Chest CT in the evaluation of child abuse - When is it useful?

BACKGROUND: Indications for chest CT in evaluation of child abuse are unknown. OBJECTIVE: Determine which groups of children can best benefit from chest CT. PARTICIPANTS AND SETTING: 10-year (1/2010 to 12/2019) retrospective study of children <3 years who had chest CT within 3 days of the initial skeletal survey. METHODS: Demographic and clinical information were obtained from medical records. Two pediatric radiologists reviewed, independently and blinded to clinical information, anonymized rib X-rays (initial and follow up when available) and chest CT. Disagreements were resolved by a third pediatric radiologist. Agreement was evaluated using kappa statistics. Number and percentage of fractures were analyzed by negative binomial models and chi-square tests, respectively. RESULTS: 50 children (21 females) with average age of 9.7 months, 27 of whom had follow-up radiography. Agreement on initial and follow-up X-rays was substantial (k = 0.72) and perfect (k = 1.00), respectively, and almost perfect (k = 0.82) for CT scans. Chest CT demonstrated more fractures than X-ray, both initially (112 vs. 42, p < 0.0001) and at follow-up (93 vs. 49, p < 0.0001). Significantly more additional fractures were found at CT (11/13, 84.6 %) in patients with positive than in those with negative initial surveys (7/37, 18.9 %, p < 0.001). Ten initial surveys had only indeterminate fractures; four of them had fractures and six had no fractures on CT. Chest CT missed one patient (1/27, 3.7 %) with acute nondisplaced anterior rib fractures. CONCLUSION: Chest CT can be considered in children with negative skeletal survey and high clinical suspicion for child abuse, and when the diagnosis of rib fractures is indeterminate.

Accuracy of ultrasound in the diagnosis of classic metaphyseal lesions using radiographs as the gold standard.

BACKGROUND: Diagnosis of classic metaphyseal lesions (CMLs) in children suspected for child abuse can be challenging. Ultrasound (US) can potentially help diagnose CMLs. However, its accuracy is unknown. OBJECTIVE: To evaluate the accuracy of US in the diagnosis of CMLs using skeletal survey reports as the gold standard. MATERIALS AND METHODS: US of the metaphysis was performed in three patient groups age <1 year. Informed consent was obtained for patients scheduled for renal US (Group 1) and for patients scheduled for skeletal surveys for possible child abuse (Group 2). Targeted US was also performed in selected patients to evaluate for possible CML suspected on radiographs (Group 3). In Groups 1 and 2, US was performed of both distal femurs, and of either the right or left proximal and distal tibia. Two radiologists (Rad1 and Rad2) independently reviewed the US studies, blinded to history and other imaging. US sensitivity and specificity were calculated using the following gold standards: CML definitely seen on skeletal survey (positive), CML definitely not seen on skeletal survey or part of renal US group (negative). Cases where the skeletal survey was indeterminate for CML were excluded. Kappa statistics were used to evaluate interobserver variability. RESULTS: Two hundred forty-one metaphyseal sites were evaluated by US in 63 children (mean age: 5 months; 33 males); 34 had skeletal surveys and 29 had renal US. Kappa for the presence of CML was 0.70 with 95.7% agreement. US sensitivity was 55.0% and 63.2% and the specificity was 97.7% and 96.7% for Rad1 and Rad2, respectively. CONCLUSION: US has low sensitivity and high specificity in CML diagnosis. Thus, negative US does not exclude CML, but when the radiographs are equivocal, positive US can help substantiate the diagnosis.

Ultrasound evaluation of right diaphragmatic eventration and hernia.

BACKGROUND: A hernia is due to a defect in the diaphragm. An eventration is due to a thinned diaphragm with no central muscle. Distinguishing right diaphragmatic hernia from eventration on chest radiographs can be challenging if no bowel loops are herniated above the diaphragm. Experience is limited with postnatal ultrasound (US) evaluation of diaphragmatic hernia or eventration. OBJECTIVE: To evaluate for specific US signs in the diagnosis of right diaphragmatic hernia and eventration. MATERIALS AND METHODS: We identified all patients (January 2007-December 2017) with right diaphragm US and surgery for eventration or hernia. We reviewed medical charts, and US images/reports for clinical presentation and diaphragm abnormalities. Surgical diagnosis was considered the reference standard. RESULTS: Seventeen children (mean age: 5 months) had US examination before surgery for hernia (n=9) or eventration (n=8). The most common presentation was respiratory distress. In the US reports, hernia was correctly diagnosed in all patients and three patients with eventration were misdiagnosed as hernia, yielding 100% sensitivity and 62.5% specificity. In a retrospective evaluation of the US studies, a combination of folding of a free muscle edge with a narrow angle waist had 100% specificity for hernia and was seen in 7/9 children with hernia. Combination of a broad angle waist and hypoechoic strip of diaphragmatic muscle covering the waist had 100% specificity for eventration and was demonstrated in 4/8 children with eventration. Five of 17 patients (31.6%) had no specific sign that differentiated hernia from eventration. CONCLUSION: On US, folding of the free edge of the diaphragm and a narrow angle waist are specific for hernia; a broad angle waist with muscle covering the elevated area is specific for eventration. Definitive differentiation between eventration and hernia may not be possible in about a third of patients.

A comprehensive severity score for the morbidly adherent placenta: combining ultrasound and magnetic resonance imaging.

BACKGROUND: Ultrasound (US) is the first-line imaging modality to assess the morbidly adherent placenta, but sensitivity and specificity are lacking. OBJECTIVE: This investigation aims to improve diagnostic accuracy with a comprehensive score using clinical history, US, and magnetic resonance imaging (MRI). MATERIALS AND METHODS: We conducted a retrospective cohort study of pregnant women who received both transvaginal US and MRI with suspicion for morbidly adherent placenta between 2009 and 2016. US was scored with the following metrics: (i) previa, (ii) hypervascularity, (iii) loss of retroplacental clear space and (iv) lacunae. MRI was evaluated for (i) intraparenchymal vessels, (ii) abnormally dilated vessels, (iii) fibrin deposition, (iv) placental bulge and (v) bladder dome irregularity. Bayesian analysis was used to estimate the probability of morbidly adherent placenta for a given score. Diagnostic testing parameters were calculated. RESULTS: Among the 41 women with concerning imaging, histologically identified disease was confirmed in 16. The probability of morbidly adherent placenta increased with the score. At the highest US score, the probability of disease was 63.7%. With the highest MRI score, the probability of adherent placentation was 90.5%. Combining the US and MRI findings had a sensitivity of 56% and a specificity of 92%. CONCLUSION: A combined scoring system using MRI and US may accurately identify patients at risk for morbidity associated with morbidly adherent placenta.

What Patients Want to Know about Imaging Examinations: A Multiinstitutional U.S. Survey in Adult and Pediatric Teaching Hospitals on Patient Preferences for Receiving Information before Radiologic Examinations.

Purpose To identify what information patients and parents or caregivers found useful before an imaging examination, from whom they preferred to receive information, and how those preferences related to patient-specific variables including demographics and prior radiologic examinations. Materials and Methods A 24-item survey was distributed at three pediatric and three adult hospitals between January and May 2015. The χ2 or Fisher exact test (categorical variables) and one-way analysis of variance or two-sample t test (continuous variables) were used for comparisons. Multivariate logistic regression was used to determine associations between responses and demographics. Results Of 1742 surveys, 1542 (89%) were returned (381 partial, 1161 completed). Mean respondent age was 46.2 years ± 16.8 (standard deviation), with respondents more frequently female (1025 of 1506, 68%) and Caucasian (1132 of 1504, 75%). Overall, 78% (1117 of 1438) reported receiving information about their examination most commonly from the ordering provider (824 of 1292, 64%), who was also the most preferred source (1005 of 1388, 72%). Scheduled magnetic resonance (MR) imaging or nuclear medicine examinations (P < .001 vs other examination types) and increasing education (P = .008) were associated with higher rates of receiving information. Half of respondents (757 of 1452, 52%) sought information themselves. The highest importance scores for pre-examination information (Likert scale ≥4) was most frequently assigned to information on examination preparation and least frequently assigned to whether an alternative radiation-free examination could be used (74% vs 54%; P < .001). Conclusion Delivery of pre-examination information for radiologic examinations is suboptimal, with half of all patients and caregivers seeking information on their own. Ordering providers are the predominant and preferred source of examination-related information, with respondents placing highest importance on information related to examination preparation. © RSNA, 2018 Online supplemental material is available for this article.

Diagnosis of pediatric colonic volvulus with abdominal radiography: how good are we?

BACKGROUND: Colonic volvulus is rare in children and associated with colonic dysmotility. Diagnosis of colonic volvulus on radiographs in these patients can be challenging. The purpose of the study was to identify the accuracy of abdominal radiographs and findings suggestive of colonic volvulus. MATERIALS AND METHODS: A retrospective (2003- 2014) study of all children with colonic volvulus proven surgically or endoscopically reviewed their medical charts for underlying disease and clinical presentation as well as their original radiograph reports. Two pediatric radiologists (reader 1 and reader 2) independently reviewed the radiographs. The kappa test was used to evaluate interobserver variability. RESULTS: There were 19 cases of colonic volvulus in 18 patients (11 males) a mean age 14 years. Cecal volvulus was the most common finding at 14/19 cases (74%). Sixteen of 18 (89%) patients had neurological impairment and 10 of 18 (56%) had intestinal dysmotility. The most common presentation was abdominal distension (14/19 [74%]) and pain (11/19 [58%]). Colonic volvulus was diagnosed in only 7/16 (44%) of the abdominal radiographs. The specific finding of a coffee-bean sign was retrospectively observed only by reader 2 in two cases. Absence of rectal gas and focal colonic loop dilation were the most common findings by the readers (average 73.5% and 87%, respectively) with Kappa values of 0.3 and 0.38, respectively. CONCLUSION: Diagnosis of colonic volvulus in children can be challenging. Radiologists should be alerted to the possibility of colonic volvulus when there is focal colonic loop distention or absent rectal gas.

Ultrasound of the pediatric scrotum.

Clinical evaluation of pediatric scrotal pathologies can be challenging. Different pathologies have similar presentations, and scrotal tenderness may limit physical examination. Ultrasound (US) is the imaging modality of choice for the pediatric scrotum. It provides excellent anatomical detail and assessment of testicular perfusion by color Doppler without ionizing radiation. Scrotal US examination should also include the inguinal area; inguinal canal pathology can extend into the scrotum. In the pediatric acute scrotum, US can differentiate between testicular torsion requiring scrotal exploration and other pathologies with conservative management. This article will review scrotal US anatomy and demonstrate how US can guide management in a variety of scrotal abnormalities including trauma, masses, varicocele, and cryptochydism.

Ultrasound for primary imaging of congenital hypothyroidism.

OBJECTIVE: The purpose of this study was to retrospectively evaluate the use of sonography as the primary imaging modality for congenital hypothyroidism (CH). MATERIALS AND METHODS: From our regional registry, we reviewed the cases of patients for whom either sonography or (99m)Tc-pertechnetate scanning was performed for CH between 2003 and 2010. Ultrasound studies were reviewed for presence, size, echotexture, vascularity, and location of the thyroid gland. Technetium-99m-pertechnetate scans were evaluated for the presence and location of the thyroid gland. The ultrasound studies were compared with the (99m)Tc-pertechnetate scans. We assessed the use of ultrasound as the primary imaging modality for the evaluation of CH. RESULTS: We identified the cases of 124 patients (89 girls, 35 boys). Ultrasound studies were available for 121 patients, and (99m)Tc-pertechnetate studies for 62 patients. Three patients were examined only by (99m)Tc-pertechnetate scanning. The final imaging results were normal location with normal size or diffuse enlargement of the thyroid gland (n = 47), sublingual thyroid gland (n = 49), agenesis (n = 18), hypoplasia (n = 8), and hemiagenesis (n = 2). Compared with (99m)Tc-pertechnetate scanning, ultrasound had high (100%) specificity and low (44%) sensitivity for detection of sublingual thyroid gland. CONCLUSION: We suggest using ultrasound as the primary imaging modality for guiding the treatment of children with CH, potentially decreasing radiation exposure and cost.

Developmental dysplasia of the hip: background and the utility of ultrasound.

Developmental dysplasia of the hip (DDH) is a spectrum of hip joint abnormalities ranging from joint laxity to dislocation. If untreated, DDH may lead to early degenerative arthritis. Ultrasound (US) is the primary imaging for evaluation of DDH in the first months of life, however, there is no consensus on the optimal use of US for screening for DDH. We will address the background of DDH, including the controversy regarding screening, as well as US technique, anatomy and findings in a normal hip and a hip with developmental dysplasia.

Should 12 months of training be required before diagnostic radiology residents take independent call? A survey of the Association of Program Directors in Radiology.

To assess program director's reactions to a Residency Review Committee rule change requiring diagnostic radiology residents to complete 12 months of training prior to taking independent call, 303 Association of Program Directors members were surveyed. A total of 147 members responded (48.5% response rate). Overall, 66.1% of respondents were opposed to the change, 21.1% were in favor of it, and 12.8% were neutral. Although this rule change has already been accepted by the residency review committee for implementation July 1, 2008, there has been much debate over this modification and the impact it will have on varying programs.