Pediatric Imaging - Children's Mercy Hospitals and Clinics

Vol. 3Issue 32011Innovations inPediatric Imaging

dearCOLLEAGUES,In this issue of Physician’s Update, weare highlighting the Children’s MercyRadiology Department and a few of thelatest imaging procedures we are able tooffer you and your patients.Radiation exposure is very important to usat Children’s Mercy Hospital. In this issue,Dr. Lisa Lowe and Dr. Steve Welch discusswhat we are doing to reduce that exposureat Children’s Mercy, and Nancy Burchell,Radiation Safety Officer, discusses how weare recording all of the radiation exposurea patient obtains at Children’s Mercy on aradiation passport that patients take withthem.Also in this issue, Nicki Stang, Child LifeSpecialist, reviews the importance of ourChild Life team and our Sedation Teams inreducing the anxiety, length of exam, andneed for deep sedation; Dr. Fickenscherdiscusses the many benefits of our newpediatric PET/CT scanner; and Dr. NeilMardis highlights functional imaging andother cutting edge techniques we aredoing with MRI.Finally, I offer a brief introduction to ourphysician portal, which will bring imagesto your computer, laptop or iPhone.We strive to keep the highest level ofimaging services for children and theirfamilies. Please let us know what we cando to better serve you and your patients.Sincerely,James C. Brown, MDChairmanDepartment of Pediatric RadiologyChild Life and Sedation TeamDecrease Procedure AnxietyGetting children to hold still longenough for CT scans or MRI’scan be difficult without theuse of sedation, but the combinedefforts of Radiology, Child Life and theSedation team at Children’s Mercy havedemonstrated success in decreasingthe need for sedation in theseprocedures.Child Life specialists work withthe Sedation Team and radiologytechnicians to assess the patient toprovide the best experience possibleand complete the exam or proceduresuccessfully.“Child Life gets the patient and familyfrom the waiting area and starts tobuild rapport with them knowingwhether or not a child will be a goodcandidate in completing the CT,” saysNicki Stang, Child Life OutpatientSupervisor. “We work with sleepdeprived patients, anesthesia patients,and sedation patients all for thecommon goal of trying to complete thisprocedure without the use of sedation.”Child Life and the Sedation Teamwork very closely together to makethe experience as comfortable aspossible, employing education, as wellas calming and distraction techniquesincluding singing songs, readingstories, and using comforting positions.Parents are always allowed to help withthe process.“Our Sedation Team also uses topicalagents for IV starts that helps reducethe child’s experience of pain duringcatheter insertion,” says Stang. “Wehave highly skilled nurses in this areaas well if the child does need to besedated.”Not all children will need sedation.Children’s Mercy urges doctors tonot prescribe anything to patients forsedation or self-sedation.“We try to do any scans withoutsedation of the child if possible, so it isimportant that if a patient is referred tous they should not have any sedationorder before arriving to the hospital,”says Kaylene Wiley, RN, Sedation Team.Since 2000, Children’s Mercy hasseen a continual drop in the number ofchildren that are sedated. According tostudies done in 2004, there are only5 percent of cases seen in radiologyrequire sedation.

CT/PET Scans: TWO iN ONEAs Children’s Mercy Hospitalsand Clinics continues to grow itspediatric hematology/oncologyprogram, the need to begin performingPET/CT scans on site moved up thepriority list. Thus, as of this past January,the Department of Radiology begandoing the combined scan in house,introducing a more reliable, advancedalternative to the traditional side-by-sidevisual comparison of PET and CT scans.While PET (positron emissiontomography) scans show metabolicor chemical activity in a body, CT- computed tomography - imaginghighlights the body’s anatomicalstructures. The fusing of the two imagesis still a fairly new radiological technique,but the method has already emerged ashighly effective in showing detailed viewsof tumors, lymph nodes and metastaticlesions.And, when considering cancer patients,it’s the advanced precision of a PET/CTthat has made it the best standard ofcare.“A PET/CT is an essential diagnostictechnique for cancer patients, helpingto redefine cancer findings, altertreatment plans and - sometimes - helppatients avoid unnecessary surgeries,”says Kristin A. Fickenscher, MD,Pediatric Radiologist andan Assistant Professorof Radiology, UMKCSchool of Medicine.“As the only pediatrichospital in theregion thatis providingthis stateof-the-artprocedure,Children’sMercy isofferinganinvaluableresource forthe treatment of ourpediatric oncologypatients.”Oncology PET andPET/CT are used todiagnose, stage andrestage cancer aswell as to evaluate thepatient’s response totherapy. Specificallyin pediatric oncologypatients, PETparticularly aids in thediagnosis of Hodgkin’sdisease and non-Hodgkin’s lymphoma,conditions seen oftenin the Children’s MercyCancer Center.The new combinedPET/CT scanner housed at Children’sMercy is a 64-slice CT scanner and PETscanner in one unit. As one machine, theCT/PET scanner is able to perform allimaging at the same time.“Factoring in our commitment to theImage Gently campaign, we administerchild-size doses with all our PET/CTscans, minimizing exposure even onthe most sophisticated radiologicalprocedures,” adds Dr. Fickenscher.“Our approach allows us to use thecombination of PET/CT to its fullestcapabilities in order to have earlier andmore accurate detection of diseasesthan either CT or PET alonecan provide.”Dr. Fickenscher andher team are doingfour CT/PET scans aweek, but expect thatnumber to increaseas the oncologyprogram at Children’s Mercy continuesto expand.In addition, the PET/CT equipmentat Children’s Mercy can operate withcombined imaging or individual imaging- solely as a PET or a CT - as the casedictates. Thus, the versatility of thedevice allows other designated “Centersfor Excellence” at Children’s Mercy toalso take advantage of the benefits ofthe unit.The Children’s Mercy ComprehensiveEpilepsy Center, which received nationalrecognition as a Level IV epilepsy centerin 2010, uses the advancement ofPET to identify seizure focus sites inneurological patients, a critical step indiagnosing and treating epilepsy.“Now, our patients - no matter what theirconditions are - have the opportunity tocome to Children’s Mercy and have alltheir care and radiological needs metunder one roof,” adds Dr. Fickenscher.“Having a PET/CT in the Departmentof Radiology allows us to offer a lessdisruptive approach to providing the bestcare for our patients who are in need ofthe most advanced scans in pediatricmedicine.”For more information on PET/CT scansperformed at Children’s Mercy, contactthe Department of Radiology at (816)234-3270.

Imaging Gently:REDUCiNG RADiAtiON RiSKS FOr CHiLDrENThe risks of exposure to radiation have been known fordecades and the risks to children are not debatable.are two to 10 times more sensitive toradiation exposure than adults,” says Lisa Lowe,“ChildrenMD, Children’s Mercy Pediatric Radiologist andProfessor of Radiology, University of Missouri-Kansas CitySchool of Medicine. “Children’s tissues are more sensitivebecause they are still developing and they have a longerlifetime to manifest exposure, therefore they have more of achance of developing cancer.”Age at time of exposure is the most important risk factor. Fora given dose, it affects a child more than an adult becausethe latency period is much longer. This is a critical factor whendealing with babies or children with illnesses or injuries thatmay require frequent images early in their lives.That is why Children’s Mercy has been a strong proponentof the Image Gently guidelines supported by the Society forPediatric Radiology and the American Academy of Pediatrics.“Children’s Mercy has always followed the ALARA guidelines,advocating imaging with radiation at the lowest amountreasonably achievable,” says Dr. Lowe. “The Image Gentlycampaign is the next step. We are doing our part to helpeducate physicians regarding safe imaging.”One study found that less than 20 percent of imagingcenters adjusted doses for children. A review of scans sentto Children’s Mercy by outside imaging centers found thatchildren were receiving as much as 50 percent more radiationthan required and that the image area was often not optimallytargeted, resulting in exposure to surrounding tissues.Image GentlyPart of the problem has been the difficulty in actuallyquantifying radiation exposure. Trying to standardize dosesacross various technologies and measuring doses absorbedby organs and secondary exposure to non-imaged areas isdifficult, according to Steven Welch, MD, Children’s MercyPediatric Radiologist and Assistant Professor of Radiology,University of Missouri-Kansas City School of Medicine.Pediatric radiologists at Children’s Mercy recommend followingthe Image Gently guidelines, including:• Reducing or “child-sizing” the amount of radiation utilized• Scanning only when necessary• Scanning only the indicated region• Scanning once; multiphase scanning is usually notnecessary in children“We are always working with physicians to push the dosedownward without compromising quality,” says Dr. Welch.“Often, subspecialists will approach us about how to reduceexposure.”For example, Children’s Mercy ENT physicians partneredwith radiologists to reduce the dosage for sinus CT scan, a

commonly prescribed procedure. A screeningexam was implemented using 1/5 the doseof the previous technique, without affectingdiagnostic capabilities.“We start with ‘What do you want to know?’”says Dr. Welch. “You can up the dose andget a very pretty image, but it doesn’t addanything to the diagnostic capability.”Children’s Mercy radiologists use filteringsoftware, including a program written byNeil Mardis, MD, pediatric radiologist,which can reduce the “noise” in images sothat lower doses of radiation can be usedwhile still maintaining image quality. Thehospital also employs an American Board ofRadiology certified medical physicist who isinstrumental in helping to establish safetylevels.Children’s Mercy radiologists have alsodeveloped a series of materials for CommonlyRequested But Frequently MisunderstoodImaging Studies, which provide guidelinesand recommendations for various conditionsand procedures. The series can be found onthe hospital website at www.childrensmercy.org/radiology.Safe Alternatives“The addition of a single CT in an infantincreases risks of developing cancer from 25percent to 25.01 percent,” says. Dr. Lowe.“That is a very small number. But the personwho does develop a malignancy is 100percent affected.”Children’s Mercy offers a full range of imagingtechniques including no radiation alternativessuch as ultrasound, MRI and PET.“We start by looking at what is the right testfor the child and then child size the dosing tomake it appropriate,” says Dr. Welch. “We’retrying to change pediatric radiology, one childat a time, because every child matters.”DON’t FOrGEt YOUrDOSE PASSpOrtDoes your patient need an X-ray?Don’t forget to ask for his or herDose Passport first.Children’s Mercy is the first pediatrichospital in the region to use aDose Passport to record a patient’sradiation exposure.“We recognize that we need to limit radiation exposure,especially in children because they are the most vulnerable toits long-term effects,” says Nanci Burchell, Radiation Safety Officerat Children’s Mercy. “This is an efficient way to monitor thosedoses.”Currently in phase one ofimplementation, the DosePassport is distributedto parents as a 3.5x4.5card similar to a patient’svaccination record. Theparents are instructedto carry the card forsubsequent visits tothe hospital or to theirchildren’s doctoror dentist visits,recording every x-rayexam.Soon, the DosePassport willconvert into anelectronic format and willinclude dose amounts. At this time, thereare no government requirements for tracking radiationdosage, but Burchell believes this will change soon.“In many cases, the Dose Passport helps physicians andradiologists determine the best test for the clinical question beingasked,” adds Burchell. “Plus, this should help everyone avoidordering duplicate exams.”To learn more about the Dose Passports used at Children’s Mercy,call (816) 234-3270.

ADVaNCING THEDIaGNOSTICPOWERS OF MRIWith a 3 Tesla MRI unit, plus two 1.5 Tesla units, Children’sMercy is the only pediatric provider in the region capableof providing advanced pediatric neurological, orthopaedic,and cardiac imaging procedures.Beyond the powerful MRI unitsthemselves, Children’s Mercy isleading the way into advancedimaging using the current technologyin new ways to provide more detailedinformation to help physicians, surgeonsand parents make more informeddecisions.Functional ImagingFunctional imaging looks at functionsof different parts of the brain and usesunique paradigms to test differentfeatures, for example, what parts of thebrain are involved in motor activity orspeech.“The idea behind functional imaging isthat you can match areas of function tothe anatomic images we are acquiringand give neurologists a better idea ofwhat is going on in certain portionsof the brain,” says Neil Mardis, DO,pediatric radiologist. “So if you weregoing to plan for surgery, you couldmap the parts of the brain which areresponsible for specific activities orabilities and the locations of these areaswith respect to areas of pathology.”That information could then be usedto preserve more eloquent areas andpreserve function, or provide a betteridea of what sort of morbidity would beinvolved with surgery.Functional MRI may be useful in betterunderstanding differences in how thebrain works in autistic children, theeffect of resecting the seizure focusin the brain of a child with epilepticseizures, or determining thebest pathway to resect a tumor.Functional imaging is not inwidespread clinical use yet.Children’s Mercy has acquiredthe additional software to dofunctional imaging and Dr.Mardis hopes to start offeringfunctional MRI by fall 2011.“This is an advanced diagnosticprocedure. It is morecommonly used in patients witha known pathology or disorder,”he says. “If it is something youare considering, you shouldprobably discuss it with thespecialist or radiologist todetermine if it is going to yieldinformation that is clinicallyuseful.”Cartilage MappingCartilage mapping is a newtechnique which provides amore detailed look at cartilageto diagnose injuries at a muchearlier stage.“With cartilage disease, we were lookingat whether the cartilage is frayed,disfigured, or if there are cartilagedefects. The cartilage is alreadydamaged at this point,” says Dr. Mardis.“Using this new technique, we canlook at the microstructural makeup ofthe cartilage, and can see changes incartilage that happen before there ismacroscopic damage.”This could be important to injuryprevention as once cartilage is lost,growing it back is difficult and thecartilage that does grow back is not thesame.Children’s Mercy is also doing researchwith this technique to better understandthe makeup of healthy cartilage inchildren versus adults.For more information on MRI proceduresand these techniques, contactRadiology at (816) 234-3270.

Viewing X-Rays WitH tHE CLiCK OF A MOUSENo more relying only ondescriptions over the phone.No more being at themercy of the patient returning adisk of images. Soon, communityphysicians will have a better, fasteroption for viewing patients’ x-raysfrom the Department of Radiologyat Children’s Mercy Hospitals andClinics.Currently, doctors who refer patientsfor x-rays at Children’s Mercy donot have easy access for viewingimages. But, that’s set to changeas the Department of Radiologyintroduces a radiology physicianportal that will allow physicians toaccess patient images - includingCTs, nuclear medicine, MRIs andmore - with the click of a mouse.“All of our referring physicians willbe able to log in, view and haveaccess to their patients’ images assoon as they are made availableby our pediatric radiologists,” saysJames C. Brown, MD, DepartmentChair, Pediatric Radiologist andAssociate Professor of Radiologyat the UMKC School of Medicine.“We’ll be able to communicate moreeffectively with both parties beingable to review the images at thesame time.”Set to be an option on the hospital’sPhysician Portal website - www.childrensmercy.org/physicians -later this year, the radiology portalwill be password restricted forreferring physicians.To inquire more about the RadiologyPhysician Portal at Children’sMercy, call (816) 234-3272 or emailDr. James Brown atjcbrown@cmh.edu.Pediatric Radiology FacultyJames C. Brown, MDChairman, Department ofPediatric RadiologyAssociate Professor ofRadiologyBrent E. Cully, MDPediatric RadiologistSection Chief, Nuclear MedicineAssistant Professor of RadiologyPediatric InterventionalRadiology and Pediatric NuclearMedicineKristin A. Fickenscher, MDPediatric RadiologistProgram Director, PediatricRadiology FellowshipSection Chief, Fetal MRIAssistant Professor of RadiologyFetal MRI, Pediatric CardiacMRI, Pediatric PET/CTJoshua Knowlton, MDPediatric RadiologistDirector, Radiology MedicalStudent EducationAssistant Professor of RadiologyPediatric Cardiac MRI, PediatricMusculoskeletalEmily D. Kucera, MDPediatric RadiologistSection Chief, UltrasoundDirector, Radiology Services,Children’s Mercy SouthAssistant Professor of RadiologyPediatric Body ImagingC. Anthony Lawrence Jr., MDPediatric RadiologistDirector, Radiology Services,Children’s Mercy Clinics onBroadwayAssistant Professor of RadiologyPediatric Body ImagingLisa Lowe, MDPediatric RadiologistRadiology Program DirectorAcademic Chairman andProfessor of RadiologyPediatric NeuroradiologyNeil J. Mardis, DOPediatric RadiologistSection Chief, MRISection Chief, Cardiac ImagingAssistant Professor of RadiologyPediatric MRI, PediatricMusculoskeletal, Cardiac MRIand PET/CTMegan McDonald, DOPediatric RadiologistSection Chief, MusculoskeletalAssistant Professor of RadiologyPediatric MusculoskeletalDavid B. Nielsen, MDPediatric RadiologistDirector, Radiology Medical ITAssistant Professor of RadiologyPediatric NeuroradiologyKay Lynn North, DOPediatric RadiologistAssistant Professor of RadiologyPediatric Body ImagingBrenton D. Reading, MDPediatric RadiologistSection Chief, FluoroscopyAssistant Professor of RadiologyPediatric InterventionalRadiologyDouglas C. Rivard, DOPediatric RadiologistVice ChairmanSection Chief, InterventionalAssistant Professor of RadiologyPediatric InterventionalRadiology, Pediatric PET/CTCynthia Taylor, MDPediatric RadiologistDirector, Radiology Services,Children’s Mercy NorthlandAssistant Professor of RadiologyPediatric Body Imaging,Pediatric PET/CTCharlotte Waugh Moore, MDPediatric RadiologistAssistant Professor of RadiologyPediatric Body ImagingIn academic affiliation with theUniversity of Missouri-Kansas City.Steven Welch, MDPediatric RadiologistSection Chief, CTAssistant Professor of RadiologyPediatric Neuroradiology,Pediatric Musculoskeletal,Pediatric Body Imaging andTimothy Zinkus, MDPediatric RadiologistSection Chief, NeuroradiologyAssistant Professor of RadiologyPediatric Neuroradiology

Physician Services2401 Gillham RoadKansas City, MO 64108-4698Non-Profit Org.U.S. PostagePAIDKansas City, MOPermit #4301Return Service RequestedChildren’s Mercy is an equal opportunity/affirmative action employer and a UnitedWay Agency.Taylor14 years oldKelli and Tom Gabel don’t mind making the 70-miledrive from Topeka, Kan., to bring their daughterTaylor to Children’s Mercy for a radiologyappointment. Diagnosed in May 2009with stage 4 Hodgkin’s lymphoma, Taylorreceives a PET scan and other imagingprocedures about every month.Previously, they had to have proceduresdone in two different places, but thatroutine changed in January whenChildren’s Mercy installed its own PET/CT.“We were getting our scans at a place thatgenerally deals with adults and are not setup to handle kids like Children’s Mercy is,”says Kelli.The caring, child-centered approach of Children’sMercy isn’t lost on the Gabels.“With the support and care thatthe entire Radiology staffprovides, Taylor has reallycalmed down and hasvery little anxiety whenit comes to the scan,”adds Kelli. “I have toldmany that I wouldnever second guessour decision tohave her treated atChildren’s Mercy,where everythingis centered aroundthe kids!”How ToReferFor Transport,InpatientAdmission or forConsult1-800 GO MERCY(1-800-466-3729)Call this number 24 hours a day tomobilize the in-house neonatal orpediatric transport teams, consultwith a specialist, or admit a patientdirectly to Children’s Mercy Hospital orChildren’s Mercy South.For Specialty Clinic Appointments(816) 234-3700 ortoll free 1 (800) 800-7300Nurses with our Physician Appointmentline can assist you with schedulingclinic appointments for Children’sMercy Hospital, Children’s Mercy Southand Children’s Mercy Northland.Physician’s Update is produced byCommunity Relations.Shawn ArniEditorMegan StockAssistant EditorFor more information, callCommunity Relations at 816-346-1370.For more physician news andinformation, visit ourPhysician News portal atwww.childrensmercy.org/physicians.