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Alive. OK. So we're live a quick check. Can everyone hear us say yes in the chat or say so? Ok, that'll do. Thank you, Nick. So should we get started? Yeah, sure, we can get started. Uh Let me just slides. OK. First off, hi, everyone. So we've got, this is the fourth lecture in our five part lecture series on radiology. And this will be covering into interventional radiology held by Doctor Teja Cobal. He's an fy two doctor working at bars and we've got one more lecture left in part of this uh series that will be on CT scans next Tuesday as well at 6:30 p.m. And just, and these lecture signs are only possible since they're being been working with the British Indian Medical Association or be ma they're a national nonprofit organization on, on developing a supporting network among students, doctors and just generally providing conference events, networking, these tutorial series that you see here and more career talks as well. The best way to keep up to date with that is through Instagram and the other social media. And there's also two links as well in the, the powerpoint for following up on the clinical sy series and also the fundamentals of medicine and pathology. And this is just a bit about Taos. He's a F two doctor and the SFP for the Royal London Hospital and graduated from Kings in 2022. He's been part of B A and B ISA previously as Welfare officer and networking specialist specialties lead. He's got a keen interest in radiology and the use of interventional techniques and the application of A I within radiology as well. And outside of that, he loves hockey and has been playing for GKT through university and quickly just to summarize where we're at, we're at the 24th of October. So we're four out of five into this lecture series. Like I said earlier, our fifth lecture will be on CT scanning and there'll be more lectures on the way on covering other specialties such as gastro neuro respiratory, which so keep in touch with the socials to be updated on those as well. And finally, just a bit of housekeeping do use the chat function and we'll be able to see the que any questions that come up here and I'll be able to forward them to us as well if we, if it looks, if we've just gone past them and if you do want to uh contribute as well, you can also use the mental function as well. So, yeah, I think that's everything it for me. Do you wanna take it away? Yeah. Thank you so much Raki for that introduction and thank you for inviting me back again to deliver this talk. I think GI has mentioned already, this is part of the five lecture series and three have already happened. Um Hopefully, you guys have been able to attend those. I've attended them as well and they've been incredibly high quality and we have our CT lecture next week as well. So this lecture is going to be slightly different from the other three. It's going to be focusing on interventional radiology, looking sort of at the theory behind it as well as some of the clinical applications of it. I think the other lectures in the series focus more on image interpretation. So this one will be slightly different in that regard. Um I think interventional radiology is naturally a very, very growing subspecialty within the UK just what you're able to do with. It is quite incredible. And I think it's very important with clinicians nowadays to understand how it can be used and leverage in clinical practice. So within this lecture, we're gonna focus on four main areas. So we're gonna start off by looking at what is interventional radiology. So giving a brief high level overview. The second area we're going to look at is the pathway to becoming specialized in interventional radiology. I think as you'll see, it's quite a niche path and it is a bit different from the usual radiology applications. The third area we're going to look at is an overview of the common applications of. Ir I think there are so many applications within clinical practice, we won't be able to look at all of them, but we're going to focus on some of the key few ones and try and categorize them. And I think the bulk of the lecture will be taken out by this fourth point. So we're gonna have a detailed look into the most common procedures and this will be done through sort of different cases which I will introduce. So these cases will focus on key clinical examples of how internal radiology will be used in clinical practice. So combining, you know, diagnosing the condition as well as the different procedures that you can use. So what is intervention radiology? So as I mentioned, it's a subspecialty within radiology. It's actually the only formally recognized subspecialty within radiology. I think you have other interests like musculoskeletal breast, but none of those have the formal accreditation and their own sort of training pathway. So at its core, it involves minimally invasive techniques that are an alternative to open surgery. And it's these surgeries using radiological image guidance. So x-rays ultrasounds CT S and MRI S to aid treatment and provide good outcomes. It first developed in the 19 sixties with diagnostic angiography, which is probably the most common use of interventional radiology that most people would know about. Um however, the term itself, interventional radiology was not conceived until March 1967. So as you can see, compared to lots of other medical subspecialties, it's very, very new. I mean, other than interventional radiology, there are only a handful of specialties, you can sort of say have come into practice within the last 50 years. And I think this has really only happened because you've had such an explosion of technology within medicine. When you consider things like ultrasound ct MRI, how recent they've come into clinical practice, you can understand why interventional radiology is so, so new and so up and coming. So, interventional radiologists um have expertise in guiding essentially these small needles and eventually these catheters and other medical equipment into the body, creating these small incisions that can be used to treat disease. Um So when combined with different imaging techniques, it allows clinicians to target specific organs and body systems. So you're able to take multiple images of the body while these needles are in and they focus on the specific organ that you want to target. Um I think one of the main benefits of interventional radiology which we'll come on to is that it has allowed patients who were previously not suitable for traditional surgery to now have these interventions. Um So this is people who for example, may have certain comorbidities like high BM I um might maybe be quite old et cetera who haven't been suitable for normal surgery. And this provides an alternative option for them Um And I think it's also the fact that you're able to have such small equipment within the body highlights the fact that IR is very targeted to specific organs. So it can be used sort of as a standalone procedure or it can be used in combination with surgery. Um So working with the surgeons together to optimize patient care and it can be done in both the elective setting and the emergency setting. I think when a lot of people think of interventional radiology, they think of someone coming in at the middle of the night to put in a stent, but there's also a lot of elective work that is done um for patients. So what are some of the key advantages of intervention radiology? So, like I mentioned, the treatment is very targeted to the specific organ. Um This improves of the accuracy and the effectiveness of the procedure. I think secondly, it has quite a lot of reduced risks compared to surgical options. So if you think about the common surgical um complications that you may have, we're talking about things like significant loss of blood infection, those are quite minimized in intervention radiology because you're entering through a very small area and you're a lot less likely to have these complications arise, you're less likely to damage the relevant tissues. So, thirdly, this is something that we've already touched upon. It's suitability for a wide range of patients. Um So we alluded to this previously, there's a lot of patients for whom traditional surgery is not an option, but interventional radiology will be an option for them due to the fact that it has a reduced risk of these complications. Um which is why I think you're seeing it more and more in clinical practice because we're getting a larger population of patients who are no longer suitable for traditional surgery. Fourthly, there is definitely the faster recovery time. So again, because you're only going through a small area, patients would experience a lot less POSTOP pain and they will require less time, sort of on a hospital bed, not being able to get up on their feet and do their normal activities of daily living. So this benefits both the patient and the hospital obviously because I think we all know there's a massive shortage of NHS beds at the moment, interventional procedures, a lot of them can be done on the day with the patient leaving that same day and going home. And finally, I think this is one area that maybe it's been touched upon as much. But I think the cosmetic aspect can't be ignored. Um So I think anyone who's seen any sort of open surgery understands that it can have quite significant scarring on the skin, um especially when you look at subspecies like S and et cetera, like this aspect is quite important. Um because you're only entering through that small area in interventional radiology, there's only gonna be a tiny, tiny scar that will come up, which can often fade through time. However, that's not to say that it doesn't come with its own downsides within interventional radiology. So I think this term turf wars is quite colloquial. What it essentially means in this context is because interventional radiology of overlaps with a number of traditional specialties. I think there can be quite a lot of politics involved in what is covered by the interventional radiology service and what is covered by different specialties. I think this can vary between different hospitals between different clinicians. Um And because interventional radiology is still growing as a specialty, um I think these will continue in the near future. Um But I think generally there is quite a lot of work to go around for everyone. And I think the role of interventional radiology is highly, highly valued. I think the second thing to be aware of is a lack of patient awareness of the specialty. Um So from my own experience, I've seen this, I did a placement in OPS and Gyne and one of the common intervention radiology procedures is uterine artery embolization and a lot of that's done for fibroids and a lot of patients may not in fact be aware that this is an option. Um And I think because patient choice is so so important nowadays, if patients don't even know that this specialty exists and these procedures exist, then they're not going to ask for it, they're not going to inquire about it. Um And clinicians may not offer it as well to them. And I think finally, this is the big one. So lack of availability across the UK, I'm sure many of you who are currently working as foundation doctors, uni doctors are aware that most hospitals will not offer this 24 7 interventional radiology service. In fact, within most of dear, there'll be maybe one or two hospitals that you'll have to send the patient to which can be quite difficult. And then obviously there's bed situation, lack of clinicians. So I think as especially grows, this will become less of a problem. But at the moment, it is something to be aware of. So you sort of listen to, I have to say your interest in becoming an interventional radiologist, you know that there's quite a few different good points about it. So how can you get into interventional radiology, as I mentioned, it has its own unique pathway which we will take a brief look at right now. So the pathway to becoming a specialist in ir so I think one thing that's very important to stress is that interventional radiology still has diagnostic radiology at its core. I think interventional radiology because of its surgical nature does attract a lot of people who maybe would otherwise um enter surgical training because they feel ok, you know, it has a lot of similarities in that aspect which is true. However, in order to be a good intervention, radiologist, you still need to have quite strong diagnostic skills. Um if you look at the training pathway itself. So after you're done foundation training or the equivalent, you still do the three years of clinical radiology, diagnostic training with everyone else before you then enter the subspecialty training. And this would involve also doing the relevant exams and building your skills in that aspect. So I think this is just to highlight that it's not a specialty for people who just you know, want to do IR itself, it's for people who are primarily interested in diagnostic radiology, but then also want to do these different procedures as well. I think to become an intervention radiologist, you need to apply for SCU and clinical radiology training. So again, same as everyone else, that's quite a competitive process at the moment. Um as I mentioned, they do undertake the same initial training before you then enter ST four. So a couple of other differences between IR and I think normal diagnostic radiology is the ST six aspect. So if you do interventional radiology, you then add an additional year into your training. So normal diagnostic radiology is ST one to ST five. Whereas intervention we add on that ST six year plus minus any fellowship that you might be interested in um because of the growing demand of the specialty. And I think a lack of trainees at the moment who are going into IR there is now the option to select IR themed programs. So these are special programs that are being advertised throughout the UK UK where you have exposure to interventional radiology quite early on. So instead of having to wait until you're much later in your training, you can potentially get placements and opportunities within IR. So if there's anyone who is particularly interested in it from the get go, they can apply for these positions and you become more specialized early on. OK. So moving on to some of the common applications of IR, so as I mentioned, it's a very, very broad subspecialty that involves lots and lots of different aspects. I think it can be quite neatly categorized into these four bits here. So you have vascular intervention, which is arterial venous intervention, then nonvascular intervention, then interventional oncology. I think naturally there's quite a lot of overlap between some of these groups, especially with oncology and maybe some of the vascular interventions. But hopefully this gives you a rough idea of where all the different procedures may fit. So we're just gonna go through some of the key um procedures within each category very quickly. So I think arterial intervention is the most widely known aspect of IR and it's probably the largest single aspect as well making up the bulk of the work um out of these different options here. I think the most well known is angioplasty and stenting but as you can see from the table here, it's covering a wide range of different specialties. So you have treatment for fibroids, treatment for BPH, treatment for gastrointestinal bleeding for trauma. So I think this really highlights how widespread IR is becoming again here. So highlighting some of the other venous interventions. I think just name a few of the more common ones. We have varicocele embolization. Um for urology patients also have other procedures such as portosystemic shunts and inferior vena car filters. I think it's nonvascular interventions as well. Again, I'll just let you read through the list, but these cover again, a wide range of specialties within medicine. Um and again, highlights how there's a lot of different options for people with different special interests. And then finally, I think one area to touch up on is interventional oncology. So this is probably the newer area of inter interventional radiology. So it's essentially using some of these procedures to treat different tumors and sort of providing an alternative to chemotherapy, radiotherapy and surgery or also just working in conjunction with them to treat cancer patients. OK. So moving on to more interactive part of the lecture. So here we have a slide here of probably what is the most common interventional radiology technique that is used in pretty much all of the procedures in some aspect. Does anyone in the chat want to say what the name of this technique is? Just give you guys a minute to put down your thoughts. Yeah. So I think someone has written in the chart here. So the selling a technique uh brilliant. So this technique is essentially the mainstay of vascular and other Luminal access in interventional radiology. So it's essentially a technique for inserting a catheter into the body which will allow sort of safe access for different equipment. So the desired vessel cavity is punctured with a needle. Um and this uses ultrasound if needed to make sure you target in the correct place around guide wire. It's an advance with the lumen of the needle and then the needle is withdrawn and then this sort of blunt cannula can now be passed over the guide wire into the cav to your vessel. So I guess it has some similarities to inserting, you know, a traditional cannula. But the point is you're just creating this area of access, you can pass different bits of equipment through. Ok. So now we're going to look at the different cases here focusing on some of the most common intervention radiology procedures. Um So go through the different cases and I'll get you guys to sort of put down what you think the key diagnosis is, which should be fairly straightforward, I think. But the more complex bit will be what is the different ir procedures that can be used to treat these conditions? So case one here, I think it is a fairly simple one to start off with So a 50 year old male presenting to the emergency department with sudden chest pain. It started two hours ago, background of diabetes and dyslipidemia, different observations are taken as well as different bloods. Um I think the ECG may be quite difficult to interpret on the screen. So I said here we've got ST segment elevation, it leads 23 A VF I've also got a raised troponin. So again, I think it's fairly clear what the diagnosis is. If you guys wanna be very, very specific in the chat as to what this is. And then secondly, just highlight to me what you think the main IR procedure is that can be used to tackle this problem. Ok. Yeah. So I think we've got one in the chart here. So angioplasty. Yeah. So the diagnosis for this would obviously be um ST elevated myocardial infarction because of the leads 23 and A VF being raised. This would actually be an inferior stemi. Um So angioplasty, as I mentioned before, as well as a minimally invasive procedure used to treat an artery which has become blocked or narrowed. Um What it involves is essentially inserting a catheter into a blood vessel, guided towards this blocked artery. And then this catheter will have a tiny balloon at its tip. So once the catheter is in the correct place, you inflate the balloon which gets rid of the narrowing of the artery and making some more room for the flow of blood. So sometimes these balloons themselves are enough. But in the majority of cases, you also need to add a stent in as well. So these stents are these small strong tubes made of metal mesh which are then placed inside the blood vessels to help support the walls from the inside. Um Yeah, as I mentioned, balloons sometimes aren't enough in itself. Um So you need these stents to keep the artery open. So tying back to the diagnostic radiology part of this. So while this procedure is being done, fluoroscopy will be done at the same time. So this is a special type of x-ray that is used during the procedure. And you essentially take multiple x-ray images as you're passing um these materials through the body, which helps the doctor find exactly where the blockage is in the heart. And then there's also a contrast dye which moves through the arteries again, this is just making sure that you're targeting the right area and you don't exactly, you know, go through the vessel or hit any other organs or any other vessels that you don't intend to go to. So here we have a sort of a diagram of how exactly the angioplasty is done. Uh So we can see here the balloon initially opens it up and then the stent stays in place, compressing the plaque and increasing the blood flow. Um I think one of the new in innovations that we have within this is the stents themselves being drug coated. So these essentially improve the durability of the stent and mean that they can stay in for longer because in a lot of cases, eventually you may need the stent sort of replaced or another one inserted. And here we have the actual fluoroscopy images as well. So you see here, we've got the left anterior descending artery and got the circumflex artery. And as the arrows point out, there are two main areas of blockage here, one on the led and one sort of on the junction between those two arteries. And then on the right hand image, you basically see where these narrowings have been removed. And now it's got this increased blood flow to the heart. So this would be done sort of as an emergency if you see a patient coming in with this, this needs to be done as soon as possible. And I guess this ties into the availability of ir you know, will you be able to get the patient there in time or not? So here we have another application of angioplasty, which isn't actually the heart. So this is actually the left common carotid. It's a slightly older case, but essentially what we see here is the left common carotid again, having that narrowing. And we have the insertion of this quite large stent within the artery to again open it up. So you can see in the middle image that sort of jagged image, which is the stent itself and then the artery being opened up in the image further to the right. OK. Brilliant. So we'll just move on to the second case now. So again, if you guys can pop in, I guess, first of all, what do you think the diagnosis could be? And secondly, what the different what the IR procedure is to help manage this. So we have an 86 year old male admitted due to dys urea with gross hematuria for the past three years. Key investigations include a raised ps A um and we have some residual bladder volume after urination. Um We have images from the CT here. So if you wanna pop into the chart, what you think this could be and then also what IR procedure is involved in this. Yeah. So I think we have BPH in the chart which is correct is this is obviously getting a bit harder than the other case. Does anyone know what the interventional procedure is to help treat BP in the context? You know what IR procedure can be used? Yeah. So it's artery embolization. So it's specifically prostate artery embolization of course, but artery embolization is used in a number of different organs used in the uterus, used in other areas as well. Um So this is essentially a treatment that helps, you know, improve lower urinary tract symptoms caused by BPH. I think BPH is quite common in the male population. And in a lot of cases, it is, you know, managed conservatively, but once it starts interfering with the patient quality of life, this is when interventions are needed. So start having urinary incontinence, irritative voiding symptoms, increased urine frequency, urgency and pain. This is when you consider prostate artery embolization. So for pae the small catheter is inserted by the radiologist in an artery, either through your wrist or groin. Um And the key part of this procedure is you have these tiny round microspheres that are injected through the catheter into the blood vessels which basically feed into the prostate and reduce its blood supply. So the key aspect of having BPH is you've got the increased blood supply to the prostate which is causing the enlargement. Once this procedure is done, the prostate will begin to shrink which relieves and improves the symptoms usually within days of the procedure. So again, here we have another quite clear image of how this works. You can see that you have the catheter going in through the right groin heading sort of towards the prostate. And you can see here that the main goal is to actually reach that prostatic artery cause that will be the main blood supply to the prostate itself. So here we have some Lioy images. So it's a bit difficult to tell on the picture. But the yellow arrow is pointing to the obturator artery and the blue arrow is pointing to the prostatic artery. So again, I think this highlights the importance of diagnostics. Again, as the individual radiologist, you need to be able to identify which artery is, which, which isn't the easiest thing. I think if a layperson took a look at these images without the labels, it's very, very unclear what exactly is the correct artery here and what we're looking at um moving to the right side of the image as well. So we've got some arrows highlighting how we got the prostatic artery. And then this massive massive network of capillaries, which is increasing the blood supply to the prostate and would have ultimately led to it increasing in size and causing these symptoms. So, moving on to the third case and we're slowly getting a bit more complicated with the IR procedures here. So again, have a read through the case. Um have a think about what the underlying diagnosis is for this case and you know what technique can be used to treat it. So, 40 year old female presenting due to aching pain, throbbing and itching in the legs and you got these unsightly appearance of the veins on examination, you have a number of different positive findings and on the duplex ultrasound, which is done, you have retrograde venous flow. So I'll just take a minute to see in the chart if there's anything. So, yeah, firstly, you know what is the diagnosis, which I think is a bit more obvious. But secondly, you know what IR procedure can be used. Um Again, they are getting a bit more tricky. So I think, not sure that's completely fine as well. Ok. So I think we've got varicose vein in the chat. Um Does anyone have any idea what the technique is to treat that? Which involves invention? Radiology? Ok. I think, yeah, this is quite comp compared to one. So we'll just move on. So this is a technique called endogenous laser therapy. So traditionally, if anyone understands how varicose veins are treated, usually they're managed with surgical techniques, most commonly a technique known as tying and stripping. So essentially what this would usually involve is you sort of stop blood entering the varicose vein, which the tying aspect and then the stripping is removing it from the body. However, this is actually a very, very expensive time consuming and uncomfortable procedure. And even though you may think, oh yeah, varicose vein is not that significant. Uh You still need to go on a general anesthetic for this and it doesn't necessarily have the best results. So endo venous laser therapy is a new technique that is used is that is using heat from a laser to essentially shrink and enclose the varicose veins from the inside, sealing off the veins and you know, forcing blood to flow through other areas and reducing the outward appearance of the varicose veins. So this one involves the ultrasound quite a lot. It's used to check the location of the varicose veins. Before the procedure is done, you go in to the varicose veins through the knee. So it'll be a tiny cut around the knee under local anesthetic where the catheter is inserted with the laser fiber. Eventually the catheter will be removed and then we have the laser heating up through the length of the vein, closing it up and then it will eventually shrink. Um, um, this procedure is actually quite quick, but it probably needs to be repeated multiple times depending on the number of varicose veins and depending on where exactly they are located on the leg. So here we have a perfect example of how it is done. So you can see the clinician doing it here. They've got the Doppler ultrasound on the one hand, sort of see where the different veins are. They're entering on what appears to be the medial side of the right knee, um entering with that catheter and then they sort of use it to treat some of the varicose veins. Ok. So moving on to the fourth case. So with this one here, I've sort of given the diagnosis already again. I think the challenge here is identifying, you know, what is the technique that can be used there. So we have a 65 year old Caucasian male with known BPH undergoing a renal ultrasound due to urinary tract symptoms, got quite significant past medical history and they found a peripheral tumor on the left kidney and quite a large one when they were doing the CT scan, he's already gone through the discussion, the N BT and they don't think he's suitable for a partial nephrectomy, which is, I guess the usual procedure people have for kidney tumors. So, what are the different options for this patient? Um, I think, think a bit more about, you know, the individual oncology side. So, you know that bucket of IR procedures, what can you be done? What can be done in that to potentially treat this man who appears to not have many other options. Yep. So just looking at the chart now, I think someone's put in tumor ablation, uh which is completely correct. Um Again, because we're working on the kidney specifically here. So this would be kidney tumor ablation. Um So as I touched upon earlier, usually, cancers are treated by, I guess a combination surgery, radiotherapy and chemotherapy depending on location of the tumor. Um You know, the TN staging. Um This is actually an incredible technique which is similar to the last one, uses heat to destroy some of the cancer cells. So if you're using heat, it's called radiofrequency ablation. You can also use something called cryoablation, which essentially the opposite involves using ice to freeze some of the tumors. Um Both of them sort of have a similar procedure. You have the small needles inserted into the tumor, the needles are either be heated or frozen and then it causes damage, which causes the destruction of the cancer cells. So I think the question in everyone's mind is when can we use this method? Because obviously, it probably isn't suitable for every single kind of tumor. Um Generally, this treatment will be reserved for those tumors which are quite small. Um So I know in our last example, the tumor was quite big that that was just an image taken from Google images. But generally, they will need to be between 3 to 5 centimeters in diameter. Um There will also be some other factors considered when deciding or not whether or not this procedure is appropriate. So this will be like I said, the location, the surrounding structures, your health and age, your kidney function, and of course, the most important one is patient preference. So this highlights again, offering the patients this as an option if it's suitable. So this is a really, really good image here, which I've taken from a case report actually, which highlights all the before during and after of kidney tumor ablation. So in this case, we're doing radiofrequency ablation. So we're using heat in the left hand image using the yellow arrow. You can see where that small renal tumor is on the right kidney. The middle image itself that bright white light is essentially the sort of probe going through and passing towards the kidney that would eventually heat up the region. Um It's quite tough, but I'm not sure if anyone knows what the red arrow is representing here. Um, if anyone can put it in the chat, what they think it could be. Otherwise I'll just explain it because I personally wasn't sure what this was either until I looked it up. So I'll just give it about 2030 seconds just in case anyone has some good ideas about what it could be. Ok. Yeah. So, yeah, this is quite complicated. So essentially this is an area called an artificial pneumoperitoneum. So the pneumoperitoneum is essentially, you know, gas that is present in the region. Essentially, this artificial pneumoperitoneum is created by the clinicians and it ensures that other structures that may be around the kidneys are actually pushed away from the kidney. So it essentially avoids the bowel specifically from being damaged by this procedure. Because if you think about, you know, when you interpret a normal CT scan, there will often be sort of bowel quite nearby. And because we're generating quite a lot of heat into the kidney, we want to avoid causing perforation or necrosis to any surrounding bowel that might be there. This is a technique that's quite commonly done. Now, moving on to the picture furthest to the right, you can see here this sort of gray region where the tumor was, this actually represents, you know, the necrosis of the ablation zone. And you know, we still have the artificial pneumoperitoneum there. But you can see how the tumor has actually been um destroyed by the heat from the ablation. Ok. So moving on to our last case here. So again, we have you a 26 year old male presenting with Colicky right lumbar pain radiating to the groin. He's passed some urine, he's passed some blood in his urine. No pain relief is helping him. Um, and the main investigations have shown a raised creatinine and a reduced EGFR and he's had a non-contrast CT performance. Again, I think it's quite clear, you know what the diagnosis is here, if you want to drop it in the chat, but try and be quite specific as to what this is. Um, I think we can all see that there's, you know, some sort of mass there in the kidney, but does anyone know sort of what the clinical name is for this particular mass? And then also, again, what technique can be used to remove it? I think if anyone's looked at past med recently, this is something that's on par med. Definitely, um, if you're revising sort of these masses, so I'll just wait in the chart to see if anyone can. First, we'll put down the specific thing we can see on the CT scan. And secondly, you know how it can be treated. Yep. So, uh this is definitely a kidney stone. Does anyone know, you know what specific type of stones is? It has a very specific name. Um, again, if anyone's done their like medical school finals recently or like looked at past med. It has a very, very specific name. Um Yeah, brilliant. So it's Staghorn. So it's essentially what is known as a Staghorn calculi. And you can see it has these two sort of branches next to each other. Um Brilliant. So the technique that's used for these cases is known as percutaneous nephrolithotomy. So it's essentially the removal of kidney stone. Using this keyhole surgery. we have this fine tube passed from below using an endoscope into the kidney, which is done through the bladder using image guidance. A small cut is made to the back of the kidney and a rigid tube is placed from the skin onto the kidney. A camera is then used to look at the stone which is then fragmented and then removed from the body. And again, like this is something that may need to be repeated multiple times based on how many stones you have um where they're located, et cetera. So I think again, a number of people may be asking here. Ok. There are quite a few different methods for managing kidney stones. I think it's quite a common presentation A&E so sometimes it's just observation with analgesia. So conservative management, sometimes it may need open surgery. Um there's also shock wave treatment. So you know, these, these waves are sent to the stones to break them up and then remove them. I think percutaneous nephrolithotomy has a very specific indication and I've listed a few here, which you need to consider. I think the main one is definitely sort of having these stag corn shaped stones. So this is a type of kidney stone with multiple branches and it often happens due to repeat infection. So you have have people that come in, you know, having these recurrent urinary problems. Um The reason why it's so complex is these branches can very easily block urine from leaving the kidney, which can ultimately lead to kidney failure. And as you can see from the shape, it's not this nice round shape, which may be easier to deal with. It's got all these different branches making it a bit more tricky. And I think this is where interventional radiology basically is used quite effectively. Um So again, you know, if it has a stag one calculi or it's quite complex calculi, that's probably the best opportunity to use this procedure. So I think thank you so much for attending and I know we've gone through a few of the key cases here. Um There's obviously many, many more individual cases, we can't go through all of them because we'll be here for five hours. But hopefully, this is giving you a quick snapshot into the life of individual radiologists. Um Most common ones you're likely to see in your clinical practice and give you a good basis. You know, for those who are interested in specializing into the field. Ok, brilliant. Thank you so much and we'll send the feedback form in now, um which you can use to obtain your certificate. So I'll just stop sharing. OK. Thank you very much. And I'm just also putting the link for the feedback form as well on to the chat. So if everyone wants to just go through it as well, that would be also be helpful. And if is there any, is there anyone who has any questions as well just for, to us as well while we're still here? Ok. Yeah. Um So like I mentioned earlier as well, one more lecture left um in the course. So we have this series next week. So make sure you attend that as well if that would be a really, really good lecture and just one more thing just to ask as well, if it would be, if everyone could just make sure to fill in that feedback form, just as a reminder, you guys do get access to the powerpoint. Do you get access to the recording of this lecture? And also you do uh just do us a favor because it helps for our portfolios as well when we're applying for our specialty training. So it'd be real nice and a certificate comes at the end as well. But is there any other questions just that anyone has? Oh, actually we do MS R A resources do you recommend? And? Oh, ok. Actually, no, we do have OK, there's a few coming in. Ok. What resources do you recommend? Ok. This is, that, that's one of my mates. Um, I'm sure, I'm sure you know what, what resources are needed. Ok. I've got some recommendations at the very least for the MS R A. I've, well, personally I've just been going through any time you need to revise for any exam. Med is a good starting point. First of all, never lets you down, especially since the exam will be split into an SJT portion, which is very much situational based on, I guess it's not really appli applicable for finals anymore since they scrap that exam. But it'll again, just help you get, it'll just simulate word scenarios and what the most appropriate actions are in specific questions can be a bit difficult to narrow down what the exact answer is, but it's def but possible. It's a good starting point. Recommend there's also other resources such as ques me and I think a couple of people I know have also mentioned Emetica as well, but I've not signed on for that. I think really, really just Googling and just getting started from there. And the main thing you'd want to focus on is the uh knowledge based section since that's the other 50% of the exam after the SJT will just be based off your, what your finals will be. So from FFF your finals, it'll just be that same level one more time. It, so it makes up a third of the overall portfolio. So and sadly, in that 3rd, 66% of that does go to the SJT section instead of the knowledge base. But there's nothing we can really do about that. We just have to maximize whatever you can get by just practicing, getting used to questions. Yeah. Um OK, I think we've got another question about the portfolio. So what can a medical student do to make successful portfolio? Um Well, to be honest, you're gonna be applying for like the general radiology positions in the majority. So I think we go through the radio online. It take the week um trying to get public patients, get some experience. Then if you're able to do some teaching on things like IR and attend some of the different si think that will definitely help as well. Um I think, you know, the portfolio is always changing. Um And if you, you get to stage of mind, things may be different. I think those are the standard things that most people do. Um There's a few good conferences online, so I have a good conference, Ir juniors have their conferences. Um It's quite good to go to and then, oh, sorry, sorry. I'm just going through the questions. Do your video of this, please. Um I'm not sure if the video is sent rang. You maybe you, you know, from my understanding, I once you do fill in the feedback form again, the trifecta of the presentation, the rec lecture recording and also a certificate to gets sent to you. It's not, then we'll try and look into it as well, but that should be how it works or so I've been told also just sharing and just to the chat as well. Something that I've been using as well, the portfolio scoring criteria, we get into radiology thing that does, it might uh again, we, this is for the current year but that might change in time, but it is something that's very helpful as well. And one thing it does also recommend is making sure to get try and apply for prizes in radiology or say case reports, essays looking up on the RCR website, Royal College of Radiology should help get some ideas to start from there. Yeah. Um It doesn't look like we have any more questions. You guys, you can fill in the feedback, you really help us and thank you so much for coming. Um Make sure to come. Oh, we got one last one for now. So I missed the other radio series lecture. Is there a way I can have slides to review those sessions? I not 100% sure, but we'll try and get in touch with be a for organizing the lectures and we'll see if that can be arranged as well. Definitely, we do. We, we, we're not gonna try and get uh just keep them locked if we do want to learn then we're certainly gonna try and provide the resources for it. So we'll keep it in mind and get in touch. Thank you. Actually, maybe contact, be a direct uh maybe you on their social media platform or email. And so I might be able to send them over to you. Um Unfortunately, because it was, it was given by lots of different people. Like I personally do not have this li to myself for those other sessions. Um, but there will be a way to get them over. I'm pretty sure is there any other questions from the rest of the team or anyone else is in the chat? Uh, I think that looks ok. All right. Oh, thank you very much to, it was really informative lecture as well. And again, everyone t try to make sure to fill in that feedback form, please for us. And also if you'd like to attend that CT lecture as well, it'll be the last one, on our radiology. Uh Whil Wind Stop Tour, but it will be a really good one. All, all the same. And it's incredibly applicable for your exams and for Fy, and then after that, we'll be going into other topics. I believe the next will be neurology. Thank you very much again.