Small-bowel MRI in children and young adults with Crohn disease: retrospective head-to-head comparison of contrast-enhanced and diffusion-weighted MRI

Background

Small-bowel MRI based on contrast-enhanced T1-weighted sequences has been challenged by diffusion-weighted imaging (DWI) for detection of inflammatory bowel lesions and complications in patients with Crohn disease.

Objective

To evaluate free-breathing DWI, as compared to contrast-enhanced MRI, in children, adolescents and young adults with Crohn disease.

Materials and methods

This retrospective study included 33 children and young adults with Crohn disease ages 17?±?3 years (mean ± standard deviation) and 27 matched controls who underwent small-bowel MRI with contrast-enhanced T1-weighted sequences and DWI at 1.5 T. The detectability of Crohn manifestations was determined. Concurrent colonoscopy as reference was available in two-thirds of the children with Crohn disease.

Results

DWI and contrast-enhanced MRI correctly identified 32 and 31 patients, respectively. All 22 small-bowel lesions and all Crohn complications were detected. False-positive findings (two on DWI, one on contrast-enhanced MRI), compared to colonoscopy, were a result of large-bowel lumen collapse. Inflammatory wall thickening was comparable on DWI and contrast-enhanced MRI. DWI was superior to contrast-enhanced MRI for detection of lesions in 27% of the assessed bowel segments and equal to contrast-enhanced MRI in 71% of segments.

Conclusion

DWI facilitates fast, accurate and comprehensive workup in Crohn disease without the need for intravenous administration of contrast medium. Contrast-enhanced MRI is superior in terms of spatial resolution and multiplanar acquisition.     

MRI of the wrist in juvenile idiopathic arthritis: proposal of a paediatric synovitis score by a consensus of an international working group. Results of a multicentre reliability study

Background

MRI is a sensitive tool for the evaluation of synovitis in juvenile idiopathic arthritis (JIA).

Objective

The purpose of this study was to introduce a novel MRI-based score for synovitis in children and to examine its inter- and intraobserver variability in a multi-centre study.

Materials and methods

Wrist MRI was performed in 76 children with JIA. On postcontrast 3-D spoiled gradient-echo and fat-suppressed T2-weighted spin-echo images, joint recesses were scored for the degree of synovial enhancement, effusion and overall inflammation independently by two paediatric radiologists. Total-enhancement and inflammation-synovitis scores were calculated.

Results

Interobserver agreement was poor to moderate for enhancement and inflammation in all recesses, except in the radioulnar and radiocarpal joints. Intraobserver agreement was good to excellent. For enhancement and inflammation scores, mean differences (95 % CI) between observers were ?1.18 (?4.79 to 2.42) and ?2.11 (?6.06 to 1.83). Intraobserver variability (reader 1) was 0 (?1.65 to 1.65) and 0.02 (?1.39 to 1.44).

Conclusion

Intraobserver agreement was good. Except for the radioulnar and radiocarpal joints, interobserver agreement was not acceptable. Therefore, the proposed scoring system requires further refinement.     

Imaging features of medulloepithelioma: report of four cases and review of the literature

Background

Intraocular medulloepithelioma is a childhood tumor arising from the nonpigmented primitive ciliary neuroepithelium. Although rarer than retinoblastoma, it remains the second most common primary intraocular neoplasm in children. The rarity of intraocular medulloepithelioma creates the challenge in establishing a clinical diagnosis, and radiologically the tumor is often confused with other intraocular masses.

Objective

To describe the clinical, imaging and pathological features of intraocular medulloepithelioma with emphasis on the role of imaging to enable its differentiation from more common intraocular pathology.

Materials and methods

We retrospectively analyzed the clinical, histopathological and imaging data of four children with intraocular medulloepithelioma.

Results

All four children had medulloepithelioma arising from the ciliary body. The children were imaged with US (n?=?3), MRI (n?=?4), whole-body ^99mTc-MDP scintigraphy (n?=?2) and CT (n?=?1). All four children had enucleation of the involved eye. One tumor was a malignant teratoid variant, two tumors were malignant nonteratoid variants and one was a nonteratoid variant of uncertain malignant potential. None of the tumors had extraocular extension on histopathology or imaging. Two children had associated retinal detachment on US and MRI examinations. All tumors were iso/hyperintense to vitreous on T1-weighted and hypointense on T2-weighted MRI and showed marked contrast enhancement of the solid components. No calcifications were identified on US or CT examinations.

Conclusion

Our findings are consistent with previously reported cases of medulloepithelioma. This series emphasizes the roles of various imaging modalities, with pathological correlation, in differentiating the tumor from other ciliary body masses, in detecting tumor extension and in identifying associated ocular complications. In this series we also describe the results of postsurgical follow-up for tumor recurrence.     

A comparison of non-contrast and contrast-enhanced MRI in the initial stage of Legg-Calvé-Perthes disease

Background

A prognostic indicator of outcome for Legg-Calvé-Perthes disease (LCP) is needed to guide treatment decisions during the initial stage of the disease (stage 1), before deformity occurs. Radiographic prognosticators are applicable only after fragmentation (stage II).

Objective

We investigated pre- and postcontrast MRI in depicting stage I femoral head involvement.

Materials and methods

Thirty children with stage I LCP underwent non-contrast coronal T1 fast spin-echo (FSE) and corresponding postcontrast fat-suppressed T1-weighted fast spin-echo (FSE) sequences to quantify the extent of femoral head involvement. Three pediatric radiologists and one pediatric orthopedic surgeon independently measured central head involvement.

Results

Interobserver reliability of percent head involvement using non-contrasted MR images had intraclass correlation coefficient (ICC) of 0.72. Postcontrast MRI improved interobserver reliability (ICC 0.82). Qualitatively, the area of involvement was more clearly visible on contrast-enhanced MRI. A comparison of results obtained by each observer using the two MRI techniques showed no correlation. ICC ranged from ?0.08 to 0.03 for each observer. Generally, greater head involvement was depicted by contrast compared with non-contrast MRI (Pearson r?=??0.37, P?=?0.04).

Conclusion

Pre- and postcontrast MRI assess two different components of stage I LCP. However, contrast-enhanced MRI more clearly depicts the area of involvement.     

Acute cerebellitis associated with rotavirus infection

Background

Rotavirus infection is occasionally associated with central nervous system involvement, including cerebellitis. However, the precise clinical sequelae of central nervous system disorders and the usefulness of neuroradiological examination for clinical therapies, such as steroid pulse therapy, have not been clarified.

Methods

We present a case of rotavirus cerebellitis examined by magnetic resonance imaging (MRI), magnetic resonance spectroscopy, and single photon emission computed tomography.

Results

MRI demonstrated abnormal intensities in the right cerebellum on fluid attenuated inversion recovery images and, much more obviously, on diffusion-weighted images, but not on T1- or T2-weighted images. Single photon emission computed tomography showed only mild hypoperfusion in the right cerebellum on the 15th day, while 4 weeks later the image showed remarkably low perfusion in the right cerebellum.

Conclusion

The findings of the reported case suggest the importance of performing radiological examinations at early phases of the disease, especially by new modalities such as diffusion weighted imaging, to make timely and appropriate therapeutic decisions.     

Clinical manifestations and MRI features of vaginal endodermal sinus tumors in four children

Background

Vaginal endodermal sinus tumor is a rare entity.

Objective

The purpose of this study was to report the clinical manifestations and MRI features in a case series.

Materials and methods

Children with vaginal endodermal sinus tumor admitted to our hospitals between January 2008 and August 2012 were included. MRI was performed in all four children and diffusion-weighted imaging was performed in two children.

Results

Four children, mean age 14 months, were included. All had a history of vaginal bleeding. Serum alpha-fetoprotein was significantly elevated on admission. Relative to muscle, the vaginal masses were uniformly isointense on T1-weighted images, heterogeneously hyperintense on T2-weighted images and heterogeneously enhancing on contrast-enhanced images. The vaginal masses were obviously hyperintense on diffusion-weighted images (b value, 800 s/mm²). Extravaginal invasion was observed in three children. Pelvic lymphadenopathy was noted in two children and pulmonary metastasis was found in one child.

Conclusion

MRI may contribute in the evaluation of vaginal endodermal sinus tumors.     

Reduced artefacts and improved assessment of hyperintense brain lesions with BLADE MR imaging in patients with neurofibromatosis type 1

Background

Assessment of small brain lesions in children is often compromised by pulsation, flow or movement artefacts. MRI with a rotating blade-like k-space covering (BLADE, PROPELLER) can compensate for these artefacts.

Objective

We compared T2-weighted FLAIR images that were acquired with different k-space trajectories (conventional Cartesian and BLADE) to evaluate the impact of BLADE technique on the delineation of small or low-contrast brain lesions.

Materials and methods

The subject group comprised 26 children with neurofibromatosis type 1 (NF 1), who had been routinely scanned at 1.5 T for optic pathway gliomas with both techniques and who had the typical hyperintense brain lesions seen in NF 1. Four experienced radiologists retrospectively compared unlabelled 4-mm axial images with respect to the presence of artefacts, visibility of lesions, quality of contour and contrast.

Results

Both techniques were comparable in depicting hyperintense lesions as small as 2 mm independent of contrast and edge definition. Pulsation and movement artefacts were significantly less common with BLADE k-space trajectory. In 7 of 26 patients (27%), lesions and artefacts were rated as indistinguishable in conventional FLAIR, but not in BLADE FLAIR images.

Conclusion

BLADE imaging significantly improved the depiction of lesions in T2-W FLAIR images due to artefact reduction especially in the posterior fossa.     

MRI assessment of bone marrow in children with juvenile idiopathic arthritis: intra- and inter-observer variability

Background

Bone marrow oedema (BMO) is included in MRI-based scoring systems of disease activity in adults with rheumatoid arthritis. Similar systems in juvenile idiopathic arthritis (JIA) are lacking.

Objective

To assess the reproducibility in a multi-centre setting of an MRI BMO scoring system in children with JIA.

Materials and methods

Seventy-six wrist MRIs were read twice, independently, by two experienced paediatric radiologists. BMO was defined as ill-defined lesions within the trabecular bone, returning high and low signal on T2- and T1-weighted images respectively, with or without contrast enhancement. BMO extension was scored for each of 14 bones at the wrist from 0 (none) to 3 (extensive).

Results

The intra-observer agreement was moderate to excellent, with weighted kappa ranging from 0.85 to 1.0 and 0.49 to 1.0 (readers 1 and 2 respectively), while the inter-observer agreement ranged from 0.41 to 0.79. The intra- and inter-observer intraclass correlation coefficients were excellent and satisfactory, respectively.

Conclusion

The scoring system was reliable and may be used for grading bone marrow abnormality in JIA. The relatively large variability in aggregate scores, particularly between readers, underscores the need for thorough standardisation.     

Melanotic neuroectodermal tumour of infancy: CT and MR findings

Background

Melanotic neuroectodermal tumour of infancy (MNTI) is a rare neoplasm of neural crest origin.

Objective

To describe three further cases of MNTI, with emphasis on CT and MRI findings.

Materials and methods

Data for children with histologically confirmed MNTI following biopsy or surgery were retrieved. Three children with available imaging at the time of diagnosis were included in the study.

Results

All three children had primary tumour in the head and neck region: one in the maxilla, one in the occipital bone (extra-axial but with intracranial extension) and one with an unusual tumour growing exophytically from the subcutaneous tissues adjacent to the occipital bone. All tumours were iso/hypointense both on T1- and T2-weighted MRI, and showed marked contrast enhancement in their non-ossified components. CT allowed identification of bone destruction and remodelling.

Conclusion

Our findings are consistent with previously reported cases of MNTI regarding age at presentation and location in the head and neck region. Our MR findings did not demonstrate the typical pattern of T1-shortening expected from melanin deposition.     

Post-contrast T1-weighted sequences in pediatric abdominal imaging: comparative analysis of three different sequences and imaging approach

Background

Post-contrast T1-weighted imaging is an essential component of a comprehensive pediatric abdominopelvic MR examination. However, consistent good image quality is challenging, as respiratory motion in sedated children can substantially degrade the image quality.

Objective

To compare the image quality of three different post-contrast T1-weighted imaging techniques—standard three-dimensional gradient-echo (3-D-GRE), magnetization-prepared gradient-recall echo (MP-GRE) and 3-D-GRE with radial data sampling (radial 3-D-GRE)—acquired in pediatric patients younger than 5 years of age.

Materials and methods

Sixty consecutive exams performed in 51 patients (23 females, 28 males; mean age 2.5?±?1.4 years) constituted the final study population. Thirty-nine scans were performed at 3 T and 21 scans were performed at 1.5 T. Two different reviewers independently and blindly qualitatively evaluated all sequences to determine image quality and extent of artifacts.

Results

MP-GRE and radial 3-D-GRE sequences had the least respiratory motion (P?Conclusions Our preliminary results support the preference of fat-suppressed radial 3-D-GRE as the best post-contrast T1-weighted imaging approach for patients under the age of 5 years, when dynamic imaging is not essential.     

High-resolution 3-D T2-weighted imaging in the diagnosis of labyrinthitis ossificans: emphasis on subtle cochlear involvement

Background

Meningitis is the most common cause of acquired sensorineural hearing loss (SNHL) in children. Labyrinthitis ossificans develops in a significant number of patients with meningitis-related SNHL. Reduced T2 signal on MRI within the membranous labyrinth is often noted in the fibrous and ossifying stages of labyrinthitis ossificans.

Objective

The purpose of this study is to demonstrate the distribution and extent of involvement of the cochlea in children being evaluated for labyrinthitis ossificans; using high-resolution 3-D T2-weighted imaging, and to evaluate for subtle involvement of the scala tympani within the basal turn of the cochlea.

Materials and methods

A retrospective review from 2002 to 2012 was performed using a cochlear implant database and PACS search function. Twenty-four patients were found to have MR findings consistent with labyrinthitis ossificans, 13 previously reported. Axial 3-D T2-weighted sequences were obtained in all patients. The presence of abnormal decreased T2 signal within the scala tympani and vestibuli of the cochlea was noted and graded according to the extent. The electronic medical record was reviewed for audiometry and risk factors as well as correlative operative findings.

Results

The average age at imaging was 4.2 years. M:F ratio?=?5:1. Eighty-eight percent (21/24) of patients had bilateral SNHL. The most common risk factor for labyrinthitis ossificans was meningitis (19/24 or 79%). Eighteen (75%) patients had a history of bacterial meningitis. The mean age for the onset of labyrinthitis was 1.2 years with an average of 2.2-year interval to imaging. Nineteen patients (79%) underwent placement of a cochlear implant. Cochlear obstruction was documented in 83% (40/48) of the ears. Lower grade (1) cochlear obstruction was present in 14 ears and limited to the scala tympani. Statistical analysis was performed correlating MRI imaging and surgical findings.

Conclusion

Subtle, isolated involvement of the scala tympani within the proximal basal turn is a common finding in labyrinthitis ossificans and history typical for meningitis is not uniformly present. The extent of cochlear obstruction is important and has surgical implications.     

Diagnostic image quality of gadolinium-enhanced T1-weighted MRI with and without fat saturation in children with retinoblastoma

Background

Gadolinium-enhanced T1-weighted MRI without fat saturation has been recommended for assessment of retinoblastoma.

Objective

The purpose of this study was to compare diagnostic image quality without and with fat saturation following gadolinium administration.

Materials and methods

High-resolution gadolinium-enhanced T1-weighted sequences with and without fat saturation performed in children with subsequently histopathologically confirmed retinoblastoma were included. Image analysis (image quality [1 = poor, 2 = moderate, 3 = good], anatomical detail depiction, tumour extension) was performed by two neuroradiologists in consensus. Enhancement was scored and measured. Signal- and contrast-to-noise ratios were calculated. Image-assessed tumour invasiveness was compared to histopathological findings. Paired sample t-test was used for statistical analysis.

Results

Thirty-six children (mean age, 19.0?±?16.8 [SD] months) were included. Image quality and anatomical detail depiction were significantly better without fat saturation (P?<?0.001). Tumour enhancement was rated higher with fat saturation (P?<?0.001). Fat saturation improved detection of (post-)laminar optic nerve infiltration. Detection of choroidal invasion was improved without fat saturation. Combining both sequences was best in the assessment of tumour extension (sensitivity/specificity for (post-)laminar optic nerve infiltration, 75.0%/100.0%, and for choroidal invasion, 87.5%/85.7%).

Conclusion

Combined T1-weighted spin-echo imaging with and without fat saturation improved the image quality for assessment of invasiveness of retinoblastoma.     

High success rates of sedation-free brain MRI scanning in young children using simple subject preparation protocols with and without a commercial mock scanner–the Diabetes Research in Children Network (DirecNet) experience

Background

The ability to lie still in an MRI scanner is essential for obtaining usable image data. To reduce motion, young children are often sedated, adding significant cost and risk.

Objective

We assessed the feasibility of using a simple and affordable behavioral desensitization program to yield high-quality brain MRI scans in sedation-free children.

Materials and methods

222 children (4–9.9 years), 147 with type 1 diabetes and 75 age-matched non-diabetic controls, participated in a multi-site study focused on effects of type 1 diabetes on the developing brain. T1-weighted and diffusion-weighted imaging (DWI) MRI scans were performed. All children underwent behavioral training and practice MRI sessions using either a commercial MRI simulator or an inexpensive mock scanner consisting of a toy tunnel, vibrating mat, and video player to simulate the sounds and feel of the MRI scanner.

Results

205 children (92.3%), mean age 7?±?1.7 years had high-quality T1-W scans and 174 (78.4%) had high-quality diffusion-weighted scans after the first scan session. With a second scan session, success rates were 100% and 92.5% for T1-and diffusion-weighted scans, respectively. Success rates did not differ between children with type 1 diabetes and children without diabetes, or between centers using a commercial MRI scan simulator and those using the inexpensive mock scanner.

Conclusion

Behavioral training can lead to a high success rate for obtaining high-quality T1-and diffusion-weighted brain images from a young population without sedation.     

Rib head protrusion into the central canal in type 1 neurofibromatosis

Background

Intraspinal rib head dislocation is an important but under-recognized consequence of dystrophic scoliosis in patients with neurofibromatosis 1 (NF1).

Objective

To present clinical and imaging findings of intraspinal rib head dislocation in NF1.

Materials and methods

We retrospectively reviewed clinical presentation, imaging, operative reports and post-operative courses in four NF1 patients with intraspinal rib head dislocation and dystrophic scoliosis. We also reviewed 17 cases from the English literature.

Results

In each of our four cases of intraspinal rib head dislocation, a single rib head was dislocated on the convex apex of the curve, most often in the mid- to lower thoracic region. Cord compression occurred in half of these patients. Analysis of the literature yielded similar findings. Only three cases in the literature demonstrates the MRI appearance of this entity; most employ CT. All of our cases include both MRI and CT; we review the subtle findings on MRI.

Conclusion

Although intraspinal rib head dislocation is readily apparent on CT, sometimes MRI is the only cross-sectional imaging performed. It is essential that radiologists become familiar with this entity, as subtle findings have significant implications for surgical management.     

MRI diffusion-weighted imaging (DWI) in pediatric small bowel Crohn disease: correlation with MRI findings of active bowel wall inflammation

Background

Restricted diffusion on diffusion-weighted imaging (DWI) sequences during magnetic resonance enterography (MRE) has been shown in segments of bowel affected by Crohn disease. However, the exact meaning of this finding, particularly within the pediatric Crohn disease population, is poorly understood.

Objective

The purpose of this study was to determine the significance of bowel wall restricted diffusion in children with small bowel Crohn disease by correlating apparent diffusion coefficient (ADC) values with other MRI markers of disease activity.

Materials and methods

A retrospective review of pediatric patients (≤ 18 years of age) with Crohn disease terminal ileitis who underwent MRE with DWI at our institution between May 1, 2009 and May 31, 2011 was undertaken. All of the children had either biopsy-proven Crohn disease terminal ileitis or clinically diagnosed Crohn disease, including terminal ileal involvement by imaging. The mean minimum ADC value within the wall of the terminal ileum was determined for each examination. ADC values were tested for correlation/association with other MRI findings to determine whether a relationship exists between bowel wall restricted diffusion and disease activity.

Results

Forty-six MRE examinations with DWI in children with terminal ileitis were identified (23 girls and 23 boys; mean age, 14.3 years). There was significant negative correlation or association between bowel wall minimum ADC value and established MRI markers of disease activity, including degree of bowel wall thickening (R?=?(?)0.43; P?=?0.003), striated pattern of arterial enhancement (P?=?0.01), degree of arterial enhancement (P?=?0.01), degree of delayed enhancement (P?=?0.045), amount of mesenteric inflammatory changes (P?<?0.0001) and presence of a stricture (P?=?0.02). ADC values were not significantly associated with bowel wall T2-weighted signal intensity, length of disease involvement or mesenteric fibrofatty proliferation.

Conclusion

Increasing bowel wall restricted diffusion (lower ADC values) is associated with multiple MRI findings that are traditionally associated with active inflammation in pediatric small bowel Crohn disease.     

MRI for the diagnosis of recurrent middle ear cholesteatoma in children—can we optimize the technique? Preliminary study

Background

Recurrent cholesteatoma after surgical excision occurs frequently in children. Until recently, a surgical second look was mandatory and considered as standard reference. MRI including a delayed T1 sequence after gadolinium injection and diffusion-weighted imaging (DWI) has proved its efficiency but has been evaluated mainly in adults.

Objective

Our purpose was to evaluate the accuracy of DWI to diagnose recurrence of cholesteatoma in children.

Materials and methods

We evaluated prospectively with MRI 20 ears in 18 children who had had surgery for cholesteatoma. We compared DWI and delayed T1-weighted images following gadolinium administration with intraoperative or follow-up findings. We calculated the sensitivity and specificity of each sequence for the diagnosis of recurrent cholesteatoma.

Results

Sensitivity to diagnose recurrent cholesteatoma was 87% for both DWI and delayed post-gadolinium sequences, specificity was 71% and 83%, respectively. Adding both sequences, the sensitivity was 87%, the specificity 100%. There was one false negative probably due to small size recurrence.

Conclusion

In our series, DWI was reliable to diagnose recurrent cholesteatoma in children and allows avoiding surgery when negative. However, because small recurrences less than 5 mm may be missed, follow-up must be prolonged (5 years).     

An MRI system for imaging neonates in the NICU: initial feasibility study

Background

Transporting premature infants from a neonatal intensive care unit (NICU) to a radiology department for MRI has medical risks and logistical challenges.

Objective

To develop a small 1.5-T MRI system for neonatal imaging that can be easily installed in the NICU and to evaluate its performance using a sheep model of human prematurity.

Materials and methods

A 1.5-T MRI system designed for orthopedic use was adapted for neonatal imaging. The system was used for MRI examinations of the brain, chest and abdomen in 12 premature lambs during the first hours of life. Spin-echo, fast spin-echo and gradient-echo MR images were evaluated by two pediatric radiologists.

Results

All animals remained physiologically stable throughout the imaging sessions. Animals were imaged at two or three time points. Seven brain MRI examinations were performed in seven different animals, 23 chest examinations in 12 animals and 19 abdominal examinations in 11 animals. At each anatomical location, high-quality images demonstrating good spatial resolution, signal-to-noise ratio and tissue contrast were routinely obtained within 30?min using standard clinical protocols.

Conclusion

Our preliminary experience demonstrates the feasibility and potential of the neonatal MRI system to provide state-of-the-art MRI capabilities within the NICU. Advantages include overall reduced cost and site demands, lower acoustic noise, improved ease of access and reduced medical risk to the neonate.     

Current status of paediatric post-mortem imaging: an ESPR questionnaire-based survey

Background

The use of post-mortem imaging, including skeletal radiography, CT and MRI, is increasing, providing a minimally invasive alternative to conventional autopsy techniques. The development of clinical guidelines and national standards is being encouraged, particularly for cross-sectional techniques.

Objective

To outline the current practice of post-mortem imaging amongst members of the European Society of Paediatric Radiology (ESPR).

Materials and methods

We e-mailed an online questionnaire of current post-mortem service provisions to members of the ESPR in January 2013. The survey included direct questions about what services were offered, the population imaged, current techniques used, imaging protocols, reporting experience and intended future involvement.

Results

Seventy-one percent (47/66) of centres from which surveys were returned reported performing some form of post-mortem imaging in children, of which 81?% perform radiographs, 51% CT and 38% MRI. Eighty-seven percent of the imaging is performed within the radiology or imaging departments, usually by radiographers (75%), and 89% is reported by radiologists, of which 64% is reported by paediatric radiologists. Overall, 72% of positive respondents have a standardised protocol for radiographs, but only 32% have such a protocol for CT and 27% for MRI. Sixty-one percent of respondents wrote that this is an important area that needs to be developed.

Conclusion

Overall, the majority of centres provide some post-mortem imaging service, most of which is performed within an imaging department and reported by a paediatric radiologist. However, the populations imaged as well as the details of the services offered are highly variable among institutions and lack standardisation. We have identified people who would be interested in taking this work forwards.