Resolution of Sonographic Appendicitis in Pediatrics: a Point of Care Ultrasound Case-Series.

Studies of pediatric appendicitis treated conservatively show a considerable rate of recurrence. Point of care ultrasound (POCUS) imaging at our facility is routinely performed for abdominal pain and may be more likely than radiology-performed ultrasound to encounter cases that then self-resolve. We present a case series collected from a POCUS quality assurance review from 2019 through 2022. Five children were identified with sonographic appendicitis on review of stored POCUS images, and subsequent improvement of pain. A pediatric radiologist reviewed blinded images and agreed with the POCUS interpretation in all five cases. No child in this series received antibiotics. The national patient database was used to ensure that the patients in this series did not present elsewhere with appendicitis. We suggest that these cases represent early appendicitis that self-resolved. Patients should be aware that POCUS showed signs of appendicitis, and should seek medical attention for recurrence of symptoms.

A Comparison of Online Self-Training and Standard Bedside Training in Lung Ultrasonography for Medical Students.

PURPOSE: Point-of-care ultrasonography (POCUS) is increasingly integrated into medical education. Traditionally taught at the bedside using a hands-on approach, POCUS is limited by cost, time, faculty availability, and access to POCUS resources. With the recent transition to digitalization in medical education, the authors compare lung POCUS performance and pathology identification among medical students to examine whether using an online, self-learning lung POCUS module is noninferior to traditional bedside, faculty-led lung POCUS training. METHOD: This study assessed the performance of 51 medical students from August to October 2021 on an elearning lung POCUS course with traditional bedside training and no training. POCUS students were scored on use of a simulator to identify pathologies, ability to identify lung ultrasonographic pathological clips, and scanning technique. RESULTS: The elearning group had a significantly higher median (interquartile range [IQR]) total test score (15/18 [10.5-16] vs. 12/18 [9-13]; P = .03) and scanning technique score (5/5 [4-5] vs. 4/5 [3-4]; P = .03) compared with the standard curriculum group. The median (IQR) accuracy in the clip segment of the examination was 7.5 of 10 (4-9) in the self-learning group and 6 of 10 (4-7) in the standard curriculum group ( P = .18). The median (IQR) grade on the simulator segment of the examination was 2 of 3 (2-3) in the self-learning group and 2 of 3 (1-2) in the standard curriculum group ( P = .06). CONCLUSIONS: This study suggests that self-directed elearning of lung POCUS is at least noninferior to bedside teaching and possibly even a superior method of learning lung POCUS. This teaching method POCUS is feasible for medical students to learn lung ultrasonography and has potential to complement or augment the traditional learning process or eliminate or lessen the requirement for bedside teaching by reaching a larger audience while minimizing costs and human resources.

Use of Artificial Intelligence in Radiology: Impact on Pediatric Patients, a White Paper From the ACR Pediatric AI Workgroup.

In this white paper, the ACR Pediatric AI Workgroup of the Commission on Informatics educates the radiology community about the health equity issue of the lack of pediatric artificial intelligence (AI), improves the understanding of relevant pediatric AI issues, and offers solutions to address the inadequacies in pediatric AI development. In short, the design, training, validation, and safe implementation of AI in children require careful and specific approaches that can be distinct from those used for adults. On the eve of widespread use of AI in imaging practice, the group invites the radiology community to align and join Image IntelliGently (www.imageintelligently.org) to ensure that the use of AI is safe, reliable, and effective for children.

COVID-Necessitated Online Radiology Elective Improves Student Imaging Appropriateness in Clinical Case Vignettes.

RATIONALE AND OBJECTIVES: The use of imaging in medicine has increased considerably over the previous decades, contributing to significant inefficiency of use. Radiology education varies amongst institutions without standardized learning objectives. Consequently, many physicians and student doctors are unprepared to make appropriate choices regarding imaging. In response to COVID-19-engendered restrictions, we created a fully online, image-intensive radiology curriculum to introduce students to clinical radiology and appropriate imaging usage. MATERIALS AND METHODS: A 2-week radiology elective curriculum was created that adopted accessible, free, online-based learning to foster student education and patient safety while upholding academic standards. Each unit included an emphasis on imaging appropriateness. Students assembled an elective portfolio including self-assessments and prepared a clinical radiology conference to present as a radiologist in training. Two final assessments were required. One consisted of clinical vignettes based on American College of Radiology (ACR) Appropriateness Criteria (AC). The second was an MRI safety quiz. RESULTS: Third and fourth year students at five institutions (N = 97) completed the elective. Examination scores on an assessment adapted from the ACR AC were significantly improved compared to previously published scores of medical students who took ACR AC-based assessments without taking a radiology course. The course was published and shared with medical schools worldwide. CONCLUSION: The elective successfully educated students in radiology through a virtual platform and introduced them to the concept of appropriateness in medical imaging. These goals were accomplished using a free, online, easily accessible curriculum. Incorporation of additional topics within the discipline of radiology should be included in the curriculum in the future.

Children With Elbow Injuries and Sonographic Elevated Posterior Fat Pad but No Identifiable Posterior Fat Pad on Lateral Radiographs: A Case Series.

Point of Care Ultrasound (POCUS) is used to evaluate the injured pediatric elbow. Standard of care, however, remains radiography. POCUS performed in the setting of normal radiographs have been obtained may demonstrate radiologic occult lipohemarthrosis indicative of occult fracture. We reviewed our pediatric emergency department (PED) POCUS archive for lipohemarthrosis, and then isolated those cases with normal elbow radiography. Radiography was deemed to be normal per the interpretation of the treating PED physician, and was reviewed for this series by an experienced ABR board certified pediatric radiologist. Fracture on POCUS was defined as fracture line or lipohemarthrosis in a posterior sagittal or transverse view of the distal humerus. Fracture was confirmed by signs of cortical healing on follow-up radiography, or clinical course consistent with fracture as documented by an orthopedist. We identified four children with elbow fractures who had no fracture line or elevated posterior fat pad on radiography but demonstrated lipohemarthrosis on POCUS. POCUS may elicit evidence of fracture even after normal radiography, and POCUS findings suggesting occult fracture may allow for more effective guidance on discharge.

Preliminary study of sound touch elastography in diffuse thyroid disease in children.

Objective: The purpose of this study was to evaluate the use of sound touch elastography (STE) in conjunction with conventional ultrasound in the differential diagnosis of diffuse thyroid disease (DTD) and normal thyroid in children. Methods: Studies performed on 62 children with DTD and 30 normal volunteers were reviewed. Standard gray scale ultrasound, Doppler ultrasound and STE of the examinees, and the serum test results of children with DTD were collected, analyzed and compared. Results: The STE-Mean values in the Graves' disease (GD) group, Hashimoto's thyroiditis (HT) group, and normal control group, respectively, were 19.35 ± 5.00 kPa, 19.43 ± 6.06 kPa, and 11.24 ± 1.99 kPa. With an area under the ROC curve (AUC) of 0.945, STE-Mean values differentiated DTD from normal children. The peak systolic velocity (PSV) of the superior thyroid artery separated DTD from normal children and AUC from children with GD and HT, respectively, and was 0.992 and 0.864. The PSV of superior thyroid artery revealed a somewhat favorable connection with FT3 and FT4. Conclusion: The STE results revealed that thyroid stiffness was higher in children with DTD than in normal children, but further differentiation into GD and HT subgroups lacked specificity, and the superior thyroid artery flow velocity might be a good supplement to distinguish both.

Delayed Neuropsychiatric Sequel Following Pediatric Carbon Monoxide Poisoning: A Case Report and Literature Review.

Carbon monoxide (CO) poisoning is a serious health problem. The main pathophysiological mechanism of acute CO poisoning is hypoxia due to the formation of carboxyhemoglobin (COHb). Delayed neuropsychiatric sequel (DNPS) occurs following an interval of several days to several weeks post-CO exposure and can present in many different manifestations, ranging from behavioral and mood disorders to encephalopathy and seizures and cause long-term neuropsychiatric sequel. The pathogenesis of DNPS following CO poisoning is a complex one that encompasses hypoxia-induced encephalopathy as well as inflammation, direct cellular changes and damage. The incidence varies and treatment is debated. We display a case of a previously healthy 13-year-old boy suffering from DNPS, presenting with seizures and encephalopathy and later developing optic nerve damage. Increased awareness to this condition might help diagnose future patients and aid in the understanding of the pathogenesis and treatment options for this poorly understood condition.

Splenic size as a marker for active inflammation in Crohn's disease.

PURPOSE: The spleen, one of the major organs of the reticuloendothelial system, frequently enlarges in a variety of inflammatory states. We propose measurement of splenic volume as an additional marker for inflammatory bowel disease activity. METHODS: This is a retrospective study of patients with Crohn's disease who had computed tomography (CT) exams. Demographic data of the patients was recorded. To determine activity of the disease we analyzed clinical records, lab results and findings on CT scan. Splenic size and volume was calculated on each exam. RESULTS: The study cohort includes 90 patients with Crohn's disease who underwent 188 [R1.4] CT exams over 6 years. Splenic volume was found to be significantly larger in patients with CD compared to published values for a healthy population. However, the mean splenic volume was 324 cm ± 130.3 did not show significant difference between the group of active 339.2 ± 118.4, and non-active disease 304.2 ± 144.2 (p 0.21 for splenic volume). Interestingly, when splenic volume/BMI index (SV/BMI) was calculated, it was found to be significantly larger in patients with active diseases, 15.26 ± 4.86 compared to non-active phase, 11.69 ± 5.19 (p 0.004). CONCLUSION: Splenic size is enlarged in patients with Crohn's disease compared to standard published literature of normal individuals. While there is no statistically significant difference in our study between splenic volume in Crohn's disease patients with active versus nonactive disease, indexed splenic volume, as an additional marker, may add value to the assessment of patient with CD and monitoring of the disease activity.

Use of Point-of-Care Ultrasound to Identify Occult Fractures of the Tibia in the Pediatric Emergency Department: A Case Series.

BACKGROUND: Although point-of-care ultrasound (POCUS) has been shown to be useful in the identification of both pediatric and adult long-bone fractures in the emergency setting, radiography remains the standard of care. Emergency physicians are often faced with the dilemma of how to evaluate and treat the child with lower leg injury and physical examination concerning for fracture but no readily identifiable fracture line on radiography. CASE REPORTS: We present four cases in which POCUS was used to diagnose a radiographically occult fracture of the proximal tibia in young children. This is the first case series of occult fracture of the tibia diagnosed with POCUS. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS can demonstrate evidence of fracture even after unremarkable radiography is obtained, and POCUS findings consistent with fracture might allow for more effective guidance on discharge.

Adapting Surgical Clerkship Curricula in Response to the COVID-19 Pandemic.

BACKGROUND: Coronavirus disease-19 (COVID-19) impacted medical education and led to the significant modification or suspension of clinical clerkships and rotations. OBJECTIVES: To describe a revised surgery clerkship curriculum, in which we divided in-person clinical teaching into smaller groups of students and adopted online-based learning to foster student and patient safety while upholding program standards. METHODS: The third-year surgery core clerkship of a 4-year international English-language program at the Medical School for International Health at Ben Gurion University of the Negev, Beer Sheva, Israel, was adapted by dividing students into smaller capsules for in-person learning and incorporating online learning tools. Specifically, students were divided evenly throughout three surgical departments, each of which followed a different clinical schedule. RESULTS: National Board of Medical Examiners clerkship scores of third-year medical students who were returning to in-person clinical clerkships after transitioning from 8 weeks of online-based learning showed no significant difference from the previous 2 years. CONCLUSIONS: To manage with the restrictions caused by COVID-19 pandemic, we designed an alternative approach to a traditional surgical clerkship that minimized the risk of exposure and used online learning tools to navigate scheduling challenges. This curriculum enabled students to complete their clinical rotation objectives and outcomes while maintaining program standards. Furthermore, this approach provided a number of benefits, which medical schools should consider adopting the model into practice even in a post-pandemic setting.

Therapeutic Computed Tomography-Guided Pericardiocentesis: Lessons Learned Based on a 7-Year Single-Center Experience.

OBJECTIVE: Pericardiocentesis is a well-known procedure commonly performed by either image-guided intervention or surgical approaches. Computed tomography (CT)-guided pericardiocentesis is not widely used, but provides certain advantages. In the article we will discuss our technique of CT-guided therapeutic pericardiocentesis, including advantages and disadvantages, patient selection, possible approaches, and complications. METHODS: The retrospective study included 121 therapeutic pericardial drainages performed under CT guidance. Demographic data of the patients, entry site, and needle orientation were recorded. Procedure complications and their significance were analyzed. RESULTS: One hundred and twenty-one pericardial drainages with catheter insertion were performed under CT guidance on 119 patients presenting with clinically significant pericardial effusion. The most common approach was at the left anterior chest wall. The rate of minor complications was 5.8%, no major complications occurred. CONCLUSIONS: Therapeutic pericardiocentesis can be obtained under CT guidance in a safe and effective manner. Recommendations for building a patient-centered protocol with an interdisciplinary team are discussed. Patient selection, procedural guidance, and lessons to avoid complications are reviewed.

Feasibility study of a novel portable digital radiography system modified for fluoroscopy in the neonatal intensive care unit.

BACKGROUND: A portable radiographic system capable of fluoroscopic imaging in the neonatal intensive care unit (NICU) potentially benefits critically ill neonates by eliminating the need to transport them to a fluoroscopy suite. OBJECTIVE: To evaluate whether a portable bedside fluoroscopy system in the NICU can deliver comparable image quality at a similar dose rate to a standard system in a fluoroscopy suite. MATERIALS AND METHODS: In phase A, 20 patients <3 years of age and scheduled to undergo upper gastrointestinal series (upper GI) or voiding cystourethrograms (VCUG) in the radiology fluoroscopy suite were recruited to evaluate a portable fluoroscopic unit. A modified portable radiographic system with a cassette-sized detector and an in-room fluoroscopy system were sequentially used in the same examination. Four radiologists compared the image quality of 20 images from each system using the Radlex score (1-4) for five image quality attributes. The radiation dose rates for the portable and in-suite systems were collected. In phase B, fluoroscopy studies were performed in 5 neonates in the NICU and compared to the 20 previous neonatal studies performed in the department. Clinical workflow, examination time, fluoroscopy time, scattered radiation dose and patient radiation dose were evaluated. RESULTS: In phase A, average dose rates for in-room and portable systems were equivalent, (0.322 mGy/min and 0.320 mGy/min, respectively). Reader-averaged Radlex scores for in-room and portable systems were statistically significantly greater (P<0.05) for all attributes on the portable system except for image contrast. In phase B, scattered radiation from the average fluoroscopy time (26 s) was equivalent to the scattered radiation of 2.6 portable neonatal chest radiographs. Procedure time and diagnostic quality were deemed equivalent. The average dose rate in the NICU with the portable system was 0.21 mGy/min compared to 0.29 mGy/min for the in-room system. CONCLUSION: The portable fluoroscopy unit is capable of providing comparable image quality at equivalent dose levels to an in-room system for neonates with minimal risks to the staff and other patients in the NICU.

Clinical Application of Postmortem Magnetic Resonance Imaging in Neonates.

BACKGROUND: Recent reports advocate the use of MRI either as a substitute for postmortem examinations or for a more targeted autopsy. METHODS: A full-body postmortem MRI (pMRI) of infants was performed as early as possible after death, and findings were compared to clinical premortem diagnoses. RESULTS: Thirty-one infants were scanned during the study period. Median gestation at birth was 34 weeks (ranges: 24-43). In 3 (10%) cases, no new findings were detected. In 2 (6%), new minor findings not related to the cause of death were detected, and in 17 (55%), new minor findings related to the cause of death were detected. New major findings related to the cause of death were detected in 4 (13%) cases, and new major findings not related to the cause of death were detected in 5 (16%) cases. In 3 (10%), findings thought to alter the perceived cause of death were detected. Overall, in 23 (74%) cases, pMRI findings reinforced the clinical premortem diagnoses. CONCLUSIONS: pMRI is a culturally accepted alternative when autopsy is not performed and can either reinforce, refute, or add to premortem clinical diagnoses.

Acute Appendicitis in Pediatric Patients With Sickle Cell Disease: Lower Incidence, More Imaging, and More False-Positives.

OBJECTIVE: Patients with sickle cell disease (SCD) experience recurrent pain crises, which may mimic appendicitis. A prior study found a significantly lower rate of appendicitis in patients with SCD compared with national averages. We investigate the incidence of appendicitis and number of imaging studies for appendicitis in pediatric patients with SCD. METHODS: Using a retrospective study design from a single institution, SCD and control cohorts were created. Inclusion criteria included age 0 to 21years and at least one follow-up appointment within 24 months. Length of observation was calculated from initial presentation to either inpatient admission for appendicitis or last clinic visit. Analysis of an SCD subgroup and a control subset (n = 1,596) was used to compare the number of imaging studies. Incidence rates of appendicitis and number of appendicitis studies were determined. Z-tests, binomial enumeration exact tests, and Fischer's exact tests were used. RESULTS: The SCD cohort included 1,064 patients between January 1, 2001, to December 31, 2014, and the control cohort included 115,109 patients without SCD between January 1, 2011, and December 31, 2011. Incidence rate of appendicitis per 10,000 patient-years was significantly lower in the SCD group compared with controls (2.9 cases versus 10.7 cases per 10,000 patient-years; P = .044). Additionally, the SCD group received significantly more ultrasounds (148 versus 60 per 10,000 patient-years; P< .0001) and CTs (94 versus 27 per 10,000 patient-years; P< .0001) for appendicitis, which remained significant when controlling for race. Patients with SCD also received more false-positive scans. DISCUSSION: Patients with SCD had a significantly lower incidence of appendicitis than controls, yet had a higher number of imaging tests performed for appendicitis. Appendicitis should be viewed as a less common cause of acute abdominal pain in SCD. This consideration should help guide imaging strategy.

A 9-Year-Old Boy With Recurrent Chest Pain and Nonresolving Pneumonia.

CASE PRESENTATION: A previously healthy, 9-year-old boy presented with five recurrent episodes of left-sided chest pain with low-grade fever over the last 18 months. The pain usually lasted for few hours, was severe and consistent, and resolved spontaneously. It worsened during inspiration, physical activity, and swallowing. He did not experience any cough, dyspnea, chills, cold sweats, or weight loss. His medical and family history was unremarkable.

Remote pathology education during the COVID-19 era: Crisis converted to opportunity.

CONTEXT: The COVID-19 pandemic led to shutting of education faculties, including clinical clerkships for medical students. OBJECTIVE: To review a selective for a course in diagnostic pathology geared toward undergraduate medical students, including its design, technical implementation, instructor and student evaluations, and suggestions for options for further adjusting and optimizing the selective. DESIGN: Whole slide images (WSI) were anonymized and students were given remote access to university computers, which were prepared with two freely available WSI viewers. Each topic was taught in a four-part module: Self-assigned reading, lecture via Zoom, quiz based on digital slide sets, and a frontal review of the slides via Zoom. Fifty-nine students participated in the selective. Following the course, students completed an anonymous questionnaire. RESULTS: Of the 59 participants, 42% (n = 25) responded. None of the respondents had any previous instruction in diagnostic pathology. Overall, the course was rated very favorably: 68% (n = 17) gave at least 3 points on a 4-point scale on questions relating to course interest, improvement in understanding of the covered diseases, and how strongly they would recommend a student take this course if given an option. The most significant disadvantage of the class, as reported by 80% (n = 20) were technical challenges in accessing the slides. CONCLUSION: We believe the course was a success and can be a model for future virtual pathology electives. Great effort should be done to provide technical support to the students. The selective demonstrated value for students and provided much-needed exposure to diagnostic pathology in clinical practice.