Evidence-Based Imaging in Pediatrics (eBook)

Improving the Quality of Imaging in Patient Care

L. Santiago Medina, Kimberly E. Applegate, C. Craig Blackmore (Herausgeber)

eBook Download: PDF

2010 | 2010
XXII, 666 Seiten
Springer New York (Verlag)
978-1-4419-0922-0 (ISBN)

Infos

This practical book is ideal for readers who want to rapidly determine the appropriate imaging for pediatric patients. The text provides a concise and accessible summary of the literature on how and when to use imaging studies. Chapters address the essentials, such as cost-effectiveness, and are written in collaboration by renowned specialists in the fields of pediatrics and pediatric radiology. Topics cover common clinical scenarios in neuroimaging and musculoskeletal, chest, and abdominal imaging. Each imaging recommendation is presented along with the supporting data and the strength of the evidence.

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Evidence-Based Imaging in Pediatrics: Optimizing Imaging in Pediatric Patient Care presents a user friendly guide to the evidence-based science and the merit defining the appropriate use of medical imaging in infants and children. Edited by Drs. Medina, Applegate and Blackmore, this ideal reference gathers contributions by internationally renowned specialists in the field. The book covers the most prevalent conditions and diseases affecting children. Each chapter is framed around important and provocative clinical questions relevant to the daily physician's practice. Key points and summarized answers are highlighted so the busy clinician can quickly understand the most important evidence-based imaging data. Topics include patient selection, imaging strategies, test performance, cost-effectiveness, radiation safety and applicability. A wealth of illustrations and summary tables reinforces the key evidence. By offering a clear understanding of the science behind the evidence,the book fills a void for pediatricians, radiologists, clinicians, surgeons, residents and others with an interest in medical imaging and a desire to implement an evidence-based approach to optimize pediatric patient care.

Inhalt

Foreword 6
Preface 10
Contents 12
Contributors 16
Part I Principles, Methodology, and Radiation Risk 22
1 Principles of Evidence-Based Imaging 23
What Is Evidence-Based Imaging? 23
The Evidence-Based Imaging Process 25
Formulating the Clinical Question 25
Identifying the Medical Literature 25
Assessing the Literature 26
What Are the Types of Clinical Studies? 26
What Is the Diagnostic Performance of a Test: Sensitivity, Specificity, and Receiver Operating Characteristic (ROC) Curve? 27
What Are Cost-Effectiveness and Cost-Utility Studies? 29
Types of Economic Analyses in Medicine 29
Summarizing the Data 31
Applying the Evidence 31
How to Use This Book 34
Take-Home Appendix 1: Equations 34
Take-Home Appendix 2: Summary of Bayes Theorem 35
References 36
2 Critically Assessing the Literature: Understanding Error and Bias 37
What Are Error and Bias? 37
What Is Random Error? 38
Type I Error 38
Confidence Intervals 38
Type II Error 39
Power Analysis 39
What Is Bias? 40
What Are the Inherent Biases in Screening? 41
Qualitative Literature Summary 43
Conclusion 44
References 44
3 Radiation Risk from Medical Imaging in Children 45
Definition and Pathophysiology 46
Radiation Terminology 46
Radiation Mechanisms of Effect 46
Types of Biological Effects 46
Radiation Doses in Medical Imaging 47
Epidemiology and Medical Utilization of Ionizing Radiation 47
Increased Dose from Medical Imaging 48
Increased Use of CT Scans 48
Assessing Risk Versus Benefit when Using Medical Imaging in Children 48
Overall Cost to Society 49
Goals 49
Methodology 49
Discussion of Issues 49
Is There a Cancer Risk from Low-Level Radiation Used in Medical Imaging? What Are the Uncertainties in the Data? 49
Cancer Risk and Radiation Following Diagnostic Medical Imaging 50
CT Scan and Risk 50
Assumptions in Estimating Radiation Risks 50
Increased Radiosensitivity in Children 51
Nonfatal Cancers 51
Additional Confounders in Risk Estimation 51
Radiation Doses from Medical Imaging and Uncertainty in Cancer Risks 51
What Is the Estimated Risk From a Single Chest X-Ray in a Child? 52
What Is the Estimated Risk from a Single Abdominal CT Scan in a Child? 52
The Changing Landscaping of Radiation Dose for Medical Imaging 52
Lowering CT Dose in Children 53
Understanding Benefit Versus Risk of Imaging Tests in Well-Indicated Studies Versus Those That Have Very Low Probability of Disease 53
The Example of CT in Children with Headache 53
How Should I Communicate Radiation Risk from Imaging to Parents and Patients? 53
Special Situation: Increased Cancer Risk Following Therapeutic Medical Radiation 54
Take-Home Tables and Figures 55
Future Research 55
References 58
Part II Neuroimaging 60
4 Imaging in the Evaluation of Children with Suspected Craniosynostosis 61
Definition and Pathophysiology 62
Epidemiology 62
Overall Cost to Society 62
Goals 62
Methodology 63
Discussion of Issues 63
I. What Is the Role of Imaging in the Diagnosis of Craniosynostosis? 63
II. What Is the Cost and Cost-Effectiveness of Imaging in Children with Suspected Craniosynostosis? 64
III. Is Imaging Required When the Clinical Diagnosis Has Clearly Been Made? 65
IV. How Often and What Intracranial Abnormalities Are Seen in Craniosynostosis? 66
V. What Is the Role of Imaging in the Prenatal Diagnosis of Craniosynostosis? 66
Take Home Figures and Tables 67
Imaging Case Studies 68
Suggested Imaging Protocol for Craniosynostosis 69
Plain Radiographs 69
CT 69
Future Research 69
References 70
5 Sickle Cell Disease and Stroke 71
Definition, Pathophysiology, and Clinical Presentation 72
Epidemiology 73
Epidemiology of Stroke 73
Risk of Stroke 74
Epidemiology of Recurrent Stroke 74
Epidemiology of Silent Infarcts Diagnosed by MRI 74
Overall Cost to Society 74
Cost of Screening 75
Cost-Effectiveness Analysis 75
Goals 75
Methodology 75
Discussion of Issues 76
I. What Is the Role of Neuroimaging in Acute Stroke in Children with Sickle Cell Disease? 76
II. What Is the Role of Neuroimaging in Children with Sickle Cell Disease at Risk of Their First Stroke? 77
III. What Is the Role of Neuroimaging in Prevention of Recurrent Ischemic Stroke in Children with Sickle Cell Disease? 78
IV. Are There Neuroimaging Criteria That Indicate That Blood Transfusions Can Be Safely Halted? 79
V. What Is the Role of Neuroimaging in Hemorrhagic Stroke in Children with SCD? 79
Take Home Figures and Tables 80
Imaging Case Studies 83
Case 1 83
Suggested Imaging Protocol for Sickle Cell Disease and Stroke 84
Future Research 84
References 84
6 Imaging of Hypoxic-Ischemic Encephalopathy in the Full-Term Neonate 88
Definition and Pathophysiology 89
Epidemiology 89
Overall Cost to Society 90
Goals 90
Methodology 90
Discussion of Issues 91
I. What Are the Clinical Features of Neonatal HIE? 91
II. What Is the Optimal Time and What Are the Ideal MRI Sequences to Image Neonatal HIE? 91
III. Why Should Infants with Neonatal Encephalopathy Be Imaged? 93
IV. Does the Pattern of Brain Injury on MR Help Predict Outcome in Neonatal HIE? 94
V. Does Cooling Alter the Pattern of Brain Injury? 95
Take Home Tables 95
Imaging Case Studies 96
Case 1 96
Suggested Imaging Protocols for HIE in the Full-Term Neonate 97
Future Research 98
References 98
7 Evidence-Based Neuroimaging for Traumatic Brain Injury in Children 101
Definition and Pathophysiology 102
Epidemiology 103
Overall Cost to Society 103
Goals 103
Methodology 103
Discussion of Issues 104
I. Which Pediatric Patients with Head Injury Should Undergo Imaging in the Acute Setting? 104
II. What Is the Sensitivity and Specificity of Imaging for Injury Requiring Immediate Treatment/Surgery? 105
III. What Is the Overall Sensitivity and Specificity of Imaging in the Diagnosis and Prognosis of Children with Head Trauma? 105
IV. What Is the Role of Advanced Imaging (Functional MRI, MR Spectroscopy, Diffusion Imaging, SPECT, and PET) in Children with TBI? 108
Take Home Figures and Tables 110
Imaging Case Studies 113
Case 1: Example of MR Imaging for Traumatic Brain Injury (TBI) 113
Case 2: Example of MR Spectroscopy 115
Suggested Protocols for Acute TBI Imaging 116
CT 116
MR 116
Future Research 116
References 116
8 Imaging of Brain Neoplasm 119
Definition and Pathophysiology 120
Definition of Brain Cancer 120
Unique Challenges of Brain Cancer 120
Epidemiology 120
Overall Cost to Society 121
Goals 121
Methodology 121
Discussion of Issues 122
I. Who Should Undergo Imaging to Exclude Pediatric Brain Cancer? 122
II. What Is the Appropriate Imaging in Subjects at Risk for Pediatric Brain Cancer? 123
Special Case: How Can a Tumor Be Differentiated from a Tumor-Mimicking Lesion? 124
III. What Is the Role of Proton Magnetic Resonance Spectroscopy (MRS) in the Diagnosis and Follow-Up of Brain Neoplasms? 125
IV. Can Imaging Be Used to Differentiate Post-treatment Necrosis from Residual/Recurrent Tumor? 126
V. What Is the Added Value of Functional MRI (fMRI) in the Surgical Planning of Patients with Suspected Brain Neoplasm or Focal Brain Lesions? 126
Take Home Tables 126
Imaging Case Studies 128
Case 1 128
Case 2 129
Suggested Imaging Protocols for Brain Neoplasms 129
Future Research 129
References 129
9 Children with Headache: Evidence-Based Role of Neuroimaging 131
Definition and Pathophysiology 132
Epidemiology 132
Overall Cost to Society 132
Goals 132
Methodology 133
Discussion of Issues 133
I. When Is Neuroimaging Appropriate in Children with Headache? 133
II. What Is the Sensitivity and Specificity of CT and MR Imaging for Space-Occupying Lesions? 134
III. What Is the Sensitivity and Specificity of CT and MRI Imaging of Patients with Headache and Subarachnoid Hemorrhage Suspected of Having an Intracranial Aneurysm? 134
IV. What Is the Role of Advance Imaging Techniques in Primary Headache Disorders? 135
V. What Is the Cost-Effectiveness of Neuroimaging in Patients with Headache? 136
Take Home Tables and Figures 137
Case 1: Colloid Cyst 138
Case 2: Chiari I 138
Case 3: Brain Stem Infiltrative Glial Neoplasm 139
Suggested Imaging Protocols for Headaches 140
CT Imaging 140
MR Imaging 140
Future Research 140
References 140
10 Pediatric Neuroimaging of Seizures 142
Definition and Pathophysiology 143
Epidemiology 143
Prevalence and Incidence 144
Overall Cost to Society 144
Goals 145
Methodology 145
Discussion of Issues 145
I. What Is the Likelihood of having an Abnormal Structural Finding in Neuroimaging in First Unprovoked Seizure or Newly Diagnosed Epilepsy in Infancy and Childhood? 145
II. Can Neuroimaging Predict Future Seizures or Patient Outcomes? 147
III. Is Neuroimaging Justified in Patients with First Febrile Seizures? 148
IV. What Is the Probability of Finding Structural Abnormalities in Neuroimaging Performed in Children with Temporal Lobe Epilepsy (TLE)? 148
V. What Is the Role of Functional MRI in Patients Who Are Candidates for Epilepsy Surgery? 149
VI. What Is the Role of Nuclear Medicine in Children with TLE Seizures? 150
Take Home Figures 150
Imaging Case Studies 153
Case 1 153
Case 2 154
Suggested Imaging Protocols for Seizures 154
CT Scan Brain Protocol for the Study of First Seizure 154
MRI of the Brain for the Workup of Epilepsy and Non-febrile Seizures 154
Future Research 154
References 154
11 Diagnosis and Management of Acute and Chronic Sinusitis in Children 156
Definition and Pathophysiology 157
Epidemiology 157
Overall Cost to Society 158
Goals 158
Methodology: Medline and PubMed 159
Discussion of Issues 159
I. Is There a Role for Imaging in the Initial Diagnosis of Uncomplicated Acute Bacterial Sinusitis in Children? 159
II. What Is the Diagnostic Performance of Sinus Radiography and Sinus CT in Acute Bacterial Sinusitis? What Diagnostic Criteria Should We Use for Acute Sinusitis? 160
III. When Are Imaging Studies Indicated for the Diagnosis and the Management of Children with Sinusitis? 162
IV. What Is the Most Cost-Effective Strategy for the Diagnosis and the Management of Patients with Acute Sinusitis? 163
V. What Is the Role of Imaging in Children with Chronic Sinusitis? 164
VI. Special Situation: What Is the Role of Imaging in Immunocompromised Children? 165
Take Home Figures and Tables 166
Imaging Case Studies 170
Suggested Imaging Protocols for Children Clinically Suspected of Acute Sinusitis 172
Sinus Radiographs 172
Low-Dose Screening Sinus CT 172
MRI 172
Future Research 172
References 172
12 Imaging of Nonaccidental Head Injury 175
Definition and Pathophysiology 176
Epidemiology 176
Overall Cost to Society 177
Goals 177
Methodology 177
Discussion of Issues 177
I. What Are the Clinical Findings that Raise Suspicion of NAHI to Direct Further Imaging? 177
II. Can Imaging Help to Predict NAHI? 178
III. Can CT and MR Imaging Help to Determine Timing of Injury? 180
IV. What Is the Sensitivity and Specificity of CT and MRI? 181
V. How Should the Newer MR Imaging Techniques Be Used? 181
Take Home Tables 183
Imaging Case Studies 183
Case 1 184
Case 2 184
Suggested Imaging Protocols for Nonaccidental Head Injury 185
Future Research 185
References 185
Part III Musculoskeletal Imaging 189
13 Evidence-Based Imaging in Non-CNS Nonaccidental Injury 190
Definition and Pathophysiology 191
Epidemiology 191
Overall Cost to Society 192
Direct Costs 192
Indirect Costs 192
Goals 192
Methodology 193
Discussion of Issues 193
I. What Are the Radiological Findings in Skeletal Nonaccidental Injury? 193
II. What Is the Preferred Imaging Modality for the Diagnosis of Nonaccidental Skeletal Injury? 194
III. What Is the Role of Repeat Surveys in Skeletal Nonaccidental Injury? 196
IV. What Is the Role of Sibling Screening with Skeletal Survey? 197
V. What Is the Role of Postmortem Imaging? 197
VI. How Well Can We Date Fractures? 197
VII. What Is the Role of Imaging in Abdominal Trauma in NAI? 198
Take Home Tables 199
Imaging Case Studies 199
Case 1 200
Case 2 201
Suggested Imaging Protocols for Non-CNS Nonaccidental Injury 201
Future Research 202
References 202
14 Imaging of Spine Disorders in Children: Dysraphism and Scoliosis 205
Spinal Dysraphism 205
Scoliosis 205
Definition and Pathophysiology 206
Spinal Dysraphism 206
Scoliosis 206
Conus Medullaris Position 207
Epidemiology 207
Spinal Dysraphism 207
Scoliosis 207
Goals 208
Spinal Dysraphism 208
Scoliosis 208
Methodology 208
Discussion of Issues in Spinal Dysraphism 208
I. How Accurate Is Imaging in Occult Spinal Dysraphism? 208
II. What Are the Clinical Predictors of Occult Spinal Dysraphism (OSD)? 208
III. What Are the Natural History and Role of Surgical Intervention in Occult Spinal Dysraphism? 209
IV. What Is the Cost-Effectiveness of Imaging in Children with Occult Spinal Dysraphism? 209
Discussion of Issues in Scoliosis 210
I. How Should the Radiographic Evaluation of Scoliosis Be Performed? 210
II. What Radiation-Induced Complications Result from Radiographic Monitoring of Scoliosis? 211
III. What Is the Role of Magnetic Resonance Imaging in Idiopathic Scoliosis? 211
Take Home Figures and Tables 213
How Should Physicians Evaluate Newborns with Suspected Occult Spinal Dysraphism? 213
How Should Scoliosis Be Evaluated? 215
Imaging Case Studies 215
Case 1: Spinal Dysraphism 215
Case 2: Scoliosis 216
Suggested Imaging protocols for Spinal Dysraphism and Scoliosis 217
Spinal Dysraphism 217
Spinal Ultrasound 217
Entire Spine MRI 217
Scoliosis 217
Scoliosis Radiographs 217
Entire Spine MRI 217
Future Research 217
References 218
15 Imaging of the Spine for Traumatic and Nontraumatic Etiologies 220
Definition and Pathophysiology 221
Epidemiology 221
Overall Cost to Society 221
Goals 221
Methodology 222
Discussion of Issues 222
I. Who Should Undergo Imaging of the Cervical Spine Following Trauma? 222
II. Who Should Undergo Imaging of the Thoracic and Lumbar Spine Following Trauma? 223
III. Who Should Undergo Imaging for Nontraumatic Back Pain? 223
IV. Special Case: Spondylolysis 224
Take Home Figures and Tables 225
Imaging Case Studies 225
Case 1 226
Case 2 226
Future Research 227
References 227
16 Imaging for Early Assessment of Peripheral Joints in Juvenile Idiopathic Arthritis 229
Definition and Pathophysiology 230
Epidemiology 230
Overall Cost to Society 231
Clinical and Laboratory Predictors 231
Goals 231
Methodology 232
Discussion of Issues 232
I. What Is the Diagnostic Performance of Radiography in JIA? 232
II. What Is the Diagnostic Performance of US and MRI in JIA? 232
III. Can US and/or MRI (Diagnostic Tests) Accurately Detect Synovial Hypertrophy in JIA Children? 233
IV. Can Cross-Sectional Imaging Modalities (US and/or MRI) Accurately Demonstrate Evidence of Cartilage Degeneration? 235
V. Is There an Association Between Imaging (US or/and MRI) Evidence of Cartilage Degeneration and Clinical Response to Treatment? 237
VI. What Is the Diagnostic Accuracy of Peripheral Quantitative Ultrasound (QUS) and Peripheral Computed Tomography (pQCT) to Detect Bone Changes in Children with JIA? 238
Take Home Figures and Tables 240
Imaging Case Studies 247
Case 1 248
Case 2 249
Case 3 250
Suggested Imaging Protocols for Juvenile Idiopathic Arthritis 250
Ultrasound 250
MRI 251
Large Joints (Knees, Ankles, Elbows, Shoulders) 251
Small Joints (Wrists, Hands, Feet) 251
Future Research 251
Appendix 251
References 252
17 Imaging of Hematogenous Osteomyelitis and Septic Arthritis in Children 254
Definition and Pathophysiology 255
Epidemiology 255
Overall Cost to Society 256
Goals 256
Methodology 256
Discussion of Issues 256
I. What Is the Diagnostic Performance of the Different Imaging Studies in Acute Hematogenous Osteomyelitis (AHOM)? 256
II. What Is the Diagnostic Performance of the Different Imaging Studies in the Evaluation of Subperiosteal and Soft Tissue Abscesses Associated with Acute Hematogenous Osteomyelitis? 258
III. What Is the Diagnostic Performance of the Different Imaging Studies in Chronic Osteomyelitis? 258
IV. What Is the Diagnostic Performance of the Different Imaging Studies in Septic Hip Arthritis? 259
Take Home Figure 260
What Are the Roles of the Imaging Modalities in the Evaluation of Acute Osteomyelitis and Septic Arthritis? 260
Imaging Case Studies 262
Case 1 262
Case 2 263
Case 3 264
Case 4 265
Suggested Imaging Protocols for Hematogenous Osteomyelitis and Septic Arthritis in Children 265
Radiography 265
Radionuclide Bone Scintigraphy 265
MRI 265
Ultrasound 265
Future Research 265
References 266
18 Imaging of Pediatric Bone Tumors: Osteosarcoma and Ewing Sarcoma 268
Definition and Pathophysiology 269
Epidemiology 269
Overall Cost to Society 270
Goals 270
Methodology 270
Discussion of Issues 270
I. What Is the Recommended Imaging Approach for Evaluation of Suspected Bone Tumors? 271
II. What Is the Best Imaging Modality for Local Staging of Pediatric Bone Sarcomas? 271
III. Do Imaging Findings of the Primary Tumor Have Prognostic Significance? 272
IV. What Is the Frequency of Skip Bone Metastases and What Is the Best Imaging Modality to Detect Them? 273
V. What Imaging Studies Should Be Performed for Staging of Pediatric Bone Sarcomas? 273
VI. What Is the Best Imaging Method to Assess Response to Chemotherapy? 274
VII. What Is the Appropriate Imaging Protocol for Posttreatment Surveillance of These Malignancies? 276
Take Home Tables 276
Imaging Case Studies 278
Case 1 278
Case 2 279
Suggested Imaging Protocols for Osteosarcoma and Ewings Sarcoma 279
Osteosarcoma Imaging Evaluation at Baseline 279
Anatomic Imaging 279
Functional Imaging 279
OS Baseline After Surgery 279
OS Surveillance During Chemotherapy 279
OS Surveillance After Chemotherapy 279
ES Imaging Evaluation at Baseline 280
Anatomic Imaging 280
Functional Imaging 280
ES Baseline After Surgery 280
ES Surveillance During Chemotherapy 280
ES Surveillance After Chemotherapy 280
Future Research 280
References 280
19 Imaging for Knee and Shoulder Injuries 283
Issues in Imaging the Pediatric Knee 283
Issues in Imaging Children with Acute Shoulder Injury 283
Definition and Pathophysiology 284
The Knee 284
Osteochondritis Dissecans 284
Discoid Lateral Meniscus 285
The Shoulder 285
Epidemiology 285
Acute Knee Trauma 285
Osteochondritis Dissecans 286
Discoid Lateral Meniscus 286
Acute Shoulder Trauma 286
Overall Cost to Society 286
The Knee 286
The Shoulder 286
Goals 286
The Knee 287
The Shoulder 287
Methodology 287
Discussion of Issues: Knee 287
I. What Is the Role of Radiographs in Children with an Acute Knee Injury and Possible Fracture? 287
II. When Should MRI Be Used in Children with Suspected Meniscal, Ligamentous, or Articular Cartilage Injuries? 288
III. What Is the Role of Imaging in the Evaluation of Osteochondritis Dissecans? 290
IV. What Is the Role of Imaging in the Evaluation of Discoid Lateral Meniscus? 291
Discussion of Issues: Shoulder 292
I. When Is Radiography Indicated for Children with Acute Shoulder Trauma? 292
II. What Is the Role of MRI in Shoulder Dislocation? 294
Take Home Tables 295
Imaging Case Studies 297
Case 1 297
Case 2 298
Case 3 298
Suggested Imaging Protocol for the Knee and the Shoulder 298
The Knee 298
Radiography 299
MRI 299
The Shoulder 299
Radiography 299
Future Research 299
The Knee 299
The Shoulder 299
References 299
20 Developmental Dysplasia of the Hip 302
Definition and Pathophysiology 303
Epidemiology 303
Overall Cost to Society 303
Goals 304
Methodology 304
Discussion of Issues 304
I. What Are the Clinical Findings of DDH and How Effective Are Clinicians at Detecting Them? 304
II. What Is the Natural History of Undetected DDH? 305
III. How Accurate Is US Imaging in Depicting Hip Anatomy and DDH? 306
IV. How Effective Is Imaging in the Diagnosis and Treatment of DDH? 307
V. Is There a Case for US Screening in Newborns to Detect DDH? 309
Take Home Figures and Tables 310
Imaging Case Studies 313
Case 1 313
Case 2 314
Suggested Imaging Protocols for Developmental Dysplasia of the Hip 314
Screening for DDH 314
Future Research 314
References 314
21 Slipped Capital Femoral Epiphysis 317
Definition and Pathophysiology 317
Epidemiology 318
Overall Cost to Society 318
Goals 318
Methodology 319
Discussion of Issues 319
I. What Is the Diagnostic Performance of Radiographs in the Initial Diagnosis of Slipped Capital Femoral Epiphysis? 319
II. What Is the Diagnostic Performance of Magnetic Resonance Imaging in the Initial Diagnosis of Slipped Capital Femoral Epiphysis? 319
III. What Is the Diagnostic Performance of Ultrasound Imaging in the Diagnosis of Slipped Capital Femoral Epiphysis? 320
IV. What Is the Role of CT in Preoperative Planning? 320
V. What Is the Imaging Method of Choice in Suspected Avascular Necrosis Associated with the Treatment of Slipped Capital Femoral Epiphysis? 320
Take Home Tables 321
Case Imaging Studies 322
Case 1 322
Suggested Imaging Protocols for Slipped Capital Femoral Epiphysis 323
Radiographs 323
CT 323
MRI and Nuclear Medicine 323
Future Research 323
References 323
22 Imaging of Legg–Calvé–PerthesDisease in Children 324
Definition and Pathophysiology 325
Epidemiology 325
Overall Cost to Society 325
Goals 326
Methodology 326
Discussion of Issues 326
I. What Is the Role of Imagingin the Diagnosis of Legg–Calvé–Perthes Disease? 327
II. Can Plain Radiographs Establish the Prognosis of the Disease? 327
III. Is MRI the Best Imaging Modality to Determine the Extent of Disease and Establish Important Predictors in LeggCalvPerthes? 328
IV. Can Patterns of Healing and Reperfusion Assessed by Scintigraphy, US, or MRI Predict the Ultimate Outcome of the Disease? 329
Take Home Figures and Tables 330
Imaging Case Studies 331
Case 1 331
Case 2 331
Suggested Imaging Protocol for LeggCalvPerthes Disease in Children 331
Future Research 331
References 332
23 Fractures of the Ankle 334
Definition and Pathophysiology 335
Epidemiology 335
Overall Cost to Society 335
Goals 335
Methodology 335
Discussion of Issues 336
I. What Are the Clinical Indications for Obtaining the Ankle X-ray Series Following Trauma in a Child? 336
II. What Is the Diagnostic Performance of Computed Tomography in the Investigation of Ankle Fractures in Children? 336
III. What Is the Diagnostic Performance of Magnetic Resonance Imaging in the Investigation of Ankle Injuries in Children? 337
IV. What Is the Diagnostic Performance of Ultrasound in the Investigation of Ankle Injuries in Children? 337
Take Home Tables 338
Imaging Case Studies 339
Case 1 339
Case 2 340
Suggested Imaging Protocol for Fractures of the Ankle 341
Radiographs 341
CT and MRI 341
Future Research 341
References 341
Part IV Chest Imaging 342
24 Evidence-Based Approach to Imaging of Congenital Heart Disease 343
Introduction, Pathophysiology, and Definitions 344
Epidemiology 344
Overall Cost to Society 345
Goals 345
Methodology 345
Discussion of Issues 346
I. What Is the Role of Conventional Chest Radiography in Initial Diagnosis of CHD? 346
II. What Is the Role of Routine Daily Chest Radiography in the Pediatric Cardiac Intensive Care Unit and in the Immediate Post-operative Period for CHD? 347
Pediatric Studies 347
III. How Does MRI Compare with Echocardiography in Evaluating RV Size and Function in CHD? 347
IV. Can MRI Determine Clinical Outcome and Timing of Pulmonary Valve Replacement in Repaired Tetralogy of Fallot? 349
MRI Predictors of Adverse Clinical Outcome in Repaired Tetralogy of Fallot 349
Timing of Pulmonary Valve Replacement 350
V. Can MRI Replace Routine Cardiac Catheterization in the Evaluation of Patients Undergoing Single-Ventricle Repair? 350
VI. What Is the Role of CT in CHD? 351
Take Home Tables 352
Imaging Case Studies 354
Case 1 355
Case 2 356
Case 3 357
Case 4 358
Case 5 359
Suggested Protocols for Imaging of Congenital Heart Disease 359
MRI Protocol for Repaired Tetralogy of Fallot 359
MRI Protocol for Patients Undergoing Single-Ventricle Repair Prior to Superior and Total Cavopulmonary Connection 360
Future Research 360
References 360
25 Congenital Disease of the Aortic Arch: Coarctation and Arch Anomalies 363
Definition 364
Thoracic Aorta Coarctation 364
Vascular Ring 365
Pulmonary Sling 366
Epidemiology 366
Coarctation 366
Aortic Arch Anomaly 366
Overall Cost to Society 367
Goals 368
Methodology 368
Discussion of Issues 369
I. Which Clinical Symptoms and Signs May Suggest the Presence of Coarctation or an Aortic Arch Anomaly? 369
Coarctation 369
Aortic Arch Anomaly 370
II. What Is the Natural History of Thoracic Aorta Coarctation and Aortic Arch Anomalies? 370
Coarctation 370
Aortic Arch Anomaly 372
III. What Are the Diagnostic Performances of Imaging Modalities Used to Evaluate Suspected Coarctation and Aortic Arch Anomalies? 372
Coarctation 372
Aortic Arch Anomaly 374
Take Home Figures 376
What Is the Diagnostic Imaging Workflow for Suspected Thoracic Aorta Coarctation? 376
What Is the Diagnostic Imaging Workflow for a Suspected Aortic Arch Anomaly? 377
Take Home Tables 378
Imaging Case Studies 379
Case 1 379
Case 2 380
Suggested Imaging Protocols for Coarctation and Arch Anomalies 381
Plain Radiograph 381
Esophagram 381
MRI 381
CTA 381
Echocardiogram 381
Future Research 381
References 381
26 Imaging Evaluation of Mediastinal Masses in Infants and Children 384
Definition and Pathophysiology 385
Epidemiology 386
Overall Cost to Society 386
Goals 386
Methodology 387
Discussion of Issues 387
I. What Are the Clinical Findings that Raise Suspicion for Possible Mediastinal Masses in Infants and Children? 387
II. What Is the Diagnostic Performance of the Major Methods to Image Infants and Children with Mediastinal Masses? 388
III. Which Imaging Approach Is Most Appropriate in Differentiating Normal Thymus from Abnormal Anterior Mediastinal Masses in Infants? 390
IV. Which Imaging Modality Is Best Equipped to Evaluate Anterior Mediastinal Masses in Infants and Children? 391
V. Which Imaging Modality Is Most Appropriate for Evaluating Middle Mediastinal Masses in Infants and Children? 392
VI. What Is the Recommended Imaging Modality for Evaluating Neurogenic Tumors in the Posterior Mediastinum in Infants and Children? 393
VII. What Is the Role of PET in the Management of Childhood Lymphomas? 394
Take Home Figures 395
What Are the Various Roles of the Principal Imaging Modalities in Evaluating Mediastinal Masses in Infants and Children? 395
Take Home Tables 396
Imaging Case Studies 398
Case 1 398
Case 2 398
Suggested Imaging Protocols 399
Plain Radiographs 399
Ultrasound 399
CT 399
MRI 399
PET 399
Future Research 399
References 400
27 Imaging of Chest Infections in Children 403
Definition and Pathophysiology 404
Pleural Effusion and Empyema 404
Lung Abscess 405
Epidemiology 405
Overall Cost to Society 405
Goals 406
Methodology 406
Discussion of Issues 406
I. What Are the Clinical Presentation and Predictors of Chest Infections in Children, and Which Findings Raise the Suspicion for Complications? 406
Viral Versus Bacterial Pneumonia 407
II. When Are Chest Radiographs Useful in Children with Suspected Pneumonia? 407
III. How Does Chest Radiography Compare to Cross-Sectional Imaging in the Evaluation of Chest Infections in Children? When Is Chest CT Indicated? 408
IV. What Is the Role and Diagnostic Performance of Imaging Studies (Radiography, Ultrasound, and CT) for Treatment Planning of Complicated Pneumonia with Empyema and Parapneumonic Effusions? 410
V. What Are the Relative Roles of Imaging in Medical Therapy, Minimally Invasive Intervention such as Thoracotomy or Thoracentesis, and Surgical Treatment for Pneumonia Complicated by Pleural Involvement? 411
Take Home Tables and Figures 412
Case Imaging Studies 418
Case 1 418
Suggested Imaging Protocols 419
Radiography 419
Ultrasound 419
Chest CT 419
Future Research 419
References 419
28 Imaging of Asthma in Children 421
Definition and Pathophysiology 422
Epidemiology 423
Asthma Attack Prevalence 423
Lifetime Asthma Diagnosis 423
Overall Cost to Society 424
Methodology 424
Discussion of Issues 425
I. Are Chest Radiographs Indicated in Patients with Acute Asthma? 425
II. What Are the Radiographic Findings of Importance in Uncomplicated Versus Complicated Asthma? 426
III. What Is the Role of CT in Patients with Asthma? 428
Take Home Tables 430
Imaging Case Studies 431
Case 1 431
Case 2 431
Suggested Protocol for Imaging for Asthma in Children 432
Chest Radiograph 432
HRCT 432
Future Research 432
References 432
Part V Abdominal Imaging 434
29 Imaging of Clinically Suspected Malrotation in Children 435
Definition and Pathophysiology 436
Epidemiology 436
Overall Cost to Society 437
Goals 437
Methodology 437
Discussion of Issues 437
I. What Are the Clinical Predictors of Malrotation and Volvulus? 437
II. Who Should Undergo Imaging? What Is the Diagnostic Performance of Imaging in the Diagnosis or Exclusion of Malrotation? 438
Abdominal Radiographs 438
UGI Series 438
Contrast Enema 439
Cross-Sectional Imaging (US, CT, and MR) 439
Volvulus: Diagnostic Performance of UGI, Sonography, and CT 439
III. How Should the UGI Series Be Performed? What Imaging Is Appropriate in Indeterminate Cases? 439
What Imaging Is Appropriate in Indeterminate UGI Cases? 440
IV. Special Situation: The Older Child (at Low Risk?) 441
V. Special Situation: The Infant or Child with Heterotaxy Syndrome 441
Take Home Tables 442
Imaging Case Studies 444
Cases 1 and 2 444
Suggested Imaging Protocol for Clinically Suspected Malrotation in Children 445
Future Research 445
References 445
30 Imaging of Infantile Hypertrophic Pyloric Stenosis (IHPS) 447
Definition, Clinical Presentation, and Pathophysiology 448
Epidemiology 448
Overall Cost to Society 449
Goals 449
Methodology 449
Discussion of Issues 450
I. What Are the Clinical Findings that Raise the Suspicion for IHPS and Direct Further Investigation? 450
II. What Is the Diagnostic Performance of the Clinical and Imaging Examinations in IHPS? 450
III. Is There a Role for Follow-Up Imaging in IHPS? 453
IV. What Is the Natural History of IHPS and Patient Outcome with Medical Therapy Versus Surgical Therapy? 454
Take Home Figures and Tables 455
Imaging Case Studies 456
Case 1 456
Case 2 456
Future Research 456
References 456
31 Intussusception in Children: Diagnostic Imaging and Treatment 458
Definition and Pathophysiology 459
Epidemiology 459
Rotavirus Vaccine 460
Overall Cost to Society 460
Goals 460
Methodology 460
Discussion of Issues 460
I. What Are the Clinical Predictors of Intussusception? What Are the Clinical Predictors of Reducibility and Bowel Necrosis? Who Should Undergo Imaging? 461
II. Which Imaging Studies Should Be Performed? 461
III. How Should Therapeutic Enema Be Performed? 463
Air Versus Liquid Enema 463
The Rule of Threes 464
Radiation Dose 464
Alternative Enema Approaches 465
Fluoroscopy Versus Sonography 465
Delayed Repeat Enema 465
Where Should Patients Be Treated? 465
What Are the Complications of Enema Therapy? 465
What Are the Surgical Management and Complications? 466
Cost-Effectiveness Analysis 466
IV. What Is Appropriate Management in Recurrent Cases? 466
V. Special Case: Intussusception Limited to the Small Bowel 467
VI. Special Case: Intussusception with a Known Lead Point Mass 467
Take Home Tables 468
Imaging Case Study 469
Case 1 469
Suggested Imaging Protocol for Intussusception in Children 470
Ultrasound for Clinically Suspected Intussusception 470
Air Enema for Reduction 470
Future Research Studies 470
References 470
32 Imaging of Appendicitis in Pediatric Patients 473
Definition and Pathophysiology 474
Epidemiology 474
Overall Cost to Society 474
Goals 474
Methodology 474
Discussion of Issues 475
I. What Is the Accuracy of Imaging for Diagnosing Acute Appendicitis in Children? 475
II. In Which Cases of Suspected Pediatric Appendicitis Is Imaging Indicated? 477
III. What Is the Effect of Imaging on the Rate of Negative Appendectomy in Pediatric Patients with Suspected Appendicitis? 478
IV. What Is the Role of Imaging in Managing Pediatric Perforated Appendicitis? 479
V. What Is the Effect of Imaging Pediatric Patients with Suspected Appendicitis on Health-Care Costs? 480
Take Home Tables 481
Imaging Case Studies 482
Case 1 482
Case 2 483
Suggested Imaging Protocols for Suspected Appendicitis 483
Future Research 483
References 483
33 Imaging of Inflammatory Bowel Disease in Children 485
Definition and Pathophysiology 486
Epidemiology and Diagnosis 486
Overall Cost to Society 487
Goals 487
Methodology 487
Discussion of Issues 488
I. What Are the Important Clinical Predictors of IBD? 488
Laboratory Markers 488
Children Under Age 5 Years 488
II. What Is the Diagnostic Performance of Current Endoscopic Techniques in the Evaluation of Patients with IBD: Lower, Upper Endoscopies and Wireless Capsule Endoscopy (WCE)? 488
III. What Is the Diagnostic Performance of Current Imaging Modalities in Evaluating IBD of the Small Bowel (Small Bowel Follow-Through, CT, MR, US, Enteroclysis)? 490
IV. Complications of IBD (Intra-abdominal Abscess, Intestinal Fistulae, Strictures and Small Bowel Obstruction, Primary Sclerosing Cholangitis [PSC]): Which Imaging Should Be Performed and What Is Its Diagnostic Performance? 493
V. What Are the Most Important Imaging Features That Lead to Surgery in a Child with Crohns Disease and Ulcerative Colitis? 494
Role of Conventional Barium Fluoroscopy and Multidetector CT 495
Role of Enteroclysis (CT/MR) and Enterography (CT/MR) 495
VI. What Are the Role and Risk of Repeat Imaging in Monitoring IBD Response to Treatment? 496
VII. Special Situation: Which Imaging Modality Provides the Best Performance for the Evaluation of Perianal/Perirectal Disease in Crohns Disease? 497
Take Home Tables and Figures 497
Imaging Case Studies 500
Case 1 500
Case 2 501
Case 3 502
Suggested Imaging Protocols for Inflammatory Bowel Disease in Children 502
Definition of Imaging Techniques 502
Upper gastrointestinal study with SBFT 502
General IBD Algorithm 502
Clinical and Imaging Pathways for CD and UC 503
Future Research 503
References 503
34 Pediatric Abdominal Tumors: Neuroblastoma 506
Definition and Pathophysiology 507
Epidemiology 507
Overall Cost to Society 508
Goals 508
Methodology 508
Discussion of Issues 508
I. What Are the Clinical Findings that Raise the Suspicion for Neuroblastoma? 508
II. What Is the Diagnostic Performance of the Different Imaging Studies in the Assessment of the Primary Tumor Mass in Patients with Neuroblastoma? 509
III. What Are the Essential Features that Need to Be Assessed by Imaging Studies in Patients with Neuroblastoma for Surgical Planning and Staging? 509
IV. What Is the Diagnostic Performance of the Different Imaging Studies in the Detection of Regional Disease in Patients with Neuroblastoma? 510
V. What Is the Diagnostic Performance of the Different Imaging Studies in the Detection of Distant Metastases in Patients with Neuroblastoma? 510
VI. Special Situations: The Child Who Presents with Opsoclonus-Myoclonus Syndrome or Intractable Watery Diarrhea 512
Take Home Figures and Tables 512
What Are the Roles of the Imaging Modalities in the Evaluation of Wilms Tumor? 512
Imaging Case Studies 513
Case 1 514
Case 2 515
Case 3 516
Case 4 517
Case 5 518
Case 6 518
Case 7 519
Suggested Imaging Protocols for Pediatric Neuroblastoma 519
Ultrasound 519
Chest Radiography 519
CT 519
MRI 519
99mTc Bone Scintigraphy 520
123I-MIBG Scintigraphy 520
Future Research 520
References 520
35 Pediatric Abdominal Tumors: Wilms Tumor 522
Definition and Pathophysiology 523
Epidemiology 523
Overall Cost to Society 524
Goals 524
Methodology 524
Discussion of Issues 524
I. What Are the Clinical Findings That Raise the Suspicion for Wilms Tumor? 524
II. What Is the Diagnostic Performance of the Different Imaging Studies in the Detection of the Primary Tumor Mass in Patients with Wilms Tumor? 525
III. What Are the Essential Features That Need to be Assessed on Imaging Studies in Patients with Wilms Tumor for Surgical Planning or Staging? 525
IV. What Is the Diagnostic Performance of the Different Imaging Studies in the Detection of Regional Disease in Patients with Wilms Tumor? 526
V. What Is the Diagnostic Performance of the Different Imaging Studies in the Detection of Distant Disease in Patients with Wilms Tumor? 527
VI. Is Screening Indicated in Children at Higher Risk of Wilms Tumor? 527
VII. What Is the Role of Imaging for Follow-Up of Wilms Tumor at the End of Treatment? 528
Take Home Figures and Tables 528
What Are the Roles of the Imaging Modalities in the Evaluation of Wilms Tumor? 528
Imaging Case Studies 530
Case 1 530
Case 2 531
Case 3 532
Case 4 532
Case 5 532
Case 6 533
Suggested Imaging Protocols for Wilms Tumor 533
Ultrasound 533
CT 533
MRI 533
Future Research 533
References 533
36 Imaging of Blunt Trauma to the Pediatric Torso 535
Definition and Pathophysiology 536
Epidemiology 536
Overall Cost to Society 536
Goals 536
Methodology 536
Discussion of Issues 536
I. What Are the Priorities in Caring for Pediatric Victims of Trauma? What Are the Goals for Diagnostic Testing Relative to These Priorities? 536
Cost-Effectiveness Analysis 537
II. Among Pediatric Victims of Trauma, Who Needs to Be Imaged? What Are the Clinical Indications Warranting Diagnostic Imaging? 537
Cost-Effectiveness Analysis 538
III. Which Pediatric Victims of Trauma Should Undergo Multiphase CT and Follow-Up Imaging? 538
Cost-Effectiveness Analysis 539
IV. How Should Children with Trauma Be Imaged? What Are the Performance Characteristics of Available Imaging Modalities? 539
Thorax 539
Aorta and Great Vessels 539
Chest Wall 540
Pleura and Lung 540
Aerodigestive Tract 540
Diaphragm 540
Abdomen and Pelvis (Table 36.3) 540
Imaging Modalities 540
Liver 541
Spleen 541
Pancreas 541
Kidneys and Ureters 541
Hollow Viscus 541
Stomach 541
Duodenum 542
Small Bowel, Colon, and Mesentery 542
Urinary Bladder and Urethra 542
Vascular 542
Cost-Effectiveness Analysis 542
V. Special Issue: What Are the Blind Spots in Imaging? How Can These Blind Spots Be Addressed? 543
Take Home Tables 543
Imaging Case Studies 545
Case 1 545
Case 2 546
Case 3 546
Suggested Imaging Protocols for Blunt Trauma to the Pediatric Torso 546
Abdominal and Pelvic CT 546
FAST 546
Future Research 546
References 547
37 Imaging of Nephrolithiasis and Urinary Tract Calculi in Children 550
Definition, Pathophysiology, and Epidemiology 551
Overall Cost to Society 551
Goals 551
Methodology 551
Discussion of Issues 552
I. What Are the Clinical Findings That Raise the Suspicion for Urolithiasis? 552
II. What Is the Diagnostic Performance of the Different Imaging Studies in Nephrolithiasis and Urinary Tract Calculi in the Pediatric Population? 552
Special Case: Bladder Calculi 555
III. What Is the Natural History of Nephrolithiasis and Urinary Tract Calculi and What Are the Roles of Medical Therapy Versus Extracorporeal Shock Wave Lithotripsy (ESWL) or Surgical Management? 555
IV. Special Case: Will the Stone Pass on Its Own? 555
V. What Is the Role of Repeat Imaging in Children with Known Stone? In Children with Recurrent Symptoms (Suggesting Obstructing Stone)? 556
Take Home Tables and Figures 556
What Are the Roles of the Imaging Modalities in the Evaluation of Urolithiasis? 556
Imaging Case Studies 557
Case 1 557
Case 2 558
Case 3 558
Case 4 559
Suggested Imaging Protocols Nephrolithiasis and Urinary Tract Calculi in Children 559
Plain Radiograph 559
Ultrasound 559
MDCT 559
MRI 559
Future Research 559
References 559
38 Urinary Tract Infection in Infants and Children 564
Definitions and Pathophysiology 565
Epidemiology 566
Overall Cost to Society 566
Goals 566
Methodology 567
Discussion of Issues 567
I. What Is Known About the Natural History of Urinary Tract Infections in Infants and Children? 567
II. What Can Imaging Reveal in the Setting of UTI? 568
III. What Are Reasonable Imaging Strategies When Caring for a Male Infant or Child with a History of a Febrile Urinary Tract Infection? 570
IV. What Are Reasonable Imaging Strategies When Caring for a Female Infant or Child with a History of a Febrile Urinary Tract Infection? 570
V. Special Case: Postnatal Management of Fetal Hydronephrosis 571
Take Home Tables and Figures 572
Imaging Case Studies 578
Case 1 578
Case 2 579
Case 3 580
Case 4 582
Case 5 583
Suggested Imaging Protocols for Urinary Tract Infections in Infants and Children 584
Future Research 584
References 584
39 Imaging of Female Children and Adolescents with Abdominopelvic Pain Caused by Gynecological Pathologies 588
Definition 589
Pathology and Epidemiology 589
Congenital Anomalies 589
Endometriosis 589
Pelvic Inflammatory Disease 590
Adnexal Torsion 590
Abdominopelvic Mass 590
Pregnancy 591
Overall Cost to Society 591
Pelvic Inflammatory Disease 591
Endometriosis 591
Goals 592
Methodology 592
Discussion of Issues 592
I. What Is the Diagnostic Performance of the Different Imaging Studies for the Diagnosis or Exclusion of Ovarian Torsion? 592
II. What Is the Best Imaging Technique for the Diagnosis of PID? 593
III. What Is the Best Imaging Technique for the Diagnosis of Endometriosis? 593
IV. What Is the Best Technique for the Diagnosis of an Ectopic Pregnancy? 593
Take Home Tables 594
Imaging Case Studies 595
Case 1 595
Case 2 595
Suggested Imaging Protocols 596
Plain Radiographs 596
Ultrasound 596
MDCT 596
MRI 596
Future Research 596
References 596
40 Imaging of Boys with an Acute Scrotum: Differentiation of Testicular Torsion from Other Causes 598
Definition and Pathophysiology 599
Epidemiology 599
Overall Cost to Society 599
Goals 600
Methodology 600
Discussion of Issues 600
I. What Are the Clinical Findings That Raise the Suspicion of Testicular Torsion in Children with Acute Scrotal Pain? 600
II. What Is the Diagnostic Performance of the Different Imaging Studies in Children with Acute Scrotal Pain? 600
III. In Cases of Testicular Torsion, Is Manual Reduction Required? 602
Take Home Figures and Tables 602
Imaging Case Studies 604
Case 1 604
Suggested Imaging Protocols for Acute Scrotum 605
Ultrasound 605
Manual Detorsion 605
Future Research 605
References 605
Part VI Prenatal Imaging 608
41 Imaging of Fetal Anomalies 609
Definition and Pathophysiology 610
Epidemiology 610
Overall Cost to Society 610
Goals 611
Methodology 611
Discussion of Issues 611
I. Does Early Fetal Imaging (Before 24 Weeks Gestation) Improve Maternal or Fetal Outcome? 611
II. Does Third Trimester Fetal Imaging Improve Maternal or Fetal Outcome? 613
III. Is US Safe for Imaging the Fetus? 614
IV. Is MRI Safe for Imaging the Fetus? 615
V. What Is the Diagnostic Performance of US and MRI in the Assessment of Fetal Anomalies? 616
VI. What Is the Role of MR Imaging in the Evaluation of the Fetus? 618
Take Home Tables 618
Imaging Case Studies 620
Case 1 620
Case 2 620
Case 3 621
Case 4 622
Suggested Imaging Protocols for Fetal Anomalies 622
Ultrasound 622
MRI 622
Future Research 623
References 623
Index 626

Produkt-Details

• Erscheint lt. Verlag: 10.3.2010
• Zusatzinfo: XXII, 666 p.
• Verlagsort: New York
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Gesundheitswesen
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Allgemeinmedizin
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Intensivmedizin
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Pädiatrie
• Themenwelt: Medizinische Fachgebiete ► Radiologie / Bildgebende Verfahren ► Radiologie
• Themenwelt: Studium ► 2. Studienabschnitt (Klinik) ► Anamnese / Körperliche Untersuchung
• Schlagworte: Computed tomography (CT) • Diagnosis • evidence-based • Family Medicine • Imaging • Pediatric • Primary Care • Radiology • Trauma • Tumor
• ISBN-10: 1-4419-0922-2 / 1441909222
• ISBN-13: 978-1-4419-0922-0 / 9781441909220