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Contrary to common perception, the advent of third- and fourth-generation scanners has lead to a significant increase in radiation dose to the patient per computed tomography (CT) head scan. With that in mind, a pilot study was designed with the objective of assessing the effectiveness of a dental-style protective bib in reducing the dose to the radiosensitive organs of the neck and thorax. Radiation doses over the thyroid gland and breast were measured with thermoluminenscent dosemeters and an ionization chamber respectively in 110 patients undergoing routine head scans. Half the patients wore the protective bib and collar. With lead protection, the thyroid measurements were reduced by an average of 45 % and the breast measurements by an average of 76 %. Similar results were seen in phantom measurements.

The diagnosis of primary aldosteronism, the most common form of secondary hypertension, is based on clinical and biochemical features. Although radiology plays no role in the initial diagnosis, it has an important role in differentiating between the two main causes of primary aldosteronism: aldosterone-producing adenoma (APA) and bilateral adrenal hyperplasia (BAH). This distinction is important because APAs are generally managed surgically and BAH medically. Adrenal venous sampling is considered the standard of reference for determining the cause of primary aldosteronism but is technically demanding, operator dependent, costly, and time consuming, with a low but significant complication rate. Other imaging modalities, including computed tomography, magnetic resonance imaging, and adrenal scintigraphy, have also been used to determine the cause of primary aldosteronism. Cross-sectional imaging has traditionally focused on establishing the diagnosis of an APA, with that of BAH being one of exclusion. A high specificity for detecting an APA is desirable, since it will avert unnecessary surgery in patients with BAH. However, an overreliance on cross-sectional imaging can lead to the incorrect treatment of affected patients, mainly due to the wide variation in the reported diagnostic performance of these modalities. A combination of modalities is usually required to confidently determine the cause of primary aldosteronism. The quest for optimal radiologic management of primary aldosteronism continues just over a half century since this disease entity was first described.

Fifty-two knees were examined using real-time highdefinition ultrasonography with a 7.5MHz probe. The extra-articular structures were easily visualized and diagnosis of patellar tendon lesions and Baker's cysts formulated. While the meniscal cartilages were shown as a homogeneous triangular structure between the femoral condyle and the tibial plateau, no lesions were detected. Deeper intra-articular structures, such as the cruciate ligaments, were not shown by the scan, thus their evaluation was not possible. Given its low cost, wide availability, non-invasiveness and patients' acceptability of the technique, ultrasonography may play an important role in the diagnosis of soft tissue lesions in and around the knee joint.

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A 46-year-old man was admitted via the emergency department with sudden onset, left-sided, sharp, abdominal pain that had awoken him from sleep. Two days previously, he had a similar episode of abdominal pain that resolved upon bowel opening. He had no other symptoms and had an unremarkable past medical history. On examination, he was distressed and in pain, but had a soft, non-distended abdomen. There was mild tenderness in the left iliac fossa on deep palpation, but nothing else of note. The bowel sounds were normal. Besides a minor leucocytosis, all preliminary investigations, including arterial blood gases, were reported normal. He remained haemodynamically stable throughout. However, his pain was significantly out of proportion to the clinical findings and the results of initial investigations. An unenhanced computed tomography (CT) scan of the abdomen was performed (Fig. 1). DiscussionFigure 1 is a composite image of a series of unenhanced CT sections in a craniocaudal direction. They demonstrate a distend loop of small bowel in a 'C' shape lying under the left anterior abdominal wall (image 5). The mesenteric vessels leading to this loop can be seen to be converging. There is loss of sharpness of these vessels with haziness of the fatty tissue surrounding them (images 1-4). The convergence of the vessels infers the presence of a defect through which this loop has herniated creating a 'closed loop' obstruction and the haziness is indicative of vascular compromise.Investigative laparoscopy revealed, blood-stained fluid with multiple distended loops of small bowel. At exploratory laparotomy (Fig. 2), a congested, but viable, ileal loop was found, herniating through the greater omentum. The herniation was released and the omental defect and abdomen closed. The patient was discharged 2 days later.Internal hernias have an autopsy incidence of 0.2-0.9%. 1Transomental (greater or lesser) are rarer still accounting for less than 1% of all internal hernias and are usually a complication of previous surgical procedures. [2][3][4] Small bowel obstruction secondary to an internal hernia is a surgical emergency. Whilst abdominal radiographs and ultrasonography may be of some diagnostic use, CT scanning remains the gold standard. 3,5 ConclusionsThis case promotes the consideration and early recognition of internal herniae as a cause of abdominal pain in patients presenting to the emergency department. Despite the rarity We present the case of a 46-year-old man admitted with acute abdominal pain with no obvious cause despite simple investigations. Further imaging revealed a rare transomental internal hernia. At exploratory laparotomy, the hernia was released, no bowel resection was required and the patient was discharged 2 days later. ON-LINE CASE REPORT

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