endocrine therapy are mandated in the VAE arm but may be omitted following surgery. Co-primary end-points are1. Non-inferiority comparison of the requirement for a second procedure following excision2. Single arm analysis of local recurrence (LR) at 5 years following VAE Recruitment of 800 patients will permit demonstration of 10% non-inferiority of VAE for requirement of a second procedure. This ensures sufficient patients for single arm analysis of LR rates, where expected LR free survival is 99% at 5 years, with an undesirable survival probability after VAE of 97%. To ensure that the trial as a whole only has 5% alpha, the significance level for each co-primary outcome is set at 2.5% with 90% power. The Data Monitoring Committee will monitor LR events to ensure these do not exceed 3% per year. Secondary outcome measures include time to ipsilateral recurrence, overall survival, complications, quality of life and health economic analysis. A novel feature of SMALL is integration of a QuinteT Recruitment Intervention (QRI), which aims to optimise recruitment to the study. Recruitment challenges are identified by analysing recruiter/patient interviews and audio-recordings of trial discussions, and by review of trial screening logs, eligibility and recruitment data and study documentation. Solutions to address these are developed collaboratively, including individual/group recruiter feedback and recruitment tips documents. Results: SMALL opened in December 2019. Recruitment halted in 2020 for 5 months due to COVID-19. At 9th July 2025, 49 centres are open, with 640 patients randomised. The randomisation rate is approximately 45%, and per site recruitment rate is 0.4-0.5 patients/month. Drawing from QRI findings and insights from patient representatives, a recruitment tips document has been circulated (on providing balanced information about treatments, encouraging recruiters to engage with patient preferences, and explaining randomisation). Individual recruiter feedback is ongoing, and wider feedback is being delivered across sites via recruitment training workshops. Patient interviews are ongoing to explore patient views and experiences of the trial. Conclusion: SMALL continues to have excellent recruitment, is expected to complete recruitment in 2026 and have a global impact on treatment of breast cancer within mammographic screening programmes. SMALL is funded by the UK NIHR HTA programme award 17/42/32 Citation Format: S. McIntosh, C. Coles, D. Dodwell, K. Elder, B. Elsberger, J. Foster, C. Gaunt, J. Henderson, C. Mabena, J. Morgan, Z. Nabi, I. Lyburn, S. Paramasivan, S. Pinder, S. Pirrie, S. Potter, T. Roberts, N. Sharma, E. Southgate, H. Stobart, A. Talwalkar, S. Taylor-Phillips, W. Teh, E. Turner, M. Wallis, D. Rea. Small: open surgery versus minimally invasive vacuum-assisted excision for small screen-detected breast cancer - a UK phase III randomised multi-centre trial [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS5-09-12.

Adult community intellectual disability services in the United Kingdom (UK) are required to deliver specialist, evidence-based care for a variety of conditions while minimising restrictive practices and reliance on inpatient provision. Care pathway models have emerged as a potential mechanism to reconcile these aims yet remain under-used in care philosophies in intellectual disabilities. We propose a generalisable pathways model for community intellectual disability services and examine its implications for policy, clinical practice, and research. The model integrates care navigation, proportionate specialist input, and defined clinical condition care including behaviours that challenge, mental and physical health, forensics, neurodevelopmental conditions, epilepsy, and dementia within a community-based service architecture. It considers recent focus on digitalsation, prevention, workforce and practice innovation. The model aligns with contemporary policy priorities. We argue that pathway-based care delivery provides a pragmatic and ethically grounded framework for organising services. It supports consistency, integration, and preventative care while reducing reliance on reactive risk-based responses. By synthesising service design principles, core pathway functions, and system interfaces, this paper offers a coherent model for contemporary community intellectual disability services. Further empirical evaluation is required to assess the impact of care pathways on outcomes, patient experience, and cost-effectiveness.

This study evaluated the efficacy and safety of misoprostol, letrozole and their combination in first trimester missed miscarriage. This single-blind, randomised controlled trial was conducted between March 2023 and August 2024 among women diagnosed with first trimester missed miscarriage at Kasr Al-Aini Hospital, Cairo, Egypt. Participants were randomly assigned to three groups: misoprostol-only (Group A), letrozole plus misoprostol (Group B) and letrozole-only (Group C). The primary outcome was the rate of complete miscarriage. Secondary outcomes included abortion timing, adverse effects, need for surgical evacuation and the effect of age, body mass index (BMI) and gestational age on success. A total of 225 women were included in this study. Group B had the highest cumulative complete miscarriage rate by day 7 (76.0%) compared with Group A (53.5%) and Group C (62.5%) (P = 0.0005). Early abortion (by day 4) occurred in 68.4% (group B), 46.5% (group A) and 37.5% (group C). Group B also had the highest incidence of adverse effects, particularly bleeding (85.3%) and pain (92.0%), although severe events were rare. Letrozole-only (group C) had the fewest side effects (26.7%) and required no surgical evacuations. Combination therapy proved most effective across subgroups by age, BMI and gestational age. Combining letrozole with misoprostol significantly improves complete miscarriage rates with tolerable safety. Letrozole alone is safer but less effective. Thus, combination therapy may offer an optimal non-surgical strategy for individualised management.

Paediatric bronchiectasis unrelated to CF is a chronic respiratory condition marked by abnormal bronchial dilatation and persistent wet or productive cough, accompanied by recurrent airway infections and inflammation. Though once considered irreversible, evidence shows that early diagnosis and optimised management can halt or even reverse disease progression in children. The condition is increasingly recognised globally, with potentially higher prevalence in indigenous and low-income populations, although prevalence data is sparse. Diagnosis relies on chest CT imaging and clinical symptoms. Causes include post-infectious damage, immunodeficiencies, and genetic disorders such as PCD, but a large proportion have no identifiable aetiology. Clinical evaluation involves detailed history, imaging, and microbiological assessments. Management focuses on airway clearance, treating infections and addressing underlying causes. Early intervention is crucial to prevent long-term complications and improve quality of life. Despite its impact, paediatric bronchiectasis remains underfunded. There is a need for increased awareness, prospective data collection and research to support standardised care protocols to reduce morbidity and healthcare burden. <bold>Cite as:</bold> Unger SA. Bronchiectasis in children. <italic>In:</italic> Chalmers JD, Shoemark A, Aliberti S, eds. Bronchiectasis (ERS Monograph). Sheffield, European Respiratory Society, 2026; pp. 327–341 [<ext-link>https://doi.org/10.1183/2312508X.10002925</ext-link>].