Imaging in myeloma with focus on advanced imaging techniques.

In recent years, there have been major advances in the imaging of myeloma with whole body MRI incorporating diffusion-weighted imaging, emerging as the most sensitive modality. Imaging is now a key component in the work-up of patients with a suspected diagnosis of myeloma. The International Myeloma Working Group now specifies that more than one focal lesion on MRI or lytic lesion on whole body low-dose CT or fludeoxyglucose (FDG) PET/CT fulfil the criteria for bone damage requiring therapy. The recent National Institute for Health and Care Excellence myeloma guidelines recommend imaging in all patients with suspected myeloma. In addition, there is emerging data supporting the use of functional imaging techniques (WB-DW MRI and FDG PET/CT) to predict outcome and evaluate response to therapy. This review summarises the imaging modalities used in myeloma, the latest guidelines relevant to imaging and future directions

Augmented reality in vascular and endovascular surgery: a scoping review

Background: Technological advances have transformed vascular intervention over recent decades. In particular, improvements in imaging and data processing have allowed for the development of increasingly complex endovascular and hybrid interventions. Augmented reality (AR) is a subject of growing interest within surgery, with potential to improve clinicians’ understanding of 3D anatomy and aid the processing of real-time information. This paper hopes to elucidate the potential impact of AR technology in the rapidly evolving field of vascular and endovascular surgery. Objective: The aim of this review was to summarise the fundamental concepts of augmented reality technologies, and to conduct a scoping review of the impact of AR and mixed reality within vascular and endovascular surgery. Methods: A systematic search of MEDLINE, Scopus and Embase was performed in accordance with the Preferred Reporting Items on Systematic Reviews and Meta-analysis (PRISMA) guidelines. All studies written in English from inception until 8th of January 2021 were included in the search. Combinations of the following keywords were used in the systematic search string: (‘augmented reality’ OR ‘hololens’ OR ‘image overlay’ OR ‘daqri’ OR ‘magic leap’ OR ‘immersive reality’ OR ‘extended reality’ OR ‘mixed reality’ OR ‘head mounted display’) AND (‘vascular surgery’ OR ‘endovascular’). Studies were selected by a blinded process between two investigators and assessed with data quality tools. Results: AR technologies have had a number of applications across vascular and endovascular surgery. The majority of studies use 3D imaging of CT angiogram-derived images of vascular anatomy to augment the clinicians anatomical understanding during procedures. A wide range of AR technologies have been employed, with ‘heads up’ fusion imaging and AR head-mounted displays being the most commonly clinically applied. AR applications have included guiding open, robotic and endovascular surgery whilst minimising dissection, improving procedural times, and reducing radiation and contrast exposure. Conclusions: AR has shown promising developments in the field of vascular and endovascular surgery, with potential benefits to surgeons and patients alike. These include reductions in patient risk and operating times, as well as contrast and radiation exposure for radiological interventions. Further technological advances are required to overcome current limitations, including processing capacity and vascular deformation by instrumentation

Missed posterior shoulder fracture dislocations: a new protocol from a London major trauma centre

Background A high incidence of missed posterior shoulder dislocations is widely recognised in the literature. Concern was raised by the upper limb multidisciplinary team at a London major trauma centre that these missed injuries were causing serious consequences due to the need for surgical intervention and poor functional outcome. Objective To identify factors contributing to missed diagnosis and propose solutions. Methods A local quality improvement report was performed investigating time from admission to diagnosis of simple posterior dislocations and fracture dislocations over a 5-year period. Factors contributing to a delayed diagnosis were analysed. Results The findings supported current evidence: a posterior shoulder dislocation was more often missed if there was concurrent fracture of the proximal humerus. Anteroposterior and scapular Y view radiographs were not always diagnostic for dislocation. Axial views were more reliable in assessment of the congruency of the joint and were associated with early diagnosis and appropriate treatment of the injury. Discussion As a result of these findings a new protocol was produced by the orthopaedic and radiology departments and distributed to our emergency department practitioners and radiography team. The protocol included routine axial or modified trauma axial view radiographs for all patients attending the emergency department with a shoulder injury, low clinical suspicion for dislocation and a low threshold for CT scan. Reaudit and ongoing data collection have shown significant increase in axial view radiographs and improved diagnosis

Changes in northern hemisphere male international rugby union players body mass and height between 1955 and 2015

Objectives We sought to establish the effects of professionalism, which officially began in 1995, on the body mass and height of northern hemisphere male international rugby union (RU) players. We hypothesised that mass would significantly increase following professionalism. We also investigated the changes in size of players according to their playing position, and we compared changes to rugby league (RL) players and the public. Methods The body mass and height of players representing their international team for that country’s first game of the Five Nations in 1955, 1965, 1975, 1985 and 1995 and, for 2005 and 2015, the Six Nations, were collected from matchday programmes. RL players’ data were collected from the Challenge Cup final games played in the same years. Results International RU player body mass has significantly increased since 1995. In 1955 mean (±SD) player body mass was 84.8  kg (±8.2); in 2015, it was 105.4  kg (±12.1), an increase of 24.3%. Between 1955 and 2015, the body mass of forwards increased steadily, whereas that of backs has mostly gone up since 1995. RU player body mass gain has exceeded that of RL, but the age-matched difference between RU players and the public has remained relatively constant. Conclusions The factors influencing the gain in body mass of rugby players are legion; however, we believe that the interpretation of the law relating to the scrum put-in and changes allowing substitutions have, at least in part, contributed to the observed changes. Injury severity is increasing, and this may be linked to greater forces (caused by greater body mass) occurring in contact. RU law makers should adjust the rules to encourage speed and skill at the expense of mass

Remote reporting in the COVID-19 era: from pilot study to practice

Aim: To assess the benefits and challenges of remote reporting using an intra-departmental teleradiology system. Materials And Methods: A pilot of an in-hospital Trust radiologist reporting on in-hospital Trust patients via a remote login was undertaken. Reporting output, training impact, and quality improvement were measured. Results: Reporting output increased by 140%. Trainee satisfaction was high in a qualitative survey, particularly for out-of-hours support and teaching. Clinicians found the service to be similar to the same service provided by a locally based radiologist. Conclusion: In the COVID-19 era, remote working has developed rapidly. This study shows that radiology departments can provide remote reporting that is equal in standard to reporting from within the hospital, and in addition, that there are advantages to output and training

Establishing the multidisciplinary Imperial Physical Activity and Diabetes clinic

Increasing numbers of people with diabetes are adopting exercise programmes. Fear of hypoglycaemia, and hypoglycaemia itself, are major issues for many people with diabetes undertaking physical activity. The risk of hypoglycaemia is exacerbated by endurance exercise. In addition, soft tissue injuries are more common in people with diabetes. We have established a multidisciplinary physical activity and diabetes clinic with the aim of empowering, educating and enabling people with diabetes to enjoy sport and exercise without fear of hypoglycaemia or frustration at glycaemic variability or soft tissue injuries. The multidisciplinary team (MDT) includes a diabetologist, sports and exercise physician, radiologist, dietitian, diabetes specialist nurse, and psychologist. Between October 2015 and September 2017, we undertook 19 clinics and saw 66 patients (48 new and 18 follow-up). Of the 48 new referrals (median age 35; range 20–72) 47 had type 1 diabetes and 27 (56%) used an insulin pump. Attendees had a median 18 years of diabetes (range 1–50). Diabetes distress was variable (median PAID score 18; range 0–64). Twenty-five patients attended for glycaemic management, 15 for musculoskeletal issues and eight for both. Sixteen (33%) required physiotherapy and nine (19%) were referred for joint imaging. It is possible to establish a new service to support physical activity in diabetes. To meet demand and enhance the MDT, physiotherapy will be added. A means of assessing the effects of diabetes on physical activity and outcome measures that matter to people with diabetes must be developed

Ultrasound-guided muscle biopsy: a practical alternative for investigation of myopathy

Objective We propose the use of ultrasound-guided muscle biopsy as a viable method of obtaining muscle specimen to aid the diagnosis of myopathy. We retrospectively review the diagnostic accuracy and patient feedback of ultrasound-guided muscle biopsies in our neuromuscular service. Method Multidisciplinary team meeting reviewed select patients and agreed on those suitable for ultrasound-guided muscle biopsy. They then underwent biopsy using direct ultrasound guidance and a modified Bergström needle. The specimens were sent for histopathological analysis, and patients were given a feedback form. Results Ten patients underwent 11 ultrasound-guided muscle biopsies. Of these 11, one was processed incorrectly, but all others were good quality specimens suitable for analysis. All 10 of those processed correctly aided diagnosis. All patient feedback was rated good or excellent. In 4 patients with a previous unsuccessful surgical biopsy, ultrasound-guided biopsy was successful in obtaining suitable muscle. Of those 4 patients, 3 preferred ultrasound-guided biopsy, and 1 did not state a preference. Discussion Our ultrasound-guided muscle biopsy technique offers a viable alternative to surgical biopsy. It yields high-quality specimen that aids diagnosis and receives good feedback from patients. It can be performed quickly as a day case and does not require theatre space. Furthermore, direct visualization of structures minimizes the risk of complications and allows biopsy of otherwise difficult to access targets. Conclusion Utilization of ultrasound guided–modified Bergström needle technique for muscle biopsy provides comparable success rates to other techniques and has practical, clinical, operational, and patient-centred benefits compared with alternative techniques

A comparison between augmented reality and traditional in-person teaching for vascular anastomotic surgical skills training

Background : Augmented Reality (AR) superimposes computer generated content to a real-world environment through multitudinous devices, and is used across multiple training fora. Its use in vascular surgery education is yet to be formally investigated. The aim is to assess feasibility and effectiveness of remote teaching of vascular anastomosis skills enhanced by AR in the form of the HoloLens2TM Head Mounted Display technology with traditional in-person skills teaching. A remote trainer used video, gestures and images superimposed over participants’ field of vision via the HoloLens2TM to teach the skills. Method: 28 participants underwent a pre-assessment performing an end-to-end vascular anastomosis on an artificial vessel. They were randomly allocated to an AR or in-person group, and underwent two teaching sessions. Individuals were asked to complete a post-session feedback form and assessment (video recorded and anonymised). The videos were marked by two blinded, independent assessors using the Objective Structured Assessment of Technique Skills (OSATS) scoring. Results: There was an overall improvement in both cohorts in OSATS score after the intervention by +7.083 in the in-person group and +8.275 in the AR. Independent T-test was performed and a p-value of 0.422 was obtained - no statistically significant difference in the change in OSATS scores when comparing the skills teaching received in-person with that through AR. Conclusion: Remote teaching enhanced by AR is feasible and effective for the teaching of vascular surgical anastomosis skills, and non-inferior to in-person teaching. There is scope for development of the use of AR in vascular surgical skills training