Diversity, equity and inclusion: a survey of pediatric radiology fellowship graduates from 1996 to 2020.

BACKGROUND: Understanding the sociodemographic diversity and the experiences of trainees is imperative for developing an inclusive pediatric radiology workforce and improving patient outcomes. OBJECTIVE: To describe the sociodemographics of a pediatric radiology fellowship program over 25 years and examine potential associations with (a) a trainee's sense of inclusion and belonging during training and (b) graduates' ultimate choice/type of practice, progression to positions of leadership and mentorship of others. MATERIALS AND METHODS: We designed and administered an online survey of sociodemographic diversity to graduates of one of the largest pediatric radiology fellowship programs in North America who graduated over the last 25 years. Respondents answered questions regarding (a) racial/ethnic identity, gender identity, sexual orientation, disability and other sociodemographics; (b) their sense of inclusion and belonging during fellowship training; and (c) their current type of practice, leadership and mentorship of others. Univariate analysis of variance (ANOVA) tests determined whether sociodemographic background was associated with inclusion/belonging during training, and with current type of radiology practice, leadership and mentorship. We assessed associations with covariates of interest and current leadership and mentorship roles using chi-square or Fisher exact tests. A heat map assessed individual and overall Likert scores across covariates. RESULTS: Seventy-six graduates completed the survey (46% response rate). Three percent of respondents identified as Black/African American, 7% as Latino/a/x, 45% as female, 4% as LGBTQ (lesbian, gay, bisexual, transgender, queer/questioning) and 5% as living with a disability at the time of fellowship. Graduates of international medical schools (P = 0.09) and osteopathic medical (DO) schools (P = 0.09), first-generation college graduates (P = 0.023), those with a first language other than English (P = 0.02) and U.S. military veterans (P = 0.048) reported significantly lower feelings of inclusion and belonging during training. Gender identity and sexual orientation did not correlate with feelings of exclusion or inequity. Graduates between 1996 and 2010 were significantly more likely to have filled a leadership role than those graduating after 2011 (P = 0.004) and were also significantly more likely to have mentored individuals underrepresented in medicine/pediatric radiology than those who graduated after 2011 (P = 0.04). None of the other sociodemographic variables demonstrated an association with leadership or mentorship, although 92.3% of those with a first language other than English served as a mentor compared to 68.2% of native English speakers (P = 0.097). CONCLUSION: Efforts to promote a more diverse and inclusive workforce in pediatric radiology should be directed toward increasing numbers of fellows who are underrepresented in medicine (Black/African American, Hispanic/Latino/a/x) and providing a more inclusive training environment for first-generation college graduates, graduates of international and DO medical schools, fellows whose first language is not English, and veterans of the U.S. Armed Forces.

Undifferentiated Embryonal Sarcoma of the Liver With Rhabdoid Morphology Mimicking Carcinoma: Expanding the Morphologic Spectrum or a Distinct Variant?

Undifferentiated embryonal sarcoma of the liver (UESL) is a rare aggressive neoplasm that occurs predominantly in children. Like mesenchymal hamartoma of the liver (MHL), UESL harbors recurrent rearrangements involving 19q13.3 and 19q13.4, a region of the genome that contains a primate-specific cluster of micro-RNAs. Here, we present a case of a high-grade neoplasm that arose in the left hepatic lobe of a 5-year-old male and gave rise to widespread lymph node, visceral, and soft tissue metastases. The tumor was composed of sheets, tubules, and papillae of epithelioid cells with rhabdoid morphology. INI1 and BRG1 expression were retained. Tumor cells diffusely expressed epithelial markers, including multiple keratins. While the morphologic and immunophenotypic features were suggestive of poorly differentiated carcinoma with rhabdoid features, the tumor was found to harbor the t(11;19)(q13;q13.3) translocation characteristic of UESL, as well as a TP53 mutation. Given the clinical presentation, imaging, clinical course, the tumor was classified as UESL with unusual, carcinoma-like histopathologic features. In the context of an unclassified high-grade hepatic tumor in a young child, molecular or cytogenetic testing for chromosome 19q13 alterations should be considered.

Quantification of popliteal artery narrowing with QISS MRA during active ankle plantarflexion in healthy, asymptomatic volunteers and its potential application in the diagnosis of popliteal artery entrapment syndrome (PAES).

OBJECTIVE: To assess the degree of narrowing of the popliteal artery during active ankle plantar flexion in healthy volunteers using a non-contrast quiescent-interval single-shot (QISS) magnetic resonance angiography (MRA) technique. MATERIALS AND METHODS: Following IRB approval, 10 healthy volunteers were recruited and following informed consent underwent QISS MRA of the lower extremity at rest and during ankle plantarflexion. Two pediatric musculoskeletal radiologists independently reviewed MR images in random order and recorded a number of subjective and objective anatomic variables including branch pattern, proximity of vessel to bony structures, gastrocnemius bulk, and presence of accessory muscle. Arterial narrowing with plantarflexion was recorded by a subjective assessment of 3D reconstructions (negligible or non-negligible) and objectively by measuring the narrowest diameter during plantarflexion and at rest. Agreement between reader scores was assessed using the concordance correlation coefficient (CCC) for continuous variables, and kappa and the proportion of agreement for categorical variables. RESULTS: Mean reduction in arterial diameter during plantar flexion was 17.1% (min 1.9%, max 64.1%, SD 16.7%) for reader 1 and 17.2% (min 1.7%, max 50.0%, SD 14.3%.) for reader 2 with high agreement between readers: CCC = 0.92 and CI = 0.82, 0.96. Arterial narrowing was described subjectively as "non-negligible" in 7/20 legs by reader 1 and 5/20 legs by reader 2 with proportion of agreement = 0.90, CI (0.77, 1.00). CONCLUSION: We observed a wide range of popliteal arterial narrowing with plantarflexion in asymptomatic volunteers. Larger studies, for which QISS is well suited, may be invaluable for distinguishing physiologic from pathologic arterial narrowing in patients with suspected popliteal artery entrapment syndrome (PAES).

DICER1-associated central nervous system sarcoma in children: comprehensive clinicopathologic and genetic analysis of a newly described rare tumor.

The spectrum of neoplasms associated with DICER1 variants continues to expand, with the recent addition of primary "DICER1-associated central nervous system sarcoma" (DCS). DCS is a high-grade malignancy predominantly affecting pediatric patients. Six pediatric DCS were identified through a combination of clinical diagnostic studies, archival inquiry, and interinstitutional collaboration. Clinical, histologic, immunohistologic, and molecular features were examined. Genomic findings in the 6 DCS were compared with those in 14 additional DICER1-associated tumors sequenced with the same assay. The six patients presented at ages 3-15 years with CNS tumors located in the temporal (n = 2), parietal (n = 1), fronto-parietal (n = 1), and frontal (n = 2) lobes. All underwent surgical resection. Histologic examination demonstrated high-grade malignant spindle cell tumors with pleuropulmonary blastoma-like embryonic "organoid" features and focal rhabdomyoblastic differentiation; immature cartilage was seen in one case. Immunohistochemically, there was patchy desmin and myogenin staining, and patchy loss of H3K27me3, and within eosinophilic cytoplasmic globules, alfa-fetoprotein staining. Biallelic DICER1 variants were identified in all cases, with germline variants in two of five patients tested. DCS demonstrated genomic alterations enriched for Ras pathway activation and TP53 inactivation. Tumor mutational burden was significantly higher in the 6 DCS tumors than in 14 other DICER1-associated tumors examined (mean 12.9 vs. 6.8 mutations/Mb, p = 0.035). Postoperative care included radiation (n = 5) and chemotherapy (n = 3); at the last follow-up, three patients were alive without DCS, and three had died of disease. Our analysis expands the clinical, histologic, immunohistological, and molecular spectrum of DCS, identifying distinctive features that can aid in the diagnosis, multidisciplinary evaluation, and treatment of DCS.

Improving Low-Dose Pediatric Abdominal CT by Using Convolutional Neural Networks.

PURPOSE: To evaluate the efficacy of convolutional neural networks (CNNs) to improve the image quality of low-dose pediatric abdominal CT images. MATERIALS AND METHODS: Images from 11 pediatric abdominal CT examinations acquired between June and July 2018 were reconstructed with filtered back projection (FBP) and an iterative reconstruction (IR) algorithm. A residual CNN was trained using the FBP image as the input and the difference between FBP and IR as the target such that the network was able to predict the residual image and simulate the IR. CNN-based postprocessing was applied to 20 low-dose pediatric image datasets acquired between December 2016 and December 2017 on a scanner limited to reconstructing FBP images. The FBP and CNN images were evaluated based on objective image noise and subjective image review by two pediatric radiologists. For each of five features, readers rated images on a five-point Likert scale and also indicated their preferred series. Readers also indicated their "overall preference" for CNN versus FBP. Preference and Likert scores were analyzed for individual and combined readers. Interreader agreement was assessed. RESULTS: The CT number remained unchanged between FBP and CNN images. Image noise was reduced by 31% for CNN images (P < .001). CNN was preferred for overall image quality for individual and combined readers. For combined Likert scores, at least one of the two score types (Likert or binary preference) indicated a significant favoring of CNN over FBP for low contrast, image noise, artifacts, and high contrast, whereas the reverse was true for spatial resolution. CONCLUSION: FBP images can be improved in image space by a well-trained CNN, which may afford a reduction in dose or improvement in image quality on scanners limited to FBP reconstruction.© RSNA, 2019.

The distal tibial classic metaphyseal lesion: medial versus lateral cortical injury.

BACKGROUND: The distal tibia is a common location for the classic metaphyseal lesion (CML). Prior radiologic-pathologic studies have suggested a tendency for medial, as opposed to lateral, cortical injury with the CML, but there has been no formal study of the geographic distribution of this strong indicator of abuse. OBJECTIVE: This study compares medial versus lateral cortical involvement of distal tibial CMLs in a clinical cohort of infants with suspected abuse. MATERIALS AND METHODS: Reports of 1,020 skeletal surveys performed for suspected abuse (July 2005-June 2016) were reviewed. Twenty-six distal tibial CMLs (14 unilateral, 6 bilateral) with anteroposterior (AP) and lateral projections on the initial skeletal survey and at least an AP view on the follow-up survey were identified in 20 infants. Two blinded pediatric radiologists determined if the medial and/or lateral margins of the distal tibial metaphysis were involved by the CML. RESULTS: Average interreader absolute agreement and kappa scores were 0.69-0.90 and 0.45-0.72, respectively. Average intrareader absolute agreement and kappa scores were 0.65-0.88 and 0.44-0.57, respectively. Analyses showed that the distal tibial CML almost always involved the medial cortical margin (reader 1=89%, reader 2=88%, pooled=89%) and the fracture infrequently involved the lateral cortical margin (reader 1=12%, reader 2=38%, pooled=26%). The percentage point difference between fracture involvement in medial and lateral margins was statistically significant from zero (P<0.001). CONCLUSION: The distal tibial CML is most often encountered medially; lateral involvement is uncommon. This observation should help guide the radiologic diagnosis and could have implications for understanding the biomechanics of this distinctive injury.

Pediatric radiology malpractice claims - characteristics and comparison to adult radiology claims.

Medical malpractice is the primary method by which people who believe they have suffered an injury in the course of medical care seek compensation in the United States and Canada. An increasing body of research demonstrates that failure to correctly diagnose is the most common allegation made in malpractice claims against radiologists. Since the 1994 survey by the Society of Chairmen of Radiology in Children's Hospitals (SCORCH), no other published studies have specifically examined the frequency or clinical context of malpractice claims against pediatric radiologists or arising from pediatric imaging interpretation. We hypothesize that the frequency, character and outcome of malpractice claims made against pediatric radiologists differ from those seen in general radiology practice. We searched the Controlled Risk Insurance Co. (CRICO) Strategies' Comparative Benchmarking System (CBS), a private repository of approximately 350,000 open and closed medical malpractice claims in the United States, for claims related to pediatric radiology. We further queried these cases for the major allegation, the clinical environment in which the claim arose, the clinical severity of the alleged injury, indemnity paid (if payment was made), primary imaging modality involved (if applicable) and primary International Classification of Diseases, 9th revision (ICD-9) diagnosis underlying the claim. There were a total of 27,056 fully coded claims of medical malpractice in the CBS database in the 5-year period between Jan. 1, 2010, and Dec. 31, 2014. Of these, 1,472 cases (5.4%) involved patients younger than 18 years. Radiology was the primary service responsible for 71/1,472 (4.8%) pediatric cases. There were statistically significant differences in average payout for pediatric radiology claims ($314,671) compared to adult radiology claims ($174,033). The allegations were primarily diagnosis-related in 70% of pediatric radiology claims. The most common imaging modality implicated in pediatric radiology claims was radiography. The highest payouts in pediatric radiology pertained to missed congenital and developmental anomalies (average $1,222,932) such as developmental dysplasia of the hip and congenital central nervous system anomalies. More than half of pediatric radiology claims arose in the ambulatory setting. Pediatric radiology is not immune from claims of medical malpractice and these claims result in high monetary payouts, particularly for missed diagnoses of congenital and developmental anomalies. Our data suggest that efforts to reduce diagnostic error in the outpatient radiology setting, in the interpretation of radiographs, and in the improved diagnosis of fractures and congenital and developmental anomalies would be of particular benefit to the pediatric radiology community.

Bone age assessment practices in infants and older children among Society for Pediatric Radiology members.

BACKGROUND: Numerous bone age estimation techniques exist, but little is known about what methods radiologists use in clinical practice. OBJECTIVE: To determine which methods pediatric radiologists use to assess bone age in children, and their confidence in these methods. MATERIALS AND METHODS: Society for Pediatric Radiology (SPR) members were invited to complete an online survey regarding bone age assessment. Respondents were asked to identify the methods used and their confidence with their technique for the following groups: Infants (<1 year old), 1- to 3-year-olds and 3- to 18-year-olds. RESULTS: Of the 937 SPR members invited, 441 responded (47%). For infants, 70% of respondents use the hand/wrist method of Greulich and Pyle, 27% use a hemiskeleton method (e.g., Sontag or Elgenmark), and 14.4% use the knee method of Pyle and Hoerr. Of these respondents, 34% were not confident with their technique. For 1- to 3-year-olds, 86% used Greulich and Pyle, and 19% used a hemiskeleton method; 21% were not confident with their technique in this age group. For 3- to 18-year-olds, 97% used Greulich and Pyle, and only 6% of respondents were not confident with their technique in this category. A logistic regression analysis demonstrated that the chronological age of the patient had the greatest impact on reader confidence, with the odds ratios for confidence being 4 times greater in the 3- to 18-year-olds category compared to the younger groups. CONCLUSION: For children older than 3 years, the majority of pediatric radiologists are very confident in their use of Greulich and Pyle for bone age assessment. However a variety of methodologies are used when assessing bone age in infants and younger children, and pediatric radiologists are less confident assessing bone age in these children. This survey highlights the need for a consensus protocol on bone age assessment of younger children and infants that provides readers with a higher degree of confidence.

Feasibility of low-dose CT with model-based iterative image reconstruction in follow-up of patients with testicular cancer.

PURPOSE: We examine the performance of pure model-based iterative reconstruction with reduced-dose CT in follow-up of patients with early-stage testicular cancer. METHODS: Sixteen patients (mean age 35.6 ± 7.4 years) with stage I or II testicular cancer underwent conventional dose (CD) and low-dose (LD) CT acquisition during CT surveillance. LD data was reconstructed with model-based iterative reconstruction (LD-MBIR). Datasets were objectively and subjectively analysed at 8 anatomical levels. Two blinded clinical reads were compared to gold-standard assessment for diagnostic accuracy. RESULTS: Mean radiation dose reduction of 67.1% was recorded. Mean dose measurements for LD-MBIR were: thorax - 66 ± 11 mGy cm (DLP), 1.0 ± 0.2 mSv (ED), 2.0 ± 0.4 mGy (SSDE); abdominopelvic - 128 ± 38 mGy cm (DLP), 1.9 ± 0.6 mSv (ED), 3.0 ± 0.6 mGy (SSDE). Objective noise and signal-to-noise ratio values were comparable between the CD and LD-MBIR images. LD-MBIR images were superior (p < 0.001) with regard to subjective noise, streak artefact, 2-plane contrast resolution, 2-plane spatial resolution and diagnostic acceptability. All patients were correctly categorised as positive, indeterminate or negative for metastatic disease by 2 readers on LD-MBIR and CD datasets. CONCLUSIONS: MBIR facilitated a 67% reduction in radiation dose whilst producing images that were comparable or superior to conventional dose studies without loss of diagnostic utility.

Quantifying Temporomandibular Joint Synovitis in Children With Juvenile Idiopathic Arthritis.

OBJECTIVE: Juvenile idiopathic arthritis (JIA) frequently affects the temporomandibular joints (TMJs) and is often undetected by history, examination, and plain imaging. Qualitative assessment of gadolinium-enhanced magnetic resonance images (MRIs) is currently the standard for diagnosis of TMJ synovitis associated with JIA. The purpose of this study is to apply a quantitative analysis of synovial enhancement to MRIs of patients with and without JIA to establish a disease threshold and sensitivity and specificity for the technique. METHODS: This is a retrospective case-control study of children (age ≤16 years) who had MRIs with gadolinium including the TMJs. Subjects were divided into a JIA group and a control group. From a coronal T1-weighted image, a ratio (enhancement ratio [ER]) of the average pixel intensity within three 0.2-mm2 regions of interest (ROIs) in the TMJ synovium to that of a 50-mm2 ROI of the longus capitis muscle was calculated. Receiver operating characteristic curves were used to determine the sensitivity and specificity. The inter- and intraexaminer reliability was evaluated with Bland-Altman plots and 2-way mixed, absolute agreement intraclass correlation coefficients. RESULTS: There were 187 and 142 TMJs included in the JIA and control groups, respectively. An ER threshold of 1.55 had a sensitivity and specificity for detecting synovitis of 91% and 96%, respectively. The inter- and intraexaminer reliability was excellent. CONCLUSION: Calculating a ratio of pixel intensity between the TMJ synovium and the longus capitis muscle is a reliable way to quantify synovial enhancement. An ER of 1.55 differentiates normal TMJs from those affected by inflammatory arthritis.

Infant bone age estimation based on fibular shaft length: model development and clinical validation.

BACKGROUND: Bone age in infants (<1 year old) is generally estimated using hand/wrist or knee radiographs, or by counting ossification centers. The accuracy and reproducibility of these techniques are largely unknown. OBJECTIVE: To develop and validate an infant bone age estimation technique using fibular shaft length and compare it to conventional methods. MATERIALS AND METHODS: We retrospectively reviewed negative skeletal surveys of 247 term-born low-risk-of-abuse infants (no persistent child protection team concerns) from July 2005 to February 2013, and randomized them into two datasets: (1) model development (n = 123) and (2) model testing (n = 124). Three pediatric radiologists measured all fibular shaft lengths. An ordinary linear regression model was fitted to dataset 1, and the model was evaluated using dataset 2. Readers also estimated infant bone ages in dataset 2 using (1) the hemiskeleton method of Sontag, (2) the hemiskeleton method of Elgenmark, (3) the hand/wrist atlas of Greulich and Pyle, and (4) the knee atlas of Pyle and Hoerr. For validation, we selected lower-extremity radiographs of 114 normal infants with no suspicion of abuse. Readers measured the fibulas and also estimated bone ages using the knee atlas. Bone age estimates from the proposed method were compared to the other methods. RESULTS: The proposed method outperformed all other methods in accuracy and reproducibility. Its accuracy was similar for the testing and validating datasets, with root-mean-square error of 36 days and 37 days; mean absolute error of 28 days and 31 days; and error variability of 22 days and 20 days, respectively. CONCLUSION: This study provides strong support for an infant bone age estimation technique based on fibular shaft length as a more accurate alternative to conventional methods.

Comparison of single CT scan assessment of bone mineral density, vascular calcification and fat mass with standard clinical measurements in renal transplant subjects: the ABC HeART study.

BACKGROUND: Despite limitations of routine methods, Clinical Practice Guidelines support the assessment of bone mineral density (BMD) and vascular calcification in renal transplant recipients. Changes in fat mass also occur post-transplantation, although they are traditionally difficult to measure accurately. We report the feasibility, convenience and accuracy of measuring the above 3 parameters using a novel CT protocol. METHODS: We conducted a cross-sectional study of 64 first renal allograft recipients (eGFR > 30 ml/min/1.73 m(2)). Quantitative CT (QCT) BMD analysis was conducted using CT lumbar spine (GE Medical Systems Lightspeed VCT & Mindways QCT Pro Bone Mineral Densitometry System Version 4.2.3) to calculate spinal volumetric BMD and compared with standard DXA calculated areal BMD at the spine, hip and distal forearm. Abdominal aortic calcification was assessed by semi-quantitative Aortic Calcification Index (ACI) method and compared with lateral lumbar x-ray Kappuila score and pulse wave velocity (PWV). Visceral and subcutaneous adipose tissue volume (Osirix 16 Ver 3.7.1) was compared with BMI. RESULTS: Participants were 61 % male, had a mean age of 47 years, median ESKD duration of 5.4 years and a mean eGFR of 54 ml/min. iDXA median T-score at proximal femur was -1.2 and at lumbar spine was -0.2. Median QCT Trabecular T-score at lumbar spine was -1.2. The percent of subjects with a T-score of < 2.5 by site and method was DXA Proximal Femur: 7 %, DXA distal radius: 17 %, DXA spine: 9 %, QCT (American College of Radiology cutoffs): 9 %. CT derived ACI correlated with PWV (r = 0.29, p = 0.02), pulse wave pressure (r = 0.51, p < 0.001), QCT Trabecular (-0.31, p = 0.01) and cortical volumetric BMD and history of cardiovascular events (Mann-Whitney U, p = 0.02). Both visceral and subcutaneous adipose tissue correlated with BMI (r = 0.63 & 0.64, p < 0.001). CONCLUSIONS: Single CT scan triple assessment of BMD, vascular calcification and body composition is an efficient, accurate and convenient method of risk factor monitoring post renal transplantation.

Clinical significance of pulmonary nodules detected on abdominal CT in pediatric patients.

BACKGROUND: The clinical significance of a pulmonary nodule that is detected incidentally on CT studies in children is unknown. In addition, there is limited information regarding the management of incidentally detected pulmonary nodules discovered on abdominal CT studies in children. OBJECTIVE: The purpose of this study was to investigate the clinical significance of incidental pulmonary nodules detected on abdominal CT studies in children. MATERIALS AND METHODS: This was a retrospective study performed following institutional review board approval. Abdominal CT reports in patients younger than 18 years of age from July 2004 to June 2011 were reviewed for the terms "nodule," "nodular" or "mass" in reference to the lung bases. The study population included those pediatric patients in whom pulmonary nodules were initially detected on abdominal CT studies. The largest pulmonary nodules detected on CT studies were evaluated for their features (size, shape, margin, attenuation, location, and presence of calcification and cavitation). Follow-up CT studies and clinical records were reviewed for demographic information, history of underlying malignancies and the clinical outcome of the incidental pulmonary nodules. Comparison of malignant versus benign pulmonary nodules was performed with respect to the size of the nodule, imaging features on CT, and patient history of malignancy using the Student's t-test and Fisher exact test. Youden J-index in receiver operating characteristic (ROC) analysis was used to determine the optimal cut-off size for suggesting a high risk of malignancy of incidentally detected pulmonary nodules. RESULTS: Pulmonary nodules meeting inclusion criteria were detected in 62 (1.2%) of 5,234 patients. The mean age of patients with nodules was 11.2 years (range: 5 months-18 years). Thirty-one patients (50%) had follow-up CT studies and two of these patients (6%) were subsequently found to have malignant pulmonary nodules. Both of these patients had a history of malignancy. Of the remaining 31 patients without follow-up CT studies, none had a history of malignancy. Clinical follow-up data was available in 26 of these 31 patients (84%) and none had any evidence of malignant pulmonary nodule development. There was a significant association between history of malignancy and incidentally detected pulmonary nodules on abdominal CT studies subsequently found to be malignant (P = 0.036). The size was significantly larger for the malignant pulmonary nodules compared to the benign pulmonary nodules with a size ≥7 mm in diameter being the optimal cut-off for suggesting a high risk of malignancy (11.5 ± 6.4 mm vs. 4.7 ± 3.0 mm, P = 0.003). CONCLUSION: The incidence of pulmonary nodules found on pediatric abdominal CT studies is 1.2%. The incidence of malignancy in such pulmonary nodules is low (3%) and only seen in the setting of pulmonary nodules ≥7 mm in diameter in children with a history of malignancy. Therefore, further investigation is warranted for pulmonary nodules that are ≥7 mm in children with a history of malignancy while further imaging work-up may not be necessary in the remaining patients in this pediatric patient population.

The role of imaging in pediatric bladder augmentation.

Bladder augmentation (also called augmentation cystoplasty) refers to a number of surgical methods that increase the capacity and compliance of the urinary bladder. Imaging has an important role in the postoperative evaluation of bladder augmentation. The most common augmentation procedures utilize enteric segments to augment the bladder. The various types of bladder augmentation have characteristic appearances on different imaging modalities. Spontaneous bladder perforation is a complication that is seen in both early and late post-operative periods and it is one of the most important complications for radiologists to be aware of as it is life-threatening. We review the indications for bladder augmentation in children, the surgical techniques employed, the normal postoperative appearances on imaging studies and the role of imaging complications of bladder augmentation including delayed spontaneous bladder rupture, which is life-threatening.

The utilisation and diagnostic yield of radiological imaging in a specialist functional GI disorder clinic: an 11-year retrospective study.

OBJECTIVES: The term functional gastrointestinal disorders (FGID) describes various aggregations of chronic gastrointestinal (GI) symptoms not explained by identifiable organic pathology; accordingly, their diagnosis rests on symptom-based criteria and a process of exclusion. Evidence is lacking on the appropriate use of abdominal imaging studies (AIS) in FGIDs. METHODS: We investigated the utilisation of AIS (site, modality, diagnostic yield/significance) at a tertiary FGID clinic over an 11-year period. RESULTS: Of 1,621 patients, 507 (31%; 67.5% women, mean age 43.9 ± 17.37 years) referred from primary care had 997 AIS (1.7 per patient): ultrasonography (US) 36.1%, fluoroscopy (FLS) 28.8%, computed tomography (CT) 19.6%, plain radiography (PR) 13.5%, nuclear medicine (NM) 1%). Of the 997 AIS, 55.6% (554/997) were normal. Of the AIS with positive findings, 9.9% (62/625) were deemed 'probably significant' and 14.7% (92/625) 'significant'. Of the CT and FLS studies, 12.3% and 13.6%, respectively, yielded 'significant' abnormalities compared to 2.2% of the US studies and 2.1% of the PR studies. CT identified five of seven neoplasms, associated with male sex, increasing age and symptom onset after age 50 years. CONCLUSIONS: This study confirmed low use of AIS in tertiary FGID clinics and a high proportion of normal studies. Barium swallow/meal and CT were more likely to identify 'probably significant' or 'significant' findings, including neoplasms. KEY POINTS: Imaging referral rates from a specialist functional gastrointestinal disorder clinic are low. Despite this, normal studies are still frequent in those who are imaged. Ultrasonography was the most frequent investigation, yet yielded significant findings infrequently. Abdominal radiographs accounted for 13.5% of investigations yet were normal in 71.8 %. CT and fluoroscopy were more likely to yield positive findings.

Acute idiopathic scrotal edema.

We report a case of acute idiopathic scrotal edema (AISE) in a 4-year-old boy who presented with acute scrotal pain and erythema. The clinical features, ultrasound appearance, and natural history of this rare diagnosis are reviewed. In this report, we highlight the importance of good ultrasound technique in differentiating the etiology of the acute scrotum and demonstrate the color Doppler "Fountain Sign" that is highly suggestive of AISE.

Metastatic mucosal melanoma: imaging patterns of metastasis and recurrence.

PURPOSE: Mucosal melanoma is a rare but aggressive subtype of melanoma with unique clinicopathologic features. We hypothesize that mucosal melanoma shows predilection for separate and unique metastatic pathways. MATERIALS AND METHODS: This was a retrospective analysis of 19 patients (5 men and 14 women; median age 60 years, range 38-76 years) with metastatic mucosal melanoma presenting to a tertiary oncology center between 2005 and 2010. We performed a review of medical records and histologic and imaging studies to evaluate the natural history, metastatic patterns and the role of imaging in the management of patients with advanced mucosal melanoma. RESULTS: At presentation, disease was confined to the primary site (58%, n = 11) or to the regional lymph nodes (32%, n = 6) in most patients. The most common site of metastasis was the lungs (89%, n = 16), followed by the liver (67%, n = 12) and peritoneum (44%, n = 8). Sinonasal melanoma preferentially spread to the liver (100%, n = 4), vaginal melanoma to the lungs (100%, n = 7) and anal melanoma to the inguinal lymph nodes (100%, n = 4). CONCLUSION: Pathways of metastatic spread in mucosal melanoma may differ from other forms of melanoma and between different primary sites of mucosal origin.