Pediatric CT radiation exposure: where we were, and where we are now.

Since the turn of the last millennium, the pediatric radiology community has blazed a patient-quality and safety trail in helping to effectively address the public and the news media's concerns about the implications of ionizing radiation from CT scanners in children. As such, this article (1) reviews the potential deleterious effects of ionizing radiation, (2) discusses why limiting radiation exposure in children is so important, (3) tells the history of pediatric CT radiation exposure concerns, (4) explains the interventions that took place to address these concerns and (5) touches on the current school of thought on pediatric CT dose reduction.

Survey of peer review programs among pediatric radiologists: report from the SPR Quality and Safety Committee.

During the last 15 years, peer review has been widely incorporated into radiology quality improvement programs. However, current implementations are variable and carry concerns, including subjectivity of numerical scores and a sense of merely satisfying regulatory requirements. The Society for Pediatric Radiology (SPR) Quality and Safety Committee sought to evaluate the state of peer review programs in pediatric radiology practices, including implementation methods, perceived functions, strengths and weaknesses, and opportunities for improvement. We distributed an online 16-question survey to SPR members. Questions pertained to the type of peer review system, the use of numerical scores and comments, how feedback on discordances is given and received, and the use of peer learning conferences. We collected 219 responses (15% of survey invitations), 80% of which were from children's hospitals. Fifty percent of respondents said they use a picture archiving and communication system (PACS)-integrated peer review system. Comment-enhanced feedback for interpretive discordances was either very important or somewhat important to performance improvement in 86% of responses, compared to 48% with a similar perception of numerical scores. Sixty-eight percent of respondents said they either rarely or never check their numerical scores, and 82% either strongly or somewhat agreed that comments are more effective feedback than numerical scores. Ninety-three percent either strongly or somewhat agreed that peer learning conferences would be beneficial to their practice. Forty-eight percent thought that their current peer review system should be modified. Survey results demonstrate that peer review systems in pediatric radiology practices are implemented variably, and nearly half of respondents believe their systems should be modified. Most respondents prefer feedback in the form of comments and peer learning conferences, which are thought to be more beneficial for performance improvement than numerical scores.

Survey of gadolinium-based contrast agent utilization among the members of the Society for Pediatric Radiology: a Quality and Safety Committee report.

BACKGROUND: Gadolinium-based contrast agents (GBCAs) have been used for magnetic resonance (MR) imaging over the last three decades. Recent reports demonstrated gadolinium retention in patients' brains following intravenous administration. Since gadolinium is a highly toxic heavy metal, there is a potential for adverse effects from prolonged retention or deposition, particularly in children. For this reason, the Society (SPR) for Pediatric Radiology Quality and Safety committee conducted a survey to evaluate the current status of GBCAs usage among pediatric radiologists. OBJECTIVE: To assess the usage of GBCAs among SPR members. MATERIALS AND METHODS: An online 15-question survey was distributed to SPR members. Survey questions pertained to the type of GBCAs used, protocoling workflow, requirement of renal function or pregnancy tests, and various clinical indications for contrast-enhanced MRI examinations. RESULTS: A total of 163 survey responses were compiled (11.1% of survey invitations), the majority of these from academic institutions in the United States. Ninety-four percent reported that MR studies are always or usually protocoled by pediatric radiologists. The most common GBCA utilized by survey respondents were Eovist (60.7%), Ablavar (45.4%), Gadovist (38.7%), Magnevist (34.4%) and Dotarem (32.5%). For several clinical indications, survey responses regarding GBCA administration were concordant with American College of Radiology (ACR) Appropriateness Criteria, including seizures, headache and osteomyelitis. For other indications, including growth hormone deficiency and suspected vascular ring, survey responses revealed potential overutilization of GBCAs when compared to ACR recommendations. CONCLUSION: Survey results demonstrate that GBCAs are administered judiciously in children, yet there is an opportunity to improve their utilization with the goal of reducing potential future adverse effects.

Postnatal sonographic spectrum of prenatally detected abdominal and pelvic cysts.

OBJECTIVE: The purpose of this article is to illustrate the sonographic findings of a spectrum of neonatal abdominal and pelvic cystic lesions. CONCLUSION: Neonatal abdominal and pelvic cystic lesions can arise from many organs, and they have a broad differential diagnosis. Distinctive sonographic findings may be present and can help establish the correct cause and guide proper management.

Early assessment of the efficacy of digital infrared thermal imaging in pediatric extremity trauma.

Young children or those with intellectual disability with trauma to an extremity often undergo radiographs of the whole limb. The objective of the study was to assess the efficacy of digital infrared thermal images (DITI) in pediatric extremity trauma. We hypothesized fractures to be associated with local hyperthermia, detectable with DITI, which could direct focused radiographs. In this exploratory study, patients seen over a 2-month period in a pediatric emergency department for limb trauma were included if an extremity radiograph was taken on the same day. Patients had DITI of symptomatic and contralateral limbs. The warmest area of each image was compared to the site of pain and/or fracture on the radiograph. Fifty-one patients were enrolled. DITI matched 73% of pain sites. Fractures were seen in 11 patients. DITI matched 7 of 11 (64%) fracture sites. DITI performance in pinpointing the site of injury, although suboptimal, is encouraging for further evaluation.

Cumulative diagnostic imaging radiation exposure in premature neonates.

BACKGROUND: To date, there has been limited work evaluating the total cumulative effective radiation dose received by infants in the neonatal intensive care unit. Most previous publications report that the total radiation dose received falls within the safe limits but does not include all types of ionizing radiation studies typically performed on this vulnerable patient population. We aimed to provide an estimate of the cumulative effective ionizing radiation dose (cED) in microSieverts (µSv) received by premature infants ≤32 weeks from diagnostic studies performed throughout their NICU stay, and predictors of exposures. METHODS: Retrospective chart review from 2004-2011. Data included demographics, gestational age (GA), birth weight (BW), length of stay (LOS), clinical diagnosis, and radiological studies. RESULTS: 1045 charts were reviewed. Median GA = 30.0 weeks (SD 2.7, range 22.0-32.6). Median BW = 1340.0 grams (SD 445.4, range 420-2470). Median number of radiographic studies = 9 (SD 28.5, range 0-210). Median cED = 162µSv (range 0-9248). The cED was positively associated with LOS (p < 0.001) and inversely correlated with GA (p < 0.001) and BW (p < 0.001). Infants with intestinal perforation had the highest median cED 1661µSv compared to 162µSv for others (p < 0.001). CONCLUSION: Our results provide an estimate of the cumulative effective radiation dose received by premature infants in a level 4 neonatal intensive care unit from all radiological studies involving ionizing radiation and identifies risk factors and predictors of such exposure. Radiation exposure in NICU is highest among the most premature and among infants who suffer from intestinal perforation.

Understanding the cancer-CT conundrum.

It is imperative that responsible clinicians understand the relationship between computed tomography imaging and radiation-induced malignancy risk. As the concept of computed tomography-induced malignancy risk becomes more widespread, it is important that clinicians are well informed and are able to intelligently answer questions and concerns posed by their patients and are able to understand and discuss the issues with their radiologist colleagues. The purpose of this article is to review the history of ionizing radiation exposure growth in diagnostic imaging, to understand the biologic effects of radiation exposure, to define the growth of ionizing radiation from computed tomography in the United States, and to explore available mechanisms that can be used to control excessive patient radiation exposure.

Screening for Pediatric Blunt Cerebrovascular Injury: Review of Literature and a Cost-Effectiveness Analysis.

BACKGROUND: Timely and accurate screening for pediatric blunt cerebrovascular injury (BCVI) is important in order to administer appropriate anticoagulation therapy thus preventing stroke. The recommended criteria for screening in children are not clear. We performed a systematic review of the literature for screening and management of BCVI in children and designed a cost-effectiveness analysis in order to determine the optimal strategy for managing pediatric BCVI from a societal perspective. METHODS: Comprehensive review of studies citing BCVI in pediatric patients was carried out with data extraction and compilation. An economic evaluation of 5 possible screening strategies was performed by designing a decision tree over a 1-year horizon using parameters derived from literature review. Base case calculations were made to compare cost effectiveness for each strategy. Monte Carlo simulation and extensive sensitivity analyses were performed to examine the robustness of the conclusion against key variables. RESULTS: Selective anticoagulation therapy in patients with high-risk factors was found to be the most cost-effective strategy and selective computed tomography angiography (CTA) in high-risk patients was the optimal imaging strategy. This conclusion was corroborated by a Monte Carlo simulation of 10,000 iterations. In all sensitivity analyses, selective anticoagulation and selective CTA continue to be the optimal strategy until the risk of anticoagulation complications rises above 3.9%. CONCLUSIONS: Our study demonstrated selective CTA to be the optimal imaging strategy in order to assess BCVI in children. Further studies are needed for more clearly defined screening criteria.

A survey of emergency physician-performed ultrasound: implications for academic radiology departments.

A survey of academic radiology departments shows that the prevalence of emergency room physician-performed ultrasound examinations is high and that providing a 24/7 attending radiology service leads to no significant reduction in physician activity.

Ayurvedic herbal medicine and lead poisoning.

Although the majority of published cases of lead poisoning come from occupational exposures, some traditional remedies may also contain toxic amounts of lead. Ayurveda is a system of traditional medicine that is native to India and is used in many parts of world as an alternative to standard treatment regimens. Here, we report the case of a 58-year-old woman who presented with abdominal pain, anemia, liver function abnormalities, and an elevated blood lead level. The patient was found to have been taking the Ayurvedic medicine Jambrulin prior to presentation. Chemical analysis of the medication showed high levels of lead. Following treatment with an oral chelating agent, the patient's symptoms resolved and laboratory abnormalities normalized. This case highlights the need for increased awareness that some Ayurvedic medicines may contain potentially harmful levels of heavy metals and people who use them are at risk of developing associated toxicities.

An "a la carte" academic radiology compensation plan: something for everyone.

The mechanism used to compensate faculty members within academic radiology practice poses a complex challenge to radiology administrative leaders. In this article, the authors discuss a novel compensation plan model that addresses many of the demands faced by modern academic radiology practices.

The value of anal endosonography compared with magnetic resonance imaging following the repair of anorectal malformations.

BACKGROUND: Surgery for anorectal malformations (ARMs) attempts to position the neo-anus anatomically within the anal sphincter complex. Currently, MRI is the imaging modality of choice in determining the position of the neo-anus after reconstructive surgery. OBJECTIVE: The aim of this study was to compare the accuracy of anal endosonography (AES) with conventional MRI in demonstrating the anatomy of the neo-anus following repair of ARMs. MATERIALS AND METHODS: Fourteen children (ten girls, four boys), born with ARMs (four low, ten high) underwent both AES and pelvic MRI following anorectoplasty. The results of both investigations were compared with muscle stimulation and were reported blindly by a clinician and a radiologist. RESULTS: AES findings were comparable with MRI in 9 of the 14 cases. In four cases, MRI and AES findings differed, with nerve stimulation supporting AES but not MRI. CONCLUSIONS: AES is an accurate alternative to MRI in the assessment of anorectoplasty. It provides more detailed information and can be performed under anaesthesia in combination with a surgical procedure.