Marta Hernanz-Schulman

The 'Image Gently' campaign: increasing CT radiation dose awareness through a national education and awareness program

ALARA (As Low As Reasonably Achievable) has been a guiding principle for pediatric radiologists for decades. The Society for Pediatric Radiology (SPR) has long been a leader in promoting safety in radiology practice in children. However, the ALARA principle has taken on new meaning in the past several years as the number of CT scans in children has skyrocketed. For example, it is estimated that since the 1980s when CT was beginning its ascendancy there has been up to an 800% increase. CT scans in children provide great benefit in patient care when used appropriately. However, increased use requires a team approach to ensure that only indicated exams are performed and at the Pediatr Radiol (2008) 38:265–269 DOI 10.1007/s00247-007-0743-3

Implications of Early Sonographic Evaluation of Parapneumonic Effusions in Children With Pneumonia

Objective. To devise a clinically relevant grading system for the sonographic evaluation of parapneumonic effusions, and to evaluate length of hospital stay as a function of treatment approach and sonographic grades. Methods. Chest sonograms of 46 pediatric patients diagnosed with empyemas and admitted to two medical centers in the last 8 years were retrospectively evaluated using a grading system based on the degree of fibrinous organization within the parapneumonic effusions. Hospital charts were reviewed to determine the method of treatment and length of hospital stay. Patients were divided into two treatment groups: nonoperative (n = 26) (antibiotics alone, or combined with thoracentesis, or tube thoracostomy) and operative (n = 20) (open decortication, or video thoracoscopy and pleural debridement). Patients in the nonoperative group were further subdivided into two groups: those who received antibiotics alone (n = 11) and those who received antibiotics plus nonoperative drainage thoracentesis and/or tube thoracostomy (n = 15). Within each treatment group, patients were subdivided into two ultrasound grades: low (no evidence of organization) and high (evidence of organization such as fronds, septations, or loculations). Studentst test was performed to compare the lengths of hospital stay for each of the treatment groups and ultrasound grades. Results. The length of hospitalization was no different for patients with low-grade ultrasounds in the nonoperative (9.8 days) and operative groups (8.0 days). In contrast, length of hospitalization was significantly shorter for patients with high-grade sonograms in the operative group (8.6 days), when compared with the nonoperative group (16.4 days). Length of hospitalization for patients in the nonoperative group with high-grade sonograms was significantly longer (16.4 days) than for those with low-grade ultrasounds (9.8 days). Furthermore, when the nonoperative patients were divided into an antibiotics alone group and a nonoperative drainage group, the patients with low-grade sonograms had no difference in the length of hospitalization (9.0 days vs. 10.4 days), whereas those patients with high-grade sonograms in the nonoperative drainage group had a significantly longer hospitalization (19.9 days) than the antibiotics alone (high-grade) group (11.4 days). Conclusions. Patients with a low-grade sonogram had similar length of hospitalization if treated with either nonoperative or operative measures. Patients with high-grade sonograms had significantly shorter length of hospitalization when treated with decortication. Our retrospective study suggests that patients with high-grade ultrasound studies treated nonoperatively do not benefit from pleural drainage procedures or chest tube placement. This study demonstrates the usefulness of early sonographic evaluation of parapneumonic effusions. A prospective study evaluating the usefulness of sonographic assessment of severity of disease in the treatment of children with parapneumonic effusions is warranted on the basis of our retrospective data.

Reduced Hindbrain Herniation after Intrauterine Myelomeningocele Repair: A Report of Four Cases

Background: It has been theorized that fetal myelomeningocele repair may reduce ongoing intrauterine injury and perhaps allow healing and regeneration of dysplastic neural tissue. We report on the postnatal imaging studies of the first 4 patients to have undergone intrauterine myelomeningocele repair at our institution. Methods: Each of the 4 patients underwent postnatal sonographic and MRI. In addition, the postnatal ultrasounds of these 4 were compared to a group of retrospective controls. Results: MRI scans of the 4 experimental subjects revealed no evidence of hindbrain herniation while other stigmata of the Chiari-II malformation persisted. In comparison to the retrospective controls this absence of herniation was distinctly unusual. Conclusion: Intrauterine myelomeningocele repair may reduce the degree of hindbrain herniation normally seen in patients with myelomeningocele. This raises the possibility that intrauterine repair may decrease the morbidity associated with the Chiari type-II malformation including brainstem dysfunction, hydrocephalus and syringomyelia.

Use of P-31 magnetic resonance spectroscopy to detect metabolic abnormalities in muscles of patients with fibromyalgia.

OBJECTIVE To investigate the metabolic and functional status of muscles of fibromyalgia (FM) patients, using P-31 magnetic resonance spectroscopy (MRS). METHODS Twelve patients with FM and 11 healthy subjects were studied. Clinical status was assessed by questionnaire. Biochemical status of muscle was evaluated with P-31 MRS by determining concentrations of inorganic phosphate (Pi), phosphocreatine (PCr), ATP, and phosphodiesters during rest and exercise. Functional status was evaluated from the PCr/Pi ratio, phosphorylation potential (PP), and total oxidative capacity (Vmax). RESULTS Patients with FM reported greater difficulty in performing activities of daily living as well as increased pain, fatigue, and weakness compared with controls. MRS measurements showed that patients had significantly lower than normal PCr and ATP levels (P < 0.004) and PCr/Pi ratios (P < 0.04) in the quadriceps muscles during rest. Values for PP and Vmax also were significantly reduced during rest and exercise. CONCLUSION P-31 MRS provides objective evidence for metabolic abnormalities consistent with weakness and fatigue in patients with FM. Noninvasive P-31 MRS may be useful in assessing clinical status and evaluating the effectiveness of treatment regimens in FM.

Effect of Intrauterine Myelomeningocele Repair on Central Nervous System Structure and Function

Background: It has been postulated that intrauterine myelomeningocele repair might improve neurologic outcome in patients with myelomeningocele. A total of 59 such procedures have been performed at Vanderbilt University. Preliminary results suggested that the degree of hindbrain herniation is reduced by intrauterine repair. In an attempt to further quantify the possible benefits of this surgery, a subset of these patients was brought back to Vanderbilt for study. Methods: A group of 26 patients who had undergone intrauterine myelomeningocele repair underwent an extensive evaluation which included manual muscle testing, MR imaging and precise determination of the anatomic level of their lesions as well as multiple other tests. The results of this analysis were compared to those in 2 groups of historical controls. Results: In this group of patients intrauterine myelomeningocele repair substantially reduced the incidence of moderate to severe hindbrain herniation (4 vs. 50%). The incidence of shunt-dependent hydrocephalus was more modestly reduced (58 vs. 92%). The average level of leg function closely matched the average anatomic level of the lesion in both the fetal surgery and control groups. Conclusion: The most dramatic effect of intrauterine repair appears to be on hindbrain herniation. A less dramatic, but significant, reduction in shunt-dependent hydrocephalus is also seen. Prospective patients should be cautioned not to expect improvement in leg function as the result of this surgery. The potential benefits of surgery must be carefully weighed against the potential risks of prematurity.

Intrauterine Myelomeningocele Repair Reverses Preexisting Hindbrain Herniation

Background: It has been reported that intrauterine myelomeningocele repair reduces the amount of hindbrain herniation normally seen in association with the Chiari type II malformation. It is not yet known, however, whether hindbrain herniation is prevented, or whether preexisting herniation is reversed. The following study was designed to elucidate this issue. Methods: A series of 9 patients underwent intraoperative ultrasound examinations immediately prior to intrauterine myelomeningocele repair. These same patients were then evaluated postnatally using ultrasound and/or MRI. The degree of hindbrain herniation before and after repair was compared using a grading system devised by the authors. Results: Eight patients had clear evidence of moderate to severe hindbrain herniation on intraoperative scans while one was mild. In contrast, on postnatal studies 5 of 9 patients had no evidence of hindbrain herniation, while the other 4 had only mild herniation. Conclusion: Intrauterine myelomeningocele repair appears to reverse preexisting hindbrain herniation. It is postulated that continuous flow of cerebrospinal fluid through the neural placode is the force responsible for inducing migration of the cerebellum and brain stem downward through the foramen magnum. By interrupting that flow during gestation, intrauterine myelomeningocele repair enables the cerebellum and brain stem to resume a normal, or nearly normal, configuration.

CT and US in the Diagnosis of Appendicitis: An Argument for CT

Radiation exposure is reduced by judicious and appropriate use of imaging modalities; in our quest to reduce potential stochastic risks, unnecessary surgery and a ruptured appendix are not the most appropriate alternatives.

Vascular rings: a practical approach to imaging diagnosis

Vascular ring is a term given to a combination of vascular and often ligamentous structures that encircle the trachea and esophagus. The diagnosis can be difficult because clinical symptoms can be variable and nonspecific, and because vascular arrangements that result in vascular rings in some patients do not form vascular rings in others. The clinical manifestations comprise a spectrum ranging from no symptoms to feeding difficulties, repeated infections, and life-threatening respiratory compromise. The diagnosis of vascular ring can be made by various imaging modalities. Therefore it is imperative that pediatric radiologists be familiar with the anatomic variants that can result in a symptomatic ring needing surgical repair, their imaging appearance and the appropriate imaging algorithm. The goals of this manuscript are to describe common and uncommon types of vascular rings, to simplify the differential diagnosis, and to outline the imaging options for accurate diagnosis.

Muscle abnormalities in juvenile dermatomyositis patients: P-31 magnetic resonance spectroscopy studies.

OBJECTIVE To characterize metabolic abnormalities in the muscles of children with the juvenile variant of dermatomyositis (JDM) by the use of noninvasive P-31 magnetic resonance spectroscopy (MRS). METHODS Thirteen patients with JDM (ages 4-16 years) were studied. Biochemical status was evaluated with P-31 MRS by determining the concentrations of the high-energy phosphate compounds, ATP and phosphocreatine (PCr), ratios of inorganic phosphate (Pi) to PCr (Pi:PCr ratio), levels of free cytosolic ADP, and phosphorylation potentials (PPs) during rest, exercise, and recovery. RESULTS Significant metabolic abnormalities were observed in the thigh muscles of 10 severely affected patients during rest, 2 graded levels of exercise, and recovery. Mean ATP and PCr levels in the muscles of JDM patients were 35-40% below the normal control values (P < 0.003). These data, along with elevated Pi:PCr ratios, higher ADP levels, and abnormal values for PPs, indicated defective oxidative phosphorylation in the mitochondria of diseased JDM muscles. MRS findings were normal in 2 additional patients who had improved with prednisone treatment and in 1 patient who had no muscle weakness (amyopathic variant of JDM). CONCLUSION JDM patients can be monitored with noninvasive P-31 MRS without sedation. Biochemical defects in energy metabolism are concordant with the weakness and fatigue reported by JDM patients. Quantitative MRS data are useful for evaluating patients and optimizing drug treatment regimens.

Image GentlySM: A National Education and Communication Campaign in Radiology Using the Science of Social Marketing

Communication campaigns are an accepted method for altering societal attitudes, increasing knowledge, and achieving social and behavioral change particularly within public health and the social sciences. The Image Gently(SM) campaign is a national education and awareness campaign in radiology designed to promote the need for and opportunities to decrease radiation to children when CT scans are indicated. In this article, the relatively new science of social marketing is reviewed and the theoretical basis for an effective communication campaign in radiology is discussed. Communication strategies are considered and the type of outcomes that should be measured are reviewed. This methodology has demonstrated that simple, straightforward safety messages on radiation protection targeted to medical professionals throughout the radiology community, utilizing multiple media, can affect awareness potentially leading to change in practice.