Q&A on MRE: Dan Podberesky, MD

Daniel J. Podberesky, MD, joined Nemours Children’s Health System as Radiologist-in-Chief in October 2014. He is a nationally recognized physician with a distinguished list of accomplishments in the pediatric imaging field. Based in Orlando, Florida, Dr. Podberesky leads one of the largest and busiest pediatric radiology departments in the country, with 35 radiologists and over 200 imaging team members performing and interpreting approximately 300,000 imaging exams and procedures annually.

Nemours Children’s Health System cares for families at more than 90 locations spread across six states including freestanding children’s hospitals in Wilmington, Delaware and Orlando, Florida.

Known as one of the nation’s leading pediatric health systems, Nemours cares for more than 400,000 children a year through primary, specialty and urgent care locations. Nemours also powers the world’s most-visited website for information on the health of children and teens, KidsHealth.org, and offers on-demand, online video patient visits through Nemours CareConnect.

Q: Nemours was an early adopter of MR Elastography for liver fibrosis staging. What factors led to Nemours offering this technology so early in its adoption curve? And was there a generally positive response from referring physicians and families to have this as an option locally?

A: Nemours’ Radiology Department has always been on the forefront of novel medical imaging technology utilization. We strive to provide the patients and clinicians that we serve with the latest, state-of-the-art, clinically proven medical imaging technology in order to fulfill our organization’s mission of improving child health in Florida and the Delaware Valley. When I joined Nemours in 2014, I was fortunate to bring with me my experience from Cincinnati Children’s Hospital, one of the earliest adopters of MRE technology in the pediatric healthcare arena, and my experience collaborating with Philips Healthcare on MRE research. These factors led to a natural desire to implement MRE as early as possible.

In general, there has been gradual acceptance of this new technology by the pediatric gastroenterology community for a variety of reasons. However, in my experience, once the initial hesitancy is overcome, there is rapid acceleration of acceptance. I think given the recent guidelines from relevant professional societies recommending MRE in a number of clinical scenarios (e.g., such as those from the American Gastroenterological Association, and American Association for the Study of Liver Diseases, and the American College of Radiology), we’ll continue to see utilization grow.

Q: For pediatric patients, the pain, expense and sampling error of liver biopsies make it less than desirable. In your view, how has MR Elastography done in overcoming these challenges, particularly in a more cost efficient manner?

A. Liver biopsy is considered the “gold” standard for diagnosis of liver pathology. However, it is an “imperfect” gold standard. It is painful, relatively expensive, carries a complication rate of approximately 6%, including life-threatening complications in approximately 0.1% of cases, samples only approximately 1/50,000th of the liver (which is significantly problematic given that most chronic liver diseases are very heterogeneous in their involvement of the liver parenchyma), generally requires sedation/anesthesia in children, and carries significant variability in interpretation by pathologists. Despite the disadvantages, liver biopsy clearly remains a critical tool in the diagnosis of acute and chronic liver disease. MR elastography offers significant advantages in certain patient populations compared to liver biopsy, and often can obviate the need for a liver biopsy and save cost to the patient/family, and the healthcare system as a whole, while also avoiding the risks associated with biopsy.

Q: What are the major clinical indications that Nemours sees for referrals for MR Elastography? Are there any growing at a faster rate than others?

A. By far, the most common indication is non-alcoholic fatty liver disease (NAFLD), which is increasing rapidly in the pediatric population. Other clinical indications we have seen not uncommonly include autoimmune hepatitis, cystic fibrosis, storage disorders, and congenital heart disease status post Fontan procedure.

Q: There is a growing awareness among patients and practitioners about the global burden of liver disease. In general, what role do you think advanced imaging can play in helping to address this growing burden of disease?

A: Advanced imaging, and specifically MR elastography, is truly a game changer for the evaluation and surveillance of chronic liver disease. We know that the prevalence of liver disease is increasing very rapidly, particularly in Western society where it is mostly related to the increase in obesity and metabolic syndrome. Researchers and clinicians have longed for a non-invasive method to evaluate for the presence of liver inflammation and fibrosis. While no method is perfect, MRE, combined with anatomic MR imaging of the liver and fat fraction quantification provides invaluable diagnostic information to hepatologists, gastroenterologists, primary care providers, and other clinicians who care for patients with liver disease.

Q: Some people have said that getting an MRE can tickle, or feels like a massage. Has a pediatric patient ever had something funny to say about their experience getting an MRE exam? Are there any strategies Radiographers at Nemours use for pediatric patients getting an MRE exam?

A: We hear many children describe the vibration sensation from the MRE passive driver as a “tickle”. We find that having our MR technologists or child life specialists speak to the pediatric patient before the exam about that sensation, and our desire for them to hold their breath for optimal imaging, make significant difference in image quality and tolerance of the exam. I will often tell children that MRE feels like when you put your hand on a speaker when the music is playing real loud, and that will be the sensation on their tummy.

Prior to joining Nemours, Dr. Podberesky was Associate Director of Clinical Services and Chief of the Division of Thoracoabdominal Imaging at Cincinnati Children’s Hospital Medical Center. He is currently Professor of Radiology at the University of Central Florida College of Medicine and Associate Professor of Radiology at Florida State University College of Medicine. Dr. Podberesky earned his medical degree at the University of Maryland School of Medicine in Baltimore. As an active duty member of the U.S. Air Force, he completed a residency in diagnostic radiology at the San Antonio Uniformed Services Health Education Consortium, followed by a fellowship in pediatric radiology at Cincinnati Children’s Hospital Medical Center. Following his radiology training, Dr. Podberesky served as Chief of Pediatric Radiology at Wilford Hall Medical Center at Lackland Air Force Base in Texas.

Dr. Podberesky is certified by the American Board of Radiology, with a certificate of added qualification in pediatric radiology. His main areas of clinical and research interest are advanced imaging of the pediatric gastrointestinal, genitourinary, and cardiovascular systems, and he has published over 65 peer-reviewed articles and numerous textbook chapters in these and other areas, including co-authoring some of the earliest articles on the use of MR elastography in children. He has also served on numerous national radiology organization committees, served as a Board examiner for the American Board of Radiology, and as a member of the Board of Directors of the Society for Pediatric Radiology.

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