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In accordance with guidance from the Chief Medical Officer's office and the Royal College of Radiologists, the British Society of Thoracic Imaging (BSTI) recognises that based on the available evidence computed tomography (CT) currently has no upfront role in the diagnostic work-up of 2019 novel coronavirus (COVID-19) infection (https://www.rcr.ac.uk/college/coronavirus-covid-19-what-rcr-doing/rcr-position-role-ct-patients-suspected-covid-19). Nevertheless, a number of reports have been published highlighting CT appearances in COVID-19, raising the possibility of a role for CT in patient management.1, 2, 3, 4, 5 In response to these reports, the BSTI published a preliminary consensus statement on 6 March 2020.6 We discuss below what role, if any, CT would play in the detection and management of COVID-19 infection in the UK, and the logistics of imaging delivery. This role is heavily predicated on the clinical context as well as the timing of its intended use within the diagnostic pathway, especially relative to the current reference standard diagnostic test, real-time reverse transcriptase polymerase chain reaction (RT-PCR) of a pharyngeal swab,7 and other clinical and laboratory investigations. Although it may not be feasible or desirable for isolation purposes to perform a chest radiograph (CXR), we should acknowledge that pragmatically patients with a respiratory complaint are likely to present via any number of routes (primary care, emergency departments [EDs] or outpatient clinics) having already had a CXR, other than to isolation pods outside a hospital, and work-up of a respiratory complaint would usually include a CXR in such settings. Cognizant of this fact, in the following discussion we have considered how a CXR would also fit into diagnostic algorithms, and in particular, how the use of CT would alter management in settings where a CXR was or was not available. As such, we deliberate the following questions: (1) would a CT thorax contribute to management of symptomatic cases after a rapidly available RT-PCR result? (2) Would a CT thorax contribute to symptomatic cases if an RT-PCR test was not available or had to be rationed, and (a) a chest radiograph had been performed and was abnormal? (b) A chest radiograph had been performed and was normal, or was not/could not be performed? (3) Would a CT thorax contribute to the detection and management of COVID-19 in asymptomatic high-risk cases? (4) How should imaging (CT thorax or CXR) be provided? (5) What would a COVID-19 diagnostic algorithm look like? In the following discussion, a high pre-test probability is assumed for symptomatic cases, based on one or more of: clinical presentation (Pyrexia of 37.8); acute onset persistent cough, hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing; and compatible laboratory abnormalities (relative lymphopenia, elevated C-reactive protein [CRP]).8

Pleural disease is common. Radiological investigation of pleural effusion, thickening, masses, and pneumothorax is key in diagnosing and determining management. Conventional chest radiograph (CXR) remains as the initial investigation of choice for patients with suspected pleural disease. When abnormalities are detected, thoracic ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) can each play important roles in further investigation, but appropriate modality selection is critical. US adds significant value in the identification of pleural fluid and pleural nodularity, guiding pleural procedures and, increasingly, as "point of care" assessment for pneumothorax, but is highly operator dependent. CT scan is the modality of choice for further assessment of pleural disease: Characterising pleural thickening, some pleural effusions and demonstration of homogeneity of pleural masses and areas of fatty attenuation or calcification. MRI has specific utility for soft tissue abnormalities and may have a role for younger patients requiring follow-up serial imaging. MRI and PET/CT may provide additional information in malignant pleural disease regarding prognosis and response to therapy. This article summarises existing techniques, highlighting the benefits and applications of these different imaging modalities and provides an up to date review of the evidence.

Endometriosis is a common condition but its precise prevalence varies depending on the type of hospital-based population being studied. Among those being investigated for chronic abdominal pain, the incidence of endometriosis is 15% [Honare GM. Extrapelvic endometriosis. Clin Obstet Gynecol Sept 1999;42(2):699–713]. Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity. It has been reported in many organs throughout the body (see further reading), however has only been reported in the adrenal gland once previously [Durlach V, Wallays C, Pluot M, Flament JB, Dorangeon P, Leuteneger M. A propos d’une etiologie exceptionnelle ‘d’incidentalome surrenalien’: l’endometriose. Gynecologie 1988;39(1):35–7]. We present a second case, with imaging which revealed an adrenal mass suggestive of a metastatic cancer. In this case we compare and contrast the imaging characteristics of metastatic adrenal masses and adrenal endometriosis.

s / Clinical Radiology 67 (2012) S11–S20 S18 Transjugular liver biopsy safety and diagnostic yield Authors: Amit Patel, Aman Khan, Pete Thurley, Dominic Clarke, Rajeev Singh Background to the audit: Previous studies have demonstrated transjugular liver biopsy (TJLB) to be an effective procedure in patients not suitable for percutaneous biopsy with high diagnostic yield and low complication rate. Standard, indicator and target: To compare our centres complication rates and outcomes with previously published national studies. Technical success rates previously quoted range from 85 to 91%. Complication rates range from 1.3 to 13%. Methodology: Retrospective review of all TJLB's performed at Royal Derby Hospital between 2009 to 2012. Data gathered from case-note review, CRIS and Isoft medical database. Results of 1st audit round: Number of cases 1⁄4 47. Common indications included alcoholic liver diseasewith ascites/coagulopathy or suspected HCC. Mean age 1⁄4 55 years (range 22-82 years). Mean PT 18, INR 1.6, PLT 177. Large majority required pre-procedural blood products. Technical success rate 1⁄4 45/47 (96%). Mean number of passes 1⁄4 2.4. Mean combined core length 1⁄4 22 mm (range 4-45). Histological diagnostic yield 1⁄4 41/45 (91%). In 4 patients, samples were haemorrhagic precluding definitive histological assessment. Early complication rate 1⁄4 1/47 (2%). One patient developed small subcapsular extravasation identified during procedure and settled spontaneously. Late complication rate 1⁄4 Nil. 1st Action Plan: To disseminate results across department and related clinical specialties. Standardisation of number of cores required for histological diagnosis and continuation of audit cycle. Are CT KUBS being performed with as low a radiation dose as possible? Authors: Adrian A. Pollentine, David Wilson, Alexis Corrigan, Mark Hawkins Background to the audit: We aim to audit whether CTKUB examinations are complying to the principle of keeping radiation exposure ALARP & whether changes to protocol and technique recommended after first round of audit have been effectively implemented. Standard, indicator and target: All CTKUBs performed on the correct CTKUB protocol Cranial extent of the scan should be at the top of the kidneys Meagher T, Sukumar VP, Collingwood J, et al. Low dose computed tomography in suspected acute renal colic. Clin Radiol. 2001 Nov;56(11):873-6 Methodology: All CTKUBs over 3 month periods July-Sept 2010 & AprilJune 2011 were analysed. Age, gender, DLP, kV, scanner used, AP diameter of patient at renal pelvis, distance scanned above kidney w 120kV on CT2 and 100kV on CT1 12% of scans on incorrect protocol Mean examination dose 1⁄4 4.5mSv Mean scan distance above kidney 1⁄4 62mm. 1st action plan: All scans to be performed on correct protocol Top of scan to be top of kidneys – not for repeat if tip of kidney missed 100 kV across both scanners Resultsof 2nd round: Statistically significant reduction inbothdose from4.5 to3.5mSvanddegreeof overestimationof cranial limit of scanfieldby20mm No repeat if top of kidney excluded initially – Compliant All scans performed on correct protocol – Non-compliant but improvement made 6% vs 12% 2nd action plan: Re-audit after introduction of iterative reconstruction software. Introducing a cardiac CT service ensuring appropriate referrals and overcoming teething problems Authors: Adrian A. Pollentine, Anthony Edey, Ladli Chandratreya Background to the audit:We aim to audit appropriateness of referrals for cardiac CT as well as factors contributing towards optimal image production and highlight tips to overcoming initial problems and providing a top notch service. Standard, indicator and target: Cardiac CT referral should adhere to appropriateness criteria published 2010 by the American College of Cardiologists 90% All patients should have on table GTN (unless C/I) 100% Heart rate should be 1000CTPAs annually. It is important to minimise the effective dose of this frequently performed study whilst maintaining diagnostic quality in accordance with IR(ME)R 2000. Standard, indicator and target: Standard 1: All CTPAs should be diagnostic (mean PA HU >200) Standard 2: Dose should be as low as reasonably practicable (mean DLP Methodology: 50 CTPAs performed at 120kVp on 128-slice CT scanner were reviewed. Mean HU in main pulmonary artery (MPA) was measured. Proportion of non-diagnostic CTPAs determined. Effective dose calculated from DLP, using conversion factors. Results of 1st audit round: At 120kVp: Standard 1: 98% CTPAs were diagnostic. Mean attenuation in MPA1⁄4355HU Standard 2: 100% compliance. Mean DLP1⁄4287mGy.cm, Effective dose1⁄44.9mSv 1st action plan: CT tube output is a to kVp squared. Lowering kVp can reduce dose and increase attenuation as more photons approximate to the k-edge of iodine and undergo photoelectric absorption. Perform CTPA at 100kVp rather than 120kVp to lower effective dose without compromising diagnostic quality. Re-audit 50 CTPAs. Results of 2nd round: At 100kVp: Standard 1: 96% CTPAswere diagnostic. Mean attenuation inMPA1⁄4 419HU* Standard 2: 100% compliance. Mean DLP 1⁄4124mGy.cm, Effective dose 1⁄42.0mSv* (*2nd Vs 1st round, P