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Background: It has long been accepted that multiple sclerosis (MS) is heterogenous regarding presentation and disease course, so that outcomes are diverse; however, there is less data on variation in the immediate period after diagnosis., Methods: Our objective was to identify the clinical and demographic factors present at diagnosis. Two cohorts were compared from the Trajectories of Outcome in Neurological Conditions-MS study: those joining within one year of diagnosis (inception cohort) compared to 9-11 years following diagnosis (decade cohort). Patient reported outcome data were fitted to the Rasch model to yield interval estimates, longitudinal data were analysed by group-based trajectory models., Results: The inception cohort (n = 813) showed impact on fatigue, disability, health status and quality of life (QOL), although as expected, less than the decade cohort (n = 679), who also had more depressive symptoms. The average trajectory of health status was deceptive, as analysis showed two distinct groups, 13.8 % having much poorer health status, sustained for at least 3 years from diagnosis. Similarly, there were distinct groups with different trajectories identified for disability and QOL. These groups varied for depression, anxiety, sleep problems, employment, comorbidities, smoking history, and deprivation indices, highlighting influences prior to diagnosis., Conclusions: MS care must be personalised from diagnosis; service design should account for those people with MS experiencing poor health status from diagnosis. Basing capacity planning on average trajectories would be misleading. Furthermore, this evidence shows that service provision to support symptom management and disability clearly needs to be resourced from the diagnostic year., Competing Interests: Declaration of competing interest The authors report there are no competing interests to declare., (Copyright © 2025 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: To investigate whether psychosocial factors account for a proportion of the difference in cognitive performance between persons with and without HIV., Design: Cross-sectional study of 273 participants (178 persons with HIV) from a low income area of Cape Town, South Africa., Methods: Participants completed comprehensive cognitive testing (7 domains) and 12 psychosocial measures (5 current: income, occupation, assets, accommodation, depressive symptoms, 7 from childhood: assets, quality of education, exposure to childhood trauma and violence, primary caregiver occupation and highest level of education), as well as demographic measures standard in cognition studies (age, sex, years of education). We investigated the HIV association with global cognitive performance after adjustment for standard demographic variables, exploratory psychosocial variables, and balancing characteristics of those with and without HIV using propensity score modelling., Results: Persons with HIV had significantly lower scores than persons without HIV in 8/12 psychosocial variables. Of these, 7/12 significantly predicted global T-score. In unadjusted regression, HIV status was associated with a reduction in global T-score of 3.72 units. Adjustment for standard variables, reduced the effect of HIV on global T score by 26.9% to 2.72, additional adjustment for psychosocial variables reduced by 40.3% to 2.22, and adjustment for propensity scores by 42.7% to 2.13., Conclusions: Persons with HIV in this setting have lower psychosocial indices, both current and in childhood, which are associated with lower cognitive test performance as an adult. This is incompletely mitigated by adjustments for standard demographic variables which risks overestimation of cognitive impairment on a population level., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

The accelerated development of vaccines to mitigate COVID-19 was crucial in the response to the 2020 pandemic. The success of vaccination strategies relies upon adequate uptake across the population. In the United Kingdom, COVID-19 vaccination began in December 2020, with population groups invited in priority groups according to age and clinical vulnerability. By February 2021, uptake rates were lower in North West London than the national average. This study aimed to explore whether behaviourally-informed (BI) letters could increase the rate of first vaccine uptake in previously uncontactable residents. BI letters were designed to invoke a sense of ownership, and highlight the ease of accessing a vaccine. Letters were sent to unvaccinated uncontactable residents in a Central London Borough over a 3-week period. Three neighbouring boroughs in London with similar non-responder data acted as controls. A linear difference in difference (DID) analysis assessed the change in the rate of vaccine uptake across all four boroughs, with percentage point change adjusted for covariates including ethnicity, age, gender and socioeconomic status. In total, 10,161 residents in Central London were eligible to receive our BI letter. All four boroughs demonstrated an increase in vaccination, with an absolute increase of 4.3 % in the intervention borough. Our linear DID analysis showed a 14.7 % increase in vaccination likelihood in the intervention borough following the intervention on average across all weeks included in the study. Residents with a mixed or multiple ethnic background were less likely to receive a COVID-19 vaccination. Those from a more deprived socioeconomic background demonstrated the largest rate of change. Our study highlights the effectiveness of traditional communication strategies such as letters in those who are uncontactable by other means. Incorporating behavioural science principles into healthcare communication, such as those designed to evoke a sense of ownership can enhance their effectiveness., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Females are typically underserved in cardiovascular medicine. The use of sex as a dichotomous variable for risk stratification fails to capture the heterogeneity of risk within each sex. We aimed to develop an artificial intelligence-enhanced electrocardiography (AI-ECG) model to investigate sex-specific cardiovascular risk., Methods: In this retrospective cohort study, we trained a convolutional neural network to classify sex using the 12-lead electrocardiogram (ECG). The Beth Israel Deaconess Medical Center (BIDMC) secondary care dataset, comprising data from individuals who had clinically indicated ECGs performed in a hospital setting in Boston, MA, USA collected between May, 2000, and March, 2023, was the derivation cohort (1 163 401 ECGs). 50% of this dataset was used for model training, 10% for validation, and 40% for testing. External validation was performed using the UK Biobank cohort, comprising data from volunteers aged 40-69 years at the time of enrolment in 2006-10 (42 386 ECGs). We examined the difference between AI-ECG-predicted sex (continuous) and biological sex (dichotomous), termed sex discordance score., Findings: AI-ECG accurately identified sex (area under the receiver operating characteristic 0·943 [95% CI 0·942-0·943] for BIDMC and 0·971 [0·969-0·972] for the UK Biobank). In BIDMC outpatients with normal ECGs, an increased sex discordance score was associated with covariate-adjusted increased risk of cardiovascular death in females (hazard ratio [HR] 1·78 [95% CI 1·18-2·70], p=0·006) but not males (1·00 [0·63-1·58], p=0·996). In the UK Biobank cohort, the same pattern was seen (HR 1·33 [95% CI 1·06-1·68] for females, p=0·015; 0·98 [0·80-1·20] for males, p=0·854). Females with a higher sex discordance score were more likely to have future heart failure or myocardial infarction in the BIDMC cohort and had more male cardiac (increased left ventricular mass and chamber volumes) and non-cardiac phenotypes (increased muscle mass and reduced body fat percentage) in both cohorts., Interpretation: Sex discordance score is a novel AI-ECG biomarker capable of identifying females with disproportionately elevated cardiovascular risk. AI-ECG has the potential to identify female patients who could benefit from enhanced risk factor modification or surveillance., Funding: British Heart Foundation., Competing Interests: Declaration of interests AS is funded by a British Heart Foundation (BHF) clinical research training fellowship (FS/CRTF/21/24183) and National Institute for Health Research (NIHR) Academic Clinical Lectureship. FSN and NSP are supported by the BHF (RG/F/22/110078). LP is funded by a Medical Research Council (MRC) clinical research training fellowship (MR/Y000803/1). KAM is supported by a BHF fellowship (FS/IPBSRF/22/27059). ES is supported by an EJP RD Research Mobility Fellowship (European Reference Networks), the Sir Jules Thorn Charitable Trust, and was previously supported by an FWO PhD Fellowship. JEH is supported by the National Institutes for Health (R01 HL160003, R01 HL168889, and K24 HL153669). ALPR is supported in part by CNPq (465518/2014-1, 310790/2021-2, and 409604/2022-4) and by FAPEMIG (PPM-00428-17, RED-00081-16, and PPE-00030-21). UT is supported by the MRC (MR/W023830/1). AS, LP, FSN, AHR, and ALPR are supported by the Academy of Medical Sciences (NGR1\1746). JWW was previously on the advisory board for Heartcor solutions and reports research funding from Anumana. JSW reports research grants from the Sir Jules Thorn Charitable Trust, MRC, BHF, Bristol Myers Squibb, and Pfizer; consulting fees from Bristol Myers Squibb, Pfizer, Foresite Labs, Health Lumen, and Tenaya; honoraria from Global Heart Hub; and is on the clinical advisory group for Cardiomyopathy UK. FSN reports speaker fees from GE healthcare and is on the advisory board for AstraZeneca. UT has received fees for educational content from Chiesi and has roles within the British Cardiovascular Society, Royal Society, and DCM SHaRe registry. The authors acknowledge support from Imperial's BHF Centre for Excellence Award (RE/18/4/34215 and RE/24/130023) and NIHR Imperial Biomedical Research Centre. KP and DBK declare no competing interests., (Copyright © 2025 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Blood cultures are the gold standard for diagnosing bacterial bloodstream infections, but test results are only available 24-48 h after sampling. We aimed to develop and evaluate models using health-care data to predict bloodstream infections in patients admitted to hospital., Methods: In this retrospective cohort study, we used routinely collected blood biomarkers and demographic data from patients who underwent blood sample collection for testing via culture between March 3, 2014, and Dec 1, 2021, at Imperial College Healthcare NHS Trust (London, UK) as model features. Data up to 14 days before blood sample collection were provided to long short-term memory (LSTM) or static logistic regression models. The primary outcome was prediction of blood culture results, defined as a pathogenic bloodstream infection (ie, isolation of pathogenic bacteria of interest) or no bloodstream infection (ie, no growth or contamination). Data collected up to Feb 28, 2021 (n=15 212) comprised the training set and were evaluated against a temporal hold-out test set comprising patients who were sampled after March 1, 2021 (n=5638)., Findings: Among 20 850 patients with available data, pathogenic bacteria were observed in the cultured blood samples of 3866 (18·5%) patients. 2920 (62·2%) of 4897 patients who had their blood samples taken more than 48 h after admission to hospital had pathogenic bloodstream infections, and so were defined as having hospital-acquired bloodstream infections. Including data from the 7 days before admission (7-day window approach) and using five-fold cross validation in the training set gave an area under receiver operator curve (AUROC) of 0·75 (IQR 0·68-0·82) and an area under the precision recall curve (AUPRC) of 0·58 (0·46-0·77) for static models and an AUROC of 0·92 (0·91-0·93) and AUPRC of 0·75 (0·72-0·76) for the LSTM model. In the hold-out test set performances were: AUROC of 0·74 (95% CI 0·70-0·78) and AUPRC of 0·48 (0·43-0·53) for static models and AUROC of 0·97 (0·96-0·97) and AUPRC of 0·65 (0·60-0·70) for LSTM. Removal of time series information resulted in lower model performance, particularly for hospital-acquired bloodstream infections. Dynamics of C-reactive protein concentration, eosinophil count, and platelet count were important features for prediction of blood culture results., Interpretation: Deep learning models accounting for longitudinal changes could support individualised clinical decision making for patients at risk of bloodstream infections. Appropriate implementation into existing diagnostic pathways could enhance diagnostic stewardship and reduce unnecessary antimicrobial prescribing., Funding: UK Department of Health and Social Care, the National Institute for Health and Care Research, and the Wellcome Trust., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2025 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

The urgency for climate action is recognized by international government and healthcare organizations, including the United Nations (UN) and World Health Organization (WHO). Climate change, biodiversity loss, and pollution negatively impact all life on earth. All populations are impacted but not equally; the most vulnerable are at highest risk, an inequity further exacerbated by differences in access to healthcare globally. The delivery of healthcare exacerbates the planetary health crisis through greenhouse gas emissions, largely due to combustion of fossil fuels for medical equipment production and operation, creation of medical and non-medical waste, and contamination of water supplies. As representatives of radiology societies from across the globe who work closely with industry, and both governmental and non-governmental leaders in multiple capacities, we advocate together for urgent, impactful, and measurable changes to the way we deliver care by further engaging our members, policymakers, industry partners, and our patients. Simultaneous challenges including global health disparities, resource allocation, and access to care must inform these efforts. Climate literacy should be increasingly added to radiology training programs. More research is required to understand and measure the environmental impact of radiological services and inform mitigation, adaptation, and monitoring efforts. Deeper collaboration with industry partners is necessary to support innovations in the supply chain, energy utilization, and circular economy. Many solutions have been proposed and are already available, but we must understand and address barriers to implementation of current and future sustainable innovations. Finally, there is a compelling need to partner with patients to ensure that trust in the excellence of clinical care is maintained during the transition to sustainable radiology. By fostering a culture of global cooperation and rapid sharing of solutions amongst the broader imaging community, we can transform radiological practice to mitigate its environmental impact, adapt and develop resilience to current and future climate and environmental threats, and simultaneously improve access to care. This article is simultaneously published in the Canadian Association of Radiologists Journal (DOI 10.1177/08465371241321390), European Radiology (DOI 10.1007/s00330-025-11413-7), Journal of Medical Imaging and Radiation Oncology (DOI 10.1111/1754-9485.13842), Journal of the American College of Radiology (DOI 10.1016/j.jacr.2025.02.009), Korean Journal of Radiology (DOI 10.3348/kjr.2025.0125) and Radiology (DOI 10.1148/radiol.250325). The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either DOI can be used when citing this article. Keywords: Climate Change, Sustainability, Resource Allocation, Radiology, Health Services Accessibility Published under a CC BY 4.0 license. © The Author(s) 2025. Editor's Note: The RSNA Board of Directors has endorsed this article.

High consequence infectious diseases (such as Ebola virus or avian influenza) require specialist management with strict isolation to avoid spread to health-care staff and the wider community. These infections present various ethical and legal issues for children and young people. Specific challenges include the impact of isolation on the child and family (potentially without a child's consent), limitations to care due to staff safety considerations, and reduction of resources for other children (due to potential closure of paediatric intensive care unit beds). The complex decision making required in these scenarios needs timely ethical support. As planning for future pandemics accelerates, we suggest that the ethical and legal considerations involved in delivering care to affected children and their families need urgent consideration, and we have highlighted the important areas for focus to provide a route map for this important undertaking., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2025 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Purpose: Avacopan is a novel C5a receptor inhibitor which was recently licensed for treatment of severe granulomatosis with polyangiitis (GPA) in the European Union and the United Kingdom. To the best of our knowledge, this is the first described case on initial ophthalmic outcomes in a patient with severe GPA and concurrent refractory scleritis treated with avacopan., Case Description: We present a case of de novo scleritis in a 77-year-old male with a background of retinitis pigmentosa with Argus II implant in situ. Severe scleral inflammation occurred following a suture removal from the implant site. Remission was not maintained despite orbital floor injections and high dose oral prednisolone. The diagnostic work-up revealed GPA which quickly progressed to involve vital organs. In view of his systemic deterioration, he was started on avacopan alongside rituximab, cyclophosphamide and high dose oral prednisolone. Sustained remission of scleritis was noted after 7 months of treatment with avacopan and low dose oral prednisolone with no other maintenance immunosuppression., Conclusion: We observed a sustained benefit of avacopan in allowing for successful taper of systemic steroids. We report that avacopan used alongside other immunosuppressants may be a viable option in patients with GPA and concurrent refractory scleritis. Further studies are needed to establish the longer term impact of this agent on the control of scleral inflammation., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Evidence for use of pulmonary arterial hypertension targeted-therapies in patients with chronic thromboembolic pulmonary hypertension (CTEPH) is limited. In MERIT-1, the endothelin receptor antagonist macitentan improved hemodynamic and functional parameters versus placebo in patients with inoperable CTEPH over a 24-week double-blind (DB) period. Its open-label (OL) extension study (MERIT-2) provides long-term safety/efficacy data., Methods: MERIT-2 (NCT02060721) was a multicenter, single-arm, OL, phase 2 extension study of MERIT-1. Patients completing MERIT-1 were eligible to receive 10 mg macitentan once-daily in MERIT-2. Safety and efficacy (6-min walk distance [6MWD] and change in World Health Organization functional class [WHO FC]) were assessed in all patients in MERIT-2 regardless of treatment received in DB (All patients MERIT-2 OL macitentan 10 mg group) and the subgroup of patients receiving DB macitentan in MERIT-1 (Long-term [DB/OL] macitentan 10 mg subgroup)., Results: Of the 80 patients randomized in MERIT-1, 76 entered MERIT-2 (All patients MERIT-2 OL macitentan 10 mg group): 40 who received DB macitentan (DB-macitentan patients) and 36 DB placebo (DB-placebo patients). Median (interquartile range) macitentan exposure in the All patients MERIT-2 OL macitentan 10 mg group was 45.5 (26.0, 66.1) months. During the OL period, treatment-emergent adverse events (AE) were reported in 72 (94.7%) patients; most frequent were worsening of pulmonary hypertension (19.7%), decreased hemoglobin (18.4%) and upper respiratory tract infection (15.8%). Fourteen (18.4%) patients died; none were assessed as macitentan-related. At Month 6 post-OL baseline, mean (standard deviation) change in 6MWD was - 0.4 m (43.62) for DB-macitentan patients and 10.7 m (45.63) for DB-placebo patients; the majority had unchanged (83.3%) or improved (12.5%) WHO FC. Safety/efficacy analyses were consistent in the Long-term (DB/OL) macitentan 10 mg subgroup., Conclusion: These analyses provide long-term safety/efficacy data in patients with inoperable CTEPH treated with macitentan. No unexpected safety findings occurred; reported AEs were consistent with the known safety profile of macitentan. At 6 months post-OL baseline, DB-placebo patients modestly improved 6MWD; DB-macitentan patients maintained improvements observed in MERIT-1. WHO FC was largely unchanged., Trial Registration: ClinicalTrials.gov Identifiers: NCT02021292; NCT02060721., Competing Interests: Declarations. Conflict of Interest: Nick H Kim served as a Scientific Committee member for Johnson & Johnson; received research grants/support from Enzyvant and Lung Biotechnology; received consultant fees from Johnson & Johnson, Bayer, Merck, United Therapeutics, Gossamer Bio, Pulnovo and Polarean; and received speaker fees from Johnson & Johnson, Bayer and Merck. Andrea M D'Armini has received fees for organising Masters-level courses, lecture fees and writing assistance from Merck and AOP health; and fees for serving on Scientific Committees from Johnson & Johnson. Luke S Howard has received consultancy fees from Ferrer, Johnson & Johnson and Morphic; fees for serving on Scientific Committees/advisory boards from Gossamer Bio, Apollo Therapeutics, Altavant, MSD and Johnson & Johnson; honoraria for lectures from Johnson & Johnson, MSD, Aerovate and Ferrer; fees for expert testimony from Johnson & Johnson; travel support from Johnson & Johnson and Gossamer Bio; received institutional grant support from MSD and holds stock in Circular, ATXA Therapeutics, iOWNA, Calibre Biometrics and OneWelbeck Clinic. David P Jenkins has received fees for serving on a Scientific Committee for Johnson & Johnson and lecture fees from Bayer. Zhi-Cheng Jing has received consultancy fees, lecture fees and fees for serving on a Scientific Committee from Johnson & Johnson, Bayer, GlaxoSmithKline, Lee’s Pharmaceuticals, and Pfizer; fees for serving on an adjudication committee from Johnson & Johnson; and grant support from Johnson & Johnson, Bayer, GlaxoSmithKline, Pfizer, The National Science Fund for Distinguished Young Scholars (81425002), CAMS Innovation Fund for Medical Sciences (2016-I2M-1–002), and The National Key Research and Development Program of China (No. 2016YFC0901502). Current affiliation: Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China. Eckhard Mayer has received consultancy fees from Johnson & Johnson, Bayer and Merck; lecture fees from Johnson & Johnson, Bayer and Merck; and fees for serving on a Scientific Committee for Johnson & Johnson. Liliya Chamitava, was an employee of Johnson & Johnson at the time of the study. Current affiliation: Valos S.r.L, Genova, Italy. Gabriela Lack, Hany Rofael and Maria Solonets are employees of Johnson & Johnson. Hossein-Ardeschir Ghofrani has received fees for serving as a board member for AbbVie, Bellerophon Pulse Technologies, Medscape, OMT, UCB Celltech, and Web MD Global; consultancy fees and fees for serving on a Scientific Committee for Johnson & Johnson, Bayer, Gilead Sciences, GlaxoSmithKline, Merck, Novartis, and Pfizer; lecture fees from Johnson & Johnson, Bayer, GlaxoSmithKline, Merck, Novartis, and Pfizer; and grant support from Johnson & Johnson, Bayer, Novartis, and Pfizer. Ethical Approval: Data were collected in MERIT-1 and MERIT-2 in accordance with the Good Clinical Practice guidelines and Declaration of Helsinki. The study protocol was approved by the institutional review board, or independent ethics committee at each participating site and patients gave full written consent for their participation and use of their data for publication. The Scientific Committee, composed of external experts in CTEPH with experience in clinical studies, were involved in the study design and provided guidance on both MERIT-1 and MERIT-2. An Independent Liver Safety Data Review Board provided assessment and advice regarding serious hepatic adverse events of special interest (AESI). The list of study sites, investigators and ethical committees are included in Supplementary Methods 1., (© 2024. The Author(s).)

Introduction: In recent years, major findings on concomitant procedures and anticoagulation management have occurred in Mitral Valve (MV) surgery. Therefore, we sought to evaluate the current practices in MV interventions across Europe., Methods: In October 2021, all national cardio-thoracic societies in the European region were identified following an electronic search and sent an online survey of 14 questions to distribute among their member consultant/attending cardiac surgeons., Results: The survey was completed by 91 consultant/attending cardiac surgeons across 12 European countries, with 78% indicating MV repair as their specialty area. 57.1% performed >150 operations/year and 71.4% had 10+ years of experience.Concomitant tricuspid valve repair is performed for moderate tricuspid regurgitation (TR) by 69% of surgeons and for mild TR by 26.3%, both with annular diameter >40 mm. 50.6% indicated ischaemic MV surgery in patients undergoing CABG if moderate mitral regurgitation with ERO >20 mm 2 and regurgitant volume >30 mL, and 45.1% perform it if severe MR with ERO >40 mm 2 and regurgitant volume >60 mL. For these patients the preferred management was: MVR if predictors of repair failure identified (47.2%) and downsizing annuloplasty ring only (34.1%).For atrial fibrillation (AF) in cardiac surgery, 34.1% perform ablation with biatrial lesion and 20% with left sided only. 62.6% perform concomitant Left Atrial Appendage (LAA) Occlusion irrespective of AF ablation with a left atrial clip. A wide variability in anticoagulation strategies for MV repair and bioprosthetic MV valve was reported both for patients in sinus rhythm and AF., Conclusion: These results demonstrate a variable practice for MV surgery, and a degree of lack of compliance with surgical intervention guidelines and anticoagulation strategy., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

UK guidelines for MR safety recommend that MRI departments refer to the implant manufacturer for advice regarding the MRI safety of scanning patients with an implantable medical device prior to scanning. This process of assuring safety can be time consuming, leading to delays and potential cancellations of a patient's MRI. Furthermore, at times the implant cannot be identified, or the implant manufacturers cannot provide up to date MRI safety information. The purpose of generic implant safety procedures is to define a process for managing patients with certain types of implants where the risk from scanning is low. This process incorporates scope for an evidence-based risk-benefit decision to scan some groups of patients under locally approved conditions, without seeking to identify the exact make and model of the implant and subsequent assurance of MR safety from the implant manufacturer. This publication provides best practice recommendations from a multi-professional working group for the development of these procedures. It is supported by The Institute of Physics and Engineering in Medicine, The Society of Radiographers, The Royal College of Radiologists, The British Institute of Radiology, The British Association of MR Radiographers, The International Society of Magnetic Resonance in Medicine British and Irish Chapter, and the NHS Scotland MRI Physics Group., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Institute of Radiology.)

Objectives: Oral HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV, but its efficacy depends on adequate absorption of drug, which may decrease following gastrointestinal surgery., Methods: Clinicians across eight Genito-urinary Medicine clinics in the United Kingdom submitted data on PrEP users with history of gastrointestinal surgery who were referred to a national complex PrEP multi-disciplinary team between June 2021 and April 2023. Anonymised data were submitted on demographics, surgical history, PrEP regimen, and results of therapeutic drug monitoring (TDM) and HIV screening tests. Descriptive analyses were performed in SPSS version 29., Results: Nine cases described cis-gender men-who-have-sex-with-men (MSM) with median age of 47.4 years (IQR = 43 - 56.5) taking tenofovir disoproxil (TDF)/emtricitabine (FTC) daily ( n = 8) or event-based ( n = 1) as PrEP. Median time between PrEP initiation and TDM was 53 days (IQR = 8.5-1705). The mean (±SD) trough concentration of tenofovir (TFV) and FTC were 90.2 ± 27.7 ng/mL and 76.0 ± 45.9 ng/mL, respectively. All patients had a negative HIV test at follow-up., Conclusions: Plasma trough concentrations of TFV observed in our cohort taking TDF/FTC were above the expected concentrations associated with PrEP efficacy as previously described in the literature, suggesting that PrEP can be safely given in this population, with TDM used for reassurance.

Objective: The aim of this study was to identify the prevalence of emergent integrase drug resistance mutations (INSTI-DRMs) in international referrals to a perinatal virtual clinic (PVC)., Design: A retrospective cohort study., Setting: Monthly multidisciplinary PVC reviewing complex case management for children and adolescents with perinatally acquired HIV (CAWHIV)., Participants: One hundred fourteen cases referred for virological failure between October 2018 and January 2024., Main Outcome Measures: Data collected included age, sex, weight, country of residence, antiretroviral therapy (ART) history, HIV viral load, CD4 + cell count, and comorbidities. Resistance mutations were interpreted using the Stanford HIV Drug Resistance database with emergent major INSTI-DRMs described., Results: Of 114 referrals, 103 (90%) had resistance sequences available. Prior INSTI exposure was documented in 61/103 (59%) with 19/61 (31%) having INSTI-DRMs. For these 19, median (IQR) age was 11 years (6-14), weight 25 kg (17-50), CD4 + cell count 485 cells/μl (153-805), and viral load 84 000 copies/ml (2380-137 000). Twelve of 19 (65%) were from low/middle-income countries (LMIC), 6/19 (32%) had current AIDS diagnoses with 14/19 (74%) referred from 2022 onwards. There were a median three prior regimens with 13/19 (68%) having at least 3 class resistance. Two developed INSTI-DRMs on first-line dolutegravir (DTG)-based ART, 17 on second+ line therapy. PVC recommendations were for tenofovir+ lamivudine/emtricitabine (six split adult tablets) with boosted darunavir [19; six twice daily (b.i.d.)], with b.i.d. DTG (6), plus fostemsavir (1) and ibalizumab (1)., Conclusion: Although uncommon, INSTI resistance is emerging, mainly in highly treatment experienced CAWHIV from LMIC, highlighting the global need for access to boosted protease inhibitors and novel classes, including formulations for children less than 35 kg., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Background: Nursing sensitive indicators are a way of measuring aspects of patient care that are most affected by the actions of the nurse. Despite the existence of nursing sensitive indicators, these are largely not suitable to measure peritoneal dialysis nursing practice., Objective: This project aimed to co-develop a set of peritoneal dialysis nursing-sensitive indicators., Design: Informed by the Donabedian quality framework (structure, process, outcome), a multinational co-production consensus design was used., Participants and Measurements: First, an expert panel of seven professionals proposed potential indicators from clinical expertise and examining peer-reviewed articles and clinical guidelines. Next, the expert panel undertook a consensus building process involving face-to-face meetings and online discussion to refine the indicators. Lastly indicator confirmation was undertaken using a 5-point rating scale involving delegates at a major conference., Results: The initial indicator proposal, based on evidence and clinical experience, identified 65 potential indicators (20 structural, 22 process and 23 outcome). The consensus process involved discussion and negotiation to reduce the potential indicators to 28 (eight structural, 12 process and eight outcome). Confirmation involved 25 nurses with all 28 indicators supported (all > 3.5/5). Indicators highly supported were patient satisfaction, fluid balance assessment, peritoneal dialysis catheter exit-site, clinical signs measurement, peritonitis investigation, peritoneal dialysis catheter complications referral and infection rates., Conclusion: Following further validity, reliability and feasibility testing, these nursing sensitive indicators can be used to measure the quality of peritoneal dialysis nursing care provided for patients and families., (© 2025 The Author(s). Journal of Renal Care published by John Wiley & Sons Ltd on behalf of European Dialysis & Transplant Nurses Association/European Renal Care Association.)

In the past decade, genetic testing for cardiac disease has become part of routine clinical care. A genetic diagnosis provides the possibility to clarify risk for relatives. For family planning, a genetic diagnosis provides reproductive options, including prenatal diagnosis and preimplantation genetic testing, that can prevent an affected parent from having a child with the genetic predisposition. Owing to the complex genetic architecture of cardiac diseases, characterized by incomplete disease penetrance and the interplay between monogenic and polygenic variants, the risk reduction that can be achieved using reproductive genetic testing varies among individuals. Globally, disparities, including regulatory and financial barriers, in access to reproductive genetic tests exist. Although reproductive options are gaining a prominent position in the management of patients with inherited cardiac diseases, specific policies and guidance are lacking. Guidelines recommend that prenatal diagnosis and preimplantation genetic testing are options that should be discussed with families. Health-care professionals should, therefore, be aware of the possibilities and feel confident to discuss the benefits and challenges. In this Review, we provide an overview of the reproductive options in the context of inherited cardiac diseases, covering the genetic, technical, psychosocial and equity considerations, to prepare health-care professionals for discussions with their patients., Competing Interests: Competing interests: J.S.W. has consulted for Foresite Labs, Health Lumen, MyoKardia, Pfizer and Tenaya Therapeutics and receives research support from Bristol Myers Squibb. J.I. receives research grant support from Bristol Myers Squibb. The other authors declare no competing interests., (© 2024. Springer Nature Limited.)

This article summarises the Joint British Diabetes Societies for Inpatient Care (JBDS-IP) Group guidelines on the use of technology to support diabetes care in hospital. The guideline incorporates two main areas: (i) use of wearable technology devices to improve diabetes management in hospital (including continuous glucose monitoring and insulin pump therapy) and (ii) information technology. Although it is reasonable to extrapolate from the evidence available, that devices developed to enhance diabetes care outside hospital will show similar benefits, there are challenges posed within the inpatient setting in hospital. This guidance provides a pragmatic approach to supporting self-management in individuals using wearable technology admitted to hospital. Furthermore, it also aims to provide a best practice guide for using information technology to monitor diabetes care and communicate between health professionals., (© 2024 The Author(s). Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Aims: To develop a position statement that identifies research priorities in diabetic kidney disease and provides recommendations to researchers and research funders on how best to address them., Methods: A one-day research workshop was conducted, bringing together research experts in diabetes and kidney disease, healthcare professionals, and people living with diabetes, to identify and prioritise research recommendations., Results: The following key areas were identified as needing increased focus: Understanding causal mechanisms in diabetic kidney disease Prevention of diabetic kidney disease Addressing health inequalities Improving diagnosis Improving care Supporting self-management CONCLUSIONS: This position statement outlines recommendations to address the urgent need to tackle diabetic kidney disease and calls on the diabetes and kidney research communities to act upon these recommendations to ensure future research works to eliminate unfair and avoidable disparities in health., (© 2025 Diabetes UK.)

Purpose: Dietary modification is one tool in the multidisciplinary and multi-faceted management of malignant bowel obstruction (MBO). However, the evidence for this has not been systematically explored and no guidelines currently exist. The purpose of this review was to identify the type and breadth of published evidence available to support the use of dietary modification in MBO, and to identify key characteristics of dietary interventions and outcome measures used in evaluating these interventions., Methods: Systematic searches of three databases were conducted, last in September 2024. Title and abstract screening and full-text review were conducted before data were extracted using a data extraction tool., Results: Only seven records met the criteria for inclusion. Quality of interventions was low, with four abstracts, one retrospective review and two feasibility studies identified. Most interventions focused on gynaecological cancers, where MBO is most prevalent. Key characteristics of dietary modification included a low-fibre diet and modification of the texture of the diet. These approaches were often used in conjunction and in a stepwise manner (progressing from liquid to soft to low-fibre diet). All records reported benefit of dietary modification, but with limited justification. The number, type and quality of records retrieved might reflect that this is a novel area of research, with local practice and clinical experience being published as abstracts. We found no methodologically robust, large-scale interventions., Conclusion: This review demonstrates a lack of evidence to support the use of dietary modification in MBO. High-quality studies assessing the efficacy and impact of dietary modification are needed to support the advice commonly being provided in clinical settings. However, this research is ethically and logistically challenging to conduct. Nutritional management guidelines based on expert consensus might be a useful resource for clinicians managing MBO given the lack of research evidence currently available to inform practice., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Early detection of thin, stage 1A melanoma is crucial in improving patient outcomes, but this can be clinically challenging in patients with multiple atypical naevi. We report an observational study evaluating the effectiveness of a UK based Clinical Nurse Specialist (CNS) led total body photography (TBP) and sequential digital dermoscopic imaging (SDDI) programme, for patients at high risk of developing melanoma. 1680 patients underwent 6890 TBP and SDDI sessions, with 345 excision biospsies of clinically suspcious melanocytic lesions performed (5% sessions). Twenty-one pT1a and pT1b melanomas (6.1% of biopsies), 20 melanoma-in-situ (5.8% biopsies) and 150 dysplastic naevi (43.5% biopsies) were identified. Mean Breslow Thickness (BT) was 0.52mm (range 0.2-1mm). 95.2% of melanomas had a BT of <0.8mm without ulceration (pT1a), and the number needed to biopsy (NNB) was 8.41. Our UK experience demonstrates that a nurse-led programme of TBP with SDDI can be a clinically effective strategy for detection of early melanoma and melanoma-in-situ., (© The Author(s) 2025. Published by Oxford University Press on behalf of British Association of Dermatologists. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Introduction: Survival from ovarian cancer in the UK is poor compared with international comparators. The Ovarian Cancer Audit Feasibility Pilot demonstrated variation in 1-year and 5-year survival across the UK as well as significant variation in treatment rates. In 2020, IMPROVE-UK was established as the first major programme to address inequalities in ovarian cancer management and survival across the UK, to develop a legacy of best practice sharing across the country and to establish and evaluate quality improvement projects that could drive care at scale., Methods: Following a competitive process, seven quality improvement projects were funded to address inequalities in care and identify strategies to improve and equalise survival rates for all women with ovarian cancer in the UK, to address health inequalities from geography, age or ethnicity., Results: Projects addressed the secondary care diagnostic pathway, genomic testing, prehabilitation and improving treatment-related decision-making, particularly decisions for surgery. All seven projects at least partial achieved their aims with numerous areas across all projects identified where processes could be refined and incorporated into standard care to improve outcomes of women diagnosed with ovarian cancer. Dissemination of information regarding best practice has been undertaken., Conclusion: IMPROVE-UK was the first programme of its kind addressing significant inequalities of care in women with ovarian cancer. We demonstrate systematic quality improvement projects in ovarian cancer targeting various aspects of the treatment journey. Scaling up the results of the improve UK pilots is likely to improve survival in the UK and potentially internationally., Competing Interests: Competing interests: AJP: nil to declare. RB: nil to declare. MW declares chair of the 'Impact and Metrics' subgroup of the Clinical Academic Research Implementation Network (CARIN), membership of the NCRI Head and Neck cancer Survivorship and Epidemiology subgroup, the Macmillan Cancer Support Nursing Advisory group and the NIHR Clinical Doctoral Research Fellowship panel. She is also on the Fellowships committee of the Imperial Health Charity. IM has sat on Advisory Boards for Clovis Oncology, Tesaro/GSK, AstraZeneca, OncoC4, Theolytics, Epsila Bio, Duke St Bio, Scancell, Roche and Takeda. Co-chief investigator ARIEL2 (Clovis Oncology) Chief Investigator OCTAVE (PsiOxus Therapeutics) Chief Investigator BriTROC-1 and BriTROC-2 His institution receives grant support from AstraZeneca SS declares Honararia from Astrazeneca and MDT that is unrelated to this work., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Human papillomavirus (HPV)-associated cervical cancer risk is greater in people with HIV, although this has been at least partially attenuated by antiretroviral medication, enhanced cervical screening and HPV vaccination. People with perinatally acquired HIV may remain at higher risk due to lifelong immunosuppression and potentially reduced vaccine effectiveness. In this study in people with a cervix with perinatally acquired HIV, we explored cervical high-risk HPV (hrHPV) prevalence and HPV serostatus., Methods: Participants were recruited from a London HIV service between 2020 and 2022. Cervical samples from those sexually active were analysed for hrHPV (Cepheid GeneXpert) and cytology, and, if abnormal, a referral was made to colposcopy. Serum samples were tested for antibodies against HPV6/11/16/18/31/33/45/52/58. A self-reported questionnaire including HPV vaccination history was completed., Results: Fifty-seven people were recruited with a median age of 25 years (range 18-34). Of those providing a cervical sample, 15/47 (32%) were hrHPV-positive and 12/40 (30%) had abnormal cytology; 1/17 referred for colposcopy had CIN2 (6%); 7/15 (47%) with hrHPV were below the national screening age of 24.5 years (range 19-23), and 9/15 (60%) reported previous HPV vaccination. No vaccinated participants had hrHPV16/18. Of those vaccinated, 37/39 (95%) were seropositive for HPV16 and 30/39 (77%) for HPV18. Two vaccinated participants were seronegative for HPV16/18; both had detectable HIV viral loads and CD4 counts <200 cells/μL at recruitment., Conclusion: In this small observational study we identified a 32% prevalence of cervical hrHPV. Cervical screening and HPV vaccination remain vital in this group, with further data required to inform screening guidelines for this population., (© 2025 The Author(s). HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association.)

Introduction: The definition of pulmonary hypertension (PH) was recently changed and led to a new subset of PH patients with mildly impaired pulmonary haemodynamics, characterised by a mean pulmonary artery pressure (mPAP) of 21-24 mmHg and with a pulmonary vascular resistance (PVR) >2 WU. We evaluated the association of PH-targeted therapy and outcome in mild precapillary PH using the PVRI GoDeep meta-registry., Methods: All patients with mild precapillary PH (mPAP 21-24 mmHg, pulmonary arterial wedge pressure ≤15 mmHg and PVR >2 WU) diagnosed with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) were enrolled. Patients were considered as "treated" if PH-targeted therapy was initiated within 6 months of diagnostic right heart catheterisation. Various statistical models, including in-depth sensitivity analyses, were used to examine the association between PH-targeted therapy and transplant-free survival., Results: 132 patients with group 1 or group 4 mild PH were identified, of whom 34 patients received PH-targeted therapy. There were no differences in baseline haemodynamics between untreated and treated groups, whereas treated patients suffered more frequently from renal comorbidities and required long-term oxygen treatment more often. Most prescribed were phosphodiesterase-5-inhibitors. PH-targeted therapy was associated with significantly higher survival rates. Cox-regression analyses revealed significantly reduced hazard ratios among treated patients adjusted for various confounders. Subgroup analyses in PAH (n=78) similarly indicated higher survival rates and reduced hazard ratios in treated patients., Conclusion: PH-targeted therapy may be associated with improved survival in PAH and CTEPH patients with mild PH. To mitigate potential bias of the results due to the retrospective study design, randomised controlled trials are warranted., Competing Interests: Conflict of interest: A. Yogeswaran reports nonfinancial support from the University of Giessen during the conduct of the study, and personal fees from MSD outside the submitted work. P.M. Hassoun reports personal fees from Merck Co., outside the submitted work. M.R. Wilkins reports personal fees from MorphogenIX, Janssen, Chiesi and Aerami, grants from the British Heart Foundation and the NIHR, personal fees from MSD, Benevolent AI and Tiakis Biotech, outside the submitted work; in addition, M.R. Wilkins has a patent Zip12 as a drug target issued. Dr Howard reports personal fees and nonfinancial support from Janssen, personal fees from MSD, personal fees from Gossamer, personal fees from Altavant, outside the submitted work. H.A. Ghofrani reports grants from the German Research Foundation and nonfinancial support from the University of Giessen during the conduct of the study, and personal fees from Bayer, Actelion, Pfizer, Merck, GSK and Takeda, grants and personal fees from Novartis, Bayer HealthCare and Encysive/Pfizer, and grants from Aires, the German Research Foundation, Excellence Cluster Cardiopulmonary Research and the German Ministry for Education and Research, outside the submitted work. W. Seeger reports grants from the German Research Foundation and nonfinancial support from the University of Giessen during the conduct of the study, and personal fees from Pfizer and Bayer Pharma AG outside the submitted work. K. Tello reports nonfinancial support from the University of Giessen during the conduct of the current study and speaker honoraria from Actelion and Bayer outside the submitted work. All other authors declare no conflicts of interest., (Copyright ©The authors 2025.)

Study Question: How does two-consecutive single embryo transfer (2xSET) affect reproductive outcomes of IVF and ICSI compared to double embryo transfer (DET)?, Summary Answer: Two-consecutive SET may provide greater or comparable live birth rate (LBR); with lower multiple birth, preterm birth, and pregnancy loss or neonatal death rates compared to DET., What Is Known Already: Elective SET in IVF/ICSI is widely encouraged over DET to minimize the risk of multiple births and associated morbidities. Despite this, multiple birth rates following IVF remain higher than the 10% target across Europe and the USA. Currently, the majority of evidence regarding SET and DET is based on various studies assessing outcomes such as LBR per treatment cycle, as opposed to per oocyte retrieval. As such, the representation of SET is mostly unfavourable. Analysis of cumulative LBR following the transfer of two embryos over consecutive cycles, rather than in one transfer event (DET) is more effective at distinguishing the two methods and will therefore provide more valuable information relevant to clinical practice., Study Design, Size, Duration: This retrospective cohort study was conducted using Human Fertilisation and Embryology Authority (HFEA) register data, which encompasses national data from all IVF clinics in the UK. All women who underwent their first oocyte retrieval and IVF or ICSI treatment cycle with subsequent SET, DET, or 2xSET between 2010 and 2019 using blastocyst embryos were included (N = 71 807)., Participants/materials, Setting, Methods: The rate of live birth, liveborn baby rate, multiple birth, preterm birth, and pregnancy loss or neonatal death was compared between SET, DET, and 2xSET IVF/ICSI pregnancies using blastocyst-stage embryos, where data were stratified by maternal age. Data analysis was conducted in RStudio v4.2, alpha equals 0.05., Main Results and the Role of Chance: Blastocyst-stage 2xSET achieved a greater median LBR of 0.47 (interquartile range [IQR] 0.13) than SET, 0.41 (IQR 0.13), and DET, 0.38 (IQR 0.13) (P < 0.05). Using SET as the reference standard, 2xSET was associated with a significantly lower odds of multiple births compared to DET ((odds ratio [OR] 6.87, 95% CI 6.14-7.68) vs 28.20, 95% CI 25.20-31.57). The odds of preterm birth were also lower following 2xSET (OR 1.11, 95% CI 1.06-1.15) compared to DET (OR 2.80, 95% CI 2.67-2.94). Similarly, the odds of pregnancy loss or neonatal death were lower following 2xSET (OR 1.14, 95% CI 1.08-1.21) compared to DET (OR 2.11, 95% CI 1.98-2.24). LBR was consistently higher following 2xSET than DET and SET in women aged 39 years and under (P < 0.05). However, results were comparable in women over 39 years (P > 0.05). Across all age groups, DET pregnancies had the highest multiple birth rate (P < 0.05). In women aged 39 years and under, DET was associated with the highest preterm birth rate (P < 0.05), whereas the rate was comparable across cohorts in women over 39 (P > 0.05). Moreover, pregnancy loss and neonatal death rates were highest following DET in women aged 37 years and under (P < 0.05), and comparable to SET and 2xSET in women over 37 years (P > 0.05)., Limitations, Reasons for Caution: Certain confounders are not recorded within HFEA registry data, including patient BMI, evaluation of embryo quality, and endometrial thickness at embryo transfer. Consequently, while our analysis identifies broad trends in embryo transfer success and morbidity, results may differ within certain patient populations., Wider Implications of the Findings: Blastocyst-stage 2xSET may provide greater LBR in women aged 39 years and under, and comparable LBR in women over 39 years old, with overall lower multiple birth and morbidity than DET. 2xSET should be considered first-line among certain patient cohorts, including women with advanced maternal age to improve reproductive outcomes and reduce the risk of morbidity following ART., Study Funding/competing Interest(s): No external funding was used for this study. None of the authors has any conflicts of interest., Trial Registration Number: This cohort study did not require registration. Following consultation with the Institutional Review Board at Imperial College London, ethical approval was not deemed necessary., (© The Author(s) 2025. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.)

Introduction and Hypothesis: Urinary tract infections (UTIs) are one of the most common reasons for seeking medical review worldwide. Women are disproportionately affected, with a life-time incidence of 50%. Women presenting with clinical symptoms of UTI such as dysuria and urinary frequency can often have negative urine culture results, especially if they have been taking multiple courses of antibiotics. This can make the diagnosis and management of recurrent or chronic UTI challenging. In this study we compared the culture results of urine and bladder tissue in women undergoing rigid cystoscopy presenting with lower urinary tract symptoms. We hypothesise that a biopsy of the bladder wall might be more likely to reveal a causative uropathogen on culture than urine., Methods: Women had clean-catheter urine samples sent for urine culture and then bladder biopsies taken at cystoscopy cultured for uropathogens. Culture results from urine and bladder tissue were analysed and compared., Results: We found that under 10% of urine cultures were positive (n = 30), whereas 51% of bladder tissues cultures grew a uropathogen (n = 155). Analysis showed that the culture results of urine and bladder tissue did have a statistically significant relationship (p = 0.008). Culture of bladder tissue revealed a wider variety of uropathogens., Conclusions: This study proposes that cystoscopy with a bladder biopsy for culture might be a useful adjunctive tool in selected women with refractory symptoms of urine infection., Competing Interests: Declarations. Ethical Approval: Ethical approval for this study was obtained from the Imperial College Healthcare NHS Trust Research and Development Department. Conflicts of Interest: V.K.: consultant for AbbVie, acceptance of paid travel expenses or honoraria from GSK., (© 2025. The International Urogynecological Association.)

Competing Interests: Conflicts of interest: The authors declare no conflicts of interest.

Objective: The Sedation and Weaning in Children (SANDWICH) trial of a sedation weaning and ventilator liberation bundle had a primary outcome of time to successful extubation, and showed significant but small difference. We explored the impact of the intervention on infants with bronchiolitis., Design: Post hoc subgroup analysis of a cluster-randomized trial, 2018 to 2019 (ISRCTN16998143)., Patients: Surviving patients with bronchiolitis under 1 year of age in the SANDWICH trial (n = 784)., Interventions: Nil., Measurements and Main Results: Time to successful extubation, and rates of unplanned and failed extubation were compared in patients exposed and not exposed to the intervention. To explore a site-level effect, we tested the correlation between the rate of unplanned and failed extubation at each trial site with the median time to successful extubation at that site. Of 784 patients (48%), 376 were exposed to the intervention. Median (interquartile range [IQR]) time to successful extubation was 69.6 (IQR 50.4-110.4) hours in patients exposed to the intervention and 86.4 (IQR 60-124.8) hours in non-exposed. Exposure to the SANDWICH intervention was associated with a 13% (95% CI, 1%-26%) reduction in time to extubation following adjustment for confounders. Thirty (3.8%) patients experienced unplanned extubation and 112 (14%) failed extubation. Patients who experienced failed extubation had an increased time to successful extubation, which remained significant after adjustment for confounders. At the site level, there was a negative correlation between failed extubation rate and median time to successful extubation (Spearman rho -0.53 [95% CI, -0.8 to -0.08], p = 0.02)., Conclusions: In a secondary analysis of the SANDWICH trial, the subgroup of bronchiolitis patients showed that exposure to the intervention was associated with a clinically significant reduction in time to successful extubation. Although failed extubation was associated with increased duration of ventilation in an individual, sites with higher rates of failed extubation had a lower median duration of ventilation., Competing Interests: Dr. Blackwood’s institution received funding from the National Institutes of Health. Dr. Ray’s institution received funding from the National Institute of Health Research (NIHR) Great Ormond Street Hospital Biomedical Research Centre, the U.K. NIHR, the Engineering and Physical Sciences Research Council, and La Roche Ltd. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: The aim of the study was to assess the feasibility of conducting a definitive multicentre randomised controlled trial (RCT) testing an online exercise rehabilitation and behavioural/motivational support intervention for people with postural tachycardia syndrome (PoTS)., Design: Feasibility RCT., Setting: Two secondary care centres., Participants: Adults aged 18 to 60 years with PoTS. Exclusions were serious mental health/cognitive problem preventing safe participation; currently undertaking physical activity equivalent to the Chief Medical Officer guidelines; pregnancy., Interventions: Participants were randomly assigned (1:1) to best-practice usual care (a single 1:1 session of advice) or the 'postural tachycardia syndrome exercise' (PULSE) intervention: (1) individual online consultation, (2) 12 weeks of supervised online group exercise and behavioural/motivational support, and (3) home exercise programme with recumbent exercise bike., Outcomes: The primary outcome was feasibility: (1) patients screened, eligible, recruited, randomised, withdrawn; (2) adherence; (3) physiological, clinical and patient-reported outcomes (4 and 7 months); and (4) embedded qualitative study to evaluate acceptability., Results: 209 patients screened between 5 May 2021 and 1 December 2022, 44 (female 98%; age 29.9 SD, 7.5) were randomised to usual care (n=21) or PULSE (n=23) (71% of target). Follow-up at 4 months was n=12 and n=17 respectively (66% of target). Median live exercise/support session attendance was 15 (IQR 12 to 17) of 18 sessions. Home exercise bike usage was highly variable. There were two serious adverse events in each treatment arm, both unrelated to the trial. Exercise rehabilitation was considered important by participants, and trial procedures, outcomes and interventions were acceptable., Conclusions: The PULSE trial procedures and interventions were acceptable, and important design considerations were identified. A definitive RCT testing a remotely supervised exercise rehabilitation and behavioural/motivational support intervention for people with PoTS is feasible in the UK National Health Service., Trial Registration Number: ISRCTN45323485., Competing Interests: Competing interests: GM is a director of Atrium Health Ltd, a non-profit cardiopulmonary rehabilitation provider, which provided the treatment hub for the PULSE trial. HS is a director of Health Psychology Services Ltd, a private health psychology provider. JB is supported by NIHR Research Capability Funding via university Hospitals Coventry and Warwickshire NHS Trust. HE is funded by a British Heart Foundation Nursing PhD fellowship award. LK is a trustee of PoTS UK. BE, GD, SH, SWH, PH, NH, SJ, PBL, AN, NP, SaP, GP, RP, ES, JS, AZ and ShP do not declare any competing interests., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Competing Interests: Declarations. Competing interests: The authors declare no competing interests.

Objectives: Ventilator-associated lower respiratory tract infections (VALRTIs) are among the most common ICU-acquired infections in patients receiving invasive mechanical ventilation (IMV). Immunocompromised patients may have a lower incidence of VALRTI when compared with nonimmunocompromised patients, but the influence of the type of immunosuppression on the epidemiology of VALRTI has not been investigated. The study objectives were to assess the association of the type of immunosuppression with the incidence, microbiology, and outcomes (ICU mortality, ICU length of stay, and duration of IMV) of VALRTI related to bacterial pathogens., Design: Multicenter, international retrospective cohort study., Setting: One hundred eighteen ICUs (118) in nine countries., Patients: Eight hundred fifty-four immunocompromised adult patients (median age, 65 yr; 57.6% males) requiring IMV for greater than 48 hours, including 162 with hematologic malignancies., Interventions: None., Measurements and Main Results: Patients with hematologic malignancies had a lower 28-day cumulative incidence of bacterial VALRTI than patients with other types of immunosuppression (13.6% vs. 20.1%; adjusted cause-specific hazard ratio, 0.61; 95% CI, 0.37-0.97), mostly due to a lower incidence of ventilator-associated pneumonia (9.3% vs. 13.9%). The proportion of VALRTI cases related to multidrug-resistant bacteria was similar between groups. Occurrence of bacterial VALRTI was associated with an increased mortality and a longer ICU length of stay, but this effect was independent of the type of immunosuppression., Conclusions: Patients with hematologic malignancies had a lower 28-day cumulative incidence of bacterial VALRTI than patients with other types of immunosuppression, mainly due to a lower incidence of ventilator-associated pneumonia., Competing Interests: Dr. Kreitmann’s institution received funding from BioMérieux and has been employed by Transgene. Drs. Póvoa, Rouzé, and Nseir received funding form Gilead and MSD. Dr. Rouzé received funding from Mundipharma. Dr. Nseir received funding from Pfizer, BioMérieux, Fisher and Paykel, and BioRad. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2025 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Competing Interests: Competing interests: None declared.

Objectives: Patients in intensive care units (ICUs) are potentially more vulnerable to medication errors than patients admitted to general wards. However, little is known about medication safety strategies used in European ICUs. Our objectives were to explore the strategies being used and being planned within European ICUs, to identify areas of variation, and to inform recommendations to improve medication safety in this patient group., Methods: We distributed an online survey, in seven European languages, via professional networks and social media. The survey explored a range of medication safety strategies and whether they were in use (and if so, whether fully or partially implemented) or being planned. Demographic information about respondents and their ICUs was also captured. A descriptive analysis was conducted, which included exploring geographical variation., Results: We obtained 587 valid responses from 32 different countries, with 317 (54%) completed by pharmacy staff. Medication safety practices most commonly implemented were patients' allergies being visible for all staff involved in their care (fully implemented in 382 (65%) of respondents' ICUs), standardised emergency medication stored in a fixed place (337, 57%), and use of standardised medication concentrations for commonly used intravenous infusions (330, 56%). Electronic prescribing systems were fully implemented in 310 (53%). A pharmacist was reported to be fully implemented in 181 (31%) of ICUs, of which there was 126 (70%) where there was a pharmacist review of all ordered medication five days per week. Critical care pharmacists were most common in Northern European ICUs (fully implemented to ICUs in 102, 50%) and electronic prescribing in Western Europe (108, 65%)., Conclusions: There is considerable variation in medication safety strategies used within European ICUs, both between and within geographical areas. Our findings may be helpful to ICU staff in identifying strategies that should be considered for implementation., Competing Interests: Competing interests: RL and VS are associate editors of the European Journal of Hospital Pharmacy. BDF is the co-editor in chief of BMJ Quality and Safety. There are no other competing interests.The work of the EAHP Special Interest Group for the Investigation of Medication Errors in Intensive Care Units was financially supported by Becton Dickinson (BD) (no grant number). This is independent research supported by BD and carried out at the National Institute for Health and Care Research (NIHR) North West London Patient Safety Research Collaboration (PSRC) (grant number: PSTRC-2016-004). The views expressed are those of the author(s) and not necessarily those of the BD, the NIHR or the Department of Health and Social Care., (© European Association of Hospital Pharmacists 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Background: Despite current antiplatelet therapy, patients remain at risk of recurrent ischemic events after acute coronary syndromes (ACS), which may reflect persistently elevated thrombin generation. Factor XIa inhibition reduces thrombin generation and may improve clinical outcomes with minimal bleeding risk., Design: Librexia ACS (ClinicalTrials.gov NCT05754957) is a Phase 3, randomized, double-blind, placebo-controlled, event-driven trial to test the efficacy and safety of milvexian, an oral, selective factor XIa inhibitor, in addition to conventional antiplatelet therapy after a recent ACS. Eligibility criteria include symptoms of spontaneous ischemia, a diagnosis of ACS and cardiac biomarker elevation indicative of myonecrosis within 7 days before randomization, along with at least two risk-enhancing factors. Participants are randomly assigned to oral milvexian (25 mg twice daily) or a matched placebo. Randomization is stratified according to the planned duration and type of antiplatelet therapy. The primary efficacy endpoint is the time to first occurrence of the composite of cardiovascular death, myocardial infarction (MI), or ischemic stroke that will enroll approximately 16,000 patients with follow-up until 875 events are accrued. The first major secondary endpoint is time to the first occurrence of cardiovascular death, MI, ischemic stroke, major adverse limb events, and symptomatic venous thromboembolism. The principal safety endpoint is Bleeding Academic Research Consortium 3c or 5 bleeding., Summary: The Librexia-ACS trial will determine the efficacy and safety of milvexian after ACS and will be the first trial to test whether factor XIa inhibition in addition to standard-of-care antiplatelet therapy reduces major adverse cardiovascular events without an increased risk of significant bleeding., (Copyright © 2025 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Ischaemic heart disease (IHD) and cardiometabolic risk factors have been extensively investigated in those of European descent, yet they are more common among South Asians who make up around 20% of the world's population. We explored the differences in IHD and cumulative metabolic profile in South Asians with stroke living in the UK, India and Qatar, compared with white British stroke patients., Methods: The study included first-ever ischemic stroke white British patients and South Asians living in UK, India and Qatar from the ongoing large Bio-Repository of DNA in Stroke (BRAINS) international hospital-based stroke study., Results: We analysed 4359 patients of which 1575 were white British (WB) UK residents, 1135 British South Asians (BSA), 1084 South Asians in India (ISA), and 565 South Asians in Qatar (QSA). Stroke patients from BSA and ISA background had a 9.5% (95%CI: 6.2-12.9, P<0.001) and 15.8% (95%CI: 13.1-28.9, P<0.001) higher prevalence of IHD respectively, compared to WB patients. Adjusting for traditional stroke risk factors, BSA patients continued to display an increased association of IHD compared to WB patients: OR=1.59 (95%CI: 1.25-2.02, P<0.001). Among South Asian ethnicity, compared to ISA, BSA had an almost twice the association of IHD: OR=1.83 (95%CI: 1.37-2.45, P<0.001). The OR for the presence of 2, or ≥3 cumulative cardiometabolic risk factors was 2.55 (95%CI: 2.02-3.23, P<0.001), and 3.86 (95%CI: 3.02-4.95, P<0.001) for South Asians (ISA, BSA, QSA) compared to WB patients, respectively., Conclusion: South Asian ischaemic stroke immigrants have a higher prevalence of IHD as well as more cumulative cardiometabolic risk factors compared to those who remain on the subcontinent. Countries with large immigrant South Asian populations should focus public health campaigns to mitigate their high cardiometabolic risk profiles., Competing Interests: Declaration of Competing Interest The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported., (Copyright © 2025 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: In the dementia field, a number of applications are being developed aimed at boosting functional abilities. There is an interesting gap as to how utilising serious games can further the knowledge on the potential relationship between hearing and cognitive health in mid-life. The aim of this study was to evaluate the auditory-cognitive training application HELIX, against outcome measures for speech-in-noise, cognitive tasks, communication confidence, quality of life and usability., Methods: A randomised-controlled trial was completed for 43 participants with subjective hearing loss and/or cognitive impairment, over a play period of 4-weeks and a follow-up period of another 4-weeks. Outcome measures included an new online implementation of the Digit-Triplet-Test, a battery of online cognitive tests and quality of life questionnaires. Paired semi-structured interviews and usability measures were completed to assess HELIX's impact on quality of life and usability., Results: An improvement in the performance of the Digit-Triplet-Test, measured four and eight weeks after the baseline, was found within the training group, however this improvement was not significant between the training and control groups. No significant improvements were found in any other outcome measures. Thematic analysis suggested HELIX prompted realisation of difficulties and actions required, improved listening and positive behaviour change., Discussion: Employing a participatory design approach has ensured HELIX is relevant and useful for participants that may be at risk of developing age-related hearing loss and cognitive decline. Whilst an improvement in the Digit-Triplet-Test was seen, it is not possible to conclude whether this was as a result of playing HELIX.

We present a case that demonstrates the novel use of consumer-grade wearable technology for the early detection of myocardial ischemia in a 48-year-old male with otherwise elusive symptoms., Competing Interests: Funding Support and Author Disclosures This study received British Heart Foundation (BHF) funding, programme grant funding to FSN (RG/F/22/110078) and BHF Centre of Research Excellence funding to Dr Ng (RE/18/4/34215 and RE/24/130023). Dr Ng is supported by the National Institute for Health Research Imperial Biomedical Research Centre. Medical Research Council (MRC) funding for clinical research training fellowship to Dr Pastika (MR/Y000803/1). BHF funding for MBPhD Studentship to Mr Zeidaabadi (FS/MBPhD/24/28032). BHF funding for clinical research training fellowship to Dr Barker (FS/CRTF/24/24624). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2025 The Authors. Published by Elsevier Inc. All rights reserved.)

Hypertrophic cardiomyopathy (HCM) is an important cause of morbidity and mortality with both monogenic and polygenic components. Here, we report results from a large genome-wide association study and multitrait analysis including 5,900 HCM cases, 68,359 controls and 36,083 UK Biobank participants with cardiac magnetic resonance imaging. We identified 70 loci (50 novel) associated with HCM and 62 loci (20 novel) associated with relevant left ventricular traits. Among the prioritized genes in the HCM loci, we identify a novel HCM disease gene, SVIL, which encodes the actin-binding protein supervillin, showing that rare truncating SVIL variants confer a roughly tenfold increased risk of HCM. Mendelian randomization analyses support a causal role of increased left ventricular contractility in both obstructive and nonobstructive forms of HCM, suggesting common disease mechanisms and anticipating shared response to therapy. Taken together, these findings increase our understanding of the genetic basis of HCM, with potential implications for disease management., Competing Interests: Competing interests: R.T. has received research support and consultancy fees from Bristol Myers Squibb. A.R.H. is a current employee and stockholder of AstraZeneca. D.P.O. has received grants and consultancy fees from Bayer. R.d.B. has received research grants and/or fees from AstraZeneca, Abbott, Boehringer Ingelheim, Cardior Pharmaceuticals GmbH, Ionis Pharmaceuticals, Inc., Novo Nordisk and Roche, and also has speaker engagements with Abbott, AstraZeneca, Bayer, Bristol Myers Squibb, Novartis and Roche. P.G. receives research funds from Abbott Cardiovascular and Medtronics. M.M. has received research support or consultancy fees from Bristol Myers Squibb, Cytokinetics, Pfizer, Sanofi Genzyme, Biomarin and Alnylam. C.M.K. received research grants from Cytokinetics and Bristol Myers Squibb. P.M.M. has received consultancy fees from Roche, Biogen, Nodthera and Sangamo Pharmaceuticals and has received research or educational funds from Biogen, Novartis, Merck and Bristol Myers Squibb. J.-C.T. has received research grants from Amarin, AstraZeneca, Ceapro, DalCor, Esperion, Ionis, Novartis, Pfizer and RegenXBio; honoraria from AstraZeneca, DalCor, HLS Therapeutics, Pendopharm and Pfizer; holds minor equity interest in DalCor; and is an author of a patent on pharmacogenomics-guided CETP inhibition. J.S.W. has received research support or consultancy fees from Myokardia, Bristol Myers Squibb, Pfizer and Foresite Labs. C.R.B. has consulted for Illumina. H.W. has consulted for Cytokinetics, BridgeBio and BioMarin. The remaining authors declare no competing interests., (© 2025. The Author(s).)

Hypertrophic cardiomyopathy (HCM) is an important cause of morbidity and mortality, with pathogenic variants found in about a third of cases. Large-scale genome-wide association studies (GWAS) demonstrate that common genetic variation contributes to HCM risk. Here we derive polygenic scores (PGS) from HCM GWAS and genetically correlated traits and test their performance in the UK Biobank, 100,000 Genomes Project, and clinical cohorts. We show that higher PGS significantly increases the risk of HCM in the general population, particularly among pathogenic variant carriers, where HCM penetrance differs 10-fold between those in the highest and lowest PGS quintiles. Among relatives of HCM probands, PGS stratifies risks of developing HCM and adverse outcomes. Finally, among HCM cases, PGS strongly predicts the risk of adverse outcomes and death. These findings support the broad utility of PGS across clinical settings, enabling tailored screening and surveillance and stratification of risk of adverse outcomes., Competing Interests: Competing interests: S.L.Z. has acted as a consultant for Health Lumen. R.T.L. has acted as a consultant for Health Lumen and Fitfile, and received funding from Pfizer. J.S.W. has acted as a consultant for MyoKardia, Pfizer, Foresite Labs and Health Lumen, and received institutional support from Bristol Myers Squibb and Pfizer. M.M. has received research support or consultancy fees from Bristol Myers Squibb, Cytokinetics, Pfizer, Sanofi Genzyme, Biomarin and Alnylam. The remaining authors declare no competing interests., (© 2025. The Author(s).)

Background: Dilated cardiomyopathy (DCM) appears to be diagnosed twice as often in male than in female patients. This could be attributed to underdiagnosis in female patients or sex differences in susceptibility. Up to 30% of cases have an autosomal dominant monogenic cause, where equal sex prevalence would be expected. The aim of this systematic review, meta-analysis, and population study was to assess the sex ratio in patients with DCM, stratified by genetic status, and evaluate whether this is influenced by diagnostic bias., Methods: A literature search identified DCM patient cohorts with discernible sex ratios. Exclusion criteria were studies with a small (n<100), pediatric, or peripartum population. Meta-analysis and metaregression compared the proportion of female participants for an overall DCM cohort and the following subtypes: all genetic DCM, individual selected DCM genes ( TTN and LMNA ), and gene-elusive DCM. Population DCM sex ratios generated from diagnostic codes were also compared with those from sex-specific means using the UK Biobank imaging cohort; this established ICD coded, novel imaging-first, and genotype first determined sex ratios., Results: A total of 99 studies, with 37 525 participants, were included. The overall DCM cohort had a 0.30 female proportion (95% CI, 0.28-0.32), corresponding to a male:female ratio (M:F) of 2.38:1. This was similar to patients with an identified DCM variant (0.31 [95% CI, 0.26-0.36]; M:F 2.22:1; P =0.56). There was also no significant difference when compared with patients with gene-elusive DCM (0.30 [95% CI, 0.24-0.37]; M:F 2.29:1; P =0.81). Furthermore, the ratio within autosomal dominant gene variants was not significantly different for TTN (0.28 [95% CI, 0.22-0.36]; M:F 2.51:1; P =0.82) or LMNA (0.35 [95% CI, 0.27-0.44]; M:F 1.84:1; P =0.41). Overall, the sex ratio for DCM in people with disease attributed to autosomal dominant gene variants was similar to the all-cause group (0.34 [95% CI, 0.28-0.40]; M:F 1.98:1; P =0.19). In the UK Biobank (n=47 549), DCM defined by International Classification of Diseases, 10th revision, coding had 4.5:1 M:F. However, implementing sex-specific imaging-first and genotype-first diagnostic approaches changed this to 1.7:1 and 2.3:1, respectively., Conclusions: This study demonstrates that DCM is twice as prevalent in male patients. This was partially mitigated by implementing sex-specific DCM diagnostic criteria. The persistent male excess in genotype-positive patients with an equally prevalent genetic risk suggests additional genetic or environmental drivers for sex-biased penetrance., Registration: URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42023451944., Competing Interests: Dr Tayal is a Freelance Research Editor at the British Medical Journal. Dr Tayal has received fees for educational content from Chiesi Medical and is a committee member of the British Cardiovascular Society and Royal Society. Dr Ware has consulted for MyoKardia, Inc, Pfizer, Foresite Labs, Health Lumen, and Tenaya Therapeutics, and receives research support from Bristol Myers Squibb. None of these activities is directly related to the work presented here. Dr O’Regan has consulted for Bayer AG and Bristol Myers-Squibb, is a committee member of the Society for Cardiovascular Magnetic Resonance, and has a patent pending for deep learning cardiac motion analysis for survival prediction in heart failure (Imperial Innovations; assignee; US20210350179A1). Dr Halliday has received honoraria from AstraZeneca. Dr de Marvao is a trustee of the Royal Brompton and Harefield Charity. Dr Lu received payment from OutSee Limited. The other authors declare no competing interests. There are no other relationships or activities that could appear to have influenced the submitted work.

Objective: To determine the prenatal progression and long-term outcome of fetal bilateral hyperechogenic kidneys (HK)., Design: Retrospective study 2005-2016. Fetal/maternal demographics, scan findings, postnatal diagnoses and outcomes were collected from electronic patient records and post-mortem reports., Results: Data available for 65 out of 72 fetuses with bilateral HK. Forty-five (69 %) had normal amniotic fluid index (AFI); of these, 23 had isolated HK and all survived the neonatal period. The remaining patients with normal AFI had other renal and multi-system anomalies; diagnoses included 13 trisomies and genetic syndromes - only one patient with suspected bladder outlet obstruction survived. Of 20 pregnancies with reduced AFI, HK were isolated in 5 fetuses, and only one survived (diagnosed with 17q12 microdeletion). The remaining 15 fetuses had multisystem anomalies and none survived; diagnoses included Meckel-Gruber Syndrome and Dandy-Walker malformation. Survival with bilateral HK and oligohydramnios was 5 %. Overall survival was 25/65 (38 %); follow-up data was available for 23 patients. HK resolved in 17 (74 %) and persisted in 6 children, who were followed-up for median 15 years (4-19 years). Of these, 3 patients developed bilateral renal cysts and were diagnosed with HNF1b/17q12 deletion kidney disease (one patient is in CKD2a, whereas the rest have normal renal function). The remaining patients were found to have a PKD1 variant; bilateral renal cysts (lost to follow-up before a genetic diagnosis) and a unilateral hydronephrosis: all have normal renal function., Conclusion: Isolated HK with normal AFI is associated with survival past the neonatal period and normal renal function in most cases (96 %). As normal kidney function may be due to glomerular hyperfiltration in early childhood to teenage years, long-term follow up is advisable, in particular for those with a genetic diagnosis that predisposes to chronic renal impairment in adulthood (HNF1b, 17q12 deletion in this study). HK in the presence of reduced AFI carries a poor prognosis, with only 5 % survival (this patient had 17q12 deletion related kidney disease). Overall survival in this study was 38 % in the first year and 34 % long-term., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest related to this submission., (Copyright © 2025 Elsevier B.V. All rights reserved.)

Background: Management of neuromuscular scoliosis (NMS) is challenging, with both surgical and conservative options involving risks. This study aimed to evaluate multimorbidity in patients with NMS and how this influences multidisciplinary team (MDT) decisions as well as postoperative outcomes., Methods: A retrospective cohort study of patients referred for assessment by the scoliosis MDT in the 8-year period between 2013 and 2021 from a single tertiary centre., Results: 84 patients with NMS were referred for assessment to the MDT. The most common underlying cause of NMS was cerebral palsy (51%). The MDT recommended surgery for 60 patients and 24 were conservatively managed. There were no significant differences in age, sex, body mass index or baseline Cobb angle between the two groups. Patients recommended surgery had fewer comorbidities (2.3 vs 3.5, p<0.05) and greater Cobb angle progression in the 18 months prior to MDT decision (22° vs 8°, p<0.05). No single comorbidity significantly influenced the MDT decision. Of the 48 patients that proceeded with surgery, immediate postoperative complications were documented in 54.1%, with no mortality. The most common complications were postoperative anaemia and respiratory infections. Multivariate logistic regression identified the use of non-invasive ventilation, forced vital capacity <70% of predicted and full-time wheelchair use as significant predictors of immediate postoperative complications. Improved posture was the most common long-term outcome (41.7%) and 81.3% of patients reported no complications at 12 months following their surgery., Conclusions: Multimorbidity in children with NMS influences scoliosis MDT decisions, alongside factors such as scoliosis curve progression. Immediate postoperative complications were common but longer term outcomes were favourable for most patients. Further research aiming to better inform shared decision-making, improve surgical selection and ultimately enhance the quality of life for patients with NMS is required., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)