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OBJECTIVE: The purpose of our study was to assess the efficacy of a commercially available digital teleradiology system in the off-site interpretation of radiologic studies performed in the emergency department. MATERIALS AND METHODS: Over a 6-month period, all radiologic studies performed at Roosevelt Hospital between the hours of midnight and 8 A.M. were digitized and then transmitted over a T1 fiberoptic link to the radiology department of St. Luke's Hospital, 4.8 km away. A total of 829 radiologic examinations were performed, 17 of which were lost to follow-up, leaving 812 studies available for review (693 plain radiographs, 118 CT exams, and one MR imaging study). The preliminary teleradiology interpretations were performed by a resident on duty (with between 1 and 3.5 years of training) using a commercially available teleradiology system (Vortech PDS; Kodak Health Imaging Systems Inc., Dallas, TX) at St. Luke's Hospital. This interpretation was compared with the official film interpretation (which was used as the gold standard) performed within 24 hr by a board-certified attending radiologist at Roosevelt Hospital. All studies with clinically significant discrepant interpretations were redigitized, and the digital images were reviewed by at least two attending radiologists. Side-by-side comparison was made with the original analog examinations to determine the source of the discrepancy. Discrepant images were then graded in conjunction with an attending physician from the emergency department to determine the clinical impact on patient management. RESULTS: Clinically significant discrepancies (those with the potential to affect patient management) in image interpretation were found in 38 cases (5% of the total). Of these 38 cases, three cases (0.4%) were due to an inadequate digital image while 14 (2%) were due to interobserver error. Two (0.2%) discrepancies were due to film reader error, and 19 (2%) were due to digital image reader error. Reasons for inadequate digital images included underpenetrated radiographs and drifting of the laser digitizer. CONCLUSION: Commercially available teleradiology equipment can be both reliably and effectively used for off-hours interpretation of radiologic studies made in the emergency department.

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The authors correlated sonographic findings with histologic findings in a rabbit model of osteomyelitis. Staphylococcus aureus osteomyelitis was induced in the femora of 11 New Zealand white rabbits. The opposite leg was used as a control. Sonographic findings showed fluid adjacent to the bone in 11 cases. The fluid was believed to be an inflammatory exudate, and its presence suggested osteomyelitis. Pathologic analysis showed extraperiosteal purulent fluid adjacent to the cortex as well as histopathologic changes of osteomyelitis in the 11 rabbits. There was one false-positive sonographic diagnosis of osteomyelitis in a rabbit that had a soft tissue abscess adjacent to the cortex.

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To evaluate the role of ultrasound (US) in the detection of osteomyelitis, the authors prospectively studied 48 patients clinically suspected of having osteomyelitis. A sonographic diagnosis was made if fluid was seen directly in contact with bone, without intervening soft tissues. Twelve of the 48 patients were subsequently found to have osteomyelitis. In 10 of them, US demonstrated abnormal fluid adjacent to the bone. This fluid was thought to represent an inflammatory exudate dissecting in a subperiosteal and/or extraperiosteal location. Eight of the 48 patients had soft-tissue fluid collections. The rest of the patients either had no abnormalities or had cellulitis. The authors conclude that US can be useful in the detection of osteomyelitis.

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Many emergency rooms do not offer full-time coverage by a radiologist. Teleradiology can enable a radiologist to offer services to a number of emergency rooms. This allows more timely interpretation of emergency room studies and improved patient care. In our clinical trial, we found several problem areas and developed ways to improve our diagnostic accuracy. Since the resolution of transmitted images is less than that of film, a review of the original films at some later time is needed.

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Ten patients with clinically suspected osteomyelitis were studied with ultrasound (US). Five patients had abnormalities detectable on sonograms. An abnormal fluid collection was demonstrated adjacent to the bone in three of these five. US-guided aspiration of the fluid in two of the three patients revealed purulent or infected fluid that was thought to represent an inflammatory exudate dissecting in a subperiosteal or extraperiosteal location. Findings from subsequent radiographic and scintigraphic studies confirmed the diagnosis of osteomyelitis in these three patients. The other two patients with abnormal sonographic results had collections of fluid that were separated from the bone by a variable amount of soft tissue. These collections were confined to the soft tissue and did not appear to arise from the bone. Aspiration revealed a soft-tissue abscess in one patient and a seroma in the second. Findings in this preliminary study suggest that fluid around the bone seen on sonograms may indicate acute osteomyelitis.

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In the febrile infant less than 3 months old, a chest radiograph is commonly obtained to identify the cause of the fever. The purpose of this study was to evaluate the necessity of obtaining chest radiographs in this population. The clinical records and chest radiographs of 192 febrile infants (greater than 100.5 degrees F, rectal) were reviewed. Nineteen patients had signs of respiratory distress; seven had positive findings on chest radiographs. Of the 173 patients without signs of respiratory distress, five had positive findings on chest radiographs. When chest radiography was considered the gold standard for the presence or absence of pneumonia, findings of respiratory distress on physical examination had a sensitivity of 58% and a specificity of 93% for the detection of pneumonia. The prevalence of positive findings on chest radiographs in febrile infants less than 3 months old was 6%. A chest radiograph should be obtained in febrile infants only when signs of respiratory distress are present.

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The application of digital teleradiology (DTR) to radiologic examinations performed in the emergency room was evaluated. A total of 919 examinations (ten computed tomographic; the rest, radiographic) were transmitted to a radiology resident at another hospital emergency room. The 512 X 512 images were reviewed by an attending radiologist and compared with another attending radiologist's interpretation of the original films. Cases with discrepant interpretations were analyzed. Inadequate DTR image quality was responsible for clinically significant discrepancies in 14 of 897 cases (1.6%) available for follow up. Problem areas such as the detection of pneumothorax and abdominal calcifications were identified. Retransmission of optically zoomed images of areas of concern and repeat radiographs of overpenetrated films are suggested to improve DTR performance.

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The nutrient foramina in the phalanges and/or the calvarial vascular markings were evaluated in 34 patients with thalassemia. Enlarged nutrient foramina were noted in 17 patients, and abnormal calvarial markings were observed in 19 patients. The prominence of the vascular changes in the phalanges paralleled those in the calvaria, and the calvarial vascular impressions correlated with the width of the skull. The enlarged superficial calvarial vessels associated with the vascular impressions may represent a hazard to the patient. A transfusion regimen from an early age seemed to prevent enlargement of these vascular impressions.

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The cross-table lateral view of the chest can facilitate a more realistic appreciation of a pneumothorax than the supine frontal projection alone or in combination with the vertical-beam lateral view. This view also permits an optimal evaluation of the relative position of the lung, intrapleural air, and the tip of the chest tube in the supine newborn. The presence and size of a pneumothorax can usually be determined by locating the anterior lung edge on the cross-table lateral view. The anteroinferior corner of lung often aids in locating this anterior lung edge. The other structures that simulate the anterior lung edge on the cross-table lateral view include sternal retraction, rib ends, the axillary soft-tissue density, and posterior atelectasis. Because of the cause-effect relation of pneumothorax to intracranial bleeding in the premature infant, more widespread use of this technique to detect pneumothorax is recommended.

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To determine the relative accuracy of the various radiologic signs of Hirschsprung disease (HD), we retrospectively reviewed both radiographs obtained after a barium enema and the medical records of 62 children who had surgery to prove or exclude the diagnosis of HD. The visualization of a rectosigmoid transition zone was highly predictive of HD, but nonvisualization did not rule out HD. A false positive transition zone at the splenic flexure was seen in four neonates who had small left colon syndrome rather than HD. Retention of barium seen on radiographs obtained 24 hours after a barium enema was not a specific sign, but it was the only sign of HD in seven neonates, including two who had total colonic aganglionosis. Anal manipulation prior to the barium enema examination did not affect the diagnostic value of that procedure. We conclude that the single most reliable radiographic sign of HD is the presence of a rectosigmoid transition zone. Statistically, the use of three radiographic features combined (rectosigmoid transition zone, retention of barium, and stool mixed with barium) correlated better with the presence or absence of HD than did any of these features alone. A comparison of 24 and 48 hour postevacuation radiographs may help to differentiate HD from meconium plug syndrome.

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Four children (ages 3-9 years) with intermittent abdominal pain and vomiting are reported. Upper gastrointestinal examinations revealed a sharply angulated to-and-fro course (Z configuration) of the distal duodenum and proximal jejunum, rather than the usual smooth duodenojejunal loop at the ligament of Treitz. At operation this configuration was associated with broad peritoneal bands extending across the involved small intestine without an accompanying volvulus at this level. The Z sign is diagnostic of incomplete rotation, even in the absence of duodenal obstruction and with a proximal jejunum that may appear to be properly placed.

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A digital video image processor, connected to a video system in a conventional pediatric fluoroscopy room, was used to determine whether the device could provide satisfactory fluoroscopic images during routine examinations when the x-ray tube was operated at substantially lower than normal radiation-dose levels. A 50% reduction resulted in image quality which was indistinguishable from conventional fluoroscopic views.

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Premature fusion of the proximal humeral epiphyses with varus deformity is a common and characteristic radiologic finding in thalassemia anemia. A review of 17 cases with bilateral and one case with unilateral involvement, coupled with known anatomic and mechanical factors, suggested an explanation for this phenomenon. Hypertrophied marrow will thin the trabeculae and cortex, perforate the cortex through normal fenestrations, and proliferate subperiosteally. Normal force vectors result in medial humeral compression and ultimately premature fusion.

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A boy with epidermolytic hyperkeratosis was treated systemically for 4 1/2 years with 13-cis-retinoic acid. At the age of 10 1/2 years, he developed pain in his right knee and radiographic evidence of partial closure of the proximal epiphysis of the right tibia. Similar radiographic changes have been described in individuals ingesting excessive amounts of vitamin A.

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In conventional fluoroscopy, the current, and therefore the dose rate, is usually determined by the level at which the radiologist visualizes a just tolerable amount of photon "mottle" on the video monitor. In this study, digital processing of the analogue video image reduced noise and generated a television image at half the usual exposure rate. The technique uses frame delay to compare an incoming frame with the preceding output frame. A first-order recursive filter implemented under a motion-detection scheme operates on the image of a point-by-point basis. This effective motion detection algorithm permits noise suppression without creating noticeable lag in moving structures. Eight radiologists evaluated images of vesicoureteral reflux in the pig for noise, contrast, resolution, and general image quality on a five-point preferential scale. They rated the digitally processed fluoroscopy images equivalent in diagnostic value to unprocessed images.

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The chest roentgenograms of 128 consecutive ambulatory children with radiologic pneumonia were read independently and without clinical information by a faculty general pediatrician (Ped), a pediatric radiologist (R-P) and a general radiologist (R-G). The films were classified as normal, indicative of a viral or bacterial process, or indeterminate. Readings were compared with results of viral titers and bacterial cultures. Agreement between any two observers in classifying films, measured by unweighted Kappa, while statistically significant (p less than 0.001) for any pair, was low. There was no significant difference between the agreement scores of Ped/R-P, Ped/R-G, and R-P/R-G. Twenty-one patients had fourfold viral titer increases (N = 16) or positive bacterial cultures of blood or pulmonary aspirate (N = 5). The sensitivity of viral readings for titers increases varied from 19% to 68% depending on observer type; the sensitivity of bacterial readings for positive bacterial cultures varied from 60% to 80%. The three observers agreed on a correct reading in only three children with viral and three with bacterial pneumonia. Because of poor observer agreement and appreciable false-negative errors when viral and bacterial readings were compared to titer increases and positive bacterial cultures, respectively, we conclude that radiographic findings are poor indicators of etiology diagnosis in ambulatory childhood pneumonias and, of themselves, are an insufficient data base for making therapeutic decisions.

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