Introduction

Erectile dysfunction (ED) affects up to 20% of men globally, with a significant subset unresponsive to first-line phosphodiesterase type 5 inhibitors (PDE5-Is). Alternatives like intracavernosal alprostadil are often declined due to administration difficulties. Intracavernosal onabotulinumtoxin type A (BoNT-A) has emerged as a potential treatment by relaxing cavernosal smooth muscle and enhancing penile blood flow, with effects lasting approximately six months.

Methods

A systematic search was conducted in accordance with PRISMA guidelines. Databases (PubMed, Embase, Cochrane Library) were searched from inception to 2025 for clinical studies (randomized controlled trials and prospective cohorts) investigating BoNT-A penile injections for ED. Data on patient demographics, BTX dosage, changes in International Index of Erectile Function (IIEF) scores, Erection Hardness Score (EHS), adverse events, and study quality were extracted using the Cochrane Risk of Bias or NIH Quality Assessment tools and narratively synthesized due to study heterogeneity.

Results:

Included studies (n=50) reported that BoNT-A injections were associated with improvements in erectile function scores (IIEF, SHIM, EHS), with response rates between 40% and 77.5%. Higher response rates were observed in patients with less severe ED and those receiving repeated doses, mainly at 100U. The treatment showed a favorable safety profile; adverse events were mostly mild and transient penile pain (1.5–6%), with no systemic complications reported. The quality of evidence was limited by study heterogeneity and small sample sizes

Conclusions

Intracavernosal BoNT-A is a promising and safe option for men with ED refractory to standard therapies. It may be moderately effective in select patients and could improve sexual function and reduce the need for invasive procedures. It may improve sexual function and reduce the need for invasive procedures. These findings warrant validation by large-scale, randomized, placebo-controlled trials to definitively establish its clinical role and optimal administration parameters.

Introduction: Bone age (BA) assessment is crucial in pediatric endocrinology, growth disorder evaluation, and forensic age estimation. Traditional methods, such as the Atlas of Greulich–Pyle and Tanner–Whitehouse, are widely adopted but remain time-consuming, operator-dependent, and prone to inter-observer variability of 0.5–1.0 years. Convolutional Neural Networks (CNNs) offer a promising automated alternative with the potential to improve accuracy and consistency. Methods: This systematic review followed PRISMA guidelines and was prospectively registered in PROSPERO (CRD42024619808). A comprehensive search was conducted across eight databases—MEDLINE (PubMed), Google Scholar, Scopus (Elsevier), EBSCOhost, Cochrane Library, Web of Science (WoS), IEEE Xplore, and ProQuest—from 2019 to 2024. Eligible studies applied CNN-based models to posteroanterior hand–wrist radiographs for BA estimation. Architectures included VGGNet, ResNet, DenseNet, Inception-v4, Inception-ResNet-v2, Xception, MobileNetV2, and EfficientNet, with or without transfer learning. Extracted data covered model architecture, dataset characteristics, training strategy, and performance metrics, focusing on mean absolute error (MAE) and measures of variability (standard deviation [SD] or confidence intervals). Results: Fifty-five studies met the inclusion criteria. CNN-based models achieved MAEs as low as 0.23 ± 0.02 years (≈2.75 ± 0.24 months), markedly surpassing traditional manual assessments. In large-scale datasets, CNN predictions showed 95% confidence intervals within ±0.4 years, compared with ±1.2 years for expert evaluations. Hybrid and ensemble approaches, which combine CNN outputs with atlas-based scoring, enhanced robustness. Methodological refinements, including preprocessing pipelines, automated region-of-interest detection, U-Net segmentation, and attention mechanisms, optimized feature extraction and reduced error variability. Conclusions: CNNs provide high-precision BA estimates with substantially lower dispersion than Atlas-based methods, achieving accuracies within less than one growth stage in standard atlases. Their integration into clinical workflows could reduce diagnostic variability, accelerate reporting, and enable population-specific calibration. Future work should prioritize multimodal data integration, cross-population validation, and explainable AI to enhance clinical trust and regulatory adoption.

Introduction: Advanced cancers produce numerous soluble factors that affect the microcirculation of organs with high capillary density. This produces a response in these organs, whose pathophysiological biomarkers can indirectly alert us to the existence of premetastatic niches. We propose a new synthetic analytical marker called Qoppa to identify the population at highest risk of metastasis to more effectively schedule the follow-up imaging tests.

Methods: In this RESOLT prospective observational study, plasma samples were obtained from cancer patients to detect 11 biomarkers of response to soluble tumor factors using multiplex immunoassay with Luminex and to calculate 20 global analytical parameters related to prognosis. A clustering study was performed using Eucledean metrics and Ward method, followed by the creation of synthetic covariates for each cluster. Their potential as classifiers for the risk of death and the development of de novo metastasis was analyzed using ROC operator curves. Finally, their classifying role was related to the clinical impact using Kapplan–Meier and Cox analyses.

Results: Thirty patients were enrolled. The clustering study resulted in two clusters: the first with only 12 global parameters and the second with the 11 response biomarkers and the remaining 9 global parameters. The synthetic covariate Stigma was built from the first cluster, and the synthetic covariate Qoppa from the second cluster. While Stigma showed a poor performance as a classifier for death or the development of de novo metastasis, Qoppa was an acceptable classifier with an AUC of 0.78 for both events (cutoff: 4.775). Likewise, the Cox and Kapplan–Meier risk analysis showed that a high Qoppa population has a statistically significantly higher risk of death and metastasis.

Conclusion: Qoppa could help detect the cancer population at higher risk of metastasis or death during the follow-up. This could allow for optimal and early scheduling of imaging tests for detection of metastasis formation.

Introduction:

West Nile virus (WNV) is a neurotropic pathogen with an increasing clinical significance. This pathogen is responsible for recurrent outbreaks of meningitis and encephalitis worldwide. Severe cases can be fatal or result in long-lasting sequelae. While its impact on the central nervous system is well documented, recent evidence also suggests potential peripheral manifestations of WN disease, including renal involvement. The aim of this study was to evaluate alterations in renal function parameters in infected patients through a systematic review and meta-analysis.

Methods:

A systematic literature search was conducted in PubMed following PRISMA 2020 guidelines to identify studies reporting numerical data on biochemical markers of kidney function in hospitalized individuals infected with WNV. Several kidney function markers were analyzed, namely serum creatinine, blood urea nitrogen (BUN), sodium, potassium, calcium, bicarbonate, magnesium, hemoglobin, and estimated glomerular filtration rate (eGFR).

Results:

Data suggested that many patients showed signs of kidney issues. Creatinine levels were high in most of the patients, and BUN was elevated in about two-thirds of patients. Low sodium levels (hyponatremia) were common. Nearly half the patients had moderately reduced eGFR, and some had values suggesting serious kidney failure. Other markers like potassium, calcium, and magnesium did not show consistent patterns, likely because of the low number of available data.

Conclusions:

Our findings suggest that WNV infection often has effects on the kidneys. The results here described invite caution and more attention to renal function in WNV-infected patients, which may reduce the complications associated with infection and improve the outcome of the patients.

Heart failure stands as a major worldwide health problem that requires immediate and precise diagnosis to enhance patient treatment results. Researchers developed a machine learning system to predict heart failure based on standard clinical data collected from patients. The researchers analyzed 918 patient records, which included information about patient demographics, physiological measurements, and electrocardiographic data. The analysis utilized nine variables, including age and sex, chest pain type, resting blood pressure, cholesterol level, fasting blood sugar, resting ECG results, maximum heart rate, exercise-induced angina, ST depression (Oldpeak), and ST segment slope.

The Random Forest classifier received preprocessed data through imputation, normalization, and one-hot encoding before achieving 88.59% accuracy, with precision (positive class) at 91.00%, recall at 90.00%, and F1 score at 90.00%. The model demonstrated balanced performance, with 67 true negatives, 95 true positives, 10 false positives, and 12 false negatives, as indicated by the confusion matrix.

The proposed model demonstrates that artificial intelligence can perform automatic heart failure diagnosis by providing a reliable risk assessment for early detection. The model achieves better performance through feature optimization and ensemble learning methods, while its ability to process various types of clinical data makes it suitable for real-world applications. The proposed method enables researchers to develop AI-based clinical decision support systems that assist doctors in making prompt medical decisions through early disease detection.

Future research should aim to enhance model interpretability while validating the model across different population groups and implementing explainable AI techniques to foster clinical trust and transparency, ultimately leading to improved translational outcomes.

Introduction: Familial Mediterranean fever (FMF) is an auto-inflammatory disorder characterized by recurrent episodes of fever and inflammation, which can lead to cardiac complications, particularly issues with cardiac conduction due to irregularities in ventricular repolarization. This study aimed to investigate the Tpe interval, QTc interval, and Tpe/QTc ratio—key indicators of ventricular arrhythmia—among FMF patients undergoing colchicine treatment compared to healthy controls.

Methods: Conducted as a cross-sectional analysis, the study included 185 participants, with 96 diagnosed with FMF and 89 healthy controls. The researchers assessed cardiac repolarization markers through 12-lead surface electrocardiography (ECG) and collected demographic, laboratory, echocardiography, and medication data during cardiology outpatient visits.

Results: The average age of the control group was 43.2 years, while the FMF group averaged 35.2 years. Notably, the control group exhibited higher prevalence rates of coronary artery disease, diabetes, hypertension, and hyperlipidemia, correlating with their older age. Electrocardiographic findings revealed significant differences between the two groups: the Tpe interval (normal range: 50-100 ms) was longer in FMF patients (110.3 ms) compared to controls (91.4 ms) (p<0.001), while the QTc interval (normal range: 360-440 ms) was shorter in FMF patients (401.4 ms) than in controls (407.5 ms)(p<0.001). The Tpe/QTc (normal range: 0.15-0.25) ratio was also higher in FMF patients (0.27) compared to controls (0.22) (p<0.001). Correlation analysis indicated a positive relationship between FMF and both the Tpe interval (r=0.567, p<0.001) and Tpe/QTc ratio (r=0.594, p<0.001), while a negative correlation was observed with the QTc interval (r=-0.163, p=0.027). In multivariate regression analysis, FMF was independently correlated with the Tpe interval (OR: 17.710; 95% CI: 13.594-21.826, p<0.001), QTc interval (OR: -6048; 95% CI: -11723--0.374, p=0.037), and Tpe/QTc ratio (OR: 0.048; 95% CI: 0.038-0.058, p<0.001).

Conclusion: Despite colchicine therapy, FMF patients may still face an increased risk of arrhythmias. The findings suggest that regular cardiology follow-ups, including ECG evaluations, are a reasonable approach for clinically stable FMF patients.

Patients who are prescribed triple antithrombotic therapy, which usually consists of an oral anticoagulant alongside dual antiplatelet therapy, are known to be at a very high risk of gastrointestinal bleeding. Current national guidelines recommend that these patients should routinely receive a proton pump inhibitor to reduce this risk. Despite the strength of this recommendation, experience in everyday practice suggests that compliance is often variable, and patients may be left unprotected against a potentially preventable complication.

This audit aims to explore how well gastroprotection guidance is followed in a large UK teaching hospital. Using retrospective data collection, we will identify all patients prescribed triple therapy during the study period. For each case, we will record key details including demographics, indication for treatment such as atrial fibrillation or acute coronary syndrome, specific antithrombotic regimen, presence or absence of a concurrent proton pump inhibitor prescription, and whether a formal bleeding risk assessment using the ORBIT score was documented.

The primary outcome measure will be the proportion of patients appropriately co-prescribed a proton pump inhibitor in line with guideline standards. Secondary outcomes will examine variation in practice between different clinical teams and whether bleeding risk assessments influence prescribing behaviour.

By establishing a clear baseline of current practice, this project will highlight gaps in safe prescribing and identify opportunities for improvement. The findings are intended to guide future interventions and raise awareness of this important patient safety issue. Ultimately, ensuring that patients on triple therapy receive adequate gastroprotection has the potential to reduce preventable gastrointestinal bleeding and improve outcomes for a group already recognised as being at high risk.

Title:

Hybrid epicardial–endocardial ablation versus catheter ablation for non-paroxysmal atrial fibrillation: a systematic review and meta-analysis

Background:

While catheter ablation (CA) is effective for paroxysmal atrial fibrillation (AF), long-term success is limited in non-paroxysmal or long-standing persistent AF. This group often experiences recurrent arrhythmias despite antiarrhythmics and repeat ablations, impairing quality of life and increasing healthcare utilization. Hybrid epicardial–endocardial ablation (HA) combines surgical and catheter techniques, enabling the creation of durable lesions and the isolation of the posterior wall for improved rhythm control. Recent randomized controlled trials (RCTs) have shown promising results; however, existing systematic reviews are outdated, and therefore an updated review is needed to clarify efficacy and safety, as well as guide practice.

Methods:

The review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was registered on PROSPERO. Multiple databases and trial registries were searched using pre-defined terms. Eligible studies were RCTs and observational studies of adults with non-paroxysmal or long–lasting persistent AF comparing HA with CA. Two reviewers independently screened and extracted data. The primary endpoint was maintenance of sinus rhythm without the use of antiarrhythmics. Secondary endpoints included major complications, quality of life, repeat ablation, and rhythm outcomes at 24 months or more.

Results:

Five RCTs compared CA with HA in non-paroxysmal AF. Across all studies, HA consistently achieved higher arrhythmia-free survival at 12- 24 months (65-76% versus 32-43%; pooled benefit approximately 30% (p<0.001), including off antiarrhythmics (57-72% versus 28-41%). Both procedures had similar safety profiles, with comparable complication rates (8-11% versus 6-10%), no procedural mortality, and infrequent serious adverse effects such as tamponade and stroke. Lastly, HA also required fewer repeat procedures, such as cardioversion (12-16% vs. 24-29%) and repeat ablation (5-8% vs. 34-37%), compared to CA.

Conclusion:

In patients with non-paroxysmal AF, HA provides superior arrhythmia-free outcomes compared to CA, while maintaining a comparable safety profile.

Introduction: Patients over 65 often have multiple comorbidities and complex polypharmacy regimens, many including falls-risk-increasing drugs (FRIDs). Falls are a leading cause of morbidity in this group and are frequently associated with polypharmacy. Using the STOPP-FALL criteria, we systematically identified and reviewed FRIDs during hospital stays to reduce falls and improve prescribing safety. The multidisciplinary team consisted of consultants, resident doctors, and nursing staff.

Methods: Cycle 1 data obtained for patients who were either admitted with a fall or had a history of falls, along with their current medications, showed that all of them were on at least one FRID. To facilitate the practical use of the STOPP-FALL tool, we developed a color-coded template for each category of FRID. We educated the ward team to review each patient’s medication regimen using the template and document this on the ward round entry.

Results: A re-audit was conducted under the PDSA model, one month after the intervention was implemented, reviewing a total of 35 patients. 69% were admitted with a fall or had a documented history of falls. Among these, 83% were prescribed one or more FRIDs. In 25% of these cases, it was considered clinically appropriate to deprescribe one or more FRIDs. The introduction of the STOPP-FALL tool led to a structured approach in identifying high-risk medications, which improved clinical awareness and accountability. Moreover, it promoted patient safety, leading to a potential reduction in future falls.

Conclusion: This project demonstrated that working closely as a team enabled us to effectively utilize the STOPP-FALL criteria in making prescribing safer for older patients. Future plans include expanding the use of the STOPP-Fall tool across other Health & Ageing wards, conducting large group teaching sessions, and further integrating it into electronic prescribing systems to ensure a consistent and sustainable practice across the Department of Clinical Gerontology at King’s College Hospital.

A 61-year-old male patient presented to the ED by ambulance following two syncopal episodes. The ambulance crew reported abnormal ECG findings. The patient had felt hot, sweaty, and clammy with palpitations preceding both syncopal events. He had chest and epigastric pain in the past 24 hours. Syncopal events were witnessed by a partner who reported a grey and clammy appearance of the patient. During the A&E review, the patient reported ongoing chest discomfort with no associated symptoms. Previous medical history included a heterotopic heart transplant for myocarditis and long-term oral amiodarone therapy. Examination findings: Pulse: 90bpm; blood pressure: 120/94; SpO2: 98%; RA RR: 18/min Apex beat palpated on the right precordium. Chest: Bilaterally clear with no difficulty in breathing. ECG findings: A sinus rhythm from the transplanted heart was observed in the right-sided leads. Ventricular tachycardia/fibrillation was being picked up from the native heart on the left lateral leads. There is, however, an overlap of these rhythms seen on the ECG. Chest X-ray showed dual cardiac shadows. A Point-of-Care Echocardiogram showed the native heart to be in Ventricular tachycardia/fibrillation with severe systolic dysfunction, and the donor heart in sinus rhythm with good systolic function. The diagnosis was considered to be syncope secondary to an Electrical Storm generated from the native heart. The arrhythmia was being propagated from the native to the donor heart. Patient was started on amiodarone infusion and later transferred to ITU. A transesophageal echocardiogram-guided direct current cardioversion was attempted. After two unsuccessful attempts, a lidocaine infusion was initiated, and a subsequent attempt at DCCV proved successful in restoring the sinus rhythm. The patient was later discharged clinically and hemodynamically stable with oral sotalol and mexiletine. This rare and complex case highlights the importance of ECG interpretation in diagnosing arrhythmias in post-transplant patients.