Troubleshooting Tips for Diagnosing Complex Fetal Genitourinary Malformations.

Fetal genitourinary anomalies can present a diagnostic challenge for the radiologist. The absence of a normally located kidney may represent agenesis or be secondary to a fusion or migration abnormality. A dilated renal pelvis should prompt evaluation for a specific cause, including ureteropelvic junction obstruction, reflux, or an obstructed duplicated system. Cystic parenchymal changes are characteristic of a multicystic dysplastic kidney but may also be seen in obstructive cystic dysplasia. There are numerous causes of megacystis including chromosomal (trisomy 18 syndrome), obstruction (posterior urethral valves, urethral atresia), or muscular dysfunction (prune belly syndrome, megacystis microcolon intestinal hypoperistalsis syndrome). Important mimics of a large bladder include hydrocolpos and urogenital sinus or cloacal malformation. Complications of genitourinary malformations are common and include oligohydramnios, urinary ascites, and urinoma. Making an accurate diagnosis often requires additional US views beyond those obtained in the standard fetal survey and occasionally performing fetal MRI. The appropriate use of orthogonal T2-weighted sequences, in conjunction with diffusion-weighted images for evaluation of the kidneys and gradient-recalled-echo sequences for evaluation of T1-hyperintense meconium in the colon, can play an integral role in diagnosis. Accurate diagnosis of fetal genitourinary malformations is vital to direct patient counseling and pregnancy management as outcomes are highly variable. Some conditions can be surgically corrected quite simply, some require multiple complex procedures, and some are lethal. The authors offer troubleshooting tips to narrow the differential diagnosis for four observations: unilateral absent kidney, dilated renal pelvis, cystic renal parenchyma, and megacystis and its mimics. ©RSNA, 2023 Test Your Knowledge questions are available in the Online Learning Center.

Cesarean Scar Ectopic Pregnancy: A Do-Not-Miss Diagnosis.

The rate of cesarean section (CS) for delivery has increased internationally, reaching 50% in some countries. Abnormal implantation of a new pregnancy at the site of the prior hysterotomy is an important complication because of the risks of hemorrhage, uterine rupture, and progression to placenta accreta spectrum (PAS), a condition with high morbidity with potential for catastrophic obstetric hemorrhage, maternal and fetal mortality, and loss of fertility. Cesarean scar ectopic pregnancy (CSEP) is the recommended term to describe these pregnancies, which are recognized on the basis of the sac implantation site, growth pattern, and associated abnormal perfusion. The true incidence of CSEP is unknown because the condition is likely underdiagnosed and underreported. The 2022 Society for Maternal-Fetal Medicine consult series notes that severe maternal morbidity and mortality are linked to difficulty in making the diagnosis of CSEP. The authors review the signs of CSEP at imaging, some pitfalls that may lead to delayed or missed diagnosis, and the consequences thereof. CSEPs must be differentiated from low implantation of a normal pregnancy, cervical ectopic pregnancy, and evolving pregnancy loss. Early recognition allows prompt and safe treatment that is usually surgical. Early treatment results in decreased health care costs, a shorter hospital stay, preservation of fertility, and prevention of iatrogenic preterm delivery, which is typical in cases that progress to PAS. Hysterectomy has serious negative psychologic consequences for patients of childbearing age; early diagnosis and prompt treatment of CSEP can prevent this often-ignored complication. ©RSNA, 2024 Supplemental material is available for this article.

Assessment of Amniotic Fluid Volume in Pregnancy.

Amniotic fluid (AF) is an integral part of the fetal environment and is essential for fetal growth and development. Pathways of AF recirculation include the fetal lungs, swallowing, absorption through the fetal gastrointestinal tract, excretion through fetal urine production, and movement. In addition to being a marker for fetal health, adequate AF is necessary for fetal lung development, growth, and movement. The role of diagnostic imaging is to provide a detailed fetal survey, placental evaluation, and clinical correlation with maternal conditions to help identify causes of AF abnormalities and thereby enable specific therapy. Oligohydramnios prompts evaluation for fetal growth restriction as well as genitourinary issues, including renal agenesis, multicystic dysplastic kidneys, ureteropelvic junction obstruction, and bladder outlet obstruction. Premature preterm rupture of membranes should also be clinically excluded as a cause of oligohydramnios. Clinical trials evaluating amnioinfusion are underway as a potential intervention for renal causes of oligohydramnios. Most cases of polyhydramnios are idiopathic, with maternal diabetes being a common cause. Polyhydramnios prompts evaluation for fetal gastrointestinal obstruction and oropharyngeal or thoracic masses, as well as neurologic or musculoskeletal anomalies. Amnioreduction is performed only for maternal indications such as symptomatic polyhydramnios causing maternal respiratory distress. Polyhydramnios with fetal growth restriction is paradoxical and can occur with maternal diabetes and hypertension. When these maternal conditions are absent, this raises concern for aneuploidy. The authors describe the pathways of AF production and circulation, US and MRI assessment of AF, disease-specific disruption of AF pathways, and an algorithmic approach to AF abnormalities. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Chronic Obstructive Pulmonary Disease: Diagnosis and Management.

Chronic obstructive pulmonary disease (COPD) affects nearly 6% of Americans. Routine screening for COPD in asymptomatic adults is not recommended. Patients with suspected COPD should have the diagnosis confirmed with spirometry. Disease severity is based on spirometry results and symptoms. The goals of treatment are to improve quality of life, reduce exacerbations, and decrease mortality. Pulmonary rehabilitation improves lung function and increases patients' sense of control, and it is effective for improving symptoms and reducing exacerbations and hospitalizations in patients with severe disease. Initial pharmaceutical treatment is based on disease severity. For mild symptoms, initial treatment with a long-acting muscarinic antagonist is recommended. If symptoms are uncontrolled with monotherapy, dual therapy with a long-acting muscarinic antagonist/long-acting beta2 agonist combination should be initiated. Triple therapy with a long-acting muscarinic antagonist/long-acting beta2 agonist/inhaled corticosteroid combination improves symptoms and lung function more than dual therapy but increases pneumonia risk. Phosphodiesterase-4 inhibitors and prophylactic antibiotics can improve outcomes in some patients. Mucolytics, antitussives, and methylxanthines do not improve symptoms or outcomes. Long-term oxygen therapy improves mortality in patients with severe resting hypoxemia or with moderate resting hypoxemia and signs of tissue hypoxia. Lung volume reduction surgery reduces symptoms and improves survival in patients with severe COPD, whereas a lung transplant improves quality of life but does not improve long-term survival.

Review of appendicitis: routine, complicated, and mimics.

Appendicitis is one of the most common sources of abdominal pain in the emergency setting and is generally considered a straightforward diagnosis. However, atypical appearances, non-visualization, and inconclusive features can make these cases more complicated. The objectives of this article are to review the differential diagnoses for right lower quadrant pain, discuss the imaging characteristics of simple appendicitis on computed tomography (CT), and provide guidance for equivocal cases, complicated appendicitis, and appendicitis mimics. This review will also discuss the identification and management of neoplasms of the appendix.

Parental presence at the bedside of critically ill children in the pediatric intensive care unit: A scoping review.

Parental presence at the bedside (PPB) of critically ill children in the pediatric intensive care unit (PICU) is necessary for operationalizing family-centred care. Previous evidence syntheses emphasize parent-healthcare provider interactions at rounds and resuscitation; our focus is the parent-child dyad. Prior to embarking on further study, we performed a scoping review to determine the breadth and scope of the literature addressing PPB of critically ill children in the PICU. We searched five online databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and PSYCHINFO) and the grey literature to identify English and French reports from January 1960 to June 2020 addressing physical parental presence with children (birth to 18 years) in intensive care units, without limitation by methodology. Screening, reference selection, and data extraction were performed by two independent reviewers. Data were extracted into a researcher-designed tool. We identified 204 publications (81 quantitative, 68 qualitative, 22 mixed methods, and 9 descriptive case or practice change studies, and a further 24 non-study reports). PPB was directly assessed in 78 (38%) reports, and was the primary objective in 64 (31%). Amount or quality of presence was addressed by 114 reports, barriers and enablers by 152 sources, and impacts and outcomes by 134 sources. While only 6 reports were published in the first two decades of our search (1960-1980), 17 reports were published in 2019 alone. Conclusions: A relatively large body of literature exists addressing PPB of critically ill children. Separate systematic evidence syntheses to assess each element of PPB are warranted. Scoping review protocol registration: Open science framework, protocol nx6v3, registered 9-September-2019. What is Known: • Parental presence at the bedside of critically ill children must be enabled to facilitate family centeredness in care. • Systematic evidence syntheses have focused on parental presence at rounds or resuscitation, rather than with the child throughout the intensive care journey. What is New: • Many reports (n=204) address parental presence at the bedside in the pediatric intensive care unit, though most do as incidental findings • Identifies studies addressing key elements of parental presence in the PICU including barriers and enablers to, amount and quality of, and impact and outcomes of parental presence, and demonstrates trends over time and geography.

Sonographic Assessment of Fetal Growth Abnormalities.

Fetal growth abnormalities have significant consequences for pregnancy management and maternal and fetal well-being. The accurate diagnosis of fetal growth abnormalities contributes to optimal antenatal management, which may minimize the sequelae of inadequate or excessive fetal growth. An accurate diagnosis of abnormal fetal growth depends on accurate pregnancy dating and serial growth measurements. The fetal size at any given stage of pregnancy is either appropriate or inappropriate for the given gestational age (GA). Pregnancy dating is most accurate in the first trimester, as biologic variability does not come into play until the second and third trimesters. The authors describe the determination of GA with use of standard US measurements and how additional parameters can be used to confirm dating. Once dates are established, serial measurements are used to identity abnormal growth patterns. The sometimes confusing definitions of abnormal growth are clarified, the differentiation of a constitutionally small but healthy fetus from a growth-restricted at-risk fetus is described, and the roles of Doppler US and other adjunctive examinations in the management of growth restriction are discussed. In addition, the definition of selective growth restriction in twin pregnancy is briefly discussed, as is the role of Doppler US in the classification of subtypes of selective growth restriction in monochorionic twinning. The criteria for diagnosing macrosomia and the management of affected pregnancies also are reviewed. The importance of correct pregnancy dating in the detection and surveillance of abnormal fetal growth and for prevention of perinatal maternal and fetal morbidity and mortality cannot be overstated. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2020.

Use of Methotrexate in Gynecologic and Obstetric Practice: What the Radiologist Needs to Know.

Methotrexate (MTX) is the primary pharmaceutical agent that is used for management of disorders arising from trophoblastic tissue. Its widespread international use is mostly attributable to its noninvasive, safe, and effective characteristics as a treatment option for ectopic pregnancy (EP) and gestational trophoblastic disease (GTD), with the large added benefit of fertility preservation. Although the effects of MTX usage are well documented in the gynecologic and obstetric literature, there is a scarcity of radiologic literature on the subject. Depending on the type of EP, the route of MTX administration and dosage may vary. US plays an essential role in the diagnosis and differentiation of various types of EPs, pregnancy-related complications, and complications related to MTX therapy, as well as the assessment of eligibility criteria for MTX usage. A knowledge of expected imaging findings following MTX treatment, including variability in echogenicity and shape of the EP, size fluctuations, changes in vascularity and gestational sac content, and the extent of hemoperitoneum, is essential for appropriate patient management and avoidance of unnecessary invasive procedures. A recognition of sonographic findings associated with pregnancy progression and complications such as tubal or uterine rupture, severe hemorrhage, septic abortion, and development of arteriovenous communications ensures prompt patient surgical management. The authors discuss the use of MTX in the treatment of disorders arising from trophoblastic tissue (namely EP and GTD), its mechanism of action, its route of administration, and various treatment regimens. The authors also provide a focused discussion of the role of US in the detection and diagnosis of EP and GTD, the assessment of the eligibility criteria for MTX use, and the identification of the sonographic findings seen following MTX treatment, with specific emphasis on imaging findings associated with MTX treatment success and failure. Online supplemental material is available for this article. ©RSNA, 2021.

Accuracy and Interobserver Reliability of Magnetic Resonance Imaging for Placenta Accreta Spectrum Disorders.

OBJECTIVE: This study aims to define the accuracy, predictive value, and interobserver reliability of magnetic resonance imaging (MRI) in the diagnosis of placenta accreta spectrum (PAS) disorders. STUDY DESIGN: Two experienced radiologists independently interpreted the MRI studies of patients with possible PAS from two referral centers. Radiologists were blinded to sonographic and clinical information. We calculated diagnostic testing characteristics and kappa statistics of interobserver reliability for MRI findings of PAS. RESULTS: Sixty-eight MRI cases were evaluated. Confirmed PAS and severe PAS were present in 44 (65%) and 20 (29%) cases. For the diagnosis of any PAS, MRI had a sensitivity 66%, specificity 71%, positive predictive value (PPV) 81%, negative predictive value (NPV) 53%, and accuracy 68%. For the diagnosis of severe PAS (percreta), MRI had a sensitivity 85%, specificity 79%, PPV 63%, NPV 93%, and accuracy 81%. The accuracy of individual signs of PAS was lower (44-65%). Interobserver agreement was almost perfect for previa; substantial for myometrial interruptions, PAS, severe PAS, and placental bulging/balling; and moderate to slight for other signs of PAS. CONCLUSION: Although the interobserver reliability of MRI for a diagnosis of PAS is substantial, the accuracy and predictive value are modest and lower than previously reported.

Mediating engagement in a social network intervention for people living with a long-term condition: A qualitative study of the role of facilitation.

BACKGROUND: Successful facilitation of patient-centred interventions for self-management support has traditionally focussed on individual behaviour change. A social network approach to self-management support implicates the need for facilitation that includes an orientation to connecting to and mobilizing support and resources from other people and the local environment. OBJECTIVE: To identify the facilitation processes through which engagement with a social network approach to self-management is achieved. METHOD: Thematic analysis was used to analyse data from a longitudinal study design using quasi-ethnographic methods comprising non-participant observation, video and qualitative interviews involving 30 participants living with a long-term condition recruited from a marginalized community. RESULTS: Findings centred on three themes about the social network approach facilitation processes: reversing the focus on the self by bringing others into view; visualization and reflection as a mediator of positive disruption and linking to new connections; personalized matching of valued activities as a means of realizing preference elicitation. DISCUSSION AND CONCLUSIONS: Engagement processes with a social network approach illuminated the relevance of cognizance of an individual's immediate social context and forefronting social participation with others as the bases of self-management support of a long-term condition. This differs from traditional guided facilitation of health behaviour interventions that frame health as a matter of personal choice and individual responsibility.

The work and relatedness of ties mediated online in supporting long-term condition self-management.

The 'care transition' is characterised by reduced state involvement in chronic illness management in response to socio-political movements aimed at meeting the challenges presented by an increased prevalence of chronic illness. Amongst these changes has been online communities' rising importance in everyday interactions and attention is being increasingly paid towards the ways online contacts might contribute to self-management. Whilst research has illuminated the relevance of personal networks in long-term condition management, it is relevant to extend this work to consider the place of ties mediated online in this bricolage of support, including better understanding the work drawn from them and the strategies involved in eliciting it. This study examined the work and relatedness of 30 participants, who used online communities. Participants were asked about the role of on and offline ties and ego network mapping was used to frame conversations about the nature of this support. The context of engagement followed three main themes. Participants drew from online communities in response to deficits in offline support, they used online ties to leverage support or action from offline ties and they used online ties to substitute offline support, with less intimate online ties.

Versatility of Pedicled Perforator-Based V-Y Advancement Flaps for Reconstruction of the Upper Limb: A Case Series and Review of the Literature.

INTRODUCTION: The aim of any reconstruction is to provide a robust and cosmetically pleasing result that does not significantly alter function. We describe our experience of using the V-Y principle in advancement flaps designed around a distinct perforator to reconstruct soft tissue defects of the upper limb. The shortcomings of fasciocutaneous and fascial flaps requiring skin grafting can be eliminated. METHODS: This was a 10-year retrospective review of patients who had V-Y flaps based on a distinct perforator for defects of the shoulder, axilla, arm, elbow, forearm, wrist, and hand. Defects of the digits and thumb were excluded. RESULTS: There were 59 flaps in 52 patients with an average age of 44 years (18-72 years). Skin malignancy was the most common primary etiology. The average defect size was 35 cm (9-80 cm). There were no total flap failures; however, there were 4 partial losses, which healed by secondary intention. Seven flaps had to be explored for the hematoma evacuation. CONCLUSIONS: The use of V-Y flaps based on distinct perforators in the upper limb retains limb aesthetics, allows early mobility and is a safe and reliable technique.

A Radiologist's Guide to the Performance and Interpretation of Obstetric Doppler US.

Doppler US provides a unique window to the fetoplacental circulation, allowing assessment of fetal well-being. Doppler US of the umbilical artery is an integral component of managing the fetus with growth restriction; and Doppler US of the middle cerebral artery, as a noninvasive means of detecting fetal anemia, has revolutionized the management of pregnancies complicated by alloimmunization. Serial use of amniocentesis, with its attendant risks, has been replaced by serial Doppler US examinations. Invasive procedures are now reserved for the treatment of anemia with intrauterine transfusion. Technique is critical to obtain the best waveforms for ease of shape assessment, velocity measurement, and calculation of various ratios. In this article, the safety of Doppler US is reviewed, the fetal circulation is described, and the role of Doppler US is demonstrated in first-trimester screening and in the evaluation of growth restriction, anemia, and other causes of fetal compromise in the second and third trimesters. Sampling technique is explained, and normal and abnormal waveforms are illustrated for the ductus venosus, umbilical artery, umbilical vein, middle cerebral artery, and uterine artery. Some examples of clinical cases are provided to illustrate how the results are used in clinical practice. Clinical examples of velamentous insertion and vasa previa are also provided to aid the practicing radiologist with recognition of these entities. In particular, vasa previa is considered a critical finding; it alters pregnancy management, requiring hospital admission, administration of steroid therapy, and planned early cesarean delivery. ©RSNA, 2019.

US Evaluation of Twin Pregnancies: Importance of Chorionicity and Amnionicity.

The twin birth rate is increasing in the United States. Twin pregnancies can be dichorionic or monochorionic (MC). MC twins account for 20% of twin pregnancies but 30% of all-cause pregnancy-related complications. This article describes the imaging findings that establish chorionicity and amnionicity. Ideally, these are established in the first trimester when accuracy is high, but they can also be determined later in pregnancy. Complications unique to MC twin pregnancy include twin-twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion sequence, and selective fetal growth restriction. The US features, staging systems, and management of these complications are reviewed, and the consequences of MC twin demise are illustrated. Ongoing surveillance for these conditions starts at 16 weeks gestation. Monoamniotic (MA) twins are a small subset of MC twins. In addition to all of the MC complications, specific MA complications include cord entanglement and conjoined twinning. Radiologists must be able to determine chorionicity and amnionicity and should be aware of potential complications so that patients may be referred to appropriate regional specialized centers. A proposed algorithm for referral to specialized fetal treatment centers is outlined. Online supplemental material is available for this article. ©RSNA, 2019.

Identifying the processes of change and engagement from using a social network intervention for people with long-term conditions. A qualitative study.

BACKGROUND: Personal and community networks are recognized as influencing and shaping self-management activities and practices. An acceptable intervention which facilitates self-management by mobilizing network support and improves network engagement has a positive impact on health and quality of life. This study aims to identify the processes through which such changes and engagement take place. METHODS: The study was conducted in the south of England in 2016-2017 and adopted a longitudinal case study of networks design. Purposive sample of respondents with long-term conditions (n = 15) was recruited from local groups. Barriers and facilitators to implementation were explored in interviews with key stakeholders (5). RESULTS: Intervention engagement leads to a deepening of relationships within networks, adding new links and achieving personal objectives relevant for improving the health and well-being of users and network members. Such changes are supported through two pathways: the mobilization of network capabilities and by acting as a nudge. The first is a gradual process where potentially relevant changes are further contemplated by forefronting immediate concerns and negotiating acceptable means for achieving change, prioritizing objective over subjective valuations of support provided by network members and rehearsing justifications for keeping the status quo or adopting change. The second pathway changes are enacted through the availability of a potential fit between individual, network and environmental conditions of readiness. CONCLUSIONS: The two pathways of network mobilization identified in this study illuminate the individual, network and environmental level processes involved in moving from cognitive engagement with the intervention to adopting changes in existing practice.

A comparison of the accuracy of fetal MRI and prenatal ultrasonography at predicting lesion level and perinatal motor outcome in patients with myelomeningocele.

OBJECTIVE: Prenatal imaging has several critical roles in the diagnosis and management of myelomeningocele, including specific family counseling and the selection of fetal surgery or postnatal repair. In this study, the authors compared the accuracy of fetal MRI and prenatal ultrasonography (US) in predicting the spinal lesion level and assessed the correlation between imaging findings and motor function as independently evaluated by a physical therapist (PT) after birth. METHODS: A retrospective review of demographic and clinical data was performed to identify children who had been treated with postnatal myelomeningocele closure at a single institution between March 2013 and December 2018. Patients were eligible for inclusion if they had all of the following: prenatal US identifying the neural tube defect level, fetal MRI identifying the neural tube defect level, and postoperative PT evaluation identifying the motor deficit level. Statistical analysis was performed using Cohen's kappa coefficient to compare the US- and MRI-demonstrated lesion level and correlate these findings with the motor level assigned postnatally by a PT via manual muscle testing. RESULTS: Thirty-four patients met the inclusion criteria. The mean gestational age at US was 23.0 ± 4.7 weeks, whereas the mean gestational age at MRI was 24.0 ± 4.1 weeks. The mean time from surgery to the PT evaluation was 2.9 ± 1.9 days. Prenatal US and MRI were in agreement within one spinal level in 74% of cases (25/34, k = 0.43). When comparing the US-demonstrated spinal level with the PT-assigned motor level, the two were in agreement within one level in 65% of cases (22/34, k = 0.40). When comparing MRI-demonstrated spinal level with the PT motor level, the two were in agreement within one level in 59% of cases (20/34, k = 0.37). MRI and US were within two spinal levels of the PT evaluation in 79.4% and 85.3% of cases, respectively. MRI and US agreed within two levels in 97.1% of cases. Prenatal US and MRI were equivalent when comparing the difference between the imaged level and the postnatal motor deficit level (mean level difference: 1.12 ± 1.16 vs 1.17 ± 1.11, p = 0.86). CONCLUSIONS: Prenatal US and MRI equivalently predicted the postnatal motor deficit level in children with myelomeningocele. These data may be valuable in prenatal prognostication.

Magnetic resonance imaging is often misleading when used as an adjunct to ultrasound in the management of placenta accreta spectrum disorders.

BACKGROUND: Magnetic resonance imaging is reported to have good sensitivity and specificity in the diagnosis of placenta accreta spectrum disorders, and is often used as an adjunct to ultrasound. But the additional utility of obtaining magnetic resonance imaging to assist in the clinical management of patients with placenta accreta spectrum disorders, above and beyond the information provided by ultrasound, is unknown. OBJECTIVE: We aimed to determine whether magnetic resonance imaging provides data that may inform clinical management by changing the sonographic diagnosis of placenta accreta spectrum disorders. STUDY DESIGN: In all, 78 patients with sonographic evidence or clinical suspicion of placenta accreta spectrum underwent magnetic resonance imaging of the abdomen and pelvis in orthogonal planes through the uterus utilizing T1- and T2-weighted imaging sequences at the University of Utah and the University of Colorado from 1997 through 2017. The magnetic resonance imaging was interpreted by radiologists with expertise in diagnosis of placenta accreta spectrum who had knowledge of the sonographic interpretation and clinical risk factors for placenta accreta spectrum disorders. The primary outcome was a change in diagnosis from sonographic interpretation that could alter clinical management, which was defined a priori. Diagnostic accuracy was verified by surgical and histopathologic diagnosis at the time of delivery. RESULTS: A change in diagnosis that could potentially alter clinical management occurred in 28 (36%) cases. Magnetic resonance imaging correctly changed the diagnosis in 15 (19%), and correctly confirmed the diagnosis in 34 (44%), but resulted in an incorrect change in diagnosis in 13 (17%), and an incorrect confirmation of ultrasound diagnosis in 15 (21%). Magnetic resonance imaging was not more likely to change a diagnosis in the 24 cases of posterior and lateral placental location compared to anterior location (33% vs 37%, P = .84). Magnetic resonance imaging resulted in overdiagnosis in 23% and in underdiagnosis in 14% of all cases. When ultrasound suspected severe disease (percreta) in 14 cases, magnetic resonance imaging changed the diagnosis in only 2 cases. Lastly, the proportion of accurate diagnosis with magnetic resonance imaging did not improve over time (61-65%, P = .96 for trend) despite increasing volume and increasing numbers of changed diagnoses. CONCLUSION: Magnetic resonance imaging resulted in a change in diagnosis that could alter clinical management of placenta accreta spectrum disorders in more than one third of cases, but when changed, the diagnosis was often incorrect. Given its high cost and limited clinical value, magnetic resonance imaging should not be used routinely as an adjunct to ultrasound in the diagnosis of placenta accreta spectrum until evidence for utility is clearly demonstrated by more definitive prospective studies.

Intrauterine Linear Echogenicities in the Gravid Uterus: What Radiologists Should Know.

Intrauterine linear echogenicity (ILE) is a common ultrasonographic finding in the gravid uterus and has variable causes and variable maternal and fetal outcomes. Correctly categorizing ILE during pregnancy is crucial for guiding surveillance and advanced imaging strategies. Common causes of ILE include membranes in multiple gestations, uterine synechiae with amniotic sheets, and uterine duplication anomalies. Less common causes include circumvallate placenta, chorioamniotic separation, and hemorrhage between membranes. Amniotic band syndrome is a rare but important diagnosis to consider, as it causes severe fetal defects. Imaging findings enable body stalk anomaly, a lethal defect, to be distinguished from amniotic bands, which although destructive are not necessarily lethal. This review describes the key imaging findings used to differentiate the various types of ILE in pregnancy, thus enabling accurate diagnosis and appropriate patient counseling. Online supplemental material is available for this article. ©RSNA, 2018.

How do people with long-term mental health problems negotiate relationships with network members at times of crisis?

BACKGROUND: Social network processes impact on the genesis and management of mental health problems. There is currently less understanding of the way people negotiate networked relationships in times of crisis compared to how they manage at other times. OBJECTIVE: This paper explores the patterns and nature of personal network involvement at times of crises and how these may differ from day-to-day networks of recovery and maintenance. METHOD: Semi-structured interviews with 25 participants with a diagnosis of long-term mental health (MH) problems drawn from recovery settings in the south of England. Interviews centred on personal network mapping of members and resources providing support. The mapping interviews explored the work of network members and changes in times of crisis. Interviews were recorded, transcribed and analysed using a framework analysis. RESULTS: Three key themes were identified: the fluidity of network relationality between crisis and recovery; isolation as a means of crises management; leaning towards peer support. Personal network input retreated at times of crisis often as result of "ejection" from the network by participants who used self-isolation as a personal management strategy in an attempt to deal with crises. Peer support is considered useful during a crisis, whilst the role of services was viewed with some ambiguity. CONCLUSIONS: Social networks membership, and type and depth of involvement, is subject to change between times of crisis and everyday support. This has implications for managing mental health in terms of engaging with network support differently in times of crises versus recovery and everyday living.

Fetal Cardiac US: Techniques and Normal Anatomy Correlated with Adult CT and MR Imaging.

Congenital heart disease (CHD) is an important cause of childhood mortality. Despite the widespread use of ultrasonography (US) as a screening tool, the prenatal detection rate is suboptimal. Improvement of the initial screening examination, which is performed in low-risk populations and often interpreted by community radiologists, targets a point in the screening process that is likely to have the largest population effect. If the goal of community-based screenings is to detect cases that may be abnormal and refer those to specialized centers for complete assessment, it is logical to use a checklist to confirm normal anatomy. This article presents a stepwise process to evaluate fetal cardiac anatomy using comparison with computed tomography (CT) and magnetic resonance (MR) images, which are more familiar to radiologists in busy general practices. In addition, this article presents a checklist for assessment of the four-chamber view and demonstrates the expected normal appearance of the outflow tract views as well as the additional views required for complex obstetric US. These additional views include the aortic arch and bicaval views, three-vessel view (3VV), and three-vessel trachea view (3TV). CHD may be isolated, but it may indicate aneuploidy or a syndrome that, if present, determines the prognosis. In isolated CHD, the prognosis is determined by the exact nature of the abnormalities. In particular, duct-dependent disease if undiagnosed results in circulatory collapse in the infant once the ductus closes. If the heart does not look normal, the patient should be referred for detailed evaluation. Timely diagnosis of significant CHD allows for development of a personalized pregnancy management plan. © RSNA, 2017.