Reduced fire severity offers near-term buffer to climate-driven declines in conifer resilience across the western United States.

Increasing fire severity and warmer, drier postfire conditions are making forests in the western United States (West) vulnerable to ecological transformation. Yet, the relative importance of and interactions between these drivers of forest change remain unresolved, particularly over upcoming decades. Here, we assess how the interactive impacts of changing climate and wildfire activity influenced conifer regeneration after 334 wildfires, using a dataset of postfire conifer regeneration from 10,230 field plots. Our findings highlight declining regeneration capacity across the West over the past four decades for the eight dominant conifer species studied. Postfire regeneration is sensitive to high-severity fire, which limits seed availability, and postfire climate, which influences seedling establishment. In the near-term, projected differences in recruitment probability between low- and high-severity fire scenarios were larger than projected climate change impacts for most species, suggesting that reductions in fire severity, and resultant impacts on seed availability, could partially offset expected climate-driven declines in postfire regeneration. Across 40 to 42% of the study area, we project postfire conifer regeneration to be likely following low-severity but not high-severity fire under future climate scenarios (2031 to 2050). However, increasingly warm, dry climate conditions are projected to eventually outweigh the influence of fire severity and seed availability. The percent of the study area considered unlikely to experience conifer regeneration, regardless of fire severity, increased from 5% in 1981 to 2000 to 26 to 31% by mid-century, highlighting a limited time window over which management actions that reduce fire severity may effectively support postfire conifer regeneration.

Utility of 3-dimensional modeling in prenatally diagnosed large fetal neck mass.

INTRODUCTION: Prenatally diagnosed large fetal neck mass requires multidisciplinary consultation and evaluation of perinatal treatment options. The decision to perform Ex-utero Intrapartum Treatment (EXIT) is based on risk-benefit assessment for both the infant and mother. Though fetal ultrasound and MRI assist with operative planning, a three-dimensional anatomic model offers improved anatomic visualization and prenatal patient counseling. CASE PRESENTATION: Multiple surveillance ultrasound exams between gestational weeks 16 and 32, plus fetal MRI at 29/3 weeks were performed for fetal evaluation. A 3-dimensional model was printed (Form 3 and 3L, clear resin, Formlabs) incorporating fetal MRI (Ax SSFSE TE 100 DL and Cor SSFSE Brain DL) and using Mimics Medical and 3-matic Medical software (Materialise). A left fetal multicystic neck mass measuring 2.1x1.8x1.5 cm was diagnosed at 16/6 weeks gestation in a G8P2416. Fetal MRI performed at 29/3 weeks showed a large exophytic mixed solid-cystic cervicofacial mass, 10.3 x 9.4 x 10.6 cm arising from the left mandible, concerning for a teratoma. Prior to delivery, the model was used to educate and counsel the family regarding the complex clinical situation and the reasoning for delivery via EXIT followed by mass resection. Additionally, the model demonstrated tracheal narrowing and oropharyngeal compression, supporting airway intervention planning. The fetus was delivered at 32/3 weeks via EXIT to intubation using rigid bronchoscopy. Duration of time on placental support was 12 minutes. On day of life 5, the patient underwent resection of the cervical mass. Pathology revealed an immature teratoma, histologic grade 3 without yolk sac elements, and negative regional lymph nodes. CONCLUSION: Three-dimensional fetal modeling facilitates perinatal airway needs assessment, patient counseling, delivery, and post¬natal management.

Refuge-yeah or refuge-nah? Predicting locations of forest resistance and recruitment in a fiery world.

Climate warming, land use change, and altered fire regimes are driving ecological transformations that can have critical effects on Earth's biota. Fire refugia-locations that are burned less frequently or severely than their surroundings-may act as sites of relative stability during this period of rapid change by being resistant to fire and supporting post-fire recovery in adjacent areas. Because of their value to forest ecosystem persistence, there is an urgent need to anticipate where refugia are most likely to be found and where they align with environmental conditions that support post-fire tree recruitment. Using biophysical predictors and patterns of burn severity from 1180 recent fire events, we mapped the locations of potential fire refugia across upland conifer forests in the southwestern United States (US) (99,428 km2 of forest area), a region that is highly vulnerable to fire-driven transformation. We found that low pre-fire forest cover, flat slopes or topographic concavities, moderate weather conditions, spring-season burning, and areas affected by low- to moderate-severity fire within the previous 15 years were most commonly associated with refugia. Based on current (i.e., 2021) conditions, we predicted that 67.6% and 18.1% of conifer forests in our study area would contain refugia under moderate and extreme fire weather, respectively. However, potential refugia were 36.4% (moderate weather) and 31.2% (extreme weather) more common across forests that experienced recent fires, supporting the increased use of prescribed and resource objective fires during moderate weather conditions to promote fire-resistant landscapes. When overlaid with models of tree recruitment, 23.2% (moderate weather) and 6.4% (extreme weather) of forests were classified as refugia with a high potential to support post-fire recruitment in the surrounding landscape. These locations may be disproportionately valuable for ecosystem sustainability, providing habitat for fire-sensitive species and maintaining forest persistence in an increasingly fire-prone world.

Radiologists' Diagnostic Performance in Differentiation of Rickets and Classic Metaphyseal Lesions on Radiographs: A Multicenter Study.

BACKGROUND. Despite evidence supporting the specificity of classic metaphyseal lesions (CML) for the diagnosis of child abuse, some medicolegal practitioners claim that CML result from rickets rather than trauma. OBJECTIVE. The purpose of this study was to evaluate radiologists' diagnostic performance in differentiating rickets and CML on radiographs. METHODS. This retrospective seven-center study included children younger than 2 years who underwent knee radiography from January 2007 to December 2018 and who had either rickets (25-hydroxyvitamin D level < 20 ng/mL and abnormal knee radiographs) or knee CML and a diagnosis of child abuse from a child abuse pediatrician. Additional injuries were identified through medical record review. Radiographs were cropped and zoomed to present similar depictions of the knee. Eight radiologists independently interpreted radiographs for diagnoses of rickets or CML, rated confidence levels, and recorded associated radiographic signs. RESULTS. Seventy children (27 girls, 43 boys) had rickets; 77 children (37 girls, 40 boys) had CML. Children with CML were younger than those with rickets (mean, 3.7 vs 14.2 months, p < .001; 89.6% vs 5.7% younger than 6 months; 3.9% vs 65.7% older than 1 year). All children with CML had injuries in addition to the knee CML identified at physical examination or other imaging examinations. Radiologists had almost perfect agreement for moderate- or high-confidence interpretations of rickets (κ = 0.92) and CML (κ = 0.89). Across radiologists, estimated sensitivity, specificity, and accuracy for CML for moderate- or high-confidence interpretations were 95.1%, 97.0%, and 96.0%. Accuracy was not significantly different between pediatric and nonpediatric radiologists (p = .20) or between less experienced and more experienced radiologists (p = .57). Loss of metaphyseal zone of provisional calcification, cupping, fraying, and physeal widening were more common in rickets than CML, being detected in less than 4% of children with CML. Corner fracture, bucket-handle fracture, subphyseal lucency, deformed corner, metaphyseal irregularity, and subperiosteal new bone formation were more common in CML than rickets, being detected in less than 4% of children with rickets. CONCLUSION. Radiologists had high interobserver agreement and high diagnostic performance for differentiating rickets and CML. Recognition that CML mostly occur in children younger than 6 months and are unusual in children older than 1 year may assist interpretation. CLINICAL IMPACT. Rickets and CML have distinct radiographic signs, and radiologists can reliably differentiate these two entities.

Imaging Review of Obstetric Sequelae of Maternal Diabetes Mellitus.

Diabetes mellitus, whether preexisting or gestational, poses significant risk to both the mother and the developing fetus. A myriad of potential fetal complications in the setting of diabetic pregnancies include, among others, congenital anomalies, delayed fetal lung maturity, macrosomia, and increased perinatal morbidity and mortality. Congenital anomalies most commonly involve the nervous, cardiovascular, genitourinary, and musculoskeletal systems. Delayed fetal lung maturity, probably secondary to hyperglycemia suppressing surfactant secretion, is a major determinant of perinatal morbidity and mortality. Besides the potential complications encountered during cesarean delivery in macrosomic fetuses, vaginal delivery is also associated with increased risks of shoulder dystocia, clavicular and humeral fractures, and brachial plexus palsy. Maternal complications are related to the increased risk of hypertensive diseases of pregnancy and associated preeclampsia and hemolysis, elevated liver function, and low platelets (HELLP) syndrome, as well as complications encountered at the time of delivery secondary to fetal macrosomia and cesarean delivery. Additional conditions encountered in the setting of maternal diabetes include polyhydramnios, placental thickening, and two-vessel umbilical cord, each of which is associated with adverse fetal and maternal outcomes including fetal growth restriction, preterm labor, placental abruption, and premature rupture of membranes. Imaging plays a vital role in the evaluation of the mother and the fetus and can provide invaluable information that can be used by maternal fetal medicine to manage this patient population effectively. The authors review the pathophysiologic alterations induced by diabetes in pregnancy, discuss the imaging spectrum of diabetic embryopathy, and provide a detailed review of potential associated maternal complications. Online supplemental material is available for this article. ©RSNA, 2021.

The undulating line sign and other more common pediatric central catheter malpositions.

Central venous and arterial catheters are among the most commonly assessed support devices by radiologists. The position of these catheters must be carefully assessed to ensure proper placement, as malpositioning may lead to life-threatening consequences. Therefore, it is important for radiologists to understand the anatomy of the central vessels and the expected location of catheters. While this can be difficult in small children and especially in neonates, knowledge of the expected course and ideal termination of catheters allows for recognition of a malpositioned line, which may be unsuspected clinically. The purpose of this article is to discuss appropriate positioning of central catheters in pediatric patients, focusing primarily on venous catheters. We also propose a new radiographic sign to recognize, the undulating line sign, as an indication of an inappropriate course of a newly placed venous catheter.

The spectrum of brain malformations and disruptions in twins.

Twins have an increased risk for congenital malformations and disruptions, including defects in brain morphogenesis. We analyzed data on brain imaging, zygosity, sex, and fetal demise in 56 proband twins and 7 less affected co-twins with abnormal brain imaging and compared them to population-based data and to a literature series. We separated our series into malformations of cortical development (MCD, N = 39), cerebellar malformations without MCD (N = 13), and brain disruptions (N = 11). The MCD group included 37/39 (95%) with polymicrogyria (PMG), 8/39 (21%) with pia-ependymal clefts (schizencephaly), and 15/39 (38%) with periventricular nodular heterotopia (PNH) including 2 with PNH but not PMG. Cerebellar malformations were found in 19 individuals including 13 with a cerebellar malformation only and another 6 with cerebellar malformation and MCD. The pattern varied from diffuse cerebellar hypoplasia to classic Dandy-Walker malformation. Brain disruptions were seen in 11 individuals with hydranencephaly, porencephaly, or white matter loss without cysts. Our series included an expected statistically significant excess of monozygotic (MZ) twin pairs (22/41 MZ, 54%) compared to population data (482/1448 MZ, 33.3%; p = .0110), and an unexpected statistically significant excess of dizygotic (DZ) twins (19/41, 46%) compared to the literature cohort (1/46 DZ, 2%; p < .0001. Recurrent association with twin-twin transfusion syndrome, intrauterine growth retardation, and other prenatal factors support disruption of vascular perfusion as the most likely unifying cause.

Multimodality Imaging Evaluation of Fetal Spine Anomalies with Postnatal Correlation.

Congenital anomalies of the spine are associated with substantial morbidity in the perinatal period and may affect the rest of the patient's life. Accurate early diagnosis of spinal abnormalities during fetal imaging allows prenatal, perinatal, and postnatal treatment planning, which can substantially affect functional outcomes. The most common and clinically relevant congenital anomalies of the spine fall into three broad categories: spinal dysraphism, segmentation and fusion anomalies of the vertebral column, and sacrococcygeal teratomas. Spinal dysraphism is further categorized into one of two subtypes: open spinal dysraphism and closed spinal dysraphism. The latter category is further subdivided into those with and without subcutaneous masses. Open spinal dysraphism is an emergency and must be closed at birth because of the risk of infection. In utero closure is also offered at some fetal centers. Sacrococcygeal teratomas are the most common fetal pelvic masses and the prognosis is variable. Finally, vertebral body anomalies are categorized into formation (butterfly and hemivertebrae) and segmentation (block vertebrae) anomalies. Although appropriate evaluation of the fetal spine begins with US, which is the initial screening modality of choice, MRI is increasingly important as a problem-solving tool, especially given the recent advances in fetal MRI, its availability, and the complexity of fetal interventions. Online supplemental material is available for this article. ©RSNA, 2021.

Limitations to recovery following wildfire in dry forests of southern Colorado and northern New Mexico, USA.

Climate warming is contributing to increases in wildfire activity throughout the western United States, leading to potentially long-lasting shifts in vegetation. The response of forest ecosystems to wildfire is thus a crucial indicator of future vegetation trajectories, and these responses are contingent upon factors such as seed availability, interannual climate variability, average climate, and other components of the physical environment. To better understand variation in resilience to wildfire across vulnerable dry forests, we surveyed conifer seedling densities in 15 recent (1988-2010) wildfires and characterized temporal variation in seed cone production and seedling establishment. We then predicted postfire seedling densities at a 30-m resolution within each fire perimeter using downscaled climate data, monthly water balance models, and maps of surviving forest cover. Widespread ponderosa pine (Pinus ponderosa) seed cone production occurred at least twice following each fire surveyed, and pulses of conifer seedling establishment coincided with years of above-average moisture availability. Ponderosa pine and Douglas-fir (Pseudotsuga menziesii) seedling densities were higher on more mesic sites and adjacent to surviving trees, though there were also important interspecific differences, likely attributable to drought and shade tolerance. We estimated that postfire seedling densities in 42% (for ponderosa pine) and 69% (for Douglas-fir) of the total burned area were below the lowest reported historical tree densities in these forests. Spatial models demonstrated that an absence of mature conifers (particularly in the interior of large, high-severity patches) limited seedling densities in many areas, but 30-yr average actual evapotranspiration and climatic water deficit limited densities on marginal sites. A better understanding of the limitations to postfire forest recovery will refine models of vegetation dynamics and will help to improve strategies of adaptation to a warming climate and shifting fire activity.

Radiographic overlap of recurrent Caffey disease and chronic recurrent multifocal osteomyelitis (CRMO) with considerations of molecular origins.

Caffey disease, or infantile cortical hyperostosis, classically describes a self-limited inflammatory disorder that presents in the infant with fussiness, focal swelling and sometimes fever. Imaging is conventionally limited to radiography, which shows mild to profound subperiosteal bone formation and sometimes deformity. This disease was not uncommonly diagnosed in the late 20th century. Interestingly, the disease may not just occur in the infant, and it may be due to a genetic mutation in the alpha-one chain of type 1 collagen (COL1A1). Recurrent or delayed onset in the older child or adolescent also occurs. In more recent years, another type of inflammatory bone disorder, chronic sterile osteomyelitis, has been frequently recognized and, depending on the radiographic stage or the diagnostic modality used, may have characteristics overlapping with Caffey disease. In this review, we discuss the demographics, imaging and known etiologies for Caffey disease and chronic recurrent multifocal osteomyelitis and raise the possibility of similar molecular origins.

"It's Not a Tumor": A Rare Case of Symptomatic Cerebellar Developmental Venous Anomaly.

Cerebral developmental venous anomalies (DVAs) are benign anatomical variants of the venous system and are commonly described as an incidental finding without clinical significance. Neurologic symptoms or abnormal examination findings are rare and usually attributed to hemorrhagic complications related to coexisting cavernous malformations. There have been limited case reports of symptomatic, uncomplicated DVAs described in the literature. The following case describes a previously healthy child who presented to the emergency department with an acute onset of altered mental status, headache, and focal neurologic examination abnormalities. Magnetic resonance imaging revealed a prominent cerebellar DVA. There was no evidence of a cavernous angioma, hemorrhage, or acute parenchymal injury. This case report illustrates a clinically symptomatic, uncomplicated posterior fossa DVA. It provides additional evidence regarding the potential for a cerebral venous malformation in causing focal neurologic deficits.

Bi-allelic mutations of CCDC88C are a rare cause of severe congenital hydrocephalus.

Congenital or infantile hydrocephalus is caused by genetic and non-genetic factors and is highly heterogeneous in etiology. In recent studies, a limited number of genetic causes of hydrocephalus have been identified. To date, recessive mutations in the CCDC88C gene have been identified as a cause of non-syndromic congenital hydrocephalus in three reported families. Here, we report the fourth known family with two affected individuals with congenital hydrocephalus due to a homozygous mutation in the CCDC88C gene identified by whole exome sequencing. Our two newly described children, as well as the previously published ones, all shared several features including severe infantile-onset hydrocephalus, mild to severe intellectual delay, varying degrees of motor delay, and infantile onset seizures. All identified homozygous mutations in CCDC88C abolish the PDZ binding site necessary for proper CCDC88C protein function in the Wnt signaling pathway. Our report further establishes CCDC88C as one of the few known recessive causes of severe prenatal-onset hydrocephalus. Recognition of this syndrome has important diagnostic and genetic implications for families identified in the future.

Part-Time Pediatric Radiology: The Realities and Perceptions of Part-Time Employment in the Academic Setting.

OBJECTIVE: The goal of this study is to evaluate the perceptions held by full- and part-time academic pediatric radiologists with regard to the value of part-time radiologists, as well as the value placed on the work of part-time colleagues by their departments and institutions. MATERIALS AND METHODS: Two online surveys were distributed to full- and part-time pediatric radiologists via the Society for Pediatric Radiology e-mail list serve. Survey questions evaluated demographic data of both full- and part-time radiologists, as well as the perceptions each group has of part-time employment. RESULTS: Part-time radiologists reported significantly greater work-life balance than did their full-time counterparts and were less likely to report job dissatisfaction. Full- and part-time faculty have comparable levels of perceived departmental contributions. Part-time faculty were more likely to be younger women, early in their careers, and older men nearing retirement. CONCLUSION: Part-time employment provides perceived benefits of increased work-life balance and job satisfaction and is viewed favorably by both full- and part-time radiologists in academic settings.

Establishment of normative values for the fetal posterior fossa by magnetic resonance imaging.

OBJECTIVE: Suspected Dandy-Walker continuum anomalies constitute a significant percentage of prenatal cases evaluated by magnetic resonance imaging (MRI). To unify the description of posterior fossa malformations, we sought to establish objective measurements for the posterior fossa in normal fetuses between 18 and 37 weeks gestation. METHODS: T2-weighted images of normal fetal brains in sagittal projection were obtained from fetal magnetic resonance (MR) studies of normal brains performed from 2009 to 2017.121 fetal brains were included in the analysis. Three radiologists reviewed images and recorded the following for each case: superior posterior fossa angle (SPFA), posterior fossa perimeter, and tegmento-vermian angle (TVA). RESULTS: For each feature, the mean of the measurements, the percentage of absolute difference of the reader measurement compared with mean measurement, and the interclass correlation (ICC) were calculated. Values are reported as mean ± standard deviation. Perimeter increases linearly with age, whereas the SPFA and the TVA are independent of gestational age. For all included cases, the SPFA averaged 100.9° ± 8° and the TVA averaged 2.5° ± 2.3°. CONCLUSION: The superior posterior fossa angle, a novel measurement, and the posterior fossa perimeter can be used for establishing the expected size of the posterior fossa in second- and third-trimester fetuses by MRI.

Waking up your lecture.

A core method of educating radiology trainees and practicing radiologists is through digital lectures, using Microsoft PowerPoint, Keynote, Prezi, Sliderocket or any number of software versions. Careful consideration of both the material to be presented as well as the visual format by which it is presented is critical for a successful lecture. Adult learners benefit substantially in comprehension and retention of material when allowed to interact with the teacher and the content. This article provides the educator with recommendations for constructing and presenting an effective and worthwhile lecture.

Area burned in the western United States is unaffected by recent mountain pine beetle outbreaks.

In the western United States, mountain pine beetles (MPBs) have killed pine trees across 71,000 km(2) of forest since the mid-1990s, leading to widespread concern that abundant dead fuels may increase area burned and exacerbate fire behavior. Although stand-level fire behavior models suggest that bark beetle-induced tree mortality increases flammability of stands by changing canopy and forest floor fuels, the actual effect of an MPB outbreak on subsequent wildfire activity remains widely debated. To address this knowledge gap, we superimposed areas burned on areas infested by MPBs for the three peak years of wildfire activity since 2002 across the western United States. Here, we show that the observed effect of MPB infestation on the area burned in years of extreme fire appears negligible at broad spatial extents. Contrary to the expectation of increased wildfire activity in recently infested red-stage stands, we found no difference between observed area and expected area burned in red-stage or subsequent gray-stage stands during three peak years of wildfire activity, which account for 46% of area burned during the 2002-2013 period. Although MPB infestation and fire activity both independently increased in conjunction with recent warming, our results demonstrate that the annual area burned in the western United States has not increased in direct response to bark beetle activity. Therefore, policy discussions should focus on societal adaptation to the effects of recent increases in wildfire activity related to increased drought severity.

A survey of pediatric diagnostic radiologists in North America: current practices in fetal magnetic resonance imaging.

BACKGROUND: Fetal magnetic resonance imaging (MRI) is an imaging examination in evolution. Rapid developments over recent decades have led to better image quality, an increased number of examinations and greater impact on patient care. OBJECTIVE: To gather data regarding current practices among established programs in North America and provide information to radiologists interested in implementing or growing a fetal MRI service. MATERIALS AND METHODS: An electronic survey containing 15 questions relevant to the use of fetal MRI was submitted to pediatric radiologists and neuroradiologists. Items regarded scheduling and reporting logistics, magnet strength, patient positioning and patient preparation. Answers and comments were collected, and descriptive statistics were summarized. RESULTS: One hundred and six survey responses were evaluated. Of the survey responses, 62/106 (58.5%) allow fetal MR scheduling any time during the day and 72/105 (68.6%) exclusively use 1.5-T strength platforms for fetal MRI, while only 7/105 (6.7%) use exclusively 3 T. Patient positioning is variable: supine, 40/106 (37.8%); left lateral decubitus, 22/106 (20.8%), and, patient's choice, 43/106 (40.6%). Of the centers responding, 51/104 (49.0%) require no particular fasting instructions, while 20/104 (19.2%) request the patient avoid caffeine before the scanning. CONCLUSION: Logistical trends in performing fetal MRI may supplement the American College of Radiology's published technical standards and offer guidance to radiologists new to the field.