Planetary health: an imperative for pediatric radiology.

The global temperature has been increasing resulting in climate change. This negatively impacts planetary health that disproportionately affects the most vulnerable among us, especially children. Extreme weather events, such as hurricanes, tornadoes, wildfires, flooding, and heatwaves, are becoming more frequent and severe, posing a significant threat to our patients' health, safety, and security. Concurrently, shifts in environmental exposures, including air pollution, allergens, pathogenic vectors, and microplastics, further exacerbate the risks faced by children. In this paper, we provide an overview of pediatric illnesses that are becoming more prevalent and severe because of extreme weather events, global temperature increases, and shifts in environmental exposures. As members of pediatric health care teams, it is crucial for pediatric radiologists to be knowledgeable about the impacts of climate change on our patients, and continue to advocate for safe, healthier environments for our patients.

Imaging of pediatric pulmonary tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper.

Pediatric pulmonary malignancy can be primary or metastatic, with the latter being by far the more common. With a few exceptions, there are no well-established evidence-based guidelines for imaging pediatric pulmonary malignancies, although computed tomography (CT) is used in almost all cases. The aim of this article is to provide general imaging guidelines for pediatric pulmonary malignancies, including minimum standards for cross-sectional imaging techniques and specific imaging recommendations for select entities.

Imaging of pediatric extremity soft tissue tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper.

Pediatric soft tissue tumors of the extremity include rhabdomyosarcoma and nonrhabdomyosarcoma neoplasms. This manuscript provides consensus-based imaging recommendations for imaging evaluation at diagnosis, during treatment, and following completion of therapy for patients with a soft tissue tumor of the extremity.

Imaging of pediatric bone tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper.

Malignant primary bone tumors are uncommon in the pediatric population, accounting for 3%-5% of all pediatric malignancies. Osteosarcoma and Ewing sarcoma comprise 90% of malignant primary bone tumors in children and adolescents. This paper provides consensus-based recommendations for imaging in children with osteosarcoma and Ewing sarcoma at diagnosis, during therapy, and after therapy.

Is Thyroid Monitoring Warranted in Infants and Young Children After Intravascular Administration of Iodine-Based Contrast Media?

On March 30, 2022, the U.S. FDA issued a drug safety communication recommending that infants and young children through 3 years of age undergo monitoring of thyroid function within 3 weeks of intravascular administration of iodine-based contrast media. This article considers the literature that was referenced for this decision and provides an outlook on thyroid monitoring after diagnostic imaging from pediatric radiology and pediatric endocrinology perspectives.

Imaging of Vesicoureteral Reflux: AJR Expert Panel Narrative Review.

Vesicoureteral reflux (VUR) is a common congenital anomaly of the urinary tract that can present with collecting system dilation or as a febrile infection. VUR can lead to permanent renal sequela requiring surgery but can also spontaneously resolve without complication. Therefore, it is important to recognize those patient populations who warrant imaging for screening, confirmation, or ongoing surveillance for VUR, while avoiding overdiagnosis. In the appropriate patient populations, an accurate diagnosis of VUR allows early treatment and prevention of pyelonephritis and scarring. Various imaging modalities are available to diagnose and grade VUR, including voiding cystourethrogram (VCUG), radionucleotide cystography (RNC), and contrast-enhanced voiding urosonography (ceVUS). The objective of this article is to summarize the current understanding of VUR diagnosis and management and to discuss these imaging modalities' strengths and pitfalls. Considerations include indications for VUR imaging, patient preparation, conduct of the examination, issues related to radiologic reporting, and cost-effectiveness. An emphasis is placed on ceVUS, which is the most recently introduced of the three imaging modalities and is receiving growing support among pediatric radiologists.

Safety considerations related to intravenous contrast agents in pediatric imaging.

Intravenous contrast media are used in MRI, CT and US studies for anatomical evaluation and lesion characterization. Safety is always of paramount importance when administering any contrast media to children, and it is important for radiologists and ordering providers to be knowledgeable of the safety profiles and potential adverse events that can occur. This manuscript reviews the frequency and types of adverse events associated with intravenous contrast agents reported in the pediatric literature. Overall, intravenous contrast agents are very safe to use in children. However, familiarity with how to treat and prevent these uncommon events is crucial in preventing poor outcomes. In addition, an understanding of gadolinium deposition in tissues can help facilitate conversations with concerned physicians and parents. This review provides a concise yet comprehensive reference for radiologists and ordering providers on intravenous contrast safety considerations in the pediatric patient.

Frequency of technical success of ultrasound-guided arthrogram injections in children.

BACKGROUND: MR arthrography is an essential diagnostic tool to assess and guide management of labral, ligamentous, fibrocartilaginous, and capsular abnormalities in children. While fluoroscopy is traditionally used for intra-articular contrast administration, ultrasound offers advantages of portability and lack of ionizing radiation exposure for both the patient and proceduralist. OBJECTIVE: The purpose of this retrospective study is to quantify technical success and frequency of complications of ultrasound-guided arthrogram injections at our institution. MATERIALS AND METHODS: This retrospective analysis investigates the results of 217 ultrasound-guided arthrograms of the shoulder, elbow, and hip in patients aged 5-18 years. Successful injection of contrast into the target joint, clinical indication for MR arthrography, and complications were reviewed. RESULTS: Accurate ultrasound-guided intra-articular administration of contrast into the target joint was successful for 100% of shoulder cases (90/90), 97% of elbow cases (77/79), and 98% of hip cases (47/48). Leak of contrast outside the target joint occurred in 1.4% (3/217) of cases. No major side effects including excessive bleeding, paresthesia, allergic reactions, or infection occurred during or after the procedure. Additionally, no major vessel, nerve, or tendon complications were observed on MR images. CONCLUSION: Ultrasound guidance is a reliable, effective, and safe approach to arthrography in children.

Turnaround time and efficiency of pediatric outpatient brain magnetic resonance imaging: a multi-institutional cross-sectional study.

BACKGROUND: Aside from single-center reports, few data exist across pediatric institutions that examine overall MRI turnaround time (TAT) and the determinants of variability. OBJECTIVE: To determine average duration and determinants of a brain MRI examination at academic pediatric institutions and compare the duration to those used in practice expense relative value units (RVUs). MATERIALS AND METHODS: This multi-institutional cross-sectional investigation comprised four academic pediatric hospitals. We included children ages 0 to < 18 years who underwent an outpatient MRI of the brain without contrast agent in 2019. Our outcome of interest was the overall MRI TAT derived by time stamps. We estimated determinants of overall TAT using an adjusted log-transformed multivariable linear regression model with robust standard errors. RESULTS: The average overall TAT significantly varied among the four hospitals. A sedated brain MRI ranged from 158 min to 224 min, a non-sedated MRI from 70 min to 112 min, and a limited MRI from 44 min to 70 min. The most significant predictor of a longer overall TAT was having a sedated MRI (coefficient = 0.71, 95% confidence interval [CI]: 0.66-0.75; P < 0.001). The median MRI scan time for a non-sedated exam was 38 min and for a sedated exam, 37 min, approximately double the duration used by the Relative Value Scale (RVS) Update Committee (RUC). CONCLUSION: We found considerable differences in the overall TAT across four pediatric academic institutions. Overall, the significant predictors of turnaround times were hospital site and MRI pathway (non-sedated versus sedated versus limited MRI).

Artificial intelligence development in pediatric body magnetic resonance imaging: best ideas to adapt from adults.

Emerging manifestations of artificial intelligence (AI) have featured prominently in virtually all industries and facets of our lives. Within the radiology literature, AI has shown great promise in improving and augmenting radiologist workflow. In pediatric imaging, while greatest AI inroads have been made in musculoskeletal radiographs, there are certainly opportunities within thoracoabdominal MRI for AI to add significant value. In this paper, we briefly review non-interpretive and interpretive data science, with emphasis on potential avenues for advancement in pediatric body MRI based on similar work in adults. The discussion focuses on MRI image optimization, abdominal organ segmentation, and osseous lesion detection encountered during body MRI in children.

Ultrasound assessment of glenohumeral dysplasia in infants.

Brachial plexus birth injury can lead to irreversible neuromuscular dysfunction and skeletal deformity of the upper extremity and shoulder girdle, ultimately resulting in glenohumeral dysplasia. Diagnosis and treatment of affected infants requires a multi-disciplinary approach in which imaging plays a vital role. While MRI is excellent for assessing both the shoulder and spine of these children, it is costly and requires sedation and is thus typically reserved for preoperative planning. US, however, is inexpensive, dynamic and readily available and provides excellent visualization of the largely cartilaginous glenohumeral joint. As such, it has become a highly useful modality during early diagnosis and follow-up of children with brachial plexus birth injuries. In this review, we describe the relevant anatomy of the glenohumeral joint, outlining the normal sonographic appearance as well as providing tips and tricks for identifying and characterizing pathology.

Whole-body MRI at initial presentation of pediatric chronic recurrent multifocal osteomyelitis and correlation with clinical assessment.

BACKGROUND: Chronic recurrent multifocal osteomyelitis (CRMO) is a diagnosis of exclusion, relying heavily on whole-body magnetic resonance imaging (WB-MRI) for diagnosing and evaluating response to therapy. Information with respect to disease distribution and imaging correlation with clinical disease severity at initial presentation is lacking. OBJECTIVE: To retrospectively characterize distribution of disease on WB-MRI and to correlate imaging findings with disease severity at initial rheumatology presentation. MATERIALS AND METHODS: Using a modified version of a recently devised imaging-based scoring system, we evaluated disease distribution and correlation between findings on WB-MRI and clinical disease severity in 54 patients presenting for initial evaluation of CRMO. Symptomatic lesion sites were extracted from chart review and physician global assessment was determined by the consensus of two rheumatologists. RESULTS: Sites of CRMO involvement evident on imaging at initial presentation had a strong predilection for the pelvis and lower extremities. There was significant correlation between the number of lesions detected on WB-MRI and total clinical severity score at initial rheumatology presentation (P<0.01). However, no other imaging parameter correlated with disease severity. CONCLUSION: While the overall number of lesions identified on MRI correlates with clinical severity scores at initial imaging, other MR parameters of CRMO lesions may not be reliable indicators of disease severity at initial presentation. Further research is needed to assess whether these parameters are implicated in longitudinal disease severity or overall response to therapy.

The current and future roles of artificial intelligence in pediatric radiology.

Artificial intelligence (AI) is a broad and complicated concept that has begun to affect many areas of medicine, perhaps none so much as radiology. While pediatric radiology has been less affected than other radiology subspecialties, there are some well-developed and some nascent applications within the field. This review focuses on the use of AI within pediatric radiology for image interpretation, with descriptive summaries of the literature to date. We highlight common features that enable successful application of the technology, along with some of the limitations that can inhibit the development of this field. We present some ideas for further research in this area and challenges that must be overcome, with an understanding that technology often advances in unpredictable ways.

Gadolinium retention: should pediatric radiologists be concerned, and how to frame conversations with families.

Gadolinium retention in the brain and other organs has recently been identified by imaging and confirmed histologically. No direct clinical effects of gadolinium retention, which occurs after gadolinium-based contrast agent (GBCA) administration for MRI, have been scientifically accepted at this time. However, there is understandable concern among medical professionals and the public about the potential effects of gadolinium retention, particularly in the brain. Part of this concern might stem from the identification of nephrogenic systemic fibrosis caused by GBCAs in people with severe renal failure in 2006. This article briefly describes the characteristics of GBCAs; reviews and differentiates gadolinium retention, nephrogenic systemic fibrosis, and "gadolinium deposition disease" or "gadolinium toxicity"; and discusses societal guidelines and current usage in children. With the belief that GBCAs should not be withheld for appropriate indications in the absence of evidence of its potential risks, we offer a framework for determining when GBCA use is appropriate and suggestions for discussing its risks and benefits with children and their families.

Palpable pediatric chest wall masses.

Pediatric chest wall lesions are varied in etiology ranging from normal and benign to aggressive and malignant. When palpable, these lesions can alarm parents and clinicians alike. However, most palpable pediatric chest lesions are benign. Familiarity with the various entities, their incidences, and how to evaluate them with imaging is important for clinicians and radiologists. Here we review the most relevant palpable pediatric chest entities, their expected appearance and the specific clinical issues to aid in diagnosis and appropriate treatment.

Non-inferiority of a non-gadolinium-enhanced magnetic resonance imaging follow-up protocol for isolated optic pathway gliomas.

BACKGROUND: Pediatric patients with optic pathway gliomas (OPGs) typically undergo a large number of follow-up MRI brain exams with gadolinium-based contrast media (GBCM), which have been associated with gadolinium tissue retention. Therefore, careful consideration of GBCM use in these children is warranted. OBJECTIVE: To investigate whether GBCM is necessary for OPG MR imaging response assessment using a blinded, non-inferiority, multi-reader study. MATERIALS AND METHODS: We identified children with OPG and either stable disease or change in tumor size on MRI using a regional cancer registry serving the U.S. Pacific Northwest. For each child, the two relevant, consecutive MRI studies were anonymized and standardized into two imaging sets excluding or including GBCM-enhanced images. Exam pairs were compiled from 42 children with isolated OPG (19 with neurofibromatosis type 1), from a population of 106 children with OPG. We included 28 exam pairs in which there was a change in size between exams. Seven pediatric radiologists measured tumor sizes during three blinded sessions, spaced by at least 1 week. The first measuring session excluded GBCM-enhanced sequences; the others did not. The primary endpoint was intra-reader agreement for ≥ 25% change in axial cross-product measurement, using a 12% non-inferiority threshold. RESULTS: Analysis demonstrated an overall 1.2% difference (95% confidence interval, -3.2% to 5.5%) for intra-reader agreement using a non-GBCM-enhanced protocol and background variability. CONCLUSION: A non-GBCM-enhanced protocol was non-inferior to a GBCM-enhanced protocol for assessing change in size of isolated OPGs on follow-up MRI exams.

The Many Faces of Pediatric Chronic Recurrent Multifocal Osteomyelitis (CRMO): A Practical Location- and Case-Based Approach to Differentiate CRMO From Its Mimics.

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disease of childhood and adolescence characterized by episodic bone pain. Diagnosis relies heavily on whole-body MRI and is made by excluding a wide variety of other disorders with overlapping imaging features, depending on location, marrow distribution, and the presence or absence of multifocality. We present an overview of the clinical and imaging features of CRMO and, through various clinical scenarios, provide tips for tailoring the differential diagnosis based on location and distribution of encountered abnormalities. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 3.

Time-Driven Cost Analysis of Noncuffed Venous Catheter Placement in Infants: Bedside versus IR Suite.

PURPOSE: To compare the direct bundled costs of interventional radiology (IR) suite versus bedside placement of noncuffed central venous catheters in infants. METHODS: A single-center retrospective review was performed of all noncuffed upper extremity (peripherally inserted central venous catheter [PICC]) and tunneled femoral (tunneled femoral central venous catheter [TCVC]) catheters placed in infants between January 1, 2018, and December 31, 2018. Propensity score matching was performed adjusting for age, birth weight, procedure weight, and catheter days. Process maps for each procedure were created based on location and sedation type. Technical success and complications were recorded for each placement. The total direct bundled cost for each catheter placement was calculated by summing the procedure and complication costs. RESULTS: A total of 142 procedures were performed on 126 matched patients with a technical success of 96% at the bedside and 100% in the IR suite (P = .08). The complication rates did not significantly differ between the 2 groups (P = .51). The total direct bundled costs for catheter placement were $1421.3 ± 2213.2 at the bedside and $2256.8 ± 3264.7 in the IR suite (P = .001). CONCLUSIONS: The bundled cost of bedside femoral catheter placement is significantly less than that of fluoroscopic TCVC and PICC placement performed in the IR suite, mainly related to differences in sedation costs.

Ultrasound Evaluation of Pediatric Slow-Flow Vascular Malformations: Practical Diagnostic Reporting to Guide Interventional Management.

OBJECTIVE. This article reviews the ultrasound characteristics of pediatric slow-flow vascular malformations and underscores findings that significantly impact diagnosis and treatment. Key imaging features are discussed including lesion size, malformation location, morphology, and mimics. CONCLUSION. Ultrasound findings affect the management of slow-flow vascular malformations and should be emphasized in lesion diagnosis. Superficial, focal lesions with well-defined margins are ideal for ultrasound evaluation.

Pediatric rib pathologies: clinicoimaging scenarios and approach to diagnosis.

Pathologies involving the ribs are diverse in nature, including entities specific to the pediatric population as well as shared pathologies with adults. These can be either localized within or adjacent to the rib, but may also cause rib alteration as a component of a systemic process. To better understand these disorders, we discuss several common rib pathologies in the context of their clinical presentation and pertinent imaging findings. In addition, we review the imaging modalities that may be used to evaluate the ribs. Encompassing both the clinical and imaging aspects of pediatric rib pathologies, this review aims to increase pediatric and musculoskeletal radiologists' awareness of the spectrum of disease and how to leverage a pattern-based approach.