Southmead Hospital

Adrenal insufficiency (AI) is a common complication following glucocorticoid (GC) therapy. However, reliable predictors of AI and GC regimens that mitigate this risk remain unclear. Previous systematic reviews (SRs) have included many observational studies with imprecise reporting of GC dose and duration. We conducted a systematic review focusing exclusively on studies with well-defined GC exposure. We searched Embase, Web of Science, and MEDLINE for original studies published since 2000 that investigated adults receiving protocolised systemic GC regimens and assessed all participants for AI using the adrenocorticotropic hormone (ACTH) stimulation test. Data extracted included AI prevalence, diagnosis, administration route, GC dose and tapering, treatment duration and timing of outcome assessment. Risk of bias was assessed using an adapted Newcastle-Ottawa Scale. Meta-analysis was performed using random-effects models in R. Of 1340 unique records identified, 12 studies (1170 participants) met inclusion criteria. AI was present in 423 individuals, with a pooled prevalence of 30% (95% CI: 19-45%) at the earliest time point tested. Reported prevalence ranged from 0 to 70%, and was not consistently associated with diagnosis, administration route, treatment duration, or study quality. AI was significantly less common in studies that included tapering (p < 0.01) and in those assessing AI ≥15 days after stopping GCs (15%, 95% CI: 8-26%) compared to testing at cessation (48%, 95% CI: 35-62%). AI is frequent following systemic GC use, with considerable variability. Tapering regimens and delayed testing post-cessation appear to reduce the observed prevalence. No specific GC regimen reliably prevents AI.

There is evidence that living with obesity can affect an individual's pay and employment, but there is little evidence on the impact of weight-management interventions in improving labour market outcomes of individuals. We evaluate the impact of bariatric surgery on monthly earnings and employee status among working-age adults, and examine variations across sociodemographic characteristics. This population-based, retrospective longitudinal cohort study for England included 40,662 individuals who had a bariatric surgery procedure and obesity diagnosis between 1 April 2014 and 31 December 2022, with no bariatric surgery history in the previous 5 years, and were 25 to 64 years old at the date of surgery. 49,921 individuals sampled from the general population who had not had bariatric surgery were also included, matched by age and sex. The main outcome measures were monthly employee pay-for all months and only months where the individual was in paid employment-expressed in 2023 prices and paid employee status. Among people living with obesity who had bariatric surgery, there was a sustained increase in monthly employee pay from 6 months after surgery with a mean increase of £84 per month (95% confidence interval [Cl]: 63-106) 5 years after surgery compared with the 6 months before surgery. There was a sustained increase in the probability of being a paid employee from 4 months after bariatric surgery, with a mean increase of 4.3 percentage points (95% Cl: 3.7-4.9) 5 years after surgery. Bariatric surgery is associated with an increased probability of being employed, resulting in increased earnings. This suggests that living with obesity negatively impacts labour market outcomes and that obesity management interventions are likely to generate economic benefits both to individuals and on a macroeconomic level by increasing the likelihood of employment of people living with obesity.

BackgroundStillbirth is a profound and devastating outcome of pregnancy that has a long-lasting emotional and physiological impact on parents and families. Current risk assessment approaches largely rely on maternal characteristics and clinical history, yet their predictive accuracy remains poor, particularly among nulliparous women (women with no previous birth beyond 24 weeks of gestation). We evaluated the extent to which routinely collected pregnancy risk factors can predict stillbirth and assessed their contribution among singleton births in nulliparous women.MethodsWe conducted a population-based retrospective cohort study of 876,279 nulliparous women receiving maternity care across 130 National Health Service (NHS) Trusts in England between 2015 and 2019. Thirty-one maternal and pregnancy factors routinely collected during antenatal care were analysed. We used modified Poisson regressions with generalised estimating equations to account for clustering of women within Trusts to compute risk ratios (RR) and 95% confidence intervals (CI). We calculated adjusted population attributable risks (PARs) for significant factors.ResultsAmong 876,279 nulliparous women receiving maternity care, 2568 stillbirths occurred. Modifiable maternal characteristics associated with increased risk included elevated body mass index (BMI) (RR 1.22, 95% CI 1.03–1.45 for BMI 35– < 40 kg/m2; RR 1.70, 95% CI 1.39–2.07 for BMI ≥ 40 kg/m2, both compared to BMI 18.5– < 25 kg/m2), smoking at booking (RR 1.34, 95% CI 1.19–1.51), current substance misuse (RR 1.52, 95% CI 1.16–1.98), lack of folic acid consumption before conception (RR 1.28, 95% CI 1.16–1.40) or during pregnancy (RR 1.38, 95% CI 1.18–1.61), and late antenatal booking after 12 weeks of gestation (RR 1.18, 95% CI 1.07–1.30). Fetal growth restriction accounted for the largest population attributable risk for stillbirth (RR 2.96, 95% CI 2.73–3.21).ConclusionsMaternal and clinical risk factors explain only a fraction of stillbirths in nulliparous women and cannot underpin a clinically useful prediction model. These findings demonstrate the limitations of risk-based screening strategies and highlight the need for integrated approaches that combine maternal characteristics with biochemical, biophysical, and system-level factors to achieve meaningful advances in stillbirth prevention.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12916-025-04598-7.

Nocturia is a prevalent condition with systematic etiologies which require multidisciplinary collaborations during diagnosis and management. Here we evaluate current evidence and present unresolved research questions regarding the three key pathophysiological domains of nocturia with respect to a conceptual brain-kidney-bladder axis, namely sleep enhancement, extra-renal water reabsorption and circadian regulation of bladder tissue. A Think Tank was convened at the 12th International Consultation on Incontinence Research Society meeting in June 2025, looking at novel therapeutic targets for nocturia. This article synthesizes key deliberations from this meeting session. The discussion was mainly focused on idiopathic nocturia with an overactive bladder symptom complex or nocturnal polyuria. Firstly, medications and conservative nondrug measures targeting sleep that could potentially improve nocturia were considered. Secondly, investigation of water reabsorption mechanisms within the bladder and the role of small molecule vasopressin receptor type-2 agonists were examined that may provide novel therapeutic options to rectify nocturnal polyuria. Finally, to address circadian misalignments, organ specific chronotherapies, based on abnormal circadian features of bladder tissues that can be curative for nocturia, were discussed. The evidence indicates that promising therapeutic modalities targeting the regulation of sleep-wake cycles, intravesical water transport mechanisms, and circadian patterns of detrusor activity may offer alternative strategies for managing nocturnal polyuria. However, further mechanistic investigations and randomized controlled trials are required to advance these approaches toward clinical translation.

BackgroundPleural infection remains a significant clinical challenge, requiring hospitalisation, intravenous antibiotics and early chest drain insertion. Medical thoracoscopy (MT), a minimally invasive procedure used electively in the UK for malignant effusions, has demonstrated good outcomes when applied to acute pleural infection in retrospective case series. However, it has not been evaluated as a first-line intervention in the UK in a randomised controlled trial (RCT).ObjectivesThe Studying Pleuroscopy in Routine Pleural Infection Treatment (SPIRIT) trial assessed the feasibility of conducting a full-scale RCT comparing MT with chest drain insertion for acute pleural infection within UK National Health Service (NHS) hospitals.MethodsSPIRIT was an open-label, randomised feasibility trial conducted across seven NHS centres between 2017 and 2019. Adults with suspected pleural infection were prescreened; eligible patients were randomised to either chest drain insertion (control) or MT (performed the same or following day) with 90-day follow-up. The primary outcome was feasibility, assessed through a composite of prescreen, screen and allocation failure rates. Secondary outcomes included inpatient-stay duration, mortality, radiological and microbiological outcomes, second-line interventions, patient-reported outcomes and adverse events.ResultsOf 193 patients prescreened, 181 (93.8%) were excluded due to at least one criterion. Key factors included lack of MT deliverability (49.2%), a not truly infected effusion (45.1%) and contraindications to drainage or study involvement (44.0%). Consequently, the primary feasibility endpoint was not met. All 12 eligible patients were randomised with no attrition. MT lasted 15 min longer than drain insertion, but chest drains remained in situ over 3 days longer (p=0.17) with a longer hospital stay (p=0.57). Radiological improvement, microbiological yield and symptom scores were similar. Adverse events occurred in one control and three MT patients.ConclusionA full-scale RCT is not likely to be feasible in an NHS setting on the proposed protocol. Targeted recruitment from centres equipped for emergency MT may enhance feasibility.Trial registration numberISRCTN98460319.

Importance: Progesterone is necessary for maintenance of early pregnancy, with luteal insufficiency implicated in miscarriage. Luteal phase progesterone is a potential treatment for women with a history of recurrent miscarriage. Objective: To evaluate evidence on luteal phase progesterone support for preventing recurrent miscarriage and improving pregnancy outcomes. Evidence review: Pubmed, Cochrane Library, Ovid MEDLINE, Ovid EMBASE, CINAHL and ClinicalTrials.gov were searched in 05/2025. Meta-analysis was not performed due to outcome heterogeneity. The protocol was pre-registered (PROSPERO CRD:420250653486). A systematic search was performed identifying English-language, peer-reviewed, randomised-controlled trials and observational studies. Eligible studies assessed pregnancy outcomes in women with a history of recurrent miscarriage treated with luteal phase progesterone compared with usual care/placebo. Primary outcomes were live birth and miscarriage. Additional outcomes for which data were extracted were informed by the miscarriage prevention core outcome set. Two independent reviewers selected studies and extracted data. We assessed risk-of-bias using the ROBINS-E tool. Findings: 6722 studies were screened. Only two prospective cohort studies met inclusion criteria, including 120 treated women and 87 controls. Both studies used luteal start micronised vaginal progesterone. Progesterone regimen varied between the two studies from 100-200mg given either once or twice daily. Women had at least two unexplained miscarriages. Treatment duration ranged until 10- and 36-weeks’ gestation. Neither study reported live birth rate. One study reported reduced risk of miscarriage <10 weeks in women receiving progesterone 30.2% (38/126) vs. controls 36.8% (14/38); the other reported miscarriage <12 weeks in 21.9% (7/32) vs. 22.4% (13/58) respectively. There is evidence of reduced pre-term births, NICU admissions and increased fetal birthweight. Both studies had a high risk of bias which alongside study heterogeneity and data quality, precluded direct comparison and meta-analysis. Conclusion and relevance: We found evidence that treatment may reduce miscarriage rate, however data is limited, of low quality and no data is available for live birth rate. Data from well-designed trials with low risk of bias are needed to inform practice.

The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations (CoSTR) pubished by the International Liaison Committee on Resuscitation (ILCOR). The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation. The post-resuscitation care of children is described in the ERC guidelines 2025 Paediatric Life Support.