Comparison of chest radiograph and lung ultrasound in children with acute respiratory failure.

PURPOSE: Chest x-ray (CXR) is the standard imaging used to evaluate children in acute respiratory distress and failure. Our objective was to compare the lung-imaging techniques of CXR and lung ultrasound (LUS) in the evaluation of children with acute respiratory failure (ARF) to quantify agreement and to determine which technique identified a higher frequency of pulmonary abnormalities. METHODS: This was a secondary analysis of a prospective observational study evaluating the sensitivity and specificity of LUS in children with ARF from 12/2018 to 02/2020 completed at the University of Wisconsin-Madison (USA). Children > 37.0 weeks corrected gestational age and ≤ 18 years of age admitted to the PICU with ARF were evaluated with LUS. We compared CXR and LUS completed within 6 h of each other. Kappa statistics (k) adjusted for maximum attainable agreement (k/kmax) were used to quantify agreement between imaging techniques and descriptive statistics were used to describe the frequency of abnormalities. RESULTS: Eighty-eight children had LUS completed, 32 with concomitant imaging completed within 6 h are included. There was fair agreement between LUS and CXR derived diagnoses with 58% agreement (k/kmax = 0.36). Evaluation of imaging patterns included: normal, 57% agreement (k = 0.032); interstitial pattern, 47% agreement (k = 0.003); and consolidation, 65% agreement (k = 0.29). CXR identified more imaging abnormalities than LUS. CONCLUSIONS: There is fair agreement between CXR and LUS-derived diagnoses in children with ARF. Given this, clinicians should consider the benefits and limitations of specific imaging modalities when evaluating children with ARF. Additional studies are necessary to further define the role of LUS in pediatric ARF given the small sample size of our study.

"What Program Directors Think" V: Results of the 2019 Spring Survey of the Association of Program Directors in Radiology (APDR).

RATIONALE AND OBJECTIVES: The Association of Program Directors in Radiology (APDR) surveys its membership annually on hot topics and new developments in radiology residency training. Here we report the results of that annual survey. MATERIALS AND METHODS: A web-based survey was posed to the APDR membership in the Fall of 2018. Members were asked 43 questions on program staffing, resident education resources/funding, impact of the integrated-Interventional Radiology residency program on Diagnostic Radiology program resources, resident interest in imaging informatics, Accreditation Council for Graduate Medical Education requirements on resident practice habits data reporting, institutional reliance on residents for clinical coverage, teaching format in the post-oral board era, resident conference attendance, confidentiality of the Match rank list, Early Specialization in Interventional Radiology pathway recruitment and selection, Diagnostic Radiology and Interventional Radiology program relationships, independent resident call, pediatric radiology training, diversity and unconscious bias training, and social media in radiology education. RESULTS: Responses were collected electronically, results were tallied using Qualtrics software, and qualitative responses were tabulated or summarized as comments. There were 86 respondents with a response rate of 31.3%. CONCLUSION: Survey result highlights include perceived resident interest in imaging informatics with the vast majority of residency programs offering an informatics curriculum; the provision of resident practice habits data by nearly all residency programs despite lack of clarity surrounding this Accreditation Council for Graduate Medical Education requirement; continued use of case-taking in the post-oral boards era; frequent disclosure of the Match rank list to departmental and hospital administration; low penetration of unconscious bias training in academic radiology; and finally, the successful integration of interventional and diagnostic radiology training programs.

Should Radiology Delay the Start of Fellowships? A Survey of the APDR.

RATIONALE AND OBJECTIVES: Several major medical specialties have recently considered delaying the start date of their fellowship training programs to allow for completion of their trainees' residency obligations. Radiology program directors (PDs) have voiced the need for a similar solution, as fellowship start dates at some institutions now occur well before the end of residency training. The objectives of this study are to assess the current state of the radiology fellowship transition and understand its impact on residency programs and clinical services. MATERIALS AND METHODS: Survey Monkey (Palo Alto, CA) was used to create a survey consisting of 9 multiple choice and 2 free text questions. The survey was approved by the survey committee of the Association of Program Directors in Radiology (APDR) and distributed via email to all 240 APDR members in November 2018. The survey was closed after 30 days. RESULTS: The response rate was 67% (160/240). Fifty-nine percent of respondents indicated some of their residents are asked to arrive at fellowships before July 1, often several days early for orientation and picture archiving and communication system (PACS) training. Sixteen percent of respondents said their own institutions ask incoming fellows to arrive early. Sixty-four percent of respondents indicated that this causes staffing problems. Seventy-eight percent of respondents supported considering a delay to the start of radiology fellowships. CONCLUSION: Most APDR members claim that residents are asked to arrive at fellowships early to complete orientation and training before July 1, and most say that this produces staffing problems on services. A significant majority of respondents support a discussion regarding delaying fellowship start dates.

Including ultrasound scans in antenatal care in low-resource settings: Considering the complementarity of obstetric ultrasound screening and maternity waiting homes in strengthening referral systems in low-resource, rural settings.

Recent World Health Organization (WHO) antenatal care recommendations include an ultrasound scan as a part of routine antenatal care. The First Look Study, referenced in the WHO recommendation, subsequently shows that the routine use of ultrasound during antenatal care in rural, low-income settings did not improve maternal, fetal or neonatal mortality, nor did it increase women's use of antenatal care or the rate of hospital births. This article reviews the First Look Study, reconsidering the assumptions upon which it was built in light of these results, a supplemental descriptive study of interviews with patients and sonographers that participated in the First Look study intervention, and a review of the literature. Two themes surface from this review. The first is that focused emphasis on building the pregnancy risk screening skills of rural primary health care personnel may not lead to adaptations in referral hospital processes that could benefit the patient accordingly. The second is that agency to improve the quality of patient reception at referral hospitals may need to be manufactured for obstetric ultrasound screening, or remote pregnancy risk screening more generally, to have the desired impact. Stemming from the literature, this article goes on to examine the potential for complementarity between obstetric ultrasound screening and another approach encouraged by the WHO, the maternity waiting home. Each approach may address existing shortcomings in how the other is currently understood. This paper concludes by proposing a path toward developing and testing such a hybrid approach.

Use of ultrasound and mHealth to improve perinatal outcomes in low and middle income countries.

The explosion of mobile health and portable obstetric ultrasound interventions in low- and middle-income countries (LMIC) reflects the optimism that technology can help reduce persistently high rates of maternal and neonatal mortality and morbidity in these settings. While these technology-driven interventions have had success in improving aspects of antenatal and perinatal care, they have not clearly demonstrated reductions in mortality. The expanding synergy between mobile health (mHealth) and ultrasound technology shows promise to enhance care, but it will likely take combining these technological advances with system-wide approaches that also address referral patterns and infrastructure barriers to improve outcomes.

"What program directors think IV": Results of the 2017 Annual Survey of the Association of Program Directors in Radiology.

RATIONALE AND OBJECTIVES: The Association of Program Directors in Radiology (APDR) regularly surveys its members to gather information regarding a broad range of topics related to radiology residency. The survey results provide insight into the opinions of residency program leadership across the country. MATERIALS AND METHODS: This is an observational cross-sectional study using a web-based survey posed to the APDR membership in the fall of 2017. The final survey consisted of 53 items, 48 multiple choice questions and five write-in comments. An invitation to complete the survey was sent to all 319 active APDR members. RESULTS: Deidentified responses were collected electronically, tallied utilizing Qualtrics software, and aggregated for the purposes of analysis and reporting at the 66th annual meeting of the Association of University Radiologists. The response rate was 36%. CONCLUSION: Over the past 16 years, more PDs have assistant and APDs to administer growing residency programs, but the time allocation for these APDs has come from the PD's protected time. An overwhelming majority of PDs consider independent call beneficial to residents and most think a call assistant is desirable. The vast majority of PDs support a unified fellowship match and allow resident moonlighting. Most fourth year residents are actively or moderately involved in clinical work and teaching. The majority of PDs have lost or expect to lose DR training positions to the new IR/DR programs. In a competitive match, PDs do not rely on residency interviews in their selection process.

Factors influencing referrals for ultrasound-diagnosed complications during prenatal care in five low and middle income countries.

BACKGROUND: Ultrasound during antenatal care (ANC) is proposed as a strategy for increasing hospital deliveries for complicated pregnancies and improving maternal, fetal, and neonatal outcomes. The First Look study was a cluster-randomized trial conducted in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia to evaluate the impact of ANC-ultrasound on these outcomes. An additional survey was conducted to identify factors influencing women with complicated pregnancies to attend referrals for additional care. METHODS: Women who received referral due to ANC ultrasound findings participated in structured interviews to characterize their experiences. Cochran-Mantel-Haenszel statistics were used to examine differences between women who attended the referral and women who did not. Sonographers' exam findings were compared to referred women's recall. RESULTS: Among 700 referred women, 510 (71%) attended the referral. Among referred women, 97% received a referral card to present at the hospital, 91% were told where to go in the hospital, and 64% were told that the hospital was expecting them. The referred women who were told who to see at the hospital (88% vs 66%), where to go (94% vs 82%), or what should happen, were more likely to attend their referral (68% vs 56%). Barriers to attending referrals were cost, transportation, and distance. Barriers after reaching the hospital were substantial. These included not connecting with an appropriate provider, not knowing where to go, and being told to return later. These barriers at the hospital often led to an unsuccessful referral. CONCLUSIONS: Our study found that ultrasound screening at ANC alone does not adequately address barriers to referrals. Better communication between the sonographer and the patient increases the likelihood of a completed referral. These types of communication include describing the ultrasound findings, including the reason for the referral, to the mother and staff; providing a referral card; describing where to go in the hospital; and explaining the procedures at the hospital. Thus, there are three levels of communication that need to be addressed to increase completion of appropriate referrals-communication between the sonographer and the woman, the sonographer and the clinic staff, and the sonographer and the hospital. TRIAL REGISTRATION: NCT01990625 .

Evaluation of Focused Obstetric Ultrasound Examinations by Health Care Personnel in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan, and Zambia.

Prior studies have suggested that obstetrical (OB) ultrasound in low- and middle-income countries has aided in detection of high-risk conditions, which in turn could improve OB management. We are participating in a cluster-randomized clinical trial of OB ultrasound, which is designed to assess the effect of basic OB ultrasound on maternal mortality, fetal mortality, neonatal mortality, and maternal near-miss in 5 low-income countries. We designed a 2-week course in basic OB ultrasound, followed by 12 weeks of oversight, to train health care professionals with no prior ultrasound experience to perform basic OB ultrasound to screen for high-risk pregnancies. All patients with high-risk pregnancies identified by the trainees were referred to higher-level health facilities where fully trained sonographers confirmed the diagnoses before any actions were taken. Although there have been several published studies on basic OB ultrasound training courses for health care workers in low- and middle-income countries, quality control reporting has been limited. The purpose of this study is to report on quality control results of these trainees. Health care workers trained in similar courses could have an adjunctive role in ultrasound screening for high-risk OB conditions where access to care is limited. After completion of the ultrasound course, 41 trainees in 5 countries performed 3801 ultrasound examinations during a 12-week pilot period. Each examination was reviewed by ultrasound trainers for errors in scanning parameters and errors in diagnosis, using predetermined criteria. Of the 32,480 images comprising the 3801 examinations, 94.8% were rated as satisfactory by the reviewers. There was 99.4% concordance between trainee and reviewer ultrasound diagnosis. The results suggest that trained health care workers could play a role in ultrasound screening for high-risk OB conditions.

Web-Based Quality Assurance Process Drives Improvements in Obstetric Ultrasound in 5 Low- and Middle-Income Countries.

High quality is important in medical imaging, yet in many geographic areas, highly skilled sonographers are in short supply. Advances in Internet capacity along with the development of reliable portable ultrasounds have created an opportunity to provide centralized remote quality assurance (QA) for ultrasound exams performed at rural sites worldwide. We sought to harness these advances by developing a web-based tool to facilitate QA activities for newly trained sonographers who were taking part in a cluster randomized trial investigating the role of limited obstetric ultrasound to improve pregnancy outcomes in 5 low- and middle-income countries. We were challenged by connectivity issues, by country-specific needs for website usability, and by the overall need for a high-throughput system. After systematically addressing these needs, the resulting QA website helped drive ultrasound quality improvement across all 5 countries. It now offers the potential for adoption by future ultrasound- or imaging-based global health initiatives.

Sedentary Behavior in the Workplace: A Potential Occupational Hazard for Radiologists.

In this study, we sought to quantify the sedentary worklife of the radiologist, a potential health risk. Radiologists of all training levels at our academic institution were surveyed to estimate the levels of at-work and out-of-work sitting. Fitbit One activity monitors were used to measure the at-work activity levels of radiology, pediatric, and internal medicine (IM) residents. Correlation between awareness and utilization of dynamic (sitting or standing, walking, or biking) picture archiving and communication system (PACS) workstations among radiology residents was assessed. Among surveyed radiologists (n = 89), 78% estimated sitting for at least 6 hours per workday. Estimated workplace sitting accounted for most of the total sitting for 81% of respondents. As measured by activity monitors, radiology residents (n = 27) took fewer steps per day (2683 vs 4602 vs 4967) and per hour (294 vs 419 vs 444) and experienced more sedentary time per hour (40.3 vs 36.2 vs 34.9min/h) than IM (n = 15) and pediatric (n = 9) residents. Activity experienced during reading room-based work and interventional work was compared by studying 4 additional radiology residents during both types of rotations. Reading-room activity was low, whereas activity on interventional rotations surpassed average levels for the pediatric and IM residents in our study. Radiology residents' (n = 28) awareness and utilization of dynamic PACS workstations varied among reading rooms, but were generally low-75% reported never or rarely using them. Resident utilization correlated with awareness of dynamic workstations available at our institution (R(2) = 0.64; P = 0.013). In conclusion, radiology residents in our study led more sedentary worklives compared with residents from other specialties and took minimal advantage of available tools to mitigate this. Potential health risks of inactivity justify individual and departmental efforts to limit workplace inactivity among radiologists.

Histiocytic disorders of the chest: imaging findings.

Histiocytic disorders of the chest comprise a broad spectrum of diseases. The lungs may be involved in isolation or as part of systemic disease. Some of these disorders are primary and have unknown etiology, and others result from a histiocytic response to a known cause. Among primary histiocytic disorders, pulmonary Langerhans cell histiocytosis (PLCH) is the most common; others include Erdheim-Chester disease and Rosai-Dorfman disease. Adult PLCH occurs almost exclusively in adults aged 20-40 years who smoke. Pediatric PLCH is extremely rare and typically occurs as part of multisystemic disease. Erdheim-Chester disease affects middle-aged and older adults; thoracic involvement usually occurs as part of systemic disease. Rosai-Dorfman disease affects children and young adults and manifests as painless cervical lymphadenopathy. Examples of secondary histiocytic disorders are storage diseases such as Gaucher disease, Niemann-Pick disease, and Fabry disease; pneumoconiosis such as silicosis and coal workers' pneumoconiosis; and infections such as Whipple disease and malakoplakia. These disorders are characterized at histopathologic examination on the basis of infiltration of alveoli or the pulmonary interstitium by histiocytes, which are a group of cells that includes macrophages and dendritic cells. Dendritic cells are a heterogeneous group of nonphagocytic antigen-presenting immune cells. Immunohistochemical markers help to distinguish among various primary histiocytic disorders. Characteristic radiologic findings in the appropriate clinical context may obviate biopsy to establish a correct diagnosis. However, in the absence of these findings, integration of clinical, pathologic, and radiologic features is required to establish a diagnosis.

Spine Computed Tomography Radiation Dose Reduction: Protocol Refinement Based on Measurement Variation at Simulated Lower Radiation Acquisitions.

STUDY DESIGN: Retrospective dose-simulation comparison. OBJECTIVE: To determine if sufficient detail for preoperative analysis of bony anatomy can be acquired at substantially lower doses than those typically used. SUMMARY OF BACKGROUND DATA: Computed tomography (CT) is a preoperative planning tool for spinal surgery. The pediatric population is at risk to express the harmful effects of ionizing radiation. Preoperative CT scans are presently performed at standard pediatric radiation doses not tailored for surgical planning. METHODS: We used the validated GE Noise Injection software to retrospectively modify existing spine and chest CT scans from 10 patients to create CT images that simulated a standard dose (100%), 50% dose, and 25% dose scans. 4 orthopedic surgeons and a pediatric radiologist, blinded to dose, measured minimum medial-lateral pedicle width and maximum anterior-posterior bony length along the axis of presumed pedicle screw placement. A total of 90 axial images were generated to create our sample set. Measurements were evaluated for accuracy, precision, and consistency. RESULTS: For any given rater, there was no clinically relevant difference between measurements at the different dose levels and no apparent degradation in precision at the different dose levels. Consistent variation was observed between raters, the likely result of individual differences in measurement approach. CONCLUSION: Spinal CT scans done for preoperative planning can be performed at 25% of current radiation doses without a loss in surgical planning measurement accuracy or precision. These 25% dose-reduced scans would have average Computed Tomography Dose Index volume dose levels of roughly 1.0 to 2.5 mGy (depending on patient size) and size-specific dose estimates of roughly 2.5 mGy representing a substantial dose savings compared to current practice for many sites. Standardization of consistent landmarks may be useful to further improve inter-rater concordance.

Screening obstetric ultrasound training for a 5-country cluster randomized controlled trial.

With decreased equipment cost, provision of ultrasound is now feasible in some low resource settings. Screening obstetric ultrasound may identify potential pregnancy complications and, with this knowledge, allow women to plan to deliver at the appropriate level of care. In this article, we describe a 10-day course with quality assurance activities to train ultrasound-naïve, nonphysician healthcare professionals at midlevel health facilities to perform screening obstetric ultrasound. Those trained will participate in a cluster randomized controlled trial to assess the impact of screening obstetric ultrasound on maternal and newborn outcomes.

Association of lung function, chest radiographs and clinical features in infants with cystic fibrosis.

The optimal strategy for monitoring cystic fibrosis lung disease in infancy remains unclear. Our objective was to describe longitudinal associations between infant pulmonary function tests, chest radiograph scores and other characteristics. Cystic fibrosis patients aged ≤24 months were enrolled in a 10-centre study evaluating infant pulmonary function tests four times over a year. Chest radiographs ∼1 year apart were scored using the Wisconsin and Brasfield systems. Associations of infant pulmonary function tests with clinical characteristics were evaluated with mixed effects models. The 100 participants contributed 246 acceptable flow/volume (forced expiratory volume in 0.5 s (FEV0.5) and forced expiratory flow at 75% of the forced vital capacity (FEF75%)), 303 functional residual capacity measurements and 171 chest radiographs. Both Brasfield and Wisconsin chest radiograph scores worsened significantly over the 1-year interval. Worse Wisconsin chest radiograph scores and Staphylococcus aureus were both associated with hyperinflation (significantly increased functional residual capacity), but not with diminished FEV0.5 or FEF75%. Parent-reported cough was associated with significantly diminished forced expiratory flow at 75% but not with hyperinflation. In this infant cohort in whom we previously reported worsening in average lung function, chest radiograph scores also worsened over a year. The significant associations detected between both Wisconsin chest radiograph score and S. aureus and hyperinflation, as well as between cough and diminished flows, reinforce the ability of infant pulmonary function tests and chest radiographs to detect early cystic fibrosis lung disease.

Pediatric CT: strategies to lower radiation dose.

OBJECTIVE: The introduction of MDCT has increased the utilization of CT in pediatric radiology along with concerns for radiation sequelae. This article reviews general principles of lowering radiation dose, the basic physics that impact radiation dose, and specific CT integrated dose-reduction tools focused on the pediatric population. CONCLUSION: The goal of this article is to provide a comprehensive review of the recent literature regarding CT dose reduction methods, their limitations, and an outlook on future developments with a focus on the pediatric population. The discussion will initially focus on general considerations that lead to radiation dose reduction, followed by specific technical features that influence the radiation dose.

Pediatric chest CT radiation dose reduction: protocol refinement based on noise injection for pulmonary nodule detection accuracy.

To establish appropriate chest computed tomography (CT) acquisition protocols that balance radiation dose and diagnostic capability in pediatric bone marrow transplant patients by assessing the accuracy of pulmonary nodule detection at simulated lower-radiation acquisitions, chest CT images from bone marrow transplant patients were reviewed by four pediatric radiologists at artificially reduced CT dose levels (0%, 30%, and 60%). Average accuracy for nodule detection in 31 randomly selected cases was 0.87 at 0% dose reduction, 0.90 at 30% reduction, and 0.86 at 60% reduction. We observed no clinically relevant difference in acceptability of images or accuracy levels with tested dose reductions to 60%.

Spontaneous Clostridium perfringens myonecrosis: Case report, radiologic findings, and literature review.

The utility of computed tomography (CT) has not been studied in the initial evaluation of a patient with suspected spontaneous Clostridial myonecrosis. Here, we present a patient with acute lymphoblastic leukemia (ALL) and neutropenia who developed spontaneous Clostridium perfringens myonecrosis after induction chemotherapy. Although suspected, the patient's symptoms and physical exam findings were not specific for Clostridial myonecrosis. CT confirmed the diagnosis and helped direct surgical intervention.