The Royal Free Hospital

To provide recommendations for the most appropriate endovascular intervention of femoropopliteal (FP) arterial disease based on plaque characterization. A panel of 22 physicians from multiple disciplines participated in a modified Delphi consensus, leveraging the RAND/UCLA Appropriateness Method. Panelists engaged in 2 rounds of voting, following a literature review, with an in-person discussion prior to the second round of voting. A rigorous statistical approach was used to analyze the points of agreement and disagreement. Consensus-based recommendations on the most appropriate endovascular approaches for treating patients with FP lesions, stratified by lesion morphology, were generated. Overall, 490 individual items were included in the voting, 458 (93%) of which achieved consensus and 32 (7%) were nonconsensus items, based on a priori criteria under the following categories: (a) recommendations on method for determining plaque morphology, (b) preferred endovascular devices for vessel preparation and definitive treatment stratified by (i) plaque morphology and (ii) Tosaka classification of in-stent restenosis, and (c) vessel preparation device safety-related considerations. This international, multidisciplinary consensus provides evidence- and expert-informed recommendations for vessel preparation and definitive treatment of FP arterial disease, tailored to plaque morphology. These consensus recommendations aim to support clinical decision making and promote best interventional practices by serving as an expert opinion supplement to existing guideline-based care pathways.

Abstract Foreign body insertion into the ear is a frequent cause for paediatric emergency presentations. When removal in the clinic is unsuccessful, children are often referred for removal under general anaesthesia. However, a subset of these procedures reveals no foreign body, exposing patients to unnecessary anaesthetic risk and adding pressure to healthcare services. This retrospective study reviewed paediatric patients (aged 2–17 years) who underwent ear foreign body removal procedures over a three-year period. The primary objectives were to determine the rate of unnecessary procedures (no foreign body detected), analyse patient demographics, and assess complication rates. A total of 66 patients were identified. Of these, 58 (87.9%) had a confirmed foreign body, while 8 (12.1%) had none. Among patients without a foreign body, 25% had autism spectrum disorder, compared with 19% in the confirmed foreign body group. No major complications were recorded. The findings suggest that children with autism may be at greater risk of unnecessary procedures, potentially due to communication difficulties, behavioural patterns, and diagnostic uncertainty. This study highlights the importance of refining diagnostic pathways to reduce avoidable interventions. Recommendations include developing enhanced diagnostic protocols tailored for autistic children, providing targeted training for clinicians, and increasing caregiver education to improve reporting accuracy. Further research is warranted to better understand the association between autism and suspected foreign body insertion. Optimizing diagnostic accuracy can enhance patient safety, reduce unnecessary exposure to general anaesthesia, and improve resource allocation within the NHS.

Sentinel lymph node biopsy (SLNB) is used in the staging of melanoma and is generally performed at the time of wide local excision (WLE) of the primary lesion, the location of which guides preoperative and intraoperative lymphatic mapping. However, the role of delayed lymphatic mapping following prior WLE remains unclear. We report the case of a patient who underwent lymphoscintigraphy before and after WLE for melanoma, compare the findings, and review the published literature. A 32-year-old woman was scheduled for WLE and SLNB of a 2.0-mm Breslow thickness melanoma on the upper arm. After her preoperative lymphoscintigram, an unplanned pregnancy was diagnosed, and she elected to proceed with WLE alone. She later requested delayed SLNB and underwent a second lymphoscintigram 2 months later. Comparison of the pre- and post-WLE lymphoscintigrams demonstrated variation in the location and number of sentinel lymph nodes, raising important questions about the accuracy of delayed lymphatic mapping and SLNB in melanoma. This report adds to the understanding of lymphatic channel behavior following WLE and may help inform decision-making for patients and clinicians.

The novel null allele MICB*068N was identified by full-length MICB genotyping.

Background: Iron deficiency (ID) is common among people with chronic kidney disease (CKD) and/or heart failure (HF). Despite the additional burden ID causes among people with CKD and HF, there is considerable uncertainty surrounding the best way to diagnose it and, subsequently, identify who is most likely to benefit from receiving iron therapy. Methods: This manuscript reports the markers and thresholds used in ID diagnosis, treatment, and management in the UK by nephrologists and cardiologists who manage people with chronic kidney disease or heart failure, as well as investigating future challenges and questions that remain unanswered. The research involved three stages: an online questionnaire, individual interviews, and a panel meeting, which discussed the findings from the first two stages. Results: The panel concluded that there is no robust definition of iron deficiency that can be applied to chronic kidney disease and heart failure. Existing methods of diagnosing iron deficiency come with various problems; a transferrin saturation of <20% is the most popular, but it is not regarded as a perfect solution. Transferrin saturation is also the most popular way of assessing the success of iron deficiency treatment. Clinicians generally do not vary treatment regimens based on severity or subgroups. There are large variations in monitoring and the ability to administer iron therapy in secondary care. Conclusions: There is a clear need to consolidate current approaches to diagnosing and treating iron deficiency in people with chronic kidney disease and/or heart failure. Simple markers and thresholds, and simple strategies to implement them are required.

Pancreatic ductal adenocarcinoma (PDAC) has poor prognosis as early-stage asymptomaticity leads to late-stage diagnoses. Strategies to detect PDAC earlier or identify high-risk individuals are therefore paramount. Here, we report results from genetically engineered mice and PDAC patients that identify serum proteins associated with pancreatic intraepithelial neoplasms (PanINs), the most common PDAC precursor, and early-stage PDAC. Initially, we screened previously described PanIN-abundant mice, harbouring pancreatic and duodenal homeobox 1 (Pdx1)-Cre, Lox-STOP-Lox-KrasG12D/+ and floxed alleles of essential autophagy genes autophagy-related 7 (Atg7) or autophagy-related 5 (Atg5). Sera from these mice were assessed by proteomics and hits were compared to those in Lox-STOP-Lox-KrasG12D/+ Lox-STOP-Lox-Trp53R172H/+ Pdx1-Cre (KPC) mice, which closely recapitulate human disease, and early-stage (I-II) PDAC patients. Levels of inter-alpha-trypsin inhibitor heavy chain H3 (ITIH3) were significantly elevated in all three screens, with complement C5, complement factors B and H (CFB/CFH), and monocyte differentiation antigen CD14 increased in KPC mice and PDAC patients; and all were significantly increased co-ordinately in PDAC according to disease stage. Serum levels of C5, CFH and CD14 together constitute a novel panel for identifying PanINs and early-stage PDAC with confidence, and when combined with additional screening, could help increase survival from this dismal disease.

Non-contrast MRI (bi-parametric MRI-bpMRI) has been investigated as a potential tool to be integrated in clinically significant prostate cancer (csPCa) screening. Moreover, artificial intelligence (AI) is emerging too as a potential support, especially for less-experienced radiologists. Therefore, the aim of this study was to evaluate the effectiveness of an AI-based software in csPCa screening using bpMRI, with a focus on supporting less-experienced radiologists. A retrospective analysis was conducted within the PROSA-trial, a randomized, single-center study involving 759 men eligible for PCa screening. BpMRI were acquired using prostate imaging reporting and data system (PI-RADS) v2.1-compliant protocols and evaluated independently by an expert radiologist, a less-experienced reader, AI-based software, and the less-experienced reader with AI support. Diagnostic performance was assessed using ROC curves and inter-reader agreement (Cohen's kappa), using expert interpretation as the reference standard. Four hundred ninety-nine bpMRI were analyzed. The AI-assisted less-experienced reader achieved the highest diagnostic performance (sensitivity 76.5%, specificity 97.2%, accuracy 95.8%, AUC 0.969), surpassing both AI-alone (sensitivity 58.8%, specificity 96.6%, accuracy 94.0%, AUC 0.952) and unaided less-experienced reader (sensitivity 67.6%, specificity 95.1%, accuracy 93.2%, AUC 0.932). Inter-reader agreement improved with AI assistance (from κ = 0.64 to 0.84). AI assistance reduced equivocal PI-RADS 3 cases (from 77 to 53) and improved exact agreement with the expert from 32.5% to 54.5%, while also reducing diagnostic discordance. AI can support less experienced radiologists and enhance consistency in bpMRI interpretation, especially considering equivocal cases. Moreover, integrating AI into radiology workflows can alleviate reporting burden and help prioritize suspicious cases, offering critical advantages in high-volume PCa screening settings. Question Can AI improve the diagnostic performance and consistency of less experienced radiologists interpreting non-contrast prostate MRI in a screening setting? Findings AI assistance significantly improved effectiveness and inter-reader agreement in prostate MRI interpretation, particularly for less experienced radiologists within a screening population. Clinical relevance Integrating AI into prostate MRI workflows may enhance screening efficiency, reduce variability, and support equitable early detection of csPCa, with a positive impact on prioritization of reporting.