ACR Appropriateness Criteria® Orbital Imaging and Vision Loss-Child.

Orbital disorders in children consist of varied pathologies affecting the orbits, orbital contents, visual pathway, and innervation of the extraocular or intraocular muscles. The underlying etiology of these disorders may be traumatic or nontraumatic. Presumed location of the lesion along with the additional findings, such as eye pain, swelling, exophthalmos/enophthalmos, erythema, conjunctival vascular dilatation, intraocular pressure, etc, help in determining if imaging is needed, modality of choice, and extent of coverage (orbits and/or head). Occasionally, clinical signs and symptoms may be nonspecific, and, in these cases, diagnostic imaging studies play a key role in depicting the nature and extent of the injury or disease. In this document, various clinical scenarios are discussed by which a child may present with an orbital or vision abnormality. Imaging studies that might be most appropriate (based on the best available evidence or expert consensus) in these clinical scenarios are also discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Direct inoculation method for identification and antimicrobial susceptibility testing using matrix-assisted laser desorption ionization-time of flight mass spectrometry and both the Vitek 2 and MicroScan Walkaway 96 Plus systems.

The aim of our study was to evaluate a protocol utilizing serum separator tubes (SST) to facilitate a faster, cost-effective, direct method for rapid sensitivity testing and identification of positive blood cultures. Spiked cultures were inoculated into either Becton Dickinson (BD) BACTECTM Aerobic Plus or Anaerobic/F bottles containing sterile human blood. Bottles were immediately processed when positive. A parallel study using patient isolates was used in which bacteria were pelleted by SST from positive blood cultures. For identification, a portion of the pellet was tested by matrix-assisted laser desorption/ionization as described by the manufacturer. MicroScan panels and Vitek 2 results were compared. Categorical agreement was used as comparison to standard subculture and/or polymerase chain reaction methods. No discordant identifications were observed, and 86% generated a successful identification when compared to subculture methods. For the Vitek 2, we observed a 99% essential agreement when compared to the subculture method. For the MicroScan Walkaway, we observed 94.9%, 97.4%, and 100% categorical agreement for MIC panels 53, 38, and MICroSTREP Plus 2, respectively. Turnaround times were reduced from 4 hours for identification and 11 hours for antimicrobial sensitivity testing. We conclude that the SST method results in timelier, actionable results for antimicrobial stewardship initiatives.

Structured coaching as a means to improve sonographic visualization of the appendix: a quality improvement initiative.

PURPOSE: Ultrasound of the right lower quadrant for appendicitis requires specific training and practice. Improved visualization of the appendix can result in decreased utilization of computed tomography. Increasing the sensitivity of ultrasound for appendicitis thus decreases radiation exposure, reduces cost, and improves the patient healthcare experience in accordance with the three principles of the triple aim designated by the Institute for Healthcare Improvement. The purpose of this study was to examine the effect of a structured training program supplemented by technologist feedback on sonographic visualization of the appendix in a large pediatric health system. METHODS: The baseline ultrasound visualization frequency was computed for 20 ultrasound technologists in a large pediatric health system. Following this, technologists were informed of their individual and relative performance. Those with visualization frequencies less than 75% were provided structured training by a designated sonographer with an appendix visualization frequency above 75% while those with greater than 75% visualization continued to be monitored and informed of their monthly frequency. Following this structured training, appendix visualization frequencies were monitored over the next 5 months. RESULTS: There was no significant effect of sonographer career experience on the baseline appendix visualization frequency. Fourteen of 20 technologists demonstrated improved visualization frequencies post-intervention. The composite visualization frequency among these 20 technologists improved from 66.55 to 69.14%. This resulted in a potential savings of 38 CT scans during the post-intervention period. CONCLUSION: An appendix visualization rate monitoring program coupled with structured training was successful in improving the appendix visualization rate throughout a large pediatric health system. This program demonstrates the positive effect that monitoring and targeted intervention can have on a quality improvement program. The program continues to be carried out as part of a plan-study-do-act cycle.

Radiologists' Diagnostic Performance in Differentiation of Rickets and Classic Metaphyseal Lesions on Radiographs: A Multicenter Study.

BACKGROUND. Despite evidence supporting the specificity of classic metaphyseal lesions (CML) for the diagnosis of child abuse, some medicolegal practitioners claim that CML result from rickets rather than trauma. OBJECTIVE. The purpose of this study was to evaluate radiologists' diagnostic performance in differentiating rickets and CML on radiographs. METHODS. This retrospective seven-center study included children younger than 2 years who underwent knee radiography from January 2007 to December 2018 and who had either rickets (25-hydroxyvitamin D level < 20 ng/mL and abnormal knee radiographs) or knee CML and a diagnosis of child abuse from a child abuse pediatrician. Additional injuries were identified through medical record review. Radiographs were cropped and zoomed to present similar depictions of the knee. Eight radiologists independently interpreted radiographs for diagnoses of rickets or CML, rated confidence levels, and recorded associated radiographic signs. RESULTS. Seventy children (27 girls, 43 boys) had rickets; 77 children (37 girls, 40 boys) had CML. Children with CML were younger than those with rickets (mean, 3.7 vs 14.2 months, p < .001; 89.6% vs 5.7% younger than 6 months; 3.9% vs 65.7% older than 1 year). All children with CML had injuries in addition to the knee CML identified at physical examination or other imaging examinations. Radiologists had almost perfect agreement for moderate- or high-confidence interpretations of rickets (κ = 0.92) and CML (κ = 0.89). Across radiologists, estimated sensitivity, specificity, and accuracy for CML for moderate- or high-confidence interpretations were 95.1%, 97.0%, and 96.0%. Accuracy was not significantly different between pediatric and nonpediatric radiologists (p = .20) or between less experienced and more experienced radiologists (p = .57). Loss of metaphyseal zone of provisional calcification, cupping, fraying, and physeal widening were more common in rickets than CML, being detected in less than 4% of children with CML. Corner fracture, bucket-handle fracture, subphyseal lucency, deformed corner, metaphyseal irregularity, and subperiosteal new bone formation were more common in CML than rickets, being detected in less than 4% of children with rickets. CONCLUSION. Radiologists had high interobserver agreement and high diagnostic performance for differentiating rickets and CML. Recognition that CML mostly occur in children younger than 6 months and are unusual in children older than 1 year may assist interpretation. CLINICAL IMPACT. Rickets and CML have distinct radiographic signs, and radiologists can reliably differentiate these two entities.

Overnight radiology resident discrepancies at a large pediatric hospital: categorization by year of training, program, imaging modality, and report type.

BACKGROUND: Overnight radiology resident discrepancies have been described in multiple studies; however, study of resident discrepancies specific to pediatric radiology is limited. PURPOSE: To examine radiology resident discrepancies as they pertain to a large pediatric hospital system. MATERIAL AND METHODS: A total of 21,560 preliminary reports issued by 39 residents over a one-year period were scored as agreement, minor discrepancy, or major discrepancy by faculty members using a modification of the 2009 RADPEER scoring system. Residents were trainees of three different diagnostic radiology programs: large university-based, medium-sized community-based, or small community-based. Discrepancy rates were evaluated based on resident postgraduate year, program, and imaging modality. The effect of a general pediatric radiology report versus pediatric neuroradiology report of a CT scan was also tested. CT was the only modality in which there were comparable numbers of studies scored by both general pediatric radiologists and neuroradiologists. RESULTS: The rate of major resident to faculty assessment discrepancies was 1.01%, and the rate of minor resident to faculty assessment discrepancies was 4.47%. Major discrepancy rates by postgraduate years 3-5 were 1.08%, 0.75%, and 1.59%, respectively. Major discrepancy rates were highest for MR (11.22%), followed by CT (1.82%), radiographs (0.91%), and ultrasound (0.56%). There was no significant difference in discrepancy rate between residency programs and general pediatric radiology report of a CT versus pediatric neuroradiology report of a CT. CONCLUSION: Radiology discrepancy rates for residents issuing preliminary reports at a large children's hospital system are similar to those reported for adult procedures.

Body mass index as a predictor of sonographic visualization of the pediatric appendix.

BACKGROUND: Appendicitis is a common condition that is often confirmed with imaging. Ultrasound (US) is recommended as the first radiologic test in the work-up of appendicitis in children. Increased body mass index (BMI) has been implicated as a limiting factor to the sensitivity of US. This has drastic public health ramifications, as pediatric obesity has been increasing at alarming rates. OBJECTIVE: The purpose of this study is to compare age-adjusted BMI z-scores to the frequency of sonographic visualization of the appendix. MATERIALS AND METHODS: A retrospective review of 500 consecutive reports of US exams ordered for appendicitis in patients with a documented BMI was performed. Patients were stratified by BMI z-score based on, and the visualization frequency of the appendix was compared to the BMI z-score group. A logistic regression analysis generated the odds of visualization of the appendix by BMI z-score group. Primary home language, ethnicity, sex and insurance status were included in the logistic regression model to assess these characteristics as potential effect modifiers. RESULTS: Of the 500 patients, 52.4% were male, 56.4% were Hispanic and 62.0% had government insurance. BMI z-score distribution groups were as follows: 4.2% were <-2, 8.0% were -2 to -1, 49.8% were -1 to 1, 26.4% were 1 to 2 and 11.6% were >2. The visualization frequency was 61.1% for boys and 46.2% for girls (P<0.05). Visualization frequency by BMI z-score group was as follows: 85.7% for <2, 72.5% for -2 to -1, 57.4% for -1 to 1, 47.7% for 1 to 2 and 29.3% for >2. Children with a BMI z-score greater than 2 were less likely to have a US with visualization of the appendix compared to children with a BMI z-score between -1 and 1 (adjusted odds ratio [aOR]: 0.21, 95% CI: 0.11-0.40, P<0.0001). Boys were more likely than girls to have a US with visualization of the appendix (aOR: 1.90, 95% CI: 1.29-2.80, P=0.001). There was no effect from insurance status, ethnicity or primary home language. CONCLUSION: Findings show that as the BMI z-score increased, sonographic visualization of the appendix decreased even after adjusting for demographic differences. These findings have implications for pediatric radiology practice in light of the worsening obesity epidemic.

Evolving forensic controversies in child abuse imaging.

Child abuse is a common cause of morbidity and mortality in the pediatric population. Despite well-defined evidence establishing bona fide clinical and imaging indicators of child abuse, denialists have emerged on behalf of defendants utilizing unaccepted scientific positions based on literature that they have often authored themselves. This manuscript describes many of the trends in recent legal proceedings while highlighting the importance of consensus statements and professional ethics as they pertain to child abuse imaging. Knowledge of these cases and legal defense strategies is valuable to potential expert witnesses in relevant proceedings.

Debunking Fringe Beliefs in Child Abuse Imaging: AJR Expert Panel Narrative Review.

Child abuse is a global public health concern. Injuries from physical abuse may be clinically occult and not appreciable on physical examination. Imaging is therefore critical in identifying and documenting such injuries. The radiologic approach for a child who has potentially been abused has received considerable attention and recommendations according to decades of experience and rigorous scientific study. Nonetheless, fringe beliefs describing alternative explanations for child abuse-related injuries have emerged and received mainstream attention. Subsequently, imaging findings identified in abused children have been attributed to poorly supported underlying medical conditions, clouding the evidence basis for radiologic findings indicative of nonaccidental trauma. Fringe beliefs that attribute findings seen in child abuse to alternate pathologies such as genetic disorders, birth trauma, metabolic imbalances, vitamin D deficiency, and short-distance falls typically have limited evidence basis and lack professional society support. Careful review of the scientific evidence and professional society consensus statements is important in differentiating findings attributable to child abuse from fringe beliefs used to discount the possibility that a child's constellation of injuries is consistent with abuse. This review refutes fringe beliefs used to provide alternative explanations in cases of suspected child abuse and reinforces the key literature and scientific consensus regarding child abuse imaging.

The Evolving Status of Fellowships and Mini-Fellowships in Diagnostic Radiology: A Survey of Program Directors and Chief Residents.

RATIONALE AND OBJECTIVES: Recent changes in radiology fellowships include musculoskeletal radiology adopting a match system, interventional radiology transitioning away from diagnostic radiology to offer direct-entry programs, and a common fellowship application timeline created by the Society for Chairs of Academic Radiology Departments (SCARD). The concept of mini-fellowships has also emerged with the elimination of the oral American Board of Radiology examinations that had been administered in the final year of residency training prior to 2014. This paper seeks to assess the opinions of fellowship program directors, residency program directors, and chief residents regarding these recent changes. MATERIALS AND METHODS: This is a cross-sectional study using a web-based survey posed to fellowship program directors, residency program directors, and chief residents in 2020. Questions sought to explore current attitudes toward the following topics: (1) a common fellowship application timeline; (2) a common fellowship match; and (3) the status of mini-fellowships in diagnostic radiology. In addition, the number of fellowship positions for each subspecialty was estimated using subspecialty society directories, Accreditation Council for Graduate Medical Education (ACGME) data, and individual program websites. RESULTS: Deidentified responses were collected electronically and aggregated. The three respondent groups preferred a common fellowship application timeline at rates of 67% among fellowship program directors, 80% residency program directors, and 74% residents. A common match system across all subspecialties was preferred at rates of 50% fellowship program directors, 74% residency program directors, and 26% chief residents. There was widespread reported compliance with the SCARD fellowship timeline policy. Subspecialty programs using the match system reported interviewing greater numbers of applicants per position. Fellowship directors and chief residents reported that the most common duration of mini-fellowship experiences was 2 to 3 months. CONCLUSION: There is a division between chief residents and program directors regarding the preference for a common radiology match. Adopting a radiology-wide fellowship match would increase the number of interviews required. The SCARD fellowship timeline policy has been successful, and there is support across stakeholders regarding the common timeline. Mini-fellowships are highly variable in length and structure.

Relative United States Medical Licensing Examination (USMLE) Performance by Specialty Is Not a Predictor of Board Exam Pass Rate: The Case of Diagnostic Radiology.

Introduction In 2010 diagnostic radiology (DR) changed the board certification process for residents using the new Core exam. However, there is not a standardized way to evaluate DR residency graduates. With no specific target pass rate for the exam, the "appropriate" pass rate has remained a debated topic among the field. In this paper, the board certification exam passage rates of DR are compared to other medical specialties to assess the standardization method of the American Board of Radiology (ABR) and serve as basis for additional specialties considering changes to their board exam structure. Methods Performance on the United States Medical Licensing Examination (USMLE) was obtained from the National Resident Matching Program (NRMP) and San Francisco match. Boards passage rates were analyzed using data from the American Board of Medical Specialties. USMLE and board exam passage rates were averaged and ranked, and statistical analysis was conducted using Stata (College Station, TX). Results DR performance on USMLE Step 1 has increased at the lowest rate (0.563 points/year) since 2005 and anesthesiology performance has increased at the greatest rate (1.313 points/year). Residents matching from US allopathic medical schools during the 2010 and 2012 years had DR oral board exams with USMLE 1 averages of 232 and 235, respectively. First-time pass rate for the first Core exam was 87% and the overall pass rate since the first Core exam has been 88.54%. The Spearman rho coefficient for specialty ranks of board passage rate and USMLE 1 was 0.0679 (p = 0.8101). The Spearman rho coefficient for board passage rate and USMLE 2 CK was 0.1430 (p = 0.6257). The Spearman rho coefficient for USMLE 1 and USMLE 2 CK was 0.8317 (p = 0.0002). Conclusions Specialty board pass rates have not increased in concert with improved trainee performance on the USMLE. USMLE performance among those matching in diagnostic radiology has increased, ABR board exam passage rate has decreased. ABR determines passing thresholds to the relative performance of examinees rather than using a criterion referenced Angoff standard.

Discrepancy rates of preliminary and final reports for after-hours pediatric teleradiology interpretations.

BACKGROUND: Children's hospitals often do not have a high enough volume to justify providing radiologist staffing overnight, leading to hospitals employing teleradiology services to offer preliminary reports. There is limited literature related to discrepancies between preliminary teleradiology pediatric radiologists and final interpretations. PURPOSE: The purpose of this study is to examine discrepancy rates for teleradiologists preliminarily interpreting pediatric exams at a children's hospital. MATERIAL AND METHODS: Eight thousand seven hundred seventy-eight consecutive preliminary reports issued by pediatric teleradiologists were reviewed. The hospital utilized a system in which local onsite radiologists rated the preliminary reports of teleradiologists following the interpretations as part of standard operating procedure. Discrepancies were also rated according to whether the discrepancy was actionable (judged to alter patient management by the final rater) or not. Rates were stratified by modality, preliminary teleradiologist reader, and final rater and compared to each using a normal approximation. The mean discrepancy rates were compared using a z test for proportions. Linear regression was applied to the effect of years of radiologist experience on the total and actionable discrepancy rates. RESULTS: The overall actionable discrepancy rate was 1.6%, similar to inter-observer discrepancy rates reported in other studies. There were no significant differences in the actionable discrepancy rates among teleradiologists. There was no correlation between years of experience and discrepancy rate for either the teleradiologists or the final raters. CONCLUSION: Pediatric subspecialty teleradiologists issue reports that mirror discrepancy rates typical of radiologists who issue reports for emergent adult studies. Years of radiologist experience is not a predictor of discrepancy rate.