The Image Gently pediatric digital radiography safety checklist: tools for improving pediatric radiography

Conventional Radiography Assessment of the Pediatric Knee: Pearls and Pitfalls

Knee pain is one of the most common indications for radiography in the evaluation of musculoskeletal disorders in children and adolescents. According to international guidelines, knee radiographs should be obtained when there is the suspicion of an effusion, limited motion, pain to palpation, inability to bear weight, mechanical symptoms (such as "locking"), and persistent knee pain after therapy. When indicated, radiographs can provide crucial information for the clinical decision-making process. Because of the developmental changes occurring in the knee during growth, the assessment of knee radiographs can be challenging in children and adolescents. Radiologists unfamiliar with the appearance of the knee on radiographs during skeletal maturation risk overcalling or overlooking bone lesions. Image acquisition techniques and parameters should be adapted to children. This article describes the most common challenges in distinguishing pathology from the normal appearance of knee radiographs in the pediatric population, offering some pearls and pitfalls that can be useful in clinical practice.

Workload and use factor data for a modern digital radiography system

The well-referenced structural shielding design NCRP Report No. 147 uses workload information based on self-reported film-screen data from the AAPM Task Group 9 survey. The aim of this study was to assess the clinical workload distributions of modern digital radiography (DR) systems in general hospital and pediatric-only practices. A retrospective analysis of DR imaging data on four radiographic systems in a hospital practice and two radiographic systems in a pediatric practice, through a custom clinical DICOM header analytics program. A total of 203, 294 exposures from the general hospital practice and 25,415 from the pediatric practice from 2019 and 2021 were included. Values for kVp, mAs, and detector type (wall bucky, table bucky, or free detector) were extracted. For each exam, mAs was accumulated in a kVp histogram with bins 5 kVp wide and further parsed by detector type. Total workload was calculated by summing all exposures, then normalized by the number of patients. The median (25th and 75th percentile) workload in the hospital practice was 0.43 (0.22, 1.13) mA-min per patient, while the average was 1.36 ± 3.08. Pediatric data yielded a median (25th and 75th percentile) of 0.10 (0.05, 0.23) and an average of 0.29 ± 0.69 mA-min per patient. Mean number of patients per week was 230 adult and 57 pediatric. Hospital workload data is approximately 44% less than the NCRP Report No. 147 value.

Impact of a radiological protection campaign in emergency paediatric radiology: a multicentric observational study in Brazil

Purpose

To evaluate the impact of a paediatric radiological protection campaign, implemented in the emergency units of a healthcare provider network in Brazil. This campaign aimed to promote awareness among emergency department physicians, regarding justification of paediatric X-ray referrals for paranasal sinus, chest and CT exams, as a strategy to reduce exposure to ionising radiation.

Method

Frequency analysis of common paediatric imaging referrals from 19 emergency departments was performed for a 3-year period (2015–2018) to coincide with before, during and after the implementation of the radiation protection campaign. The campaign was multifaceted and involved dissemination of educational materials and imaging referral guidelines along with quarterly meetings with participating centres' leaderships. Additionally, patient dose cards were distributed to patients/carers. The Chi-Square test was used to examine the association between the type of examination and the patient's age group. Exact-Fisher test was performed to check for an association between participant engagement and the existence of the radiation protection committee.

Results

Referrals reduced by 25% following the campaign with no reports of misdiagnosis. Many referrals in the youngest age groups. In 15 units, a radiological protection committee was created to raise awareness and to create a multi professional team to communicate the risks and benefits of radiological procedure in children.

Conclusion

The campaign resulted in a substantial reduction in radiological referrals while promoting a radiation protection culture. Simple education initiatives can contribute to savings in both finances and radiation doses, particularly important in radiosensitive cohorts.

Design and 3D printing of variant pediatric heart models for training based on a single patient scan

Background

3D printed models of pediatric hearts with congenital heart disease have been proven helpful in simulation training of diagnostic and interventional catheterization. However, anatomically accurate 3D printed models are traditionally based on real scans of clinical patients requiring specific imaging techniques, i.e., CT or MRI. In small children both imaging technologies are rare as minimization of radiation and sedation is key. 3D sonography does not (yet) allow adequate imaging of the entire heart for 3D printing. Therefore, an alternative solution to create variant 3D printed heart models for teaching and hands-on training has been established.

Methods

In this study different methods utilizing image processing and computer aided design software have been established to overcome this shortage and to allow unlimited variations of 3D heart models based on single patient scans. Patient-specific models based on a CT or MRI image stack were digitally modified to alter the original shape and structure of the heart. Thereby, 3D hearts showing various pathologies were created. Training models were adapted to training level and aims of hands-on workshops, particularly for interventional cardiology.

Results

By changing the shape and structure of the original anatomy, various training models were created of which four examples are presented in this paper: 1. Design of perimembranous and muscular ventricular septal defect on a heart model with patent ductus arteriosus, 2. Series of heart models with atrial septal defect showing the long-term hemodynamic effect of the congenital heart defect on the right atrial and ventricular wall, 3. Implementation of simplified heart valves and addition of the myocardium to a right heart model with pulmonary valve stenosis, 4. Integration of a constructed 3D model of the aortic valve into a pulsatile left heart model with coarctation of the aorta. All presented models have been successfully utilized and evaluated in teaching or hands-on training courses.

Conclusions

It has been demonstrated that non-patient-specific anatomical variants can be created by modifying existing patient-specific 3D heart models. This way, a range of pathologies can be modeled based on a single CT or MRI dataset. Benefits of designed 3D models for education and training purposes have been successfully applied in pediatric cardiology but can potentially be transferred to simulation training in other medical fields as well.

Percutaneous retrieval of intravascular foreign body in children: a case series and review

BACKGROUND

Percutaneous retrieval of intravascular foreign bodies has recently increased as a treatment option.

PURPOSE

To report our single-center experience of the percutaneous retrieval of 14 intravascular embolized catheter fragments in children and to conduct a literature review.

MATERIAL AND METHODS

MEDLINE databases were searched for case reports and series including children and iatrogenic catheter fragments or guidewires retrieved through percutaneous techniques. We also conducted a retrospective analysis of 14 cases from our institution over a 14-year period. A total of 27 studies were selected comprising 74 children, plus our 14 unpublished cases. Statistical analyses were performed using Microsoft Excel version 2016.

RESULTS

Port catheter fragments and peripherally inserted central catheters (PICCs) were the most embolized foreign bodies and the pulmonary artery was the most common site of embolization in 44.1% of cases. Analysis of the retrieval technique demonstrated a preference for extraction through the femoral vein (81.7%) and using snare techniques (93.5%). The success rate of percutaneous retrieval was 96.6% with only 1.1% of procedure-related complications. Patients were asymptomatic in 77.2% of cases, presented septic complications in 2.3%, and no deaths were reported. Median fluoroscopy time was 10 min (range = 1.7-80 min) and median procedure length was 60 min (range = 35-208 min).

CONCLUSION

Percutaneous retrieval of intravascular foreign bodies is a feasible, safe, and efficient technique in children and should be considered the preferred treatment option.

Does the Use of a Checklist Help Medical Students in the Detection of Abnormalities on a Chest Radiograph?

The interpretation of chest radiographs is a complex task that is prone to diagnostic error, especially for medical students. The aim of this study is to investigate the extent to which medical students benefit from the use of a checklist regarding the detection of abnormalities on a chest radiograph. We developed a checklist based on literature and interviews with experienced thorax radiologists. Forty medical students in the clinical phase assessed 18 chest radiographs during a computer test, either with (n = 20) or without (n = 20) the checklist. We measured performance and asked participants for feedback using a survey. Participants that used a checklist detected more abnormalities on images with multiple abnormalities (M = 50.1%) than participants that could not use a checklist (M = 41.9%), p = 0.04. The post-experimental survey shows that on average, participants considered the checklist helpful (M = 3.25 on a five-point scale), but also time consuming (M = 3.30 on a five-point scale). In conclusion, a checklist can help medical students to detect abnormalities in chest radiographs. Moreover, students tend to appreciate the use of a checklist as a helpful tool during the interpretation of a chest radiograph. Therefore, a checklist is a potentially important tool to improve radiology education in the medical curriculum.

Impact on Quality When Pediatric Urgent Care Centers Are Staffed With Radiology Technologists

PURPOSE

The proliferation of pediatric urgent care centers has increased the need for diagnostic imaging support, but the impact of employing radiology technologists at these centers is not known. The purpose of this study was to evaluate radiographic impact and quality at urgent care centers with and without radiology technologists.

METHODS

A retrospective case-control study was conducted comparing 235 radiographic examinations (study) performed without and 83 examinations (control) performed with a radiology technologist at the authors' pediatric urgent care centers. Studies were evaluated for quality using a five-point, Likert-type scale (1 = poor, 5 = best) regarding field of view, presentation, and orthogonal view orientation. Studies were also evaluated for the incidence of positive results, need for repeat imaging, and discrepancies between initial study and follow-up.

RESULTS

Imaging quality comparisons between study and control groups were statistically different for field of view (3.98 versus 4.29, P = .014), presentation (4.39 versus 4.51, P = .045), and orthogonal view orientation (4.45 versus 4.69, P = .033). The incidence of repeat imaging was similar (4.7% versus 2.4%, P = 0.526), as well as the discrepancy rates (3.4 versus 2.4%, P = 1.00). The incidence of abnormal radiographic findings for the study and control groups was similar (40.9% versus 34.9%, P = .363).

CONCLUSIONS

Radiography is an important triage tool at pediatric urgent care centers. It is imperative to have optimal radiographic imaging for accurate diagnosis, and imaging quality is improved when radiology technologists are available. If not feasible or cost prohibitive, it is important that physicians be given training opportunities to bridge the quality gap when using radiographic equipment and exposing children to radiation.

Radiation exposure during X-ray examinations in a large paediatric hospital in Serbia

Objective of this work is to evaluate radiation exposure from X-ray examinations in a large paediatric hospital in Serbia, including radiographic, fluoroscopic and computed tomography (CT) examinations in four age groups: 0-1, 1-5, 5-10 and 10-15 y. Incident air kerma was assessed for the following radiographies: chest (AP, PA, LAT), spine (AP, LAT), pelvis (AP), urinary tract (AP, PA) and skull (AP, PA, LAT). Kerma-area product was measured for the fluoroscopy examinations: barium swallow, barium meal, barium enema and micturating cystography. Dose in CT was assessed in terms of volume CT dose index and dose-length product for examinations of the head, chest and abdomen. The collected data were compared with other similar studies, which indicated a need to expand such survey to other paediatric hospitals in Serbia.

Pediatric aspects of inpatient health information technology systems

In the past 3 years, the Health Information Technology for Economic and Clinical Health Act accelerated the adoption of electronic health records (EHRs) with providers and hospitals, who can claim incentive monies related to meaningful use. Despite the increase in adoption of commercial EHRs in pediatric settings, there has been little support for EHR tools and functionalities that promote pediatric quality improvement and patient safety, and children remain at higher risk than adults for medical errors in inpatient environments. Health information technology (HIT) tailored to the needs of pediatric health care providers can improve care by reducing the likelihood of errors through information assurance and minimizing the harm that results from errors. This technical report outlines pediatric-specific concepts, child health needs and their data elements, and required functionalities in inpatient clinical information systems that may be missing in adult-oriented HIT systems with negative consequences for pediatric inpatient care. It is imperative that inpatient (and outpatient) HIT systems be adapted to improve their ability to properly support safe health care delivery for children.

Improving our PRODUCT: a quality and safety improvement project demonstrating the value of a preprocedural checklist for fluoroscopy

RATIONALE AND OBJECTIVES

To implement a preprocedural checklist in gastrointestinal (GI)/genitourinary (GU) fluoroscopy suites to assist radiology residents in performing studies with optimal fluoroscopic technique with a goal to lower radiation dose delivered to patients and operators.

MATERIALS AND METHODS

We introduced a preprocedural checklist in the form of a mnemonic to first-year resident fluoroscopy operators. The checklist was augmented by teaching sessions at the fluoroscopy tower. Fluoroscopy time (FT) was collected for GI/GU fluoroscopy studies performed by first-year residents who did not use the checklist (year 1) and compared with FT from first-year residents who used the checklist for one full academic year (year 2). Residents in both groups were surveyed to assess their knowledge of radiation safety at the end of their respective radiology 1 (R1) academic years.

RESULTS

A total of 778 examinations were analyzed from year 1, and 941 total examinations from year 2. After implementation of the checklist, mean FT for all studies decreased by 41.1 seconds (P < .0001) in year 2 residents. Multivariate linear regression confirmed that year of examination was the strongest independent predictor of FT when other covariates such as resident age, gender, and experience and patient age and gender were included. Radiation safety knowledge was similar in both groups but self-reported confidence in safe fluoroscopy tower operation increased slightly in year 2 (P = .144).

CONCLUSIONS

A visual preprocedural radiation safety checklist in GI/GU fluoroscopy was associated with a reduction in mean FT and may contribute to a culture of radiation safety awareness.