Triangle Edition October 2009 VOL. 11, NO. 10. Wake Radiology Expands Pediatric Imaging

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1 Triangle Edition October 2009 VOL. 11, NO. 10 Wake Radiology Expands Pediatric Imaging

cover story Wake Radiology Expands Pediatric Imaging Practice Dedicated s Staff New Stand alone Outpatient Office and Increase WakeMed Coverage To serve a rapidly growing pediatric population, Wake

2 cover story Wake Radiology Expands Pediatric Imaging Practice Dedicated s Staff New Stand alone Outpatient Office and Increase WakeMed Coverage To serve a rapidly growing pediatric population, Wake Radiology has undertaken a major expansion of its pediatric radiology services. Three new full-time, fellowship-trained pediatric radiologists have joined the group. In September, the group opened a dedicated pediatric outpatient office the first of its kind in Raleigh. Wake Radiology is one of the few private practices in North Carolina with subspecialty-trained pediatric radiologists. The expansion continues a strong tradition of firsts in pediatric radiology that began nearly 15 years ago when Wake Radiology became the first group in the area to hire a fellowship-trained pediatric radiologist, Dr. David F. Merten. In 2000, Dr. Margaret R. Douglas joined the practice to further expand pediatric services, working primarily at WakeMed. The practice now welcomes Dr. Brent A. Townsend of Children s Hospital Boston and Drs. Catherine B. Lerner and Laura T. Meyer of Duke University Medical Center. Dr. Douglas will direct the pediatric division. We hope to work closely with each child s physician to answer any clinical questions, says Dr. Douglas. We also can provide experienced guidance in selecting the most appropriate imaging protocols. The expanded practice, she notes, will help enhance the care provided by the area s pediatric community and its increasing numbers of pediatric subspecialists, including neurologists, orthopedists, urologists, surgeons, and ophthalmologists. Because Wake Radiology is a tightly integrated practice of 59 radiologists, there is close collaboration between the pediatric radiologists and the radiologists with fellowship training in other subspecialties. For complex neurological, musculoskeletal, or interventional issues, we use a team approach, says Dr. Douglas. For example, if a body MRI is needed for a complicated case, the child really benefits from having a body imaging, fellowship-trained radiologist supervising the case. Or if a teenager has had a concussion, our neuroradiologists will be reading whatever CTs or MRIs are needed. Having four dedicated pediatric radiologists is just going to be a really outstanding service for the community, says Dr. J. Duncan Phillips, a pediatric surgeon and chair of the Department of Surgery at WakeMed. He points to a host of broad-ranging advantages, including utilizing the skills of pediatric radiologists to avoid operations and to limit or altogether avoid unnecessary radiation exposures. Two forces driving the need for more pediatric radiologists are the 2010 opening of the WakeMed Children s Hospital and North Carolina s increasing incidence of premature births. It is extremely helpful, if not essentially mandatory, to have a pediatric radiologist, because those children have so many studies: chest x-rays, upper GIs, and head ultrasounds. All these pediatric radiologists have trained at busy tertiary centers, he observes. What they bring to WakeMed is a lot of experience from high-volume centers where they were doing dozens and dozens of radiology studies on kids every day. Dr. Townsend and technologist prepare a 10-year-old child for a fluoroscopy scan of her abdomen. Bryan Regan Photography How Pediatric Radiology Can Help A Child Avoid An Operation Perhaps one of the most dramatic differences a pediatric radiologist can make in patient care is helping a child avoid an operation. Dr. Douglas well remembers several times when parents had been told their child had a large tumor in his or her chest. In one case, They hung the x-rays, and I was looking and looking, but couldn t find anything. Finally the doctor pointed and said, It s right there. I replied, Well, that s her thymus, that s normal. As a person grows, the thymus gets smaller. You don t see it in an adult. In a small child, though, the thymus can be about half the size of the heart. An MRI confirmed the child had a normal thymus for her age and no surgery was needed.

What every clinician should know about radiation risk Radiation is an important concern, particularly in pediatric patients, and cooperation between referring clinicians and pediatric radiologists

3 What every clinician should know about radiation risk Radiation is an important concern, particularly in pediatric patients, and cooperation between referring clinicians and pediatric radiologists can minimize this risk. Three important points to note for pediatric imaging: Different studies impart different radiation doses. Within the pediatric population, infants and younger children are more radiosensitive than older children. Due to the small size of pediatric patients, if they are scanned with standard adult protocols, they can receive excessive radiation. Dr. Meyer prepares a 4-month-old baby for an ultrasound. The ability of a pediatric radiologist to do an intervention also helps children avoid surgery, Dr. Phillips notes. For example, a condition called intussusception classically affects children between the ages of five and twelve months. A part of their bowel gets thickened and telescopes inside the piece of bowel next to it, causing a blockage of the intestines. A good pediatric radiologist can diagnose intussusception and reduce it using an air enema, avoiding the need for an abdominal operation. If you live in a community that doesn t have a pediatric radiologist, almost all of your kids with intussusception are going to have a laparotomy. Pediatric radiologists also can prevent a misdiagnosis, he points out. There is a condition, pyloric stenosis, in which the pyloric muscle in the stomach closes down. The classic patient is about a month old, and surgery is necessary to open it up. Before Dr. Douglas arrived in Raleigh, an adult radiologist might call it pyloric stenosis when actually it was just spasm of the pyloric muscle which doesn t need surgery. Instead of a typical five-minute ultrasound, he says, Dr. Douglas understood the necessity of a longer study of 20 to 25 minutes to make sure you re not just catching pylorospasm, which is going to open up ten minutes later. When It s Good for a Child That a Is There One of the most common studies of all, a chest x-ray, illustrates the difference a pediatric radiologist brings to patient care. When films are ordered because of a fever and cough, we will be looking for pneumonia whether the patient is a child or an adult. But if the patient is an adult, the radiologist would also be checking for things like heart failure or lung cancer. In pediatrics, we are not so worried about those issues, but would be mindful of other questions, such as could the patient have croup or foreign body aspiration. It helps to have a radiologist who knows the pediatric concerns, what things we are likely to find, and what we don t want to miss. There are many more examples. In one case, Dr. Townsend recalls, a 12-year-old child with Ehlers-Danlos, a connective tissue disorder, came to the ER after spinal surgery with right-sided flank pain. The fear was that he had an aortic dissection rare, but a pos- The table below shows the estimated range of effective radiation dose associated with some common radiologic studies performed in children. These are compared with a radiation dose from a chest x-ray. Effective radiation doses* of commonly performed radiologic studies Exam or Study Effective dose in msv* Chest x-ray equivalent 2 views of the chest views of the ankle /14th Tc-99m radionuclide cystogram Tc-99m radionuclide bone scan Up to 310 Fluoroscopic VCUG < Brain CT Chest CT Up to 3.0 Up to 150 Abdominal CT Up to 5.0 Up to 250 *Doses are calculated for a theoretical 5-year-old patient. ** Millisievert is a measure of radiation dose Variation in radiation doses for fluoroscopic studies and CT is related to differences in technique. Table adapted from Frush, DP et al. CT and Radiation Safety: Content for Community Radiologists. Available at imagegently.org What can we do to minimize the risk of radiation for our patients? First, start by ordering the correct exam for the clinical situation. While CT has a high radiation dose, it may be the best test. However, other tests, such as ultrasound or MRI, may be viable options. Second, it s important to optimize protocols to impart the lowest radiation dose necessary to achieve diagnostic results. Make sure your radiologist is tailoring protocols based on the patient s size and indication of the exam. Using adult protocols on a child results in excessive radiation with no benefit to the patient and should always be avoided. Multiphase examinations (e.g., pre- and post-contrast examinations) should be avoided if possible. In summary, radiation is an important concern, particularly in pediatric patients. Cooperation between referring clinicians and radiologists can minimize this risk for our patients.

4 A Parent s guide to radiation risk Ionizing radiation is the type of energy used to create images for x-rays, CT scans, nuclear medicine exams, and fluoroscopic studies. These images can be enormously useful to your child s doctors to help diagnose medical or surgical problems. There is some risk, however, associated with this radiation. (Ultrasound and MRI do not use ionizing radiation.) Every day, all of us are exposed to a certain amount of natural, background radiation coming from Earth and space. It s helpful to compare a normal day of background radiation to a particular study. For example, a chest x-ray (two views) for a child equals about two days of background radiation. In comparison, CT scans have a much higher radiation dose. A CT of the abdomen, for instance, equals about 16 months of background radiation. What is the risk? The primary risk associated with radiation used in diagnostic imaging is a presumed increased risk of cancer. This risk is hard to study because it is low. Generally, a person who is never exposed to medical radiation has a lifetime risk of cancer estimated at between 20% 25%. For children, estimates of the increased risk of cancer from a single CT scan are around 0.1%. That means that having a CT scan may increase your child s lifetime risk to 20.1% 25.1%. Each additional CT scan increases the lifetime risk. What should I do if my doctor wants my child to have a CT scan? As with any medical procedure, the benefits of the exam need to outweigh the risk. CT scans are a very valuable tool, and in many instances, the benefits clearly outweigh the risks. If you do not understand the risks and benefits in your child s situation, please do not hesitate to ask for your doctor to explain them to you. If a CT is needed, you can help ensure that your child receives the lowest dose necessary. Ask if your child s radiologist is using a protocol appropriate for your child s age, weight, and clinical situation. Having a pediatric radiologist involved in your child s care is preferred, as he or she will have advanced training in minimizing radiation dose for children. We strive to use the smallest doses of radiation possible that will still provide diagnostic images. Across the practice, we have set up dose reduction guidelines for CT protocols. Margaret R. Douglas, MD sible complication of his disease or appendicitis. When using the Doppler ultrasound to evaluate his blood vessels, I noticed that the blood flow within one of his kidneys was decreased. This suggested the source of his pain was pyelonephritis, a kidney infection. The ER ordered a CT scan to make sure there was no appendicitis. Instead of just scanning the pelvis, as we normally do in cases of suspected appendicitis, I had the whole abdomen scanned. That confirmed the diagnosis of pyelonephritis. Dr. Phillips provides the perspective of a pediatric surgeon. Say I ve ordered an upper-gi, for which a child will swallow barium liquid, and I want to follow it, let s say, through the esophagus and down through the stomach and the duodenum. Rather than a brief report that everything is normal, a pediatric radiologist will tailor the report. She knows I m concerned about the possibility of a hiatal hernia, gastroesophageal reflux, or malrotation. She knows the various pediatric diagnoses I am specifically trying to assess, and she will give me those images. She will make sure and generate a report that says specifically, There was no tracheoesophageal fistula, there was no hiatal hernia, there was no evidence of gastroesophageal reflux. And similarly, if there is an abnormality found in a child on an x-ray study, a pediatric radiologist has a much better appreciation of the differential diagnosis of that abnormality. Another advantage to young patients is that pediatric radiology is more hands-on, and in some cases, a pediatric radiologist can better accomplish a procedure. For instance, Dr. Lerner explains, There s a study called a voiding cystourethrogram. If technologists aren t used to working with children, that can make the study more difficult. As you can imagine, catheterizing a child can be difficult not only for the patient, but for the parents who are worried their child is uncomfortable. Having pediatric radiologists and technologists who are familiar with doing the study can make it an easier experience for everyone involved. Striving to Use the Smallest Radiation Dose or None At All In recent years, concern over radiation exposure has heightened. The drive in the development of the technology has been to produce the best image possible, Dr. Douglas explains. As a consequence, the radiation dose was going up and up and up. Also, people are getting more and more scans. There are about two million CT scans done on kids every year. The increased cancer risk is concerning, not only because their young bodies are more sensitive to radiation, but also because rising generations will have more radiologic studies and receive more medical radiation over their lifetimes. The main concern is CT scan; that s the big dose, Dr. Douglas says. The National Cancer Institute has called radiation risks from CT in children a public health issue. CT is extremely valuable and can be a life-saving tool for diagnosing illness and injury in children. Despite the many benefits of CT, a disadvantage is the inevitable radiation exposure. Although CT scans comprise up to about 12% of diagnostic radiological procedures in large U.S. hospitals, it

Across the practice, we have set up dose reduction guidelines for CT protocols.

5 is estimated that CT scans contribute approximately 45% of the U.S. population s collective radiation dose from all medical x-ray examinations. CT is the largest contributor to medical exposure in the U.S. population. We strive to use the smallest doses of radiation possible that will still provide diagnostic images, says Dr. Douglas. Across the practice, we have set up dose reduction guidelines for CT protocols. In addition, Wake Radiology participates in the Image Gently initiative sponsored by the Alliance for Radiation Safety in Pediatric Imaging. There s not a law or a mandate about this, Dr. Douglas notes. I get scans from around the state, and the doses really vary. Some of them are frighteningly high unnecessarily high. In some cases, radiation can be avoided altogether. Kids are smaller, so oftentimes an ultrasound can be more diagnostic in a child than in an adult, Dr. Townsend says. If you or I come to the ER with a pain in the right lower quadrant, you re pretty much going to head to CT to look for appendicitis. While that is an option in children, a lot of times an ultrasound will give you that answer. If that doesn t give you the answer, then you can go to the next test. Ultrasound is A long-axis ultrasound view of a child s appendix. A cross-sectional view of a child s inflamed appendix. These images illustrate how ultrasound can be used to identify appendicitis in children, instead of a CT, which has the risk of radiation exposure. a step you would not necessarily consider in an adult. Dr. Townsend recently gave a presentation to the Society of Pediatric Radiology on the declining use of CT in pediatric hospitals. He was lead author for the article Current Use of Computed Tomographic Urography: Survey of the Society of Uroradiology that appeared in the January/February 2009 issue of Journal of Computer Assisted Tomography. Concerns about radiation exposure can come from clinicians themselves, as well as from the pediatric radiologist, Dr. Lerner notes. In cases of children with chronic illnesses who are being monitored, the clinician may bring it up. He or she may say, I really want to order that CT, but is there some other way we can get this information? In other cases, the pediatric radiologist may raise the issue if a study has been ordered and it is not clear that it is the most appropriate imaging modality. Where we d like it to start, she says, is before the study is done, when the physician says, This is what s going on with my patient, and I m not quite sure which imaging would be suitable at this point. That s the best place for communication to begin. Both Dr. Lerner and Dr. Meyer have been at the forefront of research into radiation exposure in children through their pediatric fellowships at Duke University Medical Center. Most recently, Dr. Meyer was lead author and Dr. Lerner a coauthor of a forthcoming article on radiation dose in pediatric cardiac CTA. That s a fairly new application of CT in pediatrics, Dr. Meyer explains. One of the questions still outstanding was what kind of radiation dose those children would receive in the process of having a coronary CTA or a CT scan to specifically look at their hearts and their coronary arteries. I worked with Dr. Frush and the other pediatric radiologists and medical physicists at Duke to assess what the radiation dose would be for that particular study. Donald P. Frush, MD, is a leading authority on dose reduction for pediatric patients. In the process of conducting the research, Dr. Meyer says, she learned practical ways to manage the dose so it would be as low as possible. I got a deeper understanding of how to manage the radiation dose associated with CT to minimize the risk to our patients. Her research received a fellow s research prize at the 2008 Radiological Society of North America annual meeting. A Stand-alone Outpatient Office Dedicated to Pediatric Patients Located just off the beltline in Raleigh, Wake Radiology s new stand-alone pediatric imaging office at 4301 Lake Boone Trail has been designed especially for children and their families. Here, Wake Radiology s four dedicated pediatric radiologists will treat patients from newborn to 18 years old. The office will be open weekdays from 8 a.m. to 5 p.m. Outpatient services include x-ray, ultrasound, fluoroscopy, and nuclear medicine. The outpatient office offers a convenient alternative for follow-up appointments after hospitalization. MRIs for pediatric patients are provided at Wake Radiology Raleigh MRI Center and, for younger patients, at WakeMed. Pediatric sedation is not offered

at outpatient offices. The new office has been designed with children and their families in mind.

Child-friendly waiting and examination rooms, decorated with eye-catching murals and bright colors, welcome patients and their families. There are separate well-child and sick-child waiting rooms.

With every decision we have made about the new office, we have been mindful of our mission in pediatric radiology, which is to care for the children we see the way we would want our own to be

6 at outpatient offices. The new office has been designed with children and their families in mind. The 2,300-square-foot facility is located on the first floor, just a few steps from plentiful free parking. Child-friendly waiting and examination rooms, decorated with eye-catching murals and bright colors, welcome patients and their families. There are separate well-child and sick-child waiting rooms. Spacious family rooms give parents a place to feed and change their children and to speak privately with their radiologist. With every decision we have made about the new office, we have been mindful of our mission in pediatric radiology, which is to care for the children we see the way we would want our own to be treated, says Douglas. Our goal is to reduce anxiety and help our patients and their families feel reassured, while collaborating with their clinicians to find the answers they need. We re proud to be a part of the terrific pediatric community here in the Triangle. Meet the s Margaret R. Douglas, MD Director of Pediatric Imaging Medical School University of Virginia School of Medicine, Charlottesville Residencies Pediatrics, University of Alabama Children s Hospital, Birmingham; Diagnostic Radiology, University of Virginia Hospital, Charlottesville Fellowship Pediatric Radiology, University of Colorado Health Sciences Center, Denver Certifications American Board of Radiology Diagnostic Radiology, American Board of Radiology Pediatric Radiology, American Board of Pediatrics Memberships Radiological Society of North America, Society of Pediatric Radiology, Southern Society for Pediatric Radiology Joined practice in 2000 Catherine B. Lerner, MD Medical School Columbia University College of Physicians and Surgeons, New York Residency Diagnostic Radiology Chief Resident, Duke University Medical Center, Durham Fellowship Pediatric Radiology, Duke University Medical Center Certification American Board of Radiology Diagnostic Radiology Memberships Radiological Society of North America, Society for Pediatric Radiology, North Carolina Medical Society, Wake County Medical Society Laura T. MEyer, MD Medical School Duke University School of Medicine, Durham Residency Diagnostic Radiology, Duke University Medical Center Fellowship Pediatric Radiology with special emphasis in cardiovascular imaging, Duke University Medical Center Certification American Board of Radiology Diagnostic Radiology Memberships Radiological Society of North America, Society for Pediatric Radiology, North Carolina Medical Society, Wake County Medical Society Brent A. Townsend, MD Medical School Duke University School of Medicine, Durham Residency Diagnostic Radiology, Brigham and Women s Hospital Boston Fellowship Pediatric Radiology, Children s Hospital Boston Certification American Board of Radiology Diagnostic Radiology Memberships Radiological Society of North America, Society for Pediatric Radiology, North Carolina Medical Society, Wake County Medical Society Wake radiology EXPRESS SCHEDULING STREAMLINE YOUR SCHEDULING 1 number, 14 locations to serve you. With Wake Radiology s Express Scheduling, scheduling patients throughout the region takes only one call or fax to order any service. As an additional feature, Wake Radiology Express Schedulers will contact referring physicians patients to coordinate the best date, time, and location for their procedures. WR Express Scheduling Wake Radiology Pediatric Imaging 4301 Lake Boone Trail, Suite 100 Raleigh, NC Scheduling: wakerad.com

Back to Basics: What Imaging Test should I order? Jeanne G. Hill, M.D. Pediatric Radiology Medical University of South Carolina

Back to Basics: What Imaging Test should I order? Jeanne G. Hill, M.D. Pediatric Radiology Medical University of South Carolina Disclosure Neither I nor any member of my immediate family has a relevant