Frequency of paediatric medical imaging examinations performed at a European teaching hospital over a 7-year period

Integration of Certified Child Life Specialists to Decrease in Periprocedural Benzodiazepine Use: A Pilot Study

INTRODUCTION

Periprocedural anxiety is common in pediatric patients and is characterized by tension, anxiety, irritability, and autonomic activation. Periprocedural anxiety increases during certain events including admission to the preoperative area, separation from caregivers, induction of anesthesia, and IV placement. A study of children aged 2-12 showed that perioperative anxiety in children may be influenced by high parental anxiety and low sociability of the child. While these are nonmodifiable variables in the perioperative setting, there are numerous ways to ameliorate both parental and patient anxiety including the use of certified child life specialists (CCLSs) to aid in child comfort. In this study, our objective was to evaluate the integration of CCLS in our perioperative setting on the rate of benzodiazepine use.

METHODS

We used a prospectively maintained database to identify patients undergoing outpatient elective surgical and radiologic procedures from July 2022 to September 2023 and January 2023 to September 2023 respectively. CCLSs were used to work with appropriately aged children in order to decrease the use of benzodiazepines and reduce possible adverse events associated with their use.

RESULTS

A total of 2175 pediatric patients were seen by CCLS in same day surgery from July 2022 to September 2023. During this period, midazolam use decreased by an average of 11.4% (range 6.2%-19.3%). An even greater effect was seen in the radiologic group with 73% reduction. No adverse events were reported during this period.

CONCLUSIONS

CCLSs working with age-appropriate patients in the periprocedural setting is a useful adjunct in easing anxiety in pediatric patients, reducing the need for periprocedural benzodiazepine administration and the risk of exposure to unintended side effects.

Cumulative radiation exposure from multimodality recurrent imaging of CT, fluoroscopically guided intervention, and nuclear medicine

OBJECTIVES

To assess cumulative effective dose (CED) over a 4-year period in patients undergoing multimodality recurrent imaging at a major hospital in the USA.

METHODS

CED from CT, fluoroscopically guided intervention (FGI), and nuclear medicine was analyzed in consecutive exams in a tertiary care center in 2018-2021. Patients with CED ≥ 100 mSv were classified by age and body habitus (underweight, healthy weight, overweight, obese), as per body mass index percentiles < 5th, 5th to < 85th, 85th to < 95th, and ≥ 95th (age 2-19 years), and its ranges < 18.5, 18.5-24.9, 25-29.9, and ≥ 30 (≥ 20 years), respectively.

RESULTS

Among a total of 205,425 patients, 5.7% received CED ≥ 100 mSv (mean 184 mSv, maximum 1165 mSv) and their ages were mostly 50-64 years (34.1%), followed by 65-74 years (29.8%), ≥ 75 years (19.5%), 20-49 years (16.3%), and ≤ 19 years (0.29%). Body habitus in decreasing occurrence was obese (38.6%), overweight (31.9%), healthy weight (27.5%), and underweight (2.1%). Classification by dose indicated 172 patients (≥ 500 mSv) and 3 (≥ 1000 mSv). In comparison, 5.3% of 189,030 CT patients, 1.6% of 18,963 FGI patients, and 0.19% of 41,401 nuclear-medicine patients received CED ≥ 100 mSv from a single modality.

CONCLUSIONS

The study of total dose from CT, FGI, and nuclear medicine of patients with CED ≥ 100 mSv indicates major (89%) contribution of CT to CED with 70% of cohort being obese and overweight, and 64% of cohort aged 50-74 years.

CLINICAL RELEVANCE STATEMENT

Multimodality recurrent exams are common and there is a lack of information on patient cumulative radiation exposure. This study attempts to address this lacuna and has the potential to motivate actions to improve the justification process for enhancing patient safety.

KEY POINTS

• In total, 5.7% of patients undergoing multimodality recurrent imaging (CT, fluoroscopically guided intervention, nuclear medicine) incurred a dose of ≥ 100 mSv. • Mean dose was 184 mSv, with 15 to 18 times contribution from CT than that from fluoroscopically guided intervention or nuclear medicine. • In total, 70% of those who received ≥ 100mSv were either overweight or obese.

Ultrashort echo time MRI of the lung in children and adolescents: comparison with non-enhanced computed tomography and standard post-contrast T1w MRI sequences

Objectives

To compare the diagnostic value of ultrashort echo time (UTE) magnetic resonance imaging (MRI) for the lung versus the gold standard computed tomography (CT) and two T1-weighted MRI sequences in children.

Methods

Twenty-three patients with proven oncologic disease (14 male, 9 female; mean age 9.0 + / − 5.4 years) received 35 low-dose CT and MRI examinations of the lung. The MRI protocol (1.5-T) included the following post-contrast sequences: two-dimensional (2D) incoherent gradient echo (GRE; acquisition with breath-hold), 3D volume interpolated GRE (breath-hold), and 3D high-resolution radial UTE sequences (performed during free-breathing). Images were evaluated by considering image quality as well as distinct diagnosis of pulmonary nodules and parenchymal areal opacities with consideration of sizes and characterisations.

Results

The UTE technique showed significantly higher overall image quality, better sharpness, and fewer artefacts than both other sequences. On CT, 110 pulmonary nodules with a mean diameter of 4.9 + / − 2.9 mm were detected. UTE imaging resulted in a significantly higher detection rate compared to both other sequences (p < 0.01): 76.4% (84 of 110 nodules) for UTE versus 60.9% (67 of 110) for incoherent GRE and 62.7% (69 of 110) for volume interpolated GRE sequences. The detection of parenchymal areal opacities by the UTE technique was also significantly higher with a rate of 93.3% (42 of 45 opacities) versus 77.8% (35 of 45) for 2D GRE and 80.0% (36 of 45) for 3D GRE sequences (p < 0.05).

Conclusion

The UTE technique for lung MRI is favourable in children with generally high diagnostic performance compared to standard T1-weighted sequences as well as CT.

Key Points

• Due to the possible acquisition during free-breathing of the patients, the UTE MRI sequence for the lung is favourable in children.

• The UTE technique reaches higher overall image quality, better sharpness, and lower artefacts, but not higher contrast compared to standard post-contrast T1-weighted sequences.

• In comparison to the gold standard chest CT, the detection rate of small pulmonary nodules small nodules ≤ 4 mm and subtle parenchymal areal opacities is higher with the UTE imaging than standard T1-weighted sequences.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08236-7.

Factors Influencing Temporal Trends in Pediatric Inpatient Imaging Utilization

BACKGROUND

Concern exists over exponential growth in cardiac imaging in adults, but there is paucity of such data for cardiac imaging trends in pediatric patients. The aims of this study were to determine temporal trends in the use of noninvasive cardiac imaging and compare these with trends in the use of noncardiac imaging and to identify factors influencing those trends using the Pediatric Health Information Service database.

METHODS

Pediatric inpatient encounter data from January 2004 to December 2017 at 35 pediatric hospitals were extracted from the Pediatric Health Information Service database. Temporal imaging utilization trends in cardiac and noncardiac ultrasound or echocardiography, magnetic resonance imaging (MRI), and computed tomography (CT) were assessed using linear mixed-effects models. Models were adjusted for case-mix index, complex chronic conditions, patient age, length of stay, payer source, and cardiac surgical volume.

RESULTS

A total of 5,869,335 encounters over 14 years were analyzed (median encounters per center per year, 11,411; median patient age, 4 years; median length of stay, 3 days). From 2004 to 2017, the rates of pediatric inpatient cardiac and noncardiac ultrasound and MRI increased, whereas the rate of noncardiac CT decreased. Cardiac CT use increased beginning in 2014 (+0.264 cardiac CT encounters per 1,000 encounters per year), surpassing the rate of rise of cardiac MRI. Case-mix index, cardiac surgical volume, and payer source affected the largest number of imaging trends.

CONCLUSIONS

Among pediatric inpatients, utilization of cardiac and noncardiac ultrasound and MRI has steadily increased. Noncardiac CT use declined and cardiac CT use increased after 2014. Factors influencing imaging trends include case-mix index, cardiac surgical volume, and payer source. This study lays a foundation for investigations of imaging-related resource utilization and outcomes among pediatric inpatients.

Radiologically isolated syndrome in children: Current knowledge and future directions

As the use of magnetic resonance imaging (MRI) grows in clinical practice, clinicians are increasingly faced with the difficult task of interpreting the significance of incidental findings on brain MRI. Among individuals found to have incidental brain MRI findings, a small number have white matter abnormalities on MRI that resemble the demyelinating lesions of multiple sclerosis (MS) in the absence of a history of relevant clinical symptoms. This has been termed radiologically isolated syndrome (RIS). Recent years have seen growing interest in RIS, with observational studies that have specifically focused on answering questions regarding the subsequent risk of future clinical events and diagnosis of MS in adults and children with these findings. Given the high rate of subsequent clinical events seen in adult studies, knowledge related to RIS in children is paramount, particularly given the higher disease activity and burden in children with MS. This review examines this question, providing an overview of RIS with a focus on its significance in children including current definitions, its association with MS, and knowledge related to therapeutic interventions for RIS. We conclude with suggestions for an approach to assessment of and subsequent surveillance in children fulfilling criteria for RIS and directions for future study.

A personalized, Monte Carlo-based method for internal dosimetric evaluation of radiopharmaceuticals in children

PURPOSE

Herein, we introduce a methodology for estimating the absorbed dose in organs at risk that is based on specified clinically derived radiopharmaceutical biodistributions and personalized anatomical characteristics.

METHODS

To evaluate the proposed methodology, we used realistic Monte Carlo (MC) simulations and computational pediatric models to calculate a parameter called in this work the "specific absorbed dose rate" (SADR). The SADR is a unique quantitative metric in that it is specific to a particular organ. It is defined as the absorbed dose rate in an organ when the biodistribution of radioactivity over the whole body is considered. Initially, we applied a validation procedure that calculated specific absorbed fractions (SAFs) from mono-energetic photon sources in the range of 10 keV-2 MeV and compared them with previously published data. We calculated the SADRs for five different radiopharmaceuticals (99m Tc-MDP, 123 I-mIBG, 131 I-MIBG, 131 I-NaI, and 153 Sm-EDTMP) based on their biodistributions at four or five different times; the biodistributions were derived from the clinical scintigraphic data of pediatric patients. We used six models representing male and female patients aged 5, 8, and 14 yr to investigate the absorbed dose variability due to anatomical variations. The GATE Monte Carlo toolkit was used to calculate absorbed doses per organ. Finally, we compared the SADR methodology to that of OLINDA/EXM 1.1 using rescaled masses according to the studied models. Four target organs were considered for calculating the absorbed doses.

RESULTS

The ratios of SAFs calculated with GATE simulations to those based on previously published data were between 0.9 and 2.2 when the liver was used as a source organ. Subsequently, we used GATE to calculate a dataset of SADRs for the six pediatric models. The SADRs for pediatric models whose total body weights ranged from 20 to 40 kg varied up to approximately 90%, whereas those for models of similar body masses varied less than 15%. Finally, we found absorbed dose discrepancies of approximately 10-150% between the SADR methodology and OLINDA for two different radiopharmaceuticals. Absorbed doses from SADRs and from individualized S-values in the same pediatric model differed approximately 1-50%.

CONCLUSIONS

Because pediatric radiopharmaceutical dosimetric estimates demonstrate large variation due to the patient's anatomical characteristics, personalized data should be considered. Using our SADR method in a larger population of phantoms and for a variety of radiopharmaceuticals could enhance the personalization of dosimetry in pediatric nuclear medicine. The proposed methodology provides the advantage of creating time-dependent organ dose rate curves.