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Introduction: Novel dedicated extremity cone beam computed tomography (CBCT) devices, recently introduced to the market, raised attention as a possible alternative in advanced diagnostic pediatric trauma imaging, today usually performed by multidetector computed tomography (MDCT). This work aimed to compare image quality and radiation dose of CBCT and MDCT., Materials and Methods: Fifty-four CBCT-MDCT examination pairs, containing nine MDCTs acquired in parallel prospectively and 45 MDCTs matched in retrospect, were included in this study. Image quality was analyzed semi-objectively by measuring noise, contrast-to-noise ratio (CNR), and signal-to-noise ratios (SNR) and subjectively by performing image impression ratings. CT dose records were readout., Results: Image noise was significantly lower in CBCT compared with MDCT, both semi-objectively and subjectively (both p < 0.001). CNR and SNRs were also in favor of CBCT, though CBCT examinations exhibited significantly more beam hardening artifacts that diminished the advantages of the superior semi-objective image quality. These artifacts were believed to occur more often in children due to numerous bone-cartilage transitions in open growth plates and may have led to a better subjective diagnostic certainty rating (p = 0.001). Motion artifacts were infrequently, but exclusively observed in CBCT. CT dose index (CTDI vol ) was substantially lower in CBCT (p < 0.001)., Conclusion: Dedicated extremity CBCT could be an alternative low-dose modality in the diagnostic pathway of pediatric fractures. At lower doses compared with MDCT and commonly affected by beam hardening artifacts, semi-objective CBCT image quality parameters were generally better than in MDCT.

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic compromise, a life-threatening disorder. Traditionally, neonatal pneumothorax diagnosis has been based on clinical images, auscultation, transillumination, and chest X-ray findings. This approach may potentially lead to a delay in both diagnosis and treatment. The use of lung US in diagnosis of PTX together with US-guided thoracentesis results in earlier and more precise management. The recommendations presented in this publication are aimed at improving the application of lung US in guiding neonatal PTX diagnosis and management.

To obtain the highest diagnostic information with least side effects when performing thoracic CT angiography (CTA) is challenging in young children. The current study aims to compare three contrast agent (CA) injection protocols regarding image quality and CA characteristic: a standard CTA, a fixed-bolus delay protocol, and the "microbolus technique (MBT)" developed in our institution. Seventy chest CTA scans of patients (<2 years) were divided into three groups. MBT was applied in group I, the standard protocol in group II and a fixed bolus delay in group III. Objective image quality was assessed by measuring peak enhancement, image noise, signal-to-noise (SNR) and contrast-to-noise ratios (CNR). Two observers scored subjective image quality and artifacts. Significantly lower amounts of CA (mean ± SD) were used in the MBT group compared to Group II (9.0 ± 3.7 ml vs. 12.9 ± 4.5 ml). A lower, but still diagnostic (>400 HU) enhancement was registered in all major thoracic vessels in group I without significant differences regarding SNR and CNR in most regions (p < 0.05). The best scores for image quality and artifacts were reached in group I. All three chest CTA contrast injection protocols offered diagnostic vessel enhancement in young patients. MBT was associated with reduced image artifacts and less injected CA.

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° 185 of the Radiation Protection series. The purpose of this article is to introduce these guidelines to the wide community of paediatric radiologists.

Significant changes can be expected in modern pediatric radiology. New imaging techniques are progressively added to basic modalities like Xrays and ultrasound. This essay summarizes recent advances and technical innovations in pediatric radiology, which are supposed to gain further importance in the future. Thus, CT dose reduction techniques including artificial intelligence as well as advances in the fields of magnetic resonance and molecular imaging are presented. KEY POINTS:   · Technical innovations will lead to significant changes in pediatric radiology.. · CT dose reduction is crucial for pediatric patient collectives.. · New MR-techniques will lower the need for sedation and contrast media application.. · Functional MR-imaging might gain further importance in patients with chronic lung disease.. · Molecular imaging enables detection, characterization and quantification of molecular processes in tumors.. CITATION FORMAT: · Staatz G, Daldrup-Link HE, Herrmann J et al. From Xrays to PET/MR, and then? - Future imaging in pediatric radiology. Fortschr Röntgenstr 2019; 191: 357 - 366., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

The paper proposes a segmentation and classification technique for fracture detection in X-ray images. This novel rotation-invariant method introduces the concept of local entropy for de-noising and removing tissue from the analysed X-ray images, followed by an improved procedure for image segmentation and the detection of regions of interest. The proposed local Shannon entropy was calculated for each image pixel using a sliding 2D window. An initial image segmentation was performed on the entropy representation of the original image. Next, a graph theory-based technique was implemented for the purpose of removing false bone contours and improving the edge detection of long bones. Finally, the paper introduces a classification and localisation procedure for fracture detection by tracking the difference between the extracted contour and the estimation of an ideal healthy one. The proposed hybrid method excels at detecting small fractures (which are hard to detect visually by a radiologist) in the ulna and radius bones-common injuries in children. Therefore, it is imperative that a radiologist inspecting the X-ray image receives a warning from the computerised X-ray analysis system, in order to prevent false-negative diagnoses. The proposed method was applied to a data-set containing 860 X-ray images of child radius and ulna bones (642 fracture-free images and 218 images containing fractures). The obtained results showed the efficiency and robustness of the proposed approach, in terms of segmentation quality and classification accuracy and precision (up to 91.16 % and 86.22 % , respectively).

Ultrasound is a safe bedside imaging tool that obviates the use of ionizing radiation diagnostic procedures. Due to its convenience, the lung ultrasound has received increasing attention from neonatal physicians. Nevertheless, clear reference standards and guideline limits are needed for accurate application of this diagnostic modality. This document aims to summarize expert opinions and to provide precise guidance to help facilitate the use of the lung ultrasound in the diagnosis of neonatal lung diseases.

Objectives: To investigate diagnostic accuracy and radiation dose of high-pitch CT coronary artery calcium scoring (CACS) with tin filtration (Sn100kVp) versus standard 120kVp high-pitch acquisition., Methods: 78 patients (58% male, 61.5±9.1 years) were prospectively enrolled. Subjects underwent clinical 120kVp high-pitch CACS using third-generation dual-source CT followed by additional high-pitch Sn100kVp acquisition. Agatston scores, calcium volume scores, Agatston score categories, percentile-based risk categorization and radiation metrics were compared., Results: 61/78 patients showed coronary calcifications. Median Agatston scores were 34.9 [0.7-197.1] and 41.7 [0.7-207.2] and calcium volume scores were 34.1 [0.7-218.0] for Sn100kVp and 35.7 [1.1-221.0] for 120kVp acquisitions, respectively (both p<0.0001). Bland-Altman analysis revealed underestimated Agatston scores and calcium volume scores with Sn100kVp versus 120kVp acquisitions (mean difference: 16.4 and 11.5). However, Agatston score categories and percentile-based risk categories showed excellent agreement (ĸ=0.98 and ĸ=0.99). Image noise was 25.8±4.4HU and 16.6±2.9HU in Sn100kVp and 120kVp scans, respectively (p<0.0001). Dose-length-product was 9.9±4.8mGy*cm and 40.9±14.4mGy*cm with Sn100kVp and 120kVp scans, respectively (p<0.0001). This resulted in significant effective radiation dose reduction (0.13±0.07mSv vs. 0.57±0.2mSv, p<0.0001) for Sn100kVp acquisitions., Conclusion: CACS using high-pitch low-voltage tin-filtered acquisitions demonstrates excellent agreement in Agatston score and percentile-based cardiac risk categorization with standard 120kVp high-pitch acquisitions. Furthermore, radiation dose was significantly reduced by 78% while maintaining accurate risk prediction., Key Points: • Coronary artery calcium scoring with tin filtration reduces radiation dose by 78%. • There is excellent correlation between high-pitch Sn100kVp and standard 120kVp acquisitions. • Excellent agreement regarding Agatston score categories and percentile-based risk categorization was achieved. • No cardiac risk reclassifications were observed using Sn100kVp coronary artery calcium scoring.

Purpose: Presently, there is no publication combining clinical follow-up with magnetic resonance imaging (MRI) to determine possible post-traumatic alterations following paediatric intra-articular fractures of the medial malleolus. Therefore, the aims of this study were to retrospectively analyze a cohort of patients with Salter-Harris (SH) III and IV fractures of the medial malleolus and to evaluate their long-term outcome. MRI was used to assess possible changes of the articular surface that cannot be diagnosed on native radiographs., Patients and Methods: Fifty-four patients with SH III ( n = 38) or IV fractures ( n = 17) of the medial malleolus treated between 2001 and 2011 were invited for a follow-up examination. Clinical outcome was assessed with the Weber score and osteoarthritis with the Kellgren and Lawrence classification. MRI was rated by the Outerbridge classification. Correlations between the clinical and radiological outcomes were calculated., Results: Seventeen patients were recruited for long-term follow-up at a mean of 112 (range, 65-184) months. The Weber score was very good for 5 patients, good for 10 patients and poor for 2 patients; the Kellgren and Lawrence score revealed a favourable grade 0 in 15 patients and grade 1 in 2 patients. The MRI-based Outerbridge classification yielded grade 0 for 12 patients, grade 1 for 1 patient, grade 2 for 2 patients and grade 3 for 1 patient. The Outerbridge score significantly ( p < 0.05) correlated with the Weber score., Conclusion: This study shows excellent and good outcome of SH III and IV fractures of the medial malleolus. Worse clinical outcome correlated with post-traumatic changes of the articular cartilage seen on MRI.

The maturity level of the digital transformation in health care ecosystems is heavily depending on human factors. Primarily the digital intelligence of the human beings - e.g. medical or nursing staff - should be taken seriously in the transformation processes. To derive sustainable strategies in a holistic manner an innovative, multi-dimensionaland human centred socio-economic capability model had to be developed and applied. By the use of our model health care ecosystems can be analysed, scored and benchmarked successfully. Furthermore, each ecosystems' digital intelligence based on their employees can be derived holistically from our four scoring scopes.

Diagnostic imaging plays a significant role in both the diagnosis and treatment of complications of pneumonia in children and chest radiography is the imaging modality of choice. Computed tomography (CT) on the other hand, is not currently a first-line imaging tool for children with suspected uncomplicated community-acquired pneumonia and is largely reserved for when complications of pneumonia are suspected or there is difficulty in differentiating pneumonia from other pathology. This review outlines the situations where CT needs to be considered in children with pneumonia, describes the imaging features of the parenchymal and pleural complications of pneumonia, discusses how CT may have a wider role in developing countries where human immunodeficiency virus (HIV) and tuberculosis are prevalent, makes note of the role of CT scanning for identifying missed foreign body aspiration and, lastly, addresses radiation concerns.

Objectives: To evaluate and compare surface doses of a cone beam computed tomography (CBCT) and a multidetector computed tomography (MDCT) device in pediatric ankle and wrist phantoms., Methods: Thermoluminescent dosimeters (TLD) were used to measure and compare surface doses between CBCT and MDCT in a left ankle and a right wrist pediatric phantom. In both modalities adapted pediatric dose protocols were utilized to achieve realistic imaging conditions. All measurements were repeated three times to prove test-retest reliability. Additionally, objective and subjective image quality parameters were assessed., Results: Average surface doses were 3.8 ±2.1 mGy for the ankle, and 2.2 ±1.3 mGy for the wrist in CBCT. The corresponding surface doses in optimized MDCT were 4.5 ±1.3 mGy for the ankle, and 3.4 ±0.7 mGy for the wrist. Overall, mean surface dose was significantly lower in CBCT (3.0 ±1.9 mGy vs. 3.9 ±1.2 mGy, p<0.001). Subjectively rated general image quality was not significantly different between the study protocols (p = 0.421), whereas objectively measured image quality parameters were in favor of CBCT (p<0.001)., Conclusions: Adapted extremity CBCT imaging protocols have the potential to fall below optimized pediatric ankle and wrist MDCT doses at comparable image qualities. These possible dose savings warrant further development and research in pediatric extremity CBCT applications.

Introduction: Pediatric cerebral hypoxic-ischemic injury frequently results in severe neurological outcome. Imaging with diffusion-weighted magnetic resonance imaging (DWi) demonstrates that the acute cerebral injury and apparent diffusion coefficient (ADC) allow the assessment of the severity of brain damage. The main objective was to examine if spatial distribution of reductions in ADC values is associated with clinical outcome in drowned children., Methods: This is a retrospective study of 7 children (7 examinations) suffering from a hypoxic-ischemic event who underwent DWi. Seven subjects with normal DWi served as controls. The mean patient age was 4.88 ± 2.93 years and the male-to-female ratio was 5:2. The neurological outcome was divided into 2 categories: 4 children with Apallic syndrome and 3 deaths. We analysed the differences between the drowned children and the control group regarding clinical data, DWi abnormalities, and ADC values., Results: The ADC values in the occipital and parietal grey matter were significantly different between the drowned children (765.14 ± 65.47 vs 920.95 ± 69.62; P = .003) and the control group (670.82 ± 233.99 vs 900.66 ± 92.72; P = .005). The ADC showed low values in the precentral area also (P = .044)., Conclusion: The ADC reduction may be useful to predict the poor outcome in drowned children and can be a valuable tool for clinical assessment., (Copyright © 2016 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.)

The aim of this study was to assess the image quality (IQ) and radiation dose of third-generation dual-source computed tomography (CT) coronary angiography (cCTA) in comparison with 64-slice single-source CT. This retrospective study included 140 patients (73 men, mean age 62 ± 11 years) with low-to-intermediate probability of coronary artery disease who underwent either third-generation dual-source cCTA using prospectively electrocardiography-triggered high-pitch spiral acquisition (n = 70) (group 1) or retrospective electrocardiography-gated cCTA on a 64-slice CT system (n = 70) (group 2). Contrast-to-noise and signal-to-noise ratios were measured within the aorta and coronary arteries. Subjective IQ was assessed using a 5-point Likert scale. Effective dose was estimated using specific conversion factors. The contrast-to-noise ratio of group 1 was significantly higher than group 2 at all levels (all p <0.001). Signal-to-noise ratio of group 1 was also significantly higher than group 2 (p <0.05), except for the distal left circumflex artery. Subjective IQ for group 1 was rated significantly better than for group 2 (median score [25th to 75th percentile]: 1 [1 to 2] vs 2 [2 to 3]; p <0.001). The median effective dose was 1.55 mSv (1.09 to 1.88) in group 1 versus 12.29 mSv (11.63 to 14.36) in group 2 (p <0.001) which corresponds to a mean radiation dose reduction of 87.4%. In conclusion, implementation of third-generation dual-source CT system for cCTA leads to improved IQ with significant radiation dose savings., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Determination of skeletal development is a key pillar in forensic age estimation of living persons. Radiological assessment of hand bone age is widely used until the age of about 17-18 years, applying visual grading techniques to hand radiographs. This study investigated whether Greulich-Pyle (GP) and Tanner-Whitehouse (TW2) grading can be equally used for magnetic resonance imaging (MRI) data, which would offer the huge benefit of avoiding ionizing radiation. In 18 subjects aged between 7 and 17 years a radiograph and an MRI scan of the hand were performed. Epiphyseal ossification of hand bones was rated by two blinded radiologists with both GP and TW2. Correlation between hand MRIs and radiographs was analyzed by linear regression and inter-observer agreement was assessed. Correlation between age estimates from MRI and radiographs was high for both GP (r(2)=0.98) and TW2 (r(2)=0.93). MRI showed a tendency to estimate age slightly lower for 14-18 year-olds, which would be favorable regarding majority age determination in case this result could be reproduced using a currently not existing reference estimation method based on MRI data. Inter-observer agreement was similar for GP in radiographs and MRI, while for TW2, agreement in MRI was lower than in radiographs. In spite of limitations regarding sample size and recruited subjects, our results indicate that the use of GP and TW2 on MRI data offers the possibility of hand bone age estimation without the need for ionizing radiation., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Aim: Food intake and acutely decompensated cardiac failure may impair liver stiffness estimations, mainly because these methods are influenced by liver blood flow variation encountered in these conditions. It is well known that also during physical effort liver blood flow changes, due to the redistribution of blood flow mainly to the skeletal muscles. The aim of this study is to assess the change of liver shear- wave velocities immediately after cessation of an acute physical effort. A secondary aim was to find the proper timing for accurate liver stiffness estimation after physical exhaustion., Material and Methods: Liver shear-wave velocities were measured using virtual touch quantification (VTQ) in seven apparently healthy volunteers, in fasting conditions. All subjects underwent a complete abdominal ultrasound study, including the liver VTQ. Then, all subjects performed a spiroergometry and thereafter, another series of three liver shear-wave velocity measurements were performed: immediately after spiroergometry, five min, and ten min after spiroergometry, respectively., Results: Before spiroergoemetry, the mean liver shear-wave velocity was 1.05+/-0.12 m/sec. Immediately after spiroergometry, mean liver shear-wave velocities increased significantly, measuring 1.34+/-0.16 m/sec (p <0.01). The mean liver shear-wave velocities at five and ten minutes after exhausting were 1.23+/-0.14 m/sec and 1.05+/-0.11 m/sec respectively., Conclusions: Liver stiffness estimation using VTQ was influenced by acute physical exercise in our study group. Despite the small number of subjects, the preliminary results show that if patients had done physical effort before VTQ elastography, they should rest at least ten minutes before reliable liver stiffness estimations can be performed.

Objective: To determine the difference in vessel measurements, signal-to-noise ratio (SNR), and voxel size between contrast-enhanced and noncontrast magnetic resonance techniques in patients with coarctation of the aorta (CoA)., Materials and Methods: In 39 patients, vessel size, SNR, and voxel size were compared in cine magnetic resonance imaging (MRI), gadolinium-free magnetic resonance angiography (Gd-free MRA), and contrast-enhanced MRA (ce-MRA)., Results: There was no significant difference in measurement and SNR, but there was a significant difference in voxel size (P<.001)., Conclusions: Our results show that, in CoA patients, monitoring of vessel size using cine MRI and Gd-free MRA is equivalent to ce-MRA while being less invasive., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: Accurate collimation helps to reduce unnecessary irradiation and improves radiographic image quality, which is especially important in the radiosensitive paediatric population. For AP/PA chest radiographs in children, a minimal field size (MinFS) from "just above the lung apices" to "T12/L1" with age-dependent tolerance is suggested by the 1996 European Commission (EC) guidelines, which were examined qualitatively and quantitatively at a paediatric radiology division., Methods: Five hundred ninety-eight unprocessed chest X-rays (45% boys, 55% girls; mean age 3.9 years, range 0-18 years) were analysed with a self-developed tool. Qualitative standards were assessed based on the EC guidelines, as well as the overexposed field size and needlessly irradiated tissue compared to the MinFS., Results: While qualitative guideline recommendations were satisfied, mean overexposure of +45.1 ± 18.9% (range +10.2% to +107.9%) and tissue overexposure of +33.3 ± 13.3% were found. Only 4% (26/598) of the examined X-rays completely fulfilled the EC guidelines., Conclusions: This study presents a new chest radiography quality control tool which allows assessment of field sizes, distances, overexposures and quality parameters based on the EC guidelines. Utilising this tool, we detected inadequate field sizes, inspiration depths, and patient positioning. Furthermore, some debatable EC guideline aspects were revealed., Key Points: • European Guidelines on X-ray quality recommend exposed field sizes for common examinations. • The major failing in paediatric radiographic imaging techniques is inappropriate field size. • Optimal handling of radiographic units can reduce radiation exposure to paediatric patients. • Constant quality control helps ensure optimal chest radiographic image acquisition in children.

Purpose: Different femoral origins for both the medial collateral ligament (MCL) and the lateral collateral ligament (LCL) have been reported in the growing skeleton (epiphyseal and metaphyseal). Knowledge about the exact attachment sites is mandatory for anatomically correct reconstruction. This study assesses the femoral origins of the knee collateral ligaments in skeletally immature individuals using magnetic resonance imaging (MRI)., Methods: MRIs of 336 knee joints (median age 15 years (range 2-18 years), m = 209 and f = 127) were retrospectively analysed to assess the distances between the femoral origins of the MCL and LCL to the distal femoral growth plate. In 175 patients, the body sizes were additionally retrieved from medical records., Results: Both MCL and LCL ligament origins were invariably located on the epiphysis. Mean MCL origin-growth plate distance was 9.6 mm (SD 2.1 mm; range 2.2-13.6 mm) in boys and 8.6 mm (SD 1.5 mm; range 3.4-12.0 mm) in girls. Mean LCL origin-growth plate distance was 9.3 mm (SD 1.8 mm; range 4.3-13.0 mm) in boys and 8.2 mm (SD 1.5 mm; range 3.4-11.8 mm) in girls. The distance between the growth plate and both collateral ligaments as well as the length of the LCL correlated positively with patients' age and body size (MCL R(2) = 0.673 and 0.556, LCL R (2) = 0.734 and 0.645, LCL length R(2) = 0.589 and 0.741; all p < 0.001)., Conclusions: During growth, the femoral origins of the MCL and the LCL are constantly located on the distal femoral epiphysis. There is a linear increase in the distances from the ligaments' origins to the growth plate according to age and body size. This new information may be of clinical importance for reconstructive surgery of the knee's collateral ligaments.

Introduction: The congenital combination of duodenal atresia and choledochal cyst has only been reported in a few children. None of these patients had an intrapancreatic choledochocele causing persistent hyperbilirubinemia in the newborn period., Presentation of Case: A female newborn presented with duodenal atresia and received a duodeno-duodenostomy on day two of life. The postoperative course was uneventful except for progressive hyperbilirubinemia and elevation of liver enzymes. No evidence for surgical obstruction, malformations of the hepatobiliary system, or infectious diseases were found. At three months of age and persistent hyperbilirubinemia an intrapancreatic choledochocele type III according to Todani was confirmed by ultrasound and MRI. Upon laparotomy no lesion was visible or palpable within the pancreas. Even after duodenotomy distally of the duodeno-duodenostomy only a normal papilla Vateri could be identified. Transduodenal ultrasound allowed for localization and saline distension to outline the borders of the choledochocele. A transduodenal marsupialization provided immediate biliary drainage and postoperatively bilirubin levels returned to normal limits., Discussion: We present a case of duodenal atresia and choledochocele requiring surgical treatment in the neonatal period. Transduodenal marsupialization prompted adequate biliary drainage without inflicting the potential complications of biliary and pancreatic diversion at this early age. A life-long endoscopic observation seems mandatory to examine the potential risk of metaplasia of the cystic remnant., Conclusion: Early transduodenal marsupialization of an intrapancreatic choledochocele in a case of duodenal atresia is safe and feasible to prevent secondary liver cirrhosis., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Vascular anomalies include a heterogeneous group of disorders that are categorized as vascular tumors or vascular malformations. Treatment options include resection, embolization, laser therapy, and sclerotherapy or medical treatment such as propranolol, steroids, interferon, and cytostatic chemotherapy. Mammalian target of rapamycin seems to play a key role in the signal pathway of angiogenesis and subsequently in the development of vascular anomalies. Recently, the successful use of sirolimus has been reported in children with lymphatic malformations and kaposiform hemangioendotheliomas. We report on six patients with different vascular anomalies (kaposiform hemangioendothelioma n = 2, combined lymphatico-venous malformation n = 2, pulmonary lymphangiectasia n = 1, and orbital lymphatic malformation n = 1) who were treated with peroral sirolimus. Three of the children initially presented with a Kasabach-Merrit phenomenon. Median duration of treatment was 10 months; two children are still on treatment. Three children each achieved complete and partial remission. Kasabach-Merrit phenomenon resolved within 1 month in all patients. Treatment with sirolimus was tolerated well; only mild reversible leukopenia was observed., Conclusion: Sirolimus proved to be effective in children with complicated lymphatic or lymphatico-venous malformations and kaposiform hemangioendotheliomas. Treatment was tolerated well with acceptable side effects. The optimum length of treatment and possible long-term side effects have to be evaluated., What Is Known: • Vascular anomalies including vascular tumors and vascular malformations may lead to life-threatening conditions.• Some patients are refractory to established treatment and/or are not available for local invasive procedures., What Is New: • We reviewed the literature focusing treatment of vascular anomalies inc hildren and adolescents.• Our data support recent studies that sirolimus is an effective treatment option in patients with complicated vascular tumors andmalformations

Background: Lung failure after acute lung injury remains a challenge in different clinical settings. Various interventions for restoration of gas exchange have been investigated. Recruitment of collapsed alveoli by positive end expiratory pressure (PEEP) titration and optimization of ventilation-perfusion ratio by prone positioning have been extensively described in animal and clinical trials. This animal study was conducted to investigate the effects of PEEP and positioning by means of advanced respiratory monitoring including gas exchange, respiratory mechanics, volumetric capnography and electrical impedance tomography., Methods: After induction of acute lung injury by oleic acid and lung lavage, 12 domestic pigs were studied in randomly assigned supine or prone position during a PEEP titration trial with maximal PEEP of 30 mbar., Results: Induction of lung injury resulted in significant deterioration of oxygenation [partial pressure of arterial oxygen/inspiratory fraction of oxygen (PaO2/FiO2): p = 0.002] and ventilation [partial pressure of arterial carbon dioxide (PaCO2): p = 0.002] and elevated alveolar dead-space ratios (Valv/Vte: p = 0.003) in both groups. Differences in the prone and the supine group were significant for PaCO2 at incremental PEEP 10 and 20 and at decremental PEEP 20 (20d) and 10 (10d), for PaO2/FiO2 at PEEP 10 and 10d and for alveolar dead space at PEEP 10d. Electrical impedance tomography revealed homogenous ventilation distribution in prone position during PEEP 20, 30 and 20d., Conclusions: Prone position leads to improved oxygenation and ventilation parameters in a lung injury model. Respiratory monitoring with measurement of alveolar dead space and electrical impedance tomography may visualize optimized ventilation in a PEEP titration trial.

Objectives: Right ventricular (RV) function represents a prognostic marker in patients with corrected congenital heart disease. In up to 80 % of these patients, right branch bundle block (RBBB) exists and leads to asynchronous ventricular contraction. The aim of this retrospective study was to evaluate the change of RV performance parameters considering delayed RV end-systolic contraction., Methods: RV volumes of 33 patients were assessed twice: 1) not taking account of RBBB (group I), and 2) considering RBBB (group II). According to the RV ejection fraction (EF) for both groups, RV function was classified in different categories (>50 % = normal, 40-50 % = mildly-, 30-40 % = moderately-, <30 % = severely-reduced)., Results: The mean time difference between maximal systolic contraction of the septum and RV free wall was 90.7 ms ± 42.6. Consequently, RV end-systolic volume was significantly decreased in group II (p < 0.001). Accordingly, RV stroke volume and RV EF were significantly higher in group II (p < 0.001). There was also a significant change in the assessment of RV function (p < 0.02)., Conclusions: RBBB induced delayed RV contraction can be detected at CMR. Ignoring the RV physiology in RBBB patients leads to a statistically significant underscoring of RV performance parameters., Key Points: • Right branch bundle block leads to an asynchronous ventricular contraction • In CMR, a delayed right ventricular contraction due to RBBB can be detected • Ignoring RV physiology in RBBB patients leads to underscoring of RV performance.

Introduction: Previous studies suggested that effects of the surfactant administration in preterm intants with respiratory distress syndrome cannot be followed by lung ultrasound (L-US)., Objective: The aim of the paper is to evaluate the surfactant replacement therapy effects using a new, proposed grading system for L-US findings., Methods: We report the series of 12 preterm infants with clinical and radiographic signs of respiratory distress syndrome, in whom L-US examinations were performed prior to, and within the first 24 hours after surfactant administration. To evaluate the surfactant replacement therapy effects, we proposed a new grading system (1 to 6) for L-US findings at each examined lung area, based on the presence of normal finding, the amount of B-lines and subpleural consolidations., Results: All preterm infants had an improvement of L-US findings from one to four grades observed within the first 24 hours after surfactant administration, which has not been previously reported. The improvement of L-US findings was most commonly observed in anterior lung areas., Conclusion: L-US might enable an early detection of the surfactant replacement therapy effects. Further prospective studies are necessary to define the role of L-US in this field.

Disability is a condition or function that is judged to be significantly impairing relative to the usual standard of an individual or group. The spectrum of musculoskeletal disabilities in children is immense and varied. Musculoskeletal disabilities are congenital or acquired; they affect a child partially or generally and can occur as a permanent or transient disability.Although injuries still represent a major concern for children and adolescents worldwide, studies focusing on injuries in physically disabled children are lacking. To detect musculoskeletal injuries, radiographs are frequently required. In disabled children the radiographic findings can detect the skeletal injury but also can present special radiographic findings of the underlying disease.This review offers an overview of different musculoskeletal disabilities and their related injuries as well as characteristic findings on radiographs., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

An avulsion fracture occurs when the growth plate of an apophysis is injured due to a sudden and forceful contraction of the attaching musculotendinous unit. Usually it is adolescents who sustain these injuries, and a significant male preponderance has been found. Even though apophyseal fractures have been described in a variety of locations, the apophyses of the pelvis and hip are more prone to these injuries. Due to their rarity, avulsion fractures of the pelvis are often misdiagnosed. Additionally, patients can present late, and other pathologies are suspected initially. In most acute cases conservative treatment is successful. However, some cases require operative intervention. To plan an optimal treatment regimen, it is important to be familiar with the typical pathomechanism, the typical clinical findings, and the most commonly applied imaging modalities of these injures. The present review analyzes the currently available literature on the most frequently encountered apophyseal injuries of the pelvis in adolescent patients. Some case examples are also presented., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

In the last few decades, sports injuries in pediatric and adolescent athletes have increased dramatically, with ∼ 38 million young athletes participating in organized sports annually in the United States. Starting at the age of 2 years, an increase of the incidence of knee injuries until adulthood with a peak at 6 and at 13 years of age has been observed. Due to a physiologic laxity of the ligaments, ligament injuries are uncommon in these patients, but they are getting more frequent. In the growing knee, open physis are the points of minor resistance. Therefore apophyseal injuries of the pediatric knee are more common. Diagnostics and treatment of ligament injuries of the pediatric and adolescent knees are challenging. This article presents an overview of ligament injuries in the pediatric and adolescent knee, their diagnostic work-up, and their treatment in the growing patient., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

In many countries pediatric radiology is responsible for imaging of patients ranging from premature babies to 19-year-olds, thus meaning a weight range from less than 500 g to sometimes much more than 100 kg. Children are not small adults and many differences exist when comparing them to adults. Therefore pediatric radiologists face a 4-D problem: the three dimensions in space as well as time, which can be summarized as maturation. Due to this multidimensionality experience exchange, knowledge transfer and teamwork is mandatory. Research consortia represent a useful approach. According the author's experience in setting up and running international, inter-institutional academic networks, this article describes pathways and barriers of such cooperations, which can be divided into external (institutional), internal (departmental) and organizational and by the research fellows themselves.

Congenital heart defects (CHD) occur in less than one percent of all newborns. Echocardiography represents the imaging modality of choice for morphological and functional assessment. In childhood the different CHD types can be diagnosed trustfully and can be performed bedside. In the follow-up of CHD cross sectional imaging plays an important role and therefore it is essential for the radiologist to know the features, challenges and limitations of echocardiography. Within this review article a systematic approach for morphological and functional assessment of the heart will is given along with representative example images. In addition, typical echocardiographic findings in common CHD is presented. In older children, adolescents and grown-ups with CHD (GUCH) echocardiography suffers from limitations - partially due to skeletal deformations and lung emphysema. In particular right ventricular function assessment is not always possible by echocardiography. Therefore strengths and limitations of echocardiography will be discussed the role of cardiac magnetic resonance imaging (cMRI) and cardiac computed tomography (cCT) emphasized., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Aim of this prospective study was to evaluate longitudinal systolic left ventricular (LV)-right ventricular (RV) interaction using M-mode compared to magnetic resonance imaging (MRI) data in 146 pediatric and adults with operated tetralogy of Fallot (TOF). We determined biventricular measures of longitudinal M-mode echocardiography [i.e., tricuspid annular plane systolic excursion (TAPSE); the mitral annular plane systolic excursion (MAPSE)] compared to longitudinal function parameters using MRI. M-mode data were compared to established normal z-score values. We found a good correlation between MAPSE and LVEF values (r = 0.788; p < 0.001). Correlations between MRI derived MAPSE and M-mode guided MAPSE (r = 0.879, p < 0.001), and between MRI derived TAPSE and M-mode guided TAPSE were significant (r = 0.780, p < 0.001). While the LVEF was normal in patients with a normal RVEF, the LVEF was decreased in patients with significantly reduced RVEF. Patients with a significantly dilated RV (RVEDVi > 150 ml/m(2)) showed a significantly reduced mean MAPSE of 1.30 ± 0.26 cm. LV longitudinal function decreases below -2 SD of normal MAPSE z-score values after a mean of 22 postoperative years. Our data confirm progressive adverse RV-LV interaction in the long-term follow-up of TOF. We show that simple M-mode measurement of the longitudinal LV function (i.e. MAPSE) is a sufficient surrogate for estimation of LVEF. Therefore determination of the MAPSE is a helpful additional tool for LV systolic function assessment late after TOF repair.

Traumatic brain injury (TBI) is the consequence of external forces that traumatically injure the brain. Closed head injury is common in children and is estimated to result in 650,000 to 1 million emergency department visits annually with approximately 7,400 deaths in the United States. Mild TBI is the most common form of closed head injury and constitutes 80 to 90% of all the TBI. Cranial computed tomography (cCT) is performed in usually more than 50% of the patients, thus, resulting in an extreme overuse with the inherent risk for inducing malignancies. The purpose of this article is to review current approaches, recommendations, and guidelines on pediatric head trauma with special emphasis on cCT. Therefore, after an overview on classification and TBI scores, diagnostic imaging, and management rules for clinical important TBI, as well as own experience including remarks on cCT technique will be discussed., (Georg Thieme Verlag KG Stuttgart · New York.)

Today CT represents about 10% of all ionizing radiation based imaging modalities, but delivers more than 50% of the total collective dose for diagnostic imaging. Compared to adults the radiation sensitivity of children is considerable higher than in adults. Additionally children differ from adults--factors like body size, mass, density, proportions as well as metabolism have to be mentioned. Children grow and mature--all this components have to be mapped in examination protocols by Pediatric Radiology. The total dose of a CT examination depends on the settings of several factors such as the scout view, the scan length, exposure settings including automated exposure control, type of scanning (single slice, helical, volume mode), slice thickness, pitch values as well as on image reconstruction parameters. If intravenous contrast media injection is needed bolus tracking or timing represents another source of radiation. The aim of the paper is to present and discuss all aspects of defining a pediatric age and query adapted CT protocol particularly concerning all dose relevant factors in pediatric CT and their adjustment in children. Moreover hints are given concerning optimization of intravenous contrast media injection as well as special (low dose) imaging protocols., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Introduction: To report the preliminary results of contrast-enhanced perfusion multi-detector CT for diagnoses of perfusion disturbances in children with clinical suspicion of stroke., Patients and Methods: Within the last two years emergency perfusion CT was performed in ten children (age: 8-17 years, male:female=3:7) for assessment of suspected childhood stroke. These intracranial perfusion CT, intracranial CT-digital subtraction angiography (CT-DSA) and extracranial CT-angiography (CTA) studies were retrospectively reviewed and compared with MRI, follow-up CT, catheter angiography and final clinical diagnosis. The total dose length product (DLP) for the entire examination was recorded. The image quality of perfusion CT-maps, CT-DSA and CTA were evaluated with a subjective three-point scale ranging from very good to non-diagnostic image quality rating perfusion disturbance, intracranial peripheral vessel depiction, and motion- or streak artifacts., Results: In nine of ten children perfusion CT showed no false positive or false negative results. In one of ten children suffering from migraine focal hypo-perfusion was read as perfusion impairment potentially indicating early stroke, but MRI and MRA follow-up were negative. Overall, perfusion-CT with CT-DSA was rated very good in 80% of cases for the detection of perfusion disturbances and vessel anatomy., Conclusions: In comparison to standard CT, contrast-enhanced perfusion CT improves CTs' diagnostic capability in the emergency examination of children with a strong suspicion of ischemic cerebral infarction., (Crown Copyright © 2011. Published by Elsevier Ireland Ltd. All rights reserved.)

The introduction of helical computer tomography (CT) and further progress to multi-slice CT enabled new applications. Most recent developments like the 320-row detector facilitate volume CT, which avoids the over-beaming effect of helical scanning. The 320-row multi-slice detector CT (MDCT) is based on a 16cm detector; a special acquisition mode allows reconstructing 640 slices from these 16cm. The shortest tube rotation time is in cardiac mode 0.35s, otherwise 0.4s and 0.5s used. At 0.5s the machine already reaches the maximum numbers of sub-second projections. Scan modes can be volume, helical and single slice mode. For image acquisition all dose savings technologies like variable tube position for scano-view, active collimation, automated exposure control, bolus and ECG tracking are available. Additionally special acquisition and post-processing techniques like head and body perfusion CT are ready for use on the console. For image reconstruction properties like filtered back projection as well as the latest development of iterative algorithms, an appropriate number of kernels and multi-planar reconstruction in all directions from the volume data at every increment are available. Volume CT allows sub second scanning of 16cm z-coverage which, however, makes administration of intravenous contrast medium to "hit or miss" event. The aim of this paper is to present the application of volume CT to body scanning in children. Representative examples of neck, cardiac and skeletal investigations are given., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

During the last years the indications of Cardiac Magnetic Resonance Imaging (CMRI) have been continuously expanded. However, the acceptance of the method by cardiologists and radiologists does not correlate with respect to the diagnostic potential. Several factors, such as expensive equipment, relatively long examination times, high technical know how and lack of remuneration, limit the application of CMRI in everyday clinical practice. Furthermore, doctors tend to apply more conventional, well established diagnostic procedures, the access to the method is still limited and there exist difficulties in the interdisciplinary collaboration. The interdisciplinary Austrian approach to Cardiac Imaging is aimed to improve the aforementioned problems and to support the implementation of CMRI in the diagnostic tree of cardiac diseases thus enabling a cost efficient management of patients in cardiology., (© Georg Thieme Verlag KG Stuttgart · New York.)

Biodegradable Mg alloys are of great interest for osteosynthetic applications because they do not require surgical removal after they have served their purpose. In this study, fast-degrading ZX50 Mg-based implants were surface-treated by micro-arc oxidation (MAO), to alter the initial degradation, and implanted along with untreated ZX50 controls in the femoral legs of 20 male Sprague-Dawley rats. Their degradation was monitored by microfocus computed tomography (μCT) over a total observation period of 24weeks, and histological analysis was performed after 4, 12 and 24weeks. While the MAO-treated samples showed almost no corrosion in the first week, they revealed an accelerated degradation rate after the third week, even faster than that of the untreated ZX50 implants. This increase in degradation rate can be explained by an increase in the surface-area-to-volume ratio of MAO-treated implants, which degrade inhomogeneously via localized corrosion attacks. The histological analyses show that the initially improved corrosion resistance of the MAO implants has a positive effect on bone and tissue response: The reduced hydrogen evolution (due to reduced corrosion) makes possible increased osteoblast apposition from the very beginning, thus generating a stable bone-implant interface. As such, MAO treatment appears to be very interesting for osteosynthetic implant applications, as it delays implant degradation immediately after implantation, enhances fracture stabilization, minimizes the burden on the postoperatively irritated surrounding tissue and generates good bone-implant connections, followed by accelerated degradation in the later stage of bone healing., (Copyright © 2012 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Tricuspid annular peak systolic velocity (S'), as an echocardiographic index to assess right ventricular (RV) systolic function, has not been investigated thoroughly in children and young adults with repaired tetralogy of Fallot (TOF) and pulmonary artery hypertension secondary to congenital heart disease (PAH-CHD)., Methods: S' values in patients with TOF (n = 183) and PAH-CHD (n = 55) were compared with those in normal subjects. S' values were compared with RV ejection fraction and RV end-diastolic volume index (RVEDVi) determined by magnetic resonance imaging., Results: S' values became significantly reduced in PAH-CHD patients after 10.4 years of age and after 13.6 years of age in patients with TOF compared with the lower boundary of the ±2-SD interval of normal subjects. Significant positive correlations between S' and RV ejection fraction were seen in patients with TOF (r = 0.66, P < .001) and those with PAH-CHD (r = 0.82, P < .001). Significant negative correlations between S' and RVEDVi were also seen in patients with repaired TOF (r = -0.29, P = .002) and in those with PAH-CHD (r = -0.59, P < .001)., Conclusions: Although initially preserved, in this prospective study, impaired S' values with increasing age were found in patients with repaired TOF and PAH-CHD. Persistent pressure overload in patients with PAH-CHD as well as volume overload in those with repaired TOF might lead to systolic RV functional impairment and increased RVEDVi. The validity of S' data was supported by magnetic resonance imaging data (RVEDVi and RV ejection fraction)., (Copyright © 2012 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

Objective:   The tricuspid annular plane systolic excursion (TAPSE), as echocardiographic index to assess right ventricular (RV) systolic function, has not been investigated thoroughly in children and young adults with tetralogy of Fallot (TOF) and pulmonary artery hypertension secondary to congenital heart disease (PAH-CHD)., Patients:   TAPSE values of 49 patients with PAH-CHD and 156 patients with TOF were compared with age-matched normal subjects. TAPSE values were also compared with RV ejection fraction (RVEF) and RV indexed end-diastolic volume (RVEDVi) determined by magnetic resonance imaging in PAH-CHD and TOF patients., Results:   Patients with a PAH-CHD showed a positive correlation between TAPSE with RVEF (r= 0.81; P < 0.001) and a negative correlation between TAPSE with RVEDVi (r=-0.67; P < 0.001). Similarly, in our TOF patients, a positive correlation between TAPSE with RVEF (r= 0.65; P < 0.001) and a negative correlation between TAPSE with RVEDVi (r=-0.42; P < 0.001) was seen., Conclusions:   Significant pressure overload in PAH-CHD patients and volume overload in TOF patients lead to a decreased systolic RV function, determined by TAPSE and magnetic resonance imaging and to increased RVEDVi values, determined by MRI, with time., (© 2012 Wiley Periodicals, Inc.)

Purpose: Liver segmentation is an important prerequisite for the assessment of liver cancer treatment options like tumor resection, image-guided radiation therapy (IGRT), radiofrequency ablation, etc. The purpose of this work was to evaluate a new approach for liver segmentation., Methods: A graph cuts segmentation method was combined with a three-dimensional virtual reality based segmentation refinement approach. The developed interactive segmentation system allowed the user to manipulate volume chunks and∕or surfaces instead of 2D contours in cross-sectional images (i.e, slice-by-slice). The method was evaluated on twenty routinely acquired portal-phase contrast enhanced multislice computed tomography (CT) data sets. An independent reference was generated by utilizing a currently clinically utilized slice-by-slice segmentation method. After 1 h of introduction to the developed segmentation system, three experts were asked to segment all twenty data sets with the proposed method., Results: Compared to the independent standard, the relative volumetric segmentation overlap error averaged over all three experts and all twenty data sets was 3.74%. Liver segmentation required on average 16 min of user interaction per case. The calculated relative volumetric overlap errors were not found to be significantly different [analysis of variance (ANOVA) test, p = 0.82] between experts who utilized the proposed 3D system. In contrast, the time required by each expert for segmentation was found to be significantly different (ANOVA test, p = 0.0009). Major differences between generated segmentations and independent references were observed in areas were vessels enter or leave the liver and no accepted criteria for defining liver boundaries exist. In comparison, slice-by-slice based generation of the independent standard utilizing a live wire tool took 70.1 min on average. A standard 2D segmentation refinement approach applied to all twenty data sets required on average 38.2 min of user interaction and resulted in statistically not significantly different segmentation error indices (ANOVA test, significance level of 0.05)., Conclusions: All three experts were able to produce liver segmentations with low error rates. User interaction time savings of up to 71% compared to a 2D refinement approach demonstrate the utility and potential of our approach. The system offers a range of different tools to manipulate segmentation results, and some users might benefit from a longer learning phase to develop efficient segmentation refinement strategies. The presented approach represents a generally applicable segmentation approach that can be applied to many medical image segmentation problems.

Objectives/hypothesis: Laryngeal framework surgery requires a good understanding of the biomechanics of the cricoarytenoid (CA) joint, the precise function of which is still only poorly understood. The aim of the study was (1) to show that, by superimposing two or more three-dimensional (3D) images, we can visualize the exact position of the arytenoid cartilages within the larynx at different phases of their movement; and (2) to demonstrate that it is possible to analyze the arytenoid cartilage movements mathematically with the help of vector analysis., Study Design: In vitro cadaver study., Methods: Twenty fresh and intact cadaver larynges were scanned by high-resolution computerized tomography with the arytenoid cartilages in "respiratory" position and in "phonatory" position. The two positions were superimposed and rendered in 3D with MIMICS (Materialise Interactive Medical Image Control System, Leuven, Belgium). The spatial trajectory of the arytenoid cartilage movements was calculated with vector analysis., Results: The movement from the "respiratory" to the "phonatory" position has three components: (1) an inward rocking action around the longitudinal CA joint; (2) a forward sliding movement along the longitudinal axis of the CA joint; and (3) an inward rotation around a virtual axis that runs perpendicular to the CA joint axis., Conclusions: Superimposing 3D images of the larynx with the help of the software package MIMICS allows us to visualize and to analyze mathematically the trajectory of the arytenoid cartilage. The arytenoid cartilages rock inward, slide forward, and rotate inward when they move from the "respiratory" to the "phonatory" position., (Copyright © 2011 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

In this prospective clinical study, we have compared 17 patients with tetralogy of Fallot (TOF) who received mechanical valve substitutes and had concomitant additional right ventricular (RV) volume reduction plasty (aRVVRP, group 1) with seven patients who underwent solitary re-do pulmonary valve replacements (PVR, group 2). All patients were evaluated by magnetic resonance imaging (MRI) two months pre- and four to six months postoperatively for assessment of ventricular geometry. At a mean follow-up of 31.9 months, the RV ejection fraction improved from 39.1 to 48.3% in group 1 vs. from 40.1 to 49% in group 2 (P<0.001), and RV indexed end-diastolic volume decreased from 174.8 to 119.9 ml/m(2) (group 1) vs. from 142.4 to 99.6 ml/m(2) (group 2, P<0.001). Indexed RV myocardial mass decreased from 52.3 to 38.7 g/m(2) in group 1 vs. 46.9 to 39.1 g/m(2) in group 2 (P<0.001). Follow-up revealed no mortality and distinct improvements in RV geometry, recommending mechanical prostheses as suitable alternatives for PVR. Selection criteria for this solution should consider multiple previous reoperations and assured patient compliance in terms of current anticoagulant usage and self-testing. aRVVRP could serve as an adjunct in re-dos of TOF surgery indicated by RV outflow tract dysfunction due to akinetic fibrous areas.

Objective: The tricuspid annular plane systolic excursion (TAPSE) as an echocardiographic index to assess right ventricular (RV) systolic function has not been investigated thoroughly in pediatric patients and adolescents with tetralogy of Fallot (TOF) after surgical repair., Methods: TAPSE was determined in 131 patients with TOF and 252 age-matched normal subjects. TAPSE values were compared with RV ejection fraction (EF) and indexed RV end-diastolic volume (EDVi) determined by magnetic resonance imaging in a cross-sectional study design. TAPSE values were also correlated to QRS duration (QRSd) determined by electrocardiogram., Results: The TAPSE values showed a positive correlation with age in normal subjects. The TAPSE was not decreased in infants and young children with TOF compared with normal subjects. A significant reduction of TAPSE values with increasing time after surgical repair was observed. After a mean of 7 years after surgical repair, the TAPSE values become significantly reduced compared with age-matched controls, being below the lower bound of -2 standard deviations. A positive correlation between TAPSE with RVEF and a negative correlation between TAPSE with RVEDVi were observed. A significant positive correlation was found between QRSd and RVEDVi, and a significant negative correlation was found between QRSd and RVEF., Conclusion: Although TAPSE was initially preserved, impaired TAPSE was observed with increasing time after surgical repair in pediatric patients with TOF., (Copyright © 2011 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

Aims: To determine whether TAPSE is an accurate marker of right ventricular (RV) systolic function in patients with tetralogy of Fallot (TOF) and patients with small atrial septal defect (ASD). The tricuspid annular plane systolic excursion (TAPSE) values were measured and compared with RV ejection fraction (EF)., Methods and Results: A prospective study was conducted in pediatric and adolescent patients with TOF (n = 110), with isolated small secundum ASD (n = 200), and age-matched patients with normally structured heart. The TAPSE values showed a positive correlation with age in both patients with ASD and normal subjects. No significant difference of TAPSE values was seen in control subjects and age-matched ASD patients. The TAPSE was not decreased compared to normal subjects in eight infant TOF patients before corrective surgery. A reduction of TAPSE values with increasing time interval following corrective surgery was seen. After a mean of 7 years TAPSE values become significantly reduced compared to age-matched controls, being below the lower bound of the -2 SD., Conclusion: In ASD patients the systolic RV function was preserved over the pediatric age group when compared to normal subjects. In contrast, although initially preserved, we found an impaired TAPSE with increasing postoperative period in our TOF patients.

Responsiveness to food cues, especially those associated with high-calorie nutrients may be a factor underlying obesity. An increased motivational potency of foods appears to be mediated in part by the hippocampus. To clarify this, we investigated by means of 3-T magnetic resonance imaging (MRI) the activation of the hippocampus and associated brain structures in response to pictures of high-calorie and low-calorie foods in 12 obese and 12 normal-weight adolescents. To investigate the relationship between neuronal activation patterns (e.g., hippocampus) to the caloric content of food images and plasma insulin levels, we performed a multiple regression analysis. Interestingly, a significant positive correlation between fasting plasma levels of insulin, waist circumference, and right hippocampal activation was seen after stimulation with high-caloric food images. BMI values did not correlate significantly with the hippocampal activation. On the other hand, we found a significant negative correlation in response to high-caloric food images and the plasma levels of insulin in the medial right gyrus frontalis superior and in the left thalamus. In summary, our data show that insulin is importantly involved in the central regulation of food intake. The significant positive relationship between hippocampal activation after stimulation with high-caloric food images, plasma insulin levels, and waist circumference suggests a permissive role of insulin signaling pathways in the hippocampal control of eating behavior. Interestingly, only the waist circumference, as a main indicator of abdominal obesity, correlated significantly with the hippocampal activation patterns, and not the BMI.