Fetal suprarenal masses - assessing the complementary role of magnetic resonance and ultrasound for diagnosis PEDIATRIC RADIOLOGY 2016; 46 (2): 246-254
To assess the value and complementary roles of fetal MRI and US for characterization and diagnosis of suprarenal masses.We conducted a multi-institutional retrospective database search for prenatally diagnosed suprarenal masses between 1999 and 2012 and evaluated the roles of prenatal US and fetal MRI for characterization and diagnosis, using postnatal diagnosis or surgical pathology as the reference standard. Prenatal US and fetal MRI were assessed for unique findings of each modality.The database yielded 25 fetuses (gestational age 20-37weeks) with suprarenal masses. Twenty-one fetuses had prenatal US, 22 had MRI, 17 had both. Postnatal diagnoses included nine subdiaphragmatic extralobar sequestrations, seven adrenal hemorrhages, five neuroblastomas (four metastatic), two lymphatic malformations, one duplex kidney with upper pole cystic dysplasia, and one adrenal hyperplasia. Ultrasound was concordant with MRI for diagnoses in 12/17 (70.6%) cases. Discordant diagnoses between US and MRI included three neuroblastomas and two adrenal hemorrhages. In the three neuroblastomas US was equivocal and MRI was definitive for neuroblastoma, demonstrating heterogeneous, intermediate-signal solid masses and liver metastases. In the two cases of adrenal hemorrhage US was equivocal and MRI was definitive with signal characteristics of hemorrhage. In 2/4 neuroblastomas, Doppler US demonstrated a systemic artery suggesting extralobar sequestration; however MRI signal characteristics correctly diagnosed neuroblastoma. All cases of extralobar sequestration were correctly diagnosed by US and MRI.US and MRI both accurately detect suprarenal masses. MRI complements US in equivocal diagnoses and detects additional findings such as liver metastases in neuroblastoma.
View details for DOI 10.1007/s00247-015-3470-1
View details for Web of Science ID 000369255800012
View details for PubMedID 26589304
Added Value of Radiologist Consultation for Pediatric Ultrasound: Implementation and Survey Assessment AMERICAN JOURNAL OF ROENTGENOLOGY 2015; 205 (4): 822-826
The purpose of this study was to determine whether radiologist-parent (guardian) consultation sessions for pediatric ultrasound with immediate disclosure of examination results if desired increases visit satisfaction, decreases anxiety, and increases understanding of the radiologist's role.Parents chaperoning any outpatient pediatric ultrasound were eligible and completed surveys before and after ultrasound examinations. Before the second survey, parents met with a pediatric radiologist on a randomized basis but could opt out and request or decline the consultation. Differences in anxiety and understanding of the radiologist's role before and after the examination were compared, and overall visit satisfaction measures were tabulated.Seventy-seven subjects participated, 71 (92%) of whom spoke to a radiologist, mostly on request. In the consultation group, the mean score (1, lowest; 4, highest) for overall experience was 3.8 0.4 (SD), consultation benefit was 3.7 0.6, and radiologist interaction was 3.7 0.6. Demographics were not predictive of satisfaction with statistical significance in a multivariate model. Forty-six of 68 (68%) respondents correctly described the radiologist's role before consultation. The number increased to 60 (88%) after consultation, and the difference was statistically significant (p < 0.001). There was also a statistically significant decrease in mean anxiety score from 2.0 1.0 to 1.5 0.8 after consultation (p < 0.001). Sixty-four of 70 (91%) respondents indicated that they would prefer to speak with a radiologist during every visit.Radiologist consultation is well received among parents and associated with decreased anxiety and increased understanding of the radiologist's role. The results of this study support the value of routine radiologist-parent interaction for pediatric ultrasound.
View details for DOI 10.2214/AJR.15.14542
View details for Web of Science ID 000361847300033
View details for PubMedID 26397331
Radiologist Compliance With California CT Dose Reporting Requirements: A Single-Center Review of Pediatric Chest CT AMERICAN JOURNAL OF ROENTGENOLOGY 2015; 204 (4): 810-816
Effective July 1, 2012, CT dose reporting became mandatory in California. We sought to assess radiologist compliance with this legislation and to determine areas for improvement.We retrospectively reviewed reports from all chest CT examinations performed at our institution from July 1, 2012, through June 30, 2013, for errors in documentation of volume CT dose index (CTDIvol), dose-length product (DLP), and phantom size. Reports were considered as legally compliant if both CTDIvol and DLP were documented accurately and as institutionally compliant if phantom size was also documented accurately. Additionally, we tracked reports that did not document dose in our standard format (phantom size, CTDIvol for each series, and total DLP).Radiologists omitted CTDIvol, DLP, or both in nine of 664 examinations (1.4%) and inaccurately reported one or both of them in 56 of the remaining 655 examinations (8.5%). Radiologists omitted phantom size in 11 of 664 examinations (1.7%) and inaccurately documented it in 20 of the remaining 653 examinations (3.1%). Of 664 examinations, 599 (90.2%) met legal reporting requirements, and 583 (87.8%) met institutional requirements. In reporting dose, radiologists variably used less decimal precision than available, summed CTDIvol, included only series-level DLP, and specified dose information from the scout topogram or a nonchest series for combination examinations.Our institutional processes, which primarily rely on correct human performance, do not ensure accurate dose reporting and are prone to variation in dose reporting format. In view of this finding, we are exploring higher-reliability processes, including better-defined standards and automated dose reporting systems, to improve compliance.
View details for DOI 10.2214/AJR.14.13693
View details for Web of Science ID 000351614700037
Fast Pediatric 3D Free-Breathing Abdominal Dynamic Contrast Enhanced MRI With High Spatiotemporal Resolution JOURNAL OF MAGNETIC RESONANCE IMAGING 2015; 41 (2): 460-473
To develop a method for fast pediatric 3D free-breathing abdominal dynamic contrast enhanced (DCE) magnetic resonance imaging (MRI) and investigate its clinical feasibility.A combined locally low rank parallel imaging method with soft gating is proposed for free-breathing DCE MRI acquisition. With Institutional Review Board (IRB) approval and informed consent/assent, 23 consecutive pediatric patients were recruited for this study. Free-breathing DCE MRI with 1 mm(3) spatial resolution and a 6.5-sec frame rate was acquired on a 3T scanner. Undersampled data were reconstructed with a compressed sensing method without motion correction (FB-CS) and the proposed method (FB-LR). A follow-up respiratory-triggered acquisition (RT-CS) was performed as a reference standard. The reconstructed images were evaluated independently by two radiologists. Wilcoxon tests were performed to test the hypothesis that there was no significant difference between different reconstructions. Quantitative evaluation of contrast dynamics was also performed.The mean score of overall image quality of FB-LR was 4.0 on a 5-point scale, significantly better (P < 0.05) than FB-CS reconstruction (mean score 2.9), and similar to RT-CS (mean score 4.1). FB-LR also matched the temporal fidelity of contrast dynamics with a root mean square error less than 5%.Fast 3D free-breathing DCE MRI with high scan efficiency and image quality similar to respiratory-triggered acquisition is feasible in a pediatric clinical setting.J. Magn. Reson. Imaging 2013. 2013 Wiley Periodicals, Inc.
View details for DOI 10.1002/jmri.24551
View details for Web of Science ID 000348850600022
Clinical Correlation Needed: What Do Emergency Physicians Do After an Equivocal Ultrasound for Pediatric Acute Appendicitis? JOURNAL OF CLINICAL ULTRASOUND 2014; 42 (7): 385-394
Although follow-up CT is recommended for pediatric appendicitis if initial ultrasound (US) is equivocal, many physicians observe the patient at home. There are limited data to understand currently how common or safe this practice is. Our objectives are to assess prevalence of acute appendicitis and outcomes in patients with equivocal US with and without follow-up CT and to identify variables associated with ordering a follow-up CT.Retrospective analysis of the prevalence of appendicitis and outcomes of patients 1-18 years old with an equivocal US at a pediatric emergency department from 2003 to 2008. Recursive partitioning analysis and multivariate logistic regression were used to identify variables associated with ordering follow-up CT.Fifty-five percent (340/620) of children with equivocal US did not receive CT, none of whom returned with a missed appendicitis. The prevalence of appendicitis in children with equivocal US was 12.5% (78/620). In children with follow-up CT, the prevalence was 22.1% (62/280); in those without follow-up CT, the prevalence was 4.7% (16/340). Recursive partitioning identified age >11 years, leukocytosis >15,000 cells/ml, and secondary signs predisposing toward acute appendicitis on US as significant predictors of CT.We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT.
View details for DOI 10.1002/jcu.22153
View details for Web of Science ID 000340536300001
View details for PubMedID 24700515
Advances in fetal imaging. American journal of perinatology 2014; 31 (7): 567-576
While ultrasound (US) has been a part of prenatal care for almost 40 years, technical progress over the last two decades has resulted in improved image quality and detection rate of congenital anomalies. The past 15 years have also seen the expansion of three-dimensional (3D) US, providing enhancements over with 2D US, and more realistic images of babies to parents and providers. Fetal magnetic resonance imaging (MRI) was first performed over 30 years ago, and has undergone major technical improvement over the past 15 to 20 years. Fetal MRI complements US by providing better visualization in the fetus when US is limited such as in oligohydramnios or severe maternal obesity. It offers a larger field of view and better tissue contrast than US and is not limited by shadowing from osseous structures. However, MRI has a limited resolution compared with US, is less readily available, and more expensive. While indications for fetal MRI have been clearly established for some abnormalities, such as neurological anomalies, other indications especially for fetal body imaging are not as clearly defined. In this article, we discuss recent developments in fetal MRI and 3D US and their common and newest indications.
View details for DOI 10.1055/s-0034-1371712
View details for PubMedID 24792771
Fetal MRI correlates with postnatal CT angiogram assessment of pulmonary anatomy in tetralogy of Fallot with absent pulmonary valve. Congenital heart disease 2014; 9 (4): E105-9
In tetralogy of Fallot with absent pulmonary valve, pulmonary stenosis and regurgitation results in significant pulmonary artery dilatation. Branch pulmonary artery dilatation often compresses the tracheobronchial tree, causing fluid trapping in fetal life and air trapping and/or atelectasis after birth. Prenatal diagnosis predicts poor prognosis, which depends on the degree of respiratory insufficiency from airway compromise and lung parenchymal disease after birth. Fetal magnetic resonance imaging (MRI) has been useful in evaluating the effects of congenital lung lesions on lung development and indicating severity of pulmonary hypoplasia. This report is the first demonstrating the utility of fetal MRI in tetralogy of Fallot/absent pulmonary valve patients, which predicted postnatal pulmonary artery size and visualized airway compression and lung parenchymal lesions. The distribution of lobar fluid trapping on fetal MRI correlated with air trapping on postnatal computed tomography angiogram.
View details for DOI 10.1111/chd.12091
View details for PubMedID 23701739
Advances in Fetal Imaging AMERICAN JOURNAL OF PERINATOLOGY 2014; 31 (7): 567-576
Clinical Performance of Contrast Enhanced Abdominal Pediatric MRI With Fast Combined Parallel Imaging Compressed Sensing Reconstruction JOURNAL OF MAGNETIC RESONANCE IMAGING 2014; 40 (1): 13-25
To deploy clinically, a combined parallel imaging compressed sensing method with coil compression that achieves a rapid image reconstruction, and assess its clinical performance in contrast-enhanced abdominal pediatric MRI.With Institutional Review Board approval and informed patient consent/assent, 29 consecutive pediatric patients were recruited. Dynamic contrast-enhanced MRI was acquired on a 3 Tesla scanner using a dedicated 32-channel pediatric coil and a three-dimensional SPGR sequence, with pseudo-random undersampling at a high acceleration (R = 7.2). Undersampled data were reconstructed with three methods: a traditional parallel imaging method and a combined parallel imaging compressed sensing method with and without coil compression. The three sets of images were evaluated independently and blindly by two radiologists at one siting, for overall image quality and delineation of anatomical structures. Wilcoxon tests were performed to test the hypothesis that there was no significant difference in the evaluations, and interobserver agreement was analyzed.Fast reconstruction with coil compression did not deteriorate image quality. The mean score of structural delineation of the fast reconstruction was 4.1 on a 5-point scale, significantly better (P < 0.05) than traditional parallel imaging (mean score 3.1). Fair to substantial interobserver agreement was reached in structural delineation assessment.A fast combined parallel imaging compressed sensing method is feasible in a pediatric clinical setting. Preliminary results suggest it may improve structural delineation over parallel imaging. J. Magn. Reson. Imaging 2014;40:13-25. 2013 Wiley Periodicals, Inc.
View details for DOI 10.1002/jmri.24333
View details for Web of Science ID 000337640700003
View details for PubMedID 24127123
Fetal MRI Correlates with Postnatal CT Angiogram Assessment of Pulmonary Anatomy in Tetralogy of Fallot with Absent Pulmonary Valve CONGENITAL HEART DISEASE 2014; 9 (4): E105-E109
Perforated appendicitis: an underappreciated mimic of intussusception on ultrasound PEDIATRIC RADIOLOGY 2014; 44 (5): 535-541
We encountered multiple cases in which the US appearance of ruptured appendicitis mimicked intussusception, resulting in diagnostic and therapeutic delay and multiple additional imaging studies.To explore the clinical and imaging discriminatory features between the conditions.Initial US images in six children (age 16months to 8years; 4 boys, 2 girls) were reviewed independently and by consensus by three pediatric radiologists. These findings were compared and correlated with the original reports and subsequent US, fluoroscopic, and CT images and reports.All initial US studies demonstrated a multiple-ring-like appearance (target sign, most apparent on transverse views) with diagnostic consensus supportive of intussusception. In three cases, US findings were somewhat discrepant with clinical concerns. Subsequently, four of the six children had contrast enemas; two were thought to have partial or complete intussusception reduction. Three had a repeat US examination, with recognition of the correct diagnosis. None of the US examinations demonstrated definite intralesional lymph nodes or mesenteric fat, but central echogenicity caused by debris/appendicolith was misinterpreted as fat. All showed perilesional hyperechogenicity that, in retrospect, represented inflamed fat "walling off" of the perforated appendix. There were four CTs, all of which demonstrated a double-ring appearance that correlated with the US target appearance, with inner and outer rings representing the dilated appendix and walled-off appendiceal rupture, respectively. All six children had surgical confirmation of perforated appendicitis.Contained perforated appendicitis can produce US findings closely mimicking intussusception. Clinical correlation and careful multiplanar evaluation should allow for sonographic suspicion of perforated appendicitis, which can be confirmed on CT if necessary.
View details for DOI 10.1007/s00247-014-2873-8
View details for Web of Science ID 000334513800004
View details for PubMedID 24463638
Urachal Duct Carcinoma Complicating Pregnancy OBSTETRICS AND GYNECOLOGY 2013; 122 (2): 469-472
Degenerating myomas are common explanations for pain associated with abdominal masses in pregnancy. However, masses arising from other pelvic organs should be included in the differential diagnosis.We present a case of an abdominal mass in pregnancy that was originally misdiagnosed as a uterine leiomyoma. Attention to the patient's history along with judicious use of imaging modalities led to the correct diagnosis of urachal duct carcinoma. This was treated appropriately and resulted in a term vaginal delivery. We present a review of the literature on this tumor and its management in pregnancy.Urologic malignancies are rare but should be considered in the differential diagnosis for any woman presenting with pain and an abdominal mass in pregnancy. A multidisciplinary approach optimizes outcomes.
View details for DOI 10.1097/AOG.0b013e318292a3ab
View details for Web of Science ID 000330460000014
Conservatively Managed Fetal Goiter: An Alternative to in utero Therapy FETAL DIAGNOSIS AND THERAPY 2013; 34 (3): 184-187
Fetal goiter may arise from a variety of etiologies including iodine deficiency, overtreatment of maternal Graves' disease, inappropriate maternal thyroid replacement and, rarely, congenital hypothyroidism. Fetal goiter is often associated with a retroflexed neck and polyhydramnios, raising concerns regarding airway obstruction in such cases. Prior reports have advocated for cordocentesis and intra-amniotic thyroid hormone therapy in order to confirm the diagnosis of fetal thyroid dysfunction, reduce the size of the fetal goiter, reduce polyhydramnios, aid with the assistance of maternal thyroid hormone therapy and reduce fetal malpresentation. We report two cases of conservatively managed fetal goiter, one resulting in a vaginal delivery, and no evidence of postnatal respiratory distress despite the presence of polyhydramnios and a retroflexed neck on prenatal ultrasound. 2013 S. Karger AG, Basel.
View details for DOI 10.1159/000353387
View details for Web of Science ID 000326134700010
Imaging of fetal chest masses. Pediatric radiology 2012; 42: S62-73
Prenatal imaging with high-resolution US and rapid acquisition MRI plays a key role in the accurate diagnosis of congenital chest masses. Imaging has enhanced our understanding of the natural history of fetal lung masses, allowing for accurate prediction of outcome, parental counseling, and planning of pregnancy and newborn management. This paper will focus on congenital bronchopulmonary malformations, which account for the vast majority of primary lung masses in the fetus. In addition, anomalies that mimic masses and less common causes of lung masses will be discussed.
View details for DOI 10.1007/s00247-011-2171-7
View details for PubMedID 22395720
Imaging of fetal chest masses PEDIATRIC RADIOLOGY 2012; 42: 62-73
Effectiveness of a Staged US and CT Protocol for the Diagnosis of Pediatric Appendicitis: Reducing Radiation Exposure in the Age of ALARA RADIOLOGY 2011; 259 (1): 231-239
To evaluate the effectiveness of a staged ultrasonography (US) and computed tomography (CT) imaging protocol for the accurate diagnosis of suspected appendicitis in children and the opportunity for reducing the number of CT examinations and associated radiation exposure.This retrospective study was compliant with HIPAA, and a waiver of informed consent was approved by the institutional review board. This study is a review of all imaging studies obtained in children suspected of having appendicitis between 2003 and 2008 at a suburban pediatric emergency department. A multidisciplinary staged US and CT imaging protocol for the diagnosis of appendicitis was implemented in 2003. In the staged protocol, US was performed first in patients suspected of having appendicitis; follow-up CT was recommended when US findings were equivocal. Of 1228 pediatric patients who presented to the emergency department for suspected appendicitis, 631 (287 boys, 344 girls; age range, 2 months to 18 years; median age, 10 years) were compliant with the imaging pathway. The sensitivity, specificity, negative appendectomy rate (number of appendectomies with normal pathologic findings divided by the number of surgeries performed for suspected appendicitis), missed appendicitis rate, and number of CT examinations avoided by using the staged protocol were analyzed.The sensitivity and specificity of the staged protocol were 98.6% and 90.6%, respectively. The negative appendectomy rate was 8.1% (19 of 235 patients), and the missed appendicitis rate was less than 0.5% (one of 631 patients). CT was avoided in 333 of the 631 patients (53%) in whom the protocol was followed and in whom the US findings were definitive.A staged US and CT imaging protocol in which US is performed first in children suspected of having acute appendicitis is highly accurate and offers the opportunity to substantially reduce radiation.
View details for DOI 10.1148/radiol.10100984
View details for Web of Science ID 000288848800028
View details for PubMedID 21324843
MR imaging in cases of antenatal suspected appendicitis - a meta-analysis JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 2011; 24 (3): 485-488
Appendicitis is the most common surgical emergency in pregnancy. Acute appendicitis is often difficult to diagnose clinically, and concerns regarding antenatal CT imaging limit its use resulting in high false negative rates at laparotomy. MRI has recently been reported as a reasonable alternative to CT imaging in cases of suspected appendicitis. Our objective was to perform a meta-analysis of recently published data regarding the utility of MR imaging in cases of antenatal suspected acute appendicitis.We searched the PubMed database using keywords 'MRI', 'appendicitis', and 'pregnancy'. Five case series describing the role of MRI in cases of antenatal appendicitis were included. The sensitivity, specificity, positive, and negative predictive values were calculated.Two hundred twenty-nine patients were included in the study. In the first analysis in which non-diagnostic scans were excluded, the sensitivity, specificity, positive and negative predictive values of MRI for diagnosing appendicitis were 95.0%, 99.9%, 90.4%, and 99.5%, respectively. In the second analysis, which included non-diagnostic scans, the sensitivity, specificity, positive and negative predictive values were 90.5%, 98.6%, 86.3%, and 99.0%, respectivelyMR imaging may be useful in cases of suspected antenatal appendicitis. Data are still limited and larger prospective studies are necessary to confirm this finding.
View details for DOI 10.3109/14767058.2010.506227
View details for Web of Science ID 000286993000020
View details for PubMedID 20695758
Improved Pediatric MR Imaging with Compressed Sensing RADIOLOGY 2010; 256 (2): 607-616
To develop a method that combines parallel imaging and compressed sensing to enable faster and/or higher spatial resolution magnetic resonance (MR) imaging and show its feasibility in a pediatric clinical setting.Institutional review board approval was obtained for this HIPAA-compliant study, and informed consent or assent was given by subjects. A pseudorandom k-space undersampling pattern was incorporated into a three-dimensional (3D) gradient-echo sequence; aliasing then has an incoherent noiselike pattern rather than the usual coherent fold-over wrapping pattern. This k-space-sampling pattern was combined with a compressed sensing nonlinear reconstruction method that exploits the assumption of sparsity of medical images to permit reconstruction from undersampled k-space data and remove the noiselike aliasing. Thirty-four patients (15 female and 19 male patients; mean age, 8.1 years; range, 0-17 years) referred for cardiovascular, abdominal, and knee MR imaging were scanned with this 3D gradient-echo sequence at high acceleration factors. Obtained k-space data were reconstructed with both a traditional parallel imaging algorithm and the nonlinear method. Both sets of images were rated for image quality, radiologist preference, and delineation of specific structures by two radiologists. Wilcoxon and symmetry tests were performed to test the hypothesis that there was no significant difference in ratings for image quality, preference, and delineation of specific structures.Compressed sensing images were preferred more often, had significantly higher image quality ratings, and greater delineation of anatomic structures (P < .001) than did images obtained with the traditional parallel reconstruction method.A combination of parallel imaging and compressed sensing is feasible in a clinical setting and may provide higher resolution and/or faster imaging, addressing the challenge of delineating anatomic structures in pediatric MR imaging.
View details for DOI 10.1148/radiol.10091218
View details for Web of Science ID 000280272100032
View details for PubMedID 20529991
Standardizing resistive indices in healthy pediatric transplant recipients of adult-sized kidneys PEDIATRIC TRANSPLANTATION 2010; 14 (1): 126-131
Small pediatric recipients of an adult-sized kidney have insufficient renal blood flow early after transplantation, with secondary chronic hypoperfusion and irreversible histological damage of the tubulo-interstitial compartment. It is unknown whether this is reflected by renal resistive indices. We measured renal graft resistive indices and volumes of 47 healthy pediatric kidney transplant recipients of an adult-sized kidney in a prospective study for six months post-transplant. A total of 205 measurements were performed. The smallest recipients (BSA or= 1.5 m(2) (p < 0.0001). Resistive indices increased during the first six months in the smallest recipients (p = 0.02), but not in the two larger recipient groups (BSA 0.75-1.5 m(2) and >or=1.5 m(2)). All three BSA groups showed a reduction in renal volume after transplantation, with the greatest reduction occurring in the smallest recipients. In conclusion, renal transplant resistive indices reflect pediatric recipient BSA dependency. The higher resistance to intra-renal vascular flow and significant decrease in renal volume in the smallest group likely reflect accommodation of the size discrepant transplanted adult-sized kidney to the smaller pediatric recipient vasculature with associated lower renal artery flow.
View details for DOI 10.1111/j.1399-3046.2009.01180.x
View details for Web of Science ID 000273478100024
View details for PubMedID 19413712
MR Assessment of Normal Fetal Lung Volumes - A literature Review American Journal of Roentgenology 2010; 194: 212-217
An Interdisciplinary Initiative to Reduce Radiation Exposure: Evaluation of Appendicitis in a Pediatric Emergency Department With Clinical Assessment Supported by a Staged Ultrasound and Computed Tomography Pathway WILEY-BLACKWELL PUBLISHING, INC. 2009: 1258-1265
In the emergency department (ED), a significant amount of radiation exposure is due to computed tomography (CT) scans performed for the diagnosis of appendicitis. Children are at increased risk of developing cancer from low-dose radiation and it is therefore desirable to utilize CT only when appropriate. Ultrasonography (US) eliminates radiation but has sensitivity inferior to that of CT. We describe an interdisciplinary initiative to use a staged US and CT pathway to maximize diagnostic accuracy while minimizing radiation exposure.This was a retrospective outcomes analysis of patients presenting after hours for suspected appendicitis at an academic children's hospital ED over a 6-year period. The pathway established US as the initial imaging modality. CT was recommended only if US was equivocal. Clinical and pathologic outcomes from ED diagnosis and disposition, histopathology and return visits, were correlated with the US and CT. ED diagnosis and disposition, pathology, and return visits were used to determine outcome.A total of 680 patients met the study criteria. A total of 407 patients (60%) followed the pathway. Two-hundred of these (49%) were managed definitively without CT. A total of 106 patients (26%) had a positive US for appendicitis; 94 (23%) had a negative US. A total of 207 patients had equivocal US with follow-up CT. A total of 144 patients went to the operating room (OR); 10 patients (7%) had negative appendectomies. One case of appendicitis was missed (<0.5%). The sensitivity, specificity, negative predictive value, and positive predictive values of our staged US-CT pathway were 99%, 91%, 99%, and 85%, respectively. A total of 228 of 680 patients (34%) had an equivocal US with no follow-up CT. Of these patients, 10 (4%) went to the OR with one negative appendectomy. A total of 218 patients (32%) were observed clinically without complications.Half of the patients who were treated using this pathway were managed with definitive US alone with an acceptable negative appendectomy rate (7%) and a missed appendicitis rate of less than 0.5%. Visualization of a normal appendix (negative US) was sufficient to obviate the need for a CT in the authors' experience. Emergency physicians (EPs) used an equivocal US in conjunction with clinical assessment to care for one-third of study patients without a CT and with no known cases of missed appendicitis. These data suggest that by employing US first on all children needing diagnostic imaging for diagnosis of acute appendicitis, radiation exposure may be substantially decreased without a decrease in safety or efficacy.
View details for DOI 10.1111/j.1553-2712.2009.00511.x
View details for Web of Science ID 000271465000031
View details for PubMedID 20053244
MR Voiding Cystography for Evaluation of Vesicoureteral Reflux AMERICAN JOURNAL OF ROENTGENOLOGY 2009; 192 (5): W206-W211
The purpose of our study is to present a real-time interactive continuous fluoroscopy MRI technique for vesicoureteral reflux (VUR) diagnosis.MR voiding cystography with a real-time interactive MR fluoroscopic technique on an open MRI magnet is feasible for the evaluation of VUR in children.
View details for DOI 10.2214/AJR.08.1251
View details for Web of Science ID 000265387300045
View details for PubMedID 19380524
Neonatal Malrotation with Midgut Volvulus Mimicking Duodenal Atresia AMERICAN JOURNAL OF ROENTGENOLOGY 2009; 192 (5): 1269-1271
The purpose of this study was to describe the clinical, imaging, and surgical findings in the cases of four neonates with radiographic findings suggesting duodenal atresia (double-bubble sign) who were subsequently found to have malrotation with midgut volvulus.When the surgical treatment of a patient with the double-bubble sign is to be delayed, an upper gastrointestinal radiographic or ultrasound study is needed to evaluate for malrotation with midgut volvulus.
View details for DOI 10.2214/AJR.08.2132
View details for Web of Science ID 000265387300020
View details for PubMedID 19380551
Three-Dimensional MRI Volumetric Measurements of the Normal Fetal Colon AMERICAN JOURNAL OF ROENTGENOLOGY 2009; 192 (3): 761-765
The use of fetal MRI markedly improves characterization of abdominal congenital anomalies. Accurate prenatal diagnosis of the level and cause of congenital intestinal obstruction is desired for optimal parental counseling and perinatal care. Because accurate diagnosis would be aided by nomograms of colonic volume, this study was conducted to determine normal colonic volumes at different gestational ages.This retrospective study consisted of a review of 83 fetal MRI examinations performed on fetuses with no gastrointestinal abnormalities. MRI was performed with a 1.5-T system. Axial, sagittal, and coronal T1-weighted fast gradient-refocused echo images were acquired at TR/TE, 165/2.6; flip angle, 90 degrees; matrix size, 384 x 192; slice thickness, 5 mm; field of view, 38 cm(2). Two investigators determined the region of interest in the colon by outlining areas of high signal intensity of meconium slice by slice. They then calculated colonic luminal volume in the regions of interest. Colonic luminal volumes were reported relative to gestational age and abdominal circumference. Normative curves were generated, and interobserver and intraobserver analyses were performed.Seventeen of the 83 fetuses (20%) were excluded because of movement artifacts on the images. Normal colonic luminal volume increased exponentially with gestational age and abdominal circumference. The range of colonic luminal volumes at 20-37 weeks' gestational age was 1.1-65 mL. Variation of volume was greater at advanced gestational age. Interobserver and intraobserver correlation was good.This study yielded preliminary volumetric measurements of the normal fetal colon at 20-37 weeks of gestational age that suggest the fetal colon grows exponentially.
View details for DOI 10.2214/AJR.08.1504
View details for Web of Science ID 000264005700032
View details for PubMedID 19234275
Prenatal diagnosis of placenta accreta - Sonography or magnetic resonance imaging? JOURNAL OF ULTRASOUND IN MEDICINE 2008; 27 (9): 1275-1281
The purpose of this study was to compare the accuracy of transabdominal sonography and magnetic resonance imaging (MRI) for prenatal diagnosis of placenta accreta.A historical cohort study was undertaken at 3 institutions identifying women at risk for placenta accreta who had undergone both sonography and MRI prenatally. Sonographic and MRI findings were compared with the final diagnosis as determined at delivery and by pathologic examination.Thirty-two patients who had both sonography and MRI prenatally to evaluate for placenta accreta were identified. Of these, 15 had confirmation of placenta accreta at delivery. Sonography correctly identified the presence of placenta accreta in 14 of 15 patients (93% sensitivity; 95% confidence interval [CI], 80%-100%) and the absence of placenta accreta in 12 of 17 patients (71% specificity; 95% CI, 49%-93%). Magnetic resonance imaging correctly identified the presence of placenta accreta in 12 of 15 patients (80% sensitivity; 95% CI, 60%-100%) and the absence of placenta accreta in 11 of 17 patients (65% specificity; 95% CI, 42%-88%). In 7 of 32 cases, sonography and MRI had discordant diagnoses: sonography was correct in 5 cases, and MRI was correct in 2. There was no statistical difference in sensitivity (P = .25) or specificity (P = .5) between sonography and MRI.Both sonography and MRI have fairly good sensitivity for prenatal diagnosis of placenta accreta; however, specificity does not appear to be as good as reported in other studies. In the case of inconclusive findings with one imaging modality, the other modality may be useful for clarifying the diagnosis.
View details for Web of Science ID 000258853200002
View details for PubMedID 18716136
Fetus in fetu: 11 fetoid forms in a single fetus - Review of the literature and imaging JOURNAL OF ULTRASOUND IN MEDICINE 2008; 27 (9): 1381-1387
Prenatal sonography of congenital renal malformations AMERICAN JOURNAL OF ROENTGENOLOGY 1999; 173 (5): 1371-1376
Normal pediatric testis: Comparison of power Doppler and color Doppler US in the detection of blood flow RADIOLOGY 1997; 204 (2): 389-393
To compare power Doppler and conventional color Doppler ultrasound (US) in the detection of blood flow in the normal pediatric testis and to assess the symmetry of blood flow and the spectral Doppler tracing waveforms in the normal pediatric testis.Testicular blood flow was assessed prospectively in 68 testes in 34 boys (age range, 6 weeks to 13 years; mean age, 4.6 years) with both conventional color and power Doppler US. Intratesticular blood flow was graded as follows: 0, no intratesticular flow; 1, single intratesticular Doppler signal identified; and 2, multiple intratesticular Doppler signals identified. The symmetry of intratesticular flow was assessed both subjectively and objectively by using the same grading system. Spectral Doppler tracings were obtained in 62 testes in 31 patients.Power Doppler US demonstrated intratesticular blood flow in 66 (97%) testes. Color Doppler US demonstrated intratesticular blood flow in 60 (88%) testes. Combined techniques depicted blood flow in all 68 (100%) testes. Testicular blood flow was judged symmetric in all 34 (100%) patients with power Doppler US and in 31 (91%) patients with color Doppler US. Spectral Doppler tracings demonstrated absence of diastolic flow in 20 (32%) of 62 testes.In children, power Doppler US is more sensitive than color Doppler US in the detection of intratesticular blood flow. With power Doppler US, testicular blood flow in healthy children is symmetric, underscoring that the asymptomatic testis can be used as a baseline for assessing flow in the symptomatic testis.
View details for Web of Science ID A1997XL64400018
View details for PubMedID 9240525
Power Doppler imaging of focal lesions of the gastrointestinal tract: Comparison with conventional color Doppler imaging JOURNAL OF ULTRASOUND IN MEDICINE 1996; 15 (1): 63-66
To compare the usefulness of power Doppler imaging and color Doppler imaging in the vascular evaluation of gastrointestinal lesions, 21 patients with focal gastrointestinal tract lesions were examined with both power and color Doppler imaging. Two reviewers blinded to the diagnosis compared intramural vascularity detected by each of these methods. Power Doppler imaging detected flow in 16 patients with nonischemic lesions, whereas color Doppler imaging detected flow in only 11 patients. Neither modality detected flow in three patients with transmural infarction, but only power Doppler imaging detected minimal flow in the two patients with reversible ischemia. Power Doppler imaging improves visualization of intramural gastrointestinal vascularity, increasing the level of confidence in differentiating ischemic from nonischemic lesions.
View details for Web of Science ID A1996TN42100010
View details for PubMedID 8667486
1ST-TRIMESTER PRENATAL-DIAGNOSIS OF OSTEOGENESIS IMPERFECTA TYPE-II BY DNA ANALYSIS AND SONOGRAPHY PRENATAL DIAGNOSIS 1993; 13 (7): 589-596
Osteogenesis imperfecta type II was diagnosed prenatally by analysis of DNA obtained from chorionic villus sampling (CVS) performed at 12 weeks of gestation in a woman who previously had had an affected child. The father had been shown to be mosaic for a mutation in the gene (COL1A2) which encodes the alpha 2(I) chain of type I collagen. An affected fetus was predicted by detection of the mutation in amplified chorionic villus genomic DNA. Ultrasound examination at 13 weeks 4 days demonstrated femoral deformity and virtual absence of calvarial mineralization. In pregnancies at risk for osteogenesis imperfecta type II, sonographic evidence of skeletal abnormalities may be evident by 13 weeks' gestation.
View details for Web of Science ID A1993LN89500008
View details for PubMedID 8415424
PERINATAL AND POSTNATAL CHEST SONOGRAPHY RADIOLOGIC CLINICS OF NORTH AMERICA 1993; 31 (3): 499-516
Sonography is the primary method used to image the fetal chest. Many significant congenital anomalies such as pleural effusion, congenital diaphragmatic hernia, cystic adenomatoid malformation, pulmonary sequestration, and congenital heart disease can be detected during early prenatal sonography. Fetal sonography also permits accurate assessment of the severity of these processes, allowing for parental counseling and optimal planning of postnatal care. After birth, sonography is the primary method for evaluating cardiac anatomy and diagnosing congenital heart disease. Sonography also serves as a useful adjunct to plain film radiology and other modalities in evaluation of the mediastinum, diaphragm, pleura, and chest wall.
View details for Web of Science ID A1993LD87200005
View details for PubMedID 8497587