The continuous lure of pediatric radiology.

Pediatric radiology is an immensely rewarding career choice. Eight pediatric radiologists, enthusiastic for their profession, were asked six questions about their career choice. Their responses illustrate the common virtues of pediatric radiology and also demonstrate the diverse paths and activities that pediatric radiologists take and pursue.

Pediatric musculoskeletal ultrasound.

The expanding applications of musculoskeletal ultrasound include many examinations that are new to pediatric radiologists but are well known to our adult colleagues. In this review we present an introduction and guide to some of these entities for pediatric radiologists making inroads into the world of musculoskeletal ultrasound.

Defining the ultrasound longitudinal natural history of newly diagnosed pediatric small bowel Crohn disease treated with infliximab and infliximab-azathioprine combination therapy.

BACKGROUND: Little is known about changes in the imaging appearances of the bowel and mesentery over time in either pediatric or adult patients with newly diagnosed small bowel Crohn disease treated with anti-tumor necrosis factor-alpha (anti-TNF-α) therapy. OBJECTIVE: To define how bowel ultrasound findings change over time and correlate with laboratory inflammatory markers in children who have been newly diagnosed with pediatric small bowel Crohn disease and treated with infliximab. MATERIALS AND METHODS: We included 28 pediatric patients treated with infliximab for newly diagnosed ileal Crohn disease who underwent bowel sonography prior to medical therapy and at approximately 2 weeks, 1 month, 3 months and 6 months after treatment initiation; these patients also had laboratory testing at baseline, 1 month and 6 months. We used linear mixed models to compare mean results between visits and evaluate whether ultrasound measurements changed over time. We used Spearman rank correlation to assess bivariate relationships. RESULTS: Mean subject age was 15.3±2.2 years; 11 subjects were girls (39%). We observed decreases in mean length of disease involvement (12.0±5.4 vs. 9.1±5.3 cm, P=0.02), maximum bowel wall thickness (5.6±1.8 vs. 4.7±1.7 mm, P=0.02), bowel wall color Doppler signal (1.7±0.9 vs. 1.2±0.8, P=0.002) and mesenteric color Doppler signal (1.1±0.9 vs. 0.6±0.6, P=0.005) at approximately 2 weeks following the initiation of infliximab compared to baseline. All laboratory inflammatory markers decreased at 1 month (P-values<0.0001). There was strong correlation between bowel wall color Doppler signal and fecal calprotectin (ρ=0.710; P<0.0001). Linear mixed models confirmed that maximum bowel wall thickness (P=0.04), length of disease involvement (P=0.0002) and bowel wall color Doppler signal (P<0.0001) change over time in response to infliximab, when adjusted for age, sex, azathioprine therapy, scanning radiologist and baseline short pediatric Crohn's disease activity index score. CONCLUSION: The ultrasound appearance of the bowel changes as early as 2 weeks after the initiation of infliximab therapy. There is strong correlation between bowel wall color Doppler signal and fecal calprotectin.

The current role of diagnostic imaging in the preoperative workup for refractory neonatal brachial plexus palsy.

INTRODUCTION: Despite recent improvements in perinatal care, the incidence of neonatal brachial plexus palsy (NBPP) remains relatively common. CT myelography is currently considered to be the optimal imaging modality for evaluating nerve root integrity. Recent improvements in MRI techniques have made it an attractive alternative to evaluate nerve root avulsions (preganglionic injuries). AIM: We demonstrate the utility of MRI for the evaluation of normal and avulsed spinal nerve roots. We also show the utility of ultrasound in providing useful preoperative evaluation of the postganglionic brachial plexus in patients with NBPP.

Prospective cohort study of ultrasound-ultrasound and ultrasound-MR enterography agreement in the evaluation of pediatric small bowel Crohn disease.

BACKGROUND: There is a paucity of published literature describing ultrasound (US)-US and US-MR enterography (MRE) inter-radiologist agreement in pediatric small bowel Crohn disease. OBJECTIVE: To prospectively assess US-US and US-MRE inter-radiologist agreement in pediatric small bowel Crohn disease. MATERIALS AND METHODS: Institutional Review Board approval and informed consent/assent were obtained for this HIPAA-compliant prospective cohort study of children with newly diagnosed distal small bowel Crohn disease (July 2012 to December 2014). Enrolled subjects (n = 29) underwent two small bowel US examinations performed by blinded independent radiologists both before and at multiple time points after initiation of medical therapy (231 unique US examinations, in total); 134 US examinations were associated with concurrent MRE. The MRE examination was interpreted by a third blinded radiologist. The following was documented on each examination: involved length of ileum (cm); maximum bowel wall thickness (mm); amount of bowel wall and mesenteric Doppler signal, and presence of stricture, penetrating disease and/or abscess. Inter-radiologist agreement was assessed with single-measure, three-way, mixed-model intra-class correlation coefficients (ICC) and prevalence-adjusted, bias-adjusted kappa statistics (κ). Numbers in brackets are 95% confidence intervals. RESULTS: Ultrasound-US agreement was moderate for involved length (ICC: 0.41 [0.35-0.49]); substantial for maximum bowel wall thickness (ICC: 0.67 [0.64-0.70]); moderate for bowel wall Doppler signal (ICC: 0.53 [0.48-0.59]); slight for mesenteric Doppler signal (ICC: 0.25 [0.18-0.42]), and moderate to almost perfect for stricture (κ: 0.54), penetrating disease (κ: 0.80), and abscess (κ: 0.96). US-MRE agreement was moderate for involved length (ICC: 0.42 [0.37-0.49]); substantial for maximum bowel wall thickness (ICC: 0.66 [0.65-0.69]), and substantial to almost perfect for stricture (κ: 0.61), penetrating disease (κ: 0.72) and abscess (κ: 0.88). CONCLUSION: Ultrasound-US agreement was similar to US-MRE agreement for assessing pediatric small bowel Crohn disease. Discrepancies in US-US and US-MRE reporting question the utility of US as an accurate, reproducible radiologic biomarker for assessing response to medical therapy and disease-related complications.

Can Shear-Wave Elastography be Used to Discriminate Obstructive Hydronephrosis from Nonobstructive Hydronephrosis in Children?

PURPOSE: To determine if ultrasonographic (US) renal shear-wave speed (SWS) measurements obtained either before or after intravenous diuretic administration can be used to discriminate obstructive hydronephrosis from unobstructive hydronephrosis in children, with diuretic renal scintigraphy as the reference standard. MATERIALS AND METHODS: Institutional review board approval and parental informed consent were obtained for this HIPAA-compliant prospective cross-sectional blind comparison with a reference standard. Between November 2012 and September 2014, 37 children (mean age, 4.1 years; age range, 1 month to 17 years) underwent shear-wave elastography of the kidneys immediately before and immediately after diuretic renal scintigraphy (reference standard for presence of urinary tract obstruction). Median SWS measurements (in meters per second), as well as change in median SWS (median SWS after diuretic administration minus median SWS before diuretic administration) were correlated with the amount of time required for kidney radiotracer activity to fall by 50% after intravenous administration of the diuretic (T1/2). Median SWS measurements were compared with degree of obstruction and degree of hydronephrosis with analysis of variance. Receiver operating characteristic (ROC) curves were created. RESULTS: Radiotracer T1/2 values after diuretic administration did not correlate with median SWS measurements obtained before (r = -0.08, P = .53) or after (r = -0.0004, P >.99) diuretic administration, nor did they correlate with intraindividual change in median SWS (r = 0.07, P = .56). There was no significant difference in pre- or postdiuretic median SWS measurements between kidneys with scintigraphic evidence of no, equivocal, or definite urinary tract obstruction (P > .5) or for median SWS measurements between kidneys with increasing degree of hydronephrosis (P > .5). ROC curves showed poor diagnostic performance of median SWS in discerning no, equivocal, or definite urinary tract obstruction (area under the ROC curve ranged from 0.50 to 0.62). CONCLUSION: US SWS measurements did not enable discrimination of obstructive hydronephrosis from unobstructive hydronephrosis in children.

Pediatric MR Urography: Indications, Techniques, and Approach to Review.

Magnetic resonance (MR) urography is a valuable imaging modality for assessing disorders of the pediatric urinary tract. It allows comprehensive evaluation of the kidneys and urinary tract in children by providing both morphologic and functional information without exposing the child to ionizing radiation. Pediatric MR urography can be used to thoroughly evaluate renal and urinary tract abnormalities that are difficult to identify or fully characterize with other imaging techniques, and it has the potential to allow earlier diagnosis while decreasing the number of imaging studies performed. Common indications for pediatric MR urography include evaluation of complex renal and urinary tract anatomy, suspected urinary tract obstruction, operative planning, and postoperative assessment. MR hydrography (T2-weighted imaging of urine) excellently depicts dilated or obstructed urinary systems, whereas postcontrast imaging (gadolinium-enhanced T1-weighted imaging of the kidneys and urinary system) excellently depicts nondilated or nonobstructed urinary systems. Postcontrast MR urography also allows a functional evaluation of the kidneys and urinary tract that includes estimation of differential renal function. The authors review common indications for pediatric MR urography, detail MR urography techniques, compare the strengths and weaknesses of MR urography with those of alternative imaging strategies for children, and describe numerous common and uncommon abnormalities of the pediatric kidneys and urinary tract.

Pediatric Small Bowel Crohn Disease: Correlation of US and MR Enterography.

Small bowel Crohn disease is commonly diagnosed during the pediatric period, and recent investigations show that its incidence is increasing in this age group. Diagnosis and follow-up of this condition are commonly based on a combination of patient history and physical examination, disease activity surveys, laboratory assessment, and endoscopy with biopsy, but imaging also plays a central role. Ultrasonography (US) is an underutilized well-tolerated imaging modality for screening and follow-up of small bowel Crohn disease in children and adolescents. US has numerous advantages over computed tomographic (CT) enterography and magnetic resonance (MR) enterography, including low cost and no required use of oral or intravenous contrast material. US also has the potential to provide images with higher spatial resolution than those obtained at CT enterography and MR enterography, allows faster examination than does MR enterography, does not involve ionizing radiation, and does not require sedation or general anesthesia. US accurately depicts small bowel and mesenteric changes related to pediatric Crohn disease, and US findings show a high correlation with MR imaging findings in this patient population.

Sonographically guided lumbar puncture in pediatric patients.

Our aim with this study was to develop a user-friendly method for pediatric sonographically guided lumbar punctures so that we can visualize intrathecal anatomy, confirm intrathecal injection at the time of injection, and, most importantly, avoid ionizing radiation to a child's already radiosensitive pelvis. Sonographically guided lumbar puncture was prospectively performed in children aged 7 weeks to 16 years. All attempts (n = 9) were successful. We were able to identify relevant anatomy (including the conus in children 10 years and younger), confirm intrathecal injection, visualize intrathecal hematoma, and avoid radiation. Sonography is a promising modality for image-guided lumbar punctures without radiation in children.

Serial ultrasound evaluation of pediatric trigger thumb.

BACKGROUND: The etiology of pediatric trigger thumb is unknown, although ultrasound in adults has shown thickening of the A1 pulley leading to constriction of the flexor pollicis longus (FPL) tendon. The purpose of this study is to characterize the underlying cause of the pediatric trigger thumb and factors responsible for resolution utilizing sonography. METHODS: A prospective analysis of children with trigger thumbs was conducted from May 2008 through June 2010. All children were initially treated with splinting. Surgical release of the A1 pulley was performed at the family's request. Bilateral dynamic ultrasonography was performed at presentation and follow-up until resolution of triggering. Ultrasound images were evaluated for tendon gliding, echotexture, cross-sectional area, and anatomic variations. RESULTS: There were 35 trigger thumbs in 28 patients. Ten thumbs resolved spontaneously. Eight patients (9 thumbs) underwent surgical release of the A1 pulley. One child who underwent bilateral release achieved only unilateral resolution. Ultrasound imaging of all 56 thumbs demonstrated normal echotexture of the FPL without evidence of inflammation or trauma. Triggering always occurred at the A1 pulley, and there was focal enlargement of the FPL but no definite ultrasound abnormality of the A1 pulley. Surgical release allowed the thickened tendon to pass smoothly, which coincided with resolution of triggering. Two of 3 patients with unilateral triggering presenting with a trigger ratio (cross-sectional area of involved maxFPL to uninvolved FPL) <1.5 converted to bilateral trigger thumbs. An FPL size for age graph was created for nontriggering thumbs in unilateral patients. CONCLUSIONS: The pediatric trigger thumb is a developmental condition with normal echotexture noted in all FPL tendons without inflammation or trauma. Triggering occurs when the cross-sectional area of the FPL exceeds the cross-sectional area at the A1 pulley, and it resolves when this size disparity is eliminated. Patients with unilateral triggering and a trigger ratio <1.5 on the uninvolved thumb are at risk for developing triggering bilaterally. LEVEL OF EVIDENCE: Level 2 diagnostic study.

Resident Physicians' Knowledge of Emergency Medical Services: A Comparison Between Emergency Medicine and Non-Emergency Medicine Resident Physicians.

Background and objective Emergency medical services (EMS) are often assumed to only involve bringing patients to physicians for treatment in the emergency department. However, EMS staff are also responsible for responding to physicians in the primary care setting when medical emergencies arise. While emergency medicine (EM) residents are exposed to EMS as part of their curriculum, little is known about the knowledge of other resident physicians who may interact with EMS. In light of this, we conducted this study to address the scarcity of data related to this topic. Methods A quantitative cross-sectional knowledge assessment was conducted among resident physicians in emergency medicine, internal medicine, family medicine, pediatric, and combined medicine and pediatric residencies at the Penn State Milton S. Hershey Medical Center. Results Eighteen EM residents and 26 non-EM residents completed the assessment. The EM residents had a higher average score when compared to non-emergency medicine residents (69.2% vs. 53.8%, p=0.0012). Conclusion Variations in scores between EM and other specialties that interact with EMS highlight the need for further training and familiarization related to EMS for residents in non-EM specialties.

Sonographic twinkling artifact for renal calculus detection: correlation with CT.

PURPOSE: To retrospectively correlate sonographic color Doppler twinkling artifact within the kidneys with unenhanced computed tomography (CT) in the detection of nephrolithiasis. MATERIALS AND METHODS: Institutional review board approval was obtained for this retrospective HIPAA-complaint investigation, and the informed consent requirement was waived. Sonographic imaging reports describing the presence of renal twinkling artifact between January 2008 and September 2009 were identified. Subjects who did not undergo unenhanced abdominal CT within 2 weeks after sonography were excluded. Ultrasound examinations were reviewed by three radiologists working together, and presence, number, location, and size of renal twinkling artifacts were documented by consensus opinion. Sonographic findings were correlated with unenhanced CT (5-mm section width, no overlap) for nephrolithiasis and other causes of twinkling artifact. The number, location, and size of renal calculi at CT were documented. RESULTS: The presence of sonographic renal twinkling artifact, in general, had a 78% (95% confidence interval: 0.66, 0.90) positive predictive value for nephrolithiasis anywhere in the kidneys at CT. The true-positive rate of twinkling artifact for confirmed calculi at CT was 49% (73 of 148 twinkling foci), while the false-positive rate was 51% (75 of 148 twinkling foci). The overall sensitivity of twinkling artifact for the detection of specific individual renal calculi observed at CT was 55% (95% confidence interval: 0.47, 0.64). CONCLUSION: While renal twinkling artifact is commonly associated with nephrolithiasis, this finding is relatively insensitive in routine clinical practice and has a high false-positive rate when 5-mm unenhanced CT images are used as the reference standard. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.11102128/-/DC1.

Toxicity of herbal medications suggested as treatment for COVID-19: A narrative review.

OBJECTIVES: In the absence of a definitive cure, herbal medications are gaining increasing popularity in the general public for treatment of coronavirus disease 2019 (COVID-19). Although many herbal preparations are safe and can be used without complication, serious toxicities do occur. This article focuses on the major characteristics and toxicities of herbal preparations that have been proposed as treatments for COVID-19. METHODS: A review was performed focusing on herbal preparations that have gained popularity as potential treatments for COVID-19. Some of these preparations have been directly recommended by government agencies, whereas others have gained popularity through various other news sources. RESULTS: The herbal preparations covered in this paper include the cardiac glycoside oleandrin, plants of the Datura genus, and herbs commonly used in traditional Chinese Medicine including plants of the Aconitum genus, bitter apricot seeds, ephedra, and licorice root. CONCLUSION: Although herbal preparations have been reported to aid in the treatment of COVID-19 with success, few clinical trials have been performed to evaluate their efficacy and instead rely mainly on in vitro studies and anecdotal reports. Furthermore, many of the herbal preparations suggested carry significant toxicities, and frontline healthcare workers should be aware of the common symptoms and toxidromes that result from these poisonings.

Breast fibroadenomas in the pediatric population: common and uncommon sonographic findings.

BACKGROUND: Sonography is usually requested to evaluate palpable pediatric breast lumps, and solid masses are almost always fibroadenomas. Lack of familiarity with the findings of fibroadenomas can lead to diagnostic uncertainty and sometimes unnecessary biopsy and excision. We sought to review the spectrum of sonographic findings in our cases of pathology proven pediatric fibroadenomas. OBJECTIVE: The purpose of this retrospective study was to describe the sonographic appearances of pathologically proven pediatric breast fibroadenomas. MATERIALS AND METHODS: A query of the Department of Radiology database at our institution was performed for all patients younger than 19 years who underwent breast US from January 2001 to June 2009. A total of 332 patients were identified: 282 girls (85%) and 50 boys (15%). Ninety-one girls and no boys had a solid breast mass based on US findings. Forty-three children had a total of 49 pathologically proven breast masses with the diagnoses of fibroadenoma (44), hamartoma (1), non-Hodgkin lymphoma (1), tubular adenoma (1), pseudoangiomatous stromal hyperplasia (1) and lactation changes (1). Reviews of medical records, histological results and sonographic examinations of all pathology-proven fibroadenomas were performed. US findings were characterized according to location, multiplicity, size, shape, echogenicity and homogeneity, definition of margins, posterior acoustic features and Doppler vascularity. RESULTS: The vast majority of solid breast masses in girls are histologically benign. Fibroadenomas accounted for 91% of the pathologically proven solid breast masses. Common findings on US imaging are an oval shape, hypoechoic echo pattern, posterior acoustic enhancement and internal Doppler signal. Lobulations were found in 57% of the masses. Less common findings are absent internal vascular flow and complex echo pattern, while isoechoic echo pattern, posterior shadowing and angular margins are rare or unusual. CONCLUSION: Fibroadenomas represent the most common solid mass in the breasts of girls. Sonographic appearances are usually characteristic and do not significantly differ from those found in adults. The radiologist must be aware of common and uncommon sonographic appearances of fibroadenomas in the pediatric age group and should be cautious when recommending histological confirmation based on imaging findings, as breast malignancy is extremely rare.

Spine ultrasound imaging in the newborn.

Ultrasound of the spine in the neonate is widely used as the initial modality to evaluate spinal canal anatomy, anatomical variants, and congenital malformations. The spinal canal and its contents are best visualized in the newborn and young infant owing to incomplete ossification of the posterior vertebral elements.

Ultrasonography for neonatal brachial plexus palsy.

Ultrasonography has previously been reported for use in the evaluation of compressive or traumatic peripheral nerve pathology and for its utility in preoperative mapping. However, these studies were not performed in infants, and they were not focused on the brachial plexus. The authors report a case in which ultrasonography was used to improve operative management of neonatal brachial plexus palsy (NBPP). An infant boy was born at term, complicated by right-sided shoulder dystocia. Initial clinical evaluation revealed proximal arm weakness consistent with an upper trunk injury. Unlike MRI or CT myelography that focus on proximal nerve roots, ultrasonography of the brachial plexus in the supraclavicular fossa was able to demonstrate a small neuroma involving the upper trunk (C-5 and C-6) and no asymmetry in movement of the diaphragm or in the appearance of the rhomboid muscle when compared with the unaffected side. However, the supra- and infraspinatus muscles were significantly asymmetrical and atrophied on the affected side. Importantly, ultrasound examination of the shoulder revealed posterior glenohumeral laxity. Instead of pursuing the primary nerve reconstruction first, timely treatment of the shoulder subluxation prevented formation of joint dysplasia and formation of a false glenoid, which is a common sequela of this condition. Because the muscles innervated by proximal branches of the cervical nerve roots/trunks were radiographically normal, subsequent nerve transfers were performed and good functional results were achieved. The authors believe this to be the first report describing the utility of ultrasonography in the surgical treatment planning in a case of NBPP. Noninvasive imaging, in addition to thorough history and physical examination, reduces the intraoperative time required to determine the extent and severity of nerve injury by allowing improved preoperative planning of the surgical strategy. Inclusion of ultrasonography as a preoperative modality may yield improved outcomes for children with NBPP.

National ultrasound curriculum for medical students.

Ultrasound (US) is an extremely useful diagnostic imaging modality because of its real-time capability, noninvasiveness, portability, and relatively low cost. It carries none of the potential risks of ionizing radiation exposure or intravenous contrast administration. For these reasons, numerous medical specialties now rely on US not only for diagnosis and guidance for procedures, but also as an extension of the physical examination. In addition, many medical school educators recognize the usefulness of this technique as an aid to teaching anatomy, physiology, pathology, and physical diagnosis. Radiologists are especially interested in teaching medical students the appropriate use of US in clinical practice. Educators who recognize the power of this tool have sought to incorporate it into the medical school curriculum. The basic question that educators should ask themselves is: "What should a student graduating from medical school know about US?" To aid them in answering this question, US specialists from the Society of Radiologists in Ultrasound and the Alliance of Medical School Educators in Radiology have collaborated in the design of a US curriculum for medical students. The implementation of such a curriculum will vary from institution to institution, depending on the resources of the medical school and space in the overall curriculum. Two different examples of how US can be incorporated vertically or horizontally into a curriculum are described, along with an explanation as to how this curriculum satisfies the Accreditation Council for Graduate Medical Education competencies, modified for the education of our future physicians.

Biliary duplication cyst with heterotopic gastric mucosa resulting in obstruction of the biliary system: a case report.

Biliary tract duplication cysts with heterotopic gastric mucosa are rare congenital anomalies, with our case representing only the fourth reported case in the literature. An 8-year-old girl with several months of abdominal pain was found to have a complex cystic mass communicating with the biliary system via the common hepatic duct. Intraoperatively, inflammation caused by the cystic mass was found to have resulted in a Mirizzi-like syndrome, with a nearly complete obstruction at the confluence of the left and right hepatic ducts. Histopathologic examination of the biliary mass revealed it to be a duplication cyst lined by heterotopic gastric mucosa with secondary ulceration and fibrosis. Biliary duplication cysts are a rare but important process that should be considered in a child with a mass in the portal triad and biliary obstruction.