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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level V.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Pediatric Odontogenic Sinusitis: A Systematic Review

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

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

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

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

BACKGROUND

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

OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gaps and priorities in innovation for children's surgery

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV; cross-sectional analysis.

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

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

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

Introduction

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

Methods

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

Results

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

Discussion

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVELS OF EVIDENCE

Level III.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Contemporary Role of Computed Tomography in Managing Pediatric Primary Spontaneous Pneumothorax

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes of Displaced Tibial Tubercle Fractures in Adolescents

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

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

HYPOTHESIS

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

OPERATIVE TECHNIQUE

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

CONCLUSION

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Asymptomatic non-occult pneumothorax in pediatric blunt chest trauma: Chest tube versus observation

BACKGROUND

The treatment of asymptomatic non-occult pneumothoraces (ANOPTX) secondary to blunt chest trauma (BCT) has not been well delineated. We sought to analyze our experience with ANOPTX in pediatric trauma patients and determine if a chest tube (CT) is mandatory.

METHODS

A retrospective chart review of patients < 17 years old with ANOPTX from BCT who presented to a level 1 trauma children's hospital, between January 2000 and June 2015 was performed. Demographics, vitals, trauma scores, imaging, interventions, hospital expenses and outcomes were analyzed.

RESULTS

Of the 77 patients who had ANOPTX, 48 (62.3%) were managed with observation only, while 29 (37.7%) underwent CT placement. The median length of stay for patients who had CT placement was 7 days (IQR, 4, 12) and 2 days (IQR, 1, 4) in those observed (p < 0.01). All patients who were observed had complete resolution of the pneumothorax without recurrence or the need for CT placement. Patients who had CT placement had more imaging performed and more hospital expenditure compared to those who were observed.

CONCLUSIONS

CT is not mandatory in all pediatric patients with ANOPTX from BCT and observation has been found to be safe and cost effective.

Management of post-septal complications of acute rhinosinusitis in children: A 14-year experience in a tertiary hospital

INTRODUCTION

Acute rhinosinusitis accounts for most of the cases of orbital infections and is the most common cause of periorbital oedema in children. Up to 10% of patients with orbital complications of acute rhinosinusitis may experience vision loss and other complications such as meningitis, intracranial abscess or even death. Therefore, these patients require prompt diagnosis and proper treatment.

OBJECTIVES

This study aims to report the clinical presentation and management of post-septal orbital complications of acute rhinosinusitis in the paediatric population.

MATERIALS AND METHODS

A retrospective medical chart review of all children aged under 18 years old who were diagnosed with post-septal orbital complications of acute rhinosinusitis at a tertiary academic hospital, between 01/2007 and 12/2020. Patients were grouped according to the Chandler Classification (groups 2-5).

RESULTS

Fifty-five children (mean age of 6.91 ± 4.61 years) fulfilled the entry criteria for post-septal orbital complications of acute rhinosinusitis, based on clinical evaluation by an otorhinolaryngologist and CT-scan findings. Forty (72.72%) patients were also evaluated by an ophthalmologist. Most patients were male (76.36%). Twenty-four patients had post-septal cellulitis (43.63%), 21 patients had a subperiosteal abscess (38.18%) and 10 patients had an orbital abscess (18.18%). Eyelid swelling was the most frequent sign, followed by fever. Microbiology varied considerably and gram-positive agents were clearly predominant. Eighteen (32.73%) patients had been treated with oral antibiotics prior to hospital admission, exhibiting a significantly higher risk of recurrence of orbital infection (p = 0.020). Ethmoid and maxillary sinuses were the most involved paranasal sinuses (90.91%). Thirty-three patients (60%) were successfully treated medically, and 22 patients (40%) required surgical drainage. Seven patients (12.73%) developed further complications and six recovered without sequelae. The mean length of hospital stay was 8.0 ± 5.0 days and recurrence of orbital infection occurred in six patients (10.91%). The absolute neutrophil blood count was significantly different amongst Chandler groups (p = 0.021), with higher counts in patients with subperiosteal abscess. The duration of hospitalization was significantly higher in patients submitted to surgery (p < 0.001).

CONCLUSION

Post-septal orbital complications of acute rhinosinusitis are infrequent but dangerous events in the paediatric population. Close collaboration with Ophtalmology is paramount, as the child's vision is at risk. Eyelid swelling and proptosis are early signs. CT-scan imaging plays an invaluable role in the diagnosis and decision-making. Predictive indicators for surgery were not found. However, emergency endoscopic nasal surgery with abscess drainage should be considered whenever vision is at risk, if there is no improvement after aggressive medical treatment, and in cases of intracranial complications.

Navigation and non-navigation CT scan of the sinuses: comparison of the effective doses of radiation in children and adults

BACKGROUND

The advent of 3D navigation imaging has opened new borders to the endoscopic surgical approaches of naso-sinusal inflammatory and neoplastic disease. This technology has gained in popularity among otolaryngologists for endoscopic sinus and skull base surgeries in both adults and children. However, the increased tissue radiation required for data acquisition associated with 3D navigation protocols CT scans is a source of concern because of its potential health hazards. We aimed to compare the effective doses of radiation between 3D navigation protocols and standard protocols for sinus computed tomography (CT) scans for both the adult and pediatric population.

METHODS

We performed a retrospective cohort study through electronic chart review of patients undergoing sinus CT scans (standard and 3D navigation protocols) from May 2019 to December 2019 using a Siemens Drive (VA62A) CT scanner. The effective dose of radiation was calculated in mSv for all exams. Average irradiation doses were compared using a Student's T-Test or a Kruskall-Wallis test when appropriate.

RESULTS

A total of 115 CT scans were selected for analysis, of which 47 were standard protocols and 68 were 3D navigation protocols CT scans. Among these, 31 exams were performed on children and 84 exams on adults. For the total population, mean effective dose in the non-navigation CT scans was 0.37 mSv (SD: 0.16, N = 47) and mean effective dose in the 3D navigation sinus CT group was 2.33 mSv (SD: 0.45, N = 68). The mean difference between the two groups was statistically significant 1.97 mSv (CI 95% - 2.1 to - 1.83; P < 0.0001). There was a sixfold increase in radiation with utilization of 3D navigation protocols. The ratio was identical when the pediatric as well as the adult subset of patients were analyzed.

CONCLUSION

In our center, utilization of 3D navigation sinus CT protocols significantly increases radiation exposure. Otolaryngologists should be aware of this significant increase and should attempt to decrease the radiation exposure of their patients by limiting unnecessary scan orders and by evaluating 3D acquisition protocols locally with radiation physicists.

LEVEL OF EVIDENCE

Level IV.

Paediatric Trauma Score as a non-imaging tool for predicting intracranial haemorrhage in patients with traumatic brain injury

To identify a useful non-imaging tool to screen paediatric patients with traumatic brain injury for intracranial haemorrhage (ICH). We retrospectively analysed patients aged < 15 years who visited the emergency department with head trauma between January 2015 and September 2020. We divided patients into two groups (ICH and non-ICH) and compared their demographic and clinical factors. Among 85 patients, 21 and 64 were in the ICH and non-ICH groups, respectively. Age (p = 0.002), Pediatric trauma score (PTS; p < 0.001), seizure (p = 0.042), and fracture (p < 0.001) differed significantly between the two groups. Factors differing significantly between the groups were as follows: age (odds ratio, 0.84, p = 0.004), seizure (4.83, p = 0.013), PTS (0.15, p < 0.001), and fracture (69.3, p < 0.001). Factors with meaningful cut-off values were age (cut-off [sensitivity, specificity], 6.5 [0.688, 0.714], p = 0.003) and PTS [10.5 (0.906, 0.81), p < 0.001]. Based on the previously known value for critical injury (≤ 8 points) and the cut-off value of the PTS identified in this study (≤ 10 points), we divided patients into low-risk, medium-risk, and high-risk groups; their probabilities of ICH (95% confidence intervals) were 0.16-12.74%, 35.86-89.14%, and 100%, respectively. PTS was the only factor that differed significantly between mild and severe ICH cases (p = 0.012). PTS is a useful screening tool with a high predictability for ICH and can help reduce radiation exposure when used to screen patient groups before performing imaging studies.

Variation in pediatric cervical spine imaging across trauma centers-A cause for concern?

BACKGROUND

Traumatic pediatric cervical spine injury can be challenging to diagnose, and the clinical algorithms meant to aid physicians differ from adult trauma protocols. Despite the existence of standardized guidelines, imaging decisions may vary according to physician education, subjective assessment, and experience with pediatric trauma patients. Our study investigates the rates of pediatric posttraumatic cervical spine imaging across trauma centers, hypothesizing that more specialized centers will have lower rates of advanced cervical spine imaging.

METHODS

The 2015 to 2016 Trauma Quality Improvement Program database was reviewed for patients younger than 18 years- to assess rates of cervical spine imaging on presentation across different trauma centers. Propensity stratification logistic regression was performed controlling for patient- and center-specific variables. p Values less than 0.05 were considered significant.

RESULTS

Of 110,769 pediatric trauma patients, 35.2% were female, and the average age was 9.6 years. Overall, 3.6% had cervical spine computed tomography (CT) and less than 1% had cervical spine MRI or X-ray. Compared with all others, Level I trauma centers were significantly less likely to use cervical spine CT for the initial evaluation of younger (≤14 years) but not older trauma patients (adjusted odds ratio [AOR], 0.89; 95% confidence interval [CI], 0.80-0.99; AOR, 0.97; 95% CI, 0.87-1.09); Level I centers had higher odds of cervical spine MRI use, but only for patients 14 years or younger (AOR, 1.63; 95% CI, 1.09-2.44). Pediatric-designated trauma centers had significantly lower odds of cervical spine CT (≤14 years: AOR, 0.70; 95% CI, 0.63-0.78; >14 years: AOR, 0.67; 95% CI, 0.67-0.75) and higher odds of cervical spine X-ray (≤14 years: AOR, 4.75; 95% CI, 3.55-6.36; >14 years: AOR, 4.50; 95% CI, 2.72-7.45) for all ages, but higher odds of cervical spine MRI for younger patients only (≤14 years: AOR, 2.10; 95% CI, 1.38-3.21).

CONCLUSION

Level I and pediatric designations were associated with lower rates of cervical spine CT. Pediatric centers were also more likely to use cervical spine X-ray. This variability of imaging use further supports the need to disseminate and educate providers on pediatric-specific cervical spine evaluation guidelines.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Low-value injury admissions in an integrated Canadian trauma system: A multicentre cohort study

BACKGROUND

Injury represents 260 000 hospitalisations and $27 billion in healthcare costs each year in Canada. Evidence suggests that there is significant variation in the prevalence of hospital admissions among emergency department presentations between countries and providers, but we lack data specific to injury admissions. We aimed to estimate the prevalence of potentially low-value injury admissions following injury in a Canadian provincial trauma system, identify diagnostic groups contributing most to low-value admissions and assess inter-hospital variation.

METHODS

We conducted a retrospective multicentre cohort study based on all injury admissions in the Québec trauma system (2013-2018). Using literature and expert consultation, we developed criteria to identify potentially low-value injury admissions. We used a multilevel logistic regression model to evaluate inter-hospital variation in the prevalence of low-value injury admissions with intraclass correlation coefficients (ICC). We stratified our analyses by age (1-15; 16-64; 65-74; 75+ years).

RESULTS

The prevalence of low-value injury admissions was 16% (n = 19 163) among all patients, 26% (2136) in children, 11% (4695) in young adults and 19% (12 345) in older adults. Diagnostic groups contributing most to low-value admissions were mild traumatic brain injury in children (48% of low-value paediatric injury admissions; n = 922), superficial injuries (14%, n = 660) or minor spinal injuries (14%, n = 634) in adults aged 16-64 and superficial injuries in adults aged 65+ (22%, n = 2771). We observed strong inter-hospital variation in the prevalence of low-value injury admissions (ICC = 37%).

CONCLUSION

One out of six hospital admissions following injury may be of low value. Children with mild traumatic brain injury and adults with superficial injuries could be good targets for future research efforts seeking to reduce healthcare services overuse. Inter-hospital variation indicates there may be an opportunity to reduce low-value injury admissions with appropriate interventions targeting modifications in care processes.

Development of Chinese mesh-type pediatric reference phantom series and application in dose assessment of Chinese undergoing computed tomography scanning

Pediatric patients are in a growing stage with more dividing cells than adults. Therefore, they are more sensitive to the radiation dose when undergoing computed tomography (CT) scanning. It is necessary and essential to assess the organ absorbed dose and effective dose to children. Monte Carlo simulation with computational phantoms is one of the most used methods for dose calculation in medical imaging and radiotherapy. Because of the vast change of the pediatric body with age increasing, many research groups developed series pediatric phantoms for various ages. However, most of the existing pediatric reference phantoms were developed based on Caucasian populations, which is not conformable to Chinese pediatric patients. The use of different phantoms can contribute to a difference in the dose calculation. To assess the CT dose of Chinese pediatric patients more accurately, we developed the Chinese pediatric reference phantoms series, including the 3-month (CRC3m), 1-year-old (CRC01), 5-year-old (CRC05), 10-year-old (CRC10), 15-year-old male (CRCM15), and a 15-year-old female (CRCF15) phantoms. Furthermore, we applied them to dose assessment of patients undergoing CT scanning. The GE LightSpeed 16 CT scanner was simulated and the paper presents the detailed process of phantoms development and the establishment of the CT dose database (with x-ray tube voltages of 120, 100 and 80 kVp, with collimators of 20, 10, and 5 mm width, with filters for head and body), compares for the 1-year-old results with other results based on different phantoms and analyzes the CT dose calculation results. It was found that the difference in phantoms' characteristics, organ masses and positions had a significant impact on the CT dose calculation outcomes. For the 1-year-old phantom, the dose results of organs fully covered by the x-ray beam were within 10% difference from the results of other studies. For organs partially covered and not covered by the scan range, the maximum differences came up to 84% (stomach dose, chest examinations) and 463% (gonads dose, chest examinations) respectively. The findings are helpful for the dose optimization of Chinese pediatric patients undergoing CT scanning. The developed phantoms could be applied in dose estimation of other medical modalities.

Variation in radiation dosing among pediatric trauma patients undergoing head computed tomography scan

BACKGROUND

When head injured children undergo head computed tomography (CT), radiation dosing can vary considerably between institutions, potentially exposing children to excess radiation, increasing risk for malignancies later in life. We compared radiation delivery from head CTs at a level 1 pediatric trauma center (PTC) versus scans performed at referring adult general hospitals (AGHs). We hypothesized that children at our PTC receive a significantly lower radiation dose than children who underwent CT at AGHs for similar injury profiles.

METHODS

We retrospectively reviewed the charts of all patients younger than 18 years who underwent CT for head injury at our PTC or at an AGH before transfer between January 1 and December 31, 2019. We analyzed demographic and clinical data. Our primary outcome was head CT radiation dose, as calculated by volumetric CT dose index (CTDIvol) and dose-length product (DLP; the product of CTDIvol and scan length). We used unadjusted bivariate and multivariable linear regression (adjusting for age, weight, sex) to compare doses between Children's Hospital Los Angeles and AGHs.

RESULTS

Of 429 scans reviewed, 193 were performed at our PTC, while 236 were performed at AGHs. Mean radiation dose administered was significantly lower at our PTC compared with AGHs (CTDIvol 20.3/DLP 408.7 vs. CTDIvol 30.6/DLP 533, p < 0.0001). This was true whether the AGH was a trauma center or not. After adjusting for covariates, findings were similar for both CTDIvol and DLP. Patients who underwent initial CT at an AGH and then underwent a second CT at our PTC received less radiation for the second CT (CTDIvol 25.6 vs. 36.5, p < 0.0001).

CONCLUSIONS

Head-injured children consistently receive a lower radiation dose when undergoing initial head CT at a PTC compared with AGHs. This provides a basis for programs aimed at establishing protocols to deliver only as much radiation as necessary to children undergoing head CT.

LEVEL OF EVIDENCE

Care Management/Therapeutic, level IV.

Deep learning based synthetic-CT generation in radiotherapy and PET: A review

Recently,deep learning (DL)-based methods for the generation of synthetic computed tomography (sCT) have received significant research attention as an alternative to classical ones. We present here a systematic review of these methods by grouping them into three categories, according to their clinical applications: (i) to replace computed tomography in magnetic resonance (MR) based treatment planning, (ii) facilitate cone-beam computed tomography based image-guided adaptive radiotherapy, and (iii) derive attenuation maps for the correction of positron emission tomography. Appropriate database searching was performed on journal articles published between January 2014 and December 2020. The DL methods' key characteristics were extracted from each eligible study, and a comprehensive comparison among network architectures and metrics was reported. A detailed review of each category was given, highlighting essential contributions, identifying specific challenges, and summarizing the achievements. Lastly, the statistics of all the cited works from various aspects were analyzed, revealing the popularity and future trends and the potential of DL-based sCT generation. The current status of DL-based sCT generation was evaluated, assessing the clinical readiness of the presented methods.

Computer-aided diagnosis with a convolutional neural network algorithm for automated detection of urinary tract stones on plain X-ray

BACKGROUND

Recent increased use of medical images induces further burden of their interpretation for physicians. A plain X-ray is a low-cost examination that has low-dose radiation exposure and high availability, although diagnosing urolithiasis using this method is not always easy. Since the advent of a convolutional neural network via deep learning in the 2000s, computer-aided diagnosis (CAD) has had a great impact on automatic image analysis in the urological field. The objective of our study was to develop a CAD system with deep learning architecture to detect urinary tract stones on a plain X-ray and to evaluate the model's accuracy.

METHODS

We collected plain X-ray images of 1017 patients with a radio-opaque upper urinary tract stone. X-ray images (n = 827 and 190) were used as the training and test data, respectively. We used a 17-layer Residual Network as a convolutional neural network architecture for patch-wise training. The training data were repeatedly used until the best model accuracy was achieved within 300 runs. The F score, which is a harmonic mean of the sensitivity and positive predictive value (PPV) and represents the balance of the accuracy, was measured to evaluate the model's accuracy.

RESULTS

Using deep learning, we developed a CAD model that needed 110 ms to provide an answer for each X-ray image. The best F score was 0.752, and the sensitivity and PPV were 0.872 and 0.662, respectively. When limited to a proximal ureter stone, the sensitivity and PPV were 0.925 and 0.876, respectively, and they were the lowest at mid-ureter.

CONCLUSION

CAD of a plain X-ray may be a promising method to detect radio-opaque urinary tract stones with satisfactory sensitivity although the PPV could still be improved. The CAD model detects urinary tract stones quickly and automatically and has the potential to become a helpful screening modality especially for primary care physicians for diagnosing urolithiasis. Further study using a higher volume of data would improve the diagnostic performance of CAD models to detect urinary tract stones on a plain X-ray.

Diagnostic utility of MDCT in evaluation of persistent stridor in children: Large airway causes and benefit of additional findings

OBJECTIVES

To assess the diagnostic utility of MDCT in the evaluation of persistent stridor in children for the underlying large airway causes and benefit of additional findings.

METHODS

All consecutive pediatric patients who underwent MDCT for the evaluation of persistent stridor from December 2018 to February 2020 were included. Two pediatric radiologists independently reviewed MDCT studies for the presence of abnormalities at six large airway levels: (1) nasopharynx, (2) oropharynx, (3) glottis, (4) subglottis, (5) trachea, and (6) mainstem bronchi. In addition, studies were evaluated for the presence of non-airway abnormalities. Interobserver agreement between two reviewers was evaluated with kappa statistics.

RESULTS

There were a total of 40 pediatric patients (age range: 1 day-4 years. MDCT detected large airway abnormalities in 20 (50%) out of 40 patients, including 4 (20%) in nasopharynx, 4 (20%) in glottis, 4 (20%) in trachea, 3 (15%) in subglottis, 3 (15%) in mainstem bronchi, and 2 (10%) in oropharynx. Non-airway abnormalities were seen in 13 (32.5%) children, including 9 (69%) in the lungs, 3 (23%) in the soft tissue, and 1 (8%) in the bone. The remaining 7 (17.5%) studies were normal. There was excellent interobserver agreement seen for detecting large airway and non-airway abnormalities (k > 0.90).

CONCLUSION

MDCT has high diagnostic utility in diagnosing large airway causes of persistent stridor in children. It can also provide additional information regarding non-airway abnormalities. Therefore, MDCT has the potential to be utilized as a noninvasive problem-solving imaging modality in pediatric patients with persistent stridor.

Assessment of hepatic artery anatomy in pediatric liver transplant recipients: MR angiography versus CT angiography

During LT screening, children undergo CTA to determine hepatic artery anatomy. However, CTA imparts radiation, unlike MRA. The aim was to compare MRA to CTA in assessing hepatic artery anatomy in pediatric LT recipients. Twenty-one children (median age 8.9 years) who underwent both CTA and fl3D-ce MRA before LT were retrospectively included. Interreader variability between 2 radiologists, image quality, movement artifacts, and confidence scores, were used to compare MRA to CTA. Subgroup analyses for ages <6 years and ≥6 years were performed. Interreader variability for MRA and CTA in children <6 years was comparable (k = 0.839 and k = 0.757, respectively), while in children ≥6 years CTA was superior to MRA (k 1.000 and k 0.000, respectively). Overall image quality and confidence scores of CTA were significantly higher compared to MRA at all ages (2.8/3 vs. 2.3/3, p = .001; and 2.9/3 vs. 2.5/3, p = .003, respectively). Movement artifacts were significantly lower in CTA compared to MRA in children ≥6 years (1.0/3 vs. 1.7/3, p = .010, respectively). CTA is preferred over fl3D-ce MRA for the preoperative assessment of hepatic artery anatomy in children receiving LT, both at ages <6 years and ≥6 years.

High-Resolution CT Following Primary Spontaneous Pneumothorax in Adolescents: Useful Tool or Wasted Radiation?

Background The current trend in management of first-time primary spontaneous pneumothorax (PSP) in children is to obtain a high-resolution chest computerized tomography (HRCT) scan to look for bleb/bullae disease or other forms of structural lung disease. We aimed to evaluate the significance of HRCT findings in relation to initial management strategies, and we hypothesized that these findings do not guide management.  Methods We evaluated patients with first-time PSP in a single-institution, retrospective, longitudinal study. Data were obtained through direct chart review. The primary endpoint was the percentage of patients who underwent surgical intervention after HRCT. Results We identified 10 children from 10 to 17 years old from January 2013 to November 2019 who met criteria for the study. Seven out of 10 patients (70%) had HRCT after the first-time PSP during the same hospital stay. Blebs/bullae were discovered in five out of seven (71%) of those patients. Two of those five patients had subsequent surgical intervention (40%) before a recurrence. Of the three patients with blebs/bullae identified on HRCT treated without initial surgery, two had a recurrence of PSP and subsequently underwent VATS with blebectomy and pleurodesis. Among the patients without initial HRCT, there were no recurrent cases of PSP noted. Conclusions Our study suggests there is value in obtaining HRCT after the first time PSP, as these results can be used to guide management strategies. Further studies in pediatric PSP are needed to validate the sensitivity of HRCT in bleb detection, the predictive value of bleb disease and recurrence, and the benefits and risks of early surgical intervention.

Spectral CT quantification stability and accuracy for pediatric patients: A phantom study

BACKGROUND

Spectral computed tomography (spectral CT) provides access to clinically relevant measures of endogenous and exogenous materials in patients. For pediatric patients, current spectral CT applications include lesion characterization, quantitative vascular imaging, assessments of tumor response to treatment, and more.

OBJECTIVE

The aim of this study is a comprehensive investigation of the accuracy and stability of spectral quantifications from a spectral detector-based CT system with respect to different patient sizes and radiation dose levels relevant for the pediatric population.

MATERIALS AND METHODS

A spectral CT phantom with tissue-mimicking materials and iodine concentrations relevant for pediatric imaging was scanned on a spectral detector CT system using a standard pediatric abdominal protocol at 100%, 67%, 33% and 10% of the nominal radiation dose level. Different pediatric patient sizes were simulated using supplemental 3D-printed extension rings. Virtual mono-energetic, iodine density, effective atomic number, and electron density results were analyzed for stability with respect to radiation dose and patient size.

RESULTS

Compared to conventional CT imaging, a pronounced improvement in the stability of attenuation measurements across patient size was observed when using virtual mono-energetic images. Iodine densities were within 0.1 mg/ml, effective atomic numbers were within 0.26 atomic numbers and electron density quantifications were within ±1.0% of their respective nominal values. Relative to the nominal dose clinical protocol, differences in attenuation of all tissue-mimicking materials were maintained below 1.6 HU for a 33% dose reduction, below 2.7 HU for a 67% dose reduction and below 3.7 HU for a 90% dose reduction, for all virtual mono-energetic energies equal to or greater than 50 keV. Iodine, and effective atomic number quantifications were stable to within 0.1 mg/ml and 0.06 atomic numbers, respectively, across all measured dose levels.

CONCLUSION

Spectral CT provides accurate and stable material quantification with respect to radiation dose reduction (up to 90%) and differing pediatric patient size. The observed consistency is an important step towards quantitative pediatric imaging at low radiation exposure levels.

Evaluation of Organ Dose and Image Quality Metrics of Pediatric CT Chest-Abdomen-Pelvis (CAP) Examination: An Anthropomorphic Phantom Study

The aim of this study is to investigate the impact of CT acquisition parameter setting on organ dose and its influence on image quality metrics in pediatric phantom during CT examination. The study was performed on 64-slice multidetector CT scanner (MDCT) Siemens Definition AS (Siemens Sector Healthcare, Forchheim, Germany) using various CT CAP protocols (P1–P9). Tube potential for P1, P2, and P3 protocols were fixed at 100 kVp while P4, P5, and P6 were fixed at 80 kVp with used of various reference noise values. P7, P8, and P9 were the modification of P1 with changes on slice collimation, pitch factor, and tube current modulation (TCM), respectively. TLD-100 chips were inserted into the phantom slab number 7, 9, 10, 12, 13, and 14 to represent thyroid, lung, liver, stomach, gonads, and skin, respectively. The image quality metrics, signal to noise ratio (SNR) and contrast to noise ratio (CNR) values were obtained from the CT console. As a result, this study indicates a potential reduction in the absorbed dose up to 20% to 50% along with reducing tube voltage, tube current, and increasing the slice collimation. There is no significant difference (p > 0.05) observed between the protocols and image metrics.