BIR Annual Congress 2014 by BIR Publishing

22–23 OCTOBER 2014

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BIR ANNUAL CONGRESS 2014 Venue: Royal College of General Practitioners CPD: 8 Credits (per day)

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BIR ANNUAL CONGRESS 2015 4–5 NOVEMBER LONDON

Day 1 • Room 1

Primers for the nonspecialists Session organised by Dr David Wilson, Consultant Interventional MSK radiologist, Oxford University Hospitals NHS Trust

• Room 2

Radiation protection

Session organised by Mr Andy Rogers, Head of Radiation Physics, Nottingham University Hospitals NHS Trust

More information available soon at www.bir.org.uk

Day 2 Clinical hybrid imaging in oncology • Room 1

Session organised by Dr Gopinath Gnanasegaran, Consultant Physician in Nuclear Medicine, St Thomas’ Hospital

• Room 2

Musculoskeletal imaging

Session organised by Dr Richard Wakefield, Consultant in Rheumatology, St James’s University Hospital

Essentials for the radiology trainee Session organised by Dr Hardi Madani, Radiology Registrar, Royal Free London Hospital and Dr Ausami Abbas, Cardiothoracic Radiology Post CCT Fellow, University Hospital Alberta

Welcome and thank you for coming to the British Institute of Radiology Annual Congress 2014. This two-day event promises a fascinating insight into various topics, including infectious diseases, cardiovascular imaging, pulmonary diseases, MSK, neuroimaging and GI radiology. We hope that by the end of the congress, you will have not only learnt technical information that will help with your daily activities, but also many other interesting historical aspects, which may trigger new research ideas on each of those subjects. We have the fantastic addition of ePosters this year, which will be displayed on the screens in the foyer, where students, trainees and consultants will be showcasing their current research. Please take the time to view these and ask the author(s) questions; the timetable of scheduled talks is in your conference pack. The first BIR Congress dates back to 1897. If you are interested in finding out what was discussed at the very first congress and those thereafter, the BIR history stand (in the foyer) will reveal all. We are extremely grateful to all our sponsors for supporting this event and we hope you will visit their exhibition stands to find out more about the services they offer. Finally, I, the organising committee and the BIR wish you a very enjoyable and educational experience at the BIR Annual Congress 2014. Dr Klaus Irion Clinical Lead, Department of Radiology, Liverpool Heart and Chest Hospital BIR Annual Congress Director 2014

We are most grateful to

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Programme

DAY 1: Wednesday 22 October

ROOM 1: Imaging in infection 08:30 Registration and refreshments 09:00 Chair:

Welcome and introduction Dr Klaus Irion, Clinical Lead, Department of Radiology, Liverpool Heart and Chest Hospital BIR Annual Congress Director 2014

09:05 A journey through the history of tuberculosis Professor Bertie Squire, Professor of Clinical Tropical Medicine, Director, LSTM Centre for Applied Health Research and Delivery 09:50 Thoracic tuberculosis Dr Alexandre Mancano, Consultant Chest Radiologist, Public Health System of Brasilia - DF, Brazil 10:20

Abdominal tuberculosis Dr Elizabeth Joekes, Consultant Radiologist, Royal Liverpool University Hospital and Dr Tom Heller, Consultant in Internal Medicine and Infectious Diseases, Klinikum Perlach, Munich

10:50 Refreshments 11:05 Infectious diseases in the head and neck Professor Pradipta Hande, Senior Consultant in Radiodiagnosis, Breach Candy Hospital Trust, Mumbai 11:35 Infection and the MSK system Dr Andrew Dunn, Consultant Musculoskeletal Radiologist and Honorary Clinical Lecturer, Royal Liverpool University Hospital 12:05 Pneumonia Dr John Reynolds, Consultant Radiologist/Deputy Clinical Director, Birmingham Heartlands Hospital 12:35 Lunch 13:35 The world of the spores and hyphae Dr Derek Sloan, Senior Lecturer and Consultant Physician, Liverpool Heart and Chest Hospital 14:05 Fungal diseases and the thorax Professor Arthur S Souza Jr, Professor, Medical School of Rio Preto, Brazil

14:35 Aspergillus: how, when and why it harms the human body Professor William Hope, Professor of Therapeutics and Infectious Diseases, University of Liverpool 15:05 Imaging of aspergillus in the lungs Dr Sujal Desai, Consultant Radiologist and Honorary Senior Lecturer, King’s College London 15:35 Refreshments 15:50 Understanding environmental mycobacteria Professor Peter Davies, Consultant Chest Physician, Liverpool Heart and Chest Hospital 16:35 Viral infections and the thorax Professor Dante Escuissato, Associate Professor of Radiology, Federal University of Paraná, Brazil 17:05 Viral infections and the abdomen Dr Elizabeth Joekes, Consultant Radiologist, Royal Liverpool University Hospital 17:30

Learn, imagine and fly through the radiological times Professor Adrian Thomas, Chairman, International Society for the History of Radiology Honorary Librarian, The British Institute of Radiology

18:15 Close of day 19:30 Congress dinner (for those who have pre-registered) _______________________________________________________________________

Certificate of attendance Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/BIRAnnualCongress2014 BIR Annual Congress 2015: 4–5 November, London

Speaker profiles (where supplied) Professor Peter Davies Consultant Chest Physician, Liverpool Heart and Chest Hospital Peter Davies qualified in medicine from Oxford University in 1973. He did his junior hospital jobs in London and Cardiff, specialising in General and Respiratory Medicine. He completed an MD thesis on tuberculosis in the UK while working for the Medical Research Council’s Tuberculosis and Chest Diseases Unit. From this, a lifelong interest in tuberculosis developed. He was appointed a Consultant Respiratory Physician to Fazakerly Hospital (now Aintree University Hospital) and the Cardiothoracic Centre Trusts in 1988. In 1990 he set up the Tuberculosis Research and Resources Unit (TBRRU), and is now Director. He has conducted research into many epidemiological aspects of TB in Liverpool and other parts of the world, particularly Hong Kong and India. In 2004 he was appointed Honorary Professor to Liverpool University. In 1998 he helped form a new national tuberculosis charity: TB Alert, of which he is the secretary. Professor Davies has written over 120 papers published in refereed Journals, 30 book chapters, over 100 letters and commissioned articles and over 170 abstracts of presentations at scientific societies. Professor Davies has also edited the only definitive reference work on tuberculosis published outside the USA: “Clinical Tuberculosis”, published by Arnold, now in its fourth (2008) edition. He has co-authored the section on tuberculosis in the Oxford Textbook of Medicine (4th edition) and co-authored “Cases in Clinical Tuberculosis,” also published by Arnold. Dr Sujal Desai Consultant Radiologist and Honorary Senior Lecturer, King’s College London Dr Sujal Desai was trained in general radiology at King’s College Hospital and in thoracic imaging at the Royal Brompton Hospital. Under the supervision of Professor David Hansell, he was awarded an MD from the University of London for his work on structure-function relationships in fibrosing lung diseases. His principal research interests are in the evaluation of fibrosing interstitial lung disease and, latterly, the area of chronic lung disease in adolescents with vertically-acquired HIV infection for which he is the principal collaborating investigator with a research group in Zimbabwe. With colleagues from the Royal Brompton Hospital and Hammersmith Hospitals, he is also the principal investigator in a study evaluating the prevalence of pleural plaques on CT and their relationship with occupational history. He is the principal author/co-author of 48 peer-review papers, 13 invited reviews/editorials, and 27 book chapters. He has also edited 4 books (including, most recently, the Oxford Specialist Series in Thoracic Imaging). He served on the editorial board of Clinical Radiology for 13 years and is presently on the board of the Journal of Thoracic Imaging and the European Journal of Radiology. In June 2012, Dr Desai was President of the European Society of Thoracic Imaging (ESTI) and hosted the 20th annual meeting of the society in London.

Dr Andrew Dunn Consultant Musculoskeletal Radiologist and Honorary Clinical Lecturer, Royal Liverpool University Hospital Dr Andrew Dunn is a Consultant MSK Radiologist and Honorary Clinical Lecturer at the Royal Liverpool University Hospital. Dr Dunn trained in the Mersey region before completing a fellowship in MSK imaging from the University of Toronto. Dr Dunn has published widely in the musculoskeletal imaging literature, including book chapters on sports injury and upper limb imaging, and is on the faculty of many national musculoskeletal imaging courses including the British Medical Ultrasound, British Society of Skeletal Radiology and Oswestry Spinal Imaging courses. Dr Dunn maintains an active role in education, teaching on the Mersey School of Radiology and the Northern Fellowship of Sports and Exercise Medicine training programmes. Professor Dante Escuissato Associate Professor of Radiology, Federal University of Paranรก, Brazil Dr Dante L Escuissato is Professor of Radiology and Internal Medicine, Federal University of Paranรก and consultant radiologist in DAPI Clinic in Curitiba, Brazil. Dr Escuissato is linked to the teaching activities of Thoracic Radiology (residency and post-graduate) at the Federal University of Paranรก. His publications (scientific articles and book chapters) mainly focus on infectious lung disease, hematopoietic stem cell transplantation and interstitial lung diseases. Professor Pradipta Hande, Senior Consultant in Radiodiagnosis, Breach Candy Hospital Trust, Mumbai Professor (Dr) Pradipta C Hande is a Senior Consultant in Radiodiagnosis at the Breach Candy Hospital Trust at Mumbai, a multispeciality tertiary care teaching hospital. An MD from the Armed Forces Medical College, University of Pune, she did her post doctoral training in head and neck imaging at Mumbai and at the University teaching hospital, Cologne, Germany. With sixteen years of academic experience, she is a university recognised post-graduate teacher and examiner with the National Board of Examinations in Radiodiagnosis. Her areas of special interest include head and neck imaging and neuroimaging. She has been part of the national faculty of the Indian Radiology and Imaging Association (IRIA) for more than ten years and has been a Visiting Fellow at the NHS University Hospitals. She has publications in various journals and presented papers and guest lectures in several national and international conferences and seminars. Dr Tom Heller, Consultant in Internal Medicine and Infectious Diseases, Klinikum Perlach, Munich Dr Tom Heller, born 1969, graduated from the Medical School of the Technical University Munich, Germany in 1995. He specialised in general internal medicine, as well as in infectious diseases and worked in Germany, Saudi Arabia and South

Africa. He has been interested in diagnostic and interventional ultrasound since the beginning of his career. His research interests are ultrasound applications in the resource-limited setting and sonographic diagnosis and treatment of infectious diseases. He worked on a project on remote teaching of ultrasound in Gabon and has conducted ultrasound trainings in Germany, UK, Italy, Zimbabwe, Ethiopia, South Africa, Ghana, Saudi Arabia, Kuwait, Peru and Cambodia. Professor William Hope Professor of Therapeutics and Infectious Diseases, University of Liverpool William Hope is currently an NIHR Clinician Scientist and Professor of Therapeutics and Infectious Diseases at The University of Liverpool in the United Kingdom. Professor Hope is a Fellow of the Royal Australasian College of Physicians and a Fellow of the Royal College of Pathologists of Australasia. William Hope qualified in Medicine in 1991 before undertaking specialist training in infectious diseases and clinical microbiology. He completed his PhD in antimicrobial pharmacology in 2006, while undertaking fellowships at The University of Manchester and the National Institutes of Health, Bethesda, USA. He was awarded a Chair in Therapeutics and Infectious Diseases in 2011 at The University of Manchester. He has recently been appointed to a Chair in the Department of Molecular and Clinical Pharmacology at the University of Liverpool. Professor Hope’s areas of special interest and research are antimicrobial pharmacokinetics and pharmacodynamics, mathematical modelling of antimicrobial agents, population pharmacokinetics, and individualisation of antimicrobial therapy. Professor Hope is Scientific Advisor to the ESCMID Fungal Infection Study Group (EFSIG), a member of the ICAAC Program Committee for Antimicrobial Pharmacokinetics, Pharmacodynamics and General Pharmacology, and Medical Guideline Director for the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). Dr Elizabeth Joekes Consultant Radiologist, Royal Liverpool University Hospital After completion of specialist training in the Netherlands in 1998, Dr Joekes worked in interventional radiology and oncology in the Netherlands. In January 2004 she took up a position as Head of Radiology at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. From 2007 she has been employed at the Royal Liverpool University Hospital, with a continuing interest in tropical and infectious diseases and global health radiology. She is associate lecturer at the Liverpool School of Tropical Medicine and external specialist for the department of diagnostic imaging of Medecins sans Frontieres in Amsterdam. Dr Alexandre Mancano Consultant Chest Radiologist, Public Health System of Brasilia - DF Dr Alexandre Mançano is a consultant chest radiologist in the State Health Secretary of Brazil’s Federal District and in Anchieta Hospital in Federal District. He is the

coordinator of the Image Deparment of the Brazilian Society of Pneumology and Phthisiology and the President of the Radiology and Diagnostic Imaging Society of Brasília – Federal District. He is also a full member of the Brazilian College of Radiology and Diagnostic Imaging. Alexandre has published widely in the chest imaging literature, including book chapters, and is on the faculty of many Brazilian chest imaging courses including Brazilian National Congress. Alexandre maintains an active role in education, teaching on the Brazilian College of Radiology and Diagnostic Imaging and in the Brazilian Society of Pneumology and Phthisiology training programmes. Dr John Reynolds Consultant Radiologist/Deputy Clinical Director, Birmingham Heartlands Hospital John Reynolds has been a consultant radiologist at Birmingham Heartlands Hospital with an interest in thoracic imaging since 1993. He has served as President of the British Society of Thoracic Imaging from 2006 to 2009. Recent publications include articles on airway disease, diffuse lung disease and pulmonary vasculitis along with several modules in the thoracic section of the Royal College of Radiologists Integrated Training Initiative. He has been on the editorial board of Clinical Radiology, British Journal of Radiology and Imaging and served as the respiratory expert lead for i-Refer, the Royal College of Radiologists clinical guideline publication. His lung cancer interest has led to him being on the medical advisory group of the UK Lung Cancer Coalition. Dr Derek Sloan Senior Lecturer and Consultant Physician, Liverpool Heart and Chest Hospital Dr Derek Sloan is a Senior Lecturer and Consultant Physician in Infectious Diseases at Liverpool Heart and Chest Hospital and the Liverpool School of Tropical Medicine. His clinical training was in Glasgow and Liverpool. He has also worked extensively in African countries with high rates of HIV-infection, including Kenya, South Africa and Malawi. His primary research interest is tuberculosis, but he has also authored several publications on fungal diseases, specifically cryptococcal meningitis. His research has been funded by the Wellcome Trust and he has a PhD in infection and global health. Professor Arthur S Souza Jr Professor, Medical School of Rio Preto Professor Arthur Soares Souza Jr graduated and trained in general radiology in São José do Rio Preto, did a Fellowship in University of Alabama at Birmingham, USA, under the supervision of Professor David M. Witten and Larry P. Elliott. His principal research interests are in the evaluation infections and diffuse lung diseases. He is the author/co-author of 110 peer-review papers, and 15 book chapters. He is presently on the board of the Brazilian Journal of Radiology and Brazilian Journal of Pneumology. He is member of Scientific Committee of Society Paulista de Radiologia.

Professor Bertie Squire Professor of Clinical Tropical Medicine, Director, LSTM Centre for Applied Health Research and Delivery Areas of interest: Tuberculosis: improving access by the poor to diagnosis and clinical care, equity in health and applied health research. Professor Squire studied medicine and immunology at University College London and Cambridge University before professional training in internal medicine, infectious diseases and respiratory medicine at the Royal London Hospital and the Royal Free Hospital. From 1992 to 1995 he was Head of the Department of Medicine, Kamuzu Central Hospital, Lilongwe, Malawi. Since his appointment at LSTM in 1995, Professor Squire has maintained his research collaboration with the National TB Control Programme in Malawi and has facilitated the transformation of the collaboration into the Malawi-registered Trust for Research on Equity And Community Health (REACH). With colleagues in many countries he has built up a programme of multi-disciplinary applied health research aimed at providing knowledge for action in making health services for tuberculosis more accessible to poor people in developing countries (including those affected by the HIV pandemic). He holds an appointment in the UK National Health Service as Honorary Consultant in Infectious Diseases and Tropical Medicine at the Royal Liverpool University Hospital and is the immediate past President of the International Union Against Tuberculosis & Lung Disease. Professor Adrian Thomas Chairman, The International Society for the History of Radiology Honorary Librarian, The British Institute of Radiology Professor Thomas was a medical student at University College London. He was taught medical history by Edwin Clarke, Bill Bynum and Jonathan Miller. In the mid-1980s he was a founding member of what is now the British Society for the History of Radiology. In1995 he organised the radiology history exhibition for the Rรถntgen Centenary Congress and edited his first book on radiology history. He has published extensively on radiology history and has actively promoted radiology history throughout his career. He is currently the Chairman of the International Society for the History of Radiology. Professor Thomas believes it is important that the radiology is represented in the wider medical history community and to that end lectures on radiology history in the Diploma of the History of Medicine of the Society Apothecaries (DHMSA). He is the immediate past-president of the British Society for the History of Medicine, and the UK national representative to the International Society for the History of Medicine. _____________________________________________________________________ Abstracts (where supplied) A journey through the history of tuberculosis Professor Bertie Squire This talk tracks our understanding of tuberculosis; the disease caused by mycobacterium tuberculosis. The major milestones of this understanding are closely linked to the major milestones in the development of modern medicine

and the control of infectious diseases. Koch’s discovery of the tubercle bacillus and his work demonstrating that this was the cause of the disease which was often referred to as “consumption” cemented the concept of micro-organisms as causative agents of disease. The use of chest x-rays to diagnose and document the extent of disease are closely linked to the development of the discipline of radiology. Randomised, controlled trials for assessing treatment options were first developed for tuberculosis and resulted in combination chemotherapy to reduce the risks of the development of drug resistance. More recently the concept of treatment as a key step in preventing transmission led to the DOTS strategy which underpins the global strategy to control tuberculosis. Finally, we have come full circle in recognising that this classical disease of poverty and deprivation will not be controlled without ensuring that effective treatment services are made available and accessible for poor populations along with interventions to tackle the underlying drivers of deprivation. Thoracic tuberculosis Dr Alexandre Mancano During the Aids pandemia, in the beginning of the 1980’s, we could see an increase in the number of Tuberculosis (TB) cases. We thought, in that time, that TB was a controlled disease, but as the AIDS pandemia has shown us, it was not. In that time, we found out that TB was the immediate cause of that pandemia, but the underlying cause was AIDS. The World Health Organization (WHO), in 1993, named TB a global emergency and made an obscure prediction: That between 1997 and 2020, we would have 1 billion of new cases in the world and we would see about 70 million deaths caused by TB. TB is a worldwide disease. In England, we have about 10 to 19 cases and in Brazil 20 to 49 cases per a 100 thousand inhabitants. In 2010, England had about 500,000 with TB, and in Brazil about 2 million patients with TB. If we compare Rio de Janeiro to London, as separate cities, we can see in Rio something between 54 to 70 TB cases per a hundred thousand inhabitants, and in London something very close to that. So, this is the reason why we are going to talk about TB in this important meeting, in the 21st century. The objectives of our lecture will be to review and recognise the main radiologic aspects in pulmonary TB. We could divide these objectives in four topics: 1. Primary TB 2. Secondary TB 3. TB in imunocompromised host 4. Complications pertinent to the disease

Abdominal tuberculosis Dr Elizabeth Joekes Dr Tom Heller This session will provide a brief clinical, case-based introduction to abdominal tuberculosis, incorporating CT imaging. This will be followed by a more in-depth discussion of the use of ultrasound (US) in the diagnosis of extra-pulmonary TB (EPTB) in HIV, as for the vast majority of affected populations CT and radiological expertise are not available. Focused assessment with sonography (FASH) by clinicians caring for TB/HIV patients is increasingly used to assist in the diagnosis of EPTB. Feasibility and training will be discussed briefly. Learning objectives: 1. Recognise typical ultrasound findings of EPTB. 2. Understand expected US changes during and after treatment. 3. Appreciate the added value of FASH, compared to chest X-rays. 4. Recognise key features of abdominal TB on CT. Infectious diseases in the head and neck Professor Pradipta Hande Infections of the head and neck are not uncommon and are often associated with high morbidity with dismal outcomes. It can result in rapid deterioration due to extension of disease and serious complications, even in the era of antibiotics, especially in immune-compromised patients. While the diagnosis is primarily by clinical examination, the extent of infection is difficult to estimate clinically. The role of radiology is well established, even though plain radiographs have a limited utility and cross-sectional imaging is vital for the assessment of disease. Educational aims: Computed tomography (CT) and magnetic resonance imaging (MRI) help in detailed evaluation of extent of disease and early detection of vascular and airway compromise and thus assist in planning surgical management. MDCT with isotropic imaging allows multiplanar reconstructions (MPR) and exquisite 3D reformats. Intravenous non-iodinated contrast injection is useful to study the enhancement patterns and help to differentiate phlegmonous mass from abscess which needs immediate surgical drainage. Soft tissue, bone and/ or lung windows for display is recommended for the extent of infection, bone involvement and to detect gas within the tissues as in abscess. CT is quick, widely available and is the modality of choice for imaging in head and neck infections. MRI has better inherent soft tissue contrast and can detect oedema early. T1-weighted images after IV injection of Gadolinium-based contrast can be problem-solving in specific situations especially in widespread disease like fungal infections. However, it has a limited role due to long acquisition times and difficulty in breath holding in very ill patients. Learning outcomes: The imaging protocols should be tailored to the clinical condition and an attempt should be made to detect intra-cranial, spinal or thoracic extension of the disease. The source of the septic focus may be otolaryngologic or dental, which can be assessed on head and neck imaging.

Infection and the MSK system Dr Andrew Dunn Successful imaging diagnosis of musculoskeletal infection often requires a multimodality approach comprising radiography, ultrasound, MRI, CT and scintigraphy. Because each of these imaging modalities has its own strengths and weaknesses, combinations of modalities are often utilised. Imaging should be combined at all times with a detailed clinical history, and discussion of imaging findings with clinicians in the setting of an Infection MDT meeting is helpful in reaching a rapid diagnosis and planning treatment. The educational aims of this presentation are as follows: 1. To cover the modes of spread of musculoskeletal infection with particular reference to patho-anatomy and discuss some of the pathological terminology of MSK infection. 2. To discuss the role and application of various imaging modalities in the diagnosis of musculoskeletal infection with particular focus on radiography and MRI. 3. Consider how and when to perform intervention in the form of image guided fluid aspiration or biopsy. 4. Present a problem-solving approach when considering how best to image in the orthopaedic post-operative setting. 5. To briefly discuss the role of newer imaging modalities such as PET-CT in the diagnosis of MSK infection. 6. Present the imaging of some atypical and some rare organism specific musculoskeletal infections. Pneumonia Dr John Reynolds Key teaching points: 1. The chest radiograph remains a key investigation with suspected pneumonia and for most it will be the only imaging they require. 2. CT is more sensitive than the chest radiograph for the detection of pneumonia and in certain clinical settings may give a strong enough indication of the type of infecting organism to allow a decision on anti-microbial treatment. 3. Complications of pneumonia such as lung abscess or complicated pleural effusions may require further assessment with ultrasound or CT. 4. MRI technology is advancing and it provides an option for follow up but it does not yet match CT as a diagnostic test. 5. Most patients with a lung abscess will respond to medical treatment. For those who do not, image guided catheter placement provides a treatment option for those not fit for a surgical approach, particularly if the abscess abuts a pleural surface. References 1. Reynolds JH, McDonald G, Alton H, Gordon SB. Pneumonia in the immunocompetent patient. British Journal of Radiology 2010; 83: 998-1009.

2. Franquet T. Imaging of pulmonary viral pneumonia. Radiology 2011; 260: 18-39. 3.Reynolds JH and Banerjee AK. Imaging pneumonia in immunocompetent and immunocompromised individuals. Curr Opin Pulm Med 2012; 18: 194-201. The world of the spores and hyphae Dr Derek Sloan Fungi are ubiquitous in the environment. Initially thought to be part of the plant kingdom, they are actually more closely related to animals. With approximately 1.5 million species on earth, fungi are amongst the most evolutionary diverse organisms on the planet. They provide valuable ecosystem services through decomposition of organic matter and symbiotic associations with other living systems. They are also used as food. However, the utility of fungi to life on earth, is counterbalanced by pathogenicity. Diseases of plants and animals may have devastating consequences for humankind; a striking historical example is infection of potatoes by phytophthora infestans which led to the 19th century Irish famine and caused the death of over 1 million people. Approximately 300 fungal species are pathogenic to humans, particularly amongst individuals with underlying immune dysfunction. Since the 1980s, effects of the global HIV epidemic and increased use of immunosuppressive medications (e.g. to treat inflammatory disease and malignancy or to prevent tissue rejection after organ transplantation) have focussed attention on the diagnosis and management of fungal infections including crypotococcosis, aspergillosis, candidiasis, histoplasmosis, and pneumocystis carinii (jerovecii) pneumonitis. This lecture will introduce fungal disease by discussing general characteristics of fungi and illustrating the threat to human health via examples of clinical disease. Fungal diseases and the thorax Professor Arthur S Souza Jr Fungal infections of the lung are less common than bacterial and viral infections but pose significant problems in diagnosis and treatment. They mainly affect people living in certain geographic areas and those with immune deficiency. Their virulence varies from causing no symptoms to causing death. Rates of invasive fungal infections have surged during recent decades, largely because of the increasing size of the population at risk. The aim of this presentation is demonstrating the main TC findings of the most common lung mycoses in South America.

Imaging of aspergillus in the lungs Dr Sujal Desai The propensity for aspergillus spp. to cause lung disease has been recognised for well over a century. Yet the satisfactory classification of these disorders has proved challenging. The problems caused invasive disease in severely neutropenic patients, saprophytic infection of preexisting fibrotic cavities and allergic reactions to aspergillus are well documented in the literature and will not be the focus of the presentation. In contrast, a more chronic form of aspergillus-related lung disease which has the potential to cause significant morbidity and mortality, has been under-reported. This will be the main focus of the presentation. The symptoms of this form of aspergillus infection are generally non-specific and because of this and the radiological findings (consolidation and cavitation in the upper zones) a presumptive clinical diagnosis of mycobacterial infection is often made. Indeed, non-tuberculous mycobacterial infections frequently co-exist with chronic pulmonary aspergillosis and the radiologist may be the first to suspect this diagnosis. The current presentation will considers the classification conundrums in diseases caused by aspergillus spp. and discusses the typical clinical and radiological profile of patients with chronic pulmonary aspergillosis. Understanding environmental mycobacteria Professor Peter Davies These mycobacteria are a real pest. I would rather treat a patient with multi-drug resistant tuberculosis any day. You know where you are with MDRTB but with the EN or NTMs as the Americans call them we are mostly in the dark. For a start if they are isolated from a patient we canâ&#x20AC;&#x2122;t be sure that they are actually causing a disease, they may be commensal especially if smear negative. When we do decide to treat there are precious few RCTs to guide us as to what to treat with our how long to treat. Because they relatively rarely cause death they are grossly under researched. Also one can virtually never discharge a patient because as the bacteria are acquired from the environment, patients can be infected time and time again. And to make matters worse the clever microbe hunters seem to come up with a new species daily. Here are just some of the names for starters. M. scrofulaceum M. szulgai , M. avium complex (MAC). M. ulcerans, M. xenopi, M. malmoense, M. terrae, M. haemophilum M. genavense. M. chelonae, M. abscessus, M. fortuitum and M. peregrinum. M. smegmatis and M. flavescens. Howâ&#x20AC;&#x2122;s a guy going to get a handle on that lot? Viral infections and the thorax Professor Dante Escuissato Viruses are common causes of lower respiratory tract infection and may result in tracheobronchitis, bronchiolitis, and pneumonia. These infections are transmitted from person to person by hand-to-hand-contact, contact with infected surfaces, or aerosol transmission. Viral pneumonia in adults can be divided into two groups: atypical pneumonia in previously normal patients and viral pneumonia in immunocompromised hosts. Clinical and imaging manifestations in viral

infections are not characteristics, making it difficult to differentiate infections with other agents. Although it is not possible to diagnose viral infections based solely on imaging methods, the combination of these with clinical data can increase the accuracy in the diagnosis. Viral infections and the abdomen Dr Elizabeth Joekes A wide range of viral infections manifests itself with intra-abdominal pathology. For many of these the role of diagnostic imaging is limited or entirely absent. For others, like hepatitis and its complications of cirrhosis and HCC, the role of imaging and imaging guided treatment is well known and features prominently in the literature. The current lecture will focus on the features of less commonly encountered viral infections and their sequelae and differentials on imaging: CMV, EBV and HPV for example. Following a brief general overview of viral infections for radiologists, clinical cases, using mainly CT and ultrasound will be discussed. Learning outcomes: To recognise when a viral infection should be considered in the differential of intra-abdominal imaging pathology. Learn, imagine and fly through the radiological times Professor Adrian Thomas There were significant advances in medicine during the 19th century with increased knowledge in medicine, surgery, bacteriology and chemical pathology. However our ability to look inside the body had shown little improvement and was limited to the probing finger or simple endoscopy. This was all to change in 1895 when Wilhelm Conrad Rรถntgen discovered x-rays. The description of the ability to see through the body was greeted by many with incredulity and early accounts had to reassure the public that this was a serious discovery by a respected scientist. Early radiology was technically difficult to perform, however during the next few decades the equipment gradually improved. Initially image interpretation was also difficult and it took many years to decipher these often confusing shadows. Radiology was also not without risk, with injuries related to ionising radiation, electrical injuries and chemical injuries from processing the films and plates. Radiology steadily progressed with the development of the modern x-ray tube, contrast medium, catheters and image intensification. Traditional radiology revolutionised medical care. However investigations were often invasive and pathology was often shown indirectly. Radiology has profoundly changed since what can be seen as the golden decade of the 1970s, starting with the announcement of CT scanning in 1972. Developments in CT scanning, ultrasound, nuclear medicine, MRI scanning, and finally interventional radiology has placed radiology in the forefront of modern medicine. Modern radiology now allows for non-invasive diagnosis, and this has facilitated minimally invasive therapy. This story is exciting and interesting.

Reading: Thomas, AMK., Banerjee, AK. The History of Radiology. Oxford: Oxford University Press (2013) Educational aims and learning outcomes: 1. To understand the background to radiology. 2. To see connections between various facets of the radiological science. 3. To understand how one development facilitated another. _____________________________________________________________________

Programme

DAY 1: Wednesday 22 October

ROOM 2: Cardiovascular imaging 08:30 Registration and refreshments 09:00 Welcome and introduction Chair: Dr Sukumaran Binukrishnan, Consultant Cardiothoracic Radiologist, Liverpool Heart and Chest Hospital 09:05 History of cardiac CT from inception to present Dr Tarun Mittal, Consultant Cardiothoracic Radiologist, Royal Brompton & Harefield NHS Trust 09:50 Dual energy in cardiac CT Dr Balazs Ruzsics, Consultant Cardiologist Royal Liverpool University Hospital 10:20 Role of CT in imaging myocardial perfusion Dr Michelle Williams, Radiology Trainee, Royal Infirmary of Edinburgh 10:50 Refreshments 11:05 Cardiac CT for the emergency department Dr Russell Bull, Consultant Radiologist, Royal Bournemouth Hospital 11:35 Imaging of the vulnerable plaque with cardiac CT Dr Balazs Ruzsics, Consultant Cardiologist Royal Liverpool University Hospital 12:05 Imaging in TAVI Dr Sukumaran Binukrishnan, Consultant Cardiothoracic Radiologist, Liverpool Heart and Chest Hospital 12:35 Lunch 13:35 Management of pulmonary embolic disease Professor Duncan Ettles, Consultant Cardiovascular and Interventional Radiologist, Hull Royal Infirmary 14:05 Acute aortic syndromes Professor Peter Gaines, Consultant Vascular Interventional Radiologist, Sheffield Vascular Institute 14:35 Management of acute thoracic dissections Dr Mohamad Hamady, Consultant Interventional Radiologist and Senior Lecturer, Imperial College London

15:05 Management of thoracic/arch aortic aneurysm Mr Manoj Kuduvalli, Consultant Cardiac Surgeon, Liverpool Heart and Chest Hospital 15:35 Refreshments 15:50 Management of aorto-iliac occlusive disease Dr Graham Robinson, Consultant Vascular Radiologist and Clinical Lead for Vascular Radiology, Hull Royal Infirmary 16:15 Stroke prevention: carotid artery stenting Dr Trevor Cleveland, Consultant Vascular Radiologist, Sheffield Vascular Institute 16:40 Management of abdominal aortic aneurysms Dr Nicholas Chalmers, Consultant Vascular Radiologist, Manchester Royal Infirmary 17:05 Interventional management of hypertension Dr Trevor Cleveland, Consultant Vascular Radiologist, Sheffield Vascular Institute THE FOLLOWING LECTURE WILL TAKE PLACE IN ROOM 1 17:30 Learn, imagine and fly through the radiological times Professor Adrian Thomas, Chairman, International Society for the History of Radiology 18:15 Close of day 19:30 Congress dinner (for those who have pre-registered) _______________________________________________________________________

Speaker profiles (where supplied) Dr Sukumaran Binukrishnan Consultant Cardiothoracic Radiologist, Liverpool Heart and Chest Hospital Dr Binukrishnan is a consultant cardiothoracic radiologist at Liverpool Heart and Chest Hospital NHS Trust and Royal Liverpool and Broadgreen University Hospitals NHS Trust. He obtained his undergraduate degree from India and MRCP from Edinburgh. Radiology specialist training was from Mersey School of Radiology. Cardiac CT training was obtained as fellow at the University of Erlangen, Nuremberg, Germany and Cardiac MRI as visiting fellow at Stanford University, California, USA. He has over 6 years of experience in cardiac CT and cardiac MRI including adult congenital heart diseases. He is also accredited in chest and general radiology. Publications are in the field of cardiac and chest imaging. Dr Russell Bull Consultant Radiologist, Royal Bournemouth Hospital Dr Bull was appointed as a consultant radiologist at the Royal Bournemouth Hospital in 2000. Dr Bull initially worked as a general Cross Sectional Radiologist and started a cardiac CT service at Bournemouth in 2003 followed by a cardiac MRI service the following year. For the last 4 years he has worked almost exclusively as a Cardiothoracic Radiologist with his time split between cardiac CT and MRI. His interests include reducing radiation and contrast doses for CT examinations and increasing efficiency within radiology departments by optimising technology and workflows. Dr Bull is currently secretary and education lead for the British Society of Cardiovascular Imaging (BSCI). Dr Nicholas Chalmers Consultant Vascular Radiologist, Manchester Royal Infirmary Dr Nick Chalmers has been a Consultant Vascular Radiologist at Manchester Royal Infirmary for more than 20 years and has been involved with endoluminal repair of aortic aneurysm for most of this time. He was a participant in the EVAR and IMPROVE Trials. Dr Trevor Cleveland, Consultant Vascular Radiologist, Sheffield Vascular Institute Dr Trevor Cleveland qualified in medicine from Nottingham University in 1985. Following a yearâ&#x20AC;&#x2122;s post in Cambridge doing A&E, neurotrauma and orthopaedics, he joined the Sheffield Surgical Training Scheme. He became Fellow of the Royal College of Surgeons of England in 1990, and commenced radiology training in Sheffield, with the intention of pursuing a career in interventional radiology. He became a Fellow of the Royal College of Radiologists in 1994. He was appointed Senior Lecturer (Honorary Consultant) in Vascular Radiology at Sheffield University in 1995 and Consultant Vascular Radiologist in 2000.

Dr Cleveland has been a member of the British Society of Interventional Radiology since 1995, and has served on the Council. He is also a Fellow and on the Advisory Board of CIRSE, and is a Director of the European School of Interventional Radiology. Dr Cleveland is also a member of the European Society of Radiology and presently serves on the Board of the Faculty of the Royal College of Radiologists. Professor Duncan Ettles Consultant Cardiovascular and Interventional Radiologist, Hull Royal Infirmary Duncan Ettles is a Consultant Cardiovascular and Interventional Radiologist for Hull and East Yorkshire Hospitals NHS Trust and Honorary Clinical Professor in radiology at the University of Hull. He currently serves as president of the British Society of Interventional Radiology, through which he has been involved in the development of UK interventional radiology for over 20 years. He has also been active in training IRs throughout his career, including roles as former head of training, regional adviser and examiner for the Royal College of Radiologists. Professor Ettles is chairman of the NHS specialised commissioning group for interventional radiology and member of the NICE GDG and Quality Standards Committee for peripheral arterial disease. Professor Peter Gaines Consultant Vascular Interventional Radiologist, Sheffield Vascular Institute Degree from Manchester Medical School, MRCP after endless clinical posts finally settling into Radiology at Guyâ&#x20AC;&#x2122;s Hospital. Moved to Sheffield to extend vascular experience with the incredible Professor David Cumberland. After a year in Hong Kong, two years as Senior Lecturer at Sheffield University, heâ&#x20AC;&#x2122;s been Consultant Radiologist in Sheffield since 1995. He developed the autonymous Sheffield Vascular Institute 1998. He has spent some time spent with DoH developing Payment by Results for Interventional Radiology, NICE, MHRA and as president of the British Society of Interventional Radiology. He has written 124 original scientific papers and several chapters and books. His specific interest is thoracic aortic disease, carotid intervention and vascular malformations. He is currently MD for two device companies and Radiology Consultant for iGene who are rolling out digital autopsy across the UK.

Dr Mohamad Hamady Consultant Interventional Radiologist and Senior Lecturer, Imperial College London Dr Hamady graduated from medical school in 1998. Following 3 years of surgical training, he joined clinical and interventional radiology training at the American University of Beirut. He completed interventional radiology training at King’s College London in 2001. He did 2 years of clinical research in IR at Guy’s and St Thomas’ Hospital. He then joined Imperial College London in 2003 as Consultant and Senior Lecturer in Vascular Interventional Radiology. His research interests include robotic endovascular intervention and navigation, virtual reality simulation training of endovascular skills, aortic stent grafting and ovarian reserve post fibroid embolisation. He recently started a research work on improving patient’s safety in IR. He has over 120 papers in peer-review journals and 12 book chapters. He has given more than 65 talks and key note lectures in national and international scientific meetings. He is currently developing, in collaboration with industry, a new generation of fenestrated/branched stent graft for thoraco-abdominal aneurysms. Dr Hamady has done the world-first robotic endovascular aortic repair in 2008 and the world-first robotic fibroid embolisation in 2012. Mr Manoj Kuduvalli Consultant Cardiac Surgeon, Liverpool Heart and Chest Hospital Mr Manoj Kuduvalli graduated in India in 1992 and trained in Mumbai as a cardiovascular and thoracic surgeon before moving to the UK in 1999. He further completed his training programme in cardiothoracic surgery in the UK and was appointed as a Consultant Cardiac Surgeon at the Liverpool Heart and Chest Hospital in 2007. In addition to general cardiac surgery, his main areas of special interest are in thoracic aortic surgery and transcatheter aortic valve implantation (TAVI). Dr Tarun Mittal, Consultant Cardiothoracic Radiologist, Royal Brompton & Harefield NHS Trust Dr Mittal was trained in all aspects of cardiac imaging in Leeds. As a consultant since 2002, he has developed and run highly successful clinical services in cardiac CT and MR at Harefield hospitals. His research interests include imaging of coronary artery disease, prevention, valve disease, heart failure and cardiac transplantation. He has been actively involved in teaching and training with RCR and running a very successful course in cardiac CT.

Dr Graham Robinson Consultant Vascular Radiologist and Clinical Lead for Vascular Radiology, Hull Royal Infirmary Dr Graham J Robinson is a Consultant Vascular Radiologist and the Clinical Lead for Vascular Radiology at the Hull and East Yorkshire NHS Trust. He qualified from Oxford, and trained in Oxford, London, Birmingham and Toronto prior to taking up post in Hull in 2000. He has served on the BSIR Scientific Programme Committee and currently sits on the BSIR Safety and Quality Committee. He is RCR tutor for Hull Royal Infirmary, and has been actively involved in the local training scheme since appointment. His interests include embolisation, aortic endografting, hereditary haemorrhagic telangiectasia and medical device regulation. Professor Adrian Thomas Chairman, The International Society for the History of Radiology Honorary Librarian, The British Institute of Radiology Professor Thomas was a medical student at University College London. He was taught medical history by Edwin Clarke, Bill Bynum and Jonathan Miller. In the mid-1980s he was a founding member of what is now the British Society for the History of Radiology. In1995 he organised the radiology history exhibition for the Rรถntgen Centenary Congress and edited his first book on radiology history. He has published extensively on radiology history and has actively promoted radiology history throughout his career. He is currently the Chairman of the International Society for the History of Radiology. Professor Thomas believes it is important that the radiology is represented in the wider medical history community and to that end lectures on radiology history in the Diploma of the History of Medicine of the Society Apothecaries (DHMSA). He is the immediate past-president of the British Society for the History of Medicine, and the UK national representative to the International Society for the History of Medicine. Dr Michelle Williams Radiology Trainee, Royal Infirmary of Edinburgh Dr Michelle Williams graduated from the University of Edinburgh in 2005. She continued her medical training in Edinburgh and recently completed a British Heart Foundation Clinical Research Fellow at the University of Edinburgh. She is now a radiology trainee at the Royal Infirmary of Edinburgh and participates in research studies at the Clinical Research Imaging Centre in Edinburgh. Her main interests are computed tomography coronary angiography and computed tomography myocardial perfusion imaging.

Abstracts (where supplied) History of cardiac CT from inception to present Dr Tarun Mittal Cardiac CT has come a long way since the origin invention of CT scanner by Sir Godfrey Hounsfield. It has always been possible for radiologists to diagnose cardiac masses and pericardial thickening even with the single slice non-helical scanners. Electron beam CT scanners brought in an innovative rapid way to scan the heart but their use remained confined to calcium scoring. Multi-slice helical scanning technology since the turn of the century has revolutionised cardiac imaging with the ability to image the coronary arteries to diagnostic level and thus become acceptable in clinical practice. Role of CT in imaging myocardial perfusion Dr Michelle Williams Advances in cardiac CT imaging mean that it is now possible to assess anatomy, function, perfusion and viability in one rapid diagnostic test. CT coronary angiography now has a diagnostic accuracy for the identification of significant coronary stenosis similar to invasive coronary angiography. In addition, CT myocardial perfusion imaging can aid in the assessment of intermediate stenosis, heavily calcified vessels or coronary artery stents. Multimodality imaging has shown the diagnostic accuracy of CT myocardial perfusion imaging in comparison with MRI, fractional flow reserve and oxygen 15 labeled water PET imaging. Importantly, CT myocardial perfusion imaging is now possible at a low radiation dose, comparative to conventional invasive coronary angiography or nuclear medicine techniques. Current research aims to optimize this technique as part of a comprehensive cardiac CT protocol. This talk will provide an overview of the current methods to assess myocardial perfusion (such as SPECT and MRI) and why assessing myocardial perfusion is useful in diagnosing and treating patients with coronary artery disease. The basic technique for the acquisition and interpretation of images will be presented. The current state of the evidence for using CT to assess myocardial perfusion will be explored and future areas for research will be highlighted. Cardiac CT for the emergency department Dr Russell Bull Chest pain is one of the commonest reasons for presentation to an emergency department. Investigation of acute chest pain varies widely across the country. Often patients with acute chest pain are hospitalised for further investigation. Following relatively time-consuming and expensive investigations, many of these patients are found to have no significant disease. Using at least 64-detector technology it is possible to exclude coronary artery disease with high reliability and at low radiation dose using ‘prospective’ ECG gating. The so-called ‘triple rule out’ examination has recently been suggested by some authors as an effective way of excluding coronary artery disease, pulmonary embolus and aortic dissection on the same CT study. These studies are technically very challenging to perform using conventional 64 detector technology due to long acquisition

times but have recently become more straightforward with the advent of wide area detector or dual tube technology. In order for CT in the investigation of acute chest pain to be safe and effective, appropriate assessment and risk stratification by an experienced clinician is absolutely essential. The technical and logistical challenges of this approach together with the potential benefits in terms of cost savings and speed of diagnosis will be discussed. Imaging in TAVI Dr Sukumaran Binukrishnan Computed tomography (CT) plays an important role in the workup of patients who are candidates for implantation of a catheter-based aortic valve, a procedure referred to as trans catheter aortic valve implantation (TAVI) or trans catheter aortic valve replacement (TAVR). CT provides information on the accurate annular sizing, aortic dimensions, predict fluoroscopic projections which are very important for a successful procedure. CT is also important in reducing/predicting post procedure complications evaluating valve/ myocardial calcification and coronary position. Imaging of peripheral access vessels provides information on suitability to accommodate the large sheaths necessary to introduce the prosthesis. The lecture will cover data acquisition, interpretation, and reporting. Management of pulmonary embolic disease Professor Duncan Ettles In the UK, pulmonary embolism (PE) is recorded on the death certificates of approximately 12,000 people per annum and the number of deaths due to PE each year is believed to be around 60,000. The presentation of this common condition is very variable, with a spectrum ranging from asymptomatic cases to massive embolism with mortality exceeding 50%. Currently available guidelines recommend the use of anticoagulation and peripheral thrombolysis in the management of most symptomatic pulmonary emboli. In a limited number of cases, treatment by mechanical thrombectomy or catheter directed thrombolysis may be indicated when there is evidence of haemodynamic instability or other signs of clinical deterioration. Mechanical disruption of large emboli followed by a period of catheter directed thrombolysis can lead to rapid reduction in pulmonary arterial pressure and reversal of right heart overload. However, clinical outcomes remain relatively poor and unpredictable. For this reason, ongoing research into selection criteria and optimal interventional management is needed. The use of inferior vena cava (IVC) filters is widely accepted in the prevention of pulmonary emboli. Placement of IVC filters may be indicated as an adjunct to conventional anticoagulation following pulmonary embolism and in patients where use of anticoagulants is contraindicated. Nowadays, retrievable filters are in common use and have largely replaced the older permanent designs. They are increasingly used in high risk and trauma patients for prevention of PE, with low reported morbidity and complication rates. The role of interventional radiology in the management of pulmonary embolic disease remains controversial. Clear recommendations regarding treatment indications and strategy are hampered by a lack of level 1 evidence, but there is continued interest and enthusiasm for the development of these potentially life saving techniques.

Acute aortic syndromes Professor Peter Gaines A syndrome defines a group of symptoms common to a particular condition. The acute aorta is therefore the converse of a syndrome since it describes three related conditions â&#x20AC;&#x201C; acute dissection (AD), intramural haematoma (IMH) and penetrating ulcer (PU) â&#x20AC;&#x201C; that share common symptomatology and potential devastating outcome. All three most commonly present with the severe aortic type tearing pain; anteriorly in the chest when the disease affects the ascending aorta and in the back, when the process involves the descending thoracic aorta. Because that pain is far from distinctive, the acute aorta is frequently diagnosed in patients initially considered to have an acute coronary syndrome or pulmonary embolus. The distribution of the pathology affects outcome and the way that the condition is treated. If the disease affects the ascending aorta, irrespective of how far around the aorta the condition extends, then this is classified as Stanford type A. If the ascending aorta is not affected, then this is referred to as Stanford type B. Type A disease has worse outcome and is usually managed as an emergency by open surgery. Type B disease is relatively more benign and is managed by pharmaceutically relieving stress upon the aortic wall and using endovascular techniques in specific situations. Aortic dissection refers to the presence of flowing blood passing into the aortic wall through an entry tear and back into the lumen through an exit tear. Intramural haematoma is the occurrence of a haematoma in the wall of the lumen, without flowing blood. This may progress on to frank dissection. A penetrating ulcer occurs when an atherosclerotic ulcer penetrates through the internal elastic lamina into the media. This may progress to IMH, dissection, or pseudo-aneurysm. The lecture will describe risk factors, natural history, diagnosis, treatment, followup and outcome for the three related conditions. Management of acute thoracic dissections Dr Mohamad Hamady Educational aims: 1. To demonstrate evidence-based practice in management of AAD. 2. To understand the current challenges in managing AAD. 3. To encourage radiologists to contribute to future research in the field of AAD. Learning outcomes: 1. To learn the indications for surgical and interventional treatment. 2. To understand the interventional strategy in managing AAD. 3. To understand the current limitations of various management approaches. 4. To understand the follow up plan for patients with AAD. Acute aortic dissection (AAD) is relatively rare but potentially devastating pathology. According to Stanford classification, AAD is classified into two types, A and B. While surgical repair is the gold standard treatment for type A dissection, endovascular stent graft (ESTG) and / or medical treatment is

the preferred option for type B AAD. Medical treatment for asymptomatic type B AAD is associated with high survival rate. Endovascular stent graft for symptomatic AAD is associated with significantly better outcome than medical treatment alone or open surgery. Revascularisation strategy might be needed to supplement ESTG in patients with visceral or limb malperfusion. Asymptomatic type B AAD remains a controversial medical problem. However, there is growing evidence that ESTG is associated with positive aortic remodelling and good 5 â&#x20AC;&#x201C; year survival. Despite developments in imaging technology, we are still short of practical and accurate imaging predictors of disease progression. Similarly, more clinical evidence is still needed to define the sub-group of patients with asymptomatic AAD who would definitely benefit from early intervention. Management of thoracic/arch aortic aneurysm Mr Manoj Kuduvalli The management of aneurysms of the thoracic aorta are heavily dependent on imaging modalities both for their surgical management as well as long term surveillance. Awareness of the requirements from imaging for surgical procedure planning is an important aspect in reporting images. This presentation will deal with the spectrum of thoracic aortic aneurysms, their management, both conservative and surgical, and the use of imaging modalities including their application to procedure planning. Management of aorto-iliac occlusive disease Dr Graham Robinson Patients with aorto-iliac occlusive disease may be asymptomatic or may have intermittent claudication or critical limb ischemia. Treatment options include management of risk factors, endovascular intervention and surgical revascularisation. The learning objectives for this presentation include appropriate diagnostic work up, patient selection for intervention and an understanding of the TransAtlantic Inter-Society Consensus (TASC) classification. The TASC guidelines, first published in 2000 and revised in 2007, classify aortic and iliac lesions by lesion morphology. TASC A lesions include unilateral or bilateral CIA stenoses or unilateral or bilateral single short stenosis (3 cm) of EIA. TASC B lesions include short segment stenosis (3 cm) of the infrarenal aorta, unilateral CIA occlusion, single or multiple stenosis totalling 3-10 cm involving the EIA and not extending into the CFA, unilateral EIA occlusion not involving the origins of the IIA or CFA. TASC C lesions include bilateral CIA occlusions, bilateral EIA stenoses 3-10 cm long not extending into the CFA, unilateral EIA stenosis extending into the CFA, unilateral EIA occlusion that involves the origins of the IIA and/or CFA, heavily calcified unilateral EIA occlusion with or without IIA and/ or CFA origin involvement. TASC D lesions involve infrarenal aorto-iliac occlusion; diffuse disease involving the aorta and both iliac arteries requiring treatment; diffuse multiple stenosis involving the unilateral CIA, EIA, and CFA; unilateral occlusions of both the CIA and EIA; bilateral occlusions of EIA; iliac stenoses in those requiring treatment for AAA who are poor candidates for endovascular treatment or who have other lesions requiring open surgical repair of aorta

or iliac arteries. TASC II recommends endovascular treatment for TASC A and B lesions and surgical therapy for TASC C and D lesions. Several studies have reported success with endovascular treatment of TASC C and D lesions, and patient presentation and comorbidities, as well as local expertise, should be taken into account when planning treatment. Stroke prevention: carotid artery stenting Dr Trevor Cleveland Stroke is an important cause of morbidity and mortality in the UK. Preventing stroke has the potential to have massive benefits for individuals, as well as healthcare more generally. A significant proportion of strokes are caused by disease of the carotid arteries, most commonly atheroma at the carotid artery bifurcation. TIA and other ischaemic events may give a warning that an individual may suffer a completed stroke, and in appropriate circumstances, invasive treatment may be beneficial, in addition to best medical care. Traditionally surgical endarterectomy has been the mainstay of carotid bifurcation intervention, but more recently angioplasty and stenting have become available for disease at the bifurcation, and elsewhere in the carotid artery territory. Carotid artery stenting has made many advances, in both technique and technology, and has been subjected to a number of randomised trials. Despite this controversy continues to rage over the indications for carotid stenting, and when this is appropriate to offer a patient. As a result, many patients do not have access to this option, at a time where the Department of Health and NICE recommend timely treatment (intervention within 2 weeks of the onset of symptoms). The presentation will examine how carotid stenting is performed, in what circumstances it should be considered, what can be done to improve its safety profile, and which patients may benefit from it. Management of abdominal aortic aneurysms Dr Nicholas Chalmers Educational aims: 1. Understand the AAA screening programme 2. Understand the evidence for Open versus Endovascular Repair (EVAR) of elective and ruptured AAA 3. Recognise some new and complex variations of EVAR and consider their place as treatment options. The NHS AAA screening programme invites men aged 65 for ultrasound. Those with an AAA of 5.5 cm or greater are referred for prompt treatment. The evidence indicates that screened men are less likely to die from an AAA related cause. However, screening will result in some early deaths due to operative mortality. More than 700 men will need to be screened to save one aneurysm related death over 4 years. Since AAA accounts for only 2% of deaths, the reduction in overall mortality will be undetectable.

The EVAR trials (and others) demonstrated reduced operative mortality of elective EVAR compared with open surgery, but early benefits were reversed after about 5 years. Also, EVAR conferred no survival benefit compared with conservative management for patients unfit for open repair. Recently the IMPROVE trial has shown equal survival following EVAR and open repair of ruptured aneurysms. Despite the relatively balanced trial outcomes, there has been a culture shift towards offering EVAR whenever possible to both fit and unfit patients. The anatomical limitations of suitability for EVAR have diminished with the development of techniques such as fenestrated EVAR, which has introduced a higher level of complexity. New concepts such as endovascular aneurysm sealing (EVAS) with the NELLIX device and multilayer flow-modulating stents (MFMS) have been introduced but their durability is unknown. CT follow-up is important, and relevant findings will be illustrated. Interventional management of hypertension Dr Trevor Cleveland High blood pressure is a major risk factor in the aetiology of cardiovascular events, including heart attack and stroke. Reduction in blood pressure, to a degree which may on the surface appear relatively minor, results in a significant reduction in cardiovascular events. The mainstay of treatment for hypertension is drug therapy, and NICE (and many other organisations) has issued guidance on how drug therapy should be delivered. There are, however, a significant number of people who have sustained blood pressures, which are higher than would be considered desirable, despite medical therapy. Such patients are considered to have drug resistant hypertension. One significant potential confounder is that non-compliance with drug recommendations is not uncommon. Nevertheless, such patients continue to run high risks of events. Interventional radiology techniques have two potential options for the treatment of hypertension, renal artery stenting, for stenotic disease, and renal denervation. Both of these procedures have potential risks and benefits, and both have been the subject of randomised trials which have recently reported. As a result, the number of renal artery stent procedures has significantly declined over recent years, the reasons for this and the present indications will be considered. Renal denervation is a new option, the role for which remains controversial, and an area where research continues. Learn, imagine and fly through the radiological times Professor Adrian Thomas There were significant advances in medicine during the 19th century with increased knowledge in medicine, surgery, bacteriology and chemical pathology. However our ability to look inside the body had shown little improvement and was limited to the probing finger or simple endoscopy. This was all to change in 1895 when Wilhelm Conrad Rรถntgen discovered x-rays. The description of

the ability to see through the body was greeted by many with incredulity and early accounts had to reassure the public that this was a serious discovery by a respected scientist. Early radiology was technically difficult to perform, however during the next few decades the equipment gradually improved. Initially image interpretation was also difficult and it took many years to decipher these often confusing shadows. Radiology was also not without risk, with injuries related to ionising radiation, electrical injuries and chemical injuries from processing the films and plates. Radiology steadily progressed with the development of the modern x-ray tube, contrast medium, catheters and image intensification. Traditional radiology revolutionised medical care. However investigations were often invasive and pathology was often shown indirectly. Radiology has profoundly changed since what can be seen as the golden decade of the 1970s, starting with the announcement of CT scanning in 1972. Developments in CT scanning, ultrasound, nuclear medicine, MRI scanning, and finally interventional radiology has placed radiology in the forefront of modern medicine. Modern radiology now allows for non-invasive diagnosis, and this has facilitated minimally invasive therapy. This story is exciting and interesting. Reading: Thomas, AMK., Banerjee, AK. The History of Radiology. Oxford: Oxford University Press (2013) Educational aims and learning outcomes: 1. To understand the background to radiology. 2. To see connections between various facets of the radiological science. 3. To understand how one development facilitated another. _______________________________________________________________________

Programme

DAY 2: Thursday 23 October

ROOM 1: Lungs and abdomen 08:30 Registration and refreshments 09:00 Chair:

Welcome and introduction Dr Klaus Irion, Clinical Lead, Department of Radiology, Liverpool Heart and Chest Hospital BIR Annual Congress Director 2014

09:05

The lung, that spongy organ: architectural solutions to keep it open,ventilated and perfused – fit for gas exchange Professor Ewald Weibel, Emeritus Professor, Institute of Anatomy, University of Bern

09:50

Differentiation of chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension Dr Nicholas Screaton, Consultant Cardiothoracic Radiologist, Papworth Hospital

10:20

Lung nodules on screening - what happened to the “suspicious ones” Dr John Holemans, Consultant Radiologist, Liverpool Heart and Chest Hospital

10:50 Refreshments 11:05 From a subjective impression to the future of imaging quantification Professor Eric Hoffman, Professor of Radiology, Medicine and Biomedical Engineering, University of Iowa 11:50 Pulmonary nodules: the role of MRI Professor Bruno Hochhegger, Professor of Radiology, Rio de Janeiro Federal University 12:10 Lumps in the lung Professor John Gosney, Consultant Thoracic Pathologist, Royal Liverpool University Hospital 12:30 Lunch 13:30

The BIR Sir Godfrey Hounsfield memorial lecture: The isotope bone scan past, present and future Professor Ignac Fogelman, Professor of Nuclear Medicine, King’s College London

14:15 Prizes and awards ceremony

14:25 Investigating abdominal diseases through the times Professor Adrian Dixon, Emeritus Professor of Radiology, University of Cambridge

15:10 Pseudo liver lesions Professor Ali Nawaz Khan, Consultant Radiologist, North Manchester General Hospital 15:30 Diffusion weighted imaging of the bowel Dr Andrew Plumb, Honorary Consultant Radiologist and Senior Lecturer in Medical Imaging, University College London 15:50 Cystic liver lesions Professor Ali Nawaz Khan, Consultant Radiologist, North Manchester General Hospital 16:10 Refreshments 16:25 Imaging and renal failure Dr Jane Belfield, Consultant Uro-Radiologist Royal Liverpool University Hospital 16:45 MR-based fat and iron quantification in the liver Dr Radhouene Neji, MR Scientist, Siemens 17:05 Digital radiography Mr Ulrich Neitzel, Senior Manager, Clinical Science Diagnostic X-Ray, Philips Healthcare, Hamburg 17:25 Grand round in thoracic imaging Dr Pablo Santana, Consultant Radiologist, Medimagen 17:40 Close of Congress __________________________________________________________________

Speaker profiles (where supplied) Dr Jane Belfield Consultant Uro-Radiologist, Royal Liverpool University Hospital Dr Jane Belfield is the lead consultant uro-radiologist at the Royal Liverpool University Hospital and have been in post since 2010. Following general radiology training, she undertook a fellowship in uro-radiology with an additional focus on teaching. Special interests include renal transplant imaging, testicular imaging and renal imaging. She is interested in medical education and has completed a Masters in Medical Education with the University of Dundee, graduating in 2013, for which she undertook a research project looking at methods of teaching renal transplant ultrasound. She is the Undergraduate Radiology Lead for the Mersey School of Radiology. She is currently the secretary of the British Society of Urogenital Radiology (BSUR) and a member of the Scrotal Working Group of the European Society of Urogenital Radiology (ESUR). Recent guidelines have been accepted regarding follow up imaging in patients with testicular microlithiasis. Professor Adrian Dixon Emeritus Professor of Radiology, University of Cambridge Professor Adrian K Dixon is Master of Peterhouse, the oldest College at Cambridge University, and Emeritus Professor of Radiology, having been head of the Department of Radiology for 15 years. He is also an honorary consultant radiologist at Addenbrooke’s Hospital, Cambridge. From an Irish background, he was born in Cambridge where he earned a bachelor’s degree at King’s College. He qualified in medicine after clinical studies at St Bartholomew’s Hospital London. He then specialised in general medicine, gaining his MRCP in 1974 before deciding to pursue a career in radiology (an appropriate career in view of his impending deafness). He qualified as a radiologist in 1978 and worked in paediatric radiology at Great Ormond Street Hospital, and in computed tomography at St Bartholomew’s Hospital. In 1979, he became a lecturer at the University of Cambridge’s Department of Radiology. He earned his doctor of medicine degree for his thesis on computed tomography of the lumbar spine. In 1986, he was elected a Fellow of Peterhouse, where he became director of medical studies. Throughout his career, Professor Dixon has been actively engaged in the field of scientific publishing, as both author and editor. He has published extensively in the areas of computed tomography, magnetic resonance imaging and various aspects of effectiveness within radiology. This is in addition to having written and co-edited various books on CT, anatomy and diagnostic radiology. He served as editor of the journal Clinical Radiology from 1998 to 2002, editor-in-chief of European Radiology 2007-2013 and Warden of the Faculty of Clinical Radiology of the RCR from 2002 to 2006. He was awarded Fellowship of the Academy of Medical Sciences in 1998.

Professor Dixon has received a number of awards throughout his career and he is an honorary member of the national radiological societies of France, Hungary, Spain, Sweden, Switzerland and the USA, as well as being an Honorary Fellow of the American College of Radiology, the Royal Australian and New Zealand College of Radiologists and the Faculty of Radiologists at the Royal College of Surgeons in Ireland. In recent years the Universities of Cork and Munich have awarded him an Honorary Doctorate of Medicine. In 2014 he was awarded the Gold Medal of the European Society of Radiology. He also serves as a Trustee of the David Ross Educational Trust and as a member of the Hong Kong University Grants Committee. Professor Ignac Fogelman Professor of Nuclear Medicine, King’s College London Professor Fogelman is currently Professor of Nuclear Medicine (NM), at King’s College London and Honorary Consultant Physician, Guy’s and St Thomas’ NHS Trust and Director of the Osteoporosis Screening and Research Unit, Guy’s Hospital. He is Chairman of the Board of Examiners for the MSc in NM, which provides the only recognised training programme for NM in the UK. He has written over 400 articles in peer reviewed journals, has written or edited 15 books, and supervised 17 PhD/MD students. He is a former board member and Trustee of the National Osteoporosis Society and was previously Chairman of its Bone Densitometry (BD) Forum. Professor John Gosney Consultant Thoracic Pathologist, Royal Liverpool University Hospital Professor John Gosney is Consultant Thoracic Pathologist at the Royal Liverpool University Hospital, Liverpool, UK, and Professor of Thoracic Pathology at the University of Liverpool. He is a specialist thoracic pathologist responsible for providing the service in diagnostic thoracic pathology to the Royal Liverpool University Hospital and to the Liverpool Heart and Chest Hospital. He has internationally acknowledged expertise in the pathology of tumours of the lung, especially their differential diagnosis and their morphological, immunochemical and genetic characterisation. He has researched widely in the field and has numerous publications including original papers, reviews and book chapters. He is co-author of the UK Royal College of Pathologists’ guidelines for the handling and reporting of thoracic tumours, advisor to Cancer Research UK and contributor to the World Health Organisation’s classification of tumours of the lungs and pleura.

Professor Eric Hoffman Professor of Radiology, Medicine and Biomedical Engineering, University of Iowa Professor Eric A Hoffman is the director of the Advanced Pulmonary Physiomic Imaging Laboratory (APPIL) in the Department of Radiology and the director of the Iowa Comprehensive Lung Imaging Center (I-Clic) at the University of Iowa. He received his Ph.D. in Physiology from the University of Minnesota / Mayo Graduate School of Medicine in 1981 and remained on staff at the Mayo Clinic where he was a member of the team which developed the earliest volumetric CT scanner, the Dynamic Spatial Reconstructor (DSR). In 1987 he joined the faculty of radiology at the University of Pennsylvania where he was the director of Cardiothoracic Imaging Research Center and moved to the University of Iowa in 1992. Professor Hoffman is a fellow of the American Institute for Medical and Biomedical Engineering, an honorary lifetime member of the Society of Thoracic Radiology, and a member of the Fleischner Society, and founder of the SPIE Medical Imaging track on Physiology and Function from Multidimensional Images. He has served on the Respiratory Integrative Biology and Translational Research (RIBT) study section of the NIH and has served as a member of the scientific review board of the American Asthma Foundation. He has published more than 450 peer reviewed journal articles, numerous book chapters and review articles and holds numerous patents related to lung image analysis, CT contrast agents and synchronization of respiration to the cardiac cycle as a means of ventricular assist. He recently received the 2014 Joseph R Rodarte Award for Scientific Distinction from the Respiratory Structure and Function Assembly of the American Thoracic Society and the 2013 John West award for Outstanding Contributions to the Field of Functional Pulmonary Imaging from the IWPFI. Throughout his career he has used advanced imaging methodologies to study basic respiratory physiology centered largely on mechanisms of ventilation and perfusion heterogeneity and regional lung mechanics. Professor Hoffman’s recent work has lead him to a new hypothesis regarding the etiology of emphysema based upon novel functional imaging protocols he has developed using dual energy multidetector row CT. His laboratory has served, or is serving as, a radiology oversight and analysis center for numerous NIH sponsored multicenter studies which include the National Emphysema Treatment Trial (NETT), the Sever Asthma Research Project (SARP), COPDGene and the Subpopulations and intermediate outcome measures in COPD study (SPIROMICS). Dr. Hoffman is a founder of VIDA Diagnostics, a company providing quantitative solutions to the evaluation of CT images of the lung Dr John Holemans Consultant Radiologist, Liverpool Heart and Chest Hospital Dr Holemans developed an interest in chest disease whilst a medical student at Charing Cross and Westminster Medical School, London. He graduated in 1989 and subsequently trained as a radiologist at Guy’s and St Thomas’ Hospitals, London and also spent a short attachment at the The Royal Brompton Hospital. In 1997 he was appointed a Consultant Radiologist at the Liverpool Heart and

Chest Hospital and became Head of Department in 2002. He is a Fellow of the Royal College of Radiologists, Royal College of Physicians and British Institute of Radiology. His major clinical interests are HRCT, lung cancer, oesophageal cancer and aortic CT angiography, coronary CT and Cardiac MRI. He read all 1000 baseline lung cancer screening CT scans performed in Liverpool as well as the follow up scans as part of the UK Lung Cancer Screening Trial. Professor Ali Nawaz Khan Consultant Radiologist, North Manchester General Hospital Professor Ali Nawaz Khan was Consultant Radiologist North Manchester Health Care Trust from1979 to 2006. He has has authored six books, 600 publications, chapters, abstracts and postgraduate lectures. He was visiting Professor to Pakistan under United Nations Development Program 1992, 1996 and 1999 & 2001 coordinating postgraduate education, teaching and training and working with Afghan refugees. He was Honorary Professor of Radiology, Andizhan State Medical Institute, Uzbekistan since October 1998 Visiting Professor to the Soviet Union, Russia, Uzbekistan, Kazakhstan and Kirghizia 1991, 1992, 1993, 1994 and 1995, forging academic links. Visiting Professor, International Network for Cancer Treatment & Research at Institut Pasteur, Brussels Belgium 2001-2005. Member Education Committee, International Network for Cancer Treatment & Research at Institut Pasteur, Brussels Belgium 2001-2007. Member Ethical Review Committee, International Network for Cancer Treatment & Research at Institut Pasteur, Brussels Belgium 2001-2007. He was visiting Professor Kuwait University April 2004. Lecturer, University of Manchester from 1982 - 2005. Have a personal experience in treating hepatocellular carcinoma in the UK with an individual series of over 400 chemoembolizationâ&#x20AC;&#x2122;s. He has extensive experience in general radiology, general ultrasound, CT, MRI, nuclear medicine, visceral angiography and visceral vascular intervention. Professor and Chairman Medical Imaging, King Fahad Hospital, NGHA, Riyadh, Saudi Arabia 31st January 2006- 28th January 2009. Mr Ulrich Neitzel Senior Manager, Clinical Science Diagnostic X-Ray, Philips Healthcare, Hamburg Dr Ulrich Neitzel has more than 30 years experience in the field of medical X-ray imaging, in particular digital radiography. He has held various positions in research, development, and clinical application of X-ray imaging systems and is presently senior manager of clinical science for the diagnostic X-ray business unit of Philips Healthcare in Hamburg, Germany. Dr Neitzel has authored or co-authored more than 60 scientific papers and book chapters and is a frequent lecturer at international conferences. He holds MS and PhD degrees in physics from GĂśttingen University, Germany.

Dr Andrew Plumb Honorary Consultant Radiologist and Senior Lecturer in Medical Imaging, University College London Dr Andrew Plumb is a Senior Lecturer in Medical Imaging at University College London and Honorary Consultant Radiologist. After undergraduate medical training in Oxford, he returned to his home town of Manchester for Senior House Officer and general radiology training. After gaining the FRCR, he moved to London for sub-specialty training in gastrointestinal imaging and to study for a PhD with Professors Steve Halligan and Stuart Taylor. His main research interests are gastrointestinal and oncological imaging, particularly CT colonography, colorectal cancer screening and the use of MRI in Crohnâ&#x20AC;&#x2122;s disease. Dr Nicholas Screaton Consultant Cardiothoracic Radiologist, Papworth Hospital Dr Screaton is a Consultant Cardiothoracic Radiologist at Papworth Hospital, Cambridge.His special interests include pulmonary hypertension, interstitial and airways diseases, and lung cancer screening. He was Radiology Clinical Director in Papworth Hospital 2004-12 and President of the British Society of Thoracic Imaging 2009-13. He sits on the British Thoracic Society Bronchiectasis Guidelines development group, National Institute of Clinical Excellence Idiopathic Pulmonary Fibrosis Quality Standards Committee, National Institute of Clinical Excellence Guidelines Updates Standing Committee, and National Clinical Commissioning group for Specialised Imaging (stakeholder representative). Professor Ewald Weibel Emeritus Professor, Institute of Anatomy, University of Bern Professor Ewald R Weibel, born in 1929, studied medicine at the University of Zurich, graduating as MD in 1955. He spent five postdoctoral years in the United States working in pathology at Yale University, in cardio-respiratory physiology at Columbia University, and in cell biology at The Rockefeller Institute. In 1963 he returned to Switzerland as Assistant Professor at the University of Zurich and became, in 1966, Professor and Chairman of the Institute of Anatomy at the University of Berne until his retirement in 1994, serving as Rector of the University of Berne in 1984-85. In his research he developed the concept and methods of morphometry, based primarily on stereology, this in view of quantitative studies of structure-function relations in the lung, focusing on gas exchange and mechanical function. He extensively used the approach of comparative physiology to study the entire respiratory system from lung to mitochondria, the pathway for oxygen. In 1962 he discovered a specific organelle of endothelial cells, today called the WeibelPalade body, of central importance in blood clotting control. He is author of

Morphometry of the Human Lung (1963), the Pathway for Oxygen (1984), and Symmorphosis (2000). He has written over 400 publications which deal with structure-function relations of the lung and of liver and muscle cells, with a focus on the quantitative methods and a systems view on integrated functions in the respiratory system. Among other honours he was awarded the Medal of the American College of Chest Physicians and the H.R. Schinz Medal of the Swiss Society of Radiology. He received Honorary Doctorates from the Universities of Edinburgh and Geneva. He is Foreign Associate of the US National Academy of Sciences, member of the Academia Europaea, and Fellow of the European Respiratory Society. He was President of the Swiss Academy of Medical Sciences, of the International Union of Physiological Sciences, and of the Fleischner Society. ______________________________________________________________ Abstracts (where supplied) The lung, that spongy organ: architectural solutions to keep it open, ventilated and perfused – fit for gas exchange Professor Ewald Weibel The “spongy” nature of the lung results from a high density of the air-blood contact surface area supported by a minimised tissue barrier. The aim of this presentation is to foster the understanding of how such a minimised structure can ensure the lung’s gas exchange function which demands that each gas exchange unit be efficiently ventilated and perfused by blood, and that the surface be kept open to air at all stages of respiration. Three architectural principles that ensure this will be discussed: (1) Complexity as the principle of building this surface and serving it by forming hierarchical fractal trees of airways and blood vessels so that all gas exchange units are reached by air and blood along short and similar pathways. (2) Correlativity that forms the structural basis for near-optimal matching of air and blood flows, but physical limitations cause the individual gas exchange units, about the size of an alveolus, to be ventilated in series while being perfused by blood in parallel with the potential of a ventilation-perfusion mismatch. (3) Connectivity established by a fiber continuum throughout the flabby lung from the central airways to the pleura passing right through the alveolar walls where the fibres are interlaced with the capillaries; the lung is a tensegrity structure, so when surfactant reduces alveolar surface tension this keeps alveoli open to the airways all through the respiratory cycle. To make the spongy lung fit for gas exchange all three principles must be realised. Differentiation of chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension Dr Nicholas Screaton Pulmonary hypertension is a diagnosis with high morbidity and significant prognostic implications independent of its cause. Whilst the diagnostic reference standard in establishing a diagnosis is invasive right heart catheterising noninvasive imaging, investigations play a fundamental role in suggesting the

diagnosis and in many cases identifying the cause. Pulmonary hypertension is classified using a clinical classification which attempts to group together diseases with similar patho-physiological mechanism and treatment option. The most recent revision of this classification followed the 5th World Symposium in Nice in 2013. The classification consists of five groups: Group 1 consists of diseases affecting the small vessels of the lung with the main group being ‘pulmonary arterial hypertension’ - diseases with predominantly arteriolar involvement. While the underlying aetiology within this group is diverse the management options are similar and focus on targeted pharmacological therapy. Groups 2 and 3 consist of pulmonary hypertension due to chronic left heart disease and chronic lung disease (or chronic hypoxia) respectively. These are both very common causes of pulmonary hypertension. Group 4 represents chronic thromboembolic pulmonary hypertension resulting from organised thrombi occluding or stenosing vascular beds. CTEPH is common and often diagnosed late. The final group (group 5) consists of disease with unclear or multifactorial mechanisms. This presentation will focus on pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Whilst treatment of the former is pharmacological with targeted agents to molecular pathways with the vascular endothelium treatment of CTEPH may be either surgical or pharmacological. CTEPH may be considered ‘proximal’ or ‘distal’ although the most important questions directing treatment are whether the distribution of disease is surgically amenable, and whether the patient is likely to benefit from surgery which consists of bilateral endarterectomy performed under deep hypothermic circulatory arrest. Some centres are now using balloon angioplasty in a subset of patients. Imaging plays a fundamental role in establishing a specific diagnosis in PH (differentiating IPAH from CTEPH as well as other causes of PH) as well as in characterising CTEPH and its distribution. Imaging also enables detailed cardiac assessment enabling assessment of haemodynamics at baseline and follow-up The objectives of this presentation are to: 1. Summarise the current clinical classification of pulmonary hypertension. 2. Describe imaging features of PAH and CTEPH highlighting their differences. 3. Discuss the role of imaging in CTEPH and IPAH and its impact on therapeutic options. Lung nodules on screening - what happened to the “suspicious ones” Dr John Holemans UKLS is a Randomised Controlled Trial (RCT) of LDCT single scan screening for lung cancer versus usual care. A population-based risk questionnaire was used to identify high risk individuals. CT screen detected nodules were categorised according to the UKLS nodule management protocol, by volume if surrounded by lung or by diameter if pleural or juxta pleural. For solid nodules Category 1 Benign calcified or fatty OR ≤3.0mm or ≤15 mm3 ; Category 2 If intraparenchymal 15-49mm3 or if pleural 3.1mm-4.9mm ; Category 3 If intraparenchymal 50-500 mm3 ; If pleural 5.0mm-9.9mm; Category 4 If intraparenchymal >500mm3 ; If pleural ≥10mm. For subsolid nodules Category 1 GGO and solid part (if any) ≤3.0mm ; Category 2 GGO 3.1-4.9 and solid part

(if any) ≤3.0mm or <15mm3 ; Category 3 GGO ≥5.0mm and solid part (if any) 3.0mm-9.9mm or 15mm3-500mm3 ; Category 4 If mixed (part-solid) and the solid component is >500mm3 or ≥10mm. 4055 subjects were randomised, 2,028 into the CT arm, of whom 1994 underwent a CT. Forty two participants (2.1%) had confirmed lung cancer, 34 (1.7%) at baseline and eight (0.4%) at or before the 12 months scan. Screen detected cancers were identified as; Stage 1 25/42 (60%), Stage 1 and 2 33/42 (79%), 34/42 (81%) had surgical resection. There were a total of 536 subjects, 472 category 3, and 64 category 4 nodules, requiring diagnostic workup, other than a repeat CT at 12 months; 40/536 were found to have lung cancer, leaving 496 false positives. The false positive rate was 24.8% (496/ 1994), and the positive predictive value 7.4% (40/536). 479 (24%) had Category 2 nodules who received a 12 month repeat scan. Of these, eight (0.8%) were referred to the MDT. Two (0.2%) individuals were diagnosed with lung cancer. Learning points: Nearly all screen detected cancers were >50 mm3 in volume or >5mm in dia. There is a high false positive rate From a subjective impression to the future of imaging quantification Professor Eric Hoffman Coincident with the introduction of computed tomographic imaging of the thorax into clinical practice in the mid 1970’s was an effort to non-invasively, volumetrically image the dynamic functioning of the heart and lung. With the development of it’s prototype in the mid 1970’s and the arrival of the Dynamic Spatial Reconstructor (with it’s 14 x-ray guns, juxtaposed hemicylindrical flourescent screen and 14 television cameras rotating at 15 RPM) at the Mayo Clinic in 1979, tools were developed allowing for the objective assessment of lung structure and function and methods for three dimensional visualization via two-dimensional computer monitors. Focus was initially placed on understanding the basic, normal functioning of the heart and lungs within the negative pressure environment of the never invaded intact thorax. The transfer of this technology into clinical research and clinical practice was delayed, largely because of the lag in computational technologies, by nearly a quarter of a century until manufacturers introduced multiple-row detector CT (MDCT) in the late 1990s. With the advent of 16 slice and greater scanners, volumetric images of the lung were achievable with scan times requiring breath holds of less than 20 seconds. Various configurations of MDCT scanners have evolved which now allow imaging of the thorax in well under a second. Multi-sepctral imaging provides new methods for quantitatively extracting measures of iodine, xenon and krypton for quantitation of regional parenchymal perfusion and ventilation. Improvements in x-ray gun techology, detector sensitivity and computational capabilities provide tools that now allow volumetric imaging at dose levels approaching 0.1 mSv with inherant spatial resolution of scanners reaching down to that needed to explore a single pulmonary ascinus, thus allowing us to begin to assess ventilation/perfusion relationships at the very interface of gas exchange. These new tools for lung quantitation offer the ability to phenotype lung disease whereby broad categories of lung pathology such as COPD, Asthma, or IPF can

now be broken down into numerous sub-categories based upon underlying anatomic and functional variants. Through the linkage of structure to function, it is now possible to use imaging as a tool to, not only assess the roadmap of anatomic destruction and remodeling, but also to assess the altered physiologic precoursors. With an understanding of the sub-phenotypes of lung diseases, one can begin to link phenotypes with genotypes. What is sought are breakthroughs in new pharmaceutical and device-based interventions with imaging providing tools for identification of appropriate populations in which to test new interventions and for assessing outcomes. Through this lecture, the evolution of the quantitative assessment of the lung via x-ray computed tomography will be explored with specific examples from the quest to understand quantitative sub-phenotypes of COPD and Asthma. Examples of regional lung function assessed from multi-sepctral MDCT will be used to explore how such CT-derived functional information might be used in the delineation of underlying disease etiology. Pulmonary nodules: the role of MRI Professor Bruno Hochhegger Current widespread use of cross-sectional imaging has led to exponential rise in detection of solitary pulmonary nodules (SPNs). Whilst large numbers of these are benign â&#x20AC;&#x2DC;incidentalomasâ&#x20AC;&#x2122;, lung cancers presenting as SPNs are often early disease, which have good prognosis. Therefore, there is rising demand and expectation for more accurate, non-invasive, diagnostic tests to characterize SPNs, aiming to avoid missed or delayed diagnosis of lung cancer. There are wide differential diagnoses of benign and malignant lesions that manifest as SPNs. On conventional imaging, the morphological features supporting benignity include stable small nodule size, smooth demarcated margins, and calcifications. Although clinical applications of pulmonary magnetic resonance imaging (MRI) face technical limitations, currently available MRI methods have contributed to morphologic and functional evaluations of pulmonary nodules. MRI using dynamic contrast enhancement or diffusion-weighted imaging (DWI) techniques, are among the growing armamentarium for diagnostic imaging of SPNs.The purpose of this lecture is to review the current status of MRI for evaluation of pulmonary nodules. Lumps in the lung Professor John Gosney The differential diagnosis of pulmonary nodules, many of which are discovered incidentally in asymptomatic individuals, is enormous, and the question of how to manage them is a matter of continuing debate. Despite the inexorable increase in the quality and resolving power of CT imaging of the thorax, the nature of many such lesions cannot be determined without excising them, a measure which often reveals a surprising and unexpected diagnosis.

The BIR Sir Godfrey Hounsfield memorial lecture: The isotope bone scan past, present and future Professor Ignac Fogelman Isotope bone scanning has a long and distinguished history. The story commences in the 1960s with strontium and with imaging at that time performed using a rectilinear scanner and with resolution so poor that anatomical outlines had often to be added to assist in skeletal localisation! However there were rapid advances relating to both radiopharmaceuticals and instrumentation and the dream team of a bisphosphonate and a gamma cameras came into existence in the late1970s. Initially, and indeed for many years thereafter, the use of the bone scan was almost exclusively in patients with known malignancy but subsequently its use has expanded into many benign applications and nowadays benign conditions account for some 50% of cases. A further significant advance occurred with the use of tomographic imaging (SPECT) in the late 1980s where a dramatic example was the identification of facet joint disease. This seemed almost magical at the time with often prominent focal uptake in individual’s who had unexplained back pain and an apparently normal planar study. However the great leap forward has been with the use of hybrid imaging (SPECT CT) combining functional with anatomical studies taking advantage of high contrast with altered metabolic activity and localising this to precise anatomical data. This has reduced the prevalence of equivocal lesions on the bone scan from some 60% to 5-10%. The future is exciting with the increasing availability of PET, eg. the potential for using F-18 as a ‘routine’ bone scan and with quantitation of tracer uptake in individual lesions now possible, and with several new tumour specific tracers. We are also at the start of the era of PET/MRI. Investigating abdominal diseases through the times Professor Adrian Dixon Educational aim: to remind the audience about the development and limitations of various abdominal imaging investigations. In the beginning was the clinical history; then followed inspection, palpation and auscultation. It is debatable whether palpation and auscultation would ever have withstood the rigours of NICE. The elicitation of shifting dullness and the nuances of borborygmi were never an exact science. Fortunately the rapid development of imaging techniques in the century following Roentgen’s discovery changed everything. Barium studies were the mainstay of abdominal imaging until the 1980s but, before image intensification, a lot of imagination was required. Nevertheless, researchers in the UK, Sweden and Japan made remarkable scientific observations by these means. The introduction of ultrasound greatly assisted the

investigation of the pelvis and upper abdomen and remains the investigation of choice in the thinner adult and children; increasing adult obesity curtails its effectiveness in much of the western world. Computed tomography, and especially the introduction of spiral CT put paid to investigation such as lymphangiography and retroperitoneal air insufflation. Magnetic resonance imaging has become the optimal method of investigating the liver, biliary tree and many structures within the pelvis. PET/CT is currently the ultimate method of assessing the abdomen for many oncological problems. Expert imaging is not only needed to help the patient, it is also needed to help the radiologist or surgeon plan appropriate treatment to reduce morbidity and cost. Learning outcomes: Appreciation of the increasing role of abdominal imaging within modern healthcare. Pseudo liver lesions Professor Ali Nawaz Khan Liver pseudo-lesions are great mimics, and unless the radiologists and the clinicians are aware of these lesions, their discovery may lead to unnecessary imaging/intervention and health service costs. One such significant pseudolesion is produced by transient hepatic attenuation difference (THAD). Increased pressure in lobe or segment, results in portal shunting to normal segments with the compensatory increase in hepatic arterial flow to the affected segment. THAD does not imply arterio-portal shunting or tumour invasion. THAD cause a physiological shutdown: no trophic hormones via portal vein thus any Insulin or Glucagon drive. Thus, the affected liver segment is depleted of glycogen and fat. The segment is vulnerable to ischaemic necrosis, which is even greater with biliary obstruction: infected biloma. Eventually, the segment/lobe atrophy Focal fatty infiltration and fatty focal sparing may mimic a variety of lesion. A variety of other pseudo-lesions will be discussed. Diffusion weighted imaging of the bowel Dr Andrew Plumb Diffusion weighted imaging (DWI) has increasingly become an integral part of MRI protocols, particularly in the field of neuroradiology and oncology. Its role in inflammatory conditions is less defined. Recently data suggests DWI may have a role in the detection and grading of Crohnâ&#x20AC;&#x2122;s disease during MR enterography. It has been well described that restricted diffusion is present in enteric Crohnâ&#x20AC;&#x2122;s, although the underlying histological reasons are complex. Increased inflammatory infiltrate likely restrict diffusion but the role of tissue oedema, increased vascularity and fibrosis in influencing signal from DWI is unclear. This may compromise the utility of DWI and apparent diffusion coefficient in grading disease activity. Its use in detecting abnormal bowel per se is clearer.

This presentation will present protocols for DWI during MR enterography and describe the underlying histological features which may influence imaging appearances. Data supporting its role as a marker of disease activity will be presented with examples. Finally, how and why DWI may be integrated into standard clinical protocols will be discussed. Cystic liver lesions Professor Ali Nawaz Khan Detection of liver cysts has become common place with increased use of cross sectional imaging. Whilst most are simple cysts other cystic lesions are great mimics. Once detected, there is an emphasis for further characterization. The differential diagnosis of hepatic cysts is very wide. Differentiation of these cystic lesions is necessary for management. The presentation illustrates the entire spectrum of cystic hepatic lesions and provides an approach for differentiating them. The important factors assessed are the size, septa, thickness of the wall, internal nodules or papillary projections, calcification, density and signal intensity patterns and contrast enhancement. Ultrasound, Doppler, CT and MRI imaging features of the cystic lesions are illustrated. The aim of this presentation is to arm the radiologist with the knowledge required to offer a definitive diagnosis as with advanced imaging it is possible to characterize most hepatic cystic lesions. Clinical input is required. With spiraling healthcare costs, the costs must be curtailed safely, minimizing patient anxiety, and avoid unnecessary invasive procedures. Imaging and renal failure Dr Jane Belfield, Chronic kidney disease (CKD) is a term used to describe patients with decreased renal function and is classified in 5 stages, with stage 5 being kidney failure (GFR <15ml/min) . The most common causes include diabetes mellitus, hypertension, vascular disease and glomerular disease. Kidney disease is the ninth leading cause of death in the United States and imaging in this group of patients can be complex due to both the aetiology of the disease and the complications. This talk aims to cover some more unusual aspects of imaging in this group of patients that are related to end stage renal failure or its complications. Encapsulating peritoneal sclerosis is defined as â&#x20AC;&#x153;a syndrome continuously, intermittently, or repeatedly presenting with symptoms of intestinal obstruction due to adhesions of a diffusely thickened peritoneum, and a purely clinical diagnosis.â&#x20AC;? It is a condition seen in patients who have previously undergone peritoneal dialysis (PD), but the exact aetiology remains uncertain. It is thought to be related to the glucose content in the dialysate within the peritoneal cavity. Many cases present when PD has been discontinued. Classic features as seen on CT will be described, including peritoneal thickening and enhancement, cocooning of the bowel within the abdomen, fluid collections and thickening of bowel wall. Cases of peritoneal sclerosis will be presented to illustrate the findings. Contrast enhanced ultrasound (CEUS) is an imaging modality that can be used in patients with renal failure due to the lack of nephrotoxicity.

Contrast agents are composed of gas microbubbles enclosed in a protein, lipid or polymer shell. The composition of the agent allows it to last in blood vessels for 5-7 minutes. The bubbles contract and expand when in contact with an ultrasound wave and can be seen in the kidneys for approximately 2 minutes. CEUS is particularly useful in distinguishing a solid renal mass from a pseudotumour, or characterising a complex cyst in this group of patients in whom CT or MRI contrast are relative contraindications . Examples of CEUS will be shown to demonstrate its use in this group of patients. Transplantation is the gold-standard treatment for patients with end stage renal failure. Increasingly, transplants are being performed from living donors, either relatives, altruistic donors or paired donations with more than one third of all renal transplants being from living donors. Prior to transplantation, imaging is required to assess vascularity and anatomy of the donor as well as to identify any salient incidental findings. Living donor CT imaging will be described with examples of abnormal vascular and anatomical anatomy to demonstrate the importance of imaging prior to selection for donor nephrectomy. References: 1.Levey AS, Coresh J, Balk E, Kausz AT, et al. National Kidney Foundation practice guidelines for chronic kidneys disease: evaluation, classification, and stratification. Ann Intern Med. Jul 15 2003;139(2):137-147. 2. Centers for Disease Control and Prevention. Deaths and Mortality. Available at http:// www.cdc.gov/nchs/fastats/deaths.htm 3. Kawanishi H, Moriishi M. Encapsulating peritoneal sclerosis: prevention and treatment. Perit Dial Int 2007 27:S289-S292. 4. Morin S, Lim A, Cobbold J, Taylor-Robinson S. Use of second generation contrastenhanced ultrasound in the assessment of focal liver lesions. World Journal of Gastroenteroloy. 2007 13(45):5963-5970. 5. Cokkinos D, Antypa E, Skilakaki M, et al. Contrast enhanced ultrasound of the kidneys: what is it capable of? BioMed Research International 2013

Digital radiography Mr Ulrich Neitzel, Philips Healthcare The development of the technology and application of digital radiography over the past thirty years will be reviewed. Today, digital radiography is the standard technique for x-ray projection examinations of the chest and the skeleton. Compared to previous screen-film imaging it offers a number of advantages, like larger dynamic range, better dose efficiency, and direct availability of the images in electronic format. Different technological variants of digital radiography exist, with their specific pros and cons. The educational aims and learning outcomes of the presentation are the following: 1. Learn to know the differences between the various detector types for digital radiography 2. understand the advantages and limitations of digital radiography 3. understand the principles and the importance of proper image processing 4. learn about present and future directions for further development of digital radiography

Programme

DAY 2: Thursday 23 October

ROOM 2: Neuro and MSK 08:30 Registration and refreshments 09:00 Welcome and introduction Chair: Dr Adam Waldman, Consultant Neuroradiologist, Imperial College London 09:05

Imaging the central nervous system; history and advances/past to future? Dr Adam Waldman, Consultant Neuroradiologist, Imperial College London

09:50 Stroke and cerebrovascular disease Dr Shawn Halpin, Consultant Neuroradiologist, University Hospital of Wales 10:20 Spinal trauma Dr Curtis Offiah, Consultant Neuroradiologist, The Royal London Hospital 10:50 Refreshments 11:05 Normal ageing and disease â&#x20AC;&#x201C; neurodegeneration and dementia Professor Alison Murray, Roland Sutton Professor of Radiology, University of Aberdeen 11:40 Brain tumours Professor Pia Sundgren, Professor of Radiology, Lund University, Sweden 12:15 Quiz 12:30 Lunch THE FOLLOWING LECTURE WILL TAKE PLACE IN ROOM 1 13:30

The BIR Sir Godfrey Hounsfield memorial lecture: The isotope bone scan past, present and future Professor Ignac Fogelman, Professor of Nuclear Medicine, Kingâ&#x20AC;&#x2122;s College London

14:15 Prizes and awards ceremony THE PROGRAMME WILL NOW CONTINUE IN ROOM 2 Session 1: Joint pain Chair: Dr David Wilson, Consultant Interventional MSK Radiologist, Oxford University Hospitals NHS Trust President, BIR

14:25 Pain – disconnection between imaging findings and patient’s symptoms Dr Franz Kainberger, Department of Diagnostic Radiology, Medical University of Vienna 14:50 Osteoarthritis as a cause of pain Dr Fiona Watt, Senior Clinical Research Fellow, Kennedy Institute of Rheumatology, University of Oxford 15:15 Synovial disease as a cause of pain (including infection) Dr Richard Wakefield, Consultant in Rheumatology, St James’s University Hospital, Leeds 15:40

Stretch, strengthen, push, pull and jab - conservative treatment of musculoskeletal syndromes Mr Mark Maybury, Extended Scope Physiotherapy Practitioner, Good Hope Hospital, Birmingham

16:05 Refreshments Session 2: Insufficiency fractures 16:20 Epidemiology in the UK Dr Simon Dolin, Consultant in Pain Medicine, BMI Goring Hall Hospital, West Sussex 16:45 Causes of insufficiency fractures Dr M Kassim Javaid, Associate Professor of Metabolic Bone Disease, University of Oxford 17:10 Diagnostic methods Dr Naomi Winn, Consultant Radiologist, Manchester Royal Infirmary 17:35 Treatment options Mr Sean Molloy, Consultant Orthopaedic Spinal Surgeon, Royal National Orthopaedic Hospital, Stanmore 18:00 Close of Congress __________________________________________________________________

BIR Annual Congress 2015: 4–5 November, London

Speaker profiles (where supplied) Dr Simon Dolin Consultant in Pain Medicine, BMI Goring Hall Hospital Dr Simon Dolin was previously NHS Consultant in Western Sussex Hospitals, now an independent practitioner in Sussex, Surrey and London. He was an early adopter of vertebroplasty in the days when we had to add opacifier on the bench by hand and there were no injection devices. Having been around the circle on this he has gone back to hand injection using cortoss system. Professor Ignac Fogelman Professor of Nuclear Medicine, King’s College London Professor Fogelman is currently Professor of Nuclear Medicine (NM), at King’s College London and Honorary Consultant Physician, Guy’s and St Thomas’ NHS Trust and Director of the Osteoporosis Screening and Research Unit, Guy’s Hospital. He is Chairman of the Board of Examiners for the MSc in NM, which provides the only recognised training programme for NM in the UK. He has written over 400 articles in peer reviewed journals, has written or edited 15 books, and supervised 17 PhD/MD students. He is a former board member and Trustee of the National Osteoporosis Society and was previously Chairman of its Bone Densitometry (BD) Forum. Dr Shawn Halpin Consultant Neuroradiologist, University Hospital of Wales Dr Halpin qualified at King’s in 1982, and completed neuroradiology training at Queen’s Square after the radiology training scheme at St Georges. He was appointed Consultant Neuroradiologist at University Hospital of Wales, Cardiff in 1993. He’s had an interest in advanced CT imaging for cerebrovascular disease in stroke for many years, and has worked with GE in developing their CT perfusion software. Dr M Kassim Javaid Associate Professor of Metabolic Bone Disease, University of Oxford Dr M Kassim Javaid is Associate Professor of Metabolic Bone Disease, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford and Honorary Consultant Rheumatologist, Nuffield Orthopaedic Centre, Oxford University Hospitals Trust. Dr MK Javaid completed his medical training at Charing Cross and Westminster Medical School then specialised in adult rheumatology at the Wessex Deanery. He completed a PhD in the epidemiology of osteoporosis as an ARC Clinical Fellow at the University of Southampton and spent a year as an ARC travelling fellow in UCSF to study the role of vitamin D and bone in lower limb OA.

He was appointed as Lecturer in Metabolic Bone Disease/ Honorary consultant Rheumatologist at Oxford. His research interests include the role of epidemiology of musculoskeletal diseases, mechanism of bone pain and co-lead for a the NIHR RD TRC rare bone diseases initiative and works within the Clinical Scientific Committee of the National Osteoporosis Society, including developing the vitamin D guidelines, and the International Osteoporosis Society, including development and implementation Mr Mark Maybury Extended Scope Physiotherapy Practitioner, Good Hope Hospital Mark is an extended scope musculoskeletal physiotherapist, at Good Hope Hospital, Heart of England Foundation Trust in Birmingham. He specialises in diagnostic and interventional ultrasound, and works in the trauma and orthopaedics, physiotherapy and radiology departments. He is a faculty member on many of the leading ultrasound courses in the UK, and a visiting speaker at several universities. Additionally, he is a published author, and currently holds an honorary lecturer position at the University of Essex. Mr Sean Molloy Consultant Orthopaedic Spinal Surgeon, Royal National Orthopaedic Hospital Mr Molloy is a Consultant Orthopaedic Spinal Surgeon at The Royal National Orthopaedic Hospital, Stanmore. He is unique in being the only person in the United Kingdom holding dual qualification as a Spinal Surgeon and a Chiropractor. He qualified as a Chiropractor in 1990. He practised as a chiropractor whilst training to be a doctor. Mr Molloy graduated from St Georgeâ&#x20AC;&#x2122;s Hospital Medical School in 1995. His specialist registrar years in orthopaedics were spent on the south west Thames training rotation. Mr Molloy undertook an MSc in Orthopaedic Engineering during his orthopaedic registrar training and graduated in 2002 from Cardiff University. Mr Molloy did a Fellowship year at the prestigious Johns Hopkins University Hospital in the United States. He then completed a further Fellowship in spinal surgery at The Royal National Orthopaedic Hospital, Stanmore, before being appointed as a consultant in the same institution. He has been active in scientific research and his work is covered in over sixty published scientific papers/presentations both nationally and internationally. Professor Alison Murray Roland Sutton Professor of Radiology, University of Aberdeen Professor Alison Murray is the Roland Sutton Professor of Radiology at the University of Aberdeen. She is Director of the Aberdeen Biomedical Imaging Centre. She leads clinical brain imaging research in structural, functional and molecular imaging correlates of cognitive ageing and dementia and work includes MRI in the Aberdeen

1936 Birth Cohort, and MRI, regional cerebral blood flow (rCBF) SPECT and FDG PET in clinical trials of novel Tau Aggregation Inhibitor therapies in Alzheimer’s disease. Particular interests are the relative contributions of vascular risk factors and subclinical Alzheimer’s disease to cognitive ageing, contributors to cognitive reserve and resilience to dementia and developing novel methods of imaging in patients with dementia. She has extensive NHS experience of brain imaging in dementia and is responsible for the majority of NHS referrals for structural and molecular brain imaging including CT, rCBF SPECT CT and FP-CIT CT studies. She is a founding member and executive member of the Scottish Imaging Network: A Platform for Scientific Excellence (SINAPSE) www.sinapse.ac.uk a successful brain imaging pooling initiative funded by the Scottish Funding Council, CSO and participating universities to develop state of the art brain imaging resources and research training across Scotland, an executive member of the Scottish Dementia Research Consortium and President Elect of the Scottish Radiological Society. Dr Curtis Offiah Consultant Neuroradiologist, The Royal London Hospital Dr Curtis Offiah is a Consultant Neuroradiologist working at the Royal London Hospital within Barts Health NHS Trust incorporating the Royal London Hospital and St Bartholomew’s Hospital. The Royal London Hospital is a level 1 trauma centre and one of the four delegated major trauma units for London and sees a wealth of varied trauma cases including those pertaining to the head, neck and spine. He has a number of subspecialty and research interests including neurotrauma. He has lectured nationally and internationally in neurotrauma and has published papers in peer-reviewed radiological journals on neuroradiological aspects of trauma. He also advises coroner services and police forces on relevant accidental and criminal neurotrauma cases. Professor Pia Sundgren Professor of Radiology, Lund University, Sweden Professor Pia Maly Sundgren is the Head of the Department of Diagnostic Radiology, Clinical Sciences Lund University, Sweden. She has a broad background in neuroradiology as senior neuroradiology consultant. She is a skilled clinician with experience in assessment and diagnosis of intracranial pathologies, and with specific training and expertise in key research areas such as fMRI, MR spectroscopy and diffusion and diffusion tensor imaging in brain disorders and pain conditions. Her main focus of research is on identifying early imaging biomarkers for early prediction of therapeutic outcome and in monitoring treatment response in patients treated for primary brain tumours, and of irradiation effects on brain parenchyma. Pia Sundgren has published over 125 original articles and reviews, several book chapters and three books. She is a well-known lecturer at international meetings with almost 200 lectures world-wide. She is the Chair of the European School of Neuroradiology and acts as board member in several international societies related to radiology and neuroradiology.

Dr Adam Waldman Consultant Neuroradiologist, Imperial College London Dr Waldman gained a PhD and undertook post-doctoral research in biophysics before training in medicine at Cambridge. He trained in radiology at University College Hospitals and subsequently in neuroradiology at the National Hospital for Neurology and Neurosurgery, Queen Square, London. Dr Waldman has been Consultant Neuroradiologist at Imperial College Healthcare NHS Trust (formerly HHNT) since 2001. Since 2006 he has been departmental academic lead as Research Director for Radiology, and has also founded an academic training programme in Clinical Radiology. He was awarded the 2009 Royal College of Radiologists Roentgen Professorship and medal, and holds honorary senior academic appointments at Imperial College London. His main research interests are in quantitative and physiological neuroimaging, particularly as applied to neuro-oncology and neurodegenerative diseases. Dr Fiona Watt Senior Clinical Research Fellow, Kennedy Institute of Rheumatology, University of Oxford Dr Watt is a senior clinical research fellow at the Kennedy Institute of Rheumatology, at the University of Oxford and Honorary Consultant Rheumatologist at the Nuffield Orthopaedic Centre, Oxford. Her research interest is osteoarthritis - the initiating mechanisms of the disease, focussing on the identification of new diagnostic and prognostic tests, and novel therapeutic targets. She leads the translational programme within the Arthritis Research UK Centre for Osteoarthritis Pathogenesis. This includes work on clinical trials but also translational studies in human cohorts, such as those with knee injury or established hand osteoarthritis. She has a PhD in cartilage biochemistry from Imperial College London, and completed specialist training in north west London, having gained research training and MBBS in Newcastle. Fiona remains passionate about clinicians entering science, and the translation of laboratory science into the clinic. Dr David Wilson Consultant Interventional MSK Radiologist, Oxford University Hospitals NHS Trust and President, BIR Dr Wilsonâ&#x20AC;&#x2122;s primary interest is in the application of modern imaging techniques to disorders of the locomotor system and spine intervention. He has undertaken original work in the application of diagnostic ultrasound to joint, muscle, and soft tissue disease with particular attention to joint effusion and congenital dysplasia of the hip. He has over 20 years of experience in vertebroplasty and is the author of publications on multicentre controlled trials on the treatment of insufficiency fractures. He has established innovative training courses in the UK in musculoskeletal ultrasound in Oxford and Bath. He teaches internationally and is a leader in the development of ultrasound in musculoskeletal disease and injection techniques in the spine. He has considerable experience in all aspects

of musculoskeletal imaging and is the Editor of the principle textbook on MSK imaging. As a former President of the British Society of Skeletal Radiologist and a previous Medical Director of the Nuffield Orthopaedic Centre he has wide clinical and research experience. Dr Naomi Winn Consultant Radiologist, Manchester Royal Infirmary Dr Winn is a Consultant Musculoskeletal Radiologist, working at Manchester Royal Infirmary. After completing her Radiology Specialty Training in the Northern Deanery, she enjoyed a year of Fellowship training in Musculoskeletal Radiology, based in Edmonton, Canada. Her subspecialty interests include musculoskeletal ultrasound and imaging of soft tissue and bone sarcomas. ______________________________________________________________ Abstracts Imaging the central nervous system; history and advances/past to future? Dr Adam Waldman Technological advances have been key to the development of brain and spine imaging, from the earliest attempts to visualise these hidden structures using cisternography and angiography, through the advent of cross sectional imaging with CT and MRI, to contemporary functional, physiological and molecular methods. We will move from a brief illustrated 20th century history of neuroimaging, to discuss the translation of emerging functional and quantitative techniques into current clinical neuroradiology practice and cognitive neuroscience, and finally consider potential future applications of novel experimental imaging tools. Stroke and cerebrovascular disease Dr Shawn Halpin Imaging in stroke has many layers. At the base is the need to exclude contra-indications to thrombolysis, while other layers lead through accurate diagnosis, and then on to an assessment of the appropriateness of thrombolysis, and then perhaps of tissue viability. This lecture discusses various imaging paradigms in the hyper acute stroke pathway, from â&#x20AC;&#x153;just do itâ&#x20AC;? to imaging tailored for individual patients. The current role for CT perfusion studies is discussed in detail. Spinal trauma Dr Curtis Offiah Accurate interpretation of computed tomography (CT) and magnetic resonance imaging (MRI) of spinal trauma can be very challenging but is central to the appropriate management and prognostication of significantly compromised and frequently obtunded patients as well as paramount in limiting morbidity in

surviving patients of significant trauma. The lecture will outline the salient basic relevant anatomical and biomechanical principles associated with acute spinal trauma and demonstrate the key CT and MR imaging features and considerations of the common traumatic injuries encountered in relation to the craniocervical junction, the sub axial cervical spine and the thoracolumbosacral spine. Important “review” areas and appropriate “red flags” in the imaging interpretation of acute spinal trauma will also be discussed which may be useful both in limiting potentially deleterious omissions from the radiological input in the patient management pathway as well as assisting clinical prognostication. Finally, imaging assessment in the more rarely-encountered civilian penetrating spinal trauma scenario will also be presented. Educational Aims and Learning Outcomes: 1. Understanding the normal anatomy of the craniocervical junction and spine. 2. Understanding the requirements of emergency CT assessment of the spinal axis. 3. Understanding the concept of “the stable” versus “the unstable” spinal injury. 4. Understanding the fracture and ligamentous injury patterns associated with some of the more typical spinal injuries including high energy mechanism injuries. 5. Understanding the urgency of MRI assessment in the severely injured intubated and ventilated patient with spinal injury. 6. Understanding prognostic MRI features in cord injury associated with spinal trauma. Normal ageing and disease – neurodegeneration and dementia Professor Alison Murray This presentation will review brain imaging in cognitive impairment and dementia, referring to research results, current evidence for imaging and national and international guidelines. The educational aims are to update participants with new information and to give a pragmatic overview of whether brain imaging is appropriate in patients with dementia, if so, when brain imaging should be used and what is practical in a cost constrained NHS. Three main learning points will be made initially: 1. Most dementia related neuropathology is mixed 2. Most evidence ignores baseline 3. Currently we cannot diagnose dementia on a scan – even an APET scan! Following a rapid review of the results of brain imaging research in the Aberdeen Birth Cohorts, a description of cognitive reserve and how this is crucial to understand cognitive ageing and dementia research. Also, what we can and cannot tell from routine brain images and recent drug development in Alzheimer’s disease, the presentation will conclude with examples of where brain imaging is useful in dementia and neurodegenerative diseases, areas for future research and with three more learning points: 1. Imaging increases diagnostic accuracy 2. In future the role of imaging is likely to be validation of cheaper tests 3. If we could “bottle” cognitive reserve it would have as much impact as an effective new drug.

Brain tumours Professor Pia Sundgren Clinical symptoms combined with the results of the neurological examination raise the first suspicion of the possibility that the person might have a brain tumour. CT and/or MR imaging are methods to confirm the presence of a brain tumour and especially MRI with tailored imaging protocol will lead to precise diagnosis. MRI is often used to plan further steps and decide on therapy options. Despite improvements in surgery, radiation and chemotherapy the overall survival of brain tumours varies. One major issue in brain tumour management is that concurrent treatment with radiotherapy and chemotherapy is associated with so called pseudoprogression, reflecting treatment-induced changes in the tumour resulting in an increase in size and/or a brighter appearance than on pretreatment MRI. These changes may misleadingly suggest tumour progression but are transient and eventually the tumour will stabilize in size or even shrink. Novel combination therapies like Bevacizumab treatment, which hampers with tumour angiogensies, may lead to diminished edema and contrast enhancement so called pseudoresponse, with imaging findings that can cause diagnostic difficulties. Also gamma knife therapy is associated with a high incidence of radiation necrosis, with similar morphological characteristics as recurrent tumour. Early identification of patients who suffer from tumour recurrence can be of great advantage: it provides the opportunity to adjust individuals more rapidly, and sparing patients unnecessary morbidity, and delay in initiation of other, maybe more effective, treatment. In this lecture, MR and CT imaging methods for detection and differentiation between different brain tumors will be discussed. In addition, issues like the differentiation between pseudoprogression and true tumour progression, the imaging findings in pseudoresponse and monitoring schemes to assess early treatment response will be discussed The BIR Sir Godfrey Hounsfield memorial lecture: The isotope bone scan past, present and future Professor Ignac Fogelman Isotope bone scanning has a long and distinguished history. The story commences in the 1960s with strontium and with imaging at that time performed using a rectilinear scanner and with resolution so poor that anatomical outlines had often to be added to assist in skeletal localisation! However there were rapid advances relating to both radiopharmaceuticals and instrumentation and the dream team of a bisphosphonate and a gamma cameras came into existence in the late1970s. Initially, and indeed for many years thereafter, the use of the bone scan was almost exclusively in patients with known malignancy but subsequently its use has expanded into many benign applications and nowadays benign conditions account for some 50% of cases. A further significant advance occurred with the use of tomographic imaging (SPECT) in the late 1980s where a dramatic example was the identification of facet joint disease. This seemed almost magical at the time with often prominent focal uptake in individualâ&#x20AC;&#x2122;s who had unexplained back pain and an apparently normal planar study.

However the great leap forward has been with the use of hybrid imaging (SPECT CT) combining functional with anatomical studies taking advantage of high contrast with altered metabolic activity and localising this to precise anatomical data. This has reduced the prevalence of equivocal lesions on the bone scan from some 60% to 5-10%. The future is exciting with the increasing availability of PET, eg. the potential for using F-18 as a ‘routine’ bone scan and with quantitation of tracer uptake in individual lesions now possible, and with several new tumour specific tracers. We are also at the start of the era of PET/MRI. Osteoarthritis as a cause of pain Dr Fiona Watt, University of Oxford Educational aims and outcomes: Delegates will be able to: 1. Describe the epidemiology of pain in osteoarthritis. 2. Understand sources of pain in the osteoarthritic joint. 3. Explore what pain pathways tell us about osteoarthritis. 4. Review the relevance of imaging painful joints in osteoarthritis. Not all people with osteoarthritis have pain. But most do. Osteoarthritis remains one of the leading causes of primary care consultations and work disability in the UK, and the most common symptom of osteoarthritis is joint pain. Pain is also the major driver for joint replacement – a procedure which is increasing exponentially in line with our ageing and obese population. Articular cartilage is aneural, but OA is a disease of the whole joint. Through MRI-based and other imaging studies, we now understand far more about the joint tissues, structures and other processes which give rise to pain. In osteoarthritis, should we aim to treat pain, or structure, or both? In the search for a disease-modifying drug (DMOAD) for the disease, there has been much focus on structure modification, but no successful drug development to date. The renewed focus of Pharma in osteoarthritis is pain modification. Drugs which block pain pathways are teaching us some interesting lessons about the disease and its pathogenesis in both animal models and humans. Imaging remains our only proven biomarker for the disease, and its applications in terms of future clinical trials will be discussed. Stretch, strengthen, push, pull and jab - conservative treatment of musculoskeletal syndromes Mr Mark Maybury This is an experiential talk acting as an overview of physiotherapy in the management and treatment of painful musculoskeletal conditions. It is not an extensive or exhaustive list of treatment options for all conditions but focuses on the use of electrotherapy, manual therapy, acupuncture and injection therapy in the treatment of musculoskeletal conditions. Although the general principles governing the use of these treatments will be described, the treatment of adhesive capsulitis will be focused on specifically as shoulder conditions represent the most common musculoskeletal condition referred in to secondary care. Other conditions such as osteo-arthritis of the knee, and other soft tissue injuries will be described.

Epidemiology in the UK Dr Simon Dolin Insufficiency fractures refer to vertebral compression fracture and sacral fractures. The latter are relatively poorly described in the literature and incidence and clinical impact probably underestimated. VCFs are common. A large population study (Tromso VI) indicates overall prevalence of 11.89% in women and 13.8% in mean. This increases considerably with age, and it is estimated that 50% will have VCF over age of 80. Studies of patients with clinical VCF (requiring investigation and treatment) indicate an annual incidence of 10.7 (women) and 5.7 (men) per 1000. Reasons for discrepancy in sex differences is likely to be complex. VCFs cluster around T11-L2 levels with a mix of wedge and biconcave deformities. Lyritis described painful VCF as either acute type 1 that was severe but settled over 4-8 weeks or chronic type 2 that developed insidiously with progressive wedging over many months. Clinical consequences of VCF include reduced pulmonary function, decreased activities of daily living with loss of independence, abdominal symptoms, increased hospital admissions and mortality ratio increased by 1.6x with a single VCF. Causes of insufficiency fractures Dr M Kassim Javaid Insufficiency fractures are fractures that occur with normal loading and abnormal bone. The commonest cause of insufficiency fractures is osteoporosis. The learning objectives of this session will be: 1. Understand the common causes of osteoporosis. 2. Understand the common secondary causes for osteoporosis. 3. The presentation of common and uncommon types of osteomalacia. 4. The presentation and differential diagnosis of primary hyperparathyroidism. 5. The features and management of atypical subtrochanteric femoral. fractures. Diagnostic methods Dr Naomi Winn This lecture on radiology will include assessment of bone mineral density and how best to image insufficiency fractures. Techniques in assessing bone mineral density will include DEXA, radiography, CT, quantitative CT and high resolution MRI. Imaging of insufficiency fractures will include radiography, CT, MRI, nuclear medicine and ultrasound, with a rationale on how to choose between the different imaging modalities. __________________________________________________________________

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