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MRI evaluation of non pulsatile unilateral pediatric proptosis
9-1 • C ~ T R A L VENOUS CATHETER MOTION INCHILDHEN~ A PITFALL IN CATHETER LOCALrZATION ON CHEST RADIOGRAPHY, satinder P. Singh, M.D., Stuart A. ~-': 1 ~yal, M.D., Gary L. Hedlund, M.D., Gar~ T. Barnes, Ph.D., University of Alabama at Birmingham, Birmingham, AL. PURPOSE: TO define experimentally and clinically the new observation of central veno~s {CV) catheter motion causing difficulties in catheter localization~. ~ETHODS: Following the recognitio n of CV catheter m o t i o n i n iO index patients, we z0nducted a prospective two,month review o ~ chest~radlographs in our intensive care Jnlt (ICU). Serial radiographs were evaluated for change in catheter tip position iscribed to motion artifact. An in vitro model is being developed to replicate clinical ~arameters. ExperlmentalIy, catheter movement, exposure lime, catheter opacity, and ~dlographic projections will be analyzed and their impact on catheter localization shall I be recorded. RESULTS: In i0 clinical index patients, CV catheter motioncaused confusion in localizing catheter tip, varying from misassignme~t to the superior vena cava from the right atrium to total disappearance of the catheter. Twelve of the 329 9rospectively reviewed ICe radiographs demonstrated similar findings. In vitro evaluation of this phenomenon will be performed. CONCLUSION: Catheter motion artifact is an important factor in assessing catheter p0sltion on" Ice chest radiographs. Catheter removal or change in position may be mimicked by this artifact. Conclusions of the experimental results will be presented.
9-3 MR1EVALUATIONOF NON PULSATILEUNILATERALPEDIATRICPROPTOSIS. Kundan L. Gunta. M. D. Daisy Gupta, Bradey S. Shore, M.D Tulane University Medical Center, New Orleans, Louisiana Purpose: To establish the role of MRI, including contrast enhancement and various pulse sequences in the evaluation of non pulsatile unilateral pediatric proptosis. Materials and Method: Twenty-six pediatric proptosts were examined with a 1.5 T GE MRI unit. Contrast enhancement gradient echo, and fat suppression technique were utilized. Results: A number of lesions were found to account for the patients' proptosia, including hamangioma, lymphangioma, metastatic disease and Grave's ophthaimopadiy, as well as other entities. Contrast enhancement and varied pulse sequences proved of benefit in detection and characterization of these pathologies. Conclusion: MRI is useful in the evaluation of the etiology of pediatric proptosts. Contrast enhancement and varied pulse sequences only add to the utilityand science of this modality.
9-5 CORRELATIONOF CYSTOGRAPH1CBLADDERMORPHOLOGYAND NEUROANATOMYIN BOYSWITH POSTERIOR URETHRALVALVES, David A. Bloom, M.D., Robert L Lebowitz, M.D., Stuart B. Bauer, M.D., Boston Children's Hospital, Boston, MA Purpose: We have observed a difference in the appearance of the body of the bladder and its base in boys with severely obstructing posterior urethral valves. We wanted to determine 1) was this a reproducible finding and 2 ) was there an anatomic a n d / o r physiologic explanation for it. Methods: We reviewed the initial voiding cystourethrogram in 47 boys with severe posterior urethral valves. The interureteric ridge was used as the division between the body and base of the bladder. The presence of trabeculation for each region was recorded• Results: Ages ranged from 1 day to 6 years at the time of initial cystographic evaluation (median 14 days). The body of the bladder was trabeculated and the base smooth in 72% (34 patients). In the remaining boys, both the body and base were smooth. In no patient was the base trabeeulated. Conclusions: The eystographie morphology of the urinary bladder in boys with posterior urethral valves can be explained by the neuroanatomy. The body of the bladder (parasympathetic, cholinergic), which contracts during micturition against the urethral obstruction, becomes trabeculated. The bladdgr base (sympathetic, adrenergic), which relaxes during voiding, remains smooth. Thus, our observation reflects the normal innervation of the urinary bladder.
9-2 ITLE: Preoperative Imaging of Symptomatic Vascular Rings - Which Tests are Necessary? UTHORS: Sleight BK, Hedlund GL, and Royal SA. URPOSE: To evaluate the diagnostic u t i l i t y , cost effectiveness, and outcomes of patients i t ~ p t o m a t i c vascular rings utilizing divergent imaging algorithms. ATERIALSAND METHODS: The records of 27 patients, from two affiliated institutions from 991 to 1995, with proven vascular rings were reviewed retrospectively. Data reflecting iagnostic testing, projected 1995 costs for imaging and outcome from surgical repair was ellected. A survey from the Society for Pediatric Radiology reflecting current membershih" ractice strategies for imaging symptomatic vascular rings was conducted. IESULTS: In the imaging evaluation of suspected symptomatic vascular rings, Institution 'A" utilized chest radiography, esophagography, and generally CT or MRI; whereas Institutio~ 'B" predominantly utilized chest radiography, ultrasonography, and angiography. Surgical )utcomes were similar from the two institutions, though the imaging related costs were ( ;ignificantly less from Institution "A". All operative patients underwent a l e f t :horacotomy. Results of the Society for Pediatric Radiology vascular ring imaging survey ~ill be presented. ~ONCLUSION: Accurate diagnostic imaging is critical for evaluation of symptomati.c vasculam ~ h this study does not support the routine use of advanced technologies i n the imaging algorithm for suspected vascular rings. Considerable costs savings from a tailored liagnostic workup can be achieved with acceptable surgical outcomes.
9-4 SONOGRAPHIC MEASUREMENTS OF NEONATAL THYROID GLAND Ellen Marie Yetter. MD.. A.Vade, MD., M.E.Gottschalk, MD., P.Subbainh, Ph.D., Loyola University Medical Center, Maywood, IL Purvnse: This study was done to establish normal dimensions of the thyroid gland ill euthyroid neonates. Methods: Ultrasound evaluation of the thyroid gland was performed in the first week of life in 54 term neonates ranging in gestatioual age 36 - 41 weeks and birth weight 2040-4790 gin. Measurements of the thyroid lobes were done in transverse (T), anteroposterior (2%)and longitudinal (L) planes. All neonates had normal thyroid stimulating hormone (TSH) levels at birth. Results: The mean measurements for tight thyroid lobe were 6.6 ram, 7.7 mm and 17.5 ram in transverse, anteroposteriur and longitudinal planes respectively. The corresponding measurements for the left thyroid lobe were 6.8 ram, 7.6 inm, and 17.0 ram. Total transverse, anteropostetior, length, area (TxA) and volume (TxAxL) measurements were calculated based on the sum of the respective measurements obtained on each thyroid lobe. There was no significant linear correlation of these measurements noted with gestational age, birth weight or TSH levels. The correlation coefficients between total area, total transverse, total anteroposterior and total length vs. total volume were 0.7 or less. Conclusion: In term neonates sonegraphic measurements of thyroid lobes should be obtained in all three planes for reliable assessment of thyroid volume.
10-1 REDUCING THE NUMBEROF RADIOLOGYRESIDENTS: ANTITRUSTAND ACGME/RRCACTION, 1ohnJ. Smith.M.D...I.D., S.B. Gay, M.D., Universityof Virginia Health Sciences Center, Charlottesville,VA Purvose: To investigatethe antitrust implicationsif the Accreditation Counc'd for Graduate Medical Education (ACGME)and/or the Residency ReviewCommitteein DiagnosticRadiology (RRC) were to attempt to limit the number of radiologyresidency positions. Method.,;: Review of antitrust decisions, current events affectinggraduate medical education (GME), and ACGME/RRCprocedures. Results: Decreased demand for radiologists,proposed cuts in GME funding,and pressure to train fewer specialistphysicianshave produced calls to limitthe number of resideney positions accredited by the ACGME/RRC. Reductions could be achieved if the ACOME/RRCwere to increase accreditation standards so as to eliminateweaker programs, or by setting an overall cap on availablepositions. Numericallimitscould also be imposedby federal or state governments, with or without the participationof the ACGME/RRC. Antitrustimplicationsunder the Sherman Act might apply in any of these cases. Conclusiop: The risk of antitrust liabilityis smallwhen the ACOMETRRCacts with an explicit government mandate. Increasingaccreditation standards to increase program qualityand decrease numbers probably also would withstand antitrust scrutiny. An explicitACGME/RRC limit on training positions,without any governmentmandate, would likelyrisk antitrust liability.
9-3 MR1EVALUATIONOF NON PULSATILEUNILATERALPEDIATRICPROPTOSIS. Kundan L. Gunta. M. D. Daisy Gupta, Bradey S. Shore, M.D Tulane University Medical Center, New Orleans, Louisiana Purpose: To establish the role of MRI, including contrast enhancement and various pulse sequences in the evaluation of non pulsatile unilateral pediatric proptosis. Materials and Method: Twenty-six pediatric proptosts were examined with a 1.5 T GE MRI unit. Contrast enhancement gradient echo, and fat suppression technique were utilized. Results: A number of lesions were found to account for the patients' proptosia, including hamangioma, lymphangioma, metastatic disease and Grave's ophthaimopadiy, as well as other entities. Contrast enhancement and varied pulse sequences proved of benefit in detection and characterization of these pathologies. Conclusion: MRI is useful in the evaluation of the etiology of pediatric proptosts. Contrast enhancement and varied pulse sequences only add to the utilityand science of this modality.
9-5 CORRELATIONOF CYSTOGRAPH1CBLADDERMORPHOLOGYAND NEUROANATOMYIN BOYSWITH POSTERIOR URETHRALVALVES, David A. Bloom, M.D., Robert L Lebowitz, M.D., Stuart B. Bauer, M.D., Boston Children's Hospital, Boston, MA Purpose: We have observed a difference in the appearance of the body of the bladder and its base in boys with severely obstructing posterior urethral valves. We wanted to determine 1) was this a reproducible finding and 2 ) was there an anatomic a n d / o r physiologic explanation for it. Methods: We reviewed the initial voiding cystourethrogram in 47 boys with severe posterior urethral valves. The interureteric ridge was used as the division between the body and base of the bladder. The presence of trabeculation for each region was recorded• Results: Ages ranged from 1 day to 6 years at the time of initial cystographic evaluation (median 14 days). The body of the bladder was trabeculated and the base smooth in 72% (34 patients). In the remaining boys, both the body and base were smooth. In no patient was the base trabeeulated. Conclusions: The eystographie morphology of the urinary bladder in boys with posterior urethral valves can be explained by the neuroanatomy. The body of the bladder (parasympathetic, cholinergic), which contracts during micturition against the urethral obstruction, becomes trabeculated. The bladdgr base (sympathetic, adrenergic), which relaxes during voiding, remains smooth. Thus, our observation reflects the normal innervation of the urinary bladder.
9-2 ITLE: Preoperative Imaging of Symptomatic Vascular Rings - Which Tests are Necessary? UTHORS: Sleight BK, Hedlund GL, and Royal SA. URPOSE: To evaluate the diagnostic u t i l i t y , cost effectiveness, and outcomes of patients i t ~ p t o m a t i c vascular rings utilizing divergent imaging algorithms. ATERIALSAND METHODS: The records of 27 patients, from two affiliated institutions from 991 to 1995, with proven vascular rings were reviewed retrospectively. Data reflecting iagnostic testing, projected 1995 costs for imaging and outcome from surgical repair was ellected. A survey from the Society for Pediatric Radiology reflecting current membershih" ractice strategies for imaging symptomatic vascular rings was conducted. IESULTS: In the imaging evaluation of suspected symptomatic vascular rings, Institution 'A" utilized chest radiography, esophagography, and generally CT or MRI; whereas Institutio~ 'B" predominantly utilized chest radiography, ultrasonography, and angiography. Surgical )utcomes were similar from the two institutions, though the imaging related costs were ( ;ignificantly less from Institution "A". All operative patients underwent a l e f t :horacotomy. Results of the Society for Pediatric Radiology vascular ring imaging survey ~ill be presented. ~ONCLUSION: Accurate diagnostic imaging is critical for evaluation of symptomati.c vasculam ~ h this study does not support the routine use of advanced technologies i n the imaging algorithm for suspected vascular rings. Considerable costs savings from a tailored liagnostic workup can be achieved with acceptable surgical outcomes.
9-4 SONOGRAPHIC MEASUREMENTS OF NEONATAL THYROID GLAND Ellen Marie Yetter. MD.. A.Vade, MD., M.E.Gottschalk, MD., P.Subbainh, Ph.D., Loyola University Medical Center, Maywood, IL Purvnse: This study was done to establish normal dimensions of the thyroid gland ill euthyroid neonates. Methods: Ultrasound evaluation of the thyroid gland was performed in the first week of life in 54 term neonates ranging in gestatioual age 36 - 41 weeks and birth weight 2040-4790 gin. Measurements of the thyroid lobes were done in transverse (T), anteroposterior (2%)and longitudinal (L) planes. All neonates had normal thyroid stimulating hormone (TSH) levels at birth. Results: The mean measurements for tight thyroid lobe were 6.6 ram, 7.7 mm and 17.5 ram in transverse, anteroposteriur and longitudinal planes respectively. The corresponding measurements for the left thyroid lobe were 6.8 ram, 7.6 inm, and 17.0 ram. Total transverse, anteropostetior, length, area (TxA) and volume (TxAxL) measurements were calculated based on the sum of the respective measurements obtained on each thyroid lobe. There was no significant linear correlation of these measurements noted with gestational age, birth weight or TSH levels. The correlation coefficients between total area, total transverse, total anteroposterior and total length vs. total volume were 0.7 or less. Conclusion: In term neonates sonegraphic measurements of thyroid lobes should be obtained in all three planes for reliable assessment of thyroid volume.
10-1 REDUCING THE NUMBEROF RADIOLOGYRESIDENTS: ANTITRUSTAND ACGME/RRCACTION, 1ohnJ. Smith.M.D...I.D., S.B. Gay, M.D., Universityof Virginia Health Sciences Center, Charlottesville,VA Purvose: To investigatethe antitrust implicationsif the Accreditation Counc'd for Graduate Medical Education (ACGME)and/or the Residency ReviewCommitteein DiagnosticRadiology (RRC) were to attempt to limit the number of radiologyresidency positions. Method.,;: Review of antitrust decisions, current events affectinggraduate medical education (GME), and ACGME/RRCprocedures. Results: Decreased demand for radiologists,proposed cuts in GME funding,and pressure to train fewer specialistphysicianshave produced calls to limitthe number of resideney positions accredited by the ACGME/RRC. Reductions could be achieved if the ACOME/RRCwere to increase accreditation standards so as to eliminateweaker programs, or by setting an overall cap on availablepositions. Numericallimitscould also be imposedby federal or state governments, with or without the participationof the ACGME/RRC. Antitrustimplicationsunder the Sherman Act might apply in any of these cases. Conclusiop: The risk of antitrust liabilityis smallwhen the ACOMETRRCacts with an explicit government mandate. Increasingaccreditation standards to increase program qualityand decrease numbers probably also would withstand antitrust scrutiny. An explicitACGME/RRC limit on training positions,without any governmentmandate, would likelyrisk antitrust liability.