Radioiodine treatment of pediatric Graves disease: a multicenter review.

BACKGROUND: There is no standardized approach to iodine-131 (I-131) therapy of hyperthyroidism in pediatric Graves disease. This prevents systematic study of outcomes. OBJECTIVE: To characterize current radioiodine dosing and define therapeutic outcomes at multiple institutions that use ultrasound to measure thyroid size to guide I-131 ablation of Graves disease. MATERIALS AND METHODS: This was a retrospective cohort study conducted at three institutions. The three sites collected demographic data, thyroid volume measured by ultrasound (mL), pre-ablation radioiodine uptake, I-131 activity administered, and outcomes at 6 and 12 months for children younger than 18 years of age treated with I-131 between November 2004 and October 2019. Comparisons of continuous variables were performed using the Mann-Whitney U test. RESULTS: Sixty-nine patients (mean age: 14.5±2.5 years) were included, 59 (85.5%) of whom were female. The mean administered I-131 radioiodine activity was 12.5 mCi (463 MBq) (range: 3.8-29.9 mCi [141-1,106 MBq]). At 6 months post-ablation, 54 (80.5% of 67) patients were hypothyroid, 8 (11.9% of 67) were euthyroid and 5 were hyperthyroid. Two of the five hyperthyroid patients had become euthyroid at 12 months. At 12 months, 1 previously euthyroid patient was hyperthyroid. Administered activity per mL of thyroid tissue adjusted for 24-h uptake was lower (0.18 mCi [6.7 MBq] x %/mL vs. 0.31 mCi [11.5 MBq] x %/mL, P=0.0054) for patients who remained hyperthyroid at 6 months. CONCLUSION: There is substantial variability in administered activity for radioiodine ablation of Graves disease in children. Efforts to standardize practice should start by standardizing administered activity guided by measurement of thyroid size by ultrasound. Our results and those of previous studies suggest the need for administered activities ≥0.25 mCi [9.3 MBq] x %/mL of thyroid tissue.

Esophageal discoid foreign body detection and classification using artificial intelligence.

BACKGROUND: Early and accurate radiographic diagnosis is required for the management of children with radio-opaque esophageal foreign bodies. Button batteries are some of the most dangerous esophageal foreign bodies and coins are among the most common. We hypothesized that artificial intelligence could be used to triage radiographs with esophageal button batteries and coins. OBJECTIVE: Our primary objective was to train an object detector to detect esophageal foreign bodies, whether button battery or coin. Our secondary objective was to train an image classifier to classify the detected foreign body as either a button battery or a coin. MATERIALS AND METHODS: We trained an object detector to detect button batteries and coins. The training data set for the object detector was 57 radiographs, consisting of 3 groups of 19 images each with either an esophageal button battery, esophageal coin or no foreign body. The foreign bodies were endoscopically confirmed, and the groups were age and gender matched. We then trained an image classifier to classify the detected foreign body as either a button battery or a coin. The training data set for the image classifier consisted of 19 radiographs of button batteries and 19 of coins, cropped from the object detector training data set. The object detector and image classifier were then tested on 103 radiographs with an esophageal foreign body, and 103 radiographs without a foreign body. RESULTS: The object detector was 100% sensitive and specific for detecting an esophageal foreign body. The image classifier accurately classified all 6/6 (100%) button batteries in the testing data set and 93/95 (97.9%) of the coins. The remaining two coins were incorrectly classified as button batteries. In addition to these images with a single button battery or coin, there were two unique cases in the testing data set: a stacked button battery and coin, and two stacked coins, both of which were classified as coins. CONCLUSION: Artificial intelligence models show promise in detecting and classifying esophageal discoid foreign bodies and could potentially be used to triage radiographs for radiologist interpretation.

Artificial intelligence research within reach: an object detection model to identify rickets on pediatric wrist radiographs.

BACKGROUND: Artificial intelligence models have been successful in analyzing ordinary photographic images. One type of artificial intelligence model is object detection, where a labeled bounding box is drawn around an area of interest. Object detection can be applied to medical imaging tasks. OBJECTIVE: To demonstrate object detection in identifying rickets and normal wrists on pediatric wrist radiographs using a small dataset, simple software and modest computer hardware. MATERIALS AND METHODS: The institutional review board at Children's Healthcare of Atlanta approved this study. The radiology information system was searched for radiographic examinations of the wrist for the evaluation of rickets from 2007 to 2018 in children younger than 7 years of age. Inclusion criteria were an exam type of "Rickets Survey" or "Joint Survey 1 View" with reports containing the words "rickets" or "rachitic." Exclusion criteria were reports containing the words "renal," "kidney" or "transplant." Two pediatric radiologists reviewed the images and categorized them as either rickets or normal. Images were annotated by drawing a labeled bounding box around the distal radial and ulnar metaphases. The training dataset was created from images acquired from Jan. 1, 2007, to Dec. 31, 2017. This included 104 wrists with rickets and 264 normal wrists. This training dataset was used to create the object detection model. The testing dataset consisted of images acquired during the 2018 calendar year. This included 20 wrists with rickets and 37 normal wrists. Model sensitivity, specificity and accuracy were measured. RESULTS: Of the 20 wrists with rickets in the testing set, 16 were correctly identified as rickets, 2 were incorrectly identified as normal and 2 had no prediction. Of the 37 normal wrists, 33 were correctly identified as normal, 2 were incorrectly identified as rickets and 2 had no prediction. This yielded a sensitivity and specificity of 80% and 95% for wrists with rickets and 89% and 90% for normal wrists. Overall model accuracy was 86%. CONCLUSION: Object detection can identify rickets on pediatric wrist radiographs. Object detection models can be developed with a small dataset, simple software tools and modest computing power.

Endovascular management of nutcracker syndrome in an adolescent patient population.

BACKGROUND: Nutcracker syndrome is defined as left renal vein compression with concomitant clinical symptoms that include flank pain and hematuria. Historically, pediatric and adolescent patients with mild symptoms of nutcracker syndrome were simply observed while those with more severe symptoms underwent left renal vein transposition. Endovascular stenting of the left renal vein is a potentially efficacious and less invasive alternative for managing nutcracker syndrome in adolescents. OBJECTIVE: The purpose of this study was to investigate the technical feasibility, efficacy and safety of left renal vein stenting in adolescents with nutcracker syndrome. MATERIALS AND METHODS: We conducted a retrospective review of electronic medical records and imaging archives to identify adolescents undergoing endovascular stenting for nutcracker syndrome. We reviewed patient demographics including age, gender, presenting symptoms and diagnostic imaging findings. We compared pre- and post-stent deployment intravascular ultrasound (IVUS) and venography and evaluated patient symptoms in clinic up to 6 months following stent placement. RESULTS: Ten patients (average age 16 years, range 12-20 years) underwent 13 procedures. Initial symptoms included pain (n=10) and gross hematuria (n=5). Diagnostic imaging studies included CT abdomen pelvis (n=8), retroperitoneal US (n=6), MRI abdomen/pelvis (n=4), scrotal US (n=2), pelvic US (n=1) and renal Doppler US (n=2). Venography and IVUS demonstrated venous collaterals, proximal blanching at the left-renal-vein-IVC junction, pre-stenotic dilation and intraluminal compression. Most patients (n=9) experienced symptomatic resolution; however, three patients required reintervention to achieve asymptomatic status. No periprocedural complications occurred. CONCLUSION: In this carefully selected adolescent cohort, left renal vein stenting for nutcracker syndrome was often technically feasible, safe and effective in symptom management.

Chest radiograph features of multisystem inflammatory syndrome in children (MIS-C) compared to pediatric COVID-19.

BACKGROUND: Although the radiographic features of coronavirus disease 2019 (COVID-19) in children have been described, the distinguishing features of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 are not well characterized. OBJECTIVE: We compared the chest radiographic findings of MIS-C with those of COVID-19 and described other distinguishing imaging features of MIS-C. MATERIALS AND METHODS: We performed a retrospective case series review of children ages 0 to 18 years who were hospitalized at Children's Healthcare of Atlanta from March to May 2020 and who either met the Centers for Disease Control and Prevention (CDC) case definition for MIS-C (n=11) or who had symptomatic, laboratory-confirmed COVID-19 (n=16). Two radiologists reviewed the most severe chest radiographs for each patient. The type and distribution of pulmonary opacities and presence or absence of pleural effusions were recorded. The chest radiographs were categorized based on potential COVID-19 imaging findings as typical, indeterminate, atypical or negative. An imaging severity score was also assigned using a simplified version of the Radiographic Assessment of Lung Edema Score. Findings were statistically compared between patients with MIS-C and those with COVID-19. Additional imaging findings of MIS-C were also described. RESULTS: Radiographic features of MIS-C included pleural effusions (82% [9/11]), pulmonary consolidations (73% [8/11]) and ground glass opacities (91% [10/11]). All of the lung opacities (100% [10/10]) were bilateral, and the majority of the pleural effusions (67% [6/9]) were bilateral. Compared to children with COVID-19, children with MIS-C were significantly more likely to develop pleural effusions on chest radiograph (82% [9/11] vs. 0% [0/0], P-value <0.01) and a lower zone predominance of pulmonary opacifications (100% [10/10] vs. 38% [5/13], P-value <0.01). Children with MIS-C who also had abdominal imaging had intra-abdominal inflammatory changes. CONCLUSION: Key chest radiographic features of MIS-C versus those of COVID-19 were pleural effusions and lower zone pulmonary opacifications as well as intra-abdominal inflammation. Elucidating the distinguishing radiographic features of MIS-C may help refine the case definition and expedite diagnosis and treatment.

Microbiology and radiographic features of osteomyelitis in children and adolescents with sickle cell disease.

BACKGROUND: Children with sickle cell disease (SCD) are at increased risk for bacterial infections including osteomyelitis (OM). Fever and bone pain, key presenting symptoms of OM, are common in SCD, thus complicating diagnosis. We reviewed presentation, imaging features, and microbiologic etiologies of children with SCD treated for OM. METHODS: The comprehensive SCD clinical database of children and adolescents with SCD followed at a single, large tertiary pediatric center were searched to identify all diagnostic coding for potential cases of osteomyelitis in children ages 6 months to 21 years from 2010 to 2019. Medical charts were reviewed to determine OM diagnostic probability based on radiographic and microbiologic findings and the duration of prescribed antibiotic treatment for OM. RESULTS: Review of 3553 patients (18 039 person-years) identified 20 episodes of probable OM in 19 children. Magnetic resonance imaging (MRI) findings to support OM were definitive in 4/19 (21%), probable in 10/19 (53%), suspected in 5/19 (26%), based on blinded radiologist review. Blood and/or operative cultures from bone and tissue debridement isolated Salmonella species in seven (35%) cases and methicillin-susceptible Staphylococcus aureus (MSSA) in two (10%). Six patients received antibiotic treatment prior to obtainment of cultures. Of culture-positive cases, MRI findings for OM were definitive or probable in six of nine (67%), suspected in three of nine (33%). CONCLUSIONS: Distinction between OM and sickle-related bone infarct or vasoocclusion is difficult based on imaging findings alone. Early attainment of blood and operative cultures increases the likelihood of identifying and adequately treating OM.

Multiphase acquisitions in pediatric abdominal-pelvic CT are a common practice and contribute to unnecessary radiation dose.

BACKGROUND: Many patients at our pediatric hospital have had a contrast-enhanced CT of the abdomen and pelvis performed by an outside imaging facility before admission. We have noticed that many of these exams are multiphase, which may contribute to unnecessary radiation dose. OBJECTIVE: To determine the frequency of multiphase acquisitions and radiation dose indices in contrast-enhanced CTs of the abdomen and pelvis performed by outside imaging facilities in patients who were subsequently transferred to our pediatric hospital for care, and compare these metrics to contrast-enhanced CTs of the abdomen and pelvis performed internally. MATERIALS AND METHODS: A retrospective analysis was performed of contrast-enhanced CTs of the abdomen and pelvis from outside imaging facilities uploaded to our picture archiving and communication system (PACS) between January 1, 2012, and December 31, 2015. CT images and dose pages were reviewed to determine the number of phases and dose indices (CT dose index-volume [CTDIvol], dose-length product, size-specific dose estimate). Exams for abdominal or pelvic mass, trauma or urinary leak indications were excluded. Data were compared to internally acquired contrast-enhanced CTs of the abdomen and pelvis by querying the American College of Radiology (ACR) Dose Index Registry. This review was institutional review board and HIPAA compliant. RESULTS: There were 754 contrast-enhanced CTs of the abdomen and pelvis from 104 outside imaging facilities. Fifty-three percent (399/754) had 2 phases, and 2% (14/754) had 3 or more phases. Of the 939 contrast-enhanced CTs of the abdomen and pelvis performed internally, 12% (115) were multiphase exams. Of 88% (664) contrast-enhanced CTs of the abdomen and pelvis from outside imaging facilities with dose data, CTDIvol was 2.7 times higher than our institution contrast-enhanced CTs of the abdomen and pelvis (939) for all age categories as defined by the ACR Dose Index Registry (mean: 9.4 vs. 3.5 mGy, P<0.0001). The majority (74%) of multiphase exams were performed by 9 of 104 outside imaging facilities. CONCLUSION: Multiphase acquisitions in routine contrast-enhanced CT of the abdomen and pelvis exams at outside imaging facilities are more frequent than those at a dedicated pediatric institution and contribute to unnecessary radiation dose. A contrast-enhanced CT of the abdomen and pelvis exam from an outside imaging facility with two passes may have as much as four times to six times the dose as the same exam performed with a single pass at a pediatric imaging center. We advocate for imaging facilities with high multiphase rates to eliminate multiple phases from routine contrast-enhanced CT of the abdomen and pelvis exams in children.

Safety-Net Academic Hospital Experience in Following Up Noncritical Yet Potentially Significant Radiologist Recommendations.

OBJECTIVE: In this retrospective study, we identified the types of noncritical recommendations radiologists issued over a 15-day period, the percentage of noncritical radiology recommendations that were not acted on or acknowledged in the medical records, potential causes for recommendations not being acted on, and the potential risk of harm to patients. MATERIALS AND METHODS: We conducted a retrospective review of radiology reports and patient records from January 1, 2014, to January 15, 2014, at a large tertiary academic center and regional safety-net hospital. RESULTS: A total of 6851 reports were reviewed; 857 (13%) contained at least one noncritical recommendation, with 978 total recommendations. The two most common recommendations were additional imaging (63%, n = 615) and clinical correlation (23%, n = 229). The majority of radiology recommendations were followed (67%, n = 655), but 323 cases (33%) contained no evidence that recommendations were followed. Of those that were not followed, 39% (n = 126) had no documentation in the medical records of the recommendation being acknowledged. Of those, 32% (n = 40) had important findings, half of which (n = 20) could have benefited from a verbal communication (18 mass lesions, two instances of fetal death). CONCLUSION: Radiologists' recommendations contained in written reports of noncritical findings may not be consistently followed or acknowledged in the medical records. Our study shows that a few report recommendations that were not consistently followed or acknowledged contained findings that referred to potentially harmful conditions. The results triggered an investment in systems improvement at the studied institution.

An Abbreviated Non-Contrast MRI Protocol for Osteomyelitis May Reduce the Need for Sedation in Young Children.

Lengthy MRI examinations in young children often requires sedation. When sedation is unavailable, critical imaging may be delayed. Abbreviating the imaging protocol to a few essential sequences may reduce the need for sedation and prevent delays in patient care. We retrospectively evaluated an abbreviated noncontrast MRI protocol to diagnose lower extremity osteomyelitis in the pediatric population. The IRB approved this study. The radiology information system was searched for lower extremity MRI examinations for osteomyelitis in patients <20 years old from August 2020 to August 2021. Three noncontrast sequences (long axis T1 without fat saturation (FS), long axis STIR, and axial T2 with FS) were independently reviewed by 2 pediatric radiologists. The accuracy of the reviewers was compared to the clinical radiology report based on the unabridged contrast-enhanced standard department protocol. The search yielded 80 exams, mean age was 7 years old, 59% (47/80) were male, and 41% (33/80) were female. The accuracies of reviewer A and reviewer B were 95% and 89%, respectively. The reviewer inter-observer agreement for the diagnosis of osteomyelitis was strong (k = 0.79). The accuracy of an abbreviated noncontrast MRI protocol to evaluate lower extremity osteomyelitis in children approaches that of the unabridged protocol and has the potential to decrease the need for sedation in young children.

Cat Scratch Disease: 9 Years of Experience at a Pediatric Center.

Background: A more complete understanding of the epidemiology, risk factors, and clinical features of cat scratch disease (CSD) in children could help guide patient care. Methods: We conducted a retrospective analysis of children presenting to a tertiary pediatric hospital system in Atlanta, Georgia between January 1, 2010 and December 31, 2018 who had serology, polymerase chain reaction, and/or cytopathological results consistent with a Bartonella henselae infection. We also retrospectively reviewed veterinary diagnostic results performed at the University of Georgia from 2018 to 2020 to ascertain the burden of bartonellosis in companion animals within the state. Results: We identified 304 children with CSD over 9 years with the largest proportion of diagnoses made during August (41 of 304, 13.5%) and September (47 of 304, 15.5%). The median age of child cases was 8.1 years (interquartile range [IQR], 5.4-12.1); 156 (51.3%) were female; 242 of 262 (92.4%) reported feline exposure; and 55 of 250 (22%) reported canine exposure of those with exposure histories documented in the medical record. Although lymphadenopathy was present on physical examination in the majority of cases (78.8%), atypical presentations lacking lymphadenopathy were also common (63 of 304, 20.7%). Among children with radiographic imaging, 20 of 55 (36.4%) had splenomegaly and 21 of 55 (38.1%) had splenic and/or hepatic microabscesses. Among veterinary data, Bartonella seroprevalence was 12 of 146 (8.2%), all among canines, with a geographic distribution that spanned the state of Georgia. Conclusions: Distinguishing clinical features of CSD included subacute regional lymphadenopathy in school-aged children in the late summer, almost all of whom had cat exposure. Atypical clinical manifestations of CSD were also commonly identified.

Retropharyngeal Edema and Neck Pain in Multisystem Inflammatory Syndrome in Children (MIS-c).

We defined the prevalence of neck pain, trismus, or dysphagia (28.4%) and retropharyngeal edema (2.9%) among 137 patients with multisystem inflammatory syndrome in children (MIS-c). Retropharyngeal edema or phlegmon has been documented radiologically in at least 9 children. Symptoms of neck inflammation are common in MIS-c.

Portable CT Pulmonary Angiogram in an Infant on Veno-Arterial Extracorporeal Membrane Oxygenation in the Pediatric Intensive Care Unit.

PURPOSE: Computed tomography (CT) has been shown to change management in children on extracorporeal membrane oxygenation (ECMO). Although techniques have been described to transport these critically ill patients to the CT suite in the radiology department, transport out of the intensive care setting is not without risk, and using portable CT is a practical alternative. However, obtaining a CT pulmonary angiogram (CTPA) in a patient on veno-arterial (VA) ECMO presents unique challenges due to bypass of the cardiopulmonary system, which may lead to suboptimal opacification of the pulmonary arteries. METHODS: We describe a method to obtain a diagnostic CTPA study in an infant on VA ECMO in the intensive care unit using portable CT. Our solution involved temporary withholding ECMO and using the venous cannula to deliver a compact contrast bolus to the right atrium to adequately opacify the pulmonary arteries. Special attention was given to the delivery of the contrast bolus, which was given by hand injection, to ensure it coincided with image acquisition and minimized the time ECMO was withheld. RESULTS: We were able to successfully obtain a diagnostic CTPA study in an infant on VA ECMO in the intensive care unit using portable CT. CONCLUSION: This case demonstrates that in select instances CTPA in infants on VA ECMO can be achieved using a portable CT system.

Towards Consensus: Training in Procedural Skills for Diagnostic Radiology Residents-Current Opinions of Residents and Faculty at a Large Academic Center.

RATIONALE AND OBJECTIVES: The Diagnostic Radiology Milestones Project provides a framework for measuring resident competence in radiologic procedures, but there are limited data available to assist in developing these guidelines. We performed a survey of current radiology residents and faculty at our institution as a first step toward obtaining data for this purpose. The survey addressed attitudes toward procedural standardization and procedures that trainees should be competent by the end of residency. MATERIALS AND METHODS: Current residents and faculty members were surveyed about whether or not there should be standardization of procedural training, in which procedures residents should achieve competency, and the number of times a procedure needs to be performed to achieve competency. RESULTS: Survey data were received from 60 study participants with an overall response rate of 32%. Sixty-five percent of respondents thought that procedural training should be standardized. Standardization of procedural training would include both the list of procedures that trainees should be competent in at the end of residency and the standard minimum number of procedures to achieve competency. Procedures that both residents and faculty agreed are important in which to achieve competency included central line/port procedures; CT-guided abdominal, thoracic, and musculoskeletal procedures; minor fluoroscopic-guided procedures; general fluoroscopy; peripheral line placements; and US-guided abdominal procedures. For most of these categories, most respondents believed that these procedures needed to be performed 6-20 times to achieve competency. CONCLUSION: Both resident and faculty respondents agreed that procedural training should be standardized during residency, and competence in specific procedures should be achieved at the completion of residency. Although this study is limited to a single institution, our data may provide assistance in developing future guidelines for standardizing image-guided procedure training. Future studies could be expanded to create a national consensus regarding the implementation of the Diagnostic Radiology Milestones Project.

Improving Procedure Start Times and Decreasing Delays in Interventional Radiology: A Department's Quality Improvement Initiative.

RATIONALE AND OBJECTIVES: To identify and reduce reasons for delays in procedure start times, particularly the first cases of the day, within the interventional radiology (IR) divisions of the Department of Radiology using principles of continuous quality improvement. MATERIALS AND METHODS: An interdisciplinary team representative of the IR and preprocedure/postprocedure care area (PPCA) health care personnel, managers, and data analysts was formed. A standardized form was used to document both inpatient and outpatient progress through the PPCA and IR workflow in six rooms and to document reasons for delays. Data generated were used to identify key problems areas, implement improvement interventions, and monitor their effects. Project duration was 6 months. RESULTS: The average number of on-time starts for the first case of the day increased from 23% to 56% (P value < .01). The average number of on-time, scheduled outpatients increased from 30% to 45% (P value < .01). Patient wait time to arrive at treatment room once they were ready for their procedure was reduced on average by 10 minutes (P value < .01). Patient care delay duration per 100 patients was reduced from 30.3 to 21.6 hours (29% reduction). Number of patient care delays per 100 patients was reduced from 46.6 to 40.1 (17% reduction). Top reasons for delay included waiting for consent (26% of delays duration) and laboratory tests (12%). CONCLUSIONS: Many complex factors contribute to procedure start time delays within an IR practice. A data-driven and patient-centered, interdisciplinary team approach was effective in reducing delays in IR.