Faculty Bibliography

BACKGROUND: To preserve radiology rounds in the changing health care environment, we have introduced virtual radiology rounds, an initiative enabling clinicians to remotely review imaging studies with the radiologist. OBJECTIVE: We describe our initial experience with virtual radiology rounds and referring provider impressions. MATERIALS AND METHODS: Virtual radiology rounds, a web-based conference, use remote sharing of radiology workstations. Participants discuss imaging studies by speakerphone. Virtual radiology rounds were piloted with the Neonatal Intensive Care Unit (NICU) and the Congenital Cardiovascular Care Unit (CCVCU). Providers completed a survey assessing the perceived impact and overall value of virtual radiology rounds on patient care using a 10-point scale. Pediatric radiologists participating in virtual radiology rounds completed a survey assessing technical, educational and clinical aspects of this methodology. RESULTS: Sixteen providers responded to the survey; 9 NICU and 7 CCVCU staff (physicians, nurse practitioners and fellows). Virtual radiology rounds occurred 4-5 sessions/week with an average of 6.4 studies. Clinicians rated confidence in their own image interpretation with a 7.4 average rating for NICU and 7.5 average rating for CCVCU. Clinicians unanimously rated virtual radiology rounds as adding value. NICU staff preferred virtual radiology rounds to traditional rounds and CCVCU staff supported their new participation in virtual radiology rounds. Four of the five pediatric radiologists participating in virtual radiology rounds responded to the survey reporting virtual radiology rounds to be easy to facilitate (average rating: 9.3), to moderately impact interpretation of imaging studies (average rating: 6), and to provide substantial educational value for radiologists (average rating: 8.3). All pediatric radiologists felt strongly that virtual radiology rounds enable increased integration of the radiologist into the clinical care team (average rating: 8.8). CONCLUSION: Virtual radiology rounds are a viable alternative to radiology rounds enabling improved patient care and education of providers.

Purpose or Case Report: To evaluate the reliability of the UTD classification system Table A. Cross-tabulation of results summarizing inter-reader agreement. There are three distinct reader pairs: score 1 is the score from the arbitrarily designated first reader in each pair and score 2 is from the remaining reader in each pair. Numbers in red denote instances of disagreement. Methods &Materials: This IRB approved, retrospective study included 129 renal ultrasound examinations performed from May 2010 - May 2015 in patients less than 6 months of age for the clinical indication of prenatal hydronephrosis identified by key word search in PACS. Three pediatric radiologists independently reviewed each study for the following: anterior posterior renal pelvic diameter (APRPD), central calyceal dilation (CCD), peripheral calyceal dilation (PPD), renal parenchymal appearance (PA), renal parenchymal thickness (PT), ureteral abnormality, and bladder abnormality. Readers assigned each study a UTD category (normal, UTD P1, UTD P2, UTD P3). Inter-rater percent agreement for individual criteria and overall UTD categorization was assessed. Results: There was overall good inter-reader agreement in assessment of individual criteria (APRPKD, PA, PT, ureter, and bladder) ranging from 85.3 to 96.1% for 3 reader pairs. Inter-reader agreement for CCD and PCD was slightly lower, ranging from 69.0 to 97.7%. Inter-reader agreement for overall risk assesment ranged from 50.4 to 67.4%. Agreement across 3 readers was 48.8% for CCD, 64.3% for PCD, and 37.2% for overall risk stratification. Conclusions: The new UTD classification system is intended to guide clinical management of postnatal urinary tract dilation. For it to be widely accepted and useful, users need to apply it with precision and accuracy. Poor agreement for categorization of risk assessment among our experienced readers suggests that further clarification of the system or training for users is necessary for its optimal use in clinical practice. (Table presented)

BACKGROUND: Acute urinary retention (AUR) is a rare diagnosis both in pediatric and adult female populations, especially when compared to adult males. AUR occurs in women at a rate of 7 in 100,000 per year in a 1:13 female to male ratio. Multiple studies have shown that within the pediatric population AUR is far less common in females and is caused by different pathologies than AUR in adult women. CASE REPORT: We report the case of an 11 year-old prepubescent female who presented to the emergency department with acute urinary retention found to be caused by a mature cystic ovarian teratoma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case is unique in that it describes an ovarian mass leading to AUR which has not previously been described in the pediatric literature. We will review the causes of AUR in the pediatric female population and compare these to the causes of AUR in other populations.

BACKGROUND: Rapid and accurate diagnosis of appendicitis, particularly with respect to the presence or absence of perforation, is essential in guiding appropriate management. Although many studies have explored sonographic findings associated with acute appendicitis, few investigations discuss specific signs that can reliably differentiate perforated appendicitis from acute appendicitis prior to abscess formation. OBJECTIVE: The purpose of our study was to identify sonographic findings that improve the specificity of US in the diagnosis of perforated appendicitis. Our assessment of hepatic periportal echogenicity, detailed analysis of intraperitoneal fluid, and formulation of select constellations of sonographic findings expands upon the literature addressing this important diagnostic challenge. MATERIALS AND METHODS: We retrospectively reviewed 116 abdominal US examinations for evaluation of abdominal pain in children ages 2 to 18 years from January 2008 to September 2011 at a university hospital pediatric radiology department. The study group consisted of surgical and pathology proven acute appendicitis (n = 51) and perforated appendicitis (n = 22) US exams. US exams without a sonographic diagnosis of appendicitis (n = 43) confirmed by follow-up verbal communication were included in the study population as the control group. After de-identification, the US exams were independently reviewed on a PACS workstation by four pediatric radiologists blinded to diagnosis and all clinical information. We recorded the presence of normal or abnormal appendix, appendicolith, appendiceal wall vascularity, thick-walled bowel, dilated bowel, right lower quadrant (RLQ) echogenic fat, increased hepatic periportal echogenicity, bladder debris and abscess or loculated fluid. We also recorded the characteristics of intraperitoneal fluid, indicating the relative quantity (number of abdominal regions) and quality of the fluid (simple fluid or complex fluid). We used logistic regression for correlated data to evaluate the association of diagnosis with the presence versus absence of each US finding. We conducted multivariable analysis to identify constellations of sonographic findings that were predictive of perforated appendicitis. RESULTS: The individual US findings of abscess/loculated fluid, appendicolith, dilated bowel and increased hepatic periportal echogenicity were significantly associated with perforated appendicitis when compared with acute appendicitis (P < 0.01). The sonographic observation of increased hepatic periportal echogenicity demonstrated a statistically significant association with perforated appendicitis compared with acute appendicitis (P < 0.01). The presence of complex fluid yielded a specificity of 87.7% for perforated appendicitis compared with the acute appendicitis group. The US findings of >/=2 regions or >/=3 regions with fluid had specificity of 87.3% and 99.0%, respectively, for perforated appendicitis compared with the acute appendicitis group. Select combinations of sonographic findings yielded high specificity in the diagnosis of perforated appendicitis compared with acute appendicitis. These constellations yielded higher specificity than that of each individual finding in isolation. The constellation of dilated bowel, RLQ echogenic fat, and complex fluid had the highest specificity (99.5%) for perforated appendicitis (P < 0.01). CONCLUSION: Our study demonstrates that identification of select constellations of findings using abdominal sonography, in addition to focused US examination of the right lower quadrant, can improve sonographic diagnosis of perforated appendicitis in the pediatric population.

BACKGROUND: Shielding of the gonads is a dose-saving strategy in pediatric radiography and its use is the law in New York and the majority of other states. However, routine use of gonadal shields is controversial because of concerns that important diagnostic information can be obscured. OBJECTIVE: The purpose of this study was to assess the frequency and spatial distribution of key findings on portable neonatal abdominal radiographs. MATERIALS AND METHODS: We reviewed the 2,544 portable neonatal intensive care unit anteroposterior abdominal radiographs performed in 2010 at a university medical center, of which 962 were inadequately shielded. These 962 radiographs were reviewed by pairs of pediatric radiologists for the presence of findings in different regions, including bowel abnormalities, pneumatosis, free air, inguinal hernias, osseous abnormalities, and catheter/tube tips. RESULTS: The fewest pertinent findings were present below the level of the sacrosciatic notches (n = 181, 18.8%). Of the 853 abnormalities below the level of the iliac crests in our cohort, six were isolated to these regions, whereas others had concomitant abnormalities more superiorly. Of 35 radiographs with pneumatosis or suspected pneumatosis in the pelvis, 33 had pneumatosis in more superior regions. Suspected free air was never isolated to the pelvis. Osseous abnormalities were only present in the pelvis below the sacrosciatic notch, and 37.5% of lower extremity catheters terminated below the level of the sacrosciatic notches. CONCLUSION: Pertinent findings on neonatal intensive care unit abdominal radiographs are rarely isolated to the pelvic regions.

Purpose or Case Report: Distinguishing perforated from non-perforated appendicitis in children, a known limitation of ultrasound, may alter surgical management. We evaluated the diagnostic utility of select groups of sonographic findings for diagnosis of perforated appendicitis. Methods & Materials: With IRB approval, we retrospectively reviewed 116 abdominal ultrasound (US) exams obtained for evaluation of abdominal pain in children aged 2-18 years from 1/2008 to 9/2011 at a university hospital pediatric radiology department. The study group consisted of surgical and pathology proven acute appendicitis (n=51) and perforated appendicitis (n=22) US exams. Negative US exams for appendicitis (n=43) confirmed by follow up verbal communication comprised the control group. The de-identified US exams were independently reviewed on PACS workstations by four experienced pediatric radiologists blinded to diagnosis and clinical information. The radiologists recorded the presence of dilated bowel, right lower quadrant (RLQ) echogenic fat, increased hepatic periportal echogenicity, and intraperitoneal fluid, indicating quantity (number of abdominal quadrants) and quality of the fluid (simple or complex). Logistic regression for correlated data was used to evaluate the association of diagnosis with the presence versus absence of each US finding in addition to selected groups of US findings. Results: The select groups of findings included increased hepatic periportal echogenicity, echogenic fat, and complex fluid yielding a specificity of 95.0%for perforated appendicitis; increased hepatic periportal echogenicity and 2+ quadrants of fluid yielding a specificity of 96.1%; increased hepatic periportal echogenicity and dilated bowel with a specificity of 98.0%; and dilated bowel, echogenic fat and complex fluid with a specificity of 99.5%. The above constellations of sonographic findings yielded higher specificities than that of each of the following individual findings in isolation: presence of complex fluid (9!

BACKGROUND: In accordance with ALARA, minimizing radiation exposure associated with voiding cystourethrograms (VCUG) is of critical importance. Advances in fluoroscopic technology might help achieve this goal. OBJECTIVE: To determine the efficacy of fluoroscopic image capture compared to conventional digital radiographic spot (DRS) images in voiding cystourethrograms (VCUG) for the evaluation of vesicoureteral reflux (VUR) in children. MATERIALS AND METHODS: The study was a retrospective review of 65 VCUG examinations (130 kidney/ureter units). Each examination consisted of fluoroscopically captured spot (FCS) images and the corresponding DRS images. Each set of images was evaluated by three pediatric radiologists for the diagnosis of VUR for a total of 390 kidney/ureter units reviewed. Using the DRS image set as the reference standard, the efficacy of the FCS images for diagnosing reflux was determined. RESULTS: The diagnostic accuracy of the FCS images in terms of the binary characterization of reflux as negative or positive was 97.2% (379/390). The sensitivity of the FCS images was 92.6% (88/95); the specificity of the FCS images was 98.6% (291/295). CONCLUSION: Fluoroscopically captured images are adequate in documenting absence of VUR on VCUG examinations, obviating the need for radiographic spot images and resulting in reduction in radiation exposure

BACKGROUND: Infection with schistosomal species is becoming a more frequent finding in hospitals throughout the United States. Some causes that can be attributed to the rise include increased immigration from and travel to endemic areas. CASE: We report a case of urinary schistosomiasis diagnosed on urine cytology in a 7-year-old Nigerian boy. Infection was suspected after review of the clinical history and correlation with radiologic images. CONCLUSION: The rise in incidence has made it necessary for cytopathologists to be increasingly aware of these infections, in particular, Schistosoma haematobium, because it is the most frequent agent to be encountered on a cytology specimen, particularly urine. Similar cases have been published, one with specimen concentration and one without. However, no cases of cytology diagnosis with radiologic correlation are seen in the English literature

Uterus didelphys is a rare congenital anomaly with a well-documented association with obstructed hemivagina and ipsilateral renal agenesis. Treatment of this anomaly includes drainage of hematocolopos and excision of the vaginal septum, which has traditionally used a scalpel or scissors, often with hymenotomy. Recently, a less invasive approach using hysteroscopic resection has been reported, allowing improved visualization with preservation of the hymenal ring. In this article, we present an alternative minimally invasive approach using a combination of laparoscopy and vaginoscopy in the case of a 10-year-old girl. This approach allows for treatment in cases wherein vaginoscopy provides inadequate visualization with the advantage of enabling full evaluation for associated complications affecting future fertility including endometriosis, pelvic infection, and pelvic adhesions

BACKGROUND: The arterial vascularity of the hip has been investigated in normal infants using duplex Doppler sonography. This study addressed the differences in hip vascularity in infants with respect to gender and acetabular morphology. OBJECTIVE: To determine whether there is a relationship between the resistive index of the vessels of the femoral chondroepiphysis and the alpha angle in normal infant hips and in those with developmental dysplasia of the hip. MATERIALS AND METHODS: We studied 76 hips (38 patients) with gray-scale and power Doppler US. The patients were referred because of a possible abnormal clinical hip examination or had risk factors for developmental dysplasia of the hip. The infants ranged in age from 1 day to 6 weeks. There were 13 boys and 25 girls. Gray-scale images were initially performed in the coronal and transverse planes to evaluate acetabular morphology, alpha angle and position of the femoral chondroepiphysis relative to the acetabulum. The hips were then examined with power Doppler US, in both sagittal and transverse planes, to identify arterial vessels within the femoral epiphysis. Resistive indices were then recorded from the spectral analysis in each vessel identified. Each examination was performed by one of five pediatric radiologists. Mixed model regression was used to assess the relationship between resistive index and alpha angle, age and gender. RESULTS: Of the 76 hips, 34 had an alpha angle of 60 degrees or greater and were classified as normal, 26 had an alpha angle between 50 degrees and 59 degrees and were classified as immature, and 13 had an alpha angle of less than 50 degrees and were either subluxed or dislocated at the time of examination. At least two vessels were documented in each femoral epiphysis except in three hips, in which no vessels could be documented because of technical factors. There was a statistically significant linear relationship between the alpha angle and resistive index, such that the resistive index tended to rise with increasing alpha angle (P=0.0022). In addition, female infants had a significantly higher average resistive index than the average resistive index in male infants with the same alpha angle (P=0.0005). CONCLUSION: There is a direct linear relationship between alpha angle and resistive index in the infant hip. Female infants have a higher average resistive index than male infants. We believe that these results might serve as a model for predicting an infant hip at risk of ischemia. In addition, the fact that lower resistive indices of the femoral epiphysis are associated with acetabular dysplasia might help explain the documented low incidence of avascular necrosis in untreated hip dysplasia