Publications by authors named "Robert C Orth"

45 Publications

Utility of Computed Tomography Overreading and Abdominal Ultrasound in Children With Suspected Appendicitis and Nondiagnostic Computed Tomography at Community Hospitals.

Pediatr Emerg Care 2020 Dec;36(12):564-570

From the Department of Pediatrics, Baylor College of Medicine, Houston, TX.

Objective: The aim of the study was to examine the ability of overreading of computed tomography (CT) and right lower quadrant ultrasound (RLQ US) to diagnose appendicitis for children with suspected appendicitis with equivocal CTs at community hospitals.

Methods: This was a retrospective chart review of all children transferred to a children's hospital from community emergency departments with suspected appendicitis over 2 years for whom both CT and RLQ US were performed.

Results: One hundred eighty-four children were included with a median age of 10.8 years, and 57.6% were female. Community hospitals documented that CTs were equivocal for appendicitis in 110 (59.8%), positive in 63 (34.2%), and negative in 11 (6.0%). Ninety-seven CTs (88.1%) designated equivocal at community hospitals were later deemed interpretable by pediatric radiologists: 21 (19.1%) as appendicitis and 76 (69.1%) as normal. In 13 children (11.8%), both the community and children's hospital CT interpretations were equivocal. In equivocal cases, RLQ US was consistent with appendicitis in 6 (46.2%), normal in 5 (41.7%), and nondiagnostic in 2. κ value between CT interpretations at community versus children's hospital was 0.13 (95% confidence interval, 0.05-0.22), and κ value between CT interpretation at the children's hospital and RLQ US was 0.59 (95% confidence interval, 0.48-0.70).

Conclusions: Most CTs deemed equivocal for appendicitis at community hospitals were interpretable by pediatric radiologists. In a few children for whom CTs were designated nondiagnostic, RLQ US provided a definitive diagnosis in almost 90% of cases. The first step in evaluation of children with suspected appendicitis for whom outside CTs are deemed equivocal should be to have the study reinterpreted by a pediatric radiologist.
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http://dx.doi.org/10.1097/PEC.0000000000002283DOI Listing
December 2020

Clinical Predictors for Abnormal Renal Bladder Ultrasound in Hospitalized Young Children With a First Febrile Urinary Tract Infection.

Hosp Pediatr 2020 05 17;10(5):392-400. Epub 2020 Apr 17.

Division of Pediatric Emergency Medicine, Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio.

Background: Physicians often obtain a routine renal bladder ultrasound (RBUS) for young children with a first febrile urinary tract infection (UTI). However, few children are diagnosed with serious anatomic anomalies, and opportunity may exist to take a focused approach to ultrasonography. We aimed to identify characteristics of the child, prenatal ultrasound (PNUS), and illness that could be used to predict an abnormal RBUS and measure the impact of RBUS on management.

Methods: We conducted a single-center prospective cohort study of hospitalized children 0 to 24 months of age with a first febrile UTI from October 1, 2016, to December 23, 2018. Independent variables included characteristics of the child, PNUS, and illness. The primary outcome, abnormal RBUS, was defined through consensus of a multidisciplinary team on the severity of ultrasound findings important to identify during a first UTI.

Results: A total of 211 children were included; the median age was 1.0 month (interquartile range 0-2), and 55% were uncircumcised boys. All mothers had a PNUS with 10% being abnormal. was the pathogen in 85% of UTIs, 20% ( = 39 of 197) had bacteremia, and 7% required intensive care. Abnormal RBUS was found in 36% ( = 76 of 211) of children; of these, 47% ( = 36 of 76) had moderately severe findings and 53% ( = 40 of 76) had severe findings. No significant difference in clinical characteristics was seen among children with and without an abnormal RBUS. One child had Foley catheter placement, and 33% received voiding cystourethrograms, 15% antibiotic prophylaxis, and 16% subspecialty referrals.

Conclusions: No clinical predictors were identified to support a focused approach to RBUS examinations. Future studies should investigate the optimal timing for RBUS.
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http://dx.doi.org/10.1542/hpeds.2019-0240DOI Listing
May 2020

Cost Comparison of In-Suite Versus Portable Tunneled Femoral Central Line Placements in Children Using Time-Driven Activity-Based Costing.

J Am Coll Radiol 2020 Apr 2;17(4):462-468. Epub 2019 Dec 2.

Department of Radiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.

Objective: Compare the cost of placing tunneled femoral central lines in the interventional radiology suite to portable bedside placement using time-driven activity-based costing.

Methods: Detailed process maps were created using information generated from interviews with frontline staff, direct shadowing of patient procedures (19 patients-8 in-suite, 11 portable; patient age 4 days to 37 months; 6 males, 13 females), and electronic medical record review (80 patients-44 in-suite, 36 portable; patient age 1 day to 20 months; 42 males, 38 females) who underwent a tunneled femoral central line placement at a tertiary care pediatric hospital from January 1, 2018, to June 30, 2018. Procedures were conducted in-suite using fluoroscopy guidance or portably at the patient's bedside using ultrasound. Capacity cost rates for each resource in the process maps were calculated for personnel, equipment, facilities, and supply costs. Costs for each process step were then calculated by multiplying the capacity cost rate by the mean duration of each step. Stepwise costs were summed for the entire process to generate a cost for each tunneled femoral central line placement pathway.

Results: Total pathway time for tunneled femoral central lines placement in-suite was 123 to 134 min (nonsedated) and 120 to 131 min (sedated) for a cost of $923 to $990 and $1,262 to $1,386, respectively. Total pathway time for tunneled femoral central lines placed portably were 117 to 119 min (nonsedated) and 115 to 147 min (sedated) for a cost of $1,060 to $1,066 and $1,379 to $1,393, respectively.

Conclusion: Total costs of tunneled femoral central lines placed in-suite were similar to total costs for lines placed portably. Cost should not be a primary consideration when deciding upon tunneled femoral central line approach in these patients.
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http://dx.doi.org/10.1016/j.jacr.2019.11.004DOI Listing
April 2020

Physiologic Ovarian Cysts versus Other Ovarian and Adnexal Pathologic Changes in the Preadolescent and Adolescent Population: US and Surgical Follow-up.

Radiology 2019 07 21;292(1):172-178. Epub 2019 May 21.

From the Department of Radiology, Texas Children's Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030 (E.K.S., A.R.M.R., R.C.O.); Department of Surgery, Children's Hospital of Michigan, Detroit, Mich (P.I.A.); Department of Radiology, Geisinger Wyoming Valley Medical Center, Wilkes Barre, Pa (M.C.P.); and Department of Pediatric and Adolescent Gynecology, Texas Children's Hospital, Houston, Tex (J.E.D.).

Background Ovarian and adnexal cysts are frequently encountered at US examinations performed in preadolescent and adolescent patients, yet there are few published studies regarding the outcomes of cysts in this population. Purpose To identify characteristics at US that help to distinguish physiologic ovarian cysts from nonphysiologic entities. Materials and Methods Female patients who underwent pelvic US with or without Doppler from January 2009 through December 2013 were identified by using a centralized imaging database. Patients older than 7 years and younger than 18 years with ovarian or adnexal cysts at least 2.5 cm were included. Demographic characteristics, date of surgery, surgical notes, and pathologic reports were extracted from the electronic medical record. Initial and follow-up dates of US, cyst size and complexity, imaging diagnosis, and change on subsequent US images were recorded. Statistical analysis was performed with the Wilcoxon rank sum and Kruskal-Wallis tests for continuous variables and the Fisher exact test for categorical variables. Results Of 754 patients who met inclusion criteria (age, 8-18 years; mean age, 14.6 years ± 1.9 [standard deviation]; mean cyst size, 5 cm ± 3.3), 409 patients underwent complete follow-up that included resolution at imaging ( = 250) or surgery ( = 159). In the patients with complete imaging follow-up, mean time to US documentation of resolution was 194 days ± 321; 59.6% (149 of 250) patients had nonsimple cyst characteristics. One-hundred fifty-nine patients underwent surgical intervention (mean cyst size, 8.5 cm ± 5.3), and 69.8% (111 of 159) of the cysts had simple characteristics. Of the 159 cysts, 100 (62.8%) were defined in the pathologic report as paratubal cysts. Of 409 patients, no malignancies were encountered in this study population with surgical or imaging resolution. Conclusion No malignancies were encountered in the study population and the majority of cysts resolved at follow-up imaging. Large size, persistence, and separability from the ovary were most helpful for identification of nonphysiologic paratubal cysts. © RSNA, 2019.
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http://dx.doi.org/10.1148/radiol.2019182563DOI Listing
July 2019

Accuracy of surgeon prediction of appendicitis severity in pediatric patients.

J Pediatr Surg 2019 Nov 24;54(11):2274-2278. Epub 2019 Apr 24.

The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030.

Purpose: Clinical prediction of disease severity is important as one considers nonoperative management of simple appendicitis. This study assesses the accuracy of surgeons' prediction of appendicitis severity.

Methods: From February to August 2016, pediatric surgeons at a single institution were asked to predict whether patients had simple or complex appendicitis preoperatively based on clinical data, imaging, and general assessment. Receiver operating characteristic curves were generated to determine area under the curve (AUC) and optimal cutoff points of clinical findings for diagnosing simple appendicitis. Outcomes included sensitivity and specificity of variables to identify simple appendicitis. Predictions were compared to operative findings using χ. A p-value<0.05 was considered statistically significant.

Results: Of 125 cases (median age 9 years [IQR 7-13], 58% male), simple appendicitis was predicted in 77 (62%) and complex appendicitis in 48 (38%). Predictions were accurate in 59 (77%) simple cases and 45 (94%) complex cases. Although surgeon prediction was more accurate than individual imaging or clinical findings and was highly sensitive (95%) for diagnosing simple appendicitis, specificity was only 71%. Lower WBC (<15.5 × 10/μL, AUC 0.61, p = 0.05), afebrile (<100.4 °F, AUC 0.86, p < 0.01), and shorter symptom duration (≤ 1.5 days, AUC 0.71, p < 0.001) were associated with simple appendicitis. Of 18 complex cases (14%) inaccurately predicted as simple, 17 (94%) lacked diffuse tenderness, 15 (83%) were well-appearing, 11 (61%) had ultrasound findings of simple appendicitis, 11 (61%) had ≤2 days of symptoms, and 8 (44%) were afebrile (<100.4 °F).

Conclusion: While surgeon prediction of simple appendicitis is more accurate than ultrasound or clinical data alone, diagnostic accuracy is still limited.

Type Of Study: Prospective survey.

Level Of Evidence: II.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.04.007DOI Listing
November 2019

Cost Comparison of Ultrasound Versus MRI to Diagnose Adolescent Female Patients Presenting with Acute Abdominal/Pelvic Pain Using Time-Driven Activity-Based Costing.

Acad Radiol 2019 12 4;26(12):1618-1624. Epub 2019 May 4.

Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St, Ste 470, Houston, TX 77030.

Rationale And Objectives: To compare the cost of ultrasound (US) versus magnetic resonance imaging (MRI) using time-driven activity-based costing in adolescent female patients with suspected appendicitis.

Materials And Methods: Process maps were created using data from electronic medical record review and patient shadowing for adolescent female patients undergoing US or noncontrast MRI exams of the abdomen and pelvis for suspected appendicitis. Capacity cost rates for all personnel, equipment, facilities, and supplies in each exam pathway were established from institutional accounting data. The cost of each process step was determined by multiplying step-specific capacity cost rates by the mean time required to complete the step. Total pathway costs for US and MRI were computed by summing the costs of all steps through each pathway, and a direct cost comparison was made between the two modalities.

Results: Process maps for US and MRI pathways were generated from 231 and 52 patient encounters, respectively. Patients undergoing US exams followed one of six pathways depending on exam order (abdomen versus pelvis performed first) and whether additional time was needed for bladder filling. Mean total US pathway time was 91 minutes longer than for MRI (US = 166 minutes; MRI = 75 minutes). Total MRI pathway cost was $209.97 compared to a mean US cost of $258.33 (range = $163.21-$293.24).

Conclusion: MRI can be a faster and less costly alternative to US for evaluating suspected appendicitis in adolescent female patients. While precise costs will vary by institution, MRI may be a viable and at times preferable alternative to US in this patient population.
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http://dx.doi.org/10.1016/j.acra.2019.03.023DOI Listing
December 2019

Correction to: Pediatric ileocolic intussusception: new observations and unexpected implications.

Pediatr Radiol 2019 03;49(3):429

Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, USA.

In this article, the fourth author's name is misspelled. The correct spelling, as shown above, should be "Nadia F. Mahmood."
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http://dx.doi.org/10.1007/s00247-019-04343-2DOI Listing
March 2019

Pediatric percutaneous renal biopsies: comparison of complications between real-time ultrasound guidance and pre-procedure ultrasound-aided skin-marking techniques.

Pediatr Radiol 2019 05 14;49(5):626-631. Epub 2018 Dec 14.

Department of Radiology, Texas Children's Hospital, 6701 Fannin St., #470, Houston, TX, 77030, USA.

Background: Percutaneous renal biopsy is a commonly performed procedure that guides decision-making for children with renal disease.

Objective: To compare complications from renal biopsies using real-time ultrasound (US) guidance versus pre-procedure US-aided skin-marking in children.

Materials And Methods: We conducted a priori power analysis using a risk-adjusted model, which indicated we needed a sample size of 643-714 procedures (effect size: 0.8). Then we retrospectively identified consecutive patients who underwent a percutaneous renal biopsy from Jan. 1, 2012, to Dec. 31, 2016. We categorized complications according to the Society of Interventional Radiology (SIR) criteria and compared rates using the Fisher exact test. We analyzed complication predictors using multivariate regression.

Results: The study consisted of 701 percutaneous renal biopsies in 553 patients: 313 used real-time US guidance and 388 used pre-procedure US-aided skin-marking. Among the 254/701 (36%) complications, 56/313 (18%) resulted from real-time US guidance and 198/388 (51%) from pre-procedure US-aided skin-marking (P<0.001). In the US real-time guidance group, 39/56 (70%) complications were SIR A, 8/56 (14%) SIR B, 6/56 (11%) SIR C and 3/56 (5%) SIR D. Among the pre-procedure US-aided skin-marking group, 139/198 (70%) complications were SIR A, 47/198 (24%) SIR B, 11/198 (6%) SIR C and 1/198 (1%) SIR D. Complications between the two groups were significantly different regarding SIR A (P<0.001) and SIR B complications (P<0.001) but not major complications. Multivariate regression demonstrated that complications were higher using US-aided pre-procedure skin-marking (odds ratio [OR]=6.30; 95% confidence interval [CI]=3.86, 10.27) than with US real-time guidance.

Conclusion: Children and young adults who underwent real-time US-guided percutaneous renal biopsies had significantly fewer minor complications, including those requiring follow-up medical care, compared to those who underwent percutaneous renal biopsies with pre-procedure US-aided skin-marking. No difference was detected in the incidence of major complications.
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http://dx.doi.org/10.1007/s00247-018-4321-7DOI Listing
May 2019

Correction to: Comparative safety and efficacy of balloon use in air enema reduction for pediatric intussusception.

Pediatr Radiol 2018 12;48(13):1975

Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.

The original version on this paper contained an error. The names of M. John Hicks and R. Paul Guillerman, though correctly appeared in the published version, are incorrectly displayed in indexing sites.
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http://dx.doi.org/10.1007/s00247-018-4278-6DOI Listing
December 2018

Pediatric ileocolic intussusception: new observations and unexpected implications.

Pediatr Radiol 2019 01 19;49(1):76-81. Epub 2018 Sep 19.

Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, USA.

Background: Ileocolic intussusception occurs when the terminal ileum "telescopes" into the colon. We observed that ileocolic intussusception lengths are similar regardless of location in the colon.

Objective: To examine the uniformity of ileocolic intussusception length and its relationship to colon location, symptom duration and reducibility.

Materials And Methods: We retrospectively reviewed ultrasound-diagnosed pediatric ileocolic intussusceptions initially treated with pneumatic reduction at the Mayo Clinic or Texas Children's Hospital. We recorded demographic, imaging and surgical findings including age, gender, symptom duration, location of the ileocolic intussusception, reducibility with air enema and, if fluoroscopically irreducible, surgical findings.

Results: We identified 119 ileocolic intussusceptions (64% boys), with 81% in the right colon. There was no significant relationship between ileocolic intussusception length and colon location (P=0.15), nor ileocolic intussusception length and symptom duration (P=0.36). Ileocolic intussusceptions were more distal with increasing symptom duration (P=0.016). Successful reductions were unrelated to symptom duration (P=0.84) but were more likely with proximal versus distal locations (P=0.02).

Conclusion: Ileocolic intussusception lengths are relatively uniform regardless of location along the course of the colon where they present. Our findings suggest that most of the apparent distal propagation of ileocolic intussusceptions is not caused by increasing telescoping of small bowel across the ileocecal valve but rather by foreshortening of the right colon. This implies poor cecal fixation and confirms fluoroscopic and surgical observations of cecal displacement from the right lower quadrant with ileocolic intussusceptions. The movement of the leading edge of the ileocolic intussusception during reduction is first due to "relocating" the cecum into the right lower quadrant after which the reduction of small bowel back across the ileocecal valve then occurs.
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http://dx.doi.org/10.1007/s00247-018-4259-9DOI Listing
January 2019

Response to Lenvatinib in Children with Papillary Thyroid Carcinoma.

Thyroid 2018 11 16;28(11):1450-1454. Epub 2018 Oct 16.

1 Department of Pediatrics, Division of Hematology/Oncology, Texas Children's Cancer Center; Division of Endocrinology; Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.

Background: Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy in children and adolescents. Infrequently, children with PTC may present with or develop disease not amenable to surgery or radioactive iodine (RAI), and systemic therapy may be an option. Lenvatinib is an oral tyrosine kinase inhibitor that is approved by the Food and Drug Administration for the treatment of adults with locally recurrent or metastatic, progressive, RAI-refractory well-differentiated thyroid carcinoma. The effect of lenvatinib in children with PTC has not been reported.

Patient Findings: Three children with metastatic PTC not amenable or refractory to RAI who responded to lenvatinib are reported. All of them developed respiratory distress requiring oxygen caused by extensive bilateral metastatic pulmonary disease. The first patient is a 14-year-old female who was initially treated with sorafenib for extensive PTC not amenable to upfront surgery or RAI. She had progressive pulmonary disease after five months, and was subsequently treated with oral lenvatinib (14 mg/m/day). She was weaned to room air after eight weeks. The second patient is a 15-year-old male who was treated with lenvatinib (14 mg/m/day) for iodine non-avid diffuse pulmonary disease after initial total thyroidectomy and cervical lymph node dissection. He was weaned off oxygen in six weeks. The third patient is a five-year-old male who was treated with lenvatinib (14 mg/m/day) for pulmonary disease progression 24 months after treatment with total thyroidectomy, cervical lymph node dissection, and RAI treatment. He was weaned off oxygen one day after starting lenvatinib. Two of the patients required dose adjustments secondary to proteinuria. Otherwise, all patients tolerated lenvatinib well. The first two patients remained clinically stable on lenvatinib 23 months and 11 months after initiation of therapy, respectively, and the third patient transitioned to a tumor-specific targeted therapy after one month.

Summary: Three pediatric patients are reported with metastatic PTC not amenable or refractory to RAI who achieved a response on lenvatinib.

Conclusion: Lenvatinib therapy is well tolerated and demonstrated clinical activity in children with advanced PTC. Lenvatinib should be considered in children with PTC that is refractory or not amenable to conventional management.
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http://dx.doi.org/10.1089/thy.2018.0064DOI Listing
November 2018

Unfounded conclusions of equivalence in diagnostic accuracy studies: a pervasive fallacy of inference in pediatric radiology scientific abstracts.

Pediatr Radiol 2018 12 13;48(13):1861-1866. Epub 2018 Aug 13.

Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston, TX, USA.

Background: In studies of diagnostic performance that fail to detect a statistically significant difference between compared techniques, investigators often declare evidence of equivalence or similarity without having actually tested that assertion due to incorrect methodology or insufficient statistical power.

Objective: The purpose of our investigation is to measure the prevalence of unfounded assertions of equivalence or similarity in comparison studies presented at the International Pediatric Radiology (IPR) meeting of 2016 and promote awareness of this fallacy of inference to the pediatric radiology community.

Materials And Methods: Two pediatric radiologists independently reviewed the methodology and reporting quality of the 194 scientific paper abstracts from the 2016 IPR meeting. All comparison studies were identified and those failing to detect a statistically significance difference and making a claim of equivalence or similarity in the results or conclusion were assessed for a description of the study design type, statistical power and sample size estimator calculation.

Results: Of 194 scientific paper abstracts, 112 (58%) were comparison studies. Of these, 36/112 (32%) made unfounded inferences of equivalence or similarity in diagnostic imaging performance. No study had an equivalence or non-inferiority design. No abstract specified the statistical power of the study, and only one abstract acknowledged a small sample size as a limitation in detecting a statistically significant difference.

Conclusion: Inadequate reporting and unfounded inferences of equivalence or similarity were common in diagnostic performance comparison studies presented at IPR 2016. Failure to recognize these limitations could have adverse consequences by leading to the adoption of unvalidated imaging techniques.
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http://dx.doi.org/10.1007/s00247-018-4222-9DOI Listing
December 2018

Modified Friedman technique: a new proposed method of measuring glenoid version in the setting of glenohumeral dysplasia.

Pediatr Radiol 2018 11 5;48(12):1779-1785. Epub 2018 Jul 5.

Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA.

Background: Glenoid version angles are measured to objectively follow changes related to glenohumeral dysplasia in the setting of brachial plexus birth palsy. Measuring glenoid version on cross-sectional imaging was initially described by Friedman et al. in 1992. Recent literature for non-dysplastic shoulders advocates time-consuming reconstructions and reformations for an accurate assessment of glenoid version.

Objective: To compare Friedman's original method for measuring glenoid version to a novel technique we developed ("modified Friedman") with the reference standard of true axial reformations.

Materials And Methods: With institutional review board approval, we retrospectively examined 30 normal and dysplastic shoulders obtained from magnetic resonance imaging examinations of 30 patients with an established diagnosis of brachial plexus birth palsy between January 2012 and September 2017. Four pediatric radiologists performed glenoid version measurements using Friedman's method, the modified Friedman method and a previously described true axial reformation method. The modified Friedman technique better accounts for scapular positioning by selecting a reference point related to the acromion-scapular body interface. Inter-rater reliability and inter-method agreement were assessed using intraclass correlation, paired t-tests and mixed linear model analysis. Equivalence tests between methods were performed per reader.

Results: Glenoid version measurements were significantly different when comparing Friedman's method to true axial reformations in normal (-10.8±5.7° [mean±standard deviation] vs. -8.8±5.3°; P≤0.001) and dysplastic shoulders (-34.6±17.7° vs. -28.1±17.5°; P≤0.001). Glenoid version measurements were not significantly different when comparing the modified Friedman's method to true axial reformations in normal (-6.3±5.8° vs. -8.8±5.3°; P=0.06) and dysplastic shoulders (-29.0±18.3° vs. -28.1±17.5°; P=0.06). Friedman's method was not equivalent to true axial reformations for measurements in dysplastic shoulders for all readers (P=0.68, 0.81, 0.86, 0.99); the modified Friedman method was equivalent to of true axial reformations for measurements in dysplastic shoulders for 3 of 4 readers (P≤0.001, P≤0.001, P≤0.001, P=0.10).

Conclusion: In glenohumeral dysplasia, the modified Friedman method and post-processed true axial reformations provide statistically similar and reproducible values. We propose that our modified Friedman technique can be performed in lieu of post-processed true axial reformations to generate glenoid version measurements.
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http://dx.doi.org/10.1007/s00247-018-4196-7DOI Listing
November 2018

How Long Does it Take to Diagnose Appendicitis? Time Point Process Mapping in the Emergency Department.

Pediatr Emerg Care 2018 Jun;34(6):381-384

Department of Pediatrics, Baylor College of Medicine, Houston, TX.

Objectives: Appendicitis is the most common surgical emergency encountered in the pediatric emergency department (ED). We analyzed the time course of children evaluated for suspected appendicitis in relation to implementation of a risk-stratified ultrasound scoring system and structured reporting template (Appy-Score).

Methods: In July 2013, a 6-level ultrasound (US)-based appendicitis scoring system was developed and implemented. The records of children (age ≤18 years) who underwent limited abdominal US exams for suspected appendicitis at a large academic pediatric ED were reviewed retrospectively. Time periods evaluated were from January 1 to April 1, 2013 (before implementation of the US scoring system, "PRE") and July 1 to October 1, 2013 (after implementation of the US scoring system, "POST"). Times are presented as medians with interquartile range.

Results: A total of 926 children were included (median age, 9.5 years [range, 0.1-18 years]; 49% female). Four hundred eighty-one patients were evaluated PRE and 445 POST. When comparing the 2 groups, there were no differences in the PRE and POST periods with regard to time from US ordered to first read (102 vs 112 minutes, P = 0.30), US ordered to disposition (215 vs 208 minutes, P = 0.40) and operating room posting (121 vs 122 minutes, P = 0.59), and overall ED stay (329 vs 333 minutes, P = 0.39).

Conclusions: The development of a radiographic appendicitis score, although allowing for a standardized reporting method, did not significantly alter the ED process flow for evaluation of appendicitis. This reflects the complexities in ED throughput and reveals the need for additional factors to change to improve patient flow.
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http://dx.doi.org/10.1097/PEC.0000000000000720DOI Listing
June 2018

Comparative safety and efficacy of balloon use in air enema reduction for pediatric intussusception.

Pediatr Radiol 2018 09 24;48(10):1423-1431. Epub 2018 May 24.

Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.

Background: Intussusception, a common cause of bowel obstruction in young children, is primarily treated with air enema reduction. There is little literature comparing the safety and efficacy of air reduction without or with a rectal balloon.

Objective: To determine the safety and efficacy of a rectal balloon seal in air enema reduction.

Materials And Methods: We retrospectively reviewed the records of children who underwent air reduction for ileocolic or ileo-ileocolic intussusception over an 8-year period. We sorted data from 566 children according to whether a rectal balloon was used in the reduction, and further sorted them by type and experience level of the practitioner. Using logistic regression analyses, we identified risk factors for iatrogenic bowel perforation or failed reduction.

Results: Significant associations with bowel perforation included balloon use (P=0.038), age <1 year (P<0.0001), and attending physician's level of experience <5 years (P=0.043). Younger age was associated with both perforation (P<0.0001) and procedural failure (P=0.001). The risk-adjusted predicted probability of perforation decreased with age, approaching zero by 10 months regardless of balloon use. For cases without bowel resection, the risk-adjusted predicted probability of failure decreased toward zero by 30 months with balloon use, while remaining constant at 3-12% regardless of age when not using a balloon.

Conclusion: The likelihood of a successful air reduction might be safely increased by using an inflated rectal balloon in children older than 9 months. Use of a balloon in younger infants is associated with a higher risk of iatrogenic bowel injury.
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http://dx.doi.org/10.1007/s00247-018-4156-2DOI Listing
September 2018

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

J Am Coll Radiol 2018 Dec 2;15(12):1717-1722. Epub 2018 Feb 2.

EB Singleton Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.

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

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

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

Conclusions: Radiography is an important triage tool at pediatric urgent care centers. It is imperative to have optimal radiographic imaging for accurate diagnosis, and imaging quality is improved when radiology technologists are available. If not feasible or cost prohibitive, it is important that physicians be given training opportunities to bridge the quality gap when using radiographic equipment and exposing children to radiation.
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http://dx.doi.org/10.1016/j.jacr.2017.12.018DOI Listing
December 2018

Diagnostic Performance of Ultrasonography for Pediatric Appendicitis: A Night and Day Difference?

Acad Radiol 2017 12 18;24(12):1616-1620. Epub 2017 Aug 18.

Baylor College of Medicine, Department of Pediatric Radiology, Texas Children's Hospital, Texas Medical Center (Clinical Care Tower, 470), 6701 Fannin Street, Houston, TX 77030.

Rationale And Objectives: For imaging pediatric appendicitis, ultrasonography (US) is preferred because of its lack of ionizing radiation, but is limited by operator dependence. This study investigates the US diagnostic performance during night shifts covered by radiology trainees compared to day shifts covered by attending radiologists.

Materials And Methods: Appy-Scores (1 = completely visualized normal appendix; 2 = partially visualized normal appendix; 3 = nonvisualized appendix with no inflammatory changes in the expected region of the appendix; 4 = equivocal; 5a = nonperforated appendicitis; 5b = perforated appendicitis) from 2935 US examinations (2161:774, day-to-night) from July 2013 to 2014 were correlated with the intraoperative diagnoses and the clinical follow-up. The diagnostic performance of trainees and attendings was compared with Fisher exact test. Interobserver agreement was measured by Cohen kappa coefficient.

Results: Appendicitis prevalence was 25.3% (day) and 22.5% (night). Sensitivity, specificity, accuracy, negative predictive value, and positive predictive vale were 94.0%, 93.7%, 93.8%, 97.9%, and 83.4% during the day and 92.0%, 91.2%, 91.3%, 97.5%, and 75.2% at night. Specificity (P = .048) and positive predictive value (P = .011) differed, with more false positives at night (7%) than during the day (4.7%). Trainee and attending agreement was high (k = 0.995), with Appy-Scores of 1, 4, and 5a most frequently discordant.

Conclusions: US has a high diagnostic performance and interobserver agreement for pediatric appendicitis when interpreted by radiology trainees during night shifts or attending radiologists during day shifts. However, lower specificity and positive predictive value at night warrants a thorough trainee education to avoid false-positive examinations.
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http://dx.doi.org/10.1016/j.acra.2017.06.007DOI Listing
December 2017

Diagnostic Performance of US for Differentiating Perforated from Nonperforated Pediatric Appendicitis: A Prospective Cohort Study.

Radiology 2017 03 31;282(3):835-841. Epub 2016 Oct 31.

From the Division of Pediatric Surgery (J.L.C., M.E.L.), Department of Pediatric Radiology (R.C.O., K.L.M., R.P.G.), and Surgical Outcomes Center (W.Z.), Texas Children's Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030; and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex (J.L.C., M.E.L.).

Purpose To prospectively evaluate the diagnostic performance of ultrasonography (US) for differentiating perforated from nonperforated pediatric appendicitis and to investigate the association between specific US findings and perforation. Materials and Methods This HIPAA-compliant study had institutional review board approval, and the need for informed consent was waived. All abdominal US studies performed for suspected pediatric appendicitis at one institution from July 1, 2013, to July 9, 2014, were examined prospectively. US studies were reported by using a risk-stratified scoring system (where a score of 1 indicated a normal appendix; a score of 2, an incompletely visualized normal appendix; a score of 3, a nonvisualized appendix; a score of 4, equivocal; a score of 5a, nonperforated appendicitis; and a score of 5b, perforated appendicitis). The diagnostic performance of US studies designated 5a and 5b was calculated. The following US findings were correlated with perforation at multivariate analysis: maximum appendiceal diameter, wall thickness, loss of mural stratification, hyperemia, periappendiceal fat inflammation, periappendiceal fluid, lumen contents, and appendicolith presence. The number of symptomatic days prior to presentation was recorded. Surgical diagnosis and clinical follow-up served as reference standards. Results A total of 577 patients with a diagnosis of appendicitis at US met the study criteria (468 with a score of 5a; 109 with a score of 5b). Appendicitis was correctly identified in 573 (99.3%) of 577 patients. US performance in the detection of perforated appendicitis (5b) was as follows: a sensitivity of 44.0% (80 of 182), a specificity of 93.1% (364 of 391), a positive predictive value of 74.8% (80 of 107), and a negative predictive value of 78.1% (364 of 466). Statistically significant associations with perforated appendicitis were longer duration of symptoms (odds ratio [OR] = 1.46, P < .0001), increased maximum diameter (OR = 1.29, P < .0001), simple periappendiceal fluid (OR = 2.08, P = .002), complex periappendiceal fluid (OR = 18.5, P < .0001), fluid-filled lumen (OR = 0.34, P = .002), and appendicolith (OR = 1.67, P = .02). Conclusion US is highly specific but nonsensitive for perforated pediatric appendicitis. Several US findings are significantly associated with perforation, especially the presence of complex periappendiceal fluid. RSNA, 2016.
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http://dx.doi.org/10.1148/radiol.2016160175DOI Listing
March 2017

Searching for certainty: findings predictive of appendicitis in equivocal ultrasound exams.

Pediatr Radiol 2016 Oct 9;46(11):1539-45. Epub 2016 Jun 9.

Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.

Background: Ultrasound (US) is the preferred imaging modality for evaluating suspected pediatric appendicitis. However, borderline appendiceal enlargement or questionable inflammatory changes can confound interpretation and lead to equivocal exams.

Objective: The purpose of this study was to determine which findings on equivocal US exams are most predictive of appendicitis.

Materials And Methods: All US exams performed for suspected pediatric appendicitis from July 1, 2013, through July 9, 2014, were initially interpreted using a risk-stratified scoring system. Two blinded pediatric radiologists independently reviewed US exams designated as equivocal and recorded the following findings: increased wall thickness, loss of mural stratification, peri-appendiceal fat inflammation, peri-appendiceal fluid, appendicolith and maximum appendiceal diameter. A third pediatric radiologist resolved discrepancies. US features were correlated with the final diagnosis via multivariate analysis.

Results: During the study period, 162/3,750 (4.3%) children had US exams initially interpreted as equivocal (mean age 9.8 +/- 3.8 years). Five outpatients were lost to follow-up. Forty-eight of the remaining 157 (30.6%) children had an operative diagnosis of appendicitis. Findings significantly associated with appendicitis were loss of mural stratification (odds ratio [OR] = 6.7, P=0.035), peri-appendiceal fat inflammation (OR = 10.0, P<0.0001) and appendicolith (OR = 15.8, P=0.025). While appendiceal diameter tended to be larger in patients with appendicitis, the difference was not statistically significant.

Conclusion: Loss of mural stratification, peri-appendiceal fat inflammation and an appendicolith are significant predictors of appendicitis in children with otherwise equivocal US exams. While maximum appendiceal diameter is not statistically associated with appendicitis in our study, mean appendiceal diameter of 6.7 mm in those without appendicitis suggests that the customary upper normal limit of 6 mm is too sensitive.
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http://dx.doi.org/10.1007/s00247-016-3645-4DOI Listing
October 2016

Renal Ultrasound for Infants Younger Than 2 Months With a Febrile Urinary Tract Infection.

AJR Am J Roentgenol 2015 Oct;205(4):894-8

2 Department of Pediatric Radiology, Texas Children's Hospital and Baylor College of Medicine, 6701 Fannin St, Ste 470.01, Houston, TX 77030-2399.

Objective: The purpose of this study is to determine the performance of renal ultrasound for detecting vesicoureteral reflux (VUR) and obstructive uropathies in infants younger than 2 months with a febrile urinary tract infection (UTI).

Materials And Methods: We performed a retrospective cohort study of infants younger than 2 months with fever and culture-proven UTI presenting from July 1, 2008, through December 31, 2011, with renal ultrasound and voiding cystourethrogram (VCUG) performed within 30 days of UTI diagnosis. Two pediatric radiologists independently reviewed the renal ultrasound and VCUG findings. Results of the renal ultrasound were deemed abnormal if collecting system dilation, renal size asymmetry, collecting system duplication, urothelial thickening, ureteral dilation, or bladder anomalies were present. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of renal ultrasound were calculated using VCUG as reference standard.

Results: Of the 197 patients included (mean [SD] age, 33 [ 15 ] days; male-to-female ratio, 2:1), 25% (n = 49) had VUR grades I-V, with 16% (n = 31) having VUR grades III-V and 8% (n = 15) having VUR grades IV-V. For grades I-V VUR, sensitivity was 32.7% (95% CI, 20.0-47.5%), specificity was 69.6% (95% CI, 61.5-76.9%), PPV was 26.2% (95% CI, 15.8-39.1%), and NPV was 75.7% (95% CI, 67.6-82.7%). For grades III-V VUR, sensitivity was 51.6% (95% CI, 33.1-69.9%), specificity was 72.9% (95% CI, 65.5-79.5%), PPV was 26.2% (95% CI, 15.8-39.1%), and NPV was 89.0% (95% CI, 82.5-93.7%). For grades IV-V VUR, sensitivity was 86.7% (95% CI, 59.5-98.3%), specificity was 73.6% (95% CI, 66.6-79.9%), PPV was 21.3% (95% CI, 11.9-33.7%), and NPV was 98.5% (95% CI, 94.8-99.8%). No obstructive uropathies were diagnosed by VCUG in patients with normal renal ultrasound findings.

Conclusion: In infants younger than 2 months, a normal renal ultrasound makes the presence of grades IV and V VUR highly unlikely but does not rule out lower grades of VUR.
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http://dx.doi.org/10.2214/AJR.15.14424DOI Listing
October 2015

Development and validation of an ultrasound scoring system for children with suspected acute appendicitis.

Pediatr Radiol 2015 Dec 18;45(13):1945-52. Epub 2015 Aug 18.

Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., MC CC470.01, Houston, TX, 77030, USA.

Background: To facilitate consistent, reliable communication among providers, we developed a scoring system (Appy-Score) for reporting limited right lower quadrant ultrasound (US) exams performed for suspected pediatric appendicitis.

Objective: The purpose of this study was to evaluate implementation of this scoring system and its ability to risk-stratify children with suspected appendicitis.

Materials And Methods: In this HIPAA compliant, Institutional Review Board-approved study, the Appy-Score was applied retrospectively to all limited abdominal US exams ordered for suspected pediatric appendicitis through our emergency department during a 5-month pre-implementation period (Jan 1, 2013, to May 31, 2013), and Appy-Score use was tracked prospectively post-implementation (July 1, 2013, to Sept. 30,2013). Appy-Score strata were: 1 = normal completely visualized appendix; 2 = normal partially visualized appendix; 3 = non-visualized appendix, 4 = equivocal, 5a = non-perforated appendicitis and 5b = perforated appendicitis. Appy-Score use, frequency of appendicitis by Appy-Score stratum, and diagnostic performance measures of US exams were computed using operative and clinical finding as reference standards. Secondary outcome measures included rates of CT imaging following US exams and negative appendectomy rates.

Results: We identified 1,235 patients in the pre-implementation and 686 patients in the post-implementation groups. Appy-Score use increased from 24% (37/155) in July to 89% (226/254) in September (P < 0.001). Appendicitis frequency by Appy-Score stratum post-implementation was: 1 = 0.5%, 2 = 0%, 3 = 9.5%, 4 = 44%, 5a = 92.3%, and 5b = 100%. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 96.3% (287/298), 93.9% (880/937), 83.4% (287/344), and 98.8% (880/891) pre-implementation and 93.0% (200/215), 92.6% (436/471), 85.1% (200/235), and 96.7% (436/451) post-implementation - only NPV was statistically different (P = 0.012). CT imaging after US decreased by 31% between pre- and post-implementation, 8.6% (106/1235) vs. 6.0% (41/686); P = 0.048). Negative appendectomy rates did not change (4.4% vs. 4.1%, P = 0.8).

Conclusion: A scoring system and structured template for reporting US exam results for suspected pediatric appendicitis was successfully adopted by a pediatric radiology department at a large tertiary children's hospital and stratifies risk for children based on their likelihood of appendicitis.
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http://dx.doi.org/10.1007/s00247-015-3443-4DOI Listing
December 2015

Radiographic screening of infants and young children with genetic predisposition for rare malignancies: DICER1 mutations and pleuropulmonary blastoma.

AJR Am J Roentgenol 2015 Apr;204(4):W475-82

1 Department of Pediatric Radiology, Texas Children's Hospital, 1102 Bates Ave, Ste 850, Feigin Center, Houston, TX 77030.

Objective: The purpose of this study was to compare the risks of radiation in screening strategies using chest radiographs and CT to detect a rare cancer in a genetically predisposed population against the risks of undetected disease.

Materials And Methods: A decision analytic model of diagnostic imaging screening strategies was built to predict outcomes and cumulative radiation doses for children with DICER1 mutations screened for pleuropulmonary blastoma. Screening strategies compared were chest radiographs followed by chest CT for a positive radiographic result and CT alone. Screening frequencies ranged from once in 3 years to once every 3 months. BEIR VII (model VII proposed by the Committee on the Biological Effects of Ionizing Radiation) risk tables were used to predict excess cancer mortality for each strategy, and the corresponding loss of life expectancy was calculated using Surveillance Epidemiologic and End Results (SEER) statistics. Loss of life expectancy owing to undetected progressive pleuropulmonary blastoma was estimated on the basis of data from the International Pleuropulmonary Blastoma Registry. Sensitivity analysis was performed for all model parameters.

Results: Loss of life expectancy owing to undetected disease in an unscreened population exceeded that owing to radiation-induced cancer for all screening scenarios investigated. Increases in imaging frequency decreased loss of life expectancy for the combined (chest radiographs and CT) screening strategy but increased that for the CT-only strategy. This was because loss of life expectancy for combined screening is dominated by undetected disease, whereas loss of life expectancy for CT screening is dominated by radiation-induced cancers.

Conclusion: Even for a rare disease such as pleuropulmonary blastoma, radiographic screening of infants and young children with cancer-predisposing mutations may result in improved life expectancy compared with the unscreened population. The benefit of screening will be greater for diseases with a higher screening yield.
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http://dx.doi.org/10.2214/AJR.14.12802DOI Listing
April 2015

Performance of CT examinations in children with suspected acute appendicitis in the community setting: a need for more education.

AJR Am J Roentgenol 2015 Apr;204(4):857-60

1 Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.

Objective: Despite a recent focus on the preferential use of ultrasound over CT for pediatric appendicitis, most children transferred from community hospitals still undergo diagnostic CT scans. The purpose of this study was to evaluate CT techniques performed for children with acute appendicitis at nonpediatric treatment centers.

Materials And Methods: All patients treated for acute appendicitis at our tertiary-care pediatric hospital from July 1, 2011, through June 30, 2012, were identified. Patient demographics, imaging modality used to diagnoses appendicitis (CT or ultrasound), location (home or referral institution), and CT technique parameters were collected. The estimated mean organ radiation dose, number of imaging phases, and use of contrast media were evaluated at home and referral institutions.

Results: During the study period, 1215 patients underwent appendectomies after imaging, with 442 (36.4%) imaged at referral facilities. Most referral patients received a diagnosis by CT (n=384, 87%), compared with 73 of 773 (9.4%) who received a diagnosis by CT at the home institution. The estimated mean (±SD) organ radiation dose was not statistically significantly different between home and referral institutions (13.5±7.3 vs 12.9±6.4 mGy; p=0.58) for single-phase examinations. Of 384 referral patients, 344 had images available for review. In total, 40% (138/344) of patients from referral centers were imaged with suboptimal CT techniques: 50 delayed phase only, 52 dual phase (eight of which were imaged twice in delayed phase), eight triple phase, and 36 without IV contrast agent.

Conclusion: CT parameters and radiation doses from single-phase examinations in children with appendicitis were similar at nonpediatric treatment centers and a tertiary care children's hospital. Future educational outreach should focus on optimizing other technical parameters.
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http://dx.doi.org/10.2214/AJR.14.12750DOI Listing
April 2015

Inferior patellar pole fragmentation in children: just a normal variant?

Pediatr Radiol 2015 Jun 7;45(6):882-7. Epub 2014 Dec 7.

E.B. Singleton Pediatric Radiology, Texas Children's Hospital, 6701 Fannin Street, Suite 470, Houston, TX, 77030-2399, USA.

Background: Fragmentary ossification of the inferior patella is often dismissed as a normal variant in children younger than 10 years of age.

Objective: The purpose of this study was to determine whether fragmentary inferior patellar pole ossification is a normal variant or is associated with symptoms or signs of pathology using MRI and clinical exam findings as reference.

Materials And Methods: A retrospective review was performed on 150 patients ages 5-10 years who underwent 164 knee radiography and MRI exams (45.1% male, mean age: 7.8 years). The presence or absence of inferior patellar pole fragmentation on radiography was correlated with the presence or absence of edema-like signal on MR images. Clinical notes were reviewed for the presence of symptoms or signs referable to the inferior patellar pole. These data were compared with a 1:1 age- and sex-matched control group without inferior pole fragmentation. Statistical analysis was performed using two-tailed t-tests.

Results: Forty of 164 (24.4%) knee radiographs showed fragmentary ossification of the inferior patella. Of these 40 knees, 62.5% (25/40) had edema-like signal of the inferior patellar bone marrow compared with 7.5% (3/40) of controls (P = 0.035). Patients with fragmentary ossification at the inferior patella had a significantly higher incidence of documented focal inferior patellar pain compared with controls (20% vs. 2.5%, P = 0.015).

Conclusion: Inferior patellar pole fragmentation in children 5 to 10 years of age may be associated with localized symptoms and bone marrow edema-like signal and should not be routinely dismissed as a normal variant of ossification.
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June 2015

Comparative effectiveness research in pediatric radiology.

Pediatr Radiol 2014 Aug 25;44(8):940-1. Epub 2014 Jul 25.

Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., MC CC470.01, Houston, TX, 77030-2399, USA,

Comparative effectiveness research is designed to help patients, physicians and policymakers choose the best medical option among alternative diagnostic and interventional strategies. In this commentary, we provide a brief overview of comparative effectiveness research, discuss some of the challenges to applying it in pediatric radiology, and give several reasons behind the continued push for more comparative effectiveness research by governmental and other funding agencies.
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http://dx.doi.org/10.1007/s00247-014-3080-3DOI Listing
August 2014

Overuse of fluoroscopic gastrostomy studies in a children's hospital.

J Surg Res 2014 Aug 9;190(2):598-603. Epub 2014 May 9.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas. Electronic address:

Background: Gastrostomy tubes are often dislodged or exchanged in children. Indications for fluoroscopic examination of gastrostomy location include concern for malposition, dislodgement, leak, or gastric outlet obstruction. We hypothesized that most of the studies obtained at our institution were not ordered for one of the aforementioned indications and do not ultimately affect patient management.

Methods: All fluoroscopic gastrostomy studies performed from January 2011 to December 2012 were reviewed. Transgastric jejunostomy studies were excluded. Patient demographics, indications for the study, elapsed time since placement, imaging findings, and short-term outcomes were recorded. Chi-square analysis was used to evaluate relationships between categorical variables.

Results: During the study period, 337 patients who underwent fluoroscopic gastrostomy studies were identified; median age was 2.5 y (0.05-23.8). Sixty-two percent (208/337) of the studies were ordered in asymptomatic patients to confirm tube placement location after routine exchange or replacement. Symptomatic patients accounted for 38% of the studies. Ordering physicians were primarily nonsurgeons (72%, 242/337). Abnormal findings were observed in 4.8% (16/337) of patients, six (1.7%) of whom required an operative intervention. The 2.9% (6/208) abnormal study rate for asymptomatic patients was significantly lower than the 7.9% (10/129) rate in the patients who were evaluated for symptomatic indications (P = 0.03).

Conclusions: Most of the fluoroscopic gastrostomy studies ordered at a tertiary care center did not appear to alter patient care. Development of a standardized management algorithm based on clinical indications is necessary to decrease the number of extraneous gastrostomy studies.
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http://dx.doi.org/10.1016/j.jss.2014.05.010DOI Listing
August 2014

Prospective comparison of MR imaging and US for the diagnosis of pediatric appendicitis.

Radiology 2014 Jul 17;272(1):233-40. Epub 2014 Mar 17.

From the Edward B. Singleton Department of Pediatric Radiology (R.C.O., R.P.G., P.M., G.S.B.) and Surgical Outcomes Center (W.Z.), Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, MC CC470.01, Houston, TX 77030.

Purpose: To prospectively compare nonenhanced magnetic resonance (MR) imaging and ultrasonography (US) for the diagnosis of pediatric appendicitis.

Materials And Methods: This HIPAA-compliant study was approved by the institutional review board, and written informed consent was obtained from the patient's parent or guardian. Eighty-one patients (34 male, 47 female; mean age, 12.3 years ± 3.5 [standard deviation]; range, 4-17 years) were enrolled in this prospective study. All patients underwent right lower quadrant US and nonenhanced, nonsedated abdominopelvic MR imaging examinations. Two pediatric radiologists blinded to US results independently reviewed the MR images. MR imaging and US findings were designated positive, negative, or equivocal for acute appendicitis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for MR imaging and US and compared by using two-sided McNemar test or the score statistics specified by Leisenring. Kappa statistics were generated to determine intertechnique agreement between MR imaging and US and interobserver agreement between the two primary MR imaging readers.

Results: Thirty (37%) patients had pathologically proved acute appendicitis. When equivocal interpretations were designated positive, sensitivity was 93.3% for MR imaging (95% confidence interval [CI]: 77.9%, 99.2%) and 90.0% for US (95% CI: 73.5%, 97.9%), P > .99; specificity was 98% for MR imaging (95% CI: 89.6%, 100%) and 86.3% for US (95% CI:73.7%, 94.3%), P = .03; PPV was 96.5% for MR imaging (95% CI: 82.2%, 99.9%) and 79.4% for US (95% CI: 62.1%, 91.3%), P = .007; and NPV was 96.2% for MR imaging (95% CI: 86.8%, 99.5%) and 93.6% for US (95% CI: 82.4%, 98.7%), P = .45, with substantial intertechnique (κ = 0.77; 95% CI: 0.63, 0.90) and interobserver (κ = 0.76; 95% CI: 0.61, 0.91) agreement. When equivocal interpretations were designated negative, MR imaging sensitivity, specificity, PPV, and NPV were unchanged. For US, sensitivity was 86.7% (95% CI: 69.3%, 96.2%), P = .5; specificity was 100% (95% CI: 93.0%, 100%), P > .99; PPV was 100% (95% CI: 86.8%, 100%), P = .31; and NPV was 92.7% (95% CI: 82.4%, 98.0%), P = .16, with almost perfect intertechnique (κ = 0.92; 95% CI: 0.83, 1.00) and substantial interobserver (κ = 0.72; 95% CI: 0.58, 0.87) agreement.

Conclusion: Nonenhanced MR imaging demonstrates high diagnostic performance similar to that of US for suspected pediatric appendicitis.
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http://dx.doi.org/10.1148/radiol.14132206DOI Listing
July 2014

Disseminated tuberculosis in 2 children with inflammatory bowel disease receiving infliximab.

Pediatr Infect Dis J 2014 Jul;33(7):779-81

From the *Sections of Infectious Diseases; †Emergency Medicine; and †Gastroenterology and Nutrition, Department of Pediatrics; and §Department of Pediatric Radiology, Baylor College of Medicine, Houston, TX.

Patients with inflammatory bowel disease are predisposed to opportunistic infections. We report 2 cases of disseminated tuberculosis in adolescents receiving a TNF antagonist, infliximab. Both had negative baseline tuberculin skin tests. Multimodal testing using tuberculin skin tests and interferon gamma release assays at the time of inflammatory bowel disease diagnosis and annually may increase the sensitivity of LTBI testing in these high risk children.
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http://dx.doi.org/10.1097/INF.0000000000000286DOI Listing
July 2014