Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement.

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Viability of contrast-enhanced voiding urosonography as an alternative to fluoroscopy during video urodynamics.

Pediatric urodynamic studies are performed to evaluate bladder function, commonly in conjunction with a voiding cystourethrogram (VCUG). Contrast-enhanced voiding urosonography (CeVUS) has been approved in the evaluation of vesicoureteral reflux and has been shown to have equal or superior diagnostic value to VCUG. In this technical innovation, we have shown that ultrasound contrast agent microbubbles are compatible with the equipment used for urodynamic evaluation. We have also shown that it is feasible to use contrast ultrasound in pediatric urodynamic examinations. The purpose of our study was to assess the technical feasibility of CeVUS during urodynamics with an in vitro test followed by a vivo evaluation. This single-center prospective study enrolled 25 patients aged 0-18 years who underwent CeVUS instead of VCUG at their regularly scheduled appointment. During the in vitro saline experiment, the radiologic and urologic equipment were found to be compatible. Microbubbles were observed at flow rates of 10 and 20 ml/min.

Contrast-enhanced ultrasound of transplant organs - liver and kidney - in children.

Ultrasound (US) is the first-line imaging tool for evaluating liver and kidney transplants during and after the surgical procedures. In most patients after organ transplantation, gray-scale US coupled with color/power and spectral Doppler techniques is used to evaluate the transplant organs, assess the patency of vascular structures, and identify potential complications. In technically difficult or inconclusive cases, however, contrast-enhanced ultrasound (CEUS) can provide prompt and accurate diagnostic information that is essential for management decisions. CEUS is indicated to evaluate for vascular complications including vascular stenosis or thrombosis, active bleeding, pseudoaneurysms and arteriovenous fistulas. Parenchymal indications for CEUS include evaluation for perfusion defects and focal inflammatory and non-inflammatory lesions. When transplant rejection is suspected, CEUS can assist with prompt intervention by excluding potential underlying causes for organ dysfunction. Intracavitary CEUS applications can evaluate the biliary tract of a liver transplant (e.g., for biliary strictures, bile leak or intraductal stones) or the urinary tract of a renal transplant (e.g., for urinary obstruction, urine leak or vesicoureteral reflux) as well as the position and patency of hepatic, biliary and renal drains and catheters. The aim of this review is to present current experience regarding the use of CEUS to evaluate liver and renal transplants, focusing on the examination technique and interpretation of the main imaging findings, predominantly those related to vascular complications.

Diagnostic yield of computed tomographic pulmonary angiography for suspected pulmonary embolism varies across settings within a community-based health system.

PURPOSE: The diagnostic yield of computed tomographic pulmonary angiography (CTPA) for pulmonary embolism varies in the literature, and very little data is available regarding community-based systems. This study evaluates the yield of CTPA for pulmonary embolism across a variety of patient care settings in a community-based healthcare system, providing relevant benchmarks for potential quality improvement efforts. METHODS: This retrospective study included data collected from three sites within a single community-based healthcare system, including a tertiary care level 1 trauma center, an urban community hospital, and a suburban free-standing emergency department. CTPAs were identified by Current Procedural Terminology codes, and diagnoses of pulmonary embolism were identified via International Classification of Diseases codes. A total of 7850 CTPA studies met criteria for inclusion between January 1, 2012, and October 8, 2014. RESULTS: Pulmonary embolism was found in 884 (11.3%) of the studies performed. Outpatients had a lower yield of pulmonary embolism (3.8%, p < 0.001) compared with inpatients (14.1%) and emergency department patients (10.7%, p < 0.001). Patients with diagnoses of deep vein thrombosis or neoplasm had increased incidence of pulmonary embolism when compared with patients without these diagnoses (p < 0.001 for both). CONCLUSION: The overall yield of CTPA for pulmonary embolism in this community-based system was similar to that at academic centers. The yield was significantly lower in the outpatient setting compared with studies originating in the emergency department or inpatient setting.

Restrictive Dermopathy: A Rare Disease with Unusual Radiographic Findings.

The patient is a unique case presenting with presumed Restrictive Dermopathy (RD) and intracranial and adrenal calcifications, an association not previously described in the literature. This case postulates the possibility of additional radiographic features that can be included in the spectrum of RD or as secondary events from the underlying pathophysiology of RD.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement.

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement.

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report.

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report.

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Relationship Between Placental Weight and Placental Pathology With MRI Findings in Mild to Moderate Hypoxic Ischemic Encephalopathy.

Introduction The placenta plays a critical role in fetal growth and development. Examination of the placenta may provide information on the timing and extent of adverse prenatal and perinatal events. Multiple studies demonstrate an association between placental changes and hypoxic-ischemic encephalopathy (HIE), but there are limited data on the association between placental pathology and MRI changes in HIE. This study assesses the relationship between placental pathology and MRI abnormalities in infants with HIE after receiving therapeutic hypothermia. Methods A retrospective study of 138 full-term infants who underwent therapeutic hypothermia for HIE at a single delivery center. Using logistic regression models, placental pathology and MRI results were analyzed to determine if placental abnormalities are associated with more significant MRI abnormalities. Placentas matched by gestational age and birthweight from a sample of convenience were included for comparison. Results Of the 138 infants who underwent therapeutic hypothermia for HIE, 84 had placental pathology and MRIs available. Of these, 30 had normal, and 54 had abnormal MRIs. Placental changes are not observed more frequently in the HIE cohort with abnormal MRI. Increased placenta weight: birthweight ratio is independently associated with increased odds of moderate-severe HIE compared to a convenient sample. Conclusion In a study sample of babies with HIE, placental pathology was not associated with subsequent abnormal MRI findings. Compared to matched controls, babies with HIE had an elevation in placental weight/birthweight.

Imaging of the Infant with Vomiting.

Infants with vomiting is a common problem for which families seek pediatric advice or treatment. Determining which children need testing versus reassurance depends on the onset, quality, frequency, and associated symptoms. Vomiting may result from a congenital atresia, an error in embryonic rotation, or may be secondarily acquired. [Pediatr Ann. 2020;49(9):e374-e379.].

Strictures, stones and cysts: an unusual cause of pancreatitis in a 20-month-old female child.

Choledochal cysts are dilations of the biliary tree that cause a variety of clinical symptoms and can lead to several types of complications. Choledochal cysts are most commonly diagnosed in childhood and frequently present with abdominal pain, jaundice and, in infants, an abdominal mass. Although the most concerning complication is malignant transformation of the cyst epithelium, other complications such as stone formation, acute pancreatitis and stricture can also occur and lead to patient morbidity. Treatment is aimed at not only relieving patient symptoms, but also decreasing a long-term cancer risk. We present a case of a child presenting with abdominal pain and vomiting secondary to a type IVa choledochal cyst complicated by acute pancreatitis, a common bile duct stricture and cystolithiasis.

Tick paralysis: atypical presentation, unusual location.

We present 2 unrelated cases of tick paralysis presenting within a 2-month period in the greater Philadelphia region, a geographic area in which this disease is highly unusual. Our first patient demonstrated early onset of prominent bulbar palsies, an atypical presentation. Our second patient, residing in a nearby but distinct community, presented with ascending paralysis 2 months after the first. The atypical presentation of our first patient and the further occurrence within a few months of a second patient, both from the Northeastern United States where this diagnosis is rarely made, suggest the need to maintain a high index of suspicion for this disease in patients presenting with acute onset of cranial nerve dysfunction or muscle weakness. Through simple diagnostic and therapeutic measures (ie, careful physical examination to locate and remove the offending tick), misdiagnosis and unnecessary morbidity can be avoided.