Publications by authors named "Benjamin H Taragin"

29 Publications

  • Page 1 of 1

Clinical Application of Postmortem Magnetic Resonance Imaging in Neonates.

Neonatology 2021 Feb 5:1-10. Epub 2021 Feb 5.

Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel.

Background: Recent reports advocate the use of MRI either as a substitute for postmortem examinations or for a more targeted autopsy.

Methods: A full-body postmortem MRI (pMRI) of infants was performed as early as possible after death, and findings were compared to clinical premortem diagnoses.

Results: Thirty-one infants were scanned during the study period. Median gestation at birth was 34 weeks (ranges: 24-43). In 3 (10%) cases, no new findings were detected. In 2 (6%), new minor findings not related to the cause of death were detected, and in 17 (55%), new minor findings related to the cause of death were detected. New major findings related to the cause of death were detected in 4 (13%) cases, and new major findings not related to the cause of death were detected in 5 (16%) cases. In 3 (10%), findings thought to alter the perceived cause of death were detected. Overall, in 23 (74%) cases, pMRI findings reinforced the clinical premortem diagnoses.

Conclusions: pMRI is a culturally accepted alternative when autopsy is not performed and can either reinforce, refute, or add to premortem clinical diagnoses.
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http://dx.doi.org/10.1159/000512923DOI Listing
February 2021

No way out: Causes of duodenal and gastric outlet obstruction.

Clin Imaging 2020 Sep 19;65:37-46. Epub 2020 Apr 19.

Pediatric Radiology, Soroka University Hospital, Ben Gurion University, Israel; Department of Pediatric Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, United States of America. Electronic address:

Upper gastrointestinal obstruction (UGIO), obstruction occurring at the level of the stomach or duodenum, represents only about 5% of bowel obstructions. As with other bowel obstructions, timely diagnosis is necessary to prevent complications including ischemia and death. Because the presenting symptoms of UGIO can be vague and nonspecific, the diagnosis may not be suspected clinically. The radiologist therefore provides immense value as the diagnosis and often the etiology of the obstruction can be ascertained through imaging. Here we present a simple classification scheme of etiologies of UGIO into congenital, malignant, infectious/inflammatory, and mechanical categories, and provide examples of the most common and some uncommon causes for each category. We highlight that several of the congenital etiologies of UGIO can present at any age, including adulthood, and therefore it is important for the radiologist to keep these diagnoses in mind when reviewing cases of UGIO. For each etiology, we provide typical imaging strategies that are used for diagnosis as well as key points regarding the diagnosis.
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http://dx.doi.org/10.1016/j.clinimag.2020.04.017DOI Listing
September 2020

Radiographic overlap of recurrent Caffey disease and chronic recurrent multifocal osteomyelitis (CRMO) with considerations of molecular origins.

Pediatr Radiol 2020 05 23;50(5):618-627. Epub 2019 Dec 23.

Department of Pediatric Radiology, Soroka University Medical Center, Ben-Gurion University, Beer Sheva, Israel.

Caffey disease, or infantile cortical hyperostosis, classically describes a self-limited inflammatory disorder that presents in the infant with fussiness, focal swelling and sometimes fever. Imaging is conventionally limited to radiography, which shows mild to profound subperiosteal bone formation and sometimes deformity. This disease was not uncommonly diagnosed in the late 20 century. Interestingly, the disease may not just occur in the infant, and it may be due to a genetic mutation in the alpha-one chain of type 1 collagen (COL1A1). Recurrent or delayed onset in the older child or adolescent also occurs. In more recent years, another type of inflammatory bone disorder, chronic sterile osteomyelitis, has been frequently recognized and, depending on the radiographic stage or the diagnostic modality used, may have characteristics overlapping with Caffey disease. In this review, we discuss the demographics, imaging and known etiologies for Caffey disease and chronic recurrent multifocal osteomyelitis and raise the possibility of similar molecular origins.
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http://dx.doi.org/10.1007/s00247-019-04590-3DOI Listing
May 2020

68Ga-DOTATATE PET/CT in Focal Fatty Sparing of the Liver.

Clin Nucl Med 2019 Oct;44(10):815-817

From the Institute of Nuclear Medicine and Molecular Imaging.

Ga-DOTATATE imaging is commonly used for the detection of metastatic disease in neuroendocrine tumors. We present a case of a 69-year-old woman postsurgery for lung carcinoid tumor in which sequential follow-up Ga-DOTATATE PET/CT studies identified focal hepatic uptake that was presumed to represent a liver metastasis. However, correlative imaging with MRI revealed a focal fatty sparing of the liver composed of benign hepatic parenchyma at that area accompanied with diffuse liver steatosis in the background of the "pseudolesion." This report demonstrates a potential "false-positive" hepatic finding that can strikingly mimic a metastasis in neuroendocrine tumor imaging.
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http://dx.doi.org/10.1097/RLU.0000000000002746DOI Listing
October 2019

Lead poisoning risk assessment of radiology workers using lead shields.

Arch Environ Occup Health 2020 24;75(1):60-64. Epub 2019 Jan 24.

Department of Pediatrics, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA.

Lead containing dust may be present on the exterior surfaces of shields used to prevent radiation exposure. We determined whether use of lead shields poses an exposure risk for radiology personnel. We collected hand dustwipe and blood samples from 58 Radiology Department employees of an academic hospital. Samples were analyzed for lead content by atomic absorption spectroscopy. Results were compared between lead apron users (46) and nonusers (12). Hand dustwipe lead was undetectable (<3 µg/sample) in all cases. Blood lead levels ranged from 0-3 µg/dL. In this study of Radiology Department workers, we did not find an increased risk of lead contamination on their hands or in their blood. Although our sample size is small, we conclude that lead poisoning is unlikely to occur with high frequency in lead shield users.
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http://dx.doi.org/10.1080/19338244.2018.1553843DOI Listing
March 2020

Radiation dose monitoring in pediatric fluoroscopy: comparison of fluoroscopy time and dose-area product thresholds for identifying high-exposure cases.

Pediatr Radiol 2019 05 10;49(5):600-608. Epub 2019 Jan 10.

Montefiore Medical Center, 111 East 210th St., Bronx, NY, 10467, USA.

Background: Fluoroscopy time has been used as a surrogate for radiation dose monitoring in pediatric fluoroscopy; however it does not account for factors such as magnification or collimation. Dose-area product (DAP) is a more accurate measure of radiation exposure but its dependence on patient weight and body-part thickness is a challenge in children of varying ages.

Objective: To determine whether fluoroscopy time and DAP produce concurrent results when they are used to identify high-exposure cases, and to establish radiation dose thresholds for our institution.

Materials And Methods: During a 2-year period we prospectively monitored pediatric fluoroscopy studies performed at the Children's Hospital at Montefiore. We recorded study type, fluoroscopy time, DAP, patient age, weight and height. We then calculated 90th percentile fluoroscopy time and DAP thresholds for weight and age.

Results: We evaluated 1,011 cases (453 upper gastrointestinal [UGI] series, 266 voiding cystourethrograms [VCUGs], 120 contrast enemas, 108 speech studies, and 64 esophagrams). Fluoroscopy time demonstrated moderate correlation with DAP (r=0.45, P<0.001, Spearman rank). DAP strongly correlated with patient weight (r=0.71, P<0.001) and age (r=0.70, P<0.001). Concordance of cases exceeding 90th percentile thresholds for fluoroscopy time and DAP were κ=0.27 for UGI series and κ=0.49 for VCUG for weight-based cutoffs, and κ=0.36 for UGI series and κ=0.40 for VCUG for age-based cutoffs.

Conclusion: The limited correlation of fluoroscopy time with DAP suggests these methods are not equivalent for dose monitoring. However, the strong correlation of DAP with patient weight and age presents a challenge for establishing DAP thresholds in children, who range widely in size. Despite controlling for weight or age, there was limited overlap of cases exceeding the 90th percentile threshold for fluoroscopy time and DAP. This further reinforces the non-overlapping outcome of these two methods and indicates that fluoroscopy time might be inadequate for dose monitoring.
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http://dx.doi.org/10.1007/s00247-018-04335-8DOI Listing
May 2019

Hepatic Imaging in Neonates and Young Infants: State of the Art.

Radiology 2017 12;285(3):763-777

From the Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, 111 E 210 St, Bronx, NY 10467.

Neonatal liver disease is an important source of morbidity in the pediatric population. The manifestation of liver disease in young infants may be different than in older patients, and there are a number of diagnoses that are unique to this age group. Familiarity with these entities is important as imaging plays a key role in the diagnostic workup, and prompt diagnosis is necessary to prevent complications. This article reviews the spectrum of liver pathologies that can manifest in the first 6 months of life and is intended to educate the general radiologist who may be faced with interpretation of neonatal liver imaging. Categories of disease that will be reviewed include cholestatic diseases, tumors, vascular anomalies, and acquired diseases. The authors will also review optimization of ultrasonography (US) and magnetic resonance imaging of the liver and present a systematic method for interpretation of neonatal liver US findings in the context of clinical and laboratory findings. RSNA, 2017.
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http://dx.doi.org/10.1148/radiol.2017170305DOI Listing
December 2017

From the bottom of the heart: Measuring liver iron concentration on cardiac MRI.

Clin Imaging 2018 Jan - Feb;47:124-129. Epub 2017 Sep 13.

Montreal Heart Institute, Radiology Department, 5000 Belanger street, Montreal, QC, H1T 1C8, Canada.

Patients with hemochromatosis require regular surveillance of liver and cardiac iron concentration with liver and cardiac MRI. However, cardiac MRI includes a part of the liver in the field of view. The purpose of this retrospective and prospective study is to determine if liver T2* measured on cardiac MRI may be used as a surrogate for T2* obtained on standard liver MRI. Liver iron concentrations were measured on cardiac and liver MRI in 21 patients. Although statistically significant, the difference may be clinically insignificant as the same patients merited chelation therapy when relying on either the cardiac or liver MRI.
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http://dx.doi.org/10.1016/j.clinimag.2017.09.008DOI Listing
May 2018

Initial experience with the 3.3 Fr Mongoose pigtail catheter for aortic angiography during patent ductus arteriosus closure in small patients.

Ann Pediatr Cardiol 2017 Sep-Dec;10(3):240-244

Department of Pediatrics, Division of Pediatric Cardiology, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA.

Background: Smaller femoral arterial sheaths may be associated with fewer vascular complications. The 3.3 Fr Mongoose Pediavascular pigtail catheter is a catheter that allows higher flow rates, potentially resulting in improved angiographic quality. We reviewed our experience with this small catheter during patent ductus arteriosus (PDA) closure.

Materials And Methods: Review of patients ≤20 kg in whom the Mongoose catheter was used during PDA closure from 12/13 to 4/15. Angiographic efficacy and procedural details were compared to ten 4 Fr catheter cases. Comparisons were performed using Mann-Whitney U-test; < 0.05 was statistically significant.

Results: Twelve (9 female) patients were catheterized with a 3.3 Fr Mongoose. Median weight 10.5 kg (range 6.4-18.2), height 81 cm (range 37-111), and body surface area (BSA) 0.47 m (range 0.33-0.75) were similar to ten patients (3 females) in the 4 Fr control group ( = NS); median weight 9.9 kg (range 6-16.8), height 80 cm (range 64-102), and BSA 0.46 m2 (range 0.31-0.74). Angiographic quality was subjectively adequate with both with no difference in the median pixel density between the two techniques (3.3 Fr: 76.7 [range 33.5-90] and 4 Fr: [70; 38-102]; = NS). Contrast used was similar between the groups (3.3 Fr: median 4.2 ml/kg and 4 Fr: 4.9 ml/kg; = NS). Median radiation dose was similar in the two groups (3.3 Fr: 28.1 mGy [range 17.2-38] and 4 Fr: 38 mGy [range 20.4-58.5]; = NS). All ducts were closed at latest follow-up ( = NS). No complications were encountered.

Conclusions: The 3.3 Fr Mongoose allowed similar angiography to the 4 Fr pigtail catheter, allowing safe and effective transcatheter PDA closure in small children.
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http://dx.doi.org/10.4103/apc.APC_9_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5594934PMC
September 2017

Clinical Factors Associated With Chest Imaging Findings in Hospitalized Infants With Bronchiolitis.

Clin Pediatr (Phila) 2017 Oct 21;56(11):1054-1059. Epub 2017 Mar 21.

4 Einstein Medical Center, Philadelphia, PA, USA.

Despite recommendations against routine imaging, chest radiography (CXR) is frequently performed on infants hospitalized for bronchiolitis. We conducted a review of 811 infants hospitalized for bronchiolitis to identify clinical factors associated with imaging findings. CXR was performed on 553 (68%) infants either on presentation or during hospitalization; 466 readings (84%) were normal or consistent with viral illness. Clinical factors significantly associated with normal/viral imaging were normal temperature (odds ratio = 1.66; 95% CI = 1.03-2.67) and normal oxygen saturation (odds ratio = 1.77; 95% CI = 1.1-2.83) on presentation. Afebrile patients with normal oxygen saturations were nearly 3 times as likely to have a normal/viral CXR as patients with both fever and hypoxia. Our findings support the limited role of radiography in the evaluation of hospitalized infants with bronchiolitis, especially patients without fever or hypoxia.
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http://dx.doi.org/10.1177/0009922817698802DOI Listing
October 2017

Non-central peripherally inserted central catheters in neonatal intensive care: complication rates and longevity of catheters relative to tip position.

Pediatr Radiol 2017 Nov 1;47(12):1676-1681. Epub 2017 Aug 1.

Division of Neonatology, Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

Background: Peripherally inserted central catheters (PICCs) represent a mainstay of intravascular access in the neonatal intensive care setting when long-term vascular access is needed. Ideally, PICCs should be inserted and maintained in a central position with the tip ending in the superior or inferior vena cava. This is not always achievable, and sometimes the tip remains in a peripheral location. Higher complication rates have been reported with non-central PICCs; however these findings have not been confirmed in a solely neonatal series and PICCs with tips in peripheral veins have not been studied.

Objective: To compare complication rates and length of catheter duration related to PICC position in neonates.

Materials And Methods: We conducted a retrospective analysis of all PICCs inserted in term and preterm infants in a tertiary neonatal intensive care unit between May 2007 and December 2009. A single pediatric radiologist reinterpreted the catheter tip site on initial anteroposterior (AP) chest radiographs and categorized sites as central (superior vena cava, inferior vena cava, brachiocephalic vein), intermediate (subclavian, axillary, common or external iliac veins), or peripheral (veins peripheral to axillary or external iliac veins). We analyzed complication rates and length of catheter duration among the three categories.

Results: We collected data on a total of 176 PICCs. Infants with PICCs in a central location had a significantly lower complication rate (18/97, 19%) than those with the PICC tip in an intermediate (24/64, 38%) or peripheral (9/15, 60%) locations (P=0.0003). Length of catheter duration was noted to be longest with central, intermediate with intermediate, and shortest with peripheral PICC tip locations (17.7±14.8 days for central vs. 11.4±10.7 days for intermediate vs. 5.4±2.5 days for peripheral, P=0.0003).

Conclusion: A central location is ideal for the tip of a PICC. When this is not achievable, an intermediate location is preferable to a more peripheral position.
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http://dx.doi.org/10.1007/s00247-017-3939-1DOI Listing
November 2017

Consensus Report by Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplantation Consortium Joint Working Committees: Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents, Part 1: Focus on Investigations, Prophylaxis, and Specific Treatment.

Biol Blood Marrow Transplant 2017 Nov 25;23(11):1817-1825. Epub 2017 Jul 25.

Fred Hutchinson Cancer Research Center and University of Washington, Seattle, Washington.

Veno-occlusive disease (VOD) is a common and potentially fatal complication in children undergoing hematopoietic cell transplantation (HCT). It occurs in about one-third of all patients undergoing transplantation and is fatal in 50% of patients with severe disease. Early intervention and specific treatment with defibrotide are associated with improved outcomes. However, there is a lack of supportive care guidelines for management of the multiorgan dysfunction seen in most cases. There is high variability in the management of VOD, which may contribute to the increased morbidity and mortality. Although there is ample research in the specific treatment of VOD, there is paucity of literature regarding the management of ascites, transfusions requirements, fluids and electrolyte dysfunction, delirium, and investigations in children with VOD. The joint working committees of the Pediatric Acute Lung Injury and Sepsis Investigators and the Pediatric Blood and Marrow Transplantation Consortium collaborated to develop a series of evidence-based supportive care guidelines for management of VOD. The quality of evidence was rated and recommendations were made using Grading of Recommendations, Assessment, Development and Evaluation criteria. This manuscript is part 1 of the series and focuses on the need to develop these guidelines; methodology used to establish the guidelines; and investigations needed for diagnosis, prophylaxis, and treatment of VOD in children.
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http://dx.doi.org/10.1016/j.bbmt.2017.07.021DOI Listing
November 2017

Identifying intestinal malrotation on magnetic resonance examinations ordered for unrelated indications.

Pediatr Radiol 2017 Oct 16;47(11):1477-1482. Epub 2017 Jun 16.

Department of Diagnostic Radiology, Montefiore Medical Center, 111 E. 210th St, Bronx, NY, 10467, USA.

Background: Anatomical imaging findings indicating normal bowel rotation can be identified on cross-sectional imaging, including magnetic resonance imaging (MRI) performed for non-related indications.

Objective: The goal of our study was to assess whether non-targeted MRI can accurately assess intestinal malrotation.

Materials And Methods: Four anatomical landmarks were assessed on MRIs of the chest, spine or abdomen performed from January 2006 to June 2014, on patients who also had upper gastrointestinal series (UGI) performed within 10 years of the MRI date: 1) retroperitoneal duodenum, 2) left upper quadrant duodenojejunal junction, 3) superior mesenteric artery to the left of the superior mesenteric vein, and 4) right lower quadrant cecum. Two attending radiologists, one pediatric and one abdominal radiologist, independently reviewed the MR images. The pediatric radiologist reviewed images from UGI (considered the gold standard) to determine the intestinal rotation for each case. Validation of the criteria was performed on new patients imaged through January 2016.

Results: The original cohort included 109 MRIs (15 chest, 41 spine and 53 abdomen) done on 109 patients (42% males, mean age: 10.2 years). If each of the 4 anatomical questions were answered "yes" (4-YES), specificity was 100% for each radiologist and malrotation was appropriately excluded. Using the 4-YES criteria, the pediatric radiologist excluded malrotation in 71 patients (65%) and the abdominal radiologist excluded it in 65 (60%), with concurrence for 57 patients. Validation of the 4-YES criteria in 23 new patients appropriately proved the 4-YES rule, with neither labeling the one new malrotation case 4-YES.

Conclusion: If a radiologist can confidently answer "yes" to the four questions evaluated in this study, then intestinal rotation can be safely considered normal. Normal bowel rotation should be commented upon in MRI reports when these four anatomical locations are imaged, thus helping patients avoid unnecessary UGI and radiation exposure.
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http://dx.doi.org/10.1007/s00247-017-3903-0DOI Listing
October 2017

MRI usage in a pediatric emergency department: an analysis of usage and usage trends over 5 years.

Pediatr Radiol 2017 Mar 12;47(3):327-332. Epub 2017 Jan 12.

Department of Radiology, Division of Pediatric Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

Background: Magnetic resonance imaging (MRI) usage has anecdotally increased due to the principles of ALARA and the desire to Image Gently. Aside from a single abstract in the emergency medicine literature, pediatric emergency department MRI usage has not been described.

Objecive: Our objective was to determine whether MRI use is indeed increasing at a high-volume urban pediatric emergency department with 24/7 MRI availability. Also, we sought to determine which exams, time periods and demographics influenced the trend.

Materials And Methods: Institutional Review Board exemption was obtained. Emergency department patient visit and exam data were obtained from the hospital database for the 2011-2015 time period. MRI usage data were normalized using emergency department patient visit data to determine usage rates. The z-test was used to compare MRI use by gender. The chi-square test was used to test for trends in MRI usage during the study period and in patient age. MRI usage for each hour and each weekday were tabulated to determine peak and trough usage times.

Results: MRI usage rate per emergency department patient visit was 0.36%. Headache, pain and rule-out appendicitis were the most common indications for neuroradiology, musculoskeletal and trunk exams, respectively. Usage in female patients was significantly greater than in males (0.42% vs. 0.29%, respectively, P<0.001). Usage significantly increased during the 5-year period (P<0.001). Use significantly increased from age 3 to 17 (0.011% to 1.1%, respectively, P<0.001). Sixty percent of exams were performed after-hours, the highest volume during the 10 p.m. hour and lowest between 4 a.m. and 9 a.m. MRI use was highest on Thursdays and lowest on Sundays (MRI on 0.45% and 0.22% of patients, respectively).

Conclusion: MRI use in children increased during the study period, most notably in females, on weekdays and after-hours.
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http://dx.doi.org/10.1007/s00247-016-3764-yDOI Listing
March 2017

Lead Aprons Are a Lead Exposure Hazard.

J Am Coll Radiol 2017 May 9;14(5):641-647. Epub 2017 Jan 9.

Department of Pediatrics, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York.

Purpose: To determine whether lead-containing shields have lead dust on the external surface.

Methods: Institutional review board approval was obtained for this descriptive study of a convenience sample of 172 shields. Each shield was tested for external lead dust via a qualitative rapid on-site test and a laboratory-based quantitative dust wipe analysis, flame atomic absorption spectrometry (FAAS). The χ test was used to test the association with age, type of shield, lead sheet thickness, storage method, and visual and radiographic appearance.

Results: Sixty-three percent (95% confidence interval [CI]: 56%-70%) of the shields had detectable surface lead by FAAS and 50% (95% CI: 43%-57%) by the qualitative method. Lead dust by FAAS ranged from undetectable to 998 μg/ft. The quantitative detection of lead was significantly associated with the following: (1) visual appearance of the shield (1 = best, 3 = worst): 88% of shields that scored 3 had detectable dust lead; (2) type of shield: a greater proportion of the pediatric patient, full-body, and thyroid shields were positive than vests and skirts; (3) use of a hanger for storage: 27% of shields on a hanger were positive versus 67% not on hangers. Radiographic determination of shield intactness, thickness of interior lead sheets, and age of shield were unrelated to presence of surface dust lead.

Conclusions: Sixty-three percent of shields had detectable surface lead that was associated with visual appearance, type of shield, and storage method. Lead-containing shields are a newly identified, potentially widespread source of lead exposure in the health industry.
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http://dx.doi.org/10.1016/j.jacr.2016.10.024DOI Listing
May 2017

Three-dimensional ultrasound of the neonatal brain: technical approach and spectrum of disease.

Pediatr Radiol 2017 May 5;47(5):613-627. Epub 2017 Jan 5.

Department of Radiology, Montefiore Medical Center and the Albert Einstein College of Medicine, 111 East 210th St., Bronx, NY, 10467, USA.

Brain pathology is an important cause of morbidity and mortality in neonates, especially in the premature population. While conventional two-dimensional neurosonography is traditionally used for screening, diagnosis and monitoring of brain disorders such as germinal matrix hemorrhage, periventricular leukomalacia and hydrocephalus, three-dimensional ultrasonography has gained popularity in a variety of clinical applications in recent years. Three-dimensional ultrasonography is not yet widely utilized in pediatric imaging but is a potentially powerful tool for evaluating the neonatal brain. Three-dimensional neurosonography allows imaging of the entire brain in a single volumetric sweep and offers the capability of reconstructing images in the axial plane and performing volumetric analyses that are unavailable in conventional two-dimensional neurosonography. The purpose of this article is two-fold: (1) to present the technical aspects of three-dimensional neurosonography and (2) to illustrate the potential applications of three-dimensional neurosonography in the context of commonly encountered neonatal neuropathology.
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http://dx.doi.org/10.1007/s00247-016-3753-1DOI Listing
May 2017

Calcified central venous catheter fibrin sheath: case report and review of the literature.

Clin Imaging 2015 Nov-Dec;39(6):1130-3. Epub 2015 Jul 17.

Radiology, Albert Einstein College of Medicine, Bronx, New York, NY, USA.

We present a 6-year-old girl with acute lymphoblastic leukemia who demonstrated on chest X-ray a radiopacity in the superior vena cava after removal of an implanted venous access device. This radiopacity was initially thought to be a retained catheter fragment. On review of previous imaging, we were able to document the temporal development of a calcified catheter cast as distinct from the catheter. This case represents a rare consequence of central venous catheterization in children. Knowledge of this finding as a possible complication may help avoid performance of unnecessary follow-up imaging or invasive procedures.
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http://dx.doi.org/10.1016/j.clinimag.2015.07.014DOI Listing
June 2016

Value of Focused Appendicitis Ultrasound and Alvarado Score in Predicting Appendicitis in Children: Can We Reduce the Use of CT?

AJR Am J Roentgenol 2015 Jun;204(6):W707-12

1 Department of Radiology, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Pkwy S, Bronx, NY 10461.

Objective: The purpose of this study was to evaluate the effectiveness of focused appendicitis ultrasound combined with Alvarado score to accurately identify appendicitis in children in whom it is suspected, thereby reducing unnecessary CT examinations and associated radiation exposure.

Materials And Methods: We retrospectively evaluated the focused appendicitis ultrasound, CT, clinical, and laboratory findings of 522 consecutively registered children (231 boys, 291 girls; mean age, 13.04 [SD, 5.02] years; range, 0.74 months-21 years) who underwent focused appendicitis ultrasound for abdominal pain in a pediatric emergency department from January 2008 through October 2009. All children underwent surgery or clinical follow-up to exclude missed appendicitis. Sonographic findings were characterized as positive, negative, or inconclusive (appendix not visualized). Alternative diagnoses were noted. Alvarado score (0-10 points based on multiple clinical criteria) was determined. Focused appendicitis ultrasound and Alvarado score results were compared with surgical and pathologic reports.

Results: Both focused appendicitis ultrasound results and Alvarado score were associated with likelihood of surgery for appendicitis (p = 0.0001). Focused appendicitis ultrasound had conclusive results: 105 positive and 27 negative in 132 of 522 (25.2%) children. In the 390 of 522 (74.7%) children with inconclusive focused appendicitis ultrasound findings, 43 of 390 (11.0%) eventually had a diagnosis of appendicitis with CT (n = 26) or Alvarado score (n = 17). Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score less than 5 (241/522, 46.1%), only one patient had appendicitis. The negative predictive value (NPV) of inconclusive ultrasound findings and low Alvarado score combined was 99.6%. Among children with inconclusive focused appendicitis ultrasound findings and an Alvarado score of 5-8, the NPV decreased to 89.7%.

Conclusion: Children with inconclusive focused appendicitis ultrasound findings and a low Alvarado score are extremely unlikely to have appendicitis (NPV, 99.6%). Avoiding unnecessary CT of these patients is a safe approach to diagnosis.
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http://dx.doi.org/10.2214/AJR.14.13212DOI Listing
June 2015

Imaging appearances of musculoskeletal developmental variants in the pediatric population.

Curr Probl Diagn Radiol 2015 Jan-Feb;44(1):88-104. Epub 2014 Nov 10.

Department of Radiology, Montefiore Medical Center, Bronx, NY.

Variations in musculoskeletal development in children are commonly encountered. These variants often have a confusing appearance on imaging and may simulate pathologic conditions. However, in many instances, these normal variants have certain features that allow for confident determination of the benign nature of these entities. An awareness of the characteristic imaging features is therefore important for radiologists. In this review, we focus on 4 specific categories of variants in the development: (1) variations in the normal ossification of skeletal structures, (2) the appearance of tendinous and ligamentous insertions in the developing skeleton, (3) overlapping lines that can be confused with fractures or other pathologic conditions, and (4) variant orientation of normal bones. We review the etiology and imaging appearance of these entities and also describe methods of differentiating these benign entities from pathologic lesions. Although in certain cases, correlation with clinical parameters is needed to confidently diagnose the lesion as benign, in many cases, an appreciation of the characteristic imaging features alone would suffice and prevent a potentially costly workup.
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http://dx.doi.org/10.1067/j.cpradiol.2014.06.002DOI Listing
September 2015

MRI findings in pediatric patients with scurvy.

Skeletal Radiol 2015 Feb 12;44(2):291-7. Epub 2014 Aug 12.

Department of Radiology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467-2401, USA,

In modern times scurvy is a rarely encountered disease caused by ascorbic acid (vitamin C) deficiency. However, sporadic cases of scurvy persist, particularly within the pediatric population. Recent individual case reports highlight an increased incidence of scurvy among patients with autism or developmental delay, with isolated case reports detailing the magnetic resonance imaging (MRI) findings of scurvy in these pediatric populations. We present the MRI findings of scurvy in four patients with autism or developmental delay, and review the literature on MRI findings in pediatric patients with scurvy. Despite its rarity, the radiologist must consider scurvy in a pediatric patient with a restricted diet presenting with arthralgia or myalgia.
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http://dx.doi.org/10.1007/s00256-014-1962-yDOI Listing
February 2015

Appropriateness of imaging studies ordered by emergency medicine residents: results of an online survey.

AJR Am J Roentgenol 2013 Oct;201(4):W619-25

1 All authors: Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467.

Objective: The purpose of this study is to determine the proficiency of emergency medicine residents in selecting appropriate radiologic examinations for specific clinical scenarios and to ascertain whether their training improves competency in this area over the course of their residency.

Materials And Methods: An online multiple-choice questionnaire was created. It included 10 clinical scenarios excerpted from the American College of Radiology Appropriateness Criteria guidelines and instructed residents to select the most appropriate initial imaging study. A link and invitation to the survey were e-mailed to the residency program directors and coordinators of all American Council for Graduate Medical Education-accredited emergency medicine residency training programs with the request that they be forwarded to their current residents. Responses were graded, with correct answers derived from the American College of Radiology guidelines. Results were stratified by year of emergency medicine training, and an analysis of variance was performed.

Results: A total of 583 residents from at least 77 different emergency medicine residency training programs completed the survey. Overall, the average number of questions answered correctly was 7.1 of 10 (SD, 1.2). First-through fourth-year residents averaged 6.9 (SD, 1.3), 7.1 (SD, 1.2), 7.1 (SD, 1.1), and 7.5 (SD, 1.1) correct answers, respectively. Analysis of variance found no significant difference between the scores of the four classes (p = 0.09).

Conclusion: Emergency medicine residents do not show significant improvement over the course of their residency in their ability to choose appropriate imaging studies. This finding suggests that there is a role for more-rigorous focused instruction to better familiarize residents with appropriateness guidelines for diagnostic imaging selection.
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http://dx.doi.org/10.2214/AJR.12.10487DOI Listing
October 2013

Retained fibrin sheaths: chest computed tomography findings and clinical associations.

J Thorac Imaging 2014 Mar;29(2):118-24

Departments of *Radiology §Medicine ∥Family and Social Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx †Department of Radiology, Staten Island University Hospital, Staten Island, NY ‡Department of Radiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.

Purpose: Fibrin sheaths may develop around long-term indwelling central venous catheters (CVCs) and remain in place after the catheters are removed. We evaluated the prevalence, computed tomographic (CT) appearance, and clinical associations of retained fibrin sheaths after CVC removal.

Materials And Methods: We retrospectively identified 147 adults (77 men and 70 women; mean age 58 y) who underwent CT after CVC removal. The prevalence of fibrin sheath remnants was calculated. Bivariate and multivariate analyses were performed to assess for associations between sheath remnants and underlying diagnoses leading to CVC placement; patients' age and sex; venous stenosis, occlusion, and collaterals; CVC infection; and pulmonary embolism.

Results: Retained fibrin sheaths were present in 13.6% (20/147) of cases, of which 45% (9/20) were calcified. Bivariate analysis revealed sheath remnants to be more common in women than in men [23% (16/70) vs. 5% (4/77), P=0.0018] and to be more commonly associated with venous occlusion and collaterals [30% (6/20) vs. 5% (6/127), P=0.0001 and 30% (6/20) vs. 6% (7/127), P=0.0003, respectively]. Other variables were not associated. Multivariate analysis confirmed the relationship between fibrin sheaths and both female sex (P=0.005) and venous occlusion (P=0.01).

Conclusions: Retained fibrin sheaths were seen on CT in a substantial minority of patients after CVC removal; nearly half of them were calcified. They were more common in women and associated with venous occlusion.
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http://dx.doi.org/10.1097/RTI.0b013e318299ff22DOI Listing
March 2014

Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children?

Pediatr Emerg Care 2013 Mar;29(3):337-41

Division of Emergency Medicine, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY 10467, USA.

Objectives: Previous studies demonstrated that the collapsibility index (percent decrease in inferior vena cava [IVC] diameter with inspiration) of 50% or greater and an IVC/aorta ratio of 0.8 or less correlated with a low intravascular volume. Our study sought to determine if bedside ultrasound (BUS) measurements of the IVC diameter correlate with central venous pressure (CVP) measurements as an indicator of intravascular volume status in acutely ill children.

Methods: A convenience sample of children younger than 21 years who were admitted to the pediatric critical care unit and required CVP monitoring had BUS measurements of both IVC and aortic diameters with simultaneous CVP measurement. The collapsibility index (sagittal view) and IVC/aorta ratio (transverse view) were calculated from these measurements. A CVP of 8 mm Hg or less was considered as a marker for decreased intravascular volume.

Results: Of the 51 participants, 21 (43%) had a CVP of 8 mm Hg or less. Eight (16%) of 51 children had a collapsibility index 50% or greater, and 8 (18%) of 43 had an IVC/aorta ratio of 0.8 or less. The sensitivity of a collapsibility index 0.5 or greater to predict a CVP of 8 mm Hg or less was 14%, the specificity was 83%, the positive predictive value was 38%, and the negative predictive value was 57%. Neither collapsibility index (r = -0.23, P = 0.11) nor IVC/aorta (r = -0.19, P = 0.22) correlated with CVP in assessing intravascular volume in our study population.

Conclusions: Based on these data, the IVC and aortic measurements by BUS are not reliable indicators of intravascular volume (as determined by CVP) in acutely ill children.
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http://dx.doi.org/10.1097/PEC.0b013e31828512a5DOI Listing
March 2013

Maximizing time-resolved MRA for differentiation of hemangiomas, vascular malformations and vascularized tumors.

Pediatr Radiol 2012 Jul 8;42(7):775-84. Epub 2012 Mar 8.

Department of Radiology, Montefiore Medical Center, Bronx, NY 10467, USA.

Contrast-enhanced magnetic resonance angiography (MRA) using time-resolved imaging is a relatively new and increasingly popular technique. We will describe the technique utilized at our institution, Time-Resolved Imaging of Contrast Kinetics (TRICKS; GE Healthcare, Milwaukee, WI), and the parameters that can be adjusted to optimize the exam. We will review key imaging features of hemangiomas and vascular malformations in various modalities, with a special emphasis on the TRICKS appearance.
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http://dx.doi.org/10.1007/s00247-012-2359-5DOI Listing
July 2012

External validation of the New Orleans Criteria (NOC), the Canadian CT Head Rule (CCHR) and the National Emergency X-Radiography Utilization Study II (NEXUS II) for CT scanning in pediatric patients with minor head injury in a non-trauma center.

Pediatr Radiol 2011 Aug 5;41(8):971-9. Epub 2011 Apr 5.

Department of Radiology, Albert Einstein College of Medicine, Bronx, NY, USA.

Background: Head CT scans are considered the imaging modality of choice to screen patients with head trauma for neurocranial injuries; however, widespread CT imaging is not recommended and much research has been conducted to establish objective clinical predictors of intracranial injury (ICI) in order to optimize the use of neuroimaging in children with minor head trauma.

Objective: To evaluate whether a strict application of the New Orleans Criteria (NOC), Canadian CT Head Rule (CCHR) and National Emergency X-Radiography Utilization Study II (NEXUS II) in pediatric patients with head trauma presenting to a non-trauma center (level II) could reduce the number of cranial CT scans performed without missing clinically significant ICI.

Materials And Methods: We conducted an IRB-approved retrospective analysis of pediatric patients with head trauma who received a cranial CT scan between Jan. 1, 2001, and Sept. 1, 2008, and identified which patients would have required a scan based on the criteria of the above listed decision instruments. We then determined the sensitivities, specificities and negative predictive values of these aids.

Results: In our cohort of 2,101 patients, 92 (4.4%) had positive head CT findings. The sensitivities for the NOC, CCHR and NEXUS II were 96.7% (95%CI 93.1-100), 65.2% (95%CI 55.5-74.9) and 78.3% (95%CI 69.9-86.7), respectively, and their negative predictive values were 98.7%, 97.6% and 97.2%, respectively. In contrast, the specificities for these aids were 11.2% (95%CI 9.8-12.6), 64.2% (95%CI 62.1-66.3) and 34.2% (95%CI 32.1-36.3), respectively. Therefore, in our population it would have been possible to scan at least 10.9% fewer patients.

Conclusions: The number of cranial CT scans conducted in our pediatric cohort with head trauma would have been reduced had any of the three clinical decision aids been applied. Therefore, we recommend that further validation and adoption of pediatric head CT decision aids in non-trauma centers be considered to ultimately increase patient safety while reducing medical expense.
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http://dx.doi.org/10.1007/s00247-011-2032-4DOI Listing
August 2011

Online survey of radiologic ordering practices by pediatric trainees.

J Am Coll Radiol 2010 May;7(5):360-3

Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA.

Objective: The ACR has developed appropriateness criteria to ensure that patients are receiving appropriate imaging studies. The purpose of this study was to compare the imaging ordering practices of pediatric residents in specific clinical scenarios with the ACR Appropriateness Criteria.

Materials And Methods: A multiple-choice questionnaire was created using 10 clinical scenarios excerpted from the ACR Appropriateness Criteria. The questionnaire was sent to 69 pediatric residents (postgraduate years 1-3) at Children's Hospital of New York at Columbia University Medical Center (CHONY) and then to 75 pediatric residents at The Children's Hospital at Montefiore Medical Center (CHAM). The responses were compared with the ACR Appropriateness Criteria.

Results: Seventy-five and 69 pediatric residents from the CHAM and CHONY, respectively, were invited to participate in the survey. Thirty-nine individual responses (52%) were received from CHAM, and 41 (59%) were received from CHONY. A total of 27 responses were received from first-year residents, 28 from second-year residents, and 25 from third-year residents. The average number of questions answered incorrectly by first-year residents was 4.1, by second-year residents was 4.4, and by third-year residents was 4.5.

Conclusions: This study demonstrates that residents appreciate the value of an imaging workup, but these examinations are often ordered without the consultation of a radiologist. The decision each resident makes reflects individual training. To improve residents' ability to make decisions regarding imaging examinations, radiologists must educate pediatric residents with uniform case-based and didactic sessions.
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http://dx.doi.org/10.1016/j.jacr.2009.12.017DOI Listing
May 2010

Comparison of ultrasound and CT in the evaluation of pneumonia complicated by parapneumonic effusion in children.

AJR Am J Roentgenol 2009 Dec;193(6):1648-54

Department of Radiology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10467, USA.

Objective: The purpose of our study was to compare chest ultrasound and chest CT in children with complicated pneumonia and parapneumonic effusion.

Materials And Methods: We retrospectively compared chest ultrasound and chest CT in 19 children (nine girls and 10 boys; age range, 8 months-17 years) admitted with complicated pneumonia and parapneumonic effusion between December 2006 and January 2009. Images were evaluated for effusion, loculation, fibrin strands, parenchymal consolidation, necrosis, and abscess. In the subset of patients who underwent surgical management, imaging findings were correlated with operative findings.

Results: Eighteen of 19 patients had an effusion on both chest ultrasound and chest CT. The findings of effusion loculation as well as parenchymal consolidation and necrosis or abscess were similar between the two techniques. Chest ultrasound was better able to visualize fibrin strands within the effusions. Of the 14 patients who underwent video-assisted thoracoscopy, five had surgically proven parenchymal abscess or necrosis. Preoperatively, chest ultrasound was able to show parenchymal abscess or necrosis in four patients, whereas chest CT was able to show parenchymal abscess or necrosis in three.

Conclusion: In our series, chest ultrasound and chest CT were similar in their ability to detect loculated effusion and lung necrosis or abscess resulting from complicated pneumonia. Chest CT did not provide any additional clinically useful information that was not also seen on chest ultrasound. We suggest that the imaging workup of complicated pediatric pneumonia include chest radiography and chest ultrasound, reserving chest CT for cases in which the chest ultrasound is technically limited or discrepant with the clinical findings.
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http://dx.doi.org/10.2214/AJR.09.2791DOI Listing
December 2009

MRI assessment of bronchial compression in absent pulmonary valve syndrome and review of the syndrome.

Pediatr Radiol 2006 Jan 9;36(1):71-5. Epub 2005 Nov 9.

Department of Radiology, Children's Hospital of New York, 3959 Broadway CHN-3, New York, NY 10032, USA.

Absent pulmonary valve syndrome (APVS) is a rare cardiac malformation with massive pulmonary insufficiency that presents with short-term and long-term respiratory problems secondary to severe bronchial compression from enlarged central and hilar pulmonary arteries. Association with chromosome 22.Q11 deletions and DiGeorge syndrome is common. This historical review illustrates the airway disease with emphasis on assessment of the bronchial compression in patients with persistent respiratory difficulties post-valvular repair. Cases that had MRI for cardiac assessment are used to illustrate the pattern of airway disease.
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http://dx.doi.org/10.1007/s00247-005-0018-9DOI Listing
January 2006

Online radiology appropriateness survey: results and conclusions from an academic internal medicine residency.

Acad Radiol 2003 Jul;10(7):781-5

Department of Radiology, Columbia Presbyterian Medical Center, 180 Fort Washington Ave, Radiology Library, HP 3-305, New York, NY 10032, USA.

Rationale And Objectives: This study was performed to evaluate the ability of medical trainees to choose appropriate diagnostic imaging studies for patients with various clinical indications.

Materials And Methods: Twelve clinical scenarios were excerpted from the 2000 edition of the American College of Radiology appropriateness criteria and arranged in multiple-choice question format. Summary answers based on the criteria were written. The questionnaire and answer key were placed online and linked; the answer key was viewable only after all 12 answers were submitted by the trainee. An invitation to participate in the online survey was forwarded to medical house staff.

Results: Sixty-five (43.3%) of 150 potential respondents completed the survey. The results were tabulated for all respondents and separately for each postgraduate-year class. Fewer than 50% of the respondents correctly answered more than half of the 12 questions. The average number of questions answered correctly by 1st-year residents was 7.02; by 2nd-year residents, 7.5; and by 3rd-year residents, 7.9.

Conclusion: Medical house staff are not adequately prepared to choose appropriate imaging examinations for specific indications. Improvements in education could prevent inappropriate use of radiology resources. Imaging centers might want to consider developing online catalogs to assist clinicians in choosing appropriate imaging tests.
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http://dx.doi.org/10.1016/s1076-6332(03)80123-xDOI Listing
July 2003