NICE 2022 guidelines on the management of melanoma: Update and implications.

AIMS: In July 2022, NICE updated the guidelines on the management of melanoma by lowering the number of follow-up appointments and sentinel lymph node biopsy (SLNB) but increasing the number of scans. This study aims to evaluate the implications of executing the new guidelines in terms of cost-effectiveness and personnel. METHODS: All patients newly diagnosed with melanoma in 2019 at a regional skin cancer specialist center were reviewed. Data were analyzed for their journey on an idealized pathway modeled over a 5-year follow-up period when adhering to both the previous and new guidelines. Differences in the management of melanoma were elucidated by comparing these changes. The cost was quantified on a perpatient basis and the financial implication on each department was considered. RESULTS: One hundred and ten patients were diagnosed with melanoma in 2019, stages I-III. The changes ease the burden on plastic surgery and dermatology; however, increased pressure is faced by radiologists and histopathologists. An overall cost benefit of £141.85 perpatient was calculated, resulting in a decrease of 1.22 hospital visits on average and an increase in the time spent there (19.55 min). The additional expenses of implementing the new guidelines due to the added BRAF tests, CT, and ultrasound scans are outweighed by savings from the reduction in follow-up appointments and SLNB. CONCLUSION: The focus has shifted to less invasive procedures for lower melanoma stages and fewer follow-up appointments, at the expense of more genetic testing and imaging. This paper serves as a useful baseline for other centers to plan their service provision and resource allocation to adhere to the updated guidelines.

Haematological risk factors predicting clinical success in transarterial embolisation for acute gastrointestinal bleeding.

OBJECTIVES: Evaluate clinical outcomes in transarterial embolisation (TAE) for acute gastrointestinal bleeding (GIB) and determine risk factors for 30-day reintervention for rebleeding and mortality. METHODS: TAE cases were retrospectively reviewed between March 2010 and September 2020 at our tertiary centre. Technical success (angiographic haemostasis following embolisation) was measured. Uni- and multivariate logistic regression analysis were performed to identify risk factors for clinical success (absence of 30-day reintervention or mortality) following embolisation for active GIB or empirical embolisation for suspected bleeding. RESULTS: TAE was conducted in 139 patients (92 (66.2%) male; median age:73, range: 20-95 years) for acute upper GIB (n = 88) and lower GIB (n = 51). TAE was technically successful in 85/90 (94.4%) and clinically successful in 99/139 (71.2%); with 12 (8.6%) reintervention cases for rebleeding (median interval 2 days) and 31 (22.3%) cases of mortality (median interval 6 days). Reintervention for rebleeding was associated with haemoglobin drop > 40 g l-1 from baseline based on univariate analysis (p = 0.047). 30-day mortality was associated with pre-intervention platelet count < 150×109 l-1 (p < 0.001, OR 7.35, 95% CI 3.05-17.71) and INR > 1.4 (p < 0.001, OR 4.75, 95% CI 2.03-11.09) on multivariate logistic regression analysis. No associations were found for patient age, gender, antiplatelet/anticoagulation prior to TAE, or when comparing upper and lower GIB with 30-day mortality. CONCLUSION: TAE had excellent technical success for GIB with relatively high (1-in-5) 30-day mortality. INR > 1.4 and platelet count < 150×109 l-1 were individually associated with TAE 30-day mortality, and pre-TAE > 40 g l-1 haemoglobin decline with rebleeding requiring reintervention. ADVANCES IN KNOWLEDGE: Recognition and timely reversal of haematological risk factors may improve TAE periprocedural clinical outcomes.

Feasibility of arterial spin labeling in evaluating high- and low-flow peripheral vascular malformations: a case series.

We present a case series highlighting a novel use of arterial spin labeling (ASL), a MRI perfusion technique, to evaluate both high- and low-flow peripheral vascular malformations (PVMs) across a range of anatomical locations. While the role of ASL in assessing intracranial vascular malformations is more established, there is limited evidence for PVMs. Our results provide preliminary evidence for the feasibility of ASL in imaging PVMs and its potential ability to distinguish between high- and low-flow PVMs. In addition, we demonstrate its ability to identify focal high blood flow, which may indicate the nidus in arteriovenous malformations. Together, these findings have important implications for patient management. We also outline the potential benefits and limitations of ASL in the imaging of PVMs, and provide justification for further validation of its diagnostic performance.

Subarachnoid haemorrhage rules in the decision for acute CT of the head: external validation in a UK cohort.

BACKGROUND: The Ottawa subarachnoid haemorrhage (SAH) rule and the Emerald SAH rule are clinical decision tools to aid in the decision for computed tomography (CT) of the head in patients attending an emergency department (ED) with acute non-traumatic headache. The objective of this study was to analyse the performance of these rules in a contemporary UK cohort. METHODS: We performed a retrospective external validation study. Patients undergoing CT of the head for the evaluation and treatment of non-traumatic headaches over a 6-month period in the ED at two tertiary centres were assessed. Each patient's Ottawa rule and Emerald rule were calculated and compared with their final diagnosis. RESULTS: The cohort consisted of 366 patients and there were 16 cases of SAH (based on CT findings or the presence of xanthochromia in cerebrospinal fluid). The Ottawa rule identified 288 patients requiring CT of the head. The sensitivity of the Ottawa rule was 100% (95% confidence interval (CI) 71-100%) and the specificity was 22% (95% CI 18-27%). The Emerald rule identified 267 patients who required CT, and achieved a sensitivity of 81% (95% CI 54-96%) and a specificity of 27% (95% CI 23-32%). CONCLUSIONS: The Ottawa SAH rule correctly identified all patients with SAH in this contemporary cohort. The Emerald rule did not perform as well in this cohort and is unsuitable for clinical use. The Ottawa rule is a useful tool to aid in the decision for CT of the head in patients presenting with acute non-traumatic headache to the ED.

Novel use of arterial spin labelling in the imaging of peripheral vascular malformations.

We present a novel use of arterial spin labelling (ASL), a MRI perfusion technique, to assess a high-flow, peripheral vascular malformation (PVM), specifically a large arteriovenous malformation in the left forearm of a 20-year-old female. While there has been experience with ASL in the assessment of intracranial vascular malformations, there has been no known use of ASL in the evaluation of PVMs. We also discuss the potential benefits and limitations of ASL in the imaging of PVMs. The promising results from this case warrant further research on ASL in the investigation of PVMs.

A comparison of arterial spin labelling with catheter angiography in evaluating arteriovenous malformations: a systematic review.

OBJECTIVES: To compare the performance of arterial spin labelling (ASL) in evaluating arteriovenous malformations (AVMs) against the current gold standard of catheter angiography. METHODS: We systematically reviewed the published literature using EMBASE and Medline. We included studies that compared ASL to catheter angiography in the assessment of AVMs in three outcome domains: detection, angioarchitectural and haemodynamic features. RESULTS: From 314 unique citations, 19 studies representing 289 patients with intracranial AVMs met our inclusion criteria. We did not pool data due to marked heterogeneity in study outcome measures. Seven studies showed high diagnostic performance of ASL in identifying arterial feeders, with sensitivity ranging from 84.6 to 100% and specificity ranging from 93.3 to 100%. Six studies showed strong ability in detecting arteriovenous shunting, with sensitivity ranging from 91.7 to 100% and specificity ranging from 90 to 100%. Seven studies demonstrated that ASL could identify nidal location and size as well as catheter angiography, while five studies showed relatively poorer performance in delineating venous drainage. Two studies showed 100% sensitivity of ASL in the identification of residual or obliterated AVMs following stereotactic radiosurgery. CONCLUSIONS: Despite limitations in the current evidence base and technical challenges, this review suggests that ASL has a promising role in the work-up and post-treatment follow-up of AVMs. Larger scale prospective studies assessing the diagnostic performance of ASL are warranted. ADVANCES IN KNOWLEDGE: ASL demonstrates overall validity in the evaluation of intracranial AVMs.

Factors associated with pseudoaneurysm development and necessity for reintervention: a single centre study.

OBJECTIVE: Evaluate the factors associated with pseudoaneurysm development and morphology. Measure ultrasound-guided thrombin injection (UGTI) and surgical treatment outcomes for pseudoaneurysms, and the necessity for post-primary intervention (reintervention). METHODS: Retrospective analysis of ultrasound scans and CT angiography of peripheral pseudoaneurysm interventions from February 2011 to April 2017. 99 patients (61.6% female) were identified; median age 72 years (range 12-89). Multivariate analysis of patient demographics, including pre-intervention anticoagulant and antiplatelet medication was performed. RESULTS: Primary intervention for peripheral pseudoaneurysms (62.6% common femoral artery) included 93 UGTI and 6 surgical repairs; with 12 reinterventions (9 UGTI and 3 surgical). Pseudoaneurysm incidence for vascular interventional radiology (VIR) was 0.48% (31/6451) and cardiology was 0.24% (60/25,229). Rates for primary success, immediate complications, 30-day mortality and reintervention were measured respectively for UGTI (98.9%, 3.0%, 2.0%, and 11.8%) and surgical repair (100%, 0.0%, 22.2% and 16.7%). Reintervention risk factors included pre-intervention thrombocytopaenia (<150 × 109/L) ( p = 0.025) and pseudoaneurysms following vascular surgery (p = 0.033). Other positive associations for reintervention (non-significant) included use of a sheath size > 6 Fr ( p = 0.108) or arterial closure device ( p = 0.111) during the pseudoaneurysm causative procedure. The pre-intervention warfarin subgroup developed a larger mean pseudoaneurysm sac size (4.21 cm, range 0.9-7.6), compared to no treatment (p = 0.003), aspirin (p = 0.005) and clopidogrel (p = 0.026) subgroups. UGTI dosage for thrombosis had a positive correlation with incremental sac size increase (p < 0.001). CONCLUSION: The main reintervention risk factor was pre-intervention thrombocytopaenia, with additional positive associations including pseudoaneurysms caused by surgery, increased sheath size and arterial closure devices. Warfarinized patients developed larger sac-sized pseudoaneurysms compared with other pre-intervention regimens, with positive correlation of higher UGTI dosage required for thrombosis. ADVANCES IN KNOWLEDGE: Patients with pre-intervention thrombocytopaenia and pseudoaneurysms attributed to vascular surgery are subgroups that may benefit from post-intervention imaging surveillance due to significant reintervention risk.

How should we use imaging in the determination of brainstem death?

Brainstem death is defined as the "irreversible cessation of brainstem function", either due to primary intracranial events or extracranial factors such as hypoxia. The importance of accurate and timely diagnosis of brainstem death in critical care should not be understated, as it allows the withdrawal of treatment when it is no longer deemed to beneficial. Additionally, it may facilitate the process of organ donation. Overall, the diagnosis of brainstem death has four common principles across the world: (1) neurological criteria based on clinical assessment; (2) evidence of irreversible brain damage from known aetiology; (3) demonstrating an absence of a reversible cause; and (4) the use of ancillary studies. The latter in particular has been a controversial issue, with much debate continuing on how imaging should be used. We discuss three key questions surrounding the role of imaging in the diagnosis of brainstem death as well as important issues the radiology community should consider.

Is it Time for a Specific Undergraduate Interventional Radiology Curriculum?

PURPOSE: Interventional radiology (IR) is traditionally underrepresented in undergraduate medical curricula. Final-year medical students ought to be familiar with some common IR procedures in order to make adequate referrals and work-up patients appropriately. We evaluated the knowledge of final-year medical students on common IR procedures and compared it with their knowledge of other specialties. MATERIALS AND METHODS: A fourteen-question, single-best-answer questionnaire assessing the knowledge of IR procedures and other minimally invasive non-IR procedures was administered to a group of final-year medical students. Paired two-tailed student's t test was used to compare knowledge across specialties. RESULTS: Fifty-one questionnaires were administered and returned. No student answered all questions correctly. The median score was 5/11. The best-answered question was on coronary intervention followed by neurosurgical procedures. The average score for IR procedures was 38% versus 57% for non-IR procedures (P < 0.0005). While most students had come across IR previously, 70% would like further exposure. We also accessed the undergraduate curricula of five London Medical Schools; all five have a radiology curriculum, but only one has a dedicated IR section. CONCLUSION: Medical students' lack of IR exposure translates into a lack of appreciation of the role of the specialty. We propose the introduction of a specific undergraduate IR curriculum to bridge this knowledge gap.

How do HIV-negative individuals in sub-Saharan Africa change their sexual risk behaviour upon learning their serostatus? A systematic review.

OBJECTIVE: To determine whether, and how, sexual behaviour of HIV-negative individuals in sub-Saharan Africa (SSA) changes upon learning their serostatus. METHODS: We systematically reviewed the published literature using EMBASE and Medline to search for publications between 2004 and 2014. We included studies that quantified behaviour change (condom use, number of sexual partners or sex acts) following an HIV test in HIV-negative adults in SSA, and extracted relevant data including study characteristics and measurement type. RESULTS: From 2185 unique citations, n=14 studies representing 22 390 participants met our inclusion criteria. We did not pool data due to marked heterogeneity in study outcome measures. The proportion of participants reporting consistent condom use (n=6) post-testing ranged from 7.6% greater, to 10.6% fewer, while 'no condom use' (n=5) ranged from 40.0% less, to 0.7% more. Condom use in serodiscordant couples increased (n=3). Five studies measured the proportion reporting abstinence, finding an increase of 10.9% to a decrease of 5.3% post-testing. The post-testing change in the mean number of sex acts (n=3) ranged from a relative decrease of 15.7% to a relative increase of 9.4%. Two studies reported relative decreases in the mean number of sexual partners of 35.2% and 14.0%. Three studies examining serodiscordant primary relationships specifically all showed increases in extrarelational sex. CONCLUSIONS: With the exception of serodiscordant couples, there is variable evidence that awareness of one's serostatus leads to substantial changes in risk behaviour among HIV-negative individuals. Further research is needed to estimate the behavioural impact of learning one's serostatus in SSA.