Global pediatric radiology education: responding to training-level specific needs.

Pediatric radiology education for pediatric and radiology trainees and practicing professionals must be adapted to the target audience. In efforts to narrow the gaps in global pediatric radiology education, the Children's Hospital of Philadelphia's radiology department's Global Outreach and Education Program has designed specific interventions and curricula according to different levels of training and desired expertise. Our initiatives include an online "Introduction to Pediatric Imaging" lecture series for pediatrics residents in Botswana, Ethiopia and Vietnam; access to a learning management system (Outreach RADIAL) for radiology residents; case-based review sessions for pediatric radiology fellows; and in-person seminars for professionals from Eastern Europe and Africa. Here, we highlight our global education efforts to encourage other departments to take a similar systematic approach to outreach activities.

Development and clinical feasibility of a reduced-dose radiograph in children for feeding tube placement.

BACKGROUND: Temporary feeding tubes are commonly used but may lead to complications if malpositioned. Radiographs are the gold standard for assessing tube position, but clinician concern over radiation risks may curtail their use. OBJECTIVE: We describe development and use of a reduced dose feeding tube radiograph (RDFTR) targeted for evaluation of feeding tube position. MATERIALS AND METHODS: Age-based abdominal radiograph was adapted to use the lowest mAs setting of 0.32 mAs with field of view between carina and iliac crests. The protocol was tested in DIGI-13 line-pair plates and anthropomorphic phantoms. Retrospective review of initial clinical use compared dose area product (DAP) for RDFTR and routine abdomen, chest, or infant chest and abdomen. Review of RDFTR reports assessed tube visibility, malpositioning, and incidental critical findings. RESULTS: Testing through a line-pair phantom showed loss of spatial resolution from 2.2 line pairs to 0.6 line pairs but preserved visibility of feeding tube tip in RDFTR protocol. DAP comparisons across 23,789 exams showed RDFTR reduced median DAP 72-93% compared to abdomen, 55-78% compared to chest, and 76-79% compared to infant chest and abdomen (p<0.001). Review of 3286 reports showed tube was visible in 3256 (99.1%), malpositioned in airway 8 times (0.2%) and in the esophagus 74 times (2.3%). The tip was not visualized in 30 (0.9%). Pneumothorax or pneumoperitoneum was noted seven times (0.2%) but was expected or spurious in five of these cases. CONCLUSION: RDFTR significantly reduces radiation dose in children with temporary feeding tubes while maintaining visibility of tube tip.

Case competition sessions: a global education and academic engagement tool.

BACKGROUND: Radiology virtual teaching sessions utilize live video conferencing to promote collaborative learning and engagement by discussing radiology cases. Because of its convenience and flexibility, this mode of education has gained popularity, particularly after the corona virus disease 2019 pandemic. OBJECTIVE: We describe our experience in organizing a series of "Global Health Imaging Case Competitions" for trainees in low- and middle-income countries (LMICs). These competitions provide the trainees with an opportunity to present unique radiology cases, network with radiologists, learn about various radiology topics, win prizes and potentially publish their case reports in a peer-reviewed journal. MATERIALS AND METHODS: Planning and execution of the competition involves several steps. First, trainees are invited to participate and submit abstracts discussing unique cases. The organizing committee grades these abstracts; the authors of the 20 abstracts with the highest scores are asked to submit a video presentation of their cases to be presented during the live webinar. During this webinar, presentations are displayed and graded to select winners. Additionally, the audience votes to choose a participant as the people's favorite. We have completed four cycles (Africa, Latin America and the Caribbean, Africa and the Middle East and Asia) and will continue in the same order of rotation. RESULTS: Attendance totalled 2,510 participants from 50 countries. Pediatric cases represented the majority of cases among finalists. Feedback was positive; 26 out of 29  (90%) participants surveyed indicated that the webinar was "very good" to "excellent" with well-organized and challenging cases. Diversity of participating countries was noted. Limitations included technology barriers such as internet connectivity. CONCLUSION: This innovative approach emphasizing audience participation engaged trainees from LMICs and fostered locoregional collegiality and mentoring.

MRI scarcity in low- and middle-income countries.

Since the introduction of MRI as a sustainable diagnostic modality, global accessibility to its services has revealed a wide discrepancy between populations-leaving most of the population in LMICs without access to this important imaging modality. Several factors lead to the scarcity of MRI in LMICs; for example, inadequate infrastructure and the absence of a dedicated workforce are key factors in the scarcity observed. RAD-AID has contributed to the advancement of radiology globally by collaborating with our partners to make radiology more accessible for medically underserved communities. However, progress is slow and further investment is needed to ensure improved global access to MRI.

Frequency of abnormal findings on chest radiograph after positive PPD in children and adolescents in an urban setting in the United States.

BACKGROUND: Chest radiographs (CXR) for tuberculosis (TB) screening in children are valuable in high-burden settings. However, less certain in low prevalence contexts. In the United States, positive PPD is sufficient to treat for "latent" TB, or TB infection in asymptomatic patients. OBJECTIVE: We sought to determine frequency of abnormal CXR findings after a positive purified protein derivative (PPD) test at a tertiary pediatric center in the United States. METHOD: A retrospective evaluation was conducted of patients (0-18 years) with a CXR after a positive PPD (e.g., known exposure, employment, migratory requirements or before immunosuppression) between 2011 and 2021. Clinical information, demographics, and reason for PPD were recorded from health record. CXRs were evaluated using initial report and by a pediatric radiologist with special interest in TB and 8 years of experience. RESULT: Of 485 patients, median [interquartile range (IQR)] age 8.5[3.3-14.4], abnormal CXRs were described in 5 (1%). Most common reasons for PPD included: close contact with someone with TB or with high risk for TB. Most patients 373 (76.9%) received treatment for latent TB, and 111 (22.9%) no treatment. One patient (0.2%) received treatment for active disease. Radiographic findings included isolated lymphadenopathy (n = 2), consolidation (n = 1), pleural fluid/thickening (n = 1) and a patient with lymphadenopathy and a calcified nodule (n = 1). CONCLUSION: In our experience, prevalence of chest radiographs findings for patients with positive PPD was very low. Moreover, no cases of severe disease were seen and those with abnormal findings would not merit treatment change under current WHO guidelines.

Improving On-Time Starts for Pediatric Cardiac MRI.

PURPOSE: Delayed start times for cardiac MRI examinations have resulted in longer patient fasts, extended wait times, and poor synchronization of anesthesia induction and contrast administration. The aim of this work was to improve on-time start rates from an initial baseline of 10%. METHODS: A multidisciplinary team comprising members of the cardiac and radiology services used the Realizing Improvement Through Team Empowerment methodology to target the root causes of the delays and enhance workflow. The main factors identified as contributing to examination delays were late patient arrival, variations in patient preparation time, unavailability of equipment, and inefficient scheduling processes. RESULTS: The implementation of various interventions, such as the use of standardized appointment scripts, ensuring timely patient preparation, and ensuring the availability of equipment when required, resulted in an increase in on-time start rates for cardiac MRI examinations to 34%. CONCLUSIONS: The study's systematic approach proved to be valuable in both understanding and resolving the identified problems. Through the continuous application of plan-do-study-act cycles, the authors effectively pinpointed obstacles and tested multiple potential measures to overcome them. This approach made it possible to comprehend the issue and to implement targeted interventions to address it.

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.

Learning from experience - Radiology ancillary review of prospective research studies involving imaging.

This report describes the operational process of a big academic children's hospital's Radiology Scientific Review Committee, with a focus on its role in integrating radiology services into pediatric clinical research. We define the step-by-step workflow used to assess research proposals involving imaging and share insights from the past three years of data collection. Trends in modalities, radiologist involvement, and interpretation possibilities are outlined in the data. This systematic methodology provides essential resource allocation concepts and promotes high-quality pediatric clinical research.

Multiple myeloma in Lebanon: Trend analysis, 10-year projections and comparisons to other countries.

BACKGROUND: Multiple myeloma (MM) is a common hematological malignancy in aging populations. This study aims to inspect the trends from 2005 to 2016 and future projections of MM in Lebanon and to compare its incidence-rates to other MENA and non-MENA countries. METHODS: The data concerning MM cases over the studied period was extracted from the National Cancer Registry (NCR) of Lebanon. The online database "Cancer Incidence in Five Continents" was screened and data of other countries were collected. The age-specific and age-standardized incidence rates (ASR(w)) were computed and analyzed using Joinpoint regression. 10 year projections were predicted by employing a logarithmic model. RESULTS: During the time period 2005-2016, MM was significantly more common in males. Both genders had a cancer peak in patients older than 75 years. MM demonstrated a significantly increasing trend in both genders over the 12 years of study. Compared to other countries in the MENA region, Lebanon ranked first in females and second in males, while it came among the lowest when compared to randomly selected developed countries from non-MENA regions. Projecting to 2026, incidence rates of MM in Lebanon are expected to rise in both males and females. CONCLUSION: Incidence of MM in Lebanon is continually rising. The elderly population, especially males, is much more affected than the younger one. Different risk factors, specifically obesity and toxic exposures, can explain the escalating burden of MM among the population. A collaboration of efforts between the government and health organization is expected for an effective disease control.

Tumor Microenvironment in Prostate Cancer: Toward Identification of Novel Molecular Biomarkers for Diagnosis, Prognosis, and Therapy Development.

Prostate cancer (PCa) is by far the most commonly diagnosed cancer in men worldwide. Despite sensitivity to androgen deprivation, patients with advanced disease eventually develop resistance to therapy and may die of metastatic castration-resistant prostate cancer (mCRPC). A key challenge in the management of PCa is the clinical heterogeneity that is hard to predict using existing biomarkers. Defining molecular biomarkers for PCa that can reliably aid in diagnosis and distinguishing patients who require aggressive therapy from those who should avoid overtreatment is a significant unmet need. Mechanisms underlying the development of PCa are not confined to cancer epithelial cells, but also involve the tumor microenvironment. The crosstalk between epithelial cells and stroma in PCa has been shown to play an integral role in disease progression and metastasis. A number of key markers of reactive stroma has been identified including stem/progenitor cell markers, stromal-derived mediators of inflammation, regulators of angiogenesis, connective tissue growth factors, wingless homologs (Wnts), and integrins. Here, we provide a synopsis of the stromal-epithelial crosstalk in PCa focusing on the relevant molecular biomarkers pertaining to the tumor microenvironment and their role in diagnosis, prognosis, and therapy development.

A 12-Year Comparative Analysis of Hodgkin and Non-Hodgkin Lymphomas in Lebanon: Trend Characteristics and 10-Year Projections.

Background  Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) are two common malignancies worldwide and in Lebanon. Analysis of their trends plays a crucial role to better understand their origins and risk factors. This study will probe incidences of both types of lymphomas from 2005 to 2016, aiming to compare between the two malignancies according to age and sex and plot projections until 2026. Methods HL and NHL cases from 2005 to 2016 were collected from the National Cancer Registry of Lebanon. Data was stratified according to age and sex. Age-specific and age-standardized incidence rates were analysed using joinpoint regression; 10-year projections were predicted based on logarithmic models. Results Between 2005 and 2016, NHL was significantly more common than HL. NHL was higher in both genders. HL showed a bimodal age distribution while NHL peaked in elderly patients. NHL incidence rates in males increased significantly from 2005 to 2014 while HL incidence rates showed an insignificant rise. Over the next 10 years, NHL and HL cases are expected to increase in Lebanon. Conclusion HL and NHL are on the rise in Lebanon. Extensive research into the main factors contributing to these lymphomas is crucial in the fight against them. More efforts must be done by the government and health organizations to better control the disease.