Are we underutilising computer tomography colonography in Australia?

Computed tomography colonography (CTC) is a safe and accurate tool for colorectal cancer (CRC) screening in both symptomatic and asymptomatic patients. CTC requires dedicated radiological expertise and demonstrates a high sensitivity and specificity in polyp detection, which is similar to optical colonoscopy (OC). Newer preparation techniques for CTC, such as faecal tagging without catharsis might further improve both the tolerability and accuracy of the test. While exposure to ionising radiation, lack of capacity for therapeutic intervention and potentially diminished sensitivity for flat serrated polyps are limitations of CTC, the technique has a role in select populations. CTC should be considered in frail or elderly patients at high anaesthetic risk for OC, patients with stricturing colonic lesions as well as incomplete colonoscopy, or in patients at risk of delayed access to timely OC. With an ever-growing demand for endoscopic services, increased utilisation of CTC could reduce waiting times for colonoscopy, thereby broadening access to timely and effective CRC screening. Further research is required to improve further the detection of flat lesions, including sessile serrated polyps.

High-grade transitional cell carcinoma masquerading as a xanthogranulomatous pyelonephritis and perinephric abscess.

Xanthogranulomatous pyelonephritis (XGPN) is an atypical long-term pyelonephritis with destruction of renal parenchyma and a long-term inflammatory infiltrate of macrophages. Reported presentations of transitional cell carcinoma (TCC) are different. A 73-year-old woman presented with loin pain, prostration, and fever. Computed tomography scan revealed poor cortical enhancement of the kidney, but some of the images bore resemblance to the characteristic "bear's paw" sign, consistent with XGPN with a 7-cm perinephric collection. She was provisionally diagnosed as severe acute pyelonephritis, possibly XGPN, with abscess. In view of the poor clinical condition, decision was made to perform nephrectomy. Histology revealed a G3pT4 high grade TCC with perineural and vascular invasion and reactive xanthogranulomatous inflammatory response. There are few reports of concomitant XGPN and TCC affecting the kidney. However, there has not been any mention of XGPN and TCC presenting as acute pyelonephritis and perinephric abscess so far.

Gallstone ileus from a non-calcified stone: a challenging diagnosis.

Gallstone ileus is an uncommon and often life-threatening complication of cholelithiasis. In this case, we discuss a difficult diagnostic case of gallstone ileus with a non-calcified gallstone. An 88-year-old female presented with abdominal pain and vomiting. A CT scan was arranged and showed an evolving bowel obstruction although no frank hyperdensity suggestive of a gallstone was noted. Initially the cause of the bowel obstruction was uncertain, but after discussion with the treating team and further review of the images, the patient was diagnosed with gallstone ileus. The patient underwent emergency surgery and a 41 mm obstructing calculus was removed from the patient's jejunum, later confirmed on histological diagnosis.

Heart or head?: A depression mimic delays diagnosis-oncotic cerebral aneurysms caused by atrial myxoma.

Complications of intracardiac tumours can carry significant morbidity and mortality. This article depicts the case of a female who presented with multiple oncotic intracranial aneurysms secondary to a left atrial myxoma. The clinical manifestations and pathogenesis of cardiac myxoma, as well as the imaging pathway, management and prognosis of myxomatous aneurysms will be discussed. Excision of the cardiac mass is mandatory both for symptomatic improvement and to prevent further embolic complications. Local recurrence and delayed onset cerebral complications do occur, and necessitate ongoing patient follow-up. Our report highlights several important features of the diagnostic and treatment pathway for atrial myxoma-in particular, the potentially non-specific clinical presentation, the pivotal role of cardiac MRI in the multimodality diagnostic imaging work up and the need for multidisciplinary communication to identify the diagnosis and guide appropriate management.

Intraosseous cavernous haemangioma of the inferior turbinate.

Intraosseous cavernous haemangiomas usually occur in the vertebral and calvarial bones, and account for <1% of primary bone tumours. Nasal cavity intraosseous cavernous haemangiomas are extremely rare. We present a case of a 47-year-old woman with an incidental left inferior turbinate mass noted on CT scan for an unrelated pathology. She had no rhinological symptoms other than a 2-year history of left-sided nasal obstruction. Preoperative imaging failed to determine the aetiology of the mass. The lesion, contiguous with the left inferior turbinate, was successfully resected via an endoscopic approach. Histopathological examination of the resected specimen demonstrated a left inferior turbinate intraosseous cavernous haemangioma.

Congenital cysts of the infant larynx.

OBJECTIVES: Congenital laryngeal cysts are a rare cause of neonatal airway obstruction. Two varieties can be distinguished, ductal cysts and saccular cysts. Treatment remains controversial, particularly with regard to saccular cysts, with some believing that endoscopic procedures leave cysts more prone to recurrence. We reviewed our management of congenital laryngeal cysts to determine the most effective intervention. METHODS: A review of all children treated by our unit for congenital laryngeal cysts between 2001 and 2011. Demographic data, age at and mode of presentation were noted. Operation notes were reviewed to determine the nature of each laryngeal cyst and treatment methodology. RESULTS: Ten children were identified, six with a ductal cyst of the vallecula and four with a saccular cyst, giving an overall incidence of 3.49 cases per 100,000 live births. Children of Pakistani ancestry were disproportionately represented, accounting for 40% of cases. Saccular cysts presented earlier with symptoms of more severe airway compromise, whilst vallecular cysts tended to present later with feeding difficulties and failure to thrive. Two-thirds of children with vallecular cysts had co-existing laryngomalacia. Treatment by single-stage endoscopic marsupialisation was effective in all cases at a mean follow-up of thirteen months. CONCLUSIONS: Congenital laryngeal cysts are rare, although they appear to be more common in the British-Pakistani population. Presentation depends on cyst size and proximity to the glottis and can be associated with laryngomalacia. Endoscopic marsupialisation is an effective means of treatment for ductal cysts and saccular cysts confined to the larynx.

NICE guidelines for the investigation of head injuries--an anticoagulant loop hole?

INTRODUCTION: NICE guidelines provide clear indications for the investigation of head injuries with CT. A patient on anticoagulation is required to have lost consciousness to warrant a CT scan unless obvious stronger indications exist. We recently observed three patients who had been assessed following head injuries that did not fulfil the NICE criteria for a CT scan, but who subsequently were found to have significant brain injury, all of whom were on warfarin. This experience prompted us to categorise whether the CT scans for head injuries performed were done so with indications consistent with the NICE guidelines, and then examine the outcomes to determine the effectiveness of the NICE guidelines for picking up positive pathology. METHODS: All patients presenting to the emergency department with isolated head injuries investigated with CT scan were included for the 3-month period April to June 2008. Notes were examined retrospectively to look at age, sex, mechanism of injury, coexisting coagulopathy, indication for CT scan and the corresponding CT scan result. RESULTS: 39 patients were included. 28/39 CT scans were unremarkable. 11 identified acute pathology. 23 scans were performed according to NICE guidelines, which revealed pathology in 10 patients. Ten scans were not performed according to NICE guidelines and none of these revealed pathology. Six scans were performed for unclear reasons and one revealed pathology. 6/39 patients were taking warfarin. Three of these six scans revealed intracranial pathology. The mean age of these six patients was 84 y. CONCLUSION: While NICE guidelines provide a valuable tool for the investigation of head injuries, we feel that elderly patients on anticoagulation may be at risk of having significant head injuries missed and a lower threshold for scanning should be adopted.

Orbital floor reconstruction: a case for silicone. A 12 year experience.

INTRODUCTION: Controversy still exists regarding the choice of implant material for orbital floor reconstructions, in particular the use of silicone. We aimed to evaluate the long-term outcomes of orbital floor reconstructions with silicone versus other non-silicone implants. PATIENTS AND METHODS: We conducted a 12 year retrospective review of patients who had orbital floor reconstructions for fractures at the Royal Hobart Hospital, Tasmania, Australia, from 1995 to 2007. Surgical admission notes, CT reports, operation records, outpatient notes, and complications were recorded. Long-term follow-up consisted of a structured telephone interview assessing patient outcomes and satisfaction, including ongoing disability, following orbital floor repair. RESULTS: Eighty one patients were identified as having had orbital floor reconstruction with an implant. Mean long-term follow-up was 63 months. Outcomes of Silicone implants (n=58) were compared to non-silicone implant materials (n=23) including titanium mesh, 'Lactasorb', 'Resorb-X', autologous cartilage, and bone graft. Statistically significant advantages in the silicone group were found in the number of patients with palpable implants (24% vs 63%, p=0.005), the number of patients without any complaint (67% vs 32%, p=0.004), and the number of patients requiring subsequent surgery for complications related to their implants (5% vs 23%, p=0.046). CONCLUSION: The appropriate use of silicone implants for orbital floor reconstruction can have good results, contrary to much of the literature, with low complication rates including an acceptably low rate of infection and extrusion, as well as high patient satisfaction. To establish definite guidelines for best surgical practise, particularly amongst synthetic implant materials, prospective study is required.

A critical evaluation of the use of Biobrane as a biologic skin substitute: a versatile tool for the plastic and reconstructive surgeon.

BACKGROUND: Biobrane and Biobrane-L are becoming increasingly popular in the management of superficial and moderate-depth partial-thickness burns, particularly in pediatric patients. When used appropriately, they have been shown to reduce pain levels, healing time, inpatient stay, and nursing requirements when compared with traditional dressings. In this manuscript, we provide a critical evaluation of the evidence base for the varied uses of Biobrane within the field of plastic and reconstructive surgery. METHODS: We present a comprehensive review of MEDLINE-cited articles, the proceedings of national meetings, relevant books, and information from the suppliers to provide the reconstructive surgeon with an evidence base for the use of Biobrane. We also take this opportunity to discuss religious and ethical issues and the complications of Biobrane application. RESULTS AND CONCLUSION: Biobrane is a versatile biosynthetic wound dressing. There is good evidence (Grade A) to support the use of Biobrane in the management of burns, particularly in partial-thickness burns in children. Biobrane also has many potential uses as a dressing outside the burns unit of which we feel reconstructive surgeons should be aware. Conditions resulting in disruption of the epidermis such as toxic epidermal necrolysis (TEN) and paraneoplastic pemphigus have been managed successfully using Biobrane (Grade B). Biobrane has also been successfully used following dermabrasion, skin-graft harvesting, and laser resurfacing (Grades B to C). Temporary coverage with Biobrane has been successfully used in individuals with chronic wounds such as open sternotomy sites and venous ulcers (Grades B to C). Biobrane has a wealth of potential uses outside its traditional remit; however, further prospective clinical trials are warranted if these new applications are to become more widely accepted.