Radiological Input Research Articles

Clinical Acceptability of Artificial Intelligence-Screened Interstitial Lung Disease (AI-ILD) in Lung Cancer Patients Treated with Radiotherapy

Patients with interstitial lung disease (ILD) treated with thoracic radiotherapy (RT) are at greater risk of pulmonary toxicity. Automatic universal screening for ILD allows radiation oncologists (ROs) to risk stratify patients and implement necessary modifications to their respiratory monitoring or treatment. Automatic screening however may affect RO workload and so it is imperative to assess the clinical acceptability of this tool. We have developed a machine learning algorithm to identify patients who are at high risk of having ILD based on RT planning computed tomography (CT) images. A quality improvement (QI) project was initiated to test feasibility and acceptability of the machine learning algorithm. If positive, the results of the machine learning algorithm were made available to ROs via structured electronic reporting. ROs were prompted to review the patient and consider expert radiologist consultation if thought appropriate. All electronic surveys and qualitative comments were summarized to describe clinical acceptability. Expert radiologist established gold standard ILD status of all patients on the study. A formal review of RO feedback was collected for all screen-positive, true-positive cases. Two hundred forty cases were screened of which 45 were flagged as AI-ILD positive and the responsible RO notified. Of these 45 screen-positive cases, all continued on to RT except for 3 patients with tumor progression. From these 45, 24 surveys were completed, 21 had no prior suspicion of ILD. There were 7 true-positives, of which 1 had a survey response. Based on the survey responses, 88% of cases underwent review by the responsible RO. In 16 cases this automatic notification prompted case consultation with an expert radiologist. Expert review was performed from 10 minutes up to 53 hours after the email prompt to the radiologist, with median response time of 1.5 hours. In the 7 screen-positive, true-positive cases, only 2 were not previously known to the responsible RO. In the two cases where true-positive ILD status was previously unknown, one was a mild case of ILD and the other had previously received thoracic RT at this institution without ILD being identified, in both cases the ROs were grateful that this diagnosis was identified prior to treatment. RO confidence in the machine learning prediction was moderate due to the high proportion of false positives. Based on available survey results, more than 75% of the screen-positive cases were reviewed by the responsible RO and two-thirds of these involved expert radiology input. RO feedback was generally positive and this tool was rated as a net benefit despite the high rate of false-positives and the need for clarification.

Research

The August 2023 Research Roundup360 looks at: Can artificial intelligence improve the readability of patient education materials?; What is the value of radiology input during a multidisciplinary orthopaedic oncology conference?; Periprosthetic joint infection in patients with multiple arthroplasties; Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies Project - Phase III outcomes; Knot tying in arthroplasty and arthroscopy causes lesions to surgical gloves: a potential risk of infection; Vascular calcification of the ankle in plain radiographs equals diabetes mellitus?

CORR Insights®: What is the Value of Radiology Input During a Multidisciplinary Orthopaedic Oncology Conference?

1Professor, Orthopaedics and Pathology Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA H. T. Temple, Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, 900 Northwesat 17th Street, Miami, FL,33136, USA, Email: [email protected] This CORR Insights® is a commentary on the article “What is the Value of Radiology Input During a Multidisciplinary Orthopaedic Oncology Conference?” by Komarraju and colleagues available at: DOI: 10.1097/CORR.0000000000002626. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

What is the Value of Radiology Input During a Multidisciplinary Orthopaedic Oncology Conference?

Multidisciplinary orthopaedic oncology conferences are important in developing the treatment plan for patients with suspected orthopaedic bone and soft tissue tumors, involving physicians from several services. Past studies have shown the clinical value of these conferences; however, the impact of radiology input on the management plan and time cost for radiology to staff these conferences has not been fully studied. (1) Does radiology input at multidisciplinary conference help guide clinical management and improve clinician confidence? (2) What is the time cost of radiology input for a multidisciplinary conference? This prospective study was conducted from October 2020 to March 2022 at a tertiary academic center with a sarcoma center. A single data questionnaire for each patient was sent to one of three treating orthopaedic oncologists with 41, 19, and 5 years of experience after radiology discussion at a weekly multidisciplinary conference. A data questionnaire was completed by the treating orthopaedic oncologist for 48% (322 of 672) of patients, which refers to the proportion of those three oncologists' patients for which survey data were captured. A musculoskeletal radiology fellow and musculoskeletal fellowship-trained radiology attending physician provided radiology input at each multidisciplinary conference. The clinical plan (leave alone, follow-up imaging, follow-up clinically, recommend different imaging test, core needle biopsy, surgical excision or biopsy or fixation, or other) and change in clinical confidence before and after radiology input were documented. A second weekly data questionnaire was sent to the radiology fellow to estimate the time cost of radiology input for the multidisciplinary conference. In 29% (93 of 322) of patients, there was a change in the clinical plan after radiology input. Biopsy was canceled in 30% (24 of 80) of patients for whom biopsy was initially planned, and surgical excision was canceled in 24% (17 of 72) of patients in whom surgical excision was initially planned. In 21% (68 of 322) of patients, there were unreported imaging findings that affected clinical management; 13% (43 of 322) of patients had a missed finding, and 8% (25 of 322) of patients had imaging findings that were interpreted incorrectly. For confidence in the final treatment plan, 78% (251 of 322) of patients had an increase in clinical confidence by their treating orthopaedic oncologist after the multidisciplinary conference. Radiology fellows and attendings spent a mean of 4.2 and 1.5 hours, respectively, reviewing and presenting at a multidisciplinary conference each week. The annual combined prorated time cost for the radiology attending and fellow was estimated at USD 24,310 based on national median salary data for attendings and internal salary data for fellows. In a study taken at one tertiary-care oncology program, input from radiology attendings and fellows in the setting of a multidisciplinary conference helped to guide the final treatment plan, reduce procedures, and improve clinician confidence in the final treatment plan, at an annual time cost of USD 24,310. Multidisciplinary orthopaedic oncology conferences can lead to changes in management plans, and the time cost to the radiologists should be budgeted for by the radiology department or parent institution.

Predicting the response to methylprednisolone pulses in patients with SARS-COV-2 infection

IntroductionTreating systemic inflammation caused by SARS-COV 2 (COVID-19) has become a challenge for the clinician. Corticosteroids have been the turning point in the treatment of this disease. Preliminary data from Recovery clinical trial raises hope by showing that treatment with dexamethasone at doses of 6mg/day shows a reduction on morbidity in patients requiring added oxygen therapy. However, both the start day or what kind of corticosteroid, are still questions to be clarified. Since the pandemic beginning, we have observed large differences in the type of corticosteroid, dose and initiation of treatment.Our objective is to assess the predictive capacity of the characteristics of patients treated with methylprednisolone pulses to predict hospital discharge. Materials and methodsWe presented a one-center observational study of a retrospective cohort. We included all patients admitted between 03/06/2020 and 05/15/2020 because of COVID-19. We have a total number of 1469 patients, of whom 322 received pulses of methylprednisolone. Previous analytical, radiographic, previous disease data were analyzed on these patients. The univariant analysis was performed using Chi-squared and the T test of Student according to the qualitative or quantitative nature of the variables respectively. For multivariate analysis, we have used binary logistic regression and ROC curves. ResultsThe analysis resulted statistically significant in dyspnea, high blood pressure, dyslipidemia, stroke, ischemic heart disease, cognitive impairment, solid tumor, C-reactive protein (CRP), lymphopenia and d-dimer within 5 days of admission. Radiological progression and FIO2 input are factors that are associated with a worst prognosis in COVID-19 that receive pulses of methylprednisolone. Multivariate analysis shows that age, dyspnea and C-reactive protein are markers of hospital discharge with an area below the curve of 0.816. ConclusionsIn patients with methylprednisolone pulses, the capacity of the predictive model for hospital discharge including variables collected at 5 days was (area under the curve) 0.816.

SP11.4 Imaging recommendations during the Covid pandemic for the investigation of right iliac fossa pain: an unachievable and unnecessary burden on radiology services?

AimsInitial Covid-19 surgical guidance, produced without radiological input, recommended that patients with right iliac fossa (RIF) pain should have imaging before intervention. This study quantified the burden on imaging services from these guidelines.MethodsPatients who presented to our surgical unit with RIF pain from March to October 2020 were identified. Clinical parameters, radiology and final diagnosis were recorded. Minimum follow-up was 12 months to identify re-admissions and morbidity.ResultsThere were 417 patients. There was a drop in admissions in the first months of each new wave of Covid (March/April, September/October) compared with intervening months (36% vs. 64%, P=0.036). 266 patients (64%) had a CT scan increasing from 42% of patients in March to 75% in September (P=0.019). The proportion of patients with normal imaging increased correspondingly with over a third (34%) of CT scans being normal. 93 CT scans (35%) showed appendicitis, which was the suspected diagnosis in all but 7 of these patients.Patients with normal imaging had lower white cell counts (Mean 10.1×109 vs. 14.8×109/L, P<0.001) and CRPs (Mean 21 vs. 99, P<0.001). Patients seen first by a consultant were less likely to require imaging.ConclusionsDuring the first year of Covid-19, two-thirds of patients with RIF pain had a CT scan with a third being normal. Most scans showing appendicitis had clinical parameters consistent with this diagnosis. Current guidelines may lead to unsustainable pressures on radiology services; ensuring consultant assessment prior to imaging requests may reduce the burden on these teams.

272 Adiposis dolorosa and deoxycholic acid: An alternative therapeutic method

Dercum disease, or adiposis dolorosa, is a rare disorder characterized by multiple painful lipomas distributed throughout the body. There are currently no approved treatments for Dercum disease and excision is often not feasible due to tumor burden and extent of disease. Here we present the use of deoxycholic acid (DCA) to reduce the size of lipomas associated with Dercum disease. Ultrasound was used to obtain 3-dimensional measurements of painful lipomas in three patients. Lesions were identified for treatment with patient and radiology input based on larger size, troublesome symptoms, and feasibility of location (e.g.

Predicting the response to methylprednisolone pulses in patients with SARS-COV-2 infection

IntroductionTreating systemic inflammation caused by SARS-COV 2 (COVID-19) has become a challenge for the clinician. Corticosteroids have been the turning point in the treatment of this disease. Preliminary data from Recovery clinical trial raises hope by showing that treatment with dexamethasone at doses of 6mg/day shows a reduction on morbidity in patients requiring added oxygen therapy. However, both the start day or what kind of corticosteroid, are still questions to be clarified. Since the pandemic beginning, we have observed large differences in the type of corticosteroid, dose and initiation of treatment.Our objective is to assess the predictive capacity of the characteristics of patients treated with methylprednisolone pulses to predict hospital discharge. Materials and methodsWe presented a one-center observational study of a retrospective cohort. We included all patients admitted between 03/06/2020 and 05/15/2020 because of COVID-19. We have a total number of 1469 patients, of whom 322 received pulses of methylprednisolone. Previous analytical, radiographic, previous disease data were analyzed on these patients. The univariant analysis was performed using Chi-squared and the T test of Student according to the qualitative or quantitative nature of the variables respectively. For multivariate analysis, we have used binary logistic regression and ROC curves. ResultsThe analysis resulted statistically significant in dyspnea, high blood pressure, dyslipidemia, stroke, ischemic heart disease, cognitive impairment, solid tumor, C-reactive protein (CRP), lymphopenia and d-dimer within 5 days of admission. Radiological progression and FIO2 input are factors that are associated with a worst prognosis in COVID-19 that receive pulses of methylprednisolone. Multivariate analysis shows that age, dyspnea and C-reactive protein are markers of hospital discharge with an area below the curve of 0.816. ConclusionsIn patients with methylprednisolone pulses, the capacity of the predictive model for hospital discharge including variables collected at 5 days was (area under the curve) 0.816.

107 Retrospective Pilot Study in Preparation for Setting Up an Acute Pancreatitis MDT in a Medium Sized NHS Acute Trust in the UK

Abstract Aim Within the spectrum of pancreatitis, patients with severe disease require specialist multidisciplinary care including dietician and radiology input. Therefore, certain patients would benefit from an MDT approach to coordinate their management. This retrospective study analyses data on pancreatitis admissions within our Trust, to inform the set-up of a new specialist MDT. Method Patients were identified using admission coding data. Relevant patient data was extracted, including demographics, disease severity (using the Atlanta classification) and relevant outcomes. Both first-time and repeat admissions were included. Incorrectly coded patients were excluded. Statistical analysis was performed using SPSS (Version 23.0). Results Over a study period of 489 days, 246 patients were coded as having pancreatitis.186 patients were first time admissions, and 27 patients were repeat admissions. 33 patients were incorrectly coded and excluded. Hence, the annual acute pancreatitis admission rate was 139 patients/year, with an additional 20 readmissions. 149 (80%) admissions were mild cases, with the remaining 14 (8%) and 23 (12%) being moderate and severe respectively. 149 (80%) were acute cases, compared to 20 (11%) chronic and 17 (9%) acute-on-chronic. 52/186 cases had no cause of pancreatitis recorded; where cause was identified, gallstones were the most common aetiology. Conclusions Pancreatitis is a common reason for admission during a general surgery on-call in our Trust; while the majority of cases are mild, the remaining 20% of moderate–severe cases qualify for discussion at an Acute Pancreatitis MDT. This pilot has facilitated the allocation of resources in our Trust and the MDT goes live in September 2021.

Multi-disciplinary team meetings with specialist radiologists may improve pre-operative clinico-radiological diagnostic accuracy in patients requiring orbital biopsy and offer reciprocal educational opportunities.

Accurate pre-operative diagnosis of orbital lesions supports appropriate prioritisation of patients into available theatre time. We examine the accuracy of pre-operative clinico-radiological diagnosis in a tertiary centre with weekly dedicated orbital clinics and associated multi-disciplinary team meetings. A retrospective case notes review was undertaken for all patients who had an orbital biopsy performed at Bristol Eye Hospital between 2007 and 2017. In this centre, pre-operative clinico-radiological differential diagnoses are discussed during multi-disciplinary team meetings including two orbital specialist ophthalmologists and a specialist neuro-radiologist. Clinico-radiological diagnoses were compared with histopathological outcomes. Subcategory analysis according to histopathological diagnosis was undertaken to look for trends. 172 biopsies were taken from 156 patients, median age 59 years (range 3 months to 91 years). 60.9% of patient were females, with equal numbers of right and left-sided biopsies. 11 patients had inconclusive histopathology. 15 patients did not have a documented preoperative diagnosis or differential offered in available notes. 71 patients (49.0%) demonstrated an exact match between clinico-radiological and histopathological diagnosis, 93 (64.1%) demonstrated a category match (e.g. inflammatory, lymphoproliferative) and for 111 (76.6%), the histopathological diagnosis was considered within the list of proffered clinico-radiological differential diagnoses. Accuracy of pre-operative diagnosis of orbital lesions undergoing biopsy was higher in our series than previously reported by Koukoulli et al. Specialist head and neck radiology input via regular orbital multi-disciplinary meetings might be reciprocally educational and explain this difference. The authors recommend all surgeons who perform orbital surgery should have access to such multi-disciplinary meetings.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Cost Evaluation Study of Management and Surveillance, and Review of the Recent USA and UK Guidelines

IntroductionBreast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell lymphoma associated with textured breast implants, recently recognized by the revised WHO Classification. Recommended management for BIA-ALCL involves a multidisciplinary team (MDT) approach with breast surgery, haemato-oncology, pathology, radiology and oncoplastic input. Definitive management for the 'effusion-only' subset is surgical implant and capsule removal; systemic therapy is reserved for 'mass-forming' and 'advanced-disease' cohorts. Overall prognosis is excellent with the vast majority achieving remission.Although the diagnostic and treatment paradigm is established, post treatment surveillance and follow-up guidance varies widely (globally); over-utilisation of imaging tests compromises the patient pathway, impacts limited health-care resources and is associated financial burdens on patients and providers. Recently, newly published consensus guidelines (UK MHRA and USA NCCN clarify follow-up and surveillance imaging (Table 1).The aim of this study was to review our BIA-ALCL specialist centre institutional practise; to quantify the direct economic cost (EC) of imaging surveillance and indirect EC of outpatient clinic (OPC) assessment compared EC if recent guidelines were followed. The secondary aim is to highlight and raise awareness of the latest international guidance to promote the standardisation of practise.MethodsA retrospective analysis of a prospectively maintained patient database between July 2015 to October 2019 was conducted, with Institutional Review Board Approval. Data collection included patient demographics, tumour subset, treatment, clinical and imaging surveillance. Follow-up and imaging undertaken for symptomatic concerns / non-BIA-ALCL related pathology was excluded. Imaging costs were calculated using UK NHS tariffs.ResultsEleven patients were treated for BIA-ALCL during the study period, with a median age of 49 at diagnosis (range 30-82years). Patients were diagnosed with: effusion-only (n=7), effusion and mass (n=2), mass-only (n=2) subtypes, at a median time of eleven years from implant insertion (IQR 8-12). All patients underwent explantation and en-bloc capsulectomy, with 1 patient required neo-adjuvant (CHOP, Brentuximab) and 1 adjuvant (CHOP) therapy (CHOP. Surveillance with imaging and OPC detected no disease recurrence to date (overall median follow-up 38 months, IQR 12-47). Post treatment episodes of surveillance imaging or follow-up related to patient symptoms were excluded.8 patients underwent surveillance imaging at our institute (Table 2). Total cost of imaging was £10,396 ($14,396) with a median cost of £1,953 ($2,705) per patient [IQR £526-2029 ($728-2,810)].7 patients had completed at least 24 months follow-up since surgery during the study period (Table 3), with 3 patients having not yet completed their follow-up period of two years. Of those with completed follow-up, the median OPC follow-up per patient was 48 months (IQR 38-52), median number of OPC was 7 (IQR 6-11) and the median cost of clinic review was £982 (IQR 804-1395). The surplus cost per patient compared with recommended follow-up was £118 ($164) [IQR £0-531 ($0-738)].ConclusionsOur data shows the variable BIA-ALCL surveillance practise pattern and the associated additional direct and indirect EC of unnecessary asymptomatic surveillance imaging, with an excessive number of follow-up OPC and period of clinical follow-up after complete remission. With no recurrence detected in our patient cohort to date, this data supports the new UK and updated USA NCCN Guidelines (extrapolated from data in other NHLs, and analogous to principles of the ASH Choosing Wisely Campaign) that routine post-treatment surveillance imaging should not be performed in BIA-ALCL patients. Routine asymptomatic post-treatment surveillance imaging is clinically unnecessary and potentially leads to a 'Cascade Effect' of further tests, with increased radiation exposure, excess costs and impact on limited health-care resources. We also support open-access follow-up for patients in remission, to reduce unnecessary follow up appointments. With UK and USA guidelines now available for BIA-ALCL, we support training and education of health-care professionals, global consensus guidelines and a registry, for this rare however increasingly recognised new entity. [Display omitted] DisclosuresIyengar: Takeda: Membership on an entity's Board of Directors or advisory committees, Other: conference support, Speakers Bureau; Gilead: Membership on an entity's Board of Directors or advisory committees, Other: conference support, Speakers Bureau; Beigene: Membership on an entity's Board of Directors or advisory committees; Abbvie: Other: conference support; Janssen: Other: conference support, Speakers Bureau. Nicholson: Pfizer: Consultancy; Kite, a Gilead Company: Other: Conference fees, Speakers Bureau; BMS/Celgene: Consultancy; Novartis: Consultancy, Other: Conference fees. El-Sharkawi: Kyowa Kirin: Other: Ad boards; Beigene: Other: Ad boards; ASTEX: Other: Ad boards; Novartis: Other: Travel Support; Takeda: Honoraria; Roche: Honoraria; Janssen: Honoraria, Other: Ad boards; AstraZeneca: Honoraria, Other: Ad boards; AbbVie: Honoraria, Other: Travel Support, Ad boards. Tasoulis: BMJ: Consultancy, Membership on an entity's Board of Directors or advisory committees. Cunningham: Roche: Research Funding; Clovis Oncology: Research Funding; Celgene: Research Funding; Eli Lilly: Research Funding; Bayer: Research Funding; OVIBIO: Membership on an entity's Board of Directors or advisory committees; 4SC: Research Funding; AstraZeneca: Research Funding; MedImmune: Research Funding.

Bio-Degradable Stents: Primary Experience in a Tertiary Hepatopancreaticobiliary Center in the United Kingdom.

Background: Management of benign biliary strictures (BBS) post bilioenteric anastomoses requires a multidisciplinary approach including surgical, radiological, and/or endoscopic input. Patients often need multiple hospital visits for treatment with the long-term possibility of restenosis. Conventionally BBS have been treated with serial percutaneous transhepatic biliary dilatations necessitating repeat procedures for drain exchange or removal. Surgery may become necessary in refractory strictures. In the last decade, there have been increasing reports of the use of biodegradable stents (BDS) in treating biliary strictures mainly to address the need for repeated procedures for drain exchange.Aim: This study aimed to report the early outcomes in patients with BBS treated with BDS.Methods: Retrospective analysis of prospectively collected data was performed in patients who had a bilioenteric anastomosis presenting with an anastomotic stricture and were intended to be treated with BDS. The primary endpoints reported were technical success (defined as a successful resolution of stricture on repeat cholangiogram) and clinical success (defined as the absence of repeated cholangitis). Clavien-Dindo (CD) grade of complication was reported.Results: Twelve patients presented with BBS and nine patients had BDS. Three patients were not considered suitable for BDS due to a non-traversable stricture and had surgery. The male-female ratio was 1:2. There was 100% technical and clinical success with one patient having stent migration not needing intervention. The procedure took an average of 45 min. In seven (77.7%) patients, it was safely performed under local anesthesia with sedation. Two patients preferred general anesthesia. There was no restenosis noted at a median follow-up of 11 months.Conclusion: The use of BDS in the treatment of BBS is a safe and effective procedure. Longer-term follow-up with multi-institutional reporting on a national database is needed to assess its long-term benefits.

P91 Phyllodes Tumours: Looking for Predictive Features from Multidisciplinary Assessments

IntroductionThe breast triple assessment enables rapid evaluation of breast abnormalities. Lesions are assessed via the assessments based on clinical examination, imaging and histological sampling. Fibroepithelial lesions (FELs) are amongst the most common breast lesions of uncertain malignant potential. They encompass a spectrum of entities ranging from benign fibroadenomas (FA) to malignant phyllodes tumours (PT), with contrasting clinical management approaches. Unfortunately, the distinction between various FELs is often difficult, despite recent diagnostic advances. This is especially so between FAs and PTs. Nevertheless, understanding how to prioritise key characteristics of PTs, both radiologically and histologically may ease this challenge. In our opinion, a multidisciplinary approach including radiological input is probably the most helpful in reaching an accurate diagnosis.MethodsWe, retrospectively studied data from breast lesions which were initially diagnosed pre-operatively as R3/B3 FELs, and those with a final diagnosis of PT on excision. 71 suitable cases were identified from 2009 to 2019. Information was extracted from reports made by specialists at the pre-operative and post-excision stages. Statistical analysis will be applied to quantify the significance of features evaluated.ResultsPreliminary results suggest diagnoses made by pathologists on pre-operative samples correlated well with the eventual final diagnosis made on post-operative specimens. Adequate sampling appears to be a significant factor in influencing the pre-operative core biopsy diagnosis.ConclusionWe anticipate to acquire a comprehensive knowledge of various predictive features of PTs, and the correlation between the key radiological features, thereby allowing accurate pre-operative diagnosis of these interesting and challenging lesions.

A Case of Central Pontine Myelinolysis due to Severe Acute Prolonged Hyponatremia in Our County Hospital

Background: Central pontine myelinolysis (CPM)is unique and rare clinical entity. It could be a neurological complication of prolonged hyponatraemia. Many predisposing risk factors (chronic alcoholism, malnutrition, malignancy) may aggravate the development of CPM. CPM usually have a poor or even fatal outcome. However, CPM does not inevitably have a bad prognosis, and could occur with proper restoration of normal serum sodium concentrations. Case Summary: Here, we presented a case of a 48-year-oldfemale. She used to drink alcohol. She presented to Our Lady’s Hospital/Navan with a history of four days feeling unwell, confused diarrhea, vomiting and by investigations, she had severe hyponatraemia. She was managed optimally in the ICU with close monitoring of her urea and electrolytes. Unfortunately, she got progressive neurological deficits (lower limbs weakness, and slurred speech) irrespective of gentle treatment of hyponatremia in intensive care unit. After Neurological and radiological input from Dublin institute, CPM confirmed under background of alcoholism and malnutrition. Following the diagnosis of CPM, she was discharged home after been rehabilitated with physiotherapy with ongoing recovery.

Hospital Presentations of Acute Diverticulitis During COVID-19 Pandemic may be More Likely to Require Surgery due to Increased Severity: A Single-Centre Experience.

The novel coronavirus disease 2019 (COVID-19) pandemic has resulted in fewer emergency presentations of many acute medical and surgical conditions. The purpose of this study was to assess the severity of disease at presentation and quantify the change in number of presentations during this period. This retrospective study includes all patients diagnosed with acute diverticulitis on abdominopelvic computerised tomography (CT) between March 1, 2020 and June 30, 2020, compared to the same period in 2019. Follow up scans on the index admission were excluded. Hinchey grade was assessed for all CT scans. Inflammatory markers were analysed, along with outcome measures including length of stay and mortality. Acute diverticulitis was diagnosed in 52 CT scans in the acute pandemic period - a decrease of 51.4%. Average age at presentation was unchanged (63.3 ± 14.3 vs. 62.8 ± 13.8, P = .848). The number of Hinchey II, III and IV presentations were significantly higher in the acute pandemic period (28.8% vs. 11.2%, P = .005) and significantly more emergency operations were carried out (7.69% vs. .93%, P = .04). Mortality was not significantly increased, nor were serum levels of C-reactive protein, white cell count and lactate. During the COVID-19 pandemic, fewer patients presented and were diagnosed with acute diverticulitis. A significantly greater proportion presented at a more advanced stage and required emergency surgery, suggesting late presentation. Our findings support the need for maintaining acute surgical services and the provision of early radiological and surgical input in patients presenting with signs and symptoms of acute diverticulitis in future pandemics.

The introduction of dedicated planning MR-CT fusion for radical radiotherapy of prostate cancer

Purpose Advances in radiotherapy planning and delivery have made target definition increasingly important. While CT images are required for plan calculation, MR fusion is increasingly used to more accurately define tumour and normal tissue. There is often significant variation seen between diagnostic and therapeutic imaging; hence, MR carried out in the treatment position is desirable. Materials and methods A multidisciplinary team of diagnostic and therapeutic radiographers, treatment planners, medical physicists and clinicians was convened. Planning MR was integrated into the radiotherapy pathway and carried out in the days immediately following CT simulation. All men underwent identical preparation (administration of a micro-enema and drinking 300 mL of water thirty minutes prior to imaging/treatment). Patients were set up in the treatment position using MR-compatible radiotherapy immobilisation. T2SE axial and sagittal images were acquired (Siemens Aera 1.5T E11, incorporating RT software platforms/LAP Laser Bridge/Civco RT Indexing Flat couch top/coil bridges), imported into the Eclipse planning system (V13.6, Varian), and fused to the planning CT for volume delineation. Results The service opened in mid-September 2017. 26 patients were scanned to the end of November 2017. All patients tolerated preparation and imaging without difficulty. Conclusion This service has been successfully introduced and will shortly expand to include other sites (rectum, lung, head and neck, complex palliative). A study is planned to assess the impact of the addition of MR on target delineation. Additional considerations include the need for dedicated radiology input and the potential role of collaboration with industry with a view to stand-alone MR simulation.

Radiological input during paediatric multidisciplinary team meetings and its influence on clinical patient management.

There is little information about the role of the radiologist at multidisciplinary team meetings; in particular their influence on patient management. To evaluate the influence of radiologists on clinical patient management during multidisciplinary meetings. Prospective data were collected over a 5-week period from multidisciplinary team meetings across four paediatric clinical domains. Radiological input was recorded for each case discussion, including the type of influence and its potential effect on clinical patient management. One hundred and forty paediatric cases were reviewed. Radiological advice was requested from the radiologist for 25.7% (N = 36) of cases. In 17.9% (N = 25) this advice was judged to have influenced clinical patient management. There were two cases where new imaging findings were discovered. Radiologists influence clinical patient management during multidisciplinary team meetings primarily by providing differential diagnoses and guidance regarding future imaging, with respect to both the necessity and the modality. Occasionally, when imaging is reviewed at these meetings, new findings are discovered that impact on patient management.

Effectiveness of Local Paediatric Murmur Clinic

Background: There has been increasing work-load in Paediatric Cardiology where majority of new referrals were asymptomatic murmurs. This has inevitably caused long waiting times impacting expectations of patients and parents as well as teaching, research and service commitments at tertiary centres. To address this concern, screening clinics locally in a supported network settings were suggested. Aim: To evaluate Local Murmur Clinic services run by a Paediatrician with Specialist Interest in Cardiology based at Royal Bolton Hospital, Bolton, United Kingdom. Method: Retrospective review of clinic letters of patients who attended the Murmur Clinic between January and December 2013. Findings: In total, 313 cases were reviewed. 98% of them were referred by General Practitioners and consultants. The Mean waiting time was 9 ½ weeks whereas the commonest waiting time (Mode) was 4 weeks. 50% of cases were aged between 6 months and 5 years. Heart murmur (67% of all cases) is the main reason of referral and 71% of these were discharged whereas 17% had abnormal Echocardiography. Overall, Cardiologist input was sought in 15% of all new cases. Murmur cases were more likely to be discharged (71% vs 43%) whereas other cases involved more cardiologist (27% vs 12%), General Paediatrics or radiology input (9% vs 2%), P=0.001. 11.5% of cases failed to attend their appointments with murmur cases being less likely to miss the appointment, P=0.001. Conclusion: This study demonstrated that local murmur clinic services avoid unnecessary referral of patients to tertiary centres which has dual benefits of patient convenience and reduced workload at paediatric cardiology outpatients. We recommend furtherance of supporting of the scheme and facilitation of early exposure of doctors in training to such services to enhance the likelihood of utilization of current training posts.

A comparison between the Example Reference Biosphere model ERB 2B and a process-based model: simulation of a natural release scenario

The BIOMASS methodology was developed with the objective of constructing defensible assessment biospheres for assessing potential radiological impacts of radioactive waste repositories. To this end, a set of Example Reference Biospheres were developed to demonstrate the use of the methodology and to provide an international point of reference.In this paper, the performance of the Example Reference Biosphere model ERB 2B associated with the natural release scenario, discharge of contaminated groundwater to the surface environment, was evaluated by comparing its long-term projections of radionuclide dynamics and distribution in a soil-plant system to those of a process-based, transient advection-dispersion model (AD). The models were parametrised with data characteristic of a typical rainfed winter wheat crop grown on a sandy loam soil under temperate climate conditions. Three safety-relevant radionuclides, 99Tc, 129I and 237Np with different degree of sorption were selected for the study.Although the models were driven by the same hydraulic (soil moisture content and water fluxes) and radiological (Kds) input data, their projections were remarkably different. On one hand, both models were able to capture short and long-term variation in activity concentration in the subsoil compartment. On the other hand, the Reference Biosphere model did not project any radionuclide accumulation in the topsoil and crop compartments. This behaviour would underestimate the radiological exposure under natural release scenarios.The results highlight the potential role deep roots play in soil-to-plant transfer under a natural release scenario where radionuclides are released into the subsoil. When considering the relative activity and root depth profiles within the soil column, much of the radioactivity was taken up into the crop from the subsoil compartment.Further improvements were suggested to address the limitations of the Reference Biosphere model presented in this paper.

Guidelines for the first line management of classical Hodgkin lymphoma

The guideline group was selected to be representative of UK-based medical experts and patients’ representatives. MEDLINE and EMBASE were searched systematically for publications in English from January 1990 to June 2013 using the key words Hodgkin, Lymphoma, Treatment, Chemotherapy and Radiotherapy. References from relevant publications were also searched. The writing group produced the draft guideline, which was subsequently revised by consensus by members of the Haemato-Oncology Task Force of the British Committee for Standards in Haematology (BCSH). The guideline was then reviewed by a sounding board of approximately 50 UK haematologists and the BCSH and comments incorporated where appropriate. The ‘GRADE’ system was used to quote levels and grades of evidence, details of which can be found in Appendix I. The objective of this guideline is to provide healthcare professionals with clear guidance on the management of patients with classical Hodgkin Lymphoma (HL). The guidance may not be appropriate for all patients with HL and in all cases individual patient circumstances may dictate an alternative approach.