Wallace Jacob,  Desilet-dobbs Debbie

Final Pr. ID: Poster #: EDU-052

Learning the skills used to master pediatric fluoroscopic exams can be challenging. Hand-eye coordination and specific timing is required while at the same time being mindful of radiation dose and interpreting the images generated in real time. Training on live neonates will often mean less diagnostic exams and increased radiation dose for those exams.

An inexpensive reusable simulator model was devised to allow residents practice of upper GI fluoroscopic exams to increase efficiency using ALARA principles and utilizing 3D printing technology off-the-shelf dolls. Generic gastrografin provided a cost effective contrast medium as its concerns in real UGI studies are of no issue on the training models. A 30ml bottle of generic gastrografin can be purchased for less than $20, which would last for several simulated exams.

The 3D model was based on a computer generated imagery (CGI) mesh of a stomach which was modified in Blender™ to try to best replicate the full duodenum and effect of the ligament of Treitz. The final iteration of the model was printed in polylactic acid polymer (PLA) in a size that would fit inside the plastic doll, which already contained portions of the necessary tubing. The model was sealed to be watertight.

Testing under fluoroscopy showed that the model behaved similar enough to an infant when placed in various positions then filled with an appropriate volume contrast.

There are several limitations of this model including the lack of the distractions of a real pediatric patient. Also, the flow of contrast is purely gravity dependent without the effects of sphincters and peristalsis. Overlying skeletal structures and bowel gas are not represented, however these could also be simulated in various ways.

Future work on this and similar projects could include expansion into other organ systems such as the colon. Read More

Authors:  Wallace Jacob , Desilet-dobbs Debbie

Keywords:  ALARA, 3D, Simulation

Cao Joseph,  Pfeifer Cory

Final Pr. ID: Poster #: SCI-004

The principle of ALARA and its application in the pediatric population serves as the focus of the Image Gently campaign. Tertiary care institutions dedicated to the care of children are well situated to be regional leaders in maximizing the ALARA concept. This study compares the size-specific dose estimates of computed tomography (CT) studies performed at our institution to those from outside facilities referring patients for emergent care. Read More

Authors:  Cao Joseph , Pfeifer Cory

Keywords:  ALARA, Radiation, SSDE

Siegel Marilyn,  Ramirez Giraldo Juan Carlos,  Cullinane Mike,  Bhalla Sanjeev

Final Pr. ID: Paper #: 136

Patients undergoing lung and stem cell transplants require serial CT examinations and hence dose reduction techniques are mandatory. The newest 3^rd generation dual-source CT scanner incorporates spectral beam shaping at 100 kilovoltage (kVp) using a dedicated tin filter (100 kVp Sn), which improves dose efficiency by removing low-energy photons that contribute little to noncontrast image quality. The purpose of this study was to compare radiation exposure in non-contrast-enhanced pediatric chest CT at 100 kVp Sn imaging and at conventional low kVp imaging in the same patient cohort. Read More

Authors:  Siegel Marilyn , Ramirez Giraldo Juan Carlos , Cullinane Mike , Bhalla Sanjeev

Keywords:  Dose Reduction, ALARA, Lung and Stem Cell Transplant

Parikh Ashishkumar,  Pruthi Sumit,  Hernanz-schulman Marta

Final Pr. ID: Poster #: SCI-001

Recently JACHO proposed to address double scanning in pediatric chest CT, yet there are no data to determine whether this takes place; similarly, there is discussion regarding validity of sending pediatric patients to adult-focused practices for routine imaging by third party payors. Our purpose is to review the technical factors that impact upon radiation dose and image quality in CT scans of children referred from adult-focused practices to a children’s hospital, referenced to pre-Image Gently values. To our knowledge this is the first such review that includes body and neuro scans and extensive technique and exposure data Read More

Authors:  Parikh Ashishkumar , Pruthi Sumit , Hernanz-schulman Marta

Keywords:  ALARA, Image Gently, Radiation

Colleran Gabrielle,  Barnewolt Carol,  Chow Jeanne,  Paltiel Harriet

Final Pr. ID: Poster #: EDU-122

Fluoroscopic voiding cystourethrography (VCUG) and radionuclide cystography (RNC) are conventional techniques used for the diagnosis of vesicoureteral reflux (VUR) in children. Contrast-enhanced voiding urosonography (ceVUS) is a radiation-free alternative to the traditional VCUG. ceVUS has gained acceptance in Europe, but has not yet been widely adopted in the USA.

The purpose of this educational review is to describe our initial experience with ceVUS using the second generation US contrast agent Optison™, with a focus on optimization of examination technique, utility in the depiction of a variety of pathological entities, and a discussion of potential pitfalls. Read More

Authors:  Colleran Gabrielle , Barnewolt Carol , Chow Jeanne , Paltiel Harriet

Keywords:  contrast enhanced voiding urosonography, VCUG, ALARA, ultrasound contrast, Optison

Semple Thomas,  Schofield Rebecca,  Petraco Da Cunha Ricardo,  Owens Catherine,  Nicol E,  King Lawrence,  Castellano I

Final Pr. ID: Poster #: EDU-009

To review the basics of CT dose calculation, in particular the nuances of dose calculation / estimation in cardiac CT and the many and varied methods of dose reduction in cardiac and cardiovascular CT. Read More

Authors:  Semple Thomas , Schofield Rebecca , Petraco Da Cunha Ricardo , Owens Catherine , Nicol E , King Lawrence , Castellano I

Keywords:  Dose Reduction, CT, Radiation, Physics, ALARA

Stewart Zachary,  Elmore Kate,  Thompson Allison,  Pham Huy

Final Pr. ID: Poster #: SCI-002

Delayed phase imaging increases the sensitivity of detection of injuries to the urinary tract and also assists in characterizing solid visceral organ injuries at the expense of doubling the radiation dose to the patient. If institutions can lower the rate of these examinations, the cumulative radiation exposure reduction would be substantial. Here we evaluate the rate of delayed phase imaging in the pediatric trauma population at our Level I trauma center as well as the frequency with which these patients demonstrate an indication on portal venous imaging for delayed phase acquisition. Finally, there are minimal guidelines dictating the appropriateness of delayed imaging in pediatric trauma. We include a review of the literature in order to elucidate appropriate indications and help guide clinicians to make evidenced based decisions. Read More

Authors:  Stewart Zachary , Elmore Kate , Thompson Allison , Pham Huy

Keywords:  Trauma, ALARA, Protocol

Stein Nina,  Kereliuk Marylin,  Schmidt Michael

Final Pr. ID: Poster #: SCI-054

Following the ALARA principle, the amount of radiation exposure to those working with x ray technology should be minimized as much as possible. The aim of this study was to access the prevalence of extraneous adult finger(s) in portable NICU chest x ray studies. Read More

Authors:  Stein Nina , Kereliuk Marylin , Schmidt Michael

Keywords:  ALARA, Occupational exposure, plain films

Boileau Caroline,  Treanor Lee,  Kapoor Cassandra,  Highmore Kerri,  Miller Elka

Final Pr. ID: Poster #: EDU-001 (T)

Imaging requisitions are the legal documents that health professionals use to communicate to radiologists and Medical Radiation Technologists (MRT(R)s) the relevant clinical information to guide their requested radiographic examination. Inadequate or incomplete information may have a substantial impact on patient care.

Since the implementation of our electronic medical record system, EPIC (Epic Systems Corp.), we have the ability to track the number of errors on requisitions; the most common error is having the incorrect body parts selected or multiple unnecessary exams being ordered. The MRT(R)’s identify these errors and correct the inconsistencies following departmental protocols. Without such vigilance on the MRT(R)’s part, inappropriate radiographs could have been performed and could lead to additional, unnecessary radiation exposure. To help select the most appropriate protocol, educate and guide the health professionals at our hospital, an electronic software tool, “EDI” has been created.

EDI (Examine the patient, Determine the correct radiograph, Input the order with pertinent and relevant clinical information) is an interactive tool that includes the exam protocol with the associated views per body part. Each exam also includes EDI with the field of view that will be exposed to radiation during the exam.

Our goal is that EDI will serve health professionals to better understand what order needs to be selected in the electronic system and which radiographs will be provided. Ultimately, this will reduce any unnecessary exams and reduce pediatric radiation exposure. Read More

Authors:  Boileau Caroline , Treanor Lee , Kapoor Cassandra , Highmore Kerri , Miller Elka

Keywords:  Appropriateness Criteria, Image Gently, ALARA

Yang Ronald,  Hayes Kari,  Milla Sarah,  Zhou Wei

Final Pr. ID: Poster #: SCI-005

Fluoroscopy is a valuable diagnostic tool, but it also exposes patients to radiation. Our study assesses variation in pediatric fluoroscopy radiation dose performance by hospital site and radiologist experience. Read More

Authors:  Yang Ronald , Hayes Kari , Milla Sarah , Zhou Wei

Keywords:  Fluoroscopy, Radiation Dose, Alara

Colleran Gabrielle,  Callahan Michael,  Chow Jeanne

Final Pr. ID: Poster #: EDU-041

Pediatric urolithiasis is an important and increasingly prevalent cause of pediatric morbidity and hospital admission.

Ultrasound is the recommended primary imaging modality for suspected urolithiasis in children and this view is endorsed by all of the largest pediatric and urological societies.

There is however widespread use of CT as a first line study for abdominal pain in many institutions involved in pediatric care, many of whom are free standing hospitals delivering predominantly adult care.

The purpose of this educational review is to outline the state-of-the-art imaging modalities and methods for diagnosing urolithiasis in children and to suggest an imaging algorithm for best practice. Read More

Authors:  Colleran Gabrielle , Callahan Michael , Chow Jeanne

Keywords:  Urolithiasis, Ultrasound, Computed Tomography, ALARA, Dose optimized

Pfeifer Cory

Final Pr. ID: Poster #: SCI-003

Given the relative sensitivity of pediatric patients to radiation, the need to limit exposure to the region of interest is of the utmost importance in pediatric radiography. This study assesses the practice of acquiring pediatric chest radiographs at a community hospital in which the imaging contract was acquired by a radiology practice with subspecialty-certified pediatric radiologists. Pediatric radiologists in the new radiology practice saw a need for improved collimation of pediatric chest radiographs at the community hospital. Many radiographs exhibited poor collimation and included much of the abdomen. This study examines an initiative to measure and improve radiograph quality. Read More

Authors:  Pfeifer Cory

Keywords:  ALARA, radiography, thoracic

Cao Joseph,  El-ali Alexander,  Siegel Marilyn

Final Pr. ID: Poster #: EDU-001

Photon-counting detector (PCD) CT utilizes a charged semiconductor element directly paired with a high-resolution detector panel. The direct conversion of detected photons into electrical signal represents the most recent generational advance in CT technology. Changes to detector technology achieved with PCDs has the potential to reduce image noise, improve spatial resolution, improve contrast resolution, and provide multispectral imaging capability. Importantly, these gains may be achieved with an overall decrease in radiation and iodinated contrast dose.

This exhibit reviews the underlying technology of the PCD using clinical scans of pediatric patients performed on the first commercially available PCCT. We present examples of (1) PCD noise reduction capability; (2) improvements in spatial resolution; (3) improvements in contrast resolution; and (4) uses of multispectral capability. These are presented in comparison to the latest generation energy integrating detector (EID) CTs to highlight reductions in radiation dose and contrast media dose. Read More

Authors:  Cao Joseph , El-ali Alexander , Siegel Marilyn

Keywords:  photon counting, CT, ALARA

Pan Patrick,  Roth Antoinette,  Chawla Soni

Final Pr. ID: Poster #: EDU-124

Acute abdomen is one of the most common presentations encountered in any pediatric emergency department. This educational exhibit refreshes reader with the most common causes of acute abdomen encountered in the pediatric population through a simple mnemonic (AIM)² which includes Appendicitis, Adhesions, Intussusception, Incarcerated inguinal hernia, Meckel’s diverticulum and Mal-rotation with midgut volvulus. Initial abdominal radiographs and confirmatory ultrasound and/or cross-sectional images including CT and MRI will be presented.
There will be emphasis on “Image Gently” principles in keeping with minimum radiation exposure to our most vulnerable pediatric population. The best use of available diagnostic modality with the least or no radiation is suggested for given pathologies and clinical scenarios in pediatric patients. Also, appropriateness criteria for the diagnostic studies will be reviewed in our exhibit.
Plain films may reveal an abnormal bowel gas pattern, which may suggest an underlying pathology. Use of ultrasound as part of the initial evaluation is advocated in many situations because it may be quickly performed at bedside and repeated as needed without harmful ionizing radiation. In certain cases, ultrasound examination may be confirmatory.
CT is best used when the initial tests are unrevealing, or when the patient is acutely deteriorating. CT has proven to save lives of children by allowing prompt and accurate evaluation. Minimizing radiation exposure while maintaining diagnostic accuracy remains an ongoing effort of the entire care team, including the radiologists, radiology technologists and the referring physicians. Read More

Authors:  Pan Patrick , Roth Antoinette , Chawla Soni

Keywords:  Gastrointestinal, ALARA

Contreras Jesus,  Seekins Jayne

Final Pr. ID: Poster #: EDU-001

The aim of this strategy is to standardize the performance of our modified barium swallow studies (MBSS) with a focus on communication between team members and the reduction of fluoroscopic radiation dose exposure to the radiosensitive head and neck region.
The radiation dose reduction strategy is composed of the following steps:
The radiology technologist will initiate the patient encounter, begin room setup, and notify the radiologist of patient arrival.
The radiologist will review prior examinations, if available, and discuss the current indication and goal of the examination with the Speech/Occupational Therapist and Radiology Technologist.
The pulsed acquisition rate is standardized at 15 frames/second, and the optimal field of view will be discussed and adjusted dynamically, if necessary.
The team will utilize standardized consistencies based on the International Dysphagia Diet Standardization Initiative (IDDSI).
Once the in-room team has a clear objective the performing radiologist will proceed with the fluoroscopic examination. The radiologist will announce to the in-room team when fluoroscopic time points are met at 1 minute, 2 minutes, and a "hard-stop" at 3 minutes of fluoroscopic exposure.
In order for an examination to continue beyond the 3 minute time point a mandatory discussion regarding clinical necessity will occur between the supervising radiologist and the in-room team members.
The average fluoroscopic time required for the acquisition of a MBSS at our institution was calculated and reviewed before (2.07 minutes) and after (1.35 minutes) the implementation of this fluoroscopic radiation dose reduction strategy. The result is a 36 percent reduction in time of fluoroscopic exposure.
The implementation of a radiation dose reduction strategy to our MBSS protocol has resulted in decreased fluoroscopic times, and therefore, a decrease in fluoroscopic radiation dose. An emphasis on verbal communication between team members ensures an understanding of the goal of the examination and awareness of proper management of radiation dose to patients and workers. This modified approach to the MBSS better aligns with the principle of “as low as reasonably achievable” (ALARA). Read More

Authors:  Contreras Jesus , Seekins Jayne

Keywords:  ALARA, FLUOROSCOPY

Gual Fabiana,  Sameshima Yoshino,  Otto Debora,  Braga Fernanda,  Cardoso Mariana,  Fernandes-ferreira Rafael,  Souza Antonio

Final Pr. ID: Poster #: EDU-084

Ultrasonography is a very powerful non-invasive diagnostic tool widely employed for examining multiple organs and systems located both superficially and deeply. This is possible thanks to a wide range of transducers that work on different frequencies and sound lengths to explore all layers of anatomical structures. Nowadays, the reduction of exposure to ionizing radiation in children is advocated by the “as low as reasonably achievable” (ALARA) principle, and therefore, ultrasound (US) has become the main investigation tool in many assessments of lung pediatric disorders. The purpose of this educational exhibit is to describe the normal artefacts produced by LUS in a healthy lung to distinguish them from pathologic patterns and the application of LUS in pediatric diseases and procedures (ultrasound-Guided Lung Recruitment). Read More

Authors:  Gual Fabiana , Sameshima Yoshino , Otto Debora , Braga Fernanda , Cardoso Mariana , Fernandes-ferreira Rafael , Souza Antonio

Keywords:  Ultrasonography, Lung Diseases, ALARA

Butler Nikki,  Brinson Dana

Final Pr. ID: Poster #: EDU-04 (R)

In a Radiology Department that solely cares for pediatric patients, transitioning from computed radiography (CR) to digital radiography (DR) was a challenge. The software for the DR system is designed for imaging adults and has limited pediatric processing features. In the CR system, technologists would manually adjust the imaging technique to child appropriate values based on a technique chart and the usage of a vast array of processing tools. With DR, these charts and processing tools became obsolete. In addition, for the DR wireless flat panel detector to process the image correctly, four percent of the surface area must be exposed to radiation; a challenge in pediatric imaging. Therefore in order to achieve significant reduction in radiation exposure with DR equipment, extensive staff education, algorithm and technique chart modification is required. Read More

Authors:  Butler Nikki , Brinson Dana

Keywords:  Radiation Reduction, Digital Radiography, Computed Radiography, Education, ALARA

Zhou Wei,  Baldwin Heather,  Allen Jeron,  Butler Renee,  White Christina,  Milla Sarah,  Hayes Kari

Final Pr. ID: Poster #: SCI-013

To diagnose intestinal disease or guide an injection treatment, radiation from a fluoroscopy exam is often nontrivial. In addition to regulatory and accreditation requirements, it is clinically important to establish a mechanism to review and improve the use of fluoroscopy, particularly for pediatric patients who are more sensitive to radiation than adults. In this study, we aimed to implement a fluoroscopy dose monitor program, assess overall fluoroscopy performance, and evaluate radiologist performance, in a pediatric hospital system. Read More

Authors:  Zhou Wei , Baldwin Heather , Allen Jeron , Butler Renee , White Christina , Milla Sarah , Hayes Kari

Keywords:  Fluoroscopy, Radiation Dose, ALARA

Schjerven Annette,  Fasmer Kristine,  Aukland Stein Magnus

Final Pr. ID: Poster #: SCI-02 (R)

Despite the development of new methods for the detection of Vesico Urethral Reflux (VUR), Voiding Cystourethrography (VCUG) still plays an important role in pediatric uroradiology. However, the use seems to have changed over time. International guidelines exist and the main indication is the Ultrasonography (US) finding of hydronephrosis, indicating a high grade VUR or, in boys, to exclude Posterior Urethral Valve (PUV). VUR is a common condition found in 30-40 % of children with UTI. Our department performs VCUG according to the guidelines given by the ESUR subgroup for Pediatric Uroradiology. Haukeland University Hospital (HUS) serve a population of 300000 people. At the Section of Pediatric Radiology, we observed a decrease in the use of VCUG. We therefore did a systematic review of all VCUGs performed at our department during 2013 and 2014, focusing in detail on the age group 1 year or less. We aim to be true to the image gently policy, maintaining the ALARA principle, keeping the radiation doses as low as reasonably possible. Read More

Authors:  Schjerven Annette , Fasmer Kristine , Aukland Stein Magnus

Keywords:  voiding cystrourethrography, vesico urethral reflux, children, alara