Sustainability of paediatric radiology in Italy.

Italy is the sixth most populous country in Europe and has the second highest average life expectancy, reaching 79.4 years for men and 84.5 for women. However, Italy has one of the lowest total fertility rates in the world: in 2018 it was 1.3 births per woman, with the population older than 65 comprising more than 30%, and those younger-than-19 less than 15%. Older people are the main concern of the Italian health system. Weighted coefficients for the allocation of funds favour older adults. As confirmed by our study, paediatric radiology is expensive, and the reimbursement based on Italian adult rates is not sufficient. The negative impact on the budget discourages the diffusion of paediatric radiology both in the private practices that provide services paid for by the state government and in the public hospitals. The 501 paediatric hospital units in Italy are not homogeneously distributed throughout the national territory. Furthermore, in Italy there are 12 highly specialised children's hospitals whose competences were defined in 2005 by the Ministry of Health. Paediatric radiology is not included among the highly qualified specialties. The quality gap in paediatric radiology between children's hospitals and general hospitals, the latter often without paediatric radiologists, is evident in daily practice with misdiagnoses and investigations not carried out.

Lung ultrasound in the diagnosis and monitoring of 30 children with coronavirus disease 2019.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has caused a new global pandemic and is responsible for millions of infections and thousands of deaths in the world. The lung ultrasound (LUS) is a noninvasive and easily repeatable tool and can be carried out by the pediatrician at the bedside of children with a consequent reduction in the risk of transmission of the virus. OBJECTIVE: We hypothesized that ultrasound findings in these patients would (1) be associated with their disease severity and (2) change over time in alignment with clinical outcome. METHODS: The study was made in the emergency department (ED) in a tertiary level pediatric hospital. All patients with swab-confirmed COVID-19 infection were subjected to a LUS within 6 h from admission and after 96 h. RESULTS: Among a total of 30 children, 18 (60%) were males, 4 reported exertional dyspnea, and only 1 chest pain. The mean oxygen saturation was 98.8 ± 1.0% in ambient air in the ED and no patient needed oxygen therapy during hospitalization. Children with moderate disease presented more B line (p = .03). After 96 h, we had observed ultrasound abnormality only in 20% of the children. We found a statistically significant reduction in pleural irregularities (30% vs. 16.7; p = .001) and in B lines (50% vs. 20%; p = .008). CONCLUSIONS: The LUS is a useful, feasible, and safe tool for the clinician to complement the clinical evaluation and to monitor the evolution of lung disease in children with COVID-19.

Italian inter-society expert panel position on radiological exposure in Neonatal Intensive Care Units.

BACKGROUND: In the recent years, clinical progress and better medical assistance for pregnant women, together with the introduction of new complex technologies, has improved the survival of preterm infants. However, this result requires frequent radiological investigations mostly represented by thoracic and abdominal radiographs in incubators. This document was elaborated by an expert panel Italian inter-society working group (Radiologists, Paediatricians, Medical Physicists) with the aim to assist healthcare practitioners in taking choices involving radiation exposures of new-born infants and to provide practical recommendations about justification and optimization in Neonatal Intensive Care Units. The adherence to these practice recommendations could ensure a high quality and patient safety. More complex and less common radiological practice, such as CT scan or fluoroscopy have been excluded. METHODS: The consensus was reached starting from current good practice evidence shared by four scientific societies panel: AIFM (Italian Association of Physics in Medicine), SIN (Italian Neonatology Society), SIP (Italian Paediatric Society), SIRM (Italian Medical Radiology Society) in order to guarantee good standard practices for every professional involved in Neonatal Intensive Care Units (NICU). The report is divided into clinical and physical-dosimetric sections: clinical Indications, good practice in radiological exposures, devices, exposure parameters and modalities, patient positioning and immobilization, Reference Diagnostic Levels, operators and patient's radiation protection. Another important topic was the evaluation of the different incubators in order to understand if the consequences of the technological evolution have had an impact on the increase of the dose to the small patients, and how to choose the best device in terms of radiation protection. At the end the working group faced the problem of setting up the correct communication between clinicians and parents following the most recent indications of the international paediatric societies. RESULTS: Taking into account the experience and expertise of 10 Italian Centres, the guideline sets out the criteria to ensure a high standard of neonatal care in NICU about procedures, facilities, recommended equipment, quality assurance, radiation protection measures for children and staff members and communication on radiation risk. CONCLUSIONS: This document will allow a standardization of the approach to the exposures in NICU, although oriented to a flexible methodology.

Quantitative Assessment of Parenchymal Involvement Using 3D Lung Model in Adolescent With Covid-19 Interstitial Pneumonia.

Background: Amount of parenchymal involvement in patients with interstitial pneumonia Covid-19 related, seems to be associated with a worse prognosis. Nowadays 3D reconstruction imaging is expanding its role in clinical medical practice. We aimed to use 3D lung reconstruction of a young lady affected by Sars-CoV2 infection and interstitial pneumonia, to better visualize, and quantitatively assess the parenchymal involvement. Methods: Volumetric Chest CT scan was performed in a 15 years old girl with interstitial lung pneumonia, Sars-CoV2 infection related. 3D modeling of the lungs, with differentiation of healthy and affected parenchymal area were obtained by using multiple software. Results: 3D reconstruction imaging allowed us to quantify the lung parenchyma involved, Self-explaining 3D images, useful for the understanding, and discussion of the clinical case were also obtained. Conclusions: Quantitative Assessment of Parenchymal Involvement Using 3D Lung Model in Covid-19 Infection is feasible and it provides information which could play a role in the management and risk stratification of these patients.

Lung Ultrasound in Children with COVID-19: Preliminary Findings.

Recent evidence indicates the usefulness of lung ultrasound (LUS) in detecting coronavirus disease 19 (COVID-19) pneumonia. However, no data are available on the use of LUS in children with COVID-19 pneumonia. In this report, we describe LUS features of 10 consecutively admitted children with COVID-19 in two tertiary-level pediatric hospitals in Rome. LUS revealed signs of lung involvement during COVID-19 infection. In particular, vertical artifacts (70%), pleural irregularities (60%), areas of white lung (10%) and subpleural consolidations (10%) were the main findings in patients with COVID-19. No cases of pleural effusions were found. According to our experience, the routine use of LUS in the evaluation of children with suspected or confirmed COVID-19, when performed by clinicians with documented experience in LUS, was useful in diagnosing and monitoring pediatric COVID-19 pneumonia, reducing unnecessary radiation/sedation in children and exposure of health care workers to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Protecting sensitive patient groups from imaging using ionizing radiation: effects during pregnancy, in fetal life and childhood.

The frequency of imaging examinations requiring radiation exposure in children (especially CT) is rapidly increasing. This paper reviews the current evidence in radiation protection in pediatric imaging, focusing on the recent knowledge of the biological risk related to low doses exposure. Even if there are no strictly defined limits for patient radiation exposure, it is recommended to try to keep doses as low as reasonably achievable (the ALARA principle). To achieve ALARA, several techniques to reduce the radiation dose in radiation-sensitive patients groups are reviewed. The most recent recommendations that provide guidance regarding imaging of pregnant women are also summarized, and the risk depending on dose and phase of pregnancy is reported. Finally, the risk-benefit analysis of each examination, and careful communication of this risk to the patient, is emphasized.

Is MRI imaging in pediatric age totally safe? A critical reprisal.

Current radiological literature is strongly focussed on radiation imaging risks. Indeed, given there is a small but actual augment in cancer risk from exposure to ionizing radiation in children, it is important to understand what the risk of alternative techniques could be. We retrospectively review literature data concerning possible MR imaging risks, focussing on the biological effects of MR, sedation and gadolinium compound risks when dealing with infant patients. The main concerns can be summarized in: (1) Biological effects of non-ionizing electromagnetic fields (EMF) employed-whose mechanisms of interaction with human tissues are polarization, induced current, and thermal heating, respectively. (2) Risks associated with noises produced during MRI examinations. (3) Hazards from ferromagnetic external and/or implanted devices-whose risk of being unintentionally brought inside MR room is higher in children than in adults. (4) Risks associated with sedation or general anaesthesia, essential problem in performing MR in very young patients, due to the exam long-lasting. (5) Risks related to gadolinium-based contrast agents, especially considering the newly reported brain deposition.

Quantification of scatter radiation from radiographic procedures in a neonatal intensive care unit.

BACKGROUND: In a neonatal intensive care unit (NICU), preterm infants are often exposed to a large number of radiographic examinations, which could cause adjacent neonates, family caregivers and staff members to be exposed to a dose amount due to scatter radiation. OBJECTIVE: To provide information on scatter radiation exposure levels in a NICU, to compare these values with the effective dose limits established by the European Union and to evaluate the effectiveness of radiation protection devices in this setting. MATERIALS AND METHODS: Radiation exposure levels due to scatter radiation were estimated by passive detectors (thermoluminescent dosimeters) and direct dosimetric measurements (with a dose rate meter); in the latter case, an angular map of the scatter dose distribution was achieved. RESULTS: The dose due to scatter radiation to staff in our setting is approximately 160 µSv/year, which is markedly lower than the effective dose limit for workers established by the European Union (20 mSv/year). The doses range between 0.012 and 0.095 µSv/radiograph. Considering a mean hospitalization period of 3 months and our NICU workload, the corresponding scatter radiation dose to an adjacent patient and/or his/her caregiver is at most 40 µSv. CONCLUSION: For distances greater than 1 m from the irradiation field, both scatter dose absorbed by a staff member during a year and that by an adjacent patient and/or his/her caregiver during hospitalization is less than 1 mSv, which is the exposure limit for public members in a year.

A novel method for CT dosimetry with a suspended phantom setup.

PURPOSE: This work presents a method for estimating CT dosimetric indices with a prototype designed for suspending the phantom/ion chamber system fixed at the CT isocenter. The purpose of this study was to validate the proposed methodology, which can be used to provide a direct assessment of dosimetric indices in helical scans. METHODS: The method is based on a reference setup in which the measuring system for CT dosimetry is in a stationary configuration, i.e. not bound to the CT table, and on a mathematical formalism developed for the proposed reference system. The reliability of the method was demonstrated through a set of experimental measurements. Firstly, dosimetric indices were measured with the new method and compared with the indices obtained with the procedure currently used for CT dosimetry (measuring system bound to the CT table). Secondly, dosimetric indices measured with the new method were compared with those displayed on the CT console. RESULTS: There is good agreement between the dosimetric indices obtained with the standard setup and those obtained with the suspended phantom setup, within the expected range of errors. The difference between dosimetric indices estimated with the proposed method and those displayed on the CT console is below 2%. CONCLUSIONS: The method enables CT dosimetry to be performed with the dose detector in a stationary longitudinal position thanks to the newly introduced suspended phantom setup. Using this approach, CT dose can be assessed for high pitch helical scans, acquisitions without complete tube rotation and for cases where dynamic collimation is used.

Radiation exposure in diagnostic imaging: wisdom and prudence, but still a lot to understand.

Since 2000, a series of scientific articles on CT have been raising increasing concern about the risk of radiation induced cancer in children. The alarming conclusions of some of these articles had international echo through global media, provoking widespread public concern. Actually, many of these alarming scientific publications appeared to be flawed by poor study design, but their conclusions were not openly contradicted. In US and Europe pediatric radiologists had to face a huge challenge, which brought to the Image Gently campaign and the Eurosafe initiative with the aim to rebut misinformation and to support medical radiation protection. The Linear No Threshold model-which is the base of contemporary radioprotection-is increasingly questioned by new recent studies suggesting that low dose radiation would decrease cancer risk thanks to the enhancement of immune system response. Actually, pediatric radiologists have to cope with many important issues and contradictory messages. Good medical practice includes good communication about the benefits and risks of health procedures, thus the communication of radiation risk is a key component for radiologists. When considering benefits and risks, an important risk is too often ignored: the risk that skipping a diagnostic exam may cause a misdiagnosis, and therefore, a poor outcome. We should emphasize that a risk from a radiological investigation is very small, if a risk at all, and we are not sure that there is a risk at very low doses, like those doses in the majority of X-ray procedures including CT.

Radiation risks knowledge in resident and fellow in paediatrics: a questionnaire survey.

BACKGROUND: Analyse through a multi-choice anonymous questionnaire the knowledge's level in paediatric residents and fellows in two different main Italian hospital, looking mainly to the information to patients and relatives related to risks of ionizing radiation used in common radiological investigations in children. METHODS: 65 multi choice questionnaires were distributed to paediatric residents and fellows of two different hospitals, an University Hospital (A.O.U.P. "P. Giaccone"- University of Palermo) and a national reference centre for paediatrics (Ospedale Pediatrico Bambino Gesù - Rome). The questionnaire included twelve multiple-choice questions with the aim of analyzing the knowledge about ionizing radiation related risks in infants and children who undergo common diagnostic radiology investigations. The data obtained were processed using software Stata/MP version 11.2. In order to measure the level of expertise of each interviewee a binary indicator was built. The value 1 was assigned if the percentage of correct answers exceeds the median of the distribution and 0 for values not exceeding the median. The association between the level of competence and demographic characteristics (gender, age) and training experience was measured by means of α(2) test. RESULTS: 51/65 questionnaires were completed, returned and analysed (87.7%). Only 18 surveyed (35%), (95% IC = [22%-48%]) can be defined as competent in radiation risk knowledge for common radiological investigations, considering the percentage of correct answers at least of 50% (sufficient knowledge was given with a minimum score of 8 correct answers out of 12). CONCLUSIONS: The study demonstrates an urgent need to implement the radiation protection knowledge in the training programme of paediatricians, that improve if just a short targeted training is performed.

Wandering spleen in children: a report of 3 cases and a brief literature review underlining the importance of diagnostic imaging.

BACKGROUND: Wandering spleen is a rare condition in children that is often caused by loss or weakening of the splenic ligaments. Its clinical presentation is variable; 64% of children with wandering spleen have splenic torsion as a complication. OBJECTIVE: To provide up-to-date information on the diagnosis, clinical management and diagnostic imaging approaches for wandering spleen in infants and children and to underline the importance of color Doppler US and CT in providing important information for patient management. MATERIALS AND METHODS: We report a series of three children with wandering spleen treated at our children's hospital over the last 6 years. All three underwent clinical evaluation, color Doppler US and CT and were surgically treated. We also reviewed 40 articles that included 55 patients younger than 18 years reported in the Medline database from 2002 to 2012. RESULTS: We correlated pathological data with imaging findings. Color Doppler US, the first imaging modality in investigating abdominal symptoms in children with suspected wandering spleen, yielded a diagnostic sensitivity of 54.9%, whereas CT achieved about 71.7%. CONCLUSION: Radiologic evaluation has a major role in confirming the diagnosis of a suspected wandering spleen and avoiding potentially life-threatening complications requiring immediate surgery.

Paediatric tubercular spinal abscess involving the dorsal, lumbar and sacral regions and causing spinal cord compression.

Tubercular spinal localization is very rare (5%) in paediatric age. We report the unusual case of a child with a history of bacillus Calmette-Guerin vaccination who presented with lymphadenitis in the absence of pulmonary involvement. Despite appropriate anti-tubercular therapy, the patient developed spinal tuberculosis with cord compression. Urgent surgical decompression was performed: laminectomy was done at D3-D5 levels and the higher abscess was then flushed using a catheter, decompressing the cauda equina. Our findings suggest that diagnosis of tuberculosis should be considered even in light of anamnestic vaccination at birth, and that surgical treatment should be rapidly provided in the event of spinal cord compression to avoid devastating sequelae.

Synchronous bilateral breast carcinoma in a 50-year-old man with 45,X/46,XY mosaic karyotype: report of a case.

We report a case of synchronous bilateral breast cancer in a patient with ambiguous external genitalia attributed to a 45,X/46,XY mosaicism. To our knowledge, this represents the first such case ever to be reported. Mammography, ultrasonography, computed tomography, and magnetic resonance imaging all showed bilateral suspicious breast masses with microcalcifications. There were no radiological findings of muscle invasion or axillary lymphadenopathy. The patient was successfully treated by bilateral radical modified mastectomy followed by external irradiation and adjuvant endocrine therapy. Histological examination revealed a bilateral ductal carcinoma in situ, with a cribriform and papillary pattern and microfoci of infiltrating ductal carcinoma. The hormonal profile revealed high levels of follicle-stimulating hormone and luteinizing hormone, and low levels of testosterone. Testicular sonography revealed small hypoechoic testicles with bilateral microlithiasis. This case shows that 45,X/46,XY men may have an increased risk of breast cancer and must be followed up carefully.

Suspected cup syndrome. Diagnostic imaging of a misunderstood breast tumor for its uncommon location.

The case of a 41-year-old female patient with axillary lymphadenopathies and negative clinical and mammographic examinations is discussed. In the suspicion of a cup syndrome of breast origin, breast sonography was performed. While the absence of alterations was confirmed, a right parasternal swelling was highly suggestive of malignancy. On histology, a malignant parasternal nodule was diagnosed. Breast MRI was performed and an ipsilateral malignant focal lesion was visualized. Chemotherapy was administered but after a disease-free interval leptomeningeal and cerebral metastases appeared.

Diagnostic imaging of breast implants: role of MRI.

The role of MRI in the evaluation of breast implants, based on the observations collected over a 2-year period at the "Istituto di Radiologia" of the "Università Cattolica del S. Cuore" of Rome, is reported. In women with breast implants both mammography and sonography have a lower diagnostic accuracy in the evaluation of the glandular parenchyma. At present, MRI plays a primary role in patients with breast implants for the diagnosis of rupture. Based on the international literature its sensitivity is 90-95% and the specificity is 95-100%. Therefore, it can be considered the gold standard procedure in the diagnosis of locoregional recurrence. In spite of the excellent sensitivity and specificity of MRI in the evaluation of patients with breast implants, the integration with information from clinical examinations and conventional imaging is required together with an exhaustive knowledge of this method whose development is still in progress.

Role of magnetic resonance imaging in the pre and postchemotherapy evaluation in locally advanced breast carcinoma.

The study was carried out to evaluate the response to preoperative chemotherapy of locally advanced breast cancer with MRI. The series included 45 women with locally advanced breast cancer who underwent MRI before and after neoadjuvant chemotherapy. Based on the volume of residual disease, the response to chemotherapy was classified as: complete response, partial response, minor response, no change and disease progression. Responses to neoadjuvant chemotherapy were compared to MRI findings and to prognostic factors. Based on MRI findings 8 patients were assigned to the complete response group, 16 to the partial response group, 11 to the minor response group, 9 to the no change group and 1 patient to the disease progression group. MRI showed 90.2% sensitivity, 100% specificity and 91.1% accuracy. The correlation between MRI findings and prognostic factors may be useful to predict cancer aggressiveness and to understand the natural history of different breast carcinomas.