Comparison of the different imaging modalities used to image pediatric oncology patients: A COG diagnostic imaging committee/SPR oncology committee white paper.

Diagnostic imaging is essential in the diagnosis and management, including surveillance, of known or suspected cancer in children. The independent and combined roles of the various modalities, consisting of radiography, fluoroscopy, ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine (NM), are both prescribed through protocols but also function in caring for complications that may occur during or subsequent to treatment such as infection, bleeding, or organ compromise. Use of a specific imaging modality may be based on situational circumstances such as a brain CT or MR for a new onset seizure, chest CT for respiratory signs or symptoms, or US for gross hematuria. However, in many situations, there are competing choices that do not easily lend themselves to a formulaic approach as options; these situations depend on the contributions of a variety of factors based on a combination of the clinical scenario and the strengths and limitations of the imaging modalities. Therefore, an improved understanding of the potential influence of the imaging decision pathways in pediatric cancer care can come from comparison among the individual diagnostic imaging modalities. The purpose of the following material to is to provide such a comparison. To do this, pediatric imaging content experts for the individual modalities of radiography and fluoroscopy, US, CT, MRI, and NM will discuss the individual modality strengths and limitations.

Diagnostic performance of ultrasound hepatorenal index for the diagnosis of hepatic steatosis in children.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is increasing in prevalence and is the most common cause of pediatric chronic liver disease. Objective US-based measures of hepatic steatosis are an unmet clinical need. OBJECTIVE: To evaluate the diagnostic performance of quantitative measurement of liver echogenicity (hepatorenal index, or HRI) for hepatic steatosis in a pediatric cohort. MATERIALS AND METHODS: We identified pediatric patients (≤18 years old) who underwent both clinically indicated abdominal US and MRI with liver proton-density fat fraction (PDFF) within the 3-month period during the timeframe of July 2015-April 2020 (n=69). Using ImageJ, we drew small circular regions of interest (ROIs) and large freehand ROIs in the liver and right kidney on single longitudinal and transverse images to measure echogenicity (arbitrary units). We calculated four HRIs (liver-to-kidney ratio) as well as liver histogram features. Five pediatric radiologists independently reported the qualitative presence/absence of hepatic steatosis. We used Pearson correlation (r) to assess associations and receiver operating characteristic (ROC) curve analyses to evaluate diagnostic performance. Multivariable logistic regression was used to further assess relationships. RESULTS: Mean patient age was 11.6 (standard deviation [SD] 4.7, range 0.3-18) years; 27/69 (39.1%) were female. Mean PDFF was 12.5% (SD 13.1%, range 1-48%); 34/69 (49.3%) patients were classified as having hepatic steatosis by MRI (PDFF ≥6%). There were significant, positive correlations between all four US HRI methods and PDFF (r=0.51-0.61); longitudinal freehand ROIs exhibited the strongest correlation (r=0.61; P<0.0001). Longitudinal freehand ROI HRI had moderate diagnostic performance for the binary presence of steatosis (area under the curve [AUC]=0.80, P<0.0001), with an optimal cut-off value >1.75 (sensitivity=70.6%, specificity=77.1%). Radiologists' sensitivity for detecting hepatic steatosis ranged from 79.4% to 97.1%, and specificity ranged from 91.2% to 100%. Significant multivariable predictors of PDFF ≥6% included HRI (P=0.002; odds ratio [OR]=34.2), body mass index (BMI) percentile (P=0.005; OR=1.06), and liver gray-scale echogenicity standard deviation (P=0.02; OR=0.79) (receiver operating characteristic AUC = 0.92). CONCLUSION: Quantitative US HRI has moderate diagnostic performance for detecting liver fat in children and positively correlates with MRI PDFF. Incorporation of BMI-percentile and gray-scale echogenicity standard deviation improved diagnostic performance.

Leveraging diversity, equity and inclusion for promoting wellness in the radiology workplace.

Over the last decade, health care professionals in the field of radiology have experienced increasing rates of burnout. A study in 2017 showed high prevalence of burnout in pediatric radiology, and other studies have identified several drivers for burnout. An important factor in promoting wellness and mitigating burnout is leveraging diversity, equity and inclusion in the workplace. This manuscript highlights the importance of diversity in high-functioning teams as well as the critical role of equity and inclusion in the workplace to help create an organization where people belong and can effectively succeed.

Detection of urinary tract calculi on CT images reconstructed with deep learning algorithms.

BACKGROUND: Deep learning Computed Tomography (CT) reconstruction (DLR) algorithms promise to improve image quality but the impact on clinical diagnostic performance remains to be demonstrated. We aimed to compare DLR to standard iterative reconstruction for detection of urolithiasis by unenhanced CT in children and young adults. METHODS: This was an IRB approved retrospective study involving post-hoc reconstruction of clinically acquired unenhanced abdomen/pelvis CT scans. Images were reconstructed with six different manufacturer-standard DLR algorithms and reformatted in 3 planes (axial, sagittal, and coronal) at 3 mm intervals. De-identified reconstructions were loaded as independent examinations for review by 3 blinded radiologists (R1, R2, R3) tasked with identifying and measuring all stones. Results were compared to the clinical iterative reconstruction images as a reference standard. IntraClass correlation coefficients and kappa (k) statistics were used to quantify agreement. RESULTS: CT data for 14 patients (mean age: 17.3 ± 3.4 years, 5 males and 9 females, weight class: 31-70 kg (n = 6), 71-100 kg (n = 7), > 100 kg (n = 1)) were reconstructed into 84 total exams. 7 patients had urinary tract calculi. Interobserver agreement on the presence of any urinary tract calculus was substantial to almost perfect (k = 0.71-1) for all DLR algorithms. Agreement with the reference standard on number of calculi was excellent (ICC = 0.78-0.96) and agreement on the size of the largest calculus was fair to excellent (ICC = 0.51-0.97) depending on reviewer and DLR algorithm. CONCLUSION: Deep learning reconstruction of unenhanced CT images allows similar renal stone detectability compared to iterative reconstruction.

Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes.

Point-of-care ultrasonography (POCUS) refers to the use of portable imaging performed by the provider clinician at the bedside for diagnostic, therapeutic, and procedural purposes. POCUS could be considered an extension of the physical examination but not a substitute for diagnostic imaging. Use of POCUS in emergency situations can be lifesaving in the NICU if performed in a timely fashion for cardiac tamponade, pleural effusions, pneumothorax, etc, with potential for enhancing quality of care and improving outcomes. In the past 2 decades, POCUS has gained significant acceptance in clinical medicine in many parts of the world and in many subspecialties. Formal accredited training and certification programs are available for neonatology trainees as well as for many other subspecialties in Canada, Australia, and New Zealand. Although no formal training program or certification is available to neonatologists in Europe, POCUS is widely available to providers in NICUs. A formal institutional POCUS fellowship is now available in Canada. In the United States, many clinicians have the skills to perform POCUS and have incorporated it in their daily clinical practice. However, appropriate equipment remains limited, and many barriers exist to POCUS program implementation. Recently, the first international evidence-based POCUS guidelines for use in neonatology and pediatric critical care were published. Considering the potential benefits, a recent national survey of neonatologists confirmed that the majority of clinicians were inclined to adopt POCUS in their clinical practice if the barriers could be resolved. This technical report describes many potential POCUS applications in the NICU for diagnostic and procedural purposes.

Ultrasound of congenital spine anomalies.

Ultrasonography (US) is the first-line imaging modality for screening neonates and young infants with suspected spinal abnormalities. Whether performed for a suspicious congenital skin lesion, such as a lumbosacral tract or lipomatous mass, or abnormal neurological findings, US can help define spinal anatomy, characterize congenital spine malformations, and direct further work-up and management. The purpose of this article is to review the diagnostic imaging approach to infant spine US, including technique and indications, normal anatomy and variants with a focus on embryological origins, and classification and diagnosis of congenital spine malformations.

The use of a patient advocate to improve the experience in pediatric radiology.

There is increasing emphasis on improving the patient experience with a shift to patient- and family-centered care throughout all areas of health care. In 2013, the American College of Radiology launched Imaging 3.0, an initiative aimed at encouraging and enabling radiologists to work on culture change to increase focus on appropriateness, efficiency, quality, safety and patient satisfaction. Many groups have subsequently used these and other tools to improve the overall patient experience, focusing on the entire imaging journey to include initial order placement, registration in the department, image acquisition, departure from the department, and how and when the patient and family receive the imaging results. In our department we have used multiple strategies and have applied quality-improvement methods and patient/family-centered care models to improve quality, safety and the patient experience. Most of these efforts have included team members across the department, including radiologists, technologists, quality-improvement personnel, managers and nurses. In addition, for the last 12 years, a key member of these teams has been our patient and family advocate (PFA). We describe the important role that a PFA can play in improving the patient and family experience in pediatric radiology.

Automatic Detection of Inadequate Pediatric Lateral Neck Radiographs of the Airway and Soft Tissues using Deep Learning.

PURPOSE: To develop and validate a deep learning (DL) algorithm to identify poor-quality lateral airway radiographs. MATERIALS AND METHODS: A total of 1200 lateral airway radiographs obtained in emergency department patients between January 1, 2000, and July 1, 2019, were retrospectively queried from the picture archiving and communication system. Two radiologists classified each radiograph as adequate or inadequate. Disagreements were adjudicated by a third radiologist. The radiographs were used to train and test the DL classifiers. Three technologists and three different radiologists classified the images in the test dataset, and their performance was compared with that of the DL classifiers. RESULTS: The training set had 961 radiographs and the test set had 239. The best DL classifier (ResNet-50) achieved sensitivity, specificity, and area under the receiver operating characteristic curve of 0.90 (95% confidence interval [CI]: 0.86, 0.94), 0.82 (95% CI: 0.76, 0.90), and 0.86 (95% CI: 0.81, 0.91), respectively. Interrater agreement for technologists was fair (Fleiss κ, 0.36 [95% CI: 0.29, 0.43]), while that for radiologists was moderate (Fleiss κ, 0.59 [95% CI: 0.52, 0.66]). Cohen κ value comparing the consensus rating of ResNet-50 iterations from fivefold cross-validation, consensus technologists' rating, and consensus radiologists' rating to the ground truth were 0.76 (95% CI: 0.63, 0.89), 0.49 (95% CI: 0.37, 0.61), and 0.66 (95% CI: 0.54, 0.78), respectively. CONCLUSION: The development and validation of DL classifiers to distinguish between adequate and inadequate lateral airway radiographs is reported. The classifiers performed significantly better than a group of technologists and as well as the radiologists.© RSNA, 2020.

Proceedings: Beyond Ultrasound First Forum on Improving the Quality of Ultrasound Imaging in Obstetrics and Gynecology.

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.

Proceedings: Beyond Ultrasound First Forum on improving the quality of ultrasound imaging in obstetrics and gynecology.

The Beyond Ultrasound First Forum was conceived to increase awareness that the quality of obstetric and gynecologic ultrasound can be improved, and is inconsistent throughout the country, likely due to multiple factors, including the lack of a standardized curriculum and competency assessment in ultrasound teaching. The forum brought together representatives from many professional associations; the imaging community including radiology, obstetrics and gynecology, and emergency medicine among others; in addition to government agencies, insurers, industry, and others with common interest in obstetric and gynecologic ultrasound. This group worked together in focus sessions aimed at developing solutions on how to standardize and improve ultrasound training at the resident level and beyond. A new curriculum and competency assessment program for teaching residents (obstetrics and gynecology, radiology, and any other specialty doing obstetrics and gynecology ultrasound) was presented, and performance measures of ultrasound quality in clinical practice were discussed. The aim of this forum was to increase and unify the quality of ultrasound examinations in obstetrics and gynecology with the ultimate goal of improving patient safety and quality of clinical care. This report describes the proceedings of this conference including possible approaches to resident teaching and means to improve the inconsistent quality of ultrasound examinations performed today.

Ultrasound imaging of renin-mediated hypertension.

The incidence of primary (i.e. essential) hypertension in children and adolescents is increasing; however, secondary hypertension, with an identifiable cause, remains relatively common and might be treatable or even curable. Renovascular hypertension is an uncommon but important secondary cause of hypertension in the pediatric population that can be associated with substantial morbidity. In this article we discuss renin-mediated causes of hypertension in children and related complications, review renal Doppler ultrasound techniques for the evaluation of renin-mediated hypertension (including both direct and indirect assessments), and briefly appraise the literature pertaining to renal Doppler ultrasound and the assessment of pediatric hypertension. Finally, we describe a proposed role for renal Doppler ultrasound in the workup of suspected renin-mediated hypertension in children and adolescents.