Pediatric CT radiation exposure: where we were, and where we are now

Two-year experience of radiation dose watch for pediatric general fluoroscopic examinations

BACKGROUND

The radiation dose of pediatric general fluoroscopy exams has historically been a topic of concern, with ongoing efforts and significant progress made.

OBJECTIVE

The purpose of this study is to evaluate dose performance with a dose monitor program for pediatric general fluoroscopy.

MATERIALS AND METHODS

Pediatric general fluoroscopy exams performed between April 1, 2020, and Dec. 31, 2022 were collected and monitored. For each exam, fluoroscopy time, dose-area-product (DAP), reference air kerma (RAK), and patient demographic information were analyzed. RAK, DAP, and fluoroscopy time were tested using Pearson's correlation methods for the three most frequently performed procedures. The influence of patient habitus on dose was studied using linear regression methods. Dose performance among radiologists was compared and so the Wilcoxon signed-rank test between radiologists with ≤ 5 years and > 5 years of experience post fellowship. A significance level of P<0.05 was used to determine statistical significance.

RESULTS

A total of 12,029 cases were analyzed and the median RAK values range from 0.10 mGy to 1.30 mGy. RAK demonstrated a stronger correlation with DAP (upper gastrointestinal (UGI), R=0.97; P<0.0001) than with fluoroscopy time (UGI, R=0.19; P<0.0001). RAK values were linearly correlated with patient weight (UGI, R=0.49; P<0.0001). A stable trend of median RAK values was observed across the studied time periods. Radiologists with ≤ 5 years' experience showed significantly lower (P<0.0001) RAK than those with > 5 years' experience.

CONCLUSION

Variations of pediatric general fluoroscopy dose performance were observed when comparing with other investigations. This study demonstrated that both patient size and operator experience influence radiation output in general fluoroscopy, factors that should be considered for pediatric fluoroscopy procedures.

Photon-counting CT yields superior abdominopelvic image quality at lower radiation and iodinated contrast doses

BACKGROUND

Photon-counting detector (PCD) computed tomography (CT) has been shown to provide better image quality at lower radiation and intravenous contrast doses than energy-integrating detector (EID) CT in adult patients. There is limited data on these benefits for the pediatric population especially for abdominopelvic CT examinations.

OBJECTIVE

This study examines a reduced weight-based iodinated contrast dosing strategy in pediatric abdominopelvic CT on a PCD-CT system compared to standard dosing protocols on EID-CT using 1 mL/kg and 2 mL/kg, respectively. Image quality is assessed using both quantitative and qualitative measures. We also compare the radiation dose profile between the two PCD-CT and EID-CT cohorts.

MATERIALS AND METHODS

This HIPAA-compliant, IRB-approved, retrospective study included pediatric patients (≤18 years of age) who underwent contrast-enhanced CT examinations of the abdomen and pelvis for routine clinical care (01/2022 - 01/2023) in the portal-venous phase on a PCD-CT (NAEOTOM Alpha; Siemens Healthineers). Inclusion criteria included a similar prior examination within 12-months on a dual-source EID-CT scanner from the same vendor. All PCD-CT and EID-CT scans were acquired using weight-based dosing for intravenous contrast media, 1 mL/kg and 2 mL/kg, respectively, based on institutional protocols. Contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were measured in the aorta, portal vein, liver parenchyma, and skeletal muscle. Three pediatric radiologists qualitatively evaluated each scan for overall image quality, noise, and contrast on a scale of 0-100. Confidence in small structure detection (common bile duct) was also rated on a scale of 0-3. Radiation doses (size-specific dose estimate (SSDE)) were calculated. Statistical analysis included paired t-tests and a mixed linear effects model to account for patient age, sex, and X-ray tube voltage. A P<0.05 indicated statistical significance.

RESULTS

A total of 49 patients were included (24 female; mean [SD] age 9.9 [6.3] years, range 0.6-18 years). Compared to EID-CT, PCD-CT had a higher mean SNR in the portal vein (23.4 [SD=9.3] vs 17.2 [SD=7.4], P<0.001), aorta (23.4 [SD=11.6] vs 17.7 [10.1], P=0.017), hepatic parenchyma (15.2 [SD=5.6] vs 13.2 [5.1], P=0.016), and skeletal muscle (5.7 [SD=3.1] vs 4.5 [SD=3.1], P=0.01). Compared to EID-CT, PCD-CT also had a higher mean CNR in the portal vein (27.5 [SD=9.6] vs 22.1 [SD=21.1], P=0.003), aorta (27.3 [SD=9.6] vs 22.3 [SD=11.8], P=0.004), hepatic parenchyma (20 [SD=6.9] vs 16.9 [SD=8.5], P=0.013), and skeletal muscle (14.6 [4.9] vs 12.1 [5.6], P=0.008). Overall image quality, image noise, and small structure detection confidence scores were higher on PCD-CT than EID-CT (P=0.037, P<0.001, and P=0.006, respectively). Mean SSDE for PCD-CT was lower than EID-CT (9.1 mGy [SD=4.3] vs 11 mGy [5.9], P=0.012).

CONCLUSION

Compared with EID-CT, contrast-enhanced pediatric abdominopelvic CT offers improved subjective and objective image quality, even at lower radiation doses and reduced intravenous contrast medium volumes.

Emergency Department Evaluation of Pediatric Patients With Abdominal Pain and Trauma During the National Intravenous Iodinated Contrast Media Shortage

INTRODUCTION

Research on the effects of the 2022 national intravenous iodinated contrast media (ICM) shortage on the pediatric population in the emergency department is limited. The purpose of this study was to evaluate pediatric patients who had a computed tomography (CT) of the abdomen/pelvis during the 2022 ICM shortage, and to identify whether any important abdominal diagnoses were missed or if additional CT scans were obtained to accommodate for a lack of available ICM. We hypothesized a decrease in ICM utilization without any increased incidence in missed diagnoses.

METHODS

This is a multi-center retrospective chart review of pediatric patients (<18 years old) who had a CT of the abdomen/pelvis in the emergency department for any indication (abdominal pain or trauma) during the ICM shortage (May 12, 2022-June 29, 2022). A control group from March 22, 2022 to May 11, 2022 was included. The primary outcome was the rate of missed clinically significant diagnoses after initial non-contrast CT.

RESULTS

There were 446 patients included; 403 patients presented for abdominal pain (224 controls) and 43 patients presented due to trauma (23 controls). ICM utilization decreased significantly during the shortage period: for the abdominal pain cohort, ICM utilization decreased by 55% (95% CI: 47-63), for trauma patients ICM utilization decreased by 41% (95% CI: 17-64). There were no cases of clinically significant missed diagnoses due to noncontrast studies during the shortage period, in both abdominal pain and trauma cohorts. In the abdominal pain cohort, there were 3 (1.7%) repeat CT scans during the shortage period and 1 (0.5%) during the control period (difference: 1.2%, 95% CI: -0.9% to 3.2%). None of these additional studies were contrast-enhanced after an initial noncontrast study. There were no repeat CT scans in the trauma cohort.

CONCLUSION

Despite the decrease in IV contrast CT scans ordered, our study did not identify any patients with missed diagnoses in the setting of the ICM shortage. We believe this data adds to the body of literature exploring the necessity of intravenous contrast when it is not utilized or unable to be utilized in computed tomography imaging.

Thoracic CT Angiographies in Children Using Automated Power Injection with Bolus Tracking Versus Manual Contrast Injection: Analysis of Contrast Enhancement, Image Quality and Radiation Exposure

Objectives: The purpose of this study was to analyze image quality and radiation exposure of thoracic computed tomography angiography (CTA) in children with congenital heart diseases (CHDs) using either manual contrast medium (CM) injection or automated power injectors with bolus tracking. Methods: A total of 137 thoracic CTAs of 120 consecutive pediatric patients were included in this retrospective study. We analyzed the method of CM administration (power injection with bolus tracking (PI) or manual injection (MI)), injection routes, volumes and flow rates of CM. For the evaluation of objective image quality, attenuation values in the heart chambers and great thoracic vessels were determined by region-of-interest (ROI) analysis and signal-to-noise (SNR) and contrast-to-noise (CNR) ratios calculated thereof. Visual image quality was assessed by two blinded readers (four-point Likert-scale) analyzing the presence of artifacts and the depiction of relevant anatomical structures. Effective radiation doses were calculated with dose length products and specific conversion factors. Results: CM administration was performed using PI in 119/137 CTAs, whereas MI was conducted in 18/137. The smallest size of peripheral venous cannulas was 24 gauge in 36/137 (26.3%) cases. Overall mean CM volume was 17 mL ± 16 mL (mean ± SD). In PI, the mean flow rate of CM was 1.52 ± 0.90 mL/s with a range between 0.5 and 5.0 mL/s. When comparing the overall PI population and an age-, size- and weight-matched PI subpopulation (18 cases) with the MI population, attenuation values in Hounsfield units (HU) and CNR values were significantly higher in the PI groups than in the MI group for each relevant cardiac structure (left ventricle, right ventricle, ascending aorta and pulmonary trunk, p = 0.02-0.001). Overall image quality and depiction of cardiac structures were rated significantly better in CTAs with PI (interquartile ranges: "good" to "excellent" (Likert 3-4)) in PI compared with CTAs acquired with MI (interquartile ranges: "fair" to "good" (2-3)) in MI by both readers (p < 0.001). The inter-observer reliability was strong, with a Kendall's Tau-b correlation coefficient of τ = 0.802 (p < 0.001). The mean effective radiation dose (E) did not differ significantly when comparing the stratified samples (i.e., the matched PI subgroup and the MI group; 0.5 (±0.3) mSv in both, p = 0.76). There were no complications associated with the CM injections for both application approaches. Conclusions: Automated contrast agent applications with power injectors and bolus tracking ensure better image quality in pediatric CTA, even when low volumes and flow rates need to be applied. There is a slight increase in radiation associated with bolus tracking. This approach represents a suitable imaging technique for the work-up of congenital heart disease.

Imaging Diagnosis of Major Kidney and Urinary Tract Disorders in Children

Background and Objectives: Diagnostic imaging is essential for evaluating urinary tract disorders, offering critical insights into renal pathology. This review examines the strengths, limitations, and clinical applications of various imaging modalities, with a focus on pediatric populations. Materials and Methods: A narrative review was conducted, synthesizing current literature on ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, and voiding cystourethrography (VCUG). Relevant studies were selected based on diagnostic accuracy, clinical utility, and safety considerations. Results: US is the preferred first-line imaging due to its safety, accessibility, and cost-effectiveness. CT excels in detecting renal calculi, trauma, and malignancies but is limited by radiation exposure. MRI offers superior soft tissue contrast without radiation but is costly and often requires sedation. Nuclear medicine evaluates renal function and scarring, while VCUG remains the gold standard for diagnosing vesicoureteral reflux and posterior urethral valves. Conclusions: Imaging modalities are vital for diagnosing and managing urinary tract disorders, with selection based on clinical needs, patient age, and safety. Ultrasound is the primary choice for its non-invasiveness and cost-effectiveness, while CT, MRI, nuclear medicine, and VCUG provide essential structural and functional insights. A balanced approach ensures accuracy while minimizing patient risk, especially in pediatrics.

Who Is Diagnosing Pediatric Thyroid Nodules? A Tertiary Children's Hospital Review

OBJECTIVE

The incidence of pediatric thyroid cancer has increased. Little is documented about which providers are diagnosing pediatric thyroid nodules and how this impacts care. Our objective was to analyze how nodules are identified and how diagnosing provider type impacts nodule size and management.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care children's hospital.

METHODS

Pediatric patients (aged 0-17) with at least one thyroid nodule diagnosed between 2006 and 2023 were reviewed. Diagnosing provider type, diagnostic method, nodule size, clinical management, and final diagnosis were analyzed.

RESULTS

The study included 351 patients. Primary care providers diagnosed the largest proportion of nodules (43.0%), followed by incidental nodules by radiologists (24.2%). The proportion diagnosed by radiologists increased from 12% to 31% after 2017 (P < .001). Primary care providers were more likely to use physical exam than pediatric endocrinologists (65% vs 42%, P = .004), who more often used ultrasound (56% vs 37%, P = .02). Primary care providers diagnosed nodules with a median diameter of 1.50 cm, larger than that of pediatric endocrinologists and radiologists, both 0.8 cm (P = .01, P < .001). Compared to patients diagnosed by radiologists, patients diagnosed by primary care providers more often underwent biopsy (P = .02) or surgery (P < .001) and received a malignant diagnosis (P = .001).

CONCLUSION

Primary care providers play a key role in detecting pediatric thyroid nodules, and a physical exam is vital in identifying significant pathology. Radiologic incidental nodules increased in frequency over our study timespan. Future research should consider the impact of socioeconomic status or geographic location on nodule size and management.

Review Article: Diagnostic Paradigm Shift in Spine Surgery

Meticulous clinical examination is essential for spinal disorders to utilize the diagnostic methods and technologies that strongly support physicians and enhance clinical practice. A significant change in the approach to diagnosing spinal disorders has occurred in the last three decades, which has enhanced a more nuanced understanding of spine pathology. Traditional radiographic methods such as conventional and functional X-rays and CT scans are still the first line in the diagnosis of spinal disorders due to their low cost and accessibility. As more advanced imaging technologies become increasingly available worldwide, there is a constantly increasing trend in MRI scans for detecting spinal pathologies and making treatment decisions. Not only do MRI scans have superior diagnostic capabilities, but they also assist surgeons in performing meticulous preoperative planning, making them currently the most widely used diagnostic tool for spinal disorders. Positron Emission Tomography (PET) can help detect inflammatory lesions, infections, and tumors. Other advanced diagnostic tools such as CT/MRI fusion image, Functional Magnetic Resonance Imaging (fMRI), Upright and Kinetic MRI, magnetic resonance spectroscopy (MRS), diffusion-weighted imaging (DWI), and diffusion tensor imaging (DTI) could play an important role when it comes to detecting more special pathologies. However, some technical difficulties in the daily praxis and their high costs act as obstacles to their further spread. Integrating artificial intelligence and advancements in data analytics and virtual reality promises to enhance spinal procedures' precision, safety, and efficacy. As these technologies continue to develop, they will play a critical role in transforming spinal surgery. This paradigm shift emphasizes the importance of continuous innovation and adaptability in improving the diagnosis and treatment of spinal disorders.

Analyzing Radiation Protection Risks in Nuclear Medicine: Cause Investigation and WSR-Based Countermeasure Evaluation

Objective

To analyze and investigate the causes of radiation protection safety risks in nuclear medicine diagnosis and treatment, formulate radiation protection safety management countermeasures, and evaluate their effectiveness.

Methods

In October 2020, the Department of Nuclear Medicine at our hospital established a radiation protection safety management team, utilizing association rules to investigate and analyze the causes of radiation protection safety risks. A Wuli-Shili-Renli (WSR) system management approach was implemented, addressing physical (Wuli), procedural (Shili), and human factors (Renli) to improve technical safeguards, optimize processes, and enhance personnel awareness. A total of 1200 patients receiving diagnosis and treatment were divided into two groups. The control group (600 cases) used standard inspection-based radiation protection, while the observation group (600 cases) adopted WSR system management in addition to standard measures. Radiation protection risk control effectiveness and safety control capability scores were compared between the two groups.

Results

The proportions of excessive diagnostic doses and additional radiation harm in the observation group were both lower than those in the control group (P < 0.05); the proportions of risk sources, including building environment, protective measures, dose monitoring, safety awareness, and waste disposal, in the observation group were all lower than those in the control group (P < 0.05). The observation group's scores in radiation protection theory, practical risk management skills, and radiation protection safety literacy, as well as the total score, were higher than those of the control group (P < 0.05).

Conclusion

The WSR system management approach effectively reduces radiation protection safety risks, improves the diagnostic and therapeutic environment, minimizes radiation exposure to patients and staff, and enhances safety risk management levels in nuclear medicine departments.

The application of lightweight AI algorithms in postoperative rehabilitation of breast cancer

The prevalence of breast cancer as a major global cancer has underscored the importance of postoperative recovery for breast cancer patients. Among the issues, postoperative patients are prone to spinal deformities, including scoliosis, which has drawn significant attention from healthcare professionals. The primary aim of this study is to design a postoperative recovery platform for breast cancer patients that can effectively detect posture changes, provide feedback and support to medical staff, assist doctors in formulating recovery plans, and prevent spinal deformities. The feasibility of the recovery platform is also validated through experiments. The development and validation of the experimental recovery platform. The recovery platform includes instrument design, patient data collection, model training and fine-tuning, and postoperative body posture evaluation by comparing preoperative and postoperative conditions. The evaluation results are provided to doctors to facilitate the formulation of personalized postoperative recovery plans. This paper comprehensively designs and implements the recovery platform and verifies its feasibility through simulation experiments. Statistical methods were employed for the validation of the rehabilitation platform in simulated experiments, with a significance level of p < 0.05. In comparison to static assessments like CT scans, this paper introduces a dynamic detection method that provides a more insightful analysis of body posture. The experiments also demonstrate the preventive capability of this method against post-operative spinal deformities, ultimately enhancing patients' self-image, restoring their confidence, and enabling them to lead more fulfilling lives.

Is imaging necessary in pediatric patients with isolated tinnitus?

OBJECTIVES

Tinnitus is a common otologic complaint which can range from bothersome to debilitating. Imaging is frequently utilized to rule out tumors, fractures, and other causes but can also cause significant medical and economic burden for patients. Furthermore, the pediatric population may require sedation for imaging. This study explored how commonly imaging was performed in pediatric patients with isolated tinnitus and whether imaging results affected clinical care.

METHODS

A retrospective case series of 266 patients aged 0-22 years diagnosed with tinnitus at a tertiary children's hospital was performed. Patients with otologic complaints other than tinnitus were excluded. Logistic regression, Wilcoxon rank-sum tests, and log-rank survival analysis were used for statistical analysis.

RESULTS

The mean age of tinnitus diagnosis was 13.4 years (IQR 10.8-16.7), 221/266 (83.1 %) of patients were white, and 139/266 (52.3 %) were male. In the 108 with details available, 29 (26.9 %) had pulsatile tinnitus. Twenty-one of two-hundred and sixty-six (7.9 %) had a history of migraines and 24/266 (9.0 %) had a history of psychiatric diagnosis. Seventy-four out of two-hundred and sixty-six (27.8 %) of patients completed CT and/or MRI imaging. Eleven out of forty-four (14.9 %) of those who underwent imaging had abnormal findings, and only 1 MRI and 1 CT showed new abnormal findings. Of note, the abnormal MRI and CT were of the same patient, and the CT was obtained as part of a trauma survey. Of the 64 patients with follow-up, 47 % of patients noted resolution of tinnitus. Patients with pulsatile tinnitus and a history of migraines were more likely to obtain imaging (OR = 8.14, 6.17; p < 0.001, <0.001, respectively). History of sinusitis, head/ear trauma, psychiatric diagnosis, and pulsatile tinnitus was not correlated with new abnormal imaging.

CONCLUSIONS

In pediatric patients with isolated tinnitus, imaging very rarely reveals new abnormalities which can impact clinical care. Additional research is needed to optimize resource utilization and identify cohorts of pediatric patients with tinnitus in whom imaging can be deferred.

Comparing Management Strategies for Thoracolumbar Injury Classification and Severity Score of 4 (TLICS = 4) in the Pediatric Population: A Single-Institutional Experience

BACKGROUND

Thoracolumbar (TL) fractures are uncommon injuries in the pediatric population. Surgery is recommended for TL fractures with significant deformity, posterior ligamentous complex disruption, or neurological compromise. The Thoracolumbar Injury Classification and Severity Scale (TLICS) has been validated in pediatric populations and serves as a valuable tool for guiding treatment decisions. However, there remains a lack of clarity regarding the appropriate treatment for patients with a TLICS of 4. While conservative and surgical techniques have been described, most studies focused on adult populations, and there is no consensus on the appropriate management in the pediatric population. We reviewed our institutional experience of TL fractures in young children with TLICS of 4, managed both non-operatively and operatively.

METHODS

A retrospective review of a single institution's experience managing pediatric patients (<18 years old) with TL fractures receiving a TLICS of 4 from 2015 to 2023 was conducted to determine the clinical outcomes following non-operative and operative treatment.

RESULTS

Among 11 pediatric patients, 4 were managed with bracing alone, primarily for posterior column fractures, using a thoracolumbar sacral orthosis (TLSO). Four patients underwent minimally invasive screw fixation (MISF), for Chance or posterior column fractures, with an average operative time of 143 min, blood loss of 29 cc, length of stay (LOS) of 9.8 days, and a follow-up interval of 6 months. Three patients received open posterior screw fixation (OPSF), most commonly for Chance fractures, with averages of 129 min operative time, 225 cc blood loss, 9.7 days LOS, and 4 months follow-up. Both MISF and OPSF utilized intra-operative imaging, with lower radiation exposure in the MISF group. One MISF patients had hardware failure evident by screw lucency on follow-up imaging.

CONCLUSIONS

Bracing and surgery are safe management options for pediatric TL fractures receiving a TLICS of 4. MISF is an effective alternative treatment strategy, comparable to OPSF, with the advantage of reduced blood loss and radiation exposure. Further studies with age-matched cohorts and long-term outcomes may help determine the optimal management course.

From age-specific to size-specific dose protocol for paediatric head computed tomography: a simple practical strategy for necessity assessment and parameter setting

This study proposes a practical approach to assessing the need for and determining the transitioning parameters from age-specific to size-specific dose protocols in paediatric head computed tomography examinations. It was designed to begin with the two different age-specific protocols currently applied on paediatric patients of 1 y ≤ age ≤ 6 y (21.34 mGy) and those of age >6 y (34.73 mGy). One characteristic size (HDthreshold) was found by measuring anteroposterior head diameter on historical topograms and used with age to set 135 cases into four groups for investigation (A, ≤6y, ≤HDthreshold; B, ≤6y, >HDthreshold; C, >6y, ≤HDthreshold; and D, >6 y, >HDthreshold). The image quality was compared in both subjective and objective manners. Results suggest patients in Group C may have received a potential overdose (38%), while the exposure setting for Group D may replace that for B. The proposed strategy was sufficient to assess the necessity and determine the transitioning parameters from age- to size-specific dose protocols.

Application of rare earth elements in dual-modality molecular probes

The unique 4f subshell electronic structure of rare earth elements endows them with exceptional properties in electrical, magnetic, and optical domains. These properties include prolonged fluorescence lifetimes, large Stokes shifts, distinctive spectral bands, and strong resistance to photobleaching, making them ideal for the synthesis of molecular probes. Each imaging technique possesses unique advantages and specific applicabilities but also inherent limitations due to its operational principles. Dual-modality molecular probes effectively address these limitations, particularly in applications involving high-resolution Magnetic Resonance Imaging (MRI) such as MRI/OI, MRI/PET, MRI/CT, and MRI/US. This review summarizes the applications, advantages, challenges, and current research status of rare earth elements in these four dual imaging modalities, providing a theoretical basis for the future development and application of rare earth elements in the field of dual-modality molecular probes.

Transphyseal Hemiepiphysiodesis: Is it Truly Reversible?

BACKGROUND

Although numerous studies reported the efficacy of percutaneous epiphysiodesis using transphyseal screws (PETS) in correcting angular knee deformities, many surgeons refrained from using it in younger children because of a lack of objective evidence of reversibility. Our hypothesis is that PETS is both truly reversible and effective.

METHODS

Twenty-one patients aged 8 to 13 years (36 lower limbs LL) with coronal plane knee deformity were enrolled into this prospective case series from January 2021 to September 2023. Besides the routine monitoring of PETS efficacy, low dose CT knee of 32 treated physes was done 6 months after screw removal. In addition, lower limb length, mechanical lateral distal femur angle (mLDFA), and medial proximal tibial angle (MPTA) were recorded preoperatively and 6 to 17 months after screw removal for 24 LL to investigate physis behavior, technique reversibility, and resumption of bone growth after screw removal.

RESULTS

The mean mechanical axis deviation (MAD) correction rate was 3.46 mm/mo and 1.78 mm/mo for genu valgum and genu varum patients, respectively. No physeal bony bars could be detected 6 months after screw removal for all patients. Out of 24 physis that underwent computerized radiography (CR) of the whole lower limb, 12 LL resumed their growth, 4 were stationary, while 8 were excluded due to inadequate calibration. A single physis showed rebound deformity, and another showed overcorrection in the genu valgum group.

CONCLUSIONS

In addition to being a highly effective method of hemiepiphysiodesis, PETS was found to be reproducible, safe, and reversible when used in the juvenile and early adolescent pediatric population.

LEVEL OF EVIDENCE

IV-Prospective case series.

Trends and variation in cervical spine imaging utilization across children's hospitals for pediatric trauma

BACKGROUND

Cervical spine (c-spine) evaluation is a critical component in trauma evaluation, and although several pediatric c-spine evaluation algorithms have been developed, none have been widely implemented. Here, we assess rates of c-spine imaging use across children's hospitals, specifically temporal trends in imaging use, variation across hospitals in imaging used, and timing of magnetic resonance imaging in admitted patients.

METHODS

Data from the Children's Hospital Associations Pediatric Health Information System were abstracted from 2015 to 2020. Patients younger than 18 years seen in the emergency department with an International Classification of Diseases, Tenth Revision , code indicative of trauma and c-spine plain radiograph or computed tomography (CT) in the emergency department were included. Data visualization and descriptive statistics were used to assess rates of imaging use by age, year, hospital, injury severity, and day of service. Changes in rates of imaging use over time were evaluated via simple linear regression.

RESULTS

Across 25,238 patient encounters at 35 children's hospitals, there was an increase in use of c-spine CT from 2015 to 2020 (28.5-36.5%). There was substantial interinstitutional variation in rates of use of plain radiographs versus CT for initial evaluation of the c-spine across all age groups. Magnetic resonance imaging was obtained more than 3 days after admission in 31.5% of intensive care patients who received this imaging.

CONCLUSION

Increasing use of CT, substantial interinstitutional variation in rates of use of plain radiographs versus CT, and heterogenous timing of magnetic resonance imaging for evaluation of the pediatric c-spine demonstrate the growing need for development and implementation of an age-specific c-spine evaluation algorithm to guide judicious use of diagnostic resources.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Non-operative management of uncomplicated appendicitis in children: a randomized, controlled, non-inferiority study evaluating safety and efficacy

BACKGROUND

Appendicitis is the commonest paediatric surgical emergency. Adult studies suggest non-operative management (NOM) may have a place in care. There have been no adequately powered randomized controlled trials in children.

OBJECTIVE

to determine the safety and efficacy of NOM for paediatric simple appendicitis.

METHODS

A non-inferiority randomized controlled trial was conducted comparing operative (OM) to NOM of SA in children aged five-15 years. Primary outcome was treatment success (no unplanned or unnecessary operation, or complication) at 30 days and 12 months, with a non-inferiority margin of 15%. (anzctr.org.au: ACTRN12616000788471).

RESULTS

From 11 June 2016 to 30 November 2020, 222 children were randomized: 94 (42.34%) to OM and 128 (57.66%) to NOM. Non-inferiority of NOM was not demonstrated at either time point, with 45.67% of NOM patients subsequently undergoing operation. There was no significant difference in complications.

CONCLUSIONS

While noninferiority was not shown, NOM was safe, with no difference in adverse outcomes between the two groups. Further research to refine the place of NOM of simple appendicitis in children is required, including nuanced patient selection, longer term evaluation, the place of choice, and the acceptability of the treatment for children and their carers.

Advancements in imaging in ChILD

Interstitial and diffuse lung diseases in children constitute a range of congenital and acquired disorders. These disorders present with signs and symptoms of respiratory disease accompanied by diffuse radiographic changes. In many cases, radiographic findings are nonspecific, while in other disorders, chest computed tomography (CT) is diagnostic in the appropriate context. Regardless, chest imaging remains central in the evaluation of the patient with suspected childhood interstitial lung disease (chILD). Several newly described chILD entities, spanning both genetic and acquired etiologies, have imaging that aid in their diagnoses. Advances in CT scanning technology and CT analysis techniques continue to improve scan quality as well as expand use of chest CT as a research tool. Finally, ongoing research is expanding use of imaging modalities without ionizing radiation. Magnetic resonance imaging is being applied to investigate pulmonary structure and function, and ultrasound of the lung and pleura is a novel technique with an emerging role in chILD disorders. This review describes the current state of imaging in chILD including recently described diagnoses, advances in conventional imaging techniques and applications, and evolving new imaging modalities that expand the clinical and research roles for imaging in these disorders.

Reducing Postoperative CT Imaging for Children With Complicated Appendicitis: A Pediatric Surgical Quality Collaborative Quality Improvement Project

BACKGROUND

Despite widespread initiatives to reduce ionizing radiation for appendicitis diagnosis, computed tomography (CT) scanning postoperatively remains common. The Pediatric Surgery Quality Collaborative (PSQC) aimed to identify differences between children's hospitals with high and low postoperative CT usage for complicated appendicitis.

METHODS

Using National Surgery Quality Improvement Program Pediatric data from PSQC children's hospitals, we compared postoperative CT imaging for complicated appendicitis (April 2020-March 2021). Key stakeholders from 11 hospitals (5 low CT utilization, 6 high CT utilization) participated in semi-structured interviews regarding postoperative imaging. Qualitative analysis of transcripts was performed deductively and inductively based on the Theoretical Domains Framework (TDF).

RESULTS

Five of twelve TDF domains were most prominent in influencing CT use: skills, beliefs about capabilities, intentions/goals, memory and decision processes, and environment. Children's hospitals with lower rates of postoperative CT use tended to: trust and educate the ultrasound technicians; believe US strengths outweigh weaknesses; image no sooner than 7 days postoperatively; have access to sufficient quality improvement resources; maintain trusting relationships between specialties; and prioritize radiation stewardship.

CONCLUSION

Hospitals at extremes of postoperative CT use for complicated appendicitis reveal strategies for improvement, which include imaging protocol development and adherence, quality improvement resource availability, interdisciplinary collaboration, and promoting radiation stewardship.

LEVEL OF EVIDENCE

Level V.

Pediatric Carotid Injury after Blunt Trauma and the Necessity of CT and CTA-A Narrative Literature Review

Background: Blunt carotid injury (BCI) in pediatric trauma is quite rare. Due to the low number of cases, only a few reports and studies have been conducted on this topic. This review will discuss how frequent BCI/blunt cerebrovascular injury (BCVI) on pediatric patients after blunt trauma is, what routine diagnostics looks like, if a computed tomography (CT)/computed tomography angiography (CTA) scan on pediatric patients after blunt trauma is always necessary and if there are any negative health effects. Methods: This narrative literature review includes reviews, systematic reviews, case reports and original studies in the English language between 1999 and 2020 that deal with pediatric blunt trauma and the diagnostics of BCI and BCVI. Furthermore, publications on the risk of radiation exposure for children were included in this study. For literature research, Medline (PubMed) and the Cochrane library were used. Results: Pediatric BCI/BCVI shows an overall incidence between 0.03 and 0.5% of confirmed BCI/BCVI cases due to pediatric blunt trauma. In total, 1.1-3.5% of pediatric blunt trauma patients underwent CTA to detect BCI/BCVI. Only 0.17-1.2% of all CTA scans show a positive diagnosis for BCI/BCVI. In children, the median volume CT dose index on a non-contrast head CT is 33 milligrays (mGy), whereas a computed tomography angiography needs at least 138 mGy. A cumulative dose of about 50 mGy almost triples the risk of leukemia, and a cumulative dose of about 60 mGy triples the risk of brain cancer. Conclusions: Given that a BCI/BCVI could have extensive neurological consequences for children, it is necessary to evaluate routine pediatric diagnostics after blunt trauma. CT and CTA are mostly used in routine BCI/BCVI diagnostics. However, since radiation exposure in children should be as low as reasonably achievable, it should be asked if other diagnostic methods could be used to identify risk groups. Trauma guidelines and clinical scores like the McGovern score are established BCI/BCVI screening options, as well as duplex ultrasound.

Pediatric Odontogenic Sinusitis: A Systematic Review

Background: Pediatric odontogenic sinusitis (PODS) is a rare condition with limited research on its clinical features, diagnostic criteria, and treatment options. The current guidelines on pediatric rhinosinusitis do not mention a possible dental origin of the disease. This systematic review aims to summarize and analyze the existing literature on PODS, focusing on epidemiology, etiology, diagnostic tools, complications, treatment options, and outcomes. Methods: A systematic review was conducted following PRISMA reporting guidelines. Electronic searches were performed in multiple databases using keywords related to PODS and therapeutic strategies. Original articles reporting data on treatment outcomes for PODS were included. Results: The review highlighted the scarcity of high-quality evidence on PODS. The literature mainly consists of case reports and low-grade evidence studies. Limited data on the epidemiology, etiology, diagnostic tools, complications, and treatment outcomes of PODS in children are available. Conclusions: Further research is needed to better understand the clinical features, diagnosis, and treatment of PODS in pediatric patients. High-quality studies are required to establish evidence-based guidelines for the management of this condition, especially given the apparently high rate of complications when compared to adult ODS.

3D Analysis of the Cranial and Facial Shape in Craniosynostosis Patients: A Systematic Review

With increasing interest in 3D photogrammetry, diverse methods have been developed for craniofacial shape analysis in craniosynostosis patients. This review provides an overview of these methods and offers recommendations for future studies. A systematic literature search was used to identify publications on 3D photogrammetry analyses in craniosynostosis patients until August 2023. Inclusion criteria were original research reporting on 3D photogrammetry analyses in patients with craniosynostosis and written in English. Sixty-three publications that had reproducible methods for measuring cranial, forehead, or facial shape were included in the systematic review. Cranial shape changes were commonly assessed using heat maps and curvature analyses. Publications assessing the forehead utilized volumetric measurements, angles, ratios, and mirroring techniques. Mirroring techniques were frequently used to determine facial asymmetry. Although 3D photogrammetry shows promise, methods vary widely between standardized and less conventional measurements. A standardized protocol for the selection and documentation of landmarks, planes, and measurements across the cranium, forehead, and face is essential for consistent clinical and research applications.

European Society of Pediatric Radiology survey of perioperative imaging in pediatric liver transplantation: (1) pre-transplant evaluation

BACKGROUND

Liver transplantation is the state-of-the-art curative treatment in end-stage liver disease. Imaging is a key element for successful organ-transplantation to assist surgical planning. So far, only limited data regarding the best radiological approach to prepare children for liver transplantation is available.

OBJECTIVES

In an attempt to harmonize imaging surrounding pediatric liver transplantation, the European Society of Pediatric Radiology (ESPR) Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra-, and postoperative phase. This paper reports the responses on preoperative imaging.

MATERIAL AND METHODS

An online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted and 22 institutions from 11 countries returned the survey. From 2018 to 2020, the participating centers collectively conducted 1,524 transplantations, with a median of 20 transplantations per center per annum (range, 8-60).

RESULTS

Most sites (64%) consider ultrasound their preferred modality to define anatomy and to plan surgery in children before liver transplantation, and additional cross-sectional imaging is only used to answer specific questions (computed tomography [CT], 90.9%; magnetic resonance imaging [MRI], 54.5%). One-third of centers (31.8%) rely primarily on CT for pre-transplant evaluation. Imaging protocols differed substantially regarding applied CT scan ranges, number of contrast phases (range 1-4 phases), and applied MRI techniques.

CONCLUSION

Diagnostic imaging is generally used in the work-up of children before liver transplantation. Substantial differences were noted regarding choice of modalities and protocols. We have identified starting points for future optimization and harmonization of the imaging approach to multicenter studies.

Minimally Invasive Techniques in the Surgical Management of Traumatic Pediatric Thoracolumbar Fractures

BACKGROUND

Thoracolumbar (TL) fractures are uncommon in children. While surgical treatment is recommended for unstable TL fractures, there is no consensus on appropriate surgical treatment. We present a case series of pediatric patients with traumatic TL fractures treated with minimally invasive techniques. We discuss our early experience and technical challenges with navigation and robotic-assisted fixation.

METHODS

A retrospective review of a prospectively maintained trauma database from February 2018 to February 2023 of all pediatric patients (<18 years old) undergoing percutaneous fixation for unstable TL fractures was performed. Minimally invasive techniques included fluoroscopy and/or navigation-guided or robotic-assisted surgery. Clinical course, radiographic findings, and technical challenges were reviewed.

RESULTS

A cohort of 12 patients (age range, 4-17 years) with 6 (50%) Chance fractures, 2 (16%) pars fractures, 2 (16%) pedicle fracture, 1 (8%) burst fracture, and 1 (8%) other fracture were identified. Nine patients had fractures involving the lumbar spine, and the remaining 3 had thoracic fractures. In all cases, percutaneous pedicle screws were placed above and below the fracture with the use of neuronavigation or robotic-assisted navigation (n = 2). Blood loss was <30 mL for single-level fractures and instrumented fusion. Two patients had hardware-related complications. At follow-up (mean 9.67 months after surgery), patients were doing well clinically, and most imaging showed stable alignment.

CONCLUSIONS

Our early experience shows that short segment instrumentation through a minimally invasive approach is a safe and effective surgical option for young pediatric patients with good clinical outcomes and favorable radiographic postoperative finding.

Gaps and priorities in innovation for children's surgery

Lack of access to pediatric medical devices and innovative technology contributes to global disparities in children's surgical care. There are currently many barriers that prevent access to these technologies in low- and middle-income countries (LMICs). Technologies that were designed for the needs of high-income countries (HICs) may not fit the resources available in LMICs. Likewise, obtaining these devices are costly and require supply chain infrastructure. Once these technologies have reached the LMIC, there are many issues with sustainability and maintenance of the devices. Ideally, devices would be created for the needs and resources of LMICs, but there are many obstacles to innovation that are imposed by institutions in both HICs and LMICs. Fortunately, there is a growing interest for development of this space, and there are many examples of current technologies that are paving the way for future innovations. Innovations in simulation-based training with incorporated learner self-assessment are needed to fast-track skills acquisition for both specialist trainees and non-specialist children's surgery providers, to scale up access for the larger population of children. Pediatric laparoscopy and imaging are some of the innovations that could make a major impact in children's surgery worldwide.

Blunt Trauma in Children: Efficacy and Safety of Transarterial Embolization, 10-Year Experiences in a Single Trauma Center

BACKGROUND

Transcatheter arterial embolization (TAE) is an established approach for controlling hemorrhage in adults with acute abdominal and pelvic trauma. However, its application in pediatric trauma is not well established. This study aimed to evaluate the safety and effectiveness of TAE in a population of pediatric patients with blunt trauma.

METHODS

This retrospective study was conducted in pediatric patients (<18 years) who underwent TAE for blunt trauma between February 2014 and July 2022. The patients were categorized into subgroups based on age and body weight. Patient demographics, injury severity, transfusion requirements, and clinical outcomes were analyzed.

RESULTS

Exactly 73 patients underwent TAE. Technical success was achieved in all patients (100%), and clinical success was achieved in 83.6%. The mortality and complication rates were 4.1% and 1.4%, respectively. The mean duration of hospitalization was 19.3 days. Subgroup analysis showed that age, body weight, and sex did not significantly affect clinical success. The injury severity score and transfusion requirement were predictors of clinical success, with lower values associated with better outcomes.

CONCLUSIONS

TAE is effective and safe for managing blunt pediatric trauma in younger and lighter patients. Injury severity and transfusion requirement are predictors of clinical success.

Dose Optimization Using a Deep Learning Tool in Various CT Protocols for Urolithiasis: A Physical Human Phantom Study

Background and Objectives: We attempted to determine the optimal radiation dose to maintain image quality using a deep learning application in a physical human phantom. Materials and Methods: Three 5 × 5 × 5 mm3 uric acid stones were placed in a physical human phantom in various locations. Three tube voltages (120, 100, and 80 kV) and four current-time products (100, 70, 30, and 15 mAs) were implemented in 12 scans. Each scan was reconstructed with filtered back projection (FBP), statistical iterative reconstruction (IR, iDose), and knowledge-based iterative model reconstruction (IMR). By applying deep learning to each image, we took 12 more scans. Objective image assessments were calculated using the standard deviation of the Hounsfield unit (HU). Subjective image assessments were performed by one radiologist and one urologist. Two radiologists assessed the subjective assessment and found the stone under the absence of information. We used this data to calculate the diagnostic accuracy. Results: Objective image noise was decreased after applying a deep learning tool in all images of FBP, iDose, and IMR. There was no statistical difference between iDose and deep learning-applied FBP images (10.1 ± 11.9, 9.5 ± 18.5 HU, p = 0.583, respectively). At a 100 kV-30 mAs setting, deep learning-applied FBP obtained a similar objective noise in approximately one third of the radiation doses compared to FBP. In radiation doses with settings lower than 100 kV-30 mAs, the subject image assessment (image quality, confidence level, and noise) showed deteriorated scores. Diagnostic accuracy was increased when the deep learning setting was lower than 100 kV-30 mAs, except for at 80 kV-15 mAs. Conclusions: At the setting of 100 kV-30 mAs or higher, deep learning-applied FBP did not differ in image quality compared to IR. At the setting of 100 kV-30 mAs, the radiation dose can decrease by about one third while maintaining objective noise.

Can magnetic resonance imaging replace computed tomography scans in the evaluation of pediatric post-appendectomy abscess?

BACKGROUND

Computed tomography scans have been used when cross-axial imaging is required to evaluate pediatric post-appendectomy abscesses. To reduce a source of radiation exposure, our institution converted to using contrast-enhanced magnetic resonance imaging to replace computed tomography scans in this clinical context. Our aim is to evaluate the performance of magnetic resonance imaging compared to computed tomography scans and associated clinical outcomes in this patient population.

METHODS

A contrast-enhanced comprehensive magnetic resonance imaging protocol was implemented to evaluate a post-appendectomy abscess in 2018. A retrospective chart review was performed from 2015 to 2022 for pediatric patients (<18 years old) with prior appendectomy and subsequent cross-sectional imaging to evaluate for an intraabdominal abscess. Patient characteristics and clinical parameters between the 2 modalities were abstracted and compared using standard univariate statistics.

RESULTS

There were a total of 72 post-appendectomy patients who received cross-axial imaging, which included 43 computed tomography scans and 29 magnetic resonance imaging during the study interval. Patient demographics were comparable between cohorts and rates of perforated appendicitis at the index operation (computed tomography: 79.1% vs magnetic resonance imaging: 86.2%). Missed abscess rate, abscess size, management technique, drainage culture results, readmission, and reoperation were similar between imaging modalities. Median request to scan time was longer for magnetic resonance imaging than computed tomography (191.5 vs 108 minutes, P = .04). The median duration of a comprehensive magnetic resonance imaging scan was 32 minutes (interquartile range 28-50.5 minutes).

CONCLUSION

Contrast-enhanced magnetic resonance imaging provides an alternative cross-sectional imaging modality to computed tomography scans to evaluate pediatric post-appendectomy abscesses.

Radiation dose reduction using spectral shaping in pediatric non-contrast sinus CT

BACKGROUND

CT is the standard imaging technique to evaluate pediatric sinuses. Given the potential risks of radiation exposure in children, it is important to reduce pediatric CT dose and maintain image quality.

OBJECTIVE

To study the utility of spectral shaping with tin filtration to improve dose efficiency for pediatric sinus CT exams.

MATERIALS AND METHODS

A head phantom was scanned on a commercial dual-source CT using a conventional protocol (120 kV) and a proposed 100 kV with a 0.4-mm tin filter (Sn100 kV) protocol for comparison. Entrance point dose (EPD) of eye and parotid gland region was measured by an ion chamber. Sixty pediatric sinus CT exams (33 acquired with 120 kV, 27 acquired with Sn100 kV) were retrospectively collected. All patient images were objectively measured for image quality and blindly reviewed by 4 pediatric neuroradiologists for overall noise, overall diagnostic quality, and delineation of 4 critical paranasal sinus structures, using a 5-point Likert scale.

RESULTS

Phantom CTDIvol from Sn100 kV is 4.35 mGy, compared to CTDIvol of 5.73 mGy from 120 kV at an identical noise level. EPD of sensitive organs decreases in Sn100 kV (e.g., right eye EPD 3.83±0.42 mGy), compared to 120 kV (5.26±0.24 mGy). Patients in the 2 protocol groups were age and weight (unpaired T test P>0.05) matched. The patient CTDIvol of Sn100 kV (4.45±0.47 mGy) is significantly lower than 120 kV (5.56±0.48 mGy, unpaired T test P<0.001). No statistically significant difference for any subjective readers' score (Wilcoxon test P>0.05) was found between the two groups, indicating proposed spectral shaping provides equivalent diagnostic image quality.

CONCLUSION

Phantom and patient results demonstrate that spectral shaping can significantly reduce radiation dose for non-contrast pediatric sinus CT without compromising diagnostic quality.

Suprapatellar pouch effusion is associated with an increased risk of neglected osteochondral fractures in primary acute traumatic patellar dislocation: a consecutive series of 113 children

BACKGROUND

The aim of this study was to investigate the risk factors of neglected osteochondral fractures in primary acute traumatic patellar dislocation in the pediatric population.

METHODS

A total of 113 patients with primary acute traumatic patellar dislocation for whom coincident osteochondral fractures could not be confirmed by X-ray examination at initial diagnosis between January 2010 and February 2022 were retrospectively analyzed. Medical history, physical examination, and radiographic images were recorded in detail. The greatest dimension of the suprapatellar pouch (SP) effusion on radiograph was measured. Computed tomography and magnetic resonance imaging were used to confirm the presence of neglected osteochondral fractures and measure the fragment size. Potential risk factors were calculated and correlated with reference to the neglected osteochondral fractures and fragment size using multivariate linear regression analysis.

RESULTS

Weight, walking ability, effusion grade, and SP measurement had a significant correlation with neglected osteochondral fractures in primary acute traumatic patellar dislocation (p = 0.046; p < 0.001; p = 0.048; p < 0.001). The cutoff point was 53.5 kg for weight and 18.45 mm for SP measurement. In the neglected fractures group, SP measurement was statistically significant with larger fragment size (beta value = 0.457; p < 0.001), and the cutoff point was 26.2 mm.

CONCLUSIONS

SP effusion is not only associated with an increased risk of neglected osteochondral fractures in primary acute traumatic patellar dislocation but also with larger fragment size. Knee radiograph, medical history, and physical examination can predict the need for further imaging examination and even surgery in primary acute traumatic patellar dislocation.

Advanced Neuromonitoring Modalities on the Horizon: Detection and Management of Acute Brain Injury in Children

Timely detection and monitoring of acute brain injury in children is essential to mitigate causes of injury and prevent secondary insults. Increasing survival in critically ill children has emphasized the importance of neuroprotective management strategies for long-term quality of life. In emergent and critical care settings, traditional neuroimaging modalities, such as computed tomography and magnetic resonance imaging (MRI), remain frontline diagnostic techniques to detect acute brain injury. Although detection of structural and anatomical abnormalities remains crucial, advanced MRI sequences assessing functional alterations in cerebral physiology provide unique diagnostic utility. Head ultrasound has emerged as a portable neuroimaging modality for point-of-care diagnosis via assessments of anatomical and perfusion abnormalities. Application of electroencephalography and near-infrared spectroscopy provides the opportunity for real-time detection and goal-directed management of neurological abnormalities at the bedside. In this review, we describe recent technological advancements in these neurodiagnostic modalities and elaborate on their current and potential utility in the detection and management of acute brain injury.

An Overview on the Alignment of Radiation Protection in Computed Tomography with Maqasid al-Shari'ah in the Context of al-Dharuriyat

The increasing utilisation of computed tomography (CT) in the medical field has raised a greater concern regarding the radiation-induced health effects as CT imposes high radiation risks on the exposed individual. Adherence to radiation protection measures in CT as endorsed by regulatory bodies; justification, optimisation and dose limit, is essential to minimise radiation risks. Islam values every human being and Maqasid al-Shari'ah helps to protect human beings through its sacred principles which aim to fulfil human beings' benefits (maslahah) and prevent mischief (mafsadah). Alignment of the concept of radiation protection in CT within the framework of al-Dharuriyat; protection of faith or religion (din), protection of life (nafs), protection of lineage (nasl), protection of intellect ('aql) and protection of property (mal) is essential. This strengthens the concept and practices of radiation protection in CT among radiology personnel, particularly Muslim radiographers. The alignment provides supplementary knowledge towards the integration of knowledge fields between Islamic worldview and radiation protection in medical imaging, particularly in CT. This paper is hoped to set a benchmark for future studies on the integration of knowledge between the Islamic worldview and radiation protection in medical imaging in terms of other classifications of Maqasid al-Shari'ah; al-Hajiyat and al-Tahsiniyat.

Do All Pediatric Femoral Shaft Fractures Need a Computed Tomography Scan of the Ipsilateral Femoral Neck? Calculating the Incidence of Concomitant Femoral Neck and Shaft Fractures

BACKGROUND

In adults, the incidence of ipsilateral femoral neck fractures in the setting of femoral shaft fractures is reported to be as high as 9%; however, scant literature exists on the same clinical scenario in pediatric/adolescent populations. Therefore, the purpose of this study was to investigate the incidence of ipsilateral femoral neck fracture in the setting of femoral shaft fractures in children and adolescents treated in pediatric hospitals across the United States.

METHODS

The Pediatric Health Information System database was queried for patients aged 18 years or younger who were treated for a femoral neck, femoral shaft, and pertrochanteric femur fractures through an emergency department, inpatient, ambulatory surgery, or observation visit. Patients were identified using ICD-9 and ICD-10 diagnosis codes. Data from 49 pediatric hospitals between the years 2002 and 2020 were included. Incidence was calculated as the number of cases including the event divided by the total number of cases.

RESULTS

A total of 90,146 records were identified from a cohort of 55,733,855 (0.16%). Distal femur fractures, pathologic fractures, and periprosthetic fractures were excluded, resulting in 65,651 unique cases. Of the 65,651 cases, 7104 (11%) were identified as isolated neck fractures. The combined incidence of femoral neck or pertrochanteric femur fractures in the setting of a femoral shaft fracture was 82.3 per 10,000 cases (0.82%). Only 283 cases of concomitant femoral neck and shaft fractures were found among 55,169 femoral shaft fractures (0.5%).

CONCLUSIONS

The incidence of ipsilateral femoral neck or pertrochanteric femur fractures in the setting of a femoral shaft fracture is 82.3 per 10,000 patients (0.82%) based on data from Pediatric Health Information System-participating institutions. The incidence of femoral neck/pertrochanteric femur fractures and femoral shaft fractures in children and adolescents is more than 10 times lower than reported for adults; therefore, the routine use of advanced diagnostic imaging in pediatric patients with femoral shaft fractures should be considered cautiously.

LEVEL OF EVIDENCE

Level IV; cross-sectional analysis.

Current state of pediatric neuro-oncology imaging, challenges and future directions

Imaging plays a central role in neuro-oncology including primary diagnosis, treatment planning, and surveillance of tumors. The emergence of quantitative imaging and radiomics provided an uprecedented opportunity to compile mineable databases that can be utilized in a variety of applications. In this review, we aim to summarize the current state of conventional and advanced imaging techniques, standardization efforts, fast protocols, contrast and sedation in pediatric neuro-oncologic imaging, radiomics-radiogenomics, multi-omics and molecular imaging approaches. We will also address the existing challenges and discuss future directions.

Lung ultrasound in children and adolescents with long-term effects of COVID-19: Initial results

Introduction

Chronic health effects following acute COVID-19 are increasingly observed as the pandemic continues and are grouped under long COVID. Although the acute course of the COVID disease is often milder, long COVID also affects children and adolescents. As the symptoms present in Long-COVID often seem to be non-specific and not limited to organ systems, clarification of the causes and the creation of a meaningful, efficient and targeted diagnostic algorithm is urgently needed.

Methods

Therefore, in this prospective observational study, we examined 30 children with long COVID using lung ultrasound and compared the results with those of 15 lung-healthy children.

Results

In our study, no significant difference was found between the two groups in the morphological criteria of lung ultrasound of the pleura or pleural lung structures. There was no significant correlation between the lung ultrasound findings and clinical Data.

Discussion

Our findings are congruent with the current, albeit sparse, data. It is possible that the causes of persistent thoracic symptoms in long COVID might be more likely to be present in functional examinations, but not morphologically imageable. Nonspecific symptoms do not appear to be due to changes in the lung parenchyma. In conclusion, lung ultrasound alone and without baseline in acute disease is not suitable as a standard in the follow-up of long COVID patients. Further investigations on the morphological and functional changes in patient with long COVID is needed.

Barriers and facilitators of CT scan reduction in the workup of pediatric appendicitis: A pediatric surgical quality collaborative qualitative study

INTRODUCTION

Despite ongoing efforts to decrease ionizing radiation exposure from computed tomography (CT) use in pediatric appendicitis, high CT utilization rates are still observed across many hospitals. This study aims to identify factors influencing CT use and facilitators and barriers to quality improvement efforts.

METHODS

The Pediatric Surgery Quality Collaborative is a voluntary consortium of 42 children's hospitals participating in the National Surgical Quality Improvement Project - Pediatric. Hospitals were compared based on CT utilization from January 1, 2019, to December 31, 2019. Semi-structured interviews were conducted with surgeons, radiologists, emergency medicine physicians, and clinical data abstractors from 7 hospitals with low CT use rates (high performers) and 6 hospitals with high CT use rates (low performers). A mixed deductive and inductive coding approach for analysis of the interview transcripts was used to develop a codebook based on the Theoretical Domains Framework and subsequently identify prominent barriers and facilitators to CT reduction.

RESULTS

Thematic saturation was achieved after 13 interviews. We identified four factors that distinguish high-performing from low-performing hospitals: (1) consistent availability of resources such as ultrasound technicians, pediatric radiologists, and magnetic resonance imaging (MRI); (2) presence of and adherence to protocols guiding imaging modality decision making and imaging execution; (3) culture of inter-departmental collaboration; and (4) presence of a radiation reduction champion.

CONCLUSIONS

Significant barriers to reducing the use of CT in pediatric appendicitis exist. Our findings highlight that future quality improvement efforts should target resource availability, protocol adherence, collaborative culture, and radiation reduction champions.

LEVELS OF EVIDENCE

Level III.

Determination gender-based hybrid artificial intelligence of body muscle percentage by photoplethysmography signal

BACKGROUND AND OBJECTIVE

Muscle mass is one of the critical components that ensure muscle function. Loss of muscle mass at every stage of life can cause many adverse effects. Sarcopenia, which can occur in different age groups and is characterized by a decrease in muscle mass, is a critical syndrome that affects the quality of life of individuals. Aging, a universal process, can also cause loss of muscle mass. It is essential to monitor and measure muscle mass, which should be sufficient to maintain optimal health. Having various disadvantages with the ordinary methods used to estimate muscle mass increases the need for the new high technology methods. This study aims to develop a low-cost and trustworthy Body Muscle Percentage calculation model based on artificial intelligence algorithms and biomedical signals.

METHODS

For the study, 327 photoplethysmography signals of the subject were used. First, the photoplethysmography signals were filtered, and sub-frequency bands were obtained. A quantity of 125 time-domain features, 25 from each signal, have been extracted. Additionally, it has reached 130 features in demographic features added to the model. To enhance the performance, the spearman feature selection algorithm was used. Decision trees, Support Vector Machines, Ensemble Decision Trees, and Hybrid machine learning algorithms (the combination of three methods) were used as machine learning algorithms.

RESULTS

The recommended Body Muscle Percentage estimation model have the perfomance values for all individuals R=0.95, for males R=0.90 and for females R=0.90 in this study.

CONCLUSION

Regarding the study results, it is thought that photoplethysmography-based models can be used to predict body muscle percentage.

Contemporary Role of Computed Tomography in Managing Pediatric Primary Spontaneous Pneumothorax

INTRODUCTION

The value of chest computed tomography (CT) in pediatric primary spontaneous pneumothorax (PSP) remains controversial. This study sought to evaluate the utility of CT scans in a contemporary cohort of children with PSP.

MATERIALS AND METHODS

An institutional review board approval was obtained for a retrospective review of all children (aged ≤18 y) who underwent video-assisted thoracoscopic surgery (VATS) for PSP between 2009 and 2019 at a university-affiliated pediatric hospital. Preoperative CT scans were evaluated for diagnostic accuracy of the CT of bleb disease.

RESULTS

Thirty nine patients underwent VATS procedures for PSP, 34 (87%) of the patients were noted to have blebs. Twenty eight (72%) patients received preoperative CT scans with a 5.5:1 male to female ratio. On CT, 17 (61%) were diagnosed with blebs and all had blebs intraoperatively. CT did not identify disease in 11 patients, but seven had blebs intraoperatively. The positive and negative predictive values of preoperative CT for detecting ipsilateral bleb disease were 100% and 36%, respectively, with a sensitivity of 71%. Eleven patients had a contralateral disease on CT (39%). Five received elective contralateral VATS and three developed spontaneous PSP, with intraoperative blebs in all eight patients. Three never developed contralateral PSP. Six (21%) patients with no contralateral disease on CT developed spontaneous PSP with intraoperative blebs.

CONCLUSIONS

The decision to operate for PSP should be made based on clinical findings rather than on the presence or absence of blebs identified by CT.

Outcomes of Displaced Tibial Tubercle Fractures in Adolescents

Tibial tubercle fractures are uncommon injuries. The purpose of this study is to report the outcomes of surgical treatment of displaced tibial tubercle fractures in adolescents. This study was approved by the College of Medicine Institutional Review Board. A retrospective review was performed at our institution for patients who underwent surgical treatment of tibial tubercle fractures. Patient demographics, injury characteristics, and outcomes were recorded. A p-value of <0.05 was considered statistically significant. Nineteen male patients were identified. The average age was 14.6 years, and the average body mass index was 25.8. Basketball (63%) was the most common mechanism of injury. No patient was treated with bicortical screws. Two patients had preoperative computed tomography. One patient presented with acute compartment syndrome (ACS), and fasciotomy was performed. Twelve patients (63%) without clinical signs of ACS received anterior compartment fasciotomy on a case-by-case basis according to surgeon's preference. No growth injury, including growth arrest, angulation, or shortening occurred. All patients returned to preinjury activities at an average of 18.5 weeks. Displaced tibial tubercle fractures in this series occurred in male adolescents during athletic activity. Unicortical screws/pins were used with no loss of fixation. Routine use of advanced imaging was unnecessary. One patient (5%) underwent fasciotomy. No growth arrest occurred. All patients returned to preinjury athletic activities.

Computed-Tomography Estimates of Interaural Mismatch in Insertion Depth and Scalar Location in Bilateral Cochlear-Implant Users

HYPOTHESIS

Bilateral cochlear-implant (BI-CI) users will have a range of interaural insertion-depth mismatch because of different array placement or characteristics. Mismatch will be larger for electrodes located near the apex or outside scala tympani, or for arrays that are a mix of precurved and straight types.

BACKGROUND

Brainstem superior olivary-complex neurons are exquisitely sensitive to interaural-difference cues for sound localization. Because these neurons rely on interaurally place-of-stimulation-matched inputs, interaural insertion-depth or scalar-location differences for BI-CI users could cause interaural place-of-stimulation mismatch that impairs binaural abilities.

METHODS

Insertion depths and scalar locations were calculated from temporal-bone computed-tomography scans for 107 BI-CI users (27 Advanced Bionics, 62 Cochlear, 18 MED-EL).

RESULTS

Median interaural insertion-depth mismatch was 23.4 degrees or 1.3 mm. Mismatch in the estimated clinically relevant range expected to impair binaural processing (>75 degrees or 3 mm) occurred for 13 to 19% of electrode pairs overall, and for at least three electrode pairs for 23 to 37% of subjects. There was a significant three-way interaction between insertion depth, scalar location, and array type. Interaural insertion-depth mismatch was largest for apical electrodes, for electrode pairs in two different scala, and for arrays that were both-precurved.

CONCLUSION

Average BI-CI interaural insertion-depth mismatch was small; however, large interaural insertion-depth mismatch-with the potential to degrade spatial hearing-occurred frequently enough to warrant attention. For new BICI users, improved surgical techniques to avoid interaural insertion-depth and scalar mismatch are recommended. For existing BI-CI users with interaural insertion-depth mismatch, interaural alignment of clinical frequency tables might reduce negative spatial-hearing consequences.

Mini thoracic CT adequately determines Haller index and decreases radiation exposure in children with pectus excavatum

INTRODUCTION

The preoperative assessment of Pectus Excavatum (PE) is resource intensive. CT chest for the purpose of calculating a Haller index (HI) remains a central component and is necessary for third-party reimbursment for surgical correction. With the goal of minimizing radiation exposure, a strategy was introduced to perform a mini-Thoracic CT (mini-CT) for the calculation of HI.

OPERATIVE TECHNIQUE

The mini-CT was performed as follows: a radio-opaque marker (ROM) was placed at the clinical deepest point of the deformity. The CT was then columnated to scan 3 cm above and 3 cm below the ROM. HI was calculated according to previously described technique. Seven children with PE who underwent mini-CT were age and weight matched to 7 children with PE who underwent standard low dose CT chest during the same time period. Radiation doses were evaluated using dose length product (DLP) and effective dose (mSv) between the two groups. Significance of differences was determined using the students t-test. The DLP of mini-CT compared to chest-CT was 17.9 vs 48.9,mGycm respectively. (p< 0.001) The mSv of the mini-CT compared to chest-CT was 0.32 vs 0.88, sMV respectively. (p<0.001) Both DLP and mSv were reduced by 63% in children who received a mini-CT. All children obtained insurance authorization and underwent uncomplicated Nuss repair.

CONCLUSION

For children with pectus excavatum deformities the mini-Thoracic CT is an effective method to calculate the HI. Compard to the conventional low dose chest CT, the mini-CT strategy significantly reduces radiation exposure to the child by 63% with no impact on third-party authorizations or Nuss repair.

Optimising whole body computed tomography doses for paediatric trauma patients: a Swiss retrospective analysis

We aimed to evaluate the impact of a low-dose whole-body computed tomography (WBCT) protocol on radiation doses in paediatric major trauma patients. Retrospective cohort study of paediatric trauma patients (<16 years) at a national level 1 paediatric trauma centre (PTC) over a 6 year period prior and post introduction of a low-dose WBCT protocol (2014-2019). Demographic data, patient characteristics, CT device, and exposure information including scan range, dose-length product, and volume CT dose index were collected. Effective dose (ED) and exposure parameters were compared before and after protocol introduction. Forty-eight patients underwent WBCT during the study period. Prior to introduction of the low-dose protocol (n= 18), the ED was 20.6 mSv (median 20.1 ± 5.3 mSv [range 12.5-30.7]). After introduction of the low-dose WBCT protocol (n= 30), mean ED was 4.8 mSv (median 2.6 ± 5.0 [range: 0.8-19.1]). This resulted in a reduction of 77% in mean ED (pvalue <0.001). Significant radiation dose reduction of 77% can be achieved with low-dose WBCT protocols in PTCs.

The Impact of Diagnostic Decisions on Patient Experience in the Pediatric Emergency Department

OBJECTIVE

Patient experience serves as both a subjective measure of value-based health care delivery and a metric to inform operational decision making. The objective of this study was to determine if specific diagnostic and therapeutic interventions affect patient experience scores for children seen in the emergency department.

METHODS

We performed a retrospective observational study in the emergency department of a large quaternary care children's hospital on patients who were discharged to home and later completed a National Research Corporation Health patient experience survey. We matched the survey results to electronic health record (EHR) data and were able to extract demographics, operational metrics, and order information for each patient. We performed multiple logistic regression analyses to determine the association of image acquisition, laboratory test ordering, medication administration, and discharge prescribing with likelihood to recommend the facility as our measure of patient experience.

RESULTS

Of the 4103 patients who met inclusion criteria for the study, 75% strongly recommended the facility. Longer wait times were associated with lower patient experience scores [odds ratio (OR) per waiting room hour increase, 0.72; 95% confidence interval (CI), 0.65-0.81]. Significant diagnostic factors associated with higher patient experience included magnetic resonance imaging ordering (OR, 2.38; 95% CI, 1.00-5.67), x-ray ordering (OR, 1.19; 95% CI, 1.00-1.42), and electrocardiogram ordering (OR, 1.62; 95% CI, 1.07-2.44). Of the treatment factors studied, only antibiotic prescribing at discharge was found to have a significant positive association with patient experience (OR, 1.32; 95% CI, 1.08-1.63).

CONCLUSION

The positive association between more intensive diagnostic workups and patient experience could have implications on the utility of patient experience scores to evaluate pediatric care teams. Consideration should be taken to interpret patient experience scores in the context of compliance with approaches in evidence-based medicine.

Sociodemographic and Appointment Factors Affecting Missed Opportunities to Provide Neonatal Ultrasound Imaging

PURPOSE

The aim of this study was to assess disparities in outpatient imaging missed care opportunities (IMCOs) for neonatal ultrasound by sociodemographic and appointment factors at a large urban pediatric hospital.

METHODS

A retrospective review was performed among patients aged 0 to 28 days receiving one or more outpatient appointments for head, hip, renal, or spine ultrasound at the main hospital or satellite sites from 2008 to 2018. An IMCO was defined as a missed ultrasound or cancellation <24 hours in advance. Population-average correlated logistic regression modeling estimated the odds of IMCOs for six sociodemographic (age, sex, race/ethnicity, language, insurance, and region of residence) and seven appointment (type of ultrasound, time, day, season, site, year, and distance to appointment) factors. The primary analysis included unknown values as a separate category, and the secondary analysis used multiple imputation to impute genuine categories from unknown variables.

RESULTS

The data set comprised 5,474 patients totaling 6,803 ultrasound appointments. IMCOs accounted for 4.4% of appointments. IMCOs were more likely for Black (odds ratio [OR], 3.31; P < .001) and other-race neonates (OR, 2.66; P < .001) and for patients with public insurance (OR, 1.78; P = .002). IMCOs were more likely for appointments at the main hospital compared with satellites (P < .001), during work hours (P = .021), and on weekends (P < .001). Statistical significance for primary and secondary analyses was quantitatively similar and qualitatively identical.

CONCLUSIONS

Marginalized racial groups and those with public insurance had a higher rate of IMCOs in neonatal ultrasound. This likely represents structural inequities faced by these communities, and more research is needed to identify interventions to address these inequities in care delivery for vulnerable neonatal populations.

Clinical application of the optimized X-ray parameter model through analysis of disease risk and image quality when combining the ion chamber of automatic exposure control of digital radiography

OBJECTIVE

To present an optimized examination model by analyzing the risk of disease and image quality according to the combination of the ion chamber of automatic exposure control (AEC) with digital radiography (DR).

METHODS

The X-ray quality was analyzed by first calculating the percentage average error (PAE) of DR. After that, when using AEC, the combination of the ion chambers was the same as the left and centre and right, right and centre, left and centre, centre, right, and left, for a total of six. Accordingly, the entrance surface dose (ESD), risk of disease, and image quality were evaluated. ESD was obtained by attaching a semiconductor dosimeter to the L4 level of the lumbar spine, and then irradiating X-rays to dosimeter centre through average and standard deviation of radiation dose. The calculated ESD was input into the PCXMC 2.0 programme to evaluate disease risk caused by radiation. Meanwhile, image quality according to chamber combination was quantified as the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) through Image J.

RESULTS

X-ray quality of DR used in the experiment was within the normal range of±10. ESD of six ion chamber combinations was 1.363mGy, 0.964mGy, 0.946mGy, 0.866mGy, 0.748mGy, 0.726mGy for lumbar anteroposterior (AP), and the lumbar lateral values were 1.126mGy, 0.209mGy, 0.830mGy, 0.662mGy, 0.111mGy, and 0.250mGy, respectively. Meanwhile, disease risk analyzed through PCXMC 2.0 was bone marrow, colon, liver, lung, stomach, urinary and other tissue cancer, and disease risk showed a tendency to increase in proportion to ESD. SNR and CNR recorded the lowest values when three chambers were combined and did not show proportionality with dose, while showed the highest values when two chambers were combined.

CONCLUSION

In this study, combination of three ion chambers showed the highest disease risk and lowest image quality. Using one ion chamber showed the lowest disease risk, but lower image quality than two ion chambers. Therefore, if considering all above factors, combination of two ion chambers can optimally maintain the disease risk and image quality. Thus, it is considered an optimal X-ray examination parameter.

Interaural Place-of-Stimulation Mismatch Estimates Using CT Scans and Binaural Perception, But Not Pitch, Are Consistent in Cochlear-Implant Users

Bilateral cochlear implants (BI-CIs) or a CI for single-sided deafness (SSD-CI; one normally functioning acoustic ear) can partially restore spatial-hearing abilities, including sound localization and speech understanding in noise. For these populations, however, interaural place-of-stimulation mismatch can occur and thus diminish binaural sensitivity that relies on interaurally frequency-matched neurons. This study examined whether plasticity-reorganization of central neural pathways over time-can compensate for peripheral interaural place mismatch. We hypothesized differential plasticity across two systems: none for binaural processing but adaptation for pitch perception toward frequencies delivered by the specific electrodes. Interaural place mismatch was evaluated in 19 BI-CI and 23 SSD-CI human subjects (both sexes) using binaural processing (interaural-time-difference discrimination with simultaneous bilateral stimulation), pitch perception (pitch ranking for single electrodes or acoustic tones with sequential bilateral stimulation), and physical electrode-location estimates from computed-tomography (CT) scans. On average, CT scans revealed relatively little BI-CI interaural place mismatch (26° insertion-angle mismatch) but a relatively large SSD-CI mismatch, particularly at low frequencies (166° for an electrode tuned to 300 Hz, decreasing to 14° at 7000 Hz). For BI-CI subjects, the three metrics were in agreement because there was little mismatch. For SSD-CI subjects, binaural and CT measurements were in agreement, suggesting little binaural-system plasticity induced by mismatch. The pitch measurements disagreed with binaural and CT measurements, suggesting place-pitch plasticity or a procedural bias. These results suggest that reducing interaural place mismatch and potentially improving binaural processing by reprogramming the CI frequency allocation would be better done using CT-scan than pitch information.SIGNIFICANCE STATEMENT Electrode-array placement for cochlear implants (bionic prostheses that partially restore hearing) does not explicitly align neural representations of frequency information. The resulting interaural place-of-stimulation mismatch can diminish spatial-hearing abilities. In this study, adults with two cochlear implants showed reasonable interaural alignment, whereas those with one cochlear implant but normal hearing in the other ear often showed mismatch. In cases of mismatch, binaural sensitivity was best when the same cochlear locations were stimulated in both ears, suggesting that binaural brainstem pathways do not experience plasticity to compensate for mismatch. In contrast, interaurally pitch-matched electrodes deviated from cochlear-location estimates and did not optimize binaural sensitivity. Clinical correction of interaural place mismatch using binaural or computed-tomography (but not pitch) information may improve spatial-hearing benefits.