Susan J. Back

Lamina propria and circulating interleukin-6 in newly diagnosed pediatric inflammatory bowel disease patients.

OBJECTIVES:Understanding cytokine production patterns in early mucosal lesions of pediatric patients newly diagnosed with inflammatory bowel disease (IBD) may be critical to understanding IBD pathogenesis. Interleukin-6 (IL-6) has a central role in a multitude of immune system reactions; however, inconsistent lamina propria and serum IL-6 has been reported in IBD patients. Newly diagnosed pediatric IBD patients have not previously been evaluated for lamina propria or serum IL-6.METHODS:Serum and intestinal lamina propria biopsy whole organ culture supernatants were evaluated by ELISA for IL-6 obtained from newly diagnosed IBD patients, before initiation of immunomodulatory therapies.RESULTS:Levels of lamina propria IL-6 demonstrated significant correlation with graded severity of histological inflammation (p < 0.001). Log-transformed serum and organ culture IL-6 levels demonstrated significant correlation (p < 0.0001, R2= 0.6226). Assigning a demarcation level of >400 pg/ml, serum IL-6 concentrations were a superior marker for the presence of microscopic intestinal inflammation than erythrocyte sedimentation rate (ESR), with a sensitivity of 82%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 82%. When evaluating subtypes of IBD, serum IL-6 levels were correlated more significantly with active disease in ulcerative colitis patients (p = 0.01, R2= 0.74) than in Crohns disease patients (p = 0.21, R2= 0.33).CONCLUSIONS:This study outlines graded production of IL-6 in intestinal lamina propria and serum of newly diagnosed pediatric IBD patients, confirming the presence of IL-6 in early IBD patients. In addition, serum IL-6 may be a good predictor of IBD in pediatric patients with suspected or newly diagnosed IBD.

Classification of pediatric urinary tract dilation: the new language

The multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system) was created to unify the language used to describe urinary tract dilation on antenatal and postnatal ultrasound examinations and thereby facilitate communication among providers and improve outcomes research. The background and new classification system are described in this review, with imaging examples.

Contrast-enhanced US Assessment of Focal Liver Lesions in Children.

Ultrasonography (US) is often the first line of imaging for the examination of children suspected of having liver lesions. However, gray-scale US with color Doppler imaging has limitations. The use of US contrast agents has recently been approved by the U.S. Food and Drug Administration (FDA). Compared with other imaging modalities, contrast material-enhanced US (CEUS) enables the assessment of contrast enhancement patterns with a higher temporal resolution and is therefore becoming a valuable alternative imaging technique. CEUS is advantageous owing to its high safety profile; lower cost, compared with the costs of conventional contrast-enhanced computed tomographic and magnetic resonance imaging examinations; reliability; and reproducibility. Furthermore, US examinations obviate the use of sedation, ionizing radiation, and iodinated or gadolinium-based contrast agents. All of these are desirable attributes for an imaging examination for children, the most vulnerable of patients. Focal liver lesions in children are commonly discovered incidentally, and this can pose a dilemma in terms of diagnosis and management. Owing to the FDAs recent approval of the use of a specific US contrast agent for evaluation of focal liver lesions in pediatric patients, CEUS can now be used as a problem-solving tool that complements conventional imaging examinations and aids in the follow-up of lesions. The temporal resolution with CEUS enables US images to readily depict the real-time internal vascularity of a lesion. The characterization of a lesion during different phases of enhancement improves diagnostic confidence and treatment. In this article, the authors review the composition, physiologic properties, and safety profile of CEUS; describe the technique for performing CEUS; and highlight the utility of this examination in the assessment of common focal liver lesions in children. Online supplemental material is available for this article. ©RSNA, 2017.

Ultrasound of congenital and inherited disorders of the pediatric hepatobiliary system, pancreas and spleen

Ultrasound is often the initial imaging examination performed of the solid organs of the pediatric abdomen. The sonographic appearance of the hepatobiliary system, pancreas and spleen changes with growth and development. This article reviews the normal US appearance of these organs in children and illustrates, through case examples, congenital and inherited conditions that affect them.

Ultrasound Tutorials in Under 10 Minutes: Experience and Results.

OBJECTIVE The objective of the present study was to validate the use of web-based tutorials to teach technical skills in pediatric ultrasound. MATERIALS AND METHODS A series of 10 video tutorials, each of which was less than 10 minutes long, was created to improve the education of radiology trainees in terms of their ultrasound technique. Pediatric radiology fellow trainees from our institution in the United States and radiology resident trainees from our partner institution in Ethiopia were invited to participate in the study. Validation of the video tutorials was performed using two learning modules that focused on the renal bladder and the right upper quadrant (RUQ). Pretest and posttest skill and confidence assessments were also conducted. After watching the tutorials, the trainees completed questionnaires that assessed the reach, appeal, and learning effectiveness of the modules. RESULTS Ten fellow trainees and eight resident trainees participated in the study. The fellows were invited to evaluate both the RUQ and the renal bladder learning modules, whereas the residents evaluated the RUQ module only. Before reviewing the RUQ module, the fellows had performed a median of four RUQ ultrasound examinations, whereas the residents had performed a median of 400 RUQ ultrasound examinations. After the trainees viewed the learning module, the median skills test scores of the fellows increased from 20 to 37.5 (highest possible score, 45) (p < 0.01), and those of the residents increased from 38 to 40 (highest possible score, 40) (p = 0.04). With a total possible score of 15, the median confidence score improved from 8 to 11 for fellows (p < 0.01) and from 13.5 to 14.5 for residents (p = 0.04). After the fellows viewed the renal bladder learning module, their median skills test scores increased from 20 to 37.5 (highest possible score, 40) (p < 0.01), and their median confidence score increased from 8.5 to 11 (highest possible score, 15) (p = 0.01). Trainees gave the tutorials positive ratings overall. CONCLUSION Radiology fellow trainees and resident trainees with disparate backgrounds in ultrasound showed significant improvement in their technical skills in pediatric ultrasound and confidence after viewing the tutorials. The web-based design of the tutorials allows integration of international pediatric radiology training communities.

How and how well do pediatric radiology fellows learn ultrasound skills? A national survey.

BackgroundUltrasound (US) comprises a significant portion of pediatric imaging. Technical as well as interpretive skills in US imaging are consequently fundamental in training pediatric radiologists. Unfortunately, formalized technical education regarding US imaging in pediatric fellowships has lagged.ObjectiveWe surveyed pediatric fellows and program directors regarding US scanning education to improve this experience moving forward.Materials and methodsWe conducted an online survey from February 2011 to March 2011 of all United States pediatric radiology body imaging fellows and fellowship program directors. Questions posed to fellows assessed their educational US experiences during their residencies and fellowships. Directors were asked to evaluate US educational opportunities in their programs.ResultsAmong the respondents, 43.9% of fellows undertook on-call US scanning without a sonographer during residency, 23.3% during fellowship; 41.8% of fellows and 58.6% of program directors reported that their fellowship had a dedicated curriculum to facilitate independent US scanning. Both fellows and program directors cited the volume of cases requiring immediate dictation as an obstacle to scanning. Fewer program directors than fellows identified lack of sufficient staffing as an obstacle, but more identified fellow disinterest. Program directors and fellows alike rated independent US scanning as highly important to pediatric radiologists’ future success.ConclusionPediatric radiology fellowship directors and fellows agree that technical US skills are crucial to the practice of pediatric radiology. However, the groups identify different obstacles to training. As US instruction is developing in undergraduate medicine and subspecialists are acquiring point-of-care US skills, pediatric radiology education should address the obstacles to US training and formalize a curriculum at the fellowship level.

Pediatric contrast-enhanced ultrasound in the United States: a survey by the Contrast-Enhanced Ultrasound Task Force of the Society for Pediatric Radiology

BackgroundThe United States Food and Drug Administration (FDA) recently approved an ultrasound (US) contrast agent for intravenous and intravesical administration in children.ObjectiveSurvey the usage, interest in and barriers for contrast-enhanced US among pediatric radiologists.Materials and methodsThe Contrast-Enhanced Ultrasound Task Force of the Society for Pediatric Radiology (SPR) surveyed the membership of the SPR in January 2017 regarding their current use and opinions about contrast-enhanced US in pediatrics.ResultsThe majority (51.1%, 166) of the 325 respondents (26.7% of 1,218) practice in either a university- or academic affiliated group. The most widely used US contrast agent was Lumason® 52.3% (23/44). While lack of expertise and training were reported barriers, all respondents who are not currently using US contrast agents are considering future use.ConclusionInterest in pediatric contrast US is very high. Education and training are needed to support members who plan to adopt contrast US into practice.

Applications of contrast-enhanced ultrasound in the pediatric abdomen

Contrast-enhanced ultrasound (CEUS) is a radiation-free, safe, and in specific clinical settings, highly sensitive imaging modality. Over the recent decades, there is cumulating experience and a large volume of published safety and efficacy data on pediatric CEUS applications. Many of these applications have been directly translated from adults, while others are unique to the pediatric population. The most frequently reported intravenous abdominal applications of CEUS in children are the characterization of focal liver lesions, monitoring of solid abdominal tumor response to treatment, and the evaluation of intra-abdominal parenchymal injuries in selected cases of blunt abdominal trauma. The intravesical CEUS application, namely contrast-enhanced voiding urosonography (ceVUS), is a well-established, pediatric-specific imaging technique entailing the intravesical administration of ultrasound contrast agents for detection and grading of vesicoureteral reflux. In Europe, all pediatric CEUS applications remain off-label. In 2016, the United States Food and Drug Administration (FDA) approved the most commonly used worldwide second-generation ultrasound contrast SonoVue®/Lumason® for pediatric liver and intravesical applications, giving new impetus to pediatric CEUS worldwide.

Emergent ultrasound evaluation of the pediatric female pelvis

Ultrasound is the primary imaging modality of the pediatric female pelvis and is often requested to evaluate girls with pelvic or abdominal pain or abnormal bleeding. The US interpretation can help guide the clinician toward medical or surgical management. Here we discuss the normal US anatomy of the female pelvis and illustrate, through case examples, conditions encountered when performing emergent pelvic US for common and uncommon clinical scenarios.

Role of magnetic resonance urography in pediatric renal fusion anomalies

Renal fusion is on a spectrum of congenital abnormalities that occur due to disruption of the migration process of the embryonic kidneys from the pelvis to the retroperitoneal renal fossae. Clinically, renal fusion anomalies are often found incidentally and associated with increased risk for complications, such as urinary tract obstruction, infection and urolithiasis. These anomalies are most commonly imaged using ultrasound for anatomical definition and less frequently using renal scintigraphy to quantify differential renal function and assess urinary tract drainage. Functional magnetic resonance urography (fMRU) is an advanced imaging technique that combines the excellent soft-tissue contrast of conventional magnetic resonance (MR) images with the quantitative assessment based on contrast medium uptake and excretion kinetics to provide information on renal function and drainage. fMRU has been shown to be clinically useful in evaluating a number of urological conditions. A highly sensitive and radiation-free imaging modality, fMRU can provide detailed morphological and functional information that can facilitate conservative and/or surgical management of children with renal fusion anomalies. This paper reviews the embryological basis of the different types of renal fusion anomalies, their imaging appearances at fMRU, complications associated with fusion anomalies, and the important role of fMRU in diagnosing and managing children with these anomalies.