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.

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.

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.