Mohammed Abdul Waduud

Validation of a semi-automated technique to accurately measure abdominal fat distribution using CT and MRI for clinical risk stratification

OBJECTIVE A valid method for accurate quantification of abdominal fat distribution (AFD) using both CT and MRI is described. This method will be primarily useful in the prospective risk stratification of patients undergoing reconstructive breast surgery. Secondary applications in many other clinical specialities are foreseen. METHODS 15 sequential patients who had undergone breast reconstruction following both CT and MRI (30 scans) were retrospectively identified at our single centre. The AFD was quantified at the level of the L3 vertebra. Image analysis was performed by at least two independent operators using free software. Intra- and interobserver differences were assessed using Bland-Altman plots. Data were validated between imaging modalities by Pearsons correlation. Linear regression analyses were used to mathematically normalize results between imaging modalities. RESULTS The method was statistically independent of rater bias (intra: Pearsons R-0.954-1.00; inter: 0.799-0.999). Strong relationships between imaging modalities were demonstrated and are independent of time between imaging (Pearsons R 0.625-0.903). Interchangeable mathematical models to normalize between imaging modality are shown. CONCLUSION The method described is highly reproducible and independent of rater bias. A strong interchangeable relationship exists between calculations of AFD on retrospective CT and MRI. Advances in knowledge: This is the first technique to be applicable to scans that are not performed sequentially or in a research setting. Analysis is semi-automated and results can be compared directly, regardless of imaging modality or patient position. This method has clinical utility in prospective risk stratification and will be applicable to many clinical specialities.

Basic surgical skills course - Why is it so costly?

Highlights • Courses can be expensive and are often criticised for the transparency of associated costs.• It is important to appreciate the organisational costs of running high quality courses.• The three Royal Colleges in the UK do not use courses as profit making vehicles.

Compensatory impingement of the dorsalis pedis artery in a property developer

A 46-year-old self-employed property developer, under surveillance for a thrombosed left dorsalis pedis artery (DPA) secondary to impingement, presented with a 4-month history of discomfort and numbness of the right foot. Symptoms were most marked whilst kneeling (Panel A). He had no other co-morbidities, although he weighed 123 kg. On examination, pallor of the plantar aspect of the left foot was evident after a period of standing, despite angiographic evidence of a patent posterior tibial artery and medial and lateral plantar arches. Magnetic resonance angiography of both legs in the neutral position demonstrated no significant disease of vessels proximal to the foot. Duplex ultrasound imaging of the right foot in the neutral position demonstrated patency of the DPA with a triphasic waveform (Panel B; pre-operative). Plantar flexion of the right foot highlighted signs of entrapment and forced plantar flexion resulted in complete cessation of flow, features which resolved on neutralizing these manoeuvres. Operative intervention was undertaken. Thickened tissue bands were divided deep to the tendon of the extensor hallucis brevis (EHB), which appeared to be compressing the DPA on extreme plantar flexion. Exostosis of the talus was also removed, as it was causing bow stringing of the DPA, which was amplified on plantar flexion (Panel C). The patient recovered with complete resolution of symptoms. Surveillance duplex ultrasonography of the right foot at 6 months demonstrated normal triphasic antegrade flow in the DPA (Panel B; post-operative). Primary vascular atherosclerotic disease is rare in young adults. Symptoms related to anatomical positioning in this patient group should prompt assessment for extra-vascular anatomical impingement. To date, causes described have been limited to the encroachment of the EHB tendon running superficial to the DPA or anomalous fibrous bands.1,2 These anatomical features are the consequences of intense physical activity leading to overuse injury and remodelling. We present a case of bilateral dorsalis pedis impingement, which is unique in highlighting bony remodelling to compromise the passage of the DPA. Our case, along with the case described by Smith et al., implicates occupation to be a potential risk factor leading to the development of dorsalis pedis entrapment syndrome.1 There also appears to be a tendency towards developing bilateral impingement, which is exemplified by existing case reports.1,2 This case highlights the importance of surveillance in patients with unilateral impingement so that contralateral impingement may be identified early and corrective surgery undertaken to prevent complications and subsequent lifestyle limiting symptomology. Compensatory impingement of the dorsalis pedis artery in a property developer

Dyslexic doctors, an observation on current United Kingdom practice

Issue: Dyslexia is a common learning difficulty with an estimated prevalence of ten percent within the general population and two percent among junior doctors training in the United Kingdom. Despite dyslexia being common, there are still many challenges sufferers face in modern medical practice. Evidence: Multiple case studies have found there to be barriers that dyslexic doctors face throughout their training. Common activities that required reading or writing in time pressured situations in front of an audience can impose an additional pressure for dyslexic doctors. In addition to the difficulties with day to day work, criticism and mockery from other staff members can make suffers of dyslexia feel undermined. From personal experiences, the authors of this article have found barriers are particularly present with regards to sitting post- graduate examinations and getting support in a modern time pressure health service. Implications: The discrepancy in the prevalence of learning difficulties between the general population and doctors in training might be due to barriers in training and difficulties when starting work. Addressing challenges will help support current dyslexic doctors and also help support future generations. Rapidly developing technology in health care makes it easier to accommodate doctors with additional needs but the impact of this are yet to be studied. If the barriers are addressed it is likely to support not only doctors with dyslexia diagnosis but all health care professionals.