Artificial intelligence-assisted interpretation of bone age radiographs improves accuracy and decreases variability.

OBJECTIVE: Radiographic bone age assessment (BAA) is used in the evaluation of pediatric endocrine and metabolic disorders. We previously developed an automated artificial intelligence (AI) deep learning algorithm to perform BAA using convolutional neural networks. We compared the BAA performance of a cohort of pediatric radiologists with and without AI assistance. MATERIALS AND METHODS: Six board-certified, subspecialty trained pediatric radiologists interpreted 280 age- and gender-matched bone age radiographs ranging from 5 to 18 years. Three of those radiologists then performed BAA with AI assistance. Bone age accuracy and root mean squared error (RMSE) were used as measures of accuracy. Intraclass correlation coefficient evaluated inter-rater variation. RESULTS: AI BAA accuracy was 68.2% overall and 98.6% within 1 year, and the mean six-reader cohort accuracy was 63.6 and 97.4% within 1 year. AI RMSE was 0.601 years, while mean single-reader RMSE was 0.661 years. Pooled RMSE decreased from 0.661 to 0.508 years, all individually decreasing with AI assistance. ICC without AI was 0.9914 and with AI was 0.9951. CONCLUSIONS: AI improves radiologist's bone age assessment by increasing accuracy and decreasing variability and RMSE. The utilization of AI by radiologists improves performance compared to AI alone, a radiologist alone, or a pooled cohort of experts. This suggests that AI may optimally be utilized as an adjunct to radiologist interpretation of imaging studies to improve performance.

Initial Clinical Experience With Extremity Cone-Beam CT of the Foot and Ankle in Pediatric Patients.

OBJECTIVE: Extremity cone-beam CT (CBCT) scanners have become available for clinical use in the United States. The purpose of this study was to review an initial clinical experience with CBCT of the foot and ankle in pediatric patients. MATERIALS AND METHODS: A retrospective review was conducted of all foot or ankle CBCT examinations performed on patients 18 years old and younger at one institution from August 1, 2013, through February 28, 2015. A t test was used to compare mean effective dose for CBCT with that for MDCT foot or ankle examinations of age-matched control subjects. To assess changes in utilization, a t test also was used to compare the mean numbers of foot or ankle CT examinations per month before and after installation of the CBCT scanner at the institution. RESULTS: Thirty-four CBCT examinations were performed. The mean effective dose was 0.013 ± 0.003 mSv compared with 0.023 ± 0.020 mSv for MDCT of age-matched control subjects (p < 0.005). The mean numbers of foot or ankle CT examinations per month were 3.4 in the 18 months before and 3.8 in the 18 months after installation of the CBCT scanner (p = 0.28). The mean number of foot or ankle MDCT examinations per month decreased significantly (3.4 vs 1.9, p = 0.03) over the same period. In 56% of patients, CBCT revealed important findings that were not visible on contemporaneous radiographs. In 68% of patients, the CBCT findings affected clinical management. CONCLUSION: CBCT of the foot or ankle of pediatric patients is a viable lower-dose alternative to MDCT that provides important information that may affect clinical management.

CT and MRI of Rare Extraintestinal Manifestations of Inflammatory Bowel Disease in Children and Adolescents.

Inflammatory bowel disease (IBD) is associated with a spectrum of extraintestinal manifestations (EIMs) affecting many organ systems. EIMs can occur in more than 40% of patients with IBD and are associated with significant morbidity. They occur at any time point in the course of disease, often during an active phase of bowel inflammation, but sometimes preceding bowel disease. Prompt recognition of EIMs enables timely and more effective therapy. Physicians who image patients with IBD should be aware of the myriad extraintestinal conditions that may be detected on imaging studies, both within and outside of the abdomen, as they may predate the diagnosis of IBD. Cross-sectional imaging of unusual conditions associated with IBD will be presented, including pathology in the hepatobiliary, pancreatic, genitourinary, musculoskeletal, mucocutaneous, vascular, neurologic, and pulmonary systems.

Fishtail deformity--a delayed complication of distal humeral fractures in children.

BACKGROUND: Concavity in the central portion of the distal humerus is referred to as fishtail deformity. This entity is a rare complication of distal humeral fractures in children. OBJECTIVE: The purpose of this study is to describe imaging features of post-traumatic fishtail deformity and discuss the pathophysiology. MATERIALS AND METHODS: We conducted a retrospective analysis of seven cases of fishtail deformity after distal humeral fractures. RESULTS: Seven children ages 7-14 years (five boys, two girls) presented with elbow pain and history of distal humeral fracture. Four of the seven children had limited range of motion. Five children had prior grade 3 supracondylar fracture treated with closed reduction and percutaneous pinning. One child had a medial condylar fracture and another had a lateral condylar fracture; both had been treated with conservative casting. All children had radiographs, five had CT and three had MRI. All children had a concave central defect in the distal humerus. Other imaging features included joint space narrowing with osteophytes and subchondral cystic changes in four children, synovitis in one, hypertrophy or subluxation of the radial head in three and proximal migration of the ulna in two. CONCLUSION: Fishtail deformity of the distal humerus is a rare complication of distal humeral fractures in children. This entity is infrequently reported in the radiology literature. Awareness of the classic imaging features can result in earlier diagnosis and appropriate treatment.

A Virtual Multi-institution Pediatric Radiology Peer Teaching Conference Improves Knowledge of Educators.

RATIONALE AND OBJECTIVES: Medical education led by peers and near-peers has been shown to benefit both teachers and learners and can be successfully incorporated into radiology education. The authors created a virtual, multi-institution pediatric radiology conference employing peer and near-peer teaching with the goals of improving radiology knowledge and enhancing the educational experience of radiology trainees. MATERIALS AND METHODS: Two radiology residency programs implemented a common pediatric radiology curriculum and joint quarterly virtual peer teaching conference. Conferences featured short teaching sessions led by six to ten radiology trainees and were facilitated by attending pediatric radiologists. Knowledge assessments (KA) consisting of multiple-choice questions inspired by conference learning objectives were sent to peer educators before the conference (pre-conference), directly after the conference (immediate post-conference), and three months after the conference (delayed post-conference). Surveys were distributed to peer educators immediately after conferences to assess conference reception and solicit feedback. Quantitative data was analyzed using ANOVA, Kruskal-Wallis test, and post-hoc Tukey HSD test. RESULTS: Four conferences featured 33 peer educators consisting primarily of first-year (60.6 %), second-year (18.2 %), and third-year (15.2 %) radiology residents. Compared to pre-conference scores, immediate post-conference scores were significantly increased (HSD 13, p = 0.02) and delayed post-conference scores were increased without statistical significance (HSD 5.8, p = 0.29). Almost all survey respondents perceived the conferences as helpful, well-organized, and effective in teaching pediatric radiology. A majority of participants expressed interest in participating in future peer teaching radiology conferences. CONCLUSION: A virtual pediatric radiology peer and near-peer teaching conference held between two radiology residencies improved short-term radiology knowledge of educators and was highly received.

Relationship between radiologist training level and fluoroscopy time for voiding cystourethrography.

OBJECTIVE: The objective of our study was to determine whether voiding cystourethrography (VCUG) fluoroscopy time is related to the training level of the performing radiologist. MATERIALS AND METHODS: VCUG reports with normal findings from 2008 to 2011 at one institution were retrospectively reviewed. The average fluoroscopy time was calculated for first-year radiology residents, senior radiology residents, pediatric radiology fellows, and attending pediatric radiologists. The average fluoroscopy time was also calculated for radiologist sex, patient sex, and patient age group. The analysis of variance was used to evaluate differences in average fluoroscopy times between training levels of radiologists, patient age groups, and patient sexes. RESULTS: We reviewed 784 VCUG reports with normal findings: 340 (43.4%) were performed by first-year residents; 181 (23%), by senior residents; 161 (20.5%), by fellows; and 102 (13%), by attending pediatric radiologists. The overall average fluoroscopy time was 1.86 minutes (SD ± 0.98). The attending pediatric radiologists had the shortest average fluoroscopy time (1.63 ± 0.92 minutes), significantly shorter than senior residents (1.96 ± 1.09 minutes; p = 0.0070) and fellows (1.91 ± 0.85 minutes; p = 0.0255). There was no significant difference between attending radiologists and first-year residents (1.85 ± 1.00 minutes; p = 0.0550). The male-to-female ratio of radiologists was 54% versus 46%, with identical average fluoroscopy times: male radiologists, 1.86 ± 1.05 minutes; female radiologists, 1.86 ± 0.90 minutes. There was no significant difference in average fluoroscopy times among patient age groups: 1.93, 1.76, and 1.78 minutes, respectively, for groups A (0-1 years), B (> 1 to ≤ 5 years), and C (> 5 years) (p = 0.1750, 0.4605, 0.6303). The average fluoroscopy time for male patients (2.02 ± 1.00 minutes) was significantly longer than that for female patients (1.71 ± 0.95 minutes; p < 0.0001). CONCLUSION: Attending pediatric radiologists have the shortest fluoroscopy time; the differences between their average time compared with the average times of pediatric radiology fellows and of senior radiology residents were statistically significant. The average fluoroscopy time is longer for male patients than for female patients.

Growth arrest and leg-length discrepancy.

Identification of congenital and acquired etiologies causing alignment disorders and leg-length discrepancies (LLD) in children is important for management. Minor differences in the lengths of the lower extremities are considered a normal variation and usually have no clinical significance. However, LLD of greater than 1 cm can cause altered biomechanics, resulting in scoliosis, back and lower extremity joint pain, pelvic tilt, abnormal gait and premature degenerative joint disease. The purpose of this pictorial essay is to review the imaging spectrum of growth arrest and resultant alignment and leg-length discrepancies in children.

Oxygen saturation can predict pediatric pneumonia in a resource-limited setting.

BACKGROUND: The World Health Organization (WHO) recommends using age-specific respiratory rates for diagnosing pneumonia in children. Past studies have evaluated the WHO criteria with mixed results. OBJECTIVE: We examined the accuracy of clinical and laboratory factors for diagnosing pediatric pneumonia in resource-limited settings. METHODS: We conducted a retrospective chart review of children under 5 years of age presenting with respiratory complaints to three rural hospitals in Rwanda who had received a chest radiograph. Data were collected on the presence or absence of 31 historical, clinical, and laboratory signs. Chest radiographs were interpreted by pediatric radiologists as the gold standard for diagnosing pneumonia. Overall correlation and test characteristics were calculated for each categorical variable as compared to the gold standard. For continuous variables, we created receiver operating characteristic (ROC) curves to determine their accuracy for predicting pneumonia. RESULTS: Between May 2011 and April 2012, data were collected from 147 charts of children with respiratory complaints. Approximately 58% of our sample had radiologist-diagnosed pneumonia. Of the categorical variables, a negative blood smear for malaria (χ(2) = 6.21, p = 0.013) and the absence of history of asthma (χ(2) = 4.48, p = 0.034) were statistically associated with pneumonia. Of the continuous variables, only oxygen saturation had a statistically significant area under the ROC curve (AUC) of 0.675 (95% confidence interval [CI] 0.581-0.769 and p = 0.001). Respiratory rate had an AUC of 0.528 (95% CI 0.428-0.627 and p = 0.588). CONCLUSION: Oxygen saturation was the best clinical predictor for pediatric pneumonia and should be further studied in a prospective sample of children with respiratory symptoms in a resource-limited setting.

Developing a Learning Objective-Based Pediatric Radiology Curriculum to Supplement Resident Education.

Learning objectives are invaluable components of medical curricula. They are required by the ACGME for all educational experiences offered by radiology residencies, but their number and quality varies significantly from program to program. In this article, we describe the development of a new pediatric radiology curriculum featuring outcome-based learning objectives with accompanying recommended resources to achieve these objectives and evaluate its initial reception by first-year radiology residents at our institution.

Validation of the Radiographic Global Impression of Change (RGI-C) score to assess healing of rickets in pediatric X-linked hypophosphatemia (XLH).

BACKGROUND: Rickets is a primary manifestation of pediatric X-linked hypophosphatemia (XLH) - a rare progressive hereditary phosphate-wasting disease. Severity is quantified from radiographs using the Rickets Severity Scale (RSS). The Radiographic Global Impression of Change (RGI-C) is a complementary assessment in which a change score is assigned based on differences in the appearance of rickets on pairs of radiographs compared side by side. OBJECTIVE: The current study evaluated the reliability, validity, and sensitivity to change of the RGI-C specifically in pediatric XLH. METHODS: The reliability, validity, and sensitivity to change of the RGI-C were evaluated using data from two studies in pediatric XLH (113 children aged 1-12 years) in which burosumab treatment significantly improved rickets severity. Intra-rater and inter-rater reliability were assessed by three pediatric radiologists. RESULTS: Intra-rater reliability for RGI-C global score was >90% for agreement within 1 point, with weighted kappa values >0.5, indicating moderate to almost perfect agreement. Inter-rater reliability was also >90% (0.47-0.52 for all reader pairs; moderate agreement). The RGI-C global score showed significant relationships with changes from baseline to week 64 in serum phosphorus (r = -0.397), alkaline phosphatase (-0.611), total RSS (-0.672), standing height (0.268), and patient-reported global functioning (0.306) and comfort/pain functioning (0.409). Based on standardized response means, RGI-C global scores were sensitive to change in RSS, differentiating between those considered improved and greatly improved. Results for validity and sensitivity to change were similar for the RGI-C wrist, knee, and standing long leg scores. CONCLUSION: The RGI-C is a reliable, valid, and sensitive measure in pediatric XLH, and complementary to the RSS.

Avascular necrosis of the metacarpal head: a report of two cases and review of literature.

BACKGROUND: Avascular necrosis (AVN) of the metacarpal head is a rare condition that can go unrecognized on radiography and progress to degenerative arthritis. Few reports describe the association with trauma, steroid use and systemic lupus erythematosus (SLE). Optimal treatment for this condition has not been established and long-term prognosis is unknown. OBJECTIVE: We present two cases of children with AVN of the fourth metacarpal head with a relatively recent history of indirect hand trauma. MATERIALS AND METHODS: Both of our cases had radiographs and MRI of the hand. RESULTS: MRI was diagnostic in both cases; however, radiographs were reported as normal in the early stage in one case. CONCLUSION: AVN of the metacarpal head is rare but can occur in children. Pediatric radiologists should be aware of this uncommon clinical entity, especially in light of increased involvement of children in sporting activities. Active children with hand trauma and children treated with steroids for a variety of conditions are particularly at risk.