Evaluation of an initiative to reduce radiation exposure from CT to children in a non-pediatric-focused facility.

We would like to share our experience of reducing pediatric radiation exposure. Much of the recent literature regarding successes of reducing radiation exposure has come from dedicated children's hospitals. Nonetheless, over the past two decades, there has been a considerable increase in CT imaging of children in the USA, predominantly in non-pediatric-focused facilities where the majority of children are treated. In our institution, two general hospitals with limited pediatric services, a dedicated initiative intended to reduce children's exposure to CT radiation was started by pediatric radiologists in 2005. The initiative addressed multiple issues including eliminating multiphase studies, decreasing inappropriate scans, educating referring providers, training residents and technologists, replacing CT with ultrasound or MRI, and ensuring availability of pediatric radiologists for consultation. During the study period, the total number of CT scans decreased by 24 %. When accounting for the number of scans per visit to the emergency department (ED), the numbers of abdominal and head CT scans decreased by 37.2 and 35.2 %, respectively. For abdominal scans, the average number of phases per scan decreased from 1.70 to 1.04. Upon surveying the pediatric ED staff, it was revealed that the most influential factors on ordering of scans were daily communication with pediatric radiologists, followed by journal articles and lectures by pediatric radiologists. We concluded that a non-pediatric-focused facility can achieve dramatic reduction in CT radiation exposure to children; however, this is most effectively achieved through a dedicated, multidisciplinary process led by pediatric radiologists.

Bedside upper gastrointestinal series in critically ill low birth weight infants.

BACKGROUND: The upper gastrointestinal (UGI) series is the preferred method for the diagnosis of malrotation. A bedside UGI technique was developed at our institution for use in low birth weight, critically ill neonates to minimize the risks of transportation from the neonatal intensive care unit (NICU) such as hypothermia and dislodgement of support lines and tubes. OBJECTIVE: To determine the ability of a bedside UGI technique to identify the position of the duodenojejunal junction (DJJ) in low birth weight, critically ill infants in the NICU. MATERIALS AND METHODS: We retrospectively reviewed bedside UGI examinations performed in premature infants weighing less than 1,500 g from 2008 to 2013 and correlated the findings with clinical data, imaging studies and surgical findings. RESULTS: Of 27 patients identified (weight range: 633-1,495 g), 21 (78%) bedside UGI series were diagnostic. Twenty of 27 cases (74%) demonstrated normal intestinal rotation. One case demonstrated malrotation with midgut volvulus, which was confirmed at surgery. In six cases (22%), the position of the DJJ could not be accurately determined. No cases of malrotation with midgut volvulus were missed. None of the patients with normal bedside UGI studies was found to have malrotation based on clinical follow-up (mean: 20 months), surgical findings or further imaging. CONCLUSION: The bedside UGI is a useful technique to exclude malrotation in critically ill neonates and minimizes potential risks of transportation to the radiology suite. Pitfalls that may preclude a diagnostic examination include incorrect timing of radiographs, patient rotation, suboptimal enteric tube position and bowel distention. In cases of diagnostic uncertainty, a follow-up study should be performed.

The predictive value of a normal radiographic anterior fat pad sign following elbow trauma in children.

OBJECTIVE: The purposes of this study were to describe the characteristics of a normal anterior fat pad (AFP) and to determine the association between a normal AFP and the absence of fracture. METHODS: A prospective cohort of children aged 1 to 18 years with elbow trauma underwent radiographic examination. All patients received standard orthopedic management and follow-up 7 to 14 days after injury. A pediatric radiologist evaluated all radiographs for the presence or absence of fracture and documented whether the AFP was normal or abnormal on the lateral view. The radiologist also recorded specific measurements of the AFP including the apical angle, which is formed by the intersection of the humerus and the superior aspect of the AFP. The interpretation of the AFP on the initial lateral radiograph was compared with the final patient outcome (fracture/no fracture). RESULTS: Two hundred thirty-one patients had elbow radiographs; 34 patients (15%) were lost to follow-up. A total of 56 fractures were identified: 49 (87%) on the initial radiograph and an additional 7 (13%) on follow-up radiographs. This latter group was defined as occult fractures. Among the 197 patients available for analysis, 113 (57%) had a normal AFP on the initial radiograph. Of these, 2 children had a final diagnosis of fracture. The sensitivity of a normal AFP was 96.4% (95% confidence interval, 86.6%-99.4%), and the negative predictive value was 98.2% (95% confidence interval, 93.1%-99.7%). There was a significant difference in mean AFP angle when the AFP was read as normal (14.7 [SD, 3.3] degrees) compared with when it was read as abnormal (27.0 [SD, 6.8] degrees) (P < 0.01). CONCLUSIONS: Our data suggest that a normal AFP is highly associated with absence of elbow fracture and that the determination of a normal AFP can be aided by measuring the apical angle of the AFP.

CT can reduce hospitalization for observation in children with suspected appendicitis.

BACKGROUND: There are no clinical or laboratory tests that can eliminate the possibility of appendicitis in a child with abdominal pain that suggests the diagnosis. The standard of care is to admit these children to the hospital for observation. More than twice as many children hospitalized for abdominal pain suggesting appendicitis are subsequently sent home after observation compared to those who undergo appendectomy. OBJECTIVE: To evaluate the ability of CT with rectal contrast medium (CTRC) to diagnose a normal appendix in children with abdominal pain. MATERIALS AND METHODS: A prospective cohort study in an urban pediatric emergency department. Children 6-17 years of age with abdominal pain were eligible when the attending physician planned to admit them for observation for possible appendicitis. All 94 patients underwent CTRC. CTRC results were compared to patient outcomes. RESULTS: Ninety-four children successfully underwent CTRC. Among the 53 patients with reflux of contrast medium into the ileum, the appendix was visualized in 43 (81.1%). Among all 94 cases, the appendix was visualized in 53 cases (55.7%); 43 studies were read as normal, and 10 showed appendicitis. Of the 43 with a normal appendix, 23 were discharged home, 18 were admitted but discharged uneventfully, and two underwent surgery for another diagnosis. When the appendix was visualized, the sensitivity, specificity, and negative and positive predictive values of CTRC were 100% (95% CI 66.4, 100.0), 97.7% (95% CI 88.0, 99.9), 100% (95% CI 91.8, 100.0), and 90% (95% CI 55.5, 99.8), respectively. The use of CTRC could have decreased the admission rate for observation for appendicitis by at least 41.8% and by more than 80% when the appendix could be seen. CONCLUSION: Our data suggest that when the appendix can be visualized, CTRC can accurately identify a normal appendix and reduce the number of children hospitalized for observation for possible appendicitis.

What can we learn from chest radiographs in hypoxemic asthmatics?

BACKGROUND: Chest radiographs (X-rays) are frequently obtained on children with asthma exacerbations who remain hypoxemic after therapy even though their utility has not been evaluated. OBJECTIVE: To compare X-rays in hypoxemic and non-hypoxemic asthmatic children. METHODS: Over 21 months, X-rays were obtained on all persistently hypoxemic asthmatics (1-17 years, oxygen saturation <93% in room air), and some non-hypoxemic asthmatics. A pediatric radiologist blinded to the patients' symptoms evaluated each X-ray for lung size, extravascular lung fluid, and atelectasis. Clinical outcomes including duration of hypoxemia, length of hospital stay, and admission to the PICU were assessed through chart audit after hospital discharge. RESULTS: A total of 445 patients were enrolled and stratified into four groups based on initial and post-treatment pulse oximetry measurements. Hypoxemic groups I and II were more likely to have large or small lungs ( P<0.05), severe interstitial fluid ( P<0.01), and atelectasis ( P<0.01) compared to non-hypoxemic group IV. Group I was more likely to have fluid in the alveolar space compared to all other groups ( P<0.01). Within hypoxemic group I, there was no association between any radiographic findings and our clinical outcomes. CONCLUSION: Large or small lung sizes, extravascular fluid, and atelectasis were more common in the X-rays of hypoxemic asthmatics.

Is a complete trauma series indicated for all pediatric trauma victims?

OBJECTIVE: Trauma series radiographs (ie, lateral cervical spine, anteroposterior chest, and anteroposterior pelvis) are routinely recommended for victims of multiple trauma. However, the utility of the chest and pelvic radiographs has never been adequately evaluated. The purpose of this study is to determine whether clinical findings alone predict the results of these radiographs. METHODS: The pediatric radiology department at the Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, maintains a log of all patients who have undergone a complete trauma series. From this group, we selected all patients younger than 2 years with a Glasgow Coma Scale greater than 14 points. The patients' emergency department charts were reviewed to note the presence or absence of localizing signs and symptoms referable to the chest and pelvis, including chest or pelvic pain, tenderness, ecchymoses or abrasions, shortness of breath or other respiratory symptoms, hematuria or difficulty voiding, and abdominal distention. RESULTS: Sixteen of the 91 subjects (18%) had localizing chest findings. Two of these patients had positive chest radiographs, whereas the 75 patients without localizing chest findings had no positive chest radiographs (P < 0.03). Thirty-two of 91 subjects (35%) had localizing pelvic signs. Five of these patients had positive pelvic radiographs, whereas the 56 patients without localizing pelvic signs had no positive pelvic radiographs (P < 0.01). The negative predictive value of localizing signs and symptoms was 100% for both chest and pelvic radiographs. CONCLUSION: These data suggest that if an adequate examination can be performed, trauma series radiographs can be ordered selectively, based on the patient's clinical findings.