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Item 126 Hormone replacement therapy (HRT) in women after myocardial infarction (MI)/ischaemic heart disease(2026-06-09)Introduction Women with diagnosed menopause suffer from symptoms that are often debilitating and impair their quality of life. Post menopausal symptoms are commonly managed with hormone replacement therapy (HRT) to provide relief and improvement in quality of life. However, given the complex role of HRT in cardiovascular risk, its use in post-menopausal women after a myocardial infarction remains controversial. Furthermore, the European Society of Cardiology, NICE, American Heart Association and British Menopause Society do not provide an agreed guidelines regarding initiation, continuation, cessation or modification of HRT post myocardial infarction (MI.) This results in inconsistent decision making with a clear need to standardise post MI management of HRT in hospitals. Oestrogen affects remodelling and thrombogenesis in a dose dependent risk therefore higher doses may cause adverse effects whereas lower doses and non-oral routes are known to be neutral or even be beneficial. The consensus from the British Menopause Society (BMS) is that there are no absolute contraindications for the use of HRT post MI with the current data also suggesting the prioritisation of symptom management with the lowest possible dose using a non-oral form of HRT.1 Additionally, the synergistic effect of combining HRT and statins yields greater improvement in Lipid profile than either therapy alone.2 The aim of this quality improvement project was to assess local practice, educate regarding current evidence and guidance available as well as develop local guidelines to provide a safe approach backed with current data on HRT prescribing post MI. Methods Retrospectively, data of all patients presenting with ACS at our local trust over the past 1 year were reviewed. Post menopausal women with confirmed STEMI/NSTEMI were included, whereas women of pre-menopausal age or non-MI diagnosis were excluded from our review. For each eligible patient, GP records as well as admission medication charts were examined to determine if HRT was started, continued, changed or discontinued following MI admission. Furthermore, a survey involving clinicians was conducted in our local cardiology department. The aim of the survey was to assess confidence when dealing with HRT in MI patients, awareness of BMS guidance and their usual practice. We used the results of these to guide a change within our department. With the help of gynaecology team and pharmacists, we formed a local guidance to inform clinicians of the current BMS recommendation, including suggested preferential routes/dosing of HRT post-MI. Results A total of 178 patients were screened, of whom 14 were taking HRT. 3 of these patients were not prescribed pre-existing HRT on admission, 6 had HRT continued as previously prescribed, and 5 patients had their HRT discontinued (table 1). There were no adjustments made to any existing HRT routes or dosages. From our departmental survey, we established that 88.89% of clinicians were not aware of BMS guidance on HRT prescribing in MI patients and similarly >66% did not feel confident managing HRT post MI (table 2). Conclusions This project identified that HRT prescribing in women following MI is inconsistently and often poorly managed, largely due to clinician uncertainty and outdated perceptions regarding cardiovascular risk. Consequently, many women are left without appropriate symptom control. This highlights a broader and well recognised issue within healthcare where women’s health concerns are frequently misjudged. Given that cardiovascular disease remains the leading cause of mortality in women, addressing gender-specific health needs should be an integral part of post MI care. The results from both our audit and survey showed a significant lack of confidence and avoidance when dealing with HRT. Consequently, we established local guidelines; the goals of which were to provide clear, evidence-informed, safe, and pragmatic recommendations for assessment, initiation, and ongoing prescribing of HRT in women who have sustained a MI. The guidelines are in keeping with British Menopause Society guidance, and local Cardiology and Gynaecology teams’ input. It also included a flowchart to aid clinicians further (appendix 1). These received excellent feedback from the local teams with reports of improved confidence and knowledge in managing women’s health post myocardial infarction. The development and implementation of clear, evidence-based guidance outlining how HRT can be safely prescribed in this patient group represents an important initial step towards improving clinical practice. It provides a practical framework to support clinician decision making and empower shared discussions with patients. Ultimately, sustained change will require on-going education, cultural shifts in prioritising women’s health with more evidence and multi-disciplinary collaboration to ensure that symptom burden, quality of life and CV outcomes are addressed in parallel.Item 382 The impact of paced ECG duration on CRT-P upgrade outcomes: an observational study(2026-06-09)Background Upgrading from dual-chamber pacemakers (DDD) to cardiac resynchronisation therapy pacemakers (CRT-P) can significantly improve left ventricular (LV) function in selected patients. However, the predictive role of electrophysiological features, including QRS duration and morphology, and the presence of atrial fibrillation (AF), remains unclear. Purpose We aimed to assess (1) whether post-upgrade QRS narrowing correlates with left ventricular ejection fraction (LVEF) response, and (2) whether baseline paced QRS duration predicts the degree of LVEF improvement after CRT-P upgrade. Methods We conducted a retrospective, single-centre analysis of 71 patients who underwent DDD-to-CRT-P upgrades between 2018 and 2024. Complete echocardiographic and electrocardiographic data were available for 66 patients (mean age 79 years; 68% male). Changes in LVEF and paced QRS duration were compared before and after upgrade. Patients were classified as ‘Responders’ (≥10% LVEF improvement) or ‘Poor Responders’ (<10%). Subgroup analyses examined baseline QRS duration (<130 ms, 130–170 ms, >170 ms) and its relationship with LVEF change. Results ‘Responders’ (n = 48) demonstrated significantly greater QRS narrowing than ‘Poor Responders’ (n = 18). Mean ΔQRS was −43.6ms ±23.3 in ‘Responders’ vs −27.8ms ± 22.6 in ‘Poor Responders’ (t = −2.50, p = 0.018). Greater post-upgrade QRS reduction was associated with more pronounced LVEF improvement. Baseline QRS duration was not a statistically significant predictor of response (F = 0.23, p = 0.9), although patients with intermediate QRS durations (130–170 ms) had the largest mean LVEF gain (15.5%). Among 66 patients, 22 had permanent Atrial Fibrillation (AF). AF was slightly more prevalent in weak responders (44% vs. 29%; R = −0.13), indicating a modest, non-significant trend toward reduced response in AF patients. Conclusion In patients undergoing DDD-to-CRT-P upgrade, greater ΔQRS was strongly associated with superior LVEF improvement. While baseline QRS duration was not a statistically significant predictor, intermediate durations may confer optimal benefit. The potential role of QRS morphology as an electrophysiological marker of CRT-P response warrants further study.Item Exploration of radiotherapy-related insufficiency fractures in gynaecological cancer: a service evaluation report(2026-03-31)Background The impact and incidence of radiotherapy-related insufficiency fractures (RRIFs) are a poorly understood late effect of pelvic radiotherapy treatment, particularly those treated for gynaecological cancers. This paper reports the results of the service evaluation proposed by Hands (2025). Aim To record the incidence of RRIFs and to capture potential risk factors for the development of RRIFs in patients diagnosed with a gynaecological cancer treated with radiotherapy. Method Electronic records of patients treated with large field radical pelvic radiotherapy for gynaecological cancers were reviewed (Hands, 2025). The data extracted captured bone health pre- and post-radiotherapy treatment including other variables that may increase RRIF risk (Razavian et al., 2020). Results Eighty-two patients diagnosed with a gynaecological cancer were treated in a 24-month period (2021-2022) at one radiotherapy centre in the South-West of England. Sixty-nine of these patients met the inclusion criteria of large field radiotherapy with radical treatment intent. Table 1 presents the data extracted from 69 patients. Fourteen of these patients developed a RRIF, all of whom were post-menopausal, with sacral fractures being the most common site. All fractures were identified retrospectively from reported Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scans.Item 387 Temporal trends in outcomes of transcatheter aortic valve replacement versus surgical aortic valve replacement in low-risk patients with aortic stenosis: a meta-analysis of randomized controlled trials(2026)Introduction Surgical aortic valve replacement (SAVR) has long been the standard treatment for patients with severe aortic stenosis (AS) at low surgical risk. However, transcatheter aortic valve replacement (TAVR) has emerged as a less invasive alternative. This meta-analysis compares the efficacy and safety of TAVR versus SAVR in low-risk AS patients across different follow-up intervals. Methods A systematic search of PubMed, Embase, and the Cochrane Library was performed through September 2024. Six randomized controlled trials (RCTs) and eight follow-up reports were included (n = 11,953). Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model via Revman (Version 5.4.1). Results At 30 days, there was no significant difference in all-cause or cardiovascular mortality between TAVR and SAVR. At 1 year, TAVR significantly reduced all-cause mortality (RR: 0.61; P = 0.0009) (figure 1) and cardiovascular mortality (RR: 0.62; P = 0.006) (figure 2), with no differences at 2 years or beyond 5 years. Stroke and myocardial infarction rates were comparable at all follow-up points. TAVR markedly reduced new-onset or worsening atrial fibrillation (AF) at 30 days (RR: 0.19; P < 0.00001), 1 year (RR: 0.24; P < 0.00001), 2 years (RR: 0.27; P < 0.00001), and ≥5 years (RR: 0.45; P = 0.001) (figure 3). Major bleeding was significantly lower with TAVR at 30 days (RR: 0.29; P < 0.00001) and 1 year (RR: 0.31; P < 0.00001) (figure 4). In contrast, TAVR increased major vascular complications at 30 days (RR: 2.19; P = 0.05) (figure 5) and permanent pacemaker implantation at 30 days (RR: 2.73; P = 0.002), 1 year (RR: 2.29; P < 0.0001), 2 years (RR: 3.38; P = 0.009), and ≥5 years (RR: 2.19; P = 0.001) (figure 6). Hospitalizations were reduced with TAVR at 30 days (RR: 0.52; P = 0.007) and 1 year (RR: 0.72; P = 0.04), with no long-term difference (figure 7). Conclusion In low-risk AS patients, TAVR offers early benefits, including lower 1-year mortality, bleeding, AF endocarditis and hospitalization, but these advantages wane over time. Higher rates of pacemaker implantation and vascular complications highlight the need to weigh short-term gains against long-term risks when selecting treatment.Item Modern Hodgkin lymphoma treatments to reduce second cancer risks: Influence of risk-adapted screening(2026-05-12)Background: Second primary malignancies (SPMs) are the leading cause of long-term treatment-related mortality in Hodgkin Lymphoma (HL). Although substantial improvements have been made to treatments over recent decades, few studies have demonstrated reduced SPM risk, particularly following modern treatments, and how risks should inform screening. Methods: We assembled a national cohort of 7,428 women treated for HL aged ,36 across England & Wales 1954-2010, with 99% complete follow-up until 2018. We analyzed SPM incidence from national cancer registry linkage. Treatment data were collated from .250 treatment centers. Standardized incidence ratios (SIRs) and Absolute Excess Risks (AERs) for SPMs were calculated, and multivariable analyses (Hazard Ratios, HR) were undertaken to assess the impact of changes in treatment and assess changing incidence trends over time. Results: Twelve hundred women (16%) developed 1,467 SPMs with mean follow-up of 22 years (range 0-62 years). Overall SIR to develop any SPM was 3.3 (95% CI 3.1-3.5), with breast cancer contributing the greatest excess risk (AER 30.8 95% CI 27.7-34.1). Radiotherapy use halved from 1954-1980 to 2000-2010 (98% to 47%) and mean dose dropped from 48Gy to 33Gy. Conversely chemotherapy use doubled from 55% to 97%, with anthracyclines used in 94% and classic alkylators in 31% of treatments in the most recent period compared with 6% and 48% respectively pre-1980. Radiotherapy conferred the greatest treatment-specific risk factor for SPMs, (SIR 3.5 95% 3.3-3.7), with a strong dose-response relationship trend (HR 1.01/Gy p,0.001), and highest relative risks seen in those treated with radiotherapy aged ,15years (SIR 7.4 (95% CI 5.7-9.1). There was a 25% reduction in SPM risk from the earliest treatment period (,1990) to most recent (2000-2010) and 34% reduction in solid SPM risk (Table). The decrease in risk for SPMs became smaller and non-significant after adjusting for reduced radiotherapy use and dose (HR 0.89, p trend 0.11). There was no attenuation after adjustment for chemother apy. Despite declining risks, risks remained significantly elevated beyond 40 years after treat ment. Conclusions: Modern HL treatments are associated with a substantial reduction in SPM risks, which appears to be largely attributable to decreased radiotherapy use and dose. However large persistent excess risks, particularly for breast and lung cancers, underscore the need for targeted screening in high-risk survivors treated in more recent eras. Research Sponsor: National Institute of Health Research Biomedical Research Centre - Royal Marsden Hospital / Institute of Cancer Research; Breast Cancer Now; Cancer Research UK.
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