Issue
Date Log
Copyright (c) 2024 Dabiaha Shabnan Saed Alshahrani, Ahmad Mohammed Khawaji, Naif Essa Mohammed Abutawil, Afnan Ali Mohammed Sahli, Hayat Yahya Ali Qarn, Faisal Saad Abdullah Alsaaid, Wafaa Mohammed Mahdi Sufiany, Ahmed Al-Abdu Dahal, Muhammad Ahmad Sharahili, Mamdouh Ahmad Abdaljabar Bosely, Essa Ali Somaili, Fatimah Saad Mohammed Dhamiri

This work is licensed under a Creative Commons Attribution 4.0 International License.
Ethical Challenges in Pediatric Radiology and Beyond: A Narrative Review of Consent, Genetics, Family Support, Image Interpretation, and Healthcare Integration
Corresponding Author(s) : Dabiaha Shabnan Saed Alshahrani
Saudi Journal of Medicine and Public Health,
Vol. 1 No. 2 (2024)
Abstract
Background: Pediatric radiology presents unique ethical dilemmas owing to children’s vulnerability, evolving autonomy, and reliance on proxy decision-makers. Aim: To synthesize ethical challenges across five interconnected domains: nursing consent practices in pediatric imaging, genetic testing in laboratory medicine, family support in social work, radiologic image interpretation, and systemic healthcare integration. Methods: A narrative review of peer-reviewed literature (2015–2024) from PubMed, Scopus, CINAHL, and Web of Science using keywords: pediatric radiology, informed consent, genetic testing, family support, social work, image interpretation, and healthcare ethics. Results: Key findings include inconsistent consent comprehension by guardians, moral distress among nurses, incidental genetic findings in pediatric imaging, social workers’ role in mediating family decisions, cognitive biases in image interpretation, and fragmented ethical oversight across specialties. Conclusion: An integrated, family-centered, and multi-professional ethical framework is urgently needed.
Keywords
Download Citation
Endnote/Zotero/Mendeley (RIS)BibTeX
- Applegate, K. E., & Frush, D. P. (2017). Image gently: a decade of international collaborations to promote appropriate imaging for children. Journal of the American College of Radiology, 14(7), 956-957. https://doi.org/10.1016/j.jacr.2017.04.039
- Baethge, C., Goldbeck-Wood, S., & Mertens, S. (2019). SANRA—a scale for the quality assessment of narrative review articles. Research integrity and peer review, 4(1), 5. https://doi.org/10.1186/s41073-019-0064-8
- Bejarano, C., Fuzzell, L., Clay, C., Leonard, S., Shirley, E., & Wysocki, T. (2015). Shared decision making in pediatrics: a pilot and feasibility project. Clinical Practice in Pediatric Psychology, 3(1), 25-36. https://doi.org/10.1037/cpp0000086
- Berdida, D. J. E., & Grande, R. A. N. (2023). Moral distress, moral resilience, moral courage, and moral injury among nurses in the Philippines during the COVID-19 pandemic: a mediation analysis. Journal of Religion and Health, 62(6), 3957-3978. https://doi.org/10.1007/s10943-023-01873-w
- Bernardo, M. O., Almeida, F. A. D., & Morgado, F. (2017). Radioprotection campaign and card: educational strategies that reduce children’s excessive exposure to radiological exams. Revista Paulista de Pediatria, 35, 178-184. https://doi.org/10.1590/1984-0462/;2017;35;2;00011
- Bhatt, M., Johnson, D. W., Chan, J., Taljaard, M., Barrowman, N., Farion, K. J., ... & Roback, M. G. (2017). Risk factors for adverse events in emergency department procedural sedation for children. JAMA pediatrics, 171(10), 957-964. doi:10.1001/jamapediatrics.2017.2135
- Bombard, Y., Brothers, K. B., Fitzgerald-Butt, S., Garrison, N. A., Jamal, L., James, C. A., ... & Levy, H. P. (2019). The responsibility to recontact research participants after reinterpretation of genetic and genomic research results. The American Journal of Human Genetics, 104(4), 578-595. https://doi.org/10.1016/j.ajhg.2019.02.025
- Brunyé, T. T., Drew, T., Weaver, D. L., & Elmore, J. G. (2019). A review of eye tracking for understanding and improving diagnostic interpretation. Cognitive research: principles and implications, 4(1), 7. https://doi.org/10.1186/s41235-019-0159-2
- Brunyé, T. T., Drew, T., Kerr, K. F., Shucard, H., Weaver, D. L., & Elmore, J. G. (2020). Eye tracking reveals expertise-related differences in the time-course of medical image inspection and diagnosis. Journal of Medical Imaging, 7(5), 051203-051203. https://doi.org/10.1117/1.JMI.7.5.051203
- Butcher, W., & Carey, L. B. (2018). Paediatric spirituality, space and environment. Nash, S., Nash, P., & Bartel, M. Paediatric Chaplaincy Principles, Practices and Skills, 246-257.
- Childress, J. F., & Beauchamp, T. L. (2022). Common morality principles in biomedical ethics: responses to critics. Cambridge Quarterly of Healthcare Ethics, 31(2), 164-176. doi:10.1017/S0963180121000566
- Clarke, A. J., & Van El, C. G. (2022). Genomics and justice: mitigating the potential harms and inequities that arise from the implementation of genomics in medicine. Human Genetics, 141(5), 1099-1107. https://doi.org/10.1007/s00439-022-02453-w
- Clayton, E. W., Tritell, A. M., & Thorogood, A. M. (2023). Avoiding liability and other legal land mines in the evolving genomics landscape. Annual Review of Genomics and Human Genetics, 24(1), 333-346. https://doi.org/10.1146/annurev-genom-100722-021725
- Coyne, I., Amory, A., Kiernan, G., & Gibson, F. (2014). Children's participation in shared decision-making: children, adolescents, parents and healthcare professionals' perspectives and experiences. European Journal of Oncology Nursing, 18(3), 273-280. https://doi.org/10.1016/j.ejon.2014.01.006
- Coyne, I., & Martins, A. (2021). Children and adolescents' participation in information-sharing and healthcare decision-making. In Child and Youth Participation in Policy, Practice and Research (pp. 103-116). Routledge.
- Goodman, M. (2022). Interpretation Strategies in Limited Field of View Cone Beam Computed Tomography: An Eye-Tracking Pilot Study (Master's thesis, Saint Louis University).
- Goske, M., Kaste, P. S., & Ey, E. (2022). Image Gently. Computed Tomography-E-Book: Computed Tomography-E-Book, 234.
- Grace, P. J. (2023). Problematizing moral distress, moral resilience and moral courage: Implications for nurse education and moral agency. In Routledge Handbook of Philosophy and Nursing (pp. 250-260). Routledge.
- Gray, B., & Brunger, F. (2018). (Mis) understandings and uses of ‘culture’in bioethics deliberations over parental refusal of treatment: Children with cancer. Clinical Ethics, 13(2), 55-66. https://doi.org/10.1177/1477750917738109
- Herington, J., McCradden, M. D., Creel, K., Boellaard, R., Jones, E. C., Jha, A. K., ... & Saboury, B. (2023). Ethical considerations for artificial intelligence in medical imaging: deployment and governance. Journal of Nuclear Medicine, 64(10), 1509-1515. https://doi.org/10.2967/jnumed.123.266110
- Hess, E. P., Homme, J. L., Kharbanda, A. B., Tzimenatos, L., Louie, J. P., Cohen, D. M., ... & Kuppermann, N. (2018). Effect of the head computed tomography choice decision aid in parents of children with minor head trauma: a cluster randomized trial. JAMA network open, 1(5), e182430. doi:10.1001/jamanetworkopen.2018.2430
- Hu, T., Wang, X., & Xu, H. (2022). Eye-tracking in interpreting studies: A review of four decades of empirical studies. Frontiers in psychology, 13, 872247. https://doi.org/10.3389/fpsyg.2022.872247
- Lee, M., Desy, J., Tonelli, A. C., Walsh, M. H., & Ma, I. W. (2023). The association of attentional foci and image interpretation accuracy in novices interpreting lung ultrasound images: an eye-tracking study. The Ultrasound Journal, 15(1), 36. https://doi.org/10.1186/s13089-023-00333-6
- Liu, Z., Yang, Z., Gu, Y., Liu, H., & Wang, P. (2021). The effectiveness of eye tracking in the diagnosis of cognitive disorders: A systematic review and meta-analysis. PloS one, 16(7), e0254059. https://doi.org/10.1371/journal.pone.0254059
- Mallory, M. D., Travers, C., Cravero, J. P., Kamat, P. P., Tsze, D., & Hertzog, J. H. (2023). Pediatric sedation/anesthesia for MRI: results from the pediatric sedation research consortium. Journal of Magnetic Resonance Imaging, 57(4), 1106-1113. https://doi.org/10.1002/jmri.28392
- Miller, D. T., Lee, K., Chung, W. K., Gordon, A. S., Herman, G. E., Klein, T. E., ... & ACMG Secondary Findings Working Group. (2021). ACMG SF v3. 0 list for reporting of secondary findings in clinical exome and genome sequencing: a policy statement of the American College of Medical Genetics and Genomics (ACMG). Genetics in medicine, 23(8), 1381-1390. https://doi.org/10.1038/s41436-021-01172-3
- Morrison, A. K., Brousseau, D. C., Brazauskas, R., & Levas, M. N. (2015). Health literacy affects likelihood of radiology testing in the pediatric emergency department. The Journal of pediatrics, 166(4), 1037-1041. https://doi.org/10.1016/j.jpeds.2014.12.009
- Munung, N. S., de Vries, J., & Pratt, B. (2021). Genomics governance: advancing justice, fairness and equity through the lens of the African communitarian ethic of Ubuntu. Medicine, Health Care and Philosophy, 24(3), 377-388. https://doi.org/10.1007/s11019-021-10012-9
- Murtagh, M. J., Machirori, M., Gaff, C. L., Blell, M. T., de Vries, J., Doerr, M., ... & Viney, W. (2021). Engaged genomic science produces better and fairer outcomes: an engagement framework for engaging and involving participants, patients and publics in genomics research and healthcare implementation. Wellcome Open Research, 6, 311. https://doi.org/10.12688/wellcomeopenres.17233.1
- Oakley, P. A., & Harrison, D. E. (2020). Are restrictive medical radiation imaging campaigns misguided? It seems so: a case example of the American Chiropractic Association’s adoption of “choosing wisely”. Dose-Response, 18(2), 1559325820919321. https://doi.org/10.1177/1559325820919321
- Patel, S. H., & Itri, J. N. (2021). Developing expertise in clinical radiology: the feedback challenge. Journal of the American College of Radiology, 18(9), 1348-1350. https://doi.org/10.1016/j.jacr.2021.05.005
- Patel, S. H., & Itri, J. N. (2022). The role of intuitive cognition in radiologic decision making. Journal of the American College of Radiology, 19(5), 669-676. https://doi.org/10.1016/j.jacr.2022.02.027
- Pesapane, F., Volonté, C., Codari, M., & Sardanelli, F. (2018). Artificial intelligence as a medical device in radiology: ethical and regulatory issues in Europe and the United States. Insights into imaging, 9(5), 745-753. https://doi.org/10.1007/s13244-018-0645-y
- Rigsby, C. K., McKenney, S. E., Hill, K. D., Chelliah, A., Einstein, A. J., Han, B. K., ... & Frush, D. P. (2018). Radiation dose management for pediatric cardiac computed tomography: a report from the Image Gently ‘Have-A-Heart’campaign. Pediatric radiology, 48(1), 5-20. https://doi.org/10.1007/s00247-017-3991-x
- Roane, J. L., Mio, M., Viner, J., Bettridge, A., Heyn, C., Roifman, I., ... & Goldstein, B. I. (2022). Incidental Findings Among Youth Participating in Multimodal Imaging Research: Characteristics of Findings and Description of a Management Approach. Frontiers in Pediatrics, 10, 875934. https://doi.org/10.3389/fped.2022.875934
- Ross, L. F., Saal, H. M., David, K. L., & Anderson, R. R. (2013). Technical report: ethical and policy issues in genetic testing and screening of children. Genetics in medicine, 15(3), 234-245. https://doi.org/10.1038/gim.2012.176
- Shamsuddin, N. A., Pien, L. S., & Atan, A. (2023). An Overview of Children’s Participation in Shared Decision-making in Healthcare Settings. Malaysian Journal of Medicine and Health Sciences, 19(5), 306-316. https://doi.org/10.47836/mjmhs19.5.37
- Sherer, M. A. S., Visconti, P. J., Ritenour, E. R., & Haynes, K. W. (2021). Radiation Protection in Medical Radiography-E-Book: Radiation Protection in Medical Radiography-E-Book. Elsevier Health Sciences.
- Tahri Sqalli, M., Aslonov, B., Gafurov, M., Mukhammadiev, N., & Sqalli Houssaini, Y. (2023). Eye tracking technology in medical practice: a perspective on its diverse applications. Frontiers in medical technology, 5, 1253001. https://doi.org/10.3389/fmedt.2023.1253001
- Ulrich, C. M., Hamric, A. B., & Grady, C. (2010). Moral distress: a growing problem in the health professions?. The Hastings Center Report, 40(1), 20-22.
- Vassallo, V. (2023). Secondary and incidental findings in genetics: ethical issues (Master's thesis, University of Malta).
- Wolf, S. M., Burke, W., & Koenig, B. A. (2015). Mapping the ethics of translational genomics: situating return of results and navigating the research-clinical divide. Journal of Law, Medicine & Ethics, 43(3), 486-501. doi:10.1111/jlme.12291
References
Applegate, K. E., & Frush, D. P. (2017). Image gently: a decade of international collaborations to promote appropriate imaging for children. Journal of the American College of Radiology, 14(7), 956-957. https://doi.org/10.1016/j.jacr.2017.04.039
Baethge, C., Goldbeck-Wood, S., & Mertens, S. (2019). SANRA—a scale for the quality assessment of narrative review articles. Research integrity and peer review, 4(1), 5. https://doi.org/10.1186/s41073-019-0064-8
Bejarano, C., Fuzzell, L., Clay, C., Leonard, S., Shirley, E., & Wysocki, T. (2015). Shared decision making in pediatrics: a pilot and feasibility project. Clinical Practice in Pediatric Psychology, 3(1), 25-36. https://doi.org/10.1037/cpp0000086
Berdida, D. J. E., & Grande, R. A. N. (2023). Moral distress, moral resilience, moral courage, and moral injury among nurses in the Philippines during the COVID-19 pandemic: a mediation analysis. Journal of Religion and Health, 62(6), 3957-3978. https://doi.org/10.1007/s10943-023-01873-w
Bernardo, M. O., Almeida, F. A. D., & Morgado, F. (2017). Radioprotection campaign and card: educational strategies that reduce children’s excessive exposure to radiological exams. Revista Paulista de Pediatria, 35, 178-184. https://doi.org/10.1590/1984-0462/;2017;35;2;00011
Bhatt, M., Johnson, D. W., Chan, J., Taljaard, M., Barrowman, N., Farion, K. J., ... & Roback, M. G. (2017). Risk factors for adverse events in emergency department procedural sedation for children. JAMA pediatrics, 171(10), 957-964. doi:10.1001/jamapediatrics.2017.2135
Bombard, Y., Brothers, K. B., Fitzgerald-Butt, S., Garrison, N. A., Jamal, L., James, C. A., ... & Levy, H. P. (2019). The responsibility to recontact research participants after reinterpretation of genetic and genomic research results. The American Journal of Human Genetics, 104(4), 578-595. https://doi.org/10.1016/j.ajhg.2019.02.025
Brunyé, T. T., Drew, T., Weaver, D. L., & Elmore, J. G. (2019). A review of eye tracking for understanding and improving diagnostic interpretation. Cognitive research: principles and implications, 4(1), 7. https://doi.org/10.1186/s41235-019-0159-2
Brunyé, T. T., Drew, T., Kerr, K. F., Shucard, H., Weaver, D. L., & Elmore, J. G. (2020). Eye tracking reveals expertise-related differences in the time-course of medical image inspection and diagnosis. Journal of Medical Imaging, 7(5), 051203-051203. https://doi.org/10.1117/1.JMI.7.5.051203
Butcher, W., & Carey, L. B. (2018). Paediatric spirituality, space and environment. Nash, S., Nash, P., & Bartel, M. Paediatric Chaplaincy Principles, Practices and Skills, 246-257.
Childress, J. F., & Beauchamp, T. L. (2022). Common morality principles in biomedical ethics: responses to critics. Cambridge Quarterly of Healthcare Ethics, 31(2), 164-176. doi:10.1017/S0963180121000566
Clarke, A. J., & Van El, C. G. (2022). Genomics and justice: mitigating the potential harms and inequities that arise from the implementation of genomics in medicine. Human Genetics, 141(5), 1099-1107. https://doi.org/10.1007/s00439-022-02453-w
Clayton, E. W., Tritell, A. M., & Thorogood, A. M. (2023). Avoiding liability and other legal land mines in the evolving genomics landscape. Annual Review of Genomics and Human Genetics, 24(1), 333-346. https://doi.org/10.1146/annurev-genom-100722-021725
Coyne, I., Amory, A., Kiernan, G., & Gibson, F. (2014). Children's participation in shared decision-making: children, adolescents, parents and healthcare professionals' perspectives and experiences. European Journal of Oncology Nursing, 18(3), 273-280. https://doi.org/10.1016/j.ejon.2014.01.006
Coyne, I., & Martins, A. (2021). Children and adolescents' participation in information-sharing and healthcare decision-making. In Child and Youth Participation in Policy, Practice and Research (pp. 103-116). Routledge.
Goodman, M. (2022). Interpretation Strategies in Limited Field of View Cone Beam Computed Tomography: An Eye-Tracking Pilot Study (Master's thesis, Saint Louis University).
Goske, M., Kaste, P. S., & Ey, E. (2022). Image Gently. Computed Tomography-E-Book: Computed Tomography-E-Book, 234.
Grace, P. J. (2023). Problematizing moral distress, moral resilience and moral courage: Implications for nurse education and moral agency. In Routledge Handbook of Philosophy and Nursing (pp. 250-260). Routledge.
Gray, B., & Brunger, F. (2018). (Mis) understandings and uses of ‘culture’in bioethics deliberations over parental refusal of treatment: Children with cancer. Clinical Ethics, 13(2), 55-66. https://doi.org/10.1177/1477750917738109
Herington, J., McCradden, M. D., Creel, K., Boellaard, R., Jones, E. C., Jha, A. K., ... & Saboury, B. (2023). Ethical considerations for artificial intelligence in medical imaging: deployment and governance. Journal of Nuclear Medicine, 64(10), 1509-1515. https://doi.org/10.2967/jnumed.123.266110
Hess, E. P., Homme, J. L., Kharbanda, A. B., Tzimenatos, L., Louie, J. P., Cohen, D. M., ... & Kuppermann, N. (2018). Effect of the head computed tomography choice decision aid in parents of children with minor head trauma: a cluster randomized trial. JAMA network open, 1(5), e182430. doi:10.1001/jamanetworkopen.2018.2430
Hu, T., Wang, X., & Xu, H. (2022). Eye-tracking in interpreting studies: A review of four decades of empirical studies. Frontiers in psychology, 13, 872247. https://doi.org/10.3389/fpsyg.2022.872247
Lee, M., Desy, J., Tonelli, A. C., Walsh, M. H., & Ma, I. W. (2023). The association of attentional foci and image interpretation accuracy in novices interpreting lung ultrasound images: an eye-tracking study. The Ultrasound Journal, 15(1), 36. https://doi.org/10.1186/s13089-023-00333-6
Liu, Z., Yang, Z., Gu, Y., Liu, H., & Wang, P. (2021). The effectiveness of eye tracking in the diagnosis of cognitive disorders: A systematic review and meta-analysis. PloS one, 16(7), e0254059. https://doi.org/10.1371/journal.pone.0254059
Mallory, M. D., Travers, C., Cravero, J. P., Kamat, P. P., Tsze, D., & Hertzog, J. H. (2023). Pediatric sedation/anesthesia for MRI: results from the pediatric sedation research consortium. Journal of Magnetic Resonance Imaging, 57(4), 1106-1113. https://doi.org/10.1002/jmri.28392
Miller, D. T., Lee, K., Chung, W. K., Gordon, A. S., Herman, G. E., Klein, T. E., ... & ACMG Secondary Findings Working Group. (2021). ACMG SF v3. 0 list for reporting of secondary findings in clinical exome and genome sequencing: a policy statement of the American College of Medical Genetics and Genomics (ACMG). Genetics in medicine, 23(8), 1381-1390. https://doi.org/10.1038/s41436-021-01172-3
Morrison, A. K., Brousseau, D. C., Brazauskas, R., & Levas, M. N. (2015). Health literacy affects likelihood of radiology testing in the pediatric emergency department. The Journal of pediatrics, 166(4), 1037-1041. https://doi.org/10.1016/j.jpeds.2014.12.009
Munung, N. S., de Vries, J., & Pratt, B. (2021). Genomics governance: advancing justice, fairness and equity through the lens of the African communitarian ethic of Ubuntu. Medicine, Health Care and Philosophy, 24(3), 377-388. https://doi.org/10.1007/s11019-021-10012-9
Murtagh, M. J., Machirori, M., Gaff, C. L., Blell, M. T., de Vries, J., Doerr, M., ... & Viney, W. (2021). Engaged genomic science produces better and fairer outcomes: an engagement framework for engaging and involving participants, patients and publics in genomics research and healthcare implementation. Wellcome Open Research, 6, 311. https://doi.org/10.12688/wellcomeopenres.17233.1
Oakley, P. A., & Harrison, D. E. (2020). Are restrictive medical radiation imaging campaigns misguided? It seems so: a case example of the American Chiropractic Association’s adoption of “choosing wisely”. Dose-Response, 18(2), 1559325820919321. https://doi.org/10.1177/1559325820919321
Patel, S. H., & Itri, J. N. (2021). Developing expertise in clinical radiology: the feedback challenge. Journal of the American College of Radiology, 18(9), 1348-1350. https://doi.org/10.1016/j.jacr.2021.05.005
Patel, S. H., & Itri, J. N. (2022). The role of intuitive cognition in radiologic decision making. Journal of the American College of Radiology, 19(5), 669-676. https://doi.org/10.1016/j.jacr.2022.02.027
Pesapane, F., Volonté, C., Codari, M., & Sardanelli, F. (2018). Artificial intelligence as a medical device in radiology: ethical and regulatory issues in Europe and the United States. Insights into imaging, 9(5), 745-753. https://doi.org/10.1007/s13244-018-0645-y
Rigsby, C. K., McKenney, S. E., Hill, K. D., Chelliah, A., Einstein, A. J., Han, B. K., ... & Frush, D. P. (2018). Radiation dose management for pediatric cardiac computed tomography: a report from the Image Gently ‘Have-A-Heart’campaign. Pediatric radiology, 48(1), 5-20. https://doi.org/10.1007/s00247-017-3991-x
Roane, J. L., Mio, M., Viner, J., Bettridge, A., Heyn, C., Roifman, I., ... & Goldstein, B. I. (2022). Incidental Findings Among Youth Participating in Multimodal Imaging Research: Characteristics of Findings and Description of a Management Approach. Frontiers in Pediatrics, 10, 875934. https://doi.org/10.3389/fped.2022.875934
Ross, L. F., Saal, H. M., David, K. L., & Anderson, R. R. (2013). Technical report: ethical and policy issues in genetic testing and screening of children. Genetics in medicine, 15(3), 234-245. https://doi.org/10.1038/gim.2012.176
Shamsuddin, N. A., Pien, L. S., & Atan, A. (2023). An Overview of Children’s Participation in Shared Decision-making in Healthcare Settings. Malaysian Journal of Medicine and Health Sciences, 19(5), 306-316. https://doi.org/10.47836/mjmhs19.5.37
Sherer, M. A. S., Visconti, P. J., Ritenour, E. R., & Haynes, K. W. (2021). Radiation Protection in Medical Radiography-E-Book: Radiation Protection in Medical Radiography-E-Book. Elsevier Health Sciences.
Tahri Sqalli, M., Aslonov, B., Gafurov, M., Mukhammadiev, N., & Sqalli Houssaini, Y. (2023). Eye tracking technology in medical practice: a perspective on its diverse applications. Frontiers in medical technology, 5, 1253001. https://doi.org/10.3389/fmedt.2023.1253001
Ulrich, C. M., Hamric, A. B., & Grady, C. (2010). Moral distress: a growing problem in the health professions?. The Hastings Center Report, 40(1), 20-22.
Vassallo, V. (2023). Secondary and incidental findings in genetics: ethical issues (Master's thesis, University of Malta).
Wolf, S. M., Burke, W., & Koenig, B. A. (2015). Mapping the ethics of translational genomics: situating return of results and navigating the research-clinical divide. Journal of Law, Medicine & Ethics, 43(3), 486-501. doi:10.1111/jlme.12291