Children are wired to be risk-takers. With that being said, there may be times in a child’s life when he or she needs diagnostic imaging. This may be due to a fractured leg, a sprained ankle, or a genetic medical condition such as scoliosis. Conventional X-ray imaging can be utilized to help diagnose numerous medical conditions, such as these, in pediatric patients.

However, when it comes to X-rays, limiting radiation exposure is particularly important in pediatric patients as high-dose levels can pose great risks, including increased risks of leukemia, brain, and thyroid cancer. Radiologists need to keep in mind the repeated exposure can result in cumulative dosing and elevated risk. Children are especially vulnerable to radiation exposure given their higher radiation sensitivity as their organs are still in development.

When pediatric patients are referred for X-rays, radiologists should …

• Discuss the rationale for the examination with the patient and/or parent to ensure a clear understanding of the benefits and risks.

• Consider alternate options. Can an alternate exam using less or no radiation be used instead? Does the patient’s medical history include an X-ray scan of the specific area of interest already?

• Use pediatric protocols when medical imaging is needed. This may include lowering dose levels based on patient age and size.

• Purchase equipment that is designed for pediatric patient use or learn how to properly configure equipment for small patients.

Medical device companies, such as Samsung, are actively focused on advancing technologies that aim to lower dose and help ensure patient safety.

Although conventional X-ray imaging produces relatively small radiation levels in comparison to other imaging modalities such as computed tomography (CT) and fluoroscopy, the cumulative radiation from multiple X-ray exams cannot be overlooked. To combat this, a team of Korea-based researchers developed an image processing engine (known as S-Vue™), which offers comparable image quality by utilizing an advanced feature preserving noise reduction algorithm.

The tool has the capability to distinguish between quanta and the noise on a diagnostic image. Quanta can be defined as the patient’s anatomy while noise represents the non-essential captured radiation. This advanced technology could differentiate quanta and noise while maintaining the integrity of anatomy.

What Recent Studies Reveal About X-Ray Radiation Dose Reduction

In a recent study at the University of Texas Health Science Center at Houston, researchers assessed Samsung’s GM85 mobile digital radiography device and evaluated the amount of probable dose reduction in pediatric patients, ranging from one month to 14 years of age, who needed two chest anteroposterior (AP) X-ray exams within three months.

Based on the patients’ conventional-dose X-ray images, low-dose images were generated using the dose simulation method, which recreates exposure parameters based on body depth and body weight. A team of radiologists then evaluated and selected the lowest acceptable dose image per patient. They selected the image where quality appeared to be most equivalent to the conventionally acquired image.

The researchers found that the average radiation dose reduction rate was 47 percent of conventional dose levels.

 They also noted the age-averaged entrance surface dose (ESD) for conventional dose levels was 58.49 ± 34.02 μGy while the low dose level was 30.86 ± 17.00 μGy.

In comparison, the European Commission guidelines noted an average ESD for conventional dose levels at 65.72 ± 10.57 μGy while the low dose level is 34.43 ± 4.89 μGy (based on subjects close to the age of 5).

A team of researchers from the Departments of Pediatrics and Radiology and the Institute of Radiation Medicine at Seoul National University Hospital conducted a 

 to develop a low-dose radiography protocol for neonatal ICU (NICU) use.

 Utilizing two X-ray devices, including Samsung’s GM85 device, in the randomized prospective study, researchers compared three radiographic dosing protocols for 40 neonatal patients who required thorax and abdomen examinations.

Protocol A: 100 percent of the equivalent dose with the conventional protocol. 
Protocol B: 80 percent of the equivalent dose with the conventional protocol. Protocol C: 64 percent of the equivalent dose with the conventional protocol.

Based on image quality and single anatomic quality criteria, researchers found that low-dose protocols B and C were non-inferior to the conventional protocol. Essentially, by adding filtrations and a new denoising technique, dose levels can be lowered without affecting image quality.

 The study findings show the use of low-dose technology in a practical setting and illustrate the tool’s effectiveness in standard medical imaging.

Safer low-dose X-ray technology will advance the way imaging exams are done for children. Whether a child has a complex chronic condition or a surgical or medical issue, the patient’s safety should always be a priority. When determining new ways to advance patient safety, it’s crucial for medical device manufacturers to keep society’s littlest members top of mind. Keeping our youth at the center of rapidly evolving technology development will further solidify a brighter future for generations to come.

1. John S. Pediatric X-ray dose reduction and image quality maintenance using S-Vue™. Samsung White Paper. 2019.

2. U.S. Food & Drug Administration (FDA). Pediatric X-ray imaging. Available at: https://www.fda.gov/radiation-emitting-products/medical-imaging/pediatric-x-ray-imaging . Updated January 18, 2018. Accessed May 11, 2022.

3. Choi G, Cheon JE, Lee S, et al. Development of quality controlled low-dose protocols for radiography in the neonatal ICU a new mobile digital radiography system. 

Articles

Could low-dose X-ray technology reinvent imaging exams for children?

Emerging Concepts in X-Ray Radiation Dosing for Pediatric Patients

Occasionally, I see posts and comments on social media critiquing the presence of private equity in medicine.

There are questions about the autonomy of physicians in those private equity-backed health-care practices and suggestions that there is a lack of investment in clinical innovation and research, just to name a few. Seeing these remarks makes me wonder: how can we share the other side of the story? In other words, what about the story of a physician in one of those private equity-backed practices? A story that is, in fact, my story.

As a practicing radiologist who also serves as Associate Chief Medical Officer, Recruitment for Radiology Partners (RP), part of my role is to talk about my experience working in a health-care practice that has true scale, even in a market like this one. When I talk to trainees, I get a sense they fear the unknown. They see negative comments and are concerned about being only a number in a health-care practice supported by private equity, but that could not be further from my experience (and that of my colleagues).

In addition to my role with Radiology Partners, I practice at ARA Diagnostic Imaging in Austin, Texas, which joined Radiology Partners in 2019. The leadership at ARA Diagnostic Imaging sought a national partner because we realized it was the direction many medical specialties were headed. Being an associate on track to partnership at that time, I had the opportunity to have a front row seat in the process. I (and others) noticed something interesting: ARA was actually calling the shots. These conversations eventually led to the integration with Radiology Partners. After ARA ultimately partnered with Radiology Partners, that style of partnership continued, emphasizing the idea that Radiology Partners really is “One Practice, Locally Led.”

That model rings true across the country. Radiology Partners serves as one practice to help its local practices. While Radiology Partners is providing access to cutting-edge technology for local practices who may not have the resources or offering the most recent research and best practice recommendations, the main governance of the local practice remains local. We know that no one knows their communities better than its own local physician practice, and Radiology Partners is there to be the support on a national level.

Another example of how Radiology Partners optimizes its scale is the investment in artificial intelligence (AI) tools that create efficiencies for our radiologists. These tools are not intended to make radiologists work harder. They actually make it easier for radiologists. The AI tools also benefit patients by offering quicker and enhanced result reports. If these tools lead to a radiologist reading more studies, this benefits everyone: patients, the local practice and referring providers.

There is also significant investment in our people. We encourage radiologists and support teammates to prioritize mental health, offering wellness seminars, coaching and spaces for teammates to connect. There are numerous opportunities to take leadership and development courses and serve on committees and boards that support different aspects of the practice. This is all to promote the health and well-being of our people and invest in our personal and professional growth. I have been at ARA Diagnostic Imaging for less than five years, and in that time, Radiology Partners has allowed me to tremendously expand my skills and abilities.

A true mainstay for Radiology Partners is that we are a practice, not a company. This core tenet is apparent in everything we do and how we are structured. Yes, part of being a practice means there are partners, but senior partners are not the only ones who benefit by joining a practice with scale. Yes, there is a vesting period, but this is not unique to private equity. Academic settings also require a certain number of years to achieve tenure as a professor. A vesting period is not a gimmick. It is a way to ensure talented physicians are committed for the long run within Radiology Partners. A career as a radiologist, not only within Radiology Partners, is indeed a marathon, not a sprint.

One of my favorite things about Radiology Partners is that we start all practice-wide meetings with one of our radiologists sharing the story of a patient save. Why? Our priority is the safety and quality of care for our patients, and we always start and come back to that focus. Radiology Partners hands us the tools and provides the support so we can continue to move forward with our passion and goals: to be the best radiologists possible, provide top quality patient care and ultimately transform radiology.

Dr. Saravanan is the Associate Chief Medical Officer, Recruitment for Radiology Partners. She is a breast radiologist in private practice at ARA Diagnostic Imaging in Austin, Texas.

While some have raised questions and concerns about a possible loss of autonomy with the increasing presence of private equity in radiology, this author says potential benefits of such an alliance, including access to new technologies, career development and a strong patient focus, go beyond the expected economies of scale.

Another Perspective on Private Equity-Backed Radiology Practices

Case submitted by Radiology in Thai via the 

Image IQ Quiz: Headaches in a 55-Year-Old Patient with Esophageal Cancer

Not only do women have higher prevalence and mortality rates with ischemic heart disease (IHD) than men, they also have more atypical symptoms of the disease, according to researchers from the Beth Israel Deaconess Medical Center (BIDMC).

In a video interview, Diana Litmanovich, MD, chief of the cardiothoracic imaging section at BIDMC, and Rokas Liubauskas, a clinical research fellow in the radiology department of BIDMC, discussed their 

recent poster presentation at the American Roentgen Ray Society (ARRS) conference

, which focused on the impact of sex-based differences with risk factors, imaging, and the diagnostic workup of suspected IHD in women.

While diabetes mellitus and hypertension are well-established risk factors for myocardial infarction (MI), Dr. Liubauskas noted that they are higher risk factors in women than men. The authors also said that fewer women symptomatic for IHD present with typical symptoms such as chest pain. Common atypical symptoms in women who could have IHD may include nausea, vomiting and epigastric pain. Other complaints in women with possible IHD may include dyspnea, jaw pain, loss of appetite or lightheadedness.

When assessing women for potential coronary artery disease (CAD), Dr. Litmanovich explained that clinical predictive factors are reliable but less reliable in women compared to men. However, she maintained that predictability of an acute coronary event in women via imaging is better than that of men.

There are also key differences with imaging findings in this patient population. They pointed out that the smaller coronary artery diameter in women plays a key role with interpretation of imaging. Drs. Litmanovich and Liubauskas also discussed a lack of flow-limiting stenosis in over 50 percent of women symptomatic for IHD.

Other considerations impact the use of imaging devices for women with suspected IHD. While coronary computed tomography angiography (CCTA) has been recognized for its ability to help stratify risk in patients with CAD, the use of some medications to mitigate anxiety-related tachycardia in women may warrant heart rate monitoring, according to Dr. Liubauskas. When microvascular dysfunction is part of the equation for cardiac ischemia, Dr. Liubauskas says this requires functional tests for diagnosis.

When it comes to CAD, Dr. Litmanovich said women with preserved myocardium and ejection fraction may still have heart failure. In these cases, she said the use of magnetic resonance imaging (MRI) with delayed gadolinium enhancement may be warranted as “what looks normal on echocardiography or CT might actually correlate with abnormal MRI findings.”

For additional insights on the imaging and diagnosis of IHD in women, watch the video below:

Videos

Sharing insights from their recent presentation at the American Roentgen Ray Society (ARRS) conference in a new video interview, researchers discussed how sex-based differences have an impact in the imaging and diagnosis of ischemic heart disease (IHD) in women.

Diagnosing Cardiac Ischemia in Women: Key Imaging Considerations

510(k) clearance from the Food and Drug Administration (FDA) for the new MR 7700 3.0T MR system

, which enables radiologists to obtain six different clinically relevant nuclei across anatomies.

In addition to seamless integration of multi-nuclei capabilities for enhanced anatomical and metabolic/functional imaging, the MR 7700 system reportedly achieves 

20 percent more functional magnetic resonance imaging (fMRI) volume and 50 percent more diffusion tensor imaging (DTI) directions

, facilitating an improved level of detail with high-resolution images, according to Philips.

The company adds that the system’s XP gradient coils allow radiologists to reduce scanning times by 35 percent and bolster signal-to-noise ratios by up to 35 percent.

“The low effort required for modifying scan parameters and protocols supports fast and easy experimentation with imaging techniques,” noted Walter Heindel, MD, a professor of radiology and chairman of the Department of Radiology at the University Hospital Münster in Germany. “These latest features clearly help improve our patient and staff experience.”

Philips said the system’s combination of ultra-high gradients and artificial intelligence (AI)-powered patient sensing and motion detection gives radiologists a unique tool to help address increased imaging volume and expectations.

“Enhanced with ultra-high gradients and artificial intelligence, Philips MR 7700 is built to deliver on the high-quality clinical performance expectations of today, and to facilitate the most demanding and promising research programs that will help drive the future of MR imaging, without sacrificing workflow efficiency or wide-bore patient comfort,” said Arjen Radder, the general manager of Magnetic Resonance and Diagnostic X-ray at Philips.

Offering integrated artificial intelligence (AI) and seamless multi-nuclei imaging capabilities, the new magnetic resonance imaging (MRI) system reportedly enhances image quality and workflow efficiency. 

Philips Gets FDA 510(k) Clearance for New MR 7700 System

Eric Postal, MD, is a diagnostic radiologist with the University of Pittsburgh Medical Center. 

I have a cast of characters residing in my noggin. They’re all me of course. Regular readers won’t be surprised that I watched Marvel’s 

 series, but I’m not claiming any dissociative identity issues. It’s just that the way I come across can vary substantially with different situations.

We’re not supposed to be like that in medicine. No matter what happens, it is expected that we will always be level-headed, cool, and calm in a crisis, etc. Stress, frustration, and the like shall never mar our consummately professional demeanor. For those familiar with the 

 franchise, we’re about as close a thing to its “mentats” as reality gets: the living equivalent of computers. Give us your data. We will process it and give you results, and our personalities won’t get in the way.

Maybe other docs have perfected this approach. I have not. However mentat-like I might manage to behave, the characters in my mind are regularly in play behind the scenes. I could call them a council to pun on the title of this piece, but with the way they behave, it is really more of a peanut gallery. They are often at their most insistent when I have to get on the phone: Talking to referrers, techs, etc. has a way of rousing my rabble to the point where it is sometimes hard to keep them from taking enough control to verbally express themselves.

Consider the following case in point. A call comes in for a computed tomography (CT) scan I read. As has been the case in most decently organized rad jobs I have had, the initial contact is from a rad support person, to a) make sure I’m available, and b) give me the patient info so I can have the case in front of me before the referrer is talking to me about it.

Organized and efficient as that may be, it doesn’t stop the peanut gallery from squawking at the interruption of my reading cases:

What is it now? Can’t I be left alone in peace?

What about my report was unclear to this individual? Did the clinician bother reading it all that carefully? Is she or he about to try telling me my read was wrong?

Of course, I ride herd on the chatter. Nothing they are saying is worth expressing out loud, especially to my helpful ancillary staff. I say thanks for the case info and that I am ready to be connected. It was a chest CT with a history of “septic emboli” and literally no other clinical info. There was plenty going on in the lungs, even some cavitary lesions. However, they did not look embolic, and I had taken pains to describe why they probably were not embolic

The referring clinician gets connected and semi-accusingly tells me that I “said something about septic emboli” in my report, but that the clinical scenario really doesn’t suggest such pathology. The peanut gallery doesn’t appreciate the tone.

 said something about emboli? That was the only history 

You didn’t really read the report, did you? I spent about half of it explaining why I didn’t think these 

 septic emboli and offered you a differential of more likely possibilities.

This time, I don’t entirely squelch their retorts. It is, after all, being alleged that my report is diagnosing the opposite of what it is, a diagnosis that this individual (or someone else on their team) provided in a clinical history that my caller is now denying. I do phrase it a little better though: “I’m sorry. Was my report unclear? I thought I explained why I didn’t think these were septic emboli. The only reason I mentioned emboli in the first place was because that was the history you provided.”

The caller responds by saying that I “don’t seem to know anything about this patient,” and continues to go on about why he or she didn’t clinically suspect emboli. This does not remotely charm a single member of the peanut gallery:

I don’t seem to know anything about your patient, huh? Whose fault do you suppose that is? The one thing you told me in your “reason for exam” is something you are now claiming you never believed.

I’m glad that neither of us thinks there are septic emboli here. We should be on the same page, since now you’ve read my report and heard me describe it out loud. Can I hang up the phone now, or is there some other way I could express this to your satisfaction? Morse code? Semaphore? Emojis?

I decide to let a quieter member of the gallery sound off. I think of him as the Professor. He likes to share knowledge and educate, even though he sometimes talks over people’s heads or gives them far more info than they wanted.

Thus, instead of trying to force my caller to understand that he or she has done a lousy job of referring and reading my report, and isn’t making up for it in verbal discourse, I lay it on super thick, offering every detail I can think of about septic emboli, what they look like on CT, what this CT shows instead, etc. It is as if I never dictated the case in the first place but instead was doing a “curbside” interpretation for this caller on demand. I made absolutely no effort at brevity.

I do my best to be that bore at a party who buttonholes you and jawbones about something till you wish not only to get away from him, but the entire party.

Mission accomplished. The caller doesn’t have to admit any deficiencies and is being told what she or he wanted to hear in the first place. However, the referring clinician is slowly being punished by wasted time as I babble and is soon climbing over him- or herself to get off the line and away from me.

If I am really lucky, perhaps there will be a lingering recollection that calling me is more of a time/effort investment than carefully reading my reports. Perhaps there will be a little better clinical history in the future with requisition imaging. One can hope.

When remaining cool and collected is a challenge, providing an overload of detail is another way of turning the tide with a frustrating referring clinician. 

Keeping My Own Radiological Counsel

's Weekly Scan is your chance to catch up on the latest radiology content, from new research and device news to the latest case quizzes and conference reports. Review the slideshow below to see this week's top content:

Diagnostic Imaging's Weekly Scan: May 1-May 7

Slideshows

Check out top radiology content from the past week.

The 45,222 gun-related fatalities in 2020 were the highest on record in the United States, according to the Centers for Disease Control and Prevention (CDC).

 Research from the University of Pennsylvania estimated a yearly average of 120,232 gun-related injuries in the U.S. between 2009 and 2017.

 In light of these statistics, researchers discussed 

key considerations in the imaging of ballistic injuries 

at the American Roentgen Ray Society (ARRS) conference.

In their online poster presentation, the researchers discussed types of bullets and resulting deformation patterns. Full metal jacket bullets create minimal deformation whereas the “mushrooms” at the tip of semi-jacketed bullets create larger surface area injuries with two different density projections on radiographs, according to the poster. With semi-jacketed bullets, the poster authors noted the copper jacket aspect of the bullet will present as a lower-density fragment and the lead core part of the bullet will show up as a high-density metal fragment.

Radically invasive projectile (RIP) bullets represent another challenge, according to the poster authors. Comprised of copper, these bullets have eight trocars that reportedly splinter off upon impact into separate wound channels.

“When interpreting imaging, one should use a mechanistic approach to establish bullet trajectory followed by assessment for injuries along the established path. Retained bullet fragments should be considered MRI conditional, and with the appropriate preceding workup, patients may be safely imaged,” noted poster co-author Jaykumar Nair, MD, who is affiliated with the Division of Emergency, Trauma and Acute Care Radiology at St. Michael's Hospital and the University of Toronto in Ontario, Canada.

Bullet yaw, fragmentation, and deflection as well as patient motion around the bullet can all influence bullet trajectory pathways, according to the poster authors. While one should not infer bullet trajectory based on surface wounds, the researchers said debris trails may be helpful in determining bullet trajectory.

Nair and colleagues also explained that retained debris from bullets does not automatically rule out the use of magnetic resonance imaging (MRI). Noting that semi-jacketed bullets are usually comprised of a lead core with a copper jacket, the study authors said injuries involving a deformed semi-jacketed bullet and retained ballistic debris with a debris trail are likely safe for MRI. Injuries involving undeformed full metal jacket bullets are another story, according to the poster authors.

“(Undeformed) full metal jacket bullets … should be imaged with caution as sometimes the jacket material in these bullets contain ferromagnetic materials,” wrote Dr. Nair and colleagues.

1. Gramlich J. What the data says about gun deaths in the U.S. Pew Research Center. Available at: 

https://www.pewresearch.org/fact-tank/2022/02/03/what-the-data-says-about-gun-deaths-in-the-u-s/

 . Published February 3, 2022. Accessed May 5, 2022.

2. Kaufman EJ, Wiebe DJ, Xiong RA, Morrison CN, Seamon MJ, Delgado MK. Epidemiologic trends in fatal and nonfatal firearm injuries in the U.S., 2009-2017. 

In a recent presentation at the American Roentgen Ray Society (ARRS) conference, researchers discussed pertinent considerations with imaging of gunshot wounds.

Imaging of Ballistic Injuries: Current and Emerging Insights

Day One Images

Image IQ Quiz: Acute Chest and Epigastric Pain in a 50-Year-Old Female

Is it time to rethink size change thresholds for incidentally detected gallbladder polyps?

In a new retrospective study presented at the American Roentgen Ray Society (ARRS) conference

, researchers assessed over 9,600 patients who had at least one ultrasound exam over an 11-year period in a screening program for hepatocellular carcinoma (HCC). They identified 759 patients who were diagnosed with at least one gallbladder polyp and 434 patients had multiple ultrasound exams, according to the study.

Noting that 16.4 percent of patients had polyps that decreased in size over time, 9.7 percent of patients had polyps that increased in size over time and 22.4 percent of patients had fluctuant polyps, the researchers detected no gallbladder carcinomas in the patient cohort that had gallbladder polyps. For the 19 patients with polyps greater than 10 mm who had a subsequent cholecystectomy, there were no gallbladder carcinomas, according to the study authors.

With most guidelines advising the use of absolute polyp size or change in size over time as a key ultrasound finding for stratifying risk and appropriate management of patients with gallbladder polyps, it may be time to rethink that approach, according to study co-authors Andrew Walsh, M.D., Ph.D., an associate with MIC Medical Imaging in Alberta, Canada, and Aya Kamaya, M.D., the director of ultrasound and interim chief of the Body Imaging Division at Stanford University.

“Understanding the natural history of change in size and number of polyps over time of sonographically detected polypoid gallbladder lesions is critical in informing potential guidelines,” wrote Drs. Walsh and Kamaya in their poster presentation, which earned magna cum laude honors at the ARRS conference. “As imaging technology and resolution of ultrasound improves, size may be less of an important distinguishing feature of gallbladder polyps in the future.”

While other studies comparing first and last ultrasound exams have found that gallbladder polyps can disappear, Walsh and Kamaya said the ability to review multiple longitudinal exams in this study led to new findings with imaging of gallbladder polyps.

“Not only do polyps disappear as other studies have described but (they) can also disappear and reappear on subsequent examinations and can both increase as well as decrease in size in the same patient over multiple examinations,” explained Drs. Walsh and Kamaya.

For patients who had multiple ultrasound exams, the study authors said the average time between the first and last ultrasound was 3.6 years with the greatest amount of time between exams being 11 years. Drs. Walsh and Kamaya noted that current guidelines from the American College of Radiology (ACR) and the Canadian Academy of Radiology (CAR) recommend yearly follow-up exams for gallbladder polyps equal to or greater than 7 mm in size. European guidelines recommend follow-up ultrasound exams at one, three and five years for monitoring of polyps less than 6 mm in size in patients with no risk factors and follow-up exams at six months and yearly for up to five years for patients with risk factors, including age over 50, sessile polyp configuration and primary sclerosing cholangitis, according to Drs. Walsh and Kamaya.

In regard to study limitations, the study authors pointed out a lack of adherence to the six-month surveillance follow-up for many at-risk patients with changes in health care insurance and local employment conditions being likely contributing factors. They also noted that they focused on patients who were being monitored over time for HCC as opposed to follow-up imaging specific to gallbladder polyps. Drs. Walsh and Kamaya acknowledged a lack of clarity on whether underlying liver disease factors into a different susceptibility for gallbladder polyps and noted that other studies have found that chronic liver disease is not a risk factor for these polyps.

Based on findings from what may be the first longitudinal study of gallbladder polyps in patients with underlying liver disease, researchers suggested that size change thresholds for cholecystectomy may need to be reevaluated.