key: cord- -nsjn q authors: page, matthew j.; welch, vivian a.; haddaway, neal r.; karunananthan, sathya; maxwell, lara j.; tugwell, peter title: ‘one more time’: why replicating some syntheses of evidence relevant to covid- makes sense date: - - journal: j clin epidemiol doi: . /j.jclinepi. . . sha: doc_id: cord_uid: nsjn q • given the urgent need for credible answers to high-priority questions about the health and social impacts of covid- , many systematic reviewers seek to contribute their skills and expertise; • rather than embarking on unnecessary, duplicate reviews, we encourage the evidence synthesis community to prioritise purposeful replication of systematic reviews of evidence relevant to covid- . the coronavirus disease (covid- ) pandemic has mobilised researchers across the world on a scale not seen before ( ) . as of may , studies presenting primary data on have been indexed in medline and embase ( ) , and clinical trials of interventions for the disease are currently underway ( , ) . preprint servers medrxiv and biorxiv host more than three thousand preprints on covid- ( ) . there is also a wealth of data from previous pandemics (e.g. sars, mers) which may inform efforts to combat covid- . to make sense of all this data, timely, relevant systematic reviews and meta-analyses have started appearing (e.g. ( ) ( ) ( ) ( ) ( ) ) and more will be necessary in the coming weeks and months. systematic reviews are required to address not only the aetiology, diagnosis, prognosis and treatment of symptoms of covid- , but also the social impacts of the disease (e.g. effects of strategies to support parents with home-schooling their children and educators with online learning pedagogical strategies; consequences of police being mobilized to police quarantines; and international development issues such as food security during the pandemic). we believe that while original reviews are essential, decision making during the pandemic would benefit also from the purposeful replication of some systematic reviews of evidence relevant to covid- . in this article, we draw a distinction between duplication and replication of systematic reviews. by 'duplication' of systematic reviews, we mean needless, frequently unwitting or unacknowledged repetition of reviews without a clearly defined purpose for the repetition. by 'replication', we mean using the same or very similar methods as a previous systematic review to determine whether comparable results are obtained, or intentionally broadening or narrowing the question addressed in a previous review to check how operationalisation of concepts in the previous review influenced the results ( ) . previous research suggests that a high proportion of systematic reviews and meta-analyses duplicate those that came before ( , ) . for example, systematic reviews of the effects of direct oral anticoagulants for stroke prevention in atrial fibrillation were published between and ( ) . duplicate systematic reviews waste time and resources, creating extra work for health care providers and other users who need to determine what unique information, if any, each review provides. duplication can also create confusion when reviews addressing the same question reach conflicting findings ( ) . by may , there were systematic reviews of human studies relevant to covid- registered in prospero, the international prospective register for systematic reviews ( ). however, many of these registered reviews appear to address the same or a similar question (e.g. reviews include chloroquine or hydroxychloroquine and include traditional chinese medicine in the title). given the urgent need for credible answers to high-priority questions about the health and social impacts of covid- , it is unsurprising that many systematic reviewers seek to contribute their skills and expertise. however, unless different teams working on the same review begin collaborating with one another, an epidemic of redundant reviews on covid- is likely on the horizon. along with minimising production of unnecessary, duplicate reviews, we encourage the evidence synthesis community to prioritise purposeful replication of some systematic reviews of evidence relevant to covid- . initially, this could involve replicating previously published, high-priority reviews conducted to address questions of relevance to a previous pandemic (e.g. what are the effects of wearing masks in public?) or questions originally posed in an unrelated context (e.g. what are the effects of programs to support physical activity at home for house-bound older adults?). thereafter, it may be necessary to replicate some reviews relevant to covid- that are conducted during the pandemic (e.g. what are the effects on covid- symptoms of drugs currently being evaluated in randomized trials?). replicating reviews might satisfy the curiosities of methodologists wondering what impact specific methods have on review findings, but that is far from their only purpose. rather, replicating reviews is a mechanism for verifying or addressing uncertainties about the results of an original review that decision makers might be relying on to formulate recommendations for practice and policy. replication of reviews is important in general but is especially valuable for syntheses of evidence relevant to covid- . results of systematic reviews are determined by many choices relating to their design, conduct and analysis ( , ) . for example, reviewers need to decide which studies to include, how to identify studies, which outcome data to collect, and how to synthesise results. there are also many opportunities for errors in reviews, for example in the selection of eligible studies, or collection of relevant data. these issues are compounded during a pandemic such as covid- , when stakeholders need answers to pressing questions as soon as possible. the time available to decide the review's scope and methods may be substantially less than usual, and potential for error may be considerably higher. replication of systematic reviews of evidence relevant to covid- therefore can serve as a useful quality control process. results of a replication could lead to an increase or decrease in confidence in the claims made in the original review, indicate constraints on the reliability of the findings, and help refine or advance theory, subsequently providing more accurate information for decision makers during the pandemic ( ) . many systematic reviews of evidence relevant to covid- are using methodological shortcuts to provide evidence in a timely manner ( ). for example, in their review of quarantine alone or in combination with other public health measures to control covid- , nussbaumer-streit et al. decided to have a single author screen % of titles and abstracts, and one author collect data with verification by another ( ) . based on registration data in prospero, there are many systematic reviewers keen to contribute to the covid- research effort, who could band together to work on purposeful replications that evaluate the impact of abbreviated methods on review findings, rather than proceeding with a redundant review. doing so could help reveal what risks the use of methodological shortcuts entail, if any, adding to the limited comparative evidence on different methods for systematic reviews ( ) . replication of systematic reviews can be done in various ways, with some requiring less resources than others. systematic reviewers could perform a full replication of a review by repeating the entire set of systematic review methods, or a partial replication by repeating a particular method for which there was reason for concern. examples of the latter include: running the same or a broader search to see if any relevant studies were missed; extracting the study data necessary to recreate one of the meta-analyses reported to see if an alternative result was obtained; or conducting a more in-depth analysis of a subgroup of studies in the original review. replication of a review could be done for the purpose of determining the impact of involving different stakeholders (e.g. patients, insurers) in the review process or using an alternative statistical or qualitative synthesis approach ( ) . replication might also be done to evaluate the impact on the review findings of using automation tools (e.g. for study selection, or risk of bias assessment) ( ) , as compared to an original review relying on human reviewers only. the commonality amongst all these approaches is the adoption of similar or somewhat expanded methods as those used in a target systematic review. by contrast, adopting the methods of an entirely different type of evidence synthesis (e.g. scoping review, overview of systematic reviews) would not constitute a replication, given the different purpose the other type of synthesis serves. even with an army of experienced systematic reviewers, replicating every review of evidence relevant to covid- is neither feasible nor desirable. systematic reviewers, commissioners and other stakeholders must therefore prioritise which reviews to replicate. an international, multidisciplinary group of individuals from seven countries met in wakefield, canada in to develop guidance on when and when not to replicate systematic reviews. the resulting guidance advises reviewers to consider various criteria, such as (i) the priority of the review question for decision makers, (ii) the potential for replication to address uncertainties, controversies or the need for additional evidence relating to the framing, conduct, potential for author influence, or discordance of findings in previous reviews, (iii) the extent to which implementation of results of the replication could affect a sizeable population, and (iv) whether resources required to replicate are offset by the potential value in reaffirming or addressing uncertainties related to the original results ( ) . a paper describing this guidance is under review, and we encourage anyone wishing further information, or keen to collaborate on research on the replicability of systematic reviews, to contact us. the covid- context provides some unique opportunities and challenges for replication of reviews. several syntheses of evidence relevant to covid- are being continually updated (i.e. "living" reviews) ( , , , ) . if one of these reviews were replicated and errors were identified, these could be corrected in the original review at a much faster pace than usually occurs. also, by bringing together various organisations to help reduce duplication and better coordinate evidence syntheses relevant to covid- , the recently established covid- evidence network to support decisionmaking (covid-end) ( ) could help facilitate the process of prioritising and coordinating replications of reviews. on the other hand, the politicisation of discussions about covid- means that the findings of replicated reviews would need to be communicated carefully, as failures to obtain the same result in a replication could be weaponised by some to discredit the entire systematic review process; something already observed in discourse on modelling studies for covid- ( ) . to enhance replication of systematic reviews relevant to covid- completed during the pandemic, we urge systematic reviewers to make their workflow publicly accessible. we recommend reviewers use reporting guidelines for systematic reviews, which typically recommend authors report what question(s) the review addressed, the types of studies they considered eligible, how they identified such studies, which data they collected, and how results were synthesized ( ) . following principles of "open synthesis" by sharing the underlying data, analytic code and other materials used in the review via one of the various public repositories available (such as the open science framework, figshare, or dryad) can supplement information provided in the review report ( ) . for example, the summary data required to re-run meta-analyses and data for other outcomes for which metaanalysis was not possible could be provided in a well curated format ready for reuse (e.g. review manager file, or a microsoft excel or csv file) along with any analytic code necessary for reanalysis. also, data extraction forms that clearly indicate what data were sought, what data were obtained and where data were obtained from may reduce uncertainties for replicators ( , ) . replicators should also register their plans to replicate a review at prospero and post working protocols in publicly accessible repositories. in addition to aiding replication efforts, making the review workflow available for scrutiny should help increase the public's trust in systematic review findings. we believe nosek and errington's view of replication as an "exciting, generative, vital contributor to research progress" ( ) easily applies to systematic reviews and other research syntheses. however, replicated systematic reviews are currently a rarity, likely because their potential value is underrecognised by researchers, funders, journals and other stakeholders. we hope that this changes throughout the covid- pandemic and beyond, with replicated systematic reviews coming to be seen as highly valued and necessary research products, and redundant reviews a relic of the past. mjp is an editorial board member and pt is the co-editor in chief for the journal of clinical epidemiology, but neither were involved in the peer review process or decision to publish. there was no direct funding for this manuscript. mjp is supported by an australian research council discovery early career researcher award (de ). the meeting to develop guidance on when and when not to replicate systematic reviews was supported by a canadian institutes of health research operating grant (ref # pjt- ). the funders had no role in decision to publish or preparation of the manuscript. all authors declare to meet the icmje conditions for authorship. mjp conceived the paper and wrote the first draft. all authors were involved in revising the article critically for important intellectual content. all authors approved the final version of the article. mjp is the guarantor of this work. a novel coronavirus outbreak of global health concern covid- : living map of the evidence global coronavirus covid- clinical trial tracker a real-time dashboard of clinical trials for covid- . the lancet digital health covid- sars-cov- preprints from medrxiv and biorxiv oxford covid- evidence service living mapping and living network meta-analysis of covid- studies when and how to replicate systematic reviews overlapping meta-analyses on the same topic: survey of published studies overlapping network meta-analyses on the same topic: survey of published studies overview of systematic reviews of non-vitamin k oral anticoagulants in atrial fibrillation discrepancies in meta-analyses answering the same clinical question were hard to explain: a meta-epidemiological study the role of judgment calls in meta-analysis vibration of effects from diverse inclusion/exclusion criteria and analytical choices: different ways to perform an indirect comparison meta-analysis coronavirus disease (covid- ) pandemic: an overview of systematic reviews quarantine alone or in combination with other public health measures to control covid- : a rapid review few studies exist examining methods for selecting studies, abstracting data, and appraising quality in a systematic review just how plain are plain tobacco packs: re-analysis of a systematic review using multilevel meta-analysis suggests lessons about the comparative benefits of synthesis methods a full systematic review was completed in weeks using automation tools: a case study when should systematic reviews be replicated, and when is it wasteful? epidemiology of and risk factors for coronavirus infection in health care workers: a living rapid review. annals of internal medicine interventions for treatment of covid- : a protocol for a living systematic review with network meta-analysis including individual patient data (the living project) coronavirus modelers factor in new public health risk: accusations their work is a hoax mapping of reporting guidance for systematic reviews and meta-analyses generated a comprehensive item bank for future reporting guidelines open synthesis: on the need for evidence synthesis to embrace open science reproducible research practices are underused in systematic reviews of biomedical interventions key: cord- - gi o mu authors: faber, timor; ravaud, philippe; riveros, carolina; perrodeau, elodie; dechartres, agnes title: meta-analyses including non-randomized studies of therapeutic interventions: a methodological review date: - - journal: bmc med res methodol doi: . /s - - - sha: doc_id: cord_uid: gi o mu background: there is an increasing number of meta-analyses including data from non-randomized studies for therapeutic evaluation. we aimed to systematically assess the methods used in meta-analyses including non-randomized studies evaluating therapeutic interventions. methods: for this methodological review, we searched medline via pubmed, from january , to december , for meta-analyses including at least one non-randomized study evaluating therapeutic interventions. etiological assessments and meta-analyses with no comparison group were excluded. two reviewers independently assessed the general characteristics and key methodological components of the systematic review process and meta-analysis methods. results: one hundred eighty eight meta-analyses were selected: included both randomized controlled trials (rcts) and non-randomized studies of interventions (nrsi) and only nrsi. half of the meta-analyses (n = , %) evaluated non-pharmacological interventions. “grey literature” was searched for meta-analyses ( %). an assessment of methodological quality or risk of bias was reported in meta-analyses ( %) but this assessment considered the risk of confounding bias in only meta-analyses ( %). in meta-analyses ( %), the design of each nrsi was not clearly specified. in ( %), whether crude or adjusted estimates of treatment effect for nrsi were combined was unclear or not reported. heterogeneity across studies was assessed in meta-analyses ( %) and further explored in ( %). reporting bias was assessed in ( %). conclusions: some key methodological components of the systematic review process—search for grey literature, description of the type of nrsi included, assessment of risk of confounding bias and reporting of whether crude or adjusted estimates were combined—are not adequately carried out or reported in meta-analyses including nrsi. randomized controlled trials (rcts) are considered the gold standard for evidence-based medicine because they are designed to minimize the risk of bias [ ] . however, the applicability of their results has been criticized because of restrictive selection criteria, with, commonly, exclusion of older adults and people with co-morbidities or severe disease [ ] [ ] [ ] . also, conducting an rct is sometimes impossible or inappropriate (eg, when studying rare or long-term events) [ , , ] , which results in critical information gaps. in contrast, observational studies, the overarching term for all non-experimental non-randomized studies (including cohort, case-control, and cross-sectional studies) [ ], generally are more likely to reflect clinical practice in real life because of their broader range of participants, longer follow-up time, and lower costs than rcts [ ] [ ] [ ] [ ] . with the aim of generating evidence that will guide healthcare decisions, the field of comparative effectiveness research (cer) emphasizes the need to incorporate data from observational studies to complement rcts [ , [ ] [ ] [ ] [ ] [ ] [ ] . a comprehensive assessment in indicated that % of cer studies had an observational study design [ ] . therefore, an increasing number of systematic reviews and meta-analyses are including data from non-randomized studies to assess therapeutic interventions. similar to systematic reviews of rcts, reviews including non-randomized studies are expected to follow the general recommendations for good conduct, such as retrieving all relevant studies and assessing their risk of bias. however, some elements should be adapted specifically to the inclusion of non-randomized studies because their study designs inherently differ from rcts [ , , , [ ] [ ] [ ] [ ] [ ] [ ] . lacking randomization, they are likely subject to confounding bias, which results in an imbalance in prognostic factors associated with the outcome of interest that may severely compromise the validity of their results [ ] . previous methodological reviews evaluating systematic reviews including observational studies exist [ ] [ ] [ ] [ ] . however, these studies have a different objective. one assessed the main characteristics of all systematic reviews indexed in medline on november whatever the type of included studies (ie, therapeutic, epidemiological, prognostic or diagnostic studies) [ ] . two others focused on the methods and reporting of harms in systematic reviews of adverse events [ , ] . the last one was in the field of psychiatry and did not concern therapeutic evaluation but assessment of prevalence or association [ ] . further, none of these previous reviews has evaluated the specific methodological problems raised by the inclusion of non-randomized studies. in this study, we performed a methodological review of meta-analyses including non-randomized studies of interventions (nrsi) to evaluate key methodological components common to all meta-analyses and those specifically related to the inclusion of non-randomized studies. this is a methodological review of meta-analyses including nrsi for therapeutic evaluation. for clarity and consistency, we refer to this article as a "methodological review", the systematic reviews with meta-analyses included in this methodological review as "meta-analyses", and the studies included in these meta-analyses as "studies". our goal was not to create an exhaustive list of all metaanalyses that include nrsi but rather to identify a relatively representative sample of recently published meta-analyses that a health professional would most likely encounter when searching for meta-analyses. we therefore searched med-line via pubmed because of its wide use among health professionals, combining keywords and mesh terms for nrsi, systematic reviews, and meta-analyses (appendix ). the search was conducted on january , and restricted to the year . to be eligible, a meta-analysis had to examine a therapeutic or preventive intervention (such as vaccines) for efficacy or safety, include data from at least one nrsi, and be published in . we excluded meta-analyses that included studies without a comparison group and meta-analyses of etiological assessment. when it was difficult to distinguish an etiological from a therapeutic evaluation, we agreed to include the former if the authors considered the inclusion of rcts in their meta-analysis. to illustrate: a metaanalysis that investigated the association of the use of statins and risk of cancer would was considered a therapeutic evaluation if the authors planned to include rcts. individual patient data meta-analyses were also excluded, as were non-randomized studies that conducted a meta-analysis of the literature as secondary analysis. finally, we did not include meta-analyses published in a language other than english or those for which the full text was not available. the selection of relevant meta-analyses was conducted in steps. in the first step, one reviewer (cr) excluded clearly irrelevant studies based on the title, abstract, and full text, then, a second reviewer (tf) performed the final selection, discussing all doubtful cases with a third reviewer (ad). the data extraction form for this methodological review was developed from the moose statement for reporting meta-analyses that include observational studies [ ] , the prisma statement for reporting systematic reviews and meta-analyses of studies evaluating healthcare interventions [ , ] , and the amstar measurement tool for assessing the methodological quality of systematic reviews [ ] . the data extraction form was tested by one reviewer (tf) with studies before data extraction commenced. two reviewers (tf, cr) independently extracted all data in duplicate, resolving discrepancies with a third reviewer (ad) if necessary. the following characteristics were extracted from the full text and online appendix of each meta-analysis: general characteristics: we collected whether the journal was a specialty or a general journal, the location of the corresponding author, and the medical area. we verified whether the metaanalysis was registered on the international prospective register of systematic reviews by the university of york's centre for reviews and dissemination (prospero). we collected whether epidemiologists or statisticians were involved, relying on the definition given by delgado-rodriguez et al. [ ] and assessed whether the authors reported the funding sources and declared conflict of interests. we assessed whether the meta-analyses evaluated a pharmacological or nonpharmacological intervention. non-pharmacological interventions were classified as surgical procedures or other interventions. we also assessed the type of studies included: only nrsi or both nrsi and rcts. ▪ search strategy: we collected how many and which electronic databases were searched, and whether the search strategy for at least one database was provided. we collected whether reference lists and journals were hand-searched and whether the authors searched for grey literature, and if yes, how: search of registries (eg, clinicaltrials.gov), conference abstracts, or contacting experts. we assessed whether the authors restrict their searches by language. ▪ study selection and data extraction process: we assessed whether study selection and data extraction were conducted in duplicate. ▪ contact of the study authors: we noted whether it was mentioned that study authors were contacted for clarification or additional results. ▪ methodological quality/risk of bias assessment: we assessed whether methodological quality or risk of bias assessment was conducted, what tools were used, and whether the assessment was conducted in duplicate. meta-analysis methods: ▪ studies combined: we assessed the types of nrsi included. nrsi were categorized as concurrent (prospective) cohort, nonconcurrent (retrospective) cohort, case-control, or historically controlled studies according to the definition by ioannidis et al. [ ] . we also assessed whether the authors combined the results from nrsi and rcts and whether they combined results from different types of nrsi (eg, cohort and case-control studies). ▪ meta-analysis model: we collected whether the authors used crude or adjusted estimates for nrsi and whether they used fixed-or random-effects models to pool the data. for adjusted estimates, we also collected whether the confounding factors taken into account were listed. ▪ assessment and exploration of heterogeneity: we collected whether and how the authors assessed heterogeneity and whether they conducted meta-regression, subgroup, or sensitivity analyses to explore heterogeneity. ▪ assessment of reporting bias: we collected information on whether the authors assessed reporting bias, and how. the analysis of the data consisted of descriptive statistics, providing numbers and percentages for qualitative variables and median (minimum, maximum, or interquartile range) for quantitative variables. the results were stratified for meta-analyses including only nrsi and those including both nrsi and rcts. we did not assess statistical differences between these strata. our medline search identified citations; among the potentially relevant meta-analyses, were eligible for this review (fig. ). complete references for the included meta-analyses and meta-analyses excluded are in appendixes and , respectively. general characteristics (table ) among the included meta-analyses, ( %) were of surgery, ( %) cardiology, and ( %) oncology. half of the meta-analyses assessed non-pharmacological interventions (n = , %); involved surgical procedures. approximately one third (n = , %) included only nrsi, and two thirds included both nrsi and rcts (n = , %). in total, meta-analyses ( %) involved epidemiologists or statisticians. conflict of interest was declared in ( %), with reporting a potential conflict of interest. about one-third of the meta-analyses did not report a source of funding (n = , %). overall, all but one of the meta-analyses reported the search of at least electronic database and ( %) reported the search of > electronic databases. one third provided the search strategy for each database (n = , %). medline, embase, and the cochrane library were most frequently searched ( [ %], [ %], and ( %) meta-analyses, respectively). in addition to the search of electronic databases, meta-analyses ( %) reported screening the reference lists of included studies, and ( %) reported hand-searching journals. about one-third of the meta-analyses (n = , %) reported searching for grey literature: ( %) conference abstracts, ( %) registries, and ( %) contacted experts. for meta-analyses ( %), the authors reported that they did not restrict their searches by language. methodological quality or risk of bias of included studies was assessed in ( %) meta-analyses. for the meta-analyses including rcts and nrsi, risk of bias was assessed in ( %) with assessing risk of bias for rcts only. rcts were assessed with the cochrane risk of bias tool in ( %) meta-analyses. the assessment of risk of bias involved the same tool for both rcts and nrsi in ( %) meta-analyses. for the assessment of nrsi, a variety of tools were used. the most frequently used tool was the newcastle-ottawa scale (n = ). grade and the cochrane collaboration risk of bias tool were used in and meta-analyses, respectively. in meta-analyses, authors used other tools; in , they developed their own tools; and in , they were unclear about the methods used for assessing methodological quality/risk of bias. overall, the authors have considered the risk of confounding bias in their risk of bias assessment in meta-analyses ( %). of the meta-analyses with an assessment of risk of bias, ( %) reported having performed it in duplicate. for meta-analyses ( %), the authors did not clearly report the design for each individual study. among the metaanalyses that included both nrsi and rcts (n = ), for ( %), the results of nrsi and rcts were combined. concerning nrsi combined, meta-analyses ( %) included only cohort studies and only prospective cohort studies; meta-analyses ( %) combined cohort and case-control studies, and ( %) included all types of nrsi. the other meta-analyses ( %) included "observational studies" (without further details) (n = , %), "prospective and retrospective studies" (n = , %), and only "retrospective studies" (n = , %). for meta-analyses ( %), whether crude or adjusted estimates of treatment effect from the nrsi were used for the meta-analysis was unclear or not reported. for the remaining meta-analyses, the authors reported combining crude and adjusted estimates for ( %) , only adjusted estimates for ( %) , and only crude estimates for ( %). for meta-analyses ( %), the authors nrsi non-randomized studies of intervention; rcts randomized controlled trials extracted both the crude and adjusted estimates and used them separately in meta-analyses. among the meta-analyses involving adjusted estimates, ( %) did not report the confounding factors adjusted for. a random-effects model was used for half of the metaanalyses (n = ). for ( %), a fixed-effects model was used primarily but then replaced with a randomeffects model if high heterogeneity was observed in the model. for meta-analyses ( %), the authors used both fixed-and random-effects models, and for ( %), a fixed-effects model. the type of model was not reported or was unclear for meta-analyses ( %). we found network meta-analyses ( %). almost all meta-analyses assessed heterogeneity (n = , %). the i statistic was used in meta-analyses ( %), cochran q χ test in ( %), and between-study variance τ in ( %). heterogeneity was explored in meta-analyses ( %) by subgroup analyses (n = , %), sensitivity analyses (n = , %) and meta-regression analyses (n = , %). for of ( %) meta-analyses combining results from rcts and nrsi, a subgroup or sensitivity analysis was based on the type of study (rct vs nrsi). for meta-analyses ( %), subgroup or sensitivity analyses were based on the type of nrsi included. reporting bias was assessed in meta-analyses ( %) by standard funnel plots (n = , %), egger's test (n = , %), or begg's test (n = , %). overall, of the meta-analyses ( %) including or more studies reported having assessed reporting bias. we systematically assessed key methodological components of a large sample of therapeutic metaanalyses including nrsi in a variety of medical areas. our results highlight some important methodological shortcomings. only % of the meta-analyses reported having searched for grey literature. specific points related to the inclusion of nrsi raise concerns, with % of the meta-analyses not reporting the study design of the included nrsi, and % not reporting whether crude or adjusted estimates were combined. to the best of our knowledge, no previous study has comprehensively assessed both key methodological components common to all systematic reviews and elements specific to the inclusion of non-randomized studies. other studies that previously evaluated methods or reporting of systematic reviews including nrsi concentrated on the reporting of harms [ , ] and on systematic reviews in psychiatric epidemiology [ ] . our study has some limitations. the representativeness of our sample could be debated because we searched for studies in only one online database (medline), and limited our selection to meta-analyses in english. in addition, for the assessment of the methods, we depended completely on the reporting; we did not assess protocols or contact the authors if methods were not clearly reported. even though poor reporting does not necessarily reflect poor conduct, it may severely limit the reader's comprehension of the systematic review process [ ] . before being able to apply the results of any metaanalysis to patient care, health professionals need to evaluate the credibility of the methods of the metaanalysis [ ] . one of the key methodological elements is the search for relevant studies. because not all studies (and particularly those with negative results) are published in scientific journals, a meta-analysis must involve a search for grey literature to try to avoid such publication bias (a type of reporting bias) [ , ] . however, we found that only % of our meta-analyses reported having searched for grey literature. because of no mandatory registration for nrsi as for rcts, most nrsi are not registered, so searching for grey literature of nrsi is difficult [ ] . however, a recent study found that for % of the observational studies registered at clinicaltrials.gov, unpublished results could be retrieved [ ] . in contrast, we found that many meta-analyses assessed reporting bias ( %). reviewers may have compensated for the absence of searching for grey only cohort studies ( ) ( ) ( ) including also case-control studies ( ) ( ) ( ) including all types of nrsi ( ) ( ) ( ) other ( ) ( ) ( ) "observational studies" ( ) ( ) ( ) "prospective and retrospective studies" ( ) ( ) ( ) "retrospective studies" ( ) ( ) ( ) did not clearly report design for each study literature by assessing reporting bias. evaluating reporting bias does not exempt the reviewers from searching for grey literature because the assessment of funnel plot asymmetry may be subjective and statistical methods to test for asymmetry of the plot may lack power [ , ] . another critical part of the systematic review process is assessing the methodological quality or risk of bias of the studies included, because the validity of the meta-analysis could be questionable with problems in the design and conduct of individual studies [ ] . we found that % of our meta-analyses reported having assessed the methodological quality or risk of bias but only ( %) considered the risk of confounding bias in their assessment. the cochrane collaboration has recognized the need to improve the assessment of risk of bias for nrsi and is currently developing a tool for this. finally, we found specific issues related to the inclusion of nrsi. in % of the meta-analyses, the study design for each included study was unclear. the risk of bias may vary depending on the type of nrsi, with case-control studies generally considered as having a higher risk of bias than cohort studies. a description of the type of studies included in the meta-analysis is crucial. in addition, nrsi are prone to confounding: an imbalance in prognostic factors associated with the outcome of interest [ ] . nrsi are expected to at least present adjusted estimates from multivariate analyses [ , ] . many of our meta-analyses ( %) did not report or were unclear about whether the crude or adjusted estimates of nrsi were combined. among the meta-analyses involving adjusted estimates, % did not report the confounding factors adjusted for. this information was likely poorly reported in the individual studies, but then the reviewers should contact the authors for clarification or report it clearly in the meta-analysis. some key methodological components of the systematic review processsearch for grey literature, description of the type of nrsi included, assessment of risk of confounding bias and reporting of whether crude or adjusted estimates were combined-are not adequately reported in meta-analyses including nrsi. attention should be paid to improving these elements in such meta-analyses to have an increased confidence in their results. not applicable. this article reports a meta-research study. not needed. this study does not include human participants. data are available upon request for academic researchers. study id the preventive effect of statin therapy on new-onset and recurrent atrial fibrillation in patients not undergoing invasive cardiac interventions: a systematic review and meta-analysis an institutional analysis and systematic review with meta-analysis of pneumatic versus hydrostatic reduction for pediatric intussusception bayesian methods affirm the use of percutaneous coronary intervention to improve survival in patients with unprotected left main coronary artery disease same-day discharge after percutaneous coronary intervention: a meta-analysis efficacy and effectiveness of seasonal and pandemic a (h n ) influenza vaccines in low and middle income countries: a systematic review and meta-analysis systematic review and meta-analysis of transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis drug-eluting stents versus coronary artery bypass graft surgery in left main coronary artery disease: a meta-analysis of early outcomes from randomized and nonrandomized studies optimal dosing of antibiotics in critically ill patients using continuous/extended infusions: a systematic review and meta-analysis association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis transanal endorectal pull-through versus transabdominal approach for hirschsprung's disease: a systematic review and meta-analysis use of peritoneal dialysis in aki: a systematic review a systematic review and meta-analysis of biological treatments targeting tumour necrosis factor alpha for sciatica stroke prevention by percutaneous closure of patent foramen ovale: a systematic review and meta-analysis statins in the prevention of dementia and alzheimer's disease: a meta-analysis of observational studies and an assessment of confounding roux-en-y versus billroth i reconstruction after distal gastrectomy for gastric cancer: a meta-analysis a meta-analysis comparing meniscal repair with meniscectomy in the treatment of meniscal tears: the more meniscus, the better outcome? combination of radiofrequency ablation with transarterial chemoembolization for hepatocellular carcinoma: a meta-analysis extracorporeal membrane oxygenation for severe respiratory failure in adult patients: a systematic review and meta-analysis of current evidence statin use and risk of bladder cancer: a meta-analysis statin use and risk of kidney cancer: a meta-analysis of observational studies and randomized trials postoperative use of the chemopreventive vitamin k analog in patients with hepatocellular carcinoma aspirin use and risk of age-related macular degeneration: a meta-analysis late thrombosis after double versus single drug-eluting stent in the treatment of coronary bifurcations: a meta-analysis of randomized and observational studies should noncurative resection of the primary tumour be performed in patients with stage iv colorectal cancer? a systematic review and meta-analysis surgical cytoreduction for recurrent epithelial ovarian cancer the association between dietary patterns and type diabetes: a systematic review and meta-analysis of cohort studies risk of bleeding on triple antithrombotic therapy after percutaneous coronary intervention/ stenting: a systematic review and meta-analysis a meta-analysis of outcomes of endovascular abdominal aortic aneurysm repair in patients with hostile and friendly neck anatomy surgical treatment and survival in patients with liver metastases from neuroendocrine tumors: a meta-analysis of observational studies segmentectomy or lobectomy for early stage lung cancer: a meta-analysis systematic review and meta-analysis of laparoscopic versus open colectomy with end ileostomy for non-toxic colitis risk of cardiovascular disease from antiretroviral therapy for hiv: a systematic review reduced esophageal cancer incidence in statin users, particularly with cyclo-oxygenase inhibition one versus double burr holes for treating chronic subdural hematoma meta-analysis a meta-analysis of reverse breech extraction to deliver a deeply impacted head during cesarean delivery preoperative use of anti-tnf therapy and postoperative complications in inflammatory bowel diseases: a meta-analysis meta-analysis of antibiotics and the risk of community-associated clostridium difficile infection laparoscopic right colectomy: a systematic review and meta-analysis of observational studies comparing two types of anastomosis infliximab versus cyclosporine as rescue therapy in acute severe steroid-refractory ulcerative colitis: a systematic review and meta-analysis the role of thiopurines in reducing the need for surgical resection in crohn's disease: a systematic review and meta-analysis the effect of anesthetic technique on survival in human cancers: a meta-analysis of retrospective and prospective studies outcome of cervicocranial artery dissection with different treatments: a systematic review and metaanalysis sulbactam-based therapy for acinetobacter baumannii infection: a systematic review and meta-analysis cytoreductive surgery and hipec for peritoneal metastases combined with curative treatment of colorectal liver metastases: systematic review of all literature and meta-analysis of observational studies cabergoline use and risk of fibrosis and insufficiency of cardiac valves : meta-analysis of observational studies vitamin d treatment and mortality in chronic kidney disease: a systematic review and meta-analysis the effect of anti-tumor necrosis factor alpha agents on postoperative anastomotic complications in crohn's disease: a systematic review association of sulphonylurea treatment with all-cause and cardiovascular mortality: a systematic review and meta-analysis of observational studies comparison of clinical outcome between simultaneous-bilateral and staged-bilateral total knee arthroplasty: a systematic review of retrospective studies meta-analysis: colonoscopic post-polypectomy bleeding in patients on continued clopidogrel therapy bisphosphonates and risk of subtrochanteric, femoral shaft, and atypical femur fracture: a systematic review and meta-analysis use of thiopurines and risk of colorectal neoplasia in patients with inflammatory bowel diseases: a meta-analysis antivenom therapy of carpet viper (echis ocellatus) envenoming: effectiveness and strategies for delivery in west africa laparoscopic total gastrectomy versus open total gastrectomy for cancer: a systematic review and meta-analysis systematic review and meta-analysis of robotic surgery compared with conventional laparoscopic and open resections for gastric carcinoma effectiveness of haemophilus influenzae type b vaccines administered according to various schedules: systematic review and meta-analysis of observational data safety and efficacy of early pharmacological thromboprophylaxis in traumatic brain injury: systematic review and meta-analysis urgent surgery compared with fibrinolytic therapy for the treatment of left-sided prosthetic heart valve thrombosis: a systematic review and meta-analysis of observational studies the role of statins in prevention and treatment of community acquired pneumonia: a systematic review and meta-analysis meta-analysis of clinical outcomes of intravenous recombinant tissue plasminogen activator for acute ischemic stroke: within h versus - . h anterior corpectomy versus posterior laminoplasty for multilevel cervical myelopathy: a systematic review and meta-analysis drugs for attention deficit-hyperactivity disorder do not increase the mid-term risk of sudden death in children: a meta-analysis of observational studies laparoscopic distal pancreatectomy and pancreatoduodenectomy: is it worthwhile? a meta-analysis of laparoscopic pancreatectomy non-steroidal anti-inflammatory drugs and chronic kidney disease progression: a systematic review robot-assisted hysterectomy compared to open and laparoscopic approaches: systematic review and meta-analysis staging laparoscopy for the management of early-stage ovarian cancer: a metaanalysis a systematic review and meta-analysis of en-bloc vs intralesional resection for giant cell tumor of bone of the distal radius antiplatelets versus anticoagulants for the treatment of cervical artery dissection: bayesian meta-analysis does off-pump coronary revascularization reduce mortality in re-operative coronary artery surgery? a meta-analysis of observational studies benefits of early tracheotomy: a meta-analysis based on observational studies meta-analysis of staged versus combined carotid endarterectomy and coronary artery bypass grafting the effect of tuberculosis treatment on virologic and cd + cell count response to combination antiretroviral therapy: a systematic review the effect of tuberculosis treatment at combination antiretroviral therapy initiation on subsequent mortality: a systematic review and meta-analysis dabigatran for periprocedural anticoagulation following radiofrequency ablation for atrial fibrillation: a meta-analysis of observational studies is laparoscopic approach for pancreatic insulinomas safe? results of a systematic review and meta-analysis long-term survival in video-assisted thoracoscopic lobectomy vs open lobectomy in lung-cancer patients: a meta-analysis effect of bariatric surgery on oncologic outcomes: a systematic review and meta-analysis reduced risk of colorectal cancer with use of oral bisphosphonates: a systematic review and metaanalysis laparoendoscopic single-site adrenalectomy versus conventional laparoscopic surgery: a systematic review and meta-analysis of observational studies a meta-analysis comparing bilateral internal mammary artery with left internal mammary artery for coronary artery bypass grafting combined portal vein resection for hilar cholangiocarcinoma: a meta-analysis of comparative studies patients get more long-term benefit from central pancreatectomy than distal resection: a meta-analysis the risk of congenital malformations associated with exposure to beta-blockers early in pregnancy: a meta-analysis dose-risk and duration-risk relationships between aspirin and colorectal cancer: a meta-analysis of published cohort studies antidepressant use and diabetes mellitus risk: a meta-analysis metformin and reduced risk of hepatocellular carcinoma in diabetic patients: a meta-analysis use of nonsteroidal anti-inflammatory drugs and bladder cancer risk: a meta-analysis of epidemiologic studies meta-analysis of clinical studies comparing coronary artery bypass grafting with percutaneous coronary intervention in patients with end-stage renal disease liver transplantation versus liver resection in the treatment of hepatocellular carcinoma: a meta-analysis of observational studies vitamin d supplementation and mortality risk in chronic kidney disease: a meta-analysis of observational studies statin therapy is beneficial for the prevention of atrial fibrillation in patients with coronary artery disease: a meta-analysis the value of scheduled repeat cranial computed tomography after mild head injury: single-center series and meta-analysis endogenous testosterone level and testosterone supplementation therapy in chronic obstructive pulmonary disease (copd): a systematic review and meta-analysis treatment and management outcomes of tibial eminence fractures in pediatric patients: a systematic review the immunogenicity of anti-tnf therapy in immune-mediated inflammatory diseases: a systematic review of the literature with a meta-analysis integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis practical role of mutation analysis for imatinib treatment in patients with advanced gastrointestinal stromal tumors: a meta-analysis plasma vitamin d levels, menopause, and risk of breast cancer: dose-response meta-analysis of prospective studies crohn's disease and ulcerative colitis are associated with elevated standardized mortality ratios: a meta-analysis meta-analysis of plasma to red blood cell ratios and mortality in massive blood transfusions for trauma systemic sclerosis (scleroderma) and cancer risk: systematic review and meta-analysis of observational studies systematic review and meta-analysis of intraoperative peritoneal lavage for colorectal cancer staging iodine and mental development of children years old and under: a systematic review and meta-analysis association between qrs duration and outcome with cardiac resynchronization therapy: a systematic review and meta-analysis cerebral microbleeds and recurrent stroke risk: systematic review and meta-analysis of prospective ischemic stroke and transient ischemic attack cohorts treatment outcomes of treatment-naive hepatitis c patients co-infected with hiv: a systematic review and meta-analysis of observational cohorts thromboembolic events and cardiovascular mortality in inflammatory bowel diseases: a meta-analysis of observational studies outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of , patients enrolled in randomized clinical trials and observational studies the effects of pre-and postoperative fibrinogen levels on blood loss after cardiac surgery: a systematic review and meta-analysis association between point-of-care crp testing and antibiotic prescribing in respiratory tract infections: a systematic review and meta-analysis of primary care studies contrast-induced acute kidney injury and risk of adverse clinical outcomes after coronary angiography: a systematic review and meta-analysis inflammatory cytokines and risk of coronary heart disease: new prospective study and updated meta-analysis carbapenem resistance and mortality in patients with acinetobacter baumannii infection: systematic review and meta-analysis adiponectin and risk of stroke: prospective study and meta-analysis nonsteroidal anti-inflammatory drugs and risk of ovarian cancer: systematic review and meta-analysis of observational studies antidepressant use and new-onset diabetes: a systematic review and meta-analysis systematic review of hepatocellular carcinoma mortality rates among hepatitis b virus-infected renal transplant recipients, with supplemental analyses of liver failure and all-cause mortality bisphosphonate use and risk of colorectal cancer: a systematic review and meta-analysis cancer risk for patients using thiazolidinediones for type diabetes: a meta-analysis menopausal hormone therapy and risk of endometrial cancer insulin therapy and risk of prostate cancer: a systematic review and meta-analysis of observational studies analgesic use and the risk of kidney cancer: a meta-analysis of epidemiologic studies fertility treatment and childhood cancer risk: a systematic meta-analysis oral contraceptive pills as primary prevention for ovarian cancer: a systematic review and meta-analysis use of insulin and insulin analogs and risk of cancer -systematic review and meta-analysis of observational studies use of bisphosphonates and the risk of osteonecrosis among cancer patients: a systemic review and meta-analysis of the observational studies risk of osteonecrosis in patients taking bisphosphonates for prevention of osteoporosis: a systematic review and meta-analysis immunogenicity of monoclonal antibodies against tumor necrosis factor used in chronic immune-mediated inflammatory conditions: systematic review and meta-analysis effects of asthma severity, exacerbations and oral corticosteroids on perinatal outcomes consumption of omega- fatty acids and the risk of skin cancers: a systematic review and meta-analysis statins use and risk of depression: a systematic review and meta-analysis statins and primary liver cancer: a meta-analysis of observational studies reproductive and exogenous hormone factors in relation to risk of meningioma in women: a meta-analysis oral contraceptive use and uterine leiomyoma risk: a meta-analysis based on cohort and case-control studies clinical risk factors of delayed gastric emptying in patients after pancreaticoduodenectomy: a systematic review and meta-analysis relationship between use of antidepressants and risk of fractures: a meta-analysis rheumatoid factor and response to tnf antagonists in rheumatoid arthritis: systematic review and meta-analysis of observational studies statin use and the risk of biochemical recurrence of prostate cancer after definitive local therapy: a meta-analysis of eight cohort studies the protective effect of alcohol on developing rheumatoid arthritis: a systematic review and meta-analysis preoperative statin therapy is associated with lower requirement of renal replacement therapy in patients undergoing cardiac surgery: a meta-analysis of observational studies statins are associated with reduced risk of gastric cancer: a systematic review and meta-analysis acid-suppressive medications and risk of oesophageal adenocarcinoma in patients with barrett's oesophagus: a systematic review and meta-analysis statins are associated with reduced risk of esophageal cancer, particularly in patients with barrett's esophagus: a systematic review and meta-analysis statins are associated with a reduced risk of hepatocellular cancer: a systematic review and meta-analysis association of statin use with risk of dementia: a meta-analysis of prospective cohort studies insulin therapy and risk of colorectal cancer: an updated meta-analysis of epidemiological studies bisphosphonate treatment and risk of esophageal cancer: a meta-analysis of observational studies the association between histamine receptor antagonist use and clostridium difficile infection: a systematic review and meta-analysis beta-adrenergic receptor antagonists and fracture risk: a meta-analysis of selectivity, gender, and site-specific effects does early life exposure to antibiotics increase the risk of eczema? a systematic review adverse peri-operative outcomes following elective total hip replacement in diabetes mellitus: a systematic review and meta-analysis of cohort studies statin use and risk of parkinson's disease: a meta-analysis of observational studies myocardial infarction and individual nonsteroidal anti-inflammatory drugs meta-analysis of observational studies a systematic review and meta-analysis on primary percutaneous coronary intervention of an unprotected left main coronary artery culprit lesion in the setting of acute myocardial infarction insulin therapy contributes to the increased risk of colorectal cancer in diabetes patients: a meta-analysis flavonol intake and the risk for stroke: a meta-analysis of cohort studies tricyclic antidepressant use and risk of fractures: a meta-analysis of cohort and case-control studies statins are associated with reduced risk of gastric cancer: a meta-analysis isoflavone consumption and risk of breast cancer: a dose-response meta-analysis of observational studies association between use of benzodiazepines and risk of fractures: a meta-analysis acid suppressive drugs and gastric cancer: a meta-analysis of observational studies acid-suppressive therapy is associated with spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis vitamin d intake and risk of type diabetes: a meta-analysis of observational studies pregnancy outcome following loop electrosurgical excision procedure (leep) a systematic review and meta-analysis aspirin and non-aspirin nsaids increase risk of colonic diverticular bleeding: a systematic review and meta-analysis effects of percutaneous revascularization of chronic total occlusions on clinical outcomes: a meta-analysis comparing successful versus failed percutaneous intervention for chronic total occlusion anaemia, prenatal iron use, and risk of adverse pregnancy outcomes: systematic review and meta-analysis proton pump inhibitors and the risk of hospitalisation for community-acquired pneumonia: replicated cohort studies with meta-analysis early application of airway pressure release ventilation may reduce mortality in high-risk trauma patients: a systematic review of observational trauma ards literature meta-analysis of joint preservation versus arthroplasty for the treatment of displaced -and -part fractures of the proximal humerus systematic review of clofazimine for the treatment of drug-resistant tuberculosis effect of oral appliances on blood pressure in obstructive sleep apnea: a systematic review and meta-analysis effects of deep brain stimulation in dyskinetic cerebral palsy: a meta-analysis rasburicase in tumor lysis syndrome of the adult: a systematic review and meta-analysis a systematic review and meta-analysis of hybrid aortic arch replacement effects of monitoring strategies on seizures in pregnant women on lamotrigine: a meta-analysis estrogen and selective estrogen receptor modulators (serms) for the treatment of acromegaly: a metaanalysis of published observational studies survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: a meta-analysis effectiveness of seasonal influenza vaccines in children -a systematic review and meta-analysis different combined oral contraceptives and the risk of venous thrombosis: systematic review and network meta-analysis strategies for reducing treatment default in drug-resistant tuberculosis: systematic review and metaanalysis efficacy of adoptive immunotherapy with donor lymphocyte infusion in relapsed lymphoid malignancies meta-analysis: the safety and efficacy of dilation in eosinophilic oesophagitis prevalence of complications in neuromuscular scoliosis surgery: a literature meta-analysis from the past years a systematic review and meta-analysis on the safety and efficacy of the frozen elephant trunk technique in aortic arch surgery long-term outcome of one-piece implants. part ii: prosthetic outcomes. a systematic literature review with meta-analysis determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis prevalence and factors associated with glucocorticoids (gc) use in systemic sclerosis (ssc): a systematic review and meta-analysis of cohort studies and registries efficacy and durability of radiofrequency ablation for barrett's esophagus: systematic review and meta-analysis biologic grafts for ventral hernia repair: a systematic review a meta-analysis of observational intra-arterial stroke therapy studies using the merci device, penumbra system, and retrievable stents use of combination neonatal prophylaxis for the prevention of mother-to-child transmission of hiv infection in european high-risk infants a meta-analysis of operative versus nonoperative treatment in scapular neck fractures the role of postoperative radiation and chemoradiation in merkel cell carcinoma: a systematic review of the literature meta-analysis of three observational studies of amlodipine/valsartan in hypertensive patients with additional risk factors can statins improve outcomes after isolated cardiac valve surgery? a systematic literature review combined anticoagulation and antiplatelet therapy for high-risk patients with atrial fibrillation: a systematic review comparative effectiveness of interventions for children exposed to nonrelational traumatic events do children with uncomplicated severe acute malnutrition need antibiotics? a systematic review and meta-analysis does the application of incisional negative pressure therapy to high-risk wounds prevent surgical site complications? a systematic review stress ulcer prophylaxis in the intensive care unit: is it indicated? a topical systematic review cardiotoxicity in cancer patients treated with -fluorouracil or capecitabine: a systematic review of incidence, manifestations and predisposing factors can cardiac resynchronization therapy improve cognitive function? a systematic review antipsychotics: a real or confounding risk factor for venous thromboembolism? complications of pelvic organ prolapse surgery and methods of prevention adverse effects of the common treatments for polycystic ovary syndrome: a systematic review and meta-analysis effect of influenza vaccination of healthcare personnel on morbidity and mortality among patients: systematic review and grading of evidence fixed-dose combination antituberculosis therapy: a systematic review and meta-analysis effectiveness and harms of recombinant human bone morphogenetic protein- in spine fusion: a systematic review and meta-analysis treatment of anemia in patients with heart disease: a systematic review nutritional interventions for reducing gastrointestinal toxicity in adults undergoing radical pelvic radiotherapy therapy of endocrine disease: impact of iodine supplementation in mild-to-moderate iodine deficiency: systematic review and meta-analysis low-versus high-dose rituximab for rheumatoid arthritis: a systematic review and meta-analysis the use of postoperative topical corticosteroids in chronic rhinosinusitis with nasal polyps: a systematic review and meta-analysis no consistent evidence of differential cardiovascular risk amongst proton-pump inhibitors when used with clopidogrel: meta-analysis risk of liver toxicity with the angiogenesis inhibitor pazopanib in cancer patients sexual dysfunction associated with second-generation antidepressants in patients with major depressive disorder: results from a systematic review with network meta-analysis vitamin and mineral supplements in the primary prevention of cardiovascular disease and cancer: an updated systematic evidence review for the u.s. preventive services task force endoscopic sphincterotomy plus balloon dilation versus endoscopic sphincterotomy for choledocholithiasis: a meta-analysis association between statin use and colorectal cancer risk: a meta-analysis of studies a meta-analysis of self-administered vs directly observed therapy effect on microbiologic failure, relapse, and acquired drug resistance in tuberculosis patients triple antithrombotic therapy versus double antiplatelet therapy after percutaneous coronary intervention with stent implantation in patients requiring chronic oral anticoagulation: a meta-analysis comparing minimally invasive and open transforaminal lumbar interbody fusion for treatment of degenerative lumbar disease: a meta-analysis transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis: a meta analysis statins and amyotrophic lateral sclerosis: a systematic review and meta-analysis the effect of flapless surgery on implant survival and marginal bone level: a systematic review and meta-analysis association of inhibitors of gastric acid secretion and higher incidence of necrotizing enterocolitis in preterm very low-birth-weight infants does tranexamic acid stop haemoptysis? thirty-day mortality after coronary artery bypass surgery in patients aged < years: results of a multicenter study and meta-analysis of the literature isotretinoin and risk for inflammatory bowel disease: a nested case-control study and meta-analysis of published and unpublished data contralateral carotid occlusion in endovascular and surgical carotid revascularization: a single centre experience with literature review and meta-analysis a trial of mercaptopurine is a safe strategy in patients with inflammatory bowel disease intolerant to azathioprine: an observational study, systematic review and meta-analysis does bcg vaccination protect against childhood asthma? final results from the manchester community asthma study retrospective cohort study and updated systematic review and meta-analysis prospective cohort study and meta-analysis of cyclic bleeding after laparoscopic supracervical hysterectomy vaccines for preventing influenza in people with asthma antiplatelet treatment for prevention of cerebrovascular events in patients with vascular diseases: a systematic review and meta-analysis biphasic versus monophasic defibrillation in out-of-hospital cardiac arrest: a systematic review and meta-analysis a meta-analysis of transcatheter closure of patent foramen ovale versus medical therapy for prevention of recurrent thromboembolic events in patients with cryptogenic cerebrovascular events observational studies in the era of randomized trials: finding the balance challenges in systematic reviews that assess treatment harms observational studies are complementary to randomized controlled trials observational studies: going beyond the boundaries of randomized controlled trials why we need observational studies to evaluate the effectiveness of health care a comparison of observational studies and randomized, controlled trials observational study designs for comparative effectiveness research: an alternative approach to close evidence gaps in head-and-neck cancer from randomized controlled trials to observational studies randomized clinical trials and observational studies: guidelines for assessing respective strengths and limitations revisiting issues, drawbacks and opportunities with observational studies in comparative effectiveness research potential bias of instrumental variable analyses for observational comparative effectiveness research the role of observational investigations in comparative effectiveness research. value health quality standards for real-world research. focus on observational database studies of comparative effectiveness should meta-analyses of interventions include observational studies in addition to randomized controlled trials? a critical examination of underlying principles observational studies in systematic [corrected] reviews of comparative effectiveness: ahrq and the effective health care program chronic subdural hematoma management: a systematic review and meta-analysis of patients systematic review and meta-analysis of perioperative and oncological outcomes of laparoscopic cryoablation versus laparoscopic partial nephrectomy for the treatment of small renal tumors macrolides and mortality in critically ill patients with community-acquired pneumonia: a systematic review and meta-analysis liberal versus restricted fluid resuscitation strategies in trauma patients: a systematic review and meta-analysis of randomized controlled trials and observational studies safety and effectiveness of recombinant human bone morphogenetic protein- for spinal fusion: a meta-analysis of individual-participant data risk of fracture with thiazolidinediones: an individual patient data meta-analysis a first look at the volume and cost of comparative effectiveness research in the united states meta-analysis of welldesigned nonrandomized comparative studies of surgical procedures is as good as randomized controlled trials randomized, controlled trials, observational studies, and the hierarchy of research designs meta-analyses of adverse effects data derived from randomised controlled trials as compared to observational studies: methodological overview comparison of evidence of treatment effects in randomized and nonrandomized studies when are observational studies as credible as randomised trials? observational studies using propensity score analysis underestimated the effect sizes in critical care medicine cochrane handbook for systematic reviews of interventions version . . [updated the cochrane collaboration methodology and reporting of systematic reviews and meta-analyses of observational studies in psychiatric epidemiology: systematic review room for improvement? a survey of the methods used in systematic reviews of adverse effects epidemiology and reporting characteristics of systematic reviews quality of reporting in systematic reviews of adverse events: systematic review meta-analysis of observational studies in epidemiology: a proposal for reporting. meta-analysis of observational studies in epidemiology (moose) group the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration preferred reporting items for systematic reviews and meta-analyses: the prisma statement development of amstar: a measurement tool to assess the methodological quality of systematic reviews participation of epidemiologists and/or biostatisticians and methodological quality of published controlled clinical trials can trial quality be reliably assessed from published reports of cancer trials: evaluation of risk of bias assessments in systematic reviews how to read a systematic review and meta-analysis and apply the results to patient care: users' guides to the medical literature making prospective registration of observational research a reality public availability of results of observational studies evaluating an intervention registered at clinicaltrials.gov the appropriateness of asymmetry tests for publication bias in meta-analyses: a large survey in an empirical evaluation of the funnel plot, researchers could not visually identify publication bias incorporation of assessments of risk of bias of primary studies in systematic reviews of randomised trials: a cross-sectional study the cochrane collaboration's tool for assessing risk of bias in randomised trials assessing the quality of reports of randomized clinical trials: is blinding necessary? grading quality of evidence and strength of recommendations the newcastle-ottawa scale (nos) for assessing the quality of nonrandomised studies in meta-analyses philippe ravaud is director of the french equator centre and a member of the equator network steering group. the researchers did not receive external sources of funding. the authors declare that they have no competing interests.authors' contribution tf was involved in the study conception, study selection, data extraction, interpretation of results, and drafting the manuscript. pr was involved in the study conception, interpretation of the results, and drafting the manuscript. cr was involved in data extraction. ep was involved in data analysis. ad was involved in the study conception, interpretation of the results, and drafting the manuscript. all authors read and approved the final manuscript.• we accept pre-submission inquiries • our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord- -jfy iviy authors: julka-anderson, naman title: how covid- is testing and evolving our communication skills date: - - journal: j med imaging radiat sci doi: . /j.jmir. . . sha: doc_id: cord_uid: jfy iviy the covid- pandemic forced us, as health care professionals and members of the general public, to adapt. simple things we take for granted have become more difficult. as pressures increased for health care professionals, conversations and decisions have become tougher. this brought the need to adapt working practices and find ways to continue providing compassionate patient-centred care remotely. in uk radiotherapy departments, radiation therapist (review radiographer)-led clinics moved to telephone-based clinics to reduce the time spent by patients in a hospital environment. this required setting up a "virtual" clinic room with patients by removing distractions and setting boundaries for the conversation. we have had to adapt our communication skills quickly as picking up on nonverbal cues is not possible through the phone. it can be challenging to understand feelings through the tone of a patient's voice and empathise accordingly. the pandemic has forced patients to slow down and really focus on themselves which has led to picking up physical and mental health changes earlier. this is one of the many positive outcomes that can be drawn from the pandemic. although we have changed how we work, ultimately we are still here to help our patients. on march rd , the united kingdom (uk) went into 'lockdown' in response to the covid- pandemic. it forced all of us, as healthcare professionals and members of the general public, to change our ways in one way or another. simple things such as the weekly food shop became more difficult. for healthcare professionals, conversations and decisions began to get a lot tougher, pressures increased. we started to feel the effects of 'moral injuries' a form of psychological distress, from actions or lack of actions that violates a person's moral code and affects our mental health ( , ) . covid- brought with it the need to adapt our working practices and adjust to the new needs of ourselves and our patients. in the uk, radiotherapy patients are reviewed weekly by radiation oncologists and through radiation therapist (review radiographer) led clinics. a review radiographer has advanced skills and qualifications in symptom management, triage, emotional support and sign posting ( ) . most radiotherapy patients are reviewed on a weekly basis with input from radiation oncologist where required. as a radiation therapist (therapeutic radiographer) and member of the radiotherapy review team, i see patients throughout their radiotherapy treatments to address their physical and emotional side effects. at the core of our skill set as review radiographers are welldeveloped listening and interpersonal skills. every review starts with the basics; making eye contact, smiling at the patient, listening and shaking their hand, to name a few… "hello, my name is naman, i'm a member of our treatment review team, i'm just going to take you to one of our counselling rooms to check-in with you and have a discussion about treatment side effects. if you have come in with someone today, they are more than welcome to join us if you feel comfortable with this." this was a normal pre-review conversation in the waiting area, before covid- . radiotherapy staff on treatment units began to work in personal protective equipment (ppe) such as masks and protective eyewear in order to minimise the risk of contracting or transmitting the virus. ppe is an uncomfortable, but necessary addition to our physical working environment that affects interactions with colleagues and patients. communication with patients is much more difficult as voices behind masks are muffled. patients who are hard of hearing or deaf are unable to read our lips. interactions between team members are hampered, impeding workflow and adding to tensions. this literal barrier to effective communication is a moral injury we faced on a daily basis through this pandemic. those of us in the radiotherapy review team have changed to telephone appointments to minimize time spent by patients in a hospital environment. telephone reviews aren't a new process within healthcare ( ); oncology teams use telephone triage when patients report treatment related side effects. triage calls need to be efficient in finding out the problem while providing reassurance -they have a standard narrative: what is going on and how long for, what needs to be done, refer on appropriately, document and reflect ( ) . radiotherapy reviews are usually face-to-face and are scheduled for each patient. they often cover much more than just physical side effects and help build up a rapport with the patient. they can cover healthy lifestyle advice, explore support networks, promote wellbeing and can help provide reassurance. face-to-face reviews provide the opportunity to pick up on non-verbal communication cues that you would miss through a telephone. in my opinion, radiotherapy reviews are more in depth than triage calls as they cover all aspects of a patient's care and side effects to help them live with and beyond cancer. despite the obvious barriers of ppe or a telephone, effective communication is vital to deliver patient centered care. communication is the cornerstone of life. it helps us build relationships, to find problems and find solutions. we learn how to communicate from what our parents or carers teach us. this develops as we experience the world socially and eventually through work. we all have unique journeys and experiences in life to make sense of an ever-changing world. we all have plans and ambitions for the future. covid- is a unique experience for all of us: plans and ambitions on hold, an ever-changing environment and uncertain vision of the future. the daily uncertainty, fear and changes have been exhausting. we do not know what tomorrow might bring. people with cancer are dealing with all of these covid- uncertainties on top of their diagnosis, treatments, side effects and everything that goes along with that. to go one step further, cancer patients can endure some form of lockdown during their cancer journey. the physical experience of lockdown to protect your health is nothing new to patients who have gone through systemic anticancer treatments that leave them with weakened immune systems. the experience of being locked down is new for other cancer patients. the uncertainty of not knowing whether treatment will be successful or whether they'll experience recurrence could be likened to the uncertainty surrounding a future coronavirus vaccine and effective treatments. we often talk to patients about adjusting to a 'new normal' after their treatment ends, but patients going through cancer treatment during a pandemic face a whole new set of challenges. in switching to telephone reviews we were concerned we would not pick up as much as an in-person review. addressing concerns face-to-face or through telephone shouldn't really be any different, should it? the british association for counselling and psychotherapy recently released a set of competencies on telephone and e-counselling ( ). although not designed for use by radiographers, it has helped us transform how we approach telephone reviews. we have been letting patients know a day in advance to expect a phone call from the review team. on the day of the review, after having read up on the patient's history and treatment plan, i then prepare to call the patient. while i'm pulling on my callcenter style headset, i like to take a moment to look at their id photo so i have their face in mind when i call them. we're due to catch up for a treatment review over the phone this morning, is now a good time? brilliant, this should take around - minutes. before we get started, are you sitting comfortably or is there somewhere in your home you want to sit for the duration of this phone call? if you need a pen and paper to write down any notes or to grab a drink, then now would be the time to grab what you need too. … is there anyone else with you joining in on this call that you feel comfortable having with you? okay … let's continue …" our new normal includes setting appropriate boundaries with time, surroundings, who can listen in on the review and awareness. we have to remember to summarize after important aspects of the conversation and give the patient time to write some of the information down. it is important to wait for anyone else in the background to ask any questions. it can be a real flowing conversation over the phone perhaps easier than face-to-mask, but it's not without its challenges… keeping the conversation on track can be more difficult; for many patients who are isolating we are tackling their loneliness as well as their treatment side effects. you might be the only person this patient has spoken to in a while. one patient i recall had no family in touch and no children. the only friends he had were the ones he'd meet at the pub which was now off limits. during our chat he began to tell me about his garden. i remember thinking briefly, i have a long list of tasks to get through today and live in a flat with no garden but this is important to him. i think "should i quickly google something about gardening?" then the patient says his wife used to love gardening and she made the garden look colorful and tidy when she was around…then i heard him crying through the phone. at this point it was difficult not to feel guilty that i couldn't do more. the use of silence and listening has become even more important; i wonder whether this patient could have opened up like this had we been speaking face-to-face? grief is difficult to overcome and stereotypes challenge all of us. the stereotype is that men don't cry. especially men of a certain generation, and especially not to other men. we are all having to live in the present, stop and notice what is around us. there are people like him everywhere, whether they have had cancer treatment or not. it isn't my job to talk about a patient's garden but by not cutting him off he got to talk about someone he loves and misses. it was sad and it upset me but it was an absolute privilege that while he was in his safe space, at home, he trusted me enough to confide in me and cry over the phone. i'm very lucky to have at least one person in my phone book who would answer and listen to me. the traditional view of face-to-face consultations by a healthcare professional has changed during this pandemic, potentially forever. change is inevitable, however uninvited it is. we all have had to adapt at what feels like breakneck speed. patients and staff have been forced to accept technology. some of our more 'mature' staff have been looking to younger staff to guide them. for some patients, seeing someone "in person" is their way of feeling looked after. it gives them the space to open up and engage with you. our new normal is a virtual review room where boundaries need to be drawn with the patient. distractions need to put aside. there are no more visual cues for you to pick up on and alter your approach. it is no longer eye contact and body language that we look for, but subtle changes in the tone of the patient's voice. it is difficult to empathize and console using just your voice. use of silence and listening are really important. however, i found that being silent on the call for too long, waiting for the patient to answer a probing question, led a patient to think i wasn't there anymore and she hung up on me. this was embarrassing and amusing but at least i've learnt that on the phone you can't be silent for too long. sporadic murmurs of agreement or support are often just as important as a fully formed answer. lockdown has meant many of our patients are less busy and are being forced to slow down and refocus on themselves. there is more time to sit and talk. perhaps the telephone helps erode some of the hesitancy and awkwardness of talking about openly themselves. for example, explaining how many times you open your bowels seems less intimate over the phone than face-to-face. i would argue we are uncovering more about side effects than we have before. patients have more time to think about they feel, what has changed, and what is on their mind. as we navigate the moral injuries that this pandemic deals us, it is possible to also sense some of the positive outcomes. for me, the bond between cancer patients and radiation therapists has grown stronger. cancer patients are risking their lives to come our department, and when they arrive they are treated by staff risking theirs. we have changed how we work, what skills we use to work, but behind a mask or telephone, we are still here to help our patients. moral injury managing mental health challenges faced by healthcare workers during covid- pandemic radiotherapy treatment review: a prospective evaluation of concordance between clinical specialist radiation therapist and radiation oncologist in patient assessments activity analysis of telemedicine in the uk what evidence is there on the effectiveness of different models of delivering urgent care? a rapid review british association for counselling & psychotherapy key: cord- - v ose authors: weston, dale; ip, athena; amlôt, richard title: examining the application of behaviour change theories in the context of infectious disease outbreaks and emergency response: a review of reviews date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: v ose background: behavioural science can play a critical role in combatting the effects of an infectious disease outbreak or public health emergency, such as the covid- pandemic. the current paper presents a synthesis of review literature discussing the application of behaviour change theories within an infectious disease and emergency response context, with a view to informing infectious disease modelling, research and public health practice. methods: a scoping review procedure was adopted for the searches. searches were run on pubmed, psychinfo and medline with search terms covering four major categories: behaviour, emergency response (e.g., infectious disease, preparedness, mass emergency), theoretical models, and reviews. three further top-up reviews was also conducted using google scholar. papers were included if they presented a review of theoretical models as applied to understanding preventative health behaviours in the context of emergency preparedness and response, and/or infectious disease outbreaks. results: thirteen papers were included in the final synthesis. across the reviews, several theories of behaviour change were identified as more commonly cited within this context, specifically, health belief model, theory of planned behaviour, and protection motivation theory, with support (although not universal) for their effectiveness in this context. furthermore, the application of these theories in previous primary research within this context was found to be patchy, and so further work is required to systematically incorporate and test behaviour change models within public health emergency research and interventions. conclusion: overall, this review identifies a range of more commonly applied theories with broad support for their use within an infectious disease and emergency response context. the discussion section details several key recommendations to help researchers, practitioners, and infectious disease modellers to incorporate these theories into their work. specifically, researchers and practitioners should base future research and practice on a systematic application of theories, beginning with those reported herein. furthermore, infectious disease modellers should consult the theories reported herein to ensure that the full range of relevant constructs (cognitive, emotional and social) are incorporated into their models. in all cases, consultation with behavioural scientists throughout these processes is strongly recommended to ensure the appropriate application of theory. the united kingdom (uk) national risk register details a broad range of threats to the public health and security of the uk incorporating infectious disease outbreaks (e.g., pandemics and emerging diseases), malicious attacks (e.g., terrorist incidents), and natural phenomena (e.g., extreme weather, earthquakes) [ ] . the risk of infectious disease outbreaks is so substantial that the uk national risk register ranks a pandemic outbreak as the number one high consequence civil emergency facing the uk (based on likelihood and probable impact [ ] . the coronavirus disease pandemic which, at the time of writing has led to , , confirmed cases and , deaths, presents a stark reminder of this public health threat [ ] . outbreaks of infectious disease, particularly those for which little or no pre-existing immunity existssuch as the covid- pandemicrepresent a significant risk to public health. for example: the - ebola outbreak in west africa led to over , cases with , deaths [ ] , while the ongoing outbreak in the democratic republic of congo has led to over deaths thus far [ ] ; since the identification of middle east respiratory syndrome coronavirus (mers-cov) in , associated deaths have been reported with cases across countries [ ] , and; although less severe than expected [ ] , the h n pandemic was estimated as responsible for between , - , deaths worldwide during the first months [ , ] . even when controlling for confounding factors (e.g., improvements in surveillance, communication infrastructure, etc.), the number of infectious disease outbreaks has substantially increased since to [ ] . similarly, deaths from terrorism have substantially increased from less than in to over , in (peaking with over , in [ ] ), and despite a decline in the number of individuals affected by natural disasters between and , the average death rate has increased over the same time period [ ] . given these trends, it is therefore critical to ensure that emergency preparedness, response and resilience is optimised to mitigate the occurrence and/or impact of these events. behavioural science represents one such broad method of mitigation. the importance of encouraging adaptive and protective behaviour change in response to public health emergencies is emphasised by the world health organisation (who), who provide risk communications guidelines designed to encourage individuals, families, and communities to act to protect themselves [ ] . this is echoed in the context of covid- , with michie and colleagues stating that: "human behaviour will determine how quickly covid- spreads and the mortality. therefore behavioural science must be at the heart of the public health response" [ ] . research in the behavioural sciences has focused on identifying barriers and facilitators to maximising public compliance with recommended emergency response and infection prevention behaviours. for example, decontamination behaviour (e.g. [ ] ), medication adherence (e.g., [ ] ), hand washing (e.g., [ ] ), social distancing/ avoidance behaviour (e.g., [ , ] ), and vaccination (e.g., [ , ] ), to name but a few. furthermore, in the context of infectious disease emergencies, mathematical models are used to both: a) understand and map out the spread and control of disease (incorporating human-to-human transmission) and, b) calculate the potential effectiveness of interventions (including behavioural interventions) to reduce the spread of the disease [ ] . considered together, the importance of human behaviour for emergency responseboth in terms of developing interventions and its relevance for modelling the potential efficacy of said interventionsis clear. however, there is still work to be done to optimise the incorporation of behavioural constructs in public health research, intervention design, and modelling. for example, despite medical research council guidelines recommending interventions be based on appropriate behaviour change theory [ ] (see also [ ] ), reference to theory is often absent in such interventions [ ] . indeed, michie and colleagues, pioneers in the field of identifying and integrating behaviour change theory and techniques in the context of health promotion, note that much intervention design is based on the principle of "it seemed like a good idea at the time", rather than a systematic consideration and assessment of the most appropriate routes to behaviour change ( [ ] , p. ). similarly, a limitation of traditional mathematical models is that they often do not allow for heterogeneous behavioural responses within a population [ ] . this assumption that human behaviour is homogenous can impact on the validity of these models. for instance, including a modest degree of fear-related flight behaviour (i.e., % of individuals in a model respond to fear of infection with flight) into a model in which fear of infection otherwise leads to hiding, caused projected disease incidence to rise to~ %, up from~ % in a model in which fear of infection led all individuals to hide [ ] . although some recent infectious disease models do incorporate social and cognitive predictors of the kinds of self-protective health behaviours that are associated with infectious disease control and emergency response (e.g., vaccination uptake, social distancing etc.), they are more commonly informed by literature from behavioural economics than psychology [ ] . that is not to say that the integration of theory is a silver bullet for the success of mitigation strategies and modelling. for example, there is mixed evidence concerning the efficacy of theory-based interventions (see [ ] , p for a summary), inconsistency that may be based on the relevance of the chosen theory for the behaviour in question [ ] . to illustrate this point, according to michie and colleagues, there are a total of behaviour change theories across the behavioural and social sciences [ ] . over the past three decades, multiple review papers and books have attempted to identify trends in theory use including those most frequently applied (e.g., [ , [ ] [ ] [ ] [ ] ). despite some commonalities in underlying psychological processes (michie and colleagues cede that many of the constructs identified within their book were different labels for overlapping constructs, [ ] ), this proliferation of competing theories and recommendations could indeed make it difficult for researchers, intervention designers, and modellers to decide which theories to use and in what context. this unfortunately leads to a catch- situation: we wish to encourage non-specialists to use appropriate psychological theories and approaches within their own disciplines, yet we fail to recognise the complex and confusing landscape of psychological theory. michie and colleagues have made great strides to simplify the process by which psychological theories are used to inform behavioural interventions [ ] . however, there are still a large number of behaviour change theories that were designed with specific applications in mind: for example, the behavioural-ecological model of adolescent aids prevention [ ] , the integrated theory of drinking behaviour [ ] , or the social ecological model of walking [ ] public health researchers, infectious disease modellers, and practitioners may therefore be understandably perplexed as to how best to model and examine or influence behaviour in the specific context of infectious disease outbreaks or emergency response. this current paper therefore seeks to present a synthesis of the behaviour change theories that are most commonly applied within an emergency response or infectious disease outbreak context. that is, focused specifically on using behaviour change theories to understand and influence individuals' engagement with protective health behaviours that are recommended during infectious disease outbreaks and public health emergencies. to identify these commonly applied theories, we conducted a scoping review of the existing literature, but with a particular focus on identifying reviews using behaviour change theory in an infectious disease or emergency response context. this approach is recognised as a method of distilling a substantial literature into a manageable summary of evidence for decision makers ( [ ] , see also [ ] ). although using this 'review of reviews' approach focused on secondary sources, which may have led to some relevant information being missed, it enabled us to reduce the quantity of papers identified in a large and highly diverse literature to a manageable level while still achieving a broad overview of the state of the art within the field. by dovetailing with weston and colleagues' recent review of the application of human behaviour within infectious disease models [ ] , the outcomes from this current review will enable us to make useful recommendations as to how psychological constructs, theory, and research can be used by public health practitioners, researchers modellers, to improve our understanding of human behaviour within the contexts of infectious disease outbreaks and emergency response. a scoping approach was adopted for our search. scoping reviews are recommended as a mechanism by which a given literature might be summarised for policy makers or practitioners [ ] . as the aim of this review was to summarise and synthesise the psychological literature on behaviour change to inform recommendations for public health researchers and modellers, the adoption of a scoping review framework was a logical and appropriate choice. the literature search was conducted using pubmed, psy-chinfo and medline databases on the th january . the databases were selected based on their coverage of discipline and context specific literature. each database was searched individually to ensure that all medical subject heading (mesh) terms were used effectively. the search terms covered four major categories: behaviour, emergency response (e.g., infectious disease, preparedness, mass emergency), theoretical models, and reviews. supplementary information provides the full list of search terms used for each database. within the theoretical model category, we a priori selected several existing behaviour change models that were either: a) frequently cited within the literature, or b) adjudged to be of particular relevance within the context of infectious disease and emergency preparedness based on the authors combined expertise in these areas. in addition, generic phrases and subject headings for theoretical modelling were included within each search strategy to ensure that papers that do not cite the most common behaviour change models would still be captured within our search. lastly, papers identified through other, non-systematic methods (e.g., some clearly relevant citations in papers, keyword google scholar searches) were also included to try to identify articles that were not indexed within these databases. as the initial search was run in , a condensed follow up search strategy was devised to identify seminal works in the field published since this date. given time and resource constraints in conducting this search, the strategy was designed to identify literature that closely corresponded to the output from the original selection process. for example, the strategy was simplified based on the broad search categories used in the original search, and as literature concerning human immunodeficiency virus (hiv)/ sexually transmitted infections (stis) was excluded from the original data extraction (see inclusion/ exclusion criteria section), the decision was taken to exclude these papers at the search strategy stage here. on / / the following search was conducted on google scholar, sorted by relevance, with a custom date range of - : "review* and behavio* and theor*, or models and infectious disease*, or emergenc* -hiv, -std, -sti"-given time and resource constraints, only the first pages of google scholar were screened, first for title, then for abstract, and finally full-text screening was conducted on any remaining papers. due to limitations concerning the use of wildcard operators (*) on google scholar in the initial top-up search, and the potential for covid- related review papers to have been published in the intervening period, a further optimised top-up search strategy was developed. this strategy consisted of the following two searches (specified for emergency response and infectious diseases respectively), conducted on google scholar on th - th may : review emergency theory behavior or behaviour. review disease theory behavior or behaviour. as for the previous top-up search, the first pages of google scholar were screened for each search (for a total of results). for the original search, duplicates were removed electronically, and all remaining papers were subjected to title and abstract screening by one author (ai) using the inclusion/ exclusion criteria. all papers retained for full text assessment were screened independently by two researchers (ai and dw) to increase the reliability of the selection process. any inconsistencies between the researchers were resolved through a joint discussion. for the top-up search, individual title, abstract, and full-text screening stages were conducted by the first author (dw). as for the original search, all papers retained for full text assessment were screened independently by two researchers (ai and dw) with any inconsistencies between the researchers resolved through a joint discussion. the inclusion/ exclusion criteria employed in the top-up search were the same as those used for the original search. for the optimised top-up search, individual title, abstract, and full-text screening stages were conducted by the first author (dw). due to time constraints imposed by the covid- pandemic, full text screening for this search was conducted by the first author alone. as for the initial top-up search, the same inclusion/ exclusion criteria were employed as used in the original review. the following inclusion/ exclusion criteria were used: (i) type of article: reviews (systematic, scoping and narrative) and meta-analysis. (ii) theoretical model/theory: the papers needed to present or apply a model or theory of behaviour change. leniency in this criterion was initially applied in so far as papers which clearly applied constructs that were adapted from theories/models, were also retained, but this was subsequently restricted to focus specifically on the presentation of behaviour change models/ theories (see original study selection section below). (iii)context: the papers needed to present or apply the theory/model to explain human behaviour in the context of emergency or infectious disease outbreaks. as per [ ] any reviews focusing on diseases that are not transferred from human-tohuman (e.g., vector borne) were excluded. (iv) target behaviour: preventive health behaviours during an emergency or outbreak (e.g. social distancing, vaccination and reducing social ties) were included in the review. (v) other: there were no restrictions on the date reviews were published or the population in question. reviews were included if they were written in the english language and involved human behaviour. for simplicity, papers exploring sti-related health behaviours (total: ) were pragmatically excluded wholesale following the initial screening of the original search as the majority were deemed either: irrelevant according to the above criteria ( ) , of unclear relevance to the researcher (ai) ( ) , or inaccessible to the researcher (ai) ( ) . for consistency, papers exploring sti-related health behaviours have also been excluded during subsequent screening of the top-up searches. based on data extracted as part of previous review work in this area (e.g., [ , ] ), the following information was extracted from the included papers in both the original and top-up stages: (i) title (ii) author (iii)number of studies included in the review (iv) target behaviour(s) (v) theories employed (vi) key outcomes/ conclusions regarding the utility of behaviour change models data concerning the theories employed was identified within the included papers using the original reviews' own definitions or conceptualisations of theory. that is, if an included review referenced a particular theory or model, it was subsequently included in our synthesis. reference to theory was either found in specific citations of theories used by individual papers incorporated within the review (commonly included in summary tables within the included papers), or as a broader framework used by included reviews to collate and synthesise the identified literature. key outcomes and conclusions regarding the utility of behaviour change models were identified similarly, using review authors' references to the theories they cite within their results and discussion sections. data from the included studies were synthesised to identify: a) the behaviour change theories most commonly employed to understand and influence protective health behaviours during public health emergencies and infectious disease outbreaks and, b) any (in) consistency in the reported utility of different behaviour change theories. a total of records were identified through database searching with an additional eight articles identified through other sources. following the removal of duplicate citations, papers were subjected to title/ abstract screening. thirteen papers were retained for full-text eligibility assessment by the first and second authors. following this assessment, one paper was excluded, leaving remaining papers [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] (see fig. ). during the conduct of this review, the focus evolved to be explicitly concerned with only the application of theories rather than a broader focus on theoretically-related constructs. subsequent reconsideration by the first author therefore led to three of these papers being excluded [ , , ] , as although they all presented constructs that are represented within behaviour change theories, none explicitly referenced theory. these papers are explicitly referenced here to signpost the interested reader to their existence. information concerning: (a) the article characteristics, (b) the application/ use of psychological theory within these reviews, (c) the total number of unique articles employing each behaviour change theory and, (d) a summary of the key conclusions regarding the utility of theory within each review, is collated and summarised in this results section. a total of approximately , papers were identified using the google scholar search. of these , , the first pages ( hits) were subjected to title screening. following this stage hits were retained for abstract screening, which yielded five papers for full-text review. following full-text review by the first and second author, two papers were retained for inclusion in this review [ , ] (see fig. ). these two papers were subsequently incorporated into a revision of the initial synthesis and analysis and are presented in table and the supplementary information alongside literature identified through the original screening process. the first pages of each optimised top-up search were subjected to title screening ( hits in total). following this stage, hits were retained for abstract screening, which yielded papers for full-text review. following full-text review by the first author, two papers were retained for inclusion in this review [ , ] (see fig. ). as part of the full-text review process, the decision was taken to exclude two reviews [ , ] which did examine the application of theory in a similar context to that of the two included reviews [ , ] . this decision was taken as the focus of these reviews were more on understanding behaviour during an emergency, rather than the primarily protective or preventative focus of this review. these citations are presented here, in order to signpost them to interested readers. as for the initial top-up process, the two included papers were incorporated into a revision of the synthesis and analysis presented within this manuscript and the accompanying supplementary information. the synthesis including both original and all top-up studies is presented together in the following sections. in addition to peer reviewed academic publications, the sample included reports published by the department of health, uk [ , ] and the european centre for disease prevention and control [ ] , and one review from within an unpublished doctoral thesis [ ] . six of the reviews cited in this synthesis had at least one author in common with another review cited herein [ - , , ] , with one [ ] explicitly cited as an update of another [ ] . to examine the extent to which the papers included in our review were sampling the same citations, this review [ ] forms part of a broader phd thesis in which it is presented as a chapter. given the focus of the chapter on conducting a systematic review of h n perceptions and responses, and the consistency in the theories identified within the review chapter and the thesis' introductory chapter, we elected to include only the specific review chapter in this synthesis. we looked across all papers to see how many citations were fully independent (that is, not cited in any other review included in this manuscript). to do this we either: a) examined the list of included studies provided by the authors of each systematic review, or; b) where such a list was not provided, we examined the full reference list for the manuscript. although the percentage of unique papers varied substantially from review to review, each paper had an average of . % unique papers (see table for the full breakdown). although heavily focused on h n pandemic influenza and vaccination behaviour, these papers did cover a wide range of health-related behaviours (e.g., hand hygiene, face mask wearing) across various infectious disease and public health emergency contexts (e.g., natural disasters, terrorism). specifically, papers [ - , , , , , ] looked at uptake of vaccination against influenza (primarily pandemic, but also including seasonal). one paper [ ] considered the relationship between risk perception and preventive behaviour related to sars and avian influenza (e.g., hand washing, diet, exercise, wearing face masks). four papers [ , [ ] [ ] [ ] also considered other outbreak preparedness behaviours in addition to vaccination (e.g. hand hygiene, non-pharmaceutical measures against influenza etc.). three papers [ , , ] investigated the application of theories/model in non-infectious disease emergencies and disasters (e.g., flood disaster preparedness, earthquake preparedness, climate change, fire preparedness, bushfire emergencies, tornado preparedness, & terrorism preparedness). all reviews were published between [ ] and [ ] [ ] [ ] and all except two [ , ] employed a systematic approach to data collection. in the first instance, we looked across the review papers to see which theories were cited by the highest number of reviews (regardless of the number of cited papers using each theory within each review, and incorporating mentions of particular theories as frameworks for synthesis as in [ , [ ] [ ] [ ] ). this initial examination revealed that the health belief model [ ] was explicitly represented in the most review papers (nine - [ , , , , - , , ] ), followed by the theory of planned behaviour [ ] (eight - [ , , , - , , ] ) and protection motivation theory [ ] (seven - [ - , - , ] ), precaution adoption process model [ ] (four - [ , [ ] [ ] [ ] ), and the common sense model of self-regulation [ ] (four - [ , , , ] ). a further two models were each included in three review papers: extended parallel process model [ ] (three - [ , , ] ), and the theory of reasoned action [ ] (three - [ , , ] ). all other models were cited two times or fewer (see table ) . next, we collated and examined the papers cited across all reviews to identify the most frequently cited theories overall. articles that the reviews specifically cited as including behavioural theories were collated from the nine reviews that extracted such data [ - , self-efficacy theory is listed as 'other' within this paper, but we have incorporated this within our review alongside the additional, explicit self-efficacy theory citation from another included review paper c although this is presented as the common sense model, distinct from the other self-regulation model citation within bults and colleagues' review, further examination of the original papers reveals they are based on the same underlying model, and so are integrated in our synthesis d examination of the reviews citing social cognitive theory [ , ] and the social cognitive model [ ] has revealed that these are distinct theories and are therefore included in our synthesis as such e the authors of these reviews briefly cite examples of additional theories before settling on the protection motivation theory and the protective action decision model respectively. only these two theories are included in this table and in our synthesis where there was close overlap between model/ theory names, we conducted a google search to determine whether the tiles likely reflect the same, or different, models. consequently, social ecological theory (see [ , ] ) and the social ecological resilience model [ ] have been included as separate models in this synthesis. on closer inspection, subjective expected utility theory [ ] and state dependent expected utility framework [ ] refer to the same paper, and so are collapsed together herein. precaution adoption theory [ ] and precaution adoption process model [ , , ] are interpreted as referring to the same theory and so are included together. [ ] [ ] [ ] ] ). thus, papers were not included either: a) if the reviews did not indicate that such papers included behavioural theories or b) from the reviews that did not provide detail on the theories used by their cited papers (specifically, [ , [ ] [ ] [ ] ). papers that were listed as including behavioural theory and were cited by multiple reviews (n = ) were only included once, leaving a total of unique papers which were listed by the various review authors as incorporating one or more behaviour change theories. see supplementary information for an overview of which theories were cited in multiple reviews, and for the overall number of times each theory was cited in a unique paper across all reviews. across the cited literature, four behaviour change theories were applied more than times. these were: when considering the application of behaviour change theories for research, the included reviews report mixed success. while all of the papers cited by [ ] were [ ] informed by theory, several other authors reported that relatively few papers included within their reviews explicitly use behaviour change theories [ , , , , ] . for example, one review found that only around one third of cited papers explicitly refer to a theoretical model [ ] and another failed to find any interventions that used behavioural frameworks in their development [ ] . nevertheless, where theory was cited, across reviews there was support for the utility of the most cited theories across reviews and within individual papers. particular support was provided in the key outcomes and conclusions across reviews for: health belief model [ - , , , , ] , the theory of planned behaviour [ - , , , ] , protection motivation theory [ - , , ] , and the common-sense model [ ] [ ] [ ] (see supplementary information for a summary of theory-related outcomes for each review cited herein). although this is based on key outcomes/ conclusions and not an exhaustive list of all successful theories reported within/ across reviews, the commonly applied behaviour change theories do seem to be identified as relevant for understanding and explaining human behaviour within an infectious disease and emergency response context. however, the use of these theories was not universally lauded: for example, one review argues that the health belief model, protection motivation theory and the theory of planned behaviour do not adequately allow for emotional factors in behavioural decision making (of the three, protection motivation theory does incorporate fear, however the impact of emotion is on threatappraisals rather than a direct effect of emotion on action [ ] ) [ ] . indeed, one review exploring the [ ] application of protection motivation theory for animal owners and emergency responders in the context of bushfire emergencies suggests that emotional attachment (to animals) could override adaptive responding [ ] . similarly, one review strongly supports the relevance of the extended parallel process model for disaster and emergency preparedness but draws on a study examining the mediating role of fear on the threatpreparedness relationship to argue for further work applying the extended parallel process model to look beyond just threat and efficacy in their applications [ ] . furthermore, although several papers do support the relevance of the theory of planned behaviour within this context (e.g., [ , , ] ), one review does identify inconsistent findings regarding the role of the theory of planned behaviour for predicting behaviour within their cited papers (but still advocates the relevance of this theory for vaccination behaviour) [ ] . in terms of intervention development, one review concludes that although there is clear evidence for the success of theory-based interventions for communicable disease control and prevention, there is no substantive difference in theories informing effective or ineffective interventions [ ] . rather than specific theories being of critical importance for intervention development, it is instead the role of theory that is important; positive effects were reported where theories were used to design and develop interventions, but more mixed effects were reported when theories were only used to evaluate interventions [ ] . this echoes points made by leppin and aro in their review of risk perceptions in relation to severe acute respiratory syndrome (sars) and avian influenza. specifically: ) few studies explicitly or theoretically define risk perceptions, ) there is a disproportionate focus on risk probability over risk severity and, ) there is a need for further work to empirically examine the role of risk perceptions as represented within multifactor models rather than just through bivariate relationships [ ] . overall, this literature synthesis yields two key conclusions. firstly, behaviour change theories are of clear relevance for understanding behaviour in the context of infectious diseases and emergency response. secondly, and related to the first conclusion, there is a definite requirement for further work to systematically examine, incorporate and test full behaviour change models within research and interventions in the context of infectious disease and emergency response. papers incorporating a total of different theories (in various combinations) were collated across these reviews. the health belief model, theory of planned behaviour, and protection motivation theory were the most cited theories both across reviews and by individual papers included within reviews. other theories that were commonly cited include: precaution adoption process model, extended parallel process model, theory of reasoned action, and social cognitive theory. although the authors indicate that papers were included in the review, no list of these papers was provided. given this, the full reference list of citations was searched following a synthesis of the key theory-related outcomes and conclusions, there was broad support for the applicability of the most commonly cited theories (listed above) within this context. however, despite this broad support for the applicability of these theories, several reviews reported low levels of explicit use of behaviour change theories in the research they cited. taken together, these results suggest that the most commonly cited theories reported herein represent an excellent starting point for practitioners and public health professionals looking to model and enact behaviour change in the context of infectious disease and emergency response. this point is explored in more detail in the recommendations subsection of the discussion. to the best of the authors' knowledge, this scoping review represents the first attempt to systematically collate review data concerning the application of behaviour change theories within a broad infectious disease and emergency response context. in this review we have synthesised the health behaviours, theories, and applications presented across review papers drawn from both peer reviewed journals and grey literature in the context of infectious disease and emergency response. this synthesis enables us to provide some key recommendations and suggestions for infectious disease modellers, researchers, and public health professionals looking to apply behaviour change theory to understand and influence behaviour in this context. looking across the reviews included in our synthesis provides a clear picture of the typical use of behaviour change theories across the current context. firstly, many papers included within these reviews do not seem to be explicitly based on a specific theory of behaviour change. secondly, whether we take a high-level approach (i.e., number of theories cited by multiple reviews) or a more granular approach (i.e., number of citations per theory across all reviews) to the synthesis, the conclusions are broadly the same. as per michie and colleagues, only a small number of theories were most commonly cited despite the broad number of theories available ( theories detailed within [ ] , and distinct theories cited at least once within our included review papers, although these may not all be present in michie and colleagues work [ ] ). specifically, three theories stand out as the most commonly applied: health belief model, theory of planned behaviour, and protection motivation theory. another four theories are also repeatedly, but less frequently, cited: precaution adoption process model, extended parallel process model, theory of reasoned action, and social cognitive theory. of these seven theories, four are consistent with the most frequently used theories as identified by michie and colleagues [ ] (theory of planned behaviour, health belief model, precaution adoption process model, & social cognitive theory), and with some of the theories cited as frequently used across other health behaviour contexts e.g., [ , ] (health belief model, theory of planned behaviour, & social cognitive theory). of the remaining theories, one (theory of reasoned action) is closely linked to the theory of planned behaviour (the latter having developed from the former [ ] ). the final two most cited theories -protection motivation theory and the extended parallel process model -are closely related (the latter builds on the former [ ] ) and both are particularly concerned with the processes underlying fear appeals and threat messaging, a focus with clear relevance in the context of this review. having identified the commonly applied theories, we subsequently conducted a rapid synthesis of the included reviews' key outcomes with regards to the utility of behaviour change theory. on the basis of this synthesis, we make two key conclusions. firstly, the most frequently cited theories do find broad (though not universal) support within the cited literature. secondly, despite this broad applicability, several reviews cited herein highlight the relative absence of behaviour change theory within research conducted in this context [ , , , , ] . indeed, several of the reviews included herein explicitly advocate further work to study the thorough application of both individual theories and a range of multivariable theories, considering the interrelationship between model factors/ components (e.g., [ , , , , [ ] [ ] [ ] ] ). overall, a clear take-home message from the current review is that there are a range of commonly applied behaviour change theories with broad support for their use within an infectious disease and emergency response context. in the following section, these findings are used to form the basis for recommendations concerning the use of behaviour change theory by researchers, practitioners, and modellers in both research and practice. based on the results of our synthesis, there are two broad categories of recommendations for future work applying and incorporating behaviour change theories into both: ) research and practice (i.e., understanding behaviour, and developing & deploying effective interventions), and; ) infectious disease modelling. furthermore, although most of the literature screening and synthesis for this review was conducted prior to the covid- pandemic, we are aware of some recent and relevant work detailing recommendations and guidance for the use of behavioural science to tackle covid- in practice. some of this work has also been incorporated into this section to signpost interested readers to additional material of relevance. behavioural science can play a critical role in combatting the effects of a global pandemic, such as covid- , both through informing our understanding of public perceptions of the virus, and through developing interventions to reduce barriers and facilitate uptake of recommended behaviours [ ] . indeed, in the context of covid- , west and colleagues indicate that in the absence of robust intervention data, behaviour change theories and constructs should be used to inform the development of policy and practice for increasing uptake of self-protective behaviours [ ] . unfortunately, however, multiple reviews cited herein lament the absence of behaviour change theory in work conducted to date [ , , , , ] , and advocate for the more in-depth study of various behaviour change theory within this context [ , , , , [ ] [ ] [ ] ] . our primary recommendation therefore reinforces that advocated in the literature cited herein. specifically, we recommend that researchers and practitioners working in the context of infectious disease and emergency response, should: a) draw on the available theoretical literature and; b) work with experts in behavioural science to inform both empirical work to understand behaviour, and the design and implementation of interventions to affect behaviour. this primary recommendation is supported by several additional recommendations, which are unpacked in the subsequent paragraphs. in describing the way forward for behaviour change theorising, michie and colleagues [ ] note that the most popular behaviour change theories are relatively context agnostic, and that there may be important insights to be taken from models that are more context dependent. in order to enhance the translation of research into public health practice, we therefore recommend that future research and intervention development should consider both general theories and theories that most closely fits the context of study. the theories identified within this review represent a mix of both context agnostic (e.g., health belief model, theory of planned behaviour) and some more context specific (e.g., protection motivation theory and extended parallel process model) theories, and would therefore seem to be a good starting point for researchers and practitioners working in this area. furthermore, although not a theory identified within the current review (see limitations section), the com-b (capability, opportunity, motivation and behaviour) model [ ] has been advocated as a key starting point for interventions to reduce the transmission of severe acute respiratory syndrome coronavirus (sars-cov- ) during the covid- pandemic (e.g., [ ] ). we would therefore further recommend considering the application of this theory when either conducting research or delivering research into practice. while these recommendations are consistent with the medical council guidelines [ ] , and echo recent work by michie and colleagues (e.g., [ , ] ), it is critically important to approach the incorporation of behaviour change theory -particularly within intervention designin a systematic fashion [ ] . indeed, one review included within our synthesis found that theory had a positive impact on the success of interventions when used at the design and development stage, relative to theory used only at the evaluation stage [ ] . to facilitate the systematic and appropriate use of behaviour change theory, we therefore strongly recommend that researchers and practitioners involve expert behavioural scientists in the design and implementation process, and also make use of available guidance within the behaviour change literature. for example, we are aware of a thorough guide to designing interventions using the behaviour change wheel [ ] that may be of use to practitioners. we also echo michie and prestwich's recommendation for researchers to use their theory coding scheme (a list of items for coding the use of theory within intervention design) to both: a) allow for researchers and practitioners to systematically assess the incorporation of theory within existing interventions and, b) facilitate transparent reporting of the incorporation of theory within novel interventions [ ] . using these resources will enable researchers and practitioners to overcome the limited use of theory acknowledged by the papers included in this review [ , , , , ] while still avoiding "it seemed like a good idea at the time" ( [ ] , p ) interventions. lastly, we include a note on the role of behavioural science in combatting the covid- pandemic. helpfully, a range of prominent behavioural scientists have developed guidelines and recommendations for the application of behavioural science within the context of covid- . for example, michie and colleagues advocate four principles to help reduce transmission by effecting behaviour change [ ] ; the british psychological society have compiled a list of nine recommendations to optimise the effectiveness of changing policy and communication/ guidance [ ] , and; west et al. draw upon com-b to provide an account of components that need to be addressed in order to increase uptake of specific covid- transmission-reduction behaviours [ ] . while this is by no means an exhaustive list, it does reinforce the importance of explicitly and systematically incorporating behavioural science into research and practice within the context of infectious disease and emergency response. alongside our recommendations detailed above, we therefore further advocate that interested readers explore these principles and guidelines in more detail. in our sister review [ ] we find that although the 'gold standard' for incorporating protective behaviour into infectious disease modelling involves the incorporation of a range of cognitive and social constructs, there is very little explicit reference to well-recognised theories of behaviour change (indeed, only five of included papers make any such reference [ ] ). acknowledging the necessary tradeoff between accurately modelling human behaviour and the computational demands of such modelling [ ] , weston and colleagues echo previous recommendations for modellers to familiarise themselves with the relevant behaviour change literature in order to improve their awareness of the main factors underlying human behaviour [ , ] . as a result, the recommendation was made for infectious disease modellers to closely consult with the psychological literature concerning the predictors of health behaviour when developing their models [ ] . based on the outcomes of this current review, we can provide further guidance for infectious disease modellers on both where to begin with this familiarisation, and how/ where to involve behavioural scientists in the process. firstly, in both the current review and weston and colleagues work, the health belief model is the most commonly cited behaviour change theory. we therefore agree that the health belief model represents an appropriate base on which to build infectious disease models incorporating human behaviour [ ] . nevertheless, as noted in the modelling review, there are a broad range of additional factors-including emotional and social constructs-that should be more fully considered when representing infection prevention behaviour [ ] . given the emphasis on protection motivation theory and the extended parallel process model within the literature reported in the current review, we first suggest that infectious disease modellers should consider these models alongside the health belief model to help improve the modelling of emotional responding and defensive avoidance behaviour (but see also bish & michie for further recommendations concerning the use of parallel processing models to incorporate cognitive and emotional constructs, [ ] ). similarly, we would also recommend infectious disease modellers use social cognitive theory, identified as a prominent public health behaviour change theory in the current review, as another starting point for behavioural model formulation. by more fully considering these theories and associated literature, infectious disease modellers will be well prepared to accurately and precisely model a range of relevant social, cognitive, and emotional constructs that may be associated with behavioural responses to a public health emergency. although this familiarisation exercise will be invaluable in helping modellers to develop a deeper understanding of the factors underlying behaviour change and is consistent with recommendations from previous literature as outlined above, it is pertinent to echo a recommendation made by michie and colleagues in the context of intervention design. that is, it is important to ensure that the theory selected is appropriate for the type of behaviour in question. for example, if a behaviour is more likely to be influenced by habitual factors then models concerning deliberative and reflective processing are less likely to be relevant [ ] . as this current review has focused on identifying the broad state of the art for incorporating behaviour change theory within infectious disease and emergency contexts, a full consideration of the appropriate theories for each individual behaviour in each specific disease or emergency context is unfortunately outside scope. however, we recommend that infectious disease modellers work closely with behavioural scientists in the design and development of their models to ensure that the most appropriate theories are being consulted and incorporated for a given target behaviour or context. through this greater collaboration between modellers and behavioural scientists, the discipline will be able to develop a more indepth understanding of the requirements for behavioural theory and the computational limitations to their incorporation within infectious disease models. although the review reported herein represents an impressive effort at addressing a herculean task (namely, the collation of psychological behaviour change theories applied across infectious disease and emergency response contexts), as with any large-scale review there are inevitably trade-offs and potential limitations that should be considered when interpreting the outcomes and recommendations from this review. firstly, although other emergency contexts are represented within the current review, we acknowledge that the papers included within this review are predominantly focused on infectious diseases. although the search strategy did include terms relating to other specific civil emergencies (e.g., terrorism), and emergencies generally (e.g., emergency response, emergency resilience), there were more search terms relating to infectious disease outbreaks/ pandemics. we therefore recommend that future reviews in this area should utilise search strategies optimised more clearly to reflect the full breadth of public health emergency contexts. secondly, and similarly to the first limitation, we are aware of some prominent behaviour change theories (e.g., com-b) that are not represented in the reviews cited herein. although this may represent a limitation of our search strategy, generic phrases and subject headings relating to theoretical models were included to ensure a breadth of focus. furthermore, as our focus was on identifying review articles that have themselves collated primary research involving behaviour change theories in the context of infectious disease and emergency response, it follows that any prominently applied theories should have also been represented within our sample regardless of the specific search terms we used. we are therefore confident that the theories identified herein represent an accurate overview of the most commonly cited theories within this specific context over the period in question (i.e., pre covid- ). thirdly, we acknowledge that several of the reviews included herein were authored by some of the same individuals [ - , , ] , with at least one [ ] explicitly cited as an update of another [ ] . although this may influence the macro-representation of theories across reviews (i.e., at review-level), our decision to also examine the frequency of theory use at a micro-level (i.e., at individual cited study level, excluding repeat citations across reviews) with similar results mitigates the likely impact of this. nevertheless, we acknowledge that frequency of theory usea key outcome within the current reviewis not the same thing as contextual-relevance of theory within these contexts. however, the purpose of this review was to identify the most commonly employed theories of behaviour change within the infectious disease and emergency response contexts. given this focus, we believe that the emphasis on theory frequency within the current review is well founded. nevertheless, we do also provide a synthesis and summary of the key outcomes and conclusions in order to further guide researchers and mathematical modellers to the points of commonality and divergence within the extant review literature. we hope that this review will therefore serve as a jumping off point for further research and modelling work building on our outcomes as detailed in the preceding recommendations section. finally, given the breadth of available primary literature, the proliferation of available reviews of behaviour change theories, and the specificity of our research question (i.e., to identify commonly applied theories of behaviour change within a public health emergency context) we elected to conduct a review of reviews rather than a systematic review of all literature. similarly, although driven by pragmatic concerns, our decision to conduct our top up searches using the first pages of google scholar searches may have limited the number of potentially relevant manuscripts for screening. furthermore, given both the unclear relevance /lack of access to a number of papers within the current review, we elected to wholesale exclude reviews concerning sexually transmitted infection. although these decisions and outcomes may have narrowed our focus, we argue that the close parallels between the theories identified herein and those remarked as commonplace within previous review work (e.g., [ ] ) render this claim ill founded. indeed, when combined, our top-up searches (which were sorted by relevance) allowed us to search through citations published since . the number of unique citations across papers included in our review (see table ) further suggests that we have succeeded in drawing together a broader range of literature than the independent systematic reviews themselves managed. nevertheless, we consider the current work to be an initial attempt at identifying and integrating the literature applying behaviour change theories in the context of infectious disease and emergency response. we therefore invite and encourage the conduct of a full and systematic review of all primary literature concerning the application of behaviour change theories across public health emergency contexts using our search strategy and extraction terms as a guide. behavioural science can play a critical role in combatting the effects of an infectious disease outbreak or public health emergency, such as the covid- pandemic. however, the proliferation of available theories, with either general or specific application, can made the landscape confusing for researchers, infectious disease modellers and public health practitioners alike. in an effort to simplify the considerable behaviour change literature for ease of use by public health emergency researchers, we conducted a systematised scoping 'review of the reviews' concerning the application of behaviour change theories in infectious disease and emergency response emergency contexts. our search strategies revealed relevant review papers from which we were able to identify and collate the seven most commonly cited and applied behaviour change theories in this context: health belief model, theory of planned behaviour, and protection motivation theory as most commonly applied, followed by precaution adoption process model, extended parallel process model, theory of reasoned action, and social cognitive theory. following a synthesis of the key theory-related outcomes and conclusions, we conclude that while there is broad support for the use of the most commonly cited theories within this context, the previous application of these theories within the literature is patchy. that is, much research in this context has not drawn on relevant theories of behaviour change. based on these identified theories and our synthesis of review outcomes, and in conjunction with a recent review by weston and colleagues [ ] , we make recommendations to assist researchers, intervention designers, and mathematical modellers to incorporate psychological behaviour change theories within infectious disease and emergency response contexts. first, we echo previous recommendations that future research and intervention design within this context should be based explicitly and systematically on relevant behaviour change theories, and in close consultation with experts in behavioural science. the theories identified herein represent an excellent starting point for this work, and we further signpost the reader to both general materials to aid in intervention design, and guiding principles for practitioners and researchers working on covid- . second, we recommend that mathematical modellers should consult the theories identified herein, and work closely with behavioural scientists to familiarise themselves with the key factors underlying behaviour change within an infectious disease and emergency response context. considered together, the results and recommendations reported herein therefore represent an important resource to enable researchers, modellers, and practitioners working in the context of infectious disease and emergency response to better incorporate a systematic and evidence-based consideration of human behaviour into their work. national risk register of civil emergencies edition. london: cabinet office world health organisation. ebola in the democratic republic of the congo. health emegency update middle east respiratory syndrome coronavirus (mers-cov the influenza pandemic. an independent review of the uk response to the influenza pandemic. london: cabinet office estimated global mortality associated with the first months of pandemic influenza a h n virus circulation: a modelling study influenza (flu) global rise in human infectious disease outbreaks the united nations office for disaster risk reduction, centre for research on the epidemiology of disasters. the human cost of natural disasters: a global perspective communicating risk in public health emergencies: a who guideline for emergency risk communication (erc) policy and practice. geneva: world health organisation behavioural science must be at the heart of the public health response to covid- the effect of communication during mass decontamination adherence to antimicrobial inhalational anthrax prophylaxis among postal workers public perceptions, anxiety, and behaviour change in relation to the swine flu outbreak: cross sectional telephone survey protection motivation theory and social distancing behaviour in response to a simulated infectious disease epidemic likely uptake of swine and seasonal flu vaccines among healthcare workers. a cross-sectional analysis of uk telephone survey data predictors of self and parental vaccination decisions in england during the h n pandemic: analysis of the flu watch pandemic cohort data mathematical modelling of infectious diseases developing and evaluating complex interventions: the new medical research council guidance abc of behaviour change theories the behaviour change wheel agent-based modelling of epidemic spreading using social networks and human mobility patterns coupled contagion dynamics of fear and disease: mathematical and computational explorations infection prevention behaviour and infectious disease modelling: a review of the literature and recommendations for the future theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review the role of behavioral science theory in development and implementation of public health interventions health behavior and health education: theory, research, and practice the use of theory in health behavior research from to : a systematic review a behavioral-ecological model of adolescent sexual development: a template for aids prevention community strategies for the reduction of youth drinking: theory and application to walk or not to walk? the hierarchy of walking needs methodology in conducting a systematic review of systematic reviews of healthcare interventions cochrane handbook for systematic reviews of interventions scoping studies: towards a methodological framework systematic literature review to examine the evidence for the effectiveness of interventions that use theories and models of behaviour change: towards the prevention and control of communicable diseases demographic and attitudinal determinants of protective behaviours during a pandemic: a review demographic and attitudinal determinants of protective behaviours during a pandemic. london: department of health factors associated with uptake of vaccination against pandemic influenza: scientific evidence base review. london: department of health factors associated with uptake of vaccination against pandemic influenza: a systematic review compliance with anti-h n vaccine among healthcare workers and general population the determinants of pandemic a/ h n influenza vaccination: a systematic review perceptions and behavioural responses of the general public during the influenza a (h n ) pandemic: a systematic review application of behavioral theories to disaster and emergency health preparedness: a systematic review risk perceptions related to sars and avian influenza: theoretical foundations of current empirical research acceptance of a pandemic influenza vaccine: a systematic review of surveys of the general public factors influencing pandemic influenza vaccination of healthcare workers-a systematic review preferred reporting items for systematic reviews and meta analyses: the prisma statement using behavior change frameworks to improve healthcare worker influenza vaccination rates: a systematic review barriers of influenza vaccination intention and behavior-a systematic review of influenza vaccine hesitancy human response to emergency communication: a review of guidance on alerts and warning messages for emergencies in buildings expanding protection motivation theory: investigating an application to animal owners and emergency responders in bushfire emergencies advances in human factors in simulation and modeling. ahfe . advances in intelligent systems and computing the role of social identity processes in mass emergency behaviour: an integrative review historical origins of the health belief model the theory of planned behavior a protection motivation theory of fear appeals and attitude change a model of the precaution adoption process: evidence from home radon testing the common-sense model of regulation of health and illness putting the fear back into fear appeals: the extended parallel process model belief, attitude, intention, and behaviour: an introduction to theory and research social foundations of thought and action: a social cognitive theory transtheoretical therapy: toward a more integrative model of change diffusion of innovations health program planning: an educational and ecological approach applying principles of behaviour change to reduce sars-cov- transmission the behaviour change wheel: a new method for characterising and designing behaviour change interventions are interventions theory-based? development of a theory coding scheme slowing down the covid- outbreak: changing behaviour by understanding it behavioural science and disease prevention: psychological guidance incorporating individual health-protective decisions into disease transmission models: a mathematical framework nine challenges in incorporating the dynamics of behaviour in infectious diseases models publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to acknowledge charlotte hall for providing additional support during the redrafting of this manuscript. supplementary information accompanies this paper at https://doi.org/ . /s - - - .additional file : supplementary information . search terms for the original selection process additional file : supplementary information . summary of key theory-related conclusions additional file : supplementary information . breakdown of: a) how many/ which theories are presented across multiple reviews, and; b) how many times each theory is cited by a unique article across all reviews authors' contributions dw conceived of the project, secured funding, contributed to the design, contributed to developing the search strategy and exclusion & inclusion criteria, provided full-text review of potential papers, read all included papers, re-analysed and re-extracted data following the initial extraction and analysis, substantially revised the initial draft of the manuscript. dw also led on manuscript revisions including the rapid synthesis of outcomes/ conclusions, the screening of citations for the top-up search, the screening of citations for the optimised top up search, and the extraction and analysis of all subsequent data. ai contributed to developing the search strategy and exclusion & inclusion criteria, conducted the review (i.e., ran the searches and conducted title/ abstract and full text review), conducted initial data extraction and analysis, prepared an initial draft of the manuscript, and developed the strategy for the top-up search. ra contributed to the conception, design, and securing funding for the project and commented on drafts of the paper. all authors approved the authorship order, and all authors read and approved the final manuscript. availability of data and materials all data generated or analysed during this study are included in this published article and its supplementary information files.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests. key: cord- -yw nk fo authors: vantarakis, a.; chatziprodromidou, i.; apostolou, t. title: covid- and environmental factors. a prisma-compliant systematic review date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: yw nk fo the emergence of a novel human coronavirus, sars-cov- , has become a global health concern causing severe respiratory tract infections in humans. human-to-human transmissions have been described with incubation times between - days, facilitating its airborne spread via droplets. the impact of environmental factors on the coronavirus disease (covid- ) outbreak is under consideration. we therefore reviewed the literature on all available information about the impact of environmental factors on human coronaviruses. temperature, humidity and other environmental factors have been recorded as environmental drivers of the covid- outbreak in china and in other countries. higher temperatures might be positive to decrease the covid- incidence. in our review, the analysis of studies show evidence that high temperature and high humidity reduce the covid- transmission. however, further studies concerning other environmental (namely meteorological) factors role should be conducted in order to further prove this correlation. as no specific therapies are available for sars-cov- , early containment and prevention of further spread will be crucial to stop the ongoing outbreak and to control this novel infectious thread. a novel coronavirus (sars-cov- ) has recently emerged from china with a total of confirmed cases of pneumonia (as of february , ). coronaviruses (covs) most commonly cause mild illness; but have occasionally, in recent years, led to major outbreaks of human disease. approximately ten years after sars, another novel, highly pathogenic cov, in december , sars-cov- , a novel cov, was identified in the city of wuhan, hubei province, a major transport hub of central china. the earliest covid- cases were linked to a large seafood market in wuhan, initially suggesting a direct food source transmission pathway this is the third highly pathogenic human coronavirus that has emerged in the last two decades. in the months since the identification of the initial cases, covid- has spread to countries and territories and there are approximately , confirmed cases and , deaths (as of march ). person-to-person transmission was confirmed as one of the main mechanisms of covid- spread (chan et al. ) . the modes of transmission have been identified as host-to-human and human-to-human. increased spread of sars-cov- causing covid- infections worldwide has brought increased attention and fears surrounding the prevention and control of sar-cov- from both the scientific community and the general public. while many of the precautions typical for halting the spread of respiratory viruses are being implemented, other less understood transmission pathways should also be considered and addressed to reduce further spread. the role of environment and its mediated pathways for infection by other pathogens have been a concern for decades. substantial research into the presence, abundance, diversity, function, survival and transmission of microorganisms in the environment has taken place in recent years. there is preliminary evidence that environmentally mediated transmission may be possible; additionally, that covid- could be affected by environmental factors such as seasonality, temperature, humidity (tan et al. ) (shaman and kohn ) (geller, varbanov, and duval ) . the aim of the review was, therefore, to summarize all available data on the impact of environmental factors on the survival of all coronaviruses including emerging sars-cov and mers cov. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . methodology of this systematic review and inclusion criteria were indicated in advance and recorded in a priori protocol in order to determine the rationale, the objectives, the eligibility and selection criteria, the search strategy and the study selection process of this systematic review. however, due to emergency of the subject and due to the pandemic awareness for covid- , this systematic review was not registered with prospero (international prospective register of systematic reviews). all study design types were considered in this systematic review. reviews were not included but screened for any information within the scope of this review. no language, publication status or publication year restrictions were imposed. as because of the covid- emergency state, even not proofread publications were included in our study. all non-english studies, including chinese, japanese and french were translated via google translator and were included in this systematic review. although covid- concerns years and , no year of publication limit was applied, in order to exploit valuable information concerning the coronavirus relationship with environmental factors, as indicated by the past sars and mers lessons. all studies included, concern human coronavirus strains of various types. this systematic review was limited to studies focusing to environmental factors' impact on covid- . searched experts' and researchers' opinions were not handed in this study. the selection criteria developed a priori are described below: • year of publication (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . the search strategy and analysis process were conducted according to the preferred reporting items for systematic reviews and meta-analyses (prisma) statement for systematic reviews (liberati et al. ; page et al. ) . titles and abstracts of the retrieved articles were screened, while full length articles were evaluated for eligibility and were further acquired via swetswise online content. search for articles was applied in three electronic databases: google scholar, pubmed & springerlink. google scholar was our starting point. no unpublished information obtained. the literature search was performed from to of march . the following terms were used to search all databases, always in combination with "coronavirus" and "covid- ": "environmental factors", "clima", "temperature", "humidity", "absolute humidity", "relative humidity", "wind speed", "wind power", "precipitation", "rainfall". the search strategy was conducted by ipc and was peer-reviewed by av as part of the systematic review process. eligibility assessment procedure was performed in standardized and independent manner, primary by two authors (ipc and av), to analyze and validate all relevant data to the top under discussion. disagreements were resolved through discussion among all authors and resulted in a final consensus. after excluding records upon the eligibility criteria set, we screened all titles and abstracts of the retrieved studies, although full text review proves also to be necessary for further consideration. a data extraction sheet was developed in order to summarize the evidence of this systematic review, based on the cochrane consumers and communication review group' data extraction all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . template for included studies (cochrane consumers and communication ) . this was pilot tested on the first ten randomly selected studies and no refinement was needed. one author (ipc) extracted all proper data from the included studies and another author (av) checked all the extracted data. no disagreements arose. in order to ascertain duplicate publications, we used the tool "check for duplicates" of mendeley desktop software (version . . ). to ascertain the validity of the included studies, two reviewers (ipc and av) in a blind manner and independently scored the included papers' quality upon the strengthening the reporting of observational studies in epidemiology (strobe) checklist (von elm et al. ). both reviewers independently scored each included paper's quality and all studies received a score that ranged from to points by each reviewer. base up on a criterion included in the initial protocol of the study, the scores between the reviewers should not differ from one to another reviewer by more than points. in order to generate a final score, both scores of the reviewers were averaged. in order to handle data and combine the results of all the included studies, we used spss (statistical package for the social sciences) (ibm spss statistics for macintosh, version . n.d.) or r software (r development core team ). all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint the search of google scholar, springerlink and pubmed provided a total of , and articles, respectively. from the initially obtained articles, were excluded as duplicated ones upon "check for duplicates" tool of mendeley desktop. the remaining articles were assessed for eligibility and a total of articles were discarded because based on a detailed evaluation of abstracts, they did not meet the eligibility criteria set and concerned: all studies selected for this systematic review were published in and in english. . % of the included studies reported china, . % did not mention a certain country of epidemics, . % concerned the epicentre of the disease, namely iran, italy, south korea, etc. and . % concerned singapore. upon continent of epidemics, asia hold the leads with , %, followed by africa with . %, whereas almost . % did not mention specific continent and . % refers to mixed continents (asia, europe, etc.). all included studies assessed the role of various environmental factors on transmission rates of the covid- . in . % of the studies, temperature was assessed for its impact on covid- , followed by humidity ( . %), absolute humidity ( . %), rainfall/precipitation ( . %), relative humidity ( . %), travel ( . %), air travel ( . %), wind speed/power ( . %), latitude ( . %), built all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint environment ( . %), general lockdown ( . %), visibility ( . %), specific humidity ( . %), airborne dust ( . %), air pollution ( . %), chemical pollution ( . %), air index ( . %), atmospheric radiation ( . %), cloud cover ( . %), precipitation of the driest month ( . %), mean temperature of the wettest quarter ( . %), isothermality (day-to-night temperatures difference relative to the summer-to-winter annual difference) ( . %), annual mean temperature ( . %), mean diurnal range ( . %), minimum temperature of the coldest month ( . %) and precipitation of the coldest quarter ( . %). in order to examine the association between those environmental factors and covid- , most of the studies employed the review method ( . %), followed by maximum entropy model ( %), the model ( . %), dynamical model and era- reanalysis ( . %), the statistical modeling loess regression (generalized-linear or non-linear model) ( . %), the r proxy method ( . %), the r reproductive number ( . %), the one-way anova followed by a post-hoc tukey's hsd test ( . %), the distributed lag log-linear model ( . %), the linear regression model ( . %), the global meta-population disease transmission model ( . %), the mann-whitney u test ( . %), the mathematical model ( . %), the restricted cubic spline function and the generalized linear mixture model ( . %) and the multivariate analysis ( . %). figure displays the environmental factor assessed, combined with the assessing method and the country of epidemics it concerns. detailed characteristics of the studies included, like author, title and year of publication, country and continent of the study, method of assessing the impact of the environmental factors and the outcome variable are described in table . (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . the studies included in this systematic review were scored from to . , upon the criteria predefined. the criteria on which studies were assessed with the minimum score were related to their not clearly addressing the following items: report of the study design and assessing method all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . in the title and abstract; clearly define the participants, the interventions and the outcomes; clearly state handle of missing data and accuracy of data; generalization of the findings. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . to the best of our knowledge, the present systematic review is the first to summarize the available evidence on the association of covid- with environmental factors. taking into consideration that the new coronavirus is a new human pathogen, which due to its outbreak in china and its rapid spread worldwide, it is important to understand reliable epidemiological information for its survival in the environment (chen et al. ) . therefore, it is necessary to find prognostic predictors to distinguish high-risk areas or countries and improve the new (bu et al. ) . concerning humidity, although the results in this review did not reveal robust associations between humidity and coronavirus survival and are always validated in combination with temperature, they need to be interpreted carefully given the monotonic functional relationship between humidity and temperature. in other words, if temperature was associated to covid- transmission, very likely absolute humidity would play a role. pooled results of the studies included in this systematic review show that combined all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . with high temperature, absolute humidity range of - g/m (sajadi, habibzadeh, vintzileos, miralles-wilhelm, et al. ) or specific humidity range of - g/kg (sajadi, habibzadeh, vintzileos, miralles-wilhelm, et al. ) apart from the he basic strengths of this review regards the study quality assessment, which was based on strobe, its prisma compliance approach and the peer-review process followed. due to limited data available, other meteorological factors such as air pressure, atmospheric particles, ultraviolet, and social factors such as population movement were not included for analysis. inclusion of such factors will provide more accurate and reliable results. in addition, the relatively short time length of the current outbreak, combined with imperfect daily reporting practices, make our results vulnerable to changes as more data becomes available. we have assumed that travel limitations and other containment interventions have been implemented consistently across provinces and have had similar impacts (thus population mixing and contact rates are assumed to be comparable), and have ignored the fact that different places may have different reporting practices. further improvements could incorporate data augmentation techniques that may be able to produce historical time series with likely estimates of case counts based on onset of disease rather than reporting dates. this, along with more detailed estimates of the serial interval distribution, could yield more realistic estimates of r. finally, further experimental work needs to be conducted to better understand the mechanisms of transmission of covid- . mechanistic understanding of transmission could lead to a coherent justification of our findings. in summary, this review provided evidence that high temperature and high humidity reduce the covid- transmission. however, further studies concerning other environmental (namely meteorological) factors' role should be conducted in order to further prove this correlation. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint figure temperature associated with the assessing methods the country of epidemics all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . figure environmental factors associated with the assessing methods the country of epidemics all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . revisiting the one health approach in the context of covid- : a look into the ecology of this emerging disease analysis of meteorological conditions and prediction of epidemic trend of -ncov infection in the effects of 'fangcang, huoshenshan, and leishenshan' makeshift hospitals and temperature on the mortality of covid- a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster roles of meteorological conditions in covid- transmission on a worldwide scale the effect of travel restrictions on the spread of the novel coronavirus (covid- ) outbreak data extraction template for included studies highly pathogenic avian influenza h n in germany: outbreak investigations the strengthening the reporting of observational studies in epidemiology (strobe) statement: guidelines for reporting observational studies environmental resistance and its influence on the development of new antiseptic strategies preparedness and vulnerability of african countries against importations of covid- : a modelling study estimated effectiveness of symptom and risk screening to prevent the spread of covid- effect of ambient temperature on covid- infection rate ibm spss statistics for macintosh, version . modeling the control of covid- : impact of policy interventions and meteorological factors the positive impact of lockdown in wuhan on containing the covid- outbreak in china interrupting transmission of covid- : lessons from containment efforts in singapore the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration the role of absolute humidity on transmission rates of the covid- outbreak role of temperature and humidity in the modulation of the doubling time of covid- cases all rights reserved. no reuse allowed without permission.(which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. key: cord- -gw i tkn authors: qu, xianshan; li, xiaopeng; farkas, csilla; rose, john title: an attention model of customer expectation to improve review helpfulness prediction date: - - journal: advances in information retrieval doi: . / - - - - _ sha: doc_id: cord_uid: gw i tkn many people browse reviews online before making purchasing decisions. it is essential to identify the subset of helpful reviews from the large number of reviews of varying quality. this paper aims to build a model to predict review helpfulness automatically. our work is inspired by the observation that a customer’s expectation of a review can be greatly affected by review sentiment and the degree to which the customer is aware of pertinent product information. consequently, a customer may pay more attention to that specific content of a review which contributes more to its helpfulness from their perspective. to model such customer expectations and capture important information from a review text, we propose a novel neural network which leverages review sentiment and product information. specifically, we encode the sentiment of a review through an attention module, to get sentiment-driven information from review text. we also introduce a product attention layer that fuses information from both the target product and related products, in order to capture the product related information from review text. our experimental results show an auc improvement of . % and . % over the previous state of the art model on amazon and yelp data sets, respectively. e-commerce has become an important part of our daily life. increasingly, people choose to purchase products online. according to a recent study [ ] , most online shoppers browse reviews before making decisions. it is essential for users to be able to find reliable reviews of high quality. therefore, an automatic helpfulness evaluation mechanism is in high demand to help user evaluate these reviews. previous work typically derived useful information from different sources, such as a review content [ , , ] , metadata [ , , ] , and context [ , , ] . however, such features are extracted from each source independently, without considering interactions. in particular, previous approaches do not take into account the customer review evaluating process. a customer's perception of helpful information of a review is affected by the sentiment of the review and what the customer already knows about the product. before reading a review text for a product, the customer is very likely to be aware of background information such as star rating, product attributes, etc. when a customer reads a review with a lower star rating, he may hold a negative opinion towards the item at first and mainly look into those aspects of the review supporting the lower star rating. although review sentiment has been previously explored [ , , ] , previous work has not used review sentiment to identify useful information from review text. moreover, the customer likely has some preconceptions of the product features they are most interested in. with these expectations in mind, the customer pays special attention to those aspects of the review text that they find most salient. there have been earlier efforts [ , , ] at capturing useful information from a review by considering product information. however, the unique aspects of each product (different levels of importance of attributes, evaluation standard, etc.) were not fully identified in those efforts. in order to address the above issues, we propose a novel neural network architecture to introduce sentiment and product information when identifying helpful content from a review text. the main contributions are summarized as follows: -to our knowledge, we are the first to propose that customers may have different expectations for reviews that express different sentiments. we design a sentiment attention layer to model sentiment-driven changes in user focus on a review. -we propose a novel product attention layer. the purpose of this layer is to automatically identify the important product-related attributes from reviews. this layer fuses information not only from related products, but also from the specific product. -we evaluate the performance of our model on two real-world data sets: the amazon data set and the yelp data set. we consider two application scenarios: cold start and warm start. in the cold start scenario, our proposed model demonstrates an auc improvement of . % and . % on amazon and yelp data sets, respectively, when compared to the state of the art model. we also validate the effectiveness of each of the attention layers of our proposed model in cold start and warm start scenarios. previous studies have concentrated on mining useful features from the content (i. e., the review itself) and/or the context (other sources such as reviewer or user information) of the reviews [ , , , , [ ] [ ] [ ] , , ] . content features have been extracted and widely utilized. they can be roughly broken down into the following categories: structural features [ , , , , , ] , lexical features [ , , , ] , syntactic features [ , , ] , emotional features [ , ] , semantic features [ , , , , , , ] , and argument features [ ] . for instance, kim et al. [ ] investigated a variety of content features from amazon product reviews, and found that features such as review length, unigrams and product ratings are most useful in measuring review helpfulness. context features have also been studied to improve helpfulness prediction [ , , ] . for example, lu et al. [ ] examined social context that may reveal the quality of reviewers to enhance the prediction of the quality of reviews. while context information shows promise for improving helpfulness prediction, it may not be available across different platforms and is not appropriate for designing a universal model. deep neural networks have recently been proposed for helpfulness prediction of online reviews [ ] [ ] [ ] [ ] ] . chen et al. [ ] designed a word-level gating mechanism to represent the relative importance of each word. fan et al. [ ] proposed a multitask paradigm to predict the star ratings of reviews and to identify the helpful reviews more accurately. they also utilized the metadata of the target product in addition to the textual content of a review to better represent a review [ ] . the methods summarized above are representative of the research progress in review helpfulness prediction. sentiment and product information have been explored previously [ , , , ] . with respect to sentiment, martin and pu [ ] extracted emotional words from review text to serve as important parameters for helpfulness prediction. however, previous research has not taken into account differences in customer expectations that can result from review sentiment perception. with respect to product information, fan et al. [ ] tried to better represent the salient information in reviews by considering the metadata information (title, categories) of the target product. however, this information can be quite similar for products of the same type, so the unique aspects of each product (different degrees of importance of attributes, evaluation standard, etc.) can not be fully captured from reviews. wu et al. [ ] presented an architecture similar to the one we propose here. however, the design of the sentiment attention layer and product attention layer in our architecture is different from their attention layers. moreover, their architecture is intended for classifying review sentiment. our model, shown in fig. , is built upon a hierarchical bi-directional lstm. we incorporate sentiment and product information to improve review representations through two attention layers. as the main components of our model are the hierarchical bi-directional lstm, the sentiment attention layer, and the product attention layer, we refer to our model as hsapa. a bi-directional lstm model is able to learn past and future dependencies. this provides a better understanding of context [ ] . the hierarchical architecture include two levels: the word level and the sentence level. these levels learn dependencies between words and sentences, respectively. a bi-directional lstm consists of two lstm networks that process data in opposite directions. at the word level, we feed the embedding of each word into a unit of both lstms, and get two hidden states. we then concatenate these two hidden states as a representation of a word. the process is defined as: , where x ij is the embedding vector of the ith word of the jth sentence. − → h ij and ← − h ij are hidden states learned from bi-directional lstm. the state h ij is the concatenation of these hidden states for the word x ij . sentence encoder. at the sentence level, a sentence representation is learned through an architecture similar to that used for the word level: , where s j refers to a weighted representation of the jth sentence after applying the attention layer. the state h j is the final representation for the sentence s j by concatenating the hidden states − → h j and ← − h j . for reviews that express different types of sentiment (positive, negative, etc.), customers may have different expectations, and attend to different words or sentences of a review. consider the following example: i loved the simplicity of the mouse, . . . and it was very comfortable . . . about months of owning the mouse the scroll wheel seemed to be in always clicked in position, and would only stop after clicking it down hard for a couple seconds . . . the above review has a star rating of out of . for a review with an overall negative sentiment like this, we may pay more attention to its descriptions of bad aspects of the product than we do to the good aspects. therefore, each word/sentence may contribute unequally to the helpfulness of a review, with regard to its sentiment. in order to learn the sentiment-influenced importance of each word/sentence, we propose a custom attention layer. in this layer, we use an embedded vector to represent each type of sentiment. we use the star rating (ranging from to ) of each review to indicate its sentiment, and map each discrete star rating into a real-valued and continuous vector sent. this vector is initialized randomly, and updated gradually through the training process by reviews with the corresponding star rating. sent can be interpreted as a high level representation of the sentiment-specific information. we measure the similarity between the sentiment and each word/sentence using a score function. the score function is defined as: where v s w is a weight vector, and (v s w ) t indicates its transpose, w s wh and w s ws are weight matrices, and b s w is the bias vector. at the word level, the input to the score function is the abstract sentiment representation sent and the hidden state of the ith word in the jth sentence h s ij . next, we use the softmax function to normalize the scores to get the attention weights: α s ij is the attention weight for the word representation h s ij . the sentence representation is a weighted aggregation of word representations, the jth sentence is represented as eq. . the number of words in the jth sentence is denoted by l. the representation of a review is also a weighted combination of sentence representations defined as eq. , where h s j is the hidden state of the jth sentence s s j , which is learned through the bi-directional lstm. the value m refers the number of sentences in a review. the value β s j indicates the corresponding attention score for h s j . the weight score β s j is calculated based on the score function f (.) defined as: as shown in the top right corner of fig. , the product attention layer consists of two components: related product information and unique product information. metadata information is embedded and fed into a cnn model [ ] to capture the related product information, and the product identifier is encoded to represent the unique product information. when reading a review, customers may refer to different attributes depending on the product the review references. for example, for a review of a mouse, we may expect to see the comments related to attributes such as scroll wheel, hand feel, etc. such attributes are considered helpful and garner more attention. we take advantage of the metadata information (such as title, product description, product category, etc.) of each product to learn common attributes shared by related products. we use the pretrained glove embedding [ ] to initialize each token in the metadata into a -dimensional embedding. we extract important attributes from the metadata through a cnn model [ ] , which is widely used for different nlp tasks [ , , , ] such as text understanding, document classification, etc. the cnn model consists of a convolution layer, a max-pooling layer, and a fully connected layer. in the convolution layer, each filter is applied to a window of words to generate the feature map. for example, we apply a filter w ∈ r hk to a window of words x i:i+h− . here k indicates the dimension of the word vector, and x i:i+h− refers to the concatenation of h words from x i to x i+h− . the context feature c ih is generated as: where b is the bias item. a feature map of the text is then generated through ..c nh refer to context features extracted from different sliding windows of the text, and c h indicates the concatenation of these features. the feature map c h is then fed into a max-pooling layer, and the maximum value is extracted as c = max{c h } as the important information extracted by a particular filter. a number of filters are used, and the extracted features are concatenated and fed into a fully connected layer to generate a vector p rod . p rod is a representation of the important related product attributes in the metadata. although reviews for the same type of product may share the same important attributes, the degree of importance of these attributes may vary from product to product. consider pet food for example. some pet food may be of good quality and fair price, but the flavor may not appeal to a picky eater. conversely, price may be the most salient feature for some brands. in order to represent the unique characteristics of each product, the unique product identifier for each product is mapped into a continuous vector p rod . at the outset, p rod is randomly initialized. during the training process, this vector is only updated when reviews specific to the product are used for training. thus p rod can be interpreted as a high level representation of product-specific information. the final product representation p rod is generated by combining the two vectors: p rod and p rod as: where w and w are weight matrices for p rod and p rod respectively, and b p is the bias vector. we calculate the product attention weights based on the score function f (.), and the input to the score function is the product representation p rod and hidden state of a word h p ij : where (v p w ) t denotes the transpose of weight vector v p w , w p wh and w p wp are weight matrices, and b p w is the bias vector. then we apply softmax function to get a normalized attention score α p ij . at the word level, the sentence representation is defined in eq. , where α p ij indicates the product attention score of the word representation h p ij . the representation of a review can be obtained formally through eq. , where β p j indicates the attention weight for hidden state of the jth sentence h p j . after applying the sentiment attention layer and the product attention layer separately, we obtain two different review representations r s and r p . these two representations are concatenated as the final representation of a review r = [r s , r p ]. then, we apply a fully connected layer on top of r, to classify the helpfulness of a review. to minimize the difference between the predicted helpfulness value and the actual helpfulness label, we utilize cross entropy loss as the objective function. it is a commonly used loss function for binary classification, and is defined as: where y i indicates the actual helpfulness label, p(y i ) indicates the probability of helpfulness. n is the number of training observations. we present details on how these y i are assigned in the following section. in this section, we evaluate performance of our architecture in two application scenarios: cold start scenario and warm start scenario. correspondingly, we split the data into training and test data differently for the two scenarios. . we pre-process the data the same way as fan et al. [ ] : first, we join the product review with corresponding metadata information. second, we filter out the reviews that have no votes. last, we label reviews that receive more than % helpful votes out of total votes as helpful, and label the remaining reviews as unhelpful. evaluation metric. in this study we use the receiver operating characteristic area under the curve (roc auc) statistic to evaluate the performance of our proposed model. this is a standard statistic used in the machine learning community to compare models. it is a robust statistic where imbalanced data sets are involved, and is a good metric for our problem where there are nearly four times as many helpful reviews as unhelpful reviews. in practice, a new product may have not yet received any helpful votes. therefore assessment standards can't be captured from past voting information and can lead to the cold start problem. to evaluate model performance in this scenario, we randomly select % of the products and their corresponding reviews as the training data set. the remaining products and their reviews are employed as the test data set. therefore, all of the reviews for a given product appear only in the training data set or test data set. consequently, all products in this test data set face the cold start problem. the statistics of the two data sets are summarized in tables and . even though the partitioning approach is the same as that reported by fan et al. [ ] , a consequence of the random selection of products into test and training data sets is that the actual number of reviews differs from that of fan et al. [ ] . however, the difference is less than %, which is not statistically significant. we compare our proposed model with several baseline models. below is a list of the hand-crafted features. -structural features (str) as introduced by xiong et al. [ ] and yang et al. [ ] , include the number of tokens, number of question sentences, the star rating. they are used to reveal a user's attitude towards a product. the baseline models that we use to compare our model are: -fusion (svm) uses a support vector machine to fuse features from the preceding feature list. -fusion (r.f.) uses a random forest to fuse features from the preceding feature list. -embedding-gated cnn (eg-cnn) [ ] introduces a word-level gating mechanism that weights word embeddings to represent the relative importance of each word. -multi-task neural learning (mtnl) [ ] is based on a multi-task neural learning architecture with a secondary task that tries to predict the star ratings of reviews. -product-aware review helpfulness net (prh-net) [ ] is a neural networkbased model that introduces target product information to enhance the representation of a review. fan et al. evaluate this model on the two data sets we are using and claim that prh-net is the state of the art. we use the same data sets as fan et al. [ ] in the cold start scenario. this allows us to directly compare the performance of our model with the results reported by fan et al. [ ] . we also randomly select % of the products and their corresponding reviews from the training set as a validation data set. we then performed a grid search of hyper-parameter space on the validation data set to determine the best choice of hyper-parameters. the models were then trained based on the entire training data set with these fixed hyper-parameters. tables and show the results on the amazon data set and yelp data set, respectively. in table we see that our model outperforms previous models on all categories of the amazon data set. the average improvement in auc is . % over the next best model. we observe that the degree of improvement varies from category to category. in the categories ac (electronics), our model achieves improvement of . %. in contrast, for the category ac (grocery & gourmet food), the improvement is only . %. we note that the category ac , has less data than most of other categories (table ) . only the category ac (pet supplies) contains fewer products and reviews. however, there are proportionally more reviews per product for the category ac than for the category ac . we suspect that sentiment embedding and product embedding may not be learned well with such limited and divergent data. therefore the improvement is not as high as that for the other categories. the results for the yelp data set are presented in table . we find that our model also outperforms the previous models in all categories. the average improvement in auc is . % over the next best model. we note that the overall improvement is not as high as that demonstrated in the amazon data set. this may be due to the relatively small number of products and reviews in the yelp data set. with the exception of the category yc (restaurants), the other categories have fewer products and reviews than all of categories of amazon data set. the comparison results presented in tables and show that our model outperforms the baseline models in the cold start scenario. in order to examine the significance of the improvement of our proposed model, we conducted a one-tailed t-test. as we are not certain as to whether the values reported in fan et al. [ ] refer to variance or standard deviation, we performed three tests: the one-sample t-test, and the two sample t-test where we evaluated both interpretations (variance and standard deviation) of the values reported in fan et al. [ ] . in all cases, the statistical results validate that our method is significantly better than the other baselines (p < . ). in order to tease out the performance contribution of each of the components of our model, we evaluated different combinations of the components. the results are show in table . here hbilstm refers to the hierarchical bi-directional lstm model without either of the attention layers. we use it as the baseline model for comparison. hsa refers to the combination of the hbilstm with the sentiment attention layer. hpa refers to the combination of the hbilstm with the product attention layer. finally, hsapa refers to the complete model which implements both attention layers. from table , we see that adding a sentiment attention layer (hsa) to the base model (hbilstm) results in an average improvement in the auc score of . % and . %, respectively on the amazon and yelp data sets. by adding a product attention layer (hpa) to the base model (hbilstm), the improvement is . % and . % on the amazon and yelp data sets respectively. combining all three components results in an even larger increase in auc score, . % and . %, respectively on the amazon and yelp data sets. we observe a synergistic effect resulting from the addition of the two attention layers. we also note that in both data sets, the improvement from the product attention layer is lower than that from the sentiment attention layer. this may be due to the fact that in the cold start scenario we have no information about the target product. possibly the helpful attributes shared by related products may not be sufficiently accurate. in order to verify that the gain in auc is a consequence of the additional attention layers and not simply a result of adding more parameters, we conducted additional experiments. we adjusted the hyper-parameters of the hbilstm, hsa and hpa models to ensure they have approximately the same number of parameters as the complete model hsapa. for example, for the category grocery in the amazon data set, the number of parameters of the complete model hsapa is , , . we increased the number of hidden units in the table . performance of each model on yelp data set in the warm start scenario. yc -yc are described in table . table . performance of each model on amazon data set in the warm start scenario. ac -ac are described in table . recall that the selection of hyper-parameters was determined by using a grid-search of the hyper-parameter space. not surprisingly, the new models with more parameters do not demonstrate an improvement in performance in comparison to the models with hyper-parameters determined by grid-search. our proposed model demonstrates improved performance, not simply because of greater modelling power due to more parameters, but because of the leveraging of sentiment and product related information by the sentiment and product attention layers. the warm start scenario is another commonly seen scenario in which some reviews for products have user votes, while other reviews haven't yet received user votes. for this scenario, we randomly select % of the reviews as the training data, and use the remaining reviews as the test data. the data statistics are essentially the same in scenario as that in scenario (tables and ). as % of the reviews for products are in training data set, this partitioning produces a warm start scenario. we also evaluated the contribution of each attention layer in the warm start scenario. tables and show that, on average, the addition of the sentiment layer (hsa) to the base model increases the auc by . % and . % on yelp and amazon data sets, respectively. we also find that the addition of the product attention layer (hpa) to the base model increases the auc by . % and . % on yelp and amazon data sets, respectively. comparing the results from warm start scenario to cold start scenario, we make the following observations. first, the average performance of the base model (hbilstm) is very similar in both scenarios. second, the auc improvement from the product attention layer (hpa) is higher than that from the sentiment attention layer (hsa) on both data sets in the warm start scenario. this improvement is not seen in the case of the cold start scenario. in the cold start scenario the product embedding can only be learned from reviews of related products. in contrast, in the warm start scenario product information can be learned from both the target product and related products. this explains why the product attention layer can achieve better performance in warm start compared to cold start scenario. from the performance results described in the cold start scenario section (tables and ) , we see that hsapa out-performs the other models. we also see that hsapa has even better performance in the warm start scenario (tables and ). in practice, one can expect a mix of cold and warm start scenarios where hsapa can be expected to demonstrate superior performance than in cold start scenario. did not fit on any of the tub spouts and was unable to stretch it enough to work. had to return did not fit on any of the tub spouts and was unable to stretch it enough to work. had to return this is a great blade. almost no sanding needed after use and they remain sharp after several uses . don't use them on rough construction material if you want them to keep doing the job they were meant to do. this is a great blade. almost no sanding needed after use and they remain sharp after several uses . don't use them on rough construction material if you want them to keep doing the job they were meant to do. we demonstrate the visual examination of attention scores applied at the word level by randomly sampling two identical review examples (shown in table ). we use two colors: red and green to represent the sentiment attention scores and product attention scores respectively. the lightness/darkness of the color is proportional to the magnitude of the attention score. there are a few interesting patterns to note. first, for the sentiment attention layer, the words that are assigned large weights have sentiment that is close to the overall sentiment of the review. for instance, in the example the overall sentiment of the review is positive ( out of ). although there are several negative words such as "no" and "don't", the positive words/phrases like "great", "remain sharp" are still assigned higher attention weights. this observation is consistent with our previous hypothesis that the word importance in a review can be affected by review sentiment. second, the attributes or descriptive words of an attribute of the product in a review text gain higher weights from the product attention layer. for instance, in the first example the descriptive words "fit", "enough" and the noun "tub" are assigned relatively high attention scores. third, the combination of the important words captured by two attention layers can give us a brief and thorough summary of a review. it may also visually explain why the combination of these two can achieve a better result compared to a single attention layer. in this paper, we describe our analysis of review helpfulness prediction and propose a novel neural network model with attention modules to incorporate sentiment and product information. we also describe the results of our experiments in two application scenarios: cold start and warm start. in the cold start scenario, our results show that the proposed model outperforms prh-net, the previous state of the art model. the increase in performance, measured by auc, as compared with prh-net is . % and . % on amazon and yelp data sets, respectively. furthermore, we evaluate the effect of each attention layer of proposed model in both scenarios. both attention layers contribute to the improvement in performance. in the warm start scenario, the product attention layer is able to attain better performance than in cold scenario since it has access to reviews for targeted products. in this work, we evaluate review helpfulness from the perspective of review quality. for future work, we may rank the helpfulness of reviews by incorporating a user's own preferences [ ] in order to make personalized recommendations. multi-domain gated cnn for review helpfulness prediction cross-domain review helpfulness prediction based on convolutional neural networks with auxiliary domain discriminators multi-task neural learning architecture for end-to-end identification of helpful reviews product-aware helpfulness prediction of online reviews ups and downs: modeling the visual evolution of fashion trends with one-class collaborative filtering what reviews are satisfactory: novel features for automatic helpfulness voting a study of factors that contribute to online review helpfulness effective use of word order for text categorization with convolutional neural networks surprise! most consumers look at reviews before a purchase automatically assessing review helpfulness convolutional neural networks for sentence classification using argument-based features to predict and analyse review helpfulness low-quality product review detection in opinion summarization exploiting social context for review quality prediction prediction of helpful reviews using emotions extraction context vec: learning generic context embedding with bidirectional lstm what makes a helpful online review? a study of customer reviews on amazon exploring latent semantic factors to find useful product reviews modeling and prediction of online product review helpfulness: a survey learning to recommend helpful hotel reviews glove: global vectors for word representation a dynamic neural network model for ctr prediction in real-time bidding review helpfulness assessment twitter sentiment analysis with deep convolutional neural networks context-aware review helpfulness rating prediction improving review representations with user attention and product attention for sentiment classification automatically predicting peer-review helpfulness semantic analysis and helpfulness prediction of text for online product reviews text understanding from scratch character-level convolutional networks for text classification acknowledgments. this work was partially supported by ibm faculty award to the university of south carolina. key: cord- - qen z y authors: peruzzi, mariangela; biondi-zoccai, giuseppe; carnevale, roberto; cavarretta, elena; frati, giacomo; versaci, francesco title: vaping cardiovascular health risks: an updated umbrella review date: - - journal: curr emerg hosp med rep doi: . /s - - - sha: doc_id: cord_uid: qen z y purpose of review: modified risk products (mrp) such as electronic vaping cigarettes (evc) and heat-not-burn cigarettes (hnbc) are alternatives to traditional combustion cigarettes (tcc) with an expanding consumer base. yet, their cardiovascular health risks are still unclear. we aimed to summarize the evidence base on this topic by conducting an updated umbrella review. recent findings: we identified systematic reviews, totaling studies and reports, ranging from in vitro and in animal studies to clinical studies in apparently healthy volunteers and patients at risk of cardiovascular disease. overall, acute evc use was associated with several toxic effects at molecular, cellular, tissue, organ, and system level. in addition, evc impacted adversely on blood pressure (bp) management, caused tachycardia, and worsened arterial stiffness. finally, evc use was associated with an increased risk of adverse clinical events, including atrial fibrillation and myocardial infarction, even if the causal link is still debated. most reviews highlighted that the detrimental impact of evc was of lesser magnitude of that of tcc. in addition, the differential impact of liquids and nicotine was not clearly disentangled. finally, no review included studies on hnbc. summary: the present umbrella review suggests that evc, and likely hnbc, despite clearly causing an increase in overall cardiovascular risk, may represent a temporary lesser evil than tcc in a risk-reduction or risk-modification strategy, aiming for eventual abstinence from all tobacco or nicotine products. smoking represents one of the leading causes of preventable morbidity and mortality worldwide, causing a plethora of adverse medical conditions, including coronary artery disease, stroke, chronic obstructive pulmonary disease, and cancer, and its detrimental effects impact also on passive smokers [ •, - ] . even in the current coronavirus-associated disease (covid- ) pandemic, smokers, especially the elderly, appear to have an increased risk of getting infected, progressing toward severely symptomatic disease, and dying due to severe acute respiratory syndrome-coronavirus- (sars-cov- ) infection [ ] [ ] [ ] [ ] . abstinence is easy to preach but harder to achieve, and several strategies have been proposed to ensure smokers can discontinue and abstain from their habit, ranging from telemedicine, nicotine replacement therapy, varenicline, and bupropion [ ••] . most recently, novel forms of smoking have been developed, which differ from traditional combustion cigarettes (tcc) as smoking is not due to combustion but vaporization of nicotine-containing liquids, i.e., electronic vaping cigarettes (evc), or heating of tobacco products without combustion, this article is part of the topical collection on cardiovascular care i.e. heat-not-burn cigarettes (hnbc) [ ] [ ] . collectively, these alternative ways to smoke are called modified risk products (mrp) or, more optimistically, reduced risk products (rrp) [ , ••, - ] . substantial evidence continues to accrue on mrp, including results of randomized controlled trials (rct), and several systematic reviews have already been published on this topic [ ••] . however, the interplay between mrp, cardiovascular physiology, and cardiovascular disease is still uncertain, with conflicting results provided by different scholarly sources [ ] . we thus aimed at conducting an updated umbrella review of systematic reviews on the cardiovascular effects, in terms of both pathophysiology and symptomatic disease, of evc and hnbc [ •] . in keeping with prior similar projects led by our group, this work was designed as an umbrella review (i.e., overview of systematic reviews) following established recommendations for evidence synthesis [ •, - ] . specifically, we searched pubmed in order to find pertinent systematic reviews on the cardiovascular safety of mpr using the following string: [ •] . from a total of publications, no specific cardiac event was reported, but chest pain was relatively common in such compiled series of cases ( %). hua and talbot screened several databases looking for case reports of adverse events associated with evc use, retrieving two cases (a case of acute myocardial infarction in a young man and a case of atrial fibrillation in an elderly woman) [ ] . in both cases reported in this hypothesis-generating systematic review, nicotinecontaining evc had been used. farsalinos and polosa conducted a systematic review on several different generations of evc focusing on their comparison versus tcc and nicotine gums, the impact of nicotine, and the risk of active as well as passive smoking [ ••] . in particular, they synthesized evidence from different reports, including several chemical studies, toxicological studies, and clinical trials. they concluded that, despite evident safety issues, including the presence of many toxic agents with established multidimensional risk (e.g., acetaldehyde, acrolein, aluminum, amino-tandalafil, copper, diethylene glycol, formaldehyde, iron, lead, nickel, particulate matter, rimonambant, and silica), evc represent an appealing alternative to tcc in a rrp strategy. in terms of hazards, they highlighted the risk of tachycardia and hypertension, as well as impaired left anterior descending flow reserve, even if it remained unclear whether these effects depended mainly on nicotine. interestingly, this old review was promising but limited by incomplete reporting and lack of quantitative synthesis. garcia and colleagues performed a systematic review and meta-analysis on the effects of evc on blood pressure (bp), heart rate (hr), and heart rate variability (hrv), pooling data from studies, and using largely explicit and valid methods [ ] . they concluded that evc are associated with acute increases in systolic blood pressure (sbp), diastolic blood pressure (dbp), and hr, and changes in hrv typical of sympathetic prevalence over vagal activity, even if mostly explained by nicotine exposure. notably, chronic use of evc still had adverse effects on hrv, but effects on bp and hr were much more diluted, potentially suggesting time-dependent adaptation. kennedy and colleagues reviewed several experimental and clinical studies on the cardiovascular safety of evc, highlighting that they may cause oxidative stress, cardiomyocyte dysfunction and mutagenesis, vascular inflammation, endothelial dysfunction, vasospasm, complement deposition, platelet aggregation, adhesion, and activation, with hypertension, tachycardia, arterial stiffening, atherosclerosis and thrombotic risk, albeit less intensely than tcc [ ] . most importantly, they suggested that studies with conflicts of interest were less likely to report adverse events. skotsimara and colleagues reviewed studies, ranging from preclinical to clinical ones, and then performed a formal meta-analysis of trials [ ] . overall, they identified the following as main signs of detrimental effects of evc: cytotoxicity, oxidative stress, endothelial dysfunction, bp, hr, arterial stiffness, and myocardial infarction. notably, most of these effects were heterogeneous and quantitatively less intense than those associated with tcc. finally, riley et al. conducted a systematic review originally focused on the interplay between hormonal contraception, evc, and cardiovascular risk [ ] . no study explicitly focused on hormonal contraception was retrieved, and thus they expanded their analysis to the pathophysiologic link between evc and cardiovascular outcomes. after including a total of studies they concluded that evc significantly impact of bp and hr, and may be associated with an increased risk of myocardial infarction. our umbrella review, poignantly synthesizing the evidence accrued so far from in vitro, in animal, in human volunteers, healthy subjects, and patients on the cardiovascular risk associated with evc use, either acute or chronic, shows that data are expanding progressively, but several conclusions can already be made on the ] . first, acute evc use is associated with several toxic effects at molecular (e.g., dna), cellular, tissue, organ, and system level [ , ] . for instance, oxidative stress, cytotoxicity, and cardiomyocyte dysfunction are established effects of evc [ ] . second, evc impact adversely on bp management, cause tachycardia, and worsen arterial stiffness [ , ] . third, evc use has been associated with an increased risk of adverse clinical events, including atrial fibrillation and myocardial infarction, even if the causal link is still debated [ , ] . yet, most reviews highlighted that the detrimental impact of evc was of lesser magnitude of that of tcc. in addition, the differential impact of liquids and nicotine was not clearly disentangled. overall, these findings confirm prior reports and support further research on the topic of cardiovascular safety of evc. several avenues for research are worth exploring. for instance, translational studies on the precise cellular mechanisms involved in evc toxicity are needed, exploring for instance microrna, inflammatory cascade, autophagy, apoptosis, and regeneration [ ] [ ] [ ] . observational studies on large samples are needed to accurately gauge the short and long-term risks of evc in apparently healthy subjects and in patients with cardiovascular disease [ ] . in addition, randomized trials, from small-sample speculative ones to large pragmatic studies, are direly needed to ensure that the place of evc in current clinical practice is correctly defined [ ] . indeed, our premise is that evc should be considered as an over-the-counter medical intervention suitable to support chronic smokers in their journey to eventual cessation. accordingly, only a comprehensive evidence platform, hopefully summarized in a formal network meta-analysis, will be able to precisely define the place and role, if any, of evc in a comprehensive approach aiming at smoking cessation and harm minimization [ ] . pragmatically, and based on our personal and professional experience, we may suggest a stepwise use of evc and hnbc with the eventual aim of total and continued abstinence (fig. ). yet, practitioners should be aware of the potential interactions between mrp and pharmacologic therapy in patients with or at risk of cardiovascular disease, ranging from atherothrombosis to heart failure and valvular heart disease [ ] [ ] [ ] [ ] [ ] , as indeed it is plausible that many of the adverse cardiovascular effects of mrp depend on nicotine, thus raising the evident risk of cumulative toxicity if nrt and mrp are inadvertently combined. this umbrella review has several drawbacks, on top of those typical of this research design [ •] . first, studies and reviews discussed hereby are mostly of small size and limited followup, and often focus on apparently healthy subjects. second, data on long-term pulmonary and cancer risk are absent, but this cannot be considered proof of absence of oncologic risk, as only longitudinal studies will be able to inform on this safety dimension. another elephant in the room is the lack of comprehensive data on hnbc, which are a mainstay in the mrp arena, and can be considered for some aspects as safe or safer than evc, and for others worse (e.g., because of small but measurable combustion) [ •] . accordingly, we expect that additional research synthesis efforts will be needed in the future, including updated umbrella reviews. the information accrued in this umbrella review, coherently showing multidimensional adverse effects of hnbc and evc, highlights the evident risk of adverse cardiovascular events associated with mrp. accordingly, further restrictions to their usage could be considered, including equating them to over-the-counter or even prescription drugs. indeed, the best perspective is considering hnbc and evc as another management strategy to promote smoking cessation and maintain abstinence (fig. ) . moreover, their usage should be monitored, minimized in intensity and duration, aiming for clear timelines to switch from hnbc to evc and then stop them altogether if a hnbc-first approach is chosen, or instead having a goal of evc usage followed by cessation if an evc-first approach is adopted. an apparently banal but potentially useful framework could indeed be considering mrp as a novel and more palatable nrt, maintaining many of the rituals of tcc without the abundance of combustion byproducts. nonetheless, dedicated large-scale and pragmatic randomized trials are needed to test the above strategy before recommending it to individuals and patients at large. the present umbrella review suggests that evc, despite clearly causing an increase in overall cardiovascular risk, may represent a temporary lesser evil than tcc in a risk-reduction or risk-modification strategy, aiming for eventual abstinence from all tobacco or nicotine products. conflict of interest the authors declare that they have no conflict of interest. human and animal rights and informed consent this article does not contain any studies with human or animal subjects performed by any of the authors. tobacco smoking, harm reduction, and nicotine product regulation neoatherosclerosis: from basic principles to intravascular imaging impact of electronic alternatives to tobacco cigarettes on indoor air particular matter levels american college of cardiology/american heart association guidelines for hypertension the circulating vegf is only marginally associated with an increased risk for atherosclerosis. minerva cardioangiol cardiovascular considerations for patients, health care workers, and health systems during the covid- pandemic sars-cov- and covid- : facing the pandemic together as citizens and cardiovascular practitioners covid- in europe: the italian lesson extracorporeal membrane oxygenation for critically ill patients with coronavirus-associated disease : an updated perspective of the european experience. minerva cardioangiol efficacy and safety of smoking cessation interventions in patients with cardiovascular disease: a network meta-analysis of randomized controlled trials cardiovascular benefits of switching from tobacco to electronic cigarettes electronic cigarettes: where to from here? acute impact of tobacco vs electronic cigarette smoking on oxidative stress and vascular function acute effects of heat-not-burn, electronic vaping, and traditional tobacco combustion cigarettes: the sapienza university of rome-vascular assessment of proatherosclerotic effects of smoking ( sur -vapes ) randomized trial profiling the acute effects of modified risk products: evidence from the sur-vapes (sapienza university of rome-vascular assessment of proatherosclerotic effects of smoking) cluster study impact of tobacco versus electronic cigarette smoking on platelet function predictors of oxidative stress and vascular function in an experimental study of tobacco versus electronic cigarettes: a post hoc analysis of the sur-vapes study safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review hormonal contraception among electronic cigarette users and cardiovascular risk: a systematic review umbrella reviews: evidence synthesis with overviews of reviews and meta-epidemiologic studies comprehensive methodological guidance for readers and writers of umbrella reviews oral antiplatelet therapy in the elderly undergoing percutaneous coronary intervention: an umbrella review transcatheter aortic valve implantation in the elderly: an umbrella review cardiovascular autonomic effects of electronic cigarette use: a systematic review potential health effects of electronic cigarettes: a systematic review of case reports the cardiovascular effects of electronic cigarettes: a systematic review of experimental studies e-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis e-cigarettes and smoking cessation: evidence from a systematic review and meta-analysis cardiovascular effects of electronic cigarettes: a systematic review and meta-analysis a systematic literature review of e-cigarette-related illness and injury: not just for the respirologist thoughtprovoking perspective on the promises and risks of using electronic cigarettes to foster cessation and abstinence from tobacco and smoking assessing modified risk tobacco and nicotine products: description of the scientific framework and assessment of a closed modular electronic cigarette electronic cigarette aerosols suppress cellular antioxidant defenses and induce significant oxidative dna damage chronic intermittent electronic cigarette exposure induces cardiac dysfunction and atherosclerosis in apolipoprotein-e knockout mice acute effects of electronic and tobacco cigarettes on vascular and respiratory function in healthy volunteers: a crossover study electronic cigarettes and cardiovascular health: what do we know so far? vasc health risk manag dihydroxyacetone exposure alters nad(p)h and induces mitochondrial stress and autophagy in hek t cells new insights into the role of mtor signaling in the cardiovascular system micrornas in coronary heart disease: ready to enter the clinical arena? are propensity scores really superior to standard multivariable analysis? a randomized trial comparing the acute coronary, systemic, and environmental effects of electronic vaping cigarettes versus heatnot-burn cigarettes in smokers of combustible cigarettes undergoing invasive coronary assessment: rationale and design of the sur-vapes trial. minerva cardioangiol network meta-analysis: evidence synthesis with mixed treatment comparison interaction study between antiplatelet agents, anticoagulants, diabetic therapy and a novel delivery form of quercetin non-vitamin k oral anticoagulants for coronary or peripheral artery disease: a systematic review and meta-analysis of mortality and major bleeding sacubitril/valsartan improves left ventricular longitudinal deformation in heart failure patients with reduced ejection fraction Β-blockers treatment of cardiac surgery patients enhances isolation and improves phenotype of cardiosphere-derived cells morphological and chemical study of pathological deposits in human aortic and mitral valve stenosis: a biomineralogical contribution heat not burn tobacco product-a new global trend: impact of heat-not-burn tobacco products on public health, a systematic review publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -aosmo authors: gebrie, d.; getnet, d.; manyazewal, t. title: efficacy of remdesivir versus placebo for the treatment of covid- : a protocol for systematic review and meta-analysis of randomized controlled trials date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: aosmo background: in spite of the global containment on prevention efforts, the spread of coronavirus disease (covid- ) is continuing to rise, with . million confirmed cases and , deaths recorded worldwide since april . the outbreak has a significant threat to international health and economy. at present, there is no approved vaccine or treatment for the disease, while efforts are underway. remdesivir, a nucleotide-analogue antiviral drug developed for ebola, is determined to prevent and stop infections with covid- , while results are yet controversial. here, we aim to conduct a systematic review and meta-analysis of randomized controlled trials to compare the effectiveness of remdesivir and placebo in patients with covid- . method and analysis: we will search medline-pubmed, embase, cochrane library, clinicaltrials.gov, and google scholar databases without restriction in year of publication. we will include randomized controlled trials that assessed the effectiveness of remdesivir versus placebo for patients confirmed with covid- . we will follow the preferred reporting items for systematic review and meta-analysis (prisma ) guidelines for the design and reporting of the results. the primary endpoint will be time to clinical recovery. the secondary endpoints will be all cause mortality, discharged date, frequency of respiratory progression, and treatment-emergent adverse events. two independent authors will perform study selection, data extraction, and methodology quality assessment. revman . software will be used for statistical analysis. random/fixed effect model will be carried out to calculate mean differences for continuous outcomes and risk ratio for dichotomous outcomes between remdesivir and placebo. ethics and dissemination: this study does not require ethical approval, because no participants data will be involved in this systematic review and meta-analysis. the findings of this study will be published in reputable and peer-reviewed journal. registration: this review protocol is submitted in prospero database for registration and we will include the registration number in the revised version of the manuscript. keywords: novel coronavirus, -ncov, coronavirus diseases , covid- , sars-cov- , remdesivir, randomized controlled trials. systematic review, meta-analysis, protocol this systematic review and meta-analysis will be derived from only randomized controlled trials which will increase the quality of evidences. this systematic review and meta-analysis will be derived from only randomized controlled trials which will reduce between study heterogeneity. subgroup and sensitivity analysis will be carried out to identify possible reasons that may cause significant heterogeneity between studies. the use of cochrane risk of bias tool to assess risk of bias for each included studies to extract and synthesize evidence based conclusions. one of the limitation of this study might be the restriction of trials published in english language. over the course of december , the health authority of wuhan city, hubei province, china reported a cluster of pneumonia cases of unknown etiology [ ] . the chinese researcher rapidly isolated sever acute respiratory syndrome coronavirus (sars-cov- ) from a patient on january and came out to genome sequencing of the sars-cov- [ ] . on january , china's communicable diseases control authority announced that novel coronavirus ( -ncov) had been detected as the causative agent for the epidemics [ ] . on [ ] [ ] [ ] . in spite of the global containment on prevention efforts, the spread of covid- is continuing to rise with . million confirmed cases and , deaths recorded worldwide since april . [ ] [ ] . the outbreak of covid- infection has a significant threat to international health and economy [ ] . at present, there is no approved vaccine or treatment for covid- , so that identifying the drug treatment options as soon as possible is critical agenda to overcome the outbreak [ ] [ ] . despite the lack of approved drugs and vaccine for covid- , many scientists are endeavoring to find medicines specific to the virus and they have been looking into repurposing the already approved drugs. as of march , there has been clinical trials registered in clinicaltrials.gov and estimated to be over [ ] . currently, several drugs such as remdesivir, hydroxychloroquine, chloroquine, ritonavir+lopinavir, arbidol and interferon are undergoing randomized controlled trials (rcts) to test their efficacy and safety for the treatment of covid- in many countries [ ] [ ] [ ] [ ] [ ] [ ] . among these investigating drugs remdesivir showed promising results [ ] [ ] . remdesivir is nucleotide analog prodrug and shows broad spectrum antiviral activity against many rna viruses including sars-cov- [ ] [ ] . remdesivir has been reported as a treatment of covid- in united states, china and italy [ , , ] . while results are yet controversial [ ] . to bridge this gap, here we aim to conduct a systematic review and all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint meta-analysis of rcts to compare the effectiveness of remdesivir and placebo in patients with covid- . the protocol for this systematic review and meta-analysis is submitted in prospero database for registration and we will include the registration number in the revised version of the manuscript. we will search medline/pubmed (http://www.ncbi.nlm.nih.gov/pubmed/), embase sars-cov- , remdesivir, nucleotide-analogue, antiviral drug and randomized controlled trials. all potentially eligible studies will be considered for this review, irrespective of the primary outcomes. manual searching will be performed to find out additional eligible trials from the reference lists of key articles. all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. study eligibility criteria for this systematic review and meta-analysis will be in accordance with participants, intervention, comparison, outcomes and study designs (picos) descriptions [ ] . population: the population will be patients confirmed with covid- and with or without other co-morbid conditions in all age groups. the intervention/ experimental group will be any dose of remdesivir the comparator group will be placebo/ standard of care the primary endpoints will be time to clinical recovery and proportion of participants relieved from clinical symptoms defined at the time (in hours) from initiation of the study treatment. the secondary endpoints will be all cause mortality, discharged date, frequency of respiratory progression, oxygen saturation and treatment-emergent adverse events in each groups. only rcts evaluating effectiveness of remdesivir versus placebo for patients with covid- will be included. the title and abstract of all searched studies will be examined by two independent review authors. from the title and abstract of all studies identified by the database search, those studies duplicated and not meet the eligibility criteria will be excluded. the full texts of the remaining studies will be further reviewed. disagreements will be resolved by consensus and if persisted, we will be arbitrated through discussion with a third review author. we will follow the preferred reporting items for systematic review and meta-analysis (prisma ) guidelines [ ] for the design and reporting of the results. all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint two authors will independently extract data according to the pre-designed data extraction tool. the following data will be extracted from each included rcts: first author, year of publication, funding information, setting, mean age of the participant, interventions, comparators, doses, number of participants randomized, duration of treatment, all primary, secondary and other outcome measurements. if any disagreement regarding the data extraction between the two m . , , er o all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint review authors exist, the third author will be consulted and consensus will be made through discussion. the cochrane risk of bias tool [ ] will be used to assess the risk of bias for each included study. the risk of bias of each trial will be judged by two independent review authors as "low", "unclear", or "high" based on the critical domains, including random sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting and other source of biases. disagreements will be resolved by discussion among all authors. if the disagreements cannot be resolved through discussion, an arbiter will make the final decision. meta-analysis will be carried out using the computer software packages revman . [ ] . continuous outcome data will be reported using a mean difference (md) and a % confidence interval (ci). binary outcome data will be summarized using risk ratio (rr) and % ci. mantel-haenszel method [ ] will be used to pool effect estimates of dichotomous outcomes and inverse variance for continuous outcomes. cochrane q test [ ] will be used to assess heterogeneity between studies, and i testing [ ] will be done to quantify heterogeneity between studies, with values > % representing moderate-to-high heterogeneity. if heterogeneity all rights reserved. no reuse allowed without permission. author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/ . / . . . doi: medrxiv preprint between study is acceptable, a fixed-effect model will be used to pool the data. on the other hand, if unacceptable heterogeneity detected or if the number of studies are small, a randomeffect model will be used to pool the data [ ] . subgroup analysis will be carried out to identify possible reasons that may cause significant heterogeneity between studies. if we get acceptable heterogeneity after the subgroup analysis, we will perform meta-analysis. otherwise, we will do a narrative description. sensitivity analysis will be conducted to see the robustness of pooled data by removing low quality studies. statistical analysis with a p-value < . will be considered statistically significant. when individual participant's data are initially unavailable, we will review the original source, and/or published trial reports and we will contact the authors to obtain clarification for these data. we will conduct funnel plot and egger test to check any possible reporting bias if a sufficient number of included studies (at least trials) are available in this study [ ] . this study does not require ethical approval, because no participant's data will be involved in this systematic review and meta-analysis. the findings of this study will be published in reputable and peer-reviewed journal. wuhan city health committee. wuhan municipal health and health commission's briefing on the current pneumonia epidemic situation in our city genomic characterisation and epidemiology of novel coronavirus: implications for virus origins and receptor binding experts claim that a new coronavirus is identified in wuhan complete genome characterization of a novel coronavirus associated with severe human respiratory disease in wuhan discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin genomic characterisation and epidemiology of novel coronavirus: implications for virus origins and receptor binding world health organization declares global emergency: a review of the novel coronavirus (covid- ) coronavirus update (live) controversial treatments: an update understanding of the coronavirus diseases drug treatment options for the -new coronavirus therapeutic options for the novel coronavirus ( -ncov). www center for disease control and prevention. information for clinicians on therapeutic options for covid- patients the first affiliated hospital zhejiang university school of medicine. handbook of covid- prevention and treatment potential antiviral therapeutics for novel coronavirus. chinese journal of tuberculosis and respiratory diseases coronavirus infections-more than just the common cold hopes rise over experimental drug's effectiveness against coronavirus. the guardian discovering drugs to treat coronavirus disease (covid- ) all rights reserved. no reuse allowed without permission author/funder, who has granted medrxiv a license to display the preprint in perpetuity coivid- : an update on the epidemiological, clinical, preventive and therapeutic evidence and guidelines of integrative chinese-western medicine for the management of novel coronavirus disease coronavirus susceptibility to the antiviral remdesivir (gs- ) is mediated by the viral polymerase and the proofreading exoribonuclease. mbio the origin, transmission and clinical therapies on coronavirus disease (covid- ) outbreak -an update on the status first case of novel coronavirus in the united states grade guidelines: . framing the questions and deciding on important outcomes preferred reporting items for systematic review and meta-analysis protocols (prisma-p) : elaboration and explanation cochrane handbook for systematic reviews of interventions copenhagen: the nordic cochrane centre, the cochrane collaboration mantel-haenszel estimators of a common odds ratio for multiple response data measuring inconsistency in meta-analyses quantifying heterogeneity in a meta-analysis fixed and random effects models: making an informed choice the authors would like to acknowledge center for innovative drug development and therapeutic trials for africa (cdt-africa), college of health sciences, addis ababa university which is funding this study. key: cord- -wuo zerg authors: portella, caio fabio schlechta; ghelman, ricardo; abdala, carmen verônica mendes; schveitzer, mariana cabral title: evidence map on the contributions of traditional, complementary and integrative medicines for health care in times of covid- date: - - journal: integr med res doi: . /j.imr. . sha: doc_id: cord_uid: wuo zerg background: due to the pandemic, there is a significant interest in the therapeutic resources linked to tcim to support potentially therapeutic research and intervention in the management of covid- . at the date of this evidence map´s publication, there is no evidence of specific treatments for coronavirus - (covid- ). this map organizes information about symptoms management (especially on dimensions related to mental health and mild viral respiratory infections, as well as immune system strengthening and antiviral activity). method: this evidence map applies methodology developed by latin american and caribbean center on health sciences information based on the ie evidence gap map. a search was performed in the traditional, complementary and integrative medicine virtual health library and pubmed, using the mesh and decs terms for respiratory viral diseases associated with epidemics, covid- symptoms, relevant mental health topics, pharmacological and non-pharmacological interventions related to tcim. results: for the map, systematic reviews and controlled clinical studies were characterized, distributed in a matrix with interventions ( phytotherapy, mind-body therapies, traditional chinese medicine, homeopathic and anthroposophic dynamized medicines and supplements), and outcomes ( immunological response, mental health, complementary clinical management of the infection and other). discussion: the map presents an overview of possible tcim contributions to various dimensions of the covid- pandemic, especially in the field of mental health, and it is directed to researchers and health professionals specialized in tcim. most of the antiviral activity outcomes described in this map refers to respiratory viruses in general, and not specifically to sars-cov- (severe acute respiratory syndrome coronavirus ). this information may be useful to guide new research, but not necessarily to support a therapeutic recommendation. finally, any suspicion of covid- infection should follow the protocols recommended by the health authorities of each country/region. the world health organization (who) has been encouraging and strengthening the insertion, recognition and use of traditional, complementary and integrative medicines (tcim), products and their practitioners in national health systems at all levels of activity: primary care, specialized care and hospital care, through the recommendations of the who strategy on traditional medicine - based on the regulation of quality, safety and efficacy [ ] . according to who, % of latin american countries have legislation on tcim, and % of them have a regulatory system for herbal therapies. although % of who member states have recognized their use of t&cm, which corresponds to member states, data from latin america show a lack of mechanisms to monitor the safety of t&cm practices and safety of t&cm products ( %); lack of financial support for t&cm research ( %) [ ] . evidence maps are a useful method with the dual function of synthesizing available evidence on a specific topic and identifying knowledge gaps. it requires a systematic review of the j o u r n a l p r e -p r o o f literature and an assessment of the type and quality of available evidence. evidence maps, unlike other synthesis methods, use graphical representations (or dynamic representations, through interactive online databases), which facilitate the interpretation of results [ ] . because of the recent covid- this evidence map summarizes tcim interventions and health outcomes related to improved immunity/antiviral effect for respiratory viruses, treatment of symptoms of respiratory infections and contributions to mental health. we report the method and results according to prisma guidelines [ ] and the international initiative for impact evaluation ( ie) evidence gap methodology [ ] . this evidence map was supported by a technical expert panel of librarians, practitioners, policy maker and researcher content experts. we searched pubmed and traditional, complementary and integrative medicine virtual health library (tcim vhl) from database inception to march for studies published in english, spanish and portuguese. vhl is a decentralized and dynamic collection of information sources, designed to provide equitable access to scientific knowledge on health. it is maintained by bireme, a paho specialized center. this collection includes databases j o u r n a l p r e -p r o o f such as lilacs, medline, cochrane library and scielo. we consulted topic experts and developed the search strategy together with bireme. a search strategy was developed, using the mesh and decs terms for respiratory viral diseases associated with epidemics, covid- symptoms, relevant mental health topics, pharmacological interventions related to tcim (medicinal plants/ phytotherapy, herbal medicine, chinese and ayurvedic herbology, drugs related to homeopathy and anthroposophic medicine, probiotics, nutritional supplements, among others), as well as non-pharmacological tcim interventions (yoga, taichi, mindfulness, meditation, qigong, tapping, body practices, among others). the terms used in the search strategy were reviewed by tcim experts and researchers, and by librarians. • any type of traditional and complementary therapies interventions, of any duration and follow up; • controlled clinical studies; • systematic reviews with or without meta-analyses with humans, for any age group. • relevant non-systematic reviews; • outcomes related to improved immunity/antiviral effect for respiratory viruses, treatment of symptoms of respiratory infections or contributions to mental health (depression, social isolation, anxiety and stress disorders including work stress); • studies in portuguese, spanish, and english; • all participants of all ages regardless of health status. we excluded studies that did not focus on tcim interventions, case reports and control case studies. two independent literature reviewers screened the systematic review search output blinded at the software rayyan. citations deemed potentially relevant by at least one reviewer and unclear citations were obtained as full text. the full-text publications were screened against the specified inclusion criteria by two independent reviewers; disagreements were resolved through discussion. from each included systematic review, we extracted the intervention (e.g., mind-body therapies practice, yoga, acupuncture) and the main health outcomes (e.g., stress, anxiety, we identified studies that met the criteria for inclusion in the evidence map ( figure ). the studies selected came from countries. the complete list of references and the interactive evidence map can be accessed in the mtci vhl, available at: http://mtci.bvsalud.org/en/contributions-of-traditional-complementary-and-integrativemedicine-tcim-in-the-context-of-covid- /. studies included were designed as randomized controlled studies (n= ), non-randomized controlled studies (n= ), coorte (n= ), prospective (n= ), retrospective (n= ), observational (n= ), meta-analysis (n= ), evidence maps (n= ), systematic reviews (n= ), systematic reviews with metanalysis (n= ), narrative reviews (n= ), scoping reviews (n= ). the included studies presented tcim interventions divided into five major groups: phytotherapy ( ), mind-body therapies therapies ( ), traditional chinese medicine interventions ( ), homeopathic and anthroposophic dynamized medicines ( ) and supplements ( ), as presented in table . tcim was evaluated as an intervention for several health outcomes. the studies showed outcomes in total divided into major groups: immunological response ( ) ; mental health ( ) ; complementary clinical management of the infection ( ) and others ( ) . every outcome effect was classified, more than one outcome for some studies: as potential negative [ ] ; as no effect; as inconclusive; as potential positive and as positive j o u r n a l p r e -p r o o f (fig. ) . effects classification was extracted from mapped studies' results as reported by their authors. the results in this category have shown for mind-body therapies and traditional chinese medicine interventions potential positive effects and positive effects. for phytotherapy and supplements there were more studies indicating potential positive and positive effects than studies indicating no effect or inconclusive effect, and for dinamized medicines the findings showed inconclusive, potential positive results and in only one study did it show one potential negative effect, headache [ ] . also, in this category, a systematic review points out the relevance of the use of probiotics [ ] for the prevention of respiratory diseases in hospitalized patients, as well as for the improvement of the immunological [ ] condition as a preventive resource for cases of aggravation of the disease. another systematic review demonstrates that the use of prebiotics and probiotics can improve the efficiency of vaccines against influenza family viruses[ ] a factor of great relevance for future research. in the phytotherapy category, other clinical studies on immunostimulating activity of echinacea purpúrea [ ] viscum album [ ] , individualized chinese herbal therapy [ ] and wolfberry [ ] stand out. the viscum album has been employed mainly by the complex medical system of anthroposophic medicine. in general, research on vitamin supplementation using vitamin c, vitamin d, selenium, and other nutrients for immunological efficiency stands out as relevant only in cases of nutritional deficiency [ ] [ ] [ ] . this category included outcomes only related to mind-body therapies, phytotherapy and traditional chinese medicine. there was a mix of potential positive, positive, inconclusive and no effect outcomes. findings in this category point to resources for post-traumatic stress disorder, relevant in a situation of pandemic and social isolation, in this category mind-body therapies and yoga [ ] [ ] [ ] [ ] , meditation techniques [ ] [ ] [ ] and acupuncture [ ] stand out. other resources that promote resilience are highlighted from mindfulness [ ] meditation techniques with the reduction of negative affective symptoms [ ] , as well as factors such as stress [ , ] , anxiety and depression [ ] [ ] [ ] [ ] [ ] . aromatherapy resources are also described for application in cases of anxiety [ , ] . the results of the group were mostly potentially positive and positive effects with only two inconclusive outcomes. the results also call attention to evidence of various formulations for respiratory symptoms present in covid- , these being potential resources for management of symptoms such as fever, body pain, runny nose and other symptoms. [ , ] the interventions with the greatest number of publications showing a positive effect refer to chinese herbology, with systematic reviews bringing relevant conclusions for the treatment of symptoms in acute respiratory syndromes [ ] [ ] [ ] [ ] . additionally, we found studies with good positive results from prospective controlled clinical studies with the herbal medicines sambucus nigra [ ] and allium sativum [ ] besides anthroposophic remedies [ , ] . america is now the epicenter of the pandemic worldwide [ ] . despite the need for evidencebased treatment for covid- , another health problems are related to the pandemic, such as mental health problems and management of respiratory infections symptoms. the creation and publication of evidence maps consists of graphically representing the best evidence found, analyzed and categorized, in addition to linking with the bibliographic records and full texts (when available) of the studies in order to facilitate access to information for all those interested. although evidence maps have several limitations, such as the fact that we only used published reviews to provide an overview of the research and that no further evidence was included, for example qualitative studies. we did not calculate effect sizes in a meta-analysis, neither provide risk of bias assessments, but we tried to overcome these limitations by relying on the author's skills in conducting and evaluation the studies quality, choice of outcomes, analysis of effects and susceptibility to publication and outcome reporting bias. this evidence map will also not be able to answer more refined questions, such as the most adequate tcim application, difference between health services, adequate training for practitioners, access of patients and self-application effects. future research, including qualitative research and case studies, are necessary to answer these questions, extremely we recommend that any suspicion of covid- infection should follow the protocols recommended by the health authorities of each region. cfsp and mcs drafted the manuscript. all authors designed the study, designed and executed the search strategy and were involved in data acquisition and analysis. all authors were involved in the interpretation of the data and contributed to the final manuscript. all authors read and approved the final manuscript. who global report on traditional and complementary medicine a typology of reviews: an analysis of review types and associated methodologies estrategia de la oms sobre medicina tradicional - preferred reporting items for systematic reviews and meta-analyses: the prisma statement evidence & gap maps: a tool for promoting evidence informed policy and strategic research agendas homeopathic oscillococcinum® for preventing and treating influenza and influenza-like illness probiotics in the critically ill: a systematic review of the randomized trial evidence clinical effects of probiotic bifidobacterium longum bb on immune function and intestinal microbiota in elderly patients receiving enteral tube feeding effect of probiotics and prebiotics on immune response to influenza vaccination in adults: a systematic review and metaanalysis of randomized controlled trials echinacea purpurea for prevention of experimental rhinovirus colds immunomodulatory and clinical effects of viscum album (iscador m and iscador p) in children with recurrent respiratory infections as a result of the chernobyl nuclear accident immunomodulatory effects of a traditional chinese medicine with potential antiviral activity: a self-control study immunomodulatory effects of dietary supplementation with a milk-based wolfberry formulation in healthy elderly: a randomized, double-blind, placebo-controlled trial potential interventions for novel coronavirus in china: a systemic review does vitamin d deficiency affect the immunogenic responses to influenza vaccination? a systematic review and meta-analysis prevention and treatment of influenza, influenza-like illness, and common cold by herbal, complementary, and natural therapies evidence map of yoga for depression, anxiety, and posttraumatic stress disorder meditation for posttraumatic stress: systematic review and meta-analysis mind-body interventions, psychological stressors, and quality of life in stroke survivors: a systematic review mind-body therapy for military veterans with post-traumatic stress disorder: a systematic review psychological trauma : theory , research , practice , and policy meditation for posttraumatic stress : systematic review meditation for posttraumatic stress : systematic review and meta-analysis meditation programs for veterans with posttraumatic stress disorder: aggregate findings from a multi-site evaluation meditation and yoga for stress disorder: a meta-analytic review of randomized controlled trials acupuncture for the treatment of adults with posttraumatic stress disorder: a systematic review and meta-analysis road to resilience: a systematic review and meta-analysis of resilience training programmes and interventions the relationship between trait mindfulness and affective symptoms: a meta-analysis of the five facet mindfulness questionnaire (ffmq) can we respond mindfully to distressing voices? a systematic review of evidence for engagement, acceptability, effectiveness and mechanisms of change for mindfulness-based interventions for people distressed by hearing voices mindfulness mediates the physiological markers of stress: systematic review and meta-analysis patients receiving integrative medicine effectiveness registry (primier) of the bravenet practice-based research network: study protocol interventions for common mental health problems among university and college students: a systematic review and meta-analysis of randomized controlled trials ayurveda and traditional chinese medicine: a comparative overview. evidence-based complement an overview of complementary and alternative medicine therapies for anxiety and depressive disorders. suppl to effic complement altern med ther posttraumatic stress disord clinical pharmacology of citrus aurantium and citrus sinensis for the treatment of anxiety influence of lavender oil inhalation on vital signs and anxiety: a randomized clinical trial anthroposophic therapy of respiratory and ear infections efficacy of lianhuaqingwen capsule compared with oseltamivir for influenza a virus infection: a meta-analysis of randomized, controlled trials chinese herbs combined with western medicine for respiratory syndrome (sars) chinese herbal medicines for the treatment of type a h n influenza: a systematic review of randomized controlled trials chinese herbal medicine for severe acute respiratory syndrome: a systematic review and meta-analysis effect of integrated traditional chinese and western medicine on sars: a review of clinical evidence randomized study of the efficacy and safety of oral elderberry extract in the treatment of influenza a and b virus infections antibiotic use in children with acute respiratory or ear infections: prospective observational comparison of anthroposophic and conventional treatment under routine primary care conditions. evidence-based who coronavirus disease (covid- ) outbreak situation key: cord- -ylgyvxtd authors: matos, ana r.; quintas-neves, miguel; oliveira, ana i.; dias, luís; marques, sofia; carvalho, raquel; alves, josé n. title: covid- associated central nervous system vasculopathy date: - - journal: the canadian journal of neurological sciences. le journal canadien des sciences neurologiques doi: . /cjn. . sha: doc_id: cord_uid: ylgyvxtd nan a -year-old man presented to the emergency department with fever, asthenia, myalgias, dry cough, and hyposmia. after detection of viral nucleic acid from severe acute respiratory syndrome coronavirus (sars-cov- ) in a nasopharyngeal swab, the diagnosis of coronavirus disease (covid- ) was made. as there were no severe criteria for admittance, the patient was discharged on symptomatic medication. one week later, he was brought to the hospital due to altered mental status, slowness of movements, and apathy. neurological examination revealed dysexecutive syndrome, perseveration, and mild dysphonia/dysphagia; there were no pyramidal/extra-pyramidal signs. blood work-up was unremarkable, and brain computed tomography (ct) showed multiple hypodense lesions involving the white matter, basal ganglia, and thalami. lumbar puncture revealed mild elevated proteins ( . mg/dl) without pleocytosis; cerebrospinal fluid (csf) viral workup was negative, including sars-cov- . extensive serological immune and infective panels were negative. suspecting an inflammatory response related to sars-cov- infection, intravenous immunoglobulin ( g/day) was initiated. brain magnetic resonance imaging (mri) ( figure a -d) confirmed multiple lesions involving the deep and subcortical white matter on both hemispheres, as well as the thalami, basal ganglia, and basal pons, that were hyperintense on fluidattenuated inversion recovery sequence; some showed restricted diffusion on diffusion-weighted imaging, namely on both corona radiata and bilateral deep frontal white matter. threedimensional time of flight ( figure e ) did not show any major vessel occlusion; however, a prominent irregularity was depicted on the p segment of the left posterior cerebral artery. there were no hemorrhages on susceptibility-weighted imaging. digital subtraction angiography was performed week later, only showing a mild irregularity in a lenticulostriate artery. cardiac investigation and carotid bulb evaluation by angio-ct were unremarkable. the findings were suggestive of multiple chronologically distinct ischemic lesions on several arterial territories, with the most recent on deep watershed zones; given the current infection by sars-cov- and presuming an infection-related vasculopathy, immunoglobulin therapy was switched to high-dose intravenous methylprednisolone ( g/day, days), tapered to mg/kg prednisolone, and aspirin ( mg/day). after days, the patient improved and was discharged under corticosteroids, with no new mri lesions. stroke in the setting of viral vasculopathy has been described with other viruses, such as varicella zoster virus (vzv) or ; more recently, it has also been associated with other coronavirus, namely, middle east respiratory syndrome coronavirus, during the outbreak in saudi arabia in . the clinical presentation of altered mental status and dysexecutive syndrome, week after being diagnosed with covid- , made us consider a probable causal association. the imaging presentation of multiple lesions involving deep and subcortical white matter, as well as deep gray nuclei, with marked restricted diffusion of some, has been described in the setting of vzv vasculopathy. in sars-cov- infection, vascular injury can occur through direct and/or indirect mechanisms: the first as result of viral affinity to angiotensin-converting enzyme- expressed by endothelial cells, , and the second by misdirected host immune response that induces coagulopathy and vasoconstriction (possibly without csf viral isolation). moreover, the association between sars-cov- and large vessel occlusion has been recently described. in our case, vascular imaging did not depict large vessel stenosis/occlusion, only detecting minor irregularities on medium-/ small-sized vessels; this could be due to preferential involvement of such arteries or a falsely negative result in the setting of concomitant immunosuppressive therapy. it is also important to note the absence of detectable sars-cov- ribonucleic acid in csf could be due to a predominant indirect pathophysiological mechanism of vasculopathy and/or lack of sensitivity of the analytical technique used. primary angiitis of the central nervous system was also considered, but the absence of obvious large vessel irregularities, normal csf cellular count, and concomitant sars-cov- infection led us consider a covid- -related vasculopathy as the most probable diagnosis, potentially induced by misdirected immune mediated-vasoconstriction of medium-/ small-sized arteries; we believe this represents a new imaging presentation of a sars-cov- -related complication. the patient was managed empirically with steroids and antiplatelets, showing no new lesions on subsequent imaging evaluations. none. arm: acquisition of data, clinical data review, literature review, and final manuscript writing; mq-n: acquisition of data, imaging data review, literature review, and final manuscript writing; aio: clinical data review, acquisition of data, and literature review; ld: clinical data review, and literature review; sm: clinical data review, acquisition of data, and literature review; rc: acquisition of data and imaging data review; jna: clinical data review, literature review and final manuscript writing. this study complies with the declaration of helsinki and was conducted in accordance to the local ethics committee requirements. no figures or videos contain information which allows patient identification, and therefore, written patient consent for the publication was not obtained. virus vasculopathy and stroke: an under-recognized cause and treatment target severe neurologic syndrome associated with middle east respiratory syndrome corona virus (mers-cov) varicella zoster virus vasculopathies: diverse clinical manifestations, laboratory features, pathogenesis, and treatment endothelial cell infection and endotheliitis in covid- electron microscopy of sars-cov- : a challenging task -authors' reply clinical course of risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study large-vessel stroke as a presenting feature of covid- in the young key: cord- -tn r lj authors: fretheim, atle; brurberg, kjetil g; forland, frode title: rapid reviews for rapid decision-making during the coronavirus disease (covid- ) pandemic, norway, date: - - journal: euro surveill doi: . / - .es. . . . sha: doc_id: cord_uid: tn r lj in response to urgent needs for updated evidence for decision-making on various aspects related to coronavirus disease (covid- ), the norwegian institute of public health established a rapid review team. using simplified processes and shortcuts, this team produces summary reviews on request within – days that inform advice provided by the institute. all reviews are published with explicit messages about the risk of overlooking key evidence or making misguided judgements by using such rapid processes. while keeping up with scientific developments is challenging also under normal circumstances, the combination of uncertainties in dealing with a novel virus and a huge outpour of research papers dealing with covid- , many of them not peer-reviewed, made it particularly challenging to provide evidence-informed guidance, either to the public, health services or policymakers. evidence-informed decision-making should rely on the best available evidence, typically in the form of systematic reviews [ ] . in a systematic review, relevant research findings on a given topic, guided by specific research questions, are identified, appraised and summarised through a transparent and scientifically sound process [ ] . since covid- is a novel disease [ ] , at its onset there were very few systematic reviews to base decisions on. in addition, systematic reviews on covid- -related topics were likely to become rapidly outdated, given the large number of new study reports published daily. scarcity of evidence and shortage of time pose specific challenges, for evidence-informed decision-making [ ] . to meet the urgent need for updated evidence, niph set up a rapid review team of - researchers and an information specialist. all team members had wide experience in conducting systematic reviews and health technology assessments, but no specific expertise in epidemics or infectious diseases. the niph's task force for managing the national response to the pandemic, selected and prioritised topics for rapid review through an informal process, based on requests from stakeholders and the perceived needs. after we established the team on march , it immediately started working on the following topics: the risk of airborne transmission, the role of children in the spread of disease, the relationship between age, comorbidity and disease severity, immunity to covid- , and transmission via surfaces. by april, we had published eight rapid reviews, which were made available on the institute's website [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . since speed was imperative, the rapid review team intended to simplify their normal systematic review production process to the extent that reviews could be prepared in a matter of days, instead of the several months usually needed to prepare a full-fledged systematic review. normally, a rapid review will rely on existing systematic reviews in order to be timely prepared [ ] . this was only partly possible in the present situation, since most questions were specific for covid- and indirect evidence from studies on other viral diseases, e.g. influenza or severe acute respiratory syndrome (sars), was of limited interest. an advantage, in terms of speed, was that we could restrict our literature searches to covid- publications, thus limiting each search on a specific aspect to publications from the last few months, and use covid- -specific search engines, e.g. the united states national library of medicine's new literature hub, litcovid [ ] . this made the number of hits manageable. on the other hand, we felt obliged to search for non-peer reviewed reports from preprint servers such as medrxiv. this increased the workload substantially, as this meant having to assess a large number of additional titles and reports, and because the quality of these manuscripts proved highly variable. the team members individually screened potentially relevant titles, i.e. not in duplicate or with doublechecking, as would be the normal practice for systematic reviews. similarly, each team member assessed the relevance and validity of each study, and checklists or other formal approaches were not used. metaanalyses were not conducted, and findings from the included studies were summarised narratively. this process entailed some degree of judgement, especially concerning which findings to emphasise, or not. all results and conclusions were discussed by two team members. we also had a rapid peer review process, which meant that at least two content experts -often the commissionaires -reviewed the manuscript. our rapid review process entailed many shortcuts compared with the standard systematic-review approach -probably also in comparison with most other rapid reviews. to make the inherent risks explicit, we always included a description of the method as well as the following statement: "in the current situation, there is an urgent need for identifying the most important evidence quickly. hence, we opted for this rapid approach despite an inherent risk of overlooking key evidence or making misguided judgements." given the infancy of the field and the large volume of covid- related research, the rapid reviews need regular updates to remain relevant. until now, we have updated one rapid review, which serves as an example of the evolving evidence base: we published the first rapid review on the relationship between age, comorbidity and disease severity on march [ ] . at that time, we only identified three studies with the multivariate analyses needed to distinguish between the effect of age and of comorbidities. three weeks later, in our updated review [ ] , we were able to include studies with multivariate analyses. our comment in the discussion section expresses the frustration that many may feel when assessing large amounts of covid- research articles, often of questionable quality: "there seems to be an abundance of publications reporting on small samples of patients, with simple univariate analyses of risk factors for severe covid- . in our view, such studies contribute little to improving our understanding of the importance of various risk factors. we encourage medical journals to refuse publication of additional research papers with small sample sizes, and to require multivariate analysis." being a national public health institute with responsibilities for infectious diseases prevention and response, as well as having the role as the national centre for evidence-based healthcare, meant that the competence and tools to develop the rapid reviews were available within the organisation. this allowed to establish fast and efficient collaborations across relevant units. the rapid reviews are highly valued and seen as key contributions to the evidence that informs advice provided by the institute. the rapid reviews have also been widely cited in the media. our expectation for the upcoming weeks and months is that the methodology of our rapid reviews will evolve towards the more thorough and standardised systematic review processes. we acknowledge that there are initiatives parallel to ours, taken by other institutions, using slightly different methodologies and published in different languages. with this current report, we hope to share methodologies and results and to prevent redundancy and overlap. [ ] [ ] [ ] [ ] [ ] . given the large volume of new publications on covid- with highly variable quality, we have no doubt that systematic reviews will play a key role in informing an evidencebased management of the ongoing pandemic. as of may, all our covid- rapid reviews are available in english versions: https://www.fhi.no/en/sys/ news/?blockid= &ownerpage= &language =en another initiative at our institute is the creation of a living map of available evidence for covid- -a collaborative effort with mcmaster university and the cochrane canada centre -to ease the work for reviewers internationally: https://www.fhi.no/en/qk/ systematic-reviews-hta/map/ european centre for disease prevention and control (ecdc) support tools for evidence-informed health policymaking (stp) : what is evidence-informed policymaking? rationale for systematic reviews evidence-based medicine applied to the control of communicable disease incidents when evidence is scarce and the time is limited mers-cov and sars-cov and risk of airborne transmission -a rapid review the role of children in the transmission of sars-cov- - -a rapid review covid- : the relationship between age, comorbidity and disease severity -a rapid review contact based transmission of sars-cov- . oslo: norwegian institute of public health aerosol generating procedures in health care, and covid- . oslo: norwegian institute of public health immunity after sars-cov- infection. rapid review. oslo: norwegian institute of public health case fatality rate for serious covid- . oslo: folkehelseinstituttet covid- : the relationship between age, comorbidity and disease severity -a rapid review, st update a taxonomy of rapid reviews links report types and methods to specific decision-making contexts keep up with the latest coronavirus research rapid hta of alternative diagnostic technologies for the detection of sars-cov- . ireland: health information and quality authority evidence summary for asymptomatic transmission of covid- . ireland: health information and quality authority evidence summary for covid- viral load over course of infection. ireland: health information and quality authority are interventions such as social distancing effective at reducing the risk of asymptomatic healthcare workers transmitting covid- infection to other household members? united kingdom: centre for evidence based medicine covid- : état des connaissances et veille documentaire none declared. all authors (af, kg, ff) participated in writing and editing the article, and in the establishment of the rapid review process for covid- . this is an open-access article distributed under the terms of the creative commons attribution (cc by . ) licence. you may share and adapt the material, but must give appropriate credit to the source, provide a link to the licence and indicate if changes were made.any supplementary material referenced in the article can be found in the online version. key: cord- -aew xr n authors: garcía-durán, alberto; gonzález, roberto; oñoro-rubio, daniel; niepert, mathias; li, hui title: transrev: modeling reviews as translations from users to items date: - - journal: advances in information retrieval doi: . / - - - - _ sha: doc_id: cord_uid: aew xr n the text of a review expresses the sentiment a customer has towards a particular product. this is exploited in sentiment analysis where machine learning models are used to predict the review score from the text of the review. furthermore, the products costumers have purchased in the past are indicative of the products they will purchase in the future. this is what recommender systems exploit by learning models from purchase information to predict the items a customer might be interested in. the underlying structure of this problem setting is a bipartite graph, wherein customer nodes are connected to product nodes via ‘review’ links. this is reminiscent of knowledge bases, with ‘review’ links replacing relation types. we propose transrev, an approach to the product recommendation problem that integrates ideas from recommender systems, sentiment analysis, and multi-relational learning into a joint learning objective. transrev learns vector representations for users, items, and reviews. the embedding of a review is learned such that (a) it performs well as input feature of a regression model for sentiment prediction; and (b) it always translates the reviewer embedding to the embedding of the reviewed item. this is reminiscent of transe [ ], a popular embedding method for link prediction in knowledge bases. this allows transrev to approximate a review embedding at test time as the difference of the embedding of each item and the user embedding. the approximated review embedding is then used with the regression model to predict the review score for each item. transrev outperforms state of the art recommender systems on a large number of benchmark data sets. moreover, it is able to retrieve, for each user and item, the review text from the training set whose embedding is most similar to the approximated review embedding. online retail is a growing market with sales accounting for $ . billion or . % of total us retail sales in [ ] . in the same year, e-commerce sales accounted for . % of all retail sales growth [ ] . for some entertainment products such as movies, books, and music, online retailers have long outperformed traditional in-store retailers. one of the driving forces of this success is the ability of online retailers to collect purchase histories of customers, online shopping behavior, and reviews of products for a very large number of users. this data is driving several machine learning applications in online retail, of which personalized recommendation is the most important one. with recommender systems online retailers can provide personalized product recommendations and anticipate purchasing behavior. in addition, the availability of product reviews allows users to make more informed purchasing choices and companies to analyze costumer sentiment towards their products. the latter was coined sentiment analysis and is concerned with machine learning approaches that map written text to scores. nevertheless, even the best sentiment analysis methods cannot help in determining which new products a costumer might be interested in. the obvious reason is that costumer reviews are not available for products they have not purchased yet. in recent years the availability of large corpora of product reviews has driven text-based research in the recommender system community (e.g. [ , , ] ). some of these novel methods extend latent factor models to leverage review text by employing an explicit mapping from text to either user or item factors. at prediction time, these models predict product ratings based on some operation (typically the dot product) applied to the user and product representations. sentiment analysis, however, is usually applied to some representation (e.g. bagof-words) of review text but in a recommender system scenario the review is not available at prediction time. with this paper we propose transrev, a method that combines a personalized recommendation learning objective with a sentiment analysis objective into a joint learning objective. transrev learns vector representations for at training time, a function's parameters are learned to compute the review embedding from the word token embeddings such that the embedding of the user translated by the review embedding is similar to the product embedding. at the same time, a regression model g is trained to perform well on predicting ratings. users, items, and reviews jointly. the crucial advantage of transrev is that the review embedding is learned such that it corresponds to a translation that moves the embedding of the reviewing user to the embedding of the item the review is about. this allows transrev to approximate a review embedding at test time as the difference of the item and user embedding despite the absence of a review from the user for that item. the approximated review embedding is then used in the sentiment analysis model to predict the review score. moreover, the approximated review embedding can be used to retrieve reviews in the training set deemed most similar by a distance measure in the embedding space. these retrieved reviews could be used for several purposes. for instance, such reviews could be provided to users as a starting point for a review, lowering the barrier to writing reviews. we address the problem of learning prediction models for the product recommendation problem. a small example of the input data typical to such a machine learning system is depicted in fig. . this reminds of knowledge bases, with 'reviews' replacing relation types. two nodes in a knowledge base may be joined by a number of links, each representing one relation type from a small vocabulary. here, if two nodes are connected they are linked by one single edge type, in which case it is represented by a number of words from a (very) large vocabulary. there are a set of users u, a set of items i, and a set of reviews r. each rev (u,i) ∈ r represents a review written by user u for item i. hence, rev (u,i) = [t , · · · , t n ], that is, each review is a sequence of n tokens. in the following we refer to (u, rev (u,i) , i) as a triple. each such triple is associated with the review score r (u,i) given by the user u to item i. transrev embeds all users, items and reviews into a latent space where the embedding of a user plus the embedding of the review is learned to be close to the embedding of the reviewed item. it simultaneously learns a regression model to predict the rating given a review text. this is illustrated in fig. . at prediction time, reviews are not available, but the modeling assumption of transrev allows to predict the review embedding by taking the difference of the embedding of the item and user. then this approximation is used as input feature of the regression model to perform rating prediction-see fig. . approx. review embedding but good price" similar g( ) fig. . at test time, the review embedding is approximated as the difference between the product and user embeddings. the approximated review embedding is used to predict the rating and to retrieve similar reviews. transrev embeds all nodes and reviews into a latent space r k (k is a model hyperparameter). the review embeddings are computed by applying a learnable function f to the token sequence of the review the function f can be parameterized (typically with a neural network such as a recursive or convolutional neural network) but it can also be a simple parameter-free aggregation function that computes, for instance, the element-wise average or maximum of the token embeddings. we propose and evaluate a simple instance of f where the review embedding h rev (u,i) is the average of the embeddings of the tokens occurring in the review. more formally, where v t is the embedding associated with token t and h is a review bias which is common to all reviews and takes values in r k . the review bias is of importance since there are some reviews all of whose tokens are not in the training vocabulary. in these cases we have h rev (u,i) = h . the learning of the item, review, and user embeddings is determined by two learning objectives. the first objective guides the joint learning of the parameters of the regression model and the review embeddings such that the regression model performs well at review score prediction where s is the set of training triples and their associated ratings, and g is a learnable regression function r k → r that is applied to the representation of the review h rev (u,i) . while g can be an arbitrary complex function, the instance of g used in this work is as follows where w are the learnable weights of the linear regressor, σ is the sigmoid function σ(x) = + e −x , and b (u,i) is the shortcut we use to refer to the sum of the bias terms, namely the user, item and overall bias: b (u,i) = b u + b i + b . later we motivate the application of the sigmoid function to the review embedding. of course, in a real-world scenario a recommender system makes rating predictions on items that users have not rated yet and, consequently, reviews are not available for those items. the application of the regression model of eq. ( ) to new examples, therefore, is not possible at test time. our second learning procedure aims at overcoming this limitation by leveraging ideas from embeddingbased knowledge base completion methods. we want to be able to approximate a review embedding at test time such that this review embedding can be used in conjunction with the learned regression model. hence, in addition to the learning objective ( ), we introduce a second objective that forces the embedding of a review to be close to the difference between the item and user embeddings. this translation-based modeling assumption is followed in transe [ ] and several other knowledge base completion methods [ , ] . we include a second term in the objective that drives the distance between (a) the user embedding translated by the review embedding and (b) the embedding of the item to be small where e u and e i are the embeddings of the user and item, respectively. in the knowledge base embedding literature (cf. [ ] ) it is common the representations are learned via a margin-based loss, where the embeddings are updated if the score (the negative distance) of a positive triple (e.g. (berlin, located_in, germany)) is not larger than the score of a negative triple (e.g. (berlin, located_in, portugal)) plus a margin. note that this type of learning is required to avoid trivial solutions. the minimization problem of eq. ( ) can easily be solved by setting e u = h rev (u,i) = e i = ∀u, i. however, this kind of trivial solutions is avoided by jointly optimizing eqs. ( ) and ( ), since a degenerate solution like the aforementioned one would lead to a high error with respect to the regression objective (eq. ( )). the overall objective can now be written as min where λ is a term that weights the approximation loss due to the modeling assumption formalized in eq. ( ). in our model, Θ corresponds to the parameters w, e, v, h ∈ r k and the bias terms b. at test time, we can now approximate review embeddings of (u, i) pairs not seen during training by computinĝ with the trained regression model g we can make rating predictionsr (u,i) for unseen (u, i) pairs by computinĝ contrary to training, now the regression model g is applied toĥ revu,i , instead of h revu,i , which is not available at test time. the sigmoid function of the regression function g adds a non-linear interaction between the user and item representation. without such activation function, the model would consist of a linear combination of bias terms and the (ranking of) served recommendations would be identical to all users. all parameters of the parts of the objective are jointly learned with stochastic gradient descent. more details regarding the parameter learning are contained in the experimental section. the choice of transe as underlying modeling assumption to this recommendation problem is not arbitrary. given the user and item embeddings, and without further constraints, it allows to distinctively compute the approximate review embedding via eq. ( ). another popular knowledge graph embedding method is distmult [ ] . in applying such modeling assumption to this problem one would obtain the approximate review embedding by solving the following optimization problem:ĥ rev (u,i) = max h (e i • e u )h, where • is the element-wise multiplication. the solution to that problem would be any vector with infinite norm. therefore, one should impose constraints in the norm of the embeddings to obtain a non-trivial solution. however, previous work [ ] shows that such constraint harms performance. similarly, most of the knowledge graph embedding methods would require to impose constraints in the norm of the embeddings. the translation modeling assumption of transe facilitates the approximation of the review embedding without additional constraints, while its performance is on par with, if not better, than most of all other translation-based knowledge graph embedding methods [ ] . there are three lines of research related to our work: knowledge graph completion, recommender systems and sentiment analysis. the first research theme related to transrev is knowledge graph completion. in the last years, many embedding-based methods have been proposed to infer missing relations in knowledge graphs based on a function that computes a likelihood score based on the embeddings of entities and relation types. due to its simplicity and good performance, there is a large body of work on translation-based scoring functions [ , ] . [ ] propose an approach to large-scale sequential sales prediction that embeds items into a transition space where user embeddings are modeled as translation vectors operating on item sequences. the associated optimization problem is formulated as a sequential bayesian ranking problem [ ] . to the best of our knowledge, [ ] is the first work in leveraging ideas from knowledge graph completion methods for recommender system. whereas transrev addresses the problem of rating prediction by incorporating review text, [ ] addresses the different problem of sequential recommendation. therefore the experimental comparison to that work is not possible. in transrev the review embedding translates the user embedding to the product embedding. in [ ] , the user embedding translates a product embedding to the embedding of the next purchased product. moreover, transrev gets rid of the margin-based loss (and consequently of the negative sampling) due to the joint optimization of eqs. ( ) and ( ), whereas [ ] is formalized as a ranking problem in a similar way to [ ] . subsequently, there has been additional work on translation-based models in recommender systems [ , ] . however, these works cannot incorporate users' feedback other than ratings into the learning, which has been shown to boost performance [ ] . there is an extensive body of work on recommender systems [ , , ] . singular value decomposition (svd) [ ] computes the review score prediction as the dot product between the item embeddings and the user embeddings plus some learnable bias terms. due to its simplicity and performance on numerous data sets-including winning solution to the netflix prize-it is still one of the most used methods for product recommendations. most of the previous research that explored the utility of review text for rating prediction can be classified into two categories. semi-supervised approaches. hft [ ] was one of the first methods combining a supervised learning objective to predict ratings with an unsupervised learning objective (e.g. latent dirichlet allocation) for text content to regularize the parameters of the supervised model. the idea of combining two learning objectives has been explored in several additional approaches [ , , ] . the methods differ in the unsupervised objectives, some of which are tailored to a specific domain. for example, jmars [ ] outperforms hft on a movie recommendation data set but it is outperformed by hft on data sets similar to those used in our work [ ] . supervised approaches. methods that fall into this category such as [ , ] learn latent representations of users and items from the text content so as to perform well at rating prediction. the learning of the latent representations is done via a deep architecture. the approaches differences lie mainly in the neural architectures they employ. there is one crucial difference between the aforementioned methods and transrev. transrev predicts the review score based on an approximation of the review embedding computed at test time. moreover, since transrev is able to approximate a review embedding, we can use this embedding to retrieve reviews in the training set deemed most similar by a distance metric in the embedding space. similar to sentiment analysis methods, transrev trains a regression model that predicts the review rating from the review text. contrary to the typical setting in which sentiment analysis methods operate, however, review text is not available at prediction time in the recommender system setting. consequently, the application of sentiment analysis to recommender systems is not directly possible. in the simplest case, a sentiment analysis method is a linear regressor applied to a text embedding (eq. ( ) ). we conduct several experiments to empirically compare transrev to state of the art methods for product recommendation. moreover, we provide some qualitative results on retrieving training reviews most similar to the approximated reviews at test time. we evaluate the various methods on data sets from the amazon product data , which has been extensively used in previous works [ ] [ ] [ ] . the data set consists of reviews and product metadata from amazon from may to july . we focus on the -core versions (which contain at least reviews for each user and item) of those data sets. there are product categories from which we have randomly picked . as all previously mentioned works, we treat each of these resulting data sets independently in our experiments. ratings in all benchmark data sets are integer values between and . as in previous work, we randomly sample % of the reviews as training, % as validation, and % as test data. we remove reviews from the validation and test splits if they involve either a product or a user that is not part of the training data. we follow the same preprocessing steps for each data set. first, we lowercase the review texts and apply the regular expression "\w+" to tokenize the text data, discarding those words that appear in less than . % of the reviews of the data set under consideration. for all the amazon data sets, both full reviews and short summaries (rarely having more than words) are available. since classifying short documents into their sentiment is less challenging than doing the same for longer text [ ] , we have used the reviews summaries for our work. we truncate these reviews to the first words. for lack of space we cannot include statistics of the preprocessed data sets. we compare to the following methods: a svd matrix factorization; hft, which has not often been benchmarked in previous works; and deepconn [ ] , which learns user and item representations from reviews via convolutional neural networks. we also include mpcn [ ] (which stands for multi-pointer co-attention networks) in the comparison, however, as indicated in previous work [ ] mpcn is a non-reproducible work . therefore, we simply copy numbers from [ ] , since they used the same data sets as the ones used in this work. additionally, we also include performance for transnets (t-nets) [ ] , whose numbers are also copied from [ ] . t-nets is similar to transrev in that it also infers review latent representations from user and item representations. different to transrev, it does not have any underlying graph-based modeling assumption among users, items and reviews. we set the dimension k of the embedding space to for all methods. we evaluated the robustness of transrev to changes in sect. . . alternatively, one could use off-the-shelf word embeddings (e.g. word vec [ ] or elmo [ ] ), but this would require to assume the existence of a large collection of text for effectively learning good word representations in an unsupervised manner. however, such a corpus may not be available for some low-resource languages or domainspecific use cases. for transrev's parameters were randomly initialized [ ] and learned with vanilla stochastic gradient descent. a single learning iteration performs sgd with all review triples in the training data and their associated ratings. for transrev we used a batch size of . we ran transrev for a maximum of epochs and validated every epochs. for svd we used the python package surprise , and chose the learning rate and regularization term from the same range of values. parameters for hft were learned with l-bfgs, which was run for , learning iterations and validated every iterations. for deepconn the original authors' code is not available and we used a third-party implementation . we applied the default hyperparameters values for dropout and l regularization and used the same embedding dimension as for all other methods. all methods are validated according to the mean squared error (mse). the experimental results are listed in table where the best performance is in bold font. transrev achieves the best performance on all data sets with the exception of the kindle store and automotive categories. surprisingly, hft is more competitive than more recent approaches that also take advantage of review text. most of these recent approaches do not include hft in their baselines. transrev is competitive with and often outperforms hft on the benchmark data sets under consideration. to quantify that the rating predictions made by hft and transrev are significantly different we have computed the dependent t-test for paired samples and for all data sets where transrev outperforms hft. the p-value is always smaller than . . it is remarkable the low performance of deepconn, mpcn and t-nets in almost all datasets. this is in line with the findings reported in very recent work [ ] , where authors' analysis reveals that deep recommender models are systematically outperformed by simple heuristic recommender methods. these results only confirm the existing problem reported in [ ] . we randomly selected the data sets baby, digital music, office and tools&home improvement from the amazon data and evaluated different values of k for user, item and word embedding sizes. we increase k from to and always validate all hyperparameters, including the regularization term. table list the mse scores. we only observe small differences in the corresponding model's performances. this observation is in line with [ ] . for most of the data sets the validated weighting term λ takes the value of either . or . . this seems to indicate that the regression objective is more important than the modeling assumption in our task, as it directly relates to the goal of the task. the regularization term is of crucial importance to obtain good performance and largely varies across data sets, as their statistics also largely differ across data sets. review embeddings, which are learned from word embeddings, are learned to be good predictors of user ratings. as a consequence the learned word embeddings are correlated with the ratings. to visualize the correlation between words and ratings we proceed as follows. first, we assign a score to each word that is computed by taking the average rating of the reviews that contain the word. second, we compute a -dimensional representation of the words by applying t-sne [ ] to the -dimensional word embeddings learned by transrev. figure depicts these -dimensional word embedding vectors learned for the amazon beauty data set. the corresponding rating scores are indicated by the color. the clusters we discovered in fig. are interpretable. they are meaningful with respect to the score, observing that the upper right cluster is mostly made up of words with negative connotations (e.g. horrible, useless. . . ), the lower left one contains neutral words (e.g. with, products. . . ) and the lower right one contains words with positive connotations (e.g. awesome, excellent. . . ). one of the characteristics of transrev is its ability to approximate the review representation at prediction time. this approximation is used to make a rating prediction, but it can also be used to propose a tentative review on which the user can elaborate on. this is related to a number of approaches [ , , ] on explainable recommendations. we compute the euclidean distance between the approximated review embeddingĥ rev (u,i) and all review embeddings h rev (u,i) from the training set. we then retrieve the review text with the most similar review embedding. we investigate the quality of the tentative reviews that transrev retrieves for the beauty and digital music data sets. the example reviews listed in table show that while the overall sentiment is correct in most cases, we can also observe the following shortcomings: (a) the function f chosen in our work is invariant to word ordering and, therefore, cannot learn that bigrams such as "not good" have a negative meaning. (b) despite matching the overall sentiment, the actual and retrieved review can refer to different aspects of the product (for example, "it clumps" and "gives me headaches"). related work [ ] extracts aspects from reviews by applying a number of grammatical and morphological analysis tools. these aspects are used later on to explain why the model suspects that a user might be interested in a certain product. we think this type of explanation is complementary to ours, and might inspire future work. (c) reviews can be specific to a single product. a straightforward improvement could consist of retrieving only existing reviews for the specific product under consideration. table . reviews retrieved from the beauty (upper) and digital music (lower) data sets. in parenthesis the ratings associated to the reviews. closest training review in embedding space skin improved ( ) makes your face feel refreshed ( ) love it ( ) you'll notice the difference ( ) best soap ever ( ) i'll never change it ( ) it clumps ( ) gives me headaches ( ) smells like bug repellent ( ) pantene give it up ( ) fake fake fake do not buy ( ) seems to be harsh on my skin ( ) saved my skin ( ) not good quality ( ) another great release from saliva ( ) can't say enough good things about this cd ( ) a great collection ( ) definitive collection ( ) sound nice ( ) not his best nor his worst ( ) a complete massacre of an album ( ) some great songs but overall a disappointment ( ) the very worst best of ever ( ) overall a pretty big disappointment ( ) what a boring moment ( ) overrated but still alright ( ) great cd ( ) a brilliant van halen debut album ( ) we believe that more sophisticated sentence and paragraph representations might lead to better results in the review retrieval task. as discussed, a promising line of research has to do with learning representations for reviews that are aspect-specific (e.g. "ease of use" or "price"). transrev is a novel approach for product recommendation combining ideas from knowledge graph embedding methods, recommender systems and sentiment analysis. transrev achieves state of the art performance on the data sets under consideration while having fewer (hyper)parameters than more recent works. most importantly, one main characteristic of transrev is its ability to approximate the review representation during inference. this approximated representation can be used to retrieve reviews in the training set that are similar with respect to the overall sentiment towards the product. such reviews can be dispatched to users as a starting point for a review, and thus lowering the barrier to writing new reviews. given the known influence of product reviews in the purchasing choices of the users [ , ] , we think that recommender systems will benefit from such mechanism. user models: theory, method, and practice topicmf: simultaneously exploiting ratings and reviews for recommendation classifying sentiment in microblogs: is brevity an advantage? in: cikm translating embeddings for modeling multi-relational data empirical analysis of predictive algorithms for collaborative filtering transnets: learning to transform for recommendation are we really making much progress? a worrying analysis of recent neural recommendation approaches jointly modeling aspects, ratings and sentiments for movie recommendation (jmars) composing relationships with translations combining two and three-way embedding models for link prediction in knowledge bases understanding the difficulty of training deep feedforward neural networks traversing knowledge graphs in vector space translation-based recommendation knowledge base completion: baselines strike back matrix factorization techniques for recommender systems research and development in intelligent systems xxxii ratings meet reviews, a combined approach to recommend visualizing data using t-sne hidden factors and hidden topics: understanding rating dimensions with review text inferring networks of substitutable and complementary products image-based recommendations on styles and substitutes distributed representations of words and phrases and their compositionality an empirical comparison of knowledge graph embeddings for item recommendation deep contextualized word representations lit@eve : explainable recommendation based on wikipedia concept vectors factorizing personalized markov chains for next-basket recommendation fast maximum margin matrix factorization for collaborative prediction interpretable convolutional neural networks with dual local and global attention for review rating prediction representation learning of users and items for review rating prediction using attention-based convolutional neural network latent relational metric learning via memorybased attention for collaborative ranking multi-pointer co-attention networks for recommendation explaining reviews and ratings with paco: poisson additive co-clustering explicit factor models for explainable recommendation based on phrase-level sentiment analysis joint deep modeling of users and items using reviews for recommendation acknowledgements. the research leading to these results has received funding from the european union's horizon innovation action programme under grant agreement no -smooth project. this publication reflects only the author's views and the european community is not liable for any use that may be made of the information contained herein. key: cord- -c mthxv authors: martin-garcia, e.; celada-Álvarez, f.; pérez-calatayud, m. j.; rodriguez-pla, m.; prato-carreño, o.; farga-albiol, d.; pons-llanas, o.; roldán-ortega, s.; collado-ballesteros, e.; martinez-arcelus, f. j.; bernisz-diaz, y.; macias, v. a.; chimeno, j.; gimeno-olmos, j.; lliso, f.; carmona, v.; ruiz, j. c.; pérez-calatayud, j.; tormo-micó, a.; conde-moreno, a. j. title: % peer review in radiation oncology: is it feasible? date: - - journal: clin transl oncol doi: . /s - - - sha: doc_id: cord_uid: c mthxv purpose: peer review has been proposed as a strategy to ensure patient safety and plan quality in radiation oncology. despite its potential benefits, barriers commonly exist to its optimal implementation in daily clinical routine. our purpose is to analyze peer-review process at our institution. methods and materials: based on our group peer-review process, we quantified the rate of plan changes, time and resources needed for this process. prospectively, data on cases presented at our institutional peer-review conference attended by physicians, resident physicians and physicists were collected. items such as time to present per case, type of patient (adult or pediatric), treatment intent, dose, aimed technique, disease location and receipt of previous radiation were gathered. cases were then analyzed to determine the rate of major change, minor change and plan rejection after presentation as well as the median time per session. results: over a period of weeks, cases were reviewed. median of attendants was six physicians, three in-training-physicians and one physicist. median time per session was ( – ) minutes. . % of cases presented in – min, . % in – min and . % in ≥ min. . % of cases were accepted without changes, . % with minor changes, % with major changes and . % were rejected with indication of new presentation. most frequent reason of change was contouring corrections ( . %) followed by dose or fractionation ( . %). conclusion: everyday group consensus peer review is an efficient manner to recollect clinical and technical data of cases presented to ensure quality radiation care before initiation of treatment as well as ensuring department quality in a feedback team environment. this model is feasible within the normal operation of every radiation oncology department. assuring quality of care is a safety challenge within radiation oncology related to the evolving growth of technology and the multistep planning process in this field. individual decision making among radiation oncology physicians and the complexity of radiation treatment plans can also contribute to potential errors in this process. target volumes and normal tissue delineations represent an important source of those errors as well as treatment prescription (total dose and dose fractionation), especially for hypofractionated schemes and sbrt plans. as such, an adequate peer-review process involving plan evaluation in a feedback environment from a multidisciplinary team is an effective strategy for assuring plan quality and patient safety recommended by professional organizations such as astro, acr and ranzcr [ ] [ ] [ ] . several reports have proven the benefit of peer-review process into facilitating treatment plans but also have enumerated a list of barriers to its effective implementation and efficiency such as scheduling, workload, time dedicated to peer review, equipment, repetition, the attendance by key personnel and distraction from clinic time with patients [ , [ ] [ ] [ ] . in addition, there is still little guidance and limited published research about the frequency, mechanics or metrics of peer review in radiation oncology from professional organizations [ , ] so nowadays, each radiation oncology department should identify and mitigate those barriers to an effective application of peer review to its individual process and workflow. currently in spain, [ ] centers provide radiation therapy services. although its delivery is relatively standardized in our country, there's no data published about peer-review system in those departments so the extent and structure of this process vary widely among centers and even remain uncertain at some point. in respect to our institution's peer-review process, we report the rate of plan changes as well as the amount of time and resources needed for this process. the aim of our study is to demonstrate the feasibility of performing peer review to every case in radiation therapy. a sample of typical results is presented just as illustrative purpose. historically, peer review was established at our institution as an audit procedure to review treatment indication, target/oars volumes, dvh analyses, treatment plan changes and any other remarkable aspects concerning patient's case, recorded in our quality guarantee department certification. these conferences occur daily at . am where all patient cases are presented prior to dosimetry and treatment initiation. the review process is performed by a multidisciplinary team that includes physicians, resident physicians and medical physicists. although daily attendance varies, typically at least six attending physicians (range - ) are present at each session. the minimum number of senior radiation oncologists required to run the meeting is two, but this situation only occurs when vacation period, attendance to several tumor committees, previous day on-calls, or special considerations such as medical leave or congress attendance meet. after this conference, radiophysics department has its own specific meeting to discuss cases presented at our peer review among other topics. this conference is attended by medical physicists, physic residents and dosimetrists. we balanced this approach to respect the workflow of both departments. during the conference, the treating physician or covering physician resident provides a brief review of the patient's history in addition to treatment intentions. patient's history, physical exam findings, radiological images and documents such as anatomopathological analysis or complete surgical reports are available within electronic medical record and linked via computer to live broadcasting during discussion if questions arise. simultaneously, all axial, sagittal and coronal slices of patient's simulation ct scan and any image fusions (pet/ ct or mri) are examined and projected streaming on a screen to review target volumes including gross tumor volume (gtv), clinical target volume (ctv) and planning target volume (ptv) as well as organ at risk (oar) contours/ constraints using aria ® . varian medical system. peer-review activity regarding patient's identification, main case's characteristics and decisions made in our conference is recorded in an official logbook. individual dvh analysis and dosimetry in relation of ptv coverage and oar sparing are reviewed only if case is considered complex (i.e., re-irradiation, cases involving re-planning or adaptive planning, pediatric, etc.). cases presented must accomplish our department's precise established dvh/constraints protocol on each pathology to facilitate workflow and to highlight those cases requiring thorough peer review to achieve efficiency compromise and make peer review % feasible. in cases of re-irradiation, composite plans with previous doses are examined during peer review. retrospectively, urgent treatments performed the previous day during on-calls are also presented. controversial cases discussed at pretreatment review might be presented again before treatment initiation focusing on final approved plan, dvh and any remarkable issue on treatment delivery. attendees are encouraged to make suggestions during and after presentation of the case regarding aspects of the radiation treatment plan such as target volumes and normal tissue contours in close proximity to them, total dose, dose fractionation, frequency, treatment intention, technique, igrt imaging or any other details with implication in treatment planning or dose calculation (i.e., skin affectation or not, prosthesis, setup margins, dibh, pacemaker and its relevance, photon/electron boost radiotherapy, registration quality, ptvs coverage and oar constrains…). cases requiring special procedures (brachytherapy, radiosurgery, total body irradiation, intra-operative radiation therapy) are currently being revised by groups with experience in those techniques prior to treatment delivery and only controversial treatment indications (i.e., salvage treatment with brachytherapy for irradiated patients) or cases in which boost with hdr-bt is going to be performed after ebrt (i.e., breast cancer, cervical cancer) go through our peer-review conferences before starting treatment. in addition, as a department with in-trainee physicians, peer-review conference serves as a forum for continuing education to collectively analyze every case to recognize proper diagnosis procedures, previous/concurrent chemotherapy, data from previous surgery, possible future oncologic procedures and indication or not for radiation therapy treatment. collectively, plans are either accepted or rejected with indication of new presentation. cases are classified into four categories: no changes, minor changes, major changes or plan rejection. parameters analyzed to determine change's nature are the same for minor/major: contouring, dose/ fractionation, technique or a combination. criteria to allocate a recommended change into minor or major takes into account the clinical impact of the plan on each patient. if approvement is achieved, then the plan does not have to go back through conference (i.e., no changes, minor/major change recommended), but if it was rejected for re-planning, then the case must be presented again according the agreed change level. changes can be done by the planner in real time (i.e., minor/major changes to total dose or dose fractionation) or can be performed later (i.e., minor/major changes in contouring). when a plan is rejected, usually a combination of circumstances might be present (i.e., more than one major change, a decision to present the case in tumor committee for neo/ adjuvant chemotherapy or immunotherapy, an indication to perform a new simulation ct scan for newly discoveries during peer review or for a better patient's immobilization, no treatment decision, a suggested confirmation of dose/ fractionation/constraints in a certain location for sbrt…). modifications made after our conference to radiation therapy plans are documented by the attendance medical physicist. dosimetry can only be assessed if changes suggested in peer review are made by the responsible radiation oncologist and therefore compliance with the conference recommendation before treatment initiation is ensured. based on our group peer-review process, we prospectively recollected some data on cases presented at our institutional conference to quantify the rate of plan changes, time and resources needed for this process. items such as time to present per case, type of patient (adult or pediatric), treatment intent, tumor type (primary, metastasis or both), dose, technique, disease location and receipt of previous radiation were gathered. cases were then analyzed to determine the rate of major change, minor change and plan rejection after presentation as well as the type of change (dose/fractionation, contouring, technique or combination) and also median time per session. over a period of weeks cases underwent peer review at our department prior to starting treatment. a total of conferences took place during this period. median of attendants was six physicians (range - ), three in-training-physicians (range - ) and one medical physicist. approach assessment was the most frequent reason for case presentation ( . %). the majority of cases presented were adult patients ( . %). in terms of type of tumor, . % were primary tumors and . % were metastasis. the most common technique proposed in the plans review was d-crt which was performed in approximately % of cases presented, followed by vmat ( . %), sbrt ( . %) and sr ( . %). . % of cases had a radical treatment intent, . % had a neo/adjuvant treatment intent and . % of cases were presented for palliation treatment. nearly % of presented cases had received previous radiation nearby the area of concern, in-field or at other location either at our institution or another institution. the most frequently reviewed sites were breast ( . %), followed by pelvis ( . %), bone/soft tissue ( . %) and central nervous system ( . %). a summary of characteristics of cases presented is found in table . as previously described, once the plan is reviewed at the conference it can be approved or rejected for re-planning if it undergoes a plan rejection. in our case, nearly % of cases were accepted without changes, . % with minor changes, % with major changes and . % were rejected with indication of new presentation. most frequent reason of change was contouring corrections ( . %) followed by dose or fractionation ( . %). peer review resulted in breast ( %), pelvis ( . %), bone/soft tissue ( . %) and h&n ( . %) cases requiring most of the changes recommended. . % of cases were accepted after presentation. overall, total rate of change including both major and minor changes and plan rejection was nearly %. a summary of the change rates is found in table . furthermore, median time per session was min (range - ). the majority of cases ( . %) were presented in - min, . % in - min and . % in ≥ min. of the sites presented, the longest median time of presentation was for abdomen cases ( min), followed by pelvis ( min) and central nervous system ( min). in terms of technique, sr ( min) and sbrt ( min) had the longest mean time of presentation. additionally, re-irradiation cases, no treatment decision cases discussed and those that had any type of change had slightly longer presentation times. a summary of presentation's length is found in both tables and . this study analyzes peer-review process at our institution and its feasible implementation to our daily clinical practice. a remarkable proportion of modifications have potential clinical implications as disease outcome could be directly affected by radiation therapy plan [ ] . introducing this 'audit and feedback' process among each center's protocol is a quality assessment whereby adherence to published guidelines is measured [ , ] . we found a total change rate of . % of all cases presented and a major change rate of %. previous studies identified similar proportions of recommended plan changes after peer review, accounting for . [ ] , [ ] , . [ ] , . [ ] and . % [ ] of total change rate and a major plan change rate of . [ ] , . [ ] , . [ ] , . [ ] and % [ ] respectively. in addition, some reviews also included changes in total dose ( . %) or fractionation ( . %) [ ] that did not resulted in re-planning and a total minor change rate of [ ] , . [ ] , . [ ] and . % [ ] respectively, which is in alignment with the . % rate of minor changes obtained at our institution. accordingly to a survey of north american teaching centers, % of respondents estimated that major changes occurred in < % whilst minor changes were estimated to be requested in < % of cases by % of respondents [ ] . contouring corrections ( . %) followed by dose/fractionation ( . %) resulted in most frequent reason of change, similarly to data reported in other reviews [ , [ ] [ ] [ ] ] . it is true that contouring plays an important role in our revision because it is known to be a major responsible for treatment outcomes and also isodose or dvh data are completely dependent on contour definition, especially when using imrt-vmat. to optimize peer-review process, ballo et al. [ ] highlighted the importance of reporting disease sites to identify those with a higher proportion of changes resulting in h&n, gi and gyn cases requiring a plan change more than % of the time. esophagus, uterus, upper/lower limb, cervix, h&n, bilateral lung, right supraclavicular lymph nodes, rectum and spine were cancer groups proposed to most necessitating mandatory peer review according to rouette et al. [ ] . we found breast ( %), pelvis ( . %), bone/soft tissue ( . %) and h&n ( . %) cases requiring most of the changes recommended from our peer-review members during our monthly recruitment period. several different models have been suggested for peerreview process within radiation oncology. a survey developed by astro to its physician members revealed considerable variations among centers in the timing and content of peer review requiring additional clear guidance and formal recommendations from expert consensus [ ] . some practices have established a multistep process with separate peerreview stages consisting of a first presenting case reunion followed by consensus planning conferences and final chart rounds to evaluate patients who have started a new treatment plan. other institutions have a dual-layer process with both early and late peer review evaluating different aspects. in addition, centers perform either prospective peer review (before radiation) or once the therapy has started (inside the first week) and mostly discuss only cases considered complex [ , , , ] . according to rd / [ ] , items such as treatment indication, contouring, isodoses, dvh and not expected reactions should be discussed in departmental clinical sessions. at our institution, peer-review process is unique: in a single conference we always gather the first two aspects of cases mentioned above and the third one when case is considered complex due to a strict established service protocol, and then modify plans when indicated based on peers recommendations always prior to treatment initiation, which is considered beneficial and easier to implement. the fourth aspect is not routinely assessed and we might contemplate including it henceforth as an additional quality control of the radiation therapy process complying with established protocols endorsed by scientific societies of recognized solvency such as astro and estro. notably, most centers focus on peer reviewing ebrt cases leaving special treatment modalities (brachytherapy, stereotactic radiosurgery) revision rates to a significantly lower proportion. in particular, lawrence et al. [ ] detected that % of institutions across the united states never peer review pre-implant or post-implant dosimetry for prostate brachytherapy, % never peer review gynecologic brachytherapy cases and only % consider rs. also, hoopes et al. [ ] pointed out that prospective review in brachytherapy cases accounted for % among physicians surveyed. it is remarkable to mention that, as a reference center for brachytherapy procedures at valencian community and at national level, we treat patients from different institutions who have already received ebrt or will be sent back to complete it after our brachytherapy treatment it's performed. although each brachytherapy procedure is unique for us, currently final treated plans are unfortunately not routinely presented at our daily peer-review conference. in agreement with lawrence et al. [ ] , brachytherapy is of potential concern because it involves high-dose radiation with curative intent in which spatial issues (applicator position, target definition) can have highly significant consequences. in our opinion, each brachytherapy procedure is unique, in the sense that depends not only on the patient conditions but also on the physician skills training, hence all brachytherapy cases might retrospectively be reviewed to evaluate the quality of the implants, fiducial marker placement, the problems and solutions found, etc. this should complete our quality control system protocol and a forthcoming event at our department along with other special treatment modalities (stereotactic radiosurgery, total body irradiation, intra-operative radiation therapy…) on which controversial treatment indications are presented but technical considerations and final treated plan should be retrospectively review for educational benefits and treatment planning consistency, reinforcing collective decision making and assuring quality control, with further investigation into its clinical impact. interestingly, the variability of parameters evaluated in the classification for minor/major changes and therefore its implication in the acceptation/rejection plan rates it's still an unsolved question as there's no specific guidance published from professional organizations [ ] . this inconsistency can be appreciated through previous articles. for example, to ballo et al. [ ] , events variations are classified in three types: radiation dose, target or major changes that changed treatment modality (i.e., surgery rather than external beam radiation) or added modalities (i.e., chemoradiation therapy rather than radiation alone). driving forward into changes' nature, rouette et al. [ ] analysis defines a minor change as a recommended change that did not meet the criteria for a "major" change and did not lead to significant repeat treatment planning whilst a major change is defined as a change requiring repeat planning and/or have a foreseeable effect on treatment toxicity or cancer outcomes in the view of the peer-review physician, which is more in alignment with our change's proposal. during our monthly prospective data base, we conducted major changes in nine cases ( %) and minor changes in cases ( . %). major recommendations at our multidisciplinary conference accounted for contouring (i.e., breast cancer case involving regional lymph nodes that have not been considered when contouring before peer review or modifications to gtv), dose/fractionation (i.e., changes in dose/fractionation for sbrt-vmat lung case from × gy to × gy or unacceptable and avoidable oar dose in a re-irradiation pelvic case) and technique (i.e., d-crt instead of vmat for soft tissue sarcoma of the limb) while a change in dose/fractionation for palliative bone metastasis from × gy to × gy due to patient's performance status was considered a minor change and adding prv to a certain oar was considered a minor contouring recommendation. from our point of view and awaiting for more official detailed guidance, the definition of recommendation magnitude to classify a change into minor or major is inherently subjective and should be appraise individually on each case and assigned to every radiation oncology department itself. arising from our experience, peer-review process brings to light unperceived considerations or additional viewpoints that could lead to changes resulting in the outcome of radiation plans that otherwise would not have been made without this process. the degree of compliance with peerreview recommendations arising from walburn et al. [ ] was reasonably good ( %) but it decreased as recommendation magnitude increased: % for minor and % for major recommendations respectively, suggesting that early rather than late peer review may enhance compliance and efficiency creating a safety-oriented culture. moreover, rouette et al. [ ] reported a rate of . % of major changes for plans presented after treatment had begun. fairchild et al. [ ] revealed that retrospective peer review resulted in higher failure rates and worse overall and progression-free survival after delivery of radiation that did not make compliant with protocol guidelines. consequently, along with astro [ ] we recommend performing peer review before the initiation of treatment for assuring plan quality and patient safety. additionally, an important overarching question remains concerning the optimal proportion of plans to review to optimize the utility of peer review. in our conferences, we present every single patient and not only those cases considered complex, explaining why breast cancer accounted for . % and therefore why d-crt was the most common technique utilized ( . %) due to the high volume of patients suffering from this pathology and to palliative cases. previous publications suggested that peer review might not be necessary on every breast cancer patient [ ] .from our point of view, breast cancer is of great importance as radiotherapy is considered a radical treatment in this pathology with significant curative rates and arising controversies among axillary management. although wide guidance recommendations published by experts help reducing practice variation, we have a high level of rigorousness when performing ct-scan-based contouring and, for patients with nodal involvement, the ct slice that will establish the separation between the beams treating breast (tangential beams) and the half beams treating nodes is also decided in our peer-review conference among radiotherapists and with the advice of the medical physicist. this decision has a huge impact in the reduction of lung dose, humeral head avoidance, spinal cord and medial extension of nodal ptv as well as an important reduction of the planning time. following on from this, lymberiou et al. [ ] showed that from breast radiation plans analyzed . % required major changes while rouette et al. [ ] identified a rate change of . % for left/right breast plans and . % for left/right chest wall. both studies noticed that plans involving the regional lymph nodes were more likely to have recommended changes suggesting that cases with locoregional nodal involvement should be a significant area of focus for peer review. moreover, from cases presented at our conference during that monthly period, seven accounted for h&n cases ( . %), with a reported change rate of . % from total changes. the majority of these changes were considered minor (dose/fractionation or contouring) and only . % were considered major enough to affect clinical care (i.e., one case was rejected with indication of presentation in the h&n tumor committee to considered neoadjuvant chemotherapy). as described in previous studies, h&n is a frequent revision's site mainly because it's inherent complexity in normal tissue contouring but also because there are always physician-specific decisions that are only exposed during a process of peer review [ ] . rouette et al. [ ] compiled peer-reviewed treatment plans among cancer centers in ontario including h&n cases ( . %) with changes recommended after peer review in . %. of the cases presented over a period of years of peer review at ballo et all analysis [ ] , were h&n patients with a reported change rate of . %, prompting that peer review should be mandatory for all h&n plans and prior to treatment initiation in favor of re-planning avoidance. similarly to our proportion of cases peer reviewed, albert et al. [ ] found h&n cases ( . %) from an overall of cases presented resulting in one of the most frequently reviewed sites and also with one of the longest mean time of presentation ( min). discussing all patients might seem to lengthen the time needed for peer-review process and also could led to an unnecessary effort, but when comparing our median time per session ( min) to other experiences [ , ] , the result is quite similar. based on site involvement, previous experiences reported differences in the time needed to present cases. albert et al. [ ] found that cases involving lung, cns and h&n required slightly more time whereas ballo et al. [ ] suggested performing peer review for all disease sites but focusing on those requiring changes more often (h&n, gi or gyn). for us, abdomen cases, pelvis (especially gu, gyn) and cns accounted for the longest mean time of presentation likely due to sbrt cases with critical structures nearby and higher number of oars reviewed for these sites. ultimately, radiation oncology departments should integrate peer-review system into their routine workflow, scheduling conferences at the optimal moment of the day and with a reasonable average of reunions per week to reassure staff that their time is well spent. furthermore, peer review serves for educational opportunities and creates an environment that fosters respectful questioning. resident physicians have the opportunity to take an active part in the process by asking questions and giving their own feedback, becoming that way proficient in plan evaluation. seasoned physicians can also benefit from peer review given the variety of cases presented, maintaining them updated for disease sites plans even if they are not their main sites of focus [ ] . topics arising from clinical cases on peer review are also adopted to create academic bibliographical sessions every weeks approximately reinforcing its importance to stay abreast of the latest updates in the oncology field. in addition, this system has also indirect quality benefits: reduces practice variation by promoting standardization, improves communication and reinforces knowledge sharing [ ] . it has also been documented that centralized plan review increases group consensus and consistency which is reflected in decreased treatment plan changes over time, suggesting that the act of peer review has an educational effect and the system directly change care by increasing adherence to institutional guidelines [ ] . all of this enhance the role and utility of peer review as part of routine clinical practices. nevertheless, despite evidences providing proof of its benefits, previous surveys showed that only approximately % of centers performed peer review of radiation plans in the united states [ ] and only . % in canada [ ] . in europe, harmonizing clinical care based on expert consensus agreement can improve clinical outcome in the face of uncertainty, with quality and safety playing a priority place in radiation medicine according to estro [ ] . recently, the working group on patient safety and quality of the spanish society of radiation oncology (seor) revised national and international recommendations for patient safety evaluating whether they are included in spanish legislation. they found that even though peer review plays an important part in maintaining quality standards and improving performance and safety of care, neither rd / nor rd / consider the peer-review process [ ] . nevertheless, a new rd / [ ] reinforcing mandatory oars and treatment volumes revision became effective a month ago so performing peer review will be a compelling reason henceforth. unfortunately, there's no data published about peer-review system in spain so far to our knowledge. this report is the first one providing information about the structure, operation and metrics analyzed in this process at national level. finally, advances in tumor genomic data and technology will enable more personalized radiation treatment based on patient-specific knowledge. in this context, artificial intelligence (ai) will be a part of our future by providing prognostic models built on radiomic features, creating automated segmentation of oars/tvs on contouring area so as to prediction of normal tissue complications and assuring quality by streamline physician peer-review process. even though potential benefits of ai in radiation quality assurance, challenges remain before its widespread implementation in clinical setting [ , ] . from our point of view, adopting contouring guidance similar to those used in clinical trials seems to be essential nowadays in the delivery of radiation treatment to assure quality as an established methodology exists. we believe peer review is a quality assurance procedure to guarantee patient safety and feasible within the structure of every radiation oncology department. emergently, due to covid- outbreak, drastic disease-control measures from official institutions have forced centers to adapt their usual clinical care and organization level [ ] . on this scenario, teleconferencing via webex ® has been established to allow staff to conduct peer review and, therefore, maintaining qa and patient's security in spite of the situation. there are several weaknesses to consider within our current analysis, but by publishing this review we would like to encourage other centers to implement peer review to their daily routine and to report their experiences proving its feasibility. one limitation is the low sample of plans compiled ( ) compared to other publications with thousands [ , , , ] . as we revise all cases, data collected represents an assortment of pathologies treated at our institution during a whole month period and, even though we assume it is not accurate to extrapolate results, we believe it gives the reader an idea of the amount of cases and disease's locations presented during a year ( ebrt cases in ). secondly, not expected reactions and retrospective peer review to other special modalities (brachytherapy, sr, tbi, iort…) are not routinely assessed and seems to be a compelling inclusion henceforth for assuring additional qa system and its impact in clinical outcomes. our findings show that everyday group consensus peer review is an efficient manner to recollect clinical and technical data of cases presented to ensure quality radiation care before initiation of treatment as well as creating a feedback team environment. it is also considered as a security system to avoid potential errors whereas serving for continuing education. despite the challenge nature of its implementation, our model demonstrates its feasibility within the normal operating of every radiation oncology department. funding not applicable. enhancing the role of case-oriented peer review to improve quality and safety in radiation oncology: executive summary practice patterns for peer review in radiation oncology group consensus peer review in radiation oncology: commitment to quality a survey of radiation treatment planning peer review activities in a provincial radiation oncology programme: current practice and future directions quality assurance peer review chart rounds in : a survey of academic institutions in the united states analysis of a real time group consensus peer review process in radiation oncology: an evaluation of effectiveness and feasibility infrastructure and equipment for radiation oncology in the spanish national health system: analysis of external beam radiotherapy - does quality of radiation therapy predict outcomes of multi center cooperative group trials? a literature review quality control and assurance quality assurance in radiation oncology. cancer a prospective analysis of radiation oncologist compliance with early peer review recommendations impact of peer review in the radiation treatment planning process: experience of a tertiary care university hospital in pakistan prospective peer review quality assurance for outpatient radiation therapy does peer review of radiation plans affect clinical care? a systematic review of the literature directly improving the quality of radiation treatment through peer review: a cross-sectional analysis of cancer centers across a provincial cancer program impact of a real-time peer review audit on patient management in a radiation oncology department real decreto / , de de julio, por el que se establecen los criterios de calidad en radioterapia. boe núm. , de de agosto de predictors of breast radiotherapy plan modifications: quality assurance rounds in a large cancer centre a pan-canadian survey of peer review practices in radiation oncology the european society of radiotherapy and oncology (estro) european higher education area levels and postgraduate benchmarking document for radiation therapists (rtts) patient safety in radiation oncology in spain: a need to change real decreto / , de de julio, sobre justificación del uso de las radiaciones ionizantes para la protección radiológica de las personas con ocasión de exposiciones médicas artificial intelligence in radiation oncology treatment planning: a brief overview the future of artificial intelligence in radiation oncology covid- : global radiation oncology's targeted response for pandemic preparedness the impact of transitioning to prospective contouring and planning rounds as peer review authors declare that there is no conflict of interests regarding the publication of this paper. informed consent not applicable. key: cord- -ksyd l authors: choi, geun joo; kim, hyun min; kang, hyun title: the potential role of dyslipidemia in covid- severity: an umbrella review of systematic reviews date: - - journal: j lipid atheroscler doi: . /jla. . . . sha: doc_id: cord_uid: ksyd l objective: the aim of this study was to analyze the available knowledge about the potential association between dyslipidemia and the severity of coronavirus disease (covid- ) as reported in previous published systematic reviews. methods: in this umbrella review (an overview of systematic reviews), we investigated the association between dyslipidemia and covid- severity. a systematic search was performed of main electronic databases (medline, embase, scopus, and the cochrane library databases) from inception until august . we evaluated the methodological quality of the included studies using the a measurement tool to assess systematic reviews (amstar) tool and used the grading of recommendations, assessment, development, and evaluation (grade) system to assess the quality of evidence for the outcome. in addition, we evaluated the strengths and limitations of the evidence and the methodological quality of the available studies. results: out of articles identified, systematic reviews were included in the umbrella review. a total of , covid- -positive patients were included. according to the amstar criteria and grade system, the quality of the included studies was not high. a history of dyslipidemia is likely to be associated with the severity of covid- infection, but the contrary is the case for cholesterol levels at hospitalization. conclusions: although existing research on dyslipidemia and covid- is limited, our findings suggest that dyslipidemia may play a role in the severity of covid- infection. more adequately powered studies are needed. trial registration: prospero identifier: crd the recent coronavirus disease (covid- ) outbreak has spread rapidly and has affected the world for almost a year, causing immense economic and social difficulties. despite efforts to develop vaccines and new treatments, preventing covid- remains challenging and no clear treatment options exist. as of september , , roughly million people worldwide have been infected with severe acute respiratory syndrome coronavirus (sars-cov- ), the virus that causes covid- , and more than , people have died. with some exceptions, most deaths are thought to be related to underlying comorbidities. therefore, identifying the risk factors related to severe covid- is important to enable stratification of risk in advance, to optimize the reallocation of medical resources, and to improve patients' overall prognoses. as sars-cov- primarily attacks the respiratory tract, several studies have investigated the relationship between chronic obstructive pulmonary disease, asthma, or smoking, and the severity of covid- . however, it has also been found that patients with underlying cardiovascular disease or cardiovascular disease risk factors have a high risk of a severe course of illness or mortality due to covid- . - covid- can also have various cardiovascular manifestations such as myocardial injury, arrhythmias, acute coronary syndrome, and venous thromboembolism. several observational studies and meta-analyses have shown that underlying cardiovascular disease, diabetes mellitus, and hypertension clearly increase the severity and mortality of covid- . [ ] [ ] [ ] however, unlike diabetes and hypertension, relatively few studies have been conducted on dyslipidemia, one of the most important risk factors of cardiovascular disease. several observational studies have reported an association between high-density lipoprotein (hdl) cholesterol levels and the severity of covid- , ; however, the results are inconsistent. to date, multiple systematic reviews and meta-analyses have been published analyzing the potential link between presence of dyslipidemia and the severity of covid- . however, to our knowledge, no attempt has been made to summarize the evidence from these systematic reviews. therefore, systematically and comprehensively re-evaluated the evidence to provide an overview of the association between dyslipidemia and covid- severity. specifically, we conducted an umbrella review to evaluate the findings of systematic reviews and/or metaanalyses that investigated the relationship of dyslipidemia and severity of covid- infection and to assess the evidence regarding potential limitations and the consistency of findings. an umbrella review was performed in this study. an umbrella review provides a summary of existing published meta-analyses and systematic reviews and determines whether authors addressing similar review questions have independently reported similar results and arrived at similar conclusions. we applied the cochrane collaboration methodology and available methodological guidelines for overviews of reviews. , the study protocol was prospectively registered in the international prospective register of systematic reviews (prospero identifier: crd ). the literature search aimed to identify systematic reviews that evaluated the association between dyslipidemia and covid- . to identify relevant systematic reviews and metaanalyses, an electronic search was conducted of databases (medline, embase, scopus, and the cochrane library) from inception until august . these databases are frequently updated when new research is disseminated in peer-reviewed publications and archive services become available. the search strategies were developed by h.k., who has expertise in systematic reviews. the search was conducted using index terms (e.g., mesh and emtree terms) and free text words and word variants. the titles and abstracts from the literature search were screened by independent reviewers (g.j.c. and h.m.k.) to identify whether they contained relevant content, and duplicate studies were excluded. additionally, the same reviewers conducted citation tracking or manual searches of all references of all included studies and all included systematic reviews. only english-language publications that presented a quantitative or qualitative review regarding the relationship between dyslipidemia and covid- were retrieved. the following criteria were applied to identify the articles to be included in the present umbrella review: ( ) systematic reviews and/or meta-analyses; ( ) studies involving adults who tested positive for covid- ; and ( ) studies reporting the association between dyslipidemia and covid- infection. two authors (g.j.c. and h.m.k.) screened the titles and abstracts of the articles independently to evaluate eligibility for inclusion. if a consensus was reached, articles were either excluded or moved to the next stage for full-text review. if a consensus was not reached, the article was moved to the full-text review stage. the full texts of the selected articles were critically appraised to determine their eligibility for inclusion in the umbrella review. disagreements were resolved by discussion with a third author (h.k.) until consensus was reached. two authors (g.j.c. and h.m.k.) independently identified the studies to be included in this umbrella review according to the pre-specified inclusion criteria. discrepancies in assessment were resolved after discussion with a third author (h.k.). the following information were extracted from eligible articles: ( ) authors, journal details, and year of publication; ( ) descriptive information, including the databases searched, the number of studies included, the outcomes of the studies included, the total number of patients, and patients' age range; and ( ) the results of the data synthesis. two authors (g.j.c. and h.m.k.) independently evaluated the methodological quality of the included studies using the a measurement tool to assess systematic reviews (amstar ) tool. inconsistencies were resolved through a discussion with a third author (h.k.). amstar is a reliable, valid and critical assessment tool developed from the initial amstar in . [ ] [ ] [ ] it contains checklists ( critical checklists and non-critical checklists) for assessing systematic reviews and meta-analyses, including randomized controlled trials, observational studies on exposure, or both ( table ). the rating criteria of amstar are as follows: the presence of - non-critical weakness is defined as high quality; more than non-critical weakness is defined as moderate quality; critical flaw with or without noncritical weaknesses is defined as low quality; and the presence of more than critical flaw with or without non-critical weaknesses is defined as critically low quality. the author responsible for the methodology of this study (h.k.) completed the online amstar checklist available on the amstar website (https://amstar.ca/amstar_checklist.php) and a final categorization of each systematic review was generated to classify them as high, moderate, low, or critically low quality. two authors (g.j.c. and h.m.k.) independently extracted the outcomes on the relationship of dyslipidemia or non-dyslipidemia and lipid profile with covid- infection severity from the identified systematic reviews and meta-analyses. we recalculated the weighted mean difference (wmd) or risk ratio (rr) and the corresponding % confidence intervals (cis) using the data of the primary studies included in the published meta-analyses. we used the chi-square test for homogeneity and the i test for heterogeneity. a level of % significance (p< . ) for the χ statistic or an i greater than % was considered to indicate considerable heterogeneity. a fixed-effects model was selected if the p-value for the χ test was > . and the i value was < %. if the i value was > %, a random-effects model was used. we conducted this meta-analysis using the revman . software provided by the cochrane collaboration network. in this umbrella review, we used the grading of recommendations, assessment, development, and evaluation (grade) system to evaluate the quality of evidence for each outcome. the grade system includes factors for downgrading and factors for upgrading the quality of evidence. the baseline quality of evidence of health outcomes depends on the design of the primary study. when a serious or very serious defect could occur because of downgrading factors, the evidence quality is downgraded by or levels, respectively. if the effect is large (rr/odds ratio [or] either > . or < . ) or very large (rr/ or either > . or < . ), the evidence quality is upgraded by level or levels, respectively. if there is evidence that the influence of all plausible confounding would reduce a demonstrated effect or suggest a spurious effect when the results showed no effect, the evidence quality is upgraded by level. the rating criteria of grade are as follows: the primary evidence quality of an observational study is considered low, and the evidence quality is downgraded to very low if it is downgraded by level, upgraded to moderate if it is increased by level, and upgraded to high if it is increased by levels. as a result, the grade system classifies the evidence quality of outcomes from eligible articles as high, moderate, low, or very low. the grade classification was independently performed by authors (g.j.c. and h.m.k.). any discrepancy was resolved via a discussion, and all discrepancies that could not be resolved through a discussion were arbitrated by a third author (h.k.). table . checklists for assessing systematic reviews and meta-analyses according to the amstar tool item checklists ( critical* and non-critical checklists) did the research questions and inclusion criteria for the review include the components of pico? * did the report of the review contain an explicit statement that the review methods were established prior to conduct of the review and did the report justify any significant deviations from the protocol? did the review authors explain their selection of the study designs for inclusion in the review? * did the review authors use a comprehensive literature search strategy? did the review authors perform study selection in duplicate? did the review authors perform data extraction in duplicate? * did the review authors provide a list of excluded studies and justify the exclusions? did the review authors describe the included studies in adequate detail? * did the review authors use a satisfactory technique for assessing the rob in individual studies that were included in the review? did the review authors report on the sources of funding for the studies included in the review? * if meta-analysis was justified did the review authors use appropriate methods for statistical combination of results? if meta-analysis was performed did the review authors assess the potential impact of rob in individual studies on the results of the meta-analysis or other evidence synthesis? * did the review authors account for rob in individual studies when interpreting/discussing the results of the review? did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review? * if they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review? did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review? amstar, a measurement tool to assess systematic reviews; pico, population, intervention, comparison, and outcome; rob, risk of bias. the literature search performed using the keywords shown in table yielded several studies. of the articles identified, duplicates were removed. after exclusion of articles through title and abstract screening, the full texts of articles were assessed. fourteen studies that did not address our topic of interest - were excluded. two studies were excluded because their focuses were on lipoprotein (a) and obesity, respectively. two studies remained after full-text screening using the eligibility criteria; these were the studies by hariyanto and kurniawan and zaki et al. finally, studies including a total of , covid- -positive participants were included in the current overview. the process followed in the selection of eligible studies is summarized in fig. . table . both of the included reviews had critical weaknesses according to the amstar criteria. they had in common critical flaws in terms of assessing the risk of bias (rob) in individual studies that were included in the review and accounting for rob in individual studies when interpreting/discussing the results of the review. additionally, the study of hariyanto and kurniawan showed critical flaws in terms of: using a comprehensive literature search strategy; providing a list of excluded studies and justifying the exclusions; using appropriate methods for the statistical combination of results if a meta-analysis was performed; performing an adequate investigation of publication bias (small study bias); and discussing its likely impact on the results of the review if a quantitative synthesis was carried out. the latter factors were not considered in the study of zaki et al. because it did not contain a meta-analysis. according to the rating criteria of amstar , both of these studies showed critically low quality. in terms of the grade system, we evaluated only the study of hariyanto and kurniawan, which conducted a meta-analysis regarding severe outcomes of covid- infection between non-dyslipidemia and dyslipidemia groups. zaki et al. performed a systematic review without a meta-analysis and included various types of studies such as clinical studies, in vitro cell studies, and a review; therefore, it was difficult to apply the grade system to each outcome in their study. consequently, as the primary evidence quality of observational studies is considered to be low in the grade system, the systematic review was initially graded as low. since there were no issues requiring down-grading, the study of hariyanto and kurniawan regarding the relationship between dyslipidemia and the severity of covid- infection was finally graded as providing a low quality of evidence. there were no overlapping studies in the systematic reviews included in this umbrella review. since data were available from study included in the review of zaki et al. on the relationship of dyslipidemia with covid- severity, we performed a meta-analysis combining data from the reviews. our meta-analysis showed that dyslipidemia was ; fig. ). regarding the other issues, since the limited number of eligible reviews restricted our ability to synthesize and interpret their findings, a narrative synthesis of the evidence is presented in the discussion section. the reviews included in current umbrella review were more suitable for providing qualitative summaries of the evidence than for conducting a meta-analysis. considerable evidence has been amassed that a history of cardiovascular disease or cardiovascular risk factors such as hypertension and diabetes is closely related to covid- infection and severity. , , since dyslipidemia is one of the most important cardiovascular risk factors, dyslipidemia is also likely to be closely related to covid- . however, research on the role of dyslipidemia in the risk and severity of covid- is relatively lacking. one cause may be that the definition of dyslipidemia itself is rather complicated, unlike diabetes mellitus, hypertension, and obesity. furthermore, numerous reports have stated that rapid changes in the lipid profile appear to occur in response to covid- infection and the progression of the disease. therefore, there may be a major difference between defining the presence of dyslipidemia before being diagnosed with covid- , and defining dyslipidemia at the time of hospitalization after a patient is diagnosed with covid- . in the meta-analysis conducted by hariyanto and kurniawan, testing or the use of lipid-lowering drugs. four of the studies were conducted in china, and study each from the us, france, and korea was included. the prevalence of dyslipidemia in these studies differed dramatically. in particular, in the studies conducted in china, hong kong, and korea, , , - the prevalence of dyslipidemia was much lower than that in the other studies ( %- %). in the us study, the number of patients with dyslipidemia was , , with a prevalence of . %, and in the french study, patients had dyslipidemia, with a prevalence of %. since there were no overlapping studies in each systematic review included in this umbrella review, we performed a new meta-analysis to analyze the relationship between dyslipidemia and the severity of covid- quantitatively. however, of the studies included in the review of zaki et al., only study described the presence of underlying dyslipidemia. in our new meta-analysis of a total of studies, combining the studies , - included in the study of hariyanto and kurniawan and the single study included in the review of zaki et al., the relationship between dyslipidemia and severe covid- was confirmed. however, a relevant limitation may be that all studies included in the systematic analyses could not be analyzed. nevertheless, given the results so far, the prognosis of covid- seems poor in patients with dyslipidemia, so dyslipidemia should be regarded as another important factor in risk stratification models for covid- . prior to the covid- pandemic, extensive research explored the link between cholesterol and viral infections. in general, cholesterol in the cell membrane plays an important role when a virus enters the host cell, and the efficiency of viral infection is significantly reduced when cholesterol deficiency is induced in the cell membrane. after a viral infection has already occurred, increased levels of ldl cholesterol itself can interact with macrophages in atherosclerotic plaques or engage in inflammasome activation and increase the secretion of proinflammatory cytokines. , furthermore, low hdl cholesterol may cause dysregulation in the innate immune response, a first-line defense mechanism against covid- infection. lastly, ldl cholesterol or triglyceride accumulation may cause endothelial dysfunction, increasing the risk of cardiovascular complications, leading to severe outcomes. however, the systematic review of zaki et al. presented completely different results. in their study, total cholesterol, hdl cholesterol, and ldl cholesterol levels were consistently lower in the covid- -infected group than in the control group, and hdl cholesterol was significantly lower in patients with a high severity of disease. zaki et al. performed a systematic review of the associations of various comorbidities, such as hypertension, diabetes, high cholesterol, and cancer, with covid- severity. a total of articles were included, and the authors stated that analyzed high cholesterol levels, but only observational studies were finally included. all of those studies were conducted in china. [ ] [ ] [ ] two studies did not confirm the presence or absence of dyslipidemia from patients' medical records, , and in study, the presence of dyslipidemia was described, but its relationship with severity was not investigated. instead, in all studies, various lipid profiles were tested at the time of admission, and in study, tests were performed serially at intervals of days for more than weeks to analyze the relationship between lipid parameters and covid- severity. among the studies included in the analysis of hariyanto and kurniawan described earlier, study specified that patients' baseline lipid profile was analyzed. we found that higher total, ldl, and hdl cholesterol levels showed an inverse association with severe covid- in our new meta-analysis. consistently with our results, fan et al. and wei et al. reported similar findings from small observational studies. in studies of and patients, patients infected with covid- had lower total cholesterol and ldl cholesterol levels than healthy controls. severe cases had lower total cholesterol, ldl cholesterol, and hdl cholesterol levels. the authors suggested that their findings may be explained by changes in cholesterol metabolism due to covid- infection, changes in lipid metabolism due to hyperinflammation, leakage of ldl cholesterol due to increased vascular permeability, and accelerated lipid degradation. changes in lipid metabolism are an early step in atherogenesis and can cause vessel injury through coagulopathy and endothelial dysfunction. thus, the authors emphasized the role of cholesterol in vasculopathy caused by related to this topic, zhang et al. reported that in a retrospective study of , patients, statin therapy (the main treatment for dyslipidemia) significantly reduced the severity and mortality of covid- . in an analysis of all participants' baseline characteristics, subjects with statin therapy had less dyslipidemia, defined as a ldl cholesterol level more than the upper limit of the normal range according to the criteria at each hospital, and even after propensity score matching, there was a slight statistical difference between the two groups. however, even after correcting for various risk factors including ldl cholesterol, the mortality rate within days was . % and . % in the statin and non-statin groups, respectively, with an adjusted hazard ratio of . . the possibility that these results may reflect the pleiotropic effects of statins, including their anti-inflammatory and antioxidant effects, rather than their ldl cholesterol-lowering effect itself, has attracted attention. in particular, protease inhibitor-based antiretroviral and immunosuppressive drugs are used to treat covid- , and these drugs may exacerbate hyperlipidemia, so statins may be particularly effective in patients receiving these medications. furthermore, in a study in which proteomic analysis was performed on various tissues obtained from autopsy samples of patients who died from covid- , niemann-pick c (npc ) was significantly upregulated in most organs, including the lung, spleen, and heart. considering that lipids and lipid metabolism play an important role in the process of viral replication, npc may be a potential drug target for covid- . prospective randomized clinical studies are needed to obtain an accurate answer. an important limitation of this overview is that the number of studies included-reflecting the number of reviews that included data regarding the association between dyslipidemia and covid- infection-was limited, precluding a stringent analysis of this end point. moreover, the methodological quality assessment showed that both reviews had multiple critical flaws, making the current umbrella review limited. the situation regarding the covid- pandemic is changing so rapidly, with such serious consequences, that numerous reports are published without a sufficient evaluation of the data quality. this may explain the low methodological quality of the reviews included in the present study. consequently, we conducted this overview as a narrative synthesis of the evidence. in addition, we only analyzed articles in english. if the search had been done in other languages, more studies could have been included. despite these limitations, however, this is the first umbrella review investigating the association between dyslipidemia and covid- infection. furthermore, we applied a rigorous methodology to conduct an umbrella review of systematic reviews. hence, the evidence from this study is important from the perspective of aggressive treatment and disease prevention. in conclusion, we conducted an umbrella review to identify the findings and contents of systematic reviews and/or meta-analyses of the relationship between dyslipidemia and covid- infection severity. according to the amstar criteria and grade system, the studies did not show high quality, and the primary evidence quality of both the observational studies and the systematic reviews was considered low. although it is difficult to draw a definitive conclusion, patients with a history of dyslipidemia are likely to be at risk for severe covid- infections, but the contrary finding was shown for cholesterol levels at hospitalization. these findings suggest that dyslipidemia may potentially play a role in the severity of covid- infection. these results provide clinically valuable evidence in this pandemic situation because existing research on dyslipidemia and covid- is limited. more adequately powered studies are needed to obtain reliable results on this issue. it is very important to ensure that future research is well-designed, since conflicting results may occur depending on when dyslipidemia is defined or laboratory tests are performed. characteristics of persons who died with covid- -united states covid- and copd asthma and covid- : review of evidence on risks and management considerations association of cardiac injury with mortality in hospitalized patients with covid- in wuhan, china clinical characteristics and risk factors for mortality of covid- patients with diabetes in wuhan, china: a two-center, retrospective study association of hypertension and antihypertensive treatment with covid- mortality: a retrospective observational study covid- and cardiovascular disease associations of type and type diabetes with covid- -related mortality in england: a whole-population study is diabetes mellitus associated with mortality and severity of covid- ? a meta-analysis association of hypertension with the severity and fatality of sars-cov- infection: a meta-analysis declined serum high density lipoprotein cholesterol is associated with the severity of covid- infection low high-density lipoprotein level is correlated with the severity of covid- patients: an observational study summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach cochrane handbook for systematic reviews of interventions: cochrane book series methodology in conducting a systematic review of systematic reviews of healthcare interventions using existing systematic reviews in complex systematic reviews amstar : a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both reaching for the stars -rating the quality of systematic reviews with the assessment of multiple systematic reviews (amstar) amstar is a reliable and valid measurement tool to assess the methodological quality of systematic reviews grade guidelines: . introduction-grade evidence profiles and summary of findings tables impact of covid- on neurological manifestations: an overview of stroke presentation in pandemic diabetes mellitus is associated with increased mortality and severity of disease in covid- pneumonia -a systematic review, meta-analysis, and meta-regression meta-analysis investigating the relationship between clinical features, outcomes, and severity of severe acute respiratory syndrome coronavirus (sars-cov- ) pneumonia sanchis-gomar f. physical inactivity and cardiovascular disease at the time of coronavirus disease (covid- ) covid- among people living with hiv: a systematic review prognosis of covid- in patients with liver and kidney diseases: an early systematic review and meta-analysis editor's presentation: staying healthy and fighting cardiovascular disease at the time of covid impact of cerebrovascular and cardiovascular diseases on mortality and severity of covid- -systematic review, meta-analysis, and meta-regression elevated n-terminal pro-brain natriuretic peptide is associated with increased mortality in patients with covid- : systematic review and meta-analysis covid- and heart: from clinical features to pharmacological implications d-dimer as an indicator of prognosis in sars-cov- infection: a systematic review prediction models for diagnosis and prognosis of covid- infection: systematic review and critical appraisal risk factors of critical & mortal covid- cases: a systematic literature review and meta-analysis lipoprotein(a) and its potential association with thrombosis and inflammation in covid- : a testable hypothesis obesity as a predictor for a poor prognosis of covid- : a systematic review dyslipidemia is associated with severe coronavirus disease (covid- ) infection association of hypertension, diabetes, stroke, cancer, kidney disease, and high-cholesterol with covid- disease severity and fatality: a systematic review low serum cholesterol level among patients with covid- infection in wenzhou metabolic disturbances and inflammatory dysfunction predict severity of coronavirus disease (covid- ): a retrospective study cholesterol metabolism--impacts on sars-cov- infection prognosis. medrxiv membrane cholesterol modulates oligomeric status and peptide-membrane interaction of severe acute respiratory syndrome coronavirus fusion peptide importance of cholesterol for infection of cells by transmissible gastroenteritis virus factors associated with hospital admission and critical illness among people with coronavirus disease changes in lipid metabolism in patients with severe covid- risk factors for disease progression in covid- patients clinical characteristics of patients with corona virus disease (covid- high prevalence of obesity in severe acute respiratory syndrome coronavirus- (sars-cov- ) requiring invasive mechanical ventilation temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by sars-cov- : an observational cohort study a novel scoring system for prediction of disease severity in covid- clinical characteristics of patients infected with sars-cov- in wuhan cytokine storm in covid- : pathogenesis and overview of anti-inflammatory agents used in treatment cholesterol, inflammation and innate immunity the innate immune system: fighting on the front lines or fanning the flames of covid- ? role of lipotoxicity in endothelial dysfunction in-hospital use of statins is associated with a reduced risk of mortality among individuals with covid- the role of statins in the setting of hiv infection statin therapy in covid- infection multi-organ proteomic landscape of covid- autopsies. medrxiv the role of lipid metabolism in covid- virus infection and as a drug target key: cord- - wtdq ia authors: kumar, jogender title: authors’ reply date: - - journal: indian pediatr doi: . /s - - - sha: doc_id: cord_uid: wtdq ia nan we appreciate the interest of the reader in our article [ ] . the search of literature was performed till may , , till when there were no published studies with ten or more patients describing the pediatric multisystem inflammatory syndrome (pmis). it might be possible that there were a few case reports, but as mentioned in the methods, we did not include case reports and case series with less than ten cases. therefore, this syndrome did not appear in our review. we do not agree with the author's suggestion of including pmis in the screening strategy for covid- in children. as of now, pmis is a rare and poorly understood presentation of covid- in children [ ] . the preliminary case definition itself is too complex to assess in the screening area [ ] . therefore, it might not be feasible to use it for the screening of covid- . living systematic review (lsr) is an emerging approach in which the review is updated frequently (classically at monthly intervals) and usually published online-only. thought lsr seems a reasonable approach in covid- , it is very time consuming, requires lots of funding, and a dedicated team with long-term commitment. moreover, agreement on methods to manage the data synthesis in lsr is still lacking, and the frequent statistical analyses can lead to an inflated falsepositive rate. moreover, such a review can be published online only, therefore requiring a major change in the existing publication norms [ ] . therefore, at present, rather than considering it as a replacement, lsr should be considered as supplementary to the conventional review. ideally, meta-analysis should not have significant heterogeneity and the confidence interval should be very narrow. however, both of these conditions are extremely difficult to meet in observational studies, that too in the early stages of a pandemic. we explored heterogeneity using subgroup and sensitivity analysis using standard methods, but did not find any significant difference in the pooled estimates of any of the clinical or laboratory parameters. for a clinician, the knowledge of the pooled estimates for various clinical and laboratory conditions is indispensable, and it did not involve any intervention, therefore the meta-analysis was warranted. the limitations pointed out were already mentioned in our review [ ] . clinical features and outcome of sars-cov- infection in children: a systematic review and meta-analysis covid- children: clinical and epidemiological implications. ijmr [e-pub ahead of print coronavirus disease (covid- ) in children -what we know so far and what we do not data extraction methods for systematic review (semi) automation: a living review protocol meta-analysis in medical research clinical features and outcome of sars-cov- infection in children: a systematic review and meta-analysis novel coronavirus, mimicking kawasaki disease in an infant multisystem inflammatory syndrome in children and adolescents temporally related to covid- available from: https:// community.cochrane.org/ review-production/productionresources/living-systematic-reviews key: cord- -e v hpx authors: ardoin, nicole m.; bowers, alison w. title: early childhood environmental education: a systematic review of the research literature date: - - journal: nan doi: . /j.edurev. . sha: doc_id: cord_uid: e v hpx abstract environmental education focused on the early-childhood years is experiencing dynamic growth in research and practice due to persistent environmental challenges coupled with burgeoning interest in the documented benefits of nature-rich experiences for infants and children. to better understand the landscape of early childhood environmental education (ecee) pedagogical practices and expected outcomes, we undertook a systematic review of empirical studies of ecee programs. focusing on a -year span, we surfaced studies that met our inclusion criteria. we found that participants in such programs spanned the early-childhood age range (birth through age eight) with the majority involving three-to six-year-olds in teacher-led, formal (school-like) programs. the primary outcomes documented in our sample studies included environmental literacy development, cognitive development, and social and emotional development. to a lesser extent, the studies addressed physical development and language and literacy development. on balance, our sample of ecee studies reported strongly positive findings associated with the aforementioned outcomes. the majority emphasized the effectiveness of play-based, nature-rich pedagogical approaches that incorporated movement and social interaction. we include a visualization that synthesizes cross-sample findings with the intention of assisting ecee practitioners in developing, implementing, and evaluating programs as well as encouraging researchers to further study elements, processes, and theoretical assumptions inherent in them. environmental conditions across the globe continue to deteriorate at an alarming pace due to a complex web of social-ecological challenges including, but not limited to, climate change, air and water pollution, ocean acidification, land degradation, and biodiversity loss (barnosky & hadly, ) . scientists focused on these declining planetary conditions emphasize the importance of healthy, functioning, and resilient ecosystems as essential to all living beings, including humans (un environment, ). many note that protecting and restoring the global environment will require transformative changes in human production and consumption-related operator environmental education search terms (childcare or "day care*" or "early childhood" or "early elementary" or "early primary" or infants or kindergarten or "nursery school*" or preschool* or "primary grade*" or toddler* or "young child" or "young children" and ("conservation education" or "education for sustainability" or "education for sustainable development" or "environmental education" or "forest kindergarten*" or "forest school*" or gardening or "nature preschool*" or "nature-based preschool*" or "outdoor classroom*"or "school garden*" or "sustainability education") note. the asterisk "*" is a truncation symbol, which directs the search engine to find all forms of a given word. the term forest school*, for example, returns results containing "forest school" or "forest schools." of key journals that regularly publish ecee research. finding that the database searches did not consistently return results from two journals, international journal of early childhood environmental education and children, youth and environments, we conducted manual table- of-contents reviews for those two journals. through the manual search process, we added citation records and removed duplicates, leaving a total of unique citation records identified via manual searches of the two journals. the combined results from both search strategies (database and manual journal searching) yielded , total citation records. to screen the , citation records, at least two research team members read each abstract and used a decision tree to identify relevant studies based on the following inclusion criteria: • focused on early childhood/young children, birth through age eight and/or through third grade within the u.s. educational system; • reported on an environmental education experience and/or program. throughout the review, we included sustainability and conservation education as nearly synonymous with environmental education; we also were broad in our definitions around early childhood-specific terms, such as nature preschools and forest schools; and • designed as empirical research or evaluation. this criterion was designed to exclude other reviews as well as long-form discussion pieces focused primarily on theoretical perspectives. during the first review round, we excluded articles in practitioner-oriented journals, which resulted in eliminating articles intended for classroom teachers, that described classroom activities, or that included detailed lesson plans. we also excluded dissertations, textbooks, and conference presentations unavailable as published resources. based on reviewing the abstracts, we excluded , citation records, many of which involved children outside of the designated age range, focused on educators rather than children, and/or did not meet other review criteria. we then located the full-text versions for the remaining citations. next, we focused on eligibility for final inclusion in the review. at least two team members reviewed the full text of those records to confirm that the articles met the previously described first-round inclusion criteria. after reviewing full-text versions of the citation records, we excluded for failing to meet the initial inclusion criteria. we devised and applied a generic framework (i.e., we did not apply different quality criteria for quantitative, qualitative, or mixed-methods studies), which relied on expert judgement and a set of predefined quality criteria. this quality-appraisal approach was informed by several review factors: the search process identified studies with varied research designs (i.e., qualitative, quantitative, and mixed-methods approaches). we employed an expert panel to provide external feedback throughout the process; our review team included research methodologists and members with prior experience conducting systematic reviews. our predefined quality criteria included ensuring that studies provided relevant program descriptions; basic information about research methods and data; and sufficiently detailed findings. we selected these criteria as our review was designed to be configurative, rather than aggregative, focusing on identifying common practices and outcomes in ecee. additionally, although we recognize that the peer-review process is at times inconsistent, we chose to include only peer- reviewed studies in our final sample, as that process suggests that some level of quality appraisal had been conducted. using a decision-tree process similar to that of the screening-and-eligibility process described above, at least two research team members reviewed each of the studies, addressing quality-related elements; in this manner, all studies were assessed at least twice (national institute for health and clinical excellence, ). in addition to asking each reviewer for an overall impression of study quality, we applied two study-quality-related eligibility criteria. specifically, we sought studies that: ( ) sufficiently described research methods and measures as well as data-collection tools/instruments, and ( ) presented clear-cut data to support claims. the research team met to discuss opinions and evaluation of quality for each study and ensure consistent application of the quality criteria. during the quality review, team members agreed on four studies that did not meet the quality criteria. the final sample included studies ( peer- reviewed articles and peer-reviewed conference paper). the studies in our final sample represented a variety of research designs that produced qualitative and quantitative data; thus, we employed a mixed research synthesis review approach table ). when possible, we used in vivo coding, extracting exact wording, leading to the development of new codes (saldaña, ) . this inductive technique did not limit coders to predetermined codes and facilitated capturing unexpected data (charmaz, team members pilot-tested the codebook, resolved discrepancies through group discussion, and reached % agreement on coding decisions before proceeding to fully code the comprehensive set of studies. to do so, we used an iterative process, facilitated through nvivo (a qualitative data analysis software), modifying the codebook based on emergent trends. we added, revised, and rearranged codes until reaching a saturation point (i.e., no new codes were generated). in initial rounds of coding, for example, we assigned codes to describe the program setting, such as a preschool or local park. in subsequent rounds, we noticed patterns related to whether the setting included an outdoor component; we therefore revised the setting category to note inclusion of an outdoor component. where appropriate, we used counting to aggregate the data, which allowed us to identify trends in the data (miles et al., ) . with publication year, for example, we coded and counted the data categories by year (e.g., , , and so on), using a combination of nvivo and excel to manage the process across the dataset. we also used counting for publication outlet, research type, country, participant age(s), facilitator, program length, program travel, program setting, and overall findings. those data provided a general description of the programs included in the final sample. to analyze data in the remaining categories of outcomes and practices, we used a modified grounded theory approach (corbin & strauss, ) to identify core categories. in initial coding rounds, we identified all reported outcomes and practices. as coding progressed, we grouped outcomes and practices into broader categories. for coding outcomes, we used a we coded of the studies ( %) as primarily focusing on qualitative data; ( %) on quantitative data; and ( %) used mixed-methods approaches to produce both qualitative and quantitative data. with regard to valence of overall findings, we coded studies ( %) as reporting mainly positive findings, ( %) as reporting a mix of positive and null findings, and ( %) as reporting only null findings (i.e., no change in the measured outcomes). we did not code any studies as reporting mainly negative findings. the studies in our sample involved programs whose participants spanned the early childhood age range. although the distribution across studies approximated a normal curve, the most common age of focus was four-and five-year-olds. to the extent possible, we extracted data about program setting, such as whether the program occurred as part of a school or daycare experience (formal setting) or related to a museum, park, or visit, not otherwise included in a structured school/daycare experience (nonformal setting). the majority of studies ( , %) examined a formal ecee program that occurred onsite at a school, daycare, or early childhood education center; only five studies ( %) described programs occurring in a nonformal setting. we considered whether programs under study involved the children spending time outside and/or in nature-rich settings. of the studies, the majority ( , %) examined programs that included time outside in a natural environment, a nature-rich setting, or an environment with a preponderance of nature-inspired features. eleven of the studies ( %) described primarily indoor programs. we developed five broad coding categories for participant outcomes based on naeyc (copple & bredekamp, ) table ). in the articles we reviewed, the most frequently reported outcomes were related to the category of environmental during the initial coding process, we found that researchers described evidence of more than pedagogical practices associated with effective ecee programs among the studies. researcher-described effective pedagogical practices included a range of engagement types and settings from highly active and immersive (e.g., hiking outdoors), to reflective (e.g., creating drawings), to analytical and synthetic (e.g., guided in-class discussions). we organized the coded practices into nine thematic codes that described ecee strategies supporting development observe; action taking; family connection; and personal connection (see table ). the most frequently studied ecee programs involved children in the four-and five-year- old age ranges participating in ongoing, educator-facilitated programs that included time in nature-rich settings and occurred in a formal setting, such as a school, daycare, or early childhood center. although this general picture emerged, diversity existed in our sample suggesting ecee variations that may be in need of additional study; we highlight those areas below. examining the data concerning participant age revealed a close-to-normal distribution with children ages four and five being the most frequently studied age group (see fig. ). in many countries, children in this age group are attending school for the first time, either as part of a preschool or kindergarten experience, or as part of their first year in primary school. given the importance of this age as many children are transitioning into formal schooling, it is not surprising that this is a well-studied age group; however, early childhood's early (birth through age two) and later (ages seven through eight) years represent areas in need of further ee-focused research. the infant and toddler stages (birth through age two) can be difficult to study using traditional research approaches because of a lack of language skills as well as their still-nascent, yet developing, psychomotor abilities. taken together, these can greatly limit programmatic outcomes as well as measurement approaches. this age, however, also represents a foundational % of the studies reported environmental outcomes and only % included non- environmental outcomes (ardoin et al., ) . these data suggest that either ( ) researchers focusing on ecee programs are more likely to address and focus on non-environmentally related outcomes than their k- counterparts; or ( ) ecee programs, overall, are more likely to pursue alternative, non-environmentally related outcomes. one explanation, in light of the growing body of evidence demonstrating the social and physiological benefits of time in nature- rich environments, is that ecee programs are leveraging critical early-childhood developmental stages and processes related to cognition, physical health, wellbeing, moral development, social concurrently, it is essential to assist key stakeholders, such as policymakers and supervisors, and influential implementers, such as educators, in understanding and embracing the complex influence of a range of nature-rich settings on young people. as adams and savahl ( ) noted, not all children and educators have equal access to safe, clean nature-rich areas that provide opportunities for enriching educational experiences. in certain places, simply "going outside" or finding a proximal nature-rich context may be difficult, or may not create a platform for a universally positive experience. to address such challenges, daycare center staff in australia, for example, worked with researchers to develop an arts program drawing on nature- inspired themes and incorporating natural materials into ongoing activities to provide children with consistent nature exposure, even when outdoor space was lacking (tarr, ) . in these ways and others, the role played by nature and nature-rich experiences can be enhanced even when teaching and learning indoors, or with limited access to nature. early in the review process, we necessarily defined our research questions tightly and constrained our search, resulting in a narrowing of the study's scope to focus on outcomes associated with birth through age eight. yet environmental education outcomes can, and often do, reach an audience far beyond the participants. in our studies, for example, we encountered measured outcomes specific to the early childhood educators, families of the young children, and the educational institutions. as those audiences were beyond this review's scope, we did not code for those outcomes, but we recognize that they, too, are important and worthy of future study. we also note geographical limitations in this study and analysis: our review sample did not include studies from latin america and africa, as our systematic approach did not uncover studies in those areas that met our criteria (i.e., empirical, participant outcomes, published in english). we necessarily limited our search to english-language studies as a practical consideration based, first, on readily available articles and papers, and second, the research team's linguistic competency. this delimitation certainly caused us to miss relevant research, and the lack of studies from areas such as central and south america may reflect a structural barrier (e.g., linguistics), rather than the amount of research (or lack thereof) conducted in those areas. latin america and considers journal articles published in both english and spanish. their review, however, does not separate the reviewed articles by language or geographic location; thus, the details provided are not granular enough to include in our sample. alternatively, our study sample represents regions where ecee is a more frequent practice due to a variety of factors. regardless of the particular reasons for which studies from latin america and africa did not surface in our review, the implication is that more ecee research in latin america and africa should be encouraged and shared in a wider venue, thus developing a comprehensive understanding of ecee research across such settings and worldwide. our discussion of the findings surfaced several additional areas requiring future research. more research is needed with very young children (birth through age two), as this is an underrepresented age group in our sample. similarly, additional research with children at the opposite end of the early childhood range (ages seven through eight) shows a dearth. we also highlighted a need for ecee research into programs that occur in less- structured, nonformal learning environments. moreover, we note a particularly vibrant opportunity for enhanced early childhood environmental learning in the course of everyday life, mediated by familial or caregiver-child interactions. our search process uncovered few such studies, although this may have been a reflection of our search terms: many researchers and practitioners do not envision caregiver-child or familial interactions in the outdoors or nature- rich settings as examples of "environmental learning," per se, regardless of content or skills developed. yet perhaps these socioculturally embedded interactions-reimagined to more richly contextualize, mark, and connect environmental learning with relevant daily-life activities- could become a consistent, more commonly recognized and studied aspect of the ecee ecosystem (jarvis, ; blinded for review). our review suggests that ecee encourages young children affectively, in terms of exploring the environment, bolstering their sense of self-confidence, and making social connections with each other; developing cognitive frameworks for understanding the natural world; and laying the groundwork for skills and dispositions related to taking action to improve and protect the environment. our review sample studies describe programs focusing on trees, water, and nature more generally; many take place in immersive, nature-rich settings, while others bring nature-rich elements into classrooms. the programs include a range of outcomes designed to nurture children's development of action skills and encourage developmentally appropriate pro-environmental behaviors. in addition to an environmental focus, the reviewed studies indicate that ecee programs emphasize related early childhood goals of personal development as well as academic progress (e.g., in the form of kindergarten readiness). our sampled studies provide evidence of strongly positive outcomes from ecee, when measured holistically across a range of affective and cognitive dimensions, conveying how those programs often engender a sense of joy and curiosity inherent in effective early childhood educational programs. the programs encourage young participants to connect those affective elements with environmentally related knowledge, action orientation, and civic engagement, focused on the environment not only as an educational setting, but in its totality (sauvé, ) . as bailie ( ) writes, "the combination of early childhood education and environmental education is more powerful together than each by itself" (p. ). such a synergistic relationship offers promise to enhance the quality of the human experience in the world with beneficial impacts for spaces and species, for generations to come. . references nature as children's space: a systematic review environmental education and k- student outcomes: a review and analysis of research early childhood education for sustainability: the relationship between young children's participation and agency-children and nature the sage handbook of outdoor play and learning connecting children to nature: a multiple case study of nature center preschools (doctoral dissertation) the effects of a health promotion program using urban forests and nursing student mentors on the perceived and psychological health of elementary school children in vulnerable populations tipping point for planet earth: how close are we to the edge systematic review of education for sustainable development at an early stage: cornerstones and pedagogical approaches for teacher professional development the nature of udeskole: outdoor learning theory and practice wonderlands of buttercup, clover and daisies': tuberculosis and the open-air school movement in britain changes in experiences with nature through the lives of environmentally committed university faculty plant yourself where language blooms: direct experience of nature changes how parents and children talk about nature constructing grounded theory childhood experiences associated with care for the natural world: a theoretical framework for empirical results growing up green: becoming an agent of care for the natural world benefits of nature contact for children school in kindergartens: the effects, interpretation, and implementation of a pilot program research synthesis and meta-analysis: a step-by step approach developmentally appropriate practice in early childhood programs serving children from birth through age basics of qualitative research: techniques and procedures for developing grounded theory ecological awareness and children's environmental experience toward a model for early childhood environmental education: foregrounding, developing, and connecting knowledge through play-based learning young children's play and environmental education in early childhood education green spaces and cognitive development in primary schoolchildren educating for sustainability in the early years: creating cultural change in a child care setting revealing the research "hole" of early childhood education for sustainability: a preliminary survey of the literature research in early childhood education for sustainability: international perspectives and provocations making "eco-waves": early childhood care and education sustainability practices in aotearoa new zealand systematic review of the empirical evidence of study publication bias and outcome reporting bias-an updated review young children's contributions to sustainability: the influence of nature play on curiosity, executive function skills, creative thinking, and resilience article childhood origins of young adult environmental behavior early-life outdoor experiences and an individual's environmental attitudes the sage handbook of early childhood research how to bring the outdoors home even when you're stuck inside (blog post publication bias in the social sciences: unlocking the file drawer the benefits of children's engagement with nature: a systematic literature review an introduction to systematic reviews an introduction to systematic reviews lifelong learning: towards a theory of practice for formal and non-formal environmental education and training what is the relationship between outdoor time and physical activity, sedentary behaviour, and physical fitness in children? a systematic review toward young children as active researchers: a critical review of the methodologies and methods in early childhood environmental education recontextualizing psychosocial development in young children: a model of environmental identity development doing research with children: a practical guide grey literature in systematic reviews: a cross-sectional study of the contribution of non- english reports, unpublished studies and dissertations to the results of meta-analyses in child-relevant reviews education for sustainable development in early childhood education: a review of the research literature using mixed methods research synthesis for literature reviews from play in nature, to recreation then vocation: a developmental model for natural history-oriented environmental professionals the routledge international handbook of lifelong learning a coordinated research agenda for nature-based learning bringing the jellyfish home: environmental consciousness and 'sense of wonder' in young children's encounters with natural landscapes and places the impact of forest school on education for sustainable development in the early years in england urban green space and its impact on human health how might contact with nature promote human health? promising mechanisms and a possible central pathway defining nature-based preschools handbook of lifelong learning for sustainable development outcome research in environmental education: a critical review going on a turtle egg hunt and other adventures: education for sustainability in early childhood key knowledge gaps to achieve global sustainability goals forest schools in great britain: an initial exploration comparing classroom context and physical activity in nature and traditional kindergartens qualitative data analysis: a methods sourcebook preferred reporting items for systematic reviews and meta-analyses: the prisma statement two avenues for encouraging conservation behaviors a framework for environmental education strategies published versus unpublished dissertations in psycho-oncology intervention research effects of nature kindergarten attendance on children's functioning. children methods for the development of nice public health guidance early childhood environmental education programs: guidelines for excellence nature preschools and forest kindergartens: national survey k- environmental education: guidelines for excellence forest school and its impacts on young children: case studies in britain ecological behavior across the lifespan: why environmentalism increases as people grow older the development of children's environmental attitude and behavior young children and the natural world including families in the learning community: family centres and the expansion of learning blank, blind, bald and bright spots in environmental education research identifying needs in environmental education research nature experiences and adults' self-reported pro-environmental behaviors: the role of connectedness to nature and childhood nature experiences the coding manual for qualitative researchers the contribution of early childhood education to a sustainable society defining and designing mixed research synthesis studies currents in environmental education: mapping a complex and evolving pedagogical field impact of urban nature on executive functioning in early and middle childhood preferred reporting items for systematic review and meta-analysis protocols (prisma-p) : elaboration and explanation nature preschools and forest kindergartens: the handbook for outdoor learning sustainability education in early childhood: an updated review of research in the field environmental education program evaluation in the new millennium: what do we measure and what have we learned? making the case for a null effects framework in environmental education and k- academic outcomes: when "just as good" is a great thing enhancing environmental awareness through the arts metrics and outcomes of conservation education: a quarter century of lessons learned mental health benefits of interactions with nature in children and teenagers: a systematic review publication bias: the achilles' heel of systematic reviews? the health benefits of the great outdoors: a systematic review and meta-analysis of greenspace exposure and health outcomes global environment outlook-geo- : healthy planet, healthy people united nations statistics division can we meet the sustainability challenges? the role of education and lifelong learning nature and the life course: pathways from childhood nature experiences to adult environmentalism children and nature: following the trail to environmental attitudes and behavior lifelong learning and the family: an auto/biographical imagination impact of garden-based learning on academic outcomes in schools: synthesis of research between environmental education programs for preschool children nature and young children: encouraging creative play and learning in natural environments educational interventions that improve environmental behaviors: a meta- analysis thanks to eeworks advisors as well as colleagues who provided particularly helpful feedback: judy braus, emilian geczi, cathy jordan, christy merrick, bora simmons, alan reid, and dilafruz williams. thanks also to numerous stanford social ecology lab members who provided research assistance, especially: estelle gaillard, avery hanna, tucker hirsch, wendi hoover, marika jaeger, fiona noonan, alexandra peers, and indira phukan. key: cord- -dzm xi authors: filardi, tiziana; varì, rosaria; ferretti, elisabetta; zicari, alessandra; morano, susanna; santangelo, carmela title: curcumin: could this compound be useful in pregnancy and pregnancy-related complications? date: - - journal: nutrients doi: . /nu sha: doc_id: cord_uid: dzm xi curcumin, the main polyphenol contained in turmeric root (curcuma longa), has played a significant role in medicine for centuries. the growing interest in plant-derived substances has led to increased consumption of them also in pregnancy. the pleiotropic and multi-targeting actions of curcumin have made it very attractive as a health-promoting compound. in spite of the beneficial effects observed in various chronic diseases in humans, limited and fragmentary information is currently available about curcumin’s effects on pregnancy and pregnancy-related complications. it is known that immune-metabolic alterations occurring during pregnancy have consequences on both maternal and fetal tissues, leading to short- and long-term complications. the reported anti-inflammatory, antioxidant, antitoxicant, neuroprotective, immunomodulatory, antiapoptotic, antiangiogenic, anti-hypertensive, and antidiabetic properties of curcumin appear to be encouraging, not only for the management of pregnancy-related disorders, including gestational diabetes mellitus (gdm), preeclampsia (pe), depression, preterm birth, and fetal growth disorders but also to contrast damage induced by natural and chemical toxic agents. the current review summarizes the latest data, mostly obtained from animal models and in vitro studies, on the impact of curcumin on the molecular mechanisms involved in pregnancy pathophysiology, with the aim to shed light on the possible beneficial and/or adverse effects of curcumin on pregnancy outcomes. maternal nutrition is an essential and modifiable environmental factor that deeply influences maternal and offspring health in the short and long-term [ ] [ ] [ ] [ ] [ ] [ ] . genetics, nutrition, and other environmental factors significantly contribute to the physiological immune and metabolic modifications occurring in pregnancy, to favor maternal adaptation to the growing and developing fetus. maternal malnutrition adversely affects these dynamic processes by acting on the mechanisms related to the nutritional programming, including nutrition sensing signals, epigenetic regulation, gut microbiome, as well as on the nutrient-nutrient and nutrient-drug interactions, modulating maternal and fetal genes in a sex-specific manner [ , [ ] [ ] [ ] [ ] . bw/day of curcumin as a food additive [ ] . however, despite its potential therapeutic benefits, curcumin is poorly bioavailable due to its rapid metabolism, and the small portion of substance that is absorbed is extensively bio-transformed into its water-soluble metabolites, glucuronides, and sulfates [ ] . therefore, several strategies have been developed to enhance its bioavailability and efficacy, to increase oral and gastro-intestinal absorption, and to reduce the clearance from the body [ ] [ ] [ ] . for this purpose, taking into consideration that curcumin is fat-soluble, several delivery systems have been developed to obtain a number of formulations by mixing curcumin with different materials, including adjuvants, such as piperine [ , ] . micelles, liposomes, phospholipid complexes, phytosomes, emulsions, microemulsions, nano-emulsions, solid lipid nanoparticles, nanostructured lipid carriers, biopolymer nanoparticles, and microgels represent different and recent technical approaches to encapsulate curcumin [ ] [ ] [ ] , although further studies are needed to evaluate their effectiveness and safety as potential health-promoting compounds in humans. it is well known that dynamic changes in insulin sensitivity take place during healthy pregnancy to allow adequate supply to the growing fetus [ ] . in pregnancy, several players, including hormones, cytokines, and metabolic factors, contribute to the development of insulin resistance through complex mechanisms, not yet completely understood [ , ] . maternal obesity, related to unhealthy diet and lifestyle, can negatively affect insulin sensitivity leading to the development of gdm and type diabetes (t d), with serious short and long-term health consequences for both the mother and the offspring [ , ] . recent evidence emphasized the anti-hyperglycemic activity of curcumin, both in animals and humans [ ] . specifically, this compound had the capability to improve glucose uptake, insulin sensitivity, and pancreatic β-cell function, as well as liver and kidney function, and to reduce glucose and lipid levels, oxidative stress, and inflammation [ ] , by interacting with almost all the players involved in these processes, as demonstrated in in vitro studies [ , ] . as regards human studies, the effects of curcumin supplementation have been evaluated in several randomized controlled trials. a recent intervention study showed that mg/day curcumin supplementation ( mg capsules: mg of curcumin, mg of demethoxycurcumin, and mg of bisdemethoxycurcumin) for weeks reduced triglycerides (tg) and c-reactive protein (crp), and increased adiponectin levels [ ] , whereas mg/day curcumin co-administered with piperine mg/day for three months was able to reduce blood glucose, c-peptide, glycated hemoglobin (hba c), alanine aminotransferase (alt) and aspartate aminotransferase (ast), in patients with t d [ ] . another study showed that the daily ingestion of mg turmeric powder for eight weeks resulted in a reduction in body weight, low density lipoprotein-cholesterol (ldl-c), and tg levels, with no significant effects on glycemia, crp, and hba c, in hyperlipidemic t d patients [ ] . in obese women with polycystic ovary syndrome (pcos), mg/day curcumin supplementation ( mg twice daily: - % curcumin, - % demethoxycurcumin and . - . % bisdemethoxycurcumin) for six weeks improved serum insulin and the quantitative insulin sensitivity check index [ ] . a recent meta-analysis reported that curcumin intake was associated with reduced body mass index (bmi), body weight, body fat, leptin value, and increased adiponectin levels in patients with metabolic syndrome and related disorders [ ] . overall, the dosage and duration of curcumin supplementation appear to differently modulate glucose metabolism in humans. a recent promising approach to treat hyperglycemia consists of combining the effects of curcumin and the ongoing antidiabetic agents, as observed in diabetic rats treated with a combination of curcumin and metformin. specifically, this association improved hyperglycemia, dyslipidemia, and oxidative stress, increasing the activity of the antioxidant enzyme paraoxonase (pon ), in diabetic rats [ ] . dietary bioactive compounds might have beneficial effects on gdm [ , ] . in particular, curcumin appeared to improve gdm and gdm-related complications in a recent study in a mouse model. specifically, c bl/ksjdb/+ diabetic pregnant mice were supplemented with different curcumin dosages: mg/kg and mg/kg/day, from gestational day zero (gd ) to gd . results showed that mg/kg curcumin significantly reduced blood glucose and insulin levels, increased hepatic glycogen content, and improved oxidative stress by reducing thiobarbituric acid reactive substance (tbars) and increasing glutathione (gsh) levels, superoxide dismutase (sod), and catalase (cat) activities in the liver of diabetic pregnant mice at gestational day . the reduced ' adenosine monophosphate-activated protein kinase (ampk) and increased histone deacetylase hdac activities observed in gdm liver were reverted by curcumin treatment. furthermore, curcumin positively influenced the offspring of mothers with gdm, restoring litter size and birth weight, and inducing the reduction of glucose- -phosphatase (g pase) expression and activity in the liver [ ] ( table ) . congenital birth defects, including neural tube defects (ntd), occur more often in the offspring of diabetic mothers. in a recent study, mouse embryos (at e . of development) were cultured for h with mg/dl glucose, in the absence or presence of curcumin ( and µm). remarkably, µm curcumin was able to reduce the rate of embryos with ntd induced by high glucose. curcumin reduced high glucose-induced oxidative and nitrosative stress [i.e., decreased -hydroxynonenal ( -hne), nitrotyrosine levels, and lipid hydroperoxide (lpo)], as well as endoplasmic reticulum (er) stress (i.e., decreased expression of er-markers stress such as phosphorylated protein kinase-like endoplasmic reticulum kinase (p-perk), phosphorylated inositol-requiring protein- α (p-ire α), phosphorylated eukaryotic initiation factor α (p-eif α), c/ebp-homologous protein (chop), binding immunoglobulin protein (bip), and x-box binding protein (xbp ). moreover, µm curcumin inhibited the cleavage of pro-apoptotic caspases (i.e., casp- and - ) [ ] . although the results from preclinical studies are overall promising, further research is needed to better understand the molecular mechanisms underlying diabetic complications, as well as the pharmacodynamics and pharmacokinetics of curcumin in pregnancy, to conceivably employ this compound as a therapeutic agent for human pregnancy complications. critical changes in the cardiovascular system occur in physiological pregnancy, to ensure maternal and fetal adaptation to the increased metabolic demand and to guarantee adequate uteroplacental circulation for fetal growth. a healthy pregnancy is hallmarked by systemic vasodilatation, significantly related to the high levels of estrogen and progesterone. cardiac output and heart rate rise during gestation and the activation of the renin-angiotensin-aldosterone system leads to a significant increase in total blood volume. alterations in these processes are associated with maternal and fetal morbidity and mortality [ ] . obesity, older maternal age, and diabetes mellitus increase the risk of cardiovascular diseases in pregnancy ( - %), with a higher prevalence when including hypertensive disorders-chronic hypertension, pregnancy-induced hypertension, pre-eclampsia, and hellp syndrome (hemolysis, elevated liver enzymes, and low platelet count) [ ] . considering the anti-inflammatory, antioxidant, and antiangiogenic activities observed in several studies, curcumin is a potential therapeutic compound in cardiovascular disorders [ ] . preeclampsia (pe) is a systemic syndrome characterized by hypertension and proteinuria, which begins after weeks of gestation; it occurs in - % of pregnancies, and it is a leading cause of maternal and fetal morbidity and mortality [ ] . although the pathophysiology of pe remains to be elucidated, alterations in maternal vascular physiology have been described, leading to a generalized vasoconstrictive state, systemic oxidative stress, inflammation, and endothelial cell dysfunction, with severe adverse effects on the placenta, one of the major organs that develops after conception [ , ] . strategies to reverse or arrest the pathological processes of pe are aimed at reducing excessive inflammatory response, micro-emboli formation, and vasoconstriction by using specific drugs or natural products [ ] . for this purpose, studies in animal models have been performed. it has been observed that in lipopolysaccharides (lps)-treated pregnant rats to create a pe model (lps . µg/kg on gestational day ), the administration of curcumin ( . mg/kg, from gd to gd ) improved hypertension, proteinuria, and renal damage, and reduced serum levels of il- and monocyte chemoattractant protein- (mcp- ). curcumin treatment ameliorated inadequate trophoblast invasion and spiral artery remodeling, significant histopathological alterations observed in pe. analysis of placental tissue showed that curcumin administration decreased the lps-induced expression of the inflammatory molecules toll-like receptor (tlr)- , il- , and the proinflammatory transcription factor nf-kb. according to the obtained data, the authors hypothesized that curcumin may positively modulate the cascade of different signaling pathways involved in pe development [ ] . similar results were obtained in a mouse model of lps-induced pe. in this study, in addition to blood pressure and proteinuria reduction, curcumin increased the number of live pups, fetal and placental weight, and decreased fetal desorption. these effects were associated with the inhibition of placental expression of tnf-α, il- β, il- cytokines, and mcp- and mip- chemokines, and with a reduction in macrophage infiltration. the reduced inflammatory status was accompanied by increased activation of the serine/threonine-specific protein kinase akt, involved in cellular proliferation [ ] . neo-vascularization is a critical event mediated by several angiogenic factors-including the vascular endothelial growth factor (vegf), fibroblast growth factors (fgfs), matrix metalloproteinases (mmps)-and inflammatory factors such as cyclooxygenase (cox)- and nf-kb, occurring not only in tumor progression but also in early placentation [ , ] . curcumin appears to modulate the above-mentioned factors, influencing vessel formation by acting either as a proangiogenic or as an antiangiogenic molecule, depending on the concentration and the cell type [ ] . a recent study investigated the effect of curcumin in htr /svneo trophoblasts cells, a model of the human first-trimester placenta. incubation with curcumin at low concentration ( - µm for h) stimulated (i) proliferation with concomitant activation of akt, (ii) tube formation of placental trophoblast htr /svneo cells, (iii) and increased the expression of the proangiogenic factors vegf, vegfr , and fabp . in addition, curcumin treatment strongly increased the mrna and protein expression of hla-g, involved in the immune regulation during trophoblast invasion; and mrna expression of a relevant number of genes related to the notch-signaling pathway, which regulates angiogenesis. the authors examined the promoter methylation of genes involved in metabolic and oxidative stress and observed that curcumin induced hypomethylation in genes involved in the protection against oxidative stress and dna damage. altogether these data indicate that curcumin is able to promote angiogenesis and to activate protective pathways in the first trimester of pregnancy, and supports the development of the placental trophoblast [ ] . moreover, htr /svneo trophoblast cells were used to evaluate the protective effects of curcumin against oxidative stress induced by h o ( µm for h). results showed that pretreatment with curcumin ( µm for h) increased cell viability, upregulated the activities of the antioxidant enzymes cat and glutathione peroxidase (gsh-px), reduced the h o -induced ros accumulation and the apoptotic rate. at molecular levels, these data were associated with an increased nuclear translocation of the antioxidant transcription factor nrf , and reduced expression of cleaved-caspase [ ] . the anti-inflammatory activity of curcumin has been also observed in vitro in human gestational tissues treated with lps. specifically, incubation with curcumin ( µm for h) reduced il- release, and il- and il- mrna expression induced by lps, in both placenta and fetal membranes. moreover, curcumin decreased placental cox- mrna expression, prostaglandin pge and pgf a release, and the expression and activity of the matrix-degrading enzyme mmp- , in association with reduced activation of nf-kb [ ] . although several clinical trials emphasized the benefits of curcumin in different pathological contexts [ , , , ] , there are few data on curcumin supplementation in human pregnancy. recently, a double-blind randomized clinical trial involving pregnant women with preeclampsia was conducted to evaluate the possible effect of curcumin on the expression of cox- and il- , thought to have a role in the pathogenesis of pe. the enrolled patients were randomized to receive either curcumin mg/d (n = ) or placebo (n = ) [ ] . the authors analyzed the circulating levels of il- and cox- , at t , min after curcumin ingestion, and h after delivery. results showed that curcumin did not modify the expression of the analyzed molecules at any tested time. the authors hypothesized that the absence of effect might be due to the low dose of curcumin, taking into account that in non-pregnant subjects doses can reach more than g/day [ ] . during the antenatal and postpartum periods, women are particularly prone to develop mental disorders, including depression. postpartum depression (ppd) occurs in - % of women, leading to significant health consequences for both mother and offspring [ ] . this condition has been largely underestimated and understudied so far. hence, its prevalence is supposed to be higher, conceivably reaching % of women. symptoms of depression begin during pregnancy in about % of women and numerous environmental, genetic, biochemical, and epigenetic factors likely contribute to the onset of ppd [ ] [ ] [ ] , although the exact mechanisms responsible for this condition are not yet completely known. several pharmacological and psychological approaches are currently adopted to treat ppd, even though complementary and alternative medicine have also been taken into consideration. increasing data have suggested the neuroprotective roles of a healthy diet, rich in fruit and vegetables, highlighting its positive influence on mental health [ ] . on the contrary, an unhealthy dietary pattern increases the risk of systemic low-grade inflammation and neuroinflammation, known to be associated with ppd [ ] . the neuroprotective and antidepressant benefits of curcumin have been known for a long time [ ] [ ] [ ] . several preclinical studies have suggested potential positive effects of curcumin in treating neurological disorders, such as alzheimer's disease, parkinson's disease, multiple sclerosis, migraine, epilepsy, brain and spinal cord injury, and depression [ , , ] . lopresti and colleagues have investigated the effects of curcumin on depression outcomes in humans. they observed that eight-week curcumin supplementation ( mg twice a day) in subjects with major depressive disorder (mdd) was effective in reducing depressive and anxiety symptoms, as demonstrated by the reduction in total depressive symptoms (total ids score), mood/cognitive depressive symptoms (idsm), arousal-related symptoms (idsa), and trait anxiety (stait) [ ] . this supplementation resulted in an increase in urinary levels of both the arachidonic acid metabolite thromboxane b (tbx-b ) and the neuropeptide substance p (sub-p), potentially involved in depression mechanisms. moreover, although curcumin did not modify plasma levels of endothelin- and leptin, a greater antidepressant benefit was observed in subjects with the highest baseline levels of these molecules. the authors hypothesized that curcumin might act by increasing endothelin and leptin receptor activities [ ] . similarly, in another trial, mg/day curcumin ingestion for six weeks or the administration of the antidepressant drug fluoxetine showed comparable efficacy in subjects with mdd [ ] . a recent meta-analysis provided relevant information about curcumin use in depression. specifically, this analysis revealed that curcumin administration (i) appears to be more effective in reducing depression symptoms at a higher dosage ( g/day) and for six weeks or more; (ii) can enhance the action of antidepressants; and (iii) has more effects on subjects with major depression and without other comorbidities [ ] . these results indicate the need for further study to better comprehend the mechanisms of action of curcumin in depression treatment. data obtained from animal and in vitro studies have indicated that curcumin might exert antidepressant activity by acting on different signaling pathways involved in mental disorders. specifically, this compound is able to ameliorate the hypothalamic-pituitary-adrenal (hpa) axis disturbances [ ] . curcumin can influence the unbalanced release of monoamine neurotransmitterssuch as serotonin ( -ht), dopamine (da), noradrenaline, and glutamate-the expression of monoamine oxidase (mao), the expression of neurotrophic factors such as brain-derived neurotrophic factor (bdnf) and neurogenesis, as well as the dysregulated immune system function and oxidative and nitrosative stress. thus, curcumin appears to promote neurogenesis and inhibit neuronal cell apoptosis [ , , , ] . despite the consistent evidence of efficacy and safety of curcumin treatment in other pathological conditions, to date, data on its effects on depression in pregnancy are completely lacking. however, in the last years, there has been a growing awareness of the possible role of anti-inflammatory micronutrients in improving ppd symptoms [ ] . according to the theory of the fetal origin of adult diseases (foad) hypothesized by david barker, the intrauterine environment has a relevant role in fetal growth and development and influences disease susceptibility in the offspring in the short and long term [ ] . the physiological processes of pregnancy require immune and metabolic modifications to accommodate the growing fetus; maternal malnutrition negatively influences this dynamic equilibrium, leading to tissue-specific impairment, with serious adverse outcomes for both mother and child [ , ] . taking into consideration the importance of nutrition in human development, there is a need for better understanding the nutritional programming and the related mechanisms and players acting during pregnancy. the placenta has the fundamental role of transferring nutrients to the fetus, and alterations in placental function have severe effects on fetal growth. placental insufficiency is the most common cause of fetal growth restriction (fgr), a serious condition that affects - % of all newborns [ ] . although the pathophysiology of fgr is not completely known, excessive oxidative stress and inflammation, as well as the activation of a complex network of several signaling pathways, appear to be involved [ , ] . the antioxidant and anti-inflammatory effects exerted by curcumin on the placenta [ ] were confirmed in a mouse model of fgr fed with a low-protein (lp) diet [ ] . the authors showed that maternal supplementation with curcumin ( mg/kg day, from . to . gd) induced a potent antioxidant response in lp-fed pregnant mice; specifically, curcumin (i) increased gsh-px activity, nfr mrna expression, and the blood sinusoids area; (ii) reduced malondialdehyde (mda) content and apoptosis in the placenta, leading to increased placental efficiency; and (iii) elevated the expression of the antioxidant genes sod , sod , and cat, and protein expression of nrf and eme oxygenase- (ho- ) in the liver. overall, curcumin supplementation during pregnancy was able to revert tissue damage and contrast the decrease in fetal weight induced by a lp diet [ ] . curcumin appeared to improve birth weight, inflammation, and oxidative damage also in fgr newborn rats. indeed, fgr rats supplemented with mg/kg curcumin (at six weeks of age for six weeks) displayed reduced levels of the inflammatory cytokines tnf-α, il- β, and il- , reduced activity of ast, alt, and mda enzymes, and increased gpx and gsh activity in serum. antioxidant defense in the liver was significantly improved as well. the attenuation of the inflammatory status induced by curcumin was associated with (i) reduced activation of nf-kb and jak ; (ii) increased expression of the antioxidant genes (nqo , hmox , gst, gpx , and sod ), and activation of their regulatory transcription factor nfr , in the liver [ ] . successively, the same authors investigated the effects of curcumin on insulin resistance (ir) and hepatic lipid accumulation in fgr newborn rats. specifically, supplementation with mg/kg curcumin (at six weeks of age for six weeks) attenuated ir by reducing serum insulin, glycemia, and homeostasis model assessment of insulin resistance (homa-ir). furthermore, in the liver, curcumin diminished total cholesterol, tg, and non-esterified fatty acids (nefa); increased glycogen concentration and induced the activation of lipolytic enzymes, together with a reduction in irs- and akt phosphorylation, a decrease in cd , srebp- , and fasn expression, and an increase in pparα levels. overall, these data showed that curcumin could improve ir and lipid accumulation in the liver by regulating insulin signaling pathways, and promoting lipolysis and fatty acid oxidation in fgr rats [ ] . of note, curcumin alleviated also jejunum damage in fgr growing pigs. indeed, the addition of mg/kg curcumin to diet improved antioxidant defense (i.e., increased sod and decreased mda activity), immune-related gene expression (reduced mrna of tnfα, il- , and ifnγ, and increased il- ), and decreased apoptotic genes, such as caspase and bax in the jejunum. moreover, curcumin supplementation increased mrna expression of the tight junction-related gene ocln [ ] . preterm birth (ptb) is a pregnancy complication that affects about % of births worldwide and is associated with increased maternal and neonate morbidity and mortality [ ] . an altered inflammatory status appears to be associated with ptb. thus the anti-inflammatory activity of curcumin has been evaluated in a mouse model of ptb, obtained through lps injection in the abdominal cavity [ ] . the injection of mg/kg curcumin into the abdominal cavity, one day before (preventative group) or one day after (treatment group) lps treatment, significantly reduced serum levels of tnf-α, il- , and mda, and increased sod levels, in both the experimental conditions, in pregnant mice. the staining intensity of nf-κb p showed that curcumin was able to reduce the lps-induced expression of this inflammatory transcription factor in placental tissue both in the preventative and in the treatment group [ ] . besides maternal nutrition, many other factors, including exposure to chemical and natural toxic agents, drugs, alcohol, smoking, and maternal stress influence fetal growth and development [ ] . among the myriad of properties, curcumin appears to be able to reduce toxicity induced by several environmental agents in different organs and tissues, including the brain and liver [ ] . bisphenol-a (bpa) is a chemical substance adapted to produce plastic. it has been considered an endocrine disruptor by the european chemicals agency (echa ) [ ] due to its estrogenic activity. bpa exposure in pregnancy is associated with negative outcomes, including impaired fetal growth and childhood adiposity [ ] . remarkably, this synthetic compound affected the processes of neurogenesis in the hippocampus of the developing rat brain, and curcumin treatment showed neuroprotective activity by reverting bpa-induced effects. specifically, pups from a pregnant rat receiving bpa ( µg/kg body weight/day from gd to pnd ) were treated with curcumin ( mg/kg body weight/day from pnd to pnd ). the authors performed accurate experiments on embryo and pup brains and examined the expression of genes and pathways involved in neurogenesis. they observed that curcumin attenuated the bpa-induced reduction in neuronal stem cells (nsc) proliferation and differentiation. at molecular levels, the improvement in neurogenesis was associated with the enhanced expression of the proneural transcription factors neurogenin and neurod , the reduced expression of the proapoptotic molecule bax, the increased expression of the antiapoptotic molecule bcl- , and the activation of wnt/βcatenin signaling that regulates nsc proliferation and differentiation. of note, the benefits of curcumin resulted in improved learning and memory in bpa-treated pups [ ] . mercury (hg) is a widely diffused toxic heavy metal that occurs naturally in three forms, namely metallic hg, organic hg, and inorganic hg. human exposure to hg occurs mainly through the environment (e.g., mercury-contaminated sea fish, dental amalgam). of note, occupation (e.g., mining) is another important source of exposure for humans and is associated with possible multi-organ toxicity [ ] . as for the influence of hg on neurodevelopment, a cross-sectional study, involving healthy saudi mothers and their infants (age - months), showed an association between hg exposure and neurodevelopmental delay, with possible negative effects persisting also in adulthood [ ] . interestingly, curcumin appeared to mitigate hg toxicity in animal models [ ] . specifically, pregnant mice were exposed (from gd to pnd) to ppm mercuric chloride (hgcl ) in the presence or absence of and ppm curcumin. hg exposure induced serious damage to the development of neuromotors, and increased anxiety behavior in pups. curcumin administration improved neurodevelopment and reduced anxiety, by restoring the levels of neurotransmitters da, -ht, and acetylcholinesterase (ache), and of the antioxidant gsh, decreased by hg exposure, in forebrain pups [ ] . moreover, by using the same experimental conditions, the authors analyzed changes in body weight, sexual behavior, and fertility in male and female pups. the obtained data showed that curcumin counteracted the perinatal effects of hg exposure by increasing (i) body weight, liver and brain weight in male and female pups; (ii) epididymis, seminal vesicle, testis weight in males; and (iii) ovary weight in females; also sexual behavior was improved in both sexes. moreover, curcumin increased testosterone and fsh levels, and sperm motility in males, as well as fsh, lh, and progesterone in females, reduced by hg exposure [ ] . lead (pb) is a heavy metal widely spread in the environment. it is extremely dangerous for both animals and humans. lead exposure occurs mainly through food and water contamination, and air pollution. lead can cross the placental and blood-brain barrier, inducing neurotoxicity. curcumin exerted neuroprotective effects contrasting lead-induced damage in rats. the concomitant exposure of rat mothers to pb ( g/l) and curcumin ( g/kg) during pregnancy and lactation resulted in the recovery of the pb-induced altered sensorimotor functions in neonatal rats. pb neurotoxicity produced alterations in locomotor neuronal network development and curcumin treatment reversed these anomalies, allowing normal locomotor behavior. these findings indicate that curcumin has the capability to prevent central nervous system dysfunction induced by lead during the earlier stages of development [ ] . celecoxib is a selective inhibitor of cox- that is able to reduce pain and inflammation caused by several inflammatory conditions [ ] . since recent data have shown that the inhibition of cox- reduced adult neural cell proliferation and differentiation [ ] , wang et al., investigated the neuroprotective action of curcumin on fetal brain development in pregnant mice treated with celecoxib [ ] . specifically, pregnant mice were pretreated with curcumin ( nmol/kg body weight) from embryonic day (e) . to e . , and then with celecoxib ( mg/kg body weight) from e . to e . . results showed that curcumin counteracted the celecoxib-induced inhibition of neurogenesis in the fetal frontal cortex, by increasing proliferation and cyclin d expression in neural progenitor cells, and by activating wnt/βcatenin signaling (i.e., decreased expression of glycogen synthase kinase beta (gsk- β), and increased expression of βcatenin) [ ] . valproic acid (vpa), a branched short-chain fatty acid, is an antiepileptic agent that has been associated with congenital malformations, including alterations in fetal brain development, and consequent intellectual disabilities and autistic spectrum disorders in the offspring [ ] . curcumin appears to attenuate the vpa-induced brain damage, as observed in a rodent model of autism. neonatal rats, born to mothers treated with vpa from . gestational day, received a single dose of curcumin ( g/kg day), and their brains were analyzed days after birth. curcumin was able to ameliorate body and brain weight, and the altered expression of il- , ifn-γ, gsh, cyp , in the brain of vpa-exposed pups [ ] . prenatal alcohol exposure (pae) has dramatic effects on fetal growth and development (fetal alcohol spectrum disorders: fasd) and is responsible for neurodevelopmental disorders (i.e., neurocognitive and behavioral deficits, and increased susceptibility to mental health disorders) and birth defects (growth deficits and physical abnormalities). pae induces chromosomal rearrangements and epigenetic alterations, therefore leading to altered gene-environment interactions that are responsible for alcohol-induced disorders [ ] . curcumin ( mg/kg body weight), administered during the peri-adolescence period (pnd - ), appeared to counteract fetal brain damage induced by prenatal and lactational alcohol exposure (plae; % (v/v) alcohol solution) in mice. the authors showed that curcumin improved anxiety and memory deficits caused by plae, and these improvements were associated with reduced microglia activation and astrogliosis. at molecular levels, curcumin reduced protein expression of il- , tnf-α, and nf-kb. these data showed that curcumin may act against cognitive deficits and neuroinflammation induced by alcohol exposure in pregnancy [ ] . curcumin can counteract the deleterious effects of pae on cardiac development, as demonstrated in a mouse model. pregnant mice were daily exposed to ethanol ( % v/v in saline) between embryonic days . to . ; at embryonic day . , mice were euthanized and embryonic hearts were removed. results showed that pae treatment increased apoptosis in pup hearts; this finding was associated with higher levels of caspase- and - mrna expression, and reduced bcl- mrna expression, due to a different modulation of histone h k acetylation near the promoter regions of caspase- , caspase- (hyperacetylation), and bcl- (hypoacetylation). in vitro, curcumin ( µm for h) treatment abolished apoptosis and reverted the expression of caspases and bcl- , induced by alcohol ( mm), in cardiac progenitor cells. these results highlighted the capability of curcumin to prevent congenital heart diseases induced by pae in pregnancy, by acting as an epigenetic modulator [ ] . embryonic development is a complex process that is finely regulated and highly susceptible to environmental influences. therefore, it is reasonable to hypothesize that the anti-inflammatory, antioxidative, antiproliferative, and antiangiogenic properties of curcumin could interfere with the blastocyst stage, implantation and post-implantation development of embryos [ ] . chen and colleagues evaluated the possible embryotoxicity of curcumin in mouse blastocysts both in vitro and in vivo. they observed that curcumin ( µm for h) induced apoptosis in mouse blastocysts, and reduced implantation rate and development, in vitro. then, embryos treated with curcumin were transferred in vivo; results confirmed a significant reduction in implantation ratio, and, among the implanted embryos, a higher rate of failure to develop normally. the authors evaluated the possible mechanisms responsible for these effects and found that curcumin-induced apoptosis was associated with the modulation of pro-and anti-apoptotic molecules (i.e., increased bax and reduced bcl- expression), ros generation, and caspase- activation [ ] . additionally, the same authors showed that curcumin ( µm) adversely affected oocytes maturation, in vitro. this effect resulted in a reduced ability of oocytes to be fertilized, increased blastocyst apoptosis, and reduced blastocyst implantation ratio and development. these results were confirmed in oocytes collected from female mice after feeding them with curcumin supplementation ( µm) for four days [ ] . another in vitro study highlighted that the degree of damage induced by curcumin ( , , or µm curcumin for h) on mouse blastocyst at the implantation stage and during the early post-implantation stage is dose-dependent. specifically, µm and µm curcumin inhibited cell proliferation of the blastocyst but increased the formation of trophoblastic giant cells, whereas µm curcumin exposure was lethal to all blastocysts, and induced severe damage to the implanted blastocysts [ ] . further evidence on these effects comes from a recent study in zebrafish. the exposure of zebrafish embryos and larvae to different concentrations of curcuma longa extract ( . , . , . , . , . , and . µg/ml) at different hours post fertilization (hpf: , , , , h) showed that a dosage above . µg/ml had toxic effects, and a dosage of . µg/ml increased embryo mortality and induced morphological deformities in larvae [ ] . despite the potential benefits of curcumin described in different pathological conditions, all these data indicate that dosage and time of exposure throughout pregnancy should be carefully evaluated to avoid serious damage to embryo development. the use of the natural product curcumin to treat medical conditions is spreading around the world. there is an increasing public interest in the potential health benefits of this compound, as evidenced by the large number of currently available curcumin formulations, aimed at increasing its bioavailability and efficacy, and by the considerable number of scientific papers published over the last years. this review has drawn attention towards the effects of curcumin on pregnancy and pregnancy complications, considering that during gestation, mother and fetus undergo significant (patho-) physiological changes. almost all data emphasizing the numerous biological activities of curcumin have been obtained from pregnant rodents and in vitro studies. curcumin appeared to ameliorate diabetes in a gdm mouse model, as well as pe in a pe rat model, and was found to be neuroprotective against environmental toxic agents. the antidepressant activity of curcumin has also been tested in humans. however, to date, studies on the possible beneficial effects of curcumin on ppd, a largely underestimated and understudied condition, are completely lacking. as regards fetal growth and development, curcumin counteracted the modifications associated with fgr and ptb in rodent models but negatively affected blastocyst stage, implantation and post-implantation embryo development in healthy animals. altogether, these results indicate that the use of curcumin in pregnancy must be carefully evaluated. the growing use of curcumin as self-medication along with the misleading perception that "natural" is the equivalent of "safe" are additional issues of concern. further studies are needed to clarify whether pregnancy might benefit from curcumin's properties; for this purpose, the collaboration between multidisciplinary scientific teams is essential to provide a holistic view of the complex networks between natural products and human physiology. systems biology and the recently developed network pharmacology represent new strategies to better comprehend the mechanisms underlying curcumin activities in the human body. maternal nutrition and birth outcomes dietary interventions for healthy pregnant women: a systematic review of tools to promote a healthy antenatal dietary intake tain the good, the bad, and the ugly of pregnancy nutrients and developmental programming of adult disease management of reproduction and pregnancy complications in maternal obesity: which role for dietary polyphenols? could gestational diabetes mellitus be managed through dietary bioactive compounds? current knowledge and future perspectives maternal obesity, inflammation, and developmental programming non-coding rna: role in gestational diabetes pathophysiology and complications epigenetics and human reproduction: the primary prevention of the noncommunicable diseases genes and diet in the prevention of chronic diseases in future generations herbs and spices-biomarkers of intake based on human intervention studies-a systematic review curcumin: a review of its effects on human health antidotal or protective effects of curcuma longa (turmeric) and its active ingredient, curcumin, against natural and chemical toxicities: a review cellular and molecular mechanisms of curcumin in prevention and treatment of disease curcumin ameliorates gestational diabetes in mice partly through activating ampk curcumin stimulates angiogenesis through vegf and expression of hla-g in first-trimester human placental trophoblasts maternal curcumin supplementation ameliorates placental function and fetal growth in mice with intrauterine growth retardation curcumin's nanomedicine formulations for therapeutic application in neurological diseases rationale for natural neurosteroid-based interventions for postpartum depression phytochemical evaluation, embryotoxicity, and teratogenic effects of curcuma longa extract on zebrafish (danio rerio). evid.-based complementary altern curcumin as "curecumin": from kitchen to clinic high-performance thin layer chromatographic method for quantitative determination of curcuminoids in curcuma longa germplasm curcumin: a modulator of inflammatory signaling pathways in the immune system pharmacokinetics, pharmacodynamics, and pkpd modeling of curcumin in regulating antioxidant and epigenetic gene expression in healthy human volunteers curcumin as an alternative epigenetic modulator: mechanism of action and potential effects mutual two-way interactions of curcumin and gut microbiota potential effects of curcumin in the treatment of covid- infection food & drug administration. gras notice inventory scientific opinion on the re-evaluation of curcumin (e ) as a food additive formulations of curcumin nanoparticles for brain diseases phytosomal curcumin: a review of pharmacokinetic, experimental and clinical studies highly bioavailable forms of curcumin and promising avenues for curcumin-based research and application: a review curcumin delivery mediated by bio-based nanoparticles: a review determinants of maternal insulin resistance during pregnancy: an updated overview gestational diabetes mellitus: the impact of carbohydrate quality in diet cross-talk between fetal membranes and visceral adipose tissue involves hmgb -rage and vip-vpac pathways in human gestational diabetes mellitus the risk stratification of adverse neonatal outcomes in women with gestational diabetes (strong) study impact of risk factors for gestational diabetes (gdm) on pregnancy outcomes in women with gdm curcumin and type diabetes mellitus: prevention and treatment antidiabetic properties of curcumin ii: evidence from in vivo studies the effects of curcumin supplementation on high-sensitivity c-reactive protein, serum adiponectin, and lipid profile in patients with type diabetes: a randomized, double-blind, placebo-controlled trial effects of curcuminoids plus piperine on glycemic, hepatic and inflammatory biomarkers in patients with type diabetes mellitus: a randomized double-blind placebo-controlled trial effect of turmeric on glycemic status, lipid profile, hs-crp, and total antioxidant capacity in hyperlipidemic type diabetes mellitus patients the effects of curcumin supplementation on glycemic status, lipid profile and hs-crp levels in overweight/obese women with polycystic ovary syndrome: a randomized, double-blind, placebo-controlled clinical trial the effects of curcumin on weight loss among patients with metabolic syndrome and related disorders: a systematic review and meta-analysis of randomized controlled trials curcumin combined with metformin decreases glycemia and dyslipidemia, and increases paraoxonase activity in diabetic rats epigenetics and gestational diabetes: consequences in mother and child curcumin ameliorates high glucose-induced neural tube defects by suppressing cellular stress and apoptosis curcumin improves lps-induced preeclampsia-like phenotype in rat by inhibiting the tlr signaling pathway curcumin inhibits placental inflammation to ameliorate lps-induced adverse pregnancy outcomes in mice via upregulation of phosphorylated akt curcumin protects human trophoblast htr /svneo cells from h o -induced oxidative stress by activating nrf signaling pathway dietary phytophenols curcumin, naringenin and apigenin reduce infection-induced inflammatory and contractile pathways in human placenta curcumin's effect on cox- and il- serum in preeclampsia's patient undergo sectio caesarea with spinal anesthesia. open access maced dietary curcumin supplementation attenuates inflammation, hepatic injury and oxidative damage in a rat model of intra-uterine growth retardation curcumin attenuates insulin resistance and hepatic lipid accumulation in a rat model of intra-uterine growth restriction through insulin signalling pathway and sterol regulatory element binding proteins effect of curcumin on expressions of nf-κbp , tnf-α and il- in placental tissue of premature birth of infected mice. asian pac correction to: bisphenol-a mediated inhibition of hippocampal neurogenesis attenuated by curcumin via canonical wnt pathway neurobehavioral protective properties of curcumin against the mercury chloride treated mice offspring curcumin palliative effects on sexual behavior, fertility and reproductive hormones disorders in mercuric chloride intoxicated mice offspring disturbed sensorimotor and electrophysiological patterns in lead intoxicated rats during development are restored by curcumin i celecoxib-induced inhibition of neurogenesis in fetal frontal cortex is attenuated by curcumin via wnt/β-catenin pathway postnatal treatment using curcumin supplements to amend the damage in vpa-induced rodent models of autism curcumin treatment attenuates alcohol-induced alterations in a mouse model of inhibition of histone acetylation by curcumin reduces alcohol-induced fetal cardiac apoptosis hazardous effects of curcumin on mouse embryonic development through a mitochondria-dependent apoptotic signaling pathway injurious effects of curcumin on maturation of mouse oocytes, fertilization and fetal development via apoptosis effect of curcumin on in vitro early post-implantation stages of mouse embryo development pregnancy and cardiovascular disease a systemic review on the antioxidant and anti-inflammatory effects of resveratrol, curcumin, and dietary nitric oxide supplementation on human cardiovascular health analysis of causes of maternal death: a systematic review disruption of placental homeostasis leads to preeclampsia the hmgb /rage pro-inflammatory axis in the human placenta: modulating effect of low molecular weight heparin preeclampsia: a review of the pathogenesis and possible management strategies based on its pathophysiological derangements extravillous trophoblast invasion in placenta accreta is associated with differential local expression of angiogenic and growth factors: a cross-sectional study effects of curcumin on vessel formation insight into the pro-and antiangiogenesis of curcumin. evid.-based complementary altern curcumin, the golden nutraceutical: multitargeting for multiple chronic diseases pathophysiological mechanisms implicated in postpartum depression antenatal depression and its association with adverse birth outcomes in low and middle-income countries: a systematic review and meta-analysis maternal depression and inflammation during pregnancy fruit and vegetable intake and mental health in adults: a systematic review multiple antidepressant potential modes of action of curcumin: a review of its anti-inflammatory, monoaminergic, antioxidant, immune-modulating and neuroprotective effects linking what we eat to our mood: a review of diet, dietary antioxidants, and depression curcumin for depression: a meta-analysis the role of curcumin administration in patients with major depressive disorder: mini meta-analysis of clinical trials benefits of curcumin in brain disorders curcumin for the treatment of major depression: a randomised, double-blind, placebo controlled study curcumin and major depression: a randomised, double-blind, placebo-controlled trial investigating the potential of peripheral biomarkers to predict treatment response and antidepressant mechanisms of change efficacy and safety of curcumin in major depressive disorder: a randomized controlled trial curcumin reverses the effects of chronic stress on behavior, the hpa axis, bdnf expression and phosphorylation of creb the influence of antidepressants on the immune system curcumin in antidepressant treatments: an overview of potential mechanisms, pre-clinical/ clinical trials and ongoing challenges developmental origins of adult health and disease fetal growth restriction-diagnostic work-up, management and delivery coordinated and highly regulated changes in placental signaling and nutrient transport capacity in iugr curcumin alleviates iugr jejunum damage by increasing antioxidant capacity through nrf /keap pathway in growing pigs global burden of preterm birth developmental programming of fetal growth and development msc unanimously agrees that bisphenol a is an endocrine disruptor bisphenol a and phthalates in diet: an emerging link with pregnancy complications medicinal plants and natural products can play a significant role in mitigation of mercury toxicity mercury (hg) exposure and its effects on saudi breastfed infant's neurodevelopment comparison of pharmacological and genetic inhibition of cyclooxygenase- : effects on adult neurogenesis in the hippocampal dentate gyrus adverse effects of prenatal and early postnatal exposure to antiepileptic drugs: validation from clinical and basic researches fetal alcohol spectrum disorders: genetic and epigenetic mechanisms author contributions: conceptualization, c.s. and s.m.; pubmed search, t.f. and r.v.; writing-draft preparation, t.f. and c.s.; writing-review and editing, s.m., e.f. and a.z.; supervision and critical revision s.m., r.v. and c.s. all authors have read and agreed to the published version of the manuscript.funding: this review received no external funding. the authors declare no conflict of interest. key: cord- -ylyhlyzw authors: luo, x.; lv, m.; wang, x.; long, x.; ren, m.; zhang, x.; liu, y.; li, w.; zhou, q.; ma, y.; fukuoka, t.; ahn, h. s.; lee, m. s.; luo, z.; liu, e.; chen, y. title: supportive care for patient with respiratory diseases: an umbrella review date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: ylyhlyzw abstract background: supportive treatment is an important and effective part of the management for patients with life-threatening diseases. this study aims to identify and evaluate the forms of supportive care for patients with respiratory diseases. methods: an umbrella review of supportive care for patient respiratory diseases was undertaken. we comprehensively searched the following databases: medline, embase, web of science, cnki (china national knowledge infrastructure), wanfang data and cbm (sinomed) from their inception to march , and other sources to identify systematic reviews and meta-analyses related to supportive treatments for patient with respiratory diseases including covid- , sars, mers and influenza. we assessed the methodological quality using the amstar score and the quality of the evidence for the primary outcomes of each included systematic review and meta-analysis. results: we included systematic reviews and meta-analyses in this study. most studies focused on the respiratory and circulatory support. ten studies were of high methodological quality, five studies of medium quality, and three studies of low quality. according to four studies extracorporeal membrane oxygenation did not reduce mortality in adults (or/rr ranging from . to . ), but two studies reported significantly lower mortality in patients receiving venovenous extracorporeal membrane oxygenation than in the control group (or/rr ranging from . to . ). besides, monitoring of vital signs and increasing the number of medical staff may also reduce the mortality in patients with respiratory diseases. conclusions: our overview suggests that supportive care may reduce the mortality of patients with respiratory diseases to some extent. however, the quality of evidence for the primary outcomes in the included studies was low to moderate. further systematic reviews and meta-analyses are needed to address the evidence gap regarding the supportive care for sars, mers and covid- . the aim of supportive care is to prevent or treat the symptoms of a disease, side effects caused by treatment of a disease, and psychological and social problems related to a disease or its treatment as early as possible ( ) . supportive care can also be called comfort care, palliative care, or symptom management. supportive care can improve the quality of life of patients who have a serious or life-threatening disease, such as cancer ( ) . besides, for patients with respiratory diseases, supportive care also is an important and effective part of the management ( ) . a systematic review related to severe acute respiratory syndrome (sars) treatment suggested that meticulous supportive care is the only form of treatment that can be recommended ( ) . another systematic review showed that continuous monitoring of vital signs outside the critical care setting is feasible and may provide a benefit in terms of improved patient outcomes and cost efficiency ( ) . according to the world health organization (who) guidelines there is currently no treatment recommended for coronavirus infections except supportive care as needed ( ) . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint in early , a pneumonia caused by a novel coronavirus (sars-cov- ) emerged in wuhan, china, and rapidly spread to more than countries around the world ( ) . as of april , more than , , cases and more than , deaths have been confirmed according to the who ( ) . the disease caused by sars-cov- , coronavirus disease (covid- ) , has had been declared a global pandemic ( ) however, there is so far no effective treatment or vaccine to curb the spread of the epidemic. thus, we conducted this overview to identify the available and effective forms of supportive care for patients with respiratory diseases. we hope this review will help physicians working on covid- to understand more about supportive care and make decisions on treatment selection for covid- . we performed a systematic search of medline via pubmed, embase, web of science, cnki (china national knowledge infrastructure), wanfang data and cbm (china biology medicine disc ) from their inception to march with the terms all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint ("covid- " or "sars-cov- " or " novel coronavirus" or " -ncov" or "wuhan coronavirus" or "novel coronavirus" or "wuhan seafood market pneumonia virus" or "mers" or "sars" or "severe acute respiratory syndrome" or "middle east respiratory syndrome coronavirus" or "influenza") and ("meta-analysis" or "systematic review" or "rapid review") (the details of the search strategy can be found in the supplementary material ). search strategies for other databases are adapted from pubmed. in addition, we searched google scholar as well as reference lists of the identified articles, to find additional studies. three preprint services, including medrxiv (https://www.medrxiv.org/), biorxiv (https://www.biorxiv.org/) and ssrn (https://www.ssrn.com/index.cfm/en/) were also searched to find relevant studies. we included systematic reviews and meta-analyses related to supportive treatment for patient with respiratory diseases including covid- , sars, mers and influenza published in english and chinese without other restrictions. we included systematic all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint reviews and meta-analyses that focused on the proportion of medical staff, monitoring of vital signs, respiratory and circulatory support, and psychological intervention. we also considered systematic reviews and meta-analyses with related indirect evidence if no sufficient literature on covid- , sars, mers and influenza was found. we excluded duplicates, conference abstracts and articles where we failed to access full text and data despite contacting the authors. two reviewers (x luo and m lv) screened all titles, abstracts and full texts independently and solved disagreements by consensus or consultation with a third reviewer. we extracted the following basic information: ) title, ) first author, ) publication year, ) journal, ) number of included studies, ) study design of included studies, and ) sample size; and the following information on the results; ) primary outcome, ) effect size (odds ratio, or; relative risk, rr), ) % confidence interval (ci), ) heterogeneity, and ) main conclusion. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. two researchers (x wang and x zhang) independently evaluated the quality of the included studies and cross-checked the results. if necessary, a third reviewer (x luo) participated in the discussion. methodological quality assessment of included literature was performed using the amstar tool ( ) . the amstar score has a total of points, with studies scoring between and being considered to be of high quality, studies scoring between and of medium quality, and studies scoring between and of low quality. we evaluated the quality of evidence for the primary outcomes of each included systematic review and meta-analysis using the grade method ( ) . we conducted a descriptive analysis of the included literature. we analyzed studies on the proportion of medical staff, monitoring of vital signs, respiratory and circulatory support, and psychological intervention for patients with respiratory diseases separately. all statistical analyses were conducted in stata . . a random-effects model was used to show the primary outcomes from each systematic review and meta-analysis. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. a total of records were identified. after reading the full texts, eighteen systematic reviews and meta-analyses were included ( , - ) (figure ). twelve reviews ( , , ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) studied respiratory and circulatory support, three ( , , ) the monitoring of vital signs, two ( , ) the proportion of medical staff, and one ( ) psychological impact. ( table ) according to the amstar scores, ten studies ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) were of high quality, five studies ( , , , , ) of medium quality, and three studies ( , , ) of low quality ( table ). according to our assessment using the grade approach, five of the primary outcomes were based on moderate-quality evidence, and ten on low-quality evidence ( table ) . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . heterogeneity was not significant in any combination of four of the five included primary studies (i = - %; p> . ) . the last of the four reviews reported the outcomes of severe influenza infection with respiratory failure. the overall risk of death was % [ % ci, %- %], the median duration for ecmo was days and for mechanical ventilation days, and the median length of icu stay was days. however, the heterogeneity among studies was large (i = %). one review reviewed the influence of ventilation in prone position on patients with ards. seven of the included studies in this review evaluated the effect of the all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. besides, the syndromic surveillance for influenza and influenza-like-illness from the emergency department is becoming more common to detect yearly influenza outbreaks, as shown in a systematic review. two systematic reviews reported the impact of the number of medical staff on disease outcomes ( figure ) . one examined the association between registered nurse (rn) staffing and patient outcomes in acute care hospitals. the results showed that increased rn staffing was associated with lower mortality in intensive care units (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . a rapid review published in focused on the psychological impact of quarantine to explore its likely effects on mental health and psychological wellbeing, and the factors that contribute to, or mitigate, these effects. a total of studies were included and the results showed that stressors during quarantine were ) duration of (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint altruism and the public health benefits of isolation rather than compulsion. overall, the psychological impact of quarantine is wide-ranging, substantial, and can be long lasting. officials should quarantine individuals for no longer than required, provide clear rationale for quarantine and information about protocols, and ensure sufficient supplies are provided. our study showed that for patients with respiratory diseases, especially h n patients, ecmo may effectively reduce mortality, but attention should be paid to the risk of bleeding. for patients in non-critical wards, monitoring and recording of vital signs can effectively reduce mortality. in addition, increasing the number of medical staff in intensive care units can also reduce mortality. at the same time, psychological intervention is equally important for isolating patients. all systematic reviews were of low to moderate quality. supportive treatment is an important and effective part of the management for patients with respiratory diseases ( ) . after systematic searching, we did not find systematic reviews or meta-analyses for supportive care in sars, mers or covid- -patients, and only five systematic reviews and meta-analyses for influenza. in the absence of direct evidence, we focused on systematic reviews and meta-analysis of ecmo for ards. overall, compared with the control group, ecmo did not reduce mortality in adult patients with ards, and the quality of evidence was relatively low due to the large heterogeneity between studies. ecmo can improve all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint severe hypoxemia in patients with ards, keep the lungs at rest, and wait for lung tissue to repair, but the clinical research results on the prognosis of patients with ards are not consistent. at the same time, two systematic reviews have shown that venovenous ecmo can reduce ards-related mortality, however the risk of bleeding needs to be considered. for patients with h n , one of the two currently available systematic reviews also reported that ecmo was associated with reduced risk of death ( , ) . a systematic review ( ) monitoring vital signs with non-critical patients can reduce patient mortality and shorten the length of hospital stay, but the specific circumstances of the patient need to be considered, such as affordability and acceptability ( ). increasing the number of medical staff in the intensive care unit can reduce the mortality of patients. the likely reason is that due to the increase in the number of caregivers, patients can receive more time, attention and care. however, given the limited medical resources, investing in more medical staff into the icu may need to be balanced by savings in some other expenditure, for example staff in other departments. therefore, investing more medical staff into the icu still needs further evaluation. in addition, for infectious diseases like sars, mers and covid- , psychological intervention is equally important. we found systematic reviews that analyzed the factors that may cause mental illness and provides psychological all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. we used the amstar tool to evaluate the methodological quality of the included systematic reviews and meta-analyses and found that the overall quality is relatively high. in terms of evidence quality, the main problem was the large heterogeneity between included studies. the included studies contained only indirect evidence, and the reliability of the overall quality of evidence was low to moderate, which must be taken into consideration when the evidence is used for making clinical practice guidelines. to our knowledge, this is the first overview of systematic review focusing on the supportive care for patient with respiratory diseases. we comprehensively searched systematic reviews and meta-analyses on sars, mers, covid- and influenza and evaluated the quality of methodology and evidence. nevertheless, our work has several limitations. first, we conducted a rapid literature searching and screening, and some relevant studies may have been missed. second, none of the included systematic reviews focused on covid- , sars or mers, so they can be only used as indirect evidence. finally, there was large heterogeneity between the included studies, and most primary studies included in these systematic reviews were observational studies, which may influence the reliability of the reviews. however, systematic reviews and meta-analyses of non-randomized studies can be meaningful and guide clinical research and practice, even if only by emphasizing the limitations of the available clinical evidence. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. in conclusion, our overview suggests that supportive cares may reduce the mortality of patients with respiratory diseases to some extent. having more medical staff in icu, using of ecmo, monitoring vital signs and conducting counselling to patients (vii) final approval of manuscript: all authors. we thank janne estill, institute of global health of university of geneva for providing guidance and comments for our review. we thank all the authors for their wonderful collaboration. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. we are very confident that the true effect lies close to that of the estimate of the effect. moderate: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. low: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. very low: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. a quality of included studies poor because of inadequate study design and follow-up time. b serious inconsistency for the scattered % ci. c indirect evidence for target population. d wide confidence intervals, serious imprecision. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . https://doi.org/ . / . . . doi: medrxiv preprint figure results of meta-analyses on mortality from the included systematic reviews. the effect sizes are reported either as risk ratio or odds ratio comparing the risk/odds of death in the intervention with control group. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april , . . the role of palliative care at the end of life utilization of supportive and palliative care services among oncology outpatients at one academic cancer center: determinants of use and barriers to access the potential of palliative care for patients with respiratory diseases sars: systematic review of treatment effects the impact of continuous versus intermittent vital signs monitoring in hospitals: a systematic review and narrative synthesis novel coronavirus ( -ncov) technical guidance: patient management world health organization; c evaluation and treatment coronavirus (covid- ) world health organization; c who characterizes covid- as a pandemic development of amstar: a measurement tool to assess the methodological quality of systematic reviews grade: an emerging consensus on rating quality of evidence and strength of recommendations the psychological impact of quarantine and how to reduce it: rapid review of the evidence extracorporeal membrane oxygenation in severe influenza infection with respiratory failure: a systematic review and meta-analysis extracorporeal membrane oxygenation in pregnant and postpartum women with h n -related acute respiratory distress syndrome: a systematic review and meta-analysis syndromic surveillance for influenza in the emergency department-a systematic review extracorporeal membrane oxygenation (ecmo) in patients with h n influenza infection: a systematic review and meta-analysis including studies and patients receiving ecmo a systematic review to inform institutional decisions about the use of extracorporeal membrane oxygenation during the h n influenza pandemic the role of extracorporeal membrane oxygenation for treatment of the adult respiratory distress syndrome: review and quantitative analysis the association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis the effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: a systematic review and meta-analysis venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis extracorporeal life support: the next step in moderate to severe ards-a review and meta-analysis of the literature extracorporeal membrane oxygenation (ecmo) as a treatment strategy for severe acute respiratory distress syndrome (ards) in the low tidal volume era: a systematic review systematic review and meta-analysis of complications and mortality of veno-venous extracorporeal membrane oxygenation for refractory acute respiratory distress syndrome a meta-analysis of extracorporeal membrane oxygenation for acute respiratory distress syndrome influence of ventilation in prone position on patients with acute respiratory distress syn-drome: a meta analysis use of extracorporeal membrane oxygenation on adults with adult acute respiratory distress syndrome: a meta-analysis and systematic review supporting patients self-managing respiratory health: a qualitative study on the impact of the breathe easy voluntary group network key: cord- -e zc ca authors: halter, mary; boiko, olga; pelone, ferruccio; beighton, carole; harris, ruth; gale, julia; gourlay, stephen; drennan, vari title: the determinants and consequences of adult nursing staff turnover: a systematic review of systematic reviews date: - - journal: bmc health serv res doi: . /s - - - sha: doc_id: cord_uid: e zc ca background: nurses leaving their jobs and the profession are an issue of international concern, with supply-demand gaps for nurses reported to be widening. there is a large body of existing literature, much of which is already in review form. in order to advance the usefulness of the literature for nurse and human resource managers, we undertook an overview (review of systematic reviews). the aim of the overview was to identify high quality evidence of the determinants and consequences of turnover in adult nursing. methods: reviews were identified which were published between and january in english using electronic databases (the cochrane database of systematic reviews, medline, embase, applied social sciences index and abstracts, cinahl plus and scopus) and forward searching. all stages of the review were conducted in parallel by two reviewers. reviews were quality appraised using the assessment of multiple systematic reviews and their findings narratively synthesised. results: nine reviews were included. we found that the current evidence is incomplete and has a number of important limitations. however, a body of moderate quality review evidence does exist giving a picture of multiple determinants of turnover in adult nursing, with - at the individual level - nurse stress and dissatisfaction being important factors and -at the organisational level - managerial style and supervisory support factors holding most weight. the consequences of turnover are only described in economic terms, but are considered significant. conclusions: in making a quality assessment of the review as well as considering the quality of the included primary studies and specificity in the outcomes they measure, the overview found that the evidence is not as definitive as previously presented from individual reviews. further research is required, of rigorous research design, whether quantitative or qualitative, particularly against the outcome of actual turnover as opposed to intention to leave. trial registration: prospero registration march : crd . electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. nurses leaving their jobs or leaving the profession, known more commonly in human resource terms as turnover [ ] , is an issue of concern in all health care systems [ ] . low retention rates of health care professionals, including qualified nurses, are detrimental to the delivery of health care systems and population health [ ] . in high income countries retention of nurses and other health care professionals is also viewed as an important health human resource strategyto reduce demand for and therefore migration of nurses from health care systems in low income countries [ ] . data from the north america have been used to suggest that many high income countries are experiencing or predicting growth in demand for qualified nurses over the next decade [ , ] . in those high income countries facing shortage of supply of experienced qualified nurses such as england, reducing turnover and improving retention rates has become an important workforce development strategy [ ] . definitions of nurse turnover differ in operational practice and in research studies [ ] . turnover can be described as voluntary (including retirement) or involuntary, [ ] avoidable or not avoidable; [ ] and can be internal, that is leaving for another nursing or nonnursing job in the same organisation or external, that is leaving for another nursing or non-nursing job in a different organisation [ ] . it can also refer to nurses leaving the nursing profession but remaining on a nurses' register, or leaving a nurses' register, [ ] or to a number of combinations of the above descriptors [ ] . it is in this context of a lack of consistency in the definition and measurement of turnover that the rate of nurse turnover has been estimated at between four and % intending to leave internationally [ ] . in a review of studies which used the same method of measuring turnover and its costs (the nursing turnover cost calculation methodology [ ] [ ] [ ] ), the rates reported in primary studies still varied from % in australia, % in canada, % in the usa to % in new zealand [ ] . in england, in addition to the usual nurse turnover rates, a significant increase in demand for nurses qualified to work with general adult patients has occurred in recent years [ ] . this has been attributed to the fall in commissioned nurse education places, [ ] to high profile reports highlighting serious quality and safety issues [ , ] and to the publication of evidence-based guidelines on safe nurse staffing levels [ ] . nurses working in general adult health services, in comparison to those working in paediatric or psychiatric services, are the largest group of nurses in all countries [ , , ] . it should be noted that there is diversity between countries in whether the education for nurse registration or licensure is generic to all populations or specialist to particular groups such as children [ ] . in this paper nurses working in general adult health services are described as those in 'adult nursing' for brevity. the human resources literature offers us a large number of antecedents of actual turnover found on meta-analysis, including those in the groupings of personal characteristics, satisfaction, work experience, external environment factors, behavioural predictors and cognitions and behaviours about the withdrawal process [ ] . such antecedents are variously represented in a number of well-developed models of turnover, including those describing organisational contexts and psychological (behavioural) explanations of turnover where characteristics lead to intentions leading to turnover, [ ] as well as those indicating the importance of the 'webs of relationships in which employees are situated' , for example the role of centrality in social networks as a moderator to the psychological processes ( [ ] , p ) or the impact of dispositional traits such as locus of control and proactive personality, particularly in explaining wide variance in the intentionsactual turnover relationship. specific to nursing, turnover is recognised to be "complex and multifaceted with factors affecting every sector of health care" [ ] and several conceptual models have been put forward, recognising the decades of work on nurse turnover [ ] . these models variously recognise a plethora of reasons why nurses leave or state their intention to leave, [ ] , although they have been broadly described in three categories: motivational characteristics, social characteristics and characteristics of the work context, although the latter has been less well explored in the research [ ] . in these models, nurse turnover is also reported to have consequences, mainly reported as negative in terms of cost, compromise to patient safety and effect on remaining staff [ ] . as these consequences take us full circle to antecedents, we have included these in this paper. our awareness of the existence of models within and outside of the nursing literature, and the large literature their authors call upon, led us to undertake a preliminary stage of review -making an assessment of potentially relevant literature specific to nursing and its size for review [ ] -when we were commissioned to carry out a review of the adult nurse turnover literature. using medline alone at this stage we identified a large body of reviews relevant to the study's objectives that indicated that nurse and human resource managers would be faced by a plethora of reviews [ , ] , many of which were not conducted according to reviews guidance [ ] . against this background, we conducted an overview which is a systematic review of systematic reviews [ ] . this paper reports on this overview, which aimed to identify high quality evidence of the determinants and consequences of turnover in nurses working in the field of adult health care services and bring that evidence together into one place to highlight where strong enough evidence to support managerial decisions exists and where gaps in the evidence may indicate the need for further research, particularly when considered in the context of the broader management literature regarding turnover. we based the review methods on the preferred reporting items for systematic review and meta-analysis protocols (prisma-p) statement [ ] and cochrane handbook for systematic reviews of interventions [ , ] . this overview included data from qualitative, quantitative and mixed methods reviews published in english from onwards. inclusion criteria were as follows: population: the reviews should be focused on those delivering adult nursing (i.e. licensed or registered) in health care services (both in hospital and community health services) in developed economies (according to the definition of the international monetary fund [ ] ). issue of interest: the reviews should have examined the determinants and/or consequences of turnover in nurses working in adult health services. comparison: any comparators, if any, used within the included reviews. outcomes: the reviews should report measures of determinants and/or consequences of adult nursing turnover outcomes. the outcomes included in the review depended on the types of outcomes examined in the retrieved reviews, but were anticipated to include turnover / retention rate and intention to leave/stay. review design i (for all stages of the overview): any form of literature review (e.g. either systematic or non-systematic reviews) which had been peer-reviewed, contained a statement of review, reported its search strategy and/or inclusion/exclusion criteria, reported either empirical findings or a list of included primary studies and included a methodological quality assessment of its included primary studies. review design ii (for narrative synthesis): any review that had carried out and reported a methodological quality assessment of its included primary studies. exclusion criteria were as follows: reports from any types of primary studies; reviews published in language other than english; reviews that did not evaluate adult nursing turnover as described in the inclusion criteria or presented data on nurses working across settings that could include the care of children or in specific mental health settings; reviews that did not report empirical findings; reviews published only in abstract form; any form of literature review using informal and subjective methods to collect and interpret evidence, commentaries and non peer-reviewed reviews; any review in which majority of included articles were non-peer reviewed publications and reviews that did not report an appraisal of the quality of the studies they included. we searched the cochrane database of systematic reviews, medline (ovid), embase (ovid), applied social sciences index and abstracts -assia, cinahl plus (ebsco) and scopus -v. (elsevier) from to (searches conducted january ). search strategies were guided by a systematic approach to the research questions [ ] and a medline search strategy was developed (table ) and converted or modified to run on other databases (additional file ). we identified additional studies by searching on pubmed by using the "related citations" algorithm and screening the reference lists of included studies for other reviews [ ] . the results of the electronic search were downloaded into an excel spreadsheet. after duplicate articles were removed, relevant reviews were selected according to eligibility criteria using a two-step screening process: title and abstract screening. two authors (fp and mh) reviewed in parallel the titles and abstracts of all the articles resulted to ascertain their eligibility for full text retrieval. disagreements were resolved by peer discussion and a third view from the project lead (vmd) if required. full-text screening. two reviewers (mh and ob or ob and cb) read in parallel all the selected full-text articles citations to analyse whether they meet all the inclusion/exclusion criteria. any discrepancies between the two reviewers will be resolved in discussion with the third reviewer (fp where mh and ob had read in parallel and mh where ob and cb had read in parallel). three authors (mh, ob and cb) extracted data from the included reviews using a predefined extraction form and spreadsheet on: general characteristics of the review: e.g. author(s), year, geographical scope, research area, and authors' aims/ research question(s); descriptive characteristics: e.g. type of review (design); selection criteria to include primary studies, number and study designs of articles incorporated in the reviews, outcome measures; results: every determinant or consequence in the included reviews, listed by the outcome measured, the direction of findings against that outcome and the references for the primary studies; main conclusions, using the review authors' words, and limitations, as noted by the review authors. discrepancies were resolved through discussion among the data extractors. the -point assessment of multiple systematic reviews (amstar) checklist [ ] was used to assess the quality of each included review. this tool has been widely used in previous similar overviews and it is considered to be a valid and reliable instrument [ ] . using the amstar scale two authors appraised each included paper. reviews that scored eight or higher were considered at low risk of bias (high quality), between five and seven were at moderate risk of bias (moderate quality) and four or less were at high risk of bias (poor quality). the primary studies included in each review were also listed and compared across the reviews to assess the degree of overlap in the reviews comprising our overview. because of the heterogeneous nature of the focus, inclusion criteria and outcome measures of the included studies data were analysed thematically. following the detailed reading involved for data extraction, the resultant spreadsheet was examined and a thematic index of determinants and consequences developed (using reviews that met our inclusion criteria for including a methodological assessment of their primary studies as well as those that did not). the thematic index (additional file ) was applied to each data extraction and four main groupings of determinants (individual, professional, interpersonal and organisational) and one of cost consequences was used to analyse across reviews, using microsoft excel to record the decisions applied for all reviews considered (additional file ). a narrative account of the findings from the reviews containing an assessment of the methodological quality of included primary studies has been structured using the risk of bias in the review as the primary grouping level and the thematic content analysis as the second level, also drawing on the number and quality of the included primary studies. in this way we aim to describe the findings by 'weight of evidence' [ ] . the systematic review protocol was registered with prospero (international database of prospectively registered systematic reviews in health and social care) prospero : crd [ ] . review selection, study characteristics and quality assessment review selection the flow chart representing study selection, including reasons for exclusion, is summarised in fig. . a total of nine reviews met the inclusion criteria and were included in the review. additional file provides a list of citations for the excluded studies in the final stage of the selection process, as well as a table describing the characteristics of the studies excluded only on the basis of not having presented a methodological assessment of the quality of the included articles. the characteristics of the nine included systematic reviews are presented in table . the included reviews were all published in english; four were authored from the united states of america [ ] [ ] [ ] [ ] , and one each from australia, [ ] canada, [ ] finland, [ ] singapore [ ] and uk [ ] . of these, six had been published since . eight reviews had been published in four academic journals about nursing (journal of nursing management, [ ] [ ] [ ] ] journal of advanced nursing, [ ] international journal of nursing studies [ ] and nursing ethics [ ] ), and one in the international journal of evidence-based healthcare. none was a cochrane review. table shows each review's criteria used to include or exclude primary studies, and the limits used to focus the reviews' scope. the majority of the reviews limited their searches to the english language, with the exception of flinkman et al. ( ) [ ] , who did not use this restriction, and coomber and barriball ( ) [ ] who did not report this limit. the majority of the reviews did not restrict their searches by geographical region. the included reviews contained a range of seven to primary studies. of the primary studies in the nine systematic reviews, were included in at least two reviews, and only two primary studies [ , ] were included in three reviews (table ). in the included systematic reviews, observational study designs were the most frequently reported in the included primary studies; a small number of qualitative studies were also included. quality assessment of included reviews figure presents the critical appraisal scores for individual reviews. the overall quality rating of the nine included systematic reviews ranged from poor (n = ) [ , ] to moderate (n = ) [ , , [ ] [ ] [ ] [ ] . from the four themes discussed, three were organisational factors (leadership, stress and pay) and only one an individual/ demographic factor (educational attainment). quantitative the empirical evidence shows that stress and issues concerning leadership consistently exert both direct and indirect effects on job satisfaction and intent to leave there are a number of published articles characterized by loosely defined terms the main reasons for reviews being in the moderate rather than strong evidence category were the lack of publication of an a priori protocol, varying levels of details about the search strategy performed, the failure to have two reviewers check the selection and data extraction, not providing a list of both included and excluded primary studies (with the exception of toh et al. [ ] ), limited use of the methodological quality of included primary studies (assessed in all included reviewsthe tools used to assess the quality of included papers in the included studies are shown in table ) and in summarising results and conclusions (used in four reviews [ , , ] ), and the absence of meta-analysis (or a justification for not using this method if inappropriate to the review data, apart from one review [ ] ). the evidence from the included reviews is presented here by thematic analysis of determinants, grouped into four content categories: individual, job-related, interpersonal, and organisational determinants and consequences. each of these content categories is divided by strength of evidence categories, within which we also account for the number and quality of the reviews' included primary studies and the outcome [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] bycio [ ] x x . all consequences were reported in relation to turnover. no reviews of determinants or consequences of turnover in adult nursing were judged to be of high quality. seven reviews were judged as of moderate quality/moderate risk of bias and addressed all four content categories of determinants. two reviews were judged to be of poor quality. eleven individual determinants were reported as having been examined in five reviews of moderate qualityage, gender, marital status, educational attainment, stress, burnout, commitment, job satisfaction, low serum cholesterol, weight and sleep disturbance [ , , , ] . two subsets of factors were considered among individual determinants sociodemographic characteristics and psychological experiences. the first subset of factors involved sociodemographic characteristics, some were 'given' characteristics such as age and gender, whereas others were acquired -education and family status. age featured in two reviews, with contrasting findings reported. one review [ ] reported an inverse relation of age and experience with intention to leave, based on splitting nurses' age groups at years or simply referring to them as 'older' in six quantitative primary studies, with the older group less likely to leave and nurses who had worked less than years being less likely to stay. this contrasted with a positive finding of intention to leave (retire) in nurses aged over from another review, [ ] albeit reporting on just one primary study using a survey design, and complicated by two other studies reported by one review [ ] that suggested a negative association between being a nurse aged less than years and newly qualified and intention to leave and another finding a greater intention to leave in nurses older than years and with longer hospital tenure (greater than years) than in nurses aged under years with less than a year tenure). the review authors suggested these contrasting findings to be due to the confounding of age with variables such as tenure and year post-qualification [ ] . with regards to gender and marital status, one review [ ] reported that male nurses and unmarried nurses had a greater intention to leave, based on three primary studies (of cross-sectional designs and excluding north american literature) for each factor. more educated nurses were reported as more likely to leave across three reviews [ , , ] , using different outcome measures and based on six primary studies. chan et al.'s review ( ) [ ] reported four primary studies where education was negatively associated with retention, although little detail was given on level of education; likewise there is evidence from a descriptive study of a statistically significant association between holders of master's degrees and intention to leave their current job in specialist oncology/haematology reported by one other review's authors [ ] . additionally, coomber and barriball ( ) [ ] described a small but stable relationship for intention to leave with educational attainment from a meta-analysis, although when analysed with job satisfaction as an antecedent or confounding factor they report no consensus despite similar methods used in the primary studies they report and they urge caution in drawing conclusions regarding the determinant of education. the second subset of individual characteristics described associations with psychological experiences of nursesstress, burnout, commitment and job satisfaction. among psychological experiences, stress and burnout are considered as negative experiences which are more likely than not to influence a decision to leave. the negative influence of stress received consistent support in three reviews [ , ] . two reviews reported positive associations of work-related stress (for example lack of stability in the work schedule or stress related to high workload or to the role, together with dissatisfaction of career prospects) with intention to leave [ ] . these findings were based on scale-based surveys from canada, singapore, the uk and the usa, written comments from australia and a meta-analysis from taiwan, although one review [ ] noted contrasting rankings of the antecedents of that stress and suggested that measurement of stress is difficult. the other review reported increased turnover [ ] to be positively associated with moral stress originating in the hospital ethical climate, this definitive finding being based on one interview study, although the review authors note inferred relationships in several other studies but a lack of methodological rigour in the included studies [ ] . similarly, burnout also featured among individual factors [ ] , in one study reported by toh et al. ( ) [ ] and, alongside emotional exhaustion in a review by chan et al. ( ) [ ] reporting three different primary studies. job dissatisfaction or satisfaction was also reported frequently as a determinant of intention to leave or to stay. four reviews reporting a total of studies (four of which appeared in more than one review) uniformly concluded on its relationship of the measure of satisfaction/dissatisfaction used with intention to leave [ , , ] or intention to stay, [ , ] based on non-validated survey responses from a large number of nurses in studies with moderate to high response rates. one review reported no association with intention to stay [ ] in responses to a survey item in one study. the sources of dissatisfaction are variously reported by the reviews from limited literature (for example nurses' feeling dissatisfied with their inability to provide high quality of care to their patients (cited in chan et al. [ ] ), dissatisfaction with staffing and workload as contributors to the intention to leave the specialty (oncology) (cited in toh et al. [ ] and dissatisfaction with salary or low pay (cited in flinkman et al. [ ] ). commitment, presented as a positive psychological experience, featured in two reviews. one review reported a uni-directional negative relationship of organisational and occupational commitment with intention to leave the hospital [ ] and another review considered different types of commitment (for example organisational, affective, continuous, normative, and professional), mostly highlighting single studies again, suggesting negative relations with intention to leave, although organisational commitment was found to have no statistical association with intention to leave nursing as a profession in one study [ ] . reviewers suggested that the multifaceted nature of commitment and different designs and tools impact on findings. one further review, [ ] judged to be of poor quality, contributed mixed evidence regarding commitment as a determinant, describing studies with negative associations with intention to leave and two studies with significant negative associations with turnover, as well as two other studies confirming a positive influence of organisational commitment on intention to stay. additionally, the impact of biological factors (low serum cholesterol, being underweight, sleep disturbance) on intention to leave is considered in one review, [ ] relying on a single study for this evidence. three reviews synthesised evidence around seven jobrelated and occupational determinantswork content, workload, task variation, role ambiguity, shift patterns, rota stability and promotional opportunities. workload, including demanding work content, high workload, variation in work tasks or role ambiguity were reported to increase intention to leave in one study and turnover in two others, while one study found no association with intention to leave [ ] . working patterns, such as shift work (evenings and night shifts mentioned specifically) [ ] were linked to intention to leave, and increasing stability from a constantly changing rota as a way to reduce stress [ ] was reported as negatively associated with intention to leave. promotional opportunities featured an influential factor too. intention to leave increased where nurses experienced fewer possibilities for development or professional growth, evidenced by two studies in one review [ ] and four studies (one overlapping) of another review, including the findings of a large study carried out in european countries [ ] . chan et al. ( ) [ ] also cited three quantitative studies confirming the impact of lack of autonomy on intention to leave. role conflict has also been suggested to be a determining factor in decreasing a nurse's intention to stay in one study in one review, [ ] while another review [ ] reported a study providing conflicting quantitative and qualitative findings from the same group of nurses; this review suggested that more experienced nurses (how they saw themselves professionally) indicated an intention to stay. the evidence on the impact of interpersonal factors included the consideration of ten determinants related to supervisor support; managerial stylepraise and recognition, trust, manager characteristics; leadership practices; staff autonomy, empowerment and decision making; group cohesion; social support; team work and workplace incivility. supervisor support featured in two reviews, [ , ] with a total of primary studies stating, relatively unambiguously, that this had a positive influence on intention to stay, with just one primary study cited as an exception in coomber and barriball ( ) [ ] . this association was illustrated by direct and indirect associations (for example, via empowerment in one study cited in one review [ ] . along the same lines, satisfaction with a supervisor was reported as negatively related to intention to quit in one study in one review [ ] . additionally, the positive influence of praise and recognition and of trust in manager was significantly correlated with intent to stay (each characteristic evidenced by singular studies in one review [ ] ). broadly defined 'poor management' featured in a qualitative study as positively related to intention to leave [ ] . with regards to types of leadership the reviews revealed that transformational (and generally participative) managerial style increased intention to stay [ ] or decreased intention to leave (although the relationship was through other factors) [ ] . on the contrary, the transactional leadership style of 'management by exception' , whereby managers only act on deviations from plan or budget, was found to increase turnover rates, and autocratic leadership was significantly negatively correlated with intention to stay [ ] . however, some of the specific manager's characteristics, in particular, the degree of power and influence the nurse perceived their manager to have within an organisation, received significantly positive association with the intention to stay [ ] . the positive and significant influences of empowerment, control over practice and shared decision-making on intent to stay received support in six studies reported in one review [ ] . group cohesion also appeared to be important with nine studies reported in the same review [ ] showing a significant positive relationship with intent to stay in the current nursing position. in a similar vein, the review by chan et al. ( ) [ ] contained a few references to the importance of social support and good communication with supervisors for nurses' intention to stay, particularly, in a hospital. low quality teamwork, on the opposite, was said to be associated with higher intention to leave [ ] . these consistent findings across a number of studies in the three reviews are tempered somewhat by the review authors' comments arising from their quality appraisal of the evidence. for example, cowden et al. ( ) [ ] raised some concern over biases of synthesis such as over-reporting of positive findings, and lack of causal analysis between leadership factors, as well as the limits to generalisability imposed by heterogeneous studies, this point also being relevant for coomber and barriball ( ) [ ] who noted a heavy reliance on mixed samples and scales. one relatively stand-alone review judged to be of poor quality in our overview looked at an interpersonal determinant workplace incivility, in particular, behaviours violating workplace standards and consideration towards new graduate nurses [ ] . lateral violence, that is co-workers' violence that redirects aggression towards those in authority on their more vulnerable co-workers was reported as a major factor in the decision to leave nursing by % of rns in a survey study and its indirect effect on low retention in new graduates was reported across five other studies. assessment of rigour and quality in this particular review is however impeded by missing information on the characteristics of the included studies. seven organisational factors outlined three strands of evidence: work environment including climate, organisational structure and financial determinants. one review [ ] cited three studies that demonstrated the influence of work environment, for example, the perceptions of a 'deteriorated external work environment' as increasing intention to leave, and 'better working conditions' as lowering it; however these concepts were not defined. this review also contained reference to ethical climate as a key aspect of work environment that can significantly influence the turnover intentions of registered nurses, referencing the same single, though robust, study as in one other review [ ] . limited evidence was found on the impact of organisational culture, with one review suggesting from two studies of asian nurses in asian countries that the individualism-collectivism dichotomy could relate to turnover phenomena: a collectivistic cultural factor played an important role in weakening nurses' intention to leave [ ] . the influence of staff shortages as well as lack of resources on intention to leave was mentioned from one qualitative study where the shortage of nurses implied insufficient manpower to satisfy nurses' personal standards of care, and one questionnaire study focused on patient workloads in one review [ ] . conversely, a single study cited in the same review [ ] also suggested that working in smaller outpatient and day care units generated a negative association with turnover. another set of organisational determinants was that of financial incentives. one review [ ] listed six primary studies suggesting that those nurses dissatisfied with their remuneration were more likely to leave, and that social rewards such as pay and job security were ranked higher for some generations (born - ) than others. gender was highlighted by another review [ ] with male participants reported in one study as being twice as likely in their intention to leave as females due to dissatisfaction with salary. the results of other three studies reviewed in one review [ ] , produced from differing methods of assessment, suggested non-uniform relations between pay and retention. although factor analysis showed pay as an important contributor to job satisfaction, pay was not a statistically significant indicator of intent to leave or turnover cognition. written comments from two studies conducted in australia and usa indicated that fairness and equality of pay was more important to nurses in retaining their positions. in other words, perceived low pay had a greater influence than pay level per se. crucial factors were commensuration according to contributions, for example, for roles with high responsibility, and additional reward mechanisms including fringe benefits [ ] . only one review included evidence of the consequences of turnover, [ ] and this review was judged to be of moderate quality / moderate risk of bias. this review focused solely on cost as the consequence of turnover [ ] . this review was based on ten studies, eight of which were in acute hospital settings, all conducted in the usa, with one also in each of australasia and canada. the review reported costs of per nurse turnover ranging from $ , to $ , and a total turnover cost ranging from $ . million to $ . million, the ratio of nurse turnover costs relative to nurses' salary ranging from . to . . orientating and training new hires was reported as the largest or second largest category of costs relative to total nurse turnover costs while several studies also noted the high costs of unfilled positions/vacancy costs (defined usually as the costs of temporary replacements, but also including wider costs, for example, patient deferral costs and productivity costs for supervisors and other staff, in some primary studies they review). the review authors note the difficulty interpreting and generalising from their included primary studies due to the variability in conceptualisation and measurement of turnover, in time-periods (spanning over two decades) and geographic locations. they also noted that all but one study, which was based on econometric methods, relied on descriptive statistical analyses and that the studies were mostly based in one setting and had relatively small sample sizes. that said the key message from the review was that nurse turnover is costly for organisations. our overview (review of systematic reviews) points us to a complex range of determinants of turnover in adult nursing, at the individual, job-related, interpersonal and organisational level, and to the cost consequences of turnover, but many reviews only cite one or two primary studies for many of the determinants they feature. the analysis here reveals that despite the publication of a large number of primary studies (n = in the reviews of primary studies we reported fully in the narrative of reviews), there is a low degree of overlap in their presence in eight reviews which focus on the same topic and present similar categories of determinants. we might suggest that the low overlap could be attributed to differences in the detail of the research questions (for example, concentrating on job satisfaction [ ] or commitment; [ ] see table ) as the international reviews with more general research questions have a greater overlap [ ] . nevertheless, the impact of this is a rather disjointed body of evidence in which both the outcome of actual turnover as opposed to intention to leave is poorly addressed, and modelling of determinants in combination, taking account of confounding factors, is rare. while the large number of reviews on the topic of nurse turnover may give the impression that the topic is saturated, our overview suggests new knowledge -that there are large gaps in the literature on determinants of turnover in adult nursing. review of the literature on the consequences of determinants is rare, although we note that some conflate these issues as consequences such as reduced staff numbers are also related to determinants such as workload pressures. the most strongly supported determinants of turnover in the literature reviewed were at the individual level: stress and burnout, job dissatisfaction and (to a lesser degree) commitment. supervisor support was the most supported determinant for retention. the reviews use a number of outcome measuresintention to leave, turnover, intention to remain and retentionand many present these unquestioningly as measuring the same concept. the largest number of reviews uses the measures of intention, in particular, intention to leave, rather than action. this is problematic as, although intention has been demonstrated to be a consistent predictor of nurse retention, how these behavioural intentions develop and the link between intention to leave a job and actually leaving are unclear [ ] . furthermore, the inconsistency in the criteria and outcomes measures used in research studies and reviews not only demonstrates the complexity of the concept of turnover, it also shows how reviews of the turnover evidence have not systematically built on previous work in a consistent way to contribute to a shared theoretical base, despite discussion about definitions, conceptual models and a need for multivariable analyses [ ] . concepts therefore remain loosely defined and are used interchangeably. it might be that this accounts for the very limited evidence related to consequences at organisational level (cost), with no evidence on individual level consequences. the quality of the reviews was mostly moderate, and, while all nine reviews stated that they had carried out a quality appraisal of their included primary studies, only one of the reviews used the assessment of studies to support their reporting and conclusions; however we know that the primary studies they report are predominantly quantitative observational designs, most often based on self-report data, with a small number of qualitative studies also included. more positively, several of the reviews highlight limitations of the body of literature, such as poor definition of intention to leave, dependence on cross sectional survey designs (with qualitative investigative depth mostly lacking [ ] ) and variability in the health systems of different countries in particular (identified in two reviews [ ] ), as well as noting the emphasis on single studies in several reviews [ ] , and the heterogeneity of nurses, [ ] often within studies [ ] . difficulties comparing across reviews due to other issues of definition, for example, of moral climate [ ] or definition and measurement of manager leadership practices [ ] or poor specificity of workplaces studied [ ] are also raised. the limitations associated with meta analysis being prevented by the above mentioned heterogeneity are also specifically mentioned [ ] . this degree of critique can be considered to ameliorate some reviews within the grouping of moderate strength of evidence in particular. our overview is limited by design. in being an overview of (systematic) reviews we have relied upon the review authors' reporting and interpretation of the primary studies and have made some assumptions about quality based on descriptions of research design rather than on a critical appraisal of each primary study. we suggest that this limitation is mitigated somewhat by only including reviews that have at least reported that they have carried out a quality appraisal of their included studies, and becomes a strength in that we have sought to review rather than add yet another review of primary studies to the large, somewhat repetitive, yet also heterogeneous decades of literature on turnover in adult nursing. we have also assessed the quality of the included reviews using a widely recognised tool for this task [ ] . our decision to include those reviews that reported a quality appraisal of their included studies also limits our review in excluding from our full narrative a number of comprehensive and recent reviews of the determinants and consequences of turnover in adult nursing that added considerably to our thematic index. in particular we have not featured the national/societal or patient level determinants and patient care outcomes that appear in the twelve reviews that did not contain a methodological appraisal of their included primary studies although they met our other inclusion criteria. we may also have excluded high quality primary studies that did not feature in reviews containing a quality appraisal. while this is acknowledged here as a limitation, we however consider this justified, and indeed a strength of our overview, in that we have based this decision on the guidance for the good conduct of systematic reviews available since the s [ ] and have only included reviews published since that date. we have therefore provided a focused account of what should be the highest quality reviews available. in spite of this, our own overview is limited in the conclusions it can come to regarding the determinants and consequences of turnover by the limitations of the systematic reviews that we systematically reviewed, for two reasons in particular. first, the coterminous use of outcome measures of intention with those of action (that is intention to leave with turnover, for example) is problematic and we are also limited in that we have partially replicated this concern in this overview, whilst also seeking to be explicit about the measures we have combined. this issue is considered in-depth in the turnover literature outside of nursing with acknowledgment of the poor translation of intentions to behavior [ ] illustrated through wide statistical credibility estimates of the relationship [ ] . evidence suggests that the relationship can be moderated by, for example, structural variables [ ] or personality traits [ ] . as intentions are considered to overestimate actual performance (here, actual turnover), the determinants we present may have moderator effects not previously presented in the nursing literature. an important recommendation of this review is that the concepts related to nursing turnover are carefully considered and defined and consensus reached about the priorities for future research and workforce development to increase the pertinence and co-ordination of future research to provide evidence that can inform decision making in human resources practice and planning in healthcare and nursing. second, and fundamentally, we are limited by the absence of any reviews that have been assessed to offer strong evidence. the literature we reviewed offered no opportunities to carry out the meta-analysis of antecedents and correlates which we find in the broader human resource turnover literature, where not only are primary studies' findings statistically pooled, but variations in base rates of turnover and moderators in statistical models of turnover are tested [ ] . we also note that the majority of the reviews we included did not specify what type of 'leaving' their primary studies referred to, that is leaving a department, an employer or the profession; only four of the studies mention this; three of these refer to leaving the profession. finally, with the inevitable time lag of publication of primary studies to their inclusion in a pertinent review, we are likely to have missed all of the more recent literature published. our findings in the context of other literature from our searches we identified reviews already published on this topic, including recent developments in conceptualising the determinants and consequences of such turnover into models [ ] . however, when we applied criteria based upon guidance for the good conduct of systematic reviews [ ] we systematically and explicitly excluded large numbers of reviews, and reviewed a relatively small number in full. the results are not surprising in content of determinants and consequences as we developed a thematic index based on the reviews we were reviewing, several of which grouped determinants similarly, for example using the groupings of individual, interpersonal and organisational factors [ ] . the results are also not entirely surprising when viewed in the context of the broader management literature on the wide range of researched antecedents to turnoverfor example, if we look at what holtom et al. ( ) [ ] described as the major trends in turnover research in the preceding decade, our overview points to some evidence on the role of interpersonal relationships, of organisational commitment and embeddedness and of job satisfaction, but it does not present evidence in the nursing literature on individual difference predictions such as personality or of working conditions; nor of dynamic processes. the overview also contains substantial literature related to demographic issues that griffeth et al. ( ) [ ] consider to be decreasing in importance. the rising issues of social networks [ ] and cultural differences [ ] , as well as multi-level investigations [ ] are equally lacking in visibility in the reviews we have included. in recognition of these differences, and the limitations of the quality of the literature and the predominance of intention to leave versus actual turnover in the nursing turnover literature, we have not sought to try to fit it to one particular model from the literature outside of nursing. it is in recognition of the plethora of previous work in nursing that we conducted this overview of systematic reviews and, in doing so, highlight an important finding: while clarity has been achieved on where the strongest current evidence lies regarding the determinants and consequences of adult nursing turnover, none of the evidence is strong when we combine different interventions, different outcomes, different conditions, problems or populations, as suggested for reviews of reviews [ ] . despite the plethora of reviews, the gaps in strongly evidencebased knowledge about adult nursing turnover limit the conclusions that can be drawn even from the relatively stronger reviews from which we built our overview. we suggest that this could contribute to a continuing problem, if managerial decision makers have not been clearly signposted to robustly conducted systematic reviews based on robustly conducted and/or robustly critiqued primary studies. what does nurse turnover rate mean and what is the rate? pol politics nurs pract nursing churn and turnover in australian hospitals: nurses perception and suggestions for supportive strategies global strategy on human resources for health: workforce : consultation paper. who table occupations with the largest projected number of job openings due to growth and replacement needs canadian occupational projection system (cops). search for occupational projection summaries growing nursing numbers literature on nurses leaving the nhs. health education england a comparative review of nurse turnover rates and costs across countries staff nurse turnover costs: part , a conceptual model baumann a for the international centre for human resources in nursing. the impact of turnover and the benefit of stability in the nursing workforce. international council of nurses nurse turnover: a literature review nurses' intention to leave the profession: integrative review how to estimate employee turnover costs financial management for nurse managers financial management series: cost per rn hired investing in people for health and healthcare. workforce plan for england proposed education and training commissions for report of the mid staffordshire nhs foundation trust public inquiry. the stationery office review into the quality of care and treatment provided by hospital trusts in england: review report. nhs safe staffing for nursing in adult inpatient wards in acute hospitals nursing workforce data rn workforce profiles by area of responsibility year australian institute of health and welfare. work characteristics of nurses and midwives. australian institute of health and welfare nursing education and regulation: international profiles and perspectives a meta-analysis of antecedents and correlates of employee turnover: update, moderator tests, and research implications for the next millennium turnover and retention research: a review of the present, and a venture into the future translating intentions to behavior: the interaction of network structure and behavioral intentions in explaining turnover behavior systematic reviews crd's guidance for undertaking reviews in healthcare nurse turnover: a literature review -an update thirty years of nursing turnover research: looking back to move forward med care res rev seventy-five trials and eleven systematic reviews a day: how will we ever keep up epidemiology and reporting characteristics of systematic reviews cochrane handbook for systematic reviews of interventions. version . . . the cochrane collaboration preferred reporting items for systematic review and metaanalysis protocols (prisma-p) cochrane handbook for systematic reviews of interventions version . . . the cochrane collaboration advanced economies. in: country groups information defining the review question and developing criteria for including studies cochrane handbook for systematic reviews of interventions version . . [updated the cochrane collaboration effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources development of amstar: a measurement tool to assess the methodological quality of systematic reviews methodological quality of systematic reviews in subfertility: a comparison of two different approaches judging the 'weight of evidence' in systematic reviews: introducing rigour into the qualitative review stage by assessing signal and noise adult nurse staff turnoverthe determinants and consequences, and interventions for reduction: two interlinked systematic reviews of reviews. part : determinants and consequences. prospero :crd . university of york centre for reviews and dissemination a systematic literature review of nurse shortage and the intention to leave incivility, retention and new graduate nurses: an integrated review of the literature a literature review of nursing turnover costs organizational commitment as a predictor variable in nursing turnover research: literature review nurses' moral sensitivity and hospital ethical climate: a literature review leadership practices and staff nurses' intent to stay: a systematic review systematic review on the relationship between the nursing shortage and job satisfaction, stress and burnout levels among nurses in oncology/haematology settings impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature turnover intentions and voluntary turnover: the moderating roles of self-monitoring, locus of control, proactive personality, and risk aversion methodology in conducting a systematic review of systematic reviews of healthcare interventions critical review of quantitative research the effects of hospital restructuring that included layoffs on individual nurses who remained employed: a systematic review the relationship between nursing leadership and patient outcomes: a systematic review factors influencing job satisfaction of front line nurse managers: a systematic review evidence-based practice for nurses: appraisal and application of research evidence based practice in nursing & healthcare: a guide to best practice integrating research. a guide for literature reviews the effects of postpartum depression on maternal-infant interaction: a meta-analysis appraising the evidence: reviewing disparate data systematically further assessments of bass's ( ) conceptualization of transactional and transformational leadership manager leadership and retention of hospital staff nurses nurses' job satisfaction, organizational commitment, and career intent the effects of nurses' job satisfaction on retention: an australian perspective a model of job satisfaction of nurses: a reflection of nurses' working lives in mainland china predicting registered nurse job satisfaction and intent to leave predictors of nurses' intent to stay at work in a university health center faces of the nursing shortage: influences on staff nurses' intentions to leave their positions or nursing hospital ethical climates and registered nurses' turnover intentions nurse intention to remain employed: understanding and strengthening determinants nurses' perceptions of severe acute respiratory syndrome: relationship between commitment and intention to leave nursing the impact of social work environment, teamwork characteristics, burnout, and personal factors upon intent to leave among european nurses explaining young registered finnish nurses' intention to leave the profession: a questionnaire survey predictors of hospitals' organizational climates and nurses' intent to stay in jordanian hospitals turnover factors revisited: a longitudinal study of taiwan-based staff nurses we are grateful to the reviewers of the first submission of this paper for their comments and suggestions for improvement. this review was independent research funded by health education england -south london, part of the national health service (nhs). the views expressed herein are those of the authors and not the funding body, the nhs or the department of health. the datasets supporting the conclusions of this article are included within the article (and its additional files. the current evidence is incomplete and has a number of important limitations. a body of moderate quality review evidence does exist giving a picture of multiple determinants of turnover in adult nursing, with individual level nurse stress and dissatisfaction factors and organisational level managerial style and supervisory support factors holding most weight, as well as the economic consequence of the turnover. our systematic review of the review literature uses the quality of the review alongside the quality of the included primary studies and which outcomes they measure to progress the usefulness of the body of review literature for decision makers, in terms of the determinants themselves. in using the quality of the review alongside the quality of the included primary studies and which outcomes they measure the evidence is far from definitive. further research, of rigorous research design, drawing on recommendations from the wider management literature on turnover, whether quantitative or qualitative, particularly against the outcome of actual turnover as opposed to intention to leave, and modelling determinants in combination, taking account of confounding factors, is required. ethics approval and consent to participate this paper presents an overview of previously published reviews and, as such, requires no ethics approval. not applicable. the authors declare that they have no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.• we accept pre-submission inquiries • our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord- -bittqpyo authors: scott, jennifer; abaraogu, ukachukwu o.; ellis, graham; giné-garriga, maria; skelton, dawn a. title: a systematic review of the physical activity levels of acutely ill older adults in hospital at home settings: an under-researched field date: - - journal: eur geriatr med doi: . /s - - -y sha: doc_id: cord_uid: bittqpyo purpose: the purpose of this review was to identify, evaluate and synthesise existing evidence reporting the physical activity levels of acutely ill older patients in a ‘hospital at home’ setting and compare this to patients with similar characteristics treated in a traditional hospital inpatient setting. functional changes and any adverse outcomes due to physical activity (e.g. falls) in both settings where pa was reported or recorded were also evaluated as secondary outcomes. methods: a search strategy was devised for the medline, cinahl, amed, pedro, ot seeker and cochrane databases. search results were title, abstract and full-text reviewed by two independent researchers. data were extracted from included articles using a custom form and assessed for quality and risk of bias using the appraisal tool for cross-sectional studies. results: no studies set in the hospital at home environments were identified. hospital inpatient studies met the criteria for inclusion. older patients managed in inpatient settings that would be eligible for hospital at home services spent . % of their day active and undertook only . daily steps. functional change was reported in four studies with both improvement and decline during admission reported. conclusion: there is a lack of published research on the physical activity levels of acutely-ill older adults in hospital at home settings. this review has identified a baseline level of activity for older acutely ill patients that would be suitable for hospital at home treatment. this data could be used as a basis of comparison in future hospital at home studies, which should also include functional change outcomes to further explore the relationship between physical inactivity and functional decline. electronic supplementary material: the online version of this article ( . /s - - -y) contains supplementary material, which is available to authorized users. hospital at home (hah) is a model of healthcare delivery which provides an alternative to hospitalisation by delivering acute-level hospital services in a residential setting [ ] . the hah care model has increased in prevalence in recent years, with well-established programmes providing services in western europe, north america, brazil, australia, israel and south east asia [ ] . home-hospitalisation has also been advocated during the recent covid- pandemic as a means of increasing bed capacity, facilitating quarantine and reducing disease transmission to vulnerable groups [ ] . research interest has also been growing, with a more than sixfold increase in hah-related citations between and [ ] . a recent systematic review found that hah may be a clinically effective alternative to inpatient care for some older, acutely-ill medical patients [ ] . furthermore, it suggested hah treatment may pose less risk of physical functional decline to patients than the traditional ward-based inpatient environment [ ] . functional decline is a known adverse effect of hospitalisation, affecting between and % of older inpatients between admission to hospital and discharge [ ] [ ] [ ] [ ] , manifesting as a loss of muscle mass, strength, physical function and/or ability to perform basic activities of daily living such as dressing, eating and maintaining hygiene and continence [ ] [ ] [ ] . physical inactivity while hospitalised, combined with older age, are predictors of functional decline [ ] . hospitalised patients are highly inactive, with acute medical and surgical inpatients spending between and . % of their time sitting or lying [ ] , and older patients spending as little as mins per day in an upright position [ ] . recently published draft recommendations on physical activity for inpatients have emphasised the importance of incorporating opportunities for physical activity into the daily care of older adults to improve clinical outcomes, focusing on function, independence and activities of daily living [ ] . however, there are many institutional barriers to physical activity in hospital including lack of staff support, tethering to medical devices, lack of assistive devices, and unfamiliar surroundings, as well as a fear of injury [ ] . treatment in a less restrictive home environment may overcome such barriers, providing more opportunity for patients to continue to perform regular activities of daily living [ ] , thereby lessening the risk of functional decline. this review sought to investigate the hypothesis that older, acutely ill patients treated in a hah setting may be more active than hospital inpatients with similar characteristics. the aim was to identify, evaluate and synthesise primary research studies reporting cumulative physical activity levels in these populations and, where reported, evaluate reports of functional decline or adverse effects resulting from physical activity during admission. as will be reported, no studies conducted in hah treatment settings were identified, and functional change outcomes were largely absent. the review protocol was developed in accordance with preferred reporting items for systematic review and meta-analysis protocols (prisma-p) [ ] guidelines and registered with the international prospective register of systematic reviews (prospero, registration number crd ) [ ] . the review followed the guidelines set out in the cochrane handbook for systematic reviews of interventions [ ] where applicable and complies with the prisma statement [ ] for the conduct and reporting of systematic reviews. a comprehensive search strategy was developed in accordance with the cochrane recommendations for health care review [ ] and reviewed by a specialist medical librarian. the search was initiated in july and updated january to ensure currency. search terms and appropriate synonyms were chosen in alignment with the research objective and combined using boolean operators, subject headings, truncations and wildcards where appropriate. filters limited results to peer reviewed, english language, human studies with available abstracts published since . all study designs were acceptable. the databases medline (ovid interface), central, cumulative index to nursing and allied health literature (cinahl), allied and complementary medicine database (amed), pedro and otseeker were chosen as the most relevant to the subject matter. the full search strategies with database-specific syntaxes for all sources are included in online resource . once key papers were identified, reference lists were handsearched and subject experts were approached to identify any further resources. 'grey' literature including conference abstracts, reports, unpublished data and dissertations were not included. multiple publications using the same participant dataset were excluded and the most comprehensive or recent publication used. setting studies set in either an hah or acute medical inpatient environment were included, studies did not have to compare both groups. hah was defined as 'a service that provides acute, hospital-level care by healthcare professionals in a home context for a condition that would otherwise require acute hospital inpatient care' [ ] . an acute inpatient setting was defined as 'a hospital (private or public) providing -h care for people who are unwell and had an unplanned admission' [ ] . as hah is designed to treat acute episodes of transient rather than chronic medical illness [ ] , studies set in non-medical or non-acute environments such as palliative care, respite, rehabilitation, mental health, long-term care or residential nursing home facilities were excluded. studies concerned with post-discharge hah services (e.g. 'step-down' hah), were also excluded, as the focus of the research project is hah as an alternative to hospital admission for the preservation of physical function. participants studies involving patients aged and over diagnosed with an acute-onset medical condition that would fall within the scope of a hah service were included. hah services predominantly manage non-surgical, non-critical conditions such as infection, acute exacerbations of cardiac and respiratory conditions, haematological and metabolic disturbances, and acute kidney injury [ ] . certain conditions are not appropriate for management in a home setting such as those requiring surgery (e.g. acute coronary syndromes, orthopaedics), critical care or advanced diagnostics and interventions (e.g. stroke). to ensure that intervention and comparison populations were similar, studies containing these large numbers of patients with such conditions were excluded unless these participants could be discounted from the results. a margin of ≤ % of patients under and ≤ % with excluded conditions was allowed. where numbers exceeded this margin, or other pertinent information was required, study authors were approached via email on up to occasions to request abridged results. where a custom dataset was provided, this was used in analysis over the published dataset. intervention and comparator the intervention of interest was treatment in a hah setting compared to standard inpatient acute care. as this review aimed to establish if there are differences in the cumulative activity levels of patients in each setting, trials of other interventions to increase patient activity such as exercise programmes or physiotherapy sessions over and above usual care were not suitable for inclusion unless the physical activity levels of the control group were available, as the intervention group would not be representative of the general older acute population. outcome the primary outcome measure was the cumulative level of pa performed by patients receiving standard medical care in a hah and/or inpatient setting. it was decided a priori that acceptable measures would include objective methods, such as activity monitor data, or subjective methods, such as direct observation, self-reported instruments or questionnaires. changes in functional independence (e.g. activities of daily living, dependent walking) and physical performance (e.g. handgrip test, timed up and go) from admission to discharge, as well as any adverse effects reported as a consequence of physical activity (e.g. falls) were selected as secondary outcomes. the inclusion and exclusion criteria are summarised in table . literature search results and bibliographic records were exported into refworks to facilitate deduplication and screening of titles and abstracts. articles meeting the inclusion criteria were then subjected to full-text appraisal. all records were reviewed by the lead researcher (js) and independently second-reviewed by another (ds, ua, mg or ge). the decision for inclusion or exclusion was recorded along with reasons for exclusion. where there was disagreement between reviewers on inclusion at any stage, a third reviewer was consulted. sixteen articles were selected for inclusion in the review. this process for identifying these is documented in the prisma flowchart [ ] below ( fig. ). the process of data extraction was performed using a custom template which was developed and piloted to extract: ( ) data relevant to the research question, and ( ) data required to perform a quality appraisal and risk of bias assessment using the appraisal tool for cross-sectional studies (axis) [ ] (data extraction table: online resource , axis appraisal: online resource ). the axis tool comprises questions and considers study design and reporting quality in addition to the risk of bias when appraising research studies [ ] . the data extracted were spot-checked for accuracy by the review team (ds, ua, mg or ge). where studies reported results for participants that were excluded from this review (e.g. surgical, non-geriatric) these were separated and excluded from the analysis. separate datasets were requested and received from karlsen [ ] and valkenet [ ] containing only participants that met the inclusion criteria. the physical activity outcomes of the studies were grouped according to their method of measuring physical activity levels and reporting format. in accordance with duvivier [ ] , standing and slow walking have both been categorised as physical activity and grouped together into 'active time' for the purposes of analysis. time spent sitting or lying down, including sleep time, has been classified as 'non-active' time. this classification allowed categories to emerge; ( ) active time recorded over h, ( ) active time recorded over variable timeframes, and ( ) physical activity as step count. the percentage of time spent actively was selected as a common scale to enable comparison of data across the studies. studies using step count as a measure of physical activity were reported separately. results reported in minutes were converted into a percentage of h. median and interquartile ranges were converted into mean values using the formula devised by wan [ ] to allow results to be summarised as pooled averages. summary independent t-tests were used to examine whether physical activity or step count differed significantly from the pooled averages when grouped by medical condition or studies at lower risk of bias. analyses were performed using spss v , p < . was considered significant and % confidence intervals are reported. study characteristics no suitable hah studies were identified. all included studies were conducted in single-site [ ] acute inpatient hospital environments. the studies were published between and , and the majority (n = ) were cross-sectional observational designs aiming to establish the physical activity levels of patients as a primary outcome. this design is consistent with the nature of the research question, which does not aim to evaluate the efficacy of an intervention. of the remaining three studies, two were validation/agreement studies [ , ] , and one was a randomised controlled trial (rct) [ ] . participants most studies concerned general acute medical patients (n = , mean sample size , range . five studies were exclusively concerned with patients with specific conditions; two each reported physical activity levels of patients with acute exacerbations of chronic obstructive pulmonary disease (mean sample size . , range - ) [ , ] , and heart failure (mean sample size , range - ) [ , ] and whilst one reported on patients with mixed medical conditions plus mild-moderate cognitive impairment (sample size ) [ ] . primary outcome all included studies assessed physical activity levels using objective accelerometer-based methods, except belala [ ] who used behavioural mapping. valkenet [ ] also performed behavioural mapping in addition to accelerometery (dynaport movemonitor). a variety of monitoring devices and algorithms were used, with the activpal (pal technologies, glasgow, uk) being the most commonly used device in studies concerned with posture ( uses), and the stepwatch activity monitor (modus health, washington, us) used most frequently for step count ( uses). the validity of the methods used was reported by most studies, except for the mediwalk pedometer (terumo, japan), used by ueda [ ] . the range and validity of outcome measures used is available in online resource . the included studies were assessed for risk of bias using the axis tool [ ] (online resource ) which was deemed appropriate due to the high proportion of observational studies identified. there is an inherent risk of bias in descriptive, observational study designs, which rank low on evidence hierarchies, however, a well-designed and conducted crosssectional study can be of some evidential value [ ] . the axis tool prompts consideration of selection, instrumentation and reporting bias as well as reporting and study design quality. it was also suitable for the evaluation of the methodology used to acquire and report physical activity levels in the rct included in this review [ ] . a domain-based risk of bias assessment indicates a low risk of instrumentation and reporting bias, with adequate measurement and reporting of physical activity levels, however, there is a high risk of selection bias within the identified research (fig. ) . the studies that performed better in the analysis [ , [ ] [ ] [ ] gave greater consideration to reporting information on non-responders (patients that were eligible for inclusion but declined to participate). in terms of quality assessment, overall reporting quality was high, however, study design considerations were less well evidenced, with a broad lack of consideration of sample size, and frequently vague reporting of ethics or consent protocols. active time recorded over h the level of inpatient physical activity reported as a percentage of h could be established in seven studies (table ) . when averages were pooled, the mean proportion of time spent active was found to be . % ± . (range . - . %). active time recorded over a variable timeframe three studies collected results over shorter, variable timeframes ( - h periods), during waking hours, and with different populations and measurement techniques (accelerometery and behavioural mapping), which precludes pooling of results, however, it can be seen that daytime-only levels are higher than the mean for h results, ranging from . to . % (median . %) ( table ) . physical activity as step count eight studies used pedometers or accelerometers to record h step count as a measure of physical activity ( functional change between admission and discharge was reported in studies, the results extracted are summarised in table . as will be discussed, the reported outcomes from these studies were highly heterogenous in terms of tools used, data collection protocols and presentation of data, such that no summative conclusions on of the impact of differing physical activity levels on the incidence of functional decline could be drawn from the data. adverse effects occurring during the period of monitoring were poorly reported, with only four studies reporting this outcome; two advised there were no adverse effects [ , ] and two reported one death (unrelated to physical activity) [ , ] during the course of their research. sub-group analyses were performed comparing studies at lower risk of bias (according to axis appraisal) and concerning only one medical condition to the overall physical activity and step count results. both sub-group analyses found no significant difference in results comparing these devices to the overall results (table ) , indicating the general results are an accurate representation of pa levels. the aim of this review was to identify, evaluate and synthesise the evidence on the physical activity levels of acutely ill older patients undergoing treatment in an hah vs inpatient setting. no hah studies of older adults could be identified, representing a significant gap in the literature surrounding this treatment model. despite the lack of hah research in this field, this review has provided useful data on the baseline physical activity levels that could be expected for patients suitable for treatment in a hah model of care: when monitored for h/day, such patients spend on average . % of the time active, and walk as few as . steps per day. these findings are consistent with other research on hospitalised older adults, despite the strict hah-specific inclusion/exclusion criteria applied. baldwin [ ] reviewed studies reporting the activity levels of acutely admitted medical and surgical adult patients, and found patients spent between % and . % of their entire stay sitting or lying, and that the majority of studies reported a daily step count of < . similarly, fazio [ ] , in a systematic review of standing/ walking activity in medical inpatients, found that patients were active for min per h ( . % of the time). the baseline pa values provided in this review may be suitable for use as an inpatient comparator value in future hah pa studies. the low levels of activity reflected in our findings can result in functional decline, however, in our results only four of the studies measuring physical activity also measured functional change. this represents a missed opportunity to further explore correlations between physical activity and functional decline that should be addressed in future pa studies in hospitalised and hah patients. where functional changes were reported there was high heterogeneity in results between studies. agmon [ ] established that walking less than steps when hospitalised was strongly associated with functional decline in older adults. both ueda [ ] and villumsen [ ] reported a mean step count below this threshold, and while both reported results using the barthel index, measurements were taken at different points in the studies and the results were presented differently: ueda [ ] reported the change in mean score, while villumsen [ ] reported the percentage of participants who improved. in all, six different metrics were used in the four studies reporting functional change, with high variability in measurement tools (see online resource ), data collection protocols and reporting formats, precluding meaningful synthesis of the results. assessing physical function in acutely ill older inpatients who may present with a wide range of medical conditions and functional levels is undoubtedly challenging, and research is ongoing to identify the most feasible tools to use in this patient group [ ] . a consensus-driven core outcome set for studies of functional performance in either older or hospitalised populations has yet to be developed and should be a research priority to allow evaluation and meta-analysis of the findings of studies in this field. placing the findings of this review in the wider context of physical activity research is challenging again due to substantial differences in the methods and outcome measures used. the techniques most frequently utilised in the studies in this review ( h recording, positional accelerometery) rarely feature in population or community-based research. including night-time activity is likely to present a more accurate picture of all activity undertaken, especially in a hospital setting where circadian rhythms may be disrupted [ ] , but will result in lower average activity levels than studies of day-time pa or sedentary behaviour only. this is evident in the results for the three studies that conducted monitoring over a shorter, daytime, timeframe (table ) which found physical activity ranged from . to . % of the monitoring period. as a result of these different outcome measures, recording periods and a lack of objectively established normative values for the -h physical activity of healthy free-living older adults, it is challenging to establish how much activity drops when hospitalised. however, as the continuous objective monitoring of research participants becomes easier and cheaper with developments in accelerometery and wearable digital technology, it may be the case that normative values for pa in free-living older adults can be established. this would allow more accurate evaluation of the extent to which normal pa is impeded by acute illness, in both hah and inpatient settings. a strength of this review is that it followed a systematic approach following cochrane guidelines where applicable [ ] and was reported in accordance with prisma statement, which reduces the risk of bias. a possible limitation of this review is its high specificity arising from highly refined inclusion and exclusion criteria. this led to some potentially relevant articles being excluded. for instance, two promising rcts were identified during the literature search and selection process which found that adult hah patients may around . times more active than inpatients [ , ] , however, these studies were excluded as it was not possible to isolate the results for participants aged over years-only. a further limitation of this review is the high risk of bias present in the studies identified, which may limit the representativeness of the findings. physical and functional decline, caused in part due to inactivity during hospital admission, can have a considerable impact on an older patient's health and ability to remain independent on discharge. hah may offer a treatment environment that preserves and facilitates physical activity in older patients, however, it has been demonstrated in this review that there is a lack of research evidence to confirm this. this review has provided an indication of the baseline activity levels of inpatients suitable for a hospital at home service, however primary objective research is needed in this treatment setting. this review also identified that functional change is infrequently measured along with physical activity, representing a missed opportunity to assess the impact of immobility in hospital on function. where they are reported, functional measures are highly diverse and data collection protocols vary, impeding comparisons between studies. a consensus-driven core outcome set for the investigation of functional decline in hospitalised patients would greatly facilitate the comparison and synthesis of research in this field. sedentary behaviour, defined as 'any waking behaviour characterized by an energy expenditure ≤ . metabolic equivalents (mets), while in a sitting, reclining or lying posture' [ ] , was included in the search strategy as a related field to physical activity. no studies reporting sedentary behaviour as the primary outcome met the inclusion criteria, therefore, this concept is not discussed further in this review. funding the writing of this review was funded through a joint nhs lanarkshire-glasgow caledonian university phd studentship. the funders have had no input in the writing of this review or it's conclusions. hospital at home, guiding principles for service development world hospital at home congress. societies and programs why we should expand hospital-at-home during the covid- pandemic citation report for "hospital at home". clarivate analytics admission avoidance hospital at home. cochrane database syst rev no one size fits all-the development of a theory-driven intervention to increase in-hospital mobility: the "walk-for" study the effectiveness of inpatient geriatric evaluation and management units: a systematic review and meta-analysis trajectories and predictors of functional decline of hospitalised older patients predictors on admission of functional decline among older patients hospitalised for acute care: a prospective observational study reducing, "iatrogenic disability" in the hospitalized frail elderly the hospital elder life program: a model of care to prevent cognitive and functional decline in older hospitalized patients rethinking hospital-associated deconditioning: proposed paradigm shift. phys therapy daytime physical activity and sleep in hospitalized older adults: association with demographic characteristics and disease severity accelerometery shows inpatients with acute medical or surgical conditions spend little time upright and are highly sedentary: systematic review daily and hourly frequency of the sit to stand movement in older adults: a comparison of day hospital, rehabilitation ward and community living groups recommendations for older adults' physical activity and sedentary behaviour during hospitalisation for an acute medical illness: an international delphi study attitudes and expectations regarding exercise in the hospital of hospitalized older adults: a qualitative study preferred reporting items for systematic review and meta-analysis protocols (prisma-p) : elaboration and explanation cochrane handbook for systematic reviews of interventions preferred reporting items for systematic reviews and meta-analyses: the prisma statement crd's guidance for undertaking reviews in health care targets for older adults' physical activity and sedentary behaviour during hospitalisation: an international delphi study development of a critical appraisal tool to assess the quality of crosssectional studies (axis) methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better improved functional performance in geriatric patients during hospital stay measuring physical activity levels in hospitalized patients: a comparison between behavioural mapping and data from an accelerometer minimal intensity physical activity (standing and walking) of longer duration improves insulin action and plasma lipids more than shorter periods of moderate to vigorous exercise (cycling) in sedentary subjects when energy expenditure is comparable estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range assessing sedentary behavior with the geneactiv: introducing the sedentary sphere impact of oral treatment on physical function in older patients hospitalized for heart failure: a randomized clinical trial gosselink r ( ) physical activity and hospitalization for exacerbation of copd a pilot study examining activity monitor use in older adults with heart failure during and after hospitalization a pilot observational study to analyze (in)activity and reasons for sedentary behavior of cognitively impaired geriatric acute inpatients levels of evidence in medicine walking in hospital is associated with a shorter length of stay in older medical inpatients mobility activity and its value as a prognostic indicator of survival in hospitalized older patients very low levels of physical activity in older patients during hospitalization at an acute geriatric ward: a prospective cohort study ) how much do hospitalized adults move? a systematic review and meta-analysis association between steps a day and functional decline in older hospitalized patients feasibility and inter-rater reliability of physical performance measures in acutely admitted older medical patients hospital-level care at home for acutely ill adults: a pilot randomized controlled trial hospital-level care at home for acutely ill adults: a randomized controlled trial sedentary behavior research network (sbrn): terminology consensus project process and outcome stepping toward discharge: level of ambulation in hospitalized patients acknowledgements thanks to dr alexandra mavroiedi of strathclyde university for advice given during the drafting of the protocol preceding this review and to julie smith, specialist librarian within the school of health and life sciences, glasgow caledonian university for assistance with devising the search strategy. thanks also to professor jon goodwin for advice on data analysis strategy and to dr phillipa dall for assisting with the full text review stage. js was funded to write this review through a joint nhs lanarkshire-glasgow caledonian university phd studentship.author contributions js, ua, ge and ds conceived the review. all authors contributed to the development of the search strategy and participated in the screening, review and selection of the included papers. js drafted the review and all authors reviewed, provided feedback and approved the final manuscript. the authors declare that they have no competing interests.ethical approval not applicable. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/ . /. key: cord- - cq authors: whiting, penny f; sterne, jonathan ac; westwood, marie e; bachmann, lucas m; harbord, roger; egger, matthias; deeks, jonathan j title: graphical presentation of diagnostic information date: - - journal: bmc med res methodol doi: . / - - - sha: doc_id: cord_uid: cq background: graphical displays of results allow researchers to summarise and communicate the key findings of their study. diagnostic information should be presented in an easily interpretable way, which conveys both test characteristics (diagnostic accuracy) and the potential for use in clinical practice (predictive value). methods: we discuss the types of graphical display commonly encountered in primary diagnostic accuracy studies and systematic reviews of such studies, and systematically review the use of graphical displays in recent diagnostic primary studies and systematic reviews. results: we identified primary studies and systematic reviews. fifty-six percent of primary studies and % of systematic reviews used graphical displays to present results. dot-plot or box-and- whisker plots were the most commonly used graph in primary studies and were included in ( %) studies. roc plots were the most common type of plot included in systematic reviews and were included in ( %) reviews. one primary study and five systematic reviews included a probability-modifying plot. conclusion: graphical displays are currently underused in primary diagnostic accuracy studies and systematic reviews of such studies. diagnostic accuracy studies need to include multiple types of graphic in order to provide both a detailed overview of the results (diagnostic accuracy) and to communicate information that can be used to inform clinical practice (predictive value). work is required to improve graphical displays, to better communicate the utility of a test in clinical practice and the implications of test results for individual patients. readers of a research report evaluating a diagnostic test may wish to assess the test's characteristics (diagnostic accuracy) or evaluate the impact that its use has on diag-nostic decisions (predictive value) for individual patients. graphical displays of results of test accuracy studies allow researchers to summarise and communicate the key findings of their study. we discuss the types of graphical dis-play commonly encountered in primary diagnostic accuracy studies and systematic reviews of such studies, and systematically review the use of graphical displays in recent diagnostic systematic reviews and primary studies. table defines the various measures of diagnostic accuracy used. primary studies figure illustrates four types of graphical display commonly used to present data on diagnostic accuracy for primary diagnostic accuracy studies. we used data from a study of the biochemical tumour marker ca- - antigen to diagnose pancreatic cancer to construct these graphs [ ] . dot plots (figure a) and box-and-whisker plots (figure b ) dot plots are used for test results that take many values, and display the distribution of results in patients with and without the target condition. box and whisker plots summarise these distributions: the central box covers the interquartile range with the median indicated by the line within the box. the whiskers extend either to the mini-mum and maximum values or to the most extreme values within . interquartile ranges of the quartiles, in which case more extreme values are plotted individually [ ] . sometimes an indication of the threshold used to define a positive test result is included, for example by adding a horizontal line or shading at the relevant point. such plots can be used to clearly summarise a large volume of data, but are only able to display differences in the distribution of test values between patients with and without the target condition; they do not directly display the diagnostic performance of the test. although the ca- - antigen test to diagnose pancreatic cancer (used to construct figure ) is an example of continuous data, it is also possible to construct similar graphs for categorical test results providing that the number of categories is reasonably large. alternatively, for smaller numbers of categories, similar information can be conveyed using paired bar charts/histograms. paired histograms show the distribution of test results in patients with the target condition above the x-axis and the distribution in patients without the target condition below the x-axis. these types of graphical display are less commonly used. used as an overall (single indicator) measure of the diagnostic accuracy of a diagnostic test. it is calculated as the odds of positivity among diseased persons, divided by the odds of positivity among non-diseased. when a test provides no diagnostic evidence then the dor is . . [ ] this measure has a number of limitations: by combining sensitivity and specificity into a single indicator the relative values of the two are lost i.e. the dor can be the same for a very high sensitivity and low specificity as for very high specificity and low sensitivity [ ] further, tests that are effective for classifying persons as having or not having the target condition have dors that whose magnitude is much greater (e.g. ) than usually considered as indicating strong associations in epidemiological studies. [ predictive values depend on disease prevalence, the more common a disease is, the more likely it is that a positive test result is right and a negative result is wrong. [ ] it is not possible to construct any of these graphs for truly dichotomous test results. however, truly dichotomous tests rarely occur in practice. examples of dichotomous tests include dipstick tests that change colour if the target condition is said to be present (although these are based on an underlying implicit threshold) or the presence/ absence of certain clinical symptoms. receiver operating characteristic (roc) plot (figure c ) roc plots show values of sensitivity and specificity at all of the possible thresholds that could be used to define a positive test result [ ] . typically, sensitivity (true positive rate) is plotted against -specificity (false positive rate): each point represents a different threshold in the same group of patients. stepped lines are used for continuous example graphical displays for primary study data test results while sloping lines are used for ordered categories. roc curves may be derived directly from the observed sensitivity and specificity corresponding to different test thresholds, or by fitting curves based on parametric [ ] , semi-parametric [ , ] , or non-parametric methods [ ] . the area under the roc curve (auc) is a summary of diagnostic performance, and takes values between . and . the more accurate the test, the more closely the curve approaches the top left hand corner of the graph (auc = ). a test that provides no diagnostic information (auc = . ) will produce a straight line from the bottom left to the top right. roc curves may be restricted to a range of sensitivities or specificities of clinical interest. roc plots show how estimated sensitivity and specificity vary according to the threshold chosen, and can be used to identify suitable thresholds for clinical practice if the points on the curve are labelled with the corresponding threshold as in figure c , which shows for example that the sensitivity and specificity corresponding to a threshold of . are % and %, respectively. confidence intervals can be added to indicate the uncertainty in estimates of test performance at each point. roc plots also allow comparison of the performance of several tests independently of choice of threshold, by plotting data sets for multiple tests in the same roc space. however, they are thought to be difficult to interpret as they describe the characteristics of the test in a way which does not relate directly to its usefulness in clinical practice; research has shown that roc plots are generally poorly understood by clinicians [ ] . flow charts (figure d ) these depict the flow of patients through the study: for example how many patients were eligible, how many entered the study, how many of these had the target condition, and the numbers testing positive and negative. such charts require categorisation of test results, for example as "positive" and "negative". although flow charts do not directly present diagnostic accuracy data, addition of percentages to the test result boxes (as in figure d ) can be used to report test sensitivity ( / = %) and specificity ( / = %). charts that first separate individuals according to test result before classification by disease status may similarly be used to depict positive and negative predictive values. the stard (standards for reporting of diagnostic accuracy) statement, an initiative to improve the reporting of diagnostic test accuracy studies similar to the consort statement for clinical trials, recommends the inclusion of a flow diagram in all reports of primary diagnostic accuracy studies [ ] . this should illustrate the design of the study and provide information on the numbers of participants at each stage of the study as well as the results of the study. the example flow chart in figure d is not a full stard flow diagram as we do not have data on numbers of withdrawals or uninterpretable results from this study. it does, however, show the design (diagnostic case-control) and results of the study. figure illustrates two graphical displays commonly used to present data on diagnostic accuracy in diagnostic systematic reviews. data from a systematic review of dipstick tests for urinary nitrite and leukocyte esterase to diagnose urinary tract infections were used to construct these graphs [ ] . forest plots (figure a ) forest plots are commonly used to display results of metaanalysis. they display results from the individual studies together with, optionally, a summary (pooled) estimate. point estimates are shown as dots or squares (sometimes sized according to precision or sample size) and confidence intervals as horizontal lines [ ] . the pooled estimate is displayed as a diamond whose centre represents the estimate and tips the confidence interval. for diagnostic accuracy studies, measures of test performance (sensitivity, specificity, predictive values, likelihood ratios or diagnostic odds ratio) are plotted on the horizontal axis. diagnostic test performance is often described by pairs of summary statistics (e.g. sensitivity and specificity; positive and negative likelihood ratios), and these are depicted side-by-side. between-study heterogeneity can readily be assessed by visual examination. results may be sorted by one of a pair of test performance measures, usually that which is most important to the clinical application of the test. a disadvantage of paired forest plots is that they do not directly display the inverse association between the two measures that commonly results from variations in threshold between studies. roc plots can be used to present the results of diagnostic systematic reviews, but differ from those used in primary studies as each point typically represents a separate study or data set within a study (individual studies may contribute more than one point). a summary roc (sroc) curve can be estimated using one of several methods [ ] [ ] [ ] [ ] and quantifies test accuracy and the association between sensitivity and specificity based on differences between studies. as with forest plots, roc plots provide an overview of the results of all included studies. however, unless there are very few studies, it is not feasible to display confidence intervals as the plot would become cluttered. results for several tests can be displayed on the same plot, facilitating test comparisons. it is also possible to display pooled estimates of sensitivity and specificity together with associated confidence intervals or prediction regions. roc plots may also be used to investigate possible expla-nations for differences in estimates of accuracy between studies, for example those arising from differences in study quality. figure shows results for a recent review that we conducted on the accuracy of magnetic resonance imaging (mri) for the diagnosis of multiple sclerosis (ms) [ ] . by using different symbols to illustrate studies that did (diagnostic cohort studies) and did not (other study designs) include an appropriate patient spectrum we were able to show that studies that included an inappropriate patient spectrum grossly overestimated both sensitivity and specificity. various other graphical methods have been developed to display the results of systematic reviews and meta-analyses [ , ] . although not generally developed specifically for diagnostic test reviews these can be adapted to display the results of such reviews. funnel plots [ ] and galbraith plots [ ] are often used to assess evidence for publication bias or small study effects in systematic reviews of the effects of medical interventions assessed in randomized controlled trials. however, their application to systematic reviews of diagnostic test accuracy studies is example graphs for systematic review data figure example graphs for systematic review data. a. paired forest plots of sensitivity and specificity for le dipstick. b. roc plot with sroc curves. problematic [ ] . diagnostic odds ratios are typically far from , and it has been shown that, for data of this type, sampling variation can lead to artefactual associations between log odds ratios and their standard errors [ ] . it is therefore recommended that the effective sample size funnel plot be used in reviews of test accuracy studies [ ] . a number of graphical displays aim to put results of diagnostic test evaluations into clinical context, based either on primary studies or systematic reviews. two graphical displays commonly used for this purpose are the likelihood ratio nomogram ( figure a ) and the probabilitymodifying plot (figure b) . each allows the reader to estimate the post-test probability of the target condition in an individual patient, based on a selected pre-test probability. to use the likelihood ratio nomogram, the reader needs an estimate of the likelihood ratios for the test. he then draws a line through the appropriate likelihood ratio on the central axis, intersecting the selected pre-test probability, to derive the post-test probability of disease. the probability-modifying plot depicts separate curves for positive and negative test results. the reader draws a vertical line from the selected pre-test probability to the appropriate likelihood ratio line and then reads the post-test probability off the vertical scale. both graph types are based on a single estimate of test accuracy (likelihood ratio), although it is possible to plot separate curves on the probability-modifying plot or lines on the nomogram to depict confidence intervals around the estimated likelihood ratios. each assumes constant likelihood ratios across the range of pre-test probabilities. however, this assumption may be violated in practice [ ] , because populations in which the test is used may have different spectrums of disease to those in which estimates of test accuracy were derived. example graphs for interpreting diagnostic study result figure example graphs for interpreting diagnostic study result. a. likelihood ratio nomogram. b. probability modifying plot. sensitivity plotted against specificity, separately for cohort studies and for studies of other designs for mri for diagnosis of multiple sclerosis figure sensitivity plotted against specificity, separately for cohort studies and for studies of other designs for mri for diagnosis of multiple sclerosis. we systematically reviewed how graphical displays are currently incorporated in studies of test performance. we included primary diagnostic accuracy studies published in , identified by hand searching journals (table ) , and diagnostic systematic reviews published in , identified from dare (database of abstracts of reviews of effects) [ ] . searches were conducted in and so these years were the most complete available years for searching (there is a delay in adding studies to dare). diagnostic accuracy studies were studies that provided data on the sensitivity and specificity of a diagnostic test and that focused on diagnostic (whether the patient had the condition of interest) rather than prognostic (disease severity/risk prediction) questions. journals were selected to provide a mixture of the major general medical and specialty journals. we particularly aimed to select journals that clinicians read. we extracted data on the different graphical displays used to summarise information about test performance, defined as any graphical method of summarising data on diagnostic accuracy or the predictive value of a test (table ) . we located primary studies and systematic reviews (web appendix). fifty-seven percent of primary studies and % of systematic reviews used graphical displays to present results. in publications using graphics, the number of graphs per publication ranged from to (median , iqr to for primary studies and median , iqr to for systematic reviews). table summarises the categories of tests evaluated in the primary studies and systematic reviews. none of the tests evaluated in any of the primary studies were truly dichotomous: they all gave continuous or categorical results. three of the eight systematic reviews that assessed clinical examination looked at whether a variety of signs or symptoms were present or absent: these can be considered as truly dichotomous tests. all other reviews evaluated continuous or categorical tests. dot-plots or box-and-whisker plots were the most commonly used graphic and were included in ( %) studies. generally the plots showed individual test results separately for patients with and without the target condition, with four including an indication of the threshold used to define a positive test result. three studies included both a dot plot and a box-and-whisker plot on the same figure. other variations included separate plots for different patient subgroups, different symbols to indicate different stages of disease, or separate plots for different tests. the majority of studies using these types of plots were of laboratory tests. an roc curve was displayed in ( %) studies. all of these plotted full roc curves; only two provided any indication of the thresholds corresponding to one or more of the points. thirteen studies included separate roc curves for different tests, either on the same plot ( studies) or on separate plots ( studies). five studies included separate roc plots for different patient subgroups. although all the primary studies were published in , after the publication of the stard guidelines, only one included a stard flow diagram. roc plots were included in ( %) reviews. twenty showed individual study estimates of sensitivity and specificity, fitted sroc curves, and two displayed a summary point. one study, which did not fit an sroc curve, added a box and whisker plot to each axis to show the distributions of sensitivity and specificity. one study plotted only summary estimates of sensitivity and specificity in roc space, with no sroc curves. some reviews included separate plots for different tests, for different patient subgroups, or for different thresholds used to define a positive test result. ten reviews ( %) used forest plots to display individual study results. one study provided a plot of diagnostic odds ratios, while all others displayed paired plots of sensitivity and specificity ( reviews), positive and negative likelihood ratios ( reviews), or positive and negative predictive values ( review). several studies displayed more than one set of forest plots, including plots for more than one summary measure, for different stages of diagnosis, different test thresholds or for different tests. one study included a forest plot of summary data only, showing how pooled estimates of positive and negative likelihood ratios varied for different patient subgroups. none of the studies included a likelihood ratio nomogram. one primary study and five systematic reviews included a probability-modifying plot. research in the area of cognitive psychology suggests that sensitivity and specificity are generally poorly understood by doctors [ , ] and are often confused with predictive values [ , , ] . doctors tend to overestimate the impact of a positive test result on the probability of disease [ , ] and this overestimation increases with decreasing pre-test probabilities of disease [ ] . this research suggests that the most informative measures for doctors may be estimates of the post-test probability of disease (predictive value), which can be presented as a range corresponding to different pre-test probabilities. however, graphical displays that facilitate the derivation of post-test probabilities, such as likelihood ratio nomograms, are usually based on summary estimates of test characteristics (positive and negative likelihood ratios) without allowing for the precision of the estimate, or its applicability to a given population. use of summary estimates in this way is questionable in the context of reviews of diagnostic accuracy studies, which typically find substantial between-study heterogeneity [ ] . it is particularly problematic if the summary estimate is the only information conveyed in a graphic and the graphic is taken as the key message of the paper. the inclusion of some form of graphical presentation of test accuracy data has a number of advantages compared to not using such displays. it allows fuller reporting of results, for example (s)roc plots can display results for multiple thresholds whereas reporting test accuracy results in a text or table generally requires the selection of one or more thresholds. in addition, (s)roc plots depict the trade-off between sensitivity and specificity at different thresholds. use of such displays also have the advantage of presenting all of the results of a primary study or systematic review without the need for selected analyses, which may be biased depending on the analyses selected. the inclusion of graphical displays, such as sroc plots or forest plots, in systematic reviews of test accuracy studies allows a visual assessment of heterogeneity between studies by showing the results from each individual study included in the review. there is also a suggestion that graphical displays may be easier to interpret than text or tabular summaries of the same data. diagnostic accuracy studies will usually need to include more than one graphic in order both to provide a detailed description of results (diagnostic accuracy) and to communicate appropriate summary measures that can be used to inform clinical practice (predictive value); the more detailed graphic provides context for the interpretation of summary measures. further work is required to improve on existing graphical displays. the starting point for this should be further evaluation of the types of graphical display most helpful to assessing the utility of a test in clinical practice and the implications of test results for individual patients. we hope that this paper will contribute to an increase in the use and quality of graphical displays in diagnostic accuracy studies and systematic reviews of these studies. include references to the stard flow diagram. stard itself does not comment on how graphical displays should be used to convey results of test accuracy studies other than to recommend the inclusion of a flow diagram and to provide an illustration of a dot-plot as a suggestion for how individual study results may be displayed. guidelines on the type of graphical displays that should be included in reports of test accuracy studies could be considered when stard is next updated, and should be considered by journals in their instructions for authors. our review suggests that graphical displays are currently underused in primary diagnostic accuracy studies and systematic reviews of such studies. graphical displays of diagnostic accuracy data should provide an easily interpretable and accurate representation of study results, conveying both diagnostic accuracy and predictive value. this is not usually possible in a single graphic: the type of information presented in the most commonly used graphs does not directly allow clinicians to assess the implications of test results for an individual patient. the author(s) declare that they have no competing interests. all authors contributed to the design of the study and read and approved the final manuscript. pfw and mew identified relevant studies and extracted data from included studies. pfw carried out the analysis and drafted the manuscript with help from jd and rh. venous doppler in the prediction of acid-base status of growth-restricted fetuses with elevated placental blood flow resistance detection of human polyomaviruses in urine from bone marrow transplant patients: comparison of electron microscopy with pcr magnetic resonance imaging of the breast prior to biopsy diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study rapid hiv- testing during labor: a multicenter study potential clinical utility of a new irma for parathyroid hormone in postmenopausal patients with primary hyperparathyroidism immuno-pcr for detection of antigen to angiostrongylus cantonensis circulating fifth-stage worms computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer comparison of clinical criteria for the acute respiratory distress syndrome with autopsy findings use of the fetal fibronectin test in decisions to admit to hospital for preterm labor soluble triggering receptor expressed on myeloid cells and the diagnosis of pneumonia prediction of outcome from the chest radiograph appearance on day of very prematurely born infants cervicovaginal interleukin- , tumor necrosis factor-, and interleukin- receptor as markers of preterm delivery natriuretic peptides as markers of mild forms of left ventricular dysfunction: effects of assays on diagnostic performance of markers association of coronary heart disease with pre-[beta]-hdl concentrations in japanese men prognostic value of tubular proteinuria and enzymuria in nonoliguric acute tubular necrosis reliability of symptoms to determine use of bone scans to identify bone metastases in lung cancer: prospective study plasma fluorescence scanning and fecal porphyrin analysis for the diagnosis of variegate porphyria: precise determination of sensitivity and specificity with detection of protoporphyrinogen oxidase mutations as a reference standard quantitative real-time pcr with automated sample preparation for diagnosis and monitoring of cytomegalovirus infection in bone marrow transplant patients ross me, the colorectal cancer study group. fecal dna versus fecal occult blood for colorectal-cancer screening in an average-risk population analysis of subforms of free prostate-specific antigen in serum by two-dimensional gel electrophoresis: potential to improve diagnosis of prostate cancer identification by proteomic analysis of calreticulin as a marker for bladder cancer and evaluation of the diagnostic accuracy of its detection in urine oesophageal endoscopic ultrasound with fine needle aspiration improves and simplifies the staging of lung cancer efficacy of mri and mammography for breast-cancer screening in women with a familial or genetic predisposition improved specificity of newborn screening for congenital adrenal hyperplasia by second-tier steroid profiling using tandem mass spectrometry a serum autoantibody marker of neuromyelitis optica: distinction from multiple sclerosis improved accuracy of detection of nasopharyngeal carcinoma by combined application of circulating epstein-barr virus dna and anti-epstein-barr viral capsid antigen iga antibody a clinical prediction rule for diagnosing severe acute respiratory syndrome in the emergency department diagnosis of tuberculosis in south african children with a t-cell-based assay: a prospective cohort study iga antibodies against tissue transglutaminase in the diagnosis of celiac disease: concordance with intestinal biopsy in children and adults comparison of new clinical and scintigraphic algorithms for the diagnosis of pulmonary embolism effect of breast augmentation on the accuracy of mammography and cancer characteristics proenzyme forms of prostate-specific antigen in serum improve the detection of prostate cancer predictive value of the balloon expulsion test for excluding the diagnosis of pelvic floor dyssynergia in constipation hyperglycosylated hcg) as a screening marker for down syndrome during the second trimester invasive trophoblast antigen (hyperglycosylated human chorionic gonadotropin) in second-trimester maternal urine as a marker for down syndrome: preliminary results of an observational study on fresh samples a novel and accurate diagnostic test for human african trypanosomiasis fecal lactoferrin for diagnosis of symptomatic patients with ileal pouch-anal anastomosis differential time to positivity: a useful method for diagnosing catheter-related bloodstream infections negative ddimer result to exclude recurrent deep venous thrombosis: a management trial predicting bacterial cause in infectious conjunctivitis: cohort study on informativeness of combinations of signs and symptoms serum markers detect the presence of liver fibrosis: a cohort study serologic assay based on gliadin-related nonapeptides as a highly sensitive and specific diagnostic aid in celiac disease diagnostic accuracy of ten second-generation (human) tissue transglutaminase antibody assays in celiac disease accuracy of computed tomographic angiography and magnetic resonance angiography for diagnosing renal artery stenosis protein profiling in urine for the diagnosis of bladder cancer surveillance of brca and brca mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination roc analysis comparison of three assays for the detection of antibodies against double-stranded dna in serum for the diagnosis of systemic lupus erythematosus is endosonography guided fine needle aspiration (eus-fna) for sarcoidosis as good as we think? mammaglobin as a novel breast cancer biomarker: multigene reverse transcription-pcr assay and sandwich elisa systematic reviews metaanalysis of the accuracy of rapid prescreening relative to full screening of pap smears antenatal screening for postnatal depression: a systematic review eponyms and the diagnosis of aortic regurgitation: what says the evidence accuracy of ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review is this woman perimenopausal? computed tomography and magnetic resonance imaging in staging of uterine cervical carcinoma: a systematic review screening for dementia b-type natriuretic peptide: a review of its diagnostic, prognostic, and therapeutic monitoring value in heart failure for primary care physicians systematic review of the value of positron emission tomography in the diagnosis of alzheimer's disease does this patient have pulmonary embolism? the effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review a systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women first-trimester prenatal screening for down syndrome and other aneuploidies. montreal, pq, canada. agence d'evaluation des technologies et des modes d'intervention en sante (aetmis) meta-analysis of eeg test performance shows wide variation among studies tumor markers in the diagnosis of primary bladder cancer: a systematic review assessment of clinical utility of f- -fdg pet in patients with head and neck cancer: a probability analysis diagnostic value of adenosine deaminase in tuberculous pleural effusion: a meta-analysis test performance of positron emission tomography and computed tomography for mediastinal staging in patients with non-small-cell lung cancer results of systematic review of research on diagnosis and treatment of coronary heart disease in women test characteristics of alpha-fetoprotein for detecting hepatocellular carcinoma in patients with hepatitis c a meta-analysis derivation of continuous likelihood ratios for diagnosing pleural fluid exudates the diagnostic accuracy of computed tomography angiography for traumatic or atherosclerotic lesions of the carotid and vertebral arteries: a systematic review accuracy of cervical transvaginal sonography in predicting preterm birth: a systematic review f- -fdg pet for the diagnosis and grading of soft-tissue sarcoma: a meta-analysis evaluation of acute knee pain in primary care assessment of diagnostic tests to inform policy decisions-visual electrodiagnosis breast cancer diagnosis by scintimammography: a metaanalysis and review of the literature screening performance of first-trimester nuchal translucency for major cardiac defects: a meta-analysis imaging in appendicitis: a review with special emphasis on the treatment of women validity of colposcopy in the diagnosis of early cervical neoplasia: a review diagnostic accuracy of nucleic acid amplification tests for tuberculous meningitis: a systematic review and metaanalysis review of the literature on the value of magnetoencephalography in epilepsy the effectiveness of community-based visual screening and utility of adjunctive diagnostic aids in the early detection of oral cancer whispered voice test for screening for hearing impairment in adults and children: systematic review diagnostic impact of signs and symptoms in acute infectious conjunctivitis: systematic literature search a systematic review and evaluation of tumour markers in paediatric oncology: ewing's sarcoma and neuroblastoma magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary disease accuracy of computer diagnosis of melanoma: a quantitative meta-analysis does this child have acute otitis media? accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis diagnostic performance of intracardiac echogenic foci for down syndrome: a meta-analysis evidence assessment of the accuracy of methods of diagnosing middle ear effusion in children with otitis media with effusion noninvasive staging of non-small cell lung cancer: a review of the current evidence invasive staging of non-small cell lung cancer: a review of the current evidence does this patient have acute cholecystitis? computed tomographic angiography for detecting cerebral aneurysms: implications of aneurysm size distribution for the sensitivity, specificity, and likelihood ratios screening accuracy for latelife depression in primary care: a systematic review the accuracy and efficacy of screening tests for chlamydia trachomatis: a systematic review a family of nonparametric statistics for comparing diagnostic markers with paired or unpaired data statistical methods in medical research fourth edition statistics notes: diagnostic tests : receiver operating characteristic plots receiver-operating characteristic (roc) plots: a fundamental evaluation tool in clinical medicine semi-parametric roc regression analysis with placement values smooth semiparametric receiver operating characteristic curves for continuous diagnostic tests smooth non-parametric receiver operating characteristic (roc) curves for continuous diagnostic tests academic calculations versus clinical judgments: practicing physicians' use of quantitative measures of test accuracy towards complete and accurate reporting of studies of diagnostic accuracy: the stard initiative clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model forest plots: trying to see the wood and the trees combining independent studies of a diagnostic test into a summary roc curve: data-analytic approaches and some additional considerations a hierarchical regression approach to meta-analysis of diagnostic test accuracy evaluations zwinderman ah: bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews empirical bayes estimates generated in a hierarchical summary roc analysis agreed closely with those of a full bayesian analysis accuracy of magnetic resonance imaging for the diagnosis of multiple sclerosis: systematic review a graphical method for exploring heterogeneity in meta-analyses: application to a meta-analysis of trials a note on graphical presentation of estimated odds ratios from several clinical trials summing up: the science of reviewing research cambridge the performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed publication and related bias in meta-analysis: power of statistical tests and prevalence in the literature sources of variation and bias in studies of diagnostic accuracy -a systematic review general practitioners' self ratings of skills in evidence based medicine: validation study interpretation by physicians of clinical laboratory results probabilistic reasoning in clinical medicine: probems and opportunities communicating accuracy of tests to general practitioners: a controlled study overestimation of test effects in clinical judgment the effect of changing disease risk on clinical reasoning exploring sources of heterogeneity in systematic reviews of diagnostic tests statistics notes: diagnostic tests : sensitivity and specificity diagnostic tests : likelihood ratios the diagnostic odds ratio: a single indicator of test performance limitations of the odds ratio in gauging the performance of a diagnostic, prognostic, or screening marker statistics notes: diagnostic tests : predictive values association of coronary heart disease with pre-{beta}-hdl concentrations in japanese men this work was supported by the mrc health services research collaboration. jonathan deeks is funded by a senior research fellowship in evidence synthesis from the department of health. the pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/ - / / /prepub key: cord- - am l ms authors: nan title: spr date: - - journal: pediatr radiol doi: . /s - - - sha: doc_id: cord_uid: am l ms nan dear colleagues, i confess i haven't read many "welcome letters" at the beginning of the spr program book over the years. perhaps the only defensible benefit of this is that there is no preconception about the content of this message…or the length. i will be brief. this meeting is about building bridges…bridges from our past to the future and bridges between all of us who believe fundamentally in maintaining or improving the health of our children. the content, which is detailed on subsequent pages, speaks for itself. this material will be presented during the sessions with an appreciative look back at past accomplishments-the legacy of our subspecialty-with a vision to the future of pediatric imaging. we can only measure how broad and deep our successes have been by connecting with these beginnings. looking beyond the titles (and the speakers), i think you will see that the material is not only about techniques and tactics but about ideas, insights, energy, all conspiring in the creative process … an aggregate for excellence in pediatric imaging. the content is also punctuated by a strong presence of our clinical colleagues. again, this builds bridges. how can we maintain and expand these relationships? moreover, the connections between science and clinical practice are evident in the structured blending of scientific papers and topical presentations by both imaging and clinical experts. this blending is also "fraternal" in that there will sometimes be disagreement and critical commentary, but this is essential in the advancement of medicine. support and criticism make a stronger mortar. in the end, this gathering is about fostering a connected community, including technologists, nurses, physicists and other allied health experts including industry experts. finally, the emblem of pediatric radiology has always been embossed by cooperation, passion, commitment, and humanistic care. i believe the program content, the presenters and you, the participants, all embrace this. i hope that you will feel the spirit and the passion of the meeting and all of us will in many ways be better able to care for children because of this-even if you never read this message! donald p. frush the gold medal of the society for pediatric radiology is our most distinguished honor. the spr medal is awarded to pediatric radiologists who have contributed greatly to the spr and our subspecialty of pediatric radiology as a scientist, teacher, personal mentor and leader. marilyn goske has always wanted to make a differenceand what a difference she has made! her role as an educator, and her lifelong commitment to improving training for residents, fellows, faculty, medical staff and radiologic technologists has resulted in many wonderful initiatives that have benefited all in pediatric radiology. the work she is most proud of-the cleveland clinic web based curriculum, working with the leadership of spr's philanthropic campaign for children, launching the image gently campaign and the pediatric research component within the american college of radiology's dose index registry share a common theme: educating others in providing the best care possible for children. born in berea, ohio, marilyn's father, george, was a chemical engineer. her mother, cornelia aka "corky", loved writing as one of the first women journalists for the associated press and later teaching, passions she passed on to her daughter. while marilyn was blessed with a strong female role model in her mother, it was her brother, james, who was her cheerleader, always pushing her to dream big. he encouraged her to follow in his footsteps first at ohio university, then on to the ohio state college of medicine to pursue an md degree during an era when nursing would have been a more conventional goal. marilyn met her husband rick on a double date in college-unfortunately, they were with different dates! luckily, they were able to get together for an actual date with each other months later. they quickly became engaged and married within a year of that first true date. when rick started his residency in internal medicine, marilyn transferred to the university of connecticut school of medicine in farmington. it was here that she met her first pediatric radiologist-and what a giant-mike ozonoff! when rick moved on to a neurology residency in rochester, new york, marilyn followed and met another pediatric radiology giant: beverly wood, at strong memorial hospital. beverly proved to be a wonderful teacher, mentor, co-researcher and lifelong friend. marilyn describes beverly as inspirational and "fearless" in trying new technologies. it was during her time in rochester that marilyn went to her first spr meeting and, not surprisingly, won the caffey award for her work on "experimental neonatal intraventricular hemorrhage: clinical, radiographic and pathologic features." by then marilyn had two young children and moved on to the private sector, practicing part-time for several years first in rochester, then in cleveland, ohio. her years in private practice were particularly helpful in learning the importance of patient oriented service-and paved the way for her intuitive public relations strategies when designing the image gently campaign in later years. dr. goske was asked to join the cleveland clinic in , as the first full-time section head of pediatric radiology. it was here that she built a new section and spearheaded the web based education program for pediatric radiology residents with co-founder janet reid. this important free web site with modules is used widely by over radiology residencies nationally and internationally. her passion for education continued, inspiring her to complete a medical education fellowship focused on professionalism within the cleveland clinic lerner college of medicine. her work towards this fellowship has led to many creative educational initiatives including yearly educational summits at the spr. she was named chair of the professionalism committee of the rsna where she along with her committee have sponsored interactive workshops on this topic dear to her heart. dr. goske's energy and effective leadership skills brought her to become involved in the society for pediatric radiology, first as the coordinator for spr's first video-taped course in . mentors diane babcock and carol rumack proposed her for the nominating committee. this was followed by chair of the membership committee, where she organized the first formal survey of the society, then as a board member, then as secretary, and finally as president and chair of the board of directors, completing years on the spr board. working together with stuart royal, she successfully energized the campaign for children raising funds for the research and education foundation of the spr and expanded the work of prior presidents in further organizing the corporate support committee. marilyn's years as president and chairman of the board of the spr were highly successful with many unique strategic goals. she was instrumental in the founding of the junior spr. she led the wonderful spr national meeting in miami which included the first educational summit to enhance knowledge in adult learning and resident competencies. most people would rest after completing their arduous year as president but as chairman of the board, marilyn was just beginning! she moved to cincinnati children's hospital, joining the radiology department and was named the dr. corning benton endowed chair for radiology education where she got to work with dr. janet strife, another influential mentor and friend. acknowledging spr's long focus on reducing radiation doses in the imaging of children but concerned about the lack of change in practice by a majority of radiologists despite increasing reports of possible side effects, marilyn developed a public relations and awareness campaign. her goal was to inspire all to work towards decreasing radiation exposure to children when possible. with the help of many, she founded the alliance for radiation safety in pediatric imaging and the image gently campaign, initially focusing on ct. her ability to encourage numerous experts and societies to work together and get involved in "child sizing the amount of radiation used" has resulted in a groundswell of research and activity in this area. currently organizations with over , members have joined the alliance including international societies. the web site, www.imagegently.org, has been immensely successful filled with free information pamphlets in over languages, pqi projects, and modules for parents, physicians, and technologists. the image gently campaign has received several awards including the associations advance america honor roll, rt image magazine group with the "most influence in radiology" and the most effective philanthropy program from aunt minnie. image gently has spawned the creation of the adult-focused image wisely campaign. the alliance has been named by the joint commission, u.s. food and drug administration, and the american medical association in their influential statements on radiation dose as providing much needed guidance and information. marilyn's exceptional talent is inspiring and coordinating experts in multiple fields to work together towards common goals. she continues to work hard on the image gently campaign with more safety and quality messages planned for the coming years. she is also proud of her work with the acr dose index registry and quality improvement registry in ct scans in children in working toward developing diagnostic reference levels with a talented consortium of pediatric radiologists, medical physicists and technologists. she has acted as a national and international expert in her work with the international atomic energy agency, the world health organization and the national council on radiation protection in medicine and the fda. dr. goske's multiple committee appointments are taken seriously, and her work is always meticulous, well thought out, and brought to successful completion. she has been an active member of numerous national and international societies including the john caffey honorary society, acr, rsna, espr, aawr, and scorch. it is important to remember that dr. goske is also a successful researcher with numerous grants obtained through the spr ref including the thorne griscom education award and the rsna scholar grant. she has published over peer-reviewed articles, electronic publications, chapters, and presented scientific exhibits as well as given numerous scientific presentations. an articulate and engaging speaker, she has been invited to give over lectures locally, nationally and internationally. while marilyn has been very focused on her work with the spr, she believes that it is her amazing family and their love that really fuels her life. her husband rick is an internationally known neurologist and researcher in multiple sclerosis. her adult children jamie and brian, both in manhattan, remain close, and spending quality time together as a family remains the joy of her life. whether it is relaxing together in florida cooking or fishing, or taking an exotic vacation to india, being with rick, jamie and brian makes her the happiest. marilyn's genius is partly refusing to take "no" as an answer. along the way, at every turn there were those who believed that what she wanted to do couldn't be done. her approach was to draft the nay-sayers to the team and charge ahead with their willing and enthusiastic help. daniel burnham might have been talking about marilyn and not about his plan for the city of chicago when he said: make no little plans; they have no magic to stir men's blood and probably themselves will not be realized. make big plans; aim high in hope and work, remembering that a noble, logical diagram once recorded will not die, but long after we are gone be a living thing, asserting itself with evergrowing insistence. as an amazing change agent, inspirational leader, and wonderful role model, the spr is proud to honor marilyn goske with the gold medal. she made big plans! dorothy i. bulas, md pioneer honorees were first acknowledged in as a means to honor certain physicians who made special contributions to the early development of our specialty. it is time to reevaluate the meaning of the pioneer honoree. the subspecialty of pediatric radiology has been in existence now for more than years. we are beyond "the early development"; we must recognize other pioneering paths and should consider contributions to the subspecialty beyond the bounds of a modality, a technique, an observation or a change in practice. whatever this advancement is, it must be forged with vision, innovative ideas, and the ability to enable and sustain science and application. george s. bisset, iii, m.d. why george bisset? has he been part of the pediatric radiology landscape these last ten years? been part of the dialogue that has been increasingly influential across all of radiology, a conversation steeped in a deep tradition of excellence in diagnosis and treatment, and the safety and welfare of our children? been a leader in science and application? part of the landscape? no. but he has been beyond that and has worked tirelessly within the horizon, surveying…a step before, but guiding us on towards our destiny. a conversant? part of the dialogue? maybe. but he has been defining thought and concept upon which such conversation is born and nurtured. part of the science and application? yes, as much as anyone who promotes, who facilitates and sustains discovery, then here we are. horizons, innovation, and the gift of en-abling…what else is needed to define a true pioneer? how was this done? simply stated, george bisset has devoted at least the last decade to the advancement of our specialty in truly novel ways through his leadership, especially in rsna and the abr. in the rsna, as the scientific program committee chair several years ago he was instrumental in the conception, development and implementation of the integration of scientific papers and refresher course topics. this has been a resounding success, is currently used in other categories during rsna and is a model for other meetings, including the annual meeting for the society for pediatric radiology over the past few years. pediatric radiology was first in this effort. george continued to endorse topics that were marquees for pediatric radiology over the year in his education role on the rsna board of directors. he endorsed and implemented the pediatric campus concept at the rsna. early returns are that this was an extremely successful model to consolidate experts in pediatric radiology (and those interested in this subspecialty), pertinent science, education and administration. george is now the president of rsna, perhaps the most widely respected scientific and educational organization for our profession across the globe…and i would argue, with more promise for our future success in pediatric radiology than has ever existed. and george bisset, who through two terms as the pediatric trustee for the board of trustees for the abr, again, was on the horizon of a critical, sometimes perilous, and complete transformation of our certification examination process, always mindful of his constituency and colleagues, his duty as a physician, and the public and patients. this required delicate diplomacy, forward thinking, professionalism, and enlistment of a cadre of experts from within our subspecialty to assure excellence in pediatric radiology through abr certification. he was also a leader in the development, validation and implementation of the imagerich computer based examination model (the pediatric caq) now the standard for the new abr examinations. with these successes in mind, who better to embody the concept of bridging horizons that is the theme for this entire meeting? if you were looking for more numbers and accolades, i apologize. here are some: more than contributions to medical and scientific literature, advancing care through pediatric body ct and mr imaging research, a litany of presentations and invited lectures, vice chairs, chairs, chiefs, boards of directors, committee member and committee leader, clinical excellence including as a pediatric cardiologist and interventional radiologist, a superb speaker and author.… all are on his cv but i believe serve really as signposts for his gifts, some of those mentioned above, that a cv simply cannot convey. he could have played it safe with all of these successes on his cv. but pioneers don't play it safe. they are on the horizon, too busy defining thought and enabling (our) advancement-building bridges. i believe it is time to reevaluate the meaning of the pioneer honoree and i have the greatest honor and pleasure of introducing george s. bisset, iii for the pioneer award for . linked with past awardees, he continues an exceptional legacy and i don't believe his explorations and discoveries are finished… donald p. frush, md the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. in , david kushner was recognized by the spr with its first presidential recognition award for his vision and foresight in working with both the american college of radiology (acr) and the society for pediatric radiology (spr) in developing an important new relationship and for his service to the spr. in summarizing his considerable efforts for that award, i noted that he "contributed substantively to the increased visibility of the spr within the acr. his tenure as our treasurer placed our organization on a firm financial foundation." with the current award, the society recognizes his indefatigable continuing efforts on our behalf including: his work with the acr: . establishing a pediatric radiology caucus at the annual acr meeting, . convincing the acr of the value of managing specialty societies by making the spr its first successful new model for imaging society management, . advocating tirelessly for pediatrics and children's health within the acr by serving on the council steering committee and then as acr council vice speaker and speaker, . helping establish the first pediatric commission, assuring that pediatric issues will receive support of the college and its resources while serving on the board of chancellors of the acr for the past five years. the spr's "image gently" campaign was a beneficiary of this pediatric commission of the board of chancellors, . continuing to shepherd and contribute to the pediatric component of the acr practice guideline process. his work with the spr: since his earlier award, david has served as: foundation from to , including the launch of the formal fundraising effort, "the campaign for children," . spr president - , organizing and running a very successful meeting in savannah, . chair of the board of directors of the spr from to , including leading a strategic planning process that resulted in a new, more focused division of labor amongst board members and defined board responsibilities. david was born in fargo, north dakota, received a ba from the university of minnesota, and received his medical education at the university of pennsylvania. this was followed by two years of training in pediatrics at children's hospital, boston. he then did a two-year fellowship at the national institute of health in bethesda, performing research in embryology and teratology. he returned to massachusetts general hospital for training in diagnostic radiology. this was followed by a year of residency in pediatric radiology at children's hospital boston, followed by a one-year fellowship. he then became director of the pediatric radiology section at massachusetts general hospital, a position he held from to . from to , david was chief of the division of diagnostic imaging and radiology at children's national medical center in washington, dc attracting a strong faculty, training many fellows and promoting research. during that time, he served as a volunteer radiologist and pediatrician to inner city healthcare systems aiding the indigent and homeless, and developing telemedicine capabilities linking free clinics with radiology experts. in , our man inside the beltway moved a bit outside by accepting the medical directorship of radiology at the children's hospital of the king's daughters in norfolk, virginia, and professor of radiology and pediatrics at the eastern virginia medical school. he assures me that life there is good, being a bit more "laid back" with fishing and sailing just outside the door. he also finds time for italian cooking and practicing jazz on his several guitars. fortunately for all of us in the spr, david is close enough to our central office and the acr that he will be able to continue work on our behalf for many years to come. the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. the spr presidential award is given in recognition of stuart's numerous significant and outstanding contributions to the spr over many years of service. the awardee is selected by the honors committee, a committee comprised of the three most recent past presidents of the society. dr. royal is a proud native of birmingham, alabama. he is a second generation physician who came naturally to his desire to care for children as the son of a pediatrician, arnold royal, who took care of children in the birmingham community until he was years old. dr. royal attended rice university in houston, texas followed by md and ms degrees from the university of alabama at birmingham. he subsequently moved to san francisco, where he completed a pediatric internship followed by a diagnostic radiology residency at the university of california, san francisco. dr. royal credits dr. charles gooding at ucsf for influencing his decision to pursue a career in pediatric radiology. during his internship stuart observed dr. gooding make a plain film diagnosis of tapvr, type on a severely ill and perplexing newborn, and he was immediately hooked into radiology. while at ucsf dr. royal was also appointed as a national institute of health research fellow in the department of radiology. following residency, stuart completed a fellowship in pediatric radiology at the children's hospital medical center in boston. from boston, stuart returned to his roots in birmingham, alabama in , where he was appointed as a pediatric radiologist at the university of alabama and subsequently the children's hospital in birmingham. in recognition of his outstanding leadership skills and accomplishments at the children's hospital, dr. royal was appointed as the radiologist-in-chief in , and subsequently the harry m. burns endowed chair of pediatric radiology. he also holds appointments as clinical professor of radiology and pediatrics at the university of alabama at birmingham and serves on the children's hospital board of trustees. at alabama dr. royal has earned the high esteem of his colleagues, referring physicians, and staff for his outstanding clinical acumen as a diagnostic radiologist and for his undaunting commitment to excellent care of children. colleagues describe stuart as one who fosters a strong work ethic, high commitment to teaching, and sincere compassion for children. in , stuart was the recipient of the children's advocate award by childcare resources for improving the quality of care and access to radiological services for underserved children in birmingham. stuart has been married to the love of his life, barbara royal, for the past years. stuart and barbara are the proud parents of two very accomplished children, jeremy a budding radiologist in training at the university of alabama, and rachael, who has an mba and works as a vice president for moody's in new york. stuart and barbara are also the proud grandparents of three grandchildren. in conversation, stuart is quick to pull out his iphone and share the latest pictures of family members while recounting their latest activities and milestones. throughout his professional career, dr. royal has worked tirelessly to advance the mission of the society for pediatric radiology. he is past president and chairman of the board of the spr and has served on numerous spr committees. he ran a highly successful spr meeting in new orleans in . those in attendance will recall the jubilant parade stuart led through the streets of new orleans to culminate the meeting. as president and then chair of the spr board, stuart played a critical and instrumental role in bringing the spr management contract under the umbrella of the acr. the synergy achieved by the spr-acr relationship has yielded results well beyond a simple management contract. pediatric radiology and spr now have a voice at the "radiology table." stuart has also been a strong advocate for supporting translational research to advance the care of children via imaging. to help achieve this goal, he has worked aggressively to secure increased funding for the society of pediatric radiology research and education foundation. following the launch of the ref's campaign for children in , stuart made it his personal mission to work with the leadership of the society, both past and present, to discuss major gifts to the foundation. through stuart's personal effort, the foundation received pledges for many significant leadership gifts, including from spr pioneers drs. hooshang taybi and ed singleton and from himself and barbara. the spr is highly fortunate to have benefited from stuart's numerous contributions and dedication to the care of children. the society is very proud to bestow the president's award on dr. stuart a. royal. the society extends honorary membership to individuals outside of pediatric radiology who have made outstanding contributions to the care of children. this evening, dr. harvey l. neiman, whose leadership of the american college of radiology is resoundingly praised, is the recipient of the honorary member award. for , as in when his contributions were similarly recognized, dr. neiman's selection by the society for pediatric radiology honors committee was made in appreciation for the strength of his efforts to further the spr's philosophy, goals, and programs for responsible diagnosis and treatment of the young patient as embodied in the acr and spr's "image gently" campaign. image gently has succeeded not only in raising awareness of the great diagnostic benefits we can offer to pediatric patients but also directs us to acknowledge the downside of overzealous diagnostic efforts where excessive radiation becomes a risk. importantly, the "image gently" campaign, an upbeat, positive program rather than a punitive one, a smile rather than a frown, makes pediatric and all radiologists aware that their best practice reflects balanced, educated, up-to-date utilization of state-of-the art technology with exercise of responsible leadership in protecting the pediatric patient. for adults, awareness of the need for patient protection is communicated in image wisely. dr. neiman's vision and successful achievements are evident on every page of his curriculum vitae. a consummate strategist in assembling teams to make forward-looking goals a reality, harvey now stands at the top of our specialty as the first physician executive director of the american college of radiology. at this time in big-business medicine, as we see the physician, leader of the patient care team, being diminished to one of many "providers," it is so important for our patients' well-being for us to recognize the obligations commanded by our training, clinical experience and commitment. dr. neiman's recognition of the need for physicians' leadership in improving the quality of patient services and his development of programs in all areas of the college's activities have been just short of miraculous-image wisely for adults, quality and safety including the performance guidelines and accreditations, education, government relations, economics, imaging metrix, acrin, and the new radiology leadership institute-to name only a few. all have contributed significantly to the care of our patients and the stature of our specialty. dr. neiman was born in detroit and attended mumford high school. from wayne state university, he received his b.s. in and his md in . harvey's postgraduate training was at the university of michigan, where he was a resident in radiology ( - ), chief resident ( , and a - fellow in angiography (cardiovascular radiology), receiving abr certification in and a caq in vascular and interventional radiology in february . dr. neiman often expresses his gratitude to and profound respect for his mentor and beloved chief at the university of michigan, dr. william martel. dr. neiman was chief of cardiovascular radiology at walter reed army hospital and a lecturer in cardiovascular radiology at the afip from - . in , he joined the northwestern radiology faculty, rising to professor in , and for ten years he headed up the section of angiography and sectional imaging, advancing its technology and honing the skills of northwestern's radiology residents. harvey also offered a highly sought-after fellowship in interventional radiology, us, and ct. in , dr. neiman left northwestern to assume the chair in medical imaging at the western pennsylvania in pittsburgh. i was the first woman to have completed his fellowship in us, ct, and interventional radiology at northwestern and accompanied him to pittsburgh. his tenure at west penn attests to his talent in making his visions a reality: the department became a highly respected, successful academic private practice notable in many areas including ultrasound, breast and women's imaging, and interventional radiology. harvey instituted an excellent radiology residency program in as well as fellowship programs in in the areas of excellence noted above. during the years since harvey received his md, he has been awarded honors from many national, international, and specialty societies, has been an invited lecturer over times on ultrasound, interventional radiologic, radiologic educational, management, turf issues, disruptive and new technology topics to name just a few. dr. neiman, who was a founder of the sru (society of radiologists in ultrasound), has to his credit peer-reviewed articles, scientific presentations and exhibits, a text co-authored with dr. james yao, angiography of vascular disease ( ) , and book chapters. he has received many honors including fellowship in the american college of radiology, american institute of ultrasound in medicine, society of radiologists in ultrasound and the society of cardiovascular and interventional radiology (now sir). as part of his strong commitment to the future leaders of radiology, for diagnostic radiology he has served as a member of the residency review committee of the accreditation council for graduate medical education. he has been a member of the american college of radiology and its committees and commissions for many years including the commissions on education, ultrasound, and economics. he also served as chair of the commissions on ultrasound and economics. from to , he was a member on the acr board of chancellors, serving as its chairman - . he was president of the radiology advocacy alliance from to . in , nine years ago, dr. neiman became the acr's executive director. he currently serves in this position, where his excellent business skills, knowledge of health policy and economic issues, and strong administrative background have furthered our specialty. his goal, to ensure that the acr's resources benefit all radiologists and patients across all economic strata, is evident in his actions at the college. harvey has a devoted, wonderful family that often included me and my youngest daughter on many pittsburgh occasions. his beautiful, elegant wife of many years, ellie neiman, is here tonight to celebrate with him the spr's recognition of his many achievements. dr. neiman has two accomplished, lovely daughters, jennifer, extremely successful in her marketing career, and hilary, an attorney. jennie's husband, dr. seth kligerman, one of many young radiologists whom harvey has mentored, is on the radiology staff at the university of maryland. how harvey has had time between, through, and among all of these achievements to have become mentor, colleague, and friend to me and to so many others who have been inspired by his ability to see into the future and to shape it in a positive way is remarkable. now that dr. neiman has taken all of radiology under his wing, not just its component parts, the future of our specialty, one of the best, can be assured but also recognized for its centrality to all of medicine. it is my honor and privilege to introduce to you harvey l. neiman md, facr as this year's society for pediatric radiology honorary member. the singleton-taybi award is given in honor of edward singleton and hooshang taybi, in recognition of their personal commitment to the educational goals of the spr. initiated in , the award is presented annually to a senior member of the spr whose professional lifetime dedication to the education of medical students, residents, fellows, and colleagues has brought honor to him/her and to the discipline of pediatric radiology. it comes as no surprise to those who know him that dr. daneman, "dr. d" as some of us call him, has been named the recipient of the singleton-taybi award in recognition of his many years of dedication to the education of residents, fellows, and colleagues. born in south africa in , he received his medical degree at the university of the witwatersrand, johannesburg, receiving the harwood-nash award for the most successful student in surgery. initially, dr. d thought he would become a pediatric surgeon; but after passing the part i examination offered by the royal australasian college of surgeons, he changed his mind and began his training in diagnostic radiology. he chose a radiology residency at the royal prince alfred hospital, in sydney, australia. this included a year in pediatric radiology at the royal alexandra hospital for children in sydney where his interest and love of pediatric radiology began. dr. d then had the foresight to pursue pediatric radiology fellowship training at the hospital for sick children in toronto, canada. after completing the fellowship, he was immediately offered a position as staff radiologist at "sick kids." he became director of body imaging in and radiologist-in-chief in serving in that capacity for years. his management style was simple but effective. he chose staff that were young, but smart and innovative. he nurtured them and provided them with all the tools they needed to become successful professionals, like him. but contributing to his own department was not enough for him. he also found the time and strength to contribute, teach, train, and help pediatric radiologists in the most remote portions of the globe in every continent, which resulted in recognition from prestigious organizations in places such as south america, israel, europe, taiwan and australia: he is an honorary member of the european society for pediatric radiology and the sociedad latinoamericana de radiologia pediatrica as well as other national societies. dr. d is an "institution" inside the great institution that is sick kids. his teaching is unique and praiseworthy in being enthusiastic, provocative, and fun at the same time. his lectures have been regarded as both instructive and practical by his students and trainees due to his special gift of making the most complicated things look as simple as possible. in sharing his diagnostic knowledge and know-how, he passes his own, innate teaching spirit on to his apprentices. he has earned several awards for this, including the outstanding teacher award granted by the university of toronto fellows at sick kids for the past consecutive years. dr. d receives numerous invitations to present at national and international meetings and symposia and has been invited as a visiting professor to more than a hundred institutions across the globe. he does not only teach us the ins and outs of pediatric radiology, but he makes sure that we learn to love it and understand the importance not only of good practice but also the imperative to pass knowledge on by teaching and publishing. dr. d is someone who inspires us to reach beyond our limits, someone we want to emulate. he shares his knowledge, his wisdom, and his advice freely. he shares with us the most incredible secrets of his own career, so we understand from his personal experience. dr. d never tells you what to do, he suggests to you, in an incredible articulate fashion, what you want to do yourself. dr. d has been and is for many of us, more than an educator, more than a mentor, he is our "coach." well before this concept was introduced into medicine by a. gawande , dr. d intuitively had the vision to "coach" his trainees, trying to get the best out of them, without pressure, but with love and passion, and especially emphasizing the importance of achieving a worklife balance in order to prevent the now so common "stress and burnout" affecting the radiology community . he warned us that many high achievers reach their goals only at the expense of their personal lives, but dr. d has been as successful personally as he is professionally. his wonderful wife of years, louise, his two daughters and his recently newborn granddaughter serve as sources of strength and pride. he is a truthful and generous friend to many, both in and out of radiology. it is not uncommon for many of us, who came through sick kids, to come back and visit and be invited to his house to share a wonderful dinner with other invitees, who may be radiologists from north america or from other parts of the globe visiting sick kids to learn from him. dr. daneman's research has widely influenced the field of pediatric radiology. examples include the work of dr. daneman and his colleagues on intussusception, which has promulgated the use of ultrasound for diagnosis, and the use of air enema for reduction. this approach has been adopted as standard practice at many institutions in north america and across the globe. to share his research with others in the field, dr. daneman has authored or co-authored more than publications, including peer reviewed articles and book chapters on a wide range of topics related to the imaging of children. dr. d is one of those rare people who are irreplaceable. he is a superb teacher, a gifted academician, a capable administrator, and a person called "friend" by so many of us. we are thrilled and proud to present our society's singleton-taybi award to dr alan daneman in recognition of his lifelong accomplishments and personal commitment to the educational goals of the spr. we cannot imagine anyone more deserving of this award than dr. d. thank you "coach"! monica epelman, md and oscar navarro, md john caffey, md - dr. caffey was regarded throughout the world as the father of pediatric radiology. his classic textbook, pediatric x-ray diagnosis, which was first published in , has become the recognized bible and authority in its field. the seventh edition of this book was completed several months before his death in . it has been among the most successful books of its kind in the medical field. dr. caffey was born in castle gate, utah on march , . it is interesting that he was born in the same year that roentgen discovered the x-ray. dr. caffey was graduated from university of michigan medical school in , following which he served an internship in internal medicine at barnes hospital in st. louis. he spent three years in eastern europe with the american red cross and the american relief administration, and returned to the united states for additional training in medicine and in pediatrics at the universities of michigan and columbia, respectively. while in the private practice of pediatrics in new york city at the old babies hospital of columbia university college of physicians and surgeons, he become interested in radiology and was charged with developing a department of pediatric radiology in . he frequently expressed appreciation and admiration for the late ross golden, chairman of radiology at columbia presbyterian hospital, who allowed him to develop a separate department of diagnostic radiology without undue interference, and who was always available to help and advise him. dr. caffey's keen intelligence and inquiring mind quickly established him as the leader in the fields of pediatric x-ray diagnosis, which recognition became worldwide almost instantaneously with the publication of his book in . dr. caffey received many awards in recognition of his achievements. outstanding among these were the mackenzie davidson medical of the british institute of radiology in , the distinguished service award of the columbia presbyterian medical center in , the outstanding achievement award of the university of michigan in , the howland award of the american pediatric society in , the jacobi award of the american medical association in , and the gold medal award of the american college of radiology in . he had been a member of the american journal of roentgenology. he was a counselor of the society for pediatric radiology and was an honorary member of the european society of pediatric radiology. dr. caffey's contributions to the pediatric radiologic literature were many. he was instrumental in directing attention to the fact that a prominent thymic shadow was a sign of good health and not of disease, an observation that literally spelled the end to the practice of thymic irradiation in infancy. infantile cortical hyperostosis was described by him and is called "caffey's disease." dr. caffey in first recognized the telltale radiographic changes that characterize the battered child, and his students helped disseminate his teachings about these findings. it was dr. caffey who first recognized and descried the characteristic bony changes in vitamin a poisoning. he recognized and described the findings associated with prenatal bowing of the skeleton. in , three years after his retirement from babies hospital, he joined the staff of the children's hospital of pittsburgh as associate radiologist and as visiting professor of radiology and pediatrics at the university of pittsburgh school of medicine. although dr. caffey came to children's hospital and the university of pittsburgh in an emeritus position, he worked daily and on weekends throughout the years he was there. in pittsburgh, he made four major new contributions to the medical literature. he described the entity, "idiopathic familial hyperphosphatasemia." he recognized and described the earliest radiological changes in perthes' disease. he called attention to the potentially serious effects of shaking children, and used this as a subject of his jacobi award lecture. he described, with the late dr. kenny, a hitherto unrecognized form of dwarfism that is now known as the caffey-kenny dwarf. the john caffey society, which includes as its members pediatric radiologists who have been intimately associated with dr. caffey, or who have been trained by his students, was established in . this society is now among the most prestigious in the field of radiology. his book and the society named in his honor will live on as important memorials to this great man. his greatness was obvious to all who worked with him. he was warm, kind, stimulating, argumentative, and above all, honest in his approach to medicine and to x-ray diagnoses. his dedication to the truth was expressed in his abiding interest in the limitations of x-ray signs in pediatric diagnosis and in his interest in normal variation in the growing skeleton. he was concerned with the written and spoken word and was a skilled semanticist. his book and his articles are masterpieces of language and construction. he stimulated and was stimulated and loved by all who had the privilege of working with him. radiology and pediatrics have lost a great man, but they shall ever have been enriched by his presence. interstitial lung disease, which is more common in infants than older children, is defined as a rare heterogeneous group of parenchymal lung conditions primarily due to underlying developmental or genetic disorders. affected infants typically present with clinical syndromes characterized by dyspnea, tachypnea, crackles, and hypoxemia. mainly due to a lack of evidence based information regarding underlying pathogenesis, natural history, imaging findings, and histopathologic features of interstitial lung disease, the understanding of interstitial lung disease in infants has been limited in the past. however, in recent years, the understanding of interstitial lung disease in infants has been substantially improved primarily due to: ) advances in imaging technology for better detection; ) improvement of thoracoscopic techniques for lung biopsy; ) established pathologic criteria for consistent diagnosis; and ) development of new classification system based on underlying etiology of the interstitial lung disease. in fact, several forms of interstitial lung disease in infants that exhibit distinct clinical, radiological, and pathological patterns are currently emerging. the overarching goal of this article is to review a new classification system, imaging findings, and pathological correlation of interstitial lung disease in infants. improved understanding of this often challenging disorder can aid in early and accurate diagnosis, which in turn, will result in improved patient care. large airway disease in pediatric patients: impact of advanced post-processing techniques catherine m. owens, bsc mbbs mrcp frcr the introduction of multidetector row computed tomography (mdct) scanners has altered the approach to imaging the pediatric thorax. in an environment where the rapid acquisition of ct data allows general hospitals to image children instead of referring them to specialist pediatric centers, it is vital that general radiologists have access to protocols appropriate for pediatric applications. this lecture will focus on the main principles of volumetric ct imaging that apply generically to all mdct scanners and in particular we describe the reconstruction techniques for imaging the pediatric thorax and the low-dose protocols used in our institution on a -slice dual source ct scanner. examples of important clinical applications with the impact and added value of post processing are also given. neoplasms, by definition, comprise an abnormal uncoordinated proliferation of cells that persists even after the inciting stimulus as ceased. the resulting mass may be benign or malignant and arise from any tissue that is normally found in the location where the mass develops. thus, tumors of the chest may arise from bone, lung, pleura, lymphatics, muscle, etc. whether benign or malignant, chest masses may be incidental findings on imaging obtained for other reasons. this presentation will focus on malignant tumors of the chest, address the imaging characteristics and staging of the most common chest malignancies and discuss characteristics that may aid in distinguishing these lesions from their corresponding benign or infectious counterparts. included in this presentation will be the most common chest wall malignancies (ewing family of tumors and rhabdomyosarcoma), mediastinal malignancies (lymphoma, germ cell tumors, and neurogenic malignancies) and pulmonary primary malignancies (pleuropulmonary blastoma and carcinoid). the changing appearance of selected tumors in patients treated with new targeted therapies will be introduced. lung disease is the most common chronic disease of childhood, but young children cannot perform the breathing maneuvers required for the most commonly used method for assessing lung function, spirometry. ct provides exquisite structure information about the lung but concerns regarding the long-term consequences of the relatively high radiation dose limit its use particularly in the pediatric population. magnetic resonance imaging (mri) has the potential to provide regional information about the lung without the use of ionizing radiation. while conventional proton mri has found widespread clinical application in most organs of the body, mri of the lung lags behind because the lung is intrinsically difficult to image with mri. the strength of the mr signal depends on the physical density of protons in the tissue being imaged and the local environment of the protons. the lung has a low physical density and thus a low proton density so little mr signal is generated by the lung. furthermore, the magnetic susceptibility effects from its many air-tissue interfaces cause what little signal is generated to rapidly decay so that the lung typically appears dark on conventional proton mr images. a variety of strategies have been developed to overcome the inherent difficulties of mri of the lung, resulting in recent substantial improvements in image quality. additionally by administering an inhaled gaseous contrast agent, such as the hyperpolarized noble gases helium- or xenon- , direct visualization of lung airspaces in an mr image is possible. a number of unique strategies for evaluating the structure and function of the human lung using hyperpolarized gas mri have been developed. although the level of structure detail possible with lung mri may never equal that of ct, mri may nonetheless has the potential to provide clinically useful information and be a sensitive, effort independent test of pediatric lung disease. for a matter of time, we will focus in this presentation only on the following: intestinal malrotation a normal visceral situs can be inferred sonographically in relation to the right-sidedness of the superior mesenteric vein, to the retromesenteric location of d and to the right iliac position of the ileocecal valve. conversely, intestinal malrotation is likely when the aforementioned features are reversed. in addition, cdu can display the whirlpool pattern in case of midgut volvulus or internal hernia, alleviating the need for preoperative opacification. the reliability of us in diagnosing intussusception is well documented since the early s. the value of us in predicting the success or failure of pneumatic reduction and/or bowel necrosis is more debatable, based upon a coexisting bowel occlusion, the presence of interloop fluid, bowel wall changes (intramural air, dilated mural vascular channels), absent blood flow at cdu. the continuous down-grading of us in comparison to ct, and the opposite conclusions of various series regarding imaging of pediatric appendicitis are based upon different prerequisites and definitions. historically and in most usa institutions, sonography reports are either negative (entire normal appendix), positive (abnormal inflamed appendix), or equivocal (non-visualization or partial visualization of appendix). the equivocal group is then logically investigated by a subsequent abdominal ct. in europe, some usa centers, and in our practice, us reporting include groups and take into account ancillary findings: . normal appendix (blind-ended, lamellated, compressible, < mm in diameter, without peristalsis; . appendix not depicted, no secondary signs; . appendix not depicted, with one of the following: hyperchoic mesenteric fat, fluid collection, local dilated small bowel loop; . appendix inflamed. group represents most cases of perforated appendicitis, groups and the negative sonogram. ct is then indicated only in obese patients and to assess the feasibility of percutaneous interventions. inflammatory bowel disease in the recent literature, mr enterography is often preferred to ct enterography. small bowel series look prehistoric and us is rarely mentioned. sonography however is very valuable both for screening children presenting with abdominal pain, diarrhea, weight loss, or gi bleeding and for following the course of the disease and searching for complication. hypervascularization has been proved to parallel the disease activity. initially mentioned by dr. rita teele, the interest of us for differentiating high-intermediate/low varieties of imperforated anus has been re-emphasized more recently. a perineal rectal cul de sac distance of mm is quoted as the significant cut-off value. us can also display rectourinary fistulae outlined by air. update on mdct and mri of hepatobiliary disease in children: what's new lisa h. lowe, md a variety of disorders may affect the pediatric liver. recent advances in histopathological knowledge and imaging techniques have led to important changes that radiologists must be aware of in order to allow for an accurate limited differential, and in some cases, specific, diagnosis. this presentation will focus on recent developments that have lead to a better understanding of the embryopathogenesis for fibropolycystic liver diseases (including choledochal cysts and caroli disease), histopathological findings that have led to new classification systems for of pediatric vascular anomalies, technological advances and contrast agents in magnetic resonance imaging that are useful to characterize and limit the differential diagnosis of hepatic masses. diagnostic errors in pediatric abdominal imaging: diagnostic pearls and pitfalls george a. taylor, md this presentation reviews the types of diagnostic errors in abdominal imaging occurring over a -year period in an academic pediatric radiology practice. radiologists engage in two interrelated processes when interpreting imaging studies: perception and analysis. failures in perception (failure to identify an important finding) are a common source of diagnostic error in pediatric imaging, while failures in the analytic portion of the process (over-or faulty interpretation of a finding) are not as common. under-interpretation of findings can be related to a number of perceptual and visual phenomena including visual isolation where attention is selectively focused on a main area of the image while less or no attention is given to secondary areas, and satisfaction of search which occurs when additional lesions remain undetected after detection of an initial lesion. many analytic errors are the result of commonly used heuristics or shortcuts in reasoning. these include the availability heuristic in which likelihoods are based on memory of a similar case, the framing effect in which a different diagnosis is reached based on how the information is presented, and the anchoring heuristic in which the initial impression is difficult to change, despite conflicting new information. another recognized pitfall is blind obedience, in which a diagnostician stops thinking when confronted by authority. this authority can be human or technical (reliance on a laboratory value). finally, diagnostic errors can result from an attitude of overconfidence. examples of these heuristics and strategies to minimize cognitive errors will be discussed. marta hernanz-schulman, md, faap, facr this session will consider abdominal masses that present in the neonatal period, spanning developmental, inflammatory and neoplastic conditions. time constraints do not allow an exhaustive list or description, but the more important or frequent lesions are discussed. the presentation is subdivided by systems. the renal section discusses various conditions presenting with hydronephrosis, such as ureteropelvic junction obstruction and duplication anomalies, followed by autosomal recessive polycystic kidney disease and multicystic dysplastic kidney, cystic entities commonly presenting in the perinatal period. neoplastic renal entities include lesions with benign behavior, such as ossifying renal tumor of infancy, with the discussion extending to entities with very poor prognosis such as clear cell sarcoma and rhabdoid tumor, while discussing the congenital mesoblastic nephroma, its histologic subtypes and the differences in their presentation, imaging findings and clinical behavior. suprarenal lesions include the adrenal hemorrhage, congenital neuroblastoma and subdiaphragmatic sequestration. hepatic lesions include developmental anomalies that present as mass lesions, such as choledochal cysts, vascular lesions such as congenital and infantile hemangiomas, and neoplastic lesions such as the mesenchymal hamartoma and hepatoblastoma. differences in clinical presentation, imaging characteristics and behavior of the lesions are discussed. the section on pancreatic lesions discusses pancreatic cysts and pancreaticoblastoma. gi tract and mesenteric lesions include duplication cysts, lymphangioma, and meconium pseudocyst, and their relationship to bowel obstruction and persistent perforation. ovarian cysts can present as large masses in neonatal girls, and should be high in the differential diagnosis of large masses encountered in female infants; the imaging characteristics of simple and complicated cysts are described, as well as their course and potential complications. pediatric procedures: from imaging to intervention the spectrum of vascular anomalies in pediatric patients: multimodality imaging evaluation and current treatment patricia e. burrows, md vascular anomalies are categorized into two main groups, vascular tumors and vascular malformations. genetic and molecular regulation of vascular genesis of angiogenesis, and mutations responsible for some of the vascular malformations, have been delineated. in order to implement future targeted treatment of vascular lesions, accurate diagnosis is important. imaging modalities that are effective in distinguishing the various types of vascular anomalies and demonstrating the extent include ultrasonography with doppler interrogation, mri and various forms of mr vascular flow imaging, conventional angiography and venography. techniques used to image lymphatic channel anomalies, conventional lymphangiography, lymphoscintigraphy and infrared fluorescent lymphangiography. in this presentation, common forms of vascular anomalies will be described and rare or recently recognized anomalies will be mentioned. current treatment of the different forms of vascular anomalies will also be discussed, including pharmacotherapy using beta blockers, angiogenesis inhibitors and mtor inhibitors. endovascular techniques used in treating vascular malformations, including embolization and sclerotherapy will be presented. pediatric vascular disease is extremely varied, with a wide range of conditions requiring diagnostic or therapeutic intervention. technological improvements in non-invasive imaging modalities such as mri and ct have reduced the need for diagnostic angiography; however, with advances in interventional techniques, arteriography in the pediatric patient is now often performed for therapeutic reasons. pediatric arteriography presents unique issues and challenges. tremendous variability in patient size and physical maturity limits the ability to standardize technical aspects of performing arteriography. in addition, radiation protection, sedation/anesthetic support, monitoring of fluid balance, and maintaining patient warmth must be considered. a regimented protocol for assessment of the pediatric patient must be followed, with review of the indications for the study requested, and review of patient-specific issues such as coagulation profile, concurrent medical disease, patient weight, and anesthetic concerns. appropriate patient monitoring is imperative to ensure patient safety. vascular access can be quite challenging. ultrasound and micropuncture access techniques have tremendously improved successful access while reducing associated complications. the smallest catheter that can accomplish procedure objectives should be used. for most diagnostic cases, french systems can be used for children> kilograms, while french catheters are preferred in those < kg. intraprocedural heparinization ( - iu/kg) is also more often used, especially in children weighing less than - kg. rates and volumes of contrast injected for pediatric arteriography are not standardized, as in adult patients. in general, contrast dose should be limited to - ml/kg, and - ml/kg in premature infants and neonates. all these new technique are less invasive, improve patients' outcomes and reduce morbidity. they are also cost-effective as patients are discharged home earlier and recover faster from the intervention. the future holds promising new technologies such as high-intensity focused ultrasound (non-invasive method of thermal ablation) and nanoparticles for drug delivery. pediatric interventional radiology will continue to be an essential part of these minimally invasive therapies. musculoskeletal imaging: from planning to performance kirsten ecklund, md the purpose of this talk is to review advanced mr imaging techniques currently being used in the evaluation of pediatric musculoskeletal tumors. the goals of these techniques include improved image resolution and quality, lesion tissue characterization, and increased acquisition speed. diffusionweighted (dw) and perfusion imaging will be emphasized; however, whole body, metallic artifact mitigation, and volumetric sequences will also be discussed. dw mri is based upon the brownian motion of water within extra and intra-cellular spaces which depends upon tissue cellularity. dwi can aid in the differentiation of benign from malignant lesions, which generally have restricted diffusion. there is even greater potential for dwi in the assessment of tumor response to therapy. the apparent diffusion coefficient (adc) maps are critical to accurate interpretation of diffusion sequences. adc maps distinguish between restricted diffusion and t effect, both of which appear bright on dwi. both qualitative and quantitative tissue assessments can be made with dwi. challenges for dwi in the pediatric musculoskeleton include susceptibility artifacts from bone, motion vulnerability, and geometric distortion at larger fields of view. our current protocols and parameters for dwi will be presented. contrast-enhanced (dce) mr using one of a variety of vendor specific sequences. qualitative and quantitative assessments of inflow and distribution of contrast have been shown to help differentiate between benign and malignant lesions and to evaluate drug efficacy during therapy. this technique is especially promising in those patients undergoing antivascular and antiangiogenic therapy. tal laor, md congenital abnormalities of the musculoskeletal system can result in alterations of limb size, configuration, and/or segmentation. these disorders often affect both the osteocartilaginous skeleton as well as the surrounding soft tissues and can be localized or diffuse. in this session, we will focus on the imaging features of several congenital abnormalities that result in a small or short limb, in altered configuration of a limb, or in abnormal segmentation. deformities of both upper and lower limbs will be examined. like congenital abnormalities, developmental disorders of the pediatric musculoskeletal system can be limited to a single area or can affect numerous sites within the body. for example, neonatal brachial plexopathy is a localized disorder that produces characteristic musculoskeletal alterations about the shoulder girdle and elbow of affected children. the alterations of morphology and function of the shoulder develop over time with growth of the child and change in response to a variety of therapies. we will review the features of developmental anomalies of the pediatric musculoskeletal system and evaluate the role that imaging plays in the initial evaluation and in the subsequent assessment of these children during treatment. multimodality imaging of skeletal trauma in children: using all of the tools peter j. strouse, md skeletal trauma is a common indication for imaging throughout the pediatric age range. newborns may suffer birth trauma. infants and toddlers may be subject to abusive injury. children of all ages may suffer accidental injury. older children and adolescents are increasing hurt in sporting activity and vehicular accidents. fracture patterns vary with maturation of the child. interference with normal growth is a potential complication. imaging of skeletal trauma begins with radiography. proper anatomic and age specific radiographic technique assures optimal diagnostic yield. radiography suffices in most cases to diagnose fracture or confirm normalcy. "clinical correlation" aids in diagnosis. ultrasound, ct, mri and nuclear medicine may play a role in specific instances where plain radiographs are non-diagnostic or to better delineate certain fractures. arthrography and conventional tomography have occasionally been used in the past and tomosynthesis may prove useful. follow-up radiographs may be useful for diagnosis or confirmation of some fractures. this presentation will focus on the imaging of acute skeletal injury. technique and approach for plain radiography will be emphasized. specific indications and roles for ancillary imaging techniques will be defined and illustrated with representative cases. although classically thought of as a disease of adulthood, stroke is much more common in the pediatric population than was once appreciated. this may be due to many factors, not the least of which is increased awareness due to the presence of subspecialty stroke teams now fairly commonplace in many children's hospitals, and the fairly recent advent of more advanced imaging technique such as diffusion-weighted imaging (dwi) and its routine use in imaging the central nervous system (cns) in the child and adolescent. causes of stroke in children can be protean, and range from idiopathic on one end of the spectrum, to traumatic on the other, with many causes in between, many of which may not be intuitive to the clinician without further research. moyamoya disease and its many causes, such as sickle cell disease (scd), trisomy and neurofibromatosis type i (nf i) can all lead to stroke in children, as can congenital clotting deficiencies such as factor v leiden deficiency and congenital cardiac lesions with their resultant shunting of blood between the left and right cardiac circulations. although usually arterial in nature, strokes may arise from the venous system in clinical scenario of venous thrombosis with resultant venous infarctions. factors contributing to venous thrombosis in children and adolescents can be due to dehydration (especially in the very young), severe iron deficiency anemia, inflammatory bowel disease and exogenous hormone ingestion such as is seen with oral contraceptives (ocp) in young women. advanced imaging techniques for neuroimaging in pediatric patients: where are we now? blaise v. jones, md the past decade has seen a large number of advanced imaging techniques introduced to the clinical armamentarium of the pediatric radiologist. from the development of multidetector ct scanners that can obtain whole head diagnostic studies in less than s to the routine use of t mr imaging, technical advances have dramatically changed our ability to diagnose and manage neurological disorders in children. however, all of these advances are not of equal clinical utility, and it is imperative that the pediatric radiologist be well versed in their judicious and appropriate application. this presentation will discuss the effective use of volume ct scanning, cta, swi, asl, fmr, pmr, and other advanced imaging techniques in the diagnosis of neurological disorders presenting in childhood. at the conclusion of the presentation the attendee will have a better understanding of how to ideally apply these technologies in practice. a spectrum of abnormality in pediatric neck: practical imaging choices and interpretation caroline d. robson, mbchb learning objectives: . become familiar with an optimized imaging approach for head and neck infections . recognize the complications of head and neck infections . recognize the utility and interpretation of imaging for neck masses this talk will cover the imaging approach and interpretation of findings in head and neck infection and neck masses. infection includes acute complicated sinusitis, coalescent mastoiditis, neck infection and local and intracranial complications. optimized imaging protocols and image interpretation for neck masses will also be discussed and illustrated. acute complicated sinusitis is diagnosed when acute sinusitis is accompanied by orbital symptoms (e.g. proptosis) and/or mental status changes, seizures or other neurological findings. coalescent mastoiditis is diagnosed when otomastoiditis is accompanied by tenderness and/or swelling over the mastoid process. ct and mr provide complementary information. ct is obtained with contrast. mr sequences include fatsuppressed t , t , diffusion, and fat-suppressed contrastenhanced t weighted images with mr venography. intracranial complications include epidural abscess, subdural empyema, meningitis, cerebritis, brain abscess, venous thrombosis and venous infarction. the limitations and usefulness of ct in the diagnosis of neck abscess will be illustrated. the imaging approach to masses depends on patient age, and the size and location of the mass. us, ct, mr, and nuclear medicine studies provide complementary information. as for infection, optimized imaging approaches and key imaging features for various masses will be discussed. embryology and diagnostic approach in spinal dysraphism l. santiago medina, md, mph and esperanza pacheco-jacome, md congenital anomalies of the spine are malformations that can be confusing due to the complexity of their embryology, and to the sometimes unclear classifications and terminology. the purpose of this review is to give a clear and basic understanding of the different stages of the embryological development of the spinal cord, starting with the bilaminar disc in the first week of gestation. during the second week, the formation of a trilaminar disc (gastrulation), the notochord, and the formation of the neural tube or neurulation. also, a review of the development of the distal cord: conus medullaris, filum terminale, ventriculus terminalis, by a different mechanism, canalization and retrogressive differentiation. beside the embryological review, a case correlation will be presented using mr imaging to demonstrate these malformations. open spina bifida entities include meningocele and myelomeningicele. closed or occult spinal dysraphism (osd) is characterized by a spinal anomaly covered with skin and hence with no exposed neural tissue. osd spectrum includes dorsal dermal sinus, thickened filum terminale, diastematomyelia, caudal regression syndrome, intradural lipoma, lipomyelocele, lipomyelomeningocele, anterior spinal meningocele and other forms of myelodysplasia. several studies have shown that mri and ultrasound have better overall diagnostic performances (i.e., sensitivity and specificity) than plain radiographs for detection of occult spinal dysraphism. for h n , most patients had mild illness but a small percentage required mechanical ventilation and icu admission. the high risk groups include children < years old and those with chronic medical conditions in particular neurodevelopmental impairment. pediatric mortality was . % of all deaths associated with the pandemic reported in the u.s. in both conditions, the most prominent radiographic and ct features were airspace disease including ground glass opacities (ggo) and consolidation, commonly with multi-focal and bilateral involvement. pleural effusion, adenopathy and cavities were absent. in some patients with viral infection, respiratory symptoms may be mild but are complicated by neurological manifestations. a brief review of mri features in h n related encephalopathy including acute necrotizing encephalopathy (ane) will be given. bernard f. laya, do tuberculosis (tb) is a worldwide major public health problem with one-third of the world's population being infected. it is a leading cause of death and disability from infection worldwide. children are amongst the most vulnerable group because of their immature immune status. a child usually gets tb infection after being exposed to a sputum-positive adult. depending on many factors, the infection can lead to latency or tb disease. it can affect virtually any organ in the body and can be devastating if left untreated. tb in children remains a diagnostic challenge. in addition to history of tb exposure, signs and symptoms, laboratory and microbiologic tests, medical imaging remains a valuable tool in its diagnosis. although findings are nonspecific, the radiograph is the most commonly ordered initial imaging tool for screening and diagnosis of pulmonary and musculoskeletal involvement. computed tomography and magnetic resonance imaging offer more detailed assessment especially in cranial and abdominal involvement. medical imaging is also utilized to follow up patients during or after anti-tb treatment. knowledge of the common imaging patterns, pitfalls and dilemma are very important in establishing the diagnosis of tb in children. the pathophysiology of pediatric tb will be discussed as it correlates with imaging findings. the wide spectrum of imaging manifestations in various modalities will be presented. imaging updates along with pitfalls and dilemma in the interpretation will also be discussed. tb can affect almost every organ system but the author will present cases that are more commonly encountered. and concurrent ct/ pet-ct (k . ) panels. there were more indeterminate nodule predictions by pet-ct (n of ; %) and concurrent ct/pet-ct (n ; %) than by ct alone (n ; %). the overall accuracy of ct alone was %, pet-ct alone % and concurrent review %. worst case sensitivity and specificity were % and % for ct alone, % and % for pet-ct alone, and % and % for concurrent ct/pet-ct. conclusions: pet-ct assessment of pulmonary nodules in children is feasible but limited by non-diagnostic quality ct images and atelectasis caused by sedation. subjective assessment of nodules by pet-ct does not appear to improve the ability to distinguish benign from malignant histology in children with solid malignancies. semi-quantitative nodule assessment using the standardized uptake value may improve the performance of pet-ct in this setting and will be investigated in the future. purpose or case report: nec is the most common lifethreatening medical/surgical emergency of the gastrointestinal (gi) system in neonates, with an incidence up to % in infants weighing < g. with advances in treatment of nec, increased survival rates result in rise in post-nec gi complications such as feeding intolerance. development of post-nec bowel strictures results from healing of involved bowel and can result in bowel obstruction. it has been routine to study the bowel of infants after medical treatment for nec by contrast enema and small bowel follow-through prior to initiating feeding. however, in order to "image gently" we are attempting to decrease the radiation exposure to these patients. we postulate that in patients with no abnormal bowel dilation prior to initiation of feeds, the incidence of colonic stricture would be so low that routine enemas would be unnecessary and could be eliminated from the workup. recorded as present or absent in anatomic abdominal regions defined as: and -from the dome of the diaphragm to top of l to the right and left of midline, respectively; and -from top of l to the iliac crest to the right and left of midline, respectively; -from the iliac crest to the top of the sacrosciatic notch; -below the top of the sacrosciatic notch. we assessed the frequency of findings in each region and how often findings in regions and were associated with findings in regions - . % confidence intervals were calculated. results: the fewest pertinent findings were present in region in . % ( / ) ( % ci: . - . %) of radiographs. findings included: abnormal bowel % (n ), bowel gas paucity . % (n ), pneumatosis . % (n ), inguinal hernia . % (n ) and osseous abnormalities . % (n ). pertinent findings were present in region in . % ( / ) ( % ci: . - . %). findings included: abnormal bowel . % (n ), bowel gas paucity gas . % (n ), pneumatosis . % (n ), free air . % (n ), and abnormal bowel with pneumatosis . % (n ). among patients with an abnormality in region , ( . %) also had an abnormality within at least one of regions through . among the patients with an abnormality in region or , ( . %) also had an abnormality within at least one of regions through . catheter/tube tips were located in region in . % (n ) and region in . % (n ) of radiographs, respectively. pneumatosis was present most frequently in regions ( . %), ( . %), and ( . %). free air was present most frequently in regions ( . %), regions and ( . % each). conclusions: our preliminary data suggest that pertinent findings on neonatal portable abdominal radiographs are rarely isolated to the pelvis, implying that gonadal shielding of regions and should not compromise diagnostic accuracy. purpose or case report: the purpose of this study was to determine the sensitivity, specificity, and positive and negative predictive value of ultrasound in diagnosing appendicitis when the appendix is visualized, using three diagnostic categories: positive, negative, and equivocal. the -category diagnostic accuracies for appendiceal diameter and radiologist impression were compared. methods & materials: a retrospective study was performed evaluating all right lower quadrant ultrasound reports dictated over a -month period. included studies were interpreted as positive, negative, or equivocal for appendicitis. report impressions that did not specify one of these categories and studies where the appendix was not seen were excluded. the pathologic diagnosis of appendicitis was considered the gold standard for a positive diagnosis. because virtually all pediatric surgical cases in the region are referred to our hospital, it was assumed that the patient did not have appendicitis if surgery was not performed. logistic modeling using appendiceal diameter as the independent variable established cutoff diameters of ≤ mm negative, > mm positive, and <x≤ mm equivocal. sensitivity, specificity, and positive and negative predictive values were calculated for both methods. results: of the patients imaged during the study period, ( %) met the inclusion criteria; ( %) reports did not categorize the impression and in ( %) studies the appendix was not seen. surgery was performed on ( %) subjects, of which ( %) had a pathologic diagnosis of acute appendicitis. using the radiologist impression, there were true positives (tp), false positives (fp), false negatives (fn), and true negatives (tn), for a sensitivity of % ( % ci - %), specificity of % (ci - %), ppv of % (ci - %), and npv of % (ci - %). there were ( %) cases reported as equivocal; of these, ( %) had a pathologic diagnosis of appendicitis. using appendiceal diameter, there were tp, fp, fn, and tn, for a sensitivity of % (ci - %), specificity of % (ci - %), ppv of % (ci - %), and npv of % (ci - %). there were ( %) cases categorized as equivocal; of these, ( %) had a pathologic diagnosis of appendicitis. conclusions: the use of diagnostic categories enables high ppv and npv with a relatively low number of equivocal cases. using appendiceal diameter alone results in higher ppv than that of the radiologist impression, but also yields a higher number of equivocal cases. purpose or case report: intussusception is an obstructive condition that a segment of the bowel invaginates into adjacent bowel and is an urgency that needs to be reduced as soon as possible to prevent bowel ischemia or necrosis. when it occurs in the infants and young child, it usually develops idiopathically and reduced by the technique such as air enema under the fluoroscopic guidance or saline enema under the ultrasound guidance. the success rate of the non-surgical reduction has reported over %. the pneumatic reduction is to introduce air into the patients' rectum via a ballooned foley catheter by hand pump. a mercury manometer connecting with the foley catheter calibrates the pressure of insufflation, and the recommended maximum pressure is mmhg. the hydrostatic reduction is to drip saline from a bag at the height of ft that may be different according to the institute's guidelines. until recently, in both techniques, the precise measurement of the intraluminal pressure was not possible. with the purpose of intraluminal pressure monitoring, we introduced a specific digital pressure gauge that can measure both pneumatic and hydrostatic pressure in various units and can give the collected data to our workstation. with the data, we purpose to make the curve of intraluminal pressure during the procedure and to compare the pattern and difference in both techniques of reduction, which permits suggesting the better technique for reducing the intussusception. from february , we performed the intraluminal pressure monitoring in children; cases of pneumatic reduction and cases hydrostatic reduction. the results indicated that the curves were similar in both techniques. however, the hydrostatic reduction tended to need longer time and higher pressure difference than the pneumatic reduction. we assumed that a higher flow rate and more fluctuating introduction of pressure in the pneumatic reduction made the difference between both methods. purpose or case report: anecdotal evidence suggests that some pediatric brain tumors, particularly pilocytic astrocytomas, demonstrate greater enhancement on delayed post-contrast t weighted mr imaging compared to early post-contrast imaging. our goal was to compare immediate post-contrast imaging with delayed post-contrast imaging in pediatric brain tumors. methods & materials: the research protocol was granted exempt status by the institutional review board (comirb# - ). between november and march , all patients for whom an mri of the brain was ordered to follow-up known brain tumor or to evaluate new brain tumor underwent a modified protocol that included both immediate and min delay post-gadolinium images. the modified protocol sequence order was dwi, t mprage, contrast injection, immediate post-contrast t mprage, t , flair, min delayed post-contrast t mprage. this sequence allowed both immediate and delayed post-contrast imaging to be performed without scanner downtime. a total of unique patients met inclusion criteria of an enhancing primary brain tumor with the delayed imaging performed within a window of - min. these studies were evaluated independently by pediatric neuroradiologists (ns and lf) and a radiology resident (jm) to compare the degree of lesion conspicuity and edge discrimination, and to determine an overall preference. in cases of discrepancy between reviewers, final grading was determined by group consensus. results: delayed post-contrast images were preferred in / tumors ( %), immediate post-contrast images were not preferred in any case, and / cases were graded as equivalent ( %). notably, delayed imaging was preferred for / pilocytic astrocytomas ( %). in / cases ( %), the improvement in conspicuity and edge discrimination on delayed imaging was felt to have a potential impact on clinical management, e.g. by extending resectable or treatable tumor margin. conclusions: delayed post-contrast imaging can be performed easily by reordering existing mri protocols, and no scanner downtime is required for this protocol change. our results indicate that pediatric brain tumors (particularly pilocytic astrocytomas) often enhance more conspicuously on delayed imaging, that no diagnostic confidence is lost on delayed imaging, and that clinical management may be more accurately guided. -directions) were retrospectively reviewed, after irb approval. both sporadic (n ) and nf- associated optic gliomas (n ) were included. tumors confined to intraconal optic nerve were excluded due to technical limitation of epi dwi within the bony orbit. apparent diffusion coefficient (adc) of the solid portions of the tumor was measured using the region of interest method both at baseline and on follow-up mri. results: for the patients, required treatment (surgery and/or chemotherapy) for symptomatic tumor progression ( sporadic opg and cases of nf- ). median follow-up interval was . years (range: months to . years, sd . years). there was no difference in adc values between sporadic and nf- associated opg. opg that required therapy had significantly higher baseline mean adc ( x - mm /s, sd . ), whereas opg with low mean adc ( x - mm /s, sd . ) remained clinically asymptomatic or stable (stratified mann-whitney test, p . ). an increase in mean adc of x - mm /s doubled the odds the patient will require treatment (or . , % ci: . - . , p< . ). enhancement patterns did not predict tumor behavior or nf- status (fisher's exact test, p . ). conclusions: significantly higher mean adc was seen in opg that required therapy for tumor progression. mri may be a useful prognostic tool in further defining a subset clinically significant sporadic or nf- associated opg. purpose or case report: fast brain mri imaging has recently been introduced for assessing brain ventricles in patients with ventriculo-peritoneal shunts (vps). however, there is minimal literature on how this method could be beneficial for other indications. compared to ct, this method reduces lifetime cumulative radiation dose and has multiplanar capabilities. it is much faster than full brain mri, reducing exam costs and potentially reducing the need for sedation. however, fast brain mri has lower resolution than a standard brain mri and cannot detect hemorrhage. the goal of our study is to retrospectively assess additional clinical applications for fast brain mri. methods & materials: patients who had undergone fast brain mri were found in xenobase, a database which references deidentified electronic medical records at our institution. xenobase was then used to identify subgroups by diagnosis. one of the most common diagnoses was arachnoid cyst. after irb approval, patients with fast brain mri and arachnoid cyst were identified so that their fast brain mri could be compared to any full brain mri and to clinical outcomes. fast brain mri findings were excluded if there was not a full brain mri within year. agreement with full brain mri, and documented effect on clinical management were coded for statistical review. results: between and , there were arachnoid cyst patients with fast brain mri exams. in members of this group, fast brain mri was used alone or in comparison with a full brain mri in the decision to follow or discharge the patient. exams failed to report a pituitary cyst and mass effect which were reported on prior exams. patients had no complications in the year following their fast brain mri. the most common complication was headache ( cases). conclusions: fast brain mri reduces radiation exposure, time, cost, and the need for sedation in vps patients. these benefits may cautiously be extended to other patient groups also requiring routine imaging, such as those with arachnoid cysts. disclosure: the authors disclose that they will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: susceptibility-weighted imaging (swi) is a new technique that exploits susceptibility differences in different tissues, to provide a different type of tissue contrast. swi is a gradient echo sequence utilizing both phase and magnitude data to achieve exquisite sensitivity to tissue magnetic susceptibility effects. it is extremely sensitive to even minute amounts of paramagnetic substances and therefore for detection of blood products (hemosiderin, ferritin), deoxygenated blood, calcium, iron, and small vein depiction. it is particularly suited for vascular imaging, especially in cerebral ischemia. swi has been shown to be more sensitive in detecting cerebral microbleeds than is conventional t *-weighted gradient-recalled echo imaging (gre) partly because of its inherent sensitivity, increased spatial resolution and the thinner slices acquired. recent studies have shown that swi detected more microbleeds in more patients, irrespective of their location and that swi may be more sensitive in detecting traumatic lesions than ct or mri. methods & materials: between january and october we have performed swi on pediatric patients (from day to yrs old) affected with different pathologies. mri was performed using either a -or . -t magnet (achieva ; philips healthcare, best, the netherlands). among these patients also received a classic gre sequence. results: our experience confirms a greater sensibility of swi than gre in detecting microbleedings and larger bleedings. swi is much more helpful in patients younger than year since it can distinguish hemorrhagic and non hemorrhagic punctuate white matter lesions detected as hyperintensities on t -w images. it is more accurate in distinguishing petechial hemorrhages and ischemic foci in patients with germinal matrix hemorrhages. swi can provide important diagnostic information not only in vascular pathologies but also in tumors showing the altered tumor microvascularity, the degree of intratumoral necrosis and the presence of subtle defects of the bbb within the surrounding parenchymal tissue. the technique also allows the detection of possible bleedings in infectious lesions. conclusions: swi is a valuable technique in the evaluation of a wide variety of intracranial pathologies in the pediatric population and its use is advisable on a routine basis. purpose or case report: a common problem with pediatric mr imaging is motion. diffusion-weighted imaging (dwi) is highly sensitive to the effects of both rigid-body motion and brain pulsation. the resulting motion artifacts can manifest in several ways, and include blurring (motion between volumes), slice 'drop-outs' (motion during the diffusion encoding), and aliasing (motion during the parallel imaging/ghost calibration scan). in order to improve image quality in pediatric dwi and avoid the potential for repeat scans, we have implemented our grappa-accelerated diffusion tensor (dt)-epi sequence on over , pediatric patients at our institution, and have developed tailored reconstruction software to correct for large motion and reduce the need for general anesthesia (ga). methods & materials: grappa-accelerated epi dti data was collected on patients at . t and , patients at t between the ages of month and years old. with these data, we investigate the use of a method to select the best grappa and ghost calibration weights; d rigid-body realignment with importance weighting; a new volume rejection criterion for large motion; together with other procedures to lower image noise and reduce phase artifacts. all image reconstruction was performed using compiled threaded matlab code on the vendor's (ge) multiprocessor reconstruction hardware. results: using the maximum motion detected from the d realignment procedure on the , dti exams, % of patients did not move (either through co-operation or ga, denoted here by < mm of motion); % of patients moved between - mm; % between - mm; % between - mm; and % between - mm. except for patients in total, the motion correction steps employed here were extremely robust in correcting for motion. in addition, the motion correction steps employed here do not blur or negatively affect the data on non-moving patients. conclusions: our proposed integrated reconstruction scheme suggests that correcting for different types of motion at different stages of the dti acquisition is critical to provide scans of diagnostic quality. apart from the very rare instance ( . %) where the patient moved continuously an extensively throughout the scan, our motion correction procedures employed here are extremely robust. using this scheme, we show that highly diagnostic motion-corrected dti data can routinely be read on our patient database within min. . participating sites followed mutually agreed upon vendor-specific dti protocols used for neonates in clinical practice: ss-epi; b ;~ mm voxel; - directions; te~ msec; acquisition; parallel imaging; multi-channel ( - ) head coil. tensor data was analyzed at one site using internally developed software in idl. b and eddy current distortion were assessed by analyzing grid line distortion on acr slice ; deviations from linearity were measured in the phase encoding direction. acr slice was used to assess snr of the center and periphery of the b image, and fractional anisotropy (fa) of the phantom, which should approach . deviations from specified sequence parameters were recorded. results: both siemens scanners had some image degradation due to vibration susequently corrected by the vendor. nonlinear gridline distortion was highest on the ge followed by philips but was corrected with the use of nd order shimming. eddy current distortion was consistently smaller than acquisition voxel size after image registration. te varied from - msec; acquisition bandwidth range was - hz/pixel. the mm slice thickness was problematic on clinical ge scanners resulting in non-isotropic voxels. across vendors, snr was consistently higher in the image periphery than center by a factor of . - . ). the greatest difference was showed in patients with fhc. no association was found between the value of ldl-c and imt. the . % received drug treatment at the time of evaluation. in dbt- a no association was found between the imt and the levels of hba c and lipids. and in the ob group found no association between imt and bmi z score. fhc %, % of dbt- and % of ob showed atherosclerotic plaques and intima irregularities. conclusions: the imt ultrasonography was able to demonstrate that patients with chronic diseases, with increased cardiovascular risk in adulthood, showed early alterations of carotid intima media in children. this allows clinical applications of preventive and therapeutic guidance. a benchmark for precision of flow assessment was determined from differences between aortic and pulmonary arterial flows, which should agree. the precision of flow when utilizing a slow flow structure (vein) and a fast flow structure (artery) was then determined, serving as an indicator of the precision of slow flow measurements. this was done in pairs for the upper body (svc flow vs difference between ascending and descending aortic flow), lower body (ivc flow vs descending aortic flow) & total body (svc flow+ivc flow vs ascending aortic flow). paired t-tests were used to identify significant differences in the respective arterial and venous flow rates. with an f-test, the relative precision of the arterial flow (determined from aortic and pulmonary arterial flow) was compared against the precision of agreement between upper, lower, and total body flows, each of which has a slow flow venous component, thus assessing precision of venous flow measurement. results: arterial & venous flow measurements were strongly correlated for the upper body (r . ), lower body (r . ) and total body flow (r . ); net aortic and net pulmonary trunk flow rates were also tightly correlated (r . ). moreover, there was no significant difference in the precision of arterial & venous flow measurements (t-test, p . ). lower venc ( cm/s or lower) improves the accuracy and precision associated with low velocity venous flow, a finding that tended to but it did not reach statistical significance. conclusions: with -d pc mri, the accuracy and precision of venous flow quantification are comparable to arterial flow quantification, though venc settings may improve venous flow assessment. disclosure: dr. tariq has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the spatial resolution requirements for imaging tiny target vessels in neonates have so far precluded its use of cemra in this patient population. the purpose of our study, therefore, was to explore the potential of high resolution cemra at . t in neonates with suspected congenital vascular anomalies methods & materials: neonates (mean age . days, range - days; mean weight . kg, range . kg- . kg) underwent cemra at . t. cemra was performed under controlled apnea on a -channel . t system using either a -channel head-neck coil ( pts) or a -channel adult knee coil ( pts). gd contrast delivery was calculated based on a total dose of . mmol /kg. parallel imaging factors of - were used, generating . x . x . mm voxels in an acquisition time of - s. images were scored for quality and the presence of artifacts independently by two observers. the cemra series were evaluated to identify pulmonary arterial and venous anatomy. extra-pulmonary vascular anatomy was divided into sections for image quality assessment on mpr. results: the mra data sets had high mean image quality and low mean artifact grading scores. no significant difference was evident between the two observers for scoring image quality and artifact (p . ), and there was good interobserver agreement (k . , % ci: . - . ). the pulmonary arteries were confidently visualized to at least the nd order branches in all patients, at least the rd order branches in ( %). out of evaluated segments, ( %) were graded as the vessel "very well visualized with excellent definition of vessel" pa abnormalities were diagnosed in patients and pv anomalies in patients. correlation was made with open surgical findings in cases, confirming the cemra diagnoses with no discrepancy between the operative and imaging conclusions. the results of our study suggest that high resolution cemra at . t is extremely promising in neonatal cchd and, in combination with echocardiography, may often provide comprehensive information for treatment planning. with appropriate use of physiological motion compensation, parallel imaging and coil configuration, voxel volumes less than . mm are routinely achievable. purpose or case report: it is not well understood whether transfusion-dependent children (mainly those who have hereditary anemias subject to excessive iron levels from regular blood transfusions) with no or mild cardiac iron overload and without signs of heart failure exhibit early changes in cardiac dysfunction. this study aims to evaluate intramyocardial deformation and subsequent cardiac dysfunction in such patients using the cardiovascular magnetic resonance technique of myocardial tagging as well as assess iron overload by another cardiovascular magnetic resonance technique of t star (t *). we hypothesize that transfusion dependent children undergoing chelation therapy will be at high-risk for cardiomyopathy despite normal or slightly elevated iron levels and no signs of heart failure due to progressive myocardial deformation as assessed by myocardial tagging; that is, we expect abnormal mechanical parameters to exist despite t * values which correspond to normal or slightly elevated myocardial iron levels. methods & materials: patients (mean age yrs) requiring regular blood transfusions for various reasons (e.g. thalassemia, sickle cell disease, other anemias) were investigated using harmonic phase magnetic resonance tagging and t * imaging. various myocardial mechanical parameters were quantified and correlated to cardiac iron levels as measured by t *. results: children with no overt signs of heart failure (as measured by ejection fraction and volume indices) exhibited normal t * iron levels in combination with global circumferential abnormal myocardial strain and children exhibited regional strain. conclusions: this preliminary data suggests that transfusiondependent children without overt signs of heart failure exhibit early signs of cardiac dysfunction (an effect of strain as assessed by myocardial tagging) in direct relation to normal or slightly elevated myocardial iron levels (as measured by t *). a larger sample size of children could support the idea of abnormal myocardial mechanics being a diagnostic imaging marker for the development of myocardial iron overload and eventual iron-mediated cardiomyopathy. the choice of coil and field of view varied according to the age and size of the patient. imaging was performed on a . t magnet (philips mri system). after the cine gradient echo time of flight sequences were acquired, the dynamic keyhole mr angiographic sequence was applied in the coronal orientation. this sequence commenced - s after initiation of the first bolus administration of - ml of undiluted gadopentetate dimeglumine ( . mmol/ml, magnevist) at a rate of - ml/sec followed by - ml of saline at a rate of ml/sec. image acquisition was repeated multiple times without delay for s during shallow breathing. contrast material was administered through a peripheral or central venous line, and sometimes via simultaneous bilateral extremity injections. rarely manual hand injection was performed. the parameters were as follows: centra k-space filling, acquired voxel size - . x - . x - , reconstructed voxel size . - x . - x - . , number of dynamics - , keyhole percentage - %, sense (parallel imaging) factor x - x , dynamic times - . s, and injection rate - cc/second. image analysis was based on original contrast-enhanced data sets, mip and volume rendering. the quality of the mrv was graded by a subjective scale from - ( excellent, no limitations; nondiagnostic). comparison with unenhanced mr venographic sequences and doppler ultrasound were available in all cases. results: d mrv provided diagnostic information on patency of venous segments in all cases, including the presence of venous occlusion or stenosis, the segments involved, and collateral venous pathways. conclusions: d mr venography using the method outlined is a reliable means of estimating central venous thrombosis in children, using short dynamic scan times with high spatial and temporal resolution, creating an effect similar to conventional venography. paper #: pa- analysis of optimal phase interval for prospective ekg-triggered cardiac ct in children prakash masand, md, texas children's hospital, savivek bogale, lorna browne, rajesh krishnamurthy purpose or case report: evaluate high temporal resolution cine mri of the heart in children to determine relationship of heart rate to the optimal motion free interval during the cardiac cycle, and to derive a chart depicting optimal reconstruction intervals across a range of heart rates which could be applied for prospective ekg triggered ct imaging of the heart. methods & materials: pediatric patients who had high temporal resolution cine steady state free precession sequence ( frames acquired across a single cardiac cycle) performed as part of a mri/mra of the heart from - were included. a single reader analyzed the high temporal resolution cine data to determine the location and duration of the motion-free phase interval in systole and diastole for heart rates ranging from - bpm. the following information was collected: age, heart rate, duration of systole and diastole, ekg phase and phase percentage of motion-free interval, and duration of motion-free interval. heart rates were grouped in ranges of ( - , - , - etc.), with at least patients in each group. wilcoxon sum rank test was performed to compare the static durations of systolic and diastolic phases for each heart rate group. two-tailed p-values< . were considered to indicate statistical significance. a chart matching heart rate range to the optimal phase of image acquisition and reconstruction was created. results: optimal reconstruction intervals for motion-free imaging of the heart in systole and diastole, and single best phase for a given heart rate are as follows: (please see table ) mean duration of the motionless phase in systole and diastole for a given heart rate is as follows: (please see table ) conclusions: this is the first time that variability in location of the motion-free interval within the cardiac cycle with respect to heart rate in children has been studied in rigorous fashion. this chart will have immediate application in the so-called 'target scan', which uses prospective ekg triggered acquisition of data in combination with half-scan reconstruction to minimize radiation dose with respect to retrospective ekg gated imaging. results: a total of patients were found to have aberrant pda by ccta. nine patients had a pda emanating from the brachiocephalic artery to the pulmonary arteries and one patient had pda emanating from the carotid or the subclavian artery according to the operative report. all ten patients had echocardiography in addition to ccta. nine of the ten patients underwent surgery. one patient was lost to follow up. comparison between ccta and echocardiography to operative report showed the following: out of the echocardiograms agreed completely with ccta and operative report. out of the echocardiograms did not report aberrant pdas which were seen on ccta and confirmed during surgery. in one patient, the echocardiogram reported a double aortic arch which was found to be an aberrant pda from the left brachiocephalic artery; a finding that changed the surgical management and pre-surgical planning. the results were statistically significant with a p value of < . . conclusions: diagnostic accuracy of ductus arteriosus anatomy is important in pre-surgical planning and management of patients with ductal dependent pulmonary circulation. cardiac ct angiography is more accurate as compared to echocardiography in diagnosis of aberrant patent ductus arteriosus. ) in patients younger than year of age. the prospective ecg-gated protocol scanned % of the cardiac cycle with msec padding in patients with heart rates greater than bpm. two experienced radiologists evaluated the image quality and course of the coronary arteries. image quality was assessed based on the degree of homogeneity of vascular enhancement, presence of stair-step artifacts, image signal and noise as well as the overall subjective image quality based on a point scale. the course of the left and right coronary arteries was also evaluated based on a point scale, focusing on how well the evaluator was able to visually follow the coronary artery from its origin to its termination. radiation dose was recorded and compared. results: the mean score of the homogeneity of vascular enhancement, stair step artifacts, image noise and signal, overall image quality, and score given to visualization of the course of the coronary arteries showed no significant difference (p> . ) in the retrospective and prospective ecg gated groups. the mean estimated effective dose was significantly lower for the prospective ecg gated group compared to the retrospective group, ( . msv vs . msv) respectively (p< . ). conclusions: prospective ecg-gated cardiac mdct provides comparable assessment of coronary anatomy, image quality with significantly less radiation dose when compared to the retrospective ecg-gated mdct. prospective ecg gated cardiac mdct is a powerful adjunct to the treatment and surgical planning of pediatric patients with congenital heart disease less than yr of age with lower radiation dose. methods & materials: pediatric neuroradiology lectures were recorded and made available to radiology residents at a university program through on-line streaming video viewed through an internet link. topics included brain tumors, phakomatosis, and congenital brain malformations. one lecture per week was recommended prior to case conferences that reviewed the same topic. pre-and post-tests and a feedback survey were administered. nonparametric paired sign test and analysis of covariance were used to evaluate changes in test scores overall and according to feedback responses. spearman's partial rank correlation coefficient was used to evaluate the relationship between the number of viewed videos and test scores. results: twenty-nine residents completed the pre-test and the post-test. the means (sd) scores were . % ( . %) and . % ( . %) respectively. there was a significant improvement in test scores (p . ). residents that agreed/strongly agreed that the streaming technology lectures were convenient had greater improvement than those who did not ( . vs. - . %, p . ). similarly, those who agreed/strongly agreed that being able to replay a lecture was helpful had greater improvement than those who did not ( . vs. - . %, p . ). finally, those who agreed/ strongly agreed that the streaming technology lecture format was a better teaching tool had greater improvement than those who did not ( . vs. - . %, p . ). significant positive correlation between number of videos watched postconference and improvement was present (spearman's rho . , p . ). conclusions: on-line streaming video with live case conferences enhances radiology resident learning of pediatric neuroradiology. step (mpps) software provided an accurate measurement of scan time. visual charting made gaps in utilization apparent. technologists and nursing notes correlated to gaps identified barriers and opportunities for improvement. nursing and anesthesiology reduced redundancies. standardized protocols lead to more consistent scan times. appointment access for sedated mri was measured by the third available appointment. results: manually entered data points were time consuming, inconsistent and unreliable. the process improvement was most effective when fewer more reliable data points were used to evaluate the effect of change. the program resulted in a reduction of appointment access for sedated mri from days to days with no change in the hours of operation. magnet utilization was increased from % to %. induction outside the scan room provided the most efficient process tested. we ranked first in utilization in a children's healthcare cooperation of america (chca) survey as measured by exams per scanner. patient preference for a.m. scheduling was shown by survey and corroborated by scheduling data. consistent scan times were achieved by protocol standardization augmented by indication driven decision support. conclusions: a consise definition of mr utilization established a metric that was used in the process cycle of analyze-optimize-measure. anesthesia induction outside the magnet was the most efficient practice but required collaboration between nursing, mr technologists and anesthesiology. protocol standardization were valuable aspects of process improvement essential to optimizing parallel sedation. these adjustments reduced appointment access from days to days, increased utilization from % to % and produced a number one rank in utilization by chca survey. we exploited the synonym option in epic order entry to translate indications into procedures mapped to specific protocols for mri neuroimaging. the order screen allows the provider to enter an indication. that indication is linked through a synonym option to a specific exam and protocol. the recommendation is based upon institutionally created clinical care guidelines, and can be accepted with a single click to complete the order. the requesting provider retains the option to override the recommendation. an step in process development utilized an order queue established within the epic inbasket. a pediatric radiologist monitored the queue and communicated with referring providers to obtain additional history and educate toward best imaging practice. these interactions facilitated development of a robust index of clinical indications used to create the synonym pool. results: mri neuroimaging indications were expanded into a robust data set linked to specific mri exams aligned with specific protocols. the synonym option within epic created the opportunity for the requesting provider to simply enter an indication which drives the procedure and recommended protocol. provider satisfaction has been high and concurrence with recommendations nearly universal. conclusions: indication driven order entry was achieved through the synonym option in order entry within the epic emr. imaging recommendations are based upon institutional clinical care guidelines developed through consensus. a robust compilation of pediatric mri neuroimaging indications has been created and linked to specific exams and protocols. compliance with the indication driven recommendation has been high. modifications of the current system are currently under development for all cross sectional modalities and organ systems. paper #: pa- cost-effectiveness of routine neonatal renal ultrasound in non-syndromic complex congenital heart disease elfrides traipe, tch, extraipe@texaschildrens.org; jill v. hunter, marthe munden purpose or case report: to assess the prevalence of abnormal renal ultrasound in non-syndromic complex congenital heart disease (cchd) and assess the cost-effectiveness of routine renal ultrasound in this population. we restrospectively reviewed the initial neonatal renal ultrasound and any subsequent renal imaging in patients with non-syndromic cchd. etiologies included hypoplastic left heart syndrome (hlhs), transposition of the great vessels (tga), coarctation of the aorta (coa), truncus arteriosos (ta), double outlet right ventricle (dorv) with or without patent ductus arteriosus. patients were recruited consecutively as part of a prospective trial for pre-and post-operative magnetic resonance imaging of the brain. results: the neonatal pre-operative renal ultrasounds were analyzed in female and male patients. only of the patients showed any congenital renal anomaly. this patient was born with hypospadias, that would have routinely stimulated neonatal follow up. conclusions: knowledge of embryology would not lead us to anticipate a high co-incidence of congenital renal and cardiac pathology. based on this statement and our findings, our recommendation to improve cost-effectiveness is not to perform routine neonatal renal ultrasound in non-syndromic cchd, but only if otherwise clinically indicated. purpose or case report: to conduct a meta-analysis of the diagnostic performance of contrast enhanced voiding urosonography (cevus) in comparison to voiding cystourethrography (vcug) or direct radionuclide cystography (drnc). a literature search was conducted for studies published on cevus in the pediatric age group. studies were included if the ultrasound contrast agents (usca) levovist® (bayer-schering pharma, germany) or sonovue® (bracco, italy) were used and enough data was available to extract x tables. if the cevus was compared to both vcug and drnc in the same patients the results for each were analyzed separately. a bivariate hierarchical model that takes into account the heterogeneity in cevus sensitivity and specificity in different studies was used for the assessment of the summary diagnostic metrics. the summary roc curve was derived and presented graphically from the parameters of the model. additionally, the % confidence intervals (ci) and the positive (lr+) and negative (lr-) likelihood ratios were calculated. results: out of publications only comparative studies fulfilled the inclusion criteria. these encompassed cevus studies in comparison with vcug and with drnc with regards to detection of vesicoureteric reflux. in studies the usca levovist® and in sonovue® were used. a total of children with pelvi-ureteral-units (puus) were included in the meta-analysis. cevus compared to vcug and drnc had a sensitivity of % (ci: - ) and a specificity of % (ci: - ) with lr+and lr-of . and . , respectively. the performance of cevus was better when compared to drnc than to vcug (sensitivity %, specificity % versus % and %, respectively. the meta-analysis of the diagnostic performance of cevus regarding the urethra included patients ( boys). excellent imaging of urethral anatomy was reported in over % of the patients. however, currently there is only one comparative study with patients available. in this study % sensitivity and % specificity were reported. conclusions: sufficient evidence is available clearly demonstrating the high diagnostic performance of cevus compared to vcug or drnc regarding the detection or exclusion of vur in children. these findings combined with the absence of radiation should be convincing reasons for promoting the widespread use of cevus in children. disclosure: dr. darge has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: prenatal ultrasound (us) has increased identification of infants with asymptomatic renal pelvic dilatation. society for fetal urology (sfu) grading is used in the sonographic evaluation of pediatric hydronephrosis. based on us findings, a nuclear medicine diuretic renogram may assess renal function, which could result in operative intervention. standardized protocols for diuresis renography, the "welltempered renogram," already exist; however, no current study has assessed effect of intravenous hydration (iv) status with us in the evaluation of childhood hydronephrosis. our study assesses the effect of hydration on sfu grading. in this prospective irb approved study, pediatric patients diagnosed with pelvicaliectasis requiring a diuretic renogram were recruited to undergo pre and post hydration renal us. a urinary catheter was placed followed by renal us pre and post iv hydration ( ml/kg normal saline bolus). imaging was performed by the same sonographer on the same us machine. a well-tempered renogram was then performed. all images were reviewed by two blinded radiologists, one pediatric radiologist who assigned sfu grades to each kidney. results: data were collected from studies, with ages ranging from weeks- years, with an average age of months. there were unique patients. of these, underwent a single renogram, underwent two renograms, and underwent renograms. one patient had a solitary kidney due to mcdk. thus, there were usable paired sonograms ( kidneys) for analysis. sfu grades were compared in the pre-and post-hydration us for each kidney. two-sided statistical tests were done to assess whether sfu grades changed significantly after hydration (sign test). of ( %) kidneys remained the same grade post hydration. when there was a difference, most demonstrated an increase ( of kidneys and p< . ). no change in sfu grade pre-and post-hydration differed by more than . only kidney went from grade to grade . sfu above grade is considered clinically significant. no kidney that was grade - pre-hydration became grade - post-hydration. when sfu is dichotomized grade - vs. - , there was no significant change in grade from pre to post hydration (p ). conclusions: hydration does not appear to have a clinically significant effect on sfu grade. therefore, performance of a "well-tempered" us is unnecessary. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. study type was significantly associated with both total and weighted score (both p < . ). rus was better and mag was worse than vcug, rnc, and dmsa, which did not differ from each other. other factors associated with worse total scores included patient age - years (p< . ) and non-white race (p . ). gender, prior testing history, wait time, and parent education were not associated with total scores. in the multivariate model, rus remained the best, mag the worst, and dmsa, vcug, and rnc in the middle (p< . ). compared directly, dmsa and vcug total score did not differ (p . ). conclusions: this study documents significant differences among gui studies with respect to the patient and family experience, but there was no overall difference between dmsa and vcug. these findings may be useful to aid decision-making when considering gui for pediatric patients. we retrospectively reviewed the imaging findings of consecutive patients with histologic diagnosis of cd ( males, females; mean age . years; age range - years) who underwent mre between / / and / / . the mre was performed in a siemens avanto . tesla scanner. standard departmental volume of polyethylene glycol and fluid were administered for bowel distention. the imaging protocol included dwi with eight b values ranging between sec/mm and sec/ mm and gadolinium enhanced dynamic d vibe (volume interpolated breath hold exam) in the coronal plane. the studies were qualitatively evaluated in a blinded fashion by two board certified radiologists. disease activity was defined as bowel wall thickening and enhancement in the gadolinium enhanced images. dwi abnormality was defined as bowel thickening, increase signal on dwi images and decrease signal on adc maps of the ileum. intra voxel incoherent motion (ivim) dwi parameters were used as quantitative biomarkers for the analysis of slow diffusion (d) and fast diffusion fraction (f). results: gadolinium enhanced vibe images identified abnormal thickening and enhancement of the ileum in / ( %) patients. dwi identified abnormal signal in / ( %) patients. the sensitivity and specificity of the qualitative dwi for identifying ileitis, as shown by gadolinium enhanced imaging, were % and %, respectively. quantitative analysis showed statistically significant difference in ivim maximal values for f (fast diffusion fraction) between abnormal (mean . , std . ) and normal (mean . , std . ) ileum segments (p . ). there was statistically significant difference in ivim maximal values for d (slow diffusion) between abnormal (mean . μm /ms, std . μm /ms) and normal (mean . μm /ms, std . μm /ms) ileum segments (p . ). abnormal loops of bowel had decreased slow and fast diffusion parameters. conclusions: diffusion weighted imaging has excellent sensitivity and specificity for the detection of active ileitis in pediatric cd. furthermore, quantitative ivim model parameters provide effective biomarkers for this condition. ivim dwi has the potential to assess bowel inflammation without intravenous contrast enhancement and further increase our understanding of cd. methods & materials: forty pediatric patients (median age . years, range . - . ) with suspected (n ) or confirmed ibd (n ) were included and underwent gastroileocolonoscopy with biopsies followed by mre (median interval days, range - ). the mre results were compared with macroscopic and microscopic assessment of the ileum. the clinical importance of the mre results was registered. results: crohn disease (cd) was diagnosed in cases, ulcerative colitis (uc) in , and ibd unclassified (ibdu) in three. macroscopic ileitis was detected in / ( %) of cd cases and in / ( %) of uc (backwash ileitis). microscopic inflammation was found in another four cd cases and one ibdu patient. in total, discrepancy between macroscopic and microscopic inflammation was found in cd, uc and one ibdu patients. the sensitivity of mri was % (against macroscopy and/or microscopy) to % (against macroscopy alone), while the specificity was % and %, respectivley. mre findings was decisive for diagnosis in / ( %) and led to treatment adjustments in / ( %) in the following six months. conclusions: mre is a reliable method for imaging of intestinal inflammation in pediatric ibd, and can be supportive or essential for clinical treatment decisions. results: of children with ec, had ct imaging of the abdomen and pelvis. these children ranged in age from months to years (mean . years +/− . ) with a male predominance (n , %). the most common presenting symptoms were abdominal pain (n ), bloody diarrhea (n ), and rectal bleeding (n ). ec was characterized as a dense and predominant eosinophilic inflammatory infiltrate in the lamina propria and/or epithelium without granulomas. ct scans were abnormal in ( %). no colonic luminal contrast was present in patients, and in one of these, the colon appeared normal. abnormal ct findings included cecal wall thickening (n , %), mucosal enhancement without colonic wall thickening, (n , %), mesenteric lymph node enlargement (n , %), terminal ileal thickening (n , %), jejunal and ileal thickening (n , %), and pneumatosis (n , %). of the patients with cecal involvement, primarily involved the cecum with less severe or no ileal or downstream colonic involvement. pneumatosis extended along the length of the colon with rectal predominance. conclusions: the predominant ct finding in our ec series was wall thickening, most severe in the cecum with variable extent downstream with mild or no involvement of the terminal ileum. although there is overlap, these findings are different from the most common patterns encountered with ulcerative colitis or crohn disease and should raise the possibility of ec in children presenting with abdominal pain and bloody diarrhea. purpose or case report: timely identification of childhood arterial ischemic stroke (ais) is critical to development of acute treatment strategies. we present our experience prior to and following development of a pediatric stroke alert system (sas). through multi-disciplinary collaboration in a tertiary care setting, a pediatric sas was established in . we describe the system, imaging protocol evolution, and impact upon the time between admission and mri initiation (time-to-mri) in patients with childhood ais. of patients in our stroke database (comirb # - ), % met inclusion criteria for stroke alert initiation (acute focal neurological deficit within h). eleven pre- and nine post- patients met criteria. we compared the time-to-mri between these two groups, utilizing a two-tailed t-test. results: the pediatric sas has two phases: i-neurological evaluation and ii-imaging and treatment consideration. phase i stroke alert is initiated when a child presents with an acute focal neurologic deficit. if neurology confirms stroke symptoms and ct head is negative for an alternative etiology, a stroke alert is called prompting an emergent brain mri. if mri confirms an acute stroke, hyperacute therapies are considered. initial mri protocol included dwi, t , flair, d tof cow mra, d tof neck mra and fat saturated t neck imaging. after internal quality review, t mprage brain and contrast enhanced d neck mra were added. the sequence order was also altered so diagnostic sequences were scanned first (dwi and cow mra). there was a trend towards decreased time-to-mri in the post- group (mean min, sd +/− ) as compared to the pre- group (mean min, sd +/− ; p . ). conclusions: institution of a pediatric sas improved urgent neurologic evaluation and demonstrated a trend towards shorter time-to-mri. ongoing quality review has enhanced imaging quality and decreased time-to-mri. continued refinement of pediatric sas's will be critical to the success of recently funded phase i clinical trials in the evaluation of hyperacute therapies. results: there were female and male infants. the mean post-gestational age at presentation was days (range - days), while the corrected age was less than days for all patients. patients presented with seizures and signs of infection; presented with lethargy and later proved to have protein c deficiency. mri was performed - days from presentation in these patients. another patient with known protein c deficiency underwent mri at d for followup of screening us abnormalities. there were a total of deep cerebral white matter lesions: frontal, parietal, temporal lobe. lesions were fluid signal cavities with restricted diffusion. larger lesions had dependent debris. all lesions had associated hemorrhage and most lesions had evidence of adjacent small vessel venous thrombosis. lesions imaged after gad showed peripheral enhancement. three lesions were seen to increase in size on follow-up imaging. three patients, with meningitis confirmed via microbiology and with presumed meningitis by csf counts, underwent surgical aspiration of a total of lesions. all specimens were sent for pathology and culture and were negative for microorganisms. conclusions: recognizing the mr appearance of necrosis and liquefaction after deep white matter cerebral venous infarction in neonates can distinguish this entity from cerebral abscess and potentially avoid an unnecessary neurosurgical aspiration procedure. all four children were initially treated with aspirin but experienced recurrent events on therapy. all four were subsequently anticoagulated. two children have remained on warfarin for - years without recurrent events, while the other two had recurrent events despite adequate anticoagulation. these two children underwent uncomplicated coil embolization of the affected vertebral artery segment, and they have remained symptom-free for five and months since then. conclusions: dava was diagnosed by ca in / patients. all four children with dava in our series suffered recurrent strokes despite aspirin therapy. two of the four experienced further strokes on anticoagulation, necessitating endovascular therapy. these findings suggest that dava in children may require ca to diagnose, and that it may be refractory to standard adult therapies. ongoing multicenter efforts in childhood ais should further evaluate the diagnostic approach and recurrence risk of childhood dava. ) and cerebral gray matter abnormalities were present in ( %). posterior fossa lesions were seen on us in . % , but mastoid views were included in only % of the centrally read us. conclusions: in the largest extreme preterm cohort to date with near-term mri and serial us, % had mod-severe wma on brain mri, similar to previous reports. cerebellar abnormalities were detected more frequently by mri than by us. neurodevelopmental outcomes at - months and school age will assess the relative and combined values of mri and us as outcome predictors. , an analysis technique based on task-free resting state fmri recording, can be useful in assessing disruption of connectivity in certain disease states, including epilepsy. in healthy control subjects, functional connectivity reveals strong bilateral interhemispheric connectivity in such system as sensory-motor, visual, auditory as well as dorsal attention and default mode networks. in patients with epilepsy associated with unilateral diffuse hemispheric disease such data is limited. differences in the pattern of activation would suggest alteration in connectivity in these entities. this finding would impact the typical interpretation of this data that is becoming routinely collected for epilepsy pre-surgical evaluation. methods & materials: siemens (erlangen, germany) system, -tesla (trio) scanner was used for imaging (epibold sequence, te ms, flip angle °). resting state fmri scan were performed in both awake and anesthetized patient. awake patients were instructed to relax and rest while keeping their eyes open. analysis was performed using functional connectomes project scripts based on afni and fsl software packages. resting state data were analyzed for connectivity with the following seeds: somatomotor, visual, auditory, and default mode (posterior cingulated cortex (pcc)). results: we applied this technique to evaluate patients with hemispheric seizure disorders, including rasmussen's, neonatal infarct and migration disorders. all the subjects demonstrated some deviation from typical interhemispheric connectivity with a spectrum of findings. the figure below shows connectivity patterns in a patient with cortical dysplasia. while some interhemispheric connectivity remained in somatomotor (sm) and auditory (a ) systems, it was disrupted in visual (v ) and default mode (pcc) networks. variable patterns were found across the cases that corresponded to lesion side, supportive of disruption in interhemispheric connectivity as measured by fmri. conclusions: resting state functional connectivity patterns are well documented in healthy subjects. these results suggest that interhemispheric connectivity disruption is a typical feature of unilateral diffuse hemispheric disease though variable in presentation, either being limited to select systems or demonstrating broad disconnect between the two hemispheres. these results should be carefully considered when evaluating data for pre-surgical epilepsy evaluation. purpose or case report: premature birth is associated with white matter injury leading to a wide ventricular system. however,normative standards for ventricular size are lacking for this particular group.aims: we aimed to, in a controlled, population based norwegian cohort of ex-prematures without major handicaps, and for men and women separately,to ) create standards for radiological indices of ventricular dilatation, )investigate associations of these measurements with subjectively assessed ventricular size, ) examine differences in ventricular size between ex-prematures and healthy controls methods & materials: the initial birth cohort included neonates, birth weight below g (low birth weight)born within hordaland county, norway, between april st and august th . of eligible survivors (without major handicaps)underwent mr examination during the period january to may . of these were expremature (born before gestational age weeks) and were included in this sub-study. based on t weighted images, the ventricular size was subjectively judged as being normal, mildly, moderately or severely dilated by an experienced paediatric neuroradiologist, while objective measurements were performed in a blinded fashion, by a second observer (sma) using an imaging software program (nordic ice®). results: the normative standards for the ventricular system in ex-premature young adults showed wide variations, in particular for the occipital horns. the agreement between subjective and objective assessment of ventricular size was good. ex-prematures had smaller heads than those born term (control group). there was no difference in ventricular size between the two groups, even after adjusting for head size. ex-premature males had larger ventricles than females; however, the difference disappeared after adjusting for head size. conclusions: young adults born prematurely with a birth weight below g do not have larger lateral ventricles than healthy controls born term, even after correcting for a smaller head size. paper #: pa- best practice for reproducibility when measuring t *: implications for liver and cardiac iron assessment mark ferguson, md, radiology, seattle children's hospital, markferg@uw.edu; randolph otto, seth d. friedman purpose or case report: patients with red blood cell transfusion-dependent conditions receive high amounts of iron that can lead to abnormal iron accumulation in tissues resulting in organ damage. while the liver is the dominant excess iron storage organ, iron related cardiotoxicity is a leading cause of morbidity and mortality in patients with transfusion-dependent thalassemia. therefore, accurate determination and tracking of tissue iron levels in both the liver and the myocardium is important for patient prognostication as well as monitoring treatment changes. while multi-echo gradient echo mri (t *) is widely used and validated method employed for iron assessment, less attention has been given to derived metrics. specifically, the literature almost exclusively reports and uses the mean value for t * from a pixel-wise (pw) map. infrequently used is the median. the median is a potentially superior metric than the mean because it is insensitive to outliers. outliers will always occur in data because of either noise or imperfect vessel exclusion. to compare mean versus median on reproducibility of t * measurement, subjects who had paired heart/liver measurements were examined. the entire liver (excluding vessels) and the interventricular septum myocardium were traced on representative images from each series. mean and median t * values were generated from the pixel maps. r * ( / t *) and coefficient of variation (cv) were computed on a patient-by-patient basis. these measures were then summarized for the group. results: markedly higher r * values were observed in both heart and liver using median summary measures (liver: t − . , p . , heart: t − . , p . ). these findings were accompanied by lower cv's (better reproducibility) for the median approach (liver: t . , p . ; heart: t . , p . ). conclusions: the consistent difference in derived t * values between the methods (median>mean) should be considered when comparing derived r * values to established normal ranges. cv data support that using the median as the final summary metric will always outperform mean metrics for measuring change in r *. this finding has immediate implications for the scientific literature and for guiding therapeutic management over time. results: twelve children (age mo- yo; m:f : ) with gsds ( abca mutations, sp-c mutations, undefined mutation) and children (age wk- yo; m:f : ) with other dlds (including pulmonary interstitial glycogenosis, neuroendocrine cell hyperplasia of infancy, lymphocytic interstitial pneumonia, lipoid pneumonia, diffuse alveolar damage, granulomatous infection, capillaritis and other pulmonary hemorrhage syndromes) were identified. ct findings with highest sensitivity for gsds were ground glass attenuation ( %), parenchymal cysts ( %), and interstitial thickening ( %). parenchymal cysts, honeycombing, and pectus excavatum were more specific for gsds compared to other dlds (p< . ). the combination of either parenchymal cysts and honeycombing or ground glass attenuation and pectus excavatum provided the highest specificity ( %) but low sensitivity ( %). the combination of parenchymal cysts and ground glass attenuation provided good specificity ( %) and modest sensitivity ( %). no combination of findings provided both high sensitivity and specificity. conclusions: ground glass attenuation is the most sensitive finding for gsds, while parenchymal cysts, honeycombing, and pectus excavatum are more specific findings for gsds than other chronic dlds of childhood. however, no single finding or combination of findings on chest ct is both highly sensitive and specific for gsds, and chest ct cannot substitute for genetic testing or lung biopsy for the differentiation of gsds from other dlds. pes were observed in scans of patients without a history of congenital heart disease (chd), and pes in scans of patients with a history of chd. z-axis scan lengths for the chest ct exams ranged from . - . cm. a z-axis scan length of cm centered . cm below the carina captured all pes in all patients, and a length of cm centered . - cm below the carina in patients with chd. a z-axis scan length of cm centered cm below the carina was sufficient to capture at least one pe in all patients, and a length of cm centered - cm below the carina in patients with chd. the radiation effective dose of the chest ctpa exams ranged from - msv. limiting the z-axis scan length on ctpa exams to cm or cm would have resulted in a % or % decrease in z-axis coverage, respectively, and estimated radiation effective dose reduction of - % due to less radiation exposure to the intrathoracic structures, thyroid gland and upper abdominal viscera. conclusions: limiting the z-axis scan length coverage for ctpa exams based on a model of the typical anatomic distribution of pes relative to the reference level of the carina permits a substantial reduction of radiation dose in children without reducing the sensitivity for detection of pulmonary emboli. purpose or case report: to determine whether the addition of multiplanar reformation mdct images affects reader performance parameters and provides added diagnostic value compared to the use of axial ct mdct images alone for diagnosing pe in children. this was an institutional review board-approved retrospective study of consecutive pediatric patients who underwent ctpa for clinically suspected pe. two faculty pediatric radiologists and two radiology residents independently reviewed each study initially using only axial mdct images and later using mpr mdct images in any x-, y-, or z-axis for detecting pe. diagnostic accuracy, confidence level, and interpretation time of mpr mdct images were compared to axial mdct images using mcnemar's test and paired t-tests. the kappa coefficient was calculated to assess interobserver agreement. diagnostic accuracy was compared between faculty pediatric radiologists and radiology residents by logistic regression whereas confidence level, interpretation time, and added diagnostic value were evaluated with analysis of variance (anova). results: the final study cohort consisted of ctpa studies from children ( m/ f; mean age . years). nine ( %) of ctpa studies were found to have pe. diagnostic accuracy in correctly detecting pe ranged from . to % (mean . %), with no significant differences between the use of axial and mpr mdct images. logistic regression indicated no significant difference in diagnostic accuracy of detecting pe between faculty pediatric radiologists and radiology residents for axial mdct images (p . ) or mpr mdct images (p . ). confidence level and interobserver agreement were significantly higher and average interpretation time was longer in evaluating pe with mpr mdct images compared to axial mdct images for all reviewers (p<. ). compared to faculty pediatric radiologists, significantly greater increases in confidence level, interobserver agreement, interpretation time, and added diagnostic value using mpr mdct images compared to axial mdct images to diagnose pe were found for radiology residents (p< . ). conclusions: use of mpr mdct images in diagnosing pe on ctpa in children significantly increases confidence, interobserver agreement, and interpretation time among faculty pediatric radiologists and radiology residents. because mpr mdct images provide significantly greater improvements in reading parameters for residents than for faculty members, their routine use should be encouraged for trainees. paper #: pa- chest ct in children, anesthesia and atelectasis beverley newman, md, radiology, stanford university, bev.newman@stanford.edu; elliot krane, terry e. robinson purpose or case report: in spite of advances in ct equipment and speed, sedation/ anesthesia is required in many young children for optimal quality ct for detailed parenchymal evaluation; resultant atelectasis is a common and important quality issue. our purpose was to evaluate the safety and effectiveness of a standardized lung recruitment technique. methods & materials: with irb approval and parental informed consent, controlled ventilation, low dose, chest ct's (cooperative effort between anesthesia, pulmonology and radiology) were performed in children ( had - cts) ( f, m; ages . - . yrs, mean . yrs). indications included cystic fibrosis ; ciliary dyskinesia ; chronic or interstitial lung disease ; evaluate pulmonary metastases . ct parameters were - kvp, - mas, iv contrast . various prior methods employed by the pediatric anesthesiologists to maintain lung inflation had unpredictable results (a brief survey showed / nonintubated anesthetized cases had problematic atelectasis). a standardized intubation technique was therefore adopted: .use of a tight fitting face mask during induction and iv placement, inspiratory pressures of - and peep of . . introduction as early as possible using an appropriately sized cuffed endotracheal tube. . alveolar recruitment maneuvers- - s breaths to cm h o/ ( - in st cases). . three breaths at / , inspiratory breathold followed by - cm on th breath for scout and inspiratory scan, and complete ventilator disconnection for expiratory scan. recruitment breaths repeated before each scan. two experienced readers reviewed and scored the images on a point scale for overall quality and atelectasis. results: all studies were completed safely with no procedural complications. one child had propofol-related postoperative emergence delirium. all ct scans were diagnostically good to excellent with small subsegmental atelectasis in ( / were the initial cases with lower recruitment pressures) and segmental atelectasis in . cases had prior cts, without this technique, that were suboptimal due to moderate procedural atelectasis, in spite of tracheal intubation in the majority of cases. conclusions: an intubation lung recruitment technique can be performed safely and consistently by different individuals using a standardized protocol. procedural atelectasis that affects quality is reliably absent and repeat sequences are not needed. obtaining a high-quality dynamic airway imaging study is critical for accurate interpretation and subsequent medical decision-making. the ideal mri sleep study is one that allows successful completion while maintaining spontaneous breathing without artificial airway, which can be an anesthesia challenge. dexmedetomidine has been shown to have sedative properties paralleling natural sleep with minimal respiratory depression. we hypothesized that dexmedetomidine compared to propofol would have less effect on upper airway tone and airway collapsibility and provide favorable conditions with less airway interventions required during dynamic mri airway imaging in children with osa. in this prospective study, we examined the requirement for airway intervention for propofol ( - mcg/kg/m) and dexmedetomidine( - mcg/kg/h) in children and adolescents with osa. severity of osa was analyzed by overnight polysomnography. for children with history of mild osa there was no intervention unless oxygen saturation decreases below %; while for children with history of moderate/severe osa, an artificial airway was placed when oxygen saturation decreased below %. results: demographics and osa severity by polysomnography were comparable. requirement for artificial airway by severity of osa as documented by polysomnography will be shown. mri sleep studies required airway intervention in / ( %) children in the dexmedetomidine group versus / ( %) children in the propofol group. mri sleep studies were successfully completed without the use of artificial airways in children ( %) in the dexmedetomidine group versus children ( %) in the propofol group. conclusions: safe and effective anesthetic management is a key factor in obtaining good quality mr images of the airway. although there was no statistical significant difference in the need for airway intervention between drugs, dexmedetomidine provided acceptable sedation for mri sleep studies with less airway intervention in children with osa. dexmedetomidine may be the preferred agent for sedation during mri sleep studies in children, and may offer benefits to children with sleep disordered breathing requiring anesthesia or sedation for other diagnostic imaging studies. an open mouth and administration of cpap resulted in smaller ap diameter of the retroglossal airway compared to images without cpap due to cpap pressure pushing the tongue posteriorly. in patient volume of oral cavity anterior to the tongue increased from . ml to . ml. meanwhile, the ap diameter of the retroglossal airway decreased from . to . mm ( % decrease). in patient the mouth was initially closed but parted when the pressure of cpap was added with the oral volume increasing from . ml to . ml. the ap measure of the retroglossal airway decreased from . mm to . mm ( % decrease). in patient the mouth was then closed and cpap reapplied resulting in an ap measurement of . mm ( % increase). the ap diameter difference between cpap and no cpap were tested with paired t-test, but were not statistically significant (p . ). conclusions: positive airway pressure on a patient by full facemask and an open mouth can have an adverse effect on the retroglossal airway. this adverse effect is an important consideration in the use of positive airway pressure to support airways for osa, or during emergency resuscitation when a full facemask is used. paper #: pa- the purpose or case report: a nanoparticle blood pool iodinated contrast agent (nctx) has been designed and tested in preclinical animal models. we report data in animal models exemplifying its advantages over conventional contrast in the setting of ct pulmonary angiography methods & materials: nctx blood pool nanoparticles of nm diameter with an encapsulated total iodine concentration of~ mgi/ml were administered by intravenous injection to mice, rabbits, dogs, pigs and sheep. (these studies were actually conducted for other purposes and a review of the data revealed the similarities that motivated this paper.) total injected volumes were~ ml/kg in large animals, and as high as ml/kg in small animals to provide satisfactory vessel enhancement. iohexol or iopamidol was administered for comparative studies with conventional contrast. in a subset of pigs, iatrogenic pulmonary arterial emboli were introduced prior to contrast administration. toxicity studies were conducted in mice and monkeys. results: the visualization of pulmonary vessels using nctx blood pool nanoparticles was generally at least equivalent to using conventional contrast, and superior in several cases, particularly in small veins and when bolus timing of the conventional contrast was suboptimal. in all cases, satisfactory vessel enhancement was achieved for a duration of several hours following a single infusion of nctx blood pool nanoparticles. there was no evidence of renal toxicity, and only transient elevation of hepatic enzymes at relevant dose levels. conclusions: nctx nanoparticle blood pool agents demonstrate several advantages over conventional glomerularfiltered iodinated contrast agents for ct pulmonary angiography in animal models, including no nephrotoxicity, no dependence on bolus injection technique, superior depiction of small veins, and capability of re-imaging for follow-up studies without needing contrast re-injection. potential applications in human pediatric subjects include the diagnostic and post-therapeutic evaluation of cardiopulmonary anomalies and pulmonary embolism, especially in patients with renal insufficiency or tenuous vascular access. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- cardiovascular image quality using a nanoparticle ct contrast agent: preliminary studies in a pig model rajesh krishnamurthy, radiology, texas children's hospital, rxkrishn@texaschildrens.org; ketan ghaghada, prakash masand, abhay divekar, eric hoffman, ananth annapragada purpose or case report: image quality in a separate study using a long circulating, liposomal-based nanoscale blood pool iodinated contrast agent (nctx) suggests clinical utility in pediatrics, potentially reducing difficulties in contrast-ct of children with congenital heart disease (chd) including the size of intravenous cannula, need for accurate timing, inability to simultaneously opacify multiple targets of interest (requiring repeated contrast administration and/or repeated imaging). methods & materials: six pigs (average weight kg) were imaged after slow intravenous infusion of nctx ( mg i/ml) at an iodine dose of approximately mg i/ kg ( . ml/kg). retrospective ekg gated ct imaging was performed h later using a -slice dual-source ct scanner at and kvp. two radiologists analyzed and graded (on a -point scale with : unreadable, : excellent) images aimed at anatomic structures relevant to chd. quality of images obtained at and kvp were compared. uniformity of contrast opacification was measured using a roi-based ctnumber method at various intracardiac and extracardiac sites and mean non-uniformity was calculated. results: there was excellent agreement between the two readers on all counts at kvp. kvp images received lower scores for coronary morphology ( / ), and aortic valve visualization ( . / ), but were comparable in other aspects. pulmonary artery and pulmonary vein branch visualization extended up to the th generation in all cases. visualization of coronary artery branches was possible up to the second generation, with good arteriovenous separation. subtle morphologic features including crista terminalis, thebesian valve, foramen ovale, membranous septum, and chordae of the mitral valve were demonstrated in all cases. automated functional analysis and myocardial mass quantitation was feasible in all cases. there was no significant difference in blood pool attenuation between the atria, ventricles, and extracardiac vasculature on quantitative assessment. no image artifacts were visible on the reconstructed images. conclusions: these findings suggest that nctx promises to be superior to conventional contrast agents for ct imaging of complex congenital heart disease, due to the absence of nephrotoxicity, avoidance of repeated contrast administration, and reduced number of scans performed. avoiding the need for accurately timed scans precludes the need for large bore intravenous access. these attributes make it a promising agent that warrants further studies. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- theoretical cost and x-ray dose reduction in pediatric congenital heart disease imaging by the use of a nanoparticle contrast agent robert bell, the university of texas-houston; rajesh krishnamurthy, gabriela espinosa, christopher petit, ananth annapragada purpose or case report: the purpose of this study is to determine the effective, population averaged reduction in costs and radiation dose that can be achieved in the diagnosis of congenital heart disease by use of a nanoparticle long circulating blood pool contrast agent. methods & materials: a markov model of the decision tree followed at the texas children's hospital in the image based diagnosis of congenital heart disease was constructed in treeage software. the model included ct angiography, mr angiography, cardiac catheterization, and echocardiography diagnostic modalities. patient records, accumulated between and were examined to inform the model. the radiation dose and cost for each step were encoded as penalty functions. markov simulations were run for two decision trees: ( ) utilizing ct angiography and ( ) replacing conventional ct angiography with blood-pool agent based ct angiography. the overall population x-ray dose and accrued cost was calculated for each pass through the model. results: x-ray dose distributions for the example populations showed substantial reductions per ct study, as much as %. averaged over the population, since a sizeable fraction of patients are diagnosed without ever being exposed to any x-ray based modality, reductions were more modest, but still substantial. costs per ct study were slightly higher when the blood pool contrast agent was used. when the diagnostic probability using the blood pool agent increased, it led to an automatic overall cost reduction. conversely when the diagnostic probability remained unchanged, costs rose, commensurate with the increased cost of the contrast agent. conclusions: the use of a blood pool contrast agent for ct angiography leads to substantial reduction in radiation dose in the setting of congenital heart disease. cost reductions are more modest, and are driven almost completely by the reduction in the number of mr and invasive angiography procedures resulting from increased diagnostic success using blood pool based ct angiography. the model as constructed does not account for potential workflow changes that might result from the use of a new contrast agent. actual reductions realized may therefore be higher. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa- frequencies and patterns of situs discordance in chest and abdomen justin boe, stanford, justinj.boe@gmail.com; beverley newman, shreyas vasanawala, frandics chan purpose or case report: incidence of situs anomalies, including heterotaxy and situs inversus, is estimated at . % of population. as the first step in the segmental analysis of structural heart disease, the determination situs position is of fundamental importance. abdominal situs, as defined by splenic position and morphology, and cardiac situs, as defined by atrial morphology, are usually but not always in agreement. echocardiographers also employ the relative position of the great arteries and vein at the hiatus to determine cardiac situs. we evaluate the frequencies of discordances among abdominal, hiatal and cardiac situses. methods & materials: with retrospective irb approval, imaging records from to were reviewed for the diagnosis of cardiac situs inversus and heterotaxy. patients who had cardiac ct or mri were included. images were evaluated on a d-processing station by a cardiac radiologist. cardiac situs was determined by the morphology of the atrial appendages. when an atrial appendage was not adequately visualized, cardiac situs was assessed by the relative position of the main pulmonary artery and bronchi. hiatal situs was determined by the relative position of the aorta and the systemic venous return, and abdominal situs by the position and morphology of the spleen. results: thirty-five cases were identified, with cardiac ct and mri. patients' age ranged from day to years old. in the abdomen, the numbers of situs inversus, asplenia, and polysplenia were ( %), ( %), and ( %). for the heart, the numbers of situs solitus, inversus, rightisomerism, and left-isomerism were ( %), ( %), ( %) and ( %). the abdominal and cardiac situses were discordant in ( %) cases. polysplenia had the highest number of discordance with the heart. hiatal situs was discordant with the abdomen in cases ( %) and with the heart in ( %) cases. conclusions: situs disagreement between the abdomen and the heart is not uncommon and they should be documented separately in radiology reports. hiatal situs, as used by echocardiographer, disagrees with the cardiac situs in a quarter of the cases. it should be used with caution in the segmental analysis. paper #: pa- diminished asl intracranial perfusion in children with neurofibromatosis type kristen yeom, md, stanford university, kyeom@stanford. edu; cynthia campen, patrick barnes purpose or case report: neurofibromatosis type (nf ), a neuro-cutaneous syndrome affecting / children is associated with moyamoya syndrome (mms). however, no comparisons of cerebral perfusion in patients with nf and nf -associated mms to healthy controls exist. we hypothesize cerebral blood flow (cbf), as measured by magnetic resonance imaging (mri) arterial-spin-labeled (asl), is diminished in children with nf compared to healthy controls, with the lowest levels seen in patients with nf -associated mms. methods & materials: twenty children aged - years with nf , four with mms, and age-matched controls underwent asl cbf on a t magnet. pseudocontinuousspin-echo-asl technique was used. measurements were taken bilaterally in cerebral cortical-subcortical regions, and the deep gray nuclei. trends in measurements as a function of disease severity were tested with the jonckheere-terpstra test for ordered alternatives. a bonferroni-adjusted p-value less than . was considered significant. results: we identified / areas with significantly diminished asl cbf (ml/ g/min) in patients with nf (midrange), and nf -associated mms (lowest) compared to healthy controls (highest). these included the: thalami (left: p . , right: p . ); superior/middle temporal lobes (left: p . , right: p . ); temporooccipital lobes (left: p . , right: p . ); occipital poles (left: p . , right: p . ); centrum semiovale (left: p . , right: p . ); and left parietal lobe (p . ). conclusions: cerebral perfusion diminishes in a graded fashion in children with nf and nf -associated mms, particularly in the posterior circulation and the mca-pca posterior watershed zones. future studies may demonstrate an important role for asl in the presymptomatic diagnosis of cerebral vasculopathy, and the definition of nf -related vasculopathy patterns. paper #: pa- cingulate gyrus mri sign in pediatric nf patients: a novel imaging marker nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; nabila hai, rhea udyavar , amir noor, gilbert l. vezina, maria t. acosta purpose or case report: we observed a magnetic resonance imaging (mri) signal abnormality in the anterior cingulate gyrus of pediatric patients with neurofibromatosis type (nf ). the cingulate gyrus could play a role in cognitive deficits of nf patients. the first objective here is to document inter-rater reliability scores for visual detection of this sign. the second objective is comparing adc values of the cingulate gyrus in areas of visually abnormal mri signal in nf patients to matched normal mris to confirm a pathophysiological basis of the visual mri sign. methods & materials: retrospective analysis, irb approved, nf patients and matched controls. in the visual assessment part, two blinded neuroradiologists rated presence or absence of mri signal abnormality in the cingulate gyrus in three different age groups of nf patients mixed with normal controls. cohen's kappa inter-rater reliability coefficients were calculated. the same blinded neuroradiologists evaluated the cohort one year later, this time by agreement at the workstation. in the adc measurements part, two researchers, one blinded, manually placed roi's in the anterior and posterior cingulate regions of nf patients and their matched controls, and student t-test was used to assess for significance of differences in measured values. results: cohen's kappa for the three age groups showed very good agreement (kappa coefficients were either . or . ). rater agreement at the workstation was %. all subjects with a positive finding also had nf and the sign was not seen in any of the normal controls. the prevalence of the sign was %. adc measurements showed significantly higher adc values in the anterior cingulate gyrus of nf patients when compared to normal controls and also when compared to the posterior cingulate gyrus in nf patients. conclusions: our results show that visual t /flair mri abnormalities in the anterior cingulate gyrus are present in % of patients with nf from ages to years. adc measurements confirm a pathophysiological basis for this finding. future correlation with clinical manifestations, such as learning and behavioral manifestations in patients with nf , are under way to further evaluate the clinical importance of this finding. tract-based spatial statistical analysis of diffusion tensor imaging in pediatric patients with mitochondrial disease seth friedman, phd, seattle children's, seth.friedman@ seattlechildrens.org; andrew v. poliakov, sandra l. poliachik, dennis w. shaw purpose or case report: often diagnosed at birth or in early childhood, mitochondrial disease presents with a variety of clinical symptoms, particularly in organs and tissues that require high energetic demand such as brain, heart, liver, and skeletal muscles. in a group of pediatric patients identified to have complex i or i/iii deficits, but with white matter tissue appearing qualitatively normal for age, we hypothesized that quantitative dti analyses might unmask deficits in microstructural integrity. methods & materials: dti and structural mr brain imaging data were collected in pediatric patients with confirmed mitochondrial disease and clinical control subjects matched for age, gender, scanning parameters, and date of exam. paired tract-based spatial statistics (tbss) were performed to evaluate differences in fractional anisotropy (fa) and mean diffusivity (md). results: in patients with mitochondrial disease, significant widespread reductions in fa values were shown in white matter tracts. md values were significantly increased in patients, having a sparser distribution of affected regions compared to fa. results of tbss statistical analysis will be shown. to be shown in green is the mean fa skeleton which represents the centers of main white matter tracts. all results p<. . red and yellow represent a significant increase, blue and light blue represent a significant decrease. conclusions: despite qualitatively normal appearing white matter tissues, patients with confirmed mitochondrial disease have widespread microstructural changes measurable with quantitative dti. this supports the evaluation of such metrics in other populations where gross imaging features may be normal. to extend our studies to patients with other plp mutations, we analyzed the brains of male pmd patients (ranging in age from to ) and female carriers for whom the plp genotype had been determined and analyzed by mri. for each patient we measured, white matter volume (wmv) and the intercaudate distance (icd). the mri data were correlated with functional disability scores (fds) using a system we developed for clinical evaluation of pmd patients and which was validated by assessments of pmd patients. brain volume and segmentation were measured using nih image . . the average number of coronal slices analyzed from each patients mri was slices. when graywhite contrast was not adequate, then the intercaudate distance (icd) and intercaudate ratio were measured as described in caon et. al., ( ) . results: comparison of the mr measurements and the fds demonstrated that white matter volume inversely correlates with functional disability, suggesting that the initial disability does correlate with the extent of myelination. the intercaudate distance also correlated with the fds, and may usefully substitute when gray-white matter segmentation is not possible. conclusions: pmd is a clinically and genetically heterogeneous disease caused by mutations in the gene encoding the major cns myelin protein, proteolipid protein (plp). myelin is a major target of disease pathogenesis in most cases of pmd, but how the various mutations cause clinical disability is not fully understood. our data demonstrate that the extent of brain white matter atrophy, measured directly by volumetric fractionation, or indirectly by analyzing the intercaudate ratio, is significantly correlated with the patient's functional disability. white matter atrophy is thus the main cause of clinical disability in patients with pmd of all ages and mutation type. paper #: pa- maturational effects on language localization in children demonstrated by fmri susan palasis, md, children's healthcare of atlanta at scottish rite, spalasis@yahoo.com; binjian sun, laura l. hayes, richard a. jones purpose or case report: language localization is of paramount importance when contemplating surgery in children with intractable epilepsy or brain tumors. the potential risk of injury to language centers in the developing pediatric brain needs to be weighed against the potential benefits of surgery. in the past, language localization was crudely and invasively determined using the wada test. most institutions are now transitioning to non invasive localization using functional mri (fmri). the purpose of our study was to analyze language localization relative to age in children using age appropriate language paradigms and fmri. methods & materials: forty three healthy, english speaking, right handed children underwent fmri evaluation for language localization. the studies were performed on a t system. three novel age appropriate language block paradigms were utilized, targeted both to expressive and receptive language processing. these paradigms were the auditory category decision task (audcat), the auditory description decision task (addt), and the listening task. the spatial statistical maps generated by the fmri data were fused to the d anatomical mri dataset. language areas were localized and statistical analysis was performed with age as the variable in a general linear model. results: our results demonstrate a distinct trend in language localization and lateralization with brain maturation. in the young age groups (less than years) the localization tended to be less focused and bilateral in the frontal and temporal regions of the brain. in the older age groups (greater than years), language became more localized and lateralized to the expected left sided pattern. the findings were more robustly demonstrated with the addt task and were statistically significant (p< . ). conclusions: our study clearly demonstrates the plasticity of language centers in the maturing pediatric brain. this observation is significant for neurosurgical planning and rehabilitation in the pediatric population. ( ) no slc a mutations were found in , and subjects, respectively. significantly higher association with slc a mutations was found in bilateral eva+v/c dysplasia ( / ). double mutations of slc a is more often associated with combined eva+ v/c dysplasia, while a single mutation with eva only. cochlear aplasia without eva ( / ) and snhl with normal imaging ( / ) are less likely associated with slc a mutation. conclusions: slc a mutation is highly associated with eva and v/c dysplasia. once eva with or without v/c dysplasia are found at imaging, genetic investigation is recommended for slc a mutation because of possible thyroid involvement. moderate-severe hie who were randomized to cooling ( . °c for h). there were in the hypothermia group and in the control group. all mris were reviewed by a cental reader masked to the clinical findings, groupings, and outcomes. the mri findings were scored according to pattern and extent of injury, including involvement of the cerebral hemispheres, basal ganglia, thalami, internal capsules, and other structures. brain injury scores were correlated with death or disability at months postnatal age. results: no mri abnormalities were observed in of infants ( %) in the hypothermia group and in of infants ( %) in the control group (p . ). infants in the hypothermia group had fewer areas of injury ( %) as compared with the control group ( %, p . ). there were of the infants with death or disability at months. the brain injury score correlated with outcome of death or disability (p . ) and disability among survivors (p . ). conclusions: fewer areas of brain injury on mri were observed following whole-body hypothermia. the mri brain injury score is a marker of death or disability at months following hypothermia for term hie. . presence or absence of the "red dot" on fa color maps was correlated to clinical (ataxia, oculomotor abnormalities etc.) and morphological data, and to fa and md measurements. results: the "red dot" was absent in js and hgpps (genetic cross wiring impairment diseases) and present in coma and wvs (no reported gene abnormalities so far) as in normal controls. js and coma presented on mri molar tooth appearance. hgpps presented "split pons" appearance. js and coma patients presented oculomotor apraxia, wvs and hgpps palsy of the horizontal gaze. mirror movements were found in js and in wvs. ipsilateral responses are present in hgpps. wvs presented multiple cranial nerves impairment. in js, fa and md values of scp, pt and pc were significantly lower than in normal controls (p > . ). in hgpps high fa and low md were found in pc and pt (p > . ) and normal in scp. conclusions: the "red dot" absence is unrelated to morphological or clinical abnormalities. absence of the "red dot" is associated to abnormal measurements of fa and md in pc and pt( low in js and high in hgpps). these findings indicate a pivotal role for the pc in the physiopathology of these diseases. the "red dot" absence seems to be a marker of genetic cross wiring diseases. in this view, coma and wvs should not be considered as part of these diseases. sonographic predictors of intermittant testicular torsion in the pediatric patient jennifer williams, md, pediatric radiology, texas children's hospital, jlwilli @texaschildrens.org; marthe munden purpose or case report: intermittent testicular torsion (itt), defined as sudden onset unilateral scrotal pain with spontaneous resolution, is difficult to confirm both clinically and sonographically. the purpose of this study was to determine if sonographic predictors exist for diagnosing itt in the pediatric patient. methods & materials: a search of the pacs data system for patients presenting with suspected intermittent testicular torsion was performed. fifteen patients with a total of episodes presenting over a year period were found. a retrospective review of the medical records for clinical presentation, surgical outcome, and comorbidities was performed. scrotal ultrasound images and reports were reviewed for testicular size and echotexture, testicular flow, epididymal appearance, vascular bundle appearance, and presence of hydrocele. results: an abnormal appearance of the vascular bundle was found in % of episodes ( / ). initial absence of testicular flow followed by reperfusion during the scan was seen in % of episodes ( / ); % had increased flow ( / ), % had decreased flow ( / ), and % had normal flow ( / ) . nine of the patients had surgery; of these were found to have evidence of itt and was found to have acute testicular torsion. of patients with itt, % ( / ) had an abnormal vascular bundle. testicular flow was not initially visualized but returned during the exam in % of patients ( / ), was increased in % of patients ( / ) and was decreased in % patients ( / ). conclusions: itt is a difficult diagnosis. the most reliable sonographic indicator is an abnormal spermatic cord, found in % of episodes and % of surgically proven itt. dedicated views of the spermatic cord must be obtained in order to differentiate an abnormal epididymis from an engorged vascular bundle (the so-called pseudomass). attention to testicular flow is of particular importance. while visualization of a transition from no or decreased testicular flow to normal flow during the sonogram is certainly diagnostic of itt, increased testicular flow should not lead to false reassurance. purpose or case report: testicular torsion is a common acute condition in boys requiring prompt and accurate diagnosis. the objective was to evaluate ultrasound accuracy and findings, and clinical predictors in testicular torsion in boys presenting to the stollery pediatric emergency department (ed) with acute scrotal pain. methods & materials: retrospective review of us, surgical and ed records for boys aged month to years, presenting with acute scrotum from to , was performed. age, demographics, clinical symptoms, physical findings, us and surgical techniques, findings and diagnoses were recorded. surgical results and follow-up were used as the gold standard as all pediatric urology in our region is performed at our centre. results: patients presented to ed with acute scrotum with the following diagnoses: testicular torsion, possible torsion-detorsion, torsion of appendix testes, epididymo-orchitis, and other. of us performed, boys had torsion confirmed by surgery. there were inconclusive us reports, none of which had torsion at surgery or follow-up. the false positive rate of us was . % ( patients), and there were no false negatives. six torsion patients had no us. median time from ed to us and surgery for torsion patients was and min. six patients had non-salvageable testes. diagnostic accuracy of us compared to surgery was % for torsion and % for other. sonographic heterogeneity was seen in % of patients with testes that the surgeon felt were non-viable at surgery and % of patients with viable testes (p . ). sudden-onset scrotal pain ( %), abnormal position ( %) and absent cremasteric reflex ( %,) were most prevalent in torsion patients. conclusions: color doppler us is accurate and sensitive for diagnosis of torsion in the setting of acute scrotum. despite heterogeneity on pre-operative us, many testes were felt to be salvageable at surgery. rate of salvage of torsion was high. common symptoms and findings of torsion were sudden onset of pain, abnormal testicular position and absent cremasteric reflex. paper #: pa- diagnostic twists of tubal torsion srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; anjum n. bandarkar, dorothy bulas purpose or case report: fallopian tube torsion is a rare cause of acute pelvic pain in a young female and requires prompt diagnosis for immediate surgical intervention. our purpose is to review varied imaging findings of surgically proven cases of tubal torsion. methods & materials: retrospective review of our data base from to revealed cases of surgically proven fallopian tube torsion. ages ranged from to years of age. all had pelvic ultrasound performed, cases had additional ct performed for acute pelvic pain. results: us findings included thickened dilated tubular hypoechoic structure ( ), cystic mass ( ); adnexal ( ), midline ( ). five cases had normal ovaries bilaterally ( with paratubal cysts). ct imaging findings include dilated, fluid filled, thickwalled tube with internal hyperdensity ( hu) likely debris/ hemorrhage in case. additional findings included cystic adnexal mass ( cases), beak sign ( case) and increased vascularity ( case). secondary signs included free fluid ( ), peritubular fat stranding ( ), vascular congestion and thickening of the broad ligament ( ) and enlarged draining vein ( ). laparoscopic salphingectomy was performed in cases (including cases with isolated tubal torsion). laparoscopic detorsion was performed in a total of cases. in addition, laparoscopic cyst drainage was performed in out of these cases. detorsion with paratubal cystectomy and hemorrhagic ovarian cystectomy was performed in of the cases. conclusions: imaging diagnosis of tubal torsion can be difficult. it can occur in isolation with a dilated thickened tubular structure adjacent to a normal ovary or potentially mimic appendicitis, pyosalpinx, complex adnexal cyst or cystic adnexal neoplasm. presence of normal ovaries, beaked tapered tubular structure with intratubal fluid level and hemorrhage may help in making the diagnosis. it is important to recognize this entity in a patient with acute pelvic pain to facilitate prompt tubal sparing surgery. paper #: pa- adjusted renal length in pediatric bone marrow transplant recipients nicholas bodmer, md, university of washington, nbodmer@gmail.com; teresa chapman, sangeeta hingorani, marguerite parisi purpose or case report: bilateral nephromegaly has been observed in the bone marrow transplant (bmt) patients at our institution. this study aims to quantify this observation, thereby providing radiologists with an adjusted baseline agedetermined renal growth curve for bmt patients. methods & materials: a retrospective clinical chart and imaging review was performed on patients who underwent bmt between and and who had abdominal imaging including the kidneys. ultrasound, ct, and mri exams were used for renal length measurement. renal lengths were assessed for each age group, first as an average length of all the patients within that age group overall, and subsequently as an average renal length by age group divided into the following time frames after transplantation: - days, - days, - days, and + days. clinic chart information collected included bun, creatinine, weight, and medication use. results: renal length was measured using imaging cases, distributed across each age group as follows: - months, n ; months- . years, n ; . - . years, n ; . - . years, n ; . - . years, n ; . years and higher, n . renal lengths were greater, on average, within every age group, compared with previously established normative age-related renal lengths (rosenbaum et al.) . the augmented renal lengths universally were observed in the - day post-transplantation timeframe. return to normal renal lengths typically occurred by months post transplant. clinic chart review revealed that the majority ( %) of patients received nephrotoxic medication within two weeks of imaging. conclusions: pediatric bmt patients have larger kidneys in the absence of known renal disease than age-matched peers. a revised, age-based renal length chart for post-bmt patients has been generated which should help prevent the misdiagnosis of nephromegaly in this population, eliminating unnecessary diagnostic evaluations. multiple etiologies to explain renal enlargement in these patients are possible, including fluid overload, nephrotoxic medication, or direct effect of the transplant. purpose or case report: mr urography can be a comprehensive exam for anatomical and functional pediatric renal evaluation. quantification of renal function may benefit when dynamic contrast enhanced images can be obtained at high spatiotemporal resolution and with minimal respiratory motion artifacts. though respiratory triggering may decrease motion artifacts, it results in loss of temporal resolution by a factor of about three. a two-echo gradient echo sequence with segmented outer k-space sampling and view-sharing/dixon image reconstruction (disco, differential subsampling with cartesian ordering) was chosen as a starting point due to its high temporal resolution. it was then modified to enable respiratory triggering while maintaining temporal resolution of one temporal frame every one to two respirations, with segments of k-space only acquired in the expiratory phase of respiration. imaging parameters were: °flip angle, ± khz bandwidth, tr~ . , matrix x , fov - cm, slice thickness mm, and x spatial acceleration. with irb approval and informed patient consent consecutive patients referred for mri renal function evaluation were recruited (age range; . to . years, mean±sd: . ± . years; males % females %), and scanned on a ge t mr using a -channel torso array with the respiratory-triggered high spatiotemporal resolution technique to extract regional gfr maps. two readers by consensus assessed image qualitative snr, motion artifacts and volumetric fat-water suppression performance. results: data acquisition was obtained to completion in all subjects without triggering failure. temporal resolution was approximately s for two respiratory cycles. no case had major fat suppression failure, whereas minor fat suppression failure was seen in % ( % c.i. to %). all cases had diagnostically acceptable snr. no motion artifacts were noted in / cases, while some artifacts with ghosting in / cases. regional gfr maps could be successfully extracted for each patient without the need for image registration. attached figure shows image quality. conclusions: view-sharing offsets loss of temporal resolution from respiratory triggering. thus, high spatiotemporal resolution renal dynamic contrast enhanced respiratory triggered images can be obtained with minimal motion artifacts in a pediatric clinical setting to evaluate renal function. disclosure: dr. chowdhury has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: the study cohort was selected from the irb approved children's oncology group aren b study. cases are evaluated for pre-operative wt rupture based on central review of surgical/pathology findings. wt cases with rupture were matched to wt controls by age and tumor weight (within months and g). ct scans were independently reviewed by blinded radiologists, for presence/absence of rupture and the following ct signs: poorly circumscribed mass, perinephric fat stranding, peritumoral fat planes obscured, retroperitoneal fluid, ascites beyond cul-de-sac, peritoneal implants, ipsilateral pleural effusion, intratumor hemorrhage. sensitivity, specificity of ct for assessing pre-operative wt rupture was determined. the relationship between ct signs and rupture was assessed by mcnemar's test, and the most predictive ct signs determined by backward selection multivariate logistic regression. results: sensitivity, specificity for detecting wt rupture were: reviewer - . %, . %, reviewer - . %, . %. kappa coefficient for interobserver agreement was substantial: . (p< . ). all ct signs tested, except peritoneal implants and intratumoral hemorrhage, had significant association with tumor rupture (p< . ). for reviewer , ascites and fat stranding around tumor were most predictive (odds ratio . and . , p< . ). for reviewer , ascites and retroperitoneal fluid were most predictive (or . and . , p< . ). conclusions: ct has high specificity but relatively low sensitivity for detecting preoperative wt rupture. the presence of ascites beyond cul-de-sac is the best indicator of preoperative rupture, followed by fat stranding and retroperitoneal fluid. paper #: pa- the failed pyeloplasty: evaluation with mr urography damien grattan-smith, children's healthcare of atlanta, damien.grattansmith@mac.com; ricahrd jones, stephen little, wolfgang cerwinka, hal scherz, andrew kirsch purpose or case report: to identify imaging characteristics associated with failed pyeloplasty seen with mr urography. we have performed mr urography in children following pyeloplasty. from this group, children had follow-up surgical intervention with repeat pyeloplasty or balloon dilatation of the upj. imaging features reviewed included degree of hydronephrosis, calyceal transit times, renal transit times, signal intensity versus time curves, as well as functional analysis based on volumetric and patlak differential function and change in the asymmetry index. results: all children who underwent a second surgical procedure had delayed calyceal transit times. the degree of hydronephrosis and renal transit times were either stable or worse when compared to pre-operative evaluation. functional derangement could show stability, slight improvement or deterioration. the asymmetry index estimated the severity of the obstruction. conclusions: mr urography is valuable in the evaluation of children who have undergone pyeloplasty. the calyceal transit time appears to be the most reliable discriminator when comparing successful and failed pyeloplasty. calyceal transit times may be prolonged before the hydronephrosis becomes progressive. disclosure: dr. grattan-smith has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: initial attempts at interpreting functional mr urography (fmru) can be challenging. a time intensive navigation through a multitude of both subjective and objective functional results is necessary to render a useful interpretation. this is a guided review of fmru, noting the important functional findings in high-grade unilateral pelvicalyceal dilatation (pcd), in the absence of ureterectasis, with a contralateral normal kidney allowing for an optimal functional comparison. methods & materials: a retrospective functional evaluation of cases with unilateral pelvicalyceal dilatation (pcd), without prior pyeloplasty, was conducted. the fmru studies were carried out according to a standard protocol and post-processing using the chop-fmru software. this included iv hydration, bladder catheterization and iv furosemide administration. fifteen minutes after diuretic administration, a dynamic coronal d fat saturated t sequence was performed in a supine position over min. a sagittal d t and delayed single coronal t , both fat saturated, followed in a supine and/or prone position. the following functional features were evaluated: visualization of the ureter, the presence of a contrast-urine level and swirling of contrast in the dilated renal pelvis. the functional results included in the analysis were calyceal transit time (ctt), renal transit time (rtt), time-to-peak (ttp), parenchymal volume (pv), differential renal functions (volumetric-vdrf, patlak-pdrf and volumetric patlak-vpdrf) and the difference between vdrf and pdrf. results: patients were comprised of males and females with an age range of . - . years (median . yrs). of the kidneys with pcd, the ureter was visualized in , during the dynamic sequence, / during supine delay and / only in prone position. a contrast-urine level was present in of the dilated systems, and swirling in . the ureter was visualized during dynamic sequence in all contralateral normal kidneys and at no time was swirling or a contrast-urine level identified. the average functional parameters are seen in table . a statistically significant (p< . ) difference between the normal and dilated pelvicalyceal systems was achieved in ttp, pdrf and vpdrf for this small sample size. conclusions: awareness of multiple functional features and the range of calculated results may aid in subsequent combined interpretation of the fmru with the morphologic analysis. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. and . demographics, clinical presentation , diagnostic studies and treatment outcomes were evaluated. post-procedure imaging was evaluated for clot burden reduction (patency) and residual venous stenosis by two-reader consensus. results: ten patients ( male; female, mean age years, range - ) presenting with acute upper extremity swelling and pre-procedure imaging revealing % occlusion of the axillary and subclavian veins received successful endovascular therapy. all patients underwent infusion catheter placement for thrombolysis with tissue plasminogen activator or urokinase. patients received additional pharmacomechanical treatment. angioplasty was also performed in all patients. the mean treatment duration was h (range - ). post-procedural imaging revealed that of patients achieved - % patency (clot burden reduction) and patient achieved - % patency. the residual venous stenosis was graded: patients had - % stenosis, patients had - % stenosis and patients had - % stenosis. all patients were discharged on full anticoagulation therapy with low molecular weight heparin. patients had surgical rib resection postthrombolysis with an average length of time from thrombolytic therapy to surgery being days (range - ). patients had re-thrombosis events during the follow-up period (mean months; range - ), with one re-thrombosis event occurring within one week of thrombolytic therapy, prior to surgery and the other two occurring - weeks post-rib resection. there were no procedure related complications. one patient was lost to follow-up after initial successful catheter directed therapy. conclusions: percutaneous endovascular techniques such as pharmacomechanical thrombolysis and angioplasty appear to be feasible and safe options for paget schroetter syndrome in otherwise healthy adolescent patients. in attempt to prevent rethrombosis and chronic symptoms, we refer all patients for adjunctive surgical decompression. future larger studies are needed to address optimal strategies for these patients. combined d fluoroscopy image guided percutaneous intervention with real-time optical sensing at the tip of a needle for tissue characterization rami nachabe, philips, rami.nachabe@philips.com; john m. racadio, drazenko babic, ross schierling, jasmine hales, benno hendriks purpose or case report: to investigate the feasibility and potential of real-time tissue characterization at the tip of a needle with diffuse optical spectroscopy (dos) sensing capabilities during d fluoroscopy guidance using cone beam ct and dedicated needle path planning software. methods & materials: a c-arm x-ray system that combines fluoroscopy and d imaging from a cone beam ct was used to image a woodchuck with hepatocellular carcinoma (hcc). the imaging system enabled needle path planning, which was used to perform insertion and navigation of a needle toward the liver tumor. the needle was integrated with optical fibers for real-time tissue spectral sensing at its tip. optical spectra measurements were obtained continuously as the needle passed through healthy liver tissue and then into the tumor. from the diffuse optical spectra measurements, the following clinical parameters were extracted for tissue characterization: blood volume fraction, blood oxygenation, lipid volume fraction and tissue light scattering (related to tissue density). the tissue parameters were compared for healthy liver and tumor using the kruskal-wallis test. results: the tissue density of the healthy liver was lower than that of the tumor. higher blood and lipid volume fractions as well as oxygenation levels were observed in the healthy liver as compared to the tumor. all differences were statistically significant (p< . ). additionally, a much wider heterogeneity in tissue density was observed in the tumor as opposed to the healthy liver. conclusions: differences in tissue properties between tumor and healthy liver enable discrimination between these two types of tissues. adding real-time optical sensing at the tip of a needle to d fluoroscopy image guidance is a feasible technique that complements the imaging information with relevant physiological parameters; it facilitates more precise definition of tumor boundaries despite any target motion during needle insertion. disclosure: dr. racadio has disclosed that he is a consultant for philips healthcare and receives travel reimbursement. rami nachabe, drazenko babic and benno hendriks are employees of philips healthcare. methods & materials: two children aged months and months were treated at this institution for liver failure resulting from urea cycle disorders, with a hepatocyte transplant procedure. the recipient liver was irradiated prior to transplant to facilitate engraftment. the procedure involves the injection of prepared hepatocytes from a suitably screened, compatible donor, via a main portal vein branch into the recipient liver. in both procedures access to the umbilical vein was achieved by the surgery service and a french arterial sheath was placed. a french angled catheter was used for diagnostic runs and to access the right and left main portal vein. a french fogarty catheter (edwards lifesciences, irvine, ca) was placed to isolate each portal vein branch in turn and hepatocytes injected using hand injections. pressures in the main, right and left portal veins were measured and hand injections of contrast made at regular intervals. careful attention must be paid for evidence of pruning of portal branches, indicating occlusion of small portal branches, or portal to hepatic vein shunting. if shunting is seen, infusion must be stopped as embolism of hepatocytes into pulmonary arteries may result with serious clinical sequelae results: in both patients, the desired number of hepatocytes were successfully delivered into the recipient liver. in both cases, mild pruning of the portal vein branches was evident at the end of the procedure. portal vein presssures remained steady. there was no venographic or clinical evidence of pulmonary arterial embolization. conclusions: the interventional radiologist plays a central role in the hepatocyte transplant procedure. familiarity with catheterizing portal branches from an umbilical vein approach, measuring venous pressures, using small occlusion catheters and recognizing venographic end points such as portal vein pruning and portal to hepatic vein shunting are necessary to the safe and successful completion of this new technique. purpose or case report: the aim of the study was to evaluate the trends in term of type of tube placed, number of procedures per year, number and age of the patients as well as the number of procedures per patient and the interval of time between two placements, and finally the irradiation burden borne by the patients. methods & materials: after reb approval the radiologic files of the patients who underwent naso-duodenal-jejunal (ndj) or gastro-jejunal (gj) or jejunal (j) tube placement under fluoroscopy over the past five years ( to ) were extracted from the ris and reviewed. the results were tabulated as a single batch and stratified by year. results: eighty-nine patients representing procedures ( ndj, , gj, j) were included. only patients underwent a single procedure. the average number of procedures per patient was . with a maximum of during the study period. the average patient's age was . months (sd . , median . ). the average fluoro time per procedure was . min (sd . , median . ). the average interval between two procedures was days (sd , , median ). the average fluoroscopy time per patient combining those having a single procedure and those having multiple ones, was . min (range . to . , sd . , median . ). conclusions: fluoroscopic placement of enteric tubes delivers a significant amount of irradiation. our data led to two interventions with respect to insertion and management of the tubes. on one hand, when the attempt pursued by a radiologist is not successful after min of fluoroscopy other strategies should be considered including another operator or an alternative technique for tube positioning. on the other hand, information will be distributed toward the clinicians and nurses in order to improve the management of these tubes and avoid fortuitous displacement which was responsible of a significant amount of repeated procedures leading to undue irradiation. purpose or case report: to evaluate drug elution pharmacodynamics of doxycycline in an albumin-based solution, as used in percutaneous imaging-directed therapy of aneurysmal bone cyst (abc) and microcystic lymphatic malformation (lm) methods & materials: doxycycline mixed with % human serum albumin (hsa), and doxycycline mixed with saline solution (both mg/ml) were evaluated using a fluid diffusion chamber system over h, recording ph and doxycycline concentration. static ph and doxycycline concentrations were recorded every min for the first min, then every min for a total of h, averaged over trials in each of the hsa and saline systems. statistical analysis evaluated standard deviation and rate of change for the trials in each system. drug elution dynamics data were correlated with clinical experience in the doxycycline/albumin treatment of patients ( treatments) with aneurysmal bone cyst (abc) and patients with lymphatic malformation microcysts. results: drug elution was linear in both the hsa and saline systems, with statistically significant (p<. ) slower elution drug release from the albumin system as compared with the doxycycline and saline solution, both over and h. purpose or case report: to describe a successful interventional radiologic approach to the management of paget schroetter syndrome presenting as acute arm swelling in adolecent athletes. methods & materials: institutional review board approval was obtained for this retrospective study. five patients aged to years (mean . years) were treated at this institution over a year period all presenting with acute arm swelling (july -july ). ultrasound confirmed subclavian vein thrombosis in all cases. all were treated with placement of an infusion catheter (ev , plymouth, mn), infusion of tissue plasminogen activator (tpa) at a rate of mg/hour overnight and aspiration of remaining clot with a "trellis" (bacchus vascular, santa clara, ca, usa) thrombectomy device. results: clot was successfully removed in all five patients. complete clearance of clot was confirmed by contrarst venography in all cases. in four patients balloon angioplasty of a narrrowing at the junction of the subclavian and brachiocephalic veins was carried out. in one, the thrombus recurred within h. the patient was retreated the next day with aspiration of clot using the "trellis" device and an infusion catheter placed with low dose ( . mgs/hour) tpa commenced until surgical review; this patient was operated on within h of final thrombolysis. all patients were seen by a vascular surgeon with an interest in this condition. all underwent surgical decompression; at end of the study period all patients were asymptomatic. conclusions: interventional radiologic management of acute axillo-subclavian thrombosis due to paget schroetter syndrome is safe and highly successful in the adolescent population. early recurrence of thrombus is not uncommon and prompt surgical consultation with a view to early surgical decompression is recommended. purpose or case report: diagnostic reference levels (drl) or target radiation dose ranges for pediatric ct scans are needed in the u.s. the first u.s. pediatric ct dose index registry (quircc) within the american college of radiology recorded estimates of patient radiation dose using a new method (ssde) based on body width(bw) for the purpose of developing diagnostic reference levels (drl). in addition to developing drl at the th percentile, the purpose of this study was to determine the ssdes associated with the lower range of acceptable image quality through subjective image quality evaluation. methods & materials: six children's hospitals participated in a retrospective review of abdominal ct with iv contrast on patients < yrs of age. from exams, each site submitted de-identified images for selected cases based on ssde and patient width. a total of cases were selected from the lowest, first quartile and median ssde. six investigators reviewed images from each case under identical viewing conditions and rated them for subjective quality according to a score sheet and reference scale of images with known quantum mottle. cases were considered non-diagnostic if at least of reviewers ranked them as such. results: first, second, and third quartile ssde and ctdi-vol values from sites for each bw will be shown. / cases were ranked non-diagnostic by the reviewers. / non-diagnostic cases were below the th percentile based on ssde. / of "non-diagnostic" cases had ssde less than the th percentile. the unacceptable case with ssde above the th percentile ( cm, ssde . mgy) was due to subcutaneous metal implant with artifact. the quircc th percentile using ctdivol for a yr old is . mgy which is % lower than the acr ct accreditation data's published th percentile. conclusions: this consortium developed target dose ranges (drls) for ct of the abdomen with iv contrast for routine exam indications based on evaluation of image quality that establish lower and upper ranges ( - percentile) of patient dose(using ssde) associated with clinically acceptable images. this study demonstrates that pediatric radiologists in this consortium are comfortable interpreting images at or above the percentile ssde and judged all but one image within this target range as diagnostically acceptable. table ). with the exception of neonate chest, most used age-based techniques; only two centers reported using thickness. no survey used grids for wrist images, while / of the surveys used grids for chest and abdomen exams in -year-olds. at the most common sid there was up to a kvp variation ( year-old chest ap) and up to -fold variation in mas ( year old scoli lat). only two surveys used equipment that displayed the new iec exposure index. conclusions: participants report variability in the techniques and methods used to acquire common radiographic studies, reflecting differences between detector types and users. radiologists, technologists, medical physicists, manufacturers, and the fda have an opportunity to work together to standardize the techniques based on detector type to optimize radiation exposure for pediatric radiographic exams. disclosure: dr. don has indicated that he performs contract research for carestream and that he is on the speaker's bureau for siemens and receives an honoraria. purpose or case report: this study assesses community adoption of ct radiation dose guidelines after a -year international initiative to reduce medical radiation exposure in children. size-specific dose estimates (ssde) from community pediatric body ct scans are compared to ssde from matched scans obtained at a children's hospital that adheres to image gently campaign principles. we reviewed pediatric ct scans ( chest (c), abdomen/pelvis (ap), chest/abdomen/ pelvis (cap)) transferred from community imaging centers to our university children's hospital between july and february . community scans were acquired with variable parameters and reconstructed with traditional filtered back projection (fbp). comparison was made to children's hospital ct scans, performed in accordance with principles of the image gently campaign. because iterative reconstruction (ir) software was added to our scanner during the study, enabling us to reduce ctdivol by %, children's hospital scans were divided into two groups: a) scans obtained with standard weightbased pediatric protocols and fbp (october -october ; c, ap, cap) and b) scans obtained with reduced-dose weight-based pediatric protocols and blended ir/ fbp (october -april ; c, ap, cap). ctdivol and greatest lateral dimension were recorded from each scan and were used to calculate ssde. mean ssde from community scans was compared to mean ssde from children's hospital groups a and b. statistical analysis was performed with student's t-test. results: patient age range was - years in both community and children's hospital groups. mean ssde for community c, ap, and cap scans was . , . , and . times higher than mean ssde for matched scans in control group a (p< . ) and . , . , and . times higher than mean ssde for matched scans in control group b (p< . ). conclusions: ssde was significantly higher for community pediatric body ct scans than for matched scans performed at a children's hospital that adheres to image gently campaign principles. results suggest that more community outreach and education are required in implementation of low-dose ct protocols outside of children's hospitals. concurrent use of ir provides a means of achieving even greater ssde reduction than is possible with fbp alone and should be encouraged. paper #: pa- optimization of tube voltage and current in size-based pediatric ct imaging: a phantom study boaz karmazyn, md, radiology, riley hospital for children, bkarmazy@iupui.edu; yun liang, keith kaser, peter johnson, mervyn cohen purpose or case report: determine the change in ct dose index (ctdivol) required to maintain the same quantum mottle noise when using lower tube voltages ( and kvp) relative to kvp in different sized cylinder water phantoms (cwp) representing a wide range of pediatric body sizes. we performed mdct scans of , , , and cm cwp. thirty scans were performed for each phantom. the tube currents ranged from to mas with increments of mas, and the tube voltage levels were , , and kvp. the noise (standard deviation in hu) was measured using center region of interest (roi) that was % of phantom's area. two other rois (each % of the area) were placed at the center and periphery of the phantom images to measure noise gradient. results: in the smallest ( cm) cwp, approximately the same noise level was maintained with all three tube voltages without a significant change in ctdivol. for the , , and cm phantoms, the average ctdivol needed to be increased by %, %, and %, respectively, to maintain same noise level when the voltage was decreased from to kvp. the average ctdivol needed to be increased by %, % and % to maintain the same noise level in the , , and cm cwp when the tube voltage was decreased from to kvp. the difference between central and peripheral noise increased on average by . %, . %, . %, and . % in the cwp of , , , and cm, respectively. in each cwp, the central to peripheral noise difference was more pronounced (up to . % more) with decrease in kvp from to or . conclusions: noise measurements in the water phantom model indicate that tube voltage could be decreased from to in cwp of cm without significant change in ctdivol. it is also possible to decrease the voltage from to kvp with a minimal (< average %) increase in dose in cwps of , , and cm. the noise gradient increases with larger cwp and smaller kvp. paper #: pa- comparison of radiation dose estimates, image noise, and scan duration in pediatric body imaging using -row and -row ct jennifer johnston, md, radiology, cincinnati children's hospital medical center, jhtai@yahoo.com; daniel j. podberesky, erin angels, terry t. yoshizumi, greta toncheva, donald p. frush purpose or case report: to compare effective dose (ed) estimates, image noise, and scan duration for pediatric chest, abdomen and pelvis protocols using -row and -row ct scanners in various acquisition modes. methods & materials: organ doses were measured using mosfet dosimeters. dose, scan duration, and noise measurements were made in a -year-old anthropomorphic phantom for conventional helical, -detector helical and volume acquisition modes for chest, abdomen and pelvis protocols on a -row ct, and for helical mode on a row ct (aquilion one and aquilion , toshiba medical systems, otawara, japan) using similar scan parameters representing currently used clinical protocols. mean organ doses from three runs for each protocol, in combination with icrp tissue weighting factors, were used to obtain ed for each protocol. noise was measured as the standard deviation of hounsfield units in equivalent locations at levels for each protocol with an roi tool. ed and noise were compared with a paired t-test or sign test. results: compared to helical acquisitions on the -row ct, ed of all tested acquisition modes on the -row volume ct were significantly lower for chest, abdomen/pelvis (ap) and chest/abdomen/pelvis (cap) protocols (table) . scan durations were lower across the board on the -row volume ct. compared to acquisitions on the -row ct, noise was in general similar to those on -row ct protocols, but some acquisition protocols on the -row ct produced greater noise (table) , specifically volume acquisition for chest ct and -detector helical and volume modes for ap and cap protocols. conclusions: dose savings can be achieved for chest, ap and cap ct examinations on a -row ct scanner compared to helical acquisition on a -row ct, with shorter scan durations. image noise was in general comparable between protocols. although noise differences between some modes did reach statistical significance, the impact on overall image quality will need to be studied further. paper #: pa- the observed to expected total fetal lung volume as a predictor of short-and long-term morbidity in surviving infants with congenital diaphragmatic hernia emily stenhouse, the royal hospital for sick children, emilysten@doctors.org.uk; neil patel, judith simpson, watt andrew, gregor walker, carl davis purpose or case report: observed-to-expected total fetal lung volume (o:e tflv) is a validated mr measure which we have previously demonstrated to be significantly reduced in non-surviving infants with congenital diaphragmatic hernia (cdh). our aim was to investigate the relationship between o:e tflv and short-and long-term morbidity outcomes in surviving infants with cdh. methods & materials: a retrospective analysis of cases of isolated left-side cdh referred to our institution for fetal mr evaluation between - weeks. mr imaging studies were performed on a . t philips system using a phased array body coil. the observed tflv was calculated by multiplying the summed area of the region of interest by the section thickness. the expected tflv was calculated with a formula previously described in the literature using the gestational age of the fetus. the observed tflv was expressed as a percentage of the expected tflv at a given gestation. morbidity outcome data was obtained from the case records of all surviving infants. specific measures of illness severity relating to short-term intensive care management and long-term outpatient management were recorded. differences in o:e tflv between outcome groups were assessed by t-test. results: liveborn infants with isolated left-side cdh and antenatal mr scans were identified. scans were performed at - weeks gestation. infants survived to discharge; gestation . ( . - ) weeks, birth weight . ( . - . ) kg. median length of admission was ( - ) days, median duration of follow-up was . ( . - . ) years. o:e tflv was significantly lower in non-surviving infants; vs. %, p . . o:e tflv was significantly lower in infants who received high frequency oscillation ventilation (hfov) versus those who were conventionally ventilated ( % vs %, p . ). o:e tflv was also significantly lower in those infants who had a length of admission greater than the median of days ( % vs. %, p . ). o:e tflv trended lower with other measures of increased morbidity; inhaled nitric oxide use, patch repair of diaphragm, rehospitalisation within year, supplemental feeding at discharge, gastro-oesophageal reflux, and developmental delay. conclusions: as well as predicting survival, lung volume measurement by o:e tflv is a promising predictor of outcome and morbidity in surviving infants with cdh. further studies in larger populations are required to provide quantitative predictive risk data. characterization of the inherent acoustic noise of a dedicated nicu mri system jean tkach, phd, cincinnati children's hospital medical center, jean.tkach@cchmc.org; yu li, ron g. pratt, christopher villa, beth m. kline-fath, charles dumoulin purpose or case report: we have developed a small foot print . t mri scanner specifically for neonatal imaging that can be easily installed in a neonatal intensive care unit (nicu). the scanner has a maximum patient bore diameter of . cm (without rf coil), and roughly twice the gradient performance of the best conventional adult whole-body . t mr systems. it is known that sensory stimulation such as acoustic noise can elicit autonomic instability in both term and preterm neonates. the inherent noise properties of the nicu mri system were measured as part of the initial safety evaluation of the system and compared against that of a conventional . t mri system. to evaluate the inherent acoustic noise characteristics of the nicu mri scanner, sound pressure level (spl) measurements were performed on it and on a conventional adult sized whole body . t hdx ge mri system (ge healthcare, waukesha, wi). a brüel & kjaer model sound level meter (brüel & kjaer sound & vibration measurement a/s, denmark) was used to perform the spl measurements for several different mr acquisitions (spin echo, gradient echo, fast rf spoiled gradient echo, fully balanced steady state free precession, gradient echo echo planar, and diffusion weighted) using acquisition parameters consistent with clinical protocols. the mr sequences, acquisition parameters, noise measurement equipment and methodology were identical for the two mr systems. the maximum spl in units of a weighted decibels (dba) was recorded for each of the mr acquisition/mr system combinations evaluated. results: the maximum spl values measured during each of the mr acquisitions were lower for all sequences (average . dba (range - dba)) for the nicu mri unit as compared to the conventional mri scanner ( table ). the average measured maximum spl value, reported in dba, across all acquisitions was . ± . for the nicu scanner, and . ± . for the conventional mri scanner. the highest spl values were measured for the diffusion-weighted sequence: and dba, for the nicu and conventional mri scanner respectively. conclusions: because of the smaller dimensions of the gradient coils in the nicu mri system, acoustic noise is less than that of conventional mri scanners despite the superior gradient performance of the smaller coils. the lower inherent acoustic noise level of the nicu system provides improved safety for the neonate, and facilitates siting of the unit in the nicu. disclosure: dr. tkach has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. paper #: pa- late neurologic events in extremely premature infants carlos guevara, md, radiology, duke university, cjg @duke.edu; brett bartz, caroline l. hollingsworth, caroline w. carrico, michael c. cotten, charles m. maxfield purpose or case report: germinal matrix hemorrhage (gmh) is a major complication of prematurity. persistence of germinal matrix and immature neurovascular autonomic regulation in the premature neonate is thought to predispose to gmh. most gmh in premature population occurs during the first days of life, and yet the persistence of the germinal matrix to weeks gestation may allow for post-natal gmh outside of the immediate perinatal period. to our knowledge, this is the first systematic review of late gmh (after the first week of life) in a large population of extremely preterm neonates (less than weeks of gestation). this irb approved retrospective review included patients weighing less than g or born at less than weeks of gestation from through . the study population included infants who had a head ultrasound (hus) within the first week of life and at least one follow hus after the first week of life. all hus were reviewed by three experienced pediatric radiologists for the presence and grade of ich or late developing hemorrhagelike lesions (hll). infants with and without hll were evaluated for several clinical variables, including neurodevelopmental outcomes (bayley scales). results: average gestational age of study population was . weeks. the incidence of gmh in the first week of life was % grade , . % grade , . % grade / , and . % posterior fossa. new echogenic foci (hll) at the caudothalamic groove were seen in . % after the first week of life. % of these lesions were bilateral. a four-fold increase in incidence of hll was seen in infants < g compared to those> g. higher grade hemorrhages were not seen in this patient population, although % of infants had late posterior fossa hemorrhages. the clinical course of infants with hll trended towards a higher incidence of stressors, but this was not statistically significant. the psychomotor development index scores were lower than those infants without hemorrhage. conclusions: small hll at the caudothalamic groove are common in extremely preterm infants after the first week of life. higher grade ( - ) hemorrhages were not seen. there were no cases of intraventricular extension and no direct complications. if isolated, this finding necessitates no follow-up imaging, but may be associated with poor neurodevelopmental outcome. disclosure: dr. guevara has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: tof/apv is a rare congenital heart lesion in which pulmonary arteries may become aneurysmally dilated and compress adjacent airways. pulmonary arterioplasty is often required to relieve tracheobronchial compression in addition to intracardiac repair. the purpose of this study was to review pre and postnatal imaging findings and their impact on patient management and clinical course. methods & materials: a retrospective database search identified infants with tof/apv between - ( fetal diagnosed cases and diagnosed postnatally). for fdc, prenatal ultrasound (us) and fetal mri were correlated with postnatal ct for the size of the central pulmonary arteries, airway compression, and presence / distribution of air trapping/atelectasis. for all cases postnatal ct findings (between - days of age) were correlated with clinical management and outcome. results: prenatal diagnosis of tof/apv was suggested sonographically, based on dilated central pas, between - weeks gestational age (ga). fetal mri, performed between - weeks ga confirmed the diagnosis and aneurysmal central pas and demonstrated air trapping &/or atelectasis in / with normal appearing lungs in fetus. size of the pas ( / ) and presence and distribution of lung abnormality ( / ) correlated closely between fetal mri and postnatal ct, although detailed visualization of the central airway/ vascular relationships were better defined on ct. fetal mri identified an unexpected diaphragmatic hernia (dh) not seen on us. for the pnd cases, ct showed aneurysmal pas and airway compression with air trapping &/or atelectasis in / infants. seven infants with airway obstruction on ct required pulmonary arterioplasty; infant with no air trapping did not have arterioplasty. / operative patients survived, one with concomitant dh died at age days due to hemorrhagic shock. one fdc was inoperable due to poor cardiac function and died at age days. conclusions: prenatal mri correlates well with postnatal ct for assessing pulmonary artery size and location and severity of lung abnormality in patients with tof/apv, this allows for appropriate management planning and may negate the need for an immediate postnatal ct. ct accurately depicts the location and extent of airway compression and resultant air trapping or atelectasis, serving to guide the need for and extent of the arterioplasty procedure. paper #: pa- craniosynostosis syndromes: prenatal findings by us and mri eva rubio, md, cnmc, rubioeva@yahoo.com; anna blask, alexia egloff, dorothy bulas purpose or case report: craniosynostosis with associated malformations is a feature of several related syndromes resulting from a fgfr or twist genetic mutation. syndromes include apert, crouzon, pfeiffer, and carpenter syndromes. our purpose was to review imaging findings which aid in suggesting the diagnosis prenatally. we retrospectively reviewed prenatal us and mri findings in cases with prenatal ( with postnatal/molecular) diagnosis of a craniosynostosis syndrome: cases of apert, case of carpenter, and cases of pfeiffer syndrome. results: / cases were correctly diagnosed prenatally. in the second trimester findings may be subtle, with mild calvarial changes; digit abnormalities, in particular, may elude the imager in unsuspected cases. although the diagnosis could be made with either modality, the full spectrum of abnormalities was best appreciated using a combined imaging approach of mri and us. by us many salient features were depicted: turribrachycephaly/trigonocephaly/cloverleaf ( / ); syndactyly ( / ); polydactyly ( / ). agenesis of the corpus callosum was identified by us in ( / ) cases. conversely, mri, performed in all cases, contributed additional observations not well seen by us: the fetal airway was well delineated in all cases ( / ); a low lying spinal cord was noted ( / ), midface hypoplasia ( / ) and migrational/sulcation abnormality ( / ). additional findings of absent ductus venosus with biliary atresia ( / ), abdominal wall defect ( / ) and renal anomalies ( / ) were seen with both modalities. reimaging in later pregnancy depicted important changes ( / ), including worsening hydrocephalus and resolution of suspected airway occlusion. conclusions: us and mri are complementary modalities in evaluating fetuses with craniosynostosis. airway patency, midface hypoplasia, spinal cord abnormalities and intracranial abnormalities are often better seen with mri. fetal activity, digits, bone detail, and cardiac anomalies are better appreciated by us. findings may be subtle in the second trimester. repeat imaging in later pregnancy may reveal specific information affecting delivery planning. paper #: pa- pcpra best paper hyperpolarized carbon- mrsi for pediatric disease john mackenzie, md, department of radiology and biomedical imaging, ucsf, john.mackenzie@ucsf.edu; yi-fen yen, linda nguyen, jeffrey gu, john kurhanewicz purpose or case report: to study the potential of carbon- mr spectroscopic imaging ( c-mrsi)-a radiation free molecular imaging strategy-for the detection and treatment monitoring of pediatric disease. methods & materials: the potential of c-mrsi to detect pediatric disease was tested in rodent models of pediatric arthritis. animals were induced with arthritis and subsequently given intravenous hyperpolarized c-pyruvate, and imaged. the amount of c-lactate produced from pyruvate in normal and arthritic joints was measured both at single points in time and dynamically at either or tesla. the c-mrsi data were compared with clinical measures of arthritis, cell stimulation studies, and joint changes on conventional anatomic mri and histology. results: alterations in lactate production as measured by c-mrsi appear to depict sites of arthritis and correlate with other more established but potentially less reliable or more invasive measures of disease status. imaging robust mouse models of pediatric disease may be feasible at telsa. this method may also be translated from high-field to clinical equipment with reasonable hardware and software modifications that allow detection of hyperpolarized c compounds. c-mrsi depicts increased lactate production at specific regions of inflammation within arthritic joints and is confirmed by histological inspection and anatomic mri. on average, lactate production is increased by % in areas affected by inflammation. conclusions: the intravenous injection of hyperpolarized carbon- compounds and subsequent imaging with c-mrsi provides a unique molecular imaging strategy to noninvasively monitor pediatric disease. this non-invasive imaging strategy may eventually provide clinical utility for several pediatric diseases involving inflammation, infection and tumor. disclosure: dr. mackenzie has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: using the hemangioma-vascular malformation clinic registry at cincinnati children's hospital, we searched for patients diagnosed with khe whose evaluation included mri. twenty such patients were found, although three of the patients had no pre-therapy mris. the imaging studies were reviewed by the authors with assessment of the following characteristics: location, margin definition, soft tissue involvement, and pre and post contrast signal intensity. results: location: lesion location was as follows: trunk ( ), extremity ( ), extremity plus trunk ( ), and head/neck ( ). signal: all lesions were dark on t weighted sequences with diffuse enhancement after contrast administration. the majority of the lesions were bright on t weighted sequences, but there were cases that had heterogenous to low t signal (with all involving the retroperitoneum). of the cases, only one had both high arterial and venous flow by mri. margin definition: four of the lesions had well defined borders (greater than % well circumscribed) with minimal to no adjacent infiltration/edema. two of those four cases were exophytic masses. the remaining cases were poorly defined lesions with adjacent infiltrative fluid signal intensity and enhancement. tissue/organ involvement: tissue/organ involvement was counted if abnormal fluid-signal intensity or enhancement was identified at that site. review of these cases showed fifteen patients with muscular involvement. dermal and subcutaneous involvement was observed in all but cases, with the uninvolved lesions being isolated and deep. additional sites of suspected involvement included bone ( ), pleura ( ), penis ( ), and pancreas ( ). conclusions: khe is a rare neoplasm of infancy with a spectrum of features by mri. poorly defined lesions are much more frequent than well-circumscribed masses. however, pathologic correlation of such infiltrative margins is usually not available as treatments after biopsy are primarily medical rather than surgical. common additional mri features include predominant involvement of muscle, subcutaneous fat, and skin over viscera and bone with lesions generally showing increased t signal and enhancement. is dedicated chest ct needed in addition to pet ct for evaluation of pediatric oncology patients? ibrahim tuna, montefiore medical center, dristuna@yahoo. com; jeffrey levsky, jeremy rosenblum, rosanna ricafort, benjamin taragin purpose or case report: to evaluate the diagnostic accuracy of low dose ct performed during pet-ct as compared to dedicated chest ct in the assessment of pulmonary findings in children with malignancy. the institutional review board approved this hipaa compliant research. pediatric oncology patients, ages between - , with known solid malignant tumors who were referred to pet-ct and standard chest ct within days for staging or assessment of treatment response between - and - were eligible for this retrospective study. radiology reports were reviewed for potential discrepancies. two radiologists re-evaluated the standard chest ct and low dose chest ct portion of the pet ct of the discordant cases, while comparing with the most recent prior studies. studies were scored for pulmonary nodules, bony metastasis, adenopathy, and pleural effusions. true discrepancies were assessed by a panel of pediatric oncologists to judge whether the differences in reports might lead to a significant change in management. results: ( female, male) patients were identified. radiologic reports of different patients ( female, male) had potential discrepancies based on review of the reports. the primary tumors were rhabdomyosarcoma (n ), hodgkin's lymphoma (n ) and others (n ). reevaluation of the original images showed true discrepancies in . % ( / total ). in studies, the discrepancy had no clinical significance. in studies, a pulmonary nodule was identified on standard chest ct which was not described on the pet-ct. both of these patients had rhabdomyosarcoma. one of these patients had findings that pediatric oncologists considered significant enough to alter patient management. conclusions: we found a low false negative rate for clinically significant findings on the low dose portion of pet-ct as compared to standard chest ct. in the future, improvements in acquisition technique and post processing of the ct portion of the pet-ct may further improve its diagnostic utility, obviating the need for a routine separate diagnostic ct, thereby minimizing radiation exposure in these young patients. methods & materials: low-dose cta examinations were performed in pediatric patients over a three year period to evaluate suspected vascular traumatic injury with some patients receiving scans of more than one area of the body. areas scanned in this include the head and/or neck (n ), chest (n ), abdomen and/or pelvis (n ), upper extremity (n ) and lower extremity (n ). in of these patients, suspected vascular injury was due to a history of either blunt (n ) or penetrating (n ) trauma. patients were referred directly from the emergency department, while were inpatients and the remaining were referred from an outpatient setting. patients ( f: m) ranged in age from to years old (mean age ). studies were performed on a -channel mdct scanner with or kv, to mas, . to . mm section thickness, reconstructed with % overlap, and . to . pitch. contrast medium was power-injected using weight-based protocols to optimize iodine delivery. exams were interpreted on a workstation using advanced imaging techniques. patient radiation dose was calculated in all cases. clinical outcome was assessed through a month follow-up when possible. results: all studies were technically adequate. . % (n ) of studies revealed no vascular injury, while . % (n ) revealed acute vascular pathology. vascular injuries included vascular occlusion (n ), vasospasm (n ), narrowing/dissection (n ), pseudoaneurysm (n ), and transection (n ). extravascular traumatic findings were demonstrated in . % (n ), including fractures, lung injury, soft tissue hematomas, and a ruptured baker's cyst. of the patients with acute vascular findings, . % (n ) underwent surgical management (including for vascular injury), while . % (n ) were managed conservatively. one patient with active extravasation was managed with angiographically-guided embolization. in no case was catheter angiography required to confirm cta findings. conclusions: low dose cta is a reliable means to screen pediatric patients emergently for acute vascular injury. vascular and non-vascular pathology can be diagnosed noninvasively for efficient patient management. paper #: pa- elasticity measurement by acoustic radiation force impulse (arfi) technique of normal liver, kidney and spleen in healthy children mi-jung lee, radiology, severance children's hospital, mjl @yumc.yonsei.ac.kr; myung-joon kim purpose or case report: there are many previous studies about using acoustic radiation foce impulse (arfi) value to measure the elasticity of tissue, mainly the liver in adult patients. however, there was limited study about arfi measurement in the children. the purpose of this study is to evaluate the arfi value in the normal liver, kidney and spleen in healthy children and to evaluate the effect of sex, age, and body mass index (bmi). the study prospectively enrolled healthy pediatric volunteers who are under years old, and underwent abdominal ultrasonography and arfi between july and august . arfi velocity measuring was performed by - mhz linear probe for children under years old and - mhz convex probe for older children. arfi velocity was measured three times at each organ. however this measurement was stopped if the child cannot tolerate. results: two hundred two children (m:f : ; mean age, ± . years) were enrolled. and arfi measurement was performed only two time for some organs in three children. the mean arfi value was . ± . m/s in liver, . ± . m/s in right kidney, . ± . m/s in left kidney, and . ± . m/s in spleen. arfi velocity was not different between boys and girls. however, arfi velocity was different between right and left kidneys (p . ). the arfi value of right kidney, left kidney and spleen was correlated with age, height, weight and bmi (p< . ). however, the arfi value of liver was not correlated with these parameters. conclusions: arfi measurement is feasible in children with only three times acquisition for each abdominal organ. the mean arfi velocity was increased according to the age, height, weight and bmi in kidney and spleen, but it was constant in liver. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: diagnostic image quality can be achieved over a wide range of radiation exposure in digital radiography. "exposure factor creep" or "dose creep'" in which technologists tend to increase dose to avoid the appearance of noise has been well described. using the alara principle, acceptable images can be achieved while minimizing dose. at our institution "dose creep" has been observed in bedside pediatric chest radiography. to address this we coupled a data mining tool with a continuous quality improvement (cqi) initiative which educates individual technologists on appropriate technique. methods & materials: radiation dose in digital radiography is estimated from an exposure index, a proprietary format that varies among manufacturers. our institution uses a fuji computed radiography system which calculates an s, or sensitivity value, that provides an approximation of the radiation dose to the imaging plate, using an inverse scale. overexposed bedside chest radiographs were defined by a s value less than . a data-mining program was developed to extract from the dicom header the s value and other relevant information, on a monthly basis. these data were used to provide training and feedback on a one-on-one-basis. results: with ad hoc feedback and group training initiatives prior to implementation of this new system, approximately . % ( / ) of bedside chest radiographs were overexposed over a four month period. after one-on-one intervention with the technologists, preliminary findings reveal a trend towards fewer overexposed radiographs with approximately . % ( / ) with s< . conclusions: our tool provides a simple method for systematically identifying overexposed radiographs and the corresponding responsible technologists. we anticipate that this personalized educational program will continue to reduce the proportion of overexposed radiographs and thus the radiation dose to our pediatric patients. purpose or case report: ensuring radiation protection for children undergoing ct scans is challenging due to rapidly changing technology, differences in ct equipment and potential lack of understanding of unique aspects of scanning children. the joint commission has named technologists' training as an "action" item. we developed online training modules to fill potential gaps in ct technologists' education. methods & materials: four modules were created by pediatric radiologists, radiologic technologists and medical physicists; were developed by education/training experts from major ct vendors (ge, philips, toshiba, siemens) through the medical imaging technology alliance. modules were created as microsoft word documents containing de-identified images and edited by education specialists at the american society of radiologic technologists and the alliance for radiation safety in pediatric imaging. they were converted to audio/video format using question/answer narration. vendor modules were created in microsoft powerpoint format and edited. all modules were converted into adobe captivate learning program to achieve uniformity of appearance. modules are hosted on the asrt server and linked to the image gently website. a certificate may be printed as documentation of completion. results: all modules are available at www.imagegently.org. two introductory modules discuss basics of ct equipment and medical physics related to radiation dose in children. the third and fourth modules discuss dose-saving strategies for neu-roct and body ct. four vendor-produced modules address unique aspects of equipment design such as automatic exposure control and dose saving strategies for children. conclusions: through collaborative efforts with medical imaging professionals and vendors, we have developed free online modules addressing radiation protection for children. ct technologist training in specific dose saving strategies for children is variable and limited. these modules have the potential to improve ct technologists' understanding of equipment. end confusion which focused attention on improving communication with patients and families. there is little research regarding health literacy (hl) in radiology. the purpose of our study was to determine if an educational intervention (brochure) improves hl for parents whose child will undergo a fluoroscopic study. methods & materials: an education exemption was obtained from the irb. a multidisciplinary team developed brochures for fluoroscopic procedures. participants were randomly selected and asked to complete a survey to assess their knowledge of the procedure and use of radiation both before and after reading a brochure. a final survey to rate and gain feedback about the brochure was completed. results: median age of children whose parents participated (n ) was years. vcug was most commonly performed ( %). prior to the brochure, % of participants knew the name of the test their child was having. after the brochure, % knew the name (p < . ). prior to the brochure, % felt informed about the test, whereas % felt informed after (p<. ). test scores showed an improvement in parent knowledge about the procedure with a median increase of points after the brochure (scale of - ; p<. ). even after reading the brochure, % of parents wanted more information. prior to the brochure, % of parents knew the test involved radiation compared to % afterwards (p<. ). parents improved their understanding of the relative amount of radiation compared to background from % before to % after the brochure (p<. ). overall, % rated the brochure > on a -point scale with % rating the brochure (p<. ). written feedback was uniformly excellent. conclusions: improving hl for parents is part of the mission of radiology medical professionals. our study demonstrates that there is room for improvement in communicating with parents about fluoroscopy. straightforward information for parents provided as a brochure improves their understanding of radiologic fluoroscopic procedures. paper #: pa- compendium of resources for radiation safety in medical imaging anum minhas, duke university, anum.minhas@duke.edu; donald frush purpose or case report: diagnostic imaging, including ionizing radiation modalities, maintains a foremost role in evaluation of medical disorders. there is increasing awareness and need for information across varied sectors about low level radiation and potential risks. many medical/scientific organizations have resources discussing radiation risk and management. however, there is no one resource compiling the same available information. methods & materials: websites, including those of national and international medical organizations (e.g., acr, "image gently" alliance, iaea) were reviewed for information on radiation dose, risk, justification, optimization, guidelines (which included general information about improvement in quality and dose reduction without specific mention of optimization techniques), appropriateness criteria, and general principles of radiation safety for radiography, fluoroscopy/angiography, and ct. this information was divided by modalities and separated into adult and pediatric populations. information from organizations that were not arbitrarily considered to be national (e.g., subspecialty society, regional organization, individual institution/practice) was not reviewed. the resources were then organized into tables, organized by modality. websites with training modules were noted as well. results: websites were explored. overall, less information is available about medical radiation safety in children compared to adults. across both, most information is available on ct, then fluoroscopy, and finally radiography. across all groups and modalities, there is no information available for patients/parents on optimization, appropriateness, or guidelines, with the exception of adult radiography where there were some guidelines. conclusions: this compendium on medical imaging radiation serves as a collective resource for communities including the public and regulatory organizations. additionally, the compendium can be used to determine redundant or deficient areas, providing opportunities for more comprehensive and efficient efforts in medical radiation protection for patients. inappropriate and cloned histories in children: how big a problem is it? leann linam, md, radiology, uams/ach, llinam@uams. edu; chetan c. shah, s bruce greenberg purpose or case report: acr standards require appropriate clinical history for obtaining imaging examinations. cloning clinical histories is a federal violation. our purpose is to determine the frequency of inappropriate histories (ih) and/or cloning histories (ch) at a tertiary children's hospital. methods & materials: three pediatric moc radiologists reviewed clinical histories for radiographs obtained at a tertiary children's hospital on randomly selected dates ( weekdays and weekend day) for appropriateness and cloning. appropriate histories have associated icd- codes. cloning is defined by identical clinical histories occurring on consecutive days and could be clinically appropriate or inappropriate. only the first patient radiograph on a day was included. χ testing was performed to determine significant differences. results: % ( / ) of exams had ih. ih were significantly more common in inpatients than outpatients (p< . ). nicu examinations accounted for % of all ih and were significantly more frequent than other inpatient locations (p . ). the cvicu examinations accounted for % of all ih and was the second most common patient location for ih, but not significantly different from other inpatient locations (p . ). the increased frequency in ih on the weekend reflects a change in patient mix with fewer outpatient examinations performed than on weekdays and was not significant (p . ). the most common ih included: evaluate ett or evaluate lungs ( each). cloning only occurs in inpatients and was combined with ih in % of patients with ch. the nicu accounted % of ch which was significantly greater than other inpatient locations (p . ). conclusions: in radiographs had ih which can lead to misdiagnoses or nonpayment by insurance companies. inpatients, especially the nicu were the most common patient locations. cloning was also a common problem and was frequently combined with ih. identifying the extent of ih allows for corrective educational measures to be instituted which should improve compliance with existing medical and legal standards for ordering radiographs. paper #: in vivo validation of size-specific dose estimates (ssde) through breast entrance skin dosimetry (esd) during pediatric chest ct angiography sjirk westra, md, radiology, massachusetts general hospital, swestra@partners.org; xinhua li, mannudeep kalra, bob liu, suhny abbara purpose or case report: ssde is a new ct dose measure that corrects scanner console ct dose index (ctdi) for cross-sectional body diameter, being a better estimate of absorbed dose in individual patients of varying body size. ssde has been developed through phantom studies and computer simulations of ct dose, but has not yet been validated in vivo. the purpose of our study was to determine correlation between ssde and measured breast entrance skin dose (esd) for pediatric chest cta across a variety of scanning techniques, scanner models and patient sizes. methods & materials: our study was irb-approved, with waiver of written informed consent. during consecutive chest cta exams done on different scanners over a period of years, we measured mid-sternal esd as an approximation of breast dose with skin dosimeters, which was also expressed as mammogram equivalents. for each scan, we recorded patient age, weight, effective ma, kvp, console ctdivol- cm and dlp- cm (from which we calculated age-adjusted effective dose (ed)). we measured effective chest diameter Ø to convert ctdi to ssde, and we correlated ssde with measured breast esd, using linear regression. we evaluated image quality with regard to answering the clinical question. (table) , due to systematic introduction of automatic exposure control, low kv and high pitch scanning techniques. all studies were of diagnostic image quality to address the clinical question. conclusions: ssde is a valid measure of ct dose in pediatric patients undergoing chest cta over a wide range of scanner platforms, techniques, and patient sizes, and may be used to model breast and other organ dose, and to document results of dose reduction strategies over time. purpose or case report: the purpose of this project was to create an automated system capable of quantifying slice-byslice ct image quality and radiation dose data based on patient size. the information generated from this system should enable size-specific optimization of ct scan parameters in order to obtain images of diagnostic quality at the lowest possible radiation doses. methods & materials: a mathematical model was developed to predict ct image noise based on kvp, effective mas, and water-equivalent diameter of the patient. a conical water phantom was used to calibrate the model on multiple scanners and accounting for different operational modes and scan parameters, including tube voltage (kvp), tube current (effective mas), bowtie filter, and focal spot size. a software application was created to process image data from the scout topogram and incorporate dicom metadata from the axial images. a database and data viewing application were developed to display individual and aggregate study data. all of these systems were integrated and automated to enable real-time monitoring of image quality and radiation dose as a function of patient size. results: since the completion of the automated system, ct exams have been processed. a search application allows the user to find an individual study or a collection of studies based on parameters such as body part imaged or study protocol. the viewing application displays slice-by-slice patient diameter, radiation dose, and image quality for each study. radiation dose estimates are adjusted for patient size, yielding size-specific dose estimates. the application also graphs individual study data compared to those of comparative studies that are included in the search. conclusions: we have successfully developed an automated system that monitors ct image quality and radiation dose data based on patient size. the system enables simultaneous real-time monitoring of all studies performed on all ct scanners at our institution. specifically, the system enables size-specific radiation dose estimates at every scan level. this system will be used to guide protocol adjustments in order to optimize ct image quality and thus optimize radiation dose. disclosure: dr. larson has disclosed that he has a patent application in process through cchmc for ct radiation dose reduction. purpose or case report: at many institutions, ct scan parameters for children are determined by patient age or weight. aapm task group recommends cross sectional body dimension, such as patient width to determine size specific dose estimates. the purpose of our study was to develop prediction models of body width based on patient age and weight and compare these models with actual measured body widths for children undergoing body ct. methods & materials: children's hospitals participated in a -month retrospective review of abdominal ct scans on patients < years of age after local irb approval. recorded values included patient width(cm) from an axial image at the level of the splenic vein, patient age (yrs) and patient weight (lbs). a regression model for predicting patient width as a function of age and weight was determined. results: exams, had all measurements. both age and weight were significant predictors of patient width (p<. ). there was also a significant interaction between weight and age (p<. ), indicating that the relationship between patient width and weight depended on the age of the patient. the r for the regression model for predicting patient width from age and weight individually were . and . respectively. the r for the model including both age and weight and their interaction was . leaving % of the variation unexplained. the regression equation for this model is: patient width . + . x age(yrs)+ . x weight(lbs)- . x age x weight. despite the r of . for the model using both age and weight, the average error (rmse) for predicting patient width compared to a direct measurement of width was . cm. the plot of observed minus predicted values (residuals) versus predicted values indicates that the best model (combination of weight and age) results in measurable errors of predicted patient width relative to direct measurement. conclusions: a combination of both patient age and weight results in a more accurate patient width prediction than using age or weight alone. while age and weight can be used to predict body width, this is not sufficiently accurate for generating ct protocols. therefore, direct measurement of body width form either physical measurement on the patient or from the scout view or an axial image is preferred to select appropriate scan parameters for pediatric abdominal ct. paper #: pa- automated size-adjusted dose monitoring for pediatric ct dosimetry olav christianson, clinical imaging physics group, olav. christianson@duke.edu; ehsan samei, donald frush purpose or case report: the potential health risks associated with low levels of ionizing radiation have created a movement in the radiology community to minimize radiation dose during ct imaging; this is especially important for pediatric patients due to their increased sensitivity to radiation. it is thus essential to accurately assess the risks to pediatric patients undergoing ct imaging. current efforts to monitor radiation dose, however, are limited because they do not account for differences in risk from ionizing radiation due to variability in patient size, age, and gender. in this context, we developed an automated size-adjusted dose monitoring program capable of performing patient-specific risk estimation to facilitate protocol optimization. methods & materials: dicom routing software was used to send dose reports and scout images to an image repository on a dosimetry server. optical character recognition was used to extract dose-relevant data from dose reports; patient size was determined from corresponding scout images. based on anatomical location, risk estimation conversion coefficients (qfactors) were determined for each series in the dose reports. the q-factors were adjusted according to patient size, age, and gender and then multiplied by the dlp to estimate the risk to each patient. this process was applied to the cohort of pediatric patients undergoing ct examination at our institution. to evaluate the impact of including patient size, age, and gender, risk estimates were obtained excluding and including the dependencies on size, age, and gender. the results were computed in units of cancer incidence per cases exposed (cpt). results: the average patient-generic risk estimate for a pilot group of patients undergoing body ct was . ± . cpt. by including patient size, the risk estimate was increased to . cpt± . cpt. by including patient age and gender, the average risk estimate was further increased to . cpt± . cpt. conclusions: we developed a new size-adjusted dose monitoring program for pediatric ct dosimetry. comparisons between patient-generic and our new patient-specific risk estimates show that failure to consider patient size, age, and gender resulted in risk estimates that were too low by a factor of seven. additionally, the increase in standard deviation we observed demonstrates that our method of including patient size, age, and gender is sensitive to the inherent variability in the patient population. disclosure: dr. christianson has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: treatment of prenatally diagnosed lung masses is controversial, with many specialists recommending elective surgical removal in the first year of life because of a reported or perceived increased risk of infection and malignancy, while other centers recommend a conservative approach to management. the natural history of unresected lung masses is not clear. in our center, our standard recommendation is prophylactic resection of asymptomatic lesions, although not all families choose this option. we asked whether respiratory morbidity increased during the time prior to elective resection of prenatally diagnosed lung masses. methods & materials: ninety-eight pregnant women carrying fetuses with chest masses were imaged by ultrasound (us) and magnetic resonance imaging (mri). medical records of the liveborn infants were retrospectively reviewed. results: fetal diagnosis of a lung mass was made at a mean of weeks gestation (range - wks). intrauterine fetal demise was documented in pregnancies. there was one elective termination of pregnancy. three infants were lost to follow up. thus, outcomes were available for children ( % m, % f) with prenatally diagnosed lung masses. significant respiratory morbidity (rm) was defined as the occurrence of pneumonia, asthma, chronic coughing or wheezing, or respiratory symptoms severe enough to require an emergency room visit or hospitalization. of the children who had surgical removal of their lung mass, ( %) had rm prior to surgery. fifteen out of children did not have surgery but have been followed expectantly, and of ( %) developed some form of rm. fifteen of ( %) infants had immediate and significant rm (tachypnea, grunting, increased work of breathing, increased oxygen requirements or need for intubation) in the newborn period leading to urgent surgery (range of age at surgery: - d; mean . d). of the initially asymptomatic infants, ( %) developed rm prior to elective removal of the mass (range - weeks, mean weeks). of the lesions removed, histology revealed: cystic adenomatoid malformation (ccam) %, ccam + sequestration %, sequestration %, congenital lobar emphysema (cle) %, ccam+cle %, other %. conclusions: the risk of respiratory morbidity appears to be increased during the time prior to elective resection of prenatally diagnosed lung masses, which may be important for parents and pediatric specialists to consider when deciding whether to remove an initially asymptomatic lung mass. purpose or case report: it is now accepted that fetal mri with its superior tissue resolution can be very helpful in clarifying anomalies detected during obstetrical ultrasound. this is particularly the case with intracranial abnormalities, although indications are expanding. the current english medical literature, though, appears to be focused on evolving mri techniques and how mri compares to ultrasound with regards to image quality and detection of additional findings which may alter the diagnosis. however, we found no study specifically evaluating the clinical relevance and impact of the information obtained by fetal mri to the specialists who counsel and treat these patients. a "satisfaction and clinical impact" survey was created and sent to all the members of our fetal diagnosis and treatment group, asking specifically how the clinicians rated their satisfaction with this type of imaging, its influence on their counseling and on various clinical decisions, both prenatal and postnatal. results: we received responses from specialists in different clinical disciplines. the greatest number of respondents came from our obstetricians ( %), many of whom perform their own ultrasounds, and from members of our medical geneticists/genetic counselors ( %), although % of respondents were from various other clinical disciplines, both medical and surgical. there was a surprisingly high degree of satisfaction overall with the quality of the images and with the type and amount of information provided. most respondents indicated they felt fetal mri was "moderately" or "extremely" useful for their particular clinical decisions, and most respondents agreed that fetal mri impacted "moderately" or "significantly" on counseling and management of these pregnancies. impact appeared greatest on the counseling of the parents and their decision to terminate/pursue the pregnancy, and the least impact was on issues around delivery. conclusions: fetal mri, in addition to providing images of better quality, particularly in certain conditions, has clinical value in that it directly impacts on the counseling of parents and on clinical decisions. - . ultrasound reports were reviewed to determine sonographic diagnoses. selected patients from this cohort underwent mri using ge . tesla magnet without contrast (sequences included ssfse, fiesta, fgre or dual echo in planes). the images were reviewed and multiple characteristics were assessed for specifiying the area of obstruction. the features included: presence of normal fluid-filled bowel, small rectum for gestational age, signal of meconium in the rectum, and meconium filled dilated bowel. results: cases of sonographically suspected bowel obstruction were identified during the study period; of these underwent fetal mri. of these cases, had normal mri and postnatal outcomes, cases did not have postnatal findings available, and had postnatal meconium peritonitis but no obstruction. one case of congenital chloride diarrhea was diagnosed by fetal mri. a variety of bowel abnormalities were observed amongst the remaining cases. proximal obstruction was diagnosed in cases: jejunal atresia (n ) and multiple atresia (n ). distal obstruction was diagnosed in cases: ileal atresia (n ), meconium plugging (n ), closed gastroschisis (n ), enteral duplication cyst (n ), and imperforate anus (n ). characteristic patterns of features were identified amongst these cases that specified the location of obstruction. these patterns of findings allowed accurate localization of the level of obstruction in all cases when compared to postnatal findings. distal obstruction was characterized by normal fluid-filled small bowel and high t signal in distended loops. jejunal atresia was characterized by multiple loops of dilated bowel with high t signal primarily in the left upper quadrant. small rectum for gestational age was not consistently associated with proximal or distal atresia. conclusions: evaluation of fetal mri with attention to specific features allows localization of bowel obstruction. this may aid in counseling and postnatal management, including the need and type of postnatal imaging study. early diagnosis and treatment of ph may prevent clinical deterioration. pvt may produce a spectrum of imaging appearances, which has not been fully recorded in the literature. the goal of this paper is to review the spectrum of imaging appearances of neonates and survivors of neonatal pvt with special emphasis on the role of us and to correlate these findings with the clinical findings including outcome. methods & materials: a retrospective review of consecutive neonates admitted between - and diagnosed with pvt was conducted. diagnosis was established by us at a mean age of days (range: - ). health records, initial and follow-up (f/u) imaging were reviewed. findings were classified as non occlusive, single branch, pvt (grade ); occlusive pvt (grade ) and pvt with extensive parenchymal ischemia (grade ). results: pvt was diagnosed in patients, of whom were followed up to for years or longer. twelve patients were excluded due to liver disease, expired and were lost to f/u. of the in whom f/u was available, at the time of initial diagnosis, grade pvt was present in , all were on the left. grade pvt was diagnosed in and grade pvt in . on f/u physical exam, findings were unremarkable in / patients. liver function tests (lft) and thrombophilia assessment were available in children, mild lft abnormalities were noted in and children had evidence of thrombophilia. us exams were available in / children. among the survivors of neonatal pvt, us was regarded as normal in only children; showed left lobar atrophy (lla), had slowly progressive splenomegaly without other signs of ph, and developed clinically significant ph requiring shunting. conclusions: pvt has a wide spectrum of imaging appearances, it is possibly underdiagnosed and clinically unsuspected. varying degrees of lla are likely a sequela of clinically silent left pvt. us is a sensitive method for the detection of disease and assessment of progression. paper #: pa- fetal mri in arthrogryposis hedieh eslamy, md, radiology, lucile packard children's hospital, hkeslamy@gmail.com; erika rubesova, louanne hudgins, britton rink, richard a. barth purpose or case report: to present the fetal mri findings in fetuses with a prenatal diagnosis of arthrogryposis and correlate with postnatal outcome or autopsy results. arthrogryposis refers to contractures involving more than one joint which often represent deformational changes secondary to decreased or absent fetal movement. prognosis varies widely dependent on diagnosis, ranging from isolated contractures in amyoplasia to lethality in some cases. we hypothesized that fetal mri may demonstrate central nervous system (cns) pathology and muscle abnormalities which are important for predicting postnatal outcome. methods & materials: we identified fetuses with a diagnosis of arthrogryposis between january and october . all had fetal mri which was performed on a ge . tesla magnet, with ssfse, fiesta and fgre sequences in planes. the fetal mri's were evaluated for cns and muscle abnormalities. the extremities were evaluated for: muscle mass, increase in subcutaneous fat (indicative of muscle atrophy), and extremity joint positioning. these findings were subsequently correlated with the clinical exam of the neonates, pathology in the abortus and karyotype when available. results: results of fetal us, amniocentesis, fetal mri and post-natal or post-termination outcomes will be summarized. five fetuses had ≥ limb joint contractures. a sixth case had neck hyperextension and lateral flexion associated with akinesia and hydrops. on mri, no structural brain or spine abnormalities were identified. the abnormalities detected in the extremities were: severe decrease in muscle mass associated with increased subcutaneous fat ( cases); normal muscle mass ( cases); moderate decreased muscle mass associated with increased subcutaneous fat ( case). in the cases that delivered, the diagnoses were amyoplasia ( ) and distal arthrogryposis ( ). in a fourth case that underwent elective termination, autopsy was consistent with amyoplasia. two cases are pending delivery. conclusions: while fetal mri can be useful to rule out cns anomalies, it may also provide important information on decreased muscle mass as an important prognostic sign in a fetus with arthrogryposis. in our series, severely decreased muscle mass was predictive of amyoplasia, and joint contractures limited to hands and feet with preserved proximal muscle mass was predictive of distal arthrogryposis. both diagnoses are associated with relatively good prognosis and usually normal intelligence. purpose or case report: the purpose of this study is to assess the effects of iterative reconstruction technique (irt) on image quality metrics measured in child-sized anthropomorphic phantoms as kvp is changed. methods & materials: ct scans were performed on anthropomorphic phantoms with sizes of , & years (atom phantoms, cirs, norfolk virginia) using low dose pediatric chest protocols ( . , & msv) to determine baseline noise and dose levels. subsequently three voltage levels ( , & kvp) were used while adjusting mas to maintain baseline ctdivol and without mas adjustment which allowed varied ctdivol. images were reconstructed using % filtered back projection (fbp) and blends fbp: ir ( : , : , & : ) . parameters including ctdivol, dose length product, scan length, kvp, and mas, were recorded for each scan. image noise, contrast:noise (cnr), and signal:noise (snr) data were recorded from rois in phantoms and dilute iodine contrast filled syringes ( , , . %). results: as kv is lowered from to , image noise is doubled if mas is not increased to maintain ctdivol, and cnr is increased but snr is decreased due to the increased image noise. as kvp is lowered from to , image noise is increased nominally ( - %) if mas is increased to maintain ctdivol; therefore the increase in cnr and decrease in snr is negligible. ctdivol is reduced > % in all phantom scans as kv is reduced from to . irt reduces image noise by up to % [range - %] in all phantom sizes and in clinical images. as ctdivol is maintained in patient scans, image noise, cnr, and snr are reduced in patients (p< . ), resulting in improved image quality. conclusions: when lowering kvp, compensation with increases in mas is necessary to maintain ctdivol. however, lower target ctdivol can be achieved when adding irt as image noise can be decreased. for these phantoms, cnr and snr improved using all [selected] levels of ir, even when kv was reduced, resulting in lower ctdivol in phantoms. at all kvp settings when irt is applied, image noise is reduced, resulting in improved cnr and snr for all phantoms. disclosure: dr. bardo has indicated she is in the speaker's bureau and receives an honorarium from koninklijke philips. paper #: pa- adaptive iterative dose reduction in evaluation of the pediatric abdomen with ultra-helical -channel mdct jeffrey hellinger, md, stony brook university, jeffrey. hellinger@yahoo.com; bernice hoppel, richard mather, monica epelman purpose or case report: radiation reduction is paramount for pediatric patients. ultra-helical -channel mdct allows for rapid acquisitions at low dose. we evaluated the ability of a new adaptive iterative dose reduction algorithm (aidr) to reduce noise in low-dose ultra-helical pediatric abdominal ct scans. aidr is an iterative algorithm that adaptively reduces noise in the raw and image domains while preserving image structure. the raw data from consecutive low-dose pediatric abdomen exams was gathered. a dose simulation tool which adds noise to raw projection data was employed to simulate tube current at / of baseline ma. data were reconstructed with both standard filtered back projection and with aidr. regions of interest were drawn in the liver and lumbar musculature to determine the signalto-noise (snr), contrast-to-noise (cnr) and overall diagnostic quality of each data set. statistical significance was determined using a student's t-test. subjective image quality was evaluated by two reader blind review using a five point scale ( excellent, unacceptable). results: the snr and cnr were significantly lower for the % dose reduction datasets compared to the original filtered back projection reconstructions (snr: . vs . , p< . ; cnr: . vs . , p . ). when aidr was applied to the % dose reduction data, the snr and cnr improved to be superior to the native case (snr: . vs . , p< . ; cnr: . vs . , p . ). the average image quality score for the low dose datasets with aidr was . compared to . with standard filtered back projection at the baseline ma conclusions: aidr significantly improves the image quality of pediatric abdominal ct images. with a simulated % reduction in dose, aidr produces images with significantly greater snr and cnr. the subjective image quality scores for aidr showed dramatic improvement over standard filtered back projection. aidr processing algorithms with ultra-helical mdct will allow % reduction in radiation exposure while achieving the same diagnostic quality as compared to routine pediatric abdomen mdct radiation protocols with filtered back projection processing algorithms. purpose or case report: to explore incorporating asir into pediatric head ct protocols, to reduce patient radiation dose while maintaining image quality. methods & materials: an alderson rando head phantom was estimated to approximate the size of a -year-old child's head, and was scanned at decreasing % ma intervals ( to %, to ma) relative to this institution's age-based head ct protocols. each of these studies was then was reconstructed at % asir intervals ( % to %), and a mm roi was obtained in a consistent location behind the frontal bone to estimate noise (sd). using this phantom data, our ventriculoperitoneal (vp) shunt follow-up ct protocol was modified, and patients were scanned at % asir with approximately % ma reductions relative to our normal age-based mas. these asir studies were then anonymously compared to older non-asir head ct studies from the same patients (with identical kvp/slice thickness) by two blinded attending pediatric neuroradiologists. all studies were evaluated subjectively for diagnostic utility ( - ), sharpness ( - ), noise ( - ), and artifacts ( - ). - mm rois were drawn in consistent locations to estimate noise in air, bone, csf, and white matter (wm). results: the phantom study suggested similar same noise levels at % ma/ % asir ( . ) and % ma/ % asir ( . ). patients (average , range to years) were then scanned at approximately % ma reductions, with an average of days (range to days) between the asir study and prior non-asir study. the average ctdivol and dlp values of the % asir studies were . mgy and . mgy-cm, and for the non-asir studies were . mgy and . mgy-cm, representing statistically significant decreases in the ctdivol ( . %, p . ) and dlp ( . %, p . ) values. there were no significant differences between the asir studies and non-asir studies in respect to diagnostic acceptability (p . ), sharpness (p . ), or noise (p . ). there was a non-significant trend that the asir studies had a lower artifact score ( . vs . , p . ). there was good to perfect (kappa . to . ) agreement. the asir studies had statistically significant decreased csf noise ( . vs . , p . ), but no noise differences were seen in air (p . ), bone (p . ), or wm (p . ). conclusions: our findings suggest that asir can provide dose reductions in pediatric head ct without affecting image quality. purpose or case report: to validate the t map as a noninvasive quantitative biomarker of fatty infiltration of muscles and to determine whether the t map can differentiate between boys with dmd and healthy boys. methods & materials: two groups of boys with similar ages (range - years) were evaluated: boys with dmd (mean age . years) and healthy boys (mean age . years). mr images were performed at t. fatty infiltration of the pelvic and thigh muscles on t -weighted images (wi) was graded from to . on t maps with and without fat suppression, the muscle with the greatest fatty infiltration on t -wi was selected, and a region of interest was placed to obtain t values. t values from t maps with fat suppression were subtracted from values of t maps without fat suppression and designated as the "t fat value." t fat values were obtained from the same muscles in all boys. comparison was made between the t fat values of the two groups. the upper reference limit of the reference interval (ri) of t fat values was obtained from the control group to establish the normal range and applied to both groups to determine the accuracy of the t map. results: the gluteus maximus muscle had the greatest fatty infiltration on t -wi. median t fat value was . msec for dmd ( % ri . , range . - . ) and . msec for the control group ( % ri . , range . - . ). when applied to the two groups, the upper reference limit of the ri for control patients yielded % sensitivity, % specificity, % positive predictive value, and % negative predictive value. conclusions: utilization of t maps for the quantitative measurement of fatty infiltration of muscles can clearly differentiate between dmd and normal control boys with a high degree of accuracy and precision. this advanced noninvasive technique may potentially replace invasive muscle biopsies currently used for diagnosis. purpose or case report: prior work has shown that the gluteus maximus muscle has the greatest t relaxation time on mr imaging using t mapping in boys with duchenne muscular dystrophy (dmd). however, an increased t value on t relaxation time mapping may reflect both fatty infiltration and inflammation of the muscle. fatty infiltration characteristically follows inflammation in this disease process. therefore, the purpose of this study was to determine the contribution of each component (fat and inflammation) within gluteus maximus muscles and to correlate each component to clinical assessments. methods & materials: forty-six boys with dmd (ages: - years) were recruited. mr imaging of the pelvis using t maps with and without fat suppression were performed. the t map "fat values" (t value calculated from the t map without fat suppression [fs] minus t map with fs) and the t map "inflammation value" (t value from the t map with fs) were obtained. clinical assessments typically used to evaluate dmd patients (including clinical functional score, ft run, gower score, and step-up time) were also performed. spearman correlation coefficients between fat and inflammation values and the clinical assessments were calculated. results: there was a statistically significant correlation between the fat value of the gluteus maximus muscle and each clinical assessment test (p< . ). however, the inflammation value of the gluteus maximus muscle did not correlate with any clinical assessment. conclusions: in dmd, the amount of fatty infiltration of the gluteus maximus muscle has excellent correlation with clinical assessment. the amount of inflammation of the gluteus maximus muscle, however, does not correlate with clinical function. therefore, further study is needed to determine whether components (fatty infiltration or muscle inflammation) of the single most involved muscle reflect the components of all the muscles of the pelvis and thighs and whether the cumulative muscle involvement of each component represents clinical disease severity. utility of contrast-enhanced mr imaging in children with osteonecrosis: does gadolinium help? lamya atweh, md, radiology, texas children's hospital, laatweh@texaschildrens.org; robert c. orth, wei zhang, r. paul guillerman, herman kan purpose or case report: at our institution, gadolinium contrast-enhanced mr sequences are often obtained to assess epiphyseal and non-epiphyseal osteonecrosis in children. several studies have shown that dynamic contrast-enhanced sequences may provide prognostic information about long-term complications and healing of osteonecrosis. to our knowledge, no studies have determined the added value of routine post-contrast mr imaging in assessing acute complications related to chronic osteonecrosis. the purpose of this study was to evaluate the utility of intravenous gadolinium contrast in the mri identification of complications in children with an established diagnosis of osteonecrosis. methods & materials: patients were restrospectively identified (age range: . years to . year; m:f : ) with an imaging diagnosis of chronic osteonecrosis who underwent contrast-enhanced mr studies between / and / . the pre-and post-contrast mr images were consensus reviewed by two caq pediatric radiologists. pre-and post-contrast images were reviewed at separate times. the pre-contrast images were available during the review of post contrast images. studies were assessed for: osteonecrosis location (epiphyseal, non-epiphyseal osteonecrosis, or both), joint effusion, marrow edema, and epiphyseal collapse. % confidence interval (ci) and cohen's kappa coefficient(κ) was calculated to assess observed agreement. results: the diagnosis of osteonecrosis without complicating features was made in . % (ci: . - . %) ( / ) of pre-contrast studies and . % (ci: . %- . %) ( / ) of post-contrast studies. when chronic osteonecrosis with complicating features was identified,pre-and postcontrast images idenfied joint effusion in . % ( / ) and . % ( / ) (κ . , p< . ); marrow edema in . % ( / ) and . % ( / ) (κ . , p< . ); and epiphyseal collapse in . % ( / ) and . % ( / ) (κ . , p< . ), respectively. myositis or muscle strain was incidentally diagnosed in . % ( / ) pre-contrast and . % ( / ) post-contrast (κ . , p < . ) studies. conclusions: the high observed agreement between the pre-and post-contrast mr images shows that the addition of intravenous gadolinium may not be necessary in the majority of children with chronic osteonecrosis. paper #: pa- systematic protocol for assessment of the validity of bold mri in a rabbit model of inflammatory arthritis at . tesla michael chan, bhsc, university of toronto, mw.chan@ utoronto.ca; afsaneh amirabadi, anguo zhong, antonella kis, rahim moineddin, andrea s. doria purpose or case report: blood oxygen level-dependent (bold) mri has the potential to identify regions of early hypoxic and vascular joint changes in inflammatory arthritis. at this point, there is no standard protocol for data analysis of bold mri measurements in musculoskeletal disorders. standardization of the technique is paramount to compare results between studies and assess the validity of this technique in tissues outside the blood-brain barrier. our objective is to optimize bold mri reading parameters in a rabbit model of inflammatory arthritis by determining the diagnostic accuracy of ( ) statistical threshold values (r> . vs r> . ), ( ) summary measures of bold mri contrast [ the mean of the % bold signal differences within the region of interest (roi) (diff_on_off) and the percentage of suprathreshold voxels within the roi (pt%)], and ( ) voxel activation algorithm (positive, negative, and positive_negative). methods & materials: using bold mri protocols with a carbogen stimulus on a . t magnet, we imaged injected and contralateral knee joints of juvenile rabbits at baseline, and days , and after a unilateral intra-articular injection of carrageenin. nine non-injected rabbits served as controls. receiver operating characteristic (roc) curves were plotted to determine the diagnostic accuracy of the reading parameters. the bold measures from [(injected knee-control knees)/control knees] were counted as positive cases, while the bold measures from [(contralateral knees-control knees)/control knees] were regarded as negative cases. areas under the curve (aucs) were calculated to determine the most accurate parameters. results: using diff_on_off and positive_negative activations as constants, r> . was found to be more accurate than r> . (p . at day ). comparison of diff_on_off and pt% yielded no statistically significant difference (p> . ). finally, positive_negative activations for diff_on_off and negative activations for pt% using r> . were the most diagnostically accurate (auc . , p< . at day , and auc . , p< . ). conclusions: from the results of this study, the most diagnostically accurate and clinically relevant reading parameters included the use of a more lenient threshold of r> . , a diff_on_off measure of bold contrast, and a positive_negative voxel activation algorithm. pt% may used as an ancillary measure of bold contrast. quantitative versus semi-quantitative mr imaging of cartilage in blood-induced arthritic ankles andrea doria, md, phd, diagnostic imaging, the hospital for sick children, andrea.doria@sickkids.ca; ningning zhang, carina man, pamela hilliard, ann marie stain, victor blanchette purpose or case report: to cross-sectionally compare the ability of a scoring system (semi-quantitative method) with a manual segmentation technique (quantitative method) to evaluate the status of the articular cartilage of growing ankles of children with blood-induced arthritis. methods & materials: boys, with hemophilia (a, n ; b, n ) and with von willebrand disease, median age (range, - ) underwent a high resolution mri protocol at . tesla, x-rays, and physical examination using the hemophilia joint health score (hjhs) system. two blinded radiologists scored the mri examinations for cartilage items (horizontal component: surface erosions, scores - and vertical component: cartilage degradation, scores - ) according to the semiquantitative method (international prophylaxis study group mri scale). an experienced operator applied a validated quantitative d-mri method (horizontal components: ac, vc, vctab, thctab; vertical component: thccab) to corresponding high resolution mr images of ankles. results: internal correlation of the semi-quantitative method components was substantial (r . , p< . , tibia) to high (r . , p< . , talus) in any site of investigation, but it was site-specific with the quantitative method, being significant only in the talar trochlea (r . , p< . ). external correlation of corresponding components of the semiquantitative and quantitative methods was moderate (r . , p . ) to poor (r . , p . ) for horizontal components, and non-existent for vertical components. components of the semi-quantitative method highly correlated with lifetime number of previous ankle bleeds (r . - . , p< . ), pettersson x-ray (r . - . , p< . ), and hjhs scores (r . , p< . ). this correlation was poor (r . , p . ) to moderate (r − . , p . ) for horizontal components of the quantitative method. conclusions: the biologic concepts of the semi-quantitative and quantitative mri methods are distinct for assessment of ankles. the semi-quantitative method is valid for assessing cartilage changes in cross-sectional studies of blood-induced arthropathy, however the quantitative method is suboptimal or less powerful for this purpose. paper #: pa- shoulder mr arthrography in skeletally immature patients nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email. chop.edu; camilo jaimes, victor ho-fung, diego jaramillo purpose or case report: there has been a well documented increase in sports participation in children which has lead to an increase in sports-related injuries. to date, there are no studies describing the value of shoulder mr arthrography compared with the gold standard, arthroscopy. we retrospectively reviewed mr shoulder arthrograms obtained in pediatric patients between and who underwent subsequent shoulder arthroscopy. interpretation of the images was performed by three pediatric radiologists who were blinded to the arthroscopy findings. images were evaluated in consensus and independently. assessment included evaluation of the osseous structures, labral-ligamentous complex, joint space and the rotator cuff interval. the mr results were compared with reported surgical findings. sensitivity and specificity were calculated. results: nine patients were excluded due to technical reasons. of the remaining patients, were boys ( . - . years, mean . years) and were girls ( . - . years, mean . years). at arthroscopy, patients ( %) had injury to the anterior inferior glenoid labrum. mr sensitivity was % for depiction of bankart-type injuries with a specificity of %. patients ( %) had hill sach lesions and mr had sensitivity of % with specificity of %. superior labrum anterior posterior (slap) tears ( %) were identified at arthroscopy with mr sensitivity of % and specificity of %. overall, mr arthrography had a positive predictive value of % for identification of a surgical lesion. agreement between the observers was high. interobserver reliability was calculated with an intraclass correlation coefficient (icc)of . with a cronbach's alpha of . . conclusions: mr shoulder arthrography can accurately depict labral and osseous injury and provides pertinent preoperative information. a novel multi-channel mr coil for improved pediatric elbow coil imaging suraj serai, phd, cchmc, suraj.serai@cchmc.org; randy giaquinto, kathleen emery, charles dumoulin purpose or case report: single flex coils or adult size coils are currently used for imaging the pediatric elbow. this frequently results in uncomfortable patient positioning, motion, poor fat suppression, low snr and there is currently lack of a dedicated pediatric elbow coil in the commercial market. our goal was to explore the usefulness of a new coil array dedicated for pediatric elbow imaging and to compare quantitative & qualitative imaging findings to commercially available coils. methods & materials: an eight channel elbow coil was designed. the coil frame was designed to be rigid and lightweight. seven identical loop coils were built into a polycarbonate frame and an eighth coil built into a paddle that fits into the top frame. the coil elements were constructed with heavy copper to provide a high q-factor and increased snr. the complete coil including electronics & covering, weighs only . kg. mr imaging under irb approval was performed on a ge . t scanner using a routine clinical elbow protocol including t w, pdw, t w, fat-sat, non-fat-sat, d & d sequences. subjects were positioned feet-first with the elbow on the side & were subjectively assessed for comfort level. images obtained from the new coil & from the current commercial coils were compared for snr. results: scan positioning was reported to be comfortable. snr was between - % higher as compared to the routine coils. fat saturation was uniform, indicating that the magnetic susceptibility of the coil is well-matched to human anatomy. anatomical detail depiction was subjectively better for anatomic features such as trochlea. detection & diagnostic confidence of elbow disorders were improved with the new coil & greatly decreased motion artifacts were observed. conclusions: the new pediatric elbow coil provided excellent image quality, patient acceptance and clinical performance improvements over existing coils. the open coil design also allows for imaging of the elbow in a partially flexed position or in a cast. the advantages provided by the new coil are expected to include shortened image acquisition times (via parallel imaging) & increased snr. disclosure: dr. serai has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. incremental value of knee radiography in the interpretation of pediatric knee mri yen-ying wu, texas children's hospital, yxwu@ texaschildrens.org; robert c. orth, wei zhang, r. p. guillerman, herman kan purpose or case report: the acr appropriateness criteria recommendation for the imaging work-up of knee pain is radiography followed by mri. in many cases, mri is performed prior to review of radiographs or the referring subspecialist does not feel radiographs add value, particularly when ligamentous injury is suspected. the purpose of this study is to determine if radiography adds incremental value in the interpretation of knee mr studies electively referred by pediatric sports medicine and orthopedic subspecialists. knee mri studies referred from pediatric sports medicine physicians or pediatric orthopedic surgeons between / and / (n , ages - years, m:f : ) with accompanying radiographs were identified. patients were separated into groups based on mri findings: normal, ligamentous injury, or osteochondral injury (osteochondral lesions, bone contusions/fracture, and avulsion injury). knee radiographs were consensus reviewed by two caq pediatric radiologists blinded to mri findings and categorized into the same groups. radiograph and mri findings were compared and categorized into groups: neutral if radiograph and mri findings were the same, misleading if findings were discordant, or helpful if radiographs improved mr interpretation. the latter group was analyzed for impact on mr diagnosis. results: for knee radiographs, were normal, showed ligamentous injuries, and showed osteochondral injuries. when radiographs were interpreted as normal (n ), by mr % were normal, % had ligamentous injury, % had osteochondral injury, and % had both ligamentous and osteochondral injury. when radiographs were interpreted as ligamentous injury (n ), by mr % were normal and % had ligamentous injury. when radiographs were interpreted as osteochondral injuries, by mr % had ligamentous injury, % had osteochondral injury, and % had both ligamentous and osteochondral injury. subset analysis of true positive radiographs (n ) found % to be helpful and % to be neutral in mr diagnosis. for radiographs considered helpful, % resulted in a change in mr diagnosis. in regards to the influence of radiographs on mr interpretation, % ( / ) were misleading, % ( / ) were neutral, and % ( / ) were helpful. conclusions: a minority of pediatric knee radiographs aided mr diagnosis, and none resulted in a change in diagnosis. pediatric knee mri and interpretation should not be predicated on radiologist review of knee radiographs in this subset of patients. paper #: pa- sonographic evaluation of pediatric skeletal lesions: is it worthwhile? henrietta rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; amish patel, neil lester purpose or case report: the purpose of this paper is to demonstrate how ultrasound(us) may serve as a readily available, cost-effective, non-invasive, non-ionizing, practical tool for the evaluation of a variety of skeletal abnormalities in the pediatric age range. we reviewed the clinical and imaging findings in patients seen during the past years in whom us demonstrated abnormalities related to the skeletal system, excluding patients with hip joint effusions or ddh. results: us proved useful in the following situations: evaluation hard superficial immobile mass (osteoma shin) ( ), absent medial end clavicle on x-ray in region of neck mass (us showed abc medial end clavicle)( ), to determine if soft tissue mass involves adjacent bone nodular fasciitis surrounding clavicular head ( ), for diagnosis and followup fracture (displaced/non-displaced) in infants ( ), diagnosis osteomyelitis in patients with cellulitis ( ), question of fracture underlying cephalohematoma or subgaleal hematoma ( ), rib mass (osteochondroma) ( ) or mass costochondral junctions (contour deformities costochondral cartilage) ( ), firm posterior knee mass (baker's cyst) ( ), firm anterior knee mass (septated cystic mass suprapatella region due to rheumatoid disease) ( ), immobile hard scalp mass due to epidermoid cranial vault ( ), painful mass occipital bone with soft tissue components extending through the skull externally and internally due to langerhan's histiocytosis ( ), indeterminate mass clavicle clinically thought to be post-traumatic sequellae, resolved on follow-up ( ), assessment craniosynostosis ( ), for differentiation of pathological entity from normal anatomic structure (lump on back of slender baby proved to be normal posterior spinous process) ( ). conclusions: us is worthwhile for evaluation of wide range of pediatric skeletal abnormalities and helps to determine if the a lesion is one that is "touch" or "don't touch". to maximize diagnostic accuracy, the imager should have thorough knowledge of the clinical history, physical findings, laboratory and other imaging findings. in equivocal cases or in those patients in whom the field of view (fov) is insufficient for complete visualization of an obvious lesion or if malignancy is suspected, us serves to triage those patients in whom further imaging is necessary. high incidence of vertebral fractures in children with acute lymphoblastic leukemia months after the initiation of therapy mary ann matzinger, md frcp(c), university of ottawa, matzinger@cheo.on.ca; nazih shenouda , brian lentle, josée dubois, helen r. nadel purpose or case report: vertebral fractures due to osteoporosis are a potential complication of childhood acute lymphoblastic leukemia (all). to date, the incidence of vertebral fractures during all treatment has not been reported methods & materials: we prospectively evaluated children with all during the first months of leukemia therapy. lateral thoracolumbar spine radiographs were obtained at diagnosis and months. vertebral bodies were assessed for incident vertebral fractures using the genant semi-quantitative method, and relevant clinical indices such as spine bone mineral density (bmd), back pain and the presence of vertebral fractures at diagnosis were analyzed for association with incident vertebral fractures. results: of the children, ( %, % confidence interval [ci] % to %) had a total of incident vertebral fractures, of which ( %) were moderate or severe. thirteen of the children with incident vertebral fractures ( %) also had fractures at the time of diagnosis. vertebral fractures at diagnosis increased the odds of an incident fracture at months by an odds ratio of . ( % ci . to . , p . ). in addition, for every . standard deviation reduction in spine bmd z-score at diagnosis, there was . -fold increased odds for incident vertebral fracture at months ( % ci . to . %, p . ). conclusions: children with all have a high incidence of vertebral fractures months after diagnosis, and the presence of vertebral fractures and reductions in spine bmd zscores at diagnosis are highly associated clinical features. purpose or case report: to provide objective measures of acetabular morphology utilizing volume-rendered ct and to better characterize normal acetabular development in adolescents. implications for the diagnosis of femoroacetabular impingement (fai) will be discussed. methods & materials: hips in consecutive patients ( female, male; ages - years) who underwent abdominal and pelvic ct for non-hip related complaints were retrospectively examined. examinations were performed for a variety of complaints, including abdominal pain, nephrolithiasis, vomiting etc. patients with obvious hip pathology were excluded. pelvic rotation was eliminated, and pelvic inclination was measured and corrected to °u tilizing a volume rendered ct model. measurements of femoral head diameter (fhd), anterior femoral head coverage (fhca), and posterior femoral head coverage (fhcp) were obtained. femoral head area (fha) was defined as π(fhd/ ) . percent anterior femoral head coverage (%fhca) was defined as (fhca/fha)* . percent posterior femoral head coverage (%fhcp) was defined as (fhcp/fha)* . acetabular version by volume-rendered ct (avvr) was defined as (fhcp/fhca). results: average pelvic inclination angle (sd) was . ( . ) for females and . ( . ) for males. average (sd) %fhca was . ( . ) for males and . ( . ) for females. average (sd) avvr was . ( . ) for males and . ( . ) for females. among males, average avvr decreased with subject age. on the other hand, there was little change in average avvr with age among females. conclusions: average avvr is greater for females than males, and this difference becomes more striking with increasing subject age. this represents an unexpected finding given the reported increased incidence of "pincer" type fai among females. characterization of acetabular morphology among adolescents with clinical fai should consider subject age and gender. in this regard, volumerendered ct is capable of providing an objective measure of acetabular morphology. mistakes in musculoskeletal plain film interpretation james crowe, pediatric radiology, texas children's hospital, jecrowe@texaschildrens.org; george s. bisset purpose or case report: to evaluate the mistakes made by trained pediatric radiologists when interpreting radiographs of the extremities obtained for the evaluation of outpatient acute pain (mostly post-traumatic). we retrospectively evaluated all radiographs and associated interpretations obtained during a month period from april , , to october , , of the elbows, wrists, knees and ankles in pediatric outpatients who presented with acute pain in the affected area. all radiographs were previously interpreted by a caq-certified pediatric radiologist varying in experience from year to years. abnormals were identified, including elbows, wrists, knees and ankles. all radiographs were determined to be "as dictated", missed significant finding, or overcall. attention was focused on the missed findings and overcalls. results: findings were as follows: elbow radiographs- missed findings and overcalls, wrist radiographs- missed findings and overcalls, knee radiographs- missed findings and overcalls, ankle radiographs- missed findings and overcalls. this resulted in a total of missed findings ( . % of abnormals) and overcalls ( . % of abnormals). of the misses, % were fractures. the highest mistake percentage occured in the ankles where the combined misses and overcalls approached %. this was also the location where we found the highest percentage of missed fractures ( . %) conclusions: when just abnormal cases were considered, fully trained pediatric radiologists have a mistake rate of approximately . %, if misses and overcalls are included. from a quality improvement perspective, we will review all of the types of misses and overcalls to expose common themes. longitudinal assessment of osteoporosis in a blood-induced hemophilia rabbit model using quantitative ultrasound kuan-chieh wang, university of toronto, kc.wang@ utoronto.ca; afsaneh amirabadi, anguo zhong, christopher tomlinson, andrea s. doria purpose or case report: the reduction of physical activities in hemophilic patients may lead to bone demineralization and consequent osteoporosis. quantitative ultrasound (qus) is free of ionizing-radiation, relatively inexpensive, and easy to use that making this technique suitable for follow-up of hemophilic children with clinical suspicion of osteoporosis. to our knowledge, no previous study has investigated the value of qus for longitudinal assessment of growing bones in an animal model which is paramount for clinical translation of the technique once change in measurements could relate to either the baseline pathology or physiologic bone growth variability. the objective of this study is to investigate the intra-and inter-operator reliability of qus over time, and its ability to discriminate bone loss in pathologic vs control knees of a rabbit model of blood induced arthritis. methods & materials: sixteen juvenile white new zealand rabbits distributed into two groups: received intraarticular blood injections over weeks (n pathologic and contralateral knees), and noninjected rabbits were used as controls (n knees). midshaft tibia speed-of-sound (sos) was measured at baseline, and weeks and of the experiment. two operators scanned each site twice at each time point. qus measurements were compared to microct (reference standard) on week to validate the study results. results: the sos measured in the control group increased significantly (p< . ) over the week period. there was not such an increase in the arthritis sos value (p> . ). in both groups the overall intra-operator coefficient of variation of sos measurements was % at baseline and decreased to % at week likely due to increased tibia size. the inter-operator reliability was % at baseline and % at week . with regard to the effect of bone growth on qus measurements for the control group (n ), sos values increased by . m/s, whereas for the pathologic group (n ), they only increased by m/s. statistically significant differences in ratios of sos between final/baseline results were noted (p . ) between the pathologic and control groups. conclusions: the longitudinal use of qus has an acceptable intra-and inter-operator reliability. even accounting for the significant impact that bone growth has on qus measurements over time, qus can differentiate pathologic from control knees in the proposed animal model and holds potential for clinical use in the assessment of osteoporosis in hemophilic children. methods & materials: the study was approved by the institutional review board. pediatric patients with abdominal tumors ( malignant and benign lesions) underwent diffusion-weighted mr imaging (dwi) on clinical . t (n ) and t (n ) mri scanners. adc maps were generated from b dwi and adc values were retrospectively and independently measured by two radiologists. adc values of benign and malignant tumors were compared with the welch two sample t-test. a p value of . was considered to indicate statistical significant differences. in addition, a receiver operating curve analysis (roc) was performed to determine the optimal cut-off adc value for differentiating benign and malignant tumors. results: the mean adc value (mm /sec) of benign tumors was . x - for the first reader and . x - for the second reader. the mean adc value (mm /sec) of malignant abdominal tumors was . x - for the first reader and . x - for the second reader. the differences between benign and malignant tumors were statistically significant (p< . for both readers). roc analysis revealed an optimal cut-off adc value for differentiating malignant and solid tumors as . x - mm /sec. conclusions: diffusion-weighted imaging with adc maps can be used to differentiate between benign and malignant pediatric abdominal tumors. creation of a database to evaluate imaging findings in long-term survivors of pediatric malignancy alexander towbin, md, radiology, cincinnati children's hospital medical center, alexander.towbin@cchmc.org; seth hall purpose or case report: over the past years, there have been significant improvements in the treatment of pediatric malignancies. improved therapy has led to an increase in the number of long-term survivors. many of these survivors are now experiencing late effects as a result of the original disease process or its treatment. these late effects are frequently identified on imaging. the purpose of this study is to create a database of the imaging findings of long-term survivors of pediatric malignancy in an attempt to begin to classify the findings and identify associations. methods & materials: after irb approval, the institutional cancer registry was searched to identify all patients younger than years of age who were diagnosed with a solid tumor between and . patients were included in the database if they survived for more than years from the date of their initial diagnosis. the electronic medical record system was then used to obtain demographic and treatment information for each included patient. the dictated reports from all cross-sectional imaging studies evaluating the chest, abdomen, or pelvis performed more than two years from the date of diagnosis were then reviewed. each positive imaging finding was classified by the involved organ. results: after querying the institutional cancer registry, patients were identified who met the inclusion criteria for this database. the most common neoplasms were neuroblastoma, wilms tumor, and astrocytoma. of the included subjects, had imaging of the chest, abdomen, or pelvis. overall, reports were evaluated and classified. findings were most commonly identified in the lungs, musculoskeletal system, kidneys, liver, and lymph nodes. conclusions: a database examining the late effects in longterm survivors of pediatric malignancies was created. this database has the potential to help identify the radiologic manifestations of the complications of cancer therapy and thus help guide rationally determined long-term risk-benefit ratios in the treatment of pediatric malignancies. imaging followup of lymphoma in pediatric patients: is pelvic ct necessary? javier lopez bueno, md, children's hospital of eastern ontario, jlopezbueno@cheo.on.ca; nishard abdeen purpose or case report: pelvic ct is often included in the imaging followup of patient with lymphoma before, during and after treatment to assess response to treatment and monitoring for relapses. while such followup is expected to improve detection of relapse, there is little objective evidence of its effectiveness in lymphoma. anecdotally, there are few pelvic relapses in pediatric patients with lymphoma regardless of primary site. we hypothesize that pelvic ct could be avoided as part of the followup without adverse impact on survival or in the detection rate of relapses, and with subsequent significant reduction in the radiation dose, particularly to the gonads. methods & materials: research ethics board approval was obtained. patients diagnosed with lymphoma and with at least one year of followup at our tertiary care pediatric hospital were included. sex, age, type of lymphoma, stage, primary site, site of relapse if any as well as the number of ct scans of the head, neck, chest, abdomen and pelvis were recorded. results: a total of patients met study criteria. there were males and females, with an average age of . years (range - years). eighteen patients had hodgkin disease ( %) and eleven had non-hodgkin lymphoma ( %). mean length of followup was . years (range - years). an average of . pelvic scans per patient were performed for surveillance (range - ). three relapses were detected. of these only one was in the pelvis, in a patient whose initial t cell non-hodgkin lymphoma was extensive and involved the neck, chest, abdomen and pelvis. conclusions: this study suggests a low incidence of pelvic relapse in pediatric patients with lymphoma. the routine use of pelvic ct in surveillance protocols may therefore be of little benefit while imposing a significant radiation burden. our study is limited by small sample size and short length of followup. further large scale studies are required. (esft) is performed by measuring the size of the tumors before and after chemotherapy. the proposed method of measuring tumor size, however, differs amongst recist . (response evaluation criteria in solid tumors), who (world health organization) and cog (children's oncology group) response criteria. in our project, we assessed whether response classification differs between the three different methods. methods & materials: after irb approval, we retrospectively analyzed mri studies of patients with ewing sarcoma who were treated at stanford and ucsf medical centers. tumor size was assessed before and after therapy. tumor measurements were obtained using recist . (longest single diameter), who (longest diameter and perpendicular diameter), and cog criteria (three measurements to calculate tumor volume). tumor response was assessed by the differences in sizes of the tumors before and after treatment using four response categories: progressive disease (pd), stable disease (sd), partial response (pr), and complete response (cr). concordance between the three response classification systems was assessed using cohen's kappa (k) coefficient and percentage of disagreement per response category. results: the k statistic for concordance in cog/who, cog/ recist and recist/who were . , . and . respectively. disagreement rates for recist/who, cog/ who, and cog/recist were . , . , and . % respectively. using tumor volume, twenty-six patients were reclassified: twenty-four cases of stable disease coded by recist were reclassified as progressive disease by cog and two cases of partial response coded by recist were reclassified as complete response by cog. conclusions: this study demonstrates poor agreement between the recist . and cog response criteria in esft. given the degree of discordance between response criteria in esft, evaluation of the prognostic impact of each of these classification systems may guide selection of the optimal system for future use in this disease. imaging recognition of chylous ascites following surgery for abdominal neuroblastoma zeyad metwalli, md, baylor college of medicine, metwalli@bcm.edu; r. p. guillerman, heidi v. russell, eugene s. kim purpose or case report: surgical resection is a standard part of multimodality treatment of neuroblastoma, the most common abdominal malignancy of infancy and early childhood. chylous ascites is a rarely reported complication of surgery for abdominal neuroblastoma, and is likely underrecognized, posing the risk of nutritional deterioration and sepsis. to facilitate early diagnosis and institution of appropriate therapy, we present the salient imaging findings of the largest known series of chylous ascites following surgery for abdominal neuroblastoma. methods & materials: all patients with abdominal neuroblastoma complicated by post-operative chylous ascites over a five-year period at a large children's hospital were identified by a database search. a retrospective review of the imaging studies and clinical charts was conducted. results: chylous ascites developed following surgical resection of abdominal neuroblastoma in of patients, with the diagnosis made between postoperative days and . four cases were high-risk neuroblastoma and one was intermediaterisk neuroblastoma. all cases involved resection of an adrenal mass and dissection around the abdominal great vessels. all cases manifested with abdominal distention on physical exam, and ascites was suspected clinically in cases. computed tomography (ct) in all cases revealed a large volume of ascites of near-water attenuation (range of − to . hounsfield units). the cases imaged with ultrasound (us) showed hypoechoic or anechoic ascites without septations. the chylous ascites resolved after - months of treatment with dietary fat restriction, medium chain triglycerides, intravenous octreotide, or peritoneal catheter drainage. conclusions: chylous ascites is an under-recognized complication of surgical resection for abdominal neuroblastoma, occurring in % of patients in this series. the diagnosis is supported by the demonstration on ct or us of a large volume of ascites causing abdominal distention - weeks post-operatively. the ascites is typically near-water in attenuation rather than fatty in attenuation and should not be misattributed to peritonitis, hemorrhage, bowel leak, or early tumor recurrence. cervical spine injuries in patients with suspected physical abuse nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; zarir p. khademian, tanya hinds, katherine deye, allison m. jackson, eglal shalaby-rana purpose or case report: to evaluate the incidence and nature of cervical spine injuries and relationship to posterior fossa abnormalities in children who underwent brain and cervical spine mri as part of the clinical workup for suspected physical abuse. methods & materials: authors retrospectively analyzed records of eighty-five children less than three years of age who were documented by the child protective services at a level one pediatric trauma center over a period of four years ( ) ( ) ( ) ( ) ( ) . only patients who underwent both mri imaging of the cervical spines (c-spine) in addition to brain imaging as part of the clinical workup were included. cspine and posterior fossa of brain mris were independently reviewed by two pediatric neuroradiologists, both blinded to clinical details. c-spine abnormalities (bone marrow edema, cord edema, intrathecal blood, disc pathology, soft tissue/ ligamentous injury, vascular injury) were documented and correlated with abnormalities seen in the posterior fossa (blood, brainstem edema, cerebellar edema). results: at this time, / patients have been reviewed. twenty patients ( %) had both cervical spine injuries and posterior fossa abnormalities. there were no patients with isolated cervical spine injuries without posterior fossa abnormalities, but there were five patients ( . %) that had posterior fossa abnormalities in the absence of c-spine injuries. fifteen patients ( . %) did not have any spinal or posterior fossa imaging abnormality. none of the patients had bone marrow edema, disc pathology, or intrathecal blood. one patient had vascular neck injury and cord edema. conclusions: our results show that the incidence of cervical spine injury in children under investigation for abusive head trauma is as high as %. our data show further that cervical spine injury predicted posterior fossa injury in all patients, while presence of posterior fossa injury predicted concomitant c-spine injury in only %. the incidence of c-spine trauma we found in these patients is higher than reported elsewhere in the literature and may impact whether or not routine c-spine mri will be included in national imaging guidelines for children under investigation of abusive head trauma. pediatric skull fracture andre loyd, phd, biomedical engineering, duke university, aml @duke.edu purpose or case report: skull fractures are often seen in the setting of non accidental trauma (abuse) abuse, and are usually attributed to falls from heights above m. part of the difficulty in assessing height is due to uncertainties in actual distance. objective: to determine what types of skull fractures can occur in pediatric and adult post-mortem human specimens during controlled impacts on hard surfaces from various heights. methods & materials: skull fracture patterns in postmortem human specimens from a unique bank of pediatric specimens ( -week gestation to -years-old, n ) were subjected to controlled drops from both arbitrarily low heights ( and cm) and high heights ( m) onto an aluminum platen. the specimens were dissected from the neck at the occipital condyles and intracranial were sealed inside the head using pmma. the heads were dropped on to five different impact locations. fractures were identified using palpation and high resolution mdct. results: no specimens between -weeks-gestation and days-old sustained fractures from the - cm drops. three out of four ( %) specimens ages between -and -months old fractured due to the or cm drops. the -and -year-old specimens and all adult specimens survived the - cm drops. all specimens subjected to the m drop fractured. the specimen between -months and -months sustained either a linear fractures or diastatic fractures from the cm and cm drops. the results indicate that some aged infants and young children can sustain skull fractures by being dropped or falling from relatively low heights. drops, as low as cm, can cause linear and diastatic fractures in pediatric skulls. the presences of compliant sutures and fontanelles in neonatal heads allow the head to deform during impact. these data add very important information to mechanisms of skull fractures across ages, including ages in which child abuse is a consideration. evaluation of a new classification system for temporal bone fractures in children aimed at increasing prognostic value badriya al-qassabi, md, mcgill university, albahlania @ yahoo.com; lucia carpineta, rania ywakim, bahar torabi, andrew m. zakhari, lily h p. nguyen purpose or case report: to compare a new classification of temporal bone fractures which specifically evaluates involvement of the otic capsule against the traditional classification system (transverse versus oblique versus longitudinal), to evaluate whether this new classification is able to better identify patients at risk of adverse otologic outcome and neurologic complications in the pediatric population. methods & materials: a retrospective hospital chart review was performed by ent colleagues searching for all patients with temporal bone fractures seen at our center over the past years. this was followed by a blinded review of the ct heads by a resident and a trained pediatric radiologist with neuro expertise. these cts were evaluated for petrous involvement, otic capsule involvement and any associated intracranial lesions. this information was then correlated with clinical outcome measures including post-traumatic hearing deficit, facial nerve palsy, persisting csf leak and global neurologic sequelae. the new classification was compared to the traditional one, and specifically analysed for the ability to better predict the clinical outcomes. results: expectedly, pediatric temporal bone fractures were infrequent and otic involvement even more rare. fractures with involvement of the otic capsule (versus otic sparing) were found more frequently in boys. they were also more likely to be associated with immediate otologic signs and neurologic findings on presentation. these fractures also had the highest association with conductive hearing deficit (> %) and were twice as likely as otic sparing fractures to be associated with immediate facial nerve palsy and with more important concomitant intracranial injuries such as midline shift. conclusions: while our numbers are small, our results suggest a trend that when temporal bone fractures show involvement of the otic capsule, there is higher risk of adverse otologic outcome and neurologic complications even in the pediatric population. absence of a causal relationship between mr detected subdural hematomas (sdh) in neonates with hypoxic-ischemic encephalopathy (hie) deniz altinok, children's hospital of michigan; jay shah, harut haroyan, gulcin altinok, nitin chouthai purpose or case report: the existing controversy regarding subdural hemorrhages noted in patients with hie is an important discussion in the medical, legal and child-welfare realms. it is our goal to provide additional information to this critical debate through mr findings on patients with clinically diagnosed hie. methods & materials: all patients born with clinically diagnosed hie, and treated at children's hospital of michigan in the past years were examined; those with head mri taken within days of life were selected. in total, patients fit the criteria, this included: males and females, and an age range of - days at scan (average age of days at scan). all traumatic births, coagulopathies, and other pertinent clinical findings were noted. mr imaging was reviewed and reported by a blinded pediatric neuroradiologist, these reports were then compared to the "original read". results: all patients were confirmed radiologically to have hie. the causes of hie in all cases examined were either intrauterine/delivery asphyxia, aspiration, or congenital disease. of these cases, the findings were: sdh, parenchymal hemorrhages, intraventricular hemorrhages, cephalohematomas, subarachnoids, large subcutaneous hemorrhage and instance of mca stroke. all patients with mr detectable sdh had or more confounding factors ( meningitis, coagulopathies, chest compressions, cardiac malformation, pph, severe pulmonary hemorrhage requiring transfusion of plasma and prbc). conclusions: it has been hypothesized that sdh is often found incidentally in children diagnosed with hie, this is however a dubious conclusion considering our results. in fact, the presence of sdh and hie concomitantly is low even when including a population with traumatic births such as ours. sports-related concussion in children: an mri and mrs study kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; todd a. maugans, james l. leach, mekibib altaye purpose or case report: the pathophysiology of sportsrelated concussion (src) is poorly understood, especially for children. following src and mild traumatic brain injury in adults, a few mri and proton mrs studies have identified axonal injury with declines in the neurometabolite n-acetyl aspartate (naa). we wanted to examine a src adolescent population with proton mrs, diffusion tensor imaging (dti) and other mri methods within h of concussion and with short term followup to determine if there were differences in imaging metrics with age and sex matched healthy control participants. methods & materials: twelve children, ages - years, who experienced src were evaluated with impact neurocognitive testing, t -weighted mri, susceptibility weighted imaging (swi), dti, proton mrs, and phase contrast angiography (pca) at less than h, days and days or greater post-concussion. healthy, age and sex matched controls for each src participant were recruited and evaluated at a single time point. quantitative imaging metrics included fractional anisotropy, metabolite concentrations, and global cerebral blood flow (cbf). group comparisons were examined by paired t-test or wilcoxon signed rank test. correlational data employed spearman rank correlation. results: impact results revealed significant differences in initial total symptom score (tss), and reaction time (rt) for the src group compared with the control group, with tss resolving by a mean of days and rt at days. no evidence of structural injury was observed qualitatively for either group. analyses between groups or over time within the src group found no decreases in naa or elevation of lactic acid upon mrs, and no changes in fractional anisotropy upon dti. within the src group, significant changes in the global cbf were observed. improvement towards control values occurred by days for % and by days for % of src group participants. conclusions: pediatric src affects global cbf without evidence of structural or metabolic injury. predictive value of high resolution mr imaging of brain and sella in children with clinical optic nerve hypoplasia for hypopituitarism charles glasier, radiology, arkansas childrens hospital, glasiercharlesm@uams.edu; raghu h. ramakrishnaiah, julie shelton, chetan c. shah, paul h. philips purpose or case report: to review the spectrum of cns abnormalities and their incidence in children with optic nerve hypoplasia and to calculate the sensitivity and specificity of magnetic resonance imaging in predicting endocrine abnormalities. methods & materials: this is an irb approved retrospective study of children with clinical optic nerve hypoplasia who underwent mri of the brain and orbits as part of the clinical workup in a tertiary care pediatric hospital. high resolution mri studies were performed on . tesla scanners. mri studies were reviewed for optic nerve hypoplasia, absent or ectopic posterior pituitary, absent pituitary infundibulum, absent septum pellucidum, migration anomalies and hemispheric injury.radiologists were blinded to patients endocrinologic status.all patients had clinical evaluation by a pediatric neuro-ophtalmologist and endocrinologist. a standardized panel of serologic testing that included serum cortisol, acth, tsh, and free t levels were performed on all patients. statistical analysis was performed to determine the sensitivity and specificity of mr findings in predicting endocrinologic deficiency. results: study included children( males and females) who had clinical optic nerve hypoplasia. the mean age of the study population was yr (sd: . yr). children had unilateral and children had bilateral optic nerve hypoplasia by mri. children had absent posterior pituitary bright spot and had ectopic posterior pituitary, had absent infundibulum, had complete callosal agenesis, partial callosal agenesis and had callosal thinning. had absent septum pellucidum. had hypopituitarism. of the patients with hypopituitarism had abnormal abnormal pituitary on mri, had absent septum pellucidum, and child had migration abnormality. none had corpus callosal abnormality. the sensitivity and specificity of mri in predicting hypopituitarism by demonstration of abnormal pituitary is % and % respectively. the positive predictive value and the negative predictive value is % and % respectively. among the patients with normal endocrinologic function, none had pituitary abnormalities on mri. conclusions: pituitary abnormalities are the most common intracranial abnormality in patients with optic nerve hypoplasia followed by absent septum pellucidum. detection of pituitary abnormalities by the mri has high specificity and high negative predictive value for endocrine abnormality. paper #: pa- ct imaging pearls for shunted pediatric brains srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; nadja kadom purpose or case report: shunted pediatric patients frequently present emergently with symptoms that could indicate shunt malfunction, such as headache and vomiting. here, we present imaging pearls on non-contrast head ct in shunted children. methods & materials: illustration of each of the following: . shunt tip and volume averaging-consider location of side holes and use of multiplanar reformatted images. . shunt at burr hole-consider radiolucent shunt parts. . shunt rupture in the neck-remember to investigate the lower extracranial shunt parts. . shunt in cyst/subdural shunt (vs dislocation)-consider primary shunt location in a cyst rather than shunt dislocation. . enlarged temporal horns-look for it. in infants occipital horns may dilate first. . enlarged rd ventricle-look for bulging of lateral walls. . sulcal effacement-use the "three shades of gray" rule. . small cisterns-detecting shape distortion can help. . periventricular edema-easily overlooked because of similar low density compared to ventricular fluid. . slit-ventricle -requires cautious reporting. conclusions: careful evaluation of ct images in shunted pediatric patients can reveal important clues for making an accurate diagnosis, even when prior images are not available. successful treatment of mice with creatine transporter deficiency kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; diana m. lindquist, matthew r. skelton, gail j. pyne-geithman, joseph f. clark purpose or case report: creatine transporter deficiency (ctd) is an untreatable x-linked mental retardation syndrome with severe cognitive and speech impairment. patients are identified by an absence of creatine in the brain on mr spectroscopy (mrs) and distinguished from two creatine synthesis deficiency syndromes with genetic testing. for ctd, the absence of the transporter (slc a ) prevents creatine from crossing the blood brain barrier and entering brain cells. a brain specific ctd knockout mouse was developed replicating key features of the human disease and establishing an animal model for treatment of ctd. we report the successful treatment of the ctd knockout mouse and present confirmation by mrs. methods & materials: brain specific knockout and littermate control mice were randomly assigned and treated with on one of three supplements: agentx (confidential), creatine or maltodextrine as placebo. h and p mrs data were collected on a t mr system (bruker). mice (n ) were studied with mrs after weeks of supplementation. single voxel h data were acquired on a ul voxel covering the cerebrum using a double spin echo sequence. p data were acquired with an isis sequence from the same voxel. metabolite quantification was performed with jmrui and compared between groups and over time with statistical tests for significance (t-tests, anova). results: creatine and phosphocreatine levels in the brain were all significantly higher after weeks supplementation of agentx in knockout mice, compared to creatine and placebo fed knockout mice (phosphorus mrs [ ul brain voxel] with phosphocreatine (pcr) ( ppm) observed only in agentx treated knockout mice. adenosine triphospate (atp) gamma (− . ppm), alpha (− . ppm) and beta (− ppm) peaks are noted in all three knockouts. conclusions: successful treatment was achieved in a slc a brain specific knockout mouse for the second largest known cause of x-linked mental retardation in humans, ctd. disclosure: dr. cecil has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. prevalence of abusive injuries in siblings and contacts of abused children kenneth feldman, md, general pediatrics/children's protection program, university of washington/seattle children's, kfeldman@u.washington.edu purpose or case report: siblings and children who share a home with a physically abused child are thought to be at high risk for abuse. however, rates of injury in these children are unknown. disagreements between medical and cps professionals are common and screening is highly variable. our objective was to measure the rates of occult abusive injuries detected in contacts of abused children using a common screening protocol. this was a multi-center, observational cohort study of child abuse teams who shared a common screening protocol. data were collected for all children < years undergoing evaluation for physical abuse and their contacts. for contacts of abused children, the protocol recommended physical examination for all children < years, skeletal survey and physical exam for children < months, and physical exam, skeletal survey and neuroimaging for children < months old. results: among , children evaluated for abuse, met criteria as "physically abused" and these had contacts. for each screening modality, screening was completed as recommended by the protocol in approximately % of cases. of contacts who met criteria for skeletal survey, new injuries were identified in ( . %). none of these fractures had associated findings on physical examination. physical examination identified new injuries in . % of eligible, examined contacts. neuroimaging failed to identify new injuries among imaged, eligible contacts less than months old. twins were at significantly increased risk of fracture relative to other non-twin contacts ( . % vs . %, or . ). conclusions: these results support physical examinations and skeletal survey, regardless of physical examination results, for contacts of abused children < months of age. too few children had cranial imaging to change recommendations to image contact children less than months old. even for children where no injuries are identified, these results demonstrate that abuse is common among children who share a home with an abused child. they support including contacts in evaluations and interventions (foster care, safety planning, social support) designed to protect physically abused children. the project was supported by the health resources and services administration/maternal shown that pediatric rib fractures may be a marker for significant intrathoracic injury. this information has been used to suggest that children with rib fractures and no underlying intrathoracic injury may have sustained them due to insufficient bony mineralization and minor trauma rather than inflicted injury. methods & materials: irb approval was obtained for a retrospective review of all children under years of age with imaging diagnosis of rib fracture over a -year period at two university hospitals. children with prior thoracotomy, previously recognized metabolic bone disease, and prematurity < weeks were excluded. medical records were reviewed and children with documented abuse or accidental trauma were evaluated. children with indeterminate injury mechanisms were excluded. sixty-six patients with rib fractures were included in analysis, due to abusive injury and due to accidental trauma. children were analyzed for associated intrathoracic, abdominal or intracranial injury, additional fractures and retinal hemorrhage. results: abused children were younger ( . +/− . months) than accidentally injured children ( . +/− . months, p< . ). children with rib fractures due to accidental trauma had a higher incidence of intrathoracic injury compared to those due to abusive injury ( % vs %,p< . ). there was no difference in the incidence of abdominal or intracranial injury between groups. mortality and icu admission rates were similar. abused children had a higher total number of rib fractures (mean . vs . , p< . ) and were more likely to sustain additional fractures outside of the thoracic cavity ( % vs %, p< . ). conclusions: abuse is a more common cause of rib fractures in young children than accidents. children with rib fractures due to abusive trauma are less likely to have intrathoracic injury compared to those sustaining rib fractures due to accidental trauma. this suggests differences in mechanism of injury between groups. pediatric elbow fractures: a different angle on an old topic shannon zingula, md, pediatric radiology, cincinnati children's hospital medical center; kathleen emery, christopher g. anton purpose or case report: the most common elbow fractures classically reported in pediatric orthopedic texts are supracondylar (sc) ( - %), lateral condylar (lc) ( %), and medial epicondylar (me) fractures ( %) with fractures of the proximal radius (including but not limited to fractures of the radial neck) being relatively uncommon ( - %). our experience at a large children's hospital suggests a different distribution. purpose: ) to describe the frequency of different elbow fracture types in a large pediatric population, and ) to determine the fracture types that were occult on initial radiographs but detected on follow-up. methods & materials: review of medical records identified children, median age years and interquartile range for age of - years (range, . - years) diagnosed with elbow fractures at our institution from october through july . initial and follow-up radiographs were reviewed in blinded fashion independently by two experienced pediatric musculoskeletal radiologists to identify fracture type(s) on initial and follow up radiographs. note was made of fractures identified on follow up only. results: the most common fractures included sc (n , %), radial neck (rn) (n , %), and lc fractures (n , %). as compared to classically referenced incidences, rn fractures were seen significantly more (p< . ) and me fractures (n , %) significantly less (p . ) than would be predicted. in patients without fracture seen on initial films, occult fractures were seen on follow up; sc (n , %) and rn fractures (n , %) were most common. the frequency of rn fractures compared to the overall group ( % vs. %) approached but did not reach statistical significance (p . ). patients with one fracture had additional fractures seen on follow-up not seen initially with olecranon fractures most frequent (n , %.) this was significantly more common than the number identified on initial radiographs (n , %) (p< . ). conclusions: sc fractures are the most frequent elbow fracture seen initially and in follow up followed by rn and lc fractures in a distribution different than classically described. the relatively high frequency of rn and olecranon fractures detected on follow up speaks to their potentially occult nature. careful attention to these areas is warranted in patients with initially normal radiographs. purpose or case report: previous studies have found that fractures involving the spine, hands and feet are rare on skeletal surveys for suspected child abuse, leading some authors to suggest eliminating views of these regions from the initial skeletal survey protocol. the purpose of this study was to assess this recommendation by performing a historical review of these injuries in a population undergoing screen-film based skeletal surveys for suspected abuse. this cross-sectional, retrospective irb approved study reviewed the reports of the initial skeletal surveys of all children < years of age with suspected abuse imaged between april, and december, . infants underwent skeletal surveys according to acr standards acquired on a mammographic type screen-film imaging system with at least line pairs per millimeter resolution. studies in toddlers were performed using a par speed screenfilm system. results: % ( / ) of all skeletal surveys demonstrated positive findings, and % ( / ) had > fracture. . % ( / ) of all studies had fractures involving the spine, hands or feet. of all positive skeletal surveys, . % ( / ) had fractures involving the spine, hands or feet, and . % ( / ) of all patients with > fracture on skeletal survey had fractures involving these regions. conclusions: these data, acquired in the screen-film era, suggest that fractures of the spine, hands and feet may not be rare in infants and toddlers in cases of suspected child abuse. the benefits of eliminating views of these regions from the initial skeletal survey should be carefully weighed against the cost of missing these potentially important injuries in at-risk pediatric populations. purpose or case report: dating fractures is critical in cases of suspected infant abuse, but there are little scientific data to guide radiologists, and dating is generally based on personal experience and conventional wisdom. we previously reported a scientific scheme for dating fractures in infants based on an analysis of subperiosteal new bone and callus formation in birth-related clavicular fractures. we hypothesize that when used as a guide this system can significantly improve the ability of radiologists to accurately date fractures in young infants. methods & materials: radiographs of presumed birthrelated clavicular fractures in infants - months were reviewed by pediatric radiologists with (reader a) and (reader b) years experience in two reading sessions separated by one year. for the first read, no guidelines were provided. training was carried out prior to the second session, and readers were given the dating scheme as a guide during fracture analysis. readers were asked to provide an estimate of the minimum and maximum fracture age in both sessions. the primary outcome was whether or not the reader's estimated range for fracture age included the actual fracture age. a secondary outcome was the width of the estimate of fracture age. these outcomes were compared across the two reading sessions. results: the rate of correct response significantly increased after training for each reader (reader a: % to %, p<. ; reader b: % to %, p . ). the width of estimated fracture age after training was significantly smaller for each reader (reader a: mean width days to days, p<. ; reader b: days to days, p . ). conclusions: our results suggest that the ability of a radiologist to accurately date fractures can improve significantly when provided with a scientifically based system outlining patterns of fracture healing. this scheme can be applied in radiologic practice and may prove particularly useful in cases of suspected abuse, where fracture dating often has forensic implications. purpose or case report: to demonstrate the acute and subacute features of proximal femoral physeal fractures in the abused child. also to demonstrate how to recognize this injury in patients with unossified femoral heads. the database of patients with suspected non-accidental trauma, accumulated over years, was reviewed. out of a total of patients ( %) were proven to be cases of non-accidental trauma, as determined by the child abuse pediatrician. from these patients, the cases of proximal femur growth plate fractures were identified. results: patients with proximal femur growth plate fractures were identified for a prevalence of . %. one patient had bilateral proximal femoral fractures, for a total of fractures in patients. were boys, were girls with ages ranging from . mos to yrs mos. in patients, the fracture was revealed on imaging performed because of refusal to bear weight; in the other patients, the fracture was found during imaging for the skeletal survey. the fracture was on the left side in cases and on the right side in (the patient with bilateral fractures). in all of the fractures, there was lateral displacement of the femoral shaft. in fractures, the femoral head was not yet ossified simulating the appearance of a dislocation. location of the femoral head in the hip joint was verified by ultrasound or ct (ct abdomen had already been done in patient) thus delineating the presence of a physeal fracture. / fractures were salter-harris i and the other were salter-harris ii fractures. the fracture was acute in cases and subacute in cases. in these subacute cases, periosteal reaction and/or calcifying subperiosteal hemorrhage was present in , and irregularity and scalloping of the metaphysis was present in the other . conclusions: proximal femoral growth plate fractures are quite uncommon in non-accidental trauma. the injuries are typically salter-harris i or ii fractures, seen more often in the healing phase. in the presence of an unossified femoral head, the laterally displaced femoral shaft can simulate hip dislocation; this can be clarified with hip sonogram. purpose or case report: in recent years, metal stents have been used to overcome airway obstruction in children for whom no better surgical option is available. these devices are not designed for use in the airway, however, and may cause significant complications. bioabsorbable airway stents may avoid some of the problems associated with metal stents. methods & materials: this is a retrospective review of all endoluminal insertions of bioabsorbable airway stents at a single institution from april to september . custom-made polydioxanone stents of various sizes (ella dv, ella, czech republic) were used. results: twelve stents were inserted in the airways of seven children. indications were: recurrent obstruction after slide tracheoplasty ( ), persistent airway compression after correction of a congenital cardiac lesion ( ), collapse of stem cell supported tracheal homograft, tracheomegaly following fetal balloon insertion, and syndromic tracheobronchomalacia (tbm). eleven stents (diameters to mm) were placed in the trachea and one in the left main bronchus. two stents had to be removed and replaced for technical reasons (one was too long and the other too narrow). the child with syndromic tbm died when treatment was withdrawn because she could not be weaned from the ventilator. the remaining children are alive at a median follow-up of nine months (range to months). the granulation tissue response was similar to that seen after placement of metal stents. the stents were observed to absorb gradually over a period of approximately three months, requiring serial stenting in two children. conclusions: bioabsorbable airway stents are more difficult to insert than metal stents. they cause similar early complications, especially granulation tissue formation, but appear to avoid potential long-term complications of metal stents, including vascular erosion and growth limitation. disclosure: dr. mcclaren has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: renal angiomyolipomas (amls) in tuberous sclerosis complex (tsc) grow at a faster rate, exhibit a wider and more problematic range of symptoms, and hemorrhage more frequently than sporadic amls. we examined the efficacy of prophylactic embolization of renal amls in tsc in decreasing tumor size, alleviating symptoms, and preventing hemorrhage while preserving renal function. we retrospectively reviewed the charts and imaging studies of consecutive patients who underwent transarterial, transcatheter embolization of amls. tumor volume was measured from available ct or mri imaging before and after embolization. pre-and postembolization symptoms and creatinine levels were documented. results: patients had available follow-up imaging at a mean of months post-embolization. the mean preembolization tumor volume was ml and postembolization was ml; median decrease in volume was %. using the schwartz method, the mean glomerular filtration rate before embolization was calculated to be . ml/min/ . m . after embolization the mean value was statistically unchanged at . ml/min/ . m . none of the patients experienced renal hemorrhage or symptom recurrence during the follow-up period. conclusions: selective embolization of renal amls in patients with tsc decreases tumor volume, relieves symptoms and reduces the risk of future hemorrhage while preserving renal function. etoh was injected percutaneously with g needle; transductal ablation performed through a f micropuncture sheath. drug volumes, technical difficulties, percentage reduction in saliva production, family reported clinical significance, and complications were recorded. results: salivary gland ablation (sga) included bilateral smg and slg ablation without parotid gland ablation in cases, and with unilateral parotid gland ablation in cases. one case of bilateral parotid gland ablation following surgical resection of bilateral smgs. mean etoh dose for smg . ml, and . ml for slg. one case of focal skin necrosis was noted; no other complications. patient families reported response to sga in / cases ( %) with mean saliva production of %. greatest health and family impact was reported with elimination of hospitalizations for recurring aspiration pneumonia ( cases), elimination of choking in bed ( cases) , and improved patient sense of self-hygiene in cases. one complication occurred with temporary marginal mandibular nerve paralysis (resolution in months). conclusions: percutaneous and transductal sga is feasible, safe, and effective in this small patient series, offering an alternative to surgical salivary gland resection, or treatment option following failed surgical intervention. paper #: pa- mr-guided procedures in children: initial experience joao amaral, md, diagnostic imaging, the hospital for sick children, joao.amaral@sickkids.ca; michael temple, dimitri parra, philip john, bairbre connolly purpose or case report: the primary purpose of this study was to review our initial experience with mr-guided procedures in children. our secondary objective was to share some aspects on how to start an mr-guided program in a tertiary pediatric center. patients with lesions identified only on magnetic resonance (mr) imaging were selected to undergo an mr-guided procedure. patients' demographic data, primary diagnosis, referring team's clinical suspicion, lesion's anatomical location, tissue adequacy for pathology, final diagnosis and clinical follow up were reviewed. aspects of starting a program of mr-guided procedures, safety concerns, imaging and technical challenges, and mr compatible materials were also addressed. results: to date, procedures ( bone biopsies, soft tissue biopsy and pre-surgical needle localization) were performed in patients during months. there were girls and boys with a mean age of . years ( y mo- yrs). one patient had a nasopharyngeal carcinoma, cardiofacial syndrome, wilm's tumor and had no previous medical issues. the clinical suspicion for procedures in patients was metastatic disease and for procedures in patients was primary malignancy or infection. lesions were located in the tibia ( -metaphysis and diaphysis), femur ( -metaphysis and epiphysis), thigh ( -soft tissues), sacrum ( ) and retroperitoneum ( ). all biopsies provided adequate tissue for diagnosis. needle localization and hook deployment was also accurate. malignancy was excluded in all patients. final diagnosis included chronic recurrent multifocal osteomyelitis (crmo), osteomyelytis, fibrous tissue, osteoid osteoma, and scar tissue. mean follow up was . months. no patient required a second procedure to confirm the diagnosis. conclusions: mr with its unique soft tissue resolution and lack of ionizing radiation is an excellent method to guide interventions in children. one of the greatest advantages of this method is the precise target localization especially in lesions located in the bone marrow or lesions better identified on mr. special safety measures, specific mr compatible material (needles, surgical instruments), dedicated imaging techniques to reduce or increase material/needle artifact and careful technique are paramount. - . m, f; . - months, mean . months, median months, mode months. sonographic approach expanded as our experience grew over months. studies performed by a single pediatric radiologist. bilateral sonography included: interscalene and supraclavicular neck, nerve roots at neural foramina, cervical spinal canal, diaphragm during spontaneous respiration, rhomboid muscle, serratus anterior muscle, posterior shoulder, all performed and interpreted blind to other imaging. results: interscalene and supraclavicular neck evaluated in all patients. all exhibited echogenic interscalene portion of brachial plexus.size and extent of traction neuroma varied. nerve roots at foramina noted in axial and coronal planes. in cases enlarged root(s)noted. cervical spinal canal studied in patients: cord oscillated normally, no syrinx, cord concentric in canal. intracanalicular traction pseudomeningoceles on concurrent ct myelography or mri were not apparent on us. in cases a "clumped" retracted nerve root on the cervical cord was later found to correspond to a pseudo-meningocele on ct myelogram. otherwise, cervical spinal canal us was unremarkable in cases. diaphragm motion was evaluated in patients during spontaneous respiration; no phrenic nerve palsy. rhomboid muscle was evaluated for atrophy in patients; had atrophy. the rhomboids are innervated by the dorsal scapular nerve which arises solely from c , prior to c joining the brachial plexus. intact rhomboid indicates that the central c root is intact. serratus anterior muscle, innervated by the long thoracic nerve (c ,c ,c ), was evaluated for atrophy in patients; had atrophy. dynamic evaluation of the posterior shoulder looking for posterior laxity was evaluated in patients; had laxity. posterior shoulder dislocation or subluxation is a known sequela of brachioplexopathy which sometimes requires muscle transfer when the child is older. conclusions: comprehensive us evaluation of perinatal brachioplexopathy detects: extent of traction neuromafibroma from the interscalene region peripherally toward clavicles (important for neurosurgeon), thick nerve roots, phrenic nerve diaphragm palsy, muscle atrophy from denervation, and posterior shoulder subluxation. us misses: intracanalicular traction pseudomeningoceles. paper #: alt- impact of the image gently campaigns in adult-focused hospitals: a survey of practice leaders brett bartz, duke university medical center; donald frush, kimberly applegate, michael callahan, laura coombs, marilyn goske purpose or case report: the alliance for radiation safety in pediatric imaging is an organization that uses social marketing to promote radiation protection for children and effect change across radiology practices. the impact of the alliance's image gently campaigns on practice patterns in radiology practices has yet to be assessed, especially outside of freestanding children's hospitals. the purpose of this investigation was to assess the impact of the image gently campaigns on academic and private practices/institutions that treat children but primarily serve adults. a web-based survey was emailed to leaders in radiology practices (n ) who do not practice at freestanding children's hospitals utilizing the acr's pred database. the survey consisted of questions designed to measure the recognition and impact of the image gently campaigns, including the impact on practice patterns. results: a total of practice leaders in u.s. states and territories responded for a response rate of . %. the majority ( %) of sites image pediatric patients in their practices. respondents consisted of department chairs ( %), group presidents/ceos ( %), and division chiefs ( %). the majority ( %) of respondents described their practice as a hospital-based private practice without a dedicated pediatric radiology division. the vast majority ( %) of respondents was familiar with the image gently campaigns; % of respondents reported that image gently had effected a change on how they imaged children. specifically, respondents (%) reported that the campaign caused a modification to lower dose protocols for head ct ( %), chest ct ( %), and abdominal/pelvic ct ( %). slightly more than half of respondents ( %), however, estimated that the image gently campaign resulted in no modification of pediatric fluoroscopy exposure. conclusions: to our knowledge, this is the first survey evaluating the impact of the image gently campaigns. there is near universal recognition of the campaigns, which have impacted practice patterns beyond the freestanding children's hospital in ct, but not in fluoroscopy. reliability of shear-wave velocity using different frequencies in acoustic radiation force impulse (arfi) elastography mi-jung lee, radiology, severance children's hospital, mjl @yumc.yonsei.ac.kr; suyon chang, myung-joon kim purpose or case report: although there are many studies about acoustic radiation force impulse (arfi) measurement, standard protocol has not been established. and a new probe with high frequency has been developed which can be applied for pediatric patients. the purpose of this study was to assess the reliability of shear-wave velocity (swv) at various depths using different frequencies to suggest standard measurement in arfi elastography. methods & materials: arfi elastography of both the elasticity phantom and normal liver was performed at different depths ( - cm) with convex ( - mhz) and linear ( - mhz) probes. ten valid swv measurements at each depth were performed. it was repeated ten times with the phantom and it was done in healthy volunteers (m:f : , age - years; mean . ). the mean value and standard deviation of swv were calculated. results: in both the elasticity phantom and the liver, variability of swv was different between the depths in both probes. the depth with lower variability in the phantom was and cm with the convex probe and cm with the linear probe. in the liver, the depth with lower variability was cm with the convex probe and and cm with the linear probe. in comparison of two probes, the linear probe showed lower variability at and cm depth in the phantom and at cm depth in the liver whereas the convex probe showed it at cm depth in both the phantom and the liver. conclusions: in arfi elastography, measurement of depth shows different variability in both low and high frequency probes. to obtain the most reliable measurement of swv, using high frequency probe is recommended for - cm depth and using low frequency probe is recommended for - cm depth. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging -year-old fetuses sabah servaes, children's hospital of philadelphia; teresa victoria, ann johnson, sandra kramer, richard markowitz, diego jaramillo purpose or case report: to demonstrate normal anatomy and pathology of medical museum specimens without disturbing the specimens. methods & materials: nine fetal specimens from a medical museum were imaged with ct and mri ( . t and . t) when possible with the specimens in their preserving fluid and containers. results: the fetal specimens are estimated to be approximately years old. one specimen is from the first trimester, seven are from the second trimester, and one is from the third trimester. normal anatomical structures at various stages of development including the brain (and varied sulcation pattern), lungs (lobar anatomy), and skeletal structures (several developmental features such as the ossification centers, perichondrial structures, and marrow cavitation) can be evaluated using imaging without causing harm to the specimens. pathologic entities including anencephaly and sirenomelia are also evaluated demonstrating features of these entities. conclusions: imaging historical fetal specimens provide an opportunity to evaluate normal developmental changes and pathological entities and also to gain a better understanding of the museum pieces without damaging the museum specimens. pediatric ct interpretations: does a tertiary care radiologist make a difference? wendy d. ellis, monroe carell jr. children's hospital at vanderbilt university; sumit pruthi, david johnson, christopher eakins, chang yu, marta hernanz-schulman purpose or case report: to determine whether a substantive difference exists between the pediatric imaging reports of community radiologists and reinterpretations by tertiary care radiologists at a free-standing children's hospital; and how those interpretations were related to the final diagnosis. methods & materials: this retrospective review examined the computed tomography (ct) reports of all pediatric patients referred to our tertiary care children's hospital over a month period ( / / - / / ). the outside reports and the requested second interpretation reports were compared and their content categorized as "agreement" vs. "disagreement: major or minor". a representative sample of major disagreements in which there was reliable followup information was correlated with the final diagnosis to determine if there was added value provided by the reinterpretation. results: ct scans from patients were submitted for reinterpretation. disagreements were found in / cases ( . %); with . % ( / ) classified as major disagreements. among the neurologic cases, major disagreements occurred in patients ( . %) and minor disagreements in patients ( . %). among the body scans, major disagreements occurred in cases ( . %) and minor disagreements in cases ( . %). in the cohort of cases reviewed for final diagnosis, the second read interpretation was more accurate in . % of cases with a p-value of < . (neurologic . %, p < . ; body . %, p < . ). conclusions: in our review, discrepancy rates between community and tertiary care radiologists in interpretation of pediatric ct scans were substantial, with discrepancies occurring in more than % of cases. further review of the cases for final diagnosis, showed that a significant number of the tertiary care interpretations were more accurate. possibilities that may account for this discrepancy include subspecialty training and elapsed time since performance of the study, which might provide additional clinical data in some cases. diagnostic ct scans performed at outside institutions should not be repeated considering added radiation burden to the child and additional expense. our data indicates there is added value to the reinterpretation which impacts the accuracy of the report (as assessed by the final diagnosis), and should be recognized by payors as integral to optimal patient care. ionizing radiation exposure from radiography in the neonatal intensive care unit-per-patient cumulative effective doses amaya basta, radiology and biomedical imaging, ucsf; jesse courtier, john mackenzie purpose or case report: to better understand the levels of exposure to ionizing radiation for infants in the neonatal intensive care unit (nicu). we retrospectively collected the number and types of radiographs performed per infant in our nicu by searching our radiology information system database over a five-year period. we focused on the most common examinations ( % of all radiographs) and assigned each an estimated equivalent dose based on published literature: chest and abdomen . micro sieverts (μsv), one-view chest . μsv, abdomen . μsv, twoview chest . μsv, two-view abdomen μsv. we then calculated a cumulative equivalent dose (ced) for each infant based on the number of each type of examination they received. descriptive statistics were generated to depict the distribution of number of examinations and ced. results: over five years, , infants cared for in our nicu received at least one radiograph of the chest and/or abdomen. the number of examinations obtained on these infants was . , , , (mean, median, minimum, maximum). the st quartile was and the rd quartile was examinations. the cumulative equivalent dose these infants received was . , . , . , , . μsv (mean, median, minimum, maximum) . the st quartile was . and the rd quartile was . μsv. two hundred infants ( . % of the study population) received a ced of over μsv. conclusions: descriptive statistics provide a valuable assessment for the broad range of radiation that infants receive in the nicu. although the distribution is skewed towards a low level of exposure, a subset of patients ( . %) received a ced of over μsv. identification of factors that cause infants to enter this group will be important for future dose reduction strategies. poster #: cr- congenital cardiac fibroma: a case report earic bonner, meharry medical college, ebonner @email. mmc.edu; seth crapp, david parra purpose or case report: a -week-old male presented to his pediatrician with a ii/vi systolic ejection murmur along the left sternal border. he had mild tachypnea without cyanosis. his oral intake was adequate with no evidence of failure to thrive. he was referred to a pediatric cardiologist who performed an ecg and a transthoracic echocardiogram. the ecg showed normal sinus rhythm at beats per minute with no abnormalities. the transthoracic echocardiogram showed a x x mm homogeneous mass originating from the anterior free wall of the right ventricle, and mild dilation of the right ventricle. mild dynamic subpulmonary stenosis and a secundum atrial septal defect were also noted. although the murmur was significantly louder at one month follow-up, a repeat echocardiogram did not reveal any increase in the size of the mass. at months of age, a cardiovascular magnetic resonance imaging (cmri) study under general anesthesia was performed. cmri revealed a x x mm cardiac tumor that was causing narrowing of the right ventricular outflow tract. the tumor was hypointense on t -weighted imaging and hyperintense on t weighted imaging, with positive delayed enhancement. these findings, along with the size and location of the mass, are consistent with a diagnosis of a cardiac fibroma. chest mra, that was also performed, showed normal extracardiac vascular anatomy with no evidence of peripheral branch pulmonary stenosis. cardiac fibromas do not usually increase in size; however, the concern is the child's risk of arrhythmias. frequent holter monitoring was recommended for this patient. considerations were also made for an electrophysiology study in the next - years to determine the risk of ventricular ectopy. at that point, the patient can be assessed for the possibility of resection of the fibroma. purpose or case report: treatment of pulmonary atresia is complex and demands intricate solutions. one solution is the creation of a conduit between the right ventricle and the main pulmonary artery. the lifespan of these conduits is limited by progressive occlusion over time, which can be treated with endovascular stent placement in lieu of surgical re-intervention. however, these stents are at high ( %) risk for fracture, typically at the stent waist. the radiologist should be aware of this complication, as they may be the first to identify it on chest radiograph. the purpose of this electronic poster is to familiarize radiologists with this entity by presenting cases of stent fracture and migration. methods & materials: over a month period, we identified three children with rv-pa stent fractures and associated stent migrations on chest radiography. imaging analysis was focused on the appearances of these fractured stents. patient management and outcomes were reviewed. results: three children, males, female (ages , , and years) were found to have asymptomatic rv-pa conduit stent fractures with fragment migration. one chest xray was performed in the er for fever and cough; one was pre-op for gi surgery; one was done to confirm abnormal findings seen on a routine cardiac echo. the time between stent placement and fracture detection ranged from to months. two patients had stent fractures and embolizations to the right ventricle that required open surgery to remove stent fragments. the third patient had embolization to both pulmonary arteries, but did not require treatment. all patients did well. conclusions: stent fractures and migrations are a relatively common complication of rv-pa conduit stent placement. pediatric radiologists need to be aware of this complication in order to provide value-added interpretations. purpose or case report: we describe the case of a week stillborn fetus with a . cm diameter craniopharyngioma detected by ultrasonography. a g p woman in her third decade had ultrasonographic examination showing hydrocephalus, polyhydramnios and an intracerebral mass. the nature of the mass was uncertain and intracerebral hemorrhage was considered. the pregnancy was terminated at weeks gestation. at postmortem examination the decedent was a g male fetus with a head circumference of . cm and a crown-rump length of . cm. anterior and posterior fontanelles appeared large. no other external abnormality was found. the placenta was unremarkable and cytogenetics on placental tissue showed a normal male karyotype. examination of fetal viscera was remarkable for mildly underweight adrenal glands ( . g, expected . g) and hepatomegaly ( . g, expected . g). intracranial csf was increased in volume. there was a suprasellar . cm diameter somewhat gritty, but smooth-surfaced tumor. the brain and tumor together weighed g. the floor of the cranium and sella turcica were grossly normal. histologic examination of the tumor showed an adamantinomatous type craniopharyngioma with characteristic epithelium, stellate reticulum, focal keratinizing squamous epithelium and calcification. pre-and postnatal mri of caudal regression syndrome claire b. beaumont, md, university of arkansas for medical sciences, cbbeaumont@uams.edu; nafisa k. dajani, leann e. linam purpose or case report: caudal regression syndrome is a rare form of caudal dysplasia characterized by a spectrum of findings including agenesis of the lumbosacral vertebra, multiple orthopedic deformities in the lower limbs, as well as anomalies of the gastrointestinal and genitourinary tracts. the mechansim of caudal regression syndrome is not completely understood but is believed to be secondary to a defect in the induction of caudal elements. mri is a valuable tool for identifying the specific anomalies involved with caudal regression syndrome on a case-by-case basis. the following is a case from our institution which includes both pre-and postnatal mri. unsuspecting tuberous sclerosis diagnosed on neonatal cranial ultrasound vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; puneet gupta, richard thomas, vaseem iqbal, jan najdzionek. purpose or case report: tuberous sclerosis (ts) is a rare autosomal dominant genetic disorder causing hamartomatous proliferation in number of organ systems. because the classical triad of epilepsy, mental retardation and adenoma sebaceum is not commonly seen on clinical examination, imaging plays a central role in the diagnosis and treatment of tuberous sclerosis. central nervous system features of ts include subependymal nodules, cortical tubers, subependymal giant cell astrocytoma, white matter bands and cysts. in patients with ts, cerebral involvement in the form of subependymal nodules is seen in % to % and white matter abnormalities are noted in % to % of cases. knowledge of expected radiological features is thus important in making the correct diagnosis. recent studies have indicated that earlier appearance of brain lesions indicate a greater risk of mental retardation and a more severe clinical course. we present a case of a -day-old neonate who was referred to us with concerns for hydrocephalus. the cranial ultrasound demonstrated multiple echogenic subependymal nodules of varying sizes and mild asymmetry of the ventricles. the differential diagnosis included ts, torch infections, and x-linked subependymal heterotropia. areas of increased echogenicity were noted within the white matter of the left frontal lobe, which favored ts. subsequently, an mri was performed to validate these findings and assess for additional white matter lesions. the mri showed classic manifestations of ts that included periventricular lesions and streaky, linear, wedge-shaped hyperintensities on flair imaging. a noncontrast ct scan was also performed which revealed classic calcified subependymal nodules. cardiac rhabdomyoma and renal angiomyolipoma are the other recognized manifestations of ts and were respectively excluded by subsequent echocardiogram and renal ultrasound. pyloric atresia with epidermolysis bullosa: fetal mri diagnosis with postnatal correlation arnold c. merrow, md, radiology, cincinnati children's hospital medical center, carl.merrow@cchmc.org; jason s. frischer, anne w. lucky purpose or case report: pyloric atresia (pa) is an uncommon disorder, accounting for % of congenital gastrointestinal atresias. up to % of cases have associated anomalies, the most common of which is epidermolysis bullosa (eb). prenatal findings have been reported sonographically for each of these anomalies, both in isolation and in the rare case of association. a case of isolated pa has been reported by fetal mri. we present the first reported case of pa with eb diagnosed by fetal mri with corroborative postnatal imaging and surgical findings. the mother of this child was initially referred to the fetal care center of cincinnati at weeks gestation for a possible myelomeningocele diagnosed by prenatal ultrasound at an outside facility. these ultrasound images were not available for review at the time of our workup. a fetal mri was the first study to be obtained at our institution. the mri showed no myelomeningocele or brain anomalies. the stomach was moderately enlarged throughout the exam and did not empty. subjective polyhydramnios was also noted. no duodenal dilation was seen, and there was minimal fluid in the distal bowel loops. this constellation of findings raised concern for pyloric atresia, resulting in a careful search for any sign of epidermolysis bullosa due to a known association of these disorders. prominent debris was seen layering dependently in the amniotic fluid and in the dilated fetal stomach, and the external ears were abnormally small and misshapen. the pa-eb association was proposed as the underlying diagnosis based on our mri findings. it was also postulated that skin blistering over the lumbosacral spine at the time of the prior outside ultrasound could have mimicked a myelomeningocele, thus prompting the referral to our center. at delivery, the baby had numerous skin defects, and the ears were malformed. an abdominal radiograph obtained after nasogastric tube placement and air injection showed no gas beyond the stomach. a pyloric ultrasound showed a distended stomach without a patent pyloric channel to the duodenal bulb, consistent with pyloric atresia. a skin biopsy confirmed epidermolysis bullosa, and the patient underwent a resection of the pa with gastroduodenostomy. the baby subsequently expired less than two weeks later, most likely due to sepsis based on wound cultures and autopsy results. our case demonstrates the ability of fetal mri to diagnose this rare condition and highlights the key imaging manifestations of the pa-eb association. disclosure: dr. merrow has indicated that he is an author for amirsys and receives a royalty accordingly. purpose or case report: we demonstrate a case where the changing position of the contrast filled appendix lead to the diagnosis of malrotation, with review of the embriology of intestinal rotation. a newborn preterm female presented with a golf ball sized umbilical mass, that reduced by itself, thought to represent an umbilical hernia vs omphalocele. she was unstable to undergo an upper gi exam under fluoroscopy, therefore a limited contrast study was performed at bedside and was inconclusive for malrotation. subsequent nicu radiographs showed changing position of the appendix filled with residual contrast, visiting all quadrants of the abdomen in a random pattern over a few days period. this confirmed our suspicion for malrotation. it is well know that in malrotation the position of the cecum can be variable, most commonly located in the right upper quadrant or left lower quadrant. to our knowledge it has not been described yet that the changing position of the appendix can lead to the diagnosis of malrotation. through this case we display the embriology of the intestinal rotation and the radiologic signs of malrotation. poster #: cr- mr imaging patters of liver transplant complications in the pediatric population edward richer, md, emory university, richerej@gmail. com; adina alazraki, jonathan loewen purpose or case report: pediatric liver transplantation is a relatively common surgery, with more than transplants in the united status annually. the spectrum of post transplant complications has been previously described, primarily utilizing ultrasound. as mri has become a more widely used technique in pediatric imaging, and ultrasound findings may be non-specific, knowledge of mr imaging patterns is an important adjunct in the post-transplant evaluation. we present a spectrum of complications, including vascular, biliary, hepatic parenchymal, and systemic complications. methods & materials: using an electronic record system, we identified pediatric patients with prior liver transplantation who subsequently underwent abdominal mri at our institution and were found to have a post transplant complication. patient management and outcomes were reviewed. results: our review of a subset of the available patients shows vascular complications to be the most commonly encountered abnormality at our institution, including hepatic artery stenosis/thrombosis, and portal vein stenosis/ thrombosis, cavernous transformation of the portal vein. biliary complications were relatively common, including bilary stenoses and bilomas. hepatic parenchymal and systemic complications, such as ptld, were less common. we demonstrate the mr imaging patterns of these complications. conclusions: pediatric liver transplantation is a relatively common surgery, and the mri appeance of post transplant complications warrants illustration as abdominal mri becomes more widely used in pediatric imaging. we present a pictorial review of common patterns of complication. imaging of progressive familial intrahepatic cholestasis (pfic) matthew d. dobbs, md , radiology, vanderbilt university medical center, matthew.dobbs@vanderbilt.edu; sumit pruthi, stephanie e. spottswood purpose or case report: progressive familial intrahepatic cholestasis (pfic) is a relatively rare pediatric liver disease due to a genetic mutation (abcb gene on chromosome q - ) in a bile salt export protein causing cholestasis leading to chronic inflammation within the biliary system. the diagnosis is made clinically with detection of a low ggt in the face of an elevated bilirubin and alkaline phosphatase. genetic testing confirms the diagnosis. one of the subtypes, type , was shown in to be highly related to the development of hepatocellular carcinoma. the vast majority in children in this study developed hcc at less than years of age. radiological contribution to the management of these chronic liver disease patients is to perform surveillance imaging to detect hcc. due to the rarity of this condition, almost no reports exist in the radiological literature describing the imaging features or management of this condition. our presentation will review the imaging findings in our small population of pfic type patients on us, ct, and mri. we will also review suggested surveillance imaging techniques and imaging algorithms. renal rhabdoid mimics wilms tumor vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; paul montgomery, jan najdzionek, vaseem iqbal purpose or case report: in the past most pediatric renal tumors have been classified together under the umbrella of wilms tumor. however, over the last decade with advancement in imaging, several distinctive imaging features specific to renal tumors have been recognized which aid in their classification as being distinct pathologically. we present a case of rhabdoid tumor where in the primary tumor arose from the kidney. it had classical imaging features of wilms tumor. we want to highlight that even with the most sophisticated imaging techniques, specific renal tumors cannot always be diagnosed with preoperative imaging and how this alters the management and prognosis for child with a renal mass. in our case, the postoperative findings, pathology and immunohistochemical techniques confirmed a rhabdoid tumor. differentiation of these two tumors is essential since in patients with rhabdoid tumor survival is poor with -year overall survival rates of % for stages i and ii and % for stages iii, iv, and v. on imaging, there are several features that suggest the diagnosis of rhaboid tumor. these include subcapsular fluid collections, linear calcifications outlining tumor lobules, and vascular invasion. also, a pertinent feature of rhabdoid tumor due to its aggressive nature is the presence of lung metastasis ( %) and synchronous malignant brain lesions ( %). these findings were not present on our case, which led us in formulating a diagnosis of wilms. our patient is unusual in the fact that the local renal findings and absence of metastasis, synchronous malignant lesions, and vascular invasion led us to an incorrect diagnosis of wilms tumor. in conclusion, we would like to stress that diagnosis of rhabdoid tumor of the kidney on imaging presents a challenge because of its imaging similarity to wilms tumor. ectopic ureters in young infants: mru findings shin-lin shih, md, department of radiology, mackay memorial hospital; yi-fang chen, chun-chao huang, fei-shih yang purpose or case report: to localize the terminations of ectopic ureters by mri methods & materials: mr urography (mru) was conducted in four female patients with hydroureter and a suspected ectopic orifice. mr imaging was performed with a t mr scanner (achieva; philips). the imaging protocol mainly consisted of a single-shot t -weighted turbo spin echo sequence with a slice thickness of mm and multiplanar reformations. the ages of the four patients were day, days and months (for two). the latter two patients presented with urinary tract infection. the newborn patients presented with abnormal prenatal examination. the pertinent findings and descriptions of a variety of renal anomalies were described. results: the locations of the ectopic ureters were two in the vagina, one in the uterus and one in the bladder neck. the associated renal anomalies were a right duplex kidney in four, a left duplex kidney in one, a left ectopic dysplastic kidney in one and vesicoureteral reflux in one (confirmed by vcug). conclusions: mru may demonstrate the exact point of termination of an ectopic ureter and also the associated renal anomalies. poster #: cr- acquired polycystic kidneys in neuroblastoma survivors richard bellah, , radiology, the children's hospital of philadelphia, bellah@email.chop.edu; bernard kaplan, camilo jaimes, yael p. mosse, jill p. ginsberg, kevin e. meyers purpose or case report: neuroblastoma (nbl) is the most common extracranial solid malignancy of childhood. with current therapy, the prognosis and long term survival of patients affected by this condition has dramatically improved. nevertheless, the treatment for nbl may account for some complications further in life. in patients with neuroblastoma, acute renal failure can occur usually as a result of a thrombotic microangiopathy associated with bone marrow transplantation. in addition, end-stage renal disease has been reported in long-term survivors of nbl. this exhibit describes and illustrates the first case series of five patients with treated nbl in whom the imaging features of polycystic kidney disease (pkd) developed over time, and in some cases, as progressive renal failure ensued. methods & materials: medical and imaging records were reviewed (irb approved) of patients with treated nbl in whom pkd became apparent during the course of followup imaging. results: five patients displayed findings of pkd on us and/or ct. three of the five patients (where images were available) had normal renal imaging at time of nbl diagnosis. the mean age at nbl diagnosis was . years (range . - . yr). the mean age at time pkd was detected was . years (range - yrs). none of the patients had a family history of pkd, or had previously undergone dialysis. all patients received chemotherapy and total body irradiation prior to bone marrow transplantation. four patients survived nbl therapy but eventually developed end-stage renal disease. conclusions: an association between acquired pkd and nbl has not been previously reported. the etiology of this observation is still unclear, but a toxic insult is likely to account for the renal changes. further research is needed to establish the epidemiology, prognosis, and etiology of this association. abnormal migration of the retention anchor suture in a case following gastrostomy tube insertion surendra narayanam, mbbs, dmrd, dnb, division of image guided therapy, department of diagnostic imaging, the hospital for sick children, nrssbabu@gmail.com; joao amaral, luke toh, bairbre connolly, vicente deoliveira, dimitri parra purpose or case report: during percutaneous gastrostomy tube placement, retention anchor suture(s) are deployed into the stomach to tack the anterior gastric wall to the abdominal wall. in our practice the thread of the retention anchor suture is cut at days and the metallic portion passes pre rectum. we report an interesting and very rare migration of the metallic portion of the retention anchor suture in post-primary gastrostomy tube insertion. an -month-old girl, with a mitochondrial disease and severe hypotonia underwent percutaneous gastrostomy placement. during the procedure the retention anchor suture thread snapped and the metallic portion of the suture remained within the stomach. day post procedure, the child became uncomfortable, so a gastrostomy tube check was performed. the suture was not visible in the abdomen on abdominal x-ray or fluoroscopically. on close review of the images, the suture was found projected over the distal esophagus. initial impression was the anchor suture had refluxed into the esopahgeal lumen. careful attempts were made to remove it along with the nasogastric tube, from above under fluoroscopic control. however on withdrawal of the nastogastric tube, the retention anchor suture moved enbloc with the nasogastric tube. once removed the retention anchor suture was confirmed to be within the nasogastric tube. this case illustrates the importance of examining the chest x-ray carefully before assuming a retention anchor suture has passed. to understand the appropriate post procedural radiographic workup and its technique for timely diagnosis. . to learn the potential complications of delayed diagnosis. pediatric retroperitoneal synovial sarcoma ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: pediatric synovial sarcoma most commonly affects the extremities, especially the lower thigh and knee region; other primary sites such as the retroperitoneum have been only infrequently reported. we report an extremely rare case of a retroperitoneal synovial sarcoma masquerading as retroperitoneal hematoma in a -year-old white female with non-traumatic back pain and non-contrast enhanced ct findings of right quadratus lumborum and psoas region presumed hematoma. coagulation studies revealed factor xi deficiency also known as hemophilia c. however, on follow-up imaging, the presumed retroperitoneal bleed persisted and a subsequent mr examination revealed a solid enhancing mass. ct, mr, and fdg-pet findings as well as a brief histopathology are discussed. our case is rare in the regards that the tumor occurred in an uncommon retroperitoneal location in a pediatric patient and was mimicking a retroperitoneal hematoma which posed a significant diagnostic challenge. despite a rare entity, synovial sarcoma among other sarcomatous lesions maybe considered in the differential consideration of a spontaneous retroperitoneal hematoma even in hemophiliac patients. longitudinal bracket epiphysis michael jubang, geisinger, mjjubang@geisinger.edu; farzad sedaghat, william j. malone, george wu, william mirenda purpose or case report: longitudinal bracket epiphysis is a rare anomaly with multiple synonyms such as delta bone, triangular bone, and congenital angular deformity. the purpose of this case report poster is to discuss an -month-old male born with an adducted right great toe with a broad nail and a notch in the center of the distal phalanx. the review will discuss radiographic findings, the natural progression of the disease, the treatment options, the mri findings used for pre-surgical planning, and associated pathology. whole body mri in pediatric non oncologic diseases: pictorial review ramy el jalbout, md, radiology, chu sainte justine, ramy.jalbout@yahoo.com; vijay moorjani purpose or case report: with the advances in scanning techniques and the scanning sequences, the role of wbmri is expanding. mri has a great role in the pediatric population owing to its inherent advantages namely lack of radiation, high tissue specificity, and high diagnostic yield at the level of the entire body under a single sedation. unlike the application of wbmri in the assessment of metastasis and bone marrow involvement in leukemia, its role in systemic diseases is yet to be further investigated. certain diseases such as crmo are very often multifocal. the extent of osteonecrosis in patients on steroids, dermatomyositis and the lesions related to child abuse are very often wide spread in the skeleton. we intend to present some of the findings of these pediatric systemic and multifocal diseases on wbmri. chronic relapsing multifocal osteomyelitis (crmo): crmo can be acute or chronic and is multifocal. the abnormality manifests as high signal intensity. wbmri can guide for the best site for biopsy and provides monitoring for response to treatment. osteonecrosis: only few small studies evaluated the usefulness of wbmri in the diagnosis of both the symptomatic and asymptomatic sites of osteonecrosis in all patients on steroid therapy. wbmri is more sensitive than conventional radiographs. the abnormalities are typically geographical areas of high stir signal intensity. myopathies: wbmri has also the role of detecting the extent of idiopathic inflammatory myopathies such as dermatomyositis in the entire skeleton. child abuse: wbmri has a low sensitivity for the highly specific fractures that are pathognomonic for child abuse. conclusions: wbmri is a useful examination in the pediatric patient that is radiation free, quick and allows imaging of the entire body. it is an adjunct to dedicated mris to look for multifocality and extent of systemic diseases such as crmo, osteonecrosis in patients on steroids and dermatomyositis. it has a great potential as a screening examination but at the same time can detect both the symptomatic and the asymptomatic lesions in the bone marrow and muscles that are otherwise not seen on conventional radiography. it also allows guidance for biopsy and monitors response to treatment. mobile "cerebroliths" in hemihydranencephaly: a case report usha d. nagaraj, md, the ohio state university medial center, usha.nagaraj@osumc.edu; brent adler purpose or case report: hydranencephaly is a congenital central nervous system disorder manifested by the replacement of the cerebral hemispheres with a thin membranous sac filled with cerebrospinal fluid and necrotic debris. hemihydranencephaly is an extremely rare brain condition in which the vascular anomaly is unilateral, with fewer than cases previously reported in the literature. this is a case of a -month-old male who presented to the ophthalmologist for evaluation of possible leukocoria of the right eye. the patient had a history of a difficult vaginal delivery that required forceps delivery with possible associated trauma to the right eye. dilated fundoscopic exam revealed retinal calcifications. this caused a clinical concern for retinoblastoma and ct and mri of the orbits were obtained. ct demonstrated profound dilatation of the left lateral ventricle with only a thin rim of cortex surrounding it. there was some midline shift to the right with mild dilatation of the right lateral ventricle. the thalami and brainstem were spared. there were multiple soft tissue bodies that layered in the dependent portion of the left lateral ventricle, which were isodense to grey matter. mri revealed similar findings consistent with hemihydranencephaly involving the left cerebral hemisphere. there were multiple round soft tissue masses that measured up to cm in size that layered posteriorly in the left lateral ventricle. these masses were isointense to grey matter on t and hyperintense on t . when the patient was placed with his head turned to the left, these masses moved to the dependent portion of the left lateral ventricle. the orbits were normal on both ct and mr. these soft tissue collections are presumed to be mobile collections of infarcted brain tissue. this unusual appearance has not been described in the radiology literature. we review the ct and mr findings and review the relevant literature. purpose or case report: citrullinemia type i is a rare inborn error of urea cycle metabolism resulting in hyperammonemia. in the classic form, the newborn presents with poor feeding, vomiting, progressive lethargy and signs of increasing intracranial pressure - days after birth, rapidly progressing to apnea, coma and death if left untreated. we present a case of a term infant who presented to the hospital on the th day of life with a typical history of poor feeding and profound hypotonia. upon admission he had multiple episodes of apnea and hemodynamic instability prompting intubation and intensive support. laboratory evaluation revealed multiple abnormalities, most notably, hyperammonemia ( umol/l) and elevated citrulline (> umol/l). mri of the brain performed on the th day of life showed findings consistent with term hypoxic ischemic encephalopathy with restricted diffusion in bilateral rolandic cortex and subcortical white matter, bilateral caudate heads and lenticular nuclei, bilateral insular cortex, and bilateral cerebral peduncles. the genu of the corpus callosum, bilateral deep frontal white matter, and the left parietal white matter also demonstrated restricted diffusion suggesting infarction secondary to thrombosis of deep intramedullary veins. an area of restricted diffusion in the right parietal cortex was suspicious for superficial venous infarct. review of the literature reveals that this case of neonatal citrillunemia has unique mri findings. while our patient had diffusion changes with some shared similarities to the previous two cases in the literature, there are also findings consistent with deep intramedullary venous thrombosis and infarction. poster #: cr- duplicated internal auditory canal: a rare anomaly of the temporal bone ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: duplicated internal auditory canal (iac) is a rare anomaly of the temporal bone, which is usually associated with sensorineural hearing loss. only a few cases have been previously described in literature. we describe an extremely rare case of duplicated right internal auditory canal in a six month-old patient with a history of down syndrome. a six month-old male with trisomy presented with profound bilateral sensorineural hearing loss. the patient failed the newborn hearing screening tests. past medical history was unremarkable for recurrent ear infections. on focused physical examination, the auricles were normal appearing. external auditory canals were patent bilaterally revealing clear and translucent tympanic membranes. patient did not reveal a facial palsy. subsequently, a high resolution computed tomography (hrct) of the temporal bone was performed. duplicated appearance of the right internal auditory canal with separation of facial and vestibulocochlear segments was noted. the facial nerve canal demonstrated normal caliber while there was significant narrowing of the cochlear canal near the fundus. significant stenosis of the vestibulocochlear segment of the duplicated iac was identified at the porus acousticus. dehiscent right posterior semicircular canal was also seen. an enlarged right vestibule was also noted. a single iac was identified on the contralateral side with significant stenosis at the porus acousticus. high-resolution magnetic resonance imaging of iac was recommended which revealed normal appearance of the bilateral cochlear and vestibular nerves. duplication of the iac is an extremely rare anomaly involving a redundant osseous canal extending from the cerebellopontine angle through the otic capsule bone toward the labyrinth or cochlea. a duplicated iac may or may not be associated with congenital sensorineural hearing loss secondary to aplasia or hypoplasia of the vestibulocochlear nerve. to evaluate for structural abnormalities that may preclude cochlear implantation, it is important to evaluate pediatric patients with sensorineural hearing loss radiologically. although hrct is the best imaging modality for evaluation of osseous iac, the iac contents are best viewed on mri in oblique sagittal planes of the iac using a -d volumetric steady state sequence. neuroimaging in hemiplegic migraine: cases and review of the literature nicholas v. stence, md, children's hospital colorado-radiology, nicholas.stence@childrenscolorado.org; sita kedia, john a. maloney, jennifer armstrong-wells, timothy bernard purpose or case report: hemiplegic migraine (hm) is a rare variant of migraine with aura. it is characterized by a motor deficit lasting up to h that is fully reversible. little neuroimaging data for hm exists in the literature. we report our experience with two pediatric cases of hemiplegic migraine. we also review published cases of pediatric hm with abnormal findings on neuroimaging. methods & materials: cases and presented to our institution with severe headache (ha), acute right-side weakness, aphasia, and altered mental status (ams), which did not resolve after h. magnetic resonance imaging (mri) and genetic testing are reviewed for these cases. the literature was reviewed for pediatric cases with neuroimaging changes during hm attacks. results: initial mri, including diffusion-weighted imaging (dwi), was negative in both patients within h of onset. repeat mris at h (case ) and h (case ) were both positive for mild hyperintensity on trace diffusion images, and corresponding reduced diffusion on adc maps, involving regions of the cortex and juxtacortical white matter in left middle cerebral artery distributions. these findings completely resolved at months in both cases. mr angiograms (mra) were negative in both cases. case had a family history of migraines and was found to have an unreported mutation in atp a gene at a highly conserved location in vertebrates. case had a family history of hm and was found to have an indeterminant mutation in the cacna a gene. infectious, metabolic and hypercoagubility work up was negative. case required inpatient rehabilitation and at year follow up was requiring speech therapy. case resolved completely. in the literature, cases of hemiplegic migraine with neuroimaging changes were reported. all cases had prolonged hemiplegic migraines (symptoms> h) and showed cerebral edema with or without restricted diffusion. conclusions: all eight hm cases in the literature with abnormal findings on neuroimaging had prolonged attacks. mris for our two cases and two cases reported in the literature were initially normal at admission. mild swelling and restricted diffusion developed in our two cases after h, and resolved on follow up mris. subtle findings on diffusion and t imaging may lag behind the clinical picture in hm, therefore serial neuroimaging may be useful in individuals with prolonged symptoms. most cases eventually show resolution clinically and on mri. correlation of neurosonographic anatomy with matching mr scan planes denise castro, hospital for sick children, denisecastro @ gmail.com; pam rasalingham, omar islam, don soboleski purpose or case report: new high-resolution mr sequences have allowed for exquisive anatomic detail and enables reconstruction of images in any scan plane desired. this ability allows for precise matching of mr image planes with the standard oblique coronal, sagittal and axial images obtained during routine neurosonography. the purpose of this poster is to correlate the morphology demonstrated on neurosonography with the mr image, utilizing this ability in order to enhance our understanding of the neuroanatomy distinguishable on sonographic imaging. we believe this will allow a better appreciation of the subtle differences in echotexture of neuroanatomic structures which are often ignored or overlooked on neurosonography and help improve our detection of subtle sonographic abnormalies. ectopic cerebellum in the posterior cranial fossa: report of a case and review of the literature usha d. nagaraj, md, the ohio state university medical center, usha.nagaraj@osumc.edu; daniel boue, lisa martin purpose or case report: cerebellar heterotopia is a common congenital anomaly frequently encountered in the form of cell rests around the fourth ventricle. however, isolated well-differentiated cerebellar ectopia is extremely rare. of the previously reported cases in the literature, only have presented as a discrete, extraaxial mass and none have been described in the posterior cranial fossa. we present a case of a -year-old male who initially presented with persistent daily headaches. physical exam including a detailed neurologic exam was within normal limits. non-contrast computed tomography (ct) of the brain was initially performed, demonstrating no abnormalities. further work-up with magnetic resonance imaging (mri) was performed, which revealed a well-defined, extra-axial mass superior to the cerebellum and inferior to the tentorium, immediately beneath the vein of galen. the mass was isointense to grey matter on t and t sequences and there was no significant enhancement on post-contrast images. there was mass effect on the vermis and the cerebellar tonsils were displaced mm below the foramen magnum. neurosurgery was consulted and the mass was removed for diagnosis and treatment of the patient's symptoms. the mass was easily identified intra-operatively and gross total resection was accomplished successfully. pathologic analysis of the mass revealed well-formed cerebellar tissue without evidence of neoplasia. to the best of our knowledge this is the only case of ectopic cerebellum presenting as a discrete extra-axial mass in the posterior cranial fossa. our case shows that an extra-axial mass that parallels grey matter on all sequences can be a presentation of ectopic cerebellum. we describe the ct and mri findings, surgical and histopatholgical results and review the relevant literature. pediatric isodense acute subdural hemorrhage jeffrey s. kao, md, msee, university of kansas-wichita, run boston@gmail.com; debbie desilet-dobbs purpose or case report: the density (attenuation coefficient) of subdural hemorrhage (sdh) in computed tomography (ct) is important in assessing the acuity of sdhs. an acute sdh is traditionally described as hyperdense and then becoming isodense in approximately weeks when entering the subacute phase. in this report, we document the case of a pediatric patient with the new appearance of an acute sdh within h of the prior ct that was isodense. greater than % of the collection was isodense, with a small focus of hyperdensity. acute sdhs are known to be isodense to gray matter in patients with anemia (wp smith, am j neurorad ). however, the hemoglobin and hematocrit was within normal limits. in addition, acute sdhs that are only a few hours old can have a mixed hyperdense and hypodense appearance because of uncoagulated blood before clotting takes place (j provenzale, ajr ) . thus, an acute sdh can have an isodense appearance in a non-anemic patient. radiologists should consider the possibility of an acute sdh with an isodense appearance, especially in case of possible non-accidental trauma where timing of an injury is important. undifferentiated sarcoma of the esophagus in an year-old male: case report and radiologic/pathologic correlation michael e. daniel, md, ut southwestern / children's medical center dallas, michael.daniel@utsouthwestern. edu; lisa sutton, sandy cope-yokoyama, neil j. fernandes purpose or case report: mesenchymal neoplasms of the gastrointestinal (gi) tract occur infrequently in the adult and are extremely rare in the pediatric population. the occurrence of these lesions in the esophagus is limited to a collection of case reports in the available literature. most esophageal mesenchymal tumors in the pediatric gi tract are benign leiomyomas. the vast majority of malignant mesenchymal tumors in children are categorized as either sarcomas or gastrointestinal stromal tumors (gist). we report a case of a high grade undifferentiated sarcoma of the distal esophagus in an year-old male. while this tumor most closely resembles a gist, the immunohistochemical profile of the lesion is not typical of any distinct mesenchymal neoplasm. a review of the literature demonstrates a single case report of a likely benign undifferentiated mesenchymal neoplasm of the distal esophagus in an adolescent. to our knowledge, this is the first reported case of an undifferentiated esophageal sarcoma in a pediatric patient. we provide radiologic and pathologic features of the above lesion, and review the typical imaging and pathologic characteristics of mesenchymal gi neoplasms. potential airway management issues in sedated children kimberly fagen, md, ms, children's national medical center, kfagen@childrensnational.org; nadja kadom, ira cohen purpose or case report: many pediatric imaging studies require sedation. it has been shown that a variety of health care professionals other than anethesiologists may provide sedation, including advanced practice registered nurses, nurse practitioners, physician assistants, fellow level trainees, emergency medicine physicians, intensivists, pediatricians and, last but not least, radiologists. moderate sedation, also called "conscious sedation", does generally not require an anesthesiologist as there is usually adequate spontaneous ventilation and no airway intervention required. however, in case of a complication during the imaging study intubation may become necessary. for patients with certain congenital or acquired conditions emergent intubation may be very difficult and should be brought to the attention of an anesthesiologist prior to inducing moderate sedation. the four "d's" is a quick way to assess potentially difficult airways that necessitate consultation with anesthesia prior to moderate sedation: dentition (incisor/tooth size, dental alignment, and macroglossia), distortion (swelling from infection, tumor, or trauma), disproportion (hyoid-chin ratio, such as with micrognathia), and dysmobility (jaw or cervical spine movement issues, i.e. trauma or atlanto-occipital instability). presence of some of these features may be an indication to consider general anesthesia for sedation; at the very least, anesthesiologist's awareness of a potentially difficult intubation adds to patient safety during moderate sedation. purpose or case report: lymphangiomatosis describes the presence of multiple lymphangiomas often with multiorgan involvement; typically bones, spleen, mediastinum and lungs. although lymphangiomatosis has been described in patients ranging from birth up to years, it most frequently presents in childhood. the lesions can occur in any tissue in which lymphatics are normally found, with a predilection for neck and chest involvement. the clinical presentation is variable including pleural or pericardial effusion, hemoptysis, protein wasting enteropathy, peripheral edema, hemihypertrophy and disseminated intravascular coagulopathy. the coexistence of lytic bone lesions and chylothorax serves as an important diagnostic clue. we describe typical radiographic, ct and mri findings in the appropritate clinical setting that narrow the differential diagnosis and raise concern for this rare entity as the etiology for the patient's symptoms. we report a -year-old girl and year-old boy with pulmonary lymphangiomatosis with typical presentation and imaging findings. results: bilateral interstitial infiltrates, pericardial and pleural effusions are evident on chest radiograph. sampling of the pleural fluid demonstrates chylous effusion. ct scans of the thorax reveal diffuse smooth thickening of interlobular septa and bronchovascular bundles with extensive infiltrative involvement of mediastinal fat. osseous and splenic lesions are demonstrated both on ct and mr. differential diagnosis includes interstitial edema, lymphoma and sarcoidosis. conclusions: the natural history of pulmonary lymphangiomatosis is characterized by progressive growth and compression of adjacent structures. therapy should aim to decrease the compressive effects, to control chylous effusions, and to maintain cosmesis. the success of surgical resection is limited by inability to separate lymph collections from normal structures. characteristic clinical and radiographic presentation, chylothorax, and extrathoracic lymphatic dysfunction should prompt a consideration of lymphangiomatosis and prevent delay in diagnosis. aortic arch congenital anomalies: what the radiologist needs to know luana stanescu, radiology, seattle children's hospital, stanescu@u.washington.edu; stephen done purpose or case report: . review classic imaging findings in congenital aortic arch anomalies which can improve detection on radiographs and barium esophagogram . describe pertinent embryologic basis of the radiologic findings . describe correlative imaging findings on ct and/or mri in dedicated cases . describe common diagnostic pitfalls methods & materials: after obtaining institutional irb approval we reviewed various patients presentations with this condition and analyzed images to characterize this particular entity and it's manifestations for better definition of diagnostic criteria. results: radiographs and barium esophagogram: algorithmic approach in reviewing chest radiographs in order to improve detection of aortic arch anomalies; classic findings and common pitfalls. cross-sectional imaging (ct and mri): what the surgeons need to know before surgical repair; detection of associated cardiac anomalies. sample cases: double aortic arch, double aortic arch with complete or partial atresia of one of the arches. conclusions: major teaching points of this exhibit are: . review of classic features of congenital aortic anomalies on radiographs, esophagogram, ct and mri with pertinent embryologic basis . describe the utility of various imaging modalities in congenital aortic anomalies, emphasizing common pitfalls. cardiovascular and mediastinal imaging in children with unexpected clinical presentation shunsuke nosaka, md, radiology, national center for child health and development, nosaka-s@ncchd.go.jp purpose or case report: children with cardiovascular and mediastinal diseases can be congenital or acquired in etiology. they usually present with straightforward clinical course. in certain situation, however, some of the children show unexpected clinical presentation predominantly with those of neighboring organs such as respiratory tract, hepatobiliary system, and gastrointestinal tract. these unexpected presentations can be the cause of delay in proper diagnosis and treatment. the purpose of this exhibit is demonstrate a variety of imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. this exhibit is case based presentation of cardiovascular and mediastinal imaging in children including tips, pitfalls and lessons learned among patients presented with unexpected clinical presentation. diagnostic imaging modalities for cardiovascular disease usually consist of various combinations of plain radiography, ultrasound, ct, mr imaging, fluoroscopy, nuclear medicine, and angiography. the general concept of alara-as low as reasonably achievable-should always be utilized when radiation-producing modalities are indicated in children. the diseases included will be double aortic arch found during workup for the cause of aspiration pneumonia, unilateral pulmonary vein atresia presented with recurrent episodes of pneumonia, severe mitral regurgitation secondary to chordal rupture mimicking fluminant hepatic failure, myocarditis initially present as acute abdomen, cardiomyopathy as unusual initial presentation of neuroblastoma, and thymolipoma mimicking gradual development of cardiomegaly. conclusions: it is important for radiologist to be familiar with imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. cardiac embryology made easy: a novel teaching approach using claymation andrew phelps, children's hospital boston, aphelpsmd@ gmail.com; purpose or case report: congenital heart disease can be an intimidating subject for radiology residents, and cardiac embryology is key to its understanding. however, this can be an equally intimidating topic to teach! various diagrams and animations are available in textbooks and online, but much like advanced origami, many of these resources suffer from being visually too complex for the first-time learner. to overcome this teaching obstacle, i created my own cardiac embryology animations using modeling clay and incorporated them into a comprehensive didactic lecture on congenital heart disease. methods & materials: cardiac embryology animations were created using modeling clay, a digital camera, and microsoft powerpoint. surface and cross-sectional views were generated, depicting the key events in cardiac embryology: heart tube formation, cardiac looping, chamber division, truncus arteriosus division, and pulmonary venous connection. example models are shown in figure . results: in this lecture, the animations are presented alongside actual embryonic heart photographs. the lecture then uses the embryology knowledge as a basis to explain the common congenital heart diseases and their mri appearances. examples of septal defects, ventricular hypoplasia, and transposition of the great arteries are presented, among others. conclusions: understanding cardiac embryology is required in order to approach congenital heart disease in a logical fashion. modeling clay animations are a cheap and easy way to simplify this complex topic. arterial tortuosity syndrome: an introduction to the clinical and radiologic manifestations in the pediatric population neal desai, umkc som, neal @gmail.com; suchit patel, ayushi gupta, marius hubbel, doug rivard purpose or case report: . to describe the clinical findings of arterial tortuosity syndrome and give a brief discussion of the disease process. . to describe the radiologic manifestations of arterial tortuosity syndrome. . to give a brief discussion of loeys-dietz syndrome-a disease with similar arterial findings, but with unique molecular characteristics from arterial tortuosity syndrome. . to use this knowledge to help establish the diagnosis and reduce mortality. methods & materials: arterial tortuosity syndrome overview • epidemiology • molecular basis • pathophysiology • review of signs, symptoms and presentation • brief discussion of treatment differential diagnosis of arterial tortuosity syndrome • loeys-dietz syndrome-similarities and differences radiologic findings and discussion • chest radiograph • computed tomographic angiography • magnetic resonance angiography-neck • magnetic resonance angiography-head • conventional angiography making a diagnosis • sample case report • review questions conclusions: arterial tortuosity syndrome is a rare disease whose chief manifestation is severe cardiovascular connective tissue defects. due to the nature of these defects and the significance of rapid intervention, it is important to be aware of and recognize the radiologic manifestations associated with arterial tortuosity syndrome in the presence of appropriate clinical history to help offer a better prognosis to the patient. dynamic pulmonary computed tomography for evaluation of cardiopulmonary disease shilpa v. hegde, md, arkansas childrens hospital, university of arkansas, shilpavhegde@gmail.com; s. bruce greenberg purpose or case report: dynamic pulmonary computed tomography (dpct) is a wide-detector ct technique that allows for continuous chest imaging during respiration. when combined with intravenous contrast, the technique is a unique tool for evaluation of cardiopulmonary abnormalities in children with cardiopulmonary abnormalities. the purpose of this poster is to illustrate the technique of dpct for evaluation of cardiopulmonary disease in children with congenital heart disease and persistent respiratory distress. methods & materials: methods and materials: dpct exams with intravenous contrast were performed on infants with a history of congenital heart disease and palliative surgery. four continuous msec gantry rotations were obtained with respiratory rates set at /minute. the imaging was accomplished during the time of a single respiratory cycle. kvp and low ma resulted in effective dose of≈ . msv. eight respiratory phases were reconstructed to create d and mpr cine loops for evaluation of cardiopulmonary abnormalities. results: cardiopulmonary abnormalities were detected in all patients. patency of sano shunt, blalock tausig shunt or patent ductus arteriosus stent was established. intimal thickening was identified in one sano shunt. hypoplastic branch pulmonary arteries were present in infants and pulmonary vein thrombosis in infant. left bronchomalacia was identified in four of five infants and best or only identified on the expiratory phase of respiration. left lung air trapping was present in two patients. conclusions: dpct with intravenous contrast is the ideal study for evaluation of the post-operative infant with congenital heart disease and persistent respiratory distress. the role of low-dose ct angiography in the evaluation of renovascular hypertension in children jessica kurian, md, chop, kurianj@email.chop.edu; monica epelman, kassa darge, els nijs, jeffrey hellinger purpose or case report: historically, the evaluation of renovascular hypertension has been accomplished via us and conventional angiography. based on the reported adult experience we introduced renal ct angiography (cta) for the evaluation of renovascular hypertension in mid- . our institution has a robust, well-established protocol, which results in reproducible, high quality images. we aim to present our imaging strategies for the evaluation of these patients and to discuss and illustrate the role of low-dose cta with -d imaging as a noninvasive alternative in the evaluation of pediatric renovascular hypertension. methods & materials: we used our department information system to identify pediatric patients (< years of age) who had documented renovascular hypertension confirmed either by conventional angiography and/or surgery during a -year period. we present our protocol and discuss the indications, limitations and benefits of renal cta. ct thin slice data, obtained employing dose reduction strategies, was reviewed and reconstructed in d and d renderings. pertinent us and mr studies as well as demographic and clinical data were reviewed and recorded. several causes for renovascular hypertension were documented and relevant ct angiographic findings were selected for presentation. results: radiation dose ranged . - msv. fibromuscular dysplasia was the most common diagnosis followed by neurofibromatosis type . vascular pathology included stenoses, beading, occlusions, and aneurysms. disease was noted in the extraparenchymal renal arteries in approximately % of the cases. the choice of the imaging modality for the investigation of renovascular hypertension in pediatric patients remains controversial. in the authors' experience, cta with -d imaging is a valuable, non-invasive diagnostic tool for the evaluation of pediatric renovascular hypertension. low dose protocols can reduce the radiation exposure associated with ct. this method can spare patients the complications associated with conventional angiography. fetal mri: brain, head and neck malformations-a pictorial essay sumit singh, md, children's hospital of wisconsin, sumitsingh @yahoo.com; mohit maheshwari, teresa c. gross kelly, tushar chandra, ibrahim s. tuna, craig johnson purpose or case report: the purpose of the exhibit is to illustrate various brain, head and neck massses/vascular anomalies on fetal mri. we will also briefly discuss the normal fetal brain anatomy as seen on fetal mri. methods & materials: major indications for fetal mri include evaluation of inconclusive sonographic findings in cases of cns malformations. in our institute patients are scanned on . t mr scanner. a body surface six channel phased array coil is used to maximize signal to noise. all the scans are checked by a neuroradiologist to make sure adequate plane imaging of the brain or other lesion in question were performed. plane scanning of the fetal body is also performed for the laterality determination of the lesion and also screen for other congenital anomalies. results: prenatal usg is frequently inconclusive for evaluation of complex fetal brain and head and neck anomalies. most studies suggest that mri after first trimester is safe. in addition, advent of rapid mri sequences like single shot fast spin echo (ssfse) have helped in reducing scan time and motion artifacts leading to availability of diagnostic quality images. these have led to increasing use of mri as supplemental tool to further investigate inconclusive fetal sonographic findings. mri provides better anatomical delineation of these complex abnormalities. it helps in making appropriate diagnosis with high confidence and aids in appropriate obstetric and prenatal/neonatal surgical planning or intervention. this educational exhibit will illustrate few common fetal anomalies. these will include agenesis of corpus callosum, malformation of cortical development, posterior fossa malformations, ventriculomegaly, in-utero stroke, orbital abnormalities and some fetal neck masses/ vascular malformation. correlation and confirmation with the postnatal mri will also be provided for some cases. conclusions: technical and therapeutic advances have driven the development of fetal mri. it is an important adjunctive tool for prenatal imaging in those instances in which a complex anomaly is suspected by sonography, when fetal surgery is contemplated, or when a definitive diagnosis cannot be determined. it has prognostic implications and may help in optimal and timely obstetric and neonatal management. purpose or case report: this educational report will provide a review of the imaging appearance of intradiaphragmatic and subdiaphragmatic pulmonary sequestrations on fetal mri. the proposed pathophysiology, review of sequestration subtypes, and surgical management options will also be described. case examples will be provided to illustrate the fetal mr imaging findings of these variants of pulmonary sequestration that help support the diagnosis. specifically a "triangle sign" of t hyperintense tissue directed toward the diaphragm will be demonstrated. illustrative case examples will be placed in the context of a differential diagnosis for subdiaphragmatic masses seen on prenatal imaging. imaging signs that help make a diagnosis of these pulmonary sequestration variants and separate this entity from other lesions will be emphasized. poster #: edu- mri of the fetal head and neck masses alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; joshua shimony, per amundson purpose or case report: fetal magnetic resonance imaging (mri) is a useful problem solving tool for abnormalities detected by prenatal ultrasound (us). masses of the head and neck region can vary from benign incidental lesions to devastating neurological lesions and life threatening tumors. we share our experience in characterizing these lesions by prenatal mri, that can have a bearing on follow up imaging, perinatal management and overall prognosis. we did a retrospective review of all fetal mri studies performed at our tertiary care children's hospital between / and / , to identify fetuses with head and neck masses. we reviewed the maternal demographic and clinical data, prenatal ultrasound, fetal outcomes and post natal imaging (when available). results: out of the fetal mri studies, had dominant head and neck masses. majority were encephaloceles ( occipital, parietal). the remaining included variety of masses such as nasal glioma, teratoma ( ), epidermoid cyst, hemangioma and lymphatic malformation ( ) . mri played a useful role in distinguishing encephaloceles from other masses based on underlying bone defect and intracranial extension. it also helped in characterizing other masses based on location and signal characteristics. the presence and degree of airway compromise was determined. intracranial anomalies associated with encephaloceles including callosal dysgenesis, cerebral and cerebellar hypoplasias, migrational disorders and spinal anomalies were also correctly identified. conclusions: we present the prenatal mr imaging findings of a spectrum of head and neck lesions, correlating with prenatal ultrasound, postnatal imaging and clinical or pathological outcomes. purpose or case report: the immaturity of the cns in neonatal infants makes neurologic assessment difficult. neuroimaging plays an essential role in the assessment of brain injury by helping to indentify the injury and expected neurologic outcome. cranial ultrasound (us) is usually the first neuroimaging modality used since the technique is portable, does not involve radiation and can be used sequentially. magnetic resonance imaging (mri), however, is the most sensitive imaging modality for the detection of hypoxic brain injury. the goal of this presentation is to compare the us and mri performed within a -hour interval, and evaluate these findings to improve the interpretation of the us which is usually the first methodology used to evaluated these patients. we performed a retrospective review of the neonatal imaging studies with us and mri performed within -hour interval on preterm and term newborns with clinical history of hypoxia-ischemia. the imaging findings of the two modalities, mri and us, were correlated with the pattern and severity of the injury and brain maturity. results: diffuse white matter abnormalities were observed in % of the patients by us or mri. the ultrasound identified diffuse increased echogenicity which did not show correlation with mri in % of patients. focal white matter abnormalities were better identified by mri on non-cavitary leukomalacia which is the most common pvl observed in premature neonates with low birth weight and the most difficult to identified using us. cavitary leukomalacia showed strong agreement in both methodologies. the mri identified % more cases of intraventricular hemorrhage, however, the corresponding increase in hemorrhage was of minimal clinical significance. in most cases extra axial hemorrhage was better identified by mri. conclusions: after viewing this exhibit, the viewer will gain a better appreciation and understanding of the neuroimaging characteristics of hypoxia-ischemia in us and mri, and thus improving the interpretation of the us which is usually the first imaging modality used to evaluate this patient population. purpose or case report: the most common thoracic lesions found on prenatal imaging, congenital pulmonary airway malformation (cpam), bronchopulmonary sequestration (bps), and congenital diaphragmatic hernia (cdh), usually have characteristic imaging findings previously described in detail. however, common entities presenting with atypical findings and rarer thoracic entities do occur and can be characterized by fetal magnetic resonance (mr) imaging. the purpose of this educational exhibit is to show examples of atypical presentations of common thoracic lesions and more unusual thoracic entities on fetal mr. when applicable, prenatal mr is compared with prenatal ultrasound, postnatal imaging, operative findings, or pathology. methods & materials: using a radiology information system database, the reports of all fetal mr exams at our institution from january through january were reviewed. when unusual thoracic findings were described in the report, all prenatal and postnatal images (when available) were evaluated. in the cases selected, medical charts were reviewed for operative findings and pathologic reports. results: the cases to be described, both pulmonary and extrapulmonary in location, include: hybrid lesion in a horseshoe lung, cpam extending across the midline, bilateral bps, bps located within the mediastinum, bps located within the leaves of the diaphragm, ectopia cordis and cdh as components in pentalogy of cantrell, cdh with herniation of liver into the pericardium, elongated esophageal duplication cyst, chest wall lymphatic malformation, and tight double aortic arch causing congenital high airway obstruction syndrome (chaos). conclusions: after studying this educational exhibit, the reader will be acquainted with a variety of unusual fetal pulmonary and extrapulmonary lesions, with emphasis on fetal mr. prenatal and postnatal imaging findings in megacystis-microcolon-intestinal hypoperistalsis syndrome (mmihs) mary kitazono, chop, mkitazono@gmail.com; richard bellah purpose or case report: to review the classic constellation of findings seen in prenatal and postnatal imaging of megacystis-microcolon-intestinal-hypoperistalsis syndrome (mmihs), as well as to illustrate additional imaging features that are variably seen in this syndrome. the imaging database at our children's hospital was searched for all cases of mmihs diagnosed since . all available prenatal and postnatal imaging studies were reviewed in patients with a diagnosis of mmihs, and representative images are provided with a description of the findings. results: since , patients ( girls, boy) have been diagnosed with mmihs at our institution, including on prenatal mri and us. the characteristic prenatal imaging findings include marked urinary bladder distension, bilateral pelvicaliectasis, and dilated, tortuous ureters, as well as a diminutive colon containing no or minimal t w-hyperintense meconium on mri. postnatal imaging studies also characteristically demonstrate a massively distended urinary bladder (with no apparent mechanical cause of obstruction) as well as a small, unused colon with dilated, hypoperistaltic small bowel seen proximal to the microcolon. additional findings which are variably seen include intestinal malrotation, stomach and esophageal hypoperistalsis or aperistalsis, gastroesophageal reflux, and biliary stasis. conclusions: although a rare syndrome, the constellation of imaging findings in mmihs is pathognomonic, and recognition of the classic pattern of findings can allow the radiologist to make a diagnosis of mmihs in both the in-utero and postnatal setting. early diagnosis is essential for allowing prenatal counseling regarding this generally fatal disorder, as well as to optimize early management options. purpose or case report: gastric mass lesion are uncommon. this presentation is an educational review of pediatric gastric mass lesions including gastro-intestinal stromal tumor (gist), inflammatory myofibroblastic tumor (pseudotumor). burkitt's lymphoma, squamous cell carcinoma, gastric teratoma, gastric varices, gastric hamartoma, gastric polyp and hypertrophic pyloric stenosis (hps). clinical presentation is varied with upper gi bleeding, feeding intolerance, pain, weight loss and fatigue manifesting. the imaging work-up might initially have been endoscopy or ultrasound. cross section imaging (ct mr) can be invaluable. the role and impact of fdg pet on the management, staging and follow up of the oncologic pathology will be emphasized. imaging findings in megacystic microcolon intestinal hypoperistalsis syndrome, a rare disease kiery braithwaite, pediatric radiology, emory-egleston, kieryb@yahoo.com; kiery braithwaite, paula dickson, marianne m. ballisty purpose or case report: megacystis microcolon intestinal hypoperistalsis (mmih) syndrome is a rare congenital form of severe functional intestinal obstruction which is more commonly found in females. the presenting clinical and imaging features of this disease can often mimic other causes of proximal bowel obstruction in the neonate. in combination with its common association with intestinal malrotation, the clinical picture of mmih syndrome may be confusing at times. awareness of additional imaging features characteristic of mmih syndrome may help the radiologist suggest this diagnosis. the purpose of this study is to enhance the ability of the pediatric radiologist to suggest this rare diagnosis by recognizing this unusual constellation of imaging features. we retrospectively reviewed the clinical data and imaging studies of four patients with mmih syndrome at our institution. imaging studies included plain radiography, ultrasonography, fluoroscopy, and cross sectional imaging. the initial presentation and clinical outcome was also reviewed. results: the clinical presentations of our patients, who were all female, were somewhat varied but typically included symptoms of intestinal obstruction. the diagnosis of mmih syndrome was made in our patients from the first few weeks of life through early childhood. the four patients demonstrated imaging features characteristic of this disease including a very large dilated bladder, severe bilateral hydroureteronephrosis, gaseous distention of the stomach and proximal small bowel, intestinal hypoperistalsis, and a very small colon. the clinical course of these patients that we observed was also quite variable, with some patients dying in neonatal period while another patient continues to do reasonably well at years old after a multi-organ transplant. conclusions: mmih syndrome is a rare and frequently lethal disease. the ability of the pediatric radiologist to recognize this constellation of imaging findings can help the clinical team arrive at a diagnosis of mmih syndrome. more prompt diagnosis can aid in the development of a long term management plan for the patient and in counseling the family regarding the prognostic implications of this disorder. pathologies of omphalomesenteric duct remnant: radiologic-surgical correlation swapnil bagade, md, pediatric radiology, mallinckrodt institute of radiology, bagades@mir.wustl.edu; geetika khanna, rebecca hulett purpose or case report: . to facilitate understanding of embryology of the omphalomesenteric(vitelline) duct and normal anatomy of the umbilicus. . review the spectrum of omphalomesenteric duct malformations and diversity of clinical presentations of these remnants. . illustrate the imaging findings of omphalomesenteric remnants, from the common such as meckel's diverticulum to the uncommon such as the omphalomesenteric duct cyst, with surgical correlation. methods & materials: cases with complications of persistent omphalomesenteric duct were collected from the joint surgery/radiology conferences at a tertiary level children's hospital. imaging features were correlated with intraoperative findings. conclusions: preoperative diagnosis of complications related to the omphalomesenteric duct remnants can be challenging because clinical and imaging features overlap with other etiologies of acute abdomen. knowledge of the embryologic, clinical, radiologic, and surgical characteristics of omphalomesenteric duct remnants will aid in early and accurate diagnosis. neonatal bowel obstruction-a pictorial essay tanmay patel, university of kentucky; harigovinda challa purpose or case report: bowel obstruction is the most common abdominal emergency in the newborn period and in most cases is secondary to a congenital anomaly requiring early surgical intervention. however not every case of abdominal distension or dilated bowel is secondary to mechanical bowel obstruction or underlying surgical condition. radiologic imaging forms a central role in the work up of newborns with suspected intestinal obstruction. the role of the radiologist is to identify whether or not mechanical obstruction is present; if obstruction is identified on initial radiographs, to determine the level of obstruction, and finally to identify the etiology of obstruction. initial plain radiographic evaluation also helps to determine the subsequent diagnostic or therapeutic approach. methods & materials: a retrospective review of multiple radiographic and fluroscopic examinations in patients with diagnosis of neonatal bowel obstruction was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: neonatal intestinal obstruction generally presents with nonspecific symptoms such as abdominal distention, vomiting, or failure to pass meconium depending on the level of obstruction and time of occurrence of underlying congenital lesion/atresia in the intrauterine life. initial plain radiographs of the abdomen reveal dilated bowel loops when obstruction is present. high intestinal obstruction is suspected when only few dilated loops are identified, while multiple dilated bowel loops are seen in low obstruction. most cases of high obstruction may not need another diagnostic imaging test. all cases of distal intestinal obstruction require water soluble enema to identify the etiology of obstruction. in conditions like functional immaturity of the colon, and meconium ileus water soluble enema is therapeutic and thus surgery can be avoided in most cases. the objective of this presentation is to present an educational exhibit of classical imaging findings of various types of neonatal bowel obstructions, and how to differentiate between them. conclusions: bowel obstruction is the most common abdominal emergency in the new born period. most cases are secondary to a congenital surgical condition and early diagnosis and treatment significantly reduces mortality and morbidity. radiographic evaluation plays a central role in the diagnosis and treatment of these conditions. poster #: edu- d t -weighted mrcp in the pediatric population-a pictorial review nathan egbert, mbbs mph, university of michigan, nathaneg@med.umich.edu; jonathan r. dillman, peter j. strouse purpose or case report: to demonstrate the utility of d t -weighted magnetic resonance cholangiopancreatography (mrcp) in the pediatric population, and to illustrate the mrcp findings of various conditions affecting in the pediatric pancreaticobiliary system. we identified all mrcp exams performed on pediatric patients (< years of age) from january , through august , by searching institutional electronic medical records. we then identified representative d t -weighted mrcp images of various conditions affecting the pediatric pancreaticobiliary system. results: representative d t -weighted mrcp images (including source, maximum intensity projection, and volume rendered images) from the following conditions will be presented: abnormal biliary narrowing/stricture (including sclerosing cholangitis, anastomotic strictures following kasai procedure & liver transplantation, and "pseudostricture"), biliary atresia, choledochal cyst (including various subtypes, based on todani classification), choledocholithiasis & cholelithiasis, congenital anomalies of the pancreaticobiliary system (including pancreas divisum and anomalous pancreaticobiliary junction), pancreatobiliary system trauma (including main pancreatic duct transection), and other rare conditions affecting the pancreaticobiliary system (including rhabdomyosarcoma of the biliary tree). conclusions: d t -weighted mrcp has become an extremely useful tool in the evaluation of children with suspected disorders of the pancreaticobiliary system. since mrcp has distinct advantages over alternative diagnostic techniques, such as endoscopic retrograde cholangiopancreatography (ercp) or percutaneous cholangiography, including lack of ionizing radiation and noninvasiveness, mrcp is a much preferred initial study for pediatric pancreaticobiliary imaging. this pictorial review is intended to highlight the d t weighted mrcp appearances of various pancreaticobiliary conditions occurring in the pediatric population. purpose or case report: magnetic resonance enterography (mre) is rapidly emerging as an important imaging tool for the diagnosis and follow-up of inflammatory bowel disease (ibd). its lack of ionizing radiation makes this imaging modality especially vital to the pediatric population. using a casebased approach, we will demonstrate the usefulness of diffusion-weighted imaging (dwi) as part of a comprehensive mre protocol for the assessment of ibd in children. the basics of dwi will be discussed with particular attention to abdominopelvic techniques. the role of mre dwi for the evaluation of pediatric crohn disease (cd) and ulcerative colitis (uc) will be reviewed using a case-based approach. key images from pertinent imaging studies will be identified by searching institutional electronic medical records and presented with relevant clinical data. results: a review of pediatric mre examinations suggests dwi can be used to detect the following: ) small and large bowel segments affected by ibd (both cd and uc) ) abdominopelvic abscesses (including within the mesentery, body wall, iliopsoas muscle, and liver) ) abnormal lymph nodes ) sacroiliitis ) perianal disease (including abscesses and other penetrating complications). conclusions: dwi has the potential to play a very important role in the diagnosis and follow-up of pediatric ibd. this mre technique is particularly useful for detecting a variety of disease-related complications. as the exact meaning of bowel wall restricted diffusion is poorly understood to date, continued investigation will be necessary to determine the clinical and histologic significance of this finding. cases of cf involving the gi tract were collected from clinical workflow encounters of the authors and from the main hospital medical records database. relevant imaging studies were reviewed for known gi manifestations of cf. these imaging studies were correlated with clinical histories and available intraoperative and pathologic findings. results: cf involvement of the gi tract presents over a wide range of ages, organs involved, and associated symptoms. these manifestations can generally be divided anatomically into those involving the alimentary tract, hepatobiliary system, and pancreas. alimentary tract manifestations consist of meconium ileus in uncomplicated and complicated forms (with the latter including secondary intestinal atresia, volvulus, and perforation with meconium peritonitisdistal intestinal obstruction syndrome, constipation, rectal prolapse, duodenal fold thickening, and appendiceal dilation. hepatobiliary disorders secondary to cf include microgallbladder, cholelithiasis, biliary ductal abnormalities, neonatal hepatitis, and cirrhosis (including complications such as portal vein thrombosis and ascites). pancreatic expressions of cf include fatty infiltration, calcifications, and cysts/ cystosis, frequently in the setting of malnutrition and/or stooling abnormalities. this exhibit will demonstrate the spectrum of clinical and radiologic gi findings in this disease from the fetal and neonatal period through adolescence across a range of imaging modalities. conclusions: gastrointestinal manifestations of cystic fibrosis occur frequently in the pediatric population and may be the earliest clinical expression of the disease. familiarity with the variety of gastrointestinal imaging findings of cystic fibrosis can expedite appropriate diagnosis and therapy, particularly in those children in whom the primary disease is not clinically suspected. beyond acute appendicitis: imaging of additional pathologies of the pediatric appendix kelly dietz, md, cincinnati children's hospital; arnold c. merrow, daniel j. podberesky, alexander j. towbin purpose or case report: primary acute appendicitis (or appendiceal inflammation caused by a superimposed bacterial infection in the setting of appendiceal obstruction) is by far the most common pathology of the appendix, and imaging evaluations to exclude this diagnosis occur daily in the pediatric radiology setting. the clinical and imaging differential diagnosis in a patient with right lower quadrant pain and suspected appendicitis is a broad but well-recognized list that predominantly involves structures adjacent to the appendix including the ovaries, small and large bowel, and ureters. there are, however, less common pathologies primarily involving the appendix which can create an imaging diagnostic dilemma in the setting of right lower quadrant symptoms. our goal is to review the imaging and clinical manifestations of these less commonly encountered appendiceal abnormalities. methods & materials: cases of appendices that were abnormal by imaging but ultimately determined not to be due to primary acute appendicitis were collected from clinical encounters by the authors as well as through a search of the radiology and pathology report databases. clinical course, surgical findings, and pathology reports (if available) were subsequently reviewed through the main hospital medical records system. results: the collected cases demonstrate a wide range of additional pathologies of the appendix outside of primary acute appendicitis. a variety of imaging modalities were employed in the workup of these cases. examples reviewed in this exhibit include crohn's disease, ulcerative colitis, cystic fibrosis, carcinoid tumor, inguinal hernia with incarceration, retained foreign body, pinworm infestation, and ileocolic intussusception. conclusions: despite the frequency of primary acute appendicitis, there is a differential diagnosis when an abnormal appendix is found by imaging. familiarity with these alternative diagnoses may be particularly helpful in guiding management of the patient whose clinical presentation is not typical for primary acute appendicitis. methods & materials: a hospital pacs database search from the past years for patients with bws. selected cases, with multimodality imaging, were cross-referenced with pathology reports from patient records database. results: intricate abdominal pathologies are depicted utilizing multimodality imaging, such as plain films, us, ct, mri and pet/ct, and with pathologic correlation. cases with highlight the following: liver: hepatoblastoma, nonspecific hepatobiliary cysts, multiple hemangiomas mimicking metastatic disease; adrenal: dysplastic organomegaly mimicking neoplasm; pancreas: diffuse and focal hyperplasia in the setting of hyperinsulinism, organomegaly; renal: neprocalcinosis, including medullary sponge kidney, nephroblastomatosis, organomegaly; adnexal: ectopic paraovarian adrenal tissue mimicking metastatic lymph node; urinary bladder: benign fibro-uroepithelial polyp. conclusions: diagnosis of bws can be difficult when the classic clinical and radiological findings are not present. these few cases highlight the unusual abdominal pathologies, so when detected, a radiologist can aid in the appropriate diagnosis and help guide therapy for these young patients. this poster will discuss pharmaceuticals the fda considers investigational for their intended use. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. radiologic-pathologic review of pancreatic masses encountered at a tertiary pediatric hospital over a -year period no kwak, md, radiology, long island jewish medical center, kwak_nb@yahoo.com; karen naar, jeanne choi-rosen, lee collins, sukhjinder singh, anna thomas purpose or case report: review of pathologically proven pancreatic masses in pediatric patients encountered at a tertiary pediatric hospital over a -year period. describe the key morphologic features and other pertinent findings using various imaging modalities. correlate pathologic and radiologic findings. methods & materials: illustrate the various imaging characteristics of pathologically proven pancreatic masses including pseudocyst, pancreatoblastoma, solid pseudopapillary tumor, acinar cell carcinoma, ductal adenocarcinoma, lymphoma, pancreatic neuroblastoma, and inflammatory myofibroblastic tumor. correlate pathologic and radiologic findings. identify the key imaging features that allow narrower differential diagnosis. results: pancreatoblastoma and solid pseudopapillary tumor are the more commonly encountered pediatric primary pancreatic tumors. both are bulky and heterogeneously enhancing tumors with solid and cystic elements. pancreatoblastoma occurs more commonly in young children. internal hemorrhage and fibrous capsule favor solid pseudopapillary tumor which more commonly occurs in adolescent girls. ductal adenocarcinoma, acinar cell carcinoma and an inflammatory myofibroblastic tumor, which were pathologically proven in our pediatric patients, are exceedingly rare entities. the imaging findings of these cases and their pathology when available will be presented, as well as a quick literature review of these rare tumors. illustration and correlation of the pathologic and radiologic findings. conclusions: pancreatic masses in children are rare but in general have a better prognosis than in adults. salient imaging findings for the various tumors encountered at a tertiary care center with pathologic and radiologic correlation. evaluation of hepatoblastoma with gadoxetate disodium-typical, atypical, pre and post treatment evaluation arthur b. meyers, radiology, cincinnati children's hospital, arthurbmeyers@yahoo.com; alexander j. towbin, daniel j. podberesky purpose or case report: gadoxetate disodium (gd-eob-dtpa) is a hepatobilliary mri contrast agent that is widely used in adults for characterization of liver tumors and is being increasingly used in pediatric patients. hepatoblastoma is the most common primary hepatic malignancy of childhood. the purpose of this presentation is to describe our experience with the use of this agent in the mri evaluation both before and after initiating therapy in patients with hepatoblastoma. methods & materials: the radiology report system at our institution was queried for all patients with pathology proven hepatoblastomas who underwent a liver mr with administration of gadoxetate disodium between / / and / / . the mr imaging characteristics of the patient's primary hepatoblastoma pre-and post-therapy (when available) and post treatment findings (when available) were reviewed. results: mri studies in different patients were reviewed. the patients ranged in age from months to years. patients had pre and post treatment evaluation with gd-eob-dtpa enhanced mri, patient had only pretreatment evaluation and patients had only post treatment evaluation. of the hepatoblastomas did not take up gd-eob-dtpa during the hepatocyte phase and were therefore low signal intensity during the hepatocyte phase of imaging. this was useful in the pretreatment evaluation of hepatoblastoma, particularly in defining the relationship of the tumor to hepatic and portal veins. post treatment gd-eob-dtpa imaging allowed characterization of the biliary anatomy and demonstrated the communication of a postoperative fluid collection with the biliary tree, consistent with biloma. atypical hepatoblastoma showed uptake of gd-eob-dtpa on hepatocyte phase imaging, similar to what has been described in adults with atypical hepatocellular carcinoma. conclusions: gadoxetate disodium enhanced mri is useful in the imaging evaluation of hepatoblastoma, particularly in defining the relationship of tumor to vascular and biliary anatomy and in characterizing post-treatment complications. disclosure: dr. meyers has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging of the gallbladder and biliary tree in pediatric age group ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; s. pinar karakas, unni udayasankar, neil vachhani, ellen park purpose or case report: interactive educational exhibit to illustrate the embryology, anatomical variants as well as congenital and acquired diseases of the bile ducts and gallbladder in pediatric patients. methods & materials: a)the embryology of the gallbladder and biliary tree will be demonstrated with diagrams. b) imaging techniques for gallbladder and biliary tree including us, ct, mri, ercp and intraoperative cholangiogram will be discussed. c)imaging findings of various lesions with special emphasis on key findings that can lead to accurate diagnosis will be discussed. d)an appropriate list of differential diagnosis will be provided. e)an algorithm for the assessment of suspected biliary pathology will be presented. f)the exhibit will be interactive and the reader will answer questions about the discussed entity, related imaging algorithm and management. results: a)discuss congenital anomalies including duplicated and septated gallbladder, choledochal cyst, caroli disease, situs abnormalities and biliary atresia. b)discuss infectious and inflammatory conditions including cholecystitis, kawasaki's disease, sclerosing cholangitis and hepatitis. c)discuss iatrogenic complications including post transplant biliary stricture and leak. d)discuss benign and malignant neoplasms invoving the gallbladder including polyps, ptld and rhabdomyosarcoma. conclusions: this exhibit will demonstrate a logical approach to imaging of the congenital and acquired diseases of the gallbladder and biliary tree based on the embryology and underlying pathology. postnatal work up of congenital uronephropathies-a pictorial essay harigovinda r. challa, radiology, university of kentucky, hch @uky.edu purpose or case report: the use of obstetric ultrasound routinely in the prenatal care has lead to the discovery of many fetal anomalies. uronephropathies in the newborn represent one of the largest groups of anomalies amenable to neonatal management. since these uropathies are detected mostly in asymptomatic patients the treatment is mainly preventive. the pediatric radiologist has a key role in the post natal work up and management of these patients with prenatally diagnosed neprhouropathies and familiarity with the congenital urinary tract abnormalities is necessary. methods & materials: a retrospective review of multiple radiographic, sonographic and fluroscopic examinations performed in the newborn babies and infants with prenatal diagnosis of urinary tract abnormalities was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: numerous anomalies can be detected in utero, including anomalies of renal number, position, morphology, collecting system dilation and bladder, urethral abnormalities. of these postnatal work of congenital hydronephrosis is the most common routinely encountered clinical entity. renal ultrasound is the initial examination in the evaluation in all cases of prenatal hydronephrosis, which is best performed around postnatal day . if collecting system dilatation persists on postnatal ultrasound, further imaging work up with vcug, radionuclide imaging may be required depending on degree of dilatation. conclusions: uroneprhopathies are increasingly detected in the prenatal life with increasing use of obstetric ultrasound. the objective of this presentation is to demonstrate in a pictorial essay of different neprhouropathies and their workup in newborns. isolated fallopian tubal torsion: causes, imaging findings, and how to suggest the diagnosis jesse courtier, md, ucsf dept of radiology, jesse. courtier@ucsf.edu; amaya m. basta, rebecca maine, pierre-alain cohen, shinjiro hirose, john d. mackenzie purpose or case report: the purpose of this educational report is to describe the rare entity of isolated fallopian tubal torsion in the pediatric population and depict the cross sectional imaging findings that help make a diagnosis and guide management. the proposed pathophysiology, predisposing factors, and surgical management will be described. an illustrative case example of -year-old female patient will be provided with surgical correlation. the exhibit will review imaging findings on us, ct and mri that help support the diagnosis including, dilated tubular structure in the pelvis, normal ovaries, and corkscrewing and beaking of the proximal fallopian tube. isolated fallopian tubal torsion will be placed in the context of a differential diagnosis for girls presenting with pelvic pain and the imaging signs that help make a diagnosis of isolated tubal torsion and separate this entity from other causes of pediatric pelvic pain will be emphasized. multimodality imaging characteristics of genitourinary rhabdomyosarcoma rhea udyavar, md, george washington university medical center, rudyavar@gwmail.gwu.edu; amir noor, pranav k. vyas purpose or case report: in this pictorial essay, we will demonstrate salient imaging features of mr, us, and ct modalities for the diagnosis of genitourinary rhabdomyosarcoma in male (n ) and female (n ) children ages - years, evaluated at our institution over the past years. background information, including tumor biology, staging, and treatment will also be discussed. the swollen scrotum: ultrasound technique and differential diagnosis kelli r. schmitz, md, oregon health & science university, schmitzk@ohsu.edu; roya sohaey purpose or case report: to review the ultrasound protocol for the performance of scrotal ultrasound and illustrate the ultrasound appearance of conditions resulting in scrotal swelling in pediatric patients. a retrospective review of the imaging database at a tertiary pediatric referral center was performed to identify pediatric patients who presented with scrotal swelling and underwent diagnostic ultrasound. when available, surgical/pathologic correlation was obtained. results: a variety of pathologic processes result in scrotal swelling. causes illustrated include: testicular torsion, epididymitis/orchitis, hydrocele, varicocele, inguinal hernia, trauma, adrenal rest, and testicular or paratesticular neoplasm. conclusions: the causes of scrotal swelling are myriad, including infectious/inflammatory, developmental, traumatic, and neoplastic etiologies. in children, the clinical presentation of a swollen scrotum is nonspecific, and ultrasound plays a key role in making the correct diagnosis. experiences of starting a functional mr urography program at a university hospital: trials and tribulations steven l. blumer, bsc, montefiore medical center/albert einstein college of medicine, sblumer@montefiore.org; ibrahim tuna, amanda north, benjamin taragin, netta blitman, terry l. levin purpose or case report: starting a functional mru program can be challenging as there are numerous potential hurdles to overcome. this presentation describes the process of starting a functional mr urography (fmru) program at a university hospital and discusses the difficulties encountered starting such a program. selecting a sufficient patient referral base, resolving common and uncommon technological issues, and education of clinicians, patients and technical staff are some of the challenges that will be discussed. conclusions: awareness of the common pitfalls in fmru imaging and close partnering with referring physicians can make establishing a functional mru program easier. despite many potential obstacles, the benefit of exquisite anatomical and functional information provided by fmru in children, without exposure to ionizing radiation, greatly outweighs any challenges. disclosure: dr. blumer has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. pictorial review of ultrasound findings in boys presenting to emergency department/urology with acute scrotum teresa liang, faculty of medicine, university of british columbia, teresaliang @gmail.com; peter metcalfe, william sevcik, michelle noga purpose or case report: testicular torsion is a common acute condition in adolescent boys. rapid and accurate diagnosis is critical. diagnosis is currently based on history, physical findings, and ultrasound (u/s) with doppler. the objective of this poster is to demonstrate ultrasound findings from a retrospective review of acute scrotum over years, and to demonstrate some pitfalls of the technique with regard to testicular torsion diagnosis. we reviewed the u/s, surgical and ed records at the stollery children's hospital for boys aged month to years, presenting with acute scrotum from july , to . age, demographics, clinical symptoms, and physical findings, u/s and surgical techniques, findings, diagnoses and follow-up were also recorded. results: patients presented to uah stollery ed with acute scrotum: were diagnosed with testicular torsion ( inguinal torsion), were suspected of a torsion-detorsion, torsion of appendix testes, epididymitis/orchitis, and other diagnoses including hydroceles, varicoceles, epididymal cysts, abscesses, cellulitis and hematomas. for the patients who had ultrasound, % sensitivity and % specificity for testicular torsion. the ultrasound findings including size, vascularity and echogenicity associated with both salvageable and necrotic testicles including use of color and pulse doppler will be reviewed. the sonographic findings and pictorial examples associated with the more common acute scrotum etiologies will be presented. sonographic findings from problematic cases (those with inconclusive ultrasound reports or false positive reports) will also be addressed. conclusions: ultrasound imaging problem case examples and characteristic findings of common acute scrotum presentations at stollery hospital at the university of alberta are reviewed in this poster. primary and secondary amenorrhea in pediatric patients: from the beginning to the end cesar cortes, md, miami children's hospital, n c @ hotmail.com; yanerys ramos, ricardo restrepo, alejandro diaz, lorena sequeira, edward lee purpose or case report: to describe the role of imaging in evaluating patients with primary and secondary amenorrhea and to illustrate the normal imaging findings of the reproductive organs in the pediatric population as well as the imaging findings of the different etiologies causing amenorrhea. a search of the literature is done to determine the different etiologies of amenorrhea and the role of imaging in their evaluation. first, we will focus on the normal physiologic hormonal influence and changes of the girl's reproductive organs since birth until adolescence on ultrasound and mri. images of the normal appearance of the female reproductive organs as well as imaging findings of the different common and uncommon etiologies of amenorrhea will be shown. then, specific reference will be made to crucial related concepts such as minipuberty of infancy, latest criteria for polycystic ovarian disease and ovarian failure syndrome among others. finally, the treatment, either medical or surgical will be briefly discussed. results: causes of amenorrhea in children range from disorders affecting the hypothalamus, pituitary gland, adrenal glands, and ovaries, as well as uterine and vaginal structural abnormalities. even though history and clinical exam are essential in evaluating a patient with amenorrhea, the pediatric radiologist plays a pivotal role helping guide the area to be imaged and thus the modality that should be used. mri and ultrasound are the main modalities in the evaluation of amenorrhea. conclusions: ultrasound and mri are the main imaging modalities used in the evaluation of amenorrhea in children and are usually part of the work up. amenorrhea in children can have implications in girl's fertility allowing pediatric radiologists to play an important role in helping not only the patient but also their offspring. imaging of mullerian duct anomalies in children kelly k. horst, md, radiology, university of michigan, khorst@med.umich.edu; maryam ghadimi mahani, deepa pai, jonathan r. dillman, peter j. strouse purpose or case report: the purpose of this educational exhibit is to provide an up-to-date appraisal of mullerian duct anomalies presenting in the pediatric population. the appearances of anatomic variants on ultrasound and mri will be used to illustrate the strengths and potential pitfalls of these imaging modalities. methods & materials: patients who have previously undergone ultrasound and/or mri in the course of their clinical workup within the university of michigan health system (umhs) were identified using electronic medical records. imaging reports were reviewed by a single author in order to identify relevant imaging findings (interesting anatomic variations, associated anomalies, etc.). pertinent images from these imaging examinations were de-identified and saved to a secure hard drive. the medical record was accessed by a single researcher to obtain relevant information regarding the patients' clinical presentations. in cases of corrective surgery, pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of mullerian duct anomalies were reviewed within the pediatric population. clinical manifestations were correlated with imaging appearances. conclusions: mullerian duct anomalies represent a range of developmental variants. although functioning ovaries and age-appropriate external genitalia are characteristic, there may be anomalies ranging from uterine and vaginal agenesis, to duplication of the uterus and vagina, to minor uterine cavity abnormalities. müllerian malformations are frequently associated with abnormalities of the renal and axial skeletal systems, and pediatric patients in particular may present with these associated anomalies. menstrual abnormalities may represent a more typical presentation in the adolescent age group. this is in contrast to the adult population, which may be more likely to present with infertility. the variation in clinical presentations make mullerian duct anomalies difficult to diagnose and, because surgical techniques for correction and treatment depend on the underlying anatomy, understanding these variants in the context of imaging studies is important to their diagnosis and management. patient had radiographs which showed an irregular left humeral metaphysis with an associated fracture. patient had a phase bone scan that showed slightly increased uptake on the angiographic and blood pool phases and increased activity on the delayed phase in the right femur. radiographs showed a moth eaten appearance of the right femur with soft tissue swelling. patient had radiographs that showed periosteal reaction in the right tibia with an associated fracture. patient , in addition to radiographs, had an mri that showed osteomyelitis of the left humerus and scapula with an associated subperiosteal abscess. patient had multi focal osteomyelitis that was demonstrated on radiographs by irregular cortices and periosteal reaction involving the upper and lower extremities. conclusions: neonatal osteomyelitis is an uncommon entity that can have severe complications if not diagnosis and treated promptly. it is important to review cases and to review the appearance of neonatal osteomyelitis on multiple modalities. radiographs will usually demonstrate periosteal reaction and possibly soft tissue swelling. additional studies may be obtained to evaluate for complications, such as abscesses or involvement of the joint space. purpose or case report: review the epidemiology of ddh. describe the critical diagnostic imaging findings of ddh. understand the role of imaging accompanying treatment. methods & materials: images including radiographs, ultrasound, ct and mri will be used to demonstrate the current and historical role of imaging in caring for patients with ddh. discussion of the importance of reducing radiation exposure when choosing imaging studies will be included. results: radiographs and ultrasound are used primarily in making the diagnosis of ddh. ultrasound and mri are most often used during the course of treatment to assess its effectiveness. mri is increasingly utilized without sedation for patients in spica cast. conclusions: imaging is critical in the care of patients with ddh. pediatric musculoskeletal ultrasound of the proximal lower extremity (pelvis to thigh) julia rissmiller, md, dept of radiology, children's hospital boston, julia.rissmiller@childrens.harvard.edu; howard christianson, michael j. callahan purpose or case report: to review indications for ultrasound of the proximal lower extremity (pelvis, hip and thigh), and to illustrate the practical use of ultrasound in evaluation of the proximal lower extremity, emphasizing the sonographic appearance of various musculoskeletal disorders. ultrasound is a well-established modality for the evaluation of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. in general, ultrasound has a more limited role for the primary evaluation of other pediatric musculoskeletal disorders including trauma, articular and periarticular diseases and tumors or tumor-like processes. advantages of ultrasound, a relatively non-invasive technique, include excellent spatial resolution, low cost, lack of ionizing radiation, lack of need for sedation, and the ability to image the patient in real-time. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. we present ultrasound examples of pathology involving the proximal lower extremity (pelvis, hip and thigh). cases include developmental hip dysplasia, hip effusion, osseous metastasis to the iliac bone, osteomyelitis of the hip, femoral acetabular impingement, rectus femoris hernia, vascular malformation, ewing's sarcoma and myositis ossificans. results: a range of images from pediatric diagnostic ultrasounds performed of the proximal lower extremity (pelvis to thigh) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: ultrasound is an excellent modality for evaluating the proximal lower extremity in children, beyond the current indications of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. a multi-modality pictorial review of lesions of the epiphysis in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco @gmail.com; jacqueline urbine, evan geller, peter pizzutillo purpose or case report: to review the imaging spectrum of epiphyseal lesions in infants and children. a retrospective review of our imaging database was performed to identify studies with either primary lesions of the epiphysis or processes that affect the epiphysis. results: multiple epiphyseal lesions were elucidated primarily by radiography, with cross-sectional imaging included where clinically necessary. congenital lesions include the epiphyseal dysplasias represented here by chondrodysplasia punctata. epiphyseal infarction may due to multiple etiologies including slipped capitol femoral epiphysis, developmental dysplasia of the hip, sickle cell disease, or idiopathic reasons. neoplasms may occur in the epiphysis, including chondroblastoma and histiocytosis. traumatic lesions include fracture and avulsion. osteomyelitis can occur in the epiphysis as well. pseudolesions that mimic pathology will also be reviewed. other pathologies that can affect the epiphysis include juvenile idiopathic arthritis and hemophilia. conclusions: a wide spectrum of congenital and acquired pathologies may affect the epiphysis in the infant and child. plain radiography, computed tomography, and magnetic resonance imaging all contribute to the diagnosis of these varied lesions. purpose or case report: we aim to present the spectrum of common and uncommon hip disorders in pediatric population. we will formulate a systematic approach and present a flowchart to workup and characterize hip diseases. methods & materials: relevant imaging appearances of normal as well as pathological hip will be presented. normal hip anatomy will be discussed through anatomic drawings and radiological images (plain radiographs, ct, usg, and mri). we will illustrate the various anatomic landmarks, measurements and lines on plain radiographs and ultrasound of hip. results: evaluation of limp and hip pain in the pediatric population has undergone rapid evolution. surgical treatment for these disorders continues to be refined, and our ability to identify patients along the spectrum of disease continues to improve. yet, despite our advances, obtaining an accurate diagnosis can remain challenging, especially in the setting of mild structural abnormalities. many imaging studies can be used to evaluate the bones and soft tissues, but conventional radiography is the primary imaging modality for most clinical conditions. plain radiographs usually are obtained first because they are sensitive and specific for a wide range of bone pathology. more sophisticated imaging modalities including radionuclide scintigraphy (bone scan), ultrasonography (usg), computed tomography (ct) and magnetic resonance imaging (mri) are reserved for specific clinical situations. each of these imaging modalities has specific advantages and disadvantages. it is the aim of this review to guide in selecting and interpreting the appropriate imaging modality for a variety of common disorders. this exhibit will illustrate imaging features of developmental dysplasia of hip, perthes disease, slipped capital femoral epiphyses, hip malformations in syndromes, femoral acetabural impingement, labral disorders, septic arthrits and other disorders. the role of various imaging modalities in evaluation of these disorders will be discussed, along with common imaging pearls and pitfalls. conclusions: a systematic approach is necessary for evaluation of pediatric hip disorders. familiarity with normal appearances, pitfalls and specific imaging of these entities is essential for proper diagnosis and management. osteoid osteomas: a pain in the "night" diagnosis nancy k. laurence, md, the children's hospital of philadelphia, nkang @gmail.com; monica epelman, richard markowitz, camilo jaimes, diego jaramillo, nancy chauvin purpose or case report: a common benign bone-forming lesion, osteoid osteoma comprises approximately % of all benign bone tumors. the tumor is composed of a nidus of vascular osteoid tissue and woven bone lined by osteoblasts, frequently with considerable surrounding inflammation. the radiolucent nidus surrounded by variable degrees of reactive sclerosis usually leads to a straightforward diagnosis; however, sometimes the diagnosis of osteoid osteoma can be challenging, as it may have a non-specific and misleading appearance on different imaging modalities, particularly on mri. the purpose of this exhibit is to review the typical and atypical features of osteoid osteomas on different imaging modalities. we present diagnostic dilemmas of osteoid osteomas from our institution and how imaging characteristics can aid in diagnosis. we performed a retrospective review of our imaging database to identify cases of typical and atypical osteoid osteomas, with special emphasis on cases which posed a diagnostic dilemma on imaging. results: when osteoid osteomas occur in atypical locations the diagnosis can be elusive. when located in the intraarticular space there is often minimal or absent cortical thickening and there may be a joint effusion with synovial hypertrophy. phalangeal lesions may cause extensive bone marrow edema and surrounding soft tissue swelling. both of these types of osteoid osteomas can be mistaken for infection. the recently described "ct vessel" or "vascular groove" sign, a low density vascular groove adjacent to the nidus, is highly specific for osteoid osteoma. in the authors' experience, a rim of sclerosis surrounding the nidus may aid in diagnosis on mri and can be identified as an outer hypointense halo on all sequences. we illustrate the findings in cases of atypical osteoid osteomas which may be difficult to diagnose including intraarticular, phalangeal, and vertebral osteoid osteomas. we also show examples of the newly described sign which has high specificity for osteoid osteoma. conclusions: imaging findings in osteoid osteomas can be misleading and cause misdiagnosis, especially in atypical cases. knowledge of their appearance in atypical locations and specific findings can aid in the correct diagnosis. ultrasound of normal entheses in the growing skeleton nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email.chop. edu; pamela f. weiss, monica epelman, diego jaramillo purpose or case report: ultrasound is an underutilized modality in the evaluation of the pediatric musculoskeletal system. evaluation of tendon insertions about the elbow, knee and foot can be easily performed with ultrasonography. a good knowledge of the age dependent normal ultrasound appearance of the entheses is crucial in order to evaluate for pathology, such as trauma or ethesitis-related arthritis. this exhibit will serve to provide the reader with a practical approach to imaging when assessing tendon insertions. optimal patient positioning and transducer selection will be discussed. in addition, important anatomic landmarks will be described to allow for reproducibility and avoiding pitfalls. methods & materials: transverse and longitudinal ultrasound images of entheseal insertion sites were performed on healthy girls and boys between the ages of and years. ultrasound of the elbow was performed while in full extension and the insertions of the common flexor and common extensor tendons were evaluated. the quadriceps and patellar insertions were imaged with patients in the supine position, with the knees flexed at degrees. the achilles tendon and plantar fascia insertion were evaluated with the patient prone, with the feet hanging off the edge of the table. results: tendons demonstrated the expected fibrillar pattern with parallel echogenic lines. the appearance of the entheses changed as the insertion matured from sonolucent cartilage to echogenic bone. conclusions: using a systematic approach and knowledge of the normal anatomy, sonography of the tendons of the elbow, knee and foot can easily be performed in children. pediatric musculoskeletal ultrasound of the distal lower extremity (knee to ankle) howard christianson, md, radiology, children's hospital boston, howard.christianson@childrens.harvard.edu; julia rissmiller, michael j. callahan purpose or case report: ultrasound is a well-established technique in children for evaluation of the painful hip, developmental dysplasia of the hip, soft tissue infection, palpable masses and foreign bodies. in general, ultrasound has a somewhat more limited role for the primary evaluation of several other pediatric musculoskeletal disorders in the setting of trauma, articular and periarticular diseases and tumors and tumor-like conditions. inherent advantages of ultrasound include excellent spatial resolution, a lack of ionizing radiation, a relatively non-invasive technique and lack of a need for sedation. real-time imaging allows problem solving not available with other modalities which is well suited for musculoskeletal applications, particularly in the setting of trauma. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. the purpose of this study is to illustrate the practical use of ultrasound in the evaluation of the distal lower extremity (knee to ankle) emphasizing the sonographic appearance of various musculoskeletal disorders. examples include: ) cystic lesions around the joints: baker's cyst, synovial cyst, ganglion cyst and suprapatellar bursitis; ) infectious processes: pretibial, subperiosteal and intramuscular abscess; ) tumor and tumor like lesions: nerve sheath tumor, tumoral calcinosis; ) trauma related injuries: sinding larsen johansson, tibialis anterior muscle herniation, hematoma. methods & materials: cases selected for presentation from a series of diagnostic musculoskeletal ultrasounds performed at our institution. results: a range of images from diagnostic ultrasounds performed of the distal lower extremity (knee to ankle) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: selected musculoskeletal ultrasounds of the distal lower extremity are presented to familiarize the audience with the sonographic appearance of various musculoskeletal disorders and to highlight the tremendous potential of ultrasound in evaluating musculoskeletal disease in children and adolescents. role of conventional and dynamic contrast enhanced magnetic resonance imaging in diagnosis of hemihypertrophy syndromes in children shrey k. thawait, md, phd , radiology, yale university-bridgeport hospital, sthawai @jhmi.edu; gaurav k. thawait, sally e. mitchell, laura m. fayad, john a. carrino, kate puttgen purpose or case report: hemihypertrophy syndromes in children are complex and there is some overlap among these conditions. hence, establishing a diagnosis can be challenging. identification of the correct vascular anomaly associated with these overgrowth disorders helps to correctly classify the disease into one of the several syndromes, which in turn guides management. in this educational poster, we will review the definition, clinical presentation, conventional magnetic resonance imaging (mri) and contrast enhanced magnetic resonance angiography and venography (mra / mrv) features of hemihypertrophy syndromes in children. methods & materials: . learn the diagnostic criteria for overgrowth syndromes in children such as klippel-trenaunay syndrome (kts) and parkes weber syndrome (pws) with special emphasis on associated vascular anomalies. . gain knowledge of high resolution mri technique for evaluation of vascular anomalies associated with the hemihypertrophy syndromes. . understand the additional value of dynamic contrast enhanced mra / mrv in the differentiation of the hemihypertrophy syndromes in the pediatric age group. results: . mri technique for a dedicated "vascular anomaly protocol" consisting of fat saturated t weighted, pre contrast axial t weighted, and post contrast triplanar t weighted fat saturated imaging will be described. . special emphasis will be provided on dynamic contrast enhanced mra/mrv. . conventional and dynamic mri features of clinically proven cases of hemihypertrophy syndromes will be demonstrated. conclusions: systematic mri interpretation utilizing a dedicated vascular anomaly protocol enables the radiologist to correctly identify the hemihypertrophy syndrome, and provide detailed extent of disease. correlative ultrasound, mri imaging and physical examination of elbows in hemophilic children andrea s. doria, md, the hospital for sick children-diagnostic imaging, andrea.doria@sickkids.ca; frederico xavier, arun mohanta, carina man, ningning zhang, pamela hilliard purpose or case report: .to report a systematic ultrasound (us) protocol for assessment of hemophilic elbows. . to discuss advantages and disadvantages of us and mri for evaluating hemophilic elbows in comparison with physical examination. .to illustrate us and mri findings and associated pitfalls in hemophilic joints. background: the value of physical examination for assessment of early arthropathic changes in hemophilic joints is unknown. us does not require sedation in young children, but involves operator training and standardized technique. mri is the reference standard imaging modality for assessment of pathology in hemophilic joints. standardization of a systematic protocol for data acquisition and interpretation of us findings and understanding of the correlation of findings between physical examination, us and mri in hemophilic elbows is essential for the use us as an outcome measure both in clinical practice and research. so far such information is not available for growing elbow joints. methods & materials: eight hemophilic boys (age range/ median, - / years) with a history of prior elbow bleeds underwent us and mr imaging, and physical examination on the same day. corresponding images on us and mri were highlighted to illustrate abnormalities and pitfalls. soft tissues (effusion/hemarthrosis,synovial hypertrophy,hemosiderin deposition) changes were characterized as small, moderate, or large. erosions, cartilage and subchondral abnormalities were graded based on depth or extent of articular changes. results: . us is helpful for discriminating synovial hypertrophy, joint effusion/hemarthrosis, and large hemosiderin deposition which otherwise generates susceptibility artifacts on gradient-echo mri obscuring adjacent tissues. . us can visualize erosions, cartilage and subchondral abnormalities at the joint periphery. however,differentiation between subchondral cysts and erosions is usually unfeasible by us. . prior knowledge of the degree of joint maturation is essential for an accurate evaluation of cartilage loss by us. . physical examination has limitations for assessment of early joint changes in contrast to us. conclusions: us can be useful for assessing hemophilic elbows, with advantages over mri in the evaluation of soft tissues. further development of an us-mri atlas on normal cartilage in growing joints is needed for definition of the value of us in the assessment of minimal osteochondral abnormalities. digital atlas of skeletal surveys of common skeletal dysplasias shawn parnell, mbbs, md, dnb, radiology, seattle children's hospital, shawn.parnell@seattlechildrens.org; corey wall, edward weinberger purpose or case report: skeletal dysplasias are conditions of abnormal bone and cartilage growth which result in short stature. developing expertise in the radiographic evaluation of skeletal dysplasias can be difficult, as more than dysplasias exist. exhaustive description of individual dysplasias can be found in hard copy textbooks, without the ability to compare individual dysplasias side by side. by providing radiographic images and descriptive text of thirteen common skeletal dysplasias and two comparative normal skeletal surveys, we aim to facilitate understanding of the terminology and highlight the differences in imaging appearances one may commonly encounter in interpreting skeletal dysplasias. methods & materials: initial skeletal surveys and/or follow up radiographs obtained for evaluation of skeletal dysplasias at our institution from to were compiled and reviewed for best quality images. selected images for each case were labeled according to body part and view, to include ap and lateral views of the spine and skull and ap views of the extremities and pelvis. for neonates, ap and lateral babygram images were used. the software program used for viewing the atlas, written in c#, may be freely downloaded. it permits linked scrolling and resizing of the images, and simultaneous comparison of different cases is available. cases may be viewed as unknowns or in a selfteaching mode. results: radiographic images for thirteen common skeletal dysplasias and two comparative normal skeletons (neonate and child) are provided within an interactive digital atlas. cases include achondroplasia, pseudoachondroplasia, cleidocranial dysplasia, thanatophoric dysplasia, diaphyseal dysplasia, multiple epiphyseal dysplasia, osteopetrosis, osteogenesis imperfecta, multiple hereditary exostoses, dysostosis multiplex, fibrous dysplasia, asphyxiating thoracic dysplasia (jeune syndrome), and spondyloepiphyseal dysplasia. conclusions: by displaying radiographic images of several common skeletal dysplasias in an interactive and comparative format with descriptive text, understanding of basic radiographic terminology and appearances will be facilitated. purpose or case report: . to classify various pediatric msk soft tissue masses . to describe pathogenesis, imaging appearances and differential diagnosis of these lesions methods & materials: radiology and clinical medical records were reviewed and pediatric patients with musculoskeletal soft tissue masses were identified. representative images were collected as examples of each lesion. the lesions were then classified into different groups based on the similar pathology and etiology. brief discussion is done for each of these masses with their multimodality imaging appearances. results: the search yielded pediatric soft tissue masses of multiple different etiologies, including post-traumatic (hematoma, fat necrosis, fibromatosis coli, myositis ossificans), inflammatory or infectious (cellulitis, abscess, granuloma annulare, retained foreign bodies), pseudotumors (synovial cysts, ganglion cysts, vascular malformations) and neoplastic lesions (fatty, vascular, neural, fibrous, muscular). multiple different imaging modalities were used to evaluate these masses, including ultrasound, ct and mri. representative examples of different lesions and their appearances on different imaging modalities will be presented and an organized approach to the diagnosis of these lesions will be discussed. conclusions: musculoskeletal soft tissue masses are relatively common in children. majority of these are benign; however, up to % of these lesions can be malignant "sarcomas". multiple different imaging modalities often provide complimentary information in the work-up of these lesions. despite multimodality imaging approach, tissue diagnosis or short interval follow-up is still often required when the mass does not show typical features of a benign etiology. pediatric radiologists should be familiar with various pediatric msk soft tissue masses and their imaging appearances, and should be able to guide appropriate management. results: elbow mri examinations were reviewed on children aged months to years with ( %) of these investigating clinical instability in children. mechanism of injuries included congenital dislocation ( %), traumatic dislocation ( %), fracture or avulsion ( %) and other injuries ( %). the patient's with congenital elbow dislocations most commonly presented with radial head dislocation and associated dysplasia or flattening, effusion and less frequently dysplasia of the olecranon or capitellum. patient's with traumatic dislocations were frequently associated with ligamentous or capsular disruption, bone oedema and epicondylar avulsion with effusion, loose osseous bodies and fractures less often. the epicondylar avulsions and ligamentous or tendon injuries occurred equally often in those few patients with unspecified injury mechanism. conclusions: a number of the bony, ligamentous, articular and developmental anomalies evident on elbow mri have been illustrated highlighting the importance of careful and systematic review of all elbow structures when presented with a child with elbow instability. accurate identification of these abnormalities is vital to facilitate their appropriate management. methods & materials: from our computerized radiology information system, we retrieved all patients that have foot ultrasound for evaluation of vertical or oblique talus deformities in the last years ( / - / ). the us was performed by a pediatric radiologist using a high resolution linear and tight convex curve probes with foot in neutral, plantar flexion and dorsiflexion. all medical charts, ultrasound scans and foot radiographs were reviewed by a pediatric radiologist. results: we identified nine patients' with foot deformities who were suspected of vertical or oblique talus and were evaluated by ultrasound. seven patients are male; two of them had initial foot radiographs that were not diagnostic. two female patients had unilateral oblique talus deformity. there were patients with vertical talus deformity; three of them had bilateral deformities. conclusions: us can directly visualize the unossified navicular, the talar cartilage and their alignment. dynamic us can. ultrasound evaluation of costal chrondral pathologies in children presented as anterior chest wall mass or pain nucharin supakul, md, radiology, riley hospital for children, tanyasupakul@yahoo.com; boaz karmazyn purpose or case report: to summarize our experience with the use of ultrasonography (us) for evaluation of costal cartilage pathology presented as anterior chest wall mass. methods & materials: from our computerized radiology information system, we retrieved all patients that have chest wall ultrasound for evaluation of a mass in the last . years ( / - / ) . the us was performed by a pediatric radiologist using a localized scan with high resolution linear probe. all medical charts, pathology results, ultrasound scans and other imaging studies were reviewed by a pediatric radiologist. results: ten patients were found with costal chrondral pathologies. nine patients presented with anterior chest wall mass and one with chest wall pain. eight patients had angular deformity of a single costal cartilage and one patient had biopsy proven osteochrondroma, presented with anterior chest wall mass. one patient had a non-union fracture after motor vehicle accident, presented with anterior chest wall pain. in patients with rib deformity, the mass was non-tender. nine patients had prior imaging study including chest x-rays (n ), ct scan (n ), breast mr (n ). all these studies were negative. conclusions: us optimally demonstrated costal cartilage abnormities. chest radiographs and cross sectional studies were negative. we therefore recommend using high resolution chest wall us in children with negative chest radiograph and anterior hard chest wall mass. challenges in pediatric marrow imaging-boning up on current mr techniques srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; neha kwatra, nabile safdar purpose or case report: a wide range of pathologies demonstrate similar findings when imaged using conventional mr sequences. however, pediatric musculoskeletal imagers are increasingly leveraging newer techniques to add specificity to their diagnoses when abnormal marrow signal is detected. the purpose of this educational exhibit is to review the application of current mr techniques to pediatric marrow imaging across the spectrum of normal, variant, and pathologic processes. methods & materials: cases with potentially overlapping imaging appearances on conventional mr sequences, including hematopoetic marrow, sickle cell disease, osteomyelitis, chronic recurrent multifocal osteomyelitis, and infiltrative neoplasms, will be presented. the basis of various mr techniques including chemical shift imaging, "whole body" marrow imaging, diffusion weighted imaging, and fat-water separation techniques such as dixon or ideal (ge) will be reviewed. the strengths and weaknesses of such techniques in differentiating between infection, neoplasm, and normal variation will be emphasized through the case examples. challenges and pitfalls in the imaging of these pathologies using such techniques will be discussed. results: current mr imaging techniques add specificity to diagnoses of marrow pathology which are otherwise difficult to differentiate using traditional sequences alone. the use of opposed phase imaging can be helpful in differentiate hematopoietic marrow or infection from infiltrative and neoplastic conditions. "whole body" marrow imaging may serve as an alternative to other modalities which involve significant radiation exposure. the use of diffusion weighted imaging is a promising, but developing, technique being applied to marrow pathology. conclusions: pediatric bone marrow mr imaging is a challenging area for a vast majority of the radiologists. understanding normal developmental bone marrow changes and being aware of the pitfalls is crucial to render accurate diagnosis. current techniques such as ideal, chemical shift imaging, and "whole body" mri have a potentially important role in further characterization of marrow abnormalities. radiologists beware: unusual imaging manifestations in child abuse eglal shalaby-rana, mbbs (hons), children's national medical center, erana@childrensnational.org; allison m. jackson, tanya hinds, katherine deye purpose or case report: to present less common imaging manifestations of injuries in child abuse that may not be readily recognized as possibly abusive injury. methods & materials: through bi-monthly review of cases with the child protection team over a period of years, the imaging studies of patients with suspected non-accidental trauma were recorded. of the pts with suspected nonaccidental trauma, outcomes were available in patients. the child protection team concluded ( %) were cases of non-accidental trauma with reasonable medical certainty. this data base was reviewed for less common injuries that were found in these medically confirmed cases of child abuse. results: less common manifestations of abuse identified by radiographs included salter-harris injuries in the proximal humerus, and proximal femur. pelvic fractures were rare and when present were associated with sexual abuse. severe chest wall injury, with associated rib fractures, causing complete or near-complete white-out of the chest was occasionally encountered. soft tissue injures, such as hematomas were found in various locations in the body including the buttocks and anterior abdominal wall, were imaged on ultrasound and ct. paraor prevertebral injuries, with or without associated bone injury were identified; one infant presented with retropharyngeal soft tissue swelling. mri identified cervical spine injuries which included ligamentous injury and intrathecal hematomas. conclusions: while classic metaphyseal lesions and rib fractures are the most common, specific injuries documented by radiologic work up of suspected non-accidental trauma, less common injuries to the soft tissue and skeletal system may occur as a result of child abuse. the ability of the radiologist to recognize these uncommon manifestations of demonstrated in axial, coronal, and sagittal planes. the ligament of interest will be denoted by arrows. at the conclusion of the anatomy section, there will be a self assessment exam. the participants then will be asked to identify the ligament. if answered correctly, a summary slide will be displayed and, if common, images of the relevant pathology will be demonstrated. if an incorrect answer is indicated, a slide will appear denoting the incorrect answer with explanation. conclusions: hopefully, with review of this educational exhibit, the participant will have a better understanding of the relevant ligamentous anatomy of the ankle and hindfoot. purpose or case report: the purpose of this educational exhibit is to demonstrate the pathologic sonographic findings, one might encounter in the pediatric ankle. a systematic methodological approach including patient positioning, transducer orientation and sonographic technique are vital for ideal sonographic assessment of the pediatric ankle. using a data search program from a large academic institution, pediatric ankle ultrasounds performed in the last years were reviewed. pathologies include trauma, inflammation/infection, masses and congenital abnormalities. examples of normal anatomy will be included particularly when demonstrating ligament and tendon pathology. the normal side was often assessed for comparison purposes. results: ankle sonography is a useful modality to evaluate commonly encountered pathologies in the pediatric ankle. radiographically occult fractures may be discovered. ligament and tendon pathology, such as tears of the anterior talofibular ligament, high ankle sprain and peroneus longus tendon tears, can be easily detected. signs of infection that can be radiographically occult such as subtle periosteal reaction or fluid collections can be identified. finally, "lumps and bumps" can be characterized. for example, one of the most commonly encountered masses in the pediatric ankle is a ganglion cyst which can be well characterized sonographically. awareness of imaging pitfalls is also critical to avoid misdiagnosis and to guide appropriate management. conclusions: with basic ultrasound skills and knowledge of normal anatomy, sonography of the pediatric ankle is a useful modality to evaluate soft tissue structures and other pathologies. it is comparable to mri and allows for dynamic evaluation without need for anesthesia. resonance angiography (mra) using time resolved imaging is a relatively new technique that has become increasingly utilized in the diagnosis of vascular anomalies. we will describe the technique used at our institution, time resolved imaging of contrast kinetics (tricks, ge healthcare, milwaukee, wi), and the parameters that can be adjusted to optimize the exam. we will review key imaging features of hemangiomas and vascular malformations in various modalities, with a special emphasis on the tricks appearance. we performed a retrospective review of all the tricks studies performed at our institution for suspected vascular anomalies. in addition to the mr imaging features, we specifically analyzed the t weighted with fat saturation post tricks enhancement and the temporal tricks enhancement pattern. we reviewed all additional imaging including plain film, ultrasound, and ct and correlated the radiographic imaging with the available clinical and histopathologic features. results: we present illustrative cases of hemangiomas, kaposiform hemangioendothelioma, venous malformations, arteriovenous malformations, lymphatic malformations, and other pitfall lesions. we propose a diagnostic algorithm that relies heavily on the post contrast t weighted with fat saturation post tricks enhancement pattern and the temporal tricks enhancement pattern. conclusions: time resolved contrast-enhanced mra has become an increasingly important adjunct in the diagnosis of vascular anomalies. optimization of the exam technique and familiarity of the tricks imaging appearance is essential and can often assist in accurate lesion characterization. purpose or case report: vertical expandable prosthetic titanium rib (veptr) is increasingly used in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. in contrast to spinal fusion surgery, veptr allows for growth while stabilizing the deformity. we review the indications, pre-operative imaging, normal radiographic appearance, and complications of this device. methods & materials: on review of the literature, the indications for veptr have expanded in the past several years to include thoracic insufficiency, idiopathic and neuromuscular scoliosis, and chest wall defects. we illustrate the normal radiographic appearance of the three common configurations of veptr (cradle-to-cradle assembly, cradle with lumbar extension assembly; cradle-to-ala hook assembly). we discuss the potential complications of veptr, including infection, rib fracture, dislodged hardware, and neurological injury, with an emphasis on imaging diagnosis. results: there is a relatively high rate of reported complications with veptr in the literature. therefore, awareness of the growing number of indications, as well as the expected and unexpected appearance of this device, aids in radiographic diagnosis of complications. conclusions: vertical expandable prosthetic titanium rib (veptr) is gaining acceptance in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. recognition of the indications, normal radiographic appearance, and complications of this device will facilitate timely and accurate diagnosis. disclosure: dr. philips has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. spectrum of pediatric spinal neoplasms: an interactive tutorial benjamin t. haverkamp, md, radiology, university of missouri-kansas city, haverkampbt@umkc.edu; salvador f. iloreta, maha jarmakani, lisa lowe, seth gibson purpose or case report: the objective of this educational electronic exhibit is to provide the radiologist with an approach to pediatric spinal neoplasms. emphasis will be placed on narrowing the differential diagnosis using a combination of lesion location, characteristic imaging findings, relevant history, and associations. the exhibit format will include a casebased review of various pediatric spinal neoplasms, radiologicpathologic correlation, and a brief discussion of imaging findings useful in guiding surgical management. an interactive selfassessment exam will be presented at the end of the exhibit. results: a review of the specific etiologies will be presented with classification as intra-and extra-medullary and extradural lesions. radiologic images will be related to gross and microscopic pathology. conclusions: after viewing this exhibit, the learner will be able to: . recognize the clinical, imaging, and pathologic characteristics of pediatric spinal neoplasms. . understand relevant imaging findings useful in surgical management. . test their understanding of the presented material through an interactive exam. poster #: edu- craniosynostosis jason tsai, mbchb, children's hospital boston, jason. tsai@childrens.harvard.edu; diana p. rodriguez purpose or case report: to review the normal developmental appearance of the cranial sutures with computed tomography (ct) and to describe ct findings of the various forms of craniosynostoses. in this irb-approved retrospective study we reviewed ct images of subjects diagnosed with craniosynostosis between and september . we included patients with single-suture synostosis, isolated bilateral coronal synostosis, pansynostosis, and combined craniosynotoses. additionally, we identified individuals with normal appearing sutures from to years of age imaged with head ct to describe the pattern of normal development of the cranial sutures. results: a description of the normal developmental ct appearance of the cranial sutures using computed tomography has been provided. of the group of patients with craniosynostosis the following variables were recorded: age at presentation, the pattern of sutural fusion, skull shape, presence of hydrocephalus, genetic testing, and types of surgical correction. conclusions: we have demonstrated the normal developmental ct appearance of the cranial sutures and the ct patterns of the various forms of craniosynostoses, with clinical, genetic and surgical correlation. posterior fossa tumours: a pictorial review sam byott, md, manchester children's hospital, sambyott@ hotmail.com; neville wright, vivian tang, abdu shabani, stavros stivaros purpose or case report: posterior fossa tumours account for - % of childhood brain tumours. the most common differentials include pilocytic astrocytoma, medulloblastoma and ependymoma. mr imaging is crucial to diagnosis, staging and identification of complications such as hydrocephalus and haemorrhage. soft tissue characteristics alongside tumour location, invasion and clinical history facilitate radiological discrimination prior to surgery. however, there is significant clinical equipoise with regards to the imaging appearances in a significant proportion of cases making definite diagnosis difficult. the aim of this study is to evaluate the radiological findings and correlate with histological data. this will allow identification of the key morphological features that discriminate different tumours. these can then be presented to educate fellow radiologists. methods & materials: radiology pacs and patient notes were used to collate radiological, histological and clinical data. results: there were patients presenting at our institution with posterior fossa tumours. had pilocytic astrocytomas, had medulloblastomas and had ependymomas. one patient had an atypical teratoid rhabdoid tumour (atrt). traditional features alongside more advanced mr characteristics were correlated with histology, and the features allowing for discrimination of tumour types are presented in this pictorial review. conclusions: posterior fossa tumours have a highly variable radiological appearance. we present a range of appearances and describe the important morphological features that allow radiological discrimination of tumour type. poster #: edu- dt imaging of the pediatric spine teresa c. gross kelly, children's hospital of wisconsin, tkelly@chw.org; ibrahim s. tuna, mia s. kelly, tushar chandra, sumit singh, mohit maheshwari, hervey d. segall purpose or case report: some abnormalities of the pediatric spine can be challenging. we have discovered that in many such cases, diagnosis of spinal lesions can be faciliated by using the dt weighted sequence. the purpose of this educational poster is to demonstrate the remarkable usefulness of dt weighted images for delineating pathology of the pediatric spine. methods & materials: lesions of the spine that will be reivewed in this educational exhibit will be categorized as: ( ) vascular ( ) due to infection/inflammation ( ) neoplastic/ neurogenic ( ) congenital ( ) traumatic/iatrogenic ( ) endocrine/metabolic. the imaging characteristics of lesions found in the pediatric spine will be described and the utility of d t -weighted mr sequences for the evaluation of these lesions will be discussed. finally the role of imaging in the treatment planning of abnormalities of the pediatric spine will be addressed. results: this educational exhibit will provide numerous examples of how d t -weighted imaging can elucidate diagnosis of lesions involving the spine. examples include enhancement of the cauda equina in guillain barre syndrome, lipomatous malformations, spondylolysis in children with low back pain, thecal cysts, filar cysts, metastasis, hydromyelia and ventriculus terminalis. conclusions: d t -weighted images of the spine performed in the sagittal plane with coronal and axial reformations, as well sagittal oblique reformations (scotty dog reformations) for evaluation of spondylolysis, can facilitate the evaluation of lesions involving the pediatric spine. the normal pediatric spine: a pictorial review of mr anatomy and development in the infant, child and adolescent ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; teresa c. gross kelly, tushar chandra, mohit maheshwari, sumit singh, hervey d. segall purpose or case report: radiological evaluation of the pediatric spine can be more challenging in child than in the adult patient due to the wide range of normal anatomic variants and synchondroses, combined with the unique effects of trauma in children. mri is an excellent imaging modality for the evaluation of the pediatric spine. however, in order to provide an accurate interpretation of acute posttraumatic changes in the pediatric spine, particularly in the setting of abusive head trauma, a fundamental knowledge of normal anatomy, variants and pathology of the pediatric spine is required. the aim of this educational exhibit is to illustrate normal mri anatomy of the spine in the infant, child and adolescent. methods & materials: this exhibit will first describe basic spinal embryology and development of the vertebra and spinal cord, followed by mri depiction of the developmental anatomy of the spine from infancy through adolescence. the changing appearance of the spinal canal, spinal cord and vertebral bodies with age will be illustrated using normal cases from the radiology database. sagittal and transverse diameter of vertebral bodies, thickness of the dural thecal sac, dimensions of the spinal canal, normal bone marrow signal changes, vertebral body heights, level of conus medullaris, prevertebral and paraspinous soft tissues and epidural fat thickness will be described and changes according to age will be pointed out. results: in early life, the spinal cord extends to the inferior aspect of the bony spinal column. because the vertebral bodies grow longitudinally faster than the spinal cord does, the conus medullaris may change. ossification of the vertebral bodies and posterior elements is nearly complete by age , with a resultant decrease in the spinal canal diameter. the nucleus pulposus becomes smaller after years and spans approximately half the disk space in the sagittal plane. the spinal cord is elliptical in cross section in the cervical spine and demonstrates a difference in signal between the normal gray and white matter of the spinal cord which should not be mistaken for intramedullary pathology. conclusions: a solid understanding of normal spine anatomy and embryological development is essential in evaluation of pediatric spine, mainly in the setting of trauma. familiarity with normal anatomic variants is essential to provide an accurate interpretation of pathology in the pediatric spine. spectrum of intracranial cystic lesions in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco @gmail.com; eric faerber purpose or case report: to review the imaging spectrum of intracranial cystic lesions in the pediatric population. methods & materials: a retrospective review of our imaging database was performed to identify studies obtained in which the findings included intracranial cystic lesions. results: multiple cystic lesions were elucidated primarily by computed tomography or magnetic resonance imaging. these lesions can be divided into nonneoplastic and nonneoplastic tumor-associated cysts. the nonneoplastic cysts, which is the largest group, include: cavum septi pellucidi and cavum veli interpositi, choroid plexus cyst, enlarged peri-vascular spaces, pineal cyst, the large spectrum of arachnoid cysts, colloid cyst, epidermoid cyst, rathke cleft cyst, and porencephalic cyst. nonneoplastic tumor-associated cysts include: craniopharyngioma, optic glioma, pilocytic astrocytoma, hemangioblastoma, and ganglioglioma. conclusions: intracranial cystic lesions are relatively common entities in the pediatric population. a wide spectrum of nonneoplastic and nonneoplastic tumor associated pathologies are presented using both computed tomography and magnetic resonance imaging. kelly, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a comprehensive review of imaging features, classification and management of pediatric spinal cord tumors. we also aim to elicit the differences between pediatric spinal cord tumors and their adult counterparts. we will summarize the differences between the individual tumors based on histological cell types and the pertinent implications on management and outcome methods & materials: this exhibit will provide an overview of the common as well as uncommon tumors of the pediatric spinal cord. various classification systems for these tumors-anatomical as well as histological will be discussed. we will illustrate the relevant imaging findings that can help in differentiating these tumors. results: pediatric spinal cord tumors account for % to % of all pediatric central nervous system tumors. mri is the mainstay for the initial diagnosis as well as the post surgical evaluation and surveillance of these tumors. pediatric and adult spinal cord tumours differ both in terms of anatomical location as well as histology. the disease and treatment related morbidities are also different in children as compared to adults. astrocytomas, ependymomas, glioneural tumors and csf metastasis represent the vast majority of cord neoplasms in the pediatric age group. some of cord tumors may also be associated with inherited syndromes (like neurofibromatosis type ) or may have genetic predisposition. these would also be discussed. we will also illustrate and discuss common non neoplastic spinal masses that may mimic tumors. conclusions: pediatric spinal cord tumors have varied clinical presentations, imaging appearance and outcome. this review would improve the understanding of these tumors thereby helping in diagnosis, management and follow up of these uncommon neoplasms. multi-modality imaging of pediatric head and neck lesions jason au, md, oklahoma university health sciences center, jasonmau@gmail.com; anthony alleman, mahmoud elkaissi, roy jacob purpose or case report: the purpose of this study is to present a side by side comparison of the multi-modality imaging features of pediatric masses. using cases that have been imaged with multiple modalities, the exhibit will delineate the sonographic, mr, and ct appearance of congenital, infectious, and neoplastic head and neck lesions in the pediatric population. methods & materials: a restrospective search of pacs was performed on studies completed at the oklahoma university medical center on the oklahoma university health science center campus from january to the present. ultrasound, ct, and mr examinations were selected that depicted relevant pediatric head and neck pathology. all studies were de-identified prior to image export. results: over twenty representative cases of pediatric infections, fibrous tumors, cystic neoplasms, vascular malformation, bony tumors, developmental anomalies, and other neoplasms were selected for inclusion. results: pictorial review of cases including the following representative cases: myelonmeningocele associated with arnold chiari malformation, lipomyelomeningocele, tethered cord with spinal lipoma/fibrofatty filum, tethered cord and dermal sinus tract, and chiari i with syringohydromyelia. several unique cases including the following will be presented as well: thoracic meningocele with arnold chiari malformation, terminal myelocystocele, diastematomyelia, and myelomeningocele without arnold chiari malformation. while mri demonstrates the cranio-cervical junction and the cervicothoracic spinal cord better than ultrasound, ultrasound often allows for improved resolution of the distal spinal cord, lumbosacral spinal canal, and spinal dysraphism structures near the skin surface in the neonate. conclusions: congenital spinal malformations are complex and variable in imaging appearance. it is important to understand the classification in order to determine the appropriate management and prognosis. in the neonatal period imaging should be performed with ultrasound and mri studies, as they may provide different and complementary information. conclusions: hypoxic ischemic injury is a common condition resulting in a wide spectrum of severe neurological defects. while in the past treatment only consisted of supportive care for hii, recent advances have yielded promising treatment options if initiated within a limited time window. thus due to the severity of the disease and the need for rapid intervention, it is important to recognize radiological manifestations of hii along with its clinical signs and symptoms to offer a better prognosis to the patient. craniosynostosis: looking beyond the sutures tushar chandra, md, children's hospital of wisconsin, drtusharchandra@gmail.com; teresa c. gross kelly, mohit maheshwari, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a framework upon which the diagnosis of the various types of craniosynostosis can be facilitated. our goal is to provide an efficient way to evaluate craniosynostosis for the radiologist in clinical practice. we plan to accomplish this goal by providing a succinct review of the sutures, an overview of the various classification schemes for craniosynostosis and potential complications associated with premature sutural closure. the role of imaging in the evaluation of craniosynostosis will be described and the features of craniosynostosis that are most important to the craniofacial surgeon will be elucidated. finally, surgical strategies for the repair of craniosynostosis and postoperative findings will be described. results: some of the forms of craniosynostosis may have a genetic basis, but many are spontaneous in nature. untreated progressive craniosynostosis can lead to inhibition of brain growth, and an increase in intracranial pressure. mdct with mip and d surface reformations is the preferred modality for diagnostic evaluation of craniosynostosis. it is also a robust modality for post operative assessment and long-term follow up. mri is a useful adjunct for assessment of associated intracranial anomalies and complications. timely and appropriate imaging is essential to assess for potential complications of craniosynostosis which may include intracranial hypertension, anomalies of external and middle ear, hydrocephalus, chronic tonsillar herniation, cranial base deformity, impaired venous drainage, enlarged emissary foramina and veins and optic atrophy. on the other hand, positional plagiocephaly should not be misinterpreted as craniosynostosis. surgical management is typical for nonsyndromic craniosynostosis, which involves correction of craniosynostosis between three to six months of age. conservative management is the mainstay for syndromic craniosynostosis. postoperative follow up imaging for surveillance for ventricular size and signs of raised intracranial pressure are necessary. conclusions: craniosynostosis is a challenging area of pediatric neuroimaging. knowledge of the sutural anatomy, an understanding of the potential intracranial complications caused by premature sutural closure, as well as the role that imaging plays in presurgical planning, can provide a practical way for the radiologist to evaluate craniosynostosis in a fast-paced clinical setting. poster #: edu- the perinatal brain and spinal cord-imaging across a life border: a case-based approach anand dorai raju, md, radiology university of tennessee, araju@uthsc.edu; harris l. cohen, matthew whitehead, asim choudhri purpose or case report: to review normal and abnormal perinatal ultrasound (us) and magnetic resonance (mr) imaging findings and note their significance for the analysis of the fetal and neonatal brain as well as spinal cord and vertebral column using a case based approach. to highlight us and mr capabilities in allowing correct perinatal diagnosis of congenital and acquired central nervous system abnormalities. methods & materials: cases will be shown of normal and abnormal anatomic findings in fetal and neonatal brain and spinal cord imaging. key teaching points necessary for the diagnosis of such brain abnormalities as ventriculomegaly, chiari malformations, holoprosencephaly, and agenesis of the corpus callosum as well as dandy walker malformations and avms will be discussed. intraventricular hemorrhage, periventricular leukomalacia, anoxic injuries and infectious abnormalities will be reviewed. abnormal anatomic findings in fetal and neonatal spine evaluations for congenital and acquired abnormalities and key teaching points necessary for the accurate diagnosis of tethered cord, myelomeninocele, caudal regression syndrome, hydromyelia, diastomatomyelia and sacrococcygeal teratoma will be reviewed. some diagnostic difficulties and controversies will be addressed. conclusions: ultrasound aided by mri can provide ready diagnosis to many central nervous system abnormalities involving fetuses and neonates. ever improving perinatal imaging experience and technique allow for better prenatal as well as postnatal diagnosis. cases showing such imaging and key points helping such imaging diagnoses will be reviewed. overview of imaging of pediatric extraocular orbital tumors srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; nadja kadom, gilbert l. vezina purpose or case report: to show the spectrum of benign and malignant extraocular orbital tumors in children. methods & materials: we reviewed the cross-sectional imaging of orbit (ct and mr) done in the last years. specific imaging signs of extraocular tumors including benign and malignant tumors such as hemangiomas, lymphangiomas, optic nerve glioma, optic nerve sheath meningioma, pseudotumors, rhabdomyosarcoma, orbital myofibroma, eosinophilic granuloma and neuroblastoma metastases will be shown. important imaging features that should be considered when formulating a differential diagnosis will be described. conclusions: the spectrum of diseases affecting pediatric orbit is substantially different from what we see in the adults. it is not easy always to differentiate between different tumors. important imaging characteristics will help us towards better differential diagnosis. in this exhibit, we will illustrate ultrasound anatomy of the neonatal spinal cord. discussion of the normal anatomic variants and pathological conditions of the spinal cord will be provided. representative images of a variety of common and uncommon pathological conditions of the spine will be presented to illustrate teaching points. in abnormal cases, follow up mri images will also be illustrated for comparison. results: ultrasound is a robust screening modality for evaluation of the lumbosacral spine in neonates. it is cheaper, readily available, safer first line imaging modality in neonates suspected to have spinal malformations. under able and well trained operator, diagnostic accuracy of spinal ultrasound approaches mri. however, mri remains the gold standard for imaging evaluation of spine. normal variants that simulate disease processes like ventriculus terminalis, prominent filum terminale and central echo complex will be presented. congenital malformations of the cord such as tethered cord, hydromyelia, lipoma, diastematomyelia, myelomeningocele, lateral meningocele and presacral masses will also be discussed. conclusions: ultrasound is a very useful screening technique for evaluation of pathological conditions of lumbosacral spine in neonates. this review would improve the understanding of utility and limitations of ultrasound in evaluation of neonatal spinal malformations. purpose or case report: although mri is the standard for detecting epilepsy and brain tumor abnormalities, pet-ct is performed to ascertain metabolism related to epileptogenic regions or characterize tumor metabolic activity. asymmetric metabolism often correlates to structural abnormalities like cortical dysplasia. metabolic activity often correlates with tumor aggressiveness or grade. fdg pet is commonly used to assess seizure and tumor metabolism. the lesser utilized amino acid pet tracers (c methionine, fdopa) show increasing value with lower grade tumors due to high tumor to normal tissue contrast. literature is accumulating regarding c methionine (cmet) in the detection of lesions like cortical dysplasia and its ability to delineate low grade seizure related tumor lesions. despite the established fdg and accumulating cmet literature, little information exists about the imaging seen with both in pediatrics. as these studies are increasingly viewed as part of fusion mri images, there is more scrutiny of focal metabolism correlating with mri findings and less interpretative reliance on abnormality based solely on asymmetry. methods & materials: review of patients who underwent cmet and fdg brain pet-ct was performed. each was imaged on a philips scanner and had prior mri. studies demonstrating a variety of tumors, postoperative findings of residual or recurrent tumor, and pseudoprogression were selected. epilepsy cases with structural cortical abnormalities or seizure-associated tumors were also selected. cmet and fdg studies were analyzed by pediatric neuroradiologists and the imaging findings correlated with prior mri and any pathology or follow-up imaging. pictorial galleries of the cmet and fdg imaging patterns were created. results: pathologically proven low-grade glial tumors showed increased cmet uptake and no hypermetabolism on fdg. high-grade tumors showed increased uptake on cmet and hypermetabolism on fdg. patients with residual or recurrent tumors showed uptake similar to their original tumor. granulation tissue and pseudoprogression changes showed increased uptake on cmet and no hypermetabolism on fdg. epilepsy surgery patients with cortical dysplasia or low grade glial tumors showed increased uptake on cmet and fdg hypometabolism. conclusions: this study illustrates the variety of findings on cmet and fdg pet-ct in pediatric patients clinically evaluated for brain tumor and epilepsy. this atlas provides readers with a guide to the appearance of these findings on an emerging imaging technique. pediatric head and neck neoplasms: a multimodality pictorial review alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; marilyn j. siegel purpose or case report: neck masses are common in children and most occur in the suprahyoid region. knowledge of the fascial spaces involved in conjunction with imaging features can help in diagnosis. in this pictorial review, we present a multimodality imaging approach based on anatomy of the suprahyoid fascial spaces for evaluation of pediatric neck tumors. methods & materials: radiology information system (ris) at our tertiary care children's hospital was queried to identify patients with suprahyoid neck masses who had imaging performed between july and present. a variety of conditions having congenital, inflammatory, neoplastic, or vascular origin were identified and the anatomic location in the neck as well as imaging and clinical findings were retrospectively reviewed. results: the imaging evaluation included ultrasound, ct and mri. lesions arose within the following fascial spaces of the suprahyoid neck: superficial, carotid, masticator, submandibular, sublingual, parotid, parapharyngeal, visceral, retropharyngeal and prevertebral. key imaging features important in diagnosis included lesion vascularity, calcification, necrosis and bone invasion. we discuss and illustrate these imaging findings and relate them to specific suprahyoid fascial spaces. specific lesions include vascular and lymphatic malformations, teratoma, nerve sheath tumors, thyroglossal duct and branchial cleft cysts, pleomorphic adenoma, dermoid cyst, ranula, lymphadenopathy, abscess, lymphoma, rhabdomyosarcoma, neuroblastoma and nasopharyngeal carcinoma. conclusions: knowledge of fascial spaces of the suprahyoid compartment and key imaging features on multiple modalities can aid in the diagnosis of pediatric neck masses. pediatric sinusitis: spectrum of imaging findings with clinicopathologic correlation roy jacob, md, university of oklahoma, drjacobr@gmail. com; paul digoy, robert s. glade, anthony alleman purpose or case report: the clinical spectrum of sinusitis in children can range from uncomplicated bacterial sinusitis to invasive fungal sinusitis. most cases respond favorably to medical management. however, complications occasionally occur due to the spread to adjacent structures. imaging plays an important role in characterizing the disease and guiding the clinical and surgical planning and treatment. this electronic presentation outlines the following- . review radiologic anatomy and unique characteristics of pediatric sinuses. . review the clinical features, pathophysiology, and microbiology of sinusitis. . review of ct and mri imaging characteristics of sinusitis with representative cases such as complicated sinusitis and invasive fungal sinusitis. . review the treatment approaches of sinusitis. methods & materials: a retrospective search of pacs was performed on studies completed at the ou children's hospital in oklahoma city for the last three years. ct and mr examinations were selected that depicted relevant disease processes. corresponding nasal endoscopic pictures were obtained from cases which required surgical management. all studies were de-identified prior to image export. results: over fifteen representative cases of the clinical spectrum of sinusitis and its complications were selected for inclusion. conclusions: this educational exhibit provides a concise review of imaging, clinical features, and treatment of pediatric sinusitis. findings will be richly illustrated with radiological and clinical images. microcephaly or hydrocephalus. knowing the embryology of the cerebellum and th ventricle is important to perceive the development of posterior fossa malformations and to further understand the imaging findings. several classifications schemes have been proposed from a pure embryologic to an imaging-based approach using some essential findings such as the size of the posterior fossa, the presence of csf collection or expansion of csf space, and the size and morphology of the cerebellum. mr is the gold-standard for adequately access and characterize the posterior fossa structures. this pictorial essay will review the mr findings of some of the most common posterior fossa malformations including dandy-walker malformation, persistent blakes pouch, mega cisterna magna, arachnoid cyst, paleocerebellar hypoplasia, cerebellar agenesis, cerebellar and pontocerebellar hypoplasia, cerebelar cortical malformations, isolated brainstem hypoplasia/dysplasia and chiari malformations. we will provide a practical approach to the mr findings of posterior fossa malformations in children. conclusions: mr plays a crucial role in identifying and characterizing malformations of the posterior fossa structures. it should give a logical approach to these complex malformations thus guiding the refereeing physician into the clinical approach and in determining further investigations. results: neuroimaging features of abnormal thalami as encountered in the pediatric population were detailed, and wherever applicable, the relevance of additional mr imaging sequences and techniques to determine etiology was described. while there was considerable overlap in imaging appearances, making a precise diagnosis was found to be challenging in difficult cases, and by and large, a stepwise approach was successfully formulated and used to: . diagnose the more emergent conditions and to . devise a management algorithm for the less acute abnormalities. conclusions: bilateral thalamic lesions are occasionally encountered in pediatric neuroimaging and have a limited differential; a good knowledge base and adequate technique are imperative to tease out the precise diagnosis and institute appropriate management. cortical developmental abnormalities in pediatric seizure patients ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; mohit maheshwari, teresa c. gross kelly, sumit singh, tushar chandra, hervey d. segall purpose or case report: to describe various cortical malformations with illustrative examples. we will also briefly discuss the embryology, genetic basis, classification schemes and characteristic imaging findings . methods & materials: this exhibit will illustrate three main categories of cortical malformations: neuronal proliferation, migration and organization. understanding of this complex topic would be facilitated by brief discussion on the embryological basis and proposed genetic causes of some of these cortical malformations. classification schemes on embryology and imaging will be discussed. characteristic imaging findings of these malformations will be discussed and examples from the authors database will be shown. results: neuroimaging in pediatric seizures is challenging. mri is considered the imaging modality of choice because of superior soft tissue contrast and better ability to characterize the pathologic process. we will also discuss the dedicated seizure protocol which is used in our institute. pet-ct imaging can also provides additional information in cases where mri is negative, inconclusive or does not correlate with eeg/clinical findings. brief discussion on advanced imaging techniques will also be presented. malformations are frequently detected in infancy. however, if the initial mri scan performed in infancy is negative, a repeat scan after years of age may be helpful. conclusions: evaluation of cortical malformation in seizure patients still remains a challenging area of pediatric neuroimaging. reviewing of the embryological basis, classification schemes and characteristic imaging findings would improve the understanding the cortical malformations and interpreting the images. poster #: edu- sprs best poster cystic neonatal lesions associated with the spinal cord: discussion and differential diagnosis for these uncommon lesions jacob pirkle, md, jpirkle@mc.utmck.edu, james boyd, brian dupree purpose or case report: to review intradural cystic neonatal spine lesions and discuss the various causes and appearance of these lesions. this poster presentation provides a brief review of neonatal cystic spine lesions, including their etiologies, and presents the targeted audience (radiology resdients, fellows, and practicing radiologists) a helpful differential diagnosis of these lesions based upon their imaging appearance. methods & materials: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. results: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. conclusions: neonatal spine ultrasound is often performed to evaluate for abnormalities related to the presence of sacral dimples, cutaneous stigmata, skin tags, hairy tufts, during the evaluation of other congenital anomalies, or when prenatal ultrasound/mri demonstrates an abnormality warranting postnatal follow-up. the identification of cystic spinal cord lesions is relatively rare in the neonate. however, the etiology of these lesions can often be deduced or surmised based upon the location and the imaging appearance of the lesion. the most common cause of a cystic intramedullary spinal lesion is ventriculus terminalis, with a reported incidence of . %. additional lesions include transient dilatation of the central canal, filar cyst, syringohydromyelia, intramedullary arachnoid cyst, and myelomalacia related to in utero/birth trauma. extremely rare etiologies in the neonate include epidermoid/dermoid, cavernous malformation, intranatal cystic infections etiologies, neuroepithelial cysts, and cystic neoplasms. mimics include diastematamyelia, spinal lipomas, and intramedullary hematomas. numerous imaging examples of these lesions are provided in the accompanying poster. brain mri in peroxisomal disorders: a pictorial essay bruno p. soares, md, radiology and biomedical imaging, university of california at san francisco, bruno.soares@ucsf. edu; leonardo vedolin, guido gonzalez purpose or case report: our presentation aims to illustrate the brain mri patterns in peroxisomal disorders. peroxisomes are intracellular organelles involved in important cellular processes including beta-oxidation of very-longchain fatty acids and plasmalogen production. peroxisomal disorders can be categorized into disorders of peroxisomal biogenesis, in which the peroxisomes are abnormally formed and several peroxisomal functions are deficient, and in defects involving a single peroxisomal function, in which the structure of the peroxisome is intact. disorders of peroxisomal biogenesis include zellweger syndrome, neonatal adrenoleukodystrophy, infantile refsum disease and rhizomelic chondrodysplasia punctata. numerous disorders are caused by loss of a single peroxisomal function including x-linked adrenoleukodystrophy and acyl-coa oxidase deficiency. clinical findings in peroxisomal disorders include dysmorphic features, hepatic dysfunction, neurodevelopmental delay, retinopathy and hearing impairment. methods & materials: pictorial essay illustrating brain mri patterns in peroxisomal disorders, including disorders of peroxisomal biogenesis and disorders with loss of a single peroxisomal function. results: brain abnormalities in peroxisomal disorders have a wide spectrum of patterns. neuronal migration disorders with abnormal myelination are typically seen in zellweger disease and neonatal adrenoleukodystrophy. specifically, the association of abnormal myelination with germinolytic cysts is suggestive of zellweger syndrome. classic x-linked adrenoleukodystrophy typically shows posterior central white matter involvement and symmetric demyelination also involving the corticospinal tracts and corpus callosum. a similar pattern of white matter involvement is seen in acyl-coa oxidase deficiency and infantile refsum disease. conclusions: brain mri helps narrow the differential diagnosis and guides subsequent evaluation in infants presenting with clinical features concerning for peroxisomal disorders. therefore, knowledge of the brain mri patterns in peroxisomal disorders is important for the radiologist interpreting neuroimaging studies. clots in tots: role of imaging in diagnosis of acute stroke and its causes in children asif abdullah, c.s. mott children's hospital of the university of michigan, asifa@med.umich.edu; ellen hoeffner, augusto elias purpose or case report: stroke is a major cause of morbidity and mortality in children. long-term neurologic deficits occur in % to % of infants and children after arterial ischemic stroke. limited awareness regarding pediatric stroke among physicians and in general community is a major concern. imaging plays crucial role in the diagnosis of pediatric stroke. the goal of this presentation is to provide awareness to the reader about the role of imaging in childhood stroke and its myriad causes in children. we will provide a case based approach to imaging diagnosis of acute pediatric stroke based on three categories: ( ) arterial ischemic stroke, ( ) cerebral venous thrombosis, and ( ) hemorrhagic. arterial ischemic stroke (ais) is classified according to the pediatric stroke classification (psc). psc includes eight subtypes of ais: ( ) sickle cell disease, ( ) cardioembolic disease, ( ) moyamoya syndrome, ( ) cervical arterial dissection, ( ) stenoocclusive cerebral arteriopathy, ( ) other determined etiology, ( ) multiple probable etiologies, and ( ) undetermined etiology. we will describe the role of computed tomography (ct) and magnetic resonance imaging including angiography (mri/mra) in identifying these causes in relation to available clinical data. the etiologies of cerebral venous thrombosis related infarction would be discussed from an imaging perspective with a case-based approach with emphasis on mrv and swi techniques. finally, we will focus on hemorrhagic causes of childhood stroke such as vascular malformation, aneurysm, neurocutaneous disorders, coagulopathy, and a variety of other causes from an imaging standpoint. perfusion imaging in pediatric stroke demonstrates flow within the brain and can detect areas that are at risk of ischemia; however, further studies in the pediatric population need to be validated for the role of this technique in pediatric stroke. results: the most important factors in the diagnosis of childhood stroke are causal investigation, appropriate laboratory tests, and imaging studies. imaging is frequently the first step in the evaluation of an acutely ill child. conclusions: pediatric stroke is a debilitating disease that requires urgent multidisciplinary approach for diagnosis and treatment. in cases of both ischemic and hemorrhagic origin, the radiological approach to be obtained in emergency setting leads to the initial screening and the first therapeutic possibility. methods & materials: this exhibit will illustrate the characteristic imaging findings of vascular anomalies in the head and neck region. vascular anomalies are divided into vascular tumors and vascular malformations which include slow flow malformations (capillary malformations, venous malformations, lymphatic malformations and their combinations) and high flow malformations (arteriovenous fistula and arteriovenous malformations). complex malformations are also seen in several syndromes including klippel-trenaunay syndrome, phace syndrome, etc. cases from author's database will be used for illustration. results: a review of clinical manifestations, characteristic imaging findings and interventional treatment strategies in cases of head and neck vascular anomalies will be presented with pre and post treatment imaging features. ultrasonography and mri are the mainstay in diagnosis of these malformations. ct scan and catheter angiography may occasionally be needed for diagnosis and treatment planning. various imaging findings and main treatment options will be listed. conclusions: head and neck vascular malformations are common in pediatric population. understanding the characteristic imaging findings and clinical presentation is essential in evaluating the vascular malformations. interventional procedures are generally the preferred treatment modality, either alone or in association with surgery in majority of these cases. isolated cortical diffusion restriction in pediatric brain mri ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; sarah stock, s. pinar karakas, unni udayasankar, janet r. reid purpose or case report: diffusion-weighted imaging continues to emerge as a powerful neuroimaging tool. isolated cortical restricted diffusion is a particularly striking pattern with specific differential in the pediatric population. we aim to review this specific imaging pattern supplemented by case examples and key physiologic and imaging concepts. methods & materials: review the concept of diffusion restriction a) pathophysiology b) specific imaging appearances pictorial review of pediatric conditions that lead to cortical restricted diffusion: a) post ictal change b) infection-i. meningoencephaliitis ii. herpes c) hypoxic ischemic injury d) infarct: venous and arterial e) posterior reversible leukoencephalopathy f) mitrochondrial cytopathy g) metabolic: hypoglycemia. discuss certain artifacts. summary table and differential clues conclusions: the pattern of isolated cortical restricted diffusion has specific differential diagnosis in the pediatric population. the radiologist should be aware of this as use of dwi continues to grow. this exhibit with familiarize the reader with common conditions that specifically affect the cortex and produces true restricted diffusion. methods & materials: high resolution ct scan and mri are mainstay of diagnosis and assessment in patients with sensorineural hearing loss. in this exhibit we will present a pictorial review of ct scan and mri images of various causes of sensorineural hearing loss (snhl) that are seen on imaging. reviewing the embryologic basis of these anomalies would enable better understanding of this complex subject. results: the new system classifies these malformations according to descending order of severity into complete labyrinthine aplasia, cochlear aplasia, common cavity, cystic cochleovestibular malformation or incomplete partition-i (ip-i), cochleovestibular hypoplasia, and incomplete partition-ii (ip-ii). there is a lot of confusion in literature pertaining to mondini deformity. the new classification divides incomplete partition into ip-i representing cystic cochleovestibular malformation and ip-ii representing the classic mondini deformity with three components (cystic cochlear apex, dilated vestibule, and large vestibular aqeduct). recently a subclassification of ip-i and ip-ii has been proposed (subdividing into typical and atypical subtypes)[ ]. this will be discussed briefly. isolated large vestibular aqueduct without associated cochlear abnormalities will also be discussed. we will discuss the relevant embryology with correlations of malformations to the timing of embryologic insult. conclusions: the new classification system provides precision in description of inner ear malformation. this also helps in providing a uniform scale for comparison of effectiveness of cochlear implant for different malformations. purpose or case report: congenital cranial nerve anomalies often present as sensory and/or motor deficits of unknown etiology in the pediatric age group. the early recognition of a definitive cranial nerve abnormality using high-resolution imaging can focus further clinical investigation and shorten the time to diagnosis. methods & materials: to promote appropriate recognition of cranial nerve anomalies, we present the imaging findings of the most commonly affected cranial nerves and provide correlation with clinical presentation. all studies were performed on a . t magnet with dedicated high resolution imaging of cranial nerve exit zones. results: ours is a tertiary care pediatric hospital with an extensive neuroimaging database. we intend to review all known cases of cranial nerve anomalies from the prior years and present interesting and representative images including optic nerve hypoplasia as part of septo-optic dysplasia, kallman syndrome, duane retraction syndrome, and mobius syndrome. conclusions: congenital cranial nerve anomalies present with varied symptomatology including anosmia, impaired vision, occulomotor deficits, and hearing loss. additionally, clinical manifestations of cranial nerve anomalies can be difficult to recognize in the pediatric age group. effective imaging and prompt diagnosis is crucial to initiate appropriate clinical management. purpose or case report: mr is the standard for evaluation of tumors or epilepsy. pet-ct imaging is often performed to ascertain metabolic asymmetries related to epileptogenic regions or to better characterize the metabolic activity of tumors. a baseline for normals with pet-ct fdg- and c methionine does not exist. methods & materials: retrospective review was performed of the pediatric patients who underwent pet-ct with c methionine and fdg. representative studies were selected for patients imaged during infancy (< yr), early childhood ( - ), childhood ( - ), late childhood ( - ), teenage ( - ). c methionine and fdg studies were analyzed for normal patterns of uptake and any trends identified across the stratified age groups. representative pictorial image galleries of the c methionine and fdg imaging patterns through development were created. results: the pattern of radiotracer uptake on c methionine differed from that of fdg. the c uptake remained low level throughout development compared to fdg uptake, which was robust in much of the cortex. the cortical fdg uptake within the frontal lobes progressively increased with age. the c uptake within the brainstem and thalamus was equal to cortex throughout development. the fdg uptake within the basal ganglia was equal to cortex while the brainstem and thalamic uptake was generally less than cortex. several anatomic structures showed robust c uptake not seen on fdg. these included the lacrimal, submandibular and parotid glands. incidentally, the pituitary gland and hippocampus consistently showed c uptake equal to cortex contrary to their appearance on fdg. our institutional protocol regarding the performance of combination c methionine and fdg brain pet-ct studies is presented. conclusions: this study illustrated the normal appearance of brain pet-ct imaging performed with c methionine and fdg in a representative cohort of the pediatric patients through development. normal variance imaging patterns and developmental trends seen with each radiotracer was demonstrated. the pediatric cerebellum: a pictorial review of normal anatomy using mri and diffusion tensor imaging ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; sumit singh, teresa c. gross kelly, mohit maheshwari, tushar chandra, hervey d. segall purpose or case report: the aim of this educational exhibit is to illustrate normal anatomical and functional anatomy of the cerebellum in the pediatric patient. the cerebellum receives sensory input from the brain and spinal cord and integrates this information to coordinate motor control. in addition, the cerebellum also plays a role in some cognitive functions such as attention and language. the first step toward understanding how cerebellar abnormalities can lead to neurological dysfunction, is to provide a solid understanding of the neuroanatomy and functional pathways of the cerebellum. we will describe basic cerebellar embryology, the various cell types and gross anatomy using mr images as well as dti fiber tractography. methods & materials: this exhibit will describe the microstructure, gross anatomy and functional pathways of the cerebellum through illustrations, mr images, diffusion tensor imaging (dti) and pathological correlation. first embryology of the cerebellum will be described, followed by mri depiction of the developmental anatomy of the cerebellum from infancy through adolescence. finally dti tractography images will be used to delineate functional pathways to and from, as well as within, the cerebellum. pathological specimens will be photographed to further illustrate gross anatomy. results: afferent white matter pathways travel mainly via the inferior and middle cerebellar peduncles. the main efferent cerebellar white matter pathway is through the superior cerebellar peduncle. transverse fiber tracts are present in the vermis. there are mainly two main systems of cerebellar white matter fibers which are easily visualized with dti color mapping; however more anterior components of dti tracts are intermixed with afferent white matter projections following the middle cerebellar peduncle. conclusions: knowledge of the precise neuroanatomy and white matter tracts of cerebellum may elucidate our ability to comprehend the clinical manifestations of cerebellar diseases in children. a solid understanding of normal cerebellar anatomy, development and functional fiber tracts in the pediatric patient can provide a baseline that may help predict the clinical outcome of various diseases or interventional procedures. gastroesophageal reflux scintigraphy: a low radiation alternative to gerd evaluation in children vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; feraas jabi, jan najdzionek, vaseem iqbal purpose or case report: gastroesophageal reflux disease (gerd) is among the common causes for failure to thrive, recurrent cough and aspiration in children. early diagnosis of gerd is essential in avoiding long-term sequelae such as growth delay, chronic lung disease, esophageal stricture, and esophagitis. gastroesophageal reflux scintigraphy, a noninvasive imaging modality, has been applied for detection of gerd and gastric emptying in children over the past few decades. the radiation burden is considerably small given that a very low dose of radioactivity via a short half-life radioisotope like technetium- m tagged to oral sulfur colloid is administered to a patient. this feature makes reflux scintigraphy especially attractive as the patient can be scanned for prolonged and delayed periods without increasing radiation dose permitting not only identification but also assessment of severity of gerd. characterizing gerd severity is essential in determining how aggressive the pediatrician should be with therapy. gastroesophageal reflux scintigraphy also allows a child to be fed their regular meal tagged to radiopharmaceutical without altering food taste. qualitative and quantitative parameters like gastrointestinal transit and gastric emptying time can be measured, respectively. scintigraphy is highly sensitive to low grade reflux making it very desirable for monitoring response to therapy. while scintigraphy like all other imaging modalities,has limitations, it continues to be an excellent technique for gerd identification and characterization as well as in monitoring response to gerd therapy. the pediatric kidney-a review of common and uncommon renal anomalies ruby lukse, staten island university hospital, drjosemorey@gmail.com; josé morey, jeremy neuman, arnold brenner, oren herman, adam bernheim purpose or case report: renal parenchymal imaging in nuclear medicine has long been performed with mtcdimercaptosuccinic acid (dmsa) due to its sufficient binding to the renal tubules to permit renal cortical imaging. dmsa is of particular value when high-resolution images of the renal cortex are needed. this poster will be a pictorial review of common and uncommon congenital anomalies evaluated on dmsa imaging, such as horseshoe kidney, pelvic kidney, sshaped kidney and crossed-fused ectopia. the poster will also correlate planar imaging findingss with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: in this poster we will review the differential diagnoses of congenital anomalies that give the appearance of hydronephrosis on renal imaging of the pediatric patient. we will show a pictorial review of both common and uncommon congenital anomalies such as congenital megaureter, ureterocele, uretero-pelvic junction (upj) obstruction, uretero-vesicular junction (uvj) obstruction and posterior urethral valves (puv). we will also review common mimickers of hydronephrosis such as multicystic dysplastic kidney (mcdk) and pseudo-obstruction secondary to bladder overdistention. the poster will also correlate planar imaging finds with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the pediatric bone scan-a review of neoplastic pathology shrita smith, staten island university hospital, drjosemorey @gmail.com; josé morey, jeremy neuman, arnold brenner, daniel klein, purpose or case report: bone imaging continues to be the second greatest-volume of nuclear imaging procedure performed today, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of m-tc bone imaging of malignant conditions have long been established. in fact, more than , , bone scans were performed in the united states in . in this poster we will review the current indications for planar bone imaging for the evaluation of malignant and benign neoplasms in the pediatric population, such as osteoid osteoma, langerhan cell histiocytosis (lch), osteoblastoma, ewing's sarcoma, lymphoma, osteosarcoma and osseous/hepatic metastatic disease from neuroblastoma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the many faces of duplex kidneys on dmsa scans-a pictorial essay neha kwatra, children's national medical center, nskwatra@childrensnational.org; massoud majd purpose or case report: renal duplication is the most common malformation of the urinary tract and is often seen in children with urinary tract infections (uti). the purpose of this study is to learn to recognize duplex kidneys on dimercaptosuccinic acid (dmsa) scintigraphy, review their entire spectrum of findings and correlate with other imaging modalities. methods & materials: dmsa scintigraphy is routinely performed in the nuclear medicine department with a single-head gamma camera (siemens e.cam, schaumberg, illinois). about . h after injection of dmsa, posterior and posterior oblique images are obtained using parallel and pin hole collimators. differential renal function is also calculated. dmsa scan reports containing the words "duplex" or "duplicated" from - were populated using a radiology search engine (montage health care solutions inc.). the images were then reviewed in pacs and representative examples were selected for the poster. the scans were evaluated for renal position, size, contour, any evidence of duplication and parenchymal damage. results: patterns of duplication included non complicated duplex kidney recognized by asymmetric renal size and a prominent cortical bar separating the two moieties, complicated duplex systems with hydronephrosis, scarring or pyelonephritis of one or both moieties. a small nonfunctioning upper moiety was sometimes evidenced by just an indentation along the superomedial aspect of the larger lower moiety. cases with bilateral duplex kidneys were also seen. illustrative examples of each will be provided. correlating findings on other imaging modalities will also be included. conclusions: establishing the diagnosis of duplex kidney on a dmsa scan requires a careful systematic review of the images. the findings can be subtle and it is important for the radiologist to recognize them. correlation with other modalities such as ultrasound or voiding cystogram can be complementary. the assessment of parenchymal function of the upper and lower moieties separately on dmsa scintigraphy can be of immense value in patient management and in choosing surgical options. poster #: edu- f-fdg pet/ct imaging of pediatric brain tumors, neurofibromatosis (nf ) and non-lymphomatous head and neck tumors. lisa states, md, radiology, chop, states@email.chop.edu; purpose or case report: this educational poster will review the current literature and summarize the value of f-fdg pet/ct in standard clinical practice in the evaluation of pediatric brain tumors, nf plexiform neurofibromas and malignant peripheral nerve sheath tumors, and nonlymphomatous head and neck tumors. normal variants and pitfalls will be reviewed. comparison with other pet tracers will be briefly discussed. case examples will be used to illustrate the value of f-fdg pet/ct in grading, staging, assessment of therapeutic response and detection of residual or recurrent disease in various pathologic entities. results: examples of cases will include: benign brain tumor, residual brain tumor in the post-operative bed, brain metastasis, malignant peripheral nerve sheath tumor in nf , head and neck rhabdomyosarcoma, mandibular osteosarcoma, and infection. conclusions: an understanding of the value of pet molecular imaging is essential to the success of the next phase of hybrid imaging with pet/mri which has the potential to play an important role in the development of new diagnostic and therapeutic approaches for the treatment of pediatric brain tumors, nf , and pediatric head and neck tumors. disclosure: dr. states has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the pediatric bone scan-a review of non-malignant pathology josé morey, staten island university hospital, drjosemorey@ gmail.com; jeremy neuman, arnold brenner, vinh phan, cheryl lin purpose or case report: bone imaging continues to be the second most performed nuclear imaging procedure, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of m-tc bone imaging of benign conditions have long been established. in fact, more than , , bone scans were performed in the united states in . in this poster we will review the current indications for planar bone imaging for the evaluation of non-malignant diseases in the pediatric population, such as acute osteomyelitis secondary to salmonella enterobacteriaceae and tubercle bacillus (tb), chronic osteomyelitis, reflex sympathetic dystrophy, spondylolysis, bone infarcts in the setting of sickle cell disease, fractures (occult/stress), ankylosing spondylitis, dermatomyositis and non-accidental trauma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: we review the radiologic features of pathologic conditions linked to diesel exposure. the hydraulic fracturing ("fracking") technique is increasingly used in many areas of the country to extract natural gas from rock formations. diesel fuel, or fluids containing diesel, are one component of fracking fluid and create a potential for ground water contamination and risk to air quality. the toxic effects of diesel exhaust are described in the literature, and include asthma, hydrocarbon pneumonitis, and leukemia. there are no scientific data currently available on the effects of chronic diesel ingestion. methods & materials: multi-modality examples of pathology were obtained from a radiology database at a tertiary care pediatric hospital. the specific cases displayed are not known to have diesel exposure, but are intended to serve as representative examples of the type of pathology that may be encountered in the setting of chronic diesel exposure. results: imaging findings of asthma include hyperexpansion, atelectasis, peribronchial thickening, and air-trapping. hydrocarbon pneumonitis may demonstrate low attenuation consolidation and subsequent pneumoatocoeles with ct. leukemia may present on plain radiographs with lucent metaphyseal bands and with marrow infiltration on mri. conclusions: in conjunction with other symptoms not necessarily evaluated in the radiology department, including rhinitis, laryngitis, acute coronary syndrome, and dementia, the radiologist may suggest the diagnosis of diesel toxicity, particularly in populations that may be at high risk of exposure. pediatric radiology in the philadelphia region: a historical review* richard markowitz, md, children's hospital of philadelphia, markowitz@email.chop.edu purpose or case report: the specialty of pediatric radiology in the philadelphia region has grown and evolved over the past eight decades originating from early "visiting" radiologists to drs. hope and kirkpatrick, the "giants" of the s and ' s, to over fifty practicing pediatric radiologists today. clinical excellence, commitment to teaching, and advancement of knowledge through research remain the goals and ideals, much as they were many years ago. philadelphia has been a fertile home and environment for this evolution, mostly because of outstanding leaders and role models who have trained and influenced generations of pediatric radiologists. developments and leadership at the children's hospital of philadelphia, st. christopher's hospital for children, and a.i. dupont institute are highlighted. the purpose of this poster is to tell the story of the growth and development of pediatric radiology in this area and to explore the intellectual origins, professional "genealogy," and legacies left by those who created and those who have carried on this tradition. *note: this material is based on a previously published article: pediatric radiology ( ) : - and "addendum" (pediatric radiology : - ), but never presented at spr. superficial lumps and bumps henrietta k. rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; diane belvin, neil lester purpose or case report: superficial soft tissue masses in the pediatric age range can be quite challenging to the pediatrician and the imager. the purpose of this presentation is to demonstrate the efficacy of duplex/color doppler ultrasound for the diagnosis and follow up of a large gamut of superficial lumps and bumps. methods & materials: we reviewed our experience during the past years using ultrasound to evaluate superficial soft tissue masses that had been encountered in many parts of the body, from the skull to the soles of the feet, in a large group of patients ranging in age from newborn to years. all sonograms were performed after obtaining pertinent clinical information as well information regarding the clinical characteristics of each of the masses, e.g. location, consistency (firm [solid], compressible [cystic]), fixed or easily movable, smooth or irregular surface, tenderness. the masses were palpated by the imaging team and duplex/color doppler ultrasound was performed. comparison sonographic views of the opposite side were obtained as needed. clinical followup and surgical/pathological correlation was obtained in most of the patients. results: most of the masses were benign and included a wide variety of etiologies. most often, us was sufficient for assessment of soft tissue masses if the entire mass was included in the field of view. if the lesion was too large for the field of view or malignancy was suspected, ct/mri were required preoperatively. nuclear medicine studies are reserved for midline masses likely due to ectopic thyroid and pet was used for more complete evaluation of a lesion that was likely malignant. conclusions: duplex/color doppler ultrasound (us) is the modality of choice for evaluation of superficial lumps and bumps! this modality allows for rapid acquisition of information without the use of ionizing radiation, intravenous contrast material, or sedation/anesthesia. reliable information can be rapidly acquired regarding the size, shape, borders, location, internal consistency, vascularity, vascular encasement/displacement. correlation of the ultrasound and clinical findings helps narrow differential diagnosis. sonography helps to determine what is the next best step: watchful waiting (clinical observation, follow-up us), surgical resection, or us guided interventional procedure. present day imaging of down syndrome rupa radhakrishnan, md, radiology, university of cincinnati college of medicine, radhakrp@ucmail.uc.edu; alexander j. towbin purpose or case report: down syndrome is a common genetic condition characterized by unique physical traits and multisystem anomalies. the purpose of this exhibit is to portray the imaging findings of down syndrome and discuss with illustrative examples, the use of imaging in multidisciplinary management. methods & materials: published literature was reviewed to identify the multisystem imaging findings in down syndrome. the electronic medical record system was then searched to find illustrative case examples from our institution. results: in patients with down syndrome, abnormalities can be found in the musculoskeletal, cardiovascular, respiratory, gastrointestinal, and central nervous systems. abnormalities can range from emergent, life threatening conditions such as malrotation with midgut volvulus to chronic conditions such as scoliosis. examples of abnormalities from each organ system and the modalities used for diagnosis and management are described. cardiovascular system: echocardiogram and cardiac mri and ct are useful in evaluating congenital heart disease associated with down syndrome. respiratory system: micrognathia with macroglossia and hypotonia predisposes patients to sleep apnea which can be evaluated with dynamic mri. chest ct demonstrates subpleural cysts which are characteristic of this syndrome. gastrointestinal system: fluoroscopy and/or radiographs are the mainstay in diagnosing many gastrointestinal disorders including duodenal atresia, malrotation, annular pancreas, imperforate anus, and hirschsprung disease. central nervous system: choroid plexus cysts may be identified on prenatal ultrasound in a fetus with down syndrome. imaging is used in the evaluation of epilepsy, hearing loss and alzheimer disease that is more common in these individuals. musculoskeletal system: multiple skeletal anomalies can be present in patients with down syndrome. radiographs are often used as the method of identifying and, if needed, following the anomalies. prenatal imaging: increased nuchal translucency is the earliest imaging finding. other features of down syndrome can be identified on prenatal ultrasound or mri. prenatal imaging is helpful in determining the prognosis of the fetus and in guiding management. conclusions: modern day multidisciplinary management has improved quality of life and survival in individuals with down syndrome. imaging plays a critical role in guiding management in these individuals. imaging the spectrum of lymphatic malformations in the pediatric patient andrew schapiro, md, radiology, university of wisconsin, aschapiro@uwhealth.org; kara gill, bradley maxfield purpose or case report: lymphatic malformations (lm) occur as a result of abnormal development of the lymphatic system during embryogenesis. as % of lm present by years of age, these lesions represent an important pediatric entity. lm can often be suspected clinically in an infant with the classic presentation of an asymptomatic, soft mass in the head, neck, or axilla. however, myriad presentations are possible as lm occur in numerous other anatomic locations, can be multiple, and can be a component of mixed vascular malformations. in addition, the true extent of lm is often not apparent clinically. given these considerations and the implications for proper management, imaging plays an important role in the assessment of lm. the purpose of this exhibit is to review the spectrum of radiographic, ct, sonographic, and mr imaging findings of a variety of lm presentations. methods & materials: cases of lymphatic malformation in pediatric patients identified at a single institution over the past ten years with available imaging were reviewed utilizing pacs. results: images of lm involving the head and neck, chest, abdomen, retroperitoneum, extremities, and skeletal system were identified. in addition, cases of lymphangiomatosis and mixed venolymphatic malformation were identified. various imaging modalities including radiography, ct, sonography, and mr were represented. conclusions: adequate knowledge of the imaging characteristics of lm across multiple modalities enables proper diagnosis, assessment of disease extent, and guidance of appropriate therapy in pediatric patients. results: ct and mr imaging findings in nine cases will be presented. they include ) congenital absence of the inferior vena cava with thrombosis of the external iliac vein secondary to venous stasis ) pyelophlebitis complicating ruptured appendicitis ) left iliac vein thrombosis in a patient with may-thurner syndrome ) splenic vein thrombosis complicating pancreatitis ) splenic vein thrombosis following splenectomy ) renal vein thrombosis in an infant of a diabetic mother ) adrenal vein thrombosis as the presenting sign of antiphospholipid syndrome ) budd-chiari syndrome associated with underlying myeloproliferative disease ) iliac vein thrombosis as a manifestation of behcet's syndrome (hughes-stovin syndrome, a variant of behcet's syndrome, which presents with systemic venous thrombosis and pulmonary artery aneurysms will also be discussed). conclusions: thrombosis of large abdominal and pelvic veins in children and adolescents is uncommon. certain conditions, both congenital and acquired, predispose to the development of venous thrombosis. ct/mr imaging defines the extent of thrombosis, and demonstrates additional findings that may elucidate the nature of the underlying condition leading to clot formation. purpose or case report: because abnormal gait in a young child has a wide range of causes, imaging plays a critical role in establishing the definitive diagnosis. the purpose of this exhibit is to review the clinical clues (age, duration, laboratory markers) and imaging findings of the causes of abnormal gait in a toddler and to assess the strengths and limitations of radiographs, ultrasound, magnetic resonance imaging (mri), and computed tomography (ct). methods & materials: cases, from a single institution experience with various causes for abnormal gait in a toddler, are reviewed and categorized into congenital, traumatic, inflammatory, neoplastic, or neuromuscular etiologies. results: there are various causes of abnormal gait in a toddler. the congenital causes include spinal dysraphism, proximal and distal skeletal deformities and dysplasias. the traumatic causes include non-accidental trauma, toddler's fracture, foreign body, and soft tissue injuries. the inflammatory causes include juvenile idiopathic arthritis, transient synovitis, and infection, including osteomyelitis, septic arthritis, discitis, cellulitis, and abscess. the neoplastic causes include various neurogenic, bone, and soft tissue tumors. the neuromuscular causes include cerebral palsy and spinal bifida. the combination of clinical presentation, supporting laboratory findings, and classic imaging findings help to distinguish the possibilities and often allows confident diagnosis. conclusions: knowledge of imaging findings and clinical factors can demystify the diagnosis of abnormal gait in a toddler. familiarity with the clinical presentation can ensure the performance of the appropriate diagnostic studies, timely diagnosis, and effective treatment. nonaccidental causes should never be overlooked. ultrasonography has become an important tool in the radiologist's armamentarium, augmenting radiography, mri, and ct. approximately different contrast agents for mri and ct are now commercially available for use. although most of them are fda approved in adults, information on usage and safety in children is not readily available. the most important reason is lack of controlled studies in children, especially for the age of - years. however, the lack of fda approval has not limited the use of these promising agents in children. in fact, there is widespread off-label use of these agents in most major pediatric hospitals in the country. based on a review of relevant literature in children, and based on a survey of radiology faculty at major pediatric hospitals, this poster will address the gap between approved use and reality in the setting of pediatrics. results: using a tabular format, this poster will provide a list of mr and ct contrast agents that are available for clinical use, their relevant clinical properties (ionic or nonionic, viscosity, linear or macrocyclic, degree of relaxivity for mri, iodine concentration for ct, cost, dosage, halftime, incidence of allergic reactions, nephrogenic systemic fibrosis and other adverse reactions), fda approval status (for ages - days, days- years, and - years), common pediatric applications, and contrast injection protocols for common applications. conclusions: to enlighten imaging personnel about usage and safety of contrast agents in children. disclosure: dr. krishnamurthy has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. a pictorial essay and literature review of the spleen in sickle cell disease david hindson, md, boston medical center, david. hindson@bmc.org; heather imsande, philippa sprinz, ilse castro-aragon purpose or case report: the morbidity and mortality of sickle cell disease (scd) results from acute and chronic infarction events that affect almost every organ. repeated infarction has some of its greatest visual and physiologic impact within the spleen. continuous hemolysis, sequestration and vaso-occlusion within the spleen result in loss of splenic function early in life and frequently autosplenectomy thereafter. by years of age, approximately % of children with hemoglobin ss disease will have diminished splenic function, putting them at increased risk for infections. treatments for scd have evolved over the last years, and among others include penicillin prophylaxis and immunizations, hydroxyurea and transfusion therapy (or hypertransfusion program). imaging findings are a reflection of the different treatments and their efficacy. methods & materials: our institution cares for a large group of patients with sickle cell disease, from birth to adulthood. this offers an unprecedented opportunity to document the imaging findings of the spleen with different treatment regimens, and over many years. the splenic size and morphology can be followed, by ultrasound, in a very straightforward way. we have compiled a pictorial essay of the various imaging characteristics of spleens from infants to adults. we also performed a literature review to compare and supplement the findings of our images. results: there is a spectrum of imaging findings in the spleen of patients with scd that changes from birth to childhood. the findings range from the normal appearance of a spleen to a calcified spleen, and include regenerative nodules, fibrosis, altered parenchymal echotexture, increased echogenicity, and changes in size, including enlargement secondary to sequestration. the ultrasound characteristics not only change with advancing age, but also appear to depend on whether or not the patient has received specific treatments, and at what age treatment was initiated. conclusions: the ultrasound appearance of the spleen in patients with scd is variable. treatments such as blood transfusions and hydroxyurea, patient compliance with therapy and type and severity of the disease are some of the factors that affect imaging characteristics. cystic fibrosis: not just for children cindy miller, md, radiology, yale-new haven hospital, cindy.miller@yale.edu purpose or case report: cystic fibrosis has been recognized for hundreds of years with the first descriptions of it including such anecdotes as mothers licking the foreheads of their children and knowing that if it tasted salty, an early death could be predicted. it was not until that the disease was first named by dr. dorothy andersen, and for the following years, treatment was largely supportive, and imaging was essentially done with plain films alone. in with the elucidation of the cftr gene, there was an explosion of knowledge which included the range of increased awareness and understanding of the suspected etiology, imaging findings and significance of the ductus bump. the contribution of d imaging for evaluation of the pediatric central airways jessica kurian, md, the children's hospital of philadelphia, kurianj@email.chop.edu; monica epelman, david a. mong purpose or case report: evaluation of the central airways in children has historically been accomplished by flexible bronchoscopy, an invasive technique associated with inherent risks and complications. multidetector ct (mdct) with volume rendering offers a noninvasive alternative for airway evaluation. in this educational exhibit, we will review imaging techniques and clinical applications of mdct for the assessment of large airway maladies in children. methods & materials: mdct imaging in children with a variety of tracheobronchial disorders is reviewed. for each entity, the characteristic clinical features are described, and key imaging features are illustrated. emphasis is placed on the contribution of d techniques for characterizing complex airway anomalies. dose reduction strategies are also highlighted. results: the entities reviewed in this exhibit include, but are not limited to, congenital anomalies of tracheobronchial branching, airway malformations associated with situs, and congenital or acquired airway compression and/or obstruction. conclusions: mdct with volume visualization is a useful adjunct for evaluation of the pediatric central airways in a variety of pathologies. as a noninvasive technique, it avoids sedation risks and spare patients from complications associated with conventional flexible bronchoscopy. low dose protocols should be used to minimize radiation exposure. bronchopulmonary foregut malformation that result from abnormal budding of the primitive foregut. currently, many such anomalies are initially detected by prenatal ultrasound and are further delineated by fetal magnetic resonance imaging (mri), while others may be incidentally detected on postnatal radiologic examinations or later in life in the setting recurrent pulmonary infection. imaging plays a very important role in the diagnosis and characterization of these lesions and assists surgical planning. the purpose of our educational exhibit is to illustrate the common and uncommon radiologic appearances of cpams using various imaging modalities, including radiography, computed tomography, prenatal and postnatal ultrasound, and prenatal and postnatal mri. methods & materials: all pediatric and adult cpam (including both sequestration and ccam) patients were identified using electronic medical records. pertinent imaging reports (including radiography, prenatal and postnatal ultrasound, ct, and prenatal and postnatal mri) were reviewed by a single author in order to identify relevant imaging findings. relevant images from these imaging examinations were de-identified and saved to a secure hard drive. medical records were accessed by a single researcher to obtain relevant demographic information as well as data regarding the patients' clinical presentations. in cases of corrective surgery, operative and pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of pediatric and adult cpam were identified and presented in a variety of clinical contexts. their appearances were reviewed through multiple imaging modalities. conclusions: congenital pulmonary airway malformations are varied in their clinical presentation and imaging appearance. the purpose of this pictorial essay is to enhance understanding of their diagnosis and to use a multidisciplinary approach in order to highlight imaging aspects that may alter clinical management. disclosure: dr. horst has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the imaging evaluation of cystic lung disease in children: an evidence-based approach jordan caplan, md, pediatric radiology, lucile packard children's hospital, stanford university, caplan@stanford. edu; beverley newman purpose or case report: the goal of the poster is to provide a framework for use when confronted with cystic lung disease in a child. methods & materials: the differential diagnosis for the types and causes of cystic lung disease in children will be presented using an evidence-based, age appropriate approach. categories of disease discussed and illustrated with case examples will include: a. congenital cystic bronchopulmonary malformations b. infectious cysts c. autoimmune/inflammatory/vasculitic disease with cavitating lesions d. neoplastic conditions e. collagen/soft tissue abnormalities f. mimics of cystic lung disease results: the pathophysiology, imaging appearance, and demographics of the above entities will be reviewed with attention to relevant recent literature. important educational points include the differentiation of bronchopulmonary malformations from neoplasm, notably pleuropulmonary blastoma (ppb), the relationship between lung cysts and ppb, and the management and surveillance of lung cysts in children. conclusions: an evidence-based approach to the broad spectrum of causes of cystic lung disease in children is a useful starting point in forming a concise and pertinent differential diagnosis. an understanding of the pathophysiology, imaging appearance, and demographics of these entities is essential in guiding patient management. pediatric interstitial lung disease (ild): a pictorial review with radiologic and pathologic correlation hollie west, md, diagnostic radiology, vanderbilt university, hollie.c.west@vanderbilt.edu; melissa a. hilmes, sudha p. singh, jennifer soares, lisa young purpose or case report: while adult interstitial lung disease is a well-described and fairly well understood group of disease processes, pediatric interstitial lung disease (ild) remains a subject of uncertainty and misunderstanding for many clinicians and radiologists. confusion surrounding the phenomenon of pediatric ild stems not only from the rarity of the disease, but also from the extensive list of disease entities that can produce ild, the existence of certain patterns that are restricted to infants and children and the fact that patterns of ild manifest differently in a child's developing lung than in an already developed adult lung. imaging plays an important role in diagnostic work-up of this disease and can guide lung biopsy in specific patient populations. methods & materials: the irb approved retrospective study will show patients at our institution over a year period diagnosed with various types of ild, including pulmonary insterstitial glycogenolysis (pig), diffuse neuroendocrine cell hyperplasia (nehi), surfactant deficiency diseases, and lung diseases associated with other systemic processes such as downs syndrome and inflammatory bowel disease. we will include patients with biopsy proven ild and will provide examples of the major ilds, including clinical, radiologic and pathologic correlation. our pictorial review will describe the radiologic patterns associated with the different forms of ild, emphasizing what the radiologist needs to know and how to be helpful to a multidisciplinary team in the diagnosis and treatment of these diseases. results: the study will report the frequency of ild at our institution, including a breakdown of the various subtypes of ild. we will show examples of the subtypes with correlative chest radiography, computed tomography, and pathology. we plan to highlight specific differentiating factors between the different diseases and demonstrate how a radiologist can be helpful in collborating with clinicians in diagnosing and treating these diseases. conclusions: pediatric ild can be a confusing topic for radiologists. increasing knowledge and awareness of these diseases, their clinincal presentation, work up, and treatment is important for pediatric radiologists who work as part of of a multidiciplinary team. poster #: sci- ct radiation dose delivered by community hospitals and imaging centers stephen little, children's healthcare of atlanta, stephen. little@choa.org; damien grattan-smith, bonnie johnson purpose or case report: to evaluate and compare ct radiation dose for pediatric abdominal and cranial ct examinations performed by community hospitals and imaging centers. methods & materials: consecutive ct examinations ( cranial, abdominal) from community hospitals and imaging centers were reviewed following transfer of care. the examinations were performed between january and july . consecutive ct examinations ( cranial, abdominal) performed at our own institution were also reviewed. ctdivol and dlp were obtained from the dose report for each examination ( cm-phantom for abdominal exams, cm-phantom for cranial exams). patient age and weight were obtained from the medical record. results: average ctdivol for abdominal ct performed by local community hospitals and imaging centers was . mgy, while average ctdivol was . mgy for abdominal ct performed at choa. there was a wide variation in ct radiation dose delivered. while some sites delivered a ct radiation dose comparable to our own, others delivered a substantially greater dose. in fact, % of pediatric abdominal ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm ( mgy using the cm phantom). low kvp technique for imaging small children was infrequent. multi-phase examinations were more often performed, resulting in additional elevation in ct radiation dose when dlp is considered. average ctdivol delivered by local community hospitals and imaging centers for cranial ct was mgy compared to a ctdivol of mgy for cranial ct performed at choa. % of pediatric cranial ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm ( mgy for - years, mgy for > years). conclusions: despite ongoing efforts at education, there is wide variation in ct radiation dose delivered for pediatric abdominal and cranial ct examinations performed by local community hospitals and imaging centers. appropriate use of dose check software on newer scanners may help reduce the number of children subjected to excessive ct radiation dose. ultimately, each site performing pediatric ct must take responsibility for minimizing radiation dose while producing diagnostic quality exams. the impact of adaptive statistical iterative reconstruction on ct image quality parameters -a phantom study karen thomas, md, radiology, hospital for sick children, karen.thomas@sickkids.ca; nancy ford, angjelina protik, paul babyn purpose or case report: to quantify the effect of adaptive statistical iterative reconstruction (asir) on ct image quality parameters. methods & materials: phantom (catphan ) studies were performed on a ge hd -slice scanner to investigate the impact of a) % asir compared to routine filtered back projection using variable kvp ( - ) and mas ( - ), and b) incremental asir % ( , , , , %), scanning at mas and variable kvp ( - ). pitch, acquisition fov and detector width were kept constant. image noise, spatial and contrast resolution, contrast noise ratio (cnr) and wiener spectrum analysis were performed on . mm ax, mm ax mpr and mm cor mpr series. results: % asir resulted in a mean decrease in noise of % ( . mm ax), % (ax mpr) and % (cor mpr) and improvement in cnr of - %. incremental advantage was seen with stepwise increase in asir %. however, application of asir was associated with a small reduction in spatial resolution ( - % at % asir). low contrast detectability (lcd) improved except at the smallest target lesion size. image quality effects at very low mas and at high asir % will be presented. conclusions: image noise reduction and improvements in cnr and lcd with asir hold considerable potential for dose reduction in pediatric ct. this study provides quantitative data that may be used to design asir-enhanced protocols with consideration of diagnostic task, balancing image quality benefits and potential pitfalls. pictorial essay on cardiac mr for congenital heart disease on t mr scanner with rf multi-transmit technology (tx) taylor chung, md, diagnostic imaging, children's hospital & research center oakland, taylorchung @gmail.com purpose or case report: this is a pictorial essay (e-poster) to show artifacts on cine ssfp images pre-tx and post-tx upgrade on congenital heart disease cardiac mr; to illustrate methods prior to tx-upgrade to minimize artifacts. disclosure: dr. chung has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. revisiting the relationship between anthropometric parameters and left ventricular mass abdullahi adamu, md, phd, ahmadu bello university, scorpion kd@yahoo.com purpose or case report: the purpose of this study was to find the correlation between anthropometric parameters and left ventricular mass in normal adolescents and young adults. methods & materials: healthy individuals in the age range to years ( males and females) were included in this study. anthropometry was performed with standard anthropometry kit and measurements of height, weight, body surface area (bsa), upper arm circumference and upper hip circumference were taken. echocardiography was performed and the american society of echocardiography (ase)-recommended method was employed for calculation of left ventricular mass (lvm). statistical analysis was performed using statistica . (stat soft, usa). results: the mean value of lvm for all our subjects was found to be . ± . g. there was significant correlation between lvm and height (r . , p< . ), weight (r . , p< . ) and bsa (r . , p< . ). correlation with upper arm circumference was moderate (r . , p< . ), while it was found to be weak with upper hip circumference (r . , p< . ). diagnostic. both field strengths can be used successfully for cardiac and vascular imaging. the decision as to which to use is weighted by local availability and the relative requirement for detailed vascular vs intra-cardiac imaging. disclosure: dr. nguyen has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. poster #: sci- color coded d cardiac cta of congenital heart disease: a five year experience nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; randy richardson purpose or case report: post-processing of cardiac computed tomography angiograms can be performed on a commercially available workstation to create color coded d volume rendered images of the segmented heart and great vessel anatomy in patients with congenital heart disease. these studies optimally demonstrate complex anatomy, streamlining communication between members of the healthcare team and providing a tool for communicating complex anatomy and treatment options with families. these studies have been ordered with more frequency over the past five years. we retrospectively reviewed the types of congenital heart disease demonstrated by cardiac d cta over the past five years at a congenital heart center. methods & materials: color coded cardiac cta postprocessing was performed from ecg gated prospective and retrospective cta data on a commercially available workstation for / patients over the past three years. the anatomy was initially segmented and colored into individual parts of the anatomy of the heart and great vessels as follows rv purple, lv light red, aorta red, pulmonary arteries blue, systemic veins and right atrium aqua, pulmonary veins and left atrium pink, pda or collaterals green, airway yellow, coronary arteries neutral. the anatomy was then reassembled and images obtained every °in a °rotation for display. results: d color coded cta images were used in the treatment and care of congenital heart patients for the following types of congenital heart diseases: cases of complex anatomy (tga, truncus arteriosus, hlhs, tricuspid atresia, tof…), coronary artery anomalies, cases of pulmonary atresia or stenosis, cases of systemic and venous anomalies, cases of coarctation or interruption of the aortic arch, and tracheobronchial tree anomalies. conclusions: color coded cardiac cta post-processing is an effective and viable method for demonstrating anatomy in complex congenital heart patients. it is an excellent tool for demonstrating anatomy which is difficult to see by echocardiography such as: coronary artery anomalies, pulmonic atresia, aortic arch coarctation or interruption, and tracheobronchial anomalies and/or stenosis. neuroimaging in the evaluation of hie in term neonates post hypothermia therapy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu; jatinder bhatia, leann vanlandingham purpose or case report: to illustrate and review the potential utility of brain mri, ct and ultrasound in hypoxic ischemic encephalopathy in newborns treated with hypothermia. neuroimaging studies including brain ultrasound, ct and mri of fifteen term newborns treated in our institution with therapeutic hypothermia, since april were evaluated retrospectively. more relevant lesions are depicted and the diagnostic and prognostic value of the findings is discussed and compared with a review of the literature. results: recent studies showed that patients treated with cooling had a more favorable prognosis than was suggested by the clinical grade of encephalopathy compared with infants treated with standard care. our institutional protocol includes the performance of mri, and ultrasound. ct is performed when is a clinical impossibility of perform mri. brain ultrasound was performed in all the patients. mri scans were obtained in neonates. ct was obtained in patients. all mri studies included dwi. the utility of dwi and adc maps as an aid in diagnosis of non-ischemic lesions is becoming increasingly established. mri evidence of brain injury was visible on basal ganglia in cases with negative ultrasound. abnormal signal intensity in the posterior limb of the internal capsule coexists with lesions in the basal ganglia and thalami have been associated with abnormal motor outcome. the remaining newborns did not develop significant mri evidence of brain injury. it has been suggested that the ability of mri to predict subsequent neurological impairment is unaltered by therapeutic hypothermia. further research is needed for defining the relation between mri findings and cooling. it is possible that imaging findings might be delayed in cooled infants. conclusions: mri offers the highest sensitivity in detecting anoxic injury of the neonatal brain. mr biomarkers in combination with clinical markers may identify patients with adverse outcome with therapeutic implications. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: to correlate bowel wall diffusionweighted imaging (dwi) apparent diffusion coefficient (adc) values with multiple mr enterography (mre) and clinical findings in pediatric small bowel crohn disease. methods & materials: pediatric crohn disease patients with mre exams containing diffusion-weighted imaging and demonstrating terminal ileitis were identified. minimum bowel wall adc values were tested for correlation/association with other mri findings and clinical parameters (including laboratory values). results: there is negative correlation between adc value and degree of bowel wall thickening (r (−) . ; p . ). lower adc values were significantly associated with striated pattern of arterial phase postcontrast enhancement (p . ), greater degree of arterial phase postcontrast enhancement (p . ), and presence of stricture (p . ). adc values were not associated with diseased bowel length, degree/pattern of delayed postcontrast enhancement, degree of mesenteric inflammation or fibrofatty proliferation, or clinical markers of inflammation. conclusions: restricted diffusion in pediatric small bowel crohn disease is associated with other mri findings of that are suggestive of active disease, including degree of bowel wall thickening and degree and pattern of arterial phase postcontrast enhancement. our data also suggests that dwi may be useful when attempting to characterize small bowel strictures as either predominantly inflammatory or fibrotic, although further investigation is needed. quantification of blood flow into and out of the liver with d phase contrast mri in the pediatric patient binh huynh, md, radiology, stanford, bhuynh@stanford. edu; shreyas vasanawala, albert hsiao purpose or case report: the ability to probe blood flow dynamics in the liver may aid management of children with liver disease, including shunt fractions in portal hypertension and arterial flow fraction in diffuse liver disease. the purpose of this study is to evaluate the ability to measure blood flow into and out of the liver with time resolved volumetric ( d) phase contrast mri in the pediatric patient. methods & materials: nineteen consecutive patients were retrospectively identified who underwent d flow imaging through the level of the hepatic vessels on . t and t magnets. a software enabling d flow program was utilized to first assess for the feasibility of measurement of flow in the hepatic artery (ha), portal vein (pv), splenic vein (spv), superior mesenteric vein (smv), supra (sivc) and infrahepatic (iivc) inferior vena cava. if measurable, calculations were performed to evaluate for internal consistency by comparing the sum of smv and spv flow to pv flow. calculations were then performed to compare hepatic inflow (pv+ha) to hepatic outflow (sivc-iivc) and for the percentage of pv and ha contribution to hepatic inflow. results: of the nineteen patients, all of the above mentioned six vessels were visualized and measurable in two patients, both of which were imaged on the . t magnet. in the remaining patients, flow measurements were limited by respiratory motion artifacts obscuring the smaller vessels, and severe eddy currents, particularly in patients imaged with the t magnet. the evaluation for internal consistency demonstrated an average of . % ( . % & - . %) difference between smv+spv and pv flow. hepatic inflow was found to closely match the measured hepatic outflow with an average difference of . % ( . % & . %). the portal vein was found to contribute . % and . % to hepatic inflow, while the hepatic artery contributed . % and . %. conclusions: measurement of hepatic flow with phase contrast mri is more challenging than assessment of thoracic flow. when respiratory artifacts are minimal, vessels can be identified and measurements have internal consistency and good agreement between hepatic inflow and outflow at . t. conversely, flow measurements were limited at t by eddy currents. thus, ongoing efforts are aimed at mitigating respiratory motion artifacts at . t. poster #: sci- mri findings in post-fontan hepatopathy adina alazraki, md, radiology, emory university/children's healthcare of atlanta, adina.alazraki@choa.org; pinar bulut, kiery braithwaite, miriam vos, rene romero, nitika a. gupta purpose or case report: as advances in congenital heart disease continue to improve both mortality and quality of life, associated complications are becoming more prevalent. amongst patients who have had fontan repair for hypoplastic left heart syndrome, tricuspic atresia, or other right heart dysfunction, it is well known that liver disease is a complication. we describe the mri findings in post-fontan patients and propose mri as a useful tool to the hepatologist's evaluation of these patients. methods & materials: irb approval was obtained for a retrospective review of patients who underwent fontan repair and were subsequently referred for hepatology evaluation between - . all but one patient was scanned on a siemenstriotrim t magnet; one patient was scanned on a ge twinspeed . t magnet with an equivalent protocol due to orthodontics. a standardized departmental protocol was utilized. mri findings were correlated with age at surgery and years since surgery. mr images were reviewed independently by pediatric radiologists and compared with the dictated report in the patients record. results: patients underwent mri of the abdomen. patients had mri incompatible hardware and patients were not scanned secondary to insurance denial. patients were divided into groups based on elapsed time since surgery: less than years, - years, - years, and greater than years.(table ) mr images were evaluated for the presence of fibrosis, congestion and any other hepatic abnormalities. fibrosis was determined based on a specific pattern of delayed reticular enhancement in combination with liver morphology. congestion was deemed present if there was increased t signal in the liver parenchyma or periportal regions in combination with cloud-like enhancement on dynamic post-contrast images. all patients demonstrated morphologic changes in the liver with varying degrees of hepatic fibrosis and hepatic congestion. fibrotic changes were often non-uniform, and thus could be underdiagnosed by biopsy. interestingly, patients, %, had focal arterially enhancing lesions speculated to represent vascular proliferative lesions, however, none warranted biopsy. conclusions: it is established that patients who undergo fontan develop hepatic abnormalities. mri is a reliable, non invasive technique that accurately demonstrates these findings. mri may be a more sensitive method to evaluate the etiology and full extent of hepatic disease. poster #: sci- complications within the interventional radiology division of a tertiary care children's hospital: initiatives for ongoing quality and practice improvement brian dillon, children's hospital boston, brian. dillon@childrens.harvard.edu; pamela sanborn, yolanda milliman-richard, darren orbach, stephan voss purpose or case report: between and , procedure-related complications occurring within the division of interventional radiology at our institution were recorded and classified according to level of severity. the goals of this study were to determine rates of procedurebased complications based on severity, to establish thresholds for complications, and to determine whether measurable trends in complications over time were evident. methods & materials: between and , , interventional procedures were performed within the division of interventional radiology at our institution. adverse events were characterized both according to level of severity (using an institutional point severity scale), and with brief descriptions of individual events. adverse events were reviewed monthly at the division's morbidity and mortality conference, with respect to procedure type and operator. based on review of our interventional radiology data and benchmarks rates used for diagnostic errors, threshold complication rates were established by consensus between the department quality improvement committee and the division of interventional radiology. for severe events (level and ) there is no allowable threshold; all such events were subjected to both internal and institutional review. results: the overall complication rate was less than % for all procedures performed. the complication rates for the respective severity levels were: level ( . ), level ( . ), level ( . ), level ( . ), and level ( . ). the severity of a given complication was not associated with procedural complexity. no operator-specific trends were identified. conclusions: since , the society of interventional radiology has offered guidelines and strategies for improving safety and quality in interventional radiology. however, no specific benchmark data or procedural recommendations are available for pediatric interventional procedures. our results demonstrate rates of complications well below published overall complication rates for interventional radiologic procedures. this database of procedure-based complications serves as a foundation for a quality improvement program that allows review of complications with respect to specific procedure types, individual operators, and procedural complexity, in an effort to institute an ongoing and continuous process of quality improvement within interventional radiology. purpose or case report: dysosteosclerosis (dss), an extremely rare dense bone disease, features short stature and fractures and sometimes optic atrophy, cranial nerve palsy, developmental delay, and failure of tooth eruption in infancy or early childhood consistent with osteopetrosis (opt). bone histology during childhood shows unresorbed primary spongiosa from deficient osteoclast action. additionally, there is remarkable progressive flattening of all vertebrae mimic ppi blocking mineralization. during ehdp treatment for gaci, in our patient prolonged high dose ehdp resulted in severe skeletal deformity resembling hypophosphatasia which was reversable with drug stoppage. methods & materials: a -year-old boy with gaci referred for profound, acquired, progressive skeletal deformity. he was receiving mg/day of ehdp and was wheelchair bound. we studied him and his response to stopping ehdp. results: skeletal radiographic findings resembled pediatric hypophosphatasia with pancranial synostosis, widened physes with metaphyseal osteosclerosis, "tongues" of radiolucency, along with cupping and fraying, and long-bone bowing. in addition there were large intra and extraarticular calcifications. radiographic features of bp-induced opt included femoral erlenmeyer flask deformity and osteosclerosis (lumbar sine dxa z-score + . ). biochemical parameters of mineral homeostasis were essentially normal although serum osteocalcin was low and he had markedly elevated serum levels of creatine kinase and trap- b consistent with osteopetrosis (opt). after stopping ehdp, he improved quickly with remarkable healing of his rachitic appearing skeleton and decreased joint calcifications. conclusions: our patient with gaci had profound skeletal deformities from high-dose ehdp therapy that significatly improved with drug stoppage. magnetic resonance imaging in the evaluation of infants with hypoxic ischemic encephalopathy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu purpose or case report: to illustrate and review a spectrum of brain abnormalities of infants with hie. defining the most useful approaches and mri sequences, to facilitate identification and early diagnosis of lesions with the potential to predict outcome and abnormal neurodevelopment. methods & materials: reviewed available evidence on mri strategies for evaluating infants with hypoxic ischemic encephalopathy. different cases illustrating lesions are presented and discussed for proper diagnosis correlating physiopathology and imaging appearance. more relevant findings are depicted with didactic illustrations. identifying studies where new techniques such as dwi, adc, dti, swi, or mrs adds significant diagnostic value to the overall interpretation. results: mri is routinely performed as a very sensitive method for detection of hie lesions. advanced mr techniques, such as dti, dwi, adc, mrs, swi offer the possibility of detecting injuries at a time when intervention is theoretically possible. the understanding of the physiopathology allows for prediction of the location and extent of lesions, facilitating identification and appropriate classification. the identification of infants with potentially abnormal neurodevelopment, offers the opportunity to provide therapeutic neurodevelopmental interventions in early childhood. mrs is the best mr biomarker to predict neurodevelopmental outcome in asphyxiated full-term neonates. brain metabolite ratios and regional adc values may vary between mr systems and coils. development of normal values for each institution is required, and support of physicists is mandatory. conclusions: mri continues to evolve as a valuable adjunctive tool routinely obtained in nearly all cases of hie. advanced mri techniques increase sensitivity of conventional t and t -w images and outperform computer tomography and ultrasound for confirming the diagnosis of hypoxic-ischemic brain injury or providing prognostic information for the care of patient with hie. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. posterior fossa abnormalities in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to demonstrate various conditions involving the posterior fossa in children with emphasis on importance of embryologic development of cerebellum in reaching a correct diagnosis. methods & materials: this pictographic presentation displays the imaging features of cases encountered in our clinical practice on . tesla magnetic resonance (mr) imaging. results: with the advent of mr imaging, there has been a revolution in identification and characterization of malformations of the brain this is especially true in posterior fossa, where the sensitivity and specificity of mr imaging with its multidimensional imaging capability are far superior to those of computed tomography (ct) in the detection of subtle morphologic abnormalities. however, there is still a great deal of confusion regarding their classification, terminology, and spectrum of expression and this is where neuroembryology is of great help. this exhibit demonstrates : ) review of embryology and normal anatomy of cerebellum. ) mr appearance of spectrum of conditions involving posterior fossa in children which includes developmental abnormalities (dandy-walker complex, arnold chiari malformations, cerebellar dysplasia/ hypoplasia, joubert's syndrome, etc.), cysts (arachnoid cyst, giant cisterna magna etc.), tumours (medulloblastoma, ependymoma, hemangioblastoma etc.) and miscellaneous conditions. significantly reduces dose ( / of other gadolinium based contrast agents), and doesn't require trigger imaging. conventional mri provides important information regarding the anatomical extent, size, and relation to critical anatomical structures thus when combined with twist, mri provides the best information without use of radiation in children. functional connectivity mri in pediatric brain tumor patients with and without epilepsy andrew v. poliakov, phd, radiology, seattle children's hospital; david bauer, edward novotny, seth d. friedman, dennis shaw, jeff ojemann purpose or case report: functional connectivity mri (fcmri) is a way to evaluate cortical networks across different modalities such as motor, sensory, vision, and the default mode network using functional magnetic resonance imaging. fcmri relies on correlation in fmri image intensity that occurs between functionally connected regions. this effect can be seen in awake as well as anesthetized patients. we evaluated these pathways in pediatric patients with brain tumors. methods & materials: patients were randomly selected from our tumor database. inclusion criteria included age less than , history of brain tumor resection, and complete fcmri data. imaging was performed on a t siemens trio system. functional mri data were acquired as part of a clinical imaging protocol over . - min using a gradient echo, echo-planar sequence. preprocessing of fmri data followed by independent component analysis (ica) was performed using fsl software. functional connectivity analysis was performed using software provided by functional connectomes project, based on afni and fsl software packages. correlation maps were produced by extracting the bold time course from a seed region, computing the correlation coefficient between that time course and the time course from all other brain voxels, correcting for multiple sampling and degrees of freedom and thresholded at a z value of . . results: fourteen patients were included in the study, eight female and six male. tumor types include ganglioglioma ( ), pleomorphic xanthoastrocytoma ( ), juvenile pilocytic astrocytoma ( ), ependymoma ( ), anaplastic astrocytoma ( ), glioblastoma multiforme ( ), and primitive neuroectodermal tumor ( ). seven patients had tumor-associated epilepsy, and seven patients did not. the figure shows connectivity patterns in the motor network in patients without (a) and with (b) epilepsy. in the patients without epilepsy, functional connectivity was often displaced but not decreased or absent. in the patients with epilepsy, we observed decreased or absent functional connectivity. similar results were found for default mode network: connectivity was diminished or absent in the patients affected by epilepsy. conclusions: fcmri is a novel technique that may prove useful for evaluation and presurgical planning by giving us insight into how tumors disrupt function. functional connectivity was often displaced but relatively preserved in the patients without epilepsy. it was disrupted or absent in the patients with epilepsy. poster #: sci- corpus callosum dti measurements in neurofibromatosis type and normal controls nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; amir noor, rhea udyavar, marine bouyssi-kobar, iordanis evangelou, maria t. acosta purpose or case report: many patients with neurofibromatosis type (nf ) have corpus callosum enlargement; pathogenesis and underlying pathophysiology are unclear. the goal of our study is to investigate the pathophysiological basis of corpus callosum enlargement in nf patients through mri diffusion tensor (dti) measurements. methods & materials: retrospective study, irb approved. patients consecutively selected from institutional data base; inclusion criteria: established diagnosis of nf , brain imaging with dti sequence, abnormally high corpus callosum to skull ratio; excluded were patients with complications of nf that could affect size of the corpus callosum. age and gender matched normal controls were randomly selected from the radiology data base. roi were placed manually over the corpus callosum for dti measurements using dti-studio by two independent researchers, one blinded to diagnosis. results: fifteen nf patients and matched controls were analyzed. the corpus callosum to skull ratio was found to be significantly different between the experimental and control group (p . ). for nf patients we found: a trend to lower apparent diffusion coefficient (adc, p . ), significantly higher radial diffusivity (p . ), significantly lower axial diffusivity (p . ), and significantly lower fractional anisotropy (fa, p . ). conclusions: the significantly lower axial diffusivity in nf can indicate that there are more crossing fibers in the corpus callosum of nf patients than in normal controls. further studies using comparative dti tractography may be helpful in further investigating this stipulation. the significant increase in radial diffusivity can be explained by a variety of factors, including thinner myelin sheaths, increased interstitial fluid, smaller axons, or a combination thereof. the trend of lower adc may indicate low axonal diameter, as adc has been shown to more strongly correlate with axonal diameter without the myelin sheath. in future studies we will correlate abnormal corpus callosum dti markers with cognitive functions in nf patients to see if relationships exist that can be used as predictors of cognitive deficits in nf patients. screening for vitamin d deficiency in children with suspected non-accidental fracture conor kain, md, tripler army medical center; veronica rooks, laura keller, jordan pinsker, allyson cordoni, sarah frioux purpose or case report: determine if routine screening of vitamin d levels after suspected non-accidental fracture detects vitamin d deficiency and changes clinical outcomes. methods & materials: after irb approval we reviewed all skeletal surveys performed at tripler army medical center (tamc) in the last years and selected the children who were evaluated for suspected non-accidental fracture. we determined if -hydroxyvitamin d [ (oh)d] level was requested for these patients and characterized the provider's clinical suspicion of vitamin d deficiency as high or low. per the institute of medicine report and endocrine society guidelines we defined vitamin d deficiency as a (oh)d level of less than ng/ml. we calculated the prevalence of children with low (oh)d levels whose providers had low clinical suspicion for vitamin d deficiency. results: skeletal surveys were done at tamc from november to july . were performed after identifying a suspected non-accidental fracture. of these patients children from ages to months had (oh)d levels requested. for children whose providers had a low pre-test suspicion for vitamin d deficiency, the prevalence of vitamin d deficiency was . % ( % binomial ci . - . , of cases. these results indicate that at least one out of every three hundred children evaluated for nonaccidental fracture could have vitamin d deficiency despite a low clinical suspicion by their provider, although the actual rate is likely much higher given that we found one in eight cases. the child we identified with a low vitamin d level whose provider had no suspicion for rickets was treated with ergocalciferol and continued to be evaluated for abuse. conclusions: routine vitamin d level screening after nonaccidental fracture may detect vitamin d deficiency in children for whom there is low clinical suspicion. as our population resides at a low latitude and receives greater than average sun exposure, the rate of deficiency in children with suspected non-accidental fracture may be much greater in other areas. comet tails and dirty shadows: the secrets behind artifacts in pediatric ultrasound adam edelstein, pediatric radiology, massachusetts general hospital; anuradha shenoy-bhangle, katherine nimkin purpose or case report: to review common ultrasonographic artifacts, explain what causes them, and show how they can be used to aid in diagnosis in a variety of pediatric conditions, including less common entities. methods & materials: ultrasonographic images in patients less than years of age were reviewed. cases were selected that showed classic artifacts which helped with the diagnosis of a variety of entities. results: ultrasound artifacts include comet tail, reverberation, ring down and "dirty" shadowing. these can be used to help characterize a variety of pediatric conditions including gossypiboma, bezoar, subcutaneous foreign body, complications of nec, and staghorn calculus. artifacts can also be used to confirm the presence of stool or bowel gas. conclusions: familiarity with ultrasonographic artifacts is critical for tissue characterization and can help narrow the differential diagnosis in difficult pediatric cases. cardiac cta: non-vascular ring tracheobronchial compression secondary to enlarged patent ductus arteriosus in infants with congenital heart disease. nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; todd chapman, randy richardson purpose or case report: tracheobronchial compression or narrowing secondary to a vascular ring has been well documented. the purpose of this study is to describe the frequency of airway compression secondary to an enlarged patent ductus arteriosus detected by ccta without the presence of a vascular ring. methods & materials: a retrospective study of ccta exams in infants was performed over the period between / / and / / . ccta was performed with a -slice mdct, with ekg gating, followed by three-dimensional reformations. results: of the congenital heart disease infant patients, there are patients with tracheobronchial compression or narrowing. of these patients, patients reported to have patent ductus arteriosus as the primary cause of tracheobronchial compression or narrowing. approximately % of patients with airway compression in patients with congenital heart disease are secondary to an enlarged and/or tortuous patent ductus arteriosus. none of these cases were due to a vascular ring. of these patients, , , and patients demonstrated to have mild, moderate, and severe airway compression respectively. conclusions: tracheobronchial compression or narrowing secondary to vascular ring with a patent ductus arteriosus has been well documented. in this study, we demonstrate that a significant percentage of airway compression in patients with congenital heart disease without a vascular ring is due to a tortuous enlarged patent ductus arteriosus. cardiac cta is uniquely equipped to evaluate airway compression due to an enlarged patent ductus arteriosus and can help improve patient care in congenital heart disease patients with respiratory symptomatology. pediatric liver mr elastography: a primer suraj serai, phd, cchmc, suraj.serai@cchmc.org; daniel j. podberesky, alexander j. towbin purpose or case report: a wide variety of pediatric liver disorders may be complicated by the development of liver fibrosis and ultimately cirrhosis. with early interventions, the progression to hepatic fibrosis can be slowed, halted, and in some cases reversed. liver biopsy has long been considered the gold standard for assessing the presence and degree of liver fibrosis. however, liver biopsy has disadvantages, due to its potential sampling error, risk of complications, relatively high cost, intra-and inter-observer variability, and, in general, poor acceptance by pediatric patients and their parents. mr elastography (mre) is a relatively new, non-invasive technique that provides a safe, rapid and cost-effective method for objectively evaluating of a wide variety of hepatic diseases by quantitative stiffness evaluation of the liver-parenchyma. the purpose of this exhibit is to review our clinical experience with this technique and illustrate the application of liver mre in the pediatric population at our medical center. methods & materials: a review of pathogenesis and staging of liver fibrosis in children and current methods available for assessing liver fibrosis will be provided. a review of mre physics and technique, including the specific liver mre protocol used at our institution will be illustrated. we will review widely-used and emerging clinical indications for liver mre, as well as benefits and limitations to the technique, supported by brief literature review. results: in addition to sharing our liver mre technique, we will illustrate clinical case examples from our institution of a variety of liver disorders including non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, storage disorders, cardiac disease, and idiopathic elevated liver enzymes. conclusions: this educational exhibit will review our experience with liver mre, a safe, newly available technique which will play an increasingly important role in the noninvasive evaluation of pediatric liver disease. poster #: sci- spectrum of tuberculosis in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to present a spectrum of tuberculosis (tb) in the human body which commonly involves pulmonary, nervous, musculoskeletal, gastrointestinal and genitourinary systems. this pictographic presentation displays the imaging features of tb cases encountered in our clinical practice with reference to plain x-rays, ct and mri as appropriate. results: with the advent of the newer modalities, the utility of the plain skaigram has been largely limited a initial screening tool only. whereas ct scores over mri in pulmonary tb (parenchymal disease, lymphadenopathy, pleural effusion, empyema, miliary disease) and abdominal tb (spectrum from mesenteric lymphadenitis to visceral involvement), the magnetic resonance (mr) imaging is much better in diagnosing cns tb (tuberculoma, abscess, meningitis, subdural empyema and myelitis). in musculoskeletal and genitourinary tb, ct and mr imaging may be preferred based on the stage of disease and the character of the lesion. cardiac involvement (pericarditis) is among the less common affections of tb. conclusions: tuberculosis is a multisystem disease that can affect virtually any part of the body from head to toe. tb demonstrates a variety of clinical and radiologic findings and has a known propensity for dissemination from its primary site and therefore can mimic numerous other disease entities. hence it is imperative for radiologists to understand the typical disease distribution, patterns and imaging manifestations of tb. janet l. strife, md carol m. rumack md ole a. eklof, md clement c. faure, md andres giedion, md denis lallemand, md arnold lassrich md donald r. kirks, md beverly p. wood, md hooshang taybi md marta hernanz-schulman, md, facr m. ines boechat, md, facr neil d. johnson, mbbs dorothy i. bulas, md *deceased singleton-taybi award investigator award this award is given to the author of the best paper presented by a resident or fellow at the spr meeting md ricardo faingold, md andrea doria, md nina m. menezes, phd anthropometric parameters are a strong determinant of lvm in healthy individuals kiyarash mohajer, pierangelo renella, paul j. finn purpose or case report: despite theoretical advantages of higher field strength ssfp cine imaging, time-resolved magnetic resonance angiography (tr-mra), and high resolution contrast-enhanced mra (ce-mra) were performed. two readers independently evaluated the data for image quality, vessel and cardiac chamber definition, and presence of artifacts. snr and cnr were calculated. results: % of ssfp cine images at t were rated as good or excellent quality with % having mild and % having moderate artifacts (k . ) % of arterial and venous phase ce-mra images were considered good or excellent cardiac chamber definition was considered good or excellent in % of arterial and venous phase ce-mra images (k . ). % ce-mra images showed good or excellent definition of the thoraco-abdominal vessels on average, both readers scored cine ssfp images higher at . t and cemra images higher at . t. overall diagnostic performance was high at both field strengths. conclusions: mri of pediatric patients with chd and vascular abnormalities at . t is feasible. relative to . t, snr and cnr are both improved at higher field strength and higher resolution cemra is achievable t are more prevalent, they rarely render cine imaging non-poster # exclusion criteria were lack of correlating us or follow up information. two pediatric radiologists blinded to us findings reviewed the mr images and analyzed the contents of abdominal wall defect, organ location and attachment; spine anomalies; umbilical cord and limb anomalies. results: our search yielded patients. all fetuses had ventral wall defects, small thorax and eviscerated liver and bowel. in two cases kidneys were in extracorporeal location. in / there was no membrane covering extruded organs. in five mr showed organs attached to the placenta or uterine wall (mainly bowel and liver) mahmoud al-hawary and, by adolescence, paradoxical metaphyseal osteopenia with thin cortical bone. reports of consanguinity indicate autosomal recessive inheritance our studies, spanning ages - mo, showed weight %, but length diminishing from~ % to − . sd. head circumference was + sd. she had frontal bossing, blue sclera, normal teeth, genu valgum, and unremarkable joints. radiographs showed orbital and facial sclerosis, basilar thickening, "bone-in-bone" appearance in the pelvis, sclerotic long bone ends, and fractures of ribs and extremities. progressive metaphyseal widening occurred as vertebrae changed from ovoid to flattened and became beaked anteriorly. consistent with opt, serum pth concentrations reflected dietary calcium levels. serum bone alkaline phosphatase, osteocalcin, and trap b were sub-normal. iliac crest contained excessive primary spongiosa and no osteoclasts. splice sites and exons were intact for the genes encoding cholride channel , t-cell immune regulator , opt-associated transmembrane protein the hallmarks include stippled epiphyses, nasal hypoplasia, and hypoplastic distal phalanges and developmental delay. punctate calcifications are seen not only in the epiphyses but also in the paravertebral regions. paravertebral puncta are commonly associated with defective ossifications in the cervical spine. the malformation of the cervical spine causes spinal canal stenosis and instability, which occasionally necessitate surgical intervention none of the cases had brain infarction. conclusions: tortuousity and luminal narrowing of the cervical arteries is a common finding in cdp-bt. this previously unknown malformation is an important factor to discriminate patients at increased risk of cerebral ischemia, particularly in patients undergoing surgical intervention. disclosure: dr. okabe has indicated that she will discuss or describe severe skeletal toxicity from protracted etidronate therapy for generalized arterial calcification of infancy william h. mcalister, md, mallinckrodt institute of radiology campbell sheen purpose or case report: generalized arterial calcification of infancy (gaci) is an autosomal recessive disorder caused by deactivating mutations within the gene for ectonucleotide pyrophosphatase phosphodiesterase- (enpp ). enpp on osteoblasts, chondrocytes, and vascular smooth muscle cells hydrolyzes nucleotide triphosphates to nucleotide monophosphates and inorganic pyrophosphate (ppi) can time-resolved contrast-enhanced mra (twist) classify soft tissue vascular anomalies in the head and neck in children accurately? aylin tekes, md children from - years of age were enrolled. twist and conventional mri was performed (triplanar t -weighted [t -w] imaging with fat saturation, pre-contrast axial t -weighted [t -w] imaging, and post contrast triplanar fat-suppressed t -w imaging). twist was performed in coronal plane using blood-pool mr contrast agent (ablavar-lantheus) to enhance image quality and spatial resolution of mra. two pediatric neuroradiologists evaluated all patients in two different sessions, days apart: one session conventional mri with contrast was evaluated, in the second session twist was evaluated. clinical evaluation and/or percutaneous venogram/lymphogram data were the gold standard. results: our patients had diagnosis of infantile hemangioma (n ), venous malformation (n ), and lymphatic malformation (n ). twist alone could accurately classify / , conventional mri with contrast could accurately classify / . conventional mri with contrast combined with twist could accurately classify all cases. conclusions: twist offers high temporal resolution in the order of seconds, and provides functional data about the dynamics of contrast enhancement comprising the arterial, venous and delayed venous phases kiery cr- , sci- edu- , edu- edu- , edu- , pa- edu- , pa- a- , pa- , pa- , pa- , pa- edu- , edu- , edu- , edu- , edu- , edu- , edu- edu- , edu- , edu- , edu- , edu- , edu- suraj sci- , pa- , pa- edu- pa- , edu- , pa- the society for pediatric radiology gratefully acknowledges the support of the following companies in presenting the th annual meeting and postgraduate course: cme committee reviewers for this activity have disclosed any relevant financial relationships. no conflicts of interest exist.abuse and offer potential mechanisms of injury may help make the diagnosis of child abuse. the pediatric elbow-mri findings with multimodality correlation michael guandalini, md, royal children's hospital; murray bartlett purpose or case report: to describe and illustrate elbow abnormalities identified by mri performed in a cohort of pediatric patients with multimodality correlation. methods & materials: retrospective review of mri elbow studies performed at the royal children's hospital, melbourne between and . the studies were reviewed by a pediatric musculoskeletal radiologist and pediatric radiology fellow with patient demographics, clinical indication, findings and selected images recorded. results: elbow mri examinations were reviewed on children aged months to years ( boys, girls) with equal numbers of left and right sides examined. clinical indications included previous trauma in cases ( %) and nontraumatic conditions in ( %). the most common traumatic indication was suspected or confirmed fractures or avulsions ( %) followed by osteochondral or cartilage injuries ( %), growth arrest ( %), loose bodies ( %) and ligament injuries ( %). hemophilia ( %) was the most frequent nontraumatic indication followed by neoplasm ( %). mild to severe arthropathy, fractures, physeal growth arrest, subluxations, osteochondral lesions and loose bodies were the most frequently demonstrated abnormalities. ligament strains and tears, bone oedema, neuromuscular abnormalities, infections and several neoplasms including lipomas, vascular/lymphatic malformations and bone tumors also featured. conclusions: this pictorial review illustrates the broad range of abnormalities one might expect to encounter on pediatric elbow mri studies, highlighting the major features and corresponding appearances on ct and plain x-ray. spectrum of patellar tendon avulsive injury on mri in children: differentiation between acute and chronic avulsive injuries of the inferior patellar pole and tibial tuberosity zeyad metwalli, md, baylor college of medicine, metwalli@ bcm.edu; herman kan, scott rosenfeld, r. p. guillerman purpose or case report: the extensor mechanism of the knee is an intricate component of the joint and is frequently injured in pediatric athletes. due to the strength of the patella tendon, trauma to the anterior knee is often manifested by avulsive injuries, which may occur on an acute or chronic repetitive basis. purpose: this pictorial review will illustrate differentiating radiographic and mri features of acute and chronic avulsive injuries of the pediatric knee. outline: . anatomy and physiology a. discuss the anatomic differences of the pediatric and adult knee extensor mechanism b. pathophysiology and biomechanical basis for chondro-osseous avulsion injuries versus tendon tears in the skeletally immature. purpose or case report: the purpose of this educational exhibit is to demonstrate the magnetic resonance imaging (mri) appearance of the ankle and hindfoot ligaments using an interactive approach. methods & materials: a tesla siemens mri scanner with a multichannel ankle coil was utilized in the acquisition of images of ankle and hindfoot. three dimensional volume acquisition proton density images will be used to demonstrate the ligamentous anatomy of the ankle and hindfoot in axial, axial oblique, coronal, and sagittal planes. results: the exhibit will begin with an interactive review of the ankle and hindfoot ligamentous anatomy with each ligament poster #: edu- cns imaging findings in hemophagocytic lymphohistiocytic syndrome rupa radhakrishnan, mbbs, md, dnb, radiology, university of cincinnati college of medicine, radhakrp@ucmail. uc.edu; marcia k. kukreja, alexandra filipovich, alexander j. towbin purpose or case report: hemophagocytic lymphohistiocytosis (hlh) is a rare, life threatening condition caused by an uncontrolled proliferation of activated lymphocytes and histiocytes with high levels of inflammatory cytokines. the organs most commonly involved in this disorder include the liver, spleen, lymph nodes, bone marrow and central nervous system (cns). the purpose of this exhibit is to review the cns imaging findings associated with hlh, its complications, and its management. the published literature was reviewed to identify the potential imaging findings hlh. the electronic medical record system was then searched to find illustrative case examples from our institution. cases demonstrating the primary imaging findings as well cases highlighting complications of the disease or its therapy were selected. results: cns involvement is common in hlh with approximately % of patients demonstrating neurological symptoms. ct findings of cns involvement include diffuse parenchymal atrophy, low attenuation lesions in the white matter and calcifications. mr findings include diffuse leptomeningeal and perivascular enhancement, t hyperintense lesions with nodular or rim enhancement as well as confluent white matter lesions, and diffuse parenchymal volume loss of the cerebrum and cerebellum. restricted diffusion has been demonstrated in some lesions. ring enhancing parenchymal lesions have been described representing active demyelination. intracranial hemorrhage may occur as a result of thrombocytopenia and coagulation abnormalities. sepsis with opportunistic organisms can involve the cns and produce intracranial findings such as parenchymal abscesses. cns changes, such as posterior reversible encephalopathy syndrome, are also seen with the commonly used immunomodulatory regimen used in the treatment of hlh. conclusions: this exhibit will aid the viewer in identifying the cns imaging findings of hlh as well as the complications of the disease and its therapy. while the cns imaging findings are not specific, they may help the radiologist formulate a diagnosis in association with the other clinical and imaging findings; furthermore, imaging can help the clinical team in managing the disease and its complications. methods & materials: medical records of our pediatric patients with palpable head masses over the last years, were reviewed and images were collected. correlation of us of these lesions with other imaging modalities and/or pathologic diagnosis was done. results: us appearances of various head masses including congenital/developmental (encephalocele, meningocele, dermoid, occipital protuberance), traumatic (cephalhematoma, subgaleal hematoma, calvarial fracture), inflammatory/infectious (sebaceous cyst, histiocytosis, dermatitis), vascular (malformations, pseudoaneurysm) and neoplastic (benign and malignant lesions including metastases) etiologies, will be illustrated with case based approach. mri and/or ct or tissue diagnosis can be problem solving. role of ultrasound guidance for percutaneous procedures (biopsy, sclerotherapy) will also be described. conclusions: ultrasound can play an important role in the delineation, diagnosis and guiding further management of pediatric palpable head masses. us can differentiate various scalp lesions and suggest the underlying calvarial defect or involvement to some extent, helping to narrow the differential diagnosis for such lesions. color doppler us can be useful to detect vascularity within the lesion or vascular lesions. given that us is often requested for the evaluation of palpable head masses, pediatric radiologists should be familiar with their sonographic features. posterior fossa malformations-a pictorial review rui santos, md, bc children's hospital, ruiradiologia@gmail. com; khalid khashoggi, angela t. byrne purpose or case report: posterior fossa malformations are a group of central nervous system anomalies that may be detected during pregnancy or present early infancy with features that include hypotonia, developmental delay, mutations responsible for the disease and proposals as to mechanism of action of the mutation with respect to disease manifestations. this preceded the development of hypotheses regarding the relationship between genotype and phenotype and the attempt to utilize imaging modalities that could better assess disease activity as it related to functional status. the purpose of this exhibit is to briefly review the history pre- and to focus on the numerous ways in which the understanding has improved since that time. conclusions: . there are over different mutations of the cftr gene responsible for cystic fibrosis with varying prevalence throughout the world. . the class of mutation often dictates its particular mechanism of action. . there is some relationship between genotype and phenotype-particularly with respect to pancreatic involvement. . newer imaging modalities including ct and mri with or without hyperpolarized helium are better predictors of disease severity than is plain film. imaging pulmonary tuberculosis in infants: what are the most useful diagnostic radiological findings? handan cakmakci, pediatric radiology, dokuz eylul university hospital, handancakmakci@gmail.com; nevin uzuner, filiz tetik purpose or case report: early diagnosis and treatment are very important for infants with tuberculosis. infantile pulmonary tuberculosis is more symptomatic, and the risk of severe and life-threatening complications such as tuberculous meningitis or miliary tuberculosis is higher. bacteriologic confirmation of the disease in children is difficult and in younger infants (< months), the tuberculin skin test is frequently negative. therefore, radiological findings play important role in diagnosing tuberculosis in infants. the purposes of this study are to identify chest x-ray and lung ct findings in pulmonary tuberculosis of infants and consider the most useful diagnostic findings of these age group patients.methods & materials: chest radiographs and chest ct images of infants who were diagnosed in our hospital from to were retrospectively reviewed. the study group included boys and girls ranging in age from to months (mean age, months). chest x-ray and computed tomography images were analyzed considering air space consolidation, nodular lesions, cavitating lesions, mediastinal enlargement, hyperinflation, bronchial narrowing, atelectasis pleural effusion on plain radiography and additional mediastinal calcific or caseating lymph nodes on ct images.results: air space consolidation was seen on out of chest x-ray and computed tomography images. nodular lesions were seen out of chest x-ray and computed tomography images. cavitating lesion was seen on out of chest x-ray and computed tomography images. mediastinal enlargement suggesting lymph node was seen out of chest x-ray and computed tomography images. hyperinflation, bronchial narrowing was seen out of chest x-ray and computed tomography images. atelectasis, pleural effusion was seen out of chest x-ray and out of computed tomography images. mediastinal caseating lymph nodes, mediastinal calcific lymph nodes were seen out of computed tomography images. conclusions: frequent and the most useful diagnostic radiological findings of pulmonary tuberculosis in infants are mediastinal or hilar lymphadenopathy with central necrosis and air space consolidations. disseminated nodules including miliary lesions and airway complications are also detected in this age group. ct can show detailed parenchymal lesions and tuberculous lymphnodes especially calcified ones. the ductus bump: radiographic findings of this normal variant and differential diagnoses anusuya mokashi, staten island university hospital, anusuya.mokashi@gmail.com; jeremy neuman, cheryl lin purpose or case report: the ductus bump: review of radiographic findings, differential diagnoses and current controversies. the ductus bump was first described in by berdon et al as a transient physiologic mass in the chest in newborn infants. some controversy remains as to the exact etiology and clinical significance. although initially thought to represent a dilated ductus arteriosus, recently it has been suggested that it actually represents a ductus arteriosus aneurysm that spontaneously resolves. others contend it represents dilation of the infundibulum of the closing ductus. regardless of etiology, the time of discovery, location, and rapid resolution are characteristic of this entity. in this presentation we will review the radiographic and echocardiogram findings of the ductus bump, as well as discuss the differential diagnosis. the frontal radiographic findings are a round mass to the left of the vertebral spine projecting from the mediastinum near the aortic arch. this mass does not indent the esophagus and it cannot be seen on the lateral view. it is classically said to resolve within the first few days of life. the controversy regarding the etiology has also led to some disagreement involving the clinical significance and appropriate follow up, which will also be discussed. after reviewing this educational poster, the reader will have conclusions: abnormalities of the posterior fossa are often difficult to differentiate solely on the basis of their radiologic appearances alone. however, an accurate diagnosis is essential for proper treatment planning and genetic counselling. therefore it is imperative for radiologists to be well versed with the normal anatomy and development of cerebellum so as to correctly diagnose the various posterior fossa abnormalities.poster #: sci- imaging of oculoauriculofrontonasal syndrome with low-dose -dimensional computed tomography paritosh c. khanna, md, radiology, seattle children's hospital, pkhanna@uw.edu; kelly evans, gisele ishak, joseph gruss, michael cunningham, anne hing purpose or case report: oculoauriculofrontonasal syndrome (oafns) combines elements of abnormal morphology of the frontonasal and maxillary processes of the face. the aim of our exhibit is to demonstrate the low-dose computed tomography (ct) features of this syndrome, in seven patients who have been followed at seattle children's hospital (sch) over years. we underscore the imaging features of this condition, and describe additional features including bony nasal abnormalities not previously described in the literature, to improve imaging recognition of this spectrum. we present d ct imaging features of a series of eight patients with oafns. in keeping with the alara (as low as reasonably achievable) concept and the image gently recommendations (www.imagegently. org), ct head and face studies were obtained on six of eight patients at sch, while two had prior exams at outside institutions. using a -slice multidetector ct scanner (ge lightspeed vct, waukesha wi), low-dose ct ( kv, mas or lower depending on age) of the head and face was obtained. planar bone window and d surface rendered images were analyzed. results: our series of patients demonstrated bifid nasal bones, uni-or bilateral mandibular hypoplasia, temporomandibular and zygomatic dysplasia and bony external auditory canal abnormalities. one patient had an interfrontal bone with a frontal bony defect that was contiguous with the metopic suture. we describe additional previously unidentified ct anomalies of the nasal bones, anterior nasal spine and nasal septum. these structures are involved in all patients who had ct imaging available, although unique features are present in each case. conclusions: ct is the mainstay of imaging of craniofacial anomalies in the post-natal period, both pre-and postoperatively. in addition to our low-dose ct imaging findings of oafns, novel nasal bone anomalies identified by our group serve to identify a new subset of patients with this syndrome and may help refine the phenotype of the oafns spectrum.