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Good morning, everyone and welcome to Rise Rise 20 to my name is now. You're very welcome along to uh 2020 2022 edition of, of this event. Delighted to have you here with us, whether you're watching it live or you're turning in on the catch up material later on. So I'm just going to, first of all, I guess, introduce myself. So we'll go to the next slide there, please. Um So as I said, my name is Nyla. I'm currently an F two in London at the moment. Uh But starting radiology training in Edinburgh in August, uh The Rise Project is something that I started in Edinburgh back in 2017 with the first event in 2018. Um And since then, have been involved in the, the in setting up. I are juniors, which is another group kind of dedicated to raising the profile of interventional radiology to medical students, junior doctors around the country as well. But uh delighted to be back here for another edition of, of Rise. And obviously, we're, we're keeping our fingers crossed that this will be the last fully virtual meeting that we have to hold. We'll go on to the next slide, please. So as I was saying, started in 2017, the trigger being that I was a medical student and noticed that there was quite a a scarcity of of radiology and interventional radiology exposure as, as medical students uh in in that university. But also it was something from talking to other people and going to different meetings that it wasn't just unique to Edinburgh. So I decided that it would be a good idea to kind of develop a symposium that would kind of bring medical students together junior doctors together. And as as time went on, I realized that there was a lot of kind of really enthusiastic and interested trainees and consultants around the country who were quite interested in, in kind of delivering these type of events. So that was where rise 18 and rise 19 came from. From the first two events. We had quite a nice bit of success with, with some, you know, awards from NHS Education Scotland, the grant from the University of Edinburgh and recognized by Cersei. So it was all gearing up for quite a big rise 20 with a lot of kind of hands on workshops, a lot of interventional radiology industry involvement. And then unfortunately, we obviously came across the pandemic in 2020 as a replacement for the Rise 20 event. We did a Taster webinar series which you will have access to watch back on today, which touched on three main areas of interventional radiology practice. So uh interventional pediatric, radiology, interventional oncology, and general and Venus, I are so I do recommend over the weekend if you get a chance to go back and have a watch of those who've got some great speakers on those three webinars recorded webinars. But yet I guess the, the event itself and, and the ongoing um events that we run to, to the last year's would not be possible without the support from many Edinburgh trainees, radiology trainees and consultants. And I'm actually very glad as we move through in a minute to tell you that we have two former trainees who helped set up this initiative who are now consultants uh presenting today. And yet through the last few years, we've had collaborations and affiliations with lots of local national and international society. So the Scottish Radiological Society, the British Society of Interventional Radiology. I are juniors, as I've mentioned, the British Institute of Radiology and Cersei, which is the European body as well. So we'll go to the next slide there. Just a few notes really just for anyone, obviously, the the the main target of the audience today is medical students and junior doctors. So a few kind of notices for, for that community, particularly the UK I are juniors, as I mentioned is a group that I've been involved in it since its inception. And uh we have a great team now who kind of deliver education events, uh and a lot of kind of medical student engagement and we're looking to expand that team. So if you keep an eye on the I R junior social media, and obviously there's an E U R L link there as well. If you want to get involved and pop onto, I are juniors dot com to find out about more, more about what we do next slide, please. Just another mention on the I R junior side is that we've got an educational, um, series ongoing at the moment called I R Bites, which is most Thursday evenings. I think we're missing this Thursday evening, but we'll be back next Thursday where we cover an element of the source, a medical student curriculum on each, each Thursday evening. So we've already covered peripheral arterial disease and uterine fibroid embolization and we'll continue on through the rest of the curriculum. So just to try and I guess these, these things that are supposed that medical students should pose supposedly be aware of but aren't really taught in medical school. So we're, we're doing that at the moment. And again, all of these will be available for ketchup on medal. So the same platform that you're using right now, next slide, uh the S R T are good friends of ours as well. We've kind of collaborated with them over the last few years. So that's the Society of Radiologists in Training, which is under the auspices of the Royal College of Radiology, they've got an upcoming uh virtual event, they're virtual conferences on in June. So I'd recommend having an eye on that and, and I'm pretty sure there's, there's reduced entry for medical students and, and pre trainees as well. So do have a look at that on their social media. Uh Next slide. Yeah. And then if you've been following us on social media at all, you will have seen that we're supporting worldwide Radiology, which is a great charity which aims to kind of ensure more equal access to quality healthcare in the form of particularly imaging related uh services in the, in the in lower middle income countries. Last year, we supported project Malawi, which was uh it was a great success in terms of people who, who are attending the symposium donating in lieu of giving a registration fee. And we're actually asking if possible that people would do the same again today. Obviously, there's quite a bit of effort that goes on behind the scenes to deliver these events. So if you enjoy the event, um if you have something to spare, anything will help. Obviously, you can scan the QR code or go to just giving dot com slash rise 22. Um That um we have a speaker later on in the in the program. Uh Doctor do body from Edinburgh, who's one of the education leads Royal Royal Radiology will be talking specifically about the sound sonography project in Ghana for which the money will go towards today. And also the on the catch up area, you'll see that. There's the last last years talk from the, the founder of worldwide radiology, Liz Yolks and one of the radiologists based in Malawi Caron Cake Cootie. They did an excellent talk in the context of the rise 21 event. So I've met that available again this year for people to watch back and just see the great work obviously that that charity is doing next slide. Uh Sore eyes 23 I think we're all keeping our fingers crossed that we're going to go back to a live or hybrid event. I think there's some talk going on behind the scenes about working with metal, which is this, hopefully uh it is a great interface and hopefully it's coming across to you well today as well. Um That will hopefully be able to at least go hybrid because obviously, we have been able to reach people across the world with, with going virtual over the last two years with both rise and the other eye are juniors events. So I'm hoping that we can continue to keep the global audience but go back towards having more live, a live version of rise in 23. So please do think about joining us in Edinburgh and we'll be aiming for April again in 2023. If you're interested in joining us, helping us run that event. Obviously, we do um need people to help us with those things. And if you're interested, motivated, then do reach out to us on, on the email there and obviously keep following us on all the social media's next slide. Finally, just a word of thanks to the Edinburgh University Radiology Society Committee who's been helping me behind the scenes, putting this all together. Um They've been doing great work. So thank you very much to them, all of our speakers. Obviously, it's um you know, the time that they have to put aside our, that they've decided to put aside to, to put together these talks for you today. So I want to thank them very much for that time. They've given us the medal team who have been great in, in helping us behind the scenes from a tech side. And hopefully that will um uh our, our collaboration and religion will continue with them into the future. We're looking forward to working with them on rise 23 the rise 21 faculty. So obviously, this is last year's event, but a lot of the workshops and talks which were presented live last year and as part of the on demand session are available that again this year as with the Taste or faculty. So that was the webinar series, the IR based webinar series with the British Institute of Radiology, which I hosted back in 2020. So in, in that we're making all of that material available to you across the weekend. I want to thank the faculties of both of those and obviously to yourself these events, we don't kind of take the decision lightly to try and put, put on a virtual event unless we feel that we can kind of do it justice. So I, I do hope you enjoy to enjoy today. And thank you very much for your interest and your ongoing support and next slide, please. So this is the outline of today. I do apologize. It's a little bit late getting out. We were just kind of finalizing some speaker times but essentially will be kicking off in a few moments with Doctor Derrick Smith, moving on to our doctor, Doctor Dunleavy, who's our speaker from across the pond in the U S A. And then doctor Kind doctor Kirsten kind who has been heavily involved with rise through the years and now a consultant, pediatric radiologist will be speaking after the break. And then we'll have Doctor David E who is going to talk about worldwide radiology and specifically project the Sound Sonography project in Ghana. And then I'll come back on at the end and just talk about the on demand section, all of the, all of the material that will be available over the weekend and there'll be some, there'll be a networking room essentially if anyone wants to come and have a bit of a chat with myself and the rest of the team at the end. So next slide, please. So now I want to introduce the first speaker. Um I want to thank Dr Derrick Smith very much for his time in putting this, this talk together. Um He's going to be talking about on oncological imaging. So, NeuroOncology, imaging and Derek has been involved again with Rice since it's been its inception when he was a trainee in Edinburgh, as, as, as you'll hear in a moment and absolutely delighted to have him back. He's also as well as being consulted, neuroradiologist. He's also heavily involved in radio pedia, um which is a great resource if you haven't used it already. I'm sure you're all aware of it, but I'm going to hand over to Derek uh and, and let, let him teach you a little bit about NeuroOncology and we'll see you in a little while. Hi, I'm Derek Smith. I'm a consultant neuroradiologist, working in the Department of Clinical Neurosciences in Edinburgh. And this session, I'm going to be speaking about imaging in NeuroOncology. I'm delighted to again be speaking out rise. This is a fantastic conference which has been arranged by some really dedicated medical students and now junior doctors and, and Edinburgh's a great city to come to. If you do get the chance, there's not many cities where you have a volcano and a castle within a couple of miles of each other. As for my background, Edinburgh's not always as sunny as that previous picture who was me on my birthday a couple of years ago, you can just see the castle through the clouds in the background. Um I first came to Edinburgh for medical school in 2007, did all my foundation jobs in around Edinburgh and started my radiology training in Southeast Scotland in 2015. Long way, I've done a couple of years of medical education and teaching and I started as a consultant neuroradiologist in August 2021. If we think of that timeline in a more longitudinal way, we're now at the far right side uh in 2022. And it's interesting to think that the first rise meeting was in 2018. So midway through my radiology training, and you guys are now attending somewhere in your medical school or early clinical practice. And so you guys have got sort of 5, 10 years ahead of most of uh the consultant group. You're going to be speaking to you today. So I want to spend this half hour talking about many ways that imaging is used in every stage of NeuroOncology. Imaging. Uh It's a central role in the diagnosis is use in the planning and intervention uh treatment of these tumor's as well as the important role that it plays in follow up both in the immediate and long term management of these patient's. Here's another sunny day in Edinburgh with a romantic artist interpretation of our new building. This is our Department of Clinical Neurosciences. This is also the home for the Edinburgh Center for NeuroOncology, which is shared with the Western General in Edinburgh. And with this, we cover a territory population of nearly two million patients' across South East Scotland. We have 20 consultant neuro radiologists and four core radiologists who attend and deliver the imaging from the weekly oncology meeting. And this is a really important multidisciplinary meeting with oncologists, surgeons, neurologists, pathologists ourselves in radiology, as well as the number of nursing and other support team who help to look after and manage the care of our brain tumor patient's across South East Scotland. Edinburgh is one of the 11 centers in the UK as well to be recognized as one of the first Tessa Jowell Centers of Excellence now. And some of you may remember Tessa Jowell as a minister in the late last labor government who herself developed and unfortunately died from uh glioblastoma and part of her campaign in the House of Lords and some that her family is taken on the future is improving the care and education for doctors and looking after brain super patient's and for the patient's themselves. And it's something which in Edinburgh, all of our units including radiology was recognized as being a center of excellence for which we're very proud of and look to continue. Thankfully, brain tumors are not an everyday occurrence with this rate of between 5 to 8 cases per 100,000 in the population. This works out for our unit being 2 to 3 new cases of high grade lyle tumor's a week. And uh, but that's for our advanced neuro radiology center. If you think about G P, they may come across four or five of these as a new diagnosis in their entire lifetime in Children. Brain tumors are the most common pediatric solid tumor. But we're not going to be talking about pediatric cases today, but there's still a significant cause of morbidity and mortality and adults and lead to the most years lost. If you think about the population who develop these as well. Despite advances, the one year survival still only around 40%. And depending on the cell type and grade of tumor, which we'll discuss. The five year survival can be still quite poor. If we think about how these tumors present, the findings are really quite nonspecific. Despite um the size of some of these things, only a quarter of patient's may initially have a headache, seizures and focal onset neurological deficits are common. And that's usually because of the cortical location of some of these lesions, which can lead to these seizures and acute presentations. By the time that these cases reach hospital or tertiary care presentation, these symptoms usually progressed with half of patient's experience experiencing headaches symptoms and we were concerned about early morning headaches. Uh the majority will have a focal deficit of some sort and actually quite a lot of patients will have nonfocal symptoms will be behavioral changes or cognitive abnormalities. Another important group to consider are those with intracranial metastases from cancers. Elsewhere in the body, with nearly 40% of cancer cases having brain metastases either picked up clinically or uh in postmortem. And it's more because nearly three quarters of these can be a symptomatic presentation. And it's part of this reason that we in our unit at least perform um contrast CT head as part of the staging protocols for newly detected lung cancers and surveillance of melanomas. So now we get to move on to looking at the imaging and you can see it's not all black and white, but we're gonna walk through the main workhorses of imaging which are CT and MRI. Now, CT computer tomography is a great tool. Um The benefits of it uh include the fact that it's available in nearly every hospital. Most emergency departments have ready access to CT scanners or even have scanners within the units themselves most with 24 7 access as well. Although for metastatic disease contrast enhanced imaging is useful, it's also really useful to have an un enhanced study. Um So our standard protocol would be to do an UN enhanced CT head and then repeat contrast imaging after five minutes delay and often body imaging will be performed at the same time, which is especially important when trying to assess if this is metastatic disease. Now, although CT does have some limits that is very useful at helping show both the location and also the side effects of these masses. And in this case, this is a patient who has uh tumor centered on the right side of their corpus callosum. Um but they've also got hydrocephalus. So there's distention of the temporal horns. Third ventricle is a bit widened as well. And there's a possibility that this tumor here maybe seeding elsewhere in the CSF which could be further guided and identified with MRI. So, Emory gives us a far better assessment of intracranial disease generally and particularly brain tumors. And it also gives us farmer information, the behavior of lesion's both the enhancement cellularity, uh certain methods will help us gauge the vascularity of lesions as well. And also importantly, the effect on the adjacent bring our typical protocol takes about 25 to 30 minutes to deliver. However, in our specialist center, we also have a number of other sequences and techniques that we like to use. Um And uh this can add on time but also gives uh phenomenal amounts of information that help us process and uh deliver information to the clinical teams which go on to inform the management. And we're going to talk about some of these more advanced techniques towards the end of this talk as well. So for the standard sequences, one of the workhorses is T T imaging. Um I'm not going to go into a breakdown of em are physics because we've only got half an hour in this session. But things to note is that fluid is bright. So CSF is bright and then edema in the brain is bright as well. And TT is really useful to show the presence of cysts within tumor's a Dema in the adjacent tissues. And we can also get an idea of major blood vessels or evidence of bleeding within lesions on T two. What we more commonly uses flare imaging, which is a cousin of T two. So this is the same case where again, the gray matter, the cortex is brighter than the white matter. Um But here we can see that the fluid in the CSF has been suppressed. So that's what flare stands for its fluid attenuated inversion recovery. Um It can show a Dema but also it shows more appreciation of the nonenhancing tumor, which is important in cli I'll series tumor's diffusion imaging with D W I and A D C is also really useful. Um This is more commonly used and uh studied in stroke disease, but we can use A D C values um to give some impression of the cellularity of tumor's. And this can also be used in grading gliomas. The T one weighted imaging fluid is dark again, but fat and blood is bright this time. And it's also particularly useful to show the contrast effects. So this is the pre and post contrast study, the same patient, we can see that this lesion in the close man thalamus is enhancing as well as that. We've got extension of enhancing tissue around the ependymal surface of the right lateral ventricle. And that's also another poor prognostic marker. So we've dipped our feet in with MRI and we'll move on to look at some of the diagnoses that we see. And these diagnoses are governed by W H O and they released the fifth edition of brain tumor classification in 2021. Now, we do not have the time or understanding to cover all of these uh 109 different diagnoses that neuro radiologist and your oncologist need to be able to deal with and know about. But within this, there are some important ones that we're going to spend some time looking at, which are the adult type, diffuse gliomas, meningiomas, metastases and lymphomas. And these are the, the communist tumors that we see in clinical practice. So many NGOS are common, they're typically benign lesion's and they get more common as you get older. But we can also see some increase in size during pregnancy. So they do affect at any age, they're typically benign and, and there are thickening and growth of dural cells. So they are usually peripherally located but they can in surrounding the brain and the meninges, they do go down the spine, but they can work themselves into other funny nooks and crannies where we know that we've got dura sitting there, usually isolated but they can be associated with other syndromes, particularly thing about neurofibromatosis type two. Again, CT is a great tool for the detection assessment and follow up of meningiomas. Uh This is quite a large case without uh slightly hypodense lesion compared to the adjacent brain. And we can see that it's causing mass effect. There is a a Dema underlying this in reaction. When contrast is administered, we get this more typical appearance with this really quite solid looking homogeneous, enhancing mass in the extra axial space. Another useful sign that we see with meningiomas and some other dural based lesion's is the dural tail. And this is a reaction where we have the growth of the tumor but also as part of the the kind of vascularity and uptake of the adjacent meninges, we get this enhancing tail uh which can be a useful sign to help identify this has been typically an extra axial lesion as well. In some cases, you can see changes in the bone on CT with high pressed acis as a reaction to the tumor growth. As I said, these meningiomas can grow in funny places. So this one is down in the cerebellopontine angle. And you can imagine this will lead to issues not just with obstruction and hydro careful is, but we can see that there's displacement and compression of the right middle cerebellar peduncle, but there's also the risk of cranial nerve injury and also vascular risks as this is uh pushing on the basilar artery and the smaller branches. And here's a case of an optic nerve meningioma because we have to remember that the optic nerves are also lined by dura. So meningiomas can develop here with textbook tram track appearance. I said earlier, metastases are common. Um and the common cancers can metastasize. So, lung and breast cancer, the commonest cases that we see um followed by renal cell carcinoma, melanomas and G I tract. Typically colorectal tumor's other tumors include thyroid and choriocarcinoma, which have risks of bleeding. And these lesions are usually peripheral subcortical. It can be multiple. This one's an enhancing tumor. But what we see is kind of disproportionate edema around this lesion because this is essentially a foreign body in the brain and you're going to get a foreign body reaction to this. So, if we look through one of these cases on radio PD, um this is a patient with a known history of breast cancer presenting with headaches and on the un enhanced CT scan, we see there's abnormalities in this right temporal lobe and coming further up. Again, we have this change in the white matter. It's something possibly here in the Pridol exceptional region and extending all the way up. So this patient was given contrast and they showed that there are multiple enhancing lesions. So the reason that looked dense on the an enhanced CT here as well as a large uh lesion in the medial temporal open hippocampus to this patient may be having memory issues as well as the effects of the mass effect of the tumor's in. Here. There's another patient with breast cancer and headaches. As we scroll through this flare, we start to see that there's not much space around the peripheries of the brain. So we've got probable cycle effacement within large ventricles and evidence of trans bendable shift. So this is CSF being squeezed out of the ventricles into the brain due to obstruction, lower down. Now tricky to see if there's a mass there. So when contrast was given what it actually it reveals is multiple diffuse metastases scattered throughout the brain probably within the CSF spaces as well. Um But also this heavy load within the posterior fossa. So this is really extensive disseminated intracranial metastatic disease. Cns lymphoma is another important group of tumor's again rarer. Um But these are, I've got some key imaging features which are useful to know about. These two are typically solid and cellular with hyperdense and enhancing masses and also restricted diffusion and cellularity. So, here's a case of CNS lymphoma on CT in contrast and given, and these tumors have said are usually hyperdense and can show enhancement on CT. And this is important with the location of this. This is sitting within the splenium. Um And this is different to metastases which tend to go around the peripheries and don't involve the splenium and the corpus close in between both sides of the brain. And again, RMR sequences show this lesion, expanding the brain here with Dema on flare and on to one, this is difficult to make out from adjacent normal brain. But when contrast is provided, we see that there's this homogeneous enhancement. This solid tumor is also tumor around the anterior horns of the lateral ventricles. One of the key things again, as I said is the diffusion pattern and this signal here is far lower than anything else we can see in the rest of the brain which tells us that this is a densely packed small cell tumor compatible with lymphoma. These tumors are typically treated with radiotherapy, but they're also usually steroid sensitive. And if steroids are given before a tissue diagnosis is made, the tumor can melt away which can limit ongoing treatment options. So it's always important to get these cases discussed in a neuro oncology center before starting treatment. So we move on to the main group of these tumors which are the gliomas. Um And there's lots of terminology that we use here. Low, high grade astrocytoma, oligodendroglioma, glioblastoma. And also genetics, which we're gonna have briefly touch on again later on lower grade gliomas are an important group of tumor's to know about. There's a broad range of them. These typically affect younger patient with a median age of 40 and these can present with seizures and nonfocal neurology and what's the key things about them on uh pathologies that there's no micro vascularity and necrosis. So these can be diffuse processes. But if there's uh none of these aggressive features, they usually have a very good survival and, but need close follow up. This case is a well recognized sign in um uh what's called astrocytoma. Zor noncoital, eat it. Toomer's of the bright T two cystic appearance and then the internal suppression on flare. So this is the t to flare, mismatched sign and lower grade Cheever's one of the other cell types to know about our oligodendroglioma as and these are one p 19 Cuco deleted tumors. And now these are cortically based and they can typically calcify, which is an important reason to do an enhanced CT in these. Um and these drugs can enhance and have increased perfusion even at lower grade. Um and all good. And Reglan was only, it can be grade two or grade three and usually have better survival than glioblastomas. So, move on to look at higher grade Lima's. So W H O grade three or four. And pathologically, these features include increase mitosis anaplasia with grade three tumor is being called anaplastic tumor's vascular proliferation and then necrosis and grade three tumor's have a lower five year survival than the lower grade tumor's. But when we get down to grade four tumor's or glad blast home is these use level, very poor long term outcome and high grade tumor are typically far more aggressive looking on imaging than lower grades and also tend to present with worse symptoms. Usually again, maybe a history of headaches and seizures, focal neurological deficits. And these are tumor's which look more organized, have peripheral nodular enhancement. Again, sitting centrally unlike metastases. And this one here has got enhancement along a biopsy tract. And this is a what used to be called a Butterfly Glow um involving both sides of the brain. So we've dipped our toes into tumor imaging, looking at the common diagnoses of metastases, meningiomas and lymphoma. And we're going to take a deeper dive. Now, thinking about low grade and high grade gliomas and particularly their genetics doesn't change much about the imaging, but this is a developing area which is impacting the management of these patient's with brain tumor's. Most of the terminology in terms of cell type and grading in the W H O classification is reliant on pathology. And it's been through the development and advances in pathological methods as well as more of an understanding of the genetics involved, which leads to the new way that we talk about brain tumors. So this complicated graphic is actually a simplified version. Um This was produced by one of my radiology colleagues in Australia. And once we identify what the tumor type is, make sure it's not metastases a lymphoma and looks like a glioma under the slides. There's this whole raft of genetic tests that can be performed in these samples which really have a massive change in the outcome for these patient's, particularly in terms of the prognosis and ongoing management. So, on top and bottom, here, we have two low grade glioma series tumor's and this is the one on the top row is one that we've already seen with the T to flare mismatch. We said this is typical of astrocytoma as um there's no uh cellularity on the A D C map and no abnormal enhancement post contrast. And when we fuse this with perfusion maps, we can see that there's no regions of increased terrible blood volume. So these are all good uh kind of low grade features. The one on the bottom road, slightly different. It's a bit more cortically based. We can get the impression that the cortex is swollen here with changes in the underlying white matter seeing on T two and flare again, no low centers, unlike the lymphoma on the A D C map and no significant regions of enhancement. But on profusion, there are some folk i of increased cerebral blood volume. But if you remember, we said that the oligodendroglioma is which is what this is, can have profusion and enhancement at lower grades. So in the old money, the top one would have been called an astrocytoma grade to the lower one and oligodendroglioma grade two and the follow up management would have been fairly similar for both of them. However, it's not the case anymore with these new genetic tests that are available to us. The top one is a lot more chunkier. It doesn't trip off the tongue, but it's a far more detailed and accurate name for the disease in the process and prognosis for this patient as a diffuse astrocytoma I D H 1 80 Rx mutant one B 19. Cute non code elated tumor W H O C N S grade two. And our bottom uh tumor here is an oligodendroglioma I D H one mutant one P 19 Cuco deleted W H O C N S grade two. It gets more confusing when we come to our higher grade tumor is now. So these are both glioblastomas or they certainly were the one on the top row as this organized right frontal tumor with a bit of surrounding white matter change, either A DM or infiltrating tumor. Small regions of this look cellular with reduced A D C and there's no blood on the hyper intense or hyperintensity on the precontrast T one. But where this thick nodular peripheral enhancement and these appearances are all compatible with glioblastoma. The bottom one has also got this enhancing nodular component again, with this dense low A D C value and surrounding white matter change. Some of you may have noticed that there's a small reception capital anterior to this. You can see where the small skull defect was because this patient had a previous low grade tumor and astrocytoma which had been resected. And after a few years of follow up, this enhancing nodule was detected and patient went on to have further debulking of this. Now, in old money, as I said, these both would have been glioblastoma grade four tumor's, but that's not what it is anymore. This one at the top is still a glioblastoma, but one of the first genetic test has said is I D H and this is an I D H wild type W H O C N S grade four. And this one at the bottom which has developed or transformed from old, low grade glioma could, could have been called a secondary glioblastoma. Previously, is now a diffuse astrocytoma I D H one mutant one P 19 Q, noncoital eat a W H O C N S grade four. And this tumor down the bottom has got a far better um prognosis and outlook than the wild type glioblastomas. And this has been one of the main changes in the 2021 update. So these are things which we as radiologists have to appreciate and try to uh identify signs of low grade disease or prior disease knowing that there's a significant prognostic and management changes that can come from it. And we work on this with our MDT. So speaking of the MDT imaging, an essential part of surgical planning and also planning for radiotherapy management. So not only do our structural sequences help show where the actual tumor is and the effect on the adjacent brain and local structures. We also have a number of advanced techniques that can help a treatment planning. One of the main techniques that we use in our center is perfusion MRI and this is useful both in the preoctive planning of lower grade or transforming tumor's and also follow up following treatment for higher grade tumours is particularly to help discriminate between treatment related effects or disease recurrence. There are three main methods. Essentially, these all give us an idea of the vascularity of tumours bearing in mind that high grade tumor is have this microvascular proliferation, essentially neo vascularity and increased perfusion markers. So here's a case with a higher grade glioma and they have more extensive disease superior early which I'm not showing. But there's this nice hyper enhancing dot in the patient's external capsule on the right hand side. And when we run one of our profusion methods, the arterials been labeling to show a cerebral blood flow. This is significantly higher than normal, appearing adjacent background brain. And the other main method we use is dynamic susceptibility contrast or uh measure of relative cerebral blood volume. And what this shows is this lesion here corresponds to this green line and the area under the curve is so much higher than normal, appearing white matter and even normal appearing grey matter, which shows us that this is a hyper vascular lesion um with high blood flow and high blood volume and is a sign of high grade disease. Other advanced techniques include functional MRI. And here we can stimulate the speech and motor centers with the patient in the scan er by asking them to do tasks and this causes increased blood flow which we can monitor in these regions, which helped to map out the brain um to help the surgical team plan their section margins. Another method looking at nerve bundle track direction is diffusion tensor imaging. Um Now, this provides these really colorful maps which can also make good album covers. This is uh the cover for muses. The second law going back to prognosis. One of the main areas that imaging has a research basin is immediate postoperative imaging. So, imaging within 72 hours or three days of tumor resection, and what we can do is help to quantify the extent of resected tumour and with those less than 50% having a poor prognosis and those are greater than 90 or as much as possible having a better prognosis. So this patient has this uh left insular temporal tumor again, glioblastoma, thick nodular enhancement. And there's been a good attempt at reception here debulking with rind around the posterior margin, but this is close to speech center. So it's understandable, this wouldn't want to be damaged and this patient had a 52 90% reception of enhancing tissue. This patient had this large grade three co deleted tumor. This uh quite extensive enhancing pattern and post operatively. Although the reception cavities 70 there's all this hyperintense T one um tissue around the margin which was concerning for residual tumor. But you have to look at the pre contrast imaging as well. You can see the blood vessels haven't enhanced, but the margins here are bright on T one. So this is all compatible with blood products. So this patient had barely any residual enhancing tumour, so greater than 90% good surgical resection. Um Although you can go in and try and resect some of the tumour, the tumor itself can grow in the meantime. Um as we can see what this one has got this uh multifocal tumor and this resulted in a less than 50% resection of the enhancing tumor. So, imaging is one of the key parts of tumor follow up along with regular clinical review and this is the nice guidance which was updated in 2021. Uh looking at the genetic types of these tumor's as saying it's important for our imaging and the time course that we should be imaging these patient's on while some of these lower grade tumor can take decades to progress. Once you have a high grade tumor, uh we keep a close eye on you. So this was a glioblastoma which was resected and the patient had adjuvant chemotherapy and radiotherapy courses. And at the end of six months of imaging, though the reception cavity still had some minor enhancement around it. There was this new enhancing region which was thought possibly to be within the uh treatment zones, possibly treat related effects. I was brought back just a few months later. And this shows this mixed response here but also in new regions of solid enhancing tissue, which was confirmed on profusion imaging has been hypervascular. So this case was uh confirmed his disease progression in a short interval. Even longer term. We can see radiation effects. And uh these patient's had crania spinal radiation as Children with development of secondary tumor. So these are meningioma is which we can see also can get cavern omagh's and disturbed and vascular disturbance, a high risk of stroke or you can have these um smart attacks. And this is a stroke like migraine after radiotherapy, which is uh kind of a rare but recognized by product of tumor treatment. So in summary brain shaper imaging overall, these are very rare lesion's but imaging is essentially every part from diagnosis, treatment planning follow up in after effects over a long course of time. Um This is a field which is always developing um with the latest update, bringing us new terminologies. Um and over 100 different diagnoses to know about. Um but in imaging, as well as pathology, surgery and oncology, we have a number of developing new technologies and techniques to help us work with these and deliver the best care for our patient's. I hope you've enjoyed this talk and find at least bits of it useful. It does go heavy on the genetics and advances, but it's developing field which will probably have changed by the time that you start doing your neuro radiology practice yourself. Um Here's a link to a QR code which has got links to my Twitter where I've provided some of the references and useful links for brain tumor interpretation imaging. Um And of course, if you have any questions, please feel free to either use the hashtag Rise 22 or just get in touch with me directly on Twitter. And I hope you enjoy the rest of your day. So thank you very much to Derrick for putting together that talk. Derek is, is not with us as he's kind of mentioned there uh to answer questions moment, but he has obviously said that he's more than happy to answer any questions that people have on his Twitter. So if you use the hashtag rise 22 you'll get him at Derek Rad on Twitter, so you can ask any questions you have there if you want to kind of any comments or, or, or feedback you have for him there. So I'm going to hand over David, who's going to introduce our next speaker. Hello, everyone. I'm David. I'm the presidente of the Edinburgh University Radiology Society this year. Uh So, Doctor Don Levy is a uh interventional radiologist um in Buffalo New York. Um So he completed his medical school and internship in the University of Vermont. Um and then went on to complete diagnostic radiology residency at the John Hopkins Hospital um which is uh has been working the number one radiology Burgum in the United States for the past four years. Um He thankfully the fellowship at the John Hopkins Hospital in Interventional Radiology where he served as the chief fellow. Um So now he's a board certified radiologist and director of the Windsong Interventional and Vascular Department, which is in Buffalo New York. Um He is also a National Faculty of Striker and Merit Spine and participates in in Innovation Committee which includes engineers and physicians from multiple countries and educates physicians of multiple specialties on public health and interventional techniques. Um He's a member of the Society of Interventional Radiology Pain Management Committee. Um and he's been a long standing member of Wind Songs Executive Committee and US Radiology Specialists, Clinical Governance Board and National Physician Committee. So he has a special interest and expertise in minimally invasive image guided spine interventions as well as uh interventional women's and men's health. Um And I will move on to his presentation. It's turned my microphone birthday. Good evening. It is the night before rise and I'm recording here on Earth Day. So happy birthday to all of you. I'm on the other side of the pond, but I thought I'd wear my dunleavy pub hat and uh represent the locals. Also, I wanted to thank David and his family and all of the great skiers and outdoorsmen, um got my ski team coat on and uh get an honor and privilege to be involved internationally with the future leaders of healthcare and able to discuss a topic that I'm very passionate about. So with that, I will share my screen and uh as we go here, just tell you a tiny bit about myself. So I'm Dana Dunleavy. I'm the Director of Interventional Radiology here in Buffalo New York at Windsong. And a longtime passion of mine has been spying intervention. And um uh everyone, you know, is curious, how do you get into that world? And, and I was kind of a mix of uh neurosurgery orthopedics, physical therapy and eventually got into the least invasive uh type, which is the image guided procedures and uh was able to raise in high school and college and, and developed pash in for joints and spine and then was able to do residency and fellowship at Johns Hopkins. And after that, um was pretty broad in my career doing all types of interventional radiology. And um I was able to learn from some great mentors uh both in terms of presidency fellowship, but, but much more beyond that. Um And that was where I was able to really delve into all details of spine intervention. And in doing so, you know, I think it's important for us to keep an open mind about all devices and all vendors and, and understand the strengths and weaknesses of each and with that, you know, get to the latest where talked about different types of mechanical augmentation, all with the same goals. But, you know, now we're in a place where things are really working well. So just to talk and overview vertebral compression fractures occur when the vertebrae collapsed. And uh this usually happens from osteoporosis can also happen from trauma in this region. We see a lot from car accidents uh but also is people falling off a roof for off a ladder. Um And then the less common reasons such as cancer or infection and some people subcategories them into uh wedge or by concave or crush. Uh and sometimes planina and that impacts how your technique is to intervene upon them. But in general, I think it just helps to make sure that we're good at recognising these fractures intervening when we need to and how to then prevent future fractures. So, with osteoporosis, uh predominantly it's an age related phenomenon and also much more common in women. But you can see all of these other factors really play an impact as well. And so we do have an opportunity to prevent fractures, not just intervene upon them. And so when you look at normal bony trabecula, you can see the difference from there on the top down to osteoporosis where you have a loss of trabecular bone. And then as that develops, you can imagine a house with very poor support eventually you start having um collapse of your structure and that's where we get and play compression first. You'll find that there's micro trabecular fracture. Even when there's no collapse, people will have tremendous pain. And these are demographics from the United States. But um overall important to recognize that this is a very common problem and impacts people's lives uh in more ways than people recognize at first. And so, most commonly, these occur in the mid thoracic region and at the throttle lumbar junction, which is where we have a lot of force and flexion. So basically areas of high stress. Now, in terms of fractures and diagnosis, we generally start with radiographs anytime someone um presents to the emergency department or to the practice um with new pain, easiest simplest test is an X ray. Once you find a fracture, though, it doesn't mean you need to intervene upon it, you really don't know the age just from the radiograph itself. And it depends whether someone's doing exam, lamination of that has a clear, full history and understands whether there's tenderness to help with that. Um Some people do what we call a ghetto X ray, which is or a ghetto MRI where they mark the site of tenderness and then take an X ray just to make sure that the site of tenderness correlates with the fracture. But um in this area, we go on to MRI or bone scan. Um CT can be very helpful as well in terms of the high resolution nature of it. Um but it doesn't tell us the acuity, it's very similar to X ray in that aspect. So as we move on, just kind of showing bone scans and CT scans, again, CT scans have higher resolution uh that MRI and bone scans. Um some people call nuclear medicine, unclear medicine and you can see that it has the physiologic benefits but doesn't really have the resolution that you need. And so in this area, um we combine see ct scans with bone scans, if we're going to treat the fracture or we use an MRI, which gives you all of that information together. Remember that MRI has high contrast differentiation and so you can see more structures. So if you had a choice, MRI can be the most helpful because it tells you about the discs and about the cord and about the Zygo apothesil joints or facet joints. So it really tells you a lot of informations besides just the fracture. So treatment options um important to know that not intervening, which sometimes people call conservative is pretty high risk in this situation. So if you look at bedrest, physical therapy, bracing opioids, all options of not intervening, it tends to have this cascade of back pain, too, spinal deformity to decrease lung capacity, impaired function and it continues on. And things you'll see is DVT pe constipation, pneumonia, all things that result from immobility and from um lack of activity or bed rest. And so as we look at, at multiple studies that have happened around the world, we find that intervening upon the fracture reduces pain in the short term and long term. And if you also compare um narcotic use, you find that it um decreases the amount of narcotics used in the short term and long term, even out to one year and two years after the fracture, there's still a big difference in terms of narcotic use. And as we've learned more about this, um we've also learned that there's a very high mortality associated with vertebral compression fractures. And that really shouldn't be too surprising because we already knew that there's very high morbidity and mortality with hip frac pictures. And so we do quite a good job with intervening on hip fractures because of that, but we don't do a very good job about intervening on spinal compression fractures. And that has very similar demographics and also similar morbidity and mortality. And so if you look at some of the benefits, you'll find uh pain relief, functional improvement, uh restoration of alignment, decreased need for other adjunctive treatments like injections or radio frequency ablation, decreased medication use, and other aspects of uh reduce morbidity such as decreased hospitalization uh for various types of causes. So, this can be done in terms of hospital, ambulatory surgery center office is really all depends on how you're set up and what your equipment is. Now, if you look at some of the choices here, this is kind of the, the standard before there was balloon kyphoplasty, there was vertebroplasty. Um And, and that has actually been shown to have tremendous improvements as well. But if we look at some of the vertebral augmentation techniques where we're augmenting the fracture, you have straight balloons for a by particular balloon kyphoplasty, you have a uni particular curve system or you have mechanical augmentation. And so if we look at step by step, just a by particular balloon kyphoplasty, you find you take your needle and you go into the posterior third of the vertebral body and then you can drill forward so that you're in the anterior third of the vertebral body, then you insert your balloon, inflate your balloon. So you're creating a cavity here and then you fill your cavity with cement. And you may think, well, why don't I just inject it and you could do that. Um So vertebral plasty is less traumatic and that you could just stick a cannula or a needle into the vertebral body and stabilize it with cement. But doing a balloon kyphoplasty provides improved control for you because you're determining where the cement is going to flow. Now, if we look at uh different choices of how you can get to the vertebral body you have here a trans particular approach. Okay. So this is the vertebral body, the pedicle, the lamina the spinous process and the transverse process. So this is the safest and best technique which we call a trans particular approach. There's also extra particular approach and para particular approach, but trans particular is the safest. And if you look at this technique, this is how we train people on the 123, we call it. And so you want to be on the upper outer aspect of the pedicle when you start in the posterior third of the pedicle, be in the mid pedicle when you're halfway to the vertebral body, and then you want to be near the medial border of the pedicle as you get to the pedicle, vertebral body junction. Okay. And the reason for that is you want to maintain a trans particular approach as well as an appropriate angle to progress towards the 45 aspect, which is in the front and medial aspect of the vertebral body. Now, this can be achieved with two views, just the A P which was showing here in the lateral. So if you look at techniques, you square off your endplates, you put the spine is process in the midline, you put your pedicles in the upper third and then from there, you can align your cannula to the upper outer aspect of the pedicle. So some people talk about driving, putting your hands in the 10 and two o'clock positions. That's how you want to start with your access. So again, on the lateral view, which were showing here, you want to have parallel in plates and have the pedicle superimposed. So that's one silly simple way that we can know where lateral is by having pedicle superimposed or if you're in the thoracic spine, having ribs superimposed. Mhm Now, if you look here, you want to identify the medial borders of the pedicle that provides a lot of safety so that you don't one go through um the neural foramen, which is where the exiting nerve roots live. And people would have a lot of pain if you were to do that. And you also don't want to violate the medial border of the pedicle and go through the spinal canal. Now, as you're going in again, this kind of simplifies the 123. And um here this showing the cannula going into the vertebral body at the pedicle vertebral junction and further into the posterior third, take your bone sample with a biopsy device, put your drill forward, remove your drill, put your two balloons in because you did buy particular techniques. So you have to cannulas inflate your balloons, you have contrasts within them. So you can identify where they are. This is in the lateral view. This is an AP view. You can see both balloons are kissing or in contact midline, remove your balloons and then stabilize your fracture with cement. And this is a minimal goal is to put cement in which crosses midline in both the AP and lateral views. So if we look at uh POSTOP imaging, you can see that cement is dark and that's helpful because you want to be able to identify any fractures that you might have missed. Now, we don't standard get an MRI after treatment clinically, they should be doing well and no need to get additional imaging for no reason. But if they were to develop pain, six months later, 12 months later, it would be helpful to identify the difference of a treated fracture in an untreated fraction. And here's an example of a CT scan. This is the actual view showing the vertebral body with nice deposition of cement. So now moving on to unit particular balloon, kyphoplasty, similar concept except you benefit here from only accessing with one cannula in one pedicle. So it reduces procedure time, reduces fluoroscopy time, reduces sedation or anesthesia time, all of which are beneficial to the patient. Now again, if you see in terms of lidocaine use or sedation use, you're gonna numb one pedicle, put one cannula in, go across midline. In terms of this company, there's, there's several that can provide this type of supply. You're going to put a curved delivery system in, remove that so that you have a sheath in and then remove the sheath so that you have your balloon exposed, inflate your balloon across the corona plane. So we're visualizing that both in the lateral and ap views and then fill you your cavity with cement. In this case, with the curve needle. Um, there's also steerable devices, you can use both steerable osteotomes as well as steerable balloons that you can use. Again with the benefit of reducing procedure time and sedation. And this can be very helpful, especially if you have an elderly patient with multiple comorbidities. Now, the access is slightly different here because you're using a curve balloon and curved needle, you can start a little bit more lateral and curve across. And again, we covered all of these benefits. Um But most importantly, you might use as an example patient that has COPD or has cardiomyopathy for various reasons, lying prone for a prolonged amount of time is an anesthesia risk. It's important to know that the spine is not the same from top to bottom. So if you look at the thoracic vertebral bodies, they're more heart shaped within vertical pedicles. And if you look at the lumbar spine, the vertebral body is more bean shaped and has thicker oblique pedicles. Now, in general, that makes access into the lumbar spine easier because of those large, wide and oblique angled pedicles versus the steep narrow pedicles of the thoracic spine. But again, the fracture is a fracture and it doesn't mean that one is more important to treat than the other. You just have to recognize the anatomy and treat it appropriately. We discussed earlier the differences of trans particular and extra particular both work but trans particular is a safer technique. This is an example of hospital um that did not have the right tools or experience in mind. They were trying to uh target this lesion in the L1 vertebral body. And as you can see here is the lesion, this here in the paravertebral region is the venous plexus. Now, here was their first attempt and you can see that they missed and um they don't show it here but basically progressed into the venous plexus. Now, here's another example of getting to the vertebral body, but they went through the neural frame in on the way. And when you do that, you provide the patient with ipsilateral pain for a pretty significant amount of time and then eventually made their way to the vertebral body only if you recognize here's the lesion, this was the disk below it. And so um got a benign uh diagnosis which was a false negative. So it's really important to understand your anatomy and have the right tools and have a good understanding of how to get where you want to get. Now, uh here the next day patient developed this huge hematoma because uh that cannula went through the venous plexus along the way. And unfortunately, the patient was told they had uh no cancer because um they missed the lesion. And so now the patient is referred to us uh from another provider due to uh progressive pain. And now you see what the vertebral body looks like here. And so here we were able to take a trans particular technique to provide this biopsy. And you can see this ghost hole, that's what it looks like when you advance your cannula into the bone. Afterwards, you can find this little drill hole. And again, here in the corona plane, you can again identify that this is a trans particular approach which is very safe. Um and doesn't have that morbidity. Now, if we look at mechanical augmentation, we've had many attempts to create something that works consistently and safely. And um this is a wonderful system. Now, this um was tested in Europe. There are five countries, 13 sites, 15 investigators and this showed many benefits. So this uh study was designed as a non inferiority study to basically show that it was not any worse than balloon kyphoplasty. However, it showed superiority in many ways, one in terms of reduced pain um to, in terms of height restoration and three, in terms of prevention of adjacent level fracture or A L F. Now, if you look at the technique starts the same, put your access cannula or osteo introducer needle into the vertebral body, put your K wire or guide wire down, remove your cannula with the K wire left behind, advance your reamer or drill over the can a wire into the vertebral body replace that Riemer with a template. This is something that's common in orthopedics. You provide to benefits here one clearing a pathway, pushing the bone out of the way and also proving that you picked the correct size implant based on the template size, you then put this cannula plug and then follow by putting two trans particular spine jacks in which opened from a single piece of titanium into this large implant, which you can then fill with cement. And um you know, again, this is a tremendous benefit in terms of providing a construct which the cement can fill, it stays in place. And so not only are you providing height restoration like you do with balloons, but the implant stays in place. So it maintains that height while you're filling it with cement. And then you also have the benefits of cement containment as your applying cement through the middle aspect of those implants. Here's a little video showing how you can watch that height restoration with the Nplate being pushed up. And as you do that, you're reducing biomechanical forces on the adjacent discs and on the adjacent vertebral bodies, reducing disc Arnie ations, symptoms from uh bulging discs and herniations and annular fissures and widening of zygapophysis, eel joints and also reducing adjacent level fractures. So again, here, um three different techniques you could use. Now, here's an example of steerable technology. So this is how the concept works is that not all fractures are created equal and it's nice to maintain a trans particular technique as you are still getting to the correct part of the vertebral body. So, here you're watching different uh animations of how that's terrible technology can work. Um Here you can see you're pointing your osteotome and you can curve it as much as you want and steer it where you need to go, uh which provides a lot of safety and clinical benefit. So here's a case of an 89 year old police officer lives alone presents to clinic with his daughter who's a nurse practitioner. And uh basically, you know, her dad was just trying to cook himself some dinner in a microwave and develops v ear pain, trying to sit down. Now he has autoimmune hepatitis, which involves his lungs as well. So he's treated predniSONE, which obviously increases the risk of fracture due to osteoporosis. And he's also on oxygen at rest. And so uh surgery was not an option for him. General anesthesia was not an option for him. And even providing a normal level of sedation was quite high risk. And so here you're able to do a simple quick procedure from a single access. So you go in here, here's the from fracture, go in with your straight device, biopsy devices straight. So it goes in and see if you're going to do your augmentation like that. It would be problematic because you would go into the desk below. But with a curved osteotome, you can provide whatever angle is best for the patient and for their fracture anatomy Now you follow that with a curved steerable balloon which you now can confirm in the E P view is beautifully across midline. Here's your spine is process in the midline. You have one facet or sorry, one pedicle and the other pedicle and you're crossing the balloon from pedicle, two pedicle, which provides tremendous surface area and providing great endplate restoration, height, restoration in the corona plane, which you then can stabilize. In this case with nine CCS of cement, which is wonderful for benefit. Um and also for reducing adjacent level fractures. Now, in our final uh segment here, I'd like to talk about metastatic disease of the spine. So, radio frequency ablation and rita bril augmentation. So, in this case, we're using a steerable bipolar radio frequency ablation probe. Uh some people call this TRF A or targeted radio frequency ablation. Now, this is non ionizing treatment. So it still allows for adjunctive radiation therapy or in the opposite effect where someone might have been treated first with radiation therapy, they've reached their dose limits. You still can do this treatment which provides quite a substantial benefit. Also, if you compare radio frequency ablation of spinal metastatic disease or spinal cancer to radiation therapy, patient's have uh symptomatic improvement in about three days after ablation versus about six weeks with radiation therapy. So they really work together very well, provides an easier way to do radiation therapy if needed after ablation because patient's are in less pain Now, here we have a 68 year old female had right breast cancer in 2012, treated with chemotherapy and radiation therapy and was noted to have elevated tumor markers. So, um I'm present at tumor boards of various different types and um this was breast tumor board. And so they showed this case and found uh this subtle hypermetabolic lesion and asked if we could biopsy it. So first step, as you've seen before is having the understanding of anatomy and knowing how to get to this lesion. So you can see you had to take a pretty steep angle coming down, but also maintaining trans particular technique, not going through this neural framing and then advancing a needle beyond that. So that could either be a fine needle, aspiration, vibes York or bone biopsy and they're even um mechanical drills you can use for that. And then here after we confirmed this was metastatic breast cancer, which was causing a tremendous pain. Um Here, you're sticking to radio frequency ablation probes which again, you can note are steerable. Now that allows you to either do a unit particular approach and steer it to wherever you need or in this case, doing a bipartisan color simultaneous radio frequency ablation, which has a lot of benefits because you can reduce something called heat sink, which is where uh some of the heat from the energy of the radio frequency ablation probe is taken away or cooled by blood and if you have two probes working simultaneously, um it reduces that risk. And so that is what we did here with tremendous benefit and she remains very happy and comfortable. Now, um education awareness, this is different from region to region. But just to show you some of the aspect of how we got where we are, as I mentioned before, we initially um started with just the basics, you know, after I was in a general uh set of hospitals covering six different hospitals, was asked to come to this practice and, and really start an interventional program. And each step along the way, as people have asked me to present to grand rounds or present um on television, basically, what I learned is if people ask you uh to teach, take the opportunity and, and that's what we've done is is to teach as much as we can. And um it's been very rewarding. So, um with that, I would like to thank everyone and uh I'll be available for questions if uh anyone wants me and you can reach out across the pond, look forward to hearing from everybody an excellent talk there by doctor. Um And thank you to him so much for obviously putting the time together to, to put that, that uh talk up for us. Um You can also reach Doctor Dunleavy on Twitter, I'm sure he'll be happy to, to answer any questions that way as well. Um And that would be the one piece of advice. I guess I would give you any of the medical students, junior doctors who are joining us this morning who are not on Med Twitter or particularly Twitter for Radiology. And I, or if that's your interest is a great way of engaging with society's like our own and other ones who are involved with, but also with, with mentors and, and really inspiring radiologist and interventional radiologists out there. So that would be my, my advice this morning. Um You can see here, there's obviously our fundraiser for worldwide Radiology. We'll keep bringing you back to this as the morning goes on. But if you could please donate whatever you can to this great cause which we'll be hearing about after the break. Um For now we're going to go on a little break and we will be back at 11 40 with Doctor Kirsten kind talking about pediatric radiology. Uh And then as I said, we'll hear from worldwide radiology. So thank you very much for your engagement so far and we'll catch up with you after the break. Hello, everyone. Just a quick message. Essentially, if you go look at the sessions tab on the left hand side, you'll see there, there's a coffee room space. It's a virtual coffee room. We've obviously never tried anything like this before. But if, if people want to pop in, I'll pop in for the next 5, 10 minutes. Any feedback you have on the event so far or let us know where your tune in from. Well, uh I'll be over there to have a chat. Okay. Just give us one moment, folks will be right with you. Okay. So, just welcome back everyone. Thank you all for uh staying with us for this part of the session. Essentially. Obviously, there is a significant element of webinar fatigue with all of these things being done virtually. So I think it's, it's always been my aim from the outset to try and keep these as short, at least the live parts as short as we can. Um So that obviously, it's you can engage with it for a few hours and then have the rest of it on demand. So obviously, take a break, have some lunch and then come back and watch the other workshops uh or more more more like tutorials and then the talks from from previous years. Um So I'm going to introduce our next speaker. Uh I don't think I can see Vivian at the moment. No, so I'll just introduce Kirsten kind. So Kirsten is a great supporter and friend of the rise project. She is a consultant, pediatric radiologist and the director for Children's Imaging at Manchester Children's, the Royal Manchester Children's Hospital, Manchester. Having finished up her register training in Edinburgh a few years ago. Um She's been involved, helped me set up the project and has been involved with it all the way through a great source of advice and uh a really excellent pediatric radiologist as well. So pediatric radiology is obviously a niche area um of, of radiology and quite a subspecialized area. So I'm, I'm excited for you all to hear about her work, the, the types of cases that she sees why she finds it so interesting. Um And hopefully some people will be inspired to, to go down that line. So I'll hand over to Kirsten now and hopefully you enjoy obviously any questions, comments, pop them in the chat and we can, we'll, we'll pass them on to her. Hi, everybody. My name is Kirsten Kind. I'm a pediatric radiologist down in Manchester Children's Hospital and I've been asked to talk to you a bit today about pediatric radiology and why it's just totally awesome. Um As some of you may already know I trained in Edinburgh. Um I did medical school there and then I had a little bit of a time in Aberdeen and then I came back down to Edinburgh again for the rest of my radiology training and the rice symposium has a fun place in my heart and I've been involved from the word go. So I'm absolutely delighted to be invited back now as a consultant to come back and talk to you and then hopefully encourage you some of you to go into radiology and in particular, go into pediatric radiology. So let's go with the plan. What's the plan Batman So we'll start with a bit about what is pediatric radiology. Hopefully, most of you've got a good idea what that is, but we'll go through that anyway, talk a bit about what modalities of imaging we use in pediatrics. A little bit about intervention. I know a lot of you here will be fans of interventional radiology. Look a bit of what a typical week is like for a pediatric radiology consultant and then say I managed to convince you that you want to be a pediatric radiologist. How can you then start making steps towards that as a career choice even now as a medical student or a junior doctor. And then we'll finish off with the real life pictures just for fun and because uh pictures are awesome. Okay. So let's get started. What is pediatric radiology? So the widely I'd amongst you will realize that this is not a child, this is a very degenerative looking older person who has broken their shoulder, but it's the only X ray background that Microsoft would give me. So apologies about that. What is video eg so definition could be something like this, the medical imaging of Children and adolescents to a diagnosis and treatment which is fine but also super boring. Nothing in that sentence is going to make you go. Yes, I really want to do pediatric radiology. How can I explain it a bit better? So I thought pictures, I do pictures, hopefully you're all picture people too. So we do a bit of this, we do some plain radiographs. We look at fractures. People in A and E kids who've fallen are stuff, do a bit of this bit of ct bit of acute sort of imaging in the abdomen. Some of this, some fancy M R, we use a lot of them are in pediatrics and I'll touch on that a bit in a minute. Um And sometimes we do this ultrasound. This is a neonate. There's a tiny, tiny baby is only three days old. But again, you also have to be able to do this. You also have to know your pepper pig characters. You also have to be able to keep up a conversation and sing the wheels on the bus to keep your patient calm while you're doing an ultrasound. You have to know about Minecraft and about Warhammer and all the cool things that the kids want to talk about because at the end of the day, that's how you make your relationship. But fundamentally pediatric radiology is about this and this and this and this and this. It's about the kids. And the best part of my job is working with these cool guys who never have a dull moment. I'd far rather sit and talk about Spiderman than talk about politics. Uh Your conversation over the ultrasound table is always variable and always hilarious and kids are just awesome. Basically, there's a lot of awesomeness and talk so onto more serious things. What modalities of imaging do we use in pediatrics? So really, we use it all. Um There's no modality that we don't ever use impedes. Um And I think probably what I love most about it is the variety. Um when I went through my radiology training, I kind of liked everything I did. Um I enjoyed using MRI though. I found it really hard but I found that I like the cross sectional stuff with CT and using the more acute things. But I also liked interacting with patient's when I was an ultrasound or fluoroscopy. Um And at the end of the day, I also really like doing plain radiographs and I've actually ended up being an M S K specialist. So bones are my thing. So I really like x rays. And so really, I didn't have to give any of that up by doing Pedes, which was really nice and just kept that variety going. So what if you like sticking needles and things like I do, I love to do biopsies. I love to do something a bit practical with my hands. Um I thought about surgery for a long time and it ended up the radiology. I was worried it wasn't gonna give me that side of things, that practical side. So I think it's easy to think of radiology is just diagnostics. Um And whilst I love a puzzle, I love working things out and that's what I love most about my job. I also love that I get to get into theater and I get to help make people better as well. So even if you like sticking needles and things kids can still be for you. Fear not. This is the team at Evelina in London doing uh running a simulation. Actually, this is a pretend child. Don't worry that those are plastic feet. Um But they're running a trauma simulation where the child has been acutely injured. They've got active bleeding. Um They went through A and E into CT um They simulated a CT scan that showed an active bleed um in the spleen. I think if I remember rightly and then they simulated right the way through to the Interventional suite and doing acute embolization of that bleed. So there's plenty of fun to be had interventional radiology and just to break it down a bit, you probably know already that we tend to break down interventional radiology into vascular intervention, which is your more traditional interventional radiology. That's what we think of as I are. Um And that's the bit, that's a separate training program. So you'll do your first three years of court radiology, same as everyone else. But then if you decide you want to do vascular intervention, then you'll split off um and do three years instead of two for your higher training. So you end up doing up to ST six, um which is great. And if that's your thing, then absolutely. Go for it. Um If you don't want to leave the diagnostics behind, then nonvascular intervention can be a really nice um compromise and that's what I do. So we do biopsies, drainages, chest trains, we do radio frequency ablation of kidney tumor's, um osteo osteo hmas, bone biopsies, all that kind of stuff. There's loads of stuff you can get involved in, excuse me. And it's, it's so much fun. There's so much variety. Uh pediatric vascular intervention is pretty niche and there are only three or four consultants in the whole country who do pure pediatric vascular intervention. Um Someone in Glasgow and then they're a couple of greater Women Street. You may have heard of Alex Barnacle, who's a bit of a hero of mine who's a one of the great Ormond Street vascular IR consultants in pediatrics. Um The slight problem is that the vast majority of vascular intervention that we see generally in radiology's and adults and it's mostly degenerative stuff. So it's things like angiograms and stenting and angioplasties and things like that, which obviously don't affect kids. So there's a vast chunk of work that you just don't see in Children, but it is a really growing field and more and more interventions are being found that could be done by radiologists rather than by surgeons. Um So sclerotherapy, something we do a lot in Manchester, one of our IR consultants does sclerotherapy. So that's of um slow flow, lymphatic malformation, cystic hygroma as things that are cyst icky and just need to be sclerosed and sort of crinkled up and dried up. And the sclerotherapy is really good for that. They do all that image guided in the IR suite vascular malformation. That's a really growing area and they're really, really common in kids. Um And so in some of these centers, they're starting to inject those and sort of embolize them off, which is really nice because there's no surgeries, no open surgery involved. And it's a really nice um non invasive way of treating these things, which can be quite unsightly. Sometimes we use um uh I R and embolization in trauma, it less often in kids because actually, despite the simulation picture, I just showed you and Children are remarkably malleable and even if you shatter your spleen, so a grade for splenic lacerations, which means you've completely shattered it. It's a vascular, they still just leave it in the child and just treat them conservatively. And the vast majority of the time they just, they just get better. It's remarkable. Um So that's a relatively small part of it um in Children, but it is there. And if that's your thing, then you can find that if you want it. And like I said, it's a rapidly growing area. So if it's something you're interested in pediatrics doesn't mean no, I are by any means. So I thought I'd talk you through a bit of what my typical week is like. So you can get an idea of what it's like to actually be a pediatric radiologist. Um, and so I've broken down. This is my actual rotor. This is what I do on a week by week basis. And the wonderful thing about being a consultant is your weakest set. So, aside from the odd covering for holidays and things, my weakest the same every week and I get to work in the same place all the time, which for those of you who are junior doctors are registrars, you'll realize and understand how unusual that is to be in somewhere longer than three months or however long your rotation is. Uh And that's a really, really nice feeling you start to get to know people and you're part of the woodwork and it's really good. So my week looks like this. I have S P A. So that's supporting professional activities. So when you become a consultant, you get at least one of those sessions a week and that is there to let you do audits or paperwork or some research if you're interested or teaching or whatever floats your boat really. But they're to let you expand your professional knowledge, keep up to date, do some reading anything like that. So that's what you're S P A time for. And again, it's a really nice change from when you were a registrar to have time. Actually time tabled in to do those sorts of activities and then on a Monday afternoon because I'm an M S K sub specialist. I do some M S K MRI reporting on a Monday afternoon and I love that to get to shut the door. Nice dark room. Cup of tea. Sorted. I'm a happy woman. Tuesdays are a bit more of an active day for me. I have an intervention list in the morning. Uh So that usually is a mixture of drainage is so this might be a child who's had their appendix out and they've got an infection and a collection after the appendix is out and they need it to be drained so the child can start getting better or it might be a new kidney tumor that needs a sample taken. It might be a chest drain or acidic drain. It's really quite sort of variable in what might be on that list. So that's my Tuesday morning and then Tuesday afternoon, I have an ultrasound list and again, because I'm an M S K sub specialist. I get a lot of M S K ultrasound on my Tuesday afternoon list, shoulders, thumbs, knees, ankles, bit of everything really. But we also cover inpatient ultrasound at the same time. So I get a bit of a mishmash of the acute stuff. Um So that's a really nice, busy but a nice day on a Tuesday, Wednesday, I prep the orthopedics and rheumatology M D T s in the morning. So I'm sure you already know that M D T meetings and radiology meetings are a really big part of your life as a radiologist. And regardless of what area you go into, you'll be involved in M D T s really anywhere across the hospital. And actually it's a really nice opportunity to, uh, talk to the clinicians to know about all the cases that are going through. And often times if you're in a bit more of a niche area, like I am in pediatric orthopedics, then I know most of the cases already and you get to know the clinicians really well and it's a nice way to build up relationships. Um Obviously, a lot of those meetings are on teams are on zoom or other online platforms at the moment, which is a real shame because we've lost that sort of all being in a room and having a chat, but hopefully we'll get back to that eventually. And so I prep both of those meetings on a Wednesday morning and those meetings happen on a Wednesday lunchtime and then on a Thursday in first thing in the morning, um on Wednesday afternoon and duty radiologist. So again, you'll probably be familiar with that as a concept that there's the vast majority of hospitals have a duty radiologist on at any one time and they're there to answer clinician queries or to do urgent reports. Um, any urgent ultrasounds or fluoroscopy, a portable ultrasounds. That kind of thing, um, is the purview of the g radiologist. So I do that on a Wednesday afternoon, Thursdays I have off, which is wonderful. Um, this is the pro of the new ways of working that certainly all the consults in my department. And I think they're in Edinburgh before I left. They were doing the same thing that everybody got one day a week off because of shuffled around. S P A time. Um And that's really, really nice having that one day to just recharge. My kids are at school. Um So I get a chance to just be, sometimes I'll do some reading for work or a bit of extra stuff that I need to catch up on. But most of the time I just get a chance to get some down time and relax. Uh which is really nice. Uh Friday morning, I do a fluoroscopy list. So that's yet another modality chucked into the week there. So, um I might be looking at barium swallow zor follow throughs or enemas or um checking lines and tubes, all kinds of different things come up on that list. A mixture of inpatient and outpatient. Uh And then Friday afternoon, I chill out with my plain film reporting session and that's probably my favorite reception of the week that I just got to sit and go through loads of A and E broken bones, which is my favorite thing to do. Um I just popped in there. At the weekend that I do a one in 12 on call. So that's something to always be aware of with whatever specialty you choose to do. Um either outside radiology or any of the specialties within radiology, um is that you will have almost certainly an on call commitment with the exception, perhaps of breast radiology and some of the district general hospitals. So when you're thinking about a specialty and then after that, thinking about consultant jobs, it's worth thinking about what kind of work life balance you want to have. Um pediatric radiology on call is a double edged sword because um we don't get called in very often. So Children don't generally have as many accidents or acute illnesses overnight as adults do. Um But when there is an emergency, it's generally not something that can be dealt with by the radiology registrar by themselves. So we generally do have to get out of bed and come in. So it's a bit of both worlds. Um I don't generally mind coming in in the middle of the night because it's usually something very urgent that I need to be in there to help with. Um But I'm sure that in 30 years time, I might feel differently about that. So just have a think about that when you're considering what specialty you want to do, I love it. I wouldn't change it any other way and I love all the variety that I've got in my week, you can see that there's MRI and ultrasounds, there's some intervention, there's plain film, there's philosophies, everything you could possibly want all in one week. Never a dull moment. So say I've convinced you that you think you might want to do pediatric radiology. How can you actually now take steps towards that? And I know lots of your medical students and some of your foundation doctors and some of you might even be radiology, registrars already. But really at whatever stage you're at, it's worth sort of pointing yourself in the direction of what you think you might want to do. And I know this is very variable. I went into medical school wanting to be an emergency surgeon and obviously didn't end up there. So, uh don't, you won't be tying yourself to anything. But even if you are early on in your training or in your career, um thinking about guiding yourself towards what you think you might want to do is a really good idea. So the first thing I would recommend is joining this society, the B S P R or the British Society of Pediatrics Radiologists. Um This is a really, really nice group of people, does what it says on the tin. It is all the pediatric radiologist from across the UK. Um And it's a really friendly environment. They have an annual meeting every year in November, usually towards the beginning of November and it travels around the UK. So you get to see different centers each time. It's been in London, it's been in older, hey, in Liverpool, it's been here in Manchester. It's been all over the place last year was in Edinburgh. Um So some of you might even have been aware of it at that, that point. It was held in the Royal College of Physicians. Um And it's a really nice non intimidating meeting. Um So if you get a chance to come along, it's super cheap for students and for registrars or foundation doctors. Um and it's a really nice chance to come and listen to a few talks. It's a couple of days, so it's not a massively intense conference. Um And people are just really enthusiastic and approachable and we'll be happy to give you advice on whatever you want to do. Um Just a small plug, the S P R meeting is going to be in Manchester here with us in 2023 in November next year. So come join us, come meet us, see the children's hospital, ask questions and um and come see about pediatric radiology. Um I believe it or not, they're even more convincing than I am uh to get you into this fantastic specialty. Um audits and qy projects are probably the next thing you can get started on. So as I'm sure, you know, part of medical school and then part of foundation years, you're often having to do audits and equality improvement projects as you're going along and if you can possibly make those slot in with what you'd like to do eventually, um, then that's always a massive help. It looks really good on your C V and it gives you something to talk about it, interview. But even if you're not 100% sure which bit of radiology you, it is that you want to go into or even if you're not 100% sure about radiology, trying to get something that's imaging based is a really good idea. And it's also really easy um imaging, it's all online, it's all on packs. Um And then you've got all the reports on a computer system that you can search. So it actually really lends itself to audit and quality improvement or too little research projects, whatever you like to do. Um And it's, it's just a fantastic idea. Looks great in your C V even better for double bonus points is if you can get that audit or that Q I project onto a poster and then present that poster of B S P R. When um they accept all kinds of projects, you can get educational posters um or case series if you see in a particularly interesting series of one particular presentation, as long as it's got some nice pictures and it's got something interesting uh then they'll usually accept it. So I get, get in there, get stuck in and you can either do an audit. Um like a, uh, an oral presentation. That's the word I'm looking for, or you can do a poster presentation. And either one of those looks great. Um, as a commitment to specialty later on once you get into Fy One and Fy Two, you can do something called a Taster Week, which is this fantastic thing where you get given a week basically for free. You don't have to use up your study leave for your annual leave, usually to do it. Um, and you get to go and spend a week doing something different and if you get the chance, go ahead and approach your local radiology department and see if they'd be willing to take you in for a week's taster week. And I guarantee you that there will be, yes, we're always so thrilled when people want to do radiology. Um, so you don't have to spend the whole week in pediatric radiology. You can usually get a chance to go around a bit of everything, give everything a try, see what you think. And it's a really nice chance to get exposure to what it's really like being a radiologist. I think it's quite difficult in medical school and, um, in foundation years to actually get an impression of what it's like to be a radiologist, mostly as a foundation doctor there. The scary people in the dark rooms that you've got to take your requests through in the morning, um, or as a medical student you sometimes get showed some X rays on ward rounds and things, but it's nowhere near what the actual reality is of being a radiologist. So, get out there for a taste a week. As soon as you can, you don't have to be in Fy to, to do it. You can do it in Fy one. Um, and it's a really, really nice chance to get a feel for it. I did my taste a week in the radiology department in Aberdeen where I was an F Y and I absolutely loved it. It was sealed the deal for me. I didn't want to leave, didn't want to go back to my fo to ophthalmology job. So it was a really, really useful experience. I thoroughly recommend that and the last thing I'd recommend that you could get started on sort of relatively early on. Um If you can see it passed this recording of my head up here is to attend radiology meetings. Um So pretty much whatever department you're attached to as a student or you're working in as a foundation doctor will have a radiology meeting or MDT of some kind where there's imaging involved, get yourself into the meeting. I know it's difficult when you're your foundation doctor. Often busy, there's lots and lots of jobs to do. Um But perhaps if there are more than one of you are in the department, you could maybe take turns or get a chance to get in there and attend those meetings as much as you can. Um, and even better is to present a couple of patient's at it if you possibly can. Um, it looks really good. It gives you a chance to pay attention to the radiologist and see what they're doing and how their interaction is because it's probably the only time you'll see a radiologist sort of leading a meeting or leading a room and it'll give you a really good insight into what it's like to be a radiologist. Plus you get to see loads of interesting cases. I always used to love radiology meetings. I just go and sit with my lunch in the background and absorb all the information. So I thoroughly recommend it. So let's finish with some real life pictures just for fun because we're picture people and that's what we like and we start with a silly picture of a dog photo bombing a mountain. Okay. So this is a three year old boy, breathless, funnily enough. And you can see here that I've got a frontal radiograph of this child's chest. Um You probably notice if you were looking at, used to looking at adults chest x rays that everything is a bit smaller. Uh the bones um seem a bit healthier probably. Um Everything is smooth. You'll notice that we've got some epiphany sees. There is some data facie. So there's our growth plates and growth centers, particularly the shoulders. You can see them there. So everything is a bit more spaced out because a lot more cartilage in the pediatric skeleton. Um But the main thing that's hopefully going to instruct you is that there's a complete white out of the left hemi Kerekes. So let's take a closer look at that X ray and see what might have happened. So I just highlighted a couple of things there. We've mentioned the white out already. So that's what draws your eye. Um So what we now have to work out is why there's complete white out and air is obviously super light, not very dense. So air is black on an X ray. So that's why that lovely aerated right lung is lovely and dark. So that's what we want it to be like. So it's when stuff gets in the way of where the air should be that it gets bright. So that could be puss. If it's consolidation or infection, it could be fluid. If it's a pleural effusion, it could be blood. If there's a hemothorax, there are lots of different things that could be. Um And we have to kind of narrow it down. This is where it's like a puzzle. I really enjoy doing it. So you can see from what I've labeled there that the trachea is tugged across to the right side. Um And actually the entire mediastinum is shifted across to the right and because of that white or we can actually see the heart there's no cardiac shadow. We can't tell where the mediastinum is. So things that can cause complete white out hemithorax or a pleural effusion. So blood or water in the pleural space, it's just filling up that whole side. Um complete consolidation of the lung which is infection or complete collapse of the left lung would be the other thing. And if you can imagine um the two hemispheres, these are separate spaces if that left hemithorax was filled with pleural effusion. So much that we've got complete white out then rather than pulling the trickier and the media's down towards it, all that fluid would push it away. And so we'd end up with the mediastinum and the tricky a pushed across to the darker side, to the aerated side. Similarly, with consolidation doesn't add that much volume, but it would add a little bit of volume. So we'd expect the media sign it too, either still be in the middle or be a little bit pushed across. And, but with collapse, were losing volume on that side. So you can imagine it's collapsed right down. It's really dense and um that's gonna tug the tricky over towards it. And so that's what's going on here. So even though all three of those things called white out of one half of the chest, by using those other little clues around the radiograph, we can work out that this is collapse of the lung as opposed to a plural fusion at human durex or infection. Obviously, you'll have clinical clues that will help you out. You know, this was a child who was raging lee septic and they were wondering about um consolidation, then there'd probably be some consolidation in there with the collapse. But this was an otherwise completely healthy child and I'll give you a clue. They happen to be playing with Lego, the culprit tiny Lego pieces. So this child that turns out to be sitting playing with his big brothers Lego um and had decided to swallow a few pieces because they look tasty and had managed to inhale this one and it had got stuck in the left main bronchus and cause complete collapse of that left lung. So that's obviously not a pathology you generally have to worry about in adults. They don't tend to eat Lego. Uh It's a fairly unique child pathology, but a really nice example of how we can piece things together. No pun intended and get to the answer using all the clues we've got in front of us, which is so fun. And next case 12 year old girl, um she's got stomach pain and vomiting again. No wonder. This looks really sore, isn't it? So, I've got a plain radiograph of the abdomen here for you again. This is a child. So you might see gaps and um sort of spaces in the bones that you're not expecting. Don't worry about that. That's normal because there's lots of cartilage and I'm going to give you a slice from the CT as well for you to look at just to help you out. And you can see here how the CT just gives us that little bit more detail, helps us work out what's going on. And so here we've got a really distended stomach. It's really full, that's really huge for a small child. Um, and then we've got something in the stomach. It's really kind of swirly and it's got areas of sort of air and fluid in. It's really bizarre looking, especially on the X ray where we see this really dense bit in the middle and then either fluid or gas around it and we can see that the rest of the bowel is, is fairly normal. It's mostly collapsed, but this stomach is just really, really distended. Um, and when you get something like this, really, the only way to 100% work out what it is is to get a scope down there and take a look and that's what they did this time. And this time it was hair, it was a trichobezoar, which is a very fancy word for a big old hairball. And this was a girl who had anxiety and she sat food, her hair loads and loads and lots of kids do it like. And if you're a hair chewer, don't worry, a trichobezoar is not necessarily in your future. This child was really going for it um but they pulled it out in endoscopy and it was just vial this enormous clumpy hairball. But can you imagine the massive relief when that came out? But again, a really nice example of how radiology and imaging has been used to piece together what's going on and help guide the surgeons and treatment. That girl felt considerably better afterwards. I'm sure you can imagine. So, just to reassure you, it's not all foreign bodies. Those are just a couple of examples I've given you there just because they tend to be a bit interesting. Um We see everything in pediatrics. That's the wonderful thing is I've already told you variety is the spice of life and that's what I absolutely love about it. Pediatrics is the whole of medicine all over again. It's just, there's nothing you don't get to see. And if you're in a big enough center, you can sub specialize within that. So for me, you know, like you can see here we do vascular malformations, cardiac anomalies, you know, acute symptoms, trauma, cancer TB, we neonate, we do fetal imaging even when the baby is still inside the mother. Um But what really gets me is I really like M S K. So I do the skeletal dysplasias and I do the trauma and the nonaccidental injury cases. And so you can pick out even from all that, the bits that you really enjoy and hone in on those. But you don't ever have to let any of it go if you don't want to. And as someone who just really enjoyed everything I did, this is absolutely perfect for me. Um, some people prefer just doing the same thing again and again, getting really good at it and I totally get that. Um, and there is, you can do that to an extent in pediatrics, but it's definitely better suited to those who prefer a bit of variety and doing something a bit different. So that's all folks. Thank you so much for listening to me. I'm so sorry. I couldn't be there with you in real life. Um Today I Edinburgh is my home. I miss it very much and I know lots of you are there virtually. Um But if you are not in, but today you should go and visit because it's a fantastic city. Um And Neil and the committee this, you have done a fantastic job putting together a great program for you. I really hope you're enjoying it. Uh I'm just really sorry, I can't be with you there today. Um If you do have any questions at all and please don't let the fact that I'm not really here put you off in any way. Please do, send me your questions. This is my email address, snap a picture, take a screenshot, jot it down whatever you want to do. I'm always always happy to answer questions no matter how big or small. Um No matter where you are in the UK. If you just want to know a bit more about pediatric radiology, um about radiology in general, about intervention. If you want to be put in touch with people who can help you, please please do get in touch um in general, pediatric radiologist. In fact, radiologists in general are approachable people so never be afraid to, to put your hand out there and ask and get involved with radiology. We, we love people who want to get involved. We love people who are enthusiastic. We all love our specialty. I can tell you 100% that I don't regret having chosen radiology. I never have. I love pediatric radiology. It is not what I went into medical school and certainly not what I went into radiology training wanting to do. Um but I would never go back and I'm sure you will feel the same if you choose radiology. So with that, I will thank you all again for coming to this fantastic conference. Thank you um to the committee for inviting me to speak and please do again. Send me your questions and enjoy the rest of your day. Thank you. Thank you to that great talk from doctor Kind. Um Next up, we have a bit of a message from worldwide Radiology, which is the charity we're supporting today. Hello, my name is Reena DVD and I am a trustee and the educational lead for worldwide Radiology. I'm also a diagnostic neuro radiology consultant in Edinburgh. Firstly, I want to thank you for your fundraising efforts. Thank you for the money you raised for a project Malawi last year and a huge thank you for choosing worldwide radiology sound sonography project in Ghana as your fundraising mission this year, it means a huge amount to us to have some support from the radiology community and particularly with people who are so enthusiastic about the work we do. In a few moments. I will be chatting with Pascal, a fantastic clinician in Ghana who can explain to you about how the money you raise really makes a difference to clinicians and ultimately to their patient's um through appropriate training in ultrasound. Um Just a few words about worldwide radiology before we chat to Pascal. Um So who are we? We uh we are a charity set up in 2017 and we have approximately 35 long term volunteers. Um In addition to this, we've got loads of people who we have had pitching in with fundraising um collaborating with projects with their expertise and also people in country um clinicians, radiographers, radiologists in the countries where we are working, who have really helped to mold and shake the projects that are happening. Um Our work is really about strengthening uh the development of imaging services in low and middle income countries. Um We work in countries such as the Gambia, Kenya Ghana, um Malawi Gabon and Uganda. Um The work is mainly centered around building appropriate safe and quality imaging services, whether that is through education and training, um through improved diagnostic support and um through mentoring for training purposes. Um The the work is broad and wide ranging and it's really about building uh imaging services that are prioritizing local community needs. We are a charity which ensures that the work is sustainable for the long term and this is definitely part of the process for the sound stenography course. We're equipping clinicians with tools that they can carry on and use for improving patient care. So now I would like to invite you to go to our website. Have a look at the projects that we undertake. Have a look at the work we do and if you are interested do get in touch, we'd love to hear from you. Um So next, we're going to have a little chat with Pascal. Uh and you can hear a bit about the work that has been happening in Ghana and how he has found the project itself. Thanks so much. So, I'd like to introduce you to Pascal. Can bury a fantastic internal medicine physician based in Cape Coast in Ghana. Um Pascal, you undertook the Pocus training last year. I'd like you to just describe how that felt, how you, how your experience was and how you think this might impact on your management of patient's. All right. So, I mean, when I got the opportunity, it was cereal. It was something I've been looking to do for a long time because I kind of found out early before I've been, became positional special importance or the rules that how ultra can augment your, your diagnosis in real time. It kind of cuts down the lag time between getting information and then taking decisions, you can do it by the bedside. So I was looking to ways in which I could get the training and then also get a mobile ultrasound scan. So I did some research, looked online at the different societies and guidelines and then the training recommendations. But it wasn't really feasible, you know, traveling just a few days just to get the the teaching. So when this worldwide radiology opportunity came, I jumped on it and then with liaison with um lays, I was able to acquire one of the scans that butterfly IQ which I used all the time and the training was, it was very good. It was very interesting because I don't have any, I didn't have any scanning experience. I've never held the ultrasound probe. So at the end of this can I was able to pick up things? It was more validating that, you know, it's not something that is hard to learn. You know, you can with a bit of patience and then practice, you can really, you know, pick up the skill. And I mean, we had a fantastic and people teaching us Jim Liz Catron Catalina also teaching us. It was, it was very good. I mean, I felt it was a bit of information overload cause that to like ultrasound anatomy and all those things, which I never really liked an atom you school. But you know, it paid off and it's made a big difference. It's made a big difference in my clinical practice. How, how are you using that on a day to day basis? What, what sort of on a day to day? So when I came back, I had this with some colleagues of mine, we had this moto leave, no one on scan. So we just go through the world just scanning everybody from liver to lungs to DVT just to get the skills. But with time, we realized that it was in much that we were doing that for skills were also picking up things that were being missed. Like someone be lying down, don't, doesn't really have an obvious leg swelling and then they have a DVT. So on a day to day basis, it really helps us a lot. You know, again, the lag time between sending patient's to radiology there, an oxygen moving them. It really kind of um a lot of wet load on both the nurses and the physicians because yeah, not getting decision done early. I scanned every day, every single day, I'm scanning someone either a liver problem trying to confirm cirrhosis at the best. I tried to confirm kidney disease at the bedside Hydromet process D D T floral infusion. I've used it to do ultrasound guy that drainage of a liver abscess. Recently, a patient who had a VP shunt from a pioneer Blastoma. And I mean, it helped the temperatures just crashed. We're doing blood cultures, all those things, but the temperatures crash when we're able to do that. So it's very, very helpful when I came to find out some patient's, even when you're not the one manager and you just kind of scan them. They feel very grateful that you're using some high tech equipment to, you know, to channel, evaluate them and they feel like, oh yeah, this is a really good hospital. They are scanning me, they haven't, they're not charging me for it, you know, and then you are relaying the information back to their doctors and they are improving their healthcare. So it really makes a huge difference for us here. I guess that's, that's an important point that you raise that the alternative would have been that you would have had to have ordered some radiology tests, but I needed to be able to afford those so that you would have paid out of pocket for, for the alternative tests. Yeah, that's true. And, you know, it's not everybody live in a very lower resource settings so everybody can back and afford some of the radiology, even ultrasound, not everybody can afford it. So it makes a huge difference when you're able to do that to get to your diagnosis and save some of the cost to direct it towards treatment of the patient is really helpful. Right. Well, thank you for describing that. Um And uh we hope that the sound pornography project which will be carrying carried out this year in 2022. Um that will also bring more clinicians who are able to, to deliver this. Do you have colleagues or friends that you've recommended uh the course to or do you know anybody who's attending this year? Yeah, I know a lot of people when we got back, it's like we we we converted daughters to believe it. So right now every day, a friend of mine notes abilities called oh yeah, we have this case. We would just like you to scan, make sure there's no DVT. Yeah, we think there's uh so a lot of them call us from different departments option Ghani. They call us and all those things. So we've kind of made, let me say people are now seeing the essence of bed sound ultrasound. And so I know a couple of people here in Cape Coz and outside Cape Coast who are interested and they apply. Some of them will be joining me, some of them were colleagues will be joining us for the training. So it's picking up slowly. But I'm sure in a couple of years they'll become the main ST it will be a skill that is required, you know, because it's going to help a lot of people here. That's great. Thank you so much for your time and your explanation of your experience. So you're welcome. And we look forward to, to hearing more from you in the future, by all means, by all means, I'm here with many great stories. Thank you. So thank you to doctor David E together for us. We might just get the slide shared again with the link, the QR code if we have a great um so obviously some great work being done, thereby worldwide Radiology. And it's honestly a privilege to be affiliated, associated with them. Again. This year, we raised quite a nice bit of cash last year from the rice 21 event. So I am urging you again, please, if you can spare whatever you have, even if it's a fiber or less, um It would be very much appreciated. Um The that I didn't get to have a chat after Kirsten's talk. Kirsten, as I was mentioning before she had, she gave her her talk. There is somebody who's been working with rise from the very early days. And you know, I think in terms of a review of a career in radiology, I don't think you'll get as a glowing one as she has given there. So I think I want to thank her again for that, that great talk and I hope you have been equally inspired by, by Kirsten and what she does. Um just to kind of touch on that, she mentioned Alex Barnicle who's a consultant, pediatric interventional radiologist Dr Barnicle was involved with the Taster webinar series which was held, it was one of the webinars which rise I are juniors and be SIRT. So the British Society of Interventional Radiology held together in 2020. So some really interesting um comments from Doctor Barnacle, some nice cases. I'm going to put the link for those webinars in the event information later on, I couldn't get the original videos to upload. But if you do want to have a look at those, I'd really recommend going and have a look at, I look at those. And the other thing was with regard to all those steps that Kirsten was mentioning in terms of how to gear your, your portfolio up towards a career in radiology. I mean, everything that you mentioned there probably is more testament to the impact that she's had on my career so far. Kirsten is that, you know, in terms of getting involved dearly with your local radiology department, getting involved in some quality improvement projects, which I did at the Royal Hospital for sick Children in Edinburgh. Getting along to be spr definitely recommend all all those things as well and you know, just, just trying to get as much exposure as you can along the way and a taster week as well. So taster week again, just from personal experience did one in pediatric interventional radiology. So there's, there's a lot of opportunities and it's, it's just about kind of making the most of the opportunities to come along your way. I'm going to be in one of the other sessions after the, the live session finishes in a few moments. Uh Just talking about applying to radiology, which I've obviously gone through quite recently. Um And I've got a job in Edinburgh. So if anyone wants to talk about gearing up your portfolio and how to, how best to do that. Any, any questions you have for me, I'm more than happy to answer them. There's also two workshops from last year's rise 21 event which were created by our juniors, which talk about specifically as a medical student and also as a junior doctor, the things that you can be doing that leads on nicely to just talk about all of the catch up content, which is available for the rest of the weekend. So it includes multiple work, multiple tutorial slash workshops which were held last year. There's ones on an introduction to MRI, there's ones on just kind of how, how ct scans are done. Kind of it's called fantastic scans. Very good kind of basics for for medical students. There's one about research, getting involved in research and I are and also kind of more basic ones on chest X ray interpretation. So I definitely advise going and have a look at those in order to get access to all that catch up content, you may have to give feedback on this event and obviously have attended at all. First of all. So that's if you're struggling to get access, just feedback on the morning session that you've watched so far and it all should be accessible to you. Then after that, um also bonus content is that there's four keynote talks, three of which were live last year. So we've got one from Professor Joanna Wardlaw who talked about dementia imaging. And if anyone wasn't there last year, that was a very interesting talk given about kind of the future prospects of dementia detection and treatment. Um There's also one from Eric Kellar who's from Stanford in California, talking about professional identity and applied ethics in IR which is obviously more and more becoming more of a clinical specialty. So how interventional radiologists deal with that? And the other one was the keynote talk by Liz Yoko's who's the founder of worldwide Radiology and Karen Kit Kuti, who's based in Malawi, a radiologist over there. And they give a, a really interesting talk about both the founding of, of the, of the charity and also the work that they're doing in Malawi. So if you found that that interesting the Doctor Dr Duval talk and chat with Pascal there, then do absolutely watch that. And there's one final one on interventional neuro radiology and specifically throw stroke, thrown back to me. So all of those are in the catch up section for Rise 22. So I really do advise going to have a look at those. Um If the moderators, David Quinn Vivian, if you can pop, if your cameras are working, please do pop on for a moment. Uh Yeah, I don't know. You might need to stop sharing your screen, David. But uh all in all I think very um happy with how things have gone. I hope it's it's kind of come smoothly on your side. Um I want to thank David Vivian Quinn and the rest of the Edinburgh University Radiology decided for all their help putting this together and making it run as smoothly as it has. Uh And also thanks to Medal obviously for providing this interface. We will be available. Any questions you have Rice Edinburgh at gmail dot com. You can pop any comments in the comment section now. And as I said, I'm going to be over in the the application session for about the next half an hour, 45 minutes of anyone wants to talk about applications or wants to talk about anything that we've discussed today. I'm more than happy to have a chat there. But thank you to my fellow moderators and, and organisers and uh enjoy the rest of the weekend. But