Jeanne G. Hill

Lactobezoars: A Patient Series and Literature Review

Lactobezoar is a compact mass of undigested milk concretions located within the gastrointestinal tract. Most often found in infants, they can precipitate gastric outlet obstruction, mimicking a variety of medical and surgical conditions. A common etiology and method of cure have yet to be elucidated. A review of the literature provides some insight into causes, clinical presentations, diagnosis, and management. Data from the Medical University of South Carolina further help dispel the belief that lactobezoars are isolated to pre-term infants on caloric-dense formulas. Findings suggest bezoar formation may be more common than previously thought and a high index of suspicion could help avoid costly evaluations for obstructive symptoms.

Evaluation of a flat panel digital radiographic system for low-dose portable imaging of neonates.

The purpose of this study was to evaluate the clinical utility of an investigational flat-panel digital radiography system for low-dose portable neonatal imaging. Thirty image-pairs from neonatal intensive care unit patients were acquired with a commercial Computed Radiography system (Agfa, ADC 70), and with the investigational system (Varian, Paxscan 2520) at one-quarter of the exposure. The images were evaluated for conspicuity and localization of the endings of ancillary catheters and tubes in two observer performance experiments with three pediatric radiologists and three neonatologists serving as observers. The results indicated no statistically significant difference in diagnostic quality between the images from the investigational system and from CR. Given the investigational systems superior resolution and noise characteristics, observer results suggest that the high detective quantum efficiency of flat-panel digital radiography systems can be utilized to decrease the radiation dose/exposure to neonatal patients, although post-processing of the images remains to be optimized. The rapid availability of flat-panel images in portable imaging was found to be an added advantage for timely clinical decision-making.

Delayed repeat enema in the management of intussusception.

Objective: To describe the demographic and clinical characteristics of children with intussusception and failed initial air enema reduction who were managed by delayed repeat enema attempts and identify predictors associated with successful reduction. Methods: This is a retrospective cross-sectional study of children diagnosed with intussusception who received care at an urban 110-bed childrens hospital. Patients who had failed initial enema reduction attempts under fluoroscopic guidance and had subsequent delayed (≥2 hours from the initial attempt) repeat enemas made up the study population. The primary outcome variable was success of delayed repeat enema reduction. Predictor variables included duration of presenting symptoms (≤1 day vs ≥2 days), gross bloody stools, dehydration, altered mental status, ileus per radiograph, time from initial to delayed repeat enema, and lack of partial reduction to the ileocecal valve with the first attempt. Results: During a 74-month period, 20 patients with 21 intussusception events managed by delayed repeat air enemas were identified. Of the 20 patients, there were 12 boys (60%). Distribution of race was as follows: 9 white (45%), 7 African Americans (35%), and 4 Hispanics (20%). Of the 21 events, the mean (SD) age at the time of intussusception was 14.4 (12.8) months, with a median of 8 months and ranging from 2.5 to 43 months. Of the first 21 attempted delayed repeat enemas, 9 (43%) were successful. Of the 12 unsuccessful attempts, 4 had a second delayed repeat enema attempt and 3 were successful. Overall delayed repeat enemas were successful in 12 patient events (57%). For the total 25 delayed repeat enemas, 12 (48%) were successful. Surgical reduction was performed in 9 patient events (43%). Of these, manual reduction was performed in 7 and surgical incision was performed in 2, with resection of a portion of the distal ileum. There were 19 ileocolic (90%) and 2 ileoileocolic (10%) intussusceptions. There were no pathologic lead points and no patient deaths. In comparing the successful from the failed delayed repeat enema reduction groups, there was no significant difference in demographic characteristics, clinical characteristics, or time from initial enema to first repeat enema. However, there was a trend toward a significant difference regarding the failed group having a greater rate of bloody stools, dehydration, or altered mental status. There was a significant difference for the degree of partial reduction achieved on the initial enema. For the successful delayed repeat enema reduction group, the location of the lead point of the intussusceptum after the initial enema was at the ileocecal valve for 9 patients (90%) versus 3 patients (33%) in the failed group. Although not significantly different, the successful versus failed delayed repeat enema reduction group trended toward significance regarding more patients with clinical improvement after initial enema (82% vs 43%). Conclusions: With the coordinated care of emergency medicine, surgery, and radiology services, delayed repeat enema seems to be an option to consider in the management of clinically stable children who, on initial air enema, have partial reduction. Our study showed that the success rate of delayed repeat enemas was greatest when the intussusceptum was initially reduced to the ileocecal valve.

Congenital lung anomalies in children and adults: current concepts and imaging findings.

This article presents the broad spectrum of congenital lung anomalies, which manifest both in childhood and can be first identified in the adult patient. Each lesion is described in terms of underlying cause, clinical presentation, imaging characteristics with emphasis on advanced cross-sectional imaging, and current treatment options. Up-to-date knowledge of currently available imaging studies and techniques as well as a clear knowledge of imaging characteristics of various congenital lung anomalies are essential for accurate diagnosis and optimal management.

Quality assurance: a comparison study of radiographic exposure for neonatal chest radiographs at 4 academic hospitals

BackgroundLittle is known about exposure differences among hospitals. Large differences might identify outliers using excessive exposure.ObjectiveWe used the newly described exposure index and deviation index to compare the difference in existing radiographic exposures for neonatal portable chest radiographs among four academic children’s hospitals.Materials and methodsFor each hospital we determined the mean exposure index. We also set target exposure indices and then measured the deviation from this target.ResultsThere was not a large difference in exposure index among sites. No site had an exposure index mean that was more than twice or less than half that of any other site. For all four sites combined, 92% of exposures had a deviation index within the range from −3 to +3. Thus exposures at each hospital were consistently within a reasonable narrow spectrum.ConclusionMean exposure index differences are caused by operational differences with mean values that varied by less than 50% among four hospitals. Ninety-two percent of all exposures were between half and double the target exposure. Although only one vendor’s equipment was used, these data establish a practical reference range of exposures for neonatal portable radiographs that can be recommended to other hospitals for neonatal chest radiographs.

The Role of Limited Head Computed Tomography in the Evaluation of Pediatric Ventriculoperitoneal Shunt Malfunction.

Background The evaluation of children with suspected ventriculoperitoneal shunt (VPS) malfunction has evolved into a diagnostic dilemma. This patient population is vulnerable not only to the medical risks of hydrocephalus and surgical complications but also to silent but harmful effects of ionizing radiation secondary to imaging used to evaluate shunt efficacy and patency. The combination of increased medical awareness regarding ionizing radiation and public concern has generated desire to reduce the reliance on head computed tomography (CT) for the evaluation of VPS malfunction. Many centers have started to investigate the utility of low-dose CT scans and alternatives, such as fast magnetic resonance imaging for the investigation of VP shunt malfunction in order to keep radiation exposure as low as reasonably achievable. This pilot study hopes to add to the armamentarium available to the clinician charged with evaluating this challenging patient population by testing the feasibility of a limited CT protocol as an alternative to a full head CT examination. Objective To evaluate the efficacy of a limited head CT protocol compared with a complete head CT for the evaluation of children presenting to the pediatric emergency department with suspected shunt malfunction. Methods We retrospectively reviewed all pediatric patients who received a head CT for suspected VPS malfunction evaluation at a tertiary care childrens hospital from January 2001 through January 2013. Children were included in the pilot study if they had at least 2 CT scans in this study period interpreted by a specific senior attending neuroradiologist. For each patient enrolled, a limited series was generated from the most recent CT scan by selecting four representative axial slices based on the sagittal scout image. These 4 slices where selected at the level of the fourth ventricle, third ventricle, basal ganglia level, and lateral ventricles, respectively. A blinded, senior attending neuroradiologist first reviewed the limited 4-slice CT data set and was asked to determine if the ventricular system had increased, decreased, or remained stable. Subsequently, the neuroradiologist compared their interpretation of the limited examination with the official report from the full CT data set as the standard of reference as well as the interpretation of the most recent prior scan. Results Forty-six patients (age range, 2 months to 18 years; average age, 6.4 years (SD, 4.2), 54% male) were included in the study. Forty-four of 46 (95.7%) limited CT scans matched the official report of the full CT scan. No cases of increased ventricular size were missed (100% positive predictive value for increased ventricular size). The use of a limited head CT (4 axial images) instead of a complete head CT (average of 31 axial images in our studied patients) confers a radiation dose reduction of approximately 87%. Conclusions Our pilot study demonstrates that utilization of limited head CT scan in the evaluation of children with suspected VP shunt malfunction is a feasible strategy for the evaluation of the ventricular size. Further prospective and multidisciplinary studies are needed to evaluate the reliability of limited head CT for the clinical evaluation of VP shunt malfunction.

Pancreatic surgery in children.

Pancreatic surgery in children is a relatively uncommon occurrence, and this unfamiliarity can be associated with significant morbidity and potential mortality. Surgical therapy of pancreatic disorders has been significantly facilitated by endoscopic retrograde cholangiopancreatography, which can now be performed in children with success rates equaling those in adults. This technique delineates pancreatic duct anatomy, which is an essential part of the diagnosis and surgical treatment of important pancreatic disease processes. Pancreatic diseases requiring surgical treatment in children can be placed into three categories: 1) congenital pancreatic ductal anomalies causing pancreatitis, 2) pancreatic trauma, and 3) pancreatic tumors. This article reviews the recent literature on pancreatic surgery in children, particularly highlighting the areas where a consensus of opinion does not exist.

An unusual pediatric case of chronic constipation and rectosigmoid prolapse diagnosed by video defecography

Rectal prolapse is a relatively common, benign condition in the pediatric population. Conservative management usually results in resolution of the problem. Persistent rectal prolapse with chronic constipation suggests more serious underlying pathologic condition that may be challenging to diagnose. We present a case of severe recurrent rectal prolapse with chronic constipation in a 13-year-old boy. Using video defecography, an unusual radiographic modality in children, a functional sigmoid obstruction was observed that was not found on more routine imaging studies. Laparoscopic sigmoidectomy provided an excellent outcome in this patient who previously had a lifestyle-limiting, chronic condition.

Practical Implications for an Effective Radiology Residency Quality Improvement Program for Milestone Assessment

Utilization of a radiology resident-specific quality improvement (QI) program and curriculum based on the Accreditation Council for Graduate Medical Education (ACGME) milestones can enable a programs assessment of the systems-based practice component and prepare residents for QI implementation post graduation. This article outlines the development process, curriculum, QI committee formation, and resident QI project requirements of one institutions designated radiology resident QI program. A method of mapping the curriculum to the ACGME milestones and assessment of resident competence by postgraduate year level is provided. Sample projects, challenges to success, and lessons learned are also described. Survey data of current trainees and alumni about the program reveal that the majority of residents and alumni responders valued the QI curriculum and felt comfortable with principles and understanding of QI. The most highly valued aspect of the program was the utilization of a resident education committee. The majority of alumni responders felt the residency quality curriculum improved understanding of QI, assisted with preparation for the American Board of Radiology examination, and prepared them for QI in their careers. In addition to the survey results, outcomes of resident project completion and resident scholarly activity in QI are evidence of the success of this program. It is hoped that this description of our experiences with a radiology resident QI program, in accordance with the ACGME milestones, may facilitate the development of successful QI programs in other diagnostic radiology residencies.

Addressing Bacterial Surface Contamination in Radiology Work Spaces.

Hospital-acquired and health carerelated infections remain a significant problem throughout nearly all avenues of health care. Infection not only can lead to patient suffering and death but also can result in significant medical costs. One recent study estimated that Americans spend approximately