Cultivating the next generation of healthcare leaders: reflections from an established healthcare leader.

BACKGROUND: Dr Andrea Doria is Professor and Vice-Chair of Radiology (Clinical Practice Improvement) at the University of Toronto, Research Director, Senior Scientist and Imaging Lead of Personalised Child Health, The Hospital for Sick Children (SickKids), Toronto, Canada. Over the past few decades, Dr Doria has established a track record of healthcare leadership. Based on Dr Doria's extensive leadership experience, she believes it is essential for established healthcare leaders to be involved in cultivating emerging healthcare leaders. METHODS: An interview was conducted with Dr Doria to learn about key lessons she believes are essential for healthcare leaders to help develop the next generation. Dr Doria reflected on her leadership style and experiences, sharing what has worked to improve the effectiveness of her teams. RESULTS: Key messages were reflected upon, including practical ways for senior leaders to support the next generation; leadership insights gained from the pandemic; the importance of building diversity in teams and nurturing leaders from underrepresented minorities; challenges to be aware of for the future of healthcare leadership; finding inspiration from team members and essential traits for healthcare leaders. CONCLUSION: Through cultivating the next generation of healthcare leaders, established leaders can be involved in establishing a brighter future for healthcare. This article describes reflections and practical takeaways that can help established leaders support emerging leaders and build their leadership skills.

The diagnostic accuracy of community spine radiology for adolescent idiopathic scoliosis brace candidates.

PURPOSE: The study aims to establish the diagnostic accuracy of community spine x-rays for brace candidates. METHODS: A review of adolescent idiopathic scoliosis patients seen for initial visit at a tertiary care pediatric hospital was conducted (n = 170). The index test was the pre-referral community spine x-ray interpreted by a community radiologist. Measures of diagnostic accuracy for the index test were determined against the reference standard if images were obtained within 90 days (n = 111). The reference standard was the 3-foot standing EOS spine x-ray evaluated by spine specialists. Diagnostic criterion for a brace candidate was dichotomized by Cobb angle range (25-40°) according to Scoliosis Research Society criteria. Risser stage was not included given significant missing data in index reports. To mitigate the uncertainty around true progression, sensitivity analyses were conducted on a sub-sample of data when index test was within 60 days of the reference standard (n = 67). RESULTS: Accuracy of the community spine x-ray to detect a brace candidate was 65.8% (95% CI 56.2-74.5). Sensitivity of the index test was 65.4% with a false negative rate of 34.6%. Specificity was 66.1% with a false positive rate of 33.9%. Positive and negative predictive values were 63.0% and 68.4%, respectively. Of the total number of brace candidates (n = 52), 32.7% were missed because of underestimation in Cobb angle (95% CI 21.5-46.2). The proportion of missed brace candidates because of underestimation was unchanged with 60-day data (p = 0.37). CONCLUSIONS: Inaccuracies in community spine radiology may lead to missed opportunities for non-operative treatment.

Identification of children with a nondiagnostic ultrasound at a low appendicitis risk using a pediatric Appendicitis Risk Calculator.

OBJECTIVES: Up to 50% of ultrasounds (USs) for suspected pediatric appendicitis are nondiagnostic. While the validated low-risk clinical pediatric Appendicitis Risk Calculator (pARC) score < 15% and the low-risk US with nonvisualized appendix and no periappendiceal inflammation carry relatively low appendicitis risks, the contribution of the combination of both characteristics to this risk has never been assessed. The primary objective was to determine the proportion of children with the low-risk US-low-risk pARC combination with appendicitis. We hypothesized that this proportion would be 2.5% (upper 95% CI ≤ 5%). METHODS: A retrospective cohort study of 448 previously healthy children 4-17 years old at a pediatric ED with suspected appendicitis, nondiagnostic US, and persistent clinical concern about appendicitis. Two investigators abstracted demographic, clinical, and imaging data. Based on published criteria, USs were classified as low-risk or high-risk. The pARC includes seven demographic, clinical, and laboratory variables and is quantified according to the published formula. The primary outcome was appendicitis, based on the histological evidence. All nonoperated patients underwent a 1-month-follow-up to exclude delayed appendicitis diagnoses. RESULTS: Sixty of the 448 (13.4%) patients had appendicitis; 269 (60%) had low-risk US, 262 (58.4%) had low-risk pARC, and 163 (36.4%) had both characteristics. The appendicitis rates with low-risk pARC alone and low-risk US alone were 14/262 (5.4%) and 21/269 (7.8%), respectively. A total of 2/163 children (1.2%) with low-risk pARC and low-risk US had appendicitis (95% CI 0%-4.4%). Higher-risk US increased the appendicitis odds 5 (95% CI 1.54-20.55) to 11 times (95% CI 2.41-51.10) across pARC levels. The low-risk combination had sensitivity of 96.7% (95% CI 88.5%-99.6%), specificity of 41.5%, positive predictive value of 20.4%, and negative predictive value of 98.8% (95% CI 95.6%-99.9%). CONCLUSIONS: The children with low-risk pARC and low-risk US combination are unlikely to have appendicitis and can be discharged home. The presence of higher-risk US-pARC score combinations substantially increases the appendicitis risk and warrants reassessment or interval imaging.

Increasing Diversity in Canadian Radiology: From the Hiring Process to Needed Active Retention Efforts.

The Canadian Association of Radiologists supports equity, diversity, and inclusion (EDI) in employment. It is imperative that institutions implement recruitment and retention practices to ensure a diverse workforce. This requires considerable attention to each step in the process, including the job posting, candidate search, hiring committee composition, interviews, hiring decision, and retention and promotion. Job postings must be widely distributed and visible to underrepresented groups. The candidate search should be completed by a diverse committee with expertise in EDI. All committee members must complete EDI and anti-bias training and conduct a broad search that ensures underrepresented groups are encouraged to apply. Interviews must be offered to all candidates. The hiring decision must avoid the use of subjective criteria. Recruitment of members of underrepresented groups ensures a diverse workforce, and organizations should commit resources to the retention and promotion of these members. Mentorship programs must be implemented and incentives provided to faculty members to serve as mentors. Transparent guidelines for promotion made universally available on department or institution websites. Recruiting a diverse workforce in Medical Imaging will only be achieved if EDI are central to the organization's goals and strategic plan. All organizational policies, practices, and procedures must be reviewed with an intersectional lens to identify potential gaps, areas for improvement, and areas of strength in the recruitment and retention of members of underrepresented groups.

Reliability assessment of the OMERACT whole-body magnetic resonance imaging scoring system for juvenile idiopathic arthritis.

Inter-reader reliability of a new scoring system for evaluating joint inflammation and enthesitis in whole body MRI (WBMRI) in juvenile idiopathic arthritis was tested. The scoring system grades 732 item-region combinations of bone marrow and soft tissue changes for commonly involved joints and entheseal sites. Five radiologists rated 17 WBMRI scans through an online rating platform. Item-wise reliability was calculated for 117 items with non-zero scores in >10 % of readings. Interquartile ranges of the five-reader Kappa reliability coefficients were 0.58-0.73 (range: 0.36-0.88) for the joints, 0.65-0.81 (range: 0.39-0.95) for the entheses, and 0.62-0.75 (range: 0.60-0.76) for chronic nonbacterial osteomyelitis-like lesions.

Defining domains: developing consensus-based definitions for foundational domains in OMERACT core outcome sets.

OBJECTIVE: To develop a set of detailed definitions for foundational domains commonly used in OMERACT (Outcome Measures in Rheumatology) core domain sets. METHODS: We identified candidate domain definitions from prior OMERACT publications and websites and publications of major organizations involved in outcomes research for six domains commonly used in OMERACT Core Domain Sets: pain intensity, pain interference, physical function, fatigue, patient global assessment, and health-related quality of life. We conducted a two-round survey of OMERACT working groups, patient research partners, and then the OMERACT Technical Advisory Group to establish their preferred domain definitions. Results were presented at the OMERACT 2023 Methodology Workshop, where participants discussed their relevant lived experience and identified potential sources of variability giving the needed detail in our domain definitions. RESULTS: One-hundred four people responded to both rounds of the survey, and a preferred definition was established for each of the domains except for patient global assessment for which no agreement was reached. Seventy-five participants at the OMERACT 2023 Methodology Workshop provided lived experience examples, which were used to contextualise domain definition reports for each of the five domains. CONCLUSION: Using a consensus-based approach, we have created a detailed definition for five of the foundational domains in OMERACT core domain sets; patient global assessment requires further research. These definitions, although not mandatory for working groups to use, may facilitate the initial domain-match assessment step of instrument selection, and reduce the time and resources required by future OMERACT groups when developing core outcome sets.

Correlative Assessment of Machine Learning-Based Cobb Angle Measurements and Human-Based Measurements in Adolescent Idiopathic and Congenital Scoliosis.

Purpose: Scoliosis is a complex spine deformity with direct functional and cosmetic impacts on the individual. The reference standard for assessing scoliosis severity is the Cobb angle which is measured on radiographs by human specialists, carrying interobserver variability and inaccuracy of measurements. These limitations may result in lack of timely referral for management at a time the scoliotic deformity progression can be saved from surgery. We aimed to create a machine learning (ML) model for automatic calculation of Cobb angles on 3-foot standing spine radiographs of children and adolescents with clinical suspicion of scoliosis across 2 clinical scenarios (idiopathic, group 1 and congenital scoliosis, group 2). Methods: We retrospectively measured Cobb angles of 130 patients who had a 3-foot spine radiograph for scoliosis within a 10-year period for either idiopathic or congenital anomaly scoliosis. Cobb angles were measured both manually by radiologists and by an ML pipeline (segmentation-based approach-Augmented U-Net model with non-square kernels). Results: Our Augmented U-Net architecture achieved a Symmetric Mean Absolute Percentage Error (SMAPE) of 11.82% amongst a combined idiopathic and congenital scoliosis cohort. When stratifying for idiopathic and congenital scoliosis individually a SMAPE of 13.02% and 11.90% were achieved, respectively. Conclusion: The ML model used in this study is promising at providing automated Cobb angle measurement in both idiopathic scoliosis and congenital scoliosis. Nevertheless, larger studies are needed in the future to confirm the results of this study prior to translation of this ML algorithm into clinical practice.

Characterization and quantification of fluid in the abdomen by ultrasound and magnetic resonance imaging in children with clinical suspicion of appendicitis.

PURPOSE: While regarded as a secondary sign of pediatric appendicitis, the frequency of physiologic intra-abdominal fluid in children with suspected but absent appendicitis is unknown. Ex vivo: to assess the validity of US/MRI measurements of free fluid. In vivo: in suspected pediatric appendicitis, to assess the amount of abdominal fluid by US and MRI, determine performance characteristics of US in fluid detection and identify fluid volume ranges in confirmed appendicitis. METHODS: Ex vivo: criterion validity of US and MRI for fluid volume measurements was tested using tissue-mimicking phantoms filled with different volumes of distilled water. In vivo: all participants from a previous prospective study of suspected appendicitis were evaluated by US; MRI was performed after equivocal USs. Qualitative and quantitative analyses of abdominal fluid and correlation of fluid presence with appendicitis were performed. RESULTS: Ex vivo: no difference was found between phantom-fluid amount and measured volume using the formula for volume of an ellipsoid for US (P=0.19) or MRI (P=0.08). In vivo: intra-abdominal fluid was present in 212/591 (35.9%) patients; 75/212 patients with fluid (35.4%) had appendicitis, 60 (28.3%) had alternate diagnoses, and 77 (36.3%) had physiologic fluid. Sensitivity and specificity of US for fluid detection were 84% (95% CI 71-93) and 65% (95% CI 52-77), respectively. In children with versus without appendicitis, the respective ranges of fluid volume were 0.7-1148.8 ml and 0.8-318 ml. CONCLUSION: The volume of an ellipsoid formula is a valid method for quantifying intra-abdominal fluid. The sole presence of intra-abdominal fluid on US does not support the diagnosis of pediatric appendicitis.

Developing standards for MRI evaluation of joints in children with juvenile idiopathic arthritis utilizing the temporomandibular joint as a model.

The treatment of a patient with juvenile idiopathic arthritis (JIA) is best monitored with standardized and validated tools to measure joint changes over time. Treatment approaches are best indicated if the clinicians are aware of the structural status of the joint at a given time, especially in anatomically deep joints for which clinical assessment is limited. Magnetic resonance imaging (MRI) is of utmost importance for assessment of deep joints and extra-articular soft tissue of the entire body for which ultrasound may be suboptimal. Because the distinction between pathologic and physiologic joint changes on MRI is key for proper diagnosis and treatment of patients with arthropathies, a comprehensive standardized approach is needed to effectively measure outcomes of growing joints of children with JIA. Such an approach is essential for both clinical assessment and to conduct clinical trials in patients with JIA treated in different centers around the world. To meet this need, several international imaging collaborative research groups have been developing MRI scales over the past years, including the MRI in JIA (JAMRI) special interest group within the Outcome Measures in Rheumatology (OMERACT) research network. This manuscript reviews the efforts of the OMERACT JAMRI working group to generate and validate pediatric MRI scoring systems for different joints in children with JIA that can have ubiquitous utilization anywhere in the world. In particular, it describes the different steps of development and validation of an MRI scale using the TMJ as a model.

Evaluating the Outcomes and Trainee Performance of a Canadian Medical Imaging Clinician Investigator Program.

Purpose: To measure the research productivity of trainees from the University of Toronto's Medical Imaging Clinician Investigator Program (MI-CIP) and comparing it with the research productivity of trainees from MI-non-CIP and General Surgery (GSx) Clinician Investigator Program. Methods: We identified residents who completed an MI-CIP, MI-non-CIP and GSx-CIP from 2006-2016. In each group of trainees, we assessed 3 research productivity outcomes with non-parametric tests before residency and at 7 years post-CIP completion/post-graduation. Research productivity outcomes include the number of total publications, the number of first-author publications, and the publication's average journal impact factor (IF). Results: We identified 11 MI-CIP trainees (male/female: 9 [82%]/2 [18%]), 74 MI-non-CIP trainees (46 [62%]/28 [38%]) and 41 GSx-CIP trainees (23 [56%]/18 [44%]). MI-CIP trainees had statistically significant higher research productivity than MI-non-CIP in all measured outcomes. The median (interquartile range, IQR) number of total publications of MI-CIP vs MI-non-CIP trainees was 5.0 (8.0) vs 1.0 (2.0) before residency and 6.0 (10.0) vs .0 (2.0) at 7 years post-CIP completion/post-graduation. The median (IQR) first-author publications of MI-CIP vs MI-non-CIP trainees was 2.0 (3.0) vs .0 (1.0) before residency and 2.0 (4.0) vs (.0) (1.0) at 7 years post-CIP completion/post-graduation. The median (IQR) average journal IF of MI-CIP vs MI-non-CIP trainees was 3.2 (2.0) vs .3 (2.4) before residency and 3.9 (3.2) vs .0 (2.6) at 7 years post-CIP completion/post-graduation. Between MI-CIP and GSx-CIP trainees, there were no significant differences in research productivity in all measured outcomes. Conclusion: MI-CIP trainees actively conducted research after graduation. These trainees demonstrated early research engagement before residency. The similar research productivity of MI-CIP vs GSx-CIP trainees shows initial success of MI-CIP trainees.

Early Cancer Detection in Li-Fraumeni Syndrome with Cell-Free DNA.

People with Li-Fraumeni syndrome (LFS) harbor a germline pathogenic variant in the TP53 tumor suppressor gene, face a near 100% lifetime risk of cancer, and routinely undergo intensive surveillance protocols. Liquid biopsy has become an attractive tool for a range of clinical applications, including early cancer detection. Here, we provide a proof-of-principle for a multimodal liquid biopsy assay that integrates a targeted gene panel, shallow whole-genome, and cell-free methylated DNA immunoprecipitation sequencing for the early detection of cancer in a longitudinal cohort of 89 LFS patients. Multimodal analysis increased our detection rate in patients with an active cancer diagnosis over uni-modal analysis and was able to detect cancer-associated signal(s) in carriers prior to diagnosis with conventional screening (positive predictive value = 67.6%, negative predictive value = 96.5%). Although adoption of liquid biopsy into current surveillance will require further clinical validation, this study provides a framework for individuals with LFS. SIGNIFICANCE: By utilizing an integrated cell-free DNA approach, liquid biopsy shows earlier detection of cancer in patients with LFS compared with current clinical surveillance methods such as imaging. Liquid biopsy provides improved accessibility and sensitivity, complementing current clinical surveillance methods to provide better care for these patients. See related commentary by Latham et al., p. 23. This article is featured in Selected Articles from This Issue, p. 5.

Systematic calibration reduces sources of variability for the preliminary OMERACT juvenile idiopathic arthritis MRI- sacroiliac joint score (OMERACT JAMRIS-SIJ).

OBJECTIVE: To determine whether systematic calibration enhances scoring proficiency of the OMERACT juvenile idiopathic arthritis MRI-Sacroiliac Joint score (JAMRIS-SIJ) and whether contrast-enhancement enhances its performance. METHODS: MRI SIJ scans of 50 cases with juvenile spondyloarthritis were scored by 7 raters after calibration with 3 different knowledge transfer tools. RESULTS: Calibrated readers achieved greater reliability for scoring certain inflammatory and structural lesions. Sensitivity and reliability for scoring inflammatory lesions was greater on fluid-sensitive compared to contrast-enhanced sequences. CONCLUSION: Systematic calibration should be implemented prior to the use of JAMRIS-SIJ for clinical trials. It is unlikely that contrast-enhanced MRI will improve the performance of this method.

Promoting Equity, Diversity, and Inclusion in Medicine: A Comprehensive Toolkit for Change in Radiology.

This toolkit presents a comprehensive framework for a toolkit intended to increase equity, diversity, and inclusion (EDI) within the medical field and recommendations. We advocate for clear, comprehensive definitions and interpretations of fundamental EDI terms, laying the groundwork necessary for initiating and maintaining EDI initiatives. Furthermore, we offer a systematic approach to establishing EDI committees within medical departments, accentuating the pivotal role these committees play as they drive and steer EDI strategies. This toolkit also explores strategies tailored for the recruitment of a diverse workforce. This includes integral aspects such as developing inclusive job advertisements, implementing balanced search methods for candidates, conducting unbiased appraisals of applications, and structuring diverse hiring committees. The emphasis on these strategies not only augments the diversity within medical institutions but also sets the stage for a more holistic approach to healthcare delivery. Therefore, by adopting the recommended strategies and guidelines outlined in this framework, medical institutions and specifically radiology departments can foster an environment that embodies inclusivity and equity, thereby enhancing the quality of patient care and overall health outcomes.

T2 mapping magnetic resonance imaging of cartilage in hemophilia.

Background: In hemophilia, recurrent hemarthrosis may lead to irreversible arthropathy. T2 mapping MRI may reflect cartilage changes at an earlier reversible stage of arthropathy as opposed to structural MRI. Objectives: To evaluate interval changes of T2 mapping compared with the International Prophylaxis Study Group (IPSG) structural MRI scores of ankle cartilage in boys with hemophilia receiving prophylaxis. Methods: Eight boys with hemophilia A (median age, 13; range, 9-17 years), 7 age- and sex-matched healthy boys (controls, median age, 15; range, 7-16 years). A multiecho spin-echo T2-weighted MRI sequence at 3.0T was used to obtain T2 maps of cartilage of boys with hemophilia and controls. Structural joint status was evaluated using the IPSG MRI score. Results: T2 relaxation times of ankle cartilage increased significantly over time in both persons with hemophilia and controls (P = .002 and P = .00009, respectively). Changes in T2 relaxation time strongly correlated with changes in IPSG cartilage scores (rs = 0.93 to rs = 0.78 [P = .0007 to P = .023]), but not with changes in age (P = .304 to P = .840). Responsiveness of T2 relaxation times were higher than that of IPSG cartilage scores, with standardized response means >1.4 for T2 mapping in all regions-of-interest compared with 0.84 for IPSG cartilage scores. Baseline T2 relaxation time strongly correlated with timepoint 2 IPSG cartilage score (rs = 0.93 to rs = 0.82 [P = .001 to P = .012]) and T2 relaxation time (rs = 0.98 to rs = 0.88 [P = .00003 to P = .004]) changes in most regions-of-interest. Conclusion: T2 mapping shows sensitivity to biochemical changes in cartilage prior to detectable damage using conventional MRI, offering potential for early detection of bleed-related cartilage damage in boys with hemophilia.

Applications of artificial intelligence in magnetic resonance imaging of primary pediatric cancers: a scoping review and CLAIM score assessment.

PURPOSES: To review the uses of AI for magnetic resonance (MR) imaging assessment of primary pediatric cancer and identify common literature topics and knowledge gaps. To assess the adherence of the existing literature to the Checklist for Artificial Intelligence in Medical Imaging (CLAIM) guidelines. MATERIALS AND METHODS: A scoping literature search using MEDLINE, EMBASE and Cochrane databases was performed, including studies of > 10 subjects with a mean age of < 21 years. Relevant data were summarized into three categories based on AI application: detection, characterization, treatment and monitoring. Readers independently scored each study using CLAIM guidelines, and inter-rater reproducibility was assessed using intraclass correlation coefficients. RESULTS: Twenty-one studies were included. The most common AI application for pediatric cancer MR imaging was pediatric tumor diagnosis and detection (13/21 [62%] studies). The most commonly studied tumor was posterior fossa tumors (14 [67%] studies). Knowledge gaps included a lack of research in AI-driven tumor staging (0/21 [0%] studies), imaging genomics (1/21 [5%] studies), and tumor segmentation (2/21 [10%] studies). Adherence to CLAIM guidelines was moderate in primary studies, with an average (range) of 55% (34%-73%) CLAIM items reported. Adherence has improved over time based on publication year. CONCLUSION: The literature surrounding AI applications of MR imaging in pediatric cancers is limited. The existing literature shows moderate adherence to CLAIM guidelines, suggesting that better adherence is required for future studies.

Properties of ultrasound-rapid MRI clinical diagnostic pathway in suspected pediatric appendicitis.

OBJECTIVE: to determine diagnostic accuracy of an US-MRI clinical diagnostic pathway to detect appendicitis in the emergency department (ED). STUDY DESIGN: prospective cohort study of 624 previously healthy children 4-17 years old undergoing US for suspected appendicitis and clinical re-assessment. Children with non-diagnostic USs and persistent appendicitis concern/conclusive US-reassessment discrepancies underwent ultra-rapid MRI (US-MRI pathway), interpreted as positive, negative or non-diagnostic. Cases with missed appendicitis, negative appendectomies, and CT utilization were considered clinically diagnostically inaccurate. Primary outcome was the proportion of accurate diagnoses of appendicitis/lack thereof by the pathway. RESULTS: 150/624 (24%) children had appendicitis;255 USs (40.9%) were non-diagnostic. Of 139 US-MRI pathway children (after 117 non-diagnostic and 22 conclusive USs), 137 [98.6%; 95% CI 0.96-1.00] had clinically accurate outcomes (1 CT, 1 negative appendectomy): sensitivity 18/18 [100%], specificity 119/121 [98.3%], positive predictive value 18/20 [90.5%], negative predictive value 119/119 [100%]. MRI imaging accuracy was 134/139 (96.4%); 3 MRIs were non-diagnostic (no appendicitis). In the overall algorithm, 616/624 [98.7% (0.97-0.99)] patients had accurate outcomes: 147/150 (98.0%) appendicitis cases had confirmatory surgeries (3 CTs) and 469/474 (98.9%) appendicitis-negative children had no surgery/CT. CONCLUSION: this study demonstrated high clinical accuracy of the US-rapid-MRI pathway in suspected pediatric appendicitis after non-diagnostic US.

Recommendations for Improvement of Equity, Diversity, and Inclusion in the CaRMs Selection Process.

Equity, diversity and inclusion (EDI) in the medical field is crucial for meeting the healthcare needs of a progressively diverse society. A diverse physician workforce enables culturally sensitive care, promotes health equity, and enhances the comprehension of the various needs and viewpoints of patients, ultimately resulting in more effective treatments and improved patient outcomes. However, despite the recognized benefits of diversity in the medical field, certain specialties, such as Radiology, have struggled to achieve adequate equity, diversity and inclusion, which results in a discrepancy in the demographics of Canadian radiologists and the patients we serve. In this review, we propose strategies from a committee within the Canadian Association of Radiologists (CAR) EDI working group to improve EDI in the CaRMS selection process. By adopting these strategies, residency programs can foster a more diverse and inclusive environment that is better positioned to address the health needs of a progressively diverse patient population, leading to improved patient outcomes, greater patient satisfaction, and advancements in medical innovation.

Determination of Relative Weightings for Sacroiliac Joint Pathologies in the OMERACT Juvenile Arthritis Magnetic Resonance Imaging Sacroiliac Joint Score.

This study aims to determine the relative weights (point value) of items of the juvenile idiopathic arthritis magnetic resonance imaging-sacroiliac joint scoring system (JAMRIS-SIJ). An adaptive multicriteria decision analysis was performed using the 1000Minds web application to determine the relative weights of the items in the JAMRIS-SIJ inflammation and damage domains. Experts in imaging and rheumatology independently completed a conjoint analysis survey (CAS) to determine the point value of the measurement items of the JAMRIS-SIJ. Each CAS survey question asked the expert to compare two hypothetical patient profiles, which were otherwise similar but different at two items at a time, and to select which item showed a more severe stage of inflammation or osteochondral damage. In addition, experts ranked 14 JAMRIS-SIJ grade only or image + grade patient vignettes while blinded to the CAS-derived weights. The validity of the weighted JAMRIS-SIJ was tested by comparing the expert CAS-weighted score and the image + grade ranking method. Seventeen experts completed the CAS (11 radiologists and 6 rheumatologists). Considering the point value for inflammation domain items, osteitis (24.7%) and bone marrow edema (24.3%) had higher group-averaged percentage weights compared to inflammation in erosion cavity (16.9%), joint space enhancement (13.1%), joint space fluid (9.1%), capsulitis (7.3%), and enthesitis (4.6%). Similarly, concerning the damage domain, ankylosis (41.3%) and erosion (25.1%) showed higher group-averaged weights compared to backfill (13.9%), sclerosis (10.7%), and fat metaplasia lesion (9.1%). The Spearman correlation coefficients of the CAS-weighted vignette order and unweighted JAMRIS-SIJ grade only order vignettes for all experts were 0.79 for inflammation and 0.80 for damage. The correlations of image vignettes among imaging experts to CAS were 0.75 for inflammation and 0.90 for damage. The multicriteria decision analysis identified differences in relative weights among the JAMRIS-SIJ measurement items. The determination of the relative weights provided expert-driven score scaling and face validity for the JAMRIS-SIJ, enabling the future evaluation of its longitudinal construct validity.

MRI of the temporomandibular joint in children with juvenile idiopathic arthritis: protocol and findings.

Contrast-enhanced magnetic resonance imaging (MRI) is the technique of choice for diagnosis and monitoring of temporomandibular joint (TMJ) disorders in patients with juvenile idiopathic arthritis (JIA), as it is able to visualize both soft tissue and osteochondral changes. Approximately 40% of children with JIA develop inflammatory and chronic osteochondral changes observable on imaging, which if left untreated can lead to significant facial growth impairment, including facial asymmetry and retrognathia. MRI of the TMJ plays a paramount role in diagnosis and treatment monitoring in JIA since early signs of TMJ involvement are difficult to detect clinically and with physical examination. Findings of TMJ arthritis may be classified into acute and chronic domains. Early or acute manifestations include joint effusion, bone marrow edema, synovial thickening, and increased joint enhancement. With disease progression, there are characteristic osteochondral changes, including deformity of the mandibular condyle with shortening of the mandibular ramus, bone erosions, and disk abnormalities. In this pictorial essay, we describe a consensus MRI protocol for the study of the TMJ and illustrate the degree of normal and pathological MRI findings using currently available MRI scoring systems of the TMJ developed for JIA.