This document details imaging approaches for children with suspected juvenile idiopathic arthritis in the axial and appendicular skeleton. It provides recommendations for the initial radiologic evaluation as well as for follow-up imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Chest pain is a common complaint in children and adolescents. The causes of chest pain are varied and include musculoskeletal, pulmonary or pleural, gastrointestinal, psychogenic, and cardiac etiologies. The etiology of pediatric chest pain is often benign but typically generates evaluation in the emergency room, urgent care, or outpatient setting. Diagnostic imaging is often used in the evaluation of pediatric chest pain. This document will discuss various clinical scenarios for children presenting with chest pain and will highlight initial imaging that is usually or may be appropriate, based on the best available evidence or expert consensus. Chest pain limited to the chest wall, from suspected pneumothorax or pneumomediastinum, secondary to suspected pulmonary embolism, from known or suspected cardiac disease, in the setting of sickle cell disease, and from suspected psychogenic causes, will be reviewed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

The range of pathology that can produce abdominal pain in children not only is broad, but can vary with age. Due to the wide differential and the inability for a child to clearly identify and describe the nature of their abdominal pain, diagnostic imaging is often needed. Various clinical scenarios are discussed for a child presenting with acute abdominal pain. Initial imaging studies that are usually appropriate or may be appropriate (based on the best available evidence or expert consensus) for suspected constipation, intussusception, small bowel obstruction without history of surgery, surgical complications, and necrotizing enterocolitis are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

With the rapid development and nearly universal acceptance of first trimester nuchal translucency ultrasound, in conjunction with screening for common aneuploidies through maternal blood testing, fetal anomalies are increasingly identified between 10 weeks and 14 weeks of gestation. When anatomic findings on sonography at this gestational age are indeterminate, options for further imaging evaluation have been limited. Historically, fetal magnetic resonance imaging (MRI) has been deferred until 18 weeks to 20 weeks of gestation due to concerns about safety, small fetal size and fetal motion. Published studies thus far show no evidence indicating harm to the fetus from MRI exposure at any stage of pregnancy for field strengths at or below 3.0 tesla. Fetal MRI can provide detailed, high-resolution diagnostic images as early as 11 weeks of gestation, despite fetal motion or small fetal size. This article presents a small series of late first and early second trimester fetuses selected from a larger cohort referred to our center for anomalies seen or suspected on sonography. We present selected images from same-day fetal sonography and MRI performed in our center, highlight the information obtained from each modality, and discuss how the combined information obtained influenced maternal counseling and pregnancy outcome. Early fetal MRI requires real-time changes in routine imaging protocols, with frequent communication between the performing MRI technologist and the reading radiologist. The cases presented here suggest that early fetal MRI can be added to our imaging armamentarium and may assist patients and clinicians with earlier and more accurate diagnoses. In our experience, the information obtained from early fetal MRI often confirms or adds details to anomalies seen or suspected on sonography.

Managing omphaloceles poses challenges in prenatal consultation and perinatal care. We hypothesized that specific fetal MRI findings could predict morbidity and mortality in these patients. We analyzed fetal MRI studies demonstrating omphaloceles from 2006 to 2022 and conducted a retrospective review of medical records. Predictor variables were correlated with outcomes using univariate and multivariate analyses, and Receiver Operating Characteristic (ROC) curves were optimized with Youden’s J statistic. Among 46 omphalocele patients, 89% survived to birth, with an overall mortality rate of 37%. Significant predictors of mortality included stomach/spleen herniation, severe anomalies, omphalocele-associated syndromes, membrane rupture, lower observed/expected total fetal lung volume (O/E TFLV), and increased percentage of liver herniation. The need for deferred repair correlated with liver/stomach herniation and “giant-omphalocele.” ROC analysis identified mortality cut points at O/E TFLV < 42% and liver herniation >77%, while deferred repair was indicated at liver herniation >51%. This study identified prenatal MRI findings associated with mortality and deferred repair, aiding in risk prediction and family counseling.

OBJECTIVE:The mechanical impact of the gravid uterus on the vasculature is well known, but its role in hypertensive disorders of pregnancy (HDP) is incompletely understood. Prior studies have demonstrated an increase in blood pressure greater than 20 mmHg in pregnant participants upon rolling from the left lateral posture (LLD) to supine is highly predictive of preeclampsia, but the use and mechanism of this test remain underexplored. Here, we assess the impact of posture on renal venous caliber, its relation to HDP, and the potential for renal venous compression to occur in the real-world environment. METHODS:We performed a retrospective study of 161 pregnant participants (22-40 weeks gestation) with previously acquired magnetic resonance imaging to measure renal vein caliber. We assessed sleeping and waking posture via a two-part cross-sectional survey of 147 pregnant and non-pregnant participants. Renal vein diameters were analyzed using repeated measures mixed-effects analysis with Tukey's post hoc test for multiple comparisons. Renal vein ratios and sleep posture vulnerability (a metric of the potential for renal venous compression) were analyzed using one-way ANOVA with Tukey's post hoc test for multiple comparisons. Renal vein ratios were additionally analyzed using multivariate linear regression with a main-effects weight least squares model weighted by 1/y. RESULTS:Left renal vein diameter ratios were larger in supine (45.8 ± 26.9%) than LLD (21.7 ± 35.8%, p < 0.01), but not right lateral decubitus (RLD, 32.2 ± 32.6%, p = 0.19). The study was underpowered to assess differences in participants with HDP: few participants underwent MRI in RLD (n = 17 normotensive, n = 1 preeclamptic, n = 0 gestationally hypertensive) or LLD (n = 23 normotensive, n = 0 preeclamptic, n = 2 gestationally hypertensive), but a multivariate linear regression demonstrated a significant effect of gestational age and maternal posture on left renal vein diameter. Self-reported sleeping posture demonstrated most pregnant participants (94.5%) fell asleep on their side, but up to 23.8% woke on their back. CONCLUSION:These results highlight the potential for renal venous compression and the flow-protective potential of the left lateral posture. Imaging data demonstrates renal venous compression in the supine posture and self-reported sleep data demonstrate that patients may inadvertently sleep supine even when falling asleep on their side. While most patients likely have a collateral network to accommodate renal venous compression, those who do not may be vulnerable to HDP. A longitudinal patient-matched prospective study is needed to fully dissect this underlying mechanism.

Prenatal hydrocolpos is characterized by fluid distension of the vagina. Hydrocolpos can be caused by multiple underlying etiologies and often demonstrates overlapping imaging features compared to other cystic abdominal and pelvic lesions. The purpose of the current pictorial essay is to provide a systematic prenatal magnetic resonance imaging (MRI) approach to differentiating the primary etiologies leading to hydrocolpos. After discussing the fundamental embryological processes involved in vaginal development, the current essay discusses the most common causes of hydrocolpos with their associated prenatal and postnatal imaging features. An approach to distinguishing the more common differential diagnoses is provided. Given the implications of parental counseling and postnatal management, this essay provides an important approach for narrowing differential diagnoses based on prenatal imaging.

RATIONALE AND OBJECTIVES:The aim of this study was to develop a validated instrument to measure radiology residents' sense of psychological ownership of patient care. MATERIALS AND METHODS:A previously validated measure of patient care ownership was adapted through a two-step process of expert review and revision by six academic radiology faculty. An online, anonymous survey was distributed to 64 residents and fellows at the end of three consecutive four-week long rotations. We calculated Cronbach's α to determine the scale's internal consistency, performed exploratory factor analysis to identify possible subscales, and conducted bivariate and correlational analysis to establish construct validity. RESULTS:The 11-item ownership scale demonstrated good internal consistency (Cronbach's α = 0.93), and three subscales were identified corresponding to assertiveness, conscientiousness, and confidence/perceived competence. Sense of ownership was significantly associated with training level, prior experience in the type of rotation, stress, sleep, burnout, peer support, relationships with clinical staff, and recognition by department. We found no significant association between ownership and age, gender, type of rotation, site of rotation, type of residency, perceived interruption frequency, or remote work frequency. CONCLUSION:The radiology resident patient care ownership scale demonstrates good internal consistency and preliminary evidence of validity. After further validation, we expect the scale to be a valuable tool in evaluating interventions aimed at increasing radiology residents' sense of ownership.

Abstract Objective Opioid use in pregnant women is a growing public health concern and is shown to be associated with lower infant birth weights. Placental volume changes in prior studies correlated with various maternal and fetal conditions. We aimed to identify differences between placental volumes in pregnant women with opioid use, and control pregnant women without drug use. Methods We prospectively recruited 27 healthy pregnant women and 17 pregnant women with opioid use disorder who were on medication-assisted treatment (MAT). All women underwent placenta/fetal MRI at 27–39 weeks gestation on a 3 Tesla MR scanner. Placental volumes were measured in a blinded fashion using a previously validated technique. Multiple linear regression was used to identify associations of placental volume with multiple maternal and fetal clinical factors. The significance threshold was set at p < .05. Results Placental volume was significantly associated with gestational age at MRI (p < .0001), fetal sex (p = .027), MAT with smoking (p = .0008), MAT with polysubstance use (p = .01), and maternal BMI (p = .032). Placental volume was not associated with opioid MAT alone in our cohort. Conclusion For pregnant women on medication-assisted treatment for opioid use disorder, there was no significant difference in placental volume compared to healthy pregnant women. However, concomitant smoking and polysubstance use in the setting of medication-assisted treatment may be detrimental to placental health. To our knowledge, this is the first study assessing placental volume in opioid use on prenatal MRI. These results support the benefit of medication-assisted treatment during pregnancy; however additional studies are needed to further elucidate the impact of opioid use on placental and fetal development and postnatal outcomes.

Fetal MRI: Point—1.5T MRI Is an Important Tool of the Fetal ImagerMorgan N. McLuckey, MD1 and Brandon P. Brown, MD, MA, FAAP2Audio Available | Share

Prior research suggests placental mechanisms as a pathophysiologic explanation for hypertensive disorders of pregnancy, but little research exists on the role of renal venous compression by the gravid uterus. Prior work has suggested radiologic evidence of significant left renal vein (LRV) compression in the gravid patient, particularly in supine position. Our study aims to assess the degree of LRV stenosis stratified by maternal position and its association with development of hypertensive disorders. MRIs for fetal indications of pregnant patients between 24 and 40 weeks of gestation from 2005-2021 at a single academic center were assessed for renal vein visibility (n=916). Renal veins were seen in 161 patients, allowing us to measure the diameter at various locations (Fig 1A). Maternal position at the time of the study was also noted (supine, left (LLD) or right lateral decubitus (RLD). Exams were measured by 2 observers under the guidance of a board-certified radiologist and results were averaged. We determined the difference in LRV diameter between the mid (D) and proximal (E) segments and report as a percentage of stenosis. Data regarding development of hypertensive disorders were abstracted from the medical record. 21/161 (13%) developed a hypertensive disorder in pregnancy up to 12 weeks postpartum. There was a greater percentage of LRV stenosis in supine (45.8 26.6%, p< 0.01) compared to LLD (21.7 35.8%, p< 0.01), with no significant difference in RLD (Fig 2A,2B). Of those who did not develop a hypertensive disorder, there was a significant difference in % stenosis of the LRV (45.8 27.1% supine vs. 22.2 37.4% LLD, p=0.01), but no significant difference among those who developed a hypertensive disorder for each position (Fig 2C). Our data suggests radiologic evidence of significantly increased LRV stenosis in the supine position in patients over 24 weeks of gestation. Presence or degree of stenosis does not correlate with higher incidence of hypertensive disorders, suggesting possible maternal adaptability as protective. Prospective studies are needed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Purpose. - The purpose of this study was to assess for any differences in brain maturation, structure and morphometry in fetuses exposed to opioids in utero , compared to non-opioid exposed fetuses on fetal MRI. Methods. - We performed a prospective study in pregnant women using opioids and healthy pregnant women without prenatal opioid use. We evaluated brain maturation, structure, and morphometry on second or third trimester fetal MRI and assessed group differences. Results. - 28 pregnant women were enrolled, 12 with opioid exposure (average gestational age 33.67, range 28-39 w), 9 of whom also smoked, and 16 without opioid exposure (average gestational age 32.53, range 27-38 w). There was a significant difference in the anteroposterior diameter of the fetal cerebellar vermis in the opioid exposed fetuses compared to non-opioid exposed fetuses (p = 0.004). There were no significant differences in brain biparietal diameter, fronto-occipital diameter, transverse cerebellar diameter and anteroposterior dimension of the pons in opioid exposed fetuses compared to non-opioid exposed fetuses. There were no abnormalities in brain maturation and no major brain structural abnormalities in the opioid exposed fetuses. Conclusion. - Smaller fetal anteroposterior cerebellar vermian dimension was associated with in utero opioid exposure. There were no abnormalities in brain maturation or major structural abnormalities in fetuses exposed to opioids. (c) 2021 Elsevier Masson SAS. All rights reserved.

Background Fetal cerebral sinovenous thrombosis (CSVT) and dural sinus malformation (DSM) are rare types of fetal cerebral venous pathology that are becoming increasingly recognized as fetal imaging advances. Fetal DSMs are a common source of fetal CSVT, although CSVT may occur without a DSM. The literature on these disorders is limited. Methods Cases of fetal CSVT and DSM were identified retrospectively through a query of the Indiana University Health fetal imaging archive from 2007 to 2021. Results Seven cases were identified, all of whom were alive at birth. A DSM was present in six. Treatments after birth included enoxaparin sodium (3), embolization (3), and shunt placements (1). Five cases had documented regression or complete resolution of the thrombus and/or malformation. One was lost to follow-up, one died from complications of hydrocephalus at nine months, one was receiving physical and occupational therapy at last follow-up at three months, one had concern for autism and mild gait abnormality at 21 months, two had concern for speech delay (18 months and 24 months), and one had normal development at most recent follow-up (four years). Conclusions Positive short-term outcomes may occur for some cases of fetal CSVT and DSM. However, risk factors and best treatments are not clear, and long-term outcome data are limited. There is a need for further study.

Background: Placenta accreta spectrum (PAS) disorders occur when the placenta adheres abnormally to the uterine myometrium and can have devastating effects on maternal health due to risks of massive postpartum hemorrhage and possible need for emergency hysterectomy. PAS can be difficult to diagnose using routine clinical imaging with ultrasound and structural MRI. Objective: To determine feasibility of using intravoxel incoherent motion (IVIM) magnetic resonance imaging (MRI) analysis in the diagnosis of the placenta accreta spectrum disorders in pregnant women. Methods: A total of 49 pregnant women were recruited including 14 with pathologically confirmed cases of PAS and 35 health controls without prior cesarean delivery and no suspected PAS by ultrasound. All women underwent diffusion-weighted imaging with an 8 b-value scanning sequence. A semi-automated method for image processing was used, creating a 3D object map, which was then fit to a biexponential signal decay curve for IVIM modeling to determine slow diffusion (D-s), fast diffusion (D-f), and perfusion fraction (P-f). Results: Our results demonstrated a high degree of model fitting (R-2 >= 0.98), with P-f significantly higher in those with PAS compared to healthy controls (0.451 +/- 0.019 versus 0.341 +/- 0.022, p = 0.002). By contrast, no statistical difference in the D-f (1.70 x 10(-2) +/- 0.38 x 10(-2) versus 1.48 x 10(-2) +/- 0.08 x 10(-2) mm(2)/s,p = 0.211) or D-s (1.34 x 10(-3) +/- 0.10 x 10(-3) versus 1.45 x 10(-3) +/- 0.007 x 10(-3) mm(2)/s, p = 0.215) was found between subjects with PAS and healthy controls. Conclusions: The use of MRI, and IVIM modeling in particular, may have potential in aiding in the diagnosis of PAS when other imaging modalities are equivocal. However, the widespread use of these techniques will require generation of large normative data sets, consistent sequencing protocols, and streamlined analysis techniques.

Diverticulitis in the pediatric population is a very rare cause of abdominal pain. When present in the cecum or ascending colon, it is often incorrectly diagnosed preoperatively as acute appendicitis. This is especially true in Western countries where right-sided diverticulitis is less common. Here we detail a case of a pediatric patient with complicated congenital cecal diverticulitis and review the literature on pertinent management. An extensive work up with imaging and endoscopy was completed and definitive surgical treatment with diverticulectomy an appendectomy was performed. As the incidence of diverticular disease in younger individuals increases, right sided diverticulitis is worthy of consideration on the differential diagnosis.

Although radiologists increasingly turn to interventions focused on the individual in order to address the symptoms of work-related stress and cultivate wellness, this approach can fail to address isolation and separation as causes of our distress. Despite many efforts focused on dietary, physical, and emotional health, relatively few discussions of burnout have focused on our role as members of health care teams as a solution to the problem. This discussion considers whether we can truly be ourselves without the assistance of those around us. Specifically, we need to cultivate time, space, and collaboration as critical ingredients in any truly healthy radiology workplace. Wholeness as a principle in radiologist health speaks to our status as interconnected persons and colleagues. Just as we cannot effectively care for complex patient needs on our own, we cannot truly restore health to the stressed-out radiologist in isolation. It may be that the opposite of burnout is not individual health. Where wellness falls short, we must seek wholeness.