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Recent advances in diagnostic imaging
Meeting organised by the Scottish Branch of
The British Institute of Radiology
Friday 14 February 2014
Royal College of Physicians and Surgeons of Glasgow
08:30 Registration, tea and coffee
Chair Dr Khalid Ali, Meeting Organiser, BIR Scottish Branch
09:00 Interventional radiology – a completely different animal!
Professor Jon Moss, Consultant Interventional Radiologist,
Gartnavel General Hospital
09:40 Update in cardiac CT
Dr Ross MacDuff, Consultant Radiologist,
Glasgow Royal Infirmary
10:20 Update in thoracic imaging
Dr John Reid, Consultant Radiologist, Borders General
Hospital
11:00 Future directions of the BIR and the implications for
education education
Professor Andrew Jones, President, BIR
11:10 Refreshments
11:30 Glasgow oxygen level dependent (GOLD) technology:
Novel metabolic MRI techniques to identify the
penumbra Dr Celestine Santosh, Consultant
Neuroradiologist,
Institute of Neurological Sciences
12:10 Brain imaging in cognitive impairment and dementia -
what, when and how?
Professor Alison Murray, Professor of Radiology,
University of Aberdeen
12:50 Lunch
13:50 Update in GI imaging
Dr Peter MacLean, Consultant Radiologist,
Western General Hospital
14:30 Selected applications of SPECT-CT
Dr Dilip Patel, Consultant Radiologist, Royal Infirmary of
Edinburgh
15:10 Refreshments
15:40 Imaging of groin pain: Inguinal disruption
Dr Scott McKie, Consultant MSK Radiologist,
Royal Infirmary of Edinburgh
16:20 Stiffness and slices: the new tools in breast imaging
Professor Andrew Evans, Professor of Breast Imaging,
University of Dundee
Honorary Consultant Radiologist, NHS Tayside
17:00 Close of meeting
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Speaker profiles and abstracts (where supplied)
Abstract
Professor Jon Moss, Consultant Interventional Radiologist,
Gartnavel General Hospital
Interventional radiology – a completely different animal!
Medicine continues to superspecialise and radiology is no exception. A major split is
occurring between diagnostic and interventional radiology with IR now having
subspecialty status in the U.K. and several other countries. The waters are murky
however with little clear guidance for trainees and many deciding to stick with
diagnostic radiology. From a strategic high point some years ago IR now faces a less
certain path with inadequate training numbers, unfilled consultant posts and other
specialities looking to take advantage of this situation. This is all happening at a time
when the number of IR techniques and the evidence base for their use has never
been higher.
Biography
Dr Ross MacDuff, Consultant Radiologist, Glasgow Royal Infirmary
Having trained in the West of Scotland I took up a Consultant post at Glasgow Royal
Infirmary and Stobhill Hospital in 2010. I have a subspecialist interest in
cardiothoracic imaging including cardiac CT and MRI.
Abstract
Update in cardiac CT
Over the past decade technological advances in CT have allowed rapid development
in CT imaging of the heart. CT coronary angiography has become a recognised and
validated technique in the assessment of coronary artery disease. The role of CTCA is
expanding and more patient subgroups are being investigated with this technique. Its
use in emergency departments is expanding and has been suggested to allow rapid
discharge and significant cost savings. In this talk we will review the current
indications for CT coronary angiography and look at potential developments in
cardiac CT.
Educational aims:
To review current indications for cardiac CT
Assess the utility of triple rule out scanning
Introduce the role of CT myocardial perfusion
Biography
Dr John Reid, Consultant Radiologist, Borders General Hospital
Consultant Radiologist at Borders General Hospital from 1996 to present.
Formerly Consultant Cardiothoracic Radiologist at Edinburgh Royal Infirmary from
1986-1996.
I was a Nycomed Scholar studying cardiac imaging and cardiac intervention in
Stockholm and Oslo in 1986.
Clinical Tutor at Edinburgh University 1986-present.
I have an interest in all aspects of cardiothoracic imaging and in all modalities from
thoracic CT to cardiac MRI. My main sphere of expertise is in the diagnosis of
thromboembolic disease and lung cancer. I have co-authored the British Thoracic
Society guidelines on the diagnosis and management of pulmonary embolism and
chaired the United Nations Atomic Energy Experts Group on the utility of
scintigraphy for the diagnosis of PE. I was a contributor to the SIGN guideline on the
diagnosis and management of lung cancer.
Abstract
Update in thoracic imaging
Today’s presentation will provide an update on selected topics in thoracic imaging.
These will include a review of the current thinking on the diagnosis and follow up of
pulmonary embolism. Recent improvements in CT technology have created a wealth
of new data concerning this common condition. Particular reference will be paid to
the place of CT perfusion imaging.
Idiopathic interstitial pneumonias confuse everyone. The America Thoracic Society
and the European Respiratory have just issued guidance on the classification of this
group of conditions and I shall review what this new guidance means for thoracic
radiologists and give a brief overview of the radiological features of IIPs.
Next up: pulmonary nodules. This vexed issue is becoming even more important with
the rising tide of thoracic CT and I shall review the current thinking on nodule follow
up.
With pulmonary nodules in mind, I shall conclude my presentation with a review of
the worrying rise of litigation against radiologists. This will have an emphasis on
thoracic imaging and the phenomenon known as hindsight bias.
Update of classification of IIPs
Am J Crit Care Med 2013,188:733-48
Missed Lung Cancer on Chest Radiography and Computed Tomography
Fardanesh M, White C. Seminars in Ultrasound, CT and MRI 2012, 33:280-7
Hindsight bias. Roese, N. J., & Vohs, K. D. 2012. Perspectives on Psychological
Science, 7:411-26
Biography
Dr Celestine Santosh, Consultant Neuroradiologist,
Institute of Neurological Sciences
I graduated in Medicine in 1982 and have been working in Neuroradiology since
1987. I am currently a Consultant Neuroradiologist at the Institute of Neurological
Sciences in Glasgow. I also have an Honorary appointment as a Clinical Associate
Professor, College of Medical, Veterinary and Life Sciences, University of Glasgow.
I have been working with the animal 7.1 MRI scanner since 2004. I have been the
lead in developing novel metabolic MRI techniques using perflourocarbons to
visualize the penumbra in stroke, now know as Glasgow Oxygen Level Dependent
(GOLD) techniques. Some of this work has been recognised by the scientific
community having received the Astra-Zeneca prize at the ISMRM British Chapter in
2008, the Integrated Mammalian Biology Poster Prize in 2009 and the Scottish Life
Sciences Awards 2013 for the best innovation originating within NHS Scotland. We
also had the privilege of being invited to present this work at the 2012 Gordon
Conference on Brain.
Discosure: I am a founding member and the Chief Medical Officer for Aurum
Biosciences Limited, which is a spinout company to take GOLD into clinical practice.
Abstract
Glasgow oxygen level dependent (GOLD) technology: Novel metabolic
MRI techniques to identify the penumbra
One in six people have a stroke in their lifetime. Actilyse, (aka rt-PA & only licensed
therapy for acute stroke), is a thrombolytic with a 4.5hrs from onset treatment
window. However, <7% of patients receive Actilyse. Inability to characterise individual
pathophysiology with imaging excludes many patients from treatment: 75% on time
criteria.
Existing brain scanning methods are impractical for urgent clinical use or give no
information about the affected brain ability to use oxygen, the critical indicator of
whether it will survive. Glasgow Oxygen Level Dependent (GOLD) techniques
comprises an intravenous perflurocarbon (PFC) oxygen carrier, increased inspired
oxygen and three novel MRI techniques to identify the penumbra. The PFC also
protects the penumbra.
Technique 1: Is based on Blood Oxygen Level Dependent (BOLD) T2* signal. The
penumbra can be defined by a T2* oxygen challenge (OC) imaging, by an increased
oxygen extraction fractions (OEF) and oxygen utilisation (Santosh et al, 2008).
Technique 2: Lactate change imaging, detects changes in lactate co-incident with
increased oxygen delivery during an oxygen challenge (OC) to identify the penumbra
(Holmes et al, 2012). This technique is able to identify hypoxic tissues with anaerobic
metabolism but still have potential for aerobic metabolism and survival, ie the
penumbra.
Technique 3: With this technique the penumbra is identified during the injection of
PFC, hyperoxia and a T2* sequence. This is identified as a sharp dip and occurs only
in the penumbra and it is due to repolarisation, which follows a peri-infarct
depolarisation wave.
Biography
Professor Alison Murray, Professor of Radiology, University of Aberdeen
Alison Murray is the Roland Sutton Professor of Radiology at the University of
Aberdeen. She is Director of the Aberdeen Biomedical Imaging Centre
www.abdn.ac.uk/ims/research/abic, Lilian Sutton Building, University of Aberdeen,
Foresterhill Health Campus. This houses the Philips 3T research magnetic resonance
imaging (MRI) scanner. Research MRI facilities are located within the acute NHS
hospital and are immediately adjacent to the John Mallard Positron Emission
Tomography (PET) Centre and the NHS Department of Nuclear Medicine, facilitating
combined studies of brain structure and function. She leads clinical brain imaging
research in structural and functional imaging correlates of cognitive ageing and
dementia and work includes MRI in the Aberdeen 1936 Birth Cohort, and MRI,
regional cerebral blood flow SPECT and FDG PET in clinical trials of novel Tau
Aggregation Inhibitor therapies in Alzheimer's disease. Particular interests are the
relative contributions of vascular risk factors and subclinical Alzheimer's disease to
cognitive ageing and contributors to cognitive reserve and resilience to dementia.
She is also involved in brain imaging research in other diseases, including CNS
correlates of fatigue in chronic inflammatory diseases and satiety in type 2 diabetes,
using quantitative assessment of disease burden, brain volumes and function.
She has extensive NHS experience of brain imaging in dementia, being responsible
for most NHS referrals for structural and molecular brain imaging including CT,
regional cerebral blood flow SPECT CT and FP-CIT studies.
She is a founding member and executive member of the Scottish Imaging Network:
A Platform for Scientific Excellence (SINAPSE) www.sinapse.ac.uk a successful brain
imaging pooling initiative funded by the Scottish Funding Council and participating
universities to develop state of the art brain imaging research training and resources
across Scotland.
Abstract
Brain imaging in cognitive impairment and dementia - what, when and how?
This presentation will review evidence for brain imaging in cognitive impairment and
dementia, referring to research results, current evidence and national and
international guidelines. The aim is to update participants with new information and
to give a pragmatic overview of whether brain imaging is appropriate in patients with
dementia, if so, when brain imaging should be used and what is practical in a cost
constrained NHS.
Three main learning points will be made initially:
Most dementia related neuropathology is mixed
Most evidence ignores baseline
Currently we cannot diagnose dementia on a scan – even a PET scan!
Following a rapid review of the results of brain imaging research in the Aberdeen
Birth Cohorts, a description of cognitive reserve and how this is crucial to understand
in cognitive ageing and dementia research, what we can and cannot tell from routine
brain images and recent drug development in Alzheimer’s disease, the presentation
will conclude with examples of where brain imaging is useful in dementia and
neurodegenerative diseases and with three more learning points:
Imaging increases diagnostic accuracy
In future role of imaging is likely to be validation of cheaper tests
If we could “bottle” cognitive reserve it would have as much impact as an
effective new drug
Biography
Dr Peter MacLean, Consultant Radiologist, Western General Hospital
Having trained as a Radiologist in Glasgow, I was appointed a Consultant in
Edinburgh in 2007. As a major cancer centre, approximately 50% of my workload is
related to oncology, particularly in the abdomen and pelvis. I have a major interest in
imaging of the small bowel and colon, especially with MR and CT.
Abstract
Update in GI imaging
Scotland has a very high incidence of early onset disease.
Faecal Calprotectin (FC) now used routinely in specialist centres to stratify risk,
monitor response.
MR perfectly placed to image this group – often young and requiring repeated
imaging studies with extra-intestinal manifestations and complications.
Technique overview with brief discussion on IV contrast, DWI, motility studies.
Important signs: mural thickening with stricture, mural oedema and contrast
enhancement.
Recent work on correlating ileal disease with FC shows positive results.
SIGGAR Trial
• Largest randomised controlled trial of CT colon (CTC) vs optical
colonoscopy (OC) and Ba enema in symptomatic patients in the diagnosis
of colonic carcinoma.
• Unique study design with 2 arms.
• CTC much more sensitive than BaE.
• CTC comparable to OC.
• Increased rates of further colonic investigation and apparent drawback of
CTC.
Biography
Dr Dilip Patel, Consultant Radiologist, Royal Infirmary of Edinburgh
Dilip Patel has been a Consultant Radiologist at the Royal Infirmary of Edinburgh for
the past 15 years and is responsible for the Radionuclide Imaging service at that
hospital.
He is Lead Radiologist for the NHS Lothian PET/CT service.
His clinical interests include Upper GI, hepatobiliary, transplant and endocrine
imaging.
Abstract
Selected applications of SPECT-CT
Whilst nuclear medicine imaging techniques provide functional information,
historically this has been at the expense of low anatomical resolution making the
imaging difficult to interpret and utilise for clinicians and non nuclear medicine
radiologists.
The development of high resolution gamma cameras latterly combined with MDCT
scanners has allowed integrated image fusion thus combining the unique functional
information obtained by nuclear medicine with the high resolution anatomical
information derived from CT.
The aim of this presentation is to outline the technique and some of the practical
applications in current clinical use.
Biography
Dr Scott McKie, Consultant MSK Radiologist, Royal Infirmary of Edinburgh
I a Consultant MSK Radiologist in the Royal Infirmary of Edinburgh (3 years), and
prior to this a consultant in NHS Fife (6 years). Radiology trained in Edinburgh and
MSK fellowship in Leeds. Initially embarked on orthopaedic surgical career before
seeing the light. I have a special interest in sports injuries, imaging of the groin and
MSK intervention. Member of British Skeletal Society and Royal College of Physicians
and Surgeons of Glasgow.
Abstract
Imaging of groin pain: Inguinal disruption
Imaging of the groin in the sportsperson is difficult due to the complex anatomy,
with many important structures converging on a very small area which often has pre-
existing abnormalities. This is compounded by the fact that the nomenclature has
been confusing and contradictory. In January 2014 a consensus was published by the
British Hernia Society retiring the diagnosis of "sportsman's hernia" and instead
advising the term "inguinal disruption- ID", referring to the specific diagnosis of
external ring dilatation, conjoint tendon damage, and tears of the inguinal ligament.
This presentation will explain the imaging features of ID on MRI and Ultrasound, and
pictorially review the other potential causes of groin pain in the sportsperson
including osteitis pubis, rectus/adductor tendinosis, stress injuries, ischiofemoral
impingement, true hernias, neural impingement, and referred pain.
In addition there will be a brief outline of the different surgical options and
radiological interventional procedures, although the use of these techniques remains
contentious and controversial.
Biography
Professor Andrew Evans, Professor of Breast Imaging, University of Dundee
Honorary Consultant Radiologist, NHS Tayside
Andy Evans is a graduate of Birmingham Medical School and after gaining his MRCP
trained in Diagnostic Radiology in Nottingham gaining the FRCR. He became a
Consultant Radiologist with a special interest in breast imaging in 1992. He was
appointed Director of the Nottingham International Breast Education Centre in 2006.
In 2009 Andy moved to Dundee to become Professor of Breast Imaging. He is the
author of over 120 peer reviewed papers, 4 books and 14 book chapters. He is the
current chairman of the British Society of Breast Radiology. Andy plays the french
horn and is a successful composer of classical music.
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FORTHCOMING EVENTS
3rd Annual SPECT/CT symposium:
Current status and future directions of SPECT/CT imaging
24 February 2014
London
Multi-parametric imaging of prostate cancer -
can it facilitate a paradigm shift in management?
28 February 2014
London
Biological optimisation of radiotherapy
13 March 2014
London
Paediatric body MRI course
1 April 2014
London
Management and radiology - a guide to current and future management issues in
radiology
2 May 2014
London
Radiotherapy - meeting the current and future workforce challenges for patient
care in a changing context
19 May 2014
London
Molecular radiotherapy dosimetry
4 June 2014
Oxford
Wessex Branch Summer meeting
13 June 2014
Winchester
Optimisation in CT
18 June 2014
Edinburgh
IRMER update
29 September 2014
London
VISIT: WWW.BIR.ORG.UK FOR MORE INFORMATION AND TO REGISTER!
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