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The purpose of this study is to determine the normal ranges of radioulnar (i.e. medial-lateral) finger deviations during growth. We retrospectively measured radioulnar interphalangeal joint angles in 6236 properly aligned thumbs and fingers in trauma radiographs of 4720 patients aged 0 to 19 years. The mean interphalangeal joint angle of the thumb was 0.2° (standard deviation 1.5°). The average proximal interphalangeal joint angles were ulnar deviation of 2.5° (1.7°) for the index, ulnar deviation 1.7° (1.5°) for the middle, radial deviation 1.3° (1.8°) for the ring, radial deviation 2.0° (2.8°) for the little fingers. The distal interphalangeal joint angles were ulnar deviation of 2.5° (1.7°), ulnar deviation 2.1° (1.7°), radial deviation 2.1° (1.7°), radial deviation 5.1° (2.8°) from index to the little fingers. Thumbs were typically straight, whereas the index and middle fingers deviated ulnarly, and ring and little fingers radially. There were no relevant differences in sex or laterality.

This paper presents a new method for selecting a patient specific forward model to compensate for anatomical variations in electrical impedance tomography (EIT) monitoring of neonates. The method uses a combination of shape sensors and absolute reconstruction. It takes advantage of a probabilistic approach which automatically selects the best estimated forward model fit from pre-stored library models. Absolute/static image reconstruction is performed as the core of the posterior probability calculations. The validity and reliability of the algorithm in detecting a suitable model in the presence of measurement noise is studied with simulated and measured data from 11 patients. The paper also demonstrates the potential improvements on the clinical parameters extracted from EIT images by considering a unique case study with a neonate patient undergoing computed tomography imaging as clinical indication prior to EIT monitoring. Two well-known image reconstruction techniques, namely GREIT and tSVD, are implemented to create the final tidal images. The impacts of appropriate model selection on the clinical extracted parameters such as center of ventilation and silent spaces are investigated. The results show significant improvements to the final reconstructed images and more importantly to the clinical EIT parameters extracted from the images that are crucial for decision-making and further interventions.

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Background and Objectives: Computer-aided diagnosis relies on machine learning algorithms that require filtered and preprocessed data as the input. Aligning the image in the desired direction is an additional manual step in post-processing, commonly overlooked due to workload issues. Several state-of-the-art approaches for fracture detection and disease-struck region segmentation benefit from correctly oriented images, thus requiring such preprocessing of X-ray images. Furthermore, it is desirable to have archived studies in a standardized format. Radiograph hanging protocols also differ from case to case, which means that images are not always aligned and oriented correctly. As a solution, the paper proposes XAOM, an X-ray Alignment and Orientation Method for images from 21 different body regions., Methods: Typically, other methods are crafted for this purpose to suit a specific body region and form of usage. In contrast, the method proposed in this paper is comprehensive and easily tuned to align and orient X-ray images of any body region. XAOM consists of two stages. For the first stage of the method, aligning X-ray images, we experimented with the following approaches: Hough transform, Fast line detection algorithm, and Principal Component Analysis method. For the second stage, we have experimented with the adaptations of several well known convolutional neural network topologies for correctly predicting image orientation: LeNet5, AlexNet, VGG16, VGG19, and ResNet50., Results: In the first stage, the PCA-based approach performed best. The average difference between the angle detected by the algorithm and the angle marked by the experts on the test set containing 200 pediatric X-ray images was 1.65 ∘ , while the median value was 0.11 ∘ . In the second stage, the VGG16-based network topology achieved the best accuracy of 0.993 on a test set containing 4,221 images., Conclusion: XAOM is highly accurate at aligning and orienting pediatric X-ray images of 21 common body regions according to a set standard. The proposed method is also robust and can be easily adjusted to the different alignment and rotation criteria., Availability: The Python source code of the best performing implementation of XAOM is publicly available at https://github.com/fhrzic/XAOM., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Ewing sarcomas of the chest wall, historically known as "Askin tumors" represent highly aggressive pediatric malignancies with a reported 5-year survival ranging only between 40 and 60% in most studies. Multimodal oncological treatment according to specific Ewing sarcoma protocols and radical "en-bloc" resection with simultaneous chest wall repair are key factors for long-term survival. However, the surgical complexity depends on tumor location and volume and potential infiltrations into lung, pericardium, diaphragm, esophagus, spine and major vessels. Thus, the question arises, which surgical specialties should join their comprehensive skills when approaching a child with Ewing sarcoma of the chest wall. Patients and Methods: All pediatric patients with Ewing sarcomas of the chest wall treated between 1990 and 2020 were analyzed focusing on complete resection, chest wall reconstruction, surgical complications according to Clavien-Dindo (CD) and survival. Patients received neo-adjuvant chemotherapy according to the respective Ewing sarcoma protocols. Depending on tumor location and organ infiltration, a multi-disciplinary surgical team was orchestrated to perform radical en-bloc resection and simultaneous chest wall repair. Results: Thirteen consecutive patients (seven boys and six girls) were included. Median age at presentation was 10.9 years (range 2.2-21 years). Neo-adjuvant chemotherapy ( n = 13) and irradiation ( n = 3) achieved significant reduction of the median tumor volume (305.6 vs. 44 ml, p < 0.05). En-bloc resection and simultaneous chest wall reconstruction was achieved without major complications despite multi-organ involvement. Postoperatively, one patient with infiltration of the costovertebral joint and laminectomy required surgical re-intervention (CD IIIb). 11/13 patients were treated with clear resections margins (R1 resection in one patient with infiltration of the costovertebral joint and marginal resection <1 mm in one child with multiple pulmonary metastases). All patients underwent postoperative chemotherapy; irradiation was performed in four children. Two deaths occurred 18 months and 7.5 years after diagnosis, respectively. Median follow-up for the remaining patients was 8.8 years (range: 0.9-30.7 years). The 5-year survival rate was 89% and the overall survival 85%. Conclusion: EWING specific oncological treatment and multi-disciplinary surgery performing radical en-bloc resections and simultaneous chest wall repair contribute to an improved survival of children with Ewing sarcoma of the chest wall., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Basharkhah, Lackner, Karastaneva, Bergovec, Spendel, Castellani, Sorantin, Benesch, Liegl-Atzwanger, Smolle-Jüttner, Urban, Höllwarth, Singer and Till.)

Introduction: Novel dedicated extremity cone beam computed tomography (CBCT) devices, recently introduced to the market, raised attention as a possible alternative in advanced diagnostic pediatric trauma imaging, today usually performed by multidetector computed tomography (MDCT). This work aimed to compare image quality and radiation dose of CBCT and MDCT., Materials and Methods: Fifty-four CBCT-MDCT examination pairs, containing nine MDCTs acquired in parallel prospectively and 45 MDCTs matched in retrospect, were included in this study. Image quality was analyzed semi-objectively by measuring noise, contrast-to-noise ratio (CNR), and signal-to-noise ratios (SNR) and subjectively by performing image impression ratings. CT dose records were readout., Results: Image noise was significantly lower in CBCT compared with MDCT, both semi-objectively and subjectively (both p < 0.001). CNR and SNRs were also in favor of CBCT, though CBCT examinations exhibited significantly more beam hardening artifacts that diminished the advantages of the superior semi-objective image quality. These artifacts were believed to occur more often in children due to numerous bone-cartilage transitions in open growth plates and may have led to a better subjective diagnostic certainty rating (p = 0.001). Motion artifacts were infrequently, but exclusively observed in CBCT. CT dose index (CTDI vol ) was substantially lower in CBCT (p < 0.001)., Conclusion: Dedicated extremity CBCT could be an alternative low-dose modality in the diagnostic pathway of pediatric fractures. At lower doses compared with MDCT and commonly affected by beam hardening artifacts, semi-objective CBCT image quality parameters were generally better than in MDCT.

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic compromise, a life-threatening disorder. Traditionally, neonatal pneumothorax diagnosis has been based on clinical images, auscultation, transillumination, and chest X-ray findings. This approach may potentially lead to a delay in both diagnosis and treatment. The use of lung US in diagnosis of PTX together with US-guided thoracentesis results in earlier and more precise management. The recommendations presented in this publication are aimed at improving the application of lung US in guiding neonatal PTX diagnosis and management.

To obtain the highest diagnostic information with least side effects when performing thoracic CT angiography (CTA) is challenging in young children. The current study aims to compare three contrast agent (CA) injection protocols regarding image quality and CA characteristic: a standard CTA, a fixed-bolus delay protocol, and the "microbolus technique (MBT)" developed in our institution. Seventy chest CTA scans of patients (<2 years) were divided into three groups. MBT was applied in group I, the standard protocol in group II and a fixed bolus delay in group III. Objective image quality was assessed by measuring peak enhancement, image noise, signal-to-noise (SNR) and contrast-to-noise ratios (CNR). Two observers scored subjective image quality and artifacts. Significantly lower amounts of CA (mean ± SD) were used in the MBT group compared to Group II (9.0 ± 3.7 ml vs. 12.9 ± 4.5 ml). A lower, but still diagnostic (>400 HU) enhancement was registered in all major thoracic vessels in group I without significant differences regarding SNR and CNR in most regions (p < 0.05). The best scores for image quality and artifacts were reached in group I. All three chest CTA contrast injection protocols offered diagnostic vessel enhancement in young patients. MBT was associated with reduced image artifacts and less injected CA.

The recent European Council Directive 2013/59/EURATOM requires the establishment of diagnostic reference levels (DRLs) to optimise radiation dose in diagnostic and interventional radiology procedures. At the time this directive was enacted, just a few European countries had already set paediatric DRLs and many of these were outdated. For this reason, the European Commission launched a project addressing European Guidelines on Diagnostic Reference Levels for Paediatric Imaging that was awarded to a consortium led by the European Society of Radiology with the collaboration of the European Society of Paediatric Radiology and other European stakeholders involved in the radiation protection of children. The main aims of this project were to establish European DRLs to be used by countries without their own national paediatric DRLs and to provide a consistent method to establish new DRLs in the future. These European guidelines have been very recently endorsed by the European Commission and published in issue N° 185 of the Radiation Protection series. The purpose of this article is to introduce these guidelines to the wide community of paediatric radiologists.

Significant changes can be expected in modern pediatric radiology. New imaging techniques are progressively added to basic modalities like Xrays and ultrasound. This essay summarizes recent advances and technical innovations in pediatric radiology, which are supposed to gain further importance in the future. Thus, CT dose reduction techniques including artificial intelligence as well as advances in the fields of magnetic resonance and molecular imaging are presented. KEY POINTS:   · Technical innovations will lead to significant changes in pediatric radiology.. · CT dose reduction is crucial for pediatric patient collectives.. · New MR-techniques will lower the need for sedation and contrast media application.. · Functional MR-imaging might gain further importance in patients with chronic lung disease.. · Molecular imaging enables detection, characterization and quantification of molecular processes in tumors.. CITATION FORMAT: · Staatz G, Daldrup-Link HE, Herrmann J et al. From Xrays to PET/MR, and then? - Future imaging in pediatric radiology. Fortschr Röntgenstr 2019; 191: 357 - 366., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

The paper proposes a segmentation and classification technique for fracture detection in X-ray images. This novel rotation-invariant method introduces the concept of local entropy for de-noising and removing tissue from the analysed X-ray images, followed by an improved procedure for image segmentation and the detection of regions of interest. The proposed local Shannon entropy was calculated for each image pixel using a sliding 2D window. An initial image segmentation was performed on the entropy representation of the original image. Next, a graph theory-based technique was implemented for the purpose of removing false bone contours and improving the edge detection of long bones. Finally, the paper introduces a classification and localisation procedure for fracture detection by tracking the difference between the extracted contour and the estimation of an ideal healthy one. The proposed hybrid method excels at detecting small fractures (which are hard to detect visually by a radiologist) in the ulna and radius bones-common injuries in children. Therefore, it is imperative that a radiologist inspecting the X-ray image receives a warning from the computerised X-ray analysis system, in order to prevent false-negative diagnoses. The proposed method was applied to a data-set containing 860 X-ray images of child radius and ulna bones (642 fracture-free images and 218 images containing fractures). The obtained results showed the efficiency and robustness of the proposed approach, in terms of segmentation quality and classification accuracy and precision (up to 91.16 % and 86.22 % , respectively).

Ultrasound is a safe bedside imaging tool that obviates the use of ionizing radiation diagnostic procedures. Due to its convenience, the lung ultrasound has received increasing attention from neonatal physicians. Nevertheless, clear reference standards and guideline limits are needed for accurate application of this diagnostic modality. This document aims to summarize expert opinions and to provide precise guidance to help facilitate the use of the lung ultrasound in the diagnosis of neonatal lung diseases.

Objectives: To investigate diagnostic accuracy and radiation dose of high-pitch CT coronary artery calcium scoring (CACS) with tin filtration (Sn100kVp) versus standard 120kVp high-pitch acquisition., Methods: 78 patients (58% male, 61.5±9.1 years) were prospectively enrolled. Subjects underwent clinical 120kVp high-pitch CACS using third-generation dual-source CT followed by additional high-pitch Sn100kVp acquisition. Agatston scores, calcium volume scores, Agatston score categories, percentile-based risk categorization and radiation metrics were compared., Results: 61/78 patients showed coronary calcifications. Median Agatston scores were 34.9 [0.7-197.1] and 41.7 [0.7-207.2] and calcium volume scores were 34.1 [0.7-218.0] for Sn100kVp and 35.7 [1.1-221.0] for 120kVp acquisitions, respectively (both p<0.0001). Bland-Altman analysis revealed underestimated Agatston scores and calcium volume scores with Sn100kVp versus 120kVp acquisitions (mean difference: 16.4 and 11.5). However, Agatston score categories and percentile-based risk categories showed excellent agreement (ĸ=0.98 and ĸ=0.99). Image noise was 25.8±4.4HU and 16.6±2.9HU in Sn100kVp and 120kVp scans, respectively (p<0.0001). Dose-length-product was 9.9±4.8mGy*cm and 40.9±14.4mGy*cm with Sn100kVp and 120kVp scans, respectively (p<0.0001). This resulted in significant effective radiation dose reduction (0.13±0.07mSv vs. 0.57±0.2mSv, p<0.0001) for Sn100kVp acquisitions., Conclusion: CACS using high-pitch low-voltage tin-filtered acquisitions demonstrates excellent agreement in Agatston score and percentile-based cardiac risk categorization with standard 120kVp high-pitch acquisitions. Furthermore, radiation dose was significantly reduced by 78% while maintaining accurate risk prediction., Key Points: • Coronary artery calcium scoring with tin filtration reduces radiation dose by 78%. • There is excellent correlation between high-pitch Sn100kVp and standard 120kVp acquisitions. • Excellent agreement regarding Agatston score categories and percentile-based risk categorization was achieved. • No cardiac risk reclassifications were observed using Sn100kVp coronary artery calcium scoring.

Purpose: Presently, there is no publication combining clinical follow-up with magnetic resonance imaging (MRI) to determine possible post-traumatic alterations following paediatric intra-articular fractures of the medial malleolus. Therefore, the aims of this study were to retrospectively analyze a cohort of patients with Salter-Harris (SH) III and IV fractures of the medial malleolus and to evaluate their long-term outcome. MRI was used to assess possible changes of the articular surface that cannot be diagnosed on native radiographs., Patients and Methods: Fifty-four patients with SH III ( n = 38) or IV fractures ( n = 17) of the medial malleolus treated between 2001 and 2011 were invited for a follow-up examination. Clinical outcome was assessed with the Weber score and osteoarthritis with the Kellgren and Lawrence classification. MRI was rated by the Outerbridge classification. Correlations between the clinical and radiological outcomes were calculated., Results: Seventeen patients were recruited for long-term follow-up at a mean of 112 (range, 65-184) months. The Weber score was very good for 5 patients, good for 10 patients and poor for 2 patients; the Kellgren and Lawrence score revealed a favourable grade 0 in 15 patients and grade 1 in 2 patients. The MRI-based Outerbridge classification yielded grade 0 for 12 patients, grade 1 for 1 patient, grade 2 for 2 patients and grade 3 for 1 patient. The Outerbridge score significantly ( p < 0.05) correlated with the Weber score., Conclusion: This study shows excellent and good outcome of SH III and IV fractures of the medial malleolus. Worse clinical outcome correlated with post-traumatic changes of the articular cartilage seen on MRI.

The maturity level of the digital transformation in health care ecosystems is heavily depending on human factors. Primarily the digital intelligence of the human beings - e.g. medical or nursing staff - should be taken seriously in the transformation processes. To derive sustainable strategies in a holistic manner an innovative, multi-dimensionaland human centred socio-economic capability model had to be developed and applied. By the use of our model health care ecosystems can be analysed, scored and benchmarked successfully. Furthermore, each ecosystems' digital intelligence based on their employees can be derived holistically from our four scoring scopes.