Board-certified Pediatric Radiologists Research Articles

Routine Urology Consultation and Follow-up After Pediatric Blunt Renal Trauma is Likely Unnecessary

IntroductionThis study examines the outcomes of high-grade renal trauma in pediatric patients and evaluates the intervention rate. In our hospital, we routinely consult urology on all high-grade injuries. We anticipated minimal intervention, casting doubt on the need for routine urology consultation and follow-up. MethodsWe conducted a retrospective review at a single pediatric trauma center from January 2018 to June 2023, focusing on patients with severe (grade III-V) renal injuries. Data collected included demographics, trauma-related variables, hospital course, interventions, and follow-up. When the grade was not readily available in the electronic medical record, we had a board-certified pediatric radiologist review the imaging and provide the grade. Follow-up was included only if it was with a pediatric urologist. ResultsThere were 92 patients that met our inclusion criteria. Of these, 47 were grade III, 32 were grade IV, and 13 were grade V. Six (6.5%) patients required inpatient renal stent procedures. Follow-up occurred in 55/92 (60%) patients with a pediatric urologist. Follow-up by grade is as follows: 22/47 (47%) grade III, 22/32 (69%) grade IV, and 11/13 (85%) grade V. Overall 5.8% of patients required antihypertensive medications and this was more likely as injury grade increased. All stents were removed outpatient and there were 3 (3.3%) additional outpatient interventions, all in patients that were symptomatic. ConclusionGiven the low prevalence of interventions after discharge, routine consultation and follow-up with urology is likely unnecessary in the absence of an inpatient urologic procedure during the index hospitalization. Patients with high-grade injuries should instead follow up with a trauma clinic or general provider with urology follow-up based on symptoms. Type of StudyRetrospective Review. Level of EvidenceLevel III.

Decreased percent change in renal pelvis diameter on diuretic functional magnetic resonance urography following administration of furosemide may help characterize unilateral uretero-pelvic junction obstruction

A well-established definition of obstruction in the setting of congenital hydronephrosis is lacking. Multiple imaging modalities and radiographic characteristics or parameters have been described to help confirm the diagnosis of ureteropelvic junction obstruction (UPJO). We sought to evaluate the change in anterior-posterior renal pelvic diameter (APRPD) following furosemide administration in patients with unilateral hydronephrosis and confirmed UPJO on functional magnetic resonance urography (fMRU) who underwent pyeloplasty. There were 49 patients who met inclusion criteria (11 females, 38 males; average age 2.2 years, SD 3.4 years) from February 2006 to September 2020, diagnosed with unilateral hydronephrosis (SFU Grade 3-4) who underwent fMRU prior to pyeloplasty for confirmed UPJO. 29 of the included patients also underwent a post-pyeloplasty fMRU. A weight-adjusted dose of 1mg/kg of furosemide (max 20mg/kg) was administered intravenously. Two board-certified pediatric radiologists measured the APRPD of the obstructed and non-dilated kidneys prior to pyeloplasty and APRPD of the hydronephrotic kidneys on the post-pyeloplasty follow up fMRUs. Measurements were performed on images prior to and approximately 30min following furosemide injection. The average APRPD before furosemide injection in the obstructed kidney prior to pyeloplasty was 26.3mm (SD 9.0mm) compared to the non-dilated (not obstructed) kidney measurement of 5.1mm (SD 3.6mm) (p<0.001). Following administration of furosemide, the average APRPD was 31.4mm (SD 8.8mm) in the obstructed kidney, and 7.8mm (SD 4.1mm) in the non-dilated kidney (p<0.001). After pyeloplasty, the pre-furosemide APRPD measurement was 17.8mm (SD 11mm), which was significantly less compared to the pre-pyeloplasty APRPD (p<0.001). The post-pyeloplasty, post-furosemide APRPD measurement was 25.8mm (SD 12mm), also significantly less compared to the pre-pyeloplasty measurement (p=0.02). The changes in APRPD in the obstructed kidney prior to pyeloplasty was 5.1mm (SD 3.5mm) and after pyeloplasty was 8mm (SD 4.6mm) (p=0.002). Change in APRPD in the non-dilated kidney was 2.7mm (SD 2.3mm). Percent APRPD change in the obstructed kidney was 22.9% (SD 18.5%), which was significantly less than 33.3% (SD 22.1%) in the post-pyeloplasty kidney (p=0.028) and 82.8% (SD 87.9%) in the non-dilated kidney (p<0.001). A relatively smaller change in APRPD on fMRU following administration of furosemide in the setting of UPJO may serve as another predictive characteristic of obstructed kidneys.

High performance for bone age estimation with an artificial intelligence solution

PurposeThe purpose of this study was to compare the performance of an artificial intelligence (AI) solution to that of a senior general radiologist for bone age assessment. Material and methodsAnteroposterior hand radiographs of eight boys and eight girls from each age interval between five and 17 year-old from four different radiology departments were retrospectively collected. Two board-certified pediatric radiologists with knowledge of the sex and chronological age of the patients independently estimated the Greulich and Pyle bone age to determine the standard of reference. A senior general radiologist not specialized in pediatric radiology (further referred to as “the reader”) then determined the bone age with knowledge of the sex and chronological age. The results of the reader were then compared to those of the AI solution using mean absolute error (MAE) in age estimation. ResultsThe study dataset included a total of 206 patients (102 boys of mean chronological age of 10.9 ± 3.7 [SD] years, 104 girls of mean chronological age of 11 ± 3.7 [SD] years). For both sexes, the AI algorithm showed a significantly lower MAE than the reader (P < 0.007). In boys, the MAE was 0.488 years (95% confidence interval [CI]: 0.28–0.44; r2 = 0.978) for the AI algorithm and 0.771 years (95% CI: 0.64–0.90; r2 = 0.94) for the reader. In girls, the MAE was 0.494 years (95% CI: 0.41–0.56; r2 = 0.973) for the AI algorithm and 0.673 years (95% CI: 0.54–0.81; r2 = 0.934) for the reader. ConclusionThe AI solution better estimates the Greulich and Pyle bone age than a general radiologist does.

Assessment of germinal matrix hemorrhage on head ultrasound with deep learning algorithms

Germinal matrix hemorrhage-intraventricular hemorrhage is among the most common intracranial complications in premature infants. Early detection is important to guide clinical management for improved patient prognosis. The purpose of this study was to assess whether a convolutional neural network (CNN) can be trained via transfer learning to accurately diagnose germinal matrix hemorrhage on head ultrasound. Over a 10-year period, 400 head ultrasounds performed in patients ages 6months or younger were reviewed. Key sagittal images at the level of the caudothalamic groove were obtained from 200 patients with germinal matrix hemorrhage and 200 patients without hemorrhage; all images were reviewed by a board-certified pediatric radiologist. One hundred cases were randomly allocated from the total for validation and an additional 100 for testing of a CNN binary classifier. Transfer learning and data augmentation were used to train the model. The median age of patients was 0weeks old with a median gestational age of 30weeks. The final trained CNN model had a receiver operating characteristic area under the curve of 0.92 on the validation set and accuracy of 0.875 on the test set, with 95% confidence intervals of [0.86, 0.98] and [0.81, 0.94], respectively. A CNN trained on a small set of images with data augmentation can detect germinal matrix hemorrhage on head ultrasounds with strong accuracy.

Communicating incidental and reportable findings from research MRIs: considering factors beyond the findings in an underrepresented pediatric population

BackgroundThe application of advanced imaging in pediatric research trials introduces the challenge of how to effectively handle and communicate incidental and reportable findings. This challenge is amplified in underserved populations that experience disparities in access to healthcare as recommendations for follow-up care may be difficult to coordinate. Therefore, the purpose of the present report is to describe the process for identifying and communicating findings from a research MRI to low-income Latino children and families.MethodsLatino adolescents (n = 86) aged 12–16 years old with obesity and prediabetes underwent a research MRI (3 Tesla Philips Ingenia®) as part of a randomized controlled diabetes prevention trial. The research MRIs were performed at baseline and 6 months to assess changes in whole-abdominal fat distribution and organ fat in response to the intervention. An institutional pathway was developed for identifying and reporting findings to participants and families. The pathway was developed through a collaborative process with hospital administration, research compliance, radiology, and the research team. All research images were reviewed by a board-certified pediatric radiologist who conveyed findings to the study pediatrician for determination of clinical actionability and reportability to children and families. Pediatric sub-specialists were consulted as necessary and a primary care practitioner (PCP) from a free community health clinic agreed to receive referrals for uninsured participants.ResultsA total of 139 images (86 pre- and 53 post-intervention) were reviewed with 31 findings identified and 23 deemed clinically actionable and reportable. The only reportable finding was severely elevated liver fat (> 10%, n = 14) with the most common and concerning incidental findings being horseshoe kidney (n = 1) and lung lesion (n = 1). The remainder (n = 7) were less serious. Of youth with a reportable or incidental finding, 18 had a PCP but only 7 scheduled a follow-up appointment. Seven participants without a PCP were referred to a safety-net clinic for follow-up.ConclusionsWith the increased utilization of high-resolution imaging in pediatric research, additional standardization is needed on what, when, and how to return incidental and reportable findings to participants, particularly among historically underrepresented populations that may be underserved in the community.Trial registrationPreventing Diabetes in Latino Youth, NCT02615353

Can Radiology Technologists be Trained to Measure Leg Length Discrepancies as Accurately as Pediatric Radiologists?

Leg length discrepancy studies are labor intensive. They are procedurally simple and represent inefficient use of the radiologists' time and expertise. We hypothesized that radiology technologists could be trained to measure leg length discrepancies, and that their performance would be statistically equivalent to that of board-certified, fellowship-trained pediatric radiologists. Four radiology technologists were selected to participate in a supervised practice session. They independently measured and calculated leg length discrepancies on 10 randomly selected cases. Their performance was compared to measurements obtained by an experienced pediatric radiologist (reference standard). After 1 week, the technologists repeated their measurements on the same cases, which were resorted to simulate new cases. Intraclass correlation coefficients (ICC) determined interobserver agreement between the technologists and radiologist and intra-observer reliability among the technologists. Among the four technologists, similarity in measurements between session 1 and the reference standard was very high, with ICC values ranging from 0.93 to 0.98 (p < 0.001). The ICC between session 2 and the reference standard was also high, ranging from 0.93 to 0.98 (p < 0.001). Finally, among the four technologists, ICC values between session 1 and session 2 were ≥ 0.96 (p < 0.001). Radiology technologists can be rapidly trained to calculate leg length discrepancies as accurately as a board-certified pediatric radiologist. Delegation of this time-consuming task to technologists or radiology assistants will permit radiologists to spend time on more demanding studies, such as studies that require subspecialty training.

Evaluating a Web-based Point-of-care Ultrasound Curriculum for the Diagnosis of Intussusception.

Intussusception is a pediatric medical emergency that can be difficult to diagnose. Radiology-performed ultrasound is the diagnostic study of choice but may lead to delays due to lack of availability. Point-of-care ultrasound for intussusception (POCUS-I) studies have shown excellent accuracy and reduced lengths of stay, but there are limited POCUS-I training materials for pediatric emergency medicine (PEM) providers. We performed a prospective cohort study assessing PEM physicians undergoing a primarily Web-based POCUS-I curriculum. We developed the POCUS-I curriculum using Kern's six-step model. The curriculum included a Web-based module and a brief, hands-on practice that was developed with a board-certified pediatric radiologist. POCUS-I technical skill, knowledge, and confidence were determined by a direct observation checklist, multiple-choice test, and a self-reported Likert-scale survey, respectively. We assessed participants immediately pre- and postcourse as well as 3months later to assess for retention of skill, knowledge, and confidence. A total of 17 of 17 eligible PEM physicians at a single institution participated in the study. For the direct observation skills test, participants scored well after the course with a median (interquartile range [IQR]) score of 20 of 22 (20-21) and maintained high scores even after 3months (20 [20-21]). On the written knowledge test, there was significant improvement from 57.4% (95% CI= 49.8 to 65.2) to 75.3% (95% CI= 68.1 to 81.6; p<0.001) and this improvement was maintained at 3months at 81.2% (95% CI= 74.5 to 86.8). Physicians also demonstrated improved confidence with POCUS-I after exposure to the curriculum, with 5.9% reporting somewhat or very confident prior to the course to 76.5% both after the course and after 3months (p<0.001). After a primarily Web-based curriculum for POCUS-I, PEM physicians performed well in technical skill in POCUS-I and showed improvement in knowledge and confidence, all of which were maintained over 3 months.

E-cigarette or vaping product use-associated lung injury in the pediatric population: imaging features at presentation and short-term follow-up.

Cases of e-cigarette or vaping product use-associated lung injury (EVALI) have rapidly reached epidemic proportions, yet there remain limited reports within the literature on the associated imaging findings. We describe the most common imaging findings observed on chest computed tomography (CT) and chest radiograph (CXR) at presentation and at short-term follow-up at our major pediatric hospital. A retrospective review of the electronic medical records was performed on all patients with suspected EVALI who were treated at a major pediatric hospital and 11 patients were included for analysis. Two board-certified pediatric radiologists then categorized the CXRs as either normal or abnormal, and further performed a systematic review of the chest CTs for imaging findings in the lungs, pleura and mediastinum. Interrater discordance was reconciled by consensus review. The 11 patients (9 males:2 females) ranged in age from 14 to 18years. Gastrointestinal and constitutional symptoms were present in all patients, whereas shortness of breath and cough were reported in 5/11 and 6/11 patients, respectively. The CXR was abnormal in 10/11 patients, whereas all chest CTs were abnormal. The most common CT findings included consolidation, ground-glass opacities, interlobular septal thickening, lymphadenopathy and crazy-paving pattern. Almost all patients demonstrated subpleural sparing, and less than half also demonstrated peribronchovascular sparing. There was complete or near-complete resolution of imaging abnormalities in 5/6 patients with a median follow-up duration of 114days. Pulmonary opacities with subpleural and peribronchovascular sparing was a commonly observed pattern of EVALI in the pediatric population at this institution. A CXR may not be sufficiently sensitive in diagnosing EVALI, and radiologists and clinicians should exercise caution when excluding EVALI based on the lack of a pulmonary opacity. Caution should also be exercised when excluding EVALI solely based on the lack of respiratory symptoms. Despite extensive pulmonary involvement at presentation, findings may resolve on short-term follow-up imaging.

Interpretation of pediatric chest radiographs by non-radiologist clinicians in Botswana using World Health Organization criteria for endpoint pneumonia.

In low- and middle-income countries, chest radiographs are most frequently interpreted by non-radiologist clinicians. We examined the reliability of chest radiograph interpretations performed by non-radiologist clinicians in Botswana and conducted an educational intervention aimed at improving chest radiograph interpretation accuracy among non-radiologist clinicians. We recruited non-radiologist clinicians at a referral hospital in Gaborone, Botswana, to interpret de-identified chest radiographs for children with clinical pneumonia. We compared their interpretations with those of two board-certified pediatric radiologists in the United States. We evaluated associations between level of medical training and the accuracy of chest radiograph findings between groups, using logistic regression and kappa statistics. We then developed an in-person training intervention led by a pediatric radiologist. We asked participants to interpret 20 radiographs before and immediately after the intervention, and we compared their responses to those of the facilitating radiologist. For both objectives, our primary outcome was the identification of primary endpoint pneumonia, defined by the World Health Organization as presence of endpoint consolidation or endpoint effusion. Twenty-two clinicians interpreted chest radiographs in the primary objective; there were no significant associations between level of training and correct identification of endpoint pneumonia; concordance between respondents and radiologists was moderate (κ=0.43). After the training intervention, participants improved agreement with the facilitating radiologist for endpoint pneumonia from fair to moderate (κ=0.34 to κ=0.49). Non-radiologist clinicians in Botswana do not consistently identify key chest radiographic findings of pneumonia. A targeted training intervention might improve non-radiologist clinicians' ability to interpret chest radiographs.

Pathologic arterial changes in neurovascularly intact Gartland III supracondylar humerus fractures: a pilot study.

This pilot study was performed to describe changes in arterial flow in completely displaced neurovascularly intact Gartland III pediatric supracondylar humerus fractures using Duplex ultrasonography. This is a prospective study of 11 Gartland type III supracondylar humerus fractures with no cortical continuity but with palpable radial pulse and normal neurologic examination. Duplex ultrasonography was performed on injured and uninjured arms, both preoperatively and postpinning, and interpreted by a board-certified pediatric radiologist. Degree of artery stenosis and peak systolic velocity (PSV) of arterial flow were recorded from the duplex. Ultrasound wrist/brachial indexes (WBI) were calculated using the higher value of the radial/brachial or the ulnar/brachial index. Only three patients had normal Duplexes without stenosis and with flow comparable in the brachial, radial, and ulnar arteries of the affected arm, compared to the unaffected arm, both preoperatively and postpinning. One group of six patients had brachial artery stenosis at the fracture site when compared to the artery proximal to the fracture site, increased PSV at the fracture site compared to proximal to the fracture site, and the WBI was variable when compared to the contralateral side. A third group of two patients also had brachial artery stenosis at the fracture site but had decreased PSV and decreased WBI compared to the contralateral side. Type III supracondylar humerus patients with a normal neurovascular examination may have abnormal Duplex ultrasonography with brachial artery stenosis and elevated peak systolic velocity preoperatively although distal flow remains comparable to the contralateral side. Level of evidence: prognostic - Level II.

Development and validation of image quality scoring criteria (IQSC) for pediatric CT: a preliminary study

ObjectiveTo develop and assess the value and limitations of an image quality scoring criteria (IQSC) for pediatric CT exams.MethodsIQSC was developed for subjective assessment of image quality using the scoring scale from 0 to 4, with 0 indicating desired anatomy or features not seen, 3 for adequate image quality, and 4 depicting higher than needed image quality. Pediatric CT examinations from 30 separate patients were selected, five each for routine chest, routine abdomen, kidney stone, appendicitis, craniosynostosis, and ventriculoperitoneal (VP) shunt. Five board-certified pediatric radiologists independently performed image quality evaluation using the proposed IQSC. The kappa statistics were used to assess the interobserver variability.ResultsAll five radiologists gave a score of 3 to two-third (67%) of all CT exams, followed by a score of 4 for 29% of CT exams, and 2 for 4% exams. The median image quality scores for all exams were 3 and the interobserver agreement among five readers (acceptable image quality [scores 3 or 4] vs sub-optimal image quality ([scores 1 and 2]) was moderate to very good (kappa 0.4–1). For all five radiologists, the lesion detection was adequate for all CT exams.ConclusionsThe image quality scoring criteria covering routine and some clinical indication-based imaging scenarios for pediatric CT examinations has potential to offer a simple and practical tool for assessing image quality with a reasonable degree of interobserver agreement. A more extensive and multi-centric study is recommended to establish wider usefulness of these criteria.

Deep learning to automate Brasfield chest radiographic scoring for cystic fibrosis

BackgroundThe aim of this study was to evaluate the hypothesis that a deep convolutional neural network (DCNN) model could facilitate automated Brasfield scoring of chest radiographs (CXRs) for patients with cystic fibrosis (CF), performing similarly to a pediatric radiologist. MethodsAll frontal/lateral chest radiographs (2058 exams) performed in CF patients at a single institution from January 2008–2018 were retrospectively identified, and ground-truth Brasfield scoring performed by a board-certified pediatric radiologist. 1858 exams (90.3%) were used to train and validate the DCNN model, while 200 exams (9.7%) were reserved for a test set. Five board-certified pediatric radiologists independently scored the test set according to the Brasfield method. DCNN model vs. radiologist performance was compared using Spearman correlation (ρ) as well as mean difference (MD), mean absolute difference (MAD), and root mean squared error (RMSE) estimation. ResultsFor the total Brasfield score, ρ for the model-derived results computed pairwise with each radiologist's scores ranged from 0.79–0.83, compared to 0.85–0.90 for radiologist vs. radiologist scores. The MD between model estimates of the total Brasfield score and the average score of radiologists was −0.09. Based on MD, MAD, and RMSE, the model matched or exceeded radiologist performance for all subfeatures except air-trapping and large lesions. ConclusionsA DCNN model is promising for predicting CF Brasfield scores with accuracy similar to that of a pediatric radiologist.

Image quality and radiation dose of ECG-triggered High-Pitch Dual-Source cardiac computed tomography angiography in children for the evaluation of central vascular stents

Assess image quality and radiation dose of ECG-triggered High-Pitch Dual-Source CTA for the evaluation central vascular stents in children. We included all children ≤ 21years old with one or more central vascular stents and available prospective ECG-triggered High-Pitch Dual-Source CTA performed at our institution between January 2015 and August 2017. Demographic and scanner information was retrieved. Two board-certified pediatric radiologists blinded to the clinical data, independently reviewed and scored each case using a four-point quality score. Scores 1, 2 and 3 were considered of diagnostic image quality. Inter-observer agreement and non-parametric test were used. 18 patients (10 girls, 8 boys) with a mean age of 9.47 ± 7.38years (mean ± SD) met inclusion criteria. Thirty-two central vascular stents were evaluated. Mean quality score was 2.07 ± 0.94 with 12.5% (4/32) of the cases classified as unevaluable. Interobserver agreement was excellent (k = 0.86). There is no significant difference between quality score and stent location (p = 0.07). There is a significant difference with stent material as all non-diagnostic scores were only seen in covered stents made of platinum-iridium (p < 0.001). There was no association between image quality and age, height, weight, BSA, heart rate, radiation dose or stent lumen size (p > 0.05). ECG-triggered high-pitch spiral DS-CTA offers appropriate image quality for assessment of central vascular stents in children.

Volvulus of the entire small bowel with normal bowel fixation simulating malrotation and midgut volvulus.

Midgut volvulus is a complication of malrotation of bowel and mesenteric malfixation. In contrast, primary volvulus of the small bowel is a distinctly different and rare entity characterized by torsion of the entire small bowel with normal mesenteric fixation. To present the clinical and imaging findings in four infants with primary small bowel volvulus and normal bowel fixation in order to improve awareness of this entity among clinicians and radiologists and to discuss the potential etiologies of this entity to distinguish it from other causes of small bowel volvulus. A retrospective review of imaging studies (two ultrasounds and four upper gastrointestinal series) in four infants (three full-term and one premature) from three institutions with surgically proven volvulus of the entire small bowel and normal bowel fixation were reviewed by three board-certified pediatric radiologists and correlated with clinical and surgical reports when available. The infants presented during the first week to 6 months of life and were acutely ill. The upper gastrointestinal series showed complete duodenal obstruction with beaking in one and partial duodenal obstruction in three. All studies were interpreted as highly suspicious for malrotation and midgut volvulus. Emergent laparotomy demonstrated primary small bowel volvulus with normal mesenteric fixation in all infants. The base of the small bowel mesentery was described by the operating surgeon as smaller than normal in one infant (case 3). There was no mesenteric defect or other abnormality predisposing to volvulus in the other three. In both infants who had abdominal US, a retroperitoneal position of the third portion of the duodenum was demonstrated. All infants survived. One infant required resection of the necrotic small bowel and currently has short gut syndrome, one has malabsorption and two were lost to follow-up. Primary small bowel volvulus with normal fixation is indistinguishable from malrotation with midgut volvulus in the acutely ill infant or child. Radiographic diagnosis can be difficult in patients with intermittent or incomplete small bowel volvulus without malrotation. In these patients, neither an upper gastrointestinal series demonstrating a normal position of the duodenojejunal junction nor the sonographic demonstration of a retromesenteric third portion of the duodenum excludes the diagnosis. In young infants, the clinical and imaging findings may mimic necrotizing enterocolitis. Sonography may be useful to evaluate the bowel for signs of bowel wall compromise or a whirlpool sign.

Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites

Extremity pain represents one of the most common reasons for obtaining conventional radiographs in childhood. Despite the frequency of these examinations little is known about the incidence of diagnostic errors by interpreting pediatric radiologists. The purpose of this study was to develop a standard error rate of pediatric radiologists by double-reading of extremity radiographs (elbow, wrists, knees and ankles) in children presenting with a history of trauma or pain. During a 6-month period all major extremity radiographs (excluding digits) obtained at a large pediatric referral hospital for evaluation of pain or trauma were reviewed by two senior pediatric radiologists and compared to the official interpretation. All radiographs were interpreted initially by a board-certified pediatric radiologist with a Certificate of Added Qualification (CAQ). We reviewed 3,865 radiographic series in children and young adults 2-20years of age. We tabulated misses and overcalls. We did not assess the clinical significance of the errors. There were 61 miss errors and 44 overcalls in 1,235 abnormal cases and 2,630 normal cases, for a 1.6% miss rate and a 1.1% overcall rate. Misses and overcalls were most common in the ankle. Interpretive errors by pediatric radiologists reviewing certain musculoskeletal radiographs are relatively infrequent. Diagnostic errors in the form of a miss or overcall occurred in 2.7% of the radiographs.

Peer Review Comments Augment Diagnostic Error Characterization and Departmental Quality Assurance: 1-Year Experience From a Children’s Hospital

The objective of our study was to categorize radiologist peer review comments and evaluate their functions within the context of a comprehensive quality assurance (QA) program. All randomly entered radiology peer review comments at our institution were compiled over a 1-year period (January 1, 2011, through December 31, 2011). A Web-based commercially available software package was used to query the comments, which were then exported into a spreadsheet. Each comment was then placed into a single most appropriate category based on consensus decision of two board-certified pediatric radiologists. QA scores associated with each comment were recorded. A total of 427 peer review comments were evaluated. The majority of comments (85.9%) were entered voluntarily with QA scores of 1. A classification system was devised that augments traditional error classification. Seven broad comment categories were identified: errors of observation (25.5%), errors of interpretation (5.6%), inadequate patient data gathering (3.7%), errors of communication (9.6%), interobserver variability (21.3%), informational and educational feedback (23.0%), and complimentary (11.2%). Comment-enhanced peer review expands traditional diagnostic error classification, may identify errors that were underscored, provides continuous educational feedback for participants, and promotes a collegial environment.

Can Whole-Body MRI Secure the Diagnosis of Suspected Infant Abuse?

Source: Perez-Rossello JM, Connoly S, Newton A, et al. Wholebody MRI in suspected infant abuse. AJR. 2010; 195(3): 744– 750; doi: 10.2214/AJR.09.3364Investigators from Children’s Hospital of Boston assessed the utility of whole-body MRI as compared to skeletal survey (SS) for finding skeletal and soft tissue injuries in infants with suspected physical abuse. They retrospectively analyzed imaging studies performed in 21 infants who met entry criteria from March 2003 to October 2005 and who underwent whole-body 1.5 Tesla magnetic resonance imaging (MR) within 5 days of the SS. Sixteen infants also had a follow-up SS; the combined findings of both surveys were referred to as the “summary skeletal survey.”Fifty-two body areas were analyzed on the MR and SS. Each examination type was reviewed for mean total number of injuries. Coronal and sagittal MR images were obtained using STIR sequences. Slice thicknesses were 3 to 5 mm. SS were performed using departmental protocol and the recommendations of the American College of Radiology. A pediatric radiologist monitored the SS studies and requested additional views, if necessary. MR images were reviewed independently by two board-certified pediatric radiologists who were aware of the history but were blinded to the SS findings. Bones, soft tissues, and solid organs were studied for abnormality. A third radiologist, blinded to the MR findings, studied the SS radiographs. The cervical spine was not evaluated as the whole-body examination began at the shoulder.Overall concordance rate was 95% for pre-MR SS versus follow-up SS, 87% for initial SS versus MR, and 89% for summary SS versus MR. There was no statistical difference between the average of 4.7 areas of abnormality seen on MR and the 5.4 fractures seen on the SS. Of the total of 167 fractures in the 21 children, 40.7% were seen by SS only, 31.7% by MR alone and 27.5% by both techniques. MR had a high specificity (95%) but a low sensitivity (40%). Radiography (24 of 37) was superior to MR (2 of 37) in finding metaphyseal corner fractures. MR sensitivity to this classic finding in child abuse was only 31%. MR was superior to SS for soft tissue injuries. Soft tissue injuries included 84 instances of muscle edema and 54 of subcutaneous edema, as well as 15 joint effusions, 12 pleural effusions, 3 intra-abdominal free fluid, 1 liver laceration, and 1 ligamentous injury of the spine.The authors emphasize the limited ability of MR to detect metaphyseal corner fractures and rib fractures, the most specific fractures for nonaccidental trauma and responsible for 90% of noncranial skeletal injuries in infant abuse fatalities. The authors conclude that MR cannot replace, but may complement, the SS.Dr Cohen has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The best imaging for the infant with suspected physical abuse continues to be “old-fashioned” skeletal radiographs. Since Caffey’s landmark article1 in 1946 describing the imaging findings of the battered child, consistently achieving the goal of early diagnosis has been a major challenge. The medical, social, and legal consequences of missed diagnosis are of obvious major importance. The current study showed that 7 of 21 cases of child abuse would not have been diagnosed by MR alone. The absence of ionizing radiation makes MR an appealing imaging option. However, despite the accompanying radiation exposure, the pediatrician should not be dissuaded from ordering SS, which provide far superior identification of classic child abuse findings like metaphyseal corner fractures and rib fractures and which provide better information on the ages of the injuries.2 This study also demonstrates the superior ability of MR to pick up soft tissue injuries which can obscure fractures on SS and require follow-up. Scintigraphy may play a complementary role.Notably, some fractures were not identified on either study. Clinicians should use their judgment based on history, physical, and radiologic findings to identify and manage possible cases of physical abuse. When child abuse is suspected, an open dialogue between pediatricians and their radiologic colleagues is vital.

Radiographic Findings in the Diagnosis of Pediatric Ileocolic Intussusception

Several previous studies have evaluated the usefulness of plain abdominal radiographs for the diagnosis of pediatric intussusception, although investigation of the most specific clues to diagnose intussusception has not been studied alone. The 3 most specific findings of intussusception include intraluminal mass or intussusceptum, nonvisualized air-filled cecum, and obscured liver margin or right upper-quadrant mass. In this study, a retrospective review of 73 known cases of intussusception with age- and sex-matched controls was performed. The cases were reviewed by 2 blinded, board-certified pediatric radiologists to aid in the determination of sensitivity and specificity. The sensitivity and specificity of plain radiographs to correctly diagnose ileocolic intussusception in pediatric patients compared with a control population were 77% and 97%, using a 50% or greater receiver operating characteristic curve cutoff.