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Purpose Imaging of the different resonances of dissolved hyperpolarized xenon‐129 (129Xe) in the lung is performed using a four‐echo flyback 3D radial spectroscopic imaging technique and is evaluated in healthy volunteers (HV) and subjects with idiopathic pulmonary fibrosis (IPF). Theory and Methods 10 HV and 25 subjects with IPF underwent dissolved 129Xe MRI at 1.5T. IPF subjects underwent same day pulmonary function tests to measure forced vital capacity and the diffusion capacity of the lung for carbon monoxide (DLCO). A four‐point echo time technique with k‐space chemical‐shift modeling of gas, dissolved 129Xe in lung tissue/plasma (TP) and red blood cells (RBC) combined with a 3D radial trajectory was implemented within a 14‐s breath‐hold. Results Results show an excellent chemical shift separation of the dissolved 129Xe compartments and gas contamination removal, confirmed by a strong agreement between average imaging and global spectroscopy RBC/TP ratio measurements. Subjects with IPF exhibited reduced imaging gas transfer when compared to HV. A significant increase of the amplitude of RBC signal cardiogenic oscillation was also observed. In IPF subjects, DLCO% predicted was significantly correlated with RBC/TP and RBC/GAS ratios and the correlations were stronger in the inferior and periphery sections of the lungs. Conclusion Lung MRI of dissolved 129Xe was performed with a four‐echo spectroscopic imaging method. Subjects with IPF demonstrated reduced xenon imaging gas transfer and increased cardiogenic modulation of dissolved xenon signal in the RBCs when compared to HV.

Background Hyperpolarised gas magnetic resonance imaging (MRI) can be used to assess ventilation patterns. Previous studies have shown the image-derived metric of ventilation defect per cent (VDP) to correlate with forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) and FEV1 in asthma. Objectives The aim of this study was to explore the utility of hyperpolarised xenon-129 (129Xe) ventilation MRI in clinical care and examine its relationship with spirometry and other clinical metrics in people seen in a severe asthma service. Methods 26 people referred from a severe asthma clinic for MRI scanning were assessed by contemporaneous 129Xe MRI and spirometry. A subgroup of 18 patients also underwent reversibility testing with spirometry and MRI. Quantitative MRI measures of ventilation were calculated, VDP and the ventilation heterogeneity index (VHI), and compared to spirometry, Asthma Control Questionnaire 7 (ACQ7) and blood eosinophil count. Images were reviewed by a multidisciplinary team. Results VDP and VHI correlated with FEV1, FEV1/FVC and forced expiratory flow between 25% and 75% of FVC but not with ACQ7 or blood eosinophil count. Discordance of MRI imaging and symptoms and/or pulmonary function tests also occurred, prompting diagnostic re-evaluation in some cases. Conclusion Hyperpolarised gas MRI provides a complementary method of assessment in people with difficult to manage asthma in a clinical setting. When used as a tool supporting clinical care in a severe asthma service, occurrences of discordance between symptoms, spirometry and MRI scanning indicate how MRI scanning may add to a management pathway., This article demonstrates the feasibility of using 129Xe MRI in clinical practice. Discordance between symptoms, spirometry and MRI can support the use of further treatment or suggest coexisting breathing control issues or laryngeal disorders. https://bit.ly/3ky4oXP

Pulmonary hypertension (PH) is a heterogeneous condition that can affect the lung parenchyma, pulmonary vasculature, and cardiac chambers. Accurate diagnosis often requires multiple complex assessments of the cardiac and pulmonary systems. MRI is able to comprehensively assess cardiac structure and function, as well as lung parenchymal, pulmonary vascular, and functional lung changes. Therefore, MRI has the potential to provide an integrated functional and structural assessment of the cardiopulmonary system in a single exam. Cardiac MRI is used in the assessment of PH in most large PH centers, whereas lung MRI is an emerging technique in patients with PH. This article reviews the current literature on cardiopulmonary MRI in PH, including cine MRI, black-blood imaging, late gadolinium enhancement, T1 mapping, myocardial strain analysis, contrast-enhanced perfusion imaging and contrast-enhanced MR angiography, and hyperpolarized gas functional lung imaging. This article also highlights recent developments in this field and areas of interest for future research including cardiac MRI-based diagnostic models, machine learning in cardiac MRI, oxygen-enhanced 1 H imaging, contrast-free 1 H perfusion and ventilation imaging, contrast-free angiography and UTE imaging. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 3.

Introduction: Novel biomarkers are needed to improve assessment of ILD. Oxygen enhanced MRI (OE-MRI) monitors regional O2 delivery from changes in the MRI relaxation time T1 in response to hyperoxia. We present OE-MRI biomarkers in different ILD phenotypes (IPF, DI-ILD, CTD-ILD, HSP) acquired in a prospective observational study and compare them with lung function tests under standard clinical care. Methods: Patients recruited and scans analysed to date are summarised in fig 1. The OE MR parameters considered were: baseline T1, change in delta pO2 (ΔpO2), O2 wash-in time and ventilated volume fraction. Biomarker values at each visit and the change between visits were compared with lung function tests (FVC%, FEV1%, Tlco%, KCO%) using Pearson correlation (no correction for multiple comparisons). Results: In the IPF subgroup, T1 correlated with Tlco% and KCO% (r=-0.43, p=0.027 and r=-0.43, p=0.028). Changes between visits in ΔpO2 and in KCO%(r = 0.86, p=0.003) were also correlated. No significant correlations were found in other phenotypes. Conclusions: In IPF, change between visits in ΔpO2 correlates with the change in KCO%, but not in the other ILD subtypes.

Background: Laser-Assisted in situ Keratomileusis (LASIK) can induce corneal aberrations that can impact vision and patient satisfaction. Recent developments in laser technologies have helped minimise these aberrations. Objective: To assess the quality of vision and change in Higher-Order Aberrations (HOAs) following wavefront-optimized LASIK in low-myopic astigmatic patients. Methods: LASIK was performed on a total of 76 eyes in patients with myopia Results: Mean postoperative Spherical Equivalent (SE) was -0.09 ± 0.26 µm with 95% of patients within ± 0.5 D of attempted SE. Postoperative uncorrected distance visual acuity was 20/20 or better for 96% of patients. Contrast sensitivity increased against horizontal and vertical gratings at all spatial frequencies except for vertical gratings at 18 cycles/degree. Spherical aberration and total HOA increased by 0.085 µm and 0.13 µm respectively. The mean VF14 score increased from 89.2 ± 16.7% to 99 ± 1.4% postoperatively. Conclusion: LASIK performed using the WaveLight® EX500 excimer and WaveLight® FS200 laser platform provided improved contrast sensitivity and visual acuity with minimal introduction of HOAs, making it a suitable platform for low myopic astigmatic patients.

PURPOSE: To assess the diagnostic accuracy of magnetic resonance imaging (MRI) perfusion against perfusion single photon emission tomography (SPECT) screening for chronic thromboembolic pulmonary hypertension (CTEPH). Ventilation/perfusion (V/Q) scintigraphy is recommended to screen for suspected CTEPH. It has previously been shown that 3D dynamic contrast-enhanced (DCE) lung perfusion MRI has a similar sensitivity for diagnosing CTEPH in comparison to planar perfusion scintigraphy; however, planar scintigraphy has now been largely replaced by SPECT, due to higher spatial resolution and sensitivity. MATERIALS AND METHODS: Consecutive patients with suspected CTEPH or unexplained pulmonary hypertension attending a referral center, who underwent lung DCE perfusion MRI at 1.5T, perfusion SPECT, and computed tomography pulmonary angiography (CTPA) within 14 days of right heart catheterization, from April 2013 to April 2014, were included. DCE-MR, SPECT, and CTPA were independently analyzed by two blinded radiologists. Disagreements were corrected by consensus. The gold standard reference for the diagnosis of chronic thromboemboli was based on a review of multimodality imaging and clinical findings. RESULTS: In all, 74 patients with suspected CTEPH underwent all three modalities. Forty-six were diagnosed with CTEPH (36) or chronic thromboembolic disease (CTED) (10). 3D DCE perfusion MRI correctly identified all patients (sensitivity of 100%), compared with a 97% sensitivity for SPECT. CONCLUSION: DCE lung perfusion MRI has increased sensitivity when compared with perfusion scintigraphy in screening for CTEPH. As MRI does not use ionizing radiation, it should be considered as a first-line imaging modality in suspected CTEPH. LEVEL OF EVIDENCE: 3

IntroductionIdiopathic pulmonary fibrosis (IPF) is a fatal disease of lung scarring. Many patients later develop raised pulmonary vascular pressures, sometimes disproportionate to the interstitial disease. Previous therapeutic approaches that have targeted pulmonary vascular changes have not demonstrated clinical efficacy, and quantitative assessment of regional pulmonary vascular involvement using perfusion imaging may provide a biomarker for further therapeutic insights.MethodsWe studied 23 participants with IPF, using dynamic contrast-enhanced MRI (DCE-MRI) and pulmonary function tests, including forced vital capacity (FVC), transfer factor (TLCO) and coefficient (KCO) of the lungs for carbon monoxide. DCE-MRI parametric maps were generated including the full width at half maximum (FWHM) of the bolus transit time through the lungs. Key metrics used were mean (FWHMmean) and heterogeneity (FWHMIQR). Nineteen participants returned at 6 months for repeat assessment.ResultsSpearman correlation coefficients were identified between TLCO and FWHMIQR (r=−0.46; p=0.026), KCO and FWHMmean (r=−0.42; p=0.047) and KCO and FWHMIQR (r=−0.51; p=0.013) at baseline. No statistically significant correlations were seen between FVC and DCE-MRI metrics. Follow-up at 6 months demonstrated statistically significant decline in FVC (p=0.040) and KCO (p=0.014), with an increase in FWHMmean (p=0.040), but no significant changes in TLCO (p=0.090) nor FWHMIQR (p=0.821).ConclusionsDCE-MRI first pass perfusion demonstrates correlations with existing physiological gas exchange metrics, suggesting that capillary perfusion deficit (as well as impaired interstitial diffusion) may contribute to gas exchange limitation in IPF. FWHMmean showed a significant increase over a 6-month period and has potential as a quantitative biomarker of pulmonary vascular disease progression in IPF.

Introduction: Preterm-births account for 10% of worldwide births, and those born at 32 weeks gestation or less have deterioration in their lung function in childhood and beyond. A combination of birth at an early stage of lung development and postnatal interventions such as mechanical ventilation and supplemental oxygen therapy can lead to the development of bronchopulmonary dysplasia, BPD, for example. Aims: Here we assessed pulmonary micro-structural and functional changes in the lungs using hyperpolarized 129Xe gas ventilation and diffusion-weighted MRI in three groups of children (mean age 10 y): (1) those born preterm with FEV1 Results: 129Xe ventilation defect percentage was significantly higher in children born preterm than in term born children, (groups 1-3 p=0.0184, and for groups 2-3 p=0.0262). Children born preterm ventilation heterogeneity measured by CV% was significantly higher in those with FEV1 The kurtosis of the distribution of mean alveolar dimension (LmD) was significantly lower in children born preterm when compared to those born at term (subjects (group 1-3 (p=0.02) and group 2-3 (p=0.05)) suggesting an increased heterogeneity of alveolar microstructural dimensions measured by diffusion-weighted MRI. Conclusion: 129Xe ventilation and diffusion imaging detected functional and microstructural changes in the lungs of children born prematurely, neither of which were detected by FEV1 or multiple-breath washout.

Background: Hyperpolarised gas ventilation MRI (V-MRI) is highly sensitive to early lung disease in CF. Here we report longitudinal comparisons of V-MRI measured with two different inhaled gases; helium-3 (3He) and xenon-129 (129Xe), alongside detailed lung physiology in CF. Method: 28 children and adults with CF performed both 3He and 129Xe V-MRI, LCI and FEV1 on the same day, and at follow up (FU) (mean (SD) = 14.7 (3.8) months). Ventilation defect percentage (VDP) was used to quantify lung disease on V-MRI. Results: At baseline median (IQR); FEV1 = -1.2 (-4.1;-0.7) z-score; LCI = 8.7 (7.7;13.1); 3He VDP = 8.4% (3.0;33.4); 129Xe VDP = 7.1% (2.8;30.4). Baseline 3He and 129Xe VDP significantly correlated with FEV1 and LCI (both p Conclusion: ΔVDP over time most closely relates to LCI %change. However, ΔVDP was often large in patients with clinically stable FEV1 or LCI, demonstrating that V-MRI can assess changes in lung function not assessed by clinical gold standards. 129Xe MRI is comparable to 3He for assessment of regional ventilation changes and provides a clinically scalable alternative.

Introduction: Apparent diffusion coefficient (ADC) is a measure of gas diffusion in the airspaces, where restrictions by tissue boundaries provide information about lung microstructure down to the alveolar level. Diffusion-weighted (DW) MRI of the lung with hyperpolarised helium in idiopathic pulmonary fibrosis (IPF) has shown that ADC correlates with DLCO, KCO and CT fibrosis score (Chan, H-F. et al. Radiology 2019; doi:10.1148/radiol.2019181714) but to date no data are available on the utility of 129-xenon (129Xe) diffusion in interstitial lung disease (ILD). Aim: To evaluate the ability of 129Xe DW-MRI to distinguish between ILD subtypes. Methods: A prospective, multicentre study of patients with ILD including drug induced ILD (DI-ILD), hypersensitivity pneumonitis (HP), IPF and connective tissue disease ILD (CTD-ILD). Hyperpolarised 129Xe DW-MRI was performed on a 1.5 T scanner and mean ADC was calculated. Results: To date, 33 patients (6 DI-ILD, 7 HP, 15 IPF, 5 CTD-ILD) have undergone baseline 129Xe DW-MRI. There was a significant difference in mean ADC between the ILD subtypes (p=0.011), with the significant difference occuring between the HP (median: 0.038cm2/s) and IPF (median: 0.048cm2/s) groups (p Conclusions: We demonstrate a correlation between mean 129Xe ADC and DLCO but not FVC. Our findings suggest significant differences in mean ADC between IPF and HP. Therefore, 129Xe DW-MRI could potentially have a role in differentiating changes in the airway microstructure in ILD subtypes.

Introduction: Hyperpolarised 129-xenon (129Xe) MR spectroscopy (MRS) can be used as a quantitative marker of gas exchange in interstitial lung disease (ILD). The ratio of the uptake of 129Xe in the red blood cells to the tissue/plasma (RBC:TP) has been shown to be reduced by 70% in idiopathic pulmonary fibrosis (IPF) patients when compared with healthy volunteers (Kaushik, S.S. et al. J Appl Physiol 2014; 117:577-585). In IPF, a significant decline in 129Xe RBC:TP over 12 months has been demonstrated but no significant change in DLCO or KCO (Weatherley, N.D. et al. Thorax 2018 [Epub ahead of print]). Aim: To compare longitudinal changes in 129Xe RBC:TP with changes in FVC and DLCO between ILD subtypes. Methods: A prospective, multicentre study of ILD patients including drug induced ILD (DI-ILD), hypersensitivity pneumonitis (HP), IPF and connective tissue disease ILD (CTD-ILD). Hyperpolarised 129Xe MRS was performed on a 1.5 T scanner. Results: To date, 18 patients (5 DI-ILD, 5 HP, 6 IPF, 2 CTD-ILD) have undergone 129Xe MRS on two separate visits (6 weeks apart for DI-ILD/HP and 6 months apart for IPF/CTD-ILD). There was a significant difference in longitudinal change in RBC:TP between the HP and IPF groups (p=0.022). Median change in RBC:TP in the HP and IPF groups was 0.022 and -0.023 respectively. There was no significant difference in longitudinal change in FVC% predicted (p=0.79) or DLCO% predicted (p=0.39) between the ILD subtypes. Conclusions: Our findings demonstrate that 129Xe RBC:TP has sensitivity to longitudinal change with significant differences between IPF and HP patients, whilst FVC and DLCO showed no change, suggesting that RBC:TP is more sensitive to change than PFTs in ILD.

Introduction: Hyperpolarised gas MRI can be used to assess ventilation patterns. Previous research studies have shown the image derived metric – ventilation defect percent (VDP) to correlate with FEV1/FVC and FEV1 in asthma. Objective: To investigate the correlations between different MRI ventilation heterogeneity indices and spirometry in patients with asthma in a clinical setting. Methods: 18 people referred from a difficult asthma clinic for investigation of breathlessness were assessed with 129Xe MRI and spirometry. Maps of the coefficient of variation of signal intensity (CV) were generated. Quantitative MRI measures of ventilation were calculated; VDP, and median and inter-quartile range (IQR) CV to assess ventilation heterogeneity. Results: 9/18 patients had abnormal FEV1. 13/18 patients had ventilation heterogeneity on MRI, of these 5 had normal FEV1. IQR CV correlated more strongly with FEV1/FVC z-score (r=-0.89, p= Conclusion: CV metrics correlated more strongly than VDP with FEV1/FVC and FEV1 z-scores in patients referred from a difficult asthma clinic. CV metrics may be important variables in the analysis and interpretation of clinical data sets of people with asthma.

MRI offers distinct advantages over CT for early disease detection in CF, being radiation free and capable of measuring both function and structure. Hyperpolarised gas ventilation MRI is highly sensitive to early lung disease and 1H MRI sequences generate high-resolution images for detection of structural disease. Here, we report the ability of different MRI sequences to detect CF-related lung abnormalities. 14 children and adults with CF and normal FEV1 and 5 healthy children (HC) were assessed. All subjects performed 129Xe ventilation and 1H anatomical MRI (sequences = 3D SPGR, acquired during breath-hold at total lung capacity (TLC) and residual volume (RV) and UTE, acquired during free-breathing). Subjects also performed lung clearance index (LCI) and spirometry. 129Xe MRI was segmented to calculate the ventilation defect percentage (VDP). 129Xe and 1H MRI were reviewed by an experienced chest radiologist, using a binary method for the presence or absence of common CF pathophysiology. All subjects had a normal FEV1. All HC had normal LCI, and normal 129Xe and 1H MRI. In contrast, 43% of CF subjects had an abnormal LCI. All CF subjects had visible 129Xe ventilation defects; VDP was significantly higher than controls (p In CF patients with normal FEV1, functional and anatomical abnormalities can be assessed and detected at the same visit using both free-breathing and breath-hold MRI sequences, highlighting the potential of MRI in the routine imaging of CF lung disease.

This article outlines a case for using symbolic interactionism as a tool to help individuals with Asperger's syndrome reconcile situations in which communication might prove challenging. This study builds on previous work carried out by the author which describes an autoethnographical approach to help the individual with Asperger's syndrome gain insights into ways to engage effectively with the social situations they encounter. It is well documented that those with Asperger's syndrome find many social situations challenging and that commonly understood verbal and non-verbal communication ‘signs’ and ‘symbols’ may be difficult for them to interpret in ways intended by others. It is within this context that the work seeks to examine communication issues in terms of the symbolic interactionism notion of the ‘Me’ and how this understanding can help the individual with Asperger's syndrome model their own behaviour from a symbolic interactionism point of view. The article begins with a discussion of the background to the research and how an inability to read the communication ‘signs’ and ‘symbols’ around them can make it difficult for the learner with Asperger's syndrome to have a commonly held understanding of the social setting in which he or she operates. The work gives a personal insight from a person with Asperger's syndrome into how symbolic interactionism coupled with autoethnography can be used as tools to enable the learner with Asperger's syndrome to explore the nature of communication patterns under such circumstances. The work includes vignettes which highlight experience from such a personal perspective.

Introduction In spite of recent advances in our understanding of the pathophysiology and treatment of idiopathic pulmonary fibrosis (IPF), clinical assessment remains challenging due to a paucity of clinically sensitive biomarkers. We present a longitudinal pilot study to assess the potential role of magnetic resonance imaging (MRI) techniques in assessing gas diffusion and perfusion in IPF. Methods Nineteen patients with IPF, but without echocardiographic evidence of pulmonary hypertension, were recruited from a tertiary centre (mean age 71.4 years). All underwent magnetic resonance spectroscopy with inhaled hyperpolarised xenon (129Xe) MRI. During breath-hold maneuvers, a high-resolution MR spectroscopy sequence acquired MR spectra of 129Xe dissolved in the pulmonary tissue and plasma (TP) and red blood cell (RBC) compartments. Integrals of RBC and TP spectral peaks were expressed as the ratio RBC:TP. Fifteen participants returned at six months, and twelve returned at 12 months. Five participants died before completing follow-up. In addition, twelve participants agreed to undergo Dynamic Contrast-Enhanced MRI (DCE-MRI) with gadolinium at baseline. Eight returned at 12 months. Parametric maps of bolus transit time across the lungs were produced and a mean transit time across all pixels is reported (MTT). Pulmonary function tests were performed at each visit, including forced vital capacity (FVC) and diffusing capacity of the lungs for carbon monoxide (DLCO). Results 129Xe RBC:TP correlated with both DLCO (r=0.65; p=0.003) and MTT (r=−0.70; 0.008). This relationship with DLCO was preserved at six (r=0.77; p=0.001) and twelve months (r=0.67; p=0.018). However, while DLCO did not significantly change over 12 months (−0.5% median change; p=0.791) both RBC:TP (−0.08 change; p=0.002) and MTT (1.69 s change; p=0.031) demonstrated whole-lung changes. RBC:TP and MTT changes were not significantly correlated (p=0.091) On parametric maps, transit time was increased in basal and peripheral regions of lung tissue (figure 1) and progressed in these areas over time. Conclusion Hyperpolarised 129Xe spectroscopy and DCE-MRI have potential to probe diffusion and perfusion pathophysiology in IPF and are potentially more sensitive to change than existing whole-lung markers of gas exchange. Regional lung mapping is likely to yield highly sensitive metrics, possibly for patient enrichment or detection of treatment response in early intervention studies.

A small survey among a group of GPs has identified certain barriers to the use of patient decision aids. But without such aids can we really claim to practice shared decision making?

Introduction: Hyperpolarised (HP) gas MRI is sensitive to early lung ventilation heterogeneity in cystic fibrosis (CF) children. However, little is known if changes in lung microstructure accompany the disease progression. HP gas diffusion-weighted (DW) MRI has been shown to be a technique sensitive to changes in lung microstructure at the acinar level. Aims: Compare 3 He DW-MRI metrics of lung microstructure in children with mild CF and healthy controls (HC) at baseline, and to reassess the CF cohort after 2-years. Methods: 19 children with CF and normal spirometry (FEV 1 z-score> -2), and 10 HC were assessed with HP 3 He DW-MRI. 14 of the CF cohort were reassessed after 2-years. Apparent diffusion coefficient (ADC) and estimates of alveolar dimension (Lm D ) were calculated at each visit, and compared to previously reported ventilation defect percentage (VD%) values in the same cohort [Smith, L., et al. (2016). ERJ 48]. Results: No significant difference in mean ADC and Lm­ D ­ was observed between HC and CF children. In contrast, VD% was significantly larger (p D ; despite a significant increase in VD% (p=0.002) (Figure 1b). Conclusion: 3 He DW-MRI suggests that no acinar microstructural changes occur in the ventilated regions of early CF lung disease despite increases in ventilation heterogeneity.

Lesson Our report serves to highlight Varicella vasculopathy as a rarity not to be overlooked in the differential diagnosis of subarachnoid haemorrhage.

The pulmonary vasculature and its role in perfusion and gas exchange is an important consideration in many conditions of the lung and heart. Currently the mainstay of imaging of the vasculature and perfusion of the lungs lies with CT and nuclear medicine perfusion scans, both of which require ionizing radiation exposure. Improvements in MRI techniques have increased the use of MRI in pulmonary vascular imaging. Here we review MRI methods for imaging the pulmonary vasculature and pulmonary perfusion, both using contrast enhanced and non-contrast enhanced methodology. In many centres pulmonary MR angiography and dynamic contrast enhanced perfusion MRI are now well established in the routine workflow of patients particularly with pulmonary hypertension and thromboembolic disease. However, these imaging modalities offer exciting new directions for future research and clinical use in other respiratory diseases where consideration of pulmonary perfusion and gas exchange can provide insight in to pathophysiology.

Introduction: Historically, hyperpolarised gas MRI of lung ventilation and microstructure has been performed using 3 He. 129 Xe presents a cost-effective alternative with similar functional sensitivity. Objectives: To compare sensitivity and assess repeatability of derived metrics of lung ventilation and microstructure from 3 He and 129 Xe MRI. Methods: 5 COPD and 6 lung cancer patients underwent 3D MRI of lung ventilation with 3 He and 129 Xe to derive ventilated volume percentages (VV%). COPD patients and 9 normals underwent 2D 3 He and 129 Xe diffusion-weighted lung MRI to obtain apparent diffusion coefficient (ADC) maps. COPD patients were scanned on 3 further occasions to assess repeatability. COPD patients and normals performed PFTs, including spirometry and TL CO . Results: A positive correlation between 3 He and 129 Xe VV% values was observed (Fig. 1a). Mean derived VV% values were larger for 3 He than 129 Xe ( P 3 He and 129 Xe ADC values exhibited a strong correlation with each other (Fig. 1b) and with PFTs, most notably TL CO ( P 3 He VV% exhibited a significant correlation with FEV 1 /FVC ( P 3 He and 129 Xe VV% CVs were Conclusion: 3 He and 129 Xe VV% and ADC values exhibited good agreement, acceptable repeatability and significant correlations with PFTs.

Introduction: FEV 1 is insensitive to early changes in lung disease in cystic fibrosis (CF). Hyperpolarised gas ventilation MRI (HP-MRI) is more sensitive than FEV 1 , CT and the lung clearance index (LCI) at detecting early lung disease in CF and therefore may be more sensitive to longitudinal change. Aim: To assess changes in lung disease using HP-MRI, LCI and spirometry in a group of children with mild CF at 2 year intervals. Methods: 7 children with CF and FEV 1 >-1.64 z-score were assessed at baseline and 2 years later. Results: Subjects FEV 1 did not significantly change (Figure 1). 2/7 subjects had an abnormal LCI at baseline. At 2 years, LCI had increased significantly (p=0.03) and 5/7 subjects had an abnormal LCI. All subjects had ventilation defects evident on HP-MRI, which significantly worsened at 2 years - ventilated volume (VV) % reduced (p=0.01) and the coefficient of variance (CV) (inter-voxel ventilation heterogeneity) increased (p=0.03). Conclusion: In CF subjects with non-clinical lung disease, HP gas ventilation MRI is more sensitive at detecting longitudinal lung function deterioration than both LCI and FEV 1 .

Hyperpolarised He ventilation-MRI, anatomical lung MRI, lung clearance index (LCI), low-dose CT and spirometry were performed on 19 children (6–16 years) with clinically stable mild cystic fibrosis (CF) (FEV1>−1.96), and 10 controls. All controls had normal spirometry, MRI and LCI. Ventilation-MRI was the most sensitive method of detecting abnormalities, present in 89% of patients with CF, compared with CT abnormalities in 68%, LCI 47% and conventional MRI 22%. Ventilation defects were present in the absence of CT abnormalities and in patients with normal physiology, including LCI. Ventilation-MRI is thus feasible in young children, highly sensitive and provides additional information about lung structure–function relationships.

Background Rapid Response Teams aim to accelerate recognition and treatment of acutely unwell patients. Delays in delivery might undermine efficiency of the intervention. Our understanding of the causes of these delays is, as yet, incomplete. Aim To identify modifiable causes of delays in the treatment of critically ill patients outside intensive care with a focus on factors amenable to system design. Methods Review of care records and direct observation with process mapping of care delivered to 17 acutely unwell patients attended by a Rapid Response Team in a District General Hospital in the United Kingdom. Delays were defined as processes with no added value for patient care. Results Essential diagnostic and therapeutic procedures accounted for only 31% of time of care processes. Causes for delays could be classified into themes as (1) delays in call-out of the Rapid Response Team, (2) problems with team cohesion including poor communication and team efficiency and (3) lack of resources including lack of first line antibiotics, essential equipment, experienced staff and critical care beds. Conclusion We identified a number of potentially modifiable causes for delays in care of acutely ill patients. Improved process design could include automated call-outs, a dedicated kit for emergency treatment in relevant clinical areas, increased usage of standard operating procedures and staff training using crew resource management techniques.

Accessible Summary This article discusses how conceptual frameworks may be used to cope with Asperger's syndrome from a personal point of view. The work encourages those with Asperger's syndrome to view the self in symbolic interactionism terms in which part of the self is projected as a thought out, projected self through reflective consideration of the ‘Other’. Symbolic interactionism describes the way we act in social situations based on our interpretations of how we think others see us. Understanding the ‘self’ in symbolic interactionism terms can help us engage more effectively with the scenarios in which we find ourselves. The work makes use of autoethnography, described as using autobiographical personal experiences to explore aspects of one's own life, to reflect on (i) personal journal narratives and (ii) experiences of school communication classes to help understand the Asperger's self in social situations. Summary This article makes use of autoethnography in which I, as researcher, explore my own awareness of Asperger's syndrome and how this, in turn, has helped me deal with many day to day situations I have encountered. The work illustrates how actively engaging with one's own life story narratives can help the Asperger's learner come to terms with his or her Asperger's self. The work makes use of symbolic interactionism to construct an outward image of the self and then use this projection to play out and engage with the social situations one encounters. The article begins with a brief biographic picture of stages of my school and college journey. This places the work in context. It then discusses the autoethnography approach I use to examine aspects of myself, and how symbolic interactionism provides a framework with which to explore social action in the learning context. Examples from personal journals are used to illustrate aspects of my quest to understand the nature and essence of my Asperger's self.

Hyperpolarised helium-3 (3He) ventilation magnetic resonance imaging (MRI) and multiple-breath washout (MBW) are sensitive methods for detecting lung disease in cystic fibrosis (CF). We aimed to explore their relationship across a broad range of CF disease severity and patient age, as well as assess the effect of inhaled lung volume on ventilation distribution.32 children and adults with CF underwent MBW and3He-MRI at a lung volume of end-inspiratory tidal volume (EIVT). In addition, 28 patients performed3He-MRI at total lung capacity.3He-MRI scans were quantitatively analysed for ventilation defect percentage (VDP), ventilation heterogeneity index (VHI) and the number and size of individual contiguous ventilation defects. From MBW, the lung clearance index, convection-dependent ventilation heterogeneity (Scond) and convection–diffusion-dependent ventilation heterogeneity (Sacin) were calculated.VDP and VHI at EIVTstrongly correlated with lung clearance index (r=0.89 and r=0.88, respectively), Sacin (r=0.84 and r=0.82, respectively) and forced expiratory volume in 1 s (FEV1) (r=−0.79 and r=−0.78, respectively). Two distinct3He-MRI patterns were highlighted: patients with abnormal FEV1had significantly (p1, who tended to have numerous small volume defects. These two MRI patterns were delineated by a VDP of ∼10%. At total lung capacity, when compared to EIVT, VDP and VHI reduced in all subjects (p

Introduction: The British Society of Gastroenterology (BSG) has set clear guidelines on post-polypectomy surveillance colonoscopy for adenomatous polyps. The present study aims to determine whether these guidelines were adhered to in a screening unit, where colonoscopy is offered to anyone between 50 and 69 with positive faecal occult blood testing. Methods: All patients (asymptomatic and symptomatic) who underwent surveillance colonoscopy were retrospectively included between 2003 and 2006. Surveillance colonoscopy was carried out as a follow-up examination to a patient previously found to have adenoma(s), malignancy, strong family history or history of inflammatory bowel disease. Patients with no evidence of adenomas on their baseline or any repeat colonoscopy were excluded. Information relating polyp number, size and histology was collected, and their subsequent schedule colonoscopy was then compared with the BSG guidelines. Results: Of the 1856 colonoscopies carried out, 779 cases of polyps were detected after exclusion criteria (478 symptomatic, 301 screened cases). In the symptomatic cohort, 344 cases (72%), whereas in the screened cohort, 242 cases (80%) were compliant with the BSG guidelines (P

Individuals diagnosed with severe mental illness have higher rates of alcohol and substance misuse than the general population. This can present the client and the care team with a variety of issues around physical and psychological well‐being, as well as social and occupational functioning. In forensic psychiatry, the effect of comorbid substance misuse on offending behaviour is particularly pertinent. There have, however, been few studies examining the treatment of alcohol and substance misuse within this particular patient group.At a regional secure unit in North Wales, a group for inpatients was set up to provide education on alcohol and substance misuse over a course of six informal meetings, and to then evaluate participants' attitudes towards substance misuse. Of the six participants, five reported that their knowledge of substances had increased, and that they had no intention to use drugs again after discharge. Staff and client participants also suggested useful future topics for the group.

Introduction: There is growing interest in assessing myocardial changes in patients with pulmonary hypertension (PH). Native T1 is a promising marker of myocardial health in several cardiovascular disorders, but the nature of myocardial changes in PH is unclear. Objective: To measure T1 in the myocardial septum, right ventricular (RV) insertion point and RV free wall in patients with PH and age-matched healthy volunteers. Method: 25 patients, age=58±18 (76% F) and 15 volunteers, age=58±5 (47% F) underwent cardiac MRI at 1.5T, including a Modified Look Locker sequence to determine T1. Regions of interest were placed on the centre of the myocardial septum, RV insertion point and, where identifiable, RV free wall. Results: In volunteers, septal T1 was 0.96±0.07s and RV insertion point T1 was 0.95±0.13s, consistent with normal myocardial T1 values (Piechnik, S. et al. Jcmr 2013; 15:13). In patients, septal T1 was 0.98±0.09s and RV insertion point T1 was 1.03±0.14s. RV free wall was identifiable in 23/25 patients and 8/15 volunteers, T1 was found to be 1.08±0.09s and 1.05±0.07s, respectively. RV blood T1 did not correlate with RV free wall T1 in patients (Pearson9s coefficient=-0.160, p=0.487) or volunteers (r=0.337, p=0.415). Conclusion: Septal, RV insertion point and, where identifiable, RV free wall T1 was measured in patients with PH and age matched volunteers. T1 measurement may represent a clinically useful tool in PH.

Objective To determine whether to use 18F-fluorodeoxyglucose positron emission tomography (FDG PET) scans in the preoperative staging of bladder cancer (BC). Patients and Methods In all, 233 patients with muscle-invasive BC (MIBC) or high-risk non-MIBC being considered for radical cystectomy (RC) between 2005 and 2011 had FDG-PET and computed tomography (CT) of the chest, abdomen and pelvis to assess for pelvic lymph node (LN) involvement or distant metastases. Sensitivity and specificity for detecting pelvic LN involvement was determined by comparing the results of the scans to the histopathology reports in patients undergoing RC. These parameters for distant metastases were determined from biopsy results or follow-up imaging. In patients who did not undergo RC, follow-up imaging was used to evaluate the sensitivity and specificity. Patients were excluded from analysis if they either had neoadjuvant chemotherapy or had

A 62-year-old lady presented with thunderclap onset, severe, bi-occipital headache with associated motion sensitivity and vomiting on a background of gradually worsening, constant bi-temporal throbbing pain over a two year period. CT brain demonstrated acute superior frontocortical subarachnoid blood but CT venogram, angiogram and brain MRI were all normal. Peripheral autoimmune and inflammatory serology was unremarkable, as were initial results from CSF analysis. Cerebral vasculitis was suspected and the patient underwent formal catheter angiography. This found multifocal irregularity of the intracranial medium and small sized vessels in addition to both superficial temporal arteries, the latter revealing intimal thickening and elastic lamina disruption on biopsy. Despite no previous shingles, viral polymerase chain reaction on CSF returned positive for Varicella zoster DNA prompting commencement of intravenous acyclovir and methylprednisolone. Within 24 hours, she developed expressive dysphasia and left-sided hemiparesis. A second CT brain showed fresh haemorrhage and low densities within the cerebellar hemispheres with MRI now revealing a flurry of cortical and subcortical infarctions bilaterally particularly within occipital and parietal lobes. Although no new lesions have occurred, she continues to experience visuoperceptual difficulties including simultagnosia. This case highlights several manifestations of intracranial Varicella vasculopathy in the absence of previous or current shingles.