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Purpose: The current guidelines for initial cross-sectional imaging in pediatric lymphomas involve computed tomography (CT) of the chest, abdomen, and pelvis. However, whole-body magnetic resonance imaging (MRI) can be favored over CT for diagnosing and staging the disease, given its lack of ionizing radiation and its higher tissue contrast. Imaging characteristics of lymphoid tissue on MRI include a high T2/short tau inversion recovery (STIR) signal. A low or intermediate signal of lymphadenopathy on T2 and STIR images is an unexpected finding, noted anecdotally in nodular sclerosing Hodgkin lymphoma. This signal may be characteristic of a histological subtype of the disease and, if confirmed, could potentially be used to avoid biopsy. In this study, we aimed to review signal characteristics of lymphadenopathy in patients with biopsy-confirmed nodular sclerosing Hodgkin lymphoma. Methods: We undertook a retrospective review of relevant MR studies of patients with nodular sclerosing Hodgkin lymphoma. Studies were reviewed by an experienced pediatric radiologist regarding lymph node signal, especially on T2/STIR. Results: Eleven children with nodular sclerosing Hodgkin lymphoma were included. Median age at the time of MRI was 14.3 (IQR: 13.9–16.1) years, and nine were boys. Five patients showed some lymphadenopathy with a low T2/STIR signal, and six showed an intermediate T2/STIR signal. Central gadolinium non-enhancement was observed in four patients. Conclusions: All eleven patients (100%) with a diagnosis of nodular sclerosing Hodgkin lymphoma showed some lymphadenopathy with a low or intermediate T2/STIR signal, and five children (45.5%) showed a frank low signal of some lymphadenopathy, a feature which may prove to be a biomarker for this histology. [ABSTRACT FROM AUTHOR]

Background: Children who are exposed to HIV in utero but are uninfected (HIV-exposed uninfected or HEU) are at higher risk of neurodevelopmental delays compared to children born to persons without HIV. Magnetic resonance imaging (MRI) studies have revealed differences in grey matter volumes, cerebral perfusion, and white matter changes in these children. However, MRI is costly and not widely available in areas with high HIV prevalence, like Botswana, where more than 15% of children are HEU. To address this, we explored the use of brain ultrasound, conducted by trained study nurses, as a safe, less costly, and accurate alternative method for assessing differences relating to HIV exposure status in the brain structures of neonates. Methods: Brain ultrasounds of newborns in the Following Longitudinal Outcomes to Understand, Report, Intervene and Sustain Health for Infants, Children, Adolescents who are HIV Exposed Uninfected (FLOURISH) observational study—comprising 35 HEU newborns and 24 HIV-unexposed (HU) newborns—were performed by study nurses and evaluated by a pediatric radiologist for quality and structural abnormalities, such as calcifications, cysts, and hemorrhages. Two radiologists measured extra-axial cerebrospinal fluid spaces, ventricles, and the corpus callosum. Results: Ultrasound studies of 59 newborns (59% boys; median gestational age 38.4 weeks) were completed. All studies were of diagnostic quality, with 90.2% rated as being of good or excellent quality. Structural abnormalities were rare (10.2% incidence) and did not differ by HIV exposure group. Corpus callosum length was shorter in HEU infants compared to HU infants (45.7 mm vs. 47.3 mm; p = 0.03). Other ventricular and corpus callosum measurements showed no significant variations. Conclusions: Brain ultrasounds conducted by study nurses are feasible and reveal differences in corpus callosum length between HEU and HU infants. The benefits of easier training, lower cost, and rapid deployment make ultrasound a promising screening tool in resource-limited settings. [ABSTRACT FROM AUTHOR]

Purpose: Tuberculous meningitis (TBM) causes significant morbidity and mortality in young children. Early treatment can be initiated with magnetic resonance (MR) imaging diagnosis. We present MR-detectable miliary meningeal TB in two patients. Case 1: A 9-year-old girl developed fevers, cough, lethargy, and seizures. Brain MRI demonstrated multiple, small, T2-dark, rim-enhancing lesions, associated with cranial nerve and leptomeningeal enhancement. CSF showed pleocytosis, low glucose, and high protein. Chest CT showed mediastinal lymphadenopathy, multiple small interstitial lung nodules, and a splenic hypo enhancing lesion. Serial bronchoalveolar lavage studies were Xpert MTB/RIF and acid-fast negative. Endobronchial US-guided biopsy of a subcarinal lymph node was positive for Xpert MTB PCR. She was started on a 4-drug treatment for TBM and dexamethasone. Contact tracing revealed a remote positive contact with pulmonary tuberculosis. Case 2: A 17-year-old female with Crohn's disease on adalimumab developed refractory ear infections despite multiple courses of antibiotics. She underwent myringotomy, with negative aerobic ear fluid culture. Brain MRI, obtained due to persistent otorrhea, showed multiple, small, round, T2-dark lesions. CSF studies were normal. CT chest, abdomen, and pelvis to assess for disseminated disease showed left upper lobe tree-in-bud nodules, hypoattenuating splenic lesions and a left obturator internus abscess with adjacent osteomyelitis. She underwent CT-guided aspiration of the obturator muscle collection, bronchoscopy with bronchoalveolar lavage, biopsy of two preexisting chronic skin lesions, and ear fluid aspiration. QuantiFERON Gold was positive. Ear fluid was Xpert MTB/RIF assay and acid-fast stain positive. Cultures from the ear fluid, skin tissue, muscle tissue, and alveolar lavage showed growth of acid-fast bacilli. She was started on 4-drug therapy and prednisone. Conclusion: Our cases highlight that TBM in many cases remains a diagnostic dilemma — both our patients presented in a prolonged atypical manner. The term miliary TB not only refers to a pattern of interstitial nodules on chest radiographs but also indicates the hematogenous spread of the disease and concurrent pulmonary and extrapulmonary involvement with high risk of TB meningitis. We promote the use of the term miliary meningeal TB — in both cases, the neuroimaging diagnosis of TB preceded both chest imaging and laboratory confirmation of the disease. Miliary meningeal nodules on MRI may have characteristic T2 low signal and may be more conspicuous in children and immunocompromised individuals where background basal meningeal enhancement is less prominent. [ABSTRACT FROM AUTHOR]

Summary: Dysregulation of the host immune response has a central role in the pathophysiology of sepsis. There has been much interest in immunomodulatory drugs as potential therapeutic adjuncts in sepsis. We conducted a systematic review and meta‐analysis of randomised controlled trials evaluating the safety and clinical effectiveness of immunomodulatory drugs as adjuncts to standard care in the treatment of adults with sepsis. Our primary outcomes were serious adverse events and all‐cause mortality. Fifty‐six unique, eligible randomised controlled trials were identified, assessing a range of interventions including cytokine inhibitors; anti‐inflammatories; immune cell stimulators; platelet pathway inhibitors; and complement inhibitors. At 1‐month follow‐up, the use of cytokine inhibitors was associated with a decreased risk of serious adverse events, based on 11 studies involving 7138 patients (RR (95%CI) 0.95 (0.90–1.00), I2 = 0%). The only immunomodulatory drugs associated with an increased risk of serious adverse events were toll‐like receptor 4 antagonists (RR (95%CI) 1.18 (1.04–1.34), I2 = 0% (two trials, 567 patients)). Based on 18 randomised controlled trials, involving 11,075 patients, cytokine inhibitors reduced 1‐month mortality (RR (95%CI) 0.88 (0.78–0.98), I2 = 57%). Mortality reduction was also shown in the subgroup of 13 randomised controlled trials that evaluated anti‐tumour necrosis factor α interventions (RR (95%CI) 0.93 (0.87–0.99), I2 = 0%). Anti‐inflammatory drugs had the largest apparent effect on mortality at 2 months at any dose (two trials, 228 patients, RR (95%CI) 0.64 (0.51–0.80), I2 = 0%) and at 3 months at any dose (three trials involving 277 patients, RR (95%CI) 0.67 (0.55–0.81), I2 = 0%). These data indicate that, except for toll‐like receptor 4 antagonists, there is no evidence of safety concerns for the use of immunomodulatory drugs in sepsis, and they may show some short‐term mortality benefit for selected drugs. [ABSTRACT FROM AUTHOR]

Background: PTEN-related hamartoma tumor syndrome results from a mutation in the PTEN gene located at 10q23.31. This syndrome represents a spectrum of different phenotypes of variable expressions, now recognized as part of the same condition. Patients with this mutation have an increased risk of developing a wide range of findings, including malignancies. Although widely described in adults, there are no large series describing the imaging findings in patients before adulthood. Knowledge of the findings seen in children and adolescents with PTEN-related hamartoma tumor syndrome can help guide further management and improve surveillance recommendations. Objective: To describe the spectrum of imaging abnormalities in pediatric patients with PTEN-related hamartoma tumor syndrome. Materials and methods: We performed a retrospective, cross-sectional, multicenter study conducted between January 2000 and October 2021 in three tertiary pediatric institutions evaluating the imaging findings in children and adolescents (≤ 18 years) with confirmed diagnoses of a PTEN mutation. For each patient, the imaging findings, histopathology reports, and at least a 2-year follow-up of clinical outcomes for non-operative cases were documented. Results: The cohort included 78 children (37 girls), with a mean age at diagnosis of 7.5 years (range 0 days to 18 years). Benign brain findings included enlarged Virchow-Robin perivascular spaces, white matter changes, developmental venous anomalies, and cerebellar hamartomas. Benign thyroid findings were common, but 5/45 (11.1%) with thyroid abnormalities had a malignant nodule. Soft tissue adipocytic tumors, GI/GU polyps, other soft tissue abnormalities, along with vascular anomalies in various anatomic locations were common. Conclusion: Brain abnormalities, benign non-vascular soft tissue abnormalities, and vascular anomalies are commonly seen in children and adolescents with PTEN-related hamartoma tumor syndrome. However, malignancies involving the thyroid gland are not uncommon. Familiarity with the phenotype of PTEN-related hamartoma tumor syndrome in the pediatric population can improve diagnosis and prompt appropriate clinical surveillance of abnormal findings that warrant further management. [ABSTRACT FROM AUTHOR]

A recent publication by the Royal College of Anaesthetists has raised concerns about the use of anaesthetic rooms in UK practice. The report found that in 33% of cases, all monitoring was removed when patients were transferred from the anaesthetic room to the operating theatre, leading to an estimated 400,000 unmonitored transfers per year. The report suggests that anaesthetizing patients in the operating theatre could help avoid these monitoring gaps and improve patient safety. The authors argue that there is little evidence to support the perceived benefits of anaesthetic rooms and that inductions in the operating theatre would be safer and more efficient. They propose that anaesthesia should preferentially be induced in the operating theatre. [Extracted from the article]

In 2008, a partnership between the academic pediatric radiology department at the Children's Hospital of Philadelphia in the USA and the radiology department at Tikur Anbessa Specialized Hospital in Ethiopia, was established. The partnership aims to support pediatric radiology education during radiology residency and to establish pediatric radiology subspeciality training in Ethiopia. In this paper, we review the needs that elicit this type of partnership, its structure, achievements, challenges and future state as a successful roadmap to the establishment of a high-impact subspeciality program in a bilateral partnership. [ABSTRACT FROM AUTHOR]

Background: Radiology virtual teaching sessions utilize live video conferencing to promote collaborative learning and engagement by discussing radiology cases. Because of its convenience and flexibility, this mode of education has gained popularity, particularly after the corona virus disease 2019 pandemic. Objective: We describe our experience in organizing a series of "Global Health Imaging Case Competitions" for trainees in low- and middle-income countries (LMICs). These competitions provide the trainees with an opportunity to present unique radiology cases, network with radiologists, learn about various radiology topics, win prizes and potentially publish their case reports in a peer-reviewed journal. Materials and methods: Planning and execution of the competition involves several steps. First, trainees are invited to participate and submit abstracts discussing unique cases. The organizing committee grades these abstracts; the authors of the 20 abstracts with the highest scores are asked to submit a video presentation of their cases to be presented during the live webinar. During this webinar, presentations are displayed and graded to select winners. Additionally, the audience votes to choose a participant as the people's favorite. We have completed four cycles (Africa, Latin America and the Caribbean, Africa and the Middle East and Asia) and will continue in the same order of rotation. Results: Attendance totalled 2,510 participants from 50 countries. Pediatric cases represented the majority of cases among finalists. Feedback was positive; 26 out of 29 (90%) participants surveyed indicated that the webinar was "very good" to "excellent" with well-organized and challenging cases. Diversity of participating countries was noted. Limitations included technology barriers such as internet connectivity. Conclusion: This innovative approach emphasizing audience participation engaged trainees from LMICs and fostered locoregional collegiality and mentoring. [ABSTRACT FROM AUTHOR]

Pediatric radiology education for pediatric and radiology trainees and practicing professionals must be adapted to the target audience. In efforts to narrow the gaps in global pediatric radiology education, the Children's Hospital of Philadelphia's radiology department's Global Outreach and Education Program has designed specific interventions and curricula according to different levels of training and desired expertise. Our initiatives include an online "Introduction to Pediatric Imaging" lecture series for pediatrics residents in Botswana, Ethiopia and Vietnam; access to a learning management system (Outreach RADIAL) for radiology residents; case-based review sessions for pediatric radiology fellows; and in-person seminars for professionals from Eastern Europe and Africa. Here, we highlight our global education efforts to encourage other departments to take a similar systematic approach to outreach activities. [ABSTRACT FROM AUTHOR]

There is a severe shortage of pediatric radiologists in the USA and across the globe due to multiple factors. These severe shortages, along with increased clinical demand, growing research costs and limited funding sources place pediatric radiologists, particularly those in academic departments, under increasing time pressure, affecting their ability to maintain research productivity. In this paper, we model a new concept that should help boost the research efforts within the pediatric radiology community, while diversifying the academic workforce through the involvement of international medical graduates (IMGs). We describe the mutual advantages this concept could have on academic pediatric radiology departments and IMGs alike, as well as pose some of the unique challenges that could impact this concept and effective strategies to ensure success. [ABSTRACT FROM AUTHOR]

Background: The standard imaging technique for the diagnosis of intestinal malrotation remains the upper gastro-intestinal series (UGIS). The lateral view is promoted as important for making a diagnosis. For this, the lateral view should be of adequate quality, and radiologists must know the normal appearance as well as the appearance of duodenal variants, as misdiagnosis may lead to unnecessary surgery. Objective: We aimed to evaluate the quality, findings including the prevalence of the "descending staircase" configuration and its correspondence to a diagnosis of duodenum redundum. Materials and Methods: This was a retrospective study and was conducted in a large tertiary children's hospital in the United States. A retrospective review of UGI fluoroscopy exams in children aged ≤ 18 years between January and December 2018 was performed by a pediatric radiologist. First, the lateral view images/cine-loops were assessed independently, followed by the anteroposterior (AP) view. The studies which were designated to have an adequate lateral view were evaluated for configuration of the duodenum and recorded as: normal, abnormal, or normal variant. Also, the presence of a descending staircase configuration was correlated with an AP view for a diagnosis of duodenum redundum. Results: A total of 26 children (26%) (males:16; females:10) with age range 0 to 16 years had adequate lateral views during UGI exams for inclusion. Of the 26, 18 (69%) were reported as normal, 7 (27%) were reported as having a descending staircase and 1 (4%) was reported as abnormal. The AP view demonstrated 2 abnormal studies (1 malrotation and 1 non-rotation), 6 duodenum redundum and 18 normal exams. The one abnormal lateral duodenum was confirmed as a non-rotation on AP view; the second patient with an abnormal AP view had a normal appearance on the lateral view. Conclusions: A total of 26% of UGI studies had adequate lateral views for interpretation. Of these, nearly a quarter (23%) demonstrated the descending stair-case sign corresponding to a diagnosis of duodenum redundum on the AP view. If the lateral view had been used alone, there would have been a missed diagnosis in one patient. [ABSTRACT FROM AUTHOR]

Since the introduction of MRI as a sustainable diagnostic modality, global accessibility to its services has revealed a wide discrepancy between populations—leaving most of the population in LMICs without access to this important imaging modality. Several factors lead to the scarcity of MRI in LMICs; for example, inadequate infrastructure and the absence of a dedicated workforce are key factors in the scarcity observed. RAD‐AID has contributed to the advancement of radiology globally by collaborating with our partners to make radiology more accessible for medically underserved communities. However, progress is slow and further investment is needed to ensure improved global access to MRI. [ABSTRACT FROM AUTHOR]

Chest radiographs (CXR) have played an important and evolving role in diagnosis, classification and management of pediatric pulmonary tuberculosis (TB). During the pre-chemotherapy era, CXR aided in determining infectiousness, mainly to guide isolation practices, by detecting calcified and non-calcified lymphadenopathy. The availability of TB chemotherapy from the mid-1900s increased the urgency to find accurate diagnostic tools for what had become a treatable disease. Chest radiographs provided the mainstay of diagnosis in children, despite high inter-reader variability limiting its accuracy. The development of cross-sectional imaging modalities, such as computed tomography, provided more accurate intra-thoracic lymph node assessment, but these modalities have major availability, cost and radiation exposure disadvantages. As a consequence, CXR remains the most widely used modality for childhood pulmonary TB diagnosis, given its relatively low cost and accessibility. Publication of the revised 2022 World Health Organization Consolidated TB guidelines added practical value to CXR interpretation in children, by allowing the selection of children for shorter TB treatment using radiological signs of severity of disease, that have high reliability. This article provides a review of the historical journey and evolving role of CXR in pediatric pulmonary TB. [ABSTRACT FROM AUTHOR]

Background: Noninvasive alternatives to biopsy for assessment of interstitial fibrosis and tubular atrophy (IFTA), the major determinant of kidney transplant failure, remain profoundly limited. Elastography is a noninvasive technique that propagates shear waves across tissues to measure their stiffness. We aimed to test utility of elastography for early detection of IFTA in pediatric kidney allografts. Methods: We compared ultrasound (USE) and MR elastography (MRE) stiffness measurements, performed on pediatric transplant recipients referred for clinically indicated biopsies, and healthy controls. Results: Ten transplant recipients (median age 16 years) and eight controls (median age 16.5 years) were enrolled. Three transplant recipients had "stable" allografts and seven had Banff Grade 1 IFTA. Median time from transplantation to biopsy was 12 months. Mean estimated glomerular filtration rate was 61.5 mL/min/1.73m2 by creatinine‐cystatin‐C CKiD equation at time of biopsy. Mean stiffness, calculated through one‐way ANOVA, was higher for IFTA allografts (23.4 kPa USE/5.6 kPa MRE) than stable allografts (13.7 kPa USE/4.4 kPa MRE) and controls (9.1 kPa USE/3.6 kPa MRE). Pearson's coefficient between USE and MRE stiffness values was strong (r =.97). AUC for fibrosis prediction in transplanted kidneys was high for both modalities (0.91 USE and 0.89 MRE), although statistically nonsignificant (p >.05). Stiffness cut‐off values for USE and MRE were 13.8 kPa and 4.6 kPa, respectively. Both values yielded a sensitivity of 100% but USE specificity (72%) was slightly higher than MRE (67%). Conclusion: Elastography shows potential for detection of low‐grade IFTA in allografts although a larger sample is imperative for clinical validation. [ABSTRACT FROM AUTHOR]

Summary: Unrecognised oesophageal intubation causes preventable serious harm to patients undergoing tracheal intubation. When capnography is unavailable or doubted, clinicians still use clinical findings to confirm tracheal intubation, or exclude oesophageal intubation, and false reassurance from clinical examination is a recurring theme in fatal cases of unrecognised oesophageal intubation. We conducted a systematic review and meta‐analysis of the diagnostic accuracy of five clinical examination tests and the oesophageal detector device when used to confirm tracheal intubation. We searched four databases for studies reporting index clinical tests against a reference standard, from inception to 28 February 2023. We included 49 studies involving 10,654 participants. Methodological quality was overall moderate to high. We looked at misting (three studies, 115 participants); lung auscultation (three studies, 217 participants); combined lung and epigastric auscultation (four studies, 506 participants); the oesophageal detector device (25 studies, 3024 participants); 'hang‐up' (two non‐human studies); and chest rise (one non‐human study). The reference standards used were capnography (22 studies); direct vision (10 studies); and bronchoscopy (three studies). When used to confirm tracheal intubation, misting has a false positive rate (95%CI) of 0.69 (0.43–0.87); lung auscultation 0.14 (0.08–0.23); five‐point auscultation 0.18 (0.08–0.36); and the oesophageal detector device 0.05 (0.02–0.09). Tests to exclude events that invariably lead to severe damage or death must have a negligible false positive rate. Misting or auscultation have too high a false positive rate to reliably exclude oesophageal intubation and there is insufficient evidence to support the use of 'hang‐up' or chest rise. The oesophageal detector device may be considered where other more reliable means are not available, though waveform capnography remains the reference standard for confirmation of tracheal intubation. [ABSTRACT FROM AUTHOR]

Magnetic resonance urography (MRU) is an important MRI application that provides noninvasive comprehensive morphological and functional evaluation of the kidneys and urinary tract. It can be used to assess congenital anomalies of the kidney and urinary tract, which often present as urinary tract dilation. In children, MRU allows for high tissue contrast and high spatial resolution without requiring ionizing radiation. Magnetic resonance urography requires patient preparation in the form of pre-examination intravenous hydration, placement of a urinary catheter, and the administration of diuretics at the time of the exam. The imaging protocol is based on T2-weighted images for anatomical assessment and dynamic post-contrast images for functional evaluation. These images are then used to generate quantitative and graphic results including contrast transit and excretion time as well as to calculate differential renal function. This review focuses on a simple approach to pediatric MRU acquisition and interpretation based on clinical cases and the authors' experience. [ABSTRACT FROM AUTHOR]

The lymphatic system has been poorly understood and its importance neglected for decades. Growing understanding of lymphatic flow pathophysiology through peripheral and central lymphatic flow imaging has improved diagnosis and treatment options in children with lymphatic diseases. Flow dynamics can now be visualized by different means including dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL), the current standard technique to depict central lymphatics. Novel imaging modalities including intranodal, intrahepatic and intramesenteric DCMRL are quickly evolving and have shown important advances in the understanding and guidance of interventional procedures in children with intestinal lymphatic leaks. Lymphatic imaging is gaining importance in the radiologic and clinical fields and new techniques are emerging to overcome its limitations. [ABSTRACT FROM AUTHOR]

The gold standard for pediatric chest imaging remains the CT scan. An ideal pediatric chest CT has the lowest radiation dose with the least motion degradation possible in a diagnostic scan. Because of the known inherent risks and costs of anesthesia, non-sedate options are preferred. Dual-source CTs are currently the fastest, lowest-dose CT scanners available, utilizing an ultra-high-pitch mode resulting in sub-second CTs. The dual-energy technique, available on dual-source CT scanners, gathers additional information such as pulmonary blood volume and includes relative contrast enhancement and metallic artifact reduction, features that are not available in high-pitch flash mode. In this article we discuss the benefits and tradeoffs of dual-source CT scan modes and tips on image optimization. [ABSTRACT FROM AUTHOR]

Key Clinical Message: This case report aims to increase awareness that pulmonary artery aneurysms may occur as a complication of neglected patent ductus arteriosus and should be sought in children with ill‐treated congenital heart diseases. Pulmonary artery aneurysm is a rare anomaly with an autopsy prevalence of 1:14,000. These aneurysms can arise secondary to various etiologies, with congenital causes identified in 25% of cases and congenital heart diseases (CHD) responsible for more than half of these cases. A 12‐year‐old boy with CHD in the form of patent ductus arteriosus (PDA) and irregular clinical follow‐up presented with new onset fatigue of 3 months duration. A physical examination revealed anterior chest wall bulging and a continuous murmur. A chest radiograph showed a smooth left hilar region opacity that has a close relation with the left cardiac border. Transthoracic echocardiogram shows no progression from the previous one; there was a large PDA and pulmonary hypertension, but no further information was available. Computed tomography angiography revealed a giant aneurysm of the main pulmonary artery (PA), with a maximum diameter of 8.6 cm, and dilatation of its branches of 3.4 and 2.9 cm for the right and left PA, respectively. [ABSTRACT FROM AUTHOR]

The article focuses on the changes in the role of chest radiographs in the diagnosis and treatment of tuberculosis (TB) in children younger than 15 years, as recommended by the World Health Organization (WHO) in their 2022 consolidated guidelines. Topics include use of chest radiographs to differentiate between non-severe and severe forms of pulmonary disease and provide shorter drug courses; and identify chest radiography as a critical tool to evaluate the severity of intrathoracic disease.

BACKGROUND፡ The thyroid, along with the breast, lung, and bone marrow, is among the most radiosensitive organs. This study aims to assess the rate of unnecessary radiation exposure to the thyroid gland in patients who had chest Computed Tomography (CT) at a large teaching hospital. METHOD: Hospital-based retrospective cross-sectional study on 1,306 patients who underwent chest CT from July 2018 to January 2019. Thyroid gland inclusion along with the CT dose of the studies was evaluated. Data was collected by evaluating chest CT scans from Picture Archive and Communication System (MedWeb). RESULT: Out of 1306 patients, who had Chest CT scans intravenous iodinated contrast media was used in 95.4% of the CT scans. The thyroid was included in 99.8% of the scans, out of which 76.9% included the whole thyroid gland. Among the patients who had previous CT scans, 75.3% had one previous scan and 24.7% had two previous scans. DLP (Dose Length Product) in mGycm was lower in females (360.33±32) compared to males (426.45±378.4). The lowest DLP value was observed in the pediatric patients in the age range of 1-5 years which was 146.83, while the highest was observed among those above 18 years of age with mean DLP of 418.31. CONCLUSION: The majority of chest CT scans unnecessarily include the whole thyroid gland, which is one of the most sensitive organs for radiation-induced effects. Authors recommend optimized technique for chest scans to avoid future impacts. [ABSTRACT FROM AUTHOR]

Background: Fluid overload is associated with morbidity and mortality in children receiving dialysis. Accurate clinical assessment is difficult, and using deuterium oxide (D2O) to measure total body water (TBW) is impractical. We investigated the use of ultrasound (US), bioimpedance spectroscopy (BIS), and anthropometry to assess fluid removal in children receiving maintenance hemodialysis (HD). Methods: Participants completed US, BIS, and anthropometry immediately before and 1–2 h after HD for up to five sessions. US measured inferior vena cava (IVC) diameter, lung B-lines, muscle elastography, and dermal thickness. BIS measured the volume of extracellular (ECF) and intracellular (ICF) fluid. Anthropometry included mid-upper arm, calf and ankle circumferences, and triceps skinfold thickness. D2O was performed once pre-HD. We assessed the change in study measures pre- versus post-HD, and the correlation of change in study measures with percent change in body weight (%∆BW). We also assessed the agreement between TBW measured by BIS and D2O. Results: Eight participants aged 3.4–18.5 years were enrolled. Comparison of pre- and post-HD measures showed significant decrease in IVC diameters, lung B-lines, dermal thickness, BIS %ECF, mid-upper arm circumference, ankle, and calf circumference. Repeated measures correlation showed significant relationships between %∆BW and changes in BIS ECF (rrm =0.51, 95% CI 0.04, 0.80) and calf circumference (rrm=0.80, 95% CI 0.51, 0.92). BIS TBW correlated with D2O TBW but overestimated TBW by 2.2 L (95% LOA, -4.75 to 0.42). Conclusion: BIS and calf circumference may be helpful to assess changes in fluid status in children receiving maintenance HD. IVC diameter, lung B-lines and dermal thickness are potential candidates for future studies. [ABSTRACT FROM AUTHOR]

The presence of airway and lung disease in children with congenital heart disease is commonly observed with both cardiac CT angiography and routine chest CT. In this review we discuss abnormalities encountered on CT imaging of the chest beyond the heart and central vasculature, focusing on the airways, lung parenchyma and peripheral vasculature. Preoperative and postoperative findings are reviewed as well. [ABSTRACT FROM AUTHOR]

Background: Generalized arterial calcification of infancy (GACI), also known as idiopathic infantile arterial calcification, is a very uncommon genetic disorder characterized by calcifications and stenoses of large- and medium-size arteries that can lead to end-organ damage.Objective: To describe changes in imaging findings in 10 children with GACI at a single institution from 2010 to 2021.Materials and Methods: In this retrospective study we reviewed initial and follow-up body imaging in children with genetic confirmation of GACI at our hospital. All initial images were analyzed for the presence and distribution of arterial calcifications, stenoses and wall thickening/irregularity within the chest, abdomen and pelvis. We compared available follow-up studies to the initial imaging findings. We extracted clinical information including prenatal and postnatal treatment from the children's medical records.Results: We evaluated 10 children (five boys) with a diagnosis of GACI. Median age at first body imaging was 8 days (range: 1 day to 5 years). Six children were identified prenatally and four postnatally. Postnatal presentation included cardiac failure, seizures and hypertension. Images in newborns (n = 8) most commonly showed diffuse arterial calcifications (6/8; 75%), while stenoses were less common (2/8; 25%) during this period. Two children were diagnosed after the neonatal period - one in infancy and one during childhood. In total, half the children (5/10; 50%) had arterial stenoses - three cases visualized at first imaging and two identified on follow-up images during infancy. Stenoses had completely resolved in one child (1/5; 20%) at last follow-up. Eight children received prenatal or postnatal treatment or both. All children who received both prenatal and postnatal treatment (n = 4) had completely resolved calcifications at last follow-up.Conclusion: Children with GACI might have characteristic vascular calcifications at birth that raise the suspicion of this disease. Arterial calcifications decrease or disappear spontaneously or after treatment, but arterial stenoses usually persist. Calcifications and arterial stenoses can be easily identified and followed with non-contrast CT and CT angiography. [ABSTRACT FROM AUTHOR]

Purpose: Ultrasound is the first-line imaging modality to evaluate adnexa in girls with clinical suspicion of torsion. Patients with equivocal ultrasound findings can undergo MRI for better delineation of adnexal pathology. Here, we assess the utility of intravenous contrast in MRI evaluation of adnexal torsion in children. Methods: Two pediatric radiologists (R1, R2) retrospectively reviewed 198 pelvic MRI exams in 172 girls (median age 15 years). Each MRI was reviewed twice. The first review included pre-contrast images only. A second review, at least 1 month later, included both pre- and post-contrast images. Readers concluded if findings were suspicious for torsion or not. Readers' findings were compared to each other's and to surgical and MRI reports and clinical course. Results: 198 MRI exams yielded 354 evaluable ovaries. Surgical and pathological reports were available for 47 patients. 11 patients had adnexal torsion. Both readers accurately diagnosed acutely torsed ovaries during pre- and post-contrast reviews (n = 4). However, readers disagreed on torsed paraovarian cysts (n = 4) and chronically/intermittently torsed ovaries (n = 3). In 21 non-torsed ovaries that had lesions, one or both readers concluded that there were pre-contrast features of torsion. In this set with ovarian lesions, contrast helped readers to correctly conclude no torsion (R1 = 8, R2 = 6) more commonly than to incorrectly conclude torsion (1 each), improving post-contrast specificity for each reader. Conclusions: Post-contrast sequences did not provide additional benefit in evaluating acutely torsed ovaries but helped in excluding torsion in patients with adnexal lesions. Therefore, contrast administration should be individualized, potentially reserved only for those with abnormal ultrasound or pre-contrast images. [ABSTRACT FROM AUTHOR]

Objective: Magnetic resonance imaging (MRI) can accurately quantify liver iron concentration (LIC), eliminating the need for an invasive liver biopsy. Currently, the most widely used relaxometry methods for iron quantification are R2 and R2*, which are based on T2 and T2* acquisition sequences, respectively. We compared the rate of change of LIC as measured by the R2-based, FDA-approved commercially available third-party software with the rate of change of LIC measured by in-house analysis using R2*-relaxometry-based MR imaging in patients undergoing follow-up MRI scans for liver iron estimation. Methods: We retrospectively included patients who had undergone serial MRIs for liver iron estimation. The MR studies were performed on a 1.5T scanner; standard multi-slice, multi-echo T2- and T2*-based sequences were acquired, and LIC was estimated. The comparison between the rate of change of LIC by R2 and R2* values was performed via correlation coefficients and Bland–Altman difference plots. Results: One hundred and eighty-nine MR abdomen studies for liver iron evaluation from 81 patients (male: 38; female: 43) were included in the study. Fifty-nine patients had two serial scans, eighteen patients had three serial scans, three patients had four serial scans, and one patient had five serial scans. The average time interval between the first and last scans for each patient was 13.3 months. The average rates of change of LIC via R2 and R2* methods were −0.0043 ± 0.0214 and −0.0047 ± 0.012 mg/g per month, respectively. There was no significant difference in the rate of change of LIC observed between the two methods. Linearity between the rate of change of LIC measured by R2 (LIC R2) and R2* (LIC R2*) was strong, showing a correlation coefficient of r = 0.72, p < 0.01. A Bland–Altman plot between the rate of change of the two methods showed that the majority of the plotted variables were between two standard deviations. Conclusion: There was no significant difference in the rate of change of LIC detected between the R2 method and the R2* method that uses a gradient echo (GRE) sequence acquired with breath-hold. Since R2* is relatively faster and less prone to motion artifacts, R2*-derived LIC is recommended for iron homeostasis follow-up in patients with liver iron overload. [ABSTRACT FROM AUTHOR]

The article discusses the potential harm that can occur during airway management by anaesthetists, emphasizing that the absence of harm in randomized controlled trials does not mean it does not exist. The authors agree that standardized outcome definitions in airway management research would minimize variability and make evidence synthesis easier. They also address concerns about relying on evidence from non-anaesthetists and highlight the biases and pitfalls that all practitioners are susceptible to. The article argues that selectively disregarding certain evidence is biased and discusses the benefits of videolaryngoscopy in experienced practitioners. The authors stress the importance of looking beyond small trials to large datasets to detect rare safety-critical events. They also express concern that the full breadth of evidence supporting the utility, safety, and superiority of videolaryngoscopy may not have been appreciated. [Extracted from the article]

BACKGROUND: Typhlitis, (neutropenic enterocolitis), is a necrotizing enteropathy of the right colon, and is characterized by the clinical triad of fever, abdominal pain, neutropenia and imaging findings of right-side colonic inflammation. It is seen in the setting of severe neutropenia in immune suppressed patients who undergo treatment for malignancies, in those who have organ transplant(s) or congenital or other acquired immunosuppression. We report the clinical and imaging findings of typhlitis in pediatric cancer patients who had received chemotherapy in the largest tertiary center in Addis Ababa, Ethiopia over a period of 20 months. METHODS: The medical records of hospitalized cancer patients on treatment and with suspected typhlitis and with ultrasound reports were screened (November 2018-July 2020). Retrospective analysis of the clinical and sonographic data of those with typhlitis was done. RESULTS: Typhlitis was identified in 4.2% (12/286) of the patients on chemotherapy. 11 (91.7%) had hematologic malignancies (leukemia, lymphoma), one had a solid tumor (Head and neck embryonal RMS). Most (83.3%) had abdominal pain, diarrhea and neutropenia. Fever was identified in 67.7%. All had ultrasound evidence of typhlitis. and treated with IV antibiotics. Neither complications requiring surgical intervention nor death were seen. CONCLUSION: The magnitude of disease was comparable to what had previously been reported in other studies. While the presence of clinical a triad should prompt suspicion for the diagnosis, sonography can be used for confirmation and follow up obviating radiation, with good access in a resource limited setting. [ABSTRACT FROM AUTHOR]

Congenital heart disease can lead to various lymphatic complications including traumatic leaks, lymphatic overproduction, conduction abnormalities or lymphedema. Advancements in the imaging of central lymphatics and guided interventions have improved outcomes in these children. Dynamic contrast-enhanced magnetic resonance (MR) lymphangiography allows for the assessment of abnormal lymphatic drainage. This technique is preferred for evaluating lymphatic conditions such as plastic bronchitis, chylothorax, chyloptysis, chylopericardium, protein-losing enteropathy and chylous ascites, among other lymphatic disorders. In this review, we discuss lymphatic abnormalities encountered on MRI in children with congenital heart disease. We also briefly review treatment options. [ABSTRACT FROM AUTHOR]

Computed tomography technology continues to undergo evolution and improvement with each passing decade. From its inception in 1971, to the advent of commercially available dual-energy CT just over a decade ago, and now to the latest innovation, photon-counting detector CT, CT's utility for resolving and discriminating tissue types improves. In this review we discuss the impact of spectral imaging, including dual-energy CT and the recently available photon-counting detector CT, on the imaging of the pediatric chest. We describe the current capabilities and future directions of CT imaging, encompassing both the lungs and the surrounding tissues. [ABSTRACT FROM AUTHOR]

Magnetic resonance imaging (MRI) and CT perform an important role in the evaluation of neonates with congenital heart disease (CHD) when echocardiography is not sufficient for surgical planning or postoperative follow-up. Cardiac MRI and cardiac CT have complementary applications in the evaluation of cardiovascular disease in neonates. This review focuses on the indications and technical aspects of these modalities and special considerations for imaging neonates with CHD. [ABSTRACT FROM AUTHOR]

Neurosonography has become an essential tool for diagnosis and serial monitoring of preterm brain injury. Preterm infants are at significantly higher risk of hypoxic–ischemic injury, intraventricular hemorrhage, periventricular leukomalacia and post-hemorrhagic hydrocephalus. Neonatologists have become increasingly dependent on neurosonography to initiate medical and surgical interventions because it can be used at the bedside. While brain MRI is regarded as the gold standard for detecting preterm brain injury, neurosonography offers distinct advantages such as its cost-effectiveness, diagnostic utility and convenience. Neurosonographic signatures associated with poor long-term outcomes shape decisions regarding supportive care, medical or behavioral interventions, and family members' expectations. Within the last decade substantial progress has been made in neurosonography techniques, prompting an updated review of the topic. In addition to the up-to-date summary of neurosonography, this review discusses the potential roles of emerging neurosonography techniques that offer new functional insights into the brain, such as superb microvessel imaging, elastography, three-dimensional ventricular volume assessment, and contrast-enhanced US. [ABSTRACT FROM AUTHOR]

Neurosonography has become an essential tool for diagnosis and serial monitoring of preterm brain injury. Preterm infants are at significantly higher risk of hypoxic–ischemic injury, intraventricular hemorrhage, periventricular leukomalacia and post-hemorrhagic hydrocephalus. Neonatologists have become increasingly dependent on neurosonography to initiate medical and surgical interventions because it can be used at the bedside. While brain MRI is regarded as the gold standard for detecting preterm brain injury, neurosonography offers distinct advantages such as its cost-effectiveness, diagnostic utility and convenience. Neurosonographic signatures associated with poor long-term outcomes shape decisions regarding supportive care, medical or behavioral interventions, and family members' expectations. Within the last decade substantial progress has been made in neurosonography techniques, prompting an updated review of the topic. In addition to the up-to-date summary of neurosonography, this review discusses the potential roles of emerging neurosonography techniques that offer new functional insights into the brain, such as superb microvessel imaging, elastography, three-dimensional ventricular volume assessment, and contrast-enhanced US. [ABSTRACT FROM AUTHOR]

Magnetic resonance imaging (MRI) and CT perform an important role in the evaluation of neonates with congenital heart disease (CHD) when echocardiography is not sufficient for surgical planning or postoperative follow-up. Cardiac MRI and cardiac CT have complementary applications in the evaluation of cardiovascular disease in neonates. This review focuses on the indications and technical aspects of these modalities and special considerations for imaging neonates with CHD. [ABSTRACT FROM AUTHOR]

Purpose: To assess the feasibility of direct intra-lymphatic administration of diluted ferumoxytol as a T1-positive contrast agent for dynamic contrast-enhanced MR lymphangiography (DCMRL) imaging of the central lymphatics in children with renal disease.Methods: In vitro scan of dilute ferumoxytol was initially performed using time-resolved and high-resolution 3D gradient echo (GRE) sequences with short TE values (1 to 1.5 ms). A ferumoxytol concentration of 0.25 to 0.40 mg/mL was found to retain high signal in the T1-weighted sequences. DCMRL was then performed in 4 children with renal disease with the same 3D GRE sequences administrating diluted ferumoxytol via intra-mesenteric (IM), intra-hepatic (IH), and intra-nodal (IN) routes (6 to 9 mL to each site; average total dose of 0.75 mg/kg) by slow hand injection (0.5 to 1.0 mL/min). The signal-to-noise ratio (SNR) of the lymphatics was measured for quantitative evaluation.Results: Ferumoxytol-enhanced DCMRL was technically successful in all patients. Contrast conspicuity within the lymphatics was sufficient without subtraction. The mean SNR was significantly higher than the muscle (50.1 ± 12.2 vs 13.2 ± 2.8; t = 15.9; p < .001). There were no short-term complications attributed to the administration of ferumoxytol in any of the four patients.Conclusion: Magnetic resonance lymphangiography using ferumoxytol via IN, IH, and IM access is a new method to directly visualize the central lymphatic system and can be applied safely in patients with renal failure based on our preliminary report of four cases. Ferumoxytol-enhanced DCMRL shows diagnostic image quality by using 3D GRE sequences with short TE values and appropriate dilution of ferumoxytol.Key Points: • MR lymphangiography using ferumoxytol via intra-nodal, intra-hepatic, and intra-mesenteric access is a new method to directly visualize the central lymphatic system from the groin to the venous angle. • FDCMRL can be applied safely in patients with renal failure based on our preliminary report of four cases. • FDCMRL shows diagnostic image quality by using 3D GRE sequences with short TE values and appropriate dilution of the ferumoxytol. [ABSTRACT FROM AUTHOR]

In fact, there are not enough paediatric radiologists in practice even in Europe, the United States or Canada, and it is unlikely that the majority of paediatric US exams are performed in children's hospitals by expert paediatric radiologists - more likely they are being performed by radiology registrars, general radiologists, junior radiologists and non-expert paediatric radiologists at general radiology practices. The "need for credentialing non-radiologists who want to become involved in non-radiologist point-of-care US" [[1]] should be balanced by what is expected of radiologists themselves. The distance between offering to assist with curriculum development and training, and paediatric radiologists' involvement in a "credentialing board" for non-radiologist POCUS is wide, and the reason given - "because paediatric radiologists are the experts in the field" - might be offensive to other disciplines [[1]]. [Extracted from the article]

Lymphatic flow disorders include a broad spectrum of abnormalities that can originate in the lymphatic or the venous system. The development of these disorders is multifactorial and is most commonly associated with congenital heart diseases and palliative surgeries that these patients undergo. Central lymphatic disorders might be secondary to traumatic leaks, lymphatic overproduction, conduction abnormalities or lymphedema, and they can progress to perfusion anomalies. Several imaging modalities have been used to visualize the lymphatic system. However, the imaging of central lymphatic flow has always been challenging. Dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) allows for visualization of central lymphatic flow disorders and has been recently applied for the assessment of plastic bronchitis, protein-losing enteropathy, chylothorax and chylopericardium, among other lymphatic disorders. The hepatic and mesenteric accesses are innovative and promising techniques for better identification and understanding of these abnormalities. The main objectives of this review are to discuss the physiology and anatomy of the lymphatic system and review the current uses of DCMRL in the diagnosis and management of lymphatic flow disorders. [ABSTRACT FROM AUTHOR]

This document is an editorial from the journal Pediatric Radiology, focusing on the special issue of the journal on Global Health. The editorial highlights the importance of expanding the range of contributing colleagues and celebrating the diverse editorial team. It emphasizes the need to invite collaboration from authors around the world and support a more nurturing scholarly publication process. The special issue contains papers addressing pediatric radiology education, diagnostic approaches, and challenges in the field. The editorial concludes by inviting researchers to collaborate in identifying and removing barriers for authors from lower middle- and low-income countries. [Extracted from the article]

The article discusses the use of clinical signs in determining the correct placement of an endotracheal tube during intubation. The authors clarify that their systematic review does not discourage the use of clinical signs for other purposes, such as diagnosing endobronchial intubation or bronchospasm. However, they emphasize that clinical signs are unreliable for excluding esophageal intubation and should not be relied upon to confirm tracheal intubation. The authors also address the limitations of their review, including the lack of recent studies, but argue that the internal validity of the included studies would not change over time. They conclude that relying on clinical signs without robust confirmatory evidence of tracheal intubation can lead to errors and advocate for the use of waveform capnography and erring on the side of safety by removing the tube if there is any doubt. [Extracted from the article]

In a recently updated Cochrane systematic review comparing videolaryngoscopy vs. direct laryngoscopy, we reported that, collectively, videolaryngoscopes reduce the incidence of oesophageal intubation approximately twofold, but when considered by device design only, hyperangulated videolaryngoscopes were associated with a statistically significant reduction in oesophageal intubation [2]. GLO:1WP/01dec22:anae15818-fig-0001.jpg PHOTO (COLOR): 1 Comparison of the point estimates and confidence intervals generated by the Peto odds ratio method, fixed-effect and random-effects models for meta-analysis of the oesophageal intubation outcome, by videolaryngoscope type. Reduced intubation failure rates are consistent with reduced oesophageal intubation, which are a subset of this, and the improved (team) view is consistent with improved recognition of oesophageal intubation. [Extracted from the article]

Background: Renal artery stenosis is an important cause of hypertension in children, accounting for 5–10% of cases. When suspected, noninvasive imaging options include ultrasound (US), computed tomography (CT) angiography and magnetic resonance (MR) angiography. However, digital subtraction angiography (DSA) remains the gold standard. Objective: To investigate the accuracy and inter-reader reliability of CT angiography in children with suspected renal artery stenosis. Materials and methods: This is a retrospective study of patients suspected of having renal artery stenosis evaluated by both CT angiography and DSA between 2008 and 2019 at a tertiary pediatric hospital. Only children who underwent CT angiography within 6 months before DSA were included. CT angiography studies were individually reviewed by two pediatric radiologists, blinded to clinical data, other studies and each other's evaluation, to determine the presence of stenosis at the main renal artery and 2nd- and 3rd-order branches. The sensitivity, specificity and accuracy were calculated using DSA as the reference. The effective radiation dose for CT angiography and DSA was also calculated. Kappa statistics were used to assess inter-reader agreement. Results: Seventy-four renal units were evaluated (18 girls, 19 boys). The patients' median age was 8 years (range: 1–21 years). Overall, CT angiography was effective in detecting renal artery stenosis with a sensitivity of 85.7%, specificity of 91.5% and accuracy of 88.9%. There was moderate inter-reader agreement at the main renal artery level (k=0.73) and almost perfect inter-reader agreement at the 2nd/3rd order (k=0.98). However, the sensitivity at the 2nd- and 3rd-order level was lower (14.3%). CT angiography provided excellent negative predictive value for evaluating renal artery stenosis at the main renal artery level (90.1%) and at the 2nd- or 3rd-order branches (82.7%). The median effective dose of CT angiography studies was 2.2 mSv (range: 0.6–6.3) while the effective dose of DSA was 13.7 mSv. Conclusion: CT angiography has high sensitivity and specificity at the main renal artery level with a lower radiation dose than previously assumed. Therefore, it can be used as a diagnostic tool in patients with low to medium risk of renal artery stenosis, and as a screening and treatment planning tool in patients at high risk. [ABSTRACT FROM AUTHOR]

However, repeat laryngoscopy by an alternative intubator (even using the original technique) was frequently the mechanism by which oesophageal intubation was identified. For this reason, accepting that no technique for detection of oesophageal intubation is infallible, the consensus guidelines set out clear criteria for repeat laryngoscopy for this purpose [[2]]. Dr Lyons [[1]] raises several questions about the consensus guidelines on prevention of unrecognised oesophageal intubation [[2]] and the Cochrane review of videolaryngoscopy vs. direct laryngoscopy [[3]]. [Extracted from the article]

Purpose: To determine the MRU imaging findings of calyceal diverticula in a large cohort of children and to compare the frequency of calyceal diverticula in our cohort with what has been previously reported. Methods: This was a HIPAA-compliant, IRB-approved retrospective study of all patients with suspected CD based on their medical records. All patients in this study underwent MRU at our institution between 2010 and 2017. Two pediatric radiologists reviewed each MRU blinded to clinical information and other urologic imaging regarding the presence, size, location, and morphology of the cyst and presence/absence of contrast within it. The time when contrast first appeared within the cystic mass was recorded, and a χ2 test was used to determine significance on differences between the different characteristics of renal cysts and diverticula. Results: Fifty children (29 girls and 21 boys; median age of 11.5 years, IQR 7–16) with a total of 66 individual cystic masses were included. 21 (21/66, 31.8%) Cystic masses demonstrated contrast filling and were characterized as diverticula, resulting in a frequency of 26.6 cases per 1000 patients (21/787). The remaining 45 cystic masses (45/66, 68.1%) were cysts. The median diameter of CD was 2.5 cm (IQR 1.5–3.7). Contrast was observed within the cystic mass on average at 4.6 min (SD ± 2.4; range 1.5–13 min). The agreement between both radiologists was 91% (k = 0.78). 6 Cysts and 18 CD were confirmed surgically, MRU demonstrated accurate diagnosis in 100% of those cases. Conclusion: Magnetic resonance urography is reliable in differentiating calyceal diverticula from renal cysts. On MRU, all diverticula were identified within 15 min of contrast administration; hence longer delays in imaging are unnecessary. [ABSTRACT FROM AUTHOR]