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This second roundtable discussion was convened at the 56th European Society of Paediatric Radiology (ESPR) 2022 Annual Meeting in Marseille, France, to discuss controversial aspects of imaging in child abuse. The following topics were discussed: Fracture dating—the published literature is broadly similar with respect to the identification of the radiographic stages of bony healing. The non-expert/general radiologist is encouraged to use broad descriptors of fracture healing (acute, healing or old) within their reports, rather than attempting to date fractures. The more experienced/expert radiologist, who may provide a timeframe/range to assist the courts, should be aware that any published timeframes are not absolute and that recent research indicates that the rate of healing may differ according to the bone affected and the age of the patient. Whole spine imaging in suspected abusive head trauma—this is recommended to enable a complete assessment of the neuraxis when abusive head trauma is suspected or diagnosed, particularly in the presence of intracranial and cervical subdural haemorrhage and cervical ligamentous injury. Cranial imaging in suspected physical abuse—both computed tomography (CT) and magnetic resonance imaging (MRI) remain complimentary depending on the clinical context in which they are used with CT remaining first-line in the assessment of children with (suspected abusive) head trauma prior to an early MRI. MRI is superior in its assessment of parenchymal injury and may be employed as first-line in age appropriate asymptomatic siblings of a child with suspected physical abuse.

Background Prematurity and perinatal risk factors may influence white matter microstructure. In turn, these maturational changes may influence language development in this high-risk population of children. Objective To evaluate differences in the microstructure of association tracts between preterm and term children and between preterm children with appropriate growth and those with fetal growth restriction and to study whether the diffusion tensor metrics of these tracts correlate with language abilities in schoolchildren with no severe neurological impairment. Materials and methods This study prospectively followed 56 very preterm children (mean gestational age: 28.7 weeks) and 21 age- and gender-matched term children who underwent diffusion tensor imaging at a mean age of 9 years. We used automated probabilistic tractography and measured fractional anisotropy in seven bilateral association tracts known to belong to the white matter language network. Both groups participated in language assessment using five standardised tests at the same age. Results Preterm children had lower fractional anisotropy in the right superior longitudinal fasciculus 1 compared to term children (P P P Conclusion There were some microstructural differences in language-related tracts between preterm and term children and between preterm children with appropriate and those with restricted fetal growth. Children with better language abilities had a higher fractional anisotropy in distinct white matter tracts.

The diagnosis of brain death is primarily clinical. Sometimes ancillary tests are needed.This study compared sensitivity and interobserver agreement of the 10-, 7- and 4-point CT angiography scoring systems for the diagnosis of brain death in children.CT angiography examinations of 50 pediatric patients with a clinical diagnosis of brain death were evaluated according to 10-, 7- and 4-point scoring systems. Images were evaluated by two radiologists who considered the vessel opacification first in the arterial phase (AUsing the clinical exam as the reference standard, we found sensitivities for 10-, 7- and 4-point scoring systems to be 70%, 88% and 92% in the AJust as in adult age groups, in children the 4-point scale appears to be more sensitive than the 10- and 7-point scales for CT angiography-based assessment of brain death. Because the scoring systems have similar sensitivities, they could be used as ancillary tests in pediatric cases.

Anorectal and cloacal malformations are a broad mix of congenital abnormalities related to the distal rectum and anus. Confusion exists between all the forms in this large and heterogeneous group. The spectrum includes everything from anal stenosis, ventral anus, anal atresia (with and without fistula) and the full spectrum of cloacal malformations. Imaging in these conditions is done through the whole armamentarium of radiologic modalities, with very different imaging strategies seen across the centres where these conditions are managed. In 2017, the European Society of Paediatric Radiology (ESPR) abdominal imaging task force issued recommendations on the imaging algorithm and standards for imaging anorectal malformations. This was followed by further letters and clarifications together with an active multispecialty session on the different imaging modalities for anorectal malformations at the 2018 ESPR meeting in Berlin. Through this paper, the abdominal task force updates its guidelines and recommended imaging algorithm for anorectal malformations.Other Information Published in: Pediatric Radiology License: https://creativecommons.org/licenses/by/4.0See article on publisher's website: http://dx.doi.org/10.1007/s00247-022-05395-7

Background Fetal growth restriction caused by placental insufficiency is associated with increased risk of poor neurodevelopment, even in the absence of specific perinatal brain injury. Placental insufficiency leads to chronic hypoxaemia that may alter cerebral tissue organisation and maturation. Objective The aim of this study was to assess the effects fetal growth restriction and fetal haemodynamic abnormalities have on brain volumes and white matter microstructure at early school age. Materials and methods This study examined 32 children born with fetal growth restriction at 24 to 40 gestational weeks, and 27 gestational age-matched children, who were appropriate for gestational age. All children underwent magnetic resonance imaging (MRI) at the age of 8–10 years. Cerebral volumes were analysed, and tract-based spatial statistics and atlas-based analysis of white matter were performed on 17 children born with fetal growth restriction and 14 children with birth weight appropriate for gestational age. Results Children born with fetal growth restriction demonstrated smaller total intracranial volumes compared to children with normal fetal growth, whereas no significant differences in grey or white matter volumes were detected. On atlas-based analysis of white matter, children born with fetal growth restriction demonstrated higher mean and radial diffusivity values in large white matter tracts when compared to children with normal fetal growth. Conclusion Children ages 8–10 years old born with fetal growth restriction demonstrated significant changes in white matter microstructure compared to children who were appropriate for gestational age, even though no differences in grey and white matter volumes were detected. Poor fetal growth may impact white matter maturation and lead to neurodevelopmental impairment later in life.

Background Evidence suggests severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may be associated with appendicitis or clinical symptoms that mimic appendicitis, but it is not clear if the findings or utility of imaging in pediatric patients with suspected appendicitis have changed since the onset of the coronavirus disease 2019 (COVID-19) pandemic. Objective To evaluate for potential differences in SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients imaged for suspected appendicitis to determine the reliability of the existing medical imaging approach for appendicitis in a population that contains both SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients. Materials and methods Patients imaged for suspected appendicitis Apr. 1, 2020, to Dec. 31, 2020, were identified via an electronic medical records search. Differences in ultrasound (US) diagnostic performance, use of computed tomography (CT) following US, rates of appendicitis, imaging findings of appendicitis and perforation were compared between SARS-CoV-2 positive and SARS-CoV-2 negative tested patients, using pathology and surgery as reference standards for appendicitis and perforation, respectively. Fisher exact test and Student’s t-test were used for statistical analysis. Results One thousand, six hundred and ninety-three patients

Imaging the coronary arteries of children, with their faster heart rates, small vessel size and common inability to lie still or breath-hold, has been a major challenge. With numerous advances in technology, CT examinations can now be performed quickly, often with children free-breathing and with much lower radiation doses than previously. This has led to increased use in children. Care must be taken with technique and choice of electrocardiogram (ECG)-gating technique to obtain adequate imaging for a diagnosis while keeping radiation dose as low as reasonably achievable (ALARA). In this paper, we discuss techniques and tips for CT imaging of the coronary arteries in children, including use of dual-source- and ultrawide-detector CT scanners.

Background The causes of idiopathic ileocolic intussusception are unknown, with infection as the most likely culprit. Recently, social distancing measures were implemented during the coronavirus disease 2019 (COVID-19) pandemic to decrease transmissible infectious diseases, creating an opportune setting to study the role of infection on the pathogenesis of intussusception on a population level. Objective To investigate the impact of social distancing on intussusception. Materials and methods We retrospectively reviewed air contrast enemas and pylorus ultrasounds performed between March 2010 and March 2021 to identify cases of ileocolic intussusception and hypertrophic pyloric stenosis (HPS), using the latter as a negative control. The study time frame was divided into two periods: pre-pandemic (March 2010–February 2020) and pandemic (April 2020–March 2021). The number of cases that occurred in these two time periods were compared using the Poisson regression model. Results Of the 407 cases of idiopathic ileocolic intussusception identified, 396 occurred in the pre-pandemic time period (mean = 39.6 per 12-month period) and 11 occurred in the 12-month pandemic time period. The mean monthly number of intussusceptions showed a decline of 72% (95% confidence interval [CI] 49–85%) between the pre-pandemic and pandemic time periods (3.3 vs. 0.9 monthly cases; P

Background The diagnostic value of cardiac magnetic resonance imaging (MRI) employing the 2018 Lake Louise criteria in pediatric and adolescent patients with acute myocarditis is undefined. Objective To evaluate the diagnostic value of the Lake Louise criteria in pediatric and adolescent patients with suspected acute myocarditis and to show the utility of cardiac MRI for follow-up in this patient cohort. Materials and methods Forty-three patients (age range: 8–21 years) with suspected acute myocarditis and 13 control patients who underwent cardiac MRI were retrospectively analyzed. T2-weighted and late gadolinium enhancement imaging were performed in all patients. T1 and T2 mapping were available in 26/43 patients (60%). The Lake Louise criteria were assessed. In 27/43 patients (63%), cardiac MRI follow-up was available. Receiver operating characteristic analysis, Pearson’s correlation coefficient and paired Student’s t-test were used for statistical analysis. Results In the total cohort, the Lake Louise criteria achieved a sensitivity of 86% (95% confidence interval [CI]: 72–95%) and a specificity of 100% (95% CI: 79–100%) for the diagnosis of acute myocarditis. In the subgroup of patients with available mapping parameters, the diagnostic performance of the Lake Louise criteria was higher when mapping parameters were implemented into the score (area under the receiver operating characteristic curve: 0.944 vs. 0.870; P=0.033). T2 relaxation times were higher in patients with admission to the intermediate care unit and were associated with the length of intermediate care unit stay (r=0.879, P=0.049). Cardiac MRI markers of active inflammation decreased on follow-up examinations (e.g., T1 relaxation times: 1,032±39 ms vs. 975±33 ms, PP=0.003). Conclusion The Lake Louise criteria have a high diagnostic performance for the diagnosis of acute myocarditis and are a valuable tool for follow-up in pediatric and adolescent patients. The mapping techniques enhance the diagnostic performance of the 2018 Lake Louise criteria.

Background Since coronavirus disease 2019 (COVID-19) was declared a worldwide pandemic in March 2020, many authors have noted the collateral damage on non-COVID-19-related illnesses. These indirect effects of the pandemic have resulted in people presenting later and with more severe stages of disease, even if their diagnoses are not directly related to SARS-CoV-2, the virus that causes COVID-19. Objective We studied these indirect effects of COVID-19 on the imaging workup and outcomes for pediatric patients at our center who had acute appendicitis during the pandemic. Materials and methods We performed a retrospective review of cases in children ≤18 years who were evaluated for acute appendicitis during the same period, March 1 to May 31, in both 2019 and 2020. We compared demographic and clinical data as well as surgical and pathological findings, and we graded imaging findings according to severity. Differences in patient outcomes were assessed using the Wilcoxon rank sum test and the Pearson chi-square test. Results The total number of pediatric patients evaluated with imaging for acute appendicitis dropped by 43% between 2019 and 2020 (298 vs. 169), but the total number of children treated remained similar (59 vs. 51). There was proportionate use of US and CT in each timeframe but a higher percentage of positive imaging findings in 2020 (50/169, 29.6% vs. 56/298, 18.7% in 2019, P=0.04). There were more imaging examinations with features of complicated appendicitis among positive cases (9/51, 18% vs. 5/59, 8% in 2019, P=0.08) and more pathologically proven perforated cases during the pandemic (14/51, 27% vs. 6/59, 10% in 2019, P=0.11), although these results did not reach statistical significance. There were no changes in surgical management, vital signs, laboratory values, length of stay or complication rates. Conclusion There was a large drop in the number of pediatric patients imaged for acute appendicitis during the acute phase of the COVID-19 pandemic despite similar numbers of patients treated. The utilization trends of US vs. CT remained stable between time periods. The differences in imaging findings and perforation rates were less pronounced compared to other published studies.

Background Axonal myelination is an important maturation process in the developing brain. Increasing myelin content correlates with the longitudinal relaxation rate (R1=1/T1) in magnetic resonance imaging (MRI). Objective By using magnetization-prepared 2 rapid acquisition gradient echoes (MP2RAGE) on a 3-T MRI system, we provide R1 values and myelination rates for infants and young children. Materials and methods Average R1 values in white and grey matter regions in 94 children without pathological MRI findings (age range: 3 months to 6 years) were measured and fitted by a saturating-exponential growth model. For comparison, R1 values of 36 children with different brain pathologies are presented. The findings were related to a qualitative evaluation using T2, magnetization-prepared rapid acquisition gradient echo (MP-RAGE) and MP2RAGE. Results R1 changes rapidly in the first 16 months of life, then much slower thereafter. R1 is highest in pre-myelinated structures in the youngest subjects, such as the posterior limb of the internal capsule (0.74–0.76±0.04 s−1) and lowest for the corpus callosum (0.37–0.44±0.03 s−1). The myelination rate is fastest in the corpus callosum and slowest in the deep grey matter. R1 is decreased in hypo- and dysmyelination disorders. Myelin maturation is clearly visible on MP2RAGE, especially in the first year of life. Conclusion MP2RAGE permits a quantitative R1 mapping method with an examination time of approximately 6 min. The age-dependent R1 values for children without MRI-identified brain pathologies are well described by a saturating-exponential function with time constants depending on the investigated brain region. This model can serve as a reference for this age group and to search for indications of subtle pathologies. Moreover, the MP2RAGE sequence can also be used for the qualitative assessment of myelinated structures.

Background Missed appointments can have an adverse impact on health outcomes by delaying appropriate imaging, which can be critical in influencing treatment decisions. Objective To assess for socioeconomic and imaging exam factors associated with missed appointments among children scheduled for diagnostic imaging. Materials and methods We retrospectively analyzed children (21 days (OR=3.7; 95% CI=2.9–4.8). The use of radiation, intravenous contrast agent or sedation was not associated with increased likelihood of missed appointments. Conclusion Expanding our knowledge of how different socioeconomic and imaging-related factors influence missed appointments among children can serve as a foundational step to better understand existing and emerging disparities and inform strategies to advance health equity efforts in radiology.

Background Secondary sonographic findings of appendicitis can aid image analysis and support diagnosis with and without visualization of an appendix. Objective We sought to determine if age affected the test performance of secondary findings for pediatric appendicitis. Materials and methods We performed a medical record review of emergency department patients younger than 19 years of age who had a sonogram for suspected appendicitis. Our primary patient outcome was appendicitis, as determined by pathology or by image-confirmed perforation/abscess. Our primary analysis was test performance of secondary sonographic findings as recorded by sonographers on the final diagnosis of appendicitis stratified by age (

Imaging speed, spatial resolution and availability have made CT the favored cross-sectional imaging modality for evaluating various respiratory diseases of children - but only for the price of a radiation exposure. MRI is increasingly being appreciated as an alternative to CT, not only for offering three-dimensional (3-D) imaging without radiation exposure at only slightly inferior spatial resolution, but also for its superior soft-tissue contrast and exclusive morpho-functional imaging capacities beyond the scope of CT. Continuing technical improvements and experience with this so far under-utilized modality contribute to a growing acceptance of MRI for an increasing number of indications, in particular for pediatric patients. This review article provides the reader with practical easy-to-use protocols for common clinical indications in children. This is intended to encourage pediatric radiologists to appreciate the new horizons for applications of this rapidly evolving technique in the field of pediatric respiratory diseases.

Background Acoustic radiation force impulse (ARFI) imaging is a noninvasive ultrasound elastography technique for evaluating tissue stiffness. The association of liver and spleen stiffness provides additional information in the assessment of portal hypertension. The technique and normal values of spleen stiffness by point shear wave elastography (p-SWE) in pediatrics have not been well documented. Objective Our aim is to describe the feasibility and normal ARFI elastography values in the spleen for healthy children and to compare measurements in two different probe positions (the axial and sagittal planes). Materials and methods Spleen p-SWE using ARFI values were measured with a 6C1 probe in 102 healthy children (age range: 8 weeks to 17 years) divided into four age groups. An average of nine (standard deviation: two) spleen stiffness measurements were taken during free breathing in each plane (axial and sagittal). The impact of age and measurement plane in the spleen was analyzed using multivariate models. Results There was no significant difference in spleen stiffness values taken at different ages, with an average of the medians of 2.43±0.31 m/s. There was no significant difference based on probe orientation: sagittal plane (median: 2.46±0.29 m/s) and axial plane (median: 2.43±0.32 m/s) with Student’s t-test P=0.18. The mean depth of measurement varied between 2.3 cm and 3.7 cm, according to age. Conclusion Normal spleen stiffness values using ARFI imaging in children do not vary with age and correspond to a median of 2.43 m/s. No significant difference was found when using different probe positions.

Contrast-enhanced ultrasound (CEUS) is increasingly being used in children. One of the most common referrals for CEUS performance is characterization of indeterminate focal liver lesions and follow-up of known liver lesions. In this setting, CEUS is performed with intravenous administration of ultrasound contrast agents (UCAs). When injected into a vein, UCA microbubbles remain confined within the vascular network until they dissipate. Therefore, visualization of UCA within the tissues and lesions corresponds to true blood flow. CEUS enables continuous, real-time observation of the enhancement pattern of a focal liver lesion, allowing in most cases for a definite diagnosis and obviating the need for further cross-sectional imaging or other interventional procedures. The recent approval of Lumason (Bracco Diagnostics, Monroe Township, NJ) for pediatric liver CEUS applications has spurred the widespread use of CEUS. In this review article we describe the role of CEUS in pediatric liver applications, focusing on the examination technique and interpretation of main imaging findings of the most commonly encountered benign and malignant focal liver lesions. We also compare the diagnostic performance of CEUS with other imaging modalities for accurate characterization of focal liver lesions. Supplementary Information The online version contains supplementary material available at 10.1007/s00247-021-04976-2.

The use of sedation and general anesthesia has facilitated the significant growth of MRI use among children over the last years. While sedation and general anesthesia are considered to be relatively safe, their use poses potential risks in the short term and in the long term. This manuscript reviews the reasons why MRI examinations require sedation and general anesthesia more commonly in the pediatric population, summarizes the safety profile of sedation and general anesthesia, and discusses an amalgam of strategies that can be implemented and can ultimately lead to the optimization of sedation and general anesthesia care within pediatric radiology departments.

In pediatric and adult populations, intravenous contrast-enhanced ultrasound (CEUS) remains off-label for imaging of organs other than the liver and heart. This limited scope inhibits potential benefits of the new modality from a more widespread utilization. Yet, CEUS is potentially useful for imaging small organs such as the thyroid gland, lymph nodes, testes, ovaries and uterus, with all having locations and vasculature favorable for this type of examination. In the adult population, the utility of CEUS has been demonstrated in a growing number of studies for the evaluation of these small organs. The aim of this article is to present a review of pediatric CEUS of the thyroid gland, lymph nodes, testes, ovaries and uterus as well as to draw from the adult literature indications for possible applications in children. Supplementary Information The online version contains supplementary material available at 10.1007/s00247-021-05006-x.

Thoracic computed tomography (CT) is the imaging reference method in the diagnosis, assessment and management of lung disease. In the setting of cystic fibrosis (CF), CT demonstrates increased sensitivity compared with pulmonary function tests and chest radiography, and findings correlate with clinical outcomes. Better understanding of the aetiology of CF lung disease indicates that even asymptomatic infants with CF can have irreversible pulmonary pathology. Surveillance and early diagnosis of lung disease in CF are important to preserve lung parenchyma and to optimise long-term outcomes. CF is associated with increased cumulative radiation exposure due to the requirement for repeated imaging from a young age. Radiation dose optimisation, important for the safe use of CT in children with CF, is best achieved in a team environment where paediatric radiologists work closely with paediatric respiratory physicians, physicists and radiography technicians to achieve the best patient outcomes. Despite the radiation doses incurred, CT remains a vital imaging tool in children with CF. Radiologists with special interests in CT dose optimisation and respiratory disease are key to the appropriate use of CT in paediatric imaging. Paediatric radiologists strive to minimise radiation dose to children whilst providing the best possible assessment of lung disease.

Background Despite the publication of a national patient safety alert in 2016, inadvertent feeding through misplaced nasogastric tubes continues to occur, either through failure to review the radiograph, misinterpretation of it, or failure to communicate the results. Objective The objectives were to determine whether training in a new pathway introduced to avoid these “never events” was followed and whether radiographer comments and prompt communication of results could reduce risk and improve patient safety in relation to nasogastric tube placement in children. Materials and methods Following radiographer training in interpretation of nasogastric tube position and use of a commenting proforma and communication pathway, we reviewed all radiographs obtained to check nasogastric tubes performed over a 13-month period in children 0–16 years of age. Then we assessed accuracy of the radiographer comments, adherence to the pathway, and any practice change in children with misplaced nasogastric tubes. Results We reviewed 282 nasogastric tube check radiographs. For 262 radiographs (92.9%) the pathway was followed correctly. Of the total 282 radiographs, 240 (85%) were immediately reported using the standardised commenting proforma, and 235 radiographer comments were affirmed by the radiologist (97% accuracy, confidence interval 0.95–0.99). Of the immediately reported radiographs, 213 (88.8%) nasogastric tubes were considered to be safe for use. Four (1.7%) of the immediately reported nasogastric tubes were misplaced in a bronchus, and the report communicated to the clinical team resulted in removal or re-siting of the tubes. Conclusion Nasogastric tube check radiographs in children can be reported accurately by radiographers trained in their interpretation and the results promptly communicated to clinical staff, improving safety in relation to nasogastric tube placement in children.

Background Coronavirus disease 2019 (COVID-19)-associated multisystem inflammatory syndrome in children (MIS-C) is an emerging syndrome that presents with a Kawasaki-like disease and multiorgan damage in children previously exposed to COVID-19. Objective To review the extracardiac radiologic findings of MIS-C in a group of children and young adults with a confirmed diagnosis of MIS-C. Materials and methods In a retrospective study from April 1, 2020, to July 31, 2020, we reviewed the imaging studies of 47 children and adolescents diagnosed with MIS-C, 25 females (53%) and 22 males (47%), with an average age of 8.4 years (range 1.3–20 years). Forty-five had chest radiographs, 8 had abdominal radiographs, 13 had abdominal US or MRI, 2 had neck US, and 4 had brain MRI. Results Thirty-seven of 45 (82%) patients with chest radiographs had findings, with pulmonary opacities being the most common finding (n=27, 60%), most often bilateral and diffuse, followed by peribronchial thickening (n=26, 58%). Eight patients had normal chest radiographs. On abdominal imaging, small-volume ascites was the most common finding (n=7, 54%). Other findings included right lower quadrant bowel wall thickening (n=3, 23%), gallbladder wall thickening (n=3, 23%), and cervical (n=2) or abdominal (n=2) lymphadenopathy. Of the four patients with brain MRI, one had bilateral parieto-occipital abnormalities and another papilledema. Conclusion The diagnosis of MIS-C and its distinction from other pathologies should be primarily based on clinical presentation and laboratory evidence of inflammation because imaging findings are nonspecific. However, it should be considered in the setting of bilateral diffuse pulmonary opacities, peribronchial thickening, right lower quadrant bowel inflammation or unexplained ascites in a child presenting with Kawasaki-like symptoms and a history of COVID-19 infection or recent COVID-19 exposure.

Background Although the radiographic features of coronavirus disease 2019 (COVID-19) in children have been described, the distinguishing features of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 are not well characterized. Objective We compared the chest radiographic findings of MIS-C with those of COVID-19 and described other distinguishing imaging features of MIS-C. Materials and methods We performed a retrospective case series review of children ages 0 to 18 years who were hospitalized at Children’s Healthcare of Atlanta from March to May 2020 and who either met the Centers for Disease Control and Prevention (CDC) case definition for MIS-C (n=11) or who had symptomatic, laboratory-confirmed COVID-19 (n=16). Two radiologists reviewed the most severe chest radiographs for each patient. The type and distribution of pulmonary opacities and presence or absence of pleural effusions were recorded. The chest radiographs were categorized based on potential COVID-19 imaging findings as typical, indeterminate, atypical or negative. An imaging severity score was also assigned using a simplified version of the Radiographic Assessment of Lung Edema Score. Findings were statistically compared between patients with MIS-C and those with COVID-19. Additional imaging findings of MIS-C were also described. Results Radiographic features of MIS-C included pleural effusions (82% [9/11]), pulmonary consolidations (73% [8/11]) and ground glass opacities (91% [10/11]). All of the lung opacities (100% [10/10]) were bilateral, and the majority of the pleural effusions (67% [6/9]) were bilateral. Compared to children with COVID-19, children with MIS-C were significantly more likely to develop pleural effusions on chest radiograph (82% [9/11] vs. 0% [0/0], P-value

Background Chest computed tomography (CT) findings in children with coronavirus disease 2019 (COVID-19) have been rarely reported in a comprehensive and systematic manner. Objective We investigated the chest CT findings in children with COVID-19, and explored the differences in these findings between symptomatic patients and asymptomatic patients. Materials and methods Demographic findings, clinical characteristics, duration of hospital stay and viral shedding, and chest CT findings in 201 children infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were retrospectively analyzed from January 15 to March 20, 2020, and divided into two groups: symptomatic group (n=136) and asymptomatic group (n=65). Chi-square test and Student’s t-test were used for statistical analysis. Results Symptomatic patients were mainly young children ≤3 years old (54/63, 86%),while asymptomatic patients were mainly children ≥ 6 years old (51/111, 46%). Fever (41%) and cough (41%) were the most common symptoms. Overall, 119/201 (59%) patients had chest CT findings, and symptomatic patients accounted for 82% (98/119). The CT findings presented as bilateral multiple lesions (60/119, 50.4%), ground-glass opacities (83/119, 70%) and/or consolidation (44/119, 37%) with a peripheral and subpleural distribution (62/83, 75%). Fifteen of 87 (7.2%) patients with lung lesions showed complete lesion absorption, and 42/87 (48%) improved within a mean of 9.1 (standard deviation [SD] 3.2) days. The mean duration of viral shedding was 8.7 (SD 4.9) days. Pleural effusion was very rare. No lymphadenopathy was found in either group. Conclusion Symptoms associated with pulmonary involvement were most common in infants and young children. The lung lesions of most patients were absorbed and improved in about 9 days.

Background Quantitative mapping of MRI relaxation times is expected to uncover pathological processes in the brain more subtly than standard MRI techniques with weighted contrasts. So far, however, most mapping techniques suffer from a long measuring time, low spatial resolution or even sensitivity to magnetic field inhomogeneity. Objective To obtain T1 relaxation times of the normal brain from early infancy to adulthood using a novel technique for fast and accurate T1 mapping at high spatial resolution. Materials and methods We performed whole-brain T1 mapping within less than 3 min in 100 patients between 2 months and 18 years of age with normal brain at a field strength of 3 T. We analyzed T1 relaxation times in several gray-matter nuclei and white matter. Subsequently, we derived regression equations for mean value and confidence interval. Results T1 relaxation times of the pediatric brain rapidly decrease in all regions within the first 3 years of age, followed by a significantly weaker decrease until adulthood. These characteristics are more pronounced in white matter than in deep gray matter. Conclusion Regardless of age, quantitative T1 mapping of the pediatric brain is feasible in clinical practice. Normal age-dependent values should contribute to improved discrimination of subtle intracerebral alterations.

The field of radiology has benefited greatly from the technological boom that has brought greater precision, efficiency and utilization amid an exponential growth in medical science. The downside is that the same technology that has allowed the field to grow is contributing to an erosion of interpersonal communication and connection with patients and referring physicians. Remote reading has displaced us from the communal reading room, where much interaction and teaching used to take place. The “invisible” radiologist must transcend these barriers in order to preserve and strengthen the role of radiology in medical care. With modest adaptation, radiologists can regain their identity as consultants, where they have the greatest chance to show their value and thwart the drive toward commoditization.

Background Imaging of novel coronavirus disease 2019 (COVID-19) has been described in adults, but children have milder forms of disease. Pediatric imaging descriptions are of asymptomatic children, raising the question of whether imaging is needed in this patient group. Objective To describe the utilization and imaging findings in children with COVID-19 along with the comorbidities, treatment and short-term outcomes. Materials and methods We retrospectively reviewed pediatric patients who had a confirmed positive test for COVID-19 during a 2-month period. We noted symptoms and presence of imaging at presentation. Comorbidities were recorded for children with imaging. Children were categorized as having multisystem inflammatory syndrome in children (MIS-C) if they met criteria for the disorder. For children who were admitted to the hospital, we documented length of hospital stay, need for intensive care unit care/ventilator support, and treatment regimen. We evaluated all imaging for acute/chronic abnormalities including chest radiographs for interstitial or alveolar opacities, distribution/symmetry of disease, zonal predominance, and pleural abnormalities. We performed descriptive statistics and compared children with MIS-C with the cohort using a Fisher exact test. Results During the study period, 5,969 children were tested for COVID-19, with 313 (5%) testing positive. Of these, 92/313 (29%) were asymptomatic and 55/313 (18%) had imaging and were admitted to the hospital for treatment. Forty-one of 55 patients (75%) with imaging had comorbidities. Chest radiographs were the most common examination (51/55 patients, or 93%) with most demonstrating no abnormality (34/51, or 67%). Children with MIS-C were more likely to have interstitial opacities and pleural effusions. US, CT or MRI was performed in 23/55 (42%) children, 9 of whom had MIS-C. Only one chest CT was performed. Conclusion In our study, most pediatric patients with COVID-19 did not require hospital admission or imaging. Most children with imaging had comorbidities but children with MIS-C were more likely to have no comorbidities. Children with imaging mostly had normal chest radiography. Advanced imaging (US, CT, MRI) was less common for the care of these children, particularly CT examination of the chest and for children without MIS-C.

Background Preterm infants may be more vulnerable to fractures due to various factors, including metabolic bone disease, but an increased risk of fractures up to the age of 2 is unproven. Objective To compare fracture patterns in premature and full-term children in the first 3 years of life. Materials and methods A retrospective study was conducted. We excluded any child who returned with the same injury, with known metabolic bone disease, with any disease or condition known to reduce bone density, who received any medication known to affect Vitamin D metabolism within 3 months of enrollment or who had fractures post-surgery/resuscitation. Variables such as the number of fractures sustained each year, age of presentation to the Emergency Department and mechanism of injury were compared between the preterm and term groups using statistical analysis (χ2 and Fisher exact test for categorical variables and Student’s t-test for continuous variables). Simple linear regression was performed on the total number of fractures sustained by age 3. Results Forty-four children with fractures were included. Of these, none were born extremely preterm, 24 (55%) were preterm, and 20 (45%) were born at term. Mean gestational ages of the preterm and term groups were 32 weeks 3 days and 39 weeks 6 days, respectively. There were no extremely low birth weight or very low birth weight children. There was no significant difference in the number of fractures sustained yearly, the age of presentation to the Emergency Department or the site of fracture between preterm and term groups. Linear regression showed that the total number of fractures sustained by age 3 years was unrelated to prematurity status, gender or birth weight category. Conclusion No significant difference in fracture number or pattern was identified.

Background Very preterm birth can disturb brain maturation and subject these high-risk children to neurocognitive difficulties later. Objective The aim of the study was to evaluate the impact of prematurity on microstructure of frontostriatal tracts in children with no severe neurologic impairment, and to study whether the diffusion tensor imaging metrics of frontostriatal tracts correlate to executive functioning. Materials and methods The prospective cohort study comprised 54 very preterm children (mean gestational age 28.8 weeks) and 20 age- and gender-matched term children. None of the children had severe neurologic impairment. The children underwent diffusion tensor imaging and neuropsychological assessments at a mean age of 9 years. We measured quantitative diffusion tensor imaging metrics of frontostriatal tracts using probabilistic tractography. We also administered five subtests from the Developmental Neuropsychological Assessment, Second Edition, to evaluate executive functioning. Results Very preterm children had significantly higher fractional anisotropy and axial diffusivity values (P<0.05, corrected for multiple comparison) in dorsolateral prefrontal caudate and ventrolateral prefrontal caudate tracts as compared to term-born children. We found negative correlations between the diffusion tensor imaging metrics of frontostriatal tracts and inhibition functions (P<0.05, corrected for multiple comparison) in very preterm children. Conclusion Prematurity has a long-term effect on frontostriatal white matter microstructure that might contribute to difficulties in executive functioning.

Bone health in children with osteogenesis imperfecta is monitored using radiographs and dual-energy X-ray absorptiometry, which have limitations. High-resolution peripheral quantitative CT can non-invasively derive bone microarchitectural data. Children with severe osteogenesis imperfecta have fragile deformed bones, and positioning for this scan can be difficult. We assessed the feasibility of high-resolution peripheral quantitative CT in nine children aged 9–15 years with osteogenesis imperfecta and compared results with dual-energy X-ray absorptiometry and with healthy controls. All nine recruited children were successfully scanned and showed no preference for either modality. It therefore appears feasible to perform high-resolution peripheral quantitative CT in children with osteogenesis imperfecta aged 9 years and older. Future studies should focus on understanding the clinical implications of the technology in this patient cohort.

Background: Diagnostic reference levels (DRLs) identify unusually high patient radiation exposures and are required for dose optimisation. DRLs for pediatric fluoroscopic examinations are not widely determined in Australia. Objective: Our objectives were to establish DRLs for pediatric fluoroscopic examinations in a South Australian tertiary hospital and compare these to previously published data and to explore relationships between patient dose area product (DAP), age and fluoroscopy times. Materials and methods: Dose data from 365 pediatric patients undergoing 5 fluoroscopic examinations were retrospectively collected for a 3-year period commencing January 2018 to develop local DRLs. Relationships between DAP, age and fluoroscopy time were explored using scatterplots, Spearman’s correlation, and regression analyses. Results: Local DRLs were significantly lower than data published previously, possibly reflecting technological and procedural advancements. Each 1-year increase in patient age was associated with a 0.77 μGy·m2 increase in DAP for barium meal and follow-through studies (95% confidence interval [CI]=0.055, 1.48) (P=0.04), and a 1.37 μGy·m2 increase in DAP for barium swallow studies (95% CI=0.61, 2.12) (P

Background Radiation dose metrics vary by the calibration reference phantom used to report doses. By convention, 16-cm diameter cylindrical polymethyl-methacyrlate phantoms are used for head imaging and 32-cm diameter phantoms are used for body imaging in adults. Actual usage patterns in children remain under-documented. Objective This study uses the University of California San Francisco International CT Dose Registry to describe phantom selection in children by patient age, body region and scanner manufacturer, and the consequent impact on radiation doses. Materials and methods For 106,837 pediatric computed tomography (CT) exams collected between Jan. 1, 2015, and Nov. 2, 2020, in children up to 17 years of age from 118 hospitals and imaging facilities, we describe reference phantom use patterns by body region, age and manufacturer, and median and 75th-percentile dose–length product (DLP) and volume CT dose index (CTDIvol) doses when using 16-cm vs. 32-cm phantoms. Results There was relatively consistent phantom selection by body region. Overall, 98.0% of brain and skull examinations referenced 16-cm phantoms, and 95.7% of chest, 94.4% of abdomen and 100% of cervical-spine examinations referenced 32-cm phantoms. Only GE deviated from this practice, reporting chest and abdomen scans using 16-cm phantoms with some frequency in children up to 10 years of age. DLP and CTDIvol values from 16-cm phantom-referenced scans were 2–3 times higher than 32-cm phantom-referenced scans. Conclusion Reference phantom selection is highly consistent, with a small but significant number of abdomen and chest scans (~5%) using 16-cm phantoms in younger children, which produces DLP values approximately twice as high as exams referenced to 32-cm phantoms

BACKGROUND: Endoscopic ultrasound is seldom available at paediatric centres; therefore drainage of pancreatic pseudocysts in children has traditionally been achieved by surgery. OBJECTIVE: This study assessed the feasibility and safety of performing image-guided internal drainage of pancreatic pseudocysts with a flanged self-expanding covered nitinol pancreatic pseudocyst drainage stent. MATERIALS AND METHODS: We conducted a retrospective case note review of children undergoing image-guided cystogastrostomy at two paediatric hospitals. Percutaneous access to the stomach was achieved via an existing gastrostomy tract or image-guided formation of a new tract. Under combined ultrasound, fluoroscopic or cone-beam CT guidance the pancreatic pseudocysts were punctured through the posterior wall of the stomach. A self-expanding covered nitinol stent was deployed to create a cystogastrostomy opening. RESULTS: Image-guided cystogastrostomy was performed in 6 children (4 male; median age 6 years, range 46 months to 15 years; median weight 18 kg, range 13.8-47 kg). Two children had prior failed attempts at surgical or endoscopic drainage. Median maximum cyst diameter was 11.5 cm (range 4.7-15.5 cm) pre-procedure. Technical success was 100%. There were no complications. There was complete pseudocyst resolution in five children and a small (2.1-cm) residual pseudocyst in one. Pseudocyst-related symptoms resolved in all children. CONCLUSION: Pancreatic pseudocyst drainage can be successfully performed in children by image-guided placement of a cystogastrostomy stent. In this cohort of six children there were no complications. ispartof: Pediatric Radiology vol:49 issue:13 pages:1816-1822 ispartof: location:Germany status: published

BACKGROUND: Traditionally, ultrasound (US)-guided bowel mass biopsies are avoided in favour of endoscopic or surgical biopsies. However, endoscopy cannot easily reach lesions between the duodenojejunal flexure and the terminal ileum and lesions not involving the mucosa may not be accessible via an endoscopic route. OBJECTIVE: The aim of this study was to report our technique and to assess the diagnostic accuracy and safety of US-guided biopsy of bowel masses in children. MATERIALS AND METHODS: We conducted a 14-year retrospective review of US-guided bowel mass biopsies at a single paediatric hospital. RESULTS: Twenty US-guided bowel mass biopsies were performed in 19 patients (median age: 6 years and 6 months, range: 22 months-17 years, median weight: 22 kg, range: 10.2-48.4 kg). For 14 biopsies, there was no other lesion that could potentially be biopsied. A percutaneous coaxial technique was used for 19 biopsies and a transanal non-coaxial biopsy was performed in 1. A median of 9 (range: 2-15) cores of tissue was obtained at each biopsy. The technical success rate and adequacy of diagnostic yield were 100%. The most common diagnosis was lymphoma, which occurred in 16 biopsies. Three biopsies contained mucosa. There was one complication out of 20 biopsies (5%, 95% confidence interval 0-15%): a self-limiting, post biopsy pyrexia. Nineteen procedures were accompanied by a bone marrow aspirate and/or trephine within 2 weeks of the bowel biopsy, only one of which was diagnostic. CONCLUSION: US-guided bowel mass biopsy can be performed safely in children, with a high diagnostic yield and low complication rate. ispartof: Pediatric Radiology vol:49 issue:13 pages:1809-1815 ispartof: location:Germany status: published

Background Dermoids are common benign head and neck cysts in children containing a variety of different skin elements. Current standard treatment is surgical removal that sometimes requires extensive dissection to ensure complete resection and often leaves unwanted facial scarring. A minimally invasive treatment alternative should offer a similar rate of success with a decrease in operative complexity, recovery time and postoperative scarring. Objective To assess the outcomes of our minimally invasive percutaneous treatment of head and neck dermoids, we reviewed our 9-year interventional radiology (IR) department experience. Materials and methods The medical records, imaging and procedural details were reviewed from a cohort of pediatric patients with dermoids treated in our IR department from January 2009 through February 2018. Patients in the study underwent ultrasound (US)-guided cyst puncture, 3% Sotradecol (sodium tetradecyl sulfate [STS]) emulsification of the thick cyst contents allowing complete drainage, and radiofrequency coblation of the cyst wall. Results In this retrospective study, we report on 22 dermoids in 21 patients. The average patient age was 3 years. Twenty-one of the 22 dermoids were successfully treated for an overall success rate of 95%. Four intraosseous dermoids were successfully treated using computed tomography (CT) guidance instead of, or in addition to, US. Average follow-up time was 22 months. Conclusion The combination of percutaneous cyst drainage using STS as an emulsifying agent followed by radiofrequency coblation is a safe, effective, minimally invasive treatment for pediatric patients with head and neck dermoids.

The recent European Council Directive 2013/59/EURATOM requires the establishment of diagnostic reference levels (DRLs) to optimise radiation dose in diagnostic and interventional radiology procedures. At the time this directive was enacted, just a few European countries had already set paediatric DRLs and many of these were outdated. For this reason, the European Commission launched a project addressing European Guidelines on Diagnostic Reference Levels for Paediatric Imaging that was awarded to a consortium led by the European Society of Radiology with the collaboration of the European Society of Paediatric Radiology and other European stakeholders involved in the radiation protection of children. The main aims of this project were to establish European DRLs to be used by countries without their own national paediatric DRLs and to provide a consistent method to establish new DRLs in the future. These European guidelines have been very recently endorsed by the European Commission and published in issue N degrees 185 of the Radiation Protection series. The purpose of this article is to introduce these guidelines to the wide community of paediatric radiologists.

Arterial spin labeling is a noninvasive, non-gadolinium-dependent magnetic resonance imaging (MRI) technique to assess cerebral blood flow. It provides insight into both tissue metabolic activity and vascular supply. Because of its non-sensitivity toward blood–brain barrier leakage, arterial spin labeling is also more accurate in cerebral blood flow quantification than gadolinium-dependent methods. The aim of this pictorial essay is to promote the application of arterial spin labeling in pediatric neuroradiology. The authors provide information on artifacts and pitfalls as well as numerous fields of application based on pediatric cases.

Osteoporosis is a generalised disorder of the skeleton with reduced bone density and abnormal bone architecture. It increases bone fragility and renders the individual susceptible to fractures. Fractures of the vertebrae are common osteoporotic fractures. Vertebral fractures may result in scoliosis or kyphosis and, because they may be clinically silent, it is imperative that vertebral fractures are diagnosed in children accurately and at an early stage, so the necessary medical care can be implemented. Traditionally, diagnosis of osteoporotic vertebral fractures has been from lateral spine radiographs; however, a small number of studies have shown that dual energy x-ray absorptiometry is comparable to radiographs for identifying vertebral fractures in children, while allowing reduced radiation exposure. The diagnosis of vertebral fractures from dual energy x-ray absorptiometry is termed vertebral fracture assessment. Existing scoring systems for vertebral fracture assessment in adults have been assessed for use in children, but there is no standardisation and observer reliability is variable. This literature review suggests the need for a semiautomated tool that (compared to the subjective and semiquantitative methods available) will allow more reliable and precise detection of vertebral fractures in children.

Background Unnecessary imaging is a potential cost driver in the United States health care system. Objective Using a clinical decision support tool, we determined the percentage of low-utility non-contrast head computed tomography (CT) examinations on emergency patients and calculated the prospective cost implications of providing low-value imaging using time-driven activity-based costing at an academic quaternary pediatric hospital. Materials and methods A clinical decision support tool for imaging, CareSelect (National Decision Support Co., Madison, WI), was integrated in silent mode into the electronic health record from September 2018 through August 2019. Each non-contrast head CT order received a score from the clinical decision support tool based on the American College of Radiology Appropriateness Criteria. Descriptive statistics for all levels of appropriateness scores were compiled with an emphasis on low-utility exams. A micro-costing assessment was conducted using time-driven activity-based costing on head CT without contrast examinations. Results Within the 11-month time period, 3,186 head CT examinations without contrast were ordered for emergency center patients. Among these orders, 28% (896/3,186) were classified as low-utility studies. The base case CT pathway time was 43 min and base case total cost was $193.35. The base case opportunity cost of these low-utility exams extrapolated annually amounts to $188,902 for our institution. Conclusion Silent mode implementation of a clinical decision support tool resulted in 28% of head CT non-contrast exams on emergency patients being graded as low-utility studies. Prospective cost implications resulted in an annual base case cost of $188,902 to Texas Children’s Hospital.

Background Neonates and young children require efficacious magnetic resonance imaging (MRI) examinations but are potentially more susceptible to the short- and long-term adverse effects of gadolinium-based contrast agents due to the immaturity of their body functions. Objective To evaluate the acute safety and diagnostic efficacy of gadoteridol (ProHance) for contrast-enhanced MRI of the central nervous system (CNS) in children ≤2 years of age. Materials and methods One hundred twenty-five children ≤2 years old (including 57 children Results Thirteen changes of laboratory values (11 mild, 1 moderate, 1 unspecified) were reported as adverse events in 7 (5.6%) patients. A relationship to gadoteridol was deemed possible though doubtful for two of these adverse events in two patients (1.6%). There were no clinical adverse events, no serious adverse events and no clinically meaningful changes in vital signs or ECG recordings. Accurate differentiation of tumor from non-neoplastic disease, and exact matching of specific MRI-determined diagnoses with on-site final diagnoses, was achieved in significantly more patients by each reader following the evaluation of combined pre- and post-contrast images compared to pre-contrast images alone (84.6–88.0% vs. 70.9–76.9%; P≤0.006 and 67.5–79.5% vs. 47.0–66.7%; P≤0.011, respectively). Conclusion Gadoteridol at 0.1 mmol/kg body weight is safe, well tolerated and effective for contrast-enhanced MRI of the CNS in children ≤2 years of age.

A pediatric MRI service is a vital component of a successful radiology department. Building an efficient and effective pediatric MRI service is a multifaceted process that requires detailed planning for considerations related to finance, operations, quality and safety, and process improvement. These are compounded by the unique challenges of caring for pediatric patients, particularly in the setting of the recent coronavirus disease 2019 (COVID-19) pandemic. In addition to material resources, a successful pediatric MRI service depends on a collaborative team consisting of radiologists, physicists, technologists, nurses and vendor specialists, among others, to identify and resolve challenges and to strive for continued improvement. This article provides an overview of the factors involved in both starting and optimizing a pediatric MRI service, including commonly encountered obstacles and some proposed solutions to address them.

In the context of pediatric cross-sectional imaging, the risk of ionizing radiation for CT and the potential adverse effects associated with sedation/anesthesia for MRI continue to provoke lively discussions in the pediatric literature and lay press. This is particularly true for issues relating to the risks of ionizing radiation for CT, which has been a topic of discussion for nearly two decades. In addition to understanding these potential risks and the importance of minimizing individual pediatric patient exposure to ionizing radiation, it is equally important for radiologists to be able to frame these risks with respect to the potential for adverse outcomes associated with the use of anesthesia for cross-sectional imaging in the pediatric population. Notably, before such risks can be estimated and compared, one should always consider the potential utility of each imaging modality for a given diagnosis. If one cross-sectional imaging modality is likely to be far superior to the other for a specific clinical question, every effort must be made to safely image the child, even if sedation/anesthesia is required.

Hepatic sinusoidal obstruction syndrome, also known as veno-occlusive disease, can occur as a complication of myeloablative chemotherapy, as a result of low-intensity chemotherapy-related liver toxicity or radiotherapy of the liver. Symptoms of sinusoidal obstruction syndrome can range from asymptomatic to liver dysfunction or severe disease with life-threatening acute multi-organ failure. Imaging features can suggest or support this clinical diagnosis. Familiarity with the imaging spectrum of sinusoidal obstruction syndrome is therefore important for both radiologists and clinical oncologists. Here, multi-modality radiologic appearances of sinusoidal obstruction syndrome in pediatric patients are illustrated, including outcome after follow-up.

Emerging manifestations of artificial intelligence (AI) have featured prominently in virtually all industries and facets of our lives. Within the radiology literature, AI has shown great promise in improving and augmenting radiologist workflow. In pediatric imaging, while greatest AI inroads have been made in musculoskeletal radiographs, there are certainly opportunities within thoracoabdominal MRI for AI to add significant value. In this paper, we briefly review non-interpretive and interpretive data science, with emphasis on potential avenues for advancement in pediatric body MRI based on similar work in adults. The discussion focuses on MRI image optimization, abdominal organ segmentation, and osseous lesion detection encountered during body MRI in children.

Background Abdominopelvic magnetic resonance imaging (MRI) is increasingly being used to evaluate children with abdominal pain suspected of having acute appendicitis. At our institution, these examinations are preliminarily interpreted by radiology residents, especially when performed after hours. Objective To determine the accuracy of preliminary reports rendered by radiology residents in this setting. Materials and methods Three hundred seventy-seven pediatric abdominopelvic MRI examinations were included. The preliminary (resident) and final (attending) radiology reports were coded as diagnosing acute appendicitis or no acute appendicitis. The concordance between resident and attending radiologist interpretations was calculated. Additionally, both resident and attending reports were compared to available surgical pathology or clinical follow-up data. Results Overall concordance rate for the diagnosis of acute appendicitis was 97.1%. Concordance for verified cases of acute appendicitis was 93.4%. Concordance rates did not differ by residents’ postgraduate year levels. When compared against surgical pathology or clinical follow-up data, residents demonstrated 91.2% sensitivity and 97.6% specificity. There was no statistically significant difference in the sensitivity or specificity of resident or attending radiologist interpretations. Conclusion Radiology residents demonstrate high concordance with attending pediatric radiologists in their interpretations of pediatric abdominopelvic MRI for acute appendicitis. The diagnostic performances of residents and attendings were comparable.

Background Diffusion-weighted imaging (DWI) has been described to correlate with tumoural necrosis in response to preoperative chemotherapy for osteosarcoma. Objective To assess the accuracy of DWI in evaluating the response to neoadjuvant chemotherapy at the mid-course treatment of long-bone osteosarcoma and in predicting survival. Materials and methods We conducted a prospective single-centre study over a continuous period of 11 years. Consecutive patients younger than 20 years treated with a neoadjuvant regimen for peripheral conventional osteosarcoma were eligible for inclusion. Magnetic resonance imaging (MRI) with DWI was performed at diagnosis, and mid- and end-course chemotherapy with mean apparent diffusion coefficients (ADC) calculated at each time point. A percentage less than or equal to 10% of the viable residual tissue at the histological analysis of the surgical specimen was defined as a good responder to chemotherapy. Survival comparisons were calculated using the Kaplan-Meier method. Uni- and multivariate analyses with ADC change were performed by Cox modelling. This is an expansion and update of our previous work. Results Twenty-six patients between the ages of 4.8 and 19.6 years were included, of whom 14 were good responders. At mid-course chemotherapy, good responders had significantly higher mean ADC values (P=0.046) and a higher increase in ADC (P=0.015) than poor responders. The ADC change from diagnosis to mid-course MRI did not appear to be a prognosticator of survival and did not impact survival rates of both groups. Conclusion DWI at mid-course preoperative chemotherapy for osteosarcoma should be considered to evaluate the degree of histological necrosis and to predict survival. The anticipation of a response to neoadjuvant treatment by DWI may have potential implications on preoperative management.

Pediatric radiology departments across the globe face unique challenges in the midst of the current COVID-19 pandemic that have not been addressed in professional guidelines. Providing a safe environment for personnel while continuing to deliver optimal care to patients is feasible when abiding by fundamental recommendations. In this article, we review current infection control practices across the multiple pediatric institutions represented on the Society for Pediatric Radiology (SPR) Quality and Safety committee. We discuss the routes of infectious transmission and appropriate transmission-based precautions, in addition to exploring strategies to optimize personal protective equipment (PPE) supplies. This work serves as a summary of current evidence-based recommendations for infection control, and current best practices specific to pediatric radiologists. Electronic supplementary material The online version of this article (10.1007/s00247-020-04713-1) contains supplementary material, which is available to authorized users.

Background Pleural effusion at presentation in Hodgkin lymphoma has been associated with inferior outcome but has not been systematically evaluated. Objective To determine whether pleural effusion at presentation in children with Hodgkin lymphoma is a primary indicator of poor prognosis or secondary to associated factors. Materials and methods Children’s Oncology Group (COG) AHOD0031, a randomized, response-based, centrally reviewed protocol, enrolled 1,712 eligible patients

Background The Amsterdam Pediatric Wrist Rules have been developed and validated to reduce wrist radiographs following wrist trauma in pediatric patients. However, the actual impact should be evaluated in an implementation study. Objective To evaluate the effect of implementation of the Amsterdam Pediatric Wrist Rules at the emergency department. Materials and methods A before-and-after comparative prospective cohort study was conducted, including all consecutive patients aged 3 to 18 years presenting at the emergency department with acute wrist trauma. The primary outcome was the difference in the number of wrist radiographs before and after implementation. Secondary outcomes were the number of clinically relevant missed fractures of the distal forearm, the difference in length of stay at the emergency department and physician compliance with the Amsterdam Pediatric Wrist Rules. Results A total of 408 patients were included. The absolute reduction in radiographs was 19% compared to before implementation (chi-square test, P

Background: Chest tube drainage with fibrinolytics is a cost-effective treatment option for parapneumonic effusion and empyema in children. Although the additional use of ultrasound (US) guidance is recommended, this is rarely performed in real time to direct drain insertion. Objective: To evaluate the effectiveness and safety of real-time US-guided, radiologically placed chest drains at a tertiary university hospital. Materials and methods: This was a retrospective review over a 16-year period of all children with parapneumonic effusion or empyema undergoing percutaneous US-guided drainage at our centre. Results: Three hundred and three drains were placed in 285 patients. Treatment was successful in 93% of patients after a single drain (98.2% success with 2 or 3 drains). Five children had peri-insertion complications, but none was significant. The success rate improved with experience. Although five patients required surgical intervention, all children treated since 2012 were successfully treated with single-tube drainage only and none has required surgery. Conclusion Our technique for inserting small-bore (≤8.5 F) catheter drains under US guidance is effective and appears to be a safe procedure for first-line management of complicated parapneumonic effusion and empyema.

International audience; BACKGROUND:The imaging features of Huntington disease are well known in adults, unlike in juvenile-onset Huntington disease.OBJECTIVE:To conduct a morphometric magnetic resonance imaging (MRI) analysis in three juvenile Huntington disease patients (ages 2, 4 and 6 years old) to determine whether quantitative cerebral and cerebellar morphological metrics may provide diagnostically interesting patterns of cerebellar and cerebellar atrophy.MATERIALS AND METHODS:We report the cases of three siblings with extremely early presentations of juvenile Huntington disease associated with dramatic expansions of the morbid paternal allele from 43 to more than 100 CAG trinucleotide repeats. Automatic segmentation of MRI images of the cerebrum and cerebellum was performed and volumes of cerebral substructures and cerebellar lobules of juvenile Huntington disease patients were compared to those of 30 normal gender- and age-matched controls. Juvenile Huntington disease segmented volumes were compared to those of age-matched controls by using a z-score.RESULTS:Three cerebral substructures (caudate nucleus, putamen and globus pallidus) demonstrated a reduction in size of more than three standard deviations from the normal mean although it was not salient in one of them at clinical reading and was not diagnosed. The size of cerebellum lobules, cerebellum grey matter and cerebellum cortex was reduced by more than two standard deviations in the three patients. The cerebellar atrophy was predominant in the posterior lobe.CONCLUSION:Our study sheds light on atrophic cerebral and cerebellar structures in juvenile Huntington disease. Automatic segmentations of the cerebellum provide patterns that may be of diagnostic interest in this disease.