Disparities in paediatric radiology research publications from low- and lower middle-income countries: a time for change.

The positive impact of diversity on health research and outcomes is well-recognised and widely published. Despite this, published evidence shows that at every step of the research pathway, issues of equity, diversity and inclusion (EDI) arise. There is evidence of a lack of diversity within research teams, in the research questions asked/research participants recruited, on grant review/funding panels, amongst funded researchers and on the editorial boards and reviewer pools of the journals to which results are submitted for peer-reviewed publication. Considering the journal Pediatric Radiology, while its editorial board of 92 members has at least one member affiliated to a country in every region of the world, the majority are in North America (n=52, 57%) and Europe (n=30, 33%) and only two (2%) are affiliated to institutions in a lower middle-income country (LMIC) (India, Nigeria), with one (1%) affiliated to an institution in an upper middle-income country (UMIC) (Peru) and none in a low-income country (LIC). Pediatric Radiology is "…the official journal of the European Society of Paediatric Radiology, the Society for Pediatric Radiology, the Asian and Oceanic Society for Pediatric Radiology and the Latin American Society of Pediatric Radiology". However, of the total number of manuscripts submitted for potential publication in the four years 2019 through 2022, only 0.03% were from a LIC and only 7.9% were from a LMIC. Further, the frequency of acceptance of manuscripts from UMIC was seven times higher than that from LMIC (no manuscripts were published from LIC). Increased collaboration is required between researchers across the globe to better understand the barriers to equity in the funding, conduct and publication of research from LIC and LMIC and to identify ways in which we can overcome them together.

Household air pollution, ultrasound measurement, fetal biometric parameters and intrauterine growth restriction.

BACKGROUND: Low birthweight, intrauterine growth restriction (IUGR) and perinatal mortality have been associated with air pollution. However, intervention studies that use ultrasound measurements to assess the effects of household air pollution (HAP) on fetal biometric parameters (FBP) are rare. We investigated the effect of a cookstove intervention on FBP and IUGR in a randomized controlled trial (RCT) cohort of HAP-exposed pregnant Nigerian women. METHODS: We recruited 324 women early in the second trimester of pregnancy. Between 16 and 18 weeks, we randomized them to either continue cooking with firewood/kerosene (control group) or receive a CleanCook stove and ethanol fuel (intervention group). We measured fetal biparietal diameter (BPD), head circumference (HC), femur length (FL), abdominal circumference (AC) and ultrasound-estimated fetal weight (U-EFW) in the second and third trimesters. The women were clinically followed up at six regular time points during their pregnancies. Once during the women's second trimester and once during the third, we made 72-h continuous measurements of their personal exposures to particulate matter having aerodynamic diameter < 2.5 µm (PM2.5). We adopted a modified intent-to-treat approach for the analysis. Differences between the intervention and control groups on impact of HAP on fetal growth trajectories were analyzed using mixed effects regression models. RESULTS: There were no significant differences in fetal growth trajectories between the intervention and control groups. CONCLUSIONS: Larger studies in a setting of low ambient air pollution are required to further investigate the effect of transitioning to a cleaner fuel such as ethanol on intrauterine growth. TRIAL REGISTRATION: ClinicalTrials.gov NCT02394574 ; September 2012.

Pediatric radiology as a subspecialty in Nigeria: to be or not to be?

We describe the advent of pediatric radiology in Nigeria and the challenges associated with establishing the subspecialty. Nigeria has very few radiologists with a special interest in pediatric radiology caring for more than 82 million children. One major challenge is the lack of interest in the subspecialty owing to the lack of remuneration when compared with others like interventional radiology. The majority of the radiologists also do not have specialized training in pediatric radiology. With very few children's hospitals, where to work after graduation is also a deterrent for pediatric radiologists. Put simply, Nigeria needs help. We also suggest ways to overcome these challenges.

Capacity for paediatric radiology in Nigeria: a survey of radiologists.

Children account for nearly half the population of Nigeria yet the capacity for effective imaging of children is unknown. In order to determine clinical resources for and challenges of paediatric radiology in Nigeria, certified radiologists at an exit examination in radiology for resident doctors, and resident doctors in radiology attending an update course, completed a semi-structured questionnaire detailing personal information, radiology training, practice and perceived priorities of paediatric radiology in Nigeria. Of 100 questionnaires, 80 were returned, completed (80%) by 46 (58%) certified radiologists, 14 (18%) senior and 20 (25%) junior radiology residents. Only 1 (2.2%) certified radiologist received dedicated albeit short training in paediatric radiology. Nine (20.0%) certified radiologists and 1 (2.9%) resident doctor target their practice to paediatric imaging. Only 2 (4.4%) certified radiologists devote at least half of their time to paediatric radiology. Forty-two (91%) of the certified radiologists are not aware of any radiologist primarily affiliated with a dedicated children's hospital or who practices in a dedicated paediatric unit of a mixed hospital. Eight (19%) radiologists work in a facility with a consultant who has some training in paediatric radiology. Surgeons (64%), neonatologists (53%) and neurologists (45%) were the other paediatric specialties usually available where the respondent works. Fourteen (4.9%), 4 (2.1%), and 1 (1.3%) ultrasound, X-ray and magnetic resonance imaging (MRI) units, respectively, were reserved for paediatric imaging while no fluoroscopy or computed tomography (CT) unit was dedicated to children. Lack of dedicated equipment (44%) and trained paediatric radiologists (24%) were the main challenges to paediatric imaging as perceived by the respondents. Substantial deficits in human and material resources require informed investment in dedicated equipment and training to boost capacity for paediatric radiology in Nigeria.

RSNA Committee on International Radiology Education: 25 Years of Global Education Outreach.

The Radiological Society of North America (RSNA) Committee on International Radiology Education (CIRE) has worked for the past 25 years to create academic programs oriented to the needs of international radiologists. The CIRE develops organized and structured approaches to help build one's capabilities and increase one's capacity for professional growth, which then facilitates better patient care. The authors describe the four programs that CIRE is responsible for and introduces its newest initiative, Global Learning Centers, which is planned to start in 2021. RSNA involvement in global radiology education provides opportunities for early, mid-, and late-career radiologists to participate in these programs as students or teachers. The authors describe some of the programs' success stories and invite readers to become a part of and contribute to the growth of radiologic academic endeavors globally. ©RSNA, 2020.

The use of uterine artery doppler indices for prediction of pre-eclampsia in Port-Harcourt, Nigeria.

CONTEXT: Pre-eclampsia (PrE), a clinical syndrome characterised by elevated blood pressure arising after 20 weeks of gestation, is a leading cause of maternal death worldwide. We evaluated the role of uterine artery Doppler (UtAD) in screening for PrE among unselected, pregnant women. METHODOLOGY: This was a prospective cohort study of 170 healthy gravid women between 18 and 26 weeks of gestation recruited consecutively from the Antenatal Clinic of Braithwaite Memorial Specialist Hospital, Port-Harcourt, Nigeria, between July 2016 and June 2017. All had UtAD scans with an abnormal result defined as pulsatility index (PI), resistance index or systolic/diastolic (S/D) ratio >95th centile for gestational age or proto-diastolic notching. Outcome was obtained from antenatal records. Data were analysed using Statistical Package for Social Sciences, version 20 at statistical significance level of P < 0.05. RESULTS: The prevalence of PrE was 7.6%. There was significant association between an abnormal PI (χ2 = 16.29, P = 0.00), S/D ratio (χ2 = 8.55, P = 0.00) and the combined result (χ2 = 11.5, P = 0.007) with subsequent PrE. The highest sensitivity (53.8%) was obtained for the combined result with specificity, negative predictive value (NPV) and positive predictive value of 86.6%, 95.8% and 25%, respectively, area under the curve (AUC) of 0.71 (95% confidence interval [CI]: 0.534-0.871). A normal result had a very high NPV for all indices. The accuracy for the prediction of severe PrE was greater for all indices being highest for the combined result AUC of 0.830 (95% CI: 0.624-1.000; P = 0.01). CONCLUSION: Abnormal UtAD indices were associated with PrE and may be used in PrE screening.

Do abnormal findings on hystero-salphingographic examination correlate with intensity of procedure associated pain?

The aim of this study is to determine if the intensity and nature of pain during Hystero-Salphingography could give a clue to the presence of abnormal finding/s. Eighty-two patients were recruited over a six-month period. Procedural pain was assessed using the numeric rating scale. Mean age was 33.2 +/- 4.9 years. The median pain score in patients with normal findings was 6.0 but 7.0, 8.0, and 8.5 in those with right tubal blockade, uterine fibroids and left tubal blockade respectively. No statistical difference in the absolute pain score between patients with normal and abnormal findings. Pain scores in patients with 1 and 2 abnormalities were 7.0 and 7.5, and the number of abnormalities did not affect pain score (P = 0.3). The presence or absence of pain during HSG may not be a suitable way of determining the presence or absence of abnormal HSG finding/s.

Ultrasonographic renal sizes, cortical thickness and volume in Nigerian children with acute falciparum malaria.

BACKGROUND: Utility of sonographic assessments of renal changes during malaria illness are rarely reported in African children in spite of the high burden of malarial-related kidney damage. METHODS: In this case-control study, renal sizes, cortical thickness and volume of the kidneys of 131 healthy children and 170 with acute falciparum malaria comprising 85 uncomplicated malaria (UM) and 85 complicated malaria (CM) cases, measured within 24 hours of presenting in the hospital were compared. RESULTS: The mean age of children with UM, CM and control groups was 49.7 ± 26.2 months, 50.7 ± 29.3 months and 73.4 ± 25.5 months, respectively (p < 0.001). The mean right kidney length of CM group was higher than control by 0.41cm (95% CI = 0.16, 0.65; p < 0.001) and UM by 0.32 cm (95% CI = 0.02, 0.62; p = 0.030). Similarly, mean left kidney length of CM was higher than control and UM by 0.34 cm (95% CI = 0.09, 0.60; p = 0.005) and 0.41cm (95% CI = 0.09, 0.72; p = 0.006), respectively. Estimated mean renal volume of the CM group was significantly higher than control group by 7.82 cm(3) for right and by 5.79 cm(3) for left kidneys respectively; in the UM group by 9.31cm(3) for right and 8.87 cm(3) for left kidneys respectively. CONCLUSION: There was a marginal increase in renal size of children with Plasmodium falciparum infection, which worsened with increasing severity of malaria morbidity. Ultrasonography provides important information for detecting renal changes in children with acute malaria.

Deploying Artificial Intelligence for Thoracic Imaging Around the World.

PURPOSE: Artificial intelligence (AI) thoracic imaging applications are increasingly being deployed in low- and middle-income countries (LMICs). Radiologists have a critical gatekeeping role to ensure the effective and ethical implementation of AI solutions. RAD-AID International uses a three-pronged implementation strategy to overcome challenges pervasive in LMICs. METHODS: During a similar period, an AI software for chest radiography (CXR) interpretation was deployed at two tertiary hospitals located in Guyana and Nigeria. The three-pronged implementation strategy of clinical education, infrastructure implementation, and phased AI introduction was used. A PACS with a cloud component was installed at each institution. Radiology residents and attending physicians at these institutions completed an introduction-to-AI course to prime them for the use of AI solutions. A phased introduction of the AI software was performed to allow local validation as well as trust building and workflow integration. Local validation processes were used at each site by comparing AI outputs with standardized prospectively generated reports by local radiologists and study team members, allowing for slight differences in the goals of AI software use between sites. RESULTS: The PACS was successfully installed at both institutions. Thirty participants completed the introduction-to-AI course with an average pre-knowledge test score of 75% and an average posttest score of 95%. The focus of the validation process at various sites was reflective of the intended use of the AI software. In Guyana, it revealed an 87% concordance rate between radiologists and the AI model for triaging normal versus abnormal findings on CXR. In Nigeria, an 85% concordance rate between radiologists and the AI model for reporting tuberculosis on CXR was noted. The AI software was successfully deployed and is being used as intended at both institutions. CONCLUSIONS: There are unique barriers to the adoption of AI in LMICs requiring an implementation strategy in collaboration with local institutions and industry partners to ensure success.

Incidence of postpartum urinary retention in a tertiary hospital in Ibadan, Nigeria.

OBJECTIVE: To determine the incidence of postpartum urinary retention (PUR) after vaginal delivery and associated risk factors. METHODS: A total of 250 women were recruited following vaginal delivery at the UCH, Ibadan. Sociodemographic and obstetrical data were collected using a pro forma. Transabdominal ultrasound scan of the urinary bladder was performed 6 hours after delivery to estimate the post-void residual bladder volume (PVRBV) of participants. PVRBV was compared with obstetrical characteristics and labor events. Data collected were analyzed using SPSS 17.0. The level of statistical significance was set at P value less than 0.05. RESULTS: The incidence of PUR was 17.6%. Women with PUR, had longer duration of first stage (591 versus 501 minutes; P = 0.001), and second stage (50 versus 32 minute; P < 0.001) of labor compared with those without PUR. There was evidence that augmentation of labor (P < 0.01), catheterization during labor (P < 0.01), perineal injury (P < 0.01), and episiotomy (P < 0.01) were associated with developing PUR. Also, women with PUR were more likely to experience storage and obstructive urinary symptoms than those without PUR. Resolution of PUR occurred within 24 hours. CONCLUSION: This study showed that postpartum urinary retention is relatively common following vaginal delivery. Awareness of risk factors will increase index of suspicion especially in women with storage and obstructive symptoms.

COVID-19: Challenges and coping strategies in radiology departments in Nigeria.

Context: COVID-19 came suddenly, bringing to the fore the challenges inherent in the health system. In a developing country, such as Nigeria, which already had myriad problems with funds and equipment in the health sector. Aims: This study aims to examine the challenges encountered by the staff in Radiology facilities and how they combated the challenges. Settings and Design: A descriptive cross-sectional study of radiology facilities in Nigeria. Subjects and Methods: Radiologists from nine government and four private facilities who attended to COVID-19 patients were asked to fill questionnaires on challenges faced and their coping strategies. Responses were sent through E-mail. Statistical Analysis Used: Data from the responses were analyzed using Microsoft excel for Mac 2011 and presented as figures and tables. Results: Majority of the government 7 (77.8%) and private facilities 4 (100%) had no equipment dedicated only to COVID-19 patients. Seven (77.8%) government facilities complained of inadequate staff, poor availability of personal protective equipment (PPEs) 8 (88.9%), and lack of technology for remote viewing 7 (77.8%). Fear of cross-infection was a challenge in one of the facilities 1 (11.1%). Coping strategies adopted include ensuring less traffic in the department by discouraging walk-in patients and canceling non-emergent cases, booking suspected/confirmed cases for lighter times, using old film for face shields and cloth for facemasks, staff education on COVID-19 and preventive measures, and sending reports to physicians through E-mail. Conclusions: There were a lot of challenges during the COVID-19 crisis, with government hospitals experiencing more challenges than private facilities. The challenges included among others inadequate staff strength and lack of technology for remote viewing. Some were overcome using education and by production of facemasks/shields production using recycled materials.

RésuméLe contexte: COVID-19 came suddenly, bringing to the fore the challenges inherent in the health system. Dans un pays en développement, comme Le Nigeria, qui avait déjà une myriade de problèmes de fonds et d'équipements dans le secteur de la santé. Objectifs : Cette étude vise à examiner les défis rencontrés par le personnel des établissements de radiologie et comment ils ont relevé les défis. Paramètres et conception: une section descriptive étude des installations de radiologie au Nigeria. Sujets et méthodes: Radiologues de neuf établissements publics et de quatre établissements privés qui ont participé aux patients COVID-19 ont été invités à remplir des questionnaires sur les défis rencontrés et leurs stratégies d'adaptation. Les réponses ont été envoyées par courrier électronique. Analyse statistique utilisée: Les données des réponses ont été analysées à l'aide de Microsoft Excel pour Mac 2011 et présentées sous forme de figures et de tableaux. Résultats: La majorité des établissements publics 7 (77,8 %) et privés 4 (100 %) ne disposaient d'aucun équipement dédié uniquement aux patients COVID-19. Sept (77,8 %) établissements publics se sont plaints d'un personnel inadéquat, d'une faible disponibilité des équipements de protection individuelle (EPI) 8 (88,9 %), et le manque de technologie pour la visualisation à distance 7 (77,8 %). La peur d'une infection croisée était un défi dans l'un des établissements 1 (11,1 %). Faire faceles stratégies adoptées comprennent la réduction de la circulation dans le service en décourageant les patients sans rendez-vous et en annulant les cas non urgents, en réservant les cas suspects/confirmés pour des périodes plus légères, en utilisant un vieux film pour les écrans faciaux et un tissu pour les masques faciaux, la formation du personnel sur COVID-19 et mesures préventives et l'envoi de rapports aux médecins par courrier électronique. Conclusions: Il y a eu beaucoup de défis pendant la COVID-19 crise, les hôpitaux publics étant confrontés à plus de défis que les établissements privés. Les défis comprenaient entre autres l'insuffisance la force du personnel et le manque de technologie pour la visualisation à distance. Certains ont été surmontés grâce à l'éducation et à la production de masques faciaux/boucliers utilisant des matériaux recyclés. Mots-clés: défis, les stratégies d'adaptation, COVID-19, Nigeria.

Cranial magnetic resonance imaging findings in kwashiorkor.

Protein energy malnutrition (PEM) is an important public health problem in the developing countries, although it is becoming uncommon in South West Nigeria. Cerebral changes have been associated with severe PEM. This study evaluated the neurological changes using Magnetic Resonance Imaging (MRI) in Ibadan south west Nigeria. The 5 children evaluated had a median age of 16 months and all the children had brain changes compatible with cerebral atrophy. In addition two of the children had periventricular white matter changes, while one these two had mega cisterna magna in addition. Though this study did not re-evaluate the brains of these children after nutritional rehabilitation, it is possible that changes are reversible as demonstrated in earlier studies.

Where COVID-19 testing is challenging: a case series highlighting the role of thoracic imaging in resolving management dilemma posed by unusual presentation.

The COVID-19 pandemic remains an evolving disease posing a challenge of incomplete understanding escalated by random atypical clinical presentations. Numerous challenges still exist with accessibility and availability of standard COVID-19 viral testing using real-time Polymerase Chain Reaction (RT-PCR), in low- and middle-income countries, especially in several hospital settings. The clinical information of three select patients at a major health facility in Southwestern Nigeria with unusual COVID-19 clinical presentation and clinical management dilemma related to challenges with COVID-19 viral laboratory testing, were retrospectively reviewed. The medical history in all three cases closely mimicked that of other medical conditions because of assumptions created by red herrings like an acute exacerbation of an underlying non-communicable disease (diaphragmatic eventration) in case 1, re-activation of a previously treated lung condition (tuberculosis) in case 2 and a sequalae of a previously diagnosed but poorly-managed chronic non-communicable disease (decompensated hypertensive heart disease). Also, viral testing was challenging in all cases due to reasons ranging from late turn-around time to inconsistent results. However, thoracic imaging was employed in all cases to heighten suspicion of COVID-19 infection, resolve management dilemma and limit intra-hospital spread. Thoracic imaging can play a major role within hospital settings in low-and middle-income countries in resolving diagnostic challenges of atypical COVID-19 clinical presentations, raising suspicion for early institution of intra-hospital disease containment measures, limiting exposure among hospital staff and guiding clinical case management of COVID-19; especially where challenges with confirmatory viral testing remain persistent.

Comparison between testicular volumes as measured with prader orchidometer and ultrasonography in Healthy Nigerian Newborns.

BACKGROUND: We compared the testicular volume (TV) measured with Prader orchidometer (PO) to the volume measured with ultrasonography in male neonates and their relationships with some selected neonatal characteristics. SUBJECTS AND METHODS: A cross-sectional study of all term male neonates who had clinical examination of their external genitalia performed and TV was measured using PO and ultrasonography. Information about the gestational age, birth weight, and birth length was also recorded to determine their relationships with TV measured. RESULTS: The mean TV measured with PO was 1.06 (standard deviation [SD] ± 0.24) ml for both sides. With ultrasonography, the mean left TV was 0.273 (SD ± 0.081) ml and the mean right TV was 0.272 (SD ± 0.079) ml. There were significant correlations between TV using both methods with the birth weight and length. CONCLUSION: TV measured with the two methods was comparable and correlates well with their birth weight and birth length.

Pregnancy outcomes and ethanol cook stove intervention: A randomized-controlled trial in Ibadan, Nigeria.

BACKGROUND: Household air pollution (HAP) exposure has been linked to adverse pregnancy outcomes. OBJECTIVES: A randomized controlled trial was undertaken in Ibadan, Nigeria to determine the impact of cooking with ethanol on pregnancy outcomes. METHODS: Three-hundred-twenty-four pregnant women were randomized to either the control (continued cooking using kerosene/firewood stove, n=162) or intervention group (received ethanol stove, n=162). Primary outcome variables were birthweight, preterm delivery, intrauterine growth restriction (IUGR), and occurrence of miscarriage/stillbirth. RESULTS: Mean birthweights for ethanol and controls were 3076 and 2988g, respectively; the difference, 88g, (95% confidence interval: -18g to 194g), was not statistically significant (p=0.10). After adjusting for covariates, the difference reached significance (p=0.020). Rates of preterm delivery were 6.7% (ethanol) and 11.0% (control), (p=0.22). Number of miscarriages was 1(ethanol) vs. 4 (control) and stillbirths was 3 (ethanol) vs. 7 (control) (both non-significant). Average gestational age at delivery was significantly (p=0.015) higher in ethanol-users (39.2weeks) compared to controls (38.2weeks). Perinatal mortality (stillbirths and neonatal deaths) was twice as high in controls compared to ethanol-users (7.9% vs. 3.9%; p=0.045, after adjustment for covariates). We did not detect significant differences in exposure levels between the two treatment arms, perhaps due to large seasonal effects and high ambient air pollution levels. CONCLUSIONS: Transition from traditional biomass/kerosene fuel to ethanol reduced adverse pregnancy outcomes. However, the difference in birthweight was statistically significant only after covariate adjustment and the other significant differences were in tertiary endpoints. Our results are suggestive of a beneficial effect of ethanol use. Larger trials are required to validate these findings.

Breast cancer screening in a resource poor country: Ultrasound versus mammography.

BACKGROUND: Breast cancer is the commonest female cancer in Nigeria. Despite its increased awareness, affordability of available screening tools is a bane. Mammography, the goal standard for screening is costly and not widely available in terms of infrastructure, technical/personnel capabilities. Ultrasound is accessible and affordable. OBJECTIVES: This study compared the use of ultrasound and mammography as breast cancer screening tools in women in South West Nigeria by characterizing and comparing the prevalent breast parenchyma, breast cancer features and the independent sensitivity of ultrasound and mammography. METHODS: This cross sectional comparative descriptive study used both ultrasound and mammography as screening tools in 300 consenting women aged 30 to 60 years who attended a free breast cancer screening campaign in a tertiary hospital in Lagos. Categorical variables were presented in tables and Chi squares for associations P-value set at ± 0.1. RESULTS: Mean age was 41.01 + 6.5years with majority in the 30 - 39 year age group 139 (55%). Fatty (BIRADS A and B) parenchyma predominated {ultrasound 237 (79%); mammography 233 (77.7%)} in all age groups. 7 (2.3%) were confirmed malignant by histology with (6) in the 30-39 age group and (1) in the 40-49 age group. Ultrasound detected all the confirmed cases 7(100%), whereas mammography detected 6 (85%). Sensitivity was higher using ultrasound (100%) than mammography (85.7%). CONCLUSION: Ultrasound can be utilized as a first line of screening especially in remote/rural areas in developing world. FUNDING: Part funding from Run for Cure governmental organization.

Clinicoradiologic and sonographic patterns of metastasis in hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is usually diagnosed at an advanced stage, when little remedy could be offered. There is a need for relatively affordable, available and non-invasive tests for diagnosis, staging and detection of metastasis among individuals at risk. A clinical, chest radiographic (CXR) and abdominal ultrasonographic examination was carried out to detect and evaluate the pattern of metastasis among 53 untreated patients. One patient had clinical paraparesis with no outward evidence of metastasis. CXR revealed lung metastasis in 11 (20.8%), with multifocal deposits and bilateral involvement in 10 (18.8%), and unilateral single deposit in one. Two (3.8%) patients had perihilar lymphadenopathy and consolidation, respectively, while 18 (34%) patients had elevated right hemidiaphragm and four 17.5%) had pleural effusion. One had right basal pneumonitis, multiple cavitatory lesions in the lung fields and soft-tissue wasting. No abnormality was seen in 17 (32.1%) cases. Abdominal ultrasonograph showed probe tenderness in 22 (41.5%), hepatomegaly in 49 (92.5%), with 33 (62.3%) of these having nodularities of varying sizes. The spleen was enlarged in 10 (18.9%) cases, with four (7.5%) showing irregular outline. There were eight (15.1%) cases with para-aortic lymphadenopathy. Portal hepatic lymphadenopathy was demonstrated in two (3.8%) cases, while pleural effusion was detected in seven (13.2%). Metastasis is common in HCC at presentation, the lung is the commonest site of spread. Clinically visible metastasis appears uncommon in HCC.

Unusual presentations of child abuse: A report of two cases and the role of imaging.

Insufficient attention has been paid to child abuse in Nigeria, where corporal punishment is still acceptable both at home and in the wider public including schools. This is notlimited to the parents; these punitive measures can also be undertaken by the extended family, caregivers, and neighbors. Mild to extreme force is allowed particularly when the crime involves tarnishing the family image. We hereby report two cases of extreme discipline that can be termed as a form of child abuse to draw the attention of clinicians and radiologists to other possible findings aside from those already reported in literature.