Download Developments in Imaging: `A Huge Difference in Primary Care`

Roundtable
Editorial Board members and other experts discuss important advances in pediatrics.
Developments in Imaging:
‘A Huge Difference in
Primary Care’
Here is another in our series of discussion and debate over advances in
pediatrics over the past 40 years.
~ Stanford T. Shulman, MD
James S. Donaldson, MD: The past 40
years have been revolutionary with regard
to imaging. Back in 1971, radiology consisted of plain X-ray and fluoroscopy with
an image intensifier. In Sweden, radiologists were doing great angiography, so we
also had angiography. Additionally, we had
nuclear medicine. In the 1970s, ultrasound
became more widely used, but that was the
gamut of available imaging modalities.
The 1980s brought computerized tomography (CT) scans. Godfrey Hounsfield invented the first CT scanner in
1972, but it didn’t get to clinical applications until the 1980s. In the 1980s, we
also saw the introduction of magnetic
resonance imaging (MRI) and positron
emission tomography (PET) scanning,
which later became a fusion technology
with PET CT and PET MRI.
One of the revolutionary changes in
imaging in the 1980s was digital imaging, or computed radiography, which led
to picture archiving and communication
systems (PACS). PACS began because
of a Digital Imaging and Communications in Medicine (DICOM) standard
that had been introduced across the field
of imaging. All the vendors, even different vendors that agreed to a particular
digital standard, could communicate.
The revolution to PACS was amazing.
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Interventional radiology, which existed as angiography back in 1970s,
really developed in the 1970s through
the 1990s in adult medicine. However,
pediatric interventional radiology has
lagged significantly behind that. I think
these modalities were introduced to
children’s hospitals and to university
settings at different times, depending
on the institution’s resources and other
factors. But all of those developments
have changed the field of what now we
call medical imaging.
Ram Yogev, MD: I was much more
impressed by the ability of invasive radiology. We send patients home much earlier.
We now have the ability to drain abscesses in areas that help us in diagnosis, and
much better treatment to relieve all fluids. I
think invasive radiology caused some surgeons to look for another job.
Stanford T. Shulman, MD: As a fellow, almost 40 years ago, I recall recognizing on a plain film a right pleural
effusion. This observation led to a potential diagnosis of a liver abscess in a
child. It was very difficult, given what
we had available at that time, to confirm
that kind of diagnosis. We relied upon a
scintigraphic liver scan, which did not
give very good imaging at all. Then you
fast-forward several decades, and you
have the ability to image intra-abdominal structures.
Thomas J. Selva, MD: I’ve been at
this now for about 22 years. It used to take
longer to get the patient on and off the
Panelists
James S. Donaldson, MD
Chairman, Medical Imaging
(Radiology), Earl J. Frederick
Professor of Radiology; Professor
of Radiology, Northwestern
University Feinberg School of
Medicine, Chicago, IL
Ram Yogev, MD
Susan B. DePree Founders’ Board
Professor in Pediatrics, Northwestern University, The Feinberg School
of Medicine; Director, Pediatric, Adolescent and Maternal HIV Infection;
and Deputy Director for Research,
Clinical Sciences and Director,
Clinical and Translational Research
Program, Children’s Memorial
Research Center, Chicago, IL
Stanford T. Shulman, MD
Virginia H. Rogers Professor of
Pediatric Infectious Diseases,
Northwestern University, The
Feinberg School of Medicine;
and Chief, Division of Infectious
Diseases, The Children’s Memorial
Hospital, Chicago, IL
Thomas J. Selva, MD
General pediatrician; Professor of
Clinical Child Health; Associate
Department Chair for Clinical
Quality Medical Director of Child
Health Chief-Division of General
Pediatrics Medical Director of
Ambulatory Care – MU Health
Care System, Columbia, MO
Welton M. Gersony, MD
Alexander S. Nadas Emeritus
Professor of Pediatrics, College
of Physicians and Surgeons, Columbia University, New York, NY
Robin H. Steinhorn, MD
Raymond and Hazel Speck Berry
Professor of Pediatrics; Vice Chair
of Pediatrics and Head, Division
of Neonatology; Interim Head,
Division of Hospital Based Medicine, Children’s Memorial Hospital,
Chicago, IL
Stan L. Block, MD, FAAP
Professor of Clinical Pediatrics,
University of Louisville, and University of Kentucky, Lexington, KY;
President, Kentucky Pediatric and
Adult Research, Inc.; and general
pediatrician, Bardstown, KY
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Roundtable
gantry than it would to do a multidetector helical CT from which you can have
a 3-D reconstruction. More recently, I’ve
watched our plastic surgeons show 3-D reconstruction to the parents and say, “This
is what I’m going to make your child look
like when I’m done.” It’s impressive to
watch all that progress.
Dr. Donaldson: As an insider, it has
been incredible for me to watch the CT
scanner develop. It’s enabled us to see
anatomy down to almost a submillimeter
resolution. The exploratory laparotomy
is a thing of the past. We’ve had very
few negative appendectomies because
we know in advance if the child does or
doesn’t have appendicitis. CT scan use
has increased dramatically since the machine was invented in the 1980s.
Around 2000, there were some landmark articles that showed the potential
risk of radiation to children and the potential risk of developing a cancer related
to the radiation.1,2 So now we’ve begun to
ratchet back the use of CT scan. When we
use the CT scanner, we reduce the dose almost to the point where we get such fuzzy
images they’re not diagnostic anymore.
So we’ve gone from thinking it was the
absolute best tool in the world to something we’ve got to be careful of. The radiation concern has now come full circle,
and in the past decade, we’ve become
aware of the potential harm.
Welton M. Gersony, MD: Imaging
techniques have revolutionized the field of
pediatric cardiology. Echocardiography
has become an extremely important modality for the diagnosis of congenital heart
disease; in some instances, even better
than angiography. MRI and CT are also
helpful at times, but often unnecessary.
They should not be overused. This is especially true for CT, which has long-term
risks related to radiation. Unfortunately,
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as clinicians rely more on imaging techniques, clinical skills have eroded. This
trend is a growing negative for the full assessment of a child with congenital heart
disease, and represents a challenge for
those who are training the next generation
of cardiologists. For every advance, there
is the threat of a step backwards, which
should not be overlooked.
Dr. Donaldson: Functional MRI
(fMRI) has allowed us to see blood oxygen activation and consumption. We can
see when certain parts of the brain are ac-
One of thhe revvoluutioonaary
changes wass diggitaal im
magginng,
which led to pictturee arrchivinng
and coommuniccatiionn
systeems (PAC
CS)).
tivated, and it allows surgeons more precision and avoidance of critical functional
areas. They can go in and resect the tumor,
and know what they need to be careful of.
The functional aspect certainly is new and
different from what radiology had been.
We also see function with some of the
nuclear medicine testing. In PET imaging,
metabolites are taken up with an isotope
and we can see which areas are more active or less active, and which tumors are
still viable or no longer viable. So certainly, it has gone from an anatomic specialty
to add other aspects such as function.
As far as interventional radiology, it
was interesting that some of the technical developments in catheters and guide
wires in the 1990s were largely driven by
the desire to instrument the coronary arteries. Many Americans need coronary artery
instrumentation and catheterization. Previ-
ously, we didn’t have catheters and materials that were able to perform sophisticated
techniques in small children because the
materials were too big. So the manufacturers of these devices figured out how to
make tinier wires and smaller catheters.
The coronary market drove the product to
be much more user-friendly in pediatrics,
and that has affected the development of
interventional radiology in pediatrics.
Robin H. Steinhorn, MD: Not only
are you able to now provide detailed imaging of almost every organ of newborn
infants, but the imaging techniques for
fetal medicine have advanced tremendously in the past 5 years. So for instance, now when we’re trying to determine how severe a diaphragmatic hernia
is going to be, the mother gets an MRI
of the fetus and we review it before delivery. We see exactly what we are going
to encounter after the baby is born. It’s
nothing short of astonishing how much
detail we are able to get.
Stan L. Block, MD, FAAP: Imaging
has added so much detail to what we do in
routine medicine. I am a team physician for
our local football team. I relish the thought
of being able to look at a knee a day or two
after an injury and say either, “We need to
send you to the orthopedist, or “Your knee
is OK. You have a tiny meniscal tear, you
can wait it out.” Better imaging makes a
huge difference for us in primary care.
REFERENCES
1. Nickoloff EL, Alderson PO. Radiation exposures to patients from CT: reality, public perception, and policy. AJR Am J Roentgenol.
2001;177(2):285-287.
2. Donnelly LF, Emery KH, Brody AS, et al.
Minimizing radiation dose for pediatric body
applications of single-detector helical CT: strategies at a large Children’s Hospital. AJR Am J
Roentgenol. 2001;176(2):303-306.
doi: 10.3928/00904481-20120206-13
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