This session is Imaging Considerations in Challenging Populations, and I am Marcia Javid. I'm your host this morning, and we're going to talk about topics that are guaranteed to create both insomnia and indigestion for you. But hopefully, in the course of going through that process, you will acquire some skills, some knowledge, and some tools that will help you with some of these difficult populations. Our team of speakers here is a dream team. They're all rock stars, so you're going to enjoy the experience, I think. So let's get started. I'm going to speak first, after we talk about the general objectives here. We're going to talk about raising your awareness and empowering you individually, every single one of you, to be responsible for these patients and do a better job of taking care of them. That's my goal for you. Let's talk about what you can do to help and what you should take home for teaching points. First of all, this is an uncommon situation. It happens one in 1,000 pregnancies. It's the second most common cause of death in childbearing age women. What's the first? Anybody? Nobody? Trauma. The problem is that people don't know much about it because it's uncommon. And when it happens, it is a disaster. You are taking care of not just the mother, but also the fetus. The weight of that responsibility is overwhelming for everyone, for you, for the patient, for her family, for every practitioner who's involved. So let's look at some statistics. The United States has a population of about 332 million people, 51% are women. And I did a back-of-the-envelope calculation. How many women are of childbearing age? What's the fertility rate? Bottom line is, in 2021, there were probably about 3,700 cases across the United States of cancer and pregnancy. So if you practice imaging of the female and of obstetrical cases, sooner or later you're going to see this. Now I want you to know that I believe, with the passion of 1,000 blazing suns, that the solution to dealing with getting evidence for this problem is to create more robust tumor registries. And there are really only three significant ones that I know about. One is the INSIP project, which came out of Belgium and includes 67 hospitals from 28 countries. This is a pretty good registry. There's a National Swedish Registry, and there's one in Cooper University in Camden, New Jersey, which is nascent and just began recently. The definition of cancer and pregnancy means it happened during the pregnancy or within the first postpartum year. Does pregnancy cause this or have a connection? Is it the immune system? Is it hormones? Is it vascularity? Nobody knows. Maybe we'll find out. So the most common tumors we'll talk about in a minute, breast is the most common. Metastases, think about this, metastases from mother to the placenta or the fetus, unreal. What are the psychological forms of baggage that come along with that? How do you think about that and deal with it? And delay in diagnosis is typical because this physiologic symptoms of pregnancy can mask all the signs and symptoms of the cancer. Here are the most common breasts. Next is lymphoma in 12 percent, cervix, leukemia, ovarian cancer, and other tumors. This is what's most common in these situations. We'll look at a few cases from that radiographics article quickly. This is a left breast cancer that presented with a one-week history of left breast pain. There was a liver met. There are multifocal lesions in the left breast, and there on the PET CT you see all the lesions. So this is ugly, and this patient decided to have treatment in the third trimester followed by chemo and radiation therapy later on after delivery. Here's an example of lymphoma in the mediastinum in this patient, 32 years old. She had respiratory distress at 22 weeks. This was biopsied. Here's the biopsy trail, the marker. And it, in this case, showed up early, but 24 weeks gestation into the third trimester. The patient had chemotherapy and delivered at 35 weeks gestational age. The baby was healthy. Here's a cervix cancer. This is the tumor on MRI, sagittal T2 weighted. Here it is again on an axial scan. And hello, here are some lymph nodes with restricted diffusion on this high B value T2 weighted image. So this patient had concomitant chemotherapy and external beam radiation after delivery. So you're getting a sense here that there are a lot of ways to go about dealing with these issues. Here's a borderline cystadenocarcinoma of the ovary in a 25-year-old woman. This was incidentally discovered at nine weeks. And this patient underwent a left salpingoforectomy at 10 weeks gestational age and had an uncomplicated vaginal delivery. So that's pretty cool. This is not just us. We are part of a team. The multidisciplinary team includes a high-risk maternal fetal medicine specialist, a reproductive endocrinologist, a mental health professional, both for the doctors and for the patient, a genetic counselor, a medical physicist is key, and us, the radiologists. So this team will have management conferences and discussions. And our job as part of that team is to participate in finding the most information, getting the best knowledge available, and creating informed consent for the patient and her family so that she can choose what she wants to do to manage. You have to balance the risks and benefits between the mother and the fetus. And I'm not giving you a news bulletin when I say to you that the recent Supreme Court decision that overturned Roe v. Wade did not make this easier. It's hard. As far as radiation exposure is concerned, MRI and ultrasound are preferred without ionizing radiation. CT, sometimes done, not much, but the fetal exposure threshold should be no greater than .1 gray, which is 100 milligray. The general principle is to keep the uterus and the fetus out of the radiated field. There are two flavors of radiation effects. Stochastic effects, based on nuclear bomb and experimental observations, occur at any level of exposure with variable timeline and can lead to radiation-induced errors and typically childhood leukemias. Deterministic effects are threshold-related. They are virtually undetectable below that magic number of .1 gray. And most imaging studies are actually less than this. However, I warn you, pay attention to the gestational age. If the fetus is in the first or second trimester, during organogenesis and radiation exposure occurs, there definitely are documented studies showing fetal malformations, neuromotor deficits, and development of malignancies. So we don't want to go there unless we've got no choice. So let's keep this number in mind, and remember you must know the gestational age. If you look over here, you can see that most studies we do don't have more than 100 milligray. Even down here, an FDG PET. But if you have a choice to do a study with FDG, frankly, I recommend MRI because you don't need the extra radiation of CT in most cases. So you can typically get away in the third trimester with doing these studies carefully. And we no longer use gonadal shielding because evidence shows that it may actually worsen the situation. Take-home points. This is rare. It's one in 1,000 pregnancy. The management has to balance the fetal and maternal risks and benefits. Radiology plays a part in every single portion of this discussion, in safety discussions, in detection of the tumor, in making the biopsy with image guidance, staging it, evaluating gestational age, finding proper therapy, and looking at the follow-up and surveillance after that treatment. The multidisciplinary team is critically important. Be part of it. The fetal dose should remain less than 0.1 gray, resulting in a tiny individual risk of developing an adverse effect of less than 1% if that dose is not exceeded. I want to say to you that often people don't care how much you know unless they know how much you care. This is a situation in which you need to be sensitive, empathetic. You need to be strong. You need to pay attention to the feedback you're getting from the patient and her family. I said to one of my favorite radiologists, who deals with cancer patients every single day, all day long, all the time, how do you get up in the morning? How do you manage this? What makes you go? I don't know if I could do what you do. And her answer was, I can offer hope where before there was only fear. You can do it too. So lay down your arms. Be honest. Be human. Be available. And do better with me. Thank you very much. Good morning, everyone. I am Kalpana Kanal, a physicist at the University of Washington, Department of Radiology. And I'm going to try and share my knowledge in the next 13 minutes, at least for some of my knowledge. All right. So my topic is imaging the obese population. And a physicist's perspective, well, there's a lot of challenges in imaging obese population across all the modalities. And I'm not going to be able to talk about all modalities. I'll be focusing mainly on CT, but just to give you a little flavor of the other modalities. In radiography, things you have to worry about is fitting a large patient on a digital detector. We're doing portable imaging, trying to position those patients. So you need very powerful generators so you can penetrate those large patients, and you can increase the source-to-image distance. But then that has implications with resolution and so on. Fluoroscopy for bariatric patients, now you could have where the tube is over the table and the detector under the table. It has a really large opening. Here's an example, a Shimatsu room that's showing the table is capable of supporting a 700-pound patient. And that kind of helps in the imaging. And the radiologist is typically out of the room, so they're not getting exposed to any scatter radiation. And here's the differences in ultrasound if you have a large patient versus an average-sized patient. As you can see, you really can't see the bile duct on the 350-pound patient as you can with the 150-pound because of all the attenuation of the ultrasound beam and the fat of the patient. So just to give you a little flavor about the other modalities, what I'm really going to focus on in the next 13 minutes is CT. And what I'm going to talk about is some of the scanner limitations, image noise, artifacts, things to watch out for, some technical parameters you could use to adjust and compensate for the noise in the images, a little bit about dose, and iterative reconstruction. So starting off, I think we could all have probably encountered this in our practice, but just trying to get an obese patient on the CT table can be challenging. And this is an old table where it shows you that maximum table loads are, you know, in this table up to about 650. But now, in more modern scanners, you can actually get tables that are capable of holding up to 725 pounds of patient weight. And that is just what the vendors specify. They're actually tested at four times the strength. But to get any kind of precision or accuracy, this is the quote that they will give you and any manufacturer will give you. But tables are getting more and more efficient in being able to carry the load of obese patients. The other scanner limitation could be the scan field of view. In this slide, on this picture on the left here, the red line is the gantry opening of a CT scanner, and the black line is actually the scanning field of view. And if the patient is so large that some part of the anatomy is outside that scanning field of view, you're going to get this white artifact, as you can see on this image over here. And one possibility of trying to get over that might be repositioning the patient with the anatomy of interest completely inside the field of view. It might be helpful. Or if your scanner is capable of doing extended field of view reconstruction, then that could, you know, give you a better image on your scanner. And that leads also to truncation artifact, as shown in this slide, where the patient on the top is an obese patient, and they can see their anatomy is falling out of the scan field of view. And so you're getting this truncation artifact, the white area here on the image, and you see another patient, much smaller, fitting right in the scan field of view, and you don't see those kind of artifacts. So these are some challenges that you will see if you are scanning a large number of bariatric patients. One way to get rid of this truncation artifact, again, is probably to have the extended field of view reconstruction, which will help sometimes, not always, in getting that anatomy reconstructed and much better image quality, but that is not always possible. Bundling is another thing you can do where basically, you know, with obese patients and their anatomy is falling on the side, here's an example of a patient on the left, patient's not wearing a bra, you can see the breasts are kind of falling when they're lying flat. You could have that patient actually wear a bra, and you can see then that the anatomy is more in the scanning field of view, and it's actually gotten rid of that truncation artifact, as well as maybe being more compact, and because there's less thickness of the anatomy potentially, you would probably see less noise in the image and no photon starvation, which is another big problem with larger patients, which makes sense, right? The larger the patient, the more photons you need to penetrate that patient to get a decent image quality. Basically, it's noise, right? Less photons, more noise. Anything you can do to reduce the noise in CT images is what you would do as well for the bariatric patient. You know, you can use more modern reconstruction methods like iterative reconstruction. You could increase your rotation time, you know, instead of .5 seconds, you can have one second rotation time, maybe reduce the pitch a little bit, and then increase the slice thickness you're reading at to take care of the noise in the image, as well as increasing the kilovoltage, the KV, to penetrate that large patient. You have to keep in mind always balancing all this with dose, as we always say, as physicists always say, but sometimes in bariatric population, you really can't worry about dose as much because you're trying so hard to get just a decent image quality to make your diagnosis that dose might take second place. You want to be aware of it, but that may not be your primary concern when imaging the bariatric population. Ring artifacts are a lot more obvious as well in an obese patient, as you can see at the top over here. And the same patient after they had a 90-pound weight reduction, you can see that the ring artifact is gone. They're more prominent because of the image noise because of those large patients and detector sensitivity that becomes more prominent in these large patients. Houndfield units is another thing that I always think the radiologists need to be aware of because you all use that maybe for diagnosis or making some kind of interpretation. Here is same patient scanned a week apart, and the radiologists noticed Houndfield units. You can't read that from where you are, but the one on the left is like 24 and 8, and the one on the right is like 40-something and 27. And they were wondering why there were so many, so much differences in the Houndfield unit, and the techniques were pretty much similar. It's a little bit more mass on the image on the right. And that was because the patient's positioning was different from the first scan. You can see they're a little bit bigger looking on the right than on the left. They were probably positioned a little over the isocenter or maybe a little closer to the tube, and so the machine thinking they're bigger gave them also a larger mass. The beam hardening effects were slightly different as well, and therefore the Houndfield units were different, something to keep in mind as radiologists when you're scanning large patients. We always advise increasing KV. For smaller patients, rule of thumb, BMI less than 30, might want to use 100 to 120. For non-angio CT, for large patients, use 140 because that's the only way you're going to penetrate a large patient to improve your contrast to noise ratio. And if you're doing CT angio, use of 120 could be considered in most obese patients. These are just rough guidelines, and with modern scanners and more options of doing iterative reconstruction, AI, model-based reconstruction, it's possible, and soon with photon counting CT, you could even go down to 80 and 90 KV. Anything we do in CT to reduce noise, one of the parameters you could do is adjust your slice thickness because that gives you more signal compared to noise. So here's a case, a very thin slice, 0.125 millimeters. At five millimeters, it's a little better. You can see the noise is better, more bearable, better image quality, but you have to keep in mind that if you do increase the reconstruction slice thickness too much, then you need to worry about partial volume averaging, and that artifact is showing up here simulating a filling defect in the right pulmonary artery. So you can balance, you know, typically I think the radiologist may be reading like a two, two and a half millimeter, but for a pediatric patient, you could consider going to a larger slice thickness. Iterative reconstruction, all of us have it with our modern scanners. Some radiologists like it, some do not, but it is very effective in reducing noise and very, very helpful in the bariatric population, as you can see here. The image over here on the top is without, and the one at the bottom is with iterative reconstruction, and you can see it probably doesn't show up that well with this projection, but it's a lot cleaner at the bottom image. As well as here on the image on the right, the top image is filtered back projection and the bottom image is with iterative reconstruction, and you can see much better how much the noise is cleaned up. Very, very useful for this type of population. Radiation dose is something, of course, we all know from physics principle, it is going to increase with obese patients. However, it's not really a linear increase with tube current, and that is because of all that access adipose tissue, a lot of the radiation is absorbed in that before it hits the internal organs. So there may be more of a dose on the entrance skin than the internal organs. So if you had a pregnant obese patient, the fetus actually will be shielded by all that fat where the radiation is being absorbed. So you have to still keep an eye on the dose. Here is our own data from University of Washington, and it shows you the CTDI as a function of weight, and you can see some outliers here, which you might want to investigate and figure out because this is a thinner patient, and this is a much larger patient, and the dose is a little low, and you need to probably investigate, is there a positioning issue where the KV is different? But in general, you can see our dose increasing with size, which is the way it should be. Modern scanners technology allows better image quality. You can see here going from BMI 31 all the way to 47. You know, with modern scanners, you have much more faster tubes, better image quality options, iterative recon, and it just shows you much better image quality than in the older scanners. Photon counting CT, which you're hearing a lot about at this meeting, has the potential of decreasing noise significantly in bariatric patients because of the way it eliminates noise, the way the technology eliminates noise, and I'm sure in a couple of years, maybe even next year, we'll see more papers at RSNA showing how photon counting CT is contributing to imaging of the bariatric population. So in summary, there are a lot of challenges when scanning a bariatric population, but there are options, technical options, that you could potentially use to an extent to clean up your images. Manufacturers vary in table weight, but now you have up to 680 pounds. Actually, earlier I said about 700 pounds as well are available. You have actually bariatric-specified CT scanners, which have larger bore sizes, larger table capacity, more powerful tubes, more powerful MA options to be able to penetrate these large patients, and also large field of view imaging to take care of those truncation artifacts that I showed you earlier. And modern scanners using iterative reconstruction, AI, now soon photon counting techniques are going to become more common, will help improve the image quality in obese patients. Thank you very much. We're going to shift gears a little bit here. I'm a pediatric radiologist, and I'm going to talk about the challenges of child abuse imaging. I'm super excited to be here. I'm going to start with a case. So this was a four-month-old who presented to our emergency room with a history of bronchiolitis. One of my partners was working on call that night, and he looked at the X-ray, and astutely I'm going to mag it for us, recognized that there were healing rib fractures that he saw despite the lung opacities and the overlying artifact, which I think is a really tough case. This was a challenging case. Here is the image when you remove the artifact. You can now see the bony callus a little more clearly, but this was clearly, in my opinion and the child abuse team's opinion at our institution, a great catch, right? Challenging, which I think sets the stage for child abuse imaging because it is, in my opinion, very challenging. And we looked at that. So we don't always make great catches. We looked at the value of a second read by a pediatric radiologist looking at outside studies for patients who were referred to our hospital. We looked at about 50 hospitals, about 185 studies, and found that there was about a 26 percent disagreement rate when the pediatric radiologist reviewed the outside interpretation of the skeletal survey. Thirty-two percent of those findings were felt to be likely normal, either there was nothing there or it was a normal variation that was misinterpreted as a fracture. The most common misfractures were ribs fractures as well as classic metaphyseal lesions. This is one example of a false negative case where you can clearly see with the arrows that helps that there are distal femoral lesions here, classic metaphyseal lesions with a corner fracture appearance, a bucket handle classic metaphyseal lesion at the proximal fibula, and as well as a Salter-Harris type 2 fracture at the proximal tibia. This is another patient from the same study. And if I kind of mag in here, you can see that there was an abnormal appearance of the right first posterior rib. This was interpreted as a healing rib fracture, when in all actuality this was a pseudoarthrosis and not a fracture. We also took the opportunity to look at how pediatric radiologists perform in reading skeletal surveys, and so we did that by doing double reads of skeletal surveys at our institution and found that there was a significant increase detection of false negative fractures, about a 5 percent discrepancy rate when you look at all of those skeletal surveys. And again, CMLs and rib fractures were the most common fractures that were misinterpreted. And so why are there challenges in child abuse imaging? I think there are many challenges. I only have a little bit of time today, so I'm going to focus on what I think are possibly three important challenges in child abuse imaging. Those are that, one, skeletal surveys are high-stakes exams, two, the interpretation is difficult at times, and three, the current education practices are not sufficient. So challenge number one, skeletal surveys are high-stakes exams. There's significant responsibility upon the radiologist and the multidisciplinary team taking care of the patient. We have responsibility to the patient, the patient's families, and the caretakers to really get this right. We want to make accurate diagnoses. That is compounded by the fact that this may be an uncommon exam for the radiologist who's reviewing the study. Depending on the practice setting, this could be a general radiologist who might read one skeletal survey over the course of a month, which is going to be quite different from perhaps an academic pediatric center where multiple skeletal surveys may be performed in a single day. And so this makes it very challenging. Dr. Stephen Brown wrote this paper in pediatric radiology ethical challenges and child abuse what is the harm of a misdiagnosis and reflects on the consequences of both false negative and false positive diagnoses returning a child to an abusive environment or removing a child from a loving family our duty as a radiologist and physicians caring for these patients of course is to protect the children from harm but there really is a lot of pressure to get it right so even before you read the skeletal survey or whatever imaging modality you have in front of you I feel like there is already a challenge in front of you to make sure that the diagnosis is accurate challenge number two interpretation is difficult at times and we're gonna go through these few reasons why I think that is the case first we'll start with technique the technique is critical and again I'm just referring here to the skeletal survey this is a poster we put together and we were able to distribute amongst our state I'm in Indiana to kind of the outlying hospitals just to remind them they can see it as the technologist going to do the exam the technique that should be performed when these studies are done so that we have the highest resolution and offer the radiologist the best ability to see these images a baby gram is not a replacement for a skeletal survey this kind of I think throws the radiologist under the bus because if you have this study it's likely that you're either going to miss a fracture or call a fracture that's not there and that's tough it would be very challenging to see a fracture like this for example CML and the proximal humerus when you're looking at a baby gram here's another example of improper technique in which this fracture was seen in the mid humerus at the outside hospital but perhaps if the images were obtained separately the humerus separate from the form and the chest separate etc the other fractures may have been identified as well additionally the pediatric skeleton is dynamic and so I think this is also very challenging particularly age-related ossification centers and perhaps maybe non-pediatric radiologists in the room might cringe when they think about an elbow I think that's the most common area that I think about when I think about ossification centers but there are many ossification centers in the pediatric skeleton that change with the age and so if you're reading these studies it's really important to be attuned to what those look like and how they can maybe mimic fractures and of course normal variations so this was a 26 day old who presented with a brewie or a brief shortened unexpected event and the radiologist looking at this nursery chest abdomen pelvis thought there was some irregularity in asymmetry of the right acromion here we weren't sure honestly if this was a fracture or if this was a normal ossification center it was the only finding on the image and so in two weeks we did a follow-up skeletal survey and you can see that this was unchanged there was no evidence of healing and it's actually a pretty typical appearance for an acromion ossification center this was a 34 day old who actually was a victim of abusive head trauma we did an initial skeletal survey and you can see there's an abnormal area in the right superior pubic ramus this increased linear density we were again unclear whether this could be a fracture it would be quite unusual location we did a follow-up skeletal survey and you can see that is unchanged no evidence of evolution of healing and this is a fairly typical for the appearance of a normal variation that we can see in the pubic rami this is a skull radiograph in which there was an unexpected longitudinal lucency in the occipital bone the CT here clearly showed that this lucency was surrounded by kind of a sclerotic margin and really helped nail down that this was just an occipital suture variance the variance of the sutures and fractures in the skull it can be difficult to determine sometimes but now that we have the added use of the 3d reconstruction of the skull this can be very helpful in distinguishing these and I do recommend that these be obtained on all of your head CT traumas there are also variations that radiologists need to be aware of in the metaphyses I'm not going to go through all of those don't have time but here is one example in which you can see some fragmentation at the proximal tibia which is a variation and not a fracture and similarly here in this proximal tibia you can see an area that you might think could be a little bit of periosteal reaction again this is an expected normal variation of the proximal tibia that we can see injuries can be subtle often this isn't the focus of the x-ray that the patient is getting for example the case I showed at the beginning in which we're doing chest imaging in the ER setting for respiratory symptoms often we're not focused on looking at those ribs but that is important often there are multiple fractures so we can be kind of stuck in that kind of satisfaction of search once you see one fracture but you would really need to keep looking and corner findings can be seen commonly as well this is two views of the elbow and you can see here that the radius and ulna are slightly medially displaced from the humerus at this point the radiologist may want to do the contralateral elbow to compare or you could do ultrasound we did ultrasound in our case and you can see that the capitellum and the trochlea are both displaced from the distal humerus and so we didn't see a fracture line on the radiograph because the fracture was through of course the physis and this was a distal humeral epiphyseal separation classic metaphyseal lesions are often subtle and so I think it's very important that if you're interpreting these studies that you know one what they can look like these are three examples of bucket handle appearance of those fractures and we need to be aware of where they occur most commonly acute rib fractures are often very challenging to see when they are acute and non displaced you'll see a linear lucency through the fracture here you can see there was a left second posterior acute rib fracture this is why oblique views of the chest are super important in that skeletal survey if we don't do the oblique views we know we miss about 20% of rib fractures so they're important to include this patient came back two weeks later for a follow-up skeletal survey and now you'll see all of the healing fractures that were nearly invisible on the initial study and so this just kind of emphasizes why that follow-up skeletal survey is important we find new information and 12 to 34 percent of cases rib fractures being the most common new fractures and of course there's differential diagnosis when you see finding on these images including medical conditions and accidental injuries this is a six-month-old who was referred to our hospital later in the course but initially was diagnosed at an outside hospital with a distal tibial CML here's the image you can see that there is kind of an abnormal mixed lucent sclerotic appearance of the distal tibia with periosteal reaction the history was the child had been fussy with cold symptoms for about three weeks after the mother was told that there was a fracture in the distal tibia she said well he rolled off the bed you know a couple weeks ago perhaps he got a fracture then he seemed fine at the time also he sleeps with me could I have accidentally rolled onto his leg and caused a fracture the child was removed from that family for several days ten days later did then come to our hospital because the lower extremity continued to swell and here now you can see a destructive process clearly in the distal tibia with increased lucency bone loss periosteal reaction and MRI demonstrated some marrow edema as well as a sub periosteal abscess and of course this was osteomyelitis this was an 11 day infant who was at our hospital and had leg swelling and so we got images in here you can see a corner fracture of the proximal tibia a midshaft femur fracture here and as well as a the appearance of a CML of the distal femur the history here was super important this child actually had never been discharged from the hospital was an inpatient with history of myelomeningocele spastic lower extremities and was ongoing undergoing inpatient physical therapy this was a 21 day old infant who presented with these radiographs of the lower extremities very abnormal appearance of the proximal taphyses and distal metaphyses of both femurs had a very abnormal chest x-ray as well this patient had hyper parathyroidism secondary to a calcium sensing receptor mutation I think the last challenge challenge number three is that current education practices are not sufficient Sharma and colleagues published this paper last year looking at resident recognition of non-accidental trauma when presented with chest radiographs of infants with posterior and lateral healing rib fractures only 10% of residents suggested that child abuse may be possible in these cases looking at our center where we do a lot of child abuse imaging with a very busy child abuse protect prevention program doing about seven to eight hundred skeletal surveys a year when I looked at our senior residents class of 13 their average over four years they dictated about 40 skeletal surveys which might sound kind of like a lot but when you think that only 20% of them are positive and fewer of those have specific injuries it's likely not sufficient currently there's no minimum number required for residents or fellows for that matter for dictating child abuse imaging studies whether that be skeletal surveys or neuroimaging studies the current education model probably at most places and ours includes case conferences lectures teaching at the workstation but I really think this is an opportunity to think outside of the box and whether that be shared teaching files between institutions competency testing at the residency level or even child abuse CME with certification after residency and fellowship I think are all opportunities so in conclusion I think being aware simply of the challenges that surround child abuse imaging is helpful interpreting when interpreting these studies as well as when teaching trainees and I do think really that education is key thank you well thank you so much and it's a great lecture Megan for preparing the groundwork for me to discuss now elder abuse and I'm kind of fascinated that you know what we will have to demonstrate with elder abuse how much of knowledge we actually have have in that particular area so I have nothing to disclose and our objectives would be to discuss challenges to the use of imaging for the investigation and diagnosis of elder abuse review imaging features that should raise clinical concern for elderly abuse and discuss future recommendations for research studies and clinical workflow to increase our awareness and participation in elder abuse detection and I just wanted to say that it's becoming more and more you know acknowledgement of presence of elder abuse and we start to be encountering it more often and paying attention to it more often and I think this topic is really of importance right now because again this is a gap in our knowledge and we have to fill this gap as much as we can so as overview we will talk a little bit about background and some risk factors that predispose for development of elderly abuse and then we'll talk more about challenges in identifying image and manifestations of abuse and other challenges in communication between the providers and imagers and then we'll talk about red flags in image and review and most common sites of injuries and examples will be provided as the background to elderly abuse results in serious physical injuries it's long-term psychological consequences and it has it is a life-threatening condition so we need to be really thinking about this when we evaluate in our patients on a daily basis and one out of six people of age 60 and older experience some sort of form of abuse with prevalence of 15.7 worldwide and by 2030 it is estimated the incidence of elderly abuse will increase up to 26% and there is a high associated risk of morbidity and mortality with three times higher than in abused patients rather than in just elderly without abuse and it's also elderly abuse is associated with substantial economical burden it cost about 5.3 billion annually for taking care of the patients who were victims of elder abuse and detection and reporting still remains to be very low and with only one out of 26 cases reported and diagnostic images although critical and diagnosis is relatively underutilized by the providers so talking about the risk factors what are the patients who are the patients who can become victims of abuse and why do we need to know those risk factors because applying those risk factors looking for them in the charts or from the providers it will help us a little bit put together the findings on imaging with the findings of social history and that will hopefully erase like raise the suspicion for abuse or decrease the suspicion so it will help us with differential for the victims poor physical health is associated with increased rate of abuse for example those who have a financial or physical emotional you know problems then they will have a higher abuse chance disabilities in peace patients ability to defense and seeking for help also patients with mental illnesses they have a cognitive impairments and sometimes they become more often causes like a victim self abuse behavioral disorders also can be a challenge and increase the risk for being a victim of abuse aggression disruptive behavior towards caregivers can also you know result in caregiver being abusive poverty and disruptive living environment is another important risk factor patients in the low income and shared living environments have a higher risk of being abused increased social interaction in the setting of limited economical resources and cohabitation other risk factors and also increase the physical and financial abuse of this patients demographic risk factors we have to consider as well it was found that women longevity relative to the man results in higher rate of abuse and then family history of violence increases the rate of physical and sexual abuse younger patients usually abused in a cohabited state and older patients are usually more commonly abused in the assistant living conditions from the risk factors of abusers a standpoint of abusers those who the providers who have or caregivers who have a depression on anxiety or other psychiatric illnesses drug alcohol abuse it's all a risk for being abusive towards the elderly and and if there is any dependency of the caregiver for example financial dependency or emotional dependency also associated with this risks of abuse of abuse so if we can identify the risk factors for elder abuse we can facilitate detection of them and contribute to the development of prevention programs and now we're going to talk a little bit about challenges identifying image and manifestations of elder abuse one of the major ones would be lack of evidence based medicine studies on imaging differences between abuse and accidental injury in elderly patients so in contrast to child abuse where there is abundancy of literature and research for elderly we have very limited data there also there is a lack of training and recognizing signs of elderly abuse again nationalized discrepancy in radiological training on child versus elder abuse is really big there is some I understand that Megan mentioned that there is some also limitations there in the pediatric world but when you compare into elder abuse literally it's a huge difference and then anatomical differences between pediatric and elderly population is another challenge because we all know that there is some specific anatomical features in children they will help us to identify child abuse such as vulnerable growth plates or small frames related to you know fractures in children from related to squeezing but in the elderly we don't have those landmarks and we don't have those anatomical differences on top of it elderly can sometimes have other comorbidities which will mask child elderly abuse findings and may mislead interpretation could be you know incorrect for example those patients who have osteoporosis it will be difficult to differentiate fractures associated with osteoporosis versus low energy fractures and it would be hard to say if it's accidental or non-accidental fractures also elderly patients suffer from balance impairment and use a lot of the times they are on anticoagulant therapies so hemorrhages and falls are very common and it's hard again to differentiate if this is related to abuse or not so knowledge of developmental milestone in children also help to state if this may be findings that related to child abuse in elderly we don't have those milestones functional ability among the elderly is not related to age as much and you know some patients we could say if they are mobile or not and then if the history really matches the findings on imaging then you know you could put that together but in a lot of cases we don't know exactly their functionality a lack of communication between frontline providers and radiology is one of the major also challenges that we experience in in diagnosis of elderly abuse clinical perception of imaging about role of radiologists playing in diagnosis of elder abuse is somewhat limited and imaging is considered to be a confirmatory rather than source of additional information it is rare for the providers to request workup for evaluation of elder abuse and the geriatricians and ED clinicians rely heavily on bedside assessments and in contrast a standard of care for suspected cases of child abuse involves a lot of imaging and communication with radiologists in elder abuse there is no standard protocols for multi-specialty investigation of potential elder abuse and we do need just as with cancer and pregnancy we do need that multidisciplinary team that can help together to evaluate the problem with the social workers involved and the ED physicians as well as other providers caregivers at home and the radiologists so there is a other contributing factors such as limited time in emergency room plays a huge role in really having the trouble of diagnosing elder abuse just because we don't have time to look through entire chart and to talk to the physicians in regards to you know a social status of the patient what kind of caregivers they have at home they leave together or not so this all creates a burden for us and limiting our abilities to make a correct diagnosis is on time and then the major also thing is that we really worried to aggravate patients or caregivers by this maybe unsubstantiated you know accusations if we suspect but not sure about abuse however you know accurate accusation without proof may also be associated with retaliation so some red flags that can help us to identify elder abuse on social and medical history red flags it includes multiple visits to emergency room with similar chief concerns or delay in reporting for over 24 hours so they would be staying at home and be suffered from some injuries and not be brought into emergency room history of prior abuse is another red flag and then ED visits with a pre in the within the previous months imaging flags would be types of fractures and types of dislocations soft tissue in injuries and specific organ injuries so when we're gonna delve a little bit into image and findings it's going to be very superficial but you can go to our recently published article on non accidental injury in radiographics and you can look at the images more carefully but here we were just trying to describe the challenges of the of the issue from imaging standpoint was his injuries and fractures usually involve long bone fractures and fractures with a high impact high energy impact also facial fractures posterior rib fractures and multiple fractures at various stages of healing and long bone fractures most commonly are spiral fractures they result from rotational twisting force and this type of fractures that were not really very heavily investigated yet in respect to elderly and a lot of knowledge comes from child abuse research and we really need to conduct more research to figure out the correlation and comparison of accidental versus non-accidental type of fractures in the patient's senior population distal ulnar diaphysis fractures is more commonly seen in patients with abuse it's associated with victim raising form as a self-defense often accompanied by bruising to the aspects of the soft tissues on their hand and arm and this is something again to think about and ask providers you know in ED if you they see soft tissue bruising fractures with high energy impact involving the girdle injuries such as proximal humerus or shoulder joint or clavicular fractures are also one of the major things that you have to raise your suspicion for possible elder abuse facial fractures are commonly seen most time it's affected left side is affected it's because you know throughout what it's thought to be due to predominance of right handedness in the population among the offenders and then additionally there is victims usually turn to the right due to reflex predominance of the left hemisphere orbital mandibular fractures are commonly also associated with elder abuse and then a lot of the times the patients would not even mention that there was some accident happened and only on imaging we detect this fracture so they there is inconsistency in presenting symptoms and the fractures that are discovered mandibular fractures can also be seen in elder patients and suffering from abuse and then it could be either affecting the mandible angle or condyles and it is essential for radiologists to reconcile injury pattern and elderly and put it together with the mechanism of injury so that correct statements could be made or suspicion can be raised for elder abuse just as with the kids posterior rib fractures associated with elder abuse and should be investigated more maybe getting extra additional images elsewhere to see if there are multiple fractures detection of non healing fractures and healing fractures different stages also helpful in detection and correct accurate diagnosis soft tissue associated bruising going along with fractures again one of the major signs that can help you because to to to state that this is elderly abuse just because the patients may be thrown on the ground or punched and those soft tissue hematomas will be very visible and could be placed together and to make a diagnosis according to the American College of Radiology appropriateness criteria for rib fractures elder abuse is one of the few diagnoses where dedicated reproteo graphic or radiography non contrast CT and bone scintigraphy is beneficial and should be done for further care and I'm gonna just skip it to the next so anytime you see multiple fractures at various stages of healing the investigation should be open up discussion should be open up with a providing team and you know suspicion for elder abuse should be raised in this patients in the intracranial a multiple hematomas could be present again of various stages and this is something to consider again if also there are scale as the skull fractures are present and other additional elsewhere fractures are present and I'm just gonna want to go to my last as the conclusion radiology should be aware of elder abuse should play a significant role in early detection and reporting of this pervasive problem knowledge of imaging findings associated with elder abuse is essential for facilitating accurate diagnosis and reducing misinterpretation patient risk factors should be investigated by clinicians and radiologists when suspicious imaging findings are discovered and additional training really is required and should be a part of our radiology training and then we still need to conduct much more research in this field thank you very much

imaging considerations

challenging populations

cancer in pregnancy

obese population imaging

child abuse detection

elder abuse imaging

MRI and ultrasound

radiologist training

interdisciplinary approaches