Requests for useful imaging investigations are primarily those whose results, if positive or negative, will add confidence to the referrers‟ diagnoses or aid in any future clinical management plans. Hence, referrers need to be aware if they are about to repeat investigations that have already been recently done; if they intend to undertake investigations when their results are unlikely to affect the patients‟ diagnoses or clinical management; if they are seeking to investigate too early, if they are about to choose the wrong imaging modality, or if they are failing to provide all the appropriate clinical information that seeks to address the clinical questions that need to be answered. This literature review has highlighted several important aspects that are already known with respect to the radiation dose justification and optimisation. Moreover, it has evaluated the current main issues relating to the physicians‟ awareness in radiation safety and imaging referral processes, as well as the appropriateness behind requesting ionizing imaging investigations. Certain gaps and conflicts in the literature were also identified.

Takotsubo syndrome (TTS), also commonly referred to as “stress cardiomyopathy”, “transient left ventricular apical ballooning syndrome”, “neurogenic stunned myocardium”, “broken heart syndrome” or “ampulla-shaped cardiomyopathy”, has steadily increased in prevalence since its primary identification circa 32 years ago (Sato, et al., 2020). This rare condition is characterised by an apical myocardial contractile dysfunction, without the presence of coronary artery obstruction (Prokudina et al., 2020). Despite increasing awareness among researchers and medical professionals, the precise mechanisms governing the pathophysiology of this disease are somewhat unclear (Lyon et al., 2008). Nevertheless, the association between TTS and a preceding immense, stressful trigger has been long-established (Wittstein et al., 2005). Similarly, recent evidence has shown that the connection between the heart and the nervous system plays a role in the development of this disease (Klein et al., 2017; Silva et al., 2019; Templin et al., 2019; X. Wang et al., 2020). This article presents an updated literature review on TTS with an emphasis on secondary TSS, followed by a case report on the presentation, investigation and management of an 87 year old Caucasian male with secondary TTS, occurring in the setting of a post-mechanical fall, and a right basi-cervical hip fracture. His secondary TTS is also believed to have been precipitated by the patient receiving the news of the passing away of his wife.

Research Objectives: This research study aimed to determine whether the patients' exposures to ionizing radiation via plain musculoskeletal radiography are indicated for the diagnostic or clinical management purposes, according to standards defined in the European Commission (Radiation safety 118) Referral Guidelines for Imaging (2001), as well as the Royal College of Radiologists (RCR) i-Refer guidelines (2017). Research Methods: A non-experimental, exploratory research design was adopted to answer the objectives of this study. Data were collected through 694 electronic, musculoskeletal imaging requests that were selected via cluster random sampling. The data collected were quantitative in nature. The study had a 3.7 % margin of error (at a confidence level of 95 %) in relation to the analysed imaging request forms. Data were analysed using descriptive statistics. A p-value of ≤ 0.05 at a confidence level of 95 % was considered as statistically significant. Results: Only 20.5 % of plain, musculoskeletal imaging requests that are being referred by Maltese, state health centres G.Ps are classified as indicated for diagnostic or clinical management purposes. In addition, 65.3 % of plain, musculoskeletal imaging requests were classified in the not routinely indicated category. The lumbo-sacral spine is the region that has registered the highest number of cases in the not routinely indicated category; being closely followed by the knee and the cervical spine respectively. These findings indicate that there is a greater tendency for Maltese state health centres G.Ps to request plain, musculoskeletal imaging investigations which are not routinely warranted according to the European Commission RP118 (2001) or the RCR i-Refer (2017) gold-standard imaging referral guidelines. Moreover, 40.0 % of these imaging requests were also referred with insufficient clinical details. Recommendations: Based on the research findings as well as the available literature, the following recommendations are being suggested: Continuing medical education in radiation safety and imaging referral criteria for Maltese state health centres G.Ps and G.P. trainees; Issuing regular departmental memos about any related evidence-based research findings; Ensuring the availability of the imaging referral guidelines on the desktops of all workplace computers, and promoting the use of imaging referral guidelines as well as kindling the safety-net of asking for advice from senior colleagues or radiologists whenever the referrers are in doubt about the management of a particular clinical case; Promoting the development of refinements and updates of locally applicable imaging referral guidelines to address any potential gaps in the older versions; Considering the introduction of a pro-forma clinical checklist for requesting online plain imaging investigations to aid G.Ps in improving the appropriateness of their imaging requests at times of clinical controversy, as well as in providing all the relevant clinical details for reporting; Organizing a radiation protection campaign to both the Primary Health Care Department (Malta) as well as to members of the general public and considering the use of radiation protection booklets or posters that may be distributed or show-cased to the patients whilst still in the primary care clinics waiting areas.