BACKGROUND: Travel restrictions implemented during the acute phases of the COVID-19 pandemic disrupted supply chain for critical radiology consumables including contrast media (CM) leading to shortages. Consequently, some departments had to restructure their clinical workflows in accordance to recommended guidelines to ensure safe continuity of patient care. This study aimed to summarise the temporary crisis-driven recommendations with implicit environmental sustainability essence and to analyse how these measures might inform the development of a more sustainable, long-term clinical guideline for safer and cost-effective CM usage without compromising diagnostic quality.
METHODS: Documents were obtained through an electronic database search together with a relevant manual search in Google Scholar and relevant reference lists. The selected documents were subjected to a pre-defined eligibility criteria for inclusion. The READ approach was employed for document analysis and a thematic analysis of the obtained data was conducted.
RESULTS: Of the 17 documents included, 70% (n = 12) emanate from the United States of America. The summary of the findings relate to minimising CM usage through strategic clinical approaches including optimisation of CM volumes, prioritisation of non-contrast imaging and/or alternative imaging depending on patient need without compromising diagnostic quality.
CONCLUSIONS: Critical lessons of sustainability essence are implicitly embedded in the policy guidelines issued during the periods of acute CM shortage in the COVID-19 pandemic. These lessons were themed around CM conservation based on: type and priority of medical imaging investigation, kind of imaging modality and use of smaller vials over multi-dose vials packaging.
CONCLUSIONS: The temporary crisis-driven strategies may offer critical lessons for post-pandemic service delivery to enhance patient safety while saving cost and promoting greener practice via strategic clinical and operational monitoring of CM through policy renewal, education and training and collaboration with industry partners.

BACKGROUND: The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture.
METHODS: A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2 cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer.
RESULTS: Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%).
CONCLUSIONS: Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice.
CONCLUSIONS: In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.

OBJECTIVE: X-ray fluorescence (XRF) is a non-destructive technique that measures the elemental concentration of different materials, including human bone. Recently, it began to be applied to paleopathological studies due to the development of portable devices and their relative ease of use. However, the lack of uniform procedures hampers comparability and reproducibility. This paper aims to provide guidelines for an efficient and standardized evaluation of bone elemental composition with a portable XRF (pXRF) device.
METHODS: This technical note is based on the application of the Thermo Scientific Niton XL3t 900 GOLDD+.
METHODS: This work includes suggestions for the choice and preparation of human bone samples, both from archaeological context and documented collections, and methodological procedures in pXRF setup, such as choice of calibration, assessment of accuracy, and analysis run time. Additionally, recommendations for data validation and statistical analysis are also included.
CONCLUSIONS: This technique has great potential in paleopathology since bone chemical variations may be associated with different pathological conditions, environmental contamination (e.g., lead), and/or administered treatments, such as mercury. Following an expected increase in the number of studies, it is essential to establish good practices that allow results from different researchers to be comparable.
CONCLUSIONS: X-ray fluorescence is a non-destructive technique that measures small concentrations (ppm) of elements from magnesium (12Mg) through bismuth (83Bi).
CONCLUSIONS: pXRF does not detect elements lighter than Mg, and its lower energy excitation penetrates less than other techniques.
UNASSIGNED: Other research groups should test these guidelines and comment on their usefulness and replicability.

BACKGROUND: This review aims to evaluate current practices regarding spine immobilization in pediatric trauma patients to evaluate their efficacy, reliability, and impact on clinical outcomes to guide future research and improved evidence-based practice guidelines.
METHODS: PubMed, ProQuest, Embase, Google Scholar, and Cochrane were queried for studies pertaining to spinal immobilization practices in pediatric trauma patients. Articles were separated into studies that explored both the efficacy and clinical outcomes of spine immobilization. Outcomes evaluated included frequency of spinal imaging, self-reported pain level, emergency department length of stay (ED-LOS), and ED disposition.
RESULTS: Six articles were included, with two studies examining clinical outcomes and 4 studies evaluating the efficacy and reliability of immobilization techniques. Immobilized children were significantly more likely to undergo cervical spine imaging (OR 8.2, p < 0.001), be admitted to the floor (OR 4.0, p < 0.001), be taken to the ICU or OR (OR 5.3, p < 0.05) and reported a higher median pain score. Older children were significantly more likely to be immobilized. No immobilization techniques consistently achieved neutral positioning, and patients most often presented in a flexed position. Lapses in immobilization occurred in 71.4% of patients.
CONCLUSIONS: Immobilized pediatric patients underwent more cervical radiographs, and had higher hospital and ICU admission rates, and higher mean pain scores than those without immobilization. Immobilization was inconsistent across age groups and often resulted in lapses and improper alignment. Further research is needed to identify the most appropriate immobilization techniques for pediatric patients and when to use them.

In Denmark, chiropractors have a statutory right to use radiography and the government-funded national Health Insurance provides partial reimbursement. Danish National Clinical Guidelines recommends against routine use of imaging for uncomplicated spinal pain; however, it is not clear if clinical imaging guidelines recommendations have had an effect on the utilisation of spinal radiography. This study aimed to describe the utilisation rate of radiographs in Danish chiropractic clinics in the period from 2010 to 2020 and to assess the impact of clinical guidelines and policy changes on the utilisation of radiographs in Danish chiropractic clinics.
Anonymised data from January 1st, 2010, to December 31st, 2020, were extracted from the Danish Regions register on health contacts in primary care. Data consisted of the total number of patients consulting one of 254 chiropractic clinics and the total number of patients having or being referred for radiography. Data were used to investigate the radiography utilisation per month from 2010 to 2020. An \'interrupted time series\' analysis was conducted to determine if two interventions, the dissemination of 1) Danish clinical imaging guidelines recommendations and policy changes related to referral for advanced imaging for chiropractors in 2013 and 2) four Danish clinical guidelines recommendations in 2016, were associated with an immediate change in the level and/or slope of radiography utilisation.
In total, 336,128 unique patients consulted a chiropractor in 2010 of which 55,449 (15.4%) had radiography. In 2020, the number of patients consulting a chiropractor had increased to 366,732 of which 29,244 (8.0%) had radiography. The pre-intervention utilisation decreased by two radiographs per 10,000 patients per month. Little absolute change, but still statistically significant for Intervention 1, in the utilisation was found after the dissemination of the clinical guidelines and policy changes in 2013 or 2016.
The proportion of Danish chiropractic patients undergoing radiography was halved in the period from 2010 to 2020. However, the dissemination of clinical imaging guidelines recommendations and policy changes related to referrals for advanced imaging showed little meaningful change in the monthly utilisation of radiographs in the same period.

The assessment and subsequent management of a potentially neoplastic bone lesion seen at diagnostic radiography is often complicated by diagnostic uncertainty and inconsistent management recommendations. Appropriate clinical management should be directed by risk of malignancy. Herein, the ACR-sponsored Bone Reporting and Data System (Bone-RADS) Committee, consisting of academic leaders in the fields of musculoskeletal oncology imaging and orthopedic oncology, presents the novel Bone-RADS scoring system to aid in risk assignment and provide risk-aligned management suggestions. When viewed in the proper clinical context, a newly identified bone lesion can be risk stratified as having very low, low, intermediate, or high risk of malignancy. Radiographic features predictive of risk are reviewed include margination, pattern of periosteal reaction, depth of endosteal erosion, pathological fracture, and extra-osseous soft tissue mass. Other radiographic features predictive of histopathology are also briefly discussed. To apply the Bone-RADS scoring system to a potentially neoplastic bone lesion, radiographic features predictive of risk are each given a point value. Point values are summed to yield a point total, which can be translated to a Bone-RADS score (1-4) with corresponding risk assignment (very low, low, intermediate, high). For each score, evidence-based and best practice consensus management suggestions are outlined. Examples of each Bone-RADS scores are presented, and a standardized diagnostic radiography report template is provided.

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OBJECTIVE: To evaluate management of children and young people presenting to the Emergency Department (ED) with magnet ingestion before and after new guidance.
METHODS: In May 2021, a National Patient Safety Agency and Royal College of Emergency Medicine (RCEM) Best Practice Guideline about management of ingested magnets was published. This was implemented in our department. Children and young people presenting after magnet ingestion were identified from SNOMED (coded routinely collected data) and X-ray requests between January 2016 and March 2022. Management was compared to national guidance.
RESULTS: There were 138 patient episodes of magnet ingestion, with a rising incidence over the 5-year period. Following introduction of the guideline, there was a higher incidence of admission (36% vs. 20%) and operative intervention (15.7% vs. 8%). Use of follow-up X-ray increased from 56% to 90%. There was substantial variation in the management prior to guidance which reduced after introduction of the RCEM guidance.
CONCLUSIONS: Management of magnet ingestion has become more standardised since introduction of the National RCEM Best Practice Guideline, but there is still room for improvement.

OBJECTIVE: Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion.
METHODS: The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations.
RESULTS: Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus.
CONCLUSIONS: Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.

BACKGROUND: The Fleischner Society established consensus guidelines for imaging in patients with coronavirus disease 2019 (COVID-19). We investigated the prevalence of pneumonia and the adverse outcomes by dividing groups according to the symptoms and risk factors of patients and assessed the suitability of the Fleischner society imaging guidelines in evaluating chest radiographs of COVID-19 patients.
METHODS: From February 2020 to May 2020, 685 patients (204 males, mean 58 ± 17.9 years) who were diagnosed with COVID-19 and hospitalized were included. We divided patients into four groups according to the severity of symptoms and presence of risk factors (age > 65 years and presence of comorbidities). The patient groups were defined as follows: group 1 (asymptomatic patients), group 2 (patients with mild symptoms without risk factors), group 3 (patients with mild symptoms and risk factors), and group 4 (patients with moderate to severe symptoms). According to the Fleischner society, chest imaging is not indicated for groups 1-2 but is indicated for groups 3-4. We compared the prevalence and score of pneumonia on chest radiographs and compare the adverse outcomes (progress to severe pneumonia, intensive care unit admission, and death) between groups.
RESULTS: Among the 685 COVID-19 patients, 138 (20.1%), 396 (57.8%), 102 (14.9%), and 49 (7.1%) patients corresponded to groups 1 to 4, respectively. Patients in groups 3-4 were significantly older and showed significantly higher prevalence rates of pneumonia (group 1-4: 37.7%, 51.3%, 71.6%, and 98%, respectively, P < 0.001) than those in groups 1-2. Adverse outcomes were also higher in groups 3-4 than in groups 1-2 (group 1-4: 8.0%, 3.5%, 6.9%, and 51%, respectively, P < 0.001). Patients with adverse outcomes in group 1 were initially asymptomatic but symptoms developed during follow-up. They were older (mean age, 80 years) and most of them had comorbidities (81.8%). Consistently asymptomatic patients had no adverse events.
CONCLUSIONS: The prevalence of pneumonia and adverse outcomes were different according to the symptoms and risk factors in COVID-19 patients. Therefore, as the Fleischner Society recommended, evaluation and monitoring of COVID-19 pneumonia using chest radiographs is necessary for old symptomatic patients with comorbidities.