The role of imaging in the management of necrotising enterocolitis: a multispecialist survey and a review of the literature.

OBJECTIVES: To investigate current practices and perceptions of imaging in necrotising enterocolitis (NEC) according to involved specialists, put them in the context of current literature, and identify needs for further investigation. METHODS: Two hundred two neonatologists, paediatric surgeons, and radiologists answered a web-based questionnaire about imaging in NEC at their hospitals. The results were descriptively analysed, using proportion estimates with 95% confidence intervals. RESULTS: There was over 90% agreement on the value of imaging for confirmation of the diagnosis, surveillance, and guidance in decisions on surgery as well as on abdominal radiography as the first-choice modality and the most important radiographic signs. More variation was observed regarding some indications for surgery and the use of some ultrasonographic signs. Fifty-eight per cent stated that ultrasound was used for NEC at their hospital. Examination frequency, often once daily or more but with considerable variations, and projections used in AR were usually decided individually rather than according to fixed schedules. Predicting the need of surgery was regarded more important than formal staging. CONCLUSION: Despite great agreement on the purposes of imaging in NEC and the most important radiographic signs of the disease, there was considerable diversity in routines, especially regarding examination frequency and the use of ultrasound. Apart from continuing validation of ultrasound, important objectives for future studies include definition of the supplementary roles of both imaging modalities in relation to other diagnostic parameters and evaluation of various imaging routines in relation to timing of surgery, complications, and mortality rate. KEY POINTS: • Imaging is an indispensable tool in the management of necrotising enterocolitis • Predicting the need of surgery is regarded more important than formal staging • There is great consensus on important signs of NEC on abdominal radiography • There is more uncertainty regarding the role of ultrasound • Individualised management is preferred over standardised diagnostic algorithms.

Global quality imaging: emerging issues.

Quality imaging may be described as "a timely access to and delivery of integrated and appropriate procedures, in a safe and responsive practice, and a prompt delivery of an accurately interpreted report by capable personnel in an efficient, effective, and sustainable manner." For this article, radiation safety is considered as one of the key quality elements. The stakeholders are the drivers of quality imaging. These include those that directly provide or use imaging procedures and others indirectly supporting the system. Imaging is indispensable in health care, and its use has greatly expanded worldwide. Globalization, consumer sophistication, communication and technological advances, corporatization, rationalization, service outsourcing, teleradiology, workflow modularization, and commoditization are reshaping practice. This article defines the emerging issues; an earlier article in the May 2011 issue described possible improvement actions. The issues that could threaten the quality use of imaging for all countries include workforce shortage; increased utilization, population radiation exposure, and cost; practice changes; and efficiency drive and budget constraints. In response to these issues, a range of quality improvement measures, strategies, and actions are used to maximize the benefits and minimize the risks. The 3 measures are procedure justification, optimization of image quality and radiation protection, and error prevention. The development and successful implementation of such improvement actions require leadership, collaboration, and the active participation of all stakeholders to achieve the best outcomes that we all advocate.

Global quality imaging: improvement actions.

Workforce shortage, workload increase, workplace changes, and budget challenges are emerging issues around the world, which could place quality imaging at risk. It is important for imaging stakeholders to collaborate, ensure patient safety, improve the quality of care, and address these issues. There is no single panacea. A range of improvement measures, strategies, and actions are required. Examples of improvement actions supporting the 3 quality measures are described under 5 strategies: conducting research, promoting awareness, providing education and training, strengthening infrastructure, and implementing policies. The challenge is to develop long-term, cost-effective, system-based improvement actions that will bring better outcomes and underpin a sustainable future for quality imaging. In an imaging practice, these actions will result in selecting the right procedure (justification), using the right dose (optimization), and preventing errors along the patient journey. To realize this vision and implement these improvement actions, a range of expertise and adequate resources are required. Stakeholders should collaborate and work together. In today's globalized environment, collaboration is strength and provides synergy to achieve better outcomes and greater success.

Globalization of P4 medicine: predictive, personalized, preemptive, and participatory--summary of the proceedings of the Eighth International Symposium of the International Society for Strategic Studies in Radiology, August 27-29, 2009.

In August 2009, the International Society for Strategic Studies in Radiology held its eighth biennial meeting. The program focused on the globalization of predictive medicine--or P4 medicine--as it relates to the practice of radiology and radiology research. P4 medicine refers to predictive, personalized, preemptive, and participatory medicine and was the inspiration of Elias Zerhouni, MD, former director of the National Institutes of Health. This article is a summary of some of the key concepts presented at the meeting by an international group of radiologists, imaging scientists, and leaders of industry. In predictive medicine, imaging and imaging-related technologies will likely play an increasing role in the early detection of disease and, thus, the preemption of the development of advanced, hard-to-treat disease. Research into systems biology and molecular imaging promises to personalize medicine, facilitating the provision of the right care to the right patient at the right time. In participatory medicine, increasing interactions with referring physicians and patients will be helpful in raising awareness and recognition of the role of radiologists and will have a positive effect on professionalism. There is also a need to increase awareness of the vital role of radiologists as imaging and radiation safety experts who evaluate the necessity and appropriateness of examinations, monitor performance quality, and are available for postexamination consultations.

Standardizing resistive indices in healthy pediatric transplant recipients of adult-sized kidneys.

Small pediatric recipients of an adult-sized kidney have insufficient renal blood flow early after transplantation, with secondary chronic hypoperfusion and irreversible histological damage of the tubulo-interstitial compartment. It is unknown whether this is reflected by renal resistive indices. We measured renal graft resistive indices and volumes of 47 healthy pediatric kidney transplant recipients of an adult-sized kidney in a prospective study for six months post-transplant. A total of 205 measurements were performed. The smallest recipients (BSA or= 1.5 m(2) (p < 0.0001). Resistive indices increased during the first six months in the smallest recipients (p = 0.02), but not in the two larger recipient groups (BSA 0.75-1.5 m(2) and >or=1.5 m(2)). All three BSA groups showed a reduction in renal volume after transplantation, with the greatest reduction occurring in the smallest recipients. In conclusion, renal transplant resistive indices reflect pediatric recipient BSA dependency. The higher resistance to intra-renal vascular flow and significant decrease in renal volume in the smallest group likely reflect accommodation of the size discrepant transplanted adult-sized kidney to the smaller pediatric recipient vasculature with associated lower renal artery flow.

Three-dimensional MRI volumetric measurements of the normal fetal colon.

OBJECTIVE: The use of fetal MRI markedly improves characterization of abdominal congenital anomalies. Accurate prenatal diagnosis of the level and cause of congenital intestinal obstruction is desired for optimal parental counseling and perinatal care. Because accurate diagnosis would be aided by nomograms of colonic volume, this study was conducted to determine normal colonic volumes at different gestational ages. MATERIALS AND METHODS: This retrospective study consisted of a review of 83 fetal MRI examinations performed on fetuses with no gastrointestinal abnormalities. MRI was performed with a 1.5-T system. Axial, sagittal, and coronal T1-weighted fast gradient-refocused echo images were acquired at TR/TE, 165/2.6; flip angle, 90 degrees; matrix size, 384 x 192; slice thickness, 5 mm; field of view, 38 cm(2). Two investigators determined the region of interest in the colon by outlining areas of high signal intensity of meconium slice by slice. They then calculated colonic luminal volume in the regions of interest. Colonic luminal volumes were reported relative to gestational age and abdominal circumference. Normative curves were generated, and interobserver and intraobserver analyses were performed. RESULTS: Seventeen of the 83 fetuses (20%) were excluded because of movement artifacts on the images. Normal colonic luminal volume increased exponentially with gestational age and abdominal circumference. The range of colonic luminal volumes at 20-37 weeks' gestational age was 1.1-65 mL. Variation of volume was greater at advanced gestational age. Interobserver and intraobserver correlation was good. CONCLUSION: This study yielded preliminary volumetric measurements of the normal fetal colon at 20-37 weeks of gestational age that suggest the fetal colon grows exponentially.

Cranial CT for diagnosis of intracranial complications in adult and pediatric patients during ECMO: Clinical benefits in diagnosis and treatment.

RATIONALE AND OBJECTIVES: To evaluate the clinical utility of cranial computed tomography (CT) in pediatric and adult patients during ongoing extracorporeal membrane oxygenation (ECMO) treatment from acute respiratory failure and to assess the frequency of intracranial hemorrhage (ICH) and infarction during the treatment. MATERIALS AND METHODS: The medical records of 123 consecutive patients, 54 children (ages 3 months-17 years) and 69 adults (ages 18-62 years), treated with ECMO over a 10-year period were searched for cranial CT performed during ECMO. Indications for CT, CT findings, impact on clinical management, and patient outcome were noted. In addition, all CT scans were reviewed for the frequency of ICH or infarction. RESULTS: Seventy-eight patients had cranial CT while on ECMO. ICH or cerebral infarction were detected in 45 (37%) of the 123 patients. Eighteen patients (15%) had focal hemorrhage, 11 (9%) focal infarction, and 16 (13%) general brain edema. In 16 of the 45 patients, the CT findings were decisive to withdraw the ECMO treatment. Five patients were weaned from ECMO, and in four patients the findings motivated cranial surgery during ECMO. In the remaining 20 patients with less extended intracranial pathology, the ECMO treatment was continued with high survival. CONCLUSION: Cranial CT has an important role during ECMO treatment to reveal or exclude severe intracranial complications where ECMO treatment should be discontinued. Less severe complications have a favorable prognosis with continued treatment. Our study suggests an underreporting of intracranial complications in adults and pediatric patients on ECMO because of low utilization of neuroimaging.

Chest and abdominal CT during extracorporeal membrane oxygenation: Clinical benefits in diagnosis and treatment.

RATIONALE AND OBJECTIVE: This study aims to evaluate the clinical usefulness of thoracic and abdominal computed tomography (CT) as an adjunct to bedside diagnostic imaging in patients on extracorporeal membrane oxygenation (ECMO) therapy because of severe acute respiratory failure. MATERIALS AND METHODS: Imaging records for 118 consecutive thoracic and abdominal CT examinations performed in 63 patients (22 neonates, 15 children, and 26 adults) on ECMO therapy during an 8-year period were retrospectively reviewed. Reported CT findings were compared with concurrent bedside radiographs and ultrasounds. The clinical importance and effect on treatment of each CT finding was determined by reviewing the medical records. RESULTS: CT showed 30 clinically important complications in 20 different patients that directly impacted on the treatment, but were not diagnosed with bedside imaging. Of the 30 complications, 15 (50%) were surgically treated, 11 (37%) required percutaneous invasive procedures, and 4 (13%) were managed conservatively. Despite the serious complications, 13 of 20 patients (65%) survived. CONCLUSION: Both chest and abdominal CT have an important clinical role in patients on ECMO therapy because of acute respiratory failure, as a complement to bedside imaging, to exclude or show complications and expedite early invasive treatment, when needed.