Pediatric Abdominal Radiographs: Common and Less Common Errors.

OBJECTIVE: Interpretation of abdominal radiographs of children benefits from a firm knowledge of the congenital anomalies and pathologies unique to this patient population, leveraged by a systematic approach. Interpretive errors place the patients and their families at risk for a delay in diagnosis, unnecessary additional imaging, a potential increase in the radiation burden, and possible psychologic trauma. CONCLUSION: In this article, we describe the common and uncommon potential pitfalls in pediatric abdominal radiography, using several of our own interpretive errors as a framework while providing teaching points to help avoid these mistakes.

Peer review comments augment diagnostic error characterization and departmental quality assurance: 1-year experience from a children's hospital.

OBJECTIVE: The objective of our study was to categorize radiologist peer review comments and evaluate their functions within the context of a comprehensive quality assurance (QA) program. MATERIALS AND METHODS: All randomly entered radiology peer review comments at our institution were compiled over a 1-year period (January 1, 2011, through December 31, 2011). A Web-based commercially available software package was used to query the comments, which were then exported into a spreadsheet. Each comment was then placed into a single most appropriate category based on consensus decision of two board-certified pediatric radiologists. QA scores associated with each comment were recorded. RESULTS: A total of 427 peer review comments were evaluated. The majority of comments (85.9%) were entered voluntarily with QA scores of 1. A classification system was devised that augments traditional error classification. Seven broad comment categories were identified: errors of observation (25.5%), errors of interpretation (5.6%), inadequate patient data gathering (3.7%), errors of communication (9.6%), interobserver variability (21.3%), informational and educational feedback (23.0%), and complimentary (11.2%). CONCLUSION: Comment-enhanced peer review expands traditional diagnostic error classification, may identify errors that were underscored, provides continuous educational feedback for participants, and promotes a collegial environment.

Interactive digital atlas of skeletal surveys for common skeletal dysplasias.

BACKGROUND: Skeletal dysplasias are conditions of abnormal bone and cartilage growth resulting in short stature. Developing expertise in the radiographic evaluation of dysplasias can be difficult because more than 250 skeletal dysplasias have been described. Exhaustive description of individual dysplasias can be found in hard copy textbooks, without the ability to compare dysplasias side by side. OBJECTIVE: To provide radiographic images of several common skeletal dysplasias with comparative normal skeletal surveys, thus facilitating understanding of the terminology and differences in imaging appearances commonly encountered in interpreting dysplasias. MATERIALS AND METHODS: Images from skeletal surveys obtained at our institution from 2006 to 2010 were compiled and reviewed for best quality images. Selected surveys were divided into body parts. The software program used for viewing the atlas permits linked scrolling, resizing of images, and simultaneous comparison of cases. RESULTS: Radiographic images for 13 common skeletal dysplasias and 3 comparative normal skeletons (neonate, infant and child) are provided as an interactive digital atlas. CONCLUSION: The placement of images of several common skeletal dysplasias with descriptive text in an interactive and comparative format facilitates understanding of basic radiographic terminology and appearances. We describe the atlas and discuss skeletal survey interpretation.

Presyrinx in a child with acquired Chiari I malformation.

Spinal cord signal abnormality resulting from alterations in cerebrospinal fluid flow at the craniocervical junction has been termed a presyrinx state. This condition has been described in the adult literature in association with a variety of conditions that cause obstruction to normal cerebrospinal fluid flow. We present a case of presyrinx in a child in the setting of acquired Chiari I malformation caused by lumboperitoneal overshunting. Awareness of the potentially reversible nature of this condition might allow for intervention before irreversible neurological damage has occurred.

Optimizing peer review: A year of experience after instituting a real-time comment-enhanced program at a children's hospital.

OBJECTIVE: Peer review has become an essential component of a comprehensive radiology department quality assurance program. Multiple commercial programs, such as RADPEER, are available to fill this need but may be limited by low radiologist compliance and delayed or limited feedback. Consequently, these peer review programs may not achieve the greater goal of improving diagnostic quality. This article presents data from a peer review system implemented in an academic radiology group at a large urban multidisciplinary children's hospital. The peer review system offered instantaneous feedback with an enhanced comment feature for peer radiologists. MATERIALS AND METHODS: Peer review data were collected on 5278 radiologic studies over a 12-month period including 15 radiologists. The data were analyzed for compliance rate, discrepancy rate, and comment usage. RESULTS: The compliance rate for peer review averaged 52% for the 12-month period. The compliance rate trended upward over the course of the year, with a final month's compliance rate of 76%. The discrepancy rate between original interpretation and peer review was 3.6%. Comments were voluntarily included in 7.3% of nondiscrepant peer review scores. CONCLUSION: Our peer review process was enhanced by real-time comment-enriched feedback on both discrepant and nondiscrepant peer reviews. We show improved radiologist compliance over the course of a year in a peer review program with no incentives or penalties for performing reviews. To our knowledge, no compliance rates exist in current literature for comparison.

Ulnar artery aneurysm causing palmar mass in 5-month-old girl.

A 5-month-old previously healthy girl presented to the emergency department with a large palpable nontender mass in the hypothenar soft tissues of her left hand. US revealed a well-demarcated nonvascular soft tissue mass. Subsequent MR imaging showed a rim-enhancing mass with heterogeneous intrinsic signal characteristics. Abscess and necrotic tumor were the primary considerations. Surgery demonstrated a thrombosed aneurysm continuous with the ulnar artery system. The aneurysm was resected and the ulnar artery was ligated at the wrist.

Interactive, computer-based pediatric chest atlas.

OBJECTIVES: The authors created a computer-based, interactive atlas of pediatric chest radiographs to facilitate (1) understanding of normal variants and (2) interpretation of pediatric chest radiographs in the acute setting. METHODS: Seventy-three normal pediatric chest radiographs were selected for inclusion in the atlas by consensus after review by 3 pediatric radiologists. Sixteen abnormal pediatric chest radiographs showing a variety of abnormalities (infection, malignancy, congenital abnormalities, foreign body, and acquired disease), as well as 4 normal adult chest radiographs, were also included in the atlas. Images for the atlas were derived from Digital Imaging and Communications in Medicine-compliant data. The atlas software was written in C# and offers features of a picture archiving and communication system viewer. In addition, the atlas offers annotated series that describe particular radiographic features of normal variants and disease. RESULTS: The digital, interactive pediatric chest atlas displays normal chest radiographs of children aged 7 days to 17.8 years, as well as 4 normal adult chest radiographs and 16 abnormal pediatric chest radiographs. The digital interactive format of the atlas allows for (1) easy manipulation of atlas cases and (2) direct comparison between normal atlas cases and provided abnormal cases, as well as (3) the potential for direct comparison with images displayed on an institution's picture archiving and communication system. The atlas is available for free download at http://www.seattlechildrens.org/radiologyeducation/pediatric-chest. CONCLUSIONS: Improved interpretation of pediatric chest radiographs in the acute setting may be facilitated by a comprehensive, computer-based, pediatric chest atlas.

PACStacker: an enhancement of the scientific and educational capabilities of PowerPoint.

OBJECTIVE: Our objective was to develop a way to enhance scientific and educational PowerPoint presentations containing stack-based, multiple-image techniques such as CT and MRI. CONCLUSION: We developed a PowerPoint add-in that facilitates the creation of stackable image sets in a simple and intuitive manner, permitting real-time scrolling, editing, and manipulation of imbedded image stacks. Contrast and brightness adjustments, cropping, and linking are supported. Once created, the PowerPoint presentation can be viewed without hardware or venue limitations on any computer, without reinstallation of the add-in.

Interactive digital MR atlas of the pediatric brain.

The interpretation of magnetic resonance (MR) images of the pediatric brain may require consultation of an atlas to determine if a perceived finding represents an abnormality. However, most hard-copy atlases show only a few levels of the brain at selected points of time in myelination, and therefore a simultaneous comparison of different age groups is difficult with a hard-copy approach. The authors believe that a digital atlas of the normal pediatric brain may be a more efficient way to present this information and that correct interpretation of potential abnormalities may be facilitated by the online atlas they have created (available for free download from http://radiology.seattlechildrens.org/teaching/pediatricbrainatlas). Images for the atlas were derived from Digital Imaging and Communications in Medicine-compliant data sets from brain MR imaging in patients younger than 4 years. The images were interpreted as normal with respect to the appearance of the brain parenchyma. The software program used for viewing the atlas, written in C#, incorporates many features of a picture archiving and communication system viewer, such as linked scrolling and resizing. Simultaneous comparison of cases also is possible. The digital atlas facilitates learning about normal changes in the MR appearance of the pediatric brain, and it may be used during online interpretation of cases on a picture archiving and communication system.

Peer Review: Lessons Learned in A Pediatric Radiology Department.

The purpose of this article is to illustrate types of diagnostic errors and feedback given to radiologists, using cases to support and clarify these categories. A comment-enhanced peer review system may be leveraged to generate a comprehensive feedback categorization scheme. These include errors of observation, errors of interpretation, inadequate patient data gathering, errors of communication, interobserver variability, informational feedback, and compliments. Much of this feedback is captured through comments associated with interpretative agreements.

"Children are not small adults": avoiding common pitfalls of normal developmental variants in pediatric imaging.

Imaging of children is complicated with a vast array of normal variants, congenital or developmental disorders, and age-dependent differential considerations. We present imaging findings of several common anatomic variants as well as physiological and maturational processes that occur in children. We compare and contrast them with pathological entities so that the reader can successfully distinguish them when interpreting pediatric imaging examinations. The content has been accrued from the authors' collective experience at a tertiary-care pediatric hospital, teaching and consulting with radiology trainees and clinicians, as well as a comprehensive review of the literature, and is intended to represent a useful error prevention tool for radiologists interpreting pediatric studies.

Effects of aging on vasopressin production in a kindred with autosomal dominant neurohypophyseal diabetes insipidus due to the DeltaE47 neurophysin mutation.

Postmortem examinations of the hypothalamus of patients with autosomal dominant neurohypophyseal diabetes insipidus (adNDI), which have been reported only on persons dying between the ages of 37-87 yr, reveal the presence of the arginine vasopressin (AVP)-producing parvocellular neurons but the absence of 95% of the expected AVP-producing magnocellular neurons. To determine whether the clinical course of adNDI is compatible with the hypothesis that the neuropathologic findings are attributable to a progressive loss of magnocellular neurons beginning in early life, we performed posterior pituitary magnetic resonance imaging and water deprivation tests, including plasma ACTH measurements, on 17 affected members of a kindred with the deltaE47 neurophysin mutation whose ages ranged from 3 months to 54 yr. Nine adult nonaffected members (ages, 20-56 yr) underwent these tests as controls. All six children undergoing magnetic resonance imaging demonstrated a posterior pituitary hyperintense signal (PPHS). Eight of nine affected adults showed an absent or barely visible PPHS, whereas eight of nine age-matched nonaffected adults produced a normal size PPHS. During water deprivation tests, infants concentrated their urine normally, and a 3-month-old infant produced a high plasma AVP level of 15.7 pmol/liter. By school age, affected children were no longer able to concentrate their urine or prevent hypernatremia. Affected adults became dehydrated; their median plasma AVP level was less than 1.0 pmol/liter, but their median fasting plasma ACTH was 2-fold greater than the level of nonaffected adults (10.0 vs. 5.0 pmol/liter; P = 0.008). These results suggest that adNDI is a progressive disease associated with chronic loss of the magnocellular neurons that supply AVP to the posterior pituitary but preservation of the parvocellular neurons that supply AVP and CRH to the median eminence and stimulate ACTH production during hypernatremia.

A theory of pragmatic information and its application to the quasi-species model of biological evolution.

'Standard' information theory says nothing about the semantic content of information. Nevertheless, applications such as evolutionary theory demand consideration of precisely this aspect of information, a need that has motivated a largely unsuccessful search for a suitable measure of an 'amount of meaning'. This paper represents an attempt to move beyond this impasse, based on the observation that the meaning of a message can only be understood relative to its receiver. Positing that the semantic value of information is its usefulness in making an informed decision, we define pragmatic information as the information gain in the probability distributions of the receiver's actions, both before and after receipt of a message in some pre-defined ensemble. We then prove rigorously that our definition is the only one that satisfies obvious desiderata, such as the additivity of information from logically independent messages. This definition, when applied to the information 'learned' by the time evolution of a process, defies the intuitions of the few previous researchers thinking along these lines by being monotonic in the uncertainty that remains after receipt of the message, but non-monotonic in the Shannon entropy of the input ensemble. It also follows that the pragmatic information of the genetic 'messages' in an evolving population is a global Lyapunov function for Eigen's quasi-species model of biological evolution. A concluding section argues that a theory such as ours must explicitly acknowledge purposeful action, or 'agency', in such diverse fields as evolutionary theory and finance.

Radiology peer-review feedback scorecards: optimizing transparency, accessibility, and education in a children׳s hospital.

Peer review is a requisite for a comprehensive quality assurance program. Although RADPEER implementations have been well documented, the feedback process has been underemphasized. Our radiology department developed feedback scorecards to address this gap. In this article, we describe our scorecard components, the software applications we independently created and utilize, and how they align missions of quality improvement and radiologist education. The result is a web-based, comment-enhanced, monthly feedback scorecard that to our knowledge is the first of its kind described in the literature.

Interhemispheric lipoma: Interval development of an associated cyst.

We report a case of an 11-year-old patient who underwent CT imaging for complications of sinusitis, and showed incidental development of an interhemispheric cyst in association with an intracranial lipoma over a 10-year interval. Cysts and lipomas are well described in association with dysgenesis of the corpus callosum. We present an uncommon association, of a new cyst in association with an intracranial lipoma, in a patient with a normal corpus callosum.

MyPACS.net: a Web-based teaching file authoring tool.

OBJECTIVE: We sought to develop a Web service that would easily allow radiologists to create their own online teaching file cases from any Web browser. CONCLUSION: We created MyPACS, a hosted teaching file authoring tool that allows easy uploading of images and descriptive information from any computer with Web access. Radiologists may designate their cases to be public or private (viewable only by the case author), and cases may be retrieved on searching for multiple parameters.

Supplemental oxygen causes increased signal intensity in subarachnoid cerebrospinal fluid on brain FLAIR MR images obtained in children during general anesthesia.

PURPOSE: To prospectively test the hypothesis that high levels of the fraction of inspired oxygen (Fio(2)) during general anesthesia cause subarachnoid cerebrospinal fluid (CSF) hyperintensity during fluid-attenuated inversion-recovery (FLAIR) magnetic resonance (MR) imaging. MATERIALS AND METHODS: At brain MR imaging during general anesthesia with propofol, two FLAIR sequences were performed in 20 children with American Society of Anesthesiologists physical status classification system grades of 3 or lower. The first FLAIR sequence was performed with the child breathing 100% oxygen; the second was performed with the child breathing 30% oxygen. CSF signal intensity was quantified on a three-point ordinal scale (0 = hypointense to brain parenchyma, 1 = isointense to brain parenchyma, 2 = hyperintense to brain parenchyma) by a pediatric neuroradiologist who was blinded to the Fio(2) level. The Wilcoxon signed rank test was used to determine if CSF hyperintensity was correlated with Fio(2). RESULTS: CSF hyperintensity was present in all 20 children (age range, 1.9-16.7 years; 12 children were boys) when the Fio(2) was 100%. The hyperintensity partially or completely disappeared in the basilar cisterns (P <.001) and cerebral sulcal subarachnoid space (P <.001) after Fio(2) was reduced from 100% to 30%. CONCLUSION: These findings are consistent with the hypothesis that increased arterial oxygen tension and consequently increased CSF Po(2) resulting from administration of high Fio(2) during general anesthesia are responsible for the increased CSF signal intensity noted on brain FLAIR MR images.