Intratendinous hamstring injuries: sequential MRIs as a tool to reduce the risk of reinjury in elite sport

Hamstring injuries are the most common muscle injuries in elite football. Injuries involving the intramuscular tendon are considered more significant, with longer return to play (RTP) times and an increased risk of reinjury. MRI is the gold standard investigation for muscle injuries, but initial findings cannot accurately determine RTP times. The role of MRI in monitoring muscle and tendon healing is not well described. We present three cases of hamstring injuries with intramuscular tendon involvement, illustrating the changes seen on MRI during progressive tendon healing and describing how we utilised this information to inform safe rehabilitation progression. We conclude that intramuscular hamstring tendon healing can be accurately seen on sequential MRI scans and that this information, when combined with traditional rehabilitation markers in and elite sport environment, can be utilised by clinicians to determine the earliest but safe RTP.

Subinguinal versus peritesticular diameters of varicocele veins in the supine and standing posture

Objective: Scrotal CDUS is a standard investigation for varicocele patients, but it is not clear that which region should be considered as a standard. The aim of study was to determine that which region should be taken as a standard of measurement for varicocele veins. Methods: The study was conducted at the andro-urology clinic of a teaching hospital. Scrotal Color Doppler Ultrasound (CDUS) parameters were determined at subinguinal and peritesticular region in 35 varicocele patients. The data was collected as mean ± SD and compared using paired t test. Results: In supine position, the mean diameters of varicocele vein at peritesticular region (3.31mm ± 0.70) was compared with the mean diameters of varicocele vein at subinguinal region (2.94mm ± 0.52) and were found to be significantly greater (p < 0.01). The mean diameters of varicocele vein at peritesticular region, when measured in standing posture (3.65mm ± 0.77) was significantly greater (p < 0.01) than the mean diameters at subinguinal region (3.29mm ± 0.62). All varicocele patients had associated semen abnormalities but the diameter of varicocele veins had no significant correlation with semen abnormalities. Conclusion: The varicocele vein diameter at peritesticular region was found to be significantly greater than the sub-inguinal varicocele vein diameter in both lying and standing position. The diameters at peritesticular region may be routinely measured to reach at a better clinical decision. Continuous...

When is CT with rectal contrast indicated in patients suspected with anastomotic leak?

There is no clear guidance about the use of intraluminal rectal contrast combined with computerised tomography (CT) scan when assessing for anastomotic leak (AL) following colorectal resections. ALs most commonly manifest after post-operative day 5, presenting with fevers, abdominal pain, tachycardia and rising inflammatory markers. However, some patients with AL also present with subtle symptoms and failure to progress. CT with or without luminal contrast is the most commonly used investigation for diagnosis; however, there is no consensus on the best protocol. This case report highlights a need for having criteria, which include intra- and post-operative pointers when having a luminal contrast may aid diagnosis, in difficult cases. Studies show that routine contrast enema is not recommended, and furthermore, no gold standard investigation is available. This case report explores the need for a low threshold to use rectal contrast in CT in cases of prolonged ileus.

Kidney biopsy practice amongst Australasian nephrologists

Background Percutaneous kidney biopsy is the gold standard investigation for the diagnosis of kidney diseases. The associated risks of the procedure depend on the skill and experience of the proceduralist as well as the characteristics of the patient. The Kidney Health Australia – Caring for Australasians with Renal Impairment (KHA-CARI) guidelines on kidney biopsies, published in 2019, are the only published national kidney biopsy guidelines. As such, this study surveys current kidney biopsy practices in Australasia and examines how they align with the Australian guidelines, as well as international biopsy practice. Methods A cross-sectional, multiple-choice questionnaire was developed examining precautions prior to kidney biopsy; rationalisation of medications prior to kidney biopsy; technical aspects of kidney biopsy; complications of kidney biopsy; and indications for kidney biopsy. This was distributed to all members of the Australian and New Zealand Society of Nephrology (ANZSN). Results The response rate for this survey is approximately 21.4 % (182/850). Respondents found agreement (> 75.0 %) in only six out of the twelve questions (50.0 %) which assessed their practice against the KHA-CARI guidelines. Conclusions This is the first study of its kind where kidney biopsy practices are examined against a clinical guideline. Furthermore, responses showed that practices were incongruent with guidelines and that there was a lack of consensus on many issues.

Recurrent epistaxis secondary to nasal haemangioma with a misleading CT angiogram

The majority of epistaxes are anterior in nature, resolve with simple first aid measures and require no further follow-up. However, some cases pose more of a diagnostic challenge and prove resistant to standard investigation and treatment. We present a case of recurrent epistaxis, refractory to multiple treatment modalities and with CT imaging suggestive of a vascular aetiology which was ultimately disproved. The case highlights the shortcomings of CT imaging and importance of thorough examination technique. Nasal haemangiomas are a rare but recognised cause of epistaxis and should be considered in refractory cases.

Basic skill in liver biopsy

Liver biopsy is the best standard investigation for diagnosis of liver diseases. This procedure is not preferred by most doctors because of its serious complication such as fatal internal bleeding. Thesecomplications are indeed less than expected. The bleeding and other complications of liver biopsy can be handled by good pre-and post-operative procedures and self-care instructions. Those are:properly inform the patients about the procedure detail, arrange proper pre-procedure preparations, understand the anatomy of intercostal nerves and vascular bundles, prepare to pose the patientposition and breathe training for performing during procedure, give intravenous analgesic and anxiolytic drugs before operative procedure to calm the patient, give the local anesthesia according to instruction procedure, perform the liver biopsy strictly according to the biopsy instructions, handle the post biopsy period closely and carefully, and give the self-care instructions at home. All of these procedures and instruction have been proved to be valid and useful to prevent all complications. Figure 1 Axillary line

The Joint Effects of Internal Auditors' Approach and Persuasion Tactics on Managers' Responses to Internal Audit Advice

ABSTRACT Internal auditors frequently provide advice to managers as important input for accounting decisions. Recent practitioner guides have touted the merits of a participative or “coach” approach relative to a traditional “police officer” approach to the internal audit role. We conduct two experiments that test how managers respond to advice from an internal auditor using these different approaches. Results across both experiments suggest that when an internal auditor provides a professional favor (e.g., waives a standard investigation of an immaterial error), managers agree more with the internal auditor's advice only when he or she takes a participative approach. In contrast, a favor reduces managers' agreement with a more traditional internal auditor's advice. Our study contributes to practice by examining how an internal auditor's approach can change how favors influence corporate governance outcomes and contributes to the advice literature in accounting by highlighting the importance of expectancy confirmation.

Can technology increase adenoma detection rate?

Colorectal cancer is the third most common cancer worldwide and the second most common cause of cancer-related death in Europe and North America. Colonoscopy is the gold standard investigation for the colon but is not perfect, and small or flat adenomas can be missed which increases the risk of patients subsequently developing colorectal cancer. Adenoma detection rate is the most widely used marker of quality, and low rates are associated with increased rates of post-colonoscopy colorectal cancer. Standards of colonoscopy and adenoma detection vary widely between different endoscopists. Interventions to improve adenoma detection rate are therefore required. Many devices have been purported to increase adenoma detection rate. This review looks at current available evidence for device technology to improve adenoma detection rate during colonoscopy.