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BACKGROUND Peripherally inserted central catheters (PICCs) are used routinely in neonatal care. Measures of surface anatomy have been used to estimate appropriate PICC depth in neonates since 1973. However, prior PICC research using anthropometric measures to estimate proper PICC insertion depth has been limited to pediatric and adult literature. PURPOSE The purpose of this study was to explore the relationships among a neonate's anthropometric measures and the appropriate PICC insertion depth. METHODS Neonates requiring PICC insertion at Nationwide Children's Hospital were enrolled between January and September 2018. Standard PICC procedures were followed. The research group corroborated appropriate PICC tip position of enrolled infants. Multivariable linear regression with robust standard errors was used to evaluate linear relationships between PICC insertion depth and current weight, current length, and PICC insertion site. RESULTS Demographics of enrolled infants included gestational ages of 23 to 39 weeks, weights of 510 to 3870 g, and lengths of 31 to 54 cm. Of the 56 infants considered, final statistical analysis included 49 neonates (14 ankle, 16 knee, and 19 antecubital insertions). Current neonatal weight was associated with PICC depth at all sites (all Ps < .0001). Current neonatal length was associated with PICC depth at all sites (all Ps < .0001). Preprocedure surface measurement was also strongly associated with PICC insertion depth (P < .0001). IMPLICATIONS FOR PRACTICE This investigation demonstrated a relationship for both neonatal weight and length that may be an anthropometric model for neonatal PICC insertion depth. IMPLICATIONS FOR RESEARCH A more robust sample size could more precisely define the anthropometric model.

The purpose of the study was to determine the accuracy of acoustic radiation force impulse (ARFI) ultrasound elastography in assessing the degree of liver disease in children with short bowel syndrome (SBS).A prospective observational cohort study of patients with SBS who underwent a liver biopsy and ARFI elastography was performed. Mean shear wave speed (SWS) and stage of fibrosis was evaluated using t-tests. Receiver operating characteristic curves (ROC) were generated and the area under the curves (AUC) estimated in order to assess the accuracy of SWS measurements to discriminate between stages of fibrosis.Thirty-seven paired elastography and biopsy samples from 31 patients were included. The median age was 0.6 years, and 61% were male. There was a significant positive correlation between stage of fibrosis and mean SWS (β=0.16 m/s increase per stage, p=0.001). ROC analysis revealed that mean SWS had good accuracy for discriminating between mild liver fibrosis (F0-F1) and moderate to severe fibrosis (F2-F4) (AUC=0.80, 95% CI 0.65-0.95). In addition, ROC analysis demonstrated that mean SWS can also accurately discriminate between mild to moderate fibrosis (F0-F2) and more severe fibrosis (F3-F4) (AUC=0.84, 95% CI 0.71-0.96).ARFI elastography is an accurate, non-invasive method to monitor liver disease in children with SBS.Retrospective Cohort Study LEVEL OF EVIDENCE: II.

1. Delia Gold, MD* 2. Pam Horn, FNP† 3. Patrick Warren, MD‡ 4. Matthew Beran, MD†,§ 1. *Department of Emergency Medicine, 2. †Department of Orthopedics, 3. ‡Department of Radiology, and 4. §Department of Sports Medicine, Nationwide Children’s Hospital, Columbus, OH An 11-year-old boy presents to the emergency department (ED) for a right thigh injury. Six weeks before presentation he was riding a large all-terrain vehicle (ATV) with a roll cage when he crashed and flipped the ATV. The roll bar hit his right thigh, and he remembered it sliding from his distal to proximal thigh anteriorly. He was taken to a local hospital for treatment at that time. He had substantial swelling and pain; however, there were no open wounds and minimal abrasions. Radiographs of the femur at that visit were negative for fracture. He was diagnosed as having a simple hematoma and discharged. He had been instructed to use a compressive elastic wrap around his thigh, apply ice intermittently for several days, and walk with crutches until follow-up with his primary care physician (PCP). The patient followed up with his PCP 4 days after the injury complaining of worsening swelling, bruising, and pain. The patient reported that he had not followed the hospital discharge instructions. Due to worsening symptoms at his PCP visit, a magnetic resonance image (MRI) was obtained 5 weeks after the injury. After reviewing the MRI results, the PCP referred the patient to an orthopedic surgeon, who recommended the patient go to the ED for an immediate evaluation. On arrival at the ED, the patient is comfortable and in no distress. His only complaint is right thigh pain and swelling. On examination, the patient has normal vital signs and denies fever. He has no difficulty with a straight leg raise and has an intact extensor mechanism. He has full range of motion …

Background Our objective was to evaluate the accuracy of acoustic radiation force impulse (ARFI) elastography in determining extent of liver fibrosis in pediatric patients with short bowel syndrome (SBS). Methods This prospective cohort study included pediatric patients with SBS who underwent ultrasound with ARFI measurements of shear wave speed (SWS) and liver biopsy within 30 days of each other between 12/2014–9/2015. The mean and median SWS were compared to the stage of fibrosis. Receiver operating characteristic curves (ROC) were also generated to assess the classification accuracy of SWS measurements for mild (F0-F1) versus moderate/severe fibrosis (F2-F4). Results Twelve patients were included with median age 1.4 years and median weight 11.3 kg. The median direct bilirubin level was 0.3 mg/dL at the time of biopsy. On liver biopsy, 6 patients had mild fibrosis (F1), 3 had septal fibrosis (F3), and 3 had cirrhosis (F4). The area under the ROC curve for elastography to differentiate moderate/severe liver fibrosis from mild disease was 0.83 (95CI 0.58–1.00) and 0.86 (95CI 0.63–1.00) for the median SWS and mean SWS, respectively. Conclusions These early results suggest that ARFI ultrasound elastography may be a reliable non-invasive method to monitor liver fibrosis in pediatric patients with SBS. Type of study Prospective observational cohort. Level of evidence 3.

Incidence of venous thromboembolism, including pulmonary embolism (PE), continues to rise in children. Optimum management of submassive PE is unclear. The principal objective of this retrospective study was to investigate the radiological and clinical outcomes in children with submassive PE treated with catheter-directed thrombolysis (CDT). Five patients underwent six episodes of CDT. No patient developed major/clinically relevant non-major bleeding. Most patients had complete radiological thrombus resolution and no patient had evidence of chronic thromboembolic pulmonary hypertension. There is an urgent need for larger prospective cohort studies/randomized controlled trials to investigate the role of CDT in pediatric PE.

Anjana Kundu,1 Mahmood Rafiq,2 Patrick S Warren,3 Joseph D Tobias2,4 1Department of Anesthesiology, Dayton Children’s Hospital, Dayton, 2Department of Anesthesiology and Pain Medicine, 3Department of Radiology, Nationwide Children’s Hospital, 4Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA Abstract: Erythromelalgia (EM) is an uncommon condition characterized by erythema, increased skin temperature, and burning pain, most frequently occurring in the lower extremities. The pain is generally very severe and treatment can be extremely challenging, especially in the pediatric and adolescent population. We report a series of three cases of primary EM in pediatric patients involving the lower extremities, refractory to medical treatment that responded favorably to computed-tomography-guided lumbar sympathetic blockade. There was a significant improvement in pain scores, quality of life, and overall function as well as decreased analgesic requirements. Lumbar sympathetic blockade should be considered as a therapeutic modality in pediatric and adolescent patients with EM who are refractory to other treatments. Keywords: primary erythromelalgia, secondary erythromelalgia, computed tomography guided, lumbar sympathetic blockade&nbsp

Ballistic injuries with retained foreign bodies from air guns is a relatively common problem, particularly in children and adolescents. If not removed in a timely fashion, the foreign bodies can result in complications, including pain and infection. Diagnostic methods to identify the presence of the foreign body run the entire gamut of radiology, particularly radiography, ultrasound (US) and computed tomography (CT). Removal of the foreign bodies can be performed by primary care, emergency, surgical, and radiologic clinicians, with or without imaging guidance. To evaluate the modalities of radiologic detection and the experience of image-guided ballistic foreign body removal related to air gun injuries within the interventional radiology department of a large pediatric hospital. A database of more than 1,000 foreign bodies that were removed with imaging guidance by the interventional radiologists at our institution was searched for ballistic foreign bodies from air guns. The location, dimensions, diagnostic modality, duration, complications and imaging modality used for removal were recorded. In addition, the use of sedation and anesthesia required for the procedures was also recorded. Sixty-one patients with ballistic foreign bodies were identified. All foreign bodies were metallic BBs or pellets. The age of the patients ranged from 5 to 20 years. The initial diagnostic modality to detect the foreign bodies was primarily radiography. The primary modality to assist in removal was US, closely followed by fluoroscopy. For the procedure, 32.7% of the patients required some level of sedation. Only two patients had an active infection at the time of the removal. The foreign bodies were primarily in the soft tissues; however, successful removal was also performed from intraosseous, intraglandular and intratendinous locations. All cases resulted in successful removal without complications. Image-guided removal of ballistic foreign bodies secondary to air guns is a very effective procedure that can obviate the need for open surgical procedures in children.

Objective To investigate treatment-related outcomes, namely radiological clot resolution, post-thrombotic syndrome (PTS), and health related quality-of-life (HRQoL) scores, in children with Paget–Schroetter syndrome (PSS) undergoing multidisciplinary management, including anticoagulation and decompressive rib-resection surgery, with or without thrombolytic therapy. Study design We identified all patients treated for PSS at our institution between the years 2010 and 2017. Baseline clinical and radiologic data were abstracted from medical records. Two validated survey instruments to quantify PTS and HRQoL were mailed to eligible patients. Standard statistical methods were used to summarize these measures. Results In total, 22 eligible patients were identified; 10 were treated with thrombolysis followed by anticoagulation and rib resection, and 12 were treated with anticoagulation and rib resection alone. Nineteen patients responded to the survey instruments. Median age at deep vein thrombosis diagnosis and survey completion were 16.3 and 20.4 years, respectively. Nineteen of 22 patients had thrombus resolution on radiologic follow-up. Fourteen of 19 survey respondents reported signs/symptoms of PTS of which the majority (12/14) reported mild PTS. Aggregate total, physical, and psychosocial HRQoL scores reported were 90.6, 96.7, and 93.3, respectively. Thrombolytic therapy was not associated with a significant improvement in radiologic, clinical or HRQoL outcomes. Conclusions Most patients with PSS had complete thrombus resolution on imaging. Only 11% of survey respondents reported moderate PTS. The entire cohort reported excellent HRQoL scores. The role for thrombolytic therapy in the management of childhood PSS remains incompletely elucidated.

Thoracic duct injury is an uncommon complication of neck dissection and cervical spinal surgery that is associated with significant morbidity. The authors describe an unusual case of thoracic duct injury during anterior spinal fusion resulting in a large prevertebral lymphocele presenting with dysphagia, respiratory distress, and chyloptysis. Surgical closure of the lymphocele was unsuccessful, and percutaneous drainage and sclerotherapy was performed. A large thoracic duct branch communicating with the lymphocele became evident during sclerotherapy, and embolization of the duct was performed via a percutaneous transcervical approach. Symptoms immediately resolved, and the patient remained asymptomatic at 6-month follow-up.

Venous aneurysms are rare clinical entities, particularly in children, and their presentation and natural history often depend on the anatomical location and underlying etiology. We present a single case of a 12-year-old girl who presented with a palpable right supraclavicular mass. Imaging evaluation with CT, conventional venography, MRI and sonography revealed a large fusiform subclavian vein aneurysm with an unusual, mass-like fibrofatty component incorporated into the vessel wall. The girl ultimately required complete resection of the right subclavian vein with placement of a synthetic interposition graft. This case provides a radiology/pathology correlation of an entity that has not previously been described as well as an example of the utility of multiple imaging modalities to aid diagnosis and preoperative planning.

Purpose: HSV1716 is an oncolytic herpes simplex virus-1 (HSV-1) studied in adults via injection into the brain and superficial tumors. To determine the safety of administering HSV1716 to pediatric patients with cancer, we conducted a phase I trial of image-guided injection in young patients with relapsed or refractory extracranial cancers. Experimental Design: We delivered a single dose of 105 to 107 infectious units of HSV1716 via computed tomography–guided intratumoral injection and measured tumor responses by imaging. Patients were eligible for up to three more doses if they achieved stable disease. We monitored HSV-1 serum titers and shedding by PCR and culture. Results: We administered a single dose of HSV1716 to eight patients and two doses to one patient. We did not observe any dose-limiting toxicities. Adverse events attributed to virus included low-grade fever, chills, and mild cytopenias. Six of eight HSV-1 seronegative patients at baseline showed seroconversion on day 28. Six of nine patients had detectable HSV-1 genomes by PCR in peripheral blood appearing on day +4 consistent with de novo virus replication. Two patients had transient focal increases in metabolic activity on 18fluorine-deoxyglucose PET, consistent with inflammatory reactions. In one case, the same geographic region that flared later appeared necrotic on imaging. No patient had an objective response to HSV1716. Conclusions: Intratumoral HSV1716 is safe and well-tolerated without shedding in children and young adults with late-stage, aggressive cancer. Viremia consistent with virus replication and transient inflammatory reactions hold promise for future HSV1716 studies. Clin Cancer Res; 23(14); 3566–74. ©2017 AACR.

Chronic upper extremity deep vein thrombosis (UEDVT) and superior vena cava syndrome (SVCS) are important and underdiagnosed entities that are associated with significant morbidity, and both are becoming increasingly common due to the use of indwelling catheters and implantable central venous access devices. Currently, as many as 25% of patients with an indwelling catheter are diagnosed with chronic UEDVT or venous stenosis. SVCS is most commonly seen in the setting of malignancy, especially lung cancer and lymphoma. Endovascular management of chronic UEDVT and SVCS is accepted as an important first-line treatment given its high overall success rate and low morbidity as compared with medical and surgical treatments. In this article, the indications for treatment, complications, and success rates of the endovascular management of UEDVT and SVCS are reviewed. Relevant findings on presentation and physical exam as well as various imaging modalities and imaging findings are evaluated. Details of preprocedure evaluation, relevant anatomy, and avoidance of potential complications are discussed.

Background: Paget-Schroetter Syndrome (PSS), also known as venous thoracic outlet syndrome or effort-induced upper extremity deep vein thrombosis, is a rare condition that occurs secondary to impingement of the subclavian vein by the overlying cervical ribs, long transverse processes of the cervical spine, musculo-fascial bands, or clavicular or first rib abnormalities. PSS often affects otherwise healthy and athletic individuals with a history of repetitive overhead activities. Given the paucity of published pediatric data, making evidence-based recommendations on appropriate therapeutic strategies is challenging. Objective: The principal objective of this single-institution study was to review the presentation, management, and outcomes of pediatric patients treated for PSS at Nationwide Children's Hospital (NCH) over a six-year period (January 1, 2010 to December 31, 2016). Methods: The study was approved by the Institutional Review Board at NCH. The Electronic Data Warehouse was used to identify patients diagnosed with PSS during the 6-year study period using modified ICD-9-CM codes. Eligible subjects were defined as children under the age of 21 who presented with an unprovoked upper extremity deep vein thrombosis (DVT) and had evidence of compression of the subclavian vein at the level on the thoracic outlet on dynamic imaging. Baseline demographic data, diagnostic and therapeutic details, and available follow-up information was abstracted from patient charts. Eligible subjects were also mailed a previously validated pediatric post-thrombotic syndrome (PTS) self-report instrument and a self-report health-related quality of life (HRQoL) instrument (PedsQL 4.0). All data were summarized and presented using descriptive statistics. Comparisons were made using nonparametric statistical methods. Results: The study cohort consisted of 21 subjects (11 female). Median age at DVT diagnosis was 16.3 (range 13.7-18.2) years. Subjects presented to NCH a median of 2 (range 0-34) days after symptom onset. Eighteen subjects (86%) reported repetitive exercise or overuse activity prior to diagnosis. Twelve subjects (57%) had evidence of congenital/acquired thrombophilia (Table 1). All subjects were treated with anticoagulation for a median duration of 3.2 (range 1.4-8.6) months. Nine subjects (43%) were also treated with catheter-directed and/or pharmaco-mechanical thrombolysis, and six of these subjects additionally underwent balloon angioplasty. All 21 subjects underwent decompressive surgery (first or cervical rib resection) a median of 7.7 (range 2-63.2) weeks after symptom onset. Four subjects (19%) experienced surgical complications, including minor bleeding/hematoma formation (3), pneumothorax (3), and winged scapula (1). Only 2/14 subjects diagnosed before 2014 underwent thrombolytic therapy, whereas all (7/7) subjects diagnosed after 2014 underwent thrombolysis. The subjects who did not undergo thrombolysis were not significantly different from those who did, except for the presence of a thrombophilia (p=0.02). Of the twelve subjects who did not undergo thrombolysis, eleven (92%) had complete/partial resolution of their DVT and one (8%) had no resolution on most recent imaging. Of the nine subjects who received thrombolysis, 100% had complete/partial resolution of their DVT on most recent imaging. We are currently analyzing data on PTS and HRQoL. Discussion: Herein, we report one of the largest pediatric cohorts of PSS. All subjects received anticoagulation and underwent decompressive surgery. Additionally, 9/21 subjects underwent catheter-directed and/or pharmaco-mechanical thrombolysis. 20/21 subjects had complete/partial resolution of the DVT on most recent imaging. Our single-institution study suggests that high rates of thrombus resolution may be achieved in children with PSS with anticoagulation and decompressive surgery, with or without thrombolytic therapy. Larger, prospective studies are needed to confirm our findings and further examine the relationship between treatment and outcomes. Disclosures O'Brien: Bristol Myers Squibb: Other: study of direct oral anticoagulant in prevention of pediatric VTE, Research Funding; Glaxo Smith Kline: Other: DSMB for Arixtra Study in Pediatric VTE; CSL Behring: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: advisory board - von Willebrand Disease diagnosis & management; Shire: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: advisory board - VWD diagnosis and management; Pfizer: Consultancy, Other: study of direct oral anticoagulant in treatment of pediatric VTE. Kumar: CSL Behring: Consultancy; Bayer: Consultancy.