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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Abstract
The incidence of kidney stones in children is increasing. Approximately two-thirds of pediatric cases have a predisposing cause. Children with recurrent kidney stones have an increased higher risk of developing chronic kidney. A complete metabolic workup should be performed. Ultrasound examination is the initial imaging modality recommended for all children with suspected nephrolithiasis. A general dietary recommendation includes high fluid consumption, dietary salt restriction, and increased intake of vegetables and fruits. Depending on size and location of the stone, surgical intervention may be necessary. Multidisciplinary management is key to successful treatment and prevention.
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Affiliation(s)
- Larisa Kovacevic
- Department of Pediatric Urology, Michigan State University and Central Michigan University, Stone Clinic, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit 48201, MI, USA.
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Peng T, Zhong H, Hu B, Zhao S. Minimally invasive surgery for pediatric renal and ureteric stones: A therapeutic update. Front Pediatr 2022; 10:902573. [PMID: 36061394 PMCID: PMC9433542 DOI: 10.3389/fped.2022.902573] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022] Open
Abstract
The incidence of pediatric urolithiasis (PU) is growing worldwide. The corresponding therapeutic methods have become a research hot spot in pediatric urology. PU has the characteristics of abnormal metabolism, easy recurrence, and immature urinary system development, which make its treatment different from that of adults. Pediatric urologists should select the optimal treatment modality to completely remove the stones to prevent recurrence. Currently, the curative treatments of PU include extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, retrograde intrarenal surgery, percutaneous nephrolithotomy (PCNL), laparoscopic, robot-assisted laparoscopic, and open surgery. This review aims to conduct a therapeutic update on the surgical interventions of both pediatric renal and ureteric stones. It accentuates that pediatric surgeons or urologists should bear in mind the pros and cons of various minimally invasive surgical treatments under different conditions. In the future, the treatment of PU will be more refined due to the advancement of technology and the development of surgical instruments. However, a comprehensive understanding of the affected factors should be taken into account by pediatric urologists to select the most beneficial treatment plan for individual children to achieve precise treatment.
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Affiliation(s)
- Tao Peng
- Department of Pediatric Surgery, Huizhou Central People's Hospital, Huizhou, China
| | - Hongcai Zhong
- Department of Pediatric Surgery, Huizhou Central People's Hospital, Huizhou, China
| | - Baohui Hu
- Department of Pediatric Surgery, Huizhou Central People's Hospital, Huizhou, China
| | - Shankun Zhao
- Department of Urology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, China
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Huang Y, Bao M, Liu C, Zheng S, Du T, Wu K. Distribution of APOE gene polymorphism in the Chinese Uyghur children & its association with urolithiasis. Indian J Med Res 2021; 154:108-114. [PMID: 34782536 PMCID: PMC8715683 DOI: 10.4103/ijmr.ijmr_1208_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND & OBJECTIVES This study was to survey the apolipoprotein E (APOE) gene polymorphism distribution among Chinese Uyghur children and to explore the relationship between APOE gene polymorphism and the occurrence of urolithiasis. METHODS A total of 144 Uyghur children with urolithiasis and 274 without the history of urolithiasis were enrolled in this study. Venous blood samples were collected from all participants, and APOE genotyping, derived from rs429358 and rs7412, was performed using Sanger sequencing. RESULTS Among the 418 children, the most prevalent genotype was E3/3, accounting for 71.3 per cent in the urolithiasis group and 71.4 per cent in the control group, followed by E3/4 and E2/3. Higher frequencies of the ɛ2 and ɛ4 alleles and lower frequencies of the ɛ3 allele were observed in the test group, and the unusual allele ɛ1 was also found in them. However, there were no significant differences between cases and controls at both rs429358 and rs7412 genotype and allele frequencies [odds ratio (OR)=0.98, 95% confidence interval (CI): 0.57-1.67; 0.98 (0.59-1.63); 1.43 (0.75-2.74) and 1.40 (0.74-2.62), respectively]. Likewise, none of significant differences was found between cases and controls at both APOE genotype and allele frequencies [OR=0.88, 95% CI: 0.51-1.53; 0.74 (0.33-1.64); 1.10 (0.73-1.66); 1.13 (0.76-1.67) and 1.14 (0.76-1.70), respectively]. INTERPRETATION & CONCLUSIONS The present study does not support any association between APOE genotyping and urolithiasis in Uyghur children.
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Affiliation(s)
- Yuanni Huang
- Department of Preventive Medicine, Shantou University Medical College, Shantou 515041, Guangdong, China
| | | | - Caixia Liu
- Department of Preventive Medicine, Shantou University Medical College, Shantou 515041, Guangdong, China
| | - Shukai Zheng
- Department of Preventive Medicine, Shantou University Medical College, Shantou 515041, Guangdong, China
| | - Taifeng Du
- Department of Preventive Medicine, Shantou University Medical College, Shantou 515041, Guangdong, China
| | - Kusheng Wu
- Department of Preventive Medicine, Shantou University Medical College, Shantou 515041, Guangdong, China
- For correspondence: Dr Kusheng Wu, Department of Preventive Medicine, Shantou University Medical College, No. 22, Xinling Rd., Shantou 515041, Guangdong, PR China e-mail:
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Shavor C, Pagenhardt J, Sun Y, Kraft C, End B, Minardi J. Ureteral Stone Mimics Appendicitis: A Point-of-care Ultrasound Case Report. Clin Pract Cases Emerg Med 2020; 4:555-558. [PMID: 33217271 PMCID: PMC7676809 DOI: 10.5811/cpcem.2020.7.48155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/24/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Abdominal pain is a common complaint in the emergency department. Point-of-care ultrasound (POCUS) is a rapid modality to evaluate for the etiology. Case Report A teenage male presented with symptoms concerning for appendicitis. POCUS revealed a non-peristalsing, non-compressible, tubular structure containing an echogenic stone. This was determined to be a ureteral stone within a dilated ureter, not appendicitis. Conclusion We propose a syndromic sonographic approach to right lower quadrant pain (RLQ) that includes the gallbladder, right kidney, bladder, and right adnexa, in addition to RLQ landmarks. This case emphasizes the value of such an approach to avoid diagnostic error.
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Affiliation(s)
- Cindy Shavor
- West Virginia University School of Medicine, Department of Emergency Medicine, Morgantown, West Virginia
| | - Justine Pagenhardt
- West Virginia University School of Medicine, Department of Emergency Medicine, Morgantown, West Virginia
| | - YuanYuan Sun
- West Virginia University School of Medicine, Department of Emergency Medicine, Morgantown, West Virginia
| | - Clara Kraft
- West Virginia University School of Medicine, Department of Emergency Medicine, Morgantown, West Virginia
| | - Bradley End
- West Virginia University School of Medicine, Department of Emergency Medicine, Morgantown, West Virginia.,West Virginia University School of Medicine, Department of Medical Education, Morgantown, West Virginia
| | - Joseph Minardi
- West Virginia University School of Medicine, Department of Emergency Medicine, Morgantown, West Virginia.,West Virginia University School of Medicine, Department of Medical Education, Morgantown, West Virginia
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Abstract
Pediatric nephrolithiasis is a disease of increasing prevalence and economic burden, with data showing a rising trend among girls and adolescents. Kidney stones in children tend to have a high recurrence rate related to underlying risk factors, and the aim of evaluation should be to understand such causes so that targeted therapy can be provided to decrease recurrence and complications. Metabolic, anatomic, and genetic abnormalities as well as environmental risk factors have all been implicated in the pathogenesis of nephrolithiasis. Recent studies have focused on identifying monogenic causes of nephrolithiasis and/or nephrocalcinosis in young patients that would result in personalization of treatment as well as future diagnostic implications for family members. Treatment aims to decrease stone burden and recurrence as well as minimize complications and is guided by stone size and location as well as surgical expertise. Multidisciplinary care for these patients has been on the rise to provide a more comprehensive medical and surgical support. [Pediatr Ann. 2020;49(6):e262-e267.].
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Sultan S, Aba Umer S, Ahmed B, Naqvi SAA, Rizvi SAH. Update on Surgical Management of Pediatric Urolithiasis. Front Pediatr 2019; 7:252. [PMID: 31334207 PMCID: PMC6616131 DOI: 10.3389/fped.2019.00252] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/03/2019] [Indexed: 12/15/2022] Open
Abstract
Urolithiasis has always been a fascinating disease, even more so in children. There are many intriguing facets to this pathology. This article is a nonsystematic review to provide an update on the surgical management of pediatric urolithiasis. It highlights the pros and cons of various minimally invasive surgical options such as extracorporeal shockwave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), laparoscopy, and robotics. This article also describes the various intracorporeal disintegration technologies available to fragment the stone, including the newer advancements in laser technology. It also emphasizes the cost considerations especially with reference to the emerging economies. Thus, this manuscript guides how to select the least-invasive option for an individual patient, considering age and gender; stone size, location, and composition; and facilities and expertise available.
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Affiliation(s)
- Sajid Sultan
- Philip G. Ransley Department of Paediatric Urology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
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Huang Y, Peng Q, Bao M, Liu C, Wu K, Zhou S. Biochemical metabolic levels and vitamin D receptor FokⅠ gene polymorphisms in Uyghur children with urolithiasis. PLoS One 2019; 14:e0212183. [PMID: 30742686 PMCID: PMC6370244 DOI: 10.1371/journal.pone.0212183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 01/29/2019] [Indexed: 02/05/2023] Open
Abstract
Because of lacking studies of urolithiasis in children, we detected the biochemical metabolic levels and FokⅠ polymorphisms in the vitamin D receptor (VDR) in Uyghur children with urolithiasis, and evaluated the associations of biochemical metabolic levels with FokⅠ genotypes. We included 142 Uyghur children (108 males) under age 14 years with a diagnosis of urolithiasis and 238 Uyghur children (154 males) under age 14 years without a history of urolithiasis as controls. Baseline information and data for serum and urine parameters were obtained from medical records. PCR-restriction fragment length polymorphism (PCR-RFLP) was used to analyze the VDR FokⅠ polymorphisms. In univariate analyses adjusting for age and sex, carbon dioxide combining power (CO2CP) (odds ratio [OR] = 1.13, 95% confidence interval [CI]: 1.07-1.19), serum magnesium (Mg) (OR = 1.27, 95% CI: 1.03-1.56) and serum chlorine (Cl) (OR = 0.93, 95% CI: 0.88-0.97) were related to Uyghur children urolithiasis risk. A multiple logistic regression model showed CO2CP (OR = 1.17, 95% CI: 1.09-1.26), levels of uric acid (OR = 1.01, 95% CI: 1.00-1.01) and serum sodium (Na) (OR = 0.90, 95% CI: 0.82-0.99) were associated with pediatric urolithiasis. The risk of urolithiasis was increased with the F versus f allele overall (OR = 1.42; 95% CI: 1.01-2.00) and for males (OR = 1.52, 95% CI: 1.02-2.27). However, metabolic levels did not differ by FokⅠ genotypes. In our population, CO2CP and levels of uric acid and serum Na as well as polymorphism of the F allele of the VDR FokⅠ may provide important clues to evaluate the risk of urolithiasis in Uyghur children.
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Affiliation(s)
- Yuanni Huang
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong, China
| | - Qing Peng
- Department of Hepatobiliary Surgery II, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Mian Bao
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong, China
| | - Caixia Liu
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong, China
| | - Kusheng Wu
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong, China
| | - Shuqin Zhou
- Department of Anesthesiology, the First People’s Hospital of Kashi, Kashi, Xinjiang, China
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong, China
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Barata CB, Valete COS. CLINICAL-EPIDEMIOLOGICAL PROFILE OF 106 PEDIATRIC PACIENTS WITH UROLITHIASIS IN RIO DE JANEIRO, BRAZIL. REVISTA PAULISTA DE PEDIATRIA 2018; 36:261-267. [PMID: 30365808 PMCID: PMC6202900 DOI: 10.1590/1984-0462/;2018;36;3;00009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 08/23/2017] [Indexed: 01/20/2023]
Abstract
Objective: To describe the frequency, clinical profile and treatment of patients with
urolithiasis in the Pediatric Nephrology Department of a public state
hospital in Rio de Janeiro, Brazil. Methods: Retrospective study. Data from pediatric patients (age: 1 month - 18 years)
with urolithiasis admitted between January/2012 and December/2014 were
reviewed from hospital charts. The studied variables were: demographic and
anthropometric data, clinical status, family history of urolithiasis,
urinary tract infection and use of lithogenic drugs, diagnostic procedures,
associated abnormalities, metabolic disorders, treatment and recurrence. Results: The frequency of urolithiasis was 13.6%. Main characteristics of the
patients: male gender, white race, eutrophy, aged between 5 and 10 years,
family history of urolithiasis, previous urinary infection and spontaneous
stone passage. Abdominal and flank pain and macroscopic hematuria were the
most common complaints. The most frequent metabolic disorders were
hypercalciuria, hyperuricosuria and hypocitraturia. Hypocitraturia was
associated with previous urinary infection (p=0.004). Abdomen/urinary tract
ultrasonography was the most commonly used diagnostic test. Hydronephrosis
occurred in 54.4% of the cases, 81.1% of the stones were in the kidneys, and
bilateral stones were associated to a family history of urolithiasis
(p=0.030). Recurrence rate was 29.3% (most patients had a metabolic
disorder). In 12.3%, the patients underwent lithotripsy, 24.5% were
surgically treated (mainly pyelolithotomy), and only 7.6% had their stones
analyzed (calcium oxalate was the main finding in the examined stones). Conclusions: The frequency of urolithiasis in these pediatric patients was similar to
that reported by the literature. A metabolic evaluation is required and the
composition of stones should be better evaluated.
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Abstract
Once considered rare, pediatric nephrolithiasis has become a critical field of study in the last decade due to the rapid increase in incidence. Understanding the changing epidemiology and lifelong implications of pediatric stone disease is critically important to effectively manage the individual patient as well as identify risk factors for childhood onset that could be modified. Determining the role of diagnostic imaging in children is a unique challenge as limiting radiation and imaging stewardship should be priorities. Approaches to management have also changed, as technology continues to evolve and both medical and surgical options expand.
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Affiliation(s)
- Diana K Bowen
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine and The Children's Hospital of Philadelphia, 3rd Floor, Wood Building, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Gregory E Tasian
- Division of Urology, Center for Pediatric Clinical Effectiveness, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, 3rd Floor, Wood Building, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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