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Three girls and 4 boys with the final diagnosis of ruptured appendicitis underwent 19 sonographic studies, 5 before any therapy was instituted and 14 follow-up studies. Four abscesses identified before treatment and 2 seen postoperatively were ovoid, irregularly marginated, and contained low-amplitude echoes. Gastrointestinal ileus with gas-and fluid-filled loops of bowel made the studies technically difficult. Follow-up studies also showed fluid collections distant from the original abscesses. The complete resolution of the abscess was followed sonographically in 1 patient treated with antibiotics. Ultrasound can be useful in confirming or suggesting the diagnosis of ruptured appendicitis in the child with abdominal pain, but careful attention to detail is necessary in these technically difficult studies.

Eleven infants were encountered (nine premature, two term) in whom well-defined small periventricular cavitations were found by sonography in the first week of life. The sonographic findings bore remarkable similarity to subependymal pseudocysts in neonates previously described in autopsy specimens. The cavitations, which were identified predominantly along the superolateral aspects of the lateral ventricles, did not evolve in the manner of postnatally acquired periventricular leukomalacia. The location of the cavitations differed from the site of previously reported lesions of posthemorrhagic and postinfectious germinolysis along the medial aspect of the caudothalamic groove. Neurosonologists and neonatologists should be alerted to this finding and encouraged to follow these infants as a separate group to learn whether neurodevelopmental sequelae occur in these children.

Osseous changes at the hips were seen in the radiographs of 36 children with long-standing juvenile rheumatoid arthritis (JRA) and no significant steroid therapy. Seven boys and one girl had progressive primary inflammatory destruction of the hip with erosive arthritis and progressive joint space narrowing. Twenty-one girls and seven boys revealed adaptive developmental changes in the growing skeleton without erosion. Both courses resulted in secondary osteoarthritis and functional disability. Early recognition of adaptive, developmental changes may identify a group of children who may benefit from orthopedic intervention to maintain concentric, congruent reduction at the hip.

Sonograms of 21 children with neuroblastoma were reviewed with attention to the following sonographic criteria: size, location, internal echo pattern, anechoic areas, and margination. Fourteen primary tumors were evaluated before therapy. All tumors were heterogeneously echogenic; all had poorly defined margins. Tumor calcification was identified in three, and 10 of 14 primary tumors contained discrete anechoic areas ranging from 0.5 to 4 cm in diameter. The average greatest dimension of primary tumor masses was 7.7 cm.

Standards for kidney length in relation to size were derived from measures of 34 normal, full-term, healthy infants aged 2-56 weeks. Of six general size variables (age, weight, length, head circumference, abdominal circumference, and C7 to coccyx length), net kidney length correlated best with a combination of infant length and weight. A nomogram has been generated from these data for use by the radiologist.

Objective evaluation of students frequently includes the utilization of multiple-choice test questions. Due to constraints on faculty time, however, the writing of these questions is usually completed quickly and somewhat haphazardly. The guidelines contained in this article were written to help radiologists produce better test questions for the purpose of improving the evaluation of clerkship students. The guidelines include choosing an item that is worth testing and has one definite answer, asking a single, clearly formulated question, avoiding true-false stems, being concise when writing the question, avoiding the use of negatives in the stem, avoiding using "all of the above" or "none of the above" as a response, avoiding subtle clues toward the keyed answer or away from the distractors, avoiding one-word definitions as responses, and placing the responses in logical or numerical order. A definition of terms used in the educational literature and a discussion of a quantitative evaluation of test questions are included.

Endotracheal intubation of a preterm infant cadaver was performed both orally and nasally to assess the relative movement of the endotracheal tube with changes in head position. For each method of intubation, anteroposterior radiographs were obtained with the head in neutral, flexed, extended, and laterally rotated positions. The results indicate slightly increased movement of the nasotracheal tube with flexion and rotation, and markedly increased movement with extension. The possible relationship between tube movement and the development of subglottic stenosis is discussed.

A malignant cystic neoplasm in the liver of a 6-month-old girl is reported. The neoplasm has unique clinical and morphological features, and despite ultrastructural and immunohistochemical studies, the tumor could not be clearly classified as any known primary hepatic neoplasm of infancy. A differentiated cystic component of the neoplasm had features of cystic peritoneal mesothelioma. Alpha-1-antitrypsin and alpha-fetoprotein were demonstrated in solid, anaplastic portions of the recurrent tumor by immunohistochemistry. The neoplasm recurred after surgical resection and proved fatal 11 months following diagnosis, despite multiple courses of chemotherapy.

The Nissen fundoplication (NFP) for the management of severe gastroesophageal reflux (GER) in infants and children has become one of the most frequently performed operations in pediatric surgical centers in the United States. Short-term outcome, morbidity, and mortality are consistently favorable in several large series. The long-term success of this procedure is presumed but has not been established objectively. To examine the late results of this operation, 46 infants and children were carefully evaluated more than 5 years after NFP (mean, 6.7 years). Evaluation included parental interview, physical examination, upper gastrointestinal series, and esophageal pH monitoring. The mean age at the time of operation was 4.13 years. Fifty-seven percent of the patients had significant neurologic impairment, and 80% had at least one serious additional medical problem. Twenty-four percent of the children died during the period of follow-up--all but one death related to serious underlying medical problems. Of the 35 survivors, 26 (74.3%) have no symptoms; five (14.3%) have mild symptoms potentially referable to GER that necessitate little if any treatment; four (11.5%) have had symptomatic recurrence of GER necessitating repeat fundoplication. Three of these patients now have no symptoms. Forty-five percent of the patients had at least one postoperative complication. NFP provides efficacious, long-term treatment of GER in infants and children, with acceptable morbidity. Mortality in this group of children is related primarily to associated diseases rather than to GER.

Published scholarly activity pertaining to radiology education is relatively uncommon compared with an extensive clinical literature. To guide future radiology educational efforts in a time of changing priorities and practice patterns, the authors undertook an in-depth review and analysis of the existing radiology education literature covering the 20-year period from 1966 to 1986. A total of 194 articles was identified via a computerized literature search and manual cross-checking of cited references. Articles pertinent to medical student radiology education (36.6%) or radiology resident education (29.9%) predominated. The majority of published radiology education articles were editorials (35.5%) or expository in nature (49.5%). Surveys (5.1%) and experimental research (8.7%) comprised the balance. Although editorial opinions and personal reflections are important and valuable resources for radiology educators, a substantial lack of empirical research in radiology education exists. Additional knowledge in underdeveloped research areas is essential for future curriculum planning and development in radiology education.

Hepatoblastoma is the third most common intraabdominal malignant neoplasm in infants. Computed tomography of six patients with surgically proven hepatoblastoma was reviewed; abnormalities included large, diffuse, or multifocal liver masses with lower attenuation values than normal hepatic parenchyma after contrast enhancement. In three patients, areas of speckled or amorphous calcifications within the tumor were evident on CT, whereas calcification was present on conventional radiography in only one patient. In four of the six infants, CT demonstrated unresectable tumor by virtue of massive pansegmental involvement. Computed tomography is a useful tool for screening patients with suspected hepatoblastoma and for determining the anatomic extent of tumor and thus selecting a group of children for aggressive surgical excision.

Diagnostic radiology is expanding, playing an increasingly central role in patient care, which heightens the importance of radiology teaching in undergraduate medical education. This study examined the impact of increased structure and systematic evaluation on student performance in a radiology elective. The evaluation protocol included premultiple and postmultiple choice examinations (70 questions each), a film interpretation quiz (ten films, 20 questions), faculty assessment of a student oral case presentation, and student evaluations of the elective experience. The relationships among the evaluation techniques, as well as differences in class level and course ratings were also examined. Two different treatment groups were studied. Group 1 was given general objectives and information regarding availability of recommended resources, including self-learning materials for the elective, didactic seminars, and viewbox exposure. Group 2 was given specific written instructional objectives, a structured schedule for viewing the self-learning materials, and the same seminars and viewbox exposure. The statistically significant higher performance of the structured group suggests that medical students achieve the objectives of an elective better when learning activities are well defined, structured, and systematically evaluated. In addition, those students receiving the structured experience rated the radiology elective more favorably.

Objective tests for gastroesophageal reflux in children have shown only fair correlation with clinical symptoms. Thirty-four children referred to the pediatric surgery service for evaluation of gastroesophageal reflux had both 24-hour pH probe monitoring and standardized upper gastrointestinal examinations. A total of 16 children (47%) had documented significant or pathologic gastroesophageal reflux, 11 on pH monitors and 9 on contrast examinations. There were 4 in whom both tests were positive. None of the pH monitoring criteria correlated with the radiographic studies. The patient population documented by contrast study did not differ from the general test-positive population by age or associated clinical findings. The 2 studies probably measure different aspects of significant gastroesophageal reflux, are confirmatory and complementary, and must be correlated with the clinical symptoms.

The plain radiographs of 40 patients with intussusception were reviewed with special attention to diagnostic features previously reported in this condition. Sixty percent of the cases demonstrated a soft-tissue mass on the radiograph. However, fully one-half of all masses were seen only on a horizontal beam radiograph. The use of plain radiographs to exclude the diagnosis of intussusception is not advocated. Nevertheless, attention is drawn to the frequency of abnormal plain findings, especially a soft-tissue mass on the horizontal beam examination.

Birth injuries of the shoulder and proximal humerus of infants can be difficult to evaluate on plain radiographs because of lack of ossification in the proximal humeral epiphysis. We here describe arthrography of the infant shoulder and advocate it as a useful diagnostic procedure in the evaluation of humeral fractures and brachial palsies. Two infants with birth injuries of the shoulder are described. The value of dynamic fluoroscopic evaluation of the injured joint in conjunction with arthrography is illustrated in evaluation of a brachial plexus palsy.

The importance of evaluating medical student performance has been widely addressed in the medical education literature. Multiple-choice examinations are the preferred method of testing because they are easy to administer and score. Development of parallel or equivalent pre- and post-examinations provides objective information regarding actual knowledge gains by the students during the elective and points to strengths and weaknesses in the elective. This article provides information for developing the parallel multiple-choice questions for effective pre- and post-tests.