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Alive. OK. So we're live a quick check. Can everyone hear us say yes in the chat or say something? OK, that'll do. Thank you, Nick. So, so we get started. Yeah, sure, I 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 Tejas Cobal. He's an fy two doctor working at bars and we've got one more lecture left and part of this uh series that will be on CT scans next Tuesday as well at 6:30 p.m. And just, and these exercises are only possible since they being, we've been working with the British Indian Medical Association or be a they're a national nonprofit organization on no developing the supporting network among students, doctors and just generally providing conference events, networking, these tutorials 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, in the powerpoint for following up on the Clinical OY series and also the fundamentals of medicine and pathology. And this is just a bit about uh Tejas. He's af two doctor and the S FP for the Royal London Hospital and graduated from Kings in 2022. He's been part of BA and B ISA previously as Welfare officer and networking and 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 a G KT 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 metal function as well. So, yeah, I think that's everything it for me. Do you wanna take it away. Yeah, thank you so much Ragi for that introduction and thank you for inviting me back again to deliver this talk. I think Ragi has mentioned already, this is part of a 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. Um Just what you're able to do with it is quite incredible. And I think it's very important for clinicians nowadays to understand how it can be used and leverage in clinical practice. So within this lecture, we're going to 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 Iri. 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 up by this fourth point. So we're going to have a detailed look into the most common procedures and this will be done through different cases which I will introduce. So these cases will focus on key clinical examples of how interventional 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 interventional 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. However, the term itself interventional radiology was not conceived until March 1967. So as you can see, compared to lots of other medical sub specialty, it's very, very new. I mean, other than interfacial 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 Mr 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 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. So when combined with different imaging techniques, it allows clinicians to target specific organs and body systems. So you are able to take multiple images of the body while these needles are in and then 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 co morbidities like high BM I um like maybe quite old et cetera who haven't been suitable for normal surgery. And this provides sort of 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 for patients. So what are some of the key advantages of interventional radiology? So, like I mentioned, the treatment is very targeted to the specific organ. This improves 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 complications that you may have, we're talking about things like significant loss of blood infection, those are quite minimized in inter radiology because you are entering through a very small area and you are a lot less likely to have these complications arises, 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 allude to this. Previously, there's a lot of patients for whom traditional surgery is not an option, but information 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 is 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 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 sub specialties like ob 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 downside within interventional radiology. So I think this term turf wars is quite colloquial. What it essentially means in this context is because interventional radiology 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 place in op and Gynae and one of the common interventional 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 that they're not gonna ask for it, they're not going to inquire about it. Um, and clinicians may sort of not offer it as well to them. And I think finally this is the big one, so lack of availability across the UK. Um 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 sort of deaneries, there'll be maybe one or two hospitals that you'll have to send the patient to um which can be quite difficult. And then obviously there's bed situation, lack of clinicians. So I think as the special 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 what I've had to say, you're interested 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 oh ok you know, it has a lot of similarities in that aspect, which is true. However, in order to be a good interventional radiologist, you still need to have quite strong diagnostic skills. Um if you look at the training pathway itself. So after you've 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 the 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 interventional radiologist, you need to apply for SD 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 T one to T five. Whereas intervention will add on that T six year plus minus any fellowships 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 are much later in your training, you can potentially get placements and opportunities within IR. So if there is anyone who is particularly interested in it from the get go, they can apply for these positions and 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 non vascular intervention, then interventional oncology. I think naturally there is 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 got varicocele embolization. Um for urology, patients also have other procedures such as portosystemic shunts and inferior venous cover filters. I think there'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 upon is interventional oncology. So this is probably the newer area of 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 Seldinger 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 safe access for different equipment. So the desired vessel cavity is punctured with a needle and this uses ultrasound if needed to make sure you're talking the correct place around guide wire. It's an advanced to the lumen of the needle and then the needle is withdrawn and then this sort of blunt cannula can now be passed over the guidewire into the cavity or vessel. So I guess it has some similarities to inserting a traditional cannula. But the point is we are just creating this area of access. You can pass different bits of equipment through. Ok. So now we're going to look at different cases here focusing on some of the most common interventional 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 is a fairly simple one to start off with. So a 50 year old male presenting to the emergency department with sudden chest pain that 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've said here, I've got ast segment elevation, it needs 23 aVF 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. Yep. 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 aVF being raised, this would actually be an inferior semi. Um So angioplasty, as I sort of mentioned before as well is 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 it 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 place inside the blood vessels to help support the walls from the inside. Um Yeah, as I mentioned, balloons sometimes aren't enough in itself. 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 there 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 these materials through the body, which helps the doctor find exactly where the blockage is in the heart. And then there is also a contrast dye which moves through the arteries again, this is just making sure that you are targeting the right area and you don't exactly go through the vessel or hit any other organs or any other vessels that you don't intend to go to. So here we are, we sort of a diagram of how exactly the angioplasty is done. Um So you can see here the balloon initially opens it up and that the stent stays in place, compressing the plaque and increasing the blood flow. Um I think one of the new 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 as you see here, we've got the left anterior descending artery and we've got the circumflex artery. And as the arrows point out here, there are two main areas of blockage here, one on the lad 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 will 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 to? 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 you to diarrhea with gross hematuria for the past three years. Key investigations include a raised psa um and we have some residual bladder volume after urination and we have images from the CT here. So if you wanna pop into the chat, what you think this could be and then also what IR procedure is involved in this. Yep. So I think we have B ph in the chat, which is correct as this is obviously getting a bit harder than the other case. Does anyone know what the intervention procedure is to help treat BPH in the context? You know what IR procedure can be used? Yeah. So it's artery embolization. So 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 an 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 you start having urinary incontinence, irritated, voiding symptoms, increased urine frequency, urgency and pain. This is when you consider prostate artery embolization. So for P AE, 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 to increase 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 sort of going in through the right groin heading, sort of towards the prostate. And you can see here that the main goal is to as you reach that prosthetic artery because that will be the main blood supply to the prostate itself. So here we have some arthroscopy 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 prosthetic artery. So again, I think this highlights the importance of diagnostics. Again, um 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 prosthetic artery and then this massive massive network of capillaries, which is increasing the blood supply to the prostate and will 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've 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 you 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 in ventral radiology? Ok, I think, yeah, this is quite a complicated one. So we'll just move on. So this is a technique called endovenous laser therapy. So traditionally, if anyone understands how varicose veins are treated, usually they are managed with surgical techniques, most commonly a technique known as tying and stripping. So essentially what this would usually evolve is you sort of stop blood entering the varicose vein, which is 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, you still need to go on a general anesthetic for this and it doesn't necessarily have the best results. So endovenous laser therapy is a new technique that is that is using heat from a laser to essentially shrink and close the varicose veins from the inside, sealing off the veins and forcing blood to flow through other areas and reducing the outward appearance of the varicose veins. So this one involves do 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 And this procedure is actually quite quick when it will probably need 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 M BT and I 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 intervention oncology sides, 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 chat 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 of surgery, radiotherapy and chemotherapy depending on location of the tumor. Um You know, the TNM 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 either be heated or frozen and then causes this damage which causes the destruction of the cancer cells. So I think the question on 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 of that before, during and after a 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 bowels 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 a 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 is 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 essentially been destroyed by the heat from the ablation. Ok. So, moving on to our last case here. So again, we have 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 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 has looked at pasmed recently, this is something that's on pasmed. Definitely, um if you are revising sort of these masses, so I'll just wait in the chat to see if anyone can, first of all 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 me, 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 stones. 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 for 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 in 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. You know, these, these waves are sent to the stones that 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 staghorn shaped stones. So this is a type of kidney stone with multiple branches and it often happens due to repeat infections. 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. It will 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 gives you good basis, you know, for those who are interested in specializing into the field. OK. Brilliant. Thank you very 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 onto 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 Just like I mentioned earlier, 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 uh if everyone could just make sure to fill in that feedback form, just as a reminder, you guys do get access to the powerpoint, you uh 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 the certificate comes at the end as well. But is there any other questions just that anyone has? Oh, actually we do M sra resources. Do you recommend? And? Oh OK. Actually, no, we do have OK, there's a few coming in, I think. Ok. What resources do you recommend? Ok, this is, that's one of my mates. Um, I'm sure, I'm sure you know what, what resources are needed. Ok. Um, ok, I've got some recommendations at the very least for the M sra I've, well, personally I've just been going through anytime you need to revise for any exam. Possible is a good starting point. First of all, never lets you down, especially since the exam will be split into an S JT portion, which is very much situational based on, uh I guess it's not really apply applicable for finals anymore since they scrapped that exam. But it'll again, just help you get, it'll just simulate board scenarios and what the most appropriate actions are in specific questions. It can be a bit difficult to narrow down what the exact answer is, but it's def but posed is a good starting point. Recommend there's also other resources such as SMED. And I think a couple of people I know have also mentioned em Medica 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 S JT. So we'll just be based off uh your, where your finals will be. So from, if, if f your finals, it'll just be that same level one more time. It's the one it makes up a third of the overall portfolio. So, and sadly, in that 3rd, 66% of that does go to the S JT 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 here about the portfolio. So what can a medical student do to make a successful portfolio? Um Well, to be honest, you're gonna be applying for like general radiology positions in the majority of cases. So I think you go through the radio portfolio online. It's the standard taste the weeks. Um trying to get public to get some experience. Then if you're able to do some teaching on things like IR and attend some of the different conferences, I think that will definitely help as well. Um I think, you know, the portfolio is always changing. Um And if you're and you get to the stage of 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 would be Ir have a good conference. Ir Juniors have their conferences. Um It's quite good to go to and then sorry, sorry, I'm just going through the questions. Um You your video of this, please. Um I'm not too sure if the video is sent, right? Maybe you, you know, so my understanding a uh I want you to fill in the feedback form again, the trifecta of the presentation, the rec lecture recording and also a certificate to get sent to you. If 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 from getting into radiology thing that does it might 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 to apply for prizes in radiology or say case reports, essays is 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 could fill in the feedback will really help us and thank you so much for coming. Um Make sure to come. 01 last one I was now. So I missed the other radiology series lecture. Is there a way I can have slides to review those sessions? I not 1% sure, but we'll try and get in touch with be for organizing the lectures and we'll see if that can be arranged as Well, definitely we do. 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. Potential. Maybe contact beer directly. Uh Maybe one of their social media platforms 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 the slides 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 in the chat? No, I think that looks ok. Right. Hello. Thank you very much. It was a really informative lecture as well. And again, everyone tr try to make sure to fill in that back 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, a whirlwind stop tour, but it will be a really good one 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.