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This report describes a case of mesenchymal cystic hamartoma of the liver with diagnostic imaging work-up using only ultrasound and MRI. We demonstrate an approach starting from the pediatrician’s physical exam culminating in surgical resection and pathologic confirmation with an emphasis on MR imaging.

The imaging and procedural recommendations as elaborated by the ESPR Paediatric Uroradiology Taskforce and the ESUR Paediatric Uroradiology Working Group were presented and discussed at the first uroradiology panel held during the ESPR Annual Congress in Barcelona in 2007. These recommendations were published in this journal [1] and have gained wide acceptance throughout Europe and beyond. A few imaging algorithms have been newly proposed by group members, partially completing the existing recommendations, and further important recommendations have been added. The imaging algorithm for prenatally diagnosed hydronephrosis (HN) has been supplemented by a statement on imaging neonates with fetally diagnosed high-grade HN and suspected posterior urethral valves (PUV). Recommendations referring to imaging children with suspected obstructive uropathy, the imaging algorithm for childhood haematuria, and the imaging algorithm for children with suspected urolithiasis have been formulated. The aim was again to reduce invasive and unnecessary investigations wherever possible without running the risk of missing potentially damaging conditions and increasing patient morbidity. As with the existing algorithms, the new proposals are consensus-based recommendations since little Pediatr Radiol (2009) 39:891–898 DOI 10.1007/s00247-009-1233-6

Background: Though Onchodermatitis was a public health problem in Ghana, sowda had never been reported there. Sowda patients have been isolated from and forgotten by society. Thus, it was crucial to find out whether sowda was present in Ghana and, if so, to treat these patients with ivermectin and monitor the outcome. Methods: An active search for patients with sowda was carried out in 16 villages around Hohoe, Volta Region, Ghana. The patients underwent clinical examinations including photographic documentation of their skin lesions. Skin snips were taken and a local Mazzotti test was performed. Blood was drawn for eosinophil count. A single oral dose of ivermectin was administered. Adverse events were monitored over 3 days. Follow-up was carried out one month later and the above examinations repeated. Results: A total of 18 patients, 6 males and 12 females, with an age range from 7-60 years were diagnosed to have sowda. The skin lesions were asymmetric (94%) and involved predominantly the gluteal region (89%) and lower extremities (94%). The severely pruritic skin lesions included papules, pustules, lichenification and hyperpigmentation. Onchocercomata were found only in 28% of the patients and 56% had a positive skin snip for microfilaria (median 0.77 mf/mg). A topical Mazzotti test was positive in all cases. The ivermectin administration was associated only with minor and transient adverse events in the first 72 hours. The follow-up one month later revealed significant improvement of the itching and skin lesions. The parasitological tests turned out negative as well. Conclusion: Sowda is present in Ghana. A single oral dose of ivermectin results in significant clinical and parasitological improvements., Ethiopian Journal of Health and Biomedical Sciences, Vol. 1 No. 1 (2008): ETHIOPIAN JOURNAL OF HEALTH AND BIOMEDICAL SCIENCES

One week after a Ladd procedure, a 21-day-old infant was noted to have an enlarging and tender left hemiscrotum (Fig. 1), with fever and elevated white blood cell count. Sonography (Fig. 2) demonstrated a heterogeneously echogenic and avascular mass occupying the hemiscrotum, with wall thickening (double-headed arrow) showing hyperemia (arrow). A normal testis was not seen, and the processus vaginalis was not patent. The spermatic cord was not twisted. The right testis was normal (arrowhead). Emergency exploration revealed a large amount of purulent material under pressure, which was drained. The testis was adherent to the scrotal wall and was viable, and the spermatic cord had no twist. Cultures demonstrated Bacteroides fragilis. Scrotal abscess is rare in the pediatric population. In most of the reported cases [1, 2], patients had recently undergone laparotomy or laparoscopy. The differential diagnosis includes missed torsion, testicular rupture from trauma, and neoplasm. In institutions where surgical

BACKGROUND: Voiding urosonography with harmonic imaging (VUS HI) has been introduced as a sensitive and radiation-free imaging method for the diagnosis and follow-up of vesicoureteral reflux (VUR) in children. OBJECTIVE: The purpose of this study was to evaluate the sensitivity of VUS HI using a second-generation US contrast agent compared to standard voiding cystourethrography (VCUG). MATERIALS AND METHODS: A total of 228 children with 463 kidney-ureter units (KUUs) underwent two cycles of VUS HI and two cycles of VCUG at the same session. VUS HI was performed after intravesical administration of 1 ml of a second-generation US contrast agent (sulphur-hexafluoride gas microbubbles, SonoVue, Bracco, Italy). For statistical analysis we used McNemar's test, Student's t-test and k coefficient tests. RESULTS: VUR was shown in 161/463 (34.7%) KUUs, 57 by both methods, 90 only by VUS, and 14 only by VCUG. Concordance in findings regarding the presence or absence of VUR was found in 359/463 (77.5%) KUUs (k=0.40). The difference in the detection rate of reflux between the two methods was significant (P

Magnetic resonance enterography with oral contrast administration using fast T2-weighted and fat saturated, contrast-enhanced T1-weighted sequences is the most common technique for bowel evaluation. The main indication for bowel MR imaging in children has been evaluation of inflammatory bowel diseases. A less common application is appendicitis. Other potential applications include evaluation of vascular malformations and transplanted bowel.

Whole-body MRI (WBMRI) is a novel technique that makes imaging of the whole patient in a manner similar to scintigraphy or positron emission tomography (PET) possible. Unlike the latter two methods, it is without exposure to radiation and thus gaining increasing importance and application in pediatrics. With the introduction of a moving tabletop, sequential movement of the patient through the magnet has become possible with automatic direct realignment of the images after acquisition. The common scan plane is coronal with additional planes being added depending on the indication. WBMRI is targeted for maximum coverage of the body within the shortest possible time using the minimum number of sequences. The evaluation of the bone marrow has been the primary indication thus inversion recovery sequences like STIR or TIRM are mostly used with the T1-weighted sequence being added variably. For correct evaluation of the bone marrow in the pediatric age group understanding normal pattern of marrow transformation is essential. The primary role of WBMRI has been in oncology for the detection of tumor spread and also for the follow-up and evaluation of complications. The initial comparative studies of WBMRI with scintigraphy and PET in children have shown the high diagnostic potential of WBMRI. Emerging potential applications of WBMRI include the evaluation for osteonecrosis, chronic multifocal recurrent osteomyelitis, myopathies, and generalized vascular malformations. Future use of WBMRI may incorporate non-accidental trauma, virtual autopsy, body fat mapping and diffusion-weighted imaging.

The efficiency of ultrasonography (US) for the diagnosis and clinical characterization of onchocerciasis was evaluated. US was performed on 120 probands in Liberia. Ninety-two patients had generalized onchocerciasis, 21 patients suffered from the chronic hyperreactive form of onchocerciasis (sowda), and 7 probands served as controls. Patients were examined by US with linear (7.5 MHz and 5 MHz) and sector (3.5 MHz) scanners. US results were evaluated by examination of extirpated nodules. The US structure of nodules revealed a typical pattern consisting of a homogeneous echogenicity with small echodense particles and a lateral acoustic shadow, and differentiation from lymph nodes, lipoma, or fibroma was achieved. Within the onchocercomata, calcifications or fluid were identified. Regarding the estimation of the worm burden, it is important to note that in 24 patients, additional nodules not previously palpated were found by US. Also, the number of worm centers in palpable conglomerate nodules were determined more exactly by US than by palpation. In 4 of 16 sowda patients, impalpable nodules were found by US. In 13 patients with positive microfilaria counts, no nodules could be detected. The highly characteristic ultrasonographical pattern of onchocercomata may serve as a basis for further US investigations in onchocerciasis.

We report a 12-year-old girl with a long history of constant urinary dribbling and apparently only a left kidney. Using a multimodality approach involving the fusion of MR urography and (99m)Tc-dimercaptosuccinic acid (DMSA) SPECT datasets, it was finally possible to exactly localize the very small dystopic, dysplastic right kidney and its ectopic ureter draining into the vagina.

Chronic recurrent multifocal osteomyelitis is the most severe form of chronic non-bacterial osteomyelitis and presents with clinical variability. This Case Study highlights the need for a multi-disciplinary approach for diagnosis and therapy of patients. Background Chronic recurrent multifocal osteomyelitis (CRMO) is the most severe form of chronic nonbacterial osteomyelitis. In children and adolescents, chronic nonbacterial osteomyelitis predominantly affects the metaphyses of the long bones, but lesions can occur at any site in the skeleton. Other organs (the skin, eyes, gastrointestinal tract and lungs) can also be affected. Clinical diagnosis is often difficult because the symptoms and course of disease vary significantly. We present a 10-year-old girl diagnosed with CRMO involving several vertebrae, the femur and the metatarsus. Investigations Physical examination, abdominal ultra sonography, conventional X-ray, MRI, technetium bone scan, esophagogastroduodenoscopy, colonoscopy, tests for HLA-B27 and thiopurine methyltransferase, polymerase chain reaction and thoracic vertebral bone biopsies. Diagnosis CRMO and Crohn's disease. Management The patient's condition improved whilst being treated with NSAIDs for 3 months; however, the patient had an allergic skin reaction to this therapy. Treatment was switched to sulfasalazine, accompanied by 3 weeks of therapy using oral prednisone, but sulfasalazine was discontinued 2 months later because the patient exhibited a minor elevation in the levels of liver enzymes. The patient was free of musculoskeletal symptoms for 6 months, at which time she started to complain again about pain in her back and bowel. Multimodal therapy, consisting of mesasalazine, corticosteroids (budesonide) and azathioprine, induced clinical remission of Crohn's disease.

The Klippel–Trenaunay Syndrome (KTS) is defined as a triad of cutaneous capillary malformations, venous varicosities, bone and soft tissue hemi-hypertrophy. The urinary tract is involved in up to 10%. We report the clinical presentation and surgical management of a 9-year-old boy with extensive lympho-venous malformations of the bladder which led to massive recurrent gross hematuria.

In der neonatalen Medizin ist eine respiratorische Anpassungsstorung, insbesondere bei Fruhgeborenen, ein haufiges Problem. Bei der Ursache der respiratorischen Anpassungsstorung stehen die nicht chirurgischen Ursachen im Vordergrund. Die haufigsten sind: Atemnotsyndrom, Mekoniumaspiration, perinatale Pneumonie und transitorische Neugeborenentachypnoe. Die chirurgischen Ursachen kommen seltener vor, aber deren Erkennung in der Bildgebung ist von hoher Wichtigkeit. Hierzu zahlen Zwerchfellhernien und die zystisch-adenomatoide Malformationen. Bei der diagnostischen Bildgebung ist die Rontgendiagnostik des Thorax das Hauptstandbein. Eine Kenntnis des normalen Rontgenthoraxbefundes des Neugeborenen ist erforderlich, um eine richtige Bildinterpretation durchzufuhren. Eine entscheidende und weitere Voraussetzung zur richtigen Stellung einer Differenzialdiagnose ist eine aktuelle ausfuhrliche Anamnese. Eine qualitativ gute Diagnostik kann nur erzielt werden mit einer intensiven gemeinsamen Besprechung von (Kinder-)Radiologen und betreuenden Kinderarzten (Neonatologen). Lernziele: 1. Erkennung der Rontgenthoraxmerkmale der wichtigsten, nicht chirurgischen Ursachen der Respirationsanpassungsstorung im Neugeborenenalter. 2. Erkennung der Rontgenthoraxmerkmale der wichtigsten chirurgischen Ursachen der Respirationsanpassungsstorung im Neugeborenenalter. 3. Erkennung der Differenzierungsmerkmale in der Rontgenthoraxdiagnostik der verschiedenen Ursachen der respiratorischen Anpassungsstorung im Neugeborenenalter. Korrespondierender Autor: Darge K Institut fur Rontgendiagnostik, Uniklinik Wurzburg, Abt. fur Padiatrische Radiologie, Josef-Schneider-Str. 2/D31, 97080, Wurzburg E-Mail: darge@roentgen.uni-wuerzburg.de

In children, diagnostic imaging for vesicoureteral reflux (VUR) encompasses both radiologic and sonographic modalities. The former comprises voiding cystourethrography (VCUG), the most widespread method for examination for reflux, and radionuclide cystography (RNC). In RNC the radiation exposure is significantly less than in VCUG with continuous fluoroscopy, but the anatomic details depicted are much inferior. With the introduction of pulsed fluoroscopy, the radiation exposure of VCUG has been markedly curtailed. VCUG is the first imaging choice for the urethra. The sonographic diagnosis of VUR with the intravesical administration of an ultrasound (US) contrast agent-voiding urosonography (VUS)-is being used increasingly in the routine diagnostic imaging work-up of reflux. Various sonographic reflux examination methods had been tried in the past. The real breakthrough came with the availability of stabilized US contrast media. Further impetus came with the introduction of harmonic US imaging. The recent release of a second generation US contrast medium promises to make a further positive impact on VUS. The diagnostic accuracy of contrast-enhanced VUS has been found to be comparable to radiologic methods. VUS is primarily performed in follow-up studies and as the primary reflux examination modality in girls.

In human alveolar echinococcosis (AE), benzimidazoles are given throughout life because they are only parasitostatic. It has been a longstanding goal to limit treatment, and recent reports suggest that, in selected cases, benzimidazoles may be parasitocidal. Previously, we showed that positron -emission tomography (PET) using [(18)F]fluoro-deoxyglucose discriminates active from inactive lesions in AE. We have now performed a 3-year prospective study in 23 patients and conducted a structured treatment interruption in those without signs of PET activity. Disease progression was further assessed by ultrasound, computerized tomography, laboratory parameters, and clinical examination. We found PET-negative lesions in 15 of 23 patients and benzimidazoles were discontinued in these patients. After 18 months, patients were reevaluated, and, of the 15 initially PET-negative patients, 8 showed either new activity on PET (n = 6) or signs of clinical progression (n = 2). Reinitiation of benzimidazoles halted parasite growth again. No further progression was detected after 36 months. PET had a sensitivity of 91% for the detection of active lesions. In conclusion, despite successful suppression of metabolic activity, in most cases benzimidazoles do not kill the parasite. PET is a reliable tool for assessing metabolic activity and for timely detection of relapses. Neither duration of treatment, kind of treatment, lesion size, calcifications, or regressive changes reliably indicate parasite death. We discourage the discontinuation of benzimidazoles in inoperable AE even after many years of treatment. However, patients with a poor compliance of benzimidazole intake or patients suffering from side effects to benzimidazoles might be assessed for PET negativity. If permanent discontinuation of benzimidazoles is attempted, the course of disease should be followed by PET.

The diagnostic imaging modalities for vesicoureteral reflux in children comprise both radiologic and sonographic methods. The radiologic methods are voiding cystourethrography and radionuclide cystography. Voiding cystourethrography is the commonest imaging modality for reflux. With the introduction of pulsed fluoroscopy the radiation exposure of this examination is significantly curtailed. It is the imaging of first choice of the urethra. Various sonographic methods of reflux examination had been tried in the past. The real breakthrough came with the availability of stabilized US contrast media. The diagnostic accuracy of contrast-enhanced voiding urosonography has been found to be comparable to the radiologic methods. With the emergence of harmonic imaging the potential for significant improvement of the sonographic method has been achieved. Voiding urosonography is primarily performed in follow-up studies and as the first reflux examination in girls.

To assess combined static-dynamic magnetic resonance (MR) urography in the evaluation of congenital urinary tract dilatation in infants and children.Sixty-two patients with urinary tract dilatation underwent prospective examination with combined static-dynamic MR urography. A combination examination involved use of a static T2-weighted three-dimensional inversion-recovery fast spin-echo sequence and a dynamic T1-weighted two-dimensional fast field-echo sequence with gadopentetate dimeglumine-DTPA and furosemide application. Twelve additional patients underwent examination with only static MR urography. Thus, both image quality and morphologic features were assessed in 74 patients with the use of MR urography. The results were compared with those of ultrasonography and, when available, conventional urography or surgery. In 62 patients, the dynamic sequence was used to calculate split renal function from renograms generated from parenchymal regions of interest and to assess urinary excretion from whole-kidney renograms. Results were compared with those of diuretic renal scintigraphy (DRS) for split function (Spearman rank correlation coefficient) and urinary excretion (kappa coefficient).Stenoses at the ureteropelvic (n = 33) and ureterovesical (n = 31) junctions and within the ureter (n = 3) and nonstenotic dilatation (n = 23) were clearly depicted, while the normal urinary tract (n = 51) was depicted in its entirety in 47 of 51 examinations. Image quality was considered good or excellent in 95% of the kidney-ureter units. For split renal function, dynamic MR urography and DRS showed significant correlation (r = 0.92, P.001). For urinary excretion, MR urography and DRS showed strong agreement (kappa = 0.67), with concordant classification of urinary excretion in 59 (81%) of 73 abnormal kidney-ureter units and in all 47 (100%) normal kidney-ureter units.Combined static-dynamic MR urography provides high-quality depiction of the urinary tract in infants and children, while allowing accurate determination of single-kidney function and reliable evaluation of urinary excretion.

(1) Elimination of exposure to ionizing radiation (CT enterography:2–6× higher than small bowel follow-through [SBFT]; repeated studies raise lifetime cumulative dose) (2) Diagnostic accuracy is relatively high (sensitivity: 74– 88%; specificity 78–93%) (3) Early changes easier to appreciate (mild focal bowel wall thickening and hyperemia) (4) Rapid and effective complement to clinical decisionmaking (positive predictive value 99.5%: positive blood work-up with bowel wall thickening) (5) Preparation for US not obligatory (avoid oral contrasts and enteric tubes) (6) Fastest imaging modality (15 min) (7) Widespread availability of US scanners and easier accessibility (“while-the-clinician-is-waiting” and same-day studies)

Purpose To evaluate the diagnostic performance and safety of intravesical administration of a-second-generation ultrasound contrast-agent (UCA) for the diagnosis of vesicoureteric reflux (VUR) in children. Methods and materials 1350 children (587 boys/763 girls, mean-age 2.6y, range 15d-17y) with 2720 pelvi-ureter-units, underwent contrast-enhanced voiding urosonography (ceVUS) to rule out VUR and urethral pathology. A second-generation UCA (SonoVue ® , Bracco, Milan) was administered intravesically through 5–8F feeding-tube at a dose of 0.5 ml/bladder filling. Possible adverse-events were monitored during the examination and followed-up for 7 days after the ceVUS by phone-calls. Urine analysis and culture were performed 3–5 d before ceVUS in all children and 24–48 h in any patient reported with adverse-events. Results VUR was detected in 450/1350(33%) patients (162 boys/288 girls). This was in 653 pelvi-ureter-units (reflux-grade distribution: grade I = 1, grade II = 276, grade III = 266, grade IV = 100, grade V = 10). The urethra was normal in all children. Mean duration of examination was 14 ± 7 min, including urethral imaging. Minor adverse-events were reported in 45(3.3%) children. These included dysuria (n = 39), abdominal pain (n = 2), increased frequency of micturition (n = 1), vomiting (n = 1), perineal irritation (n = 1), and urinary-tract-infection after ceVUS (n = 1). The onset of adverse-events were subacute in 92% and delayed in 8% and were self-limited non-requiring hospitalisation. Conclusions There were no serious adverse-events with intravesical use of SonoVue ® . Only a few minor adverse-events were reported during ceVUS most likely due to catheterization process. Thus ceVUS with intravesical administration of a second generation UCA (SonoVue ® ) for VUR and urethral pathology detection is a safe and reliable diagnostic procedure in children.

Purpose The diagnostic accuracy of contrast-enhanced voiding urosonography (ce-VUS) in diagnosing vesicoureteral reflux (VUR) is high compared with voiding cystourethrography. However, its reliability has not been yet adequately evaluated. The purpose of this study is to assess the reliability of ce-VUS in VUR detection and grading by estimating the inter- and intra-observer agreement of two radiologists. Patients and methods Two hundred ten children (86 boys/124 girls, mean-age 2.7y) with 421 pelvi-ureteral-units underwent ce-VUS examination with a second-generation contrast-agent to detect possible (180) or follow-up known (30) VUR. The video-clips of all ce-VUS examinations were twice independently assessed by two paediatric radiologists 4–6 weeks apart. The inter- and intra-observer agreement was estimated by kappa statistic. Results The inter- and intra-observer agreement of both radiologists regarding the presence or grading of VUR was perfect (k=0.90–0.94). There were only two disagreements regarding the presence of VUR (grade I and II false-negative and false-positive respectively). There were 5 cases of disagreement in VUR grading: three cases of VUR grade II-III and two cases grade III-IV. VUR was detected in 123(29%) pelvi-ureteral-units of 87(41.4%) children and it was more common in completely duplicated ureters (6/7) than in single ones (p = 0.03). The rate of VUR was independent of sex/age/presence of hydronephrosis (p > 0.05). Conclusions The reliability of ce-VUS in VUR detection and grading is high. VUS with a second generation ultrasound contrast-agent could be used as a radiation-free alternative.

Four major factors necessitate the support for and advancement of pediatric imaging in Ethiopia. First, the demographics are loud and clear: 44% of the population is younger than 14 years and 60% is younger than 20 years. At the largest general referral hospital of the country, Tikur Anbessa Hospital in Addis Ababa, 47% of the patient population is children. Second, higher education in Ethiopia has witnessed historical undertakings through the establishment of more than 20 universities that have high need of well-trained professionals. Third, various medical specialties have already started or are in the process of establishing subspecialties like pediatric surgery, pediatric oncology and neonatology— specialties that necessitate dedicated pediatric imaging support. However, there is not a single pediatric radiologist in the country, which has an estimated population of 93 million. Fourth, there is a significant discrepancy with regard to the availability of radiologic equipment between the public and private sectors. The Faculty of Medicine of the Addis Ababa University, in Tikur Anbessa Hospital, which is a public entity, runs the only radiology residency program in the country. Currently, there is no MRI scanner at this facility. Thus graduates face major challenges when they go out to work in better-equipped public or private facilities. The Children’s Hospital of Philadelphia (CHOP) Pediatric Radiology Outreach Program in Ethiopia has made the commitment to lead the efforts to support pediatric radiology education in Ethiopia. Building on the training of local radiology academic faculty members through a pediatric radiology fellowship is likely to have a sustainable positive outcome. Thus efforts to implement pediatric radiology education need to consider residents, faculty members and practicing radiologists. The educational support is multifaceted and includes regular pediatric radiology visiting professorships, tele-radiology for teaching, provision of teaching cases and recorded pediatric radiology lectures, organization of an observership at our institution (supported through the Soroosh Mahboubi International Fund for Higher Education) and research mentorship. We conduct an annual pediatric radiology continuing education course in collaboration with the Radiological Society of Ethiopia to develop pediatric imaging in the country by focusing on practicing radiologists. We emphasize how to optimize and broaden the spectrum of ultrasound studies in children. There is scarcity of CTandMRI scanners in the teaching hospitals. In the private sector these modalities are more prevalent. We specifically address pediatric CT and MRI techniques, indications and interpretations to help close the existing knowledge gap. In conclusion, the vision of the CHOP international outreach program is that there will be increasing and appropriate emphasis of pediatric imaging in the radiology residency, supported by the first batch of graduating local pediatric radiologists.

10053 Background: Serum creatinine (sCr) is an imprecise renal function marker in children. Serum cystatin C (cysC) is a more sensitive marker to estimate glomerular filtration rate (GFR). Function...

The aim of this study was to determine in children the prevalence rate and to describe the sonographic morphology of the valves in the internal jugular veins. One hundred twenty children (60 boys and 60 girls; mean age ± SD 10 ± 4 years, age range 3–20 years) were recruited for the study. They underwent sonographic examination of both internal jugular veins. The number of valvular cusps, the length of the cusps and exact site of origin were recorded. In 96 % of the children a valve was found in one or both internal jugular veins. Within this group a valve was detected unilaterally in 26 % and bilaterally in 74 % of the cases. Ultrasound morphological and morphometric analysis was carried out in a total of 239 internal jugular veins; 200 (84 %) veins were found to have valves. The origin of the cusps was located at a mean distance of 9 mm (0–26 mm) proximal to the confluence of the subclavian and internal jugular veins into the brachiocephalic vein. A valve in the distal part of the internal jugular vein is a very common finding with characteristic features on US.

The primary diagnostic procedure for evaluation of vesicoureteral reflux (VUR) in children is fluoroscopic voiding cystourethrography (VCUG). Radionuclide cystography (RNC) is an alternative, sensitive method for diagnosing VUR, but it lacks spatial resolution. Over the past 2 decades, in an effort to eliminate the radiation exposure intrinsic to these methods, many endeavors had been made to use ultrasonography (US) for the diagnosis of VUR. The various attempts that have been undertaken are reviewed. The real breakthrough in the US diagnostic option has come with the availability of stable US contrast media that can be administered intravesically. Comparison between contrast-enhanced sonographic reflux examination (voiding urosonography, VUS) and VCUG/RNC has revealed the high concordance between these imaging modalities regarding the diagnosis or exclusion of VUR. Imaging of the urethra still necessitates the performance of VCUG. VUS is used in routine imaging primarily for follow-up cases, girls, and screening high-risk groups for reflux. Using these selection criteria, the number of VCUG investigations can be reduced by over half and, consequently, a significant reduction of radiation exposure in children can be achieved. With the emergence of harmonic US imaging, the sonographic reflux examination will gain further diagnostic potential and widespread application. The whole field of sonographic diagnosis of reflux is still in the process of rapid development.

Objective. To compare the morphological and functional US appearance of the pylorus in healthy infants with those suffering from idiopathic hypertrophic pyloric stenosis (IHPS) in order to determine the pathological limits and to find out the most discriminating morphometric parameter. Materials and methods. The pylorus of 84 asymptomatic infants was prospectively evaluated with respect to morphology (pyloric length, pyloric diameter, muscle thickness and pyloric volume) and function (gastric peristalsis and emptying, pyloric opening and the fluid passage). Results were compared with 85 patients with proven IHPS. Results. In every normal infant we observed frequent pyloric opening with passage of gastric contents and quick gastric emptying. All infants with proven IHPS presented with a permanently closed pylorus and exaggerated, retrograde gastric peristalsis. For each of the four parameters, highly significant differences (P < 0.0001) were found between the control and IHPS groups. Pathological limits were 3 mm for muscle thickness (accuracy 100 %), 15 mm for pyloric length (accuracy 94 %), 11 mm for pyloric diameter (accuracy 92 %) and 12 ml for pyloric volume (accuracy 96 %). Conclusions. Evaluation of pyloric function plays an important role in the diagnosis of IHPS. The morphometric parameters are highly accurate in differentiating IHPS from a normal pylorus, muscle thickness being the most discriminating parameter.

Objectives. To describe the imaging features of nephroblastomatosis with US, CT and MR, to point out characteristics of differentiation between nephrogenic rests (NR) and Wilms' tumour (WT) and to determine the most appropriate imaging modality. Materials and methods. We reviewed the US, CT and MR images of 29 cases of histopathologically confirmed nephroblastomatosis sent to our department for reference evaluation (German nephroblastoma study). The series included 17 kidneys with NR, 6 kidneys with WT and 32 kidneys with both NR and WT. Results. NR presented as multinodular, peripheral, cortical lesions, the diffuse form of distribution being less common. Foci were homogeneous and of low echogenicity, density or signal intensity. The lesions were most clearly depicted with contrast-enhanced CT and T1-weighted (T1-W) MR images. Lesions smaller than 1 cm were rarely identified by US. The most reliable criterion to differentiate NR from WT was their homogeneity. Conclusions. Contrast-enhanced CT and T1-W MR images are of similar potential and superior to US in the diagnosis of nephroblastomatosis. Due to the significant radiation dose of serial CT, MR imaging should be the method of choice wherever it is available. The cost-effectiveness and availability of US makes it ideal for serial follow-up of known lesions.

Proteus syndrome is a rare congenital hamartomatous syndrome. We report on the clinical and radiological appearances of a boy in order to illustrate the typical signs which include subcutaneous masses, in mild forms partial gigantism of hands and feet, hemihypertrophy, and bony abnormalities. We discuss how to make the definitive diagnosis on the basis of using a known rating scale, important aspects of differential diagnosis and clinical features, and diagnostic management.

The role of macrophages in the killing and elimination of microfilariae (mf) was studied immunohistologically in 14 lymph nodes from 10 patients with generalized onchocerciasis 20-68 h after treatment with a single oral dose of 150 microg/kg ivermectin. Mf with signs of damage at light microscopical level were surrounded by a cellular infiltrate comprising macrophages, eosinophils and neutrophils, whereas light microscopically intact mf mostly showed no cellular reaction. Resident mature macrophages expressing the CD 68 epitope usually neither migrated nor attached to damaged mf, especially on the first and second day after ivermectin treatment. However, many young invading macrophages labelled for the L1 protein (antibodies 27 E 10, MAC 387, S 36.48 and 8.5C2) were found within the cellular infiltrate around damaged mf and in adherence to the mf in all lymph nodes after ivermectin treatment. Free L1 protein was observed on the cuticle of the mf. The attacking macrophages contained increased amounts of the enzymes lysozyme, alpha-1-antichymotrypsin and alpha-1-antitrypsin compared to resident macrophages. Free enzymes were found on the cuticle of the mf and around them, indicating a role of these enzymes in the inflammatory reaction to the parasites. The attacking macrophages were strongly labelled for human HLA-DR and they showed further an increased expression of the complement receptors CR1 (CD 35) for C3b and CR3 (CD 11b) for C3 bi in comparison to resident macrophages and thus were considered as activated macrophages. Rarely fragments of mf were seen within multinuclear macrophages. We conclude that young activated macrophages play a major role in the elimination of mf transported to the regional lymph nodes after ivermectin treatment. The immunohistological findings are in accordance with the assumption that these activated macrophages together with granulocytes contribute to the killing of the damaged mf. They also help to limit the damage of the host tissue by release of alpha-1-antichymotrypsin and alpha-1-antitrypsin.

PURPOSE: To assess the diagnostic value of spinal ultrasonography (US) in pediatric patients. MATERIALS AND METHODS: The findings on 38 spinal US scans in 30 patients (mean age, 5.5 months) were compared with those of corresponding magnetic resonance (MR) images. RESULTS: MR imaging showed a normal spinal canal in 14 of 38 examinations, a congenital anomaly in 22, and a neoplasm in two. In 32 of 38 examinations, US allowed exactly the same diagnosis as MR imaging. In five examinations, US depicted the main abnormality, but MR imaging revealed additional findings. In one examination, no consensus was achieved. Whenever US scans were normal, MR images also did not depict any spinal disorder. In all 24 examinations with abnormal MR findings, US enabled detection of the abnormality. CONCLUSION: Spinal US seems to represent a valuable diagnostic tool for congenital anomalies of the lower spine in infants and is recommended as the primary imaging modality in those patients.

Clinical trials of macrofilaricidal drugs against Onchocerca volvulus are impeded due to the lack of means for assessing in vivo drug-induced changes in the onchocercomas. The application of ultrasonography in the sequential monitoring of morphologic alterations of onchocercal nodules after six weeks of suramin therapy was evaluated in 20 male patients from Ghana with a total of 64 nodule sites. After each follow-up session, a number of onchocercal nodules were extirpated so that by the end of one year, all nodules had been removed for histologic examination. The sonomorphologic changes observed and their time of appearance correlated well with the histologic findings of the onchocercomas. Eighty-three percent of the onchocercal nodules became hyperechogenic and 22% developed echo-free areas at the end of the follow-up period. Absence of the lateral acoustic shadow increased by more than 30% and the lack of differentiation of the worm center from the capsule and the nodule from its surrounding tissue increased by the end of one-year posttreatment to 100% and 91%, respectively. A mean reduction of nodule size of 27% was also documented. The histologic studies revealed that the proportion of the dead female worms increased from 17% at the end of the suramin therapy to 48% six months later and reached 61% at one year. It is concluded that ultrasonographic monitoring of onchocercomas can provide essential information on drug effects and facilitate clinical trials of macrofilaricidal drugs, limiting histologic evaluation to a few objectively selected onchocercomas.

To compare the usefulness of voiding US of the bladder and retrovesical space with echo enhancement with that of voiding cystourethrography (VCUG) for diagnosis of vesicoureteral reflux (VUR) and to assess patient tolerance of the echo-enhancing agent.One hundred eighty-eight patients (aged 5 days to 20 years) referred for investigation of VUR underwent voiding US with echo enhancement, which was followed by VCUG in 110 patients (226 kidney-ureter units). After US of the renal tract, the bladder was filled with normal saline solution. Then SU U 508 A, a galactose-based, microbubble-containing echo-enhancing agent, was administered. Reflux was diagnosed when microbubbles appeared in the ureter or pelvicalyceal system.VUR was detected in 80 of the units with one (n = 18) or both (n = 62) methods. All grades of reflux were identified. In 15 units, reflux diagnosed at voiding US was not observed at VCUG; the reverse was true in three units. In 208 (92%) of the 226 kidney-ureter units, there was concordance between the two methods regarding the diagnosis or exclusion of VUR. The echo-enhancing agent was well tolerated.SH U 508 A enhanced voiding US is as good as VCUG in the detection or exclusion of VUR and thus will make it possible to reduce the number of children having to be exposed to ionizing radiation.