Royal College of Physicians

Purpose Delirium and cognitive impairment are common in older adults with hip fracture and are associated with adverse patient outcomes. The Fragility Fracture Network recommends that national hip fracture registries (HFRs) include a measure of cognitive status. However, inconsistency in recording of delirium and cognitive assessment data hinders international comparison and may reduce care quality. This scoping review aims to identify delirium and cognitive assessment data items collected by national HFRs and the associated key data reported in the latest annual reports. Methods We searched three databases (Medline Ovid; Embase; CINAHL EBSCOHost) from inception to 18 November 2024 and relevant organisational websites. Two authors independently assessed titles, abstracts, and full texts for eligibility. Prespecified data items were extracted from identified eligible HFRs. Descriptive analysis was used to summarise findings. Results Twenty-two eligible HFRs were identified. Of these, 14 (64%) collected delirium assessment data, 18 (82%) collected cognitive assessment data, while only one registry collected neither. There was heterogeneity in delirium and cognitive assessment tools, though seven (50%) HFRs recommended using the 4AT. Delirium assessment completion rates were 47.7–95.9% pre-operatively and 34.2–95.9% post-operatively, while positive delirium score rates were 14.7–22% pre-operatively and 5–42% post-operatively. Cognitive assessment tool completion and positive score rates were 58.5–100% and 9.9–52.4%, respectively. Conclusion Most HFRs incorporate delirium and cognitive assessment data items, but there is heterogeneity in tools and methods. Improving the consistency of data collection across HFRs can improve comparability and patient care.

Chest pain in children can be a common presentation with causes including idiopathic, musculoskeletal and respiratory conditions, but is rarely cardiac in origin. However, in rare cases, it may indicate life-threatening conditions such as anomalous origin of coronary arteries. Among these, anomalous origin of the left coronary artery from the right sinus (ALCRSV) with an intramural and inter-arterial course is particularly concerning due to its association with myocardial ischemia and sudden cardiac death. We present the case of a previously healthy seven-year-old girl who experienced an episode of chest pain and syncope, initially misattributed to heat syncope. On her second presentation, she was acutely unwell with signs of central cyanosis and ischemic changes on ECG. Further investigation with echocardiography revealed a suspected coronary anomaly. She was transferred to a specialist centre where a diagnosis of the left main coronary artery arising from the right sinus of Valsalva was confirmed. The patient underwent successful surgical correction, including coronary unroofing and reimplantation, and was started on spironolactone and aspirin. Her recovery was uneventful, and she was discharged with a scheduled follow-up. ALCRSV is a rare but serious congenital coronary anomaly that can present with exertional chest pain and syncope in children. Diagnosis is often challenging due to nonspecific symptoms and inconclusive initial investigations. However, timely recognition and surgical intervention can prevent fatal outcomes. This case emphasises the importance of maintaining a high index of suspicion for coronary anomalies in paediatric patients presenting with exertional syncope or ischemic ECG changes, even in the absence of prior cardiac history.

Since the Food and Drug Administration in the United States approved the first robotic platform for use in humans in 2000, there has been a steady increase in the popularity of robotic approaches to surgery. Robotic-assisted surgery (RAS) offers enhanced 3D visualisation of the operative field and increased flexibility and agility of the instruments, amongst other benefits. However, robotic platforms are complex systems and there is evidence that they may be associated with increased patient risk, particularly in the initial learning curve of a surgeon's robotic training. To ensure the continued safe use of RAS, adequate governance policies must be in place to regulate training, ensure patient safety and maximise the benefits of RAS programs. This systematic review synthesises all available evidence on RAS governance structures internationally for the first time. It was conducted and reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. This systematic review identified, for the first time, three guidelines offering recommendations on the Governance Structures for RAS programs. We extracted the key recommendations to provide a holistic set of guidelines. Through consensus, we offer recommendations for the composition of a RAS governance committee, the frequency with which the committee should sit, and the remit of the committee, including training, granting of privileges, quality assurance and continued professional development. We also stress future research needs in RAS team credentialing and vendor-agnostic training pathways. These recommendations may serve as a template for establishing future RAS programs.

Background: Scholarly settings lack racial, ethnic, sex, gender, geographic, and linguistic diversity. Despite initiatives to promote more inclusive scholarly com-munities, the extent of implementation of policies related to equity, diversity, and inclusion (EDI) remains low. Objectives: The objective is to survey the perceptions and opinions of journal editors and other stakeholders with reference to policies related to EDI and relevant prac-tices in their journals and organizations. Methods: We sent out, through email, a link to a survey with 16 Likert-scale items and 8 open-ended questions in English to assess the perceptions of EDI. Questions were generated based on discussions at meetings of the European Association of Science Editors (EASE) EDI Committee in November and December 2023. The survey was available from 8 to 30 January 2024. Snowball sampling was used among members of EASE and those of related professional organizations recruited through social networks. Results: Of the total of 232 participants, 129/232 (56%) responded on behalf of jour-nals and 103/232 (44%) on behalf of organizations. Most (72%) considered EDI to be important or very important for their journal or organization, and even more (76%) wanted examples of existing policies and guidelines for implementing EDI. Exactly 50% (27/54) reported that their organizations have no published EDI policies, and 59% (54/91) reported the absence of an EDI statement. Conclusion: Although the survey showed wide support for EDI within journals and organizations, efforts to develop EDI policies and statements have been limited, as reflected in the responses that welcomed guidance on EDI. This suggests a need for increased awareness and knowledge-sharing about EDI policies and practices, as well as concrete actions to create a more diverse scholarly community.

Background The blood concentration of myeloperoxidase (MPO) is related to the severity of many age‐related inflammatory diseases. However, it is unknown whether enzyme activity in the blood provides information on the degree of functional disability of Parkinson's disease (PD), a multifactorial disease in which aging and inflammation play an important role. Objective The aim of the study was to discern the relationship between MPO activity in blood serum and the clinical characteristics of PD, assessed by disease rating scales and neuroimaging methods. Methods This cross‐sectional study included 217 participants (114 patients and 103 controls). Disease rating scales included the Hoehn‐Yahr scale, the International Parkinson and Movement Disorder Society‐sponsored revision of the Unified Parkinson's Disease Rating Scale motor section (MDS‐UPDRS), and the Schwab‐England Daily Living scale. The neuroimaging study was based on dopamine transporter single‐photon emission computed tomography (DAT‐SPECT) and specific binding ratio (SBR) quantification of ¹²³ I‐Ioflupane on basal ganglia. Results The findings revealed that serum MPO activity significantly increased in PD patients ( P < 0.0001). MPO activity correlated with the degree of clinical impairment measured with rating scales and with striatal DAT availability assessed with DAT‐SPECT. Multivariate linear regression, correcting for all confounding factors, shows that the Hoehn‐Yahr staging ( P = 0.004) and left striatum specific binding ratio (SBR) ( P < 0.05) are predictors of serum MPO activity, along with dysthyroidism and statins use ( P < 0.005). MPO activity cutoff greater than 40.350 U/L differentiated patients from controls with good accuracy (78.9%). Conclusions In PD, MPO activity in blood serum is associated with the stage of functional disability, apart from dysthyroidism and use of statins, assessed with the Hoehn‐Yahr scale and striatal DAT binding.

Elevated levels of the inflammatory enzyme myeloperoxidase (MPO) in the blood are associated with the development of age-related inflammatory diseases. Given that age, inflammation, and blood MPO play a role in the pathogenesis of Parkinson´s disease (PD), we hypothesized that serum MPO could be associated with PD status. This case-control study (199 participants) was conducted using an extensive protocol, and the concentration and activity of MPO in blood serum were measured. The findings reveal that serum MPO concentration and activity are significantly increased in the patients, and that rates of PD in all individuals are associated with increasing tertiles of MPO concentration and activity. In multivariate logistic regression model adjusting for confounding factors, MPO activity (not concentration) is the factor that is most associated with PD status (OR, 6.921, P = 0.001). Mental depression is directly associated with MPO activity and with PD status (OR, 0.121, B = −2.108, P = 0.002). The use of statins or nonsteroidal anti-inflammatory drugs significantly reduces serum MPO activity, but the possible association with the odds of having PD does not survive correction for multiple testing. In summary, both serum MPO concentration and activity are increased in patients with PD, but only MPO enzyme activity is associated with PD status. These findings may have implications for the evaluation of PD.

Pacemaker lead misplacement is a rare but clinically significant complication of pacemaker implantation. We present the case of a male patient in his 80s with a permanent pacemaker (PPM) who was found to have an inadvertently misplaced right ventricular (RV) lead coursing through a patent foramen ovale (PFO) into the left ventricle (LV). The patient presented with progressive dyspnoea and was found to have moderate mitral regurgitation related to lead interference with valve closure. Imaging modalities confirmed the lead's anomalous position. A multidisciplinary discussion concluded that conservative management with anticoagulation was the safest approach. This case highlights the importance of multimodal imaging in identifying lead misplacement and the clinical implications of inadvertent LV pacing. Furthermore, it underscores the importance of routine post-implantation assessment to detect lead displacement, which can often occur without symptoms. Early identification through systematic evaluation is essential to prevent complications and ensure optimal device function.

Background Medical education is essential for training competent healthcare professionals capable of addressing evolving patient needs. Faculty development plays a crucial role in improving teaching quality and supporting competency-based education (CBE), particularly in Honduras, where reforms aim to modernize medical curricula. Despite a long history of medical training, formal, standardized faculty development programs remain limited, with many instructors relying on informal, unstandardized training. This study evaluates the impact of a structured faculty development program designed to strengthen teaching competencies and integrate CBE into medical education. Objectives This study aimed to identify gaps in faculty knowledge regarding self-directed learning (SDL), formative assessment (FA), reflective practice (RP), and problem-based learning (PBL); assess instructors’ interest in these methodologies; and evaluate competency improvements following a voluntary faculty development course. Methods A descriptive, cross-sectional study was conducted at two campuses of the National Autonomous University of Honduras (UNAH)-Ciudad Universitaria and Valle de Sula-with 219 active laboratory instructors. A voluntary learning needs assessment survey was completed by 141 instructors (64%) to evaluate baseline knowledge, perceived proficiency, and interest in SDL, FA, RP, and PBL. Based on the results, 107 instructors (49%) enrolled in a 10-week faculty development course and 45 instructors (20%) completed it. PBL was selected as the primary methodology due to its effectiveness in fostering critical thinking and alignment with UNAH’s educational reforms. The course included interactive sessions, competency-based assessments, and structured feedback. The primary outcome was the ability to design, facilitate, and assess a PBL session, evaluated using a standardized competency-based framework. Descriptive statistics were used to measure learning gains. Results The survey (N=141) revealed that 93% of instructors lacked formal pedagogical training, despite 83.8% having over two years of teaching experience. Institutional barriers - such as limited budget or development opportunities - contributed to this gap. Instructors rated their knowledge of SDL and FA as “good,” while RP was “average,” though interest in all methodologies was high. Post-training, participants demonstrated mastery of 91% of assessed competencies, with 70% struggling with PBL assessment tools. Inferential analysis using a Chi-square Test for Independence showed a significant association between training participation and competency achievement (χ² = 425.73, df = 75, p = 1.81 × 10⁻⁵⁰, Cramér’s V = 0.27). A majority (66.7%) rated the course a perfect 10/10, and 91.1% reported an improved understanding of educational methodologies. Conclusions This study underscores the urgent need for structured faculty development in Honduras. Implementing competency-based training earlier through policy changes, mandatory certification, and continuous professional development could enhance teaching quality, improve student engagement, and modernize medical education. Future research should include follow-up assessments to measure long-term retention, apply further inferential analysis, and explore challenges across specific competencies while addressing potential biases such as social desirability.

Elimination of burnout and work-related mental illness in hospital doctors, at least in the short term, is unrealistic. Supporting doctors’ recovery continues to be important. Despite this, the aftermath of work-related mental illness and burnout, is not well understood. Using a descriptive phenomenological method, we describe the experience of coming to terms with mental crisis perceived to be caused or exacerbated by work stress for six senior consultant hospital doctors. Findings show that, in the aftermath of crisis, doctors engaged in two types of reflection: ‘situational sense-making’ to make sense of their experiences and ‘transformative self-reflection’, reflection in a deeper way on the experience, themselves and their lives. Transformative self-reflection led to change and in some cases growth. Not all doctors engaged in transformative self-reflection, and the process of recovery was complicated by contextual factors and when support from employers was perceived as absent, poor or acrimonious.

Aortic root abscess is a severe complication of infective endocarditis (IE), particularly in patients with prosthetic valves, nearly doubling mortality risk. Due to the potential for rupture and systemic spread, urgent surgical intervention is recommended. We present the case of a 77-year-old man with a recent aortic valve replacement and a history of discitis who presented with non-specific symptoms, complete heart block, and persistent Staphylococcus epidermidis bacteremia. Multimodal imaging, including positron emission tomography (PET) and CT coronary angiography, confirmed an aortic root abscess. Following the IE multidisciplinary team (MDT) recommendations, the patient underwent successful aortic valve and root repair. Post-operatively, he required a pacemaker and dual antibiotic therapy for eight weeks, with no further infection detected. This case highlights the diagnostic challenges of prosthetic valve endocarditis, the critical role of multimodal imaging in detecting complications, and the necessity of early surgical intervention. The development of a heart block underscores the impact of aortic root abscess on conduction pathways. MDT management was essential in optimising patient outcomes.

Non-tuberculous mycobacteria, particularly Mycobacterium avium complex (MAC), have become significant causes of pulmonary infections, especially in immunocompromised individuals. MAC lung disease presents a diagnostic challenge due to its clinical overlap with other pulmonary conditions, including Mycobacterium tuberculosis infections. The need for microbiological confirmation and radiological evaluation complicates early diagnosis. New molecular diagnostic methods, such as PCR, have improved detection but are not universally accessible. Treatment for MAC lung disease typically involves a multidrug regimen including macrolides, rifamycins, and ethambutol. However, the disease often proves resistant to standard therapies, and treatment failure is common due to drug resistance, delayed diagnosis, and poor adherence. Recent research has highlighted the need for personalized treatment strategies and alternative therapies, such as intravenous antibiotics and host-directed treatments, to improve outcomes. The prognosis for MAC lung disease remains poor, especially in patients with preexisting lung conditions like bronchiectasis or rheumatoid arthritis, who are at increased risk of disseminated infection. This case report and review underscore the importance of early recognition and intervention, highlighting the role of a multidisciplinary approach in managing complex infections. Additionally, it emphasizes the need for continued research to identify more effective treatment options and improve patient outcomes in this growing patient population.

Aim High‐impact infectious diseases pose major global health challenges, underscoring the urgent need for robust public health preparedness. Despite efforts to improve global health security, recent pandemics have revealed significant weaknesses in health systems’ preparedness and response capabilities. Methods We reviewed and synthesized key strategies and lessons from existing public health preparedness plans for high‐impact infectious diseases. This included examining national and global plans, focusing on strategic approaches, evidence integration, and real‐world implementation lessons. A narrative synthesis, based on the Public Health Emergency Preparedness (PHEP) model, identified effective practices and areas needing improvement. Results We screened 1987 documents, selecting 38 for detailed analysis. Findings highlighted strategies for long‐term health emergency preparedness, workforce development, enhancing global health frameworks, and investing in infrastructure. Challenges included maintaining laboratory detection, managing sentinel surveillance, and logistical issues. Effective approaches emphasized early threat detection, rapid response, healthcare capacity, medical supply management, and strategic communication. Conclusions Effective public health preparedness for high‐impact infectious diseases requires a coordinated approach, including early threat detection, rapid response, robust healthcare systems, and strategic communication. Past outbreaks show the need for continuous investment, evidence‐based policies, and adaptable health systems. Future research should assess ongoing preparedness efforts and implementation challenges.

Introduction Digestive diseases (DD) pose a significant global health burden, with the Middle East and North Africa (MENA) region providing a unique landscape to study the impact of socioeconomic disparities on DD incidence and outcomes. This study examines the burden of DD in the MENA region, focusing on socioeconomic influences. Methods We utilized data from the Global Burden of Disease (GBD) dataset from 1990 to 2021, analyzing trends in incidence, mortality, and disability-adjusted life years (DALYs) for DD. Percentage changes and estimated annual percentage changes (EAPCs) were calculated for age-standardized rates, and correlations were assessed between disease metrics and socio-demographic indices, including the Socio-demographic Index (SDI), Human Development Index (HDI), and Gender Inequality Index (GII). Results Between 1990 and 2021, the total incidence of DD rose by 129.8%, from 19.7 million to 45.4 million cases. Age-standardized mortality and DALY rates decreased by 48.3% and 44.7%, respectively. Strong correlations were observed between age-standardized incidence rates (ASIR) and SDI (r = 0.90), HDI (r = 0.88), and GII (r = − 0.86). EAPCs for incidence, deaths, and DALYs were 0.79, -2.29, and − 1.88, respectively. Conclusion Despite a reduction in mortality and DALY rates, the persistently high incidence rates of DD in the MENA region underscores ongoing public health challenges. Socioeconomic factors strongly influence disease burden, highlighting the need for targeted interventions to address disparities and improve digestive disease outcomes across the region.

Background Asthma and chronic obstructive pulmonary disease (COPD) outcomes vary by sex. We investigated whether males and females with asthma or COPD are managed differently in-hospital when admitted for an exacerbation. Methods Data from the National Asthma and COPD Audit Programme were used to determine three cohorts of people hospitalised for an exacerbation: (1) adults with asthma, (2) children and young people (CYP) with asthma, and (3) adults with COPD. Outcomes included the following in-hospital interventional measures: spirometry recording, respiratory specialist review, respiratory medication administration and discharge bundle recording. Linked hospital data were used to determine 30-day and 90-day readmissions and Office for National Statistics data for 90-day mortality. Random effects logistic regression was used to investigate the association between sex and in-hospital outcomes, readmission and mortality. Results 16 370 adults with asthma, 7156 CYP with asthma and 28 354 adults with COPD were included. Female adults with asthma had higher odds of being seen by a respiratory specialist ( a OR 0.1.13, 1.02-1.26) and higher odds of readmission within 30 and 90 days ( a OR 1.22, 1.10–1.37, a OR 1.34, 1.23–1.46) compared with males. Female adults with COPD had higher odds of being seen by a respiratory specialist, ( a OR 1.10,1.02–1.19), being administered non-invasive ventilation ( a OR 1.18, 1.09–1.29), and receiving a discharge bundle ( a OR 1.07, 1.00–1.14), and lower odds of readmission within 90 days ( a OR 0.95, 0.90–1.01), or mortality within 90 days ( a OR 0.88, 0.81–0.96). Lastly, female CYP had higher odds of steroids administered within 1 hour ( a OR 1.13, 1.00–1.28) and higher 30-day and 90-day readmission compared with males ( a OR 1.21, 1.00–1.44 and 1.17, 1.03–1.34). Interpretation Sex differences in in-hospital care exist in adults COPD, which may impact readmissions and mortality; however, little to no sex differences in in-hospital care were seen in people with asthma yet females were more likely to be readmitted to hospital.

The triple threat of changing climate, loss of biodiversity and pollution poses a significant challenge to our patients and the planet, and healthcare contributes to all three elements of the threat. The carbon footprint of continued professional development (CPD) is increasingly recognised, although a cognitive dissonance exists whereby climate change is acknowledged but air travel to conferences continues unabated. A CO2 allowance for CPD activities has been suggested previously. We suggest that CO2 footprint estimates could be incorporated into existing CPD diaries as a step towards visualising the environmental impact of CPD. Electronic CPD diaries are already widely used and typically contain dates and locations for CPD activities. It would be relatively easy and inexpensive to add an estimate of CO2 footprint to these diaries. Such an approach would initiate reflection, promote insight and help facilitate behavioural change. We call on institutions involved in CPD licensing, administration and documentation to trial this approach and share their experience.

Patients and carers must be part of the move toward reducing waste, improving sustainability and tackling climate change in the current emergency. Without accurate, practical information they cannot contribute. Patients have fears associated with climate change and health, which are explored here.