Publications by authors named "Ramesh S Iyer"

133 Publications

Is Thyroid Monitoring Warranted in Infants and Young Children After Intravascular Administration of Iodine-Based Contrast Media?

AJR Am J Roentgenol 2022 Jun 22. Epub 2022 Jun 22.

Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115.

On March 30, 2022, the U.S. FDA issued a drug safety communication recommending that infants and young children "through three years of age" undergo monitoring of thyroid function within three weeks of intravascular administration of iodine-based contrast media. This Viewpoint considers the literature that was referenced for this decision and provides an outlook on thyroid monitoring after diagnostic imaging from pediatric radiology and pediatric endocrinology perspectives.
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http://dx.doi.org/10.2214/AJR.22.28007DOI Listing
June 2022

Imaging to intervention: Thoracic outlet syndrome.

Clin Imaging 2022 Jun 8;89:23-36. Epub 2022 Jun 8.

Mallinckrodt Institute of Radiology at Washington University School of Medicine, St. Louis, MO, United States of America. Electronic address:

Thoracic outlet syndrome (TOS) is a clinical disorder resulting from compression of the neurovascular bundle of the lower neck and upper chest. TOS can be categorized into neurogenic, venous, and arterial subtypes which result from anatomical compression of the brachial plexus, subclavian vein, and subclavian artery, respectively. This can lead to neurogenic pain as well as vascular injury with thrombosis and thromboembolism. Interventional and diagnostic radiologists play a critical role in the imaging diagnosis and treatment of vascular TOS. Prompt imaging and endovascular management with surgical collaboration has been shown to provide the most successful and long-lasting clinical outcomes, from vessel patency to symptom relief. In this article, we review the anatomy and clinical presentations of TOS as well as the initial imaging modalities used for diagnosis. Furthermore, we detail the role of the diagnostic and interventional radiologist in the management of TOS, including pre-procedure and endovascular interventions, along with medical and surgical treatments. PRECIS: Diagnostic and Interventional Radiologists play a key role in diagnosis and management of vascular thoracic outlet syndromes and are critical for timely and successful outcomes.
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http://dx.doi.org/10.1016/j.clinimag.2022.06.003DOI Listing
June 2022

Whole-body MRI at initial presentation of pediatric chronic recurrent multifocal osteomyelitis and correlation with clinical assessment.

Pediatr Radiol 2022 Jun 7. Epub 2022 Jun 7.

Pediatric Radiology Department, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way N.E, Seattle, WA, 98105, USA.

Background: Chronic recurrent multifocal osteomyelitis (CRMO) is a diagnosis of exclusion, relying heavily on whole-body magnetic resonance imaging (WB-MRI) for diagnosing and evaluating response to therapy. Information with respect to disease distribution and imaging correlation with clinical disease severity at initial presentation is lacking.

Objective: To retrospectively characterize distribution of disease on WB-MRI and to correlate imaging findings with disease severity at initial rheumatology presentation.

Materials And Methods: Using a modified version of a recently devised imaging-based scoring system, we evaluated disease distribution and correlation between findings on WB-MRI and clinical disease severity in 54 patients presenting for initial evaluation of CRMO. Symptomatic lesion sites were extracted from chart review and physician global assessment was determined by the consensus of two rheumatologists.

Results: Sites of CRMO involvement evident on imaging at initial presentation had a strong predilection for the pelvis and lower extremities. There was significant correlation between the number of lesions detected on WB-MRI and total clinical severity score at initial rheumatology presentation (P<0.01). However, no other imaging parameter correlated with disease severity.

Conclusion: While the overall number of lesions identified on MRI correlates with clinical severity scores at initial imaging, other MR parameters of CRMO lesions may not be reliable indicators of disease severity at initial presentation. Further research is needed to assess whether these parameters are implicated in longitudinal disease severity or overall response to therapy.
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http://dx.doi.org/10.1007/s00247-022-05388-6DOI Listing
June 2022

ACR Appropriateness Criteria® Crohn Disease-Child.

J Am Coll Radiol 2022 05;19(5S):S19-S36

Specialty Chair, Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.

Crohn disease is an inflammatory condition of the gastrointestinal tract with episodes of exacerbation and remission occurring in children, adolescents, and adults. Crohn disease diagnosis and treatment depend upon a combination of clinical, laboratory, endoscopic, histological, and imaging findings. Appropriate use of imaging provides critical information in the settings of diagnosis, assessment of acute symptoms, disease surveillance, and therapy monitoring. Four variants are discussed. The first variant discusses the initial imaging for suspected Crohn disease before established diagnosis. The second variant pertains to appropriateness of imaging modalities during suspected acute exacerbation. The third variant is a substantial discussion of recommendations related to disease surveillance and monitoring of Crohn disease. Finally, panel recommendations and discussion of perianal fistulizing disease imaging completes the document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2022.02.020DOI Listing
May 2022

ACR Appropriateness Criteria® Osteomyelitis or Septic Arthritis-Child (Excluding Axial Skeleton).

J Am Coll Radiol 2022 05;19(5S):S121-S136

Specialty Chair, Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.

Imaging plays an integral role in the evaluation of suspected musculoskeletal infections in children, not only in the accurate identification of infection such as osteomyelitis or septic arthritis, but also in guiding management. Various diagnostic modalities serve different purposes in the assessment of suspected pediatric musculoskeletal infections. The purpose of this document is to provide imaging guidance in the most frequently encountered clinical scenarios in which osteomyelitis and/or septic arthritis are suspected, outside of the axial skeleton. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion.
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http://dx.doi.org/10.1016/j.jacr.2022.02.017DOI Listing
May 2022

Palpable pediatric chest wall masses.

Pediatr Radiol 2022 Mar 22. Epub 2022 Mar 22.

Department of Radiology, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way N.E, Seattle, WA, 98105, USA.

Pediatric chest wall lesions are varied in etiology ranging from normal and benign to aggressive and malignant. When palpable, these lesions can alarm parents and clinicians alike. However, most palpable pediatric chest lesions are benign. Familiarity with the various entities, their incidences, and how to evaluate them with imaging is important for clinicians and radiologists. Here we review the most relevant palpable pediatric chest entities, their expected appearance and the specific clinical issues to aid in diagnosis and appropriate treatment.
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http://dx.doi.org/10.1007/s00247-022-05323-9DOI Listing
March 2022

Increasing Cases of Chronic Nonbacterial Osteomyelitis in Children: A Series of 215 Cases From a Single Tertiary Referral Center.

J Rheumatol 2022 Aug 15;49(8):929-934. Epub 2022 Mar 15.

S. Wong, MD, Y. Zhao, MD, PhD, Seattle Children's Hospital, and Center of Clinical and Translational Research, Seattle Children's Research Institute.

Objective: Chronic nonbacterial osteomyelitis (CNO) is a rare autoinflammatory bone disease that is gaining recognition from clinicians and researchers. We aim to publish data from our cohort of patients with CNO living in the northwestern United States to increase the awareness of specific demographics, characteristics, and presentation of this rare disease.

Methods: A retrospective chart review was performed of our electronic medical records. Patients with complete chart records who met criteria for a diagnosis of CNO from 2005 to 2019 were included. Extracted data including patient demographics, bone biopsy results, and lesion locations on advanced imaging were analyzed. King County census data were used to calculate the annual new case rate within our center.

Results: A total of 215 CNO cases were diagnosed at our large tertiary pediatric hospital. The majority of cases were of White race residing in Washington's most populous county, King County. Most cases were diagnosed in 2016 to 2019, showing a significant increase in the annual case rate from 8 to 23 per million children in King County, though there did not appear to be a seasonal predilection. Biopsy rate decreased from 75% to 52%. One hundred fifty-two (71%) children had family history of autoimmunity. With increasing use of whole-body magnetic resonance imaging (WB-MRI), results showed 68% had multiple lesions.

Conclusion: CNO has been diagnosed at an increased rate in recent years. WB-MRI may assist in identifying other lesions that may be asymptomatic on presentation. Bone biopsy is still required in some children at the time of diagnosis.
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http://dx.doi.org/10.3899/jrheum.210991DOI Listing
August 2022

Pearls and Pitfalls of Thoracic Manifestations of Abuse in Children.

Semin Ultrasound CT MR 2022 Feb 15;43(1):51-60. Epub 2021 May 15.

Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA. Electronic address:

Child abuse is a broad term that includes, but is not limited to, physical or emotional harm, neglect, sexual abuse, and exploitation. In 2018 in the United States, there were nearly 700,000 victims of such maltreatment, of which 1700 children died. The majority of deaths occur in infants and toddlers under 3 years of age. While clinical signs and symptoms may raise suspicion for inflicted injury, such as bruising in young infants, imaging often plays a central role in identifying and characterizing nonaccidental trauma. The purpose of this article is to discuss the array of inflicted traumatic injuries to the thorax in children. Rib fractures are among the most common and telling features of physical abuse, especially in infants. The locations of such fractures and differences in appearance while healing will be presented, along with potential mimics and pitfalls. Less typical fractures seen in abuse will also be reviewed, including those of the sternum, clavicle, spine, and scapula. Finally, uncommon injuries to the lungs, heart and esophagus will also be considered.
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http://dx.doi.org/10.1053/j.sult.2021.05.006DOI Listing
February 2022

Non-inferiority of a non-gadolinium-enhanced magnetic resonance imaging follow-up protocol for isolated optic pathway gliomas.

Pediatr Radiol 2022 Mar 9;52(3):539-548. Epub 2021 Nov 9.

Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.

Background: Pediatric patients with optic pathway gliomas (OPGs) typically undergo a large number of follow-up MRI brain exams with gadolinium-based contrast media (GBCM), which have been associated with gadolinium tissue retention. Therefore, careful consideration of GBCM use in these children is warranted.

Objective: To investigate whether GBCM is necessary for OPG MR imaging response assessment using a blinded, non-inferiority, multi-reader study.

Materials And Methods: We identified children with OPG and either stable disease or change in tumor size on MRI using a regional cancer registry serving the U.S. Pacific Northwest. For each child, the two relevant, consecutive MRI studies were anonymized and standardized into two imaging sets excluding or including GBCM-enhanced images. Exam pairs were compiled from 42 children with isolated OPG (19 with neurofibromatosis type 1), from a population of 106 children with OPG. We included 28 exam pairs in which there was a change in size between exams. Seven pediatric radiologists measured tumor sizes during three blinded sessions, spaced by at least 1 week. The first measuring session excluded GBCM-enhanced sequences; the others did not. The primary endpoint was intra-reader agreement for ≥ 25% change in axial cross-product measurement, using a 12% non-inferiority threshold.

Results: Analysis demonstrated an overall 1.2% difference (95% confidence interval, -3.2% to 5.5%) for intra-reader agreement using a non-GBCM-enhanced protocol and background variability.

Conclusion: A non-GBCM-enhanced protocol was non-inferior to a GBCM-enhanced protocol for assessing change in size of isolated OPGs on follow-up MRI exams.
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http://dx.doi.org/10.1007/s00247-021-05226-1DOI Listing
March 2022

Ultrasound assessment of glenohumeral dysplasia in infants.

Pediatr Radiol 2022 Aug 21;52(9):1648-1657. Epub 2021 Sep 21.

Department of Radiology, Seattle Children's Hospital and University of Washington School of Medicine, 4800 Sandpoint Way NE, MA.7.220, Seattle, WA, 98105, USA.

Brachial plexus birth injury can lead to irreversible neuromuscular dysfunction and skeletal deformity of the upper extremity and shoulder girdle, ultimately resulting in glenohumeral dysplasia. Diagnosis and treatment of affected infants requires a multi-disciplinary approach in which imaging plays a vital role. While MRI is excellent for assessing both the shoulder and spine of these children, it is costly and requires sedation and is thus typically reserved for preoperative planning. US, however, is inexpensive, dynamic and readily available and provides excellent visualization of the largely cartilaginous glenohumeral joint. As such, it has become a highly useful modality during early diagnosis and follow-up of children with brachial plexus birth injuries. In this review, we describe the relevant anatomy of the glenohumeral joint, outlining the normal sonographic appearance as well as providing tips and tricks for identifying and characterizing pathology.
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http://dx.doi.org/10.1007/s00247-021-05180-yDOI Listing
August 2022

Normative Values for the Sonographic Measurement of the Pediatric Median and Ulnar Nerves.

Acad Radiol 2022 03 10;29 Suppl 3:S147-S156. Epub 2021 Sep 10.

Department of Radiology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle Washington.

Rational And Objectives: Ultrasound investigation of peripheral nerves, long used in the adult population, has been shown to be of value in diagnosing a variety of peripheral nerve abnormalities. More recently, nerve sonography has also been shown to be of use in pediatrics. However, normative values for nerve size in children have been lacking. As such, the goal of this research was to establish normative data for cross sectional area (CSA) measurements of the median and ulnar nerves in children.

Materials And Methods: The median and ulnar nerves of 48 children ranging in age from 2 years to 17 years were imaged by ultrasound. CSA measurements were made at 2 separate sites for each nerve and measured independently by 6 pediatric radiologists. Reliability of ultrasound measurements between the radiologists was assessed by calculating intraclass correlation coefficients. Linear mixed-effects modeling was performed to develop prediction models for nerve cross sectional area for each nerve segment; 95% prediction values were generated from these models to approximate normal ranges.

Results: Agreement in nerve cross-sectional area measurements among the 6 radiologists for all nerve segments was good (ICC 0.82, 95% CI 0.78 to 0.85). CSA for both the median and ulnar nerves is larger in older children. However, statistical models to predict CSA using height perform better rather than those using a child's age. The range of normal nerve segment CSA using these prediction models based on child height are reported.

Conclusion: Median and ulnar nerve CSA can be reliably measured with ultrasound. Normal reference values for ulnar and median nerve CSA correlate with patient age but may be more optimally determined based on a child's height.
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http://dx.doi.org/10.1016/j.acra.2021.07.018DOI Listing
March 2022

Uniquely pediatric upper extremity injuries.

Clin Imaging 2021 Dec 27;80:249-261. Epub 2021 Jul 27.

Radiology Department, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA. Electronic address: https://twitter.com/ThapaMD.

The pediatric population is prone to unique upper extremity injuries that are not typically seen in adults. The normal dynamic maturation pattern of ossification centers and open physis can potentially confuse radiologists who are not familiar with the pediatric patients. In this review article, we discuss the normal anatomy and commonly encountered acute and chronic upper extremity injuries such as supracondylar distal humeral fracture and osteochondritis dissecans, in pediatric patients. Diagnosing the correct type of fracture (e.g., buckle vs Salter-Harris) is important for proper management of the injury. With an increasing number of adolescents participating in competitive sports, specific sports related injuries such as little league shoulder, gymnast wrist, and medial epicondyle apophysitis, are also discussed in this review. We examine late complications of injuries, such as physeal bar formation and fishtail deformity of the distal humerus.
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http://dx.doi.org/10.1016/j.clinimag.2021.07.010DOI Listing
December 2021

Time-Driven Cost Analysis of Noncuffed Venous Catheter Placement in Infants: Bedside versus IR Suite.

J Vasc Interv Radiol 2021 10 3;32(10):1479-1487. Epub 2021 Aug 3.

Department of Radiology, Seattle Children's Hospital, Seattle, Washington.

Purpose: To compare the direct bundled costs of interventional radiology (IR) suite versus bedside placement of noncuffed central venous catheters in infants.

Methods: A single-center retrospective review was performed of all noncuffed upper extremity (peripherally inserted central venous catheter [PICC]) and tunneled femoral (tunneled femoral central venous catheter [TCVC]) catheters placed in infants between January 1, 2018, and December 31, 2018. Propensity score matching was performed adjusting for age, birth weight, procedure weight, and catheter days. Process maps for each procedure were created based on location and sedation type. Technical success and complications were recorded for each placement. The total direct bundled cost for each catheter placement was calculated by summing the procedure and complication costs.

Results: A total of 142 procedures were performed on 126 matched patients with a technical success of 96% at the bedside and 100% in the IR suite (P = .08). The complication rates did not significantly differ between the 2 groups (P = .51). The total direct bundled costs for catheter placement were $1421.3 ± 2213.2 at the bedside and $2256.8 ± 3264.7 in the IR suite (P = .001).

Conclusions: The bundled cost of bedside femoral catheter placement is significantly less than that of fluoroscopic TCVC and PICC placement performed in the IR suite, mainly related to differences in sedation costs.
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http://dx.doi.org/10.1016/j.jvir.2021.07.020DOI Listing
October 2021

A Novel Algorithm Using Within-leg Calibration for Enhanced Accuracy of Detection of Arthritis by Infrared Thermal Imaging in Children.

J Rheumatol 2022 01 1;49(1):81-88. Epub 2021 Jul 1.

C.A. Wallace, MD, Pediatric Rheumatology, Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, Washington, USA.

Objective: To standardize and improve the accuracy of detection of arthritis by thermal imaging.

Methods: Children with clinically active arthritis in the knee or ankle, as well as healthy controls, were enrolled to the development cohort; another group of children with knee symptoms was enrolled to the validation cohort. Ultrasound was performed in the arthritis subgroup for the development cohort. Joint exam by certified rheumatologists was used as a reference for the validation cohort. Infrared thermal data were analyzed using custom software. Temperature after within-limb calibration (TAWiC) was defined as the temperature differences between joint and ipsilateral mid-tibia. TAWiC of knees and ankles was evaluated using ANOVA across subgroups. Optimal thresholds were determined by receiver-operating characteristic analysis using Youden index.

Results: There were significant differences in mean and 95th TAWiC of knee in anterior, medial, lateral views, and of ankles in anterior view, between inflamed and uninflamed counterparts ( < 0.05). The area under the curve was higher by 30% when using TAWiC than that when using absolute temperature. Within the validation cohort, the sensitivity of accurate detection of arthritis in the knees using both mean and 95th TAWiC from individual views or all 3 views combined ranged from 0.60 to 0.70, and the specificity was > 0.90 in all views.

Conclusion: Children with active arthritis or tenosynovitis in knees or ankles exhibited higher TAWiC than healthy joints. Our validation cohort study showed promise for the clinical utility of infrared thermal imaging for arthritis detection.
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http://dx.doi.org/10.3899/jrheum.210077DOI Listing
January 2022

Pediatric rib pathologies: clinicoimaging scenarios and approach to diagnosis.

Pediatr Radiol 2021 Sep 12;51(10):1783-1797. Epub 2021 Jun 12.

Radiology Department, Seattle Children's Hospital, University of Washington Medical Center, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.

Pathologies involving the ribs are diverse in nature, including entities specific to the pediatric population as well as shared pathologies with adults. These can be either localized within or adjacent to the rib, but may also cause rib alteration as a component of a systemic process. To better understand these disorders, we discuss several common rib pathologies in the context of their clinical presentation and pertinent imaging findings. In addition, we review the imaging modalities that may be used to evaluate the ribs. Encompassing both the clinical and imaging aspects of pediatric rib pathologies, this review aims to increase pediatric and musculoskeletal radiologists' awareness of the spectrum of disease and how to leverage a pattern-based approach.
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http://dx.doi.org/10.1007/s00247-021-05070-3DOI Listing
September 2021

The current and future roles of artificial intelligence in pediatric radiology.

Pediatr Radiol 2021 May 27. Epub 2021 May 27.

Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, MA.7.220, Seattle, WA, 98105, USA.

Artificial intelligence (AI) is a broad and complicated concept that has begun to affect many areas of medicine, perhaps none so much as radiology. While pediatric radiology has been less affected than other radiology subspecialties, there are some well-developed and some nascent applications within the field. This review focuses on the use of AI within pediatric radiology for image interpretation, with descriptive summaries of the literature to date. We highlight common features that enable successful application of the technology, along with some of the limitations that can inhibit the development of this field. We present some ideas for further research in this area and challenges that must be overcome, with an understanding that technology often advances in unpredictable ways.
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http://dx.doi.org/10.1007/s00247-021-05086-9DOI Listing
May 2021

Gadolinium retention: should pediatric radiologists be concerned, and how to frame conversations with families.

Pediatr Radiol 2022 Feb 12;52(2):345-353. Epub 2021 May 12.

Department of Radiology, Seattle Children's Hospital, M/S MA.7.220, P.O. Box 5731, Seattle, WA, 98145-5005, USA.

Gadolinium retention in the brain and other organs has recently been identified by imaging and confirmed histologically. No direct clinical effects of gadolinium retention, which occurs after gadolinium-based contrast agent (GBCA) administration for MRI, have been scientifically accepted at this time. However, there is understandable concern among medical professionals and the public about the potential effects of gadolinium retention, particularly in the brain. Part of this concern might stem from the identification of nephrogenic systemic fibrosis caused by GBCAs in people with severe renal failure in 2006. This article briefly describes the characteristics of GBCAs; reviews and differentiates gadolinium retention, nephrogenic systemic fibrosis, and "gadolinium deposition disease" or "gadolinium toxicity"; and discusses societal guidelines and current usage in children. With the belief that GBCAs should not be withheld for appropriate indications in the absence of evidence of its potential risks, we offer a framework for determining when GBCA use is appropriate and suggestions for discussing its risks and benefits with children and their families.
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http://dx.doi.org/10.1007/s00247-021-04973-5DOI Listing
February 2022

Employing caution when applying the American College of Radiology Thyroid Imaging Reporting and Data System for pediatric thyroid nodule management.

Pediatr Radiol 2021 07 6;51(8):1290-1293. Epub 2021 May 6.

Department of Pediatric Radiology, Seattle Children's Hospital, Seattle, WA, USA.

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http://dx.doi.org/10.1007/s00247-021-05083-yDOI Listing
July 2021

Artificial intelligence development in pediatric body magnetic resonance imaging: best ideas to adapt from adults.

Pediatr Radiol 2022 Feb 13;52(2):367-373. Epub 2021 Apr 13.

Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.

Emerging manifestations of artificial intelligence (AI) have featured prominently in virtually all industries and facets of our lives. Within the radiology literature, AI has shown great promise in improving and augmenting radiologist workflow. In pediatric imaging, while greatest AI inroads have been made in musculoskeletal radiographs, there are certainly opportunities within thoracoabdominal MRI for AI to add significant value. In this paper, we briefly review non-interpretive and interpretive data science, with emphasis on potential avenues for advancement in pediatric body MRI based on similar work in adults. The discussion focuses on MRI image optimization, abdominal organ segmentation, and osseous lesion detection encountered during body MRI in children.
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http://dx.doi.org/10.1007/s00247-021-05072-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043435PMC
February 2022

Contemporary imaging of the pediatric shoulder: pearls and pitfalls.

Pediatr Radiol 2021 03 5;51(3):338-352. Epub 2021 Feb 5.

Department of Radiology, University of Washington and Seattle Children's Hospital, 4800 Sand Point Way N.E, Seattle, WA, 98105, USA.

In skeletally immature patients, the presence of growth plates and articular cartilage of the shoulder can create a predisposition for unique injuries not observed in adults. Furthermore, increasing participation in sports by children and adolescents appears to be leading to a corresponding increase in the number of sports-related injuries. The importance of radiologists being familiar with pediatric shoulder imaging and its associated injuries is therefore growing. In this article, we review the normal development and maturation pattern of ossification centers of the shoulder from the early gestational period through adolescence. Brachial plexus birth palsy, physeal injuries, shoulder dislocation, and internal impingement are discussed within the context of the child's age and the mechanism of injury to guide radiologists to a correct diagnosis.
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http://dx.doi.org/10.1007/s00247-021-04963-7DOI Listing
March 2021

Pediatric biliary disorders: Multimodality imaging evaluation with clinicopathologic correlation.

Clin Imaging 2021 Jul 21;75:34-45. Epub 2021 Jan 21.

Radiology Department, Seattle Children's Hospital, University of Washington School of Medicine, 98105, United States of America. Electronic address:

The spectrum of pathologies affecting the biliary tree in the pediatric population varies depending on the age of presentation. While in utero insults can result in an array of anatomic variants and congenital anomalies in newborns, diverse acquired biliary pathologies are observed in older children. These acquired pathologies display different presentations and consequences than adults. Multimodality imaging assessment of the pediatric biliary system is requisite to establishing an appropriate management plan. Awareness of the imaging features of the various biliary pathologies and conveying clinically actionable information is essential to facilitate appropriate patient management. In this paper, we will illustrate the anatomy and embryology of the pediatric biliary system. Then, we will provide an overview of the imaging modalities used to assess the biliary system. Finally, we will review the unique features of the pediatric biliary pathologies, complemented by histopathologic correlation and discussions of clinical management.
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http://dx.doi.org/10.1016/j.clinimag.2021.01.006DOI Listing
July 2021

Ultrasound Evaluation of Pediatric Slow-Flow Vascular Malformations: Practical Diagnostic Reporting to Guide Interventional Management.

AJR Am J Roentgenol 2021 02 23;216(2):494-506. Epub 2020 Dec 23.

Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, MA.7.220, Seattle, WA 98105.

This article reviews the ultrasound characteristics of pediatric slow-flow vascular malformations and underscores findings that significantly impact diagnosis and treatment. Key imaging features are discussed including lesion size, malformation location, morphology, and mimics. Ultrasound findings affect the management of slow-flow vascular malformations and should be emphasized in lesion diagnosis. Superficial, focal lesions with well-defined margins are ideal for ultrasound evaluation.
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http://dx.doi.org/10.2214/AJR.20.23338DOI Listing
February 2021

ACR Appropriateness Criteria® Vomiting in Infants.

J Am Coll Radiol 2020 Nov;17(11S):S505-S515

Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana.

Vomiting in infants under the age of 3 months is one of the most common reasons for parents to seek care from their doctor or present to an emergency room. The imaging workup that ensues is dependent on several factors: age at onset, days versus weeks after birth, quality of emesis, bilious or nonbilious vomiting, and the initial findings on plain radiograph, suspected proximal versus distal bowel obstruction. The purpose of these guidelines is to inform the clinician, based on current evidence, what is the next highest yield and most appropriate imaging study to pursue a diagnosis. The goal is rapid and accurate arrival at a plan for treatment, whether surgical or nonsurgical. The following modalities are discussed for each variant of the symptom: plain radiography, fluoroscopic upper gastrointestinal series, fluoroscopic contrast enema, ultrasound of the abdomen, nuclear medicine gastroesophageal reflux scan. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.09.002DOI Listing
November 2020

ACR Appropriateness Criteria® Antenatal Hydronephrosis-Infant.

J Am Coll Radiol 2020 Nov;17(11S):S367-S379

Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana.

Antenatal hydronephrosis is the most frequent urinary tract anomaly detected on prenatal ultrasonography. It occurs approximately twice as often in males as in females. Most antenatal hydronephrosis is transient with little long-term significance, and few children with antenatal hydronephrosis will have significant obstruction, develop symptoms or complications, and require surgery. Some children will be diagnosed with more serious conditions, such as posterior urethral valves. Early detection of obstructive uropathy is necessary to mitigate the potential morbidity from loss of renal function. Imaging is an integral part of screening, diagnosis, and monitoring of children with antenatal hydronephrosis. Optimal timing and appropriate use of imaging can reduce the incidence of late diagnoses and prevent renal scarring and other complications. In general, follow-up neonatal ultrasound is recommended for all cases of antenatal hydronephrosis, while further imaging, including voiding cystourethrography and nuclear scintigraphy, is recommended for moderate or severe cases, or when renal parenchymal or bladder wall abnormalities are suspected. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.09.017DOI Listing
November 2020

Boggy pseudomass sonographic sign for testicular torsion.

Abdom Radiol (NY) 2021 03 28;46(3):1286-1287. Epub 2020 Sep 28.

Radiology Department, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, 98105, USA.

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http://dx.doi.org/10.1007/s00261-020-02784-0DOI Listing
March 2021

Focal nodular hyperplasia masquerading as malignancy in an infant with elevated alpha-fetoprotein: A case report with literature review.

Clin Imaging 2021 Jan 27;69:228-232. Epub 2020 Aug 27.

Radiology Department, Seattle Children's Hospital, University of Washington School of Medicine, United States of America. Electronic address:

We describe a unique case of focal nodular hyperplasia (FNH) in a 6-month-old-girl with elevated alpha-fetoprotein (AFP). Given the patient's age and elevated AFP, a diagnosis of hepatoblastoma was presumed. However, the histopathologic assessment of the lesion was typical for focal nodular hyperplasia. This was further corroborated using hepatobiliary contrast agent to exclude the possibility of a collision or a composite liver tumor.
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http://dx.doi.org/10.1016/j.clinimag.2020.08.026DOI Listing
January 2021

The Many Faces of Pediatric Chronic Recurrent Multifocal Osteomyelitis (CRMO): A Practical Location- and Case-Based Approach to Differentiate CRMO From Its Mimics.

J Magn Reson Imaging 2021 08 25;54(2):391-400. Epub 2020 Aug 25.

Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA.

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disease of childhood and adolescence characterized by episodic bone pain. Diagnosis relies heavily on whole-body MRI and is made by excluding a wide variety of other disorders with overlapping imaging features, depending on location, marrow distribution, and the presence or absence of multifocality. We present an overview of the clinical and imaging features of CRMO and, through various clinical scenarios, provide tips for tailoring the differential diagnosis based on location and distribution of encountered abnormalities. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 3.
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http://dx.doi.org/10.1002/jmri.27299DOI Listing
August 2021

Optimization of Pediatric Body CT Angiography: What Radiologists Need to Know.

AJR Am J Roentgenol 2020 09 22;215(3):726-735. Epub 2020 Jul 22.

Department of Medical Imaging/Radiology, Nemours Children's Health System/Nemours Children's Hospital, 13535 Nemours Pkwy, Orlando, FL 32827.

Pediatric CT angiography (CTA) presents unique challenges compared with adult CTA. Because of the ionizing radiation exposure, CTA should be used judiciously in children. The pearls offered here are observations gleaned from the authors' experience in the use of pediatric CTA. We also present some potential follies to be avoided. Understanding the underlying principles and paying meticulous attention to detail can substantially optimize dose and improve the diagnostic quality of pediatric CTA.
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http://dx.doi.org/10.2214/AJR.19.22273DOI Listing
September 2020

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

Pediatr Radiol 2020 09 17;50(10):1409-1420. Epub 2020 Jul 17.

Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, MA.7.220, Seattle, WA, 98105, USA.

Background: Common cause analysis of hospital safety events that involve radiology can identify opportunities to improve quality of care and patient safety.

Objective: To study the most frequent system failures as well as key activities and processes identified in safety events in an academic children's hospital that underwent root cause analysis and in which radiology was determined to play a contributing role.

Materials And Methods: All safety events involving diagnostic or interventional radiology from April 2013 to November 2018, for which the hospital patient safety department conducted root cause analysis, were retrospectively analyzed. Pareto charts were constructed to identify the most frequent modalities, system failure modes, key processes and key activities.

Results: In 19 safety events, 64 sequential interactions were attributed to the radiology department by the patient safety department. Five of these safety events were secondary to diagnostic errors. Interventional radiology, radiography and diagnostic fluoroscopy accounted for 89.5% of the modalities in these safety events. Culture and process accounted for 55% of the system failure modes. The three most common key processes involved in these sequential interactions were diagnostic (39.1%) and procedural services (25%), followed by coordinating care and services (18.8%). The two most common key activities were interpreting/analyzing (21.9%) and coordinating activities (15.6%).

Conclusion: Proposing and implementing solutions based on the analysis of a single safety event may not be a robust strategy for process improvement. Common cause analyses of safety events allow for a more robust understanding of system failures and have the potential to generate more specific process improvement strategies to prevent the reoccurrence of similar errors. Our analysis demonstrated that the most common system failure modes in safety events attributed to radiology were culture and process. However, the generalizability of these findings is limited given our small sample size. Aligning with other children's hospitals to use standard safety event terminology and shared databases will likely lead to greater clarity on radiology's direct and indirect contributions to patient harm.
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http://dx.doi.org/10.1007/s00247-020-04711-3DOI Listing
September 2020

A primer for pediatric radiologists on infection control in an era of COVID-19.

Pediatr Radiol 2020 08 7;50(9):1191-1204. Epub 2020 Jul 7.

Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, MA.7.220, Seattle, WA, 98105, USA.

Pediatric radiology departments across the globe face unique challenges in the midst of the current COVID-19 pandemic that have not been addressed in professional guidelines. Providing a safe environment for personnel while continuing to deliver optimal care to patients is feasible when abiding by fundamental recommendations. In this article, we review current infection control practices across the multiple pediatric institutions represented on the Society for Pediatric Radiology (SPR) Quality and Safety committee. We discuss the routes of infectious transmission and appropriate transmission-based precautions, in addition to exploring strategies to optimize personal protective equipment (PPE) supplies. This work serves as a summary of current evidence-based recommendations for infection control, and current best practices specific to pediatric radiologists.
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http://dx.doi.org/10.1007/s00247-020-04713-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340753PMC
August 2020
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