Transrectal ultrasound-guided (TRUS) biopsy of the prostate is associated with increased risk of post-procedural sepsis with associated morbidity, mortality, re-admission to hospital, and increased healthcare costs. In the study institution, active surveillance of post-procedural infection complications is performed by clinical nurse specialists for prostate cancer under the guidance of the infection prevention and control team. To protect hospital services for acute medical admissions related to the coronavirus disease 2019 (COVID-19) pandemic, TRUS biopsy services were reduced nationally, with exceptions only for those patients at high risk of prostate cancer. In the study institution, this change prompted a complete move to transperineal (TP) prostate biopsy performed in outpatients under local anaesthetic. TP biopsies eliminated the risk of post-procedural sepsis and, consequently, sepsis-related admission while maintaining a service for prostate cancer diagnosis during the COVID-19 pandemic.

Background Surveillance of sporadic renal angiomyolipomas is a growing issue for physicians and radiologists. Current treatment recommendations favor active surveillance. However, the evidence underlying these is based on small case series, which also typically include angiomyolipomas associated with tuberous sclerosis. Purpose To evaluate the natural growth pattern of sporadic renal angiomyolipomas in patients without tuberous sclerosis. Material and Methods A retrospective review was performed in three separate tertiary referral centers. A keyword search of each institutions PACS history was performed. Inclusion criteria were angiomyolipomas > 1 cm in size, three years of follow-up, and lesions requiring treatment before reaching three years of follow-up. Exclusion criteria included a diagnosis of tuberous sclerosis, pregnancy, prior treatment with embolization without any prior imaging, and lesions which were treated on presentation. Growth of the angiomyolipomas was evaluated on the basis of maximum dimension on initial and follow-up images. Results Sixty-three patients were identified in total, with 64 lesions eligible for inclusion. The majority of patients were women (55/63). The mean age at which the angiomyolipomas discovered was 56.4 years. Mean total growth was 0.085 mm and mean follow-up was 65.5 months. At initial measurement, the mean maximum dimension of the lesions in our cohort was 2.08 cm. After follow-up, this was 2.16 cm. The average rate of growth was 0.015 cm per year. Conclusion Sporadic angiomyolipomas exhibit minimal, if any, natural growth. Current surveillance strategies could be relaxed.

Mass casualty incidents (MCIs) create a large number of casualties in a short period of time. Diagnostic radiology plays an important role in major incident responses but is often underrepresented during major incident planning (MIP) and simulation. Surveys suggest radiologists are unfamiliar with their role during an MCI. We aimed to identify key topics for radiology MIP, familiarize radiologists with their role during an MCI and identify areas for future research. The terms “radiology” and “mass casualty incident” were entered into the advanced search builder on PubMed. Abstracts from this primary search were reviewed and papers selected for inclusion. Additional studies of interest were identified upon review of reference sections of relevant articles and from the related article tab on PubMed. MCI and trauma guidelines were reviewed. Key factors that caused issues during prior MCIs were identified including staff alert mechanisms, patient identification strategies, patient tracking, scan ordering and result communication. Limitations of local imaging resources and capacity should be identified and inform plans for the utilization of diagnostic radiology in the MCI setting. Simulation can help identify areas for improvement and familiarize staff with their roles. Further development of reliable MCI alert technology and patient identification strategies are needed as well as prospective validation of trauma CT selection criteria to identify patients who will benefit most from CT. Radiology should take part in MIP to address key issues encountered during prior MCIs and in MCI simulation to optimize major incident response.

Purpose To qualitatively assess the legibility of radiopaque patient identification stickers and their effect on image quality. These stickers are intended for use as a part of a patient registration and identification pack utilized in a mass casualty incident (MCI), to prevent errors in correlating patients with their diagnostic imaging and reports. Methods Four different prototype designs of stickers with radiopaque identification numbers which are legible on radiographs and CT were created. These were affixed to head and thorax phantoms and scanned using standard imaging protocols. Images were reviewed qualitatively for legibility and the presence of image degradation due to the radiopaque sticker materials using Likert scales by four radiologists and four emergency physicians. Results All four prototypes were confidently legible on forehead, shoulder and sternum on CT on topogram and reconstructed images. Sticker positioning over the temple resulted in unreliable legibility on topogram. All prototypes were confidently legible on shoulder and sternum on CT and radiographs. Significant image degradation was reported on radiographs with sticker position over the sternum. The preferred anatomic position was the forehead. Conclusion In a mass casualty incident, radiopaque patient identification stickers affixed to injured patients may help to ensure confidence in the correlation between patients and their imaging. Tested prototypes were found to be easily legible without substantial degradation of image quality. Preferred anatomical position and construction material was established. Consideration should be given to addition of such radiographic identity aides to MCI patient registration packs.

Objective To establish the incidence and define the nature of complications occurring following image-guided musculoskeletal injections at our institution. Materials and methods All patients undergoing image-guided musculoskeletal injection during the study period (16/3/2016 to 24/01/2020) were included. Departmental records were reviewed to identify all patients describing possible complications following injection, what therapy was required (if any) and what the outcome was. No patients were excluded. Complications were classified as minor or major. Injections were categorised as follows: cervical spine, lumbar facet joint, lumbar nerve root, caudal epidural and ‘other’. The complication rate for each individual category of procedure was compared with the combined complication rate for all other categories by constructing contingency tables and using Fisher’s exact test. Results A total of 8226 patients underwent image-guided musculoskeletal injections within the study period. Exactly 100 patients were identified as having reported a complication, producing an overall complication rate of 1.2%. One complication was categorised as ‘major’, with the patient requiring expedited surgery. The remainder (99 patients) were categorised as having experienced minor complications. The incidence of complications after ‘other’ injections was significantly greater than for other categories of injection (1.86%, p = 0.028). There was no significant difference in the complication rate for cervical spine (0.93%, p = 0.257), lumbar nerve root (0.85%, p = 0.401), lumbar facet joint (0.67%, p = 0.326) or caudal epidural (1.29%, p = 0.687) injections. ‘Other’ injections were subsequently further sub-categorised by anatomical site and imaging modality used. Glenohumeral (2.97%, p = 0.0361) and sacro-iliac (3.51%, p = 0.0498) joint injections were associated with a significantly increased risk of complications. There was no difference in the incidence of complications with fluoroscopic or ultrasound guidance. Conclusion In conclusion, image-guided musculoskeletal injections are safe and well-tolerated procedures. Complications are rare, occurring in just 1.2% of patients. 99% of complications are minor, either not requiring intervention or resolving with simple supportive treatment.

INTRODUCTION:Cardiac implantable electronic devices (CIEDs) are increasing in prevalence. Exposing patients with CIEDs to magnetic resonance imaging (MRI) can lead to adverse outcomes. This has led certain radiology departments to not accept MRI referrals related to patients with CIEDs. Patients with MR-conditional CIEDs can be safely scanned under specific conditions. Our institution has accepted such referrals since 2014. The aim of this study was to systematically identify and reduce risk in our CIED-MRI protocol using failure mode and effects analysis (FMEA).METHODS:A multidisciplinary FMEA team was assembled and included senior stakeholders from the CIED-MRI protocol. A process map was constructed followed by risk analysis and scoring. Targeted interventions were formulated and implemented; high-risk failure modes were prioritized. A new process map and protocol were drafted and repeat risk analysis was performed. Monitoring and re-evaluation of the CIED-MRI pathway were instigated at departmental quality assurance (QA) meetings.RESULTS:Interventions included direct CIED characterization using wireless technology pre-MRI, CIED programming and reprogramming in the MRI suite before and immediately after MRI reducing device downtime and continuous patient monitoring during MRI by a cardiac physiologist. The cumulative risk priority number (RPN) decreased from 1190 pre-FMEA to 492 post-FMEA.DISCUSSION:Despite the risk of exposing CIEDs to the MR environment, patients with MR-conditional CIEDs can be safely scanned with an appropriate multidisciplinary support. We found FMEA an indispensable tool in identifying and minimizing risk with no adverse events recorded since FMEA recommendations were implemented.

Renal angiomyolipomas (AMLs) are benign tumours that may occur sporadically in the general population or in patients with tuberous sclerosis complex. The concern with AMLs is that of retroperitoneal hemorrhage, which can be fatal. Classically the trigger for prophylactic intervention was thought to be an AML diameter of ≥4 cm. However, this value is largely based on data from case series and heterogeneous retrospective studies. The PICO (patient, intervention, comparison, outcome) paradigm was used to systematically search the Cochrane database, TRIP database, and PubMed. The quality of evidence in the literature is poor regarding the indications for prophylactic embolization of AMLs (level 4). There are no prospective studies that adequately assess embolization vs other treatment modalities. However, using the available evidence we have produced recommendations for when intervention should be considered. We have also made recommendations regarding the direction of future research.

A man in his 60s presented for a testicular ultrasound due to asymptomatic scrotal swelling. Ultrasound showed a right-sided varicocoele (figure 1). A varicocoele is an abnormal dilatation of the pampiniform venous plexus in the scrotum. A renal ultrasound demonstrated a heterogeneous mass arising from the right kidney (figure 2). Histology subsequently revealed a renal cell carcinoma. CT identified duplication of the right testicular vein (figure 3). The first emptied into the inferior venacava (IVC) as expected. The second had a tortuous course arcing over the upper pole of the right kidney and emptying into the right renal vein (figure 4). Tumour extension …

A 39-year-old woman was noted to have hypertension and a palpable abdominal mass at a routine general practitioner appointment. Her medical history was unremarkable. An ultrasound of the abdomen demonstrated a large mass arising from the left kidney with a smooth echotexture and patchy areas of signal heterogeneity (figure 1). Figure 1 Ultrasound: there is a large mass arising from the left kidney measuring 22×13 cm. The renal mass demonstrated poor intrinsic vascularity on power Doppler assessment. A CT scan showed an expansile hypoenhancing solid tumour arising from the mid-upper pole of the left kidney …

A woman in her 70s presented for a scheduled CT scan for workup of an adnexal lesion. The adnexa were within normal limits; however, a blind-ending tubular structure was noted in the right femoral canal (figures 1 and 2). The diagnosis of a de Garengeot hernia was made. This is a rare type of hernia that occurs when the appendix descends to lie in the femoral canal. Femoral hernias comprise roughly 3% of all abdominal wall hernias, and de Garengeot hernias comprises 0.8%–1% of all femoral hernias.1 Figure 1 CT scan axial images. Green arrows: dilated appendix in …

An elderly patient was admitted for a coronary artery bypass graft. The postoperative course was complicated by decompensated atrial fibrillation requiring repeat endotracheal intubation.On examination subcutaneous emphysema was noted, which progressed to involve the upper arms, cervical region and face.Chest X-ray and CT scan demonstrated subcutaneous emphysema and pneumomediastinum (figures 1 and 2). Fibre optic bronchoscopy revealed a normal tracheobronchial tree, without obvious orifices in the tracheal wall. A CT scan of the thorax revealed a tracheal diverticulum on the right posterolateral aspect of the …

A young man in his early 30s presented with a 3-day history of left upper arm swelling and erythema (figure 1). He had no significant medical history. Of note he had a strong family history of deep venous thrombosis (DVT) with both parents having had lower limb DVTs. D-dimers were elevated, and the remaining laboratory investigations were within normal limits. Figure 1 Erythematous, oedematous left upper limb. An upper limb Doppler ultrasound scan showed occlusive thrombus in the left subclavian vein (figure 2). A CT venogram further delineated the extent of the thrombus confirming the diagnosis of Paget Schroetter syndrome (figures 3 and 4). Subsequently, a conventional venogram …

A middle-aged patient presented with partial third nerve palsy with pupillary sparing; the time of onset was unclear. A collateral history revealed that the patient had suffered gradual memory impairment, difficulty performing tasks and word finding problems in the preceding months. The patient's blood pressure on admission was 210/140 mm Hg; subsequently malignant hypertension was diagnosed. There was no significant medical history and the patient did not take any prescription medications. There was a family history of stroke. On examination there was partial third nerve palsy, …