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Longitudinal extensive transverse myelitis (LETM) is a rare but recognised complication of vaccination. We report the case of a 58-year-old man admitted to hospital 10 days after his first AstraZeneca COVID-19 vaccination with progressive neurological symptoms and signs, and investigations and imaging consistent with LETM. This case reviews the literature and the investigative process behind excluding other diagnoses given the patient’s background of pulmonary sarcoidosis. It is unique in being the first UK report of a case of LETM with a strong temporal link to COVID-19 vaccination.

Sentinel lymph node biopsy (SLNB) remains the gold standard for assessing axillary node status in breast cancer. Preoperative scintigrams have been used to identify the sentinel lymph node (SLN); however, their use is controversial. Studies suggest they add little to successful SLN detection in theatre, immediately prior to node excision. They have been associated with high false negatives, time expense, patient dissatisfaction, and unnecessary costs. The aim of the present study was to evaluate the diagnostic accuracy of scintigrams in comparison to intraoperative SLN identification techniques. This study included all patients undergoing a SLNB for breast cancer from April 2010 to 2011. Scintigram reports, operation notes, and histology results were analyzed. Mann–Whitney U and chi-squared tests were used for statistical analysis of data. Two hundred nineteen female patients with a median age of 59.6 years (24.0–89.9 years) were included in this study. Scintigram was performed in 185 and not in 34 patients due to time constraints. Combined γ-probe and Isosulfan blue dye for SLN detection (intraoperative methods) have an identification rate of 98.2 % ( p  = 0.005), compared to 92.4 % ( p  = 0.088) from scintigrams alone. Scintigrams confer no additional advantage to the operating surgeon for successful SLN detection and excision in theatre. Intraoperative SLN identification is more accurate and reliable. Routine scintigram use is unjustified and should be withdrawn from current practice.

[...]it should be ensured that the conclusions answer the clinical question that prompted the referral if possible, and if not it may be relevant to make recommendations for further investigation or management. 9 FACTORS AFFECTING THE QUALITY OF STUDIES 9.1 Stress technique Inadequate stress reduces the sensitivity for detecting coronary artery disease (table 6). 20, 72 Table 6 Factors affecting the quality of studies Phase of study Factor Stress Incorrect agent or protocol Submaximal stress Drug treatment-for example, use of antagonists (if the study is done for diagnostic purposes) Radiopharmaceutical administration Inadequate activity for patient weight/size Misadministration (for example, extravascular injection) Image acquisition Inadequate camera positioning or orbit selection Inappropriate energy window selection or collimation Patient comfort and motion External attenuating objects or inadequate breast strapping Incorrect ECG gating Image reconstruction and processing Inappropriate filtering or reconstruction technique Inaccurate definition of long axis of left ventricle Image display Inappropriate colour/grey scale or incorrect windowing Comparison of non-equivalent tomograms 9.2 Tracer activity and delivery Inadequate delivery of the radiopharmaceutical degrades image quality and may decrease the diagnostic accuracy of the technique.

Introduction Bile Acid Malabsorption (BAM) causes chronic diarrhoea and can be confirmed using SeHCAT retention. There are limited data on the use of SeHCAT for diagnosis and management of BAM, but its use is supported in dated BSG guidelines. Recently, NICE recommended that SeHCAT use in irritable bowel syndrome (IBS) and Crohn's disease should be restricted. Method A prospective study evaluated SeHCAT usage across the UK. This resulted in a dataset with more than 200 variables, capturing centre and patient-level information. Eligible data from 38 centres and 1,036 patients were entered into a validated management system. Results Mean age was 50 years (6-89), 65% female. Prior colonoscopy was recorded in 76%, blood tests in 89%. Only 27% of patients had an IBS diagnosis reported. Overall, the centre-defined 'normal' retention was seen in 47% of cases, and 'abnormal' retention in 43%, the rest being considered borderline. Suspected Type 1 (BAM secondary to ileal resection/disease) was the smallest group (14%). Of these, 83% had Crohn's disease and 64% had an ileal resection. SeHCAT retention was predictably low: mean 9%, (SD 13%), median 2%. The largest group (44%) with suspected Type 2 (idiopathic/primary BAM), had a mean retention of 21% (SD 17%), median 18%. In suspected Type 3 (41%; BAM secondary to various gastrointestinal diseases) mean retention was 22% (SD 20%), median 17%. Of these ​34% were post-cholecystectomy and 12% were diabetic. Conclusion SeHCAT in the UK is used widely. However protocols are variable and reliable cut-offs for clinical significance remain ill-defined. Dated BSG algorithms and recent NICE guidelines are not currently being consistently followed. Clinicians suspecting BAM predominantly consider this as primary bile acid diarrhoea or as secondary to other disorders. Analysis of the detailed clinical data acquired in this study will assist in the design of future definitive prospective research. Disclosure of interest None Declared.

In 3646 children with at least one confirmed urinary tract infection the prevalence of vesicoureteric reflux at presentation was correlated with progressive renal damage during follow up of not less than two and up to 16 years. Reflux was not demonstrated either at presentation or at any subsequent time in almost one half of the children who suffered progressive renal damage and was not a risk factor for progressive renal damage in boys under 1 year. It was an important risk factor in boys over 1 year and in girls of any age. The risk of progressive renal damage in children in whom micturating cystourethrography (MCU) did not reveal vesicoureteric reflux was substantially greater than in those who indirect isotope voiding study (IVS) did not show reflux. The risk of deterioration for those in whom reflux was demonstrated was similar for both techniques. This discrepancy indicates an appreciably higher false negative rate for the MCU than the IVS. Dilatation of the renal pelvis detected by ultrasound was associated with a significantly increased risk of progressive damage only when associated with reflux, but most children with progressive damage did not have a dilated collecting system at presentation.

Long term follow up of children with urinary tract infections, in whom imaging investigations were performed at presentation, has been used to identify features that distinguish those at greatest risk of progressive renal damage. No single investigation at presentation was able to predict subsequent deterioration but, by employing a combination of imaging investigations, it was possible to separate groups with high or low probability of progressive damage. In the low risk group the incidence of progressive damage was 0.2% (95% confidence interval (CI) 0 to 1.3%). The combination of both scarring and reflux at presentation, or one only of these but accompanied by subsequent documented urinary tract infection, was associated with a 17-fold (95% CI 2.5 to 118) increase in the relative risk of progressive renal damage compared with children without these features. The recommended combination of investigations at presentation for girls of any age and boys over 1 year is ultrasound and dimercaptosuccinic acid (DMSA) scintigraphy in all, to detect both scarring and significant structural abnormalities, renography in children with dilatation of any part of the urinary tract on ultrasound, to distinguish dilatation from obstruction, and an isotope voiding study in all who have acquired bladder control. This gives the best separation between those at high and those at low risk of progressive damage with least radiation dose and lowest rate of instrumentation. Micturating cystourethrography (MCU) should be restricted to girls who have not acquired bladder control, unless there is reason to suspect a significant structural abnormality such as urethral valves. A single non-febrile urinary tract infection that responds promptly to treatment is not a justification for performing MCU in boys under 1 year or in children of any age with bladder control. No case can be made for any abbreviated schedule of investigation. These risk factors should be taken into account when designing follow up protocols.

This study investigated the hypothesis that some features of functional gastrointestinal disorders may be associated with abnormalities of ileocaecal transit by measuring ileocaecal transit using a scintigraphic technique in 43 patients with chronic constipation, 20 patients with irritable bowel syndrome (IBS), and 18 control subjects. Subjects ingested enteric coated capsules, which delivered 111-indium radionuclide to the distal ileum. Gammacamera images were acquired at hourly intervals until caecal filling was complete. Ileocaecal transit was defined as the time between peak scintigraphic activity in the terminal ileum and peak activity in the caecum. The mean (SD) ileocaecal transit of 103 (50) minutes in patients with IBS was significantly faster than that in control subjects (mean (SD) ileocaecal transit 174 (78) minutes, p < 0.002). There were no significant differences in ileocaecal transit between patients with chronic idiopathic constipation and the control subjects, or between patients with constipation predominant and diarrhoea predominant IBS. This study developed a practical scintigraphic method of measuring ileocaecal transit. The rapid ileocaecal transit in both the constipation and diarrhoea predominant forms of IBS suggests that bloating may not after all result from delayed ileal emptying.

Segmental colonic transit has been measured in 101 patients. Two MBq of 111Indium absorbed on resin pellets and encapsulated in an enteric coated capsule was given at 7 00 am. Hourly images during the first day, and three images during each subsequent day were acquired for up to three days. Using all scan and patient data the scans were categorised in one of the five patterns of colonic transit: normal, rapid, right delay, left delay, or generalised delay. The geometric centres and per cent activity at each time point was compared between the five groups of colonic transit patients to find the best time for imaging and so to distinguish the five groups. During the first day, early images did not help in diagnosis of patterns of transit, however, in the later images (six hours onwards after the ingestion of the activity) the rapid transit groups could be identified. Images at 27 and 51 hours were both required to distinguish all five groups of patients from each other. Only in the 'normal' transit patients was there some excretion of the activity during the course of the second day, otherwise there was no difference in the images taken in the course of a day (second or third day). A simplified protocol requires a minimum of three images to distinguish all five patterns of colonic transit. The activity should be ingested in the morning (7 00 am) and the first image taken at the end of the working day (8-10 hours after ingestion), the second image on the morning of the second day, and the third image during the course of the third day. This simple protocol would provide all the clinically relevant information necessary for correct classification of the colonic transit.

This study describes a graphic presentation of the results of a simplified segmental colonic transit model. This study requires three sets of images on three consecutive days after intake of indium-111 resin capsule at each time point. The per cent of ingested activity is calculated in each region of the colon and in the faeces. The program uses standard PC compatible graphic package, CorelDRAW (Corel Corporation). The report for the patients' notes consists of three schematic diagrams of colon with regions identified and a pot representing the faecal activity. The per cent of administered activity in each region and pot is both printed and represented by shades of grey (white representing 0% and black 100% activity), for each region and the pot. The distribution of activity is clearly seen at each time point and the report is presented on single A4 size sheet of paper. Using a simplified colonic study protocol it is possible to produce clinician friendly reports on a single sheet of paper.