Dr. Laura Chapman (Pediatrics): A 9-year-old boy with autism was admitted to this hospital becaus... more Dr. Laura Chapman (Pediatrics): A 9-year-old boy with autism was admitted to this hospital because of pain in the hip, refusal to walk, and the recent onset of a rash and gingival swelling.
The incidental detection of small lung nodules in children is a vexing consequence of an increase... more The incidental detection of small lung nodules in children is a vexing consequence of an increased reliance on CT. We present an algorithm for the management of lung nodules detected on CT in children, based on the presence or absence of symptoms, the presence or absence of elements in the clinical history that might explain these nodules, and the imaging characteristics of the nodules (such as attenuation measurements within the nodule). We provide suggestions on how to perform a thoughtfully directed and focused search for clinically occult extrathoracic disease processes (including malignant disease) that may present as an incidentally detected lung nodule on CT. This algorithm emphasizes that because of the lack of definitive information on the natural history of small solid nodules that are truly detected incidentally, their clinical management is highly dependent on the caregivers' individual risk tolerance. In addition, we present strategies to reduce the prevalence of these incidental findings, by preventing unnecessary chest CT scans or inadvertent inclusion of portions of the lungs in scans of adjacent body parts. Application of these guidelines provides pediatric radiologists with an important opportunity to practice patient-centered and evidence-based medicine.
No guidelines are in place for the follow-up and management of pulmonary nodules that are inciden... more No guidelines are in place for the follow-up and management of pulmonary nodules that are incidentally detected on CT in the pediatric population. The Fleischner guidelines, which were developed for the older adult population , do not apply to children. This review summarizes the evidence collected by the Society for Pediatric Radiology (SPR) Thoracic Imaging Committee in its attempt to develop pediatric-specific guidelines. Small pulmonary opacities can be characterized as linear or as ground-glass or solid nodules. Linear opacities and ground-glass nodules are extremely unlikely to represent an early primary or metastatic malignancy in a child. In our review, we found a virtual absence of reported cases of a primary pulmonary malignancy presenting as an incidentally detected small lung nodule on CT in a healthy immune-competent child. Because of the lack of definitive information on the clinical significance of small lung nodules that are incidentally detected on CT in children, the management of those that do not have the typical characteristics of an intrapulmonary lymph node should be dictated by the clinical history as to possible exposure to infectious agents, the presence of an occult im-munodeficiency, the much higher likelihood that the nodule represents a metastasis than a primary lung tumor, and ultimately the individual preference of the child's caregiver. Nod-ules appearing in children with a history of immune deficiency , malignancy or congenital pulmonary airway malfor-mation should not be considered incidental, and their
ABSTRACT ■ Imaging studies have limited value in the differentiation between viral and bacterial ... more ABSTRACT ■ Imaging studies have limited value in the differentiation between viral and bacterial lower respiratory tract infections (moderate evidence). ■ CT provides more information than plain radiographs for complicated pulmonary infections with empyema, pleural effusion, or bronchopleural fistula (moderate evidence). ■ In immunocompromised patients, CT has been shown to characterize the type of infection better than plain radiographs (moderate evidence). ■ Ultrasound has an advantage over CT in the identification and characterization of complicated effusions (moderate evidence). ■ Early detection and therefore intervention for pleural complications of pneumonia are critical and can result in better outcomes (moderate evidence). ■ Early surgery (VATS) is more cost-effective than thoracotomy (without or with image guidance) in the treatment of empyemas in children (strong evidence).
Any queries or remarks that have arisen during the processing of your manuscript are listed below... more Any queries or remarks that have arisen during the processing of your manuscript are listed below and are highlighted by flags in the proof. (AU indicates author queries; ED indicates editor queries; and TS/TY indicates typesetter queries.) Please check your proof carefully and answer all AU queries. Mark all corrections and query answers at the appropriate place in the proof (e.g., by using on-screen annotation in the PDF file http://www.elsevier.com/framework_authors/tutorials/ How_to_Annotate_PDF_Proofs.pdf) or compile them in a separate list, and tick off below to indicate that you have answered the query. Please return your input as instructed by the project manager.
with the administrative assistance of Ms. Angela Davis, the Alliance for Radiation Safety in Pedi... more with the administrative assistance of Ms. Angela Davis, the Alliance for Radiation Safety in Pediatric Imaging and the Society for Pediatric Radiology organized the third ALARA CT meeting and second Image Gently CT meeting into a single conference, titled "The Image Gently ALARA CT Summit: How to Use New CT Technologies for Children." The meeting, conducted in Orlando, FL, on Feb. 21-22, featured 21 course faculty members (including 9 pediatric radiologists, 2 adult radiologists, 8 medical imaging physicists, a pediatrician and a radiologic technologist), who collectively presented 30 lectures.
Purpose—To evaluate reader variability of white matter lesions seen on cranial sonographic scans ... more Purpose—To evaluate reader variability of white matter lesions seen on cranial sonographic scans of extreme low gestational age neonates (ELGANs). Methods—In 1,452 ELGANs, cranial sonographic scans were obtained in the first and second postnatal weeks, and between the third postnatal week and term. All sets of scans were read independently by two sonologists. We reviewed the use of four diagnostic labels: early periventricular leucomalacia, cystic periventricular leucomalacia, periventricular hemorrhagic infarction (PVHI), and other white matter diagnosis, by 16 sonologists at 14 institutions. We evaluated the association of these labels with location and laterality of hyperechoic and hypoechoic lesions, location of intraventricular hemorrhage, and characteristics of ventricular enlargement.
Our prospective cohort study of extremely low gestational age newborns evaluated the association ... more Our prospective cohort study of extremely low gestational age newborns evaluated the association of neonatal head ultrasound abnormalities with cerebral palsy at age 2 years. Cranial ultrasounds in 1053 infants were read with respect to intraventricular hemorrhage, ventriculomegaly, and echolucency, by multiple sonologists. Standardized neurological examinations classified cerebral palsy, and functional impairment was assessed. Forty-four percent with ventriculomegaly and 52% with echolucency developed cerebral palsy. Compared with no ultrasound abnormalities, children with echolucency were 24 times more likely to have quadriparesis and 29 times more likely to have hemiparesis. Children with ventriculomegaly were 17 times more likely to have quadriparesis or hemiparesis. Forty-three percent of children with cerebral palsy had normal head ultrasound. Focal white matter damage (echolucency) and diffuse damage (late ventriculomegaly) are associated with a high probability of cerebral palsy, especially quadriparesis. Nearly half the cerebral palsy identified at 2 years is not preceded by a neonatal brain ultrasound abnormality.
Objectives—To evaluate the developmental correlates of microcephaly evident at birth and at 2 yea... more Objectives—To evaluate the developmental correlates of microcephaly evident at birth and at 2 years in a cohort born at extremely low gestational age. Methods—We assessed development and motor function at 2 years of 958 children born before the 28th week of gestation, comparing those who had microcephaly at birth or 2 years with children with normal head circumference while considering the contribution of neonatal cranial ultrasound lesions. Results—A total of 11% of infants in our sample had microcephaly at 2 years. Microcephaly at 2 years, but not at birth, predicts severe motor and cognitive impairments at 2 years. A total of 71% of children with congenital microcephaly had a normal head circumference at 2 years and had neurodevelopmental outcomes comparable with those with normal head circumference at birth and 2 years. Among children with microcephaly at 2 years, more than half had a Mental Developmental Index <70, and nearly a third had cerebral palsy. The risks were increased if the child also had cerebral white matter damage on a cranial ultrasound scan obtained 2 years previously. Conclusion—Among extremely low gestational age newborns, microcephaly at 2 years, but not at birth, is associated with motor and cognitive impairment at age 2. Ahead circumference more than 2 standard deviations (SD) below the mean for age defines microcephaly, an indicator of reduced brain volume,1 and a correlate of cognitive and motor dysfunctions.2 – 5 Compared with infants born at term, low birth weight and extremely low gestational age newborns (ELGANs) are at increased risk of having microcephaly at birth (congenital microcephaly), as well as subnormal head size evident later in childhood.2 , 3 , 6 This
To assess how well early ultrasound lesions in preterm newborns predict reduced head circumferenc... more To assess how well early ultrasound lesions in preterm newborns predict reduced head circumference at 2 years, the investigators followed 923 children born before the 28th week of gestation who were not microcephalic at birth. Six percent of children who had a normal ultrasound scan were microcephalic compared with 15% to 20% who had intraventricular hemorrhage, an echolucent lesion, or ventriculomegaly. The odds ratios (95% confidence intervals) for microcephaly associated with different ultrasound images were intraventricular hemorrhage, 1.5 (0.8-3.0); ventriculomegaly, 3.3 (1.8-6.0); an echodense lesion, 1.6 (0.7-3.5); and an echolucent lesion, 3.1 (1.5-6.2). Ventriculomegaly and an echolucent lesion had very similar low positive predictive values (24% and 27%, respectively) and high negative predictive values (91% and 90%, respectively) for microcephaly. Ventriculomegaly had a higher sensitivity for microcephaly than did an echolucent lesion (24% vs 16%, respectively). Focal white-matter lesion (echolucent lesion) and diffuse white-matter damage (ventriculomegaly) predict an increased risk of microcephaly.
In low birth weight and preterm newborns, cranial ultrasound abnormalities indicative of white ma... more In low birth weight and preterm newborns, cranial ultrasound abnormalities indicative of white matter damage are the strongest predictors of cerebral palsy and developmental delays.
Epidemiology Pneumonia is a significant health problem, affecting more than 150 million children ... more Epidemiology Pneumonia is a significant health problem, affecting more than 150 million children younger than 5 years per year worldwide [1]. It remains the most common cause of illness in children [2] and is implicated in the hospitalization of 20 million children annually in the United States [1]. Chest radiography is, therefore, the most frequently requested imaging test in children. Antibiotics are often prescribed even in cases when no bacterial agent can be proven, which has resulted in the development of bacteria that are antibiotic-resistant, such as methicillin-resistant Staphylococcus aureus (MRSA) [3]. Originally believed to be a hospital-acquired infection, the incidence of MRSA is now rapidly rising not only in hospitals but also in the community. Maternal antibodies protect newborns against viral infections, and bacterial pneumonia is therefore more common in this age group, usually due to pathogens acquired during labor and delivery. With decreasing maternal antibodies, viral pneumonias become relatively more prevalent in infants between 2 months and 2 years old, most commonly leading to the clinical and radiographic presentation of bronchiolitis. After that age period, bacterial infections again become relatively more common. Clinical signs and symptoms of pneumonia in infants and young children are often nonspecific [2] and include cough and fever (or hypothermia in young infants). Non-respiratory symptoms such as malaise, irritability, vomiting, and decreased appetite frequently dominate the clinical presentation. In older children, pleuritic chest pain may occur, and abdominal pain with bowel distention is a classic mimic of acute appendicitis or another abdominal processes, caused by a subtle lower lobe pneumonia that should be searched for when abdominal radiographs are obtained. The classic pulmonary symptoms—respiratory distress, tachypnea, rales, and decreased breath sounds—are poor predictors of pneumonia in children; therefore, radiography is frequently requested and remains the most reliable confirmatory test for pneumonia in children [2]. Epidemiologic studies are complicated by the lack of a reliable clinical gold standard because the value of microbial cultures in young children is limited [2]. In addition , bacterial infections frequently superimpose on viral illnesses. In early childhood , it appears that the lung response to the inflammation caused by an infective agent is more age-specific than antigen (i.e., bacterial vs viral) dependent [4–8].
In order to personalize the communication of the CT risk, we need to describe the risk in the con... more In order to personalize the communication of the CT risk, we need to describe the risk in the context of the clinical benefit of CT, which will generally be much higher, provided a CT scan has a well-established clinical indication. However as pediatric radiologists we should be careful not to overstate the benefit of CT, being aware that medico–legal pressures and the realities of health care economics have led to overutilization of the technology. And even though we should not use previously accumulated radiation dose to a child as an argument against conducting a clinically indicated scan (the " sunk-cost " bias), we should consider patients' radiation history in the diagnostic decision process. As a contribution to future public health, it makes more sense to look for non-radiating alternatives to CT in the much larger group of basically healthy children who are receiving occasional scans for widely prevalent conditions such as appendicitis and trauma than to attempt lowering CT use in the smaller group of patients with chronic conditions with a limited life expectancy. When communicating the CT risk with individual patients and their parents, we should acknowledge and address their concerns within the framework of informed decision-making. When appropriate, we may express the individual radiation risk, based on estimates of summated absorbed organ dose, as an order of magnitude rather than as an absolute number, and compare this with the much larger natural cancer incidence over a child's lifetime, and with other risks in medicine and daily life. We should anticipate that many patients cannot make informed decisions on their own in this complex matter, and we should offer our guidance while maintaining respect for patient autonomy. Proper documentation of the informed decision process is important for future reference. In concert with our referring physicians, pediatric radiologists are well-equipped to tackle the complexities associated with the communication of CT risk, a task that often falls upon us, and by becoming more involved in the diagnostic decision process we can add value to the health care system.
The theory of radiation carcinogenesis has been debated for decades. Most estimates of the radiat... more The theory of radiation carcinogenesis has been debated for decades. Most estimates of the radiation risks from CT have been based on extrapolations from the lifespan follow-up study of atomic bomb survivors and on follow-up studies after therapeutic radiation, using the linear no-threshold theory. Based on this, many population-based projections of induction of future cancers by CT have been published that should not be used to estimate the risk to an individual because of their large margin of error. This has changed recently with the publication of three large international cohort follow-up studies, which link observed cancers to CT scans received in childhood. A fourth ongoing multi-country study in Europe is expected to have enough statistical power to address the limitations of the prior studies. The United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) report released in 2013 specifically addresses variability in response of the pediatric population exposed to ionizing radiation. Most authorities now conclude that there is enough evidence to link future cancers to the radiation exposure from a single CT scan in childhood but that cancer risk estimates for individuals must be based on the specifics of exposure, age at exposure and absorbed dose to certain tissues. Generalizations are not appropriate, and the communication of the CT risk to individuals should be conducted within the framework of personalized medicine.
In 30 young children suspected of gastroesophageal reflux (GER), the G-E junction was examined wi... more In 30 young children suspected of gastroesophageal reflux (GER), the G-E junction was examined with ultrasonography directly after a feeding while these children were on overnight extended esophageal pH monitoring (EEpHM) (32 simultaneous ultrasound/EEpHM studies). The two tests showed 81% to 84% agreement in the detection of the presence or absence of GER, depending on whether the whole period of EEpHM or only the part of it covering the ultrasound observation period were used as the standard. The discrepancies between the two tests were explained by the much longer monitoring period of EEpHM compared to ultrasonog-raphy and the inability of EEpHM to show reflux of neutralized gastric contents directly after milk feedings. The two studies probably measure different aspects of clinically significant reflux and must be correlated with the clinical symptoms. Morphological findings associated with significant reflux were (1) a short intra-abdominal part of the esophagus, (2) a rounded gastroesophageal angle, and (3) a " beak " at the gastroesophageal junction. Barium meal findings confirmed these sonographic signs, indicating a sliding hiatal hernia of the distal esophagus, either fixed or intermittent. Ultrasonography can be recommended as a useful and physiological screening test to demonstrate clinically significant GER and a predisposing hi-atal hernia of the esophagus in symptomatic children.
OBJECTIVE. The purpose of this study was to determine the significance of portal vein pulsatility... more OBJECTIVE. The purpose of this study was to determine the significance of portal vein pulsatility on duplex Doppler waveforms in children with end-stage hepatic failure undergoing liver transplantation. SUBJECTS AND METHODS. Thirty-eight children with end-stage hepatic decom-pensation were examined with color-assisted spectral Doppler waveform analysis of the hepatic artery and the portal vein. Correlation was made with age, duration of illness , clinical and pathologic diagnosis, and presence of portal hypertension. Findings were compared with those for six patients with acute viral hepatitis and 12 healthy control subjects. RESULTS. Portal vein pulsatility was noted in all 36 patIents in whom portal vein flow was detected by Doppler imaging. The majority of these (34) had clinical or sono-graphic evidence of portal hypertension. In two patients, no portal vein flow was Identified in the liver hilum; both had a large portosystemic shunt through collaterals or surgical graft. Significantly increased pulsatility of the hepatic artery waveform (resis-tive Index (RI] = 0.89 ± 0.15, p < .0001) was seen in patients with end-stage liver disease. In contrast, no portal vein pulsatility and normal hepatic artery pulsatility (RI = 0.60 ± 0.11) was noted in all patients with acute hepatitis and control subjects. CONCLUSION. Portal vein waveform pulsatility is 94% sensitive and 90% specific for portal hypertension in end-stage liver disease.
Dr. Laura Chapman (Pediatrics): A 9-year-old boy with autism was admitted to this hospital becaus... more Dr. Laura Chapman (Pediatrics): A 9-year-old boy with autism was admitted to this hospital because of pain in the hip, refusal to walk, and the recent onset of a rash and gingival swelling.
The incidental detection of small lung nodules in children is a vexing consequence of an increase... more The incidental detection of small lung nodules in children is a vexing consequence of an increased reliance on CT. We present an algorithm for the management of lung nodules detected on CT in children, based on the presence or absence of symptoms, the presence or absence of elements in the clinical history that might explain these nodules, and the imaging characteristics of the nodules (such as attenuation measurements within the nodule). We provide suggestions on how to perform a thoughtfully directed and focused search for clinically occult extrathoracic disease processes (including malignant disease) that may present as an incidentally detected lung nodule on CT. This algorithm emphasizes that because of the lack of definitive information on the natural history of small solid nodules that are truly detected incidentally, their clinical management is highly dependent on the caregivers' individual risk tolerance. In addition, we present strategies to reduce the prevalence of these incidental findings, by preventing unnecessary chest CT scans or inadvertent inclusion of portions of the lungs in scans of adjacent body parts. Application of these guidelines provides pediatric radiologists with an important opportunity to practice patient-centered and evidence-based medicine.
No guidelines are in place for the follow-up and management of pulmonary nodules that are inciden... more No guidelines are in place for the follow-up and management of pulmonary nodules that are incidentally detected on CT in the pediatric population. The Fleischner guidelines, which were developed for the older adult population , do not apply to children. This review summarizes the evidence collected by the Society for Pediatric Radiology (SPR) Thoracic Imaging Committee in its attempt to develop pediatric-specific guidelines. Small pulmonary opacities can be characterized as linear or as ground-glass or solid nodules. Linear opacities and ground-glass nodules are extremely unlikely to represent an early primary or metastatic malignancy in a child. In our review, we found a virtual absence of reported cases of a primary pulmonary malignancy presenting as an incidentally detected small lung nodule on CT in a healthy immune-competent child. Because of the lack of definitive information on the clinical significance of small lung nodules that are incidentally detected on CT in children, the management of those that do not have the typical characteristics of an intrapulmonary lymph node should be dictated by the clinical history as to possible exposure to infectious agents, the presence of an occult im-munodeficiency, the much higher likelihood that the nodule represents a metastasis than a primary lung tumor, and ultimately the individual preference of the child's caregiver. Nod-ules appearing in children with a history of immune deficiency , malignancy or congenital pulmonary airway malfor-mation should not be considered incidental, and their
ABSTRACT ■ Imaging studies have limited value in the differentiation between viral and bacterial ... more ABSTRACT ■ Imaging studies have limited value in the differentiation between viral and bacterial lower respiratory tract infections (moderate evidence). ■ CT provides more information than plain radiographs for complicated pulmonary infections with empyema, pleural effusion, or bronchopleural fistula (moderate evidence). ■ In immunocompromised patients, CT has been shown to characterize the type of infection better than plain radiographs (moderate evidence). ■ Ultrasound has an advantage over CT in the identification and characterization of complicated effusions (moderate evidence). ■ Early detection and therefore intervention for pleural complications of pneumonia are critical and can result in better outcomes (moderate evidence). ■ Early surgery (VATS) is more cost-effective than thoracotomy (without or with image guidance) in the treatment of empyemas in children (strong evidence).
Any queries or remarks that have arisen during the processing of your manuscript are listed below... more Any queries or remarks that have arisen during the processing of your manuscript are listed below and are highlighted by flags in the proof. (AU indicates author queries; ED indicates editor queries; and TS/TY indicates typesetter queries.) Please check your proof carefully and answer all AU queries. Mark all corrections and query answers at the appropriate place in the proof (e.g., by using on-screen annotation in the PDF file http://www.elsevier.com/framework_authors/tutorials/ How_to_Annotate_PDF_Proofs.pdf) or compile them in a separate list, and tick off below to indicate that you have answered the query. Please return your input as instructed by the project manager.
with the administrative assistance of Ms. Angela Davis, the Alliance for Radiation Safety in Pedi... more with the administrative assistance of Ms. Angela Davis, the Alliance for Radiation Safety in Pediatric Imaging and the Society for Pediatric Radiology organized the third ALARA CT meeting and second Image Gently CT meeting into a single conference, titled "The Image Gently ALARA CT Summit: How to Use New CT Technologies for Children." The meeting, conducted in Orlando, FL, on Feb. 21-22, featured 21 course faculty members (including 9 pediatric radiologists, 2 adult radiologists, 8 medical imaging physicists, a pediatrician and a radiologic technologist), who collectively presented 30 lectures.
Purpose—To evaluate reader variability of white matter lesions seen on cranial sonographic scans ... more Purpose—To evaluate reader variability of white matter lesions seen on cranial sonographic scans of extreme low gestational age neonates (ELGANs). Methods—In 1,452 ELGANs, cranial sonographic scans were obtained in the first and second postnatal weeks, and between the third postnatal week and term. All sets of scans were read independently by two sonologists. We reviewed the use of four diagnostic labels: early periventricular leucomalacia, cystic periventricular leucomalacia, periventricular hemorrhagic infarction (PVHI), and other white matter diagnosis, by 16 sonologists at 14 institutions. We evaluated the association of these labels with location and laterality of hyperechoic and hypoechoic lesions, location of intraventricular hemorrhage, and characteristics of ventricular enlargement.
Our prospective cohort study of extremely low gestational age newborns evaluated the association ... more Our prospective cohort study of extremely low gestational age newborns evaluated the association of neonatal head ultrasound abnormalities with cerebral palsy at age 2 years. Cranial ultrasounds in 1053 infants were read with respect to intraventricular hemorrhage, ventriculomegaly, and echolucency, by multiple sonologists. Standardized neurological examinations classified cerebral palsy, and functional impairment was assessed. Forty-four percent with ventriculomegaly and 52% with echolucency developed cerebral palsy. Compared with no ultrasound abnormalities, children with echolucency were 24 times more likely to have quadriparesis and 29 times more likely to have hemiparesis. Children with ventriculomegaly were 17 times more likely to have quadriparesis or hemiparesis. Forty-three percent of children with cerebral palsy had normal head ultrasound. Focal white matter damage (echolucency) and diffuse damage (late ventriculomegaly) are associated with a high probability of cerebral palsy, especially quadriparesis. Nearly half the cerebral palsy identified at 2 years is not preceded by a neonatal brain ultrasound abnormality.
Objectives—To evaluate the developmental correlates of microcephaly evident at birth and at 2 yea... more Objectives—To evaluate the developmental correlates of microcephaly evident at birth and at 2 years in a cohort born at extremely low gestational age. Methods—We assessed development and motor function at 2 years of 958 children born before the 28th week of gestation, comparing those who had microcephaly at birth or 2 years with children with normal head circumference while considering the contribution of neonatal cranial ultrasound lesions. Results—A total of 11% of infants in our sample had microcephaly at 2 years. Microcephaly at 2 years, but not at birth, predicts severe motor and cognitive impairments at 2 years. A total of 71% of children with congenital microcephaly had a normal head circumference at 2 years and had neurodevelopmental outcomes comparable with those with normal head circumference at birth and 2 years. Among children with microcephaly at 2 years, more than half had a Mental Developmental Index <70, and nearly a third had cerebral palsy. The risks were increased if the child also had cerebral white matter damage on a cranial ultrasound scan obtained 2 years previously. Conclusion—Among extremely low gestational age newborns, microcephaly at 2 years, but not at birth, is associated with motor and cognitive impairment at age 2. Ahead circumference more than 2 standard deviations (SD) below the mean for age defines microcephaly, an indicator of reduced brain volume,1 and a correlate of cognitive and motor dysfunctions.2 – 5 Compared with infants born at term, low birth weight and extremely low gestational age newborns (ELGANs) are at increased risk of having microcephaly at birth (congenital microcephaly), as well as subnormal head size evident later in childhood.2 , 3 , 6 This
To assess how well early ultrasound lesions in preterm newborns predict reduced head circumferenc... more To assess how well early ultrasound lesions in preterm newborns predict reduced head circumference at 2 years, the investigators followed 923 children born before the 28th week of gestation who were not microcephalic at birth. Six percent of children who had a normal ultrasound scan were microcephalic compared with 15% to 20% who had intraventricular hemorrhage, an echolucent lesion, or ventriculomegaly. The odds ratios (95% confidence intervals) for microcephaly associated with different ultrasound images were intraventricular hemorrhage, 1.5 (0.8-3.0); ventriculomegaly, 3.3 (1.8-6.0); an echodense lesion, 1.6 (0.7-3.5); and an echolucent lesion, 3.1 (1.5-6.2). Ventriculomegaly and an echolucent lesion had very similar low positive predictive values (24% and 27%, respectively) and high negative predictive values (91% and 90%, respectively) for microcephaly. Ventriculomegaly had a higher sensitivity for microcephaly than did an echolucent lesion (24% vs 16%, respectively). Focal white-matter lesion (echolucent lesion) and diffuse white-matter damage (ventriculomegaly) predict an increased risk of microcephaly.
In low birth weight and preterm newborns, cranial ultrasound abnormalities indicative of white ma... more In low birth weight and preterm newborns, cranial ultrasound abnormalities indicative of white matter damage are the strongest predictors of cerebral palsy and developmental delays.
Epidemiology Pneumonia is a significant health problem, affecting more than 150 million children ... more Epidemiology Pneumonia is a significant health problem, affecting more than 150 million children younger than 5 years per year worldwide [1]. It remains the most common cause of illness in children [2] and is implicated in the hospitalization of 20 million children annually in the United States [1]. Chest radiography is, therefore, the most frequently requested imaging test in children. Antibiotics are often prescribed even in cases when no bacterial agent can be proven, which has resulted in the development of bacteria that are antibiotic-resistant, such as methicillin-resistant Staphylococcus aureus (MRSA) [3]. Originally believed to be a hospital-acquired infection, the incidence of MRSA is now rapidly rising not only in hospitals but also in the community. Maternal antibodies protect newborns against viral infections, and bacterial pneumonia is therefore more common in this age group, usually due to pathogens acquired during labor and delivery. With decreasing maternal antibodies, viral pneumonias become relatively more prevalent in infants between 2 months and 2 years old, most commonly leading to the clinical and radiographic presentation of bronchiolitis. After that age period, bacterial infections again become relatively more common. Clinical signs and symptoms of pneumonia in infants and young children are often nonspecific [2] and include cough and fever (or hypothermia in young infants). Non-respiratory symptoms such as malaise, irritability, vomiting, and decreased appetite frequently dominate the clinical presentation. In older children, pleuritic chest pain may occur, and abdominal pain with bowel distention is a classic mimic of acute appendicitis or another abdominal processes, caused by a subtle lower lobe pneumonia that should be searched for when abdominal radiographs are obtained. The classic pulmonary symptoms—respiratory distress, tachypnea, rales, and decreased breath sounds—are poor predictors of pneumonia in children; therefore, radiography is frequently requested and remains the most reliable confirmatory test for pneumonia in children [2]. Epidemiologic studies are complicated by the lack of a reliable clinical gold standard because the value of microbial cultures in young children is limited [2]. In addition , bacterial infections frequently superimpose on viral illnesses. In early childhood , it appears that the lung response to the inflammation caused by an infective agent is more age-specific than antigen (i.e., bacterial vs viral) dependent [4–8].
In order to personalize the communication of the CT risk, we need to describe the risk in the con... more In order to personalize the communication of the CT risk, we need to describe the risk in the context of the clinical benefit of CT, which will generally be much higher, provided a CT scan has a well-established clinical indication. However as pediatric radiologists we should be careful not to overstate the benefit of CT, being aware that medico–legal pressures and the realities of health care economics have led to overutilization of the technology. And even though we should not use previously accumulated radiation dose to a child as an argument against conducting a clinically indicated scan (the " sunk-cost " bias), we should consider patients' radiation history in the diagnostic decision process. As a contribution to future public health, it makes more sense to look for non-radiating alternatives to CT in the much larger group of basically healthy children who are receiving occasional scans for widely prevalent conditions such as appendicitis and trauma than to attempt lowering CT use in the smaller group of patients with chronic conditions with a limited life expectancy. When communicating the CT risk with individual patients and their parents, we should acknowledge and address their concerns within the framework of informed decision-making. When appropriate, we may express the individual radiation risk, based on estimates of summated absorbed organ dose, as an order of magnitude rather than as an absolute number, and compare this with the much larger natural cancer incidence over a child's lifetime, and with other risks in medicine and daily life. We should anticipate that many patients cannot make informed decisions on their own in this complex matter, and we should offer our guidance while maintaining respect for patient autonomy. Proper documentation of the informed decision process is important for future reference. In concert with our referring physicians, pediatric radiologists are well-equipped to tackle the complexities associated with the communication of CT risk, a task that often falls upon us, and by becoming more involved in the diagnostic decision process we can add value to the health care system.
The theory of radiation carcinogenesis has been debated for decades. Most estimates of the radiat... more The theory of radiation carcinogenesis has been debated for decades. Most estimates of the radiation risks from CT have been based on extrapolations from the lifespan follow-up study of atomic bomb survivors and on follow-up studies after therapeutic radiation, using the linear no-threshold theory. Based on this, many population-based projections of induction of future cancers by CT have been published that should not be used to estimate the risk to an individual because of their large margin of error. This has changed recently with the publication of three large international cohort follow-up studies, which link observed cancers to CT scans received in childhood. A fourth ongoing multi-country study in Europe is expected to have enough statistical power to address the limitations of the prior studies. The United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) report released in 2013 specifically addresses variability in response of the pediatric population exposed to ionizing radiation. Most authorities now conclude that there is enough evidence to link future cancers to the radiation exposure from a single CT scan in childhood but that cancer risk estimates for individuals must be based on the specifics of exposure, age at exposure and absorbed dose to certain tissues. Generalizations are not appropriate, and the communication of the CT risk to individuals should be conducted within the framework of personalized medicine.
In 30 young children suspected of gastroesophageal reflux (GER), the G-E junction was examined wi... more In 30 young children suspected of gastroesophageal reflux (GER), the G-E junction was examined with ultrasonography directly after a feeding while these children were on overnight extended esophageal pH monitoring (EEpHM) (32 simultaneous ultrasound/EEpHM studies). The two tests showed 81% to 84% agreement in the detection of the presence or absence of GER, depending on whether the whole period of EEpHM or only the part of it covering the ultrasound observation period were used as the standard. The discrepancies between the two tests were explained by the much longer monitoring period of EEpHM compared to ultrasonog-raphy and the inability of EEpHM to show reflux of neutralized gastric contents directly after milk feedings. The two studies probably measure different aspects of clinically significant reflux and must be correlated with the clinical symptoms. Morphological findings associated with significant reflux were (1) a short intra-abdominal part of the esophagus, (2) a rounded gastroesophageal angle, and (3) a " beak " at the gastroesophageal junction. Barium meal findings confirmed these sonographic signs, indicating a sliding hiatal hernia of the distal esophagus, either fixed or intermittent. Ultrasonography can be recommended as a useful and physiological screening test to demonstrate clinically significant GER and a predisposing hi-atal hernia of the esophagus in symptomatic children.
OBJECTIVE. The purpose of this study was to determine the significance of portal vein pulsatility... more OBJECTIVE. The purpose of this study was to determine the significance of portal vein pulsatility on duplex Doppler waveforms in children with end-stage hepatic failure undergoing liver transplantation. SUBJECTS AND METHODS. Thirty-eight children with end-stage hepatic decom-pensation were examined with color-assisted spectral Doppler waveform analysis of the hepatic artery and the portal vein. Correlation was made with age, duration of illness , clinical and pathologic diagnosis, and presence of portal hypertension. Findings were compared with those for six patients with acute viral hepatitis and 12 healthy control subjects. RESULTS. Portal vein pulsatility was noted in all 36 patIents in whom portal vein flow was detected by Doppler imaging. The majority of these (34) had clinical or sono-graphic evidence of portal hypertension. In two patients, no portal vein flow was Identified in the liver hilum; both had a large portosystemic shunt through collaterals or surgical graft. Significantly increased pulsatility of the hepatic artery waveform (resis-tive Index (RI] = 0.89 ± 0.15, p < .0001) was seen in patients with end-stage liver disease. In contrast, no portal vein pulsatility and normal hepatic artery pulsatility (RI = 0.60 ± 0.11) was noted in all patients with acute hepatitis and control subjects. CONCLUSION. Portal vein waveform pulsatility is 94% sensitive and 90% specific for portal hypertension in end-stage liver disease.
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Papers by Sjirk J Westra