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

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

Controversial aspects of imaging in child abuse: a second roundtable discussion from the ESPR child abuse taskforce.

This second roundtable discussion was convened at the 56th European Society of Paediatric Radiology (ESPR) 2022 Annual Meeting in Marseille, France, to discuss controversial aspects of imaging in child abuse. The following topics were discussed: Fracture dating-the published literature is broadly similar with respect to the identification of the radiographic stages of bony healing. The non-expert/general radiologist is encouraged to use broad descriptors of fracture healing (acute, healing or old) within their reports, rather than attempting to date fractures. The more experienced/expert radiologist, who may provide a timeframe/range to assist the courts, should be aware that any published timeframes are not absolute and that recent research indicates that the rate of healing may differ according to the bone affected and the age of the patient. Whole spine imaging in suspected abusive head trauma-this is recommended to enable a complete assessment of the neuraxis when abusive head trauma is suspected or diagnosed, particularly in the presence of intracranial and cervical subdural haemorrhage and cervical ligamentous injury. Cranial imaging in suspected physical abuse-both computed tomography (CT) and magnetic resonance imaging (MRI) remain complimentary depending on the clinical context in which they are used with CT remaining first-line in the assessment of children with (suspected abusive) head trauma prior to an early MRI. MRI is superior in its assessment of parenchymal injury and may be employed as first-line in age appropriate asymptomatic siblings of a child with suspected physical abuse.

Fifteen-minute consultation: A structured approach to the child with palpable cervical lymph nodes.

Palpable cervical lymph nodes are common in children and are a frequent reason for presentation to both primary and secondary care. Enlarged lymph nodes are most commonly the result of self-limiting infection, and in children, are rarely the first indicator of a malignant process. This article presents an evidenced-based approach to evaluating these patients.

The diagnostic performance of chest computed tomography in the detection of rib fractures in children investigated for suspected physical abuse: a systematic review and meta-analysis.

OBJECTIVES: To assess the diagnostic performance of chest CT in the detection of rib fractures in children investigated for suspected physical abuse (SPA). METHODS: Medline, Web of Science and Cochrane databases were searched from January 1980 to April 2020. The QUADAS-2 tool was used to assess the quality of the eligible English-only studies following which a formal narrative synthesis was constructed. Studies reporting true-positive, false-positive, true-negative, and false-negative results were included in the meta-analysis. Overall sensitivity and specificity of chest CT for rib fracture detection were calculated, irrespective of fracture location, and were pooled using a univariate random-effects meta-analysis. The diagnostic accuracy of specific locations along the rib arc (anterior, lateral or posterior) was assessed separately. RESULTS: Of 242 identified studies, 4 met the inclusion criteria. Of these, 2 were included in the meta-analysis. Chest CT identified 142 rib fractures compared to 79 detected by initial skeletal survey chest radiographs in live children with SPA. Post-mortem CT (PMCT) has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures when compared to the autopsy reference standard. PMCT has low sensitivity (45%, 21% and 42%) but high specificity (99%, 97% and 99%) at anterior, lateral and posterior rib locations, respectively. CONCLUSIONS: Chest CT detects more rib fractures than initial skeletal survey chest radiographs in live children with SPA. PMCT has low sensitivity but high specificity for detecting rib fractures in children investigated for SPA. KEY POINTS: • PMCT has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures; extrapolation to CT in live children is difficult. • No studies have compared chest CT with the current accepted practice of initial and follow-up skeletal survey chest radiographs in the detection of rib fractures in live children investigated for SPA.

Avoiding skull radiographs in infants with suspected inflicted injury who also undergo head CT: "a no-brainer?"

OBJECTIVES: To assess whether head CT with 3D reconstruction can replace skull radiographs (SXR) in the imaging investigation of suspected physical abuse (SPA)/abusive head trauma (AHT). METHODS: PACS was interrogated for antemortem skeletal surveys performed for SPA, patients younger than 2 years, SXR and CT performed within 4 days of each other. Paired SXR and CT were independently reviewed. One reviewer analysed CT without and (3 months later) with 3D reconstructions. SXR and CT expert consensus review formed the gold standard. Observer reliability was calculated. RESULTS: A total of 104 SXR/CT examination pairs were identified, mean age 6.75 months (range 4 days to 2 years); 21 (20%) had skull fractures; two fractures on CT were missed on SXR. There were no fractures on SXR that were not seen on CT. For SXR and CT, respectively: PPV reviewer 1, 95% confidence interval (CI) 48-82% and 85-100%; reviewer 2, 67-98% and 82-100%; and NPV reviewer 1, 95%, CI 88-98% and 96-100%; reviewer 2, 88-97% and 88-98%. Inter- and intra-observer reliability were respectively the following: SXR, excellent (kappa = 0.831) and good (kappa = 0.694); CT, excellent (kappa = 0.831) and perfect (kappa = 1). All results were statistically significant (p < 0.001). CONCLUSIONS: CT has greater diagnostic accuracy than SXR in detecting skull fractures which is increased on concurrent review of 3D reconstructions and should be performed in every case of SPA/AHT. SXR does not add further diagnostic information and can be omitted from the skeletal survey when CT with 3D reconstruction is going to be, or has been, performed. KEY POINTS: • Head CT with 3D reconstruction is more sensitive and specific for the diagnosis of skull fractures. • Skull radiographs can be safely omitted from the initial skeletal survey performed for suspected physical abuse when head CT with 3D reconstruction is going to be, or has been, performed.

Bilateral fibular fractures in a pre-ambulant infant.

Multiple long-bone fractures, particularly bilateral fractures, are of moderate specificity for inflicted injury (physical abuse) in infants and young children. Bilateral healing fractures of the fibulae are rare and, depending on age, raise the suspicion of inflicted injury. We report healing undisplaced fractures of both fibulae, in almost identical positions, in a pre-ambulant infant. The caregivers reported that the infant repeatedly banged his legs against the metal frame of his playpen. A video of this mechanism was provided to the instructed radiology expert and showed that the point of impact of the infant's legs against the metal frame was at a similar level to the radiographic abnormalities. This mechanism was therefore believed to be consistent with the injuries, resulting in a diagnosis of self-inflicted bilateral fibular fractures and not of inflicted injury.

The Social Media Index as an Indicator of Quality for Emergency Medicine Blogs: A METRIQ Study.

STUDY OBJECTIVE: Online educational resources such as blogs are increasingly used for education by emergency medicine clinicians. The Social Media Index was developed to quantify their relative impact. The Medical Education Translational Resources: Indicators of Quality (METRIQ) study was conducted in part to determine the association between the Social Media Index score and quality as measured by gestalt and previously derived quality instruments. METHODS: Ten blogs were randomly selected from a list of emergency medicine and critical care Web sites. The 2 most recent clinically oriented blog posts published on these blogs were evaluated with gestalt, the Academic Life in Emergency Medicine Approved Instructional Resources (ALiEM AIR) score, and the METRIQ-8 score. Volunteer raters (including medical students, emergency medicine residents, and emergency medicine attending physicians) were identified with a multimodal recruitment methodology. The Social Media Index was calculated in February 2016, November 2016, April 2017, and December 2017. Pearson's correlations were calculated between the Social Media Index and the average rater gestalt, ALiEM AIR score, and METRIQ-8 score. RESULTS: A total of 309 of 330 raters completed all ratings (93.6%). The Social Media Index correlated moderately to strongly with the mean rater gestalt ratings (range 0.69 to 0.76) and moderately with the mean rater ALiEM AIR score (range 0.55 to 0.61) and METRIQ-8 score (range 0.53 to 0.57) during the month of the blog post's selection and for 2 years after. CONCLUSION: The Social Media Index's correlation with multiple quality evaluation instruments over time supports the hypothesis that it is associated with overall Web site quality. It can play a role in guiding individuals to high-quality resources that can be reviewed with critical appraisal techniques.

Quality Evaluation Scores are no more Reliable than Gestalt in Evaluating the Quality of Emergency Medicine Blogs: A METRIQ Study.

Construct: We investigated the quality of emergency medicine (EM) blogs as educational resources. PURPOSE: Online medical education resources such as blogs are increasingly used by EM trainees and clinicians. However, quality evaluations of these resources using gestalt are unreliable. We investigated the reliability of two previously derived quality evaluation instruments for blogs. APPROACH: Sixty English-language EM websites that published clinically oriented blog posts between January 1 and February 24, 2016, were identified. A random number generator selected 10 websites, and the 2 most recent clinically oriented blog posts from each site were evaluated using gestalt, the Academic Life in Emergency Medicine (ALiEM) Approved Instructional Resources (AIR) score, and the Medical Education Translational Resources: Impact and Quality (METRIQ-8) score, by a sample of medical students, EM residents, and EM attendings. Each rater evaluated all 20 blog posts with gestalt and 15 of the 20 blog posts with the ALiEM AIR and METRIQ-8 scores. Pearson's correlations were calculated between the average scores for each metric. Single-measure intraclass correlation coefficients (ICCs) evaluated the reliability of each instrument. RESULTS: Our study included 121 medical students, 88 EM residents, and 100 EM attendings who completed ratings. The average gestalt rating of each blog post correlated strongly with the average scores for ALiEM AIR (r = .94) and METRIQ-8 (r = .91). Single-measure ICCs were fair for gestalt (0.37, IQR 0.25-0.56), ALiEM AIR (0.41, IQR 0.29-0.60) and METRIQ-8 (0.40, IQR 0.28-0.59). CONCLUSION: The average scores of each blog post correlated strongly with gestalt ratings. However, neither ALiEM AIR nor METRIQ-8 showed higher reliability than gestalt. Improved reliability may be possible through rater training and instrument refinement.

Examining Reliability and Validity of an Online Score (ALiEM AIR) for Rating Free Open Access Medical Education Resources.

STUDY OBJECTIVE: Since 2014, Academic Life in Emergency Medicine (ALiEM) has used the Approved Instructional Resources (AIR) score to critically appraise online content. The primary goals of this study are to determine the interrater reliability (IRR) of the ALiEM AIR rating score and determine its correlation with expert educator gestalt. We also determine the minimum number of educator-raters needed to achieve acceptable reliability. METHODS: Eight educators each rated 83 online educational posts with the ALiEM AIR scale. Items include accuracy, usage of evidence-based medicine, referencing, utility, and the Best Evidence in Emergency Medicine rating score. A generalizability study was conducted to determine IRR and rating variance contributions of facets such as rater, blogs, posts, and topic. A randomized selection of 40 blog posts previously rated through ALiEM AIR was then rated again by a blinded group of expert medical educators according to their gestalt. Their gestalt impression was subsequently correlated with the ALiEM AIR score. RESULTS: The IRR for the ALiEM AIR rating scale was 0.81 during the 6-month pilot period. Decision studies showed that at least 9 raters were required to achieve this reliability. Spearman correlations between mean AIR score and the mean expert gestalt ratings were 0.40 for recommendation for learners and 0.35 for their colleagues. CONCLUSION: The ALiEM AIR scale is a moderately to highly reliable, 5-question tool when used by medical educators for rating online resources. The score displays a fair correlation with expert educator gestalt in regard to the quality of the resources. The score displays a fair correlation with educator gestalt.

Quantification of total fetal brain volume using 3D MR imaging data acquired in utero.

OBJECTIVE: Interpretation of magnetic resonance (MR) imaging of the fetal brain in utero is primarily undertaken using 2D images to provide anatomical information about structural abnormalities. It is now possible to obtain 3D image acquisitions that allow measurement of fetal brain volumes that are potentially useful clinically. The aim of our current work is to provide reference values of total brain volumes obtained from a cohort of low risk fetuses with no abnormalities on ante-natal ultrasonography and in utero MR imaging. METHOD: Images from volume MR acquisitions of 132 fetuses were used to extract brain volumes by manual segmentation. Reproducibility and reliability were assessed by analysis of the results of two subgroups who had repeated measurements made by the primary and a secondary observer. RESULTS: Intra-observer and inter-observer agreement was high with no statistically significant differences between and within observers (p = 0.476 and p = 0.427, respectively). The results of the brain volume assessments are presented graphically with mean and 95% prediction limits alongside estimates of normal growth rates. CONCLUSION: We have shown that fetal brain volumes can be reliably extracted from in utero MR (iuMR) imaging 3D datasets with a high degree of reproducibility. The resultant data could potentially be used as a reference tool in the clinical setting. © 2016 John Wiley & Sons, Ltd.

IgG4-related periaortitis presenting as left flank pain.

We present the case of periaortitis which presented initially with left flank pain. A diagnosis of IgG4-related disease (IgG4-RD) was subsequently made and managed as such. IgG4-RD is rare, can be difficult to diagnose, and requires clinical, serological, radiological and pathological correlation, particularly given that serum IgG4 levels may be normal. Immunosuppression is the mainstay treatment for this chronic condition alongside regular rheumatology input.

Corrigendum to "Juxta-articular extraskeletal myxoid chondrosarcoma mistaken for a benign cyst presenting with multiple lung metastases" [Radiology Case Reports 19 (2024) 684-690].

[This corrects the article DOI: 10.1016/j.radcr.2023.10.075.].

Juxta-articular extraskeletal myxoid chondrosarcoma mistaken for a benign cyst presenting with multiple lung metastases.

Extraskeletal myxoid chondrosarcoma (EMC) is a malignant cartilage neoplasm usually encountered in the proximal extremities. We report the case of a 58-year-old male who presented initially with a 3-month history of cough. Initial staging demonstrated a right upper lobe mass with bilateral pulmonary nodules and moderate tracer uptake in the right lung mass and right groin on positron emission tomography imaging. Endobronchial ultrasound biopsy confirmed a histological diagnosis of EMC for which the patient underwent right upper lobe wedge resection. Pelvic MRI revealed a peripherally enhancing juxta-articular lesion within the region of the right obturator externus bursa, which was thought initially to represent either a ganglion or paralabral cyst. However, ultrasound-guided biopsy yielded identical histology to the resected lung mass leading to the diagnosis of primary EMC in the right groin with pulmonary metastases. The patient underwent surgical excision of the right groin mass with no local recurrence on the surveillance computed tomography at 5, 12, and 18 months but eventual disease recurrence in the right groin and further progression of the pulmonary metastases at 29 months. We emphasize that the contrast enhancement pattern of EMC can mimic a benign cystic lesion, in particular, when in a juxta-articular location, which has the potential to mislead radiologists and delay diagnosis and definitive treatment.

Rate and severity of radiological features of physical abuse in children during the first UK-wide COVID-19 enforced national lockdown.

Rate and severity of radiological features of physical abuse in children during the first UK-wide COVID-19 enforced national lockdown. OBJECTIVE: To assess the number, type and outcome of radiological investigations for children presenting to hospital with suspected physical abuse (SPA; including abusive head trauma) during the first national COVID-19 enforced lockdown compared with the prelockdown period. DESIGN: Multicentre, retrospective, observational, interrupted time series analysis. SETTING: Eight secondary/tertiary paediatric centres between January 2018 and July 2020 inclusive. PARTICIPANTS: 1587 hospital assessed children undergoing radiographic skeletal surveys (SkS) and head CT imaging performed for SPA/child protection concerns. MAIN OUTCOME MEASURES: Incidence and severity of fractures identified on SkS; head injury (composed of incidence rates and ratios of skull fracture, intracranial haemorrhage (ICH) and hypoxic ischaemic injury (HII)) on head CT imaging; and ratio of antemortem and postmortem SkS. RESULTS: 1587 SkS were performed: 1282 (81%) antemortem, 762 (48%) male, and positive findings in 582 (37%). Median patient age was 6 months. There were 1.7 fractures/child prelockdown versus 1.1 fractures/child during lockdown. There was no difference between positive/negative SkS rates, the absolute ratio of antemortem/postmortem SkS or absolute numbers of head injury occurring between January 2018 and February 2020 and the lockdown period April-July 2020. Likewise, prelockdown incidence and rates of skull fracture 30/244 (12%), ICH 28/220 (13%) and HIE 10/205 (5%) were similar to lockdown, 142/1304 (11%), 171/1152 (15%) and 68/1089 (6%), respectively. CONCLUSION: The first UK COVID-19 lockdown did not lead to an increase in either the number of antemortem or postmortem radiological investigations performed for SPA, or the number or severity of fractures and intracranial injuries identified by these investigations.

Pediatric Cerebral Cavernous Malformations.

Cerebral cavernous malformations are the second most common vascular malformations in the central nervous system, and over one-third are found in children. Lesions may be solitary or multiple, be discovered incidentally, be sporadic, or be secondary to familial cavernomatosis or radiation therapy. Children may present with focal seizures, intracranial hemorrhage, or focal neurological deficits without radiological evidence of recent hemorrhage. We present several children with cerebral cavernous malformations and explore the challenges of their diagnosis in children, their key imaging features, the role of follow-up imaging, and their subsequent management including stereotactic radiosurgery and microsurgical resection. Individual patient risk stratification is advocated for all affected children and their families.