David Naumann

Radiation exposure during paediatric emergency CT: Time we took notice?

INTRODUCTION Concerns exist about radiation exposure during medical imaging. Comprehensive computerised tomography (CT) dose standards exist for adults, but are incomplete for children. We investigated paediatric CT radiation doses at a NHS Trust in order to define the extent of the risk. METHODS CT dose indicators (CTDI) were recorded for all scans on paediatric patients from January - December 2011 and benchmarked against American College of Radiologists reference levels (75 mGy for adult head, 25 mGy for adult abdomen, and 20 mGy for paediatric (5-year-old) abdomen). Size-specific dose estimates (SSDE) were calculated based on effective patient diameter as recommended by the American Association of Physicists in Medicine. Student t-test was used to compare CTDI and SSDE values for each anatomical region. RESULTS Of 53,648 paediatric emergency presentations, CT was requested in 211 (0.39%). One hundred fifty-four patients underwent 169 scans, with the rest being cancelled for clinical improvement or senior overrule. Indication for CT was trauma in 130/154 (90%), of which 55% were after falls, 19% following road traffic collisions, 12% after sporting injury, and 12% after alleged assault. CTDI values were available for 96/169 (57%) scans, with the rest lacking sufficient data. There was no significant difference between CTDI and derived SSDE values. 3% of head scans exceeded the adult head reference level. CONCLUSION There is wide variation in radiation exposure during paediatric trauma CT, with some scans delivering doses in excess of recommended adult values. There is an urgent need to define standards for radiation dose in paediatric CT for all ages and anatomical regions.

Differences in screening vs. non‐screening colonoscopy: scope for improvement?

Colonoscopy performed as part of the NHS Bowel Cancer Screening Programme (BCSP) is of high standard as measured using global rating scale (GRS) criteria. Screening practitioners also provide a non‐screening colonoscopy service. The current study compares colonoscopy quality indicators between screening and non‐screening groups performed by a single practitioner using the GRS.

The Director's Cut – video editing as a training modality for minimally invasive surgery

Since recent reductions in training hours mandated by the Accredication Council for Graduate Medical Education (ACGME) in the United States, and the EuropeanWorkingTimeDirective(EWTD)inEurope, there has been widespread controversy and concern regarding the perceived detrimental effects to surgical training from fewer working hours (1,2). Newer and more time-efficient techniques for training have therefore been suggested to compensate for this, such as simulation training (3), and the production of audiovisual learning tools (4). With regards to minimally invasive surgery, utilisation of validated virtual reality and virtual trainer models may be beneficial in this modern era of surgical training (5,6). Such ‘virtual’ techniques may train a surgeonwhilst avoiding risk to patients from the learning curve involved with the acquisition of complex psychomotor skills (7). However, training for laparoscopic surgery cannot simply be condensed into the mastery of sensorimotor feedback based on procedural tasks. Instead it must also incorporate the subtle visual sense of the real life tissue planes, contrasts and colours – sensory stimuli that may only be learnt from real tissues.Withthis inmind,weadvocateanadditional training modality for laparoscopic training: The use of video editing for trainees. Commonly laparoscopic trainees begin their basic training by holding the camera for a more senior surgeon to operate. The development and acquisition of skills of the trainee take them on a pathway over time from only holding the camera and watching the operation (relatively passive), to performing tasks under supervision (active), to eventually performing the entire operation – a pathway that may be modular in nature (8,9). However, the understanding of the acquisition and decay of laparoscopic skills is incomplete (10). Nevertheless, before a trainee embarks on the transition between passive and active phases, it is vital that they understand the steps and anatomy of the operation, and have seen it many times. Editing a recorded video of the same operation compels the editor to watch it in parts many times until they have created a smooth, seamless and compressed video of the procedure. There is an added advantage that the trainee must view and delete unnecessary movements, whilst repeatedly viewing the useful movements. Critical stages of an operation, such as the identification and dissection of correct tissue planes, and the skeletonising and clipping of vessels will be seen many times by the trainee when editing. The same operation may therefore act as a proxy for dozens of operations where the trainee might be simply holding the camera. Furthermore, when the trainee progresses to actively performing parts of the operation, it may also be useful for them to retrospectively edit their own videos. Again, useful and non useful physical movements can be repeatedly re-lived by the trainee in their own time, with the aim of reviewing the former and deleting the latter – a kind of retrospective visuomotor feedback which can be utilised by the trainee on the next occasion that they perform that operation. In the modern epoch of electronic record keeping, with surgical portfolios such as that hosted by the

Heterogeneity in practice during negative scrotal exploration for clinically-suspected testicular torsion

Diagnostic uncertainty, inadequate training and inexperience could lead to surgeons performing unnecessary orchidopexy during negative scrotal exploration for suspected testicular torsion. In the present study, we aimed to examine current practice, in order to highlight areas for improvement and focused guideline recommendations.

Pouch dysfunction: don't forget the surgeons!

We read the article ‘Pouchitis: a practical guide’1 with great interest, and support the authors’ efforts to simplify the management of patients with ileal pouch dysfunction. In particular, we agree that a diagnosis of pouchitis must not be presumptive, but should be made based on clinical, histological and endoscopic findings, and that pouch complications are best defined as a deviation from normal pouch function. Although their well considered algorithm is comprehensive from a gastroenterologists perspective, Steinhart and Ben-Bassat1 have rather skated over crucial elements that inform a surgeons practice. Although pouchitis is the most common long-term complication of ileal pouch–anal anastomosis (IPAA), there are several ‘surgical’ entities that have similar presenting symptoms and signs, such as pelvic sepsis, fistulae, abscesses, strictures, sinuses and cuffitis. The timely diagnosis and treatment of these …