ESR Essentials: imaging of suspected child abuse-practice recommendations by the European Society of Paediatric Radiology.

The goal of this paper is to provide a useful desktop reference for the imaging of suspected child abuse with clear, age-specific pathways for appropriate evidence-based imaging and follow-up. We aim to provide a road map for the imaging evaluation and follow-up of this important and vulnerable cohort of patients presenting with signs and symptoms concerning for inflicted injury. As the imaging recommendations differ for children of different ages, we provide a flowchart of the appropriate imaging pathway for infants, toddlers, and older children, which allows ease of selection of which children should undergo skeletal survey, non-contrast computed tomography (CT) brain with 3-dimensional (D) reformats, and magnetic resonance imaging (MRI) of the brain and whole spine. For ease of review, we include a table of the common intracranial and spinal patterns of injury in abusive head trauma. We summarise search patterns, areas of review, and key findings to include in the report. To exclude skeletal injury, infants and children under 2 years of age should undergo a full skeletal survey in accordance with national guidelines, with a limited follow-up skeletal survey performed 11-14 days later. For children over 2 years of age, the need for skeletal imaging should be decided on a case-by-case basis. All infants should undergo a non-contrast-enhanced CT brain with 3-D reformats. If this is normal with no abnormal neurology, then no further neuroimaging is required. If this is abnormal, then they should proceed to MRI brain and whole spine within 2-5 days. Children older than 1 year of age who have abnormal neurology and/or findings on skeletal survey that are suggestive of inflicted injury should undergo non-contrast CT brain with 3-D reformats and, depending on the findings, may also require MRI of the brain and whole spine. We hope that this will be a helpful contribution to the radiology literature, particularly for the general radiologist with low volumes of paediatrics in their practice, supporting them with managing these important cases when they arise in daily practice. KEY POINTS: The choice of initial imaging (skeletal survey and/or brain CT) depends on the age of the child in whom abuse is suspected. A follow-up skeletal survey is mandatory 11-14 days after the initial survey. If an MRI of the brain is performed, then an MRI of the whole spine should be performed concurrently.

The prevalence of subdural blood products in extremely premature infants with no history of abusive head trauma, studied by magnetic resonance imaging around term-equivalent age.

BACKGROUND: Prematurity and enlarged subarachnoid spaces are both hypothesised to represent an increased risk of subdural haemorrhages (SDHs) in infancy, both with and without a history of abuse. OBJECTIVE: To examine the prevalence of a previous haemorrhage, particularly SDHs, in infants born extremely prematurely around term-equivalent age; to examine intra- and inter-observer agreement for identification of haemorrhages; and to examine the width of the subarachnoid spaces. MATERIALS AND METHODS: A total of 121 extremely premature infants had cerebral magnetic resonance imaging (MRI) performed around term-equivalent age (mean chronological age 14.7 weeks, range 10.3-24.0 weeks). There were no infants investigated for abuse in our cohort. Intracranial haemorrhages were classified as isolated germinal matrix-haemorrhages, parenchymal haemorrhages (cerebellar- and cerebral haemorrhages), or extra-axial haemorrhages (subarachnoid haemorrhages, SDHs, or epidural haemorrhages). Sinocortical width and interhemispheric distance were measured. RESULTS: No appreciable SDH was detected with the performed sequences. Haemorrhage/blood products related to prematurity were seen in 60 (49.5%) of the neonates. Agreement was good to very good for identification of haemorrhage. The mean sinocortical width was 3.5 mm with a standard deviation (SD) of 1.4 mm on the right side and 3.3 mm (SD 1.2 mm) on the left side. The mean interhemispheric distance was 3.1 mm (SD 1.1 mm). 61.1% of the infants had a sinocortical width > 3 mm on one or both sides. CONCLUSION: Our study does not support the hypothesis that premature infants are more prone to SDH unrelated to abusive head trauma during the first 3-4 months of life. A large percentage of the ex-premature infants had prominent subarachnoid spaces.

Genetics of hip dysplasia - a systematic literature review.

BACKGROUND: Developmental dysplasia of the hip (DDH) is a congenital condition affecting 2-3% of all newborns. DDH increases the risk of osteoarthritis and is the cause of 30% of all total hip arthroplasties in adults < 40 years of age. We aim to explore the genetic background of DDH in order to improve diagnosis and personalize treatment. METHODS: We conducted a structured literature review using PRISMA guidelines searching the Medline, Embase and Cochrane databases. We included 31 case control studies examining single nucleotide polymorphisms (SNPs) in non-syndromic DDH. RESULTS: A total of 73 papers were included for full text review, of which 31 were single nucleotide polymorphism (SNP) case/control association studies. The literature review revealed that the majority of published papers on the genetics of DDH were mostly underpowered for detection of any significant association. One large genome wide association study has been published (N = 9,915), establishing GDF5 as a plausible risk factor. CONCLUSIONS: DDH is known to be congenital and heritable, with family occurrence of DDH already included as a risk factor in most screening programs. Despite this, high quality genetic research is scarce and no genetic risk factors have been soundly established, prompting the need for more research.

The incidence of fractures in children under two years of age: a systematic review.

BACKGROUND: Epidemiological research on fractures in children under the age of two is of great importance to help understand differences between accidental and abusive trauma. OBJECTIVE: This systematic review aimed to evaluate studies reporting on the incidence of fractures in children under two years of age, excluding birth injuries. Secondary outcome measures included fracture location, mechanisms of injury and fracture characteristics. METHODS: A systematic literature review (1946 to February 7th 2024), including prospective and retrospective cohort studies and cross-sectional cohort studies, was performed. Studies including children from other age groups were included if the actual measures for those aged 0-2 years could be extracted. We also included studies restricted to infants. Annual incidence rates of fractures were extracted and reported as the main result. Critical appraisal of was performed using the Appraisal tool for Cross-Sectional Studies. RESULTS: Twelve moderate to good quality studies met eligibility criteria, of which seven were based on data from medical records and five were registry studies. Studies investigated different aspects of fractures, making comprehensive synthesis challenging. There was an overall annual fracture incidence rate of 5.3 to 9.5 per 1,000 children from 0-2 years of age; with commonest sites being the radius/ulna (25.2-40.0%), followed by tibia/fibula (17.3-27.6%) and the clavicle (14.6-14.8%) (location based on 3 studies with a total of 407 patients). In infants, the reported incidence ranged between 0.7 to 4.6 per 1,000 (based on 3 studies), with involvement of the clavicle in 22.2% and the distal humerus in 22.2% of cases (based on 1 study). Only a single metaphyseal lesion was reported (proximal humerus of an 11-month-old infant). Fracture mechanisms were detailed in four studies, with fall from chair, bed, table, own height or fall following indoor activities causing 50-60% of fractures. CONCLUSIONS: There is a paucity of good quality data on fracture incidence in children under the age of two. Larger, prospective and unbiased studies would be helpful in determining normal pattern of injuries, so that differences from abusive trauma may be better understood.

Radiographic markers of hip dysplasia in young adults: predictive effect of factors in early life.

ABSTRAC: BACKGROUND AND OBJECTIVES: Acetabular dysplasia in young adults occurs, despite screening for developmental hip dysplasia (DDH) in the neonatal period. We aimed to examine how early life factors predict radiographic measurements of acetabular dysplasia at 18-19 years of age. METHODS: From a previous randomized trial (n = 12,014; 1988-90) evaluating the role of hip ultrasound in newborn screening of DDH, 4469 participants (2193 males) were invited to a follow-up 18 years later (2007-09), of which 2370 (53% attendance; 932 males) met. We examined associations between early life factors and four radiographic measurements for acetabular dysplasia at skeletal maturity. Hierarchical regressions, with addition of variables observed/measured consecutively in time, were analyzed using mixed effects models considering hip as the unit in the analyses. The study is approved by the Regional Ethics Committee. RESULTS: In total, 2340 participants (921 boys), mean age 18.7 years, (SD 0.6) had hip radiographs performed at follow-up and were included. Early life factors significantly predicting radiographic acetabular dysplasia at age 18-19-years included female gender, breech, low acetabular inclination (alpha) angle and sonographic instability, abduction treatment, as well as the velocity of growth during childhood. A positive family history of DDH was not associated with acetabular dysplasia at skeletal maturity. CONCLUSION: The acetabular inclination (alpha) angle as measured on ultrasound at birth turned out to be a significant predictor of dysplasia at 18-19 years of age. The discordant role of a positive family history in early versus adult hip dysplasia is intriguing, warranting further studies on the genetic mechanisms of DDH.

The effect of selective ultrasound screening on the incidence of late presentation of developmental hip dysplasia-a meta-analysis.

Different screening strategies for developmental dysplasia of the hip (DDH) exist. Despite screening efforts, cases of late presentation continue to occur, often necessitating surgery. This systematic review and meta-analysis assess the effect of newborn selective ultrasound screening for DDH on the incidence of late presentation in infants and children, compared to a universal ultrasound strategy. A systematic search across Medline and EMBASE databases was performed between January 1950 and February 2021. A consensus-based evaluation of abstracts led to retrieval of relevant full text, original articles or systematic reviews in English only. These were assessed according to agreed eligibility criteria, and their reference lists were reviewed to identify additional eligible publications. Following final consensus on included publications, data was extracted, analysed and reported as per PRISMA and Prospero (CRD42021241957) guidelines. The 16 eligible studies consisted of 2 randomised controlled trials and 14 cohort studies, published between 1989 and 2014, with a total of 511,403 participants. In total, 121,470 (23.8%) received a neonatal hip ultrasound, of whom 58,086 and 63,384 were part of a selective or a universal ultrasound screening strategy, respectively. The difference in the proportion of late presentation between the universal and selective strategies was 0.0904 per 1,000 (P = 0.047). The time effect, i.e. the difference between early and late presentation defined respectively, as less than and more than 3 months of age, regardless of screening strategy, was not significant (P = 0.272). Although there was variability in study design and reporting, the quality of the evidence, based on the critical appraisal skills programme appraisal tools, was generally good. Compared to universal ultrasound screening for DDH, selective screening resulted in a slightly higher rate of late presentation. Uniformity in design and reporting of DDH studies and a cost-effectiveness analysis are needed.

European recommendations on practices in pediatric neuroradiology: consensus document from the European Society of Neuroradiology (ESNR), European Society of Paediatric Radiology (ESPR) and European Union of Medical Specialists Division of Neuroradiology (UEMS).

Pediatric neuroradiology is a subspecialty within radiology, with possible pathways to train within the discipline from neuroradiology or pediatric radiology. Formalized pediatric neuroradiology training programs are not available in most European countries. We aimed to construct a European consensus document providing recommendations for the safe practice of pediatric neuroradiology. We particularly emphasize imaging techniques that should be available, optimal site conditions and facilities, recommended team requirements and specific indications and protocol modifications for each imaging modality employed for pediatric neuroradiology studies. The present document serves as guidance to the optimal setup and organization for carrying out pediatric neuroradiology diagnostic and interventional procedures. Clinical activities should always be carried out in full agreement with national provisions and regulations. Continued education of all parties involved is a requisite for preserving pediatric neuroradiology practice at a high level.

A novel magnetic resonance imaging scoring system for active and chronic changes in children and adolescents with juvenile idiopathic arthritis of the hip.

BACKGROUND: Hip involvement predicts severe disease in juvenile idiopathic arthritis (JIA) and is accurately assessed by MRI. However, a child-specific hip MRI scoring system has not been validated. OBJECTIVE: To test the intra- and interobserver agreement of several MRI markers for active and chronic hip changes in children and young adults with JIA and to examine the precision of measurements commonly used for the assessment of growth abnormalities. MATERIALS AND METHODS: Hip MRIs from 60 consecutive children, adolescents and young adults with JIA were scored independently by two sets of radiologists. One set scored the same MRIs twice. Features of active and chronic changes, growth abnormalities and secondary post-inflammatory changes were scored. We used kappa statistics to analyze inter- and intraobserver agreement for categorical variables and a Bland-Altman approach to test the precision of continuous variables. RESULTS: Among active changes, there was good intra- and interobserver agreement for grading overall inflammation (kappa 0.6-0.7). Synovial enhancement showed a good intraobserver agreement (kappa 0.7-0.8), while the interobserver agreement was moderate (kappa 0.4-0.5). Regarding acetabular erosions on a 0-3 scale, the intraobserver agreement was 0.6 for the right hip and 0.7 for the left hip, while the interobserver agreement was 0.6 for both hips. Measurements of joint space width, caput-collum-diaphyseal angle, femoral neck-head length, femoral width and trochanteric distance were imprecise. CONCLUSION: We identified a set of MRI markers for active and chronic changes in JIA and suggest that the more robust markers be included in future studies addressing clinical validity and long-term patient outcomes.

Deep phenotyping of pubertal development in Norwegian children: the Bergen Growth Study 2.

BACKGROUND: The Bergen Growth Study 2 (BGS2) aims to characterise somatic and endocrine changes in healthy Norwegian children using a novel methodology. SUBJECTS AND METHODS: A cross-sectional sample of 1285 children aged 6-16 years was examined in 2016 using novel objective ultrasound assessments of breast developmental stages and testicular volume in addition to the traditional Tanner pubertal stages. Blood samples allowed for measurements of pubertal hormones, endocrine disruptive chemicals, and genetic analyses. RESULTS: Ultrasound staging of breast development in girls showed a high degree of agreement within and between observers, and ultrasound measurement of testicular volume in boys also showed small intra- and interobserver differences. The median age was 10.4 years for Tanner B2 (pubertal onset) and 12.7 years for menarche. Norwegian boys reached a pubertal testicular volume at a mean age of 11.7 years. Continuous reference curves for testicular volume and sex hormones were constructed using the LMS method. CONCLUSIONS: Ultrasound-based assessments of puberty provided novel references for breast developmental stages and enabled the measurement of testicular volume on a continuous scale. Endocrine z-scores allowed for an intuitive interpretation of changing hormonal levels during puberty on a quantitative scale, which, in turn, provides opportunities for further analysis of pubertal development using machine-learning approaches.

Dental plaque and gingival bleeding in adolescents with juvenile idiopathic arthritis and controls: a multilevel analysis.

OBJECTIVE: To explore whether plaque and gingival bleeding are more frequently experienced by adolescents with juvenile idiopathic arthritis (JIA) compared to matched controls without JIA; explore whether surface- and site-specific periodontal outcomes vary between the two groups; and for participants with JIA, investigate associations between disease-specific features and periodontal outcomes. MATERIAL AND METHODS: In this comparative cross-sectional study, selected surfaces, and sites of index teeth in 10-16-year-olds with JIA and matched controls were examined by modified versions of Simplified Oral Hygiene Index (OHI-S) and Gingival Bleeding Index (GBI). Mixed-effects logistic regressions, reporting odds ratios (OR) with 95% confidence interval (CI), were applied. Intra-class correlation coefficients (ICCs) were calculated to quantify the degree of dependency of measures within the same individual. RESULTS: 144 and 159 adolescents with JIA were evaluated according to OHI-S and GBI; corresponding numbers of controls were 154 and 161. Plaque and gingival bleeding were more frequent in individuals with JIA than controls. Adjusted analyses showed association between JIA status and OHI-S > 0 (OR = 2.33, 95% CI: 1.47 - 3.67, ICC = 0.45) and GBI > 0 (OR = 1.54, 95% CI: 1.10 - 2.16, ICC = 0.41 and 0.30). Surface-specific distribution of plaque varied among the two groups. CONCLUSIONS: Our results highlight the importance of increased awareness of oral health care in patients with JIA and that surface- and site-specific differences in periodontal outcomes exist between individuals with JIA and controls. Few JIA disease-specific variables associated with plaque or gingival bleeding.

Cone beam computed tomography in the assessment of TMJ deformity in children with JIA: repeatability of a novel scoring system.

BACKGROUND: The temporomandibular joint (TMJ) is frequently involved in juvenile idiopathic arthritis (JIA). Diagnostic imaging is necessary to correctly diagnose and evaluate TMJ involvement, however, hitherto little has been published on the accuracy of the applied scoring systems and measurements. The present study aims to investigate the precision of 20 imaging features and five measurements based on cone beam computed tomography (CBCT). METHODS: Imaging and clinical data from 84 participants in the Norwegian study on juvenile idiopathic arthritis, the NorJIA study, were collected. Altogether 20 imaging features and five measurements were evaluated independently by three experienced radiologists for intra- and interobserver agreement. Agreement of categorical variables was assessed by Fleiss', Cohen's simple or weighted Kappa as appropriate. Agreement of continuous variables was assessed with 95% limits of agreement as advised by Bland and Altman. RESULTS: "Overall impression of TMJ deformity" showed almost perfect intraobserver agreement with a kappa coefficient of 0.81 (95% CI 0.69-0.92), and substantial interobserver agreement (Fleiss' kappa 0.70 (0.61-0.78)). Moreover, both "flattening" and "irregularities" of the eminence/fossa and condyle performed well, with intra- and interobserver agreements of 0.66-0.82 and 0.55-0.76, respectively. "Reduced condylar volume" and "continuity" of the fossa/eminence had moderate intra- and interobserver Kappa values, whereas continuity of the condyle had Kappa values above 0.55. Measurements of distances and angles had limits of agreement of more than 15% of the sample mean. CONCLUSIONS: We propose a CBCT-based scoring system of nine precise imaging features suggestive of TMJ deformity in JIA. Their clinical validity must be tested.

[Hip dysplasia in infants ­ screening, treatment and follow-up]. / Hofteleddsdysplasi hos spedbarn ­ screening, behandling og oppfølging.

BACKGROUND: Hip dysplasia occurs in up to 3 % of neonates and if untreated can lead to dislocated hip, osteoarthritis and the need for a hip prosthesis. The study aimed to identify routines for ultrasound screening, treatment and follow-up of hip dysplasia in Norwegian hospitals. MATERIAL AND METHOD: An online questionnaire was sent to radiologists responsible for paediatric examinations at all hospitals with paediatric departments. INTERPRETATION: Routines for screening, treatment and follow-up of hip dysplasia varied to a considerable degree between the hospitals.

Artificial intelligence in paediatric radiology: international survey of health care professionals' opinions.

BACKGROUND: The nature of paediatric radiology work poses several challenges for developing and implementing artificial intelligence (AI) tools, but opinions of those working in the field are currently unknown. OBJECTIVE: To evaluate the attitudes and perceptions toward AI amongst health care professionals working within children's imaging services. MATERIALS AND METHODS: A web-based questionnaire was distributed to the membership of several paediatric and general radiological societies over a 4-month period (1 Feb - 31 May 2020). Survey questions covered attitudes toward AI in general, future impacts and suggested areas for development specifically within paediatric imaging. RESULTS: Two hundred and forty responses were collected with the majority being from radiologists (159/240, 66.3%; 95% confidence interval [CI] 59.8-72.2%) or allied health care professionals (72/240, 31.3%; 95% CI 25.4-37.5%). Respondents agreed that AI could potentially alert radiologists to imaging abnormalities (148/240, 61.7%; 95% CI 55.2-67.9%) but preferred that results were checked by a human (200/240, 83.3%; 95% CI 78.0-87.8%). The majority did not believe jobs in paediatric radiology would be replaced by AI (205/240, 85.4%; 95% CI 80.3-89.6%) and that the development of AI tools should focus on improved diagnostic accuracy (77/240, 32.1%; 95% CI 26.2-38.4%), workflow efficiencies (60/240, 25.0%; 95% CI 19.7-30.9%) and patient safety (54/240, 22.5%; 95% CI 17.4-28.3%). The majority of European Society of Paediatric Radiology (ESPR) members (67/81, 82.7%; 95% CI 72.7-90.2%) welcomed the idea of a dedicated paediatric radiology AI task force with emphasis on educational events and anonymised dataset curation. CONCLUSION: Imaging health care professionals working with children had a positive outlook regarding the use of AI in paediatric radiology, and did not feel their jobs were threatened. Future AI tools would be most beneficial for easily automated tasks and most practitioners welcomed the opportunity for further AI educational activities.

Whole-body MRI in children aged 6-18 years. Reliability of identifying and grading high signal intensity changes within bone marrow.

BACKGROUND: Whole-body magnetic resonance imaging (MRI) is increasingly being used in children, however, to date there are no studies addressing the reliability of the findings. OBJECTIVE: To examine intra- and interobserver reliability of a scoring system for assessment of high signal areas within the bone marrow, as visualized on T2-weighted, fat-saturated images. MATERIALS AND METHODS: Ninety-six whole-body MRIs (1.5 T) in 78 healthy volunteers (mean age: 11.5 years) and 18 children with chronic nonbacterial osteomyelitis (mean age: 12.4 years) were included. Coronal water-only Dixon T2-weighted images were used to score the left lower extremity/pelvis for high signal intensity areas, intensity (0-2 scale), extension (0-4 scale) and shape and contour in a blinded fashion by two pairs of radiologists. RESULTS: For the pelvis, grading of bone marrow signal showed moderate to good intra- and interobserver agreement with kappa values of 0.51-0.94 and 0.41-0.87, respectively. Corresponding figures for the femur were 0.61-0.68 within and 0.32-0.61 between observers, and for the tibia 0.60-0.72 and 0.51-0.73. Agreement for assessing extension was moderate to good both within and between observers for the pelvis (k = 0.52-0.85 and 0.35-0.80), for the femur (0.52-0.67 and 0.51-0.60) and for the tibia (k = 0.59-0.69 and 0.47-0.63) except for the femur metaphysis/diaphysis, with interobserver kappa values of 0.29-0.30. Scoring of shape was moderate to good within observers, but in general poorer between observers, with kappa values of 0.40-0.73 and 0.18-0.69, respectively. For contour, the corresponding figures were 0.35-0.62 and 0.09-0.54, respectively. CONCLUSION: MRI grading of intensity and extension of high signal intensity areas within the bone marrow of pelvis and lower limb performs well and thus can be used interchangeably by different observers, while assessment of shape and contour is reliable for the same observer but is less reliable between observers. This should be considered when performing clinical trials.

Automated segmentation of magnetic resonance bone marrow signal: a feasibility study.

BACKGROUND: Manual assessment of bone marrow signal is time-consuming and requires meticulous standardisation to secure adequate precision of findings. OBJECTIVE: We examined the feasibility of using deep learning for automated segmentation of bone marrow signal in children and adolescents. MATERIALS AND METHODS: We selected knee images from 95 whole-body MRI examinations of healthy individuals and of children with chronic non-bacterial osteomyelitis, ages 6-18 years, in a longitudinal prospective multi-centre study cohort. Bone marrow signal on T2-weighted Dixon water-only images was divided into three color-coded intensity-levels: 1 = slightly increased; 2 = mildly increased; 3 = moderately to highly increased, up to fluid-like signal. We trained a convolutional neural network on 85 examinations to perform bone marrow segmentation. Four readers manually segmented a test set of 10 examinations and calculated ground truth using simultaneous truth and performance level estimation (STAPLE). We evaluated model and rater performance through Dice similarity coefficient and in consensus. RESULTS: Consensus score of model performance showed acceptable results for all but one examination. Model performance and reader agreement had highest scores for level-1 signal (median Dice 0.68) and lowest scores for level-3 signal (median Dice 0.40), particularly in examinations where this signal was sparse. CONCLUSION: It is feasible to develop a deep-learning-based model for automated segmentation of bone marrow signal in children and adolescents. Our model performed poorest for the highest signal intensity in examinations where this signal was sparse. Further improvement requires training on larger and more balanced datasets and validation against ground truth, which should be established by radiologists from several institutions in consensus.

Oral health-related quality of life in 4-16-year-olds with and without juvenile idiopathic arthritis.

BACKGROUND: Few studies have investigated oral health-related quality of life (OHRQoL) in young individuals with juvenile idiopathic arthritis (JIA). Aims were to investigate whether OHRQoL differs between children and adolescents with JIA compared to controls without JIA, while adjusting for socio-demographic-, behavioral- and oral health-related covariates. Furthermore, to explore whether socio-behavioral and oral health-related covariates of OHRQoL vary according to group affiliation and finally, specifically for individuals with JIA, to investigate whether disease-specific features associate with OHRQoL. We hypothesized that participants with JIA have poorer OHRQoL compared to participants without JIA. METHODS: In this comparative cross-sectional study participants with JIA (n = 224) were matched to controls without JIA (n = 224). OHRQoL was assessed according to Early Childhood Oral Health Impact Scale (ECOHIS) (4-11-years-olds) and the child version of Oral Impacts on Daily Performances (Child-OIDP) (12-16-years-olds). JIA-specific characteristics were assessed by pediatric rheumatologists and socio-demographic, behavioral and self-reported oral health information collected by questionnaires. Index teeth were examined for caries by calibrated dentists. Multiple variable analyses were performed using logistic regression, reporting odds ratio (OR) and 95% confidence interval (CI). Two-way interactions were tested between group affiliation and the socio-behavioral- and oral health-related variables on the respective outcome variables. RESULTS: In total, 96 participants with JIA and 98 controls were evaluated according to ECOHIS, corresponding numbers for Child-OIDP was 125 and 124. Group affiliation was not associated with impaired ECOHIS or Child-OIDP in adjusted analyses (OR = 1.95, 95% CI 0.94-4.04 and OR = 0.99, 95% CI 0.46-2.17, respectively). Female adolescents with JIA were more likely than males to report oral impacts according to Child-OIDP. Continued activity or flare was found to adversely affect Child-OIDP, also self-reported outcome measures in JIA associated with Child-OIDP. CONCLUSIONS: This study did not provide consistent evidence to confirm the hypothesis that children and adolescents with JIA are more likely to have impaired OHRQoL compared to their peers without JIA. However, female adolescents with JIA were more likely than males to report impacts on OHRQoL. Furthermore, within the JIA group, adolescents with continued disease activity, flare or reporting pain, physical disability, had higher risk than their counterparts of impaired OHRQoL.

Incorporating radiomics into clinical trials: expert consensus endorsed by the European Society of Radiology on considerations for data-driven compared to biologically driven quantitative biomarkers.

Existing quantitative imaging biomarkers (QIBs) are associated with known biological tissue characteristics and follow a well-understood path of technical, biological and clinical validation before incorporation into clinical trials. In radiomics, novel data-driven processes extract numerous visually imperceptible statistical features from the imaging data with no a priori assumptions on their correlation with biological processes. The selection of relevant features (radiomic signature) and incorporation into clinical trials therefore requires additional considerations to ensure meaningful imaging endpoints. Also, the number of radiomic features tested means that power calculations would result in sample sizes impossible to achieve within clinical trials. This article examines how the process of standardising and validating data-driven imaging biomarkers differs from those based on biological associations. Radiomic signatures are best developed initially on datasets that represent diversity of acquisition protocols as well as diversity of disease and of normal findings, rather than within clinical trials with standardised and optimised protocols as this would risk the selection of radiomic features being linked to the imaging process rather than the pathology. Normalisation through discretisation and feature harmonisation are essential pre-processing steps. Biological correlation may be performed after the technical and clinical validity of a radiomic signature is established, but is not mandatory. Feature selection may be part of discovery within a radiomics-specific trial or represent exploratory endpoints within an established trial; a previously validated radiomic signature may even be used as a primary/secondary endpoint, particularly if associations are demonstrated with specific biological processes and pathways being targeted within clinical trials. KEY POINTS: • Data-driven processes like radiomics risk false discoveries due to high-dimensionality of the dataset compared to sample size, making adequate diversity of the data, cross-validation and external validation essential to mitigate the risks of spurious associations and overfitting. • Use of radiomic signatures within clinical trials requires multistep standardisation of image acquisition, image analysis and data mining processes. • Biological correlation may be established after clinical validation but is not mandatory.

Non-radiologist-performed point-of-care ultrasonography in paediatrics - European Society of Paediatric Radiology position paper.

Non-radiologist point-of-care ultrasonography (US) is increasingly implemented in paediatric care because it is believed to facilitate a timely diagnosis, such as in ascites or dilated renal pelvicalyceal systems, and can be used to guide interventional procedures. To date, all policy statements have been published by non-radiologic societies. The European Society of Paediatric Radiology hereby issues a position statement on paediatric non-radiologist point-of-care US from the point of view of those leading on children's imaging, i.e. paediatric radiologists. In this position statement, we will address the boundaries, education, credentialing, quality control, reporting and storage of images in paediatric practice.

Incidence, pattern and mechanisms of injuries and fractures in children under two years of age.

BACKGROUND: Fractures in children under 2 years of age are rare, and little has been published on their mechanisms. We aimed at examining the incidence, mechanisms, pattern and fracture characteristics in a large, population-based cohort of otherwise healthy children. METHODS: This retrospective, cross-sectional study includes all children aged 0-2 years, attending the Accident and Emergency department in Bergen between 2010 and 2015, due to an injury warranting radiography. Clinical data was categorized from the medical notes, and all radiographs were reviewed by an experienced paediatric radiologist. RESULTS: In total 408 children (212 male), 3-23 months of age (mean 17.7 months), were included. 149 (77 male) children had a total of 162 fractures, yielding an annual incidence of 5.4 per 1000, varying from 0.7 per 1000 for those under 12 months of age, increasing tenfold to 7.3 per 1000 for children aged 12-24 months of age. More than half of the fractures (53.1%) were seen in children aged 18-23 months, while none was found in those under 7 months of age. The youngest age group had mostly femur and tibia fractures, the oldest mostly forearm fractures (n = 55, 33.9%), followed by tibia fractures (21.6%) and fractures to the clavicle (14.8%). The reported mechanisms for the 162 fractures were fall from a chair/bed/table (41.4%), fall from own height (18.5%) or crush injury (15.4%). In 8 of 162 (4.9%) fractures, the history was clearly inconsistent and suspicious of non-accidental injury (NAI). CONCLUSION: Injuries and fractures in young children in general, and non-ambulant children in particular, are rare and should be thoroughly assessed for NAI. LEVEL OF EVIDENCE: Retrospective, population based cross-sectional study. Level 3.

Whole-body magnetic resonance imaging in children - how and why? A systematic review.

Whole-body magnetic resonance imaging (MRI) is increasingly being used for a number of indications. Our aim was to review and describe indications and scan protocols for diagnostic value of whole-body MRI for multifocal disease in children and adolescents, we conducted a systematic search in Medline, Embase and Cochrane for all published papers until November 2018. Relevant subject headings and free text words were used for the following concepts: 1) whole-body, 2) magnetic resonance imaging and 3) child and/or adolescent. Included were papers in English with a relevant study design that reported on the use and/or findings from whole-body MRI examinations in children and adolescents. This review includes 54 of 1,609 papers identified from literature searches. Chronic nonbacterial osteomyelitis, lymphoma and metastasis were the most frequent indications for performing a whole-body MRI. The typical protocol included a coronal STIR (short tau inversion recovery) sequence with or without a coronal T1-weighted sequence. Numerous studies lacked sufficient data for calculating images resolution and only a few studies reported the acquired voxel volume, making it impossible for others to reproduce the protocol/images. Only a minority of the included papers assessed reliability tests and none of the studies documented whether the use of whole-body MRI affected mortality and/or morbidity. Our systematic review confirms significant variability of technique and the lack of proven validity of MRI findings. The information could potentially be used to boost attempts towards standardization of technique, reporting and guidelines development.