Yield of skeletal surveys in national network of child abuse pediatricians: Age is key.

BACKGROUND: Skeletal surveys (SS) are recommended for the evaluation of suspected physical abuse in children <2 years old. No guidelines exist for SS completion in children between 2 and 5 years old. OBJECTIVE: To determine rates of SS completion by age and examine variables associated with occult fracture identification in older children. PARTICIPANTS AND SETTING: Observational cross-sectional multi-center study of 10 US pediatric centers 2/2021-9/2022 including children <6 years old evaluated for physical child abuse. METHODS: The principal outcome is occult fracture identified on SS. Non-parametric tests were conducted from comparison between age groups and those with and without occult fractures. RESULTS: The rate of SS completion declined with increasing age from a high of 91 % in infants <6 months old to 7 % in children 5-5.9 years old. The proportion of SS with occult fractures also decreased with age. Of 450 children 2-5 years old with a SS, 20 [4 % (95 % CI: 3-8 %)] had an occult fracture. The rate of occult fractures among children 2-5 years old who were diagnosed with abuse and not admitted to the hospital was 0.3 % (95 % CI 0-0.6 %)]. Over 30 % of children 2-5 years old were diagnosed with child abuse by a child abuse pediatrician without completion of a SS. CONCLUSION: In children 2-5 years of age being evaluated for physical abuse, use of SS and the rate of occult fractures is low. The number of SS performed in children in this age group could potentially be decreased by up to 60 % by limiting SS to children admitted to the hospital.

Deep generative model of the distal tibial classic metaphyseal lesion in infants: assessment of synthetic images.

Background: The classic metaphyseal lesion (CML) is a distinctive fracture highly specific to infant abuse. To increase the size and diversity of the training CML database for automated deep-learning detection of this fracture, we developed a mask conditional diffusion model (MaC-DM) to generate synthetic images with and without CMLs. Purpose: To objectively and subjectively assess the synthetic radiographic images with and without CMLs generated by MaC-DM. Materials and Methods: For retrospective testing, we randomly chose 100 real images (50 normals and 50 with CMLs; 39 infants, male = 22, female = 17; mean age = 4.1 months; SD = 3.1 months) from an existing distal tibia dataset (177 normal, 73 with CMLs), and generated 100 synthetic distal tibia images via MaC-DM (50 normals and 50 with CMLs). These test images were shown to 3 blinded radiologists. In the first session, radiologists determined if the images were normal or had CMLs. In the second session, they determined if the images were real or synthetic. We analyzed the radiologists' interpretations and employed t-distributed stochastic neighbor embedding technique to analyze the data distribution of the test images. Results: When presented with the 200 images (100 synthetic, 100 with CMLs), radiologists reliably and accurately diagnosed CMLs (kappa = 0.90, 95% CI = [0.88-0.92]; accuracy = 92%, 95% CI = [89-97]). However, they were inaccurate in differentiating between real and synthetic images (kappa = 0.05, 95% CI = [0.03-0.07]; accuracy = 53%, 95% CI = [49-59]). The t-distributed stochastic neighbor embedding analysis showed substantial differences in the data distribution between normal images and those with CMLs (area under the curve = 0.996, 95% CI = [0.992-1.000], P < .01), but minor differences between real and synthetic images (area under the curve = 0.566, 95% CI = [0.486-0.647], P = .11). Conclusion: Radiologists accurately diagnosed images with distal tibial CMLs but were unable to distinguish real from synthetically generated ones, indicating that our generative model could synthesize realistic images. Thus, MaC-DM holds promise as an effective strategy for data augmentation in training machine-learning models for diagnosis of distal tibial CMLs.

Whole-body low-dose computed tomography in patients with newly diagnosed multiple myeloma predicts cytogenetic risk: a deep learning radiogenomics study.

OBJECTIVE: To develop a whole-body low-dose CT (WBLDCT) deep learning model and determine its accuracy in predicting the presence of cytogenetic abnormalities in multiple myeloma (MM). MATERIALS AND METHODS: WBLDCTs of MM patients performed within a year of diagnosis were included. Cytogenetic assessments of clonal plasma cells via fluorescent in situ hybridization (FISH) were used to risk-stratify patients as high-risk (HR) or standard-risk (SR). Presence of any of del(17p), t(14;16), t(4;14), and t(14;20) on FISH was defined as HR. The dataset was evenly divided into five groups (folds) at the individual patient level for model training. Mean and standard deviation (SD) of the area under the receiver operating curve (AUROC) across the folds were recorded. RESULTS: One hundred fifty-one patients with MM were included in the study. The model performed best for t(4;14), mean (SD) AUROC of 0.874 (0.073). The lowest AUROC was observed for trisomies: AUROC of 0.717 (0.058). Two- and 5-year survival rates for HR cytogenetics were 87% and 71%, respectively, compared to 91% and 79% for SR cytogenetics. Survival predictions by the WBLDCT deep learning model revealed 2- and 5-year survival rates for patients with HR cytogenetics as 87% and 71%, respectively, compared to 92% and 81% for SR cytogenetics. CONCLUSION: A deep learning model trained on WBLDCT scans predicted the presence of cytogenetic abnormalities used for risk stratification in MM. Assessment of the model's performance revealed good to excellent classification of the various cytogenetic abnormalities.

Identification and Evaluation of Non-Accidental Trauma in the Pediatric Population: A Clinical Review.

Non-accidental trauma (NAT) is a major cause of morbidity and mortality for children around the world and most significantly impacts children under one year of age. Prompt and comprehensive treatment of these children relies on a high index of suspicion from any medical provider that treats pediatric patients. This review discusses those most at risk for experiencing NAT, and common initial presentations, to assist providers in the identification of potential victims. In addition, this review provides guidance on the recommended workup for these patients so that the full extent of associated injuries may be identified and the appropriate healthcare team may be assembled.

Impact of Structured Reporting of Skeletal Survey in Skeletal Dysplasia: A Single Institution Experience.

Background Structured reporting has the advantages of reducing ambiguity in written radiology reports with greater uniformity and comparability of reports amongst different institutes. It has multiple facets: structured format, structured content, and standardized language. While structured reporting initiative has been used in various radiology subspecialties such as oncology, cardiothoracic, abdominal and interventional radiology; skeletal dysplasia is a domain that remains largely untouched by this concept. Purpose To evaluate the impact of structured reporting in skeletal dysplasia. Methods and Materials This was an ethically approved pragmatic clinical trial. A defined number (75) of clinically diagnosed and/or genetically confirmed skeletal dysplasia radiographs were evaluated by two radiologists (reader A and reader B) with 5-and 7-years' experience in general radiology, respectively. A pre-defined structured reporting format for skeletal dysplasia was used as an interventional tool. Both the readers interpreted the radiographs before and after the training session. In addition to diagnosis, diagnostic confidence was noted using a semiquantitative scale. Improvement in diagnostic accuracy and diagnostic confidence after training were assessed. McNemar's test was used to assess the statistical significance of difference in proportion of correct diagnoses in pre- and post-education phases. An interrater reliability analysis using the Kappa statistic was performed to determine interobserver agreement between readers both in pre- and post-education phases. Results In the post-education phase, the proportion of accurate diagnosis improved from 48% (36/75) to 64% (48/75) for reader A, and from 44% (33/75) to 60% (45/75) for reader B as compared with the pre-education phase. Amongst the cases with a correct radiologic diagnosis, an increase in diagnostic confidence was noted in 18 cases for reader A, and 15 cases for reader B. In none of the cases, there was a reduction in diagnostic confidence after training. A McNemar's test determined that there was a statistically significant difference in the proportion of correct diagnoses in pre- and post-education phases, p < 0.001. The interobserver agreement between the readers was found to increase from Kappa = 0.33 ( p = 0.004) using non-structured reporting in pre-education phase to Kappa = 0.46 ( p < 0.001) using structured reporting in the post-education phase. Conclusion A structured reporting of skeletal survey can improve accuracy and confidence in diagnosing skeletal dysplasia.

Skeletal survey yields in low vs. high risk pediatric patients with skull fractures.

BACKGROUND: To assess for occult fractures, physicians often opt to obtain skeletal surveys (SS) in young, acutely head-injured patients who present with skull fractures. Data informing optimal decision management are lacking. OBJECTIVE: To determine the positive yields of radiologic SS in young patients with skull fractures presumed to be at low vs. high risk for abuse. PARTICIPANTS AND SETTING: 476 acutely head injured, skull-fractured patients <3 years hospitalized for intensive care across 18 sites between February 2011 and March 2021. METHODS: We conducted a retrospective, secondary analysis of the combined, prospective Pediatric Brain Injury Research Network (PediBIRN) data set. RESULTS: 204 (43 %) of 476 patients had simple, linear, parietal skull fractures. 272 (57 %) had more complex skull fracture(s). Only 315 (66 %) of 476 patients underwent SS, including 102 (32 %) patients presumed to be at low risk for abuse (patients who presented with a consistent history of accidental trauma; intracranial injuries no deeper than the cortical brain; and no respiratory compromise, alteration or loss of consciousness, seizures, or skin injuries suspicious for abuse). Only one of 102 low risk patients revealed findings indicative of abuse. In two other low risk patients, SS helped to confirm metabolic bone disease. CONCLUSIONS: Less than 1 % of low risk patients under three years of age who presented with simple or complex skull fracture(s) revealed other abusive fractures. Our results could inform efforts to reduce unnecessary skeletal surveys.

Professional practice and awareness of child abuse among radiologists and radiologic technologists: results from Saudi Arabia.

BACKGROUND: The knowledge, awareness and professionalism of health care providers in the field of child protection are crucial in identifying and reporting suspected child abuse. Radiologic technologists and radiologists play a vital role in the diagnosis of suspected physical child abuse. OBJECTIVE: To assess current practice, knowledge and awareness of child abuse among radiologic technologists and radiologists in Saudi Arabia. MATERIALS AND METHODS: We distributed an internet-based questionnaire to radiologic technologists and radiologists working in Saudi Arabia via national radiology societies and social media channels over a 6-week period (27 October to 8 December 2021). Survey questions covered knowledge regarding child abuse, professional practice in radiology departments in Saudi Arabia in cases of suspected physical abuse (SPA), and knowledge of the national legislation and reporting and acting procedures in child abuse. RESULTS: A total of 315 respondents (224 radiologic technologists and 91 radiologists) participated in this study. The median score for knowledge of abuse was higher amongst radiologists (4.8) than radiologic technologists (4.0); P < 0.001. In total, 210 (93.8%) radiologic technologists and 61 (67.0%) radiologists reported that there was no protocol (i.e. skeletal survey) at their hospital for imaging children with SPA. Most radiologic technologists had no training in paediatric radiology (165/224, 73.7%) and most radiologists had received no training in evaluating imaging performed for SPA (73/91, 80.2%). More than half of respondents - 131 (58.5%) radiologic technologists and 44 (48.4%) radiologists - were not familiar with the reporting and acting procedures at their hospitals in cases of child abuse. CONCLUSION: Although radiologic technologists and radiologists in Saudi Arabia have good knowledge and awareness of child abuse in general, they lack specific knowledge of the reporting and acting procedures at their hospitals in cases of suspected child abuse. National imaging guidelines and training courses are needed to develop appropriate skills in the recognition, imaging and reporting of SPA in infants and young children in Saudi Arabia.

Whole-body magnetic resonance imaging for staging Langerhans cell histiocytosis in children and young adults.

INTRODUCTION: Radiographic skeletal survey (R-SS) is the standard imaging technique for the initial staging of Langerhans cell histiocytosis (LCH). Whole-body magnetic resonance imaging (WB-MRI) has been proposed as an effective, radiation-free alternative. METHODS: We prospectively assessed patients with LCH followed at three tertiary centers in Italy and Austria. Two national study protocols were independently designed, and data were then pooled to increase the power of their findings. R-SS and WB-MRI were performed at diagnosis and repeated at the follow-up to confirm the nature of the identified lesions and to study their evolution. RESULTS: Data from 67 patients were analyzed (52 from Italy and 15 from Austria). Compared to R-SS, WB-MRI identified 29 additional skeletal lesions in 14 patients (including two false-positive lesions). Two skeletal lesions were detected at R-SS and missed at WB-MRI (false negative). Per-lesion sensitivity rates were 78.6% (95% CI: 71.0-85.9) for R-SS and 98.4% (95% CI: 94.4-99.8) for WB-MRI, respectively. Based on WB-MRI findings, six patients would have been upstaged to a higher risk class than staging with R-SS. CONCLUSIONS: WB-MRI had a significantly higher detection rate for skeletal lesions compared to R-SS. Clinical and radiology expertise is required to avoid upstaging and overtreatment.

The added value of skeletal surveys in the initial evaluation of children diagnosed with Langerhans cell histiocytosis in the era of staging 18 F-FDG PET/CT: A retrospective study.

OBJECTIVE: Currently, there is no consensus protocol on the initial staging evaluation for Langerhans cell histiocytosis (LCH). Our institutional protocol consists of a skeletal survey and a whole-body positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro-D-glucose integrated with computed tomography (FDG PET/CT) study. The utility of the PET/CT lies in its sensitivity in detecting osseous and extra-osseous lesions, and in determining the baseline metabolic activity of LCH lesions to assess treatment response. However, the added utility of the skeletal survey in staging LCH is unclear. Therefore, this study retrospectively assessed the added diagnostic value of skeletal surveys in patients with baseline PET/CTs for initial staging of LCH. METHODS: We retrospectively searched the medical records of all patients less than or equal to 18 years old at a large children's hospital (May 2013 to September 2021). The inclusion criteria were (a) biopsy-proven diagnosis of LCH and (b) initial staging PET/CT and skeletal survey performed less than or equal to 1 month apart. A blinded pediatric radiologist reviewed the skeletal surveys and another reviewed the PET/CTs in identifying LCH osseous lesions. RESULTS: Our study cohort consisted of 49 children with 86 LCH osseous lesions. In non-extremity locations, PET/CT identified 70/70 (100%) osseous lesions, while skeletal surveys detected 43/70 (61.4%) osseous lesions. In the extremities, PET/CT identified 13/16 (81.3%) osseous lesions, while skeletal surveys detected 15/16 (93.8%) osseous lesions. CONCLUSION: Skeletal surveys increased the detection rate of osseous lesions in the extremities, but added no diagnostic value to the detection of osseous lesions in non-extremity locations. Therefore, we propose to abbreviate the skeletal survey to include only extremity radiographs.

Typical median effective radiation doses using an anthropomorphic bone fracture phantom for initial radiographic skeletal surveys in the investigation of suspected physical abuse.

BACKGROUND: A series of 31 radiographs is recommended by the Royal College of Radiologists (RCR) when investigating suspected physical abuse (SPA). OBJECTIVE: To determine the radiation dose delivered for skeletal surveys performed for SPA in Victorian radiology departments based on their local protocols. MATERIALS AND METHODS: A 5-year-old paediatric bone fracture phantom was radiographed at five radiology sites using both the RCR recommended protocol and, where applicable, the local departmental SPA protocol. The radiation doses were measured and recorded. These were scaled down to estimate the effective radiation doses for a 2-year-old child at each site and the associated radiation risks estimated. RESULTS: The median effective dose for all radiographic projections in the RCR skeletal survey radiographic series was 0.09 mSv. The estimated risk of radiation-induced cancer and radiation-induced death from cancer for 2-year-old children is classified as "very low," with girls having a higher risk than boys. CONCLUSION: The median effective radiation dose for the RCR skeletal survey for imaging in SPA was 0.09 mSv resulting in a "very low" additional risk of radiation-induced cancer. The authors will now aim to ascertain whether whole-body CT skeletal survey can replace the radiographic series for imaging in SPA while maintaining a comparable radiation dose.

Effective radiation dose of skeletal surveys performed for suspected physical abuse.

BACKGROUND: A skeletal survey is an important diagnostic tool for patients presenting with suspected physical abuse. A relatively recent change in guidelines for skeletal surveys by the Royal College of Radiologists (RCR) in 2017 has led to more initial and follow-up images for these patients, which would be expected to have led to an increase in effective radiation dose. OBJECTIVE: To estimate the effective dose following the change in guidelines and to ascertain the difference between doses before and after the change in guidelines. MATERIALS AND METHODS: Data were collected retrospectively on children younger than 3 years old referred for skeletal surveys for suspected physical abuse at a tertiary paediatric centre. A Monte Carlo radiation patient dose simulation software, PCXMC v 2.0.1, was used to estimate the effective dose, expressed in millisieverts (mSv). RESULTS: Sixty-eight children underwent skeletal surveys for suspected physical abuse. The total estimated effective dose for skeletal surveys with the previous RCR guidelines was found to be 0.19 mSv. For initial skeletal surveys with the current RCR guidelines, the estimated effective radiation dose was 0.19 mSv. Eighteen children had both initial and follow-up skeletal surveys as indicated by the current RCR guidelines, with an estimated effective total radiation dose of 0.26 mSv. CONCLUSION: Skeletal surveys deliver a relatively low estimated effective radiation dose equivalent to 1 month of United Kingdom background radiation, with no significant change in dose following the change in guidelines. Therefore, the benefits of having a skeletal survey outweigh the main radiation risk. However, accurate data regarding the radiation dose are important for clinicians consenting parents/guardians for imaging in suspected physical abuse.

Modern imaging techniques for monitoring patients with multiple myeloma.

Bone disease is a serious problem for many patients, often causing pathological bone fractures. A spinal collapse is a condition that affects the quality of life. It is the most frequent feature of multiple myeloma (MM), used in establishing the diagnosis and the need to start treatment. Because of these complications, imaging plays a vital role in the diagnosis and workup of myeloma patients. For many years, conventional radiography has been considered the gold standard for detecting bone lesions. The main reasons are the wide availability, low cost, the relatively low radiation dose and the ability of this imaging method to cover the entire bone system. Because of its incapacity to evaluate the response to therapy, more sophisticated techniques such as whole-body low-dose computed tomography (WBLDCT), whole-body magnetic resonance imaging, and 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) are used. In this review, some of the advantages, indications and applications of the three techniques in managing patients with MM will be discussed. The European Myeloma Network guidelines have recommended WBLDCT as the imaging modality of choice for the initial assessment of MM-related lytic bone lesions. Magnetic resonance imaging is the gold-standard imaging modality for the detection of bone marrow involvement. One of the modern imaging methods and PET/CT can provide valuable prognostic data and is the preferred technique for assessing response to therapy.

Machine learning to identify distal tibial classic metaphyseal lesions of infant abuse: a pilot study.

BACKGROUND: The classic metaphyseal lesion (CML) is an injury that is highly specific for infant abuse, and the distal tibia is one of the most common sites of occurrence. A machine learning tool that identifies distal tibial CMLs on infant skeletal surveys could assist radiologists in the diagnosis of infant abuse. OBJECTIVE: To develop and evaluate a machine learning-based classification algorithm to identify distal tibial CMLs on skeletal surveys performed for suspected infant abuse. MATERIALS AND METHODS: We reviewed medical records of infants (≤1 year old) who had skeletal surveys for suspected abuse at a large tertiary children's hospital over the past 13 years to identify those at low and high risk for abuse. Normal distal tibial radiographs from the low-risk group formed the normal study cohort; radiographs with distal tibial CMLs from the high-risk group formed the abnormal study cohort. We used these two cohorts to train a machine learning algorithm to classify distal tibial radiographs as normal or abnormal. We systematically evaluated this algorithm using a fivefold cross-validation procedure and statistically analyzed the results. RESULTS: The normal study cohort consisted of 177 radiographs from 89 infants, and the abnormal study cohort consisted of 73 radiographs from 35 infants. Our machine learning algorithm showed an overall performance accuracy of 93% and Kappa of 0.84. The overall sensitivity and specificity of the model were 88% and 96%, respectively. CONCLUSION: Our developed machine learning model shows encouraging results as an automated tool to identify CMLs of the distal tibia on skeletal surveys performed for suspected infant abuse.

A prospective study of Skeletal survey versus Low-dose whole-body CT for Osteolytic lesions in Multiple Myeloma.

Whole-body low-dose CT (WBLDCT) is recommended over classical skeletal surveys (CSS) for investigating bone disease in multiple myeloma (MM) based on retrospective studies. No prospective studies with serial follow-up scans exist. OBJECTIVE: To compare WBLDCT to CSS for identifying progressive bone disease in MM in a prospective setting. METHODS: Ninety-six patients with MM at Odense University Hospital and Stavanger Hospital were followed for up to four years. Patients were scanned with WBLDCT and CSS every year for the first two years and every six months thereafter or at suspicion of progression. RESULTS: Nineteen cases of progressive bone disease were found using WBLDCT vs eight cases using CSS (p < 0.001). All cases of progressive bone disease using CSS were also identified by WBLDCT. Progression not found by CSS was primarily in the spine, sternum, and pelvis. Of the 19 cases, five patients had progressive bone disease only without other criteria for clinical progression. WBLDCT consistently identified more bone lesions per patient, 8.2 CI(6.8;9.6) vs CSS, 3.6 CI(2.7;4.5). CONCLUSION: WBLDCT outperformed CSS for finding progressive bone disease and osteolytic lesions. More new lesions were found during follow-up by WBLDCT than CSS. Using CSS for lytic lesions will underestimate progression rates. Our data offer prospective evidence for the current recommendation using WBLDCT for skeletal evaluations in patients with multiple myeloma.

Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study.

Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.

Clinical evaluation of a phantom-based deep convolutional neural network for whole-body-low-dose and ultra-low-dose CT skeletal surveys.

OBJECTIVE: This study evaluated the clinical utility of a phantom-based convolutional neural network noise reduction framework for whole-body-low-dose CT skeletal surveys. MATERIALS AND METHODS: The CT exams of ten patients with multiple myeloma were retrospectively analyzed. Exams were acquired with routine whole-body-low-dose CT protocol and projection noise insertion was used to simulate 25% dose exams. Images were reconstructed with either iterative reconstruction or filtered back projection with convolutional neural network post-processing. Diagnostic quality and structure visualization were blindly rated (subjective scale ranging from 0 [poor] to 100 [excellent]) by three musculoskeletal radiologists for iterative reconstruction and convolutional neural network images at routine whole-body-low-dose and 25% dose CT. RESULTS: For the diagnostic quality rating, the convolutional neural network outscored iterative reconstruction at routine whole-body-low-dose CT (convolutional neural network: 95 ± 5, iterative reconstruction: 85 ± 8) and at the 25% dose level (convolutional neural network: 79 ± 10, iterative reconstruction: 22 ± 13). Convolutional neural network applied to 25% dose was rated inferior to iterative reconstruction applied to routine dose. Similar trends were observed in rating experiments focusing on structure visualization. CONCLUSION: Results indicate that the phantom-based convolutional neural network noise reduction framework can improve visualization of critical structures within CT skeletal surveys. At matched dose level, the convolutional neural network outscored iterative reconstruction for all conditions studied. The image quality improvement of convolutional neural network applied to 25% dose indicates a potential for dose reduction; however, the 75% dose reduction condition studied is not currently recommended for clinical implementation.

Value of chest CT over skeletal surveys in detection of rib fractures in pediatric patients.

Recent literature has raised concerns about the sensitivity and accuracy of radiographs at diagnosing rib fractures. Studies have shown that chest computed tomography (CT) has far greater sensitivity at detecting rib fractures than radiographs. The purpose of this study was to evaluate the sensitivity of skeletal survey (SS) radiographs at diagnosis of rib fractures compared to CT in the pediatric population. This retrospective review included 57 patients who had undergone both a SS and a CT chest or CT chest/abdomen/pelvis within 30 days of each other for the indication of either non-accidental (NAT) or accidental trauma between 2009 and 2017. Images and reports were analyzed by a pediatric radiology fellow for presence/absence of fracture, evidence of healing and location of rib fracture, including rib level, location within the rib (anterior, lateral, and posterior), and side (right versus left). 225 rib fractures were identified in 25 patients on CT. 38 of those fractures were missed on the preceding SS, yielding a miss rate of 17%. Acute fractures were more likely to be missed than chronic or healing fractures (p ≤ 0.01). Location within the rib did not impact rib detection on radiographs. Left-sided rib fractures were not more common in NAT patients, compared to accidental trauma. SS miss approximately 17% of all rib fractures and CT is more sensitive modality in the detection of rib fractures, particularly acute rib fractures, regardless of location. Low-dose Chest CT could be a helpful modality in the work-up of NAT trauma.

[Guideline adherence and quality assurance in radiological diagnostics in cases of suspected child abuse in Germany]. / Leitlinientreue und Qualitätssicherung in der bildgebenden Diagnostik bei Verdacht auf Kindesmisshandlung in Deutschland.

BACKGROUND: Diagnostic imaging plays a key role in the evaluation of non-accidental consequences of injuries in childhood. Fractures are the second most common consequence of child abuse, after skin lesions such as abrasions or bleeding. With the evidence of radiological criteria, non-accidental fractures can be differentiated from accidental fractures. Special types of fractures such as the classic metaphyseal lesion can only be differentiated if the image quality is high. AIM: The goal of this prospective study was to assess adherence to guidelines and quality assurance of radiological diagnostics in the event of suspected abuse in Germany. For this purpose, the quantity and diagnostic quality in university and non-university hospitals as well as the existence of a pediatric radiology department were analyzed. MATERIALS AND METHODS: In all, 958 X­ray examinations of 114 suspected abuse cases (46 girls, 68 boys) were evaluated; 42 cases from university, 42 from maximum care and 30 from regular care clinics with a median age of 6 months (3 weeks-3 years of age) were assessed as DICOM data by 3 pediatric radiologists in a consensus procedure with regard to adherence to guidelines and various quality parameters. An accompanying questionnaire was used to compare the theoretical knowledge with the respective practical implementation. RESULTS: A mean of 8.4 X­rays (range 1-22) were made per case. In 12 of 114 assessed cases (10%) there was a complete skeletal status according to the S1 guideline. A babygram was performed in 13 cases (10.5%). Departments with focus on pediatric radiology produced significantly more X­rays per skeletal status than facilities without this specialization (p < 0.04). Significantly higher qualitative implementation was recorded in university hospitals (p < 0.001). Regardless of the type of institution, there was only marginal agreement between the questionnaire response and the available image material. CONCLUSION: In Germany, a guideline-compliant procedure in the event of suspected child abuse is largely lacking. It remains to be seen whether this will change in the future with the broader implementation of child protection groups and the S3+ child protection guideline adopted in 2019 (AWMF register 027-069). The establishment of reference centers for a second diagnosis and recommendations for imaging technology can also improve the quality of care over the long term.

A survey study investigating perceptions and acceptance of the whole-body imaging techniques used for the diagnosis of myeloma.

INTRODUCTION: The purpose of this study was to investigate patient perceptions and acceptance of the three whole-body imaging (WBI) modalities used for diagnosing myeloma; radiographic skeletal survey (RSS), low-dose whole-body computed tomography (LD-WBCT) and whole-body magnetic resonance imaging (WB-MRI). The secondary aim was to explore the factors affecting the acceptance of whole-body imaging for myeloma. METHODS: 60 participants (median age = 58.5 years old) recruited from three NHS trusts and social media completed a survey in which they scored their experiences of each WBI modality on nine 5-point rating scales. Spearman's correlation coefficient, Kruskal-Wallis, Mann-Whitney and Wilcoxon signed-rank tests were used to compare scores between different WBI techniques. Participants were invited to provide additional open text responses for interpretation using thematic analysis. RESULTS: All modalities demonstrated high levels of acceptability (median score = 4). WB-MRI was perceived as more stressful (p=<0.01) and claustrophobic (p=<0.01) than RSS and LD-WBCT. Thematic analysis showed patients understood the importance of imaging but had concerns about exacerbated pain and the results. WB-MRI was difficult to tolerate due to its duration. Respondents were averse to the physical manipulation required for RSS while remaining stationary was perceived as a benefit of LD-WBCT and WB-MRI. Staff interactions had both positive and negative effects on acceptance. CONCLUSIONS: Despite the psychological and physical burdens of WBI, patients accepted its role in facilitating diagnosis. Staff support is vital for facilitating a positive whole-body imaging experience. Healthcare practitioners can improve WBI acceptance by understanding the burdens imposed by WBI and adopting the personalised care model. IMPLICATIONS FOR PRACTICE: Patient experience can be improved by tailoring examinations to individual needs. RSS can be as burdensome as other WBI techniques and could be superseded by LD-WBCT or WB-MRI.

What's in a name? Sentinel injuries in abused infants.

Infants are at greatest risk of severe and fatal physical abuse yet they sometimes present for medical care multiple times with abusive injuries prior to being diagnosed with abuse and having protective actions taken. Efforts to identify these infants in a timely manner are critical to prevent repeated, escalating abuse and subsequent harm. Increasing the identification and evaluation of sentinel injuries has been highlighted as a strategy for improving timely detection of abuse in infants. Sentinel injuries are visible, minor, poorly explained injuries in young infants that raise concern for abuse. These injuries include cutaneous injuries such as bruising, subconjunctival hemorrhages and intra-oral injuries. Sentinel injuries can signal concurrent clinically occult but more serious injuries or precede more significant trauma from abuse. As such, sentinel injuries offer an opportunity to intervene and protect infants from further harm. A thorough physical exam is critical for detecting sentinel injuries. Imaging with skeletal survey and, when appropriate, neuroimaging are key components of the medical evaluation of sentinel injuries in these high-risk infants.