Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

The Patient Pathway > Cardiovascular/respiratory > Flashcards

Cardiovascular/respiratory Flashcards

1
Q

What is the initial/referal/imaging/diagnosis pathway for tumours?

A

GP
CXR - primary lung or Advanced mets
if there is further clinical concern more imaging modalities will be used:
CT/MRI/Radionuclide
Biopsy done under CT or US
Diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is bronchial adenoma?

A

(Covers a wide range of neoplasms)
- can cause obstruction
typically late diagnosis due to lack of symptoms
Rare cancer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What imaging modalities are used for bronchial adenoma?

A

CT is the most commonly used/useful:
Virtual bronchoscopy
Biopsy
However MRI is used if CT is unclear
- not first line due to length of time:
movement artefacts
- main use for pancoast (apical) tumour - subset of lung carcinoma invasion of the chest wall

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the treatment for a bronchial adenoma?

A

Chemo for Mets
Radiotherapy for singular area/lesion (depends on size)
Biopsy results:
Small cell carcinoma:
chemo +/- radiotherapy
bronchial (invasion of airway):
stent - palliative
Excision - depends on complexity/vascularity:
Small (wedge) resection
lobar
whole lung
Radiofrequency ablation (can only be used in certain areas)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the imaging pathway for lung carcinoma?

A

X-Ray of chest - diagnosis is not definitive
CT non-con
CT and IV contrast - chest + liver (primary and secondary mets)
MRI is superior for chest wall invasion:
assesses size/location/identifies liver mets (staging)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the advantages of using PET/CT imaging lung carcinoma?

A
  • More accurate than CT alone
  • Highly sensitive in picking up metabolic deposits
  • PET can identify the extent of the disease at initial diagnosis:
  • Essential for surgical/treatment planning
    to assess spread
    -PET is more accurate than CT in assessing spread and stage
  • And is more cost-effective in terms of determining if a tumour is operable or non-operable
  • PET is useful in determining lung tumour response to therapy and detecting recurrence in successfully treated lesions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the disadvantages of PET/CT in imaging lung carcinoma?

A

Not readily available
Time-consuming
Costly
High dose
Slower throughput (waiting list)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the use (Why) of CT-guided biopsy in lung cancers?

A

Accurate location means an accurate sample
Avoids major anatomical structures (nerves/peritoneal/major blood vessels)
CT fluoroscopy interventional - used with fluoro

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the advantages of fine needle aspiration?

A

Less invasive than core biopsy
Less tissue damage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the risks associated with lung biopsies?

A

bleeding
pnuemothorax

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the advantages of CT fluoroscopy?

A

do not need to move in/out of room constantly
save images for reporting - reducing radiation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is an endobronchial ultrasound used for?

A

Bronchoscopic technique
used for submucosal tumour for example

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Future trend in imaging of lung tumours?

A

CT virtual imaging:
computer software programme
creates 3D environment from 2D CT scans
High resolution
Narrow collimation resulting in increased dose
overlapping needed for reconstruction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is Lung radiofrequency ablation + what is it used for?

A

under imaging guidance - needles inserted into lesion - the tip of the needles/electrodes are then heated for controlled burning
used for early-stage lung cancer
or as palliative pain relief for inoperable cancer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

When is Lung radiofrequency ablation contraindicated?

A

in patients with tumours that are adjacent to the:
- Mediastinum
- Airways
- Oesophagus
- Large blood vessels (aorta)

Pace makers must be evaluated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the process for Lung radiofrequency ablation + prep + why?

A

Preliminary images are used to assess best access route:
To avoid structures such as:
Ribs
fissures
Brachial Plexus
central bronchi
large blood vessels (aorta)

CT guidance - patient is under sedation (LA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is the post-op care for patients after Lung radiofrequency ablation?

A

CXR at 1hr and 3hr to check for pneumothorax (occurs in 30% of cases)

Night observation

Prescribed analgesic narcotics (for pleuritic pain)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What imaging modalities are most useful for imaging the vascular structures?

A

CTA
MRA
US doppler

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is interventonal imaging used for?

A

Diagnostic and therapeutic interventions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the benefits of interventional radiography?

A

Less invasive than surgery so risks are reduced

Available, must have access to an interventional suite at all hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is needed staff wise for coronary and for peripheral vascular interventions?

A

Coronary:
Cardiologist
Radiologist
Radiographer
Nursing staff

Peripheral:
Radiologist
Radiographer
Nursing staff

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is the gold standard imaging done in interventional?

A

Arteriography/angio

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

How is CTA/MRA used in vascular imaging/treatment?

A

Assessment tool used prior to intervention:
provide info about:
what intervention is needed
detail about blockage:
what it is
location
size

This means that in the suite only the intervention needs to be focussed on

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What are the advantages of CTA in vascular imaging compared to interventional?

A

Less invasive
less prep required
Although may need to use interventional regardless if intervention is required
3D/MIP to visualise arterial structures and contrast flow in one image (pelvis to toes)
follow up on stent without contrast

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What imaging and treatment can be used for cardiac/coronary vascular structures?

A

percutaneous coronary angiography

PTCA - percutaneous transluminal coronary angioplasty

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Explain the procedure of a CTA used for cardiac imaging?

A

Requires fast acquisition
+
Gated (ECG)
=
Image taken within 1 heartbeat
to reduce movement artefacts

Fast heart rate, Beta blockers can be administered to slow down heart rate

Contrast can be triggered by HU using ROI to get most optimised highlighting from contrast

Calcium score can be calculated (pre-contrast)
which can predict a cardiac event
or
explain patient symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Advantages of CTA used for cardiac imaging?

A

Ventricles dynamics are assessed
Function and anatomy
only requires 5 cardiac cycles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Explain the use of an MRA for cardiac imaging.

A

Assesses valves functionality
Dynamic studies:
the flow of blood through the heart

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Avantages of MRI for cardiac imaging.

A

Contrast media is not always essential
Depends on local protocol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

MRA/CTA how are movement issues solved?

A

Gated studies
ROI trigger

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Discuss the use of NM in the imaging of CAD?
when?
what does it look at/see?

A

Diagnose and assess CAD:
ischemia
Cardiomyopathy
Possible damage to the heart
Reversible ischemia?

  • Visualise blood flow pattern to cardiac walls (Myocardial perfusion scan)
  • The extent of injury after an attack/myocardial infarction
  • Evaluates the results of bypass surgery or other revascularization intervention designed to restore blood flow (angioplasty/catheter)
    + with ECG - heart wall movement and function
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

what conditions is Myocardial perfusion scan done under and what can it identify?

A

Rest v Stressed = compared
can identify hibernating myocardium and reversible ischemic damage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What is a MUGA scan and why is it used?

A

Multi-Gated-Acquisition
Assesses left ventricular fraction rate
assessed pre-chemo (as chemo affects the rate)

Process:
Red blood cells are labelled
MIN and MAX ROI are captured and assessed to assess functionality

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What is a future trend imaging for cardiac/coronary imaging?

A

Rubidium PET/CT - assesses cardiac function
More sensitive and specific for myocardial viability
Done at stress and rest
Short half life at 75 secs
Expensive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What is a echocardiography + what is it used for?

A

Cardiac ultrasound - heart and surroundingv structures imaged

Diagnosis/management/follow up - used alongside other imaging modalities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What does an echocardiography see in images?

A

Chamber size
wall thickness
motion
proximal vessels
size and location of heart chamber

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What does an echocardiography assess?

A

Assess:
location and the extent of tissue damage
The function of heart:
pumping capacity
Calculation of cardiac output
Ejection fraction
diastolic function

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What does an echocardiography pick up abnormality wise?

A

Doppler:
heart flow and efficiency
abnormalities:
eddy currents
regurgitation
hypertrophic
dilated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What are the positives of echocardiography?

A

Non invasive
no side effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

What is a trans oesophageal echocardiography?
when is it used?

A

Echocardiography done through mouth

Used when normal echocardiography is inconclusive or further detail is required

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

what is an exception for an echocardiography being non-invasive?
what is the benefit?

A

Trans-oesophageal echocardiography
3D echocardiography + 4D
Detailed anatomical assessment
of cardiac pathology
Such as:
Valvular defects
Cardiomyopathies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

What is the gold standard imaging for peripheral vascular imaging?

A

Interventional

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

What prep will a coronary angiogram require?
And what final image is required?

A

Vascular access
Monitoring
Room prep - scrub
Must be available for emergency/acute situations

Peripheral run-off

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Why cant DSA be used on Interventional angiograms?

A

Movement - panning movement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

What is angioplasty?

A

The use of balloons and stents to open vessels (ensure patency)
ballons and stents can be tailored to the length and

46
Q

What is the indication of a successful stent?

A

Patent vessels/blood flow
less than 30% of residual plaque left behind

47
Q

What are complications that can occur from angioplasty?

A

Perforation
occlusion of artery/collaterals
Haematoma
Increased aneurysm risk

Follow up imaging is essential

48
Q

What can be done for CAD if angioplasty fails?

A

Surgery:
Mechanical removal of plaque - peripheral
CABG - coronary

Drug-eluting stent:
antiproliferative drug (anti-clotting)
Prevents:
scar tissue/narrowing

49
Q

Future trend in treatment of blockages of vessels?

A

Drug-eluting stent:
antiproliferative drug (anti-clotting)
Prevents:
scar tissue/narrowing
Peripherals

50
Q

What is C02 angiography?

A

C02 is used as an alternative for iodine contrast (used for contraindications)

51
Q

What are the advantages for C02 angiography?

A

Used for patients with contraindications to iodine

No allergic reactions

52
Q

What are the limitations for C02 angiography?

A

Can only be used below diaphragm:
increased risk of embolisation to spinal/coronal/cerebral arteries

Less viscous + lighter than blood plasma
in larger vessels not dispersed evenly

Image quality slightly reduced

May cause nausea/pain for aortograms/coeliac arteriography (for a few mins)

53
Q

How is CTA used for imaging inflammation?

A

CTA:
assess inflammation changes on fat around coronary arteries
Use of colourisation
Create a CT fat attenuation index - predict potential heart attack

54
Q

What is aortitis?

A

Inflammtion of the aorta

55
Q

What is used in the imaging of aortitis?

A

PET/CT:
functionality to detect inflammation

56
Q

Thrombus in artery treatment if interventional does not work?

A

Surgical alternative:
peripheral vascular endarterectomy (pelvic bypass graft)

CABG:
Coronary artery bypass graft

Requires GA
Invasive
more risk
longer recovary time/hospital stay
Graft patency and PTCA follow up

57
Q

ANUERYSM screening/imaging?

A

Targeted screening program for AAA
US
Measure artery - compare to what should be normal
VASCULAR SURGEON CONSULTS

CTA:
Assessing
planning approaches
Follow up

3D MIP
MRA

58
Q

EVAR?

A

tailor the size, dimensions of the stent, - which is used to support the vessel wall
redirect blood flow
in hopes to prevent anuersym rupturing
to previous images

Placed in vascular/interventional suite

59
Q

What is CT volume rendering?

A

3D

60
Q

What is the initial/referring pathway for DVT?

A

Emergency
A/E
GP -> A/E
Then referred for further imaging

61
Q

what imaging modalities are used for DVT?

A

First line:
us dopler
OR
CT

Interventional:
Stents
Inferior vena cavography

MRI to see extent of ischemia

62
Q

What treatment is used for DVT?

A

Anticoagulant drugs:
IV heparin followed by oral warfarin

IVC filter

63
Q

What are the limitations of anticoagulant drugs in the treatment of DVT?

A

Patients at risk of haemorrhage:
stroke
recent surgery
ongoing/active bleeeding

64
Q

What is an IVC filter?

A

Metal pieces of equipment are inserted to catch and trap blood clots
Can be permanent or temporary

65
Q

What are essential qualities IVC filters must have?

A

Ease of placement and removal if temp
clot trapping effectiveness
ability to preserve blood flow
Non-thrombogenic - maintain caval patency
Durable and non-corrosive material
shape and structural integrity
must still work even in a suboptimal position
should not migrate
no perforation of IVC
antiferromagnetic - so can be scanned in mri

Trap most or all clots (preventing new or recurrent PE)

66
Q

How is IVC placed?

A

Interventional procedure + US if needed
Inferior vena cavography - before to assess iVC
femoral vain
Pigtail catheter for illiac vins
DSA + roadmapping
AP or biplane (lateral)

67
Q

How is the diameter of the IVC determined in different modalities?

A

Fluoro (DSA):
Ruler with metallic markings - along left side of patient
Marker catheters
Guidewires
Internal software calibration

Typically other imaging modalities are used for a more accurate measurement:

CT and MRI:
visualise:
size
configuration
anatomic variants
potentially to monitor IVC after deployment

68
Q

PE imaging pathway?

A

Chest x-ray:
Preliminary investigation
Dmonstrates:
consilidation
pleural effusion
However, it does not exclude PE

VQ (ventilation/perfusion) scan:
Can only exclude clinically significant PE
Is not useful for patient without COPD or Consilidation

CTPA (done out of hours and most available so will be most commonly done):
Reliably exclude clinically significant PE
if VQ is inconclusive or alternative to VQ

Transoesophageal echocardiography (not an alternative but in connection with CT)

68
Q

Explain the VQ NM scan for PE?

A

2 Scans:
Ventilation phase - radioactive gas
Perfusion phase - injection of radioactive
Difference/mismatch will demonstrate emboli

69
Q

what does LPO/RPO stand for NM VQ:

A

Left posterior oblique etc.

70
Q

Disadvantage of MRI for PE?

A

Long scan
PE -struggling to breath
so would be unable to hold their breath

ALSO

Emergency situation

71
Q

How is US useful in imaging/detecting PE?

A

Difficult to detect emboli

However is useful in terms of DVT and can detect if PE could be a complication

72
Q

how does the outcome of the CXR impact the imaging modality used next for a PE?

A

CXR + go for CTPA

CXR - go for a VQ scan

73
Q

What is a dissection?

A

When blood enters the wall of the artery between the layers and creates a cavity/false lumen in the vessel wall

Can rupture;
leading to bleeding out

74
Q

Imaging pathway dor dissection?

A

CTA initial
alongside us

However if high-risk injury Fluoro - interventional first

75
Q

Treatment for dissection?

A

Stent or surgery

Haematoma/bleeding out:
Embolisation - deployment of material distally to cut off bleeding to reduce damage
(materials such as particles/gel foams/coils)

76
Q
A

What soft tissue structures are nearby

CT - identify extravasation
US
Interventional - identify specific vessel

77
Q

CT virtual imaging for dissection?

A

detection
diagnosis
surgical planning

virtual intra-arterial angiography
DSA
see inside vessel and compare to dsa

used to compliment

78
Q

Endovascular ultrasound in the imaging of dissection/vessels?

A

Can evaluate normal and abnormal vascular anatomy from an endoluminal position
(can look at the different layers/wall)

Angio can only be used on lumen

Miniature US probe on catheter
Can determine amount of atheromatous plaque or stenosis which can be done at the same time as an angio

Can be used alongside other modalities for a more accurate procedure/type + size of devices and the device deployment + position

79
Q

What is a 3D fluoroscopic arteriography?

A

fast specific c-arm movements to produce 3D images from 2D

used in:
carotid
cerebral
cardiac
pelvic

80
Q

What are the limitations for 3D fluoroscopic arteriography?

A

Limitations:
cost
increased dose

81
Q

What are the advantages for 3D fluoroscopic arteriography?

A

Advantage:
only need to use CM once

CVA - time is brain:
quicker to prevent damage

82
Q

Therapeutic hypothermia with coronary angioplasty
What is it used for, how and why?

A

STEMI - ST-elevation myocardial infarction - normally use angioplasty

Reducing body temp to try and reduce damage

Interventional procedure:
done by using via cooling catheter in the vena cava whilst external temp is maintained with warming blankets

83
Q

Interventional image guided mechanical thrombectomy

What is it used for, how and why?

A

Alternative to surgical mechanical thrombectomy

Under fluoroscopy stent retriever devices is used

CVA (Ischemic) intervention

time-sensitive

Used when:
more severe CVA
and when thrombolysis/drug thinning drugs will be ineffective

To reduce:
risk
time for treatment

84
Q

Hybrid imaging in interventional?
What and why?

A

CT + fluoro

Reduce time:
CT first line
to interventional

Limitations:
cost
staff
lack of use of ct

85
Q

List of heart/ cardiac problems?

A

Tachycardia
Bradycardia
SVT - arterioventicular node
AF - flutter
Heart block - pathway interrupted
Wolff Parkison white syndrome wpw - abnormal pathway

86
Q

How are cardiac pathways mapped?

A

Triggered using internal catheters which monitor pre-treatment (under fluoroscopic guidance)

87
Q

Treatment for cardiac arrhythmias?

A

Atrial fibrillation - cardioversion treatment

done in the cath lab - may not need cath lab

monitoring is needed after
may present initial success

may need further treatment

such as a pacemaker - inserted under fluoroscopy
For:
bradycardia
cardiac arrest
heart block
(1-3 leads)

88
Q

ICD what is it and what does it do?

A

Implantable cardioverter defibrillator

constant small shock simillar (cardioversion)

larger shock (defibrillation)

Prevents sudden death syndrome

89
Q

future trends with pacemakers?

A

Pacemaker with no leads

90
Q

What is RFA and how is it applied to cardiac pathway treatment?

how is it done?

A

Radio frequency ablation
Non surgical
used on rapid heartbeat (arrhythmia)

look for accessory pathways that may be disrupting the cardiac pathway

radiofrequency wave is then applied to restore the normal rhythm
heart muscle cells are destroyed

and can be repeated

Successful 90-95% of patients with recurring WPW

uncommon 2-3% have complications

Under fluoro - catheter - road map (colourised) - try to find or trigger abnormal rhythm - patient can communicate - RFA done (can take from 3-4 hrs but can be longer)

10% - recurrence

91
Q

Lung infection imaging modalities:

A

Initially CXR
CT - esp if CXR is not definitive
US - differentiate between consolidation and pleural effusion

92
Q

What is bronchiectasis?

A

Dilation of bronchioles
leads to an increased amount of mucous
Increases the risk of lung infection
Damage is permanent

93
Q

What is the treatment for bronchiectasis?

A

Medication to keep airways open:
Nebulisers
oxygen
Respiratory exercises
postural drainage

Tram line radiographic appearance

94
Q

What is a lung abscess?

A

Necrosis of lung tissue.
development of a cavity which fills with necrotic debris (or fluid)

95
Q

What is pericarditis?

A

An inflammation of the membrane that surrounds the heart
Caused by infection
metastatic disease
kidney disease
radiation therapy
recent heart attack

96
Q

What imaging is used for pericarditis\?

A

CT and MRI:
demonstrate pericardium surrounding the heart
CT - calcifications

US - demonstrate fluid

97
Q

What imaging modalities are used for a pleural effusion?

A

CXR - for detection, not characterisation
CT/US - further definition/assessment of cause
echo-free space
MRI - if CT is not definitive/unclear

Pleural effusion moves

98
Q

Why is US so useful for imaging pleural effusions?

A

US - locates small or large amounts of fluid
isolated loculated pockets of fluid
locates fluid - can be used to guide drainage - shows exact location
echo-free space between the visceral and parietal pleurae

99
Q

What is the treatment for a pleural effusion?

A

percutaneous abscess drainage:
done under image guidance
- ct
- us
- fluoroscopy

needle
then
guidewire
then
drainage tube (guidewire removed)
then
an external drainage bag is connected
maybe a biopsy (for pneumonia)

100
Q

What is cardiac tamponade?

A

Abnormal accumulation of blood or fluid in the pericardial sac
heart is compressed
great vessels enlarged

101
Q

What imaging is used for cardiac tamponade?

A

US (echocardiography):
demonstrates fluid level and its location

102
Q

What is the treatment for cardiac tamponade?

A

MEDICAL EMERGENCY
may be done blind
Needle aspiration
image guidance:
Echocardiography +/- fluoroscopy

positioned semi-recumbant
precise needle position
drainage via a catheter (in situ for 1-2 days)
Underlying conditions need assessed

103
Q

What imaging is used for pulmonary oedema?

A

CXR

104
Q

What is pulmonary oedema?

A

Build up of fluid in the alveoli fluid leaks into the lungs
Can result from heart failure (poor circulation and changes in pressure)

105
Q

What is the treatment for pulmonary oedema?

A

Oxygen
Diuretics - short term

Diagnosing and treating underlying cause

105
Q

What is a haemo/pneumothorax?

A

The presence of air and/or blood in the pleural space

106
Q

What is the imaging used for a haemo/pneumothorax?

A

Initially CXR assessment and follow up
Follow-up CT to see the extent (esp if patient cannot move from a supine position)

Trauma-related:
FAST
CT

107
Q

What is the treatment for a haemo/pneumothorax?

A

medium or large will require intervention
tension pneumothorax

Chest drain

Thoracotomy:
used to drain large amounts as well as to locate the origin of the bleed

108
Q

what is the imaging pathway for covid?

A

Initial CXR - cannot exclude covid
CT if more complex to assess respiratory

109
Q
A

The Patient Pathway (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions