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Background: The World Health Organisation declared a global pandemic on the 11 March 2020 resulting in implementation of methods to contain viral spread, including curtailment of all elective and non-emergent interventions. Many institutions have experienced changes in rostering practices and redeployment of trainees to non-surgical services. Examinations, study days, courses, and conferences have been cancelled. These changes have the potential to significantly impact the education and training of surgical trainees., Aim: To investigate the impact of the COVID-19 pandemic on training, educational, and operative experiences of Irish surgical trainees., Methods: Surgical trainees were surveyed anonymously regarding changes in working and educational practices since the declaration of the COVID-19 pandemic on 11 March 2020. The survey was circulated in May 2020 to both core and higher RCSI surgical trainees, when restrictions were at level five. Questions included previous and current access to operative sessions as well as operative cases, previous and current educational activities, access to senior-led training, and access to simulation-/practical-based training methods. A repeat survey was carried out in October 2020 when restrictions were at level two., Results: Overall, primary and secondary survey response rates were 29% (n = 98/340) and 19.1% (n = 65/340), respectively. At the time of circulation of the second survey, the number of operative sessions attended and cases performed had significantly improved to numbers experienced pre-pandemic (p < 0.0001). Exposure to formal teaching and education sessions returned to pre-COVID levels (p < 0.0001). Initially, 23% of trainees had an examination cancelled; 53% of these trainees have subsequently sat these examinations. Of note 27.7% had courses cancelled, and 97% of these had not been rescheduled., Conclusion: Surgical training and education have been significantly impacted in light of COVID-19. This is likely to continue to fluctuate in line with subsequent waves. Significant efforts have to be made to enable trainees to meet educational and operative targets., (© 2021. The Author(s).)

Background: In patients with distal humerus fractures that are unreconstructible, total elbow arthroplasty is an established alternative to open reduction-internal fixation. Distal humerus hemiarthroplasty is a further alternative to avoid the significant lifestyle limitations associated with total elbow arthroplasty. Distal humerus hemiarthroplasty is an increasingly popular treatment option for unreconstructible distal humeral fractures not amenable to reconstruction. The aim of this systematic review was to assess the literature regarding the functional outcomes and complications of the use of distal humerus hemiarthroplasty for acute trauma., Methods: A systematic review of the PubMed, Embase, and Scopus databases was performed. The search terms included "distal humerus fracture" OR "elbow fracture" AND "hemiarthroplasty" OR "arthroplasty" OR "replacement." Studies were limited to those published in the English language with reported functional outcome measures and complications. Patient demographic characteristics, implant systems, clinical outcomes (range of motion and functional outcome scores), and complications were extracted., Results: Thirteen studies with a total of 207 patients met the inclusion criteria. The average age ranged from 44 to 79 years, with the mean length of follow-up ranging from 11 to 82 months postoperatively. A mean range-of-motion arc ≥ 93° was achieved in all studies, with 11 of 13 studies achieving mean functional range of motion ≥ 100°. All studies reported good to excellent mean outcome scores. Heterotopic ossification, ulnar cartilage wear, stiffness, and ulnar neuropathy were the most commonly encountered complications. The reoperation rate and revision rate were 17% and 3%, respectively., Conclusions: Distal humerus hemiarthroplasty is a viable option in the treatment of unreconstructible distal humerus fractures, with good to excellent outcomes expected. Long-term outcome data and the use of distal humerus hemiarthroplasty in younger patients are yet to be fully defined., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The initial operation of choice in many patients presenting as an emergency with ulcerative colitis is a subtotal colectomy with end ileostomy. A percentage of patients do not proceed to completion proctectomy with ileal pouch anal anastomosis., Aim: To review the existing literature in relation to the significant long-term complic-ations associated with the rectal stump, to provide an overview of options for the surgical management of remnant rectum and anal canal and to form a consolidated guideline on endoscopic screening recommendations in this cohort., Methods: A systematic review was carried out in accordance with PRISMA guidelines for papers containing recommendations for endoscopy surveillance in rectal remnants in ulcerative colitis. A secondary narrative review was carried out exploring the medical and surgical management options for the retained rectum., Results: For rectal stump surveillance guidelines, 20% recommended an interval of 6 mo to a year, 50% recommended yearly surveillance 10% recommended 2 yearly surveillance and the remaining 30% recommended risk stratification of patients and different screening intervals based on this. All studies agreed surveillance should be carried out via endoscopy and biopsy. Increased vigilance is needed in endoscopy in these patients. Literature review revealed a number of options for surgical management of the remnant rectum., Conclusion: The retained rectal stump needs to be surveyed endoscopically according to risk stratification. Great care must be taken to avoid rectal perforation and pelvic sepsis at time of endoscopy. If completion proctectomy is indicated the authors favour removal of the anal canal using an intersphincteric dissection technique., Competing Interests: Conflict-of-interest statement: The authors have no conflict of interest to declare., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Many orthopaedic units measure hemoglobin (Hb) levels after primary joint arthroplasty to identify patients with postoperative anemia. With the refinement of surgical techniques, blood loss in primary arthroplasty has decreased. The aim of this study was to investigate the postoperative Hb monitoring and transfusion practices in our own institution after elective hip or knee arthroplasty., Methods: We conducted a retrospective audit of all patients who underwent elective total hip or knee arthroplasty in Galway University Hospital between March 1 and June 1, 2019. We recorded when they underwent postoperative Hb testing, whether or not they had a drop of Hb, which would indicate transfusion (<8 g/dL), and whether or not they were transfused. In patients who underwent transfusion, a chart review was performed to establish the presence of factors that would have triggered repeat Hb testing., Results: One hundred thirty-six patients underwent elective primary hip or knee arthroplasty in the period. All had a full blood count sent on the first postoperative day. None (0%) had a clinically significant (to < 8g/dL) postoperative Hb drop on day 1. Eighteen (13.2%) patients underwent repeat testing on day 2 or subsequently. Eight (5.9%) exhibited a drop in Hb to less than 8 g/dL, with a mean Hb drop of 4.26 (standard error of the mean ± 0.862, standard deviation ± 0.98), and 5 (3.7%) proceeded to undergo allogenic blood product transfusion. All 5 underwent documented indications for repeat Hb testing., Conclusions: There is no evidence for performing routine Hb testing on day 1 after elective hip or knee arthroplasty. We recommend that postoperative Hb testing should only be carried out on patients with additional indications., (© 2020 Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons.)

Perforator-based flaps have in recent years become the mainstay of autologous breast reconstruction practice. Imaging modalities ranging from Doppler ultrasound to CT angiography demonstrate varying utility in the preoperative identification and localisation of perforators. Despite these available radiological investigations, finding and quantitatively assessing perforators remain a time-consuming and tedious process that is often complicated by a number of factors including variable anatomy prior surgery and body habitus. Thermographic imaging shows promise as a novel modality for preoperative localisation of perforator vessels. This review summarises the currently available evidence for its application in perforator mapping for abdominal-based autologous breast reconstruction. We discuss the development of the technology over the years, its current use, its advantages and how it may impact on reconstructive breast surgery., Competing Interests: None., (© 2020 The Authors. Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.)

National databases, such as the Irish Hip Fracture Database (IHFD), are known to contain inaccuracies. The coordination of services, national funding and future research rely on the integrity of the IHFD so as to avoid policy and budget planning being based on misrepresentative data. An audit was performed to assess the accuracy of the 2016 IHFD data collected in our trauma unit. The Hospital In-Patient Enquiry (HIPE)-recorded fracture classification, IHFD-recorded fracture classification and IHFD-recorded operation performed for each hip fracture patient was identified. Each variable was compared with the classifications and procedures derived by the authors. Two hundred fifty-two cases were identified. The HIPE-recorded fracture classification was accurate in 29% of cases, and the IHFD-recorded fracture classification in 61% (p < 0.001). The IHFD-recorded operation performed was accurate in 76% of cases. Thirty-six cases (14%) were omitted by HIPE, and eight (3%) from the local IHFD (p < 0.001). Errors resulted from poor documentation, in determining the presence of fracture displacement, prosthesis coating and intramedullary nail length. Diagnoses and procedures were identified from ward and theatre logbooks that the data coordinator was unable to record. The data coordinator in our unit doubled the accuracy of the data, and reduced the rate of omitted cases by a factor of 4.5. Accuracy levels would be significantly improved with clear, thorough documentation by the medical team following education of junior surgical trainees on hip fracture classification and procedural coding. Inaccurate data has a negative effect on hospital reimbursement and compromises the integrity of the IHFD.

Heart Failure (HF) and chronic obstructive pulmonary disease (COPD) are morbid diseases that often coexist. In patients with coexisting disease, COPD is an independent risk factor for readmission and mortality. However, spirometry is often inaccurate in those with active heart failure. Therefore, we investigated the association between the presence of emphysema on computed tomography (CT) and readmission rates in smokers admitted with heart failure (HF). The cohort included a consecutive group of smokers discharged with HF from a tertiary center between January 1, 2014 and April 1, 2014 who also had a CT of the chest for dyspnea. The primary endpoint was any readmission for HF before April 1, 2016; secondary endpoints were 30-day readmission for HF, length of stay and all-cause mortality. Over the study period, there were 225 inpatient smokers with HF who had a concurrent chest CT (155 [69%] males, age 69±11 years, ejection fraction [EF] 46±18%, 107 [48%] LVEF of < 50%). Emphysema on CT was present in 103 (46%) and these were older, had a lower BMI, more pack-years, less diabetes and an increased afterload. During a follow-up of 2.1 years, there were 110 (49%) HF readmissions and 55 (24%) deaths. When separated by emphysema on CT, any readmission, 30-day readmission, length of stay and mortality were higher among HF patients with emphysema. In multivariable regression, emphysema by CT was associated with a two-fold higher (adjusted HR 2.11, 95% CI 1.41-3.15, p < 0.001) risk of readmission and a trend toward increased mortality (adjusted HR 1.70 95% CI 0.86-3.34, p = 0.12). In conclusion, emphysema by CT is a frequent finding in smokers hospitalized with HF and is associated with adverse outcomes in HF. This under recognized group of patients with both emphysema and heart failure may benefit from improved recognition and characterization of their co-morbid disease processes and optimization of therapies for their lung disease., Competing Interests: The authors have declared that no competing interests exist.

Background and Purpose: Interventions to reduce the risk for cerebrovascular events (CVE; stroke and transient ischemic attack [TIA]) after radiotherapy (RT) for head and neck cancer (HNCA) are needed. Among broad populations, statins reduce CVEs; however, whether statins reduce CVEs after RT for HNCA is unclear. Therefore, we aimed to test whether incidental statin use at the time of RT is associated with a lower rate of CVEs after RT for HNCA., Methods: From an institutional database we identified all consecutive subjects treated with neck RT from 2002 to 2012 for HNCA. Data collection and event adjudication was performed by blinded teams. The primary outcome was a composite of ischemic stroke and TIA. The secondary outcome was ischemic stroke. The association between statin use and events was determined using Cox proportional hazard models after adjustment for traditional and RT-specific risk factors., Results: The final cohort consisted of 1,011 patients (59±13 years, 30% female, 44% hypertension) with 288 (28%) on statins. Over a median follow-up of 3.4 years (interquartile range, 0.1 to 14) there were 102 CVEs (89 ischemic strokes and 13 TIAs) with 17 in statin users versus 85 in nonstatins users. In a multivariable model containing known predictors of CVE, statins were associated with a reduction in the combination of stroke and TIA (hazard ratio [HR], 0.4; 95% confidence interval [CI], 0.2 to 0.8; P =0.01) and ischemic stroke alone (HR, 0.4; 95% CI, 0.2 to 0.8; P =0.01)., Conclusions: Incidental statin use at the time of RT for HNCA is associated with a lower risk of stroke or TIA.

Background: Data from broad populations have established associations between incidental carotid plaque and vascular events. Among people living with HIV (PLWHIV), the risk of vascular events is increased; however, whether incidental carotid plaque is increased and there is an association between incidental carotid plaque, plaque characteristics, and vascular events among PLWHIV is unclear., Methods and Results: Data from the multi-institutional Research Patient Data Registry were used. Presence and characteristics (high-risk plaque, including spotty calcification and low attenuation) of carotid plaque by computerized tomography among PLWHIV without known vascular disease were described. Data were compared with uninfected controls similar in age, sex, and cardiovascular risk factors, including diabetes mellitus, hyperlipidemia, and cigarette smoking to cases. Primary outcome was an atherosclerotic cardiovascular disease event, and secondary outcome was ischemic stroke. Cohort consisted of 209 PLWHIV (45±10 years, 72% male) and 168 controls. Using computerized tomography, PLWHIV without vascular disease had higher rates of any carotid plaque (34% versus 25%; P =0.04), noncalcified (18% versus 5%; P <0.001) and high-risk plaque (25% versus 16%; P =0.03). Over a follow-up of 3 years, 19 atherosclerotic cardiovascular disease events (9 strokes) occurred. Carotid plaque was independently associated with a 3-fold increase in atherosclerotic cardiovascular disease events among PLWHIV (hazard ratio, 2.91; confidence interval, 1.10-7.7, P =0.03) and a 4-fold increased risk of stroke (hazard ratio, 4.43; confidence interval, 1.17-16.70; P =0.02); high-risk plaque was associated with a 3-fold increased risk of atherosclerotic cardiovascular disease events and a 4-fold increased risk of stroke., Conclusions: There is an increase in incidental carotid plaque, noncalcified plaque, and high-risk plaque among PLWHIV, and the presence and characteristics of carotid plaque are associated with subsequent vascular events., (© 2017 American Heart Association, Inc.)

Background: Although plaque rupture is responsible for most myocardial infarctions, few high-risk plaques identified by intracoronary imaging actually result in future major adverse cardiovascular events (MACE). Nonimaging markers of individual plaque behavior are therefore required. Rupture occurs when plaque structural stress (PSS) exceeds material strength. We therefore assessed whether PSS could predict future MACE in high-risk nonculprit lesions identified on virtual-histology intravascular ultrasound., Methods and Results: Baseline nonculprit lesion features associated with MACE during long-term follow-up (median: 1115 days) were determined in 170 patients undergoing 3-vessel virtual-histology intravascular ultrasound. MACE was associated with plaque burden ≥70% (hazard ratio: 8.6; 95% confidence interval, 2.5-30.6; P<0.001) and minimal luminal area ≤4 mm(2) (hazard ratio: 6.6; 95% confidence interval, 2.1-20.1; P=0.036), although absolute event rates for high-risk lesions remained <10%. PSS derived from virtual-histology intravascular ultrasound was subsequently estimated in nonculprit lesions responsible for MACE (n=22) versus matched control lesions (n=22). PSS showed marked heterogeneity across and between similar lesions but was significantly increased in MACE lesions at high-risk regions, including plaque burden ≥70% (13.9±11.5 versus 10.2±4.7; P<0.001) and thin-cap fibroatheroma (14.0±8.9 versus 11.6±4.5; P=0.02). Furthermore, PSS improved the ability of virtual-histology intravascular ultrasound to predict MACE in plaques with plaque burden ≥70% (adjusted log-rank, P=0.003) and minimal luminal area ≤4 mm(2) (P=0.002). Plaques responsible for MACE had larger superficial calcium inclusions, which acted to increase PSS (P<0.05)., Conclusions: Baseline PSS is increased in plaques responsible for MACE and improves the ability of intracoronary imaging to predict events. Biomechanical modeling may complement plaque imaging for risk stratification of coronary nonculprit lesions., (© 2016 American Heart Association, Inc.)

Objectives: Clinically meaningful change in systemic sclerosis (SSc) related interstitial lung (SSc-ILD) disease is unknown. The aim of this study was to quantify change in pulmonary function as a predictor of outcome in SSc-ILD., Methods: All patients had SSc-ILD defined by HRCT chest. All PFTs during follow-up, including FVC (L), DLCO (ml/min/mmHg) and KCO (DLCO/alveolar volume ratio; DLCO/VA) (ml/min/mmHg/L) were retrieved. The rate of change over the first four years, and percentage change in the first year of follow-up were used in ROC curve analysis to determine the best cut-off points to predict adverse outcome (home oxygen, lung transplantation, or death)., Results: Among 264 patients, there were 49 events (38 deaths, 10 supplemental oxygen, one lung transplant) over a mean (±SD) follow-up of 3.0 (±1.7) years. The rates of decline over time and percentage change over one year in each of FVC, DLCO and KCO were predictive of adverse outcome. Stable PFTs over four years gave the optimal negative predictive values (NPVs) of 88-96%. The best sensitivity-specificity trade-off was a decline in FVC of 10% and in DLCO and KCO of 15% with NPVs of 92-93%., Conclusions: The course that SSc-ILD takes is evident within the first 1-4 years of follow up. Patients who have no decline in PFTs over 4 years have better outcomes. A decline within one year in DLCO or KCO of 15% or more is a poor prognostic factor, and identifies patients who should be monitored more closely and considered for therapy.

Objectives: In a multi-centre study, we sought to determine whether extent of disease on high-resolution CT (HRCT) lung, reported using a simple grading system, is predictive of decline and mortality in SSc-related interstitial lung disease (SSc-ILD), independently of pulmonary function tests (PFTs) and other prognostic variables., Methods: SSc patients with a baseline HRCT performed at the time of ILD diagnosis were identified. All HRCTs and PFTs performed during follow-up were retrieved. Demographic and disease-related data were prospectively collected. HRCTs were graded according to the percentage of lung disease: >20%: extensive; <20%: limited; unclear: indeterminate. Indeterminate HRCTs were converted to limited or extensive using a forced vital capacity threshold of 70%. The composite outcome variable was deterioration (need for home oxygen or lung transplantation), or death., Results: Among 172 patients followed for mean (s.d.) of 3.5 (2.9) years, there were 30 outcome events. In Weibull multivariable hazards regression modelling, baseline HRCT grade was independently predictive of outcome, with an adjusted hazard ratio (aHR) = 3.0, 95% CI 1.2, 7.5 and P = 0.02. In time-varying covariate models (based on 1309 serial PFTs and 353 serial HRCTs in 172 patients), serial diffusing capacity of the lung for carbon monoxide by alveolar volume ratio (ml/min/mmHg/l) (aHR = 0.4; 95% CI 0.3, 0.7; P = 0.001) and forced vital capacity (dl) (aHR = 0.9; 95% CI 0.8, 0.97; P = 0.008), were also strongly predictive of outcome., Conclusion: Extensive disease (>20%) on HRCT at baseline, reported using a semi-quantitative grading system, is associated with a three-fold increased risk of deterioration or death in SSc-ILD, compared with limited disease. Serial PFTs are informative in follow-up of patients.

The focus of this article includes 1 Revision of normal small bowel anatomy on sequences performed at our institution, with advantages and disadvantages. 2 Brief summary of the disease. 3 Appearance of acute active disease. 4 Usefulness of ancillary findings of active disease. 5 Appearance of chronic disease both active and inactive. 6 Complications of Crohn's disease. 7 Pitfalls and limitations of interpretation. 8 Clinically relevant reporting through clinician feedback., (© 2012 The Authors. Journal of Medical Imaging and Radiation Oncology © 2012 The Royal Australian and New Zealand College of Radiologists.)

A wide variety of pathologies can produce focal lesions within the spleen. These are being more frequently encountered as imaging technology improves. It is vital that radiologists are aware of these pathologies to enable accurate diagnosis. The role of ultrasound contrast in splenic disease will be discussed and illustrated with cases likely to be encountered by general and abdominal radiologists.

Ultrasound contrast agents have gained wide acceptance for the detection and characterization of focal liver lesions. This pictorial essay reviews the growing body of evidence that supports the use of modern ultrasound contrast agents and illustrates the enhancement characteristics of commonly encountered focal liver lesions. Pathologies discussed include metastases, hepatocellular carcinomas, focal nodular hyperplasia, hepatocellular adenomas, hemangiomas, abscesses, complex cysts, and focal fatty deposition., (Copyright © 2011 Wiley Periodicals, Inc.)

Introduction: Aim of this study was to determine if there is a statistically and clinically significant difference in diagnostic performance (cancer diagnosis) and perceptual performance (microcalcification detection) when detecting left-sided or right-sided breast cancers and microcalcifications., Methods: Eight radiologist readers (8-20 years experience in radiology, five current BreastScreen readers) read a set of 100 digital mammograms (23/100 had proven malignancies and 52/100 had confirmed microcalcifications) for three reads (random case order in each read). The same mammograms were presented on two reads, serving as the baseline reads. The data from these reads were used to calculate intra-observer variability (presented in an earlier study). The experimental read consisted of left-right mirror images of the original mammograms. In each read, the radiologists were requested to 'clear' or 'call-back' cases and to indicate if any microcalcifications (benign and malignant) were present on the mammograms. Reading conditions were standardised., Results: Comparison of intra-reader performance difference for left-sided versus right-sided breast cancers and microcalcifications with intra-observer variability for breast cancer diagnosis and microcalcification detection, respectively, revealed no clinically significant difference between left-sided and right-sided detections. Per-case analysis showed more left-sided breast cancers and microcalcifications correctly detected. This left-right difference in detection did not reach statistical significance, P-value of 0.28 for cancer diagnosis and 0.74 for microcalcification detection., Conclusion: There is no statistically or clinically significant difference between left-sided and right-sided breast cancer diagnosis and microcalcification detection in a group of experienced radiologists. Individual reading patterns do not affect detection rates of left-sided and right-sided cancers and microcalcifications., (© 2011 The Authors. Journal of Medical Imaging and Radiation Oncology © 2011 The Royal Australian and New Zealand College of Radiologists.)

Introduction: The purpose of this study was, for a group of experienced radiologists, to identify the magnitude of and statistical significance of intrareader variability in mammographic diagnostic performance or cancer diagnosis and mammographic perceptual performance or microcalcification detection., Methods: Eight radiologist readers (8-30 years experience in radiology, five current BreastScreen readers) read a set of 100 digital mammograms on two separate reads with random case orders. Twenty-three of the 100 had proven malignancies, and 52 of the 100 had confirmed microcalcifications. The same mammograms were presented for both reads. The radiologists were requested to clear or call back cases and to indicate if any benign and malignant microcalcifications were present on the mammograms. Reading conditions were standardised., Results: Intrareader variability in accuracy was demonstrated to be between 0% and 6% for the diagnostic task of breast cancer diagnosis and between 0% and 16% for the perceptual task of microcalcification detection. Intrareader agreement in the group of readers was high; between 75% and 93% (κ=0.36-0.72) for cancer diagnosis and between 77.5% and 93% (κ=0.17-0.77) for microcalcification detection. There was no correlation between reader's experience in radiology or being a BreastScreen reader and level of intrareader variability in cancer diagnosis and microcalcification detection., Conclusion: There exists intrareader variability in diagnostic and perceptual performance. Despite this variability, intrareader agreement remains high., (© 2011 The Authors. Journal of Medical Imaging and Radiation Oncology © 2011 The Royal Australian and New Zealand College of Radiologists.)

Introduction: Picture archiving and communication systems images designed to be viewed on high-resolution medical-grade monitors are routinely viewed on office-grade monitors on the wards or at home. This study aimed to determine whether a statistically significant difference in diagnostic (cancer detection) and perceptual (microcalcification detection) performance exists between 3MP grade and 1MP office-grade monitors., Methods: 3MP Dome medical-grade liquid crystal display (LCD) monitors (Planar, Beaverton, OR, USA) were compared to 1MP Dell office-grade LCD monitors (Dell Inc, Round Rock, TX, USA). Eight radiologists (reader experience 8-30 years) read the same set of 100 mammograms (23/100 with proven cancers and 52/100 with microcalcifications) presented in random order on three occasions separated by two time intervals of 12 weeks. Reads 1 and 3 utilised 3MP monitors and formed the baseline read. Read 2 utilised 1MP monitors and constituted the experimental read. Reading conditions were standardised. Readers were aware of which monitors they were using. Multivariate logistic regression analysis (to account for reader variability and monitor impact) was performed to assess for statistical significance., Results: At α = 5%, confidence intervals analysis comparing the measured parameters between 1MP to 3MP monitors demonstrated no statistically significant difference in diagnostic and perceptual performance for the reader group. In cancer detection (the diagnostic task), reader accuracy remained high irrespective of monitor type. Regression analysis comparing performance with 1MP against 3MP monitors found P values of 0.693 and 0.324 for diagnostic and perceptual performance, respectively., Conclusion: There were no statistically and clinically significant differences between 3MP and 1MP monitors in mammographic diagnostic and perceptual performance. Comparable performance may be due to compensatory behaviour by readers., (© 2011 The Authors. Journal of Medical Imaging and Radiation Oncology © 2011 The Royal Australian and New Zealand College of Radiologists.)

We report a case of primary splenic lymphoma incidentally detected on abdominal ultrasound as a well-defined homogenous hypoechoic splenic mass. Further characterization with contrast-enhanced ultrasound showed the mass to enhance homogenously during the arterial phase to a degree similar to that of the normal splenic parenchyma followed by rapid washout becoming hypoenhanced on delayed phase.

Renal transplants are the most frequent visceral transplant, and because of the absence of nephrotoxicity and radiation, ultrasound is widely used to monitor grafts and assess for complications. Complications can be categorised as vascular, parenchymal, ureteric and perinephric collections, with many occurring at predictable times post transplant. Awareness of these pathologies and their features is vital for all radiologists to enable early intervention and prolong graft survival.

Focal lesions within the spleen are being increasingly recognized as imaging technologies advance, and often provide a diagnostic challenge for radiologists. Knowledge of the types of pathologies that occur, determination of solid or cystic nature and a search for characteristic features including correlation with extrasplenic findings can usually allow a specific diagnosis or brief differential to be offered.

There is a shortage of radiologists in the Pacific Island nations. To help 'fill the gap', a project was conducted between 2004 and 2006 aimed at upskilling radiographers from South Pacific countries in basic radiological interpretation of plain film radiographs. It was intended that the radiographers would act as a resource, identifying and describing abnormalities to the local doctors and nurses, thus reducing the risk of misdiagnosis. A total of 23 participants, including one doctor and three health-care assistants, attended a 2-week course in 2004 or 2005. The course covered common abnormalities of the musculoskeletal system, chest and abdomen. Although they found the course challenging, most participants performed satisfactorily. Follow-up visits to the radiographers and their nominated, medically qualified mentors emphasized interprofessional, sociocultural and workload challenges experienced by some of the radiographers in implementing their extended role. Most of them, however, had found ways to integrate their new knowledge and skills into their clinical practice. Thirteen radiographers attended a further 1-week refresher course in 2006, showing their commitment to continued learning.

Intrathoracic extramedullary haematopoiesis occurring as a complication of osteopetrosis is uncommon. The combination of classic plain film and CT findings should suggest the diagnosis, which can be non-invasively confirmed with bone marrow scintigraphy.

The peritoneal cavity is a potential space that is divided by the peritoneal reflections into various complex subspaces. It can be involved in many disease processes including developmental, inflammatory, neoplastic and traumatic conditions. Computed tomography is highly sensitive and consistent in detecting peritoneal pathology. This pictorial essay aims to emphasize and illustrate the CT features of the spectrum of peritoneal diseases.

Background: The diagnosis of small-bowel Crohn's disease sometimes is difficult and may be missed by conventional imaging studies. Capsule endoscopy might identify small-bowel disease undetected by other investigations., Methods: Patients with or without known Crohn's disease who were suspected to have small-bowel Crohn's disease were prospectively evaluated with push enteroscopy, enteroclysis, and capsule endoscopy. Each examiner was blinded to results of other investigations. Referring doctors were required to complete questionnaires before and after the investigations., Results: Twenty-two patients were known to have Crohn's disease (Group 1), and 21 were suspected to have small-bowel Crohn's disease (Group 2). In Group 1, capsule endoscopy detected more erosions than the other two investigations (p < 0.001). In Group 2, a new diagnosis of Crohn's disease was made in two patients, but there was no significant difference in yield compared with the other two investigations. Referring physicians rated the usefulness of capsule endoscopy as 4.4 on a scale of 5. Capsule endoscopy changed management for 30 patients (70%)., Conclusions: Capsule endoscopy has a higher yield than push enteroscopy and enteroclysis in patients with known Crohn's disease when small-bowel mucosal disease is suspected, and this leads to a change in management in the majority of these patients.

Acute pulmonary schistosomiasis occurs in non-immune hosts, particularly visitors to regions where Schistosoma species are endemic. While radiological findings of acute pulmonary schistosomiasis might resemble neoplastic or granulomatous disease, an appropriate travel history might suggest the diagnosis. With rising popularity of travel to Africa and South-East Asia, the incidence of acute pulmonary schistosomiasis can be expected to increase. We describe a case of acute pulmonary schistosomiasis occurring in an Australian returning from Lake Malawi, Sub-Saharan Africa.

Storage of skin flaps in the cold before replantation increases their tolerance to ischemic damage. Rat epigastric skin flaps were perfused immediately before 2 days of cold ischemia with 3 ml of normal saline containing either 10 U per milliliter of heparin (group 1, N = 11) or normal saline (group 2, N = 10), or stored without perfusion (group 3, N = 6), and replanted. Flap viability was assessed 7 days later. The mean flap survival in groups 1, 2, and 3 was 73% (p<0.01 compared with group 2), 10%, and 33% respectively. Intravascular fibrin deposits were detected histochemically 5 minutes before reperfusion in nonperfused flaps and 5 minutes after reperfusion in saline-perfused flaps, but not in flaps perfused with heparinized saline. Angiography revealed evidence of no reflow in the first 5 minutes of reperfusion in saline-perfused flaps, but normal blood flow in heparinized saline-perfused flaps. Tissue water content, myeloperoxidase activity, and hydroperoxide levels after 1 and 24 hours of reperfusion were not significantly different in flaps perfused with heparinized saline and normal saline. These findings indicate that in skin flaps perfused before ischemia, flaps perfused with heparinized saline survive significantly better than flaps perfused with normal saline. They also survive better than nonperfused flaps but the improvement is not significant.

Transjugular intrahepatic portosystemic shunts (TIPS) have recently been used to manage the portal hypertensive complications of the Budd-Chiari syndrome. We report this application of TIPS (to our knowledge the first such application in Australia) in a young man with an excellent result and no major complications. This treatment offers an alternative to portacaval shunt surgery and has the advantage of bypassing a stenosed or compressed inferior vena cava. Additionally, the procedure does not complicate liver transplantation surgery if this is indicated at a later date.

Antiglomerular basement membrane (GBM) antibodies have been described previously in patients with microscopic polyarteritis but not in patients with polyarteritis nodosa alone. Where anti-GBM antibodies occur in microscopic polyarteritis, antineutrophil cytoplasm antibodies (ANCA) are usually present. We describe here a patient with polyarteritis nodosa and anti-GBM antibodies in whom ANCA could not be demonstrated. A 72-year-old woman presented with abdominal pain, diarrhoea and acute renal failure. A renal biopsy showed crescentic glomerulonephritis and linear immunofluorescence of the GBM consistent with anti-GBM disease. In addition, there was evidence of large-and medium-sized vessel vasculitis on abdominal angiography, performed because of persisting abdominal pain. There was no small vessel vasculitis on histological examination of the renal biopsy and ANCA could not be demonstrated by indirect immunofluorescence or ELISA.

Objective: The purpose of this study was to test the efficacy of sonography in the diagnosis of rupture of the anterior cruciate ligament in the setting of a recent traumatic hemarthrosis., Subjects and Methods: Sonography was prospectively performed in 37 patients with a recent traumatic hemarthrosis of the knee, no bone abnormality seen on plain radiographs, and no history of a previous knee injury. The presence of a hypoechoic collection along the lateral wall of the femoral intercondylar notch was interpreted as a hematoma at the femoral attachment of the anterior cruciate ligament. Arthroscopy was subsequently performed in 30 patients. The findings of three diagnostic techniques (sonography, MR imaging, and arthroscopy) were compared., Results: The sonographic findings were confirmed by MR imaging and arthroscopy in 34 of the 37 patients. For the three false-negative results, sonographic findings were abnormal but equivocal in two cases and were reported as negative. The technique was therefore 91% sensitive and 100% specific. The positive predictive value was 100%. The negative predictive value was 63%., Conclusion: Sonography is a useful and inexpensive method of detecting the presence of rupture of the anterior cruciate ligament in the clinical setting of a traumatic hemarthrosis.

The purpose of this essay is to illustrate sonographic findings for patients with abnormalities of the tendon of the long head of the biceps muscle of the arm. The tendon is vulnerable to a variety of injuries caused by abnormalities of its osseous and soft-tissue supports, including impingement of the tendon against the acromion and arthritis of the glenohumeral joint. These abnormalities include acute and chronic tenosynovitis, rupture, subluxation, and dislocation.

Background: The clinical role of the transjugular intrahepatic portal-systemic shunt (TIPS) has not been fully defined., Aims: To determine the technical results of TIPS and the clinical outcome of patients undergoing the procedure., Methods: Retrospective audit of the results of the first 31 procedures performed in Melbourne., Results: Thirty procedures were performed for variceal haemorrhage, one procedure was for ascites. The aetiology of the liver disease was cirrhosis due to alcohol in 20, cryptogenic in five, chronic viral infection in four, and autoimmune chronic active hepatitis in one. Nodular regenerative hyperplasia was present in one patient. Seventy-seven per cent of procedures were considered successful based on the angiographic demonstration of shunt patency at the end of the procedure. The in-hospital mortality in all patients undergoing TIPS was 45% and was 42% in patients undergoing technically successful TIPS. Only age could be identified as predictive of death in hospital. In patients leaving hospital, we found a rebleeding rate of 57% with one patient dying of bleeding, one requiring balloon tamponade and two requiring variceal sclerotherapy. Hepatic trauma was documented in six cases, shunt thrombosis in four cases, stent displacement in two cases and severe hepatic encephalopathy in one case., Conclusions: TIPS has the potential to decompress the portal venous system, but the procedure is technically complex and should be performed in the knowledge that mortality and morbidity can be relatively high, particularly in patients whose condition is poor.

A phase I/II study of the intralesional administration of ricin-labelled monoclonal antibodies was conducted in patients with hepatic metastases of gastrointestinal origin. The anti-carcinoembryonic antigen (CEA) antibody I-1 was conjugated to blocked ricin via a disulphide bridge. After a test dose of antibody, patients were injected with ricin-antibody conjugates under computed tomography (CT) guidance on two occasions 1 week apart. Patients with stable or responding disease would receive a third course. The dose of ricin relative to surface area was increased in a predefined manner in cohorts of 3 patients. A total of 27 patients with hepatic metastases were entered into this study. All patients had metastatic colorectal cancer (26 patients) or adenocarcinoma of unknown primary with elevated CEA levels (1 patient). The presence of malignancy was documented cytologically in 9 of 11 patients tested. Minor responses were seen in 7 patients. However, no major objective responses or changes in the growth rate of injected lesions were observed. Toxicity was generally mild, the most common being hepatic capsular pain 24-48 h after each injection. 6 patients experienced rigors. One patient had anaphylaxis. Human anti-mouse and anti-ricin antibody responses were observed. Although substantial amounts of ricin conjugated to monoclonal antibodies were delivered into single lesions, this therapeutic approach was unsuccessful. Future studies of ricin-labelled antibodies should incorporate the systemic administration of immunoconjugates.

Aims: To assess the safety and efficacy of the intra-arterial administration of streptokinase within 24 hours of acute ischaemic stroke., Methods: Patients who presented to the Austin Hospital casualty department between 3 and 22 hours after an acute stroke were considered for the study. Eligible patients had pretreatment non-contrast computed tomographic scans of the brain to exclude haemorrhage. Streptokinase (250,000 units) was administered directly into the common carotid artery or the cervical portion of the internal carotid artery., Main Outcome Measures: The incidence of symptomatic and asymptomatic cerebral haemorrhage, haemorrhagic transformation of infarction, angiographic reperfusion, clinical outcome at seven to 10 days and the frequency of other complications., Results: Thirteen patients were treated over a 16-month period. Major clinical improvement occurred in five patients (39%) at 48 hours. This was associated with angiographically demonstrated recanalisation of a middle cerebral artery occlusion in two patients and partial recanalisation in two others. Significant hypotension in two patients required therapy to be stopped. In five other cases mild hypotension developed but the streptokinase infusion was completed. Haemorrhagic transformation of the infarct occurred in four patients without clinical deterioration., Conclusion: Intra-arterial administration of streptokinase is safe in selected patients with acute ischaemic stroke. The theoretical benefit of an increased local thrombolytic effect and reduced systemic complications, compared with the use of higher intravenous doses, justifies a randomised clinical trial. If therapies such as this are to be successful, rapid referral to an appropriate centre is necessary.