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BACKGROUND AND PURPOSE: Fluoroscopic-guided lumbar puncture is an effective alternative to bedside lumbar puncture in challenging patients. However, no published guidelines are available for an acceptable range of fluoroscopic time for this procedure. The purpose of this study was to set department benchmark fluoroscopic times for lumbar puncture, accounting for body mass index in our patient population. MATERIALS AND METHODS: We identified and reviewed all patients who underwent fluoroscopic-guided lumbar puncture at 4 hospitals during a 2-year period (July 2011 to June 2013). Data collection included patient information (demographics, body mass index, history of prior lumbar surgery and/or lumbar hardware, scoliosis); procedure details (fluoroscopic time, level of access, approach, needle gauge and length); level of operator experience; and hospital site. A generalized linear model was used to test whether body mass index influenced fluoroscopic time while controlling other factors. RESULTS: Five hundred eighty-four patients (mean age, 47.8 ± 16.2 years; range, 16–92 years; 33% male) had successful fluoroscopic-guided lumbar puncture s. Mean body mass index and fluoroscopic time were higher in female patients (34.4 ± 9.9 kg/m(2) and 1.07 minutes; 95% CI, 0.95–1.20) than in male patients (29.2 ± 7.3 kg/m(2) and 0.91 minutes; 95% CI, 0.79–1.03). Body mass index (P = .001), hospital site (P < .001), and level of experience (P = .03) were factors significantly affecting fluoroscopic time on multivariate analysis. Benchmark fluoroscopic times in minutes were the following: 0.48 (95% CI, 0.40–0.56) for normal, 0.61 for overweight (95% CI, 0.52–0.71), 0.63(95% CI, 0.58–0.73) for obese, and 0.86 (95% CI, 0.74–1.01) in extremely obese body mass index categories. CONCLUSIONS: In patients undergoing fluoroscopic-guided lumbar punctures, fluoroscopy time increased with body mass index We established benchmark fluoroscopic-guided lumbar puncture time ranges as related to body mass index in our patient population.

This investigation evaluates the impact of the no oral contrast abdominopelvic CT examination (NOCAPE) on radiology turn around time (TAT), emergency department (ED) length of stay (LOS), and patient safety metrics. During a 12-month period at two urban teaching hospitals, 6,409 ED abdominopelvic (AP) CTs were performed to evaluate acute abdominal pain. NOCAPE represented 70.9 % of all ED AP CT examinations with intravenous contrast. Data collection included patient demographics, use of intravenous (IV) and/or oral contrast, order to complete and order to final interpretation TAT, ED LOS, admission, recall and bounce back rates, and comparison and characterization of impressions. The NOCAPE pathway reduced median order to complete TAT by 32 min (22.9 %) compared to IV and oral contrast AP CT examinations (traditional pathway) (P

Radiolucent foreign bodies (FBs) such as plastic objects and toys remain difficult to identify on conventional radiographs of the neck and chest. Children may present with a variety of respiratory complaints, which may or may not be due to a FB.To determine whether radiolucent FBs such as plastic LEGOs and peanuts can be seen in the tracheobronchial tree or esophagus using low-dose spiral CT, and, if visible, to determine the optimal CT imaging technique.Multiple spiral sequences were performed while varying the CT parameters and the presence and location of FBs in either the trachea or the esophagus first on a neck phantom and then a cadaver. Sequences were rated by three radiologists blinded to the presence of a FB using a single scoring system.The LEGO was well visualized in the trachea by all three readers (both lung and soft-tissue windowing: combined sensitivity 89 %, combined specificity 89 %) and to a lesser extent in the esophagus (combined sensitivity 31 %, combined specificity 100 %). The peanut was not well visualized (combined sensitivity35 %). The optimal technique for visualizing the LEGO was 120 kV, 90 mA, 3-mm collimation, 0.75 s/revolution, and 2.0 pitch. This allowed for coverage of the cadaver tracheobronchial tree (approximately 11 cm) in about 18 s. Although statistical power was low for detecting significant differences, all three readers noted higher average confidence ratings with lung windowing among 18 LEGO-in-trachea scans.Rapid, low-dose spiral CT may be used to visualize LEGO FBs in the airway or esophagus. Peanuts were not well visualized.

Rationale and Objectives In practice readers must often choose between multiple diagnoses. For assessing reader accuracy in these settings, Obuchowski et al have proposed the “differential diagnosis” method, which derives all pairwise estimates of accuracy for the various diagnoses, along with summary measures of accuracy. The current study assessed the correspondence between the differential diagnosis method and conventional binary-truth state experiments. Materials and Methods Two empirical studies were conducted at two institutions with different readers and diagnostic tests. Readers used the differential diagnosis format to interpret a set of cases. In subsequent readings they interpreted the cases in binary-truth state experiments. Spearman rank correlation coefficients and the percentages of agreement in scores were computed, and the areas under the receiver operating characteristic curves were estimated and compared. Results The between-format Spearman rank correlation coefficients were 0.697–0.718 and 0.750–0.780 for the two studies; the between-reader correlations were 0.417 and 0.792, respectively. The percentages of agreement between formats for the two studies were 50.0%–51.7% and 72.9%–78.8%; the percentages of agreement between readers were 45.0% and 80%, respectively. In the first study there were several significant differences in the areas under receiver operating characteristic curves; in the second study these differences were small. Conclusion The differences observed between the two formats can be attributed to within-reader variability and inherent differences in the questions posed to readers in the multiple-diagnoses versus binary-truth state reading sessions. The differential diagnosis format is useful for estimating accuracy when there are multiple possible diagnoses.

To compare negative appendectomy and perforation rates in children who underwent ultrasonography (US), computed tomography (CT), or no imaging before urgent appendectomy.All children who underwent urgent appendectomy during a 4(1/2)-year period were identified in a surgical billing database. Pathology reports were coded as negative or as showing acute inflammation or perforation. Imaging up to 14 days before appendectomy or abscess drainage was noted, and imaging-based diagnoses were compared with pathologic findings. Patient age and sex were recorded.Two hundred ninety-nine children, 176 (59%) male and 123 (41%) female (mean age, 10.4 years; age range, 1--21 years), underwent urgent appendectomy. One hundred twenty-six (42%) underwent no imaging, 121 (41%) underwent US with or without CT, and 52 (17%) underwent CT only; 44 (15%) underwent both US and CT. There were significantly higher rates of appendectomy with normal pathologic findings ("negative appendectomy") in patients who underwent no imaging (14% [18 of 126]) or US (17% [20 of 121]) versus the rates in those who underwent CT only (2% [one of 52]) (P =.02 and P =.007, respectively). The negative appendectomy rate was 7% in 96 patients who underwent CT with or without prior US. The perforation rates were not significantly different.As compared with children who underwent no preoperative imaging and those who underwent US, children who underwent CT had a significantly lower negative appendectomy rate, without a significantly higher perforation rate.

Purpose. To compare the accuracy of unenhanced, helical CT with sonography for the detection of complications of urinary tract reconstruction. Materials and methods. Forty-six kidneys in 24 patients were examined with CT and sonography. All scans were assessed for ease of renal visualization, presence of renal, ureteral, and bladder calculi, renal scars, hydronephrosis, and abdominal wall hernia. The results of both imaging modalities were independently reported. Results. CT provided excellent visualization of all 46 kidneys, while sonography provided poor visualization of 8 kidneys (17 %) (P < 0.001). CT detected calculi in 10 kidneys, 1 ureter, and 7 bladders. Sonography detected calculi in only 2 kidneys, and 2 bladders. Overall, CT detected significantly more calculi than US (18 vs 4, P = 0.01). CT detected scarring in 15 kidneys, while sonography detected scarring in 10. Hydronephrosis was detected in 6 kidneys by CT and in 8 kidneys by sonography. Three abdominal wall hernias were seen at CT that were not seen at sonography. Conclusion. CT is superior to sonography for the detection of urinary tract calculi and renal scarring. CT will demonstrate abdominal wall hernias that are unsuspected.

Helical CT in children shows an overlapping and wide spectrum of appearances of the normal and acutely inflamed appendix. The normal appendix may measure up to 10 mm in maximal diameter but should not have other CT signs of acute inflammation.

In evaluating the accuracy of diagnostic tests there are many situations where the true disease status can be one of multiple disorders. For example, when paediatric patients suffer acute abdominal pain, the underlying diagnosis could be appendicitis, intestinal obstruction, gastroenteritis, urinary tract infection, etc. In this paper we describe a format for collecting data for the case of multiple truth states. This new format allows one to make pairwise comparisons of the diagnostic accuracy between all of the different truth states. We propose a summary measure of accuracy which is a weighted average of the pairwise estimates of accuracy. Estimators are derived for the variance and covariance of the estimated summary accuracy. The small sample properties of the estimators are evaluated in a Monte Carlo simulation study. The new data collection format and summary measure were used in a paediatric acute abdominal pain study; data from this study are used to illustrate the methods.

OBJECTIVE. Our objective was to evaluate the impact of unenhanced CT on clinician diagnostic confidence and therapeutic efficacy in emergency department patients with clinically suspected renal colic.SUBJECTS AND METHODS. Questionnaires were completed on 93 patients who were referred to the radiology department with clinically suspected renal colic. We prospectively surveyed the clinician's diagnostic confidence and treatment plan before and after unenhanced abdominal and pelvic CT.RESULTS. Fifty-six patients (60%) had positive findings for calculi, 20 patients (22%) had normal findings, and alternative diagnoses were found in 17 patients (18%). The clinician's diagnostic certainty of stones before CT was variable with the largest frequencies at 41-60% (n = 30) and 71-90% (n = 35). The diagnostic certainty of stones after CT showed movement toward either less than or equal to 10% (n = 25) or greater than or equal to 91% (n = 51). The mean change in diagnostic confidence was 34%. Fifty-seven patients (61%)...

To evaluate the accuracy of helical computed tomography (CT) for the diagnosis of appendicitis in children and to assess the utility of CT in establishing alternative diagnoses.The medical records of 154 children (median age, 12 years; age range, 1-20 years) who were suspected to have appendicitis and who underwent CT were reviewed. The gastrointestinal tract was opacified in 151 of 154 patients: Only orally administered contrast material was used in 126 patients; only rectally administered contrast material, in 21 patients; and both oral and rectal contrast material, in four patients. CT findings were correlated with surgical and histopathologic findings or with clinical follow-up findings.Sixty-four CT scans were interpreted as positive for appendicitis and included 58 true-positive and six false-positive scans. Ninety scans were interpreted as negative and included 87 true-negative and three false-negative scans. CT had a sensitivity of 95% and a specificity of 94% for the diagnosis of appendicitis. In addition, in 32 (34%) of 93 patients without appendicitis, an alternative diagnosis was established on the basis of CT findings.Helical CT is useful in a pediatric population to diagnose or exclude appendicitis and to establish an alternative diagnosis.

Background. Pneumatosis intestinals (PI) represents gas in the bowel wall. The appearance of PI using high-resolution ultrasound (HRUS) has not been well described. Objective. The purpose of this report is to describe a new ultrasound sign of pneumatosis seen in three patients. This sign, called the “circle sign”, is indicative of bubbles of gas within the circumference of the bowel, producing an appearance of a continuous echogenic ring on ultrasound. Further studies of the sonographic characteristics of pneumatosis were performed with an in vitro model. Materials and methods. HRUS was performed prospectively in three patients demonstrating extensive PI radiographically. The appearance of the gas was characterized and the behavior of the intramural bubbles was studied when the bowel was compressed with the ultrasound transducer. Either CT scan or pathologic correlation was obtained in all patients. Experimental models of PI using air injected into the wall of sausage casing were developed. Results. The presence of echogenic gas bubbles within the circumference of the wall of the bowel seen with HRUS was shown to represent pneumatosis intestinalis at histologic examination or by CT scanning in the three study patients. In vitro studies confirmed the clinical impression that the use of compression is helpful in distinguishing intramural from intraluminal air. Conclusion. The presence of echogenic gas bubbles in the wall of the bowel, often seen as a circle within the circumference of the bowel, may be helpful in diagnosing PI on ultrasound using HRUS.

Both underrecognized and underreported, child abuse has a spectrum of findings on imaging of the musculoskeletal structures that may permit the radiologist to first suggest the occurrence of child abuse or to help support clinical concern for a diagnosis of child abuse. This article will discuss the approach to imaging of the musculoskeletal system in suspected child abuse, illustrate many of the more common imaging findings, and present imaging pitfalls and alternative diagnostic considerations. Injuries to the brain, spinal cord, gastrointestinal and genitourinary systems, and cardiopulmonary structures are outside the scope of this article.

As the name implies, proximal femoral focal deficiency (PFFD) is a failure in development of the proximal femur and acetabulum of varying degrees. This article reviews the classification schemes with illustrated examples. Clinical findings, associated anomalies, imaging, and treatment are discussed. Patients are classified by radiographs, often changing classes as the patientÕs skeleton matures. Magnetic resonance imaging (MRI) can aid in earlier and more accurate classification. The classification scheme exists to predict future function and the role of surgical intervention.

Trisomy 9 syndrome is characterized by "bulbous" nose, microphthalmia, dislocated limbs, and other anomalies of skeletal, cardiac, genitourinary, and central nervous systems. With the exception of one reported case study, all surviving infants have had severe mental impairment. The prospect of severe mental retardation often overwhelms parents who are faced with prenatal diagnosis of trisomy 9. We report on two new cases of mosaic trisomy 9, both of whom are only mildly developmentally delayed. One patient presented with the distinctive facial appearance, large fontanels, and joint abnormalities. The other had none of the typical congenital abnormalities. However, the patient was found to have a congenital heart defect and hypoplastic left heart syndrome, which to our knowledge has not been reported previously in the trisomy 9 syndrome. When these two patients are added to the published patients with this syndrome, there appears to be a range of manifestations, especially with respect to mental status, which has not fully been recognized.

We report an unusual case of superficial venous thrombosis in a cyanotic 12-year-old child who had undergone recent appendectomy. Although compression, color Doppler, and duplex ultrasound techniques remain the keys to the diagnosis of venous thrombosis, SieScape sonography was beneficial in demonstrating the extent of the thrombi and their location along a superficial thrombosed vein. © 1998 John Wiley & Sons, Inc. J Clin Ultrasound 26:470–473, 1998.

OBJECTIVE. Radiologists often regard risk management as a burden or even a threat. This article examines some of the most important reasons every radiologist should regard managing risk as an opportunity.CONCLUSION. There are short-term risks and costs to a program of risk management, but they are far less than the long-range costs of inaction. More importantly, managing risk well is an opportunity to excel as a physician and leader.

To investigate residents' knowledge of adverse effects of ionizing radiation, frequency of their education on radiation safety, and their use of radioprotective equipment.Residents from 15/16 residency programs at Emory University were asked to complete a resident radiation safety survey through SurveyMonkey(®). The associations between the residents' knowledge and use of radioprotective equipment with residents' specialty and year of training were investigated.Response rate was 32.5% (173/532 residents). Thirty-nine percent residents reported radiation safety is discussed in their residency curriculum at least every 6 months. Ninety-five percent believed in a link between radiation exposure and development of cancer. Overall and Radiology residents' knowledge about specific estimated dose effects (correct responses) was limited: radiation dose associated with fetus brain malformation in pregnancy (10% vs. 26%), risk of developing cataract in interventional personnel (27% vs. 47%), lifetime risk of cancer mortality from a single abdominal computed tomography (CT) in children (22% vs. 29%), greater radiosensitivity of children compared to adults (35% vs. 50%), and relative radiation dose from an abdominal CT compared to a chest x-ray (51% vs. 48%). Radiology residents had modestly higher knowledge. There was no significant difference in residents' knowledge across their postgraduate training years. Use of lead thyroid shields was reported by 86% (97% radiology vs. 80% nonradiology; P = .03) and radiation-monitoring badges in 39% (68% radiology vs. 15% nonradiology; P.001) of the residents.Although radiology residents scored higher, knowledge of radiation safety for patients and healthcare workers is limited among residents regardless of medical specialty. These findings emphasize the need for educational initiatives.

OBJECTIVE:To update the American Academy of Pediatrics clinical practice guideline regarding the diagnosis and management of acute bacterial sinusitis in children and adolescents.METHODS:Analysis of the medical literature published since the last version of the guideline (2001).RESULTS:The diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection (URI) presents with (1) persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement), (2) a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement), or (3) severe onset (concurrent fever [temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days). Clinicians should not obtain imaging studies of any kind to distinguish acute bacterial sinusitis from viral URI, because they do not contribute to the diagnosis; however, a contrast-enhanced computed tomography scan of the paranasal sinuses should be obtained whenever a child is suspected of having orbital or central nervous system complications. The clinician should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course. The clinician should either prescribe antibiotic therapy or offer additional observation for 3 days to children with persistent illness. Amoxicillin with or without clavulanate is the first-line treatment of acute bacterial sinusitis. Clinicians should reassess initial management if there is either a caregiver report of worsening (progression of initial signs/symptoms or appearance of new signs/symptoms) or failure to improve within 72 hours of initial management. If the diagnosis of acute bacterial sinusitis is confirmed in a child with worsening symptoms or failure to improve, then clinicians may change the antibiotic therapy for the child initially managed with antibiotic or initiate antibiotic treatment of the child initially managed with observation.CONCLUSIONS:Changes in this revision include the addition of a clinical presentation designated as “worsening course,” an option to treat immediately or observe children with persistent symptoms for 3 days before treating, and a review of evidence indicating that imaging is not necessary in children with uncomplicated acute bacterial sinusitis.

To evaluate whether addition of nonenhanced computed tomography (NECT) to intravenous contrast-enhanced (CE) abdominal CT improves detection or characterization of hypervascular liver masses. Patients were referred for initial staging or follow-up with known breast, melanoma, neuroendocrine, or thyroid cancer.The literature was searched using the patient, intervention, comparison, and outcome (PICO) method. Retrieved articles were critically appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-based Medicine hierarchy of validity for diagnostic studies.One thousand one hundred studies were reviewed; only 11 studies matched the PICO of our study and were appraised. Most of the appraised articles were published in the 1990s using older technology and contrast delivery. The retrieved diagnostic performance for characterization of liver metastases showed sensitivity/specificity of 97%/76% for NECT, 97%/75% for arterial CT, and 98%/76% for portal venous phase CT in patients with breast cancer; sensitivity of 96% (arterial and portal CT) versus 100% (NECT, arterial and portal CT) in patients with melanoma; and sensitivity of 43% (portal CT) versus 17% (NECT) in patients with neuroendocrine tumor. No primary study was found for performance of different CT protocols in patients with thyroid cancer. Available evidence showed radiologists reported more conspicuous liver masses on CECT compared to NECT in patients with breast or neuroendocrine cancer.Based on existing evidence, NECT only adds a small incremental value to CECT for detection/characterization of hypervascular liver metastases. Addition of NECT increases patient's exposure to radiation and the number of images available for interpretation.

At their initial emergency room presentation, four children were thought to have hip osteomyelitis. Skeletal scintigraphy, however, demonstrated multiple areas of abnormal tracer uptake in the bones in all four, and in three there was abnormal uptake in a soft tissue abdominal mass. The skeletal scintigraphic findings promptly led to the correct diagnosis of neuroblastoma.

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.

To determine population-based rates of the use of diagnostic imaging procedures with ionizing radiation in children, stratified by age and sex.Retrospective cohort analysis.All settings using imaging procedures with ionizing radiation.Individuals younger than 18 years, alive, and continuously enrolled in UnitedHealthcare between January 1, 2005, and December 31, 2007, in 5 large US health care markets.Number and type of diagnostic imaging procedures using ionizing radiation in children.A total of 355 088 children were identified; 436 711 imaging procedures using ionizing radiation were performed in 150 930 patients (42.5%). The highest rates of use were in children older than 10 years, with frequent use in infants younger than 2 years as well. Plain radiography accounted for 84.7% of imaging procedures performed. Computed tomographic scans-associated with substantially higher doses of radiation-were commonly used, accounting for 11.9% of all procedures during the study period. Overall, 7.9% of children received at least 1 computed tomographic scan and 3.5% received 2 or more, with computed tomographic scans of the head being the most frequent.Exposure to ionizing radiation from medical diagnostic imaging procedures may occur frequently among children. Efforts to optimize and ensure appropriate use of these procedures in the pediatric population should be encouraged.

Significant progress has been made in radiation protection for children during the last 10 years. This includes increased awareness of the need for radiation protection for pediatric patients with international partnerships through the Alliance for Radiation Safety in Pediatric Imaging. This paper identifies five areas of significant progress in radiation safety for children: the growth of the Alliance; the development of an adult radiation protection campaign Image Wisely™; increased collaboration with government agencies, societies and the vendor community; the development of national guidelines in pediatric nuclear medicine, and the development of a size-based patient dose correction factor by the American Association of Physicists in Medicine, Task Group 204. However, many challenges remain. These include the need for continued education and change of practice at adult-focused hospitals where many pediatric CT exams are performed; the need for increased emphasis on appropriateness of pediatric imaging and outcomes research to validate the performance of CT studies, and the advancement of the work of the first pediatric national dose registry to determine the “state of the practice” with the final goal of establishing ranges of optimal CT technique for specific scan indications when imaging children with CT.

Medical radiation currently accounts for an increasing percentage (approximately 50%) of the total radiation exposure for the US population (previously about 15%) (moderate evidence). Children are 2–5 (some cite up to 10) times more sensitive to radiation than adults (moderate evidence). There are no data that prove a direct link between low-level radiation from diagnostic imaging and cancer. The best data regarding long-term effects of low-level radiation (100–150 mSv) exposure come from the longitudinal survivor study (LSS) of atomic bomb survivors (moderate evidence). Most major medical and scientific organizations accept the linear, no-threshold model as the preferred model for low-level radiation and cancer risk estimation. The lifetime risk of fatal cancer from a single (relatively high dose) CT in a child has been estimated to be 1:1,000 (limited to moderate evidence).

Children with clinically suspected IBD should have both upper and lower endoscopies as part of the initial workup (strong evidence). Fluoroscopic small bowel follow-through (SBFT) studies are typically performed as part of the initial diagnosis (limited evidence). Wireless capsule endoscopy (WCE) is a safe, moderately sensitive test for the detection of small bowel inflammatory changes and should be utilized in patients without small bowel obstruction and when other diagnostic small bowel exams are negative. However, the specificity and positive predictive value need to be further established (limited evidence). MRI is superior to CT and is the preferred initial diagnostic and follow-up imaging exam of perirectal and perianal disease in Crohn’s disease (CD) patients (moderate–strong evidence). About 70–80% of CD patients and 30–40% of UC patients will require surgery for disease refractory to medical therapy, or severe disease with complications, or risk of malignancy (UC) (moderate evidence). Repeat imaging with SBFT and CT results in significant ionizing radiation exposure and risk of later cancer induction so that alternative imaging methods, MRI and US, should be used (limited evidence).

Nephrolithiasis in Adults Low radiation dose, noncontrast-enhanced computed tomography (MDCT) with 2.5-mm image reconstruction in at least one plane is the test of choice for the patient with a suspected obstructing ureteral stone. In the absence of an available MDCT scanner, intravenous urography (IVU) or a combination of plain radiograph (KUB) and ultrasonography (US) should be performed (moderate evidence). Plain radiograph may be used to follow the descent of stones along the ureter (moderate evidence). For the pregnant patient when US is not diagnostic, MRI avoids ionizing radiation and may be useful with suspected nephroureterolithiasis (insufficient evidence).

Background: Children with inflammatory bowel disease (IBD) undergo imaging using ionizing radiation and may be exposed to high cumulative radiation. We hypothesized that children with IBD have high exposure to radiation from medical imaging. Methods: An Institutional Review Board (IRB)-approved retrospective chart review from 2002–2008 was performed on all patients with IBD. Radiographic studies performed were recorded and exposure for each study was estimated. Results: A total of 117 children with IBD (86 Crohn's disease [CD], 31 ulcerative colitis [UC]) were evaluated. The median current exposure was 15.1 mSv in CD and 7.2 mSv in UC (P = 0.005). Computed tomography (CT) scan and small bowel follow-through (SBFT) were responsible for 43% and 36% of all radiation exposures, respectively. The rate of radiation was higher in CD compared to UC (4.3 versus 2.2 mSv/yr). In CD, the rate of exposure was highest in the first 3 years of diagnosis (8.2 mSv/yr), and no different between the 3–5 year follow-up and 5+ year follow-up groups (3.8 versus 4.3 mSv/yr). Using the annual dose rate in those followed for more than 3 years, an estimated 47 out of 78 (60%) children (40 CD, 7 UC) would exceed 50 mSv by 35 years of age. Conclusions: Radiation exposure from medical imaging is high in a subset of children diagnosed with IBD. Estimation of radiation exposure at age 35 suggests a significant portion of children with IBD will have high radiation exposure in their lifetime. Nonionizing imaging such as magnetic resonance imaging (MRI) and ultrasound should be offered to children with IBD as an alternative to current imaging that employs radiation. Inflamm Bowel Dis 2011

Background Americans without health insurance generally receive fewer health care services than those with insurance. Less studied are the specific types of services for which the uninsured face access and utilization differences. This article fills in some of the knowledge gaps by presenting comparisons between uninsured and insured individuals in the use of imaging services in the hospital inpatient setting. Methods The primary data source for this study was the 2003 National Hospital Discharge Survey. The principal source of payment was used to define insurance status. Global relative value units were assigned by imaging procedure. To ensure sufficient numbers of observations, individual imaging procedures were aggregated into 6 modalities. Multivariate regression was used to estimate the utilization and value of imaging services as a function of insurance status and other control variables. Results Just over 9% of inpatients were uninsured (range, 15.7% aged 18-24 years to 5.8% aged 55-64 years). After controlling for measurable factors, uninsured hospital inpatients who underwent imaging received the same mean number of imaging services (1.51) of the same mean value (11 relative value units) as those for comparable insured persons. The uninsured received fewer interventional and image-guided procedures but more CT studies than insured patients ( P Conclusions Because insurance status does not seem to significantly influence the quantity or value of imaging services received by hospital inpatients who receive imaging, efforts to assist uninsured patients with imaging needs would be better directed elsewhere than the hospital inpatient setting.

The aim of this study was to investigate factors influencing career choices in radiology trainees. We distributed a 27-question written survey to all radiology registrars in Queensland. The questions investigated whether radiology was their first specialty choice, career satisfaction, ideal working conditions and attitudes regarding having children during the time of training. Forty-four of 51 surveys were returned (86% participation rate, 73% men, P = 0.048055) with 100% reporting a high job satisfaction; 28% of male registrars compared to 8% of female registrars did extra work outside of training to earn extra money (P = 0.000003), and 17% of female registrars took a leave of absence during their training, while no male registrar did (P = 0.087923). Only one female trainee worked part-time (P = 0.272727). In addition, 58% of female registrars planned a pregnancy (P = 0.731789) before completion of training; 83% of women versus 75% of men had no children (P = 0.329263). Only 5% of trainees agreed that it was easy to arrange part-time training, only 14% stated that it was easy to negotiate flexible work schedules and 7% agreed that it was easy to return to work after a period of absence. 'Time spent with immediate family' was rated the most important lifestyle factor, followed by 'work hours' and 'on-call duty'. The least important factors were 'being away from extended family', 'availability of part-time work' and whether 'work was in a rural location'. Overall job satisfaction is high among radiology trainees. Nevertheless, lifestyle factors, particularly those related to work time, are becoming more important for career decisions. This should be taken into account when designing and structuring radiology training to ensure that it is considered an attractive career choice.

AJR:194, April 2010 This article suggests 10 steps that radiologists and radiologic technologists, with the assistance of their medical physicist, can take to obtain good quality CT images while properly managing radiation dose for children undergoing CT. The first six steps ideally should be completed before performing any CT on a pediatric patient. The final four steps address the unique consideration that should be given for each scanned patient.

This is a book that will appeal to an audience of radiologists, pediatricians, primary care physicians, residents and fellows, midlevel providers, and others in the fields of diagnostic radiology and pediatric radiology who request imaging for children. Through a review of the literature and an algorithmic approach, the authors provide a guide to efficient imaging of specific clinical problems in children while minimizing unnecessary radiation risk and efficiently using health care dollars. A total of 41 chapters are included, with sections on neuroimaging, the musculoskeletal system, the chest, the abdomen, and prenatal imaging. The first 3 chapters address the principles of evidencebased imaging, a critical assessment of the literature with regard to error and bias, and radiation risk from medical imaging in children. Other chapters address common issues in pediatric imaging such as nonaccidental trauma, neuroimaging of seizures, mediastinal masses, congenital heart disease, developmental dysplasia of the hip, and urinary tract infection. Each chapter opens with specific issues and key points to address them. Each clinical entity is further described with definition and pathophysiology, epidemiology, overall cost to society, clinical and laboratory predictors, goals of imaging, and the methodology used in the review of the literature. The key imaging issues are then further discussed, with citations. Imaging algorithms are included where appropriate, and questions for further research are provided. At the end of each chapter are imaging case studies with classic imaging findings, followed by references. Using this format, the book often concisely answers the reader’s question in the well-written initial paragraphs, rather than leaving one to complete the entire chapter and summarize on one’s own. Each chapter, although not long (usually 12‐15 pages, with 30 pages being the longest), is packed with highly useful information. Many chapters include imaging protocols. Limitations of the book include its lack of detail on the topics of neck, liver, and biliary tract imaging. Suggestions for the next edition include chapters on complications of solid-organ and stem cell transplantations and on imaging for pediatric hypertension. I expected to be overwhelmed by the book but found it enjoyable. There was no such reference 10 years ago, after the panic of late January 2001 initiated by lay press articles regarding pediatric CT dose and cancer. Pediatric radiology as a specialty responded by developing more thoughtful processes and better imaging methods, many of which are summarized in this commendable book.

Key Points: □ Child abuse is a serious health problem with severe long-term consequences and high societal costs (strong evidence). □ Child abuse is both underdetected and underreported, and the role of imaging is a critical part of the investigation of abuse (moderate evidence). □ Radiographic skeletal survey is the main diagnostic tool in the diagnosis of skeletal injuries in both living and dead children (moderate evidence). □ Repeat skeletal surveys can clarify and substantiate initially equivocal findings (moderate evidence). □ Skeletal scintigraphy can be used as an adjunct to the skeletal survey (moderate evidence). □ Infant deaths are most likely due to head trauma, whereas toddlers are more likely to die from blunt abdominal trauma (strong evidence).

■ Skilled clinical examiners are capable of detecting the vast majority of developmental dysplasia of the hip (DDH) in neonates, and this remains the primary screening method in the United States. Ultrasound (US) is no better than these examiners but may improve DDH diagnosis or exclusion for less-experienced clinical examiners (strong evidence).

■ Children with clinically suspected IBD should have both upper and lower endoscopies as part of the initial workup (strong evidence). Fluoroscopic small bowel follow-through studies are typically performed as part of the initial diagnosis (limited evidence).

■ Medical radiation currently accounts for an increasing percentage (approximately 50%) of the total radiation exposure for the US population (previously about 15%) (moderate evidence).

■ Malrotation of the bowel is associated with risk of intestinal volvulus and can be fatal (strong evidence). Volvulus is a surgical emergency that is treated with the Ladd procedure (strong evidence).