Ensuring Appropriateness of Pediatric Second Opinion Consultations.

PURPOSE: We sought to evaluate discrepancy rates between outside interpretations, radiology trainee preliminary reports, and subspecialist attending final interpretations for pediatric second opinion consultations on plain film and computed tomography imaging and to evaluate the impact of a process improvement for second opinion consultations. METHODS: Of a total of 572 requests for second opinion consultations during 1-year preintervention period, we utilized RADPEER to score concurrence of 158 requests which occurred overnight and included outside radiologist interpretations and resident preliminary reports. In consultation with clinician committees, we developed new guidelines for requesting second opinion consultations. We evaluated the impact on the number of consultations for the 1-year period following implementation of this process improvement. RESULTS: There was concurrence between the outside interpretation and pediatric subspecialist second opinion in 146 of 158 cases (92%). There was concurrence between the radiology resident and pediatric subspecialist second opinion in 145 of 158 cases (92%). During the 1-year period following our process improvement implementation, the total number of second opinion consultations decreased to 185 (from 572, a decrease of 68%) and the number of overnight requests for resident preliminary reports decreased to 11 (from 158, a decrease of 93%). CONCLUSIONS: There was a high degree of concurrence between interpretations provided by outside radiologists, overnight radiology residents, and attending pediatric radiologists at our institution. Analyzing institutional-specific discrepancy rates is a valuable first step in partnering with clinicians to develop appropriate guidelines for second opinion consultations.

Congenital neuroglial choristoma of the foot.

Neuroglial choristomas are rare malformations of heterotopic neural tissue that have been previously reported predominantly in the head and neck. Competing theories of embryogenesis propose their origin as encephaloceles that have undergone resorption of their cranial connection or displaced neuroectodermal cells which have undergone ectopic proliferation. Most cases occur in midline or para-midline structures. There have been no prior published cases of a neuroglial choristoma in the extremities. We present a case of a 13-month-old otherwise healthy child who presented to our institution with a slowly growing foot mass who was found to have a neuroglial choristoma. This case suggests an early embryological migration defect as the etiology and offers a unique differential consideration for a benign extremity mass.

Contrast-induced nephropathy.

Contrast-induced nephropathy (CIN) has been extensively studied since the 1950s due, in part, to its devastating adverse events. The intellectual push for additional investigation into pathogenesis and prevention has heightened in recent years due to increased utilization of contrast enhanced imaging studies. Lack of a universal CIN definition and varied glomerular filtration rate markers have resulted in a varied reported incidence. Risk assessment and risk reduction strategies have evolved over the past several years. Current evidence supports volume supplementation before the administration of intravascular contrast to reduce the hazard of CIN. Other strategies to reduce the risk of CIN, including low osmolar contrast media, N-acetylcysteine, and intrarenal fenoldopam therapy, have variable levels of evidence, and further randomized trials are necessary.