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Um So what, what one you tell them about? OK, good morning. We must as well kick start because we actually live too. So there are virtual participation as well as face to face. And then if you want to grab a seat, come and join the right hand side. First, this, I want to thank all industry partners for sponsoring this event for all of you to be able to come. And so this is our fourth event in um since we launched this in 2020. So we did our first one before the pandemic and then we went into pandemic. We have uh a couple one year of virtual and then last year we came back and then, so here we are the fourth year and it's really, really good to see all of you make an effort to attend on this uh Saturday uh event. And we don further do we are gonna kickstart this event or let uh hen take over. Um I'm just going to pass the time to doctor Phil mcnay who is joining us on metal, um who is the founder of the kind of metal platform you won't see him yet, but you will see him now on here and I'll stop sharing. Thanks Helen. Um It's really great to be with you virtually today and just to send massive congratulations er, to the year's team on bringing together a hybrid event that's welcoming people from, er, around the world. Um I'm Phil, my background is as a doctor as well and we're really passionate about metal but how we make healthcare training accessible for everyone so incredible just to see the work that er that Helen and the team have done today to to bring this together. Um why are we passionate about that? Well, this is, this is why we need to train 18 million more healthcare professionals by 2030 but it takes 15 years up to $700,000 in countries around the world to train a healthcare professional. When you combine that with what the lancet describe a severe institutional shortages in our healthcare training capacity, we've got a bit of a toxic combination. We need to train a third more healthcare professionals on planet Earth, but we barely have enough training resources to teach and train the doctors that we already have. And unfortunately, where the need is at its greatest resources are at their least. And this is why we love to see amazing events like this accessible to colleagues around the world. There are 11 countries on the continent of Africa which do not have a single medical school for the entire nation. There are over 20 which only have one medical school for the entire nation and for us as a team, we find that intolerable and, and it's why we started to build metal, but actually it's not a problem that's confined to somewhere else in inverted commas. These are headlines from around the world from the last 12 months and it covers high income countries. Us, Australia, New Zealand UK, all facing staffing crises on BBC news only a few months ago. Uh The the headline was that the NHS in England was facing its worst staffing crisis in history. And I don't think we need to elaborate on those details. We've all felt it but when you look at the cost of training to the individual trainee, um you actually can see a bit of a problem here too. This is actually a a AAA slide about surgical training, but it applies across many specialties in the UK. And it talks about the cost of uh post graduate surgical training. So it doesn't include the up to 200,000 lbs of student debt, but it talks about the cost of the individual training of the post graduate surgical training. And it talks about how that's costing on average 20 to 26,000 lbs or up to 71,000 lbs. If you're an oral maxillofacial surgical trainee, 1300 lbs of that you'll see in the top right being spent on courses, conferences, travel tickets and events every single year and 41% of those people get zero recourse from their regional study budget. So it's a problem that's facing us here too. Why? Well, our, our buying power as, er, doctors is decreasing, it has decreased by 10 to 20% depending on the source that you look at over the last 10 years. And it has fed into a lot of, uh, the un, the un, un unsettled feeling in the profession over the last 12 months. And that means that um uh we find ourselves in a situation described really well by Maria Prill here, who is the eventually for the widening participation, medics network. And she says as a widening participation, doctor money is and always has been tight. Study budget covers one big course or maybe two or three small ones and you can insert the specialty you like here. So to meet core surgical training needs of the wealthy can easily treat the applications of paid tick box exercise with little actual development. And again, we find that intolerable at, at all, this isn't how we should be choosing the best doctors to treat our patients. Every doctor everywhere should have access to the same great healthcare training. It shouldn't be based on where you live, how much money you have or who you know, and that's why we've started to, to do what we do at metal. And we're passionate about making healthcare training, amazing healthcare training that you're getting from years to day accessible in every country around the world. And we wanna do that at scale. If we're really gonna tackle that big problem of 18 million more healthcare professionals, we've got to do it at scale. And when we started to look at how healthcare organizations were running that accessible teaching, we saw a really consistent pattern happening. We saw organizations being given technology that was really not fit for purpose. They were taking registrations on eventbrite bouncing people to a Zoom call pinging in a Google for link to collect feedback, ubiquitously, someone called Steve in an office somewhere manually making certificates of attendance, copying and pasting names, emailing it out to people downloading the video from Zoom because there was only a gigabyte storage available, uploading it after resizing it in imovie to youtube or Vimeo and then adding in the same Google form link into the youtube description so that people could watch on demand and give feedback on demand. And we thought if we're going to train 18 million more healthcare professionals with planet Earth, we ain't gonna do it like that. And so we started to build metal to solve a real pain for those organizations to automate that process end to end. So they could just focus on delivering amazing teaching, not all of the faff that goes with it. And maybe if we could do that, we could help encourage the healthcare community to share their teaching and training with colleagues around the world. And this quote inspired us to do that, ask yourself every day if your technology works to help the poorest in the world and to reduce inequalities from Dr Tedros at a tech conference in 2020. And I'm just gonna skip to uh a few of our last slides. Does it work? Yeah, I know. We've not got lots of time. So I'm just gonna skip straight to the um straight to the me because I wanna tell you a story about how this really works and the humanitarian impact of us making health, healthcare, teaching and training accessible to colleagues around the world. And it's this one last story in the spring of last year, we er noticed that we had high tens into the 100s of colleagues reaching out to us to say that they couldn't verify themselves on metal and we verify colleagues joining a healthcare event on metal because it keeps it really safe whilst allowing them to welcome the world and make it publicly um accessible. So we can trust that these are actually healthcare professionals who are joining and it's a professional event. But occasionally 1 to 2 times per week, we get people who reach out to us to say I can't verify myself for whatever reason. And in, in this one occasion, we had these people reach out and they couldn't verify themselves high tens into the 100s. And they said they didn't have access to their institutional email address and they didn't think it was that important to get a letter from their dean before they fled the country when we asked them why they couldn't verify themselves. And what we found was actually these were Ukrainian medical students who'd have their entire curriculum flipped online on a moment's notice. And a wonderful NGO based in London had recruited 250 doctors from around the UK to teach and train students in Ukraine seven times a day every single day for two months to keep Ukrainian medical education alive in a time of crisis. I think we're doing it as some sort of UK teach Ukraine imperialistic thing. They were doing it because they were freeing up the colleagues on the ground who would otherwise be f providing face to face medical education, to now provide face to face patient care and to bolster the medical resources of a war torn country. At that time, we have a real human impact when we make our healthcare teaching and training accessible and we're really proud to, to work alongside years today. Here's a quote from that Ukraine medical school professor who participated in that program. Thank you for everything you're doing for me, for the people who are trapped in this situation. And I saw this as a direct message to every single organization who's running accessible, teaching and training on metal. You are making an impact and you're welcoming colleagues in some of the most challenging circumstances around the world. We need to train 18 million more healthcare professionals by 2030. And we believe it's only by radical collaboration as a community that we can make that possible. If you wanna host a healthcare event, you can host it completely for free. If you're running a free and open access event, our technology is free and open access. We only ever charge if you're charging for your event and we're about half the price of event, right? Even if you're doing that middle.org/host, if you wanna just find an event to join metal.org/events, if you wanna watch on demand, if you live in a low resource setting, then that's actually really important. Or if you live in a high resource setting, but you just happen to live in northern Ireland like me, that's also still really important because the internet connection here is not that great either metal.org/on demand. I'm gonna leave you with this one last quote which is a quote from Sarah Fryer who's actually Jack Dorsey's CFO or was his CFO? She's on the board but Board of Slack, she's on the board of Walmart. She is the CEO of one of the largest social networks in the US called Next door. And her brother is an anesthetist in the UK. And this is something that she said and, and this is getting the, the attention of people, not just in the healthcare community, but also the people in the tech community. And that's what's really exciting is collaboration really wins. And I'm not saying this to blow her own trumpet. But there's two words in here that I think if we can get these right, not only as, as a uh uh a tech organization, but also as a healthcare community, we can really begin to make an impact. And those words are enabled and owed the medical platform has enabled and owed the medical community, the medical community, not us, the medical community to deliver medical education at a scale. Never before imaginable. I just wanna say thank you for years for participating in that vision, participating on that mission with us er today. And I hope you have a really wonderful er course er today, the program looks exceptional and thank you for allowing me to share a little bit about the work that we're doing at me. Thanks. Um See you. Thank you. Um So I'm going to drag you back home for now. Um People won't see you. So thank you very much. We'll see you later. Bye. Um So uh let me show the screen again. Um Just a couple of things for me. Sorry, I'm Helen uh president for exposure and also part of the student committee for years. Um I'm just here today. Well, to introduce things and just a co do a couple of reminders. So we're not expecting any fire testing today. So if you hear any loud, no, like a loud alarm alarm. That is a fire. So just go out via there's exits that you've come in. So either that way or that way. Um, and belongings wise, er, please try and keep them with you. Er, we can, if you've got like massive bags, we can, we don't have a room to store them. Um, but it's better that if you, if you keep them with you because you have to ask one of us to unlock it and the rooms. Um, so just let us know. Um I don't have my orange badge on me but um because the key, this was the key. Um, but all the other committee members have an orange badge. So if you need any help in terms of going to toilet or finding something, er, just let one of us know. Um, and then on the program, I just want to remind everybody about the afternoon activities. Um, the, the hands on interactive sessions, they're all in the massive room up in level nine, um, 9.58 you'll find a lot of people in there so you won't miss it. Um, the CV session is still running. So we've encourage people to send in their CV early on for a review and you can also have a 1 to 1 session with uh Doctor Chris Clark later on today and Doctor Vincent who's over there, um, about advice. Um, if you are convinced to do radiology by the end of this. Um So you're welcome to go and just ask for advice. Um And we also have a IR museum set up and that is being sponsored by the British Society of Interventional Radiology Trainees Group. Um And that is in the room also along the same corridor opposite the interactive session. So what that is, is a museum. So you can go in as if you're visiting a museum and uh kind of have a look at the items, read the information. Um You can touch the stuff. If the stuff is open, you can hold it and touch it. Just please please put them back exactly how you found it. That is the only request. Um Obviously, please do not take anything out of the room if that's all right. Thank you. All right. So I'll pass the time to pro to introduce our first speaker. Thank you. That has been an amazing start. So we have to continue the team. So everybody find out joining healthcare journey. And I think that um I just wanted to check, are you all medical students who are the support? So I know there are a lot of qualified doctors here. So we'll start the day by inviting my colleague, Doctor Costa Tires to talk to all of you about trauma in ir remember interventional radiology is a spectrum. So he's on Kickstart. Hi, good morning, everyone. Um Thanks to organizers for inviting me. Uh It's incredible to see how many of you, um, came here at nine o'clock in the morning on a Saturday, uh, to watch talks about radiology. So we'll try and make it worth your while. I'm gonna talk about trauma, uh, in, uh, um, uh, well, radiology in trauma, uh, and with a bit of emphasis in ir, so trauma is the most common cause of death in, uh, people, uh, under the age of 45 t which is an organization which keeps uh tabs on uh what is happening in the world of trauma in the UK. Uh Estimates that we have 16,000 deaths per year. Um A third of the major trauma patients are over the age of 60 there are people with um who sustain uh quite, quite low impact injuries such as falling down a flight of stairs. Uh And the estimated uh economic loss from, from, from trauma is huge is in the billions. So humanity has realized for, for millennia that trauma care needs a systematic and organized approach. And you can find references to that in ancient text. Um The first rudimentary trauma care systems um came about because of war uh and evolved in times of war. That's because you have the high number of casualties and a lot of resources together. Um So 180 Roman um uh soldiers um they introduced the first uh trauma uh organized trauma care with first aid kit and 24 7 availability of surgeons, the Napoleonic Wars um they brought in the fly ambulance, which was a big innovation, taking the patient away from the theater of war uh into um a, a rudimentary field hospital. And then the American Civil War uh was a major um advance advancement in the in in the world of trauma. They introduced things like life saving amputation, uh the anesthesia inhalers, um closing chest wound, um patient reconstructions and other um uh innovations uh including the levels of hospital care uh which we still use at uh this day, the first radiograph ever taken is on the screen. It was taken in 1895. Um So only six months after that, Italian Italian surgeons used uh x rays to locate bullets um from people uh injured in the Abyssinian War. So six months after that, six months after that uh time point, um x rays were taken on the battlefield in uh uh a war between Greece and Turkey and in fact, on both sides. So, um when, when there is war, the resources are there, the casualties are there uh and advancements happen by World War One. plain x rays were uh very um common on both sides. These are two iconic pictures um from civilian life that caused huge advancements in uh trauma care. On, on the left is um er Doctor Steiner's uh plane. Doctor Steiner was a um just a box standard American orthopedic surgeon with a private plane, you know, that kind of thing. Very, very common. He was flying his, his family to some holiday resort somewhere and crashed his plane and had to be taken to a rural hospital, uh, somewhere in the US. Um, and he was, he, he did not like the standard of care. He found it not organized and not systematic. Um, and therefore he introduced the ATL S which I'm sure you've all heard of, which is a systematic way of um of going through trauma in non uh trauma settings. So it's very, very common now. Uh in uh if you go to any hospital in the UK, you find ATL S trained doctors uh who um uh provide care on those lines. I'm sure you all recognize because you have an interest in radiology, a picture on the, on the, on the right. It's uh it's the first ever CT image um in the mid seventies in North London. Um uh CT came about um CT evolved. Um The first time I saw um an old uh old style CT scanner, a single slice CT scan um in uh in Huddersfield, sorry, in, in Harrogate. They even they were, they were um servicing their proper scanner and they brought an old time, a old style one slice scanner which took 15 minutes to do head and neck. Um So from that to what we have today, um a multi uh you know, a multi detector CT scanner which is capable of uh scanning the whole body in a single breath hold um with high spatial resolution, you can see absolutely everything and I propose to nothing. I always play this video. No, no. Yeah, there's only one reaction just when you think it can go any faster. It does that. So it's something else space age really. Um uh and not your book standard um um medical device. Um So the CT scanner has put radiology in the center of trauma care. So now we're probably part of the trauma team and when the patient comes into the hospital, er everyone is geared towards getting the patient to the CT scanner. They used to call it the Donald of Death because people were perishing it while um trying to get a diagnosis because they were bleeding and now it's definitely the, the, the, the, the to of truth, I call it because they come to you and they say, oh the patients got this that and the other and you, you don't even listen because you're gonna put them through the scanner and you're gonna give them the answers. So, um we try and get CT scans within half an hour of a seriously injured patient arriving to the hospital. Um We design the protocol so that we can pick up um the, the injuries that are suspected. Um There is uh the same approach as ATL S with the primary survey. We do a primary survey on the pictures to find out the, uh whether there any life threating injuries and take care of those first. And within one hour we give them a definitive report. And Ir um is there for hemorrhage control as well? I'm gonna speak about that uh in a, in a, a few minutes. So in the UK, in the last 10 years, we've split um uh the country into um networks for providing trauma care. There's a collaboration between providers uh in order to provide trauma care and in the middle of, of that network is the major trauma center. Um we are a major trauma center, least teaching hospital is one. Um There is multispecialty uh hospital optimized for the provision of trauma care. Uh All types of injuries are taken care of. Uh here at consultant level, uh care and trauma units are smaller hospitals typically which can receive a patient for uh urgent, urgent care. For example, if the patient needs intubation, um they'll stop at a trauma unit to get intubated and then they'll be brought to the trauma center. So if you have an accident outside in fe, the ambulance will pick you up bypass in fe and bring you uh into the L GI. So this is our network, this is to scale as how big the L GI is compared to the other, right? Um radiology um came about itself in, in increments because of innovations. Um And uh we're now uh at a stage where we have this type of equipment. Um This is um az device that uh um um hybrid suite uh equipment that we've, we've purchased recently. Um It has a robotic arm, um, the same type that you find any car factory in the world, um er, which is an extraordinary machine. Um It takes uh radiographs, er, and all sorts of imaging um uh capabilities. Uh and we do uh image guided procedures. Um You're gonna be able to see um some of the equipment that um intervention urology works from. I always try and tell people how it starts. It starts with a sheath, access into a vessel. Um is a tube with a hemostatic b at the back uh through which you can put in catheters of different shapes in order to cannulate any vessel in the body. Um and wires can be uh used through the through the catheters to guide you through the body. Um So here's a video of um of the beginning of an interventional procedure with a chief inserted into the uh uh common femoral artery, which is the main uh access point for ir. Um even although other access points points are, are utilized then through the sheath, um the Cavs of different shapes are introduced um and X rays are used to guide us to where we want to get to. And once we get there, when there's hemorrhage, we have an arsenal um of uh equipment uh in order to uh stop the bleeding. Uh these include balloon occlusions, uh embolization, um stent graft insertion and we also do hybrid procedure with, with our surgical colleagues. So, balloon occlusion, I'm gonna talk about uh Robo which is um uh the introduction of a of, of a balloon inside the, the aorta. Uh The idea is that if your patient is hypotensive because of hemorrhage, uh typically in the pelvis and lower limbs, uh you can uh put a balloon into the aorta cl the aorta, thus increasing the afterload. Uh so that you can keep the BP up the perfusion of the brain going until you can get definitive um hemostasis. So we offer that and for that reason, we've um we've made a robo bag. Everything you need is in a bag, you take it with you um anywhere um that the patient is where they're bleeding, uh trauma patients are in research typically, but you can use this in obstetrics in obstetric theaters, et cetera. Um So that's one of our hemostatic or our um weapons of dealing with hemorrhage, uh the balloon occlusion. He has a ct uh of um a patient uh with a partial robo, partially occluding the aorta at the level of the mesenteric arteries. Embolization refers to the process of occluding a vessel by introducing some foreign uh material in it. Um There is a particle embolization which blocks um the blood supply, the capillary level and then there is different sizes of embolic material to block bigger vessels. Um uh it get, it, it gets to the point where you can block. I don't know the internal Iliac art, for example, with a single device called the plug. Uh This is an animation of um the process of embolization. You have the a a catheter inside the vessel that you want to block and you deliver um the embolic um material. Uh and then you can check whether you've done the job. The vessel here is uh is occluded and therefore, uh beyond that, there will be hemostasis. Hopefully. Um Again, IR has come into trauma in incurrence and one of the main indications for using IR in trauma is in uh splenic embolization. So, splenic injuries when I was a kid, um go around on BMX spikes of just age myself. Um and very, very commonly you get handled by injury. Um And at least two of my classmates, I remember they went to hospital with abdominal pain uh after handled by injury and they had laparotomy and had the spleens taken out. Um trauma care evolved since then, we tried to conserve uh to use um to preserve the spleen with conservative approaches. Uh and embolization can help in that. Uh So here is a picture of an angiogram where you can see um uh injury inside the branch of the spleen and that is um embolized with coils um to avoid the need for laparotomy and splenectomy uh that can be used in, in other settings as well. Here's an example from a upper gi bleeding uh where the G da has been embolized stent grafts um is, are basically stents which are um uh uh I'm sure you're aware what a stent is, which are, which have a covering of uh of fabric um which uh can be inserted into the vessel to exclude an inju they're very, very flexible and um we um can uh deploy them in different ways. Um In this example, here, uh the access is from one leg, treating the leg artery in the opposite limb uh over, over a wire. So here are some examples of um from our center um where we use um ir to treat some difficult problems. Um This is a child who sustained plant injury to his abdomen. Um When we scanned him, um we realized that there is an injury of the abdominal aorta. Um That's a problem because the child um will grow. Um and therefore you have, if you're going to put a stent in, you have to put a kind of stent that um you can um expand as the child grows. So thankfully that technology exists because of quantitation of the aorta. So the cardiologist put them in and then they go in uh regular intervals and give them a stretch so that they match the diameter of the aorta of the growing child. Um So um the CT is the amazing CT scan can give you a, a different uh plane to see the injury. And you can see here the renal arteries and the injury in the infrarenal aorta. So here is in the angiogram, the computer has taken out the uh bones from the background and all you all you see is the roadmap of, of the blood vessels. Um and you can put in a, a balloon, expandable balloon, put it at the level that you want to put in and it beautifully excludes the injured area. Um uh And that pseudoaneurysm uh is no longer in circulation. Um Hybrid procedures are my favorite part of trauma care. Uh is when you have the is there or when you have the surgeon there. And typically, um it's when we can go in to provide solutions to difficult problems such as this case, which is my favorite case um that I was involved in ever. Um This patient was stabbed um through the liver and through the aorta. So this ct scan shows uh hematoma around the um around the aorta. Uh And you can see that the aorta has two irregularities in the wall, the front wall and the back wall. That's because the knife went through and through the aorta, the patient was severely hypotensive and stopped at the trauma unit, but he was about to arrest and therefore they're taking him straight to the theater for a laparotomy. But when they got to, it opened up, they realized that, um, they couldn't deal with this injury through laparotomy. That's because it was too high. So this is, um, the, er, sagittal plane of, of the CT scan that happened a little bit later, um, before the patient was transferred. Um, so you can see the spine here, you can see the sternum and the sternum here. You can see that the through and through injury in the aorta is quite high. So in order to control this, they had to open the chest, but they were in gear that they didn't have the, the uh the necessary expertise there to do that. So, um one of the vascular surgeons had to go from leads to uh Pinder fields. She had one look in the, in the belly and said, um we can uh this, this hemorrhage can be controlled uh with just packing with, with lots of uh swabs and we can take the patient to leads and deal with this endovascularly. So, uh three o'clock in the morning, you receive a call that says there's a patient with a BP that is very, very low. Uh in another hospital, the surgeons have opened the belly and they can't control it and they want you to go in and put a stent. And at that point, you're thinking back to medical school days and thinking maybe dermatology, maybe pediatrics have been a little bit better on this. Um but then you get yourself out of bed, take yourself to the hospital, um, and start the procedure. So this is, uh, the celiac axis, um, started the, the process, uh to find a landmark, uh, in order to, uh place a stent. Uh, and this is the stent, um, on, in, inside the sheath. So it's, it's crippled onto a, onto a sheath and you find the position that you want to put it in just above uh the celiac axis uh and uh covering the pseudoaneurysms. So once you deploy it, um and you uh check the uh the angiogram afterwards, the celiac axis is still patent and the pseudoaneurysm is excluded from the circulation and that is seen on the, on the subsequent ct scan. So, in conclusion, um IR is one of the latest innovations in a huge series of uh innovations for trauma care uh is a hugely rewarding um part of medicine to be working in. Um I'm, I'm uh part of the uh team in the major trauma center in Leeds. Um I work with uh an um surgeons who, who lead their, their uh respected parts uh in the process and we get together once a week, we discuss all the seriously injured patients that have been treated um in uh in leads um in a, in a period of a week, a few weeks beforehand. Um And there's always lots and lots of debate, um lots of different ways of, of approaching. Um they they injured patients and lots of um uh good stuff coming out of it uh and amazing stories. Um uh So if you get a chance to work in trauma, I have th th recommended as medical students or as senior doctors. Thank you very much. I'm happy to take any questions if there are any great because that was a, that was a great to, I was just, you know, you, you, you very nicely elaborate with the fact that if you have a small arterial bleed and if you want surgically approach it, less of hematoma around the surgery, get it, I, you can get it from the outside. So I was just from a medical student perspective if I were, if I were a medical student and I was in, you know, observing trauma in leads in A&E and a patient was being taken up to your theater. Would I be welcome to come and see the procedure? Absolutely. If you, if you have a, if you are attached to a, to a team, um, then it'd be, it'd be very easy to just follow um, the person you're shadowing er, into theater. If you, if you are anesthetics, the anesthetist will, will, will go there. Um, if you're, if you're, er, with the surgeons, um, again, um, you can, you can follow them there. Um, a medical student are always welcome in it. It's a teaching hospital. Um, it's um, uh, you might not get a lot of attention during the procedure, but I'm sure if it goes well, people love to show you the pictures of, of, uh, of how they, uh, prevented all these catastrophes. Um, take everything with a pinch of salt. But I think, um, and the second thing that you very elegantly showed was that innovation at such a short period of time, this speciality is innovated stuff so much, isn't it? And, um innovation comes in various ways. 11 doesn't need to be an expert in order to innovate. I hear that in the Iraq war, what people figured out when they had trauma and bleeding was some of the um female uh people who were around there. They realized that they can stick a tampon into that wound and that would swell up and stop the bleeding and it was working much better than a tourniquet and every soldier who went up tampons in their, in their backs because that was an easy way once you had trauma to your leg in order to stop the bleeding. So innovation comes in, I think, uh you know, if you, if you come up with ideas, you should go and tap on the doors of cost and say I have a new idea. So you're absolutely right. It, it's really fascinating to read how innovations come up in medicine. I thoroughly um recommend you doing that. If you, if you get into any field, just read a bit about the history. It is very, very inspiring how some people complete geniuses have taken the the the whole specialty to the next level. Thank you. Just have a show hand who wants to be a surgeon. Excellent, welcome on board. Because intervention radio is where you want to be. And actually, you know, I want to say this because I'm very passionate about this intervention, radiology. We talk about radiolog intervention radio. If you want at any time to join the profession, this the time is now because with a bias, you know, that's my disclosure. But the most exciting I stand for innovation because uh we have the greatest innovations, either we work with industry or you can innovate with the space. Because you see when you work as a um a healthcare professional in the environment, you are in it in the wall or in the current environment, you see gaps in the system that you can innovate to actually address the issues. And then that's when all the interesting things start happening. This is now. So University of Nexus Nexus Ma is the innovation hub in the trust. We have the innovation pop up now is the time to join. This is fascinating. We are really not only just translate in notation into our patient care, but there are some exciting things happening now. So without further, do I want to introduce my second speaker? Um My colleague is doctor here, he's going to talk about intervention, radiology in pediatrics. So I cool, thanks very much guys. So, so, so yeah, I'm na one of the um uh pediatric interventional radiologists who work here at Leeds. Um Thanks to um Z and Helen for putting on such an amazing er event. You know, it's really great to see the enthusiasm and the energy that they've put in to make this thing um happen. I think at her stage, I didn't even know what interventional radiology was and that's part of the reason I think she's, she's doing this. My thanks also to you guys as well. I know it's for a Saturday morning. I know where I would have rather been, but it's great to see that, that, that year over here. Now, I want to do something different here. I just wanna make this a bit more of an attractive presentation because I know you guys will probably get bored of me talking. Um So, so it really would be good if you can sort of uh participate in this. Uh And it also, it will help you kind of understand the innovative and interesting nature of, of intervention. So, pretty much every single case that I do go through all these steps that I'm gonna show you and I'm gonna illustrate it with, with, with, with a, with a case in terms of the instructions. Um Can I just, is it this one? Yeah, so, so what I need you guys to do is to go to this link over here at slides.com slash P IR or you, I don't know if you can even scan the, it's, it's, can I click on that? Ah, there we go. So, so if you, if you, if you can try and try and get that, that, that, that would be great. Um And what that will mean is that you guys will participate, hopefully it'll be a bit more interesting, generate some questions. Um and, and it, and it will show you the kind of the things that you need to think about before undertaking any intervention because you know, the last thing you want to do is do something which is not the right thing. Um and end up harming a patient and causing more, a lot more harm than good. So hopefully is everyone got that perfect. All right, we'll get back to my talk. Which one? Perfect, right. Excellent. Okie doke. So just a bit of background about, about the case. So this uh was a 17 year old male. So he's on the borderline of pediatric adult, but he did come to the pediatric surgeon because the adults didn't want to take him and, and he presented about six months previously with infective pericarditis. So he had some chest pain, went to see the doctor, they did an echo and they kind of diagnosed infective pericarditis from blood results and, and the rest of it and he had a bit of uh fluid around the, the, the heart, which is called a pericardial effusion. Um So he was put on long term treatment with antibiotics. Uh and, and he seemed to get better clinically. He then went to, went back for a follow up um echo. Uh that's a, an ultrasound of, of, of the heart. And at that four month scan, it showed that there was a mass within the heart and that kind of perplexed everyone. They weren't really sure what, what this was. And so what they did was that they performed some cross secular imaging. Uh and this, these are some images from the the MRI scan. So you can see over here he's got so this front patient back of patient size over here. So, so you can see that this over here is the heart and this thing over here is, is the mass that they saw on the echo, this thing over here and this is a sagittal section of the same thing. So again, you can see this thing over here compressing the heart. So it's a affecting the uh the outflow of the of the heart. So, so there again, Okie Doke. And then this is just a fancy Mr picture just to show you that we do some fancy pictures every now and then. But but you can see the heart beating and, and you know, sort of affecting uh the, the function of the heart. OK. So the first question is this, what is the differential diagnosis? II don't want general things. I don't want like some massive amazing diagnosis just like general things which, which you think that this, this, this might be. Um. Ok, great. So, we're, we're Rh sarcoma, lymphoma, aneurysm teratoma tumor. Excellent. Yeah. Yeah. So, so when I, when I was a, a trainee, um, my, my, one of my tutors told me a, a good way of thinking of differentials and just when, when you go to an exam, if, if you tell your examiner three differentials, then that's great. That'll pretty much get you out of trouble and, and the three general things are tumor. So tt tumor trauma or infection, OK? Or you can rearrange it and make some other interesting word if you want. Um But as long as you come up with that, so tumors could be things like lymphoma, rhabdomyosarcoma. Um uh if, if it's infection that it and, and we know that this kid's already had an infection so he could have an infected collection. Uh So, so, so that's another thing in, in the differential. Um And then, and then the, the, the other thing is trauma. So if he's had some trauma, it could be like a big, big blood clot. OK. So in terms of differential, I'll just bring on the next slide. Uh So, so the, these are the main things that we were sort of thinking about. So, so the most commonest thing uh would be an atrial myxoma. So that's a benign tumor of the, the, the, the atrium. Um they tend to be so, so benign tumors tend to be the, the vast majority of, of cardiac tumors. But we've got to remember that cardiac tumors are really, really rare. OK. And then there are other things, the these malignant tumor sarcomas and, and um some, some of the malignant type of tumors and lymphomas we've also a already mentioned. Ok. So the next question is, what are the options? So, what should we do about this? Now, we, we found a lesion in the heart. What do we do? And I'll get you started. Um, just move on right here. So, yeah, what, what are the options? So I'll get you started. So number one, we can do nothing, you know, can we just say, well, let's just observe this, this, this kid seems to be clinically. Well, it's not really causing any problems. Why don't we just observe it and maybe get a follow up scan in, in, I don't know, couple of weeks or whatever just to see. Is it growing, is it getting smaller? Um, how the, how I II is, is the kid actually getting better or is it getting worse in which case we might be forced to do something? So, yeah, we could do follow up. Yeah, so we could do surgery. That's, that's absolutely right. Obviously, everything we do carries a risk. So if we just decide to follow this kid up, the risk is that if this is a tumor it's gonna get bigger and bigger. It may start to metastasize and that's gonna be worse for, for the, for the child. Yeah, we could do an operation, but that's gonna be quite a big invasive thing, isn't it? Like cardiac surgery is a massive thing. Soot toy, you're gonna have to get perfusionist. You know, you, you know, there's a high risk of mortality, high risk of complications, stroke. Uh um MRI the rest of it bleeding and the rest of it. Biopsy. Yeah, that, that, that's, that's a, a good option. But again, biopsy is gonna be, it's gonna come with its risks, isn't it? That there, there could be complications related to the, to the biopsy? But they're all, they're all, all, all of these things that they are, all, they are all good idea and, and, and things that, that we kind of thought about. So, yeah, we, we could observe biopsy or, or we could resect the thing and get the surgeons to, to resect it. So the next question is if we were gonna biopsy it because we're interventional radiologists. So we're just kind of thinking a bit head here. Now, how, how, how can we biopsy this and that's bringing back the P one second. So how, how, how can we biopsy this again? Just, just sort of general ways on, on how, how, how we, we could biopsy this. So, so, so number one, we, we could do it as radiologists. So, you know, we could get a needle, get an ultrasound machine or, or a CT scanner and, and put a needle in, watch the needle go in. So, so that would be 11 way of doing it. Um Yeah, CT guided. OK. But which, which other specialties might, it might be able to help us biopsy it so we could do it as radiologists. But who else could biopsy this? Yep. So intravascular. So that, that's right. So some cardiologists do en endovascular biopsies, that's where they pass the, the, the needle or a catheter first up through the veins towards the heart. Uh and then they try and aim the catheter and needle towards the, towards the, the, the, the tumor. The benefit of that is that if the tumor or, or, or whatever the, the biopsy bleeds, it will bleed back into the circulation. So it bleeds back into the heart. So they don't get any loss of blood if that makes sense. Ok. Perfect. Yeah. Ultrasound guided. Yep. Pathologist is obviously, once we've got a specimen, we're gonna send it to pathology. Um But the other way is that you could get the sur surgeons to do it. You know, the surgeons could open up the chest and, and, and, and take samples, you know, they, they don't have to resect it completely, but, but they could just take a sample. The problem with that is again, it's gonna be quite an invasive thing. Uh And also if it turns out this is a malignant tumor, it's then gonna make things difficult for when they actually do the definitive surgery. So anyway, the, the, the patient, they, they, they went back to um uh the, so, so what we do in these sort of complex cases is we, we have what we call MDT. So, so multidisciplinary meetings and everyone clever sits down and they have a big discussion about what the right thing to do is um there's no right or wrong answers here. But, you know, we all have a discussion and we think, well, what's gonna be in the patient's best interest. And so what the MDT decided was that it's probably better to biopsy this rather than resect it or do a follow up scan. So they came to me and they said, well, you know, you're probably gonna be the best place to, to do this. Can you, can you biopsy this? And so if anyone ever asked you to do that as a radiologist, what you need to do is you need to see the patient yourself and you need to scan the thing because if you can't see the thing and, and you don't think there's a, there's a way of biopsying it, then you shouldn't be doing it. So I brought the patient down being a pediatric uh intervention radiologist. We use a lot of ultrasound. So, ultrasound is my preferred go to technique for when I'm doing a biopsy or any um intervention. Um the benefit of ultrasound is that it's, it's dynamic. Um And also there's no radiation involved. Um So, so you, you know, you can do it um really, really easily and, and sometimes we have young patients who don't like stool. So if you, if you need to do a CT scan, for example, you're gonna have to do a, a general anesthetic II in order to, to, to do that. Whereas ultrasound, you know, you can get someone just to hold the kid down and, and just do the scan. So I brought the, the, the patient down. We we did a scan and you can see over here. So this is the the the kind of the the skin over here and then the razor coming through, this is one of the ribs. Um And this over here is, is a mass. So you can see that you can see the mass with, with ultrasound. This over here is a lung over here. And then I use a higher frequency probe and you can see again, we've got skin up here, this is the muscle layer over here. And then this over here is kind of coming in between the interface of of the tumor itself. So again, we've got the rib over here. So, so this is the tumor. So it looks like, yeah, we probably can get to this, you know, there's nothing in the way really. I mean there there there is lung up here but actually if we got a needle in through here, we should be able to get into that. So I thought, yeah, ok. Sounds reasonable. Why don't we think about doing that? Ok. So then the next question is OK. Technically possible, right? But what are the risks? You know if I do the biopsy in this child, what what, what potential risk might I cause? So let me just show you this image. So, so just, just have a look at this image. So, so this is the lesion over here. OK. So there's all these structures in the way that may get damaged in, in the way and that this is what you've got to think about. So you've got lung over here, you've got this white thing over here, white on, on, on, on CT usually means blood vessel. There's another white thing over here as well. And there's this big thing over here which we all know is, is the heart. So let me just bring up the polling software again. So, so what are the risks if, if I do this biopsy? And I've got to tell the patient that these are the risks. It's difficult to sometimes quantify uh the the actual risk. But, but you've gotta be upfront with the patient. You've gotta say, well, if I do this, I might do this, I might call this and I might cause that complication and then you kind of let them have a bit of an informed um choice about whether or not they wanna go ahead with it. Great. Yep. So, bleeding again, that that's a really, really big, big uh um risk, obviously, if we damage the heart, then, you know, we're gonna get loads of bleeding. There were those blood vessels I showed you as well. Um Yeah, pneumothorax. Absolutely. So, so we may end up going through the lung. Although on, on the ultrasound, it looked like, you know, the lungs seemed to be away from, from there. So, so, so we may cause a pneumothorax. Ok. Great. Yeah, absolutely. Yeah. So, so I quoted AAA figure of um 5% risk of death. I don't know where that figure came from. It was actually the cardiothoracic surgeon who quoted that figure. But, but yeah, you've got most of the, you, well, in fact, you've got all the risks that, that I, that I wanted to, to, to hear. So, bleeding. So, so yeah, the tumor itself could bleed. Ok. Um This over here. Does anyone know what this vessel is? Internal mammary artery? Ok. The the cardio cardio cardiothoracic surgeons like this artery when they're doing bypasses, there's another vessel down here as well and th this is the right coronary artery. Ok. So this could be damaged and this is the reason why the endovascular surgeons didn't wanna do do a biopsy from, from within because they were worried that they might damage, damage this thing over here and then cause cause an M I. Um And yeah, pneumothorax, we we've talked about, OK. One way of, of, of trying to minimize the risk of pneumothorax. This was something that I learned whilst I was doing the biopsy is that we can collapse this this lung down. Ok. If you collapse this lung down, this tumor will then kind of come closer towards the, the chest wall. And the way that the, the anesthesist cleverly did that was they, they used a double lube and, and a tracheal tube. So essentially what they can do is they can preferentially allow breathing on one side of the lung and they can block the other one down. So what he did was that he blocked the right side, which caused that lung to collapse down and it brought the tumor nicely into, in, into view. And then, you know, the patient was ventilating on the left lung and this is something that they do all the time actually. And you know, is to, to me, that's quite, quite an interesting thing. So, so I I'm learning all the time as well. A and, and again, that's the sort of innovative side of, of, of, of um interventional radiology. Ok. So now we've told them about the risks, we've told them what complications may happen. So, what the next one you need to do is try and mitigate those risks and those complications. So who should be present in theater when we're doing this biopsy? Bearing in mind we, we've thought about all those um tho tho those complications. So back to your uh mobile phone, you can do a bit more voting and uh or typing. Ok. Patient. Well done. Yeah. If you've got no patient then yeah, we're not gonna be able to do anything, are we? And that would have been AAA lifesaver for me. Actually, I would have thought. Yeah, great. Um Because these are obviously u usually they're very, very anxiety provoking because you think, you know, these parents have actually put this child in your care saying look, there's nothing that I can do but you might be able to save my child and sometimes that's very, very humbling. Um So, so, so, so yeah, and it we we need to put this patient to, to sleep, correct? Yeah, we need the cardiothoracic surgeon. So I made sure that the cardiothoracic surgeon was inserted but not just inserted but scrubbed with the gloves on, ready to go, you know, with all their blades and all their tools just in case we had a bleed and they needed to open up straight away. Yeah, it's good to have a cardiologist as well. So, you know, they may be able to provide some informa some, some help in terms of medication and and other, the therapeutics. Um, yeah, vascular surgery. Um, osteo surgeon, radiologist. Yep, obviously I've got to be there to do the procedure. Um, so there, there, there is another sort of radiologist. So, so I do mainly nonvascular, but I do, I do lots of venous work as well but, but I do mainly nonvascular. But there's also these clever guys over here, most of these guys, they're the vascular interventional radiologists because they can help if we cause a bleed. So that that internal mammary artery that we talked about at the front. If I damage that, for example, these kind of guys can come in, put in their catheters and then they can block off that artery and stop the bleeding straight straight away. Great. You guys are doing really well. It still be interventional radiologist, right? So yeah, th this is what we should have. So, so we need an operator like probably me. Well, it was me on the day. Uh We need a nest, this cardio surgeon, we need a perfusionist as well. So if the patient needs to go to bypass, we need to make sure all that equipment is there and the perfusionist is ready to, to kind of put the cannulas in and, and, and get the patient on, on bypass. Yeah, interventional radiologist um and, and a cardiologist as well. And yeah, these are some of the things like that we need. So yeah, a chest drain kit just in case, we call it a pneumothorax um embolization stuff which the vascular interventionists had had brought with them. And this was a dual lumen endo tracheal tube which the, the anest cyst had and yet. And a a a AAA cardio pulmonary bypass machine. This is just an intro picture. So you can see that that's the needle in. So it seemed like we, we, we were doing really well. So yeah, and lots of things we've obviously got shot pad here as well and you know, the anesthetic um machine o over here. So yeah, II mean I got in there, I got some really, really nice views of of the actual tumor, put the needle in uh and and managed to get some some good cause apparently this, this is the way people used to diagnose death in the past. If, if there was any doubt, what they would do is that they would stick a needle into the heart and they would look to see if it moved like this. So, so we can tell this patient is alive. Anyway, these are the pictures I got in intra op. So, so you can see this. This is uh the rib over here. Skin's at the top here again, but this is my needle right into the middle of the, the lesion. So, so we managed to take some nice biopsies. II normally do about 8 to 10 biopsies just to make sure we get enough tissue. Uh as I was doing the biopsy, I suddenly saw this artifact. You see all the speck things. I spot the difference. And I thought, oh my God, what's happened here? So the next question is which complication do you think? I'm, I'm worried about it might be difficult for you as med students to, to answer this because you don't know much about ultrasound but, but just have, have a, have a go. Let's sir, just get the uh polling software back on. So o of those complications we mentioned, we mentioned about bleeding. We, we mentioned pneumothorax and, and we mentioned death. W which, which of those that might be OK? All of air embolus. All right. Yep. Yep. Great. Yeah. Yeah. II II mean the, the, the main complication that I was worried about was pneumothorax. But actually pneumothorax doesn't quite look like that, although it looks similar, it doesn't quite look like that. No, normally you get uh this white stuff just over the top over here. Does, does anyone know what this artifact is? Just to shout out? So what happened was that what unknown to me, the, the uh the anesthetist had a um a transesophageal echo. So essentially had, had the transesophageal echo looking at the heart from, from inside and they used ultrasound as well. And, and the reason he had that was to make sure that this patient wasn't gonna develop a pericardial effusion cos then we need to act on that immediately otherwise they get tampered out. So he was doing his ultrasound at the same time. So I was doing by ultrasound and so the ultrasound raved by bouncing off each other and, and that's what give this, this gave this pretty ask about. So as soon as I told him to send his machine off, we were back to square one which is over here and I took a few more biopsies. So, yeah, pneumothorax. OK. So, so post biopsy. So the biopsy went well, we, we sent the, the samples off, got them analyzed. Um What we do is something called a fresh frozen sample where the pathologist looks at the slide, the the the the pathology sample. Um uh I immediately or within within half an hour just to make sure that we've actually got representative tissue. So it just makes sure that actually, you know, they've got something to, to, to go on um A and we waited to get confirmation of that. Uh uh And once, once that had happened, we, we then w the patient up and then POSTOP, you've gotta put down what, what things you you need in terms of um follow up for this patient. So there's no point doing a biopsy and then saying, I'll see you later. I, you, you know, you take care of the patient, you've gotta tell them what you want to. Um ii in terms of for the patient because you know what complications may occur. You know, the ward doctor may not know what that this patients at a high risk of bleeding or a high risk of the thorax. So you need to clearly document all of that in your in in your notes. So, so with this patient, because a relatively high risk biopsy, we made sure this patient went to cardiac ICU, he had continuous ecg monitoring uh just to make sure his heart, his heart didn't go any from the arrhythmia. Um He had regular echoes as well just to make sure he didn't develop a pericardial effusion because again, that's something that should kill the patient or causes significant morbidity. Um And then we also did a, a chest X ray regular intervals just to make sure he didn't develop a pneumothorax. Ok. And the thing that you're waiting for is is actually the the biopsy result. What did it turn out to be? Well, what happened was that 80% of the tissue was necrotic. So, so it was kind of dead tissue, interestingly, no malignant cells were seen. And that was probably the main or the most important thing because if there were malignant seen cells seen, then it's something that, that we would have needed to, to act upon. So the working diagnosis is um inflammatory myofibroblastic tumor. And what we decided in the MDT. So again, we followed them up in the MDT is just to do some follow up imaging just to see what happened? And the follow up, Mr did, did show that the, the lesion itself had reduced in size. So it's all heading in, in, in the right direction. Cool. So in conclusion, um the whole point of doing this talk was just to show you that, you know, whenever anyone asks you to do a complex intervention, it really should go through a multidisciplinary team meeting. And that's the way medicine works these days. There's no point in you making your own decision. I mean, obviously basic things, you can make your own decision, but complex decisions should be made with a big team with really um kind of all, all the people who might be involved in the care of that patient should be there just to make sure we're not doing something stupid. And you, you do really do need to make up that adequate work up before you per perform any, any procedure. And that's thinking about, you know, how you're gonna do the procedure, what are the potential complications and also how you may mitigate those, those complications. Uh A a and then finally think about those risks. A a and, and how you, you know, you shouldn't really be doing a procedure unless, you know, you might cause this complication and also how you're gonna deal with it and just make sure that everything is sort of uh taken into account. Great. Okey doke. I think that's it. Have you got any questions for doctor ta I get to the top first. No, no, you're fine, thank you. Hi. Um, I'm 1/4 year medical student. I was just wondering what is the kind of age range, um, and most common presentations that you work with? So I II work with a range of patients. So from zero to, from, right, right. From birth all the way up to, I mean, this, this, this child who was 17. So he, he's a teenager but, but I sometimes do up to about 20 because what, what sometimes happens is that the, the patients are under the pediatric team and, and they get attached to them and then it's difficult for them to leave it. If, if a new patient comes in from the age of 16, they'll go to the adults regardless. But if you've already got a patient on your box, you know, I still treat patients who are 20. Uh, but, but it's a massive age range but it's not the age, that's the important thing. It's actually the size. So you could have a 16 year old who looks like a five year old. For example, it's, it's the size that, that's really important in, in pediatric, but a very varied range of sizes. Thank you. And I push your valve here, go over. I could probably hear you. Um, so you a um, and I just wondered if, when you get that figure of the CP and, and, and if so sort of because I understand obviously why as pediatrician or as part of a pediatric team, you don't like CT, but would that have significantly augmented the odds of death in this procedure if it was CT? Yeah. So, so, so that's a very good question. So, so I think that the risk would have been the same regardless the, the downside of doing it in CT apart from the radiation is that you're away from theater. So, so the majority of our CT S machines are down in, in, in a different department that, that there are some intraoperative CT S, but they use slightly higher radiation. And if we're gonna do a CT guided biopsy, it's not just a matter of doing one CT, you'd probably have to do four or five CT S because you're gonna advance your needle and each time you advance it, you want to take another CT just to make sure you've not actually caused uh another complication. And each time you do a CT takes, you know, it, it'll, it'll take like 30 seconds a minute or whatever to kind of look, look at the images. So II did wonder about doing a CT but, but the fact I could see it all sound guided and ultrasound, very dynamic. Um And you know, you see the images straight away. I thought that this was a way to go forward. We, we did have the capability of doing CT in the, if, if we really needed. But, but it was only as a, as a backup because there were, as I said, there, there were limit with CT. It's not an instant thing. It takes a bit of time. It's got to reconstruct the data, you know, and with within that minute, you know, if you got a, if you developed per card effusion, for example, patients gone into tamponade, you know, that minute could be really critical. Thanks. Sorry. Did, did you have a question as well? Sure, sorry, sorry, I didn't, I didn't see you before. I'm sorry about that. Um So I've spoken to a lot of people who actually have a quite a big debate between doing kind of pediatric, pediatric surgery and pediatric ir um So kind of what are your kind of your insight on, on kind of this and how it is gonna go in the future and kind of what range of condition do each manage and how do they kind of overlap? Yeah. Again, it's just that's a very good question. The the thing with pediatric IR is it's a very kind of developing specialty. I mean, I started 10 years ago and we did, I think that whole year when I started the year before rather there were only 14 cases that, that, that we did that because no one was really interested in doing pediatric ir the following year when I started, we did 214 cases purely because I was kind of running it. We now do over 1000 cases a year. Um And when I started, I was on my own there, there's three of us now doing, doing similar sort of work and even still we're inundated with, with work. There's a lot more that, that we could do, but we just don't have the manpower all the time, time to do it. For me. The reason I chose pediatric ir was that II, like kids, I think they're very fun. They're very interactive. It's a bit of a skill to do, to deal with Children. You, you've got to deal with the parents again. That's, that's another skill I really liked ultrasound and I knew ultrasound was a really big thing in pediatric IRA. And also there's a lot of interaction you have with the rest of the specialties like from, from the adult side. I II think quite, quite often, you know, you know, they, they may just go ahead and, and just do a procedure but pretty much every single case that I do involves the, the physicians as, as well as the, the surgeons a and, and they tend to be a nice bunch actually, compared to the adult counterparts I II find pedi pediatricians on the whole, generally nice bunch of people not there to kind of, you know, take, take things against the, the, you know what I mean? Like they, they are really, really nice. They, they wanna work to together work, work in collaboration. Having said all of that, there are some downsides to pediatric ir so, so nn number one, every pretty much everything we do has gotta be done under general anesthetic and, and to do something under general anesthetic, 10 takes time, you know, you, you, you've got to have a n this present, it then takes probably about 20 minutes for the patient to go to sleep and, and in that 20 minutes you're kind of waiting, twiddling your thumbs. You know, in that time, Costa could have embolized a, you know, an artery or stunted and an aorta for all, for all I know. But, but it takes time. Um uh num number two, it's very anxiety provoking. Like I said, you know, these parents are actually trusting their child with you and I've had 1 kg babies. You know, you can literally put them in the palm of your hand, having to put them inside central line. And I'm thinking, is this the right thing that, you know, I could kill this patient even with this little needle? You, you know, it's really, really anxiety provoking. Um So, so, so, so that's, that's the other downside, I guess. The third thing is if you're really in it for the money, there's hardly any money in pediatric ir but then again, you're a doctor, you've got food on the tails, you've got a car, you've got a house, you know, you actually need more money. Do you know what I mean? So, so, so, so y yy, you know, these are all things that probably don't really, as far as I'm concerned, you know. Um, you know, the, the fact that every single day is, is different for me. II get a chance to interact with loads of different specialties and I get to you, you know, at the end of the day, the parents are so grateful. Um uh uh And not only that, you know, I'm in demand for pretty much all the time and sometimes that can be a bit of a bummer. But actually, yy, you know, someone comes down to the department saying, oh na you know, you can really hold us here, please. Can you tell us what, what we should do over here? Sometimes that makes it kind of bring on that sort of humbling feeling that gosh, you know, I'm so lucky that I've been given the skill and I can help people make a difference. So, so yeah, they're, they're probably the main reasons that, that I came into it, but there, there is a shortage. So, you know, you know, by all means, speak to me afterwards and, you know, we, we can try and sort things out for you and uh facilitate things. Thank you. Yes, that was a very excellent interaction. I have to say to you that you'll be fascinated today because uh you don't know what we go up to. So um the, so the last talk before um the the quiz um announcement is actually my colleague, um Doctor Omar Abha that was very close with me. He's gonna give you guys a really amazing talk on intervention, oncology, omma. That's the deal. Hi, good morning, everyone. Uh Thank you very much for the introduction and thank you to wire for inviting me to talk. You guys have done a fantastic job as always organizing uh this, this committee and organizing this conference. I just wanna say kudos to the students again for coming in nine o'clock on a Saturday. I'm very impressed and to the guys tuning in from home, I'm very jealous. So just gonna talk briefly about intervention oncology. So my name is Omar. I'm an interventional radiologist in Leeds and my self specialist interest is intervention oncology. So I find myself a very small and tight niche and just a bit about my background and where I am so far. So can anyone name this is the most intractable? We get to this session where the image on the left is any ideas where that is Greece? Our nice. Oh, I wish Margate absolutely sunny southeast. Margate. So I grew up in Margate in the Southeast and I went to University in London. And the reason I got these images is at this time in my life, all I ever wanted to be was a pediatrician who wanted to be a pediatric doctor. It's gonna be amazing saving these children's lives and then all changed when I became the foundation doctor. Anyone know where this is? This is where I did my foundation f I one, this is a much harder one actually. Sorry. Oh, close. It's, uh, you can tell I've got an affinity for crap seaside towns. This is South end I got from south end. So, um, er, it thinks we get better but it was here that I met Professor Iris Grim who's a neurointerventional radiologist. And she did a talk at the beginning of mi 51 and she said that I had a patient last week who had dense hemiparesis couldn't move one side of the body at all. Did the thrombectomy and the patient shook my hand with the side that they couldn't move. I said that's just something else sci fi, you know, unbelievable stuff that people are doing and I didn't believe it until I saw it and it is real. And then I was introduced to this world of IR. That was really fascinating, um, really growing emerging field. We were doing some amazing things and many, many invasive techniques and these offering therapies to patients just, just weren't available and this was back in 2014. So about 18 years ago. And you could think about the time that's happened in, in the interim period, the development and the improvement in those service and those therapies. So then I came to at least teaching hospitals. Uh And I've been here for the last seven years. It's a consultant job and I put down roots here. What's interesting about fun facts about the south east in Margate. It has the highest number of days of sunshine per year. So it's one of the warmest and sunniest parts of the UK. I can't say that about leaves, unfortunately, but I've adjusted. I bought a big coat and I've become a proper northerner. So what is intervention oncology? Well, it's what's considered the fourth pillar of modern oncology care. Traditionally speaking, there are medical therapies, chemotherapies, um immunotherapies, surgical therapies where you go in and resect the tumor radiation therapies, which are really broad but delivering radiation to try and kill those cancer cells. And then we've got a new emerging field which is the area that we work in. The exciting area. I want to talk to you about that's intervention oncology. And broadly speaking, there are three main categories and three main areas and that's image guided ablation. So, delivering energy into cells directly and killing those cancer cells, trans arterial chemo embolization. So, going in and getting the blood supply and delivering agents that into the blood supply. And then similar kind of thing with radiation therapy going in the inside and delivering that radiation therapy into the tumor supply. So we start off by talking about image guided ablation and ultimately, it's delivering energies to cells to try and cause apoptosis to try to induce cell death and then ultimately cure the cancer. And there are two main categories of energies. Really, there are heat energies. So that's microbe ablation, radio frequency ablation, and there's cryotherapy which is freezing energy. And we're gonna talk about those very briefly and then give you an idea of the different kind of things that we can do. So, here's an image of a typical interventional oncology procedure. This is an image of our intervention suite at Saint James's. And you can see there are lots of things going on here. You can see lots and lots of probes going into the patient over here. And you can see these two big screens over here. This is called a navigation device. And this is a really interesting innovation within intervention oncology. That means that we can deliver these therapies to harder to treat lesions, harder to reach lesions using the capabilities of technology and A I. So what here we have a camera. We've got fiducial markers and what it does, it maps out the body maps out where the ribs are, maps out where everything is. It reads the data of the scan that we've inputted into the machine. And then we tell the machine where the tumor is and what it does using the camera is when we put this arm on, loaded with a needle, it will tell us which trajectory we need to take on the surface of the skin in order to target that lesion to make sure we get a direct hit and treat the ablation appeal. The reason why this is really important is that it's emerged. So now the case, we can treat tumors basically anywhere because you can target really hard to reach lesions before we couldn't do free hand. And this is an example of innovation within that sphere. That means that we can deliver these minimally invasive techniques to cure lots of different kind of cancers. A couple more images of the close ups of this kind of procedure of these kind of things. So this is what we expect. Patients are an exercise. You can see general anesthesia in the background. And here's an image in the, in the top left that shows what we're doing on the inside. These are ice balls and we're creating spheres, ice spheres within tumors to try and ablate them to cause their cell death. And it looks a bit mad that we're putting this into bodies, but we do and it works. So we're carrying on to do it, I think. And I've just got some CT images. Now, I know a lot of your medical students. So this is just uh shades of gray and black and white, but we'll talk through them briefly. So here's a tumor, then interpolar RCC in the medial aspect of the right kidney. And what we've done is we've taken the scan, identified the tumor and then we map and target our, our root into the tumor itself. And these are some probes heading into the tumor itself. And we go into the next images, you can see that that ice ball is forming. So you see this slightly darker gray going around as that ice ball forming and that tumor is getting ablated. Once that's finished, we finish the procedure, the tumor will gradually reabsorb the it will start to break down and the kind of the blood and the hematogenous spread, the hematogenous um, hematoma will just end up dissolving into the system. A slightly different view which shows the ice will forming really nicely. And the advantage of this is that we're sparing lots of healthy normal kidney. The alternative to this is surgery, we can do partial nephrectomy. Surgeons are fantastic at getting really clear and nice margins, but you are inevitably taking away more tumor. Plus it general aesthetic, laparoscopic open, you're going through a surgical process. This is putting patients to sleep, going through the surface of the skin, passing a few needles, turning the machine on, turning off, taking it all out and then you're finished and that's a really nice and rewarding thing about it. So we thought that doing these kind of things are a bit too easy. So then we find harder ones. So here's a tumor that I treated just a couple of weeks ago actually. So this is a lady with a 4.5 centimeter tumor. She had lots of comorbidities. She's not a surgical candidate. And you can see, so this is a tumor in the lower pole of the left kidney and this is small bowel and you can see the small bowel is basically sat on top of the kidneys touching it. And we wanna deliver these therapies, we wanna make sure we get all of the tumor. So if we're going to do that in this position, we're going to unfortunately involve some of the small bowels. So we need to think about clever techniques to try and move the organs that we don't want to treat out of the way and only treat the lesions and the cancers that we want to. So what do we do? We get them into the room, move them in position. You can see the small bowels move slightly, but then the colon got in the way. So you win some, you lose some. So it's good with one hand, take away with the other and then we start to plan away and try and get into the tumor and you can see that we're starting to make progress. We've got a needle into the tumor at the front a couple more, couple more. And then we start to get clever. So you've got all of these needles going into the tumor itself and then you've got this needle coming into that side. And what it's done is it's found a gap between the colon and the tumor and then we inject loads of fluid into it basically. And what that does is it moves away the healthy normal small bowel that we don't want to treat. And it gives us a plain so that we can create an iceball to just treat the cancer. And you can see treatment going on and there's the ice ball forming. So you can see that that ice is really nicely encompassing the tumor. You've got a really nice clear ablation margin. This white fluid going around the outside is fluid that we've injected. And then you've got the codon safely. Well, away from that patient woke up the next day, minimal pain, no problems with the bowels, went home, the cancer's cured and here's just a, a kind of a different view to show the eyeball formation of some of the things that we go through to try and get a good margin. And then if you're really brave, this isn't one of my cases cos I'm not really brave. This is one of professor w we've got a tiny lesion at the front here on this lower pole, this er, right kidney, the patient's not got another kidney. So they're known to form cancers. They've already had one kidney taken out, had surgery before they're growing tumors. What we can do with these is we can leave them, see how they get on or we can. So, actually, this is somebody who forms cancers and we've seen how cancers grow before. So we really need to get on with this rather than, than leave it. And we need to act sooner rather than later. And when I looked at this image, I thought, well, there's no window here cos you've got colon, you've got liver, you've got a lot of kidneys trying to get in from the other way. I couldn't really see a window. But this is experience and expertise. It shows that with a bit of persistence, you can get to anything. So we've got the tumor here. It's got into a slightly different position. So we've got a window coming in just beneath the liver, but there's a lot going on here. It's still colon, it's still small bowel. There's still this big thing called the IVC. So we need to be a little bit careful about our routine. But here's some progressive imaging. You can see really nicely targeted straight into the tumor. And then what has done is injected some contrast and move all of that small bowel out of the way. And then we've successfully delivered the therapy in into the eye. We got a really nice margin and a successful outcome for that patient. And that's a way of trying to minimize damage to a normal healthy kidney. If somebody's got a single kidney, the alternative is a partial nephrectomy or a nephrectomy completely. I mean, you're, you're essentially condemning patients with dialysis. So this is a really nice innovative technique to try and keep these patients going for as long as possible. Just a quick example, we're talking about heat energy. So this is a microwave ablation of a liver tumor HCC. And this is giving some ideas about the navigation software that you use and the planning that we can use to target into these into these lesions, finding these roots in. So this dark area is the the lung just around the tumor. The tumor is very high up in the liver. In the past. These are quite hard to treat. But using our navigation software, we can direct it all the way up. And you can see here, you've got a nice big margin. This is all tissue that's been burned away and there's a scar in the middle that really dark scar that shows that we've got a nice treatment margin. We heat these, these uh these lesions up to 100 and 40 100 and 50 degrees. So we really are cooking them to make sure that we really get on top of them. So moving on from ablation, talking about taste. This is something that I thought was really cool when I heard about it and I thought it could be the magic bullet for cancer treatment for H CCS. But unfortunately, it it hasn't progressed in that way, but it's uh highlighting the different routes that we can get into tumors. So all of our arteries are connected in the body, you go in in the femoral artery, travel up, find the branches and essentially deliver co chemotherapy gets coated onto these plastic beads that then insert straight into these tiny plastic beads that go into the tumor, stop the blood supply, but also deliver that chemotherapy. The idea is to shrink back the tumor initially. When it was devised, the thought was this could be a cure, but unfortunately, isn't. But what we have done is demonstrate that by shrinking these tumors back, slowing their growth, making them smaller, they can then go on to alternative therapies later on down the line. So that's sections, transplants, et cetera. And here are just some images to show some of the work that we do. So we've got here this really dark blob at the top, lots of blood supply to it going in selectively, going gradually up injecting our beads. And you can see that afterwards, you can't appreciate the vascularity to it at all. So that's a sus successful treatment from endovascular perspective, similar kind of thing with radiotherapy inserting radioactive beads, VC in the same method, try and shrink back those tumors and make them smaller. And um you think about the side effects of radiotherapy, the effects on the skin, the effects on other organs. This is a way of really directing the therapy purely to the treatment. So let's think about the future. What's next? This is a really nice thing about IO we're doing all this fantastic work curing all these tumors. But what's next, what's the next stage? And the next big exciting thing which thankfully needs to be involved in is using ultrasound beam waves to try and treat these tumors. So that's delivering high frequency ultrasound way of using a, a robotically controlled transducer and delivering those energies straight into the tumor c. The advantage of this in there are no needles. It's all through the surface of the skin. You can go in and cure someone's cancer. Get out and they won't have anything stroke it whatsoever. You think about the progress of that compared to years ago when we were doing laparotomies, we've come a long way. Think about what's after that. It's even more exciting. And here's just a, a short video demonstrating those effects going on in real time delivering. Yeah. Hi, the areas. So and here is just some serial ct imaging from early day to and early studies showing that that progression and how effective it works. So we've got this high white area that's a HC, a tumor. And then we've got the treatment after day one week, one and eight weeks. And you can see that the liver around is starting to regenerate and heal the central layer of cancer is gone and that's cured and that's purely through medium of ultrasound energy. No needles involved, very much, very little risk. And the next thing I wanna talk about is that we're real evidence is on the horizon. So when I went to spectrum, which is a um intervention Oncology conference in North America, it's in Miami. It's absolutely beautiful. It's ridiculous place that they talked about and presented some of the really exciting evidence of really exciting trials that are coming out that will change the face of how we interpret and think about interventional oncology. And there was AAA professor of surgery who stood at the front and said, I'm a surgeon. I know I'm in a room of interventional radiologists. I truly believe that if interventional oncology came before surgery, it would be the gold standard. The only reason surgery is a gold standard is because it came first and we start to see that with evidence. So the, the Dutch group presented a collision trial, their preliminary findings five days into their study and they essentially showed that this is a for, for understanding, it's a randomized controlled trial, head to head ablation versus surgery, which is better when they presented their findings. Halfway through their study, it was 96% likely that treatment for ablation is more cost effective than surgery. It is 90% likely that ablation is either better or as good as surgery. When you combine those two factors together, you really feel like this is a field that we're emerging in. It means that we'll do more and more of these because patients are being offered, offered alternatives with real durable. Um evidence to back it up. And that's something we haven't had in the past and a similar kind of thing. We're in the very early stages in the UK, looking at comparing partial nephrectomy, full nephrectomy versus ablation and that evidence will emerge in the next, hopefully in the next decade to show that ablation is as good as surgery. And you can tell patients at the moment we don't tell them, we tell them that surgery is 100% effective and that ablation is 90 to 95% effective in the future. If you say, well, they're just as good as each other. You give the patients a choice. I think a lot of people become more and more towards minimum invasive techniques. The last thing I want to say is that healthcare is a quite a hard place to work in. And I think any as a medical student, seeing people going on strike, seeing people um being discontent or not happy leaving medicine is a really hard thing to see. But the thing, all the stressors are working in healthcare is a really rewarding, fulfilling practice and there is really nothing like it. You, you, you see these patients on a Thursday morning, they come and see you. They have a cancer, you do their treatment, you see them on a Friday morning, they're sat in the chair in their clothes, they look at you and they go was everything ok? And you go, yeah, it's absolutely fantastic. Everything went really well. He goes, well, I was worried cos I feel completely fine, I feel like you canceled the procedure and you didn't do anything cos I feel completely normal and that's a really rewarding thing. You can tell someone that their cancer's gone, you treated them and they feel completely fine. That's something that's really, really nice and it's something that hopefully you'll get to experience as doctors when you finally get to work. Um Just try and find a specialty that you really enjoy and just know that things can change over time and what you think you want to do may change in the future. Don't let that off. So I'm happy to take any questions. Do you have any questions? Thank you. That was really interesting. Um So one other question I've got is that I think a lot of IO treatment is actually still very referral dependent, um either from surgeon directly or from MDC. Um I personally work in Derby, I just, I still see a lot of kind of, you know, three millimeters exophytic tumors being taken out like radical nephrectomy and complications. Um And I know that there are a lot of evidence coming out kind of in different io treatments. I'm just wondering kind of kind of what are your thoughts and, and kind of ethically if patients are not actually even offered these choices, kind of, you know, how can we put this forward and kind of, you know, improve the situation there and kind of just what are your insights. Yeah, you're absolutely right. It's a problem, especially in hospitals that don't offer the service locally and that's something that we need to think about and we're privileging leads to work in a sense. We have a really well established DT where these patients with cancers are discussed centrally, decisions are made about each one and then we decide what's best for them as a group as a collaboration. In other senses, it's not the same. Unfortunately, where the option of ablation isn't readily available. So you're gonna have to refer to another center. It introduces time and because there's no representation in those MDT S, there's an inherent bias. In this case, you're prescribing particularly towards surgery. What we try to do is really encourage those centers to know about us to know that they can refer to us. We treat loads of patients from derby and loads of patients from Manchester all over the country for people driving up from Northampton for ablation. It, it's absolutely amazing but the point is that they need to know about them and that's really hard with time. I do believe that these centers will develop their own ablation practice so that there is a radiologist in that N DT saying, hold on, have we thought about ablation in him in this patient? And that will take time and it will take training and it will take resources, but I do believe that it will come far more commonplace across the UK so that people do have an option. Ho you know, thank you. Thank you. That was brilliant. So, um are you guys fire out because uh this is so you look at intervention, radiologist, like minimally invasive surgeon, but the best part is we also do imaging. So there is very few specialty you can diagnose and you can treat and you can follow them up all in one stop. So um I don't wanna over sell this, but I graduated um from, in fact, I used to sit in that row actually as a bad student, I graduated from here in 1995. And um really exciting for all of you. I actually wanted to say that despite all the challenges you hear in the news, remember when there are crisis, there are huge opportunities. Remember that? In fact, this is now the fun time. So don't let any all these things put you up. But the thing is you, any anyone of you haven't uh look at a TED talk by Simon S the why? How and what to find out why you're doing what you're doing, which specialty you're choosing? Even with intervention, radiology, there's a big spectrum. So choose the one that can inspire, wake you up, you know, like, you know, we're all loving every space, but we're all doing different things. And I know and then, but then this thing is just, the area is always gonna fire up. And I'm actually in my last decade now, in my uh frontline career, I like to think so. And um but I II still love my job. You know, I really, uh you know, I, I'm still loving it despite the fact that the, the challenges never go away. But then I love looking after my patient and their first and foremost. So find something for you. Uh because you can find that place. You will excel because you're just doing something you love. So I'll pass it to you. I think that's, I think there's a quiz announcement. I think Edam and Nick and one is that your stage before we have our copy break. There you go. Yeah. So I think c basically has highlighted everything we've said. Essentially three of us are some of the ir trainees uh place in the region, but we've done a quiz. It's just a bit of fun. It's basically trying to give you a bit of an introduction to some equipment, some history, some device and procedural stuff. Um I believe there might be a prize at the end. I'm not 100% sure. But um we'll be going through the answers later on uh to try and give you a bit more kind of background information. So just have a go and later on we'll be able to go into the office. Thank you. That's it. Thank you. Yeah, I know we are running behind our schedule. So we will give everyone a break now. Um, and we're gonna reintervene at around uh, in 10 minutes time, quarter to um, yeah, the quiz you can take a, we'll show it up during the, the break. You can do it throughout the day as you learn more. There will be a prize, uh which um, after we've collected every, everything we'll contact you via, via email, most likely. Is that all right? Any questions, any questions from online participants? No. Ok. Um We'll see you back in 10 minutes then. Thank you. Good. I lost my eyes to I was. Mhm I Yeah. Ok. Thank you. As a as you're settling down, do you want to um do you wanna take a pot shot? When was the first uh intervention performed? Take a guess, fifties, sixties, seventies, any takers 9, 1964 apparently on 16th of January 1964. So we're uh we're not too far away from uh February. Um uh Welcome back to the second session. The, the first talk in this session is uh uterine artery embolization by my colleague. Doctor say, um when was the first uterine artery embolization done? Do you know uh hamed? It was some time after 1964. And, and the reason I asked you specifically was, it was apparently done by a neuroradiologist, not an interventional neuroradiologist, a neuroradiologist in 1974. A French radiologist, but having said that one had to wait until 19 nineties before it got popularized for fibroids. And the excellent Doctor Saeed is going to take us through it and tell us how the whole thing found out. Hi, thank you very much. Um There have been absolutely fantastic talks. Um My talk today is uh to tell you a bit, a bit about IRS role in uh obstetric and gynecological emergencies. And the person who introduced me, Doctor Rugu has a lot to do with um with um with, with the, with the service that we use in, in um how and this my story, it's just right. So how can interventional radiology um help in uh obstetric and gynecological emergencies? Um We all know there are a lot of different types of gynecological and obstetric obstetric um emergencies. IR is mainly helpful in two postpartum hemorrhage and um abnormal presentation. And we're gonna talk a little bit about that as we go on. So how can I help? What is the basic mechanism we come to embolization? Now, Costa has given an excellent talk and he's talked about all different types of plugging that we can do in order to control the bleeding. Um So what is embolization? It is plugging up of arteries or group of arteries? And basically a simple example is a tap running and you basically close it, either reduce it to dripping or completely close it. In 1864 A Russian surgeon actually said in a new era for surgery would become if we will be able to stop the flow in major artery without exploration, external compression and ligation. So back back then they, they had, you know, the the the idea or the basis of intervention, radiology without exploration, without surgical intervention opening up, you can, you can stop major traumas, you can stop major bleedings and control traumas, right? So that's the mechanism is embolization. How do we access it? What's the technique? Um Again, it's been talked about. So I'm just gonna quickly go through it. We always obtain, well, uh mostly obtain access from the common femoral. You put a sheath in which is, which is called a valve. Uh he hemostatic valve. So you can use a six french femoral sheath and the catheters through them are of different um shapes and sizes. So you're going to the common femoral on, you're going to the common femoral. I don't know if you can see my arrow. Yes, you can common femoral over here and you leave a pigtail catheter above the bifurcation. You do some runs just to, you know, find out the anatomy of the pelvic as we all know, common iliac arteries, bifurcate into internal iliac arteries and external iliac arteries. And then the internal iliac arteries are basically the arteries that we're interested in because that's apply the MTA division. Um uh is where the branch, the uterine artery branch comes off. And then with the help of the catheter, you go over the bifurcation from that side and then you get into the internal artery and this is a patient who's got fibroids. You can see a very hypertrophied, sort of tortuous artery. How do you get into that? You basically use micro catheters. So the, the main catheters are called the parent catheters. There's six French inside them, you can introduce smaller catheters, which are called micro catheters. And you can get your way into the smallest of arteries and, and treat. So that's basically the technique of how we get into the arteries. What do we use? So previously, when there was a major trauma bleed in obstetric gynecological in any sort of trauma, patients would have a big cut in the abdomen opened up and you would ligate the artery, find the artery which is bleeding and ligate it or put a tie around it. What do we do? We do an internal tie, which is basically costa spoke about it already. So it's like a metal, um metal coil or spring which comes in different sizes and shapes and it could, it can be deployed through catheters. Um and you can deploy it, it physically occludes it and then it, it, it attracts thrombogenesis. So you can see on the angiogram over here. Um That's the, that's the a small catheter on in one of the branches of the internal iliac artery which is bleeding. Uh uh there's extra of contrast, we've put con we've put coils through it. Nice result, right. So what is distal embolization usually in fibroid embolization? We cause we, we do distal embolization. It's basically your catheter, you can leave it in anywhere in the artery proximately and you inject particles like PVA and embosphere which are very small micrometers in sizes and they can flow with the blood flow go distally and block smaller vessels And they can actually cause tissue ischemia and necrosis and very good for fibroid embolizations. Um The difference between coiling and distal embolization is for coiling. You put coils in big arteries, so you still leave a room for collaterals and the organ can still get blood supply. These are, these are permanent embolization which you know, which go into smaller vessels and cause tissue ischemia. So no chance of forming colla collaterals. That's why they use more in, in fibroids. So I can see that the catheters is uh the microcatheter is based in the internal artery in the uterine artery. And contrast um is injected through it and that's, there was one is the other and that's the position and from here with particles and, and as I said, you know, you can inject particles approximately and they flow in um to, to distal vessels. Ok. Right. Um Then balloon occlusion, we've already, we've already talked about balloon balloons. You can put either if it's an emergency and patient is bleeding, you want to control, you put a balloon in the aorta. Um We talked about rabo um balloons. Um You can put them in the aorta, you can put them in the, in the common ileac over here or you, if you have time, you can put them in the internal Ilex which we will talk about. Um So all the embolization that we talked about uh um and not, not uh talking about the balloon but the particles as well as the coils are permanent embolization. What is gel form, gel form is eight. So if you smaller pieces, you put it through small um small syringes. So you put them in a syringe like that and then you obviously need to know where exactly they're going. So you fill another half of saline and contrast and with a three way tab, you make you form a nice slurry and then the mixture is ready to be injected. So they did they temporary um embolize form of embolization. So they kind of dissolve in three months. So the blood supply can be restored. So, in, in, you know, in gynecological and obstetric emergencies, we use gel form uh quite often because it's, it's temporary for the same reason. Yeah. So the two most important things that we can, that I can help is as we already talked about is the postpartum hemorrhage and the abnormal placentation for postpartum hemorrhage. There are certain, you know, causes that you have to remember forties tone, tissue trauma and thrombin. Um and these are the causes which can cause PPH um just briefly through them abnormal presentation. Um you know, different types of abnormal presentations. So normal presentation, um then you have placenta accreta, which is when the placenta goes deeper into the wall of the uterus. So in accreta, it um it is, it uh goes into the endometrium, increta, it invades the myometrium and then percreta is when it invades the cirrhosa and goes outside the wall of these. So there are different types of um different types of place, abnormal placentation. And we're just gonna briefly talk about in um uh the next few slides of how um the treatment has changed over time. So if there's a postpartum hemorrhage, um usually this is what happens to an aesthetic team and obstetricians, they work together. And in the 1st 30 minutes, it's resuscitation of the patient and everybody, all the teams are doing their own things. And then obviously, the medical treatment, you, you're putting lines in fluid resuscitation bloods come in after 60 minutes. Obviously, if there was no, if there was no control, then you think about surgical options. So, balloon tampon uterine artery ligation opening up and then thinking about uterine artery embolization. We think that if Trina embolization was brought forward and done earlier, it could actually, you know, and it has proven that it has saved lives, uh less loss of blood and saved time as well So this is basically our hospital Royal infirmary, the blue building, the Women and Children Center, which connect ok, on the second floor, main floor to say, you know, previously, what used to have was if there was any abnormal presentation of people or patients who they were known to be, you know, at a very high risk of bleeding after delivery, they were still delivered in uh the women and Children, you know, S and G the and then if there was any bleeding, they were transferred all the way through this corridor um into the IR department, we will be, we will be ready for them. But you know, if you, if any of you have ever been in, in and have ever seen an s can lose a lot of blood within seconds. So time is very, very important and this is, this video is made on a day where, you know, you can see all the trolleys. So you have a big team running, you know, with anesthetists, with obstetricians, gynecologists, pediatricians running with the patient um um staff. Um and this is the, when the, when the hospital was actually it was during evening time. So not a lot of people, you know, on normal days, you have people talking about patients going in and out. Um And you know, it, so it takes a lot of time. So um um Rau who's actually they took, took the lead on this, um said we, if it's a lot of time. Um I'm not gonna go through the whole video but it takes about 11 minute 47. It may not seem like and it's on a day when they are not, you know, the corridor is empty and there's not a lot of people around. It will take longer. This is, they're entering into the, into the IR department. Now, this is Iri R department and you'll see within a second. Doctor Rago waving on the side, see me. Um So it, it takes that much time. So in order to save that you can use, you can, we, you can lose liters of blood. What do we do and what we have done, right? So hybrid theaters, as Costa said, it's his favorite, favorite thing. It's our favorite as well. It's much more controlled. What is a hybrid theater. We have a hybrid theater and it's basically you can do interventional procedures as well as open surgeries, but nobody used it for hysterectomies and for babies. Um uh you know, to be delivered. So planning and timing is key to success. You always think interventional radiology. And so we have been using this hybrid theater for delivery as well as his Hysterectomy. The whole team. We have a whole team. We have um um a whole group, uh an email that, you know, if there's any case, an email gets um to everybody we know about the patient. We did sign the date on that date, we have a whole team of obstetricians, gynecologists, pediatricians, anesthetists, IRS, all of them O DPS, the staff, they're all there. Um looking after the patient. So what happens? Step one um under local anesthetic. So the patient is not put to sleep yet. We get access into both groins and we go up and over and we put balloons in the internal eyelids on both sides. We don't inflate the balloon, We leave everything in position. The patient is put to sleep. Um So this is just an example. So you can see uh access from both groins. Um and both the wires up and over on both sides. These is the internal dilate arteries and the balloons are placed. So what is step two patient is then put to sleep and when the patient is put to sleep, the patient have ac section, the baby is delivered and the cord is clamped. After that, you inflate the balloon. So it's it inflate the balloon. Um and it's more controlled way. So you've inflated the balloons in the internal IIAC arteries which are supplying blood to the uterine arteries. So the placenta is removed. So if there's abnormal placentation, obviously, previously, people used to go, the definitive treatment for that is hysterectomy. What are you doing? You're doing it in a more controlled fashion. So you've inflated the balloon and then the placenta comes off and then you slowly deflate if there's bleeding a lot of bleeding, you, you have the balloons in place, you inflate it again and then, um, you, um, in the lights, the balloon positioning. Um There's been a lot of people doing it differently. Some people inflate the balloon in the infrarenal aorta, uh just above the bifurcation. Um, so you put in one balloon in and, uh, that takes care of both the internal iliac or you can put two balloons in the common iliac or if you have time like us, when we do it in more controlled fashion before the C section, you can put it in more accurately in the internal iliac artery without blocking the blood supply to the, to the leg or, or, or both legs. So, embolization of uh uterine arteries, obviously, this is one of the, so we talked about the type, the PPH, this is one of the example of uterine A 20 when during delivery or after delivery. Obviously, the uterus loses its tone. So there's a lot of bleeding from a lot of places. So this is how it looks like. Um uh So you, we've, we've done a run from uh the uh above the bifurcation and then we go in selectively in this case, obviously, um we've, we've got catheters, we've got the balloons inside. So all we do is replace them with catheters go in a bit more selectively into the uterine arteries and then you've got the pre and how it looks like post. So, and we use gel form for most of the um the emergency cases. It's a nice result. So another obviously you assess the bleeding again and if there's still bleeding, you go in and do further embolization. Um after that, right? So what are the concerns? The main concerns? Um and questions that usually um you know, the mom to be or patient or everybody else ask is are there any femoral artery complications? What is the, you know, the risk of radiation to baby radiation to mom and embolization effects where the long term embolization effects, femoral artery complications are there but not very, very high. Um um You're talking about hematoma, which is the highest 1 to 2% without any serious um um um sequela uh pseudo pseudoaneurysm formation, retroperitoneal hemorrhage, less than 2.2% thrombosis and dissection. So, the risks are actually low as compared to the benefits that the patient gets from the. There have been a lot of studies, there's still um an area which is not very clear. Uh But there have been some studies which have strongly suggested that there is no effect on fertility after embolization. And basically, the embolization that we do is from gel form, which is a temporary form of embolization. Um And the artery that you've put the gel foam in can be is recanalized within three months. The risk of radiation again is, is not very high. It is um it is uh low apparently the, the lifetime risk of cancer in the UK is 50%. So that's much higher. So, as compared to that, the risk of radiation, just a quick one, we actually looked at a few patients that we did in our um um uh hospital. Um So a total of 16 patients, nine patients had accreta, five increta and two per accreta and they were um treated by um by, you know, they, they all went through the same sort of um uh uh planning. Um So uterine preservation was actually um happened in 66% of patients. So nine out of 16 patients, that's quite good. Um In comparison to if you compare it with previously, when people used to do just hysterectomies for abnormal presentation because the bleeding was so much and they were unable to control if you compare it with that, it's quite good. Um Hysterectomy happened in seven patients which is 44% total blood loss was um um a bit more than 3 L. Um So estimated blood draw ranged from uh from 500 to 5 l 500 mils to 5 L. Um and average average on average um patients lost about 2 L of blood. So overall, there were no fetal complications, there were no no patients required repeat embolization or reexploration in the future. There was no mortality or significant morbidity following the procedure, there was no site, access complications, you know, access sites, common femoral complications. Um only two patients required one day of ICU admission. Um mean duration of hospital stay post delivery was five days, which is fantastic. Um And 14 out of 16 patients were at home by the fifth day. So that's actually a AAA brilliant achievement. So conclusion embolization is an effective method for control of BPH and abnormal presentation timing is very important and IR plays a crucial role in that. So always um think of that. Um there are complications to be aware of. They are rare but they are there. Um um But obviously there's more evidence needed and more, more cases need to be done, more evidence. Thank you very much. Have any questions? Any questions? Good fun. Thank you, sir. Thank you. Um It's great talk um about this topic which uh keeps me up at night quite literally sometimes, especially when I get the talk uh the call. So we are more reactive than you guys um in that we don't go in beforehand and, and put the, the balloons into the internal uh we um get the call to say we're standby. Uh And uh if there is a need, we, we do robo. So we include the, the AORTA. Um And I've heard a recent uh podcast episode from uh a podcast called Back Table, which is an American podcast in intervention ology. And I was amazed because the whole program was about um the uh postpartum hemorrhage uh team in the same sense that there has, there's ap reactive team or um, or a stroke team, et cetera. They have a postpartum team and there's a postpartum crash call and they, and they, and they, they react in the same way and it looks like you guys are, are going, are getting that way. So, um my question is, did you, I find a lot of um um blocks in your way to a lot, a lot of problems in order to get to the level that you have got to, especially the access to the hybrid suite. And that looks, that sounds like a, a big uh hurdle to overcome. How did you find that process? Yeah, it was a difficult one. Ragu. Do you want to talk about it? I don't want to because I II Yeah. Hybrid suit fee is an IR and I think you have to look at the overall and when you start every, you know, anything, there's a lot of, there's a lot of um what your resistance from a lot of people because it's some, it's something new, you know, ba babies getting delivered in IR with something new. What do they do with them? What happens to the babies after they're delivered? Um So it was a learning curve for all of us. Um How do you initially, how do you transfer the patient? What sort of, you know, positioning you need? But because obviously for hysterectomy, you need different. So yes, we it's, it's, it's multiple meetings. It's, um, we have a good team of s and g good relationship with them. A good team of an, an, they're all on board and all all you need at the end of the day is a good teamwork, isn't it? And everybody enthusiast and everybody knows that they, you know, what kind of benefit you're gonna get out of it. Um, so, yes, I mean, it's not something that happened overnight. Um There was a lot of trial and errors, there was a lot of problems initially and obviously, um yeah, Rgo being the lead, I didn't wanna. So he's presented it in, in, in a lot of conferences and meetings and slowly and gradually over years, we we improved. Um So, so yes, there were a lot of hurdles of uh it's, it's, it's uh it's, but I think measuring risks versus benefits because previously people, patients used to be nr uh if you see, if you look at our department, there's a, there's, there's this, they're not there two separate buildings, the women and Children in the hospital. Um Even now if there is a patient who is at high, high risk, not all patients get done. If the patient who is not at, at, at very high risk, they get done in um women and Children and we kept on standby. So that happens, but then is so many problems there with the X ray machines, not there in those theaters, it's a separate theater. It's not main theater. So it was so I think overall, um there were a lot of plus points and a lot of doing it in IR in a more controlled fashion. Great. Uh So thank you because we just, just make your documents and just implement with all your hard work. I don't wanna put you on the spot, but I think it's, it's extremely important for me to ask you this question. Um You're a female in IR it has nothing to do with obstetrics. We have a dome here, sat in front of you. Professor Wall. You also are part of the diversity equality, you know, part of the BS I and I know that there are a lot of medical students looking at you. Um Do you really enjoy it? And if so why I love it? Uh to be very honest, like, I don't know, I mean, um the professor actually asked who wants to be a surgeon? I think when I was a medical student, all of us wanted to be surgeons. But when I actually started working and practically i surgery just, it was, it was exciting, but it didn't excite me that much. And II, the, the, the turning point was I didn't know anything about interventional radiology and that's why I'm very enthusiastic whenever I'm asked to come and talk to you about IR is because I had no idea what intervention radiolog. It's sad. But the first time I found out about intervention radiolog is when I was a foundation, a one doctor. And I just randomly signed myself for an IR session and it was an IVC filter and I was just chatting to the nurses and the, the, the intervention radiologist, um, started the procedure and he turned around and he said it's done in like two minutes. And I was like, well, wait a minute, I thought it would be a very, you know, huge procedure and, you know, you're putting an IVC filter inside the IVC, but that was back in 2007. Um things have changed and I, uh you know, and, and I just, and I always wanted to do hands, I always was, you know, more hands on. I wanted to do, you know, interact with patients, more hands on more procedures. I II love doing that. Uh It's a, it's a ch, it's a challenge but I think it's, it's, it's probably not gender based. It's a challenge for everybody. Um But to be very honest, all you need is a good support at work and a good support at home and everything is just very, you know, becomes easy. Um So I love it. I would never um um look back to and, you know, I enjoy everything. There's so many things happening, so many exciting things happening. And I think if you're passionate about it and that's, that's what's the most important thing being passionate about it. Um um and just takes you wherever you want to go. Oh, yes. Oh, apparently, um 20 million people in this country have musculoskeletal problems. I was looking at it and the question is, you know, interventional radiology has gone into virtually every speciality as you can see. And we are very fortunate to have uh uh Doctor O Gray. He's come all the way from uh uh Portsmouth Southampton. Sorry, very near. And he's gonna tell us a bit about the gamut of what IR has achieved in M SK radiology. Thank you. Hello, everyone. Yes. So my name's Aidan. Um I've been asked to come and have a chat to you about the role of uh intervention radiology in er musculoskeletal disease. Um I was hoping to come into you that um you should definitely choose IR as a specialty. Um, but I think people have already done that already. So I'm just gonna hopefully to that and you can stay convinced. Um I think this is one of the fastest growing areas of radiology and I think it's gonna be huge in people's careers later on down the line that are at our similar stage and hopefully I can er come into that. So just before I start, if I can move ASL. Yeah. Yeah, cool. So I always say thank you to these people that have supported me uh in our research. So, Press Mark Little er, and the team at the Royal Berkshire and then um the team at Kiel that have spotted my anatomical work as well. So just to sort of start by discussing the role of um how big big M SK disease actually is. So essentially one in seven of those precious GP slots that we are so desperate to get into will be taken up because of musculoskeletal disease. And one in five people in the UK will actually go to their GP to discuss musculoskeletal disease every year. So, why does that matter? Well, the fact is that we're not actually that great at treating some of these problems. So of the years lived with disability in the UK, actually four are musculoskeletal disease related. So I'm gonna use osteoarthritis. That's the area that I know most about, um, to really demonstrate exactly why we have such a problem. So in osteoarthritis over the age of 40 around 23% of people will have some form of oa and the knee is gonna be the most common area for that to affect. So nice, gives us, uh, a treatment summary of how we should, er, approach these patients. So it's three steps, it looks like this, don't need to read it. I'll talk through it just very briefly. So there's conservative management. So, physic therapy, exercise and weight loss, then you have pharmacological approaches. So that's mainly paracetamol and topical nonsteroidal antiinflammatories and then moving on to oral nsaids and then if those don't work and you have severe disease and that's important. You must have severe disease. You'll go on to have potentially surgery. Usually in the form of total knee arthroplasty. There's a few issues. So, weight loss, huge problem in the, you know, in the, um, developing world and, uh, in the sort of, er, first world countries as well, um, it's not that easy actually to get people to lose weight and manage their weight. So that's an issue. The second thing is that the evidence around how well pharmacological methods work is strong to say that they do have some improvement, but the improvement they bring is actually not that great. So there's many patients that actually these pharmacological interventions don't work or as we all know from your GP placement and things like that, lots of people can't take nonsteroidals orally cos they've got renal disease, they've got risk of peptic ulcers and that sort of thing. So they don't work in that, in that, really that relation either. And then onto joint replacement. So it's a really successful procedure in the right person. So they've got to have severe disease. So the question then rises, if you've got mild to moderate disease, that's limiting your life and causing a lot of pain and these things at the top have failed. What option do you have? The answer at the minute is nothing. So that's one of the reasons why we're trying to develop a procedure called tacular artery embolization to help these people. The other thing is that if you're of the age of 50 the lifespan of the uh prosthesis is around 25 years. So you're likely to outlive that. So, again, there's big risks for revision arthroplasty. There's a 30% chance of chronic pain and there's a massive mortality related to a morbidity uh related to those surgeries as well. The last thing is comorbidities and these aren't in the studies yet. But people that have got COPD, heart failure, that can't have these kind of surgeries, you know what options do they have. And again, it's just the things to the top really. So how can I help with this whole gambit of musculoskeletal disease? Well, I split it up into embolization and non embolization procedures. So, these are currently all of the areas that people are looking in. It's not an exhaustive list to embolize in order to try and treat. And the most developed of those is genicular artery embolization for the knee. There's also a whole other gambit of non embolization techniques. The most developed of which is vertebroplasty and kyphos corrective um things for insufficiency fracture. And you might see that in your local departments, if you, if you were asked to go and see those procedures, there's also ablation for tumors and things that's a lot more um specialized in probably more related to oncology, but I've just er, included there just for a total list. So, I'm gonna discuss knee osteoarthritis and, er, genicular artery embolization and just to put a little bit of a different spin on it, I'm also gonna discuss how to actually develop a new procedure. Um, so the way I look at it is these four steps. So the first thing you have to know is what you're doing. So you have to have a pathological understanding of actually what you're targeting and why you think that will work. The second is you have to have evidence that when you're doing this thing, it's safe and that justifies you to try it on more people and then try and prove that actually this thing works. And when you know all of those things, you can take it to a body like nice and say, look, this works and this is safe, but we need some money and this is the number of people we're gonna try and treat and this is the group. So just to start off with the pathology. So this is the only pathology slide just for everyone's nerves. Um So only won't go on for too long. So most people look at osteoarthritis, a wear and tear disease of joints over time and it's increased by injury. But actually, when you look in the lancet and other reviews about osteoarthritis, the there's a change in tone to looking into wear and repair and actually how the joint tries to fix itself is actually part of the problem of why we get the pain and the disease. So why do interventional radiologists care about this at all? But the main thing is that one finding is that you get neoangiogenesis. So that's new growth of vessels into tissues that are either avascular like cartilage or have very little vasculature like the synovium. And they found that alongside this, you have the growth of new nerves and the reason for that is they share a cellular lineage. So, and it's proposed that these new nerves growing alongside these vessels could be the source of pain in osteoarthritis. So, do we have any evidence to back this up? Well, we do have some animal models. So in canines and in rams, we found that those that display more pain behaviors, actually, they have increased levels of neoangiogenesis and that gives us some evidence um that actually targeting those vessels might bring along some improvement. Um So the question is, how do we actually target those vessels? Well, I'm not gonna go into the access cos people have um covered that much better than I have. So it's the u the Seldinger technique that people have been talking about already with the access of a sheath and we access through the er, and that's the er common femur where we would actually access through. So, if you've had any time in the IR department, this is a picture that you might look at um, of the, essentially the superficial femoral artery coming down the back, the popliteal artery and then you've got your tibial and your peroneal arteries coming down the bottom. And that's important for when you're looking at angioplasty and things like that. You might have, um, talked to some of your local IRS about that before, but we can forget the bottom because we're bothered about these vessels here. So they're furcular arteries. So I'm gonna tell, I haven't labeled them specifically because it's not important that you remember them. So you've got a descending artery, which is the one right at the top, you've got two superiors. So a medial and a lateral, you've got one middle and then you've got an infra medial and an infralateral there. And that looks a little bit like this on angiography. Now, when I first got involved in M SK embolization research, we didn't know a lot actually about the anatomy of these vessels. So, uh part of my work was um doing a dissection er, project where I essentially dissected twen a few knees and, er, generated a little bit more of a complicated diagram. Um, and also came up with some explanations of how to make the procedure safer, which I'll talk about the interesting stuff. But again, that's a lot of labels that you don't need to know. Um, so I'll move on to keep it interesting. So, what does J actually look like? So this is a very simplified version of a knee and that's a popliteal artery coming down. And one of the genicular arteries coming off and off of the genicular artery, you have all of these neoangiogenic vessels. So essentially we get the access like we talked about before and somebody has already thankfully discussed uh microcatheter and things. So um you pop your Custer in and you attach that looks like this. So these syringes have really precisely um machines, really small beads, essentially of certain sizes. So they're micrometers big. So the usual ones are 300 micrometers. So if you have a look on your phone, what a millimeter to a micrometer is, you can see how small these things actually are. And the aim is to block the little vessel without blocking the big vessel because some of you might think from the past ones. Well, actually you could just coil up at the sort of origin. The issue is that'll cause bone necrosis and joint collapse. And that was a big worry um from the orthopedic people when we started to do this is that this would happen in everybody. So thankfully, that's not happened, but we need to be careful and essentially what the way that Professor little describes it is essentially trimming the trees er rather than killing the branches and that's what we need to do. So we inject the embolic material and then all of the neoangiogenic vessels go away. So this is what it actually looks like in the procedure. So on the left. This is a supra, medial Juul the artery. So the medial compartment of the knee is the most common area to have osteoarthritis. It's the most commonly treated. And you can see there all the blush and all these new vessels that are essentially grow out. So you access it with your micro catheter and then you inject your beads and essentially you get rid of all the extra stuff that shouldn't be there. And then it looks like that on the left. So, um that's essentially a successful procedure and this patient did quite well. So that's answered the pathology and how we actually do it. The next question that I wanted to answer is, is it safe? So the short answer is yes. So there's been no serious um adverse events from any trial around the world for gene artery embolization. These are the five most common um causes of um side effects. So this is from a, a er data review that we wrote. Um and essentially like with the other procedures, you've got things that are common to all arterial procedures. So, punct site hematoma and you've got some other things. So, skin discoloration, which is the most common side effect essentially is like a um vasogenic rash, essentially that occurs. There's been some evidence of skin necrosis, but that's self limiting. And then we also was getting plantar paesia that we didn't exactly know the cause of um until we did our anatomical study So just to talk about the interesting things from the, the anatomical study that we did. So we found lots of different anastomoses between all of these five vessels and other vessels around the knee. So that allowed essentially in this diagram, you can see that if you inject the um microspheres, which are those little beads into one of the arteries through the anastomosis, it can make its way back into the popliteal artery And that would embolize bits of the foot, which is obviously a disaster, especially when you gotta remember. This isn't a life procedure. This is a procedure to make somebody's life better. So if you're given an ischemic foot, you've actually done the complete opposite of what you come to do. So what does that reflux actually look like? So this is under the procedure, you can see the microcatheter is in the descending, which is that one that comes down at an angle like this. And when you inject, you can see all of these other arteries are lighting up. And essentially, that's where your particle are gonna go when you inject them and you really don't want that. So you can see certain uh you see part of the popal artery appearing and you can actually see them brown part of the medial serial artery as well. Um That uh actually we found in our, in our anatomical study supplies part of the tibial nerve. And that's why you were getting the paresthesia cos you cause neuropraxia of that nerve during er from non target embolization. So we came up with a method of essentially placing your CF in the most inferior vessel, using the long run off of the other vessel. And after that, it looks like that. So you can see that all the particular matter then is essentially going where you want it to go and not down to the foot, um which is obviously the aim. And that's just to compare what the two look like just so you remember, so the last question that we had essentially was, does it actually work? So the answer is so far so good is the honest answer. So just to remember our pyramid of evidence, we're here. So we have a lot of prospective cohort studies and they all show in this data summary um that we wrote essentially that va which is a visual analog scale where people just put out what their pain is out of 10 and then a Wo max score, which is essentially a more complex way of measuring people's pain and limitation to function as well. And you find that actually their um scores are improved um over time. So they've got less pain, which is obviously the aim. And also when you look at other parts of the womac scale, so that's just the pain part of womac. But when you look at actually their functionality, people are able to go out and do more, which is ultimately the aim of all of this is that people have more opportunities to do the things they want to do. So, the next step is to get to here, so randomized controlled trials. So that's what the genesis two trial will be er, in reading and the proil. Uh and there's also trials elsewhere in the world, there has been one trial by a gentleman called Begala um in the US. And that has shown again that there is improvement over time uh in people's function and in pain. So the last section essentially is who will get ge when and how much it costs? That is the magic question. The answer actually is, I don't know. Um But what do I actually think? Well, I think the people who will get G AE is people with mild to moderate osteoarthritis that are li essentially limited in function. Those with severe disease, knee replacement is a really good option. We're not, not here to knock knee replacement. That TK A works really well and it's been shown to work really well. Other people that you might consider are people that are younger, is potentially a bridge to get them to older. If you can get them 567 years, maybe they can get to a knee replacement and not need revision when they're much older, which is obviously gonna reduce morbidity over time. And how much will it cost? Well, there's one American study. So everything is astronomically expensive in the US. But J AE is less astronomically expensive than some of the other proposed ideas. So like Hyaluronic acid injections and things like that, that are comparable in terms of um what people are trying to achieve. Actually, this sits um in that area also if we can reduce the number of joint replacements that also as a saving in effect. So hopefully it will be cost neutral or even potentially beneficial. So, thank you very much for listening and any questions go question, I'll come to you. OK. All right. Thank you very much. I think around. But the question is, how long does this or will this last in terms of the efficacy? So if someone has got improved pain, it's a long term studies that have shown, you know, if, if you're gonna say this is better than X because it negates the need for revision. Do you need to do this? Maybe, I don't know a couple of times over a 10 year span or is, is that much evidence on that? Yeah, so, so far we know two years it works and there's durable effects up to them in prospective cohort studies that randomized controlled trial only went on for six months. Um So we don't have as uh they'll release more data as they go on, but that was their interim analysis for six months. So, so far we know that in prospective cohort studies, it works till 24 months, I guess it depends which cohort we're looking at. You're right. So, where in the cohort of delaying the procedure then we need to show that there's robust evidence that it will last and it will actually delay for people that wouldn't receive the replacement anyway. It's, there's actually not a lot of competition in that area. Um, there's been medications developed, you know, selective cox inhibitors and things, but they're out of the window because of increased risk of cardiovascular disease. That's been shown it's actually quite significant. So they're no longer used. There's other areas of essentially nerve, local nerve blocks and things like that. Again, the robustness that they work over time isn't there like it is for G AE. So I think at the minute, this is the front runner in what will fill that gap? That essentially that is a void, there's nothing there at the minute. Ok. Exactly. My question to you. Thank you for pioneering this. Um, you know, where are we with this becoming a tariff procedure in the NHS? Because that is, I think that is the one point which will try and enhance the procedure going forward, isn't it? Yeah. So at the minute, it's in randomized control trial phase. Um So essentially, if you're not part of that, you can't do it. Um in terms of how long it will take, it's gonna be five years, 10 years before this actually go and it goes back to those stages that we were talking about before or will before. Nice, accept it as this is something that works. We can start teaching everybody and everyone needs to do it. We'll probably need to have that top of the evidence pyramid of systematic, you know, reviews and things. So I hope it's quick because there's a lot of people out there that actually could really benefit from this, that don't have any options for how quickly it goes. It depends on how robust the data is and how well these current trials that have been run work so that you know that how important they are is critical because you know, if professor little, you know, I, you know, I'm seeing him work, it will produce robust data. So as long as everybody else is performing the trials like his, then we'll have robust data to work on and then evidence to be able to say these people need this procedure. I have a quick question. Excellent talk. Um Well, congratulate you and, and then please pass my uh well wishes to um, when you see, um, just quick question, you know, when you say randomized, who are you? Because are you treating cohort that no other options? So who are you randomized against? Yeah. So it's, it's people in that group with um, mild to moderate osteoarthritis over the age of 50 that don't that essentially have EGFR and things that allow them to have the procedure that's who goes into that. So there's nobody from that group that is young to try and delay and there's nobody from the comorbid group either. It's just the people with mild to moderate disease that are over the age of 50 having treatment or no treatment. Yeah, essentially that's what it is. So it will be best pharmacological treatment. Um So obviously, the main endpoint is to look at the vas and the Womac and also another one called cos, um which are all scores sensitive for functionality. But also part of that we'll look at as well is how the um medication use decreases and things like that as well. So both groups will get the best medical therapy. Um So we'll get the physio, we'll get the medications review from GPS, et cetera. One will get to arter embolization, one will get a shunt procedure and then that's hopefully how we'll have some better evidence. Thank you very much. I think if you, if, if some of you are contemplating, um considering interventional radiology, what happens is you finish your uh foundation year courses and start with radiology or an ST one in Ir. And then once you come to year three, then you kind of branch off, you either do IR or you do neuro Ir and you spend three years in either speciality before you come out as your CCT as an interventional radiologist or a neurointerventional radiologist. So, what you heard through the day is various aspects of treating cardiovascular musculoskeletal cancer based and pediatric based diseases. What's so special? Why do these guys want to bifurcate? And every time I get a chance, I'd like to say, Doctor Najada Z Gilani, am I nearly there? It's an absolute pleasure to welcome Hamed who works with us as a neurointervention radiologist who is gonna tell us what's so special I want to see, right guys. Thank you very much Raggi for the very kind introduction. Uh Thank you all for coming. Thanks to the YR S prof for, for, for again, running a very, very excellent event. Um Just give me a second. So as ra who said, my name is Hamed, I have a long surname, I have a lot of surname Envy this morning. We've had W Abdelhadi Reis Lakshman or Ryan Brady. So yeah, if you have a really long surname, you get a lot of surname, you. Um There's a few comments, I will talk about my bit and what not, but there's a few comments that have just come from the four talks this morning, but I just wanted to the questions and comments. So the highlight of Costa's talk for me was the fact that this year he mentioned the word Arsenal in his talk even though he's a Liverpool supporter. And that was amazing. I thought that was kind of fraud and very subliminal that it's forgotten as a Liverpool supporter. Um Nas said, um I don't know if NAS is still here actually. Um he may not be, but he mentioned about that knowledge, you know what we were talking about how he enjoys what he does. But that kind of one, he was saying 12 kg baby in my head, II could kill this baby. And that actually applies to all of us. Everything that we do with a patient, you have the ability to, to do something amazing for the for the patient. But also just as Aidan said, you have the ability to cause a ischemic foot in someone who's just got yes or be debilitating but pain in their knee. So everything we do is about a balance of being confident and competent in what you do doing what's best for the patient. But also being aware that you do enough cases, there will be cases that you will cause harm to a patient. And so it's about having that mental resilience as well to pick yourself up. So it's even though it's not a surgical specialty, you need a surgical mindset for I arm. Um What did Omar say? Omar said on the left of the screen, even though he was talking about something that was on the right of the screen, the ones of you that picked up on it, you're probably not in the radiology mindset yet. Everything is flipped for a radiologist. So it's chest X ray, you've got the right of the patient is actually on the left of the screen. That's what that was. Um Sa mentioned that when Tara Talk, Rau said something about the first person who did a uterine artery embolization was actually a neuroradiologist who, which I turned around and said, well, did was the patient upside down? Did they get lost? What happened? And the thing I want to say actually was Sa Ragu and actually a lot of our non neuro ir colleagues that do ir do stuff both at the bottom end and the top end. So they do a lot of the treatments that I do. And that's why Ir is evolving as a specialty. Yes, we have all these niches but there's a lot of things that we can do in any bit of the body that you can imagine. OK? And then finally Aiden, you mentioned something about um a trial that looked at animals and you mentioned about pain behaviors in a ram, right? What's the pain behavior in around? Did you ever look into that? Ok. Fuck. I thought there was like a secret sign on the face or something. No. OK. Fair enough. No, that would have been innovative. Final question to you guys. A lot of you are on that side of the room which is weird. Are you all left handed? No. OK. Maybe not. Fine. II should do my talk now. Sorry guys. Um So I'm Hamed, I'm a bit weird but I'm gonna try and talk to you a little bit about this, these various things that I'm not gonna run uh over too much. Um So I'm gonna talk to you about history of interventional neuroradiology. What does a new interventionalist do? What's a training pathway? Is this potentially for you and the future? I really like action movies. Who's seen this movie? Did you put your hand up uh eventually put your hand up online even though I can't see you or pretend I saw it? Great. Perfect. I love Jason Statham. This is one of my favorite movies of it is the mechanic. The tagline of this er trailer poster. I should, there was someone has to fix the problems. Well, if you become an I nr you can be the Jason Stale who fixes all the stroke problems, you can become the mechanical thrombectomy. And so, yeah, just think about it. All right. So history of I NRI try not to bore you. I try to go through it quickly. Ok. Um So let's go through your history. It's really good that I actually asked you all. When was the first interventional procedure done? I kept quiet cos I had this on here. Um But if you look at the middle of that 1964 16th of January Charles Dotter did the first interventional radiology, vascular radiology procedure. So you were right. Absolutely. I need to find out who that new radiologist that did the U A was and put their money out as well. But essentially this is how things have evolved. And this isn't just ir obviously, you have to have x rays to be able to do something, interventional radiology, but I quickly run you through these guys and who they were. So I'm gonna skip over this for the sake of time. So, um Acosta already mentioned rodent going, you know, discovered x-rays won a Nobel Prize in physics for her. His wife's hand apparently was uh yeah, a sacrifice. But anyway, um Mons, this guy is actually, I love this guy because he was a Portuguese neurologist. We're talking 19, early 19 twenties. OK. He decided to do cerebral angiography and just they didn't have um contrast assay. So he just picked some random stuff. A few patients died on the way. But eventually he found something that worked and he produced the first cerebral angiogram before 1926. This is before CT S before MRI S et cetera. So it's incredible for me. But he was, even though he was a neurologist, he was a politician until his fifties and then he took a step back a little bit and then started doing some medicine. I find that incredible. So if you do go into interventional radiology, you can still do other stuff. All of us have things that we do outside the medicine that are completely unrelated to medicine. So it just shows you that you can still be a, a non doctor in your life. And I know this is amazing for me. So Seldinger, you've all probably heard of the Seldinger technique, which is where, you know, needle into a space wire over the needle, needle out and then put your sh tube or whatever it is that you put it in catheter wherever that is, whether it's in the pleural space, whether it's in the artery here in the groin, whether it was in the wrist, wherever, right. This guy has developed this as a radiology trainee, right? And now everyone's just selling the technique. So again, try and find a gap like prof said, find the gap in this crisis and just make the most of it. Alright, find, find the gap to get your name out there. Charles, not a not, I'm not gonna say too much his, you know, first intervention radiology procedure 1964 and er obviously revolutionized what, what we do as a subspecialty. Um And then a couple of actual surgeons did the first vascular um or neurovascular, I should say um um embolization or catheter catheterization, I should say. And it's really interesting for those of you online, if you look at the left, the picture on the left of the screen, not right. And then um look at how archaic this instrumentation is. So they've essentially had to attach their own um you know, very um elegant, I suppose or maybe not elegant into the external carotid artery to then go up into the internal carotid artery. But essentially times moved on this guy again, neurosurgeon from Russia. And he was the guy who really started to take things forward. He started using detachable balloon to try and get aneurysms in the brain rather than having to open someone's skull up. Um, and potentially risk causing some damage to the brain on the way in to get to the aneurysm. And so he published things in 1974 and everything got brought over to the West with uh by Debra afterwards. And then this was really the tipping point. Um in terms of again, another massive acceleration of what an interventional neuroradiologist can do in terms of treatments. Um Hemi and his scientist counterpart, his engineering counterpart uh counterparts. Um spec I'm tr despite having a really difficult surname, I'm also very diff I'm, I'm very rubbish at pronouncing other people's surnames. Um But essentially he came up before then where we treated, you've seen some pictures of coils before then you had to manually try and attach the coils. He came out with this device where you could induce a current upon the coil and the wire it was on. So it would just electrolytically detach, you just press a little button, bit of current gets sent through the lead wire in the coil and they break away. OK. So it became a lot more refined. I talk about coils. A lot of you aren't women in this room. So you'd probably think what on earth was this? I didn't really know what this is, but if you all just have a look at your little kind of pinky. Now, look at the nail. How wide do you think it is? Roughly? Just shout out it doesn't matter. Give me some figures millimeters or centimeters, 10 millimeters. That's good. You know, some of us have slightly fatter wider. Some of us have slightly bigger and this is a scale of different uh fingernails that you can get done thick nails apparently. So, you know, it goes up from some fingers little as 11 millimeters all the way up to proper wide, 34 millimeters, right? Um Although that's the length, so ignore the bottom row. So 11 to 21 I wanted you just to know that the things that you were treating your ir can be as small as a 1 to 2 millimeter aneurysm, ok. That you have to coil. So you have to get access into an aneurysm all the way from someone's come from an artery in the groin or someone's really artery the wrist into something a target that's 1 to 2 millimeters and trying to close it from the inside. So it's all about precision. OK. Um So that's II did I didn't wanna say this but I'll say it. Um Someone there when I was training, I don't even remember who it was. Said to me that the difference, what's the difference between a nonvascular radiologist, a vasad and a vascular neuroradiologist. And you've probably heard of the similar to counterpart to this about the movements in the elbows. For a nonvascular radiologist, the movements in the wrist, for a vascular radiologist, the movements in the fingertips, for a neuroradiologist that does vascular intervention. And that's because you're talking about navigating into arteries that are sometimes 1 to 2 millimeters and targets that are 1 to 2 millimeters in depth. You can easily go through the aneurysm. The patient bleeds and they die on the table before you can do anything. So if you like things that are very much precise, if you have that sort of mentality, if you have that manual dexterity, this could definitely be for you anyway, very quickly. What do I actually do in my day to day job? Um I'll tell you about it. Essentially, lots of stuff. Ok. Um Very much. We close stuff up, we opened stuff up. So with your aneurysms, avm s your artery venous fistula, there's lots of vascular abnormalities in the brain. Ok? Both in an elective and an acute basis. Acute being patients that have already had a bleed in their brain. Ok. We treat off tumors preoperatively. We could actually take out a lot of the vascular supply, help the surgeons get a better resection margin, whether that's in the, in the head, in the skull, base in the spine. We do a lot of that massive thing right now. Opening up stuff. Ok. About 10 to 15 pa pa percent of patients that have ischemic stroke might have a large or medium vess of occlusion. If they get to a hospital that provides a service called The Mechanical Thrombectomy. In quick enough time, you can have a patient who's have on the table taking 10 or 15 minutes. They're not speaking, they're not moving their arm, they're not moving their leg. You do the MT and on the table they start to speak again. You've saved that patient from potentially being in the hospital for weeks, being in a care home for months to going home within a day or two massive massive scope for impact. There's a lot of other stuff we'll do that for the sake of time are trying to talk about. Um when it comes to aneurysms, everything, almost everything that we do um is evidence based actually as a specialty, just as Aidan is doing all his hard work to build up an evidence basis to then progress the field when it comes to those patients who would benefit from Icar artery embolization. Um This was done for aneurysm work almost 20 years ago now. Ok. So it was an ISA trial on international. So I trial or aneurysm trial essentially changed practice overnight. It compared clipping. So open neurosurgical clipping versus endovascular coid of aneurysms and it showed better morbidity and mortality outcomes in patients that received um endovascular. Um and it was actually, they said it's unethical to, they did a mid interim analysis. They said it's un unethical to continue doing this trial. It's so the, the, the, the difference is so vast. And overnight everyone started to, if you were an interventional neurologist at the time, your life probably became a lot worse because as Nas was saying, when he was just one ir doing a box of work on his own, there was not a lot of people doing it. And so your work just went through the roof overnight. But essentially immediate shift. Let's show you some pictures. We love radio, huge aneurysm basil, the tip top left of the screen, it's, you know, over 20 millimeters in maximal dimensions. You might think what on earth or posterior circulation, aneurysms notoriously very difficult for surgeons to access cos they've got all of the actual um hind brain, your posterior fossa, you've got, you know, your brainstem, your cerebellum and the way to get to so that the the high mortality, high morbidity case got in there. You can see there's a couple of stents on either side. I don't know how well this projects, I promise I won't use a pointer, but yeah, bottom left of the screen. I'm not using a pointer guys online. Um We got stents there calling their aneurysm approved from the circulation on that run in the posterior circulation. So, you know, and again, we follow things up, the radiologists would love to show that our work has actually done the job two years and there's no other reason left, which is great for that patient stroke. I talked to you. There's a massive burden, massive cost to society. I'm not gonna go into this massive cost of disability, actually a significant cause of death as well worldwide. So what is mechanical thrombectomy? I've kind of briefly told you, but essentially there's lots of evidence out there. It's kind of common sense. You've got a blockage, lack of oxygen, the quicker you unblock that vessel, the quicker the patient gets better. Initial data was from a meta analysis of four or five randomized controlled trials back in 2013. And that again, changed the picture overnight. It showed massive benefits in patients that received mechanical thrombectomy. OK? Um I want for you to death with stuff about science. Um But essentially this is a, a pictorial representation of what I just said, you've got a blockage, you've had some collateral supply, the things that have better collateral supply on the edges, the the cells that have it have a bit longer, you'll have a core that if you don't get to it very quickly, that central part of the brain where you've got endo arteries going to it. Like the basic idea where there's venulous perforators helping it, they'll grow quicker, but you still have areas of brain potentially to save. So the quicker that patient gets onto your table, the quicker you can sort them out. Um a bit of a physiology, why not? Um I won't bore you. I'll show you some exciting pictures. This is really important. Slide, Geffrey Sa from the States quantified that actually for every minute that you've got a large vessel occlusion causing you a stroke, you lose 2 million neurons. Ok. So time is definitely key, right? Um And then, you know, large vessel occlusion. What is it? Well, you know, it's just the blockage either in your internal carotid or middle cerebral artery. Um And you know, it's got potential to do lots of harm. First, interventional arterial structuring was actually thrombolysis. Um and some people started doing intra arterial thrombolysis is going back for some years now. Um And they showed that, you know, you can er break the clot down chemically by going into that basilar artery injecting some drugs um quite serendipitously if that's the word, you show a case where I showed you a stent that we'd used um with some coil to treat a ba aneurysm. Someone was doing the same thing for a different aneurysm when they took the stent out, they say, oh, there's some clot here and it's like, ah maybe I can use this to treat actually when patients do get clots. If I instead of detaching the stent, I use a stent that doesn't detach and bring that out. So that was the neuro application of it. And so this is what happens really you try and go, this doesn't project amazingly well. But there is a clot there in that imaginary M one that you essentially kebab your wire through. OK. Then you take a selling technique, you take a micro cap over the top, then you remove it, then you open a stent that doesn't detach it, it stays on, let it incorporate with the clot itself. And then you yank it out under some aspiration, evidence, evidence, evidence number needed to treat for me or thrombectomy to, to, to, to have a good outcome. Or you make a patient less disabled and actually be relatively independent. In terms of the ability is somewhere between two and four, very few medical treatments or surgical treatments. Whether pharmacological medical surgical have anywhere near as low. A number needed to treat to, to be effective as, as mechanical thrombectomy does OK? Take that home with you. Um Another quick case, I'll show you, um 10 year old boy proves to fit in. Well. Um again, this is from actually some time back, but essentially his mother realized that he's, he's having some food and then he's choking and coughing and not speaking, calls the her mother who is the child's grandmother who was living in eastern Europe and says, what was going on? She was a nurse. So she said, no, take him to the hospital. Comes to the hospital. Has a CT has an MRI there's a basilar artery occlusion kid gets intubated comes over to leeds for those of you that aren't radiologist for the vast majority of you. This is a injection. So you've got into the lab, this is an injection from the left vertebral artery, which shows you that we use the mouse for those online. Maybe. Um It shows you that there's, there's an abrupt cut off in the, in the kind of proximal basilar artery. Ok. So we go, ok, fine. We'll do an empty. Uh We have a few go multiple different different go eventually managed to open up most of that vessel. There's a tiny bit of non occlusive clot in the distal artery. Uh but after five passes, then that's kind of the little bit where you think, OK, I might start doing more harm than good here. You can start to cause injury to the actual vessel and cause a bleed and they were gonna get some other medical treatment. So if OK, that's great. Let's call it quits. Unfortunately, the patient did deteriorate it three days later, they had a repeat CT scan which shows that actually that pons in the middle of the midbrain is starting to swell up. Ok. Um So that patient, you know, could essentially be locked in. So they're, they're, they're alive, but there's not that much function brainstem. Ok? But we can go back in. Ok. So we take him back for another mechanical thrombectomy. This time cleared up Vasin artery to its entirety from what was previously to afterwards and you end up with a child that is able to have a function for those of you that are paying attention. There's still a bit of a facial drip there, but you've prevented a patient from being a child locked in or potentially completely dead to being able to live a relatively normal life. That's the effect that you guys can have if you decide to go down this route. So what do you need to do to be able to get there? Oh, I have to put this out for the radio racers. So don't do this if you're going to A&E Alright. Um Journey, right? Well, it's my journey. Um I don't know what other see um my journey is you do poor radiology, you do your exams, you do it on call, you survive through all of that, then you do that higher training. And Ir was saying three years. So we have to be a diagnostic radiologist to be a good interventional radiologist. You have to be a diagnostic radiologist to be any form of interventional radiologist. Anyway. Well, yeah, you get involved. You know, you can spend time in the lab. You learn about an after in college. You've got to spend routine interaction like NAS was saying both in your training as well. Um you learn about and then you have to kind of again have that surgical mentality logbooks, all these different cases having. Ok. Where am I gonna get to punctures, guides the actual treatments with my boss in the room, with my boss in the control room with my boss, maybe outside the hospital. Um, and then you get there eventually. Oh, yeah. Um, and then you have to know loads of stuff. You have to know the kit in the room, all this vast array of different equipment that we've got. You have to know all the drugs that you might be putting into a patient, ok? You might be asking the initiatives to start getting them intravenously. You have to know how to deal with stressful situations. You've caused an aneurysm to burst. What on earth are you gonna do? Ok. You have to be the one that leads that room um and hide your emotions and in a turmoil. Ok? Um And then you have, you know, there's loads of opportunities to go to different places across the world. Omar was saying you went to the States last year lucky. Um But you know, there's lots of places to go. Ok. Lots of additional qualifications you can get as well. But is I nr for you? Ok, you have to ask yourself some questions. Are you a hard worker? Cos it takes hard work. I'm sure you all are. You're in medical school. So, you know, that's, that's the sign in itself. OK. So you have the resilience to keep going despite pressures from all sorts of environment, you have diagnostic boss, you have an interventional boss. You have, I don't know, friends or family at home. You have patients, patient relatives, all sorts. But can you be deal with those patients and relatives in actually really difficult situations such as when a patient is having a stroke and that family are in tears or such as the patient is actually intubated because they've had a subarid hemorrhage and the G CS has dropped. You have to then be able to have a sensible conversation with that family and say this is what I'm proposing to do. This is why, what the risks are and these are what the um benefits are. And this is what the scientists based on essentially. Can you be methodical? You need a surgical mindset. OK? You need to have a plan A plan B and plan C almost for everything that you do. OK. And can uh will you always keep your patients well being at the center of retention? Do things become d are you someone that just keeps going at something for the sake of it? Cos you know, there's an abnormality on that, on that angiogram and I have to make it look perfect or do you have limits where you say actually, if I keep persisting, there's a patient still on the table that I'm trying to achieve a good for. So you have to be able to have limits. OK? And realize um that there's a patient on that table, not just a technical challenge. Lots of patient interaction I want. But I feel like I might have even gone over my 20 minutes. But why I nr for me, technology, imaging precision patient interaction, think what I said about your fingertips and the limitation, the tolerance II have orthopedic friends. So, ah, this is normally how bad conversations start, isn't it? II have a ex friend so I can say this, but it doesn't matter. I have orthopedic friends so I can say this. You know, you don't have the tolerance of saying, ah, that prosthesis is a few, few centimeters out. Everything is down to the millimeter. Ok. But you get to work excellent. People collaborate with them and innovate just as we're seeing prof innovate in massively citing things indeed aid and innovate um in not Portsmouth Southampton, I think. And then, er, yeah, there, there's lots of, and you'll see what I mean by this, but you have to remember there are loads, ok? It's a high risk situation, someone's brain, there are arteries, it's not easily accessible. You mess something up, the outcome is normal and that patient dies. Ok. So you have to be able to deal with that. It's a test to your character. You do enough cases, you will have complications and those complications are severe. So you have to have supportive colleagues, supportive environment, but also have that network outside of work. But that ns strength and resilience to carry on and pick yourself up and actually that patient died yesterday. I've got the exact same aneurysm in a different patient. The next day I can do your job, try and save that patients, either brain or life. So you have to be able to just move on. How could I have avoided that? I, so this is all about, I'm sorry, I just started reading my slides. Um, so you have to be able to reflect and improve as well just as you would in anything and you have to be able to pick yourself up. Let's do another case. This is a 58 year old guy who was playing golf. Um I don't, so this is why I can't really do um golf movements. Um He, he, he on the golf field collapsed. Two CS went down to three, he got intubated by air ambulance who was on, came in again. We've got a basilar artery occlusion. We've got a non contrast in city head. She was a hype against basilar on the left. And then we've got the basilar artery which is kind of just stopping in its midsegment again, transferred to LG II. Don't know why these are getting bigger, doesn't matter. Um Essentially we found that he's got a dissection of one of his vertebral arteries which has probably thrown off the clot, but he's got a really good. Um And again, the dissection doesn't go all the way all the way intracranial, but essentially, um on this bottom left corner, you can see we've taken our equipment all the way via the left vertebral artery into the bas artery. This time, we only applied suction. We didn't open a stent and it cleared it within minutes. Ok. So the patient went from being low G CS, you know, um intubated, ventilated to having a post mechanical thrombectomy and is score, which is how you quantify how much neurological deficit they have are having zero. They were back to normal when they woke up, they were back to normal. Nothing has happened and they got discharged um to home on day three and then went on and won the US majors. Um I think it goes in it does the future, not sure. OK. No, let's not read that. Um So what's in it for the future? OK. All of these things you see have either come back in a come out in terms of um in the past few years or are due to come out. OK? We have technology evolves. You can, you don't have to just stick a coil in someone's aneurysm anymore. You can put in a web, you can put in all sorts of different things and it's evolving all the time. OK. So we have lots of new technology available to us even that those, those, those RC TSI mentioned about mechanical thrombectomy and stroke. Those were based on patients that come to hospital within six hours of the onset of their symptoms. Now we have evidence to, to allow us to treat patients up to 24 hours after their stroke has started and still be able to save brain. Ok. Um, lots of devices, lots of seagulls and we do lots of um, yeah, it's, it's growing as a specialty. We can start treating uh, patients that have recurrent subdural uh hematomas to stop them, having repeated bur holes, we can start treating more and more small aneurysms, more and more small clots, ok? We're kind of as a specialty in your ir still doing plumbing. Ok. So everything Omar was saying about treating things in terms of chemo embolizations, um possibly doing joint procedures with neurosurgeons with RFA. There's a lot of scope for us to go forward as an as, as a, as a, as a specialty and they will only open doors to what we do. So we need more and more people. I'll give you an example in terms of interventional neuroradiologist in the country in the UK. There's 100 it's very small, but what we do is only growing day by day and this is testament to all of these things that I'm mentioning. We use a lot of A II won't go. So I just want you to watch a really, really short video. If that's all right. Thanks for allowing this before I that hopefully it'll play. If it doesn't, then it's faint. Ok? I think it's fake that we don't see this video. It's fine. Don't worry, it's fate. Essentially, the video showed to you two patients that have got very limited function in their limbs, they're paralyzed. Ok. They cannot use their arms. Interventional neuroradiologist goes in into the superior sagittal sinus drops a stent that stent is hooked up to some um, device that sits on the top of the under the scalp. Ok. And um essentially allows them to because the stent is right near the motor cortex. It allows them to start having full control of a computer just by their fa falls. OK? And they can scroll up and down. That's why that video. If you go and Google stent road, a stent R OD E youtube that you'll see that video and that patient can now read their own email whenever they want. They can scroll through a web browser when they want. So the the the scope to to to innovate is vast and they only published this last month. Finally, this is a story, true story. So why is there loads of seagulls in my talk? This is from uh last uh last October. It's not, I know it would have been nice if it was the independent or the guardian, but I'll take the mirror. It's alright. 84 year old lady who was on holiday from uh from Scotland, she'd actually lived in Glasgow, a little village outside of Glasgow was having fish and chips got attacked by a seagull Alright, went to get back some more fish and chips. Whether it was the her being startled her suddenly having something, whatever it was. While she went to buy another portion of fish and chips, she started having a stroke in the fish and chip shop. 84 year old came in. My excellent colleagues and nursing team and radiographers, everybody, consultants. Ir, non ir absolutely. We treated her to the point where the next day when we discharged her, she went back to finish her holiday before she went to school. 84 years old. Ok. She, when I spoke to her on the phone, about six weeks later, she was saying, no one believes I've had a stroke and that's what you can do as the future interventional radiologist or neuroradiologist. And that's the impact you can have on someone's life. Um Thank you for your time all over and I'll take any questions you got. Is anyone thank you for that extensive uh talk hamed. The, the moral of the story is don't eat fish and chips. And um, in order to keep that going, we're gonna break your lunch break down to 10 minutes so that you don't have a stroke. Um, you know, when it, when it came to CV, writing my understanding of writing the CV, si always wrote it backwards in time, I fell into things and then figured it out that I need to put it on my CV. The world's moved on and how has it? I'd like to welcome Chris Clark. He comes from Nottingham and he's gonna tell us something about how to write the CV. And I'm sure I'm gonna learn and then improve my CV when I go back. Thank you. I use the keyboard. Yeah. Brilliant. Hi. Hi, everyone. Thank you. What an inspiring talk. I don't know how I'm gonna follow that with CV talk. Um, yeah, this is practically dull compared to that stuff. That's, I mean, and it's also lovely to, to see a lot of faces. I was in leeds for a bit. So it's nice to see many people that before. And, um, it's also good to see that neuroradiology does exactly the same presentations as they do day to day in the theater. You know, I do nephrostomy and it's always go out with doing an em. So, yeah, we've got a lovely narrow team. Actually, if there's only 100 half of them seem to be in Nottingham, they've got, must have a team about six or seven there. Anyway, I'll crack on because we need to get some food and I'm very hungry. So, who am I? I'm Chris Clark. I'm from Nottingham. Um, I always like to say a little bit about me. So this is where I work. It's a big sort of concrete building. Queens medical Center. Um, and obviously after the talks today, um, we all know that it's, is it just sitting in a dark room but obviously not, you know, you've seen everything. We have to get coffee, ok. We have to go to get coffee. That's a very important part of being a radiologist. But in all seriousness, um I did radiology training at Nottingham. I came to Leeds for a year after training to do a fellowship and this is my last day in Fluoro um with Karen, one of the trainees, we bought some Maltese. Um, I did do a website Radiog cafe which is uh kind of helping people apply to radiology. I've done a few books and I like making cakes. But what am I gonna talk about? Um, I had a thought when, when I was asked to talk about CVI thought, well, there's two options I've got here. Do I go down the route of trying to tell you what you should do in terms of projects and doing CVI? And I thought, well, that's, that would be great. That's probably what I'd want, but it's not gonna work with such a varied audience with lots of different skill sets and things. And I'd probably say that if anyone wants to come and chat about C VS, come and find me afterwards in, um, this afternoon. So I thought what I'd do cos we don't often get much on this is, well, what is a CV? And go for a bit about how I do it. What, why, why is it important? Cos actually a lot of the time we think it's not that important, is it? You don't, we don't really use C VS that much anymore. So I'm gonna go through this stuff here. So, first of all, what is the purpose of a CV? OK. What is it? It's a document. It's a summary of what you've done. And essentially it's to summarize this and this is all me, by the way, this isn't from, I'm taking this from a website. This is just my experience. It's to summarize and communicate your experience, your skills, achievements and interests for a specific role at that point in time. And I've seen some really great cvs and I've also seen some like, really not great C VS all from excellent trainees and doctors applying for the same role. And the variation is staggering and I know this guy's good or this girl's good. This, this person is perfect and your C VS terrible, like, and I'm thinking I might not be on this panel. I'm not gonna be looking at this, the people that's gonna give this person the the role are not gonna see this. So I'm gonna go for, give you some tips. So number one, you've gotta tailor it to the role. Um And in general, you just wanna put everything you've done in the last five years unless it's amazing you, I don't care, you know, you're at medical school. I don't care what your A levels are. I think you could have got BCI think you could d I know you got into medical school. That's all that matters. Have you got a degree? Fine, you've got your medical degree. Fine. I don't care about school prizes. It doesn't matter unless you've won the Nobel Prize. I'm not interested in anything over sort of 5, 10 years ago. It's all about communication. Ok. It's to tell someone in a simplest way as possible why you're suitable for that post. Um And nowadays I know of your foundation applications and or whatever you might be doing, it's all online. It heavily guides you through it. Now this is a, an application for a, a current job in Nottingham for a consultant, radiology job. Um And you can see it just talks you through, it says your history and things. So it's no longer a case of writing a CV. And we can use that to say, oh, this person is not very organized, they've missed all this stuff. It really talks you through it. So it doesn't discriminate very well. Now between someone who's organized and someone who isn't and even on their consultant job, it's optional. OK? You don't even need to send a CV. So the question is if it has to change for every application you do and sometimes it's not even required, why should you bother maintaining a CVI? Mean, that's what I'd be asking myself. So we all have portfolios. I don't know, as a medical student I'm interested, but it's obviously changed a lot since I was a medical student about five years ago. No, II graduated in 2009. So I can do the maths. Do you have a portfolio or anything like that in medical school? I assume you don't. But I don't know if they introduced anything like that fine as a doctor. So from foundation year one onwards, you will have a portfolio. So the the one for foundation it might change depending if you do medical or surgical training. This one at the bottom left here is um the current one we use for radiology trainees, Kaiser. And the one on the bottom right is the one that I have to do as a consultant and I have to keep it. It's all online now. Um And it's different depending on where you work. But essentially a portfolio is a record of all my achievements. It's all my courses I've attended. It's my reflections, my CPD um um certificates from courses like this. So you, you come to this course, you might get a certificate, you pop it in your portfolio, keep it. Um but when you're applying for a job, you're telling someone you want to do something. I don't want you to give me a link to your portfolio. I'm not going to have time to look for all that. It's huge, you know, it's got all everything you've done. I need a summary. So the CV is a summary document of this. Um And there's two main benefits. So you want to have a single record of your achievement and this has got a lot of benefits. One, it makes it easier to do job applications. If you do it in the right way, it means that when you're filling out these forms, you can just go copy paste, copy, paste, copy paste, you're less likely to forget something you've done, particularly publications. If you've done, you know, a few, you, you might forget one a few years ago and if it's on your CV, you remember it and it's one less barrier to applying for a new role. Um And this may seem a bit far ahead if, particularly if you're a medical student. But a lot of the stuff I had when I was a radiology trainee, particularly ST 123, a lot of the sort of management or leadership stuff was stuff I did at medical end of medical school. It wasn't stuff that I've done in foundation as a doctor because there's a lag time of, you know, a few years between you doing something and then it goes on your CV and you use that for jobs and it, and, and now it's only now five years consultant that I've started to get publications and things glittering up. My CVI didn't have anything like that when I was a trainee. Um And if you have a job, you know, I don't know, something comes out like uh so, so for example, when I was a trainee, there was a job for an honorary lecturer in Human Anatomy at the Nottingham Medical School. And there's a few people that applied and as part of that you needed a CV, if I didn't have something ready, that would be like one more barrier to stop me applying, I think, uh as well as the application I've, I've got to do my CV. Uh maybe I won't, maybe I'll do it next year and it just puts another wall in front of you progressing or doing something. So it's good to keep an one up to date if you can. Um And obviously you want to, you to communicate your skills. So I'm just gonna quickly go through what you should put on it. I mean, it's pretty common sense. You put your personal, you know, put your personal details, what, what you do a bit about you. So they get an idea of who you are. You want your qualifications, I guess, put your GMC number on when you've got your, you know, hopefully you'll do fantastic in medical school, you'll get your medical degree, you put that on. Um If you have any skills, put them on, but, you know, don't put on, you can do a word document or a powerpoint. I mean, yes, 20 years ago, that might be great. But nowadays, we kind of assume you can do those things. It's gotta be stuff that sets you apart. Can, you know, so if you, I know if you can program, I don't know something put that on. If you're good at formulas in Excel, put that on. If you can do a liver biopsy, I put that on. But if you're a foundation trainee don't put on that, you can do a cannula or an NJ. We expect that from all doctors, you know, training, research, teaching management. If you've got any prizes, obviously put that on, that's great conferences like this course, put that on that. You've come to this professional memberships. And I always like to know if there's any other experience or interest you have outside of, of just the job and any future plans. I find that really nice. So when have I used it? I've used it for my registrar, job application consultant, job application consultant, job interview. Um I'd say when they went on election into human anatomy, I had to have it for that for my fellowship. After I finished radiology training for five years, I came to leeds for a year. So I use it for that. And even now as a consultant, I have to submit a CV, every now and then for projects or grants or research and like a short research CV. And they ask for that. So I use it even now and I also review C VS for other people for various university jobs, consultant jobs um and lead roles. Um And I know I'm talking from a consultant point of view, but actually, it will make sense cos the stuff you do now will matter in the, in the future for your CV. It, you have to start early. The 22 points here I wanna make is that you fill in your big application form online. You might not have a paper CV. But remember the person shortlisting you for a particular role is probably might not be the same person who's gonna interview you. And I think people forget this. You think, oh, I've already submitted all my stuff to, to the trust and you assume that they talk to each other but they often don't. Um So you also need something to give to someone who's interviewing and I've done interviews and often I just get to see a glance at it just beforehand and I wanna see what I, you know, why are you amazing for this? Usually I do look through them properly but actually sometimes you literally get it the morning and you're just like you want to have a look quickly and even though you might have read online like a medical, you know, sometimes you think about medical C DS, they are, they can be really long, they can be, you know, loads and loads of pages. I actually don't agree with that. I think it, it needs to be a summary. Yes, it depends on the job, but really, I don't want a CV, that's like 20 pages that's not helpful to me. So this is how I do it. I have a ma, a Master CV document. Um and this is my, my CV, and it's just got everything on it and then I use this to make what I need as and when I need it. So I kind of keep this up to date. So if I get a new publication, something, I'll just add it to the list and I use it for training application. I've used it for honorary lecturers. I've used it for locum worker consultant, job applications. I've used it to make my two page sort of research. CV. It doesn't have all my research on, it's just got the, the top things on it. You don't want to put everything on it. Um And it's also, you forget. It's like, I don't know if you've ever moved house or flat. You have to get, you need to get a credit check. You have to ask, they ask you for like the last five years of where you've lived. And when I was like a registrar, I moved around a lot. And sometimes I couldn't remember the postcode or where I worked. And it's the same for when you apply for jobs. When I applied for my consultant job, I had to list every job I've had right down to F one and before and I had to name the supervisor and I think I had to give an email address. I can't remember that. And if I didn't have that written down, it would take me ages searching for all my old documents to figure out who was my educational supervisor for my second rotation in F one. But if you've got that all on here, it's very quick, you can just save it. Um, this is a bit controversial. This is what I was always told. Um And it kind of works. This is mainly outside medicine. This is keep it to two pages if you can make it really sure. It is literally a summary. I just want, I, I'm not gonna read more than two pages worth of texts anyway. Now, in reality, it's like it's impossible if you've got, you know, if you've got your things, it's impossible to do that. I could just about get mine to 44 to 5 pages. But for a long time, my CV was not longer than five pages um throughout the whole of, of registrar training. Um And now I'm a consultant for five years. I do actually have a lot more. So it is a lot, it is a bit longer now. But essentially I keep the same principle. If it gets too long, you're missing the point of what it's for. So what's good. It needs to be really easy to navigate. This is probably one of the most important slides if you can remember this. That's great. I'm not gonna bother reading these for you, but basically clear from, needs to be constant lay out, it needs to be organized. The grammar and spelling has gotta be perfect. There shouldn't be any typos on your, on your CV. There's no excuses for that. You should give dates and years for anything you've done. Don't just say I did this. I want to know when you did it. You don't have to give exact date. It's just a rough month or, or even just a year. That's fine. It needs to be short, it needs to look professional. What I want to do now, I was going to think, oh, should I show lots of examples of C vs? And actually it's a very personal thing. It actually doesn't matter what it looks like or how you do it, it, it, it, it should reflect your personality in you as long as you follow these principles that should be enough for you to give a really good CV. Having said that I will show you some good and bad examples. So, examples of poor practice. Ok, spelling or layout errors. What does that tell me if I see spelling or lay out errors? It just tells me that you're a bit lazy or careless. And to be honest, you know, if it's logical flow, well, maybe you're unorganized, you haven't really thought about it. If you use lots of different fonts or formats of underlining, it looks messy. Too many pages and this is the worst. You don't appreciate the role you're applying for and you can't prioritize. You know, it's like when you have an exam and there's a free text answer and it's like, what's the diagnosis? And you put three? Because one of them is correct. It's like, well, that just tells me you don't really know. You know, you, you should put one, don't put everything you need to know what's relevant to the role you're applying for. And if it looks like an essay, then you don't care if you fall asleep or don't wanna read it. So the key thing is to ask other people and get them to look at your CV, which is I can do that this afternoon or if you don't have AC I'm around this afternoon. Happy. You can see. Well, so these are, I'm gonna, I blurred them so you can't read them hopefully. But these are three real C vs that I've had for the same job application from three excellent, fairly junior doctors and you can see how different they all are. Ok. So I'm just gonna point out a few things here that just bugged me. So this first one, you've got a cover page and, and you've got like an index, why it's, it's supposed to be a summary. What is the point? I am not gonna look at that. I go, where's the audit Oh, it's page three. I'm gonna go to page three. I'm just gonna go. Where's the audit? Oh, there it is. You know, so complete waste of time. Look at all these paragraphs. I, I'm not gonna read that. I'm not gonna be able to look at that at a glance and figure out what you're trying to communicate there. When, when was your, what courses you've been on? What projects? Complete waste of time. This one's way too long. I mean, just courses alone two is 1.5 pages. That's completely unnecessary. And again, I'm not gonna be able to quickly get an idea of who you are. This one is nice. It's quite short. Um The one on the right II actually quite like that. Um The second page, it all looks a bit Samish. I can't really see any dates, the titles and words, they all kind of look the same. I can't, I look dancing. It, it doesn't inspire me. The prize is, they've got a prize. They put it right at the bottom. Well, if you had a prize, why would you put it right at the bottom of your CV? On page three, you put that on the front page. So it's about making, trying to communicate, you know what you're trying to get over. So I'm gonna show you mine. Now when I was an ST two, I'm not saying this is right or wrong, but I can kind of explain why I did it. Ok. Um, so this is mine and you can see it first glance. Oh, it's a bit messy. It's not very organized, but actually it's not, it's all the same ish, it's not supposed to be the same ish. What I wanted to do here was to pull you into different areas. Listing your job should not look exactly the same as listing courses or exactly the same as listing of publications. You want each sexual to be slightly different, but you also want the formatting style to be the same throughout. So I used the same font, same size as for heading the same spacing between. There is actually quite a logical way that this is done. Um There are a few little paragraphs but that's kind of saying rather than listing 20 talks that I've done, I just said I gave 20 talks in this time period. I don't care about every single one you've given. Obviously, if that's what all you have expand it, you know, use it to your advantage. Um This is how I space. It's on the first page. I put prizes and publication cos those are the biggest things and that's what I wanted people to see. I then had my past jobs. Page two, I did a lot of teaching. So I had a whole page worth of teaching stuff and that's partly because I had no research and audit. So I was ST two, I'd done one on here. I've done one audit and the other two and that bit are ones that are in progress. So I hadn't done any research. So I called it research audit and I put an audit in there. It doesn't matter. Management. Leadership. I had a little bit of stuff. ST two radiology. So this is four years after medical school. Two of those things, there are things I did at medical school. Ok. I did some marrows coordinated some marrows anti no interest bone marrow register stuff. I was president. I did lots of work there. Um, and doing that, I did lots of courses, raised lots of money, did lots of. So I put all that in there cos that's still important and it's within, ok. Yeah, it's probably within five years, you know, but as you go, get more senior through your, your training, you'll take on more management roles in the NHS and you'll replace those things with more recent things. And that, that's fine courses again, just one line for each course with the dates, other skills. But the future plans and references tried to make it two pages. Couldn't quite, so what should you include? Um, prizes put that at the top? Ok. If you don't have any professional memberships, don't, don't put it on there. If you don't have any skills, don't put it on there. That's fine. If you don't have any research like me, maybe it like that in one line. And have it all together. Ok. You know, you can, you can kind of play, you know, play. This is a bit if however you're very, you know, you've done lots of research, you might have done a P HDI. Mean, I had lots of friends that have done loads. You'd have a whole page or two just for research and you'd split the research into your roles, the funding your grants, you've got your, your, your research and then you can list publications, all your publications and then another heavy editorial, all your editorials, your correspondence, your book chapters, your orations and poster. I mean, if you have that, uh you know, by the time you apply for radiology, I'll be absolutely, it's mind blowing like you have to have been really serious and I have nothing. So what, so this is the next thing I want to say, it's better to have 1 to 2 really, really good projects or achievements I think than 10 average projects. Um And I see this a lot, particularly from a junior doctor at the moment, a medical student, you want to kind of tick the box, do everything and kind of. And I think the thing to remember is systems change. I actually don't like the way the applications work at the moment. I'm five years into consultant. I might start applying for college roles and get involved in interviews and things might just change it and these things come around in cycles, we've gone from a very sort of ticks and very interview thing now to a very much like you have to do this many audits or this many and this many. And I think we might start to be going back the other way now cos the people that didn't like that are now coming through to be consultants like me and I'm like, I really don't like the system and now we're in a position where we're gonna start probably changing that. So if you're trying to play the system now, it might be completely different in five years time, we didn't have the M sra exam even a few years ago. And now it's in, it might come out who knows. So the key thing to do is do something you enjoy and make sure that you're kind of using your skills for the best. I'll give you an example. The other thing I want to say here is the earlier you start, the easier it is. So definitely the just the fact that you guys are here, you've always got a massive advantage with this stuff. You've got a group of consultants in the room that are key in all these projects. We can chat, you can link up, you can start to get ideas um and we can support you with doing projects or getting involved in sort of radiology things. So you're, you're massively ahead of the game, which is great. Um So quick to tell you a story about what, what happened to me. So this is university less where I went to university. Brand new, fantastic med school in 2023. Back when I was there, it was 2008. This was the style, this was the building, the M shock. It was an old, you know, I applied to do my dermatology student selected component which was three weeks, didn't get it, got my second choice radiology. So did three weeks of radiology with this gentleman is Tony Ducks. And he was kind of my mentor. Um, uh he's a pediatric radiologist. Unfortunately, he's passed away now. He did like his biscuits and he used to sit reporting with his box of biscuits. He called it brain food. Um, and he'd be like, oh, it's another pneumonia from the GP, you know, none. At the same time I was a student, I was doing all this Photoshop stuff and various stuff at the university. And this was back before we had radio pedia before the internet had really kicked. I mean, just about Facebook had just about started. Um, you know, we were when the universities only were allowed to do it. And I thought, well, why don't I color in these, use my skills color in some x rays, try and show things. Cos back then there was nothing like this online. It was all just arrows and most of it was plain film So he said, yeah, he said, yeah, I'll support you doing that. Let's find some X rays. Let's put together a little teaching thing for the students. So, um a lot of them were playing films. So I remember sitting in his office for hours with my camera and a tripod getting x- on the film, getting it right. Taking the picture had to edit it a little bit to make it look. OK? Um And then produce this um this teaching resource that I put together. And the med school said they'd print it out and give it to all the medical students. I said, that's great. And then I had to do a reflection. Oh God, do you still have to do reflections? Ah This is before I kind of appreciated. Oh my goodness. I had to do a reflection on it. And then there was an essay prize for the Royal College of Radiologists and it was basically asking for the same thing. So I was copy and pasted it, edited a bit, send it in and I got the essay prize in the Royal College. So I was like, oh, great. I can put that on my CV. So I went back to the medical school and they said, look, this teaching result is quite good. Why don't you go to a publisher and try and publish it? So I filled in a new book proposal, picked a publisher and they said yes. And then I was I was a poster. Um And that was an fy one an academic day and just did that. And again, remember at this point, I had no research, no, a nothing like that. I just had this. And then one week before my radiology interview in fy two, they sent me the cover design for this book. Cos that's how long these things take. It took 23 years to get this through. And so I printed it off, put it in my portfolio. And at the interview, one of the things they asked in the portfolio station was show me one thing in your portfolio and just turned to this page and talked about this and it didn't matter that I've done all this other stuff now, I know it's changed now and actually there's a lot more things, but I'll, I'll come on to that minute. So that's just my, my story. So what should you do? The most important thing is, is one thing to take away from this is that you need to go to your radiology department and you need to talk to consultants and radiology trainees and you need to get your face known. Don't just come in saying I wanna do an audit. You know, I get this all the time. I usually, it's an email usually it's from an F one sometimes medical student um saying hello, I want to do an re audit in three weeks and present nationally. Can you help me? And I'm like, hm, that's not physically possible. Like, no, you're not being realistic and it's usually September time and they want to apply, you know, in, in, in November. And you're just thinking, hey, you've left it too late, but also you're not doing it for the right reasons. You're not gonna get anything out of this. Why are you emailing? You know, it doesn't make any sense. Go there now while you're a medical student, talk to people, you not all radiologists are good. There's good radiologists and then there are also bad radio. I know we don't talk about it. There are bad radiologists. You don't want a bad mentor, you want a good mentor. And the only way you're gonna know who's good or bad it is by talking to people and figuring out who is gonna support you and particularly for your skill set. Not all radiologists are the same if you want to do an audit or some research as me or someone else that can help you. No one else in my group of 10 gi sos would, would do that. Um If you wanted education, I would absolutely not be the right person but met my colleague. She'd be excellent. She does the medical student teaching. She could help me with a project to teach the radiographers and you could put together a thing and then, you know, I don't know, make it about some new process and then we're looking at the X rights and, and, and a radiographer training and then they can present it to the board and then you can do something nationally. If it's an audit, I might already have loads of audits that are done and I need to re audit straight away. So I can just give you a re audit, you know, and get that presented and it can be something that the department needs and wants and then you're much more likely to get success from it. If you want an interesting case. Absolutely. Don't ask me or met. Tell, ask you Taro, he's got all the cases, but he hates research. OK? He is absolutely not the person you want to do, supervise research. He would, I had to drag him to a conference last year, like that's how bad it is, but he's got all the great cases. So he finds the case and then we work and we try and do that with you. So that's the most important thing. Um be proactive. OK. Again, coming here, you'll all obviously be very proactive and play to your strengths. If you're good at web programming, maybe you can do something along those lines. If you're not, don't try and do that, you're gonna fail, you need to do something that, that plays to your strengths. Um So I'm gonna say something here. That's why I put the animation in, but I think I've covered it all and I want to get some lunch. So, what I would say is, yeah. Er, if you do want to have a chat, I'm happy to come and chat to you anytime this afternoon. 1 to 1, look at your CV, talk about what you want. Maybe, maybe we can find you a skill set, try and point you in the right direction. I know a few radiologists who are trying to figure something out. It is not about what, you know, it is about who, you know, don't let anyone pretend it's about friendship. It's about meeting consultants. You have to kind of get your space known in the department and, and come and approach us and, and generally will be nice and will help you, you know. Um Don't assume that if you just do all the little bits that you'll get through because if you have a mentor and someone in radiology, you'll get so much more out of it, you know, maybe an audit will spin off into lots of publications rather than just being one little thing that you do and locally, so that would be my one take home tip and that is it. So, have you got any questions? Thank you, Chris. Uh What a fantastic lecture. Uh I'm in queue first to, to, to, to learn, to learn a bit more. I was just wondering really, it, it, it's so important to have your CV. Right? And being a T PDI R, we have shortlisting process going on and you know, the Deanery, the way it works is they are asking us to shortlist in the middle of term. So, brevity is the sole of was, you know, everybody has their own issues. And the only other thing that I thought of when you said, you know, I wouldn't see a CV with all those research qualifications on, I guess you haven't seen Professor Waugh's CV on, on that cheery note, I think uh please please take a moment to go speak to Chris about it and this, this whole meeting cannot happen without the fantastic uh work that's been done by so many of the medical students. Uh Oh, you have a question. Yeah, my question. Uh um The technology advancements such as bots being introduced to do these type of C vs and stuff, potentially. What's your thoughts on that? And is there any combat on that? Like bots doing C VS if you give the bot the structure, it will write the CV for you. I absolutely don't care. Uh It reflects you. OK. When I see a CV, that is my, that's all I, before I see you. That's all I've got. So if it looks like it's, you know, if it's really clever A I good on you, you've, you've made one that looks good and II don't have an issue with that. If it clearly looks like you've copied another design online, I'm like, mm OK. But it depends how you do it, if, if it looks professional and it, it works. That's fine. I've seen lots of, I was going through online looking at example C DS and there's a lot of rubbish that said this is a good example and it, I think this is terrible. Some of them have like stars like a, like a rating site on them. I was like, that is not appropriate for medicine. I'm like three out of five stars that NJ tube and I'm four out of five stars for liver biopsy. Five for rigs. That's, you know, that's my, er, I was like, that's not, that doesn't give me confidence, you know. So don't, I wouldn't copy those. What the answer. Yeah, it's gotta be honest. Yeah, I is not gonna write it because everything you do is personal to you. So it, it can't because it doesn't know what you've done. So, on behalf of the consultant speakers, you know, thanks to he and the team for having us here. I hand back to you to tell us what we are supposed to do. You have any more questions? Obviously, we've got the workshop session to go to in the afternoon. So doctor C will be in room 9.5 69.60. Ok. Ok. Hi everyone. Um, thank you so much for attending this morning and we hope you enjoyed the morning so far. So it is lunch time at the moment. Just a few important announcements before we go on. Um There's some gluten free people. Um There's limited gluten-free resources so please only take them if you need them. Um But I appreciate you might wanna try some gluten-free bread um allergies if you are unsure, the labels are still on the packages. But again, if you're unsure, ask a member of the team, um lunch will be going until 130. So about 125 make your way upstairs to level nine and you can see the um interactive sessions and we will be probably skipping the afternoon coffee break at 4 p.m. just to make up time so you guys can go home as well. Um But yeah, thank you so much for coming mingle, make friends um chat away. But yeah, any questions, ask any of us, so help yourself outside and thank you. Thank you so much. See you.