P ic to r i a l E s s ay(2) While the exact cause of lipoma arborescens is unknown, it has been hypothesised to be a nonspecific reactive synovial fatty proliferation in response to chronic traumatic or inflam matory stimuli rather than a neoplastic process. (1,3,4) We discuss the clinical features, morphological types and imaging findings of lipoma arborescens, with particular attention on the role of magnetic resonance (MR) imaging, which is considered the best, (3,4) and often the first, imaging modality in the evaluation of articular masses in the current era. The value of imaging in lipoma arborescens lies in its early diagnosis, delineating the exact anatomical extent, identifying associated abnormalities and differentiating it from other closely mimicking intra-articular masses.(5-17) CLIN ICA L FE AT U R E SClinical presentation usually consists of an insidious onset of painless swelling of the affected joint, usually persisting for many years, followed by progressive pain accompanied by intermittent episodes of joint effusion.(1,4) Intermittent worsening pain and swelling of the involved joint may be related to the trapping of hypertrophied fatty villi between the moving joint surfaces.Although the knee joint is the most common site of involvement, lipoma arborescens has also been reported in several other joints, including the shoulder, hip, elbow, ankle and wrist, as well as in periarticular bursae and tendon sheaths. (6)(7)(8)11) Although it is usually monoarticular, polyarticular and bilateral involvements are not uncommon; for example, involvement of both knees have been reported in up to 20% of affected patients in some studies. (2,9,16) Lipoma arborescens has been observed in patients aged between 9 and 68 years, with equal predominance in men and women. There are two aetiological types of lipoma arborescens, primary and secondary, depending on the age of onset and underlying precipitating condition. (4,10,12) The more common secondary type is defined as synovial lipomatosis associated ABSTRACT Lipoma arborescens is a chronic, slowly progressive intra-articular lesion characterised by villous lipomatous proliferation of the synovium, usually involving the suprapatellar pouch of the knee joint. It is an uncommon cause of intra-articular masses that presents as slowly progressive painless swelling of the joint, which persists for many years and is accompanied by intermittent effusions. We highlight this condition to raise awareness of its clinical spectrum and imaging features, so that early diagnosis and appropriate treatment can be given, and misinterpretation of this condition as other more complex intra-articular masses is avoided. This pictorial essay aims to provide a brief yet comprehensive review of the clinical features, distribution, morphological types and imaging characteristics of lipoma arborescens, including its common differential diagnoses and management. Lipoma arborescens

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AimGuided by the ALARA - “As Low As Reasonably Achievable” principle in radiation safety, a quality improvement project to optimise the bedside diagnostic imaging process to the best standards of care was conducted over a six month period. The goal was too reduce the radiation hazard opportunities in the neonatal intensive care unit by at least 75% from the existing level at Q2/2015, within 6 months.MethodsThe existing bedside imaging process was critically analysed and the following quality improvement initiatives were implemented namely, mandatory lead protective gear to healthcare staff, gonadal shield for neonates, guidelines for optimal collimation of X-ray beam and optimal positioning of neonates. Radiation dosimetry results, regular staff awareness sessions and strong collaboration between neonatologists, radiologists, radiographers and neonatal nurses helped to ensure compliance to the revised imaging process. Radiation hazard opportunities were measured by analysing all radiographs done during the period under baby exposure and healthcare staff exposure categories.Summary of resultsRadiation hazard opportunities were reduced by 100% to healthcare staff and 75% to neonates, and the overall reduction was 83%. The rate of discordance between radiograph request forms and images taken was measured as a surrogate marker for compliance to the project initiatives and it declined by 77%. Mandatory orientation of staff to the revised policy on the standardised diagnostic imaging process, regular radiation awareness talks and staff feedback sessions are among several measures taken to sustain the project.

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In light of the rising rate of incidentally detected subcentimetre thyroid nodules due to improved surveillance and diagnostic imaging, the decision of whether to perform fine needle aspiration cytology is increasingly pertinent. We aim to assess (1) the sampling adequacy of fine needle aspiration cytology, (2) malignancy rate, (3) thyroidectomy rate and (4) diagnostic accuracy of fine needle aspiration cytology. A total of 245 subcentimetre nodules in 220 patients underwent fine needle aspiration cytology between 2011 and 2014. Medical records were reviewed for cytology results, subsequent management and histopathological results in the event the patient underwent thyroidectomy. Sampling adequacy was calculated as the percentage of diagnostic results (Bethesda II-VI). Malignancy rate was defined as the percentage of Bethesda IV-VI diagnoses. Amongst patients with Bethesda IV-VI diagnoses who underwent thyroidectomy, their cytology reports were correlated with post-operative histopathological findings. The sampling adequacy of fine needle aspiration cytology was 77.1%. Malignancy rate (Bethesda IV-VI) was 9.7%. The respective malignancy rates in the < 5 mm nodule group and 5 mm nodule group were 6.67 and 10.0%. In total, 79.2% (19/24) of the malignant nodules underwent surgical excision. The rest declined surgery and/or were lost to follow-up. Amongst the malignant nodules which were surgically resected, 84.2% (16/19) had definitive malignant histology. Five of these demonstrated multifocal carcinoma and/or extrathyroidal extension of carcinoma on histology. Initial fine needle aspiration cytology and subsequent histopathological diagnoses matched in all cases except for three that had false-positive fine needle aspiration cytology results. Majority of our patients with suspicious cytology results subsequently underwent thyroidectomy, notwithstanding the relatively lower diagnostic accuracy of fine needle aspiration cytology in subcentimetre thyroid nodules.

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