Quality and Diagnosis on the Lateral View of Pediatric Upper Gastro-Intestinal Series.

BACKGROUND: The standard imaging technique for the diagnosis of intestinal malrotation remains the upper gastro-intestinal series (UGIS). The lateral view is promoted as important for making a diagnosis. For this, the lateral view should be of adequate quality, and radiologists must know the normal appearance as well as the appearance of duodenal variants, as misdiagnosis may lead to unnecessary surgery. OBJECTIVE: We aimed to evaluate the quality, findings including the prevalence of the "descending staircase" configuration and its correspondence to a diagnosis of duodenum redundum. MATERIALS AND METHODS: This was a retrospective study and was conducted in a large tertiary children's hospital in the United States. A retrospective review of UGI fluoroscopy exams in children aged ≤ 18 years between January and December 2018 was performed by a pediatric radiologist. First, the lateral view images/cine-loops were assessed independently, followed by the anteroposterior (AP) view. The studies which were designated to have an adequate lateral view were evaluated for configuration of the duodenum and recorded as: normal, abnormal, or normal variant. Also, the presence of a descending staircase configuration was correlated with an AP view for a diagnosis of duodenum redundum. RESULTS: A total of 26 children (26%) (males:16; females:10) with age range 0 to 16 years had adequate lateral views during UGI exams for inclusion. Of the 26, 18 (69%) were reported as normal, 7 (27%) were reported as having a descending staircase and 1 (4%) was reported as abnormal. The AP view demonstrated 2 abnormal studies (1 malrotation and 1 non-rotation), 6 duodenum redundum and 18 normal exams. The one abnormal lateral duodenum was confirmed as a non-rotation on AP view; the second patient with an abnormal AP view had a normal appearance on the lateral view. CONCLUSIONS: A total of 26% of UGI studies had adequate lateral views for interpretation. Of these, nearly a quarter (23%) demonstrated the descending stair-case sign corresponding to a diagnosis of duodenum redundum on the AP view. If the lateral view had been used alone, there would have been a missed diagnosis in one patient.

Distinguishing multicystic from focal encephalomalacia on delayed MRI in children with term hypoxic ischemic injury.

BACKGROUND AND PURPOSE: To define cystic patterns resulting from term hypoxic ischemic injury (HII) on delayed Magnetic Resonance Imaging (MRI) and determine associated HII patterns and lesions that reflect the severity of injury, from a database of African children with cerebral palsy. METHODS: Retrospective review of 1175 children with cerebral palsy due to term HII diagnosed on late MRI, identifying those with cystic changes. These were classified as multicystic or (multi-) focal-cystic, and were evaluated for associated injuries-thalami, basal ganglia, hippocampi, cerebellum, and presence of ulegyria. RESULTS: Three hundred and eighty-eight of 1175 (33%) children had cystic encephalomalacia. Two hundred and seven of 388 (53.3%) had focal-cystic and 181/388 (46.6%) had multicystic injury. The focal-cystic group comprised 87.9% (182/207) with thalamic injury, 25.6% (53/207) with basal ganglia injury, and 15% (31/207) with cerebellar involvement. Basal-ganglia-thalamus (BGT) pattern was present in 43.9% (91/207) and ulegyria in 69.6% (144/207). In the multicystic group, 88.9% (161/181) had thalamic injury, 30.9% (56/181) had basal ganglia injury, and 21% (38/181) had cerebellar involvement. BGT pattern was observed in 29.8% (54/181) and ulegyria in 28.7%. (52/181). Significant associations (p<.05) were found between multicystic injury and caudate/globus pallidus involvement, and between focal-cystic pattern of injury and ulegyria. CONCLUSIONS: Cystic encephalomalacia was seen in almost one-third of patients with term HII imaged with delayed MRI, with a similar prevalence of focal-cystic and multicystic injury. Multicystic injury was associated with caudate and globus pallidi involvement, typical of the BGT pattern of HII, whereas the focal-cystic pattern was associated with ulegyria, typical of watershed injury.

Frequency of Cerebellar Abnormalities Associated With the Differing Magnetic Resonance Imaging Patterns of Term Hypoxic-Ischemic Injury in Children.

BACKGROUND: We aimed to determine the frequency of cerebellar injury using delayed magnetic resonance imaging (MRI) in children with cerebral palsy, diagnosed with term hypoxic-ischemic injury (HII), and to characterize this for the different MRI patterns of HII. METHODS: We retrospectively reviewed delayed MRI scans in children with cerebral palsy, of whom 1175 had term HII. The pattern of HII was classified into basal ganglia-thalamus (BGT) pattern, watershed (WS) pattern, combined BGT/WS, and multicystic HII. Cerebellar location (hemisphere versus vermis) and the MRI characteristics were documented overall and for each of the different patterns of HII, as well as the association with thalamic injury. RESULTS: Cerebellar injury was found in 252 of 1175 (21.4%) (median age 6 years [interquartile range: 3 to 9 years]). Of these, 49% (124 of 252) were associated with a BGT pattern, 13% (32 of 252) with a WS pattern, 28% (72 of 252) with a combined BGT/WS pattern, and 10% (24 of 252) with a multicystic pattern. The vermis was abnormal in 83% (209 of 252), and the hemispheres were abnormal in 34% (86 of 252) (with 17% [43 of 252] showing both vermis and hemispheric abnormality). CONCLUSIONS: Over a fifth of patients with cerebral palsy due to HII had a cerebellar abnormality on delayed MRI, most commonly involving the vermis (83%), and as part of a BGT pattern of injury in just under half of these likely reflecting the association of cerebellar vermis injury with profound insults.

A "global village": promoting research and careers in the pediatric radiology community through diversity.

There is a severe shortage of pediatric radiologists in the USA and across the globe due to multiple factors. These severe shortages, along with increased clinical demand, growing research costs and limited funding sources place pediatric radiologists, particularly those in academic departments, under increasing time pressure, affecting their ability to maintain research productivity. In this paper, we model a new concept that should help boost the research efforts within the pediatric radiology community, while diversifying the academic workforce through the involvement of international medical graduates (IMGs). We describe the mutual advantages this concept could have on academic pediatric radiology departments and IMGs alike, as well as pose some of the unique challenges that could impact this concept and effective strategies to ensure success.

Unequal Cerebral Magnetic Resonance Imaging Changes in Perinatal Hypoxic Ischemic Injury of Term Neonates.

BACKGROUND: Perinatal hypoxic ischemic injury (HII) has a higher prevalence in the developing world. One of the primary concepts for suggesting that an imaging pattern reflects a global insult to the brain is when the injury is noted to be bilateral and symmetric in distribution. In the context of HII in term neonates, this is either bilateral symmetric ( a ) peripheral/watershed (WS) injury or ( b ) bilateral symmetric basal-ganglia-thalamus (BGT) pattern, often with the peri-Rolandic and hippocampal injury. Unilateral, asymmetric, or unequal distribution of injury may therefore be misdiagnosed as perinatal arterial ischemic stroke. OBJECTIVES: We aimed to determine the prevalence of unequal cerebral injury in HII, identify patterns, and determine their relationship with existing classification of HII. MATERIALS AND METHODS: Review of brain magnetic resonance imaging from a database of children with HII. Reports with any unequal pattern of injury were included and further classified as a unilateral, bilateral asymmetric, or symmetric but unequal degree pattern of HII. RESULTS: A total of 1213 MRI scans in patients with a diagnosis of HII revealed 156 (13%) with unequal involvement of the hemispheres: unilateral in 2 of 1213 (0.2%) (involvement only in the WS), asymmetric in 48 of 1213 (4%) (WS in 6 [0.5%], BGT in 4 [0.3%], and combined BGT and WS in 38 [3.1%]), and bilateral symmetric but unequal degree in 106 of 1213 (8.7%) (WS in 20 [1.6%], BGT in 17 [1.4%], and combined BGT and WS in 69 [5.7%]). CONCLUSIONS: The majority of children with cerebral palsy due to HII demonstrate a characteristic bilateral symmetric pattern of injury. In our study, 13% demonstrated an unequal pattern. Differentiation from perinatal arterial ischemic stroke, which is mostly unilateral and distributed typically in the middle cerebral artery territory, should be possible and recognition of the typical BGT or WS magnetic resonance imaging patterns should add confidence to the diagnosis, in such scenarios.

Comparison of chest radiograph findings in ambulatory and hospitalized children with pulmonary tuberculosis.

BACKGROUND: The diagnosis of childhood tuberculosis (TB) is, in many instances, solely reliant on chest radiographs (CXRs), as they are often the only diagnostic tool available, especially in TB-endemic areas. Accuracy and reliability of CXRs for detecting TB lymphadenopathy may vary between groups depending on severity of presentation and presence of parenchymal disease, which may obscure visualization. OBJECTIVE: To compare CXR findings in ambulatory versus hospitalized children with laboratory confirmed pulmonary TB versus other lower respiratory tract infections (LRTI) and test inter-rater agreement for these findings. MATERIALS AND METHODS: Retrospective review, by two pediatric radiologists, of CXRs performed on children < 12 years old referred for evaluation of LRTI with clinical suspicion of pulmonary TB in inpatient and outpatient settings. Each radiologist commented on imaging findings of parenchymal changes, lymphadenopathy, airway compression and pleural effusion. Frequency of imaging findings was compared between patients based on location and diagnosis and inter-rater agreement was determined. Accuracy of radiographic diagnosis was compared to laboratory testing which served as the gold standard. RESULTS: The number of enrolled patients was 181 (54% males); 69 (38%) were ambulatory and 112 (62%) were hospitalized. Of those enrolled, 87 (48%) were confirmed to have pulmonary TB, while 94 (52%) were other LRTI controls. Lymphadenopathy and airway compression were more common in TB patients than other LRTI controls, regardless of patient location. Parenchymal changes and pleural effusion were more common in hospitalized than ambulatory patients, regardless of patient diagnosis. Agreement for parenchymal changes was higher in the hospitalized group (kappa [κ] = 0.75), while agreement for lymphadenopathy (κ = 0.65) and airway compression (κ = 0.68) was higher in the ambulatory group. The specificity of CXRs for TB diagnosis (> 75%) was higher than the sensitivity (< 50%) for both ambulatory and hospitalized groups. CONCLUSION: Higher frequency of parenchymal changes among hospitalized children may conceal specific imaging findings of TB such as lymphadenopathy, contributing to the poor reliability of CXRs. Despite this, the high specificity of CXRs shown in our results is encouraging for continued use of radiographs for TB diagnosis in both settings.

Imaging fibrosis in pediatric kidney transplantation: A pilot study.

BACKGROUND: Noninvasive alternatives to biopsy for assessment of interstitial fibrosis and tubular atrophy (IFTA), the major determinant of kidney transplant failure, remain profoundly limited. Elastography is a noninvasive technique that propagates shear waves across tissues to measure their stiffness. We aimed to test utility of elastography for early detection of IFTA in pediatric kidney allografts. METHODS: We compared ultrasound (USE) and MR elastography (MRE) stiffness measurements, performed on pediatric transplant recipients referred for clinically indicated biopsies, and healthy controls. RESULTS: Ten transplant recipients (median age 16 years) and eight controls (median age 16.5 years) were enrolled. Three transplant recipients had "stable" allografts and seven had Banff Grade 1 IFTA. Median time from transplantation to biopsy was 12 months. Mean estimated glomerular filtration rate was 61.5 mL/min/1.73m2 by creatinine-cystatin-C CKiD equation at time of biopsy. Mean stiffness, calculated through one-way ANOVA, was higher for IFTA allografts (23.4 kPa USE/5.6 kPa MRE) than stable allografts (13.7 kPa USE/4.4 kPa MRE) and controls (9.1 kPa USE/3.6 kPa MRE). Pearson's coefficient between USE and MRE stiffness values was strong (r = .97). AUC for fibrosis prediction in transplanted kidneys was high for both modalities (0.91 USE and 0.89 MRE), although statistically nonsignificant (p > .05). Stiffness cut-off values for USE and MRE were 13.8 kPa and 4.6 kPa, respectively. Both values yielded a sensitivity of 100% but USE specificity (72%) was slightly higher than MRE (67%). CONCLUSION: Elastography shows potential for detection of low-grade IFTA in allografts although a larger sample is imperative for clinical validation.

Retrograde urethrography in children: a decade of experience at a children's hospital.

BACKGROUND: Retrograde urethrography (RUG) is a radiologic procedure that optimizes imaging evaluation of the urethra, particularly in settings of difficulty with micturition or urethral injury. OBJECTIVE: To review our experience with RUG at a large pediatric radiology practice. MATERIALS AND METHODS: We conducted a retrospective review of medical records and fluoroscopic images of RUGs performed from January 2010 to December 2020. RESULTS: We identified 180 RUG exams (median frequency 17 exams per year), all in male children (median age 13 years). The most common indications were stricture (42%; n=76), postsurgical evaluation (34%; n=62) and trauma (16%; n=29). The most commonly used catheter was Foley (40%; n=72), with a median catheter size of 5 French (Fr) for infants younger than 1 year, 7 Fr for children ages 1-5 years and 8 Fr for children older than 5 years. About a third of the children (57; 32%) had combined voiding cystourethrography (VCUG)-RUG exams. Water-soluble contrast agent, either 17% or 43% Cysto-Conray, was used. Most RUG exams were normal (46%; n=83). The most common urethral pathology was stricture (30%; n=54), commonly involving a bulbar urethra (n=26). Urethral trauma was seen in 11 children (6%), 10 bulbar and 1 membranous. Most children with stricture were surgically treated (n=40; 74%), whereas most children with trauma were conservatively treated (n=8; 73%). The remaining diagnoses included diverticula, polyps, valves, fistulas and duplications, constituting <17% of our sample; most of these were surgically treated. Four exams (2%) were non-diagnostic. RUG showed 89% sensitivity and 97% specificity compared to cystourethroscopy/VCUG findings. Technical difficulties occurred in 14 (8%) children (e.g., pain or inappropriate catheter seal). CONCLUSION: Our experience indicates that when catheterization techniques are properly tailored, RUG provides a useful and successful radiologic method of evaluating the pediatric male urethra.

Length of Bowel Rest Does Not Predict Gastrojejunostomy Tube-Associated Intussusception Recurrence.

OBJECTIVES: One potential treatment for gastrojejunostomy (GJ) tube-related intussusception is bowel rest, whereby the GJ tube is replaced with a gastrostomy tube. The aim of this study was to determine whether bowel rest length was associated with decreased risk of re-intussusception. METHODS: Pediatric patients with GJ tube-related intussusceptions were identified during the study period of January 1, 2010 and August 1, 2021. Records were reviewed for demographics, symptoms, need for central access to initiate parenteral nutrition, and length of stay. Comparison was made between patients with intussusception recurrence within 30 days and those without. Those undergoing earlier replacement, defined as the first quartile of rest time, or 72 hours, were then compared to longer periods of bowel rest. RESULTS: Forty-six intussusceptions were included, with a median age of 2.8 years (interquartile range, IQR: 1.4-4.1) and weight of 12 kg (IQR: 8.9-15.4). All patients diagnosed as outpatient (54.3%) required hospital admission and 9 of 46 (19.6%) required central access. There were 7 recurrences (15.2%). There was no difference in recurrence based on time of bowel rest (5 days in those without vs 6 days in those with, P = 0.30) nor a difference in recurrence with <72 hours of bowel rest compared to >72 hours (1/15, 6.7% vs 6/31, 19.3%). Patients undergoing earlier exchange had a shorter median length of hospital stay (3 vs 8.5 days, P = 0.003). CONCLUSION: Length of bowel rest was not associated with recurrent GJ tube-related intussusceptions. If bowel rest is utilized, <72 hours may be sufficient to decrease length of hospital stay.

Distribution of IntraThalamic Injury According to Nuclei and Vascular Territories in Children With Term Hypoxic-Ischemic Injury.

BACKGROUND: Term hypoxic-ischemic injury (HII) on magnetic resonance imaging (MRI) is described as the basal ganglia thalamus [BGT], watershed [WS], or combined [BGT/WS] groups. We aimed to determine differences between HII groups in intrathalamic distribution. METHODS: Delayed MRIs of children with HII and thalamic injury were reviewed. Custom tools were placed over T2-weighted and/or fluid-attenuated inversion recovery axial images to determine distribution of intrathalamic injury: (1) six subjective (whole/near-whole, central, anterior, posterior, lateral, medial); (2) four nuclear (anterior [AN], ventrolateral [VLN], medial [MN], and pulvinar [PN]); and (3) three arterial (thalamoperforating arteries [TPA], thalamogeniculate arteries [TGA], and posterior choroidal arteries [PCA]) locations. We compared the frequency of injury of the aforementioned intrathalamic locations between HII groups. RESULTS: The 128 children (mean age at MRI 7.35 ± 3.6 years) comprised 41% (n = 53) BGT, 26% (n = 33) WS, and 33% (n = 42) BGT/WS. The VLN was the most frequent injured nuclear region (66%, n = 85), and the TGA (93%, n = 128) was the most frequent arterial region involved. VLN injury occurred more frequently in the BGT group (P < 0.001), PN in the WS group (P < 0.001), and AN (P < 0.001), MN (P < 0.001), PN (P = 0.001), and all nuclei together (P < 0.001) in the BGT/WS group. The combination of all vascular territories was significantly associated with BGT/WS (P < 0.001). CONCLUSIONS: There are significant differences in intrathalamic nuclear and arterial injuries between the different types of HII.

Frequency of ulegyria on delayed MRI scans in children with term hypoxic-ischemic injury.

BACKGROUND: Ulegyria is an under-recognized and underreported potential sequela of hypoxic-ischemic injury (HII) in full-term neonates. Ulegyria is a unique form of parenchymal scarring that leads to a mushroom-shape of the affected gyri resulting from volume loss at the deep portions of the sulci during HII in this specific period in infantile neurodevelopment. Identifying ulegyria is important for ascribing cause and timing of HII on delayed magnetic resonance imaging (MRI) scans and because of its close association with pharmaco-resistant epilepsy. OBJECTIVE: The purpose of this study was to determine the frequency of ulegyria and characterize the anatomical distribution of watershed injury in a large database of patients who developed cerebral palsy with term HII pattern and underwent delayed MRI. MATERIALS AND METHODS: Patients with term HII patterns on MRI were analyzed for ulegyria. The frequency of ulegyria overall and for each pattern of HII distribution was determined as was the anatomical distribution of watershed injury. RESULTS: Of the 731 children with term HII and cortical injury, 484 (66%) had ulegyria. Ulegyria was most common in those cases with a combined watershed/basal ganglia-thalamic pattern (56%) and isolated watershed pattern (40%). Watershed injury in patients with ulegyria was most common at the posterior watershed (80.6%) and perisylvian watershed (76.7%). CONCLUSION: Ulegyria was present in nearly two-thirds of patients with term HII and cortical injury and should be sought to support the diagnosis of previous perinatal HII, especially in posterior and perisylvian watershed regions. The implications of ulegyria can be significant for clinical decision-making and for ascribing timing of injury to the perinatal period.

Magnetic resonance urography: a practical approach to preparation, protocol and interpretation.

Magnetic resonance urography (MRU) is an important MRI application that provides noninvasive comprehensive morphological and functional evaluation of the kidneys and urinary tract. It can be used to assess congenital anomalies of the kidney and urinary tract, which often present as urinary tract dilation. In children, MRU allows for high tissue contrast and high spatial resolution without requiring ionizing radiation. Magnetic resonance urography requires patient preparation in the form of pre-examination intravenous hydration, placement of a urinary catheter, and the administration of diuretics at the time of the exam. The imaging protocol is based on T2-weighted images for anatomical assessment and dynamic post-contrast images for functional evaluation. These images are then used to generate quantitative and graphic results including contrast transit and excretion time as well as to calculate differential renal function. This review focuses on a simple approach to pediatric MRU acquisition and interpretation based on clinical cases and the authors' experience.

Added value of gadolinium-based contrast agents for magnetic resonance evaluation of adnexal torsion in girls.

PURPOSE: Ultrasound is the first-line imaging modality to evaluate adnexa in girls with clinical suspicion of torsion. Patients with equivocal ultrasound findings can undergo MRI for better delineation of adnexal pathology. Here, we assess the utility of intravenous contrast in MRI evaluation of adnexal torsion in children. METHODS: Two pediatric radiologists (R1, R2) retrospectively reviewed 198 pelvic MRI exams in 172 girls (median age 15 years). Each MRI was reviewed twice. The first review included pre-contrast images only. A second review, at least 1 month later, included both pre- and post-contrast images. Readers concluded if findings were suspicious for torsion or not. Readers' findings were compared to each other's and to surgical and MRI reports and clinical course. RESULTS: 198 MRI exams yielded 354 evaluable ovaries. Surgical and pathological reports were available for 47 patients. 11 patients had adnexal torsion. Both readers accurately diagnosed acutely torsed ovaries during pre- and post-contrast reviews (n = 4). However, readers disagreed on torsed paraovarian cysts (n = 4) and chronically/intermittently torsed ovaries (n = 3). In 21 non-torsed ovaries that had lesions, one or both readers concluded that there were pre-contrast features of torsion. In this set with ovarian lesions, contrast helped readers to correctly conclude no torsion (R1 = 8, R2 = 6) more commonly than to incorrectly conclude torsion (1 each), improving post-contrast specificity for each reader. CONCLUSIONS: Post-contrast sequences did not provide additional benefit in evaluating acutely torsed ovaries but helped in excluding torsion in patients with adnexal lesions. Therefore, contrast administration should be individualized, potentially reserved only for those with abnormal ultrasound or pre-contrast images.

Liver and spleen volume and stiffness in patients post-Fontan procedure and patients with ARPKD compared to normal controls.

PURPOSE: Both congestive (patients post-Fontan hepatopathy) and congenital (patients with ARPKD) disease can lead to hepatic fibrosis and portal hypertension with eventual development of splenomegaly. We investigated liver and spleen stiffness as measured by MRE between post-Fontan, ARPKD patients and controls independent of organ volume. METHODS: Our study included 122 subjects (70 Fontan patients, 14 ARPKD patients, and 38 controls). The mean MRE liver and spleen stiffness values of Fontan patients and patients with ARPKD were compared to controls. Similarly, the liver and spleen volumes of the Fontan patients and patients with ARPKD were then compared to the volumes of controls. RESULTS: Post-Fontan and ARPKD patients, mean liver stiffness, mean liver volume as well as mean spleen stiffness and mean spleen volume were higher than mean liver stiffness, mean liver volume, mean spleen stiffness, and mean spleen volume of controls. While liver stiffness correlated to liver volume in controls, we found no correlation between stiffness and volume in either Fontan or ARPKD patients, which indicates MRE's ability to act as an independent biomarker. However, these findings are not true in the spleen, where there is significant association between volume and stiffness in patients with ARPKD, but not in Fontan patients or controls. CONCLUSION: Liver and spleen stiffness and volumes are significantly different among Fontan patients, ARPKD patients, and controls. Our findings suggest that beyond diagnosing fibrosis, MRE cut-off values could be disease-specific since not only the severity but the underlying pathology causing organ congestion or fibrosis influences MRE results.

Frequency of duodenal anatomical variants in neonatal and pediatric upper gastrointestinal tract series (UGI) and the influence of exam quality on diagnostic reporting of these.

AIM: To determine frequency of duodenal anatomical variants on clinically indicated pediatric UGI examinations and determine the influence of these variants and exam quality on the reliability of diagnosis. MATERIALS AND METHODS: Two-pediatric radiologists retrospectively reviewed 100-UGI exams performed on children ≤18-years. Exams were considered diagnostic if the duodenojejunal (DJ) flexure was identified. For diagnostic exams, readers categorized the duodenal location and shape as: normal, normal variant, or abnormal. Exam quality was assessed according to duodenal visualization, number of boluses required, and patient positioning. RESULTS: Reader 1: 90/100 exams diagnostic -77% normal duodenum, 20% normal variant, and 3% abnormal. Reader 2: 97/100 exams diagnostic - 88% normal, 8% normal variant, and 4% abnormal. Original reports: 99/100 exams diagnostic - 92% normal, 3% normal variant, and 5% abnormal. 42% of exams were "high-quality" and 58% were "low-quality". The number of abnormal was the same between readers in "high-quality" studies. In "low-quality" studies reader 1 and the original read diagnosed 1 further case as non-rotation which was diagnosed as a normal variant by reader 2. Two further cases were reported as non-rotation by the original reader. Inter-rater reliability was significantly higher among each pair of raters in "high quality" exams (κ 0.3; p ≤ 0.05) compared to "low quality" exams (k < 0.1 - p > 0.05). CONCLUSION: Duodenal variants were diagnosed in 8-20% of UGI. Compromised exam quality contributes to poor interrater reliability and may result in diagnostic errors of normal variant duodenums, posing a risk for unnecessary intervention and/or delayed treatment.

Impact of routine chest radiographs after removal of pigtail chest tubes placed by pediatric interventional radiology.

BACKGROUND: Chest radiographs are commonly obtained after chest tube removal to assess for complications. The benefit of this practice in children is uncertain. OBJECTIVE: To determine the clinical impact of a routine chest radiograph following removal of chest tubes placed by pediatric interventional radiology. MATERIALS AND METHODS: This single-center retrospective study evaluated 200 chest tube removals in 176 patients (median age: 4 years, interquartile range [IQR]: 1.2-12; median weight: 17.2 kg, IQR: 10.67-37.6), who had a chest tube placed and removed by pediatric interventional radiology over a 16-year period. A chest radiograph obtained on the day of removal was compared to the preceding study. For patients with imaging changes, medical records were reviewed to determine whether clinical actions occurred as a result. All records were reviewed for 7 days after tube removal or hospital discharge, whichever occurred first. RESULTS: The most common indication for chest tube insertion was simple effusion (53%, 106/200) and the most common tube size was 10.2 French (38.7%, 81/209). The median tube dwell time was 8 days (IQR: 5-17). There was a median of 14 h (IQR: 7-33.5) between imaging before and after tube removal. Imaging changes occurred in 10% (n = 20/200) of chest tube removals. Three of 200 (1.5%) of these were symptomatic after removal and only 0.5% (1/200) required chest tube reinsertion. For the remaining removals resulting in chest radiograph changes, patients were asymptomatic and required no change in clinical management. CONCLUSION: For chest tubes placed by pediatric interventional radiology, these findings do not support the practice of a routine chest radiograph after removal in asymptomatic children.

Evaluation of quality of renal tract ultrasound scans and reports performed in children with first urinary tract infection.

PURPOSE: To determine the quality of renal tract ultrasound (US) imaging records performed in children for evaluation of urinary tract infection (UTI) by multiple professionals with different levels of experience in a dedicated academic children's hospital. METHODS: Retrospective analysis of US images and reports for children ≤ 13-years with first presentation of a UTI. 9 Operators (6 consultant radiologists and 3 sonographers) were anonymised and the adequacy of their US images and reports were evaluated for the following categories; Image acquisition, Image labelling, Metric labelling, and Final reporting. The frequency of the reporting quality of the elements assessed was compared between radiologists and sonographers using Chi-square or fisher exact test. RESULTS: Renal tract US studies for 100 children (20 males, 80 females) with first UTI episode were assessed. Mean age was 4.5 ± 3.4 years. 54% of the studies were performed by sonographers and 46% by radiologists. Kidneys and pre-micturition bladder scans were acquired in more than 96% of exams by both sonographers and radiologists. Kidney image and metric labelling was adequate in almost all exams (98-100%) with the exception of plane labelling which was not routinely done by US operators (less than 3%). Sonographers performed consistently better than radiologists in post-micturition bladder scanning, pre- and post-micturition bladder labelling and renal length reporting (p<0.05). Least to be recorded by US operators (both radiologists and sonographers) were doppler scan acquisitions (less than 3%), bladder wall thickness labelling (less than 3%), and renal calculi reporting (less than 1%). CONCLUSION: The inconsistency of the reporting quality between the different elements assessed highlights the difference in US training and experience received by sonographers and radiologists. A pro-forma structured reporting template may ensure US operators provide consistent, thorough and good quality ultrasound images and reports.

Ultrasound-Based Renal Parenchymal Area and Kidney Function Decline in Infants With Congenital Anomalies of the Kidney and Urinary Tract.

Congenital anomalies of the kidney and urinary tract are the leading cause of chronic kidney disease in children. Noninvasive imaging biomarkers that predict chronic kidney disease progression in early infancy are needed. We performed a pilot study nested in the prospective Chronic Kidney Disease in Children cohort study to determine the association between renal parenchymal area (RPA) on first post-natal renal ultrasound and change in estimated glomerular filtration rate (eGFR) in children with congenital anomalies of the kidney and urinary tract. Among 14 participants, 78.6% were males, the median age at the time of the ultrasound was 3.4 months (interquartile range, 1.3-7.9 mo), and the median total RPA z-score at baseline was -1.01 (interquartile range, -2.39 to 0.52). After a median follow-up period of 7.4 years (interquartile range, 6.8-8.2 y), the eGFR decreased from a median of 49.4 mL/min per 1.73 m2 at baseline to 29.4 mL/min per 1.73 m2, an annual eGFR percentage decrease of -4.68%. Lower RPA z-scores were correlated weakly with a higher annual decrease in eGFR (Spearman correlation, 0.35; 95% confidence interval, -0.25 to 0.76). This pilot study shows the feasibility of obtaining RPA from a routine ultrasound and suggests that a lower baseline RPA may be associated with a greater decrease in eGFR over time. Further studies with larger patient cohorts are needed to confirm this association.

Inter-rater reliability in quality assurance (QA) of pediatric chest X-rays.

PURPOSE: The goal of the study is to determine the inter-rater agreement on multiple factors that were utilized to evaluate the quality of pediatric chest X-ray exams from different levels of healthcare provision in an African setting. METHODS: The image quality of pediatric chest X-rays from 3 South African medical centers of varying level of healthcare service were retrospectively assessed by 3 raters for 12 quality factors including: (1) absent body parts; (2) under inspiration; (3) patient rotation; (4) scapula in the way; (5) patient kyphosis/lordosis; (6) artefact/foreign body; (7) central vessel visualization; (8) peripheral vessels visualization; (9) poor collimation; and (10) trachea and bronchi visualization; (11) post-cardiac vessel visualization; and (12) absent or wrong image orientation. Analysis was performed using the Brennan--Prediger coefficient of agreement for inter-rater reliability and Cochran's Q statistic and McNemar's test for inter-rater bias. RESULTS: 1077 X-rays were reviewed. The least difference between observers in the frequency of the errors was noticed for factors (1) absent body parts and (12) absent or wrong image orientation with almost perfect agreement between raters. κ score for these two factors among all raters and between each pair of raters was more than 0.95 with no significant inter-rater bias. Conversely, there was poor agreement for the remaining factors with the least agreed on being factor (3) patient rotation with a κ score of 0.23. This was followed by factors (2) under inspiration (κ score of 0.32) and factors (4) scapula in the way (κ score of 0.35) respectively. There was significant inter-rater bias for all these three factors. CONCLUSION: Many of the factors used to assess the quality of a chest X-ray in children demonstrate poor reliability despite mitigation against variations in training, standard quality definitions and level of healthcare service provision. New definitions, objective measures and recording tools for assessing pediatric chest radiographic quality are required.