Imaging of Sports-related Injuries of the Lower Extremity in Pediatric Patients.

With increasing participation and intensity of training in youth sports in the United States, the incidence of sports-related injuries is increasing, and the types of injuries are shifting. In this article, the authors review sports injuries of the lower extremity, including both acute and overuse injuries, that are common in or specific to the pediatric population. Common traumatic injuries that occur in individuals of all ages (eg, tears of the acetabular labrum and anterior cruciate ligament) are not addressed, although these occur routinely in pediatric sports. However, some injuries that occur almost exclusively in high-level athletes (eg, athletic pubalgia) are reviewed to increase awareness and understanding of these entities among pediatric radiologists who may not be familiar with them and thus may not look for them. Injuries are described according to their location (ie, hip, knee, or foot and ankle) and pathologic process (eg, apophysitis, osteochondritis dissecans). Examples of abnormalities and normal variants of the anatomy that are often misdiagnosed are provided. The injuries reviewed represent a common and growing subset of pathologic processes about which all pediatric and musculoskeletal radiologists should be knowledgeable. Understanding physeal injury is especially important because missed diagnoses can lead to premature physeal closure and osteoarthritis. ©RSNA, 2016.

Image quality and dose differences caused by vendor-specific image processing of neonatal radiographs.

BACKGROUND: Image processing plays an important role in optimizing image quality and radiation dose in projection radiography. Unfortunately commercial algorithms are black boxes that are often left at or near vendor default settings rather than being optimized. OBJECTIVE: We hypothesize that different commercial image-processing systems, when left at or near default settings, create significant differences in image quality. We further hypothesize that image-quality differences can be exploited to produce images of equivalent quality but lower radiation dose. MATERIALS AND METHODS: We used a portable radiography system to acquire images on a neonatal chest phantom and recorded the entrance surface air kerma (ESAK). We applied two image-processing systems (Optima XR220amx, by GE Healthcare, Waukesha, WI; and MUSICA(2) by Agfa HealthCare, Mortsel, Belgium) to the images. Seven observers (attending pediatric radiologists and radiology residents) independently assessed image quality using two methods: rating and matching. Image-quality ratings were independently assessed by each observer on a 10-point scale. Matching consisted of each observer matching GE-processed images and Agfa-processed images with equivalent image quality. A total of 210 rating tasks and 42 matching tasks were performed and effective dose was estimated. RESULTS: Median Agfa-processed image-quality ratings were higher than GE-processed ratings. Non-diagnostic ratings were seen over a wider range of doses for GE-processed images than for Agfa-processed images. During matching tasks, observers matched image quality between GE-processed images and Agfa-processed images acquired at a lower effective dose (11 ± 9 µSv; P < 0.0001). CONCLUSION: Image-processing methods significantly impact perceived image quality. These image-quality differences can be exploited to alter protocols and produce images of equivalent image quality but lower doses. Those purchasing projection radiography systems or third-party image-processing software should be aware that image processing can significantly impact image quality when settings are left near default values.

Cinegraphic versus Combined Static and Cinegraphic Imaging for Initial Cranial Ultrasound Screening in Premature Infants.

BACKGROUND: Cranial ultrasound is an essential screening and diagnostic tool in the care of neonates and is especially useful in the premature population for evaluation of potential germinal matrix/intraventricular hemorrhage (GM/IVH). There are typically two screening examinations, with the initial cranial sonography performed between 3 days and 14 days after birth, usually consisting of a series of static images plus several cinegraphic sweeps. OBJECTIVE: Our primary goal was to assess whether cinegraphic sweeps alone are as accurate for diagnosing neurological abnormalities as combined static and cinegraphic imaging in the initial cranial US evaluation of premature infants. Our secondary goal was to establish the difference in time required to perform these two examinations. MATERIALS AND METHODS: We retrospectively obtained 140 consecutive initial cranial US screening studies of premature infants. Three pediatric radiologists blinded to patient data read cinegraphic images alone and also combined (dual) imaging sets for a subset of subjects, recording findings for seven disease processes: germinal matrix/intraventricular hemorrhage (GM/IVH), right or left side; periventricular leukomalacia (PVL); choroid plexus cyst; subependymal cyst; cerebral and cerebellar infarction or hemorrhage; posterior fossa hemorrhage or infarction, and extra-axial hemorrhage. Separately, we compared retrospective dual imaging acquisition time against prospectively collected cinegraphic imaging time for premature infants undergoing initial cranial US evaluation. RESULTS: Equivalence testing demonstrated no difference in equivalency between initial cranial US screening using cinegraphic evaluation alone and dual imaging for GM/IVH, cerebral and cerebellar infarct or hemorrhage, and subependymal cyst (all P < 0.05). For PVL and choroid plexus cyst, cinegraphic imaging and dual imaging did not demonstrate equivalence (P > 0.05). Cinegraphic images were obtained in less than one-third of the time required for dual imaging. CONCLUSION: For the diagnoses that are critical to establish at initial screening (GM/IVH, cerebral and cerebellar infarct or hemorrhage) initial cranial US screening using cinegraphic sweeps was equivalent to dual imaging. Cinegraphic imaging required significantly less time to perform than dual imaging. We suggest that performance of cranial US screening using cinegraphic imaging alone is a potentially advantageous option in the initial evaluation of the premature neonate.

Subglottic dilatation in extremely preterm infants on prolonged mechanical ventilation.

BACKGROUND: Airway injuries are reported among preterm infants with bronchopulmonary dysplasia. We hypothesized that prolonged ventilation in preterm infants is associated with subglottic dilatation that can be reliably evaluated by point of care ultrasonography (POCUS). METHODS: All preterm infants (<29-weeks) admitted to the neonatal ICU at the Advent-Health from January-2020 to June-2022 were eligible if they required invasive ventilation for ≤7 days in the first 28 days of life (control) or remained intubated for ≥28 days (prolonged ventilation). Sonography was performed by one technician and all images were reviewed by the pediatric radiologist. The trachea size was measured 3 times by randomly selecting three images. The first 20 scans were also independently reported by a different pediatric radiologist. Intra and inter-observer variability was estimated. Mean trachea size and weight at the time of imaging were compared. RESULTS: Out of 417 eligible infants; 11 died before 28 days and 163 required ventilation for 8-27 days. Consent missed for 80 infants during COVID-19 pandemic. We enrolled 23 and 28 infants in the control & prolonged ventilation groups, respectively. Inter and intra-observer correlations were 0.83 and 0.97 respectively. Infants in the control group had higher gestation and birth weight. Infants on prolonged ventilation were at higher risk for infections, BPD, longer hospital stay and significant subglottic dilation (4.51 ± 0.04 vs 4.17 ± 0.02 mm, p < 0.01) despite smaller body weight at the time of imaging (884 ± 102 vs 1059 ± 123g, p < 0.01). CONCLUSION: Extremely preterm infants on prolonged ventilation are at risk for sub-glottic dilatation that can be reliably measured by POCUS.

A National Survey of Neonatologists: Barriers and Prerequisites to Introduce Point-of-Care Ultrasound in Neonatal ICUs.

Point-of-care (POC) ultrasound refers to the use of portable imaging. Although POC ultrasound is widely available to the neonatologists in Australia and Europe, neonatologists in the United States report limited availability. Our objective was to seek the US neonatologists' perception of barriers and prerequisites in adopting POC ultrasound in neonatal intensive care units. An online survey link was sent via e-mail to 3000 neonatologists included in the database maintained by the American Academy of Pediatrics. Survey results (n = 574) were reported as percentage of total responses. Personal experience requiring an urgent sonography in managing cardiac tamponade or pleural effusion was reported by 78% respondents. However, emergent ultrasound (≤10 min) was not available in 80% of the neonatal intensive care units. We compared the responses based on years of clinical experience (>20 vs <20 years), with 272 (48%) neonatologist reporting more than 20 years of experience. Similarly, results from neonatal fellowship programs were compared with nonteaching/teaching hospitals, with 288 (50%) replies from neonatology fellowship programs. Compared with senior neonatologists, respondents with less than 20 years of clinical experience consider POC ultrasound enhances safety and accuracy of clinical procedures (87% vs 82%) and favor adopting POC ultrasound in clinical practice (92% vs 84%). There were no differences in opinion from neonatology fellowship programs compared with the nonteaching/teaching hospitals. Lack of training guidelines, inadequate support from local radiology department, and legal concerns were reported as the top 3 primary barriers in adopting POC ultrasound. If these barriers could be resolved, 89% respondents were inclined to adopt POC ultrasound in clinical practice.