Contemporary Practice Patterns of Voiding Cystourethrography Use at a Large Tertiary Care Center in a Single Payer Health Care System.

PURPOSE: Voiding cystourethrogram involves radiation exposure and is invasive. Several guidelines, including the 2011 AAP (American Academy of Pediatrics) guidelines, no longer recommend routine voiding cystourethrogram after the initial urinary tract infection in children. The recent trend in voiding cystourethrogram use remains largely unknown. We examined practice patterns of voiding cystourethrogram use and explored the impact of these guidelines in a single payer system in the past 8 years. MATERIALS AND METHODS: We identified all voiding cystourethrograms performed at a large pediatric referral center between January 2008 and December 2015. Patients 2 to 24 months old who underwent an initial voiding cystourethrogram for the diagnosis of a urinary tract infection in the first 6 months of 2009 and 2014 were identified. Medical records were retrospectively reviewed. RESULTS: During the study period 8,422 voiding cystourethrograms were performed and the annual number declined over time. In the pre-AAP and post-AAP cohorts 233 and 95 initial voiding cystourethrograms were performed, respectively. While there was no statistically significant difference in the vesicoureteral reflux detection rate between 2009 and 2014 (37.3% vs 43.0%, p = 0.45), there was a threefold increase in high grade vesicoureteral reflux in 2014 (2.6% vs 8.4%, p = 0.03). CONCLUSIONS: A clear trend toward fewer voiding cystourethrograms was noted at our institution. This decrease started before 2011 and cannot be attributed to the AAP guidelines alone. While most detected vesicoureteral reflux remains low grade, there was a greater detection rate of high grade vesicoureteral reflux in 2014 compared to 2009. This may reflect a favorable impact of a more selective approach to obtaining voiding cystourethrograms.

Effective dose estimation for pediatric upper gastrointestinal examinations using an anthropomorphic phantom set and metal oxide semiconductor field-effect transistor (MOSFET) technology.

BACKGROUND: There is a need for updated radiation dose estimates in pediatric fluoroscopy given the routine use of new dose-saving technologies and increased radiation safety awareness in pediatric imaging. OBJECTIVE: To estimate effective doses for standardized pediatric upper gastrointestinal (UGI) examinations at our institute using direct dose measurement, as well as provide dose-area product (DAP) to effective dose conversion factors to be used for the estimation of UGI effective doses for boys and girls up to 10 years of age at other centers. MATERIALS AND METHODS: Metal oxide semiconductor field-effect transistor (MOSFET) dosimeters were placed within four anthropomorphic phantoms representing children ≤10 years of age and exposed to mock UGI examinations using exposures much greater than used clinically to minimize measurement error. Measured effective dose was calculated using ICRP 103 weights and scaled to our institution's standardized clinical UGI (3.6-min fluoroscopy, four spot exposures and four examination beam projections) as determined from patient logs. Results were compared to Monte Carlo simulations and related to fluoroscope-displayed DAP. RESULTS: Measured effective doses for standardized pediatric UGI examinations in our institute ranged from 0.35 to 0.79 mSv in girls and were 3-8% lower for boys. Simulation-derived and measured effective doses were in agreement (percentage differences <19%, T > 0.18). DAP-to-effective dose conversion factors ranged from 6.5 ×10(-4) mSv per Gy-cm(2) to 4.3 × 10(-3) mSv per Gy-cm(2) for girls and were similarly lower for boys. CONCLUSION: Using modern fluoroscopy equipment, the effective dose associated with the UGI examination in children ≤10 years at our institute is < 1 mSv. Estimations of effective dose associated with pediatric UGI examinations can be made for children up to the age of 10 using the DAP-normalized conversion factors provided in this study. These estimates can be further refined to reflect individual hospital examination protocols through the use of direct organ dose measurement using MOSFETs, which were shown to agree with Monte Carlo simulated doses.

Effective dose estimation for pediatric voiding cystourethrography using an anthropomorphic phantom set and metal oxide semiconductor field-effect transistor (MOSFET) technology.

BACKGROUND: The risks associated with radiation exposure are higher in children than in adults. Therefore the use of fluoroscopy in common pediatric examinations such as voiding cystourethrography (VCUG) requires accurate determination of the associated effective dose. OBJECTIVE: To estimate effective dose for VCUG examinations performed in children younger than 10 years using anthropomorphic phantoms and metal oxide semiconductor field-effect transistor (MOSFET) dosimeters. MATERIALS AND METHODS: MOSFETs were placed within four phantoms representing children 0.12). DAP was strongly correlated with effective dose for both genders (r (2)>0.97, P < 0.0001). CONCLUSION: Effective doses for VCUG examinations performed in children

The role of imaging in the preoperative assessment of children with inflammatory colitis.

BACKGROUND: Accurate diagnosis of Crohn's disease or ulcerative colitis is essential for surgical planning. This study compared the accuracy, safety, and utility of small bowel follow-through (SBFT) and magnetic resonance enterography (MRE) for detecting small bowel (SB) involvement preoperatively. METHODS: A retrospective review of children who underwent colectomy for inflammatory bowel disease (2000-2014) was performed. Preoperative SBFT and MRE were independently reviewed by two radiologists blinded to clinical data. Gold standard for diagnosis was surgical pathology. RESULTS: 68 patients (36 female) were included. 45 patients had SBFT prior to colectomy, 17 patients had MRE, and 6 both. Interrater reliability for radiologic interpretation was 90% (SBFT) and 91% (MRE). Mean study durations were 190min (SBFT) and 59min (MRE). Median effective dose for SBFT was 1.5mSv, while MRE involved no ionizing radiation. Specificities for diagnosing SB involvement were 87.5% (SBFT) and 94% (MRE). 54 patients underwent subtotal colectomy and ileostomy, 12 restorative proctocolectomy, and 2 colectomy with ileorectal anastomosis. Preoperative imaging correlated with surgical pathology in 83% (SBFT) and 90% (MRE). CONCLUSION: MRE is at least as effective as SBFT for assessing SB disease in children with colitis prior to colectomy. MRE requires less time and does not expose children to ionizing radiation. Retrospective Case Series, Level 4 Evidence.

Retrospective Review of Current Nasojejunal Tube Insertion Practice.

Repeated fluoroscopically guided nasojejunal tube (NJT) insertions, particularly in children, can pose health risks through increased radiation exposure. We analyzed frequency of NJT reinsertions and associated radiation exposure through retrospective evaluation of children <18 years at our institution who underwent fluoroscopically guided NJT insertions from 2007 to 2012. Age and weight, reinsertion frequency per patient, radiation dose (dose actual percentage [DAP]), time interval between, and indication for reinsertion were recorded. A total of 252 children (3 days to17 years, 11 months) had 449 NJT insertions. Reinsertions occurred in 105 (41.7%) patients with 14 (5.6%) having ≥5 reinsertions, and 67.6% of reinsertions occurring in patients <1 year. Mean DAP increased with frequency of reinsertion, along with age and weight. Most common indication for reinsertion was a pulled NJT (34.0%). Fluoroscopic NJT reinsertion was most frequent in younger, smaller patients. Self-guided, bedside NJT insertion, and/or earlier instigation of definitive nutritional therapy delivery should be considered.