Radiology Pathology Research Articles

Necrotizing Enterocolitis in Infants with Periventricular Hemorrhagic Infarction: Associations and Outcomes

Background: Necrotizing enterocolitis (NEC) and periventricular hemorrhagic infarction (PVHI) are complications of prematurity associated with poor neurodevelopmental outcomes. Objectives: We characterized temporal and causal associations between NEC and type of PVHI as well as associations with outcomes. Methods: This was a multicenter retrospective study of infants with birth weight <1,500 g and diagnosis of PVHI by a pediatric radiologist at 3 neonatal intensive care units in North Carolina, USA, between January 1998 and December 2004. NEC was confirmed using radiological and surgical pathology findings. Infants were assessed by 3 years using the Bayley Scales of Infant Development, second edition. Results: 35 of 112 (31%) of study patients developed NEC. NEC was diagnosed subsequent to PVHI by a median of 16.6 days (95% CI [9.5, 24.9], p < 0.0001). Indomethacin use and the presence of bilateral PVHI were associated with an increased risk of subsequent NEC (OR 2.8, 95% CI [1.1, 7.2] and OR 2.4, 95% CI [1.1, 5.7], respectively). Having bilateral versus unilateral PVHI was associated with a 2.34-fold increased risk of death (95% CI [1.27, 4.33], p = 0.007). NEC was not associated with worse motor outcomes in this population. Overall, the probability of a mental development index >70 was greatest for infants with unilateral PVHI versus bilateral PVHI, although the presence of NEC was associated with worse cognitive outcomes in both groups. Conclusions: Premature infants with PVHI often subsequently develop NEC, especially if they have bilateral PVHI and are exposed to indomethacin. While NEC results in worse neurodevelopmental outcomes, PVHI severity appears more important to the outcome of these infants.

Multimodality imaging and interventional management of a complex congenital vascular malformation

Hepatic vascular lesions are not an uncommon finding in children, and represent the most common benign liver tumours to present in infancy. We present a case of a complex vascular malformation with an intrahepatic component suggestive of a venous/arteriovenous malformation as well as a large extrahepatic lesion. The extrahepatic mass was present in both sub- and supra-diaphragmatic locations ,with features of a congenital haemangioma.&#x0D; &#x0D; In view of the clinical presentation and different imaging appearances, this case was felt to be interesting in its radiological workup, management and eventual unusual pathology.

Testicular Epidermoid Cysts

The purpose of this series was to describe the sonographic features of intratesticular epidermoid cysts with clinicopathologic correlation. A retrospective review of the sonographic features of all intratesticular epidermoid cysts within the radiologic pathology archive of the Armed Forces Institute of Pathology with correlation with clinical, surgical, and pathologic data was performed. On sonograms, intratesticular epidermoid cysts were evaluated for shape, borders, and the presence of characteristic features, including alternating hypoechoic and hyperechoic rings, mural calcifications, and echogenic central core. Color Doppler imaging was evaluated for the presence of internal flow. Of 21 cysts seen in 20 male patients (mean age, 24 years; range, 11-52 years), the most common finding was mural calcifications, which were seen in 18 lesions (86%). Concentric rings of alternating echogenicity were shown in 13 lesions (62%), and 7 cysts (33%) had an echogenic central core. No cysts showed internal vascularity. Testicular epidermoid cysts are uncommon solid-appearing testicular masses that usually present as palpable masses and are benign. Knowledge of the sonographic and pathologic features may help differentiate these lesions from malignancy and possibly prevent unnecessary orchiectomy.

Cost-benefit analysis of using large-format histology sections in routine diagnostic breast care

Large-format histopathology allows correct documentation of tumor size, lesion distribution, disease extent, and surgical margins, and facilitates better understanding of the complex morphology of breast carcinoma. Large-format histology slides are optimal tools for radiology–pathology correlations. Adapted to the needs of diagnostic routine, this method has the advantages of the conventional small block techniques while being able to analyze large contiguous pieces of breast tissue. The costs connected to implementing and utilizing this technique, analyzed in detail in this paper, exceed those of conventional histopathology only if the conventional sampling is limited and specimen work-up is insufficient. Documenting equally large tissue surfaces with thorough conventional sampling is much more expensive and laborious than when using large-format sections. Thus, large-format histopathology is the only cost-effective histotechnology method that meets the needs of modern multidisciplinary diagnostic breast care.

AMSER National Medical Student Curriculum in Radiology (Out of Print)

Abstract This resource for medical students is a 4-year curriculum covering modality/specialty-specific areas that they should be exposed to. It includes anatomy, radiology pathology, risks, and im...

Bisphosphonate-related osteonecrosis of the jaw: position paper from the Allied Task Force Committee of Japanese Society for Bone and Mineral Research, Japan Osteoporosis Society, Japanese Society of Periodontology, Japanese Society for Oral and Maxillofacial Radiology, and Japanese Society of Oral and Maxillofacial Surgeons

Bisphosphonates (BPs) have been widely, efficiently, and safely used for the treatment of osteoporosis, malignant hypercalcemia, bone metastasis of solid cancers, and multiple myeloma bone diseases. Accumulating recent reports describe that surgical dental treatments in patients with cancer or osteoporosis who have been receiving intravenous or oral BPs are associated with osteonecrosis of the jaw (bisphosphonate-related osteonecrosis of the jaw, BRONJ). The accurate incidence, clinical backgrounds, and pathogenesis of BRONJ have been unclear and appropriate approaches for prevention and treatment have not been established to date. To address the current situation of BRONJ in Japan, the "Allied Task Force Committee of Bisphosphonate-Related Osteonecrosis of the Jaw," consisting of physicians specializing in bone biology, orthopedic surgery, rheumatology, obstetrics/gynecology, and medical oncology and dentists specializing in oral surgery, periodontology, dental radiology, and oral pathology, was organized. The committee attempted to propose a standard position paper for the treatment of BRONJ. The committee expects that this proposal will provide objective and correct scientific information on BRONJ and will serve as a reference for conducting dental procedures for patients receiving BPs and in designing prevention and treatment of BRONJ. However, because this position paper is not based on direct clinical evidence, it should be used as a reference, and a decision on treatment in each case should be made after an extensive discussion among physicians, dentists/oral surgeons, and the patients.

Contemporary Issues in Head and Neck Pathology and Radiology

The comprehensive evaluation, assessment, and management of patients with non-tooth-related conditions of the head and neck area are essential aspects of the practice of dental medicine. The manuscripts selected for publication in this special issue serve to illustrate the importance of close cooperation between oral and maxillofacial pathology, radiology, oral medicine, and head and neck anatomy in both the initial diagnostic and subsequent treatment phases when evaluating and treating patients with non-tooth-related conditions of the oral and maxillofacial complex. I would like to genuinely thank my Guest Editors, Dr. Neil S. Norton from Creighton University in Omaha, Neb, USA Dr. Preetha P. Kanjirath, from the University of Michigan at Ann Arbor, Mich, USA and Dr. Tarnjit Saini, Brooke Army Medical Center Fort Sam Houston, in San Antonio, Tex, USA for their assistance. Without their involvement and thoughtful discussions, this special issue would not have been possible. I also extend my thanks to the authors who have contributed to this special issue, as well as to the many reviewers who graciously volunteered with the peer-review process. In the lead article in this special edition, “Bone Diseases of the Jaws”, by P. J. Slootweg, provides an overview of the more common and/or important lesions occurring in the oral and maxillofacial complex, while emphasizing the considerable overlap in clinical, histological, and radiological features among these entities. Y. Morimoto and colleagues review the usefulness of ultrasound imaging for the detection of noninvasive and soft tissue-related diseases and introduce three new potential applications of ultrasonography: guided fine-needle aspiration, measurement of tongue cancer thickness, and diagnosis of metastasis to cervical lymph nodes. Subsequent manuscripts explore the relationship between craniofacial pathology and anatomy. L. Sonnesen summarizes recent studies on the link between morphological deviations of the cervical vertebral column and craniofacial morphology, while Guest Coeditor Neil S. Norton and colleagues employ volumetric tomography to review the anatomy of the greater palatine canal and also to rule out a statistically significant association between the prevalence of maxillary sinus disease and the presence of concha bullosa and/or nasal septal deviation. R. A. Mesquita and colleagues critically review the available literature on the nonsurgical treatment of oral leukoplakia, while E. de S. Tolentino and colleagues present a well-documented case of an ameloblastic fibroma that illustrates the need to integrate radiology, oral and maxillofacial pathology, and head and neck anatomy in both the initial diagnosis and subsequent treatment of lesions of the maxillofacial complex. On behalf of my Guest Coeditors and myself, I hope that you will find the manuscripts that comprise this special issue both interesting and informative. Paul C. Edwards Preetha P. Kanjirath Tarnjit Saini Neil S. Norton

ビスフォスフォネート製剤関連顎骨壊死の病態とそのマネージメント

Bisphosphonates (BPs) have been widely, efficiently and safely used for the treatment of osteoporosis, malignant hypercalcemia, bone metastasis of solid cancers and multiple myeloma bone diseases. Accumulating recent reports describe that surgical dental treatments in patients with cancer or osteoporosis who have been receiving intravenous or oral BPs are associated with osteonecrosis of the jaw (BRONJ). The accurate incidence, clinical backgrounds and pathogenesis of BRONJ have been unclear and appropriate approaches for prevention and treatment have not been established to date. To address the current situation of BRONJ in Japan, the “Allied Task Force Committee of Bisphosphonate-Related Osteonecrosis of the Jaw” consisting of physicians specializing in bone biology, orthopedic surgery, rheumatology, obstetrics/gynecology and medical oncology and dentists specializing in oral surgery, periodontology, dental radiology and oral pathology was organized. The committee attempted to propose standard position paper for the treatment of BRONJ. The committee expects that this proposal will provide objective and correct scientific information on BRONJ and will serve as a reference for conducting dental procedures for patients receiving BPs and designing prevention and treatment of BRONJ. However, since this position paper is not based on direct clinical evidence, it should be used as a reference and a decision on treatment in each case should be made after an extensive discussion among physicians, dentists/oral surgeons and the patients.

The transition from acute to chronic pain

Why some patients develop chronic pain after an acutely painful event remains an enigma. For example, over 90% of the population will experience acute back pain at some time in their lives. In most cases this resolves but, in a few, it does not, even though these patinets have radiologic pathology similar to those in whom the pain does improve. Similarly, there are few people who escape the hands of the surgeon. What is becoming increasingly apparent is that those who do experience the sharp end of the scalpel frequently experience persistent pain as a result of the damage caused by this instrument. The reasons for this chronic post-surgical pain are discussed in this presentation, as are possible preventative strategies.

Surgical luxation and elevation as treatment approach for secondary eruption failure of permanent molars

BACKGROUND. Secondary eruption failure of permanent molars is a rare disturbance that usually causes serious clinical problems to the patient. Various treatment approaches have been proposed that depend on the age of the patient, the developmental stage of the root, the position of the tooth, the severity of infraocclusion and the presence of one or more affected teeth. Surgical luxation followed by elevation and stabilization of the luxated tooth has been proposed as a first-step treatment in cases of young patients with incomplete root formation and favourable position of the tooth. CASE REPORT. A boy initially aged 7.5 years old presented with localized secondary eruption failure of the mandibular right first permanent molar (46) and infra-occlusion. The medical and dental history of the child was uneventful, while there was no history of eruption failure or ankylosis in any other family member. TREATMENT. This included surgical luxation of the tooth, followed by elevation to the occlusal plane and immobilization to the adjacent primary molar. The splint was removed after 4 weeks. FOLLOW-UP. Three years follow-up revealed a successful result with no clinical or radiological pathology of the area. Root development of the affected tooth was arrested, but there was no sign of pulp necrosis. CONCLUSION. Favourable treatment outcome using surgical luxation and repositioning of the teeth in the present case of permanent molar with secondary eruption failure was observed.

Heart Failure and Cardiac Involvement as Isolated Manifestation of Familial Form of Transthyretin Amyloidosis Resulting From Val30Met Mutation With No Clinical Signs of Polyneuropathy

A 63-year-old white man with a 6-month history of progressive exertional dyspnea was referred for evaluation. In 1997, he presented an episode of unconsciousness as first symptom of a cardiac disease. In 2003, arterial hypertension, as well as atrioventricular block Mobitz type I, was diagnosed. A worsening of the biventricular heart failure over the last 2 years led to his admission at our clinic in 2008, with dyspnea at rest and bilateral pleural effusions. At admission, the patient appeared to be well, with a blood pressure of 142/76 mm Hg and a pulse of 97 bpm. Jugular venous pulse was not elevated, but mild bilateral edema of the lower extremities was noted. The lungs were clear to auscultation, with attenuation on the right side because of pleural effusion. The patient’s symptoms improved slightly through pharmacological therapy, but he remained in New York Heart Association functional class III heart failure. Laboratory studies revealed normal blood cell counts and electrolyte panel, with signs of load on the right side of the heart. The highest B-type natriuretic peptide was 818.6 pg/mL (normal, <100 pg/mL). The 24-hour urine protein collection was outside of normal limits at 0.27 g (normal, <0.15 g), and glomerular filtration rate according to the modified …

Place du curage ganglionnaire après chimioradiothérapie dans les carcinomes épidermoïdes des voies aérodigestives supérieures avec atteinte ganglionnaire initiale (nasopharynx exclu)

The optimal timing and extent of neck dissection in the context of chemoradiation for head and neck cancer remains controversial. For some institutions, it is uncertain whether neck dissection should still be performed upfront especially for cystic nodes. For others, neck dissection can be performed after chemoradiation and can be omitted for N1 disease as long as a complete response to chemoradiation is obtained. The question is debated for N2 and N3 disease even after a complete response as the correlation between radiological and clinical assessment and pathology may not be reliable. Response rates are greater than or equal to 60% and isolated neck failures are less than or equal to 10% with current chemoradiation protocols. Some therefore consider that systematic upfront or planned neck dissection would lead to greater than or equal to 50% unnecessary neck dissections for N2-N3 disease. Positron-emission tomography (PET) scanning to assess treatment response and have shown a very high negative predictive value of greater than or equal to 95% when using a standard uptake value of 3 for patients with a negative PET at four months after the completion of therapy. These data may support the practice of observing PET-negative necks. More evidence-based data are awaited to assess the need for neck dissection on PET. Selective neck dissection based on radiological assessment and peroperative findings and not exclusively on initial nodal stage may help to limit morbidity and to improve the quality of life without increasing the risk of neck failure. Adjuvant regional radiation boosts might be discussed on an individual basis for aggressive residual nodal disease with extracapsular spread and uncertain margins but evidence is missing. Medical treatments aiming at reducing the metastatic risk especially for N3 disease are to be evaluated.

Radiology pathology conference of Brooke Army Medical Center: trichoblastoma of breast

The differential diagnosis of a superficial breast lesion detected on mammography typically includes seborrheic keratosis, dermal nevus, epidermal inclusion cyst, and basal cell carcinoma with subcutaneous invasion [Kopans DB. Breast Imaging. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2007; pp. 481-2]. The case presented is of a trichoblastoma of the superficial breast. Trichoblastoma is a benign skin neoplasm that is rarely found in the breast. It has not previously been described in the radiologic literature. This case describes and correlates the findings of trichoblastoma of the breast on mammography, sonography, and histology.

Incidental gynecological findings on computed tomographic colonography: Prevalence and outcomes☆

ObjectivesComputed tomographic colonography (CTC) is an investigational method for detecting colorectal polyps. Our objectives were to determine the prevalence of gynecologic findings found incidentally on CTC, and to determine the incidence of additional radiological studies and surgical procedures. MethodsAn electronic database identified female patients who underwent CTC at Walter Reed Army Medical Center from January 2002 to July 2005. CTC reports were pared down using gynecologic keywords. Subsequent radiological studies and pathology reports were evaluated for women with gynecological findings. ResultsGynecologic extracolonic findings (ECF) were identified in 71 (9.5%) of the 749 women who underwent CTC. Of these 71 women, 14 (20%) underwent additional radiological and/or surgical evaluation. Nine (13%) of these women underwent surgical evaluation; all pathologic diagnoses were benign. ConclusionGynecologic extracolonic findings are common in women undergoing CTC. These gynecologic ECF identified on CTC may lead to additional investigative studies and procedures.

The influence of talonavicular versus double arthrodesis on load dependent motion of the midtarsal joint

Today the most frequently used operative procedures in advanced arthritis of the hindfoot joints are isolated talonavicular arthrodesis and double arthrodesis (involving the talonavicular and calcaneocuboid joints, i.e. the Chopart joint). This in vitro study investigates whether the fusion of the talonavicular joint alone can provide the hindfoot, as well as a midfoot, with comparable biomechanical stability as the double arthrodesis does. Hence with the less-invasive intervention the same benefit in terms of pain reduction and better functionality could be achieved. In a series of ten fresh cadaver feet without any radiological pathologies, we measured the range of motion of different tarsal bones in three planes under axial stress. Every foot was loaded without arthrodesis, after talonavicular and after double arthrodesis, by charging tibia and fibula with a force of 350 N using a calibrated Instron® load frame. Each tarsal bone was marked with a K-wire and its motion was measured by registering the movement of the wire’s shade that was projected onto the surrounding walls of the trial box. Both operative procedures led to a considerable reduction of the motion of every marked bone to a mean of 18% of the preoperative value. In direct comparison of the two simulated arthrodeses we found for every bone and in every plane only minimal differences of the mean excursions of 1.0 mm on average. Both fusions lead to equal residual tarsal bone motion postoperatively, and provide the midtarsal joint as well as the subtalar joint with comparable biomechanical stability. Isolated talonavicular arthrodesis is a useful and effective alternative to double arthrodesis. It is the less complicated, less-invasive and functionally equivalent operative option for arthritic alterations of the hindfoot and transverse tarsal joint.

A Novel Nomenclature to Classify Parathyroid Adenomas

A uniform and reliable description of the exact locations of adenomatous parathyroid glands is necessary for accurate communications between surgeons and other specialists. We developed a nomenclature that provides a precise means of communicating the most frequently encountered parathyroid adenoma locations. This classification scheme is based on the anatomic detail provided by imaging and can be used in radiology reports, operative records, and pathology reports. It is based on quadrants and anterior-posterior depth relative to the course of the recurrent laryngeal nerve and the thyroid parenchyma. The system uses the letters A-G to describe exact gland locations. A type A parathyroid gland is a gland that originates from a superior pedicle, lateral to the recurrent laryngeal nerve compressed within the capsule of the thyroid parenchyma. A type B gland is a superior gland that has fallen posteriorly into the tracheoesophageal groove and is in the same cross-sectional plane as the superior portion of the thyroid parenchyma. A type C gland is a gland that has fallen posteriorly into the tracheoesophageal groove and on a cross-sectional view lies at the level of or below the inferior pole of the thyroid gland. A type D gland lies in the midregion of the posterior surface of the thyroid parenchyma, near the junction of the recurrent laryngeal nerve and the inferior thyroid artery or middle thyroidal vein; because of this location, dissection is difficult. A type E gland is an inferior gland close to the inferior pole of the thyroid parenchyma, lying in the lateral plane with the thyroid parenchyma and anterior half of the trachea. A type F gland is an inferior gland that has descended (fallen) into the thyrothymic ligament or superior thymus; it may appear to be "ectopic" or within the superior mediastinum. An anterior-posterior view shows the type F gland to be anterior to the trachea. A type G gland is a rare, truly intrathyroidal parathyroid gland. A reproducible nomenclature can provide a means of consistent communication about parathyroid adenoma location. If uniformly adopted, it has the potential to reliably communicate exact gland location without lengthy descriptions. This system may be beneficial for surgical planning as well as operative and pathology reporting.

Otologic effects of environmental conditions at high-altitude

Purpose: The aim of this study was to investigate the otologic effects of high-altitude environmental conditions.Materials and Methods: Study was performed at altitude of 2200 m. Medical records between August 2007 and March 2009 were investigated retrospectively. Previously healthy patients with no history of otological and infectious diseases, no medication, no trauma, no evidience of radiological and laboratory pathology were included this study. Results: 41 patients with otologic complaints were concordant with inclusion criterias. The most common otologic complaints were sudden onset tinnitus (n:15) and ear fullness (n:11). The other otologic problems were vestibular disorders (n:7), otalgia (n:7) and sudden hearing loss (n:1). Except the sudden hearing loss, tinnitus and vestibular disorders were resolved after descending to low altitude without any medication. Sudden hearing loss was restored after hyperbaric oxygen treatment. Otalgia and ear fullness were recovered spontaneously within 10 days.Conclusions: High-altitude conditions are one of the causes of otologic disorders. The exact pathogenesis of the otologic problems is not known. We think that not only hypoxia, but also other factors are necessary to give rise to otologic disorders. Immediate descent is the treatment of choice. Physicians and high-altitude travelers must be aware of these entities.

Anthropological Measurement of Lower Limb and Foot Bones Using Multi‐Detector Computed Tomography

Anthropological examination of defleshed bones is the gold standard for osteological measurement in forensic practice. However, multi-detector computed tomography (MDCT) offers the opportunity of three-dimensional imaging of skeletal elements, allowing measurement of bones in any plane without defleshing. We present our experiences of the examination of 15 human lower limbs in different states of decomposition using MDCT. We present our method of imaging and radiological measurement of the bones including sex assessment. The radiological measurements were undertaken by three professional groups--anthropology, radiology, and forensic pathology--both at the site of scanning and at a remote site. The results were compared to anthropological oestological assessment of the defleshed bones. We discuss the limitations of this technique and the potential applications of our observations. We introduce the concept of remote radiological anthropological measurement of bones, so-called tele-anthro-radiology and the role that this could play in providing the facility for standardization of protocols, international peer review and quality assurance schemes.

Unusual Presentation of Anaplastic Large Cell Lymphoma with Clinical Course Mimicking Fever of Unknown Origin and Sepsis: Autopsy Study of Five Cases

To describe a subset of cases with the unusual clinical and histomorphological presentation of anaplastic large cell lymphoma (ALCL) mimicking fever of unknown origin (FUO) and sepsis. A pathology database was searched using full term Systematized Nomenclature of Medicine codes for ALCL to identify 23ALCL cases from the period 1999-2006. Of those, five cases that did not have a correct premortem diagnosis were further analyzed to elucidate the reasons for delayed and incorrect pre-mortem diagnosis. The analyzed data included clinical presentation, duration of symptoms, duration of hospital stay, premortem presumed cause of death, white blood cell count, platelet count, anion gap and blood pH, liver enzymes (alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, alkaline phosphatase), lactate, coagulation tests (prothrombin time, partial thromboplastin time, fibrinogen, D-dimers), microbiology cultures, and radiology and surgical pathology reports. Autopsy reports were reviewed for description of major gross findings, initial clinical diagnosis, and cause of death. Five fatal and pre-mortem unrecognized ALCL cases were characterized by rapid decline, with histologic findings showing predominantly extranodal involvement, intravascular lymphomatosis, and hemophagocytosis. The cases were also characterized by unusual clinical manifestations including a FUO, sepsis, and disseminated intravascular coagulation-like picture, lactic acidosis, hepatosplenomegaly, and absence of significant peripheral adenopathy. There is a distinct group of ALCLs with unique and specific clinical, gross autopsy, and histopathologic findings. Recognition of this clinical variant may facilitate early detection and potentially timely diagnosis and therapy.

The Diamond Anniversary of the NHS – A View from the Floor

As this issue of the Annals goes to press, the NHS is celebrating its Diamond Anniversary. At a Royal Society of Medicine lecture, the Chief Medical Officer highlighted the historical developments in public health, culminating in the recent ban on smoking in public places. Over the last 60 years, a thin line has persisted between the interests of government and those of the health of the nation as illustrated by the reluctance of successive governments to endorse the proven link between smoking and ill health on account of perceived loss of revenue from falling cigarette sales. An accompanying brochure listed the top sixty NHS figures – selected by a panel chosen by the Health Services Journal. Given the background of the panel, unsurprisingly, politicians (Margaret Thatcher and Gordon Brown included) and senior administrators topped the list. The highest-ranking surgeon (at number 31) was Sir John Charnley – curiously low in the view of the unquestionable international benefit of his pioneering arthroplasty, coupled with the momentous advances in biomedical engineering necessary to produce the initial prostheses and Charnley's own skills in operative teaching. Many hospitals held photographic exhibits to mark the occasion. One particular photograph caught my attention – that of a ward with a highly polished floor, 20 beds with a neatly folded towel at the foot and each bed occupied by a patient who was constricted by the tightest of hospital bed linen. Each nurse wore a neat uniform with a starched collar, cuffs and hat. No Staphylococcus aureus, whether methicillin resistant or common or garden, would have had the temerity to attempt to defy the withering stare of the ward sister or, indeed, the energy to cross the generous space between beds. How clinical practice has changed 60 years on: the same afternoon, modern technology had enabled me to access cross-sectional radiological images and pathology results at the touch of a button. Developments in medical instrumentation, electronics, fibre-optic technology and pharmacology had allowed two patients in my clinic to undergo minimally invasive oesophagectomy. What progress. Of the 18 patients in my clinic, however, eight had temporary or incomplete notes, one had three separate numerical identifiers on the PMS and three should never have attended a surgical clinic. Not one letter of referral was personal – all were addressed as Dear Colleague or Dear Surgeon. Is communication a victim of Choose & Book? Over the last 60 years, unimaginable benefits to patients have resulted from painstaking research into basic biomedical sciences, mathematics and medical engineering amongst others and the maturation of this into everyday clinical surgery. Politically driven and largely untrialed managerial developments (such as the NHS University and Choose & Book) arguably have resulted in poorer services to patients at an extensive and rarely acknowledged financial cost. Senior management, like the first war army staff, sit far behind the front line and know little of the consequences of their actions for the troops: sadly, the gulf between the two widens. For the profession, our trainees work half the hours of their parents: continuity of care has been lost and specialisation is leading us into a ‘silo’ mentality. What has not changed? Our patients are better educated in health matters, are more questioning and involved in decision making but still appear to respect and to have confidence in the medical profession. That, and the continued devotion of nurses, ambulance drivers, porters and other front-line staff give reason to be optimistic. I have two wishes for the Platinum Anniversary – first, that the NHS should invest in people rather than systems; second, government should cease to meddle with the NHS and give it some sea room allowing it to sail unfettered for a few years. To quote Professor Karol Sikora: ‘the government doesn't run supermarkets so why should they run health’. Happy anniversary