Download Wake Radiology Expands Pediatric Imaging

Triangle Edition | October 2009
VOL. 11, NO. 10
Wake Radiology Expands
Pediatric Imaging
cover
story
Wake Radiology Expands Pediatric
Imaging Practice
Dedicated Pediatric Radiologists 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
TRIANGLE edition m.d. news
October 2009
Bryan Regan Photography
Dr. Townsend and technologist prepare a 10-year-old child for a fluoroscopy
scan of her abdomen.
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.”
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 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
Pediatric Radiologist 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
0.02
1
3 views of the ankle
0.0015
1/14th
Tc-99m radionuclide cystogram
0.18
9
Tc-99m radionuclide bone scan
4.0–6.2
Up to 310
<0.33
16
Fluoroscopic VCUG
Brain CT
2.0
100
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.
TRIANGLE edition m.d. news
October 2009
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
TRIANGLE edition m.d. news
October 2009
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
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
TRIANGLE edition m.d. news
October 2009
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 Pediatric Radiologists
Margaret R. Douglas, MD
Laura T. MEyer, MD
Pediatric Radiologist
Director of Pediatric Imaging
Pediatric Radiologist
• Medical School | Duke University School of Medicine, Durham
• 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
• Residency | Diagnostic Radiology, Duke University Medical Center
Catherine B. Lerner, MD
Brent A. Townsend, MD
Pediatric Radiologist
• 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
Pediatric Radiologist
• 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
• 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
•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
919-232-4700
TRIANGLE edition m.d. news
October 2009
Wake Radiology Pediatric Imaging
4301 Lake Boone Trail, Suite 100
Raleigh, NC 27607
Scheduling: 919-232-4700
wakerad.com
TRIANGLE edition m.d. news
October 2009