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.

Physiologic Ovarian Cysts versus Other Ovarian and Adnexal Pathologic Changes in the Preadolescent and Adolescent Population: US and Surgical Follow-up.

Background Ovarian and adnexal cysts are frequently encountered at US examinations performed in preadolescent and adolescent patients, yet there are few published studies regarding the outcomes of cysts in this population. Purpose To identify characteristics at US that help to distinguish physiologic ovarian cysts from nonphysiologic entities. Materials and Methods Female patients who underwent pelvic US with or without Doppler from January 2009 through December 2013 were identified by using a centralized imaging database. Patients older than 7 years and younger than 18 years with ovarian or adnexal cysts at least 2.5 cm were included. Demographic characteristics, date of surgery, surgical notes, and pathologic reports were extracted from the electronic medical record. Initial and follow-up dates of US, cyst size and complexity, imaging diagnosis, and change on subsequent US images were recorded. Statistical analysis was performed with the Wilcoxon rank sum and Kruskal-Wallis tests for continuous variables and the Fisher exact test for categorical variables. Results Of 754 patients who met inclusion criteria (age, 8-18 years; mean age, 14.6 years ± 1.9 [standard deviation]; mean cyst size, 5 cm ± 3.3), 409 patients underwent complete follow-up that included resolution at imaging (n = 250) or surgery (n = 159). In the patients with complete imaging follow-up, mean time to US documentation of resolution was 194 days ± 321; 59.6% (149 of 250) patients had nonsimple cyst characteristics. One-hundred fifty-nine patients underwent surgical intervention (mean cyst size, 8.5 cm ± 5.3), and 69.8% (111 of 159) of the cysts had simple characteristics. Of the 159 cysts, 100 (62.8%) were defined in the pathologic report as paratubal cysts. Of 409 patients, no malignancies were encountered in this study population with surgical or imaging resolution. Conclusion No malignancies were encountered in the study population and the majority of cysts resolved at follow-up imaging. Large size, persistence, and separability from the ovary were most helpful for identification of nonphysiologic paratubal cysts. © RSNA, 2019.

Pediatric percutaneous renal biopsies: comparison of complications between real-time ultrasound guidance and pre-procedure ultrasound-aided skin-marking techniques.

BACKGROUND: Percutaneous renal biopsy is a commonly performed procedure that guides decision-making for children with renal disease. OBJECTIVE: To compare complications from renal biopsies using real-time ultrasound (US) guidance versus pre-procedure US-aided skin-marking in children. MATERIALS AND METHODS: We conducted a priori power analysis using a risk-adjusted model, which indicated we needed a sample size of 643-714 procedures (effect size: 0.8). Then we retrospectively identified consecutive patients who underwent a percutaneous renal biopsy from Jan. 1, 2012, to Dec. 31, 2016. We categorized complications according to the Society of Interventional Radiology (SIR) criteria and compared rates using the Fisher exact test. We analyzed complication predictors using multivariate regression. RESULTS: The study consisted of 701 percutaneous renal biopsies in 553 patients: 313 used real-time US guidance and 388 used pre-procedure US-aided skin-marking. Among the 254/701 (36%) complications, 56/313 (18%) resulted from real-time US guidance and 198/388 (51%) from pre-procedure US-aided skin-marking (P<0.001). In the US real-time guidance group, 39/56 (70%) complications were SIR A, 8/56 (14%) SIR B, 6/56 (11%) SIR C and 3/56 (5%) SIR D. Among the pre-procedure US-aided skin-marking group, 139/198 (70%) complications were SIR A, 47/198 (24%) SIR B, 11/198 (6%) SIR C and 1/198 (1%) SIR D. Complications between the two groups were significantly different regarding SIR A (P<0.001) and SIR B complications (P<0.001) but not major complications. Multivariate regression demonstrated that complications were higher using US-aided pre-procedure skin-marking (odds ratio [OR]=6.30; 95% confidence interval [CI]=3.86, 10.27) than with US real-time guidance. CONCLUSION: Children and young adults who underwent real-time US-guided percutaneous renal biopsies had significantly fewer minor complications, including those requiring follow-up medical care, compared to those who underwent percutaneous renal biopsies with pre-procedure US-aided skin-marking. No difference was detected in the incidence of major complications.

Pediatric ileocolic intussusception: new observations and unexpected implications.

BACKGROUND: Ileocolic intussusception occurs when the terminal ileum "telescopes" into the colon. We observed that ileocolic intussusception lengths are similar regardless of location in the colon. OBJECTIVE: To examine the uniformity of ileocolic intussusception length and its relationship to colon location, symptom duration and reducibility. MATERIALS AND METHODS: We retrospectively reviewed ultrasound-diagnosed pediatric ileocolic intussusceptions initially treated with pneumatic reduction at the Mayo Clinic or Texas Children's Hospital. We recorded demographic, imaging and surgical findings including age, gender, symptom duration, location of the ileocolic intussusception, reducibility with air enema and, if fluoroscopically irreducible, surgical findings. RESULTS: We identified 119 ileocolic intussusceptions (64% boys), with 81% in the right colon. There was no significant relationship between ileocolic intussusception length and colon location (P=0.15), nor ileocolic intussusception length and symptom duration (P=0.36). Ileocolic intussusceptions were more distal with increasing symptom duration (P=0.016). Successful reductions were unrelated to symptom duration (P=0.84) but were more likely with proximal versus distal locations (P=0.02). CONCLUSION: Ileocolic intussusception lengths are relatively uniform regardless of location along the course of the colon where they present. Our findings suggest that most of the apparent distal propagation of ileocolic intussusceptions is not caused by increasing telescoping of small bowel across the ileocecal valve but rather by foreshortening of the right colon. This implies poor cecal fixation and confirms fluoroscopic and surgical observations of cecal displacement from the right lower quadrant with ileocolic intussusceptions. The movement of the leading edge of the ileocolic intussusception during reduction is first due to "relocating" the cecum into the right lower quadrant after which the reduction of small bowel back across the ileocecal valve then occurs.

Correction to: Pediatric ileocolic intussusception: new observations and unexpected implications.

In this article, the fourth author's name is misspelled. The correct spelling, as shown above, should be "Nadia F. Mahmood."

Unfounded conclusions of equivalence in diagnostic accuracy studies: a pervasive fallacy of inference in pediatric radiology scientific abstracts.

BACKGROUND: In studies of diagnostic performance that fail to detect a statistically significant difference between compared techniques, investigators often declare evidence of equivalence or similarity without having actually tested that assertion due to incorrect methodology or insufficient statistical power. OBJECTIVE: The purpose of our investigation is to measure the prevalence of unfounded assertions of equivalence or similarity in comparison studies presented at the International Pediatric Radiology (IPR) meeting of 2016 and promote awareness of this fallacy of inference to the pediatric radiology community. MATERIALS AND METHODS: Two pediatric radiologists independently reviewed the methodology and reporting quality of the 194 scientific paper abstracts from the 2016 IPR meeting. All comparison studies were identified and those failing to detect a statistically significance difference and making a claim of equivalence or similarity in the results or conclusion were assessed for a description of the study design type, statistical power and sample size estimator calculation. RESULTS: Of 194 scientific paper abstracts, 112 (58%) were comparison studies. Of these, 36/112 (32%) made unfounded inferences of equivalence or similarity in diagnostic imaging performance. No study had an equivalence or non-inferiority design. No abstract specified the statistical power of the study, and only one abstract acknowledged a small sample size as a limitation in detecting a statistically significant difference. CONCLUSION: Inadequate reporting and unfounded inferences of equivalence or similarity were common in diagnostic performance comparison studies presented at IPR 2016. Failure to recognize these limitations could have adverse consequences by leading to the adoption of unvalidated imaging techniques.

Modified Friedman technique: a new proposed method of measuring glenoid version in the setting of glenohumeral dysplasia.

BACKGROUND: Glenoid version angles are measured to objectively follow changes related to glenohumeral dysplasia in the setting of brachial plexus birth palsy. Measuring glenoid version on cross-sectional imaging was initially described by Friedman et al. in 1992. Recent literature for non-dysplastic shoulders advocates time-consuming reconstructions and reformations for an accurate assessment of glenoid version. OBJECTIVE: To compare Friedman's original method for measuring glenoid version to a novel technique we developed ("modified Friedman") with the reference standard of true axial reformations. MATERIALS AND METHODS: With institutional review board approval, we retrospectively examined 30 normal and dysplastic shoulders obtained from magnetic resonance imaging examinations of 30 patients with an established diagnosis of brachial plexus birth palsy between January 2012 and September 2017. Four pediatric radiologists performed glenoid version measurements using Friedman's method, the modified Friedman method and a previously described true axial reformation method. The modified Friedman technique better accounts for scapular positioning by selecting a reference point related to the acromion-scapular body interface. Inter-rater reliability and inter-method agreement were assessed using intraclass correlation, paired t-tests and mixed linear model analysis. Equivalence tests between methods were performed per reader. RESULTS: Glenoid version measurements were significantly different when comparing Friedman's method to true axial reformations in normal (-10.8±5.7° [mean±standard deviation] vs. -8.8±5.3°; P≤0.001) and dysplastic shoulders (-34.6±17.7° vs. -28.1±17.5°; P≤0.001). Glenoid version measurements were not significantly different when comparing the modified Friedman's method to true axial reformations in normal (-6.3±5.8° vs. -8.8±5.3°; P=0.06) and dysplastic shoulders (-29.0±18.3° vs. -28.1±17.5°; P=0.06). Friedman's method was not equivalent to true axial reformations for measurements in dysplastic shoulders for all readers (P=0.68, 0.81, 0.86, 0.99); the modified Friedman method was equivalent to of true axial reformations for measurements in dysplastic shoulders for 3 of 4 readers (P≤0.001, P≤0.001, P≤0.001, P=0.10). CONCLUSION: In glenohumeral dysplasia, the modified Friedman method and post-processed true axial reformations provide statistically similar and reproducible values. We propose that our modified Friedman technique can be performed in lieu of post-processed true axial reformations to generate glenoid version measurements.

Correction to: Comparative safety and efficacy of balloon use in air enema reduction for pediatric intussusception.

The original version on this paper contained an error. The names of M. John Hicks and R. Paul Guillerman, though correctly appeared in the published version, are incorrectly displayed in indexing sites.

Comparative safety and efficacy of balloon use in air enema reduction for pediatric intussusception.

BACKGROUND: Intussusception, a common cause of bowel obstruction in young children, is primarily treated with air enema reduction. There is little literature comparing the safety and efficacy of air reduction without or with a rectal balloon. OBJECTIVE: To determine the safety and efficacy of a rectal balloon seal in air enema reduction. MATERIALS AND METHODS: We retrospectively reviewed the records of children who underwent air reduction for ileocolic or ileo-ileocolic intussusception over an 8-year period. We sorted data from 566 children according to whether a rectal balloon was used in the reduction, and further sorted them by type and experience level of the practitioner. Using logistic regression analyses, we identified risk factors for iatrogenic bowel perforation or failed reduction. RESULTS: Significant associations with bowel perforation included balloon use (P=0.038), age <1 year (P<0.0001), and attending physician's level of experience <5 years (P=0.043). Younger age was associated with both perforation (P<0.0001) and procedural failure (P=0.001). The risk-adjusted predicted probability of perforation decreased with age, approaching zero by 10 months regardless of balloon use. For cases without bowel resection, the risk-adjusted predicted probability of failure decreased toward zero by 30 months with balloon use, while remaining constant at 3-12% regardless of age when not using a balloon. CONCLUSION: The likelihood of a successful air reduction might be safely increased by using an inflated rectal balloon in children older than 9 months. Use of a balloon in younger infants is associated with a higher risk of iatrogenic bowel injury.

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.

Diagnostic Performance of US for Differentiating Perforated from Nonperforated Pediatric Appendicitis: A Prospective Cohort Study.

Purpose To prospectively evaluate the diagnostic performance of ultrasonography (US) for differentiating perforated from nonperforated pediatric appendicitis and to investigate the association between specific US findings and perforation. Materials and Methods This HIPAA-compliant study had institutional review board approval, and the need for informed consent was waived. All abdominal US studies performed for suspected pediatric appendicitis at one institution from July 1, 2013, to July 9, 2014, were examined prospectively. US studies were reported by using a risk-stratified scoring system (where a score of 1 indicated a normal appendix; a score of 2, an incompletely visualized normal appendix; a score of 3, a nonvisualized appendix; a score of 4, equivocal; a score of 5a, nonperforated appendicitis; and a score of 5b, perforated appendicitis). The diagnostic performance of US studies designated 5a and 5b was calculated. The following US findings were correlated with perforation at multivariate analysis: maximum appendiceal diameter, wall thickness, loss of mural stratification, hyperemia, periappendiceal fat inflammation, periappendiceal fluid, lumen contents, and appendicolith presence. The number of symptomatic days prior to presentation was recorded. Surgical diagnosis and clinical follow-up served as reference standards. Results A total of 577 patients with a diagnosis of appendicitis at US met the study criteria (468 with a score of 5a; 109 with a score of 5b). Appendicitis was correctly identified in 573 (99.3%) of 577 patients. US performance in the detection of perforated appendicitis (5b) was as follows: a sensitivity of 44.0% (80 of 182), a specificity of 93.1% (364 of 391), a positive predictive value of 74.8% (80 of 107), and a negative predictive value of 78.1% (364 of 466). Statistically significant associations with perforated appendicitis were longer duration of symptoms (odds ratio [OR] = 1.46, P < .0001), increased maximum diameter (OR = 1.29, P < .0001), simple periappendiceal fluid (OR = 2.08, P = .002), complex periappendiceal fluid (OR = 18.5, P < .0001), fluid-filled lumen (OR = 0.34, P = .002), and appendicolith (OR = 1.67, P = .02). Conclusion US is highly specific but nonsensitive for perforated pediatric appendicitis. Several US findings are significantly associated with perforation, especially the presence of complex periappendiceal fluid. © RSNA, 2016.

Searching for certainty: findings predictive of appendicitis in equivocal ultrasound exams.

BACKGROUND: Ultrasound (US) is the preferred imaging modality for evaluating suspected pediatric appendicitis. However, borderline appendiceal enlargement or questionable inflammatory changes can confound interpretation and lead to equivocal exams. OBJECTIVE: The purpose of this study was to determine which findings on equivocal US exams are most predictive of appendicitis. MATERIALS AND METHODS: All US exams performed for suspected pediatric appendicitis from July 1, 2013, through July 9, 2014, were initially interpreted using a risk-stratified scoring system. Two blinded pediatric radiologists independently reviewed US exams designated as equivocal and recorded the following findings: increased wall thickness, loss of mural stratification, peri-appendiceal fat inflammation, peri-appendiceal fluid, appendicolith and maximum appendiceal diameter. A third pediatric radiologist resolved discrepancies. US features were correlated with the final diagnosis via multivariate analysis. RESULTS: During the study period, 162/3,750 (4.3%) children had US exams initially interpreted as equivocal (mean age 9.8 +/- 3.8 years). Five outpatients were lost to follow-up. Forty-eight of the remaining 157 (30.6%) children had an operative diagnosis of appendicitis. Findings significantly associated with appendicitis were loss of mural stratification (odds ratio [OR] = 6.7, P=0.035), peri-appendiceal fat inflammation (OR = 10.0, P<0.0001) and appendicolith (OR = 15.8, P=0.025). While appendiceal diameter tended to be larger in patients with appendicitis, the difference was not statistically significant. CONCLUSION: Loss of mural stratification, peri-appendiceal fat inflammation and an appendicolith are significant predictors of appendicitis in children with otherwise equivocal US exams. While maximum appendiceal diameter is not statistically associated with appendicitis in our study, mean appendiceal diameter of 6.7 mm in those without appendicitis suggests that the customary upper normal limit of 6 mm is too sensitive.

Renal Ultrasound for Infants Younger Than 2 Months With a Febrile Urinary Tract Infection.

OBJECTIVE: The purpose of this study is to determine the performance of renal ultrasound for detecting vesicoureteral reflux (VUR) and obstructive uropathies in infants younger than 2 months with a febrile urinary tract infection (UTI). MATERIALS AND METHODS: We performed a retrospective cohort study of infants younger than 2 months with fever and culture-proven UTI presenting from July 1, 2008, through December 31, 2011, with renal ultrasound and voiding cystourethrogram (VCUG) performed within 30 days of UTI diagnosis. Two pediatric radiologists independently reviewed the renal ultrasound and VCUG findings. Results of the renal ultrasound were deemed abnormal if collecting system dilation, renal size asymmetry, collecting system duplication, urothelial thickening, ureteral dilation, or bladder anomalies were present. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of renal ultrasound were calculated using VCUG as reference standard. RESULTS: Of the 197 patients included (mean [SD] age, 33 [ 15 ] days; male-to-female ratio, 2:1), 25% (n = 49) had VUR grades I-V, with 16% (n = 31) having VUR grades III-V and 8% (n = 15) having VUR grades IV-V. For grades I-V VUR, sensitivity was 32.7% (95% CI, 20.0-47.5%), specificity was 69.6% (95% CI, 61.5-76.9%), PPV was 26.2% (95% CI, 15.8-39.1%), and NPV was 75.7% (95% CI, 67.6-82.7%). For grades III-V VUR, sensitivity was 51.6% (95% CI, 33.1-69.9%), specificity was 72.9% (95% CI, 65.5-79.5%), PPV was 26.2% (95% CI, 15.8-39.1%), and NPV was 89.0% (95% CI, 82.5-93.7%). For grades IV-V VUR, sensitivity was 86.7% (95% CI, 59.5-98.3%), specificity was 73.6% (95% CI, 66.6-79.9%), PPV was 21.3% (95% CI, 11.9-33.7%), and NPV was 98.5% (95% CI, 94.8-99.8%). No obstructive uropathies were diagnosed by VCUG in patients with normal renal ultrasound findings. CONCLUSION: In infants younger than 2 months, a normal renal ultrasound makes the presence of grades IV and V VUR highly unlikely but does not rule out lower grades of VUR.

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.

Radiographic screening of infants and young children with genetic predisposition for rare malignancies: DICER1 mutations and pleuropulmonary blastoma.

OBJECTIVE: The purpose of this study was to compare the risks of radiation in screening strategies using chest radiographs and CT to detect a rare cancer in a genetically predisposed population against the risks of undetected disease. MATERIALS AND METHODS: A decision analytic model of diagnostic imaging screening strategies was built to predict outcomes and cumulative radiation doses for children with DICER1 mutations screened for pleuropulmonary blastoma. Screening strategies compared were chest radiographs followed by chest CT for a positive radiographic result and CT alone. Screening frequencies ranged from once in 3 years to once every 3 months. BEIR VII (model VII proposed by the Committee on the Biological Effects of Ionizing Radiation) risk tables were used to predict excess cancer mortality for each strategy, and the corresponding loss of life expectancy was calculated using Surveillance Epidemiologic and End Results (SEER) statistics. Loss of life expectancy owing to undetected progressive pleuropulmonary blastoma was estimated on the basis of data from the International Pleuropulmonary Blastoma Registry. Sensitivity analysis was performed for all model parameters. RESULTS: Loss of life expectancy owing to undetected disease in an unscreened population exceeded that owing to radiation-induced cancer for all screening scenarios investigated. Increases in imaging frequency decreased loss of life expectancy for the combined (chest radiographs and CT) screening strategy but increased that for the CT-only strategy. This was because loss of life expectancy for combined screening is dominated by undetected disease, whereas loss of life expectancy for CT screening is dominated by radiation-induced cancers. CONCLUSION: Even for a rare disease such as pleuropulmonary blastoma, radiographic screening of infants and young children with cancer-predisposing mutations may result in improved life expectancy compared with the unscreened population. The benefit of screening will be greater for diseases with a higher screening yield.

Inferior patellar pole fragmentation in children: just a normal variant?

BACKGROUND: Fragmentary ossification of the inferior patella is often dismissed as a normal variant in children younger than 10 years of age. OBJECTIVE: The purpose of this study was to determine whether fragmentary inferior patellar pole ossification is a normal variant or is associated with symptoms or signs of pathology using MRI and clinical exam findings as reference. MATERIALS AND METHODS: A retrospective review was performed on 150 patients ages 5-10 years who underwent 164 knee radiography and MRI exams (45.1% male, mean age: 7.8 years). The presence or absence of inferior patellar pole fragmentation on radiography was correlated with the presence or absence of edema-like signal on MR images. Clinical notes were reviewed for the presence of symptoms or signs referable to the inferior patellar pole. These data were compared with a 1:1 age- and sex-matched control group without inferior pole fragmentation. Statistical analysis was performed using two-tailed t-tests. RESULTS: Forty of 164 (24.4%) knee radiographs showed fragmentary ossification of the inferior patella. Of these 40 knees, 62.5% (25/40) had edema-like signal of the inferior patellar bone marrow compared with 7.5% (3/40) of controls (P = 0.035). Patients with fragmentary ossification at the inferior patella had a significantly higher incidence of documented focal inferior patellar pain compared with controls (20% vs. 2.5%, P = 0.015). CONCLUSION: Inferior patellar pole fragmentation in children 5 to 10 years of age may be associated with localized symptoms and bone marrow edema-like signal and should not be routinely dismissed as a normal variant of ossification.

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.

Overuse of fluoroscopic gastrostomy studies in a children's hospital.

BACKGROUND: Gastrostomy tubes are often dislodged or exchanged in children. Indications for fluoroscopic examination of gastrostomy location include concern for malposition, dislodgement, leak, or gastric outlet obstruction. We hypothesized that most of the studies obtained at our institution were not ordered for one of the aforementioned indications and do not ultimately affect patient management. METHODS: All fluoroscopic gastrostomy studies performed from January 2011 to December 2012 were reviewed. Transgastric jejunostomy studies were excluded. Patient demographics, indications for the study, elapsed time since placement, imaging findings, and short-term outcomes were recorded. Chi-square analysis was used to evaluate relationships between categorical variables. RESULTS: During the study period, 337 patients who underwent fluoroscopic gastrostomy studies were identified; median age was 2.5 y (0.05-23.8). Sixty-two percent (208/337) of the studies were ordered in asymptomatic patients to confirm tube placement location after routine exchange or replacement. Symptomatic patients accounted for 38% of the studies. Ordering physicians were primarily nonsurgeons (72%, 242/337). Abnormal findings were observed in 4.8% (16/337) of patients, six (1.7%) of whom required an operative intervention. The 2.9% (6/208) abnormal study rate for asymptomatic patients was significantly lower than the 7.9% (10/129) rate in the patients who were evaluated for symptomatic indications (P = 0.03). CONCLUSIONS: Most of the fluoroscopic gastrostomy studies ordered at a tertiary care center did not appear to alter patient care. Development of a standardized management algorithm based on clinical indications is necessary to decrease the number of extraneous gastrostomy studies.