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Background: Outpatient care for patients with heart valve disease (HVD) is best provided by valve clinics delivered by specialists. Modern day practice in the United Kingdom (UK) is currently poorly understood and has not been evaluated for nearly a decade. Furthermore, the COVID 19 pandemic changed the management of many chronic diseases, and how this has impacted patients with heart valve disease is unclear. Methods: A British Heart Valve Society survey was sent to 161 hospitals throughout the UK. Results: There was a general valve clinic in 46 of the 68 hospitals (68%), in 19 of 23 Heart Centres (83%) and 29 of 45 DGHs (64%). Across all settings, 3824 new patients and 17,980 follow up patients were seen in valve clinics per annum. The mean number of patients per hospital were 197 (median 150, range 48–550) for new patients and 532 (median 400, range 150–2000) for follow up. On the day echocardiography was available in 55% of valve clinics. In patients with severe HVD, serum brain natriuretic peptide (BNP) was measured routinely in 39% of clinics and exercise testing routinely performed in 49% of clinics. A patient helpline was available in 27% of clinics. 78% of centres with a valve clinic had a valve multidisciplinary team meeting (MDT). 45% centres had an MDT co-ordinator and MDT outcomes were recorded on a database in 64%. COVID-19 had a major impact on valve services in 54 (95%) hospitals. Conclusions: There has been an increase in the number of valve clinics since 2015 from 21 to 68% but the penetration is still well short of the expected 100%, meaning that valve clinics only serve a small proportion of patients requiring surveillance for HVD. COVID-19 had a major impact on the care of patients with HVD in the majority of UK centres surveyed. [ABSTRACT FROM AUTHOR]

Schizophrenia (SCZ) and bipolar disorder (BD) are severe psychiatric conditions that can involve symptoms of psychosis and cognitive dysfunction. The 2 conditions share symptomatology and genetic etiology and are regularly hypothesized to share underlying neuropathology. Here, we examined how genetic liability to SCZ and BD shapes normative variations in brain connectivity. We examined the effect of the combined genetic liability for SCZ and BD on brain connectivity from two perspectives. First, we examined the association between polygenic scores for SCZ and BD for 19,778 healthy subjects from the UK Biobank and individual variation in brain structural connectivity reconstructed by means of diffusion weighted imaging data. Second, we conducted genome-wide association studies using genotypic and imaging data from the UK Biobank, taking SCZ-/BD-involved brain circuits as phenotypes of interest. Our findings showed brain circuits of superior parietal and posterior cingulate regions to be associated with polygenic liability for SCZ and BD, circuitry that overlaps with brain networks involved in disease conditions (r = 0.239, p <.001). Genome-wide association study analysis showed 9 significant genomic loci associated with SCZ-involved circuits and 14 loci associated with BD-involved circuits. Genes related to SCZ-/BD-involved circuits were significantly enriched in gene sets previously reported in genome-wide association studies for SCZ and BD. Our findings suggest that polygenic liability of SCZ and BD is associated with normative individual variation in brain circuitry. [ABSTRACT FROM AUTHOR]

Background: Previous studies show the uptake of biannual ultrasound (US) surveillance in patients with cirrhosis is suboptimal. Here, our goal was to understand in broader terms how surveillance is being delivered to cirrhosis patients with cured hepatitis C in the UK. Methods: Hepatitis C cirrhosis patients achieving a sustained viral response (SVR) to antiviral therapies were identified from the national Hepatitis‐C‐Research‐UK resource. Data on (i) liver/abdominal US examinations, (ii) HCC diagnoses, and (iii) HCC curative treatment were obtained through record‐linkage to national health registries. The rate of US uptake was calculated by dividing the number of US episodes by follow‐up time. Results: A total of 1908 cirrhosis patients from 31 liver centres were followed for 3.8 (IQR: 3.4–4.9) years. Overall, 10 396 liver/abdominal USs were identified. The proportion with biannual US was 19% in the first 3 years after SVR and 9% for all follow‐up years. Higher uptake of biannual US was associated with attending a liver transplant centre; older age and cirrhosis decompensation. Funnel plot analysis indicated significant inter‐centre variability in biannual US uptake, with 6/29 centres outside control limits. Incident HCC occurred in 133 patients, of which 49/133 (37%) were treated with curative intent. The number of US episodes in the two years prior to HCC diagnosis was significantly associated with higher odds of curative‐intent treatment (aOR: 1.53; 95% CI: 1.12–2,09; p =.007). Conclusions: This study provides novel data on the cascade of care for HCC in the UK. Our findings suggest biannual US is poorly targeted, inefficient and is not being delivered equitably to all patients. [ABSTRACT FROM AUTHOR]

Human activities have raised the atmosphere's carbon dioxide (CO2) content by 50% in less than 200 years and by 10% in the last 15 years. Climate change is a great threat and presents a unique opportunity to protect cardiovascular health in the next decades. CO2 equivalent emission is the most convenient unit for measuring the greenhouse gas footprint corresponding to ecological cost. Medical imaging contributes significantly to the CO2 emissions responsible for climate change, yet current medical guidelines ignore the carbon cost. Among the common cardiac imaging techniques, CO2 emissions are lowest for transthoracic echocardiography (0.5–2 kg per exam), increase 10-fold for cardiac computed tomography angiography, and 100-fold for cardiac magnetic resonance. A conservative estimate of 10 billion medical examinations per year worldwide implies that medical imaging accounts for approximately 1% of the overall carbon footprint. In 2016, CO2 emissions from magnetic resonance imaging and computed tomography, calculated in 120 countries, accounted for 0.77% of global emissions. A significant portion of global greenhouse gas emissions is attributed to health care, which ranges from 4% in the United Kingdom to 10% in the United States. Assessment of carbon cost should be a part of the cost-benefit balance in medical imaging. [ABSTRACT FROM AUTHOR]

The visual comparison of 2D images, or 'photographic monitoring', is commonly used in cultural heritage conservation to assess rates of deterioration and the impact of interventions. While it is an accessible technique, three-dimensional changes can be difficult to discern and identifying change can be subjective. Structure from Motion (SfM) photogrammetry, which generates 3D point clouds from digital photographs, has the potential to make monitoring more objective and more informative by recording three dimensions of change rather than two. A methodology was tested on the Romanesque wall paintings of St Botolph's church, Hardham, UK to develop a SfM photogrammetric condition monitoring system that is affordable, portable, non-contact, and repeatable. Commercially available camera equipment was used for capture, and readily available or free software was used to generate and detect change between two 3D point clouds. Time-SIFT, an in-software workflow of point cloud alignment, was used as a reliable non-contact method to replace adhered or embedded registration points on the wall to align the clouds from different capture epochs. The technique was able to identify change in the wall paintings, with the smallest verified changes at a scale of 0.5 mm. The results are discussed in relation to their advantages over 2D imaging, the avenues for further research, and the limitations of applying the technique on site. This research demonstrates the potential of photogrammetry as an accessible in situ condition monitoring tool using a workflow and equipment tailored to working on sites with wall paintings. [ABSTRACT FROM AUTHOR]

The care and management of surgical incisional wounds continues to attract both interest and concern, due to continued high rates of surgical site infection (SSI) and morbidity. Novel approaches to objective wound assessment using noninvasive imaging modalities show promise in providing independent, objective wound assessment but only with the proviso that the wound is visible and can be 'seen' by the imaging detector. Methods: An online semi-structured questionnaire was distributed via Survey Monkey to tissue viability nurses. Data was summarised descriptively, with responses relating to participant demographics and use of wound dressings tabulated. Key variables were also cross tabulated to investigate possible associations between variables. An economic analysis was conducted to estimate average weekly costs associated with changing and applying dressings, including both staff and equipment costs. Conclusion: The largest type of dressing products currently in use were nonadherent. Dressing changes took place approximately twice per week: more frequently if wounds were assessed/diagnosed as infected. The majority of wound assessment and dressing changes were undertaken by band 5, 6 or 7 nurses. There is a potential role for non-invasive infrared thermography to stratify risk of later SSI based upon the temperature distribution across wound site and adjacent skin territories. Early and objective interventions for early wound infection can reduce hospital inpatient stay, community visits, antimicrobial usage, patient morbidity and healthcare costs related to wound infection. [ABSTRACT FROM AUTHOR]

Endovascular thrombectomy (EVT) for large vessel occlusion in acute ischaemic stroke is the standard of care when initiated within 6 hours of stroke onset, and is performed between 6--24 hours using advanced neuroimaging (CT perfusion or MR imaging) for patients who meet the strict imaging selection criteria. However, adherence to the restrictive imaging criteria recommended by current guidelines is impeded in many parts of the world, including the UK, by resource constraints and limited access to advanced neuroimaging in the emergency setting. Furthermore, recent randomised and non-randomised studies have demonstrated that patients selected without advanced neuroimaging (with non-contrast CT and CT angiography only) using less restrictive imaging criteria for EVT eligibility beyond 6 hours from onset still benefited from EVT treatment, thereby increasing the proportion of patients eligible for EVT and widening the potential treatment impact at a population level. Hence, current guidelines should be updated expeditiously to reflect the level I evidence in support of more liberal imaging selection criteria for patients presenting with acute ischaemic stroke due to a large vessel occlusion. [ABSTRACT FROM AUTHOR]

Purpose: To estimate prevalence and incidence of diabetic retinopathy (DR) in a UK region by severity between 2012 and 2016 and risk factors for progression to proliferative DR (PDR). Methods: Electronic medical records from people with diabetes (PWD) ≥18 years seen at the Gloucestershire Diabetic Eye Screening Programme (GDESP) and the hospital eye clinic were analysed (HEC). Prevalence and incidence of DR per 100 PWD (%) by calendar year, grade and diabetes type were estimated using log‐linear regression. Progression to PDR and associated risk factors were estimated using parametric survival analyses. Results: Across the study period, 35 873 PWD had at least one DR assessment. They were aged 66 (56–75) years (median (interquartile range)), 57% male, 5 (1–10) years since diabetes diagnosis, 93% Type 2 diabetes. Prevalence of DR decreased from 38.9% (95% CI: 38.1%, 39.8%) in 2012 to 36.6% (95% CI: 35.9%, 37.3%) in 2016 (p < 0.001). Incidence of any DR decreased from 10.9% (95% CI: 10.4%, 11.5%) in 2013 to 8.5% (95% CI: 8.1%, 9.0%) in 2016 (p < 0.001). Prevalence of PDR decreased from 3.5% (95% CI: 3.3%, 3.8%) in 2012 to 3.1% (95% CI 2.9%, 3.3%) in 2016 (p = 0.008). Incidence of PDR did not change over time. HbA1c and bilateral moderate–severe NPDR were statistically significant risk factors associated with progression to PDR. Conclusions: Incidence and prevalence of DR decreased between 2012 and 2016 in this well‐characterized population of the UK. [ABSTRACT FROM AUTHOR]

Partial breast irradiation (PBI) and ultra-hypofractionated whole breast irradiation (uWBI) are contemporary alternatives to conventional and standard hypofractionated whole breast irradiation (WBI), which shorten treatment from 3 to 6 weeks to 1–2 weeks for select patients. PBI and accelerated PBI (APBI) can be delivered with external beam radiation (3D conformal radiation therapy (3D-CRT) or intensity modulated radiation therapy (IMRT)), intraoperative radiation (IORT), or brachytherapy. These new radiation techniques offer the advantage of convenience and lower cost, which ultimately improves access to care. Globally, the COVID 19 pandemic has accelerated APBI/PBI and ultra-hypofractionated regimens into routine practice for carefully selected patients. Recent long-term data from randomized controlled trials (RCTs) have demonstrated these techniques are safe and effective in suitable patients demonstrating equivalent or improved local recurrence, acute/late toxicity, and cosmesis. PBI and APBI should be limited to low risk unifocal invasive ductal carcinoma and ductal carcinoma in situ with tumor size < 2 cm, clear margins (≥2 mm), ER+, and negative nodes. Based on the results from UK Fast-Forward and UK FAST ultra-hypofractionated breast radiation can be safely employed for early stage node negative patients, but is not yet considered an international standard of care. In this review, authors will appraise recent data for these shorter course radiation treatment regimens, as well as, considerations for breast radiologists including surveillance imaging and radiographic findings. • Age ≥ 18 years old, invasive ductal or lobular carcinoma, pTis/T1/T2, node negative, lumpectomy or mastectomy. • Partial breast radiation is safe and effective for suitable patients. • Age >40-50, Stage I (node negative) invasive ductal carcinoma, ER+PR+, grade 1-2 and low risk pure DCIS. • Lobular carcinoma may also benefit, but proceed with caution. • Globally, these shorter course regimens are becoming routine practice due to increased randomized evidence. • Mammogram or DBT should be obtained 6-12 months after completion of RT and yearly thereafter. [ABSTRACT FROM AUTHOR]

Background: Young athletes are thought to be models of peak physical condition, capable of exceptional physical accomplishments. However approximately 64 UK athletes aged 12 to 35 will die each year from a phenomenon known as Sudden Cardiac Death (SCD). SCD can be defined as an unexpected death as a result of abrupt loss of cardiac function within an hour of symptom onset. Undiagnosed heart conditions such as arrhythmias are often found to be the cause of SCD. Advantageous physical attributes found in athletes' hearts can complicate diagnoses as hearts with inherited conditions can appear physiologically similar to hearts adapted to strenuous exercise. Growing research surrounding SCD within sporting populations aims to decrease mortality rates however there is an absence of study specifically into SCD in dance. Within sport, the topic of cardiac screening has generated widespread controversy which is fueled by a lack of empirical evidence. There is currently no international consensus of pre participation cardiac screening methods within dance or sport, potentially leaving many dancers and athletes at risk. Methods: As part of this study, existing material surrounding the topics of SCD and cardiac screening in athletes and dancers was gathered. All existing studies at the time of writing in relation to cardiac screening in athletes and dancers were collected and analysed in order to compare results and evaluate the methodological limitations.This process aimed to identify gaps in current knowledge and research to inform future study. Results: This article aimed to analyze the epidemiology of SCD within sport and dance and to make recommendations for pre-participation screening within dance institutions. The study highlights the need to increase awareness of SCD within the dance community and determine appropriate screening approaches depending on context and setting., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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. [ABSTRACT FROM AUTHOR]

Background: Schizophrenia is a highly heritable disorder with undetermined neurobiological causes. Understanding the impact on brain anatomy of carrying genetic risk for the disorder will contribute to uncovering its neurobiological underpinnings.Aims: To examine the effect of rare copy number variants (CNVs) associated with schizophrenia on brain cortical anatomy in a sample of unaffected participants from the UK Biobank.Method: We used regression analyses to compare cortical thickness and surface area (total and across gyri) between 120 unaffected carriers of rare CNVs associated with schizophrenia and 16 670 participants without any pathogenic CNV. A measure of cortical thickness and surface area covariance across gyri was also compared between groups.Results: Carrier status was associated with reduced surface area (β = -0.020 mm2, P < 0.001) and less robustly with increased cortical thickness (β = 0.015 mm, P = 0.035), and with increased covariance in thickness (carriers z = 0.31 v. non-carriers z = 0.22, P < 0.0005). Associations were mainly present in frontal and parietal areas and driven by a limited number of rare risk alleles included in our analyses (mainly 15q11.2 deletion for surface area and 16p13.11 duplication for thickness covariance).Conclusions: Results for surface area conformed with previous clinical findings, supporting surface area reductions as an indicator of genetic liability for schizophrenia. Results for cortical thickness, though, argued against its validity as a potential risk marker. Increased structural thickness covariance across gyri also appears related to risk for schizophrenia. The heterogeneity found across the effects of rare risk alleles suggests potential different neurobiological gateways into schizophrenia's phenotype. [ABSTRACT FROM AUTHOR]

Introduction: Late stage clinical trials in non-alcoholic steatohepatitis (NASH) are currently required by the FDA to use liver biopsy as a primary endpoint. The well-reported limitations with biopsy, such as associated risks and sampling error, coupled with patient preference, are driving investigation into non-invasive alternatives. MRI-derived biomarkers proton density fat fraction (PDFF) and iron-corrected T1 mapping (cT1) are gaining traction as emerging alternatives to biopsy for NASH. Our aim was to explore the correlations between cT1 and PDFF (from Liver MultiScan ®), with the histological components on the NAFLD-NASH spectrum in a large cohort of cross-sectional data, in order to calibrate the measurement to histology, and to infer what might constitute a clinically meaningful change when related to the FDA's criteria. Materials and Methods: In a retrospective analysis of data combined from three previously published observational NASH studies, in which adult participants who underwent liver biopsy on suspicion of NAFLD or NASH and had an MRI scan measuring cT1 and PDFF (Liver MultiScan ®, Perspectum Ltd, UK), associations between imaging biomarkers and histology were tested using Spearman's rank correlation coefficient (rs), and further exploration of the relationships between the imaging variables and histology were performed using linear regression. Results: N = 264 patients with mean age of 54 (SD:9.9), 39% female, and 69% with BMI ≥ 30kg.m−2 were included in the analysis. cT1 and PDFF both correlated with all features of the NAFLD activity score (NAS). cT1 was also positively correlated with Kleiner-Brunt fibrosis. Partial correlations, adjusting for steatosis, revealed cT1 correlated with inflammation and fibrosis, whereas PDFF did not, and both were still associated with the NAS, but correlation was weaker with PDFF than cT1. An estimated difference of 88 ms in cT1, or 21% relative difference in PDFF was related to a two-point difference in overall NAS. Conclusion: The correlations between cT1 and PDFF with the histopathological hallmarks of NASH demonstrate the potential utility of both cT1 and PDFF as non-invasive biomarkers to detect a pharmacodynamic change in NASH, with cT1 showing superiority for detecting changes in inflammation and fibrosis, rather than liver fat alone. [ABSTRACT FROM AUTHOR]

Purpose: The emergence of the novel SARS-CoV-2 pathogen and lethal COVID-19 disease pandemic poses major diagnostic challenges. The study aims to describe the spectrum and prevalence of thoracic and extrathoracic incidental findings in patients who have undergone 18F-FDG PET/CT during the first 3 weeks of the COVID-19 UK lockdown. Methods: This is a single-centre retrospective controlled observational study. 18F-FDG PET/CT scans (n = 160) acquired from 23/3/2020 to 9/4/2020 were retrospectively reviewed for incidental findings in the lungs and extrapulmonary sites (heart, nasal sinuses, parotid and salivary glands, colon, large vessels, renal cortex, brain, spleen and testes). A date-matched control group (n = 205) of patients from 2019 was used for comparison. Results: The total prevalence of suspicious findings was 26/160 (16.25%). Fifteen patients presented with incidental findings in the lungs, while eleven patients had only non-pulmonary incidental findings. There was a significant increase in the appearance of incidental 18F-FDG PET/CT findings during the 2nd week (OR = 3.8) and 3rd week (OR = 7.6) in relation to the 1st week. There was a significant increase in the average maximum standardised uptake values (SUVmax) in the parotid/salivary glands of patients scanned during week 2 in relation to week 1 (p = 0.036). There was no significant difference in the prevalence of incidental findings compared to the control group, but the number of pulmonary vs. extrathoracic findings was different between the two populations. Conclusion: The study provides a novel base of evidence to identify asymptomatic patients and those without symptoms strongly associated with COVID-19 with incidental 18F-FDG PET/CT findings suspicious of SARS-CoV-2 infection during the initial stages of the pandemic. [ABSTRACT FROM AUTHOR]

Background: Breast cancer is the leading cause of death in women worldwide. Imaging and radiographers play an important role in the diagnosis and treatment of breast cancer. With the increase in demand and a shortage of radiologists in the UK, consultant breast radiographers were introduced to perform some roles previously performed by radiologists. However, there is a scarcity of research to assist other countries, such as Zambia, who are planning to extend the role of radiographers. Objective: To explore the impact and challenges of the radiography consultancy role regarding the delivery of breast imaging services in the United Kingdom. Methods: The study was guided by a qualitative research design. The sample was purposively selected, and semi-structured interviews was used to collect data from consultant breast radiographers in the UK. Data saturation was reached after interviewing eight participants. Interviews were audio-recorded, transcribed and data analysed thematically. Results: Two themes were identified: the impact and challenges of the radiography consultancy role regarding the delivery of imaging breast services. The creation of consultant posts impacted positively on the service delivery: reduction in patient waiting times, career progression and job satisfaction, and reduction in the workload of radiologists. Participants also faced challenges: increased workload and time pressure, isolation and poor support from colleagues, and animosity from a few radiologists. Conclusion: It is evident that consultant breast radiographers have contributed greatly to improved healthcare delivery. However, consultant breast radiographers encounter challenges in their role as consultants. Radiographers undertaking new roles should be supported to improve the delivery of imaging services. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to explore the experiences of consultant breast radiographers regarding breast imaging services in the United Kingdom (UK). Methods: The study used a qualitative research design. Data were collected using semistructured interviews from eight purposively selected consultant breast radiographers across the UK. Interviews were recorded, transcribed, and analyzed by themes. Results: Four themes emerged: Reasons for the introduction of breast consultancy role in radiography, education and training, domain of practice, and autonomy and support. This study found that participants were carrying out roles similar to those performed by consultant breast radiologists and that they had been performing such roles even before they were appointed. The study further revealed that the creation of consultancy posts came because of an increase in demand for breast imaging services and the shortage of radiologists. Four domains of practice were clinical expert, professional leadership, research and evaluation, and education and training. Participants worked independently with adequate support from fellow consultants and non-radiology staff. Conclusion: Consultant breast radiographers are performing most of the consultancy roles stated in their scope of practice, except for research and evaluation, which they are mainly unable to do due to clinical workload. Therefore, there is a need to provide protected time for research and evaluation activities so that consultant breast radiographers can utilize their full potential. The findings have provided baseline information for countries planning to extend the scope of practice of radiographers in breast imaging. [ABSTRACT FROM AUTHOR]

The diagnosis of multiple sclerosis is based on a combination of clinical and paraclinical tests. The potential contribution of retinal optical coherence tomography (OCT) has been recognized. We tested the feasibility of OCT measures of retinal asymmetry as a diagnostic test for multiple sclerosis at the community level. In this community-based study of 72 120 subjects, we examined the diagnostic potential of the inter-eye difference of inner retinal OCT data for multiple sclerosis using the UK Biobank data collected at 22 sites between 2007 and 2010. OCT reporting and quality control guidelines were followed. The inter-eye percentage difference (IEPD) and inter-eye absolute difference (IEAD) were calculated for the macular retinal nerve fibre layer (RNFL), ganglion cell inner plexiform layer (GCIPL) complex and ganglion cell complex. Area under the receiver operating characteristic curve (AUROC) comparisons were followed by univariate and multivariable comparisons accounting for a large range of diseases and co-morbidities. Cut-off levels were optimized by ROC and the Youden index. The prevalence of multiple sclerosis was 0.0023 [95% confidence interval (CI) 0.00229-0.00231]. Overall the discriminatory power of diagnosing multiple sclerosis with the IEPD AUROC curve (0.71, 95% CI 0.67-0.76) and IEAD (0.71, 95% CI 0.67-0.75) for the macular GCIPL complex were significantly higher if compared to the macular ganglion cell complex IEPD AUROC curve (0.64, 95% CI 0.59-0.69, P = 0.0017); IEAD AUROC curve (0.63, 95% CI 0.58-0.68, P < 0.0001) and macular RNFL IEPD AUROC curve (0.59, 95% CI 0.54-0.63, P < 0.0001); IEAD AUROC curve (0.55, 95% CI 0.50-0.59, P < 0.0001). Screening sensitivity levels for the macular GCIPL complex IEPD (4% cut-off) were 51.7% and for the IEAD (4 μm cut-off) 43.5%. Specificity levels were 82.8% and 86.8%, respectively. The number of co-morbidities was important. There was a stepwise decrease of the AUROC curve from 0.72 in control subjects to 0.66 in more than nine co-morbidities or presence of neuromyelitis optica spectrum disease. In the multivariable analyses greater age, diabetes mellitus, other eye disease and a non-white ethnic background were relevant confounders. For most interactions, the effect sizes were large (partial ω2 > 0.14) with narrow confidence intervals. In conclusion, the OCT macular GCIPL complex IEPD and IEAD may be considered as supportive measurements for multiple sclerosis diagnostic criteria in a young patient without relevant co-morbidity. The metric does not allow separation of multiple sclerosis from neuromyelitis optica. Retinal OCT imaging is accurate, rapid, non-invasive, widely available and may therefore help to reduce need for invasive and more costly procedures. To be viable, higher sensitivity and specificity levels are needed. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the study was to describe clinical examination and thoracic CT (TCT) findings in cats after trauma, and to identify physical examination findings associated with both abnormalities on TCT and the need for therapeutic interventions., Methods: A multicentre, retrospective, observational study was conducted. Cats admitted to the participating hospitals with a history of blunt trauma and that underwent TCT were eligible. Data were collected on signalment, history, physical examination, TCT findings and subsequent interventions., Results: In total, 137 cats were included. Road traffic accidents (RTAs) were the most frequently reported cause of trauma (69%). Tachypnoea (32%), pale mucous membranes (22%) and dyspnoea (20%) were the most common abnormal findings on thoracic examination. The most frequently identified thoracic pathologies on TCT were atelectasis (34%), pulmonary contusions (33%), pneumothorax (29%) and pleural effusion (20%). Thoracocentesis was the most commonly performed intervention (12%), followed by chest drain placement (7%). A total of 45 (33%) cats had no physical examination abnormalities but did have abnormalities detected on TCT; six of these cats required interventions. Increasing numbers of thoracic abnormalities on clinical examination were associated with increasing likelihood of having abnormal findings on TCT (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.21-3.44, P  = 0.008) and of requiring an intervention (OR 1.82, 95% CI 1.32-2.51, P <0.001)., Conclusions and Relevance: RTAs were the most common reported cause of blunt trauma. Atelectasis, pulmonary contusions and pneumothorax were the most common abnormalities identified on TCT, and thoracic drainage was the most utilised intervention. TCT may be useful in identifying cats with normal thoracic physical examination findings that have significant thoracic pathology, and a high number of abnormal findings on thoracic examination should raise suspicion for both minor and major thoracic pathology. The results of this study can be used to assist in selecting appropriate cases for TCT after blunt trauma., Competing Interests: Conflict of interestThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

SUMMARY: Addiction is a global health problem with a chronic relapsing nature for which there are few treatment options. In the past few decades, neuroimaging has allowed us to better understand the neurobiology of addiction. Functional neuroimaging paradigms have been developed to probe the neural circuits underlying addiction, including reward, inhibitory control, stress, emotional processing and learning/memory networks. Functional neuroimaging has also been used to provide biological support for the benefits of psychosocial and pharmacological interventions, although evidence remains limited and often inconclusive in this area, which may contribute to the variability in treatment efficacy. In this article, we discuss the changing definitions and clinical criteria that describe and classify addictive disorders. Using examples from functional neuroimaging studies we summarise the neurobiological mechanisms that underpin drug use, dependence, tolerance, withdrawal and relapse. We discuss the links between functional neuroimaging and treatment, outline clinical management in the UK and give an overview of future directions in research and addiction services. [ABSTRACT FROM AUTHOR]

Rationale, Aims, and Objectives: While different imaging and treatment options are available in acute coronary syndrome (ACS) care, there is a lack of data regarding their use across Europe. We examined the diagnostic and treatment strategies in patients with known or suspected ACS as reported by physicians and identified variations in responses across European countries and geographical areas. Method: A web‐based clinician survey focusing on ACS imaging and revascularization treatments was circulated through email distribution lists and websites of European professional societies in the field of cardiology. We collected information on respondents' clinical setting and specialty. Reported percentages of patients receiving imaging or treatment modalities and percentages of clinicians reporting to use modalities in a range of clinical scenarios were analyzed. Statistical comparisons were performed. Results: In total, 69 responses were received (Sweden [n = 20], United Kingdom [n = 16], Northern/Western Europe [n = 17], Southern Europe [n = 9], and Central Europe [n = 7]). Considerable variations between geographical areas were seen in terms of reported diagnostic modalities and treatment strategies. For example, when presented with the scenario of a theoretical 45‐year‐old smoking female with a suspected ACS, 56% of UK clinicians reported to use coronary computed tomography angiography, compared to only 10% of Swedish clinicians (P =.002). Large variations were observed regarding the reported use of fractional flow reserve by physicians for non‐culprit lesions during invasive management of myocardial infarction patients (44% in Sweden, 31% in the United Kingdom, and 30% in Northern/Western Europe vs non‐use in Central and Southern Europe). Conclusions: In this survey, respondents reported different diagnostic and treatment strategies in ACS care. These variations seem to have geographic components. Larger studies or real world data are needed to verify these observations and investigate their causes. More research is needed to compare the quality and efficiency of ACS care across countries and explore pathways for improvement. [ABSTRACT FROM AUTHOR]

Possible School was a research project undertaken with students studying art in a UK secondary school. Used as a research tool, student-initiated practice explored what an image of school might be and how, through those images, school might be constituted differently. In this project, the pre-existent, fixed meaning of the school portrait extends the concept of imaging beyond the production of compliant students who will conform to the normalized reproduction of themselves as school subjects. The image of school and reflection on what it means to be a student become purposeful and powerful modes of exploration, where – through art practice – school might critically show itself to itself. [ABSTRACT FROM AUTHOR]

Approximately 1.4% of emergency medical admissions are due to epileptic seizures. For the majority of such cases, computed tomography (CT) will not inform acute management and is unnecessary. Pseudonymised, routinely collected data from seven hospitals within the Cheshire and Merseyside area of the UK were analysed. All patients with emergency admissions to hospital due to seizures between 2014 and 2017 were included. Use of CT of the head was identified from routine coding. We identified 4,183 individuals with an acute seizure admission, of which over 30% received a CT of the head. There was significant variation in CT among hospital trusts. The rate of CT for patients admitted with seizures is high and CT is not being directed to those where they may be indicated. Integrated care pathways and guidelines are required to improve the management of patients presenting acutely with seizures. [ABSTRACT FROM AUTHOR]

Medial temporal lobe (MTL) atrophy is correlated with risk and severity of Alzheimer disease (AD) pathology and cognitive decline. Increasing evidence suggest that oestrogens affect the aging of MTL structures. Here we investigate the relationship between reproductive hormone exposure, polygenic scores for AD risk and oestradiol concentration, MTL anatomy and cognitive performance in postmenopausal women. To this end, we used data from 10,924 female participants in the UK Biobank from whom brain MRI and genetic data were available. We fitted linear regression models to test whether the volume of structures comprising the MTL were predicted by a) timing related to menopause, b) the use and timing of hormone replacement therapy (HRT) and c) polygenic scores for AD risk and oestradiol concentration. Results showed that longer use of HRT was associated with larger parahippocampal volumes (2.53 mm3/year, p = 0.042). A later age of natural menopause, and a longer reproductive span, was associated with larger hippocampal (6.08 and 5.72 mm3/year, p = 0.0006 and 0.0005), parahippocampal (4.17 mm3 and 4.19 mm3/year, p = 0.00006 and 0.00001), amygdala (2.10 and 2.22 mm3/year, p = 0.028 and 0.01) and perirhinal cortical (2.56 and 2.95 mm3/year, p = 0.028 and 0.008) volumes. Superior prospective memory performance was associated with later age at natural menopause, and a longer reproductive span (ß = 0.05 and 0.05 respectively, p = 0.019 and 0.019). Polygenic scores for AD risk and for oestradiol concentration were not associated with MTL volume and did not interact with menopause-related factors to affect MTL structure. Our results suggest that HRT use did not have any detrimental effects on cognition or brain structure, whilst greater exposure to reproductive hormones across time is associated both with slightly larger volumes of specific MTL structures and marginally superior memory performance, independent of genetic risk for AD and genetic predisposition for higher oestradiol levels. However, the clinical utility of maintenance of oestrogens post-menopause for brain health and protection against cognitive decline is curtailed by the small effect sizes observed. • Later menopause age was associated with larger volume in temporal brain structures. • Longer reproductive span was associated with larger brain temporal volumes. • Later menopause age was associated with better prospective memory. • Longer reproductive span was associated with better prospective memory. • Hormone Replacement therapy was weakly associated with parahippocampal volume. [ABSTRACT FROM AUTHOR]

The number of diagnostic imaging examinations being undertaken in the UK is rising. Due to the expensive nature of producing these examinations and the risks associated with exposing living tissue to the ionising radiation used by many of the imaging techniques, this growth comes with both a financial and a human cost. In a time of limited resources, it is important that we are able to maximise the benefits which we extract from these resources. Therefore, a broad search of the current literature was undertaken to assess our current understanding of the nature of benefit available from diagnostic radiological images. Two broad categories of benefit were identified: primary benefit (n = 470) and secondary benefit (n = 49). Primary benefits are those which are related to the justification for undertaking the imaging, e.g., abnormality detection, to assist in diagnosis or staging, or acting as an aid to clinical decision making, or intervention. Secondary benefits are those that are not related to the justification for imaging, e.g., to promote patient engagement and understanding or to facilitate communication. Existing work considering primary benefits is comprehensive. Secondary benefit, however, is less well recognised and may not be reliably realised. Use of the image to realise these benefits has far-reaching potential. Particularly, there may be underexplored benefits which access to the images may provide to patients. This represents a gap in existing research which should be addressed. [ABSTRACT FROM AUTHOR]

Ischaemic stroke is a treatable medical emergency. In an era of time-dependent reperfusion techniques, it is crucial that an accurate and prompt diagnosis is made. Approximately 30% of patients admitted to hyperacute stroke units are subsequently found not to have a final diagnosis of acute stroke although some of these patients do have incidental or previously symptomatic cerebrovascular disease. These patients do not benefit from thrombolysis and may require the input of other specialists or treatments. Meanwhile, a proportion of patients with acute stroke have unusual presentations and are sometimes initially admitted to general medical admissions units prior to accessing stroke unit care. It is important that atypical presentations of stroke are recognised so that patients are not denied the benefits of stroke unit care and secondary prevention. This article describes some characteristics of common stroke mimics and chameleons, considers how to avoid diagnostic mistakes and discusses the contributory role of imaging. [ABSTRACT FROM AUTHOR]

Rationale & Objective: The incidence of kidney failure is known to increase with age. We have previously developed and validated the use of retinal age based on fundus images as a biomarker of aging. However, the association of retinal age with kidney failure is not clear. We investigated the association of retinal age gap (the difference between retinal age and chronological age) with future risk of kidney failure., Study Design: Prospective cohort study., Setting & Participants: 11,052 UK Biobank study participants without any reported disease for characterizing retinal age in a deep learning algorithm. 35,864 other participants with retinal images and no kidney failure were followed to assess the association between retinal age gap and the risk of kidney failure., Exposure: Retinal age gap, defined as the difference between model-based retinal age and chronological age., Outcome: Incident kidney failure., Analytical Approach: A deep learning prediction model used to characterize retinal age based on retinal images and chronological age, and Cox proportional hazards regression models to investigate the association of retinal age gap with incident kidney failure., Results: After a median follow-up period of 11 (IQR, 10.89-11.14) years, 115 (0.32%) participants were diagnosed with incident kidney failure. Each 1-year greater retinal age gap at baseline was independently associated with a 10% increase in the risk of incident kidney failure (HR, 1.10 [95% CI, 1.03-1.17]; P=0.003). Participants with retinal age gaps in the fourth (highest) quartile had a significantly higher risk of incident kidney failure compared with those in the first quartile (HR, 2.77 [95% CI, 1.29-5.93]; P=0.009)., Limitations: Limited generalizability related to the composition of participants in the UK Biobank study., Conclusions: Retinal age gap was significantly associated with incident kidney failure and may be a promising noninvasive predictive biomarker for incident kidney failure., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Accurate prevalence data are important when interpreting diagnostic tests and planning for the health needs of a population, yet no such data exist for axial spondyloarthritis (axSpA) in the UK. In this cross-sectional cohort study we aimed to estimate the prevalence of axSpA in a UK primary care population.Methods: A validated self-completed questionnaire was used to screen primary care patients with low back pain for inflammatory back pain (IBP). Patients with a verifiable pre-existing diagnosis of axSpA were included as positive cases. All other patients meeting the Assessment of SpondyloArthritis international Society (ASAS) IBP criteria were invited to undergo further assessment including MRI scanning, allowing classification according to the European Spondyloarthropathy Study Group (ESSG) and ASAS axSpA criteria, and the modified New York (mNY) criteria for ankylosing spondylitis (AS).Results: Of 978 questionnaires sent to potential participants 505 were returned (response rate 51.6 %). Six subjects had a prior diagnosis of axSpA, 4 of whom met mNY criteria. Thirty eight of 75 subjects meeting ASAS IBP criteria attended review (mean age 53.5 years, 37 % male). The number of subjects satisfying classification criteria was 23 for ESSG, 3 for ASAS (2 clinical, 1 radiological) and 1 for mNY criteria. This equates to a prevalence of 5.3 % (95 % CI 4.0, 6.8) using ESSG, 1.3 % (95 % CI 0.8, 2.3) using ASAS, 0.66 % (95 % CI 0.28, 1.3) using mNY criteria in chronic back pain patients, and 1.2 % (95 % CI 0.9, 1.4) using ESSG, 0.3 % (95 % CI 0.13, 0.48) using ASAS, 0.15 % (95 % CI 0.02, 0.27) using mNY criteria in the general adult primary care population.Conclusions: These are the first prevalence estimates for axSpA in the UK, and will be of importance in planning for the future healthcare needs of this population.Trial Registration: Current Controlled Trials ISRCTN76873217. [ABSTRACT FROM AUTHOR]

Background: The association of adiposity with prostate cancer specific mortality remains unclear. We examined how adiposity relates to fatal prostate cancer and described the cross-sectional associations of commonly used adiposity measurements with adiposity estimated by imaging in UK Biobank. We also conducted a dose-response meta-analysis to integrate the new data with existing prospective evidence., Methods: 218,237 men from UK Biobank who were free from cancer at baseline were included. Body mass index (BMI), total body fat percentage (using bioimpedance), waist circumference (WC) and waist-to-hip ratio (WHR) were collected at recruitment. Risk of dying from prostate cancer (primary cause) by the different adiposity measurements was estimated using multivariable-adjusted Cox proportional hazards models. Results from this and other prospective cohort studies were combined in a dose-response meta-analysis., Results: In UK Biobank, 661 men died from prostate cancer over a mean follow-up of 11.6 years. In the subsample of participants with magnetic resonance imaging and dual-energy X-ray absorptiometry, BMI, body fat percentage and WC were strongly associated with imaging estimates of total and central adiposity (e.g. visceral fat, trunk fat). The hazard ratios (HR) for prostate cancer death were 1.07 (95% confidence interval = 0.97-1.17) per 5 kg/m 2 higher BMI, 1.00 (0.94-1.08) per 5% increase in total body fat percentage, 1.06 (0.99-1.14) per 10 cm increase in WC and 1.07 (1.01-1.14) per 0.05 increase in WHR. Our meta-analyses of prospective studies included 19,633 prostate cancer deaths for BMI, 670 for body fat percentage, 3181 for WC and 1639 for WHR, and the combined HRs for dying from prostate cancer for the increments above were 1.10 (1.07-1.12), 1.03 (0.96-1.11), 1.07 (1.03-1.11), and 1.06 (1.01-1.10), respectively., Conclusion: Overall, we found that men with higher total and central adiposity had similarly higher risks of prostate cancer death, which may be biologically driven and/or due to differences in detection. In either case, these findings support the benefit for men of maintaining a healthy body weight., (© 2022. The Author(s).)

Aim: To examine the associations of air pollution with both self-reported age-related macular degeneration (AMD), and in vivo measures of retinal sublayer thicknesses., Methods: We included 115 954 UK Biobank participants aged 40-69 years old in this cross-sectional study. Ambient air pollution measures included particulate matter, nitrogen dioxide (NO 2 ) and nitrogen oxides (NO x ). Participants with self-reported ocular conditions, high refractive error (< -6 or > +6 diopters) and poor spectral-domain optical coherence tomography (SD-OCT) image were excluded. Self-reported AMD was used to identify overt disease. SD-OCT imaging derived photoreceptor sublayer thickness and retinal pigment epithelium (RPE) layer thickness were used as structural biomarkers of AMD for 52 602 participants. We examined the associations of ambient air pollution with self-reported AMD and both photoreceptor sublayers and RPE layer thicknesses., Results: After adjusting for covariates, people who were exposed to higher fine ambient particulate matter with an aerodynamic diameter <2.5 µm (PM 2.5 , per IQR increase) had higher odds of self-reported AMD (OR=1.08, p=0.036), thinner photoreceptor synaptic region (β=-0.16 µm, p=2.0 × 10 -5 ), thicker photoreceptor inner segment layer (β=0.04 µm, p=0.001) and thinner RPE (β=-0.13 µm, p=0.002). Higher levels of PM 2.5 absorbance and NO 2 were associated with thicker photoreceptor inner and outer segment layers, and a thinner RPE layer. Higher levels of PM 10 (PM with an aerodynamic diameter <10 µm) was associated with thicker photoreceptor outer segment and thinner RPE, while higher exposure to NO x was associated with thinner photoreceptor synaptic region., Conclusion: Greater exposure to PM 2.5 was associated with self-reported AMD, while PM 2.5 , PM 2.5 absorbance, PM 10 , NO 2 and NO x were all associated with differences in retinal layer thickness., Competing Interests: Competing interests: CR reports employment by Topcon Healthcare Solutions, Inc, outside the submitted work. PJF reports personal fees from Allergan, Carl Zeiss, Google/DeepMind and Santen, a grant from Alcon, outside the submitted work. PJP reports grants from Topcon Inc, outside the submitted work., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract: Aims: To determine the frequency and pattern of metastatic disease as detected by staging computed tomography in patients presenting with locally advanced primary breast cancer, comparing non-inflammatory and inflammatory subtypes. Materials and methods: Patients who underwent staging computed tomography for locally advanced breast cancer were identified from the hospital’s computerised radiology system. The computed tomography scans, breast imaging and pathology were reviewed. Results: Over a 29 month period, 97 patients underwent staging computed tomography for locally advanced primary breast cancer. Sixteen patients (16%) were found to have metastatic disease at presentation. Thirty-eight patients (39%) presented with the inflammatory subtype and 59 patients (61%) with the non-inflammatory subtype. Metastases were significantly more likely in patients with the inflammatory subtype, with 10 patients (26%) having metastases at presentation compared with six patients (10%) with the non-inflammatory subtype (P =0.034). Metastases to the lung and the pleura were the most commonly encountered sites, with pleural-based metastases more likely in patients with the inflammatory subtype (P =0.05). Conclusion: Routine computed tomography staging of patients with locally advanced breast cancer is worthwhile with the inflammatory subtype of locally advanced disease having the higher risk of metastatic disease at presentation. Pleural-based metastatic disease is more likely in patients with the inflammatory subtype. [Copyright &y& Elsevier]

Introduction. District general hospital scanners have historically been linked to regional neuroscience units for specialist opinions on scans and to make decisions on transfer of patients requiring neurosurgical management. The implementation of digital picture archiving and communication systems (PACS) in all hospitals in the UK has disrupted these dedicated links and technical and information governance issues have delayed reprovision of electronic transfer of images for rapid expert decision making in this group of patients. We studied improvement in image transfer to acute neurosurgery units over a 4-year period. Methods. Four-year sequential review of national provision of image transfer facilities into neurosurgery units; observational study of delays associated with image transfer modalities in one representative tertiary referral centre. Results. During the 4 years of study, all hospitals nationally have implemeted digital PACS systems for image viewing. Remote image viewing facilities have gradually changed with dedicated image links being replaced by remote PACS access. However, a minority of referrals (12%) still require images to be physically transferred between hospitals using couriers for CD-ROMs. The detailed study within our own unit shows that this adds a mean delay of 5.8 h to decision making. Conclusions. Image transfer in neuroscience has been neglected following the shift to PACS servers. The recommendations of the 2004 Neuroscience Critical Care Report are unmet and patient safety is being threatened by a continued failure to implement a coordinated solution to this problem. [ABSTRACT FROM AUTHOR]

This retrospective study aimed to evaluate the applicability of the selective approach of imaging infants < 6 months old with urinary tract infection (UTI) according to the UTI guidelines of the National Institute for Health and Clinical Excellence (NICE) 2007. Infants < 6 months old with their first UTI from January 2001 to December 2006 having undergone an ultrasound examination of the urinary tract, a micturating cystourethrogram, and a late di-mercaptosuccinic acid (DMSA) scan, were included. Their condition was evaluated against a set of risk features according to the UTI guidelines. Those having any one of these were classified as atypical and those having none as typical. There were 134 infants reviewed, with a typical (98 infants) to atypical (36 infants) ratio of 2.7 to 1. Girls were found to be relatively more represented in the atypical group [male (M):female (F) = 1.3:1] than in the typical group (M:F = 4.4:1) ( P < 0.004). There were significantly more infants with abnormal micturating voiding cystourethrograms (MCUGs) ( P = 0.007), more refluxing ureters ( P < 0.001) and more significant vesico-ureteral reflux (VUR) (≥ grade III) ( P = 0.013) in the atypical group than in the typical group; while there was no significant difference in ultrasound (US) and DMSA scan findings between the two groups. In the atypical group there was no difference in imaging studies (and, thus, the results) between the conventional practice and the NICE UTI recommendation. In the typical group, if the recommendations of the guidelines had been followed (i.e. only those with abnormal US would have been further investigated), 25 refluxing ureters and 22 scarred kidneys would have been left undiagnosed. In conclusion, application of the suggested selective imaging approach would leave a significant number of VUR and renal scars undiagnosed, and it may not be an optimal practice for infants less than 6 months old with their first UTI. The best approach remains to be clarified. [ABSTRACT FROM AUTHOR]

Pleural empyema in children is increasing in incidence. The British Thoracic Society published guidelines for the management of empyema in children in 2005, including recommendations regarding imaging. In this article we review the pathophysiology, treatment options and imaging findings of complicated parapneumonic effusion and empyema in children. We also review the published evidence that supports the roles imaging is called upon to play in the management of these conditions. Imaging in the form of chest radiography and US is recommended to identify and guide drainage of complicated parapneumonic effusions. CT is recommended in special circumstances only. Imaging techniques have not been shown to accurately stage empyema, predict outcome or guide decisions regarding surgical versus medical management. [ABSTRACT FROM AUTHOR]

Abstract: The chest radiograph is the most commonly requested radiological examination in the UK and the referring clinician often performs the initial interpretation. This contribution provides a methodical reporting routine and the basic information required for interpretation. The technical factors relating to the most frequently performed projections are discussed, and a systematic method for interpretation is suggested in order to aid the assessment of unfamiliar appearances and to reduce errors. The radiological anatomy of the chest radiograph and the various common pathological processes that affect it are described. The pathology and appearances of consolidation, pleural effusions, pulmonary collapse, nodules and masses are discussed. The key points of interpretation in several surgical scenarios are described. [Copyright &y& Elsevier]

Twenty-three thousand doctors in the UK have undertaken The Advanced Trauma Life Support Course for doctors over the past 12 years. The course was never designed to provide anything more than a framework within which inexperienced doctors could safely manage multiple injured patients until expert help arrived. Its critics will say that the course is didactic and its treatment protocols are not always up to date. Since its inception in 1976 in Nebraska it has undergone constant revision and the seventh edition of the course will appear in 2002. With each revision, evidence for new methods of management for the trauma victims are reviewed; some of these are discussed in this paper. [ABSTRACT FROM AUTHOR]

`Mild' head injury is increasingly recognized as a potential source of physical and psychological disability, but there is a lack of consistency about the definition and management of these patients. We discuss and define the terms `mild' and `minor', the assessment of post-traumatic amnesia, and the relevance of other signs and symptoms. Previous guidelines and recent evidence that a `mild' injury may be followed by an intracranial complication are reviewed as a basis for recommendations for investigation and management in accident and emergency departments, for in-patient observation and for discharge planning. [ABSTRACT FROM AUTHOR]

Adrenal tumors are commonly discovered incidentally on cross-sectional abdominal imaging performed for reasons other than adrenal mass. Incidence of adrenal tumors increased 10-fold in the past 2 decades, with most diagnosed in older adults. In any patient with a newly discovered adrenal mass, determining whether the adrenal mass is malignant and whether it is hormonally active is equally important to guide the best management. Malignancy is diagnosed in 5% to 8% of patients with adrenal tumors, with a higher risk in young patients, if history of extra-adrenal malignancy, in those with large adrenal tumors with indeterminate imaging characteristics, and in bilateral adrenal tumors. Although overt hormone excess is uncommon in adrenal incidentalomas, mild autonomous cortisol secretion can be diagnosed in up to 30% to 50% of patients. Because autonomous cortisol secretion is associated with increased cardiovascular morbidity and metabolic abnormalities, all patients with adrenal incidentalomas require work up with dexamethasone suppression test. Management of adrenal tumors varies based on etiology, associated comorbidities, and patient's preference. This article reviews the current evidence on the diagnosis and evaluation of patients with adrenal mass and focuses on management of the most common etiologies of adrenal incidentalomas., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Excessive alcohol consumption is associated with damage to various organs, but its multi-organ effects have not been characterised across the usual range of alcohol drinking in a large general population sample., Methods: We assessed global effect sizes of alcohol consumption on quantitative magnetic resonance imaging phenotypic measures of the brain, heart, aorta, and liver of UK Biobank participants who reported drinking alcohol., Results: We found a monotonic association of higher alcohol consumption with lower normalised brain volume across the range of alcohol intakes (-1.7 × 10 -3 ± 0.76 × 10 -3 per doubling of alcohol consumption, p=3.0 × 10 -14 ). Alcohol consumption was also associated directly with measures of left ventricular mass index and left ventricular and atrial volume indices. Liver fat increased by a mean of 0.15% per doubling of alcohol consumption., Conclusions: Our results imply that there is not a 'safe threshold' below which there are no toxic effects of alcohol. Current public health guidelines concerning alcohol consumption may need to be revisited., Funding: See acknowledgements., Competing Interests: EE E.E. acknowledges consultancy fees from OpenDNA, HS, WB, RP, HG, PE No competing interests declared, PM PM acknowledges consultancy fees from Roche, Adelphi Communications, Celgene and Biogen. He has received honoraria or speakers' honoraria from Novartis, Biogen, Medscape, Adelphi Communications and Roche and has received research or educational funds from Biogen, Novartis, GlaxoSmithKline and Nodthera., (© 2021, Evangelou et al.)

Introduction: Despite scaphoid fractures being relatively uncommon pro-active treatment of suspected fractures has been seen as a risk management strategy. The poor positive predictive value of X-rays has led to published guidelines advocating MRI as a first-line or early imaging tool. It is unclear whether UK hospitals have been able to introduce early scanning and this national survey sought to establish the current management strategies for patients with a suspected scaphoid fracture., Method: An electronic survey of UK emergency departments (ED) was conducted to establish the initial and follow up strategies for patients with negative imaging. Comparison of first and second-line imaging modalities was undertaken together with review of the clinical speciality responsible for ongoing management., Results: 166 UK NHS Trusts were identified with emergency department facilities of which 66 (39.8%) responded. All sites perform an X-ray as the initial examination. For those with a negative examination ED follow up was the most common approach (54.6%), although many sites refer patients to other specialities including orthopaedics (39.4%) for follow up. The data demonstrated inconsistencies in the number of follow-up episodes and the different imaging investigations utilised. Frustration with the challenges presented by this patient cohort was evident., Conclusion: The suspected scaphoid fracture represents an ongoing challenge to the NHS with many resource intensive pathways reliant on access to complex imaging investigations., Implications for Practice: Our study identified that UK Emergency Departments have limited early access to complex imaging for scanning of the scaphoid. A range of strategies are used for follow up of suspected scaphoid fractures and these are resource intensive. Overtreatment of patients with suspected scaphoid fracture is used as a risk management approach., (Copyright © 2020 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Background: Early tranexamic acid (TXA) treatment reduces head injury deaths after traumatic brain injury (TBI). We used brain scans that were acquired as part of the routine clinical practice during the CRASH-3 trial (before unblinding) to examine the mechanism of action of TXA in TBI. Specifically, we explored the potential effects of TXA on intracranial haemorrhage and infarction., Methods: This is a prospective substudy nested within the CRASH-3 trial, a randomised placebo-controlled trial of TXA (loading dose 1 g over 10 min, then 1 g infusion over 8 hours) in patients with isolated head injury. CRASH-3 trial patients were recruited between July 2012 and January 2019. Participants in the current substudy were a subset of trial patients enrolled at 10 hospitals in the UK and 4 in Malaysia, who had at least one CT head scan performed as part of the routine clinical practice within 28 days of randomisation. The primary outcome was the volume of intraparenchymal haemorrhage (ie, contusion) measured on a CT scan done after randomisation. Secondary outcomes were progressive intracranial haemorrhage (post-randomisation CT shows >25% of volume seen on pre-randomisation CT), new intracranial haemorrhage (any haemorrhage seen on post-randomisation CT but not on pre-randomisation CT), cerebral infarction (any infarction seen on any type of brain scan done post-randomisation, excluding infarction seen pre-randomisation) and intracranial haemorrhage volume (intraparenchymal + intraventricular + subdural + epidural) in those who underwent neurosurgical haemorrhage evacuation. We planned to conduct sensitivity analyses excluding patients who were severely injured at baseline. Dichotomous outcomes were analysed using relative risks (RR) or hazard ratios (HR), and continuous outcomes using a linear mixed model., Results: 1767 patients were included in this substudy. One-third of the patients had a baseline GCS (Glasgow Coma Score) of 3 (n=579) and 24% had unilateral or bilateral unreactive pupils. 46% of patients were scanned pre-randomisation and post-randomisation (n=812/1767), 19% were scanned only pre-randomisation (n=341/1767) and 35% were scanned only post-randomisation (n=614/1767). In all patients, there was no evidence that TXA prevents intraparenchymal haemorrhage expansion (estimate=1.09, 95% CI 0.81 to 1.45) or intracranial haemorrhage expansion in patients who underwent neurosurgical haemorrhage evacuation (n=363) (estimate=0.79, 95% CI 0.57 to 1.11). In patients scanned pre-randomisation and post-randomisation (n=812), there was no evidence that TXA reduces progressive haemorrhage (adjusted RR=0.91, 95% CI 0.74 to 1.13) and new haemorrhage (adjusted RR=0.85, 95% CI 0.72 to 1.01). When patients with unreactive pupils at baseline were excluded, there was evidence that TXA prevents new haemorrhage (adjusted RR=0.80, 95% CI 0.66 to 0.98). In patients scanned post-randomisation (n=1431), there was no evidence of an increase in infarction with TXA (adjusted HR=1.28, 95% CI 0.93 to 1.76). A larger proportion of patients without (vs with) a post-randomisation scan died from head injury (38% vs 19%: RR=1.97, 95% CI 1.66 to 2.34, p<0.0001)., Conclusion: TXA may prevent new haemorrhage in patients with reactive pupils at baseline. This is consistent with the results of the CRASH-3 trial which found that TXA reduced head injury death in patients with at least one reactive pupil at baseline. However, the large number of patients without post-randomisation scans and the possibility that the availability of scan data depends on whether a patient received TXA, challenges the validity of inferences made using routinely collected scan data. This study highlights the limitations of using routinely collected scan data to examine the effects of TBI treatments., Trial Registration Number: ISRCTN15088122., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form and declare: AM received a PhD Studentship from the Clinical Trials Unit (LSHTM) from September 2015 to February 2020; A Belli received grants from the Medical Research Council (MRC) and National Institute for Health Research (NIHR) during the conduct of this study; CL is an Associate Editor for the Emergency Medicine Journal; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Patients taking direct oral anticoagulants (DOACs) commonly undergo CT head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK National Institute for Health and Care Excellence head injury guideline group., Methods: An observational cohort study was performed in the UK South Yorkshire major trauma centre between 26 June and 3 September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and ED information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery, ICH or death due to head injury. A previously published meta-analysis was updated with the current results and the findings of other recent studies., Results: 148 patients with minor head injury were included (GCS 15, n=107, 72%; GCS 14, n=41, 28%). Patients were elderly (median 82 years) and most frequently injured from ground level falls (n=142, 96%). Overall risk of adverse outcome was 3.4% (5/148, 95% CI 1.4% to 8.0%). Five patients had ICH, of whom one died within 30 days. One patient was treated with prothrombin complex concentrate but no patient received critical care management or underwent neurosurgical intervention. Updated random effects meta-analysis, including the current results and two further recent studies, showed a weighted overall risk of adverse outcome of 3.2% (n=29/787, 95% CI 2.0% to 4.4%)., Conclusions: The risk of adverse outcome following mild head injury in patients taking DOACs appears low. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury while taking DOACs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The purpose of this paper is to understand the barriers and enablers to lean implementation as part of an imaging quality improvement programme from a socio-cultural perspective., Design/methodology/approach: An in-depth 33 month ethnographic study, using observation and qualitative interviews, examined the process of lean implementation as part of an improvement programme., Findings: Implementation of lean was more successful compared with other reports of lean in healthcare settings. Key enablers of lean were high levels of multidisciplinary staff involvement and engagement; the professional credibility of facilitators and clinicians as early adopters, all within a wider culture of relatively strong inter-professional relationships in the imaging department. These enablers combined with the more routinised and standardised nature of imaging pathways compared to some other acute specialties suggest that imaging is fertile ground for lean, linked to the manufacturing origins of lean., Practical Implications: When introducing lean within healthcare settings, special attention needs to be paid to the specific healthcare context and the existing cultures of inter-professional relationships. Fostering an improvement culture and engagement with training, together with adequate financial resource, are a key to contributing to the level of acceptability of an improvement tool such as lean., Originality/value: This ethnographic study, bringing together rich multi-source data, has provided a detailed insight into the cultural workings of the process of lean implementation within a complex healthcare system., (© Emerald Publishing Limited.)

The current COVID-19 pandemic is causing diagnostic and risk stratification difficulties in Emergency Departments (ED) worldwide. Molecular tests are not sufficiently sensitive, and results are usually not available in time for decision making in the ED. Chest x-ray (CXR) is a poor diagnostic test for COVID-19, and computed tomography (CT), while sensitive, is impractical as a diagnostic test for all patients. Lung ultrasound (LUS) has an established role in the evaluation of acute respiratory failure and has been used during the COVID-19 outbreak as a decision support tool. LUS shows characteristic changes in viral pneumonitis, and while these changes are not specific for COVID-19, it may be a useful adjunct during the diagnostic process. It is quick to perform and repeat and may be done at the bedside. The authors believe that LUS can help to mitigate uncertainty in undifferentiated patients with respiratory symptoms. This review aims to provide guidance regarding indications for LUS, describe the typical sonographic abnormalities seen in patients with COVID-19 and provide recommendations around the logistics of performing LUS on patients with COVID-19 and managing the infection control risk of the procedure. The risk of anchoring bias during a pandemic and the need to consider alternative pathologies are emphasised throughout this review. LUS may be a useful point-of-care test for emergency care providers during the current COVID-19 pandemic if used within a strict framework that governs education, quality assurance and proctored scanning protocols., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Background/aims: Prospective data on switching anti-vascular endothelial growth factors in patients with neovascular age-related macular degeneration (nAMD) who have previously shown no/partial response are limited. This prospective study assessed the effect of switching from aflibercept to ranibizumab on anatomical and functional outcomes in patients with persistent/recurrent disease activity., Methods: SAFARI (NCT02161575) was a 6-month, prospective, single-arm study conducted in the UK and Germany. Patients, meeting strict eligibility criteria for one of two subgroups (primary treatment failure or suboptimal treatment response), received 3 monthly intravitreal ranibizumab injections (0.5 mg). Thereafter, ranibizumab was administered pro re nata at monthly visits. The primary endpoint was change from baseline (CfB) to day 90 in central subfield retinal thickness (CSRT). Best-corrected visual acuity (BCVA) and retinal morphology parameters were assessed., Results: One hundred patients were enrolled (primary treatment failure, 1; suboptimal treatment response, 99). In the overall population, there was a significant CfB in median CSRT of -30.75 µm (95% CI -59.50,-20.50; p<0.0001) to day 90. Improvements were also observed in other quantitative and qualitative optical coherence tomography parameters. In Early Treatment Diabetic Retinopathy Study letters assessed by category, 55% and 59% of patients gained 0-≥15 letters versus baseline at day 90 and day 180, respectively. However, mean improvements in BCVA (CfB) to each time point were small (≤2 letters). No new safety signals were identified., Conclusion: Switching from aflibercept to ranibizumab led to a significant improvement in CSRT, with ~60% experiencing stabilised/improved BCVA. Therefore, patients with nAMD who have shown a suboptimal response to aflibercept may benefit from switching to ranibizumab., Competing Interests: Competing interests: RPG: consultancy, educational grants and institutional research grants for Novartis and Bayer; IP: speakers’ fees, consulting fees and travel support from Novartis and Bayer; NE: grant/research support from Novartis and Bayer; speakers’ honoraria from: Novartis, Bayer, Allergan and Heidelberg Engineering; Advisory board member for: Novartis, Bayer, Allergan, Bausch and Lomb, Alimera Sciences and Roche; consultancy fees from Bayer; FG: consultant for Novartis and Bayer; advisory board member for Novartis and Bayer; speakers’ fees and research support from Bayer; FGH: financial support from: Acucela, Allergan, Bayer, Bioeq, CenterVue, Hoffmann-La Roche/Genentech, Heidelberg Engineering, Novartis, and Zeiss; Consultant for Acucela, Alcon, Bayer, Boehringer-Ingelheim, Hoffmann-La Roche/Genentech, Grayburg Vision, Heidelberg Engineering, Lin Bioscience, Novartis, Stealth Biotherapeutics, and Zeiss; SS-V: financial support from: Acucela, Alcon/Novartis, Allergan, Bayer, Bioeq/Formycon, Carl Zeiss MedicTec, CenterVue, Hoffman-La Roche/Genentech, Heidelberg Engineering, Katairo and Optos; consultant for: Alcon/Novartis, Bioeq/Formycon and Galimedix Therapeutics; recipient of gifts, honoraria, travel reimbursement, patent royalties and/or any other financial compensation from: Alcon/Novartis, Allergan, Bayer, Carl Zeiss MedicTec and Hoffmann-La Roche/Genentech; KB: travel grants and speakers’ fees from: Novartis, Bayer, Alimera, Topcon and Heidelberg Engineering; research grants from Novartis and Bayer; BJLB: advisory board and international conference attendance sponsored by Novartis and Bayer; SD: principal investigator on trials sponsored by: Novartis, Bayer, Roche, and Ely Lilly; speakers’ honoraria from: Novartis, Bayer, Roche and/or Eli Lilly; conference and travel support from Novartis and Eli Lilly; consultant for Hakko Kyowa and Circadian Therapeutics; grant/research support from Novartis; HE: travel grants and speakers’ fees from Novartis; advisory board member for Novartis; SG: speakers’ fees from Hoffman-La Roche and Novartis; advisory board member for, and travel grants from Bayer; DFG: travel grants from Novartis and Bayer; speakers’ fees from Novartis; RH: research support and travel grants from, and advisory board member for Novartis, Bayer, Allergan, and Ellex; AL: travel support to attend educational meetings from Bayer; NP: grant support and travel grants from Novartis and Bayer; PP: none declared; CS: speakers’ fees, consulting fees, conference and travel support from Novartis and Bayer; ST: travel grant and conference registration from Bayer; DV: travel grants from Novartis, Bayer and Allergan; Advisory board member for: Allergan, Novartis, Bayer, Alcon and Polyphotonix; investigator on clinical trials sponsored or funded by: Novartis, Bayer, Hoffmann-La Roche and Allergan; Speakers’ fees from Bayer and Novartis; GW: advisory board member for, and support to attend conferences from Novartis and Bayer; MAW: travel grants from Novartis, Bayer and Allergan; recipient of grant to develop medical education material on ophthalmology; AW: consulting fees from Novartis and Bayer; speakers’ fees from Novartis; advisory board member for Novartis; travel grants from Bayer; research support from Novartis and Bayer; RHZ: none declared; FI: employee of Novartis Pharmaceuticals UK Ltd; FA: employee of Novartis Pharmaceuticals UK Ltd., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Neurodevelopmental impairment has become the most important comorbidity in infants with congenital heart disease (CHD). We aimed to (1) investigate the burden of brain lesions in infants with CHD prior to surgery and (2) explore clinical factors associated with injury., Study Design: Prospective observational study., Setting: Single centre UK tertiary neonatal intensive care unit., Patients: 70 newborn infants with critical or serious CHD underwent brain MRI prior to surgery., Main Outcome Measures: Prevalence of cerebral injury including arterial ischaemic strokes (AIS), white matter injury (WMI) and intracranial haemorrhage., Results: Brain lesions were observed in 39% of subjects (95% CI 28% to 50%). WMI was identified in 33% (95% CI 23% to 45%), subdural haemorrhage without mass effect in 33% (95% CI 23% to 45%), cerebellar haemorrhage in 9% (95% CI 4% to 18%) and AIS in 4% (95% CI 1.5% to 12%). WMI was distributed widely throughout the brain, particularly involving the frontal white matter, optic radiations and corona radiata. WMI exhibited restricted diffusion in 48% of cases. AIS was only observed in infants with transposition of the great arteries (TGA) who had previously undergone balloon atrial septostomy (BAS). AIS was identified in 23% (95% CI 8% to 50%) of infants with TGA who underwent BAS, compared with 0% (95% CI 0% to 20%) who did not., Conclusions: Cerebral injury in newborns with CHD prior to surgery is common., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Detection of large vessel occlusion (LVO) is required for endovascular therapy in acute ischemic stroke (AIS) but CT angiography (CTA) is not always performed at primary stroke centers. Eye deviation on CT brain has been associated with improved stroke detection, but comparisons with angiographic status have been limited. This study sought to determine if radiological eye deviation was associated with LVO., Methods: All AIS patients given intravenous thrombolysis who had acute CTA performed in 2 stroke units were reviewed over 2013-2015 for the presence of LVO. Eye deviation was determined by 2 clinicians blinded to LVO status. Logistic regression was performed to determine which factors predicated LVO., Results: Total 195 AIS patients with acute CTA were identified; 124 (64%) had LVO. Median age was 72 (IQR 64-82) years, median National Institutes of Health Stroke Scale (NIHSS) was 12 (IQR 7-14). LVO patients had a higher NIHSS (15 versus 7, p < .01) and were more likely to have eye deviation on CT brain (71% versus 22.5%, p < .01). Logistic regression confirmed NIHSS score and eye deviation were associated with LVO, with odds ratios of 1.15 (per point) and 5.13 respectively. NIHSS less than equal to 11 gave greatest sensitivity (78.5%) and specificity (76.1%) for LVO with a positive predictive value of 84.7%. Eye deviation was similar with sensitivity 71%, specificity 77.5%, and 84.6%., Conclusions: Eye deviation on CT brain is strongly associated with LVO. Presence of eye deviation on CT should alert clinicians to probability of LVO and for formal angiographic testing if not already performed., (Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Screening for Barrett's esophagus (BE) with conventional esophagogastroduodenoscopy (C-EGD) is expensive. We assessed the performance of a clinic-based, single use transnasal capsule endoscope (EG Scan II) for the detection of BE, compared to C-EGD as the reference standard., Methods: We performed a prospective multicenter cohort study of patients with and without BE recruited from 3 referral centers (1 in the United States and 2 in the United Kingdom). Of 200 consenting participants, 178 (89%) completed both procedures (11% failed EG Scan due to the inability to intubate the nasopharynx). The mean age of participants was 57.9 years and 67% were male. The prevalence of BE was 53%. All subjects underwent the 2 procedures on the same day, performed by blinded endoscopists. Patients completed preference and validated tolerability (10-point visual analogue scale [VAS]) questionnaires within 14 days of the procedures., Results: A higher proportion of patients preferred the EG Scan (54.2%) vs the C-EGD (16.7%) (P < .001) and the EG Scan had a higher VAS score (7.2) vs the C-EGD (6.4) (P = .0004). No serious adverse events occurred. The EG Scan identified any length BE with a sensitivity value of 0.90 (95% CI, 0.83-0.96) and a specificity value of 0.91 (95% CI, 0.82-0.96). The EG Scan identified long segment BE with a sensitivity value of 0.95 and short segment BE with a sensitivity values of 0.87., Conclusions: In a prospective study, we found the EG Scan to be safe and to detect BE with higher than 90% sensitivity and specificity. A higher proportion of patients preferred the EG Scan to C-EGD. This device might be used as a clinic-based tool to screen populations at risk for BE. ISRCTN registry identifier: 70595405; ClinicalTrials.gov no: NCT02066233., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: The UK's National Health Service (NHS) is currently subject to unprecedented financial strain. The identification of unnecessary healthcare resource use has been suggested to reduce spending. However, there is little very research quantifying wasteful test use, despite the £3 billion annual expenditure. Geographical variation has been suggested as one metric in which to quantify inappropriate use. We set out to identify tests ordered from UK primary care that are subject to the greatest between-practice variation in their use., Methods: We used data from 444 general practices within the Clinical Practice Research Datalink to calculate a coefficient of variation (CoV) for the ordering of 44 specific tests from UK general practices. The coefficient of variation was calculated after adjusting for differences between practice populations. We also determined the tests that had both a higher-than-average CoV and a higher-than-average rate of use., Results: In total, 16,496,218 tests were ordered for 4,078,091 patients over 3,311,050 person-years from April 1, 2015, to March 31, 2016. The tests subject to the greatest variation were drug monitoring 158% (95%CI 153 to 163%), urine microalbumin (52% (95%CI 49.9 to 53.2%)), pelvic CT (51% (95%CI 50 to 53%)) and Pap smear (49% (95%CI 48 to 51%). Seven tests were classified as high variability and high rate (clotting, vitamin D, urine albumin, prostate-specific antigen (PSA), bone profile, urine MCS and C-reactive protein (CRP))., Conclusions: There are wide variations in the use of common tests, which is unlikely to be explained by clinical indications. Since £3 billion annually are spent on tests, this represents considerable variation in the use of resources and inefficient management in the NHS. Our results can be of value to policy makers, researchers, patients and clinicians as the NHS strives towards identifying overuse and underuse of tests.

Background: The increasing incidence of medical retinal diseases has created capacity issues across UK. In this study, we describe the implementation and outcomes of virtual medical retina clinics (VMRCs) at Moorfields Eye Hospital, South Division, London. It represents a promising solution to ensure that patients are seen and treated in a timely fashion METHODS: First attendances in the VMRC (September 2016-May 2017) were included. It was open to non-urgent external referrals and to existing patients in a face-to-face clinic (F2FC). All patients received visual acuity testing, dilated fundus photography and optical coherence tomography scans. Grading was performed by consultants, fellows and allied healthcare professionals. Outcomes of these virtual consultations and reasons for F2FC referrals were assessed., Results: A total number of 1729 patients were included (1543 were internal and 186 external referrals). The majority were diagnosed with diabetic retinopathy (75.1% of internal and 46.8% of external referrals). Of the internal referrals, 14.6% were discharged, 54.5% continued in VMRC and 30.9% were brought to a F2FC. Of the external referrals, 45.5% were discharged, 37.1% continued in VMRC and 17.4% were brought to a F2FC. The main reason for F2FC referrals was image quality (34.7%), followed by detection of potentially treatable disease (20.2%)., Conclusion: VMRC can be implemented successfully using existing resources within a hospital eye service. It may also serve as a first-line rapid-access clinic for low-risk referrals. This would enable medical retinal services to cope with increasing demand and efficiently allocate resources to those who require treatment., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)