Search Results

Intermittent left flank pain as a child • Xray of the Week What is the diagnosis? Figure 1. A. Sagittal CT of the chest. B.and C. Axial CT of chest and abdomen. Figure 2. A. Sagittal CT of chest. H-shaped vertebrae due to endplate depressions of the vertebral bodies (red arrows) caused by central growth plate infarction. Sclerosis in the spine and sternum (blue arrow) due to medullary bone infarcts. B. Axial CT of chest. Cardiomegaly (yellow arrows) due to anemia. C. Axial CT of abdomen. Densely calcified small spleen (green arrows) indicating autospenectomy. Discussion Sickle cell disease (SCD) a hereditary (autosomal recessive) condition common in people of African descent which causes a hemoglobinopathy, resulting in anemia and ischemia/infarction of multiple organs. Up to 8% of the African population is homozygous for sickle cell as it confers a resistance to malaria. SCD often presents during sepsis or dehydration as a painful vaso-occlusive crisis such as bone,chest or abdominal pain depending on the affected organ. Musculoskeletal manifestations of SCD are due to chronic anemia resulting in extramedullary hematopoiesis, vaso-occlusive crises resulting in bone infarcts, and much less commonly osteomyelitis. Bone infarcts are initially radiolucent on CT, then progress to regions increased attenuation as as fibrosis and sclerosis replace the infarcted bone. As in this case, vertebral body infarcts are seen as a central, squared off endplate depression referred to as the Lincoln log or H-shaped vertebra. (Fig. 1A) Pathognomonic for SCD, but seen in only 10% of cases, this deformity is caused by central growth plate infarction. Anemia causes extramedullary hematopoiesis and leads to cardiomegaly. (Fig. 1B) Splenic infarction is very common such that by age 5 close to 95% of children with SCD have functional autosplenectomy. As seen here, this is manifested by as small densely calcified spleen. (Fig. 1C) Management of vaso-occlusive crises is supportive with oxygen, hydration and analgesia. Treatment with hydroxyurea tends to lessen the severity of vaso-occlusive crises. Bone marrow transplantation can be curative. References: 1. Lonergan GJ, Cline DB, Abbondanzo SL. Sickle cell anemia. Radiographics. 21 (4): 971-94. Radiographics https://pubs.rsna.org/doi/full/10.1148/radiographics.21.4.g01jl23971 2. Stoller DW, Tirman PF, Bredella MA. Diagnostic imaging, Orthopaedics. Amirsys Inc. (2004) ISBN:0721629202. Find it at Amazon 3. Ejindu VC, Hine AL, Mashayekhi M et-al. Musculoskeletal manifestations of sickle cell disease. Radiographics. 27 (4): 1005-21. https://pubs.rsna.org/doi/10.1148/rg.274065142 4. Al-Salem AH. Splenic Complications of Sickle Cell Anemia and the Role of Splenectomy. ISRN Hematol. 2011; 2011: 864257. http://dx.doi.org/10.5402/2011/864257 5. Voskaridou E, Christoulas, D, Terpos E. (2012), Sickle‐cell disease and the heart: review of the current literature. Br J Haematol, 157: 664-673. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2141.2012.09143.x 6. Pecker LH, Schaefer BA, Luchtman-Jones L. Knowledge insufficient: the management of haemoglobin SC disease. (2017) British journal of haematology. 176 (4): 515-526. https://onlinelibrary.wiley.com/doi/full/10.1111/bjh.14444 7. Ganguly A, Boswell W, Aniq H. Musculoskeletal Manifestations of Sickle Cell Anaemia: A Pictorial Review. Hindawi, 2011. Anemia, vol. 2011, Article ID 794283. https://www.hindawi.com/journals/anemia/2011/794283/ 8. Kosaraju V, Harwani A, Partovi S, et al. Imaging of musculoskeletal manifestations in sickle cell disease patients. Br J Radiol 2017; 90: 20160130 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605094/ 9. Resnick D, Kransdorf MJ. Hemoglobinopathies and Other Anemias. Bone and joint imaging: Philadelphia, PA: Elsevier BV; 2005. pp. 635–51. [Google Scholar] 10. Kartikueyan R, Chowdhury SR, Krishnan P, and Das S. Characteristic Vertebral Imaging in Sickle Cell Disease. J Neurosci Rural Pract. 2017 Apr-Jun; 8(2): 270–271. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5402497/ Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of Staff of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

As part of Global Radiology CME's ongoing commitment to providing eco-conscious CME conferences we are pleased to announce the engagement of Lisa Ricci Rofsky as our Eco Conscious Consultant. A long term business owner with expertise and a passion for sustainable initiatives Lisa will be assessing our current company practices, then developing and integrating environmental actions that will assist us on journey towards eco-conscious meetings. We are currently endeavoring to work with venues and suppliers that support these objectives. The SPG chain of hotels that include Marriott/Westin have been an industry leader in green meeting initiatives. We are proud to be partnering this year with the Westin Dublin and to have partnered last year with the Prague Marriott. As part of our ongoing effort to reduce our carbon footprint all our marketing is done through social media networks and email, not paper brochures. Our mobile friendly website provides on-line education, paperless registration and payment options for our courses, electronic syllabus, and even our CME certificates. We prioritize working with suppliers that use locally sourced products in our host cities. We embrace the challenge of further identifying and implementing initiatives at every level of our conferences, encourage the input of the Global Rad community and warmly welcome Lisa to the Global Radiology CME Team! The Imaging in Dublin 2020 #iid2020 conference will be held in Dublin, Ireland from June 7 to June 10, 2020, at the Westin Dublin Hotel. This is a unique opportunity to meet radiologists from all corners of the globe in an intriguing location, and learn from some of the best specialists in their field. Indulge all your senses and join the Global Rads for the trip of a lifetime to Dublin, Ireland in June, 2020! Register here for Imaging in Dublin 2020: https://www.globalradcme.com/imagingindublin2020-registration World renowned Body Imager, Neil Rofsky, Professor and Chair of UT Southwestern's Department of Radiology and holder of the Effie and Wofford Cain Distinguished Chair of Diagnostic Imaging will serve as Scientific Director for Imaging in Dublin. Dr. Rofsky will be joined by the luminaries in Radiology: Chief of the Breast Imaging Service at Memorial Sloan Kettering- Elizabeth Morris, ACR's 2018 Gold Medalist- Donald Resnick, Professor of Radiology and Director of Cardiothoracic Imaging, University of Michigan- Ella Kazerooni, MSK MRI expert- Phillip Tirman, and acclaimed neuroradiologist- Blake Johnson, as well as top local experts for cutting edge lectures at The Dublin Westin Hotel. Meet radiologists from all corners of the globe in an intriguing location, and find out why Lonely Planet has named Dublin as one of the top ten cities in the world to visit! Natalie Rice is the co-founder of Global Radiology CME Natalie graduated from the University of Manitoba majoring in Economics. After completing her economics degree she attended Business School, majoring in accounting. Her past work experiences include Dunwoody Accounting Firm, The Conference Board of Canada, and school principal. Having sat on numerous community boards, she is well connected and knows how to see a project to completion. Natalie has planned numerous successful international events throughout Canada, US, Europe, and the Middle East. Natalie managed Global Radiology’s conferences in Israel, Oxford, and Prague. Successfully managing hundreds of delegates from 40 countries and overseeing all aspects of the congresses including faculty management, venue selection, registration, itinerary and social programming.

Global Radiology CME congratulates Dr. Neil Rofsky, MD Scientific Program Director for Global Radiology CME' Imaging in Ireland 2020, for being named an Aunt Minnie semifinalist candidate, in the category of "Most Effective Radiology Educator". The Minnies are a "campaign to recognize the best and brightest in medical imaging". Join Global Rads from around the world and learn from our award winning faculty best described as the luminaries of radiology: Elizabeth Morris, Blake Johnson, Donald Resnick, Neil Rofsky, and Phillip Tirman at Imaging in Dublin 2020 June 7-10, 2020 at the Westin Hotel in Dublin, Ireland. Immerse yourself in academic excellence and network with radiologists from around the world in a city rich in history, rugged beauty, and friendly people on the Emerald Island. Neil Rofsky, MD, MHA, FSCBTMR, FISMRM, FACR, is Professor and Chair of UT Southwestern’s Department of Radiology and holder of the Effie and Wofford Cain Distinguished Chair in Diagnostic Imaging. Dr. Rofsky also serves as Director of Translational Research for the Advanced Imaging Research Center (AIRC), a collaboration of UT Southwestern and the University of Texas at Dallas. Semifinalists for AuntMinnie.com's 2019 Most Effective Radiology Educator: Dr. Jenny Bencardino, University of Pennsylvania Dr. Sanjeev Bhalla, Mallinckrodt Institute of Radiology Dr. Michael Callahan, Boston Children's Hospital Dr. Soonmee Cha, University of California, San Francisco Dr. Carl Fuhrman, University of Pittsburgh Dr. Wende Gibbs, University of Southern California Dr. Darel Heitkamp, Adventist Health System Danny Hughes, PhD, American College of Radiology Dr. Emanuel Kanal, University of Pittsburgh Dr. Faisal Khosa, University of British Columbia Dr. Petra Lewis, Dartmouth College Dr. Frank Lexa, Radiology Leadership Institute Dr. William Masch, University of Michigan Dr. Christine Menias, Mayo Clinic Arizona Dr. Tan-Lucien Mohammed, University of Florida Dr. Gregory Nicola, Hackensack Radiology Group Dr. Ryan Peterson, Emory University Dr. Neil Rofsky, University of Texas Southwestern Dr. Sumer Sethi, Delhi Academy of Medical Sciences Dr. Scott A. Simpson, University of Pennsylvania Dr. Zhonghua Sun, PhD, Curtin University Dr. Scott Williams, Advanced Radiology Consultants Dr. Sanjay Yadav, Mysore Medical College and Research Institute Dr. Mary Yamashita, University of Southern California Logo courtesy of Brian Casey, Editor in chief of AuntMinnie.com

Radiologic technologists have an opportunity to greatly assist the radiologists by performing high quality exams. Unfortunately there is variable quality seen in radiology. (Fig. 1). I explain how these top ten quality tips will greatly reduce errors in the radiology department and improve the ability for radiologists to make an accurate diagnosis. Figure 1. The good, the bad, and the ugly. Unfortunately there is variable quality seen in radiology. Dr. Rice’s Radiography Top Ten: 1. Verify that all images and notes are in PACS for the radiologist. 2. Use a lead side marker with your initials. 3. Remove all clothing, jewelry, and other foreign objects from the field. 4. Use a metal pointer on the area of maximal bone or joint pain. 5. Abdomen x-ray must show both sides of diaphragm and lesser trochanters. 6. Shoulder x-ray must collimate to the shoulder and have 3 views. 7. Wrist X-ray must include a scaphoid view if patient is age 10 or older. 8. CXR must include both lung apices and both lung bases. 9. Accession #, order, and study description for the exam must match the images in PACS. 10. Indication must be available to the radiologist. 1. Verify that all images and notes are in PACS for the radiologist. No sense going to all the trouble to get great images if the radiologist can't see them. If your system does not send an electronic receipt message to the modality, the tech should check the PACS after each case to be sure all the images went through. 2. Use a lead side marker with your initials. The initials are essential so if there is a problem, the radiologist can discuss it with the appropriate person. Technologists should always use physical anatomic side markers placed on the image receptor. Putting on the side marker after taking the image may lead to errors. (Figs. 2-4). This is well documented in the standard textbook for radiographers here: Merrill's Atlas of Radiographic Positioning and Procedures Information on Anatomic Side Markers Figure 2. Electronic side marker, placed on the image with software AFTER it was obtained. The "L" has actually been incorrectly pasted on the patient's right side. Figure 3. Same patient as in Fig. 2 above done the next day, with physical lead side marker placed on the image receptor BEFORE the image was obtained. Technologist has correctly used lead side marker. Figure 4. Example of ambiguous side markers. The radiologist is unable to determine if this is left or right. Study description is LEFT ankle; Marker is RIGHT. If the order is for the wrong side, it is crucial to get the order corrected BEFORE obtaining the radiograph. Also the technologist improperly added the "R" with the imaging software after the image was taken. 3. Remove all clothing, jewelry, and other foreign objects from the field. Extraneous items such as clothing, EKG leads, and jewelry can obscure pathology. (Figs. 5-6) Technologists should be sure to remove it all before taking the image. If the patient refuses or the items can not be removed, the technologist should make a note of it so the radiologist is aware. (Fig. 7. B) Figure 5. Hair extensions on xray. All foreign objects need to be removed prior to taking the radiograph. Figure 6. Jewelry needs to be removed prior to taking the radiograph. Figure 7. A. If there is a reason the images are not following protocol, the tech should make a note of it. Figure 7. B. If the patient refuses or the items can not be removed, the tech should make a note of it. 4. Use a metal pointer on the area of maximal bone or joint pain. The referring physicians have an advantage when they look at the radiographs as they know the exact spot where the patient is having pain. Technologists can give the radiologist the same benefit by placing a metal pointer at the site of pain prior to taking the image. (Figs. 8-10). The technologist should not use the software to insert an electronic pointer after taking the image since this has the same drawbacks as inserting the "L" or "R" after taking the image. (Fig. 10). Using an electronic pointer may result in pointing to the wrong place, or the technologist may be tempted to point to a suspected radiographic abnormality rather than the region of clinical concern. Figure 8. Tech has correctly put a lead marker on the site of maximal tenderness. Figure 9. Same patient as above Fig. 8. Subtle fracture visualized, with help from the tech. Blue arrows are the author's, showing the fracture. Figure 10. A: The tech has put an electronic arrow on the image after it was done. Figure 10. B: The tech has put a physical marker on the site of maximal tenderness. 5. Abdomen x-ray must show both sides of diaphragm and lesser trochanters. Radiologists can miss pathology such as free air or urinary tract calculi if all the anatomy is not included on the images (Fig. 11). Figure 11. A: The upper abdomen is not included on this abdomen radiograph. Figure 11. B: The subsequent chest xray demonstrates free air under the diaphragm (red arrow). Figure 11. C: This is confirmed on the CT scan which shows free air in the abdomen outlining the falciform ligament (blue arrow). 6. Shoulder x-ray must collimate to the shoulder and have 3 views. The central beam should be on the shoulder to avoid geometric distortion. The tech should always shoot a scapular Y view, axillary view, or Grashey view to evaluate for dislocation (Fig. 12). Figure 12. A: The frontal radiograph of the left shoulder demonstrates internal rotation which may give the radiologist a clue to the diagnosis. Figure 12. B: The axillary radiograph of the same patient's left shoulder demonstrates the posterior dislocation and reverse Hill Sachs lesion (also known as a McLaughlin lesion). 7. Wrist X-ray must include a scaphoid view if patient is age 10 or older. Missing a scaphoid fracture may result in non-union and avascular necrosis. Adding the scaphoid view will help the radiologist to make this important diagnosis (Fig. 13). Figure 13: A subtle scaphoid fracture (white arrow) seen on scaphoid view. 8. CXR must include both lung apices and both lung bases. Radiologists can miss pathology such as pneumothorax (Fig. 14), a small pleural effusion, or free air in the abdomen (Fig. 11) if all the anatomy is not included on the images. Figure 14. A: The lower chest is not included on this supine chest radiograph. Figure 14. B: With the lower chest now visible, bilateral pneumothoraces are visualized with a deep sulcus sign on the right (red arrow) and a large lucency on the left (blue arrow). 9. Accession #, order, and study description for the exam must match the images in PACS. All the demographic information has to be correct before sending images to PACS. Trying to fix something after it is in PACS is a nightmare for PACS administrators! 10. Indication must be available to the radiologist. Technologists need to make sure the relevant clinical information is available to the person reading the images. Not only is it important from a patient care perspective, but it is a compliance matter to have a relevant indication on the final report. Through the use of excellent technique, radiographers can greatly assist the radiologists in making an accurate diagnosis, which in turn is a major benefit for our patients. By using the tips in this article you will be on the journey to high quality and safety in the radiology department. Kevin M. Rice, MD serves as the Chair of the Radiology Department and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice together with Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Progressive dysphagia in a 57 year old male • Xray of the Week This 57-year old male presented with a 4-year history of progressive dysphagia with both solid foods and and liquids. CT scan of the chest with contrast and barium esophagogram were performed. What is the diagnosis? Figure 1. CT scan of the chest with IV contrast. A. Axial image. B. Coronal image. What is the diagnosis? Figure 2. Annotated CT scan of the chest with IV contrast. A. Axial image demonstrates a large outpouching (red arrow) with an air fluid level, due to the large esophageal diverticulum. B. Coronal image clearly shows the large right-sided esophageal diverticulum (red arrow) which communicates with the esophagus (green arrow). The esophagus is also dilated (yellow arrow). Figure 3. Esophagram depicts the presence of a large right-sided diverticulum (red arrow) approximately 8 cm from the gastroesophageal junction. There is pooling of the contrast inside the diverticulum as it communicates with the esophagus. The esophagus is also dilated with a characteristic “bird’s beak appearance”/tapering (yellow arrow) near the gastroesophageal junction. Discussion: Epiphrenic esophageal diverticulum (EED) is an uncommon form of esophageal diverticulum with an incidence of only 1:500,000/year in the adult population, and comprises about 10% of all esophageal diverticula. Arising in the distal esophagus, it is typically located 4 to 8 cm above the cardia or in the last 10 cm of the esophagus (1-3). It is a pulsion type of diverticulum caused by motility disorders with markedly increased intraluminal esophageal pressures (1-2). Presentation in infants and children is rarely seen (4). In addition to other motility disorders, achalasia is almost always associated with EED (5). Achalasia itself is a rare entity with an approximate incidence of 1:100,000 people/year (6-7). Clinical manifestations of EED are variable but most commonly include dysphagia and regurgitation which usually progress over time (8). However, up to eighty percent of patients may be asymptomatic. Diagnosis is usually made via barium swallow with supplemental evaluation including upper endoscopy to exclude malignancy and esophageal manometry to delineate any underlying motility disorder (9). Treatment strategies, either open or laparoscopic surgery, involve esophageal myotomy, diverticulectomy and fundoplication. Myotomy decreases the incidence of diverticulum recurrence and partial fundoplication has been proposed as the most appropriate anti-reflux method. Surgery appears to be an effective treatment but is associated with significant mortality and morbidity, thus is it reserved for patients with symptomatic EED (10). References: 1. Debas HT, Payne WS, Cameron AJ, et al (1980). Physiopathology of lower esophageal diverticulum and its implications for treatment. Surg Gynecol Obstet; 151:593–600. 2. Dodds WJ, Stef JJ, Hogan WJ, et al (1975). Radial distribution of peristaltic pressure in normal subjects and patients with esophageal diverticulum. Gastroenterology; 69:584–590. 3. Clouse RE, Diamant NE (2006). From Esophageal motor and sensory function and motor disorders of the esophagus. Sleisenger and Fordtran’s Gastrointestinal and Liver disease. Edited by Feldman M, Freeman LS, Brandt LJ. Philadelphia, WB Saunders; 855-904. 4. Zaninotto G, Portale G, Costantini M, et al (2011). Therapeutic strategies for epiphrenic diverticula: Systematic review. World J Surg; 35:1447-53. 5. Fisichella PM, Jalilvand A, Dobrowolsky A (2015). Achalasia and epiphrenic diverticulum. World J Surg.; 39 (7):1614-9. 6. Vaezi MF, Richter JE (1999). Diagnosis and management of achalasia. American College of Gastroenterology Practice Parameter Committee. Am J Gastroenterol; 94: 3406 – 12. 7. Francis DL, Katzka DA (2010). Achalasia: update on the disease and its treatment. Gastroenterology; 139: 369 – 74. 8. Thomas ML, Anthony A, Fosh BG, et al (2001). Esophageal diverticula. Br J Surg; 88: 629-42. 9. Fasano NC, Levine MS, Rubesin SE, et aI (2003). Epiphrenic diverticulum: clinical and radiographic findings in 27 patients. Dysphagia; 18 (1):9e15. 10. Benacci JC, Deschamps C, Trastek VF, et al (1993). Epiphrenic diverticulum: results of surgical treatment. Ann Thorac Surg; 55:1109 –1114. Karl John A. Koa, MD completed his Doctor of Medicine at West Visayas State University, in La Paz, Iloilo City, Philippines. He is currently the senior and Chief Resident Physician in the Department of Radiology at Chong Hua Hospital, also in Philippines. He has presented case reports in the West Visayas State University including a case report contest on Neurofibromatosis Type 2, which he won last 2015 during his post graduate internship training.

Global Radiology CME is pleased to welcome Prof. MUDr. Jiri Ferda, President of the Czech Radiological Society, Deputy-Head of Department of Imaging, Head of Molecular Imaging Center, Professor of Radiology - Medical Faculty Pilsen, Charles University, Czech Republic to Global Radiology's world renowned faculty for Imaging in Prague. Professional Qualification Diploma in Radiology, Diploma in Neuroradiology, Diploma in Interventional Radiology and Diploma in Nuclear Medicine Professional orientation: Vascular diagnostic and intervention radiology, Computed tomography - advanced CT applications, Magnetic resonance imaging – neuroimaging, cardiac, vascular and abdominal imaging, molecular and hybrid imaging PET/CT, PET/MRI Publications and presented lectures More than 100 scientific publications, 5 monographies, 7 chapters in monography Selected publications: Ferda J, Novák M, Mírka H, Baxa J, Ferdová E, Bednárová A, Flohr T, Schmidt B, Klotz E, Kreuzberg B. The assessment of intracranial bleeding with virtual unenhanced imaging by means of dual-energy CT angiography. Eur Radiol. 2009 Oct;19(10):2518-22. Ferda J, Ferdová E, Záhlava J, Matejovic M, Kreuzberg B. Fever of unknown origin: a value of (18)F-FDG-PET/CT with integrated full diagnostic isotropic CT imaging. Eur J Radiol. 2010 Mar;73(3):518-25. Ferda J, Ferdová E, Mírka H, Baxa J, Bednářová A, Flohr T, Schmidt B, Matějovič M, Kreuzberg B. Pulmonary imaging using dual-energy CT, a role of the assessment of iodine and air distribution. Eur J Radiol. 2011 Feb;77(2):287-93 Ferda J, Ferdová E, Hes O, Mraček J, Kreuzberg B, Baxa J. PET/MRI: Multiparametric imaging of brain tumors. Eur J Radiol. 2017 Sep;94:A14-A25. Ferda J, Hromádka M, Baxa J. Imaging of the myocardium using (18)F-FDG-PET/MRI. Eur J Radiol. 2016 Oct;85(10):1900-1908. ​

6 Week Old Baby with Skin Rash and Bilateral Bone Abnormalities • Xray of the Week What is the diagnosis? Figure 1. Radiographs of the upper and lower extremities. Clinical images of the hand and foot. What is the diagnosis? Clinical images courtesy of Peter Koetters, MD. Figure 2. Annotated radiographs of the upper and lower extremities. There is diffuse mild periostitis of the long bones (red arrows). Mild irregularity of the distal femoral and proximal tibial metaphyses is also present (green arrows). There is mild sclerosis and cupping of the distal radial and ulnar metaphyses as well as the proximal fibular metaphysis (yellow arrows). A rash on the hands and soles with associated with desquamation is another clue to the diagnosis. Clinical images courtesy of Peter Koetters, MD. Discussion: Congenital syphilis is still a major problem in sub-Saharan Africa, but there is a resurgence in several European countries and in North America. Congenital syphilis occurs when Treponema pallidum crosses the placenta during birth or by contact with an infectious lesion. Mucocutaneous involvement is present in about 70% of infants with early congenital syphilis. It is typically a vesicular or maculopapular rash occurring on the palms and soles. As seen in this case, it may be associated with desquamation. The musculoskeletal anomalies include periostitis, metaphysitis, sawtooth metaphysis, diaphyseal osteomyelitis, pathological fractures, joint effusions, sabre shin, dactylitis, and several craniofacial anomalies. Treatment is with benzathine penicillin G, and prognosis is usually good unless non-reversible changes have occured. References: 1. Rasool MN, Govender S. The Skeletal Manifestations of Congenital Syphilis: A Review Of 197 Cases from the University of Natal. J Bone Joint Surg [Br] 1989 :7 I-B :752-755. https://online.boneandjoint.org.uk/doi/pdf/10.1302/0301-620x.71b5.2584243 2. Ferreira ST, Correia C, Marçal M, et al. Skin rash: a manifestation of early congenital syphilis. BMJ Case Rep Published online: 12 May 2016 doi:10.1136/ bcr-2016-216148 3. Hook EW, Peeling RW. Syphilis control--a continuing challenge. The New England Journal of Medicine. 2001 July. 351(2):122-124. doi:10.1056/NEJMp048126 4. Russo PE, Shryock LF. Bone lesions of congenital syphilis in infants and adolescents: report of 46 cases. Radiology. 44(5):477-84. 5. Phiske MM. Current trends in congenital syphilis. Indian J Sex Transm Dis AIDS. 2014 Jan-Jun; 35(1): 12–20. doi: 10.4103/2589-0557.132404 6. Gupta R, Vora R. Congenital syphilis, still a reality. Indian J Sex Transm Dis AIDS. 2013 Jan-Jun; 34(1): 50–52.doi: 10.4103/2589-0557.112941 Kellie Greenblatt, MD Pediatric Radiologist, RIMA A native of the Bay Area, Dr. Greenblatt attended the University of California at Berkeley where she earned a BA in Human Biodynamics. Following graduation, Dr. Greenblatt performed basic research for four years in the toxicology laboratory at Lawrence Livermore Laboratory focusing on carcinogens found naturally in cooked meat. Following her work at Lawrence Livermore, Dr. Greenblatt attended medical school at the Chicago Medical School. After medical school, Dr. Greenblatt did two years of residency training in Surgery before entering a Diagnostic Radiology residency. She completed her Radiology Residency at Kaiser Permanente in Los Angeles, California, then did a one year fellowship in Pediatric Radiology at Children’s Hospital Los Angeles. Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of staff and Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Representatives from Global Radiology CME visited Prague the week of September 24, 2018 to work on the final preparations for Imaging in Prague 2019. We had the pleasure of meeting Dr. Josef Vymazal, Head, Department of Radiology at Na Homolce Hospital, Full Professor at Charles University, Prague, Czech Republic to our faculty. Dr. Vymazal is a neuroradiologist who trained in the USA at the NIH. He is also a practicing neurologist and the director of Na Homolce Hospital in Prague, a neurology and cardiac specialty center. In 2014-2016, Dr. Vymazal served as Deputy Minister of Health for the Czech Republic, and is currently an Adviser to Minister of Health in the Czech Republic. Dr. Vymazal will join our prestigious team that includes, Dr. Donald Resnick, MSK expert, and 2018 recipient of the ACR Gold Medal, Dr. Phillip Tirman, MSK expert, a 2018 Aunt Minnie semifinalist, in the category of most Effective Radiology Educator, Dr. Blake Johnson, highly sought Neuroradiologist lecturer, and Medical Director and Director of Neuroimaging at Center for Diagnostic Imaging, Dr. Neil Rofsky, world renowned body imager, past president SCBTMR, and currently, Professor and Chair of Radiology and the Effie and Wofford Cain Distinguished Chair in Diagnostic Imaging of University of Texas Southwestern. We are also honored to be adding Dr. Paul Parizel, Past President of the ESR and Chairman of the Department of Radiology at the Antwerp University Hospital, and tenured Professor of Radiology, University of Antwerp, Belgium as well as Dr. Nicole Hindman, Associate Professor - Departments of Radiology and Surgery and Director, Female Pelvic Imaging at New York University. We welcome you to join Radiologists from around the world to experience academic excellence and networking and social opportunities the city renowned as the Architectural Jewel of World, rich in history, with a vibrant energy! Natalie Rice, Kevin Rice, and Josef Vymazal in Prague

"Radiology is an adventure, a voyage of discovery." (1) - Paul M. Parizel, MD Paul Parizel, MD, PhD Chairman of the Department of Radiology at the Antwerp University Hospital, and tenured Professor of Radiology, University of Antwerp, Belgium | Past President of the European Society of Radiology and the European Congress of Radiology​ Paul M. Parizel graduated summa cum laude as M.D. from the Faculty of Medicine, University of Antwerp, Belgium, in 1982. He is a board-certified radiologist, and completed fellowships in neuroradiology at Massachusetts General Hospital, Harvard Medical School (Prof. Dr. Juan M. Taveras), and at Hôpital Erasme, University of Brussels (Prof. Dr. Danielle Balériaux). He developed the neuroradiology division at Antwerp University Hospital. In 2016 Prof. Parizel was elected as the first radiologist to be President of both the European Society of Radiology (ESR) and the European Congress of Radiology (ECR) at the same time. (2)In 1994, he obtained a Ph.D. degree with a dissertation entitled “The influence of field strength on magnetic resonance imaging (a comparative study in physicochemical phantoms, isolated brain specimens and clinical applications).” He was able to continue his research thanks to a 3-year ‘Fundamental Clinical Research’ grant from the “Foundation for Scientific Research” in Belgium.Since 2003, he is Chairman of the Department of Radiology at the Antwerp University Hospital, and tenured Professor of Radiology in the Faculty of Medicine and Health Sciences, University of Antwerp. He is a member of the Board of Trustees of the University of Antwerp, representing the Faculty of Medicine and Health Sciences.Prof. Parizel has authored or co-authored more than 300 peer-reviewed scientific papers (listed in PubMed) and more than 30 book chapters. He is editor and co-editor of several books, including “Clinical MR Imaging, a Practical Approach” (Reimer P, Parizel PM, Meaney JFM, Stichnoth F-A, Eds.) and “Spinal Imaging” (Van Goethem J, van den Hauwe L, Parizel PM, Eds.). His main fields of interest are neuroradiology and MRI, with a focus on integrating basic science with clinical applications. Throughout his career he has always strived to combine scientific research with patient-oriented imaging. He has presented invited lectures in many scientific meetings and courses on neuroradiology.Prof. Parizel received several international awards, including the prize of the European Society of Neuroradiology, ECR best presentation award, CompuRAD Exhibition Award. His national awards include the Award of the Belgian Government, Kodak Grant of the Royal Belgian Society of Radiology, and the “Astra Foundation Chair” for Lectures in Medicine. In 2014 he presented the Honorary Wilhelm Conrad Röntgen Honorary Lecture during the European Congress of Radiology (ECR 2014) in Vienna. During the Swiss Congress of Radiology (SCR) in May 2018 Prof. Parizel was awarded the Swiss Society of Radiology's highest honour- The Schinz Medal.Prof. Parizel is an active member of many scientific societies and organizations. He served as President of the Royal Belgian Radiological Society (RBRS) from 1999 to 2000, was chairman of the Scientific Program Committee of the 2003 ESMRMB meeting in Rotterdam, and chairman of the Postgraduate Educational Course Programme for ECR 2011 in Vienna. From 2010 to 2012, he served as President of the European Society of Neuroradiology(ESNR). From March 2016 to March 2017 he was the President the European Society of Radiology (ESR) which is the largest radiology society in the world with more than 65,000 members. Since March 2017, he has been the Chairperson of the ESR Board of Directors. He is an Honorary Fellow of the Royal Australian and New-Zealand College of Radiology (2002), honorary member of the Serbian Society of Neuroradiology (2012) and honorary and founding member of Russian National Society of Neuroradiology (2012). He became Honorary Member of the Serbian Society of Radiology (2013) and Honorary Member of the Societatea Radiologie și Imagistică Medicală din România (2015). In 2016 he became honorary member of the Sociedad Española de Radiología Médica, the European Society of Neuroradiology, the Société Française de Radiologie, the Israel Radiological Association and the Hellenic Radiological Society. In 2017, he became the Honorary Member of the American Society of Neuroradiology and the Iranian Society of Radiology.He has been a member of the Harvard Club of Belgium for almost twenty years.​ References: 1. Parizel identifies youth as central theme for ECR 2017. By Julia Patuzzi. March 7, 2016. Accessed July 26, 2018. https://www.auntminnie.com/index.aspx?sec=rca&sub=ecr_2016&pag=dis&ItemID=113648 2. Paul Parizel, MD: 10 Things to Know about the ECR 2017 President. By Philip Ward. February 15, 2017. Accessed July 26, 2018. https://www.auntminnie.com/index.aspx?sec=rca&sub=ecr_2017&pag=dis&ItemID=116558 ​Image of Prof. Dr. Paul M. Parizel from Linkedin via Wim Van Hecke. https://www.linkedin.com/feed/update/urn:li:activity:6379224435911647232

Hypoxia in a Neonate • Xray of the Week What is the diagnosis? Figure 1. Frontal chest and abdomen radiographs. What is the diagnosis? Figure 2. Annotated frontal chest and abdomen radiographs. The orogastric tube (blue arrow) is in a blind ending pouch due to esophageal atresia. The presence of air in the bowel indicates that there is a tracheoesophageal fistula. T7 is a butterfly vertebral body (yellow arrow). There is hypoplasia of the sacrum with multiple lumbar appearing vertebral bodies (green arrow). There is also a small right pneumothorax (red arrow). Figure 3. A different patient with VACTERL. Note the orogastric tube (blue arrow) coiled in a blind ending pouch due to esophageal atresia. There is also a left sided hemivertebra at L3-4 (green arrow). Discussion VACTERL association is not a syndrome, but due to an constellation of congenital anomalies involving several systems. The incidence is approximately 1 in 10,000 to 1 in 40,000 live-born infants and the etiology of the disorder is unknown. At least 3 of the following anomalies must be ​present to confirm the diagnosis: V- vertebral body defects A - anal atresia C - cardiac anomalies T- tracheoesophageal fistula E - esophageal atresia R- renal anomalies L- limb anomalies (especially radial) Fortunately, VACTERL is not associated with neurocognitive impairment. Treatment is variable depending on the malformations and is typically focused on severe gastrointestinal malformations such as anal atresia and tracheoesophageal fistula as well as any significant cardiac anomaly. References: 1. Solomon BD. VACTERL/VATER Association. Orphanet Journal of Rare Diseases 2011;6 (1): 56. doi:10.1186/1750-1172-6-56. Kellie Greenblatt, MD Pediatric Radiologist, RIMA A native of the Bay Area, Dr. Greenblatt attended the University of California at Berkeley where she earned a BA in Human Biodynamics. Following graduation, Dr. Greenblatt performed basic research for four years in the toxicology laboratory at Lawrence Livermore Laboratory focusing on carcinogens found naturally in cooked meat. Following her work at Lawrence Livermore, Dr. Greenblatt attended medical school at the Chicago Medical School. Following medical school, Dr. Greenblatt did two years of residency training in Surgery before entering a Diagnostic Radiology residency. She completed her Radiology Residency at Kaiser Permanente in Los Angeles, California, then did a one year fellowship in Pediatric Radiology at Children’s Hospital Los Angeles. Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of staff and Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

LLQ Abdominal pain • Xray of the Week 2018 An 83 yo F presented to the Emergency Department with suspected diverticulitis. What is the diagnosis? Figure 1. Axial (A) and coronal (B) non-contrast CT of the abdomen and pelvis. Figure 2. Axial (A) and sagittal (B) non-contrast CT of the abdomen and pelvis. Red arrow: Spigelian hernia with surrounding mesenteric fat stranding indicative of incarceration and small amount of fluid. Green arrow: lateral border of the rectus abdominis muscle. Figure 3. Axial non-contrast CT of the pelvis. Right sided Spigelian hernia containing only mesenteric fat. Discussion: Spigelian hernia is a rare abdominal hernia, which accounts for about 1% of ventral hernias. The peak incidence is in the 4th to 7th decades. The orifice of a Spigelian hernia is located in the Spigelian fascia, between the lateral border of the rectus abdominis muscle and the semilunar line, through the transversus abdominis aponeurosis. As seen in this case, there is a high risk of bowel incarceration and strangulation. (Fig. 1-2) The most common symptom is pain which varies depending on the location and contents of the hernia. Since the hernia lies deep to a muscle and there frequently is no abdominal wall bulge, it is difficult to diagnose clinically. CT is usually diagnostic, demonstrating a hernia sac protruding through the linea semilunaris containing bowel or fat.(Fig. 1-3) Sonography may suggest the diagnosis with a complex mass in the anterolateral aspect of the abdominal wall, which may contain fluid or gas-filled loops of bowel. Treatment is surgical and there is a low risk of recurrence. References: 1. Spangen L. Spigelian hernia. World J Surg. 1989;13 (5): 573-80. 2. Harrison LA, Keesling CA, Martin NL et-al. Abdominal wall hernias: review of herniography and correlation with cross-sectional imaging. Radiographics. 1995;15 (2): 315-32. 3. Mittal T, Kumar V, Khullar R et-al. Diagnosis and management of Spigelian hernia: A review of literature and our experience. J Minim Access Surg. 2008;4 (4): 95-98. 4. Rettenbacher T, Hollerweger A, Macheiner P, et al. Abdominal Wall Hernias: Cross-Sectional Imaging Signs of Incarceration Determined with Sonography AJR Am J Roentgenol. 2001;177 (5): 1061-1066 5. Kirby, R. Strangulated Spigelian hernia. Postgraduate Medical Journal (1987) 63, 51-52 6. Stabile Ianora AA, Midiri M, Vinci R, et al. Abdominal wall hernias: imaging with spiral CT. European Radiology. June 2000, Volume 10, Issue 6, pp 914–919 7. Aguirre DA, Casola G, Sirlin C. Abdominal wall hernias: MDCT findings. AJR Am J Roentgenol. 2004;183 (3): 681-90. Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of staff and Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Global Radiology is deeply honored to be awarded the British Institute of Radiology official seal of approval for our Imaging in England conference in Oxford, UK June 3-6, 2018. Be part of history at this extraordinarily exciting time to visit the U.K. Join Global Rads from around the world and study with the luminaries in radiology at the iconic University of Oxford! With a royal baby due in April and the the wedding of Prince Harry to Meghan Markle on May 26, 2018 England will be THE place to visit this summer. For those who have already registered, we strongly recommend that you make your travel plans early to ensure best selection. For those who have not yet registered, we urge you to register soon and join us for this unforgettable experience. For more information please visit the conference website here: Meeting at BIR with (left to right) Kevin Rice- President of Global Radiology CME, Carole Cross- BIR Communications Manager, Natalie Rice- Vice-President of Global Radiology CME, and Abbey Shaw- BIR Events Manager. The Imaging in England 2018 conference will be held in Oxford, UK from June 3 to June 6, 2018, at the Mathematical Institute on the campus of The University of Oxford. Condé Nast recently named the University of Oxford as one of the top 50 most beautiful places to visit in Europe. Click here for more information--> REGISTRATION INFORMATION Join the Luminaries in Radiology in magical Oxford, UK for an educational and fun experience. Our outstanding faculty will include, Drs. Donald Resnick, László Tabár, Phillip Tirman, Blake Johnson, Neil Rofsky, Vikas Shah, David Wilson, Simon Blease, and Sanjay Prabhu. In addition to a cutting edge scientific program which will include lectures on Artificial Intelligence in Radiology we will be offering our attendees ample opportunities for networking in relaxed social settings, including a welcome reception at the iconic Macdonald Randolph hotel and an evening of delicious food, fine wine and punting at the Cherwell Boathouse. Who attended our last congress? We had registrants from: Australia, Austria, Canada, China, Denmark, France, Greece, Hungary, Indonesia, Ireland, Israel, Kenya, Lithuania, New Zealand, Slovenia, South Africa, Sweden, Switzerland, Turkey, and the USA. Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD Natalie Rice is the co-founder of Global Radiology CME Natalie graduated from the University of Manitoba majoring in Economics. After completing her economics degree she attended Business School, majoring in accounting. Her work experiences include Dunwoody Accounting Firm, The Conference Board of Canada, and Principal of a Religious School. Having sat on numerous community boards, she is well connected and knows how to see a project to completion. Natalie has planned numerous successful international events throughout Canada, the Middle East, and the USA. Most recently, Natalie spearheaded Global Radiology’s inaugural conference in Israel. Successfully managing 250 delegates from 20 different countries and overseeing all aspects of the congress including faculty management, venue selection, registration, itinerary and social programming.