Utility of Computed Tomography Overreading and Abdominal Ultrasound in Children With Suspected Appendicitis and Nondiagnostic Computed Tomography at Community Hospitals.

OBJECTIVE: The aim of the study was to examine the ability of overreading of computed tomography (CT) and right lower quadrant ultrasound (RLQ US) to diagnose appendicitis for children with suspected appendicitis with equivocal CTs at community hospitals. METHODS: This was a retrospective chart review of all children transferred to a children's hospital from community emergency departments with suspected appendicitis over 2 years for whom both CT and RLQ US were performed. RESULTS: One hundred eighty-four children were included with a median age of 10.8 years, and 57.6% were female. Community hospitals documented that CTs were equivocal for appendicitis in 110 (59.8%), positive in 63 (34.2%), and negative in 11 (6.0%). Ninety-seven CTs (88.1%) designated equivocal at community hospitals were later deemed interpretable by pediatric radiologists: 21 (19.1%) as appendicitis and 76 (69.1%) as normal. In 13 children (11.8%), both the community and children's hospital CT interpretations were equivocal. In equivocal cases, RLQ US was consistent with appendicitis in 6 (46.2%), normal in 5 (41.7%), and nondiagnostic in 2. κ value between CT interpretations at community versus children's hospital was 0.13 (95% confidence interval, 0.05-0.22), and κ value between CT interpretation at the children's hospital and RLQ US was 0.59 (95% confidence interval, 0.48-0.70). CONCLUSIONS: Most CTs deemed equivocal for appendicitis at community hospitals were interpretable by pediatric radiologists. In a few children for whom CTs were designated nondiagnostic, RLQ US provided a definitive diagnosis in almost 90% of cases. The first step in evaluation of children with suspected appendicitis for whom outside CTs are deemed equivocal should be to have the study reinterpreted by a pediatric radiologist.

How Long Does it Take to Diagnose Appendicitis? Time Point Process Mapping in the Emergency Department.

OBJECTIVES: Appendicitis is the most common surgical emergency encountered in the pediatric emergency department (ED). We analyzed the time course of children evaluated for suspected appendicitis in relation to implementation of a risk-stratified ultrasound scoring system and structured reporting template (Appy-Score). METHODS: In July 2013, a 6-level ultrasound (US)-based appendicitis scoring system was developed and implemented. The records of children (age ≤18 years) who underwent limited abdominal US exams for suspected appendicitis at a large academic pediatric ED were reviewed retrospectively. Time periods evaluated were from January 1 to April 1, 2013 (before implementation of the US scoring system, "PRE") and July 1 to October 1, 2013 (after implementation of the US scoring system, "POST"). Times are presented as medians with interquartile range. RESULTS: A total of 926 children were included (median age, 9.5 years [range, 0.1-18 years]; 49% female). Four hundred eighty-one patients were evaluated PRE and 445 POST. When comparing the 2 groups, there were no differences in the PRE and POST periods with regard to time from US ordered to first read (102 vs 112 minutes, P = 0.30), US ordered to disposition (215 vs 208 minutes, P = 0.40) and operating room posting (121 vs 122 minutes, P = 0.59), and overall ED stay (329 vs 333 minutes, P = 0.39). CONCLUSIONS: The development of a radiographic appendicitis score, although allowing for a standardized reporting method, did not significantly alter the ED process flow for evaluation of appendicitis. This reflects the complexities in ED throughput and reveals the need for additional factors to change to improve patient flow.

An honest day's work: pay for performance in a pediatric radiology department.

Compensation models in radiology take a variety of forms, but regardless of practice type, successful models must reward productivity, be simple, and epitomize fairness. The ideal model should also be flexible enough to transition, based upon the changing strategic goals of a department. The plan should be constructed around rewarding the behaviors that the organization values. In this minisymposium article the author presents the value of different types of compensation plans and discusses advantages and disadvantages. Finally, the author presents a pay-for-performance model that has had long-term success at a private-turned-academic practice in pediatric radiology.

A clinical decision rule for the use of ultrasound in children presenting with acute inflammatory neck masses.

OBJECTIVE: To identify the association between clinical and ultrasound findings and surgical drainage in children with inflammatory neck masses and to create a clinical decision rule that allows for reduction of unnecessary use of ultrasound in inflammatory neck masses. MATERIALS AND METHODS: We reviewed data on patients ≤18 years who visited our emergency department between 2012 and 2014 with inflammatory neck swelling and who underwent ultrasound examinations of the neck. We used multivariate logistic regression to identify factors associated with drainage within 24 h of ultrasound study (early drainage). Recursive partitioning was used for risk stratification. RESULTS: Of 341 consecutive patients included in this study, 37 patients underwent early drainage and all had purulent material drained. All patients but one with non-suppurative adenitis and 95% (97/102) of those with suppurative adenitis or early/suspicious abscess on ultrasound were initially treated medically. Of those with a definite diagnosis of abscess/fluid collection, 89% (32/36) underwent early drainage. Patients who underwent drainage were more likely to be younger, female and have a longer duration of neck swelling, with fluctuance and erythema on exam. Recursive partitioning analysis revealed that among children with neck swelling >3 days and ≤3 days, the rate of early drainage was 24.3% and 4.4%, respectively. None of the children >7 months with neck swelling ≤3 days underwent early drainage. CONCLUSION: Children older than 1 year with inflammatory neck swelling ≤3 days are at low risk of having ultrasound findings that require drainage. In this subgroup of patients, ultrasound could be avoided unless the patient fails to improve after a trial of antibiotic therapy.

The Daily Readiness Huddle: a process to rapidly identify issues and foster improvement through problem-solving accountability.

BACKGROUND: Because of the increasing complexities of providing imaging for pediatric health care services, a more reliable process to manage the daily delivery of care is necessary. Objective We describe our Daily Readiness Huddle and the effects of the process on problem identification and improvement. MATERIALS AND METHODS: Our Daily Readiness Huddle has four elements: metrics review, clinical volume review, daily readiness assessment, and problem accountability. It is attended by radiologists, directors, managers, front-line staff with concerns, representatives from support services (information technology [IT] and biomedical engineering [biomed]), and representatives who join the meeting in a virtual format from off-site locations. Data are visually displayed on erasable whiteboards. The daily readiness assessment uses queues to determine whether anyone has concerns or outlier data in regard to S-MESA (Safety, Methods, Equipment, Supplies or Associates). Through this assessment, problems are identified and categorized as quick hits (will be resolved in 24-48 h, not requiring project management) and complex issues. Complex issues are assigned an owner, quality coach and report-back date. Additionally, projects are defined as improvements that are often strategic, are anticipated to take more than 60 days, and do not necessarily arise out of identified issues during the Daily Readiness Huddle. We tracked and calculated the mean, median and range of days to resolution and completion for complex issues and for projects during the first full year of implementing this process. RESULTS: During the first 12 months, 91 complex issues were identified and resolved, 11 projects were in progress and 33 completed, with 23 other projects active or in planning. Time to resolution of complex issues (in days) was mean 37.5, median 34.0, and range 1-105. For projects, time to completion (in days) was mean 86.0, median 84.0, and range 5-280. CONCLUSION: The Daily Readiness Huddle process has given us a framework to rapidly identify issues, bring accountability to problem-solving, and foster improvement. It has also had a positive effect on team-building and coordination.

Pre-authorization processes have no effect on patients undergoing knee MRI in a pediatric setting when evaluated by specialists.

OBJECTIVE: Pre-authorization processes are often used by medical insurance companies to reduce costs by managing the utilization of advanced diagnostic imaging, and their impact on patient care is unclear. The purpose of our study is to determine if a pre-authorization process increases the rate of surgically significant abnormal knee MRI and surgical referrals compared with patients referred from pediatric orthopedic specialists who do not undergo a pre-authorization process. MATERIALS AND METHODS: A retrospective study was performed; 124 patients were identified who were referred for knee MRI by a pediatric orthopedist. The study population included patients who underwent an insurance pre-authorization process and the control group consisted of those who did not. The results of the MRI and whether they were deemed surgically significant, in addition to surgical referral, were recorded and compared. RESULTS: The study and control groups showed no statistically significant difference in outcome with regard to surgically significant findings on MRI (p = 0.92) or whether the patient required surgery (p = 0.6). CONCLUSIONS: In this population, there is no difference in the likelihood of an abnormal knee MRI demonstrating surgically significant findings or referral to surgery in patients who did and those who did not undergo an insurance pre-authorization process when patients are referred from a pediatric orthopedic specialist. The insurance pre-authorization process does not appear to have an impact on patient diagnosis and treatment and may unnecessarily add bureaucracy and costs.

Kocher Criteria Revisited in the Era of MRI: How Often Does the Kocher Criteria Identify Underlying Osteomyelitis?

BACKGROUND: The Kocher criteria are established clinical parameters that predict hip septic arthritis (SA) with a 93% or greater positive-predictive value when 3 or 4 variables are present. The incidence of osteomyelitis (OM) in these patients has not been reported. The purpose of this study is to evaluate the incidence of OM in patients who have 3 or 4 positive Kocher criteria. METHODS: A total of 71 consecutive patients (mean age, 4.7 y) treated between January 2007 and July 2013 for suspected hip SA who had 3 or 4 positive Kocher criteria were retrospectively reviewed. The Kocher criteria variables include: non-weight-bearing status, fever>38.5°C, white blood cell>12 K, and erythrocyte sedimentation rate>40 mm/h. All patients underwent ultrasound (US) and magnetic resonance imaging as part of their workup. RESULTS: There were a total of 71 patients with 3 or 4 positive Kocher criteria. Of these, 22.5% (n=16) had a diagnosis of SA and 47.9% (n=34) had a diagnosis of OM. Of the 71 patients, 52.1% (37/71) had a hip effusion on US. When an effusion was identified, 18.9% (7/37) had isolated SA, 18.9% (7/37) had isolated OM, and 24.3% (9/37) had combined SA and OM. When no effusion was identified, a total of 18/34 (52.9%) had underlying OM. CONCLUSIONS: Patients with 3 or 4 Kocher criteria have a high incidence (47.9%) of OM. Even in patients with a hip effusion on US, the incidence of OM was equal to that of SA. These results suggest that the combination of Kocher criteria and US alone is not sufficient to make a diagnosis in patients presenting with hip irritability and consideration should be given to adding magnetic resonance imaging to their workup. LEVEL OF EVIDENCE: Level III-retrospective chart review.

Image-guided prediction of pseudocyst formation in pediatric pancreatic trauma.

BACKGROUND: To determine if there is an effective alternative to the current standard of computed tomography (CT) grading of pediatric pancreatic injuries. We hypothesized that the Wong grading scale, which is based on the depth and location of the pancreatic laceration, is more predictive of pseudocyst formation than the American Association for the Surgery of Trauma (AAST) scale after nonoperative management of traumatic pancreatic injury in children. MATERIALS AND METHODS: A retrospective review of children admitted for pancreatic trauma to two level 1 pediatric trauma centers between 2000 and 2012 was conducted. Patients who underwent primary operation were excluded. Initial CT scans were reviewed by two radiologists blinded to clinical outcomes, and injury grades from both scales were assigned. The primary outcome was pseudocyst formation. RESULTS: Fifty-three patients (ages 7 mo-17 y) were included. As per the Wong scale, pseudocysts occurred in 0/20 patients with grade A injuries, 2/17 (12%) with BI/CI injuries, and 9/15 (60%) with BII/CII injuries. Using the AAST scale, pseudocysts developed in 2/27 (7%) patients with grade I/II injuries, 7/20 (35%) patients with III/IV/V injuries, and 1/6 (17%) patients with a scan that was indeterminate between grades II and III. Positive Predictive value, negative predictive value, sensitivity, and specificity for pseudocyst formation were all higher using the Wong scale (AAST/Wong: Positive Predictive value 42%/50%, negative predictive value 91%/94%, sensitivity 80%/82%, and specificity 65%/77%). CONCLUSIONS: The Wong CT grading scale may be superior to the AAST scale for early risk stratification for pseudocyst development after nonoperative management of pediatric pancreatic trauma; however, a larger study is needed for verification of these findings.

Septic arthritis in children: frequency of coexisting unsuspected osteomyelitis and implications on imaging work-up and management.

OBJECTIVE: Osteomyelitis and septic arthritis clinically present at any age with overlapping signs and symptoms. The purposes of this study were to evaluate the demographic distribution of septic arthritis and osteomyelitis in children and to explore optimal imaging guidelines for these patients. MATERIALS AND METHODS: We performed a retrospective study of children up to 18 years old who were treated for osteomyelitis or septic arthritis between January 2011 and September 2013. All patients underwent MRI without previous intervention. Studies were reviewed to determine the incidence of septic arthritis or superimposed osteomyelitis. The reference diagnosis was based on the combined review by the orthopedic surgeon and infectious disease notes, discharge summary, operative report, and MRI examination. RESULTS: One hundred sixty-two children who underwent 177 MRI examinations were diagnosed with acute musculoskeletal infection. One hundred three patients were included in the septic arthritis category, of whom 70 (68%) had septic arthritis with osteomyelitis. Seventy-four (42.1%) patients had isolated osteomyelitis without septic arthritis. Children under 2 years old were more likely to have septic arthritis (either isolated or with osteomyelitis) than isolated osteomyelitis compared with older children (p = 0.0003). CONCLUSION: In children who underwent MRI for suspected musculoskeletal infection, septic arthritis was more prevalent in children under the age of 2 years than in older children. However, both septic arthritis and osteomyelitis were found frequently in older children. Musculoskeletal infection imaging workup guidelines for children of all ages should address the frequent association of osteomyelitis and septic arthritis. We recommend that MRI should be used in the evaluation of suspected musculoskeletal infections in children, and the nearest joint should always be included to evaluate the extent of articular disease.

Performance of CT examinations in children with suspected acute appendicitis in the community setting: a need for more education.

OBJECTIVE: Despite a recent focus on the preferential use of ultrasound over CT for pediatric appendicitis, most children transferred from community hospitals still undergo diagnostic CT scans. The purpose of this study was to evaluate CT techniques performed for children with acute appendicitis at nonpediatric treatment centers. MATERIALS AND METHODS: All patients treated for acute appendicitis at our tertiary-care pediatric hospital from July 1, 2011, through June 30, 2012, were identified. Patient demographics, imaging modality used to diagnoses appendicitis (CT or ultrasound), location (home or referral institution), and CT technique parameters were collected. The estimated mean organ radiation dose, number of imaging phases, and use of contrast media were evaluated at home and referral institutions. RESULTS: During the study period, 1215 patients underwent appendectomies after imaging, with 442 (36.4%) imaged at referral facilities. Most referral patients received a diagnosis by CT (n=384, 87%), compared with 73 of 773 (9.4%) who received a diagnosis by CT at the home institution. The estimated mean (±SD) organ radiation dose was not statistically significantly different between home and referral institutions (13.5±7.3 vs 12.9±6.4 mGy; p=0.58) for single-phase examinations. Of 384 referral patients, 344 had images available for review. In total, 40% (138/344) of patients from referral centers were imaged with suboptimal CT techniques: 50 delayed phase only, 52 dual phase (eight of which were imaged twice in delayed phase), eight triple phase, and 36 without IV contrast agent. CONCLUSION: CT parameters and radiation doses from single-phase examinations in children with appendicitis were similar at nonpediatric treatment centers and a tertiary care children's hospital. Future educational outreach should focus on optimizing other technical parameters.

The 'wandering appendicolith'.

Acute appendicitis is a common pediatric surgical emergency. Successful surgical appendectomy requires removal of the appendix and its contents. A retained appendicolith is a complication that occurs when the appendicolith is expulsed from the appendix as a result of perforation or failure of removal during surgery. An ectopic appendicolith can migrate to a variety of ectopic locations, acting as a nidus for abscess. Clinical presentation may be delayed by days, weeks or even months after surgery. We present and discuss an unusual case of empyema caused by migration of an appendicolith into the chest cavity. Management of these retained appendicoliths requires drainage of the abscess and extraction of the appendicolith.

Metaphyseal osteomyelitis in children: how often does MRI-documented joint effusion or epiphyseal extension of edema indicate coexisting septic arthritis?

BACKGROUND: Joint effusions identified by MRI may accompany osteomyelitis and determining whether the joint effusion is septic or reactive has important implications on patient care. OBJECTIVE: Determine the incidence of epiphyseal marrow edema, joint effusions, perisynovial edema and epiphyseal non-enhancement in the setting of pediatric metaphyseal osteomyelitis and whether this may be used to predict coexisting septic arthritis. MATERIALS AND METHODS: Following IRB approval, we retrospectively evaluated children who underwent MRI and orthopedic surgical consultation for suspected musculoskeletal infection between January 2011 and September 2013. Criteria for inclusion in the study were microbiologically/pathologically proven infection, MRI prior to surgical intervention, long bone involvement and age 0-18 years. MRI exams were independently reviewed by two faculty pediatric radiologists to confirm the presence of appendicular metaphyseal osteomyelitis, to evaluate extent of edema, to determine subjective presence of a joint effusion and to assess perisynovial edema and epiphyseal non-enhancement. Any discrepant readings were reviewed in consensus. Charts and operative notes were reviewed to confirm the diagnosis of osteomyelitis and septic arthritis. RESULTS: One hundred and three joints with metaphyseal osteomyelitis were identified (mean age: 7.1 years; M:F 1.3:1), of whom 53% (55/103) had joint effusions, and of those, 75% (41/55) had surgically confirmed septic arthritis. The incidence of coexisting septic arthritis was 40% in the setting of epiphyseal edema, 74% in epiphyseal edema and effusion, 75% with perisynovial edema, 76% with epiphyseal non-enhancement and 77% when all four variables were present. Of these, the only statistically significant variable, however, was the presence of a joint effusion with a P-value of <0.0001 via Fisher exact test. Statistical significance for coexisting septic arthritis was also encountered when cases were subdivided into intra-articular vs. extra-articular metaphyses (P-value = 0.0499). No statistically significant difference was found between patients younger than 24 months and those older than 24 months. CONCLUSION: Patients with joint effusions identified by MRI, in the setting of metaphyseal osteomyelitis, should be presumed to have septic arthritis until proven otherwise. Epiphyseal extension of edema, perisynovial edema and epiphyseal non-enhancement in the setting of metaphyseal osteomyelitis are not helpful predictors in differentiating reactive and pyogenic joint effusions. Osteomyelitis at a site with an intra-articular metaphyses, however, is more likely to have concurrent septic arthritis.

Development and validation of an ultrasound scoring system for children with suspected acute appendicitis.

BACKGROUND: To facilitate consistent, reliable communication among providers, we developed a scoring system (Appy-Score) for reporting limited right lower quadrant ultrasound (US) exams performed for suspected pediatric appendicitis. OBJECTIVE: The purpose of this study was to evaluate implementation of this scoring system and its ability to risk-stratify children with suspected appendicitis. MATERIALS AND METHODS: In this HIPAA compliant, Institutional Review Board-approved study, the Appy-Score was applied retrospectively to all limited abdominal US exams ordered for suspected pediatric appendicitis through our emergency department during a 5-month pre-implementation period (Jan 1, 2013, to May 31, 2013), and Appy-Score use was tracked prospectively post-implementation (July 1, 2013, to Sept. 30,2013). Appy-Score strata were: 1 = normal completely visualized appendix; 2 = normal partially visualized appendix; 3 = non-visualized appendix, 4 = equivocal, 5a = non-perforated appendicitis and 5b = perforated appendicitis. Appy-Score use, frequency of appendicitis by Appy-Score stratum, and diagnostic performance measures of US exams were computed using operative and clinical finding as reference standards. Secondary outcome measures included rates of CT imaging following US exams and negative appendectomy rates. RESULTS: We identified 1,235 patients in the pre-implementation and 686 patients in the post-implementation groups. Appy-Score use increased from 24% (37/155) in July to 89% (226/254) in September (P < 0.001). Appendicitis frequency by Appy-Score stratum post-implementation was: 1 = 0.5%, 2 = 0%, 3 = 9.5%, 4 = 44%, 5a = 92.3%, and 5b = 100%. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 96.3% (287/298), 93.9% (880/937), 83.4% (287/344), and 98.8% (880/891) pre-implementation and 93.0% (200/215), 92.6% (436/471), 85.1% (200/235), and 96.7% (436/451) post-implementation - only NPV was statistically different (P = 0.012). CT imaging after US decreased by 31% between pre- and post-implementation, 8.6% (106/1235) vs. 6.0% (41/686); P = 0.048). Negative appendectomy rates did not change (4.4% vs. 4.1%, P = 0.8). CONCLUSION: A scoring system and structured template for reporting US exam results for suspected pediatric appendicitis was successfully adopted by a pediatric radiology department at a large tertiary children's hospital and stratifies risk for children based on their likelihood of appendicitis.

Prospective comparison of MR imaging and US for the diagnosis of pediatric appendicitis.

PURPOSE: To prospectively compare nonenhanced magnetic resonance (MR) imaging and ultrasonography (US) for the diagnosis of pediatric appendicitis. MATERIALS AND METHODS: This HIPAA-compliant study was approved by the institutional review board, and written informed consent was obtained from the patient's parent or guardian. Eighty-one patients (34 male, 47 female; mean age, 12.3 years ± 3.5 [standard deviation]; range, 4-17 years) were enrolled in this prospective study. All patients underwent right lower quadrant US and nonenhanced, nonsedated abdominopelvic MR imaging examinations. Two pediatric radiologists blinded to US results independently reviewed the MR images. MR imaging and US findings were designated positive, negative, or equivocal for acute appendicitis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for MR imaging and US and compared by using two-sided McNemar test or the score statistics specified by Leisenring. Kappa statistics were generated to determine intertechnique agreement between MR imaging and US and interobserver agreement between the two primary MR imaging readers. RESULTS: Thirty (37%) patients had pathologically proved acute appendicitis. When equivocal interpretations were designated positive, sensitivity was 93.3% for MR imaging (95% confidence interval [CI]: 77.9%, 99.2%) and 90.0% for US (95% CI: 73.5%, 97.9%), P > .99; specificity was 98% for MR imaging (95% CI: 89.6%, 100%) and 86.3% for US (95% CI:73.7%, 94.3%), P = .03; PPV was 96.5% for MR imaging (95% CI: 82.2%, 99.9%) and 79.4% for US (95% CI: 62.1%, 91.3%), P = .007; and NPV was 96.2% for MR imaging (95% CI: 86.8%, 99.5%) and 93.6% for US (95% CI: 82.4%, 98.7%), P = .45, with substantial intertechnique (κ = 0.77; 95% CI: 0.63, 0.90) and interobserver (κ = 0.76; 95% CI: 0.61, 0.91) agreement. When equivocal interpretations were designated negative, MR imaging sensitivity, specificity, PPV, and NPV were unchanged. For US, sensitivity was 86.7% (95% CI: 69.3%, 96.2%), P = .5; specificity was 100% (95% CI: 93.0%, 100%), P > .99; PPV was 100% (95% CI: 86.8%, 100%), P = .31; and NPV was 92.7% (95% CI: 82.4%, 98.0%), P = .16, with almost perfect intertechnique (κ = 0.92; 95% CI: 0.83, 1.00) and substantial interobserver (κ = 0.72; 95% CI: 0.58, 0.87) agreement. CONCLUSION: Nonenhanced MR imaging demonstrates high diagnostic performance similar to that of US for suspected pediatric appendicitis.

Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites.

BACKGROUND: Extremity pain represents one of the most common reasons for obtaining conventional radiographs in childhood. Despite the frequency of these examinations little is known about the incidence of diagnostic errors by interpreting pediatric radiologists. OBJECTIVE: The purpose of this study was to develop a standard error rate of pediatric radiologists by double-reading of extremity radiographs (elbow, wrists, knees and ankles) in children presenting with a history of trauma or pain. MATERIALS AND METHODS: During a 6-month period all major extremity radiographs (excluding digits) obtained at a large pediatric referral hospital for evaluation of pain or trauma were reviewed by two senior pediatric radiologists and compared to the official interpretation. All radiographs were interpreted initially by a board-certified pediatric radiologist with a Certificate of Added Qualification (CAQ). We reviewed 3,865 radiographic series in children and young adults 2-20 years of age. We tabulated misses and overcalls. We did not assess the clinical significance of the errors. RESULTS: There were 61 miss errors and 44 overcalls in 1,235 abnormal cases and 2,630 normal cases, for a 1.6% miss rate and a 1.1% overcall rate. Misses and overcalls were most common in the ankle. CONCLUSION: Interpretive errors by pediatric radiologists reviewing certain musculoskeletal radiographs are relatively infrequent. Diagnostic errors in the form of a miss or overcall occurred in 2.7% of the radiographs.

Thyroid disease in children: part 1: State-of-the-art imaging in pediatric hypothyroidism.

Hypothyroidism, defined as inadequate production of thyroid hormone, can be secondary to various underlying abnormalities in the pediatric population. Most frequently, hypothyroidism is related to structural abnormalities of the gland (dysgenesis), particularly in the neonatal population. However, other etiologies including intrinsic biochemical (dyshormonogenesis) and autoimmune abnormalities, as well as other rare causes, must be considered. Imaging is required to differentiate among the various etiologies of hypothyroidism and can be helpful in guiding therapy. This review aims to present an organized approach to hypothyroidism in the pediatric population, and assist the imager in guiding patient care.

Thyroid disease in children: part 2 : State-of-the-art imaging in pediatric hyperthyroidism.

Hyperthyroidism occurs secondary to overproduction of thyroid hormone by the thyroid gland. This condition can have rather serious effects on children, and thus timely diagnosis and treatment are of utmost importance. Imaging is quite useful in the management of children with hyperthyroidism. In addition to determining the underlying pathology, radiologic exams are crucial for therapy. This article describes the underlying etiologies of pediatric hyperthyroidism and provides general information on treatment.