Search

This chapter discusses a case of myocarditis and pericardial effusion in a pediatric patient. It addresses a notoriously difficult diagnosis to make, which can result in significant morbidity and mortality if missed. This case highlights the departure from presentation in pediatric cardiac failure compared to the adult population. Herein, pediatric heart failure is explored in the context of a subtle history with few abnormal physical findings and elusive radiographic evidence. A high index of suspicion is required to entertain the diagnosis in adolescents. Lessons in careful history taking and attention to detail demonstrated in this case will aid the clinician in making this potentially fatal diagnosis, which might otherwise be overlooked.

Pediatric imaging use and payment trends in accountable care organizations (ACOs) are seldom studied but are important for health policy decisions and resource allocation. To evaluate patterns of advanced imaging use and associated payments over a 7-year period at a large ACO in the USA serving a Medicaid population. We reviewed paid claims data from 2011 through 2017 from an ACO, analyzing the MRI, CT and US use trends and payments from emergency department (ED) and outpatient encounters. We defined “utilization rate” as the number of advanced imaging procedures per 100 enrolled children per calendar year. Average yearly utilization and payments trends were analyzed using Pearson correlation. Across 7 years, 186,552 advanced imaging procedures were performed. The average overall utilization rate was 6.99 (95% confidence interval [CI]: 6.9–7.1). In the ED this was 2.7 (95% CI: 2.6–2.8) and in outpatients 4.3 (95% CI: 4.2–4.3). The overall utilization rate grew by 0.7% yearly (P=0.077), with US growing the most at 4.0% annually (P=0.0005), especially in the ED in the US, where it grew 10.8% annually (P=0.000019). The overall payments were stable from 2011 to 2017, with outpatient MRI seeing the largest payment decrease at 1.8% (P=0.24) and ED US showing the most growth at 3.3% (P=0.00016). Head CT and abdominal US were the two most common procedures. Over the study period, advanced imaging utilization at this large pediatric ACO serving the Medicaid population increased, especially with US use in the ED. Overall payments related to advanced imaging remained stable over this period.

Objective Particularly for pediatric patients presenting with acute conditions or challenging diagnoses, identifying variation in emergency radiology staffing models is essential in establishing a standard of care. We conducted a cross-sectional survey among radiology departments at academic pediatric hospitals to evaluate staffing models for providing imaging interpretation for emergency department imaging requests. Methods We conducted an anonymous telephone survey of academic pediatric hospitals affiliated with an accredited radiology residency program across the United States. We queried the timing, location, and experience of reporting radiologists for initial and final interpretations of emergency department imaging studies, during weekday, overnight, and weekend hours. We compared weekday with overnight, and weekday with weekend, using Fisher’s exact test and an α of 0.05. Results Surveying 42 of 47 freestanding academic pediatric hospitals (89%), we found statistically significant differences for initial reporting radiologist, final reporting radiologist, and final report timing between weekday and overnight. We found statistically significant differences for initial reporting radiologist and final report timing between weekday and weekend. Attending radiologist involvement in initial reports was 100% during daytime, but only 33.3% and 69.0% during overnight and weekends. For initial interpretation during overnight and weekend, 38.1% and 28.6% use resident radiologists without attending radiologists, and 28.6% and 2.4% use teleradiology. All finalized reports as soon as possible during weekdays, but only 52.4% and 78.6% during overnight and weekend. Discussion A minority of hospitals use 24-hour in-house radiology attending radiologist coverage. During overnight periods, the majority of academic pediatric emergency departments rely on resident radiologists without attending radiologist supervision or outside teleradiology services to provide initial reports. During weekend periods, over a quarter rely on resident radiologists without attending radiologist supervision for initial reporting. This demonstrates significant variation in staffing practices at academic pediatric hospitals. Future studies should look to determine whether this variation has any impact on standard of care.

Morphological features including interarterial course, intramural course, high ostial location and slit-like ostium are presumed risk factors for sudden cardiac death in children with anomalous aortic origin of the coronary artery (AAOCA). To facilitate clinical risk stratification, the diagnostic accuracy of CT angiography for individual risk factors in the setting of AAOCA must be established. We assessed diagnostic accuracy of standardized CT angiography interpretation for morphological characteristics that might determine risk in children with AAOCA by comparing them to surgical findings. We created a standardized protocol for CT angiography of AAOCA and retrospectively evaluated diagnostic performance in 25 consecutive surgical patients. Relevant morphological variables in AAOCA were assessed by three independent blinded readers, with surgery as the reference standard. We used Cohen kappa coefficients and accuracies to assess agreement between readers and surgical findings, and we calculated intraclass correlation coefficients to compare length of the intramural course. CT angiography correctly identified AAOCA in all patients. For the three readers, accuracies for detecting ostial stenosis were 84%, 94% and 96%; for high ostial origin, accuracies were 76%, 78% 82%; for intramurality using the peri-coronary fat sign, accuracies were 98%, 96% and 92%; and for intramurality using oval shape of coronary artery, accuracies were 98%, 94% and 92%. The intraclass correlation coefficients (ICCs) for predicting intramural length among the three readers were 0.67, 0.75 and 0.81 using peri-coronary fat, and 0.69, 0.50 and 0.81 using oval shape, respectively. CT angiography reliably identified AAOCA in all children and detected the presence of intramurality with high accuracy.

Interruptions have been shown to adversely impact efficiency, accuracy, and patient safety.To analyze the frequency and types of interruptions and effect on report interpretation efficiency.A business process improvement team was consulted to make detailed recordings of the activities of the radiologists. Activities were categorized as interpreting studies, active interruptions initiated by the radiologist, and passive interruptions initiated by an external source.Thirteen board-certified, pediatric radiologists were observed for 61 hours. Radiologists spent 52% of their time interpreting studies, 29% on active interruptions, and 18% on passive interruptions. Approximately 50% of non-interpretive time involved in-person conversations or consults and 16% involved phone calls of which 67% were incoming. The longest time period without an interruption was 20 minutes. 85% of the time, an interruption came within 3 minutes of beginning an interpretation and lasted 1 minute or less 70% of the time. Interruptions increased the time a radiologist needed to read a study by 1 minute for radiographs, 2 minutes for ultrasounds, 6 minutes for CTs, and 10 minutes for magnetic resonance imaging.Total interruption time nearly equaled the total time interpreting studies for radiologists, and interruptions decreased efficiency and increased report interpretation times for all modalities studied. This study highlights the type and extent of interruptions in radiology and examines the effect on report interpretation times. With the frequency of interruptions and impact on efficiency, there is a need to dedicate resources to manage the radiologist workflow. Strategic interventions may ultimately improve outcomes, efficiency, and the overall work environment.

Appropriate imaging is imperative in evaluating children with a primary hepatic malignancy such as hepatoblastoma or hepatocellular carcinoma. For use in the adult patient population, the American College of Radiology created the Liver Imaging Reporting and Data System (LI-RADS) to provide consistent terminology and to improve imaging interpretation. At present, no similar consensus exists to guide imaging and interpretation of pediatric patients at risk for developing a liver neoplasm or how best to evaluate a pediatric patient with a known liver neoplasm. Therefore, a new Pediatric Working Group within American College of Radiology LI-RADS was created to provide consensus for imaging recommendations and interpretation of pediatric liver neoplasms. The article was drafted based on the most up-to-date existing information as interpreted by imaging experts comprising the Pediatric LI-RADS Working Group. Guidance is provided regarding appropriate imaging modalities and protocols, as well as imaging interpretation and reporting, with the goals to improve imaging quality, to decrease image interpretation errors, to enhance communication with referrers, and to advance patient care. An expanded version of this document that includes broader background information on pediatric hepatocellular carcinoma and rationale for recommendations can be found in Appendix E1 (online).

Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Introduction: Pulmonary atresia with the ventricular septal defect is a rare congenital heart defect with high anatomic variability. The most important management question relates to the sources of pulmonary blood flow. The ability to differentiate between ductal dependence and major aortopulmonary collateral arteries is critical to achieving good outcomes and avoiding life-threatening hypoxia in the postneonatal period. Having accurate information about pulmonary arteries, major aortopulmonary collateral arteries, and sources of blood supply to each pulmonary segment is crucial for choosing the optimal surgical strategy. The purpose of this study is to compare computed tomography angiography (CTA) with cardiac catheterization for anatomic delineation of surgically relevant anatomy in pulmonary atresia with ventricular septal defect with major aortopulmonary collateral arteries. Materials and Methods: Retrospective review of all children with pulmonary atresia with ventricular septal defect with major aortopulmonary collateral arteries cared for at a large tertiary children's hospital who underwent cardiac catheterization with angiography and CTA close to each other without interval therapy. All studies were performed between 2007 and 2011. Results: There were 9 patients who met the inclusion criteria. Pulmonary artery anatomy (confluent vs. nonconfluent) was correctly identified in 9 patients by CTA and 8 patients by catheterization. There were no significant differences between CTA and catheterization in the identification of major aortopulmonary collateral arteries (mean = 3.4 collaterals/study via catheterization; mean = 3.1 collaterals/study via CTA; P = 0.67). CTA was superior to catheterization in the delineation of segmental pulmonary blood flow (P = 0.006). Conclusion: CTA and catheterization are equivalent in their ability to delineate pulmonary artery anatomy and major aortopulmonary collateral arteries.

Standard methods to evaluate tracheal pathology in children, including bronchoscopy, may require general anesthesia. Conventional dynamic proximal airway imaging in noncooperative children requires endotracheal intubation and/or medically induced apnea, which may affect airway mechanics and diagnostic performance. We describe a technique for unsedated dynamic volumetric computed tomography angiography (DV-CTA) of the proximal airway and surrounding vasculature in children and evaluate its performance compared to the reference-standard of rigid bronchoscopy.Children who had undergone DV-CTA and bronchoscopy in one-year were retrospectively identified. Imaging studies were reviewed by an expert reader blinded to the bronchoscopy findings of primary or secondary tracheomalacia. Airway narrowing, if present, was characterized as static and/or dynamic, with tracheomalacia defined as50% collapse of the tracheal cross-sectional area in exhalation. Pearson correlation was used for comparison.Over a 19-month period, we identified 32 children (median age 8 months, range 3-14 months) who had undergone DV-CTA and bronchoscopy within a 90-day period of each other. All studies were unsedated and free-breathing. The primary reasons for evaluation included noisy breathing, stridor, and screening for tracheomalacia. There was excellent agreement between DV-CTA and bronchoscopy for diagnosis of tracheomalacia (κ = 0.81, p 0.001), which improved if children (n = 25) had the studies within 30 days of each other (κ = 0.91, p 0.001). CTA provided incremental information on severity, and cause of secondary tracheomalacia.For most children, DV-CTA requires no sedation or respiratory manipulation and correlates strongly with bronchoscopy for the diagnosis of tracheomalacia.3 Laryngoscope, 2022.

Dyspnea is the symptom of perceived breathing discomfort and is commonly encountered in a variety of clinical settings. Cardiac etiologies of dyspnea are an important consideration; among these, valvular heart disease (Variant 1), arrhythmia (Variant 2), and pericardial disease (Variant 3) are reviewed in this document. Imaging plays an important role in the clinical assessment of these suspected abnormalities, with usually appropriate procedures including resting transthoracic echocardiography in all three variants, radiography for Variants 1 and 3, MRI heart function and morphology in Variants 2 and 3, and CT heart function and morphology with intravenous contrast for Variant 3. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

3D printing (3DP) applications for clinical evaluation, preoperative planning, patient and trainee education, and simulation has increased in the past decade. Most of the applications are found in cardiovascular, head and neck, orthopedic, neurological, urological, and oncological surgical cases. This review has three parts. The first part discusses the technical pathway to realizing a physical model, 3DP considerations in pediatric MRI image acquisition, data and resolution requirements, and related structural segmentation and postprocessing steps needed to generalize both virtual and physical models. Standard practices and processing software used in these processes will be assessed. The second part discusses complementary examples in pediatric applications, including cases from cardiology, neuroradiology, neurology, and neurosurgery, head and neck, orthopedics, pelvic and urological applications, oncological applications, and fetal imaging. The third part explores other 3D printing applications and considerations such as using 3DP to develop tissue-specific phantoms and devices for testing in the MR environment, to educate patients and their families, to train clinicians and students, and facility requirements for building a 3DP program. Level of Evidence: 5 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2020;51:1641-1658.

Positive end-expiratory pressure (PEEP) is a key mechanical ventilator setting in infants with bronchopulmonary dysplasia (BPD). Excessive PEEP can result in insufficient carbon dioxide elimination and lung damage, while insufficient PEEP can result in impaired gas exchange secondary to airway and alveolar collapse. Determining PEEP settings based on clinical parameters alone is challenging and variable. The purpose of this study was to describe our experience using dynamic airway CT to determine the lowest PEEP setting sufficient to maintain expiratory central airway patency of at least 50% of the inspiratory cross-sectional area in children with BPD requiring long-term ventilator support. We retrospectively identified all infants with BPD who underwent volumetric CT with a dynamic airway protocol for PEEP optimization from December 2014 through April 2019. Sixteen infants with BPD underwent 17 CT exams. Each CT exam consisted of acquisitions spanning the trachea and mainstem bronchi. We measured cross-sectional area of the trachea and mainstem bronchi and qualitatively assessed the amount of atelectasis. We documented changes in management as a result of the CT exam. The average effective dose was 0.1–0.8 mSv/scan. Of 17 CT exams, PEEP was increased in 9, decreased in 3 and unchanged after 5 exams. Dynamic airway CT shows promise to assist the clinician in determining PEEP settings to maintain airway patency in infants with BPD requiring long-term ventilator support. Further evaluation of the impact of this maneuver on gas exchange, cardiac output and other physiological measures is needed.

Pediatric imaging use and payment trends in accountable care organizations (ACOs) are seldom studied but are important for health policy decisions and resource allocation.To evaluate patterns of advanced imaging use and associated payments over a 7-year period at a large ACO in the USA serving a Medicaid population.We reviewed paid claims data from 2011 through 2017 from an ACO, analyzing the MRI, CT and US use trends and payments from emergency department (ED) and outpatient encounters. We defined "utilization rate" as the number of advanced imaging procedures per 100 enrolled children per calendar year. Average yearly utilization and payments trends were analyzed using Pearson correlation.Across 7 years, 186,552 advanced imaging procedures were performed. The average overall utilization rate was 6.99 (95% confidence interval [CI]: 6.9-7.1). In the ED this was 2.7 (95% CI: 2.6-2.8) and in outpatients 4.3 (95% CI: 4.2-4.3). The overall utilization rate grew by 0.7% yearly (P=0.077), with US growing the most at 4.0% annually (P=0.0005), especially in the ED in the US, where it grew 10.8% annually (P=0.000019). The overall payments were stable from 2011 to 2017, with outpatient MRI seeing the largest payment decrease at 1.8% (P=0.24) and ED US showing the most growth at 3.3% (P=0.00016). Head CT and abdominal US were the two most common procedures.Over the study period, advanced imaging utilization at this large pediatric ACO serving the Medicaid population increased, especially with US use in the ED. Overall payments related to advanced imaging remained stable over this period.

Radiographic bone age assessment by automated software is precise and instantaneous.The aim of this study was to evaluate the accuracy of an automated tool for bone age assessment.We compared a total of 586 bone age radiographs from 451 patients, which had been assessed by three radiologists from 2013 to 2018, with bone age analysis by BoneXpert, using the Greulich and Pyle method. We made bone age comparisons in different patient groups based on gender, diagnosis and race, and in a subset with repeated bone age studies. We calculated Spearman correlation (r) and accuracy (root mean square error, or RBone age analyses by automated and manual assessments showed a strong correlation (r=0.98; RAutomated bone age assessment was found to be reliable and accurate in a large cohort of pediatric patients in a clinical practice setting in North America.

IMPORTANCE: There is increased awareness of radiation risks from computed tomography (CT) in pediatric patients. In emergency departments (EDs), evidence-based guidelines, improvements in imaging technology, and availability of nonradiating modalities have potentially reduced CT use. OBJECTIVE: To evaluate changes over time and hospital variation in advanced imaging use. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study assessed 26 082 062 ED visits by children younger than 18 years from the Pediatric Health Information System administrative database from January 1, 2009, through December 31, 2018. EXPOSURES: Imaging. MAIN OUTCOMES AND MEASURES: The primary outcome was the change in CT, ultrasonography, and magnetic resonance imaging (MRI) rates from January 1, 2009, to December 31, 2018. Imaging for specific diagnoses was examined using all patient-refined diagnosis related groups. Secondary outcomes were hospital admission and 3-day ED revisit rates and ED length of stay. RESULTS: There were a total of 26 082 062 visits by 9 868 406 children (mean [SD] age, 5.59 [5.15] years; 13 842 567 [53.1%] male; 9 273 181 [35.6%] non-Hispanic white) to 32 US pediatric EDs during the 10-year study period, with 1 or more advanced imaging studies used in 1 919 283 encounters (7.4%). The proportion of ED encounters with any advanced imaging increased from 6.4% (95% CI, 6.2%-6.2%) in 2009 to 8.7% (95% CI, 8.7%-8.8%) in 2018. The proportion of ED encounters with CT decreased from 3.9% (95% CI, 3.9%-3.9%) to 2.9% (95% CI, 2.9%-3.0%) (P

Background and Objective This study aims to determine the accuracy of patient specific 3D printed models in capturing pathological anatomical characteristics derived from CT angiography (CTA) in children with anomalous aortic origin of a coronary artery (AAOCA). Methods & Materials Following institutional regulatory approval, a standardized protocol for CTA of AAOCA was utilized for imaging. Blood volume of the aorta and coronaries were segmented from the DICOM images. A total of 10 models from 8 AAOCA patients were created, including 2 post-operative models. Mechanical properties of Agilus30 a flexible photopolymer coated with a thin layer of parylene, polyurethane (PU) and silicone and native aortic tissue from a postmortem specimen were compared. AAOCA models with wall thicknesses of 2mm aorta and 1.5mm coronaries were 3D printed in Agilus30 and coated with PU. CT of the printed models was performed, and 3D virtual models were generated. Transfer of anatomical characteristics and geometric accuracy were compared between the patient model virtual models. Results Dynamic modulus of Agilus30 at 2mm thickness was found to be close to native aortic tissue. Structured reporting of anatomical characteristics by imaging experts showed good concordance between patient and model CTA Comparative patient and virtual model measurements showed Pearson's correlation (r) of 0.9959 for aorta (n=70) and 0.9538 for coronaries (n=60) linear, and 0.9949 for aorta (n=30) and 0.9538 for coronaries (n=30) cross-sectional, dimensions. Surface contour map mean difference was 0.08 ± 0.29mm. Conclusions Geometrically accurate AAOCA models preserving morphological characteristics, essential for risk stratification and decision-making, can be 3D printed from a patient's CTA.