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To investigate diagnostic performance and radiation dose with the use of computed tomographic (CT) enterography in children and young adults and to compare reconstruction with filtered back projection (FBP) to that with adaptive iterative dose reduction (AIDR) with three-dimensional (3D) processing.This retrospective investigation was HIPAA compliant and approved by the institutional review board. Informed consent was waived. CT enterographic examinations performed between October 2008 and June 2009 with FBP and between August 2012 and April 2014 with AIDR 3D in patients who had received histologic evaluation within 45 days of imaging were included. Two reviewers retrospectively and independently evaluated the studies for findings of active inflammation, and diagnostic performance and interreader reliability were assessed. The reference standard was histologic findings. Objective and subjective image quality also was assessed. The size-specific dose estimate was compared between the two groups. Two-sample t tests or analysis of variance tests were performed to assess for differences in diagnostic accuracy, image quality, and radiation dose between the FBP and AIDR 3D examinations.Fifty patients were included in the FBP group (mean age, 14.1 years; range, 8-21 years) and 68 patients were in the AIDR 3D group (mean age, 13.2 years; range, 2-29 years). Sensitivity and specificity for detection of active inflammation were 96% (26 of 27) and 96% (22 of 23), respectively, for the FBP group and 90% (45 of 50) and 89% (16 of 18), respectively, for the AIDR 3D group. Dichotomous interreader reliability (κ) for the entire group was 0.86. The mean size-specific dose estimate for all weights was significantly lower for the AIDR 3D group (6.1 mGy ± 2.1) than that for the FBP group (16.7 mGy ± 5.2; P.0001). No significant difference was found in objective image noise for soft-tissue structures (P = .2-.8).CT enterography is highly accurate for detection of active inflammation in pediatric patients and has excellent interreader reliability. Reduced-dose CT enterography with AIDR 3D allowed substantial dose reduction compared with that used with FBP CT enterographic examinations, while maintaining a high diagnostic performance.

Rationale and Objectives The purpose of this study was to determine the accuracy of magnetic resonance enterography (MRE) compared to histopathology in the evaluation of pediatric inflammatory bowel disease and to assess interreader reliability for image interpretation. Materials and Methods All magnetic resonance enterography studies performed for known or suspected inflammatory bowel disease between July 2009 and July 2010 were retrospectively reviewed by two pediatric radiologists. Exams were evaluated for signs of enteric inflammation and extraenteric disease. A five-point, Likert-type scale was used to assess the overall likelihood of active inflammation, with scores ≥ 3 considered positive. Cohen's κ coefficient was calculated to assess interreader agreement. A subset of patients who had undergone ileocolonoscopy or surgery with confirmed histopathology within 45 days of MRE were used to assess the accuracy of MRE for detecting active inflammation in the terminal ileum and large bowel. Results A total of 91 magnetic resonance enterography studies were reviewed. Of these, 45 had comparison histopathology within 45 days. The overall sensitivity of MRE for detecting active inflammation compared to ileocolonoscopy was 92% for both readers, while specificity was 100% for reader 1 and 75% for reader 2. Of the individual parameters evaluated, mucosal hyperenhancement and bowel wall thickening were the most sensitive indicators of active inflammation, each having sensitivity of 86% and specificity of 88%. Cohen's κ coefficient was 0.59, indicating moderate agreement between the readers. Conclusions MRE has high overall diagnostic accuracy for detecting active bowel inflammation in pediatric patients compared to ileocolonoscopy and demonstrates moderate interreader reliability.

In contrast to the general population, patients with chronic kidney disease (CKD) experience increased total adiponectin levels despite an increased prevalence of cardiovascular disease. Adiponectin circulates as trimer, low molecular weight (LMW), and high molecular weight (HMW) complexes. The distribution and role of each subfraction in CKD is unknown. This cross-sectional analysis examined the association of serum adiponectin and its subfractions with known cardiovascular risk factors in 105 children (median age 12 years; 56% male) enrolled into the Chronic Kidney Disease in Children (CKiD) study, an observational cohort study of children with CKD stage 2–4.HMW accounted for 46% of total adiponectin, followed by LMW (34%) and trimer (20%). In multivariable analysis, LMW was independently associated with iohexol glomerular filtration rate (GFR) (p = 0.004) and was higher in pubertal versus prepubertal children (p = 0.005). HMW/LMW ratio was independently associated with age and iohexol GFR (all p < 0.001). Unexpectedly, systolic blood pressure was positively correlated with HMW (p = 0.01), and HMW/LMW ratio (p = 0.007) and inversely correlated with LMW (p = 0.009). Among subfractions, only LMW was significantly correlated with left ventricular mass (LVM) index (p = 0.05). In multivariable analysis, decreased LMW was independently associated with higher LVM index [β= −0.25, 95% confidence interval (CI) −0.50, −0.03, p=0.04) after adjustment for body mass index (BMI), age, and blood pressure.The higher total adiponectin levels in children with CKD are associated with higher HMW and lower LMW. This imbalance may be an important biomarker for increased cardiovascular risk despite higher levels of total adiponectin in children with CKD.

OBJECTIVE: Our goal was to determine the prevalence of intestinal parasites in internationally adopted children, to examine factors associated with infection, and to determine if evaluating multiple stool specimens increases the yield of parasite identification. METHODS: We evaluated internationally adopted children with at least 1 stool specimen submitted for ova and parasite testing within 120 days after arrival to the United States. In children submitting 3 stool specimens, in which at least 1 specimen was positive for the pathogen studied, we examined whether multiple stool specimens increased the likelihood of pathogen identification. RESULTS: Of the 1042 children studied, 27% had at least 1 pathogen identified; with pathogen-specific prevalence of Giardia intestinalis (19%), Blastocystis hominis (10%), Dientamoeba fragilis (5%), Entamoeba histolytica (1%), Ascaris lumbricoides (1%), and Hymenolepsis species (1%). The lowest prevalence occurred in South Korean (0%), Guatemalan (9%), and Chinese (13%) children, and the highest prevalence occurred in Ethiopian (55%) and Ukrainian (74%) children. Increasing age was significantly associated with parasite identification, whereas malnutrition and gastrointestinal symptoms were not. Overall, the yield of 1 stool specimen was 79% with pathogen recovery significantly increasing for 2 (92%) and 3 (100%) specimens, respectively (P < .0001). Pathogen identification also significantly increased with evaluation of additional stool specimens for children with and without gastrointestinal symptoms. CONCLUSIONS: We provide data for evidence-based guidelines for intestinal parasite screening in internationally adopted children. Gastrointestinal symptoms were not predictive of pathogen recovery, and multiple stool specimens increased pathogen identification in this high-risk group of children.

The clinical course of juvenile dermatomyositis (JDMS) is unpredictable. MRI is used to determine muscle biopsy site and to monitor disease activity. It is unknown whether soft-tissue features on MRI obtained at diagnosis correlate with clinical outcome. The purpose of our study is to determine whether initial MRI findings in the pelvis and thighs in children with JDMS can predict clinical disease course.Forty-five children (31 girls and 14 boys; median age, 6 years; range, 1-18 years) with clinically diagnosed biopsy-proven JDMS and at least 24 months of clinical follow-up were included. Clinical outcome was categorized as limited or chronic disease, according to the established Crowe clinical classification scheme. Pretreatment MRI examinations of the pelvis and thighs were evaluated for signal abnormalities of muscle and fascia and reticulated signal changes in subcutaneous fat; associations with clinical outcome were examined.Twenty-two patients had limited disease and 23 had chronic disease. Signal intensity ranged from normal (n = 3) to floridly increased in all muscle compartments (n = 17). Muscle and fascial involvement were not associated with clinical outcome. Controlling for duration of symptoms, the adjusted odds of progressing to chronic disease were higher for patients with abnormal subcutaneous fat signal than for those with normal fat signal (odds ratio, 9.0; 95% CI, 1.5-53.5; p0.02).MRI findings of muscle or fascia involvement do not predict clinical outcome in children with newly diagnosed JDMS. Abnormal subcutaneous fat signal appears to have a significant association with a more aggressive chronic disease course.

Our finding of a substantial increase in the use of CT in children who visit emergency departments in the United States underscores the need for special attention to this vulnerable population to ensure that imaging is appropriately ordered, performed, and interpreted.

BACKGROUND Few studies exist with regard to the ability of electromyography (EMG) and volumetric magnetic resonance imaging (MRI) of the infraspinatus muscle to complement the physical assessment of active global shoulder external rotation (GER) in the neonatal brachial plexus palsy (NBPP) population. Therefore, the purpose of this study was to evaluate the relationships of EMG and MRI with active GER based on analysis of the infraspinatus muscle. METHODS Seventy-four NBPP patients (mean age, 5 y 1 m; range, 1 y 1 m to 13 y 3 m) who had undergone physical examination of the shoulder, EMG evaluation of the infraspinatus muscle, and shoulder MRI were included in this study. The outcome variable active GER was dichotomized into

Turner syndrome affects one in 2,500 girls and women and is associated with cardiovascular anomalies. Visualizing the descending thoracic aorta in adults with Turner syndrome with echocardiography is difficult. Therefore, cardiac MRI is the preferred imaging modality for surveillance. Our goals were to use cardiac MRI describe the spectrum and frequency of cardiovascular abnormalities and to evaluate aortic dilatation and associated abnormalities in pediatric patients with Turner syndrome.The cases of 51 patients with Turner syndrome (median age, 18.4 years; range, 6-36 years) were evaluated with cardiac MRI. The characteristics assessed included aortic structure, elongation of the transverse aortic arch, aortic diameter at multiple locations, and coarctation of the aorta (CoA). Additional evaluations were made for presence of bicuspid aortic valve (BAV), and partial anomalous pulmonary venous return (PAPVR). Associations between the cardiac MRI data and the following factors were assessed: age, karyotype, body surface area, blood pressure, and ventricular sizes and function.Sixteen patients (31.4%) had elongation of the transverse aortic arch, eight (15.7%) had CoA, 20 (39.2%) had BAV, and eight (15.7%) had PAPVR. Aortic dilatation was most common at the aortic sinus (30%). Elongation of the transverse aortic arch was associated with CoA (p0.01) and BAV (p0.05). Patients with elongation of the transverse aortic arch had dilated aortic sinus (p0.05). Patients with PAPVR had increased right heart mass (p0.05), increased ratio of main pulmonary artery to aortic valve blood flow (p = 0.0014), and increased right ventricular volume (p0.05).Cardiovascular anomalies in pediatric patients with Turner syndrome include aortic abnormalities and PAPVR. The significant association between elongation of the transverse aortic arch and CoA, BAV, and aortic sinus dilatation may contribute to increased risk of aortic dissection. The presence of PAPVR can be hemodynamically significant. These findings indicate that periodic cardiac MRI screening of persons with Turner syndrome is beneficial.

To identify nationwide trends and factors associated with the use of computed tomography (CT) in the emergency department (ED).This study was exempt from institutional review board approval. Data from the 1995-2007 National Hospital Ambulatory Medical Care Survey were used to evaluate the numbers and percentages of ED visits associated with CT. A mean of 30 044 visits were sampled each year. Data were also subcategorized according to multiple patient and hospital characteristics. The Rao-Scott χ(2) test was performed to determine whether CT use was similar across subpopulations. Data were evaluated according to exponential and logistic growth models.From 1995 to 2007, the number of ED visits that included a CT examination increased from 2.7 million to 16.2 million, constituting a 5.9-fold increase and a compound annual growth rate of 16.0%. The percentage of visits associated with CT increased from 2.8% to 13.9%, constituting a 4.9-fold increase and a compound annual growth rate of 14.2%. The exponential growth model provided the best fit for the trend in CT use. CT use was greater in older patients, white patients, patients admitted to the hospital, and patients at facilities in metropolitan regions. By the end of the study period, the top chief complaints among those who underwent CT were abdominal pain, headache, and chest pain. The percentage of patient visits associated with CT for all evaluated chief complaints increased-most substantially among those who underwent CT for flank, abdominal, or chest pain.Use of CT has increased at a higher rate in the ED than in other settings. The overall use of CT had not begun to taper by 2007.

Objective Many outcome measures assess function of children with cerebral palsy (CP), but establishing meaningful clinical change remains challenging. This study explored correlations between subjective status ratings in several functional domains, made by children, parents, and medical professionals. The ratings were compared with three outcome measures in preparation for longitudinal work to establish minimal clinically important change. Method Children were assessed with the Gross Motor Function Measure (GMFM), Pediatric Evaluation of Disability Inventory (PEDI), and Cerebral Palsy Quality of Life Questionnaire for Children (CP-QOL). Respondents provided Likert scale and Linear Analogue Scale ratings of gross motor function, self care, social function, quality of life, and overall function. Correlations were calculated for outcome measure scores and ratings. Results 122 children with CP across all GMFCS and MACS levels, 79 male, aged 8.1 ± 2.9 years generated status ratings by 27 child reports, 122 parent reports, and 110 medical professional reports. Most ratings were moderately to highly correlated between parents and medical professionals. Outcome measure scores were frequently significantly correlated with pertinent ratings from medical professionals and parents but usually not with child ratings. Conclusions Parents and medical professionals have similar perceptions of gross motor, self-care, quality of life, and overall status for children with CP and these perceptions correlate with standard outcome measures, but often do not agree with children's ratings. Longitudinal use of subjective status ratings from parents and professionals should contribute to establishing minimal clinically important differences for CP outcome measures.

Increased cartilage T2 relaxation time is thought to be an early marker of disease progression in juvenile idiopathic arthritis, because it can identify microstructural changes before damage becomes visible. The purpose of this study was to investigate longitudinal changes in T2 relaxation time mapping (i.e., T2 map) in children with early juvenile idiopathic arthritis and to compare with changes in clinical assessments.Twenty children (age range, 6.4-16 years) with early juvenile idiopathic arthritis completed at least four evaluations with T2 maps and clinical assessments: at enrollment, at 3 months, and at 1, 2, and 3 years. Sagittal T2 maps of distal femoral cartilage were generated, a region of interest was selected, and a T2 relaxation time profile was generated. The area under the curve from the T2 profile (i.e., T2 value) was correlated with patient age and sex and the following clinical assessments: total knee score, Childhood Health Assessment Questionnaire, physician global assessment, parent global assessment, and total number of active joints.There was a significant increase in mean T2 values from 3 months to 2 years (p0.05). There was a significant decrease in mean Childhood Health Assessment Questionnaire values between enrollment and 2 years (p0.05) and a significant decrease in parent global assessment, physician global assessment, total number of active joints, and total knee score values between enrollment and 1 year (p0.05). There were no statistically significant correlations between T2 values and patient age, sex, or clinical assessments.In patients with early juvenile idiopathic arthritis, T2 maps showed increased T2 values from the 3-month to 2-year follow-up, during which time the clinical assessments improved. This increase likely represents progressive microstructural changes, even though clinical symptoms improved with treatment.

Angiomyolipomas in patients with the tuberous sclerosis complex or sporadic lymphangioleiomyomatosis are associated with mutations in tuberous sclerosis genes resulting in constitutive activation of the mammalian target of rapamycin (mTOR). The drug sirolimus suppresses mTOR signaling.We conducted a 24-month, nonrandomized, open-label trial to determine whether sirolimus reduces the angiomyolipoma volume in patients with the tuberous sclerosis complex or sporadic lymphangioleiomyomatosis. Sirolimus was administered for the first 12 months only. Serial magnetic resonance imaging of angiomyolipomas and brain lesions, computed tomography of lung cysts, and pulmonary-function tests were performed.Of the 25 patients enrolled, 20 completed the 12-month evaluation, and 18 completed the 24-month evaluation. The mean (+/-SD) angiomyolipoma volume at 12 months was 53.2+/-26.6% of the baseline value (P0.001) and at 24 months was 85.9+/-28.5% of the baseline value (P=0.005). At 24 months, five patients had a persistent reduction in the angiomyolipoma volume of 30% or more. During the period of sirolimus therapy, among patients with lymphangioleiomyomatosis, the mean forced expiratory volume in 1 second (FEV1) increased by 118+/-330 ml (P=0.06), the forced vital capacity (FVC) increased by 390+/-570 ml (P0.001), and the residual volume decreased by 439+/-493 ml (P=0.02), as compared with baseline values. One year after sirolimus was discontinued, the FEV1 was 62+/-411 ml above the baseline value, the FVC was 346+/-712 ml above the baseline value, and the residual volume was 333+/-570 ml below the baseline value; cerebral lesions were unchanged. Five patients had six serious adverse events while receiving sirolimus, including diarrhea, pyelonephritis, stomatitis, and respiratory infections.Angiomyolipomas regressed somewhat during sirolimus therapy but tended to increase in volume after the therapy was stopped. Some patients with lymphangioleiomyomatosis had improvement in spirometric measurements and gas trapping that persisted after treatment. Suppression of mTOR signaling might constitute an ameliorative treatment in patients with the tuberous sclerosis complex or sporadic lymphangioleiomyomatosis. (ClinicalTrials.gov number, NCT00457808.)

Objective: To understand how traumatic brain injury (TBI) affects parent–child interactions acutelyfollowinginjury. Participants: YoungchildrenhospitalizedforTBI( n 80)andorthopedicinjuries(OI;n 113). Method: Raterscodedvideotapedinteractionsduringfreeplayandstructuredtasksforparentalwarmth/responsiveness and negativity and child warmth, behavior regulation, and cooperation. Ratersalso counted parental directives, critical/restricting statements, and scaffolds. Results: Parents of childrenwith TBI exhibited less warm responsiveness and made more directive statements during a structuredtaskthanparentsintheOIgroup.ChildrenwithTBIdisplayedlessbehaviorregulationthanchildrenwithOI. Parental warm responsiveness was more strongly related to child cooperativeness in the OI groupthan in the TBI group. Child behavior also mediated group differences in parental responsiveness anddirectiveness. TBI accounted for as much variance in parental behaviors as or more than did sociode-mographic factors. Conclusion: TBI-related changes in child behavior may negatively in uence parent–child interactions and disrupt the reciprocity between parent and child.Keywords: early childhood, traumatic brain injury, parent–child interaction, family impact

Background and Purpose— The natural history of perihematomal edema in human hyperacute spontaneous intracerebral hemorrhage (ICH) has not been well described. Methods— This study was a secondary analysis of a previously reported prospective, population-based study of hematoma growth in 142 patients with spontaneous ICH. Patients were first imaged within 3 hours of onset, then 1 and 20 hours later. We excluded patients with anticoagulant use (n=7), underlying aneurysm/vascular malformation (n=9), trauma (n=1), incomplete data (n=20), infratentorial ICH (n=17), and no consent (n=2), leaving an overall study population of 86 patients. From this overall group we further excluded patients with intraventricular extension (n=38), subsequent surgery (n=5), or death (n=2) before 20-hour postbaseline CT. This second, “restricted” analysis group of 41 patients was relatively devoid of clinical or radiological variables likely to confound edema measurement. Absolute and relative edema volumes (edema volume divided by hematoma volume) were descriptively summarized. Correlations between baseline edema volumes and relevant clinical and radiological variables were then performed. Results— Overall, median absolute edema volume increased from 6.93 to 14.4 cm 3 during the first 24 hours after ICH, and median relative edema volume increased from 0.47 to 0.81. In the restricted group, median absolute edema volume was 7.4 cm 3 at baseline and 11.0 cm 3 at 24 hours after ICH, and median relative edema volume increased from 0.55 to 0.81. Baseline relative edema volume was significantly negatively correlated with subsequent change in relative edema volume from baseline to 20-hour CT ( r =0.57, P =0.0002) but was not significantly correlated with other clinical and radiological variables, including hematoma volume or change in hematoma volume. Conclusions— Perihematomal edema volume increases by approximately 75% during the first 24 hours after hyperacute spontaneous ICH. Patients with the least amounts of baseline relative edema volume were most likely to develop significant additional amounts of edema during the first 24 hours after spontaneous ICH.

Background and Purpose— Little is known about the relationship between perihematomal edema in spontaneous intracerebral hemorrhage (ICH) and outcome. The purpose of this study was to determine whether absolute or relative edema volume (edema volume divided by hematoma volume) predicts mortality or functional outcome in patients with hyperacute spontaneous ICH. We hypothesized that increasing baseline relative edema volume is associated with greater probability of poor functional outcome. Methods— This was a secondary analysis of a prospective, population-based study of hematoma growth in 142 patients with spontaneous ICH. Patients were imaged within 3 hours of onset, then 1 and 20 hours later. Our primary analysis excluded patients with anticoagulant use (n=7), underlying aneurysm/vascular malformation (n=9), trauma (n=1), incomplete data (n=20), infratentorial ICH (n=17), intraventricular extension (n=38), and no consent (n=2). We analyzed whether associations existed between baseline edema volumes or other clinical/radiological variables and either 12-week modified Rankin Scale score >2 or 30-day mortality. Secondary analyses used 20-hour CT scan data, all patients with supratentorial ICH, and 12-week Barthel Index score Results— By multivariable logistic regression analysis, baseline relative edema was the strongest independent predictor of functional outcome and was associated with lesser odds of poor 3-month functional outcome (odds ratio, 0.09 per 1.0-unit [100%] increase; 95% CI, 0.01 to 0.64; P =0.016) and 12-week Barthel Index score P =0.039) but did not predict mortality. Secondary analyses confirmed this result. Absolute edema volume predicted neither mortality nor functional outcome. Conclusions— Relative edema is strongly predictive of functional outcome in patients with hyperacute supratentorial spontaneous ICH without intraventricular extension.

The purpose of this study was to retrospectively evaluate the time course, cause, and imaging characteristics of all new liver lesions in pediatric patients with a previously treated malignancy.Our hospital cancer registry was used to identify patients between 1980 and 2005 who met the following criteria: solid tumor, survival2 years after diagnosis, no liver lesions at a posttreatment baseline, and cross-sectional imaging follow-up of2 years. Final dictated reports of all cross-sectional imaging examinations including the abdomen were reviewed for any mention of new liver lesions. Positive reports were followed by consensus review of the images and clinical data. Patients were divided into three groups: those with suspected or proven focal nodular hyperplasia (FNH), those with suspected or proven metastases, and those with other lesions. An exact Wilcoxon test was used to evaluate the differences between the groups.Of 967 patients who met the initial inclusion criteria, 273 had adequate follow-up to be included in the study. Forty-six patients (16.8%) developed new liver lesions during the study period, and 14 of those 46 were classified into the FNH group (30.4%) and seven were classified into the metastasis group (15.2%). A significant difference was found in the median time to the development of FNH versus metastasis and other lesions (FNH, 92.9 months; metastasis, 43.2 months; other lesions, 18.5 months; p0.0001). A significant difference was also seen in the median length of follow-up between the groups (FNH, 115.6 months; metastasis, 57 months; other lesions, 50.8 months; p = 0.002). The imaging features of the groups also differed.The most common liver lesion encountered in pediatric patients previously treated for malignancy was FNH, which occurred farther from the time of diagnosis and had different imaging characteristics from both metastases and other liver lesions.

A limited review is presented of articles published between 1982 and 1993 that deals with the association of risk factors for cardiovascular disease and body composition. The risk factors included in this article are blood pressure, and lipids and lipoproteins. Body composition variables included were obtained from anthropometry, bioelectric impedance, body density, and dual energy x-ray absorptiometry. Specific attention is paid to the various definitions of obesity, regional fat distribution, and their cross-sectional and longitudinal associations with risk factors. In addition, we address issuses of tracking of risk factors and of body composition from childhood into adulthood. Relative risks of cardiovascular morbidity and mortality for elevated body fat and adverse fat distribution are explored also. The review is summarized extensively in tables to assist the reader in making his/her own interpretation and conclusion. Areas of future research are suggested.

Objective The purpose of this study was to determine the reliability, feasibility, and image quality of a limited, fast magnetic resonance imaging (MRI) protocol for preoperative evaluation of pectus excavatum in a pediatric population referred for presurgical imaging. Materials and methods A total of 47 patients, median age 14 years, referred for preoperative imaging of pectus excavatum, underwent axial balanced steady-state free precession MRI of the chest, with a limited patient charge. Two pediatric radiologists independently conducted a blinded retrospective study. The Haller and asymmetry indices were calculated at the level of greatest anterior-posterior chest narrowing. In addition, right heart compression and image quality were subjectively assessed, and scan duration was determined. Results Intraclass correlation coefficient reliability was between 0.85 and 0.98, indicating almost perfect agreement for quantitative measurements. Subjective evaluation of right heart compression and image quality showed moderate interreader agreement. Image quality was graded as good or excellent by both readers for all studies. No difference in the Haller index was observed between modalities in 3 patients on both computed tomographic scan and MRI (P = 0.2697). The median scan duration was 8 minutes. Conclusions Limited MRI is a reliable and cost-effective alternative for preoperative assessment of pectus excavatum. It is fast, free of ionizing radiation, and there is excellent interreader reliability for measurements of chest wall deformity.

The purpose of this article is to determine whether the phase of respiration at the time of imaging affects chest wall measurements and compression of internal structures in patients with pectus excavatum.Forty-seven patients (median age, 14 years) imaged for preoperative pectus excavatum underwent limited axial balanced steady-state free precession MRI of the chest at inspiration, expiration, and stop quiet breathing. Two radiologists, who were blinded to prior measurements, independently calculated the Haller index, asymmetry index, and sternal tilt in each phase of respiration. Compression of internal structures was recorded. Statistical comparison was performed.The Haller index was significantly lower at inspiration, compared with stop quiet breathing and expiration, with medians (interquartile ranges) of 3.96 (3.27-4.61), 5.16 (4.02-6.48), and 5.09 (4.14-6.63), respectively (p0.0001 for both). No significant difference in Haller indexes was observed between expiration and stop quiet breathing (p = 0.1171). Of 11 patients with a Haller index less than 3.25 at inspiration, eight (72.7%) had an index greater than 3.25 on expiration and stop quiet breathing, which accounted for 17% (8/47) of all patients imaged. Compression of the liver or vascular structures was present in 24 (51%) patients. There was no significant difference in the asymmetry index, sternal tilt, or right heart compression between phases of respiration.Obtaining the Haller Index at inspiration may result in a value significantly lower than that at expiration, potentially affecting surgical and financial decision making. Compression of the liver and vascular structures was observed in 51% of patients, but additional research is needed to determine the clinical significance of this finding.

BACKGROUND Intraoperatively administered tranexamic acid (TXA) lessens blood loss during orthopedic and cardiovascular surgery. Its use for craniosynostosis surgery warrants investigation. Therefore, we analyzed our use of TXA during minimally invasive (MI) and open craniosynostosis procedures. METHODS Fifty-six patients were retrospectively studied: 20 in the MI group, 10 receiving TXA; 36 in the open group, 16 receiving TXA. Study variables were weight-adjusted estimated blood loss (EBL) and calculated blood loss (CBL), transfusion and incidence, transfusion volume, and complications. Calculated blood loss was determined by a novel formula based on red cell mass. RESULTS In the MI group, median EBL was significantly lower for TXA recipients (9.62 vs 15.94 mL/kg, P = 0.0231), whereas median CBL was not (36.59 vs 34.12 mL/kg, P = 0.7976). Transfusion incidences were 80% TXA versus 100% control (P = 0.4737). Median transfusion volume trended lower (10.76 vs 19.43 mL/kg, P = 0.0723).In the open group, median EBL and CBL for TXA recipients were lower but not significantly different than for nonrecipients (21.86 vs 23.40 mL/kg, P = 0.7416; 53.54 vs 80.13; P = 0.3137). All patients had a transfusion. Median transfusion volume for TXA recipients versus nonrecipients was 34.01 versus 40.35 mL/kg (P = 0.3137). Tranexamic acid greatly minimized the range of EBL and CBL in both surgical groups. There was a significant correlation between the CBL and EBL (P < 0.0001). There were no adverse events. CONCLUSIONS Intraoperative TXA administration is safe with modest benefit suggested, especially in the MI group. Calculated blood loss correlated well with EBL at lower blood loss volumes, implicating it as a potential measurement of true blood loss.

The retropharyngeal lymph nodes are the least well-described portion of the Waldeyer ring. Originally described as occurring in medial and lateral groups, reports have described only the presence of lateral nodes in children. We have seen cases of MRI sleep studies in children with obstructive sleep apnea (OSA) in which lateral and medial retropharyngeal lymph nodes are present and have been misinterpreted. Our purpose is to describe the frequency and appearance of retropharyngeal lymph nodes in children with and without OSA.Axial and sagittal T2-weighted MRI scans were reviewed in 150 children with OSA and 150 control subjects without OSA, who underwent imaging for other indications. The presence, size, and location of the retropharyngeal lymph nodes were evaluated. Retropharyngeal lymph nodes were evaluated for frequency of medial nodes, frequency of lateral nodes, size as indicated by the anterior-to-posterior diameter, laterality (bilateral or unilateral), and superior-to-inferior location compared with the cervical vertebral body level. Analyses were performed using the chi-square or Fisher's exact test (for categorical data) and generalized linear model or two-sample Wilcoxon's Mann-Whitney test (for continuous data).Lateral retropharyngeal lymph nodes were common in both children with OSA (137/150 [91.3%]) and children without OSA (146/150 [97.3%]). Medial retropharyngeal lymph nodes occurred not uncommonly in both children with OSA (32/150 [21.3%]) and those without OSA (26/150 [17.3%]). Lateral retropharyngeal lymph nodes were more commonly bilateral (95% CI, 88.4-97.4%; p0.0001) and located at the skull base (C1) or C1-C2 level (99%; p0.0001). Medial retropharyngeal lymph nodes were more commonly unilateral (95% CI, 71.9-84.6%; p0.0004) and located at the C2-C3 level (95% CI, 78.13-84.62%; p0.0001). There were no statistically significant differences in the proportion of medial or lateral retropharyngeal lymph nodes in the OSA group compared with the control group.Retropharyngeal lymph nodes are seen commonly in children in both lateral (95% CI, 91.3-97.3%) and medial (95% CI, 17.3-21.3%) locations. Media nodes are present more frequently than previously described. Such nodes occur almost equally frequently in populations with and without OSA. Retropharyngeal lymph nodes should be considered normal in children and not be interpreted as abnormal or misdiagnosed.

Definitive immunization guidelines for internationally adopted children are lacking. We examined whether these children had serologic evidence of protection against vaccine-preventable diseases. For children with ≥3 vaccine doses, overall protection was high for diphtheria (85%), tetanus (95%), polio (93%), hepatitis B (77%), and Hib (67%). For children ≥12 months of age with ≥1 dose of measles, mumps, or rubella vaccines, 95%, 72%, and 94% were immune, respectively. Children without immunization documentation had lower immunity. Serologic testing was useful in verifying the immunization status in internationally adopted children with and without documentation of immunizations.

We sought to evaluate amniotic fluid brain natriuretic peptide (BNP) levels as a biomarker of recipient twin (RT) cardiomyopathy (RTCM) in twin-twin transfusion syndrome.Amniotic fluid samples were obtained from 157 twin-twin transfusion syndrome RTs and from 6 singletons (controls) from 2007 through 2009. N-terminal prohormone BNP (NT-proBNP) levels were quantified by enzyme-linked immunosorbent assay. RTCM was classified as mild (IIIA), moderate (IIIB), or severe (IIIC) by fetal echocardiography. The relationship between NT-proBNP and RTCM was evaluated using analysis of variance. The ability of NT-proBNP to predict moderate or greater RTCM was evaluated by receiver operating characteristic analysis.There is a significant positive correlation between NT-proBNP levels and worsening RTCM (r = 0.33; P.001). NT-proBNP thresholds of 569 fmol/mg and 369 fmol/mg had a sensitivity of 70% and 87%, and specificity of 67% and 42%, respectively, in predicting moderate or greater RTCM.This is the first large case series that demonstrates a relationship between NT-proBNP and RTCM. This pathophysiologic insight supports ongoing efforts to develop screening biomarkers.

The purpose of this study was to compare the diagnostic utility of (123)I-metaiodobenzylguanidine ((123)I-MIBG) scintigraphy and (18)F-FDG PET in neuroblastoma.A total of 113 paired (123)I-MIBG and (18)F-FDG PET scans in 60 patients with neuroblastoma were retrospectively reviewed. Paired scans were acquired within 14 days of each other.For stage 1 and 2 neuroblastoma (13 scans, 10 patients), (18)F-FDG depicted more extensive primary or residual neuroblastoma in 9 of 13 scans. (123)I-MIBG and (18)F-FDG showed equal numbers of lesions in 1 of 13 scans, and 3 of 13 scan results were normal. For stage 3 neuroblastoma (15 scans, 10 patients), (123)I-MIBG depicted more extensive primary neuroblastoma or local or regional metastases in 5 of 15 scans. (18)F-FDG depicted more extensive primary neuroblastoma or local or regional metastases in 4 of 15 scans. (123)I-MIBG and (18)F-FDG were equal in 2 of 15 scans, and 4 of 15 scan results were normal. For stage 4 neuroblastoma (85 scans, 40 patients), (123)I-MIBG depicted more neuroblastoma sites in 44 of 85 scans. (18)F-FDG depicted more neuroblastoma sites in 11 of 85 scans. (123)I-MIBG and (18)F-FDG were equivalent or complementary in 13 of 85 scans, and 17 of 85 scan results were normal.(18)F-FDG is superior in depicting stage 1 and 2 neuroblastoma, although (123)I-MIBG may be needed to exclude higher-stage disease. (18)F-FDG also provides important information for patients with tumors that weakly accumulate (123)I-MIBG and at major decision points during therapy (i.e., before stem cell transplantation or before surgery). (18)F-FDG can also better delineate disease extent in the chest, abdomen, and pelvis. (123)I-MIBG is overall superior in the evaluation of stage 4 neuroblastoma, especially during initial chemotherapy, primarily because of the better detection of bone or marrow metastases.

This study aim to assess the potential of prenatal predictors of postnatal severe pulmonary artery hypertension (PAH) in isolated left congenital diaphragmatic hernia (CDH) and to define a new prenatal pulmonary hypertension index (PPHI).A retrospective chart review of CDH patients between May 2005 and October 2008 was conducted. Ten patients with systemic/suprasystemic and 9 patients with subsystemic pulmonary hypertension at 3 weeks of age were identified. Diameters of the right pulmonary artery, left pulmonary artery (LPA(d)), aorta, and the length of vermis of the cerebellum were obtained from prenatal magnetic resonance imaging to calculate the PPHI [=(LPA(d)/length of vermis of the cerebellum) x 10] and the modified McGoon index (MGI) [=(diameter of the right pulmonary artery + LPA(d))/diameter of aorta]. Prenatal pulmonary hypertension index and MGI were compared with lung-to-head ratio, percent predicted lung volume, and total lung volume for pulmonary hypertension and survival.The PPHI and MGI had a significant, negative correlation with pulmonary hypertension (r = -0.61, P = .005, and r = -0.72, P.005, respectively). The PPHI and MGI are significantly lower in the systemic/suprasystemic PAH group compared with the subsystemic PAH group (1.11 +/- 0.32 versus 1.63 +/- 0.28, P = .004, and 0.71 +/- 0.15 versus 1.05 +/- 0.11, P.001, respectively). There were no significant differences between the groups comparing the lung-to-head ratio, percent predicted lung volume, and total lung volume.Both PPHI and MGI accurately predict the severity of postnatal PAH in isolated left CDH.

Objective Except when the diagnosis of juvenile dermatomyositis (DM) is in doubt, a case has not been made for routine muscle biopsy (MB). We sought to determine whether MB findings prior to systemic therapy have prognostic value. Methods We reviewed the hospital records and slides prepared from the initial open MB of 72 patients treated at one center between 1977 and 2002 and followed for a minimum of 2 years. None of the patients had received a course of systemic corticosteroid therapy at the time of MB. Our approach to MB evaluation was based on recent discussions with muscle pathology experts to develop criteria for assessing inflammation, vasculopathy, myofiber atrophy, regeneration, acute and chronic myopathic change, and stromal changes. Using simple and multivariate logistic regression, we tested each MB parameter for ability to predict outcome using 2 published classification systems. Results Extensive active myopathic changes (excluding regeneration) and central nuclei without basophilia predicted chronic juvenile DM. Severe arteropathic change, positive arterial direct immunofluorescence, obvious foci of severe capillary loss/endomysial fibrosis, and muscle infarcts predicted chronic juvenile DM, particularly with ulceration. Other MB parameters, regardless of severity, were not significant predictors of chronic juvenile DM versus limited disease. Conclusion A scoring system for evaluating pretreatment MB in juvenile DM that focuses on extent of necrotizing myopathy, severity of vasculopathy, and features of established chronicity such as central nucleation of nonbasophilic myofibers may provide a basis for stratification of therapeutic regimens according to risk for chronic disease. The validity of our findings should be prospectively tested.

Background and Purpose —The aim of this study was to determine the incidence rates of ischemic stroke subtypes among blacks. Methods —Hospitalized and autopsied cases of stroke and transient ischemic attack among the 187 000 blacks in the 5-county region of greater Cincinnati/northern Kentucky From January 1, 1993, through June 30, 1993, were identified. Incidence rates were age- and sex-adjusted to the 1990 US population. Subtype classification was performed after extensive review of all available imaging, laboratory data, clinical information, and past medical history. Case-control comparisons of risk factors were made with age-, race-, and sex-matched control subjects. Results —Annual incidence rates per 100 000 for first-ever ischemic stroke subtypes among blacks were as follows: uncertain cause, 103 (95% confidence interval [CI], 80 to 126); cardioembolic, 56 (95% CI, 40 to 73); small-vessel infarct, 52 (95% CI, 36 to 68); large vessel, 17 (95% CI, 8 to 26); and other causes, 17 (95% CI, 9 to 26). Of the patients diagnosed with an infarct of uncertain cause, 31% underwent echocardiography, 45% underwent carotid ultrasound, and 48% had neither. Compared with age-, race-, and sex- (proportionally) matched control subjects from the greater Cincinnati/northern Kentucky region, the attributable risk of hypertension for all causes of first-ever ischemic stroke is 27% (95% CI, 7 to 43); for diabetes, 21% (95% CI, 11 to 29); and for coronary artery disease, 9% (95% CI, 2 to 16). For small-vessel ischemic stroke, the attributable risk of hypertension is 68% (95% CI, 31 to 85; odds ratio [OR], 5.0), and the attributable risk of diabetes is 30% (95% CI, 10 to 45; OR, 4.4). For cardioembolic stroke, the attributable risk of diabetes is 25% (95% CI, 4 to 41; OR, 3.1). Conclusions —Stroke of uncertain cause is the most common subtype of ischemic stroke among blacks. Cardioembolic stroke and small-vessel stroke are the most important, identifiable causes of first-ever ischemic stroke among blacks. The incidence rates of cardioembolic and large-vessel stroke are likely underestimated because noninvasive testing of the carotid arteries and echocardiography were not consistently obtained in stroke patients at the 18 regional hospitals. Most small-vessel strokes in blacks can be attributed to hypertension and diabetes.

Background and Purpose —Intracerebral hemorrhage (ICH) is a highly morbid disease process. Perihematomal edema is reported to contribute to clinical deterioration and death. Recent experimental observations indicate that clotting of the intrahematomal blood is the essential prerequisite for hyperacute perihematomal edema formation rather than blood-brain barrier disruption. Methods —We compared a series of patients with spontaneous ICH (SICH) to a series of patients with thrombolysis-related ICH (TICH). All patients were imaged within 3 hours of clinical onset. We reviewed relevant neuroimaging features, emphasizing and quantifying perihematomal edema. We then analyzed clinical and radiological differences between the 2 ICH types and determined whether these factors were associated with perihematomal edema. Results —TICHs contained visible perihematomal edema less than half as often as SICHs (31% versus 69%, P P P P P P P Conclusions —The striking qualitative and quantitative lack of perihematomal edema observed in the thrombolysis-related ICHs compared with the SICHs provides the first substantial, although indirect, human evidence that intrahematomal blood clotting is a plausible pathogenetic factor in hyperacute perihematomal edema formation.