Evidence-Based Imaging in Pediatrics. L. Santiago Medina, Kimberly E. Applegate, C. Craig Blackmore (Editors). Springer 2010, 666 pages, $79.95.
“I don’t know” is a phrase I use all too often when trying to address questions from my Radiology and Pediatric residents who ask me detailed questions about the evidence behind a radiological “call” and consequences of my diagnostic decisions. I say, “I don’t know” because I believe in giving answers based on evidence and not on anecdote. “Because that’s what I was taught” is a very unsatisfactory answer for me and our residents. I wish I had the time to master the evidence-base of all topics in pediatric imaging practice, but the option of taking multi-year sabbaticals for independent study is not feasible. This is why I enthusiastically picked up Evidence-Based Imaging in Pediatrics to provide some insight into these difficult questions.
The book opens up with some principles of evidence-based imaging and an assessment of the literature. I’ve amassed a collection of biostatistics and methods books to try and understand these topics and advise residents and other faculty on study design. The discussion of the evidence based process, Bayes theorem, and ROC curves was discussed briefly and is as good if not better than books devoted to biostatistics. The discussion on confidence interval, which actually takes less than a full page, is the clearest description of the topic I’ve read to date, finally makes sense and kept me awake, unlike most other treatises on the topic. These two chapters set the framework for the remainder of the manuscript.
The book is divided into 6 parts. Part 1: “Principles, Methodology, and Radiation Risk” describes principles of evidence-based imaging and delves into the evidence behind radiation risk in children. Part 2: “Neuroimaging is divided into 9 chapters.” Topics include Craniosynostosis, sickle cell disease and stroke, neonatal hypoxic ischemic encephalopathy, traumatic brain injury, neoplasms, headache, seizures, sinus disease and nonaccidental head injury. Part 3: “Musculoskeletal Imaging” is divided into 11 chapters and covers a variety of topics including non-accidental trauma, spine trauma, other spine disorders and dysraphisms, assessment of the peripheral joints, osteomyelitis and septic arthritis, bone tumors, knee and shoulder injuries, developmental hip dysplasia, slipped capital femoral epiphysis, Legg-Calve-Perthes, and ankle fractures. Part 4: “Chest Imaging” is composed of 5 chapters. Topics include congenital heart disease, aortic arch anomalies, mediastinal masses, chest infections, and asthma. Part 5: “Abdominal Imaging” covers 12 chapters. They include malrotation, pyloric stenosis. intussusception, appendicitis, inflammatory bowel disease, neuroblastoma, wilms tumor, trauma, nephrolithiasis, urinary tract infection, GYN cause of pain, and testicular torsion. Part 6: “Prenatal Imaging” is composed of one chapter that discusses methodologies of fetal imaging safety concerns and societal cost.
Each chapter is well organized to for ease of reading and quick reference and review. A clear statement of 3-6 major issues begins each chapter in a table format with each issue phrased as a question. It is followed by a table of statements that summarize the key points that are discussed in greater detail throughout the chapter. Each of these statements as well as most of the statements of “fact” throughout the book is qualified with level of evidence ranks. The classification system is divided into 4 levels: strong, moderate, limited and insufficient evidence. The methodology of how information is classified is included in chapter 2: “Critically Assessing the Literature.”
Chapter content is consistently organized throughout the book. Each begins with a section on “Definitions and Pathophysiology” that defines important concepts and reviews the relevant pathophysiology. Clinical findings, signs, symptoms and important historical information are often reviewed. The second section discusses epidemiology including prevalence and incidence data. All information is well referenced and described in relation to the study that reported the data. Study features including age ranges, patient numbers and study type are mentioned so the reader can formulate an assessment of the data. Commentary on the study is offered when relevant. The next section is “Overall Cost to Society” which describes studies on total cost and cost-benefit for diagnosis. If data are limited or no studies are available, it is clearly explained as such. Goals of diagnosis and therapy are then described with evidence-based discussion on therapeutic options.
Subsequent sections in each chapter are devoted to answering the questions posed in the issues table. As is expected with an evidence-based approach, this begins with a discussion on the author’s methodology for answering these questions. Descriptions of the databases searched and medical subject headings are described. For each of the key issues, a summary of evidence is written which is very helpful for later review. A detailed description of supporting evidence follows that reviews studies in greater detail which often includes Bayesian and parametric statistical results from each study. Finally, take home tables summarize the evidence and a few imaging case studies highlight features of the previous discussion and give every radiologist the satisfaction of viewing an image. Future areas of research and a complete list of references conclude each chapter.
Each of the chapters is thorough, and references are very complete. There are few actual cases, but the included examples having good images and figures are well explained. I recommend this book for any radiologist who participates in the care of pediatric patients. It is a “must have” for pediatric radiologists and fellows. Neuroradiologists who take care of pediatric patients will be interested in the neuroimaging sections, but most of the book is not dedicated to neuroimaging. Residents who are interested in pursuing a career in pediatric radiology would be well served by having a copy.
I have not found a book on pediatric radiology that covers these topics in such an organized and evidence-based approach. The format is very easy to grasp and helpful when referencing and reviewing topics after the first read. In summary, this book explores pediatric radiology from an evidence-based approach that is well organized, well referenced, and I highly recommend it for practitioners of pediatric imaging.
