Classification Criteria for Axial Disease in Youth with Juvenile Spondyloarthritis.

OBJECTIVES: To develop and validate classification criteria for axial disease in youth with juvenile spondyloarthritis (SpA; AxJSpA). METHODS: This international initiative consisted of four phases: 1) Item generation; 2) Item reduction; 3) Criteria development; and 4) Validation of the AxJSpA criteria by an independent team of experts in an internationally representative Validation cohort. RESULTS: These criteria are intended to be used on youth with a physician diagnosis of juvenile SpA and for whom axial disease is suspected. Item generation consisted of a systematic literature review and a free-listing exercise using input from international physicians and collectively resulted in 108 items. After the item reduction exercise and expert panel input, 37 items remained for further consideration. The final AxJSpA criteria domains included: imaging: active inflammation, imaging: structural lesions, pain chronicity, pain pattern, pain location, stiffness, and genetics. The most heavily weighted domains were active inflammation and structural lesions on imaging. Imaging typical of sacroiliitis was deemed necessary, but not sufficient, to classify a youth with AxJSpA. The threshold for classification of AxJSpA was a score of ≥55 (out of 100). When tested in the validation data set, the final criteria had a specificity of 97.5% (95% CI: 91.4-99.7), sensitivity of 64.3% (95% CI: 54.9-73.1) and Area Under the Receiver Operating Characteristic (AUROC) curve of 0.81 (95% CI: 0.76-0.86). CONCLUSIONS: The new AxJSpA classification criteria require an entry criterion, physician diagnosis of juvenile SpA, and include seven weighted domains. The AxJSpA classification criteria are validated and designed to identify participants for research studies.

Imaging Stewardship: Triage for Neuroradiology MR During Limited-Resource Hours.

OBJECTIVES: To decrease call burden on pediatric neuroradiologists, we developed guidelines for appropriate use of MR overnight. These guidelines were implemented using triage by in-house generalist pediatric radiologists. Process measures and balancing measures were assessed during implementation. METHODS: For this improvement project, interdepartmental consensus guidelines were developed using exploratory mixed-methods design. Implementation of triage used plan-do-study-act cycles. Process measures included reduction in the number of telephone calls, frequency of calls, triage decisions, and number and type of examinations ordered. Balancing measures included burden of time and effort to the generalist radiologists. Differences in examination orders between implementation intervals was assessed using Kruskal-Wallis, with significance at P < .05. RESULTS: Consensus defined MR requests as "do," "defer," or "divert" (to CT). Guidelines decreased neuroradiologist calls 74% while adding minimal burden to the generalist radiologists. Most nights had zero or one triage request and the most common triage decision was "do," and the most common examination was routine brain MR. Number of MR ordered and completed overnight did not significantly change with triage. DISCUSSION: Multidisciplinary consensus for use of pediatric neurological MR during limited resource hours overnight is an example of imaging stewardship that decreased the burden of calls and burnout for neuroradiologists while maintaining a comparable level of service to the ordering clinicians.

Consensus-Driven Definition for Unequivocal Sacroiliitis on Radiographs in Juvenile Spondyloarthritis.

OBJECTIVE: Radiography is still used worldwide for the detection of sacroiliitis in juvenile spondyloarthritis (JSpA), despite its low sensitivity and reliability. We aimed to define unequivocal evidence of sacroiliitis on pelvic radiography in skeletally immature youth for use in classification criteria when magnetic resonance imaging (MRI) is unavailable. METHODS: Subjects were a retrospective cohort of juvenile patients with spondyloarthritis with a radiograph and MRI as part of a diagnostic evaluation for axial disease. Six musculoskeletal imaging experts underwent an iterative consensus process to define unequivocal sacroiliitis on radiography in skeletally immature youth. Radiographs were graded using the modified New York (mNY) criteria and the unequivocal sacroiliitis criteria. Interrater agreement was assessed with the Fleiss [Formula: see text] statistic. Specificity, area under the receiver operator characteristic curve (AUROC), and sensitivity of the 2 measures were tested using 2 MRI reference standards. RESULTS: A total of 112 subjects, with a median age of 14.9 (range 6.7-20.1) years, were included. The Fleiss [Formula: see text] was fair for the mNY criteria (0.54, 95% CI 0.42-0.67) and the unequivocal sacroiliitis criteria (0.58, 95% CI 0.46-0.69). The unequivocal sacroiliitis criteria achieved > 90% specificity using both MRI reference standards. Sensitivity (59.26 and 57.14 vs 44.83 and 43.33) and AUROC (0.76 and 0.76 vs 0.71 and 0.71) were higher, for both reference standards, for the unequivocal sacroiliitis in youth definition than for the mNY criteria, respectively. CONCLUSION: In this study, we propose the first consensus-derived definition to our knowledge of unequivocal sacroiliitis by radiography in skeletally immature youth. This definition achieved excellent specificity and had higher AUROC and sensitivity values than the mNY criteria using both MRI reference standards. This definition has applicability to the JSpA axial disease classification imaging criterion when MRI is unavailable.

Data-Driven Magnetic Resonance Imaging Definitions for Active and Structural Sacroiliac Joint Lesions in Juvenile Spondyloarthritis Typical of Axial Disease: A Cross-Sectional International Study.

OBJECTIVE: We aimed to determine quantitative sacroiliac (SI) joint magnetic resonance imaging (MRI) cutoffs for active and structural lesions that will be incorporated as imaging domains in classification criteria of axial disease in juvenile spondyloarthritis (SpA). METHODS: MRI scans from an international cross-section of juvenile SpA patients were reviewed by 6 musculoskeletal imaging experts blinded to clinical details. Raters globally assessed the presence/absence of lesions typical of axial SpA and performed SI joint quadrant- or joint-based scoring. Sensitivity and specificity of lesion cutoffs were calculated using a rater majority (≥4 of 6 raters) on a global assessment of the presence/absence of active or structural lesions typical of axial SpA with high confidence as the reference standard. Cutoffs were validated in an independent cohort. RESULTS: Imaging from 243 subjects, 61% male, median age 14.9 years, had sequences available for detailed MRI scoring. Optimal cutoffs for defining lesions typical of axial disease in juvenile SpA were: 1) inflammatory lesion: bone marrow edema in ≥3 SI joint quadrants across all SI joint MRI slices (sensitivity 98.6%, specificity 96.5%); 2) structural lesions: erosion in ≥3 quadrants or sclerosis or fat lesion in ≥2 SI joint quadrants or backfill or ankylosis in ≥2 joint halves across all SI joint MRI slices (sensitivity 98.6%, specificity 95.5%). Sensitivity and specificity of the optimal cutoffs in the validation cohort were excellent. CONCLUSION: We propose data-driven cutoffs for active inflammatory and structural lesions on MRI typical of axial disease in juvenile SpA that have high specificity and sensitivity using central imaging global assessment as the reference standard and excellent reliability.

Feasibility of T2 Mapping of the Sacroiliac Joints in Healthy Control Subjects and Children and Young Adults with Sacroiliitis.

OBJECTIVE: To assess the feasibility of T2 mapping for evaluating pediatric SIJ cartilage at 3 Tesla (T) magnetic resonance imaging (MRI). METHODS: Healthy control subjects and adolescents with sacroiliitis underwent a 3T MRI dedicated pelvic protocol that included a T2 mapping sequence consisting of multislice, multiecho acquisition. Healthy control subjects were prospectively recruited from our primary care practices as part of a larger imaging study, whereas adolescents with sacroiliitis were recruited specifically for this study. Regions of interest (ROIs) were hand-drawn by a senior pediatric radiologist twice and a radiology fellow twice to calibrate and test reliability using the intraclass correlation coefficient (ICC). T2 relaxation time between control subjects and cases was compared using univariate linear regression. We tested the association of T2 relaxation time in adolescents with sacroiliitis with patient-reported outcomes and the Spondyloarthritis Research Consortium of Canada sacroiliac joint (SIJ) inflammation and structural scores using Pearson correlation coefficients. RESULTS: Fourteen subjects were evaluable (six control subjects: median age 13.7 years [interquartile range (IQR): 12.2-15.5], 67% male patients; eight cases: median age 17.4 years [IQR: 12.5-20], 88% male patients]. Acquisition time for T2 mapping sequences was approximately 6 minutes, and segmenting the ROI for each SIJ took approximately 3 minutes. The intrarater and inter-rater ICCs were 0.67 and 0.46, respectively, indicating good to fair reliability. There was a trend, albeit statistically insignificant, in longer median T2 relaxation time in cases (43.04 ms; IQR: 41.25-49.76 ms) versus healthy control subjects (40.0 ms; IQR: 38.9-48.6 ms). Although not statistically significant, cases with longer T2 relaxation time tended to occur with poorer patient-reported outcomes. Correlations with the SIJ inflammation and structural lesion scores were weak. CONCLUSION: T2 mapping of the SIJ cartilage in children was feasible and reliable. Larger controlled and longitudinal assessments are needed to assess the validity and utility of these measurements for routine clinical practice and trials.

Changes over time in inflammatory and structural lesions at the sacroiliac joint in children with spondyloarthritis exposed and unexposed to tumor necrosis factor inhibitor.

BACKGROUND: The objective of this work was to describe magnetic resonance imaging (MRI) changes over time in inflammatory and structural lesions at the sacroiliac joint (SIJ) in children with spondyloarthritis (SpA) exposed and unexposed to tumor necrosis factor inhibitor (TNFi). METHODS: This was a retrospective, multicenter study of SpA patients with suspected or confirmed sacroiliitis who underwent at ≥2 pelvic MRI scans. Images were reviewed independently by 3 radiologists and scored for inflammatory and structural changes using the Spondyloarthritis Research Consortium of Canada (SPARCC) SIJ inflammation score (SIS) and structural score (SSS). Longitudinal, quantitative changes in patient MRI scans were measured using descriptive statistics and stratified by TNFi exposure. We used an average treatment effects (ATE) regression model to explore the average effect of TNFi exposure over time on inflammatory and structural lesions, adjusting for baseline lesion scores. RESULTS: Forty-six subjects were evaluated using the SIS (n = 45) and SSS (n = 18). Median age at baseline imaging was 13.6 years, 63% were male and 71% were white. Twenty-three subjects (50%) were TNFi exposed between MRI studies. The median change in SIS in TNFi exposed and unexposed subjects with a baseline SIS ≥0 was - 20.7 and - 14.3, respectively (p = 0.09). Eleven (85%) TNFi exposed and 8 (89%) unexposed subjects with a baseline SIS ≥0 met the SIS minimal clinically important difference (MCID; ≥2.5). Using the ATE model adjusted for baseline SIS, the average effect of TNFi on SIS in patients with a baseline SIS ≥2 was - 14.5 (p < 0.01). Unadjusted erosion change score was significantly worse in TNFi unexposed versus exposed subjects (p = 0.03) but in the ATE model the effect of TNFi was not significant. CONCLUSION: This study quantitatively describes how lesions in the SIJs on MRI change over time in patients exposed to TNFi versus unexposed. Follow-up imaging in TNFi exposed patients showed greater improvement than the unexposed group by most metrics, some of which reached statistical significance. Surprisingly, a majority of TNFi unexposed children with a baseline SIS≥2 met the SIS MCID. Additional studies assessing the short and long-term effects of TNFi on inflammatory and structural changes in juvenile SpA are needed.

Artificial Intelligence Algorithm Improves Radiologist Performance in Skeletal Age Assessment: A Prospective Multicenter Randomized Controlled Trial.

Background Previous studies suggest that use of artificial intelligence (AI) algorithms as diagnostic aids may improve the quality of skeletal age assessment, though these studies lack evidence from clinical practice. Purpose To compare the accuracy and interpretation time of skeletal age assessment on hand radiograph examinations with and without the use of an AI algorithm as a diagnostic aid. Materials and Methods In this prospective randomized controlled trial, the accuracy of skeletal age assessment on hand radiograph examinations was performed with (n = 792) and without (n = 739) the AI algorithm as a diagnostic aid. For examinations with the AI algorithm, the radiologist was shown the AI interpretation as part of their routine clinical work and was permitted to accept or modify it. Hand radiographs were interpreted by 93 radiologists from six centers. The primary efficacy outcome was the mean absolute difference between the skeletal age dictated into the radiologists' signed report and the average interpretation of a panel of four radiologists not using a diagnostic aid. The secondary outcome was the interpretation time. A linear mixed-effects regression model with random center- and radiologist-level effects was used to compare the two experimental groups. Results Overall mean absolute difference was lower when radiologists used the AI algorithm compared with when they did not (5.36 months vs 5.95 months; P = .04). The proportions at which the absolute difference exceeded 12 months (9.3% vs 13.0%, P = .02) and 24 months (0.5% vs 1.8%, P = .02) were lower with the AI algorithm than without it. Median radiologist interpretation time was lower with the AI algorithm than without it (102 seconds vs 142 seconds, P = .001). Conclusion Use of an artificial intelligence algorithm improved skeletal age assessment accuracy and reduced interpretation times for radiologists, although differences were observed between centers. Clinical trial registration no. NCT03530098 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Rubin in this issue.

RADIAL: leveraging a learning management system to support radiology education.

Increasing volume and complexity of cases in academic radiology and the drive toward pediatric sub-specialization have threatened knowledge assimilation for radiologists. There is a clear need for a system that retrieves vetted information from the excess available on the internet. Partnered with an interdisciplinary team from the Graduate School of Education, the authors created the first comprehensive learning management system (LMS) for radiology, implemented in the reading room to augment image interpretation and point-of-care education. The LMS supports quantitative analysis using a robust analytics platform to evaluate user statistics, facilitating improved quality of patient care by revolutionizing the way radiologists assimilate knowledge. This integration promises to enhance workflow and point-of-care teaching and to support the highest quality of care.

CTA utilization for evaluation of suspected pulmonary embolism in a tertiary pediatric emergency department.

OBJECTIVE: To evaluate changes in the utilization of computed tomography angiography (CTA) for evaluating suspected pulmonary embolism (PE) and the positive rate of ancillary for those studies negative for PE in the last 13 years. MATERIALS AND METHODS: A retrospective review of patient ≤ 20 years of age who underwent a chest CT angiography to rule out PE was performed in a 13-year-period. CT angiographies were grouped into three categories: Positive for PE, negative for PE and positive for ancillary findings, and negative for any pathology. From the exams with ancillary findings, we examined how many of these had a chest radiograph perform within 24 h prior to the CTA and how many of them had an impression stating the same conclusion as the CTA. RESULTS: 307 chest CT angiographies for suspected PE were included. 50 (16%) were reported as positive for PE and 91 (30%) were negative for PE but positive for ancillary findings. The most frequent ancillary findings were pneumonia (n = 26) and pleural effusion (n = 11). Out of 91, 73 patients had a previous chest radiograph and 28 of them reported a similar diagnosis than the CTA. The number of CT angiographies indicated for PE increased by 3.2 studies per year. The rate of CT angiographies positive for ancillary findings (slope = 1.5) and positive for PE (slope = 0.3) remained similar throughout the same period. CONCLUSIONS: CTA orders for PE have been increasing without any increased detection of PE or ancillary findings in children.

Variability in Interpretation of Magnetic Resonance Imaging of the Pediatric Sacroiliac Joint.

OBJECTIVE: Magnetic resonance imaging (MRI) is pivotal in the assessment of early sacroiliitis in children. We aimed to evaluate the agreement between local radiology reports and central imaging reviewers for active inflammation and structural damage at the sacroiliac (SI) joints. METHODS: Eight hospitals each contributed up to 20 cases of consecutively imaged children and adolescents with juvenile idiopathic arthritis and suspected sacroiliitis. Studies were independently reviewed by 3 experienced musculoskeletal pediatric radiologists. Local assessments of global impression and lesions were coded from the local radiology reports by 2 study team members. Test properties of local reports were calculated using the central imaging team's majority as the reference standard. RESULTS: For 120 evaluable subjects, the median age was 14 years, half of the cases were male, and median disease duration at the time of imaging was 0.8 years (interquartile range 0-2). Sensitivity of local reports for inflammation was high, 93.5% (95% confidence interval [95% CI] 78.6-99.2), and specificity was moderate, 69.7% (95% CI 59.0-79.0), but positive predictive value (PPV) was low, 51.8% (95% CI 38.0-65.3). Twenty-seven cases (23%) had active inflammation reported locally but rated normal at the central reading, 19 (70%) with subsequent medication changes. The sensitivity of local reports detecting structural damage was low, 45.7% (95% CI 28.8-63.4), and specificity was high, 88.2% (95% CI 79.4-94.2); PPV was low, 61.5% (95% CI 40.6-79.8). CONCLUSION: Substantial variation exists in the interpretation of inflammatory and structural lesions at the SI joints in children. To reliably identify pathology, additional training in the MRI appearance of the maturing SI joint is greatly needed.

Specific Absorption Rate and Specific Energy Dose: Comparison of 1.5-T versus 3.0-T Fetal MRI.

Background MRI performed at 3.0 T offers greater signal-to-noise ratio and better spatial resolution than does MRI performed at 1.5 T; however, for fetal MRI, there are concerns about the potential for greater radiofrequency energy administered to the fetus at 3.0-T MRI. Purpose To compare the specific absorption rate (SAR) and specific energy dose (SED) of fetal MRI at 1.5 and 3.0 T. Materials and Methods In this retrospective study, all fetal MRI examinations performed with 1.5- and 3.0-T scanners at one institution between July 2012 and October 2016 were evaluated. Two-dimensional (2D) and three-dimensional (3D) steady-state free precession (SSFP), single-shot fast spin-echo, 2D and 3D T1-weighted spoiled gradient-echo (SPGR), and echo-planar imaging sequences were performed. SAR, SED, accumulated SED, and acquisition time were retrieved from the Digital Imaging and Communications in Medicine header. Data are presented as mean ± standard deviation. Two one-sided tests with equivalence bounds of 0.5 (Cohen d effect size) were performed, with statistical equivalence considered at P < .05. Results A total of 2952 pregnant women were evaluated. Mean maternal age was 30 years ± 6 (age range, 12-49 years), mean gestational age was 24 weeks ± 6 (range, 17-40 weeks). A total of 3247 fetal MRI scans were included, with 2784 (86%) obtained at 1.5 T and 463 (14%) obtained at 3.0 T. In total, 93 764 sequences were performed, with 81 535 (87%) performed at 1.5 T and 12 229 (13%) performed at 3.0 T. When comparing 1.5- with 3.0-T MRI sequences, mean SAR (1.09 W/kg ± 0.69 vs 1.14 W/kg ± 0.61), mean SED (33 J/kg ± 27 vs 38 J/kg ± 26), and mean accumulated SED (965 J/kg ± 408 vs 996 J/kg ± 366, P < .001) were equivalent. Conclusion Fetal 1.5- and 3.0-T MRI examinations were found to have equivalent energy metrics in most cases. The 3.0-T sequences, such as two-dimensional T1-weighted spoiled gradient-echo and three-dimensional steady-state free precession, may require modification to keep the energy delivered to the patient as low as possible. © RSNA, 2020 Online supplemental material is available for this article.

Osteochondral lesion of the talus in children: Are there MRI findings of instability?

PURPOSE: The purpose of our study was to investigate the performance of MRI findings to predict instability of osteochondral lesion of the talus (OLT) in children and the association between skeletal maturity and lesion stability. MATERIALS AND METHOD: This retrospective IRB-approved and HIPPA-compliant study included children with OLT, who underwent an ankle MRI examination between March 1, 2011, and May 31, 2018. Blinded to the clinical outcome, 2 radiologists retrospectively assessed each MRI study for the presence or absence of various features on the articular side, along the interface, and on the subchondral side of each lesion. Regional skeletal maturity was recorded. Lesion stability was classified using clinical and surgical findings. Mann-Whitney U, Chi-square, Fisher's exact, and Cochran-Armitage tests were used to compare demographic and MRI findings between children with stable and unstable lesions. RESULTS: Of the 48 ankles identified, 36 were stable (12.7 + 3.9 years) and 12 were unstable (14.2 + 1.6 years) lesions. None of the lesions presented as a detached fragment. Skeletal immaturity (p = 0.01) was significantly more common in stable than unstable lesions. No other MRI features were found to be significantly different between stable and unstable lesions, which included the presence of an effusion (p = 0.27), intra-articular body (p = 0.25), cartilage changes (p = 0.19), subchondral disruption (p = 0.51), T2-weighted signal intensity rim (p = 0.16), cysts (p = 0.48), marginal sclerosis (p = 0.70), and perilesional marrow edema (p = 0.17). CONCLUSION: Results from our study suggest that previously published OCD criteria using conventional MRI are not sufficient for predicting stability of OLT in children. Regional skeletal maturity and older age were more predictive of unstable lesions.

Spondyloarthritis Research Consortium of Canada sacroiliac joint inflammation and structural scores: change score reliability and recalibration utility in children.

BACKGROUND: The SPARCC sacroiliac joint inflammation (SIS) and structural (SSS) scores are reliable measures to quantify abnormalities in the pediatric sacroiliac joint. We aimed to evaluate the utility of online calibration modules for the SIS and SSS and the reliability of their component change scores. METHODS: Change score reliability of 6 raters was assessed by overall and pairwise intraclass correlation coefficients (ICCs) before and after the use of real-time iterative calibration (RETIC) modules for both the SIS and SSS comprised of 20 adult cases. Acceptable ICC for change scores was > 0.7 for SIS and > 0.5 for all SSS components. Sensitivity to change was assessed by the standardized response mean (SRM). RESULTS: In scoring exercise 1, the SIS had acceptable reliability with a change score ICC of 0.80 and sclerosis was the only SSS lesion that met the acceptability threshold with a change score ICC of 0.52. After RETIC calibration, the SIS overall (ICC = 0.83) and mean pairwise (ICC = 0.83) change scores remained reliable with a large SRM (0.90). All SSS components except sclerosis met the overall and mean pairwise change score ICC acceptability thresholds-backfill: overall = 0.54, mean pairwise = 0.50; fat metaplasia: overall = 0.65, mean pairwise = 0.57; erosion: overall = 0.60, mean pairwise = 0.58; and ankylosis: overall = 0.96, mean pairwise = 0.96. The SSS RETIC module augmented the number of SSS components surpassing the acceptability threshold from 1 to 4. Sensitivity to change, as measured by the SRM, was large for erosion (0.96), moderate for backfill (0.55) and sclerosis (0.70), and small for fat metaplasia (0.36) and ankylosis (0.28). CONCLUSION: RETIC modules improved the overall reliability of SPARCC SIS and SSS change scores for previously calibrated raters. SIS recalibration was not as helpful to the most experienced raters who achieved high levels of agreement before recalibration. The SPARCC SIS and all SSS components except sclerosis are reliable measures to quantify change over time in children. A pediatric-specific RETIC tool should be developed to enhance the calibration of readers.

Imaging Properties of Additive Manufactured (3D Printed) Materials for Potential Use for Phantom Models.

Over the last few decades, there has been growing interest in the application of additive manufacturing (AM) or 3D printing for medical research and clinical application. Imaging phantoms offer clear benefits in the way of training, planning, and quality assurance, but the model's availability per catalog tend to be suited for general testing purposes only. AM, on the contrary, offers flexibility to clinicians by enabling custom-built phantoms based on specific interests or even individual patient needs. This study aims to quantify the radiographic properties (ultrasound, magnetic resonance imaging, and computed tomography) of common additive manufacturing technologies and to discuss potential opportunities to fabricate imaging phantoms. Test phantoms were composed of samples from the three most common AM styles, namely PolyJet, fused deposition modeling (FDM), and stereolithography (SLA). Test imaging of the phantoms was performed on ultrasound, MRI, and CT and reviewed and evaluated with radiology software. The ultrasound images showed clearly defined upper and lower edges of the material but did not demonstrate distinct differences in internal echogenicity between materials. The MR scans revealed a distinct signal intensity difference between the model (17 grayscale value) and the printer support (778 grayscale value). Finally, the CT images showed a slight variation between the plastic (82 HU) and rubber (145 HU) materials. The radiographic properties of AM offer a clear opportunity to create basic two- or three-material phantoms. These would be high-accuracy and cost-effective models. Although the materials currently available are not suitable for complex multi-material applications as realistic as true human anatomy, one can easily foresee the development of new materials with broader density in the near future.

Buckle fracture of the proximal tibia in children and frequency of association with trampoline and inflatable bouncer use.

BACKGROUND: Proximal tibial buckle fractures are often called "trampoline fractures," but mechanisms are more varied. OBJECTIVE: To assess the frequency of trampoline or bouncer etiology among children with buckle fracture of the proximal tibia, characterizing demographics, alternative etiologies, and fracture patterns. MATERIALS AND METHODS: We performed retrospective chart review of mechanisms, age and gender of children with radiographs interpreted as proximal tibial buckle fracture between 2010 and 2016. Two pediatric radiologists assessed presence of cortical impaction, cortical break, increased anterior scoop deformity, and oblique extension of fracture toward the physis. We studied the associations among demographics, etiology and fracture appearance using analysis of variance and chi-square/Fisher exact tests. RESULTS: We identified 145 exams interpreted as proximal tibial buckle fracture (median age 34 months, 64% girls). Bouncing surface was the most common mechanism (44%), and 80% of those cases reported multiple people on the bouncing surface. Falls were the second most common mechanism (30%). Children injured while bouncing were older (median 41 months) than others (median 21 months, P<0.005) and more likely to have oblique extension of fracture toward the physis (P<0.05). Buckle deformity was associated with a younger age (F=8.67; P<0.01), while oblique extension to the physis and concurrent fibula fracture were associated with older age (F=18.62, P<0.001; and F=8.02, P<0.01, respectively). CONCLUSION: Trampoline use was the most common single mechanism of injury in children with proximal tibial fracture interpreted as buckle deformity. However, non-bouncing mechanisms were overall more common and occurred in a younger age group at risk for "toddler fractures."

Clinical decision support: the role of ACR Appropriateness Criteria.

Clinical decision support is a way to decrease inappropriate imaging exams and promote judicious use of imaging resources. The adoption of clinical decision support will be incentivized by requiring the use of approved mechanisms to qualify for Medicare reimbursement starting in January 2020. Insurance providers base their reimbursement policies on Medicare, so clinical decision support could soon become relevant to pediatric imaging. We present the process behind the American College of Radiology (ACR) Appropriateness Criteria (a set of appropriate use criteria developed by the ACR) that will form the basis for software that can be used to fulfill the criteria for clinical decision support. For most organizations, this software is expected to be the easiest way to implement clinical decision support. Clinical decision support will affect how providers order imaging exams. This article should help readers understand how clinical decision support is expected to change the practice of the ordering providers, how the ACR Appropriateness Criteria are related to clinical decision support and how the ACR Appropriateness Criteria are developed. This will help the interpreting radiologist better communicate with the referring clinician, including informing the latter about how the clinical decision support software is making decisions.

Clinical decision support: practical implementation at two pediatric hospitals.

Clinical decision support has been identified by the United States government as a method to decrease inappropriate imaging exams and promote judicious use of imaging resources. The adoption of this method will be incentivized by requiring appropriate use criteria to qualify for Medicare reimbursement starting in January 2020. While Medicare reimbursement is unlikely to directly impact pediatric imaging because of largely disparate patient populations, insurance providers typically use Medicare to benchmark their reimbursement guidelines. Therefore soon after their adoption these guidelines could become relevant to pediatric imaging. In this article we discuss how pediatric imaging was initially underrepresented in the clinical decision support realm, and how this was addressed by a subcommittee involving both American College of Radiology and Society for Pediatric Radiology members. We also present the experience of implementing clinical decision support software at two standalone pediatric hospitals and summarize the lessons learned from these deployments.

Learning, teaching and writing with reference managers.

Reference managers, also known as citation managers, were designed to create bibliographic citations but have evolved into powerful tools for education. In addition to their core competency of easily managing in-text citations and automatically generating a list of works cited, modern reference managers can help researchers manage increasingly large libraries of portable document format (PDF) files, web pages and other documents. Users can annotate, store, organize, tag and search PDFs. These programs fetch useful associated metadata such as publication information, author lists and article abstracts. Additionally, the programs create a searchable index that can include the article abstract and often the complete text of many articles' PDFs. Modern reference managers allow for rapid creation, organization and classification of a curated collection of reference articles that can be made available anywhere, including on mobile devices. In this article the author describes how pediatric radiologists can use reference managers to facilitate learning, teaching and writing.

Ultrasound features of purulent skin and soft tissue infection without abscess.

PURPOSE: Ultrasound (US) aids clinical management of skin and soft tissue infection (SSTI) by differentiating non-purulent cellulitis from abscess. However, purulent SSTI may be present without abscess. Guidelines recommend incision and drainage (I & D) for purulent SSTI, but US descriptions of purulent SSTI without abscess are lacking. METHODS: We retrospectively reviewed pediatric emergency department patients with US of the buttock read as negative for abscess. We identified US features of SSTI with adequate interobserver agreement (kappa > 0.45). Six independent observers then ranked presence or absence of these features on US exams. We studied association between US features and positive wound culture using logistic regression models (significance at p < 0.05). RESULTS: Of 217 children, 35 patients (16%) had cultures positive for pathogens by 8 h after US and 61 patients (32%) had cultures positive by 48 h after US. We found kappa > 0.45 for focal collection > 1.0 cm (κ = 0.57), hyperemia (κ = 0.57), swirling with compression (κ = 0.52), posterior acoustic enhancement (κ = 0.47), and cobblestoning or branching interstitial fluid (κ = 0.45). Only cobblestoning or interstitial fluid was associated with positive wound cultures in logistic regression models at 8 and 48 h. CONCLUSIONS: Cobblestoning or interstitial fluid on US may indicate presence of culture-positive, purulent SSTI in patients without US appearance of abscess. Although our study has limitations due to its retrospective design, this US appearance should alert imagers that the patient may benefit from early I & D.