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Mazurek MH, Abruzzo AR, King AH, Koranteng E, Rigney G, Lie W, Razak S, Gupta R, Mehan WA, Lev MH, Hirsch JA, Buch K, Succi MD. Implementation of a Survey Spine MR Imaging Protocol for Cord Compression in the Emergency Department: Experience at a Level 1 Trauma Center. AJNR Am J Neuroradiol 2024; 45:1378-1384. [PMID: 38702066 PMCID: PMC11392377 DOI: 10.3174/ajnr.a8326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND AND PURPOSE Imaging stewardship in the emergency department (ED) is vital in ensuring patients receive optimized care. While suspected cord compression (CC) is a frequent indication for total spine MR imaging in the ED, the incidence of CC is low. Recently, our level 1 trauma center introduced a survey spine MR imaging protocol to evaluate for suspected CC while reducing examination time to avoid imaging overutilization. This study aims to evaluate the time savings, frequency of ordering patterns of the survey, and the symptoms and outcomes of patients undergoing the survey. MATERIALS AND METHODS This retrospective study examined patients who received a survey spine MR imaging in the ED at our institution between 2018 and 2022. All examinations were performed on a 1.5T GE Healthcare scanner by using our institutional CC survey protocol, which includes sagittal T2WI and STIR sequences through the cervical, thoracic, and lumbar spine. Examinations were read by a blinded, board-certified neuroradiologist. RESULTS A total of 2002 patients received a survey spine MR imaging protocol during the study period. Of these patients, 845 (42.2%, mean age 57 ± 19 years, 45% women) received survey spine MR imaging examinations for the suspicion of CC, and 120 patients (14.2% positivity rate) had radiographic CC. The survey spine MR imaging averaged 5 minutes and 50 seconds (79% faster than routine MR imaging). On multivariate analysis, trauma, back pain, lower extremity weakness, urinary or bowel incontinence, numbness, ataxia, and hyperreflexia were each independently associated with CC. Of the 120 patients with CC, 71 underwent emergent surgery, 20 underwent nonemergent surgery, and 29 were managed medically. CONCLUSIONS The survey spine protocol was positive for CC in 14% of patients in our cohort and acquired at a 79% faster rate compared with routine total spine. Understanding the positivity rate of CC, the clinical symptoms that are most associated with CC, and the subsequent care management for patients presenting with suspected cord compression who received the survey spine MR imaging may better inform the broad adoption and subsequent utilization of survey imaging protocols in emergency settings to increase throughput, improve allocation of resources, and provide efficient care for patients with suspected CC.
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Affiliation(s)
- Mercy H Mazurek
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - Annie R Abruzzo
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - Alexander H King
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - Erica Koranteng
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - Grant Rigney
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - Winston Lie
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - Shahaan Razak
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - Rajiv Gupta
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
- Department of Radiology (R.G., W.A.M., M.H.L., J.A.H., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - William A Mehan
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
- Department of Radiology (R.G., W.A.M., M.H.L., J.A.H., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - Michael H Lev
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
- Department of Radiology (R.G., W.A.M., M.H.L., J.A.H., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - Joshua A Hirsch
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
- Department of Radiology (R.G., W.A.M., M.H.L., J.A.H., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - Karen Buch
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
| | - Marc D Succi
- From the Harvard Medical School (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Boston, Massachusetts
- Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO) (M.H.M., A.R.A., A.H.K., E.K., G.R., W.L., S.R., R.G., W.A.M., M.H.L., J.A.H., K.B., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
- Department of Radiology (R.G., W.A.M., M.H.L., J.A.H., M.D.S.), Massachusetts General Hospital, Boston, Massachusetts
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Mishra S, Srinivasan A, Kelsey L, Bojicic K, Masotti M, Chen Q, Hoeffner E, Kronick S, Gomez-Hassan D. Implementing a rapid cord compression Magnetic Resonance Imaging protocol in the emergency department: Lessons learned. Neuroradiol J 2024:19714009241269540. [PMID: 39115980 DOI: 10.1177/19714009241269540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND & PURPOSE (1) Evaluate efficacy of an abbreviated total spine protocol in triaging emergency department (ED) patients through retrospective evaluation. (2) Describe patient outcomes following implementation of a rapid cord compression protocol. METHODS (1) All contrast-enhanced total spine magnetic resonance imaging studies (MRIs) performed on ED patients (n = 75) between 10/1-12/31/2022 for evaluation of cord compression were included. Two readers with 6 and 5 years of experience blindly reviewed the abbreviated protocol (comprised of sagittal T2w and axial T2w sequences) assessing presence of cord compression or severe spinal canal stenosis. Ground truth was consensus by a neuroradiology fellow and 2 attendings. (2) The implemented rapid protocol included sagittal T1w, sagittal T2w Dixon and axial T2w images. All ED patients (n = 85) who were imaged using the rapid protocol from 5/1-8/31/2023 were included. Patient outcomes and call-back rates were determined through chart review. RESULTS (1) Sensitivity and specificity for severe spinal canal stenosis and/or cord compression was 1.0 and 0.92, respectively, for reader 1 and 0.78 and 0.85, respectively, for reader 2. Negative predictive value was 1.0 and 0.97 for readers 1 and 2, respectively. (2) The implemented rapid cord compression protocol resulted in 60% reduction in imaging time at 1.5T. The call-back rate for additional sequences was 7%. In patients who underwent surgery, no additional MRI images were acquired in 82% of cases (9/11). CONCLUSIONS Implementing an abbreviated non-contrast total spine protocol in the ED results in a low call-back rate with acquired MRI images proving sufficient for both triage and treatment planning in most patients.
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Affiliation(s)
- Shruti Mishra
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Ashok Srinivasan
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Lauren Kelsey
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Katherine Bojicic
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Maria Masotti
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Qiaochu Chen
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Ellen Hoeffner
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Steven Kronick
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Diana Gomez-Hassan
- Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
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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: Policy Statement. Ann Emerg Med 2024; 84:e13-e23. [PMID: 39032991 DOI: 10.1016/j.annemergmed.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 07/23/2024]
Abstract
Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access 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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Andrews JP, Ore CD, Falcone J, Hirschhorn M, Sagar C, Sigford K, Mitsuya Y, Chung T, Sun PP. Single-level laminoplasty approach to selective dorsal rhizotomy with conus localization by rapid spine MRI. Childs Nerv Syst 2024; 40:2565-2571. [PMID: 38797737 PMCID: PMC11269339 DOI: 10.1007/s00381-024-06439-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/27/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION While selective dorsal rhizotomy (SDR) was originally described as a multilevel approach, single-level approaches are now popularized. Conus localization is beneficial for operative planning in single-level selective dorsal rhizotomy. Our approach to SDR involves minimal exposure for a single-level laminoplasty, preserving one attached interspinous ligament. Pre-operative conus localization is required for this tailored approach to determine the laminoplasty level and dictate rostral or caudal division of the superior spinus ligament. While rapid MRI sequences have been popularized for pediatric cranial imaging, its utility for spinal imagining is less well-described, and specific application for conus localization has not been reported. OBJECTIVE Illustrate that rapid MRI without sedation is sufficient to identify conus level for tailored single-level laminoplasty SDR. MATERIAL AND METHODS Patients undergoing SDR from 2014 to 2022 at one institution were reviewed for type of pre-operative MRI (rapid vs full), conus level, procedural time for MRI, and radiology report. The typical rapid MRI has four sequences utilizing single-shot technique (scout, sagittal T2, axial T2, and axial T1) that typically take less than 1 min each of acquisition time, with non-single-shot sequences added periodically in cooperative patients. To include time for patient positioning, pre-scan shimming, procedural incidentals, and other patient-specific variations, MRI procedure length was recorded as documented in the electronic medical record. RESULTS N = 100 patients had documentation of an MRI for pre-operative imaging. Seventy-nine of these had a rapid MRI, and 21 required a full MRI with anesthesia for their treatment plan. Mean total procedure time for rapid MRI was 21.5 min (median 17). Mean procedure time for MRI under general anesthesia was 91.2 min (median 94). Of patients with rapid MRI imaging, 2/79 had an ambiguous conus level (1 from motion artifact, 1 from spinal hardware) vs 1/21 with a full MRI under anesthesia (due to spinal hardware). CONCLUSION Rapid spinal MRI without sedation can be used for conus localization in a pediatric population. This may be routinely used as pre-operative imaging for a single-level approach to selective dorsal rhizotomy, without sedation or intubation procedures.
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Affiliation(s)
- John P Andrews
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, CA, 94143, USA.
| | - Cecilia Dalle Ore
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, CA, 94143, USA
| | - Joseph Falcone
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, CA, 94143, USA
| | - Melessa Hirschhorn
- Department of Neurological Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, USA
| | - Courtney Sagar
- Department of Physical Medicine and Rehabilitation, UCSF Benioff Children's Hospital Oakland, Oakland, USA
| | - Kathryn Sigford
- Department of Physical Medicine and Rehabilitation, UCSF Benioff Children's Hospital Oakland, Oakland, USA
| | - Yumi Mitsuya
- Department of Physical Medicine and Rehabilitation, UCSF Benioff Children's Hospital Oakland, Oakland, USA
| | - Taylor Chung
- Department of Diagnostic Imaging, UCSF Benioff Children's Hospital Oakland, Oakland, USA
| | - Peter P Sun
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, CA, 94143, USA
- Department of Neurological Surgery, UCSF Benioff Children's Hospital Oakland, Oakland, USA
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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: Policy Statement. J Am Coll Radiol 2024; 21:1108-1118. [PMID: 38944444 DOI: 10.1016/j.jacr.2024.03.015] [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 imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access 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: Policy Statement. Pediatrics 2024; 154:e2024066854. [PMID: 38932710 DOI: 10.1542/peds.2024-066854] [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] [Received: 03/28/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access 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. 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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9
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Foust AM, Rameh V, Lee EY, Winant AJ, Sarma A. Pediatric Neuroradiologic Emergencies: From Techniques to Imaging Findings. Semin Roentgenol 2024; 59:220-237. [PMID: 38997178 DOI: 10.1053/j.ro.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 03/17/2024] [Accepted: 03/25/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Alexandra M Foust
- Department of Radiology, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN.
| | - Vanessa Rameh
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Abbey J Winant
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Asha Sarma
- Department of Radiology, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
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10
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Chan KS, McBride D, Wild J, Kwon S, Samet J, Gibly RF. A Rapid MRI Protocol for the Evaluation of Acute Pediatric Musculoskeletal Infections: Eliminating Contrast and Decreasing Anesthesia, Scan Time, and Hospital Length of Stay and Charges. J Bone Joint Surg Am 2024; 106:700-707. [PMID: 38630054 DOI: 10.2106/jbjs.23.00564] [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] [Indexed: 04/19/2024]
Abstract
BACKGROUND Acute musculoskeletal infection affects >1 in 6,000 children in the United States annually. Magnetic resonance imaging (MRI) is the gold standard for the diagnosis of musculoskeletal infection, but it traditionally requires contrast and anesthesia for children, delaying management. A rapid MRI protocol involves MRI without anesthesia and with limited non-contrast sequences optimized for fluid detection and diffusion-weighted images to identify abscesses. We hypothesized that a rapid MRI protocol would improve imaging and treatment efficiency for pediatric patients undergoing musculoskeletal infection evaluation without substantially affecting accuracy. METHODS This was a single-center, retrospective study of patients undergoing evaluation for musculoskeletal infection before (60 patients in the traditional cohort [TC]) and after (68 patients in the rapid cohort [RC]) implementation of the rapid MRI protocol. Sociodemographic and clinical variables were extracted from electronic health records, and statistical comparisons were performed. RESULTS The anesthesia rates were 53% for the TC and 4% for the RC, and the contrast administration rates were 88% for the TC and 0% for the RC. The median time to MRI after ordering was 6.5 hours (95% confidence interval [CI], 5.0 to 8.6 hours) for the TC and 2.2 hours (95% CI, 1.4 to 3.6 hours) for the RC (p < 0.01). The median duration of MRI was 63.2 minutes (95% CI, 56.8 to 69.6 minutes) for the TC and 24.0 minutes (95% CI, 21.1 to 29.5 minutes) for the RC (p < 0.01). The median hospital length of stay was 5.3 days (95% CI, 3.7 to 6.9 days) for the TC and 3.7 days (95% CI, 1.9 to 4.1 days) for the RC (p < 0.01). The median hospital charges were $47,309 (95% CI, $39,137 to $58,769) for the TC and $32,824 (95% CI, $22,865 to $45,339) for the RC (p < 0.01). Only 2 positive cases of musculoskeletal infection in the RC were missed on the initial imaging, but these instances were not attributable to the rapid protocol itself. Although 10 of 68 rapid MRI scans resulted in nondiagnostic outcomes due to patient motion, only 6 of 68 required repeat MRI with anesthesia. CONCLUSIONS In patients evaluated for musculoskeletal infection, the rapid MRI protocol eliminated contrast and minimized anesthesia while improving MRI access and decreased scan and interpretation times, hospital length of stay, and hospital charges. The rapid MRI protocol had high sensitivity for diagnosing musculoskeletal infection and a low rate of imaging failure. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kyle S Chan
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel McBride
- Division of Orthopaedic Surgery and Sports Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jacob Wild
- Division of Orthopaedic Surgery and Sports Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Soyang Kwon
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jonathan Samet
- Department of Radiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Romie F Gibly
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Orthopaedic Surgery and Sports Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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11
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De Luca F, Kits A, Martin Muñoz D, Aspelin Å, Kvist O, Österman Y, Diaz Ruiz S, Skare S, Falk Delgado A. Elective one-minute full brain multi-contrast MRI versus brain CT in pediatric patients: a prospective feasibility study. BMC Med Imaging 2024; 24:23. [PMID: 38267889 PMCID: PMC10809606 DOI: 10.1186/s12880-024-01196-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 01/08/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Brain CT can be used to evaluate pediatric patients with suspicion of cerebral pathology when anesthetic and MRI resources are scarce. This study aimed to assess if pediatric patients referred for an elective brain CT could endure a diagnostic fast brain MRI without general anesthesia using a one-minute multi-contrast EPI-based sequence (EPIMix) with comparable diagnostic performance. METHODS Pediatric patients referred for an elective brain CT between March 2019 and March 2020 were prospectively included and underwent EPIMix without general anesthesia in addition to CT. Three readers (R1-3) independently evaluated EPIMix and CT images on two separate occasions. The two main study outcomes were the tolerance to undergo an EPIMix scan without general anesthesia and its performance to classify a scan as normal or abnormal. Secondary outcomes were assessment of disease category, incidental findings, diagnostic image quality, diagnostic confidence, and image artifacts. Further, a side-by-side evaluation of EPIMix and CT was performed. The signal-to-noise ratio (SNR) was calculated for EPIMix on T1-weighted, T2-weighted, and ADC images. Descriptive statistics, Fisher's exact test, and Chi-squared test were used to compare the two imaging modalities. RESULTS EPIMix was well tolerated by all included patients (n = 15) aged 5-16 (mean 11, SD 3) years old. Thirteen cases on EPIMix and twelve cases on CT were classified as normal by all readers (R1-3), while two cases on EPIMix and three cases on CT were classified as abnormal by one reader (R1), (R1-3, p = 1.00). There was no evidence of a difference in diagnostic confidence, image quality, or the presence of motion artifacts between EPIMix and CT (R1-3, p ≥ 0.10). Side-by-side evaluation (R2 + R4 + R5) reviewed all scans as lacking significant pathological findings on EPIMix and CT images. CONCLUSIONS Full brain MRI-based EPIMix sequence was well tolerated without general anesthesia with a diagnostic performance comparable to CT in elective pediatric patients. TRIAL REGISTRATION This study was approved by the Swedish Ethical Review Authority (ethical approval number/ID Ethical approval 2017/2424-31/1). This study was a clinical trial study, with study protocol published at ClinicalTrials.gov with Trial registration number NCT03847051, date of registration 18/02/2019.
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Affiliation(s)
- Francesca De Luca
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden.
| | - Annika Kits
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Daniel Martin Muñoz
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Åsa Aspelin
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ola Kvist
- Department of Pediatric Radiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Yords Österman
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Sandra Diaz Ruiz
- Department of Pediatric Radiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
- Department of Radiology, Lund University, Lund, Sweden
| | - Stefan Skare
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Falk Delgado
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
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12
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Lopez-Rippe J, Schwartz ES, Davis JC, Dennis RA, Francavilla ML, Jalloul M, Kaplan SL. Imaging Stewardship: Triage for Neuroradiology MR During Limited-Resource Hours. J Am Coll Radiol 2024; 21:70-80. [PMID: 37863151 DOI: 10.1016/j.jacr.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVES To decrease call burden on pediatric neuroradiologists, we developed guidelines for appropriate use of MR overnight. These guidelines were implemented using triage by in-house generalist pediatric radiologists. Process measures and balancing measures were assessed during implementation. METHODS For this improvement project, interdepartmental consensus guidelines were developed using exploratory mixed-methods design. Implementation of triage used plan-do-study-act cycles. Process measures included reduction in the number of telephone calls, frequency of calls, triage decisions, and number and type of examinations ordered. Balancing measures included burden of time and effort to the generalist radiologists. Differences in examination orders between implementation intervals was assessed using Kruskal-Wallis, with significance at P < .05. RESULTS Consensus defined MR requests as "do," "defer," or "divert" (to CT). Guidelines decreased neuroradiologist calls 74% while adding minimal burden to the generalist radiologists. Most nights had zero or one triage request and the most common triage decision was "do," and the most common examination was routine brain MR. Number of MR ordered and completed overnight did not significantly change with triage. DISCUSSION Multidisciplinary consensus for use of pediatric neurological MR during limited resource hours overnight is an example of imaging stewardship that decreased the burden of calls and burnout for neuroradiologists while maintaining a comparable level of service to the ordering clinicians.
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Affiliation(s)
- Julian Lopez-Rippe
- Research Scholar, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erin S Schwartz
- Division Chief Neuroradiology and Associate Chair for Diversity, Equity, and Inclusion, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Professor of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Christopher Davis
- Section Director for Emergency Radiology, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca A Dennis
- Director of Fellowship, Residency and Observership Program, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael L Francavilla
- Associate Professor and Chief Medical Information Officer for Radiology, Department of Radiology, University of South Alabama, Mobile, Alabama
| | - Mohammad Jalloul
- Research Scholar, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Summer L Kaplan
- Associate Chair for Quality and Medical Director of Point-of-Care Ultrasound, Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Assistant Professor of Clinical Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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13
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Li Z, Ooi MB, Murchison JA, Karis JP. Rapid T 2 ∗ -weighted MRI using multishot EPI with retrospective motion and phase correction in the emergency department. Magn Reson Med 2023; 90:2500-2509. [PMID: 37668095 DOI: 10.1002/mrm.29809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/07/2023] [Accepted: 07/08/2023] [Indexed: 09/06/2023]
Abstract
PURPOSE Brain MRI is increasingly used in the emergency department (ED), whereT 2 * $$ {\mathrm{T}}_2^{\ast } $$ -weighted MRI is an essential tool for detecting hemorrhage and stroke. The goal of this study was to develop a rapidT 2 * $$ {\mathrm{T}}_2^{\ast } $$ -weighted MRI technique capable of correcting motion-induced artifacts, thereby simultaneously improving scan time and motion robustness for ED applications. METHODS A 2D gradient-echo (GRE)-based multishot EPI (msEPI) technique was implemented using a navigator echo for estimating motion-induced errors. Bulk rigid head motion and phase errors were retrospectively corrected using an iterative conjugate gradient approach in the reconstruction pipeline. Three volunteers and select patients were imaged at 3 T and/or 1.5 T with an approximately 1-min full-brain protocol using the proposed msEPI technique and compared to an approximately 3-min standard-of-care GRE protocol to examine its performance. RESULTS Data from volunteers demonstrated that in-plane motion artifacts could be effectively corrected with the proposed msEPI technique, and through-plane motion artifacts could be mitigated. Patient images were qualitatively reviewed by one radiologist without a formal statistical analysis. These results suggested the proposed technique could correct motion-induced artifacts in the clinical setting. In addition, the conspicuity of susceptibility-related lesions using the proposed msEPI technique was comparable, or improved, compared to GRE. CONCLUSION A 1-min full-brainT 2 * $$ {\mathrm{T}}_2^{\ast } $$ -weighted MRI technique was developed using msEPI with a navigator echo to correct motion-induced errors. Preliminary clinical results suggest faster scans and improved motion robustness and lesion conspicuity make msEPI a competitive alternative to traditionalT 2 * $$ {\mathrm{T}}_2^{\ast } $$ -weighted MRI techniques for brain studies in the ED.
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Affiliation(s)
- Zhiqiang Li
- Department of Neuroradiology, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - James A Murchison
- Department of Neuroradiology, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - John P Karis
- Department of Neuroradiology, Barrow Neurological Institute, Phoenix, Arizona, USA
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14
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Siahaan AMP, Tandean S, Nainggolan BWM, Tarigan J, Sitanggang JS. A Critical Analysis of Intracranial Hemorrhage as a Fatal Complication of Dengue Fever. J Korean Neurosurg Soc 2023; 66:494-502. [PMID: 36642946 PMCID: PMC10483153 DOI: 10.3340/jkns.2022.0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/21/2022] [Accepted: 01/12/2023] [Indexed: 01/17/2023] Open
Abstract
Dengue fever is the most rapidly spreading mosquito-borne virus in the world, infecting about 100 million individuals. A rare but possibly dangerous consequence of dengue illness is intracranial hemorrhage (ICH). Currently, the pathogenesis of ICH is unknown. A number of studies have found a variety of risk factors for ICH in dengue. In addition, studies have reported the use of emergency surgery while monitoring thrombocytopenia in the therapy of dengue ICH. This review enumerates the potential predictors of ICH in dengue, discusses the use of brain imaging, and mentions the possibility of emergency surgery.
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Affiliation(s)
| | - Steven Tandean
- Department of Neurosurgery, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | | | - Junita Tarigan
- Division of Infection and Tropical Medicine, Department of Internal Medicine, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Johan Samuel Sitanggang
- Undergraduate Program in Medicine, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
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15
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Eisenmenger LB, Peret A, Roberts GS, Spahic A, Tang C, Kuner AD, Grayev AM, Field AS, Rowley HA, Kennedy TA. Focused Abbreviated Survey MRI Protocols for Brain and Spine Imaging. Radiographics 2023; 43:e220147. [PMID: 37167089 PMCID: PMC10262597 DOI: 10.1148/rg.220147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/12/2022] [Accepted: 10/18/2022] [Indexed: 05/13/2023]
Abstract
There has been extensive growth in both the technical development and the clinical applications of MRI, establishing this modality as one of the most powerful diagnostic imaging tools. However, long examination and image interpretation times still limit the application of MRI, especially in emergent clinical settings. Rapid and abbreviated MRI protocols have been developed as alternatives to standard MRI, with reduced imaging times, and in some cases limited numbers of sequences, to more efficiently answer specific clinical questions. A group of rapid MRI protocols used at the authors' institution, referred to as FAST (focused abbreviated survey techniques), are designed to include or exclude emergent or urgent conditions or screen for specific entities. These FAST protocols provide adequate diagnostic image quality with use of accelerated approaches to produce imaging studies faster than traditional methods. FAST protocols have become critical diagnostic screening tools at the authors' institution, allowing confident and efficient confirmation or exclusion of actionable findings. The techniques commonly used to reduce imaging times, the imaging protocols used at the authors' institution, and future directions in FAST imaging are reviewed to provide a practical and comprehensive overview of FAST MRI for practicing neuroradiologists. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
| | | | - Grant S. Roberts
- From the Departments of Radiology (L.B.E., A.P., A.D.K., A.M.G.,
A.S.F., H.A.R., T.A.K.) and Medical Physics (G.S.R., A.S., C.T.), University of
Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI
53792-3252
| | - Alma Spahic
- From the Departments of Radiology (L.B.E., A.P., A.D.K., A.M.G.,
A.S.F., H.A.R., T.A.K.) and Medical Physics (G.S.R., A.S., C.T.), University of
Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI
53792-3252
| | - Chenwei Tang
- From the Departments of Radiology (L.B.E., A.P., A.D.K., A.M.G.,
A.S.F., H.A.R., T.A.K.) and Medical Physics (G.S.R., A.S., C.T.), University of
Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI
53792-3252
| | - Anthony D. Kuner
- From the Departments of Radiology (L.B.E., A.P., A.D.K., A.M.G.,
A.S.F., H.A.R., T.A.K.) and Medical Physics (G.S.R., A.S., C.T.), University of
Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI
53792-3252
| | - Allison M. Grayev
- From the Departments of Radiology (L.B.E., A.P., A.D.K., A.M.G.,
A.S.F., H.A.R., T.A.K.) and Medical Physics (G.S.R., A.S., C.T.), University of
Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI
53792-3252
| | - Aaron S. Field
- From the Departments of Radiology (L.B.E., A.P., A.D.K., A.M.G.,
A.S.F., H.A.R., T.A.K.) and Medical Physics (G.S.R., A.S., C.T.), University of
Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI
53792-3252
| | - Howard A. Rowley
- From the Departments of Radiology (L.B.E., A.P., A.D.K., A.M.G.,
A.S.F., H.A.R., T.A.K.) and Medical Physics (G.S.R., A.S., C.T.), University of
Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI
53792-3252
| | - Tabassum A. Kennedy
- From the Departments of Radiology (L.B.E., A.P., A.D.K., A.M.G.,
A.S.F., H.A.R., T.A.K.) and Medical Physics (G.S.R., A.S., C.T.), University of
Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI
53792-3252
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16
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Sun LR, Lynch JK. Advances in the Diagnosis and Treatment of Pediatric Arterial Ischemic Stroke. Neurotherapeutics 2023; 20:633-654. [PMID: 37072548 PMCID: PMC10112833 DOI: 10.1007/s13311-023-01373-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/20/2023] Open
Abstract
Though rare, stroke in infants and children is an important cause of mortality and chronic morbidity in the pediatric population. Neuroimaging advances and implementation of pediatric stroke care protocols have led to the ability to rapidly diagnose stroke and in many cases determine the stroke etiology. Though data on efficacy of hyperacute therapies, such as intravenous thrombolysis and mechanical thrombectomy, in pediatric stroke are limited, feasibility and safety data are mounting and support careful consideration of these treatments for childhood stroke. Recent therapeutic advances allow for targeted stroke prevention efforts in high-risk conditions, such as moyamoya, sickle cell disease, cardiac disease, and genetic disorders. Despite these exciting advances, important knowledge gaps persist, including optimal dosing and type of thrombolytic agents, inclusion criteria for mechanical thrombectomy, the role of immunomodulatory therapies for focal cerebral arteriopathy, optimal long-term antithrombotic strategies, the role of patent foramen ovale closure in pediatric stroke, and optimal rehabilitation strategies after stroke of the developing brain.
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Affiliation(s)
- Lisa R Sun
- Divisions of Pediatric Neurology and Cerebrovascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Ste 2158, Baltimore, MD, 21287, USA.
| | - John K Lynch
- Acute Stroke Research Section, Stroke Branch (SB), National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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17
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European recommendations on practices in pediatric neuroradiology: consensus document from the European Society of Neuroradiology (ESNR), European Society of Paediatric Radiology (ESPR) and European Union of Medical Specialists Division of Neuroradiology (UEMS). Pediatr Radiol 2023; 53:159-168. [PMID: 36063184 PMCID: PMC9816178 DOI: 10.1007/s00247-022-05479-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/27/2022] [Accepted: 08/01/2022] [Indexed: 01/24/2023]
Abstract
Pediatric neuroradiology is a subspecialty within radiology, with possible pathways to train within the discipline from neuroradiology or pediatric radiology. Formalized pediatric neuroradiology training programs are not available in most European countries. We aimed to construct a European consensus document providing recommendations for the safe practice of pediatric neuroradiology. We particularly emphasize imaging techniques that should be available, optimal site conditions and facilities, recommended team requirements and specific indications and protocol modifications for each imaging modality employed for pediatric neuroradiology studies. The present document serves as guidance to the optimal setup and organization for carrying out pediatric neuroradiology diagnostic and interventional procedures. Clinical activities should always be carried out in full agreement with national provisions and regulations. Continued education of all parties involved is a requisite for preserving pediatric neuroradiology practice at a high level.
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18
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Jiang B, Mackay MT, Stence N, Domi T, Dlamini N, Lo W, Wintermark M. Neuroimaging in Pediatric Stroke. Semin Pediatr Neurol 2022; 43:100989. [PMID: 36344022 DOI: 10.1016/j.spen.2022.100989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/30/2022]
Abstract
Pediatric stroke is unfortunately not a rare condition. It is associated with severe disability and mortality because of the complexity of potential clinical manifestations, and the resulting delay in seeking care and in diagnosis. Neuroimaging plays an important role in the multidisciplinary response for pediatric stroke patients. The rapid development of adult endovascular thrombectomy has created a new momentum in health professionals caring for pediatric stroke patients. Neuroimaging is critical to make decisions of identifying appropriate candidates for thrombectomy. This review article will review current neuroimaging techniques, imaging work-up strategies and special considerations in pediatric stroke. For resources limited areas, recommendation of substitute imaging approaches will be provided. Finally, promising new techniques and hypothesis-driven research protocols will be discussed.
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Affiliation(s)
- Bin Jiang
- Department of Radiology, Neuroradiology Section, Stanford University, Stanford, CA.
| | - Mark T Mackay
- Murdoch Children's Research Institute, Royal Children's Hospital and Department of Paediatrics, University of Melbourne, Victoria, Australia.
| | - Nicholas Stence
- Department of Radiology, pediatric Neuroradiology Section, University of Colorado School of Medicine, Aurora, CO
| | - Trish Domi
- Department of Neurology, Hospital for Sick Children, Toronto, Canada.
| | - Nomazulu Dlamini
- Department of Neurology, Hospital for Sick Children, Toronto, Canada.
| | - Warren Lo
- Department of Pediatrics and Neurology, The Ohio State University & Nationwide Children's Hospital, Columbus, OH.
| | - Max Wintermark
- Department of Neuroradiology, University of Texas MD Anderson Center, Houston, TX.
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19
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Lang M, Rapalino O, Huang S, Lev MH, Conklin J, Wald LL. Emerging Techniques and Future Directions: Fast and Portable Magnetic Resonance Imaging. Magn Reson Imaging Clin N Am 2022; 30:565-582. [PMID: 35995480 DOI: 10.1016/j.mric.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Fast MRI and portable MRI are emerging as promising technologies to improve the speed, efficiency, and availability of MR imaging. Fast MRI methods are increasingly being adopted to create screening protocols for the diagnosis and management of acute pathology in the emergency department. Faster imaging can facilitate timely diagnosis, reduce motion artifacts, and improve departmental MR operations. Point-of-care and portable MRI are emerging technologies that require radiologists to reenvision the role of MRI as a tool with greater accessibility, fewer siting constraints, and the ability to provide valuable diagnostic information at the bedside. Recently introduced commercially available pulse sequences and new MRI scanners are bringing these technologies closer to the patient's clinical setting, and we expect their use to only increase over the coming decade. This article provides an overview of these emerging technologies for emergency radiologists.
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Affiliation(s)
- Min Lang
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Otto Rapalino
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Susie Huang
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Athinoula A. Martinos Center for Biomedical Imaging, 149 13th Street, Charleston, MA 02129, USA
| | - Michael H Lev
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - John Conklin
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Lawrence L Wald
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Athinoula A. Martinos Center for Biomedical Imaging, 149 13th Street, Charleston, MA 02129, USA
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Wiesinger F, Ho ML. Zero-TE MRI: principles and applications in the head and neck. Br J Radiol 2022; 95:20220059. [PMID: 35616709 PMCID: PMC10162052 DOI: 10.1259/bjr.20220059] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/21/2022] [Accepted: 05/12/2022] [Indexed: 12/17/2022] Open
Abstract
Zero echo-time (ZTE) MRI is a novel imaging technique that utilizes ultrafast readouts to capture signal from short-T2 tissues. Additional sequence advantages include rapid imaging times, silent scanning, and artifact resistance. A robust application of this technology is imaging of cortical bone without the use of ionizing radiation, thus representing a viable alternative to CT for both rapid screening and "one-stop-shop" MRI. Although ZTE is increasingly used in musculoskeletal and body imaging, neuroimaging applications have historically been limited by complex anatomy and pathology. In this article, we review the imaging physics of ZTE including pulse sequence options, practical limitations, and image reconstruction. We then discuss optimization of settings for ZTE bone neuroimaging including acquisition, processing, segmentation, synthetic CT generation, and artifacts. Finally, we examine clinical utility of ZTE in the head and neck with imaging examples including malformations, trauma, tumors, and interventional procedures.
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Affiliation(s)
| | - Mai-Lan Ho
- Nationwide Children’s Hospital and The Ohio State University, Columbus, USA
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21
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Pedersen C, Aboian M, McConathy JE, Daldrup-Link H, Franceschi AM. PET/MRI in Pediatric Neuroimaging: Primer for Clinical Practice. AJNR Am J Neuroradiol 2022; 43:938-943. [PMID: 35512826 DOI: 10.3174/ajnr.a7464] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/13/2021] [Indexed: 11/07/2022]
Abstract
Modern pediatric imaging seeks to provide not only exceptional anatomic detail but also physiologic and metabolic information of the pathology in question with as little radiation penalty as possible. Hybrid PET/MR imaging combines exquisite soft-tissue information obtained by MR imaging with functional information provided by PET, including metabolic markers, receptor binding, perfusion, and neurotransmitter release data. In pediatric neuro-oncology, PET/MR imaging is, in many ways, ideal for follow-up compared with PET/CT, given the superiority of MR imaging in neuroimaging compared with CT and the lower radiation dose, which is relevant in serial imaging and long-term follow-up of pediatric patients. In addition, although MR imaging is the main imaging technique for the evaluation of spinal pathology, PET/MR imaging may provide useful information in several clinical scenarios, including tumor staging and follow-up, treatment response assessment of spinal malignancies, and vertebral osteomyelitis. This review article covers neuropediatric applications of PET/MR imaging in addition to considerations regarding radiopharmaceuticals, imaging protocols, and current challenges to clinical implementation.
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Affiliation(s)
- C Pedersen
- From the Department of Radiology (C.P., M.A.), Yale School of Medicine, New Haven, Connecticut
| | - M Aboian
- From the Department of Radiology (C.P., M.A.), Yale School of Medicine, New Haven, Connecticut
| | - J E McConathy
- Division of Molecular Imaging and Therapeutics (J.E.M.), Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - H Daldrup-Link
- Department of Radiology and Pediatrics (H.D.-L.), Stanford University School of Medicine, Palo Alto, California
| | - A M Franceschi
- Neuroradiology Division (A.M.F.), Department of Radiology, Northwell Health/Donald and Barbara Zucker School of Medicine, Lenox Hill Hospital, New York, New York
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22
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Radiologic and clinical outcome of isolated fourth ventricle following post-hemorrhagic hydrocephalus in children. Childs Nerv Syst 2022; 38:977-984. [PMID: 35305115 DOI: 10.1007/s00381-022-05494-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/03/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Few studies report radiologic and clinical outcome of post-hemorrhagic isolated fourth ventricle (IFV) with focus on surgical versus conservative management in neonates and children. Our aim is to investigate differences in radiological and clinical findings of IFV between patients who had surgical intervention versus patients who were treated conservatively. METHODS A retrospective analysis of patients diagnosed with IFV was performed. Data included demographics, clinical exam findings, surgical history, and imaging findings (dilated FV extent, supratentorial ventricle dilation, brainstem and cerebellar deformity, tectal plate elevation, basal cistern and cerebellar hemisphere effacement, posterior fossa upward/downward herniation). RESULTS Sixty-four (30 females) patients were included. Prematurity was 94% with 90% being < 28 weeks of gestation. Mean age at first ventricular shunt was 3.6 (range 1-19); at diagnosis of IFV, post-lateral ventricular shunting was 26.2 (1-173) months. Conservatively treated patients were 87.5% versus 12.5% treated with FV shunt/endoscopic fenestration. Severe FV dilation (41%), severe deformity of brainstem (39%) and cerebellum (47%) were noted at initial diagnosis and stable findings (34%, 47%, and 52%, respectively) were seen at last follow-up imaging. FV dilation (p = 0.0001) and upward herniation (p = 0.01) showed significant differences between surgery versus conservative management. No other radiologic or clinical outcome parameters were different between two groups. CONCLUSION Only radiologic outcome results showed stable or normal FV dilation and stable or decreased upward herniation in the surgically treated group.
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Kessler BA, Goh JL, Pajer HB, Asher AM, Northam WT, Hung SC, Selden NR, Quinsey CS. Rapid-sequence MRI for evaluation of pediatric traumatic brain injury: a systematic review. J Neurosurg Pediatr 2021; 28:278-286. [PMID: 34171833 DOI: 10.3171/2021.2.peds20852] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Rapid-sequence MRI (RSMRI) of the brain is a limited-sequence MRI protocol that eliminates ionizing radiation exposure and reduces imaging time. This systematic review sought to examine studies of clinical RSMRI use for pediatric traumatic brain injury (TBI) and to evaluate various RSMRI protocols used, including their reported accuracy as well as clinical and systems-based limitations to implementation. METHODS PubMed, EMBASE, and Web of Science databases were searched, and clinical articles reporting the use of a limited brain MRI protocol in the setting of pediatric head trauma were identified. RESULTS Of the 1639 articles initially identified and reviewed, 13 studies were included. An additional article that was in press at the time was provided by its authors. The average RSMRI study completion time was variable, spanning from 1 minute to 16 minutes. RSMRI with "blood-sensitive" sequences was more sensitive for detection of hemorrhage compared with head CT (HCT), but less sensitive for detection of skull fractures. Compared with standard MRI, RSMRI had decreased sensitivity for all evidence of trauma. CONCLUSIONS Protocols and uses of RSMRI for pediatric TBI were variable among the included studies. While traumatic pathology missed by RSMRI, such as small hemorrhages and linear, nondisplaced skull fractures, was frequently described as clinically insignificant, in some cases these findings may be prognostically and/or forensically significant. Institutions should integrate RSMRI into pediatric TBI management judiciously, relying on clinical context and institutional capabilities.
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Affiliation(s)
| | - Jo Ling Goh
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Hengameh B Pajer
- 3Campbell University School of Osteopathic Medicine, Buies Creek, North Carolina and
| | | | | | - Sheng-Che Hung
- 5Division of Neuroradiology, Department of Radiology
- 6Biomedical Research Imaging Center, University of North Carolina, Chapel Hill
| | - Nathan R Selden
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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24
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Replacing Computed Tomography with "Rapid" Magnetic Resonance Imaging for Ventricular Shunt Imaging. Pediatr Qual Saf 2021; 6:e441. [PMID: 34345754 PMCID: PMC8322500 DOI: 10.1097/pq9.0000000000000441] [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: 10/28/2020] [Accepted: 02/04/2021] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Children with ventricular shunts undergo frequent neuroimaging, and therefore, radiation exposures, to evaluate shunt malfunctions. The objective of this study was to safely reduce radiation exposure in this population by reducing computed tomography (CT) and increasing “rapid” magnetic resonance imaging (rMRI-shunt) among patients warranting neuroimaging for possible shunt malfunction. Methods: This was a single-center quality improvement study in a tertiary care pediatric emergency department (ED). We implemented a multidisciplinary guideline for ED shunt evaluation, which promoted the use of rMRI-shunt over CT. We included patients younger than 18 years undergoing an ED shunt evaluation during 11 months of the preintervention and 25 months of the intervention study periods. The primary outcome was the CT rate, and we evaluated the relevant process and balancing measures. Results: There were 266 encounters preintervention and 488 during the intervention periods with similar neuroimaging rates (80.7% versus 81.5%, P = 0.8.) CT decreased from 90.1% to 34.8% (difference −55.3%, 95% confidence interval [CI]: −71.1, −25.8), and rMRI-shunt increased from 9.9% to 65.2% (difference 55.3%, 95% CI: 25.8, 71.1) during the preintervention and intervention periods, respectively. There were increases in the mean time to neuroimaging (53.1 min; [95% CI: 41.6, 64.6]) and ED length of stay (LOS) (52.3 min; [95% CI: 36.8, 67.6]), without changes in total neuroimaging, 72-hour revisits, or follow-up neuroimaging. Conclusions: Multidisciplinary implementation of a standardized guideline reduced CT and increased rMRI-shunt use in a pediatric ED setting. Clinicians should balance the reduction in radiation exposure with ED rMRI-shunt for patients with ventricular shunts against the increased time of obtaining imaging and LOS.
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25
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Accuracy of Brain MRI Interpretation of Emergency Medicine Specialists Versus Radiologist and Neurologist in Suspected Acute Ischemic Stroke Patients; a Diagnostic Accuracy Study. ARCHIVES OF NEUROSCIENCE 2021. [DOI: 10.5812/ans.112166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Despite numerous brain magnetic resonance imaging (MRI) utilization in the emergency department (ED), certainly, imaging alone is not enough, and it is necessary to have a correct interpretation by a physician who has sufficient skills in this regard. Objectives: Here, we decided to investigate the accuracy of interpreting brain MRI of suspected acute ischemic stroke (AIS) patients conducted by emergency medicine physicians (EMPs) in comparison with a radiologist and a neurologist. Methods: This diagnostic accuracy study was conducted from April to November 2019 in Tehran, Iran. All attending EMPs of one major educational, medical center, a radiologist, and a neurologist also participated. A set of brain MRI stereotypes related to patients suspected of having a AIS was randomly selected. By reviewing the brain MRI interpretation of EMPs, once in comparison with the radiologist and once in comparison with the neurologist, misinterpretations (presence or absence of findings compatible with the diagnosis of AIS) were extracted. Results: Brain MRI stereotypes of 287 suspected AIS patients were interpreted of these patients, 160 cases (55.7%) were male. The mean age of the study patients was 65.0 ± 14.1 (range of 18 to 98) years. The value of the agreement for diagnosis between EMPs and neurologists was 0.684 (95% CI: 0.580 to 0.787). Considering the neurologist as the gold standard, the accuracy of AIS diagnosis by the EMPs was 0.85% (95% CI: 79.3 to 89.6). The agreement value for diagnosis between EMPs and radiologist was 0.673 (95% CI: 0.553 to 0.794). Considering the radiologist as the gold standard, the accuracy of AIS diagnosis by the EMPs was 86.3% (95% CI: 79.8 to 91.3). The agreement value for diagnosis in these two groups was 0.752 (95% CI: 0.627 to 0.877). Conclusions: The findings of the current study revealed that the accuracy of brain MRI interpretation performed by the EMPs, compared with both neurologist and radiologist was proper.
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26
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Ramgopal S, Zhou AZ, Hickey RW, Marin JR. Rates of Presentation, Treatments and Serious Neurologic Disorders Among Children and Young Adults Presenting to US Emergency Departments With Headache. J Child Neurol 2021; 36:475-481. [PMID: 33356803 DOI: 10.1177/0883073820979137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate rates of presentation, neuroimaging, therapies, and serious neurologic disorders (SNDs) among children and young adults presenting to the emergency department with headache. METHODS We performed a cross-sectional study of a nationally representative sample survey of visits to US emergency departments between 2002 and 2017. We identified encounters of patients ≤25 years old with chief complaint of headache. We report the rates of presentation, imaging, and treatments and report proportions having concomitant diagnoses of serious neurologic disorders. RESULTS Among encounters ≤25 years, 2.0% had a chief complaint of headache, with no change in the yearly rates of encounters (P = .98). Overall, 20.8% had a head computed tomography (CT), with a reduction in performance between 2007 and 2016 (P < .01). One-quarter (25.2%, 95% confidence interval [CI] 22.2%-28.3%) were given narcotics and 2.5% (95% CI 1.7%-3.2%) had serious neurologic disorders. CONCLUSION Overall, 2.0% of emergency department encounters among patients ≤25 years were for headache, with low rates of serious neurologic disorders. CT use appeared to be declining.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amy Z Zhou
- Division of Emergency Medicine, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, 6619UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, 6619UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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27
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Khaira G, Kurz JE. Rapid Brain MRI Use in a Pediatric Emergency Department. Pediatr Neurol Briefs 2020; 34:21. [PMID: 33354103 PMCID: PMC7747511 DOI: 10.15844/pedneurbriefs-34-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Investigators from the University of Pittsburgh (Department of Emergency Medicine and Division of Pediatric Radiology) and Feinberg School of Medicine (Division of Emergency Medicine) studied the rates of neuroimaging (rapid brain MRI [rMRI], head CT [HCT], and full MRI) before and after implementation of four rapid MRI protocols in their ED.
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Affiliation(s)
- Gurpreet Khaira
- Davee Pediatric Neurocritical Care Program, Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Jonathan E Kurz
- Davee Pediatric Neurocritical Care Program, Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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28
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Lanzman BA, Huang Y, Lee EH, Iv M, Moseley ME, Holdsworth SJ, Yeom KW. Simultaneous time of flight-MRA and T2* imaging for cerebrovascular MRI. Neuroradiology 2020; 63:243-251. [PMID: 32945913 DOI: 10.1007/s00234-020-02499-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 07/13/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE 3D multi-echo gradient-recalled echo (ME-GRE) can simultaneously generate time-of-flight magnetic resonance angiography (pTOF) in addition to T2*-based susceptibility-weighted images (SWI). We assessed the clinical performance of pTOF generated from a 3D ME-GRE acquisition compared with conventional TOF-MRA (cTOF). METHODS Eighty consecutive children were retrospectively identified who obtained 3D ME-GRE alongside cTOF. Two blinded readers independently assessed pTOF derived from 3D ME-GRE and compared them with cTOF. A 5-point Likert scale was used to rank lesion conspicuity and to assess for diagnostic confidence. RESULTS Across 80 pediatric neurovascular pathologies, a similar number of lesions were reported on pTOF and cTOF (43-40%, respectively, p > 0.05). Rating of lesion conspicuity was higher with cTOF (4.5 ± 1.0) as compared with pTOF (4.0 ± 0.7), but this was not significantly different (p = 0.06). Diagnostic confidence was rated higher with cTOF (4.8 ± 0.5) than that of pTOF (3.7 ± 0.6; p < 0.001). Overall, the inter-rater agreement between two readers for lesion count on pTOF was classified as almost perfect (κ = 0.98, 96% CI 0.8-1.0). CONCLUSIONS In this study, TOF-MRA simultaneously generated in addition to SWI from 3D MR-GRE can serve as a diagnostic adjunct, particularly for proximal vessel disease and when conventional TOF-MRA images are absent.
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Affiliation(s)
- Bryan A Lanzman
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Yuhao Huang
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
| | - Edward H Lee
- Department of Radiology, Stanford University, Stanford, CA, USA.,Department of Electrical Engineering, Stanford University, Stanford, CA, USA
| | - Michael Iv
- Department of Radiology, Stanford University, Stanford, CA, USA
| | | | - Samantha J Holdsworth
- Mātai Medical Research Institute, Gisborne-Tairāwhiti, Gisborne, New Zealand.,Department of Anatomy and Medical Imaging & Centre for Brain Research, The University of Auckland, Auckland, New Zealand
| | - Kristen W Yeom
- Department of Radiology, Stanford University, Stanford, CA, USA. .,Lucile Packard Children's Hospital, Palo Alto, CA, USA.
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29
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Marin JR, Rodean J, Hall M, Alpern ER, Aronson PL, Chaudhari PP, Cohen E, Freedman SB, Morse RB, Peltz A, Samuels-Kalow M, Shah SS, Simon HK, Neuman MI. Trends in Use of Advanced Imaging in Pediatric Emergency Departments, 2009-2018. JAMA Pediatr 2020; 174:e202209. [PMID: 32761186 PMCID: PMC7400208 DOI: 10.1001/jamapediatrics.2020.2209] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance There is increased awareness of radiation risks from computed tomography (CT) in pediatric patients. In emergency departments (EDs), evidence-based guidelines, improvements in imaging technology, and availability of nonradiating modalities have potentially reduced CT use. Objective To evaluate changes over time and hospital variation in advanced imaging use. Design, Setting, and Participants This cross-sectional study assessed 26 082 062 ED visits by children younger than 18 years from the Pediatric Health Information System administrative database from January 1, 2009, through December 31, 2018. Exposures Imaging. Main Outcomes and Measures The primary outcome was the change in CT, ultrasonography, and magnetic resonance imaging (MRI) rates from January 1, 2009, to December 31, 2018. Imaging for specific diagnoses was examined using all patient-refined diagnosis related groups. Secondary outcomes were hospital admission and 3-day ED revisit rates and ED length of stay. Results There were a total of 26 082 062 visits by 9 868 406 children (mean [SD] age, 5.59 [5.15] years; 13 842 567 [53.1%] male; 9 273 181 [35.6%] non-Hispanic white) to 32 US pediatric EDs during the 10-year study period, with 1 or more advanced imaging studies used in 1 919 283 encounters (7.4%). The proportion of ED encounters with any advanced imaging increased from 6.4% (95% CI, 6.2%-6.2%) in 2009 to 8.7% (95% CI, 8.7%-8.8%) in 2018. The proportion of ED encounters with CT decreased from 3.9% (95% CI, 3.9%-3.9%) to 2.9% (95% CI, 2.9%-3.0%) (P < .001 for trend), with ultrasonography increased from 2.5% (95% CI, 2.5%-2.6%) to 5.8% (95% CI, 5.8%-5.9%) (P < .001 for trend), and with MRI increased from 0.3% (95% CI, 0.3%-0.4%) to 0.6% (95% CI, 0.6%-0.6%) (P < .001 for trend). The largest decreases in CT rates were for concussion (-23.0%), appendectomy (-14.9%), ventricular shunt procedures (-13.3%), and headaches (-12.4%). Factors associated with increased use of nonradiating imaging modalities included ultrasonography for abdominal pain (20.3%) and appendectomy (42.5%) and MRI for ventricular shunt procedures (17.9%) (P < .001 for trend). Across the study period, EDs varied widely in the use of ultrasonography for appendectomy (median, 57.5%; interquartile range [IQR], 40.4%-69.8%) and MRI (median, 15.8%; IQR, 8.3%-35.1%) and CT (median, 69.5%; IQR, 54.5%-76.4%) for ventricular shunt procedures. Overall, ED length of stay did not change, and hospitalization and 3-day ED revisit rates decreased during the study period. Conclusions and Relevance This study found that use of advanced imaging increased from 2009 to 2018. Although CT use decreased, this decrease was accompanied by a greater increase in the use of ultrasonography and MRI. There appears to be substantial variation in practice and a need to standardize imaging practices.
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Affiliation(s)
- Jennifer R. Marin
- Division of Pediatric Emergency Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul L. Aronson
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut,Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Alberta Children’s Hospital Research Institute, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada ,Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Rustin B. Morse
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Alon Peltz
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Harold K. Simon
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia,Department of Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mark I. Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Henry MK, Feudtner C, Fortin K, Lindberg DM, Anderst JD, Berger RP, Wood JN. Occult head injuries in infants evaluated for physical abuse. CHILD ABUSE & NEGLECT 2020; 103:104431. [PMID: 32143091 PMCID: PMC7276264 DOI: 10.1016/j.chiabu.2020.104431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/05/2020] [Accepted: 02/19/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Abusive head injuries in infants may be occult but clinically or forensically important. Data conflict regarding yield of neuroimaging in detecting occult head injuries in infants evaluated for physical abuse, with prior studies identifying yields of 4.3-37.3 %. OBJECTIVES (1) To quantify yield of computed tomography or magnetic resonance imaging in identification of occult head injuries in infants with concerns for physical abuse and (2) to evaluate risk factors for occult head injuries. PARTICIPANTS AND SETTING We conducted a retrospective, stratified, random systematic sample of 529 infants <12 months evaluated for physical abuse at 4 urban children's hospitals in the United States from 2008-2012. Infants with signs or symptoms suggesting head injury or skull fracture on plain radiography (N = 359), and infants without neuroimaging (N = 1) were excluded. METHODS Sampling weights were applied to calculate proportions of infants with occult head injuries. We evaluated for associations between hypothesized risk factors (age <6 months, rib or extremity fracture, facial bruising) and occult head injury using chi-square tests. RESULTS Of 169 neurologically normal infants evaluated for abuse, occult head injury was identified in 6.5 % (95 % CI: 2.6, 15.8). Infants <6 months were at higher risk (9.7 %; 95 % CI: 3.6, 23.3) than infants 6-12 months (1.0 %; 95 % CI: 1.3, 20.2). Rib fracture, extremity fracture and facial bruising were not associated with occult head injury. CONCLUSIONS Occult head injuries were less frequent than previously reported in some studies, but were identified in 1 in 10 infants <6 months. Clinicians should have a low threshold to obtain neuroimaging in young infants with concern for abuse.
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Affiliation(s)
- M Katherine Henry
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States.
| | - Chris Feudtner
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States
| | - Kristine Fortin
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States
| | - Daniel M Lindberg
- Department of Emergency Medicine and The Kempe Center for the Prevention and Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17(th) Ave. Aurora, CO, 80238, United States
| | - James D Anderst
- Department of Pediatrics, Division of Child Adversity and Resilience, University of Missouri Kansas City School of Medicine and Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, United States
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA, 15224, United States
| | - Joanne N Wood
- Division of General Pediatrics, Children's Hospital of Philadelphia, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, United States; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34(th) Street and Civic Center Boulevard, Philadelphia, PA, 19104, United States; PolicyLab, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, United States
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