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Background Previous studies suggest that use of artificial intelligence (AI) algorithms as diagnostic aids may improve the quality of skeletal age assessment, though these studies lack evidence from clinical practice. Purpose To compare the accuracy and interpretation time of skeletal age assessment on hand radiograph examinations with and without the use of an AI algorithm as a diagnostic aid. Materials and Methods In this prospective randomized controlled trial, the accuracy of skeletal age assessment on hand radiograph examinations was performed with (

Osteosarcoma is the most common pediatric malignant bone tumor, frequently surgically managed with limb salvage rather than amputation. Local recurrences are seen in up to 9% of osteosarcoma patients, with CT and MRI imaging often limited by metal artifacts. To describe the [F-18]2-fluoro-2-deoxyglucose (FDG) PET/CT appearance of local osteosarcoma recurrences with correlation to findings on other imaging modalities. A retrospective review of pediatric osteosarcoma patients imaged with FDG PET/CT was performed in patients with pathologically proven local recurrences. FDG PET/CT findings were reviewed and correlated with available comparison imaging studies. Ten local osteosarcoma recurrences in eight pediatric osteosarcoma patients were imaged with FDG PET/CT. All eight patients had a local recurrence after limb salvage; two patients had a second local recurrence after amputation. All local recurrences were seen with FDG PET/CT, demonstrating solid (n=5) or peripheral/nodular (n=5) FDG uptake patterns. Maximum standard uptake values (SUVs) ranged from 3.0 to 15.7. In five recurrences imaged with FDG PET/CT and MRI, MRI was limited or nondiagnostic in three. In four recurrences imaged with FDG PET/CT and bone scan, the bone scan was negative in three. Local osteosarcoma recurrences are well visualized by FDG PET/CT, demonstrating either solid or peripheral/nodular FDG uptake with a wide range of maximum SUVs. FDG PET/CT demonstrates the full extent of local recurrences, while MRI can be limited by artifact from metallic hardware. PET/CT appears to be more sensitive than bone scan in detecting local osteosarcoma recurrences.

Because of the widening gap between need for child mental health services and availability of child specialists, secure videoconferencing options are more needed than ever to address access challenges across underserved settings. This article reviews real-time videoconferencing evidence across telemental health with children and adolescents. It summarizes emerging guidelines that inform best practices for child telemental health using videoconferencing. It presents a case example of best practices across behavioral health specialties. Videoconferencing is an effective approach to improving access to behavioral health interventions for children and adolescents. Telemental health shows promise for disseminating evidence-based treatments to underserved communities.

Metal endoprostheses and internal fixation devices cause significant artifacts on CT after limb salvage surgery; positron emission tomography (PET) images should be evaluated for artifacts. (1) To describe [F-18]2-fluoro-2-deoxyglucose (FDG) PET uptake patterns after limb salvage surgery. (2) To determine whether metal endoprostheses and fixation hardware cause significant artifacts on CT attenuation-corrected PET that interfere with diagnostic use of PET/CT after limb salvage surgery. We reviewed 92 studies from 18 patients ages 5–21 years. Diagnoses were osteogenic sarcoma in 14, Ewing sarcoma in 3, and malignant peripheral nerve sheath tumor originating in bone in 1. Nine patients had distal femur/knee endoprostheses, five had lower-extremity bone allografts secured by large metal plates and four had upper-extremity limb salvage procedures. Maximum standardized uptake value was calculated at lower-extremity soft-tissue–endoprosthesis interfaces. In 15 patients with PET/CT imaging, the first PET/CT scan after limb salvage surgery was reviewed for metal artifacts on CT images and for artifacts at locations on PET corresponding to the CT metal artifacts. Increased FDG uptake was consistently present at soft-tissue interfaces with endoprostheses, allografts and internal fixation devices, with little or no FDG uptake at cemented endoprosthesis–bone interfaces. Maximum standardized uptake value at margins of femur/knee endoprostheses ranged from 1.4 to 5.7. In four patients with distal femur/knee endoprostheses, minimal artifact was noted on attenuation-corrected PET images, but image interpretation was not affected. In the other 11 patients who had CT attenuation correction, we detected no artifacts caused by the attenuation correction. CT attenuation correction did not cause artifacts that affected interpretation of attenuation-corrected PET images.

Granulocyte colony-stimulating factors (G-CSF) speed recovery from chemotherapy-induced myelosuppression but the marrow stimulation they cause can interfere with interpretation of F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG PET) exams. To assess the frequency of interfering G-CSF-induced bone marrow activity on FDG PET imaging in children and young adults with Ewing sarcoma and rhabdomyosarcoma and to define an interval between G-CSF administration and FDG PET imaging that limits marrow interference. Blinded, retrospective review of FDG PET exams performed in patients treated with long-acting G-CSF as part of their chemotherapeutic regimen. Exams were subjectively scored by two reviewers (R1 and R2) who assessed the level of marrow uptake of FDG and measured standardized uptake values in the marrow, liver, spleen and blood pool. FDG PET findings were correlated with time since G-CSF administration and with blood cell counts. Thirty-eight FDG PET exams performed in 17 patients were reviewed with 47.4% (18/38) of exams having marrow uptake of FDG sufficient to interfere with image interpretation. Primary predictors of marrow uptake of FDG were patient age (P = 0.0037) and time since G-CSF exposure (P = 0.0028 for subjective marrow uptake of FDG, P = 0.008 [R1] and P = 0.004 [R2] for measured maximum standardized uptake value (SUVmax)). The median interval between G-CSF administration and PET imaging in cases with marrow activity considered normal or not likely to interfere was 19.5 days (range: 7–55 days). In pediatric and young adult patients with Ewing sarcoma and rhabdomyosarcoma, an interval of 20 days between administration of the long-acting form of G-CSF and FDG PET imaging should limit interference by stimulated marrow.

Advances made in genetic testing and tools applied to pharmacogenetics are increasingly being used to inform clinicians in fields such as oncology, hematology, diabetes (endocrinology), cardiology and expanding into psychiatry by examining the influences of genetics on drug efficacy and metabolism. We present a clinical case example of an adolescent male with anxiety, attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder who did not tolerate numerous medications and dosages over several years in attempts to manage his symptoms. Pharmacogenetics testing was performed and DNA results on this individual elucidated the potential pitfalls in medication use because of specific pharmacodynamic and pharmacokinetic differences specifically involving polymorphisms of genes in the cytochrome p450 enzyme system. Future studies and reports are needed to further illustrate and determine the type of individualized medicine approach required to treat individuals based on their specific gene patterns. Growing evidence supports this biological approach for standard of care in psychiatry.

The association of trauma exposure and coping style to sexual risk behavior has yet to be fully examined in the context of primary and casual sexual partnerships. The current study assessed a high risk sexual behavior-unprotected anal intercourse (UAI)-in a high risk population of HIV-positive men who have sex with men (MSM) with a history of trauma. Using audio computer-assisted self-interview technology, 132 HIV-positive MSM completed measures of trauma exposure, trauma symptoms, coping strategies, and sexual risk behavior. Hierarchical logistic regression analyses indicated that completing more years of education and having experienced sexual abuse were positively associated with UAI with casual partners. Additionally, use of active coping was negatively associated with UAI with casual partners and the final model significantly predicted variance in UAI with casual partners. However, no variables were significantly associated with UAI with primary partners, suggesting that sexual risk behavior with primary partners may be associated with factors not commonly assessed in risk prediction or prevention research. We discuss the results in the context of developing new or modifying existing interventions to address rates of sexual risk in the relationships of HIV-positive MSM.

Altered FDG uptake patterns were noted in certain lymphoblastic lymphoma patients during therapy. To describe these altered FDG uptake patterns and their relationship to chemotherapy. Thirty-five FDG PET or PET/CT scans obtained in 11 children with lymphoblastic lymphoma were retrospectively reviewed. FDG uptake patterns were recorded. SUV measurements were performed in liver and facial soft tissues. Results were correlated with induction chemotherapy regimens. Six of the children had transiently altered FDG uptake with increased uptake in the superficial soft tissues, most notably involving the face. Altered uptake was noted approximately 1 month after initiation of chemotherapy and subsequently resolved. Hepatic uptake was transiently reduced on the 1-month scan in all six children with increased facial uptake. No significant FDG uptake in lymphoma was seen on five of six scans with altered uptake; however, two of these five affected children had FDG uptake in lymphoma on the next follow-up examination. Blood glucose levels in the affected children were in the normal range. All six children with altered FDG uptake received the same induction chemotherapy regimen, which included very high doses of corticosteroids. Children with lymphoblastic lymphoma on induction chemotherapy protocols including very high doses of corticosteroids transiently demonstrated altered FDG uptake patterns, including increased superficial facial uptake and reduced hepatic uptake. The facial uptake is probably the FDG PET equivalent of Cushingoid facies. Caution in interpreting scans with this altered FDG uptake pattern is suggested, as uptake at sites of lymphomatous involvement may potentially be affected.

The purpose of this analysis was to evaluate the utility of FDG PET/CT scanning in patients with Wilms' tumors.A total of 58 scans were performed in 27 patients (14 male, 13 female; ages: 1.9-23 years, median: 7 years) with proven Wilms' tumor. Twenty-six patients (56 scans) were studied at the time of suspected relapse, progressive disease, persistent disease, or for monitoring of therapy.In the 27 patients with Wilms' tumor, 34 scans showed areas of abnormal uptake consistent with metabolically active tumors. Of the patients, 8 (24 scans) had pulmonary metastases larger than 10 mm in diameter, 10 (12 scans) had hepatic metastases, 11 (11 scans) had regional nodal involvement, 3 (3 scans) had bone metastases, 1 (1 scan) had chest wall involvement, 2 (2 scans) had pancreatic metastasis, and 5 (5 scans) had abdominal and pelvic soft tissue involvement. Two of eight patients with lung metastases had variable uptakes. Lung lesions 10 mm or smaller were not consistently visualized on PET scans. One patient with a liver metastasis showed no uptake on PET scan after treatment (size decreased from 45 to 15 mm).Most Wilms' tumors concentrate FDG. However, small pulmonary metastases may be better visualized with CT. FDG PET/CT appears useful for defining the extent of involvement and assessing the response to treatment.

Background: Exposure-based therapy for anxiety disorders is believed to operate on the basis of fear extinction. Studies have shown acute administration of D-cycloserine (DCS) enhances fear extinction in animals and facilitates exposure therapy in humans, but the neural mechanisms are not completely understood. To date, no study has examined neural effects of acute DCS in anxiety-disordered populations.Methods: Two hours prior to functional magnetic resonance imaging scanning, 23 spider-phobic and 23 non-phobic participants were randomized to receive DCS 100 mg or placebo. During scanning, participants viewed spider, butterfly, and Gaussian-blurred baseline images in a block-design paradigm. Diagnostic and treatment groups were compared regarding differential activations to spider versus butterfly stimuli.Results: In the phobic group, DCS enhanced prefrontal (PFC), dorsal anterior cingulate (ACC), and insula activations. For controls, DCS enhanced ventral ACC and caudate activations. There was a positive correlation between lateral PFC and amygdala activation for the placebo-phobic group. Reported distress during symptom provocation was correlated with amygdala activation in the placebo-phobic group and orbitofrontal cortex activation in the DCS-phobic group.Conclusions: Results suggest that during initial phobic symptom provocation DCS enhances activation in regions involved in cognitive control and interoceptive integration, including the PFC, ACC, and insular cortices for phobic participants.

Society for Pediatric Radiology, Research and Education Foundation (Dorst-Fleischer Grant) OBJECTIVE. the purpose of this article is to assess the feasibility and utility of PET/CT in distinguishing benign from malignant pulmonary nodules in patients with solid childhood malignancies.SUBJECTS and METHODS. This prospective study was conducted between March 2008 and August 2010. We enrolled 25 subjects 21 years old or younger with solid childhood malignancies and at least one pulmonary nodule measuring 0.5-3.0 cm. PET/CT was performed within 3 weeks of diagnostic chest CT. Three panels of three reviewers each reviewed diagnostic CT only (panel 1), PET/CT only (panel 2), or diagnostic CT and PET/CT concurrently (panel 3) and predicted each nodule's histologic diagnosis as benign, malignant, or indeterminate. Interreviewer agreement was assessed with the kappa statistic. Using nodule biopsy or clinical follow-up as reference standards, the sensitivity, specificity, and accuracy for each panel was assessed. Logistic regression was used to assess the nodule's maximum standardized uptake value (SUVmax) association with its histologic diagnosis.RESULTS. There were 75 nodules with a median size of 0.74 cm (range, 0.18-2.38 cm); 48 nodules were malignant. Sensitivity was 85% (41/48) for panel 1, 60% (29/48) for panel 2, and 67% (32/48) for panel 3. All panels had poor specificities. Interreviewer agreement was moderate for panel 1 (0.43) and poor for panels 2 (0.22) and 3 (0.33). SUVmax was a significant predictor of histologic diagnosis (p = 0.004).CONCLUSION. PET/CT assessment of pulmonary nodules is feasible in children with solid malignancies but may not reliably improve our ability to predict a nodule's histologic diagnosis. the SUVmax may improve the performance of PET/CT in this setting. St Jude Childrens Res Hosp, Div Diagnost Imaging, Memphis, TN 38105 USA St Jude Childrens Res Hosp, Dept Biostat, Memphis, TN 38105 USA Cincinnati Childrens Hosp Med Ctr, Dept Radiol, Cincinnati, OH 45229 USA British Columbia Childrens Hosp, Dept Radiol, Vancouver, BC V6H 3V4, Canada Hosp Sick Children, Dept Radiol, Toronto, ON M5G 1X8, Canada Universidade Federal de São Paulo, Paulista Sch Med, GRAACC, Pediat Oncol Inst, São Paulo, Brazil St Louis Childrens Hosp, Dept Radiol, St Louis, MO 63178 USA St Jude Childrens Res Hosp, Dept Surg, Memphis, TN 38105 USA St Jude Childrens Res Hosp, Dept Oncol, Memphis, TN 38105 USA Universidade Federal de São Paulo, Paulista Sch Med, GRAACC, Pediat Oncol Inst, São Paulo, Brazil Web of Science

In Langerhans cell histiocytosis (LCH), FDG PET demonstrates active disease in bone. Other imaging modalities show the effects of bone destruction by LCH.To evaluate a selective CT method for reducing effective dose from FDG PET/CT in LCH, using whole-body modified attenuation correction CT at extremely low exposure settings, with repeat selective limited-volume CT at typical localization settings.Fifty-one PET/CT scans were performed in 23 LCH patients, median patient age 8.5 years (range: 1-25 years). Thirty-four were performed with modified attenuation correction CT settings, with bed positions (excluding head and neck) repeated at localization CT settings in regions with abnormal or difficult to interpret PET findings.Of 34 modified attenuation correction PET/CT scans, 10 required repeat localization CT of 1 to 3 bed positions (total: 17 bed positions). Lytic bone lesions were easily recognized at modified attenuation correction settings. Calculated average effective dose for the 34 whole-body CT scans at modified attenuation correction settings was 1.65 mSv. Average effective dose per patient for repeat imaging of 17 bed positions at localization settings was 1.19 mSv. Average total effective dose from CT for all 34 scans performed at the modified attenuation correction CT settings, including the 10 repeat localization CT scans, was 2.0 mSv. High-quality PET scans were consistently obtained with reduced FDG-administered activities of 3.7 MBq/kg (0.10 mCi/kg). In active LCH, abnormal FDG uptake was seen in all lytic bone lesions ≥9 mm, including cranial vault lesions.Substantial reduction in effective dose is possible using selective CT techniques for FDG PET/CT.

SPECT/CT improves localization of single photon-emitting radiopharmaceuticals. To determine the utility of SPECT/CT in children with papillary thyroid carcinoma. 20 SPECT/CT and planar studies were reviewed in 13 children with papillary thyroid carcinoma after total thyroidectomy. Seven studies used I-123 and 13 used I-131, after elevating TSH by T4 deprivation or intramuscular thyrotropin alfa. Eight children had one study and five children had two to four studies. Studies were performed at initial post-total thyroidectomy evaluation, follow-up and after I-131 treatment doses. SPECT/CT was performed with a diagnostic-quality CT unit in 13 studies and a localization-only CT unit in 7. Stimulated thyroglobulin was measured (except in 2 cases with anti-thyroglobulin antibodies). In 13 studies, neck activity was present but poorly localized on planar imaging; all foci of uptake were precisely localized by SPECT/CT. Two additional foci of neck uptake were found on SPECT/CT. SPECT/CT differentiated high neck uptake from facial activity. In six studies (four children), neck uptake was identified as benign by SPECT/CT (three thyroglossal duct remnants, one skin contamination, two by precise anatomical CT localization). In two children, SPECT/CT supported a decision not to treat with I-131. When SPECT/CT was unable to identify focal uptake as benign, stimulated thyroglobulin measurements were valuable. In three of 13 studies with neck uptake, SPECT/CT provided no useful additional information. SPECT/CT precisely localizes neck iodine uptake. In small numbers of patients, treatment is affected. SPECT/CT should be used when available in thyroid carcinoma patients.

The purpose of this study was to compare the diagnostic utility of (123)I-metaiodobenzylguanidine ((123)I-MIBG) scintigraphy and (18)F-FDG PET in neuroblastoma.A total of 113 paired (123)I-MIBG and (18)F-FDG PET scans in 60 patients with neuroblastoma were retrospectively reviewed. Paired scans were acquired within 14 days of each other.For stage 1 and 2 neuroblastoma (13 scans, 10 patients), (18)F-FDG depicted more extensive primary or residual neuroblastoma in 9 of 13 scans. (123)I-MIBG and (18)F-FDG showed equal numbers of lesions in 1 of 13 scans, and 3 of 13 scan results were normal. For stage 3 neuroblastoma (15 scans, 10 patients), (123)I-MIBG depicted more extensive primary neuroblastoma or local or regional metastases in 5 of 15 scans. (18)F-FDG depicted more extensive primary neuroblastoma or local or regional metastases in 4 of 15 scans. (123)I-MIBG and (18)F-FDG were equal in 2 of 15 scans, and 4 of 15 scan results were normal. For stage 4 neuroblastoma (85 scans, 40 patients), (123)I-MIBG depicted more neuroblastoma sites in 44 of 85 scans. (18)F-FDG depicted more neuroblastoma sites in 11 of 85 scans. (123)I-MIBG and (18)F-FDG were equivalent or complementary in 13 of 85 scans, and 17 of 85 scan results were normal.(18)F-FDG is superior in depicting stage 1 and 2 neuroblastoma, although (123)I-MIBG may be needed to exclude higher-stage disease. (18)F-FDG also provides important information for patients with tumors that weakly accumulate (123)I-MIBG and at major decision points during therapy (i.e., before stem cell transplantation or before surgery). (18)F-FDG can also better delineate disease extent in the chest, abdomen, and pelvis. (123)I-MIBG is overall superior in the evaluation of stage 4 neuroblastoma, especially during initial chemotherapy, primarily because of the better detection of bone or marrow metastases.

Background: For quality assurance reasons, it is important to monitor the services provided over time for infants and their families through both hospital and community-based early hearing detection and intervention programs (EHDIPs) and to compare results for local programs to national benchmarks. This two-part study is an update to earlier reports published for a particular EHDIP. Purpose: To evaluate a maturing, diverse community-based EHDIP partially managed through a private practice in Santa Barbara, California, and to compare results to earlier reports for this program and to national data. Research Design: A parent questionnaire and a retrospective case-report chart review process was used. Study Sample: Charts were reviewed for 150 babies that were referred to the practice from two hospitals and were seen for screenings and follow-up. Also, parents of 34 infants seen beyond their initial or secondary screenings were surveyed about their experiences with and impressions of the program. Data Collection And Analysis: Babies seen by the practice between May 2003 and November 2006 were tracked across five levels (from hospital screening through intervention) to determine if parents complied with professionals' recommendations, time taken to comply, and highest level reached and whether it was an appropriate termination point. Also, parents' responses to an 11-item questionnaire assessing their impressions about their participation in the program were analyzed and compared to the compliance data. Results: Of the 150 babies, 116 passed initial or secondary screenings; compliance details at the subsequent levels of follow-up are provided for the remaining 34 infants. Seven of the 34 families completed the questionnaire. Compliance at early levels was excellent, meeting EHDIP benchmarks and previous results for this program; that for subsequent levels was poorer, possibly due to the diverse population. Parents' impressions of this program ranged from neutral to generally positive. Conclusions: This maturing EHDIP generally met national benchmarks and continued to serve the infants and families well. However, parents' compliance with physician visits and audiologic follow-up for habilitation including hearing aids in a timely manner could still be improved.