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To investigate if the detergent sclerosant sodium tetradecyl sulfate (STS) is deactivated by the lipid-based contrast agent ethiodised oil. 3% STS was mixed with ethiodised oil and room air in a 2:1:4 ratio in two luer lock syringes and a three way connector and agitated to make foam (the Tessari technique) to replicate the clinical use of the products. The assay of STS in the mixture was assessed using the British Pharmacopoeia method. Briefly this is a manual titration method where the solution of STS is mixed with an indicator solution and titrated with hyamine solution of known concentration; the concentration of the STS can then be calculated with the titration results. To further mimic the clinical environment with the presence of blood, the effect of adding increasing amounts of albumin to the STS-ethiodised oil mixture was assessed. The assay of STS in the solution after mixing with ethiodised oil was 3% indicating that the ethiodised oil did not deactivate the STS. The addition of albumin to the STS-contrast mixture resulted in near linear neutralisation of the STS with increasing concentrations in the same quantities as with STS alone. The mixture of the lipid-based contrast agent ethiodised oil with the detergent sclerosant STS did not affect the availability of the sclerosant. The continued use of STS-ethiodised oil in the management of vascular malformations can be supported.

To investigate if the detergent sclerosant sodium tetradecyl sulfate (STS) is deactivated by the lipid-based contrast agent ethiodised oil.3% STS was mixed with ethiodised oil and room air in a 2:1:4 ratio in two luer lock syringes and a three way connector and agitated to make foam (the Tessari technique) to replicate the clinical use of the products. The assay of STS in the mixture was assessed using the British Pharmacopoeia method. Briefly this is a manual titration method where the solution of STS is mixed with an indicator solution and titrated with hyamine solution of known concentration; the concentration of the STS can then be calculated with the titration results. To further mimic the clinical environment with the presence of blood, the effect of adding increasing amounts of albumin to the STS-ethiodised oil mixture was assessed.The assay of STS in the solution after mixing with ethiodised oil was 3% indicating that the ethiodised oil did not deactivate the STS. The addition of albumin to the STS-contrast mixture resulted in near linear neutralisation of the STS with increasing concentrations in the same quantities as with STS alone.The mixture of the lipid-based contrast agent ethiodised oil with the detergent sclerosant STS did not affect the availability of the sclerosant. The continued use of STS-ethiodised oil in the management of vascular malformations can be supported.

Background The COVID-19 pandemic has had an unprecedented effect upon the National Health Service (NHS). Like other specialties, Interventional Radiology (IR) rapidly adapted to the evolving situation. Members of BSIR were surveyed to obtain a snapshot of the experiences of UK IRs in response to COVID-19. An electronic survey was compiled using Google Forms, approved by the BSIR Council Officers and distributed to BSIR members by email on 18 th April 2020. A total of 228 responses were received. The survey was open for a 14-day period and the data analysed in Microsoft Excel 365. The response rate was 29% (228/800). Results Two thirds of respondents work in a Tertiary unit and 33% deliver IR in a District Hospital. 84% have a day-case facility. After the COVID-19 crisis, 81% of respondents were able to maintain 24–7 On-call service. 59% of respondents had been required change their day to day practice to allow the on-call service to continue. 55% of respondents were involved in providing a central line service. Of those questioned, 91% continued to offer endovascular services, 98% genitourinary and 92% hepatobiliary services, although a degree of service reduction was described. 38% have provided IR trainees with additional training material during this pandemic. Conclusions This survey has confirmed that the responses of UK IR departments to the COVID-19 crisis have ensured vital on-call and urgent services have continued, including ongoing availability of most IR sub-specialties. Availability of a day case facility has possibly influenced the positive response.

Vascular anomalies are a complex group of conditions that are divided into vascular tumours and vascular malformations. The key to understanding lies in the classification and the correct terminology. The correct terminology is essential for the understanding and development of treatment algorithms within the literature and wider community. The use of an accepted classification system helps to easily understand the broad clinical groups and diagnosis to facilitate the correct treatment pathways.

Congenital intrahepatic arterio-portal fistulae (cIAPF) are rare, high-flow vascular malformations that usually present with portal hypertension. They almost never cause heart failure, unless there is associated congenital heart disease or the ductus venosus in patent. We present an unusual case of IAPF in an 11-day-old boy, who presented with features of cardiac failure associated with increased N-terminal pro-brain natriuretic peptide (NT pro-BNP). The IAPF arose directly from the aorta, separated from the hepatic artery and divided to separately supply both left and right portal veins. The ductus venosus was occluded. The IAPF was treated with embolization of the aorto-portal fistula, accessed through a direct percutaneous puncture of the fistula. Embolization was associated with an immediate clinical improvement and a rapid and sustained normalization of the NT pro-BNP level. A similar re-presentation was noted and treated with repeat embolization. The child is well on follow-up. To our knowledge, this is the first case of cIAPF, which was presented with cardiac failure when the ductus venosus has closed and has been treated successfully with direct, percutaneous transhepatic embolization of the fistula, twice. Serial clinical follow-up and ultrasonographical examinations have proven to be an effective strategy to detect recurrent fistulae.

Introduction: The frozen elephant trunk (FET) technique may be complicated by a risk of spinal cord injury (SCI) which has been reported as high as 10%.Precise mechanisms responsible for SCI after FET are still unclear and so the best protection strategy to avoid it. Hypothesis: We aim to review our experience with a specific protocol developed to reduce the risk of SCI during open surgery of the descending aorta applied to patients operated with FET in order to increase spinal cord protection Methods: Spinal cord protection protocol included: 1.Careful preoperative planning to deploy of stent above the level of the 10th thoracic vertebra and preserving the patency of the left subclavian artery; 2.Postoperative management with goal directed therapy aimed to achieve mean systemic blood pressure between 85 and 105 mmHg, cardiac index >2.4 l/min/m2, urine output >1 ml/Kg/min, a base excess of 0±5, a pH>7.3 and haemoglobin level >10 g/dl; 3.Cerebrospinal fluid (CSF) drainage was used in 4 patients (5.8%) only Results: From April 2006 to December 2015 69 patients underwent aortic repair with the FET at our Institution.There were 31 males (51.7%). Median [IQR] age was 69 [59-75] years and median [IQR] Log EuroSCORE was 20.3 [13.9-36.2]. There were 19 (27.5%) reoperations. Operative times and outcomes are reported in Table 1. Conclusions: SCI remains the Achilles’ heel of the FET procedure.Elevated blood pressure in the preoperative period may reduce the risk of SCI by increasing the collateral network remodeling.Careful preoperarative planning and avoidance of sacrifice of all thoracic segmental arteries and preservation of left subclavian artery patency may reduce the risk of SCI maintaining good collateralization of the spinal cord perfusion network.Attention to all haemodynamic and metabolic parameters may avoid further ischemic insults to the spinal cord. CSF drainage may not be necessary in all cases of FET

Abdominal trauma is increasing and although penetrating wounds are also on the increase, blunt trauma remains more common. The cornerstone of management is accurate diagnosis and the advent of high-quality rapid CT scanning has revolutionised the treatment of serious abdominal injury. It has allowed the introduction of selective non-operative management which is applicable to many low- and intermediate-grade injuries, whereas application of interventional radiology can avert laparotomy in higher grade injuries. This review examines the pathophysiology of the commonest forms of abdominal injury and uses a series of cases to illustrate the impact of modern radiology in management.

ONYX® is a non-adhesive liquid embolic agent, ethylene vinyl alcohol copolymer dissolved in various concentration of dimethyl sulfoxide. Onyx has been used for endovascular treatment of cerebral vascular malformation. In our series, we present our experience in seven paediatric patients with peripheral high-flow arteriovenous malformations (AVMs) treated with Onyx. Seven patients were treated in our institution from 2005 to 2010 for their AV malformation with Onyx embolisation. Their case notes were reviewed and data on site, stage, number of embolisations, pre and post-procedure stage of AVMs and complications noted. AVMs involving profunda femoris, posterior tibial arteries, facial and maxillary arteries were embolised with Onyx. Three patients received multiple embolisation procedures. All AVMs were downgraded from Schobinger III to Schobinger I after embolisation. Two patients underwent surgical removal of AVM post-embolisation. One patient experienced post-procedure pain, skin ulceration and necrosis, which was managed conservatively. One patient had stiffness and discomfort over ankle joint. Onyx induced an inflammatory reaction in tissues in one patient. In our experience, Onyx embolisation of extracranial high-flow AVM in children has shown to downgrade the stage of AVMs which are otherwise very difficult condition to treat surgically. Appropriate use of Onyx decreases complications and achieves symptomatic improvement. Level of Evidence: Level V, therapeutic study.

Summary Introduction and aims Sclerotherapy has become first line treatment for most venous malformations and some lymphatic malformations. We aimed to measure our sclerotherapy treatment success using 3% sodium tetradecyl sulphate (STD) and describe our experience. Materials and methods Retrospective five year review (Jan 04–09) of children with vascular malformations treated at our centre with 3% STD. Patients were classified using the Birmingham classification and treatment success was measured through case note review and pre- and post-treatment photographs. Findings and results Forty-three (84.3%) of the 51 patients with vascular malformations (VM) who underwent sclerotherapy derived a benefit. Twelve patients (23.5%) had an excellent result, 31 (60.8%) were improved whilst eight (15.7%) were unchanged. Using Fisher's exact test, there was a statistically significant difference in achieving complete resolution of superficial VMs compared to lesions involving the deeper layers of the head and neck. 17.6% of patients developed a complication with an overall complication rate of 12.2% per injection. There was one major complication with the remainder consisting of superficial skin necrosis that resolved conservatively. Conclusions Treatment with 3% STD sclerotherapy is effective in venous and some lymphatic vascular malformations. It should be considered an important treatment modality within a multi-disciplinary setting in these difficult problems.

The management of vascular anomalies in upper and lower limbs is complex. The current practice at Birmingham Children's Hospital is based on a multidisciplinary approach, involving plastic surgeons, interventional radiologists, vascular surgeons, dermatologists and laser specialists. This study reviews the management strategies for peripheral venous malformations (VMs) and proposes a simple classification system to aid treatment. A retrospective review was undertaken involving all paediatric patients presenting with (VMs) of the upper and lower limbs, managed by the same multidisciplinary team over a period of 3 years. A total of 33 patients were identified, of whom 19 had lesions located in the upper limb. Treatment modalities included surgery, sclerotherapy, a combination of the two and conservative management. The indications for treatment included: (1) worsening pain, (2) increased swelling, (3) reduced function, (4) bleeding or ulceration and finally, (5) cosmetic deformity. Following treatment, outcome measures with regards to the symptoms were graded into (1) improved, (2) worsened and (3) unchanged. Based on magnetic resonance imaging, we were able to apply our classification to separate the lesions into Type 1a (superficial localised): nine, Type 1b (superficial diffused): five, Type 2 (Fascia/muscle infiltration): nine, Type 3 (Bone/joint infiltration): seven and Type 4 (Extensive whole-limb infiltration): three. In patients with upper limb VMs (n=19), eight lesions (42%) were superficial and localised (Type 1a) while the rest were diffused lesions. In contrast, in the lower limb (n=14), only one lesion (7%) was superficial while the rest were diffused lesions. Lower success rate for treatment was noted in lower limb malformations (p0.05). In eight patients with recurrence of symptoms, six had Type 3 (intra-articular) lesions. There was one major and three minor complications following treatment. An outline of the management strategies for VMs in peripheral limbs is discussed in this article. An anatomical classification is described which aids in management and communication.

This unique case reports the first recorded episode in the medical literature of vasculitis post-liver transplantation, presenting as life-threatening gastrointestinal hemorrhage. A 52-year-old Caucasian woman underwent orthotopic liver transplantation (OLT) for autoimmune cirrhosis complicated by hepatoma and portal vein thrombosis. Late hepatic artery thrombosis led to a second liver graft. Following recovery from an episode of acute rejection, the patient presented with large volume hematemesis, melena, and hemochezia (passage of fresh blood from the rectum). Following upper and lower gastrointestinal endoscopy and surgery, angiography illustrated the presence of polyarteritis nodosa (PAN), which was successfully treated with high-dose steroid therapy. Gastrointestinal hemorrhage is an unusual presentation of vasculitis, especially PAN. The occurrence of this phenomenon post-OLT, in the presence of immunosuppression is previously unreported.

Lymphangioleiomyomatosis (LAM) is a rare multisystem disease. Progressive airflow limitation, pneumothorax and angiomyolipoma-related bleeding are major morbidities. As treatments are available for these complications, we prospectively audited loss of FEV1 (ΔFEV1), pneumothorax and angiomyolipoma bleeding against clinical standards over 4 years at the UK Clinical Centre. ΔFEV1 for these patients is lower than previously reported and rates of pneumothorax and angiomyolipoma haemorrhage are low. This suggests that real-time analysis of clinical data with targeted interventions can reduce morbidity in LAM. These measures could be applied as quality standards to compare the emerging LAM clinical networks worldwide.

Introduction: At present, there are not risk scoring tools to predict in-hospital mortality for total aortic arch replacement (TAR), Hypothesis: To assess if Logistic Euroscore (LogES) is a useful tool for risk assessment in aortic arch surgery and which other operative factors may help to better identify high-risk patients. Methods: All patients who underwent open arch procedure between 1998 and 2013 were identified from our prospectively collected database which include 93 preoperative variables. Results: Three-hundred-fifty-seven open arch procedures were identified. Two-hundred-forty-two patients underwent TAR, 199 with conventional technique and 43 with frozen elephant trunk (FET) technique. Patients with higher LogES had higher in-hospital mortality (see table 1). Patient with a LogEs 60 were classified as low-, high- or very high-risk, respectively. Complexity of surgery, defined as need for aortic root replacement (ARR) and/or mitral valve repair/replacement (MVR), increased significantly the risk of operation (27% vs. 4.2%, p:0.004) only in conventional TAR in high-risk patients. Low-risk patients were associated with low mortality regardless the extent of surgery whilst very high risk-patients had a high-risk of death even with simple operations. Mortality risk in FET was not increased by need for ARR/MVR. Rate of permanent neurological deficit remained low in all category of patients. Spinal cord injury (SCI) did not occur in any conventional TAR. Conclusions: Open surgery should remain the treatment of choice for patients with low/moderate LogES and high LogES without need for ARR/MVR. Patient with very-high LogES who do not need ARR/MVR should be consider for endovascular repair. Patient with high and very-high LogES and need for ARR/MVR cannot undergo endovascular treatment and remain a significant challenge. FET remains a procedure with an increase risk of death and SCI.

ObjectiveTo map out the current provision of interventional oncology (IO) services in the UK.DesignCross-sectional multicentre study.SettingAll National Health Service (NHS) trusts in England and Scottish, Welsh and Northern Ireland health boards.ParticipantsInterventional radiology (IR) departments in all NHS trusts/health boards in the UK.ResultsA total of 179 NHS trusts/health boards were contacted. We received a 100% response rate. Only 19 (11%) institutions had an IO lead. 144 trusts (80%) provided IO services or had a formal pathway of referral in place for patients to a recipient trust. 21 trusts (12%) had plans to provide an IO service or formal referral pathway in the next 12 months only. 14 trusts (8%) did not have a pathway of referral and no plans to implement one. 70 trusts (39%) offered supportive and disease-modifying procedures. One trust had a formal referral pathway for supportive procedures. 73 trusts (41%) provided only supportive procedures (diagnostic or therapeutic). Of these, 43 (59%) had a referral pathway for disease-modifying IO procedures, either from a regional cancer network or through IR networks and 30 trusts (41%) did not have a referral pathway for disease-modifying procedures.ConclusionThe provision of IO services in the UK is promising; however, collaborative networks are necessary to ensure disease-modifying IO procedures are made accessible to all patients and to facilitate larger registry data for research with commissioning of new services.

This review article aims to give an overview of the current state of imaging, patient selection, agents and techniques used in the management of low-flow vascular malformations. The review includes the current classifications for low-flow vascular malformations including the 2014 updates. Clinical presentation and assessment is covered with a detailed section on the common sclerosant agents used to treat low-flow vascular malformations, including dosing and common complications. Imaging is described with a guide to a simple stratification of the use of imaging for diagnosis and interventional techniques.

OBJECTIVES Open total aortic arch replacement (TAR) in high-risk patients is considered by some to be associated with a prohibitively perioperative risk. Recent reports describe hybrid techniques to treat this group. We reviewed our outcomes of open surgery in a 'high-risk' group of patients. METHODS All patients who underwent open TAR between 2000 and 2013 were identified from our prospectively maintained database. Patients comparable with the ones who underwent hybrid repair in previous studies (logistic EuroSCORE between 20 and 60 without intervention on the aortic root or on the mitral/tricuspid valve) were selected for analysis. RESULTS Fifty-eight patients were identified. Median logistic EuroSCORE was 27.4 (range 20-57) and median age was 76 years (34.5% male). There were 11 resternotomies (18.9%) and 20 procedures were urgent/emergency (34.5%). Preoperative comorbidities included chronic obstructive pulmonary disease (31%), coronary artery disease (22.4%), peripheral vascular disease (48.3%), previous stroke (5.2%), previous myocardial infarction (3.4%) and left ventricular dysfunction (12%). Concomitant procedures included aortic valve replacement/resuspension (58.7%), coronary artery bypass grafting (22.4%), open descending aorta replacement (10.3%) and frozen elephant trunk (19%). Overall in-hospital mortality, permanent stroke and spinal cord injury rate were 6.9, 1.7 and 0%, respectively. There were no deaths or stroke in the elective group. One-year, 5-year and 10-year estimates of survival were 82.7, 70.0 and 37.8%, respectively. CONCLUSIONS Open TAR can be performed with low mortality and morbidity and excellent long-term results even in high-risk patients. Total endovascular repair may represent an option for patients not suitable for open surgery.

Bilateral Renal Cell Carcinoma (RCC) is an uncommon clinical entity, affecting 3%-6% of patients with localized RCC. Sunitinib has proven efficacy in the management of metastatic RCC (mRCC), however, there is very limited evidence of primary tumor response. With the changing treatment paradigm, the role of sunitinib should be extended to the neoadjuvant setting, to downstage locally advanced primary renal tumors, to facilitate nephron-sparing surgery (NSS), and to select responding patients with mRCC for continuation of treatment after cytoreductive nephrectomy. The role of sunitinib in downstaging primary renal tumors to facilitate curative NSS has not been previously reported. We report the case of recurrent renal tumors in a solitary kidney, where neoadjuvant sunitinib downstaged the tumors enough to allow NSS.

Vascular malformations are a diffuse collection of abnormalities that are usually present at birth but may present any time during childhood or as an adult. Historically terminology has been complicated and used interchangeably causing confusion to patients and clinicians alike; however, a structured internationally agreed classification system exists. It is not uncommon for patients with vascular malformations to be referred to various specialties without obtaining a correct diagnosis and appropriate treatment. Vascular malformations can occur anywhere within the body and all patients will require imaging at some stage; therefore, it is important for all radiologists to be aware of the correct terminology and imaging characteristics. This review discusses classification and illustrates salient imaging findings and the modern approach to treatment of vascular malformations.

Purpose To determine the effectiveness of stent-grafts for the treatment of central venous disease in hemodialysis patients with functioning arteriovenous (AV) fistulas. Materials and Methods Between October 2004 and March 2010, 42 VIABAHN stent-grafts were deployed in central veins of 30 patients (16 men, 14 women; mean age 60 y) with functioning AV fistulas and central venous disease that did not respond to percutaneous transluminal angioplasty (PTA). Eighteen patients had central vein stenosis and 12 had occlusion. Previous PTA and/or bare metal stent placement had been performed in 23 patients (77%). Surveillance was carried out at 3, 6, 9, 12, 18, and 24 months with diagnostic fistulography. The mean follow-up was 705 days (range, 66–1,645 d). Statistical analysis included Kaplan–Meier and log-rank studies. Results Technical success rate was 100%. Primary patency rates were 97%, 81%, 67%, and 45% at 3, 6, 12, and 24 months, respectively. Primary assisted patency rates were 100%, 100%, 80%, and 75% at 3, 6, 12, and 24 months, respectively. Patients without previous procedures had significantly shorter times to repeat intervention ( P = .018) than those who had undergone PTA or bare metal stent placement previously. Patients with occlusive lesions had a significantly shorter primary patency interval ( P = .05) than patients with stenoses. Occluded veins were more likely to require further stent-grafts ( P = .02). Twelve patients required further stent-grafts to maintain patency. There was one minor complication. Conclusions Stent-graft placement to treat central venous disease in hemodialysis patients with autogenous AV fistulas is safe and effective if PTA fails to maintain luminal patency.

ascular malformations can be treated in different ways epending on the type of lesion and its presenting symptoms. ne of the simplest conservative ways is by sclerotherapy, hich is done by an interventional radiologist who injects sclerosant into the lesion under ultrasound guidance. This auses an intense inflammatory reaction within the lesion, nd fibrosis during healing causes the lesion to shrink. The sclerosant used is Fibro-vein (STD Pharmaceutical, ereford, UK), which contains sodium tetradecyl sulphate STD), a commonly used agent in the treatment of lower

Cardiovascular complications following coarctation repair include aorto bronchial fistulas (ABF) which if untreated are invariably fatal. Reoperative surgery is associated with considerable mortality and morbidity. Endovascular stent aortoplasty provides a relatively new and viable alternative. Two cases of ABF post coarctation repair that presented with life threatening haemoptysis are discussed. Endovascular repair appears safe and feasible in an emergency and may become the preferred treatment modality in such cases.

Reports on a trip to St Petersburg and Russian attitudes to health education as well as some of the health problems in Russia. Outlines educational practices in Russia – looks at lack of support with regard to the development of health education policies and the growing desire to press for change. Concludes that, in addition to environmental and economic difficulties, there is a substantial threat from the Western problems of alcohol, illegal drugs and HIV; some of the more pressing concerns related to disease prevention and nutritional health have delayed the resources allocated to health education in the curriculum.

Clinical Summary A 31-year-old woman was admitted to a peripheral hospital with an episode of massive hematemesis. She had undergone a patchtechnique coarctation repair at age 3 years and required balloon dilatation for recoarctation at age 14 years. Annual cardiologic follow-up detected, at age 26 years, a pseudoaneurysm at the coarctation site with dimensions of 2.4 1.9 cm. The pseudoaneurysm size remained stable, but 8 months before the hematemesis, TEVAR was recommended to avert any risk of rupture and a Jomed 48 20-mm covered stent (Abbott Vascular Ltd, Kent, United Kingdom) was deployed at the coarctation site pseudoaneurysm. Post-TEVAR imaging suggested satisfactory exclusion. After the hematemesis, she underwent esophagogastroduodenoscopy, which showed a 1.5-cm bluish polypoid lesion 26 cm from the incisura. Biopsy revealed blood clot only. She was discharged but readmitted 4 weeks later with a further massive hematemesis. A repeat esophagogastroduodenoscopy revealed that the lesion had enlarged 3-fold. This finding, together with the history of coarctation surgery, prompted a computed tomographic (CT) scan (Figure 1), which demonstrated a perigraft hematoma suggestive of AEF. After transfer to our center, aortography confirmed peri–stent-graft extravasation, further supporting a diagnosis of AEF. Another covered stent (38 12 mm, Jostent; Abbott Vascular Ltd) was deployed and the hematemesis abated. However, a postprocedure angiogram demonstrated persistent filling of the pseudoaneurysm. The incomplete pseudoaneurysm exclusion and the perceived risk of further complications prompted surgical referral. Echocardiography demonstrated moderate bicuspid aortic valve stenosis. Surgery was performed via a transsternal thoracotomy in the left fourth intercostal space and comprised mechanical aortic valve replacement, retrocardiac ascending–descending aortic conduit insertion, and an interposition graft between the conduit and the left subclavian artery. The aortic arch was staple-ligated between the left common carotid artery and the left subclavian artery. The descending aorta was stapled below the stent site. The aortic pseudoaneurysm was opened and the previously placed stents were removed. Inspection revealed a section of necrotic and partially absent aortic wall with erosion of the longitudinal esophageal muscle but no mucosal breach. It was assumed that stent deployment had perforated or disintegrated the aortic wall leading to an AEF. The aortic remnant was left open, a feeding enterostomy and decompression gastrostomy performed, and the chest closed with drainage. Recovery was uneventful, with a contrast swallow examination showing no abnormalities. At 12 months, the patient remains free of symptoms, and CT scan (Figure 2) demonstrates resolution of perigraft hematoma and satisfactory anatomic reconfiguration.

Introduction: Conventional CT demonstrates pathology of the thoracic aorta. This study aimed to evaluate the additional contributions to surgical planning of multiplanar reformatting, maximum intensity projections and three-dimensional (3-D) reconstruction. Design: Retrospective. Subject and Methodology: Fifty-three patients with newly diagnosed pathology of the thoracic aorta were scanned over a 15-month period; 25 scans were spiral acquisitions. Scans were acquired during and following rapid injection of 100 ml of intravenous iopromide. The reconstructed data was displayed as axial images, oblique or other multiplanar reformats and shaded surface display 3-D reconstructions. Two radiologists and two surgeons reviewed the images. The axial images were assessed initially, subsequently the reformats and 3-D reconstructed views were examined looking particularly for additional information that might add to the surgical management. Results: Pathologies encountered were aortic dissection (21 patients including two with Marfan's syndrome), saccular aneurysms (eight), fusiform aneurysms (16), aortic root and ascending aortic dilatation (seven) and coarctation (one). The relationship of aneurysms and dissections to major vessels are better shown with 3-D reconstruction or oblique reformats. Morphology of saccular aneurysms, particularly the neck, is well shown with 3-D reconstruction. Coarctation was best demonstrated by oblique reformats. There was little additional information from 3-D reconstruction or reformats in assessment of type A dissection. Improved spatial orientation by visualization in varying projections was helpful for surgical planning in certain cases of type B dissection, fusiform aneurysms and aortic root and ascending aortic root dilatation. Spiral acquisitions have the advantage of speed and hence a greater anatomical coverage for a single breath-hold. Conclusion: Oblique reformats and 3-D reconstruction, although using identical data as the axial images, in specific cases were felt to aid surgical assessment of aneurysms and dissections, thus assisting pre-operative planning.

WHILE there is general agreement that research in health education is valuable, there is considerable disagreement on the form it should take, and how it should be organised. After a review of the problems and opportunities from two perspectives, a number of points are suggested which should be taken into account by anyone considering basing research posts in service units.

Any manager or entrepreneur who aims to survive for a considerable period needs information not only on what is going on now, and what happened several months ago, but also what is likely to happen in the future. As none of us has perfect vision in this area, we are going to rely on a certain amount of intuition — playing hunches — and on the information that can be gained from forecasting.

T cell activation is commonly assayed in vitro by measuring the proliferative response of primed cells to an antigenic stimulus. We have modified the conventional form of this assay by dividing up the response into two stages. During the first stage, antigen drives the specific expression of IL-2 receptor expression. This phase is carried out in the presence of homologous mouse serum, in order to reduce non-specific responses to a minimum. During the second phase, proliferation of these activated T cells is driven by the addition of excess exogenous IL-2. This modified form of proliferatiion assay significantly increased the signal to noise ratio which can be attained, and is of particular value when looking at the T cell response to weak (e.g., cross-reactive) antigens, or low concentrations of antigen.